A Systematic Review of the Health Worker-Patient Relationship in China

Background With a surge of medical disputes in recent years, the health worker-patient relationship (HWPR) in China is presently in a tense situation. Meanwhile, consequent social problems have begun to emerge, such as the practice of defensive medicine and distrust between health workers and patients. Although many empirical studies about the HWPR have been conducted in China, no related systematic reviews have been found. This study can convey the general ndings from China to other areas of the world. tense, which is higher than the proportion of patients who hold this view (33.7%). The HWPR was signicantly associated with individual factors and socioeconomic factors of both health workers and patients, as well as factors related to the health worker-patient interaction. More targeted strategies should be developed to improve the HWPR. or below vs. senior, OR: 0.77, 95% CI: 0.74-0.81, P (cid:0) 0.00001) signicantly HWPR. years of (P=0.21) was associated indicated that male health workers, those over those with in non-surgical departments those with senior professional titles were more likely be pessimistic about HWPR


Background
As con icts between health workers and patients have dramatically increased worldwide in recent years [1][2][3][4][5], the health worker-patient relationship (HWPR) has been in crisis and has attracted global attention. Previous studies have reported that medical professionals are more vulnerable to workplace violence than other professionals [6,7]. In the United States, the number of medical disputes more than tripled from 1991 to 2005 [8]. A survey of workplace violence among nurses in the United States showed that 76% of nurses had been attacked by patients or patient family members within the past year [9]. In 2017, 288 physical injuries and approximately 2600 psychological insults occurred in Germany, and nearly 40% of doctors experienced physical con icts [10]. This rapid growth of medical disputes existed not only in Western countries but also in Asia. For example, in Japan, it was reported that the number of medical malpractice lawsuits had increased 10 times from 102 in 1960 to 1019 in 2003 [11]. Furthermore, this pattern may trigger a vicious cycle [12] in that poor HWPR would undermine the mutual trust between health workers and patients, which would in turn result in medical disputes. Therefore, it is important to analyse the determinants of the HWPR and to establish effective strategies to improve such relationships.
In the Chinese context, medical disputes are highly prevalent. A survey conducted by the Chinese Medical Doctor Association in 2017 reported that 66% of medical personnel had experienced verbal abuse or physical injury [49]. Although many empirical studies have been conducted in China, most were published in Chinese journals, and no related systematic reviews have been found.
Based on the above, this study aimed to systematically review the HWPR and related determinants in China and to further compare these ndings with existing international evidence from other countries.

Methods
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [50], this study comprehensively searched published studies that investigated the determinants of the HWPR in electronic databases. This systematic review was conducted based on English and Chinese databases from January 1, 2000 to January 1, 2020. We searched the following English databases: PubMed, EMBASE and Web of Science; we also searched the following Chinese databases: China National Knowledge Internet Database (CNKI), Wanfang database, and China Biology Medicine disc (CBM/Sinomed).

Search strategy
For the three English databases, i.e., PubMed, EMBASE and Web of Science, we used a search strategy based on a combination of the OR (the relationship between physician and patient) OR (the relation between doctor and patient) OR (the relation between health worker and patient) OR (the relation between physician and patient) OR (the interactions between doctor and patient) OR (the interactions between health worker and patient) OR (the interactions between physician and patient) OR (medical dispute) OR (con ict between doctor and patient) OR (con ict between physician and patient) OR (con ict between health worker and patient) OR (medical trouble)] AND [(determinants) OR (factors) OR (in uences)].
The search strategy is shown in additional le 1.

Eligibility criteria
The eligibility criteria were as follows: (1) Studies (without language restrictions) that were published in a peer-reviewed journal from January 1, 2000 to January 1, 2020 and located in China were included. (2) Studies in which participants included medical personnel (excluding medical personnel in internship and medical students) and patients were included. (3) Studies that analysed related determinants of the HWPR were included. (4) Studies that analysed the determinants of the HWPR in special departments (i.e., psychiatry department, dental department, etc.) or diseases (i.e., urinary system diseases, cancer, etc.) were excluded. (5) Only crosssectional studies were included.

Data extraction and quality assessment
Two independent reviewers participated in the data extraction by screening the acquired studies at the same time, according to the ow diagram (illustrated in Fig. 1). All discrepancies were resolved through discussions, leading to full group consensus. All articles were extracted into a standard extraction form focused on identifying the following for each study: the rst author, year of publication, locations, participants, sample size, quali ed rate, analytical perspective, determinants, negative cases, rate of negative cases and number of references (shown in Table 1).
According to the Grading of Recommendations: Assessment, Development, and Evaluation (GRADE) approach [51], a modi ed Newcastle-Ottawa scale (NOS) was utilized to assess the quality of the included studies. The quality assessment criteria consisted of seven components: (1) representativeness of the sample, (2) sample size, (3) non-respondent rate, (4) ascertainment of the exposure, (5) comparability of subjects in different outcome groups, (6) assessment of the outcome, and (7) use of an appropriate statistical test (shown in Table 2). The total quality assessment score of each study was 7, which was divided into three levels: good quality (score of 5-7), medium quality (score of [3][4], and poor quality (score of 1-2). Studies with medium and good quality were included in our analysis.

Statistical analysis
We used RevMan 5.3 (The Cochrane Collaboration, Oxford, UK) and Stata 16.0 (Stata Corp, College Station, TX, USA) to statistically analyse the results from the included studies. This study mainly analysed the determinants of the HWPR from the perspectives of health workers, patients and health worker-patient interactions. All related variables extracted from the included articles were added to the standard extraction form, and the different variables were transformed into binary variables to permit dichotomous meta-analysis.
However, only the same variables or variables that could be combined into the same types were included in the meta-analysis. The variable screening process is shown in Additional le 1.
The determinants included in the meta-analysis were those reported in at least three articles. For the meta-analysis, we conducted a dichotomous meta-analysis and computed the summary risk estimate by using a xed-effect model. The signi cance of the pooled odds ratio (OR) was determined by the Z-test, with P < 0.05 considered statistically signi cant. The Q statistic was calculated to estimate the heterogeneity, and P ≤ 0.10 was considered statistically signi cant [52]. We assessed the possibility of publication bias for the studies included in the meta-analyses with Egger's linear regression test, which was used to quantitatively evaluate the publication asymmetry, and a P < 0.05 was set as statistically signi cant.
If it was infeasible to make a quantitative synthesis and conduct a meta-analysis for a variable, studies that reported the same determinants were grouped, and a narrative approach and descriptive statistics were used to compare their associations with the HWPR.

Search results
As shown in Figure 1, 3290 articles were initially identi ed 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.

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][56][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 rst visit, registration, sources of patients, whether have family doctors, referral, and operation; (3) 8 health worker-patient interaction-related factors: health workerpatient 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.

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 modi ed 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.

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. were signi cantly associated with HWPR. However, years of experience (P=0.21) was not signi cantly 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 signi cantly 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 satis ed 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].

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, ve 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 signi cantly associated with HWPR. However, gender (P=0.11) and age (P=0.96) were not signi cantly 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 signi cantly 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 rst 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 rst visit [58], visited a specialty hospital [58], visited the department of gynaecology or paediatrics [58], and resided in the western region of China [58].

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 signi cantly associated with HWPR. The results indicated that cultivating trust between health workers and patients can reduce con icts between them.
Among other health worker-patient interaction-related factors reported in 4 studies, the determinants that were signi cantly 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], su cient medical information sharing [59], and effective communication [61] in the doctorpatient 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.

Discussion
In this study, we conducted a systematic review of the present situation and related determinants of the HWPR in China. Seven articles reported the present situation of the HWPR from the perspective of health workers, whereas six articles reported the present situation of the HWPR from the perspective of patients.
The synthesis of the data of 11 articles con rmed that there were signi cant differences in the evaluation of the HWPR situation between health workers and patients [20]. The proportion of health workers with pessimistic attitudes towards the HWPR or who had experienced medical disputes ranged from 8.16% to 82.50% (mean: 55.73%, SE: 10.10%, 95% CI: 31.02%-80.43%). However, the proportion of patients with pessimistic attitudes towards the HWPR or who had experienced medical disputes ranged from 13.19% to 57.10% (mean: 33.45%, SE: 6.70%, 95% CI: 16.24%-50.66%). These results demonstrated that the proportion of health workers who held that the HWPR with a relatively tense situation was higher than that of patients. This nding was considered to be the result of the high sensitivity to disputes and the poor practice environment of health workers [64,65], which was thought to be related to the fact that most patients are inclined to rely on and trust health workers when seeking medical help [20].
This study also analysed the related determinants of the HWPR. A total of 50 determinants were identi ed, of which 36 were determined to have signi cant associations with the HWPR, including 16 health worker-related factors, 12 patient-related factors, and 8 health worker-patient interaction-related factors.
In terms of health worker-related factors, rst, male health workers were more likely to hold a pessimistic attitude towards the HWPR or to encounter medical disputes than female health workers were. However, many previous studies in China reported that there was no gender difference [15,53,55,60]. Conversely, studies in other countries reported the same conclusion as our study [19,21,[23][24][25].
communication skills in health workers [28]. Meanwhile, education played a buffering role in avoiding medical disputes as communication skills, doctor-patient relationships and other issues are covered in higher education [28]. Some previous studies reported the same results [55,57]. Fourth, the relationship with patients is more harmonious for surgical health workers than for other departments' health workers. A previous study found that the proportion of surgeons who believed that the HWPR was increasingly harmonious was signi cantly higher than that of practitioners of internal medicine, obstetrics, gynaecology, etc. [13]. Meanwhile, some studies concluded that health workers in emergency departments were more likely to experience medical disputes than health workers in other departments [33,34,53,55]. On the one hand, the patients in the emergency department and their family members are more anxious and have higher expectations for the health workers [67]; on the other hand, the health workers in the emergency department have a heavy workload [67]. Thus, it is particularly crucial to cultivate empathy between doctors and patients in the emergency department. Fifth, senior professional titles had a signi cant association with a high risk of medical disputes. A previous study reported that compared with intermediate and junior doctors, senior doctors had a stronger sense of tension towards the HWPR [31].
Although these senior doctors had rich experience in communication with patients, their workload and work pressure affected the doctor-patient relationship. In addition to the above factors, substantial previous studies have suggested that doctors with high income satisfaction could maintain a harmonious relationship with patients [30,37,38,54]. In Germany, America, and Italy, a better health workers-patient relationship was correlated with higher job satisfaction [68][69][70], which was con rmed by many previous studies [14,[71][72][73][74][75]. In studies from the United States and Hong Kong, a heavy workload was shown to worsen the quality of communication and medical service, which in turn easily triggered medical disputes [76,77]. In Iran and the United States, a better doctor-patient relationship was inseparable from the enhancement of medical ethics [39,40].
In terms of patient-related factors, rst, rural patients were more likely to hold a pessimistic attitude towards the HWPR or to encounter medical disputes than urban patients, which was consistent with the conclusions of previous studies in China [26,58,62]. As the majority of urban patients had more income than rural patients, their medical burden was relatively lighter, which partly eased the tensions. Nevertheless, a study from Germany suggested that urban patients showed poorer doctor-patient relationships than rural patients [41]. Second, patients with a better educational background tended to hold a worse perception of HWPR. This conclusion was similar to that of studies in China [15,26,58] and other countries [42,43]. Patients with low educational levels are highly dependent on and have high trust in doctors [15,42]. In contrast, patients with better educational backgrounds had higher expectations and requirements of doctors in all aspects, which partly raised the bar for patient satisfaction. Finally, medical insurance, medical expense, and household income had signi cant associations with HWPR. High medical expenses would place a substantial economic burden on patients with low household incomes, which could increase their dissatisfaction with health workers when defensive medical behaviour occurs. Adequate evidence has shown that patients with medical insurance tend to have a better relationship with health workers than do patients who pay out of pocket [26,58,62,63]. Moreover, the reimbursement rate and range of medical insurance coverage may also affect the HWPR [78]. Therefore, the establishment of a sound medical insurance system, to a certain extent, would ease patient burdens and improve the HWPR [32,44].
In terms of health worker-patient interaction-related factors, rst, a higher prevalence of medical disputes was found amongst health worker-patient relationships with a low degree of trust. Mutual trust between health workers and patients could construct a favourable atmosphere for the HWPR. Substantial previous studies from Norway [45], Singapore [79], America [46], the Netherlands [80], Australia [81] and China [32,78] argued that trust played a crucial role in fostering a win-win HWPR. Second, effective communication could promote rapport between health workers and patients. This viewpoint is consistent with abundant previous studies [47,48,[82][83][84]. The important components of effective communication should include patient-centred communication [45,85] and adequate medical information sharing [44,86]. Therefore, this study supports the idea that health workers occupy the dominant position in health worker-patient communication, which suggests that training in communication skills for health workers should be strengthened [87,88]. Third, service attitude [65,89] and medical quality [89,90] had signi cant associations with HWPR. Evidence from a previous study showed that patients not only paid attention to the quality of their medical results (medical effects) but also took the quality of the service process seriously [91]. Meanwhile, service attitude is also an important factor in the assessment of service process quality. Therefore, more attention to doctors' behaviour and attitudes is needed in the process of standardizing medical services. Finally, the existence of medical rebates and rent-seeking behaviour negatively impact HWPR [31,37,59,[92][93][94].
To our knowledge, this is the rst systematic review to analyse the determinants related to the HWPR in China. Our ndings present an overview of the current evidence from Mainland China. One strength of this review was that the analysis of the HWPR in China was based on a large sample size of 11 articles and 96,906 individuals (65,006 health workers and 31,900 patients). Another strength was the comprehensive analyses of the determinants, particularly the meta-analysis and narrative analysis. Fifty determinants were extracted from the 11 included studies. Sixteen health worker-related factors, twelve patient-related factors, and eight health workerpatient interaction-related factors were signi cantly associated with the HWPR. However, two limitations existed in this systematic review. First, signi cant heterogeneity among the individual studies was found when performing the meta-analyses, which limited the ability to synthesize evidence clearly. Furthermore, articles using the Patient-Doctor Relationship Questionnaire (PDRQ) and the Di cult Doctor-Patient Relationship Questionnaire (DDPRQ) measurement tools were not included in this study, resulting that the current situation of the HWPR in China could not be measured systematically. To address these limitations, more studies should be included by changing the search strategy.

Conclusion
This systematic review and meta-analysis highlights the determinants related to the HWPR in China. The ndings contribute to taking effective measures to promote the harmony and stability of the HWPR. From the perspective of health administration, rst, the government should ameliorate the regulations of medical service standards and norms, especially in the attitudes and behaviours of doctors in the medical process, to improve patient satisfaction. Moreover, constant improvement of the medical coverage system in China is necessary to reduce the economic burden of disease on patients. At the same time, it is crucial that the medical coverage policy should be focused on patients with nancial challenges. Finally, in view of the current situation of overcrowding in tertiary hospitals in China [95], the government should pay close attention to the implementation of a hierarchical medical system, which can lighten the workload of health workers in tertiary hospitals by diverting patients to different levels of hospitals. From the perspective of health workers, hospitals at all levels should not only strengthen the training of communication skills and empathy but also build a communication system and platform for health workers and patients to unblock communication channels. From the perspective of patients, community doctors should be used to strengthen the public perception of the HWPR and enhance patients' understanding of and respect for health workers. Furthermore, additional studies that explore the in uences of health policy-related determinants on the HWPR in the Chinese context are necessary.      The forest plot of health worker-patient trust Supplementary Files