Residents willingness towards first-contact with primary health care under uncertainty in healthcare: a cross-sectional study in rural China

Discussion

Respondents’ overall TDSP was relatively low, indicating their willingness to seek primary care was deficient. More than 70% of respondents did not have a high TDSP. The general overestimation of disease severity and the underestimation of PHC capacity together manifest as low TDSP, which explains residents’ preferences and habitual visits to larger hospitals first even for treating mild diseases.26 27 Although no research directly proved the results, previous research corroborated the findings of this study. Research stated that patients’ health condition and disease perception could influence their willingness to seek primary care and that patients’ willingness to first visit PHC was insufficient and even continuously decreasing.13 28–30 Under the freedom of choice of doctors without strict stipulations about referral or triage of patients, the advocacy of the tiered healthcare delivery system cannot effectively guide patients’ decision-making process. Residents’ lack of awareness of PHC capacity results in the distrust of PHC, which has been regarded as the most immediate reason for residents to skip PHC.31 32 In addition, residents’ misconceptions about disease severity under uncertainty are perhaps also essential and fundamental reasons for them bypassing PHC.

Low TDSP level is the focus of this study. Compared with respondents with general TDSP, age, education, economics, substitute medical decision-maker, level of risk aversion and experience for visiting PHC significantly influenced low TDSP. Respondents older than 75 years old with common diseases were more willing to go to PHC first. As people age, they become more tolerant of diseases, and PHC can be more convenient for them in terms of their visit frequency, distance and medical costs. However, these advantages are not similarly attractive to young residents. As for economics, rich respondents’ probability of low TDSP was more than two times that of poor respondents. Rich respondents were inclined to consider PHC only when undergoing a really minor disease. Research also proved that better economic condition was positively correlated with residents’ willingness towards high-level hospitals.33 Higher income represents insensitivity to healthcare costs and high demand for quality health resources, which can simplify the decision-making process directed to high-level hospitals.34 Moreover, high risk-averse respondents were more likely to have low TDSP. Residents’ aversive reactions to uncertainty and its unknown risk can lead to an increased focus on their disease severity and a careful decision-making process.27 35 Patients would rather choose high-level hospitals to bear high financial costs than take the little risk of medical delay, which is to ‘pay for the peace of mind’. We also found that respondents who had no visits to PHC in the last 6 months tended to have low TDSP. Personal experience may modify residents’ understanding of PHC institutions and mitigate their perceived risk of seeking primary care. However, this study found no significant relationship between individual chronic disease condition and their TDSP level. The Chinese government has dedicated itself to constructing PHC for managing chronic diseases sustainably, which has also been regarded as an opportunity to develop the gatekeeping function of PHC.36 37 By the goal, a previous study found that rural residents with chronic diseases had stronger acceptance of the tiered healthcare system and were less likely to skip PHC.38 As for our findings, chances are that the management of chronic diseases has not been fully underlined in study areas.

Results also suggested that 28.2% of respondents had high TDSP, which meant they continuously considered PHC first when their disease was relatively severe. The high willingness towards PHC is beneficial to residents’ sequential and effective utilisation of medical resources according to the advocacy of the tiered healthcare delivery system. However, compared with respondents with general TDSP, we did not find factors that could significantly influence high TDSP. Possibly, residents’ high TDSP is mainly due to individual estimates of disease severity rather than other factors. However, residents with high TDSP might underestimate severe diseases and have the risk of delaying treatment in PHC, even though PHC brings convenience and good health accessibility to them.12 Special attention needs to be paid to providing serious patients with appropriate referrals to high-level hospitals.

Rural residents’ average low willingness towards first-contact with PHC reflects the dilemma of ‘matching supply and demand’ between residents and the government. The conflict lies in the fact that the government makes plans based on the population’s probability of disease and group objective health needs, while the individual resident moves based on her subjective judgement and perceived health demand.39 Under the freedom of choice of doctors residents are responsible for determining their healthcare providers, but their perception of disease severity is inherently biased and difficult to match with the treatment combinations they truly deserve. Moreover, the category of PHC in rural areas depends on the geographical location, rather than the disease varieties, indicating that PHC may remain ambiguous in its quality and service scope to residents.40 In this way, residents’ preference for high-level hospitals can arise due to risk aversion and insufficient confidence towards PHC.41 ,42

To modify rural residents’ willingness towards PHC in an attempt to promote health equity and the efficient use of health resources, we make the following recommendations. First, the example of the UK’s well-established gatekeeping mechanism provides meaningful references.43 The establishment of a disease triage mechanism with both professionalism and accessibility is a feasible solution, and web-based intelligent healthcare consultation can be an effective form of triage.44 45 Video and graphic information can eliminate the restriction of time and space, and the consultation suggestions given by intelligence can help control residents’ uncertainty. By narrowing down the gap between residents’ perceived health demands and their objective health needs, it can guide residents to make rational medical decisions and accordingly increase their willingness towards first-contact with PHC, so that the tiered healthcare delivery system can be facilitated efficiently.46 Second, what residents think and perceive plays an intrinsic role in leading their rational decision-making. Promoting the scientific knowledge of common diseases and the accurate cognition of PHC among rural residents can probably relieve their psychological stress about common diseases and motivate them to contact PHC first for minor diseases. Third, empowering general practitioners by promoting basic clinical skills and in-depth doctor–patient communication may improve patients’ experience of visiting PHC and make residents trust PHC more.47 A good experience at PHC may change residents’ impressions and shift the previous habitual visits to high-level hospitals.

Limitations

This study also has several limitations. First, the connotation of disease severity is ambiguous, so in most previous studies, disease severity has been referred to by descriptive ratings. Although the methodology is not yet perfect, this paper has attempted to quantify the concept of disease severity and tried to optimise it by integrating actual treatment situations, clinical experts’ opinions and government guidelines. Second, only 10 diseases were selected for scenario tests in this study. Each disease severity was represented by one disease, which was susceptible to be impacted by patients’ preference for a certain disease. Third, this study estimated the capacity of PHC according to its achievable treatment combinations from government guidelines, but the guidelines may not be objective and comprehensive enough, which may also give rise to some deviation.

Conclusions

TDSP can be a good indicator of residents’ willingness towards first-contact with PHC under uncertainty and freedom of choice in healthcare based on residents’ decision-making process. Residents’ overall TDSP was relatively low with low willingness towards PHC, and a small percentage of residents had high TDSP with high willingness to visit PHC. Age, education, economics, substitute medical decision-maker, level of risk aversion and experience of visiting PHC in the last 6 months were the predictors of low TDSP level. Those results may intervene in future improvement for modifying residents’ medical decisions and rationally promoting their willingness towards PHC.

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