A New Perspective of Urban-rural Differences: the Impact of Supply and Demand on Healthcare Services for the Older Adults: a Case Study of Shaanxi Province


 Background: With the rapidly aging of Chinese society and the change of Chinese residents’ disease spectrum, the older adults utilization of the healthcare services surges as well. Studies on factors that potentially influence the utilization of healthcare services for the older adults becomes increasing important, which could benefit improving the service effect and the quality of life of the older adults in later life. This article compares and analyzes the differences in the using of healthcare services by the older adults in urban and rural areas based on the supply and demand of healthcare services for the older adults and analyzes the reasons for potential differences. Methods: Using data from a survey conducted in three cities in Shaanxi Province in 2019. All authors participated in the questionnaire survey. We obtained a total of 948 questionnaires. Multivariate regression model and Oaxaca-Blinder decomposition model are used to analyze the difference between the supply and demand of medical services for the older adults in urban and rural areas.Results: The results find that age, household register, living activities of daily living (ADL), (P<0.01) and healthcare treatment insurance significantly impact the older adults use of healthcare services. Meanwhile, factors from the supply and demand factors have a significant correlation with the utilization of services for the older adults, including the healthcare service quality(P<0.01), the diversity of service content(P<0.01), the rationality of service charge(P<0.01), service satisfaction(P<0.01), family support (P<0.1) level and the main illness(P<0.05). Moreover, the results show a significant difference in the use of healthcare services for the older adults between urban and rural areas. Specifically, in urban areas, the influences of service quality, the diversity of service content and the rationality of service from the supply have a significant correlation with the utilization of services for the older adults. The service satisfaction, service demand and family support in the demand factors have a significant correlation with the utilization of services for the older adults. In comparisons, for the older adults in rural areas, the diversity of service content from the supply factors as well as economic level and main illness from the demand factors have a significant correlation with the utilization of services for the older adults.Conclusions: From the perspective of supply and demand, this paper constructs an analytical framework of the determinants of healthcare services for the older adults from a new perspective. Based on the analysis framework and from the perspective of supply and demand of healthcare services utilization, the differences between urban and rural areas in the utilization of medical care for the older adults and the influencing factors are studied. It provides a new research perspective to explore the influencing factors of healthcare services utilization for the older adults. Supply factors and demand factors have a significant correlation with the utilization of healthcare services for the older adults. There are also significant differences in the factors influencing the utilization of health services by urban and rural older adults. When strengthening and improving the supply of healthcare services for the older adults, the previous thinking of “top-down” and “service-centered” should be changed, and gradually transformed into “bottom-up” and “demand-centered”.


Introduction Background
In recent years, with the accelerating aging population in China, the utilization of healthcare services for the older adults has been paid more attention by the government and the public [1]. At the same time, the disease spectrum's changes in China drive the older adults increasing demand for healthcare services [2].
Although China older adults healthcare services experienced a rapid development under the guidance of the government's policies and the market promotions, the utilization level of healthcare services for the older adults is still relatively low, which leads to the dilemma of "supply " and "demand " [3]. To better solve the dilemma of supply and demand imbalance, improve the effect of healthcare services, and promote the healthcare and sustainable development of healthcare services, the research on the factors in uencing the utilization of healthcare services for the older adults will be of great value. At the same time, due to the dual economic system of urban and rural areas and the inverted "pyramid" con guration of healthcare resources, the utilization of healthcare services between urban and rural residents have signi cant difference, which is getting larger day by day [4].
The reform of household registration and the integration of the healthcare insurance system for urban and rural residents provides a channel for rural residents to enter into urban areas freely [5], which is conducive to improving the accessibility of healthcare services [6]. Studies have found that even in rural areas where purchasing power is strong, the use of healthcare services is still much lower than in cities, and it is pervasive in almost every country in the world [7]. Therefore, under this situation, it is of great practical signi cance to reconsider and study the utilization of healthcare services for urban and rural residents.
At present, the research on the utilization of healthcare services for the older adults is mainly focused on the overall community older adults healthcare services, and there is a lack of discussion on the mechanism and in uencing factors of the utilization of healthcare services for the older adults. Along with the deepening of aging in China, the service demands of the older adults in China have been transformed and upgraded, and the older adults have the greatest demand for healthcare services among all kinds of older adults needs. Therefore, it is necessary to discuss the in uencing factors of health service utilization of the older adults in urban and rural areas and the inequality mechanism behind. Most of the studies on the in uencing factors of healthcare service utilization of the older adults discuss the demand-side factors such as economic level, health status, and family support for inequality, and lack the discussion of supply factors such as service supply and service price. Therefore, it is necessary to explore the inequality of healthcare service utilization among the older adults in urban and rural areas and the in uencing factors behind it from both the supply and demand factors.

Analysis Framework
The Anderson Model of Health Care Delivery is the most widely used model in academia to measure the in uences on health care delivery. The Anderson Model classi es the in uences on individual health care utilization into Predisposing characteristics, enabling resources, and Needs [8]. This article analyzes the factors in uencing the utilization of medical services from the supply and demand perspectives, so it is necessary to expand the Anderson model from the supply and demand perspectives of healthcare services for the older adults to form a model of supply and demand for healthcare services for the older adults. rstly, the predisposing characteristics in the Anderson model are used as the control variables in the article, such as age, marriage, education and other characteristics [9]. Previous research shows: Personal self-assessment of health and gender will have a signi cant impact on the utilization of healthcare services the utilization of healthcare services for the older adults will be affected by the basic healthcare insurance (Health Insurance) [10]. The increase in the older adults will promote the probability of healthcare service utilization, and the aging rate will signi cantly affect the utilization of healthcare services for the older adults [11]. Education level and income of the older adults will in uence the utilization of healthcare services for the older adults [12]. Marital status and self-care ability will also affect the use of healthcare services for the older adults [13]. Enabling resources in the Anderson model are used as supply factors in the article, including community-provided healthcare service resources for the older adults, healthcare Accessibility and others. nally, Needs in the Anderson model are used as demand factors in the article, the degree of subjective needs of the older adults for healthcare service resources, health status, and family support are taken as demand factors. Thus, using the original Anderson model, Supply and demand model of healthcare services utilization for the older adults in urban and rural areas was constructed.
Finally, this study constructed an analytical framework for the impact of supply and demand on older adults healthcare services, as shown in Figure 1. An additional gure le shows this in more detail [see Additional le 1]. H1: Supply factors, including: healthcare quality, accessibility, diversity, rationality have a signi cant correlation with the utilization of services for the older adults From the supply factors, healthcare services supply is an important prerequisite for the utilization of healthcare services for the older adults. On the basis of adequate service supply, some scholars point out that healthcare services quality [14], healthcare services accessibility affect healthcare service utilization affects healthcare service utilization [15], healthcare services charges affect frequency of use of medical services for the older adults [16].The greater the diversity of community-supplied medical services, the higher the utilization of medical services for the older adults [17].Quality of healthcare services are the deciding factor of healthcare utilization among older adults [18].
H2: Demand factors, including: healthcare satisfaction, need, economic level, family support, major illness have a signi cant correlation with the utilization of services for the older adults.
From the demand factors, Different models of healthcare affects the probability of healthcare service utilization for the older adults [19]. Healthcare reform plan and healthcare system affect the utilization of healthcare services for the older adults [20]. The type of healthcare services, the accessibility of healthcare services, and the price of healthcare services will all affect the use of healthcare services by the older adults [21]. the demand for healthcare services is the direct driving force for the older adults to use healthcare services [22]. At the same time, this potential demand is transformed into actual demand, which is directly affected by the economic level, family support, illness of the older adults and other factors, as well as the feedback of service satisfaction [23]. Relevant studies have shown that the higher the service satisfaction [24], the better the economic level [25], and the more likely the older adults are to use healthcare services in the case of severe illness [26]. The lower the income of the older adults, the less healthcare services will be used [27]. The higher the drug usage rate, the higher the utilization rate of healthcare services [28][29]. The research of Yonatan (2020) shows that providing psychedelic therapy is economically bene cial to the healthcare system, reducing the utilization and cost of healthcare services [30]. Chronic diseases and major diseases will increase the use of healthcare services by the older adults [31]. Healthcare services satisfaction affects healthcare service utilization [32]. Family support, including nancial support, partner support, and children's support will affect the use of healthcare services for the older adults [33][34].
H3: There are obviously differences in the utilization of healthcare services for the older adults between urban and rural areas.
Due to the urban-rural dual structure in China, there are signi cant differences between urban and rural areas in the supply of healthcare services and the economic income of the older adults [35], and there are also signi cant differences in the in uence of supply-side and demand factors on the utilization of healthcare services for the older adults in urban and rural areas [36]. In general, urban older adults are more inclined to use healthcare services due to their higher economic level, education level, and better healthcare insurance [37]. Tendency factors and demand factors will narrow the gap between urban and rural areas in the use of healthcare services, and rural older adults who are supported by their children are more willing to use healthcare services [38]. Ming-Chung (2018) showed that there is no signi cant urbanrural difference in the frequency of emergency department utilization for the older adults, but there are signi cant differences in health services [39]. There are also signi cant differences in the types and in uencing factors of healthcare service utilization between urban and rural older adults [40].

Ethics approval and consent to participate
This study is approved by the Department of Social Sciences of the Ministry of Education, PRC and the Medical Ethics Committee of Health Science Center of Xi 'an Jiaotong University (Approval Number 2016-416). The questionnaire is anonymous, and participation in the questionnaire is considered as informed consent.

Data Sources
The data for the study come from eld surveys. The survey is conducted in Shaanxi Province from July to August 2019 by strati ed random sampling method. The rst stage strati cation is based on cities, the second stage strati cation is based on counties, the third stage strati cation is based on villages, and the fourth stage strati cation sampling is based on older adults. Three cities, Hanzhong, Baoji and Yan 'an, are selected. These three cities are characterized by high aging degree and rapid development of geriatric medical and health services. A total of 948 valid questionnaires are obtained in this survey. This paper selects the data of the demand and supply of medical services for the older adults, and nally obtains 670 valid samples.

Variable Selection
Utilization of healthcare services is de ned as the number of older adults who have used the healthcare services provided by the community. It is measured by asking "the content of healthcare services provided by the community you have used (multiple choice)", including healthcare management, on-site diagnosis, and community healthcare. Accompanying healthcare treatment, rehabilitation care, and smart older adults care services. A value of 1 means that the older adults have used the service, and a value of 0 means that the older adults have not used the service. The score for the use of each service by adding up, we get the healthcare service utilization variable, with a value range of 0-6. The higher the score, the more the older adults use healthcare services.
According to the analysis framework of the research, the independent variables mainly include two categories. The rst category is the supply side, which is mainly measured through service quality, service accessibility, service supply diversity, and service charges. Service quality refers to the level of the older adults perception of the quality of healthcare services, ranging from 0 to 5. The higher the score, the better the quality of service; the accessibility of services refers to the convenience of the older adults to the nearest clinic/healthcare service center. The Likert scale is measured with a value of 1~5; the service provision mainly includes healthcare management, on-site diagnosis, community healthcare, accompanying healthcare treatment, rehabilitation care, and smart older adults care services, through inquiring about "healthcare services provided by the community" Content (multiple choice)" is measured, the main illnesses refer to the physical healthcare of the older adults, including major illness requiring hospitalization, chronic diseases, mental diseases, common diseases or frequently-occurring diseases.
According to previous research literature, the control variables used in the analysis include age, gender, education, marriage, household registration, work before retirement, activities of daily living in life, mental state, and healthcare insurance. Among them, the activities of daily living for daily life is a composite of the interviewees' scores on the 6 indicators of eating, dressing, getting in and out of bed, going to the toilet, walking indoors, and bathing, with a value of 0~6. The worse the activities of daily living. The setting and description of the variables are shown in Table 1.

Results
Descriptive statistics of the control variables Table 2 showed the control variables selected in this article. Among the surveyed older adults, the mean value of age was 70 years old, the ratio of men to women was about 0.6:1, in terms of education, the proportion of older adults with elementary school education or below was as high as 43.28%, the ratio of urban and rural population was 1.3:1, the mean value of the ability to take care of oneself in life (ADL) was 0.05, that is, the vast majority of the older adults were not physically damaged, the type of marriage had the most older adults in marriage, accounting for The overall situation of the surveyed older adults people's use of healthcare care services was average, the percentage of those who had used healthcare care services was 72.24%. 72.24% of the respondents had used healthcare care services, but less than 3% of them had used three or more services.  Table 3 showed the results of the multiple regression analysis, with the dependent variable being healthcare services utilization, model 1 incorporating only the control variables, models 2 and 3 being the results of incorporating supply-side and demand factors, respectively, based on the control variables, and model 4 being the full model. Although there may be multicollinearity among the variables, the statistics showed that the four models did not have serious multicollinearity problems (see the notes to Table  3), which could be used as the basis for the analysis.   Note: (1) *** means signi cant at the 1% level, ** means signi cant at the 5% level, and * means signi cant at the 10% level. (2) Tolerance is a test of covariance of independent variables, and the tolerance of the above four models are all much larger than 0.10, indicating that there is no serious covariance between the independent variables.
Model 1 incorporated only control variables, and the results showed that age (b=0.008), Education (b=0.07), and health insurance (b=0.497) had a signi cant and positive correlation with the utilization of healthcare services for the older adults. Model 2 examined the impact of supply factors on the utilization of healthcare services for the older adults based on control variables, and the results showed that healthcare services quality (b=0.038), service accessibility (b=0.047), and service supply diversity (b=0.261) had a signi cant and positive correlation with the utilization of healthcare services for the older adults, and service rationality(b=-0.06) had a signi cant and negative correlation with, but service accessibility became no longer signi cant in the subsequent full model. This indicated that the better the service quality, the more likely the older adults would use the healthcare services; the more abundant and diverse the service supply, the more likely the older adults would use the healthcare services; the higher the healthcare services price, the less likely the older adults would use the service. This veri es the hypothesis 1 of this article: Supply factors, including: healthcare quality, accessibility, diversity, rationality had a signi cant correlation with the utilization of services for the older adults. Result indicated that the more satis ed the older adults were with the service, the more likely they were to use the healthcare services; the greater the need for the healthcare services, the more likely they were to use the service; the greater the family support, the more likely they are to use the healthcare services; and the more illness the older adults were, the more likely they were to use the service. This veri es the hypothesis 2 of this article: Demand factors, including: healthcare satisfaction, need, economic level, family support, major illness had a signi cant correlation with the utilization of services for the older adults.

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Difference between urban and rural areas in the utilization of healthcare services Because the household registration variables signi cantly impacted the healthcare services utilization of the older adults in the model 4. Therefore, urban and rural older adults were discussed separately to explore the differences in the factors in uencing healthcare services between urban and rural older adults, and Table 4 showed the regression results of healthcare services utilization for urban and rural older adults.  Note: (1) *** means signi cant at the 1% level, ** means signi cant at the 5% level, and * means signi cant at the 10% level. (2) Tolerance is a test of covariance of independent variables, and the tolerance of the above two models are all much larger than 0.10, indicating that there is no serious covariance between the independent variables.
The results were presented in Models 5 and 6. For the urban older adults, unlike Model 4, the major medical illness P > 0.1 in the demand factors were no longer signi cant. For the rural older adults, only healthcare services diversity (b=0.268) and major illness (b=0.152) had a signi cant and positive correlation with the utilization of healthcare services for the older adults. but the economic level ((b=-0.042) had a signi cant and negative correlation with the utilization of healthcare services for the older adults, the better the economic level of the older adults, the less likely they were to use community healthcare services. Models 5 and 6 veri ed hypothesis 3: There were obviously differences in the utilization of healthcare services for the older adults between urban and rural areas.

Oaxaca-Blinder decomposition analysis of medical service utilization factors among urban and rural older adults
In order to understand the contribution of different factors to the difference in the utilization of healthcare services for the older adults in urban and rural areas, this article attempted to conduct Oaxaca-Blinder for the utilization of healthcare services for the older adults in urban and rural areas. Table 5 was the Oaxaca breakdown of the difference in outpatient expenditure between urban and rural areas. The coe cient effect explained 99.8% of the total urban-rural expenditure difference, when urban and rural older adults had the same explanatory variables in all cases, Because of the difference between urban and rural attributes, urban older adults had 99.8% more health utilization in uencing factors than rural older adults with the current urban-rural difference.
Among the control variables, males generally spend more on hospitalization than females, and the proportion of urban males was higher than the proportion of rural males, so gender explained 4.7% of the total expenditure difference. Age, and Mental state explained the difference in health care services utilization factors between urban and rural older adults in a negative direction, implying that when urban older adults and rural older adults had the same age, ADL, and mental state were the same, it would lead to the widening of the difference in medical service utilization factors. Health insurance explained 16.8% of the difference, which meant that when the level of medical insurance was the same in urban and rural areas, the factors affecting rural residents' medical service utilization increased accordingly, Age Gender Education Marriage Work ADL Mental state Health insurance and other factors explained a total of urban and rural The factors such as Age Gender Education Marriage Work ADL Mental state Health insurance explained 10.59% of the total expenditure difference between urban and rural areas.
Among the supply factors, quality of medical services explained 5.1% of the variance, accessibility explained -5.8% of the variance, diversity explained 5.3% of the variance, and rationality explained 8.1% of the variance. Among the supply factors, service satisfaction explained 6.5% of the variance, service need explained 8.1% of the variance, economic level explained 6.3% of the variance, family support explained 8.1% of the variance, and major illness explained -8. Among all the control variables, age is highly signi cant in models 1 to 5, the older the older adults are, the more likely they are to use health services [41],it can be assumed that there is an "aging" tendency in the use of health services in China. At the same time, health insurance, as the biggest guarantee for the older adults to use health services in their later years, signi cantly in uences the level of health service utilization, and the higher the level of health insurance, the more the older adults tend to use healthcare services, especially in the rural areas of China, due to the low income in rural areas, health insurance becomes the main reliance of the rural residents to use healthcare services. This is consistent with the expected hypothesis.
[42] ADL has a signi cant and positive correlation with the utilization of healthcare services for the older adults. As the disease spectrum of Chinese residents continues to change, the incapacity of the older adults to take care of themselves due to chronic diseases and other diseases is becoming more prominent, and the less capable of taking care of themselves, the more willing they are to use healthcare services due to their objective needs. And since older adults in rural areas of China generally need to farm as well as farm work and are more capable of taking care of themselves, the ability of living self-care cannot signi cantly affect the healthcare services utilization of older adults for the rural older adults.
The results of the article show that the effect of economic level on the utilization of health services for the urban older adults was insigni cant, this nding is contrary to previous studies on the utilization of social care services. The effect of economic level on the utilization of health services for the rural older adults was signi cant. On the one hand, China has built a nationwide medical insurance system, especially in urban areas, and medical insurance basically ensures that the health service needs of the older adults can be met. Since rural older adults with an annual income of less than 10,000 RMB account for more than 50% of the surveyed rural older adults people, the economic level is still a factor in uencing their health service utilization due to their low savings and agricultural work in their later years.
The higher the quality of healthcare services supply, the greater the supply of healthcare services content, and the higher the reasonableness of service charges, the higher the level of healthcare services utilization of the older adults. Older adults people living in urban areas prefer service quality and reasonableness of service charges, while rural older adults people preferred diversity of healthcare supply.
The accessibility of healthcare services has not signi cantly affect the utilization of healthcare services for the older adults, which is due to the fact that with the construction of urban and rural road networks, the overall transportation level is more convenient, and healthcare services can be accessed quickly and easily in both rural and urban areas, so with the development of social economy, accessibility does not affect the utilization of healthcare services for the older adults.
The results of the article show that the higher the acceptance of healthcare services by the older adults, the more satis ed the services, the greater the need for services, and the greater the possibility of their use of services. The higher the level of family support, the more older adults people prefer to use healthcare services [43]. The older adults with more illness prefer to use healthcare and healthcare services. The healthcare services need factors are further divided into urban and rural areas. The results show that among the urban older adults, those in need of healthcare services account for 64% of the surveyed urban older adults, and among the rural older adults, those in need of services account for the surveyed rural older adults. 58% of the population, it can be seen that the healthcare needs of the rural older adults are almost the same as the urban older adults, and the healthcare needs of the rural older adults may increase explosively in the future [44]. The in uence of economic level among the demand factors is not signi cant, but it is a negative in uence. To a certain extent, the higher the economic level of the older adults, the more likely they are to choose professional market-oriented services.

Conclusion
From the perspective of supply and demand, this paper constructs an analytical framework of the determinants of healthcare services for the older adults from a new perspective. Based on the analysis framework and from the perspective of supply and demand of healthcare services utilization, the differences between urban and rural areas in the utilization of medical care for the older adults and the in uencing factors are studied. It provides a new research perspective to explore the in uencing factors of healthcare services utilization for the older adults.
This article compares and analyzes the factors that differentiate urban and rural older adults in healthcare utilization based on the supply and demand of healthcare services for older adults and analyzes the causes of potential differences and making feasible recommendations to improve health service utilization among the older adults. The main ndings are as follows: age, health insurance, and ability to care for oneself in life (ADL) have a signi cant correlation with the utilization of healthcare services for the older adults. Supply factors and demand factors have a signi cant correlation with the utilization of healthcare services for the older adults. There are also signi cant differences in the factors in uencing the utilization of health services by urban and rural older adults.
The main recommendations are as follows. When strengthening and improving the supply of healthcare services for the older adults, the previous thinking of "top-down" and "service-centered" should be changed, and gradually transformed into "bottom-up" and "demand-centered". When carrying out the content of healthcare and health services, do a good job of demand investigation and assessment, and strive to provide services from the perspective of the actual needs of the older adults, and improve the e ciency of service utilization. Second, the supply of healthcare services should be differentiated between urban and rural areas. The supply of healthcare services for the older adults in urban areas is in place, so we should focus on the professionalization of service supply, from " available" to "excellent"; healthcare services for the older adults in rural areas are lacking, and the healthcare needs of the older adults in rural areas may increase explosively in the future. Therefore, attention should be paid to the quantity of service supply, that is, from "none" to "with". At the same time, service accessibility is also an important factor affecting the utilization of rural older adults healthcare services. Finally, we should improve the subsidy system and expand the scope of services purchased by the government. On the one hand, for some older adults with low income and insu cient ability to pay, reasonable subsidies should be set according to their health and income levels, so that low-income older adults can also use medical and healthcare services; on the other hand, the scope of government purchased services should be expanded to include medical and healthcare services, so as to improve the utilization rate of services.
The limitations of the article are as follows. The article is limited by data limitations and only focuses on the factors affecting the utilization of healthcare and healthcare services in Shaanxi Province, which lacks typicality. The second is that the inclusion of explanatory variables is insu cient and the explanatory power of the model is not high. Future research can work in two ways: (1) Further expand the scope of research, eld surveys in the developed eastern regions, verify and enrich existing research; (2) In the selection of indicators for the utilization of healthcare services for the older adults, more detailed measures will be adopted in the future. Interviews and surveys, continuous adjustment and improvement of indicators, provide a theoretical basis for enriching the analysis framework of the utilization of healthcare and health services for the older adults.
Declarations Acknowledgments