The investigators used two-way fixed-effects models to assess associations between check-up type and healthcare utilization while accounting for stable, time-invariant individual characteristics. Compared with participants who had not received a check-up, those in the self-paid group had a significantly higher probability of hospital admission and higher medical expenditure. Free health check-ups showed no consistent association with greater overall healthcare utilization.

Their clearest association was with inequality in inpatient outcomes. The pro-rich concentration index for annual hospital admissions was 0.07 lower in the free check-up group than in the no-check-up group, with a P value of 0.018. The difference in annual inpatient expenditure was 0.06, with a P value of 0.026.

The free check-up group also had a lower pro-rich inequality index than the self-paid group for annual hospital admissions, by 0.10 (P = 0.003), and for annual inpatient expenditure, by 0.07 (P = 0.013). The study did not define the term “pro-rich” in the supplied research summary, so the inequality measures should not be interpreted more specifically than the reported concentration-index comparisons allow. The authors additionally applied Recentered Influence Function regression decomposition, including an Oaxaca decomposition, to identify factors correlating with differences in inequality between check-up groups.

The factors accounting for those differences varied across pairwise comparisons, indicating that the statistical sources of inequality were not uniform across the three check-up categories or across the measured outcomes. Because the analysis was observational, its findings describe associations rather than causal effects. The fixed-effects approach reduced the influence of persistent individual differences, but the design could not rule out every source of confounding.

The results also apply to the older-adult population and setting covered by the CHARLS survey rather than establishing the effects of free or self-paid check-ups in other populations. The study did not show that free examinations reduced total hospitalization or spending, nor did it show that self-paid examinations caused greater use. Instead, it separated two related findings: self-paid check-ups were associated with more utilization and expenditure, while free check-ups were associated with smaller measured inequalities in selected inpatient outcomes.

The researchers argued that policy should go beyond expanding check-up coverage by strengthening follow-up, referral support and financial protection. Its central result is that the type of check-up was linked to different patterns of healthcare utilization and inequality: self-paid participation accompanied higher utilization and medical expenditure, whereas free participation did not consistently increase overall utilization and was associated with lower pro-rich inequality in hospital admissions and inpatient expenditure among older Chinese adults.

Subject of Research: Health check-up type, healthcare utilization and inequality among older adults in China

Article Title: Associations of different health check-up types with healthcare utilization and its inequalities among older adults in China: evidence from a nationally representative survey

Article References: Qian, Y., Liu, Y., Zhu, R., Wang, G., & Wang, Z. (2026). Associations of different health check-up types with healthcare utilization and its inequalities among older adults in China: evidence from a nationally representative survey. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03086-5

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03086-5

Keywords: health check-ups, older adults, healthcare utilization, health inequality, hospital admissions, inpatient expenditure, CHARLS, free screening, self-paid care, China, Associations, different

The study, published in BMC Health Services Research by Ji-Hwan Kim of Daegu University and colleagues at Seoul National University, including corresponding author Seung-Sup Kim, set out to answer a deceptively simple question: who cares for the caregivers? Preventive health examinations are a cornerstone of public health policy in South Korea, where the National Health Insurance Service offers general health examinations and organized cancer screening programs to virtually the entire population. Yet participation is not uniform across social groups, and populations facing structural barriers, such as those with intensive caregiving responsibilities, may systematically fall through the cracks even when services are free or heavily subsidized.

To capture both the subjective and the administrative dimensions of the problem, the research team designed a two-pronged investigation. The first component was a nationwide survey conducted in 2024 among 1,903 mothers caring for children with developmental disabilities. Respondents were asked whether they had participated in any national health check-up over the previous two years, and those who had not were asked to identify the reasons. The second component leveraged the National Health Insurance Service database, covering 118,289 individuals, to compare the check-up participation of these mothers with that of the general female population in 2022, using a statistical technique designed to make the comparison as fair as possible.

The survey results were striking. Nearly a quarter of the mothers, 22.5 percent, had not participated in any national health check-up during the two-year window. When asked why, the most frequently cited reason was a lack of time, selected by 38.0 percent of non-participants. The second most common answer, given by 29.4 percent, was that they had utilized only private health check-ups instead of the national program. The third leading reason, reported by 23.1 percent, was particularly revealing: no one was available to care for their child during the health check-up. Together, these responses sketch a portrait of women whose calendars, finances, and childcare obligations leave little room for routine preventive medicine, even when they understand its importance.

The administrative data told a consistent story. Using the National Health Insurance Service database, the researchers calculated age- and income-standardized prevalence ratios, a statistical measure that compares the participation rate of the mothers with that of the general female population while accounting for differences in age and income distribution. A standardized prevalence ratio below 1.0 indicates lower participation after this adjustment. For general health examinations, the mothers showed a ratio of 0.98, with a 95 percent confidence interval of 0.97 to 0.98, meaning their participation was statistically significantly lower than expected given their age and income profile. Similar downward trends were observed across all five cancer screening programs examined in the study.

The standardized prevalence ratio approach deserves attention because it addresses a common weakness in observational health services research. Mothers caring for children with developmental disabilities might differ from other women in age, household income, or other characteristics that independently influence screening behavior. By standardizing on both age and income, the researchers isolated the effect most plausibly attributable to caregiving itself. The consistency of the finding, spanning general examinations and multiple cancer screening modalities, strengthens the interpretation that the caregiving role, rather than some incidental demographic feature, is the operative barrier. The confidence intervals, which exclude 1.0, indicate that the shortfall is unlikely to be a statistical fluke, even though the absolute magnitude of the difference is modest.

Why does a modest statistical gap matter? Public health experts emphasize that preventive screenings operate on population scale, where small individual decrements translate into large absolute numbers of missed examinations, delayed diagnoses, and avoidable disease burden. For caregivers, the stakes are compounded by what is already known about chronic caregiving stress, which has been associated in prior literature with elevated rates of physical and mental health problems. A mother who cannot find time for a cervical cancer screening or a general metabolic check today may face a diagnosis at a later, less treatable stage tomorrow. The Korean findings suggest that the very population shouldering extraordinary daily health burdens is the one least positioned to benefit from early detection infrastructure.

The finding that nearly 30 percent of non-participants relied exclusively on private check-ups adds an important nuance. It suggests that some of these mothers are not entirely disengaged from preventive care; rather, they may prefer or find it easier to use private facilities, perhaps because of scheduling flexibility, perceived quality, or convenience. From a policy standpoint, this distinction matters. If a substantial share of the gap reflects substitution between the national program and private alternatives, the public health concern shifts from total non-participation toward inequities in what services are actually received, since private check-ups vary widely in content and may not include the standardized cancer screenings embedded in the national program. For the remaining mothers, however, particularly those citing absent childcare, the barrier is not substitution but complete exclusion.

The childcare barrier deserves particular emphasis. That 23.1 percent of non-participating mothers reported having no one available to care for their child during a check-up points to a concrete, addressable failure of support systems. Preventive care appointments typically require only a few hours, yet for a parent whose child requires continuous supervision due to a developmental disability, even a few hours can be logistically impossible without respite care, trusted relatives, or specialized childcare services. This is a structural problem, not a motivational one. The mothers in the study are not declining check-ups because they undervalue their health; they are being squeezed out by the arithmetic of caregiving, in which every hour devoted to their own medical needs is an hour subtracted from their child’s care.

The study’s implications extend well beyond South Korea. Countries with organized screening programs, from Japan and the United Kingdom to various European systems, face parallel questions about whether caregivers of children with disabilities, and indeed informal caregivers of all kinds, are reaching preventive services at equitable rates. The Korean research offers a methodological template: pairing self-reported survey data, which illuminates reasons and lived experience, with large-scale insurance claims data, which provides objective participation measures across an entire population. The convergence of the two data sources here, with the survey explaining the why and the claims database quantifying the how much, gives the findings a credibility that neither alone could achieve.

Policy responses suggested by the pattern of results could include flexible check-up scheduling, including evening and weekend slots; integration of childcare support or respite services into preventive care programs; outreach campaigns tailored to caregiver households; and reimbursement structures that recognize the logistical costs caregivers face in accessing care. The authors note that caregiving burden is a potential primary barrier to participation, and their data give policymakers a specific target. As populations age and the prevalence of developmental disabilities and chronic childhood conditions continues to rise, the number of parents in this position will only grow. The question posed by the study’s title, who cares for the caregivers, is not rhetorical. It is a measurable gap in health system performance, and this research provides both the evidence and the starting point for closing it.

Subject of Research: Health check-up participation among mothers caring for children with developmental disabilities in South Korea

Article Title: Who cares for the caregivers? Health check-up participation among mothers caring for children with developmental disabilities in Korea: findings from the National Health Insurance Service database and a nationwide survey

Article References: Kim, J.-H., Kim, J. Y., Paeng, E.-J., & Kim, S.-S. (2026). Who cares for the caregivers? Health check-up participation among mothers caring for children with developmental disabilities in Korea: findings from the National Health Insurance Service database and a nationwide survey. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15767-6

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15767-6

Keywords: caregivers, developmental disabilities, health check-ups, cancer screening, preventive care, South Korea, National Health Insurance Service, health services research, maternal health, health equity, caregiving burden, public health