The hope gap: a qualitative analysis of tiered hypertension care in China

Despite China's tiered healthcare system positioning primary care as the cornerstone of hypertension management, patients' bypassing of community clinics for hospital care reveals a hope gap as an unequal institutional capacity to cultivate the resources essential for sustained condition management that quality- and trust-based explanations leave unexamined. Drawing on abductive thematic analysis of 24 semi-structured interviews with hypertensive patients in Shenzhen, and guided by Gili & Mangone's sociology of hope, this study explores how hope is socially mediated through patient-provider interactions across care levels and how these experiences of hope influence treatment-seeking decisions. Findings reveal that community clinics typically generated fragile, contingent forms of hope due to perceived limitations in expertise and resources, leading some patients to delay or avoid care. Hospitals, by contrast, offered structured and anticipatory hope, albeit undermined by overcrowding and long waits, reinforcing patients' preference for hospital care. Patients navigated these hope differentials, investing time, money, and effort to secure hope as a resource for managing hypertension. By conceptualising hope as relational, socially embedded, and structurally produced, the study advances a sociological understanding of systemic inequities in healthcare access and utilisation. Addressing the hope gap, rather than solely redistributing clinical resources, may be key to strengthening primary care and alleviating hospital strain in China and comparable tiered systems.