Chronic disease knowledge and its determinants among chronically ill adults in rural areas of Shanxi Province in China: a cross-sectional study

Chronic diseases (CDs) are the leading global causes of death, and they are concentrated in the world's low- and middle-income populations. CDs were responsible for 36 million of the 57 million deaths that occurred globally in 2008, and mainly comprised cardiovascular diseases, cancers, and diabetes. Nearly 80% of CD deaths occur in low- and middle-income countries [1]. In 2008, data of the Fourth Chinese National Health Services Survey showed that 270 million Chinese people were diagnosed with at least one chronic disease, and about 82% of deaths and 70% of disability-adjusted life years lost were caused by CDs. By 2020, it is predicted that the number of deaths attributable to CDs will rise to 85% [2]. The rapidly growing burden of chronic illnesses in low- and middle-income countries threatens the health condition of their population and their economic development. Because most health-care costs must be paid by patients out of their own income in these countries, the cost of health care for CDs creates significant strain on household budgets. Each year, an estimated 100 million people are pushed into poverty because they have to pay directly for health services [1, 3]. In China, indirect economic loss caused by CDs was 4.1% of GNP in 2000, and rural residents have taken 65% more economical risk of CDs than urban residents. Rural people had greater likelihood of impoverishment cause of treatment of CDs [4].

CDs are diseases of long duration and generally slow progression that are largely preventable through the reduction of their main lifestyle risk factors, such as unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol [5]. Research shows that increasing the health knowledge of chronically ill and high-risk populations is the most effective way to prevent and delay the onset of CDs [6, 7]. The improvement of health knowledge contributes to an increased awareness of health care, which not only helps people know more about diseases and increases their ability for self-care, but also helps them to quit unhealthy behaviours and lead healthy lifestyles. In rural China, health care providers are the main disseminators of health knowledge. Compared with urban residents, in 2008, the rural population had a lower educational level with 18.9% of them illiterate and 69.2% not having attended senior middle school. Accessing the rural population for the purpose of providing health information is difficult. Most of them obtain health knowledge mainly from the television and their physicians, but there is no systematic television broadcast of health information [2]. Therefore, the most effective way to improve rural residents' health knowledge and encourage health behaviour is through heath education and promotion.

Trying to prevent, control, and curb the growth trend of CDs in rural areas is a main activity of the Ministry of Health of China. More than half of the Chinese population (53.41% of 1.3 billion in 2009 [8]), still live in rural areas where residents cannot access the same level of health services as their urban counterparts, which is partly because of a lower level of economic growth, lack of amenities, and poor health service capacity in rural areas [9]. In 2008, the prevalence of CDs in rural China was 17.1%, a 5% increase on the 2003 prevalence, which is a faster rate of increase than that observed in the urban population (24% in 2003, 28.3% in 2008) [10]. Shanxi Province is an example of a large middle-income province of China that is located in north China. It has a population of 33.92 million, of which 55.97% live in rural areas. Heart attack, cancer, stroke, diabetes, and chronic obstructive pulmonary disease are now the leading causes of death in rural areas among middle-aged and elderly people, and represent a major burden on CD prevention and control.

In China, county hospitals, town hospitals, and village clinics compose the three-tier rural health service network. They are the principal providers of health care services to rural residents to maintain their health. They are also responsible for CD prevention and control. Compared with countries that implement a family physician practice system of primary health care [11], Chinese citizens can choose to have their check-ups at any hospital (i.e. village clinic, community health services centre, municipal hospital, or provincial hospital). It was reported that 81.7% of rural residents preferred to obtain health care services from village clinics and town hospitals [12]. Therefore, primary health care institutions are the major 'health keepers' for rural residents. Research shows that the health service capabilities of health institutions, to some extent, determines the health level of local residents; which is influenced by disease treatment, public health services, and health promotion and education, with the latter having an enormous influence on people's level of health knowledge [13, 14].

So far, most investigations of the factors contributing to CD-related knowledge among chronically ill adults mainly focused on the characteristics of patients instead of health providers. It has been demonstrated that educational level, occupation, rural/urban statuses of residence, and region of residence were risk factors for inadequate or low CD knowledge [15‐19]. American researchers have confirmed that the receipt of health knowledge from different health care providers (practitioners, nurses, diabetes educators, physicians or pharmacists) was a key contributor to one's health knowledge [20]. Yet, to our knowledge, there are no studies analysing the influence of health institution services on the health knowledge of chronically ill adults in China. Therefore, we set out to assess the determinants of CD knowledge from the perspectives of both patients and health providers, and analyse the influence of health care services (of the three-tier rural health institutions) on the health knowledge of rural residents with CDs. Specifically, our research questions are: (1) How is CD knowledge distributed among chronically ill rural residents? (2) What are the potentially modifiable factors associated with CD knowledge? (3) What is the influence of different health institutions on CD knowledge among rural adults with CDs? A cross-sectional survey was used to answer these questions.

More than 70% of participants in our study had inadequate CD heath knowledge, including the highly educated rural participants who had high school education or higher. Participants had a higher level of basic CD knowledge than professional knowledge. For example, they know about the normal blood pressure range of healthy adults, and disease control through smoking cessation and reasonable alcohol consumption, but few of them know about hyperglycaemia and hyperlipidaemia as risk factors for hypertension (with only 17.36% of them answering correctly), and that weight loss is a means of disease control (with just 15% answering correctly). These finding are consistent with studies conducted in other provinces of China [24‐26].

As is indicated in the multivariate model, participants who had a longer duration of CDs, and those who had a family history of CDs were more likely to have adequate CD health knowledge, which may have led to increased attention on disease control for themselves and their family members over time. In such circumstances, they may have been more willing to see physicians and obtain health information and self-care instructions from them than people without a family history of CD, or with a short duration of CD.

Our findings convince us that those who receive health information and self-care instructions from their physicians are more likely to have adequate CD health knowledge. The information in Table 3 reveals that adequate CD health knowledge among the respondents was associated with receiving health care from regularly-attended fixed health institutions. We also identified a significant relationship between the health services of different health institutions and the CD knowledge of participants who had regular check-ups.

As part of the Chinese Health System Reform (initiated in 2009), CD management and health education are main components of basic public health services, and are at the top of the policy agenda for rural health [27]. The Ministry of Health has outlined the main responsibilities of each level of health institution for CD prevention and control. Village clinics, the basic part of the rural health care system, are responsible for providing basic outpatient diagnosis and treatment, basic public health care including health education and medication management, and long-term monitoring for patients with CDs. In addition to supplying health care services to patients with CDs, township hospitals are also obligated to help to build and maintain health records, conduct health education and promotion, and supply service guidance and technical training for village clinics. County hospitals, as the medical centre for a county area, also have a responsibility to provide service and technical guidance for township hospitals and village clinics.

According to our findings, township hospitals have the most positive influence on CD knowledge for rural chronically ill residents among the three-tier rural health care institutions. Almost all participants in township hospitals (93.96%) received health education and promotion services; and most of them had significantly higher scores of CD knowledge. While more than half of the participants attending village clinics self-reported that they had received such services from village physicians, less than 10% of them had adequate CD health knowledge. This disappointing finding may be partially attributable to a low capacity of health care supply and a chronic inadequateness of public health care services among village clinics. Village clinics are subject to a lack of health infrastructure, and low educational levels of their health faculty.

It is reported that nearly 90% of village physicians are below vocational educational level, and one third of them practice without a degree [28]. Most of them lack knowledge about CD prevention and control, so it is difficult for them to provide health knowledge to patients. Moreover, most village clinics set up by village or township hospitals are operated as small businesses, although the actual facilities may be owned by the government [29]. In rural areas, nearly 36% of village clinics are privately run and do not offer public health services to rural residents for two main reasons [12]. First is the lack of relevant professional training and equipment available to these practitioners, and the influence this has on the overall quality of health services they provide. The second reason is that a lack of government funding discourages them from paying adequate attention to public health services such as health education and promotion [30].

County hospitals are the centres of medical and technical guidance and training for a county, yet seem to provide less effective health education services than township hospitals. This disparity may be attributable to the heavy burden of diagnosis and treatment of diseases at county hospitals. It was reported in "An Analysis Report of National Health Services Survey in China 2008" that clinicians mainly focused on curing diseases and reversing the unhealthy status of patients, instead of supplying public health care services [31]. In county hospitals, most clinicians are specialists with a high responsibility for managing difficult diseases, and this consumes most of their attention. Therefore, there is no effective coordination of health education, disease prevention and control, and disease therapy for patients [31, 32]. Furthermore, because of the profit-oriented nature of county hospitals, physicians pay more attention to disease therapy, which can bring direct economic benefits than to public health care services, and this further contributes to the chronic inadequacy of health education and promotion among county hospitals [29, 33].

Our study highlights the continuing need for greater CD knowledge in the rural areas of China, as well as the positive effects of health care institutions' health education and promotion for rural residents. In addition, our results emphasize the importance of establishing a community based CD prevention and control programme. This would require township hospitals to take a leading role and supply service guidance, technical training, and health supervision to village clinics to increase the quality of public health care services in rural China. Furthermore, efforts should be made to strengthen the basic construction of village clinics, and to develop a team of grass-roots health care workers with the purpose of enhancing health care service capacity in rural areas. Sound supervision of the public health care service system should be established to ensure proper implementation of public health services in rural health institutions.

The sample in this study consists of rural adults with hypertension or T2D, which may or may not represent the chronically ill population. Our data of health knowledge and self-care instructions were based on self-report, which may be subject to respondent bias. The factors influencing attendance at particular hospitals for rural residents with CDs are complicated, such as distance, economic condition, attitude of physicians, diagnosing and treating environment, qualification of the physicians, and waiting times. Our findings may be influenced by these factors, and we assume that distance and economic conditions are likely to be the main factors of influence for participants in Shanxi Province. Another potential limitation of our research is the use of closed-ended questions (i.e. true/false/don't know) in the health knowledge test, which may have allowed participants to guess the correct answer.