Characteristics of respondents
Table 1 shows the basic characteristics of the study respondents. Most were male (56.2%) and in the age category between 30–50 years (68.5%). Most respondents had been trained under the conventional medical school curriculum (68.5%) and the majority had been practising as GPs for more than ten years (56.2%). In terms of employment, the majority were working full time (61.6%) and had civil servant status (67.1%). The majority were practising in facilities located in rural areas (69.9%), most worked in public primary healthcare centres (49.3%), and most in facilities contracted by the NHI less than two years previously (53.4%).
Table 1. Basic characteristics of the survey respondents
|
n
|
%
|
|
|
|
Personal characteristics
|
|
|
Gender
|
|
|
Male
|
41
|
56.2
|
Female
|
32
|
43.8
|
|
|
|
Age
|
|
|
< 30 years
|
12
|
16.4
|
30–50 years
|
50
|
68.5
|
> 50 years
|
11
|
15.1
|
|
|
|
Medical school curriculum
|
|
|
Conventional
|
50
|
68.5
|
Competency-based
|
23
|
31.5
|
|
|
|
Working experience
|
|
|
< 5 years
|
16
|
21.9
|
5–10 years
|
16
|
21.9
|
> 10 years
|
41
|
56.2
|
|
|
|
Nature of employment
|
|
|
Full-time
|
45
|
61.6
|
Part-time
|
28
|
38.4
|
|
|
|
Civil servant
|
|
|
Yes
|
49
|
67.1
|
No
|
24
|
32.9
|
|
|
|
Facility characteristics
|
|
|
Location
|
|
|
Rural
|
51
|
69.9
|
Urban
|
22
|
31.1
|
|
|
|
Type of primary care facility
|
|
|
Public health centre
|
36
|
49.3
|
Private clinic
|
13
|
17.8
|
Private physician practice
|
24
|
32.9
|
|
|
|
Duration contracted by NHI
|
|
|
≤ 2 years
|
39
|
53.4
|
> 2 years
|
34
|
46.6
|
|
|
|
Knowledge, attitude and performance with respect to the gatekeeper role
We display the respondents’ overall scores on knowledge, attitude and performance, as well as the distribution of scores among various groupings, in Table 2. The average GP knowledge score was 75.1% (SD 20.5). Comparing the knowledge scores among groups, we observed notable differences between age groups and between public and private primary care settings. GPs in the oldest age group scored highest on knowledge, with a mean of 78.4% (SD 18.1), while those practising in private settings had the highest means of around 81%.
Table 2. Distributions of GPs’ scores on knowledge, attitude and performance regarding the gatekeeper role of primary care
|
Knowledge
|
Attitude
|
Performance
|
|
Mean
|
SD
|
p
|
Mean
|
SD
|
p
|
Mean
|
SD
|
p
|
|
|
|
|
|
|
|
|
|
|
Overall
|
75.1
|
20.5
|
|
64.5
|
24.5
|
|
78.5
|
11.2
|
|
|
|
|
|
|
|
|
|
|
|
Personal characteristics
|
|
|
|
|
|
|
|
|
|
Gender
|
|
|
|
|
|
|
|
|
|
Male
|
75.9
|
20.3
|
.65
|
65.0
|
21.2
|
.67
|
77.3
|
11.9
|
.34
|
Female
|
74.1
|
20.9
|
|
63.9
|
21.1
|
|
79.9
|
10.2
|
|
|
|
|
|
|
|
|
|
|
|
Age
|
|
|
|
|
|
|
|
|
|
< 30 years
|
67.9
|
27.3
|
|
52.8
|
22.2
|
|
76.2
|
7.0
|
|
30–50 years
|
74.0
|
19.0
|
.04
|
64.4
|
24.9
|
.04
|
78.9
|
11.9
|
.67
|
> 50 years
|
88.3
|
12.5
|
|
77.7
|
19.2
|
|
79.2
|
11.7
|
|
|
|
|
|
|
|
|
|
|
|
Medical school curriculum
|
|
|
|
|
|
|
|
|
|
Conventional
|
76.8
|
17.9
|
.52
|
67.3
|
25.6
|
.09
|
79.7
|
11.9
|
.12
|
Competency-based
|
71.4
|
25.1
|
|
58.4
|
21.2
|
|
75.7
|
9.1
|
|
|
|
|
|
|
|
|
|
|
|
Working experience
|
|
|
|
|
|
|
|
|
|
< 5 years
|
67.9
|
28.3
|
|
47.2
|
22.0
|
|
75.0
|
8.2
|
|
5–10 years
|
74.1
|
18.2
|
.54
|
65.3
|
28.4
|
.00
|
78.6
|
12.7
|
.25
|
> 10 years
|
78.4
|
17.2
|
|
71.0
|
20.9
|
|
79.8
|
11.5
|
|
|
|
|
|
|
|
|
|
|
|
Nature of employment
|
|
|
|
|
|
|
|
|
|
Full-time
|
72.7
|
19.9
|
.14
|
62.9
|
24.6
|
.44
|
77.1
|
11.1
|
.34
|
Part-time
|
79.1
|
21.1
|
|
67.1
|
24.6
|
|
80.6
|
11.1
|
|
|
|
|
|
|
|
|
|
|
|
Civil servant
|
|
|
|
|
|
|
|
|
|
Yes
|
76.1
|
18.9
|
.86
|
63.5
|
24.3
|
.57
|
79.6
|
11.3
|
.18
|
No
|
73.2
|
23.6
|
|
66.7
|
25.3
|
|
76.2
|
10.8
|
|
|
|
|
|
|
|
|
|
|
|
Facility characteristics
|
|
|
|
|
|
|
|
|
|
Location
|
|
|
|
|
|
|
|
|
|
Rural
|
73.4
|
20.8
|
.18
|
67.1
|
23.9
|
.17
|
77.8
|
11.5
|
.40
|
Urban
|
79.2
|
19.6
|
|
58.5
|
25.4
|
|
79.9
|
10.5
|
|
|
|
|
|
|
|
|
|
|
|
Type of primary care facility
|
|
|
|
|
|
|
|
|
|
Public health centre
|
68.6
|
22.1
|
|
58.9
|
25.1
|
|
80.5
|
10.3
|
|
Private clinic
|
81.3
|
14.7
|
.03
|
67.5
|
26.6
|
.16
|
78.0
|
15.0
|
.24
|
Private physician practice
|
81.5
|
18.1
|
|
71.3
|
21.1
|
|
75.6
|
9.8
|
|
|
|
|
|
|
|
|
|
|
|
Duration contracted by NHI
|
|
|
|
|
|
|
|
|
|
≤ 2 years
|
74.3
|
19.4
|
.35
|
64.9
|
23.9
|
.89
|
76.5
|
10.6
|
.12
|
2 years
|
76.0
|
21.8
|
|
64.1
|
25.5
|
|
80.7
|
11.6
|
|
|
|
|
|
|
|
|
|
|
|
In the attitude domain, GPs’ overall average score was 64.5% (SD 24.5). Differences in attitude scores emerged among different age groups and in relation to medical school curriculum, work experience as GPs, and location and type of primary care setting. The highest mean scores were found among GPs in the oldest age group (77.7%, SD 19.2), the conventionally trained (67.3%, SD 25.6), the most experienced (71.0%, SD 20.9), those practising in rural areas (67.1%, SD 24.6) and the solo practitioners (71.3%, SD 21.1).
The GPs’ average overall score for the performance domain was 78.5% (SD 11.2), the highest average score of the three domains. GPs of older age, with more work experience, in urban practice, and practising in public facilities tended to have higher scores on performance than those in the respective comparison categories, but the differences were relatively small.
Factors associated with GPs’ knowledge, attitudes and performance as gatekeepers
In Table 3, we explore personal and facility characteristics as factors potentially associated with GPs’ scores in terms of knowledge, attitude and performance with regard to the primary care gatekeeping role. For knowledge scores, we found no personal or facility characteristics with significant associations in either Model 1 or 2, although GPs in private practice tended to score higher on knowledge than those working in public primary healthcare centres (B = 10.27, p = .06; Model 2).
Table 3. Factors associated with GPs’ scores on knowledge, attitude and performance regarding the gatekeeper role of primary care
|
Knowledge
|
Attitude
|
Performance
|
|
Model 1
|
Model 2
|
Model 1
|
Model 2
|
Model 1
|
Model 2
|
|
B
|
p
|
B
|
p
|
B
|
p
|
B
|
p
|
B
|
p
|
B
|
p
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Personal characteristics
|
|
|
|
|
|
|
|
|
|
|
|
|
Medical school curriculum
|
|
|
|
|
|
|
|
|
|
|
|
|
Conventional
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Competency-based
|
0.29
|
.99
|
−0.31
|
.96
|
−1.27
|
.87
|
−5.50
|
.43
|
−4.40
|
.23
|
−4.72
|
.17
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Working experience
|
|
|
|
|
|
|
|
|
|
|
|
|
< 5 years
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
5–10 years
|
5.35
|
.55
|
7.10
|
.45
|
25.00
|
.01
|
22.10
|
.00
|
5.10
|
.31
|
7.59
|
.14
|
> 10 years
|
5.92
|
.49
|
3.49
|
.70
|
28.93
|
.00
|
32.20
|
.00
|
6.68
|
.18
|
6.91
|
.16
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Nature of employment
|
|
|
|
|
|
|
|
|
|
|
|
|
Full-time
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Part-time
|
6.88
|
.14
|
5.23
|
.31
|
5.34
|
.34
|
2.13
|
.70
|
3.99
|
.13
|
6.81
|
.01
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Civil servant
|
|
|
|
|
|
|
|
|
|
|
|
|
Yes
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
No
|
−5.53
|
.33
|
−4.72
|
.44
|
5.64
|
.41
|
15.13
|
.02
|
−3.69
|
.25
|
0.65
|
.84
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Facility characteristics
|
|
|
|
|
|
|
|
|
|
|
|
|
Location
|
|
|
|
|
|
|
|
|
|
|
|
|
Rural
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Urban
|
0.90
|
.87
|
3.77
|
.53
|
−17.31
|
.00
|
−14.05
|
.03
|
2.54
|
.62
|
4.12
|
.20
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Type of primary care facility
|
|
|
|
|
|
|
|
|
|
|
|
|
Public health centre
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
Private clinic
|
10.65
|
.10
|
10.26
|
.14
|
6.79
|
.15
|
4.87
|
.52
|
−3.40
|
.36
|
−4.73
|
.20
|
Private physician practice
|
10.24
|
.05
|
10.27
|
.06
|
9.40
|
.39
|
8.17
|
.17
|
−6.03
|
.04
|
−6.00
|
.04
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Duration contracted by NHI
|
|
|
|
|
|
|
|
|
|
|
|
|
≤ 2 years
|
Ref
|
–
|
Ref
|
–
|
Ref
|
|
Ref
|
–
|
Ref
|
–
|
Ref
|
–
|
> 2 years
|
−0.81
|
.86
|
1.32
|
.70
|
−3.57
|
.52
|
1.14
|
.82
|
4.17
|
.11
|
3.69
|
.15
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Model 1: each factor, adjusted for age; Model 2: all factors included, adjusted for age
In the attitude domain, GPs’ work experience and facility location were consistently associated with their scores in both models. In Model 2, our finding showed that GPs practising 5 to 10 years (B = 22.10, p = .00) and more than 10 years (B = 32.20, p = .00) scored higher than those practising less than five years. Privately employed GPs were likely to have higher attitude scores than those with civil servant status (B = 15.13, p = .02). GPs practising in urban areas were likely to score lower in attitude than those in rural areas (B = −14.05, p = .03).
In terms of performance, our findings showed that part-time employment was associated with a higher score than full-time work (B = 6.81, p = .01; Model 2). With regard to facility characteristics, employment in private practice was associated with lower performance scores than employment a public primary healthcare centre (B = −6.00, p = .04).
The association between GPs’ knowledge and attitude with GPs’ performance as gatekeepers
In table 4, we displayed the association between GPs’ knowledge and attitude with GPs’ performance as gatekeepers. In all four models, GPs’ knowledge consistently was not associated with GPs’ performance. For attitude, our findings showed that GPs’ attitude was positively associated with the GPs’ performance as gatekeeper. In three of four models, the regression coefficients were statistically significant. After adjusted for all variables, a higher score of GPs’ attitude was associated with higher score of GPs’ performance as gatekeepers (B = 0.160, p = .00) as shown in the fourth model.
Table 4. Association between knowledge and attitude of GPs’ with the performance of GPs as gatekeepers.
|
Model 1
|
Model 2
|
Model 3
|
Model 4
|
|
B
|
p
|
B
|
p
|
B
|
p
|
B
|
p
|
|
|
|
|
|
|
|
|
|
Knowledge
|
-0.065
|
0.32
|
-0.075
|
0.23
|
-0.096
|
0.11
|
-0.114
|
0.06
|
|
|
|
|
|
|
|
|
|
Attitude
|
0.101
|
0.64
|
0.137
|
0.01
|
0.118
|
0.03
|
0.160
|
0.00
|
|
|
|
|
|
|
|
|
|
Model 1: Knowledge or attitude adjusted to age; Model 2: Knowledge or attitude adjusted to age, personal characteristics, and facility characteristics; Model 3: Knowledge and attitude adjusted to age; Model 4: Knowledge and attitude adjusted to age, personal characteristics, and facility characteristics.