Community-based rehabilitation service in Chengdu: a cross-sectional general survey

Background Community-based rehabilitation (CBR) was initiated by World Health Organization in 1984, and by then it has been an essential process of medical services in the worldwide. China had strengthened primary health care via constructing more than 35 thousand community health centers (CHCs) in cities, and more than 35 thousand township health centers (THCs) in rural area. Nevertheless, it remains unclear that if these basic health center could provide optional rehabilitation services for disabilities. And this study aims at evaluating supply capacity of rehabilitation service in basic health centers of Chengdu, a regional center city of southwest China. Method We conducted a general investigation of primary health centers in Chengdu, a city located in south west China with more than 15 million population. Totally, our investigation covered 115 CHCs and 264 THCs from October to November 2016. We investigated these primary health center on basic rehabilitation services, disease spectrum and rehabilitation equipment quantity and quality, and traditional Chinese medicine (TCM) physiotherapy

neighbor community health centers of Chengdu City. Whereas, available rate of CBR in rural CHCs is lesser than in urban CHCs, which indicates imbalance in basic health service development between rural and urban area. A bit of baseline of CHCs makes significant impact on number of patients per year, including species of rehabilitation diseases, service population and number of rehabilitation bed.

Background
Community-based rehabilitation (CBR) has been a widely-accepted pattern for individuals to get access to convenient, flexible and economical rehabilitation services since it was introduced in the 1970s (1). In 1978, in an attempt to decrease the burden of disability in low-and middle-income countries, the World Health Organization launched a strategy called community-based rehabilitation (CBR). CBR is now implemented in more than 90 countries and is defined as an inclusive community development strategy, which aims at the equalization of opportunities, rehabilitation, poverty reduction, and social inclusion of the population living with a disability. Statistics show that more than 2 million disabilities are under the condition of inconvenient rehabilitation medical service assessment. The World Health Organization (WHO) set CBR as a critical development direction for disabilities, according to the Global Disability Action Plan (2) The development of rehabilitation services in China has been evoking since the 1980s when it was introduced into China. In the early years, volunteers recruited by the government were main providers of CBR, however, due to lack of systematic training for volunteers, CBR service remains in a low quality for many years. With support from the central and provincial governments and organizations, grassroots rehabilitation communities have mobilized and integrated local resources to meet the rehabilitation needs of people with disabilities(3). However, insufficient financial resources and personnel in rural communities, compounded by a lack of awareness from local authorities and the traditional hierarchical administrative system, have hampered the growth of CBR services in China(4).
Nevertheless, there are rare data about how widely the community health centers could cover disabilities who are in sore need of convenient and economical rehabilitation services. Because so many challenges during the process of CBR evaluation would hamper investigators to get real and effective data. For instance, community health centers in the Chinese vast rural area are difficult to be evaluated because of the low literacy and the large variety of dialects. Additionally, using Likert scaled in Chinese culture is difficult because participants tend to select the midpoint(5) and probably skip some items (6). This is because of the deeply held collectivist values within Chinese culture affect the self-reporting behavior of Chinese people: Chinese people are expected to modestly rate their performance and refrain from exaggerating their achievements (7). They are relatively conservative and encouraged not to openly discuss or comment on a person's family or organization (8). The reluctance in China to evaluate service systems, programs or a family can result in the underrating of performance when using self-reporting scales (7).

Subjects
In order to effectively evaluate CBR in CHCs, we selected Chengdu, with a 13.5 thousand dollars general domestic production (GDP) per capita(9) as the target place. Chengdu city is located at

Development of the questionnaire
The questionnaire was self-developed. The questionnaire(10) items were designed according to the policy of <Service quality evaluation guideline for primary care facilities>, made by National health and family planning commission of the people's republic of China in 2016, then modified after consideration of specific applicability as well as an expert discussion. We focus on evaluating the basic capabilities of primary care facilities in providing services, thus we mainly collected the following variables: 1. Total

Administration of the questionnaire
An instruction for data quality control was developed. Questionnaires were distributed by local health bureaus to the leaders of every single basic health center. 390 leader physicians received questionnaires, completed independently and handed them over to the investigation team in 2 weeks after they received the questionnaires. Then the investigation team staff rechecked the collected questionnaires, and complementary filled the missing data by telephone review for leaders of basic health centers. At last, we randomly sent staff to 5% of the CHC facilities to examine the authenticity and validity of the returned questionnaires.

Data analysis
Data were entered into Epidata by dual investigators and analyzed with SPSS 22.0 (SPSS Inc., Chicago, IL, USA), Normally, distributed continuous variables were reported as mean ± standard deviation (SD), while undistributed continuous variables used median ± interquartile range.
Categorical variables are reported as frequency and proportions.
In order to determine which specific characteristics-among the number of diseases, rehabilitation Statistics about the basic condition of CHCs read that total number of rehabilitation patients in 2015 is more than 2 million person-time (Table 2.) In order to quantitively analysis potential factors that could influence the capacity of CHCs rehabilitation service, we covert the dependent variable, the number of rehabilitation patients to level varies according to quartile. (Table 3.)  influence rehabilitation service capacity in the primary health system. In the general survey, we found more than 88% of CHCs and THCs involved in this survey have been well equipped to provide convenient, economical and high-quality rehabilitation services. But, the imbalance between urban and rural community health centers remains obvious, even though the THCs make efforts to shorten the gap. Compared to rural community health centers, urban community health centers obviously carry out higher-quality equipment, more rehabilitation doctors and wider-cover of rehabilitation diseases. Reasons that make this kind of gap between urban and rural may be various, such as economic level, physician attraction, transport construction, and citizens' health sense. Consequently, this phenomenon of the urban-rural imbalance inspires the government and community to pay more financial support and health education to the rural area in order to improve the rehabilitation capacity of rural basic health centers.
Since 2009, the Chinese government has been carrying out strategies and investing lots of money to improve its primary health care system. For example, in 2014, the expenditure on primary care reached ¥110 billion (11). In less than 10 years, the infrastructures and facilities of the CHCs and THCs were greatly enhanced (12). In our study, we found majority (90%) of involved CHCs and THCs were well equipped of basic diagnostic tests, such as blood routine, biochemical test, ultrasound, X-ray as well as electrocardiogram, which were essential auxiliary examinations for dealing with common diseases in the primary care settings.
Along with the giant leap in medical service in the primary health care system under a powerful and effective push from China government, rehabilitation capacity of these basic health centers also carried out a splendid progression in both hardware and software. But in the southwest region of China, there are still dozens of district troubling in short of appropriate medical service, and inevitable lack of affordable and convenient rehabilitation medical services, because of poverty, poor transportation and lack of health senses. Chengdu, as a regional center city, shows off its powerful and comprehensive influence on regional development in every aspect, including economic, education, culture, technology and medicine, which may lead to radiate our survey's outcome to entire southwest China rather than a city.
Due to weak education and training systems on general practitioners, rehabilitation services could not be well delivered to disabilities, even though CHCs are rapidly equipped with the newest equipment and technology. Hence, completing an optimal general practitioner training system would be another driving force to further rehabilitation service capacity in the primary health system.

Conclusion
Rehabilitation service capacity of primary health facilities in Chengdu has a giant leap in the past 20 years to reach a relatively high-level quantity and quality. However, there are still many aspects of flaws and shorts during the rapid development of the primary health system and rehabilitation service. To furtherly improve the rehabilitation capacity of CHCs, the government needs to take measures: to increase species of rehabilitation diseases; to train more rehabilitation physicians; to augment the number of rehabilitation beds, which are proved directly correlated with rehabilitation service capacity.

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