Community health workers' knowledge and attitudes toward advance directives in China: a cross-sectional study

Jianshu ZhangRonghua Fang^*

• West China Hospital, Sichuan University, Chengdu, China

Background: Advance Directives (ADs), including living wills and durable powers of attorney for healthcare, are vital to uphold patient autonomy in end-of-life care, reducing family conflicts, shortening hospital stays. ADs’ implementation varies globally. In China, both the public and healthcare workers have a relatively low awareness of ADs. Community health workers (CHWs) play a significant role in the quality of end-of-life care, but there is a lack of relevant research in China. This study aims to explore Chinese CHWs’ knowledge, attitudes, and intentions regarding ADs and identifies influencing factors to inform policy recommendations for ADs implementation in China. Methods: A cross-sectional survey was conducted among 426 CHWs from 12 community health centers in southwestern China (December 2024-February 2025) via online questionnaires. Data included demographics, ADs knowledge, intentions, and attitudes. SPSS 21.0 was used for chi-square tests, t-tests, and binary logistic regression to analyze influencing factors. Results: Among 426 CHWs, only 22.54% possessed prior knowledge of ADs, with a mean knowledge score of 3.82 ± 2.85. Although 83.33% expressed support for ADs, merely 46.95% reported willingness to sign one. The predominant barrier identified by 87.79% of CHWs was the lack of relevant legislation. Logistic regression analysis revealed that: (1) each one-point increase in ADs knowledge score was associated with a 25% higher likelihood of supporting ADs (OR = 1.250, P < 0.05); (2) CHWs with higher education levels were significantly more likely to support ADs (OR = 1.547, P < 0.05); and (3) CHWs’ belief in participating in medical decision-making was negatively correlated with their level of ADs support (OR = 0.386, P < 0.05). Conclusions: CHWs in China exhibit limited knowledge of ADs but generally supportive attitudes. However, the gap between expressed support and personal willingness to sign ADs, coupled with the perceived legal barrier, highlights an urgent need for targeted interventions to facilitate ADs implementation. Key policy priorities should include establishing a legal framework for ADs, clarifying the role of CHWs in end-of-life care processes, and incorporating mandatory ADs training into continuing medical education programs.