3.1 Search results
As shown in Figure 1, 3290 articles were initially identified after conducting the search strategy, and 2118 articles remained after directly removing duplicate literature. After reviewing the title or abstract, 1957 articles that did not meet the eligibility criteria were discarded. Among the remaining 161 studies, 150 articles were removed after full-text review for the following reasons: (1) 46 articles were not cross-sectional studies, (2) 71 articles had no original data, (3) 25 articles did not adopt the standard sampling method, (4) 6 articles had obvious quality problems, and (5) 2 articles were literature reviews. Ultimately, 11 studies were included.
3.2 Analysis of the included articles
The characteristics of the included articles are presented in Table 1. A total of 11 articles contained 65,006 health workers and 31,900 patients distributed throughout China. Of the 11 articles, 4 articles analysed the determinants only from the health worker perspective (HWP)[53, 55-57], 2 articles analysed the determinants from only the patient perspective (PP)[58, 63], 1 article analysed the determinants from both the HWP and the health worker-patient interaction perspective (HWPIP)[54], 2 articles analysed the determinants from both the PP and the HWPIP[59, 61], 1 article analysed the determinants from both the HWP and the PP[62], and 1 article analysed the determinants from the HWP, PP, and HWPIP[60].
Fifty determinants were extracted from the included studies and were categorized into three groups: (1) 24 health worker-related factors: gender, age, years of experience, education level, professional title, department, hospital type, region, income, income satisfaction, working time per day, marital status, employment form, administrative position, whether disputed with patient, workload, medical ethics, whether medical disputes interfere with work, career satisfaction, ability to handle dispute, whether worry about encountering dispute, daily average rate of outpatient visits, medical liability insurance, and time spent in direct contact with the patient; (2) 18 patient-related factors: gender, age, registered residence, education level, occupation, medical insurance, medical expenses, household income, whether have a familiar doctor, hospital type, region, department, whether first visit, registration, sources of patients, whether have family doctors, referral, and operation; (3) 8 health worker-patient interaction-related factors: health worker-patient trust, service attitude, service quality and level, treatment effect, whether health worker receives kickbacks on medications or medical devices, whether adequate medical information is shared, health worker-patient communication, and whether patient bribes or entertains doctors.
3.3 Quality of the included articles
The quality score of 11 articles ranged from 5 to 7 (shown in Table 2), and the average score was 6 out of 7 according to the modified Newcastle-Ottawa scale. All studies were of good quality. Five articles did not meet the sample representative standard (sample size ≥1000). Five articles did not report the non-respondent rate. All studies met other assessment criteria.
3.4 Analysis of health worker-related factors
Of the 11 included articles, a total of 7 analysed the health worker-related factors. Based on these 7 studies, the incidence of health workers with pessimistic attitudes towards the HWPR or who had experienced medical disputes ranged from 8.16% to 82.50%, as shown in Table 1. Overall, the mean proportion of negative attitudes was 55.73% (SE: 10.10%, 95% CI: 31.02%- 80.43%).
Among all extracted health worker-related factors, six factors were included in the meta-analysis, and all the extracted determinants were included in the descriptive analysis. Figure 2 shows the meta-analysis results of the health worker-related factors. Gender (male vs. female, OR: 1.48, 95% CI: 1.42- 1.55, P<0.00001), age (≤50 years old vs. >50 years old, OR: 0.86, 95% CI: 0.80-0.93, P<0.0001), education level (undergraduate or below vs. master or above, OR: 1.39, 95% CI: 1.21-1.60, P<0.00001), department (surgery vs. other, OR: 0.92, 95% CI: 0.88-0.96, P<0.0001), and professional title (intermediate or below vs. senior, OR: 0.77, 95% CI: 0.74-0.81, P<0.00001) were significantly associated with HWPR. However, years of experience (P=0.21) was not significantly associated with the HWPR. The results indicated that male health workers, those over 50 years old, those with a bachelor’s degree or less, those in non-surgical departments and those with senior professional titles were more likely to be pessimistic about the HWPR or to encounter medical disputes.
Among other health worker-related factors reported in these 7 studies, the determinants that were significantly associated with the HWPR included working time per day, workload, income satisfaction, medical ethics, whether medical disputes interfere with work, whether worry about encountering disputes, daily average rate of outpatient visits, hospital type, administrative position, medical liability insurance, and time spent in direct contact with patients. The occurrence of pessimistic attitudes and medical disputes was more likely for health workers who had longer working times[53, 57], had greater working pressure[54, 57], were less satisfied with income [54], had worse medical ethics[54], had more daily outpatients [57], worked in comprehensive hospitals rather than specialty hospitals[56], had no administrative position[56], had no medical liability insurance[56], and spent longer time in contact with patients[53]. Meanwhile, the more likely the health workers are to be affected by medical disputes, the more pessimistic their perception of the HWPR is[54].
3.5 Analysis of patient-related factors
Of the 11 included articles, a total of 6 analysed patient-related factors. Based on the 6 studies, the incidence of patients with pessimistic attitudes towards the HWPR or who had experienced medical disputes ranged from 13.19% to 57.10%, as shown in Table 1. Overall, the mean proportion of negative attitudes was 33.45% (SE: 6.70%, 95% CI: 16.24%- 50.66%).
Among all extracted patient-related factors, five determinants were included in the meta-analysis, and all the extracted determinants were included in the descriptive analysis. Figure 3 shows the meta-analysis results of patient-related factors. Registered residence (urban vs. rural, OR: 0.92, 95% CI: 0.87-0.97, P<0.001), education level (below undergraduate vs. undergraduate or above, OR: 0.75, 95% CI: 0.72-079, P<0.00001), and lack of medical insurance (medical insurance vs. no medical insurance, OR: 0.77, 95% CI: 0.67-0.89, P=0.0004) were significantly associated with HWPR. However, gender (P=0.11) and age (P=0.96) were not significantly associated with the HWPR. The results indicated that rural patients, patients with a bachelor’s degree or above, and uninsured patients were more likely to be pessimistic about the HWPR or to encounter medical disputes.
Among other patient-related factors reported in these 6 studies, the determinants that were significantly associated with the HWPR included occupation, medical expenses, household income, whether they had a familiar doctor, type of visiting hospital, region, department, and whether they were at their first visit, and whether they had family doctors. The occurrence of pessimistic attitudes or medical disputes was more likely to occur in patients who had no regular occupation[60], had higher medical expenses[59, 60], had no familiar doctors or family doctors[58, 59], were not at their first visit[58], visited a specialty hospital[58], visited the department of gynaecology or paediatrics[58], and resided in the western region of China[58].
3.6 Analysis of health worker-patient interaction-related factors
Of the 11 included articles, a total of 4 analysed the health worker-patient interaction-related factors. Among all extracted health worker-patient interaction-related factors, one determinant was included in the meta-analysis, whereas all the extracted determinants were included in the descriptive analysis. Figure 4 shows the meta-analysis results of health worker-patient interaction-related factors. Health worker-patient trust (trust vs. distrust, OR: 0.24, 95% CI: 0.18-0.32, P<0.00001) was significantly associated with HWPR. The results indicated that cultivating trust between health workers and patients can reduce conflicts between them.
Among other health worker-patient interaction-related factors reported in 4 studies, the determinants that were significantly associated with the HWPR included service attitude, service quality and level, treatment effect, whether health worker receives kickbacks on medications or medical devices, whether adequate medical information is shared, health worker-patient communication, and whether patient bribes or entertains doctors. These 3 of 4 studies reported that if there are good service attitudes[59, 60], high service quality and level[59], good treatment effects[59], sufficient medical information sharing [59], and effective communication[61] in the doctor-patient interaction, the HWPR will tend to be harmonious. However, if the health workers receive kickbacks on medications or medical devices, or the patients bribe or entertain the doctor during the treatment[59], the HWPR will become tense.