Status and determinants of health services utilization among elderly migrants in China
Zhang et al. Global Health Research and Policy
Status and determinants of health services utilization among elderly migrants in China
Xiaofang Zhang 0
Bin Yu 1
Tiantian He 0
Peigang Wang 0
0 School of Health Sciences, Wuhan University , Wuhan , China
1 Department of Epidemiology, University of Florida , Gainesville, Florida , USA
Background: The household registration system in China places migrants in a vulnerable status regarding access to local public services, including limited access to health services. Most studies on migrants' health services utilization targeted on working-age migrants, and there has been a paucity of studies conducted among elderly migrants. This study aims to investigate the status of health services utilization and its influential factors among elderly migrants. Methods: Data (13,043 participants, 52.4% male, mean age 66.22 ± 6.20) were derived from the 2015 Migrant Dynamics Monitoring Survey. The outcome variable in the study was health services utilization, consisting of doctor visits, hospitalization and local inpatient care. The Behavioral Model of Health Service Use was applied to categorize the influential factors into three components, including predisposing, enabling and need factors. Multivariate logistic regression analysis was used to investigate the influential factors of the three components of health services utilization. Results: Of the total sample, 45.5% would visit a doctor when they were ill, 81.8% would prefer to be hospitalized when recommended by doctors, and 71.6% (those who were hospitalized) would choose to receive local inpatient care rather than going back to their hometown. Age, marital status, household income, years of residence, migration range, reasons for migration, size of friend network, health insurance type, local health insurance status and chronic disease status were significantly associated with health services utilization. Conclusion: A low level of local health services utilization was observed among elderly migrants. Enabling factors played important roles in promoting health services utilization among elderly migrants. Policy and decision makers may consider improving the capability for elderly migrants to access health services, such as increasing income and providing local health insurance.
Elderly migrants; Health services utilization; Influential factors
Migration in the world and in China
With the advancement of industrialization and urbanization,
a growing number of people are migrating from rural areas
to urban areas or from less developed countries to more
developed countries [
]. According to a World Bank report,
more than 247 million people migrated from their home
country to another country, with 750 million migrating
within countries . The large number of migrants presents
a global and public health challenge for health policy makers
and practitioners. In the past two decades, more Chinese
people have migrated from rural areas to urban areas to
pursue a higher quality of life. According to the sixth
nationwide population census in 2010, the number of
rural-to-urban migrants increased to 260 million,
accounting for 19.5% of the total population. Meanwhile,
the number of elderly migrants aged 60 years and older
reached 9.34 million [
]. With the aging of the national
population and the rising trend of entire family
migration, the number of elderly migrants is anticipated to
increase continuously in the future.
Challenging life of elderly migrants in urban areas
The quality of life among elderly migrants in the urban
areas is challenging, and requires more attention from
researchers and policy makers. In general, most elderly
migrants do not have a steady income to support themselves
as well as their family. Economically, they are partially or
fully dependent on their children. However, a considerable
number of the elderly are still active in the labor market
with extremely disadvantaged positions [
]. Most of them
are occupied in labor-intensive work with long working
hours, poor working environment, and low payment, such
as manufacturing or catering fields [
]. Elderly migrants
also have experienced much difficulty in integrating
themselves into urban life [
2, 7, 8
]. There are several possible
reasons. First, migrants leave their familiar social
environment in the place of origin with a loss of social capital and
face a series of problems due to differences in language,
living habits, poor ability to accept new things, social capital
reconstruction, and obstacles to interpersonal
]. Second, most elderly migrants live with their
children and may experience more conflicts with
intergeneration interactions. Especially in families with low
socio-economic status, there is always an imbalance
between taking care of the elderly and supporting the young,
and in most situations, the needs of the elderly are usually
ignored. These challenges and difficulties exert negative
effects on the health of the elderly migrants [
Limited health care services among elderly migrants
As the physiological functions of elderly migrants
deteriorate with age, they are at high risk of health-related
problems, such as cancer, fractures, hypertension and diabetes
], leading to a great need of health care services in the
urban area. Nevertheless, their migrant status in the
household registration system has prevented them from enjoying
the same social welfare as urban residents. In addition,
without local health insurance, elderly migrants have
limited access to health care services considering the high
costs and inconvenience in obtaining insurance
]. Surveys conducted among migrant workers
indicated that the utilization of health services was at a low
level both in the areas where migrants originated from and
in their new locations . Another study conducted in
Shenzhen, China, indicated that 55.1% of migrant workers
did not have health insurance and that 62.1% did not visit
a doctor when they were ill [
]. As the number of elderly
migrants continues to grow, the utilization of health care
services among elderly migrants in urban areas is of great
significance for public health and social harmony.
However, most studies on health care services utilization among
migrants have mostly focused on workers ranging from 20
to 50 years old, and few studies have paid attention to the
elderly migrants. One purpose of the study is to investigate
the status of health care services utilization among elderly
migrants by using national survey data.
Behavioral model of health service use
The Behavioral Model of Health Service Use, which was
put forward by Anderson at the University of Chicago in
1968, has received international recognition in
explaining influential factors of health services utilization [
This model explores factors from three components:
predisposing factors, enabling factors and need factors.
Predisposing factors refer to individual
sociodemographic characteristics that influence recognition of
health problems and need for health services, such as
gender, age and education. Enabling factors include
individual and community resources that facilitate the use of
services, such as income, insurance coverage, social
support from family and friends, and accessibility of
services. Need factors include the assessment of one’s
health condition, objective and professional evaluation
of need (e.g., diagnosed diseases), and a subjective
assessment (e.g., self-rated health). These three
components are integrated together, influencing the utilization
of health care services. Many scholars around the world
and in China have applied this model to investigate
health services utilization among different populations.
A study based on the 2013 Migrant Dynamics
Monitoring Survey Data in China indicated that predisposing
factors (e.g., gender, marital status), and enabling factors
(e.g., the duration of stay in the city of residence and
local health insurance) exerted significant effect on
health services utilization. Married females who have
lived in the area for a long time and have local health
insurance were more likely to visit a doctor when they
were ill [
]. Another study using the Korea Health
Panel Survey data indicated that need factors, such as
chronic diseases, were important determinants of using
physician and inpatient hospital services among Koreans
]. Further, one study conducted among first
generation Afghan migrants in Istanbul found that the
determinants of health care services utilization were income
and other enabling factors, such as family presence in
]. However, to our knowledge, no study has
applied the Behavioral Model to investigate health care
utilization among elderly migrants in China.
Purpose of study
This study aims to employ the Behavioral Model of
Health Service Use to investigate the status and
determinants of health services utilization among elderly
migrants. The ultimate purpose is to provide evidence for
developing future effective interventions and potential
policies to improve access to health services for
Data source and study sample
Data in the study were derived from the 2015 Migrant
Dynamics Monitoring Survey, an annual nationwide
cross-sectional survey sponsored by the National Health
and Family Planning Commission. The purpose of the
survey was to examine the socioeconomic status of
migrants, public health services utilization and family
planning management and services. The participants in this
survey were migrants aged 15 years and older, who did
not have local Hukou and had been residing at their
current location for more than one month. The
participants were selected by adopting a three-stage stratified
probability proportionate to size (PPS) sampling strategy.
Overall, 348 cities and 10,300 communities were
selected from 31 provinces and Xinjiang production and
construction corps based on the PPS method. Twenty
eligible individual migrants were randomly selected in
each selected community. A total of 206,000 participants
were recruited. Signed informed consent was collected.
For the purpose of this study, only migrants aged
60 years and older (born before May, 1955) were
included, yielding a final sample of 13,043, with a return
rate of 100.0%.
The survey was conducted using a paper-and-pencil,
self-administered questionnaire, and the participants
returned the questionnaire to the data collector after
completion. The survey was anonymous and
confidential, and the participants had the right to refuse to
answer questions or withdraw from the survey.
Three outcome variables were used to measure health
services utilization, including doctor visits,
hospitalization and local inpatient care. Doctor visits
were measured using the question, “How do you deal
with diseases with minor symptoms in daily life?” The
answer options included “1 = See a doctor”, and “0=Not
to see a doctor (self-medication or not taking any
measures)”. In the question, “minor symptoms” referred to
symptoms that make the patient feel uncomfortable but
do not have a serious effect on daily life. Hospitalization
was measured using the question, “In the past year, did
you get inpatient care when you were recommended to
be hospitalized by doctors?” with an answer option of “1
= Yes”, and “0 = No”. Local inpatient care was measured
using the question, “If you were hospitalized, where did
you get the treatment?” with answer options of “1 =
Local hospital”, and “0 = Hospital in hometown”.
Predisposing factors included age (in years), gender
(male/female), marital status (currently married/single,
single including unmarried, divorced and widowed),
Hukou (rural residence/urban residence) and education
(elementary school and below/middle school/high school
Enabling factors included monthly household income (less
than 3500 yuan/3501–7000 yuan/more than 7000 yuan),
migration characteristics, and health insurance status.
Migration characteristics were measured by duration of
migration (in years), the range of migration (across
provinces/across cities within a province/across counties
within a city), and reasons for migration (seeking jobs/
looking after children or grandchildren/ retirement or
keeping fit/others). Health insurance status included
health insurance types (New Rural Cooperative Medical
Scheme (NCMS), Urban Employment Medical Insurance
(UEMI), Urban Residents Medical Insurance (URMI),
Cooperative Medical Insurance for Urban and Rural
Residents (CMIURR) and free health services), and locations
where they were enrolled in insurance. According to the
difference in locations where they were enrolled in
insurance, health insurance was categorized into local health
insurance and hometown health insurance.
Need factors included chronic disease status and
selfrated health status. Chronic disease status was measured
using the question, “Did you suffer from hypertension or
diabetes diagnosed by physicians?” with options of “0 =
No”, and “1 = Yes”. Self-rated health status was measured
by asking “How do you feel about your health?” with
answer options of “1 = Poor”, “2 = Neutral” and “3 = Good”.
Descriptive statistics (frequency, percentage, mean (SD))
were used to describe the characteristics of the study
sample. A Chi-square test was used to analyze the
difference of health services utilization among elderly
migrants with different characteristics. Multivariate logistic
regression analysis was employed to further explore
factors influencing health services utilization. Statistical
analyses were conducted using SPSS, version 21.0 (IBM,
Armonk, North Castle, NY).
Characteristics of the study sample
The mean age of the sample was 66.22 (SD = 6.20) years
old and 52.4% were males. Most participants were married
(81.5%), had an education attainment of middle school
level and below (85.4%), and indicated legal rural
residences (67.0%). The duration of migration was 6.15 (SD =
6.51) years on average. The proportion of across-province
migration was the highest (42.8%), followed by across
cities within a province migration (31.8%), and across
counties within a city migration (25.4%). Three main reasons
for movement were taking care of children or
grandchildren (34.0%), retirement/keeping fit (32.8%) and seeking
jobs (23.4%). Overall, 92.2% of the participants had one
type of health insurance. Additionally, 22.2% of the
participants suffered from hypertension or diabetes.
Selfreported health status of poor, neutral and good were
10.9%, 43.9%, 45.2%, respectively (Table 1).
Health services utilization
The results in Table 2 indicate that when the elderly
migrants felt ill, 45.5% would see a doctor, 52.5% would
buy medicine in local dispensaries or bring medicine
from hometown and 2.0% would not take any measures.
In the past 12 months, 1283 (9.8%) of the elderly
migrants were recommended to be hospitalized by their
doctors. Among them, 81.8% received inpatient care and
18.2% did not. As for the reasons why they were not
hospitalized, responses of hospitalization being
unnecessary, economic hardship and inconvenience of obtaining
insurance reimbursement accounted for 40.2%, 22.2%
and 12.0%, respectively. Among the elderly who received
inpatient care, 71.6% chose local hospitals, 18.0% chose
hometown hospitals and 10.4% had been hospitalized in
both places (current city and hometown) or other places.
Factors associated with health services utilization
Chi-square test results in Table 3 indicate that the older,
female, single migrants with urban residence, high
school education or above, higher monthly household
income, short duration of migration, migration across
provinces, migration to take care of children or
grandchildren or illness treatment/retirement, more friends in
current residence, local health insurance, and with
chronic diseases were more likely to visit a doctor with
minor symptoms. People with higher household income,
migration for looking after children or grandchildren
and with chronic diseases were more likely to be
hospitalized when recommended by doctors. People with
migration time longer than 10 years, migration across
counties within a city, more friends in current residence,
and with local health insurance had a higher probability
of receiving local inpatient care.
Predictors of health services utilization
The results from multivariate logistic regression analysis
in Table 4 show that predisposing factors (i.e., age,
marital status), enabling factors (i.e., household income,
duration of residence, range of migration, reasons for
migration, size of friend network in current residence,
type of health insurance, location where they obtained
health insurance) and need factors (i.e., chronic diseases)
were significantly associated with doctor visits.
Compared to migrants aged 60–64 years, migrants aged 70
and older were more likely to see a doctor when they
were ill (OR = 1.23, P < 0.01). Compared to the migrants
with monthly household income less than 3500 yuan,
migrants with household income of more than 7000
yuan were more likely to see a doctor when they were ill
(OR = 1.65, P < 0.01). Elderly migrants who joined local
health insurance were more likely to see a doctor than
those who joined hometown health insurance (OR =
1.57, P < 0.01).
Household income and reasons for migration were
significantly associated with hospitalization. Compared to
the elderly migrants with monthly household income no
more than 3500 yuan, elderly with household income of
more than 7000 yuan were more likely to receive
inpatient care when they needed (OR = 1.89, P < 0.05).
Respondents who indicated descendants care (OR = 3.09, P
< 0.01) and retirement/keeping fit (OR = 1.83, P < 0.05)
as their migration reasons were more likely to be
hospitalized than those who migrated for work.
Local inpatient care was predicted by duration of stay
in the city of residence, the range of migration, friends’
number, and location where they joined health
insurance. Compared to migrants with a duration of
migration of less than 5 years, migration across provinces, the
elderly with migration duration more than 10 years (OR
= 2.64, P < 0.01), migration across counties within a city
(OR = 1.87, P < 0.01) were more likely to be hospitalized
in local hospitals. Elderly migrants with local health
insurance were more likely to receive local inpatient care
than those with hometown insurance (OR = 3.60, P <
0.01). Elderly respondents who had 5 or more friends in
their current residence were more likely to receive local
inpatient care than elderly respondents who indicated
fewer than 5 local friends (OR = 1.88, P < 0.01).
In this study, we used the data from the 2015 Migrant
Dynamics Monitoring Survey, and analyzed health
services utilization status among elderly migrants, and we
explored factors associated with the use of health
services, as guided by the Behavioral Model of Health
Service Use. The behavioral model focused on defining and
measuring equitable health care access to develop
policies and programs that promote optimal resource use.
This study was of great significance in providing
evidence for policy makers to develop appropriate
regulations and laws to improve health care services utilization
among elderly migrants.
Overall, elderly migrants used medical health services
at a relatively low level compared with the general
population. We found that more than half of the elderly
migrants did not see a doctor when they had a minor
illness, which was significantly higher than that of the
general population (54.5% vs.15.5%, respectively) [
The annual rate of hospitalization among elderly
migrants was 8.0%, smaller than half of that in the general
elderly population surveyed in the Fifth National Health
Service Survey (17.9%) [
]. Additionally, the proportion
of migrants without hospitalization to those who were
supposed to be hospitalized was 18.2%. The low level of
health services utilization among elderly can be
explained from two aspects. Elderly migrants could not
enjoy the same social welfare and public services as local
residents due to the restriction of household registration
system. There was also a lack of health care awareness
and health literacy among elderly migrants, leading to
an underestimation of their health services needs.
The Behavioral Model of Health Service Use consists
of three components, including predisposing factors,
enabling factors and need factors, all of which can
influence the health services utilization. Predisposing factors
are not directly related to health services use, but can
exert effects on health services use through enabling
factors and need factors. Enabling factors are indirect
influential factors while need factors are direct influential
factors of health services use. In this study, we found
that relative to predisposing and need factors, enabling
factors contributed a lot to the health services utilization
among elderly migrants.
Elderly migrants with increasing age were more likely
to visit doctors with minor symptoms. It is possible that
the oldest migrants were more concerned about their
health. The study also indicated that a considerable
number of elderly participants did not visit doctors when
they suffered from diseases with minor symptoms, but
they treated the illness by using the medicine bought in
dispensaries or did not take any measures at all. This
finding may be due to the absence of scientific health
knowledge among the elderly. Usually, they did not have
appropriate insight of illness symptoms, and often
adopted negative attitudes toward curative services.
Failure to promptly seek medical treatment caused the
deterioration of illness, leading to more demands for
health services [
]. The absence of health care
awareness and risk perception of the elderly deserves prompt
attention from health departments. More health
education campaigns should be implemented to popularize
health knowledge and improve health literacy.
Enabling factors consist of household income,
duration of migration, migration range, reasons for
migration, number of friends, and locations where they
enrolled in health insurance. Elderly migrants with
higher household income were more likely to visit
doctors when they suffered from diseases with minor
symptoms and the proportion of utilizing inpatient services
was also higher compared to migrants with low income.
Due to limited benefits from local social welfare, elderly
migrants relied more on individual or family resources
for medical services [
]. This finding was consistent with
previous studies about the influence of income on health
services utilization [
]. A study conducted among
middle-aged and elderly individuals in Gansu, China,
showed a pro-rich inequality in both outpatient and
inpatient utilization [
]. Economic hardship has been
proved to be one of the main barriers for migrants
accessing health services [
]. Due to the low capability
to pay for the medical services expenses, migrants
usually do not choose to go to the hospital until they
perceive themselves to be seriously ill, after experimenting
failures with a series of ineffective health-seeking
behaviors such as unsupervised self-treatment, unregulated
clinics, or “just holding on” [
Another important reason underlying the low utilization
of health care services among elderly migrants was that
they were not entitled to receive local health insurance
and couldn’t utilize local medical resources as the urban
residents do. Among migrants underinsured, 88.5% of
them had health insurance from their original hometown;
only 11.4% had a more accepted, local health insurance.
Due to the limitations of local administration, the usage of
hometown insurance in their living and working cities was
faced with a series of barriers, such as inconvenient access
to health services, complicated procedures, and low
reimbursement rates [
]. This study also explored whether
the location where elderly migrants enrolled in health
insurance influenced health services utilization, and found
that elderly migrants with local health insurance were
more likely to visit a doctor when they were ill and choose
local hospitalization. The status of health services
utilization was obviously better than that of those who
enrolled in their hometown health insurance. Migrants
without local health insurance were limited to access medical
services, which should be noted by health administration.
More social welfare benefits should be provided by the
government to improve elderly socioeconomic status in
urban areas and lower qualifications for the elderly
migrants to join the local health insurance.
The findings of the study indicate that migrants who
originated from the counties within the same city, had
longer duration of stay, and had more friends in the city
of residence were more likely to use local inpatient
services. This finding may be attributed to the fact that they
had more social cohesion in their current locations and
had better knowledge about local medical services [
Previous studies confirmed that more friends in current
residence can help migrants reconstruct relatively rich
social network, have greater social capital and get more
functional and emotional social support [
migrants with good social support could get access to
better medical services . Therefore, more community
activities should be organized to strengthen the social
networks of elderly migrants, assisting them in
integrating into urban life and finding a sense of belonging. Few
studies have been conducted to investigate the influence
of migration reasons on health services utilization. In
this study, we found that elderly migration for business
were the more vulnerable group in accessing to health
services. It was possible that the difference of health
services utilization among the elderly with different reasons
for migration may be related with their family economic
status. The study also found that the elderly migrating to
take care of descendants or live out their life in
retirement usually had better family socioeconomic status.
Need factors are important factors influencing health
services utilization. Two need factors, chronic disease
status and self-rated health status, were investigated in
the study. Elderly migrants with chronic diseases were
more likely to visit doctors when they suffered from
minor illnesses. People in poor health had more need for
medical care and incurred more health services
There are limitations in the study. First, the data used
in the study were cross-sectional in nature, and no
causal relationship could be detected without
longitudinal data. Second, the study investigated the possibility
of accessing services rather than the actual detailed
behaviors of utilization. Third, the study was
selfreported, and elderly migrants may have difficulties in
memorizing their health services utilization for the past
year. Recall bias could not be ruled out.
This is the first study to apply the Behavioral Model of
Health Service Use to investigate health care services
use among elderly migrants in China. Elderly migrants
utilized health care services at a relatively low level.
Enabling factors, such as family economic status, health
insurance and migration experience were important
factors influencing health-seeking behaviors. Elderly
migrants with low household income and without local
health insurance were disadvantageous groups in
utilizing local medical services. Recognizing the heterogeneity
of elderly migrants, our findings recommend that policy
makers may put more attention on these vulnerable
populations and take targeted measures to optimize
access to and utilization of health care services by elderly
migrants in need of medical care.
CMIURR: Cooperative Medical Insurance for Urban and Rural Residents;
NCMS: New Rural Cooperative Medical Scheme; PPS: probability
proportionate to size; UEMI: Urban Employment Medical Insurance;
URMI: Urban Residents Medical Insurance
Thanks for the suggestion provided by Junfeng Jiang in the revision of the
Wuhan University Population and Health Young Academic Team (Whu2016026).
Availability of data and materials
The datasets used and analyzed during the current study are available from
the corresponding author on reasonable request.
XZ contributed to the manuscript preparation, data analysis and wrote the
first draft of the manuscript. BY gave critical comments on the initial draft.
TH checked the analysis of the data. PW conceived the study and helped
revise the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
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