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RESEARCHARTICLEOpenAccessFactorsassociatedwithhealth-seekingbehavioramongmigrantworkersinBeijing,ChinaYingchunPeng1,WenhuChang1,HaiqingZhou1,HongpuHu2,WannianLiang3*AbstractBackground:MigrantworkersareauniquephenomenonintheprocessofChina'seconomictransformation.
Thehouseholdregistrationsystemclassifiesthemastemporaryresidentsincities,puttingtheminavulnerablestatewithanunfairshareofurbaninfrastructureandsocialpublicwelfare.
TheamountofpressureinflictedbymigrantworkersinBeijing,asoneofthemajormigrationdestinations,iscurrentlyatathreshold.
Thisstudywasdesignedtoassessthefactorsassociatedwithhealth-seekingbehaviorandtoexplorefeasiblesolutionstotheobstaclesmigrantworkersinChinafacedwithwhenaccessinghealth-care.
Methods:Asampleof2,478migrantworkersinBeijingwaschosenbythemulti-stagestratifiedclustersamplingmethod.
Astructuredquestionnairesurveywasconductedviaface-to-faceinterviewsbetweeninvestigatorsandsubjects.
Themultilevelmethodology(MLM)wasusedtodemonstratetheindependenteffectsoftheexplanatoryvariablesonhealthseekingbehaviorinmigrantworkers.
Results:Themedicalvisitationrateofmigrantworkerswithinthepasttwoweekswas4.
8%,whichonlyaccountedfor36.
4%ofthosewhowereill.
Nearlyone-thirdofthemigrantworkerschoseself-medication(33.
3%)ornomeasures(30.
3%)whileillwithinthepasttwoweeks.
19.
7%ofthesickmigrantswhoshouldhavebeenhospitalizedfailedtoreceivemedicaltreatmentwithinthepastyear.
Accordingtoself-reportedreasons,thehighcostofhealthservicewasasignificantobstacletohealth-careaccessfor40.
5%ofthemigrantworkerswhobecamesick.
However,94.
0%ofthemigrantworkersdidn'thaveanyinsurancecoverageinBeijing.
Themultilevelmodelanalysisindicatesthathealth-seekingbehavioramongmigrantsissignificantlyassociatedwiththeirinsurancecoverage.
Meanwhile,suchfactorsashouseholdmonthlyincomepercapitaandworkinghoursperdayalsoaffectthemedicalvisitationrateofthemigrantworkersinBeijing.
Conclusion:Thisstudyassessestheinfluenceofsocio-demographiccharacteristicsonthemigrantworkers'decisiontoseekhealthcareserviceswhentheyfallill,anditalsoindicatesthatthecurrenthealthservicesystemdiscouragesmigrantworkersfromseekingappropriatecareofgoodquality.
Relevantpoliciesofpublicmedicalinsuranceandassistanceprogramshouldbevigorouslyimplementedforprovidingaffordablehealthcareservicestothemigrants.
Feasiblemeasuresneedtobetakentoreducethehealthrisksassociatedwithcurrenthygienepracticesandequityshouldbeassuredinaccesstohealthcareservicesamongmigrantworkers.
BackgroundTheinceptionofChina'sreformandopeningpolicythreedecadesagohasresultedinthecreationofagrow-ing,historicallyuniquesocialgroup:ruralmigrantsinthebigcities.
Accordingtostatisticaldata,theruralmigrantpopulationinChinarosefrom70millionin1993to140millionin2003,doublingtheoriginalnum-berin10yearsandincludingnearly30%oftherurallaborforce[1].
RuralmigrantshavegrownintoanimportantnewsocialstratumofChina,particularlyasasizeablecomponentofindustrialworkersinChinaandadrivingforceforurbanization.
Investigationsindicatethatover60%ofruralmigrantworkersswarmintolargecitiessothatmanyChinesemetropolises,suchasBeij-ing,ShanghaiandGuangzhoubecomeoverloaded.
Beij-ing,thecapitalcityofChina,isamajormigrationdestination,wherethemigrantpopulationcurrentlyexceeds4million,accountingfor1/4ofthetotalpopu-lation[2].
Asmostmigrantscanonlydosimple,*Correspondence:wsglyjy@gmail.
com3OfficeofHealthEmergency,MinistryofHealth,Beijing100044,ChinaPengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/692010Pengetal;licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
unskilledjobs,typicallyunstableandinsecurework,theyareoftenlowpaidandfrequentlylaidoff.
Graduallytheybecomethegrowingpoorgroupinthebigcities,lackingasocialassistancesystemandpublicinfrastructureandsufferingfromhealthriskswhichgounnoticed[3].
Althoughruralmigrantworkershavecontributedmuchtourbanandnationaleconomicdevelopment,aseriesofexistingproblemsdragtheminto"vulnerablegroups"[4].
China'snationalpolicyhaslongbeenestab-lishedonlocality-basedschemes.
Accordingtolawallindividualsmusthavehouseholdregistration(hukou),bywhichcertainrights,suchasfreeeducationandaccesstosocialwelfare,areoffered.
Sincehouseholdregistra-tionisnoteasilytransferablefromruraltourbanareas,migrantsarerarelyentitledtopublicmedicalinsuranceandassistanceprogramsinplacesoutsidetheiroriginalresidentialarea,forcingthemtopayout-of-pocketexpensesformedicalservicesincities[5,6].
WhileavailablestudieshaveprimarilyfocusedonAIDSandtuberculosis,orreproductivehealthoffemalemigrants,onlylimitedresearchhasbeenconductedonhealthcareaccessandthehealth-seekingbehaviorsofthispopulation[7,8].
SystematicresearchonhowChineseruralmigrantsperceivehealth,disease,andthehealthcaresystemisfarfromsufficient.
Itbehoovesustounderstandhowthisgroupperceivesthevariouspossibilitiesforhealthcare:self-medication,privateclinicswithvariedlevelsofcare,andmoreformalhospitaltreatment.
Theconceptandawarenessofhealthrisksandtheknowledgeofmedicineaswell,playabigpartinhealth-relatedbeha-viorsofthemigrants.
Understandingthesefactorswillbecrucialtoprevention,intervention,andotherhealth-relatedmeasuresforthemigrantworkersinChina[9].
Withviolentlyphysical,demographicandsocioeco-nomicchanges,Beijingistypicalofthebigcitiesunder-goingmarkettransitionandeconomicrestructuring.
Therefore,itisanidealcasetostudythemigrantpopu-lationagainstthebackgroundofmarkettransitioninChina.
Thispaperistocollectinformationabouttheattitude,perception,preferencesandhealth-seekingbehavioramongthemigrantworkersinBeijing.
Ourpresentstudywillalsoassesstheirneedsinhealthcareservicesandtheobstaclestheymeetinenjoyinghealthservicesaswellassuggestfeasiblesolutionstopresentedproblems.
Itisalsohopedthatpolicyimplicationsonthemanagementoftheissuesrelatedtothemigrantworkerscanbedrawnfromtheanalysis.
MethodsResearchsitesAbout60percentofthemigrantpopulationlivesinthreeofeighturbandistrictsofBeijing,i.
e.
Chaoyang,HaidianandFengtai[10].
Chaoyangdisricthasthehighestnumberanddensityofmigrantsamongall,owingtoitsrapidcommercializationinrecentyears.
Itsmigrantpopulationof1millionaccountsfor1/4ofallthemigrantsinBeijing,andnearlyathirdofalltheresi-dentsinthatdistrict.
Thethreedistrictslistedabovewerechosenforthisstudy.
DataCollectionandMeasuresAccordingtotheBeijingMunicipalRegulationsonmigrants,migrantsmustregisterwiththelocalcommu-nityagencieswheretheyarelivingtoreceiveandrenewtheirtemporaryresidencycertificates.
Themigrantstendtocongregateamongthemselvesaccordingtotheirhometown(laoxiangguanxi),andliveinsocalled'migrantvillages'(liudongrenkoujujudian)dispersedamongthecitydistricts.
Amulti-stagestratifiedclustersamplingmethodwasusedinthisstudy.
Inthefirststage,forhavingthelargestanddensestmigrantpopula-tionsamongalldistricts,thethreedistrictsChaoyang,HaidianandFengtaiwereselectedfromBeijing.
Inthesecondstage,5to8townswerechosenfromeachselecteddistrictaccordingtothenumberofmigrants.
Inthethirdstage,1to2'migrantvillages'fromeveryselectedtownwerechosenaccordingtogeographicaloriginofthemigrants,i.
e.
wheretheyusedtolive.
Finally,basedonrecordsofmigrantskeptinthecom-munityagencies,alleligibleindividualparticipantswerechosenfromtheselected'migrantvillages'.
Thecriteriaforselectingparticipantswere:1)Theywereagedfrom15to65yearsold;2)TheyhadbeenlivinginBeijingforatleast3months;3)Theyweren'tregisteredasper-manentresidentsinBeijing.
Withthehelpoflocalcommunityagenciesinthesethreedistricts,theinterviewwasconductedface-to-facebetweeninterviewersandintervieweesattheirtempor-aryplacesofresidenceinBeijingduringtheirfreetime.
Thestudyteamsetupastrictprocessofreviewandsupervisiontoensuresurveyquality.
Alloftheintervie-weeswereassuredthattheywouldremainanonymousduringtheinterviewandtheanalysis.
Therighttorefuseparticipationwasguaranteed.
Informedconsentwasobtainedfromeachparticipantatthestartoftheinterview,andallparticipantsreceivedagiftfollowing.
ThisstudywasapprovedbytheethicscommitteeofCapitalMedicalUniversity.
ThestructuredquestionnairesurveywasconductedbyateamoftrainedinvestigatorsfromMarchtoApril,2008inthethreedistrictsselectedinBeijing.
Atotalof2,545migrantworkerswereenrolledinthestudy.
Thequestionscoveredsuchareasassocialdemographicfea-tures,perceivedhealthstatus,healthinsurancecoverage,health-seekingbehavior,perceptionsofhealthriskandsoon.
Pengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page2of10Thequestionnairewasdevelopedinthreesteps:Firstly,theitemsofthequestionnaireweregeneratedfromliteratureresearch.
Secondly,theywereevaluatedbyaformalconsensusprocessbasedonanominalgrouptechnique(NGT),whichisastructuredvariationofsmallgroupdiscussionmethods.
Theprocesspre-ventsthedominationofdiscussionbyasingleresearcher,encouragesthemorepassivegroupmemberstoparticipate,andresultsinasetofprioritizedsolutionsorrecommendations[11,12].
Lastly,thequestionnairewaspilotedon94migrantworkersfromChaoyangdis-trict.
Theinternalconsistencyreliability(Cronbach'sa)forthefullscalewas0.
812.
Meanwhile,facevalidityandcontentvalidityofthequestionnairewerebothcon-firmedbyepidemiologistsandexpertsfromhealthadministration.
Theresultsindicatedthatthequestion-nairehadgoodreliabilityandvalidity.
StatisticalAnalysisPriortotheanalysis,allquestionnaireswerereviewedforaccuracy.
TworesearchassistantsindependentlyuploadedthedataintoacomputerizeddatabaseusingEpiData3.
0.
Chi-squaretestwasperformedtoanalyzedifferencesinthehealth-seekingbehaviorbetweendif-ferentsocio-demographicgroupsofmigrantworkers.
Thedifferencewasconsideredstatisticallysignificantifthe2-sidedPvaluewaslessthan0.
05.
Asahierarchyexistsinthedataset,amultilevelmethodology(MLM)isusedtodemonstratetheindependenteffectsoftheexplanatoryvariablesonhealthseekingbehaviorinthefinalmodels,theparameterestimatesareexponentiatedandinterpretedasrelativerisks.
Amongthemultilevels,level1isindividual,level2is'migrantvillage',level3istown,andlevel4isdistrict,respectively.
AllanalyseswereperformedusingtheMLwiNsoftwarepackage(MlwiNversion2.
02,RasbashJetal,2005)andSPSSforWindows,version12.
0(SPSSInc.
,Chicago,IL).
ResultsSocio-demographiccharacteristicsoftherespondentsAtotalof2,545migrantworkerswereenrolledinthestudy,excludingincompletedata,2,478validrespon-dentswerereceived(97.
4%responserate).
71.
4%ofrespondentslivedinChaoyangDistrict,13.
2%inHai-dianDistrict,and15.
4%inFengtaiDistrict.
AsTable1shows,ofthe2,478participantsagedfrom15to65,theiraverageagewas33.
9(standarddeviation(SD)7.
2),71.
2%agedfrom20to39yearsold,and57.
2%aremales.
11.
3%ofthemwereilliterateoralmostilliterate.
Thewholesaleorretailsectorandlodgingcateringservicesectorwerethemajoremployersofemployedgroups,andaccountedfor28.
3%and19.
9%oftherespondents,respectively.
Table1Socio-demographiccharacteristicsofmigrantworkersinBeijing(n=2478)Variablen%GenderFemale106042.
8Male141857.
2Age(years)15-19883.
620-2976430.
830-3998440.
440-4946818.
950-591245.
0Over601521.
3EducationIlliteracy28011.
3Primaryschool52821.
3Secondaryschool120648.
7Highschool40616.
4University/collegedegree582.
4OccupationWholesaleandretail70228.
3Lodgingcateringservice49419.
9Construction45418.
3Manufacturing32012.
9Transport,storageandpostal30212.
2Domesticservice1124.
5Others943.
8Workinghoursperday(hours)Lessthan849419.
98-955022.
210-1167227.
112-1359424.
0Over131686.
8Monthlyhouseholdincomepercapita(RMB)Lessthan250984.
0251-5001526.
1501-75064025.
8751-100092837.
41001-125041016.
5Over125025010.
1DurationofstayinBeijing(years)Lessthan152021.
01-5154962.
5Over540916.
5InsurancecoverageNone232994.
0Employer-basedmedicalinsurance572.
3Commercialmedicalinsurance271.
1Socialhealthinsurance220.
9Industrialinjuryinsurance20.
1Others401.
6Note:Table1presentsthesocio-demographiccharacteristicsofallthemigrantworkersthatparticipatedinthestudy,thetotalsampleis2,478.
Pengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page3of10Thesurveyalsoshowedthatmigrantworkers'averageworkingtimewas6.
2daysperweek,10.
3hoursperday.
30.
8%ofthetotalsubjectsworkedmorethan12hoursperday.
Itwasfoundthatthemigrants'monthlyhouse-holdincomepercapitawas842YuanRMB,amongthem10.
1%madelessthan500Yuan,andonly10.
1%mademorethan1,250Yuan.
Ofallthemigrantsinvestigated,58.
2%livedwiththeirfamilymembersinthe'migrantvillages'.
96.
9%ofthesubjectslivedinrentalhouses,and2.
5%livedindormi-tory-styleaccommodationsprovidedbytheirworkunits,sharingwithcolleagues,andwherethereexistpublictoiletfacilities.
Thissurveyshowedthat2,329(94.
0%)ofthetotalrespondentshadnoanyinsurancecoverageinBeijing,only2.
3%hademployer-basedmedicalinsurance,1.
1%hadcommercialmedicalinsurance,0.
9%hadsocialhealthinsurance,and0.
1%hadindustrialinjuryinsurance.
HealthseekingbehaviorandriskperceptionsamongmigrantworkersAccordingtoself-ratedhealthstatuses,1,135(45.
8%)oftherespondentsfeltverygood,whileonly2.
3%feltbadand0.
2%feltverybad.
Astothepreferablemedicalinstitutionstheywouldconsult,504(20.
3%)ofthetotalsubjectsrepliedtheyneverseekanytreatmentinmedi-calinstitutionsinBeijing.
Oftheremainingsubjects,31.
6%selectedvillagehealthclinicsorcommunityhealthservicestations(Table2),while172(6.
9%)selectedso-calledprivateclinics(accordingtothesuper-visedrecordskeptinthelocalhealthbureau,mostoftheso-calledclinicsinthe'migrantvillages'ofthethreedistrictswereunlicensed,andtheserviceproviderswereunqualifiedpractitionersinBeijing).
Regardingtherea-sonswhytheyselectedso-calledprivateclinics,therela-tivelylowermedicalexpenses(48.
8%of172subjects)andeasieraccesstohealthservices(36.
0%)weremainlymentioned.
ConcerningwhatmeasureswouldusuallybetakenwhentheyfellillinBeijing(Inthisstudy,illnessmeanssicknessorimpairmentthatoftenaffectsawholebodyorwholesystem),316(11.
8%)ofthetotalsubjectsrepliedtheyhadnotsofarfallenill,66.
1%oftheremaining2,162respondentsansweredthattheywouldseeadoctor,27.
6%wouldtakeself-medication,3.
7%wouldhavearest,andanother2.
6%wouldn'ttakeanymeasures.
Astowhythemigrantworkerswouldn'tvisitadoctorwhenill,66.
2%of732subjectsansweredthattheyfeltit'snotabigtrouble,8.
9%admittedthattheywereunabletopaymedicalexpenses,7.
0%saidthatitwasduetotheunreasonablechargesinmedicalinstitu-tions,5.
5%expressedhavingnofreetime,and6.
2%thoughttheyknewhowtodealwithillnessthemselves(Table3).
Astable4shows,309(324incidents)ofthetotalrespondentsfellillwithinthepasttwoweeks(two-weekprevalencerateofthemigrantswas13.
1%).
Of324inci-dents,36.
4%hadseenadoctor(two-weekvisitationrateofthetotalsamplewas4.
8%),33.
3%hadtakenself-med-ication,while30.
3%hadn'ttakenanymeasures.
Reasonsastowhysubjectsdidn'tseeadoctorwereduetoinabilitytoaffordthehighmedicalexpenses(40.
5%of206subjects),neglectoftheseverityofthediseases(33.
4%)andnofreetime(26.
1%).
Amongthosewhoevervisitedadoctor,44.
6%hadchosentogotovillagehealthclinicsorcommunityhealthservicestations,while20.
0%selectedtheso-calledprivateclinics.
Withinthepasttwelvemonths,4.
6%(114)ofrespon-dentshadreceivedhospitalinpatientcare,ofwhich42(36.
8%)selectedhospitalsinBeijingand72(63.
2%)selectedhospitalsintheirhometown.
ThereasonsastoTable2Self-reportedpreferredmedicalinstitutionsbymigrantworkerswhenfallenillinBeijingMedicalinstitutionsn%Notseekingcareinmedicalinstitutions50420.
3Villagehealthclinicsorcommunityhealthservicestations78431.
6Townshiphospital35814.
4District-levelhospital26610.
7City-levelhospitalorabove36214.
6Unlicensedprivateclinic1726.
9Others321.
3Total2478100.
0Note:Table2presentstheself-reportedpreferredmedicalinstitutionsbymigrantworkerswhenfallenillinBeijing,504ofthetotalsubjectsrepliedtheywouldneverseekanyhealthcarefrommedicalinstitutions(n=2478).
Table3Self-reportedmainreasonsfornotseekinghealthcareamongmigrantworkerswhenfallenillinBeijing(n=732)Mainreasonsn%Feelingtheirowndiseasesnotsevereenough48566.
2Unabletopaymedicalexpenses658.
9Unreasonablechargesinmedicalinstitutions517.
0Knowinghowtodealwithdiseasesthemselves456.
2Havingnofreetime405.
5Longdistancefrommedicalinstitutions131.
8Complicatedmedicalprocedures131.
8Longqueuingandwaitingtime121.
6Poorserviceattitudeanddiscrimination40.
6Excessiveservice10.
1Others20.
3Total732100.
0Note:316ofthetotalsubjectsrepliedtheyhadnotyetgottensick,1,430(66.
1%)oftheremaining2,162respondents(2,478minus316)answeredthattheywouldseeadoctor,whiletheremaining732subjects(2,162minus1,430)wouldnotseekinghealthcare,thereasonswereshowninTable3.
Pengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page4of10whysomedidn'tselecthospitalsinBeijingincludehighmedicalexpenses(52.
7%of72subjects),inconvenientandinaccessibleservices(28.
6%),andbeingdiscriminatedagainst(4.
8%).
Meanwhile,28intervieweesof142subjectswhowererecommendedbytheirdoctorstobehospita-lizedwerenotadmittedtoahospitalwithinthepasttwelvemonths(from1Mar,2007to28Feb,2008),theratioofwithouthospitalizationtothosewhoshouldhavebeenhospitalizedwas19.
7%.
Ofthisgroup,14(50.
0%)answeredtheywereunabletoaffordthehighmedicalexpensesand33.
3%thoughttheirillnessweren'tsosevere.
AnalysisoffactorsassociatedwithhealthseekingbehavioramongmigrantworkersinBeijingInordertoexplorethefactorsassociatedwithhealthseekingbehavioramongmigrants,Chi-square(c2)testswerefirstlyconductedtocomparethedifferencesbetweenmigrantworkerswithdifferentsocio-demo-graphiccharacteristics.
Astable5shows,nostatisticallysignificantdifferencewasfoundinthehealthseekingbehavioramongthoseofdifferentgender,age,occupa-tionordurationofstayinBeijing.
However,differingeducationlevel,monthlyhouseholdincomepercapita,workinghoursperdayandinsurancecoveragewerefoundtobestatisticallysignificantlyassociatedwiththehealthseekingbehaviorofmigrantworkers(Pcomepercapita,andinsurancecoverageasindependentvariables(Table6).
Healthseekingbehaviorwasmeasuredasfol-lows:one,ifthemigrantworkervisitedadoctorwhenhefellillwithinthepasttwoweeks,andzero,ifhedidn'tgotovisitadoctor.
Themultilevelmodelanalysisrevealedthathealthseekingbehaviorwassignificantlyassociatedwithinsurancecoverage.
Meanwhile,monthlyhouseholdincomepercapitaandworkinghoursperdayalsomadeasignificantdifferencetothehealthseekingbehavioramongmigrantworkersinBeijing.
DiscussionHealthissuesofmigrantworkersinBeijingInBeijing,theincreasingmigrantpopulationhasincreaseddemandfortheprovisionofvarioushealthservices,includingprimaryhealthcareservices,alliedmedicalservices,schoolhealthprogramsaswellasover-allhealthservicemanpower.
Inthisstudy,thetwo-weekprevalencerateofthemigrantworkerswas13.
1%,whichwas4.
6%lowerthanthatofthetotalruralpopulation(17.
7%)reportedbythenationalhealthservicessurveyin2008[13],andalsolowerthanthatofmigrantpopulationsinothercitiesofChina,suchasKunshanCity,JiangsuProvince(18.
2%)[14].
Thisphenomenaismainlyduetomostmigrantworkersareyoungandhealthycomparedtoresidentsinreceivingcom-munitiesandsendingcommunities.
Moreseriouscondi-tionsresultedinamigrant'sreturnhometobelookedafterbyfamilyandtoavoidthehighmedicalandlivingcostsincities,whichhastheperverseeffectofmakingthecountry-sideexportgoodhealthandre-importillhealth[15].
ArecentchangeistakingplaceamongmigrantsinBeijing,whichistheproportionofmigrantsmovewiththeirfamilymembersincreases[3].
ThisstudyshowsthatmorethanhalfofthemigrantsbringtheirfamilytoBeijing.
Withthehouseholdregistration(hukou)systeminChina,rural-urbanmigrantsareclassifiedastemporaryresidents,irrespectiveofhowlongtheystayinBeijing.
Theytendtorebuild'aruralsociety'inthecity,andestablish'avillage-amidst-the-city'.
Withveryfewexceptions,migrantsarefrequentlymarginalizedinurbancommunitiesandaretargetsofdiscrimination[16,17].
Theyusuallyliveinpoorlysanitizedandover-crowdeddormitoriesprovidedbytheiremployersorinothersharedaccommodations[18,19].
Inthissurvey,mostofthemigrantworkerswereoflowsocioeco-nomicstatusandtheylivedinrentedhousingonthecityoutskirts,whileotherslivedindormitory-styleaccommodationswithpublictoiletfacilities.
Over-crowded,insalubriouslivingconditionsmayamplifytheeaseofspreadofinfectiousdiseasesamongthepopulation.
Poorlivingconditionsandinattentiontotheirownhealthmakemigrantsvulnerabletolong-termhealthproblems[20].
Table4HealthseekingbehaviorwithinthepasttwoweeksamongmigrantworkerswhofellillandvisiteddoctorsItemPerson-time%UtilizationofhealthservicesSawadoctor11836.
4Self-medication10833.
3Nonuse9830.
3Total324100.
0TypeofselectedmedicalinstitutionsVillagehealthclinicsorcommunityhealthservicestations5344.
6Townshiphospital76.
2District-levelhospital2016.
9City-levelhospitalorabove1512.
3Unlicensedprivateclinic2420.
0Total118100.
0Note:309(324incidents)ofthetotalrespondentsfellillwithinthepasttwoweeks,whileonly4.
6%(118)oftherespondentshadvisitedadoctor.
Pengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page5of10FactorsassociatedwithhealthseekingbehaviorandriskperceptionofmigrantworkersBecausetheirjobswereonshort-termbases,migrantworkerssufferedfromunstablelives,littlesocialsupportandconcernabouttheirfuture[21].
Whentheirexpectedresidencyinagivenlocationislimited,themigrantworkersarestronglydiscouragedtoinvesttimeandmoneyintheirtemporarylivingplacesorTable5AssociationofdemographiccharacteristicsandhealthseekingbehavioramongmigrantworkerswhofellsickinthepasttwoweeksCharacteristicNumberoffallensickNumberofthosewhosawadoctor(%)c2PvalueGenderFemale15758(36.
9)0.
0360.
850Male16760(35.
9)Age(years)15-194517(37.
8)0.
8270.
97520-295319(35.
8)30-394821(43.
8)40-495715(26.
3)50-596123(37.
7)Over606023(38.
3)EducationIlliteracy5312(22.
6)9.
8570.
043Primaryschool6521(32.
3)Secondaryschool14555(37.
9)Highschool5124(47.
1)University/collegedegree106(60.
0)OccupationWholesaleandretail4121(51.
2)10.
6990.
098Lodgingcateringservice5214(26.
9)Construction4010(25.
0)Manufacturing4615(32.
6)Transport,storageandpostal4217(40.
5)Domesticservice5826(44.
8)Others4515(33.
3)Workinghoursperday(hours)Less87034(48.
6)15.
2900.
0048-96027(45.
0)10-115623(41.
1)12-136517(26.
2)Over137317(23.
3)Monthlyhouseholdincomepercapita(RMB)Less2506510(15.
4)37.
1980.
000251-5005915(25.
4)501-7505116(31.
4)751-10006326(41.
3)1001-12504625(54.
3)Over12504026(65.
0)DurationofstayinBeijing(years)Less18925(28.
1)4.
0750.
1301-512351(41.
5)Over511242(37.
5)InsurancecoverageYes2014(70.
0)10.
3800.
001No304104(34.
2)Note:309(324incidents)ofthetotalrespondentsfellillwithinthepasttwoweeks(n=324).
Pengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page6of10employer-basedinsuranceprograms,oreventoinvestintheirpersonalhealthandsafetymeasures[22].
Thecompletedstudyshowsthatlessthan3%ofmigrantswerecoveredbyhealthinsuranceschemes,albeiteventhosewouldhaveverylimitedaccesstohealthservicesduetothelowleveloffinancialprotectionthattheseschemesprovide[18].
Thisstudyshowsthatinsurancecoverageplaysanimportantroleinhealthseekingbeha-vior,while94.
0%ofthemigrantworkersdon'thaveanyinsurancecoverageinBeijing.
Thisindicatesthat,todate,anoverwhelmingmajorityofthispopulationhasbeenuninsuredandhavingtopayout-of-pockethealthexpenses.
Moreover,thecostofmedicalcarehasrisendramaticallyinrecentyears,20.
3%ofthemigrantsinthisstudystatedthattheywouldneverseekanyhealthcarefrommedicalinstitutions.
Amajordrivingforcebeingthatperverseincentivesalteredphysicians'beha-viortowardself-interestattheexpenseofpatients,evenwhereprofessionalethicsdictatedotherwise[23].
Themigrantworkersarethusputinadisadvantagedposi-tionregardingaccesstohealthcareserviceswhenwork-ingandlivingintheurbanareas[24,25].
ThemeanstoprovideeffectivehealthservicesformigrantpopulationshasbecomeanissueofurgencyfortheChinesegovernmentandlocalcitycouncils[26].
Expandinghealthcoveragetomigrantswillbecriticalforeffectivepreventionandcontrolofepidemicdiseasesandforclosingthewideninggapsinhealthstatusesacrosssub-populationsinChina.
Thesuccessofhealthreformswillbeshapedtoalargeextentbyhowmigrantworkersareincorporatedintotheruralorurbaninsuranceschemesandhoweffectivepopulationhealthinitiativesareinreachingthemigrantpopulation[27].
Inthissurvey,thetwo-weekvisitationratetodoctorswas4.
8%,onlyaccountingfor36.
4%ofthemigrantworkerswhofellillwithinthepasttwoweeks.
Thisis10.
4%lowerthanthatofruralpopulations,and7.
9%lowerthanthatofurbanpopulationsreportedbythenationalhealthservicessurveyin2008[13].
Mean-while,nearlyone-fifthofthesickmigrantswhowererecommendedbyphysicianstohavebeenhospitalizedfailedtoreceivemedicaltreatment.
Accordingtoself-reportedreasons,thehighcostofhealthservicewasasignificantbarriertohealthcareaccess.
Themultilevelmodelanalysisalsoindicatesthathouseholdincomeisakeyfactorintheutilizationofhealthservices.
Beingunabletopay,somepeoplemaychoosetonotseekhealthcareserviceswhentheyfallill.
AlthoughmigrantworkerslivetemporarilyinBeijing,theyhavetofacethesameproblemsasthefarmersfacedinruralChina,whichismedicalexpenditurehasclearlybecomeanimportantcauseoftransientpoverty,and,indeed,oneofthemajorpovertygenerators[28-30],Studiesshowthatthehighcostofhealthservicesandthelackofanyhealthinsurancehaveresultedinunder-utilizationofhealthcareservicesamongmigrants,whichhadledtoaseriesofineffectivehealthseekingbehaviorssuchasunsupervisedself-treatment,goingtounregulatedclinics,or'justholdingon'with-outseekinganymedicalcare[8].
Thissurveyindicatesthattheabsenceofhealthcareawarenessandriskperceptionamongmigrantsdeservesmoreattention.
Nearlyone-thirdofthemigrantworkerschosetotakeself-medication(33.
3%)ornomeasures(30.
3%)whentheywereillwithinthetwopastweeks.
Moreover,theChi-squaretestresultindicatesthatthosewithlowereducationallevelsshowalowerprobabilitytoutilizehealthservicesthanthatofthehigheredu-catedgroups.
Someofthosethoughttheirdiseaseswer-en'tsevere,andwhatismorenoteworthyisthatasmallnumberofthemthoughttheycouldtreatthediseasesthemselves.
Duringtheinterview,wefoundmorethantenpercentofthemigrants(273subjects)whosethoughtpatternsusuallyreflectedanimisticandreligiousbeliefstosomeextent,andtheyhadlittleknowledgeorabilitytopreventdiseasesandcareforthoseinanunhealthystate,potentiallyresultingingravehealthconsequencesinthelongterm.
Table6MultilevelmodelsonfactorsrelatedtohealthseekingbehavioramongmigrantworkerswhofellsickinthepasttwoweeksVariablebSEc2PORFixedpartConstant-2.
1850.
1677.
3540.
0070.
112EducationPrimaryschool(illiteracy)0.
3580.
2172.
8530.
0911.
430Secondaryschool(illiteracy)0.
4200.
1092.
5230.
1121.
522Highschoolorabove(illiteracy)0.
4530.
1653.
3010.
0741.
573Monthlyhouseholdincomepercapita251-500(Less250RMB)0.
4480.
1674.
4580.
0351.
565501-750(Less250RMB)0.
5770.
1568.
2010.
0041.
781751-1000(Less250RMB)0.
6110.
1835.
9620.
0151.
8421001-1250(Less250RMB)0.
6460.
2546.
9870.
0081.
908Workinghoursperday8-9(Less8hours)0.
1450.
1021.
3770.
2411.
15610-11(Less8hours)-0.
0080.
0033.
9510.
0470.
99212-13(Less8hours)-0.
0130.
0094.
2520.
0390.
987Over13(Less8hours)-0.
5321.
1639.
2140.
0020.
587Insurancecoverage(Yes)0.
8960.
11510.
1060.
0012.
450RandompartLevel2u0jk20.
7320.
2183.
5810.
0582.
079Level1scaleparameterδ10.
000---Note:Categoryofeachvariableintheparenthesesisthereferencegroup.
309(324incidents)ofthetotalrespondentsfellillwithinthepasttwoweeks(n=324).
Pengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page7of10Ourinvestigationshowsthatworkingovertimeiscommonformigrantworkers,nearlyone-thirdofthetotalsubjectsworkmorethan12hoursperday,andmostcannotrestonstatutoryholidays.
Moreover,31.
2%workinthemanufacturingandconstructionsectors,whichbelongtolabor-intensivesectors,andhigh-riskjobs,workareasinwhichovertimewillseverelyharmtheirphysicalandmentalhealth[4,31].
Themultilevelmodelanalysisindicatedthatthelongerworkinghourswereassociatedwithlowerprobabilityforhealthseekingbehavior.
Thiscanalsobeseenintheself-reportedmainreasonsfornotseekinganymedicalcarewhiletheywereillasnearlyone-thirdcomplainedofhavingnofreetime.
Ourfindingsstronglysuggestthatatten-tionshouldbepaidtoover-workinginmigrantpopula-tions.
Tomaintainmigrantswell-being,thelaborandsocialsecuritysectorsshoulddesignandimplementappropriateregulationsorlawstoguaranteelegalrest-ingtimeforthemigrantworkers.
Thedifferentbackgroundsandperspectivesoflocalhealthcareprovidersandpatientsrequireattentionbepaidtothepotentialdifficultiesofdoctor-patientinterac-tion.
Duringtheinterview,wefoundthatduetoper-ceiveddiscriminationandmistrustfrommedicalprofessionals,someofthemigrantworkerswerereluc-tanttoresorttohealthservicesbeforetheythoughttheirdiseaseswereseriousenoughtogotohospitals.
More-over,one-fifthofthemigrantworkerssoughtfolkreme-diesfromunlicensedprivateclinics.
Becausethesepractitionersoftencomefromthesamehometownsasmigrantworkers,familiaritywashelpfulindevelopingagoodphysician-patientrelationship.
Migrantstendtoputtheirtrustinthefolkhealersmorethanformallytrainedhealthcareproviders.
However,mostoftheservicepro-vidersintheso-calledprivateclinicswereunqualifiedpractitionersinBeijing.
TheycamefromdifferentruralareasofChinaandsomeofthemusedtobevillagedoc-torsintheirhometown.
Toavoidsupervisionfromthelocalhealthadministrativedepartments,theyusuallypracticedsecretlyintheirrentalhousesorprovidedhomevisitingservicesformigrantworkersinBeijing.
Moreover,throughourfieldobservationsandinvestiga-tionfromthelocalhealthbureau,wefoundthereexistedalotofdisappointingfactsregardingtheso-calledprivateclinics,includingunsanitaryconditionsinmedicalfacil-itiesandalackofmodernmedicalequipment.
Misdiag-nosisandmistreatmentmaybeinevitableandseriousharmcouldbedonetomigrantworkerswhentheyseekhealthcareservicesfromtheseunlicensedclinics.
SuggestionsonsolutionstothehealthseekingbehaviordilemmaofmigrantworkersAdequatehealthcareisonecrucialconsiderationinacivilsociety,andeverypersonshouldhavetherighttoaccesscare[32].
Themigrantsshouldnotbedeprivedofentitlementtohealthbenefitsandcommunityser-vicesbecauseoftheirhouseholdregistrationstatus[8].
Oneofthemainchallengestohealthcareplannersistoreachthemostmarginalizedandvulnerablepopulationsandtoensureuniversalaccesstoaffordableandequita-blehealthcareservices[33].
Whilehealthinsuranceschemeswillremainlimitedfortheforeseeablefuture,attentionshouldfocusonprovidingaffordablehealthcareservicestouninsuredmigrants[20].
Relevantpoli-ciesofpublicmedicalinsuranceandassistancepro-gramsshouldbevigorouslyimplementedformigrants.
Tofurtherimprovethehealthsituationandriskpercep-tionamongthemigrantworkers,andfundamentallysolvetheirproblemofhealthservicesaccess,properattentionandappropriatepoliciesareespeciallyrecom-mended.
Firstly,thecentralgovernmentshouldincreaseitsinvestmentinmedicalandhealthservicesforthemigrantworkers.
Theexpensesfortheprovisionofhealthcareservicesforthemigrantpopulationshouldbeincorporatedintothestatebudgetbymeansofgov-ernmenttransferpayment.
Theresponsibilitiesofallrelevantgovernmentalbodies,includingpublicsecurity,medicalandhealthcareinstitutionsandthemigrantpopulationadministrationdepartmentsshouldbecoor-dinated[34].
Secondly,tosupplyadequatebasicmedicalandpublichealthserviceforthemigrants,thecurrentcapacityofserviceprovisionincommunityhealthser-viceorganizationsneedstobeexpanded.
Thehealthcareserviceinstitutionsshouldbestaffedinproportiontothenumberofbothpermanentresidentandmigrantpopulation.
TheStateshouldacknowledgethenecessityfordiversifyingthehealthcareworkforceforthebenefitofallpopulations.
Thirdly,thegovernmentandcon-cernedorganizationsshouldofferhealtheducationandimprovesocialsupportforthemigrants[35].
Thehealthservicesprovidersinformalmedicalinstitutionsshouldprovidepatient,considerateandprofessionalservicesformigrantstohelpthemincreasetheirsenseofattach-menttotheircurrentcommunities.
Professionalhelpshouldbemorereadilyaccessibleandaffordabletothepopulationsothatdemandsofdifferentlevelscanbesatisfied[33,35].
ConclusionThissurveycontributestoourunderstandingofthehealthseekingbehavioramongChineserural-to-urbanmigrantworkersandindicatesthatthestateofthecur-renthealthservicessystemdiscouragesmigrantworkersfromseekingappropriateandqualitycare.
AwidespreadchallengeofChina'spublichealthsystemintermsofhowtoprovideequitableaccesstothemigrantworkersemerges,andthereisstillalongwaytogotoameliorateurban-ruralinequalityandintegratemigrantsintothePengetal.
BMCHealthServicesResearch2010,10:69http://www.
biomedcentral.
com/1472-6963/10/69Page8of10urbansocietyandsocialwelfarenetwork[36].
Feasiblemeasuresneedtobetakenimmediatelytoreducetheriskofunhygienicpractices,andequityshouldbeassuredinaccesstohealthcareservicesamongmigrantgroups.
Theresearchisdesignedasdescriptiveratherthananalytical,itoffersadescriptionofthemigrantwork-ersinBeijing,causalfactorsareundeterminedthroughthiscross-sectionalsurvey,andovergenerali-zationislikelydespiteeffortstoavoidit.
Acontinu-oussurveyisneededtoupdatethesedatasoastogeneratemorefeedbackforexperience-basedsugges-tionsonimprovingthehealthseekingbehaviorofthemigrantworkers.
AcknowledgementsTheauthorsaregratefulforthehelpfulcommentsoftwoanonymousreviewers.
ThisstudywasconductedwiththesupportoftheCapitalFoundationofMedicalDevelopmentofChina.
Authordetails1SchoolofHealthAdministrationandEducation,CapitalMedicalUniversity,Beijing100069,China.
2SchoolofPublicHealth,PekingUniversity,Beijing100083,China.
3OfficeofHealthEmergency,MinistryofHealth,Beijing100044,China.
Authors'contributionsWNLparticipatedinthedesignofthestudyanddraftedthemanuscript.
YCPparticipatedinthedesignofthestudyandhelpedtoedit,draftandrevisethemanuscript.
WHCconceivedthestudyandhelpedtodraftthemanuscript.
HQZassistedwitheditingandperformedthestatisticalanalysis.
HPHparticipatedinthestatisticalanalysisandreviewofthemanuscript.
Allauthorsreadandapprovedthefinalmanuscript.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
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