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Abstract: In China, conventional medicine does not exclude traditional Chinese medicine (TCM). Traditional Chinese Medicine (TCM) 

treatments must be provided by publicly funded community health centers. Perceived quality of traditional Chinese medicine (TCM) treatment at 

community health centers was the focus of this research. Methods. Participants in the study were 471 TCM users from four different Hangzhou 

community health facilities, and the research was a cross-sectional questionnaire survey. On a Likert scale, we asked participants to score the 

TCM services they got in terms of how tangible, reliable, responsive, assured, and empathic they felt. We used linear regression models to 

identify the service and sociodemographic variables linked to the ratings. Final product. With certainty receiving the greatest score and empathy 

receiving the lowest, the average evaluations on the five components of TCM treatment varied from 78 to 88 out of 100. When compared to 

Western medicine, TCM was preferred by those who had a higher opinion of its quality of treatment (apart from assurance). The attentiveness 

and empathy of the care were judged higher by those who reported spending more than 100 yuan on TCM treatment. When it came to 

dependability, certainty, and empathy, however, more frequent trips to community TCM services were linked to poorer scores. They also felt less 

real care for those who had two or more TCM treatments. Furthermore, women did better than males when it came to dependability and 

responsiveness. Reliability and responsiveness were scored higher by those with a university degree, while assurance and empathy were rated 

lower by those with a top education of senior high school. A decrease in both perceived tangibility and certainty was likewise linked to living in a 

rural area. Respondents in the service and retail industries rated assurance higher than those in the public sector, but empathy lower. In summary. 

Patients at Hangzhou's community health centers who used traditional Chinese medicine (TCM) reported generally good results. Still, in order to 

win over and keep customers who have faith in TCM, the quality of TCM services must be enhanced. 

 

Chinese Traditional Medical Journal 

 

Community Health Services in Hangzhou, China: A Cross-

Sectional Survey on the Perceived Quality of Traditional 

Chinese Medicine Care 

Sai Krishna, Krishna Vamshi 

Department of Pharmacy, COMSATS University Islamabad, Abbottabad Campus, Abbottabad, Pakistan 

Received on:  21 Dec 2024   Revised on: 20 Jan 2024    Accepted Date: 25 Feb 2024  
Published on: 16 April 2025 

 

 

 

 
 

1. Background  

Among the many CAM practices available today, 

Traditional Chinese Medicine (TCM) ranks high in 

popularity. To ensure the safe and effective use of 

complementary and alternative medicine (CAM), the 

World Health Organization (WHO) released the 

"Traditional Medicine Strategy 2002-2005" in 2002 [1]. 

The "Traditional Medicine Strategy 2014–2023," its most 

current revision, aims to advance a  

 

conventional health systems' incorporation of CAM on a 

worldwide scale [2]. More and more people in 

industrialized nations are turning to CAM, according to the 

available data. For instance, in 2012, Americans spent 

$30.2 billion on complementary and alternative medicine 

(CAM), and 59 million individuals tried some kind of 

CAM. The accessibility, affordability, and availability of 

CAM make it a potentially life-saving option in many low- 

and middle-income nations. According to the World Health 

Organization, traditional medicines are used by as much as 

80% of the African population for basic healthcare 

purposes [3]. There has been an effort by some developing 

nations to include traditional medicine into their primary 

care systems [3-5]. 

 



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Traditional Chinese Medicine (TCM) encompasses a 

variety of practices that have achieved global prominence, 

including acu-puncture, moxibustion, herbal medicine, and 

therapeutic massage. More than seventy-five public health 

centers in the Tuscan Network of Integrative therapy, for 

instance, provide alternative treatments including herbal 

therapy and acupuncture [4]. Traditional Chinese Medicine 

(TCM) has been an integral part of the health care system in 

mainland China ever before the PRC was founded [6]. It 

has permeated every aspect of health care, from illness 

prevention to emergency room treatment, long-term care, 

and rehabilitation [7]. Nevertheless, traditional Chinese 

medicine (TCM) was put at risk during the market-driven 

health reform of the 1980s and 1990s in China, when 

allopathic medicine and hospital treatment were the norm 

[8]. Ever since then, the costly and disjointed nature of 

health care services has been the target of growing 

criticism. In 2006, the federal government implemented a 

program to promote traditional Chinese medicine (TCM) by 

mandating that all community health centers employ a 

TCM specialist [9]. Approximately 52.0% of primary care 

physicians[11] and 51.6% of community health centers[10] 

offered TCM treatments by 2009. The federal government 

reaffirmed traditional Chinese medicine's (TCM) 

significance in 2016 and established a target of providing 

TCM to all residents via community health programs by 

2020 [12].  

There are several systems that use different methods to give 

TCM services. A big plan to ensure that all people in 

mainland China have access to primary care incorporates 

TCM as one of its fundamental tenets. One TCM hospital 

should be built in each county, and TCM services should be 

widely available even in non-TCM health facilities [13]. 

There are 43 traditional Chinese medicine (TCM) 

universities and institutions in China, as reported by the 

National Administration of TCM. More than 729,000 

students enrolled at these institutions in 2018, and over 

48,300 academic members were employed by them [14]. 

Under the same legal framework, practitioners of traditional 

Chinese medicine (TCM) are registered as medical 

physicians much like their Western medical counterparts. 

Thirty foreign centers were also intended to be established 

by the Chinese government by the end of 2020 [15]. The 

traditional Chinese medicine (TCM) system in mainland 

China is marked by a high number of institutions, heavy 

reliance on governmental funding, and close cooperation 

between TCM and Western medicine. Despite a persistent 

attempt to modernizing the TCM workforce via higher 

education, these traits are substantially different from those 

in Hong Kong, Taiwan, and other locations where TCM 

services are also extensively provided [16]. Notably, social 

health insurance plans in mainland China support traditional 

Chinese medicine (TCM) services, which encompass about 

1300 TCM items and 892 components [18]. Acute 

respiratory syndrome (SARS) and new coronavirus 

pneumonia (COVID-19) outbreaks have also seen the 

utilization of traditional Chinese medicine (TCM) products 

for both infection prevention and patient treatment [19].  

As a result of official directives, the use of traditional 

Chinese medicine (TCM) in public health services is clearly 

on the rise in mainland China. In Hangzhou, the location of 

the research,  

reported a 47.11% increase in traditional Chinese medicine 

(TCM) visits to community health services between 2012 

and 2015. Among all visits to community health services in 

2013, 2014, and 2015, the proportion of visits attributed to 

traditional Chinese medicine was 25.46%, 26.87%, and 

30.64%, respectively [20]. It is unclear, however, if TCM 

patients are satisfied with the treatment they get. Through a 

cross-sectional survey of TCM users in Hangzhou's 

community health facilities, this research sought to address 

this topic. There has been a lot of push from the World 

Health Organization to raise the bar for complementary and 

alternative medicine (CAM) services [2]. We may learn 

more about the requirements of people who use traditional 

Chinese medicine (TCM) and how to improve policies in 

China's primary care system based on the results of this 

research. 

2. Methods 

This study adopted a cross-sectional design. The study was 

undertaken in Hangzhou, one of the most developed mu- 

nicipalities in China with over 9.8 million permanent res- 

idents. Hangzhou is divided into 13 local jurisdictions and 

the majority (over 77%) of its residents live in the 10 urban 

districts. In 2019, its per capita GDP reached 152,000 yuan 

(US$22,969), much higher than the national average of 

71,000 yuan (US$10,729). Hangzhou established 129 com- 

munity health centers, 100 of which have a dedicated TCM 

unit. The total volume of TCM visits in community health 

services have exceeded 10 million since 2013 [21]. 

Ethics approval for the study protocol was obtained from 

Hangzhou Normal University (Reference number 

20190070). The survey was anonymous and verbal informed 

consent was obtained prior to proceeding of the survey. 

2.1. Sampling. Participants of this study were selected using 

a multi-stage sampling strategy. Four urban districts 

(Shangcheng, Xiacheng, Jianggan and Gongshu) were 

purposively identified first, representing different levels of 

economic development and geographical locations in 

Hangzhou. Per capita GDP of the four districts ranged from 

12,218 USD (Jianggan) to 42,728 USD (Shangcheng) in 2017 

[22]. In each district, an average-sized community health 

center with a well-established TCM unit was selected. 
About 3,200 patients visited the selected TCM units over 

the period of the survey (1–4 July 2017) and 500 adult 

patients (≥18 years) were conveniently approached by the 

trained data collectors to participate in the survey. Of those 
invited, 471 (94.2%) completed the survey. This sample size 

allowed us to make a reliable estimation of the quality ratings 

and perform linear regression modelling on the ratings with 

up to 50 independent variables [23]. 

2.2. Instruments. Data were collected using a self-developed 

questionnaire. The questionnaire comprised two sections. 

The first section investigated the participants’ use of health 

care services based on Andersen’s behavioral model [24]. It 

captured needs factors (measured by the demographic 

characteristics of respondents, chronic conditions, and a 

self-rating on overall health) and enabling factors (measured 



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by marital status, education, income, job, residency, and 

health insurance). Previous studies show that these variables 

are significant predictors of health and health care outcomes 

[25, 26]. In this study, chronic condition was identified from 

a list of diagnosed conditions, including hypertension, di- 

abetes, gout, cardiovascular and cerebrovascular diseases, 

digestive diseases, chronic obstructive pulmonary disease, 

liver disease, kidney disease, and tumor. Self-rating on 

overall health was assessed on a five-point Likert scale, which 

was then recoded into three categories (good, fair and poor) 

in data analyses. Income was estimated as monthly 

household average income per capita. Residency was defined 

by the household registration system “Hukou.” In China, 

welfare entitlements are attached to local Hukou registra- 

tions. China has established almost universal health insur- 

ance coverage thanks to multiple Hukou-based funds 

subsidized by the government [26]. These funds can be 

categorized into three types: basic health insurance for urban 

employees, basic health insurance for urban residents, and 

new rural cooperative medical scheme. Overall, urban 

employees enjoy a higher level of entitlements than others. 

The questionnaire also captured the frequency, type, and 

cost of TCM care services, which encompassed medicine 

conditioning, acupuncture, massage, cupping, scraping, 

fumigation, acupoint injection, moxibustion, “hot ironing,” 
and traditional treatment for bone injuries. 

The second section assessed patient perceived quality of 

the current TCM visit in community health services using 

the SERVQUAL framework proposed by Parasuraman and 

colleagues [27–29]. It is perhaps the most commonly used 

framework for measuring quality of healthcare services in 

both developed and developing countries [30]. The 

SERVQUAL framework taps into five dimensions of quality 

of care: tangibility, reliability, responsiveness, assurance and 

empathy. Tangibility measures accessibility to physical and 

human resources. Reliability indicates the ability to accu- 

rately and reliably complete the promised services. Re- 

sponsiveness captures the adequacy of service providers to 

meet consumer requests. Assurance reflects trust and con- 

fidence of consumers on the competency of service pro- 

viders. Empathy addresses personalized needs and context 

[31]. Minor modifications were made on the SERVQUAL 

instrument after two rounds of consultations with 15 experts 

and interviews with 20 TCM users for the purpose of ad- 

aptation to the context of TCM services in China. For ex- 

ample, responsiveness involved simplification of services 

procedures and disclosure of information about the prac- 

titioners. This resulted in an adapted version of SERVQUAL, 

comprising 23 items, with an overall Cronbach’s α coeffi- 

cient of 0.936, well above 0.70 as required [32]. The final data 

analyses further excluded three items since deletion of these 

items produced a higher Cronbach’s α coefficient for their 

respective domains in the pilot study involving 100 par- 

ticipants. Three items were “Q12 The institution provides 

convenience services such as consultation, consultation, and 

triage,” “Q17 The number of Chinese medicine personnel 

and the allocation of professional titles are reasonable, which 

can meet your medical needs,” “Q21 Doctors provide you 

with personalized service.” The finalized SERVQUAL-based 
community TCM health service evaluation questionnaire is 
shown in the (available (here)) appendix. The exploratory 
factor analysis (varimax rotation) with the final sample 

(n � 471) suggested a five-factor structure of the instrument, 

supporting the construct validity of the instrument con- 
firmed by the studies in Asian populations including in 

China [33, 34]. 

 

2.3. Data Collection. The questionnaire was administered 

through face-to-face interviews in the participating com- 

munity health centers. Eight interviewers were trained over a 

two-day workshop. They were taught about how to follow 

the protocol, how to initiate a conversation with the study 

participants appropriately considering their literacy level, 

and how to avoid bias and ensure completeness of data. 

The trained interviewers were paired and deployed to the 

selected community health centers. However, they worked 

independently. Data were collected at the customer services 

area. Patients who had completed the TCM care were 

approached whenever one of the interviewers was available. 

On average, each interviewer collected 15 questionnaires per 

day. Each interview took about 13 minutes (ranging from 10 

to 20 minutes). 

The interviewers explained the purpose and procedure of 

the study and obtained oral informed consent from the 

participants prior to the survey. Participation in the survey 

was completely voluntary. The interviewers had no servicing 

relationships with the interviewees. 

 

2.4. Data Analysis. The primary outcome of this study was 

perceived quality of the TCM care reflected on five domains: 

tangibility, reliability, responsiveness, assurance and em- 

pathy. Each quality item in the questionnaire was rated on a 

five-point Likert scale, with a higher score indicating a 

higher level of quality of care. A summed score was then 

calculated for each quality domain and subsequently 

transformed into a score ranging from 0 to 100 [35]. The 

score was interpreted as a continuous quality spectrum. 

Means and standard deviations of quality scores were 

presented. 

The secondary outcome of this study examined varia- 

tions of perceived quality of the TCM care and determinants 

of the variations. Student’s t-tests or analysis of variance (F 

tests) for independent samples were performed to examine 

the statistical differences in quality scores across groups of 

respondents with different characteristics. Multivariate 

linear regression models were established to identify the 

independent variables associated with the five domains of 

quality ratings. A stepwise approach was adopted in the 

modelling involving all the tested independent variables 

(section one of the questionnaire). Missing data, if any, were 

handled through listwise deletion. 

Data were double entered into EpiData 3.1 to ensure 

accuracy. Statistical analyses were performed using SPSS 
21.0. A p value at 0.05 (two sides) was set for statistical 

significance. 



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3. Results 
3.1. Respondent Personality Traits. Of those who took 

part in the poll, 67.7% were female, 66.5% were 45 and 

over, and 83.7% were married. A local household 

registration was held by the majority of respondents 

(17.8%), while 17.8% were not. Similarly, the two urban 

insurance schemes covered the majority of the 

respondents. Respondents' distribution across 

educational attainment was very consistent. With an 

average salary of 5,389 yuan in Hangzhou in 2018, more 

than 42% of respondents reported a monthly family 

income of less than 5,000 yuan. The majority of 

respondents (36.5%) reported having at least one chronic 

illness, and almost one-seventh(17%) evaluated their 

health as bad. A mere 32% of those who took the survey 

really lived within the designated walking distance of a 

community health center, which is a goal set by the 

government. People rated secondary hospitals as the 

worst option for medical treatment. While only 18.7% of 

those who took the survey specifically indicated a 

preference for TCM, 41.2% said they would rather have 

a combination of TCM and Western treatment. The 

community health centers were the initial point of 

contact for about 28.5% of respondents seeking TCM 

treatments. More than two-thirds of the patients (64%), 

often at a cost of less than 100 yuan (about $15 USD) 

(Table 1), received several TCM modalities.  

3.2. How Great TCMCare Is Seen. On average, the 

respondents rated tangibility at 82.52 (SD = 12.05), 

dependability at 83.14 (SD = 10.96), responsiveness at 

79.63 (SD = 11.77), assurance at 87.64 (SD = 11.84), 

and empathy at 78.27 (SD = 13.12). Reliability, 

education, job, health insurance, chronic conditions, 

preferred health providers, frequency of visits to 

community health services, TCM modalities, and TCM 

cost were the factors that affected the ratings. Table 2 

shows that there was an association between the five 

dimensions of care quality and factors such as preferred 

care, number of visits, and frequency of traditional 

Chinese medicine (TCM) treatment in community health 

facilities.  

After accounting for variations in other variables, the 

multivariate linear regression models confirmed that 

gender, education, job, health insurance, preferred care, 

frequency of TCM care received in community health 

services, TCM modalities, and care cost were significant 

predictors of quality ratings (Table 3). When compared 

to Western medicine, TCM was preferred by those who 

had a higher opinion of its quality of treatment (apart 

from assurance). The attentiveness and empathy of the 

care were judged higher by those who reported spending 

more than 100 yuan on TCM treatment. However, 

dependability, certainty, and empathy scores were lower 

among those who visited community TCM services 

more often. They also felt less real care for those who 

had two or more TCM treatments. Additionally, women 

scored better on the responsiveness and dependability 

measures. Respondents with a bachelor's degree or 

above rated dependability and responsiveness higher; in 

contrast,  

 

Those who had completed senior high school scored 

lower on the measures of certainty and empathy. 

Residency in rural areas was similarly linked to lower 

levels of perceived tangibility and certainty. Respondents 

in the service and retail industries rated assurance higher 

than those in the public sector, but empathy lower. 

4. Discussion 
Results showed that traditional Chinese medicine (TCM) 

treatment in community health services was well-received by 

participants, who gave it good marks across all five quality 

characteristics (76–88 out of 100). Consistent with previous 

research [36, 37], this study found that assurance received the 

highest rating, whereas empathy received the lowest. A number 

of initiatives and investments have been made by the Chinese 

government in recent years to support the growth of traditional 

Chinese medicine (TCM) in community health services. It is 

possible that the increasing competence and skill of the TCM 

staff is the only explanation for the comparatively higher 

assurance rating. The comparatively low score on empathy, 

however, suggests that TCM's strengths in holistic and 

individualized approaches were not fully operational. Patients' 

perceptions of the efficacy of TCM treatment did not correlate 

with their actual health requirements, as assessed using 

contemporary notions of illness and wellness, according to this 

research. However, community health services in China and 

other contemporary healthcare institutions are often shaped to 

meet the demands of healthcare providers rather than patients 

[38]. When traditional Chinese medicine (TCM) becomes more 

embedded in the allopathic-dominated mainstream, it runs the 

risk of departing from its traditional practices [39]. Crowded, 

fragmented, and episodic TCM services are possible outcomes 

[40].  

Women with higher levels of education are more likely to take 

CAM, according to studies conducted in other nations [41, 42]. 

Findings from this study are in line with previous research 

showing that female TCM users in community health services 

had better ratings of the responsiveness and dependability of 

TCM services compared to male users [43]. However, 

correlations between education and how well people feel their 

TCM therapy was delivered do not follow a predictable 

pattern. Consistent with Zun's results [44], we discovered that 

individuals with a university degree ranked better on 

dependability and accountability. This seems to go against the 

grain of what these users may have greater expectations of 

[45]. But we also discovered that TCM users with a high 

school diploma or equivalent scored worse on measures of 

confidence and empathy than those with lesser levels of 

education.  

Retail and service industry employees had a lower empathy 

rating and a higher assurance rating, which is an intriguing 

discovery. It stresses the need of looking at quality evaluation 

from many angles. The likelihood of having one's unique 

requirements addressed is hampered by the lesser credentials 

held by retail and service personnel on a global scale [46]. 

Urban-rural disparities in perceived tangibility and as- 

surance of TCM care deserves further investigations. Urban- 

rural inequalities in health care and health outcomes have been 

a major policy concern in China [6]. This study was 



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TABlE 1: Characteristics of respondents and TCM services. 
 

Characteristics 
Number (%)∗ of respondents 

Shangcheng Xiacheng Gongshu Jianggan Total 

Male 32 (30.5) 39 (31.5) 42 (37.8) 39 (29.8) 152 (32.3) 

Female 73 (69.5) 85 (68.5) 69 (62.2) 92 (70.2) 319 (67.7) 

18–25 0 (0.0) 11 (8.9) 6 (5.4) 3 (2.3) 20 (4.2) 

Age (years) 
26–45 7 (6.7) 56 (45.2) 47 (42.3) 28 (21.4) 138 (29.3) 
46–65 60 (57.1) 51 (41.1) 41 (36.9) 73 (55.7) 225 (47.8) 

>65 38 (36.2) 6 (4.8) 17 (15.3) 27 (20.6) 88 (18.7) 
 

Local 94 (89.5) 83 (66.9) 97 (87.4) 113 (86.3) 387 (82.2) 

Non-local 11 (10.5) 41 (33.1) 14 (12.6) 18 (13.7) 84 (17.8) 

≤ Primary school 32 (30.5) 11 (8.9) 15 (13.5) 41 (31.3) 99 (21.0) 

Education 

 

 

Marital status 

 

Monthly household 

income per capita (¥) 

 

 

 

Job 

 

 

 

Health insurance 

Junior high school 32 (30.5) 28 (22.6) 24 (21.6) 32 (24.4) 116 (24.6) 

Senior high school 21 (20.0) 34 (27.4) 31 (27.9) 34 (26.0) 120 (25.5) 

University 20 (19.0) 51 (41.1) 41 (36.9) 24 (18.3) 136 (28.9) 

Single 1 (1.0) 23 (18.5) 15 (13.5) 5 (3.8) 44 (9.3) 

Married 93 (88.6) 97 (78.2) 86 (77.5) 118 (90.1) 394 (83.7) 

Divorced/Widowed 11 (10.5) 4 (3.2) 10 (9.0) 8 (6.1) 33 (7.0) 

<5000 61 (58.1) 38 (30.6) 37 (33.3) 64 (48.9) 200 (42.5) 
5000–9999 36 (34.3) 50 (40.3) 62 (55.9) 55 (42.0) 203 (43.1) 

≥10000 8 (7.6) 36 (29.0) 12 (10.8) 12 (9.2) 68 (14.4) 

Public institution 5 (4.8) 13 (10.5) 12 (10.8) 10 (7.6) 40 (8.5) 

Corporate company 6 (5.7) 36 (29.0) 26 (23.4) 15 (11.5) 83 (17.6) 

Retail and services 9 (8.6) 19 (15.3) 20 (18.0) 13 (9.9) 61 (13.0) 

Retired 72 (68.6) 26 (21.0) 36 (32.4) 66 (50.4) 200 (42.5) 

Self-employed 10 (9.5) 19 (15.3) 10 (9.0) 21 (16.0) 60 (12.7) 

Others 3 (2.9) 11 (8.9) 7 (6.3) 6 (4.6) 27 (5.7) 

Urban employee 74 (70.5) 86 (69.4) 79 (71.2) 100 (76.3) 339(72.0) 

Urban residents 22 (21.0) 26 (21.0) 29 (26.1) 20(15.3) 97 (20.6) 

Rural residents 9 (8.6) 12 (9.7) 3 (2.7) 11 (8.4) 35 (7.4) 
 

Yes 57 (54.3) 29 (23.4) 37 (33.3) 49 (37.4) 172 (36.5) 

No 48 (45.7) 95 (76.6) 74 (66.7) 82 (62.6) 299 (63.5) 

Poor 20 (19.0) 17 (13.7) 13 (11.7) 30 (22.9) 80 (17.0) 

Perceived health 

 

Distance to nearest community 

health center (minutes) 

 

Preferred health provider 

 

 

Preferred health care 

Fair 41 (39.0) 68 (54.8) 62 (55.9) 74 (56.5) 245 (52.0) 

Good 44 (41.9) 39 (31.5) 36 (32.4) 27 (20.6) 146 (31.0) 

≤15 36 (34.3) 38 (30.6) 36 (32.4) 41 (31.3) 151 (32.1) 
16–30 30 (28.6) 38 (30.6) 44 (39.6) 47 (35.9) 159 (33.8) 

>30 39 (37.1) 48 (38.7) 31 (27.9) 43 (32.8) 161 (34.2) 

Community facility 67 (63.8) 78 (62.9) 90 (81.1) 97 (74.0) 332 (70.5) 

Secondary hospital 10 (9.5) 12 (9.7) 0 (0.0) 12 (9.2) 34 (7.2) 

Tertiary hospital 28 (26.7) 34 (27.4) 21 (18.9) 22 (16.8) 105 (22.3) 

TCM 17 (16.2) 26 (21.0) 8 (7.2) 37 (28.2) 88 (18.7) 

Western medicine 36 (34.3) 49 (39.5) 50 (45.0) 54 (41.2) 189 (40.1) 

Integrated 52 (49.5) 49 (39.5) 53 (47.7) 40 (30.5) 194 (41.2) 
 

Yes 28 (26.7) 37 (29.8) 36 (32.4) 33 (25.2) 134 (28.5) 

No 77 (73.3) 87 (70.2) 75 (67.6) 98 (74.8) 337 (71.5) 
 

Visits to community health 

institutions over the past month 

 

Visits to community TCM 

over the past month 

 

Average TCM cost per visit (¥) 

 

TCM modalities received in 

the current visit 

 

Purpose of the current visit 

<5 23 (21.9) 71 (57.3) 48 (43.2) 39 (29.8) 181 (38.4) 
5–9 67 (63.8) 50 (40.3) 60 (54.1) 55 (42.0) 232 (49.3) 

≥10 15 (14.3) 3 (2.4) 3 (2.7) 37 (28.2) 58 (12.3) 

<5 27 (25.7) 74 (59.7) 54 (48.6) 42 (32.1) 197 (41.8) 
5–9 63 (60.0) 48 (38.7) 54 (48.6) 55 (42.0) 220 (46.7) 

≥10 15 (14.3) 2 (1.6) 3 (2.7) 34 (26.0) 54 (11.5) 

<50 28 (26.7) 41 (33.1) 26 (23.4) 47 (35.9) 142 (30.1) 
50–99 68 (64.8) 59 (47.6) 82 (73.9) 74 (56.5) 283 (60.1) 

≥100 9 (8.6) 24 (19.4) 3 (2.7) 10 (7.6) 46 (9.8) 

<2 17 (16.2) 42 (33.9) 36 (32.4) 73 (55.7) 168 (35.7) 
2 25 (23.8) 37 (29.8) 36 (32.4) 26 (19.8) 124 (26.3) 

>2 63 (60.0) 45 (36.3) 39 (35.1) 32 (24.4) 179 (38.0) 

Disease treatment 68 (64.8) 64 (51.6) 56 (50.5) 77 (58.8) 265 (56.3) 

Preventive care 9 (8.6) 35 (28.2) 35 (31.5) 14 (10.7) 93 (19.7) 

Rehabilitation 28 (26.7) 25 (20.2) 20 (18.0) 40 (30.5) 113 (24.0) 
 

Note. ∗Missing values were not included in the statistics; TCM–traditional Chinese medicine. 

Gender 

Residency 

Chronic condition 

First visit to the TCM unit 



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TABlE 2: Quality ratings (Mean ± SD) on TCM care by characteristics of respondents. 

Characteristics of respondents Tangibility Reliability Responsiveness Assurance Empathy 

Gender 

Male 81.41 ± 12.01 81.50 ± 12.01 78.46 ± 11.43 87.63 ± 13.21 75.99 ± 14.29 

Female 83.14 ± 12.06 83.97 ± 10.37 80.56 ± 12.16 89.30 ± 11.20 77.36 ± 14.69 
Group comparison (p) 0.154 0.022 0.074 0.153 0.340 

 

Age (years) 

18–25 84.40 ± 14.15 84.00 ± 14.57 83.00 ± 15.78 86.75 ± 15.50 79.67 ± 17.64 

26–45 82.52 ± 12.08 83.65 ± 11.70 80.54 ± 12.14 87.78 ± 12.75 75.65 ± 14.99 

46–65 82.98 ± 12.06 83.08 ± 10.69 79.84 ± 11.92 89.07 ± 11.30 76.92 ± 14.94 

>65 80.91 ± 11.52 82.27 ± 9.57 78.01 ± 10.55 89.92 ± 10.98 78.51 ± 11.16 
Group comparison (p) 0.498 0.808 0.336 0.882 0.817 

Residency 

Local 82.82 ± 12.16 83.27 ± 11.04 79.99 ± 11.72 89.16 ± 11.91 77.51 ± 14.65 

Non-local 81.33 ± 11.61 82.70 ± 10.75 79.40 ± 11.77 86.90 ± 11.77 74.17 ± 13.90 
Group comparison (p) 0.306 0.664 0.686 0.116 0.056 

Education 

≤ Primary school 82.46 ± 12.71 81.78 ± 10.26 78.59 ± 11.35 87.88 ± 12.27 78.65 ± 12.27 

Junior high school 82.97 ± 12.07 84.62 ± 10.30 79.42 ± 11.01 88.42 ± 10.08 79.17 ± 12.62 

Senior high school 80.93 ± 10.73 80.44 ± 11.04 77.13 ± 11.49 85.33 ± 12.67 74.28 ± 12.23 

University 83.69 ± 12.64 85.34 ± 11.31 82.94 ± 12.40 88.93 ± 11.994 80.91 ± 14.25 
Group comparison (p) 0.318 0.001 0.001 0.081 0.001 

Monthly household income per capita (¥) 

<5000 83.24 ± 13.29 82.85 ± 11.65 79.20 ± 12.23 86.35 ± 12.60 79.43 ± 13.30 

5000–9999 82.63 ± 11.52 82.66 ± 10.53 79.47 ± 11.21 88.55 ± 11.08 77.03 ± 13.08 

≥10000 83.25 ± 9.76 85.60 ± 10.04 81.68 ± 12.14 88.91 ± 11.50 78.89 ± 12.74 
Group comparison (p) 0.831 0.135 0.304 0.113 0.172 

Marital status 

Single 83.73 ± 13.44 84.81 ± 13.00 82.04 ± 13.72 87.44 ± 13.43 78.22 ± 15.00 

Married 82.69 ± 11.77 82.93 ± 10.79 79.26 ± 11.50 87.42 ± 11.69 78.38 ± 13.13 

Divorced/Widowed 79.39 ± 13.42 83.84 ± 10.38 81.45 ± 12.28 90.91 ± 11.14 77.78 ± 10.76 
Group comparison (p) 0.254 0.516 0.217 0.265 0.968 

Jobs 

Public institution 86.60 ± 13.24 87.08 ± 12.18 84.20 ± 11.63 89.25 ± 11.85 84.83 ± 13.50 

Corporate company 82.80 ± 12.94 83.37 ± 11.52 80.77 ± 12.36 86.02 ± 13.99 77.27 ± 13.93 

Retail services 82.69 ± 10.60 81.31 ± 11.81 79.21 ± 12.02 89.26 ± 10.60 73.22 ± 12.02 

Retired 81.73 ± 12.08 83.25 ± 10.13 78.94 ± 11.02 88.45 ± 10.76 79.17 ± 11.85 

Self-employed 82.33 ± 11.13 82.44 ± 10.49 78.64 ± 12.03 85.42 ± 12.43 78.33 ± 14.91 

Other 82.14 ± 12.24 82.02 ± 12.08 78.43 ± 13.87 86.07 ± 13.08 77.14 ± 13.750 
Group comparison (p) 0.356 0.190 0.143 0.222 0.001 

Health insurance 

Urban employees 83.33 ± 12.06 83.63 ± 10.56 79.99 ± 11.59 87.89 ± 11.75 78.50 ± 12.88 

Urban residents 82.20 ± 11.82 82.72 ± 11.98 79.88 ± 12.45 88.88 ± 11.94 78.74 ± 13.97 

Rural residents 76.00 ± 10.93 80.00 ± 11.77 76.11 ± 11.66 82.14 ± 11.20 75.43 ± 13.41 
Group comparison (p) 0.003 0.159 0.177 0.012 0.397 

Chronic condition 

Yes 82.58 ± 11.98 83.30 ± 11.48 80.32 ± 12.22 88.56 ± 12.19 75.87 ± 15.07 

No 82.51 ± 12.23 82.95 ± 10.07 79.13 ± 11.49 89.09 ± 11.41 78.72 ± 13.49 
Group comparison (p) 0.949 0.729 0.300 0.640 0.041 

Perceived health 

Poor 81.75 ± 12.71 82.17 ± 10.91 79.90 ± 11.47 88.75 ± 12.26 78.92 ± 12.25 

Fair 83.57 ± 12.18 83.25 ± 10.47 79.80 ± 11.86 87.65 ± 11.64 77.76 ± 13.43 

Good 81.31 ± 11.42 83.58 ± 11.81 79.35 ± 11.93 87.11 ± 11.96 78.93 ± 13.19 
Group comparison (p) 0.161 0.642 0.918 0.608 0.627 

Distance to nearest community health center (minutes) 

≤15 82.41 ± 13.12 83.05 ± 11.14 78.68 ± 12.08 88.21 ± 11.89 77.53 ± 13.61 

15–30 82.94 ± 11.68 83.17 ± 10.59 80.57 ± 11.10 89.11 ± 12.33 76.33 ± 14.20 

>30 82.31 ± 12.33 83.29 ± 11.26 80.90 ± 12.53 88.93 ± 11.54 76.91 ± 15.77 
Group comparison (p) 0.881 0.981 0.077 0.787 0.769 



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TABlE 2: Continued. 
 

Characteristics of respondents Tangibility Reliability Responsiveness Assurance Empathy 

Preferred health provider 

Community facility 82.74 ± 12.20 83.0 ± 11.09 80.18 ± 11.69 85.69 ± 9.30 80.29 ± 13.37 

Secondary hospital 81.41 ± 11.98 85.00 ± 9.22 78.97 ± 11.47 89.23 ± 12.10 77.05 ± 14.61 

Tertiary hospital 82.32 ± 11.74 82.2 ± 11.18 79.24 ± 12.99 88.25 ± 11.97 76.53 ± 14.66 
Group comparison (p) 0.809 0.592 0.702 0.012 0.001 

Preferred care 

TCM 85.18 ± 12.88 86.40 ± 10.02 82.09 ± 12.53 88.75 ± 12.85 80.83 ± 12.90 

Western medicine 80.40 ± 11.09 80.37 ± 11.23 76.08 ± 10.85 85.40 ± 12.05 74.59 ± 12.24 

Integrated 83.46 ± 12.29 84.43 ± 10.55 82.07 ± 11.49 89.38 ± 10.81 80.80 ± 13.31 
Group comparison (p) 0.003 0.000 0.000 0.003 0.000 

First visit to the TCM unit 

Yes 79.73 ± 11.69 79.9 ± 11.35 77.20 ± 12.15 85.22 ± 12.22 73.13 ± 13.82 

No 83.67 ± 12.04 84.4 ± 10.57 80.95 ± 11.73 90.16 ± 11.50 78.42 ± 14.59 
Group comparison (p) 0.001 0.000 0.000 0.000 0.000 

Visits to community health services over the past month 

<5 83.89 ± 12.18 85.46 ± 10.27 82.07 ± 11.7 89.34 ± 11.66 79.74 ± 12.52 

5–9 81.68 ± 12.00 81.67 ± 11.42 78.40 ± 12.2 87.00 ± 11.56 77.95 ± 13.85 

≥10 81.86 ± 11.78 82.01 ± 10.26 77.31 ± 9.00 85.09 ± 12.89 75.34 ± 11.68 
Group comparison (p) 0.162 0.001 0.002 0.028 0.071 

TCM visits community health services over the past month 

<5 84.18 ± 12.21 85.74 ± 10.10 82.22 ± 11.52 89.42 ± 11.56 80.56 ± 12.51 

5–9 81.52 ± 11.94 81.36 ± 11.53 78.18 ± 12.31 86.89 ± 11.59 77.15 ± 13.83 

≥10 80.81 ± 11.48 81.11 ± 9.99 76.44 ± 8.47 84.44 ± 13.02 74.88 ± 11.30 
Group comparison (p) 0.041 0.000 0.000 0.009 0.004 

Average TCM cost over the past month (¥) 

<50 83.66 ± 11.98 84.17 ± 10.74 80.70 ± 10.71 89.02 ± 11.45 79.65 ± 12.95 

50–99 82.37 ± 11.95 82.20 ± 10.74 78.59 ± 12.03 86.91 ± 11.63 77.09 ± 13.08 

≥100 80.26 ± 12.88 86.01 ± 12.68 83.22 ± 12.78 88.15 ± 13.96 81.74 ± 13.44 
Group comparison (p) 0.230 0.039 0.022 0.211 0.029 

TCM modalities received in the current visit 

<2 85.70 ± 11.74 84.62 ± 10.82 81.68 ± 11.81 89.08 ± 11.58 78.30 ± 13.99 

2 81.48 ± 11.27 82.20 ± 10.35 78.19 ± 10.78 86.98 ± 12.36 76.56 ± 11.95 

>2 80.32 ± 12.32 82.48 ± 11.46 78.82 ± 12.25 86.82 ± 11.64 79.55 ± 13.05 
Group comparison (p) 0.000 0.100 0.020 0.152 0.150 

Purpose of the current visit 

Disease treatment 81.57 ± 12.10 82.5 ± 10.67 79.06 ± 11.47 88.70 ± 11.57 76.11 ± 13.55 

Preventive care 83.44 ± 11.69 83.9 ± 12.00 80.97 ± 13.26 87.67 ± 12.81 75.98 ± 16.71 

Rehabilitation 84.14 ± 12.15 83.9 ± 10.83 80.93 ± 11.93 89.79 ± 11.92 79.56 ± 14.78 
Group comparison (p) 0.121 0.416 0.236 0.442 0.086 

 

 

conducted in urban community health settings. Rural re- 

spondents are likely to feel less engaged than their urban 

counterparts [47]. 

Trust is a strong enabler of TCM use [48]. Indeed, a 

choice of western medicine in preference to TCM was found 

in this study to be a significant predictor of lower quality 

ratings on TCM care. Higher quality ratings of TCM care 

were also found to be associated higher spending on TCM. It 

is important to note that the price of TCM care is over- 

whelmingly low in China [49]. The relatively higher 

spending is perhaps an indicator of higher willingness to 

accept TCM care. 
It is a great challenge to maintain trust. This study found 

lower ratings on assurance and empathy in those who most 

frequently received TCM care (≥10) in community health 

services. The results are consistent with the findings of a 
study conducted elsewhere [44]. Accumulated visits may 

increase the expectation of consumers, leading to deflated 

ratings on quality of care [50]. We also found that receiving 

two or more TCM modalities is associated with lower ratings 

on tangibility. Health consumers nowadays hold very high 

expectations on modern technologies. TCM care usually 

requires long term compliance. Adding up more TCM 

modalities may not help but jeopardizing the confidence of 

consumers [51]. A study in Hong Kong showed that a belief 

of TCM efficacy is not enough to translate into preferred care 

[48]. Consumer trust in TCM needs to be strengthened 

through its whole-person approach and high levels of em- 

pathy. Unfortunately, empathy attracted the lowest score 

among the five dimensions of quality assessed in this study. 

This study has several limitations. Firstly, it adopted a 

cross-sectional design and no causal inferences can be 

drawn. The study did not investigate how and why re- 

spondents chose TCM care in community health services. 

Secondly, the quality ratings on TCM care may be biased by 

its users. The study was conducted in Hangzhou, one of the 



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TABlE 3: Predictors of perceived quality of care in traditional Chinese medicine (TCM)—results (standardized β coefficient) of linear 

regression models. 
 

Variable 
Tangib 

β 

ility 

p 

Reliability 

β p 

Responsiveness 

β p 

Assurance 

β p 

Emp 

β 

athy 

p 

Gender 

Male (reference) 

Female — 

 

 

— 

 

 

0.130 

 

 

0.004 

 

 

0.119 

 

 

0.007 

 

 

— 

 

 

— 

 

 

— 

 

 

— 

Education 

≤ Primary school (reference) 
Junior high school — —  0.123  0.010 — — — — — — 

Senior high school — — — — — — −0.118  0.010  −0.133  0.003 

University — — 0.192 <0.001 0.208 <0.001 — — — — 
 

Job 
Public institution (reference) 

Retail and services — — — — — — 0.099 0.032 −0.104 0.023 

Health insurance 

Urban employees (reference) 

Urban residents — — — — — — — — — — 

Rural residents −0.157 <0.001 — — — — −0.128  0.004 — — 
 

Preferred health service 

TCM (reference) 

Western medicine −0.129 0.004 −0.181 <0.001 −0.261 <0.001 −0.196 <0.001 

First visit to the TCM unit 

Yes (reference) 

No — — — — — — 0.193 <0.001 - - 
 

Visits to community TCM 

<5 (reference) 

5–9 — — −0.105 0.020 — — — — — — 

≥10 — — — — — — −0.122 0.008 −0.097 0.028 
 

TCM cost (¥ yuan) 

<50 (reference) 

≥100 — — — — 0.108 0.013 — — 0.104 0.018 
TCM modalities received 

<2 (reference) 

� 2 −0.149 0.003 — — — — — — — — 

>2 −0.214 <0.001 — — — — — — — — 

 

most developed regions in China. The study sample is not 

representative of China. In addition, the study was con- 

ducted in urban settings. Rural residents are under-repre- 

sented. Given the large urban-rural differences, further 

studies are needed to examine the views of rural TCM users 

in rural settings. A study conducted in Singapore shows that 

low-income residents are more likely to choose community 

CAM services than their richer counterparts [50]. Thirdly, 

the SERVQUAL instrument does not measure service 

outcomes. As a result, we are currently exploring the use of 

Goal Attainment Scale to measure TCM service outcomes, 

which are highly personalized [52]. 

5. Conclusions 

Overall, the quality of TCM care is well recognized by its 

users in community health services in Hangzhou, in par- 

ticular among women and those who have a choice of TCM 

in preference to western medicine. Enhancing TCM care can 

bring benefits to the growth of community health services. 

However, there is a need to further improve TCM care from 

 

all quality perspectives in order to attract and maintain 

consumer trust in TCM. 

Acknowledgments 

Thanks to the funds and authors for their support of this 

article. National Natural Science Foundation of China 

(71874047); Fundamental Public Welfare Research Project 

of Zhejiang Province (LGF21G030003). The funders played 

no role in the design and execution of the study. 



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