Preamble

Study on Demand Characteristics of Family Doctor Contract Services for Functional Building Populations Based on the KANO Model

CAI Chengjun¹, XU Xin¹, SHAO Jie¹, ZHOU Lulu¹, ZHANG Shengbing¹, HUANG Jiaoling², SHI Jianwei², MI Yikai³, HUANG Qian¹*

¹Pudong District Weifang Community Health Center, Shanghai 200122, China
²School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
³Institute of Community Health, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai 200335, China

Corresponding author: HUANG Qian, Associate Chief Physician; E-mail: shania926@163.com

Abstract

Background: As the family doctor contract service system continues to deepen, effectively extending these services to functional building populations has become a key focus. Understanding the demand characteristics of this group is essential for developing effective strategies.

Objective: To investigate the demand for family doctor contract services among functional building populations and provide references for improving and optimizing these services.

Methods: In March–April 2024, three functional buildings were selected using typical sampling within the research group's jurisdiction. A cluster random sampling method was used to survey 396 working-age individuals in functional communities. The questionnaire included general demographic information, a KANO questionnaire on family doctor service demands, the most frequent time periods for receiving services in the past six months, and willingness to pay.

Reliability and validity analysis was conducted on the KANO questionnaire. A Better-Worse matrix was constructed to analyze the KANO demand characteristics of 19 service items, with sensitivity analysis performed based on different service time slots and payment willingness.

Results: A total of 396 valid questionnaires were collected. The Cronbach's α coefficient for the 19-item scale was 0.991. Initial classification using the KANO model categorized all 19 items as indifferent attributes. However, further analysis using the Better-Worse matrix revealed that "medication dispensing service" and "expert consultation service" under diagnostic and treatment services, along with nine items under health management services including "physical examination report interpretation and health consultation," "eye disease prevention and treatment," and "cervical spondylosis prevention and treatment," were classified as "expected attributes." The "extended prescription" service was classified as an attractive attribute, while the remaining items were indifferent attributes.

Sensitivity analysis showed that the "long prescription" service had the highest SR value during the one-hour period before work and on weekends. The "Traditional Chinese Medicine (TCM) constitution identification/massage/moxibustion/cupping/scraping/acupuncture" service had the highest SR value during the one-hour lunch break. The "expert consultation" service had the highest SR value when willingness to pay was 0–50 yuan/person/year and ≥201 yuan/person/year, while the TCM service had the highest SR value at the 151–200 yuan/person/year payment level.

Conclusion: Functional building populations demonstrate high demand for specialized health management services under family doctor contracts, with diversified content needs. Long prescriptions, medication dispensing, and expert consultations serve as the cornerstone for meeting the needs of working-age populations. Service content design for this group should be further optimized and refined.

Keywords: Contracted family doctor services; Functional buildings; Health service demand; KANO model

Introduction

As the family doctor contract service system continues to deepen, coverage levels and utilization rates among urban and rural residents have steadily improved [1]. Currently, extending these services to functional community populations, particularly working-age individuals in functional buildings, has emerged as a priority for the next phase of development [2]. In 2021, the Shanghai Municipal Health Commission issued the "Guiding Opinions on Promoting Community Health Services in Functional Communities," exploring a service model that extends community health services to functional communities through family doctor contracts [3]. Recent pilot programs have entered an advanced implementation stage, with personalized family doctor service packages tailored to building populations becoming the mainstream approach to attracting this demographic [4]. In practice, effectively identifying service demands and continuously optimizing content and delivery formats remains a research hotspot for advancing family doctor services in functional buildings. Existing research has primarily focused on demand identification and influencing factor analysis, but systematic quantitative analysis of demand hierarchies and priorities for working-age populations in functional buildings remains insufficient [5-6].

The KANO model can precisely identify demand priorities through attribute classification (basic, expected, etc.), providing a scientific basis for optimizing service delivery sequences [7]. Therefore, this study employs the KANO model [8-9] and its theoretical framework to conduct a demand-side survey among working-age populations in functional buildings, offering references for understanding service demand characteristics and improving family doctor contract service models.

Methods

1.1 Study Population

From March to April 2024, three functional buildings were selected using typical sampling within the jurisdiction of Weifang Community Health Center based on the following criteria: (1) single office-use purpose; (2) ≥20 tenant enterprises; and (3) ≥300 employees. Cluster random sampling was then applied: floor plans were obtained, actual office floors were consecutively numbered, and 50% of floors were randomly selected as survey units using RAND function-generated sequences. All full-time employees on selected floors were included.

Inclusion criteria: (1) age ≥18 years; (2) working in the building for ≥6 months; (3) understanding the study content and providing informed consent.

Exclusion criteria: (1) non-full-time employees; (2) inability to complete the survey due to work or business travel.

1.2 Survey Instrument

Based on literature review and the research group's experience in delivering family doctor services to functional building populations, a KANO-based questionnaire was developed through expert group discussion. The questionnaire comprised four sections:

1. General demographic information: gender, age, marital status, education, living situation, medical insurance type, self-rated health status, and chronic disease status.

2. KANO questionnaire on family doctor service demands: Based on preliminary practice and policy documents including the "Guiding Opinions on Promoting Community Health Services in Functional Communities," 19 service items were identified for functional building populations, including "long prescription service," "extended prescription," and "medication dispensing." Following KANO model theory [9], each item included both positive ("if this service is provided") and negative ("if this service is not provided") questions with five response options: "dislike very much," "reluctantly accept," "indifferent," "should be this way," and "like very much."

3. Service utilization timing: Options for the most frequent service period in the past six months included "one hour before work," "one hour during lunch break," "one hour after work," "weekends," and "none of the above."

4. Willingness to pay: Acceptable annual out-of-pocket fees were categorized as "0–50 yuan/person/year," "51–100 yuan/person/year," "101–150 yuan/person/year," "151–200 yuan/person/year," and "≥201 yuan/person/year."

1.3 Survey Procedure

The research team established a survey group and conducted unified training for investigators. A pilot test of 12 questionnaires ensured clarity and unambiguity. After obtaining consent from building management, investigators conducted one-on-one surveys in functional buildings. The questionnaire was administered via the "Wenjuanxing" online platform; participants scanned QR codes with smartphones, and investigators assisted with completion while respondents confirmed answers before submission. A total of 401 questionnaires were distributed, yielding 396 valid responses (98.8% valid response rate).

1.4 Statistical Analysis

Data were compiled using Excel 2019. Categorical data were expressed as percentages, and normally distributed continuous data as (x±s). Following KANO model theory, demand analysis proceeded as follows:

1. Reliability and validity analysis: Cronbach's α coefficient was calculated for the 19-item KANO scale. Content validity was assessed using Bartlett's test of sphericity and Kaiser-Meyer-Olkin (KMO) coefficient for positive, negative, and total scales.

2. Demand attribute classification: A KANO demand attribute classification table was constructed for each item (Table 1 [TABLE:1]). Frequency distributions across attributes were calculated, and a Better-Worse matrix was developed for further classification. Better (SI) represents user satisfaction index: SI = (A+O)/(A+O+M+I), where higher SI indicates greater improvement effect. Worse (DSI) represents user dissatisfaction index: DSI = -1×(O+M)/(A+O+M+I), where larger absolute DSI indicates more severe dissatisfaction from unmet needs.

3. Sensitivity analysis: The urgency of demand improvement was determined by SR, the distance from the origin (0,0) in the Better-Worse matrix: SR = √(SI² + DSI²). Larger SR values indicate higher sensitivity and greater urgency for improvement. SR values were calculated across different service time periods and payment willingness levels. Statistical significance was set at P<0.05.

Results

2.1 General Characteristics of Functional Building Population

Among the 396 participants, the male-to-female ratio was 1:1.04. The largest age group was 41–50 years (170 participants, 42.9%). Most were married (304, 76.8%), held bachelor's degrees (186, 47.0%), and lived with spouses (280, 70.7%). Urban employee medical insurance was the primary coverage type (334, 84.3%). Self-rated health status was good for 168 (42.4%), and 276 (69.7%) reported no chronic diseases. Notably, 242 (61.1%) had never received building-based services, and 162 (40.9%) were willing to pay only 0–50 yuan/person/year (Table 2 [TABLE:2]).

2.2 Reliability and Validity of the KANO Scale

The 19-item scale demonstrated high reliability: Cronbach's α coefficients were 0.973 for the positive scale, 0.987 for the negative scale, and 0.991 for the total scale (all >0.800). Validity analysis showed KMO values of 0.961, 0.964, and 0.894 respectively (all >0.600), with Bartlett's test significance <0.001 and cumulative variance explanation rates of 88.052%, 85.368%, and 88.470% (all >50.000%). These results confirm excellent validity, supporting further demand analysis.

2.3 Demand Attribute Analysis

Demand attributes were initially classified using the maximum frequency principle (Table 3 [TABLE:3]). All 19 items were initially categorized as indifferent attributes. The Better-Worse matrix was then constructed using the mean DSI absolute value (0.260) and mean SI (0.411) as dividing points (Figure 1 [FIGURE:1]). This refined classification differed slightly from the initial categorization due to exclusion of reverse (R) and questionable (Q) items, with the Better-Worse matrix results taken as final.

Expected attributes included: "medication dispensing service" and "expert consultation service" under diagnostic/treatment services; and nine health management services including "physical examination report interpretation and health consultation," "eye disease prevention and treatment," and "cervical spondylosis prevention and treatment."

Attractive attribute: "extended prescription" service.

Indifferent attributes: All remaining items.

2.4 Sensitivity Analysis

Within each demand attribute category, items were ranked by SR value (higher = more urgent):

• Indifferent attributes: Items 7 > 5 > 9 > 19 > 4
• Expected attributes: Items 6 > 15 > 3 > 18 > 17 > 11 > 2 > 1 > 16 > 13 > 14 > 10 > 8 > 12

Further analysis by service timing and payment willingness revealed:

Service timing:
- One hour before work: "Long prescription" had highest SR
- Lunch break: "TCM constitution identification/massage/moxibustion/cupping/scraping/acupuncture" had highest SR
- One hour after work: "Extended prescription" had highest SR
- Weekends: "Long prescription" had highest SR
- No service received: "Expert consultation" had highest SR

Payment willingness:
- 0–50 yuan/person/year: "Expert consultation" highest SR
- 51–100 yuan/person/year: "Long prescription" highest SR
- 101–150 yuan/person/year: "Exercise rehabilitation guidance" highest SR
- 151–200 yuan/person/year: TCM service highest SR
- ≥201 yuan/person/year: "Expert consultation" highest SR (Table 4 [TABLE:4]).

Discussion

3.1 Limited Implementation of Family Doctor Services in Functional Buildings

Our findings show that 61.1% (242/396) of working-age individuals in functional buildings had never received building-based family doctor services, consistent with Liu et al.'s survey of non-contracted residents in Shanghai [11]. Initial KANO classification categorized all 19 items as indifferent attributes, suggesting that low service utilization and weak service perception among this population result in unclear primary demand differentiation, similar to Zhang et al.'s findings [12]. In practice, clear demand identification requires deep service implementation. Therefore, future efforts should expand coverage in functional buildings, optimize service package content, and implement accountability systems to enhance service perception and demand recognition, aligning with the overall policy direction of promoting high-quality family doctor services.

3.2 KANO Model Identifies Refined Demand Characteristics

Better-Worse matrix analysis revealed that "medication dispensing" and "expert consultation" (diagnostic services) and nine health management items including "physical examination report interpretation," "eye disease prevention," and "cervical spondylosis prevention" were expected attributes, while "extended prescription" was an attractive attribute. This indicates that working-age populations prioritize personalized health management services. According to KANO theory, comprehensive health assessment systems should be established with "one-person-one-file" family doctor health management models. Targeted services such as customized examination report interpretation, cervical spondylosis prevention education, eye disease prevention, and appropriate technology promotion should be provided based on health assessment results to enhance service feasibility.

Interestingly, "downward referral" showed low demand, yet "extended prescription" and "expert consultation" were attractive/expected attributes. This may reflect that working-age populations typically seek care directly at secondary/tertiary hospitals [13], with unclear understanding of family doctors' role in facilitating priority access and specialist resources. This suggests that contract services should actively integrate specialist resources, such as leveraging internet hospital platforms and green referral channels, to provide targeted specialist consultations that demonstrate the advantages of family doctor contracts and enhance attractiveness.

Digital health management items like "health record establishment/update/query," "health knowledge promotion and psychological guidance," and "personal smart health device usage guidance" remained indifferent attributes, indicating low demand within the family doctor service framework. However, research shows that health coaching, online consulting, and remote thematic health education services are flourishing among functional community populations, though quality varies widely [14]. The indifferent classification does not imply these services are meaningless, but rather signals an urgent need for family doctor services to standardize and establish trust before delivering effective digital health management.

3.3 Sequential Service Delivery Based on Demand Characteristics

Sensitivity analysis across service timing and payment willingness revealed that "long prescription," "extended prescription," and "medication dispensing" represent stable demands across all time periods, consistent with their expected/attractive attributes and previous research [13]. Specialized services like "TCM constitution identification" and "cervical spondylosis prevention" were popular during lunch breaks and after work, while "expert consultation," "seasonal cold prevention," and "eye disease prevention" were preferred on weekends and before work. This pattern suggests that technical, immediately effective services should be scheduled during lunch and post-work hours, while communication-intensive services requiring health assessment and education should target weekends, informing optimal service delivery timing [15-16].

Payment willingness analysis showed a "similar at both ends, different in the middle" pattern. Low-payers (0–50 yuan) and high-payers (≥201 yuan) focused on diagnostic services like long prescriptions, extended prescriptions, and medication dispensing, while middle-range payers (51–200 yuan) prioritized personalized health management such as exercise rehabilitation, chronic gastritis care, and weight management. Low-payers, typically healthier, view basic diagnostic services as essential conveniences. High-payers, likely with chronic conditions, demand higher-quality diagnostic services and medical resources [16]. The middle group, possibly experiencing sub-health conditions, shows diversified needs, suggesting targeted service provision based on personalized health assessments.

Based on these findings, we recommend offering "long prescription," "extended prescription," and "medication dispensing" as foundational services to attract functional building populations. During weekdays, targeted technical services with clear efficacy and good experience (e.g., TCM appropriate techniques, cervical spondylosis prevention) should be provided based on population health profiles. On weekends, comprehensive health assessments, specialist resource integration, and health education should be delivered to establish diagnosis and drive precision services on weekdays. This creates a systematic, well-paced service system to improve utilization and satisfaction.

Limitations: This exploratory study represents only one jurisdiction's functional building population. Limited sample size prevented effective stratification by occupation, age, and social background. Future research should expand coverage and incorporate multi-dimensional data sources to develop clearly stratified, sequentially implementable family doctor service packages.

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Author Contributions: CAI Chengjun drafted and revised the manuscript; XU Xin, SHAO Jie, and ZHOU Lulu collected and organized data; ZHANG Shengbing coordinated the survey; HUANG Jiaoling, SHI Jianwei, and MI Yikai provided statistical analysis support; HUANG Qian was responsible for overall study design, implementation, and interpretation.

Conflict of Interest Statement: The authors declare no conflicts of interest.

Received: November 7, 2024; Revised: March 5, 2025; Accepted: [Not specified]
Edited by: WANG Fengwei