Confidence in China's healthcare system : a focus on lower-middle class

Background During the post-pandemic era, there has been growing anxiety regarding health security, especially among the middle class worldwide. The public's confidence in the healthcare system encompasses their expectations and perceptions of the healthcare system's ability to meet their needs without financial hardship. This study aims to examine the disparities of confidence and to identify potential vulnerable subgroups. Methods Adopting the China General Social Survey (CGSS) 2021, we performed multivariate logistic regression to analyze the associations between confidence level and socioeconomic classes, controlling for demographics. Results Among all respondents (n = 2341), 71% reported confidence. However, respondents identified as lower- middle class had the least likelihood of reporting confidence (OR = 0.64, p = 0.006) compared to the lowest social class. De facto married respondents had 21% lower odds of confidence (OR = 0.78, p = 0.046) compared to unpartnered respondents. Conclusions Our findings reveal that, contrary to expectations, the lower-middle class in China-rather than the lowest social strata-exhibits the least confidence in the healthcare system. This low confidence appears closely linked to heightened insecurity about downward social mobility stemming from catastrophic healthcare expenditure. Moreover, married individuals also revealed low level of confidence in the healthcare system. These results underscore the urgent need for universal healthcare policies in China and similar emerging economies that specifically address the unique health security concerns of the lower-middle class and consider the dynamics inherent in marriages and families associat