Fam Med Com Health: first published as 10.15212/FMCH.2014.0105 on 1 March 2014. Downloaded from Family Medicine and Community Health ORIGINAL ORIGINAL RESEARCH ORIGINAL RESEARCH

Types of community health services selected by urban and suburban residents in and influencing factors

Hong Fan, Qianyuan Wang, Yinyan Wu

Abstract Social and Health Education Objective: The purpose of the current study was to determine the types of community health Department, School of Public services selected by urban and suburban residents in Nanjing and the influencing factors in an ef- Health, Nanjing Medical Uni- fort to improve the community health services to better meet the residents’ demands. versity, Nanjing City, Methods: Between 15 May 2013 and 15 June 2013, eight community health service centers Province 210029 from four districts in Nanjing (Gulou and in urban areas and Jiangning Corresponding author: District and in suburban areas; two centers from each district) were selected using Hong Fan a stratified random sampling method of investigation sites. After an intercept interview with 487 Social and Health Education community residents, univariate and multivariate analyses were performed by means of logistic Department, School of Public regression. Health, Nanjing Medical Results: Among the 487 users of community health services, there were 241 residents from ­University, Nanjing City, Jiangsu urban areas (49.5%) and 246 residents from suburban areas (50.5%). Among the respondents, Province 210029 there were 191 (39.2%) who usually received medical treatment from community health service E-mail: [email protected] institutions, including 74 (38.7%) from urban areas and 117 (61.3%) from suburban areas. The Funding: Philosophy and So-

analysis showed that the factors which influenced urban residents in Nanjing to choose community http://fmch.bmj.com/ cial Science Fund Project in health services for medical treatment included income, payment terms of medical fees, reasonable Jiangsu Province: “Research prices, medical fees, and expenses for medications, while factors influencing suburban residents on Evaluation Index System to choose community health services for medical treatment included income, level of education, of Excessive Medical Behav- carrier, medical institutions selected when feeling severely ill, availability of preventive health ior in Jiangsu Provincial Public services, availability of health counseling services, medical fees, and expenses for medications. Hospitals” [2011SJB630042]; Philosophy and Social Science Based on an analysis of the results by means of unconditioned binary logistic stepwise regression, on September 25, 2021 by guest. Protected copyright. the factors influencing whether or not the urban residents chose community health services for Special Fund Project in Nanjing Medical University: “Establish- medical treatment included gender, age, level of education, payment terms of medical fees, treat- ment of Rating Scale for Doc- ment environment, and expenses for medications, while the factors influencing suburban residents tor’s Professional Behavior in included availability of preventive health services and expenses for medications. Chinese Public Hospital under Conclusion: There was a difference between the types of community health services selected the New Health Care Reform” by residents in urban and suburban areas of Nanjing and factors influencing the selection of ser- [2013NJZS02]; Project Support- vices were different. Community health service institutions in different areas should strengthen ing for Training Talents in “Ji- their own service capability according to the local residents’ health demands. angsu Provincial Advantageous Discipline” [JX10331801].

Keywords: Nanjing, Community health service, Service type, Influencing factors, Urban and suburban residents, Diagnosis and treatment of diseases and injuries Received 20 December 2013; Accepted 18 February 2014

8 Family Medicine and Community Health 2014;2(1):8–14 www.fmch-journal.org DOI 10.15212/FMCH.2014.0105 © 2014 Family Medicine and Community Health RESEARCH ORIGINAL Fam Med Com Health: first published as 10.15212/FMCH.2014.0105 on 1 March 2014. Downloaded from

Types of community health services selected by urban and suburban residents

Introduction sociodemographic characteristics of the users of CHSs, and Community health services (CHSs) have gained wide accept- the type of CHSs and factors influencing use of CHSs. The ance since the 1990s when first made available in . With sociodemographic data included gender, age, income, level of the continuous improvement in service functions and service education, marital status, career, and payment terms of medi- quality, CHSs have an irreplaceable role in relieving the eco- cal fees, while the latter included medical treatment, purchase nomic burden and difficulty for people in need of medical treat- of medications, physical examination, disease prevention, ment [1]. With the development of new medical reform, the health guidance, and rehabilitation. The factors influencing community health service institution is playing an important CHS use included type of treatment institutions selected for role in providing medical treatment services in urban areas. minor illnesses, type of treatment institutions selected for New health care reform has now passed and the post-medi- severe illnesses, reasons to select CHSCs, diagnosis and treat- cal reform era has come. The health care policymakers still ment fees, and expenses for medication. focus on the sustainable development of community health ser- vice centers (CHSCs), which are the backbone of the primary Statistical methods health care system [2–4]. The purpose of the current study Data processing and analysis was performed with Office 2003, was to provide scientific and real references for each region to Epi-data, SPSS 18.0, and SAS 9.0 statistical analysis software. conduct specific CHSs by analyzing the types of CHSs chosen Enumeration data comparisons were performed using a χ2 test. by residents from urban and suburban CHSCs in Nanjing and Univariate logistic regression analysis was used for factors the factors which influence patient choices, thus promoting the influencing CHS type; unconditioned binary logistic stepwise “Six in One” CHS function in Nanjing and meeting the basic regression analysis was used for factors influencing residents’ health service demand of the public. choice of CHSs for medical treatment. The inspection stand- ard was set at an α=0.05. Subjects and methods Results http://fmch.bmj.com/ Investigation subjects Between 15 May 2013 and 15 June 2013, in consideration of Sociodemographic characteristics the economic development state of different areas, humani- The differences between urban and suburban users of CHSs ties, and geographic features, as well as the current status with respect to age, level of education, marital status, career, of CHSCs in Nanjing, eight CHSCs from four districts in and payment terms of medical fees were statistically signifi-

Nanjing (Gulou District and Baixia District in urban areas and cant (P<0.05), while the differences between the two groups on September 25, 2021 by guest. Protected copyright. and Pukou District in suburban areas; two with respect to gender and income were not statistically sig- centers from each district) were selected using a stratified ran- nificant P( >0.05, Table 1). dom sampling method at investigation sites to conduct inter- Key points: The purpose of the current study was to com- cept interviews with 487 community residents (n=241 [49.5%] pare the main services provided by the urban and suburban from urban areas and 246 [50.5%] from suburban areas. CHSCs in Nanjing, focusing on opportunities for improve- ment by analyzing the types of CHSs selected by residents in Methods the two areas and the factors which influenced the selections. A questionnaire was self-designed by referring to related The current study is novel; specifically, content was presented materials and amended according to pre-research results. which has seldom been addressed in similar studies conducted Then, the questionnaires were completed by the respondents in China. The sample size and independent variables involved anonymously at each investigation site and were collected in the study were small and should be increased in future stud- and checked after informed consent was provided by the ies. A comparative study involving CHSCs and stations and a respondents. The content of the questionnaire mainly included longitudinal study is warranted.

Family Medicine and Community Health 2014;2(1):8–14 9 Fam Med Com Health: first published as 10.15212/FMCH.2014.0105 on 1 March 2014. Downloaded from ORIGINAL ORIGINAL RESEARCH Fan et al.

Table 1. Comparison of sociodemographic characteristics of the two groups [n (%)]

Item Urban Suburban χ2 value P value Gender 0.370 0.543 Male 108 (44.81) 117 (47.56) Female 133 (55.19) 129 (52.44) Age (years) 18.168 0.003 0~29 35 (14.52) 32 (13.01) 30~39 22 (9.13) 39 (15.85) 40~49 25 (10.37) 39 (15.85) 50~59 37 (15.35) 53 (21.55) 60~69 62 (25.73) 43 (17.48) ≥70 60 (24.90) 40 (16.26) Income (yuan/month) 9.028 0.108 0~999 13 (5.39) 27 (10.98) 1000~1999 53 (21.99) 64 (26.02) 2000~2999 86 (35.69) 79 (32.11) 3000~3999 44 (18.26) 42 (17.07) 4000~4999 22 (9.13) 21 (8.54) ≥5000 23 (9.54) 13 (5.28) Level of education 66.543 <0.001 Illiterate/semi-literate 21 (8.71) 42 (17.07) Primary school 30 (12.45) 83 (33.74) Junior high school 71 (29.46) 71 (28.86) High school/secondary technical school/technical school 71 (29.46) 41 (16.67)

College/university and above 48 (19.92) 9 (3.66) http://fmch.bmj.com/ Marital status 10.360 0.016 Unmarried 28 (11.62) 11 (4.47) Married 196 (81.33) 207 (84.15) Divorce 2 (0.83) 3 (1.22) Bereaved of a spouse 15 (6.22) 25 (10.16)

Career 176.787 <0.001 on September 25, 2021 by guest. Protected copyright. Organization/enterprise and public institution staff 36 (14.96) 17 (6.91) Commerce and service personnel 51 (21.16) 53 (21.54) Agricultural worker 4 (1.67) 77 (31.30) Student 11 (4.56) 2 (0.81) Retired 116 (48.13) 20 (8.13) Unemployed or jobless 5 (2.07) 27 (10.98) Others 18 (7.47) 50 (20.33) Payment terms of medical fees 139.979 <0.001 Socialized medicine 31 (12.86) 9 (3.66) Basic medical insurance for urban workers 82 (34.03) 41 (16.67) Basic medical insurance for urban residents 71 (29.46) 24 (9.75) New-style rural cooperative medical care 5 (2.07) 96 (39.02) Business insurance 3 (1.24) 1 (0.41) Labor protection medical care 13 (5.39) 11 (4.47) Self-paid expenses 36 (14.94) 64 (26.02)

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Types of community health services selected by urban and suburban residents

Type of CHSs independent variables. Unconditioned binary logistic stepwise In the current study there were 191 patients (39.2%) who regression analysis was used with inclusion (Sm=0.05) exclu- selected CHSCs for medical treatment, including 74 (38.7%) sion criteria (Su=0.10). Whether or not an urban resident selected from urban areas and 117 (61.3%) from suburban areas. The CHSs for medical treatment was affected by many factors, includ- difference between types of CHSs selected by urban and ing gender, age, level of education, payment terms of medical suburban residents were statistically significant (χ2=25.384, fees, treatment environment, and expenses for medication (Table P<0.001, Table 2) 4). Whether or not suburban residents selected CHSs for medical treatment was affected by factors, such as availability of preven- Univariate analysis on factors influencing resident tive health services and expenses for medications (Table 5). selection of CHS type CHS was the dependent variable in univariate analysis, while Discussion the following factors were independent variables: gender; age; income; level of education; marital status; career; payment terms The sociodemographic characteristics of Nanjing of medical fees; type of treatment institutions selected when urban and suburban users of CHSs are typical mildly or severely ill; reason for selecting this CHSC; medi- The service target population of CHSs mainly includes cal treatment expenses; and expenses for medications (Table women, children, the elderly, persons undergoing rehabilita- 3). The factors influencing Nanjing urban residents to select tion, the disabled, and other vulnerable groups in need of care, CHS type included income (χ2=11.544, P=0.042), payment as well as persons with low levels of education, low income, terms of medical fees (χ2=14.334, P=0.026), reasonable price the unemployed, and disadvantaged groups outside the cover- (χ2=6.878, P=0.009), medical treatment expenses (χ2=180.291, age of the national medical insurance system. The above-men- P<0.001), and expenses for medications (χ2=5.120, P<0.001). tioned groups of patients generally have poor health status and The factors influencing Nanjing suburban residents to select have a great demand for CHSs. The results of the current study CHS type included income (χ2=11.637, P=0.040), level of edu- also demonstrated that among Nanjing urban and suburban http://fmch.bmj.com/ cation (χ2=10.349, P=0.035), career (χ2=14.447, P=0.025), type users of CHSs, the following vulnerable and disadvantaged of treatment institutions selected when severely ill (χ2=27.418, groups account for a significant proportion of the total, includ- P<0.001), availability of preventive health services (χ2=9.641, ing females, patients >40 years of age, patients with a monthly P=0.002), availability of health counseling services (χ2= 6.618, income

Table 2. Comparison of application of community health services by the two groups

Group Case Medical Drug purchasing Physical Disease Health Rehabilitation number treatment examination prevention guide Urban 241 74 (30.7) 69 (28.6) 54 (22.4) 6 (2.5) 20 (8.3) 18 (7.5) Suburban 246 117 (47.6) 34 (13.8) 62 (25.2) 7 (2.8) 11 (4.5) 15 (6.1)

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Table 3. Assignment of factors influencing resident selection of community health service type

Variable Devalue Gender 1=male, 2=female Age 1=0–29, 2=30–39, 3=40–49, 4=50–59, 5=60–69, 6=≥70 Income (yuan/month) 1=0–999, 2=1000–1999, 3=2000–2999, 4=3000–3999, 5=4000–4999, 6=≥5000 Level of education 1=not literate/literate rarely, 2=primary school, 3=junior high school, 4=high school/secondary technical school/technical school, 5=college/bachelor and above Marital status 1=unmarried, 2=married, 3=divorce, 4=bereft of one’s spouse Career 1=enterprise and institution personnel, 2=business and service personnel, 3=agricultural workers, 4=student, 5=retired, 6=unemployed or jobless, 7=others Payment terms of medical fees 1=socialized medicine, 2=basic medical insurance for urban workers, 3=basic medical insurance for urban residents, 4=new-style rural cooperative medical care, 5=business insurance, 6=labor protection medical care, 7=at one’s own expense Type of treatment institution selected when 1=provincial hospital, 2=municipal hospital, 3=district hospital, 4=township hospital, feeling mildly ill 5=community, 6=street hospital, 7=military and enterprise hospitals, 8=private clinics, 9=self-medication, 10=others Type of treatment institution selected when 1=provincial hospital, 2=municipal hospital, 3=district hospital, 4=township hospital, feeling severely ill 5=community, 6=street hospital, 7=military and enterprise hospitals, 8=private clinics, 9=self-medication, 10=others Reasons for selecting this community health service institution Convenience 1=yes, 2=no Good service attitude 1=yes, 2=no Designated health care unit 1=yes, 2=no http://fmch.bmj.com/ Whether or not cost is inexpensive 1=yes, 2=no Good treatment environment 1=yes, 2=no Whether or not preventive health services 1=yes, 2=no are provided Whether or not health counseling services 1=yes, 2=no are provided More familiar with physicians 1=yes, 2=no on September 25, 2021 by guest. Protected copyright. Other 1=yes, 2=no Diagnosis and treatment expenses (yuan) 1=0–99, 2=100–199, 3=200–299, 4=300–399, 5=400–499, 6=≥500 Expenses for medications (yuan) 1=0–99, 2=100–199, 3=200–299, 4=300–399, 5=400–499, 6=≥500

prevalence of various chronic diseases increases, resulting in significant part of the retired population, and people without an increasing demand for medical health services [5]. In the free medical treatment usually have a low level of education, low-income group, poor health status results from spending low-paying jobs, and poor health status, resulting in a high most of their energy and money on food and clothing instead demand for health services [6–8]. of health and a lack in self-health care consciousness. People Therefore, CHSCs focus on the population with high demand, with a low level of education generally lack health knowledge especially the vulnerable and disadvantaged groups, to further for disease prevention and have poor acceptability of health enhance their self-protection awareness by health knowledge knowledge, thus it is quite possible for them to behave in way popularization and education. The CHSCs provide accessible and that is bad for their health. Generally, the elderly comprise a sustainable health care services to improve the health conditions

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Types of community health services selected by urban and suburban residents

Table 4. Multiple factors influencing urban resident selection of community health service for medical treatment

Variable β Wald χ2 value P value OR value 95% CI Gender –0.796 5.034 0.025 0.451 (0.225, 0.904) Age –0.497 11.583 0.001 0.609 (0.457, 0.810) Education –0.383 4.096 0.043 0.682 (0.471, 0.988) Payment terms –0.292 9.214 0.002 0.747 (0.619, 0.902) Treatment environment 1.101 6.010 0.014 3.007 (1.247, 7.250) Expenses for medications –0.722 10.341 0.001 0.486 (0.313, 0.754) Constant 6.641 6.947 0.008 765.852

Table 5. Multivariate logistic regression analysis on factors influencing suburban resident selection of community health service for medical treatment

Variable β Wald χ2 value P value OR value 95% CI Availability of preventive health services –1.216 6.415 0.011 0.296 (0.116, 0.760) Expenses for medications 0.766 5.308 0.021 2.152 (1.121, 4.131) Constant 0.766 0.036 0.850 2.150

of the above-mentioned population. Only in this way can CHS be the current study results, the CHSCs in urban areas provide recognized and accepted by more community residents [9]. The services according to resident demand, such as physical exam- current investigation showed that there were differences between inations, rehabilitation, health counseling services, and other the urban and suburban users of CHSs with respect to age, level non-medical treatment services, while the CHSCs in suburban of education, marital status, career, and payment terms of medi- areas improve medical technology and medical service quality

cal fees, thus the CHSCs in different areas must provide health so that more residents will choose CHSs for medical treatment. http://fmch.bmj.com/ services according to the actual demands and needs of residents. The factors influencing Nanjing urban and suburban There was a difference between types of CHs se- resident selection of CHS type were different lected by Nanjing urban and suburban residents Based on univariate analysis and unconditioned binary logis- Specifically, there were 191 persons (39.2%) who selected tic regression analysis, the urban and suburban residents CHSCs for medical treatment, including 74 persons (38.7%) were affected by medication expenses. For urban residents, on September 25, 2021 by guest. Protected copyright. from the urban areas and 117 persons (61.3%) from the subur- the lower the expenses for medications, the more likely they ban areas. Thus, CHSCs in suburban areas were a main place would choose CHSCs for non-medical treatment. For sub- for residents to receive medical treatment. The urban users of urban residents, the lower the expenses for medications, the CHSs generally had higher health awareness and were more more likely they would choose CHSCs for medical treatment. concerned about their health status. Moreover, it is more con- This indicates that utilization of CHSCs by suburban residents venient for urban residents to travel to the general and special- mainly focused on medical treatment, and it is thus difficult to ized hospitals. Therefore, most of the urban residents choose give full attention to the service function of “Six in One” of large hospitals for medical treatment, but choose CHSCs only CHS because the types of service provided by the CHSCs are for medication purchases, physical examinations, rehabilita- limited. Furthermore, a lack of awareness and trust of residents tion, and health counseling services. Considering factors, such towards CHSs is also a possible reason. Compared with subur- as traffic and medical expenses, the suburban users of CHSs ban areas, the urban areas have rich resources and convenient prefer to choose CHSCs for the treatment of common diseases, traffic, so CHSCs cannot provide more reasonable prices than frequently occurring diseases, and minor injuries. Based on large general or specialized hospitals, and the urban residents

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would prefer to seek medical treatment in general or special- resident demand. The sample size should be increased to com- ized hospitals which can provide services of higher quality. pare the service items in Nanjing urban and suburban CHSCs Therefore, it is important for the survival of the urban CHSCs and stations, and track and investigate the establishment and to develop specialized services, such as physical examinations, development of CHSCs to conduct longitudinal comparative rehabilitation, and preventive and health counseling service, in research and provide a more detailed theoretical basis for the addition to basic medical health services, which are also the sustainable development of Nanjing CHSCs. main service offerings used by urban residents in CHSCs. Additionally, whether or not the urban residents select Conflict of interest CHSs for medical treatment is affected by many factors, The authors declare no conflict of interest. including gender, age, level of education, payment terms of medical fees, and treatment environment. Among the urban References users of CHSCs, women, people with higher levels of educa- 1. Kurimoto A. How social economy can improve user access and tion, the elderly, people without public medical security, and the capability of health services: The case of health coops. Con- those who do not care about the treatment environment prefer sumer Co-op Inst Japan 2004;25:48–52. to receive medical treatment in the CHSCs. With the exception 2. Jiang Z, Zhou X, Zhong H. Investigation of Nanchang residents’ of the level of education, other factors influencing selection of application of community health service and their satisfaction. CHSs conform to common sense. It is notable that the higher Soft Sci Health 2009;23:59–62. the level of education an urban resident has, the more likely 3. Lu Z, Liu J, Peng J, Cheng JQ, Yang DH, Xia TS. Analysis of a CHSC will be chosen for medical treatment. It is possible Shenzhen application of community health service and its influ- ence factors. Chin Manag Magaz 2005;21:464–7. because such persons have learned more about the CHSCs 4. Wang D, Wang J, Zhou Y, Chen WJ, Ma GS, Wang HL, et al. through various channels, so they do not treat CHSCs as low Investigation and analysis of Nanjing certain community resi- level, small clinics. When urban residents have common ill- dents’ awareness, demand, and application of community health nesses or frequently-occurring diseases, they may choose the

service. Chin Gen Pract 2013;16:446–9. http://fmch.bmj.com/ convenient CHSCs for medical treatment. With respect to the 5. Zhou Y, Hua J, Cheng H. Analysis of influence factors of poor suburban users of CHSCs, the availability of preventive health population’s application of community health service. Chin J services and the expenses for medication are important when Public Health 2010;26:1200–1. selecting a CHSC; however, the suburban residents consider 6. Green EJ, Osband K. A revealed preference theory for expected the medical treatment function and the availability of pre- utility. Rev Econ Stud 1991;58:677–95.

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