Unveiling pathways to enhance hypertension and diabetes care in rural China: a mixed methods study using the care cascade model

Abstract

Background Significant gaps remain in the screening, diagnosis, treatment, and control of hypertension and diabetes. This study aimed to assess the care cascade for these conditions in rural China, identifying barriers and facilitators at each stage to inform strategies for improving care delivery. Methods A sequential exploratory mixed methods study was conducted from July 2023 to June 2024 across three rural counties in China (Linqu, Gongyi, Wugang). The qualitative phase included in-depth interviews with policymakers, healthcare providers, and patients to identify contextual barriers and facilitators across each care cascade stage. Insights from the qualitative phase informed the design of a subsequent quantitative survey tool. The survey was administered to a stratified, non-random sample of rural residents to quantitatively assess factors identified in the qualitative phase. Findings Qualitative interviews were conducted with 82 participants, including 10 policymakers, 36 healthcare providers, and 36 patients with hypertension and/or diabetes. There were 7488 rural residents aged 35-74 years who completed the quantitative survey. Of these, 2668 (35.6) had hypertension alone, 516 (6.9) had diabetes alone, and 977 (13.0) had both conditions. The care cascade for all conditions revealed significant gaps, with high rates of uncontrolled disease: 87.6 for hypertension, 72.3 for diabetes, and 96.6 for those with both conditions. Integrated qualitative and quantitative analyses highlighted key barriers at the patient level, including misconceptions about disease severity, low perceived need for care, and fear of diagnosis and lifelong medication use. Provider and system-level challenges, such as limited diagnostic capacity and inconsistent follow-up, were exacerbated by resource constraints in primary care. Facilitators included strong patient-provider relationships, targeted health education initiatives, the use of digital tools, and chronic disease reimbursement policies. Interpretation By combining qualitative and quantitative methods, the study identifies distinct care cascades for hypertension, diabetes, and comorbid hypertension and diabetes patients. The study highlights the need for integrated, context-specific strategies, including enhanced health education, stronger primary care systems, and the adoption of electronic health systems to improve the continuity of care in rural China. Copyright (c) 2025 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).