China Twenty Years After: Substance Use Under Rapid Social Changes

This dissertation discusses how China’s rapid modernization and social transformation over the last twenty years since a series of reforms at the end of 1980s contribute to the changes in substance use behaviors. Specifically, there are three individual empirical chapters in this dissertation, each exploring one dimension of social change and its association with substance use. First, I have demonstrated how substance use can be a protective factor against unemployment over the long term, especially against the background of massive layoffs among former socialist industrial workers and landless peasants during this period. Second, another chapter examines how social mobility (i.e. changes in a person’s social position in society) contributes to substance use. And finally, I have tested the impact of economic and social modernization on substance use, and considered the social disorganization aspects of community change. Using survival analysis, I have found that general drinking protected against unemployment risk for both men and women, while smoking, even heavy smoking, only protected men but penalized women. However, on the other hand, heavy drinking was not a significant factor against unemployment hazards. Possible explanations have been drawn from social capital theory and the social nature of substances. In order to disentangle the class assimilation effect and mobility effect from the overall differential distribution of substance use among classes, diagonal reference modeling has been employed in the second chapter to show that, overall, higher classes smoked and drank more than lower classes in China. While people, especially those who moved upward in the class ladder, tend to assimilate into their destination class’ drinking pattern, there was no assimilation effect for smoking among the upwardly mobile people. Instead, the independent mobility effect contributes to a higher level of smoking, suggesting that adaptive responses emerged during socially mobile events. I conclude that drinking has more socially vested interests for socially mobile people than smoking. Through multilevel modeling with a feature of growth curve analysis, this dissertation also assesses the influence of community-level social changes and modernization on substance use. I have found that there are certain “good” and “bad” dimensions of modernization, even though all dimensions have been growing together in the past twenty years. Economic modernization amplifies the income effect on substance use, making people with higher incomes smoke even more. Meanwhile, social modernization can mitigate the harmful effect of income on both drinking and smoking. With regard to inequality, its negative interaction with individual income also confirms our hypothesis that poor people tend to use substances more than the rich do in an unequal community. Furthermore, the modernization process has also elevated women’s risk of using substances

Analysis of the current status and influencing factors of cross-regional hospitalization services utilization by basic medical insurance participants in China − taking a central province as an example

BackgroundThe geographically uneven distribution of healthcare resources has resulted in a dramatic increase of cross-regional hospitalization services in China. The over-use of cross-regional hospitalization services may hinder the utilization and improvement of local hospitalization services. It is of great practical significance to study the utilization of cross-regional hospitalization services and its influencing factors in order to effectively allocate medical resources and guide patients to seek medical treatment rationally. Therefore, this study aims to analyze the current situation and influencing factors of the utilization of cross-regional hospitalization services by patients insured by basic medical insurance in China.MethodsA total of 3,291 cross-provincial inpatients were randomly selected in a central province of China in 2020. The level of medical institutions, hospitalization expenses and actual reimbursement rate were selected as indicators of hospitalization service utilization. Exploratory factor analysis was used to assess the dimensionality of influencing factors and reduce the number of variables, and binomial logistic regression analysis and multiple linear regression analysis to explore the influencing factors of the utilization of cross-regional hospitalization services.ResultsThe proportion of cross-provincial inpatients choosing tertiary hospitals was the highest with average hospitalization expenses of 24,662 yuan and an actual reimbursement rate of 51.0% on average. Patients insured by Urban Employees’ Basic Medical Insurance (UEBMI) were more frequently (92.9% vs. 88.5%) to choose tertiary hospitals than those insured by Urban and Rural Residents’ Basic Medical Insurance (URRBMI), and their average hospitalization expenses (30,727 yuan) and actual reimbursement rate (68.2%) were relatively higher (p < 0.001). The factor “income and security,” “convenience of medical treatment” and “disease severity” had significant effects on inpatients’ selection of medical institution level, hospitalization expenses and actual reimbursement rate, while the factor “demographic characteristics” only had significant effects on hospitalization expenses and actual reimbursement rate.ConclusionCross-provincial inpatients choose tertiary hospitals more frequently, and their financial burdens of medical treatment are heavy. A variety of factors jointly affect the utilization of cross-provincial hospitalization services for insured patients. It is necessary to narrow down the gap of medical treatment between UEBMI and URRBMI patients, and make full use of high-quality medical resources across regions

How does the health care reform affect citizens’ access to health care in urban China?

This thesis is centered on the issue of how does the health care system reform change urban citizens’ healthcare utilization in China. The new health care reform, against the background of building “a Harmonious Society”, aims to provide a universal health care for the whole population and makes citizens’ access to health care easier. Based on both quantitative and qualitative data, the study sets out to analyze strengths and flaws of the new health care system. The theoretical framework, consisting of East Asian Welfare Model and China’s welfare mix, is operationalized by analyzing the impacts of government’s new health policy and urban citizen’s perception on the health care reform. More specifically, health financing and health service provision have been explored. The findings show that the government has been expanding basic medic insurance coverage, improving medical institutions and increasing healthcare expenditure in order to achieve the objects of health care reform. Those efforts have brought some good effects on urban citizens’ healthcare utilization; however, the still high health care cost as well as other problems which haven’t been solved yet has brought negative impacts

Migration, Marital Fertility and Marital Fertility Preferences Among Migrant Women in China

This dissertation investigates the contribution of migration and urbanization to China’s demographic dynamics. Migration in China from the rural to the urban areas has increased substantially over the last thirty years. And it is believed that migrants are influenced by both the rural and urban settings. Prior research in China has centered largely on the fertility transitions within the perspective of Demographic Transition Theory, and on the different fertility transition in rural and urban areas. Prior research on the fertility of migrants in China and other countries has been guided by one or more of the four hypotheses of selectivity, disruption, adaptation, and socialization. Few prior studied consider the influence of social context. I argue that context should have an independent effect on the fertility of migrants. In this dissertation I estimate both microlevel and multilevel models to explain the fertility of migrants. I first investigate the effects of migration status on the transition from marriage to the first birth. I estimate Cox proportional hazards models using five waves of data from the 2000 to 2011 China Health and Nutrition Surveys. To better understand the influence of community contexts, I next examine the effects of urbanization levels on the fertility preferences of migrants. I estimate generalized multilevel logistic regression models using data from the 2006 China Health and Nutrition Survey. My results clearly show that the four hypotheses are applicable for understanding the fertility of migrants in China. The results demonstrate that the transition from marriage to first birth is significantly accelerated for rural-to-urban migrants compared to urban non-migrants, and rural-to-urban migrants have a lower desire for more children than urban non-migrants and rural non-migrants. However, I did not find any significant differences in the transition between marriage and the first birth for rural-to-urban migrants compared to rural non-migrants. Urbanization level of communities has an indirect and significant effect on a woman’s intention for more children for women with children: the more urbanized a community, the more similar the fertility intentions of rural-to-urban migrants are to those of urban non-migrants

An analysis of inequities and inefficiencies in health and healthcare in China

China’s remarkable economic growth heralds substantial improvements in population health for the Chinese people. While economic growth in some respects acts as a positive stimulus to the health sector, it also brings challenges to the health system, in particular, a widening inequity in healthcare across the social spectrum, rising healthcare costs and low efficiency in health provision. The overarching aim of the thesis is to investigate whether inequities and inefficiencies exist in China’s healthcare system. It then seeks to understand, whether and to what extent a newly developed social health insurance scheme—the New Rural Cooperative Medical Scheme (NCMS)—responses to issues of inequities and inefficiencies in China’s healthcare system. This thesis uses a variety of analytical tools, such as the Concentration Index, Decomposition Analysis, Two-part Regression Analysis and Differences-in-Differences analysis. Data from a longitudinal individual level survey—the China Health and Nutrition Survey of 2004, 2006 and 2009—are used. The findings of this thesis suggest that inequalities in health and health care in China are ubiquitous and favouring better-off socioeconomic groups. Health status for the urban poor is surprisingly worse than their rural counterparts; more than two-thirds of the inequalities for the rural population are driven by socioeconomic factors. In rural areas, the NCMS was introduced to improve equity in access to healthcare and financial protection to rural farmers in 2003. This thesis finds that, even though the coverage of the NCMS reached more than 97% in 2009, the poor were still less likely to use formal care, such as preventive care, and were more likely to use folk doctor care compared with the rich. They may also have difficulty in meeting the costs of care that they need, and have to pay a substantial fraction of their incomes on healthcare. This thesis also finds that the NCMS may exacerbate the problem of inefficiency in healthcare provision because the scheme may lead to cost escalation in healthcare. Outpatient treatments for the NCMS participants incur significantly higher pre-reimbursement per episode costs than those for the uninsured. This pre-reimbursement inflation in costs is most noticeably observed at village clinics and township health centres—the backbone of the health system for poor rural farmers—than at county and municipal hospitals. This thesis urges policy makers to explore ways to improve equitable access and control supplier-induced demand in health care in China. In terms of the NCMS, it is important to improve the benefit package for both outpatient and inpatient care, and to offer additional benefits for the poor households. The government should also reform provider payment mechanism, regulate provider behavior, as well as implement other measures to prevent over prescribe of medicines and over supply of healthcare

Dependence of Spending Patterns of Households on their Income in the Context of Health-Related Behaviour: Numerical Study

The academic community has been actively discussing and assessing the results of the reform of the Russian healthcare system, which began in the early 2000s. This study considers the results of the reform from the perspective of a concept of health-related behaviour. The paper determines the behaviour patterns of household members concerning personal expenditures on medical goods and services, depending on their monetary income and spending pattern. The main research method was an econometric (correlation and regression) analysis of time series. As a result, we discovered that household income dynamics significantly influence expenditures on medical goods and hygiene items (that vary according to the household income). Moreover, household expenditures on health care depend on its spending on food products. We conclude that, firstly, in 2005–2019, Russia has been showing a steady growth of paid medical services (in total medical care), which are available to less than half of the households. Secondly, health-related behaviour of different groups of households divided by income level significantly changes depending on the income dynamics and spending pattern. Thirdly, an increase in income decreases expenditures on medical services and goods, as well as in an increase in expenditures on health-improvement (preventive) services. We have revealed that spending on food products on average determines 55.9 % of a change in expenditures on medical services. Simultaneously, in the households’ budgets, a 1 % increase in food expenditures displaces 2 % of expenditures on health-improvement services. The obtained results extend the understanding of the features of health-related behaviour that is defined by households’ income, as well as by the spending pattern on food, medical goods and services. Public authorities can consider the revealed features of health-related behaviour of different groups of households divided by income when developing and improving the socio-economic policy in the field of health care.Оценка результатов реформирования системы здравоохранения России, начавшегося в 2000-х гг., стала предметом активной научной дискуссии. В нашем исследовании результаты оценки рассматриваются в контексте концепции самосохранительного поведения населения. Целью исследования являлось определение моделей поведения членов домохозяйств в отношении расходования личных средств на медицинские товары и услуги, в зависимости от уровня их денежных доходов и структуры расходов. Исследование проведено с использованием эконометрического (корреляционно-регрессионного) анализа временных рядов. В результате были выявлены существенное влияние динамики доходов домохозяйств на долю их расходов на медицинские товары и предметы гигиены (различающееся по характеру в зависимости от уровня доходов домохозяйств), а также зависимость расходов домохозяйств на здравоохранение от уровня их затрат на покупку продуктов питания. В работе были сделаны следующие выводы: во-первых, в 2005–2019 гг. в нашей стране наблюдается устойчивая тенденция роста доли платных медицинских услуг в общем объеме медицинских услуг, воспользоваться которыми могут менее половины всех домохозяйств России, во-вторых, самосохранительное поведение различных по уровню доходов групп домохозяйств существенно различается при изменении динамики их доходов и структуры расходов, в-третьих, по мере роста доходов населения сокращается доля расходов на медицинские услуги и товары, а доля расходов санаторно-оздоровительного (профилактического) характера увеличивается. Так, определено, что уровень расходов на продукты питания в среднем определяет 55,9 % изменения расходов населения на медицинские услуги. В то же время повышение на 1 % их бюджета расходов на продукты питания вытесняет из него 2 % расходов на санаторно-оздоровительные услуги. Полученные результаты расширяют представления об особенностях самосохранительного поведения населения, определяющегося, с одной стороны, уровнем доходов, с другой — структурой расходов на продукты питания, медицинские товары и услуги. Выявленные в работе особенности самосохранительного поведения различных по уровню доходов групп населения могут быть использованы представителями органов государственной власти при разработке и совершенствовании государственной социально-экономической политики в сфере здравоохранения.The article has been prepared with the support of the Russian Foundation for Basic Research, the grant № 18–010–01049 «Methodology and methods of system assessment of interrelation of environmental factors and public health in the context of the Russian regions’ sustainable development».Статья выполнена при финансовой поддержке гранта РФФИ № 18–010–01049 «Методология и методика системной оценки взаимосвязи средовых факторов и здоровья населения в задаче устойчивого развития регионов России»

Three Essays about Health and Welfare.

My dissertation is comprised of three separate essays that investigate health and welfare issues, both in China and US. The first essay provides insights into the net effects of increasing women’s bargaining power on the health outcomes of their children. Using Chinese longitudinal data in the 1990s, I find evidence in favor of women’s empowerment: children in families where the mother was head of household or made more purchasing decision had better Body Mass Index (BMI) than their counterparts whose mother had less power. The second essay explores the health consequences of computer use in internet cafés compared with usage at home only or in both settings. Using Chinese longitudinal data in the mid 2000s, I find suggestive evidence that adolescents and youth using computers in internet cafés are more likely to smoke and to self-report poor health status, and to consume a higher share of fat in their daily diets. The health disparities between computer users in internet cafés and other settings are significant. The third essay examines changing levels of Unemployment Insurance (UI) eligibility and benefits receipt among low-educated single mothers who entered unemployment between 1990 and 2005, and changing participation in cash welfare and the Food Stamp Program (FSP). Using the Survey of Income and Program Participation (SIPP), the study shows that low-educated single mothers who enter unemployment experience an increase in UI eligibility but not an increase in UI benefits receipt, when compared to low-educated, single, childless women who enter unemployment. The proportion of this population accessing benefits from at least one of these programs remains similar across the study period.Ph.D.Social Work and EconomicsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/89638/1/wuly_1.pd

The Health-Seeking Behavior of the Elderly with Non-communicable Diseases at Coastal areas, Vietnam

Background The aging population is rapidly increasing globally. It proves a severe impact on developing and low-income countries due to insufficient resources and lack of awareness towards the challenges of health issues. In Vietnam, over 11 million people aged 60 and over, accounting for 11.8% of the population. It is projected that by 2050 there will be nearly 29 million people (HelpAge, 2018). People over 60 years old have 2.6 diseases, over 80 years old have 6.8 diseases on average (Dang Thi Thanh et al., 2018; MOH, 2020). Therefore, healthcare facilities and the health services behavior of older populations with non-communicable diseases are considered important in formulating a health program targeting this group. Significantly, the coastal area is a challenging area where participants live (Government, 2016b). Purpose This study aimed to investigate the health-seeking behavior of the elderly with non-communicable diseases, and its associated factors.   Method A Cross-sectional study was conducted in seven coastal areas in Thua Thien Hue province, Vietnam, with a sample of 370 people aged 60 years and older. Physicians diagnosed the presence of non-communicable diseases at health care facilities. Information on independent variables such as social, demographic, perceived health status, etc., and dependent variables such as health-seeking behavior through the utilization of healthcare services were collected using a structured questionnaire. In addition, a pilot investigation questionnaire on patients who visit a primary healthcare unit in one of seven coastal areas was conducted, and investigators were trained before collecting data. Chi-square and multiple logistic regression analyses were used to examine the factors associated with the utilization of health care services. Results The mean age of participants was 69.70 ± 6.6 (SD). Over half of the participants were fishery or agriculture, 14.3% of them were under an average standard of economic. The proportion of multiple non-communicable diseases was 18%. The disease duration was mainly about 5-10 years and more than ten years with the rate over 40%, respectively. Most participants were diagnosed at public health facilities. A third of quarter of participants required health care counseling. The results of the study showed that 69.8% of the total participants had health-seeking behavior. The findings also revealed that the elderly living alone were likely to have 4.5 times less health-seeking behavior than those who did not live alone (OR: 4.48, 95% CI: 1.016-19.78, p=0.048). Similarly, the economic status was related to the health-seeking behavior. People with an average and wealthier income seemed to have 2.8 times higher utilization of healthcare services than the poor and below the average group (OR: 2.81, 95% CI: 1.11-7.11, p=0.029). A group with multiple NCDs were more likely to have nine times higher health-seeking behavior than those with only one disease (OR: 9.24, 95% CI: 2.665-32.15, p=<0.001). Health insurance and the needed for health care counseling were also relevant (OR: 4.16, 95% CI: 1.30-13.31, p=0.016), (OR: 3.91, 95% CI: 2.04-7.49, p<0.001), respectively. Conclusion Health-seeking behavior is one of the most important positive implications for the aged population, encompassing one's physical, mental, and psychological wellbeing. The future study would be clarifying the same results in-depth to understand and improve the health-seeking behavior in the elderly and enhance their quality of life.open석