Factors associated with the health record participation among migrant older adults in Mainland China

Abstract

Background

Health records are vital for healthcare informatization and public health initiatives. The enrollment of health records among China’s migrant older adults is critical to improving their health outcomes and promoting healthcare equity. Therefore, it is important to examine the factors associated with their participation in record enrollment.

Methods

A total of 5,038 migrant older adults aged 60 years and older were selected from the 2018 China Migrants Dynamic Survey (CMDS) for analysis. Binary logistic regression was employed to explore factors associated with health record establishment among this population.

Results

The health record establishment rate among migrant older adults in mainland China was 35.93%. Several factors positively associated with this outcome were identified, including residing in the central region (OR = 2.46, 95% CI: 1.88–3.21), being female (OR = 1.29, 95% CI: 1.11–1.50), being aged 80 years or older (OR = 1.79, 95% CI: 1.07–2.98), having a monthly household income below average (OR = 1.41, 95% CI: 1.16–1.71), having a migration history of more than five years (OR = 1.38, 95% CI: 1.17–1.62), and having received three or more types of community health education (OR = 4.73, 95% CI: 3.79–5.89).

Conclusion

Health record participation rates among migrant older adults remain comparatively low. To address this gap, targeted interventions and management strategies are warranted, with a particular focus on younger migrants and those residing in eastern regions of China. Recommended measures include the integration of health resources and the enhancement of community-based health education to improve participation.

Background

The effective implementation of tiered healthcare delivery, chronic disease management, and public health programs is significantly dependent on the utilization of health records. Encouraging participation in health record systems among the migrant population presents a crucial yet challenging endeavor due to various barriers that must be addressed. A study reported that a health record participation rate of 28.3% among the migrant population across eleven eastern Chinese provinces (municipalities) [1] and 37.0% in western regions [2], both falling short of the 70% target established for migrants [3]. Furthermore, the National Health Commission (2018) reported that the average annual growth rate of China’s older adult migrant population was 6.6% [4]. In light of this rapid growth, promoting their health through initiatives such as increased participation in health records is becoming increasingly imperative.

Since the early 21st century, China has actively promoted the equalization of basic public health services, with a particular emphasis on encouraging older adults’ residents to participate in health record systems. As early as 2009, the former Ministry of Health issued the National Basic Public Health Service Standards (2009 Edition), which explicitly mandated that older adults’ residents be enrolled in health records at no cost and receive annual physical examinations. This initiative marked the systematic implementation of a nationwide health record system. In 2011, the State Council released the Twelfth Five-Year Plan for Developing China’s Aging Cause, further underscoring the importance of enhancing health record management for older adults and promoting their participation in such systems, while facilitating the integration of older adults’ care services with medical and health care services. The Guiding Opinions on Promoting the Construction of the Tertiary Medical Care System, issued in 2015, re-emphasized that grassroots institutions are responsible for primary care, and that residents’ health records should serve as the informational foundation for tiered healthcare delivery. Furthermore, it is imperative to promptly promote the dynamic updating and utilization of health records specifically for the older adults. Collectively, these policies indicate that by 2018, the development and management of health records for older adults had been institutionalized nationwide. However, actual progress faces numerous institutional challenges, including a shortage of personnel at grassroots levels [5], Personnel file separation resulting from the household registration system [6], constraints imposed by territorial management of medical insurance [7], and a lack of cross-regional interoperability within medical information systems [8]. These obstacles have significantly undermined the effectiveness of health record promotion on-the-ground, particularly among migrant older adults.

Furthermore, migrant older adults exhibit dual characteristics of aging and mobility [9]. The aging aspect indicates that they typically undergo physical decline, experience a higher prevalence of chronic diseases, and face functional impairments. Additionally, these individuals often develop a greater psychological dependence on familiar social environments and a sense of belonging, which makes them less inclined to accept and adapt to new surroundings. Conversely, the characteristic of mobility necessitates that these individuals leave their long-term residences, thereby relinquishing established neighborhood relationships, community networks, and habitual living patterns. Consequently, they must readjust to unfamiliar environments while navigating challenges such as different climates, local dialects, cultural nuances, and varying public service systems. These dual characteristics place migrant older adults in an identity dilemma characterized by being neither local nor from their hometown, significantly hindering their social integration [10]. Due to insufficient social integration, migrant older adults frequently lack awareness regarding local health record policies and digital platforms. Their geographically mobile lifestyles create barriers to sustaining continuous engagement with health records across administrative regions. Furthermore, age-related physical frailty and cognitive impairment further diminish their ability to independently complete health record registration processes or update personal health information while accessing related healthcare services. Collectively, these individual-level impediments may reduce migrant older adults’ participation in health record initiatives, ultimately undermining the effectiveness of preventive care and chronic disease management for this highly vulnerable population.

While participation in health record is crucial for enhancing the health security of migrant older adults and promoting equitable access to medical care, current research on the factors influencing their participation in China remains inadequate. Existing studies predominantly focus on macro-level aspects, such as social integration into the specific factors that correlate with participation in health records. Furthermore, many studies concerning health records among older adults have primarily recruited residents as research subjects, without adequately accounting for the unique characteristics of migrant older adults arising from their dual attributes. Factors such as household registrations, length of migration, mobility range, and frequency of community health education participation may all exert influences on their willingness to establish and actual completion of health records. Therefore, a comprehensive analysis of the factors associated with migrant older adults’ participation in health records holds significant theoretical and practical value. This analysis will not only facilitate an increase in health record participation among this demographic but also contribute to advancing equitable access to essential public health services for the migrant population.

Methods

Data source

This study employed data from the 2018 China Migrants Dynamic Survey (CMDS), which guarantees the scientific rigor and representativeness of the analytical dataset. Conducted annually by the National Health Commission between 2009 and 2018, the CMDS was a nationwide, large-scale annual dynamic survey targeting the migrant population, employing a stratified probability-proportional-to-size (PPS) sampling design. The survey covers 1,459 county-level units, 3,776 towns and subdistricts, and 8,993 community committees across all 31 provinces, autonomous regions, and municipalities directly under the central government in China. It collects comprehensive and systematic information on core domains related to migrants and their family members, including basic demographic characteristics; migration scope and patterns; employment, social security, and income and expenditure; place of residence; access to basic public health services; marriage, childbirth, and family planning administration; migrant children’s education; as well as psychological and cultural integration.

Participants

This study involved a total of 5,038 migrant older adults in the final analysis. The inclusion criteria were as follows: (1) participants should be aged 60 years and above; (2) participants should not have severe mental illnesses or significant communication impairments and must be capable of completing the survey independently or with minimal assistance; (3) written informed consent must be obtained, and participants must agree to participate in the study. Exclusion criteria comprised samples with missing values or unsure responses regarding the key variable “Have you participated in the health record?“.

Measurements

Participation in health records

Participation in health records was evaluated through the question, “Have you participated in the health record?” with response options of “Yes” or “No”.

Individual sociodemographic characteristics

The individual sociodemographic characteristics examined in this study included the following variables: region (eastern, central, western, and northeastern), gender, age groups (60 ~ 69, 70 ~ 79, or ≥ 80), ethnic group (ethnic minority, or Han Chinese), living arrangement (living with family living alone), average monthly household income (below the average monthly income, equal to or above the average monthly income), educational attainment (middle school and below, high school or technical secondary school, college degree or above), household registration (agricultural, non-agricultural), marital status (unmarried, first marriage, or other) and number of biological children (childless, one child, two children or more).

Migration characteristics

Migration characteristics encompassed both the range and duration of migration. The migration range was assessed through the question, “Which option best describes the scope of your move?” with three possible responses: Inter-provincial, Inter-city within the same province, and Inter- County. Migration duration was measured by asking, “What was the length of your migration?” with two response options: Less than five years, and five years or above.

Access to public health services

This study selected three indicators, namely insurance enrollment location, type of medical insurance, and community health education exposure, to examine the associations between access to public health services and health record participation. Insurance enrollment location was measured by using the question, “Where did you enroll in medical insurance?” with response options including place of domicile, place of household establishment, and somewhere else. Type of medical insurance was measured via the question: “what type of medical insurance have you participated in?” with response options of “medical insurance for urban and rural residents”, “Urban Employees Medical Insurance”, or “Other types or unclear”.

Additionally, community health education exposure was measured using the question: “In the past year, have you received any health education in the community?” with nine response options consisting of occupational disease prevention, tuberculosis prevention, chronic disease prevention, sexually transmitted disease (STD) and AIDS prevention, tobacco control, self-rescue training for public emergencies, and mental health education. For data coding, participants who receive none of the aforementioned health education services were categorized as never received; those who received one or two types were classified as one or two; and those who received three or more types were coded as three or more.

Data analysis

Data analysis was performed using IBM SPSS Statistics version 20.0. Sociodemographic characteristics, migration-related characteristics and utilization of public health services among migrant older adults were summarized using descriptive statistics, with results presented as frequencies (N) and percentages (%). Chi-square tests were performed to examine associations between various categorical variables and health records participation among migrant older adults, and the distribution of study variables was also evaluated. Given the dichotomous nature of the outcome variable (health record participation), a binary logistic regression model was applied to identify factors associated with health record participation. All statistical tests were two-tailed, and a p -value less than 0.05 was considered statistically significant.

Results

Basic Characteristics

Table 1 presents the characteristics of a sample comprising 5,038 elderly migrants. The demographic profile indicates a predominance of males (57.5%) and individuals aged between 60 and 69 years (81.36%), with 35.57% originating from western regions of the country. A significant majority resided with family members (93.81%) and reported low-income levels (67.9%) or educational attainment at middle school level or below (75.23%). Additionally, 49.68% maintained rural household registration status. Regarding migration patterns and insurance coverage, it was found that 66.99% had migrated for five years or more, while 45.24% were classified as trans-provincial migrants; furthermore, 83.65% were insured in their place of household registration, and an overwhelming majority (93.88%) participated in the Urban and Rural Residents’ Medical Insurance Program. Finally, regarding community health education engagement, approximately 46.67% received one to two types of such education programs, whereas 26.34% accessed three or more types.

Table 1.

The basic demographic characteristics of participants

Variables		n	%	Variable		n	%
Region	Eastern	1668	33.11	Marital status	Unmarried	27	0.54
	Central	613	12.17		First marriage	4103	81.44
	Western	1792	35.57		Other	908	18.02
	Northeast	965	19.15	Migration duration	Less than five years	1663	33.01
Gender	Male	2897	57.50		At least 5 years	3375	66.99
	Female	2141	42.50	Migration range	Trans-provincial	2279	45.24
Age	60 ~ 69	4099	81.36		Across cities in the province	1754	34.82
	70 ~ 79	826	16.40		Cross county within the city	1005	19.95
	80 years and above	113	2.24	Place of insurance	Place of domicile	708	14.94
Ethnic group	Ethnic Minority	419	8.32		Place of household registration	3964	83.65
	the Han Chinese	4619	91.68		Somewhere else	67	1.41
Whether living with family	Living with family	4726	93.81	Type of insurance	Medical insurance for urban and rural residents	3331	93.88
	Living alone	312	6.19		Urban employee medical insurance	93	2.62
Average monthly household income	Below the average monthly income	3421	67.90		Others or unclear	124	3.49
	Equal to or above the average monthly income	1617	32.10	Community health education	Never received	1360	26.99
Educational attainment	Middle school and below	3790	75.23		One or two	2351	46.67
	High school or technical secondary school	859	17.05		Three or more	1327	26.34
	College degree or above	389	7.72	Number of biological children	Childless	97	1.94
Nature of household registration	Agriculture	2503	49.68		One	1609	32.11
	Non-agriculture	2535	50.32		Two or more	3305	65.95

Comparison of health record participation among migrant older adults with different characteristics

Significant differences of migrant older adults’ health record participation were observed across various factors (Table 2). Higher participation rates were associated with the following characteristics: residence in central China (44.86%), aged greater than 80 years (47.79%), living alone (44.55%), below average income (39.20%), migration duration of greater than five years (38.49%), within-city migration (44.78%), enrollment in Urban Employee Medical Insurance (51.61%), local insurance coverage (51.98%), engagement in greater than three types of health education activities (52.52%), and having greater than two children (37.58%). Chi-square tests confirmed significant differences for these variables (χ²=205.19, 41.19, 10.75, 49.58, 29.15, 100.19, 11.45, 86.09, 324.38, and 11.20, respectively). However, participation did not differ significantly by gender, ethnicity, educational attainment, household registration status or marital status.

Table 2.

Comparison of health record participation of elderly migrants with different characteristics

Variables		Not participated		Participated		χ²	P
		n	%	N	%
Region	Eastern	1294	77.58	374	22.42	205.19	< 0.01
	Central	338	55.14	275	44.86
	Western	1008	56.25	784	43.75
	Northeast	588	60.93	377	39.07
Gender	Male	1889	65.21	1008	34.79	3.80	0.05
	Female	1339	62.54	802	37.46
Age	60 ~ 69	2711	66.14	1388	33.86	41.19	< 0.01
	70 ~ 79	458	55.45	368	44.55
	80 years and above	59	52.21	54	47.79
Ethnic group	Ethnic Minority	263	62.77	156	37.23	0.34	0.56
	the Han Chinese	2965	64.19	1654	35.81
Whether living with family or being alone	Living with family	3055	64.64	1671	35.36	10.75	0.01
	Living alone	173	55.45	139	44.55
Average monthly household income	Below the average monthly income	2080	60.80	1341	39.20	49.58	< 0.01
	Equal to or above the average monthly income	1148	71.00	469	29.00
Educational attainment	Middle school and below	2414	63.69	1376	36.31	0.98	0.61
	High school or technical secondary school	559	65.08	300	34.92
	College degree or above	255	65.55	134	34.45
Nature of household registration	Agriculture	1581	63.16	922	36.84	1.79	0.18
	Non-agriculture	1647	64.97	888	35.03
Marital status	Unmarried	19	70.37	8	29.63	0.89	0.64
	First marriage	2636	64.25	1467	35.75
	Other	573	63.11	335	36.89
Migration duration	Less than five years	1152	69.27	511	30.73	29.15	< 0.01
	At least 5 years	2076	61.51	1299	38.49
Migration range	Trans-provincial	1625	71.30	654	28.70	100.19	< 0.01
	Across cities in the province	1048	59.75	706	40.25
	Cross county within the city	555	55.22	450	44.78
Place of insurance	Place of domicile	340	48.02	368	51.98	86.09	< 0.01
	Place of household establishment	2618	66.04	1346	33.96
	Somewhere else	48	71.64	19	28.36
Type of insurance	Medical insurance for urban and rural residents	2139	64.21	1192	35.79	11.45	< 0.01
	Urban employee medical insurance	45	48.39	48	51.61
	Others or unclear	86	69.35	38	30.65
Community health education	Never received	1099	80.81	261	19.19	324.38	< 0.01
	One or two	1499	63.76	852	36.24
	Three or more	630	47.48	697	52.52
Number of biological children	Childless	67	69.07	30	30.93	11.20	0.04
	One	1079	67.06	530	32.94
	Two or more	2063	62.42	1242	37.58

Binary logistic regression analysis on health record utilization among migrant older adults

Binary logistic regression was conducted with health record participation (1 = participated; 0 = did not participated) as the dependent variable. The model demonstrated good fit (Model χ² = 537.46, P < 0.001; Nagelkerke R² = 0.19; Hosmer-Lem test χ² = 1.35, P = 0.995). Migrant from central region (OR = 2.46, 95% CI:1.88–3.21) and female participants (OR = 1.29, 95% CI: 1.11–1.50) exhibited higher odds of health record participation. Compared with individuals aged 60 to 69 years, those aged 70 to 79 years (OR = 1.54, 95% CI:1.25–1.89) and aged 80 years and above (OR = 1.79, 95% CI:1.07–2.98) were more likely to participate in health records services. Having a below-average income (OR = 1.41, 95% CI:1.16–1.71), a migration duration of greater than 5 years (OR = 1.38, 95% CI:1.17–1.62), receiving one to two types of health records (OR = 2.42, 95% CI: 1.97–2.96) and greater than three types of health records (OR = 4.73, 95% CI:3.79–5.89) were all associated with an increased likelihood of participation (Table 3).

Table 3.

Binary Logistic regression analysis of the participation of migrant older adults

Variable(control)	B	S.E	χ²	P	OR	OR 95%CI
						Lower limit	Superior limit
Region (Eastern)			59.35	< 0.01
Central	0.90	0.14	43.13	< 0.01	2.46	1.88	3.21
Western	0.76	0.11	47.37	< 0.01	2.14	1.72	2.65
Northeast	0.73	0.13	32.14	< 0.01	2.08	1.61	2.67
Gender (Male)	0.25	0.08	10.45	< 0.01	1.29	1.11	1.50
Age (60 ཞ 69 years)			19.72	< 0.01
70 ཞ 79 years old	0.43	0.11	16.43	< 0.01	1.54	1.25	1.89
80 years and above	0.58	0.26	4.95	0.03	1.79	1.07	2.98
Ethnic group (Ethnic Minority)	0.29	0.14	4.44	0.04	1.34	1.02	1.76
Whether living with family (Living with family)	0.36	0.19	3.58	0.06	1.44	0.99	2.09
Average monthly household income (Equal to or above the average monthly income)	0.34	0.10	11.96	< 0.01	1.41	1.16	1.71
Educational attainment (middle school and below)			6.81	0.03
High school or technical secondary school	-0.02	0.13	0.02	0.89	0.98	0.77	1.26
College degree or above	0.56	0.22	6.37	0.01	1.76	1.13	2.72
Nature of household registration (non-agriculture)	0.16	0.09	3.40	0.07	1.18	0.99	1.40
Marital status (Unmarried)	-0.16	0.12	1.93	0.16	0.85	0.67	1.07
Migration duration (Less than 5 years)	0.32	0.08	15.19	< 0.01	1.38	1.17	1.62
Migration range (Trans-provincial)			6.85	0.03
Across cities in the province	0.10	0.09	1.05	0.31	1.10	0.92	1.32
Cross county within the city	0.28	0.11	6.75	0.01	1.32	1.07	1.63
Place of insurance (Somewhere else)			39.05	< 0.01
Place of domicile	0.55	0.48	1.32	0.25	1.74	0.68	4.48
Place of household establishment	-0.07	0.48	0.02	0.88	0.93	0.37	2.36
Type of insurance (other or unclear)			7.59	0.02
Medical insurance for urban and rural residents	-0.13	0.23	0.33	0.56	0.87	0.56	1.38
Urban employee medical insurance	0.53	0.31	2.88	0.09	1.69	0.92	3.11
Community health education (never received)			190.96	< 0.01
One or two types	0.88	0.10	73.38	< 0.01	2.42	1.97	2.96
Three or more types	1.55	0.11	190.10	< 0.01	4.73	3.79	5.89
Number of biological children (childless)			2.46	0.29
One	0.46	0.30	2.41	0.12	1.58	0.89	2.83
Two or more	0.40	0.29	1.97	0.16	1.50	0.85	2.64

Discussion

Health record participation is fundamental and essential for the informatization of healthcare, serving as a critical element in chronic disease management and tiered healthcare delivery. This study indicated that only 35.93% of migrant older adults possess health records, reflecting a low overall participation rate and highlighting the urgent necessity to enhance health record management within this demographic. Despite the eastern region of China being more economically developed than its central and western counterparts, only 22.42% of migrant older adults in this region had health records, which aligns with findings from previous study [11]. This situation can be attributed to several factors: lower levels of psychological and cultural integration among migrant older adults in eastern regions compared to other areas [12], more pronounced education-linked household registration barriers in these cities [13], disparities in access to comprehensive public services for urban residents [14], and variations in public health resource subsidy policies. Conversely, the central government’s preferential support for healthcare infrastructure in central and western regions may have inadvertently enhanced their participation rates in health record systems, thereby creating a late-mover advantage. This phenomenon highlights the persistent institutional barriers and insufficient policy inclusiveness that characterize current health record development. The provision of public services to migrant populations remains constrained by the household registration system and governance mechanisms. Furthermore, the enrollment and maintenance of health records lack cross-regional responsibility-sharing and financial compensation mechanisms, rendering migrant populations vulnerable to service exclusion while underscoring the inadequacy of policy inclusiveness. Meanwhile, information system integration is inadequate, characterized by enduring information silos. Regional disparities exist regarding electronic health record standards, with a lack of platform interconnection severely impeding data mobility and sharing, this limitation constrains progress toward achieving of the goal of health records following individuals. Therefore, it is recommended that priority be given to advancing cross-regional information platform interconnectivity based on existing policy frameworks, unifying data standards, and strengthening system integration. At the policy level, collaborative mechanisms for managing migrant population health records should be explored. While adhering to the current fiscal system, pilot programs for joint regional construction and sharing models should be implemented to enhance accessibility and continuity of relevant services.

Consistent with previous findings [15], participants aged 70 to 79 years and those aged 80 years and older were 1.54 and 1.79 times more likely to engage in health records keeping, respectively, compared with those aged 60 to 69 years. This association may be attributed to the increased prevalence of illness and a greater demand for healthcare services among migrant older adults as they age. Furthermore, this study demonstrated that migrant older adults with below-average incomes exhibited a higher likelihood of health record participation than their counterparts with above-average incomes. This finding can be explained by the heightened attention and support provided by state agencies and communities to elderly individuals with low incomes. As the risk of chronic diseases escalates exponentially with age [16], participants from low-income backgrounds often lack adequate care and have limited access to such services, which increases their engagement with community health workers and participation in health records [17]. These findings suggest that health safeguards for migrant older adults should be strengthened at both community and governmental levels. In addition to prioritizing advanced-age migrant older adults and those with low incomes. It is crucial not to overlook younger-age migrant older adults regarding their health security and supportive services. Efforts must focus on raising their health awareness, integrating relevant measures with the family doctor contract system [18], enhancing early screening initiatives, providing comprehensive health education, and preventing intergenerational accumulation of health inequality [19].

Although the difference was not statistically significant, migrant older adults with children were more likely to possess health records compared to their childless counterparts. Previous research [20] has indicated that intergenerational support from children positively influences the health status of older adults. The daily care and emotional support provided by children can alleviate negative psychological states among older adults, enhance their life satisfaction, and facilitate access to and utilization of public health services, thereby increasing participation rates in health record systems. Consequently, it is essential for children to pay greater attention to the daily lives, physical and mental well-being, and social interactions of their parents. They should assist their parents in learning how to use modern communication technologies to keep pace with social developments, encourage participation in community activities designed for older adults, and provide kinship support to help them overcome negative psychological states. Simultaneously, there is a need for improvements in family-friendly policy frameworks through the implementation of inclusive policies aimed at families with senior members while accelerating the integration of social resources to promote community-based home care services [21]. Such measures are anticipated not only to alleviate the caregiving burden on children but also to enhance health record participation among their aged parents.

In terms of migration duration and range, migrant older adults who have resided in their destination for less than five years and those who have migrated across provincial boundaries exhibit a relatively lower likelihood of participating in health record initiatives, which aligns with findings from previous research [22–23]. This phenomenon may be attributed to the fact that longer migration durations and smaller the migration ranges foster a greater sense of stability, social integration, and reliance on local healthcare resources among migrant older adults [24]. Conversely, frequent long-distance migrations complicate the ability of healthcare institutions and communities to establish health records while simultaneously diminishing migrant older adults’ motivation to engage in such initiatives. Additionally, this phenomenon may stem from the underdevelopment of cross-regional medical insurance reimbursement systems and health record transfer mechanisms in China; the heterogeneity of public health services further impedes participation by migrant older adults’ motivation to engage in such initiatives [25]. Furthermore, these individuals often possess limited knowledge regarding local policies in their destination areas, lack robust community support networks, and face additional barriers related to language differences, cultural disparities, and digital divide that reduce their willingness to participate. Therefore, it is imperative to accelerate the equalization of basic public services for migrant populations by dismantling barriers associated with household registration system. This would enable migrant older adults to access equivalent public service policies and preferential treatment as those available to local seniors. Such measures could enhance coordination within medical security systems while integrating urban-rural frameworks aimed at addressing practical challenges faced by migrant older adults concerning healthcare access and medical reimbursement [26]. Ultimately, incorporating health records into the basic public health service list for migrants is essential; implementing a residence-based management approach through community grid workers and family doctor teams will facilitate targeted screening and dynamic management for those who have lived in an area for less than five years.

Furthermore, this study indicated that migrant older adults who have participated in three or more community health education activities are significantly more likely to engage with their health records. This finding underscored the strong correlation between participation in health records and engagement in community health education initiatives. Enhancing residents’ health literacy is essential for improving overall population health outcomes [27] and promoting awareness of health literacy but also expand their social networks, rebuild connections within the community, and cultivate trust with healthcare professionals and community workers. Such interactions can substantially diminish skepticism and resistance toward the establishment and maintenance of personal health records. Moreover, when elderly individuals begin to focus on their own health data, they tend to become more proactive in seeking relevant knowledge to interpret this information effectively; consequently, they engage more actively in subsequent community, based educational activities which further enhance their self-management capabilities. Based on these findings, several recommendations are proposed: First, optimize the design and outreach of existing health education activities by continuing to offer diverse and practical activities while skillfully integrating health record promotion into these activities. It is crucial to emphasize the role of these records as health identity cards thereby helping migrant older adults fully comprehend the benefits associated with establishing and maintaining such documentation. Second, it is essential to leverage the peer effect [28] by encouraging active participants who have successfully engaged in both educational activities and documented their medical histories to share their experiences. By harnessing the influence of their social networks, more hesitant migrant older adults can be motivated to participate in health records initiatives. Third, it is important to provide one-stop services. During health education activities or free medical clinics, convenient on-site services should be made available for health record enrollment or updates. Capitalizing on the heightened health awareness among migrant older adults can reduce participation barriers and translate willingness into action. Through these measures, the participation rate in health record among migrant older adults can be significantly improved, thereby establishing a solid foundation for their access to continuous and high-quality medical services.

Limitation

Several limitations should be acknowledged in this study. First, potential selection bias may exist in the sampling process, which may compromise the representativeness and external validity of the results. This study excluded respondents with severe mental disorders, major communication difficulties, and those who responded unsure to the key question regarding health record participation. Such exclusions may limit the sample’s ability to fully reflect the heterogeneity of migrant older adults in mental health, social vulnerability, and access to health information. Accordingly, caution is required when generalizing the findings to wider and more diverse migrant older adults. Future studies may adopt qualitative and mixed method designs to explore participation barriers and unmet needs of excluded groups, and recruit more diverse samples with assisted communication or proxy responses to improve study inclusiveness. Sensitivity analyses can also be applied to enhance ecological validity and policy implications.

Second, the data were collected in 2018, before the full implementation of China’s ‘Internet + Healthcare’ and Healthy China 2030 strategies, which have promoted cross-regional electronic health records and equitable primary care, thus, the data cannot fully capture the latest developments in health record management for migrant older adults, limiting the timeliness of this research. Nonetheless, the core issues identified, including developmental paradoxes, passive participation, and household registration barriers, remain meaningful for policy evaluation and reform.

Third, the cross-sectional design precludes causal inference due to the absence of a temporal framework. Sample heterogeneity may also reduce external validity and generalizability. Longitudinal and cohort studies withe long-term follow-up are recommended to verify causal relationships. Multi-center and large-sample studies are also encouraged to test the stability and generalizability of the present findings across subgroups of migrant older adults.

Conclusions

The low health record participation rate among migrant older adults in mainland China underscores the necessity of this study. Community health education engagement is identified as the strongest correlate of health record establishment. Accordingly, multi-pronged strategies are required: developing targeted health education materials tailored to this population to improve their willingness to establish health records. Priority should be given to tailed health record management for younger and eastern-residing migrant older adults, in accordance with the equalization of basic public health services. Intersectoral collaboration involving families, communities, and social organizations is needed to provide personalized outreach and support. Furthermore, digital and information technologies should be fully utilized to effectively boost health record participation among migrant older adults.

Authors’ contributions

SM was responsible for applying for the public dataset from the National Health Commission Migrant Population Service Center, performing data cleaning and processing, conceiving and designing the study framework, to proposing statistical analysis strategies, revising the manuscript, and overseeing the submission process. WXZ conducted the data analysis, drafted the original manuscript, and revised the paper according to comments from the editor and reviewers. YX, YTC and RRX offered valuable comments on the study results and discussion sections.

Funding

This research was supported by the Zhejiang Provincial Natural Science Foundation (Grant NO. LQ21G030001).

Data availability

The datasets utilized and analyzed in the present study are available from the National Health Commission of the People’s Republic of China via the following URL: https://www.ncmi.cn/phda/dataDetails.do? id=CSTR: A0006.11.A000T.201906.000225-V1.0.

Declarations

Ethics approval and consent to participate

The data used in this study are secondary data derived from the CMDS survey, for which ethical approval has already been obtained.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.