The elders’ choices of first-contact care and related factors in Zhejiang and Province,

Xiaoqian Hu , Hao Zhang , Xueshan Sun , Yuxuan Gu , Xuemei Zhen , Shuyan Gu , Yuanyuan Li , Minzhuo Huang , Jingming Wei, Hengjin Dong*([email protected]) Zhejiang University, School of Medicine, Hangzhou, China

Abstract Results Aim: This study aims to investigate elders’ choices of first-contact care when they felt ill in Zhejiang and Qinghai Choices of first-contact care province and its related potential pathways respectively. The proportion of elders preferred PHI as first contact-care in Qinghai was significant higher than that in Zhejiang. Family Methods: Data was from a cross-sectional survey in Zhejiang and Qinghai. We firstly compared elders’ choices of income, distance to nearest PHI and type of nearest health institution were significant factors affecting elders’ choices of first- first-contact care in two provinces. Then, we applied structural equation modeling to explore pathways from contact care in two provinces. Furthermore, along with the education and income level increasing, less Zhejiang elders selected socioeconomic status, accessibility, and health status to elders’ choices of first-contact care. PHI for first-contact care. In Qinghai, the time to nearest PHI was a significant factor related to choices. Results: The proportion of elders who selected primary health-care institutions as first-contact care in Qinghai was higher than that in Zhejiang. Socioeconomic status played an important role in Zhejiang model through direct and Pathways related to choice of first-contact care indirect ways. In Qinghai model, accessibility to primary health-care institutions was the leading cause for choosing The conceptual model based on theoretical considerations was used for analysis to obtain the optimal SEM, which was preferred first-contact care. theoretically meaningful and best fit our dataset. Modification indices suggested that some indicators in health status were Conclusions: A better understanding of complex pathways from factors to elders’ choices of first-contact care was allowed to co-vary. Thus, we modified them in two models accordingly. These two models had adequate fit. The squared essential which may inform priorities for maximizing the utilization of primary care further. multiple correlation calculated for choice of institutions was 0.611 in Zhejiang model and 0.289 in Qinghai model. Zhejiang model revealed statistically significant and negative direct effects from SES to choices of first-contact care, which implied that elders with higher SES didn’t prefer PHI as their first-contact care. Accessibility to PHI and health status had Methods positive direct effect on choices. That is, elders with better accessibility and better health status were more likely to choose PHI. Among these three latent factors, SES had the largest direct effect on choices followed by accessibility to PHI and health status. Data sources The indirect effect of SES on choices, through the mediating factor of health status, was positive and significant. After the sum Data used in this study was from a cross-sectional household survey conducted from June 2016 to August 2017 in Zhejiang and Qinghai province. The target population was residents of all ages lived in the survey area for more than 6 months. We adopted multi- of direct and indirect effects, we got a negative total effect of SES on preferred source of first-contact care. (Fig. 1) stage stratified cluster random sampling in this study. In the first stage, according to cluster analysis from the perspective of GDP in two In Qinghai model, only SES and accessibility to PHI had statistically significant direct effects on choices of first-contact care. provinces, we selected Jiashan county in Zhejiang and Chengxi , Pingan district in Qinghai to represent developed areas; Jinyun Unlike Zhejiang model, accessibility to PHI had the largest direct effect on choices among three latent factors. SES had a county in Zhejiang and Huzhu county, Jianzha county in Qinghai to represent underdeveloped areas. In the second stage, one urban significant and positive direct effect on accessibility to PHI, which implied that those with higher SES had better accessibility to and one rural area were randomly selected from each county or district. In the third stage, a number of households were randomly PHI. In addition, SES had a significant and positive indirect impact on choices, through the factor of accessibility to PHI. To sum Fig.1. Zhejiang structural equation model standardized results selected in line with the proportion of registered population and migrant population. In selected household, we interviewed every up, total effects of SES on choice of first-contact care were slight and negative. (Fig. 2) residents who have lived in the survey area for more than 6 months. In total, 4900 participants in 1619 households were interviewed. Our questionnaire was designed based on the high-quality questionnaire of National Health Services Survey (NHSS), which was organized by Chinese government. After widely used in national surveys, the NHSS questionnaire had been shown to have high reliability and validity 19. According to NHSS questionnaire, our questionnaire covered the following parts: family general information, family member demographic information, health status (EQ-5D), chronic disease information, health service utilization (included illness information of participants in previous two weeks, and inpatient service utilization during last one year), satisfaction and accessibility to PHI and willingness of utilization of medical services. Before the survey, this questionnaire was reviewed and evaluated by experts from health administrative department, hospitals and universities to ensure its quality further. Face-to-face household interviews were Conclusions conducted by trained and qualified investigators. A fieldwork supervisor was arranged to monitor the investigation process and conduct quality control. 5% of the sampled households were randomly revisited to check accuracy of the collected data. In conclusion, this study explored the complex network of factors associated with elders’ choices The Ethics Committee of School of Public Health, Zhejiang University approved this study. Written informed consent for all participants in the survey were obtained before the survey. of first-contact care in Zhejiang and Qinghai province. In Zhejiang, a developed area, SES was the leading cause for preferred source of first-contact care. While in Qinghai, an underdeveloped Study samples Since elders usually use more medical resources than other age groups9, this study limited the samples to those aged above 60 province, accessibility to primary care played an important role. Policies should be tailored to local years old. Thus, 694 Zhejiang elders and 319 Qinghai elders from 4900 respondents were involved in analysis. Then three Zhejiang conditions. A better understanding of pathways to choices of first-contact care among elders was elders and six Qinghai elders with missing information were excluded. Therefore, the final sample size in analysis was 1004, of which 691 elders were from Zhejiang and 313 elders were from Qinghai. critical, as we still need to promote utilization of PHI and strengthen primary care system. Our findings highlighted three policy implications： Indicator Choice of first-contact care. In the model, choice of first-contact care was a dichotomous observed dependent variable (1 = Primary 1.it may be helpful to adopt policies to widen the gap of reimbursement ratio among different Health-care Institutions (PHI); 0 = Hospital). levels of health institutions to guide elders increasing utilization of PHI.

Variables 2.Secondly, policymakers could strengthen propaganda and education of NHMS on elders with Variables were chosen based on availability in questionnaires, Andersen Health Services Utilization Model and their associations with higher SES in Zhejiang province. choices of first-contact care demonstrated by previous studies 2, 3, 7, 13-16: Socioeconomic status (SES). The latent construct of SES included education level, family income per capita and basic medical 3.Thirdly, it was essential to promote accessibility to PHI in Qinghai province, especially focusing insurance situation. on elders with lower SES. The government could make effort to increase the number and improve Accessibility to PHI. This latent variable included the distance to nearest PHI, the time to go to nearest PHI, and the nearest facilities was PHI or hospital. The higher value of this latent variable represents better accessibility to PHI. the ability of PHI, which would play an important role in optimizing the allocation and maximizing Health status. This latent variable included the mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, chronic utilization of medical resources. diseases, and self-rated health status, with increasing values for worse health status. In addition, more time are needed for health reform to achieve, as systemic improvements will Statistical Analyses ineluctably take a long time and cannot be achieved overnight. We firstly made Chi square tests to compare differences in choices of first-contact care by factors in Zhejiang and Qinghai respectively. Then SEM 20 was used to estimate model fit of the data and analyze direct and indirect pathways related to elders’ choices. The goodness of fit of the model was assessed by root-mean-square error of approximation (RMSEA), comparative fit index (CFI) and Tucker-Lewis Index (TLI). We considered that CFI and TLI greater than 0.90 and RMSEA less than 0.08 indicated a good fit Fig.2. Qinghai structural equation model standardized results of the model 21. The Bootstrapping method was used to verify statistical significance of indirect effects at p < 0.05 22.

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