Association Between External Training and Self-Reported Competence Improvement Among County Hospital Healthcare Providers: A Cross-Sectional Study from China.

BACKGROUND: Training has been shown to be associated with competence improvement among healthcare providers. This study aimed to evaluate the relationship between external training and self-reported competence improvement among county hospital healthcare providers in the context of China's "Thousand-County Project" policy. METHODS: A multi-center cross-sectional survey was conducted from June to September 2025, involving 605 healthcare providers from 30 county hospitals across six provinces in China. Propensity score matching was used to control for observed confounding, and multivariable ordinal logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the association between post-policy external training and self-reported competence improvement, using 5-point Likert scale as the ordered outcome. Interaction tests and a series of sensitivity analyses were conducted to assess robustness and explore potential effect modification. RESULTS: Matching effectively balanced the distribution of covariates between the two groups. Ordinal logistic regression showed that participants who received post-policy external training reported significantly higher self-reported competence improvement than those who did not (OR = 3.36, 95%CI: 1.74-6.48, p < 0.001). Policy awareness was also strongly associated with self-reported competence improvement (OR = 4.50, 95%CI: 2.53-7.99, p < 0.001), and a significant interaction indicated that this association was substantially stronger among those who were aware of the policy (p for interaction = 0.043). Sensitivity analyses, including cluster-robust standard errors and alternative propensity score specifications, yielded consistent results, supporting the robustness of the findings. CONCLUSIONS: Post-policy external training was significantly associated with higher self-reported competence improvement among county hospital healthcare providers, and this association appeared stronger among those with greater policy awareness. To better support such initiatives, policymakers could consider strengthening financial support for external training, while hospitals might optimize staffing arrangements to facilitate training participation. Additionally, improving policy dissemination may help raise healthcare providers' awareness of relevant policies.