The impact of contract service policy and doctor communication skills on rural patient-doctor trust relationship in the village clinics of three counties

The doctor-patient relationship in rural China plays a pivotal role in the country’s three-tiered healthcare delivery system. It is regarded as the main selection criterion used by patients to choose doctors. It has also been viewed as a key determinant of the success of village clinics in carrying out their function as the bottom tier of the three-tiered healthcare network [1]. However, the doctor-patient relationship has deteriorated since the implementation of rural health reforms in the 1980s [2]. Many studies have pointed out that the main cause of this deterioration is the degeneration of patient-doctor trust [3‐6]. Trust is regarded as the keystone of the doctor-patient relationship [7] in the treatment process. It has been linked to patient satisfaction, treatment adherence, and treatment outcomes, as well as fewer malpractice lawsuits [8]. Generally speaking, a patient who has a high level of trust in his or her doctor is more likely to share relevant information, improving the outcome of treatment [7]. In view of this, China’s Health Department enacted a series of policies to improve the doctor-patient relationship in the primary health system. The most important policy for improving the relationship is the newly implemented contract service in primary health. The policy in rural China may be regarded as a Chinese counterpart of family medicine in western countries [9‐12]. It can be defined as a system of contracts signed between village doctors and villagers in household units that prompts village doctors to provide demand-tailored public health services like general practitioners [13]. This policy was piloted in 15 counties in 2013 and then was implemented across the whole country in 2014. The model relies on the voluntary participation of patients and is intended to be responsive to their needs [13]. The initial purpose of enacting the policy is to increase village doctors’ annual income and provide positive incentives; however, after the policy had been deeply implemented, health researchers and managers found that the doctor-patient relationship in rural areas had changed. They considered the policy as being able to closely connect patients and village doctors, and it seemed the best way to keep patients in the primary health service. A body of research in China pointed out that implementing the contract service policy in rural area could enhance the trust of patients in village doctors [14‐16]. However, as these studies used the method of normative analysis, whether the contract service has influenced rural patient-doctor trust is still unstudied empirically. Therefore, this study will analyze whether the contract service influences patient-doctor trust-building in the village clinics of rural China.

Numerous studies have shown that communication is the most effective vehicle for engendering trust [7, 17‐19]. One study has found a correlation between effective patient-doctor communication and lower blood pressure, reduced anxiety, and a higher quality of life among breast cancer patients [20]. A follow-up study demonstrated that patients’ perceptions of the therapeutic communication skills of their GPs affects adherence [21]. Other studies have shown that features of doctor-patient communication can predict health outcomes [20, 22]. A more recent study analyzed a group of elderly people in the United States, showing that effective communication generates high levels of trust among elderly Medicare beneficiaries [17]. Another newly published research explored the mediating role of patient-provider communication among team members within the Patient-Centered Medical Home and patient satisfaction with providers [23]. Despite the fact that the current literature in patient-doctor communication is flourishing and proliferating, little research has investigated the mediating role of doctor-patient communication in establishing the patient-doctor relationship, especially in the village clinics of rural China.

Based on the above literature review and analysis, the main objective of this study was to explore whether there is a direct association between contract service and patient trust in doctors, whether doctors’ communication skills acted as a mediator, and whether both a direct and indirect association exist between contract service and patient trust in doctors in the village clinics of rural China, after controlling for sociodemographic factors, medical expenditures, and other health policy characteristics. Therefore, we hypothesized that the contract service policy positively influences the patient trust in doctors in the 25 village clinics of rural China that we studied, and that the patient perception of doctor communication skills mediates the pathway between contract service and patients’ trust in doctors.

In order to verify the relationship between patient-doctor communication and their trust in doctors, the following strategies of statistical analysis were employed. First, descriptive statistics were used to determine the main characteristics of the samples. Second, t-tests were used to test the differences between the effects of different groups of contract service on trust and perception of the doctor’s communication skills. Third, Multivariate Analysis of Variance (MANOVA) was used to examine whether the differences existed in different levels among sociodemographic characteristics. Fourth, Multiple Linear Regression (MLR) was used to examine the association between contract service, doctor communication skills, and patient trust in doctors in rural clinics. According to Baron and Kenny [28], a perfect mediation is demonstrated when (a) the independent variable is significantly related to the dependent variable, (b) the independent variables are significantly related to the mediator, (c) the mediator is significantly related to the dependent variable when the independent variable is controlled. If in step (c) the previous significant relationship between independent variable and dependent variable is insignificant when the mediator is added, the effect of the independent variable on the dependent variable is completely mediated by the mediator; if its effect is still significant but its standardized regression coefficient is smaller than in the step (b), its effect is partially mediated by mediator. The regression model can be written as follows, and the Stata software package was used to implement it (version SE15, Stata Corp., College Station, TX, USA); p-values < 0.05 were considered statistically significant.

In this model, T, CS, and DCS are the dependent variable (trust), independent variable (contract service), and mediator (doctor communication skills). The constants a, c, and f are the intercepts; b, c, and h are the regression coefficients; and e₁, e₂, and e₃ are error terms.

To our knowledge, this study may be the first to explore the potentially important mediational pathway between contract service and rural patient trust in village doctors in the village clinics of rural China.

In this study, we have identified contract service as an independent predictor of rural patient trust in their doctors after controlling for other factors (β = 0.173, p < 0.01), which confirmed the hypotheses we set up. A previous study explained that contract service made patients satisfied in their relationships with village doctors because they enjoyed the service of public health that they felt they deserved [12]. This study confirmed that contract services contributed to the improvement of the patient-doctor relationship and their trust-building. For one thing, the contract service increased doctors’ annual income, which improved their job-related efficiency and positivity; for another, it changed the service manner of village doctors, who previously sat passively in clinics waiting for patients to visit, while after signing the contract service, doctors must provide service actively, as by home visits and follow-ups [12, 29]. An earlier study confirmed that contract services increased the work burden of village doctors and brought about staff shortages when providing public health and primary prevention [12], but another study analyzed the contract service as increasing convenience and patient safety and alleviating their uncertainties on health [30]. Other studies have also confirmed that contract service routinized the professional and technique training and enhanced the service capability of village doctors [12, 29]. The findings of this study are consistent with previous studies indicating that contract patients had a positive perception of doctors’ communication skills during the provision of services. A recent study discussed the differences between patients who had and had not signed up for contract service on their reasons for accepting the services, which indicated that patients who signed the contract were more likely to accept the services than those who had not signed [31]. Similarly, this study also found that patients who had and had not signed the contract service presented significant differences in their perceptions of doctor communication skills. Patients who had signed up for the contract service showed a higher perception of doctor communication skills than those who had not.

The most significant finding of this study is the discovery of the mediating effect of doctors’ communication skills between contract service and patients’ trust in village doctors in the village clinics of rural China. The result showed that the significant influence of contract service in the model decreased when the variable of doctor communication skills was added (p = 0.014). Numerous studies have verified that communication skills of doctors influence the patient-doctor relationship among a variety of patients in different cultural environments [32‐34]. The results of this study together with overseas research further confirm the importance of doctor communication skills in patient-doctor trust. A study by Jennifer Fong Ha et al. determined that doctors expressing a willingness to listen increased patients’ confidence and willingness to talk, and their patients thus generally shared more information about their symptoms [35]. This in turn helps doctors carry out causal analyses and provide appropriate treatment [36]. Previous studies showed that most deterioration in the patient-doctor relationship was due to the inadequate explanation of the diagnosis or treatment [37, 38] and to patients feeling ignored [39]. However, this study found that the mean score of doctor communication skills (Table 2) was high, which indicates that village doctors used good communication skills in their daily work. For instance, the ability to clearly explain prescriptions reduces confusion and misunderstanding among patients taking medication [34]. Doctors who explain why they are prescribing a particular drug or choosing one treatment over another increase their patients’ ability to understand prescription choices; they reduce the levels of anxiety, worry, and fear of illness among those patients. Clear explanations of drugs and medications, including both positive and negative efficiency, reduce fear and uncertainty and increase the likelihood that patients will comply with their doctors’ advice [35]. Finally, these communication skills served to increase patients’ trust in their doctors.

This is a preliminary and exploratory study, and the present findings require further investigation. This study has several limitations. First, we only chose three counties in the eastern and central parts of China as our study sites according to economy and region, and even though the study was sufficient to support the statistical analysis we used, its results cannot be extrapolated to the whole country. Further research is needed to expand the sample size when analyzing the complex dynamic mechanism between contract service and patients’ trust in doctors. Second, although we adjusted for some potential confounders likely to have an impact on patients’ trust in doctors in the multiple regression analysis, other confounders may have been overlooked, such as the rural interpersonal relationship, which should be considered in future studies. Third, this study used a questionnaire methodology to collect data, which might suffer the social-desirability bias effect because of the lack of observation data. Last but not least, this cross-sectional data cannot be used to analyze the direction of causality. Future studies will need to improve the sampling and use a longitudinal study design, a comprehensive questionnaire, observations, and perhaps even experimental intervention to test and extend this research.

Despite these limitations, this study is the first to use the TCom-skills GP scale and WFPTS to measure village doctors’ communication skills and patients’ trust in doctors to explore trust-building in China’s rural culture.

This study empirically investigated the relationship between the policy of contract service, a doctor’s communication skills, and patient-doctor trust in the village clinics of rural China. Contract service plays a vital beneficial role in building patient-doctor trust. Doctors’ therapeutic communication skills played a mediating role between contract service and patients’ trust in doctors in that adequate patient-doctor communication increased patients’ trust in their doctors.