Shaping Long-term Care Insurance Intentions among Chinese Older Adults: Role of Information Interventions in Health Risks

doi:10.21203/rs.3.rs-3812000/v1

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Shaping Long-term Care Insurance Intentions among Chinese Older Adults: Role of Information Interventions in Health Risks

https://doi.org/10.21203/rs.3.rs-3812000/v1

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Long-term care insurance (LTCI) is an essential system in the context of fast-growing population aging, yet it lacks evidence on how to improve the acceptance and coverage of non-compulsory LTCI in China. Using a survey experiment, we randomly assigned 1025 older adults to control group, disability information group and dementia information group, and explored whether information about the adverse health outcomes would change their willingness to LTCI insure. We found that disability and dementia information significantly changed respondents’ willingness to LTCI insure, and health status had negative moderating effects on the relationship between information interventions and the change of LTCI intentions. Also, we found respondents with lower education and living in non-pilot cities were more sensitive to information interventions. We recommend LTCI information campaigns differentiating information by dementia-related and disability-related risks; by LTCI pilot and non-pilot cities; by education levels and by physical and mental health status.

Scientific community and society/Social sciences

Health sciences/Diseases

long-term care insurance

Chinese older adults

information intervention

disability

dementia

With the world’s fastest aging population, China’s increasing life expectancy and declining birth rates challenges the provision of healthcare (Peng, 2011). In 2020, there were 264 million people aged 60 years old and over, accounting for 18.7% of the Chinese population, forecast to rise to more than 500 million by 2050 (The National Bureau of Statistics, 2021; United Nations, 2022). Within the aging population, 52.7 million suffered disabilities, estimated to reach 82.7 million by 2030 and 89.6 million by 2050. (Luo et al., 2021). The number of over 60-year-old Chinese suffering dementia was 15.07 million in 2018, and is expected to rise to 50 million by 2050 (Jia et al., 2020; Li et al., 2021). Older adults with disabilities and dementia pose a serious challenge to the sustainability of China’s long-term care (LTC) system (Feng et al., 2012; Lei et al., 2022). With the reduction in the size of the Chinese family, the effects of the one-child policy, urban migration and the decline in informal family provided LTC, the demand for formal LTC has surged (Feng et al., 2020). To address this challenge, the Chinese government launched in 2016 a long-term care insurance (LTCI) scheme in 15 pilot cities, expanding to 49 cities by 2020, to provide the old aged with disabilities and dementia accessible and affordable long-term care services (National Healthcare Security Administration, 2021). LTCI aimed to alleviate the shortage of caregivers for severely disabled patients by providing nursing service payments in public care facilities and also some support for home-based care services (Jiang & Yang, 2023). China’s National Medical Insurance Administration aims to build a nation-wide and unified LTCI system independent from China’s basic pension and medical social insurance system (Information Office of the State Council, 2023). How to promote the expansion of China’s LTCI is an urgent challenge for China.

Non-compulsory LTCI markets are widespread, with people's LTCI purchasing decisions analyzed from the economic, behavioral, and psychosocial perspectives (Boyer et al., 2017; Brown et al., 2012; Curry et al., 2009; He & Chou, 2020; Sloan & Norton, 1997). Behavioral economics provides a powerful framework for understanding the purchase decision behavior for LTCI by focusing on individual risk perceptions in intertemporal health decision-making choices (White & Dow, 2015). An individual’s risk perception, derived from objective knowledge of LTC risks, subjective knowledge of LTC risks and subjective knowledge of one’s own health, has been shown to shape LTCI needs (Costa-Font & Rovira-Forns, 2008; Lambregts & Schut, 2020; Ugarte Montero & Wagner, 2023). Cognitive biases or overconfidence means individuals’ health cognition may deviate from rational expectations, resulting in a misunderstanding of LTCI risks affecting decision-making (Baicker et al., 2012; Y.-P. Chen, 2003). Individual LTCI perceptions biases reflect physical, mental, financial and other factors associated with future projection of disability or dementia in old age (Finkelstein & McGarry, 2006; Tennyson & Yang, 2014). Motivated by self-protection, the probability of older adults purchasing LTCI increases with their knowledge of the risks associated with their future likely LTC needs (Zhou-Richter et al., 2010). These studies suggest that expectations of LTC risk are positively correlated with changes in LTCI demand, and thus it is possible to promote older adults’ participation in LTCI by increasing their risk perception.

In healthcare research, these behavioral hypotheses have been widely applied to insurance enrollment, vaccination decisions and medication use to facilitate the public's health-favorable decision-making (Capuno et al., 2016; Handel et al., 2019; Stuart et al., 2013). Surprisingly, there is currently a lack of research on the role of information interventions in shaping the LTC insurance risk perceptions of older Chinese adults with disabilities and dementia. To address this research gap, we designed a scenario experiment to explore whether older Chinese adults with information about the adverse health outcomes of disability or dementia would change their willingness to buy LTCI. People’ evaluation of their own health status, their knowledge of the consequences of illness and their understanding of their health behaviors will impact their perception of future health risks (Jones et al., 2014), so we also investigate the moderating effect of health status on the impact of information interventions on LTCI decisions. Since our study is concerned with the effect of information interventions on the changes of older adults’ LTC risk perceptions and LTCI intentions, the results are expected to vary depending on the older adults’ own risk perceptions. Participants’ education background and whether they reside in a LTCI pilot city proxy respondents’ knowledge about LTCI (Lassen, 2005; Pförtner & Hower, 2022). Our paper also conducted a heterogeneity analysis to explore the intervention effects of disability and dementia information for subgroups with different education levels and pilot city conditions.

Our study makes contributions in the following three aspects. From the perspective of risk perception, we explore whether increasing people's understanding of the risk of disability or dementia could change their willingness to participate in LTCI. This not only enriches the research on information intervention on health promotion, but also provides empirical reference for the Chinese government to improve the LTCI coverage rate of residents. Second, we examine the moderating role of an individual's health status and LTCI knowledge on LTCI decision-making, providing evidence for the implementation of individualized and effective interventions. Finally, our nationally representative survey experiment provides to government evidence on LTCI willingness in China, helping improve China’s “person-centered” LTC system.

Respondent characteristic

Table 1 shows the respondents’ socioeconomic demographic characteristics. Out of the 1,025 respondents, 466 (45.46%) were male, 572 (55.80%) were between the ages of 50 and 59; 456 (44.49%) had a high education level; most had a spouse (85.76%); were urban residents (62.63%), earned less than RMB6000 a month (76.39%) and had 2 or more children (60.49%). In terms of the health status, 689 (67.22%) respondents rated their own health status as good. After 0–1 standardization, the average physical health status was a high 0.94 level and mental health status was a moderate 0.67 level. The last column of Table 1 shows the ANOVA results. There were significant inter-group differences in age, educational level, monthly personal income, number of children, physical health and mental health. To control the influence of these variables on the intervention results, they were added to the statistical model as control variables.

Table 1

Characteristic of respondents
Variables	Total (n = 1025)		Control group (n = 354)		Disabled group (n = 339)		Dementia group (n = 332)		P value
Variables	N	%	N	%	N	%	N	%	P value
Sex
Female	559	54.54	214	60.45	167	49.26	178	53.61	0.012
Male	466	45.46	140	39.55	172	50.74	154	46.39	0.012
Age
50–59	572	55.80	161	45.48	221	65.19	190	57.23	< 0.001
60–69	453	44.20	193	54.52	118	34.81	142	42.77	< 0.001
Marital status
No spouse	146	14.24	52	14.69	46	13.57	48	14.46	0.907
Have a spouse	879	85.76	302	85.31	293	86.43	284	85.54	0.907
Residence
Rural	383	37.37	138	38.98	129	38.05	116	34.94	0.523
Urban	642	62.63	216	61.02	210	61.95	216	65.06	0.523
Educational level
Low(≤ 6 yrs)	300	29.27	167	47.18	51	15.04	82	24.70	< 0.001
Medium(6 to ≤ 9 yrs)	269	26.24	92	25.99	93	27.43	84	25.30
High (> 9 yrs)	456	44.49	95	26.84	195	57.52	166	50.00
Monthly personal income (RMB)
1 (≤ 3000)	404	39.41	194	54.8	73	21.53	137	41.27	< 0.001
2 (3000–6000)	379	36.98	126	35.59	133	39.23	120	36.14
3 (> 6000)	242	23.61	34	9.6	133	39.23	75	22.59
Number of children
1	405	39.51	92	25.99	131	38.64	182	54.82	< 0.001
>=2	620	60.49	262	74.01	208	61.36	150	45.18	< 0.001
Self-rated health status
Not good	336	32.78	123	34.75	94	27.73	119	35.84	0.051
Good	689	67.22	231	65.25	245	72.27	213	64.16	0.051
Physical health (mean, SD)	0.941	0.131	0.933	0.102	0.918	0.182	0.973	0.081	< 0.001
Mental health(mean, SD)	0.672	0.194	0.603	0.176	0.679	0.182	0.738	0.199	< 0.001

Willingness to LTCI insure

Figure 1 presents the percentages of respondents willing to LTCI insure in the control group, disability group and dementia group before and after the information intervention. Before the information intervention, the proportion of respondents who were willing, unwilling and uncertain about willingness to LTCI was roughly a 4:1:5 ratio, which changed to 7:2:1 ratio after the information intervention. For the control group, the rate of respondents who were not willing to insure LTCI increased from 10.45% to 30.23%; those uncertain decreased from 47.18% to 19.21%; and the willing to insure increased from 42.37% to 50.56%. For the disability group (43.07% to 79.35%) and dementia group (35.54% to 85.54%), the percentage of respondents who were willing to insure LTCI increased substantially. We also analyzed the willingness to LTCI insure before and after the information interventions by ANOVA. The results showed that before the information interventions, there was no significant inter-group difference in the willingness to LTCI insure in the control, disability and dementia groups (F=1.59, P=0.204). However, the differences became statistically significant after the interventions (F=39.45, P<0.001), indicating that the information interventions impacted LTCI decisions.

Main results of logit regression

Model 1 in Table 2 shows the logit regression results of the disability and dementia information interventions on changes in LTCI willingness among older adults. Compared with the control group, both disabled and dementia information intervention group had a significant positive impact on respondents’ LTCI intentions. After the information intervention, respondents in the dementia group (β = 2.409, p < 0.01) were more willing to change their LTCI intentions than the disability group (β = 2.126, p < 0.01). Sex, age, marriage status, residence status, number of children, self-rated health and mental health had no significant impact on the willingness to change the LTCI insure intention, but education, personal income and physical health significantly influenced the change of LTCI willingness. The more educated the respondents, the less likely they were to change their LTCI insurance intentions. Compared to personal income less than RMB3000, respondents with a middle income level were more willing to change their LTCI intentions. Older adults with better physical health status were more likely to increase their willingness to LTCI insure.

Table 2

Logit model
Variables	Model 1	Model 2	Model 3	Model 4
Disability intervention	2.126***	3.135***	8.299***	4.481***
	(0.227)	(0.425)	(2.946)	(0.835)
Dementia intervention	2.409***	2.412***	9.557***	3.867***
	(0.223)	(0.412)	(3.189)	(0.829)
Sex	0.139	0.115	0.108	0.096
	(0.148)	(0.150)	(0.149)	(0.149)
Age	-0.009	-0.011	-0.017	-0.025
	(0.155)	(0.157)	(0.156)	(0.156)
Marriage status	-0.250	-0.265	-0.219	-0.276
	(0.216)	(0.219)	(0.217)	(0.219)
Educational level (Reference: Low)
Medium	-0.453**	-0.399*	-0.467**	-0.492**
	(0.218)	(0.220)	(0.218)	(0.219)
High	-1.195***	-1.185***	-1.187***	-1.210***
	(0.236)	(0.239)	(0.235)	(0.237)
Urban-Rural Residence	-0.187	-0.205	-0.177	-0.214
	(0.172)	(0.174)	(0.172)	(0.173)
Monthly personal income (Reference: ≤RMB3000)
2(RMB3000-6000)	0.318*	0.300	0.275	0.311
	(0.191)	(0.193)	(0.192)	(0.192)
3(≥ RMB6000)	0.222	0.257	0.196	0.246
	(0.239)	(0.242)	(0.239)	(0.240)
Number of children	0.173	0.193	0.195	0.184
	(0.165)	(0.167)	(0.164)	(0.164)
Self-rated health status	0.097	0.607	0.106	0.107
	(0.169)	(0.406)	(0.170)	(0.170)
Physical health	1.264**	1.510**	7.524**	1.338**
	(0.608)	(0.618)	(2.983)	(0.613)
Mental health	0.677	0.778*	0.604	3.107***
	(0.427)	(0.435)	(0.431)	(1.032)
Self-rated health status×Disability intervention		-1.414***
Self-rated health status×Disability intervention		(0.477)
Self-rated health status×Dementia intervention		0.032
Self-rated health status×Dementia intervention		(0.469)
Physical health×Disability intervention			-6.459**
Physical health×Disability intervention			(3.041)
Physical health×Dementia intervention			-7.447**
Physical health×Dementia intervention			(3.284)
Mental health×Disability intervention				-3.590***
Mental health×Disability intervention				(1.195)
Mental health×Dementia intervention				-2.281*
Mental health×Dementia intervention				(1.167)
Constant	-3.364***	-4.020***	-9.312***	-4.934***
	(0.640)	(0.718)	(2.879)	(0.891)
Observations	1,025	1,025	1,025	1,025
Notes: Standard errors in parentheses;*significant at 1% level; significant at 5% level; * significant at 10% level

Moderation effects

Model 2–4 in Table 2 presents the moderation effects of self-reported health status, physical health condition and mental health condition on the effect of disabled and dementia information interventions on the LTCI intentions. Model 2 shows the moderation effect of the self-report health status was significant (β=-1.414, P < 0.01) only for the disability group. Model 3 shows the moderation effect of the physical health status, where older adults with poorer physical health were willing to LTCI insure after the disability (β=-6.459, P < 0.05) and dementia (β=-7.447, P < 0.05) scenario information intervention. The moderation effect of mental health status in Model 4 shows that older adults with poor mental health were willing to LTCI insure after the disability and dementia information interventions. The intervention effect of disability information (β=-3.590, P < 0.01) was greater than that of dementia group (β=-2.281, P < 0.1). Overall, respondents with poorer health tended to change their willingness to LTCI insure after receiving disability and dementia information interventions.

Heterogeneity analysis

The upper section of Table 3 shows the results of heterogeneity of different educational levels and LTCI pilot cities, and the lower section used simulated empirical evidence to test for differences in effects between the subgroups. For respondents with different levels of education and LTCI pilot cities, disability and dementia interventions both played a significant role in the change of their LTCI intentions. We found that the effects between each subgroup were different by testing the empirical p-values. For the difference between different educational levels, respondents with low education levels were the most sensitive to disability information, and respondents with high education levels were the least sensitive to dementia information. Further, respondents in non-pilot cities were more affected by both disability and dementia information than those in pilot cities.

Table 3

Heterogeneity analysis results
	(1)	(2)	(3)	(4)	(5)
VARIABLES	Education_low	Education_medium	Education_high	Non-pilot city	Pilot city
Regression estimates
Disability intervention	2.731***	1.375***	1.663***	3.233***	1.123***
	(0.424)	(0.397)	(0.387)	(0.402)	(0.316)
Dementia intervention	3.085***	2.582***	1.529***	3.567***	1.391***
	(0.379)	(0.430)	(0.387)	(0.401)	(0.300)
Control variables	Yes	Yes	Yes	Yes	Yes
Constant	-4.678***	-3.589***	-2.782***	-4.329***	-2.537*
	(1.311)	(1.271)	(1.039)	(0.829)	(1.480)
Observations	300	269	456	586	439
Empirical p-values ^a	(1) vs. (2)	(1) vs. (3)	(2) vs. (3)	(4) vs. (5)
Disability intervention	1.356**	1.069**	-0.287	2.110***
Dementia intervention	0.504	1.557***	1.053*	2.176***
Notes: Standard errors in parentheses; *significant at 1% level; significant at 5% level; * significant at 10% level; a is the difference of coefficient between the subgroups, and the star represents the significance of the difference, which was obtained by Bootstrap sampling for 500 times.

By conducting a randomized intervention experiment, we analyzed the effect of different types of information intervention on the change of the intention to enroll in LTCI among 50 to 70 year old Chinese adults. After the information intervention, more than a third of respondents changed their LTCI intentions from unwilling or uncertain to willing, including 40.50% in the disability group and 48.32% in the dementia group. Only 11.17% in the control group shifted to willing to LTCI insure. After the information intervention, 71.41% of older adults were willing to LTCI insure, much higher than the 40.39% before the experiment. These percentage are consistent with an intervention survey conducted in two pilot LTCI Chinese cities (Q. Chen & Ma, 2023) and previous international studies on LTCI, health insurance, and catastrophic insurance that found information interventions increased people’s willingness to enroll in insurance (Baicker et al., 2012; Ganderton et al., 2000; Zhou-Richter et al., 2010). Our results show that with awareness-raising measures, it is possible for government to increase the acceptance and expand the coverage of non-compulsory LTCI.

In the context of sample characteristics, the respondents in our survey were between the ages of 50 and 70 with no cognitive impairment. It has been shown that there is an association between midlife behaviors and a range of later life outcomes, such as disability, dementia and frailty (Lafortune et al., 2016), which increase the likelihood of requiring LTCI needs in the near future. Compared to those with disability information, we found that the older aged had a greater probability of changing their intention to enroll in LTCI after dementia information. This might be due more stigma being attached to dementia than disability, and that people show anxiety about loss of self-identity and dignity related to dementia (Corner & Bond, 2004). We recommend that government LTCI information campaigns differentiate its message to disabled versus dementia audiences.

In the analysis of moderation effects, the health status variables, comprising self-assessed health, physical health, and mental health, had significant negative moderating effects on the relationship between information interventions and the change of LTCI intentions, except for self-assessed health under the dementia information intervention. This implies that when providing participants with information about the risks of long-term care, especially for disability risks, participants with poorer self-rated health status were more affected. One reason is that older adults with poor self-reported health self-assess a high risk of future further decline than older adults with good health (Stuck et al., 1999), so they chose to LTCI insure. Information on dementia had a more significant effect on respondents with poor physical health, while information on disability had a more significant effect on respondents with poor mental health. Since the existing research has only focused on the direct impact of health conditions on LTCI demand (Brown et al., 2012; Kim et al., 2013; McGarry et al., 2014; Tennyson & Yang, 2014), our study extends the literature by differentiating between physical and mental health respondents’ willingness to LTCI insure. For policymakers, the cost-effectiveness of LTCI policy advocacy can be optimized by differentiating information about dementia-related risks and disability-related risks for individuals with self-reported poor physical health.

We also examined the effect of information interventions on individuals with different levels of education and living in different LTCI pilot cities. The results show that respondents with less than 6 years of education were most affected by disability information, and respondents with more than 12 years of education were least affected by dementia information. Respondents with higher levels of education tend to have higher initial risk perceptions (Costa-Font & Costa-Font, 2011), and were less exposed to informational interventions. Subgroup regressions for pilot cities suggest that respondents from non-pilot cities with lower levels of initial risk perception were more sensitive to informational interventions. The lower sensitivity of higher education and non-pilot city respondents to information intervention compared to the other groups may reflect their higher perception of risk in old age and previous willingness to enroll in LTCI, with 60.22% of respondents before information intervention willing to enroll in LTCI were highly educated. Our dependent variable was the change in willingness to LTCI insure before and after the information intervention, so the extent of change in their willingness to insure may have been less pronounced than in the other groups. This suggests that the government should conduct policy advocacy by segmenting the target population, focusing on the less educated and non-piloted municipalities, to maximize the conversion rate to LTCI.

There are several limitations. First, the questionnaire only has options related to the subjective intentions to measure the respondents’ willingness to insure LTCI, but the degree of risk perception was not directly measured. Although socioeconomic-demographic characteristics that may affect risk perception were controlled, future studies should include variables to measure the degree of risk overestimation or underestimation. Second, our informational intervention was completed through an offline face-to-face survey and only provided information about the risks of LTC through the scenarios. Recent studies have noted the effectiveness of information interventions, such as mass media and the Internet, in promoting health risk cognition (Beleigoli et al., 2019; Wang et al., 2023). Future research should explore the effectiveness of different types of information intervention measures and the content of information interventions in influencing people’s participation in health-related behaviors. Third, our study measured respondents’ stated preferences, which may not perfectly reflect their actual health behavior in a complex real world. Although relevant studies have demonstrated a positive correlation between people’s willingness to participate in insurance and their actual behavior (Giles et al., 2021), the results of this study should be interpreted with caution when generalizing.

Disability and dementia risk information interventions significantly changed respondents’ willingness to LTCI insure. After information interventions, the disability group’s willingness to LTCI insure increased from 43.07–79.35% of respondents and the dementia group from 35.54–85.54% of respondents. The control group only increased their willingness to insure from 42.37% in the first survey to 50.56% in the re-survey. Our moderation estimates showed the health status variables, comprising self-assessed health, physical health and mental health, had significant negative moderating effects on the relationship between information interventions and the change of LTCI intentions, except for self-assessed health under the dementia information intervention. For respondents with different knowledge levels, measured by levels of education and LTCI pilot cities, we found respondents with lower education and living in non-pilot cities were more sensitive to the information intervention. Government LTCI information campaigns can change people’s risk assessments, increasing the acceptance and expanding the coverage of non-compulsory LTCI. We recommend government LTCI information campaigns differentiate information by dementia-related risks and disability-related risks; by LTCI pilot and non-pilot cities; by education level; by individual initial risk perception levels; and by physical and mental health status.

Data and sample

To examine the relationship between disability and dementia information interventions and the change of LTCI intentions among older adults in China, we conducted a nationwide survey experiment in August 2022. Using a stratified random sampling method, we chose 8 provinces based on the high, medium and low level of GDP per capita in eastern, central and western China. Between one and three LTCI pilot and non-pilot cities were randomly selected in each province and 100 individuals were randomly recruited and interviewed face-to-face by trained interviewers in each city. The inclusion criteria were respondents aged from 50 to 70 and without cognitive impairments. A total of 1,172 questionnaires were distributed, of which 1,025 respondents answered all the options, with a response rate of 87.46%. Respondents were informed about the study, allowed to withdraw at any stage and gave informed consent. Ethical clearance for this study was obtained from the Ethics Committee of Center for Health Management and Policy Research in Shandong University (No. ECSHCMSDU20220901).

Procedure

The same questionnaire was administered twice. The before information intervention questionnaire ask participants to provide their basic information (sex, age, marital status, urban-rural residence, education level and number of children), self-reported mental and physical health and LTCI intentions. Participants were then randomly assigned to one of the three different scenarios: control group, disability scenario group and dementia scenario group. The after information intervention questionnaires were the same as the before information intervention questionnaire, but re-administered after the disability group was given disability information, the dementia group was given dementia information and the control group was not given any new information. The disability scenario group’s information intervention was:

An 80-year-old person was able to eat, wash, go to the toilet or get dressed on his/her own. However, his/her bladder and bowel functions were weakening and he/ she gradually became incontinent. After a broken bone, he/ she has difficulty walking and currently requires a wheelchair, and is unable to bathe and go outdoors independently. Family members are unable to provide adequate care support for the older person due to their own health problems or work needs.

The dementia scenario group’s information intervention was:

An 80-year-old person is able to eat, wash, go to the bathroom, dress or walk on his/her own. However, his/her bladder and bowel functions were weakening and he/ she gradually became incontinent. With Alzheimer’s disease (which is a form of dementia), there are some symptoms of dementia, such as significant memory loss, forgetting whether or not they have eaten or taken their medication, forgetting to turn off the gas, and it is becoming increasingly difficult to control with drugs, and they are unable to bathe independently and go outdoors to be active. Family members are unable to provide adequate care support for the older person due to their own health problems or work needs.

Measures

The dependent variable was the change of LTCI intention, or the changes in the before information intervention and after information intervention responses to the question: “Would you like to enroll in long-term care insurance?”. The before and after information intervention question on LTCI choice had the same three answer options, “Yes”, “No”, and “Uncertain”. When respondents’ LTCI intentions changed to ‘Yes”, we assigned a value of 1; when the LTCI intentions were unchanged, changed to “No” or changed to “Uncertain”, we assigned a value of 0.

Self-reported health status, physical health condition and mental health condition were used as moderating variables to explore the effect of disability and dementia information intervention on the change of LTCI intention under different health status scenarios. Self-rated overall health status was measured by the question, “How do you think your current health is compared to your peers?”. For responses “very good” or “good” the value was 1, the other values (fair, bad, and very bad) were assigned 0. Physical health and mental health were measured by the activity of daily living (ADL/IADL) scale and ICECAP-O scale, as shown in Table 4 and Table 5. The number 1 to 4 represented the scores for each item, and we added up the scores of each item for each respondent. To eliminate the impact of dimensions, then we standardized them for final physical health and mental health scores of each respondent.

As shown in Table 1, the control variables comprised individual sociodemographic characteristics, measured by sex, age, marital status, urban—rural residence, education level and number of children.

Table 4

Measurement of physical health status: Activities of daily living (ADL/IADL) scale
Items	Completely able to do	Somewhat difficult to do	Need help to do	Completely cannot do
Take public vehicles	4	3	2	1
Do housework	4	3	2	1
Feed yourself	4	3	2	1
Wash your clothes	4	3	2	1
Do the shopping	4	3	2	1
Talk on the phone	4	3	2	1
Brush your hair or teeth	4	3	2	1
Prepare a meal	4	3	2	1
Take medicine	4	3	2	1
Dress yourself	4	3	2	1
Wash your body	4	3	2	1
Get on and off the toilet	4	3	2	1
Handle own money	4	3	2	1

Table 5

Measurement of mental health status: ICECAP-O scale
Dimension	Content	Degree 1 (for 4 scores)	Degree 2 (for 3 scores)		Degree 4 (for 1 scores)
Attachment	Love and friendship	I can have all the love and friendship I want.	I can have as much love and friendship as I want.	I can only have a little of the love and friendship that I want.	I can't have the love and friendship I want.
Security	Thinking about the future without concern	I'll be thinking about the future with no worries.	I'll think about the future with a few concerns.	I'll think about the future with only a few concerns.	I'll think about the future with a lot of concerns.
Role	Doing things that make you feel valued	I am able to do all the things that make me feel valuable.	I can do many things that make me feel valuable.	I can do a little of what makes me feel valuable.	I can't do anything that makes me feel valuable.
Enjoyment	Enjoyment and pleasure	I can have all the enjoyment and pleasure I want.	I can have as many pleasures as I want.	I can have a few of the pleasures I want.	I can't have any of the pleasures I want.
Control	Independence	I can be completely independent.	I can be independent of many things.	I can be independent of some things.	I'm not independent at all.

Analytic strategy

Given that the dichotomous LTCI outcome variable, we used a logit regression model. All data processing and analyses were performed with the use of STATA 16.0.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Acknowledgments

The authors are grateful to research students in in Shandong University, Nanjing Medical University, Inner Mongolia Medical University and Guangxi Medical University for their assistance in collecting data.

Funding

This work was supported by the National Natural Science Foundation of China (No.72004117).

Authors’ information

These authors contributed equally: Jin Liu, Anli Leng.

Authors and affiliations

School of Political Science and Public Administration, Shandong University, Qingdao, China

Jin Liu, Jiaozhi Hao, Anli Leng

Center for Health Preferences Research, Shandong University, Jinan, China

Anli Leng

Smart State Governance Lab, Shandong University, Qingdao, China

Anli Leng

School of Management, University of Liverpool, Liverpool, England

Elizabeth Maitland

Newcastle Business School, University of Newcastle, Newcastle, Australia

Stephen Nicholas

Dong Fureng Institute of Economic and Social Development, Wuhan University, Beijing, China

Jian Wang

Center for Health Economics and Management at School of Economics and Management, Wuhan University, Wuhan, China

Jian Wang

Contributions

JL: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft, Writing - review & editing. JH: Investigation, Validation, Writing-review & editing. EM: Writing - review & editing. SN: Writing - review & editing. JW: Conceptualization, Funding acquisition. AL: Conceptualization, Methodology, Resources, Supervision, Writing-review & editing. All authors reviewed the paper and approved its submission.

Corresponding authors

Correspondence to Anli Leng.

*Anli Leng: [email protected], Tel: +8613256690121

Ethics declarations

Competing interests

All authors declare that they have no conflicts of interest.

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Shaping Long-term Care Insurance Intentions among Chinese Older Adults: Role of Information Interventions in Health Risks

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Willingness to LTCI insure

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