Improving the hepatitis cascade: assessing hepatitis testing and its management in primary health care in China

Improving the hepatitis cascade: assessing hepatitis testing and its management in primary health... Abstract Objective The study aimed to decentralize hepatitis testing and management services to primary care in China. Methods A nationwide representative provider survey amongst community health centres (CHCs) using randomized stratified sampling methods was conducted between September and December 2015. One hundred and eighty CHCs and frontline primary care practitioners from 20 cities across three administrative regions of Western, Central and Eastern China were invited to participate. Results One hundred and forty-nine clinicians-in-charge (79%), 1734 doctors and 1846 nurses participated (86%). Majority of CHCs (80%, 95% CI: 74–87) offered hepatitis B testing, but just over half (55%, 95% CI: 46–65) offered hepatitis C testing. The majority of doctors (87%) and nurses (85%) felt that there were benefits for providing hepatitis testing at CHCs. The major barriers for not offering hepatitis testing were lack of training (54%) and financial support (23%). Multivariate analysis showed that the major determinants for CHCs to offer hepatitis B and C testing were the number of nurses (AOR 1.1) and written policies for hepatitis B diagnosis (AOR 12.7–27.1), and for hepatitis B the availability of reproductive health service. Conclusions Primary care providers in China could play a pivotal role in screening, diagnosing and treating millions of people with chronic hepatitis B and C in China. China, clinical management, hepatitis, primary health care, testing Introduction Hepatitis B and C are responsible for nearly half a million deaths in the Western Pacific Region (the ‘Region’)—a toll outnumbering deaths from HIV, tuberculosis and malaria combined (1). Effective antiviral treatment of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) can halt or even reverse progression to liver cirrhosis and cancer and reduce hepatitis-related mortality (2–5). Because of this high disease burden, countries have endorsed a regional action plan on viral hepatitis which established 2020 targets that 30% of people living with HBV and HCV would be diagnosed, and 50% of eligible people begin treatment and have sustained viral suppression (1). WHO globally now calls for elimination of hepatitis as a public health threat by 2030 (6). Yet, only a fraction of people living with hepatitis are being diagnosed and receiving treatment in this region (7,8). Health services in low- and middle-income countries have limited capacity to provide specialized care such as for hepatitis and other gastroenterological disease conditions (9,10). However, primary care providers can play a pivotal role in diagnosis and engagement in care for these diseases traditionally managed in specialty services (11). The American Association for the Study of Liver Diseases (AASLD) and the United States Centers for Disease Control and Prevention (US CDC) emphasized the importance of a multidisciplinary approach to HCV care calling for engaging primary care providers to improve both prevention and treatment effectiveness (12). China’s burden of chronic HBV and HCV is among the highest in the world, accounting for 25% of the global burden of hepatitis B and 7% of those with hepatitis C (7,13). There are an estimated 74 million people living with chronic hepatitis B and up to 10 million people living with chronic hepatitis C in China (7,13). Half (51%) of the global burden of new liver cancers and deaths due to liver cancer occur in China. Approximately 7 million people chronically infected with hepatitis B are estimated to urgently need treatment because of advanced liver disease and are at high risk of developing liver cancer. Among people chronically infected with hepatitis C, 2.5 million people are the priority for treatment but most are not even aware of their infection (14). Since 2009, the Chinese government has committed themselves to re-establishing primary healthcare, and by 2014, there has been a network of 8669 community health centres (CHCs) employing over 300000 health professionals. CHCs are providing basic public health services, diagnosis and treatment, nursing, rehabilitation for common disease and frequently occurring diseases (15). Transforming hepatitis tertiary care services offered by gastroenterology, infectious disease and few hepatology specialists to primary care workers could devolve the high volume of people seeking care at tertiary level whilst improving the continuity of care (16–18). Some CHCs are already testing for hepatitis B and C and could be capacitated to meet the high demand for hepatitis care and treatment, and chronic disease management. Currently, we do not know the extent to which hepatitis testing and management are taking place in primary care in China. The objectives of this survey were to determine availability of hepatitis testing and care services in CHCs, to assess the barriers and facilitating factors for offering hepatitis screening and to identify needs of primary care practitioners (PCPs) in China. Materials and Methods A nationwide representative provider survey amongst CHCs using stratified random sampling methods was conducted between September and December 2015. CHCs (180) from 20 cities across three administrative regions of Western, Central and Eastern China were randomly selected. Further details of the sampling methods are published elsewhere (19). The provider survey instrument was developed by study investigators and consisted of two questionnaires, one for the clinician-in-charge who would provide organizational and service details of CHCs as well as patient characteristics, and another for all PCPs (nurses and doctors) responsible for direct patient contacts in the selected CHCs. Questions were asked about availability of hepatitis testing and experiences of testing and managing patients with HBV and HCV, and identifying barriers and facilitators for initiating screening and management of HBV and HCV. The surveys were pilot-tested twice in three CHCs and amongst 25 PCPs. Ethics Committee approvals from a local board (HKU/HAW IRB: UW15-350) and the World Health Organization Regional Office for the Western Pacific (2016.4.CHN.1.HSI) were obtained. Descriptive analyses were conducted to provide percentages and frequencies of key parameters. Confidence intervals for the sample proportions were calculated using the Agresti–Coull (adjusted Wald) method. The statistical modelling focused on determining factors associated with CHCs offering hepatitis screening. Univariate logistic regression was performed to assess explanatory factors such as CHC composition of staff, available medical services and availability of onsite testing. Purposeful selection was used to select explanatory variables (P < 0.25) used in an overall multivariate logistic regression model. The Hosmer–Lemeshow test, a statistical test for goodness-of-fit for logistic regression model, was performed. To evaluate the sensitivity of the model to individual effects, we performed logistic regression diagnostics and did not find any individuals influencing the final model. Data were analysed using STATA (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP). Results One hundred and forty-nine clinicians-in-charge (response rate of 79% for CHCs), 1734 doctors and 1846 nurses participated in the survey (response rate 86% for PCPs). Table 1 summarizes the demographics of the doctors and nurses working in CHCs. Table 2 summarizes the key characteristics of the CHCs. Of note, the majority of CHCs (80%, 95% CI: 74–87) offered hepatitis B testing onsite, but just over half of those surveyed (55%, 95% CI: 46–65) offered hepatitis C testing onsite. Table 1. Demographics of CHC doctors and nurses Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) CHC, community health centres. View Large Table 1. Demographics of CHC doctors and nurses Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) CHC, community health centres. View Large Table 2. CHC characteristics (n = 149) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) CHC, community health centres. View Large Table 2. CHC characteristics (n = 149) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) CHC, community health centres. View Large Table 3 describes the experience of CHC doctors and nurses in dealing with patients with HBV and HCV. Amongst the doctors surveyed, 19% had diagnosed HBV but only 5% had diagnosed HCV within the last 1 month. Similarly amongst the nurses, 15% were involved in diagnosis of HBV but only 5% with HCV testing within the preceding month. In terms of management, the figures were even lower: 15% of doctors have managed patients with HBV and 4% have managed patients with HCV within the preceding month. More than half (56%, 95% CI: 51–61) of doctors who had diagnosed HBV cases did not continue further management in the last 1 month. Similarly, about half (45%, 95% CI: 35–54) of doctors who had diagnosed HCV cases did not manage it in the last 1 month. Table 3. Experience with hepatitis patients in the CHC Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) 95% CI, 95% confidence interval; IQR, interquartile range; STIs, sexually transmitted infections, CHC, community health centres. aIn those not providing hepatitis testing. View Large Table 3. Experience with hepatitis patients in the CHC Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) 95% CI, 95% confidence interval; IQR, interquartile range; STIs, sexually transmitted infections, CHC, community health centres. aIn those not providing hepatitis testing. View Large The majority of doctors (87%) and nurses (85%) felt that there was a benefit for providing hepatitis testing at CHC. For those not offering hepatitis testing, the major barriers were the lack of appropriate training (54%) and lack of financial support (23%). Equally, the nurses also cited the lack of training (66%) as the biggest barrier but lack of financial incentives (17%) was also of concern. Both doctors and nurses called for more training (50–53%) and provision of guidelines (24–26%). However, 58% of doctors perceived that offering hepatitis testing to people that self-identify or are being identified as drug users or men-having-sex with men (MSM) would be too difficult to manage and 34% of doctors were worried that such patients might drive other patients away. Fifty-six percent of nurses felt that these patients could be too difficult to manage, 42% were worried about getting infected by them and 41% worried that they might drive other patients away. Multivariate analysis showed that the major determinants for CHC to offer hepatitis B testing were the number of nurses (AOR 1.1), having a written policy for hepatitis B diagnosis (AOR 12.7) and a CHC that also offered reproductive and sexually transmitted infection (STI) services (AOR 3.6) (Table 4). Similarly, CHCs offering hepatitis C testing were more likely to have more nurses (AOR 1.1) and had a written policy for hepatitis C diagnosis (AOR 27.1) (Table 5). Table 4. Multivariate analysis of variables associated with CHCs offering hepatitis B testing Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 CHC, community health centres; STIs, sexually transmitted infections. View Large Table 4. Multivariate analysis of variables associated with CHCs offering hepatitis B testing Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 CHC, community health centres; STIs, sexually transmitted infections. View Large Table 5. Multivariate analysis of variables associated with CHCs offering hepatitis C testing Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 CHC, community health centres. View Large Table 5. Multivariate analysis of variables associated with CHCs offering hepatitis C testing Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 CHC, community health centres. View Large Discussion This is the first ever national representative survey studying hepatitis services in primary health care and the needs of PCPs in China. Our surveys showed that hepatitis B testing and management are already offered in a significant proportion of CHCs in China but much less so for hepatitis C. Nonetheless, having the right staffing, policies, guidelines and training seem to be the prerequisite for introducing HBV and HCV testing at primary care level. On the ground, the health care providers recognized benefits of offering hepatitis testing but expressed the need for specific training, guidelines and support. A lack of studies from Asia A recent systematic review on hepatitis interventions showed that only one of the 56 studies included was from an Asian country but there were 10 studies, all from high-income countries addressing hepatitis testing in primary care settings (17). Most of these studies were focused on HCV testing and care as it is the most prevalent infection in Western Europe, Canada and the USA. These studies show that engaging primary care providers through issuing hepatitis testing policies, making system adjustments, training of PCPs and education of patients increased uptake and yield of HBV and HCV and improved linkage to care (9,18,20–27). Hepatitis testing has been integrated into primary care clinics in the Netherlands which provides a range of other related services such as HBV immunization, HIV testing, viral hepatitis and HIV prevention education and medical care (28). Hepatitis testing combined with liver cancer screening in primary care clinics in rural Mongolia has started in 2011. To date, this project has provided testing for 2489 individuals in six provinces of Mongolia, with a seropositive rate of 14% for HBV and 25% for HCV (29). The China Centre for Disease Control (CDC) has conducted an evaluation on HCV antibody testing and availability of HCV RNA testing in CHCs in China and found that 70% of CHCs in fact have capacity to conduct HCV antibody testing but only 49% of those offering antibody testing were able to conduct HCV RNA testing (30). Patients having to pay for hepatitis testing and lack of HCV RNA testing may be major limiting factors for linking patients to care and treatment in CHCs. Hepatitis C and primary health care HCV is concentrated among former injecting drug users in Western Europe, Canada and the USA, and they are most likely to present in general practice or primary care settings (18,20–24,27,31). The proportion of people living with HCV knowing their status is low in all these countries. Therefore, a number of studies are designed to improve uptake and yield of hepatitis testing in primary care settings. For example, the US CDC’s Hepatitis Testing and Linkage to Care initiative promoted HBV and HCV screening, post-test counselling and linkage to care at 34 US sites. The project showed that offering combination of routine opt-out HCV testing and linkage to care at five primary care centres combined with new written policies in Philadelphia could significantly improve uptake of HCV testing, increase yield and linkage to care (32). A dual-routine HCV/HIV testing model at four CHCs in Philadelphia offering opt-out testing among people living with HIV in a primary care setting showed similar results (33). Our study suggests that having clear written policies were perceived as an important factor for conducting hepatitis testing. Another example is the project, The Extension for Community Healthcare Outcomes (ECHO) model which trained PCPs to test and manage underserved populations with complex health problems such as HCV infection. The results of this study showed that the ECHO model was an effective way to diagnose and manage HCV infection (34). Our study also identified the need for training to test and manage patients infected with hepatitis. A survey conducted among PCPs in San Francisco showed that patient education improved hepatitis C treatment outcomes and virologic response rates and attitude of primary care providers (18). Policies increase uptake of hepatitis testing in primary care Studies have suggested that targeted active case finding in general practice in older age groups with a history of injecting drug use was most cost-effective for HCV screening (18,20–24,27,35,36). Similarly hepatitis B screening targeting Asian immigrants was considered a cost-effective approach in USA and Canada (25,37). HBV screening in European countries among pregnant women and migrants was also considered cost-effective (38). HCV in most Asian countries is found in general population due to past nosocomial transmission and is very high among former and present drug injectors, as well as for plasma donors and people who have received unscreened blood or blood products in the past (31,39,40). Our study suggests that many CHCs do not have any written policies for hepatitis screening. In practice, HBV testing is widespread in most tertiary and secondary health services as hospital standards are well established. Testing guidelines for HCV by China CDC and in healthcare settings have been available since 2008 and 2014, respectively. Traditionally, testing for hepatitis is limited to hospitals and confirmatory testing is conducted in the China CDC (41,42). There is a need to have appropriate training for PCPs to provide testing including nucleic acid testing, hepatitis care and treatment. At the same time, further studies of service delivery models and approaches for combined screening, diagnosis and treatment including epidemiological and cost-effectiveness would help determine the optimal screening strategies for both HBV and HCV in China. Differential of labour has been proposed to pilot-test projects when hospitals would screen for HBV/HCV; the China CDC centres conduct confirmatory testing and initiate treatment and then refer to CHCs for continuation of treatment and adherence counselling. The questions remain whether CHCs are a good place to reach key populations given the prevailing stigma and discrimination. Shifting roles of primary health care in China Within the last decade, China has implemented strategies to strengthen its primary health care system in order to prepare for, or improve on universal health coverage. In fewer than 10 years, the Chinese Government has succeeded in establishing a primary medical care service infrastructure composed mainly of rural township centres, village clinics and CHCs in cities. The basic primary care team in China is made up of doctors, including traditional Chinese practitioners, as well as nurses with very few pharmacists, clinical psychologists or social workers which are important in providing comprehensive care to patients with hepatitis B/C. CHCs provide management of common ailments, chronic diseases such as hypertension and diabetes, traditional Chinese medicine, maternal and infant healthcare and vaccinations, and can refer to specialist services. With the large number of people living with chronic hepatitis being undiagnosed and unlinked to care, enhancing the role of CHCs could help us to meet these needs. Expanding the capacity of primary care for testing and management would be opportunities to improve chronic care as well as reduce the overall health costs. Studies have shown that PCPs can provide hepatitis drug treatment even for hepatitis C, if adequately supported and trained (43,44). In the same survey, we found 88% of doctors had a computer in the consultation rooms and 81% had internet access (19). Therefore, telemedicine consultation is a potential option for those living in rural areas to gain specialist support on hepatitis care. Using audio-visual application (now widely and freely available in China) to connect the patient, PCP and the specialist that based in the hospitals, could allow real-time interaction for difficult cases. Success in California has demonstrated its effectiveness in minimizing the gap to specialty care access and strengthen supports to PCPs in managing patients with HCV (45). The implementation of telemedicine can also be utilized in teaching and proved to be more effective than traditional didactic method in increasing PCPs’ clinical knowledge regarding HCV (46). Policy and practice implications Chronic hepatitis B and C are major public health issues in China, with significant social and economic burden. The economic costs of chronic hepatitis infection and its complications increase with disease progression and with age. China is now facing the challenge of slower economic growth, an aging population and a rapid increase in non-communicable diseases including cancer and other chronic diseases. At the same time, health care costs are rising. The health reforms are shifting away from expensive hospital-centric model to one centred on primary care. Our study shows that PCPs have important roles in providing chronic hepatitis management. However, lack of knowledge and supportive policies to implement better services are challenging. Clear policies and guidelines for the roles of PCPs in delivery of hepatitis care would facilitate expansion of hepatitis management capacities throughout the country. In practice, establishing models where PCPs are linked to higher level medical institutions so as to ensure continuity of care could be a pragmatic approach. Further studies to evaluate the impact of screening as well as system changes to allow decentralization of diagnostic and care services to CHC, and studying client perceptions and willingness to utilize hepatitis services are primary level, could revolutionize hepatitis care in China. Strengths and limitations The main limitation of this study is that only self-reported information on hepatitis B and C diagnosis and management among PCPs were collected and did not include questions about history taking, hepatitis treatment and patient interviews especially amongst key populations. It is a limitation of this study that we did not ask for common practice in history taking on sexual and injecting behaviours. Moreover, there is a need to hear the views from key populations for their preferences on how and where they would prefer to access services. Nonetheless, it is the first step on understanding the delivery of hepatitis service in primary care in China. The strengths are that the data were collected from large sample of both doctors and nurses in CHCs throughout China and hence should be generalizable. Conclusions and next steps Primary care providers in China could play a pivotal role in screening, diagnosing and treating the millions of people living with chronic hepatitis. Our study suggests that with minimal investment such as policies, guidelines and training of staff, PCPs would be willing to offer hepatitis testing and management. There are ample opportunities for public health research in China to improve the hepatitis care continuum. Declaration Funding: This project is supported by three funding sources: The construction of key subjects of public health in Shanghai (Shanghai Municipal Health and Family Planning Commission no. 12GWZX1001); Shanghai excellent academic leaders in public health training program (Shanghai Municipal Health and Family Planning Commission no. GWDTR201210); and RGC Seed fund for basic research, University Grant Council, Hong Kong SAR Government, entitled, ‘Survey of the attitudes and needs of integrated HIV and STI services in community health centres in China (2015–16)’ (project number 201411159004). Ethical approval: Ethical Committee approvals from a local board (HKU/HAW IRB: UW15-350) and the World Health Organization Regional Office for the Western Pacific (2016.4.CHN.1.HSI) were obtained. Conflict of interest: None. Acknowledgements We thank the General Practice Society of Chinese Medical Association for offering assistance to organise this study. The biggest thank is given to the experts of General Practice Society of the provinces and municipalities, including Profs. Dongdong Chen (Shanghai), Bo Xie (Chongqing), Xiaosong Yu and Shuang Wang (Liaoning), Lizheng Fang (Zhejiang), Mei Feng (Shanxi), Guangbin Zhao (Sichuan), Haiqin Tang and Jing Rui (Anhui) and Li He (Yunnan), who provided the communication with the CHCs and the investigation implementation. We also thank all the CHCs and doctors/nurses who have engaged in the survey. References 1. WHO . Regional Action Plan for Viral Hepatitis 2016–2020 , Manila : World Health Organization , 2015 . 2. Chang TT , Liaw YF , Wu SS et al. Long-term entecavir therapy results in the reversal of fibrosis/cirrhosis and continued histological improvement in patients with chronic hepatitis B . Hepatology 2010 ; 52 : 886 – 93 . Google Scholar CrossRef Search ADS PubMed 3. Gutierrez JA , Lawitz EJ , Poordad F . Interferon-free, direct-acting antiviral therapy for chronic hepatitis C . 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Litwin AH , Smith BD , Drainoni ML et al. Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk . Dig Liver Dis 2012 ; 44 : 497 – 503 . Google Scholar CrossRef Search ADS PubMed 28. Zuure FR , Urbanus AT , Langendam MW et al. Outcomes of hepatitis C screening programs targeted at risk groups hidden in the general population: a systematic review . BMC Public Health 2014 ; 14 : 66 . Google Scholar CrossRef Search ADS PubMed 29. FIRE . Viral Hepatitis and Liver Cancer Prevention [Online] . Flagstaff, ZA 86002, United States , 2016 . https://www.fireprojects.org/mongolia/hepatitis-prevention/ (accessed on 23 August 2016 ). 30. Wang XC. Hepatitis C Testing in Primary care Services in China . Beijing : China Centre for Disease Control and Prevention , 2016 . 31. Walsh N , Durier N , Khwairakpam G , Sohn AH , Lo YR . The hepatitis C treatment revolution: how to avoid Asia missing out . J Virus Erad 2015 ; 1 : 272 – 5 . 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Thompson Coon J , Castelnuovo E , Pitt M et al. Case finding for hepatitis C in primary care: a cost utility analysis . Fam Pract 2006 ; 23 : 393 – 406 . Google Scholar CrossRef Search ADS PubMed 37. Wong WW , Woo G , Jenny Heathcote E , Krahn M . Cost effectiveness of screening immigrants for hepatitis B . Liver Int 2011 ; 31 : 1179 – 90 . Google Scholar CrossRef Search ADS PubMed 38. Hahné SJ , Veldhuijzen IK , Wiessing L et al. Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening . BMC Infect Dis 2013 ; 13 : 181 . Google Scholar CrossRef Search ADS PubMed 39. Chen F , Sun D , Guo Y et al. Spatiotemporal scan and age-period-cohort analysis of Hepatitis C virus in henan, China: 2005-2012 . PLoS One 2015 ; 10 : e0129746 . Google Scholar CrossRef Search ADS PubMed 40. Best J , Tang W , Zhang Y et al. Sexual behaviors and HIV/syphilis testing among transgender individuals in China: implications for expanding HIV testing services . Sex Transm Dis 2015 ; 42 : 281 – 5 . Google Scholar CrossRef Search ADS PubMed 41. NHFCP . Hepatitis Testing in Health Care Settings in China [Online] . Hainan : National Health and Family Planning Commission , 2014 . http://www.wst.hainan.gov.cn/zwgk/jgsz/zcfgc/tzgg/201408/W020140808426025909880.pdf (accessed on 15 September 2016 ). 42. CDC, C . National Guidelines for Laboratory Testing for Hepatitis C . Beijing : China Center for Disease Control and Prevention , 2011 . 43. Brew IF , Butt C , Wright N . Can antiviral treatment for hepatitis C be safely and effectively delivered in primary care?: a narrative systematic review of the evidence base . Br J Gen Pract 2013 ; 63 : e842 – 51 . Google Scholar CrossRef Search ADS PubMed 44. Wang YH , Guy R , Hellard M . The Victorian hepatitis C education program for GPs–an evaluation . 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Improving the hepatitis cascade: assessing hepatitis testing and its management in primary health care in China

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Oxford University Press
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Abstract

Abstract Objective The study aimed to decentralize hepatitis testing and management services to primary care in China. Methods A nationwide representative provider survey amongst community health centres (CHCs) using randomized stratified sampling methods was conducted between September and December 2015. One hundred and eighty CHCs and frontline primary care practitioners from 20 cities across three administrative regions of Western, Central and Eastern China were invited to participate. Results One hundred and forty-nine clinicians-in-charge (79%), 1734 doctors and 1846 nurses participated (86%). Majority of CHCs (80%, 95% CI: 74–87) offered hepatitis B testing, but just over half (55%, 95% CI: 46–65) offered hepatitis C testing. The majority of doctors (87%) and nurses (85%) felt that there were benefits for providing hepatitis testing at CHCs. The major barriers for not offering hepatitis testing were lack of training (54%) and financial support (23%). Multivariate analysis showed that the major determinants for CHCs to offer hepatitis B and C testing were the number of nurses (AOR 1.1) and written policies for hepatitis B diagnosis (AOR 12.7–27.1), and for hepatitis B the availability of reproductive health service. Conclusions Primary care providers in China could play a pivotal role in screening, diagnosing and treating millions of people with chronic hepatitis B and C in China. China, clinical management, hepatitis, primary health care, testing Introduction Hepatitis B and C are responsible for nearly half a million deaths in the Western Pacific Region (the ‘Region’)—a toll outnumbering deaths from HIV, tuberculosis and malaria combined (1). Effective antiviral treatment of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) can halt or even reverse progression to liver cirrhosis and cancer and reduce hepatitis-related mortality (2–5). Because of this high disease burden, countries have endorsed a regional action plan on viral hepatitis which established 2020 targets that 30% of people living with HBV and HCV would be diagnosed, and 50% of eligible people begin treatment and have sustained viral suppression (1). WHO globally now calls for elimination of hepatitis as a public health threat by 2030 (6). Yet, only a fraction of people living with hepatitis are being diagnosed and receiving treatment in this region (7,8). Health services in low- and middle-income countries have limited capacity to provide specialized care such as for hepatitis and other gastroenterological disease conditions (9,10). However, primary care providers can play a pivotal role in diagnosis and engagement in care for these diseases traditionally managed in specialty services (11). The American Association for the Study of Liver Diseases (AASLD) and the United States Centers for Disease Control and Prevention (US CDC) emphasized the importance of a multidisciplinary approach to HCV care calling for engaging primary care providers to improve both prevention and treatment effectiveness (12). China’s burden of chronic HBV and HCV is among the highest in the world, accounting for 25% of the global burden of hepatitis B and 7% of those with hepatitis C (7,13). There are an estimated 74 million people living with chronic hepatitis B and up to 10 million people living with chronic hepatitis C in China (7,13). Half (51%) of the global burden of new liver cancers and deaths due to liver cancer occur in China. Approximately 7 million people chronically infected with hepatitis B are estimated to urgently need treatment because of advanced liver disease and are at high risk of developing liver cancer. Among people chronically infected with hepatitis C, 2.5 million people are the priority for treatment but most are not even aware of their infection (14). Since 2009, the Chinese government has committed themselves to re-establishing primary healthcare, and by 2014, there has been a network of 8669 community health centres (CHCs) employing over 300000 health professionals. CHCs are providing basic public health services, diagnosis and treatment, nursing, rehabilitation for common disease and frequently occurring diseases (15). Transforming hepatitis tertiary care services offered by gastroenterology, infectious disease and few hepatology specialists to primary care workers could devolve the high volume of people seeking care at tertiary level whilst improving the continuity of care (16–18). Some CHCs are already testing for hepatitis B and C and could be capacitated to meet the high demand for hepatitis care and treatment, and chronic disease management. Currently, we do not know the extent to which hepatitis testing and management are taking place in primary care in China. The objectives of this survey were to determine availability of hepatitis testing and care services in CHCs, to assess the barriers and facilitating factors for offering hepatitis screening and to identify needs of primary care practitioners (PCPs) in China. Materials and Methods A nationwide representative provider survey amongst CHCs using stratified random sampling methods was conducted between September and December 2015. CHCs (180) from 20 cities across three administrative regions of Western, Central and Eastern China were randomly selected. Further details of the sampling methods are published elsewhere (19). The provider survey instrument was developed by study investigators and consisted of two questionnaires, one for the clinician-in-charge who would provide organizational and service details of CHCs as well as patient characteristics, and another for all PCPs (nurses and doctors) responsible for direct patient contacts in the selected CHCs. Questions were asked about availability of hepatitis testing and experiences of testing and managing patients with HBV and HCV, and identifying barriers and facilitators for initiating screening and management of HBV and HCV. The surveys were pilot-tested twice in three CHCs and amongst 25 PCPs. Ethics Committee approvals from a local board (HKU/HAW IRB: UW15-350) and the World Health Organization Regional Office for the Western Pacific (2016.4.CHN.1.HSI) were obtained. Descriptive analyses were conducted to provide percentages and frequencies of key parameters. Confidence intervals for the sample proportions were calculated using the Agresti–Coull (adjusted Wald) method. The statistical modelling focused on determining factors associated with CHCs offering hepatitis screening. Univariate logistic regression was performed to assess explanatory factors such as CHC composition of staff, available medical services and availability of onsite testing. Purposeful selection was used to select explanatory variables (P < 0.25) used in an overall multivariate logistic regression model. The Hosmer–Lemeshow test, a statistical test for goodness-of-fit for logistic regression model, was performed. To evaluate the sensitivity of the model to individual effects, we performed logistic regression diagnostics and did not find any individuals influencing the final model. Data were analysed using STATA (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP). Results One hundred and forty-nine clinicians-in-charge (response rate of 79% for CHCs), 1734 doctors and 1846 nurses participated in the survey (response rate 86% for PCPs). Table 1 summarizes the demographics of the doctors and nurses working in CHCs. Table 2 summarizes the key characteristics of the CHCs. Of note, the majority of CHCs (80%, 95% CI: 74–87) offered hepatitis B testing onsite, but just over half of those surveyed (55%, 95% CI: 46–65) offered hepatitis C testing onsite. Table 1. Demographics of CHC doctors and nurses Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) CHC, community health centres. View Large Table 1. Demographics of CHC doctors and nurses Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) Variable Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) Median age (IQR) 35 (28–43) 38 (32–46) 31 (26–39) Male 660/3478 19 (18–20) 650/1675 39 (37–41) 10/1793 0.6 (0.3–1.0) Han Chinese 3236/3398 95 (95–96) 1562/1637 95 (94–96) 1674/1759 95 (94–96) Highest qualification  Lower than associate degree 584 17 (16–19) 202 12 (10–13) 382 21 (19–23)  Associate degree 1502 45 (43–47) 582 34 (32–36) 920 50 (48–53)  Graduate degree 1302 39 (37–41) 832 48 (46–51) 470 26 (24–28)  Graduate degree with post-graduate qualification 167 (3355) 5 (4–6) 108 (1724) 6 (5–8) 59 (1831) 3 (3–4) Specialty  Integrative medicine 147 4 (4–5) 145 9 (7–10) 2 0.1 (0–0.4)  General practice 884 25 (24–27) 799 47 (45–49) 85 5 (4–6)  Other Specialty 786 22 (21–24) 749 44 (42–46) 37 2 (1–3)  Nurse 1735 49 (47–51) 23 1 (1–2) 1712 93 (92–94)  Not yet specialized 105 (3534) 3 (2–4) 75 (1700) 4 (4–6) 30 (1834) 2 (1–2) Median years working in above specialty (IQR) 11 (5–20) 14 (7–23) 9 (4–18) Title  Senior title 226 6 (6–7) 180 11 (9–12) 46 3 (2–3)  Intermediate title 1176 33 (32–35) 705 41 (39–44) 471 26 (24–28)  Junior title 1841 52 (51–54) 683 40 (38–42) 1158 64 (62–66)  None 283 (3526) 8 (7–9) 143 (1711) 8 (7–10) 140 (1815) 8 (7–9) Participation in continuous education 3136/3459 91 (90–92) 1545/1676 92 (91–93) 1591/1783 89 (88–91) Median number of hours on patient care per week (IQR) 40 (30–42) 40 (28–45) 40 (30–40) CHC, community health centres. View Large Table 2. CHC characteristics (n = 149) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) CHC, community health centres. View Large Table 2. CHC characteristics (n = 149) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) Median population size of catchment area (IQR) 50000 (30000–96000) Mean age (standard deviation) of patients 49.9 (11.1) Median ratio of M:F (IQR) of patients 1 (0.7–1.3) Appointments can be made in advance 62 (54–70) Median number of days open (IQR) 7 (7–7) Median number of doctors per day (IQR) 7 (4–12) Median number of patients per day (IQR) 70 (28–200) Median number of nurses (IQR) 13 (8–21) Median number of pharmacists (IQR) 2 (1–5) Median number of social workers (IQR) 0 (0–1) Median number of lab technicians (IQR) 2 (1–3) Median number of radiographers (IQR) 1 (1–2) Gender ratio of full time staff male:female 0.3 (0.3–0.6) Facilities available  Drug dispensing 84 (78–90)  Treatment/wound dressing room 93 (89–97)  Observation/iv drug room 100 (97–100)  Inpatient beds 87 (81–92) Onsite testing  Blood tests—biochem/hematology 95 (91–98)  Doppler/ultrasound 91 (86–95)  Hepatitis B serology 80 (74–87)  Hepatitis C serology 55 (46–65) Written policies  Hepatitis B diagnosis 68 (60–75)  Hepatitis B management 31 (23–40)  Hepatitis C diagnosis 43 (35–51)  Hepatitis C management 14 (7–20) CHC, community health centres. View Large Table 3 describes the experience of CHC doctors and nurses in dealing with patients with HBV and HCV. Amongst the doctors surveyed, 19% had diagnosed HBV but only 5% had diagnosed HCV within the last 1 month. Similarly amongst the nurses, 15% were involved in diagnosis of HBV but only 5% with HCV testing within the preceding month. In terms of management, the figures were even lower: 15% of doctors have managed patients with HBV and 4% have managed patients with HCV within the preceding month. More than half (56%, 95% CI: 51–61) of doctors who had diagnosed HBV cases did not continue further management in the last 1 month. Similarly, about half (45%, 95% CI: 35–54) of doctors who had diagnosed HCV cases did not manage it in the last 1 month. Table 3. Experience with hepatitis patients in the CHC Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) 95% CI, 95% confidence interval; IQR, interquartile range; STIs, sexually transmitted infections, CHC, community health centres. aIn those not providing hepatitis testing. View Large Table 3. Experience with hepatitis patients in the CHC Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) Total % (95 CI) Doctors (n = 1734) % (95 CI) Nurses (n = 1846) % (95 CI) In the last month, diagnosed patients with  Hepatitis B 663/3490 19 (18–20) 403/1698 24 (22–26) 260/1792 15 (13–16)  Hepatitis C 188/3453 5 (5–6) 107/1680 6 (5–8) 81/1773 5 (4–6) In the last month, managed patients with  Hepatitis B 548/3497 16 (15–17) 257/1692 15 (14–17) 291/1805 16 (15–18)  Hepatitis C 148/3471 4 (4–5) 61/1684 4 (3–5) 87/1787 5 (4–6) Barriers to providing Hepatitis testing at CHCa  Not interested 96 5 (4–6) 53 7 (5–8) 43 4 (3–6)  Lack of relevant medical training 1106 61 (58–63) 444 54 (50–57) 662 66 (63–69)  Lack of financial support 353 19 (18–21) 187 23 (20–26) 166 17 (14–19)  Lack of support from senior 132 7 (6–9) 57 7 (5–9) 75 8 (6–9)  colleagues or management Others(no treatment available at CHCs, easy to be infected etc.) 137 (1824) 8 (6–9) 86 (827) 11 (8–13) 51 (997) 5 (4–7) Benefit of offering hepatitis testing at CHC  Expand clinical services 1261 36 (34–38) 597 35 (33–38) 664 37 (35–39)  Enhance income 171 5 (4–6) 85 5 (4–6) 86 5 (4–6)  Improve job satisfaction 517 15 (14–16) 286 17 (15–19) 231 13 (11–14)  Earning trust from patients 926 27 (25–28) 432 26 (24–28) 494 27 (25–30)  Others 142 4 (3–5) 77 5 (4–6) 65 4 (3–5)  No benefit 482 (3499) 14 (13–15) 215 (1692) 13 (11–14) 267 (1807) 15 (13–17) Resources needed before hepatitis testing offered at CHCa  More medical training 1210 53 (51–55) 553 50 (47–53) 657 53 (50–56)  Guidelines 590 26 (24–28) 264 24 (22–27) 326 26 (24–29)  Better support from hospitals 376 17 (15–18) 198 18 (16–20) 178 14 (13–16)  Direct hotline to specialists 105 5 (4–6) 57 5 (4–7) 48 4 (3–5)  Other 55 (2265) 3 (2–3) 24 (1096) 2 (1–3) 31 (1240) 3 (2–4) Worries about offering hepatitis testing to key populations  Drive other patients away 1293 38 (36–39) 566 34 (32–37) 727 41 (38–43)  Patients too difficult to manage 1947 57 (55–58) 948 58 (55–60) 999 56 (54–58)  Get infected by them 1237 36 (34–38) 479 29 (27–31) 758 42 (40–45)  Not interested 209 6 (5–7) 93 6 (5–7) 116 7 (5–8)  Hate these people 180 5 (5–6) 78 5 (4–6) 102 6 (5–7)  Others 270 (3437) 8 (7–9) 164 (1647) 10 (9–11) 106 (1790) 6 (5–7) 95% CI, 95% confidence interval; IQR, interquartile range; STIs, sexually transmitted infections, CHC, community health centres. aIn those not providing hepatitis testing. View Large The majority of doctors (87%) and nurses (85%) felt that there was a benefit for providing hepatitis testing at CHC. For those not offering hepatitis testing, the major barriers were the lack of appropriate training (54%) and lack of financial support (23%). Equally, the nurses also cited the lack of training (66%) as the biggest barrier but lack of financial incentives (17%) was also of concern. Both doctors and nurses called for more training (50–53%) and provision of guidelines (24–26%). However, 58% of doctors perceived that offering hepatitis testing to people that self-identify or are being identified as drug users or men-having-sex with men (MSM) would be too difficult to manage and 34% of doctors were worried that such patients might drive other patients away. Fifty-six percent of nurses felt that these patients could be too difficult to manage, 42% were worried about getting infected by them and 41% worried that they might drive other patients away. Multivariate analysis showed that the major determinants for CHC to offer hepatitis B testing were the number of nurses (AOR 1.1), having a written policy for hepatitis B diagnosis (AOR 12.7) and a CHC that also offered reproductive and sexually transmitted infection (STI) services (AOR 3.6) (Table 4). Similarly, CHCs offering hepatitis C testing were more likely to have more nurses (AOR 1.1) and had a written policy for hepatitis C diagnosis (AOR 27.1) (Table 5). Table 4. Multivariate analysis of variables associated with CHCs offering hepatitis B testing Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 CHC, community health centres; STIs, sexually transmitted infections. View Large Table 4. Multivariate analysis of variables associated with CHCs offering hepatitis B testing Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 Hepatitis B testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00–1.00) 0.34 1.00 (0.99–1.00) 0.09 Number of nurses – 1.11 (1.04–1.18) <0.01 1.13 (1.05–1.22) <0.01 Written policy for Hepatitis B diagnosis 87 (92) 7.70 (2.97–20.00) <0.01 12.70 (3.58–45.07) <0.01 Reproductive and STI care 93 (86) 4.01 (1.58–10.21) <0.01 3.61 (0.99–13.15) 0.05 Hosmer-Lemeshow test χ2 (8) = 6.73, P = 0.566 CHC, community health centres; STIs, sexually transmitted infections. View Large Table 5. Multivariate analysis of variables associated with CHCs offering hepatitis C testing Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 CHC, community health centres. View Large Table 5. Multivariate analysis of variables associated with CHCs offering hepatitis C testing Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 Hepatitis C testing N (%) Crude OR (95% CI) P value Adjusted OR** (95% CI) P value Population size catchment area – 1.00 (1.00-1.00) 0.84 1.00 (0.99–1.00) 0.28 Number of nurses – 1.05 (1.01–1.08) <0.01 1.06 (1.01–1.10) 0.01 Written policy for Hepatitis C diagnosis 45 (89) 20.4 (7.13–58.13) <0.01 27.12 (8.09–90.88) <0.01 Hosmer-Lemeshow test χ2 (8) = 9.81, P = 0.279 CHC, community health centres. View Large Discussion This is the first ever national representative survey studying hepatitis services in primary health care and the needs of PCPs in China. Our surveys showed that hepatitis B testing and management are already offered in a significant proportion of CHCs in China but much less so for hepatitis C. Nonetheless, having the right staffing, policies, guidelines and training seem to be the prerequisite for introducing HBV and HCV testing at primary care level. On the ground, the health care providers recognized benefits of offering hepatitis testing but expressed the need for specific training, guidelines and support. A lack of studies from Asia A recent systematic review on hepatitis interventions showed that only one of the 56 studies included was from an Asian country but there were 10 studies, all from high-income countries addressing hepatitis testing in primary care settings (17). Most of these studies were focused on HCV testing and care as it is the most prevalent infection in Western Europe, Canada and the USA. These studies show that engaging primary care providers through issuing hepatitis testing policies, making system adjustments, training of PCPs and education of patients increased uptake and yield of HBV and HCV and improved linkage to care (9,18,20–27). Hepatitis testing has been integrated into primary care clinics in the Netherlands which provides a range of other related services such as HBV immunization, HIV testing, viral hepatitis and HIV prevention education and medical care (28). Hepatitis testing combined with liver cancer screening in primary care clinics in rural Mongolia has started in 2011. To date, this project has provided testing for 2489 individuals in six provinces of Mongolia, with a seropositive rate of 14% for HBV and 25% for HCV (29). The China Centre for Disease Control (CDC) has conducted an evaluation on HCV antibody testing and availability of HCV RNA testing in CHCs in China and found that 70% of CHCs in fact have capacity to conduct HCV antibody testing but only 49% of those offering antibody testing were able to conduct HCV RNA testing (30). Patients having to pay for hepatitis testing and lack of HCV RNA testing may be major limiting factors for linking patients to care and treatment in CHCs. Hepatitis C and primary health care HCV is concentrated among former injecting drug users in Western Europe, Canada and the USA, and they are most likely to present in general practice or primary care settings (18,20–24,27,31). The proportion of people living with HCV knowing their status is low in all these countries. Therefore, a number of studies are designed to improve uptake and yield of hepatitis testing in primary care settings. For example, the US CDC’s Hepatitis Testing and Linkage to Care initiative promoted HBV and HCV screening, post-test counselling and linkage to care at 34 US sites. The project showed that offering combination of routine opt-out HCV testing and linkage to care at five primary care centres combined with new written policies in Philadelphia could significantly improve uptake of HCV testing, increase yield and linkage to care (32). A dual-routine HCV/HIV testing model at four CHCs in Philadelphia offering opt-out testing among people living with HIV in a primary care setting showed similar results (33). Our study suggests that having clear written policies were perceived as an important factor for conducting hepatitis testing. Another example is the project, The Extension for Community Healthcare Outcomes (ECHO) model which trained PCPs to test and manage underserved populations with complex health problems such as HCV infection. The results of this study showed that the ECHO model was an effective way to diagnose and manage HCV infection (34). Our study also identified the need for training to test and manage patients infected with hepatitis. A survey conducted among PCPs in San Francisco showed that patient education improved hepatitis C treatment outcomes and virologic response rates and attitude of primary care providers (18). Policies increase uptake of hepatitis testing in primary care Studies have suggested that targeted active case finding in general practice in older age groups with a history of injecting drug use was most cost-effective for HCV screening (18,20–24,27,35,36). Similarly hepatitis B screening targeting Asian immigrants was considered a cost-effective approach in USA and Canada (25,37). HBV screening in European countries among pregnant women and migrants was also considered cost-effective (38). HCV in most Asian countries is found in general population due to past nosocomial transmission and is very high among former and present drug injectors, as well as for plasma donors and people who have received unscreened blood or blood products in the past (31,39,40). Our study suggests that many CHCs do not have any written policies for hepatitis screening. In practice, HBV testing is widespread in most tertiary and secondary health services as hospital standards are well established. Testing guidelines for HCV by China CDC and in healthcare settings have been available since 2008 and 2014, respectively. Traditionally, testing for hepatitis is limited to hospitals and confirmatory testing is conducted in the China CDC (41,42). There is a need to have appropriate training for PCPs to provide testing including nucleic acid testing, hepatitis care and treatment. At the same time, further studies of service delivery models and approaches for combined screening, diagnosis and treatment including epidemiological and cost-effectiveness would help determine the optimal screening strategies for both HBV and HCV in China. Differential of labour has been proposed to pilot-test projects when hospitals would screen for HBV/HCV; the China CDC centres conduct confirmatory testing and initiate treatment and then refer to CHCs for continuation of treatment and adherence counselling. The questions remain whether CHCs are a good place to reach key populations given the prevailing stigma and discrimination. Shifting roles of primary health care in China Within the last decade, China has implemented strategies to strengthen its primary health care system in order to prepare for, or improve on universal health coverage. In fewer than 10 years, the Chinese Government has succeeded in establishing a primary medical care service infrastructure composed mainly of rural township centres, village clinics and CHCs in cities. The basic primary care team in China is made up of doctors, including traditional Chinese practitioners, as well as nurses with very few pharmacists, clinical psychologists or social workers which are important in providing comprehensive care to patients with hepatitis B/C. CHCs provide management of common ailments, chronic diseases such as hypertension and diabetes, traditional Chinese medicine, maternal and infant healthcare and vaccinations, and can refer to specialist services. With the large number of people living with chronic hepatitis being undiagnosed and unlinked to care, enhancing the role of CHCs could help us to meet these needs. Expanding the capacity of primary care for testing and management would be opportunities to improve chronic care as well as reduce the overall health costs. Studies have shown that PCPs can provide hepatitis drug treatment even for hepatitis C, if adequately supported and trained (43,44). In the same survey, we found 88% of doctors had a computer in the consultation rooms and 81% had internet access (19). Therefore, telemedicine consultation is a potential option for those living in rural areas to gain specialist support on hepatitis care. Using audio-visual application (now widely and freely available in China) to connect the patient, PCP and the specialist that based in the hospitals, could allow real-time interaction for difficult cases. Success in California has demonstrated its effectiveness in minimizing the gap to specialty care access and strengthen supports to PCPs in managing patients with HCV (45). The implementation of telemedicine can also be utilized in teaching and proved to be more effective than traditional didactic method in increasing PCPs’ clinical knowledge regarding HCV (46). Policy and practice implications Chronic hepatitis B and C are major public health issues in China, with significant social and economic burden. The economic costs of chronic hepatitis infection and its complications increase with disease progression and with age. China is now facing the challenge of slower economic growth, an aging population and a rapid increase in non-communicable diseases including cancer and other chronic diseases. At the same time, health care costs are rising. The health reforms are shifting away from expensive hospital-centric model to one centred on primary care. Our study shows that PCPs have important roles in providing chronic hepatitis management. However, lack of knowledge and supportive policies to implement better services are challenging. Clear policies and guidelines for the roles of PCPs in delivery of hepatitis care would facilitate expansion of hepatitis management capacities throughout the country. In practice, establishing models where PCPs are linked to higher level medical institutions so as to ensure continuity of care could be a pragmatic approach. Further studies to evaluate the impact of screening as well as system changes to allow decentralization of diagnostic and care services to CHC, and studying client perceptions and willingness to utilize hepatitis services are primary level, could revolutionize hepatitis care in China. Strengths and limitations The main limitation of this study is that only self-reported information on hepatitis B and C diagnosis and management among PCPs were collected and did not include questions about history taking, hepatitis treatment and patient interviews especially amongst key populations. It is a limitation of this study that we did not ask for common practice in history taking on sexual and injecting behaviours. Moreover, there is a need to hear the views from key populations for their preferences on how and where they would prefer to access services. Nonetheless, it is the first step on understanding the delivery of hepatitis service in primary care in China. The strengths are that the data were collected from large sample of both doctors and nurses in CHCs throughout China and hence should be generalizable. Conclusions and next steps Primary care providers in China could play a pivotal role in screening, diagnosing and treating the millions of people living with chronic hepatitis. Our study suggests that with minimal investment such as policies, guidelines and training of staff, PCPs would be willing to offer hepatitis testing and management. There are ample opportunities for public health research in China to improve the hepatitis care continuum. Declaration Funding: This project is supported by three funding sources: The construction of key subjects of public health in Shanghai (Shanghai Municipal Health and Family Planning Commission no. 12GWZX1001); Shanghai excellent academic leaders in public health training program (Shanghai Municipal Health and Family Planning Commission no. GWDTR201210); and RGC Seed fund for basic research, University Grant Council, Hong Kong SAR Government, entitled, ‘Survey of the attitudes and needs of integrated HIV and STI services in community health centres in China (2015–16)’ (project number 201411159004). Ethical approval: Ethical Committee approvals from a local board (HKU/HAW IRB: UW15-350) and the World Health Organization Regional Office for the Western Pacific (2016.4.CHN.1.HSI) were obtained. Conflict of interest: None. Acknowledgements We thank the General Practice Society of Chinese Medical Association for offering assistance to organise this study. 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Family PracticeOxford University Press

Published: May 8, 2018

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