Effect of social integration on family doctor contracting services among migrant populations in China: a national cross-sectional survey

Abstract

Background

The family doctor (FD) contracting system is a key reform in the development of the Chinese health system, and is considered an effective way to ensure equitable access to healthcare services. This study investigates the effects of social integration on FD contracting services among migrant populations.

Methods

In total, 120,106 respondents from the 2018 China Migrants Dynamic Survey were included in this study. Two multivariate regression models were used to estimate the effect of social integration and other factors on FD contracting services among migrant populations.

Results

This study found that only 14.0% of the migrant populations had a FD. Multiple dimensions of social integration and some covariates were shown to be positively associated with FD contracting services, including average monthly household income, local medical insurance (odds ratio [OR] = 1.34, 95% confidence interval [CI] = 1.29–1.39), employment status (OR = 0.86, 95% CI = 0.82–0.91), settlement intention (OR = 1.15, 95% CI = 1.09–1.22), received health education (OR = 4.88, 95% CI = 4.51–5.27), sex (OR = 1.16, 95% CI = 1.12–1.20), age (OR = 1.66, 95% CI = 1.51–1.82), marital status (OR = 1.38, 95% CI = 1.31–1.46), sickness within a year (OR = 0.84, 95% CI = 0.79–0.89), and flow range (OR = 1.12, 95% CI = 1.07–1.16).

Conclusions

All dimensions of social integration, including economic integration, social identity, and social involvement, are associated with FD contracting services among migrant populations. Policymakers should focus on improving the signing rates of migrant populations and implement more effective measures to enhance their social integration, such as settlement incentives and encouraging social participation.

Background

Primary healthcare is the foundation of an effective health system, playing a crucial role in ensuring essential healthcare services that are accessible for the entire community. Family doctor (FD) contracting services are core components of primary healthcare and have been implemented in over 50 countries and regions worldwide.^1–3 Compared to other developed countries such as the United States and the United Kingdom, China’s FD contracting services system was introduced relatively late. Official implementation of FD contracting services in China began in 2016, with FD teams typically comprising FDs, nurses, and public health physicians from primary health institutions. FDs mainly include general practitioners, as well as practising doctors in township health hospitals and rural doctors. The FD is the first person in charge of contracting services and is responsible for the task assignment, management, and assessment of team members. Residents voluntarily select 1 FD team to sign a service agreement, and the FD team provides basic medical care, public health, and agreed health management services to residents, such as diagnosis and treatment of common and multiple diseases, referral appointments, basic public health services, health assessment, rehabilitation guidance, and home care.⁴ Funds allocated for contracted services include resources for national basic public health service projects, social medical insurance funds, and resident contracted fees.⁵

Although previous studies have found that FD contracting services in China can improve the quality of primary care and the health status of the population as well as effectively reduce medical care costs,^6–8 the signing and utilisation rates of FD contracting services are much lower than in developed countries. For example, 2 studies conducted in China found that the signing and utilisation rates of FD contracting services were 46.2% and 6.9%, respectively; however, in Europe, the average general practitioner utilisation rate was 75%.^9–11 Many factors affect Chinese residents’ use of FD contracting services. Most studies have found that age, sex, income level, education, insurance status, and health status are important factors influencing residents’ willingness or behaviour to sign up with a FD team.^12,13 Another important reason may be that FD contracting services are not mandatory in China, as in other countries. However, improving the implementation status of FD contracting services in China is essential to provide equal access to basic healthcare services and promote a “Healthy China”.

Migrant populations, defined as people who have resided in the inflow area for 1 month or more and do not have a local hukou, represent a large group in China. In China, the hukou system is a household registration system in which Chinese citizens are required to register their birth locations and are assigned a hukou type, either an agricultural (rural) hukou or a nonagricultural (urban) hukou, which affects the use of certain benefits in that area, such as hospitals, schools, or land purchasing rights. With rapid urbanisation and economic development, the size of the migrant population has increased rapidly. In 2020, there were 376 million migrants in China according to the seventh census data, accounting for 1 in every 4 people in the country. Despite the global COVID-19 pandemic, the migrant population has continued to expand. Migrant populations face many barriers when accessing healthcare resources and services due to the hukou system, lack of inclusive health policies, and their distinct characteristics.^14–16 Previous studies have reported disparities in access to and utilisation of health education services, essential public health services, and medical services between migrant and nonmigrant populations.^14,15,17 Ensuring equal access to healthcare services for migrant populations is an important goal within the Chinese health system. However, to the best of our knowledge, most previous studies have focussed on the accessibility of medical and public health services, neglecting the implementation status of FD contracting services among migrant populations.

Previous studies have found that social integration positively affects the health of migrant populations.^18,19 In addition, social integration has been found to be an important way of increasing the use of medical and basic public health services among migrant populations.^20,21 These effects may be due to the fact that social integration can help migrant populations learn about local health information and resources and use these health services effectively by enhancing their sense of belonging and health awareness. Social integration does not have a standard definition but can be understood as a dynamic process in which individuals become part of a social system.^22,23 Social integration typically includes 3 dimensions: economic integration, social identity, and social involvement.^24,25 Economic integration is the foundation of social integration and can be measured by employment status, household income, and insurance. Social involvement is an important pathway to social integration, and social identity is the goal of social integration, which includes the intention to settle.²⁶ Although previous studies have demonstrated that enhancing the social integration of the migrant populations is an important means of improving their health status and public health service utilisation, the impact of social integration on FD contracting services is unknown.

Thus, the main purpose of this study is to investigate the current status of FD contracting services, explore the effect of social integration on FD contracting services among migrant populations, and provide suggestions for promoting the equalisation of basic medical and healthcare services.

Methods

Data sources

This study used the pooled data from the 2018 China Migrants Dynamic Survey (CMDS), which is publicly available from the National Health Commission’s Migrant Population Data Platform (http://www.chinaldrk.org.cn). The CMDS is an annual large-scale national sample survey of migrant populations organised by the National Health Commission of the People’s Republic of China since 2009. The CMDS covers different survey topics each year, and the 2018 CMDS was the first to assess the status of FD contracting services. A stratified multistage probability-proportional-to-size (PPS) sampling method was used to select survey participants who were over 15 years old, had resided in the inflow area for 1 month or more, and did not have a local hukou. Eligible participants were interviewed. The PPS method was used to select towns and communities from 32 provincial units across the country. Subsequently, the villages/communities were selected using the same methodology. In total, 152,000 respondents from 7,000 sample sites completed the survey. A total of 152,000 migrants were interviewed (not including migrants from outside China), and after removing respondents with missing key information on social integration and FD contracting services, a total of 120,106 respondents were eventually included in this study.

Measures and definitions

FD contracting services

This study measured the signing rate of FD contracting services using a self-reported question: “Currently, have you signed a contract with a local family doctor?”. If the answer was “Have signed”, the signing situation of FD contracting services was coded as “yes”; if the answer was “Never signed, never heard of it” or “Never signed, but heard of it”, the FD signing situation was coded as “no”.

Social integration

Based on the previous literature and the questionnaires used in the survey, social integration was measured using 3 dimensions: economic integration, social identity, and social involvement.^20,24,25 Economic integration was measured using 3 indicators: average monthly household income, local medical insurance (with or without), and employment status (unemployed or employed). The quartile method was used to divide average monthly household income into 4 levels: Q1 (poorest), Q2, Q3, and Q4 (richest). Local medical insurance was measured through the question “Are you currently covered by any of the following social health insurance schemes? Where are you insured?”. Employment status was measured using the question, “Did you work for more than one hour for pay in the week before May Day this year? (this includes work within your family or being elf-employment)”. Social identity was measured by gauging settlement intention with the question, “Do you plan to stay locally in the future?”, which could be answered with no, not decided, or yes. Social involvement was measured using 2 indicators: health education (yes or no) and partymembership (yes or no). Specifically, receiving health education was measured by asking “In the past year, have you received health education in the following areas in your current community/unit of residence?”. Meanwhile, partymembership was measured by asking “Are you a member of the Chinese Communist Party or the Communist Youth League?”.

Covariate variable

Covariate variables include sex (male and female), age (≤44, 45–59, and ≥ 60), educational attainment (primary education or below, junior and senior high education, and college or above), hukou (agriculture and nonagriculture), marital status (single and nonsingle), self-reported health status (health, basic health, and poor health), sickness within a year (no and yes), and flow range (interprovincial and intraprovincial). Self-reported health status was measured by asking the question, “What is your health status?”, while sickness within a year was measured by asking the question, “Have you been ill (injured) or unwell in the past year?”.

Statistical analysis

First, descriptive analyses were conducted to describe the social integration and demographic characteristics of the migrant populations, using frequencies and percentages. Chi-square tests were used to analyse differences in social integration characteristics according to FD contracting status. Finally, multivariate logistic regression was used to estimate the association between social integration and FD contracting services using odds ratios and 95% confidence intervals. All data analyses were conducted using SPSS version 22.0, and P-value less than 0.5 were considered statistically significant.

Results

The demographic characteristics of migrant populations

The respondents’ demographic characteristics are shown in Table 1. In total, 120,106 respondents were included in the analysis (Fig. 1). The FD signing rate in the migrant population was only 14%. Of the 120,106 respondents, 51.1% were male, 75.8% were younger than 45 years old, 64.1% had junior and senior high school education levels, 82.9% had an agricultural hukou, 84.2% were nonsingle, 86.2% had a healthy self-reported health status, 88.0% had no disease for 1 year, and 50.3% were intraprovincial migrants.

Social integration characteristics of migrant populations

The social integration characteristics of the migrant population are shown in Table 2. In terms of economic integration, 35.8% of the migrant population had an average monthly household income in Q3, 68.7% did not have local medical insurance, and 83.2% were employed. Regarding social identity, 86.8% of the migrant population planned to stay locally in the future. In the context of social involvement, 81.4% of the migrant population received health education, and 94.5% were not party members. FD contracting services among migrant populations differed significantly across all social integration indicators (P < 0.001).

Association between social integration and FD contracting services

The association between social integration and FD contracting services is shown in Table 3. Two multivariate logistic regression models, both adjusted for province, were used to assess the effects of social integration on FD contracting services. In unadjusted Model 1, which included only 3 dimensions of social integration, social integration was statistically associated with FD contracting services. In Model 2, which was adjusted for respondents’ general characteristics, social integration was still positively associated with FD contracting services. Specifically, migrant populations who had local medical insurance (OR = 1.34, 95% CI = 1.29–1.39), had settlement intention (OR = 1.15, 95% CI = 1.09–1.22), had received health education (OR = 4.88, 95% CI = 4.51–5.27), and were party members (OR = 1.10, 95% CI = 1.02–1.19), were more likely to sign with an FD, while those who had higher average monthly household income, and were employed (OR = 0.86, 95% CI = 0.82–0.91), were less likely to sign with an FD. Simultaneously, some general characteristics were associated with FD contracting services. For example, migrant populations who were female (OR = 1.16, 95% CI = 1.12–1.20), were aged 60 or older (OR = 1.66, 95% CI = 1.51–1.82), were nonsingle (OR = 1.38, 95% CI = 1.31–1.46), and were intraprovincial migrants (OR = 1.12, 95% CI = 1.07–1.16), were more likely to sign with a FD, while those who had a self-reported health status of basic health (OR = 0.84, 95% CI = 0.79–0.89) and had been sick within the last year (OR = 0.84, 95% CI = 0.79–0.89) showed the opposite trend.

Discussion

The FD contracting system is one of the key reforms in the development of the Chinese health system, and is also considered an effective way for people to have equitable access to healthcare services.²⁷ In this study, we found that only 14.0% of the migrant population had signed with a FD, which was much lower than the average signing rate of permanent resident populations in Shanghai from 2017 to 2020 (29.36%),²⁸ residents in Zhejiang in 2017 (50.43%),¹² and local residents in southern China in 2015 (54.7%).⁸ Although the Chinese government has made great efforts to improve access to healthcare services for the entire population, there is still a disparity between migrant populations and local residents regarding access to FD contracting services. Thus, further attention needs to be paid to this population in improve access to FD contracting services in the future.

In this study, an association was observed between social integration and FD contracting services, encompassing multiple dimensions of social integration. Economic integration emerged as an important factor influencing FD contracting services. Migrant populations with higher average monthly household income or who were employed were less likely to sign up with a FD. This is in line with previous studies showing that people with higher incomes tend to choose higher-level medical services.²⁹ One possible explanation for this finding is that higher-income migrant populations have better access to healthcare and management services and are more likely to use higher-level health services.^30,31 FDs are more focussed on providing basic treatment and may be perceived as less specialised than doctors in higher-level hospitals. The government should strengthen the promotion of a hierarchical medical treatment system and ensure a balanced layout of medical resources to facilitate the establishment of a sound primary medical service system. We found that migrant populations with local medical insurance are more likely to sign up with a FD. Medical insurance is an effective tool for promoting access to healthcare services, and prior studies have revealed that having medical insurance is associated with healthcare service use and health-seeking behaviours among migrant populations.^32,33Ontheotherhand, we speculated that migrant populations with insurance have greater health needs and are thus more likely to sign up with a FD and seek healthcare when they need it.³⁴

In relation to social identity, migrant populations with settlement intentions were more likely to sign up with a FD. Their willingness to remain in the inflow area indicates a strong sense of identity and belonging,³⁵ facilitating better integration with local life and use local health resources.³⁶ In addition, one study found that settlement intention may affect the awareness of health services among migrant populations³⁷; thus, migrant populations without settlement intention may not be aware of FD contracting services, and therefore be less likely to sign up with a FD. Therefore, it is necessary to increase the publicity of FD contracting services to the migrant population. In addition, more settlement incentives such as housing purchase subsidies, rental subsidies, and settlement fees should be implemented to improve migrant populations’ sense of identity and belonging.

This study found that social involvement is associated with FD contracting services among migrant populations. Higher levels of social involvement indicate that migrant populations are more adapted to local life and are more aware of local policies. This, in turn, can promote their initiative to seek health education and pay more attention to their health, thereby increasing the likelihood of accessing FD contracting services.³⁸ Specifically, migrant populations who had received local health education or were party members were significantly more likely to sign up with a FD. Social involvement is important for migrant populations to obtain information and resources. Those who received health education demonstrate better health awareness, making them more receptive to information about FD contracting services, and more inclined to enrol. Party membership is relatively difficult to obtain and the proportion of migrant population with party membership is less than 6%, which is lower than the proportion of nonmigrant population (more than 10%). In addition, party members are more advanced in terms of political landscape, thought, and action, so they are more receptive to new things and have stronger social involvement ability, making them more willing to sign with FD. To strengthen the social involvement of migrant populations, the government can implement measures, such as increasing the provision of health education services for the migrant population.

In addition to the dimensions of social integration, sex, age, marital status, illness status, and flow range were also related to the likelihood of contracting FD services. Similar to previous studies, those who were older or female were more likely to have a FD, possibly due to their increased focus on health issues.³⁹ Nonsingle migrant populations were more likely to sign up with a FD, potentially due to their heightened concern for the health of family members and a stronger sense of family responsibility. Contrary to previous findings,¹² we found that people with medical conditions were less likely to sign up with a FD, possibly due to a desire to access more specialised medical resources for their illness. In addition, due to the recency of the FD program and the population not informed about the type of medical care that FDs provide, the public may have more trust in specialists in high-class hospitals. Further, compared with inter-provincial migrant populations, intraprovincial migrant populations may be more likely to sign up with a FD to save on medical costs, considering the distance from their place of origin.

Limitations

The 2018 CMDS is a nationally representative survey of Chinese migrant populations. With a valid response rate of nearly 80% for the questionnaires, it provides a comprehensive overview of the FD contracting status among Chinese migrants. Nevertheless, this study has several limitations. Firstly, the cross-sectional design of CMDS precludes temporal and causal inferences. Secondly, information was self-reported, which can lead to recall bias. In addition, due to limitations of the indicators used, they may not fully reflect the social integration of migrant populations.

Conclusion

The rate of FD contracting among China’s migrant population is inadequate. All dimensions of social integration, including economic integration, social identity, and social involvement, are associated with FD contracting services among migrant populations. These findings suggest that policymakers should focus on improving the signing rate of migrant populations and implementing more effective measures to improve their social integration, such as implementing settlement incentives and encouraging social participation.

Acknowledgments

This study used data from the 2018 China Migrants Dynamic Survey, and did not receive any specific grants from funding agencies. We thank all health agency officials, staff, and participants associated with this survey.

Funding

Financial support was received from the Special fund for Clinical Research of Shandong Province Medical Association (Project No. YXH2019ZX009) and Wu Jieping Medical Foundation (Project No. 320.6750.2020-04-29). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflict of interest

The authors declare no competing interests.

Ethical approval

Non-applicable.

Data availability

The data that support the findings of this study are available from the National Health Commission of the People’s Republic of China; however, restrictions apply to the availability of these data, which were used under licence for this study and are not publicly available. However, the data are available from the authors upon reasonable request and with permission from the National Health Commission of the People’s Republic of China.

References