Violence by patients against doctors is on the increase in China. Therese Hesketh and colleagues examine the reasons behind it and the policy changes needed to tackle the problem

HIV testing rates are suboptimal among at-risk men. Crowdsourcing may be a useful tool for designing innovative, community-based HIV testing strategies to increase HIV testing. The purpose of this study was to use a stepped wedge cluster randomized controlled trial (RCT) to evaluate the effect of a crowdsourced HIV intervention on HIV testing uptake among men who have sex with men (MSM) in eight Chinese cities. An HIV testing intervention was developed through a national image contest, a regional strategy designathon, and local message contests. The final intervention included a multimedia HIV testing campaign, an online HIV testing service, and local testing promotion campaigns tailored for MSM. This intervention was evaluated using a closed cohort stepped wedge cluster RCT in eight Chinese cities (Guangzhou, Shenzhen, Zhuhai, and Jiangmen in Guangdong province; Jinan, Qingdao, Yantai, and Jining in Shandong province) from August 2016 to August 2017. MSM were recruited through Blued, a social networking mobile application for MSM, from July 29 to August 21 of 2016. The primary outcome was self-reported HIV testing in the past 3 months. Secondary outcomes included HIV self-testing, facility-based HIV testing, condom use, and syphilis testing. Generalized linear mixed models (GLMMs) were used to analyze primary and secondary outcomes. We enrolled a total of 1,381 MSM. Most were ≤30 years old (82%), unmarried (86%), and had a college degree or higher (65%). The proportion of individuals receiving an HIV test during the intervention periods within a city was 8.9% (95% confidence interval [CI] 2.2–15.5) greater than during the control periods. In addition, the intention-to-treat analysis showed a higher probability of receiving an HIV test during the intervention periods as compared to the control periods (estimated risk ratio [RR] = 1.43, 95% CI 1.19–1.73). The intervention also increased HIV self-testing (RR = 1.89, 95% CI 1.50–2.38). There was no effect on facility-based HIV testing (RR = 1.00, 95% CI 0.79–1.26), condom use (RR = 1.00, 95% CI 0.86–1.17), or syphilis testing (RR = 0.92, 95% CI 0.70–1.21). A total of 48.6% (593/1,219) of participants reported that they received HIV self-testing. Among men who received two HIV tests, 32 individuals seroconverted during the 1-year study period. Study limitations include the use of self-reported HIV testing data among a subset of men and non-completion of the final survey by 23% of participants. Our study population was a young online group in urban China and the relevance of our findings to other populations will require further investigation. In this setting, crowdsourcing was effective for developing and strengthening community-based HIV testing services for MSM. Crowdsourced interventions may be an important tool for the scale-up of HIV testing services among MSM in low- and middle-income countries (LMIC). ClinicalTrials.gov NCT02796963

Objective To explore the factors influencing doctors’ job satisfaction and morale in China, in the context of the ongoing health system reforms and the deteriorating doctor–patient relationship. Design Cross-sectional survey using self-completion questionnaires. Study setting The survey was conducted from March to May 2012 among doctors at the provincial, county and primary care levels in Zhejiang Province, China. Results The questionnaire was completed by 202 doctors. Factors which contributed most to low job satisfaction were low income and long working hours. Provincial level doctors were most dissatisfied while primary care doctors were the least dissatisfied. Three per cent of doctors at high-level hospitals and 27% of those in primary care were satisfied with the salary. Only 7% at high-level hospitals were satisfied with the work hours, compared to 43% in primary care. Less than 10% at high levels were satisfied with the amount of paid vacation time (3%) and paid sick leave (5%), compared with 38% and 41%, respectively, in primary care. Overall, 87% reported that patients were more likely to sue and that patient violence against doctors was increasing. Only 4.5% wanted their children to be doctors. Of those 125 who provided a reason, 34% said poor pay, 17% said it was a high-risk profession, and 9% expressed concerns about personal insecurity or patient violence. Conclusions Doctors have low job satisfaction overall. Recruitment and retention of doctors have become major challenges for the Chinese health system. Measures must be taken to address this, in order to ensure recruitment and retention of doctors in the future. These measures must first include reduction of doctors’ workload, especially at provincial hospitals, partly through incentivisation of appropriate utilisation of primary care, increase in doctors’ salary and more effective measures to tackle patient violence against doctors.

Strengthening the primary care system and promoting utilization of primary care are the major targets of China's ambitious health reforms to meet its people's escalating health care needs. However, the changing trend of primary care utilization 4 years before and after 2009, when the health reforms started, is against the government's stated goal. The percentage of outpatient visits in primary care significantly declined from 63% in 2005 to 59% in 2013 (P = .002). In Western China it went down from 66% in 2010 to 62% in 2013 (P = .017) and slightly dropped in Eastern and Central China. Causes are multiple and include major historic and institutional factors such as severe maldistribution of human resources and lack of primary care practitioners (PCPs), lack of a functional gate-keeping mechanism, the low educational attainment of PCPs, and the detrimental elements of health reforms. Immediate measures need to be taken to improve the situation. These include taking irrational hospital expansion under strict control through enhancing the government's accountability for health care industry regulation, strategies to recruit and retain a quality primary care workforce, empowering PCPs as gatekeepers in the system, timely evaluation of the impact of health reforms on primary care, and modifying damaging policies.

China has low seasonal influenza vaccination rates among priority populations. In this study, we aimed to evaluate a pay-it-forward strategy to increase influenza vaccine uptake in rural, suburban, and urban settings in China. We performed a quasi-experimental pragmatic trial to examine the effectiveness of a pay-it-forward intervention (a free influenza vaccine and an opportunity to donate financially to support vaccination of other individuals) to increase influenza vaccine uptake compared with standard-of-care user-paid vaccination among children (aged between 6 months and 8 years) and older people (≥60 years) in China. Recruitment took place in the standard-of-care group until the expected sample size was reached and then in the pay-it-forward group in primary care clinics from a rural site (Yangshan), a suburban site (Zengcheng), and an urban site (Tianhe). Participants were introduced to the influenza vaccine by project staff using a pamphlet about influenza vaccination and were either asked to pay out-of-pocket at the standard market price (US$8·5–23·2; standard-of-care group) or to donate any amount anonymously (pay-it-forward group). Participants had to be eligible to receive an influenza vaccine and to have not received an influenza vaccine in the past year. The primary outcome was vaccine uptake. Secondary outcomes were vaccine confidence and costs (from the health-care provider perspective). Regression methods compared influenza vaccine uptake and vaccine confidence between the two groups. This trial is registered with ChiCTR, ChiCTR2000040048. From Sept 21, 2020, to March 3, 2021, 300 enrolees were recruited from patients visiting three primary care clinics. 55 (37%) of 150 people in the standard-of-care group (40 [53%] of 75 children and 15 [20%] of 75 older adults) and 111 (74%) of 150 in the pay-it-forward group (66 [88%] of 75 children and 45 [60%] of 75 older adults) received an influenza vaccine. People in the pay-it-forward group were more likely to receive an influenza vaccine compared with those in the standard-of-care group (adjusted odds ratio [aOR] 6·7 [95% CI 2·7–16·6] among children and 5·0 [2·3–10·8] among older adults). People in the pay-it-forward group had greater confidence in vaccine safety (aOR 2·2 [95% CI 1·2–3·9]), importance (3·1 [1·6–5·9]), and effectiveness (3·1 [1·7–5·7]). In the pay-it-forward group, 107 (96%) of 111 participants donated money for subsequent vaccinations. The pay-it-forward group had a lower economic cost (calculated as the cost without subtraction of donations) per person vaccinated (US$45·60) than did the standard-of-care group ($64·67). The pay-it-forward intervention seemed to be effective in improving influenza vaccine uptake and community engagement. Our data have implications for prosocial interventions to enhance influenza vaccine uptake in countries where influenza vaccines are available for a fee. Bill & Melinda Gates Foundation and the UK National Institute for Health Research.

Social media and secondary distribution (distributing self-testing kits by indexes through their networks) both show strong promise to improve human immunodeficiency virus (HIV) self-testing uptake. We assessed an implementation program in Zhuhai, China, which focused on the secondary distribution of HIV/syphilis self-test kits among men who have sex with men (MSM) via social media. Men aged ≥16 years, born biologically male, and ever had sex with another man were recruited as indexes. Banner ads on a social media platform invited the participants to apply for up to 5 self-test kits every 3 months. Index men paid a deposit of US$15/kit refundable upon submitting a photograph of a completed test result via an online submission system. They were informed that they could distribute the kits to others (referred to as “alters”). A total of 371 unique index men applied for 1150 kits (mean age, 28.7 [standard deviation, 6.9] years), of which 1141 test results were returned (99%). Among them, 1099 were valid test results; 810 (74%) were from 331 unique index men, and 289 tests (26%) were from 281 unique alters. Compared to index men, a higher proportion of alters were naive HIV testers (40% vs 21%; P < .001). The total HIV self-test reactivity rate was 3%, with alters having a significantly higher rate than indexes (5% vs 2%; P = .008). A total of 21 people (3%) had a reactive syphilis test result. Integrating social media with the secondary distribution of self-test kits may hold promise to increase HIV/syphilis testing coverage and case identification among MSM.