Relationship between subjective socioeconomic status and sense of gain of health-care reform and the mediating role of self-rated health: a cross-sectional study in China

“Difficult and Expensive Medical Treatment” is a serious health problem that has always existed in China and other countries. Since China launched the new health-care reform in 2009, a series of favourable policies have been introduced, and staged progress has been made including but not limited to the following aspects: hierarchical diagnosis and treatment, modern hospital management, universal medical insurance, drug supply guarantees and comprehensive supervision [1‐4]. Important health indicators in China beyond the average level of high-income countries and objective indicators such as maternal mortality, infant survival rate and average life expectancy have shown that China’s health service capacity and health of the public have been improved [5]. Evidence from existing research suggests that China’s new healthcare reform offers valuable lessons for the world, especially reflected in the coverage and service quality of primary health care [6‐8]. Although the Chinese government has continuously increased its investment in medical and health-care and various objective indicators have reflected the results of this comprehensive measure, what is the actual benefit to the public? Classical indicators such as satisfaction, well-being and subjective quality of life are typically used to measure the public’s subjective evaluation of the effectiveness of health services, but some experts believe that such indicators are too vague and often difficult to base themselves on objective actual needs, which is not in line with the current reform background in China [9‐12]. Therefore, a suitable evaluation index is needed to explain how people feel about the dividend based on the results of health-care reform.

‘Sense of gain’, a social psychology concept to evaluate the effectiveness of a specific reform policy, has gradually become a research hotspot in the context of China’s comprehensive deepening of reform. This concept was used to evaluate the implementation effect of the reform from the subjective view of the public while emphasizing the objective material gain of the public, that is, the possession of public policy interests. Compared with classical concepts such as satisfaction and subjective well-being, sense of gain was of more practical significance in the current reform background of China [9‐11, 13]. Moreover, some experts suggest that sense of gain had a positive prediction effect on happiness and satisfaction [14, 15]. The public’s sense of gain comes from the effective solution of existing social contradictions, which is usually reflected in the implementation of major livelihood infrastructure projects such as health-care, education, housing and the public environment, as well as the realization of social rights such as fairness and justice. However, current research on the sense of gain has not been specific to a certain field and primarily regards the overall sense of gain of social reform. Therefore, exploring the factors that may affect the public’s sense of gain in medical reform and their role can provide another perspective for evaluating the effectiveness of health-care reform implementation.

Socioeconomic status affects people’s behaviour patterns, psychological state, knowledge, resource acquisition ability and people’s sense of gain, which is usually measured from two aspects: objective socioeconomic status (SES) and subjective socioeconomic status (SSS). Relevant studies have shown that SES has a positive effect on SGHR. For example, Xiang’s empirical research shows that years of education, occupational status and income all have a significant positive impact on the sense of gain, and occupational status also has a positive impact on the sense of gain of intergenerational mobility [16]. Using longitudinal data, Lu found that with the improvement of personal living standards and subjective socioeconomic status, the sense of gain also increases [17]. Based on social comparison theory and expectation theory, Wang and Run et al. found that when people compare their SSS with their past or peers, the higher their evaluation of their current socioeconomic status, the stronger their sense of gain [18]. Sun’s research confirmed that the higher the socioeconomic status, the higher the urban residents’ sense of gain, and the predictive effect of SSS on the sense of gain was stronger than that of SES [19]. In addition, based on the positive prediction effect of the sense of gain on subjective well-being or satisfaction, relevant studies provide indirect evidence for this finding: people with low socioeconomic status also have low happiness and satisfaction and are prone to depression, anxiety, despair and even negative psychological states and behaviours such as self-harm and suicide [20‐25]. Conversely, people with higher SES have more sound social functions, higher positive emotions and thus more positive cognitive evaluation of society [26]. As the result of health-care reform is an important source of the public’s sense of gain, it can be speculated that SES also positively affects the sense of gain of health-care reform (SGHR).

SGHR are affected not only by socioeconomic status but also by other factors such as an individual’s health status. Empirical studies show that self-rated health significantly (SRH) affects residents’ SGHR, and residents with lower health levels have a significantly lower SGHR than residents with higher health levels [27]. Relevant studies provide indirect evidence that SRH level is closely related to satisfaction and subjective well-being [28]. For example, Nader’s cross-sectional survey of residents in western Iran showed that residents with higher SRH have higher life satisfaction and both physical and mental health [29]. Data from the Canadian Community Health Service Survey showed that with the improvement of residents’ SRH, life satisfaction improved correspondingly, and self-rated mental health had a greater positive predictive power on life satisfaction [30]. Data from a survey on the oral health of children and adolescents in Lithuania showed that adolescents with a poor self-perception of oral health were more likely to report lower subjective well-being [31].

Although SRH has an impact on sense of gain, it may be also affected by SES. People with higher SES have a higher level of health, which is reflected in physical, psychological and social adaptation. Compared with SES, SSS is more effective in predicting the health level [32, 33], which can better reflect individuals’ sense of belonging to a certain social class, future prospects, social phenomena and job opportunities, as well as their attitudes and behaviours toward themselves and others. This trend is reflected in the above and earlier studies [34‐36]. Therefore, this study explores whether SRH has a potential effect on the relationship between SSS and SGHR. Although some studies explored the potential influencing way of residents’ sense of gain and socioeconomic status from the perspective of community identity [37], there are few research on the potential influencing factors and what role they play in a specific field such as health-care reform.

To provide more sufficient evidence for relevant studies on the influencing factors of SGHR, this study proposes the following two hypotheses:

The hypothetical model relationships are shown in Fig. 1.

If a mediation effect is to be established, then it needs to meet the following requirements [38]: (1) The SSS must influence SGHR, that is, the coefficient c is significant (path c). (2) The SSS must affect the SRH, that is, the coefficient a is significant (path a). (3) When SSS, SRH and SGHR are included in the model at the same time, the influence of SRH on the SGHR must be significant (path b), and the influence of the SSS on the SGHR must be less than Eq. 1 (path c’); that is, the significance level or coefficient (absolute value) of coefficient c’ decreases compared with coefficient c. When the significance level of coefficient c’ decreases or the coefficient (absolute value) decreases, the part of the mediation function of SRH is verified. When the significance level of coefficient c’ disappears completely, the complete mediating effect of the mediator variable is verified. That is, when SRH is controlled, the SSS has no effect on SGHR.

The new round of health-care reform in China has achieved remarkable results in all aspects, but it is not clear which factors affect people’s feelings about this effect and its possible impact paths. Using 2018 CFPS data, this study explored the differences in SGHRs under different demographic characteristics and proposed two hypotheses about the relationships among SSS, SRH and SGHR as well as their internal influencing paths based on relevant studies. The results of the mediating effect analysis support the hypothesis proposed in this study: SSS may have a positive association with SGHR., and SRH perhaps play a part in the mediating effect between the two.

In the difference analysis, this study found:

Another interesting phenomenon is differences in educational background show that respondents with higher education have a lower sense of medical reform acquisition, which is contrary to the positive impact of SSS on SGHR in this study. Generally, a higher education level means higher socioeconomic status and thus a higher SGHR [54]. Such results may indicate that the evaluation or predictive efficacy of SES and SSS indicators is not entirely consistent [32‐36]. At the same time, from another point of view, the young group with higher education is the main employment body in the city, and they bear higher medical insurance costs and medical expenses. Moreover, compared with the elderly, young people have higher expectations for the medical and health conditions around them and do not benefit much from medical reform. The uneven distribution of high-quality health resources aggravates the anxiety of this group, which reflects the realistic medical problem of ‘difficult and expensive medical treatment’.

In addition, in terms of the selection of daily medical institutions, the results show that compared with other medical institutions, those who often choose general hospitals have the lowest sense of obtaining medical reform, while those who often go to township health centres and community health service centres have the highest SGHR. Such results are consistent with the current status of China’s health-care reform. On the one hand, although China’s health-care reform has made remarkable achievements in all aspects, the phenomenon of ‘difficult and expensive medical treatment’ still exists, especially in general hospitals [4, 55, 56]. On the other hand, the coverage, content and quality of primary health services and public health services in China have been significantly improved with the support of health-care reform policies in recent years [1, 2, 4, 5, 8]. Thus, people benefit more from primary health institutions and thus have stronger SGHR.

Finally, we find that differences in SGHR among people with different medical insurance types. New rural cooperative medical insurance and supplementary medical insurance for the general health and economic burden of rural residents for a long time provides the help, at the same time, since the new healthcare reform is to expand the basic medical service coverage to a large extent, resolves the problem of people “ Difficult and Expensive Medical Treatment “, and to live in this part of the urban population, which is involved in urban employee basic medical insurance or public medical insurance or Urban resident basic medical insurance for urban residents of this part of the crowd, they are less likely to benefit from such benefits, which may explain why the SGHR is highest among those who participate in New rural cooperative medical insurance and supplementary medical insurance [57, 58]. The difference analysis results suggest that these demographic characteristics may have different degrees of influence on the public’s SGHR, so they should be considered as control variables to reduce the mixed impact of mediation analysis.

The results of the correlation analysis provide statistical support for us to explore the mechanism of action among SSS, SRH and SGHR; that is, the three are positively correlated with each other. Besides, the relationship between satisfaction with medical institutions and trust in doctors and the three key variables provides hints for the inclusion selection of control variables and may provide indirect evidence for the claim that the sense of gain can predict satisfaction.

Based on the above, the two hypotheses proposed in this study may be verified in the results of the mediation effect analysis.

One demonstration is that SGHR may association with SSS. The higher the SSS, the higher the SGHR, which is consistent with the general direction of existing studies [15, 17, 19]. However, as mentioned above, most of the existing studies focus on residents’ overall sense of gain from reform rather than the specific field of health reform. Hypothesis 1 is statistically reflected in the implementation of medical reform policies. Policy-makers need to attach importance to enhancing the public’s SES, especially SSS. Shortening the distance of SSS between people may be of great significance for enhancing the whole SGHR. These policies are not confined to health policy and still need to link to the macrosocial environment such as education, employment and other social security [16, 54, 59‐61].

The other demonstration is that SRH probably has a positive effect on SGHR and may play a partial mediating role in the relationship between SSS and SGHR. As stated earlier, SRH is a comprehensive evaluation about people’s physiological health, psychological health and social adaptation level [41, 43, 44]. This is closely related to all kinds of satisfaction or happiness and is reflected in different ages and different health statuses of the crowd. At the same time, the higher SRH of people in the social evaluation is more active and positive [28‐30, 62]. This is the key reason that the hypothesis was proposed in this study. In this mediating relationship, the results of this paper first support the classical relationship that SSS has a positive impact on SRH in previous studies. People with higher SSS have more social resources including health resources, which determines their higher health level and health literacy [34‐36]. In addition, it is clear that people with higher SRH are more positive in their evaluation of the effectiveness of health-care reform. This suggests that SGHR is indeed closely related to the indicators of happiness and satisfaction [12, 14], but the specific relationship between SGHR and medical satisfaction needs to be supported by more rigorous investigation and evidence. Most important, SRH played a mediating effect of nearly 9%, indicating that SSS exerts an influence on SGHR through SRH in the process of influencing SGHR. In other words, people with strong SSS have higher SRH, which leads to stronger SGHR. Such a logical chain relationship suggests that politicians and scholars need to pay attention to people’s health status. Focusing only on social and economic status may easily fall into the trap of the ‘Easterlin Paradox’. In addition, the public’s SRH is a key factor that reflects whether the health-care reform policy is in place and whether the public gains benefits. This further suggests that SRH plays an important role in assessing and predicting people’s social adjustment.

In brief, this study explored the relationship between SSS and SGHR by using data from a large-scale cross-sectional survey across the country and tested the mediating effect of SRH between them. With the advancement of the health reform process, it is necessary to have an effect-based evaluation index based on the public’s standpoint to endorse it. The SSS and SRH of the public deserve the attention of health policy-makers and relevant scholars or should be included in the evaluation mechanism of the health-care reform policy effect.