Peer effects on older adults' preferences for formal long-term care in China

doi:10.21203/rs.3.rs-4211179/v1

Download PDF

Research Article

Peer effects on older adults' preferences for formal long-term care in China

https://doi.org/10.21203/rs.3.rs-4211179/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective

To examine the impact of the peer effects on the preferences of the older-aged Chinese for formal long-term care (LTC) services.

Methods

During July-August 2022, the study conducted a randomized controlled experiment using a survey design. Respondents aged 50–70, were randomly assigned to a control group and a peer effect group, where the peer group was divided into Peer 1 not having friends and relatives receiving LTC and Peer 2 having relatives and friends receiving LTC. Data included personal socioeconomic-demographic information, LTC service needs, and willingness to accept formal LTC. Statistical analysis was performed using descriptive statistics, logistic regressions, and heterogeneity analysis.

Results

Compared to the control group, the peer effect groups showed a statistically significant increase of 20.06% in the proportion of elderly individuals opting for formal LTC. The study found that willingness to accept formal long-term care services increased with the peer effect intervention, and Peer 2, with family and friends receiving LTC, had a larger uptake of LTC than Peer 1 with no family and friends receiving LTC. Statistical analysis confirmed significant differences between the control, Peer 1 and Peer 2 groups. In terms of peer effects interventions, older people with high incomes and unsure about their future risks of developing a chronic disease were more likely to opt for formal LTC. Heterogeneity analysis of the peer effects group revealed that sex, age, marital status, residential location, educational level, monthly income, number of children, presence of chronic diseases, and risk of chronic diseases, significantly influenced the willingness to accept LTC services within the two peer groups.

Conclusion

The findings suggest that peer effects played a critical role in shaping the preferences of older aged Chinese for formal LTC services. The study highlights the need for strategies to utilize peer influences, as well as socioeconomic and demographic factors, in policy-making and communicating strategies to enhance acceptance of LTC services among China’s older-aged population. Tailored interventions and information dissemination that leverage peer networks and address varied socioeconomic-demographic needs are crucial for effective LTC policy and service implementation.

formal Long-term care

willingness

peer effects

the elderly

health policy

Text box 1. Contributions to the literature

1.This study uniquely illuminates how peer effects significantly influence older Chinese adults' preferences for formal long-term care (LTC), a novel finding in the realm of public health and LTC policy research.

2.By employing a rigorous randomized controlled experiment, research offers concrete evidence on the effectiveness of peer influences, filling a critical gap in understanding how social networks can be leveraged to enhance LTC service uptake among China’s aging population.

3.The study's findings advocate for the integration of peer effects into policy-making and communication strategies, presenting a viable pathway to increase the acceptance and utilization of formal LTC services.

In 2022, the aged 60 and above population in China reached 280 million, accounting for 20% of the total population, of whom nearly 210 million were aged 65 and above^[^]. By 2035, people aged 60 and above will exceed 400 million, accounting for over 30% of the total population, with China entering the stage of severe aging. Within the old-age population, the disabled elderly will exceed 77 million by 2030, living on average 7.4 years with a disability ^[^] and reaching 120 million by 2050 ^[^]. Unsurprisingly, the demand for long-term care (LTC) services is experiencing explosive growth, estimated to require more than 13 million caregivers in 2030. In the face of declining family sizes, rural-urban migration, economic development and shifting cultural attitudes, the breakdown of China’s traditional family care model, where family members care for the old-aged, exacerbates the old aged LTC challenge. Beginning in 2016, China piloted a long-term care insurance policy in 15 cities. By 2022, nearly 170 million old-aged adults were cared for by 331,000 nurses in 7,679 long-term care service facilities in 49 cities^[^]. The demand for LTC insurance is expected to grow with LTC facilities becoming the main care model for the old aged.

Formal long-term care offers significant advantages for the old aged, including specialized care, enhanced safety, and personalized care plans, facilitated by professionally trained caregivers and supported by advanced medical equipment and services. Despite an extensive literature from various countries examining older adults' preferences for LTC, research on the influence of peer effects on the old-aged preferences for LTC services remains limited. To address this lacuna, our study evaluated peer effects on older adults’ preferences for formal LTC in China, seeking to enrich the formal LTC literature and highlighting the role of social dynamics in shaping the over 60s’ care preferences in China.

Studies of the LTC preferences by the old-aged have yielded diverse findings. Jennifer et al. discovered that disabled older women generally prefer home assistance, whether unpaid or paid, for instrumental activities of daily living (IADL) and activities of daily living (ADL), yet opted for nursing home care in cases of dementia^[^]. Examining how age, period, and cohort influenced LTC preferences of older Japanese adults, Sugisawa et al found time and age explained the gap between the preferences for LTC services and actual LTC use^[^]. In an exploratory literature scoping review on LTC preferences, Thomas et al. found most participants favor receiving LTC in their known physical and social environment when care needs were moderate, but residential care when care needs were extensive, dependent on a variety of personal, environmental, social and cultural aspects^[^]. In Germany, Lehnert et al. found that the old aged preferred regular small nursing service teams, providing a narrow range of services^[^], and Kim and Choi revealed that the perspectives of the Korean old-aged and of their caregivers were the primary predictive factors for the use of formal and nursing home care services ^[^]. Research has also studied adjustment to “prison-like” Taiwanese LTC facilities^[^], LTC financing^[^], preferences for home-based, family care and community care ^[^] and the role of race on LTC preferences^[^]. In China, the elderly's preferences for long-term care services are shaped by diverse factors, including traditional culture and family structure. Cao et al. argued that due to the influence of traditional Chinese values, such as filial piety and the concept of "raising children for old age security," many rural elderly show a preference for receiving LTC at home, provided either by family members or external caregivers^[^]. But societal shifts, the ‘one-child’ policy, urban migration and the transformation of family structures, the prevalent family model in China places the burden for elderly care predominantly on the only-child generation, leading to considerable caregiving pressures. This shift has prompted a growing number of elderly individuals to explore alternative care options, including community and institutional care^[^,^]. The existing international and Chinese literature suggests diverse preferences among the elderly for LTC, including desires for home-based care, residential care, community involvement in LTC, and the influence of family and caregivers. These findings underscore the complexity of LTC preferences, which are influenced by individual, cultural and social factors.

Our study focuses on the influence of peers, or peer effects, on the preferences of the old-aged Chinese for formal LTC. Mainly concentrated in economics, sociology and education research^[^,^,^], peer effects refer to the influence on an individual’s preferences by peers who share similar ages, backgrounds, attitudes, values and socioeconomic position ^[17,^,^]. Peer effects may imply a form of contagion, where one person’s social decisions exert subsequent impacts on the behaviors of others, magnifying positive or negative effects^[21]. Similarly, peer effects mean individuals conform to group consciousness and seek to integrate into their immediate social environments for a sense of belonging^[^]. Through a randomized controlled experiment, we test the peer effects on Chinese older aged adults’ preferences for formal LTC and analyze the extent to which the peer effects influence the willingness of the elderly to accept formal LTC services.

2.1 Survey Design

During July—August 2022, we collected data to evaluate the peer effects on the willingness of old-aged individuals to opt for LTC services. We conducted a questionnaire survey, collecting personal information, LTC service needs, and willingness to accept formal LTC. After answering the basic personal information and LTC service needs in the questionnaire, respondents were randomly assigned to a control group and a peer effect group. In the control group, interviewees were not given any additional information, and only answered questions about their willingness to choose formal LTC. After reading information depicting a peer effect scenario, the peer effect group answered the same questions as the control group. The scenario was based on the majority of people around the interviewee having already received formal long-term care services by a qualified caregiver. To investigate how descriptions of the same scenario interventions can elicit different reactions and decisions in different real-world environments, we divided interviewees into a Peer 1 group who did not have relatives or friends receiving LTC and Peer 2 group who had relatives or friends receiving LTC. Respondents in Peer 1 did not have real-life acquaintances who had received formal LTC services, while respondents in Peer 2 group had friends and relatives who had received LTC services. By creating two different peer effect groups, we assessed different peer effects on respondents’ decision-making processes regarding LTC service acceptance.

The questionnaire distribution and data collection were conducted by trained professionals to ensure data authenticity and reliability. The response to the key question, "Would you be willing to receive long-term care services?", was categorized as willing to accept formal LTC when answered ‘yes’ or unwilling to accept formal LTC when answered ‘no’ or ‘don’t know’, facilitating a comparative study between these two respondent groups. This question serves as the dependent variable in our analysis. Participants were assured of anonymity, informed about the academic purposes of the research, and gave informed consent. Ethical clearance for this study was obtained from Center for Health Management and Policy Research of Shandong University (No. ECSHCMSDU20220901).

2.2 Study Sample

We adopted a stratified random sampling method based on the per capita GDP levels of various provinces in China. Twelve provinces representing the eastern (Shandong, Jiangsu, Fujian, Zhejiang), central (Shanxi, Hubei, Henan, Anhui) and western (Inner Mongolia Guangxi, Shaanxi, Yunnan) regions were selected. Corresponding with the implementation of China's long-term care insurance policy, one LTC insurance pilot city and one non-pilot city were randomly selected in each province, with approximately 100 individuals surveyed in each city. The inclusion criteria were age 50–70 years, absence of cognitive impairments and voluntary participation.

The questionnaire was distributed in July and August 2022. After removing missing values, there were 688 valid questionnaires. The survey included two versions of the questionnaire: the control group and the peer effects group. There were 359 respondents in the control group, 222 respondents in Peer 1, and 107 respondents in Peer 2. The participant demographic included a 6:4 urban to rural population ratio, a broadly equal male-to-female ratio and diverse socioeconomic backgrounds and health conditions. Table 1 displays the socioeconomic and demographic information included sex, age, marital status, urban-rural residence, education level, monthly income, number of children, chronic illnesses diagnosed by a doctor within the past six months, and perceptions of future risk for multiple chronic diseases.

2.3 Statistical Analysis

Our methodology encompassed descriptive statistical analysis, logistic regressions and heterogeneity analysis to evaluate the sample characteristics, compare differences among groups, examine the influence of social norm interventions and explore old- aged adults’ needs and perspectives regarding LTC services. Statistical analysis was conducted using Stata version 17.

3.1 Respondent Characteristics

Table 1 presents the socioeconomic and demographic characteristics of the 359 respondents in the control group and 329 in peer group. There were some significant differences: the control group had more males, were better educated and more wealthy and had a lower self-perceived risk of chronic disease than the peer group.

Table 1

Sample Characteristics (N = 688)
Variable	Respondents No.(%)	Control Group (N = 359)	Peer Effects (N = 329)	T test P-Value
Sex
Male (reference: female)	305(44.33)	143(39.83)	162(49.24)	0.007
Age
60–70 (reference: 50–59)	340(49.42)	198(55.15)	142(43.16)	0.999
Marital status
With spouse(reference: without spouse)	593(86.19)	304(84.68)	289(87.84)	0.115
Residence
Rural (reference: urban)	258(37.50)	142(39.55)	116(35.26)	0.877
Educational level
Low (≤ 6 years)	273(39.68)	170(47.35)	103(31.31)
Medium (6 to ≤ 9 years)	204(29.65)	93(25.91)	111(33.74)	< 0.001
High (> 9 years)	211(30.67)	96(26.74)	115(34.95)
Monthly income tertile^a
0(≤$276)	278(40.41)	118(32.87)	160(48.63)
1($276—$827)	323(46.95)	206(57.38)	117(35.56)	< 0.001
2(≥$827)	87(12.65)	35(9.75)	52(15.81)
Children
≥ 2 (reference: 0–1)	491(71.37)	258(71.87)	233(70.82)	0.619
Suffering from several chronic diseases
One or more (reference: none )	381(55.38)	231(64.35)	150(45.59)	1.000
High risk of chronic diseases in future
No	334(48.55)	237(66.02)	97(29.48)
Unknown	189(27.47)	58(16.16)	131(39.82)	< 0.001
Yes	165(23.98)	64(17.83)	101(30.70)

^a Based on a currency exchange rate of RMB7.259 to $US1.00 in 2023

3.2 The results of peer intervention scenarios

As shown in Fig. 1, in the control group, 178 (49.58%) individuals were unwilling and 181 (50.42%) were willing to receive formal LTC; in Peer 1, 61 (27.48%) were unwilling and 161 (72.52%) willing to receive LTC; and in Peer 2, 21 (19.63%) were unwilling and 86 (80.37%) were willing to receive LTC. The Pearson Chi-Square test indicated statistically significant differences among the three groups, which suggest an increased willingness to accept long-term care services with peer effect intervention, most notably in the Peer 2 group.

3.3 Logistic Regression Models

Table 2 displays the results of logistic regression analysis concerning the willingness to receive formal LTC. Peer 1 (β = 1.17, P < 0.001) and Peer 2 (β = 1.5,P < 0.001) displayed a significant and positive correlation between peer effects and an individual’s willingness to accept formal LTC. No significant correlations were found between willingness to accept long-term care and sex, age, marital status, residential location, education level and number of children. Monthly income and perceived risk of future chronic diseases exhibited a significant impact on LTC preferences. Individuals with a monthly income over $US827 (β = 0.80, P = 0.028) showed a significant willingness to accept LTC services, suggesting that higher income levels influenced attitudes towards long-term care. Additionally, those perceiving a high risk of future known (β= -0.62, P = 0.006) or unknown (β= -0.61, P = 0.011) chronic diseases demonstrated increased willingness for formal LTC.

Table 2

Logistic regression models of willingness for long-term care services
Variable	β (95% CI)	SE	z	P value
questionnaire version
Peer effects 1	1.17 (0.73 to 1.61)	0.23	5.21	< 0.001
Peer effects 2	1.55 (0.97 to 2.12 )	0.29	5.28	< 0.001
Sex
Male	0.03(-0.32 to 0.37)	0.17	0.15	0.883
Age
60–70	0.11(-0.23 to 0.46)	0.18	0.65	0.513
Marital status
With spouse	0.03(-0.45 to 0.50)	0.24	0.11	0.914
Location
Rural	-0.10(-0.50 to 0.29)	0.20	-0.51	0.613
Educational level
Medium (6 to ≤ 9 y)	-0.20(-0.63 to 0.23)	0.22	-0.90	0.366
High (> 9 y)	0.19(-0.32 to 0.69)	0.26	0.72	0.473
Monthly income tertile^a
1($276—$827)	-0.37(-0.76 to 0.03)	0.20	-1.83	0.068
2(≥$827)	0.80(-0.32 to 0.69)	0.36	2.20	0.028
Children
≥ 2	-0.03(-0.44 to 0.38)	0.21	-0.16	0.871
Suffering from several chronic diseases
One or more	0.21(-0.17 to 0.59)	0.19	1.10	0.271
High risk of chronic diseases in future
Unknown	-0.62(-1.06 to -0.18)	0.22	-2.76	0.006
Yes	-0.61(-1.09 to -0.14)	0.24	-2.55	0.011
^aBased on a currency exchange rate of RMB7.259 to $US1.00 in 2023

To investigate whether the peer effects on the willingness to receive formal long-term care services varied significantly among different groups, we employed heterogeneity analysis using subgroup regression. Table 3 reports the subgroup regression, including sex, age, marital status, residence, educational level, monthly income, number of children, diagnosed chronic diseases, and perceived risk of future chronic diseases. Females in Peer 1 (β = 1.71, P < 0.001) and Peer 2 (β = 2.33, P < 0.001) showed a significant increased willingness to receive formal LTC. Age grouping revealed that individuals aged 60 to 70 in Peer 1 (β = 1.67, P < 0.001) and Peer 2 (β = 2.30, P < 0.001) exhibited a stronger willingness to accept LTC than those aged 50–59; those unmarried in Peer 1 (β = 1.42, P < 0.001) and Peer 2 (β = 1.58, P < 0.001) showed a significant increased willingness to receive LTC and urban residents in Peer 1(β = 1.71, P < 0.001) and Peer 2 (1.81, P < 0.001) displayed a higher willingness to receive LTC under both peer effects than rural residents. The group with lower educational levels showed a significant increase in willingness for LTC under Peer 1 (β = 1.57, P < 0.001) and Peer 2 (β = 1.95, P = 0.001). In the monthly income group, the Peer 2 middle-income bracket (β = 2.03, P < 0.001) showed the strongest willingness to receive LTC, while the highest income groups did not show a significant peer effect. Individuals in the Peer 1 with children (β = 0.90, P = 0.042) and Peer 2 with children (β = 0.99, P = 0.055), especially those with two or more (Peer 1 β = 1.14, P < 0.001 and Peer 2 β = 1.62, P < 0.001), showed a significant increase in willingness to receive LTC. Those suffering from one or more chronic diseases had a significant increase in the willingness under Peer 1 (β = 1.78, P < 0.001) and Peer 2 (β = 2.29, P < 0.001) to accept LTC, while those without chronic diseases did not show any significant increase. Regarding the perception of the risk of chronic diseases in the future, Peer 1 (β = 2.01, P < 0.001) and Peer 2 (β = 2.08, P < 0.001) individuals who consider themselves at high risk or uncertain showed a significant increase in willingness to receive LTC.

Table 3

Subgroup regression results for willingness to accept long-term care services
Subgroups	peer effects 1 β (95% CI)	P value	peer effects 2 β (95% CI)	P value
Sex
Female	1.71(1.06 to 2.36)	< 0.001	2.33(1.43to 3.23)	< 0.001
Male	0.77(0.12 to 1.42)	0.020	0.91(0.11to1.72)	0.026
Age
50–59	0.85 (0.26 to 1.45)	0.005	1.05(0.25to 1.84)	0.010
60–70	1.67 (0.95to 2.39)	< 0.001	2.30(1.37to 3.24)	< 0.001
Marital status
With spouse	0.07 (-1.31to 1.45)	0.923	/	/
Without spouse	1.42 (0.93to 1.91)	< 0.001	1.58(0.98to 2.18)	< 0.001
Location
Urban	1.71 (1.09 to 2.33)	< 0.001	1.81(1.12to 2.52)	< 0.001
Rural	0.71(-0.01to 1.44 )	0.053	1.63(0.46to2.81)	0.007
Educational level
Low (≤ 6 year)	1.57 (0.80 to 2.34)	< 0.001	1.95(0.83to3.08)	0.001
Medium (6-≤9 year)	1.21 (0.38 to 2.03)	0.004	2.03(0.98to3.08)	< 0.001
High (> 9 year)	0.88 (0.03 to 1.74)	0.043	1.12(0.14to2.10)	0.014
Monthly income tertile^a
0(≤$276)	1.35 (0.64 to 2.06)	< 0.001	1.63(0.65to2.06)	0.001
1($276—$827)	1.29 (0.62 to 1.97)	< 0.001	2.03(1.14to2.92)	< 0.001
2(≥$827)	0.59(-1.98to 3.17)	0.652	0.61(-2.04to3.27)	0.650
Children
0–1	0.90 (0.03 to 1.77)	0.042	0.99(-0.02to2.00)	0.055
≥ 2	1.14(0.61 to 1.67 )	< 0.001	1.62(0.89to2.34)	< 0.001
Suffering from several chronic diseases
None	0.47(-0.19 to 1.12)	0.162	0.53(-0.33to1.39)	0.229
One or more	1.78(1.11 to 2.45 )	< 0.001	2.29(1.46to3.11)	< 0.001
High risk of chronic diseases in future
No	0.38(-0.27 to 1.03)	0.258	0.29(-0.70to1.28)	0.569
Unknown	1.87( 0.87 to 2.86)	< 0.001	2.50(1.42to3.58)	< 0.001
Yes	2.01( 1.11 to 2.91)	< 0.001	2.08(0.97to3.19)	< 0.001
^aBased on a currency exchange rate of RMB7.259 to $US1.00 in 2023

Peer effects significantly influenced the willingness of older aged individuals to select formal LTC services. Older-aged individuals with scenario family and friends Peer 2 had a greater propensity to choose formal LTC than scenario no family and friends Peer 1. The acceptance of formal LTC was more pronounced among old-aged individuals with higher monthly incomes, those uncertain about their future risk of chronic illness, and those perceiving a high risk of such illnesses. Heterogeneity analysis revealed varying degrees of willingness to accept formal LTC was influenced by sex, age, marital status, residential location, education levels and monthly income.

Our results suggest that when individuals knew their peers were receiving formal LTC, they experienced social conformity pressure, making similar choices, maintaining consistency with their peer group and avoiding exclusion or isolation^[^,^]. Our results confirm that peer effects were stronger when individuals came from a common age group ^[^]. While peer effects can influence individual perceptions of long-term care through various channels, including family, community and the media, we recommend that policymakers promote formal LTC options through community organizations, where people share common age, sex, income and health characteristics.

Existing research has identified several factors that influence the willingness of old-aged individuals to accept long-term care services, including economic factors, such as nursing expenses ^[^]. We found individuals with higher monthly incomes were more likely to accept long-term care services, which aligns with previous research^[14,^], reflecting the ability of the financially better off to afford LTC costs, including specialized medical care and emotional support. The propensity of more affluent individuals to opt for formal LTC was influenced not only by their financial capacity to afford such services, but also by their increased awareness of health issues. Affluence is frequently associated with a higher level of health consciousness, prompting these individuals to prioritize preventive strategies and extensive treatment plans, rendering LTC a more appealing and feasible choice. Compared to older-aged individuals who do not perceive themselves as having a high risk of developing chronic diseases in the future, those who are uncertain or believe they have a high future chronic diseases risk were more willing to opt for formal LTC. Individuals uncertain about future risks may adopt a cautious approach to health care, displaying conservative and prudent healthcare choices. Accepting long-term care may also be a proactive measure to reduce potential health risks in the future. Additionally, the uncertainty about one’s future health condition may lead individuals to seek healthcare stability and support, where the future provision of long-term care, such as LTC insurance, can offer psychological support. Respondents who perceived a high risk of future chronic diseases may feel a sense of urgency regarding their health, paying close attention to their LTC needs. These individuals are likely to take proactive actions to prevent future illnesses and monitor their future health, making them more inclined to accept LTC services. We found that sex, marital status, place of residence, educational level, number of children, and the presence of chronic diseases, were not significant in the willingness to accept LTC, which is consistent with some previous studies^[^,^].

Assessing the differences among various subgroups on their willingness to accept formal LTC, we conducted heterogeneity analysis, focusing on the impact of peer effects interventions. We found that different individual characteristics and sociocultural factors influenced the choices individuals to accept formal LTC. Sex and age significantly shaped perceptions and values concerning LTC, while marital status and place of residence influence the availability and appeal of care services. Similarly, educational level and monthly income not only determined access to information and resources, but also influenced attitudes towards formal care. Factors such as sex, age, marital status, place of residence, educational level, and monthly income impacted individual sensitivity to peer effects, influencing behavior regarding LTC acceptance. This highlights the importance of considering differences among various groups when formulating related policies and intervention measures to effectively enhance the level of acceptance of formal LTC services. First, it is imperative to develop specific and targeted policies and interventions tailored to the unique needs of older adults, varying by sex, age group, marital status, residence, education level and income. For instance, older individuals with low education need to be targeted with clear and simple LTC information and individuals with low income provided information on the benefits of cost-effect LTC options. Second, given the impact of marital status and residence on acceptance of formal LTC, LTC packages should be structured around community and family support, such as community nursing services and formal training for at-home family carers. For LTC providers, the design of LTC advertising should incorporate the role of peers, leveraging the older-aged individuals’ social networks to encourage accepting formal LTC.

Our study has several limitations. First, we only included individuals aged 50 to 70 years old, and the sample studied may not represent the views of those over 70 years old. Second, future studies should include additional variables, such as religious beliefs and traditional culture values. Finally, this is a cross-sectional study, and future studies should collect data to capture long-term trends and changes.

Our result underscore the influence of peer effects on the old-aged Chinese adults' willingness to opt for formal LTC. When informed that their peers have already received formal LTC, respondents exhibited a markedly increased willingness to also utilize similar LTC services. At the same time, we also observed that there was a significant difference in the willingness to choose LTC services between Peer 1 and Peer 2, with individuals in relatives and friends Peer 2 showing a markedly higher inclination towards accepting LTC services. This suggests that the decision to accept formal LTC was significantly influenced by the experiences and choices of peers, especially when these peers are part of one's direct social network. This underscores the strong influence of peers who have already accepted formal LTC in real life, reflecting the role of the real social network environment in shaping perceptions and behavioral choices regarding LTC.

To enhance the acceptance and utilization of LTC services among the older aged adults in China, we recommend tailored interventions and communication strategies. These strategies should not only leverage peer networks but also address the varied needs of different socioeconomic-demographic groups. Old-aged communities can boost their members’ awareness and acceptance of LTC by publicizing the real-life LTC experiences of those receiving LTC services. Given that the influence of peer effects was modulated by personal characteristics, cultural backgrounds, and socioeconomic status, peer effect impacts varied across different socioeconomic-demographic groups. To ensure effective policy communication and implementation in varied social and cultural contexts, tailored policies and interventions are required to improve health outcomes for a broad spectrum of the old aged population.

Ethical Approval

Ethical approval was granted by the Ethics Committee of the Center for Health Management and Policy Research at Shandong University, China (No.ECSHCMSDU20220901).

Funding

This work was supported by the National Natural Science Foundation of China (grant numbers 72004117) and Tsinghua University Initiative Scientific Research Program(2022THZWJC27).

Availability of data and materials

Present study data sets are available from the corresponding author on request.

Competing interests

The authors declare that they have no competing interests.

Statistical Bulletin on the Development of Civil Affairs, 2022. https://www.mca.gov.cn/n156/n2679/c1662004999979995221/attr/306352.pdf
Luo Y, Chen W, Wang Y, et al. To design an intelligent analysis platform for the disabled population data[J]. Wei Sheng yan jiu= Journal of Hygiene Research, 2021, 50(4): 660-664.
Ge Yanfeng, Wang Liejun, Feng Wenmeng, etc. Challenges and strategic choices for healthy aging in China [J]. Managing the World, 2020, 36(4): 86-96.
National Statistical Bulletin on the Development of Health Care Coverage,2022.National Healthcare Security Administration.http://www.nhsa.gov.cn/art/2023/7/10/art_7_10995.html
Wolff J L, Kasper J D, Shore A D. Long-term care preferences among older adults: a moving target?[J]. Journal of aging & social policy, 2008, 20(2): 182-200.
Sugisawa H, Sugihara Y, Nakatani Y. Long-term care preference among Japanese older adults: differences by age, period and cohort[J]. Ageing & Society, 2020, 40(6): 1309-1333.
Lehnert T, Heuchert M A X, Hussain K, et al. Stated preferences for long-term care: A literature review[J]. Ageing & Society, 2019, 39(9): 1873-1913.
Lehnert T, Günther O H, Hajek A, et al. Preferences for home-and community-based long-term care services in Germany: a discrete choice experiment[J]. The European Journal of Health Economics, 2018, 19: 1213-1223
Kim H, Choi W Y. Willingness to use formal long-term care services by Korean elders and their primary caregivers[J]. Journal of aging & social policy, 2008, 20(4): 474-492.
Chien N H, Tsai C H, Lin H R. Lived experiences of newly admitted to long-term care facilities among older adults with disabilities in Taiwan[J]. International Journal of Environmental Research and Public Health, 2022, 19(3): 1816.
Feng Z, Glinskaya E. Aiming Higher: Advancing Public Social Insurance for Long-term Care to Meet the Global Aging Challenge: Comment o”" Financing Long-term Care: Lessons From Japa”"[J]. International Journal of Health Policy and Management, 2020, 9(8): 356.
Kasper J D, Wolff J L, Skehan M. Care arrangements of older adults: What they prefer, what they have, and implications for quality of life[J]. The Gerontologist, 2019, 59(5): 845-855.
Wallace S P, Levy-Storms L, Kington R S, et al. The persistence of race and ethnicity in the use of long-term care[J]. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 1998, 53(2): S104-S112.
Cao Yan-chun, WU Bei, DAI Jian-Bing.Analysis of the Elders' Long-Term Care Arrangement and Its Influencing Factors in Rural China--Based on a Comparative Analysis between Shanghai and Hubei [J]. Journal of Dalian University of Technology: Social Science Edition, 2014, 35(1): 117-123.
Xu Xiaojun, Li Qiang, Xue Xingli. Analysis of Rural Disabled Elders' Long-term Care Willingness and Its Influencing Factors--Based on Questionnaire of Rural Disabled Elderly from Shandong Province[J]. Population and Development,2018,24(04):87-96.
Liu Jing. e Study on the Impact of Community Care Services on Home Care for the Disabled Elderly——Based on 2018 CLASS Data[D]. Shanxi university of finance and economics, 2023. DOI: 10.27283 /, dc nki. GSXCC. 2023.000389.
Angrist J D. The perils of peer effects[J]. Labour Economics, 2014, 30: 98-108.
Li X, Ding P, Lin Q, et al. Randomization inference for peer effects[J]. Journal of the American Statistical Association, 2019.
Li Lu, Wang Jingqun, Ye Baojuan, et al. Neighbourhood effects on college students' altruistic behaviours: empathy, chain-mediated effects of pro-social motives[J]. **Journal of Clinical Psychology, 2018, 26(6): 1215-1217.
Wolske K S, Gillingham K T, Schultz P W. Peer influence on household energy behaviours[J]. Nature Energy, 2020, 5(3): 202-212.
Tan X, Yan Y, Dong Y. Peer effect in green credit induced green innovation: An empirical study from China's Green Credit Guidelines[J]. Resources Policy, 2022, 76: 102619.
Shang Jun, Wu Guolai. Self-identity and self-esteem, attachment and peer relationship [J]. Psychological Research, 2014, 7(1): 10-14.
Hornsey M J. Social identity theory and self‐categorization theory: A historical review[J]. Social and personality psychology compass, 2008, 2(1): 204-222.
Brown Z, Tiggemann M. Attractive celebrity and peer images on Instagram: Effect on women's mood and body image[J]. Body image, 2016, 19: 37-43.
Perdrix E, Roquebert Q. Does the amount of formal care affect informal care? Evidence among over-60s in France[J]. The European Journal of Health Economics, 2022: 1-13.
Chen Mei, Gao Weidong, Meng Yanchen et al. Research on the willingness to purchase and participate in long-term care insurance and its influencing factors among community residents in Beijing[J]. China Health Policy Research,2019,12(12):66-74.
LI Qiang, YUE Shuming, BI Hongxia. Analysis of long-term care willingness and its influencing factors of rural incapacitated elderly--Based on questionnaire survey of rural incapacitated elderly in Shandong Province[J]. Agricultural Economic Issues,2015,36(05):30-41+110.DOI:10.13246/j.cnki.iae.2015.05.004.
Dai Weidong. Analysis of the demand for long-term care for the elderly and its influencing factors--A comparative study based on the survey of Suzhou and Anhui provinces[J]. Population Research,2011,35(04):86-94.
Huang S T, Chen C M, Su Y Y, et al. Retrospective evaluation of discharge planning linked to a long-term care 2.0 project in a medical center[J]. International Journal of Environmental Research and Public Health, 2022, 19(16): 10139.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Peer effects on older adults' preferences for formal long-term care in China

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Text box 1. Contributions to the literature

1. Introduction

2. Methods

2.1 Survey Design

2.2 Study Sample

2.3 Statistical Analysis

3. Results

3.1 Respondent Characteristics

3.2 The results of peer intervention scenarios

3.3 Logistic Regression Models

4. Heterogeneity Analysis

5. Discussion

6. Limitations

7. Conclusions

Declarations

References

Additional Declarations

Status:

Version 1