Is the Family Doctor Contract Service Program widely and equitably known among Chinese community residents? A national cross-sectional survey

doi:10.21203/rs.3.rs-4909957/v1

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Research Article

Is the Family Doctor Contract Service Program widely and equitably known among Chinese community residents? A national cross-sectional survey

https://doi.org/10.21203/rs.3.rs-4909957/v1

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Background:

The Family Doctor Contract Service Program in China aims to enhance the accessibility and continuity of primary care by fostering ongoing, patient-centered relationships between residents and primary care physicians. This study examines nationwide awareness levels of the program in 2023, with a focus on disparities across different economic development levels, socioeconomic strata, and urban versus rural areas.

Methods:

A stratified, quota-sampled national survey was conducted from June to August 2023, targeting Chinese residents aged 18 and older across 800 communities in 32 provinces. The survey assessed awareness of the Family Doctor Contract Service Program along with related sociodemographic and health characteristics. Statistical analysis included estimating awareness rates, adjusted for age and gender weighting, and examining the association between sociodemographic factors and awareness using multilevel modeling, with provinces as the first level and residents as the second.

Results:

The survey included 12,403 respondents, with an overall awareness rate of 49.75%. Awareness rates were 63.7%, 53.24%, and 48.28% in high-, middle-, and low-income provinces, respectively, and 57.23%, 49.42%, and 44.69% across high-, middle-, and low-socioeconomic status (SES) groups. Urban residents had a higher awareness rate (56.78%) compared to rural residents (45.50%). Residents in provinces where the average annual income is less than 40,000 yuan were significantly less likely to be aware of the program (OR=1.70, 95% CI: 1.24-2.31, P=0.001) compared to those in provinces with an average annual income of 60,000 yuan or more. Similarly, individuals in SES levels 1-2 were more likely to be unaware of the program compared to those in SES levels 6-7 (OR=1.47, 95% CI: 1.27-1.71, P≤0.001). Rural residency was also associated with a higher likelihood of being unaware of the program (OR=1.13, 95% CI: 1.03-1.22, P=0.006).

Conclusion:

Nine years after its implementation, only about half of mainland China's community residents are aware of the Family Doctor Contract Service Program, with particularly low awareness among economically disadvantaged provinces, lower socioeconomic groups, and rural areas. There is a critical need to enhance the dissemination of information about the program and enhance primary care to meet the health service needs of these vulnerable populations.

Primary Care

General Practice

Primary Health Care

Family Doctor

Health Policy Promotion

Health Service Inequality

Social Determinant of Health

A fundamental design feature of China's primary care system is its strong emphasis on accessibility and equity, aiming to ensure that every resident has access to affordable and basic medical and health services through primary care facilities located near their communities and villages¹. However, to this day, China's primary care continues to face severe limitations in the scope and quality of clinical services provided, leading to a gradual decline in trust and reliance on primary care among residents with more complex and higher medical needs^2,3. Since 2010, there has been a noticeable decrease in the percentage of patients initially choosing primary care facilities for medical treatment, accompanied by weakening ties between patients and doctors⁴.

Beginning with pilot programs in 2009 and expanding nationwide in 2016, the Family Doctor Contract Service Program launched by the Chinese government aims to rebuild the personal connections and trust between residents and primary care doctors⁵. "Its core design encourages residents to sign annual, renewable primary health care service contracts with family doctors in nearby primary care facilities, thereby fostering long-term and stable doctor-patient relationships, and gradually instilling the habit of consulting their family doctor first when health issues arise^6,7. The promotion of this project is primarily managed by national and provincial health departments through administrative documents and transformed into performance indicators that require regular supervision, mandating primary care facilities to propagate it. These institutions further delegate the tasks to teams or individual primary care practitioners, who are often responsible for a specific community or rural area, promoting the project to the residents and inviting them to sign contracts with the family doctor teams^8–10. According to official data from several provinces in China, as well as the results of a recent study, by 2023, the nominal contracting rate of family doctors is projected to be around 30%^11–13. Moreover, the National Health Commission has devised an ambitious long-term plan to increase the national family doctor contracting rate to 75% by 2035⁷.

However, multiple studies have shown that although many residents have formally "contracted" family doctor services, they rarely utilize these services^8,14. This phenomenon, termed "contract without engagement," is commonly attributed to the longstanding distrust residents hold towards primary care facilities, coupled with the facilities' inadequate clinical scope, capabilities, resources, and equipment, which deter residents from seeking actual services despite having completed the necessary contracts^3,8.9,14. Additionally, frontline general practitioners propose another explanation: the insufficient resources of primary care facilities, such as manpower and medical supplies, along with the clinical task-centered traditions of these institutions, limit their ability and willingness to disseminate and implement family doctor contracts to community residents. Consequently, many details of these contracts are still not widely or equitably understood among all community residents to this day^15,16. Available data from studies across various provinces and regions reveal significant variability in residents' awareness rates, ranging from 25% to over 80%^17–21.Moreover, a comprehensive nationwide survey on the awareness and influencing factors of family doctor contract services in China is still lacking.

Therefore, in this study, we aim to investigate from a nationwide perspective the awareness rata of community residents regarding the Family Doctor Contract Services Program and the factors contributing to disparities in awareness situations. Considering that health equity is both a core outcome of primary care²² and a central focus of China's current health reforms²³, we will prioritize examining the differences in awareness rates among residents in provinces with varying economic development levels, across different socioeconomic strata, and between urban and rural areas.

Population and Sample

The target population of this study comprises community residents living in Mainland China aged 18 and older. It was conducted as part of the "Psychological and Behavioral Investigation of Chinese Residents" (PBICR)²⁴, a national, face-to-face field survey that has been carried out annually since 2020. The 2023 survey ran from June 20 to August 31, and employed stratified sampling by province and quota sampling by gender and age, encompassing 21,916 residents from 800 communities and villages across 32 provincial administrative units in China. Participants were required to be over 12 years old, residing in the specified communities or villages, willing to participate, and free from cognitive impairments, mental instability, or disorganized thinking. The survey design and questionnaire underwent a review by a dedicated expert committee, which ensured the validity of the data through rigorous logical checks, including only those questionnaires that were completed validly in the final analysis. The target information gathered included personal and family data, as well as individual health, mental health, and behavioral health status.

The survey was implemented through a public health academic network. In each province, university researchers or teams from related research institutions set up a network of survey sites in collaboration with local community health centers or neighborhood offices. During the survey period, trained interviewers recruited local residents who met the inclusion criteria at each site using posters and face-to-face interactions, guiding them to complete electronic questionnaires via smartphones or tablets. The completed questionnaires were automatically recorded on a backend server. The response rate for the 2023 survey was 98.3%. Additional details about the study design are provided in a separate publication²⁴.

Given that the educational level of participants in the original PBICR2023 data was significantly higher than the national statistics for China, we conducted a pre-screening of the data based on the educational levels of different age groups from the 2022 national statistics of China²⁵, to align the sample's educational distribution more closely with the national level. Considering that the Family Doctor Contract Service Program is currently only implemented in the provinces of mainland China, inclusion criteria were set as: a. permanent residency in China (travel abroad ≤ 1 month per year); b. age ≥ 18 years; c. non-military personnel; and d. not a resident of Hong Kong, Macau, or Taiwan. The data analysis period was from January 3, 2024, to April 3, 2024.

Key Variables

In the 2023 PBICR, we incorporated a preset question to determine whether the surveyed residents are aware of the Family Doctor Contract Services Program. Drawing from the literature on the promotion, awareness, and utilization of this program^{8–11,14−19}, we initially selected two province-level administrative variables: residents' per capita disposable income in 2022 and the number of general practitioners per 10,000 people. Additionally, we included 13 individual-level variables: gender, age, ethnicity, household registration, educational level, family per capita annual income, subjective social status (SSS), marital status, health insurance coverage, social media usage habits, chronic disease status, behavioral health, and self-perceived health. These variables are thoroughly detailed in Supplementary Table 1, which also includes the measurement methods and categorization standards used for statistical analysis.

Statistical Analysis

We initially applied weighting to the age and gender distributions of the sample population, leveraging the gender ratios by age group from the recent China Statistical Yearbook²³. This allowed us to calculate the awareness rates of the Family Doctor Contract Services among the entire resident population, as well as among residents in provinces with varying income levels, different SSS groups, and different household registrations.

Subsequently, we applied descriptive statistics to analyze the sociodemographic and health characteristics of the sample population, reporting means and 95% confidence intervals (CI) or medians and interquartile ranges (IQR) for continuous variables, and percentages for categorical variables. To assess differences between residents aware of the Family Doctor Contract Services and those unaware, we utilized chi-square tests, Student's t-tests, and non-parametric tests.

Ultimately, we constructed multilevel models with provinces as the first level and residents as the second level to explore the association between different covariates, particularly concerning the income levels of provinces, SSS levels, and household registration, and whether residents were aware of the Family Doctor Contract Services. We identified Minimal Sufficient Adjustment Sets (MSAS) from causal directed acyclic graphs (DAGs)²⁶ (refer to Figure S1), which aided in estimating both the total and direct effects. Besides, as a subgroup analysis, we conducted association analyses using multilevel models for residents within each category of provinces based on varying levels of average annual income, similar to the analyses performed on the entire sample.

We crafted weighted trend graphs regarding residents' awareness of family doctors using Tableau 2023.2 (Tableau Software, Seattle, USA) and generated causal directed acyclic graphs via DAGitty (version 3.1). Additionally, statistical analysis was performed using Stata software, version 17.0 SE (StataCorp), with a significance level set at p ≤ 0.05.

Ethical Considerations

The PBICR survey was conducted in accordance with the Declaration of Helsinki, and informed consent was obtained from all participants. The study received approval from the Biomedical Ethics Committee of Shandong Provincial Hospital (Approval No.: SWYX: NO.2023 − 198) on May 5, 2023.

Figure 1 illustrates the awareness rates of the Family Doctor Contract Services Program for the entire sample and key subpopulations, adjusted for gender and age. The overall awareness rate among all residents is 49.75%. Awareness rates decrease progressively with reductions in provincial per capita income and SSS levels (from the highest income provinces to the lowest: 63.7%, 53.24%, 48.28%; from the highest to the lowest SSS groups: 57.23%, 49.42%, 44.69%). Moreover, urban residents have a significantly higher rate than rural residents (56.78% vs. 45.50%).

Table 1 presents the sociodemographic and health characteristics of the 12,403 respondents. Compared to residents who are aware of the Family Doctor Contract Services Program, those who are unaware show higher proportions in the following groups: residing in provinces where the average annual per capita income is below 40,000 yuan (81.43% vs. 76.79%, P ≤ 0.001), having middle or lower socioeconomic status (SSS) levels (87.89% vs. 83.63%, P ≤ 0.001), and having rural household registration (69.33% vs. 57.96%, P ≤ 0.001). Additionally, among those unaware of the Family Doctor Contract Services, a greater proportion also includes residents aged 60 or older, those with an educational level of middle school or below, those with a family annual per capita income of less than 54,000 yuan, those with high-copay insurance scheme or no insurance, those using social media infrequently to gather information, those suffering from chronic diseases, and those belonging to ethnic minorities (all P < 0.05). Moreover, these individuals exhibit significantly lower behavioral health scores (Median: 1.33 vs. 1.5, P ≤ 0.001), EQ-VAS scores (Median: 74 vs. 79, P ≤ 0.001), and fewer general practitioners per 10,000 people (Mean: 3.08 vs. 3.15, P ≤ 0.001).

Table 1

Sociodemographic and Health Characteristics of Survey Participants
	Awareness of Family Doctor Contract Service Program				Total		P-value
	Yes		No
	No.	Col %	No.	Col %	No.	Col %
Gender							0.958
Female	3088	51.79	3332	51.74	6420	51.76
Male	2875	48.21	3108	48.26	5983	48.24
Age							≤ 0.001
18–29 years	984	16.50	785	12.19	1769	14.26
30–39 years	829	13.90	678	10.53	1507	12.15
40–49 years	1482	24.85	1266	19.66	2748	22.16
50–59 years	1293	21.68	1316	20.43	2609	21.04
60–69 years	743	12.46	1199	18.62	1942	15.66
≥ 70 years	632	10.60	1196	18.57	1828	14.74
Ethnicity							0.01
Han	5460	91.56	5811	90.23	11271	90.87
Minority	503	8.44	629	9.77	1132	9.13
Household Registration							≤ 0.001
Urban	2507	42.04	1975	30.67	4482	36.14
Rural	3456	57.96	4465	69.33	7921	63.86
Education							≤ 0.001
College or above	1246	20.90	665	10.33	1911	15.41
High school	1096	18.38	770	11.96	1866	15.04
Middle school	2183	36.61	2102	32.64	4285	34.55
Elementary school or less	1438	24.12	2903	45.08	4341	35.00
Per Capita Annual Household Income							≤ 0.001
≥ 54,000 Yuan	2123	35.60	1588	24.66	3711	29.92
18,000–53,999 Yuan	2893	48.52	3312	51.43	6205	50.03
< 18,000 Yuan	947	15.88	1540	23.91	2487	20.05
Subjective Social Status							≤ 0.001
High level (levels 6–7)	976	16.37	780	12.11	1756	14.16
Middle level (levels 3–5)	4211	70.62	4681	72.69	8892	71.69
Low level (levels 1–2)	776	13.01	979	15.20	1755	14.15
Marital Status							0.019
Yes	4408	73.92	4878	75.75	9286	74.87
No	1555	26.08	1562	24.25	3117	25.13
Health Insurance							≤ 0.001
Low copay	348	5.84	244	3.79	592	4.77
Medium copay	1085	18.20	601	9.33	1686	13.59
High copay	4324	72.51	5200	80.75	9524	76.79
No insurance	206	3.45	395	6.13	601	4.85
Using Social Media to Find Information							≤ 0.001
Very Likely	1228	20.59	839	13.03	2067	16.67
Likely	2384	39.98	2169	33.68	4553	36.71
Neutral	1522	25.52	1789	27.78	3311	26.70
Unlikely	434	7.28	852	13.23	1286	10.37
Very unlikely	395	6.62	791	12.28	1186	9.56
Chronic Disease Status							≤ 0.001
No	4266	71.54	4033	62.62	8299	66.91
Yes	1697	28.46	2407	37.38	4104	33.09
Annual Income Level of Residents - Provincial Level							≤ 0.001
≥ 60,000 Yuan	316	5.30	186	2.89	502	4.05
40,000–59,999 Yuan	1068	17.91	1010	15.68	2078	16.75
< 40,000 Yuan	4579	76.79	5244	81.43	9823	79.20
Total	5963	100.00	6440	100.00	12403	100.00

The results of the multilevel model (Fig. 2) illustrate the disparities in awareness of the Family Doctor Contract Services Program based on provincial income levels and other demographic factors. Specifically, residents of provinces with an average annual income between 40,000 and 59,999 yuan are approximately 1.41 times more likely to be unaware of the program compared to those in provinces where the average income exceeds 60,000 yuan (95% CI: 1.01–1.97, P = 0.042). This likelihood of unawareness increases even further among residents of provinces with incomes below 40,000 yuan, where the odds are 1.71 times greater (95% CI: 1.25–2.34, P = 0.001). Relative to residents with a subjective social status of levels 6–7, those categorized within levels 3–5 have 1.37 times the odds of being unaware of the services (95% CI: 1.23–1.54, P ≤ 0.001), and the odds increase to 1.49 times for those within levels 1–2 (95% CI: 1.29–1.73, P ≤ 0.001). Additionally, rural residents are slightly less likely to be aware of the services compared to their urban counterparts, with an odds ratio of 1.13 (95% CI: 1.04–1.23, P = 0.005). Other factors significantly associated with a higher likelihood of being unaware of the Family Doctor Contract Services include being male, aged between 40–59 years, possessing a lower educational level, having a lower family annual per capita income, with moderate insurance scheme or no insurance at all, using social media less frequently to obtain health information, and maintaining better behavioral health practices (all P < 0.05).

Subgroup analysis shows that in middle-income provinces, awareness of the program is significantly lower among rural residents compared to urban residents (OR = 1.32, 95% CI: 1.07–1.64, P ≤ 0.001), and among those with lower SSS levels compared to those with higher SSS levels (OR = 1.38, 95% CI: 1.06–1.79), P ≤ 0.001. These disparities are more pronounced than in low-income provinces and significantly greater than in high-income provinces (Table 2).

Table 2

Multilevel Model: Factors Associated with Unawareness of Family Doctor Contract Services-for Residents Living in Areas with Different Economic Levels
	High Income Provinces (> 60,000 Yuan)			Medium Income Provinces (40,000–60,000 Yuan)			Low Income Provinces (< 40,000 Yuan)
	OR	95%CI	P-value	OR	95%CI	P-value	OR	95%CI	P-value
Gender
Female	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Male	1.367	[0.90,2.07]	0.14	1.198	[0.99,1.45]	0.066	1.135**	[1.04,1.24]	0.004
Age
18–29 years	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
30–39 years	0.759	[0.33,1.76]	0.522	1.073	[0.73,1.58]	0.72	0.842	[0.70,1.01]	0.062
40–49 years	1.121	[0.46,2.73]	0.802	0.791	[0.54,1.16]	0.234	0.731***	[0.61,0.87]	< 0.001
50–59 years	1.221	[0.50,3.00]	0.663	0.826	[0.55,1.25]	0.364	0.711***	[0.59,0.85]	< 0.001
60–69 years	1.113	[0.43,2.85]	0.823	0.858	[0.55,1.33]	0.496	0.928	[0.76,1.13]	0.464
≥ 70 years	2.173	[0.77,6.10]	0.141	0.812	[0.52,1.27]	0.365	0.921	[0.75,1.14]	0.442
Ethnicity
Han	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Minority	0.994	[0.37,2.67]	0.991	0.685	[0.37,1.27]	0.232	1.102	[0.95,1.27]	0.19
Household Registration
Urban	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Rural	1.044	[0.65,1.66]	0.858	1.324**	[1.07,1.64]	0.01	1.106*	[1.01,1.22]	0.037
Education
College or above	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
High school	0.955	[0.48,1.89]	0.895	1.093	[0.78,1.54]	0.611	1.216*	[1.04,1.42]	0.014
Middle school	1.383	[0.72,2.67]	0.334	1.228	[0.89,1.69]	0.205	1.618***	[1.39,1.88]	< 0.001
Elementary school or less	1.71	[0.83,3.52]	0.145	2.879***	[1.99,4.16]	< 0.001	2.605***	[2.20,3.08]	< 0.001
Per Capita Annual Household Income
≥ 54,000 Yuan	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
18,000–53,999 Yuan	1.647*	[1.07,2.54]	0.025	1.077	[0.88,1.32]	0.475	1.214***	[1.09,1.35]	< 0.001
< 18,000 Yuan	1.455	[0.62,3.40]	0.386	0.861	[0.61,1.21]	0.386	1.372***	[1.20,1.57]	< 0.001
Subjective Social Status
High level (levels 6–7)	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Middle level (levels 3–5)	1.203	[0.64,2.26]	0.565	1.377*	[1.06,1.79]	0.017	1.376***	[1.21,1.56]	< 0.001
Low level (levels 1–2)	1.51	[0.65,3.51]	0.338	1.707**	[1.17,2.49]	0.006	1.463***	[1.24,1.73]	< 0.001
Marital Status
Yes	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
No	1.834	[0.98,3.45]	0.059	1.008	[0.77,1.32]	0.952	0.943	[0.84,1.06]	0.333
Health Insurance
Low copay	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Medium copay	0.77	[0.33,1.81]	0.549	1.277	[0.79,2.06]	0.316	0.872	[0.69,1.10]	0.249
High copay	1.573	[0.75,3.31]	0.233	1.525	[0.99,2.35]	0.055	1.266*	[1.03,1.56]	0.024
No insurance	3.598*	[1.17,11.11]	0.026	3.858***	[2.12,7.03]	< 0.001	1.835***	[1.38,2.43]	< 0.001
Using Social Media to Find Information
Very Likely	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Likely	0.912	[0.51,1.63]	0.757	1.2	[0.91,1.58]	0.189	1.148*	[1.01,1.30]	0.031
Neutral	0.959	[0.52,1.78]	0.894	2.011***	[1.51,2.69]	< 0.001	1.231**	[1.07,1.41]	0.003
Unlikely	2.417	[0.99,5.90]	0.052	2.397***	[1.57,3.65]	< 0.001	1.507***	[1.26,1.80]	< 0.001
Very unlikely	0.977	[0.37,2.55]	0.963	2.832***	[1.89,4.25]	< 0.001	1.359**	[1.12,1.64]	0.002
Poor Behavioral Health	1.021	[0.81,1.29]	0.858	0.99	[0.89,1.10]	0.852	0.848***	[0.81,0.89]	< 0.001
Chronic Disease Status
No	1	[1.00,1.00]		1	[1.00,1.00]		1	[1.00,1.00]
Yes	0.956	[0.59,1.56]	0.858	1.206	[0.95,1.52]	0.116	1.064	[0.96,1.18]	0.233
Self-perceived Health	1	[0.99,1.01]	0.951	0.996	[0.99,1.00]	0.139	0.999	[1.00,1.00]	0.519
Number of General Practitioners per 10,000 Residents	0.403*	[0.17,0.98]	0.044	1.123	[1.00,1.26]	0.051	1.03	[0.91,1.17]	0.64
N	502			2078			9823
Exponentiated coefficients; 95% confidence intervals in brackets
* p < 0.05, p < 0.01, * p < 0.0

The results of this national survey, conducted in 2023, indicate that half of the residents aged 18 and older in Mainland China remain unaware of the Family Doctor Contract Services Program. Moreover, the dissemination of information about the program demonstrates significant social disparities: residents in lower-income provinces, those from lower social classes, and those with rural household registrations are particularly more likely to be unaware of the program, with the differences being especially stark among the former two groups. Additionally, several well-recognized social determinants of health—such as lower educational attainment, lower income levels, lack of health insurance, and limited access to information through media—are associated with this lack of awareness. This issue is most acute in provinces where the average annual per capita income is between 40,000 and 59,999 yuan.

The survey's findings firstly underscore significant regional and socioeconomic disparities, shedding light on the considerable variations in service awareness across different regions as documented in existing research. For example, several studies conducted 7 in major urban centers such as Beijing, Guangzhou, and Zhejiang reported awareness rates surpassing 65%, with some areas reaching beyond 80%^19–21. In stark contrast, research in cities like Hangzhou and Xuzhou recorded awareness rates under 50%, with figures dropping to as low as approximately 25% in locales like Shenzhen^16–18. Considering that previous research reveals that over 90% of residents learn about the Family Doctor Contract Services predominantly through community outreach¹⁷. This method of information dissemination crucially depends on health governance institutions issuing administrative orders to networks of public primary care facilities^8.9. Consequently, the effective spread of information relies on the collaboration between local primary care facilities and community governance organizations, such as neighborhood and village committees, to actively engage and educate residents. The disparities in health service information access identified in this study may be closely tied to regional differences in the reach and capabilities of primary care facilities and grassroots community organizations in disseminating information to residents with diverse socioeconomic and demographic characteristics^27,28.

Additionally, from the perspective of community residents, the sociodemographic characteristics of these residents, along with the local appeal of primary care services, can also inversely influence their interest in gaining a deeper understanding of Family Doctor Contract Services. Past researches and findings from this study consistently show that younger, healthier residents with lower educational levels, lower socioeconomic status, and higher migration rates are less likely to be aware of these services^16,19. This trend subtly aligns with the original design intent of China's Family Doctor Contract Services, which primarily targets the management of chronic illnesses, minor ailments, and common diseases^1,7. Furthermore, since the healthcare reforms of the 1980s, investment in and the construction of China’s healthcare system have centered on comprehensive hospitals, gradually eroding the clinical scope and capabilities of primary care facilities. As a result, these facilities have increasingly been able to offer only basic health services of limited quality and scope, a reality that has become a long-standing public perception³. This situation could further reduce the appeal of Family Doctor Contract Services provided by family doctor teams at local primary care facilities. Residents whose needs for effective diagnosis and treatment exceed the scope and quality of currently offered services may lose interest in learning more about the program.

Recent qualitative studies have identified multiple challenges in the practical implementation of the Family Doctor Contract Services as it seeks to expand its coverage. At both national and provincial levels, current policy design appears to prioritize the government’s emergency response to societal aging over the establishment of a sustainable, person-centered primary care system⁸. At the primary care facility level, this manifests in the government's reliance on setting overly ambitious administrative targets, such as mandating reported contracting rates that exceed specified levels, and implementing overly complex, process-oriented supervision, including requirements for photographic documentation of each doctor’s visit. These measures impose heavy administrative burdens, forcing family doctor teams to operate under less-than-ideal conditions^9,15. Additionally, there is a significant shortfall in increasing manpower, pharmaceutical supplies, and equipment resources at local primary care facilities, hindering their ability to fully meet the health needs of residents^8,9,15. A telling example of this challenge is the case of a patient who took the government-issued promotional bag for the Family Doctor Contract Services package, presumably because the bag itself was useful for carrying items. However, he discarded the promotional materials upon leaving the primary care facility, likely because he either did not fully understand or did not see the value of these services in maintaining and improving his health¹⁵.

Although variations in primary care system design mean that the issues identified in this study may not manifest in the same manner in the United States, where primary care services are losing their appeal under the competitive pressures of specialty departments or retail clinics^29,30, or in Commonwealth systems, where economically disadvantaged patients face longer waiting times for primary care³¹, this study underscores a crucial area for future focus in the development of primary care in mainland China: community residents must be aware of the Family Doctor Contract Services, as this awareness forms the foundation for their access to primary care and its functional features. This requires collaboration between China's health and civil affairs authorities to implement systematic, top-down planning and support, ensuring that residents across different regions and social strata have equal opportunities to learn about and access family doctor contract services. Local governments should also consider managing and allocating resources to primary care facilities and community organizations to establish more equitable and effective pathways for disseminating information about these services to their communities. Additionally, it may be necessary to further enhance the clinical and health service capabilities and quality of primary care facilities to better attract local community residents for medical care.

This study presents two primary limitations. Firstly, after extracting samples based on educational levels, the resultant distribution across various provinces did not allow for precise stratification by provincial populations. We therefore grouped the samples into three broad categories based on the economic development of the provinces and utilized a multilevel model with the province as the primary level to alleviate the impact of sample proportion disparities on our results. Secondly, our research was limited to statistical regressions on multiple variables, which might not comprehensively capture all factors that potentially influence awareness of the Family Doctor Contract Services. To address this, we plan to conduct qualitative and mixed-methods research across various regions in future studies. These efforts aim to provide deeper insights into the effectiveness of community outreach and how well it aligns with community residents' expectations for health services provided by the program.

This national survey conducted in 2023 reveals that the awareness rate of the Family Doctor Contract Services among community residents aged 18 and older in China stands at 49.75%. Additionally, residents in economically underdeveloped provinces, those with lower SSS, and rural inhabitants exhibit relatively lower awareness levels. This highlights significant health service inequalities, with less socially advantaged residents being less informed about this program. Policymakers are therefore urged to prioritize more vulnerable groups in the future expansion of these services, by enhancing community outreach capabilities and adopting a more universal and equitable promotional strategy to better inform community residents about these services. Moreover, there is a crucial need to refine the operational design of the Family Doctor Contract Services and bolster the resources and capabilities of primary care facilities to make these services more appealing to a wider spectrum of residents, particularly the socially disadvantaged.

Ethics approval and consent to participate: The PBICR survey was conducted in accordance with the Declaration of Helsinki, and informed consent was obtained from all participants. The study received approval from the Biomedical Ethics Committee of Shandong Provincial Hospital (Approval No.: SWYX: NO.2023-198) on May 5, 2023.

Consent for publication: Not applicable.

Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflict of Interest Statement: The authors declare no conflict of interest.

Funding: This research was funded by the Shanghai Municipal Health Commission Health Policy Research Project (Grant No. 2023HP28&2023HP71), and Shanghai Leading Talents Program (Grant No. YDH-20170627).

Authorship contributions：Conceptualization, Yang Wang.; Methodology, Yang Wang and Yibo Wu; Data curation, Yang Wang and Yibo Wu; Formal analysis, Yang Wang; Funding acquisition, H.J and D.Y; Project administration, D.Y and Yang Wang; Resources, Yang Wang and Yibo Wu; Supervision, D.Y; Validation, Yang Wang; Writing—original draft, Yang Wang; Writing—review and editing, Yang Wang, Yibo Wu, H.J, and D.Y. All authors have read and agreed to the published version of the manuscript.

Acknowledgments: None.

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Is the Family Doctor Contract Service Program widely and equitably known among Chinese community residents? A national cross-sectional survey

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