This survey was conducted under the theme of “Research on the Medical Treatment Behavior of Residents in Yicheng, Zhumadian City.” This study used the random sampling method, and based on the map of population density in Yicheng District, three public places, Tianzhong Plaza, Aijia Plaza, and Dashang New Mart, which are the top three places in terms of foot traffic, were selected as sampling locations. The questionnaire was given to participants at random during their normal routines in the morning, midday, and evening. 225 of the 230 questionnaires that were sent out were returned, resulting in a 97.83% response rate. 216 of these were deemed valid. This data does not contain any data which can identify individual. Therefore, ethical approval is exempted. Additionally, as this research is based on routinely collected data, it is exempt from informed consent requirements.

This study adopts the classic Anderson model for healthcare utilization in the field of healthcare demand, designing and analyzing the empirical process around the research subjects and themes. The research variables are categorized into predisposing characteristics, enabling resources, and healthcare needs, explaining residents’ healthcare utilization behavior from these three dimensions (14). Existing research has demonstrated that the Anderson model applies to China’s social context (15). The questionnaire content includes three aspects: the first part covers residents’ basic information, including gender, age group, educational attainment, marital status, occupation, monthly income, health insurance, self-assessed health status, and chronic disease prevalence. The second part addresses healthcare service accessibility, including the time required to reach the nearest healthcare facility and the duration of the most recent visit to that facility. The third part concerns healthcare-seeking behavior, including how individuals recover their health after falling ill, how they choose healthcare facilities for minor illnesses and the reasons behind their choices, how they choose healthcare facilities for major illnesses and the reasons behind their choices, whether they have had experience with primary care facilities, and their suggestions for primary care facilities. Descriptive statistics were conducted on each section to understand the healthcare-seeking behavior of residents in Yicheng District, Zhumadian City, as well as the factors influencing residents’ different healthcare-seeking behaviors.

Based on this, a database was established using EpiData3.1, and the data were processed using SPSS 26.0. The variables of the three dimensions were then analyzed in interaction with the tiered diagnosis and treatment model. In subsequent multiple logistic regression analyses, we used the multiple independent samples rank sum test and multiple comparison analysis to examine whether there were significant differences in residents’ preferred healthcare institutions for common illnesses and major illnesses based on individual characteristics and healthcare service accessibility. This allowed us to identify factors influencing residents’ healthcare choice preferences and propose recommendations for rational healthcare utilization. Count data were analyzed using the chi-square test, with p < 0.05 considered statistically significant.

The sample’s age and occupational structure differed from the overall population demographics; in particular, the percentage of individuals over 50 is less than 5%, which may lead to an underestimation of the demand for hierarchical treatment for older individuals.

Due to the presence of highly educated individuals in the sampling locations within commercial areas, both students and these highly educated groups were overrepresented. In the future, the study will employ stratified sampling and supplement community sampling sites with a “15-min medical circle” coverage.

In the section of the study on arrival time to healthcare facilities, the fact that people with different modes of travel have different arrival times to the same hospital from the same location was not taken into account, as the mode of transportation was not explicitly studied. In the future, the method of measuring travel time and other influencing factors will be broken down. Previous studies have shown that stratified sampling can more comprehensively explore the factors that influence patients’ intentions to seek medical treatment for common diseases (16, 17).

Table 1 shows the basic profile of the residents. Of the 216 valid samples surveyed, 99 were male and 117 were female, for 45.83 and 54.17%, respectively, suggesting a generally balanced male-to-female ratio. The majority, 104 people, are within the 18 to 29 age bracket, accounting for 48.15% of the total people, followed by 55 people aged 30 to 39, constituting 25.46% of the total. Over half of the sample, totaling 133 people, possessed a bachelor’s degree or above, constituting 61.57% of the total; in contrast, 31 people had an education level of junior high school or below, representing 14.35% of the total. Of the respondents, 83 were students, for 38.43% of the total; whereas, farmers, workers, and other occupations had the least representation, with merely 9 respondents, constituting 4.17% of the total. Regarding health insurance composition, 63 individuals possess basic health insurance for urban workers, for 29.17% of the total; 132 people have basic health insurance for urban and rural residents, accounting for 61.11% of the total. A large number of respondents rated their health state as excellent, including 104 people, or 48.15% of the total, followed by 51 respondents who rated their health as very satisfactory, accounting for 23.61% of the total. Of the respondents, 42 had chronic diseases, for 19.44%, and 174 had none, totaling 80.56% of the total respondents.

Among the survey respondents, 77 people, or 35.65% of the total, reach the nearest medical institutions in less than 15 min, while 103 people, or 47.69%, take 15 to 30 min. The length of consultation refers to the total time used on examination, diagnosis, and treatment of the illness. The largest number of people, 75, or 34.72% of the total, were consulted for a duration of 15 to 30 min at their most recent visit to a healthcare facility, followed by 69 people, or 31.94%, who had a consultation time of 30 to 60 min (see Table 2).

Of the 216 survey respondents, 128, or 59.26% of the total, would choose to go to a medical facility after becoming ill; 78, or 36.11% of the total, would choose to self-medicate; and 10, or 4.63%, would choose to let it run its course and recover.

Seventy-six residents preferred primary medical care after suffering from common and frequent illnesses, accounting for only 35.19% of the total; 111 preferred hospitals, accounting for 51.39% of the total. Most residents preferred tertiary hospitals after suffering from major diseases, accounting for 66.67% of the total number of people surveyed, followed by 65 people choosing secondary hospitals, accounting for 30.09% of the total number of people surveyed (see Table 3).

Among the sample of this survey, 115 people, or 53.24% of the total, had the experience of primary care; 101 people, or 46.76% of the total, did not have the experience of primary care. Of the 216 residents surveyed, 171, or 79.17% of the total, suggested improving the medical standards of healthcare personnel, followed by 158, or 73.15%, who suggested bringing in professionals to strengthen the construction of the medical team (see Table 4).

As shown in Table 9, the difference in the length of consultation of the most recent visit to the healthcare facility (H = 14.379, p = 0.006) was statistically significant for the difference in the choice of healthcare facility after the resident suffered from a common disease (multiple illnesses), and the difference in the time it took the resident to get to the nearest healthcare facility (H = 5.118, p = 0.163) was statistically significant for the difference in the choice of healthcare facility after the resident suffered from a common disease (multiple illnesses) significance; the difference in the length of consultation and treatment at the nearest medical institutions (H = 9.587, p = 0.048) was statistically significant for the difference in residents’ choice of medical institutions after suffering from a major illness, and the difference in the time it took residents to get to the nearest medical institutions (H = 2.604, p = 0.457) was statistically significant for the difference in residents’ choice of medical institutions after suffering from a major illness.

Multiple comparisons were performed on statistically significant results from the rank-sum test. Results with adjusted p-values less than 0.05 are presented in Table 10. Significant differences were observed in the selection of healthcare facilities by residents after contracting common diseases (frequent diseases) between the 30–60 min and over 2-h consultation duration groups (p = 0.014), and between the 1–2 h and over 2-h consultation duration groups (p = 0.028). Additionally, a significant difference was found in the selection of healthcare facilities by residents after contracting serious diseases between the 30–60 min and under 15-min consultation duration groups (p = 0.047).

Table 11 shows that residents with common diseases prefer medical institutions for reasons such as good medical technology (H = 16.525, p < 0.001), reasonable medical costs (H = 12.053, p = 0.001), high reimbursement ratio of health insurance (H = 11.573, p = 0.001), good medical equipment (H = 16.905, p < 0.001), good medical environment (H = 20.952, p < 0.001), and acquaintances (H = 4.772, p = 0.029). After a statistical test showed that the difference was statistically significant, the health insurance reimbursement ratio is more willing to choose primary health care institutions, while residents preferred the hospital because of the hospital’s good level of medical technology, medical equipment, and environment, as well as the fact that the hospital has acquaintances. A favorable service attitude (H = 1.943, p = 0.163), proximity to medical care, convenience of access to medical care (H = 2.954, p = 0.086), and recommendations from family members or other relatives and friends (H < 0.001, p = 0.983) were examined, but there were no statistically significant differences.

According to Table 12, among the reasons why residents preferred medical institutions after suffering from major illnesses were the reasonable medical costs (H = 5.822, p = 0.016), the high reimbursement ratio of medical insurance (H = 4.899, p = 0.027), the favorable service attitude (H = 9.713, p = 0.002), and the presence of acquaintances (H = 5.442, p = 0.020). After a statistical test showed the difference residents choose different levels of hospitals for different statistically significant reasons. For example, citizens who are concerned about the cost of medical care are more likely to pick second-tier hospitals after a serious illness. Good medical technology level (H = 1.673, p = 0.196), good medical equipment (H = 2.168, p = 0.141), good medical environment (H = 2.395, p = 0.122), proximity to medical treatment, convenient to consult (H = 0.312, p = 0.576), and family or other relatives and friends suggested (H = 1.728, p = 0.189) after testing. The difference was not statistically significant.

Only 35.19% of the residents preferred primary healthcare organizations to seek medical treatment after suffering from common diseases, and 53.24% had the experience of primary first medical treatment, which indicates that there is still the phenomenon of choosing a healthcare institution from a higher rather than a lower level healthcare organization among the residents. The results of the study based on Anderson’s health service utilization model show that tendency and need factors have a more significant impact on residents’ healthcare behavior (18), and the traditional concept of “delaying minor illnesses and resisting major illnesses” affects their choice of healthcare (19), with residents with a lower level of education and those who are employed as workers being more inclined to choose primary medical institutions, and more likely to choose secondary hospitals when suffering from a major illness. When suffering from serious illnesses, they also choose secondary hospitals more often, i.e., the higher the level of education, the higher the level of medical institutions they tend to choose, while residents who work as farmers and laborers tend to choose lower-level medical institutions (20). In Li et al.’s article, it was also noted that when a major illness struck, people with better self-assessed health status were more inclined to choose tertiary hospitals than those with poor self-assessed health status. That’s given that individuals with poor self-perceived health status choose proximity or accessibility when selecting hospitals, as people with self-perceived health status choose quality of care (21).

The results of the survey show that there is also a phenomenon of residents seeking medical treatment based on familiarity rather than alienation, with many residents choosing to contact their acquaintances after falling ill to inquire about beds, doctors, medications, and methods of treatment, and that medical institutions “where there are acquaintances” are more likely to be the first choice of medical institutions for them. The advice of family members or other relatives and friends is also a factor influencing residents’ choice of medical care, and the more supportive a significant other is of a resident’s choice of medical care, the greater the likelihood that the resident will take action.

The implementation of the hierarchical diagnosis and treatment system still needs to be promoted more aggressively because some residents value the level of medical technology, medical equipment, and the medical environment of medical institutions more than others, and primary health care institutions are unable to meet the residents’ requirements in these aspects. According to this survey, residents prefer going to hospitals when choosing medical institutions over primary medical institutions. Residents have chosen primary medical institutions due to their reasonable costs and high medical insurance reimbursement. According to the survey, the most typical suggestions for primary healthcare organizations were to improve the medical standards of the staff, hire professionals, and provide them with sophisticated medical equipment. That shows that primary healthcare organizations urgently need to improve on two aspects: talent and equipment. Medical equipment is another factor that results in residents being unwilling to choose primary healthcare organizations for medical treatment. The precision of the medical equipment in primary healthcare organizations, which may have been purchased many years ago, inevitably has many shortcomings compared to the equipment in big hospitals. Healthcare talents are the foundation of healthcare services, and many healthcare talents are unwilling to work in primary healthcare organizations due to the low salary and poor career development opportunities of primary healthcare organizations. Primary healthcare organizations’ medical equipment is inevitably less sophisticated when compared to that of large hospitals.

The accessibility of medical institutions is one of the key factors influencing residents’ choice of medical institutions, which is specifically manifested in the fact that the better the accessibility of a medical institution, the greater the likelihood of residents choosing that medical institution (22). The survey shows that 35.65% of the total number of residents spend less than 15 min to get to the nearest medical institution, with most of them concentrating on 15–30 min, which indicates that the accessibility and service capacity of medical institutions still need to be further improved, and that we need to give play to the important role of primary medical institutions in the construction of the “15-min healthcare circle” to realize the principle of “resolving minor illnesses in the community” and to achieve the goal of “resolving minor illnesses in the community.” It is necessary to play an important role in the construction of the “15-min medical circle,” to realize the goal of “resolving minor illnesses in the community and treating major illnesses in hospitals”.

The survey results show that awareness of the tiered healthcare system has a certain impact on residents’ choice of primary care provider, which is consistent with the findings of Liu et al. (23). And the basis for residents’ choice of medical treatment is their level of medical health literacy. The phenomenon of passive medical treatment, self-treatment, and blindly choosing large hospitals for medical treatment is caused by a lack of basic medical knowledge, whereas the development of medical health literacy will help the residents in assessing the severity of their disease conditions and in making scientific decisions concerning the treatment method and the medical institution. Zhumadian City in recent years has closely followed the popularization of health knowledge, rational diet, fitness, and 15 other special actions to carry out health promotion work, and through the prescription of exercise as a cure for prevention, the level of residents’ health literacy has been improved, but the popularization of medical knowledge should continue to be promoted so that they set up a scientific concept of medical care and make reasonable choices of medical institutions. We should actively use community bulletin boards to fully leverage the power of public media. Furthermore, schools and communities should hold lectures on the basic concepts of medicine and widely distribute knowledge about disease prevention and treatment and ways to help residents better comprehend and accept primary health care institutions and hierarchical diagnostics and treatment. Residents also should be influenced to change their views about medical care and their patterns of behavior, choosing nearby primary medical and health care institutions for medical treatment.

Graded diagnosis and treatment efficiently address the issue of difficulty obtaining doctors; nonetheless, the current rate of residents visiting primary medical institutions remains low due to insufficient exposure to this system, as well as a lack of awareness and acceptance by residents. Furthermore, many residents are still concerned that obtaining primary care may delay their therapy. Many residents have yet to abandon their rejection of primary care, fearing that obtaining care at the main level may prolong their disease. Medical institutions at all levels should actively publicize the tiered diagnosis and treatment system through lectures, in-hospital bulletin boards, posters, banners, and other means to educate residents about the convenience of primary care and the benefits of medical insurance reimbursement. In addition, we should use newspapers, radio, television, microblogs, WeChat, and other media to widely and comprehensively carry out publicity and education on knowledge related to hierarchical diagnosis and treatment for groups of different ages and educational levels to increase residents’ awareness and acceptance of hierarchical diagnosis and treatment so that they can understand the meaning of hierarchical diagnosis and treatment, change their concepts of medical care, and actively choose primary care as their first point of contact.

The graduated diagnosis and treatment system is an important part of the medical system reform. The construction of the graduated diagnosis and treatment system is the fundamental strategy to reconstruct China’s medical and health care service system and improve the efficiency of the service (24), and the primary first diagnosis and treatment system is the important foundation of the graduated diagnosis and treatment system, and comprehensively improve the service capacity of primary medical institutions is an important part of the construction of the graduated diagnosis and treatment system. The service capacity of primary medical institutions largely depends on the performance of their talent teams; however, the current shortage of skilled personnel and the low technical proficiency within these institutions are significant factors contributing to residents’ reluctance to seek treatment there. Zhumadian City is now constantly innovating the recruitment mode, optimizing the recruitment process, optimizing the salary structure, improving the treatment of personnel, and opening up a green channel for talents. The healthcare talent has increased. Talent team building is a continuous process. To fully implement the Henan Province “369” talent project, it is essential to utilize the resources of Zhumadian City, including the three hospitals, the general practitioner training base, and the Zhumadian School of Health. This should be based on grassroots doctors and involve establishing specialized training channels for grassroots health personnel in Zhumadian City. Additionally, large hospitals should include medical personnel in their assessments for grassroots support services and provide better promotion opportunities for those with several years of experience in grassroots service.

One of the main reasons hindering the development of primary medical institutions is the irrational allocation of medical resources and the inability to effectively meet the population’s medical needs. This requires the government to continue to provide strong support to grassroots medical institutions while taking various measures to attract talent and strengthen the training of existing medical personnel. To motivate and encourage grassroots medical personnel to take initiative in their work, it is also necessary to improve their salary levels and establish a robust performance appraisal and incentive mechanism. At the same time, it is necessary to consider the convenience of medical care from the perspective of residents and reasonably increase the number of grassroots medical institutions in accordance with local conditions. Standardized construction of 143 township health centers across the city will be carried out, and 962 village health rooms that do not meet the standards will be newly built, expanded, or renovated in batches. In addition, by conducting performance evaluations of medical staff at large hospitals and establishing a comprehensive and complementary medical and health service compensation incentive mechanism, expert physicians who regularly provide assistance and consultation services at grassroots medical institutions will be included in the evaluation scope, thereby achieving effective coordination of medical and health resources between large hospitals and grassroots medical institutions (25). Finally, with the advent of the information age, leveraging the internet for remote network-based medical case analysis and providing diagnostic and treatment knowledge education to primary care medical staff can facilitate the downward flow of high-quality resources from large hospitals to primary care facilities (26).

Medical institutions at all levels should clarify their position in the health care service system and play their respective roles. The diagnosis and treatment of critical illnesses and difficult diseases are the main focus of tertiary hospitals. In addition to being responsible for providing technical guidance and training to primary healthcare organizations, county hospitals are also responsible for the diagnosis and treatment of critically ill patients, as well as for the treatment of generally difficult diseases. It also accepts patients who are in recovery after being referred by tertiary hospitals and is responsible for referring patients with difficult and complex diseases upward. Primary healthcare facilities should take advantage of their close connections with residents with the aim of thoroughly understanding their illnesses, providing them with the medicines they need, treating common and frequent diseases, and offering high-quality, reasonably priced medical services.

The current differences in reimbursement rates for various levels of medical institutions do not yet offer an effective incentive for participants to give preference to primary health care institutions. So the reimbursement rate gap between primary health care institutions and other health care institutions should be widened, and the proportion of reimbursement rates for visits to primary health care institutions should be appropriately increased. The use of the economic leverage of health insurance reimbursement and the adoption of differentiated reimbursement standards for different levels of medical institutions can standardize residents’ choice of medical institutions. On this basis, to promote an uninterrupted patient flow, the reimbursement rate should be increased for those who receive a first consultation and referral at the primary level and reduced for those who do not follow the prescribed procedures.