1. Introduction
Since the new Chinese health system reform was launched in 2009, the government has increased the budget in primary healthcare delivery. One of the vital policies was the equalization of Essential Public Health Service (EPHS), which aims to ensure that Chinese citizens have equal access to essential services and to satisfy primary health needs. The package of EPHS, which mainly includes annual physical examinations and free follow-up services for those diagnosed with hypertension or diabetes, is free for people aged 65 or above since 2009 [
1]. In China, while management and guidance are provided by the administrative health departments and higher-level organizations such as the Centers for Disease Control and Prevention and hospitals for chronic diseases [
2], the essential health services are mainly provided by community healthcare centers with subordinate clinical stations in urban areas and by township hospitals with subordinate village clinics in rural areas [
3].
The Chinese elderly migrants refer to the elderly who migrated for caring for the younger generations, employment, and other causes within China, such as the acceleration of urbanization [
4]. The reports showed that the population of the Chinese elderly migrants increased from 5.03 million to 13.04 million with an annual increase of 6.6% from 2000 to 2015 [
5]. China is a country with rapid economic development, and the migrating population also has its specificity in historical characteristics. The Hukou system is the household registration system in China to provide a foundation for the population administrative policy and public services. It links people’s healthcare and public welfare to their household registration area. In fact, the majority of migrants have health insurance in their previous area without local health insurance [
4,
6]. In addition to a lack of proactive behavior in seeking health services, elderly migrants also suffer from limited access to healthcare information [
7]. Hence, the Hukou system may result in an exclusion against elderly migrants, since most Chinese elderly migrants migrated for supporting offspring rather than receiving support from their family. The social support in this study is measured by medical insurance and local friends, indicating social support besides family support. Besides the lack of local medical insurance, the elderly migrants have to reconstruct their social networks. Thus, the issue of social support and the use of health services for Chinese elderly migrants are more crucial than ever.
To deal with the increasing elderly migrant population, the “Active Aging—Policy Framework” recommended three directions, such as health, participation, and preservation [
8,
9]. The Chinese government’s migration policy adjustment has gone through three stages: a liberalization of entry into the city, an addressing of equal rights, and a comprehensive promotion of urbanization [
5,
10]. Several studies focused on the associations among the migrating factors, medical insurance, and the use of health services for working-aged migrants [
4,
11,
12]. Nevertheless, within the context of population migration, the issue of the intergenerational connection between outer social support and the use of health services among elderly migrants is under-investigated. Therefore, it still needs further study to develop a model to identify the associated factors and the pathway of the health services use among Chinese elderly migrants. As such, this study aims to establish a health services use model for the Chinese elderly migrants through structural equation modeling (SEM) and estimate the interactions among migration, outer social support, and health services use.
5. Discussion
This study investigated differences in the use of different health services by elderly migrants within China, and estimated the effects of the associations and their interaction pathway, concluding with the findings as follows: the use of essential public health services was insufficient compared with the use of outpatient or inpatient services in elderly migrants; migrating duration and migrating for offspring were negatively associated with the use of community physical examinations, while outer social support demonstrated a directly positive effect; and the mediating effect of outer social support was observed in the relations between the use of health services and independent variables including migrating duration and migrating for offspring.
This study found that those that migrated for offspring received insufficient outer social support and restrained the use of health services, whereas outer social support partially mediated this negative association. The insufficient use of public health services might be related to weak awareness and ineffective equalization in preventive care. Currently in China, although the health-centered health delivery system has been widely endorsed in recent years, the prevention-oriented model has not actually been fully established. Public health services were mainly provided by the community health service centers, while the migrants prefer to seek health services from subordinate clinical stations due to increased accessibility with regards to economic and space concerns. Moreover, with the unique characteristics of guardians, Chinese parents tend to be more concerned about their descendants and enjoy the role of caregiver in the family. Thus, they are more likely to provide more support to their offspring rather than receive support [
9]. With the beliefs of selfless dedication, elderly migrants that migrated for offspring may ignore or sacrifice their health needs so as to care better for their younger generations [
28]. Additionally, the intergenerational conflicts may also undermine the well being and the use of health services among the senior population [
29,
30]. Those with better intergenerational relationships are more likely to receive care at home [
31,
32]. The female is more likely to migrate for caring for younger generations. Whereas, the sex did not mediate the relationship between migrating for offspring and the use of health service. The main factors related to health services utilization among those that migrated for offspring would be the demand, income, etc., instead of sex [
4,
33].
Interestingly, this study also discovered a significant influence of outer social support on the use of public health services in comparison with outpatient services utilization. It might be explained by the exclusive features of the services and the elasticity demand on the services. The public health services are available and free to everyone, while outpatient services are in rigid demand with small elasticity. Thus, the sensibility varies from public services to medical services, and the price of the services might exclude the groups who are poor or with a lower willingness to pay. The health services with a price were also popular to use in the context of reimbursement, which was consistent with previous studies concluding that the elderly with a poor socioeconomic status are more likely to use OS with local insurance and family support [
34,
35]. The evidence also demonstrates that outer social support contributes to releasing the suppressed demand, or in other words, the seniors covered by insurance are encouraged to utilize more health services than those without health insurance [
36].
Simultaneously, we found that health insurance partially mediated the negative relationship between the use of outpatient services and migrating duration. It might be explained by the reimbursement disparity among the health insurance policies [
37] since the out-of-pocket nature of healthcare and health insurance reimbursement are the vital issues for their decision on visiting physicians [
38,
39]. Evidence shows that merely 85.2% of the elderly migrants had health insurance and 88.5% of migrants had to receive health insurance from their household registration [
23]. Compared with the migrants, evidence shows that outer social support also plays a mediating role in OS utilization since local residents with local health insurance are more likely to have larger social networks [
4]. In the context of Chinese culture, the elderly regard living with offspring as a burden to their family due to the hectic routine of their offspring. This elderly population migrating for offspring shows a sign that the elderly have the initiative to migrate and their families are more likely to have a comparatively better socio-economic characteristic to invite the elderly to the immigration area. It would be affordable for these elderly migrants to receive OS, while health insurance is inclined to support primary health services. Hence, without affordable and reasonable health insurance policies targeting migrants, the healthcare equalization objective is still difficult to achieve even with an incremental number of health services [
40].
However, the effect of outer social support on the use of public health services should not be ignored, given that those with more outer social support were more likely to use the services. The elderly’s health behavior is largely dependent on their subjective consciousness despite their health need. The use of public health services is easily influenced by the surrounding environment [
4]. Local friends, as a trusted information source [
41], play an important role in the transmission of an individual’s health behaviors and knowledge [
42].
As we hypothesized, local friends partially mediated the relationship not only between the use of outpatient services and migrating duration but also between the use of community physical examinations and migrating for offspring. The concept of assimilation could explain the behavior of migrants seeking health services [
34,
43]. Elderly migrants have limited access to health services due to the Hukou system. Meanwhile, with the complexity of the living environment and conservative consciousness dismissed to adopt new circumstances and health behaviors, the dilemma of loneliness and the difficulty of finding a companion in a new environment were quite common among elderly migrants reconstructing social networks [
4]. With the migrating duration extended, migrants are gradually integrated into the society in the immigration areas, new ideas are adopted selectively, and health behaviors may change accordingly [
42]. More specifically, the social convey model suggests that the closer to the inner of the social network circle, the higher the intimacy. The degree of emotional intimacy depends on the number of friends which plays a role in complementing and supporting the inner intimacy [
28]. Seniors prefer to seek comfort from friends rather than offspring, to address family stress and alleviate the pressure of intergenerational conflicts, which might be the internal mechanism to improve health services utilization.
As such, the delivery capacity of preventive care at the grassroots level and equalization efforts of health services for elderly migrants should be improved. Outer social support is suggested as a key effort to improve the use of health services among elderly migrants. Family members should enhance positive intergenerational communication and construct a harmonious intergenerational relationship. Seniors are encouraged to discuss their health needs and to not regard seeking health services as a burden to the family [
9]. At the community level, committees and friends should help provide the instrumental and emotional support to the elderly migrants in terms of health services utilization. On-site consultation is suggested to help obtain health information and develop healthy behaviors. The government should further implement the Hukou reform, conduct social work intervention for migrants, advance the equalization of health services, and advocate a traditional culture of filial piety in the society.
To the best of our knowledge, this study focused on Chinese elderly migrants, investigated the interaction pathway of outer social support in the use of health services, and explored the interactions between the use of health services, migrating for offspring, and outer social support in the context of population migration. This study contributed to the development of new models that identify the factors related to the use of health services among Chinese elderly migrants and provided suggestions for improving its utilization and social work for the elderly migrants.