Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University, Kathmandu, Nepal
Institute for Population and Social Research, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom 73170, Thailand
Abstract
Background
Many countries are facing the burden of accelerated population aging and a lack of institutional support to meet the needs of older individuals. In developing countries, adult children are primarily responsible for the care of their elderly parents. However, out-migration of adult children is common in these countries. This study aims to explore the impact of migration on the health of the elderly left behind and their health care-seeking behavior.
Methods
This paper uses data from a national survey of older persons in Thailand conducted in 2007. The analysis is confined to those who were aged 60 years or above and who had at least one child (biological or step/adopted) (n = 28,677). Logistic regression was used to assess the net effect of migration of adult children on the health of the elderly left behind and their health care-seeking behavior, after controlling for other socio-demographic and economic variables.
Results
More than two-thirds of the elderly (67%) had at least one migrant child. About three-fifths (58%) reported that they had at least one symptom of poor mental health. Almost three in five elderly (56%) rated their health as poor, and 44% had experienced at least one chronic disease. About two-thirds of the elderly (65%) got sick during the 5 years preceding the survey. An overwhelming majority of elderly (88%) who got sick during the five years preceding the survey had sought treatment for their last illness.
After controlling for socio-demographic and economic variables, our study found that those elderly who had a migrant child were more likely (OR = 1.10; 95% CI 1.05-1.17) to have symptoms of poor mental health than those whose children had not migrated. However, no significant association was observed among physical health, such as experience of chronic disease, perceived poor health, and illness of the elderly left behind. Interestingly, however, out-migration of adult children was independently associated with higher utilization of health services. The elderly who had migrant children were more likely (odds ratio = 1.22, CI 1.11-1.33) than those whose children had not migrated to seek treatment for their most recent illness, after controlling for socio-demographic and economic variables.
Conclusion
Our study provides novel evidence on an issue of special importance to countries affected by heavy out-migration of adult children, an issue that has received little attention. Out-migration of adult children was highly associated with poor mental health but it was not associated with the physical health of the elderly left behind. Out-migration of children was also highly associated with higher utilization of health facilities by the elderly. Thus, in order to decrease morbidity among the elderly as well as to maintain and enhance the well-being of families, programs should focus on alleviating the symptoms of poor mental health among the elderly left behind and aim to reduce the differences in utilization of health care-seeking behavior among elderly with children present in the community and elderly left behind.
Background
In modern times, many factors have intensified migration. Improvement in transportation infrastructure, advances in communications technology (which makes keeping in contact with left-behind over much easier and cheaper), increased trade between countries (including the impact of trade resulting from globalization), political instability, poverty, and unemployment in economically disadvantaged areas/countries are some of the important factors that contribute to this phenomenon
The interaction between health and migration is complex and dynamic. Migration can have an impact on physical, mental, and emotional health and well-being of migrants themselves, on those left behind in the place of origin, and on those at the destination
In many places, and especially in most developing countries, the growing proportion of aging individuals challenges public and social institutions responsible for elderly care. These countries face an additional burden of accelerated population aging and a lack of institutional support to meet the needs of older individuals
Evidence from the literature shows that migration can affect the health of those left behind both positively and negatively. With additional money coming from remittances, people have easier access to health services, can buy expensive medicine, and eat better quality food
On the other hand, some research notes that out-migration of young adults has severe negative consequences for ageing parents, namely, loneliness, isolation, and the loss of basic instrumental and economic support
Although the separation of families due to migration might have serious implications on the health status of elderly left behind and their health care-seeking behavior, the possible health effects on elderly left behind in Thailand remain unclear. This study aims to explore the impact of migration of adult children on the health of the elderly left behind and on their health care-seeking behavior. In-depth examination of these issues will provide policy makers and program planners with needed information and will raise public attention to this public health issue. The findings of this study will help fill the gap in the literature and provide the understanding necessary for advocacy and for the design of appropriate interventions related to migration in Thailand.
Methods
Sources of data and study design
This paper uses data from a cross-sectional survey conducted in 2007 among the elderly in Thailand. This nationally representative survey was conducted by the National Statistical Office (NSO) of Thailand. The NSO has conducted three nationally representative household surveys of older persons, in 1994, 2002, and 2007
The survey is based on a probability sample of persons aged 50 years old or older who were usual residents of their own or family members' households. A stratified two-stage sampling procedure was employed to collect the information. The primary sampling units were blocks for municipal areas and villages for non-municipal areas. The secondary sampling units were households, using random sampling from the list of all enumerated households in each block or village selected. The number of households selected was 15 households per block in municipal areas and 12 households in non-municipal areas. In total, 56,002 persons were interviewed. However, the analysis for this paper is confined to those who were aged 60 years or above and who had at least one child (biological or step/adopted) (n = 28,677). A structured questionnaire was used by trained interviewers to interview selected subjects at the household level. This study was approved by the ethics committee of the NSO of Thailand.
Dependent and independent variables
Dependent variables
This study examines several aspects of the health of elderly parents. These include symptoms of poor mental health, self-assessed health status, chronic diseases, illnesses, and treatment-seeking behavior.
Symptoms of poor mental health
Items measuring symptoms of poor mental health experienced by elderly persons during the month preceding the survey were: i) feeling stress, ii) feeling moody, iii) feeling hopeless, iv) feeling useless, v) feeling down/unhappy, and vi) feeling lonely. One composite indicator, "symptoms of poor mental health," was developed from all the above-listed symptoms (Cronbach's α = 0.86), resulting in 4 categories: had no symptoms of poor mental health, had 1 symptom, had 2 symptoms, and had 3 or more symptoms. For the logistic regression, two further categories were created: "no symptoms poor mental health" and "at least one symptom of poor mental health".
Self-assessed health
Respondents in the survey were asked, "How has your health been in the past 7 days?" The question had five response categories (very good, good, fair, bad, and very bad). The authors categorized the response categories into two groups: "good," which included "very good" and "good," and "poor," which included "fair," "bad," and "very bad."
Chronic diseases
Individuals were asked about the presence of hypertension, heart disease, diabetes, cancer, stroke, and paralysis. One composite indicator, "chronic disease condition," was developed from all the chronic diseases, resulting in 4 categories: had no chronic disease, had 1 chronic disease, had 2 chronic diseases, and had 3 or more chronic diseases. For the logistic regression, two more categories were created: "no chronic disease" and "at least one chronic disease."
Illness
The study explored whether the elderly had symptoms of an illness (self-reported) during the five years preceding the survey. This variable was split into two categories: "experienced symptoms" and "did not experience symptoms."
Treatment sought
The study explored whether the elderly who experienced symptoms of an illness during the five years preceding the survey sought treatment for the most recent illness. This variable was categorized into two categories: "sought treatment" and "did not seek treatment."
Independent variables
Migration of adult children
In this study, we have defined an out-migrant child as one living outside their parents' province. We have used migration of adult children as a main independent variable. This variable was split into two categories: "0 no migrant child" and "1 at least one migrant child."
The other demographic and socioeconomic variables were used as control variables in this study. Many previous studies have shown that demographic and socioeconomic variables have strong effects on health and health care-seeking behavior. Hence we needed to control for their effect to determine the independent effect of migration. Demographic variables included age (60-69 years, 70-79 years, and 80 years and above), sex (male and female), place of residence (urban and rural), and number of respondent's children. The economic variable was the average total income per year (100,000 baht or more, 30,000-99,999 baht, 10,000-29,999 baht, and less than 10,000 baht). Social variables included education (higher than secondary level, secondary level, primary/elementary level, no schooling) and living arrangements (living alone, living with children, living with other relatives).
Methods of analysis
Analysis for this study was confined to those who were aged 60 years or above and who had at least one child (biological or step/adopted) (n = 28,677). Univariate and multivariate analysis were used to analyze the data. Initially, univariate or descriptive analysis was used to describe the respondents' socio-demographic characteristics. Then, after controlling for the other socio-demographic and economic variables, multivariate analysis in the form of logistic regression was used to identify whether migration of adult children affected the elderly's likelihood of experiencing symptoms of diseases, self-assessed health, experience of chronic diseases, illnesses, and treatment-seeking behavior.
Results
Sociodemographic and economic characteristics of the sample population
More than half of the sampled respondents were aged 60-69 while about one out of seven were aged 80 or above, and nearly three out of five were female. The large majority had only an elementary-level education. Respondents had an average of 4 children. About three in five respondents were from rural areas. Half reported that their household income per year was about 30,000 baht or less. Only about one in ten elderly lived alone, and two-thirds had at least one migrant child. About four in five elderly (79%) who had at least one migrant child had received money from their child(ren) during the 12 months preceding the survey (Table
Selected background characteristics of the sampled elderly
Characteristics
%
N
Age group
60-69 years
52.6
15,089
70-79 years
34.3
9,824
80 years or +
13.1
3,764
Sex
Male
44.0
12,626
Female
56.0
16,051
Place of residence
Rural
57.1
16,365
Urban
42.9
12,312
Level of education
Higher than secondary
3.8
1,080
Secondary level
7.1
2,026
Primary or below
89.2
25,571
Number of children
One
8.0
2,303
Two
16.3
4,688
Three
19.7
5,653
Four
17.5
5,030
Five or more
38.4
11,003
4.2
Living arrangement
Alone
7.5
2,151
With child (ren)
61.9
17,742
With other relatives
30.6
8,784
Average household income per year
100,000 baht or more
16.0
4,578
30,000-99,999 baht
33.9
9,715
Less than 30,000 baht
50.1
14,363
Migration of child(ren)
No
32.8
9,402
Yes
67.2
19,275
Total
100.0
28,677
Received money (baht) during the preceding 12 months from migrant children#
None
20.9
4,031
Up to 4999 baht
21.8
4,199
5000-9999 baht
17.8
3,424
10000-29999 baht
25.6
4,930
30000 or above baht
14.0
2,691
Total
100.0
19,275
# Only those elderly who had migrant child(ren), 1USD = approx. 30 Baht
Health status and health care-seeking behavior
Table
Health status and healthcare-seeking behavior among elderly according to migration status of child(ren)
With migrant child(ren)
Without migrant child
Total
Symptoms of poor mental health
No symptom
41.0
44.1
42.0
1 symptom
14.3
13.3
14.0
2 symptoms
16.1
15.4
15.9
3 or more symptoms
28.5
27.3
28.1
Self assessed health
Good health
43.8
44.5
44.0
Poor health
56.2
55.5
56.0
Number of chronic diseases
No
55.9
56.2
56.0
1 disease
29.1
29.2
29.1
2 diseases
11.7
11.6
11.7
3 or more diseases
3.3
3.0
3.2
Illness during the previous 5 years
Yes
64.6
64.7
64.7
No
35.4
35.3
35.3
Total
100.0
100.0
100.0
N
19,275
9,402
28,677
Treatment sought for the most recent illness+
Yes
89.0
86.5
88.2
No
11.0
13.5
11.8
Total
100.0
100.0
100.0
N
12,455
6,086
18,541
It is encouraging to note that an overwhelming majority of elderly who felt sick (88%) had sought treatment for their most recent illness. Interestingly, a higher proportion of the elderly who had migrant child(ren) had sought treatment for the last illness compared to those whose children did not migrate (Table
Multivariate analysis
Logistic regression was used to assess the net effect of the migration of children on the health of the elderly left behind and their treatment-seeking behavior after controlling for the other control variables in the model.
Separate logistic regressions were run for 5 dependent variables. The odds ratio is presented in Table
Odds ratio (OR) and 95% confidence interval (CI) for the effect of children's out-migration on elderly's experience of health problems (symptoms/diseases), perceived health status, chronic disease, illness and treatment-seeking behavior
No out-migration of adult children = reference category
Dependent variables
OR
CI
Cox & Shell R square
Mental health status (n = 28, 677)
Symptoms of poor mental health (ref: No symptom)
At least one poor mental health symptom
1.10***
1.05-1.17
0.124
Perceived health status within previous 7 days (n = 28, 677)
Self-assessed health (ref: Good )
Poor
1.03
0.98-1.09
0.128
Chronic diseases (n = 28, 677)
Chronic disease (ref: No)
At least one chronic disease
1.02
0.97-1.08
0.161
Illness (n = 28, 677)
Felt sick during the previous 5 years (ref: No)
Yes
1.00
0.95-1.07
0.116
Healthcare-seeking behavior (n = 18, 541)
Treatment sought for the last illness (ref: No)
Yes
1.22***
1.11-1.33
0.113
Migration of children was found to have a strong association with poor mental health symptoms among the elderly left behind. Those elderly who had at least one migrant child were more likely (OR = 1.10; 95% CI 1.05-1.17) to have poor mental health symptoms than those whose children had not migrated. On the other hand, no significant association was observed with physical health, such as experience of chronic disease, self-rated health status, or experience of symptoms of illness during the previous 5 years.
Furthermore, the results show that the migration of children is a significant predictor of treatment-seeking behavior among the elderly left behind. For instance, those elderly who had at least one migrant child were more likely (OR = 1.22; 95% CI 1.11-1.33) to seek treatment for their most recent illness than were those who had no migrant children (Table
Discussion
This study has attempted to investigate the impact of out-migration of adult children on health issues and health care-seeking behavior of the elderly left behind in a society in which, traditionally, children take responsibility for older parents. Findings show that the majority of the elderly (68%) have at least one out-migrant child and that an overwhelming majority (79%) received money from their migrant children.
Out-migration of adult children was highly associated with poor mental health symptoms among the elderly left behind. It is likely that out-migration of children reduces opportunities for face-to-face interaction. This finding is similar to other studies
Our study found that the migration status of children was not associated with the physical health of the elderly left behind (as measured by self-rated health, experience of chronic diseases, and illnesses during the 5 years preceding the survey). It should be noted that this may be because adult children are less likely to migrate when a parent is ill
An earlier national survey in Thailand also found that 77% of Thai elderly reported receiving financial support from children during the previous year
There are some limitations in the interpretation of the results of this study. Because of the survey's cross-sectional design, all of the factors analyzed in the study were measured at a single point in time. Thus, the analysis can only provide evidence of statistical association between those items and the health status of the elderly left behind and health care-seeking behavior; it cannot show a cause-effect relationship. Besides, we have to be careful while comparing the results of this study with those of other research studies that have used pre-existing validated questionnaires to measure mental and physical health.
Conclusion
Our study provides novel evidence on an issue of special importance to countries affected by heavy out-migration of adult children, an issue that has received little attention. Findings here show that out-migration of adult children is highly associated with poor mental health but is not associated with the physical health of elderly left behind. Out-migration of children is also highly associated with greater utilization of health facilities. Thus, in order to decrease morbidity among the elderly as well as to maintain and enhance the well-being of families, programs should focus on alleviating the symptoms of poor mental health among the elderly left behind and aim to reduce the differences in utilization of health care-seeking behavior among elderly with children present in the community and elderly left behind.
Endnotes
a. We were unable to keep both 'remittances' and 'out migration of children' in the same model as it is highly correlated. Therefore, we run separately to see the association between 'remittance' and 'treatment seeking' variables after controlling for other demographic and socio-economic variables.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
RA analyzed, interpreted the data, and drafted the manuscript. AJ and AC commented and provided suggestions on the analysis and interpretation. All authors read and approved the final version of the manuscript.
Acknowledgements
The authors thank the National Statistical Office (NSO) of Thailand for providing access to the data. The authors would also like to thank Dr. Kerry Richter and Dr. Kusol Soonthorndhada for their valuable suggestions for this paper.
Pre-publication history
The pre-publication history for this paper can be accessed here: