Wamsiedel Marius, Li Boyang
Global Health Research Center, Duke Kunshan University, Kunshan, China.
School of Political Science and Public Administration, Wuhan University, Wuhan, China.
Int J Qual Stud Health Well-being. 2025 Dec;20(1):2536103. doi: 10.1080/17482631.2025.2536103. Epub 2025 Jul 18.
This study contributes to the understanding of primary care bypassing in China by focusing on an underexplored demographic: the oldest old (individuals aged 80 years and above). While previous research has predominantly focused on health system determinants of bypassing, this study also considers social and cultural factors involved in the oldest old's health-related decision-making and health-seeking behaviour.
Data were collected through 20 in-depth interviews with participants from Shandong, Henan, and Shanghai. Data analysis combined inductive and deductive approaches. Initially, we used the constructive grounded theory approach of inductive coding to allow codes to emerge from participants' narratives. Later, we integrated the emerging categories within the Health Belief Model to provide a more structured understanding of the factors influencing bypassing behaviours.
Our findings reveal that bypassing cannot be explained only through distrust in the quality of services and resource shortages at primary care facilities. Participants often regarded ageing as a natural, inevitable process, which, combined with the cultural norm of endurance, delayed care-seeking for minor health issues and reduced the use of preventive services. Family involvement in health-related decisions also contributes to bypassing, as children often push for hospital-based care, reflecting both the cultural expectation of filial devotion and the belief that hospitals provide better care. Personal connections within hospitals increase trust, facilitate access, and secure privileges, which reduce the appeal of primary healthcare facilities.
Our findings suggest that health system improvements alone, albeit necessary, are insufficient to reduce the bypassing of primary care. Interventions should also address the socio-cultural factors influencing this practice. Specifically, this paper calls for improving the quality of primary health services, reforming the essential medicines policy, and promoting cultural change by prioritizing preventive care and improving the general perception of community health centres, township health centres, and village clinics.
本研究通过关注一个未被充分探索的人群：高龄老人（80岁及以上的个体），有助于加深对中国初级医疗被绕过现象的理解。虽然先前的研究主要关注导致医疗被绕过的卫生系统决定因素，但本研究还考虑了高龄老人健康相关决策和就医行为中涉及的社会和文化因素。
通过对来自山东、河南和上海的参与者进行20次深入访谈收集数据。数据分析采用归纳法和演绎法相结合的方式。最初，我们使用归纳编码的建构性扎根理论方法，让代码从参与者的叙述中浮现出来。后来，我们将新出现的类别整合到健康信念模型中，以便更有条理地理解影响医疗被绕过行为的因素。
我们的研究结果表明，医疗被绕过现象不能仅通过对基层医疗服务质量的不信任和基层医疗机构资源短缺来解释。参与者通常将衰老视为一个自然、不可避免的过程，这与忍耐的文化规范相结合，导致他们在出现轻微健康问题时延迟就医，并减少了预防性服务的使用。家庭在健康相关决策中的参与也导致了医疗被绕过，因为子女通常会推动以医院为基础的治疗，这既反映了孝道的文化期望，也反映了他们认为医院能提供更好治疗的信念。医院内部的个人关系增加了信任、便利了就医并获得了特权，这降低了基层医疗机构的吸引力。
我们的研究结果表明，仅改善卫生系统，尽管有必要，但不足以减少对初级医疗的绕过。干预措施还应解决影响这种做法的社会文化因素。具体而言，本文呼吁提高基层医疗卫生服务质量，改革基本药物政策，并通过优先考虑预防保健和改善社区卫生中心、乡镇卫生院和村卫生室的总体认知来促进文化变革。
