The aim of the article is to help general practitioners and primary care researchers understand the fundamentals of designing case studies by explaining and analysing the standard developing procedures. The analysis of the rigorous designing and implementing steps will help academic general practitioners having comprehension of the specific research design process, which is to ensuring the quality of case studies. In the first part of the article, findings of literature review were described for exploring evolution of case studies, the concept and contexts of the study, as well research questions that suitable be answered by the study. In the next part of the article, the standard operational procedures for conducting a case study were introduced, with examples from general practice and primary healthcare. These procedures include: (1)initiating the planning phase to determine the appropriateness of a case study; (2)designing the study, including case selection and identifying the type of case study; (3)preparing for fieldwork through researcher training and pilot testing; (4)collecting data from multiple sources; (5)analyzing the data to generate evidence-based conclusions; (6)reporting results and communicating with readers. Case study is suitable for addressing the "what" "how" and "why" questions in general practice and primary healthcare, with a broad application prospect.

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.

Objective: To review the strengths and limitations of the development of general practice in China during the last decade (2010—2020) and to assess the opportunities and challenges for its future development.

Methods: Data were collected from statistic reports, journal articles and official policies and guidelines regarding general practice development in China from 2010 to 2020. Donabedian model was applied to examine and assess the quality of general practice services in China. SWOT analysis was used to identify internal and external determinants of general practice development in China.

Results: (1) Structural quality of general practice:the ten-year policies about general practice development were a continuation of the past relevant policies in essence but with developments, with highlights on continuous construction of general practice workforce and discipline, tiered diagnosis and treatment and regional medical consortium, but relevant fiscal and management policies still need improvements. The number of general practice workforce has increased rapidly, while the lion share of them are still allocated at tertiary hospitals. Full-time equivalent is suggested to be used to predict the staffing and assess the performance of general practice professionals. The number of community health centres showed a steady increase, but its growth rate was still slower than that of hospital facilities. Relevant health economics data need to be further supplemented. (2) Process quality of general practice:in 2020, there were 2.045 billion visits in community health centers (stations) and township health centers, that is, 1.5 visits per person per year on average. There was a significant development when found only 1 visit per person per year for primary care in 2010. However, the frequency of visits for primary care was still lower than that of visiting hospital-based outpatients (an average of 2.7 visits per person per year). The COVID-19 pandemic had a significant impact on community health services/general practices, and the number of outpatient visits dropped by about 20%. The number of general practice research articles reached a peak in 2018, mainly focusing on dual-directional referrals, tiered diagnosis and treatment, general practitioners (GPs) /family doctors, general medicine, community health services, chronic disease management (especially hypertension and diabetes), and analysis of factors associated with aspects involved in general practices. General practice research is expected to provide more support for developing innovative and critical thoughts, more practice based evidence for clinical services, and more assistance for service quality and patient outcomes improvement as the discipline advances. (3) Results of implementing general practices:there is no sufficient evidence on the influence of general practices on people's health. The experiences and views of people including healthy individuals and patients indicated that those receiving general practices or contracted family doctor services perceived positive experience and expressed high satisfaction, but perceptions and views of general population in the community toward general practices need to be explored. GPs' own experience and opinions on general practice were quite different. Gender, age, professional title, urban and rural areas, and geographical location may be associated with their experience and job satisfaction. There may be instability in the general practice workforce, mainly due to personal income, workload and time pressure. (4) The major strengths of developing general practice in China are as follows:strong policy-based promotion and government leadership;rapidly constructing and developing GPs teams owing to the excellent resource allocating ability shown by the centralized system from central to all local governments;significantly enhanced general practice education and training systems;increased core professionals as general practice educators and trainers;special development of general practice characterized by the integration of medical sciences and Chinese traditional humanistic theories. (5) The development of general practice in China has been facing limitations similar to those in other countries. Besides that, its evident limitations include late development of the discipline, unsatisfactory quality of workforce, high work pressure and high prevalence of burnout in the workforce, as well as impact of generation gap on education and practice among GPs. In addition, the relation between specialists and GPs is on transition of from undifferentiated attachment to self-recognised uniquity, and further seeking transdisciplinary. The teaching competences of GPs teachers, especially those teaching community and clinical care, are inadequate. GPs team building and management need to advance from the formation to the storming and performing phases. (6) Opportunities for further development of general practice in China include strategies for achieving the goals of Healthy China, and an all-round well-off society, the important role of primary health care in sustainable development and universal health coverage reaffirmed by the Declaration of Astana, as well as significantly improved health literacy of people. (7) Challenges for the development of general practice in China include population ageing, and aging-related changes in burden of disease and socio-economic status, the aging and dynamic changes of GPs human resources, the variation of urban and rural areas and regional differences, and the inverted pyramid structure of allocation of medical and health resources (namely, the largest part is allocated to tertiary care while the smallest to primary care). Relevant recommendations to address these challenges comprise strengthening the advocacy of the development of general practice services, establishing a wide-ranging community collaborative network, and developing general practice professional organizations.

Conclusion: The development of general practice in China is advancing, which is manifested as rapidly increased number of general practitioners(GPs), strong government promotion, quickly improved accessibility of essential medical services, and notably increased utilization rate of primary care services. However, the development is facing challenges, such as high discipline and social expectations regarding general practice, instability in the workforce due to high work pressure of the knowledge- and labor-intensive job, GPs' insufficient recognition of their self-identity, and unclear status of financial funding for general practice development. Given that there are unprecedented favorable conditions for general practice development, medical industries and GPs are suggested to make efforts to turn challenges into opportunities to develop general practice, thereby universal health outcomes will be improved.

Background: The tiered healthcare delivery system is a crucial component in deepening healthcare reform. Analyzing the healthcare-seeking choices of outpatients and their influencing factors from the demand-side perspective, based on real-world data, holds significant practical importance for advancing the tiered healthcare system and promoting the high quality development of healthcare services.

Objective: To identify outpatient healthcare-seeking behavior and influencing factors among residents of Guangdong Province in the context of tiered healthcare system. The report is for supporting policies on rational healthcare utilization.

Methods: Data were obtained from the Seventh National Health Service Survey in 2023, covering eight sampled counties (districts/cities) of Guangdong Province. Descriptive statistics were performed using frequencies and proportions. Univariate analysis was conducted using the Chi-square test, followed by multivariable logistic regression, with “whether patients choose first contact at primary care facilities for sickness within two-weeks” as the dependent variable, variables with statistical significance in univariate analysis (P<0.05) were included in the regression model.

Results: In total, 72.2% patients choose first contact at primary care facilities within two-weeks. Patients in rural areas(OR=1.561, 95% CI: 1.170-2.082), proximity to a primary care facility (OR=3.870, 95% CI: 2.915-5.136), enrollment in urban-rural resident basic medical insurance (OR=2.209, 95% CI: 1.695-2.879), and perceived mild illness (OR=3.458, 95% CI: 2.449-4.883) are more likely to choose primary care facility, while those with education levels above high school (OR=0.498, 95% CI: 0.293-0.847) and didn’t contract with a family doctor (OR=0.671, 95% CI: 0.504-0.894) were more likely to seek care at general hospitals.

Conclusion: The majority of Guangdong residents preferred primary care facility for first contact, but there is still a space of improvement. Both environmental and individual factors significantly influence healthcare-seeking choices. Efforts should focus on optimizing the distribution and accessibility of primary care facilities, strengthening service capacity and management efficiency, to promote rational healthcare utilization of residences.

Objective: To compare primary healthcare workers’ (PHCWs) initial motivation of choosing medicine and current work motivation based on Self-Determination Theory (SDT), reveal changes in autonomous motivation—defined as engaging in an activity out of full volition and personal choice—and analyze the causes and consequences of these changes on work outcomes.

Methods: The participants were PHCWs of Shandong Province of China. A mixed-methods design was adopted. The cluster, multi-stage sampling method was applied for questionnaire survey, and 1200 PHCWs were selected in 36 primary care facilities. The purposive sampling method was used for in-depth interviews and 107 PHCWs among survey participants were selected. The questionnaire was developed by the authors for exploring PHCWs’ initial motivation of choosing medicine and current work motivation. The motivations were categorized into autonomous motivation and controlled motivation based on the SDT. The “motivation change” variable was constructed by comparing the dominant types of initial motivation and current motivation. Descriptive statistics, ANOVA, and multiple linear regression were used to analyze survey data, thematic framework method was used to analyze interview data.

Results: The largest proportion of participants maintained their autonomous motivation (36.2 %), followed by those who became more autonomous (27.8 %), those who maintained controlled motivation (23.2 %), and those whose motivation became less autonomous (12.8 %). PHCWs who maintained autonomous motivation showed the most favorable outcomes, including lower turnover intention and job burnout, and higher job satisfaction and work performance, followed by those who became more autonomous. In contrast, PHCWs who maintained non-autonomous motivation and less autonomous motivation demonstrated the poorest outcomes. Interview data indicated that motivation changes were mainly influenced by the fulfillment of three psychological needs: meaning, competence, and relatedness.

Conclusions Autonomous motivation is associated with better work outcomes among PHCWs. Enhancing autonomous motivation requires a more supportive organizational environment based on enhanced informatics infrastructure, improved training systems, and innovative patient communication mechanisms.

Objective: To investigate the status and influencing factors of consistency between expressed and perceived needs for family doctor contracted services among rural older adults in Ningxia Autonomous Region of China.

Methods: A cross-sectional study was conducted from July to September 2024. Stratified cluster sampling method was applied for find participants. Two counties were selected from each of the five cities in Ningxia, and one village was chosen from each of the county. A total of 456 rural older people from the 10 villages were invited into the survey. Socio-demographic information and expressed and perceived needs for family doctor contract services were collected using a self-designed questionnaire. Multiple stepwise regression analysis was used to identify influencing factors, while a random forest model was employed to rank the importance of these factors.

Results: The average score for consistency between expressed and perceived needs was (11.64 ± 5.31), indicating an overall low level of consistency. The expressed need for basic public health services (that provided to all signatories, such as establishing health records) reached 96.1%, the perceived need reached 96.7%, and the satisfaction rate also reached 92.9%, all of which are at a high level. In contrast, only 5.3% of participants expressed need for individual health services (that provided according to the specific need patients, such as home-based care), 40.1% perceived the need, and satisfaction was as low as 5.0%, all indicating low levels. Stepwise regression analysis identified several key influencing factors of demand side on the consistency, including satisfaction with services, awareness of self-health, chronic diseases, economic burden, healthcare-seeking habits at primary care facilities, and current smoking. Among these factors, satisfaction with services was the most significant predictor of consistency of the two needs.

Conclusion: The consistency between expressed and perceived needs for individual health services in the family doctor contract among rural older adults remains low, influenced by both subjective factors and objective factors, such as chronic conditions, satisfaction with services and awareness of self-health. Therefore, the author suggests designing and providing the family doctor contract service packages in a way that is tailored to local contexts, especially focusing on service items that address individual perceived needs. The improvement of consistency between expressed and perceived needs will better meet the diverse health management needs of the rural elderly.

Background: Basic medical service is the primary manifestation of primary care within China's healthcare system. Since the 2009 healthcare reform, the theory of primary care functional features has been introduced to China. Chinese researchers have since employed international instruments and developed localized tools to evaluate the process quality of these services across diverse regions and populations. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence regarding the conceptual connotations, intensity levels, and relationships with health service outcomes of different functional features in China's primary care services.

Methods: Following the JBI mixed-methods systematic review framework, we searched six databases (PubMed, Embase, Web of Science, Google Scholar, CNKI, and Wanfang) for qualitative, quantitative, and mixed-methods studies published between January 2009 and March 2025. Two reviewers screened literature using Rayyan and assessed methodological quality using JBI tools. Utilizing a convergent segregated approach, we synthesized the qualitative and quantitative findings separately, and subsequently integrated them to explain the pathways and mechanisms underlying the associations between functional features and health service outcomes.

Results: The review included 60 studies (52 quantitative studies, 4 qualitative studies, and 3 mixed-methods studies). The functional features of China’s primary care services can be broadly categorized into six core dimensions: First Contact, Accessibility, Comprehensiveness, Continuity, Coordination, and Patient Empowerment. Their local conceptual connotations have undergone significant reconfiguration compared to the original theoretical constructs. Overall, the intensity level of these features is medium-to-high. Stronger measurement levels are positively associated with multiple critical health service outcomes, including improved patient health status, enhanced patient experience, lower healthcare costs, preference for primary care first-contact, and reduced general hospital utilization. Furthermore, clear mechanistic pathways influencing key outcomes were identified for the first five features.

Conclusion: This review validates the real-world value of sustained investment by the Chinese government and society in primary healthcare reform. It supports the strategic enhancement of these functional features to maximize their capacity to improve health outcomes. Finally, it highlights the imperative for future research to employ broader, deeper, and more precise methodologies to capture the evolving nature of primary care in China.

Background: As the emerging of structural imbalance characterized by surging demand and insufficient high-quality supply in China’s health management system, smart health management services become a novel measure to address this gap. Smart health management services refer to the health monitoring, assessment and intervention with support of information communication and artificial intelligence technologies.

Objective: To systematically analyze the current status, needs, and influencing factors of the using of smart health management services and devices among China’s adults, thereby providing evidence support and suggestions for its development.

Methods: A mixed-methods design was employed, combining quantitative and qualitative research methods. In the quantitative section, participants aged 18 years and above were selected by a stratified cluster random sampling method, their intentions and behaviors in utilizing smart health management services were analyzed by structural equation model (SEM).

In the qualitative research section, 13 interviewees were selected for semi-structured, one-on-one interviews, the findings were analyzed by grounded theory coding. Quantitative and qualitative findings were integrated using an explanatory sequential mixed-methods framework.

Results: A total of 2786 adults participated the questionnaire survey with a response rate of 96.07 %. Of them, 13 participants agreed to attend the semi-structured, one-on-one interviews. The main findings are as follows: (1) 37.7 % of the adult participants used smart health management devices. The use rate presents decline with increasing age, and lower use among older adults. (2)The demand for smart health management systems shows a diversified trend, and significant differences between age groups. Overall, participants believe that certain basic functions of the smart health systems, such as health monitoring, are needed, and they hope that it can answer questions raised by users. Qualitative study further revealed that participants' needs for smart health systems are in line with Maslow's Hierarchy of Needs, which includes needs at various levels from "basic life safety and health security" to "active learning and self-actualization." Young participants prefer the support function for basic preventive activities and optimization of lifestyle; older participants then are more concerned about whether the system has practical functions for disease management. (3)The average using willingness was moderately high (62.68 ± 20.65). In the SEM, behavioral attitude emerged as the strongest predictor of willingness of use(β=0.568, P < 0.001), followed by subjective norms (β = 0.103, P < 0.001) and media motivation (β = 0.094, P < 0.001). Electronic health literacy exerted significant indirect effects on both willingness (β = 0.045, P < 0.001) and behavior (β=0.051, P < 0.001) via media motivation, while perceived behavioral control influenced them indirectly (β = 0.014 and 0.016, both P < 0.001). Living in urban areas positively affected both willingness(β = 0.056, P < 0.001) and behavior (β = 0.125, P < 0.001). Health insurance coverage significantly promoted willingness (β = 0.039, P < 0.001). (4)Qualitative findings revealed multiple barriers to using, including high costs, product quality concerns, discomfort during using, and security issues. Attitudes toward smart health management devices were polarized, positive or negative evaluations stemmed directly from experience, perceived benefits, and device intelligence level, whereas neutral users tended to discontinue use due to a lack of perceived value. In addition, personal beliefs and cultural values strongly influenced individuals’ acceptance.

Conclusion: The study identified a distinct pattern of “high wish and low use” among adults regarding smart health management services. Both using behavior and demand pattern exhibited clear age-specific differences and were shaped by a number of factors. To bridge the gap between willingness to use and actual using behavior, future efforts should focus on age-appropriate design, precision implementation, and collaboration with primary care facilities, thereby enhancing adults’ capacity for actively managing their health.

Background: Pre-frailty represents a transitional risk status between health and frailty. Early identification and intervention during this stage can delay or even reverse the frailty development. However, there is a lack of standardized pre-frailty assessment tool tailored for community-dwelling older adults.

Objective: To compare the effectiveness of Fried's Frailty Phenotype (FP) and the FRAIL scale in assessing pre-frailty among community-dwelling older adults undergoing health examinations, thereby providing evidence for the selection of appropriate assessment tools.

Methods: A cross-sectional study was conducted using convenience sampling to recruit older adults aged 60 years and above undergoing health examinations at five community health centres in Beijing from December 1, 2024, to March 20, 2025. Demographic data were collected, and frailty status was assessed using the FP and the FRAIL scale. Activities of daily living (ADL) were evaluated using the Modified Barthel Index (MBI), and quality of life was assessed using the 36-Item Short Form Survey (SF-36). Spearman rank correlation and Kappa statistics were used to analyze the consistency and correlation between the two scales. Using MBI and SF-36 scores as validity criteria, the validity of both tools was evaluated via Spearman rank correlation, Receiver Operating Characteristic (ROC) curve analysis, and Bayes discriminant analysis.

Results: The prevalence of pre-frailty detected by the FP was higher than that by the FRAIL scale (36.3 % vs. 25.3 %). The two scales showed a moderate positive correlation (r = 0.713, P < 0.001) and moderate agreement (Kappa = 0.606, P < 0.001), with consistent classification in 81.2 % of participants. Frailty severity assessed by both scales was positively correlated with ADL decline and negatively correlated with SF-36 total, Physical Component Summary(PCS), and Mental Component Summary (MCS) scores. Both scales demonstrated associations with ADL decline, with ROC curve areas under the curve (AUC) of 0.736 and 0.735, respectively (P < 0.001). Bayes discriminant analysis indicated that the cross-validation accuracy for ADL decline was higher for the FP (86.3 %) than the FRAIL scale (85.1 %). ROC analysis revealed that the FP had higher sensitivity (74.0 % vs. 64.4 %), while the FRAIL scale had superior specificity (80.1 % vs. 65.8 %) for predicting ADL decline. The optimal cutoff value for both scales in predicting ADL decline was 0.5.

Conclusion: The FP and FRAIL scale demonstrate moderate correlation and consistency, and both are negatively associated with quality of life. Both tools possess moderate validity in verifying ADL decline and are suitable for assessing pre-frailty in community-dwelling older adults. The FP, with its higher sensitivity and inclusion of objective indicators, is more suitable for pre-frailty screening in health examination settings aiming for “early detection and intervention.” Conversely, the FRAIL scale, due to its simplicity and high specificity, serves as a viable alternative for rapidly identifying high-risk individuals in resource-limited settings. These findings suggest practical value in integrating frailty screening into routine community health examinations and initiating interventions based on a 0.5 cutoff value.

This article outlines the statistical methods and practical steps involved in designing and developing valid and reliable questionnaires in primary care. Based on literature review on questionnaire development and scale design, we proposed a standardized protocol for scale development in primary care. This process encompasses key practical steps and statistical methods, illustrated by cases from prior research.

The recommended seven-step approach includes: (1) defining the construction of measurement; (2) generating the pool of items; (3) selecting the scoring system and response format; (4) pre-testing (assessing content validity and face validity, etc.); (5)eliminating items by item analysis; (6)evaluating the scale initially, including evaluating the reliability and validity of the scale, and factor analysis or Rasch analysis; (7)re-evaluating the scale to re-examine the nature of the scale, including retesting reliability and constructing validity. In conclusion, scale development studies should adhere to standardized procedures, and the integrated use of Rasch model and factor analysis can make the measurements more objective.