Setting and participants

This qualitative study was conducted in three rural counties of Yichang City, Hubei Province in central China in January and February 2013. The gross domestic product (GDP) of Hubei ranks ninth among 31 provinces, municipalities, and autonomous regions in mainland China. Yichang, a city with approximately 4.08 million residents, ranks second among 13 cities in Hubei Province. Yichang City began the implementation of BPHS in 2009.

Three different rural counties with different levels of economic development (low, medium, and high) in Yichang City were selected for this study. In each county, two towns were selected based on their distance from the county center and their economic development. In each county, three FGDs were held; two groups consisted of PHCWs from the township hospitals and village clinics in the two selected towns (one single FGD in each town) respectively, and one group consisted of the directors from local public health institutions (as mentioned above). Interviewees were purposefully selected on the basis that they were currently providing BPHS in primary healthcare settings (for PHCWs only) or in the BPHS administration field (for directors only). To maximize variation in the sample, interviewees were recruited with a range of demographic characteristics (age, gender, and educational background) to achieve varying perspectives about the topic. All participants were identified and approached by the researchers with help from a head director (from Yichang CDC). They were invited to participate in the study by e-mail or telephone. Nine FGDs, each with 8–9 participants, were conducted. Theme saturation was reached by the end of the ninth FGD.

Interviews and data collection procedures

Before each scheduled interview, all of the participants were contacted by text messages and reminder calls to attend the interviews at a scheduled time. The first author, a healthcare researcher with a medical education background, conducted all of the interviews. She received training in qualitative methods as part of her doctoral (PhD) studies and has extensive experience in conducting interviews. The second author concurrently kept detailed handwritten notes of nonverbal and verbal communication (quoted material) of the group interactions among the participants [34]. The first author conducted all of the interviews to minimize differences in the influences of interviewers’ professional backgrounds and personal characteristics on the participants’ responses, and thus, to ensure consistency across all of the FGDs [35]. All of the discussions were audio-recorded.

The first author developed the semi-structured topic guide used to facilitate all of the FGDs. The topic guide for the six FGDs consisting of PHCWs was the same. It focused on eliciting their understanding of BPHS, previous training experiences on BPHS, and attitudes about web-based training. The topic guide used in the three FGDs with the directors was essentially the same with a few minor differences. This guide included questions about the directors’ perceptions of the PHCWs’ capacity to provide BPHS, perceptions of the BPHS existing training, and attitudes and concerns about web-based training.

After a brief self-introduction by each participant and an explanation of the purpose of the FGD, the researcher encouraged the participants to speak freely and to reflect, share, compare, and react to the group’s interactions. The use of the topic guide was adjusted gradually according to the participants’ perspectives, in order to increase their openness and obtain more information about their topic. At the end of each FGD, the interviewer provided a brief summary of the discussion to assess the accuracy of her understanding and impressions of the participants’ interactions. The participants were encouraged to clarify any discrepancies [36].

The FGDs with the PHCWs (n = 6) were conducted in a meeting room at each local township hospital. The FGDs with the directors (n = 3) were conducted at each local county CDC. Each FGD lasted approximately 80 minutes. All of the participants were compensated for transportation costs and received refreshments at the FGD; there were no other incentives to participate in the FGDs.

Data analysis

A pragmatic approach was employed in this study to ensure a suitable fit between the research methods and research questions [37]. Thematic analysis techniques were employed, as described below, in which the transcripts were examined closely to identify themes [37, 38].

All of the recordings were transcribed verbatim and hand-written notes were used to supplement the records. The transcripts were checked for accuracy and completeness and then were analyzed by the first and second authors independently. The recurring viewpoints relevant to the questions were listed and the data were coded line by line to produce initial codes. They were compared for similarities and differences to reform the themes and were collated into relevant themes [38]. Finally, the emerging themes were identified and discussed to ensure rigor and reliability until a consensus on the overall themes was reached. Any data that did not fit the themes were discussed and new themes/subthemes were added when necessary. The constant comparative approach [39] in which researchers move back and forth between the data and emerging themes was used until all data were analyzed. When necessary, the researcher reviewed the raw data and used the self-reflexivity method to ensure that the themes were consistent and coherent. The analysis was performed using the NVivo 8 (QSR International) qualitative data analysis software program. We reported the study consistent with the consolidated criteria for reporting qualitative research (COREQ) checklist (S1 Checklist).

Ethical considerations

Ethical approval for this study was obtained from the Institutional Review Board of Tongji Medical College, Huazhong University of Science and Technology. Written consent was obtained before the study and each participant was assured that individual comments would remain confidential.

Knowledge about BPHS

Most of the PHCWs, especially the village doctors, acknowledged that their knowledge of BPHS was limited and disorganized, affecting their routine work. A small number of PHCWs from the township hospitals stated that they were well qualified for their duties and responsibilities because they had many years of work experience. However, when some professionals’ knowledge was probed by asking questions such as “What was the standard management rate of patients with hypertension,” they responded with inaccurate answers.

“The PHCWs in our village clinics are old and less educated. We do not know much about basic public health services. Some of the staff does not even know how to provide health education to the patients with hypertension or type 2 diabetes.”

(Village doctor, male, FGD 8)

“We still lack knowledge about public health services. For example, it is difficult for us to do follow-ups for patients with hypertension, type 2 diabetes, and mental disorders. We also know little about children’s health management. We do not know how to provide guidance on infant supplementary food feeding and children's psychological development.”

(PHCW from a township hospital, female, FGD3)

The directors in the other three groups also commented that the PHCWs’ knowledge was insufficient and the quality of public health services they provided was suboptimal. Additionally, the directors stated that the village doctors had less knowledge than the township hospital providers did.

“We still lack professional health care providers. Many of the PHCWs have a low-level educational background. As far as I know, some PHCWs were unable to do some essential physical assessments. For example, some of them don’t know the correct method of measuring blood pressure or head and chest circumference of the patients.”

(Director, male, FGD9)

“About 70% or more of the village doctors in our county are over the age of 60. To be honest, I think their knowledge is poorer compared to the township hospital providers. Most of them did not know how to provide health education to pregnant women.”

(Director, female, FGD6)

Previous experiences in BPHS training

The participants reported that most of the training sessions on BPHS provided by the local township hospitals or the local county CDC were held using the face-to-face format in conjunction with the regularly scheduled job-related meetings at a fixed location. Only a limited number of personnel had the opportunity to participate in the training because those with busy schedules were unable to leave their work units. The village doctors especially encountered difficulties participating in the county-level training when transportation was needed. At the same time, the directors noted that they also faced difficulties in organizing the training because of time and place constraints.

“Generally speaking, we are busy with our work, so we cannot leave our post. We have little opportunity to attend the training and we are frustrated.”

(Village doctor, female, FGD5)

“For some village clinics, there are only two village doctors. If both of them go (to receive the training), there will be no one left to work. It is impractical for both of them to join in the training.”

(PHCW from a township hospital, female, FGD5)

“It is difficult for everyone (township hospital personnel) to receive county-level training. The person who participated in the training needs to communicate the training knowledge to the others who can’t join the training.”

(Director, male, FGD3)

“It is difficult for us to arrange a suitable training time for the PHCWs. The PHCWs are very busy with their job and it is not easy for them to attend the training at a fixed time and place.”

(Director, male, FGD6)

Moreover, the amount of training may not meet trainees’ needs. Although the township hospitals held many scheduled job-related meetings with the PHCWs, most of the meeting time was devoted to coordinating routine work or introducing health policies. Only a limited amount of time remained to deliver BPHS training. The PHCWs complained that the knowledge they received was insufficient due to this.

“We have a job-related meeting every month in our township hospital and the meeting usually lasts half a day (three hours). About two hours are used to arrange the daily work and then the remaining hour (of the time) is used to deliver knowledge. I strongly believe the training time is so limited that I learn little every time.”

(PHCW from a township hospital, male, FGD3)

“Given the limited training time, many of the training content areas were taught quickly and did not provide details. It was difficult for me to understand this knowledge in such a short time. At times, I did not even understand half of the (training) content.

(Village doctor, female, FGD4)

“It is difficult to deliver comprehensive knowledge of BPHS in the limited training time. I do not remember receiving any training on maternal healthcare and healthcare management of patients with severe mental illness.”

(Village doctor, female, FGD7)

Some PHCWs also reported that the face-to-face training did not pay attention to learners’ individual differences.

“The knowledge level of BPHS is diverse among different individuals. Some individuals with a higher knowledge level understood the (training) content better. Some people have poor knowledge levels, especially the older individuals, and it could be difficult for them to understand the content in the limited training time.”

(PHCW from a township hospital, female, FGD2)

However, some participants felt that face—to-face training would be helpful to acquire a better understanding of the training since the trainees could interact with each other and the instructors immediately.

Previous experiences with web-based training

Discussions revealed that only a few participants had web-based training experience. The participants with previous experience of web-based training were the PHCWs from the township hospitals. They stated that the web-based training delivered by a learning platform was mainly about clinical medicine, such as internal medicine and surgery. At the same time, they recognized the convenient, timesaving aspects of online learning and expressed a preference for online training rather than the face-to-face method.

“Last year, we received a web-based training program on clinical medicine. It mainly provided (us) with basic medical knowledge. We could login to the platform by using a designated username and password. The main learning format was to see the video in the platform…In my opinion, we have not received such (web-based) training on BPHS.”

(PHCW from a township hospital, female, FGD5)

Although the majority of PHCWs did not have web-based training experience, their discussions suggested their strong willingness to accept this novel training approach. They reported their belief that web-based learning could be an informative and educational tool. They welcomed the advantages of online learning, such as the equal opportunities it offered individual learners, and its ability to overcome geographical limits. They said they would be able to continue working while studying. Some directors commented that web-based learning is productive and cost-effective and avoids facility constraints. Moreover, many of them affirmed they have easy access to a computer and that every primary healthcare institution (both township hospitals and village clinics) is equipped with at least one computer.

“The web-based training sounds new and interesting to me. I think this learning method is convenient since we can learn (by ourselves) in our clinic without traveling. There are 21 village clinics in our town and it is not practical for us to centralize in a fixed location to receive the training often. Besides, web-based learning can also broaden our view.”

(Village doctor, male, FGD 7)

“I think web-based learning is a good choice for me. I can study not only in my workplace, but in my home…I will continue my work while studying.”

(PHCW from a township hospital, male, FGD5)

“I strongly think web-based training is very important and it is so necessary to establish a learning website for us. In my opinion, everyone can accept this learning method. You can know how much you have learned and self-assess the learning effect.”

(PHCW from a township hospital, male, FGD6)

“I think it is feasible to develop a web-based training program in the village, as almost all of the villages are equipped with computers, and it is a good opportunity for all of the village doctors to receive more systematic knowledge so that their ability to deliver public health services will improve accordingly. It is cost-effective as it will take place at their (PHCWs’) health institutions (no accommodations, food, and transport costs).”

(Director, male, FGD9)

Barriers to implementing web-based training

Participants identified several potential barriers to web-based training discussed in this section.

Facilitators to implementing web-based training on BPHS

The importance of BPHS training

Previous studies reported that the PHCWs’ capabilities were insufficient, preventing them from providing adequate services to residents; the quality of public health service is still a major concern in China [6, 8, 40]. Findings from our study complemented the existing literature by providing a similar view that most PHCWs in rural China, especially the village doctors, have insufficient knowledge of BPHS. One cause of the insufficient knowledge is that most of them have a lower educational background [41]. The other cause pertains to the large disparity in salaries, promotion opportunities, and work environments between urban and rural medical institutions. Young medical students or doctors with better educational backgrounds prefer to work in urban medical organizations [7, 42]. Consequently, priorities should be given to building PHCWs’ capacity in rural China to sustainably develop BPHS.

The deficiencies of face-to-face training on BPHS

The PHCWs’ BPHS training was inadequate and ineffective; this was a significant finding of the study and had not been reported previously. Similar to previous studies, the training method for China’s rural doctors was the face-to-face method concentrated in conference sessions and the training time was inadequate [9–11]. It was difficult to extend the training period in the limited time available and the amount of training content had to be reduced, adversely affecting the training efficacy [43]. Trainees were required to learn content in a limited amount of time, resulting in a discrepancy between their learning needs and preferences and the pace of content presentation. Other limitations related to face-to-face training were also presented, such as inflexibility, time constraints, travel costs, and limited training opportunities [44]. Similar to previous studies, it was difficult for the healthcare workers to make suitable arrangements between work and training [9, 45]. Due to the different knowledge levels and learning needs of the PHCWs, the face-to-face training ignored personal differences and learners’ needs [44]. Challenges in the existing training program suggest that there is an urgent need to develop an innovative and effective training strategy that complements the face-to-face approach to training PHCWs.

The potential of Web-based training as a method of learning BPHS in rural China

Web-based training might be an effective alternative to overcome the limitations of the existing training strategies in rural settings. Due to the tremendous economic development in China, the number of internet users is approaching 156 million. The internet penetration rate reached 23.7% in rural areas in 2012 [46]. The web has been effectively developed for medical education and health worker capacity training in rural China and other developing countries, such as rural Yunnan province, India, Tanzania, and South Africa [20–23, 27, 28, 30]. Moreover, the majority of PHCWs in the study could easily access a computer and the internet and desired to receive web-based training because of its flexibility, convenience, and cost-effectiveness. Hence, our findings suggest that the internet is a promising tool to deliver knowledge to strengthen the health service capacity of PHCWs in rural China.

Barriers to the implementation of web-based training on BPHS

Despite the potential of web-based training described herein, several obstacles described in this study should be addressed before applying web technology to BPHS training.

First, low computer literacy of the elderly and inadequate infrastructure had been reported as challenges in resource-constrained countries [20–22]. Age may be an additional factor influencing computer use [47]. Older PHCWs with more years of clinical practice were less likely to access the computer and might not have been familiar with computer and internet use. Recent studies in rural China reported more than 30% of the village doctors in the sample areas (both developed and under-developed regions) were aged 50 or above [48, 49]. As computer literacy is essential to implementing web-based training [21], efforts are needed to help older individuals develop computer skills.

Second, lack of interaction associated with web technology also has been perceived as prevalent and a major drawback [20, 21, 50, 51]. The lack of face-to-face interaction may contribute to professional isolation, a decrease in learning experience quality, unsatisfactory learning outcomes, and a high withdrawal rate from online learning programs [21, 52, 53]. Hence, the PHCWs expressed a strong desire for communication with fellow students and obtaining instruction from experts when studying online.

Third, the societal barriers of lack of time and motivation involve training implementation. Similar to previous studies, time was a common issue for web-based training or education of health professionals [50, 51, 54, 55]. Dickmann et al. reported that 29% of the health workers felt that web-based education might increase their workloads [55]. Given their heavy workloads, it might pose a challenge for PHCWs who would need to schedule time to learn how to use a new training website and join a web-based training course while continuing to work. Motivation also was found to be an obstacle in this study and had not been described previously in web-based training for PHCWs in primary care settings. Motivation is an essential element for successful training. It is important to identify potentially compelling reasons for trainees to engage fully in the process [56]. Garrison’s Dimensional Self-Directed Learning Model, which is an integration of self-management, self-monitoring, and motivational dimensions, indicates that self-management and motivation are critical to successful learning [57]. Previous study also revealed that motivation and time management skills are important factors influencing online learning persistence [58].

Facilitators of implementation of web-based training on BPHS

The facilitators of web-based training, which include computer and internet skills training, user-friendly packages, and technical and administrative support on infrastructure building in the village clinics, etc., might mitigate the effects of the above barriers or eliminate them [20, 23, 50, 51]. Several methods (e.g., e-mail, computer conference discussions, telephone, interactive quizzes, forums, pre-post tests, online discussions) reported in previous studies could be used to facilitate trainee-trainee and trainee-trainer communication and prevent or decrease feelings of isolation [21, 51, 52, 54]. Moreover, consistent with previous studies, online training programs should be tailored to the actual needs of the trainees, adapted to fit a country’s healthcare realities, and intended to preserve idiomatic meaning [20, 45, 56]. Finally, incentives such as economic rewards and certificates of completion might promote the enrollment and retention of public health professionals in programs using web-based training strategies [14, 50].

Strengths and limitations

This study has several strengths. First, it assessed participants’ perceptions about integrating web technology into their BPHS training in rural China’s primary health care settings. Second, the use of FGDs allowed in-depth exploration of the participants' perceptions of web-based training and provided a more detailed report and better understanding of their opinions that would not be gained through quantitative methods alone. The use of qualitative methods prior to the training’s implementation should help identify potential problems and solutions before interventions are needed, which is consistent with recommendations to incorporate qualitative work into intervention development [59, 60].

There are two limitations in this study. First, as this qualitative study and interviews were conducted only in Yichang City, Hubei Province, our findings might not be generalizable to a larger population of PHCWs in rural areas of China. However, data saturation was reached as no new themes or viewpoints were generated. To minimize potential bias in representation, our interviewees included individuals with a diverse set of demographic characteristics and thus varying perspectives about the topic. Second, as is usual in focus groups, we found that some participants were “quieter” on the topic than others were; some of them may also have adjusted their viewpoints to conform to the popular viewpoints. Efforts were made to minimize such bias, including informing participants that there were no “right” or “wrong” answers and encouraging the quieter participants to agree or disagree with any comments. Given the relaxed nature of the FGDs, we believe that this type of bias was minimal in our study. Informed by the findings of this research, follow-up studies might consider applying a quantitative methodology to reach a larger and nationally representative sample.