| BackgroundThe shortage and uneven distribution of healthcare resources is an issue globally.The rapid development of the Internet and Communication Technology(ICT)provides the alternative routes for healthcare quality and accessibility enhancement.In our western rural areas,the main barriers in health system are insufficient health workers and deficiency capacity,coupled with the geographical and economic obstacles for residents to receive health care services.The role of ICT is be accounted to health access enhancement for its efficiency,timely and interactive characteristics.The health-related services provided through the Internet has become an important supplementary part for traditional health system,which can provide conveniently and efficiently about health information and services to meet their diverse needs.At the same time,the development of online health services may also increase the inequitably usage of healthcare.The World Health Organization mentioned that the health outcomes must be the central mission for the online health strategy,and the origin and impetus for it was the health demand.The inadequate demanding among residents in western rural areas for online health services is a bottleneck for long-term sustainable development.Based on the literature review,most of the theoretical frameworks of studies in online healthcare were technical theories,which ignored the essence of health services,to meet the health demand and improve health outcomes.To improve the capability for improving the access in western rural areas,studies need to be focused on health needs,as well as the health demanding,residents’ ability and willingness to pay for the online health services.And the participants can be residents in rural and remote areas,in which the limited health resources urge the ICT to play a role in health access improvement.ObjectivesStudies are insufficient and superficial on China’s online health services,especially for resident in western rural areas.The research questions we want to figure out in this study are as follows:1)How to explore the factors based on the health service utilization model of online health service utilization from the demand side?2)How is the characteristics of online health services usage among residents in western rural areas?Is the online health services utilization health-oriented?3)Are residents in western rural areas willing to choose online health services when they encounter health problems?4)Are residents in remote rural areas willing to pay for online health services?Based on the research questions,the aim of our study is to explore the characteristics of utilization,willingness to choose and willingness to pay for online health services among residents in western rural areas in China,and to provide the evidence for develop online health services in remote rural areas from the perspective of demand side.Specific objectives:to comprehensively understand the utilization status and influencing factors of online health services in western rural areas,to build online health service utilization and selection analysis models,to reveal factors of utilization and willingness to pay for online health service,to explore the relationship between willingness to pay and prices for online health services,and to provide policy recommendations for the development of online health services in western rural areas.The western province Ningxia was selected for its remote location and policy implications.The theoretical and practical meaning of our study are as follows,providing theoretical support from health demanding and utilization other than the theories based on technology acceptance,and providing adaptive policy evidence from western rural areas.MethodsThe theoretical framework of our study was built based on the classical Anderson health service utilization model,which is widely accepted and implemented in health system.Two types of utilization indicators were analyzed in the study,which are the actual usage of online health services,and the willingness to use them.Four kinds of services were classified based on the WHO’s eHealth guidelines and the situation in China,included online health information acquisition,online consultation,online communication with physicians and other activities.The willingness to use the online services included the ability to pay,the willingness to choose in some virtual scenarios and the values of willingness to pay.The independent variables were determined according to the Anderson model,which included households’ enabling resources,social structure characteristics,health needs,and access to health institutions.The cross-sectional survey was conducted in rural areas in 4 counties/districts from Ningxia from June to July 2018.A total of 1354 households from 49 villages were selected by a multi-stage stratified cluster random sampling method.1354 key informants from the selected households,who were familiar with the health needs and utilization of the family and aged lower than 65.At the same time,the primary health care facilities of the selected villages and towns were surveyed and interviewed.32 residents,primary health workers from village clinic and town hospitals were interviewed.The statistic description and univariate analysis were used to describe the characteristics of online healthcare utilization and willingness,and logit models were used to analyze the determinant of online health services utilization and chose.The Extended Linear Expenditure System Model was used to access the respondents’ ability to pay.A two-step analysis model was conducted on the willingness to pay analysis,which included the determinants of willingness to choose and the specific values of willingness to pay.The Tobit regression model was used to determinants of willingness to pay values,and the price elasticity coefficient were calculated based on the demand curves fitted by the willingness to pay values.Results1.Characteristic of the respondents Ningxia local government has taken the lead position national on the online healthcare development and policy strategies.The 5-level mHealth service system has been built up,which covers primary health institution,comprehensive hospitals in Ningxia and national wide,and has improved the primary healthcare capacity.The Internet hospital cooperated by Yinchuan,the capital city and Internet health company Haodaifu online,is another initiative action in online service providing.The data we obtained from the website showed that the average price of online consultation was 65.52±67.87 yuan,and the price was determined by the providers’ levels,hospitals,cities,and regions.The 4 counties/districts we chose for the survey is representative on characteristics economical,geographic,and health resources.1354 respondents were investigated,with an average age of 44.54±10.22 years,two-thirds Han(67.95%);and half(47.78%)were women.85.82%of surveyed households had access to the Internet,and the average health knowledge score 3.57±1.18.The surveyed households’average income of past year(2017)was 39,150.17 ± 51196.30 yuan,and average distance to county was 21.39±30.04 kilometers.In terms of health needs characteristics,30%households had members who aged 60 or members aged 5 or lower,while 512 had outpatients in the past mouth or 486 had inpatients in the past year,accounting for 37.81%and 35.89%respectively.2.The utilization online health services 640 households had used one or two or more online health services(including online health information inquiry,online consultation,online communication with doctors,and other types),accounting for 47.27%.The most frequent usage was online health information obtaining,which accounted for 37.08%,while the percentage of online consultation usage was 7.24%,and online communication with doctors was 15.51%.In general,the social structure,enabling resources,health needs,and access to health services of survey respondents had an impact on the use of online health services.From the perspective of social structure,education level had an important influence on the use of online health services.Among enabling resources,higher health knowledge scores and income levels promoted the use of online health services.Among the health needs factors of the surveyed households,the use of online health services was related to chronic patients in the households,family members’ illness in the past month,and family members’hospitalization in the past year.In terms of access to health services,families who are far away from city-level hospitals are more likely to use various health services provided by the Internet.Other types of online health services had similar usage characteristics.From the perspective of the actual use of online health services,the most important determinants of whether or not use online health services were social structural factors,especially education and occupational status.Health needs characteristics were only secondary factors affecting utilization.Therefore,the surveyed respondents’ overall usage to online health services were not demand-oriented,and it didn’t reflect the health equality.3.The ability to pay and willingness to choose for online health services Three types of households were categized based on the ability to pay for online health services,which was calculated by the Extended Linear Expenditure System Model.Households with less than 5301.33 yuan a per capita income were defined as without ability to pay,which were accounted for 6.57%.The households with annual per capita income between 5301.33 yuan and 19562.19 yuan had weak ability to pay and accounted for 22.60%,while other households with higher than 19,562.19 yuan were 70.83%of the total.Under the health consultation scenario,60.27%of the households would choose to consult online for the doctors from the secondary hospital or 62.48%for doctors from tertiary hospitals online.When the health problems involved privacy,the percentage would 55.24%and 58.94%,respectively.The social structure,enabling resources,health needs,access to health services,and online consultation experience of the respondents were the determinants of the choosing of online consultation services in health consultation scenarios.Under the test confirmation scenario,57.09%and 60.93%of the households were willing to use online confirmation from doctors in secondary or tertiary hospitals respectively,while if the service was provided by local primary hospitals 62.32%and 66.54%households were willing to consult doctors in secondary or tertiary hospitals.Households that chose the online test confirmation services were those with higher education levels,higher incomes,higher health demanding,like family members as the chronic disease patients,inpatients and outpatients.4.Willingness to pay for online health services In the health consultation scenario,the average values of willingness to pay for who were willing to choose the online services provided by doctor from secondary or tertiary hospital were 65.69± 97.36 yuan and 97.98 ± 119.73 yuan,and the median values were 30 yuan and 50 yuan respectively.The influencing factors of willingness to pay values included the ethnicity,health need characteristics and accessibility of health institutions and the previous online consultation experiences.The demand curves,which were fitted by the willingness to pay values,saw a downward trend as the price rising,at the same price level,more households chose online consultation services provided by doctors from tertiary hospitals.The price elasticity of demand saw an upward trend as the price increasing in the online health consultation scenario.When the price was 56 yuan or 87 yuan,the price elasticity of demand was 1 if the online services were provided by doctors from the secondary or tertiary hospitals respectively.If the health consultation scenario involved privacy information,the average values of willingness to pay were 65.87±93.71 yuan or 100.37 ± 123.25 yuan,with median values of 30 yuan or 50 yuan for services provided by doctors from secondary or tertiary hospitals.When the price was 56 yuan or 89 yuan,the price elasticity of demand was 1.In the test confirmation scenario,the average willingness to pay values were 82.18 ± 105.18 yuan or 121.54 ±136.29 yuan for online services provided by doctors from secondary or tertiary hospital,and the median values were 50 yuan and 80 yuan,respectively.When the online services were provided by local primary institutions,the average willingness to pay values were 87.00 ± 109.25 yuan or 131.80 ± 141.41 yuan for the services provided by doctors from the secondary or tertiary hospitals,while the median values of willingness to pay were 50 or 90 yuan.When the price was 75 yuan or 119 yuan,the price elasticity of demand was 1 for online health services provided by doctors in secondary and tertiary hospitals.Discussion and Policy ImplicationsThe main findings of the study were as follows:The Internet has played an important role in health information and related services requirements in western rural areas in China.The utilization of online services was determined by the social economic characteristics,rather than the health needs,which may lead to the digital divide and health inequity for the health-related Internet usage.Residents in western rural areas have a rather high willingness to choose the online consultation services,as well as pay some fee for the services.The online health services conducted in Ningxia need to be health demand oriented to be attainable development.According to results and discussion,the following policy recommendations were put forward:1)Online health services should be provided based on the health demand,rather than the supply or the technology.2)The health education contents focus on rural residents can be enlarged to online literacy,which includes how to get the services and information online,the skills to search online,the ability to identify health information.3)Strengthen the enrollment and supervision policies for online health services to build the friendly and well-organized online health service environment.4)Pay more attention to those who have low-income or low-education groups,who may have diversified online health needs.5)Take maximum advantage of the online health service to strengthen the health system in western rural areas.6)Establish financing and sustainable development mechanisms,which is essential for the online health service providing.7)The whole society involvement to promote the development of online health services.Innovations and limitationsInnovations:The innovations of the study are as follows,1)We chose the western rural areas and residents there to conduct our study,which can provide direct evidence for Internet Communication Technology to improve access to health services in the poor accessibility regions in western rural areas.2)We chose the actual and potential utilization and the determinations from the perspective of the demand side,and explored the willingness to choose,ability to pay,and willingness to pay for online health services.The double-border binary method was used to get the willingness to pay values in our investigation,which can get the accurate values.3)Our study provides the demand price elasticity under our scenario,which can be reference for the financial and pricing policies in the emerging online health service areas.Limitations:At the same time,our study has some limitations.1)The cross-sectional design can only provide factors that influence the online services utilization,and the causal inference requires more in-depth,longer-term studies in the future.2)The hypothesis scenario in our study was simplified,and the description of the service providers only identified by the hospitals.However,the actual situation is more complex.Future research can explore the potential demand of online consultation service for chronic diseases.3)New types of online services are emerging endlessly under the rapid development of the Internet and Communication Technology.Under this situation,we may ignore some kind of new services,such as use of health-related apps,online medical services,etc. |
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