Factors Associated with Perceived Continuing Medical Education Necessity Among General Practitioners in Southeast Henan, China

Abstract

Background

Continuing medical education (CME) is crucial for maintaining the competency of general practitioners (GPs). Understanding factors associated with GPs’ perceived necessity of CME is essential for optimizing training programs, especially in resource-constrained regions. This study aimed to identify factors associated with GPs’ perceived necessity of CME in Southeast Henan, China.

Methods

A cross-sectional survey was conducted among GPs in Zhoukou City, Southeast Henan, from August to September 2024. Data were collected via an online questionnaire. The primary outcome was the perceived necessity of CME (binary: yes/no). Univariable and multivariable logistic regression analyses were employed to identify factors associated with this outcome. Structural equation modeling (SEM) was used to explore pathways linking CME policy cognition, self-efficacy, attitude towards CME, and perceived necessity.

Results

Among 5537 eligible registered GPs, 2,480 valid responses were obtained (response rate, 44.8%). Overall, 35.6% perceived CME as necessary, whereas 89.6% had participated in CME during the previous three years. In the multivariable model, understanding the linkage between CME credits and career advancement showed the strongest positive association with perceived CME necessity (adjusted odds ratio [aOR]=3.74, 95% CI: 2.97–4.72). Organizational support (aOR=1.76), high self-directed learning ability (aOR=1.60), absence of anxiety (aOR=1.37), and more than 30 years of practice experience (aOR=1.58) were also positively associated with perceived CME necessity.

Conclusion

The perceived necessity of CME among GPs was associated with policy awareness, organizational support, psychological factors, and professional experience. These findings may inform policy transparency, organizational support, and tiered CME curricula that address the needs of GPs with different competency levels.

Background

Continuing Medical Education (CME) serves as a cornerstone for lifelong learning and competency maintenance among healthcare professionals.¹ For general practitioners (GPs), who act as gatekeepers in primary healthcare, effective CME is directly linked to the quality of community-based medical services and the achievement of population health objectives.² In China, the GP workforce is expected to fulfill a comprehensive “six-dimensional competency” framework that encompasses clinical diagnosis and treatment, preventive care, and health management.³ However, this workforce is characterized by significant heterogeneity in training backgrounds (eg, transitioning specialists, graduates of standardized residency programs), and faces severe shortages and maldistribution, particularly in rural areas.^4–6 This diversity presents considerable challenges for a one-size-fits-all CME system in meeting varied learning needs.

Current CME provision in China is marked by several systemic issues: a mismatch between course content and the actual demands of primary care (eg, overemphasis on specialized knowledge over generalist skills);^7,8 inequitable geographical distribution of resources;⁷ and a lack of tiered programs tailored to GPs at different competency levels.⁹ Consequently, many GPs—especially those with higher qualifications or working in underserved regions—may perceive CME as irrelevant, inaccessible, or of limited value, thereby undermining their willingness to participate.

Within the Chinese context, CME credits are often formally or informally tied to professional title promotion and career advancement, making policy awareness a potentially key motivator. Nevertheless, awareness and understanding of these policies among frontline GPs, particularly in less developed areas, remain unclear. The decision to engage in CME can be understood through theoretical lenses such as adult learning theory (emphasizing self-direction and problem-centeredness)¹⁰ and the theory of planned behavior (involving attitudes, subjective norms, and perceived behavioral control).¹¹ However, existing research tends to examine individual-level barriers (eg, time constraints, motivation) or system-level disparities in isolation.^7,12 There is a notable gap in research that investigates the perceived necessity of CME—a critical precursor to actual engagement—within specific, high-need healthcare settings using an integrated framework that simultaneously considers individual (eg, competency, psychological factors), environmental (eg, organizational support, policy awareness), and systemic determinants.

Therefore, this cross-sectional study aimed to: (1) assess the level of perceived necessity of CME among GPs in Southeast Henan, a representative resource-constrained region; and (2) identify the factors associated with this perception by constructing a comprehensive analytical model that integrates demographic characteristics, psychological traits, self-assessed competencies, policy awareness, and organizational support. The findings are intended to inform the development of targeted, stratified, and context-sensitive CME strategies to enhance the effectiveness of GP training in China and similar settings.

Methods

Study Design and Setting

We conducted a cross-sectional study in Zhoukou City, a prefecture-level city in Southeast Henan Province, China, from August 11 to September 10, 2024. Zhoukou is a predominantly agricultural region with a population of 8.63 million (2024 census) and faces typical challenges of healthcare resource constraints and a high demand for primary care services. This setting provides a relevant context for investigating CME issues in resource-limited areas of central China. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Participants and Sampling

The target population comprised all actively practicing general practitioners (GPs) in Zhoukou City. Given the difficulty in accessing the geographically dispersed GP workforce, a non‑probability, convenience sampling method was primarily adopted for participant recruitment. Recruitment was conducted through institutional WeChat groups. Notifications containing a brief study description and a link to the online questionnaire were distributed.

The inclusion criteria were: (1) holding a valid GP practicing license in Zhoukou City; (2) currently engaged in frontline general practice clinical work; and (3) providing electronic informed consent.

Exclusion criteria were as follows: (1) GP trainees still enrolled in standardized residency training programs; (2) administrative staff without current clinical responsibilities; and (3) individuals unable to complete the online questionnaire due to severe limitations in digital literacy (in practice, very few participants were excluded for this reason).

Sample size considerations: The total number of registered GPs in Zhoukou City was 5,537 (the sampling frame). Using the finite population formula with a 95% confidence level (Z=1.96), a 5% margin of error, and a conservative estimated proportion of 0.5, the minimum required sample size was calculated to be approximately 374. We aimed to recruit as many participants as possible to ensure sufficient power for subgroup and multivariate analyses. Ultimately, 2,480 GPs completed the survey, yielding a response rate of 44.8% based on the known sampling frame, which far exceeded the minimum requirement.

Data Collection and Instrument

Data were collected via a self-administered electronic questionnaire. The questionnaire was developed based on a literature review and discussions with general practice experts. It comprised four sections: (1) Sociodemographic and work characteristics; (2) Psychological and competency self-assessments; (3) Continuing Medical Education (CME) policy awareness and previous participation; and (4) CME needs and preferences.

Questionnaire Validity and Reliability: Content validity was assessed by a panel of five experts (in family medicine and medical education) using the Scale-Content Validity Index (S-CVI/Ave), which was 0.91, indicating excellent relevance. Internal consistency was evaluated using Cronbach’s alpha coefficient (α=0.82) based on a subset of 29 related items, suggesting good reliability. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.785, and Bartlett’s test of sphericity was significant (χ²=20,035.720, df=406, p<0.001), supporting the factorability of the data for the intended constructs (Table 1).

Table 1.

Analysis of Questionnaire Reliability and Validity

Metric	Value	Standard Threshold	Interpretation
Reliability
Cronbach’s α	0.82	≥0.70	High internal consistency
Validity
S-CVI/Ave	0.91	≥0.80	Excellent content coverage
KMO	0.785	≥0.60	Suitable for factor analysis
Bartlett’s p	<0.001	<0.05	Valid factor structure

Variables and Measurements

Outcome Variable: The primary outcome was the participants’ perception of the necessity of Continuing Medical Education (CME). This was operationalized through the question: “Do you consider participating in Continuing Medical Education (CME) necessary for your current professional development?” Responses were dichotomized into “Yes” (coded as 1) and “No” (coded as 0).

Explanatory Variables: Based on the theoretical framework, explanatory variables were categorized into the following domains:

Sociodemographic and Work Characteristics: Age (categorized as ≤30 vs >30 years to distinguish early-career GPs), gender, education level (associate degree or below vs bachelor’s degree or above), years of practice (≤30 vs >30 years), professional title, institution level (community health center/clinic, secondary hospital, tertiary hospital), monthly income, and night-shift frequency.

Psychological and Competency Factors: Self-rated job competency (competent/not competent), presence of anxiety (yes/no), self-efficacy (high/low), work pressure (none, mild, severe), and self-directed learning ability (high/low). These were assessed via single-item self-reports.

CME Policy Awareness: Awareness of CME policies, understanding of credit requirements, categories, allocation rules, and the linkage between CME credits and career advancement (all items: yes/no).

Organizational Support and Past Experience: Institutional support for CME (yes/no), funding sources (self-paid, jointly paid, institution/society sponsored), assessment methods (single vs multiple), overall satisfaction with past CME (satisfied/dissatisfied), and whether past training occurred during work hours.

Statistical Analysis

Data analysis was conducted using SPSS Statistics version 22.0 and Amos version 24.0. A two-tailed p-value < 0.05 was considered statistically significant.

1. Descriptive Statistics: Frequencies and percentages were calculated for all categorical variables to describe the characteristics of the study population.

2. Univariable Analysis: Chi-square tests were used to examine the association between each explanatory variable and the perceived necessity of Continuing Medical Education (CME). Crude odds ratios (ORs) with their corresponding 95% confidence intervals (CIs) were calculated for each variable separately using binary logistic regression.

3. Multivariable Analysis: Variables that showed an association with the outcome at a significance level of p < 0.10 in the univariable analysis, or those deemed clinically/theoretically important (eg, education level), were entered into a multivariable binary logistic regression model using a backward stepwise (likelihood ratio) selection procedure. The goodness-of-fit of the model was assessed using the Hosmer-Lemeshow test. Results are presented as adjusted odds ratios (aORs) with 95% CIs.

Results

Participant Characteristics

A total of 2,480 general practitioners from Zhoukou City were included in the final analysis. The demographic characteristics are detailed in Table 1. The majority were male (54.0%, 1,340/2,480) and aged over 30 years (90.8%, 2,253/2,480). More than half (55.7%, 1,382/2,480) held an associate degree or lower as their highest level of education. In terms of workplace, 55.5% (1,376/2,480) worked in primary care community health centers or clinics. Most participants had less than 30 years of practice experience (84.5%, 2,095/2,480) and held intermediate or junior professional titles (91.6%, 2,271/2,480). Regarding psychological self-assessment, 63.5% (1,574/2,480) expressed confidence in their job competency, while 65.8% (1,631/2,480) rated their self-efficacy as low, and 63.5% (1,574/2,480) perceived their self-directed learning ability as insufficient.

CME Awareness and Participation Status

Awareness of CME policies among GPs was suboptimal. Only half of the participants (50.2%, 1,246/2,480) reported being familiar with CME policies. Specifically, 44.2% (1,096/2,480) understood credit requirements, 40.2% (998/2,480) were aware of credit categories, and 38.7% (959/2,480) knew the rules for credit allocation. Notably, just over half (53.7%, 1,332/2,480) recognized the link between CME participation and career advancement.

Regarding participation, 89.6% (2,222/2,480) had engaged in CME activities in the past three years. Most participants (66.6%, 1,652/2,480) attended training outside of working hours, and 51.4% (1,274/2,480) bore the full cost themselves. The majority of participants (81.7%, 2,025/2,480) received 7 days or less of training annually. Although 68.8% (1,706/2,480) reported receiving workplace support for CME, only 29.7% (736/2,480) benefited from partial institutional funding. Overall, 72.5% (1,798/2,480) expressed satisfaction with their past CME experiences.

Perceived Necessity of CME and Training Preferences

Overall, 35.6% (882/2,480) of GPs perceived CME as necessary for their professional development. Regarding future training preferences, most GPs favored short-duration (87.0% preferred sessions lasting ≤7 days) and low-to-moderate frequency formats (47.1% preferred 1–2 sessions annually, and 42.2% preferred 3–6 sessions annually).

Univariable Analysis of Factors Associated with Perceived CME Necessity

The results of the univariable logistic regression analysis are presented in Table 2. Several factors showed significant associations (P<0.05) with the perceived necessity of CME.

Table 2.

Univariable Logistic Regression Analysis of Factors Associated with the Perceived Necessity of CME Among General Practitioners (N=2480)

Variable	N(%)	Necessity of CME N (%)	Crude Odds Ratio (COR*)	95% CI		P
				Lower	Upper
Sociodemographic characteristics
Gender
Female	1140(46%)	389(15.7%)	Ref
Male	1340(54%)	493(19.9%)	1.124	0.953	1.326	0.167
Age
≤30	227(9.2%)	77(3.1%)	Ref
>30	2253(90.8%)	805(32.5%)	1.083	0.812	1.444	0.587
Educational status
Junior college and below	1382(55.7%)	531(21.4%)	Ref
Undergraduate	1085(43.8%)	348(14.0%)	0.757	0.640	0.895	0.001
Postgraduate and Professional	13(0.5%)	3(0.12%)	0.481	0.132	1.755	0.268
Years of Work Experience
≤30	2095(84.5%)	707(28.5%)	Ref
>30	385(15.5%)	175(7.1%)	1.636	1.313	2.039	<0.001
Physician tittle
Intermediate title and below	2271(91.6%)	797(32.1%)	Ref
Senior title	209(8.4%)	85(3.4%)	1.268	0.949	1.693	0.108
Workplace
Clinic or community health center	1376(55.5%)	514(20.7%)	Ref
Secondary hospital	981(39.6%)	311(12.5%)	0.778	0.655	0.926	0.005
Tertiary hospital	123(5.0%)	57(2.3%)	1.448	1.000	2.099	0.050
Marriage
Unmarried	176(7.1%)	64(2.6%)	Ref
Married	2304(92.9%)	818(33.0%)	0.963	0.700	1.325	0.818
Personal monthly income (RMB)
≤3000	1196(48.2%)	445(17.9%)	Ref
3001–5000	1049(42.3%)	352(14.2%)	0.852	0.716	1.014	0.071
≥5001	235(9.5%)	85(3.4%)	0.956	0.715	1.279	0.763
Frequency of night shift per month
≤4	1464(59.0%)	531(21.4%)	Ref
5–8	507(20.4%)	162(6.5%)	0.825	0.665	1.023	0.080
>8	509(20.5%)	189(7.6%)	1.038	0.842	1.279	0.728
Self-assessment
Self evaluation of job competency
No	906(36.5%)	243(9.8%)	Ref
Yes	1574(63.5%)	639(25.8%)	0.536	0.449	0.641	<0.001
Self evaluation of psychological state
Anxiety	1063(42.9%)	261(10.5%)	Ref
No anxiety	1417(57.1%)	621(25.0%)	2.397	2.013	2.855	<0.001
Self evaluation of self-efficacy
Low	1631(65.8%)	466(18.8%)	Ref
High	849(34.2%)	416(16.8%)	2.402	2.022	2.853	<0.001
Self evaluation of working pressure
No pressure	589(23.8%)	295(11.9%)	Ref
A little bit of pressure	1584(63.9%)	491(19.8%)	0.448	0.369	0.543	<0.001
Much pressure	307(12.4%)	96(3.9%)	0.453	0.339	0.606	<0.001
Autonomous learning ability
Low	1574(63.5%)	412(16.6%)	Ref
High	906(36.5%)	470(19.0%)	3.040	2.560	3.611	<0.001
Cognition of CME
Understanding of CME policy
No	1234(49.8%)	257(10.4%)	Ref
Yes	1246(50.2%)	625(25.2%)	3.826	3.206	4.565	<0.001
Understanding of credit requirement
No	1384(55.8%)	309(12.5%)	Ref
Yes	1096(44.2%)	573(23.1%)	3.812	3.205	4.533	<0.001
Understanding of credit category
No	1482(59.8%)	355(14.3%)	Ref
Yes	998(40.2%)	527(21.3%)	3.552	2.990	4.220	<0.001
Understanding of regulations on credit granting
No	1521(61.3%)	364(14.7%)	Ref
Yes	959(38.7%)	518(20.9%)	3.734	3.140	4.440	<0.001
Understanding of correlation between CME policy and title awarding
No	1148(46.3%)	163(6.6%)	Ref
Yes	1332(53.7%)	719(29.0%)	7.088	5.817	8.637	<0.001
Previous participation in CME
Participated in CME in the past three years
No	258(10.4%)	61(2.5%)	Ref
Yes	2222(89.6%)	821(33.1%)	1.893	1.402	2.554	<0.001
Training time
Non-working time	1652(66.6%)	625(25.2%)	Ref
Working time	828(33.4%)	257(10.4%)	0.740	0.619	0.883	<0.001
Training days of CME
≤7d	2025(81.7%)	705(28.4%)	Ref
>7d	455(18.3%)	177(7.1%)	1.192	0.967	1.470	0.100
Frequency of CME per year
1–2	1215(49.0%)	387(15.6%)	Ref
3–6	1004(40.5%)	373(15.0%)	1.265	1.061	1.508	0.009
>6	261(10.5%)	122(4.9%)	1.878	1.431	2.464	<0.001
Attitude of department on CME
Not Support	774(31.2%)	130(5.2%)	Ref
Support	1706(68.8%)	752(30.3%)	3.905	3.161	4.824	<0.001
Assessment methods of CME
Single approach	1148(46.3%)	314(12.7%)	Ref
Two or more approaches	1332(53.7%)	568(22.9%)	1.975	1.667	2.339	<0.001
Source of funding
Individual payment	1274(51.4%)	398(16.0%)	Ref
Individual and Company payment	736(29.7%)	301(12.1%)	1.523	1.261	1.839	<0.001
Company payment and social sponsorship	470(19.0%)	183(7.4%)	1.403	1.126	1.749	0.003
Overall satisfaction of CME
Dissatisfied	682(27.5%)	98(4.0%)	Ref
Satisfied	1798(72.5%)	784(31.6%)	4.607	3.648	5.819	<0.001
Expectation of CME
Expected training days of CME
≤7d	2158(87.0%)	741(29.9%)	Ref
>7d	322(13.0%)	141(5.7%)	1.490	1.175	1.889	<0.001
Expected frequency of CME per year
1–2	1168(47.1%)	315(12.7%)	Ref
3–6	1046(42.2%)	431(17.4%)	1.898	1.588	2.269	<0.001
>6	266(10.7%)	136(5.5%)	2.833	2.156	3.722	<0.001

Sociodemographic Factors: GPs with a bachelor’s degree or higher were less likely to perceive CME as necessary compared to those with lower educational attainment (OR=0.76, 95% CI: 0.64–0.90). Conversely, those with more than 30 years of practice experience showed higher odds (OR=1.64, 95% CI: 1.31–2.04).

Psychological and Competency Factors: Higher self-rated job competency was associated with lower perceived necessity (OR=0.54, 95% CI: 0.45–0.64), whereas higher self-efficacy (OR=2.40, 95% CI: 2.02–2.85) and self-directed learning ability (OR=3.04, 95% CI: 2.56–3.61) were strong positive predictors. The absence of anxiety was also a positive factor (OR=2.40, 95% CI: 2.01–2.86), while work pressure was a negative factor (eg, mild pressure: OR=0.45, 95% CI: 0.37–0.54).

Policy Awareness and Organizational Factors: All policy awareness items demonstrated strong positive associations, with understanding the link to career advancement being the strongest (OR=7.09, 95% CI: 5.82–8.64). Institutional support (OR=3.91, 95% CI: 3.16–4.82), joint or institutional funding, and overall satisfaction with past CME (OR=4.61, 95% CI: 3.65–5.82) were also significant enablers (Table 2).

Multivariable Analysis of Factors Associated with Perceived CME Necessity

The final multivariable logistic regression model identified independent factors associated with the perceived necessity of CME (Table 3). The model demonstrated good fit (Hosmer-Lemeshow test, P=0.124). Understanding the linkage between CME credits and career advancement remained the strongest independent predictor (adjusted OR [aOR]=3.74, 95% CI: 2.97–4.72). Other significant independent predictors included: organizational support (aOR=1.76, 95% CI: 1.37–2.27), high self-directed learning ability (aOR=1.60, 95% CI: 1.28–2.00), the absence of anxiety (aOR=1.37, 95% CI: 1.08–1.74), and more than 30 years of practice experience (aOR=1.58, 95% CI: 1.20–2.07). Training conducted during work hours was associated with a lower perceived necessity (aOR=0.69, 95% CI: 0.55–0.87). Notably, the association between higher education level (bachelor’s degree or above) and lower perceived necessity was attenuated and became non-significant in the multivariable model (aOR=0.93, 95% CI: 0.76–1.14) (Table 3).

Table 3.

Multivariable Logistic Regression Analysis of Factors Associated with the Perceived Necessity of CME Among General Practitioners in Southeast Henan

Variable	Category (Reference)	aOR	95% CI	P-value
Recognition of CME-career advancement linkage	Yes (Ref: No)	3.74	2.97–4.72	<0.001
Organizational support	Supported (Ref: Not supported)	1.76	1.37–2.27	<0.001
Self-directed learning ability	High (Ref: Low)	1.60	1.28–2.00	<0.001
Psychological state	No anxiety (Ref: Anxiety)	1.37	1.08–1.74	0.009
Years of practice	>30 years (Ref: <=30 years)	1.58	1.20–2.07	0.001
Training time	During work hours (Ref: Outside work hours)	0.69	0.55–0.87	0.002
Education level	Bachelor’s degree or above (Ref: below bachelor’s)	0.93	0.76–1.14	0.482

Structural Equation Modeling (SEM)

The hypothesized SEM model exhibited an acceptable fit to the data. The standardized factor loadings for the observed indicators of CME policy cognition ranged from 0.78 to 0.97, supporting the measurement structure. CME policy cognition had a strong direct positive effect on attitude towards CME, and attitude towards CME strongly predicted perceived necessity. Self-efficacy was also associated with CME policy cognition and attitude towards CME. Model fit indices and standardized path coefficients are summarized in Table 4. Because of the cross-sectional design, these SEM results should be interpreted as exploratory pathway evidence rather than causal effects.

Table 4.

Structural Equation Model Fit Indices and Standardized Path Coefficients for Perceived CME Necessity

Item	Estimate	P-value/Criterion	Interpretation
Model fit: χ2/df	3.85	<5.00	Acceptable fit
Model fit: CFI	0.954	>0.900	Good fit
Model fit: TLI	0.938	>0.900	Good fit
Model fit: RMSEA	0.054	<0.080	Acceptable fit
Model fit: SRMR	0.042	<0.080	Good fit
CME policy cognition indicators	Factor loadings: 0.78–0.97	-	Supported measurement structure
CME policy cognition -> Attitude towards CME	β=0.85	<0.001	Strong positive association
Self-efficacy -> CME policy cognition	β=0.28	<0.001	Moderate positive association
Self-efficacy -> Attitude towards CME	β=0.08	<0.01	Weak positive association
Attitude towards CME -> Perceived CME necessity	β=0.72	<0.001	Strong positive association
Variance explained: Attitude towards CME	R2=0.46	-	Model explained 46% of variance
Variance explained: Perceived CME necessity	R2=0.52	-	Model explained 52% of variance

Abbreviations: CFI, comparative fit index; CME, continuing medical education; RMSEA, root mean square error of approximation; SEM, structural equation modeling; SRMR, standardized root mean square residual; TLI, Tucker-Lewis index.

Discussion

This study aimed to identify factors influencing the perceived necessity of Continuing Medical Education (CME) among general practitioners in resource-constrained regions of China. Multivariable analysis revealed that policy awareness, organizational support, psychological factors, and professional experience were independent predictors.

The Interplay of Competence, Educational Background, and Perception

Although a higher educational level (bachelor’s degree or above) showed a negative association with perceived CME necessity in univariable analysis, this association was attenuated and lost statistical significance after adjusting for other factors such as self-assessed competency and policy awareness. This suggests that the lower demand observed among highly educated GPs may be mediated by their higher self-rated competency and insufficient awareness of CME’s career relevance. Highly competent GPs, often with specialized training backgrounds, may perceive current standardized CME courses as lacking advanced or relevant content designed for complex primary care scenarios, leading to a phenomenon akin to “knowledge saturation”.¹³ This highlights the urgent need for implementing tiered CME curricula that extend beyond basic chronic disease management to include advanced modules on complex comorbidities and integrative decision-making, thereby addressing the specific needs of this subgroup.

Senior Experience and the Drive for Continuous Learning

Physicians with more than 30 years of practice experience were significantly more likely to perceive CME as necessary (aOR=1.58). From the perspective of adult learning theory, experienced doctors need to translate clinical experience into practical skills and keep pace with knowledge updates (eg, new guidelines).¹⁰ This aligns with career development stage theory, where experienced physicians may prioritize continuing education due to knowledge renewal needs or professional advancement requirements. However, this group also faces participation barriers, such as time constraints (eg, handling over 30 patient visits per day) and insufficient applicability of course content (eg, less than 20% of training covering primary care-appropriate skills).¹⁰

The Role of Psychological Factors

Higher self-efficacy and the absence of anxiety were independent positive predictors of perceived CME necessity, consistent with social cognitive theory which posits that confidence promotes proactive learning.¹⁴ Conversely, work pressure—a significant negative factor in univariable analysis—may deplete cognitive resources and motivation, creating a barrier to engagement.¹³ This indicates that CME programs should not only impart knowledge but also incorporate elements that enhance psychological resilience, such as stress management workshops or supportive learning communities, to foster a more conducive learning environment.

Policy Awareness and Organizational Support: The Most Potent and Modifiable Factors

Policy awareness, particularly the understanding of the link between CME credits and career advancement, exerted a strong influence and emerged as the strongest independent predictor (aOR=3.74). This finding is contextualized within China, where CME credits are formally integrated into the professional title promotion system. When GPs perceive CME as a direct pathway to career development (instrumental motivation), their perceived necessity increases substantially.^15,16 This reveals a key actionable lever for policymakers: enhancing the transparency and dissemination of CME policy information through digital platforms, hospital briefings, and visual “career development navigation maps”.

Complementing policy awareness, concrete organizational support (aOR=1.76), such as paid study leave and cost-sharing, significantly increased the perceived necessity of CME. Training scheduled during non-working hours was associated with lower perceived necessity. These findings align with the normative beliefs and perceived behavioral control dimensions of the theory of planned behavior,¹¹ indicating that institutional norms and resource provision are crucial for translating positive attitudes into actual learning intentions.

Optimizing Training Design and Satisfaction to Promote Long-Term Engagement

Training conducted during non-working hours (univariable OR=0.740) and the use of multi-dimensional assessment methods (univariable OR=1.975) significantly impacted participation rates. Flexible learning models (eg, blended learning, micro-courses) can better accommodate physicians’ clinical schedules. Primary care doctors in China generally face heavy workloads,¹⁷ which limits their available time and energy for learning, leading to the abandonment of in-person training due to “work-study conflict”.⁶ Therefore, optimizing CME design should focus on creating flexible learning modules (eg, micro-courses), which may increase participation rates.¹⁸ Simultaneously, developing online learning platforms⁹ can help mitigate the negative impact of occupational stress on willingness to participate. High-satisfaction CME programs (univariable OR=4.607) were more likely to foster long-term engagement. Future improvements should concentrate on optimizing course content (eg, adding general practice-appropriate skills and case discussions) and establishing feedback mechanisms for dynamic quality adjustment.⁹

Integrated Recommendations: A Multi-Level Intervention Framework

Based on the above findings, we propose a multi-level intervention framework: (1) Curriculum Level: Implement a tiered CME curriculum and credit system to meet the needs of physicians at different career stages and competency levels; (2) Policy and Institutional Level: Strengthen publicity regarding CME credit policies and their link to career development, and provide substantive organizational support through institutionalized measures (eg, paid study leave, dedicated CME funding, incorporating CME participation into performance evaluations); (3) Implementation Level: Adopt flexible learning models (eg, online-offline hybrid teaching); (4) Support Level: Integrate psychological empowerment strategies (eg, case-based learning to enhance self-efficacy, stress management modules) into the CME system. Adopting this multi-stakeholder collaborative strategy, which integrates individual psychological factors, organizational support, and policy optimization, will help build a sustainable lifelong learning system, ultimately enhancing the training effectiveness of GPs in the region.

Study Limitations

This study has several limitations. First, the cross-sectional design precludes causal inference. Second, the convenience sampling method may have introduced selection bias, potentially over-representing GPs with higher digital literacy and stronger motivation. Future research should utilize official registry data to ensure rigorous participant selection. Despite these limitations, the findings from this large-sample, real-world study in a high-need region provide valuable empirical evidence for optimizing CME strategies.

Conclusions

This study identified policy awareness, organizational support, psychological factors, and professional competency as key determinants of the perceived necessity of Continuing Medical Education among general practitioners in Southeast Henan, China. The findings indicate that engagement in CME is influenced by the interaction between individual cognitive-behavioral characteristics and systemic environmental factors.

Based on this research, we recommend: (1) implementing tiered CME curricula to accommodate different competency levels and learning needs; (2) enhancing the transparency and dissemination of CME policies, particularly the linkage between credits and career advancement; (3) strengthening institutional support through concrete measures such as paid study leave and dedicated funding; and (4) integrating psychological empowerment strategies into CME programs to enhance self-efficacy.

By integrating these systemic and individual-level interventions, this study provides an actionable framework for optimizing CME implementation. Such efforts are essential for strengthening primary care capacity, improving the quality of community health services, and ultimately aligning with national health goals.

Funding Statement

This work was supported by the Project No. 20241003 from Zhoukou Municipal Medical Science Research Center.

Abbreviations

CME, Continuing Medical Education; GPs, General Practitioners.

Data Sharing Statement

The anonymized dataset supporting the conclusions of this article will be made available by the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of Zhoukou Central Hospital, Henan Province (Approval No. 20240625003). Informed consent was obtained from all subjects involved in the study.

Author Contributions

Juan Kong and Xu Yang are joint first authors. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.