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Why patients prefer high-level healthcare facilities: a qualitative study using focus groups in rural and urban China
  1. Yun Liu1,
  2. Liwei Zhong2,
  3. Shasha Yuan3,
  4. Joris van de Klundert4
  1. 1 Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  2. 2 Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
  3. 3 Institute of Medical Information and Library, Chinese Academy of Medical Sciences and Peking Union Medical College (IMICAMS), Beijing, China
  4. 4 Prince Mohammad Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia
  1. Correspondence to Yun Liu; liu{at}


Introduction Despite policy measure to strengthen and promote primary care, Chinese patients increasingly choose to access higher level hospitals. The resulting overcrowding at higher level hospitals and underutilisation of primary care are viewed to diminish the effects of the continuing health system investments on population health. We explore the factors that influence the choice of healthcare facility level in rural and urban China and aim to reveal the underlying choice processes.

Methods We conducted eight semistructured focus group discussions among the general population and the chronically ill in a rural area in Chongqing and an urban area in Shanghai. Respondents’ discussions of (evidence-based) factors and how they influenced their facility choices were analysed using qualitative analysis techniques, from which we elicited choice process maps to capture the partial order in which the factors were considered in the choice process.

Results The factors considered, after initial illness perception, varied over four stages of health service utilisation: initial visit, diagnosis, treatment and treatment continuation. The factors considered per stage differed considerably between the rural and urban respondents, but less so between the general population and the chronically ill. Moreover, the rural respondents considered the township health centres as default and prefer to continue in primary care, yet access higher levels when necessary. Urban respondents chose higher levels by default and seldom moved down to primary care.

Conclusions Disease severity, medical staff, transportation convenience, equipment and drug availability played important roles when choosing healthcare facilities in China. Strengthening primary care correspondingly may well be effective to increase primary care utilisation by the rural population but insufficient for the urban population. The developed four-stage process maps are general enough to serve as the basis for (partially) ordering factors influencing facility level choices in other contexts.

  • healthcare-seeking behavior
  • patient choice
  • focus groups
  • qualitative study
  • Chinese health reform
  • primary health care

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  • Handling editor Nicola Foster

  • Contributors YL and JvdK conceived and designed the study. LZ and SY coordinated the fieldwork. YL conducted the fieldwork, did the initial analyses of the data and wrote the draft manuscript. LZ and SY commented on the interpretation of the data. YL and JvdK revised and reviewed the manuscript. All authors have seen and approved the final version of the abstract for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Funding This work was partly supported by the China Scholarship Council (CSC) (grant number 201507720036).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval This study received ethical approval from Shanghai General Hospital Medical Ethical Review Committee (no 2017KY207).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.