The dramatic increase in numbers of the oldest-old is an urgent concern, presenting a major challenge for health and social care systems because of their need for daily assistance and medical care. However, there is a marked imbalance between the supply and demand of elderly care services. The objective of this study was to understand the demand for elderly care services and the anticipated living arrangements among the oldest-old in China, based on an adapted framework of Andersen’s behavior model, thereby providing a reference for building a sound healthcare system.
The need for care services
From the comparative analysis of the demand and supply of aged care services for the oldest-old, it can be seen that the demand is far greater than the supply. And the supply of various care services based in the community needs improvement. There were gaps in universal health coverage and increasing funding for the healthcare system before reforming the delivery system could lead to more inefficiencies [17]. Thus, it is a problem that must be solved to improve the balance between demand and supply and meet the multi-level and diversified pension needs of the oldest-old to promote further development of aged care services. Furthermore, the results showed that the demand for aged care services for the oldest-old is influenced by predisposing factors, enabling factors, and need factors.
Predisposing factors
Age and residence have a significant impact on the demand for elderly care services. The older people in the 80-89 age group have higher demand for social recreational activities than those over the age of 90, mainly due to differences in physical fitness and enthusiasm of social participation. While those aged over 100 were more willing to enjoy daily care services, they may become universally frail with increasing age. With advancing age, health status and needs of adults may change due to age-related functional impairments. The oldest-old individuals aged 100 and over have survived because of improvements in medical care and increased longevity but they may be in relatively poor health, which is described by the term “costs of success” [15]. In rural areas, where medical technology may not be as advanced, transportation is underdeveloped, and medical resources are unevenly distributed and therefore less accessible, the oldest-old have a greater need for home visit services than those living in urban areas. The health status of the oldest-old living in remote rural areas is poorer as their access to healthcare services is often limited. Conversely, urban residents with formal employment education enjoy relatively advanced medical resources [5]. Therefore, it is necessary to improve rural infrastructure, such as facilities, traffic, and medical and health systems, to enable access to elderly care services in rural areas. Furthermore, it is crucial to address the imbalance of supply and demand between rural and urban areas. Accessibility for the elderly on public transit — an important aspect of the community environment — may facilitate access for individuals living in low-supply areas by enabling travel to other service areas [18].
Enabling factors
Living arrangements and economic status have a significant impact on the demand for elderly care services. Compared to those who co-reside with children, the oldest-old living alone or living in a nursing home are more willing to engage in eight types of aged care services. The reason may be that the oldest-old who lack family care and emotional support, require aged care services to meet their physical and mental needs. Living alone does not adversely influence survival if the individual receives support from family and friends [19]. Meanwhile, the oldest-old with more difficult economic circumstances have greater demand for daily care services, which may be related to the lack of basic health services and health insurance. However, New Cooperative Medical Scheme (NCMS) did not increase utilization of outpatient and inpatient services for the following reasons: the deductibles are generally high; the enrollees do not get reimbursement immediately or is very difficult to get reimbursed if the enrollees use health facilities in other counties or cities [20]. Therefore, to improve healthcare utilization of the disadvantaged who cannot afford health insurance, health insurance programs need to provide a specific policy intervention, such as reducing deductibles [21] and coinsurance rates or offering immediate reimbursement instead of later reimbursement. The oldest-old with economic difficulties may have lower utilization and awareness rates of community services, which demonstrates a need for the government and society to give more attention and emphasis on health education.
Need factors
Self-rated health, feeling lonely and isolated, and ADL have a significant impact on the demand for elderly care services. The oldest-old with poor self-rated health have a higher demand for daily care services, home visits, daily shopping, and health education, in line with the conclusion that additional services are needed for the oldest-old whose self-rated health is fair or poor [22]. Compared to the oldest-old who often or always feel lonely and isolated, those who seldom or never feel lonely and isolated were more inclined to engage in social and recreational activities and use legal aid services, suggesting that they may be more busy socializing and in relatively good physical condition. This is in accordance with the notion that a stable social network is the key factor for preventing loneliness in the oldest-old despite their age-related limitations, particularly for those who live alone [23]. The elderly who sometimes feel lonely and isolated have a higher demand for old-age services, such as daily care, home visits, and psychological consulting, indicating that mental characteristics are positively related to health status, and play an important role in the demand for elderly care services. Therefore, when providing community-based care services, it is important to be attentive to the mental health of the oldest-old. The oldest-old whose ADL were not limited had a higher demand for social and recreation activities, health education, and neighboring relations than those with highly limited ADL. This may be because the oldest-old without limitation of ADL are more willing to participate in social activities, have a stronger sense of health, and are in better physical condition. For the oldest-old with constrained ADL, the community-based pension service should adopt the “walk in” approach, as an initiative to provide basic daily care for that group. Lower quality of life is experienced in older people with ADL-disability irrespective of living situation, whether at home or in residential care [24]. Therefore, in addition to informal care, it is also necessary to provide formal care for the oldest-old who are limited in ADL. When persons were disabled in two or more ADL-activities, the amount of formal care was greater than the amount of informal care, mainly due to help with ADL [25].
In summary, we found that the needs of the oldest-old are diverse, involving daily care, home visits, psychological consulting, daily shopping, social entertainment, legal aid, health education, and neighboring relations by analyzing the needs of elderly care services for the oldest-old in the CLHLS data in 2014. The demand for aged care services for the oldest-old was affected by residence, age, years of education, living arrangements, housing property rights, wealth, self-reported health, loneliness, and ADL. Enormous social changes, such as migration to rapidly growing urban areas, the one-child policy, and variable access to health care, would have affected the health of China’s oldest-old [26]. In order to meet the multi-level and diversified health care service needs of the oldest-old and promote the equilibrium of basic old-age services, we offer some specific suggestions. First and foremost, driven by demand expression, communities should enrich the content of old-age services, and increase the high-demand old-age services, such as home visits, health education, and spiritual comfort. Second, targeted services should be provided for the oldest-old with different age groups, places of residence, and education level. Third, a sound healthcare system based on home-community-institutions needs to be built by joint forces to optimize the balance between supply and demand of aged care services. Furthermore, the management of service quality should be highlighted, to promote the informationization and refinement of the community pension service and continuously improve the service level and the satisfaction of the oldest-old who receive community pension services.
Anticipated living arrangements
This study shows that the most common way of living for the oldest-old is to live with their children (44.4% in urban, 55.6% in rural), which is closely related to the traditional concept of nurturing children and preventing old age, consistent with the results of previous studies. In addition, some choose (45.4% in urban, 54.6% in rural) to live alone, rather than living with their children, indicating that the traditional concept of home-based care for the oldest-old has undergone subtle changes. We observed that the anticipated living arrangements for the oldest-old is significantly different depending on predisposing factors, enabling factors, and need factors.
Predisposing factors
Age has a significant impact on the living arrangements of the oldest-old. Compared with people aged 80-89, those aged 100 or older were more likely to live with their children or in LTC institutions and were reluctant to live alone. Here are some possible explanations. First, the older people who aged 100 or older are more vulnerable to poor perceived health and chronic diseases [27], which requires daily care provided by their children or professional nursing staffs. Then, when health deteriorates, functional loss increases the rate of depression [28], and declining memory that could be a psychological barrier to greater longevity and maintaining good health. Chronic diseases can affect the brain and mind, aside from disability, these disorders are very likely to lead to dependency on caregivers, presenting stressful, complex, and long-term challenges [29]. Therefore, projects to prevent chronic disease among the oldest-old through personalized health interventions need to be prioritized and avoiding solitude could prevent psychological problems and promote social emotional support.
Enabling factors
Housing properties and the number of children have a significant impact on the living arrangements of the oldest-old . For housing property rights, the oldest-old who do not own or rent a house tended to live in nursing homes. A plausible explanation could be that the oldest-old without a stable place to live lack a certain economic basis and therefore live in LTC institutions to reduce the burden on their children and family. Housing properties reflect the economic level of the oldest-old. The socioeconomic-related inequalities can influence living arrangements, health seeking behaviors, access to health care, as well as self-reported health of the elderly, so certain programs and policies can be implemented in the health sector to address these disparities [30]. Compared to the oldest-old with three or more children, those without children were more likely to live in a nursing home. This may be because childless oldest-old are in a predicament with no one to rely on and are less likely to be reached by service providers, requiring assistance from society. It has been suggested that intergenerational support counteracts the negative association between living arrangements and old-age psychological health [31]. Chinese older adults were still very active in providing support to family members and highlighted the beneficial effects of contributory behaviors (i.e., providing their children with economic support, housework, emotional support, and grandchild care ) on life satisfaction [32]. Thus, when designing new elderly care programs, the importance of family ties and support to older adults should be considered by policy makers.
Need factors
ADL may have a significant effect on the living arrangements of the oldest-old. Compared to the oldest-old with ADL that are not subject to health restrictions, those with highly restricted ADL were reluctant to live alone. There is evidence that deterioration in ADL is a sign of intellectual disability or may be associated with other age-related medical conditions [13]. With ADL limitations, oldest-old people have more difficulties with bathing, eating, dressing, walking across a room, and getting in and out of bed, requiring help from others. The poorer the health status of the elderly, the more likely they are to live with their children, particularly if they have daughters [33]. We recommend developing intervention programs aimed at improving ADL among the oldest-old as being physically active can be a protective factor for ADL-disability. In addition, assistive devices should be provided as device use may increasingly become a viable option to bridge deficits in functioning even at very old ages [2].
In summary, by analyzing the anticipated living arrangements of the oldest-old, we observed that living with children is still the most common way of providing for the oldest-old. Residential care services remain a major service provision for older people, and family plays an essential role in the healthcare of the oldest-old. However, the Chinese population is aging rapidly, especially the oldest-old, and the changes in the family structure of “Four-Two-Ones” means that children cannot effectively balance family and work time; the traditional pension model can no longer meet the needs of the elderly, especially of the oldest-old. This situation calls for actions for policy change. Caregivers’ resources under the universal two-child policy will be substantially better than that under the rigorous unchanged fertility policy [4]. It is crucial to build a pension service system with shared contributions from national security [34], government leadership, and community implementation to family response. Constructing a comprehensive pension service system based on home-community-institution can play an increasingly important role in alleviating the burden on the state, making up for the shortage of traditional family pensions, and optimizing the allocations to solve the imbalance problem between supply and demand of elderly care services.