primary health care in the philippines essay

Primary Care in the Philippine Health System

Noel L. Espallardo, MD, MSc, FPAFP and Nicolas R. Gordo, MD, MHA, CFP

Health service in the Philippines is provided in the public and private sector in hospitals, group practice clinics, individually-run clinics and midwifery clinics. They range in size from small basic service units operated by individuals to sophisticated tertiary hospitals. Health services are more for curative and personal care and less on preventive care. The private sector accounts for about 60 percent of the national expenditures on health. It also employs over 70 percent of all health professionals in the country. It is patterned from the North American models of health facilities economically dependent on Medicare reimbursement and fee-for-service payments. Health workers in the Philippines are mainly doctors, nurses, midwives, dentists and physical therapists. Majority of these health workers are employed in the private sector and a significant proportion (mainly nurses) are employed overseas. As a result, the private sector continues to be the dominant source of health care financing. The households’ out-of-pocket (OOP) payments accounted for 82.5% of all private expenditure in 2005 and increased to 83.5% of all private expenditure. These are the findings of the late and former health secretary Dr. Alberto “Quasi” Romualdez Jr. in his analysis of the Philippine Health System in 2011.1

What happened since then?

In this issue of our journal, we included a special theme “Primary Care in the Philippine Health System”. This is a very important issue to raise discussion and hopefully more research since this may be a pressing concern in the implementation of the Universal Health Care (UHC) reform. The first article by Lavina, et al., describes in general the nature of practice of primary care providers. Family physicians are still mostly in the private sector and a mixed of hospital and free-standing clinic still much the same as in 2011. Another article is by Carpio, which describes the nature and capacity of primary care clinics. The basic structure and available services are described. Because of some services lacking in regular primary care facilities, access to other essential primary services are provide in special facilities or hospitals as described in the paper of Cruz, et al. The paper of Nicodemus, et al. describes the process of care which is the primary care orientation of family practice. This is again a very important issue in the UHC.

Primary care is an endeavor marked by complexity and clinical uncertainty. The World Health Organization defined primary care as “the first level of contact of individuals, the family and the community within the national health system”.2 Its functions are the “provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community”.3 Primary care physicians are providers of initial care and continuing point of contact, coordinator, and navigator in the health care delivery system for patients. They refer patients when appropriate for secondary or specialist care. Thus, primary care is the first level of health care where patients consult their health problems. At this level their curative and preventive health needs are provided. It should therefore be available in the community with no barriers to access and utilization. It is a generalist care, focused on the person with a felt health problem in the patient’s social context and biomedical process.4 This is the vision of the UHC and one of PAFP’s organizational priority as it makes itself very relevant to the Philippine health system.

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Scaling up Primary Health care in the Philippines: Lessons from a Systematic review of Experiences of community-based Health Programs

• Edna Estifania A. Co
• Ruben N. Caragay
• Jaifred Christian F. Lopez
• Isidro C. Sia
• Leonardo R. Estacio
• Hilton Y. Lam
• Jennifer S. Madamba
• Regina Isabel B. Abola
• Maria Fatima A. Villena

Background. In view of renewed interest in primary health care (PHC) as a framework for health system development, there is a need to revisit how successful community health programs implemented the PHC approach, and what factors should be considered to scale up its implementation in order to sustainably attain ideal community health outcomes in the Philippines.

Objective and methodology. Using the 2008 World Health Report PHC reform categories as analytical framework, this systematic review aimed to glean lessons from experiences in implementing PHC that may help improve the functioning of the current decentralized community-level health system in the country, by analyzing gathered evidence on how primary health care evolved in the country and how community health programs in the Philippines were shaped by the PHC approach.

Results. Nineteen (19) articles were gathered, 15 of which documented service delivery reforms, two (2) on universal coverage reforms, three (3) on leadership reform, and one (1) on public policy. The literature described how successful PHC efforts centered on community participation and empowerment, thus pinpointing how community empowerment still needs to be included in national public health thrusts, amid the current emphasis on performance indicators to evaluate the success of health programs.

Conclusion and recommendations. The studies included in the review emphasize the need for national level public health interventions to be targeted to community health and social determinants of health as well as individual health. Metrics for community empowerment should be developed and implemented by government towards sustainable health and development, while ensuring scientific validity of community health interventions.

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Experiences from the Philippine grassroots: impact of strengthening primary care systems on health worker satisfaction and intention to stay

Regine ynez h. de mesa.

1 University of the Philippines Diliman, Quezon City, Philippines

Jose Rafael A. Marfori

2 University of the Philippines Manila, Manila, Philippines

Noleen Marie C. Fabian

Romelei camiling-alfonso, mark anthony u. javelosa, nannette bernal-sundiang, leonila f. dans, ysabela t. calderon, jayson a. celeste, josephine t. sanchez, cara lois t. galingana, ramon pedro p. paterno, jesusa t. catabui, johanna faye e. lopez, maria rhodora n. aquino, antonio miguel l. dans, associated data.

The datasets generated and/or analyzed during the current study are not publicly available to uphold participant privacy. Datasets are available from the corresponding author on reasonable request.

Inequities in health access and outcomes persist in low- and middle-income countries. While strengthening primary care is integral in improving patient outcomes, primary care networks remain undervalued, underfunded, and underdeveloped in many LMICs such as the Philippines. This paper underscores the value of strengthening primary care system interventions in LMICs by examining their impact on job satisfaction and intention to stay among healthcare workers in the Philippines.

This study was conducted in urban, rural, and remote settings in the Philippines. A total of 36 urban, 54 rural, and 117 remote healthcare workers participated in the study. Respondents comprised all family physicians, nurses, midwives, community health workers, and staff involved in the delivery of primary care services from the sites. A questionnaire examining job satisfaction (motivators) and dissatisfaction (hygiene) factors was distributed to healthcare workers before and after system interventions were introduced across sites. Interventions included the introduction of performance-based incentives, the adoption of electronic health records, and the enhancement of diagnostic and pharmaceutical capabilities over a 1-year period. A Wilcoxon signed-rank test and a McNemar’s chi-square test were then conducted to compare pre- and post-intervention experiences for each setting.

Among the factors examined, results revealed a significant improvement in perceived compensation fairness among urban ( p = 0.001) and rural ( p = 0.016) providers. The rural workforce also reported a significant improvement in medicine access ( p = 0.012) post-intervention. Job motivation and turnover intention were sustained in urban and rural settings between periods. Despite the interventions introduced, a decline in perceptions towards supply accessibility, job security, and most items classified as job motivators was reported among remote providers. Paralleling this decline, remote primary care providers with the intent to stay dropped from 93% at baseline to 75% at endline ( p < 0.001).

The impact of strengthening primary care on health workforce satisfaction and turnover intention varied across urban, rural, and remote settings. While select interventions such as improving compensation were promising for better-supported settings, the immediate impact of these interventions was inadequate in offsetting the infrastructural and staffing gaps experienced in disadvantaged areas. Unless these problems are comprehensively addressed, satisfaction will remain low, workforce attrition will persist as a problem, and marginalized communities will be underserved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08799-1.

Introduction

Background of the study.

The passage of the Universal Health Care Law in 2019 marked the Philippines’ commitment to achieve equitable health coverage for all, an endeavor shared by countries worldwide [ 1 ]. However, even if primary care is acknowledged as an essential element to achieving universal health coverage [ 1 – 3 ] and as a mechanism for improved health equity [ 4 ], the lack of health system readiness remains an issue. In the Philippines, as in many low- and middle-income countries (LMICs) [ 5 , 6 ], primary care networks remain undervalued, underfunded, and ultimately underdeveloped [ 7 ]. This has contributed to compromised health outcomes such as significantly shorter life expectancies [ 8 ] and higher child mortality rates among the country’s poorest quintiles [ 9 ]. National data reveals that 6 out of 10 Filipino deaths were medically unattended—with only the capital region of Metro Manila exhibiting higher attended than unattended deaths [ 10 ]. The World Health Organization sets the ideal skilled health worker (i.e., physicians, nurses, and midwives) to population ratio at 4.45:1000 [ 11 ]. However, human resources for health (HRH) deficits of at least 60,000 doctors, 121,000 nurses, and 109,000 midwives were reported among Philippine public facilities alone [ 12 ]. This bears significance as over 83% of outpatient visits from the two poorest wealth quintiles were made to government-funded community health stations [ 13 ].

Largely driven by workforce maldistribution and system fragmentation, inequities in health have persisted in the absence of a well-supported primary care network [ 14 ]. Disparities in health access have likewise had a disproportionate impact on low-income families [ 13 ] and geographically disadvantaged regions [ 15 ]. In rural and remote areas, health stations are often gravely understaffed, lacking supplies of basic drugs, and left without the regular supervision of an attending physician [ 16 ]. Despite severe HRH shortages, the Philippines remains a leading exporter of health professionals with nearly 85% of locally trained nurses deployed overseas [ 17 ]. The country’s economic reliance on the mass exodus of its workforce without comprehensively addressing the steep decline in HRH retention has adversely impacted health service delivery in underserved communities [ 18 ]. Thus, improving the retention of HRH is at the cornerstone of operationalizing primary care systems in LMICs like the Philippines.

Literature examining emigration patterns forward the substantial impact of job satisfaction on turnover intention. Locke broadly defines job satisfaction as “a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences” [ 19 ]. A myriad of job attributes, such as workload, training opportunities, compensation, and enabling environments, influence job satisfaction [ 20 ]. Herzberg’s two-factor theory distinguishes between attributes that induce satisfaction from those that lead to dissatisfaction. These attributes are categorized as a) motivators and b) hygiene factors [ 21 ]. Motivators such as workplace morale and job involvement were linked to employee satisfaction, whereas hygiene factors such as compensation and job security were associated with dissatisfaction if not aptly addressed [ 22 ]. While Herzberg’s theory suggests that the absence of motivators may not necessarily lead to attrition, environments that only support good workplace hygiene can result in retaining an unsatisfied workforce [ 23 ]. Exploring the impact of strengthened primary care on HCW satisfaction has widespread implications for health outcomes in LMICs. Sustained contentment towards various workplace attributes enables HCWs to direct optimal focus towards patient care. With low HCW retention directly resulting in poor outcomes [ 24 ], HCW satisfaction proves integral for mitigating the effects of workforce maldistribution in LMICs.

Study objectives

Adopting Herzberg’s two-factor framework for analyzing job satisfaction, the objectives of this study are: 1) to evaluate the impact of strengthening urban, rural, and remote primary care system interventions on HCW satisfaction; and 2) to compare turnover intention among HCWs before and after the intervention period.

Methodology

Study design.

A pretest-posttest design was used to assess HCW job satisfaction and turnover intention across urban, rural, and remote settings in the Philippines. This entailed data collection of satisfaction measures through a single pre-test, followed by an intervention, and then a collection of post-test data on the same measure. The present study was conducted as part of the Philippine Primary Care Studies (PPCS) program, a longitudinal and multi-sited research series aimed at strengthening primary care systems through patient-centered interventions. In 2016, PPCS piloted its urban program to model comprehensive primary care, which provided free access to outpatient services, laboratory and diagnostic procedures, and medicines to eligible patients. This model and its package of interventions were extended to the study’s rural and remote sites in 2019. In delivering these interventions, HCWs were supported through enhanced capacity-building, the development of electronic health records (EHR), and the introduction of performance-based financial incentives. The impact of these interventions was then assessed, with HCW job satisfaction being one of the eight health system outcome measures outlined in the PPCS primary care model [ 25 ].

Instrumentation

A pre-validated Stayers questionnaire [ 26 ] initially used to measure job satisfaction and turnover intention among remote primary care physicians [ 27 ] was adapted for this study. The adapted instrument comprised a Likert-type section to measure satisfaction/dissatisfaction and a multiple-choice assessment to measure turnover intention. Following Herzberg’s two-factor framework, Likert items were classified as: 1) motivator factors; and 2) hygiene factors (see Table ​ Table1 1 ).

List of Likert scale items by Herzberg’s two-factor classification

Since the original instrument was used to measure physician satisfaction in a remote setting, several sections of the original questionnaire did not apply to the practice types and settings examined in this study. As such, only 18 of the original 77 items were maintained (see Appendix A ) to enhance questionnaire adaptability. Overall consistency for the tool used in this study proved reliable [ 28 ] with a Cronbach’s α score of 0.8.

Sampling and survey distribution

This study was conducted across three pilot sites, namely: a) an urban site—the University of the Philippines Health Service Diliman in Metro Manila; b) the rural municipality of Samal, Bataan; and c) the remote municipality of Bulusan, Sorsogon. A census of all HCWs from the urban, rural, and remote sites was obtained—totaling 36, 54, and 117 respondents respectively. Self-administered questionnaires were distributed to the respondents in September 2016 for the baseline period and again in December 2017 for the endline assessment at the urban site. Baseline surveys for rural and remote sites were distributed during the study preparation phase in April 2019 and assessed after the one-year implementation in June 2020 through the endline survey. Verbal and written consent from each respondent was obtained before survey distribution.

Data analysis

Data gathered were encoded in Microsoft Excel and were analyzed using Stata version 12.0 and R version 3.5.0. Demographics were expressed through percentage comparisons for categorical variables, whereas mean scores were used to compare continuous data. Likert responses were scored as 1 = Strongly Disagree (SD); 2 = Disagree (D); 3 = Neutral (N); 4 = Agree (A); 5 = Strongly Agree (SA). Upon analysis, Likert-type responses were examined per item and as dichotomized responses (i.e., generally dissatisfied for scores 1–3 and generally satisfied for scores 4–5) [ 29 – 31 ]. Multiple-choice items on intent to stay were encoded as a binary before analysis. HCWs intending to leave were segregated from HCWs intending to stay in their jobs indefinitely. To determine the significance between baseline and endline scores, hypothesis testing was conducted using the Wilcoxon signed-rank test for ordinal data and McNemar’s chi-square test for dichotomous data. Hodges-Lehmann point estimates reflecting the direction of change in Likert satisfaction scores between periods were reported along with their 95% confidence intervals (see Appendix B ). P -values of < 0.05 were considered statistically significant for this study. Ethical approval for this study was obtained from the University of the Philippines Manila Research Ethics Board (UPMREB – 2015-489-01) and the Philippines’ Department of Health Single Joint Research Ethics Board (SJREB – 2029-55). Ethics approval was annually renewed for all study sites. Furthermore, verbal and written informed consent was obtained from all health workers who have participated in this study.

Demographic profile

Majority of our respondents were female. Our participants were HCWs from the sites and included family physicians, nurses, midwives, community health workers, and staff. The urban site had the most number of physicians while the rural and remote sites being serviced by community health workers (CHWs or locally referred to as barangay health workers) who bridge the gap between health systems and localities [ 25 ]. The distribution of HCWs, particularly the doctor to patient ratio, reflects the disparities across communities. The average length of stay in years was also highest in the urban site (14 years) and lowest in the remote site (11 years). Most HCWs from the urban (86%) and remote (73%) sites reported no previous work experience apart from the job they occupied during the survey period (Table ​ (Table2 2 ).

Demographic profile of survey respondents

Comparison of health worker satisfaction across sites

The baseline proportion of generally satisfied HCWs was relatively low at the urban site compared to rural and remote responses towards job motivators. While almost all urban HCWs felt secure with their current jobs (92%), far less perceived their work as enjoyable (63%) or felt positively towards their workplace morale (72%) at baseline. In contrast to urban data, the majority of rural and remote HCWs (> 85%) were generally more motivated despite experiencing moderate to low workplace hygiene at the start of the study period. Among hygiene factors, over half of the workforce across all sites felt undercompensated during the baseline period. The baseline percentage of HCWs satisfied with their job hygiene was lowest at the remote site, with less than 30% of remote HCWs expressing sufficient access to medical equipment (Table ​ (Table3 3 ).

McNemar’s chi-square comparison of generally satisfied HCWs from the baseline and endline periods

* p < 0.05; statistically significant difference in the proportion of generally satisfied responses

We found a marked increase in the endline proportion of generally satisfied HCWs towards perceived compensation fairness at the urban and rural facilities and access to medicines at the rural site. However, significantly fewer rural HCWs felt satisfied with the accessibility of equipment during the endline period. The endline proportion of satisfied urban and rural HCWs remained constant towards motivation factors. However, there was a decrease in satisfaction on workplace morale and enjoyment towards HCWs working in the remote community.

We also found two notable improvements in scores, specifically in: a) perceived compensation fairness among urban ( p  = 0.001) and rural HCWs ( p  = 0.016), and b) perceived sufficiency in medicine supply among rural HCWs ( p  = 0.012). Point estimates on the change in scores for both sites suggest that median satisfaction on perceived compensation fairness increased by a full rank (Table ​ (Table4). 4 ). For the urban and rural cohorts, median satisfaction scores increased from being neither satisfied nor dissatisfied [ 3 ] at baseline to being satisfied [ 4 ] at the end of the study (see Appendix B ).

Wilcoxon signed-rank test comparison of median satisfaction scores between baseline and endline periods

1 P  < 0.05; statistically significant increase between baseline and endline ranks

** P  < 0.05; statistically significant decrease between baseline and endline ranks

When remote data were analyzed, significantly lower satisfaction scores were reported for both motivator and hygiene factors. Satisfaction towards motivating factors was significantly lower at the end of the study—with workplace morale exhibiting the steepest decline ( p  < 0.001). Remote HCWs also reported lower satisfaction scores towards hygiene factors like supply accessibility and job security post-intervention. In contrast to urban andrural responses, no statistically significant changes were noted in perceived compensation fairness at the remote site.

Comparison of intention to stay across sites

Intention to stay did not change in the urban site after the primary care system interventions ( p = 1.000 ) . More HCWs in the rural site indicated intention to stay (baseline: 75% vs. endline: 89%; p = 0.090) while fewer HCWs practicing in the remote site intended to stay post-intervention (baseline: 93% vs. endline: 76%; p < 0.001) (Table ​ (Table5 5 ).

McNemar’s chi-square test results on intent-to-stay across sites

* P  < 0.05; statistically significant difference in the proportion of generally satisfied responses

Health sector performance hinges on a competent, motivated, and well-supported workforce. If performance gains are to be realized when transitioning from vertical disease-based health programs to integrated primary care systems, HCW satisfaction must be considered as a desired outcome measure. Technical training and enhanced incentives are necessary for improving HCW satisfaction [ 32 ]. However, the existing curricula of health-related professions in the Philippines have limited content and training on primary care. An appraisal conducted on HCW job motivation underscores a systemic approach in improving satisfaction scores and workforce retention [ 33 ]. According to existing literature, insufficient performance incentives and compensation have resulted in poor health outcomes and HCW maldistribution across challenging environments such as the Philippines [ 34 – 37 ]. Non-financial incentives also play a role in attracting physicians to practice in rural health systems, which includes supervision and being near to their families. To address maldistribution, this study initiated several interventions to encourage system integration and HCW capacity-building [ 38 ]. Primary care training workshops and access to UpToDate were provided to HCWs throughout the study period. Additional pharmacies and laboratories were incorporated into existing networks in the rural and remote sites to expand drug supply and services. A unified EHR system was also introduced to all sites to ease patient intake, diagnosis, referral, and monitoring.

In the study’s rural and remote sites, clinical care is delivered across a multitude of facilities. These range from central health units that house a limited number of physicians, to smaller community health stations that primarily operate through the services rendered by nurses, midwives, and CHWs. The introduction of the EHR enhanced system integration across these facilities through a unified patient database. In effect, the EHR enabled previously underutilized community health stations to refer patients to the central health unit and to likewise produce laboratory requests or prescriptions with the remote approval of the patient’s attending primary care physician. Rural HCWs were less dissatisfied with their ability to prescribe medical drugs post-intervention. As supported by post-intervention studies conducted in rural terrains, this likely resulted from the expansion of these services alongside the remote referral/approval capabilities provided by the EHR [ 39 , 40 ]. The central health unit of the rural site experienced the highest number of consultations year-round. As such, the referral/approval capabilities aided in distributing patients across the network of available community health stations. While most rural satisfaction scores have remained consistent, majority of rural HCWs (> 90%) were already highly satisfied with all motivational factors during the baseline period. Considerable institutional support and tight integration pre-intervention may have contributed to the high confidence level demonstrated by rural HCWs at baseline [ 41 ]. Their overall satisfaction was mirrored in their greater intention to stay after the implementation of primary care system interventions.

Dissatisfaction towards perceived compensation fairness was consistently high pre-intervention. To address possible gaps in remuneration, performance-based financial incentives were provided to all primary care providers across the three sites during the intervention period. These incentives were calculated based on completed consultations by the involved HCWs per consult. When a patient is initially assessed by a nurse and referred to an attending physician, both HCWs would merit financial incentives in the implemented payment scheme. As indicated in research evaluating the impact of HCWs income, adequate wage provisions are vital to system-incentivized performance improvements [ 42 , 43 ] and coordinated care among HCWs within the primary care network [ 25 ]. The results of this study reveal that perceptions towards compensation fairness significantly improved among urban and rural HCWs post-intervention. This may largely be due to the provision of the aforementioned incentives as wages and other fringe benefits across all sites remained the same.

Job hygiene at the remote site showed a conservative decline. Remote HCWs were more dissatisfied with supply accessibility and job security post-intervention. Although urban and rural job hygiene improved with the introduction of financial incentives, the remote site reported no significant difference in HCW perceptions towards perceived compensation fairness post-intervention. A slight decline in the level of satisfaction and the proportion of generally satisfied HCWs were also noted towards several motivation factors. Four underlying contexts can be examined to qualify these results: 1) delayed incentivization [ 36 ]; 2) HCW maldistribution [ 42 ]; 3) weak infrastructure [ 44 ]; and 4) the impact of COVID-19 [ 45 ]. Irregular payments and delayed remuneration contribute to HCW dissatisfaction and ultimately poor retention [ 46 ]. Resulting from administrative delays in the disbursement of additional financial incentives, most remote HCWs received these incentives several months after their services were rendered. This may have significantly mitigated the intended positive impact of incentivization. Although delays in incentive payouts occurred in other sites, the impact of delayed remuneration may have been more difficult to ignore in the remote site given the abundance of other challenges shouldered by its workforce.

Apart from administrative challenges, the demographic composition of remote-based staff likely had some impact on the reported dissatisfaction towards several hygiene factors. CHWs comprised the vast majority of the remote-based workforce surveyed in this study. CHWs are part-time volunteer workers, rendering them ineligible for receiving a regular wage, unlike other primary care providers. Non-urban CHWs typically receive a marginal monthly allowance of Php 1150 (estimated at $24.00 per month) alongside other benefits such as free groceries or medical care depending on the local government unit [ 47 ]. While intrinsic job factors such as perceived social prestige and acquired technical skills have been shown to be critical motivators for CHWs in existing literature [ 47 ], heightened dissatisfaction towards the inadequacy of job hygiene factors relative to the work expected may increase turnover intention as Herzberg’s theory and the findings of this study present.

The sporadic distribution of HCWs, particularly physicians, in remote areas proves potentially hazardous for providers—threatening to overload both staff and infrastructure. Expanding primary care providers’ responsibilities to include public health service delivery may cause low job satisfaction due to inadequate work autonomy and high dissatisfaction due to income mismatch [ 48 ]. HCWs are expected to deliver quality clinical services to individual patients while assuming population health roles for specific health programs (i.e., vaccination, sanitation). Despite the range of tasks HCWs are expected to fulfill, infrastructural gaps in the remote site vastly surpass those of other sites. Intermittent internet connectivity, unreliable transportation, poor maintenance of select health stations, and frequent electrical outages are additional challenges to an already understaffed workforce. These challenges potentially diminish health outcomes, rendering clinical efforts futile or frustrating, and may reinforce low regard for the primary care system—amongst providers and patients [ 44 , 49 ]. With infrastructural lacunae and the regular onslaught of natural disasters in this Pacific-facing site, seemingly minor inconveniences have resulted in adverse delays. This is evident in hours of back-encoding patient data, longer patient queues, difficulties in servicing remote communities, and challenges in referring patients throughout the primary care network.

Enhanced retention necessitates providing basic resources required for the job—including improved infrastructure, a unified EHR, supply accessibility, and fair compensation. Furthermore, experiences from the remote site suggest that financial incentives prove more effective once other infrastructural hurdles have already been addressed. System interventions must indeed provide enabling environments to prevent dissatisfaction and reduce workforce attrition. However, as Herzberg’s theory posits, job satisfaction is primarily achieved with a motivated workforce. In the urban site, most HCWs were not dissatisfied with hygiene factors such as workload and overall job security. However, satisfaction with motivational factors was still lower compared to rural and remote scores. Despite being in a well-supported job environment that retained its workforce the longest compared to other sites, urban data shows that good job hygiene alone does not ascertain HCW satisfaction. Providing non-monetary incentives such as training opportunities, pathways for career advancement, and involvement in clinical decision-making proves foremost essential in improving job satisfaction.

Scope and limitations

This study employed a diachronic approach in evaluating HCW satisfaction across three sites, with varying baseline and endline periods per site due to funding and infrastructural constraints. The endline responses from the rural and remote sites were obtained shortly after the onset of the COVID-19 pandemic. As such, the shifting social and economic climate may have affected responses at the time of the survey. Other factors such as survivor bias may have had some impact on the reported results. Only respondents with matched scores (i.e., HCWs present in both baseline and endline periods) were included for analysis. Other factors influencing satisfaction were not controlled. As such, the magnitude of each factor and its corresponding effect on satisfaction and intent to stay was outside the scope of the present study. Attempts to further contextualize satisfaction scores have been undertaken to grasp a holistic understanding of HCW experience. These were done through informal interviews with HCWs, and long-term participant observation of field teams deployed to each site. However, we were unable to measure the role of corruption in this study and we suggest that future studies collect data on this to better qualify and quantify its effect. With these limitations outlined, this research places greater focus on the possible impact of specific interventions undertaken in strengthening primary care networks in each area.

This study presents the observed impact of strengthening urban, rural, and remote primary care system interventions on primary care providers. Using Herzberg’s two-factor classification, overall job satisfaction and turnover intention were examined through motivational and hygiene factors experienced in each site before and after the implementation of study interventions. Perceptions towards job hygiene factors improved post-intervention at urban and rural sites—likely because of performance-based financial incentives provided to all HCWs during the study. Alongside the provision of monetary incentives, the expansion of service delivery networks to include additional pharmacies in the rural site showed a positive impact among HCWs in their regard for medical supply.

Despite attempts to strengthen the existing primary care system and potentially exacerbated by the effects of the COVID-19 pandemic, infrastructural deficits have contributed to lower motivation and higher dissatisfaction among remote HCWs during the endline period. Reducing dissatisfaction by addressing hygiene factors at the workplace proves vital in retaining HCWs in remote and disadvantaged areas. This may be done by providing adequate remuneration and ensuring work environments support the demands of person-centered integrated care. However, targeting system interventions aimed at improving motivational factors may render beneficial in retaining a satisfied workforce in the long term. Strengthening primary care systems must, therefore, consider interventions that address motivational and job hygiene needs to improve healthcare worker satisfaction and intention to stay. This includes addressing HCW needs, strengthening infrastructural support, and enhancing primary care training across all HCW cadres. In doing so, patient-centered primary care can ultimately be better sustained by the very workforce it is founded upon.

Acknowledgements

The authors extend their gratitude to all healthcare worker participants, the University of the Philippines Health Service administration, and the local government units of Samal and Bulusan for their unwavering support towards the objectives of this research. We also wish to acknowledge the expertise of Arianna Maever Amit – with whom the research team consulted with during the revision of the present manuscript. Her critical insight into manuscript ensured all assertions made by the research team were evidence-based and punctiliously reported.

Abbreviations

Authors’ contributions.

ALD, JAM, LFD, RPP, and MPR conceptualized the program as a whole. RDM and ALD conceptualized the submitted manuscript. CTG, JFL, and NBS gathered and processed study data. MAJ, MPR, and RDM statistically analyzed the elicited results. RDM led the development of the manuscript, writing majority of the enclosed sections. NCF and YTC assisted in cross-referencing and revising the manuscript. All authors suggested substantial revisions, commented, and approved the final manuscript.

This study was supported by the Philippine Department of Health, the Philippine Health Insurance Corporation (PhilHealth), the University of the Philippines Center for Integrative and Development Studies (UP-CIDS), the Emerging Interdisciplinary Research Program (EIDR), the Philippine Council for Health Research and Development (PCHRD) and the National Academy of Science and Technology (NAST) under the Philippines’ Department of Science and Technology (DOST).

Availability of data and materials

Declaration.

Ethical approval for this study was obtained from the University of the Philippines Manila Research Ethics Board (UPMREB – 2015-489-01) and the Philippines’ Department of Health Single Joint Research Ethics Board (SJREB – 2029-55). Ethics Board approval was annually renewed for all study sites. The methodology was executed in accordance with the rules of the aforementioned ethical boards and guidelines under the Declaration of Helsinki. Furthermore, verbal and written informed consent was obtained from all health workers who have participated in this study.

All data obtained for this study were anonymized upon data collection and analysis. No personally identifiable participant information is included in the present manuscript. All participants of this research consented to the publication of their anonymized data.

All authors have no relevant or competing conflicts of interest to declare.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Primary Health Care and Management of Noncommunicable Diseases in the Philippines

• Ulep, Valerie Gilbert T.
• Casas, Lyle Daryll D.
• noncommunicable diseases
• health systems
• primary healthcare

As the Philippines adopts major reforms under the Universal Health Care Act and embarks on an integrated and primary healthcare-oriented system, it is critical to assess its readiness to manage noncommunicable diseases (NCDs), the leading disease burden in the country. This study assesses the readiness of the primary healthcare system to handle NCDs, in the context of governance, financing, service delivery, human resources, and information and communications technology. It identifies challenges in the availability, quality, and equity of the health system, which hamper the provision of comprehensive and continuous healthcare services in local communities.

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Essay on Health Care System In The Philippines

Students are often asked to write an essay on Health Care System In The Philippines in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Health Care System In The Philippines

The basics of health care in the philippines.

The Philippines’ health care system is a set of health services provided by public and private providers. Public health care is managed by the Department of Health (DOH), while private health services are offered by various hospitals and clinics.

Public Health Care

Public health care is available to everyone. It is funded by taxes and contributions from workers. The Philippine Health Insurance Corporation (PhilHealth) is the main public health care provider. It gives Filipinos access to basic medical services.

Private Health Care

Private health care is offered by private hospitals and clinics. It’s usually more expensive than public health care. People who can afford it often choose private care for more personalized service and shorter waiting times.

Challenges in the Health Care System

The health care system in the Philippines faces many challenges. These include a lack of resources, unequal access to health services, and a high cost of care. The government is working on these issues to improve the health care system.

Future of Health Care in the Philippines

The government aims to improve the health care system through the Universal Health Care Act. This law aims to provide all Filipinos with access to quality health care. It’s a big step towards better health care in the Philippines.

250 Words Essay on Health Care System In The Philippines

Introduction.

The health care system in the Philippines is a mix of public and private providers. It aims to give medical help to all its citizens. The Department of Health (DOH) is the main body in charge of health care.

The government provides health care through public hospitals and clinics. These are usually free or cost very little. The Philippine Health Insurance Corporation (PhilHealth) is the national health insurance program. It helps people pay for medical services.

There are also private hospitals and clinics. These usually offer better facilities and shorter waiting times. But, they are more expensive. Many people have private health insurance to help cover these costs.

The health care system in the Philippines faces some issues. There are not enough doctors and nurses, especially in rural areas. Also, the quality of care can vary greatly. Some people can’t afford the cost of private health care but need it due to the lack of public facilities.

Improvements

The government is working to improve the health care system. One step is the Universal Health Care Act. This law aims to give all Filipinos access to quality health care, without causing financial hardship.

In conclusion, the health care system in the Philippines is a mix of public and private providers. It faces some challenges, but efforts are being made to improve it. Everyone in the Philippines deserves access to good health care.

500 Words Essay on Health Care System In The Philippines

The basics of the health care system in the philippines.

The health care system in the Philippines is a mix of public and private providers. The Department of Health (DOH) is the main public health agency. It sets policies, plans, and programs for health services. It also runs special health programs and research.

The Philippine Health Insurance Corporation (PhilHealth) is another important part of the public health system. It provides health insurance for Filipinos. This helps to make health care more affordable.

Public and Private Health Providers

There are both public and private health care providers in the Philippines. Public providers include hospitals, clinics, and health centers run by the government. These offer free or low-cost services. But sometimes, they may not have enough resources or staff.

Private providers include doctors, clinics, and hospitals that are not run by the government. They usually offer more services and shorter waiting times. But, their services cost more.

Health Care Challenges

The health care system in the Philippines faces several challenges. One is the uneven distribution of health services. More health services are available in urban areas than in rural areas. This means people living in rural areas may have to travel far to get health care.

Another challenge is the cost of health care. Even though PhilHealth helps, many Filipinos still find health care expensive. Some may not be able to afford the medicines or treatments they need.

Efforts to Improve Health Care

The government is working to improve the health care system. In 2019, it passed the Universal Health Care Law. This law aims to give all Filipinos access to quality health care. It also aims to make health care more affordable.

The government is also investing in health technology. This includes telemedicine, which allows people to consult with doctors online. This can help people in rural areas get health care more easily.

The health care system in the Philippines is a mix of public and private providers. It faces challenges like uneven distribution of services and high costs. But, the government is taking steps to improve it. It is working to provide universal health care and make health care more affordable. It is also investing in health technology to reach more people. Despite the challenges, the future of health care in the Philippines looks hopeful.

That’s it! I hope the essay helped you.

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RECONSTRUCTING THE FUNCTIONS OF THE GOVERNMENT: THE CASE OF PRIMARY HEALTH CARE IN THE PHILIPPINES: A LITERATURE REVIEW

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RATIONALE The main obstacles to attaining universal health care are the following: 1) The two national healthcare financing mechanisms of direct govemment subsidy through DOH and LGU budgets, and the National Health Insurance Program (NHIP) have not been able to adequately provide financial risk protection for the poor; 2) As a result, poor households have inadequate access to quality outpatient and inpatient care from health care facilities. Rural Health Units (RHUs) and City Health Units in municipalities and cities, district and provincial hospitals, and even DOH-retained regional hospitals and medical centers do not have the necessary provisions to meet the needs of poor families; and 3) Owing to the failure of the financing and health care delivery systems to address the needs of poor Filipinos, it is unlikely that the Philippines will meet its MDG commitments by 2015. This is especially problematic for our targets to reduce maternal and infant mortality. Administrative Order No. 2010-0036 entitled, "The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos" provided for three strategic thrusts to achieve universal health care or Kalusugan Pangkalahatan (Y-P):1) Rapid expansion in NHIP enrollment and benefit delivery using national subsidies for the poorest families; 2) Improved access to quality hospitals and health care facilities through accelerated upgrading of public health facilities; and 3) Attainment of the health-related MDGs by applying additional effort and resources in localities with high concentration of families who are unable to receive critical public health services. Implementation of KP will also involve aligning the DOH budget behind these aforementioned three strategic thrusts. Furthermore, KP execution shall use well-defined and area-specific deliverables as performance targets to be pursued by DOH managers within a set timeframe and with clearly defined accountabilities. OBJECTIVE This Order provides for guidelines and management arrangements to implement Kalusugan Pangkalahatanby accelerating the accomplishment of specif,rc performance targets. This is intended to streamline the tasks and functions of central office units to provide critical supporl and assistance to field units, who in turn shall be better supervised by Operations ClusterAssistant Secretaries andlor Building I,

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Strengthening primary health care provision in the philippines.

With support from the WHO, ThinkWell conducted a study to develop a primary care competency certification framework and a corresponding tool to certify primary care health workers. As part of the study, we mapped the current state of primary care delivery in the Philippines, developed options for primary care provider models for the Philippines based on global best practices, created and piloted primary care provider competency assessment tools, and designed a primary care provider certification framework. Our study helped ensure that the Department of Health is prepared to certify primary care providers to deliver services in primary care facilities, as mandated under the country’s Universal Health Care (UHC) Law.

Breaking New Ground

Our work consolidated and aligned initiatives that the Health Human Resource Development Bureau of the Philippine Department of Health has led to clarify and re-shape the traditional roles of health care workers in front-line health facilities, particularly in the public sector. More importantly, this work paved the way to ensure that primary health care services be prioritized and institutionalized.

ThinkWell helped to ensure that when the UHC Law was implemented in 2020, the Philippines had a certification tool to help identify and certify primary care providers who are equipped to deliver an expanded primary care benefit package for all Filipinos.

ThinkWell reviewed existing studies and documents that articulate important health care worker competencies. Our work aligned with the goal for primary health care services in the Philippines to be high-quality, efficient, and accessible to all.

Our research uncovered primary care delivery models that are potentially applicable in various settings in the Philippines. In addition, we identified and validated essential competencies for primary care health workers. Finally, we proposed a certification framework and tool that was pilot tested in selected primary care facilities. For a summary of the rationale and proposed design of the certification process of primary care providers, please visit the SP4PHC Philippines page .

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... A decade before healthcare devolution, the country implemented a primary healthcare policy which created a large cadre of community-based health workers locally called barangay (village) health workers (BHW).(15) Organisationally, the BHW fall under the governance of the barangay and are selected to work in their respective areas of residence; functionally, they are under the local government health unit (LGHU). ...

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• Published: 03 November 2023

The impact of eHealth on relationships and trust in primary care: a review of reviews

• Meena Ramachandran   ORCID: orcid.org/0000-0003-4670-5375 1 , 2 ,
• Christopher Brinton 1 , 3 ,
• David Wiljer   ORCID: orcid.org/0000-0002-2748-2658 4 , 5 , 6 , 7 ,
• Ross Upshur   ORCID: orcid.org/0000-0003-1128-0557 1 , 8 &
• Carolyn Steele Gray 1 , 6  

BMC Primary Care volume  24 , Article number:  228 ( 2023 ) Cite this article

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Given the increasing integration of digital health technologies in team-based primary care, this review aimed at understanding the impact of eHealth on patient-provider and provider-provider relationships.

A review of reviews was conducted on three databases to identify papers published in English from 2008 onwards. The impact of different types of eHealth on relationships and trust and the factors influencing the impact were thematically analyzed.

A total of 79 reviews were included. Patient-provider relationships were discussed more frequently as compared to provider-provider relationships. Communication systems like telemedicine were the most discussed type of technology. eHealth was found to have both positive and negative impacts on relationships and/or trust. This impact was influenced by a range of patient-related, provider-related, technology-related, and organizational factors, such as patient sociodemographics, provider communication skills, technology design, and organizational technology implementation, respectively.

Conclusions

Recommendations are provided for effective and equitable technology selection, application, and training to optimize the impact of eHealth on relationships and trust. The review findings can inform providers’ and policymakers’ decision-making around the use of eHealth in primary care delivery to facilitate relationship-building.

Peer Review reports

Primary care is a person’s first point of contact in healthcare systems and includes “disease prevention, health promotion, population health, and community development” ([ 1 , 2 ] p1). Primary care across the globe is shifting towards team-based models that bring together interprofessional teams of family physicians, nurse practitioners, registered nurses, social workers, dietitians, and other professionals to provide holistic and comprehensive care [ 3 , 4 , 5 , 6 ]. These models are designed to address the needs of individuals with multimorbidity and complex conditions in the community as they can offer a diverse skill set to meet the variable needs of this population [ 7 ]. Along with an evolution towards team-based primary care models, this past decade has also witnessed an increasing global interest and rapid uptake of digital health in primary care [ 8 , 9 , 10 ], hastened by the COVID-19 pandemic [ 11 , 12 ]. Some jurisdictions are considering a “digital-first” primary care model where technology is used as the default care delivery mechanism [ 13 ], while others have noted a need to balance appropriate and equitable hybrid care delivery [ 10 ].

Digital health broadly refers to the use of technologies for health [ 14 ]. Technologies include information and communication technology (also referred to as eHealth), which includes the use of mobile wireless technologies (often referred to as mHealth as a specific type of eHealth) [ 14 ]. Digital health technologies can also include emerging technologies, processes, and platforms like big data, genomics, machine learning, and artificial intelligence [ 14 ]. eHealth includes: (i) management systems; (ii) communication systems; (iii) computerised decision support systems; and (iv) information systems [ 15 ]. The implementation and effectiveness of eHealth is influenced by a complex array of factors and can impact several facets of care delivery [ 16 ].

One aspect that can potentially be altered is the nature of relationships and trust between patients and their providers, and within provider teams. Relationships between patients and providers, built on trust, knowledge, regard, and loyalty, have been demonstrated to be fundamental to healthcare delivery [ 17 ]. This is particularly important in primary care where patients will tend to have longer-term relationships with their provider or practice [ 18 ]. Strong trust-based relationships between providers within teams can enable a positive work environment, improved communication, effective teamwork, and care coordination [ 19 , 20 ].

eHealth and patient-provider relationships

Patient-provider relationships are often referred to using terms like therapeutic relationship, therapeutic alliance, communication, interaction, and rapport [ 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. Trust is thought to be an important component of this relationship [ 28 ] and its development has been found to require multiple interactions over time [ 29 ]. Promoting trust in the patient-provider relationship includes the demonstration of three key provider attributes: interpersonal and technical competence, moral comportment, and vigilance [ 30 ]. Patients perceive trust in providers as linked to their active participation and satisfaction with care [ 31 , 32 ]. An absence of trust in providers is associated with reductions in treatment adherence and care seeking behaviours by patients, and reduced continuity of care [ 33 ] (i.e., connected and coordinated care while moving through the healthcare system) [ 34 ].

Trust-based patient-provider relationships are changing with the expansion of eHealth. Henson et al. use the term ‘digital therapeutic alliance’ to refer to patient-provider relationships established through mental health apps [ 35 ]. The interconnection between technology and therapeutic relationships is evident in Mesko and Győrffy’s ([ 36 ] p2) definition of digital health as “the cultural transformation of how disruptive technologies that provide digital and objective data accessible to both health care providers and patients leads to an equal-level doctor-patient relationship with shared decision-making and the democratization of care”. Studies have reported positive changes accompanying this transformation. Patients may experience greater empowerment through improved access to health information and resources and can assume a more active role in communication and decision-making [ 36 , 37 , 38 ]. Providers may experience shifts towards empathy-driven care [ 39 ], assume the role of a guide to direct patients towards high-quality information and services [ 36 ], and support active patient engagement with technology [ 40 ]. Some providers value the use of technology for prioritizing patient values, enabling patient autonomy [ 41 ], and making caregivers part of the team [ 42 ].

However, the impact of technology on relationships has also been termed “a double-edged sword” with significant ethical and safety implications [ 38 ]. Technology is thought to harm the relationship and reduce efficiency if patients obtain irrelevant information or misinterpret information [ 37 , 38 ]. ( For instance, patients may misinterpret data or test results accessed through technology such as self-monitoring devices and smartphone apps when the provider’s involvement is limited) [ 37 ]. Patients may also access information through resources on the Internet that may enable them in engage actively in dialogue with the provider but may also lead to them obtaining irrelevant or inaccurate information. Some providers have expressed concerns related to overuse of technology by patients and caregivers (e.g., frequently checking blood sugar or pressure when deemed unnecessary by the provider) [ 42 ] and technology taking their attention away from patients during the clinical encounter [ 41 ].

eHealth and provider-provider relationships

Relationships between primary care providers that “provide support and sustenance” are among the key factors for compassion among healthcare workers ([ 43 ] p123). Like the case of patient-provider relationships, trust is integral to strong team relationships and can contribute to better quality of care and practice improvement through open discussions of successes and failures among team members [ 23 ]. In an increasingly virtual care delivery environment, trust-based relationships between providers can facilitate interprofessional collaboration [ 44 ]. Interpersonal trust has been identified as a primary determinant of performance in virtual relationships between telemedicine providers [ 45 ]. A lack of trust between telehealth nurses and other primary care professionals was found to create tensions in their relationships [ 37 ]. The use of health information technology can enhance trust between providers when it facilitates reviewing and affirming non-physician clinicians’ decisions or erode trust when it limits opportunities for developing familiarity and comfort [ 25 ].

Objectives and approach

While there is a growing body of literature on the impact of eHealth on patient-provider and provider-provider relationships and trust in primary care, questions remain around how to best integrate eHealth into primary health care systems to facilitate relationship-centred care and uphold the “humanness” of primary care [ 46 ]. There is a need to examine this issue to generate specific information that can inform decision- and policymaking around the integration and implementation of eHealth into primary care while considering its impact on relationships and trust.

This paper reports on a review of reviews [ 47 ] to synthesise high-level evidence on relationships and trust as related to the use of eHealth in primary care. This approach was selected to identify what is currently known and unknown in this field by summarizing evidence from the large number of existing evidence syntheses, and to generate recommendations on how to ensure eHealth adoption permits and strengthens relationships and trust in primary care. To guide the review, we sought to answer the research question: How does eHealth impact patient-provider and provider-provider relationships and trust in primary care? Given the importance of health equity, especially in relation to the use of digital health in primary care [ 48 ], we also sought to understand if eHealth has a differential impact on trust and relationships across different groups (e.g., sociodemographic groups).

Search strategy

The search strategy was developed for Medline and adapted to EMBASE and Cochrane databases (Additional file 1 ). Four concepts were included: ‘ primary care’, ‘digital health technologies’, ‘relationships’, and ‘ trust’. Strategies developed for previous reviews with a librarian’s assistance helped build the search for ‘ primary care’ and ‘digital health technologies’ . A strategy was developed for the other two concepts (i.e., ‘relationships’ and ‘trust’ ) using subject headings and non-indexed keywords identified through team brainstorming and literature scans. The initial search was conducted in May 2021, followed by an updated search using the same strategy in June 2022.

Inclusion criteria and study selection

The search focused on peer-reviewed evidence syntheses published in English from 2008 onwards. This timeline was determined based on trends noted in two reviews on digital health in primary care that indicated that most papers were published after 2008 [ 49 , 50 ]. Included reviews (i) were located in a primary care setting, either exclusively or along with other settings (ii) discussed patient-provider and/or provider-provider relationships and/or trust, and (iii) included the use of digital health/eHealth/mHealth technologies (as defined above, and as consistent with our search criteria listed in search lines 10–25 in Additional file 1 ) allowing for interaction or information-sharing between patients and providers and/or between providers. As the focus of the review was on adult patients receiving primary care services, reviews exclusively discussing patients below 18 years of age were excluded. Primary empirical studies, conference abstracts, editorials and grey literature were also excluded.

The search results were validated using five articles chosen by the research team that met the inclusion criteria. Articles were then uploaded to EndNote reference manager to remove duplicates, and then transferred to Covidence review management platform for screening. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Fig.  1 ) depicts the study selection process. Text screening followed two phases: 1) title and abstract and 2) full text.

Title and abstract screening: Two rounds of title and abstract screening tests between three team members were conducted to ensure agreement and alignment with the inclusion criteria at this stage. All three members screened a random sample of 100 titles and abstracts to check if they met the inclusion criteria. Cohen’s Kappa values [ 51 , 52 ] were calculated between pairs of reviewers (e.g. Rev 1-Rev2; Rev 2-Rev3; Rev 1- Rev3) resulting in Kappa values ranging from 0.496 to 0.754, suggesting moderate to substantial agreement by the second round. Team meetings were held to discuss conflicts, and after the second round it was determined that all three reviewers had come to a common understanding of the inclusion/exclusion criteria to proceed with a single-reviewer approach.

Full-text screening: At the stage of full-text screening a single-reviewer approach was deemed sufficient due to clear understanding of inclusion and exclusion criteria established by the reviewers, and due to time and resource constraints..

PRISMA chart

Data extraction and synthesis

Three members of the research team conducted data extraction. A data extraction sheet was developed for this study and piloted on three articles. It included: type of review; number of studies; research paradigm of authors (e.g., postpositivist, constructionist); study aims; participants; settings; type(s) of technology; definitions of relationships and trust and/or connected terms; factors influencing impact of eHealth on relationships and/or trust; and any discussions around equity (how this impact might differ in different groups).

Based on definitions of relationships from our preliminary literature searches [ 21 , 22 , 23 , 24 , 25 , 26 , 27 ], we included reviews directly referring to ‘relationships’ or using other related terms like ‘collaboration’, ‘communication’, ‘connectedness/connection’, ‘interaction’, ‘empathy’, ‘respect’, and ‘understanding’. We searched each included review to see how they had described these terms and then aggregated and analysed these descriptions to identify patterns and interrelationships between terms. We also searched each review for descriptions of the impact of eHealth on relationships and/or trust and classified the impact as positive, negative, or mixed (both positive and negative). When the type of impact was not directly mentioned by the authors, two members of the research team classified the impact based on their interpretations of the authors’ descriptions and following discussions with each other. Technologies were classified using Mair et al.’s four eHealth domains described in Table 1 [ 15 , 53 ]. Thematic analysis was conducted to determine the impact of different types of eHealth on relationships and/or trust and any influencing factors. Two members of the research team coded data from each article on influencing factors separately. Coding involved highlighting and labelling relevant sections from the extracted data in a Word document. Both members then met to discuss and merge the developed codes into a single document. One member then analysed these codes, and four broad categories were developed (patient-related, provider-related, technology-related, and other factors). The second member then reviewed these categories by checking if they aligned with data extracted from 10 reviews.

Overview of reviews

The screening process yielded a total of 79 reviews were included (55 from the initial search and 24 from the updated search). Most reviews were published from 2015 onwards with a notable increase in numbers in 2020, 2021, and 2022 (Fig.  2 ). Most reviews focused on patient-provider relationships and/or trust (76 of 79), three reviews only discussed provider-provider relationships and/or trust, and 19 reviews focused on both groups. The majority of reviews either focused exclusively on adult patient populations (31 of 79) and providers from multiple disciplines (37 of 79) or did not describe the patient (37 of 79) and provider population (35 of 79). Reviews either exclusively focused on primary care (14 of 79), discussed a range of settings including primary care (40 of 79), or did not clearly describe the settings (25 of 79). Of the four domains of eHealth technology, communication systems were discussed most frequently (38 of 79), followed by reviews discussing multiple types of technology across the four domains (19 of 79) and management systems (17 of 39). Fourteen reviews discussed how the impact of eHealth (mostly communication systems) on patient-provider relationships and/or trust may differ based on age, socioeconomic status, functional ability, language, or being part of a minority/disadvantaged group [ 16 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ].

Number of reviews by year

Note: As the updated search was conducted in June 2022, the number of reviews in 2022 only includes those conducted between January and June

Seventeen reviews discussed the impact of COVID-19 pandemic [ 56 , 57 , 58 , 63 , 64 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ]. Eight reviews described the role of the pandemic in facilitating a rapid shift towards the increased use of digital health in the background or discussion sections, mostly to justify the need for their review [ 56 , 67 , 68 , 70 , 71 , 72 , 74 , 75 ]. Seven reviews mentioned including studies related to the COVID-19 pandemic and factored this into their analysis [ 57 , 64 , 69 , 73 , 76 , 77 , 78 ] to understand things like feasibility of implementation of digital health [ 64 ] but did not conduct any analyses related to the impact of digital health on relationships and/or trust. Only two reviews specifically focused on the use of telemental health [ 58 ] and remote consultations [ 63 ] during the pandemic and reported some positive and negative impacts of these types of technology on patient-provider relationships.

Eight reviews directly examined relationships and/or trust in the context of eHealth [ 59 , 79 , 80 , 81 , 82 , 83 , 84 , 85 ]. Eleven reviews examined related concepts like communication, interaction, and therapeutic alliance in an eHealth context [ 61 , 62 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 ]. In all other reviews, relationships and/or trust were not the focus but were discussed along with other findings. Tables 2 and 3 outline the characteristics of the included reviews.

Conceptualization of relationships and trust

Patient-provider relationships were defined in six reviews [ 83 , 85 , 91 , 110 , 121 , 125 ]. One review defined trust in doctor-patient relationships [ 59 ]. Provider-provider relationships were not defined and only directly referred to in three reviews [ 53 , 54 , 107 ]. These definitions provided some insight into how authors understood and used the terms ‘trust’ and relationships’ within the context of their review. The reviews also used different terms that were either explicitly connected with relationships or were interpreted by us as related to relationships based on our operational definition. Connections between terms were most often not described and challenging to identify (Table 4 ).

The terms used to refer to patient-provider relationships were organized into three non-mutually exclusive sets: 1) Overarching concepts and care models; 2) Relationship equivalents or elements; and 3) Relationship elements. Overarching concepts and care models (category 1) included terms that encompassed relationships, such as continuity of care, person-centred/patient-centred care, ethics, and morals. Relationship equivalents included terms that were used interchangeably with relationships, whereas relationship elements included terms that were encompassed within relationships. Terms that were both relationship equivalents and elements (category 2) included communication, rapport/rapport-building, and therapeutic alliance. Terms that were only relationship elements (category 3) included trust, interaction, patient and provider roles, shared decision-making, empathy, and connectedness. Some terms that came up less frequently and consistently (e.g., information sharing, support, collaborative care) could not be meaningfully mapped and connected to other concepts. Future research could explore the interpretation and use of these other less frequently used terms. Figure  3 indicates our interpretation of the connections between different terms used for patient-provider relationships.

Terms used to describe patient-provider relationships

With respect to provider-provider relationships, we were unable to categorize terms as the smaller number of reviews made it challenging to identify patterns and connections between terms. Terms mostly appeared to be used either interchangeably with relationships or as standalone terms and included: communication, collaboration, interaction, information sharing/exchange, connection, support.

Impact of eHealth on patient-provider relationships

Forty-seven reviews reported a mix of positive and negative impacts of eHealth on patient-provider relationships [ 16 , 54 , 57 , 59 , 62 , 64 , 65 , 66 , 67 , 68 , 70 , 72 , 74 , 73 , 75 , 76 , 78 , 79 , 80 , 81 , 85 , 88 , 89 , 91 , 92 , 95 , 96 , 97 , 98 , 99 , 104 , 105 , 106 , 107 , 108 , 112 , 113 , 116 , 117 , 120 , 122 , 123 , 124 , 126 , 127 , 128 , 129 ] (e.g., communicating via technology created a distance between the patient and provider in some instances, but also reduced loneliness in others). Nineteen reviews reported mainly positive impacts (e.g., more collaboration and closeness between patient and provider) [ 53 , 55 , 56 , 60 , 71 , 77 , 83 , 100 , 102 , 103 , 109 , 110 , 111 , 115 , 118 , 119 , 121 , 125 , 130 ] while seven reviews reported mainly negative impacts (e.g., reduced conversation flow) [ 58 , 61 , 63 , 69 , 82 , 87 , 114 ]. Three reviews noted no impact of technology on patient-provider relationships [ 84 , 93 , 94 ]. We also noted a collection of factors that influenced whether the impact of eHealth on patient-provider relationships and trust was positive, negative, or neutral. We categorized the influencing factors as patient-related, provider-related, technology-related, and organizational factors. Each category is described below with examples from relevant reviews. Table 5 displays the frequency of factors across different types of technology. Additional file 2 describes the factors and impact reported in each study discussing patient-provider relationships.

Patient-related factors

Patient perceptions, expectations, motives, and concerns were the most reported factors influencing relationships and trust (18 reviews), particularly in reviews focusing on management and communication systems. For example, patients had greater trust in providers and satisfaction with the relationship when using Electronic Health Records (EHRs) and telemedicine when they perceived providers as competent, knowledgeable, or experienced [ 96 , 113 ]. Patient perceptions that remote patient monitoring would replace personal care was related to a negative impact on communication, interaction, and trust, whereas feeling like an “equal partner” when providers included them in discussions about their data was related to a positive impact on relationships [ 112 ].

This factor was also discussed in two reviews focusing on information systems. For example, a positive impact on relationships was noted when patients’ motives for seeking online health information were to support rather than challenge the therapeutic relationship [ 80 ] and when they were willing to discuss online health information with the provider as compared to when they were afraid of challenging the provider’s authority [ 85 ].

Patient functional ability was linked to patient-provider relationships in six reviews mostly discussing communication systems. For example, the alliance built through videoconferencing was seen as impaired for patients with epilepsy, post-traumatic stress disorder [ 62 ] and cognitive-behavioural challenges [ 58 ]. Communication challenges during teleconsultations were reported with patients with visual and hearing impairments [ 63 , 64 ]. With mental health, the patient-provider relationship was sometimes seen as better (patients were more willing to share information virtually) and sometimes worse (providers perceived a need for human contact to facilitate recovery) when using virtual modalities [ 54 ]. One review noted that patients and providers felt that the ability of remote consultations to facilitate patient empowerment and participation could change as the patient’s illness progressed [ 77 ].

Sociodemographic factors were related to relationships and trust in 10 reviews, mostly focusing on communication systems. With respect to age, remote consultations and telehealth were linked to the development and sustenance of positive and trusting relationships particularly in younger [ 56 ] and more computer literate patients [ 57 ]. Contrastingly, one review noted that older patients felt that telehealth facilitated discussions with their provider and supplemented standard visits [ 55 ].

Three reviews indicated that language barriers can lead to communication systems having a negative impact on patient-provider communication [ 63 , 64 , 65 ] and one noted that language barriers were more common with patients in high social vulnerability areas [ 63 ].

Two reviews indicated that the impact of communication systems like telemental health and mHealth on patient-provider relationships and trust can vary according to socioeconomic status [ 16 , 58 ]. Two reviews discussing management systems [ 59 ] and multiple types of technology [ 60 ] reported socioeconomic status as a factor or barrier influencing trust and relationships .

Two reviews discussed the impact of communication and management systems on relationships and trust in minority/disadvantaged groups . One noted a negative impact on relationship-building during telephone consultations for minority patients [ 57 ]. The other reported a positive impact on patient trust in providers for disadvantaged patient groups related to the use of Patient Accessible Electronic Health Records (PAEHRs) [ 66 ].

Table 6 outlines the varying impact of eHealth by functional ability and sociodemographic factors.

Familiarity and consistency within the relationship or presence of a pre-existing relationship was reported in reviews discussing communication systems (five reviews). For instance, regular and effective patient-provider communication was noted when the provider remained the same [ 117 ]. Patients were found to report mostly positive experiences when telehealth facilitated maintenance of a pre-existing relationship [ 57 ]. A pre-existing patient-provider relationship when using remote consultations was linked to positive outcomes including enabling providers to engage patients in shared decision-making and self-management [ 56 ] and better treatment continuity and clinician outcomes [ 68 ]. However, Verma et al. reported that patients found telemedicine impersonal even when they knew their provider [ 63 ].

Provider-related factors

Providers’ communication skills and technology use style (i.e., provider’s style of using technology during an in-person visit or for remote patient communication) were frequently connected to the impact of technology on relationships and trust (18 reviews), particularly in reviews discussing management and communication systems.

With use of management systems like EHRs during in-person visits, examples of provider behaviours that impacted relationships positively included making computer use less obvious; inviting patients to look at the screen to facilitate conversation particularly during sensitive discussions; maintaining eye contact and conversation with patients [ 79 , 122 , 126 ]; giving patients time to reflect by turning away to enter data on the computer [ 122 ]; using technology as a discussion tool for emotional support [ 69 ] and collaborative planning and documentation [ 104 ]. On the other hand, screen gaze [ 79 , 89 , 91 , 92 ], keyboarding [ 79 , 89 , 91 ], closed body posture [ 79 ], and indirect facial orientation [ 91 ] had a negative impact.

With respect to communication systems (teleconsultations and remote monitoring systems), providers’ ability to develop a “video presence” [ 65 ], adjust communication style by using non-verbal cues [ 62 , 65 ], provide undivided attention and create a supportive and relaxed environment [ 77 ], use technology for direct and indirect patient communication [ 110 ] and information exchange by sharing charts and test results [ 113 ] were linked with a positive impact on relationships.

Nine reviews suggested that the negative impact resulting from the provider’s technology use style and communication can be mitigated by: using strategies specific to the care delivery modality (telephone or video consultation) [ 58 , 64 , 77 , 124 , 129 ]; provider training in technology use [ 89 , 91 ], in the limitations and regulations related to technology and in judging appropriateness of the modality [ 107 ]; considering the context and patient preferences and experiences while designing and implementing new technologies [ 89 , 72 ]; and setting clear expectations between patient and provider [ 81 ].

Provider perceptions, reactions and attitudes were reported in 16 reviews, mostly those discussing communication systems. For example, the impact of mHealth could be positive or negative depending on provider perceptions about the need for face-to-face contact (some wanted in-person contact or expressed concerns with “impersonalization” of interactions), access (some perceived increased access to services through mHealth), and the need for boundary setting (some felt the need to set boundaries to being contactable outside working hours) [ 16 ].

Provider perceptions and beliefs were also noted in reviews discussing other types of technology. For example, negative provider perceptions and concerns around the potential for management systems like EHRs to reduce time spent with patients and interfere with direct care provision was linked to a negative impact on relationships [ 97 ]. Relating to information systems, a positive impact of patient online health information seeking was noted when providers believed that patients have the right to be informed and created an open environment, whereas a negative impact resulted when providers believed that patients seek online information because they don’t trust them [ 80 ].

Differences in impact were also found depending on whether a provider had used technology or not. For instance, providers using management systems (EHRs) and communication systems (remote monitoring equipment and videophone) generally perceived greater positive impact compared to nonusers who anticipated challenges [ 98 , 106 ]. Two reviews noted that providers’ initial concerns about potential negative impacts of teleconsultations changed to a perceived positive impact after use [ 75 , 77 ].

In one review, provider perceptions of patient expectations influenced the impact on relationships and trust. For example, providers believed that patients preferred in-person interactions and that use of patient-generated health data would exacerbate social isolation and hinder collaboration [ 81 ]. Provider and patient perceptions sometimes conflicted. For example, providers felt that patients found technology difficult to use; however, patients felt that technology reduced anxiety and improved self-management [ 106 ].

Technology-related factors

Type of care delivery modality (video, phone, or in-person) was the most reported technology-related factor (15 reviews) discussed in reviews of communication systems.

In-person vs. remote (phone and video) consultations

Two reviews found that the therapeutic alliance did not differ for remote and in-person interventions [ 93 , 94 ] while one found that it was stronger over teleconsultation compared to in-person [ 68 ]. Patients and providers reportedly perceived that remote consultations build trust [ 129 ], facilitate strong alliances and quick exchanges over time [ 129 ], continuity and consistent access to the same provider [ 56 , 129 ], individualized and timely support [ 56 ], leading to positive working relationships [ 56 ]. In contrast, one review noted that in-person visits allowed for providing richer information and advice compared to teleconsultations [ 68 ] and another reported that increased trust created through asynchronous communication could lead to assumptions about other users’ intentions (e.g., assumption that the other user is being truthful) [ 129 ].

One review reported varying perceptions of virtual visits, with some patients and providers noting greater family inclusion and support and others perceiving less compassion, empathy, and discomfort with the possibility of multiple people watching during video visits [ 78 ]. Another noted that providers perceived blended care (mix of in-person and remote care) as “different” but “not necessarily worse” than in-person care; some providers were surprised by their ability to build relationships online and found that blended models provided more opportunities for rapport, support, and monitoring [ 128 ].

In-person vs. phone consultations

The alliance over phone consultations was found to be “different” compared to in-person care in one review focused on psychological therapy; greater task/treatment focus over the phone appeared to compensate for a reduction in bond, made it easier to stick to time boundaries, and, in one review, patients found the visual anonymity beneficial [ 88 ].

In-person vs. video consultations

Compared to in-person consultations, relationship-building over videoconferencing took longer and resulted in reduced conversation flow [ 111 ]. The therapeutic alliance could either be equivalent, improved, or impaired in videoconferencing compared to in-person depending on the patient’s diagnosis and the therapist’s and patient’s ability to adjust communication styles [ 62 ]. Providers found that videoconferencing provided more time to deliver personalized care and patients perceived more individual attention and focus via videoconferencing compared to in-person consultations after initial scepticism [ 76 ]. Videoconferencing was also reported to lead to loss of professional boundaries when patients were unintentionally able to view providers’ homes, leading to patients getting more personal information than the provider would like [ 58 ].

Phone vs. video consultations

Compared to phone consultations, patients and providers perceived that videoconferencing increased closeness, engagement, and continuity [ 111 ], facilitated rapport building [ 68 ] and non-verbal communication [ 57 ]. Phone consultations reportedly limited capacity for relationship-building and maintaining therapeutic alliance due to limited access to non-verbal cues [ 57 , 58 , 68 , 78 ], particularly among minority participants [ 57 ]. Some patients desired to see the provider’s reaction and perceived inadequate time for questions during audio-only visits as compared to video and in-person consultations [ 78 ]. However, some also valued the “undivided communication” offered via phone-based interventions [ 74 ]. One review noted that patients reported more positive experiences with both phone and video consultations being used together [ 57 ].

Technology design and features were reported in 10 reviews, across management, communication, and information systems. For example, personalized design, real-time monitoring, and two-way communication through mHealth apps were reported to improve information sharing and continuity of care, facilitate power and responsibility sharing, and increase trust [ 83 ]. Features like provider access to trends and summary measures [ 81 ], joint viewing of imaging results with patients [ 90 ], screensharing and document editing [ 56 ], and integration of social determinants of health [ 60 ] in EHRs and Patient Generated Health Data (PGHD) supported collaboration, communication, and shared decision-making. Technology that provided opportunities for communication was perceived by patients to reduce isolation, increase trust in the provider, and led to providers perceiving patients to be “more open”, whereas technology that reduced communication led to patients missing human contact and created a “distance” [ 67 ]. One review identified usability (e.g., ease of use) as important for synchronous technology like video consults and asynchronous remote decision-making technology to facilitate partnerships and interactions [ 71 ].

Organizational factors

Organizational factors relating to implementation and use of technology were reported in three reviews that discussed multiple types of technology. For example, implementers were noted to be concerned about the potential negative impact of technology like Electronic Medical Records (EMRs), EHRs, and computerized clinical decision support systems on patient-provider relationships [ 122 ]. The absence of guidelines and insufficient training for using technology were reported as impediments, and stakeholder engagement as an enabler of stakeholder trust in technology [ 59 ]. Synchronous technology like video consults and asynchronous shared decision-making technology could reportedly facilitate “partnerships” and “remote interactions” if factors like training in technology use and broadband access were addressed [ 71 ].

Impact of eHealth on provider-provider relationships

eHealth appeared to have a positive (7 reviews) [ 53 , 55 , 98 , 102 , 111 , 113 , 114 ], negative (6 reviews) [ 58 , 64 , 73 , 86 , 97 , 101 ], or mixed (9 reviews) [ 16 , 54 , 67 , 77 , 87 , 90 , 99 , 107 , 108 ] impact on provider-provider relationships depending on provider-related, technology-related, and organizational factors. Examples from relevant reviews describing each category of factors are discussed in this section. Table 7 displays the frequency of each factor across types of technology. Additional file 3 describes the factors and impact reported in each study discussing provider-provider relationships.

Provider communication and technology use skills/style were reported to influence provider-provider relationships in four reviews discussing management and communication systems. With respect to communication systems, a negative impact was noted when providers had impaired technical communication skills like sending delayed email responses (potentially leading to friction) and because of limited non-verbal cues and informal contact in virtual teams (leading to weaker working relationships) [ 107 ]. On the other hand, clarification actions (or “utterances” intended to clarify and understand) between providers while using videoconferencing equipment were reported to enhance collaborative working [ 87 ].

For management systems, providers with higher skill in technology use perceived greater benefit from EMRs [ 98 ]. Providers’ technology use style (e.g., frequent use of the copy-and-paste function) led to “cluttered” notes and limited providers’ ability to develop “shared understandings” [ 101 ].

Provider attitudes towards and perceptions of technology were noted to impact team relationships in two reviews (one discussing mana>gement systems and the other discussing multiple technologies). For example, negative provider perceptions of EMR as “management control systems” were reported to infringe on privacy and autonomy [ 97 ]. Providers’ lack of willingness to learn how to use online communities was reported to be a barrier to the otherwise positive impact of the technology on interprofessional collaboration [ 86 ].

Technology features and design were linked to a negative impact on team relationships in three reviews (one discussing management systems, one discussing communication systems and the other discussing multiple types of technology). Relating to management systems, the templated structure of EHR, lack of ease in informational retrieval, lack of representational structures for communicating nurse, patient, and psychosocial perspectives on care had a negative impact on team communication [ 101 ]. With communication systems, unidirectional paging systems were noted to impair communication [ 90 ]. One review discussing multiple types of technology reported positive or negative provider perceptions of team communication and teamwork depending on the ability of the technology to connect members (e.g., when technology did not have features that allowed physicians to connect with specialists, it negatively impacted communication) [ 67 ].

Fit between task and technology was reported in one review discussing multiple types of technology; selecting communication technology that fits the task was found necessary to support team routines and communication [ 107 ].

Availability of resources like standards and guidelines, training, strategic and creative adaptations was reported to be vital for facilitating virtual team operations and dynamics [ 107 ]. The extent of perceived benefit of EMR was linked to the size of the practice, such that larger practices saw greater benefit of EMR in communicating with other providers and organizations.

This review of reviews intended to better understand how eHealth impacts patient-provider and provider-provider relationships and trust in primary care by examining existing evidence syntheses. We found 79 reviews that described the impact of management systems, communication systems, information systems, and computerized decision support systems on relationships and trust. Most of the reviews discussed patient-provider relationships and only a small number focused on provider-provider relationships. Overall, management and communication systems were the most frequently discussed types of eHealth technologies and they appeared to have a mixed impact (both positive and negative) on patient-provider and provider-provider relationships and trust.

A steady increase was observed in the number of reviews emerging in this area, particularly in 2021 and 2022. However, only a few intentionally examined and clearly defined relationships and trust. Most of the included reviews had explored the impact of eHealth on relationships as part of another primary aim. Therefore, this impact and the influencing factors were not always explicitly or directly described. This made it challenging to understand what impact the use of technology was having on relationships and why, and often called for us to make connections based on our interpretations. The fluid and expanding nature of eHealth as a group of technologies [ 14 ] further adds to the complexity of this issue. For the sake of convenience, we limited our analysis to the four types of eHealth technologies within Mair et al.’s classification [ 15 ].

The terms ‘relationships’ and ‘trust’ were not defined in most of the included reviews and several interrelated terms such as ‘communication’ and ‘information-sharing’ were used without drawing out clear connections between each other. Often there appeared to be an underlying assumption that the reader would share the same implicit definition as the authors. Additionally, limited reporting of the authors’ epistemological background made it difficult to unpack these concepts in a meaningful manner. This resulted in a definitional soup or lack of conceptual clarity on what ‘relationships’ and ‘trust’ mean within the context of a specific review. Our analytical challenges in disentangling and interpreting the various terms used made it difficult to determine the impact of eHealth on the different elements or aspects of relationships. This finding points towards the need for better taxonomies in this area that conceptualise relationships, trust, and interrelated terms within the context of eHealth. The conceptualisation we have proposed in this review (Fig.  3 ) could serve as a starting point that could be built on using participatory approaches with experts (e.g., patients, caregivers, providers, managers) such as Delphi or deliberative methods [ 131 ].

Our analysis revealed a mixed impact of eHealth on patient-provider relationships and trust. This impact appeared to be positive, negative, or mixed depending on different influencing factors (patient-, provider-, technology-related, and organizational factors or a combination of these). These influencing factors were not always mentioned directly (if mentioned at all) in the included reviews and were often difficult to identify, possibly indicating the need for more work that is directly focused on understanding how these human and non-human factors might be impacting relationships and trust while using technology.

Of the patient-related factors, ‘patient perceptions, expectations, motives, and concerns’ were most frequently found to influence the impact of management and communication systems on patient-provider relationships. Patients often seemed to perceive a positive impact of these types of technology on the relationship when they perceived that it supported personalised and collaborative care. Another patient- and provider-related factor that came up in more recent reviews (from 2021 onwards) and was associated with a positive impact on the patient-provider relationship was familiarity or presence of a pre-established relationship prior to using communication systems like telehealth. These findings suggest that these types of technology are more likely to positively impact relationships and trust when used as part of hybrid care delivery models (where virtual care is used to support patient-provider relationships that have been established through initial in-person interactions) rather than a “digital-first” approach [ 13 ]. Similar recommendations have been provided in recent reports and policy documents to guide the use of technology in primary care delivery. For instance, the 2022 Virtual Care Task Force Report in Canada notes that this type of care may be better used “in the context of an ongoing relationship with a family physician or specialist and their care team” ([ 10 ] p17). Likewise, the American College of Physicians Policy Recommendations on telemedicine recommend that it “can be most efficient and beneficial between a patient and physician with an established ongoing relationship” ([ 132 ] p788).

Our analysis found a small number of reviews that discussed the impact of eHealth on patient-provider relationships (and none on provider-provider relationships) using an equity lens. Equity and the differential impact of technology among different groups on relationships was not considered as a primary aim of most reviews and usually reported as part of other findings, suggesting a need for a more explicit focus on this aspect in future studies. We found a possible differential impact of communication systems (and less frequently of management systems) on patient-provider relationships based on certain sociodemographic factors . eHealth mostly appeared to positively impact patient-provider relationships among younger patients, but there was some evidence that this positive impact could extend to older patients as well. These findings are similar to Rodgers et al.’s review [ 50 ] that found that although younger healthier patients tend to use digital consultations more, some older patients do use it as well. The impact of eHealth was also linked to the patient’s functional abilities and/or health condition . When there were language barriers between patients and providers and for patients with visual, auditory, and cognitive-behavioural challenges, eHealth appeared to negatively impact relationship. In the case of mental health conditions, a varied impact was reported. Therefore, eHealth needs to be used judiciously in these situations, possibly by identifying ways to work through challenges that may arise while working with some patients (for example, by offering patients a choice between virtual and in-person consultations, using virtual consultations as a supplement to in-person care only when preferred or needed, designing technology that better fits individual patients’ needs). Overall, these findings indicate that it is important for providers and organizations to be mindful of these sociodemographic factors and patient preferences in order to facilitate relationship building and maintenance when implementing eHealth solutions. Providers and organizations also need to consider existing inequities in terms of digital literacy and patient access to technology and internet connectivity to ensure that the use of eHealth does not exacerbate existing healthcare disparities [ 133 ]. Designing and adapting technology that meets the needs of different patient groups can also ensure that the positive impacts of technology on building relationships and trust with these groups are not lost.

Among the provider-related factors, ‘provider communication skills and technology use style’ (in relation to management and communication systems) were the most frequently reported, particularly during teleconsultations as well as relating to the use of EHRs during in-person consultations. When providers were able to successfully use technology-specific communication skills (like effective non-verbal communication during remote consultations and while accessing EHRs during in-person consultations), there was a positive impact on relationships and trust. While there is already evidence to suggest that provider communication and interaction styles can influence the therapeutic alliance [ 134 ], our findings add to this by highlighting the need for providers to adapt these communication skills to the type of technology being used in order to effectively build relationships with patients. While previous research has highlighted the need to train providers in communication and technology use [ 49 ], our review specifically brings out the possible benefits of training on optimizing the positive impact of technology on the patient-provider relationship and trust, and how this training may need to account for patient characteristics and needs, technology functionality and organizational contexts. Initiating training early on during medical school and offering continued opportunities for training during post graduate education and through continuing professional development can help providers build skills in using and communicating via technology.

‘Provider perceptions, attitudes, and concerns’ (in relation to communication systems) were also frequently found to influence the impact of eHealth on patient-provider relationships and trust. Although negative provider perceptions about technology sometimes seemed to have a negative impact on the patient-provider relationship [ 80 , 97 ], we found that these perceptions could change after providers use technology (see for example Walthall et al., [ 77 ] Bassi et al., [ 98 ] Brewster et al., [ 106 ] and Sharma et al. [ 75 ]). We also found that there were some discrepancies between providers’ perceptions of patient expectations and patients’ actual expectations regarding technology use (see for example Brewster et al. [ 106 ]). These findings could be because included reviews sometimes appeared to report providers’ perceptions of technology based on its anticipated rather than experienced impact on relationships and trust. It was often challenging to distinguish which of the two the review focused on and making this distinction may have helped us analyse the findings better. More research that collects patients’ and providers’ actual experiences of using technology and its impact on their relationships could help better understand the experienced rather than perceived impact. As well, mutual clarification of expectations regarding use of technology between patients and providers can help optimize its positive impact on their relationship with each other.

With respect to technology-related factors, the type of care delivery modality was most frequently found to influence the impact of communication systems on patient-provider relationships. We found mixed evidence on the impact of different types of care delivery modalities (phone, video and in-person consultations). While describing the impact of communication systems on relationships, some reviews did not distinguish between telephone and video consultations when referring to virtual care (see for example, Keenan et al. [ 72 ]). As a result, it was difficult to determine which care delivery modality had positive or negative impacts and when. Technology design and features were also found to influence the impact of management, communication, and information systems on patient-provider relationships, with a more positive impact noted with technology that facilitated collaboration and communication. These technology-related factors were often reported along with patient- and provider-related factors. For example, what was considered an appropriate care delivery modality depended on patient and provider perceptions (such as in Penny et al. [ 111 ] where providers perceived that videoconferencing prolonged the relationship-building process compared to in-person consultations). This suggests that considering these technology-related factors together with person-related factors and targeting the modifiable factors (e.g., increasing awareness and education to change patient and provider perceptions and attitudes towards technology, training providers in communication skills, and designing and choosing technology that meets patient needs) can help achieve good technology-person fit to help facilitate positive patient-provider relationships. Notably, some common technology-related measures like satisfaction were not represented in these reviews, suggesting a potential gap in understanding how usability measures like satisfaction may play a role in patient-provider and provider-provider relationships [ 135 ].

Given the very small number of reviews that discussed the impact of eHealth on provider-provider relationships, we were unable to clearly determine the impact by the type of technology. However, the influencing factors that our analysis identified were similar to those influencing the impact of patient-provider relationships. Impaired provider communication and technology use style (such as poor email communication skills and ineffective use of EMR functions), negative provider perceptions of technology, unwillingness of providers to learn about technology, and technology design that did not facilitate communication or ease of use were linked with a negative impact on provider-provider relationships. Organizations can potentially address these factors through strategies such as encouraging initial in-person communication and frequent and continuous communication between providers [ 136 ], improving providers’ knowledge of and motivation to use technology [ 136 ], and choosing technology that fits with team members and the situation [ 137 ]. As teams increasingly work in hybrid environments, organizational behaviour literature can provide valuable insights into optimal ways in which teams can build relationships [ 138 ].

Although some of the reviews included in our study provided a few recommendations for the use of technology in primary care settings, these were not always clearly stated or presented as actionable strategies, nor did they directly focus on relationships or trust. Our review addresses this gap by presenting some key recommendations and implications for different stakeholders (such as patients, providers, managers, policy makers, educators, and technology developers) relating to optimal ways to design and use eHealth to facilitate relationship and trust building in different aspects of primary care (such as care delivery, care coordination, team communication, and training/education). These recommendations have been proposed based on the authors’ analysis of the findings from the included reviews and are outlined in Table 8 .

Strengths and limitations

By focusing on the relational aspects of primary care in the context of eHealth technologies, this review of reviews addresses an important issue, particularly in the current post-pandemic context where primary care settings are increasingly contemplating how best to integrate technology into care delivery. The recommendations offered for different stakeholders within primary care can inform decision-making around when and how to use different types of eHealth technologies. The search strategy for this review was rigorously developed and implemented. Although single reviewer screening may have led to some relevant articles being excluded, we attempted to minimize this by conducting multiple rounds of agreement checks and discussions between team members to ensure consistency during screening and data extraction. A quality appraisal of each included review was not indicated as this review aimed to provide an overview of existing knowledge in the area [ 139 ]. This may have also contributed to our including a wide range of literature thereby providing a comprehensive synthesis of the evidence in this area. The findings of this review also need to be considered in light of certain limitations. Firstly, as relationships and trust were discussed using several interrelated terms that were not always clearly defined, our analysis and findings are based on our interpretation of these terms. We acknowledge that these terms could be interpreted in multiple ways and that the authors of the included reviews may have their own interpretations. The conceptualization presented in this paper represents one way of interpreting these terms. This variation in terminology used and interpretations could have also led to some relevant articles being excluded.

As this study focused on reviews rather than studies discussing individual technologies, the type of technology discussed in different reviews had to be abstracted to high-level categories using an existing classification system (communication, management, information, and computerized decision support systems). As a result, it was difficult to determine the type of impact (positive, negative, or neutral) of individual technologies. Most of the included reviews discussed communication and management systems. As very few reviews discussed computerized decision support systems and information systems or discussed these along with other types of eHealth technologies, it was hard to draw meaningful conclusions about these two types of technologies. While beyond the scope of our study, we do recognize that patient and provider relationships in primary care settings may be influenced by access to and care delivery from other care providers and specialists which is not captured in our results. The findings presented are mostly reflective of the impact of communication and management systems on relationships and trust in primary care settings and should be considered within this context.

eHealth impacts relationships and trust in positive and negative ways depending on how it is used and who is using it. The potential positive impacts can be lost if it is not used effectively, and negative impacts can be mitigated or compensated for through different strategies, such as designing and using technology that meets the needs of the situation and people involved, and training providers in using and communicating appropriately with technology. The findings of this review have implications for healthcare providers, patients, managers, educators, policy makers, technology developers, and other stakeholders’ decision-making around optimal ways to integrate eHealth in primary care to facilitate relationship-building and maintenance.

Availability of data and materials

Data generated and analysed during this study are largely included in this published article (and its supplementary information files). Raw data sets used to initially collect and sort data can be made available upon request.

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Acknowledgements

The authors would like to thank Alana Armas for her expertise and assistance during the early stages of conceptualising this review and developing the search strategy.

Primary funding for this research was through the AMS Healthcare Fellowship in AI/Digital Health and Compassion program. As well, this research was undertaken, in part, thanks to funding from the Canada Research Chairs Program.

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MR: Conceptualisation, methodology, project administration, writing – original draft preparation, review and editing; CB: Methodology, writing – review and editing; DW: Writing – review and editing; RU: Writing – review and editing; CSG – Conceptualisation, methodology, project administration, writing – review and editing.

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CSG, RU and DW all have expertise in primary care research, digital health, compassionate care, and the evidence synthesis methods used in this study. CSG holds a Tier 2 Canada Research Chair in Implementing Digital Health Innovation. She previously held a 2020–2021 AMS Healthcare Fellowship in Compassion and Artificial Intelligence and Digital Health through which she conducted ethnographic research to understand how trust-based relationships, needed for compassionate care, can be built (or prevented) through digital health tools. RU has previously held a Canada Research Chair in Primary Care (2005–2015) and is also a primary care clinician. DW is a compassionate care expert, and his work focuses on exploring the role of digital technologies in supporting patient partnership and co-designing technologies to promote compassionate care.

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Correspondence to Meena Ramachandran .

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Supplementary Information

Additional file 1..

Search strategy.

Additional file 2.

Impact of technology on patient-provider relationships.

Additional file 3.

Impact of technology on provider-provider relationships.

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Ramachandran, M., Brinton, C., Wiljer, D. et al. The impact of eHealth on relationships and trust in primary care: a review of reviews. BMC Prim. Care 24 , 228 (2023). https://doi.org/10.1186/s12875-023-02176-5

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Received : 18 February 2023

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DOI : https://doi.org/10.1186/s12875-023-02176-5

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