The migrating mediators and the interaction associated with the use of essential public health services: a cross-sectional study in Chinese older migrants

“Health for all” has gradually become the core effort to achieve the Sustainable Development Goal [1, 2]. The depth-released health needs have attracted more attention around the worldwide. An efficient delivery system and sufficient use of health services are the most effective approach to achieve population health [2]. In China, the equalization of public policies aims to ensure citizens with equal access to essential public health services (EPHS), regardless of gender, age, place of residence, or household income. However, the equalization of EPHS for migrants was one of the hardest nuts to crack. The use of EPHS was insufficient compared with the general populations, especially the older migrants’ health needs were generally ignored due to the complexity of the migration and the restrictive Hukou system.

Historically, the Chinese population management policy has been formed on the Hukou system, linked to different types of social security, such as employment, retirement, education, health insurance, et al. [3]. This unique culture and policy environment resulted in migrants being excluded from the social security system [4]. Simultaneously, urbanization and industrialization have accelerated the development process of the national economy and society. The older migrant, who used to be migrant workers, received more attention in the last decade. As forecasted, China’s aging rate might increase to 34.1% by 2050, which is much higher than the global average of 21.2% [5]. The number of older migrants aged over 60 in China reached 9.34 million, accounting for 7.2% of the total floating population [6].

Give the importance of this obstacle on the way of public services equalization, the work of Essential Public Services Equalization for Migrants was launched in 2013. “Health China 2030” strategy calls for integrating health into all policies, especially in protecting people’s health in all directions, entire life-cycle, and adhering to the goal of “health in all”. Compared with the studies on the use of health services among the general population, the issues on the older migrants await more exploration [7, 8]. Extant studies focused on the indirect effects of migrating and household factors on the relationships between physical status and the use of EPHS, especially for improving the equalization of EPHS among older migrants. Therefore, this study aims to examine whether the supply side meets the needs of older migrants, to explore the associated mediators and the moderators in the relationships between health status and the use of EPHS, and to provide implications for China and other developing countries that face similar challenges.

The coefficients of correlation were illustrated in Table 2. The use of PE, HR, and FS were positively correlated with each other. The variables of monthly household income and migrating for offspring were negatively correlated with the use of EPHS. However, physical status was correlated with the use of HR and FS, while it was positively correlated with the use of PE, which was partially confirmed the H1. Similarly, migrating for employment and willingness for long-stay merely were correlated with the use of PE and HR. However, it was not significantly correlated with the use of FS.

This study investigated the associated factors with the use of EPHS in Chinese older migrants and estimated the mediators and moderators on the paths that translated physical status to the use of EPHS. According to EPHS’ national manual, the follow-up services such as monitoring blood pressure or blood glucose should be covered no less than four times a year. Relevant examination results should be timely recorded in the electronic health record after each follow-up services. Unfortunately, this study did not find that the indirect effects of household income, migrating for employment, and willingness for long-stay on the use of FS. It might be explained by the rigid demand with small elasticity comparatively, which varied across different types of medical services [21]. Generally, follow-up services were mainly covered by older adults with chronic disease. Its sensitivity might decline with long-term implementations in older patients’ subjective proactiveness or objective conditions.

The use of self-reported data would lead to underestimated prevalence estimates [22]. The EPHS conducted by the primary care providers could actively detect the prevalence of relevant diseases. Evidence revealed that follow-ups with blood pressure control helped reduce the mortality of congestive heart failure [23, 24]. The EPHS is free for all, and it is originally designed to ensure the population in need with equal access to the related services. However, only 33.8% of older migrants used the PS. Further improvement on the coverage is needed in comparison to the general population (43.3%). Simultaneously, the FS coverage rate gap between the older migrants and those aged over 15 years reached 36.7% (34.6% Vs. 71.3%) [25]. This gap might be explained by the instability of migration, weak health literacy, inadequate publicity, or excessive worries about costly treatment expenses [26, 27]. In terms of household income, we found a moderating effect rather than a mediating effect in the relationship between physical status and the use of FS. The key point is that health status was weakly associated with family income, and some of the older migrants were retired with an unvaried pension. Besides, household income has an impact on the use of FS, which is related to further treatment costs [4]. Those with a better social-economic level are more likely to suffer from hypertension or diabetes, and they were more likely to seek follow-up services [28].

As we hypothesized, migrating for children or employment mediated the relationship between physical status and the use of EPHS. Previous research evidenced that those migrated for offspring or employment have better health status, resulting in a negative association with the use of healthcare [4]. However, it is noteworthy that migration leads to the reconstruction of family structure and intergenerational relationships [29, 30]. Meanwhile, family conflicts and existed family devotion might undermine the utilization of health services in older adults. Those who migrated for employment or offspring have to support the whole family rather than merely living for retirement. Besides, the fully mediating effects of migrating for children in the relationship between physical status and the use of FS might be explained by the gap between the supply side and demand side [31, 32]. EPHS are mainly provided by health community centers and its subordinate clinics in the urban areas, while chronic disease treatment is separately provided by secondary or tertiary hospitals [33]. Hence, patients with chronic disease prefer to obtain treatment from professional physicians rather than health workers who confront a severe confidence crisis.

Notably, the effect of migrating for employment on the use of EPHS should not be ignored. This study found that those who migrated for employment were less likely to use the services. It might be explained by the fact the better physical health status older adults have, the more work they did, no matter to reduce their family’s economic burden or prefer to take family responsibilities [34, 35]. Unfortunately, the Hukou system excluded the migrating workers and incurred discrimination in employment, pension, and healthcare [27, 36]. Interestingly, given the mediating effects of willingness for long-stay, the likelihood of the decision-making on establishing a health record was increased. With the extension of migration duration, older migrants could selectively integrate themselves into the new circumstances and obtain equal opportunities to the corresponding social benefits [16].

In the short run, the community is suggested to provide support for the older migrants to incorporate them into the new circumstances [37]. On-site consultation regarding EPHS might be an efficient way to improve older migrants’ health behaviors, especially for those who suffer from chronic diseases [38]. Simultaneously, the offspring are suggested to pay attention to the senior’s health needs. Meanwhile, older adults are encouraged to not regard seeking EPHS as a burden [39]. The care delivery is worthy of strengthening the integration of medical services and preventive service, enhancing the delivery capacity of community health service centers, and implementing the equalization of EPHS [40]. The policies that may be worthy of consideration include developing a comprehensive reform to promote equity in terms of employment, pension, and healthcare for the older migrants [26], which would help achieve the goal of the equalization of EPHS, enhance the intergenerational relationship and social stability, promote the urbanization, and response to the healthy aging.

As the findings indicated, the use of EPHS (PE, HCR, and FS) was correlated with each other. Income, migrating for employment, migrating for offspring were negatively associated with the use of EPHS, while a positive association was observed in the relationship between willingness for long-stay and the use of EPHS. The mediating effects of household income, migrating for employment, migrating for offspring, and willingness for long-stay were observed on the relationship between physical status and the use of EPHS, while household income and migrating for employment demonstrated moderating effects in these relationships. Hence, policies that may be worthy of consideration include further developing the health system reform to promote the delivery capacity of primary health institutions, integrating the professional physicians into public health departments, and launching equality policies.