A Multilevel Logit Estimation on the Determinants of Utilization of Preventive Health Care and Healthy Lifestyle Practice in China

AuthorLida Fan,Nazim N. Habibov,Jianye Liu
Published date01 December 2015
Date01 December 2015
A Multilevel Logit Estimation on the Determinants of
Utilization of Preventive Health Care and Healthy
Lifestyle Practice in China
Lida Fan, Jianye Liu, and Nazim N. Habibov
The purpose of this study is to provide policy implications by estimating the individual and
community level determinants of preventive health-care utilization in China based upon data from
the China Health and Nutrition Survey. Two different frameworks, a human capital model and
a psychological-behavioral model, are tested using a multilevel logit estimation. The results
demonstrate different patterns for medical and nonmedical preventive activities. There is a strong
correlation between having medical insurance and utilizing preventive health services. For the usage
of medical-related preventive health care (MP), age, gender, education, urban residence, and medical
insurance are strong predictors. High income did not provide much of an increase in the usage level
of MP, but the lack of income was a huge obstacle for low-income people to overcome. Community
variation in number of facilities accounted for about one third of the total variation in the utilization
of MP. The utilization of MP in China remains dependent upon the individual’s social-economic
KEY WORDS: determinants, preventive health care, China
How do people deal with threats to their health? In the developed world, the
answers to this long-standing question tend to be either behaviorally or
cognitively oriented (Kirscht, 1983; Prentice-Dunn & Rogers, 1986). However, the
utilization of preventive health care in developing countries can be substantially
different from that in the developed world (Dupas, 2011). Preventive health-care
activities are associated with socioeconomic conditions, and their use depends on
the types of activities involved; for example, whether they require medical
facilities or can be done by individuals. In this study, we will investigate the
determinants of both medical preventive health care and healthy lifestyle practice
in China, using a data set from a nationally representative survey.
“Prevention f‌irst” has been one of the major health-care policies in China
since the 1950s. This policy was considered a success in improving the health
World Medical & Health Policy, Vol. 7, No. 4, 2015
1948-4682 #2015 The Authors. World Medical & Health Policy published by Wiley Periodicals, Inc. on behalf of Policy Studies Organization
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
Published by Wiley Periodicals, Inc., 350 Main Street, Malden, MA 02148, USA, and 9600 Garsington Road, Oxford, OX4 2DQ.
status of the Chinese people in pre-reform China (Sidel & Sidel, 1982; World
Health Organization, 1975). The merit of the pre-reform Chinese medical system
was characterized by an emphasis on prevention: “low-cost, locally controlled
health services and promoting accessible primary health care in rural areas”
(Hillier & Shen, 1996, p. 258). The pre-reform era’s health-care system was
eff‌icient in terms of the control of infectious diseases; despite pervasive low
productivity and shortage of services in almost every area, Chinese people’s
health status improved throughout the 1980s and 1990s (Fang & Bloom, 2010; Shu
& Yao, 1997). During the economic reform, the utilization of preventive health
care became challenging for many people, especially people living in rural areas
and people without medical insurance, because of decentralization and marketi-
zation. Financial decentralization limits the role of the government in providing
public health programs. During the reform, the urban medical scheme has been
f‌inanced mainly through municipal-level risk pooling for employees with basic
medical insurance. The rural “New Cooperative Medical Scheme” (NCMS)
initiated in 2003 focuses “almost exclusively on medical care and funds only a
few preventive services” (Fang & Bloom, 2010, p. 32). This policy may lead
individuals to a more curative care focus, since one of the fundamental changes
lies in increasing out-of-pocket expense. Thus spending on preventive health care
becomes more of a personal choice for future well-being, rather than a public
policy arrangement as it was before the reform. Although the ongoing health-care
reform initiated in 2009 aims to provide comprehensive universal health coverage
for all citizens by 2020, individuals’ incentives would remain an important
element in the new system (Yip et al., 2012). In this way, it becomes more about
the individual’s investment in their own human capital, impacted both by the
individual’s understanding of the importance of preventive care, and their
economic ability to carry the associated costs.
In recent years, an increasing literature has focused on various key factors
affecting the utilization of health care in China (Gao, Raven, & Tang, 2007; Liu,
Zhang, Lu, Kwon, & Quan, 2007; Qian, Pong, Yin, Nagarajan, & Meng, 2009;
Wagstaff, Lindelow, & Hsiao, 2009; Zhang & Kanbur, 2005; Zhang, Wang, &
Zhang, 2014). However, although early studies explored the preventive health-
care system before and after the reform (Hillier, 1986; Hillier & Shen, 1996;
Kaufmana & Jing, 2002), if we limit our searching area to the determinants or
factors affecting the utilization of preventive health care, we still have the
impression that we know little in this area. Among the very few studies on the
determinants of preventive health care in China, van Dalen (2006) estimated a
few socioeconomic variables, including insurance and wealth, using probit-
estimation and instrumental variables (IV) based on the data of the China Health
and Nutrition Survey 2004. Using probit-estimation he found that possessing
health insurance increased the probability of using preventive health care by 3
percent, but this effect was not statistically signif‌icant per the results of the IV
probit-estimation. He also found that being in the lowest 40 percent of population
wealth would reduce the likelihood of using preventive health care by 1 percent.
However, being in the top 20 percent wealth group did not have any effect when
310 World Medical & Health Policy, 7:4

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