Xu et al. BMC Fam Pract (2021) 22:117 https://doi.org/10.1186/s12875-021-01431-x RESEARCH ARTICLE Open Access Can social capital play a role in contracting services of family doctors in China? Reflections based on an integrative review Xinglong Xu1, Henry Asante Antwi2,3*, Lulin Zhou1, Tehzeeb Mustafa1 and Ama Boafo‑Arthur4 Abstract Background: The family doctors’ contract service problem is not about government management alone, but an interaction of a complex social environment. Consequently, the effect of contracted services of family doctors not only depends on policy incentives but also needs to win the participation, acknowledgement, and confidence of community residents. The purpose of this integrative review is to examine whether there is any significant evidence that social capital in the form of social networking groups and other forms of social groups have any positive impact on the acceptance and the effectiveness of family doctors’ contractual services. Method: Research on qualitative, quantitative and hybrid methods published in peer‑reviewed journals on the social capital role in the process of contract service of family doctors were eligible for inclusion. In view of the increasing attention paid to the contract service effect of family doctors during this period, a 10‑year time scale was selected to ensure full coverage of relevant literature in the same period. In total, 809 articles were determined in the database retrieval results which were downloaded and transferred to the Mendeley reference application software. Results: Twelve articles met the inclusion criteria for this integrative review and the quality of the included studies were assessed using the published criteria for the critical appraisal of quantitative and qualitative research methods. Majority of the articles assessed reported that there was evidence of a positive link between social support, especially a sense of belonging and the presence of regular family doctors. The influencing factors of patients’ contract behavior of studies conducted in China were social interaction of social capital, acceptance of the first contact in the commu‑ nity, year of investigation, and exposure to the public. Conclusion: The study affirms previous studies that suggest that social resources have the propensity to improve relationship between patients and clients and between doctors and peers for the benefit of the patients and the stability of the overall healthcare system. Through the integration of various social resources family doctor systems accelerate the development of community construction. These social capital (social network groups) can guide resi‑ dents to use family doctor services to maintain health. Social capital can also help residents have a regular and reliable family doctor. Keywords: Family doctor, General practitioners, Integrative review, Social capital, Social network, General practice, Family physician *Correspondence: 5103150217@stmail.ujs.edu.cn 2 Center for Health and Public Policy Res, earch, Jiangsu University, 301 Xuefu Road, Zhenjiang, Jiangsu, P.R. China Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creati vecom mons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons.o rg/p ubli cdoma in/z ero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Xu et al. BMC Fam Pract (2021) 22:117 Page 2 of 17 Background affecting effective family practice in China. The concept China continues to make significant strides in her effort of social capital has evolved through series of schol- to reform its primary healthcare system to provide effec- arly research studies across the globe. Between 1700 tive and efficient patient care services to its citizens. The and 1900, Adam Smith, Marx Rousseau, Tocqueville primary healthcare system in China is divided into rural etc. established the basic tenets of social capital theory and urban components but the organizations are very through the social exchange theory and the psychological similar [38]. Generally, healthcare is provided through construct theory. Hanifan [17] first used the term “Social a three-tiered system. The first tier is village clinics and Capital” to refer to the goodwill, mutual sympathy, fel- medical centers often manned by the barefoot doctors lowship, and social intercourse that exist among families and physician assistants due to the absence of highly and group of individuals and families. Jacobs [19] also qualified medical personnel. The second tier is made up defines social capital as a tool for strengthening urban of township and community health clinics that function vitality. Thus social capital is social network used in stim- primarily as out-patient clinics. These centers also serve ulating positive relationships. The modern concept of as referral centers for village clinics and often attract social capital is derived from the ground breaking works fairly qualified medical professionals. The county hospi- of Coleman [7] and Bourdieu [3]. tals with very qualified medical practitioners complete According to Coleman [7] social capital are features of the third level of health service delivery in Chinese sub- social organizations such as networks, norms, and social urban regions. Similarly, the urban health service delivery trust that facilitates coordination and cooperation for starts with factories and neighborhood health stations. mutual benefits. Bourdieu [3] on the other hand explains These are supervised by the district hospital while the social capital as the aggregate of the actual or potential most serious cases were handled by municipal hospitals resources which linked to possession of a durable net- and tertiary hospitals [20]. work of more or less institutionalized relationships of Nevertheless, China’s healthcare system in general and mutual acquaintance and recognition. In the midst of primary healthcare in particular still faces challenges in the insecurities of family doctor contract services, both structural characteristics, incentives and policies, and doctors and patients need social capital to maintain quality of care, all of which diminish its preparedness their trust in the system. Doctors need social support to care for its large, aging population amidst the grow- from supervisors and colleagues to openly communi- ing prevalence of chronic non-communicable diseases. cate their grievances, reduce burnout, improve wellbe- With an ever-increasing healthcare demands, individu- ing and become more engaged in the practice. On the als started contracted their own family physicians hence part of patients, Shang et al. [30] discloses, traditionally, the family doctor contract services. To that extent, China family doctors have been seen as “people doctors”, rather introduced the family doctor system to strengthen its pri- than “disease doctors”. They are expected to form infor- mary healthcare delivery services but the family doctor mal social relationships with their patients as part of both system is plagued with several social problems that have preventive and medical care services. They must bring rendered it less attractive to both doctors and patients. patients to the doorstep of the medical services through The family doctor system is assailed with community warmth, trust, mutual help, shared value and coordina- health resource constraints, unmotivated doctors, lack of tion of communal healthcare tasks. Therefore, social social participation etc. [30]. capital will have an impact on the effect of contracted For example, Binder [2], many Chinese are not aware of services of family doctors [20, 26, 30]. the benefits of family doctor contract services. The policy Since May 2016, the Chinese government has expan- of government at the onset was to encourage more people sively promoted family doctor contracted services to enroll with much investment on effective strict super- throughout the country and made it the main task of vision and quality family doctor contract services [6]. expanding the transformation of the clinical care and Naturally, the confidence of residents eroded with per- healthcare system in this new era [21] but effective sistent unsatisfied medical services [6]. Moreover, only family practice goes beyond setting up a system. It also few doctors are willing to accept family doctor services involves, having sound personnel, effective incentive in China due to poor remuneration, excessive supervi- methods, smooth referral channels, and service-ori- sion and poor career progression [20, 30]. As explained ented residents’ needs but these are poorly integrated in [30], effective family doctors services depends on both in China’s family doctor system [34]. The after-effect policy incentives and winning the participation, acknowl- of COVID-19 has increased the urgency for China to edgement, and confidence of community residents [30]. strengthen it family doctor contract services. China According to Zhou, et al. [40] social capital can be an believes that family doctor contract service has a effective way to resolve some of the social challenges great influence on the ability of health service at the X u et al. BMC Fam Pract (2021) 22:117 Page 3 of 17 grass-roots level, and its effectiveness and accessibil- select, evaluate/examine critically, and synthesize arti- ity are the keys to the realization of universal health cles on social capital which can positively affect the coverage [13]. This review summarizes the qualitative effect of family doctor’s contract services. and quantitative results from articles and the effective impact of social capital (social network groups) in the Literature Search contracted services of family doctors and its applica- A strict inclusion and exclusion criteria was set in the bility in China. This paper also reviews the influence search for qualifying articles. Firstly the paper should have of social capital on the form and effect of family doctor been peer reviewed published, abstracted or indexed in a services. To further explore the mechanism and man- recognized database such as such as Medline, Web of Sci- agement of social capital in the contracted services of ence, Science Direct and PubMed. Pre-print databases with family doctors. articles under review in high impact factor journal were also consulted for current information that is in the review process. Secondly, the articles should have been published Methods in English language. The studies also included quantitative This particular integrative review was steered by the research, qualitative research and mixed research stud- updated version of Whittemore and Knafl’s comprehen- ies in so far as the focus is on the role of social capital and sive methodology review outline. This is a description of family doctor contract service. The included articles must the mythological approach to integrative review that was primarily focus on China or compare the case of China published in 2005. Since then the model has become the and other countries. This criterion notwithstanding, some basic benchmark and the conceptual structure of most studies that were not China based were included because integrative review due to its robustness especially in the they have significantly explored and advanced the frontiers field of healthcare. The model combines both quantita- of social capital in family medicine. They include studies tive and qualitative study findings on targeted topics and Small et al., [32] that highlight the benefits of peer support provides a comprehensive understanding of the review networks established in conjunction with doctors to help issues. The framework includes five stages, such as iden- needy doctors and patients without access important med- tification of the research problem, articles retrieval, eval- ical information. uation of the data retrieved, analysis of the retrieved data, Another inclusion criterion was that the field of medicine and the presentation of the findings [25]. The PRISMA is a highly specialized area hence specialized professional guidelines were consulted to augment the process of groups abound. Thus journals or publications by profes- reporting the study’s findings in order to ensure robust- sional groups within the healthcare sector that bothered ness of inference. The extent to which each of these on family practice were also consulted. The family doctor stages were applied to this study is highlighted in the next contract services in China do not have a long history but sections. interest dates back to more than a decade. For this reason, studies spanning a ten year period up to 2019 were selected to ensure full coverage of relevant literature in the same Identification of the problem period Table 1. The purpose of the study is to examine whether there In total, 809 articles were determined in the database is any significant evidence that social capital in the retrieval results which were downloaded and transferred form of social networking groups and other forms of to the Mendeley reference application software. Repeated social groups have any positive impact on the accept- articles (353) were deleted after which all the authors ance and the effectiveness of family doctors’ contrac- reviewed the copies of the papers and discussed their dif- tual services. It also seeks to recommend any practical ferences until a consensus was reached. After delibera- learning suggestions that can be applied to healthcare tion, 456 articles were further deleted. Article titles and management projects, such as the family doctor ser- their summaries were examined by XX and HAA for vices policy development in China. The main purpose their importance based on the exclusion and inclusion of this integrative review is to thoroughly identify, criteria. After the screening, the two authors discussed Table 1 Terms used for the literature search Article Search Terms “family doctor” OR “family physician” OR “general practice” OR “general practitioner” OR “family practice” OR “social capital” OR “social network” OR “family doctor” AND “social capital” OR “primary care” AND “social capital” OR “family physician” AND “social capital” OR “service form for family doc‑ tor” OR “service results for family doctor” Xu et al. BMC Fam Pract (2021) 22:117 Page 4 of 17 their outcome with the other authors and 31 articles were on the study objectives, sampling strategy, sam- selected for full-text assessment. On this basis, the authors ple size, study design, data collection technique, further screened the above-mentioned articles around the strengths and limitations, key findings, and analyti- research topic and objectives and forwarded 12 papers for cal approach of the studies (Table 2). analysis (Fig. 1). (2) The evaluation of the second level involved the critical appraisal (XX, ZLL, HAA, and JOM) Data extraction and evaluation to determine the methodological quality of the The assessment of the 12 full-text articles composed of 2 included studies. Due to the variety of method- level evaluations. ologies and designs, two method-specific tools were identified to assess the quality of evidence. (1) The first stage evaluation involved the exclusion For qualitative studies, the Critical Appraisal Skills of studies using the layout for the exclusion and Programme (CASP) [9] tool was used (Table  3) inclusion criteria rules. In this level, 12 articles and the Rees et. al. [28] survey checklist (Table  4) were selected based on the inclusion criteria. These was utilized for cross-sectional studies. Each cri- comprise of 1 qualitative and 11 quantitative stud- terion was recorded as “Yes” or “No” or “Clear” or ies as indicated in (Fig.  1). Data were extracted “Unclear” and results of appraisal were discussed Fig. 1 The prisma flow diagram X u et al. BMC Fam Pract (2021) 22:117 Page 5 of 17 Table 2 Descriptive characteristics of the studies included in the review Title, Author, Study aim Design Sample strategy and Data collection Analytical approach Strengths and / Key findings reported publication year and sample size method Limitations by authors country Factors influencing To analyze the main A cross‑sectional A random sampling of Questionnaire Descriptive and The main limitation of The influencing factors patients’ contract influencing factors of survey 1200 patients t-test, χ2 test, factor this study was that of patients’ contract choice with general contract behav‑ analysis, and logistic just one district was behavior were age practitioners in ior, including the regression analysis studied in Shanghai (OR = 1.03; 95% shanghai: a prelimi‑ concept of social were used to analyze CI = 1.02–1.04), educa‑ nary study capital, and put the data tion (OR = 0.83; 95% [20] forward some sug‑ CI = 0.75–0.93), social CHINA gestions for further interaction of social development of the capital (OR = 1.34; GP system of health 95% CI = 1.15–1.56), care acceptance of first contact in com‑ munity (OR = 3.25; 95% CI = 2.07–5.12), year of investiga‑ tion (OR = 2.58; 95% CI = 1.92–3.47), and exposure to the public (OR = 1.60; 95% CI = 1.39–1.85) Social capital and To explore the asso‑ Based on a cohort The sampling for The survey was dis‑ Descriptive and This study was con‑ Frequent attendance frequent attenders ciation between study survey participants used tributed in a paper multiple logistic ducted explicitly at was associated with in general practice: frequent attendance a municipality by mail in February regression analysis the individual level, lower scores (adjusted a register‑based and individual social stratified random 2010, and both whereas previous lit‑ for age, education, cohort study capital sampling strategy paper and online erature has featured and income) in [26] and in total 35,700 responses were multilevel or area‑ women’s interpersonal Denmark residents, above the possible level analyses, which trust (OR 0.86 (0.79 age of 16, were sam‑ might influence the – 0.94)) and social pled from 579,000 findings networking (OR 0.88 inhabitants in 11 (0.79 – 0.98)). There municipalities was no significant relationship between reciprocal norms and citizen participa‑ tion and frequent attendance of women (1.05 (0.99–1.11) and 1.01 (0.92–1.11), respectively. These associations were not statistically significant for men Xu et al. BMC Fam Pract (2021) 22:117 Page 6 of 17 Table 2 (continued) Title, Author, Study aim Design Sample strategy and Data collection Analytical approach Strengths and / Key findings reported publication year and sample size method Limitations by authors country Social networks and To examine the role Cross‑Sectional Five Canadian Com‑ Extraction of data from estimated coefficients Continuing to develop There was evidence the probability of played by social sup‑ munity Health Sur‑ a community survey from a probit model ways of quantifying that there is a positive having a regular fam‑ ports in helping to veys spanning 2001 social supports and link between social ily doctor explain why a signifi‑ to 2010 (n = 13,872 incorporating them support, especially a [10] cant portion of the to n = 30,814) into longitudinal sense of belonging Canada Canadian population surveys would help and the presence of does not have a facilitate empirical regular doctors regular family doctor analyses on how even though primary social supports care is fully covered affect health‑ care by the public insurer utilization and when having a regular physician is associated with better care and with access to specialists Social capital and hav‑ to examine the impact longitudinal survey the Canadian National the Canadian National dynamic random Since past access to There was evidence that ing a regular family of social capital (e.g., data Population Health Population Health effects probit model a family doctor is a there is a statistically doctor: Evidence tangible support, longitudinal longitudinal survey strong predictor of significant positive from longitudinal friends, and family) survey (1994–2010: (1994–2010) both current and causal relationship data, on having a regular n = 41,022) future access, we between social capital [1] family doctor taking show that social and the possibility of Canada into account that capital is much more having regular family social capital may important in helping doctors be endogenously individuals find a determined family doctor than for keeping one X u et al. BMC Fam Pract (2021) 22:117 Page 7 of 17 Table 2 (continued) Title, Author, Study aim Design Sample strategy and Data collection Analytical approach Strengths and / Key findings reported publication year and sample size method Limitations by authors country Social support, flexible To examine how social Qualitative study The study combines Interview and observa‑ Descriptive and quali‑ Results from this study The results show that resources, and health support operates as design in‑depth interviews tional methods tative data analysis improve understand‑ doctors evaluate par‑ care navigation, a flexible resource with parents of software NVivo 8 ing of the mecha‑ ents’ visibility in hospi‑ [15] that helps people pediatric cancer nisms that underlie tal, medical vigilance USA navigate the health patients (N = 80), the development and adherence to care system direct observation of and deployment of children’s treatment, clinical interactions strategies for navi‑ and use these judg‑ between families gating the health ments to form clinical and physicians care system and decisions. Parents (N = 73), and in‑ highlight the role of who get help from depth interviews social support as a personal networks with pediatric flexible resource that are more flexible in oncologists (N = 8) helps people meet balancing competing institutional expecta‑ needs, which enables tions for appropri‑ parents to more ate involvement in effectively meet the health care agency’s expectations of parents’ proper participation in child care Residents’ Awareness The aim of this study Cross‑sectional Survey enrolled 3960 self‑designed ques‑ Descriptive and On the one hand, this Health consultation of Family Doctor was to investigate residents from nine tionnaire analytical. Data were was a cross‑sectional (84.64%), regular Contract Services, the residents’ aware‑ counties in Zhejiang analyzed by SPSS study using a physical examina‑ Status of Contract ness of Zhejiang Province using a 21.0 multistage stratified tion (81.71%) and with a Family Doctor, Province, China, multistage stratified random sampling medical insurance and Contract Service of family doctor random sampling method to select reimbursement Needs in Zhejiang contract services, method respondents. As we (80.06%) were the top Province, China: the status of signing know, most young three demands for A Cross‑Sectional such a contract, people go out to contracted services. Study, and the demand for work and the elderly The awareness rate [30] service items in the stay at home, which and signing rate of CHINA contracted service may lead to under‑ household doctors in package representation of the Zhejiang Province are whole population in not ideal Zhejiang Province Xu et al. BMC Fam Pract (2021) 22:117 Page 8 of 17 Table 2 (continued) Title, Author, Study aim Design Sample strategy and Data collection Analytical approach Strengths and / Key findings reported publication year and sample size method Limitations by authors country General practitioners to identify GPs’ atti‑ Cross‑sectional Survey Seventy‑eight out of a self‑completion ques‑ Descriptive and The study had a high General Practition‑ and carers: a ques‑ tudes, awareness of total of 95 GPs tionnaire analytical response rate. A ers consider time, tionnaire survey of issues, and percep‑ limitation is that resources and lack attitudes, awareness tions of the barriers the study par‑ of knowledge as of issues, barriers and enablers to the ticipants had mostly obstacles, but only and enablers to the provision of services chosen to attend a 9% agreed that they provision of services, workshop on carers can provide little [16] and may have been support. However, UK an atypical group 89% of the ten GPS (9) motivated to sup‑ think they don’t have port carers enough training, and about half (47%) lack confidence The influential role The main goal of cross‑sectional data Extracted data from A questionnaire was Descriptive and mul‑ Alternatively, Social capital may affect of personal advice our study consists from one LHA of the the Italian National used for collecting tivariate regression qualitative in‑depth the ability of a General networks on general of assessing the Italian NHS Health System, local data from archival models analyses could Practitioner to achieve practitioners’ per‑ influence of a GP’s health authorities sources of the Italian better explain the his/her goals. In formance: a social social capital on (LHA) from 80 GPs’ National Health micro‑dynamics particular, the higher capital perspective, her/his capacity to System, local health behind the findings the professional het‑ [5] accomplish two authorities (LHA) from this study erogeneity of the GP’s Italy organizational from 80 GPs’ personal counselling objectives related network, the lower his to his/her prescrib‑ / her ability to achieve ing behaviour: the specified appropri‑ containing health ateness goals expenditures and fostering prescriptive standards X u et al. BMC Fam Pract (2021) 22:117 Page 9 of 17 Table 2 (continued) Title, Author, Study aim Design Sample strategy and Data collection Analytical approach Strengths and / Key findings reported publication year and sample size method Limitations by authors country Social relations and to analyze the social Cross‑sectional survey Stratified sam‑ Questionnaire Descriptive and it is a limitation that 36.2% of the people loneliness among relations and loneli‑ pling of Patients analyzed using we only included have a high degree of older patients con‑ ness of patients aged aged ≥ 65 years univariate logistic patients who are social participation, sulting their general 65 years and above consulted their regression able to visit the 45.5% have a medium practitioner, consulting their GP general practitioner practice and to fill degree of social par‑ [12] in the study period out the question‑ ticipation, 18.3% have Denmark in 12 practices in the naire. By not includ‑ a low degree of social Capital Region of ing those receiving participation, 17.9% Denmark (N = 459), home visits, very old often or occasionally and frail patients are feel lonely. Higher probably under‑ social participation represented, and was associated with they are most likely lower loneliness. lonelier than the Only 15.2% of autistic respondents used in patients asked their this study GPs about their loneli‑ ness Family physician– To investigate the Cohort study design German population Patient‑Doctor Rela‑ Descriptive and multi‑ Besides several Frequent visits by patient relationship association between sample (N = 2266) tionship Question‑ variate analysis strengths, like the family doctors were and frequent attend‑ the quality of the naire use of a large sample associated with lower ance of primary and family physician– representative of the income (OR 1.43, 95% specialist health patient relationship German population CI 1.02–2.00), unpaid care: Results from a and the frequent and the use of a work (OR 1.58, CI 1.08– German population‑ attendance of pri‑ validated measure 2.30), mental distress based cohort study, mary and specialist of perceived family (OR 1.14, CI 1.07–1.22), [11] health care physician–patient physical symptoms Germany relationship quality, (OR 1.07, CI 1.04–1.11), the study has some and comorbidity (OR limitations. The study 1.54, CI 1.36–1.74). could not access Family doctors should health care use data be aware that demand of the participants factors, namely available at health symptom burden and insurance compa‑ physical comorbidity, nies are the main drivers of frequent visits Xu et al. BMC Fam Pract (2021) 22:117 Page 10 of 17 Table 2 (continued) Title, Author, Study aim Design Sample strategy and Data collection Analytical approach Strengths and / Key findings reported publication year and sample size method Limitations by authors country No Spouse, No Son, To investigate the kin Cross‑sectional survey nationally representa‑ Extracted secondary Descriptive and N/A In China, the proportion No Daughter, No Kin availability among data extraction tive survey data from data from a national regression models of people without in Contemporary adults aged 45 + in the China Health and survey analysis relatives is very low China: Prevalence, contemporary China, Retirement Longi‑ (less than 2% of them Correlates, and Dif‑ with an emphasis on tudinal Study (2011) do not have spouses/ ferences in Economic child gender With a multi‑stage partners and children), Support, area probability but the availability of [40] sampling design relatives is determined CHINA by gender, age group and socio‑demo‑ graphic characteristics. The proportion of the elderly without spouse/partner and daughter (3.2%) was more than twice that of the elderly without spouse/partner and son (1.4%). Adults without close relatives are disadvantaged in terms of health, wealth and financial support Understanding the The study examined A longitudinal study 4682 older adults This study utilized data Descriptive and infer‑ A study that will utilize Social capital plays a Association Between the association of 2014 Health and (between the ages extracted from the ential analysis e.g. more accurate vari‑ significant role in the Perceived Financial between perceived Retirement Study of 51 and 104) were 2014 Health and t‑tests and F‑tests ables that capture relationship between Well‑Being and Life financial well‑being (HRS) included in the study Retirement Study were conducted the bridging social financial well‑being Satisfaction Among and life satisfac‑ sample (HRS) and Ordinary Least capital would be and life satisfaction of Older Adults: Does tion while focus‑ Square (OLS) regres‑ desirable the elderly Social Capital Play a ing on a potential sion models were for Role? mechanism, that is, the analysis of data [39] whether or not social USA capital mediated the relationship between these two important factors in the lives of older adults X u et al. BMC Fam Pract (2021) 22:117 Page 11 of 17 between XX, ZLL, HAA and JOM with discrepan- in nature [5, 10–12, 16, 30, 40]; two were based on data cies resolved by consensus. Overall studies were extracted from a cohort studies [11, 26] and the other found to be of good methodological quality with the two studies were based on longitudinal data [1, 39]. only qualitative study recording nine out of the ten The sample size of these studies varied from 78 to 4682 appraisal criteria (Table 3) and quantitative studies respondents. recording between 11 and 14 of the total appraisal A study reported that the quality of social capital may score (Table 4). All the studies have determined the invariably obstruct a General Practitioner’s propensity to research objectives, proved the appropriateness of achieve specific targets. Specifically, it is demonstrated the design, used a clear sampling strategy, made a that when a GP is networked in a highly heterogeneous clear statement of the research results, and outlined social or professional group, the advice from this group the value of its research. In terms of the quantitative can limit the extent to which he can make accurate per- studies, response rates varied between 65.5% [26] sonal prescription decisions [5]. to 97.75% [30] and only a study attempted to con- Causes and affect relationships on family doctor con- tact non-responders [26]. Most of the studies were tract services is also well established and discussed limited to the purposive sampling method (Table 4). in the retrieved literature. Some studies confirmed Four studies did not provide sufficient informa- the effect of social capital on the relationship between tion to appraise the reliability of the measurement financial well-being and life satisfaction of the elderly items (Table 4). Five of the quantitative studies were [39]. Two studies retrieved from Canada also reported unclear regarding ethical approval or informed con- that there was evidence of a positive linkage between sent from an ethical committee (Table 4). Similarly, social support, especially a sense of belonging and the the conclusions of all quantitative studies are sup- presence of regular family doctors [1, 10]. The low level ported by data used for analysis, and the objectives of social participation affected family doctor services of the study are described (Table  4). Qualitative while higher social participation was associated with research is valuable and provides details that fully lower loneliness in studies conducted in Denmark [12, consider the relationship between researchers and 26]. The effect of socio-economic on patient-family participants (Table 3). doctor behavior is also addressed by the studies. In the extant literature outside China, the main social factors that have been explored include education, income, gender and age. In the particular case of studies in Retrieved data analysis China, the common social factors that moderates the In light of the heterogeneity of the literature contained, social capital and doctor patient relationship were age, the results of each study were examined [4], because con- education, social interaction of social capital, accept- clusions can be drawn based on common factors [22]. ance of the first contact in the community, year of inves- Procedures which were used to carry out the thematic tigation, and exposure to the public [20, 30, 40]. examination were guided by Smith et  al. (V. [33], and Frequent attendance at GPs offices is a long standing Lucas et. al. [22]. critical issue for GPs because of its capacity to unduly impose excessive burden on the doctor. Moreover, fre- Findings presentation quent patient visits can be a huge drain on the limited The summary of the findings from the 12 studies included healthcare resources. The interplay between social capi- in the review is depicted in Table 2. The selected papers tal and frequent doctor visits came up in some of the were mainly research works conducted in the USA [15, reviewed studies especially in the context of Europe. One 39], Denmark [12, 26], Canada [1, 10], China [20, 30, 40], study sought to examine whether social capital resources UK [16], Germany [11], and Italy [5]. Out of the eleven can be harnessed to support or reduce frequent use of quantitative studies; seven of them were cross-sectional general practice, which may in turn lower the frequency Table 3 Methodological quality of qualitative studies Study 1 2 3 4 5 6 7 8 9 10 Total Scores E. Gage‑Bouchard, [15] Yes Yes Yes Yes Yes Yes Unclear Yes Yes Clear 9/10 Keys: “1. Is there a clear statement of the purpose of the study?; 2. Whether the qualitative method is appropriate?; 3. Whether the research design is suitable for the research purpose?; 4. Whether the recruitment strategy is suitable for the purpose of research?; 5. Can data collection methods solve research problems?; 6. Whether the relationship between researchers and participants is fully considered?; 7. Whether moral issues are taken into consideration?; 8. Is data analysis rigorous enough?; 9. Whether there are clear findings?; 10. How valuable is this research?” Xu et al. BMC Fam Pract (2021) 22:117 Page 12 of 17 Table 4 Methodological quality of quantitative studies Study 1a 2a 2b 2c 2d 3a 3b 3c 4a 4b 5a 6a 7a 8a Total Scores Jing et. al. [20] Y Y Y Y N Y Y Unclear Y Y Y Y Y Clear 12/14 Pasgaard et. al. [26] Y Y Y Y Y Y Y Y Y Y Y Y Y Clear 14/14 Devlin et. al. [10], Y Y Y N N Y Y Unclear Y Y Y Y Y Clear 11/14 Bataineh et. al. [1] Y Y Y N N Y Y Unclear Y Y Y Y Y Clear 11/14 X. Shang et. al. [30] Y Y Y Y N Y Y Y Y Y Y Y Y Clear 13/14 Greenwood et al. [16] Y Y Y Y N Y Y Y Y Y Y Y Y Clear 13/14 Calciolari et. al. [5] Y Y Y Y N Y Y Y Y Y Y Y Y Clear 13/14 Due, T. D., et. al. [12] Y Y Y N N Y Y Unclear Y Y Y Y Y Clear 11/14 A. Dinkel et. al. [11] Y Y Y Y N Y Y Y Y Y Y Y Y Clear 13/14 Z. Zhou et. al. [40] Y Y Y N N Y Y Y Y Y Y Y Y Clear 12/14 J. Yeo and Y. Lee, [39] Y Y Y N N Y Y Y Y Y Y Y Y Clear 12/14 Key: Y – for Yes, N – for No. “A. Is the result valid? 1. Objectives: 1a. Is the research objective clear? 2. Design: 2a. Whether the study design is suitable for the target? 2b. Does this theme represent all interested groups? 2c. Whether it has obtained moral/ethical recognition? 2d. Whether to take measures to contact non-responders? 3. Measurement and observation; 3a. Whether it is clear what has been measured, how to measure and what the result is? 3b. Is the measurement valid? 3c. Is the measurement result reliable? B What are the results; Presentation of results; 4a. Whether the basic data is fully described? 4b. Whether the results are clear, objective and detailed enough for the readers to make their own judgment? Analysis; 5a. Is the method used suitable for the collected data? C Will the results help locally? 6 Discussion; 6a Is the outcome of the discussion related to the existing knowledge about the discipline and research objectives? 7 Interpretation; 7a. Is the author’s conclusion confirmed by data? 8 Implementation; 8a Can any necessary changes be implemented in practice?” Rees et al. [29] to attend hospitals [26]. It emerged from this study that quality respectively. While three other articles (also social capital deficit in some cases can induce frequent representing 25%) obtained met 12 of the 14 MMAT GP visits. quality benchmark, the remaining 5 articles represent- A German study linked the frequent visit of family doc- ing 41.6% obtained 13 out of the 14 MMAT quality tors to their lower-income level [11]. The sample size of benchmarks. The most frequent weaknesses related to the qualitative study was 80 participants, including 59 lack of discussion on the reason for studying specific women and 21 men [15]. This particular article reported organisations, the influence of the organisation on the on the examination of “how social support operated as research and researcher influence in qualitative and a flexible resource that might help people navigate their mixed methods studies. There were also issues with health care system in their locality”. The study used lack of a clear description of the sampling process of interview and observational methods for data collec- respondents adopted by authors in quantitative stud- tion. The study also combined in-depth interviews and ies and sub threshold rates for acceptable response or direct clinical interactions observations among families follow-up in non-randomized quantitative studies were and their medical doctors. Descriptive and qualitative also recorded as major weaknesses of the quantitative data were analyzed with the statistical software, NVivo research. Most of the studies had support from fund- version 8 [15]. The results from this study reported hav- ing agencies or organisations for whom the research ing improved the understanding of the mechanism that outcome serve their interest. Thus the influence of such inspire the expansion and the distribution of the poli- organisations in the conduct of the research was not cies for steering the health care system. It further high- disclosed by the researchers. lights the impact of social network support as a flexible resource that helped people met their organizational Results prospects for suitable involvement in health care [15]. Identification of social capital/network influence of family To evaluate the quality of the studies, the Mixed doctor acceptance Methods Appraisal Tool (MMAT) was applied as shown The theme identification of social capital /network influ- in Table 4. Pluye & Hong [27] explains that the MMAT ence of family doctor acceptance explores. tool helps to provide quality appraisal for quantitative, qualitative and mixed methods to be included in sys- (1) Benefits of having a family doctor tematic reviews. In the MMAT the least paper met 11 (2) Benefits of belonging to social capital or social net- out of the 14 quality benchmarks (3 articles) whereas work the highest obtained 14 out of 14 quality benchmarks (3) Influence of social capital or social network groups (1 article). This represents 25% and 8.3% MMAT on accepting a family doctor X u et al. BMC Fam Pract (2021) 22:117 Page 13 of 17 (4) Family doctor policies capital has nothing to do with their acceptance of fam- (5) Barriers to the family doctor contract services ily doctors or GPs. This shows that there are various and acceptance varied relationships between social capital and the gender of regular attendance [26]. In Zhejiang Province, China, for instance, the level of family doctor contract services (FDCS) awareness and the signing rate of family doctors Benefits of having a family doctor are not the ideal, aside from that there is still a lot to be GPs play a unique role in dealing with social relations and done for further improvement [30]. However, age, edu- loneliness [12]. GPs identified the important influence of cational level and chronic medical history were some of general practice in supporting patients but also wished the factors identified to be influencing residents’ aware- to get more training and support [16]. The family doctor ness of FDCS. Concurrently, residents’ understanding of is the first call point in an emergency situation. There is FDCS also affects their signing rate with family doctors. evidence that finding a regular family doctor can improve Surprisingly, patients who signed the agreement with health [1]. Better continuity and quality of care, as well as the family doctors had a large request for FDCS. But the improved health, are some of the overall benefits of hav- demand rate of residents with different social and demo- ing a regular family doctor [1]. graphic characteristics was different for different FDCS projects. Therefore, this is a call for the government to strengthen the policy support, strengthen the informa- Benefits of belonging to social capital or social network tion campaign, expand the service scope, and provide group more attractive service items in order to encourage the Undoubtedly, in terms of quality of life, morbidity, expansion of FDCS in China [30]. Residents should be and mortality, the community social network relation- allowed to choose a family doctor of their choice to sign ships are very vital for the people in the community. the contract with. In addition, they should be allowed to This applies especially to the elderly [12]. The health also choose the projects they need when signing a con- of the people in the community, as well as their social tract with family doctors. The family doctors should also network groups, are interconnected. In recognition of offer better services to the satisfaction and fulfilment of this social fact, over the past decade, there has been the residents [30]. increasing conceptual and empirical attention to the There is evidence that a positive link exists between impact of social networks on health [31]. According to social support (especially a sense of belonging) and main- a study conducted by E. A. Gage-Bouchard [15], most taining a consistent medical doctor [10]. There is also parents who received aids through their personal social evidence that shows a significant positive causal associa- networks were most comfortable in balancing their tion between social capital and the likelihood of attaining competing demands. This enabled them to effectively a regular family doctor [1]. Nevertheless, social capital comply with their agencies’ hopes of parents’ proper was reported by a study as being much more important participation in child care [15]. In this way, social sup- to helping individuals to find family doctors than to keep- port provided some families with flexible resources, ing them [1]. Undoubtedly, the influence of social capital which enabled them to acclimatized to the needs of (social networking groups) in the relationship between caring for children with cancer more quickly. It also economic well-being and the life satisfaction of the raised a fruitful social relationship between parents elderly was statistically significant [39]. It is worth noting and their medical care providers which played an active that obtaining social capital through strong family rela- impact in the health of their children [15]. Notably, tionships and active social networks may decide the life quite a number of studies on social support and health satisfaction of the elderly [39]. have shown that emotional, logistical, information and financial support from personal networks enhance peo- Family doctor policies in China ple’s coping choices in managing serious diseases [31, Under the dual system of government guidance and 35]. market regulation, FDCS improves the quality of medi- cal services through policy guidance and individual independent contracting [30]. Based on the government- Influence of social capital or social network groups led contract to provide a certain limit of service con- on accepting a family doctor tent, standardize service pricing, maintain service order, Some aspects of women’s social capital groups are related and adjust the exclusive personalized service according to regular participation in the acceptance and use of to the market demand. This system not only produces GPs or family doctors [26]. On the contrary, men’s social a unique medical service model but also faces a huge Xu et al. BMC Fam Pract (2021) 22:117 Page 14 of 17 Governance Dilemma of doctor-patient trust and risk relation doesn’t certainly prevent frequent visits to a resolution. In order to give social power, give full play to doctor’s office or to make appointments with a special- the effective role of social organizations, build an inter- ist. It does not also imply that GPs should not be con- active, integrated and trusted network governance struc- cerned in building robust relationships with patients, ture, and straighten out the role relationship between as strong family doctor-patient relationships are related the government and the market, it has an important to other essential issues such as patients’ compliance role in promoting the integration of market and social and satisfaction [11, 14]. Over the past 20  years, the resources across borders and regions and promoting the issues of social capital have been linked to a diversity social empowerment of the government. Therefore, this of healthcare outcomes such as causes of mortality [18, policy is considered to be an effective way to promote 24]. Social capital(interpersonal relationships) is a com- the development of family doctor relationship under plicated imaginary structure with a very intricate pedi- contracted services. gree [23]. In fact, the understanding of social capital can be seen as the actual or likely benefits that individuals Barriers to the FDCS acceptance can obtain through their social network, such as nurs- Based on self completed questionnaire, Greenwood ing, advice, emotional and financial support. Therefore, et al., [16] investigated the attitude of GPs to carers, their in terms of health care exploitation, we expect closer awareness and knowledge of issues affecting these car- ties and greater impact on their behaviour. Due to the ers as well as the barriers that hinder the effective func- fact that health is often discussed with family members tioning of their supporting carers. The GPs in this study and other close confidants, leading to the use of infor- indicated that the lack of time, resources and knowledge mal resources, which may reduce the desire for formal of inpatients or patients were some of the obstacles for healthcare system. However, the relationship between patients or carers to accept the FDCS [16]. These GPs social behaviour and health care utilization is complex. also recognize that they also have a vital role to play in Frequent attendance is defined as a disproportionate supporting carers [16]. The promotion and coverage amount of general practice consultation compared to the of FDCSs will be expanded, and personalized contract general public [36]. The evidence presented from vari- programs will be launched to meet the needs of differ- ous papers reviewed illustrates numerous ways in which ent social network groups, so as to promote the rapid personal health and good life affect the state of health development of family doctor’s contracts in all provinces and wellness of others [31]. The studies on the impact of China [30]. The factors that affect residents’ trust and of social networks on health, the role of social support satisfaction are family doctors’ medical service skills, res- in determining individual health, and the spread of dis- idents’ familiarity with family doctors, communication ease from one person to another have demonstrated ability of family doctors, patients’ medical care concept the interconnectedness or interdependence of health and medical environment of community hospitals [8]. among individuals in the society. In short, a person’s ill- The other factors that influence the work attitude and ness, healthiness behaviour, infirmity, use of medical activities of family doctors’ services are work task and care facility, and death are related to similar outcomes in income level, the management of community health cen- many other people that the person is associated with, and tre, and the understanding of their own occupation and may have an abiotic spread of the disease. In the area of service objective attitude [8]. The family doctor system clinical and public health, the existence of social network should take the community as the carrier, integrate vari- health effects provides a strong theoretical and practical ous social resources, improve the doctor-patient relation- basis for the utilization and the healthiness of the people ship, cultivate social network groups in the community, in the community. If a person’s health outcome depends and accelerate the development of community construc- not only on his / her own biology and behaviour but also tion. In addition to the support of hardware facilities and on the biology and behaviour of people around him/her, supporting policies, social capital, and other soft envi- then collective intervention rather than individual inter- ronments are of great significance to the establishment of vention is particularly prominent. Social network groups FDCS [8]. exist to signify that individuals and events are interde- pendent, and health and healthcare can transcend indi- Discussion viduals in ways that patients, doctors, decision-makers The main aim of this integrative review report is to deter- and researchers care about. The Chinese government vig- mine if the benefits of social networking groups tend to orously promotes the family doctor policy system which help or enable residents to better understand the fam- requires everyone to have a family doctor especially for ily doctors’ policies and make them healthy by using children and the elderly. The National Health and Fam- FDCS. It is of no doubt that a solid family doctor-patient ily Planning Commission even has a system of assigning X u et al. BMC Fam Pract (2021) 22:117 Page 15 of 17 family doctors to families, yet many citizens are either even though they have been successfully applied in ignorant of this requirement or have deliberately ignored other industries. The need to stimulate practitioners it. Moreover, systemic constraints underpins why some to accept family doctor contract services is equally residents do not have a registered family doctor. Firstly, critical for the success of the venture and more sys- the number of family doctors is not enough. The family tematic research is needed to advance the frontiers of doctors in China currently comprise of community GPs, knowledge in this regard. retired doctors, and rural doctors. Since they also work Typical of academic studies a number of limitations as GPs, they do not have enough time and energy to work may affect the findings of this research. Particularly this as family doctors with its peculiar demands. On the part study focuses primarily on the interplay between social of residents a common reason for low patronage is that capital and family doctor contract services in China. many of them do not know the benefits the family doctor This restriction severely limited the number of papers system can bring to them. Moreover sustained economic included (12) but also the scope regarding the poten- prosperity in China since its opening up in 1979, has led tial of social capital. We recommend future research to richer citizens who have the means to afford high qual- to consider widen the scope of research and explore ity and exclusive care in big hospitals both at home and other emerging benefits of social capital in family prac- abroad. tice. For example, the rapid evolution of peer support networks established in conjunction with doctors is Conclusion believed to be helping needy patients must be interro- The study affirms previous studies that suggest that social gated in a future studies. resources has the propensity to improve relationship Similarly, the studies were taken from only a few between patients and clients and between doctors and databases and supplemented with three additional peers for the benefit of the patients and the stability of sources. This implies that all other studies outside the overall healthcare system. This underscores the need these sources were ignored. The small sample size of for healthcare managers to harness, nurture and sustain articles studied may limit the findings of this research. the different social network systems within the organi- Relatedly, the strict inclusive and exclusive criteria zation to support effective health service delivery. With used to select articles means that other articles with diligence these social networks can be transformed into potentially useful information were deemed lower- a multitude of social capital resources that can be opti- quality, downgraded and disregarded. Further, the mized and deployed to support a robust, reliable, respon- methodological limitations of the parent studies (par- sive, effective and efficient family care delivery across the ticularly, regarding the sampling strategies of reviewed healthcare delivery strata. materials in the case of primary studies) limits the With China’s strong collectivist culture, social capi- findings of the research. This is because most of these tal is that it can help the Government to better pro- studies did not clearly indicate how participants in mote and disseminate family doctor policies through the studies were recruited and sampled and that may the already established social network groups. There- limit the transferability of the findings of this research. fore understanding social capital or social network Even in the case of the secondary research based stud- groups on the concept of family doctor system can ies, the authors themselves have disclosed limitations promote and encourage residents to fully register and regarding the process of sampling the studies which use family doctor services. The results of this review further limits any analysis made from them. This study provide important rudimentary information for more included only articles published in English language advanced studies in the area of family doctor con- and the coverage of the final set of admitted articles tract services in China and beyond. Firstly, while these did not equally cover all the geographical areas of the study focuses on the extent to which social capital world. This limits the generalizability of the findings to can play a role in patients desire to obtain family con- other contexts. tract service, an emerging strand of literature equally suggest the reluctance of doctors to opt for family Abbreviations practice in China due to several factors. Some family GPs: General practitioners; CASP: Critical appraisal skills programme; FDCS: doctors believe that an enormous demand is imposed Family doctor contract service. by a bureaucracy that has little or no knowledge about Acknowledgments the medical practice and it is not possible to pro- The support of colleagues and staff at the Department of Public Management test. For example, the requirement for monitoring of the School of Management and the Center for Health and Public Policy Research and the Overseas Education College of Jiangsu University is deeply and evaluation of family doctors are perceived to be appreciated. We are also grateful to the Zhenjiang Administration Bureau for unfriendly and unsuitable to the healthcare industry Scientific and Industrial Research for their support Xu et al. BMC Fam Pract (2021) 22:117 Page 16 of 17 Authors’ contributions Author details XX: Conceived the idea, collected the data, and revised the manuscript in 1 School of Management, Jiangsu University, 301 Xuefu Road, Zhenjiang, line with the objectives. HAA: conducted the analysis of the data and drafted Jiangsu, P.R. China. 2 Center for Health and Public Policy Res, earch, Jiangsu manuscript. LZ: is the supervisor of the project and sequentially aligned the University, 301 Xuefu Road, Zhenjiang, Jiangsu, P.R. China. 3 Shanghai Normal parts of the research paper, AB: collected data and analyzed the data. TM: University, 2151 Gongji Road, Pudongxin, Shanghai, P.R. China. 4 School of Con‑ collected the data, conducted the analysis. 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