Functional needs: Agreement between perception of rural patients and health professionals in China

Headnote

ABSTRACT: This study aimed to investigate the common areas of functional needs of patients with different chronic diseases and to compare the level of agreement between patients and doctors, and patients and an occupational therapist, on perceived priority functional goals. A sample of 113 rural patients from Hebei Province attending outpatient neurology, orthopaedic and cancer clinics completed the COOP/WONCA Charts. These charts are a screening tool that assesses limitations in a set of functional domains. The 80 patients who indicated significant functional difficulty on the charts, 11 doctors and one occupational therapist then responded to questionnaires to elicit the perceived priority functional needs. Respondents remained blind to one another's responses. A consulting doctor and the occupational therapist saw each patient's COOP/WONCA Charts before interviewing the patient. Additional questionnaire items and a focus group interview provided data by professionals on health services thought to be beneficial to improve the function of clinic patients. The difference between the mean percentage of agreement on perceived functional difficulty in therapist/patient matches and doctor/patient matches was 18.5% (95% CI for the difference = 12.4% to 24.6%). The therapist on average agreed or matched with patients significantly more often than did doctors (p<0.0001). The discrepancy between the doctor's and patient's perception of priority functional goals was substantial, indicating a need for initiated effort to narrow this gap. The match rate of doctors with patients in choosing priority goals was significantly lower than for the therapist with patients in this study. Doctors expressed a desire for closer involvement in clinics by appropriate rehabilitation staff. This could expedite the process towards the starting level of a patient-centred approach to health care, within the natural context of teamwork, and with little disruption to clinic routines. Replication of this study using a control group would allow direct comparison of patient incidents when the charts are used and when they are not.

Headnote

Key words: Chinese healthcare, COOP/WONCA Charts, functional priorities, patient-centred treatment, rural patients

Introduction

Functional independence is a core concept of occupational therapy theory and the main goal of occupational therapy interventions and processes (Christiansen, 1991). The Model of Human Occupation, on which much of occupational therapy practice is based worldwide, suggests that all assessment should provide information on the status of the patient from the patient's own perspective (Miller, 1993).

Several studies (Law et al., 1995; Neistadt, 1995) have shown that a patient-centred approach to health care results in improved functional outcomes and patient satisfaction, decreased length of hospital stay and increased adherence to health service programmes. Problems that often arise if one does not attend to the patient's goals include inefficient use of time and efforts in achieving outcomes that do not transfer readily to the patient's environment, and poor cost-effectiveness in issuing materials and equipment unsuitable or not relevant to their life context (Dutton, 1995). Working with patients to determine treatment goals is central to the philosophy of occupational therapy, but is often less compatible with traditional medical models. This incompatibility may in some cases be attributed to the need for a shift in power from the professional to the patient. This can create discomfort for professionals in current healthcare systems that value competence over caring, or that equate expertise with technical methods (Mew and Fossey, 1996). It is a growing expectation of western patients that their opinions be sought and their values and dignity be respected throughout the treatment process (Law et al., 1995). Studies have indicated that Asians have a greater external locus of control than westerners (Spadone, 1992). In some instances in China, this is probably because of the society's notion of collective responsibility to a central authority such as the government. Patients in China, who are accustomed to being passive recipients of health care, may be reluctant initially to assume responsibility for partnership in their treatment process partly because of inexperience as well as historical habituation. The medical model practitioner may feel that their intervention enables patients to return to healthier states, yet this is often linked to a power issue in which strong medical practitioners determine goals for the patient based on what they consider important. Occupational therapists define enablement as helping the patient to achieve what is important to that person, not what any health professional considers necessary (Stewart, 1994).

China has a population of more than 1.2 billion people, of whom at least 900 million are considered rural peasants. Following major economic policy change almost 20 years ago, which dismantled a controlled collective healthcare system, many rural residents now pay directly for healthcare services. Today rural residents frequently seek specialist or better medical care in urban hospitals, by periodically travelling long distances or by temporarily staying with friends or family in larger cities. They now have a choice in seeking health care and this has provided the incentive for hospitals to enhance their marketability through improved services to attract this large rural market (Agence France-Presse, 1997a). These services must be tailored to suit the patients who will return to a lifestyle with needs quite different from their city cousins.

The need for increased emphasis on functional independence in China has been driven in part by increasing numbers of an ageing population, attributed to improved health conditions and living standards. The average life expectancy in China has risen to 70 years and, at the end of the year 2000, the aged population was predicted to reach 132 million (Agence France-- Presse, 1997b). Maximizing patient function will allow this older population to be managed at home by their families, in a society where filial piety makes this the norm (along, 1997). The increased interest by Chinese healthcare providers and administrators in the rehabilitation practices of western countries has resulted in pockets of efforts fuelled by outside observations, short internal courses and lectures provided by overseas specialists. The result in many cases is the start of a functional approach to health, which is struggling to integrate into a long-standing medical model of health care in China. The gatekeepers to many patients, who would greatly benefit from occupational therapy and other rehabilitation efforts, are the outpatient clinic doctors in China's hospitals.

In order to introduce or integrate a rehabilitation service into the medical system of China, we need to identify priority needs of patients and bring these to the attention of doctors, who are the entry point to the system. Without this awareness by doctors, professions such as occupational therapy and other allied health professions will struggle for acceptance, recognition and appropriate referrals. The aims of this study were: to investigate the common areas of functional needs of rural patients with chronic diseases and to compare the level of agreement in perceived priority functional needs between patients and doctors and patients and an occupational therapist.

Methods

Study setting

This study was conducted at Hebei Provincial Hospital in Shijiazhuang, the provincial capital of Hebei Province, China. It is a large public provincial hospital offering primary and tertiary medical care to residents of Hebei Province, and it is seeking to establish itself as a Centre of Excellence in Rehabilitation. In addition to the main hospital (which has about 1000 beds) is a newly established Rehabilitation Centre with a medical staff of 39. Occupational therapy, physical therapy and speech therapy services are provided by several staff who, over the past decade, have travelled internationally to learn some of the skills practised by allied health professionals abroad. At the time of this study most of this department's patients were cadres (members of the Communist Party) or were from urban upper-income families who had been attended to on a ward or who had been referred from a private clinic. However, for this service to have a significant impact, it will need to reach more patients from the main hospital's many outpatient speciality clinics. The outpatient doctors in this study were at the time not, or very rarely, referring patients to the Rehabilitation Centre.

Rural patients are the focus of this study because those attending provincial hospitals in China are least able to make frequent visits for functional rehabilitation because they have to travel long distances and have lower incomes, so speedy identification of priority functional difficulties and providing context-specific intervention are important imperatives. The main hospital's speciality clinics involved were neurology, orthopaedics and cancer. These clinics were chosen for the study because they had an adequate weekly volume of rural patients for the study. Patients in participating clinics did not have scheduled appointments, were mostly ambulatory and were accompanied by at least one member of their family. Patients brought their own charts with them each visit and the information in the charts was sometimes very limited. Often no confirmed specific diagnosis was indicated.

Sample

All patients attending neurology, orthopaedic and cancer outpatient clinics on 11 weekdays between 13 and 27 October 1997 who were rural residents (outside the metropolitan area as defined by the Shijiazhuang Municipal Authorities), over the age of 20 and with adequate cognitive ability were invited to participate in the study. All eligible patients approached by the trained local interviewer consented verbally (response rate = 100%) to take part and were administered the Chinese version of the COOP Functional Health Assessment Charts/WONCA (COOP/WONCA Charts) by the same interviewer in a more private area of the busy clinics. The charts took 3-5 minutes for the patient to complete.

If the patient indicated any significant limitation in function or poor health by a self-score of 3-5 on at least one of the first four of the COOP/WONCA Charts or a 4 or 5 on either of the final two charts, they progressed to the next level of the questionnaire completion. Each patient took his/her completed COOP/WONCA Charts to the consulting speciality doctor, who was encouraged to look at these responses before beginning discussions with the patient. Following their appointment with the doctor, the patient proceeded to a short interview with the occupational therapist, who also viewed the patient's chart responses prior to discussions. All doctors in these three clinics who consulted with surveyed patients during the 11 days of data collection were invited to take part in the study. In total 11 doctors participated in the study: seven were from neurology, three from orthopaedics, and one from the cancer clinic. None of the doctors involved had prior experience in research projects involving questionnaires or requests for perceptions, goals or opinions. Several had participated in research to document surgical outcomes. Clinic nurses assisted in screening patients for residency requirements. All participating doctors and nurses were invited to the focus group conducted after the final day of clinic data collection.

Study instrument

The main instruments used for data collection in this study were the Chinese version of the Dartmouth COOP Functional Health Assessment Charts/WONCA (COOP/WONCA Charts), a questionnaire for patients, and a questionnaire for outpatient doctors and the participating occupational therapist. Test-retest reliability was tested on the doctors' questionnaire, resulting in a > 70% concordance rate on 60 or 63 items (two items 50% and one item 37.5%). Copies of study questionnaires are included in Appendix A.

The COOP/WONCA Charts comprise the following six charts (Scholten and Van Weel, 1992): physical fitness - showing physical endurance, not strength; feelings - showing emotional health; daily activity - showing difficulties accomplishing daily tasks at home or work; social activity - showing the extent to which physical and/or emotional health interferes with one's social activities; change in health - showing whether physical and emotional conditions have changed; and overall health - the level of overall wellbeing.

Each of the six charts involves a question and a Likert scale of five response choices with a corresponding illustration for each answer. Patients self-rated their perceived function over the past two weeks on the above six charts. Higher scores correspond to a perceived worse status in that domain. The COOP/WONCA Charts have been validated and found reliable for use on Chinese populations (Lam et al., 1999).

Data collection and analysis

The patient questionnaire was designed to take 10 minutes to complete before the appointment with their doctor. Nine items asked for demographic information and one investigated the four currently perceived priority areas of functional difficulties. A final question explored patients' perceived importance of independence in their daily activities. The format of most questions was of a forced-choice type. Every patient questionnaire was administered verbally by the local research associate, never in the presence of and prior to being seen by the doctor and therapist.

The doctors/therapist questionnaire took about 5 minutes to complete following the patient/doctor or patient/therapist consultation. The doctors' and therapist's first questionnaire item was the same, except for the Chinese translation of the former, and mirrored the question asked of each patient. It consisted of choosing from 21 activities or activity areas the four currently perceived priority areas of functional difficulties for the specific patient previously seen. Patient, therapist and doctor remained blind to the others' responses. The second item required reflection on and selection of appropriate health services perceived beneficial to improve the function of each patient. The patients' and doctors' questionnaires were developed in English and then translated into Chinese by forward and backward translations.

A concluding one-hour focus group and debriefing with participating doctors and nurses was scheduled. A directive nominal style was selected, to allow the researcher to probe and validate ideas resulting from previous questionnaires completed and observations made during the data collection process. The tool chosen for use in the focus group was the Affinity Diagram (Brassard, 1989; Alison, 1991), which had been used successfully by this researcher during an investigation conducted at Kunming Medical University (Yunnan Province, PRC) in 1994. The following broad question was posed: What referral services or programmes might help improve your outpatients' function?

Participants were then asked, using 'Post It' notes provided, to document one idea/comment/issue per note and place them randomly on a large glass pane situated in the centre of the group. This was done in silence until all participants seemed to have no further contributions. Participants then engaged in randomly moving items into clusters with consistent themes, and lastly the group created header cards for each cluster. The occupational therapist/researcher was the group moderator and the local research assistant acted as translator and co-moderator at times.

Chi-square tests were used to test for statistical significance of the difference between proportions of functional impairment across the three speciality clinics and paired t-tests were used to analyse concordance or agreement of responses concerning functional priorities of patients versus doctors and patients versus therapist.

Results

Sample characteristics

A sample of 113 rural patients met the criteria of residency, age and cognitive ability. Of these, 52 came from the orthopaedic clinic, 44 from the neurology clinic and 17 from the cancer clinic. The sample patient characteristics are shown in Table 1. Of the 113 patients completing the charts, 71% (n = 80) were considered to report significant difficulty on at least one chart. The percentages of patients reporting significant functional difficulty by speciality outpatient clinic were as follows: neurology 70% (n = 31); orthopaedic 73% (n = 38) and cancer 65% (n = 11). The three most frequently reported conditions of neurology patients in this study were headaches/dizziness (n = 7), leg pain (n = 7) and stroke (n = 6). In the orthopaedic clinic the most frequently reported conditions were leg pain (n = 13), back pain (n = 9) and knee pain (n = 6). Cancer conditions or tumour sites varied throughout the anatomical range, with six conditions reported as simply `internal cancer', possibly indicating multiple areas. There was no statistically significant difference in the proportion of patients reporting at least one significant functional impairment between the three clinics.

TABLE l:

The 80 patients who had reported one or more functional limitations had a predominant (54%) age range of 41-60 years, an almost even distribution of males (49%) and females (51%), and were mostly married and resided with their spouse and/or children. Most participating patients classified their occupation as either farmers or workers, which was congruent with the high proportion of the workforce nationwide in rural China. Review of the demographic data of the 33 patients who did not report significant functional impairment indicated no notable differences other than in educational level. The proportion of subjects who had seven or more years of education was lower in the group reporting functional limitations than in the group who did not report any functional limitations (Chi square = 9.7, p=0.0078, df=2).

Perceived functional priorities of patients

From identical lists of 21 functional activities, the patient, the consulting doctor and the occupational therapist indicated their four perceived priority areas of functional difficulty for that specific patient following review of the COOP/WONCA Charts and an appointment with the patient.

Table 2 compares the prevalence of activities chosen by the consulting doctors or occupational therapist with those chosen by the 80 patients reporting at least one significant functional impairment. The overall differences in frequency of selecting an item between the doctors and the patients, and between the therapist and the patients, are also presented. Negative percentage differences indicate that the health professional selected an activity more frequently than did patients for the sample of patients as a whole.

When overall differences in activity choices were reviewed for patient versus therapist they were all less than 10% except for the item of mobility in the home. This is in contrast to the eight activities in which the difference in selection percentages differed by >10% for patients versus doctors.

The mean proportion of matches of the items chosen by patient versus therapist was 65.6% (95% CI = 60.5% to 70.7%) and the mean percentage of matches of the items chosen by patient versus doctor was 47.1% (95% CI = 41.9% to 52.3%). The difference between the mean proportion of agreement in therapist/patient matches and doctor/patient matches was 18.5% (95% CI for the difference = 12.4% to 24.6%), which was statistically significant by the paired t-test (p<0.0001).

Desired health :services by health professionals

The overall frequencies by speciality clinic were examined item by item as shown in Table 3, and then analysed for overall differences between doctors' and therapist's responses. Once those items with very small differences (<=10% difference) were excluded, nine items remained and are presented in Table 4 from highest to lowest difference. Negative scores in percentage differences indicate that the therapist selected an activity more frequently than did doctors for the sample of patients as a whole. Although this approach does not show specific agreement or disagreement, it does present an overall picture of services or interventions identified by doctors compared with those identified by the therapist.

Five of the 11 consulting doctors participating in the clinic data collection and two clinic nurses participated in the focus group. There were 35 responses to the focus group question pertaining to desired health services for patients. Eleven themes evolved, confirming questionnaire responses and highlighting more specific or additional needs in some of the questionnaire response categories. Any participant could make more than one suggestion that might fit into a single theme. Those themes indicating the services or programmes that were felt to be needed by doctors and nurses participating in this focus group are presented in Table 5.

Discussion

TABLE 2:

Agreement in priority goal selection

Results indicated that the therapist's pattern of priority goal selection was closer to the pattern for the patient sample than was that of the doctors. This shows that the functional limitations as perceived from the patients' perspectives were more closely understood by the occupational therapist than by the doctors, for whom this approach is an innovation.

TABLE 3: TABLE 4:

TABLE 5:

The stronger rate of agreement or pattern of priority goal selection between patient and therapist than between patient and doctor can be considered from three aspects. First, the occupational therapist had much greater previous experience exploring functional problems, using interactive reasoning and a patient-centred functional approach to intervention.

Second, the therapist relied more heavily on the COOP/WONCA Chart information, as it was her primary source of documented information about the patient, other than their occupation and presenting complaint or diagnosis. This, rather than physiological data or diagnostic test results, became the focus of her interview and approach. The patients were observed by the researcher to seem more relaxed and eager to speak to the therapist (through the research associate) than with their clinic doctor, and therefore more context-specific information may have been revealed in this encounter.

Finally, most, if not all, of the doctors participating in this study were making their first attempts to emerge from practice within a traditional strong medical model and take first steps toward a patient-centred functional approach to practice.

This study showed that the doctors from these clinics were not fully aware of the functional needs of their patients, so it is not surprising that the hospital rehabilitative services receive almost no referrals from these clinics. Further research investigating the use of the COOP/WONCA Charts as a trigger to move health professionals in China towards an increased focus on patients' functional needs is encouraged by the experience and results of this study. The match rate of doctors and patients in choosing priority goals might be improved with increased use of screening tools such as the COOP/WONCA Charts and increased comfort of doctors in discussing functional problems with their patients. Replication of this study using a control group would reveal whether doctors and patients using the charts have a significantly higher overall match rate in their priority goal selection than those without the charts, and whether regular use of the charts over a period of time will result in higher overall match rates.

Functional difficulties identified by professionals and patients

From the list of 21 possible choices of areas of functional difficulties, three areas were repeatedly found to be most frequently selected by patients, doctors and the occupational therapist. These were work/employment issues, endurance in daily physical activities, and ambulation/mobility in the community. Housework/home management and cycling followed as fourth and fifth most frequent choices overall. These findings were consistent among the patient sample when data were analysed for the whole sample, by gender, by age groups and by clinical speciality. Four of these top five most frequently selected areas of priority functional difficulty are considered instrumental activities of daily living (IADL), felt to be necessary for successful functioning in the community (Campbell and Thompson, 1990). This may be related to the greater 'cultural acceptance' of allowing family members to assist with or perform personal activities of daily living in Chinese culture and less acceptance of receiving or using assistance in public.

With 54% of the patient sample in the 41-60 year age group, it is not surprising that work/employment issues were of paramount concern. This is particularly true for rural residents whose occupation is farming, whether this is for the purpose of market sale or subsistence. Many women of working age in rural areas work independently or alongside their husbands in the fields.

Ambulation/mobility in rural communities of China can be difficult for even the able and fit resident because of the often-poor pedestrian facilities and large numbers of people. In addition, buildings rarely have lifts, public transport is crowded and substantial travel on foot to access necessities such as toilets, showers, water sources and markets is often required daily. Difficulty with mobility because of disease or ageing makes access to daily necessities, which are more easily accessed in urban China or western countries, considerably more difficult in rural China.

Discussions with numerous patients by this researcher during data collection revealed that many quickly dismiss the proposition of a walking aid such as a cane, tripod or walker. Further exploration found this to be due to a perceived negative stigma attached to such an aid. Patients seemed to feel much less 'loss of face' or embarrassment in allowing their family to do things for them than in being perceived by the community as an 'invalid' by using a walking aid. Yet, the fact that ambulation in the community was repeatedly chosen as a priority area of functional difficulty would seem to indicate that there is concern and unhappiness among patients unable to achieve this goal. Patient/family education and experimentation with a range of aids may allow patients to re-evaluate their fear of community perception against the rewards of independent or less painful mobility. The presence of an occupational therapist or physiotherapist in outpatient clinics providing samples of locally available assistive devices and orthotic aids would allow patients to try ambulation aids on a variety of surfaces in the hospital grounds. They could then make a more educated decision, rather than an immediate dismissal, based on a potentially exaggerated stigma. Family members may also then be able to express their difficulty in caring for a family member, allowing other options from the rehabilitation professional to be heard. The patient will then be able to be looked at in the context of their roles and environment.

For those few patients who were non-ambulatory, and were assisted or carried to their appointment by their family members, wheelchairs were a desired option, but were either too expensive or the family were still hoping for a `surgical cure' to restore ambulation. Rehabilitation professionals could be valuable sources of information regarding new or used wheelchairs, could introduce alternative ambulation aids or could educate patients and their family regarding safe transfer and lifting techniques.

Results indicated that, overall, doctors' responses were more restricted than the occupational therapist's responses over the spectrum of functional area choices. Ambulation and endurance difficulties were responses chosen to a much greater degree by doctors than any others. Physiological signs other than the information triggered by the COOP/WONCA Charts may have allowed doctors to infer endurance difficulties, with the subsequent logical assumption that this would also affect community ambulation. However, further investigation is required with patients to understand the context of their life before assumptions can be made about the degree to which endurance difficulties affect areas such as cycling, work, use of public transport or personal activities of daily living.

As might be expected, doctors in all three clinics rated western and Chinese pharmacy services as those most frequently needed for the patient sample. These two services and acupuncture/acupressure are the only services on the list currently readily available to outpatients at Hebei Provincial Hospital. The subsequent high-frequency items need to be considered when examining planned funding and training in new areas of rehabilitation and allied health in the hospital. Special notice should be taken where doctors and therapist agree on services needed by both professionals as these are clearly of the highest priority. Using an arbitrary cut-off threshold frequency of 30%, these high-priority service areas include physiotherapy for the neurology clinic; occupational therapy, physiotherapy, pain management programmes, and education regarding conditions for patients for the orthopaedic clinic; and community health services and patient support groups for the cancer clinic.

Weekly participation by the physiotherapist in the neurology clinic and by an occupational therapist in the orthopaedic clinic is suggested. The high agreement on physiotherapy needs in the neurology clinic reflects the great need for improved ambulation of patients. The four agreed choices in the orthopaedic clinic indicate a need for improved function in general daily activities with prevention and management of additional stresses, which may worsen function. An occupational therapist is considered the most appropriate allied health professional to work on functional independence.

The agreed choice of community health services and patient support groups for cancer patients was not surprising, given that Hebei Provincial Hospital currently provides predominantly surgical, chemotherapy and radiotherapy options for these patients. Both doctors and therapist acknowledged the great need for emotional support to be available in accessible community centres for rural residents with cancer and their families. Cross-discipline conducted support groups could be developed at Hebei Provincial Hospital's Rehabilitation Centre, providing a model that could also be used at rural district facilities.

There were five health service areas in which the overall differences between doctors' and therapist's responses differed significantly (> 10% difference), with the therapist as the more frequent selector. These services included (from highest to lowest % difference) occupational therapy, adapted equipment for daily activities, community health service, social worker and home modifications.

As the experienced occupational therapist felt these services to frequently be beneficial to patients seen in these three outpatient clinics, the contrasting opinions should be explored further. Assurance of doctors' understanding of the extent of each service listed above should form the first step of exploration.

During the focus group, ambulation needs received the highest number of responses, although they had low frequencies on the questionnaires. This may indicate a dilemma between the perceived high priority of this functional area by doctors and patients and acknowledging many patients' initial resistance to, and the lack of availability of, needed ambulation aids in the clinics. The need for pain management, patient education and support groups was reiterated in focus group responses.

Five of the seven health professionals in the focus group indicated a desire to have a rehabilitation professional (occupational therapists and physiotherapists) in outpatient clinics, further acknowledging their desire for closer teamwork and provision of more functional options for their patients. Placement of rehabilitation department staff in clinics will also provide clinical education for the doctors on therapists' skills, while giving medical students the opportunity to have experience of working with therapists early in their medical career.

Limitations

There are recognized limitations to this study. The significantly smaller number of patients with cancer makes the sample size for some variables in analysis quite small and therefore some differences may not reach statistical significance. In this study the notable difference in educational level between patients reporting significant functional limitations (group 1) and those who did not report any significant functional limitation (group 2) may reflect the lesser degree to which functional limitations are likely to affect employment opportunities of more educated persons in less physical or more skilled work. Research on a larger and more representative sample would allow for more detailed subgroup analysis to identify whether morbidity and sociodemographic factors have an effect on patients' perceived functional limitations and needs.

In addition, the use of a Likert scale may be more appropriate for response to questions with attitudinal clauses. However, in field testing of this study questionnaire we found that time pressure in busy outpatient clinics and lack of prior experience among most doctors and patients in completion of questionnaires made the selected format of predominantly quantitative questions requiring 'checked' responses most feasible and appropriate. Data collection among the rural Chinese population needs to be approached with great cultural sensitivity because of this group's lack of education, their limited exposure to institutions asking consumer opinions and their reluctance to having negative opinions recorded from past social experiences. Future studies may also wish to consider whether doctors in one clinic may have a better awareness of functional limitations than doctors of other clinics.

Conclusion

More than two-thirds of the patients surveyed in this study reported significant functional limitations. When these functional limitations were explored further, considerable discrepancy was found between the doctor's and patient's perception of functional areas of greatest concern or need. As the occupational therapist's perception of priority functional limitations and needs matched the patient's much more closely, they could play a significant role in helping to bridge this gap in China by working in clinics or in closer collaboration with outpatient doctors.

Based on the results of this study, senior rehabilitation staff and directors could be advised to introduce rehabilitative services, possibly with the help of foreign therapists, in the following areas (in no specific order of priority): pain management; patient education on conditions (prevention and work simplification); manual handling and movement; adapted equipment for daily activities; ambulation aids; home modifications; and development of cancer patient support groups.

Further education of outpatient doctors in the potential contribution of rehabilitation department staff to the improved functional performance of their patients is needed at Hebei Provincial Hospital. Placement of rehabilitation staff for weekly sessions in the clinics will allow this to occur in the natural context of teamwork between `allied health professionals' and doctors, with little or no disruption to clinic routines. This will help facilitate the long-sought closer teamwork and understanding between front-line doctors and the newly expanded rehabilitation efforts of this hospital.

Acknowledgments

We thank the following people for their assistance with this research: Professor Qu Lei (Director of Rehabilitation), Dr Huang Liping (research associate); Wei Guorong and Linda Cheung (translations), and the following doctors, nurses and professors of Hebei Provincial Hospital for their assistance with this project: (orthopaedics) Professor Liu Shu Qin, Dr Meng Xiang Guang, Dr Wang Shu Mao, Dr Zheng Shu Hui, Ms Zhang Lan Geng; (cancer) Dr Zhang Hang Zhen; (neurology) Professor Young Kang Nu, Dr Lu Pei Yuan, Dr Zhang Yu Xin, Dr Wang Pei Ze, Dr Li Ling, Dr Zhao Pao Hua, Ms Jiang Qiu Ling, Dr Gong Zhen Hua. This study was completed as part of the requirements for the first author's master of rural health degree from Monash University and was funded in part by the Anne Marden Foundation.

Appendix A

Appendix A

Appendix A

Appendix A

Footnote

Notes

Footnote

The COOP/WONCA Charts may be used for research and clinical care. The English version is available from the Northern Centre for Health Care Research (NCH), University of Groningen, The Netherlands. The Chinese version can be obtained from Dr Cindy L.K. Lam, University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.

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