Demand Analysis and Satisfaction Survey of Family Doctor Contracted Services Among Tianjin Residents Based on the Kano Model

Wei Tingting¹, Zhang Zhibo², Li Ruolan³, Liu Pei³, Liu Ying³, Pan Liping³, Jia Jie³, Zhang Na⁴, Bian Bo³*

¹Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
²Department of General Practice, Yangliuqing Town Community Health Service Center, Tianjin 300380, China
³Department of General Practice, Tianjin Medical University General Hospital, Tianjin 300052, China
⁴Department of General Practice, Wah Yuen Street Community Health Service Centre, Tianjin 300384, China

Corresponding author: Bian Bo, Chief physician; E-mail: bianbozyy@163.com

[Abstract]
Background: Family doctor contracted services have been widely implemented across China. However, challenges remain in further improving the contract rate and service quality. Therefore, conducting in-depth research and analysis on residents' actual needs for these services is critically important. Objective: To analyze the differences in demand for family doctor contracted services among residents of varying ages and contract statuses in Tianjin communities using the Kano model and evaluate satisfaction levels among contracted residents. Methods: A cluster stratified sampling method was adopted to distribute questionnaires to residents in six Tianjin communities from October 2023 to January 2024. Data were collected through face-to-face interviews. A Kano model-based demand analysis was conducted, and satisfaction levels with contracted services were assessed. Results: A total of 600 questionnaires were collected. Kano model analysis categorized residents' demands as follows: Must-be attributes included community health education, diagnosis and treatment of common diseases, a 5% increase in outpatient reimbursement rates, and extended prescription services. One-dimensional attributes included home visits, family health lifestyle guidance, referral services, and comprehensive health status evaluations. Attractive attributes included family medication guidance, personalized annual health plans, and home-based medical care. Indifferent attributes included health knowledge/skill development and electronic health record establishment. Demand categories varied significantly by age and contract status. The top five satisfaction items among contracted residents were: increased outpatient reimbursement rates (4.1±1.1), extended prescriptions (4.0±1.1), electronic health records (3.6±1.2), common disease treatment (3.3±1.4), and community health education (3.3±1.2). The lowest five were: health knowledge/skill development (3.1±1.2), family medication guidance (3.1±1.3), referral services (3.1±1.0), home-based medical care (3.0±1.3), and home visits (2.9±1.2). Conclusion: Significant differences exist in the demands for family doctor services among Tianjin residents of different ages and contract statuses. Stratified service strategies are essential to precisely align core healthcare needs with extended service provision.

Keywords: Family doctor; Family doctor contracted services; Residents' needs; Tianjin; Kano model

Main Body

Family doctor services constitute a core component of primary healthcare systems and hold promise for opening new prospects for China's tiered diagnosis and treatment system [1]. Centered on general practitioners, these services provide continuous, comprehensive medical care and health management through contractual arrangements, aiming to improve health outcomes, rationalize resource utilization, and reduce medical expenses [2-3]. In 2016, following State Council approval, multiple departments jointly issued the "Guiding Opinions on Promoting Family Doctor Contracted Services" [4], launching these services in 200 pilot cities for comprehensive public hospital reform. To standardize and promote high-quality development of family doctor contracted services, the Tianjin Municipal People's Congress Standing Committee formulated the "Several Provisions on Family Doctor Contracted Services in Tianjin" on December 1, 2022 [5], based on local conditions. Tianjin has continuously optimized its "3+1+N" family doctor contracted service model, where "3" refers to the basic medical-nursing-public health team (family doctors, nurses, public health personnel), "1" denotes the addition of experts from higher-level hospitals to enhance technical support, and "N" represents the integration of diverse professional forces including rehabilitation, healthcare, and psychological counseling to build a multidisciplinary collaborative service system. The city has also improved the specialization of team services, actively exploring innovations in individual family doctor contracting and flexible contract cycles to continuously enhance residents' sense of gain and satisfaction. As of May 2025, a total of 2,557 family doctor service teams have been established, with the goal of reaching 5 million contracted residents by 2025 [6]. However, expanded contract scale does not directly equate to synchronized service quality improvement, nor can it comprehensively reflect residents' differentiated demands regarding service content, format, and priorities. Therefore, this study systematically analyzes residents' core demand attributes for family doctor contracted services and inter-group differences based on the Kano model, aiming to reveal a synergistic optimization path between "quantity" and "quality" and provide scientific evidence for precise supply-demand matching.

The Kano model, developed by Professor Noriaki Kano of Tokyo Institute of Technology in 1984, combines the degree of product quality characteristic implementation with user satisfaction, constructing a two-dimensional cognitive framework of "quality characteristic implementation degree-user perceived satisfaction" [7]. Based on the relationship between actual product performance and customers' subjective experiences, the model summarizes a series of relational attributes within this dual-dimensional framework, aiming to classify and prioritize customer needs [8-9]. Currently, it has been widely applied to evaluate patient needs for medical services [10-11].

1. Methods

1.1 Study Subjects

This cross-sectional study conducted a questionnaire survey among Tianjin residents from October 2023 to January 2024. Inclusion criteria were: (1) aged 18-80 years; (2) having resided in Tianjin for at least 6 months. All participants provided informed consent and voluntarily participated in the survey. The study was approved by the Ethics Committee of Tianjin Medical University General Hospital (approval number: IRB-2023-KY-250).

1.2 Sample Size Calculation

Using the formula n=Z²×p×(1-p)/d², we set parameters prioritizing control of potential bias risks. With a 50% response distribution (p=0.5) to address limitations from lack of prior data, a 5% acceptable margin of error (d=0.05) to balance precision and cost, and a 95% confidence level (Z=1.96) to ensure reliability, the calculated minimum total sample size was 384.

1.3 Sampling Method

This study employed multi-stage sampling: (1) Stratified sampling: Based on economic vitality index (foreign capital utilization intensity 25%, local and foreign currency deposit balance 20%, private economy proportion 30%, physicians per thousand population 25%, with weights determined by public health expert scoring), Tianjin's 10 districts were divided into tertiles by index, with one district randomly selected from each high, medium, and low tier (3 districts total); (2) Community sampling: In selected districts, communities were divided into old and commercial housing types based on construction year, housing price, and property type, with one community randomly selected from each type per district (6 communities total), with sample sizes allocated according to household proportion (formula: community sample size = 600 × households/total households); (3) Population sampling: Over 14 consecutive days across 4 time periods (8:00-10:00, 11:00-13:00, 14:00-16:00, 18:00-20:00), dynamic systematic sampling was implemented at community activity centers (interval = foot traffic/20, random seed = 202310), with one person selected per household using the Kish table method, supplemented by 15% mobile households (n=90). The final target was to collect 600 questionnaires.

1.4 Questionnaire Design

1.4.1 Formation of Thematic Working Group

According to the research purpose and subjects, a thematic working group was formed comprising 3 attending physicians from tertiary hospitals (all with over 10 years of experience in grassroots referral coordination), 2 specialists from tertiary hospitals (cardiovascular and endocrinology departments, covering chronic diseases with high prevalence among contracted residents), and 3 general practitioners from community health service centers (as policy implementation effects of community health services may vary by community economic level [12], GPs from high-, medium-, and low-income communities with ≥5 years of service were selected).

1.4.2 Questionnaire Development

In 2017, Tianjin Municipal Health Commission comprehensively defined various service categories [13] and formulated the "Tianjin Family Doctor Contracted Service Agreement," explicitly dividing family doctor contracted services into three major components: basic medical services (4 items), basic public health services (6 items), and personalized health management services (2 items), plus other agreed services (1 category), totaling 4 categories and 13 service items, as shown in Table 1 [TABLE:1]. Based on this framework, the thematic working group compiled the demand analysis and satisfaction sections of the questionnaire, adhering to dual standards of scientific rigor and precision. Two community health center family doctor team leaders and one statistics expert were invited to discuss questionnaire item completeness, discrimination, and convenience, further refining the instrument.

1.4.3 Questionnaire Content

(1) Part 1: Basic demographic information of residents, including gender, age, education level, marital status, etc.; (2) Part 2: Kano model-based family doctor contracted service demand survey, with 13 items. Each service item included both positive and negative questions, such as "How would you feel if this service were provided?" and "How would you feel if this service were not provided?" For each question, respondents selected the most appropriate answer from: "dislike," "can tolerate," "don't mind," "should be this way," "like"; (3) Part 3: Satisfaction with 13 service items stipulated in Tianjin's family doctor contracted service regulations, with 13 items rated as "very dissatisfied," "somewhat dissatisfied," "neutral," "somewhat satisfied," or "very satisfied," administered only to contracted residents.

1.4.4 Pilot Survey

The pilot survey was conducted September 10-15, 2023, in Huayuan Juhuali Community, Nankai District, Tianjin, using convenience sampling to test the questionnaire with 30 residents. Thirty valid questionnaires were collected, yielding an 81.1% response rate (30/37). Reliability analysis showed an overall Cronbach's α coefficient of 0.847; validity testing revealed a KMO value of 0.828 (Bartlett's test of sphericity P<0.001), indicating good reliability and structural validity.

1.5 Kano Model

The Kano model investigates each function/demand through positive and negative questions. By combining answers to both directions, 25 combination patterns emerge, each corresponding to a Kano model attribute. Based on statistical results, the attribute with the highest proportion serves as the final classification, including indifferent attribute (I), must-be attribute (M), one-dimensional attribute (O), and attractive attribute (A). When implementing quality improvements based on attributes, priority should focus on must-be attributes, followed by one-dimensional attributes, and finally attractive attributes [7,14].

1.6 Satisfaction Calculation

Patient satisfaction refers to patients' satisfaction with received medical services, depending on the degree of alignment between actual needs and healthcare experiences. Satisfaction scoring employed a 5-point Likert scale, with items assigned values 1-5 corresponding to "very dissatisfied," "somewhat dissatisfied," "neutral," "somewhat satisfied," and "very satisfied." Contracted residents' satisfaction was surveyed, with individual scores ≥4 defined as satisfied and <4 as dissatisfied. Service satisfaction scores = (5.00×very satisfied + 4.00×somewhat satisfied + 3.00×neutral + 2.00×somewhat dissatisfied + 1.00×very dissatisfied)/total respondents.

1.7 Survey Methods and Quality Control

One community staff member from each community served as surveyors. Twelve surveyors received training covering: (1) understanding the survey's purpose and significance; (2) learning communication techniques. Professional surveyors assisted residents in completing questionnaires one-on-one, providing health education beforehand and obtaining consent. During the survey, all questionnaires were collected through face-to-face interviews. A total of 714 questionnaires were distributed, with 634 collected (response rate 88.8%). After collection, all questionnaires underwent double cross-checking to ensure no duplication or omission, retaining complete cases without logical errors and excluding 34 invalid questionnaires, yielding 600 valid questionnaires (valid response rate 94.6%). Invalid questionnaire criteria were: (1) fewer than 5 completed items; (2) patterned consecutive responses.

1.8 Statistical Methods

Data were double-entered using EPiData 3.1 software and analyzed using SPSS 27.0. Categorical data were expressed as frequencies (percentages), and continuous data as (x̄±s). Descriptive analysis was used for patients' basic information, contract status, reasons for non-contracting, and satisfaction evaluation. Residents' family doctor contracted service demands were classified and prioritized according to the Kano model.

2. Results

2.1 Basic Information and Contract Status of Residents

Among the 600 surveyed residents, 29.3% were male and 70.7% female; 39.7% were aged 18-39, 39.7% aged 40-60, and 20.7% over 60; 53% had underlying diseases and 47% did not; 44.3% had contracted services and 53.7% had not. See Table 2 [TABLE:2].

2.2 Kano Model Demand Analysis

Based on Kano model analysis of residents' family doctor contracted service demands, indifferent attributes included health knowledge/skill development, community health education, and electronic health record establishment. Must-be attributes included 5% outpatient reimbursement increase, common disease diagnosis and treatment, and extended prescription services. One-dimensional attributes included home visits, family health lifestyle guidance, referral services, and comprehensive health assessments. Attractive attributes included personal annual health planning, family medication guidance, and home-based medical care. See Table 3 [TABLE:3].

Age-stratified analysis: Electronic health record establishment and health knowledge/skill development were indifferent attributes across all age groups. Personal annual health planning was an attractive attribute across all ages. Home visits were a one-dimensional attribute across all ages. Common disease diagnosis and treatment, 5% outpatient reimbursement increase, and extended prescriptions were must-be attributes in the 40-50 and ≥60 age groups, while in the 18-39 group they were must-be, must-be, and indifferent respectively. Referral services and family health lifestyle guidance were one-dimensional attributes in the 40-50 and ≥60 groups, but must-be and indifferent respectively in the 18-39 group. Comprehensive health assessments were one-dimensional in the 18-39 and 40-59 groups but must-be in the ≥60 group. Family medication guidance was attractive in the 18-39 and 40-59 groups but one-dimensional in the ≥60 group. Community health education was indifferent in 18-39, one-dimensional in 40-59, and must-be in ≥60. Home-based medical care was one-dimensional in 18-39, attractive in 40-59, and must-be in ≥60. See Table 4 [TABLE:4].

Contract status-stratified analysis: Electronic health record establishment and health knowledge/skill development were indifferent attributes in both contracted and non-contracted groups. The 5% outpatient reimbursement increase was a must-be attribute in both groups. Common disease diagnosis and treatment, community health education, and extended prescriptions were must-be attributes in the contracted group but one-dimensional, indifferent, and indifferent respectively in the non-contracted group. Referral services, family medication guidance, and family health lifestyle guidance were one-dimensional attributes in the contracted group but must-be, attractive, and attractive respectively in the non-contracted group. Comprehensive health assessments, personal annual health planning, and home-based medical care were attractive attributes in the contracted group but one-dimensional in the non-contracted group. See Table 5 [TABLE:5].

2.3 Satisfaction of Contracted Residents

The top five satisfaction items among contracted residents were: 5% outpatient reimbursement increase (4.09±1.14), extended prescriptions (4.03±1.14), electronic health record establishment (3.55±1.20), common disease diagnosis and treatment (3.29±1.40), and community health education (3.27±1.20). The bottom five were: health knowledge/skill development (3.14±1.24), family medication guidance (3.12±1.26), referral services (3.11±1.02), home-based medical care (2.97±1.30), and home visits (2.94±1.21). See Table 6 [TABLE:6].

3. Discussion

Currently, domestic research on supply-demand matching of family doctor contracted services remains limited [15]. This study, focusing on Tianjin community residents, employs the Kano model to deeply analyze core demand differences across population groups, providing evidence for optimizing service delivery.

3.1 Overall Population Demand Analysis

Our findings reveal significant variations in residents' cognitive attributes toward different services, consistent with Zhang et al.'s research [16]. Outpatient reimbursement increase, common disease diagnosis and treatment, and extended prescriptions were classified as must-be attributes, reflecting residents' rigid demands for basic medical security. This aligns with Huang et al.'s findings [17-18] that prescription services are among residents' primary needs. SHANG et al. [19] demonstrated that over 80% of residents prioritize medical insurance reimbursement services. Home visits, family health lifestyle guidance, referral services, and comprehensive health assessments were classified as one-dimensional attributes, indicating that supply levels of these services positively correlate with resident satisfaction. Zhu et al. [20] found that residents prefer service delivery methods centered on home visits. The State Council's "Guiding Opinions on Promoting Hierarchical Diagnosis and Treatment System Construction" [21] explicitly emphasizes the importance of referral services. Notably, personal annual health planning, family medication guidance, and home-based medical care were classified as attractive attributes, suggesting these innovative services hold substantial potential for satisfaction improvement, though their absence does not cause significant dissatisfaction. Primary care facilities should meet home-based medical care needs while ensuring universal basic medical services, improving service accessibility so residents can resolve health issues within their communities [22].

3.2 Age-Specific Demand Characteristics

3.2.1 Elderly Population (≥60 years)

This study demonstrates that elderly individuals have strong dependence on must-be services such as outpatient reimbursement increase, extended prescriptions, and common disease diagnosis and treatment, reflecting their high demand for medical cost and medication convenience directly related to high chronic disease prevalence in this group. This parallels Sun et al.'s findings [23]. Improving healthcare accessibility and expanding drug reimbursement lists can significantly enhance elderly satisfaction with contracted services [24]. We recommend that primary care institutions strengthen chronic disease management capacity for elderly patients, optimize outpatient reimbursement policies, and promote extended prescription services. Additionally, this study shows elderly individuals have high demand for community health education (must-be attribute). Gu et al. [25] similarly found that 74.3% of elderly individuals have health consultation needs, with urban elderly showing higher demand than rural areas, possibly related to higher education levels among urban elderly [26]. While existing educational content partially meets needs, optimization remains possible in format and specificity. For example, conducting thematic health lectures based on elderly health issues or enhancing interactivity through community activities may more effectively improve participation and satisfaction. Meanwhile, home-based medical care was a must-be attribute for elderly, and home visits were one-dimensional, yet coverage remains low, failing to meet actual demand. This relates closely to their declining physical function, high chronic disease prevalence, and need for regular medication and medical support, consistent with Han et al.'s findings [27]. We recommend enhancing accessibility of home-based services through policy support and technical means (e.g., telemedicine, smart health monitoring devices) while exploring standardized models for home-based medical care.

3.2.2 Middle-aged Population (40-59 years)

Middle-aged individuals' demands reflect dual characteristics of upgraded health management and family responsibility-driven needs. On one hand, due to increasing health risks, this group shows high demand for comprehensive health assessments (one-dimensional attribute), reflecting vigilance toward personal health risks. Family doctors should provide comprehensive health assessments and personalized health management plans for this population. On the other hand, bearing dual responsibilities of childcare and elderly care, this group demonstrates high demand for family-level health management and medical resources, particularly family health lifestyle guidance (one-dimensional), family medication guidance (one-dimensional), and home-based medical care (attractive attribute). We recommend exploring family-unit-based health management models to better meet middle-aged individuals' diversified needs. The "Guiding Opinions on Promoting High-Quality Development of Family Doctor Contracted Services" [28] proposes family-unit contracting, which aligns well with middle-aged population needs. Previous research shows that interventions targeting both patients and family members are more effective, with symptoms showing significant improvement [29].

3.2.3 Young Population (18-39 years)

Young individuals exhibit efficiency-prioritized characteristics. Due to conflicts between work hours and community service hours, this group shows particularly prominent demand for flexible medical services [30]. This study found referral services were a must-be attribute for young people, yet actual utilization and implementation effectiveness remain inadequate [16,31-32]. We recommend optimizing referral processes through information technology, such as establishing online referral platforms for seamless integration between medical institutions, while strengthening support for primary care facilities to enhance their diagnostic and treatment capabilities. Although young individuals generally have good health status and lower disease burden, they show high demand for common disease diagnosis and treatment (must-be attribute) and occupational disease prevention [33-34]. Notably, family medication guidance (attractive attribute) and home-based medical care (one-dimensional attribute) represent underexplored potential needs among young people. We recommend gradually promoting related services as resources permit, combined with personalized health management plans tailored to young individuals' actual needs.

3.3 Differences Between Contracted and Non-contracted Residents

This study reveals that contracted residents' demands are "core security"-oriented, focusing on must-be services (outpatient reimbursement increase, common disease diagnosis and treatment, etc.), yet supply of one-dimensional services (referral services, family medication guidance, etc.) remains insufficient. Attractive attributes like comprehensive health assessments and personal annual health planning can enhance satisfaction, but their absence does not cause significant dissatisfaction, suggesting current services remain at the basic security stage. Non-contracted residents exhibit dual characteristics of institutional security dependence and lagging service value cognition. This study shows outpatient reimbursement increase and referral services were must-be attributes, indicating potential contractors have rigid demands for basic medical security and hierarchical diagnosis and treatment systems. However, family medication guidance and family health lifestyle guidance were attractive attributes, suggesting non-contracted residents' cognition of family health management value remains insufficiently activated. This cognitive lag may stem from information asymmetry, disconnect between service supply and demand, insufficient service accessibility and flexibility, and doubts about service effectiveness. Previous research indicates residents' understanding of family doctor contracted services significantly affects contract rates [35-36].

3.4 Limitations

First, sample selection carries dual bias risks: on one hand, only daytime community activity center residents were included, failing to cover long-term homebound, night-shift workers, paralyzed, bedridden, and mobility-impaired populations, limiting population representativeness; on the other hand, satisfaction survey subjects were limited to contracted residents but actually included "contracted-but-uncontacted" individuals who signed without receiving services, potentially failing to reflect experiences of actual service beneficiaries. Second, this study's questionnaire was a non-structured instrument designed based on relevant literature, preventing reliability and validity testing. Third, as a cross-sectional study, influencing factor analysis results show only associations without establishing causality. Future research should expand sample sizes, cover more populations, and further explore influencing factors of family doctor contracted services to provide evidence for policy and service development.

4. Conclusions and Recommendations

This study employs the Kano model to analyze demands for and satisfaction with community family doctor contracted services among Tianjin residents, revealing significant differences in service demands across age groups and contract statuses. These findings suggest that service content should be optimized according to group-specific demand characteristics, with strengthened promotion and supply of family health management, particularly for non-contracted residents, to enhance contract conversion rates through targeted education and service innovation.

Author Contributions: Liu Pei, Liu Ying, and Pan Liping proposed the topic and designed the study protocol; Wei Tingting, Zhang Zhibo, and Li Ruolan wrote the manuscript; Jia Jie and Zhang Na proofread and revised the initial draft; Bian Bo was responsible for quality control of the article, overall accountability, and supervision.

Conflicts of Interest: None declared.

Acknowledgments: (Received: March 3, 2025; Revised: May 23, 2025) (Edited by: Cheng Sheng)

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