Health Care Seeking Behaviour

Young Chinese are eager users of health facilities, even for minor illness. Fifty-three percent had attended a health facility in the last year with significantly more in Hangzhou, after controlling for other socio-economic variables. Sixty-three percent attended a health facility for their last illness, the majority of which were for minor self-limiting illnesses, 61% for cold-type symptoms. Therefore the fact that rural dwellers used services less should perhaps be regarded favourably, suggesting more appropriate use of services rather than limited access. But naturally much of this behaviour is simply a reflection of parental patterns of help-seeking. Many of these young people will not be making their own decisions about health-seeking, but will simply be following parental advice. This is reinforced by the finding that 95% attended health facilities with a parent or other relative. Those who went alone were all 17 or 18 year-olds. To put this into perspective a UK study showed that 26% of 15-year olds made their own appointments to see a GP and had

attended alone.

This apparently excessive utilisation of health facilities for minor illness is partly because of easy access, partly cultural and partly encouraged by health providers. Geographical

access is easy because of the large number of health facilities in Eastern China. A large study across eight Eastern Chinese provinces found that no-one was more than a half hour walk or bike ride away from a health f a c ility .F u r th e r m o r e the consultation fee is very low (though as we have seen the cost of drugs is not). The cultural perspective is that there is an expectation of attendance at a health facility for minor conditions. The use of

infusions of glucose for common colds is still the norm in many parts of China, and users often expect to receive such treatment. Most hospitals have an infusion room specifically for this purpose. Overprescription and polypharmacy are recognised as endemic in the Chinese health care system, since profits are made on the mark-up on d r u g s , a n d over 50% of all health care costs are attributable to drugs.^^ A study carried out in village clinics in rural Zhejiang showed that an average of four drugs (mean cost 65 RMB) was prescribed for uncomplicated upper respiratory tract infections in children.

The cost of care is high given that the majority of cases are minor self-limiting illnesses. This clearly disproportionately affects the poor. For the poor accessing health care can absorb a considerable proportion of disposable income, with 42 % of the Chunan

adolescents claiming that meeting the health care costs of their last illness was difficult. It can be thus assumed that in the case of severe, costly illness this could cause real hardship to the family.

While the health system continues to rely on user-fees and the mark-up on drugs as a source of funding, however, there is little incentive to educate people about the disadvantages and dangers of excessive use of drugs. But this is starting to change as providers, in cities particularly, have started to compete for “clients” and the high cost of drugs is now on the political agenda. Reforms are underway in a number of cities which involve bidding processes for drugs ensuring purchase at a lower price, which can passed onto the consumer.

However, utilisation of health services for apparently trivial conditions is not unique to Chinese adolescents. In fact compared with their North American counterparts they are positively reluctant. Eighty percent of the 14,000 Oregon students questioned in the Youth Risk Behaviour Surveillance Survey had seen a doctor or health practitioner in the last year. Only 7% had not seen a doctor in two years. A Canadian study shows 80% of 15-21 year olds had visited a doctor in the last year,"^^ and while the proportion was 73% in

Texas."^ Another American study showed that an enormous 93% had consulted a physician in the past year.'^^ The breakdown of the reasons for the visits, however, contrasts

somewhat with those in China, since while minor illness accounts for over 50% overall of these visits a proportion are for check-ups, which don’t figure in the Chinese data at all.

Time taken off school is low compared with elsewhere. A study of Swiss adolescents showed that 63% had taken at least one day off school in the previous year.^^^ UK children take on average 4 days off in every school year.^^^ However direct comparison is difficult because of the acknowledged problem of truancy in children and adolescents in these countries and the difficulty of establishing what is genuine time-off for illness.

The main exception to the high use of health facilities is the low use for explicit

psychological problems. Despite the obviously high psychological morbidity only 0.5% said they attended a health facility for a psychological problem. Since there is almost no other access to psychiatric services, this represents a large area of unmet need.

Although there is high utilization for probably trivial conditions, there is also high

utilization of local facilities and little inappropriate self-referral to higher level services for trivial conditions. The huge disparity between the utilisation of the school health clinics by place also illustrates that the school health clinic can serve a useful primary care function • and this should perhaps be exploited more fully.

Not only is there almost certainly overuse of prescription drugs, but there is also massive use of regular medication and supplements with some children (15%) taking three or more different types. Again this must reflect parental demand as much as personal. Vitamins, minerals and nutritional supplements are heavily promoted as essential to health, growth and often intelligence. In Traditional Chinese Medicine theory there is no sharp distinction between food and m e d i c i n e s , a n d the widespread use of these supplements needs to be viewed from that perspective. While probably not conferring much real benefit, they probably do little harm. More worrying is the widespread use of painkillers, laxatives and even sedatives. Clearly education is needed, even if only to counter the misleading claims allowed in advertising campaigns and to draw attention to the long term effects of the regular use of such drugs