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Article(id=1321170005811642942, tenantId=1146029695717560320, journalId=1319373219989389464, issueId=1321169924697993338, articleNumber=null, orderNo=null, doi=10.11847/zgggws1144932, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1715616000000, receivedDateStr=2024-05-14, revisedDate=1734019200000, revisedDateStr=2024-12-13, acceptedDate=1743523200000, acceptedDateStr=2025-04-02, onlineDate=1792921075537, onlineDateStr=2026-10-25, pubDate=1746806400000, pubDateStr=2025-05-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1792921075537, onlineIssueDateStr=2026-10-25, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1792921075537, creator=13701087609, updateTime=1792921075537, updator=13701087609, issue=Issue{id=1321169924697993338, tenantId=1146029695717560320, journalId=1319373219989389464, year='2025', volume='41', issue='5', pageStart='513', pageEnd='640', issueExtLink='null', onlineDate='null', pubDate='1746806400000', pubDateStr='2025-05-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1792921056198, creator='13701087609', updateTime=1792921056198, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=574, endPage=579, ext={EN=ArticleExt(id=1321170006004580927, articleId=1321170005811642942, tenantId=1146029695717560320, journalId=1319373219989389464, language=EN, title=Ability of health management services among grassroots doctors under the integration of disease treatment and prevention in China, 2020: an online self-administered survey, columnId=1320427686514770171, journalTitle=Chinese Journal of Public Health, columnName=Survey and Report, runingTitle=null, highlight=null, articleAbstract=
Objective

To explore the association between the ability to diagnose and treat common diseases and the capacity to provide health management services among grassroots doctors, from the perspective of integrating disease treatment and prevention, and to provide a reference for improving grassroots doctors′ health management service capacity.

Methods

An online self-administered questionnaire survey was conducted in August 2020 among 8 469 specialists, general practitioners, and rural doctors. Participants were recruited using stratified multi-stage sampling and typical sampling from primary healthcare institutions located in 11 municipalities across eastern, central, and western China. Utilizing a previously self-developed index system for evaluating the health service capabilities of grassroots doctors, the survey questionnaire was designed based on indicators related to health management service capabilities. The questionnaire assessed the health management service capabilities of primary care physicians in three areas: diagnosis and treatment of common diseases, health management, and health promotion.

Results

Of all the participants, 5 288 (62.44%) were practicing (assistant) doctors, 2 201 (25.99%) were rural doctors, and 6 497 (76.72%) were assessed as capable of diagnosing and treating common diseases. Among all the grassroots doctors surveyed, 7 099 (83.82%) had the ability to provide nutritional guidance for children, and 7 068 (83.46%) could conduct physical examinations for children as part of children's health management. Regarding women's health management, 6 746 (79.66%) could provide family planning guidance, 6 539 (77.21%) offered prenatal health guidance, 5 921 (69.91%) provided perimenopausal health care, and 5 456 (64.42%) conducted cervical/breast cancer screening. More than 90% of the participants were assessed as able to conduct health management for the elderly and individuals with chronic conditions. However, only 6 234 (73.61%) had the ability to analyze community health issues.

Conclusions

The ability to diagnose and treat common illnesses significantly affects the capacity of grassroots doctors to deliver health management services. Moreover, there is a noticeable gap in the health management service capabilities among grassroots doctors in China. Therefore, it is crucial to strengthen collaborative service mechanisms between hospitals and primary care institutions.

, authors=Yahui LI1, Kun XIE1, Lu LIAN2, Xuanxuan WANG3, Jiaying CHEN1, authorsList=Yahui LI, Kun XIE, Lu LIAN, Xuanxuan WANG, Jiaying CHEN, authorCompany=null, correspAuthors=Jiaying CHEN, authorNote=null, correspAuthorsNote=
CHEN Jiaying, E-mail:
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目的

从医防融合视角，探讨基层医生常见病诊治能力水平与健康管理服务能力具备情况的关联，为提高基层医生的健康管理服务能力提供参考。

方法

于2020年8月，采用多阶段分层抽样与典型抽样相结合的方法，对中国东、中、西部基层医疗卫生机构的8 469名医生进行线上问卷调查，利用课题组既往开发的基层医生卫生服务能力指标体系，选取其中健康管理服务能力部分的指标为依据设计调查问卷，从常见病诊治、健康管理、健康促进3个方面评价基层医生健康管理服务能力的具备情况。

结果

8 469名基层医生中，取得执业（助理）医师资格5 288人（62.44%），乡村医生2 201人（25.99%）。基层医生具备常见病诊治能力人数6 497人（76.72%）；在儿童健康管理能力方面，基层医生具备儿童营养指导、体格检查能力人数分别为7 099（83.82%）和7 068（83.46%）人；在妇女健康管理能力方面，基层医生具备计生指导、孕期健康指导、围绝经期健康、妇科两癌筛查的人数分别为6 746（79.66%）、6 539（77.21%）、5 921（69.91%）、5 456（64.42%）人；在老年人、慢性病健康管理方面，基层医生具备老年人和慢性病健康管理的比例均>90%；在健康促进方面，基层医生具备社区健康问题分析能力的人数最低，有6 234人（73.61%）。

结论

高素质人才短缺和常见病诊治能力影响基层医生开展健康管理服务，且我国基层医生掌握健康管理服务能力存在“短板”，因此需要加强医院与基层之间服务协同机制建设。

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李亚慧（1995—），助教，硕士，研究方向：卫生政策

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陈家应，E-mail：
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pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=13, rfOrder=12, authorNames=null, journalName=null, refType=null, unstructuredReference=米术斌, 王经纬, 马超, 等. 河北省乡村医生公共卫生服务情况及影响因素[J]. 中国公共卫生, 2019, 35(6): 689-692., articleTitle=null, refAbstract=null), Reference(id=1321170013323641476, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, doi=null, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=14, rfOrder=13, authorNames=null, journalName=null, refType=null, unstructuredReference=周冬冬, 葛许华. 我国东西部地区乡镇卫生院全科医生岗位胜任力现况研究[J]. 中国初级卫生保健, 2022, 36(7): 32-35., articleTitle=null, refAbstract=null), Reference(id=1321170013390750341, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, doi=null, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=15, rfOrder=14, authorNames=null, journalName=null, refType=null, unstructuredReference=方立亿, 孙英, 张远, 等. 新时期城乡居民对健康管理服务内容和形式需求调查分析[J]. 中国卫生事业管理, 2018, 35(7): 550-553., articleTitle=null, refAbstract=null), Reference(id=1321170013520773766, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, doi=null, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=16, rfOrder=15, authorNames=null, journalName=null, refType=null, unstructuredReference=刘仕方, 余昌胤, 陈玲丽, 等. 基于SERVQUAL量表的农村家庭医生团队模式服务质量评价[J]. 安徽医学, 2017, 38(1): 93-97., articleTitle=null, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1321170007904600641, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, xref=1, ext=[AuthorCompanyExt(id=1321170007917183554, tenantId=1146029695717560320, journalId=1319373219989389464, 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The general and specific skill domains, along with the corresponding number of competency items, assessed in the evaluation of grassroots doctors' capabilities in common disease diagnosis and treatment, health management, and health promotion

, figureFileSmall=null, figureFileBig=null, tableContent=
能力指标分类能力具体技能项目具备分类能力的标准具备能力的标准
常见病诊治常见病诊断识别呼吸道感染腹泻、高血压、糖尿病、脑卒中、慢阻肺同时具备≥4个
技能项目		同时具备3个
分类能力
常用辅助检查检验
结果解读		三大常规、B 超、X 线检查、生化检查报告、心电图检查报告同时具备≥4个
技能项目
常用药应用能力抗生素、常用感冒药、慢性病药物、急救药物同时具备≥3个
技能项目
健康管理儿童健康管理儿童营养指导、儿童体格检查同时具备2个
技能项目		同时具备≥ 3个
分类能力
妇女健康管理计生指导、孕期健康指导、围绝经期健康、妇科两癌筛查同时具备≥2个
技能项目
老年人健康管理体检指导与常见病筛查、健康与自理能力评估、不良情绪识别
与干预、功能减退预防		同时具备≥2个
技能项目
慢性病患者健康管理掌握常见慢性病临床诊断依据、主要危险因素与干预方法、
危急状况识别与处理方法、稳定期治疗与并发症预防		同时具备≥2个
技能项目
健康促进健康知识传播及时准确解答居民询问的健康问题、采用易于居民理解的
方式进行健康知识宣传		同时具备2个
技能项目		同时具备4 个
分类能力
健康生活方式指导根据居民健康状况及健康需求提供四大类健康生活方式指导具备1个技能项目
家庭健康状况诊断搜集家庭成员等相关家庭健康资料、指导健康家庭实践活动同时具备2个
技能项目
社区健康问题分析搜集到社区健康档案记录等资料、协助制定合理的社区卫生
服务计划		同时具备2个
技能项目
), ArticleFig(id=1321170010337297002, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=CN, label=表1, caption=

健康管理服务能力具备情况评价内容

, figureFileSmall=null, figureFileBig=null, tableContent=
能力指标分类能力具体技能项目具备分类能力的标准具备能力的标准
常见病诊治常见病诊断识别呼吸道感染腹泻、高血压、糖尿病、脑卒中、慢阻肺同时具备≥4个
技能项目		同时具备3个
分类能力
常用辅助检查检验
结果解读		三大常规、B 超、X 线检查、生化检查报告、心电图检查报告同时具备≥4个
技能项目
常用药应用能力抗生素、常用感冒药、慢性病药物、急救药物同时具备≥3个
技能项目
健康管理儿童健康管理儿童营养指导、儿童体格检查同时具备2个
技能项目		同时具备≥ 3个
分类能力
妇女健康管理计生指导、孕期健康指导、围绝经期健康、妇科两癌筛查同时具备≥2个
技能项目
老年人健康管理体检指导与常见病筛查、健康与自理能力评估、不良情绪识别
与干预、功能减退预防		同时具备≥2个
技能项目
慢性病患者健康管理掌握常见慢性病临床诊断依据、主要危险因素与干预方法、
危急状况识别与处理方法、稳定期治疗与并发症预防		同时具备≥2个
技能项目
健康促进健康知识传播及时准确解答居民询问的健康问题、采用易于居民理解的
方式进行健康知识宣传		同时具备2个
技能项目		同时具备4 个
分类能力
健康生活方式指导根据居民健康状况及健康需求提供四大类健康生活方式指导具备1个技能项目
家庭健康状况诊断搜集家庭成员等相关家庭健康资料、指导健康家庭实践活动同时具备2个
技能项目
社区健康问题分析搜集到社区健康档案记录等资料、协助制定合理的社区卫生
服务计划		同时具备2个
技能项目
), ArticleFig(id=1321170010404405867, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=EN, label=Tab.2, caption=

Numbers and proportions of individuals proficient in delivering family planning counseling, prenatal health guidance, perimenopausal care, and cervical/breast cancer screening services among 6 497 grassroots doctors with and 1 972 without capabilities in common disease diagnosis and treatment, surveyed across Eastern, Central, and Western China in 2020

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妇女健康管理具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
计生指导536582.581 38170.03674679.66
孕期健康指导519279.911 34768.31653977.21
围绝经期健康486074.801 06153.80592169.91
妇科两癌筛查449969.2595748.53545664.42
), ArticleFig(id=1321170010467320428, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=CN, label=表2, caption=

不同常见病诊治能力基层医生妇女健康管理能力比较

, figureFileSmall=null, figureFileBig=null, tableContent=
妇女健康管理具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
计生指导536582.581 38170.03674679.66
孕期健康指导519279.911 34768.31653977.21
围绝经期健康486074.801 06153.80592169.91
妇科两癌筛查449969.2595748.53545664.42
), ArticleFig(id=1321170010542817901, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=EN, label=Tab.3, caption=

Numbers and proportions of individuals proficient in conducting common disease screening, health assessment, identification and intervention of abnormal emotions, and prevention of functional decline among 6 497 grassroots doctors with and 1 972 without capabilities in common disease diagnosis and treatment, surveyed across Eastern, Central, and Western China in 2020

, figureFileSmall=null, figureFileBig=null, tableContent=
老年人健康管理具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
常见病筛查637598.121 66084.18803594.88
健康评估632097.281 61882.05793893.73
情绪识别与干预619695.371 51977.03771591.10
功能减退预防618495.181 44973.48763390.13
), ArticleFig(id=1321170011813692014, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=CN, label=表3, caption=

不同常见病诊治能力基层医生老年人健康管理能力具备情况

, figureFileSmall=null, figureFileBig=null, tableContent=
老年人健康管理具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
常见病筛查637598.121 66084.18803594.88
健康评估632097.281 61882.05793893.73
情绪识别与干预619695.371 51977.03771591.10
功能减退预防618495.181 44973.48763390.13
), ArticleFig(id=1321170011910161007, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=EN, label=Tab.4, caption=

Numbers and proportions of individuals proficient in conducting clinical diagnosis of chronic diseases, intervention of risk factors, management of critical conditions, and treatment and prevention of complications among 6 497 grassroots doctors with and 1 972 without capabilities in common disease diagnosis and treatment, surveyed across Eastern, Central, and Western China in 2022

, figureFileSmall=null, figureFileBig=null, tableContent=
慢性病健康管理具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
慢性病临床诊断641198.681 58080.12799194.36
危险因素的干预636597.971 52277.18788793.13
危急状况处理630597.041 42372.16772891.25
治疗与并发症预防632097.281 45173.58777191.76
), ArticleFig(id=1321170012002435696, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=CN, label=表4, caption=

不同常见病诊治能力基层医生慢性病健康管理能力具备情况

, figureFileSmall=null, figureFileBig=null, tableContent=
慢性病健康管理具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
慢性病临床诊断641198.681 58080.12799194.36
危险因素的干预636597.971 52277.18788793.13
危急状况处理630597.041 42372.16772891.25
治疗与并发症预防632097.281 45173.58777191.76
), ArticleFig(id=1321170012094710386, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170005811642942, language=EN, label=Tab.5, caption=

Numbers and proportions of individuals proficient in conducting health knowledge dissemination, healthy lifestyle guidance, family health assessment, and community health issues analysis among 6 497 grassroots doctors with and 1 972 without capabilities in common disease diagnosis and treatment, surveyed across Eastern, Central, and Western China in 2022

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健康促进具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
健康知识传播633997.571 63182.71797094.11
健康生活方式指导643799.081 80891.68824597.36
家庭健康状况诊断618095.121 59680.93777691.82
社区健康问题分析512078.811 11456.49623473.61
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不同常见病诊治能力基层医生健康促进能力具备情况

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健康促进具备常见病诊治能力（N=6 497）不具备常见病诊治能力（N=1 972）合计（N=8 469）
人数占比/%人数占比/%人数占比/%
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社区健康问题分析512078.811 11456.49623473.61
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医防融合视角下我国基层医生健康管理服务能力现状分析
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李亚慧 1 , 谢坤 1 , 练璐 2 , 王萱萱 3 , 陈家应 1, *, *
中国公共卫生 | 调查报告与分析 2025,41(5): 574-579
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中国公共卫生 |调查报告与分析 2025 , 41 (5) : 574 -579
医防融合视角下我国基层医生健康管理服务能力现状分析
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李亚慧（1995—），助教，硕士，研究方向：卫生政策

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李亚慧1, 谢坤1, 练璐2, 王萱萱3, 陈家应1, *, *
作者信息
  • 1南京医科大学康达学院，连云港 222000
  • 2南京医科大学第一附属医院，南京 210029
  • 3南京医科大学医政学院，南京 211166
通讯作者:
陈家应，E-mail：
作者简介:

李亚慧（1995—），助教，硕士，研究方向：卫生政策

Ability of health management services among grassroots doctors under the integration of disease treatment and prevention in China, 2020: an online self-administered survey
Yahui LI1, Kun XIE1, Lu LIAN2, Xuanxuan WANG3, Jiaying CHEN1
Affiliations
  • 1Kangda College, Nanjing Medical University, Lianyungang 222000, China
  • 2First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
  • 3School of Health Policy and Management, Nanjing Medical University, Nanjing 211166, China
    • Corresponding Author:
    CHEN Jiaying, E-mail:
出版时间: 2025-05-10 doi: 10.11847/zgggws1144932
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摘要
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目的

从医防融合视角，探讨基层医生常见病诊治能力水平与健康管理服务能力具备情况的关联，为提高基层医生的健康管理服务能力提供参考。

方法

于2020年8月，采用多阶段分层抽样与典型抽样相结合的方法，对中国东、中、西部基层医疗卫生机构的8 469名医生进行线上问卷调查，利用课题组既往开发的基层医生卫生服务能力指标体系，选取其中健康管理服务能力部分的指标为依据设计调查问卷，从常见病诊治、健康管理、健康促进3个方面评价基层医生健康管理服务能力的具备情况。

结果

8 469名基层医生中，取得执业（助理）医师资格5 288人（62.44%），乡村医生2 201人（25.99%）。基层医生具备常见病诊治能力人数6 497人（76.72%）；在儿童健康管理能力方面，基层医生具备儿童营养指导、体格检查能力人数分别为7 099（83.82%）和7 068（83.46%）人；在妇女健康管理能力方面，基层医生具备计生指导、孕期健康指导、围绝经期健康、妇科两癌筛查的人数分别为6 746（79.66%）、6 539（77.21%）、5 921（69.91%）、5 456（64.42%）人；在老年人、慢性病健康管理方面，基层医生具备老年人和慢性病健康管理的比例均>90%；在健康促进方面，基层医生具备社区健康问题分析能力的人数最低，有6 234人（73.61%）。

结论

高素质人才短缺和常见病诊治能力影响基层医生开展健康管理服务，且我国基层医生掌握健康管理服务能力存在“短板”，因此需要加强医院与基层之间服务协同机制建设。

健康管理服务  /  医防融合  /  基层医生
Objective

To explore the association between the ability to diagnose and treat common diseases and the capacity to provide health management services among grassroots doctors, from the perspective of integrating disease treatment and prevention, and to provide a reference for improving grassroots doctors′ health management service capacity.

Methods

An online self-administered questionnaire survey was conducted in August 2020 among 8 469 specialists, general practitioners, and rural doctors. Participants were recruited using stratified multi-stage sampling and typical sampling from primary healthcare institutions located in 11 municipalities across eastern, central, and western China. Utilizing a previously self-developed index system for evaluating the health service capabilities of grassroots doctors, the survey questionnaire was designed based on indicators related to health management service capabilities. The questionnaire assessed the health management service capabilities of primary care physicians in three areas: diagnosis and treatment of common diseases, health management, and health promotion.

Results

Of all the participants, 5 288 (62.44%) were practicing (assistant) doctors, 2 201 (25.99%) were rural doctors, and 6 497 (76.72%) were assessed as capable of diagnosing and treating common diseases. Among all the grassroots doctors surveyed, 7 099 (83.82%) had the ability to provide nutritional guidance for children, and 7 068 (83.46%) could conduct physical examinations for children as part of children's health management. Regarding women's health management, 6 746 (79.66%) could provide family planning guidance, 6 539 (77.21%) offered prenatal health guidance, 5 921 (69.91%) provided perimenopausal health care, and 5 456 (64.42%) conducted cervical/breast cancer screening. More than 90% of the participants were assessed as able to conduct health management for the elderly and individuals with chronic conditions. However, only 6 234 (73.61%) had the ability to analyze community health issues.

Conclusions

The ability to diagnose and treat common illnesses significantly affects the capacity of grassroots doctors to deliver health management services. Moreover, there is a noticeable gap in the health management service capabilities among grassroots doctors in China. Therefore, it is crucial to strengthen collaborative service mechanisms between hospitals and primary care institutions.

health management service  /  integration of disease treatment and prevention  /  grassroots doctors
李亚慧, 谢坤, 练璐, 王萱萱, 陈家应. 医防融合视角下我国基层医生健康管理服务能力现状分析. 中国公共卫生, 2025 , 41 (5) : 574 -579 . DOI: 10.11847/zgggws1144932
Yahui LI, Kun XIE, Lu LIAN, Xuanxuan WANG, Jiaying CHEN. Ability of health management services among grassroots doctors under the integration of disease treatment and prevention in China, 2020: an online self-administered survey[J]. Chinese Journal of Public Health, 2025 , 41 (5) : 574 -579 . DOI: 10.11847/zgggws1144932
正文
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随着我国经济社会的不断发展、居民行为和生活方式的不断变化及人口老龄化进程的逐步加快，我国居民慢性病发病率不断攀升[1]。政府及社会各界对于健康的关注已经提升到新的高度，2016年10月《健康中国2030规划纲要》提出要对人的全面健康进行细化管理，实现全生命周期、全过程健康服务覆盖，保障全民获得系统连续的预防、治疗、康复、健康促进等全方位健康服务，对慢性病患者、老年人等重点人群开展健康管理服务[2]。社区基层是全民健康服务的主要承担者，基层医生作为居民“健康守门人”[3]，是健康管理服务的主要提供者，而实现系统、有效健康管理服务的基础和核心内涵就是医防融合，强调基层医生在为居民提供健康管理服务时要加强疾病预防和健康促进，使疾病预防、治疗、康复有效融合，使全体居民获得最好的健康服务，实现普及健康生活的健康中国目标。本研究于2020年8月，采用多阶段分层抽样和典型抽样相结合的抽样方法，对中国东部地区（江苏省）、中部地区（安徽省、河南省）、西部地区（重庆市、甘肃省）的8 469名基层医生进行问卷调查，从医防融合视角，探讨基层医生常见病诊治与健康管理服务能力具备情况及其关联，发现基层医生卫生服务能力的薄弱环节，为不断提升其健康管理服务能力、实现“以健康为中心”的服务模式提供参考依据。
1　对象与方法
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1.1　对象
于2020年8月，采用多阶段分层抽样与典型抽样相结合的方法，对中国东、中、西部基层医疗卫生机构的医生进行线上问卷调查。根据中国经济发展水平由东到西逐步降低的特点，从东、中、西部分别选取2个样本省（市），并选择样本省（市）中的2个样本市（在各样本市分别选取1个城市样本和1个农村样本市），以市为单位进行整群抽样调查，将样本市所有基层医疗卫生机构的基层医生作为研究对象。基层医疗卫生机构包括社区卫生服务中心、社区卫生服务站、乡镇卫生院和村卫生室。根据抽样设计及实际实施情况，最终选取江苏省、浙江省、安徽省、河南省、甘肃省、重庆市作为调查省（市），因浙江省2020年遭遇自然灾害，无法进行调查，故在江苏省增加2个与浙江样本点情况近似市进行调查，以作为补充，最终选取11个样本市，包括江苏省的常州市、苏州市、徐州市和盐城市，安徽省的阜阳市和合肥市，河南省的开封市和许昌市，甘肃省的白银市和定西市，以及重庆市。纳入标准：样本市所有基层医疗卫生机构的医生，包括专科医生、全科医生、乡村医生等临床一线人员。排除标准：不直接提供医疗服务的公卫执业医师、护士、药剂师、行政人员等。本研究已通过南京医科大学伦理委员会批准〔伦理审批号：南医大伦审（2020）589号〕，所有研究对象已签署知情同意书。本次共调查8 537名基层医生，剔除选择“不同意”填写问卷的68人后，共回收有效问卷8 469份，有效回收率为99.2%。
1.2　方法
1.2.1　问卷调查
调查工具为本课题组开发的“家庭医生能力指标体系–家庭医生个人能力自评表”，内容包括基层医生的年龄、学历、执业资格、工作机构等基本信息和卫生服务能力自评指标[4]，其中健康管理服务需要具备的能力包括健康促进能力、重点人群健康管理能力，同时从医防融合考虑，在分析中还包括了常见病诊治能力。
1.2.2　调查方法
本次调查利用问卷星平台进行基层医生卫生服务能力自评在线调查。对基层医生的健康管理服务能力具备情况进行评价。其中基层医生的不同服务能力被称为分类能力，每一服务能力又由不同的技能项目组成，即能力评价的具体要素。经专家咨询和课题组讨论，制定了基层医生健康管理能力的判断依据和标准（表1）。本次调查由课题组教师和卫生事业管理专业研究生共同组成调查员队伍，并对调查员就现场调查相关内容进行统一培训。在样本区（县、市）卫生行政部门的协调下，将调查问卷定点推送到每位基层医生，由基层医生自行填写问卷，调查员对收到的问卷及时检查数据的一致性、完整性、正确性及答案逻辑性，一旦发现问题及时核实、纠正，以保证数据来源的准确性，调查结束后进行问卷抽查复核，确保问卷质量。
1.3　统计分析
采用 SPSS 19.0 统计软件进行数据分析，计数资料以相对数表示，运用χ2检验，比较不同常见病诊疗能力水平下基层医生具备健康管理能力差异情况，检验水准取双侧α=0.05。
2　结　果
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2.1　调查对象基本情况
调查的8 469名基层医生中，东部地区2 953人（34.87%），中部地区3 200人（37.78%），西部地区2 316人（27.35%）；男性4 747人（56.05%），女性3 722人（43.95%）；年龄为19～81岁，平均年龄（42.12±11.38）岁；学历分布上，以高中/中专以下学历为主，为3 262人（38.52%），其次为本科以上2 876人（33.85%），大专2 340人（27.63%）；在执业资格方面，取得执业（助理）医师资格人数最多，为5 288人（62.44%），其次为乡村医生执业资格2 201人（25.99%），其他（其他和无资格人员）为534人（6.31），全科医师执业资格为446人（5.27%）。
2.2　重点人群健康管理能力
2.2.1　儿童健康管理
8 469名基层医生中具备儿童营养指导、体格检查能力的人数分别为7 099人（83.82%）和7 068人（83.46%），其中具备常见病诊治能力的6 497名基层医生掌握儿童营养指导和体格检查的人数分别为5 688人（87.55%）和5 668人（87.24%），不具备常见病诊治能力的1 972名基层医生掌握儿童营养指导和体格检查的人数分别为1 411（71.55%）和1 400人（70.99%），掌握常见病诊治能力的基层医生具备儿童营养指导和体格检查能力的比例高于未掌握常见病诊治能力的基层医生，差异有统计学意义（χ2=285.48、289.22，均P<0.001）。
2.2.2　妇女健康管理（表2）
基层医生掌握妇女健康管理的能力较低，具备比例均<80.0%。是否具备常见病诊治能力的基层医生在计生指导（χ2=146.94，P<0.001）、孕期健康指导（χ2=115.84，P<0.001）、围绝经期健康（χ2=317.19，P<0.001）和妇科两癌筛查（χ2=283.32，P<0.001）能力具备的比例差异均有统计学意义。其中基层医生具备妇女两癌筛查和围绝经期健康管理能力的比例最低，占比分别为64.42%和69.91%，且掌握常见病诊治能力的基层医生在具备这两种能力的比例要远高于未掌握常见病诊治能力的基层医生。
2.2.3　老年人健康管理（表3）
基层医生掌握老年人健康管理的能力较强，具备比例均>90%。是否具备常见病诊治能力的基层医生在常见病筛查（χ2=604.97，P<0.001）、健康评估（χ2=596.86，P<0.001）、情绪识别与干预（χ2=627.31，P<0.001）和功能减退预防（χ2=800.93，P<0.001）能力具备的比例差异均有统计学意义。其中基层医生具备功能减退预防能力的比例相对较低，且掌握常见病诊治能力的基层医生在具备老年人健康管理能力的比例要远高于未掌握常见病诊治能力的基层医生。
2.2.4　慢性病健康管理（表4）
基层医生掌握慢性病健康管理的能力较强，具备比例均>91%。是否具备常见病诊治能力的基层医生在慢性病临床诊断（χ2=977.93，P<0.001）、危险因素的干预（χ2=1 021.49，P<0.001）、危急状况处理（χ2=1 173.35，P<0.001）和治疗与并发症预防（χ2=1 123.19，P<0.001）能力具备的比例差异均有统计学意义。其中基层医生具备危急状况识别与处理方法能力的比例相对较低，且掌握常见病诊治能力的基层医生在具备慢性病健康管理能力的比例要远高于未掌握常见病诊治能力的基层医生。
2.3　健康促进（表5）
是否具备常见病诊治能力的基层医生在健康知识传播（χ2=602.48，P<0.001）、健康生活方式指导（χ2=321.10，P<0.001）、家庭健康状况诊断（χ2=405.31，P<0.001）、社区健康问题分析（χ2=387.79，P<0.001）能力具备的比例差异均有统计学意义。基层医生掌握社区健康问题分析能力的比例较低，占比为73.61%，且掌握常见病诊治能力的基层医生具备此能力的比例要远高于未掌握常见病诊治能力的基层医生。
3　讨　论
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本调查结果显示，我国健康管理服务的基层医生整体学历不高，本科学历占比仅为33.85%，与英国[5]、美国[6]要求基层医生必须完成5年的医学本科教育相比，我国基层医生学历水平远低于国外培养要求。与国内其他研究相比，本研究结果低于重庆市基层医生的本科学历占比的50.5%[7]，但高于另一项调查的中国7个省/直辖市农村医生本科学历占比的5.38%[8]。提示我国基层医生本科学历水平相对较低。不同研究间基层医生本科学历水平存在差异可能与所调查地区经济发展水平及调查时间和调查对象年龄结构不同有关。
从医防融合视角来看，基层医生作为健康管理服务提供的主体和核心力量，需要具备较高的临床技能、预防保健等综合能力水平，因而基层医生的数量和质量是开展健康管理服务的基石。相较于国外发达国家基层医生的准入及管理制度已趋向完善，基层医生队伍培养实行“严进严出”管理模式，严格的准入制度使得国外基层医生素质和能力较强。我国在基层医生准入及管理方面相比国外发达国家仍有较大差距，基层医学人才培养滞后于经济社会发展需要，缺乏系统、规范和标准化的教育体系[9]。
本调查结果显示，我国基层医生具备儿童健康管理能力的比例>80.0%。有调查发现城市社区卫生服务中心基层医生儿童健康服务能力知识水平测试平均正确率为52.40%[10]。调查结果与本次研究中儿童健康管理能力具备率存在较大差异，原因可能在于本研究是基层医生实际工作中需要开展的儿童健康管理服务，基本能满足日常工作需求，而理论知识水平测试对于基层医生而言掌握范围更广泛，掌握水平存在一定的不足。在妇女健康管理方面，基层医生具备围绝经期健康、妇科两癌筛查的能力比例<70.0%。有调查发现江苏省基层全科医生日常能够开展三类人群（妇女、儿童、老年人）随访的比例为86.5%[11]，调查结果与本次研究中妇女健康管理能力具备率存在差异，分析原因可能是江苏省作为经济发达地区，在能吸引高水平基层医生的同时，也注重其日常技能的培训，使其能完成日常健康管理工作，但本次调研的结果更能反映基层医生在妇女健康管理能力存在的薄弱问题。在老年人和慢性病健康管理方面，基层医生具备老年人和慢性病健康管理能力比例>90%。有调查发现重庆主城基层医疗机构对老年人健康档案、体格检查与辅助检查等健康管理利用率>90%[12]，与本研究结果类似，但略高于河南省乡村医师慢性病健康管理得分率的81.25%[13]，原因可能是慢性病和老年人健康管理作为国家基本公共卫生服务项目的重要组成部分，是基层医生必须具备的服务能力，因此对老年人和慢性病健康管理的具备比例较高。在健康促进方面，基层医生掌握社区健康问题分析能力的比例较低，占比为73.61%。有调查结果显示我国东部地区全科医师在社会健康问题分析的自评得分率为72%[14]，与本研究结果相似。原因可能是目前基层医生在传染病学、流行病学等专业能力存在“短板”，使其无法对社区居民的群体健康风险进行分析和评估，从而不能协助制定合理的社区卫生服务计划，因此在掌握社区健康问题分析能力的具备比例较低。
本研究结果显示，掌握常见病诊治能力的基层医生在具备各项健康管理能力的比例都要高于没有掌握常见病诊治能力的基层医生，且差异有统计学意义，可见基层医生常见病诊治能力水平会直接影响其为居民提供健康管理服务的效果。有相关研究显示，重庆地区老年人对基层医疗机构提供的健康管理服务项目评价的满意度偏低的主要原因之一在于基层医生的诊疗技术水平[12]，同时对山东省城乡居民健康管理服务需求开展的调查发现，居民对常见病诊疗和用药指导的医疗服务需求最高[15]。由此可见，基层医生需要提高自身常见病诊治能力方能满足居民的健康管理服务需求，其原因可能在于医防融合的核心内涵是医疗与公共卫生服务有效协同，根据个体具体健康状况，有针对性地提供医疗和公共卫生服务[16]，二者之间相辅相成。
综上所述，高素质人才短缺影响基层医生开展健康管理服务，且我国基层医生在掌握健康管理服务能力存在“短板”，同时常见病诊治能力会影响基层医生开展健康管理服务的效果，因此建议依托医院和基层医疗卫生机构的协同机制，组成基层医师、三级医院专科医生等人员共同参与的家庭医生团队开展服务工作，使家庭医生团队具备医疗、预防、康复等各项服务能力，从而强化基层医防融合，最终为居民提供全方位的健康管理服务。本研究基于医防融合视角为提高中国基层医生健康管理服务能力提供了依据，所采用的评价工具经过验证，适合中国国情。但本文也存在不足之处：目前对基层医生能力进行问卷评价的视角较为单一，仅从基层医生视角进行了自评，下一步还需要从患方进一步评价基层医生的健康管理服务能力水平，为健康管理服务能力提升提供多角度的依据。

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doi: 10.11847/zgggws1144932
  • 接收时间：2024-05-14
  • 首发时间：2026-10-25
  • 出版时间：2025-05-10
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  • 收稿日期：2024-05-14
  • 修回日期：2024-12-13
  • 录用日期：2025-04-02
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    1南京医科大学康达学院，连云港 222000
    2南京医科大学第一附属医院，南京 210029
    3南京医科大学医政学院，南京 211166

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2种不同金属材料的力学参数
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Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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