Impact of children's migration on health and health care-seeking behavior of elderly left behind

In modern times, many factors have intensified migration. Improvement in transportation infrastructure, advances in communications technology (which makes keeping in contact with left-behind over much easier and cheaper), increased trade between countries (including the impact of trade resulting from globalization), political instability, poverty, and unemployment in economically disadvantaged areas/countries are some of the important factors that contribute to this phenomenon [1].

The interaction between health and migration is complex and dynamic. Migration can have an impact on physical, mental, and emotional health and well-being of migrants themselves, on those left behind in the place of origin, and on those at the destination [2]. The connection between health status and migration is clearly bidirectional. In one direction, the act of migration may influence health outcomes. In the other direction, a person's health may influence one's propensity to migrate or the destination one chooses [3].

In many places, and especially in most developing countries, the growing proportion of aging individuals challenges public and social institutions responsible for elderly care. These countries face an additional burden of accelerated population aging and a lack of institutional support to meet the needs of older individuals [4]. Changes in demographic events, especially sharp declines in fertility and mortality, have resulted in rising life expectancies and increasing rates of population aging [5]. As is the case in most other countries in Asia, the elderly in Thailand have traditionally relied on their children for personal care and financial support [6]. Trends in declining fertility and increasing internal migration have prevailed in Thailand since 1985, when a period of sustained economic development began [7, 8]. These patterns have resulted in decreasing numbers of children available to care for their elderly parents. Increasing out-migration of young adults has created concerns about whether the absence of children in the household or community affects the health of elderly left behind or their health care-seeking behavior. Existing literature on the consequences of migration has focused mainly on the impact of migration on receiving areas and on migrants themselves but has paid little attention to the effects of migration on sending communities and of the family members "left behind" by migrants [9‐11].

Evidence from the literature shows that migration can affect the health of those left behind both positively and negatively. With additional money coming from remittances, people have easier access to health services, can buy expensive medicine, and eat better quality food [12]. Thus, migration can benefit both migrants and left-behind family members as it would enhance their well-being [13, 14]. Remittances received from migration could support the family left behind by minimizing economic risk and overcoming capital constraints [14, 15]. A study in South Africa found that temporary internal migrants, by increasing their household income, were able to bring positive health outcomes not only for themselves but also for family members [16] including elderly parents left behind [17]. Other research also shows that migration can lead to better health among the population left behind [18‐20]. Similarly, a study conducted by Abas et al. [21] found that out-migration of children was independently associated with less depression in parents.

On the other hand, some research notes that out-migration of young adults has severe negative consequences for ageing parents, namely, loneliness, isolation, and the loss of basic instrumental and economic support [22]. A study of Mexico-US migration found evidence of a causal link between poor elderly health outcomes and children's migration to the US [23]. Research in Bangladesh has found that those left behind by adult migrant children face risks stemming from the loss of personal support and care [18].

Although the separation of families due to migration might have serious implications on the health status of elderly left behind and their health care-seeking behavior, the possible health effects on elderly left behind in Thailand remain unclear. This study aims to explore the impact of migration of adult children on the health of the elderly left behind and on their health care-seeking behavior. In-depth examination of these issues will provide policy makers and program planners with needed information and will raise public attention to this public health issue. The findings of this study will help fill the gap in the literature and provide the understanding necessary for advocacy and for the design of appropriate interventions related to migration in Thailand.

This study has attempted to investigate the impact of out-migration of adult children on health issues and health care-seeking behavior of the elderly left behind in a society in which, traditionally, children take responsibility for older parents. Findings show that the majority of the elderly (68%) have at least one out-migrant child and that an overwhelming majority (79%) received money from their migrant children.

Out-migration of adult children was highly associated with poor mental health symptoms among the elderly left behind. It is likely that out-migration of children reduces opportunities for face-to-face interaction. This finding is similar to other studies [22, 23] that found that out-migration of young people increased the loneliness felt by their aging parents. However, the findings of present study conflict with those of Abas et al., which found that out-migration of children was associated with less depression in parents [18]. This could be due to the fact that in their study most of the parents with migrant children were male, better educated, and married which would reduce the risk of depression.

Our study found that the migration status of children was not associated with the physical health of the elderly left behind (as measured by self-rated health, experience of chronic diseases, and illnesses during the 5 years preceding the survey). It should be noted that this may be because adult children are less likely to migrate when a parent is ill [27]. However, out-migration of adult children was independently associated with higher utilization of health facilities among the elderly left behind. It is encouraging to note that a significantly higher proportion of the elderly who had migrant children sought treatment compared to those who had no migrant child. This may be a result of remittances from migrant children, which make healthcare affordable. Indeed, about four-fifths of the sampled elderly had received money from their migrant children in the year preceding the survey.

An earlier national survey in Thailand also found that 77% of Thai elderly reported receiving financial support from children during the previous year [28]. Furthermore, after controlling the demographic, and socio-economic variables ^a, we also found that those who had received remittances from their children were more likely (OR = 1.43, 95% CI 1.30-1.57) to seek treatment than those who had no migrant children. This could be due to the fact that the benefits of remittances offset the potential negative effect of migrant children living apart from their parents. The financial support provided by migrant children may operate primarily through amelioration of financial hardship of their parents. Studies have also found that most elderly Thai parents are getting financial support from their children and that this contributes positively to their material well-being [29, 30]. Many families with migrant members moving within and between low- and middle-income countries tend to benefit economically [31] and to enjoy improved general health [20]. The other reason could be that adult migrant children can provide emotional support to their parents back home (by visiting home or via frequent telephone calls, mail, etc.) or provide both emotional and financial support [32] that help parents maintain good health through improvement of emotional and psychosocial well-being [33]. Yet another reason could be health knowledge transfers between migrants and their parents who are left behind.

There are some limitations in the interpretation of the results of this study. Because of the survey's cross-sectional design, all of the factors analyzed in the study were measured at a single point in time. Thus, the analysis can only provide evidence of statistical association between those items and the health status of the elderly left behind and health care-seeking behavior; it cannot show a cause-effect relationship. Besides, we have to be careful while comparing the results of this study with those of other research studies that have used pre-existing validated questionnaires to measure mental and physical health.

Our study provides novel evidence on an issue of special importance to countries affected by heavy out-migration of adult children, an issue that has received little attention. Findings here show that out-migration of adult children is highly associated with poor mental health but is not associated with the physical health of elderly left behind. Out-migration of children is also highly associated with greater utilization of health facilities. Thus, in order to decrease morbidity among the elderly as well as to maintain and enhance the well-being of families, programs should focus on alleviating the symptoms of poor mental health among the elderly left behind and aim to reduce the differences in utilization of health care-seeking behavior among elderly with children present in the community and elderly left behind.