With the development of adequate controls for infectious diseases, such as vaccination and antibiotic use, China has experienced an epidemiological transition, shifting the focus from infectious diseases to non-communicable diseases (NCDs) like diabetes and hypertension. For example, the prevalence of hypertension increased from 18% in 2002 to 25.2% in 2012 (1). Compared to treatments, prevention of NCDs at the community level has become more important. Even though the primary health care system was introduced to China in the 1980s, no attention was paid to establishing effective primary health care institutions, such as training primary health-care doctors and constructing insurance reimbursement systems. Due to the economic reforms in the early 1980s, the Chinese government reduced healthcare expenses and the market-oriented health care reforms caused an increased concentration of health care resources at higher-level care facilities, such as university-affiliated hospitals (2, 3). The neglect of the government's primary health care system caused discontent among the public (4). Thus, the Chinese government have been trying to strengthen the ability of health care services in primary health care system within recent years.
Community health care centers (CHCs) and community health care stations (CHSs) are the leading health care providers in the primary health care system and reform in urban China. Primary health care services provided by CHCs include essential public health services, such as immunization, and generalist clinical care, such as general physician (GP) health care services (2). One of the most critical healthcare reform policies was increasing subsidies to primary health care institutions from $2.8 billion in 2008 to $20.3 billion in 2015 (2). The number of CHCs increased from 24,000 to 35,000 in 2018 (1). The policy implementation of primary health care aims to provide affordable and accessible health care services.
With the implementation of primary health care, the concept of primary physicians was introduced in Chinese society. Before 2009, primary physicians included village doctors and “barefoot doctors” (2, 5). After 2009, the Chinese government began to identify physicians in primary health care centers, such as CHCs, to play the gatekeeper's role. In 2011, the central government proposed the Guiding Opinions on Establishing a General Practitioner (GP) System to standardize the primary health care workforce (6). This guideline restricted the establishment of the GP system by training system and qualification exam. Family doctor contract services (FDCS) was published in 2016 (7). The GPs serve as family physicians (FPs) in the community and provide FDCS. FDCS are the extension of health care services based on voluntary signing contract with residents in the communities, providing consistent health care services, and building stable relationship with community’s residents and. To use FDCS, individuals need to sign the service contract with a FD (8).
With the publication of “Healthy China 2030” in 2016, it suggested that FDCS should play an essential role in achieving the goal of Healthy China 2030, which is to improve population health by changing lifestyles, preventing and managing chronic diseases (9, 10). As FDs were designed to serve community residents in CHCs, FDs should become a bridge and referral mechanism between secondary or tertiary hospitals, managers of NCD prevention, and community health monitors (2, 9). The adoption of the FD policy improved utilization of primary health care services for community residents. In 2016, the National Medical Reform Office released a new document to increase community residents' willingness to visit and sign with FDs (11). This document proposed the primary serving population as the elderly, pregnant women, children, individuals with disabilities, and those with hypertension, diabetes, and other chronic diseases. According to the document, in 2017, the FD signing rate should have reached 30% for the general population and 60% for the primary serving population. The document also suggested by 2020, the coverage of the general population should reach 100% of the population. Meanwhile, FDs should hold a stable contract relationship with residents in the communities.
According to previous studies, FDs can effectively save health care resources and manage patients with chronic diseases (12, 13). However, the willingness to visit and sign with FDs have not been well identified. Recently, more researchers have started exploring the utilization of FDCS. Studies have indicated that the awareness of FDCS and the FD signing rate were low (14, 15). Other research also suggested that NCDs patients were more likely to have FDCS (16). Based on previous researches concentrated on estimating the awareness of FDCS, willingness to sign FD, and satisfaction of FDCS, it was found that FDCS provided efficient health care services in the communities (9, 15, 17). Most of these studies or surveys were conducted in Shanghai (9, 12, 16–18), Guangzhou (19), and Zhenjiang province (15). There is an urgent need to examine the primary health care system, FDs, and FDCS in other communities and cities within China. Shenzhen, a southeastern metropolis located in Guangdong, China, and China’s first Special Economic Zone (SEZ), where it attracts millions of migrants to work, live, and study. Thus, the importance of studying the awareness of FDCS, willingness to sign with FD, and utilization of primary health care services in Shenzhen is profound.
Andersen’s Behavioral Model of Health Services Use is widely used in health care utilization research (20). This model provides a conceptual framework for understanding different dimensions of access to medical care and individuals’ decision to use health care services. The determinants of utilization of primary health care vary across different geographical locations, population construction, and socio-economic settings (2, 3, 9, 12, 14–16, 18, 19, 21–23). The relationship between FDs and CHC utilization is not well identified. Also, the relationship between chronic disease and FDs has not been well understood. We adapted Andersen’s Behavioral Model of Health Services Use to identify factors that potentially facilitate FDs' impact on CHC utilization and the impact of chronic diseases on FD utilization. According to the model, the utilization of CHCs is determined by three factors, predisposing, enabling, and needs. Predisposing factors are demographic characteristics, such as age, gender, education, and marital status. Enabling factors can be defined as insurance status, such as the availability of insurance. This research estimated two perspectives of needs. First, the awareness of FD and the likelihood of signing with a FD were used to estimate the utilization of CHCs. Second, the status of chronic disease was used to estimate the awareness of FD and the likelihood of signing with a FD (12, 24).
Compared to Shanghai, Shenzhen has a shorter history of FDCS. Shanghai was the first city to pilot FDCS in 2013 (9). Shenzhen published the FD guideline and policy at the end of 2017, and established the FDCS in 2018 (8). The function of FDs in Shenzhen is the same as in other cities. With the development and transformation of the economy, Shenzhen attracts millions of rural laborers and non-permanent migrants to work in the city (22). In 2018, the permanent year-end population was 13.02 million in Shenzhen, and 24.24 million in Shanghai. However, the year-end registered population was 4.55 million in Shenzhen, and 14.63 million in Shanghai suggested that the migration rate was 65% in Shenzhen, which was higher than 40% in Shanghai (25, 26). Compared to Shanghai, the policy implementation of FDCS may have a different impact on the utilization of health care services in CHCs. To the authors’ knowledge, limited research has conducted to estimate the impact of awareness of FDCD on probability of using CHCs, and the impact of signing with a FD on probability of utilizing community based CHCs in Shenzhen. Furthermore, limited research has been done to estimate the impact of having any chronic diseases on awareness of the FDCS and signing with a FD.
The purpose of this study is to identify effects, if any, of the awareness of FDCS on the probability of healthcare-seeking behavior change, and of having signed with a FD on healthcare-seeking behavior. We hypothesized that being aware of the FD services increases the probability for community residents to select CHCs as their first choice of health care institute. We also hypothesized that signing with a FD increases community residents' probability of choosing CHCs as their preferred health care institute. Furthermore, we also hypothesized that individuals with chronic disease are more likely to be aware of FDCS and have signed with a FD.