From Habit to Justification: A Dual Process Theory Approach to Primary Care Bypassing in China

China's tiered healthcare system is designed to guide patients through a two-way referral process, with primary care as the first point of contact. However, prevalent bypassing of lower-tier facilities undermines the system's effectiveness. While previous research has examined healthcare choices, the cognitive drivers of bypassing behaviour remain insufficiently understood. A case study design was employed, involving 23 semi-structured interviews with hypertensive patients in Shenzhen. Deductive thematic analysis, guided by dual process theory, explored the cognitive mechanisms underlying bypassing, focusing on intuitive (System 1) and deliberative (System 2) decision-making. Bypassing behaviour emerged from the interplay between Systems 1 and 2 processes. System 1, driven by automatic heuristics, reinforced habitual hospital use and social norms, maintaining status quo bias and the belief that tertiary hospitals offer superior care. System 2, involving reflective risk assessment, led patients to favour hospitals due to concerns over service quality and adequacy. Importantly, System 1 established bypassing as the default, while System 2 provided retrospective justifications, entrenching this decision. However, a subset of patients, influenced by health status and personal circumstances, exhibited more flexibility, opting for primary care for convenience or accessibility. This delineates the cognitive model's boundary conditions, revealing that behavioural outcomes are not deterministic but contingent on individual and situational factors. The application of dual process theory offers a nuanced understanding of bypassing behaviour within China's tiered healthcare system, emphasising the roles of both instinctive and analytical cognitive processes. Findings suggest the need for multidimensional interventions targeting both cognitive pathways to improve primary care utilisation.