Patients' continued willingness to seek initial treatment at primary care facilities: A study of trust-based driving mechanisms^☆

Abstract

Background: Initial treatment at primary care facilities can promote rational use of healthcare services and alleviate imbalance between healthcare supply and demand. However, the proportion of Chinese patients seeking medical services primarily at primary healthcare institutions is very low, far below policy expectations. This phenomenon suggests that we need to explore strategies and methods to encourage patients to firstly contact with primary care when they seek medical help. Therefore, it is of great significant to explore the driving mechanisms of patients' willingness to seek initial treatment at primary care facilities.

Objective: To verify the social and psychological mechanisms of patients' continued willingness to seek initial treatment at primary care facilities by empirical research. This study constructed a theoretical model of "Expectation Confirmation-Patient Trust-Continued Willingness to Seek Initial Treatment at Primary Care Facilities" in the context of family doctor contracted services.

Methods: A questionnaire survey was conducted among patients at a community health centre in Chengdu. Independent sample t-tests and one-way ANOVA were used to examine the differences in patient trust across various groups; structural equation modeling was employed to verify the theoretical hypotheses and mediation effects.

Results: Patients expect a higher level of confirmation. The patients' trust is generally high, among which the emotional trust is the highest and the service trust is the lowest. Patients who were adults, aged 60 and above, suffered hypertension or diabetes, had signed a family doctor, chose a fixed doctor, and had higher expectation confirmation showed higher trust in primary care. Expectation confirmation did not significantly affect the willingness to seek initial treatment at primary care facilities, but patient trust served as a complete intermediary.

Conclusion: Patient trust has a complete mediating effect between expectation confirmation and the willingness to seek initial treatment at primary care facilities. Meeting patients' targeted needs and providing experiences that exceed their expectations are the starting points for patient trust. Patients' willingness to seek initial treatment at primary care facilities can be enhanced by emotional trust based on public health services, technical and service trust by improved diagnostic capabilities and referral services.

Keywords

Basic initial diagnosis / Patient trust / Expectation confirmation / Medical seeking willingness / Structural equation model

Authors' contributions

Conceptualization, X.L.; Methodology, X.L., W.Y.; Data curation, M.X., L.X., H.X. and Z.S.; Formal analysis, M.X., L.X. and H.X.; Funding acquisition, X.L.; Project administration, not applicable; Resources, not applicable; Supervision, X.L; Validation, X.L.; Writing—original draft, M.X.; Writing—review and editing, X.L. and M.X. All authors have read and agreed to the published version of the manuscript.

Ethical approval and consent to participate

The study received approval from Ethics Committee of the Fifth People's Hospital of Chengdu (Approval No: Lunsen 2021-071 (Ke)-01).

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

Sichuan Centre for Applied Psychology Research Grant numbers: CSXL-23310

Declaration of competing interest

All authors declare that there are no competing interests

Acknowledgements

We extend our sincere gratitude to the Cujin Community Health Service Center in Wuhou District, Chengdu for their tremendous support in conducting this survey.

Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.cgpj.2025.100083.

References

[1] Cao DL, Zhou W, Zhang XF, et al. A survey on general practitioners’ willingness to participate in graded diagnosis and treatment based on the integration of the Theory of Planned Behavior and the Technology Acceptance Model. (Chinese). Chin J Gen Med. 2024; 27(25):3108-3114. doi: 10.12114/j.issn.1007-9572.2023.0415.

[2] De Dumast L, Moore P, Snell KI, et al. Trends in clinical workload in UK primary care 2005-2019: a retrospective cohort study. Br J Gen Pr. 2024; 74(747). doi: 10.3399/bjgp.2023.0527.

[3] Greiner GG, Schwettmann L, Goebel J, et al. Primary care in Germany: access and utilisation —A cross-sectional study with data from the German Socio-Economic Panel (SOEP). BMJ Open. 2018; 8:e021036. doi: 10.1136/bmjopen-2017-021036.

[4] OECD. Health At a Glance 2023: OECD Indicators. OECD Publishing; 2023 Available from.

[5] Swiss Federal Office of Public Health. Swiss Health Report 2023; 2023.

[6] National Bureau of Statistics of the People’s Republic of China. Significant progress in health and wellness, effective protection of people’s health rights and interests - series report on achievements in economic and social development of New China, No. 22. [Internet]. (Chinese) [cited 2025 Sep 4]. Available from https://www.gov.cn/lianbo/bumen/202409/content_6976411.htm.

[7] National Health Commission of the People’s Republic of China. Statistical Bulletin on the development of Health and Wellness in China. [Internet]. (Chinese). 2024 Aug 29 [cited 2025 Apr 7] Available from http://www.nhc.gov.cn/cms-search/downFiles/58c5d1e9876344e5b1aa5aa2b083a51a.pdf.

[8] General Office of the State Council. Guidelines on promoting the construction of the graded diagnosis and treatment system. [Internet]. (Chinese) [cited 2025 Apr 7]. Available from https://www.gov.cn/gongbao/content/2015/content_2937321.htm.

[9] Zhao L, Wang XW, Kong XJ, et al. China Hospital Management; 2021:30-34.

[10] Tang M, Li XG, Wang XY, et al. A data-driven study of patient inquiries in online health communities from a multidimensional trust perspective. (Chinese). Inf Sci. 2023; 41(5):2-9. doi: 10.13833/j.issn.1007-7634.2023.05.001.

[11] Chen HL, Xiang YR, Gao Y, et al. A study on the relationship between inpatient trust in doctors, self-efficacy, and medical decision-making behavior — The mediating role of doctor-patient interaction. (Chinese). China Health Policy Res. 2022; 15(3):68-74. doi: 10.3969/j.issn.1674-2982.2022.03.010.

[12] Shen XJ, Yang Y, Sun SR. Empirical analysis of the factors influencing patients’ willingness to choose primary care under the graded diagnosis and treatment system. (Chinese). J Shanghai Univ Sci Technol. 2020; 42(04):390-398. doi: 10.13255/j.cnki.jusst.20191220003.

[13] Xiang F, Yang Y. A study on the factors influencing patient choice of medical providers in online health communities — The mediating effect of online trust. (Chinese). J Med Inform. 2023; 44(12):1-7.

[14] Zhao SC, Tong XY, Zhang AQ, et al. The impact of patient trust models and levels on the willingness to choose primary care. (Chinese). China Health Policy Res. 2021; 14(8):5. doi: 10.3969/j.issn.1674-2982.2021.08.003.

[15] Yang JL, Du T, Zang W. A study on the factors influencing patients’ willingness to choose primary care based on the extended TAM-TPB integrated model. (Chinese). J Med Inform. 2023; 44(9):56-61. doi: 10.3969/j.issn.1673-6036.2023.09.008.

[16] Tian YD, Sun HM, Xin MQ, Li YS. The impact of emotions on doctor-patient shared decision-making. (Chinese). Med Philos. 2023; 44(15):27-31. doi: 10.12014/j.issn.1002-0772.2023.15.06.

[17] Oliver RL. A cognitive model of the antecedents and consequences of satisfaction decisions. J Mark Res. 1980; 17(4):460-469. doi: 10.2307/3150499.

[18] Xiong WL, Wang SF. Public perception of public cultural services and its enhancement — A case study of Liaoning. (Chinese). Libr Forum. 2020; 40(02):45-55.

[19] Li J, Wang ST, Wang JJ. The willingness of elderly people to continue using health apps based on the expectation confirmation theory. (Chinese). Chin J Gerontol. 2023; 43(12):3043-3047.

[20] Li XY, Xie SR, Ye ZQ, et al. Chinese Health Resources; 2023:66-70.

[21] Churchill GA, Surprenant C. An investigation into the determinants of customer satisfaction. J Mark Res. 1982; 19(4):491-504. doi: 10.2307/3151722.

[22] Hsu CL, Lin CC. What drives purchase intention for paid mobile apps? - An expectation confirmation model with perceived value. Electron Commer Res Appl. 2015; 14(1-6):46-57. doi: 10.1016/j.elerap.2014.11.003.

[23] Möllering G. The nature of trust: from Georg Simmel to a theory of expectation, interpretation, and suspension. Sociology. 2001; 35(2):403-420. doi: 10.1017/S0038038501000190.

[24] Zhang N, Zhang YQ, Wu KK. The psychological and neurophysiological mechanisms of trust. (Chinese). Psychol Sci. 2011; 34(5):7.

[25] Qian Y, Ning N, Su YX, et al. Chinese Hospital Management; 2023:72-75.

[26] Bhattacherjee A. Understanding information systems continuance: an expectation-confirmation model. MIS Q. 2001; 25(3):351-370 Available from. doi: 10.2307/3250921.

[27] Miao XY, Liu XY, Hu XY, et al. Development of the Patient Trust Scale for Family Physicians. Chinese Rural Health Serv Admin. 2025; 45(10):742-748. doi: 10.19955/j.cnki.1005-5916.2025.10.010.

[28] Li L, Duan YL, Liu XY, et al. The chinese version of the peer support scale for cancer patients: translation and validation. (Chinese). Chin J Nurs. 2023; 58(3). doi: 10.3761/j.issn.0254-1769.2023.03.016.

[29] Barrett P. Structural equation modeling: adjudging model fit. Pers Individ Dif. 2006; 42:815-824.

[30] Kline RB. Principles and Practice of Structural Equation Modeling. New York: The Guilford Press; 2023:158.

[31] Lele L, Shuo Z. Understanding the public policy of global budget payment reform improves the quality of public healthcare from the perspective of patients in China. Front Psychol. 2022; 13:911197.

[32] Zhou L, Li H, Liu SZ. Chinese translation and reliability test of the three-dimensional disease risk perception scale. (Chinese). Nurs Res. 2025; 39(12):2057-2062.

[33] Jiang CZ, Luo CY, Zeng GH. Optimal distance to medical care and its relation to healthcare equity and irrational medical behavior. (Chinese). Jiangxi Soc Sci. 2019; 39(5):73-84.

[34] Zhang NL, Zhao J. Research on doctor-patient trust crisis based on expectation disconfirmation theory. (Chinese). Chin Med Ethics. 2014; 27(3):391-393.

[35] Li Y, Liu RJ. Factors affecting the continuous use intention of mobile health based on meta-analysis. (Chinese). Syst Manag J. 2022; 31(5):893-909.

[36] Meng XL, Yuan QJ. Application and prospects of expectation confirmation theory in the IS field. (Chinese). Mod Inf. 2018; 38(9):169-177.

[37] Dong ZY, Zhao CX. "New medical reform" in the past decade: achievements, dilemmas, and path choices in the development of China’s healthcare system. (Chinese). Reform. 2020(9):11.

[38] Lian L, Chen JY, Wang XX, et al. Research on the current status and countermeasures of medical service capabilities of primary care physicians in China. (Chinese). Chin Gen Pr. 2023; 26(34):4246-4253. doi: 10.12114/j.issn.1007-9572.2023.0289.

[39] Li XR, Li JH, Zhou AD, et al. Relationship between residents’ perceived service quality and the utilization of primary healthcare services in Jilin Province. (Chinese). Med Soc. 2022; 35(09):15-19. doi: 10.13723/j.yxysh.2022.09.004.

[40] Li XY, Jing LM, Xu YF, et al. Research on the current status of community palliative care pilot projects in Shanghai. (Chinese). Chin Gen Pr. 2022; 25(13):1624-1628.

[41] Li W. The Surprise effect: Unlocking the Code of Psychological Contracts. (Chinese). Beijing: Beijing United Publishing Co.; 2015.

[42] Wu LF, Ren JP, Wang JJ, et al. Survey on the trust of community doctors for patients with chronic neck and shoulder pain in primary healthcare institutions in Hangzhou. (Chinese). Chin Health v Manag. 2024; 41(02):142-145.

[43] Wang Y, Jin H, Yang H, Zhao Y, Qian Y, Yu D, Fang H. Primary care functional features and their health impact on patients enrolled in the Shanghai family doctor service: a mixed-methods study. J Glob Health. 2025; 15:04007. doi: 10.7189/jogh.15.04007.

[44] Chen HL. The Return of the "familiar healthcare Model."(Chinese) China Health; 2017:35. doi: 10.15973/j.cnki.cn11-3708/d.2017.06.013.

[45] Cai Q, Zhou C, Tan F, et al. The impact of doctor-patient relationships from the trust perspective on primary healthcare management services in Hangzhou. (Chinese). Med Soc. 2023; 36(03) 56-59 + 65. doi: 10.13723/j.yxysh.2023.03.010.

[46] Wang H, Wang C. The impact of relational healthcare on initial trust and trust evolution in doctor-patient relationships. (Chinese). Mod Finance (J Tianjin Univ Finance Econ). 2019; 39(02):70-83. doi: 10.19559/j.cnki.12-1387.2019.02.006.

[47] Bazemore A, Grunert T. Sailing the 7C’s: Starfield revisited as a foundation of Family Medicine residency redesign. Fam Med. 2021; 53(7):506-515. doi: 10.22454/FamMed.2021.383659.

[48] Zhu X, Lin YW, Zeng ZR. The concept, evolution path, and driving mechanisms of patient trust in family doctor contract services. (Chinese). Chin Health v Manag. 2024; 41(07):740-743.

[49] Lin KW. Trust and relationships remain at the heart of primary care. Ann Fam Med. 2021; 19(6):482-483. doi: 10.1370/AFM.2752.