The action logic of the older adults about health-seeking in South Rural China

**Background:** China faces a rapidly aging population, with 60% of older adults living in rural areas and a chronic disease prevalence of 82.6%. Despite government investments in rural healthcare infrastructure—including universal health insurance coverage, village clinics within 15-minute walking distance, and free health management plans—health service utilization among rural older adults remains low. Only 37.4% had annual physical exams, and less than 30% of those with hypertension or diabetes received treatment. This study uses participatory rural appraisal (PRA) to explore the behavioral logic behind this low utilization.

**Methods:** This qualitative study employed PRA in 12 villages in southern China between November 2020 and January 2021. A total of 108 participants (49 males, 59 females; mean age 74.19 years, range 60–93) were recruited via purposive sampling. All had at least one chronic disease (e.g., hypertension, arthritis). Data collection included social and resource mapping, daily routine diagrams, and semi-structured interviews, conducted in Mandarin or Cantonese, then translated. Interviews lasted 20–50 minutes (mean 42.6 min). Data were analyzed using content analysis with NVivo 11. Ethical approval was obtained from Zhongshan Eye Center, Sun Yat-sen University.

**Key Results:** Three themes emerged: 1. **Perceptions of health status:** Participants defined health as the ability to perform routine chores and self-care. They normalized discomfort as a natural part of aging, only seeking care when illness prevented daily activities. For example, they said, 'being able to work and take care of themselves' means healthy. 2. **Prioritization of symptom relief over cure:** Older adults preferred informal self-treatment (e.g., over-the-counter medications, herbal remedies) over professional care. When they did seek medical help, they selectively followed advice that was most convenient and least disruptive to their lives. They aimed to banish symptoms and return to routine quickly, rather than cure the disease. 3. **'Unpredictable' troubles:** Participants feared that healthcare-seeking would disrupt their established life patterns, incur extra costs (transportation, lost labor), and lead to uncontrolled rehabilitation cycles. They were concerned about invasive tests causing 'energy damage' requiring expensive nutritious foods. Even free services (e.g., cataract surgery) were avoided due to perceived hidden costs.

Social and resource mapping revealed that participants' activity range was limited to the village (average distance to clinic 800 m), but only 11 of 108 reported visiting village clinics for health management. Daily routines showed ample leisure time, debunking the notion that time constraints prevented healthcare use.

**Clinical Implications:** The study highlights that healthcare accessibility is not merely physical or financial but also subjective. Rural older adults' health perceptions and cultural values lead to underutilization of modern medical services. Healthcare reform should focus on culturally adaptable health education, respecting local definitions of health and illness. Providers should acknowledge that patients prioritize symptom relief and maintaining daily life order over disease prevention. Building trust and addressing fears of 'unpredictable' consequences are essential. The concept of 'two-way' accessibility is proposed: resources exist but are perceived as 'inaccessible' by the elderly. Future interventions should empower communities through participatory approaches like PRA to bridge this gap.