| BackgroundWith the accelerated industrialization and urbanization of our country, the population movement, especially that rural population who migrates to the urban areas or economically developed areas has become irreversible. And it is also an inevitable phenomenon for our country's economic development and social transformation. Therefore, the left-behind population has become a common phenomenon. Although the elder left-behind can get some financial support from their children who has gone out for work, their health condition and physiological function are decreasing when the time past, and can not get a concern in nearby, lacking the comfort of kinship and the physical help. Some even still need to undertake the responsibility to take after and educate the offspring, or cultivate responsible farmlands which were left behind by their going out families. Therefore they become a population with special needs and problems. Long-term being left behind could bring psychological or physical health affects on the elder, as well as series of social problems. For example, the most essential problems are safety, economic support, daily care, medical care, spiritual comfort and so on. Deeper levels of social problems showed gradually as well, such as the establishment for rural pension system, financial capacity for the rural elder of our country, social stability, sense of responsibility of the young for the aging society, the establishment of harmonious society and so on. During the process of economic development and social changes, the elder left-behind becomes one of the important problems that can't be ignored in the process of our country's economic development and population aging. To improve the quality of their life, to better use of health service are the impressing problems in the field of social medicine and health service management, which would bring important practical significance for building a socialist harmonious society and realizes the aim of building new countryside. Hence, to study on the medical and health services utilization of the elder left-behind could bring practical significance and value for the improvement of the rural health service system and medical security system. The elder left-behind becomes the focus of the academia. The previous. studies had showed that①Most of the previous national scholars have been focused on causes of left behind problems, life quality, life satisfaction, life care, living condition, Social Solidarity mechanism, support, difficulties, problems,family relationships of the elder when their children going out, and so on;②The previous researches were mainly discussed the problem from the demographic and sociological aspects and most were the qualitative researches. However, no operational definition has been given by the current academia to the elder left behind. Though several researches have studied the life quality of the elder left behind, they were not systematical and comprehensively. The findings also mainly remained at the description of their health condition, lacking of in-depth analysis of health factors affecting the elderly staying in rural areas.③Studies on the use of health services for the elder left-behind population has not been reported.ObjectivesVia studying the general characteristics, health status, life quality and putative influencing factors, health and health care utilization and putative influencing factors among the elder left-behind population, we aims at giving advise and suggestion on improving the life quality of the elder left-behind population, establishing their pension system, increasing utilization of health services, discussing and solving their health problem. We also could give the theoretical basis for solving such problems to the government and the communities, and scientific basis for exploring health system reform in the rural areas as well.1. Describe the general characteristics of the elder left-behind popultaion.2. Quantitatively evaluate the life quality among the elder left-behind population and analyze the main influence factors. 3. Quantitatively evaluate health and health service utilization among the elder left-behind population and analyze the main influence factors.4. Give suggestions on the health policy for the improvement of health conditions of the elder left-behind population.MethodsThe study attempted to define " Elder left-behind " as the rural elderly who cannot live with their family members for a variety of reasons, over 60 years of age, having surviving children (including daughter-in-law and son-in-law)who went out to the outside of the town for more than 6 months and cannot carry out the duty of maintenance.1.Study area and Study population(1)Study areaThe study area is in Hengyang County of Hunan province. Hengyang is one of the 88 counties (county-level cities), belonging to the second largest city-Hengyang City which has 26 towns and 893 villages. At the end of 2007, it is the second most populous city of Hengyang City with a population of 1,114,700. It is a typical agricultural county with 803 800 agricultural population and163 700 migrant workers. In the study of the elder left behind, with the population ranking at the seventh and the per-capita GDP being in the middle level among 88 counties of Hunan Province, the per-capita net income of farmers being in the upper level, Hengyang County could be a representative sample,.(2) Study populationUsing multi-stage stratified cluster sampling, Firstly we divided the 26 townships into three layers according to the economic level (good,Medium and poor).Then one township was selected from each level and three villages were randomly selected from every township. Finally, all qualified old people of nine villages were selected as study population.2.Research Content and Instrument(1) General demographic data:Demographic variables were collected using self-made basic situation questionnaire. The contents involves gender, age, marital status, educational level, economic status, source of income, living habits, living conditions and child status etc al.(2)Health Status and Medical Service:We made the situation questionnaire with indices including prevalence of chronic diseases, two-week prevalence, two-week consultation rate, two-week non-consultation rate, hospitalization rate,non-hospitalization rate.(3) QOL:The quality of Life was collected using the version 2 of the SF-36 health survey.(4) Activity of Daily Living:Activities of Daily Living Scale was used.(5)Negative Life Events:Life Events Scale for the Elderly which was made by XiaoLin etc.(6)Sleep Quality:PSQI was used to measure sleep quality.3.Data CollectionOwing to the education level of the old, the face to face interview was adopted. The investigator asked the contents of the questionnaire one by one and recorded the results according to the answer of interviewees.4.Quality ControlThe quality of research was controlled by adopting piolt investigation, trained investigators,selecting credible guider,using quality control table,double data entry etc al. The reliability was measured by using the Consistency of investigator,test-retest reliability.5.Data AnalysisEpiData 3.0 was adopted to establish data-base. SPSS 13.0 was used in all analyses. The data was analyzed by using descriptive analysis, comparative analysis, Pearson correlation analysis, Ordinal regression, Logistic progressive regression analyses. And the level of significance is 0.05.ResultsData has been collected during February 10,2009 and May 28,2009. In the nine villages, there were 1198 elderly people aged 60 years and older, of which 1126 were qualified as our target population. Finally 1042 were investigated, the response rate was 92.54%. Except two persons, all the 1040 had completed information. For research,13 were eliminated because of having no surviving child.1.The general Characteristics of Rural Remained Elderly(1)24.83%of the total sample accorded with the definition of "Elder left behind".(2)Imgration Situation of the childrenBased on the definition, in the 1027 objects, there is 58.23% population having some of children going out and 24.83%having all of the children going out, left only 16.94%having no children going out for work.The five most prevalent situations were "Going out to other provinces" (70.5%), "going out for work" (84.5%), "going out for more than three years (91.42%), "Back home once every 0.5-1 years" (40.8%)and "back home once every 1-2years"(33.4%).(3) The general Characteristics of Rural Remained ElderlyIn the 1027 objects,255 were the elder left-behind, in which male accounted for 64.70%.The general comparison between the elder left-behind and the elder not left-behind:the elder left-behind population were younger, more likely to be male; After controlling the age factors,60-69 age group and the 70-79 age group had higher proportion of surviving spouses, and 60-69 age group and the 70-79 age group had higher level of education; Controlling for both gender and age, remained elderly had higher incidence of suicidal ideation and higher proportion of living with grandchildren (P<0.05); Among the elder left-behind group, the daily expenses and medical fees are more likely to be paid by their own,while among the elder not left-behind group, the daily expenses and medical fees are more likely to be paid by their children; When being sick, the elder left-behind population had higher proportion of taking care of themselves than the elder not left-behind population and had lower proportion of nursing by their children (P<0.05).The situations did not differ significantly in terms of household registration, nation, self-rating economic status, drinking, smoking, sleeping.The elder left-behind group had significantly higher scores in PSMS, IADL, ADL (P< 0.05). The five most prevalent life events for the elder left-behind population were " children for long-term immigration' (96.86%), "suffering chronic disease" (78.43%), "family financial difficulties" (33.73%), "self-hospitalization" (27.45%), "family member hospitalization" (27.06%). The five most prevalent life events for the elder not left-behind were " suffering chronic disease " (82.90%), "children for long-term immigration" (73.96%), "family financial difficulties"(39.77%)," loss of spouse"(33.68%), " self-hospitalization" (29.66%). The stimulus quantity of negative life events did not differ significantly between the two groups (P> 0.05)2.The life quality of rural remained elderly(1)The effects of "left-behind" on rural elderRegarding Rural physical and psychological health as dependent variables, "left-behind" as independent variables, univariate and multivariate analysis of ordinal regression analysis showed that "left-behind" decreased psychological health condition (P<0.05).(2)Univariate analysis①General condition:Gender, age, registered permanent residence, education level, occupation, economic status, medical insurance, drinking, amusement and suicide were associated with physical health; Economic status were associated with psychological health.②two-week prevalence:The elder left-behind who were not sick in past two weeks had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, psychological health, general health (P< 0.05)③ADL:The elder left-behind who had normal activity of daily living had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, mental health, general health (P< 0.05).④negative life events:The elder left-behind who had low stimulus quantity of negative life events had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, mental health, general health (P< 0.05) ⑤leep quality:The elder left-behind who had good sleep quality had significantly higher scores in physical function, role-physical, bodily pain, social function, role-emotional, general health (P< 0.05)(3)Multivariate AnalysisThe Ordinal Stepwise Regression show:①Gender, self-rating economic status, smoking, quantity of chronic disease, two-week prevalence, activity of daily living were the influencing factors of physical function. Gender self-rating economic status, quantity of chronic disease,two-week prevalence, stimulus quantity of negative life events were the influencing factors for psychological health. The Ordinal Stepwise Regression equation were (GenderX1, self-rating economic status X7,smoking X10,quantity of chronic disease X15 two-week prevalenceX16,activity of daily livingX17,stimulus quantity of negative life events X18): Logitl=-10.535+1.688Xl+1.221X7+0.985X7+0.887X10+1.850X15+1.2 71X16+2.923X17 Logit2=-7.425+1.688X1+1.221X7+0.985X7+0.887X10+1.850X15+1.27 1X16+2.923X17; Logitl=21.300+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18 Logit2=24.306+0.736X1+0.684X7+1.368X15+1.182X16+0.935X18In the village health clinics or private clinics, hospitals accounted for more than 70%.②35.4%of elderly people staying in hospitals hospital, 40.0%in the county hospital,24.6%more than in the municipal hospital; 43.7%of non-Aging hospitalized in hospitals,26.5%in the county hospital,29.8%in municipal above hospital.3.Health seeking behavior and health status(l)Health seeking behavior of rural elderly①70%of population chose village health clinics, private clinics or rural public health centre.②35.4%of the elder left-behind hospitalized in rural public health centre,40.0%in county hospital, and 24.6%in Municipal level and above hospital; 43.7%of elder not left-behind hospitalized in rural public health centre,26.5%in county hospital and 29.8%in Municipal level and above hospital.(2)Two-week prevalence and chronic disease prevalenceThe two-week prevalence of the elder left-behind was 56.86%, lower than these of elder not left-behind (65.28%). But after controlling for gender and age, there was no significant differences between those two groups (P>0.05)The chronic disease prevalence of the elder left-behind was 63.92%,lower than these of elder not left-behind (65.28%). But there was no significant differences between those two groups (P> 0.05)4.The Utilization of Health Service(1)The situation of using health serviceThe two-week consultation rate of the elder left-behind was 14.90%, lower than these of elder not left-behind (15.80%).But there was no significant differences between the two groups (P> 0.05).②Among the patients who was sick in the past two weeks,73.79%the elder left-behind and 75.79%the elder not left-behind did not visit doctors. The the first three reasons for not visiting doctors were economic difficulty, thinking that disease is mild, having related drug.③The hospitalization rate of the elder left-behind was 16.86%, and these of elder not left-behind was 15.93%.④The non-hospitalization rate of the elder left-behind and the elder not left-behind were 48.19%and 53.93%respectively. The first three reasons for not accepting hospitalization were economic difficulty, unattended, thinking that disease is mild.(2) Univariate analysis①Gender, registered permanent residence, education level, occupation, source of income, economic status, suicide ideation, situation of chronic disease, stimulus quantity of negative life events and sleep quality were associated with the two-week prevalence.②Age, marital status, education level, economic status, suicide ideation, situation of chronic disease, self-rated health status, sick or not within the past two weeks, and hospitalization or not within the past one year were associated with the two-week consultation rate.③Gender, drinking, ADL, stimulus quantity of negative life events and sleep quality were associated with chronic disease prevalence.④Age, marital status, education level, economic status, medical insurance, situation of chronic disease, self-rated health status, ADL, and stimulus quantity of negative life events were associated with the hospitalization rate within the past one year.(3)Multivariate Analysis of Health Service UtilizationThe Logistic Stepwise Regression show:Occupation, self economic status arid the situation of chronic disease were the influencing factors of two-week prevalence; Age and the situation of chronic disease were related with the two-week consultation rate; Drinking, stimulus quantity of negative life events and sleep quality were the influencing factors of chronic disease prevalence. Marital status, medical insurance, self-rated health status, and ADL were associated with the hospitalization rate within the past one year.Conclusions1. The rate of the elder left-behind in Hengyang County is 24.83%.2. Being left-behind could bring negative effects on physical and psychological health of the rural elder.3.Being left-behind can not improve the economic status of rural elder popultaion, however it could change the structure of the family and created the new family structure which is dominated by inter-generational family members. This situation increased agricultural labor for the rural elder and resulted in the lack of child caring and other issues.4.Gender, self-rating economic status, smoking, quantity of chronic disease, two-week prevalence, activity of daily living were associated with the physical function. Gender, self economic status, quantity of chronic disease, two-week prevalence, stimulus quantity of negative life events were associated with the psychological health.5.Among the elder left-behind in Hengyang county, the prevalence of chronic diseases and the two-week prevalence rate was higher than the national average level in 2008. The two-week consultation rate was the same as the national average level.6.Occupation, self-rated economic status and situation of chronic disease were associated with the two-week prevalence; Age and situation of chronic disease were associated with the two-week consultation rate. Drinking, stimulus quantity of negative life events and sleep quality were associated with chronic disease prevalence. marital status, medical insurance, self-rated health status, and ADL were associated with the hospitalization rate within the past one year.The Value and InnovationChina's economic and social development is in the transition period and the health system is also facing reform, the research on general situation, life quality, health status, and health service of the elder left-behind could reveal the characteristics of this special population in rural areas and reflect the fundamental problems. We hope the whole society and government could pay more attention to the elder left-behind popultaion, and show concern about their living status and needs, which could make real achievement on social equity and harmony effectively when making the rural pension policy and rural health policy.Through systematically analyzing the effects caused by being left-behind and the conception of the elder left-behind popultaion, our research made the conception to the elder left-behind population for reference of the other academic studies. The version SF-36 V2 Scale was firstly implicated to the rural elder, which provided the basis for the promotion.2Our research analyzed the associated facts for the life quality and health service utilization among the elder left-behind population.
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