Facilitators and barriers to palliative care delivery in rural China: a qualitative study of the perceptions and experiences of rural healthcare professionals

Abstract

Background

Palliative care improves the quality of life and quality of death, yet in China, existing resources remain largely concentrated in urban areas. Limited access to palliative care exacerbates the sufferings of patients with life-threatening diseases such as cancer in rural regions.

Objectives

This study aimed to explore the facilitators and barriers to palliative care delivery in rural China, based on the perceptions and experiences of rural healthcare professionals.

Methods

Between July and August 2024, semi-structured interviews were conducted with 25 participants from rural areas, including 18 village doctors and 7 staff from township health centers (5 doctors and 2 nurses). A thematic analysis approach was used to identify key themes and subthemes.

Results

Three themes were identified, including (1) the necessity of rural palliative care: highlighting the growing population of left-behind older individuals, and poor quality of death in rural areas; (2) facilitators of rural palliative care: including door-to-door service provided by village doctors, close doctor-patient relationships, support from families and neighbors, and care in familiar environment; and (3) barriers of rural palliative care: such as heavy workloads for village doctors, limited professional authority and high perceived legal risk, unbalanced healthcare resources allocation, poor economic conditions, lack of service standards, death-related taboo and stigma, performative filial piety, and limited understanding of palliative care.

Conclusion

Palliative care in rural China remains underdeveloped. There is an urgent need to establish home-based palliative care services in low-resource regions. Implementing hospital-community-home care model can support more equitable allocation of healthcare resources. Expanding insurance reimbursement and promoting culturally adapted death education may further facilitate the delivery and acceptance of rural palliative care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-025-01848-6.

Background

China is undergoing a demographic transition, characterized by a rapidly aging population and increasing life expectancy [1]. In 2020, individuals over 65 accounted for 13.5% of the total population in China, marking a 4.63% increase from 2010 [2]. This proportion is projected to rise to one-third by 2050 [3], accompanied by a growing incidence of chronic diseases including cancer [1]. Meanwhile, rapid urbanization has led to significant labor migration from rural to urban areas, resulting in a growing number of older adults residing alone in rural areas with limited family support [4]. This demographic shift has created a critical need for palliative care in rural China.

Palliative care aims to improve the quality of life for patients with life-threatening illnesses, especially cancer, and their families by addressing physical, psychological, emotional, and spiritual needs holistically through the identification, assessment, and management of disease-related symptoms and distress [5]. It is recommended that palliative care should be introduced early in the disease trajectory and integrated with curative treatments [6].

Palliative care was introduced in China during the 1980s. This service was firstly referred to as hospice care for more than three decades [7]. The term “palliative care” began to be formally used in 2016 [8] and was officially adopted in 2017 [9]. According to the guidance from the National Health Commission, palliative care is for patients with life-threatening diseases and estimated life expectancy less than six months [9]. However, the taboo surrounding death in Chinese cultural often leads to delayed uptake of services, with many patients receiving palliative care only in the last month of life [10].

Despite steady growth over the past years, the availability of palliative care services remains insufficient to meet the increasing need [11]. In a 2021 international index of quality of death, mainland China ranked 53rd out of 81 countries and regions [12], reflecting the early stage of palliative care development. To further support the local development, Chinese government has incorporated palliative care into the “14th Five-Year Plan” Implementation Plan for the Construction of High-quality and Efficient Medical and Health Services for building a high-quality and efficient healthcare system [13]. Since 2017, three rounds of national palliative pilot projects have been launched, primarily on provincial level, with limited implementation at city and district level [14, 15].

The development of palliative care has been uneven, favoring urban over rural regions. At present, services are concentrated in secondary and tertiary hospitals in urban areas [7]. Moreover, the policy target for rural and urban regions differs. In details, by 2025, for rural areas, each township health center in rural areas is expected to have at least one palliative care bed, while each urban district aims to establish at least one palliative care center [16]. This disparity reflects the development of palliative care in China follows a broader of “urban first, rural second” approach, raising significant concerns regarding the access and equity of palliative care in rural areas. In short, rural palliative care remains at an early and underdeveloped stage.

The healthcare services in rural China are delivered through a three-layer system compromising county hospitals, township health centers, and village clinics [17]. At present, healthcare services in rural China primarily focus on disease prevention, maternal and child healthcare, and treatments for basic illnesses such as fever, cold, and monitoring of high blood pressure [18]. As a result, the quality of care for the aging population remains basic, as the local professionals often lack the capacity and resources to manage complex disease conditions. Compared to urban patients, those in rural areas are more likely to experience shorter survival times, higher health costs, reduced access to health care, and poorer health-related quality of life [19, 20]. In addition, the challenge imposed by population ageing – often described as “silver tsunami” is particularly acute in rural areas. In 2020, the proportion of the aged population in rural areas was 6.61% higher than that in urban areas, and the pace of ageing is accelerating more rapidly in these regions [21]. This demographic trend underscores the urgent need for a comprehensive, integrated palliative care system tailored to rural population, while also revealing numerous under-acknowledged challenges. Due to the shortage of palliative care professionals at county level, insufficient resources in primary care facilities, and underdeveloped referral and payment mechanisms, palliative care services remain inconsistent and fragmented in rural areas. Such uneven development constrains the rural residents’ access to palliative care services [22].

To date, limited evidence exists on the quality of palliative care in rural China. Recent studies have focused on rural healthcare professionals’ knowledge of palliative care [23] or their role in rural end-of-life care [24]. Two of Leng et al.’s studies found only 0.8% of rural deceased cancer patients received hospital-based palliative care, compared to 2.1% in urban areas [19]. Furthermore, cancer patients in urban regions appear to have better access to palliative care than those in rural regions [25]. Currently, palliative care practice in rural areas is in an exploratory phase. Due to ongoing resource constraints, the quality of care in rural settings continues to lag behind that of urban counterparts [26].

This study aimed to explore the facilitators and barriers to palliative care delivery in rural China. In addition, the researchers also investigated potential strategies for the effective and sustainable development of rural palliative care, with a focus on integrating such services into existing healthcare infrastructure. Ultimately, the goal is to promote equitable access to high-quality care for all patients, regardless of their place of residence.

Methods

Design and settings

A descriptive phenomenological qualitative study was conducted to explore the facilitators and barriers to palliative care delivery in rural China from the perspectives of rural healthcare professionals. Rural areas in China refer to administrative divisions below the level of county-seat cities, including townships and villages – situated beyond urban built-up zones, characterized by natural, social, and economic attributes, and endowed with multifunctional capacities encompassing productive, residential, ecological, and cultural dimensions [27].

The research was carried out in 40 counties across ten provinces (Sichuan, Henan, Hebei, Shandong, Shanxi, Zhejiang, Fujian, Gansu, Hubei, and Hunan) and two municipalities (Beijing and Chongqing) across in mainland China.

Participants

The study recruited doctors working in village clinics and healthcare professionals working in township health centers through purposive sampling. Initially, the administrators of the local village committees and township health centers were contacted by phone call or email with an introduction to the study, including its purpose and methods. Upon receiving administrative approval, researchers then, under the guidance of the administrators, contacted potential participants to explain the study and establish rapport. Participants were also recruited through researchers’ local contacts, including family members or acquaintances residing in local areas. Eligibility criteria for participants included, (1) being 18 years old or older, (2) having at least three years of working experience in rural areas, and (3) holding valid registration and license to practice. Non-Chinese individuals were excluded. There were no restrictions regarding participants’ prior awareness of palliative care in order to capture a broad range of perspectives on the facilitators and barriers to its delivery. In total, 25 participants were purposefully sampled from the selected settings in the regions. Specifically, participants included 18 village doctors, 5 doctors and 2 nurses from township health centers.

Interview guides

This study employed a set of self-developed interview guides (Supplementary 1) consisting of open-ended and non-leading questions. The guides were developed based on a review of relevant literature and the consultations with subject matter experts. The guides aimed to explore the facilitators and barriers related to the implementation of palliative care in rural areas by examining participants’ understanding of palliative care and their practical experiences.

The interview guides included six sections:

1. conditions of rural decedents (e.g., cause of death, dying process, hospitalizations and associated costs).

2. patients’ and families’ preferences for medical intervention in cancer care.

3. participants’ support for bedridden older adults, cancer patients and terminally ill patients.

4. participants’understanding of palliative care.

5. perceived necessity for delivering palliative care in rural areas; and

6. perceived advantages and disadvantages of delivering palliative care in rural areas.

Before the formal interviews, two village doctors and two healthcare professionals in township health centers were selected for a pilot trial to assess the semantic clarity and cultural adaptability of the interview guides. These participants demonstrated limited awareness of palliative care, which risked disrupting the flow of interviews. Based on their feedback, an additional question concerning “the perceived advantages and disadvantages of caring for patients in rural areas” was incorporated to facilitate more meaningful discussion.

Data collection

Data were collected between July and August 2024. The research team, established prior to the study, comprised of more than 20 members, including university professors, postgraduate students and undergraduate students from the fields of medicine, nursing, education, sociology, politics and law. All team members had prior experience of qualitative exploratory research and received a four-day training session on palliative care concepts and interview techniques before data collection. In-depth interviews were conducted after participants provided written informed consent. At the beginning of each interview, participants were asked to complete a general demographic survey. Throughout the interviews, techniques such as using probing questions, requests for clarification and reflective listening [28] were used to encourage participants to share their experiences and reflections on the facilitators and barriers to delivering palliative care in rural areas, within the contexts of existing local healthcare system. All interviews were carried out in person in a private setting to ensure confidentiality. There was no fixed time limit, and the duration of each interview was determined by the participants’ willingness to share. Semi-structured interviews were conducted by one or two researchers who spoke the local language to facilitate communication. The interviews lasted, on average, approximately one hour. All interviews were audio-recorded using smartphones or other recording devices, with the procedure explained to participants in advance and their consent granted. Participants’ non-verbal cues, including facial expressions, gestures, and emotional responses, were also documented in real time through handwritten notes by the researchers. Rigor in data collection was ensured in accordance with the principles of credibility, dependability, confirmability and transferability [29]. Guided by the data saturation theory, data were collected until no new meaningful themes emerged, that is, when the participants’ responses began to echo or overlap with previously collected data [30].

Data analysis

A thematic analysis approach was employed for data coding, following the steps of familiarization with the data, developing a thematic framework, grouping codes with similar meaning into themes, examining relationships between codes and themes, and synthesizing and interpreting the resulting themes and subthemes [31]. NVivo 11.0 software was used to facilitate the coding process. In the presentation of results, village doctors were labelled as V1 ~ V18, and healthcare professionals in township health centers were labelled as T1 ~ T7. All participants spoke local dialect during the interviews. All interviews were transcribed verbatim in Chinese by the interviewers within 24 h of completion. The transcripts were then returned to the respective participant for verification to ensure consistency and accuracy in their expression, thereby enhancing data credibility. Once verified, the transcripts were translated into English by the first author with the assistance of a bilingual researcher with oversea training. Data were analyzed by two researchers with academic training in palliative care specialty who had not participated in the interviews. All transcripts were anonymized and independently coded by the two analysts to ensure credibility. Any discrepancies in coding were resolved through discussion with a third researcher. To minimize potential bias, the data analysts also consulted with the original interviewers as the themes and interpretations developed.

Results

Participants’ characteristics

At first, 28 participants were screened for eligibility, but 3 of them dropped out due to no enough time for the intact interviews. Finally, a total of 25 participants took part in this study, including 18 village doctors and 7 healthcare professionals (5 doctors and 2 nurses) from township health centers. The average age of village doctors was 55.1 years, with the majority (89.0%) having 20 to 49 years of work experience. Most village doctors held an educational qualification from a secondary specialized school (55.6%). Among healthcare professionals in township health centers, the average age was 41.8 years, and most of them (71.4%) had 10 to 29 years of work experience. The healthcare professionals’ educational background was in general higher than village doctors, with 71.5% holding a bachelor’s degree. Overall, most participants had heard of palliative care prior to the study – 61.1% among village doctors and 100% among township health centers staff respectively (Table 1).

Table 1.

Characteristics of the participants interviewed (n = 25)

Characteristics	Village doctors (n = 18)	Healthcare professionals in township health centers (n = 7)
Age, median (range)	55.1 (37–73)	41.8 (30–56)
Sex (%)
Male	14 (77.8)	4 (57.1)
Female	4 (22.2)	3 (42.9)
Educational level (%)
Junior high school	3 (16.7)	0 (0)
Secondary specialized school	10 (55.6)	0 (0)
Senior high school	2 (11.1)	0 (0)
Junior college*	2 (11.1)	2 (28.5)
University	1 (5.5)	5 (71.5)
Occupation (%)
Doctor	18 (100)	5 (71.4)
Nurse	0 (0)	2 (28.6)
Years of work experience (%)
0 ~ 9	0 (0)	1 (14.3)
10 ~ 19	1 (5.5)	3 (42.9)
20 ~ 29	5 (27.8)	2 (28.5)
30 ~ 39	5 (27.8)	0 (0)
40 ~ 49	6 (33.4)	1 (14.3)
50 and above	1 (5.5)	0 (0)
Whether heard of palliative care
Yes	11 (61.1)	7 (100)
No	7 (38.9)	0 (0)

^*Chinese higher education comprises three levels: specialist education, undergraduate education, and postgraduate education. Specialist education typically lasts 2 to 3 years in junior college, culminating in the award of a Higher Education Specialist Graduation Certificate, but do not confer an academic degree

Major themes

Data analysis identified 3 themes with 14 subthemes, including the necessity of, facilitators and barriers to palliative care delivery in rural areas (Table 2).

Table 2.

Themes and subthemes related to palliative care delivery in rural areas

Theme	Subtheme
Necessity of palliative care in rural areas	Growing population of left-behind older individuals
	Poor quality of death in rural areas
Facilitators of palliative care in rural areas	Door-to-door service provided by village doctors
	Close doctor-patient relationships
	Support from families and neighbors
	Care in familiar environment
Barriers of palliative care in rural areas	Heavy workloads for village doctors
	Limited professional authority and high perceived legal risk
	Unbalanced healthcare resources allocation
	Poor economic conditions
	Lack of service standards
	Death-related taboo and stigma
	Performative filial piety
	Limited understanding of palliative care

Theme 1: Necessity of palliative care in rural areas

Subtheme 1: Growing population of left-behind older individuals

According to participants’ accounts, the proportion of older adults among local residents was high and continuing to rise. As more young people migrate to urban areas in search of employment, a growing number of older adults are left to live alone in rural communities, often with limited access to family support and care

This situation is occurring in the countryside now, that many older people die at home alone without anyone knows. (V2).

The care for those left-behind older adults in the aging countryside is indeed a big problem. In fact, they are not afraid of death, they wish for a dignified death. (V15).

Our town now has a population of about 30 thousand people, of which older adults basically account for half. The growing number of the older population, especially older adults with disability and semi-disability, makes the demand for home-based palliative care services in rural areas increasing. (T1).

Subtheme 2: Poor quality of death in rural areas

A good death is generally understood as a natural death with less pain and preserved dignity. With shifting disease profile in rural China, cancer has become the leading cause of rural death. Several participants noted that the outcomes for cancer patients were often distressing due to complex symptoms and unrelieved suffering. In addition, although the number of long-term bedridden older adults in the villages was not high, providing adequate care for them remained a significant challenge. The decline in natural, uncomplicated death suggests an increasing need for medical support and intervention to help achieve a good death – an objective at the core of palliative care

Some patients had pain which could not be relieved by painkillers. Some patients could not eat, and they were hungry and thin when died. Some patients vomited several times a day. It was too painful. (V3).

Long-term bedridden people did not die very well. They smelt bad and lived in an unsanitary environment. (V8).

Advanced cancer patients always have cancer-related pain. He (an advanced cancer patient) once told me he wanted to jump from the window when he was painful. (V14).

Theme 2: Facilitators of palliative care in rural areas

Subtheme 1: Door-to-door service provided by village doctors

Home-based palliative care is a critical component of palliative care service delivery, particularly in rural areas. Several participants indicated that palliative care in rural settings often relied on door-to-door services, which were primarily provided by village doctors

It (palliative care) is similar to the service of “family ward”. For patients who cannot take care of themselves and lie in bed for a long time, village doctors can regularly provide door-to-door services such as diagnosis of cold or fever, monitoring of blood pressure and blood glucose, and follow up of chronic illness. (V9).

In fact, we provide home care for patients who are discharged and in need of palliative care. If they need to change their nasogastric tubes or urination tubes, or they have pressure ulcer, we can also come to their home to provide care. (T7).

Subtheme 2: Close doctor-patient relationships

Village doctors play a key frontline role in palliative care delivery in rural areas due to their close familiarity with the local residents. Nearly all participants reported having strong relationships with villagers, which helped to establish a foundation of trust essential for the development of palliative care in rural areas

You (researchers) can conduct it (palliative care) together with village doctors, but you cannot do it by yourself, because the trust foundation is necessary. (V7).

Village doctors are indispensable in developing rural palliative care, because they are familiar with things and people in the village. (V13).

Subtheme 3: Support from families and neighbors

The development of palliative care needs contributions from both healthcare professionals and family members. Rural families are often characterized by larger household sizes and stronger intergenerational ties compared to their urban counterparts. According to two participants, having more family members allowed the caregiving burden for older adults to be shared more evenly. In addition to the familial support, the close-knit nature of rural communities enabled patients to receive timely help from neighbors. Both forms of informal care – family-based and community-based – were deemed as key advantages in the development of rural palliative care

The advantage is our residents have a large family who can take care of them. Compared with urban people, it is easier for rural residents to receive care from families when they are sick. (V15).

Rural residents have more harmonious relationships with each other, and the majority of an entire family lives in the village together, both of which provide strong family and community support for terminally ill patients. Family members, relatives, friends, and neighbors can take turns to take care of the patient and provide support for daily life, which is helpful to improve the physical and psychological state before death. (T1).

Subtheme 4: Care in familiar environment

Palliative care emphasizes respect for the patient’s autonomy, including individual preferences for place of care and place of death. As indicated by participants, most patients preferred to receive care in familiar settings, which helped to alleviate their psychological distress and foster a sense of comfort. In addition, rural areas offer unique advantages of their natural environment, which may also contribute positively to patients’ emotional wellbeing at the end of life

The promotion of palliative care in rural areas provides some convenience to rural people, for the place offering palliative care is closer to home. (T3).

One of the main advantages of caring for older adults in the countryside is that they are in a familiar environment with family members nearby. For the patient, on the one hand, his/her psychological resistance is not so much, and sometimes the mood will become a little better; on the other hand, the patient is more relaxed in familiar surroundings, not like a little nervous in the hospital. (T7).

In our rural areas, the natural environment is more beautiful and the air is fresher, which is helpful for patients’ physical and mental relaxation and rehabilitation. (T1).

Theme 3: Barriers of palliative care in rural areas

Subtheme 1: Heavy workloads for village doctors

According to the participants, the responsibilities of a village doctor included diagnosing and treating common illnesses, delivering public health services (such as managing chronic illness, providing health education, maintaining health records, and completing birth and death certificates) among other tasks. Due to these extensive duties, the village doctors’ tight schedule left them limited time to promote and provide palliative care along their existing workloads

I do not think I will participate in it (palliative care delivery). I do not have time to do it. I cannot leave here (the clinic). (V8).

Village doctors have a lot of things to do. It is impossible to let them do nothing but this (palliative care delivery). (V13).

Subtheme 2: Limited professional authority and high perceived legal risk

Some participants noted that their limited professional authority as a village doctor hindered the provision of quality palliative care. For example, several participants reported that they lacked the authorization to prescribe painkillers, despite pain being one of the most common symptoms among cancer patients. Furthermore, participants also expressed concerns that their medical practices would expose them to legal risk or accusation of malpractice. These fears led some to refrain from administering injections or providing other forms of treatments, which further restricted the scope of care village doctors could offer

Now we are not allowed to inject antibiotics, take infusion treatment, and do wound dressing change for patients. What else can we do (in palliative care work)? (V5).

I think the first thing to do is to liberalize the prescription of medication (if conducting palliative care in rural areas). Patients are very painful especially in the terminal stage of some diseases. They need painkillers, but I cannot prescribe painkillers, because we do not have the authority. (V8).

If you inject the drug (taken from hospitals) for him/her (patient) and he/she feels uncomfortable later, are you blaming the drug or the action of injection? Village doctors cannot afford the risk. (V18).

Subtheme 3: Unbalanced healthcare resources allocation

There were clear disparities in healthcare resource allocation between urban and rural areas. In details, participants noted that rural areas faced significant limitations in terms of infrastructure, equipment, medications, and staffing, all of which were considered as the major barriers to the delivery of palliative care. For example, V12 and V18 operated their own village clinic at their home due to the absence of designated clinical space. Similarly, V5 explained that it was impractical to set up two palliative beds in the clinic due to the severe space constraints. In addition, T1 also observed that medical equipment in rural facilities was relatively less advanced compared to that found in urban institutions. As a result, the overall quality of care was lower in rural areas as compared to that in urban areas, further hindering the effective implementation of palliative care

In order to promote palliative care, more and more people must be involved. In the past, doctors and nurses who were affiliated to the health centers in the counties were required to go to the villages or countryside to provide public health services, but now fewer and fewer people come here. (V13).

The medical level in these (rural) regions is relatively low, and the technical level and professional knowledge of health professionals are inadequate. In the case of complex disease conditions, it may be difficult for rural health professionals to make an accurate diagnosis and develop a better treatment plan. (T1).

In fact, the unbalanced allocation of healthcare resources in China is very obvious between urban and rural areas. Both healthcare resources and medical care are still relatively lagging behind in countryside, so rural palliative care faces a big challenge. (T5).

It is better to provide a quiet environment for advanced cancer patients. But we could not provide a separate room because there is a shortage of beds in our hospital. Whether village/township health centers have enough space for dying or palliative patients to rest is a relatively worrisome issue. (T7).

Subtheme 4: Poor economic conditions

From the patient’s perspective, the cost of care posed a significant financial burden due to relatively low household incomes in rural areas. This burden could significantly impact rural patients’ decisions regarding care planning and treatment choices. From the provider’s perspective, the underdeveloped local economy also limited the income level of rural healthcare professionals as well, which might reduce their motivation to engage in or sustain palliative care services

Urban economic conditions are good, so a charge of 100 yuan, 200 yuan, or 300 yuan (for palliative care) is acceptable there. But even 30 yuan is too expensive in the countryside. If the cost (of palliative care) can be less than 100 yuan in rural areas, it is estimated that at least half of the people can accept it (palliative care). (V10).

The difficulty (of delivering palliative care) is that no one (rural healthcare professionals) wants to do it (palliative work) if they do not get paid. (V14).

Rural residents have no financial ability to pay for these services (palliative care). (T6).

Subtheme 5: Lack of service standards

Several participants noted the absence of official guidance on the service standards for rural palliative care, including but not limited to insurance coverage, service pricing, facility locations and infrastructures requirements. This lack of regulatory clarity created substantial obstacles to promoting palliative care in rural areas. As a result, the palliative care wards were often overlooked

I do not know where, who, and how to implement palliative care. (V2).

No one would like to pay for something without clear charge. (V16).

I am not sure whether the country has any policy on rural palliative care. In fact, there may be a risk in promoting rural palliative care because the place of palliative care practice may be not standardized. (T5).

I think it (palliative care) has not been covered by the medical insurance yet, because at present I have not seen any document issued by the country or the health care agency about the clear charge of palliative care. (T7).

Subtheme 6: Death-related taboo and stigma

Two dominant cultural ideas emerged across the rural areas. First, the taboo surrounding death appeared to have a more profound impact in these regions. Second, the belief that “a living dog is better than a dead lion” often influenced the family’s decision-making for terminally ill patients. These perspectives stand in contrast to the ethos of palliative care, which emphasizes the quality of life and death over the length of life. As a result of such prevailing attitudes towards terminal illnesses and death, illness-related shame was common among rural patients. For example, some patients were reluctant to disclose their diagnosis or conditions to others in their community

Basically, everyone would cover the fact that they were sick, especially those who have cancer. (V4).

Most families would definitely opt for life-prolonging treatments for patients rather than palliative care. Even if the patient has been declared into terminal stage, the families still struggle for any possibility of the patient’ one more day of life. (V13).

The attitude towards death and dying may be more conservative in rural areas. The topic of death is not welcomed here, and you can be scolded when you mention that conversation, which makes it difficult for palliative care to be delivered here. (T1).

Subtheme 7: Performative filial piety

Performative filial piety was also observed during the care planning for terminally ill patients. Specifically, influenced by rural traditions, families often prioritized elaborate funeral arrangement over medical care during patients’ lifetime. The willingness to invest in a grand funeral was largely motivated by the desire of social recognition. A lavish funeral was viewed as a demonstration of filial devotion, which could enhance the family’s social reputation within the village. Nevertheless, such performative expression of filial piety would undermine patients’ autonomous decision-making, which runs counter to the goal of palliative care

Some children prefer to spend money on a grand funeral after older adults’ death than pay for the treatments or the care when patients are still alive, because they can be praised for what they did for their parents’ afterlife. There will be such a psychological comparison, who does not have such vanity? (V16).

Subtheme 8: Limited understanding of palliative care

According to participants, palliative care was misinterpreted as equivalent to giving up hope, facilitating euthanasia, or providing ineffective treatments. These misunderstandings significantly hindered the acceptance, promotion and delivery of palliative care in rural communities

The families are more likely to reject it (palliative care) because they think it is a sign that he/she (patient) is dying. (V8).

Palliative care is actually not included in the health care system, because it is neither preventive care nor treatment, it is psychological comfort, it belongs to the category of psychology…I think palliative care is provided when people are going to die, or within a few hours or within a day before death. It actually does not make sense. (V12).

Discussion

This study aimed to provide empirical evidence on how healthcare professionals perceived the delivery of palliative care in rural China. Driven by the effects of “silver tsunami” and the intergenerational separation of rural residents [4], the number of left-behind older individuals continues to grow, leading to a rapidly increasing demand for rural palliative care. The quality of death in rural areas has also become a pressing concern.

The development and promotion of rural palliative care has important implications for healthcare equity. All individuals, regardless of their residency status, should have equal access to essential health care services, including palliative care. However, due to the stark disparities in development between urban and rural regions, rural residents have benefited much less from China’s rapid social and economic progress. These inequalities are reflected in various forms of unevenly distributed welfare, including but not limited to inadequate sanitation infrastructure, poor economic conditions, and unequal allocation of healthcare resources [32]. Therefore, it is imperative to advance palliative care services in rural areas to ensure that rural residents receive care of equal quality to that of their urban peers.

According to our findings, palliative care in rural China remains in the early stage of development. The promotion of palliative care has been constrained by a range of barriers, including societal attitudes, economic limitations, cultural beliefs and structural weaknesses in the healthcare system. In rural settings, village doctors act as the frontline healthcare providers, offering immediate and accessible care to rural patients [33]. However, the misalignment between staff level, workload and income have led participants to express reluctance to further engage in learning about palliative care.

In our study, although most participants were aware of palliative care prior to the research, some still had misconceptions about the nature and the scope of this service. This finding aligns with the results of Niu et al., whose research showed that the rural healthcare professionals scored lower in the assessment of basic palliative care knowledge [23]. The limited professional capacity might be attributed to the significantly fewer training opportunities available to healthcare workers in rural areas. Without adequate training, these knowledge gaps can further hinder the promotion and delivery of palliative care. These findings underscore persistent deficits in palliative care training and education across primary care settings in rural China. To address this issue, it is important to ensure the equal access to professional development opportunities for rural healthcare providers. More training programs should be offered at the village level, comparable in quality and frequency to those provided at in district/county medical institutions.

Moreover, it is imperative to ensure a reasonable distribution of workload among rural healthcare providers’ workload and to optimize the staffing allocation to support sustainable palliative care delivery. The performance appraisal system for palliative staff should also be improved to ensure fair compensation and recognition of their professional contribution.

Uneven allocation of healthcare resources between urban and rural areas was also identified as a barrier to the delivery of palliative care in rural settings. This geographical imbalance in resource distribution may contribute to unequal end-of-life experience, particularly due to disparities in access to medical care and differences in healthcare-related costs [19, 25]. In China, only 3% of the population has access to palliative care, and the service availability is primarily concentrated to urban areas [23, 32]. Due to the limited availability of services and the disadvantaged economic conditions in rural regions, rural patients may be unable to access the service or afford its costs [23]. Furthermore, awareness of palliative care remains low in many rural communities, resulting in minimal demand, as the need for such services is rarely recognized [34].

Limited healthcare resources have contributed to the underdevelopment of palliative care in rural areas. As a result, rural residents often pursue more aggressive treatment options focused on life prolongation as alternatives. This prevailing attitude towards life, death, and illness hinders the adoption of palliative care. Cultural beliefs also play a critical role in shaping healthcare priorities. Compared to their Western counterpart, Chinese people demonstrate greater reluctance to embrace the concept of palliative care, largely due to the cultural taboo surrounding death [19]. This cultural taboo has contributed to the marginalization of palliative care. Notably, despite growing attention to the quality of life and quality of death, healthcare providers often prioritize preventable and curable diseases over palliative care. This tendency may stem from a perception of death as a medical failure rather than a natural process of life [18]. These cultural perceptions further hinder the integration of palliative care into the existing healthcare system. In low-income areas, such beliefs interact with the limited access to formal healthcare services, making traditional complementary and alternative medicine – such as herbal or dietary supplements – more commonly adopted as substitutes for professional medical care [35].

Currently, palliative care in China is delivered through three primary models: hospital-, community-, and home-based care [36]. In alignment with national policies aimed at establishing a coordinated referral system that links institutions, communities and homes [37], it is recommended that rural areas adopt this hospital-community-home palliative model through institutional alliances and digital platforms. Strengthening cooperation among institutions is expected to promote more equitable reasonable allocation of healthcare resources and help to reduce the regional disparities between urban and rural areas [36]. In addition, death education and sustained awareness efforts should be promoted among both rural residents and healthcare professionals to overcome the death-related taboo and stigma [38].

Our study indicated that the lagging rural economic development, along with the absence of clear guidance on the insurance coverage for rural palliative care, are key factors restricting the growth of palliative care in rural China. Treatment costs impose a significant burden on rural families, which encompass both unreimbursed out-of-pocket expenses and indirect expenses such as transportation costs for medical treatments [39]. This excessive financial strain also contributes to the phenomenon of performative filial piety, in which families prioritize short-term ceremonial spending on funerals rather than long-term investments in healthcare.

Insurance coverage for palliative care is a key factor influencing patients’ willingness to access such services. In countries with high quality of death ranks, e.g., USA, Canada, Singapore, Japan, palliative care is typically covered by various mechanisms, including Medicare [40], public foundations [41], governmental funding and charitable donations [42], and long-term care insurance schemes [43]. In China, the healthcare insurance system consists of two primary components: the urban employee basic medical insurance and the urban-rural resident basic medical insurance [44]. Although insurance coverage has expanded significantly in recent years, rural patients still face considerable financial burdens. This is largely due to the uneven reimbursement policies for inpatient and outpatient care across various hospitals and regions, which disproportionately affect low-income and rural populations [45]. Despite China’s partial reimbursement policies of palliative care [46], rural patients remain unable to afford such services, resulting in reduced willingness to access palliative care. In the future, insurance coverage should be further expanded to benefit rural residents, with greater inclusion of palliative care services under universal health insurance. Adequate reimbursement would enable rural families to allocate their resources more equitably between caregiving and afterlife arrangement, thereby supporting the patient’s autonomy and potentially weakening the influence of performative filial piety. In addition, improving the remuneration of palliative care staff would help incentivize healthcare professionals to engage in this field and contribute to the long-term sustainability of rural palliative care services.

Additionally, limited professional authority of village doctors and the concerns about legal liability posed significant constraints on the delivery of palliative care in rural areas. For example, certain medications, such as morphine, cannot be prescribed by village doctors. As a result, the patient in need of pain relief must travel longer distances to access care at a higher-level medical institution. To align with the standards of high-quality palliative care, it is recommended that palliative care services be formally included in the performance evaluation system for village doctors. In addition, the prescription rights for pain management medications should be piloted among trained and certified village doctors. This pilot scheme could help ensure that terminally ill patients in rural areas can access professional, dignified palliative care closer to home.

Despite the multiple barriers to palliative care in rural areas, this research also highlighted the important role of village doctors in service delivery. Village doctors can not only provide door-to-door services but also develop close, trusting relationships with local residents. In addition, since most village doctors live in the same communities they serve [47], these doctors often speak the same dialect as their patients – an advantage that supports culturally and contextually sensitive communication and facilitates the fulfilment of patient’s preference to die at home [48]. Based on these strengths, it is recommended that village doctors collaborate with family members to establish home-based palliative care arrangements, such as family palliative care wards, tailored to the needs and contexts of rural households. To better support primary rural healthcare professionals, a telemedicine-based palliative care system could be developed through the existing medical alliance structure that links tertiary hospitals, secondary hospitals and township health centers. This model has been shown to improve access to home-based palliative care services, reduce hospital readmission rates, and lower overall medical costs [49].

With demographic shifts, older people have gradually become the dominant population group in rural areas [4]. Given that rural families often have multiple members living nearby, support from relatives or neighbors is more readily available [50]. Such connection has enabled mutual aid to emerge as a key strategy for coping with population aging. To improve the delivery of rural palliative care, government planning should take into account the realities of rural health service practice by integrating the efforts of primary healthcare providers and family caregivers. Basic medical institutions should act as resource coordinators and service providers, while trained primary care teams assist with the planning, delivery and continuous improvement of care plans [51]. Families can play a supplementary role, offering emotional and spiritual support. This model aligns with China’s current direction of developing community-based health services [52] and responds to the care challenges posed by shrinking family sizes. It aims to deliver professional, accessible palliative care through the coordinated use of community resources in rural areas.

Strengths and limitations

This is the first study to explore the facilitators and barriers to palliative care delivery in rural China from the perspectives of rural healthcare professionals. However, several limitations should be acknowledged. First, the sample was limited to village doctors and doctors in township health centers, with participants recruited predominantly from the central, eastern, and western of China. As such, the sample lacked interdisciplinary representation. Second, some participants were recruited through the researchers’ personal contacts, which may have introduced selection bias. Third, due to the cultural norms surrounding death avoidance in Chinese culture, participants may have withheld or softened their responses, raising questions about whether their views fully reflected their inner thoughts. Future culturally sensitive studies should involve a broader range of rural healthcare professionals, especially nurses from county hospitals, township health centers, and village clinics across diverse regions of China. In addition, incorporating perspectives from rural patients and families will help provide a more comprehensive understanding of the barriers and facilitators of rural palliative care.

Conclusion

This study offers valuable insight into the necessity for, and the facilitators and barriers to palliative care delivery in rural China. Rural palliative care remains underdeveloped compared to urban areas. Village doctors play an important role in this setting, and there is an urgent need to establish home-based palliative care in low-resource regions. To support the development of rural palliative care, policymakers and healthcare administrators should prioritize the expansion of insurance coverage for palliative care services through universal health insurance. Additionally, clear service standards tailored to rural contexts should be established. The hospital-community-home care model can be adapted to enable more equitable allocation of healthcare resources between urban and rural areas. To achieve the goal of good death in rural China, a county-township-village training mechanism should be developed to enhance the palliative care competencies of rural healthcare professionals, including symptom assessment, pain management and psychological support. Meanwhile, culturally sensitive approaches, such as dialect-based educational materials and door-to-door communication by village doctors, can help address public misconceptions about palliative care and foster more informed and rational attitudes toward life and death.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

H.L. carried out data analysis, and contributed to the writing of the manuscript. Y.H. contributed to data collection and revising of the manuscript. Y.W. designed the study, gave feedback on initial themes, and contributed to data collection and revising of the manuscript. All authors reviewed the manuscript.

Funding

This work was supported by the Talent Introduction Project (Academic Leader Project) in University of Jinan, titled “Exploration of the Construction of Rural Hospice Care in China under the Background of ‘Healthy China’”.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by the ethics committee of Jinan University. Before data collection, researchers introduced the purpose and methods of the study to all participants and promised confidentiality. All participants were informed of their right to withdraw from the interviews at any time without reprisal. Each participant signed the informed consent. All principles of research ethics indicated in the Declaration of Helsinki were followed.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.