Analysis of diverse factors influencing the health status as well as medical and health service utilization in the floating elderly of China
影响中国流动老年人健康状况及医疗卫生服务利用的多种因素分析

Keywords: Floating elderly, Self-rated health, Chronic disease, Physical examination, Medical and health service utilization
关键词：流动老人， 自评健康， 慢性病， 体检， 医疗卫生服务利用

In China, citizens aged 60 and above are defined as the elderly (GB/T 24433-2009). The floating elderly refers to the population aged 60 or above who have lived in the local area for 1 month or more and are not registered in the district (county, city). With the rapid development of urbanization and aging population in China, the proportion of the elderly among the floating population has been increasing rapidly. According to the China Floating Population Development Report 2018, the number of the floating elderly in China has already entered a rapid growth stage in 2000 and has increased to 13.04 million in 2015, accounting for $5.3\mathrm{\%}$$5.3\mathrm{\%}$5.3%5.3 \% of the national floating population, with an average annual growth rate of approximately $6.6\mathrm{\%}$$6.6\mathrm{\%}$6.6%6.6 \% [1]. In 2018, the European Office of the World Health Organization (WHO) pointed out in the report “Health of older refugees and migrants”, that population aging and floating itself are a complex multi-dimensional process, and the needs of elderly refugees and migrants must be included in the scope of the whole European aging policy.
在中国，60 岁及以上的公民被定义为老年人 （GB/T 24433-2009）。流动老年人是指在当地居住 1 个月或以上且未在区（县、市）登记的 60 周岁或以上人口。随着中国城市化和人口老龄化的快速发展，老年人在流动人口中的比例一直在迅速增加。根据《2018 年中国流动人口发展报告》，中国流动老年人的数量在 2000 年已进入快速增长阶段，2015 年已增加到 1304 万，占 $5.3\mathrm{\%}$$5.3\mathrm{\%}$5.3%5.3 \% 全国流动人口的比例，年均增长率约为 $6.6\mathrm{\%}$$6.6\mathrm{\%}$6.6%6.6 \% [1]。2018 年，世界卫生组织欧洲办公室 （WHO） 在《老年难民和移民的健康》报告中指出，人口老龄化和流动本身是一个复杂的多维过程，老年难民和移民的需求必须纳入整个欧洲老龄化政策的范围。
However, for the overall health status of the floating elderly, Yang JH (2018) declared that the health management of the floating elderly is poor, and less than half of them have established health records [2]. Song QC (2018) found that for the elderly, with increase in age, the physiological functions of organs may start degenerating, and the immunity can substantially decline, thereby leading to an increasing risk of various degenerative diseases such as diabetes [3]. Zhang JR (2017) found that because of rapid changes in the economic conditions, living environment and social roles, the floating elderly may face more hurdles in the utilization of medical and health services than the general elderly or other floating population, for example, the utilization rate of health services of the elderly floating population is low, and the demand for off-site medical treatment is difficult to meet [4]. Choi SH (2012) also stated that the floating elderly have their own particularities, including greater health risks, more unfavorable socio-economic status, language barriers and low health literacy, cultural factors affecting health seeking behavior, and social psychological vulnerability and discrimination [5]. Chu B (2015) found that the health awareness of the floating elderly is relatively weak, and the choice of medical institutions is irrational [6].
然而，对于流浪老人的整体健康状况，Yang JH （2018） 宣称流浪老人的健康管理较差，只有不到一半的人建立了健康档案 [2]。Song QC （2018） 发现，对于老年人来说，随着年龄的增长，器官的生理功能可能开始退化，免疫力会大幅下降，从而导致糖尿病等各种退行性疾病的风险增加 [3]。Zhang JR （2017） 发现，由于经济条件、生活环境和社会角色的快速变化，流动老年人在利用医疗卫生服务方面可能面临比一般老年人或其他流动人口更多的障碍，例如，流动老年人口的卫生服务利用率低， 并且难以满足异地就医需求 [4]。Choi SH （2012） 也指出，流浪老年人有其自身的特殊性，包括更大的健康风险、更不利的社会经济地位、语言障碍和低健康素养、影响健康寻求行为的文化因素以及社会心理脆弱性和歧视 [5]。Chu B （2015） 发现，流浪老人的健康意识相对较弱，医疗机构的选择不理性 [6]。
Kristiansen M (2016) found that the incidence and mortality rate of floating elderly in Europe were the same as those in the local population, but the relative importance, severity and age of onset were different. However, with the increase of age, the gap between the floating elderly and the local population was widening, and there were also great differences among the floating elderly themselves [7]. Gubernskaya Z (2015) also found
Kristiansen M （2016） 发现，欧洲流浪老人的发病率和死亡率与当地人群相同，但相对重要性、严重程度和发病年龄不同。然而，随着年龄的增长，流动老年人与当地人口之间的差距越来越大，流动老年人本身也存在很大差异 [7]。Gubernskaya Z （2015） 也找到了
that the older the migrants were, the greater the risk of poor health in their later years, which may be related to their long-term adverse conditions in the inflow area and limited opportunities for health care [8]. González HM (2011) also stated that the floating years, the age of migration and the floating reasons had a significant impact on the health and quality of life of the floating elderly. However, some studies had come to the opposite conclusion: the longer the migrants lived in the inflow area, the better the health status of them. This may result from that the more abundant social and economic resources and cultural adaptation played an important role in the later life of the migrants [9].
移民年龄越大，晚年健康状况不佳的风险就越大，这可能与他们在流入地区的长期不利条件和有限的医疗保健机会有关[8]。González HM （2011） 还指出，漂浮年限、迁移年龄和漂浮原因对流动老年人的健康和生活质量有重大影响。然而，一些研究得出了相反的结论：移民在流入区生活的时间越长，他们的健康状况就越好。这可能是由于更丰富的社会和经济资源以及文化适应在移民的晚年生活中发挥了重要作用 [9]。
At present, there is no comprehensive study to investigate the influence of the elderly’s floating characteristics on their health status as well as utilization of medical and health services. It is rare to combine the two attributes of age and mobility. Based on this, this paper intends to select age and many related variables representing the floating pattern to comprehensively investigate the health status as well as utilization of medical and health services. This may aid to decipher the various influencing factors affecting their overall wellness. The findings provide a strong basis for improving the health level of the floating elderly and formulating novel policies related to their health status.
目前，尚无全面的研究来调查老年人的浮动特性对其健康状况以及医疗卫生服务利用的影响。很少将年龄和活动能力这两个属性结合起来。基于此，本文拟选取年龄和代表浮动模式的许多相关变量，对健康状况以及医疗卫生服务的利用情况进行全面调查。这可能有助于破译影响他们整体健康的各种影响因素。研究结果为提高流浪老年人的健康水平和制定与其健康状况相关的新政策提供了有力的基础。

This study used the latest special survey data of floating elderly in China, “China Migrants Dynamic SurveySpecial investigation on Floating Elderly in 8 megacities in 2015 [10]”, to analyze the health status and utilization of medical and health services among the floating elderly. The overall sample is all the floating population aged 60 or above in 8 megacities including Beijing, Shanghai, Dalian, Wuxi, Hangzhou, Hefei, Guangzhou and Guiyang. Stratified, multi-stage and population proportion sampling (PPS) was used in this survey. In the first stage, villages and towns / streets were selected; in the second stage, village committees / neighborhood committees were selected; in the third stage, individual respondents were selected. A total of 2279 people met the study requirements.
本研究利用最新的中国流动老年人专项调查数据《中国流动人口动态调查 2015 年 8 个特大城市流动老年人专项调查 [10]》，分析了流动老年人的健康状况和医疗卫生服务的利用情况。总体样本为北京、上海、大连、无锡、杭州、合肥、广州和贵阳等 8 个特大城市的所有 60 岁或以上流动人口。本调查采用分层、多阶段和人口比例抽样 （PPS）。在第一阶段，选择了村庄和城镇/街道;第二阶段，遴选村委会/居委会;在第三阶段，选择个人受访者。共有 2279 人符合研究要求。

The Behavioral Model of Health Service Utilization (Andersen Model) was first proposed in 1968. Since its establishment, it has been widely used in medical and health services utilization research and health system evaluation [11]. According to the Anderson model, the utilization of personal medical and health services can be predominantly determined by three different factors: predisposing factors, enabling factors and need factors.
卫生服务利用行为模型（安德森模型）于 1968 年首次提出。自成立以来，它已广泛应用于医疗卫生服务利用研究和卫生系统评价 [11]。根据安德森模型，个人医疗和保健服务的利用主要由三个不同的因素决定：易感因素、促能因素和需求因素。

Predisposing factors include demographic characteristics (age, gender, etc.), social factors (ethnic groups, education, occupation, marital status, social interaction, etc.) and health beliefs (attitudes, values, and knowledge of health systems, etc.). The enabling factors include personal/family resources (household income, health insurance, etc.) and community resources (access to health service, such as distance to the nearby hospital, waiting time to see a doctor, etc.). Finally, the need factors include cognition and objective evaluation of medical and health services. Based on Andersen model, this study utilizes the particularity of the research object and the actual content of the survey data into consideration so as to adjust the model. Therefore, the different floating characteristics including floating reasons, floating scope and floating years were added to the model and the theoretical frame diagram was established, as shown in Fig. 1.
诱发因素包括人口统计学特征（年龄、性别等）、社会因素（种族、教育、职业、婚姻状况、社会交往等）和健康信念（态度、价值观和卫生系统知识等）。有利因素包括个人/家庭资源（家庭收入、健康保险等）和社区资源（获得医疗服务的机会，例如到附近医院的距离、看医生的等待时间等）。最后，需求因素包括对医疗卫生服务的认知和客观评价。本文以 Andersen 模型为基础，综合考虑研究对象的特殊性和调查数据的实际内容，对模型进行调整。因此，在模型中加入不同的浮动特性，包括浮动原因、浮动范围和浮动年限，并建立理论框架图，如图 1 所示。

Health has the dual characteristics of subjectivity and objectivity [12]. The subjective health and objective health of the floating elderly have been evaluated from the perspectives of individuals and professionals, including self-assessed health parameters, hypertension or diabetes diagnosed by doctors and diseases requiring hospitalization within 1 year, so as to comprehensively measure the overall health status among the floating elderly. The classification codes have been shown in Table 1.
健康具有主观性和客观性的双重特征 [12]。从个人和专业人员的角度对流动老年人的主观健康和客观健康状况进行评估，包括自我评估的健康参数、医生诊断的高血压或糖尿病以及 1 年内需要住院治疗的疾病，从而综合衡量流动老年人的整体健康状况。分类代码如表 1 所示。

Medical and health service utilization mainly refers to the utilization of prevention, medical treatment and rehabilitation services for the management of chronic diseases [13]. It has been well established that with the
医疗卫生服务利用主要是指利用预防、医疗和康复服务来管理慢性病 [13]。众所周知，随着
increase of age, the body functions gradually decrease, and the adaptability of the elderly population to the external environment can deteriorate significantly [14]. Hence the elderly population become more susceptible to several diseases and easily prone to minor ailments, and develop an increased risk of acquiring major diseases and common chronic diseases. However, physical examination can effectively identify high-risk groups, which may be significantly beneficial for disease prevention [15]. In fact, the early hospitalization for diseases or injuries, treatment for minor ailments and follow-up for hypertension, diabetes or other life-style related diseases reflect the optimum utilization of medical and rehabilitation services by the floating elderly. As a result, free physical examination, follow-up for hypertension or diabetes, treatment for minor ailments and hospitalization within 1 year were selected to carefully evaluate the utilization of medical and health services by the floating elderly in this study.
随着年龄的增长，身体机能逐渐下降，老年人群对外部环境的适应能力会显著恶化 [14]。因此，老年人口更容易患上多种疾病，容易患上小病，患重大疾病和常见慢性病的风险增加。然而，体格检查可以有效识别高危人群，这可能对疾病预防有显著益处 [15]。事实上，疾病或受伤的早期住院治疗、小病的治疗以及高血压、糖尿病或其他与生活方式相关的疾病的随访反映了流动老年人对医疗和康复服务的最佳利用。因此，选择免费体检、高血压或糖尿病随访、小病治疗和 1 年内住院治疗，仔细评估本研究中流浪老年人对医疗卫生服务的利用情况。

According to the adjusted Anderson model, age, gender, ethnic groups, education level and marital status were selected among the predisposing factors. The “number of friends there” has been used to reflect the social interaction among the floating elderly. In addition, considering the imbalanced infrastructure development between urban and rural areas in China, the household registration type was also incorporated into the model. The average exercise time daily and health knowledge acquisition were used to understand the health beliefs among the subjects. Health knowledge in the investigation includes nine kinds, such as occupational disease prevention, nutritional health knowledge, reproduction and contraception/prenatal and postnatal care, chronic disease prevention and control, smoking control, mental disorders prevention and control, tuberculosis prevention and control, sexually transmitted disease (STD) or acquired immune deficiency syndrome
根据调整后的 Anderson 模型，年龄、性别、种族、教育程度和婚姻状况是易感因素。“那里的朋友数量”被用来反映流动老年人之间的社交互动。此外，考虑到中国城乡基础设施发展不平衡，户籍类型也被纳入模型。采用每日平均运动时间和健康知识获取来了解被试的健康信念。调查中的健康知识包括职业病预防、营养健康知识、生殖避孕/产后保健、慢性病防控、吸烟控制、精神障碍防治、肺结核防控、性传播疾病（STD）或获得性免疫缺陷综合症等九种

Fig. 1 The framework of health service utilization model after adjustment
图1 调整后的卫生服务利用模型框架