Professor Kate Hunt Institute of Health and Well-being Glasgow University

1. Using vignettes in focus groups to prompt discussion about attitudes to health care provision and reform in China 在深度小组访谈中运用场景模拟去推进关于中国医疗卫生服务与改革的态度的讨论 Professor Kate Hunt Institute of Health and Well-being Glasgow University

2. Methods: Main issues addressed研究方法：讨论的主要问题 • How people know about changes in the health care system 人们是如何知晓医疗卫生系统的变化的 • How people make decisions to see a doctor when they are unwell 当人们感到不舒服的时候是如何决定去看医生的 • Health care system evaluations 医疗卫生系统的评估 • Trust in doctors and the health care system 对医生以及医疗卫生系统的信任 • What kind of health care system people would like 人们想要什么样的医疗卫生系统

3. Methods -9 focus groups9次深度小组访谈 • Chifeng赤峰(city below national mean GDP per capita城市人均国内生产总值低于全国平均水平) • Yueyang岳阳 (city close to national mean GDP per capita 城市人均国内生产总值与全国平均水平基本持平) • Shaoxing绍兴 (city above national mean GDP per capita 城市人均国内生产总值高于全国平均水平) • Variation in participants by 通过以下各项区别参与者 Gender, age, income/employment 性别，年龄，收入/是否有工作; Rural / urban 农村/城市;Recent experience of health care system 近期与卫生医疗系统有关的经历; Current health status 身体健康现状;Types of insurance cover 保险覆盖范围

4. Methods: Vignettes to prompt discussion around how people make decisions about health care研究方法：用场景模拟推进受访者关于人们如何在医疗卫生上做决定的讨论 • Presented short scenarios in which Mr Xie and Ms Chen who grew up in the local area meet up at a funeral. They have known each other’s families from childhood. They discuss the health of family members. 故事背景：谢先生和陈女士在这个地区从小一起长大，他们在一个葬礼上相遇。他们从小就熟知对方的家人。他们相遇后开始讨论家人的健康情况。

5. Methods: Vignettes to prompt discussion around how people make decisions about health care研究方法：用场景模拟推进受访者关于人们如何在医疗卫生上做决定的讨论 • Four scenarios varied the severity of illness 四个场景：以疾病严重程度区分 • Mr Wang – died of stomach cancer at age 46 王先生：因胃癌逝世，享年46岁 • Ms Chen’s father - a smoker, who has a bad cough and has coughed up blood recently 陈女士的父亲：吸烟者，有严重的咳嗽，并且最近有咳血症状出现 • Mr Xie sister - has high blood pressure 谢先生的姐妹：有高血压 • Mr Xie’s grandmother - in her early 70s, has cataracts谢先生的祖母：刚过70岁，患有白内障

6. Responses to vignette presenting most severe illness:对疾病程度最严重的场景的反应 • Mr Wang who died of stomach cancer at age 46 • 王先生 于46岁死于胃癌

7. Vignette 1: Exploring rationales for stopping treatment for a serious disease (a fatal cancer)场景1：探索停止治疗严重疾病（致命的癌症）的原因 • 谢先生和陈女士在[这个城市/县]长大，他们两家是老相识，在邻居王先生的葬礼上，两人相遇。王先生46岁死于胃癌，谢先生告诉陈女士，王先生之前曾去市里一家公立综合性医院做过手术，但他后来决定不再做进一步的治疗。 • Mr Xie and Ms Chen grew up in [this city/county]. They have known each other’s families from childhood. They meet up at the funeral of their neighbour, Mr Wang. Although he was only 46, Mr Wang died recently of stomach cancer. Mr Xie tells Ms Chen that Mr Wang had been to a public general hospital in [this city/county] for an operation for his cancer but he had decided afterwards not to have any further treatment.

8. Vign. 1: Prompts to explore rationales for Mr Wang’s decision场景1：引导参与者探讨王先生停止治疗原因的小问题 您认为是什么原因让王先生决定做手术？ 您认为王先生可能因为什么原因决定不再做进一步的治疗？ 您认为，王先生在决定是否治疗以及如何治疗的问题上，可能存在什么顾虑？ What factors do you think might have made Mr Wang decide to have his operation? Why do you think he may have chosen not to have any further treatment? What worries, if any, do you think Mr Wang may have had when he was making his decisions about his illness?

9. Vignette 1: Additional prompts to explore rationales for Mr Wang’s decision场景1：引导参与者讨论王先生的决定的其他小问题 If these issues did not arise in the discussion then prompts asked how the following things might change people’s decision-making:如果在讨论中没有提及以下内容，那么请进一步询问下面的观点可能如何改变人们的决定 • Whether Mr Wang has health insurance • 王先生是否有医疗保险 • What if he came from a wealthy family? • 如果他来自于富裕的家庭？ • Would a public or private hospital be better? • 公立或者私立医院，哪个会更好呢？

10. Predominant issues:主要问题 • Costs of treatment, wealth (of family) and assumed course of illness following a cancer diagnosis 治疗费用，家庭经济状况和癌症的后续治疗费用 • Considerations about money and the illness were usually intertwined, and often the first thing mentioned, 对于钱和病的顾虑总是纠结在一起，并常常首先被提及 • particularly amongst less affluent. and more rural groups/participants 特别是在那些并不是很富裕或更多农村参与者的小组里 • Most people held very negative views generally about cancer and prospects of recovery from cancer 大部分人对于癌症的观点和患癌后恢复的前景比较悲观 • All groups considered importance of costs, money and wealth, at least to some degree 所有小组都一定程度上顾虑到花销，钱和富裕程度

11. Example: FG5 Yueyang, people with UEBMI 举例：岳阳，湖南省，城镇职工基本医疗保险 他自己认为癌症是不治之症，第一家里经济不够宽裕，第二个可能儿女比较小，怕花了钱治不好 He thinks his cancer is an incurable disease. Firstly, the family isn’t rich enough, and secondly, his children might be quite young; he’s worried about spending money yet not curing the cancer. 可能是治过一次手术了，再去做手术肯定是人才两空 It could be that he’s already had surgery once, having surgery again would mean the loss of both his life and his money. …… 有钱的活命，没钱的就等死，现在农村就是这样的有钱就救，没钱就等死 With money you live, without money you just wait for death. In rural areas it’s like this; if they have money, they act, if not, they just wait for death.

12. Example: 要看家里的条件来说，条件好就治，条件不好就不去治了，经济条件是一个主要问题，经济决定他的命运 （岳阳，湖南，农村合作医疗保险） It depends on his financial situation at the time. If he had the money, he’d get treatment, if not he wouldn’t. His financial situation is a core consideration; it determined his fate. (FG6, Yueyang, Hunan province, people with Rural Cooperative Medical Insurance) ================================================= 主要考虑经济负担，有钱大部分报销，肯定会去，生命最宝贵 He’s mainly thinking about the burdensome cost. If most expenses could be reimbursed, he’d definitely get treatment, life is precious (FG8)

13. Other important considerations discussed:讨论到的其他重要的顾虑 • Inequalities in health care provision 医疗服务提供中的不公平现象 • Issues of trust, and the relative trustworthiness of different providers信任以及不同提供方的相对可信度 • Examples of bad or unethical medical practice医疗行为中的不好的或不道德的例子 • The burden faced by families – and mixed views on who should make the decision about whether to continue treatment家庭所面临的负担：谁来做决定-到底是否该继续治疗

14. Examples: Lack of trust 举例：缺乏信任 现在的医生比较喜欢把病情夸大其词，本来很小的病，却说是大病吓死人 Doctors like to exaggerate patients’ diseases nowadays. It’s a small illness, but they make it out to be a major problem in order to frighten people. (F:那你们是不相信医生的吗？So you don’t you trust doctors?) 不相信医生啊，但不相信不行啊。 We don’t trust them, but we don't really have a choice. (FG7) .... 岳阳这边的教授医生都是假的，都是水货医生。 The professors and doctors in Yueyang city are fake, they didn’t get their positions through regular channels. (FG7) ....

15. Example: differential trust (FG5) 举例：有差别的信任 现在的药全是假的，都不是真的。小医院的药都是假的，治疗没有效果，只是门槛钱贵点。 All medication is fake these days, none of it is genuine. All medication sold at small hospitals is fake and ineffective. People only go there because the admission fees at large hospitals are really expensive. (F:人们一般在什么情况下会选择离开岳阳，去外面的医院治病呢？Under what condition would you choose to leave Yueyang and get treatment elsewhere? 一般是疑难杂症，我不相信这里的医生的技术，会出去外地医院. Normally, if I have a complicated disease, I won’t trust the medical skills of the doctors here, I’ll go to a hospital in some other place. .

16. Notable differences to the UK:与英国情况的显著不同 • Detailed discussions of the complexity of reimbursement in different health care situation and with different types of insurance 更具体的讨论复杂的报销情况：在不同的医疗机构中或者不同类型的保险 • People spent less time talking about the side effects of the treatment 人们花更少的时间讨论治疗的副作用 • People assumed that more treatment is always better, either for small chance of cure or to die in hospital 人们认为只要治疗就总是好的，不论是为了那很小可能性的治愈率，或者是更倾向于在医院过世。

17. Problem areas for reform: Medications改革的问题领域：药物 • price of medicines too high 药价高 • insufficient supply of medicines 药品供给不足 • prescribing unnecessary medicines eg. nutritional supplements 不必要的药物处方，如营养药 • medicines not covered by insurance 药品不给报, 自费的 • non-transparency/inconsistency of prices for medicines 药品没有明码标价

18. Problem areas for reform: Insurance provision改革的问题领域：保险条款 • outpatient treatment costs not reimbursed看门诊不可以报销 • premiums too low, risks too high 保险费太低，风险太高 • time taken to obtain reimbursement 报销周期时间长 • minimum spend/threshold too high 最小花费/报销门槛太高 • necessary transfers to larger hospitals are not covered 转院不可报销

19. Problem areas for reform: Quality and inaccessibility of care改革的问题领域：医疗治疗和医疗准入 • technical competence of doctors in different hospitals 不同医院医生的技术能力 • quality of equipment in different hospitals 不同医院的医疗设备质量 • service attitudes of doctors in public hospitals 公立医院医生的服务态度 • inadequate explanations of treatment在治疗期间没有给患者提供充分的解释说明 • having to travel long distances and/or overcrowding in city hospitals医院离得很远/市里医院人满为患 • restricted choice of hospitals (esp. for NCMS) 不是所有医院都能报销（特别是新农合） • long queues, waiting times排队很长，等待时间长

20. Question areas in the survey developed from the FG discussions and literature从小组访谈和文献中总结出来的问卷调查问题 • Perceptions of fairness, quality of care, value for money & doctor ethics • 对以下的看法：公平，护理质量，金钱的价值和医生的伦理 • Levels of trust in doctors and the health care system as a whole. Different dimensions of trust, including fidelity (or pursuing the truster‘s interests), competence, honesty, confidentiality and holistic trust • 对于医生和整个医疗卫生系统的信任程度。不同纬度的信任，包括忠诚尽责（病人利益至上），能力，诚信，保密性和整体性的信任