Zhang Jianshu, Fang Ronghua
General Practice Ward, International Medical Center Ward, General Practice Medical Center, West China Hospital/West China School of Nursing, Sichuan University, Chengdu, China.
Front Public Health. 2025 Sep 12;13:1661934. doi: 10.3389/fpubh.2025.1661934. eCollection 2025.
Advance Directives (ADs), including living wills and durable powers of attorney for healthcare, are vital to uphold patient autonomy in end-of-life care, reducing family conflicts, shortening hospital stays. ADs' implementation varies globally. In China, both the public and healthcare workers have a relatively low awareness of ADs. Community health workers (CHWs) play a significant role in the quality of end-of-life care, but there is a lack of relevant research in China. This study aims to explore Chinese CHWs' knowledge, attitudes, and intentions regarding ADs and identifies influencing factors to inform policy recommendations for ADs implementation in China.
A cross-sectional survey was conducted among 426 CHWs from 12 community health centers in southwestern China (December 2024-February 2025) via online questionnaires. Data included demographics, ADs knowledge, intentions, and attitudes. SPSS 21.0 was used for chi-square tests, t-tests, and binary logistic regression to analyze influencing factors.
Among 426 CHWs, only 22.54% possessed prior knowledge of ADs, with a mean knowledge score of 3.82 ± 2.85. Although 83.33% expressed support for ADs, merely 46.95% reported willingness to sign one. The predominant barrier identified by 87.79% of CHWs was the lack of relevant legislation. Logistic regression analysis revealed that: (1) each one-point increase in ADs knowledge score was associated with a 25% higher likelihood of supporting ADs (OR = 1.250, < 0.05); (2) CHWs with higher education levels were significantly more likely to support ADs (OR = 1.547, < 0.05); and (3) CHWs' belief in participating in medical decision-making was negatively correlated with their level of ADs support (OR = 0.386, < 0.05).
CHWs in China exhibit limited knowledge of ADs but generally supportive attitudes. However, the gap between expressed support and personal willingness to sign ADs, coupled with the perceived legal barrier, highlights an urgent need for targeted interventions to facilitate ADs implementation. Key policy priorities should include establishing a legal framework for ADs, clarifying the role of CHWs in end-of-life care processes, and incorporating mandatory ADs training into continuing medical education programs.
预立医疗指示（ADs），包括生前遗嘱和医疗保健持久授权书，对于在临终护理中维护患者自主权、减少家庭冲突以及缩短住院时间至关重要。ADs的实施在全球范围内存在差异。在中国，公众和医护人员对ADs的认知度相对较低。社区卫生工作者（CHWs）在临终护理质量方面发挥着重要作用，但中国缺乏相关研究。本研究旨在探讨中国社区卫生工作者对ADs的知识、态度和意愿，并确定影响因素，为中国ADs的实施提供政策建议。
2024年12月至2025年2月，通过在线问卷对中国西南部12个社区卫生中心的426名社区卫生工作者进行了横断面调查。数据包括人口统计学信息、对ADs的知识、意愿和态度。使用SPSS 21.0进行卡方检验、t检验和二元逻辑回归分析影响因素。
在426名社区卫生工作者中，只有22.54%的人之前了解ADs，平均知识得分为3.82±2.85。尽管83.33%的人表示支持ADs，但只有46.95%的人表示愿意签署。87.79%的社区卫生工作者认为主要障碍是缺乏相关立法。逻辑回归分析显示：（1）ADs知识得分每增加一分，支持ADs的可能性就会增加25%（OR = 1.250，<0.05）；（2）受教育程度较高的社区卫生工作者更有可能支持ADs（OR = 1.547，<0.05）；（3）社区卫生工作者参与医疗决策的信念与他们对ADs的支持程度呈负相关（OR = 0.386，<0.05）。
中国的社区卫生工作者对ADs的了解有限，但总体态度支持。然而，表达的支持与个人签署ADs的意愿之间的差距，以及感知到的法律障碍，凸显了迫切需要有针对性的干预措施来促进ADs的实施。关键政策重点应包括建立ADs的法律框架，明确社区卫生工作者在临终护理过程中的作用，并将强制性的ADs培训纳入继续医学教育项目。
