Demographic and social contacts
The analytical sample included 1544 internal elderly migrants across four districts. Our sample was 55.6% male, and the mean age was 66.34 years (SD, 5.94), 50.2% of which were in the 60 to 64 age range. On average, we observed a low level of education: 88.6% of the individuals had received an education of high school or below. 78.2% were married, and 94.7% rated their health as healthy or basically healthy. Most of the respondents (74.7%) were in the eastern region. The 25% to 75% interquartile range of the migrants’ average monthly household income was 5,000-12,000 RMB (or US$784 to US$1881).Gender (p < 0.05), age (p < 0.01) and regional classification (p < 0.001) were related to participation (or lack of participation) in free medical check-ups at community health service organizations in the prior year.
In terms of medical insurance, more than half of them (52.5%) had New Rural Cooperative Medical Care Insurance, which means that the majority of internal elderly migrants came from rural areas. This was followed by Urban Employee Medical Insurance (22.8%), Urban Residents Medical Insurance (9.7%), Urban and Rural Residents Cooperative Medical Insurance (4.0%), Free Medical Service (2.1%), and, for 8.9%, no medical insurance. As regards local friends, the average number of local friends was 8.29 (SD, 11.90), but 12.9% had no local friends. The distribution of the number of friends was relatively balanced, with local friends numbering from 1 to more than 10. With respect to exercise time, 5.2% did not exercise, and most (62.2%) of the exercise time was within 60 minutes per day. Further statistical analysis shows that gender, age, number of local friends (p < 0.001) and exercise time per day (p < 0.01) were associated with the utilization of primary health care among internal elderly migrants. It was interesting to note that the elders’ physical condition was irrelevant to their participation in free medical check-ups.(Table 2).
Table 2 Demographic and social contacts of internal elderly migrants (n = 1544)
|
N(%)(n = 1544) |
Number of people attending community free medical examinations (%)(n = 511) |
Gender* (χ2 = 4.757, p = 0.029) |
|
|
Male |
858(55.6) |
304(59.5) |
Female |
686(44.4) |
207(40.5) |
Age** (χ2 = 13.28, p = 0.01) |
|
|
60-64 |
775(50.2) |
229(44.8) |
65-69 |
387(25.1) |
132(25.8) |
70-74 |
208(13.5) |
75(14.7) |
75-79 |
125(8.1) |
54(10.6) |
80- |
49(3.2) |
21(4.1) |
Education |
|
|
Primary school or below |
683(44.2) |
218(42.7) |
Middle and high schools |
685(44.4) |
232(45.4) |
College and above |
176(11.4) |
61(11.9) |
Marital status |
|
|
Married |
1208(78.2) |
397(77.7) |
Single |
336(21.8) |
114(22.3) |
Physical condition |
|
|
Healthy |
837(54.2) |
284(55.6) |
Basically healthy |
626(40.5) |
201(39.3) |
Unhealthy, but can take care of themselves |
69(4.5) |
25(4.9) |
Unhealthy, and cannot take care of themselves |
12(0.8) |
1(0.2) |
Regional classification*** (χ2 = 81.224, p = 0.000) |
|
|
Eastern Region |
1153(74.7) |
325(63.6) |
Central Region |
46(3.0) |
14(2.7) |
Western Region |
169(10.9) |
106(20.7) |
Northeast Region |
176(11.4) |
66(12.9) |
Medical insurance |
|
|
None |
138(8.9) |
39(7.6) |
New Rural Cooperative Medical Scheme (NCMS) |
811(52.5) |
272(53.2) |
Urban and Rural Resident Cooperative Medical Insurance |
62(4.0) |
26(5.1) |
Urban Resident Basic Medical Insurance (URBMI) |
149(9.7) |
43(8.4) |
Urban Employee Basic Medical Insurance (UEBMI) |
352(22.8) |
121(23.7) |
Free Medical Service |
32(2.1) |
10(2.0) |
Number of local friends*** (χ2 = 59.398, p = 0.000) |
|
|
0 |
199(12.9) |
23(4.5) |
1-2 |
248(16.1) |
74(14.5) |
3-4 |
233(15.1) |
76(14.9) |
5-6 |
262(17.0) |
95(18.6) |
7-8 |
91(5.9) |
37(7.2) |
9-10 |
236(15.3) |
90(17.6) |
Above 10 |
275(17.8) |
116(22.7) |
Exercise time per day** (χ2 = 15.536, p = 0.008) |
|
|
0 |
81(5.2) |
14(2.7) |
Within 30 minutes |
352(22.8) |
116(22.7) |
31-60 minutes |
608(39.4) |
206(40.3) |
61-90 minutes |
61(4.0) |
29(5.7) |
91-120 minutes |
335(21.7) |
108(21.1) |
Over 120 minutes |
106(6.9) |
38(7.4) |
*p < 0.05; ** p < 0.01;***p < 0.001
Utilization of PHC
As a national basic public health service project, elderly people over the age of 60 can receive free medical check-up services in community health service institutions where primary health care is delivered mainly. Elders are not restricted by their household registration, as long as they have lived in their community for more than six months. In our study, on average, 33.1% of internal elderly migrants had participated in a free medical check-up offered by a community organization within the previous year.
Association between variables and Utilization of PHC
An associative model was constructed sequentially, first by entering the demographic and region variables (model I), then adding the income and health status variables (model II), and finally the other variables (model III). The models are displayed in Table 3 along with odds ratios (OR) and 95% confidence intervals for OR. The collinearity analysis shows that the tolerances of all independent variables are much greater than 0.1, and the variance inflation factors are less than 10, hence multi-collinearity does not exist.
In the model with demographic and regional variables (Model I), age and region were significant predictors of primary health care use. When socioeconomic and health variables were added, both of them remained significant. Of the other variables, an unexpected finding was that average monthly household income was a risk factor for primary health care use (Model II, OR=0.846). The social contact variables, when added, all showed positive association with the utilization of primary health care (Model III, Figure 1). The forest map of the OR values in Model III shows the significance of sociacontact more intuitively (Figure 1). Other variables that remained significantly associated were age and region. Comparing the results of Model II and Model III, we believe that for internal elderly migrants, economic income had an influence in their utilization of primary health care by virtue of the social opportunities it provided for them (table 3).
Evidence from correlation analysis suggested a significant variation across regions in utilization of primary health care. Therefore, regional classification and demographic characteristics were controlled in logistic regression Model III with regions as fixed effects. The Hosmer and Lemeshow test indicated that the P value (P = 0.908) was greater than the inspection level (0.05), which meant that the information in the current data had been completely extracted. The percentage accuracy in classification was 70.4%, suggesting that the means regression model could correctly classify 70.4% of the observations. The odd ratios of the association between social contact and utilization of primary health care are showed in Model III.
Results in Model III also show that age impacts the utilization of primary health care significantly. The probability that respondents more than 75 years old used PHC was more than twice as high as for 60-64-year-olds (OR = 2.099, 95% CI: 1.349-3.265; OR = 2.171, 95% CI: 1.111-4.243). Gender, education, marital status, family average monthly income, and physical condition had no association with the utilization of primary health care. Respondents in different regions had a different probability of using primary health care; internal elderly migrants in the western region even had fourfold higher odds than those in eastern region (OR = 4.191, 95% CI: 2.902-6.053), where the relatively developed cities are located, such as Beijing, Shanghai, Guangzhou, Hangzhou, etc.; those in the northeast region (Dalian) had 55% (OR = 1.555, 95% CI: 1.093-2.211) higher odds than those who lived in the eastern region.
No matter the region, Associations tended to be stronger for the number of local friends than for the other factors (p < 0.001). Respondents who reported having local friends had an almost triple (OR = 2.859, 95% CI: 1.677-4.875) or more than fourfold (OR = 4.607, 95% CI: 2.709-7.837) higher odds of utilizing primary health care than those without local friends. In short, the more local friends, the more likely respondents were to use primary health care. Similarly, respondents who had social medical insurance care had higher odds of utilizing primary health care compared to those who did not have medical insurance, especially for the people who had Urban and Rural Residents Cooperative Medical Insurance (OR = 2.370, 95% CI: 1.213-4.632). Respondents who exercised for 61-90 minutes per day had more than triple (OR = 3.515, 95% CI: 1.538-8.032) the odds of utilizing primary health care than those who did not exercise as much. In a word, internal elderly migrants who had Urban and Rural Resident Cooperative Medical Insurance, many local friends, and engaged in 61-90 minutes of exercise time were more inclined to use primary health care (table 3, Figure 1).
Table 3 Results of Binary Logistic Regression of the Relationship between variables and Utilization of Primary Health Care among Internal Elderly Migrants in China
|
Model I |
Model II |
Model III |
|
Demographic + region |
Model I+ socioeconomic and Physical conditions |
Model II + social integration |
|
OR |
95% C. I. |
OR |
95% C. I. |
OR |
95% C. I. |
Gender |
0.819 |
0.648-1.034 |
0.836 |
0.661-1.058 |
0.889 |
0.698-1.134 |
Age (years) |
|
|
|
|
|
|
60-64 |
- |
- |
- |
- |
- |
- |
65-69 |
1.259 |
0.962-1.648 |
1.257 |
0.959-1.649 |
1.403* |
1.058-1.861 |
70-74 |
1.295 |
0.924-1.815 |
1.315 |
0.935-1.851 |
1.420 |
0.999-2.018 |
75-79 |
1.665* |
1.105-2.510 |
1.804** |
1.182-2.754 |
2.099*** |
1.349-3.265 |
80- |
1.617 |
0.862-3.036 |
1.782 |
0.940-3.380 |
2.171* |
1.111-4.243 |
Education |
|
|
|
|
|
|
Primary school or below |
- |
- |
|
- |
- |
- |
Middle and high schools |
1.240 |
0.970-1.585 |
1.258 |
0.982-1.611 |
1.214 |
0.925-1.594 |
College and above |
1.334 |
0.917-1.941 |
1.363 |
0.935-1.851 |
1.245 |
0.814-1.905 |
Marital status |
|
|
|
|
|
|
Married |
1.0 |
- |
1.0 |
- |
1.0 |
- |
Single |
0.949 |
0.707-1.257 |
0.987 |
0.734-1.329 |
1.008 |
0.740-1.374 |
Region classification |
|
|
|
|
|
|
Eastern region |
1.0 |
- |
1.0 |
- |
1.0 |
- |
Central region |
1.331 |
0.693-2.556 |
1.328 |
0.690-2.557 |
1.312 |
0.662-2.597 |
Western region |
4.525*** |
3.195-6.409 |
4.650*** |
3.268-6.617 |
4.191*** |
2.902-6.053 |
Northeast region |
1.500* |
1.073-2.097 |
1.544** |
1.101-2.165 |
1.555* |
1.093-2.211 |
Average monthly household income |
|
|
0.846* |
0.722-0.991 |
0.885 |
0.758-1.033 |
Physical conditions |
|
|
|
|
|
|
Healthy |
|
|
- |
- |
- |
- |
Basically healthy |
|
|
0.862 |
0.683-1.089 |
0.866 |
0.680-1.103 |
Unhealthy, but can take care of themselves |
|
|
0.890 |
0.512-1.574 |
1.011 |
0.567-1.805 |
Cannot take care of themselves |
|
|
0.104* |
0.013-0.861 |
0.211 |
0.024-1.865 |
Medical insurance |
|
|
|
|
|
|
None |
|
|
|
|
- |
- |
New rural cooperative medical care insurance |
|
|
|
|
1.560* |
1.016-2.394 |
Urban and Rural Resident Cooperative Medical Insurance |
|
|
|
|
2.370* |
1.213-4.632 |
Urban Residents Medical Insurance |
|
|
|
|
1.062 |
0.609-1.852 |
Urban Employee Medical Insurance |
|
|
|
|
1.260 |
0.779-2.037 |
Free Medical care |
|
|
|
|
0.842 |
0.344-2.060 |
Number of local friends |
|
|
|
|
|
|
0 |
|
|
|
|
- |
- |
1-2 |
|
|
|
|
2.859*** |
1.677-4.875 |
3-4 |
|
|
|
|
3.318*** |
1.943-5.665 |
5-6 |
|
|
|
|
3.945*** |
2.341-6.648 |
7-8 |
|
|
|
|
4.391*** |
2.320-8.309 |
9-10 |
|
|
|
|
4.377*** |
2.580-7.426 |
Above 10 |
|
|
|
|
4.607*** |
2.709-7.834 |
Exercise time per day |
|
|
|
|
|
|
0 |
|
|
|
|
1.0 |
- |
Within 30 minutes |
|
|
|
|
1.661 |
0.852-3.238 |
31-60 minutes |
|
|
|
|
1.804 |
0.943-3.451 |
61-90 minutes |
|
|
|
|
3.515** |
1.538-8.032 |
91-120 minutes |
|
|
|
|
1.526 |
0.777-2.997 |
Over 120 minutes |
|
|
|
|
1.320 |
0.613-2.840 |
*p < 0.05; **p < 0.01;***p < 0.001,” -” was reference, C.I. = confidence interval
Figure 1 Association between Social contacts and Utilization of Primary Health Care