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      Factors associated with residents’ contract behavior with family doctors in community health service centers: A longitudinal survey from China

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          Abstract

          Background

          China adopted family doctor (FD) to help achieve “Healthy China 2030” through providing continuous, comprehensive, and life-cycle contract services. However, there is a disparity between actual and targeted FD use, as residents continue to visit specialists in large hospitals. The government implemented initiatives to improve residents’ willingness to sign up with and visit their FDs. Factors that influence contract behavior are therefore significant for frontier policy research.

          Methods

          Two survey waves were conducted in Shanghai (2013 and 2016). The first wave included 2754 people and the second 1995 people. Exploratory factor analysis was used to synthesize “satisfaction” as a predictor of contract behavior. Pearson’s chi-square, pooled and logistic regression models were used to estimate associations between influencing factors and contract behavior, and clarify variations in factors across the two waves.

          Results

          Four factors were extracted from 15 satisfaction items: “Treatment Environment,” “Medical Technology,” “Service Specification” and “Service Attitude”. Consistent with descriptive analysis, longitudinal analysis showed sociodemographic characteristics (age, education, marital status, and hukou) were significant predictors of contract behavior. The odds ratio of non-communicable diseases (NCD) patients for contract behavior was 2.218 times that of residents without NCD. Contract behavior was positively correlated with awareness of FD services (OR = 21.674, 95%CI = 15.043–31.229), satisfaction with Service Attitude (OR = 1.210, 95%CI = 1.009–1.451), and visit compliance (OR = 1.959, 95%CI = 1.564–2.452). Over time, the odds ratios of the married, Shanghai hukou, NCD, and awareness of FD services declined from 0.456, 1.795, 2.492, 28.690 to 0.443, 1.678, 1.910 and 14.031 respectively, while those of age, and visit compliance increased from 1.027, 1.521 to 1.041 and 2.305 respectively. In 2016, an education-contract gradient had formed (the higher the education level, the higher probability of signing with a FD), whereas high school education had the highest odds ratio (OR = 1.163,95%CI = 0.740–1.827) in 2013. Service Attitude was the only significant satisfaction-related predictor (OR = 1.358, 95%CI = 1.001–1.842) in 2016, compared with “Treatment Environment” (OR = 1.224, 95%CI = 1.001–1.496) and “Service Specification” in 2013(OR = 1.270, 95%CI = 1.040–1.552).

          Conclusions

          Except for the socio-demographic variables, NCD, awareness of FD services, satisfaction and visit compliance were significant predictors of contract behavior with FDs. The effect of visit compliance had increased over time while NCD and awareness of FD services were losing impact over time. Significant satisfaction factors had also changed from “Treatment Environment” and “Service Specification” to “Service Attitude”.

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          Most cited references 53

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          General practice and primary health care in Denmark.

          General practice is the corner stone of Danish primary health care. General practitioners (GPs) are similar to family physicians in the United States. On average, all Danes have 6.9 contacts per year with their GP (in-person, telephone, or E-mail consultation). General practice is characterized by 5 key components: (1) a list system, with an average of close to 1600 persons on the list of a typical GP; (2) the GP as gatekeeper and first-line provider in the sense that a referral from a GP is required for most office-based specialists and always for in- and outpatient hospital treatment; (3) an after-hours system staffed by GPs on a rota basis; (4) a mixed capitation and fee-for-service system; and (5) GPs are self-employed, working on contract for the public funder based on a national agreement that details not only services and reimbursement but also opening hours and required postgraduate education. The contract is (re)negotiated every 2 years. General practice is embedded in a universal tax-funded health care system in which GP and hospital services are free at the point of use. The current system has evolved over the past century and has shown an ability to adapt flexibly to new challenges. Practice units are fairly small: close to 2 GPs per unit plus nurses and secretaries. The units are fully computerized, that is, with computer-based patient records and submission of prescriptions digitally to pharmacies etc. Over the past few years a decrease in solo practices has been seen and is expected to accelerate, in part because of the GP age structure, with many GPs retiring and new GPs not wanting to practice alone. This latter workforce trend is pointing toward a new model with employed GPs, particularly in rural areas.
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            The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998.

            To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades. Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n = 504). Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression. Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts. The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health. (1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.
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              Internal migration and health: re-examining the healthy migrant phenomenon in China.

               Juan Chen (2011)
              This study re-examines the healthy migrant phenomenon in China's internal migration process and investigates the different trajectories of place of origin on migrants' self-rated physical health and psychological distress. Data came from a household survey (N = 1474) conducted in Beijing between May and October in 2009. Multiple regression techniques were used to model the associations between self-rated physical health, psychological distress, and migration experience, controlling for sociodemographic characteristics. The healthy migrant phenomenon was observed among migrants on self-rated physical health but not on psychological distress. Different health status trajectories existed between physical health versus mental health and between rural-to-urban migrants versus urban-to-urban migrants. The study draws particular attention to the diminishing physical health advantage and the initial high level of psychological distress among urban-to-urban migrants. The initial physical health advantage indicates that it is necessary to reach out to the migrant population and provide equal access to health services in the urban area. The high level of psychological distress suggests that efforts targeting mental health promotion and mental disorder prevention among the migrant population are an urgent need. The findings of the study underline the necessity to make fundamental changes to the restrictive hukou system and the unequal distribution of resources and opportunities in urban and rural areas. These changes will lessen the pressure on big cities and improve the living conditions and opportunities of residents in townships/small cities and the countryside. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: Writing – original draftRole: Writing – review & editing
                Role: Writing – original draft
                Role: Project administration
                Role: Data curation
                Role: Data curation
                Role: Project administration
                Role: Conceptualization
                Role: Conceptualization
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                29 November 2018
                2018
                : 13
                : 11
                Affiliations
                [1 ] School of Social Development and Public Policy, Fudan University, Shanghai, China
                [2 ] Pudong Institute for Health Development, Shanghai, China
                [3 ] Shanghai Pudong Gongli Hospital, Shanghai, China
                [4 ] School of Economics and Management, Hainan Normal University, Hainan, China
                [5 ] Health and Family Planning Commission of Pudong New District, Shanghai, China
                Sefako Makgatho Health Sciences University, SOUTH AFRICA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-18-20382
                10.1371/journal.pone.0208200
                6264849
                30496254
                © 2018 Huang et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 0, Tables: 5, Pages: 16
                Product
                Funding
                Funded by: the National Natural Science Foundation of China
                Award ID: 71403171
                Award Recipient :
                Funded by: Shanghai Municipal Health and Family Planning Commission Research Project
                Award ID: No.201740016
                Award Recipient :
                This work was funded by the National Natural Science Foundation of China (71403171 to YZ) and the Shanghai Municipal Health and Family Planning Commission Research Project (No.201740016 to JW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                The data generated and analyzed during the present study are not publicly available because of data sensitiveness. However, they are available from the Academic Ethics Committee of Shanghai Pudong Institute for Health Development (via yanhua373@ 123456126.com ) for researchers who meet the criteria for access to confidential data.

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