Determinants of Future Care Preparation Among Community-Dwelling Older Adults with Chronic Diseases: A Mixed-Method Study

doi:10.21203/rs.3.rs-4930301/v1

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Research Article

Determinants of Future Care Preparation Among Community-Dwelling Older Adults with Chronic Diseases: A Mixed-Method Study

https://doi.org/10.21203/rs.3.rs-4930301/v1

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Background: The global population is aging rapidly, leading to a surge in older adults with chronic diseases and an increasing demand for geriatric care services. Future care preparation is a proactive coping strategy aimed at pre-allocating care resources. However, a significant proportion of older adults do not engage in care preparation, underscoring the importance of bolstering care planning efforts and comprehensively understanding the contributing factors among community-dwelling older adults. This study aimed to explore the status and influencing factors of preparation for future care among community-dwelling older adults diagnosed with chronic diseases.

Methods: A convergent mixed-method design was employed from May 2024 to July 2024. The sample consisted of older adults with chronic diseases recruited from five community hospitals in Zhejiang Province, China. Quantitative data were analyzed using t-tests, one-way ANOVA, multiple linear regression, and network analysis to identify key factors and their strengths of association in the network related to preparation for future care. Deductive thematic analysis was used to analyze the interview data. Triangulation was conducted to identify the multiple factors influencing preparation for future care.

Results: A total of 362 older adults participated in the quantitative study, and 16 older adults participated in the qualitative study. Multiple linear regressions indicated that participants who were older age, with fewer adult children, more chronic diseases, lower health literacy, higher resilience, and greater availability of chronic illness resources were associated with better overall preparation for future care. In network analysis, chronic illness resources demonstrated the strongest positive relationships with preparation for future care. The qualitative analysis identified six main themes, including the influence of traditional culture and family structure, the effects of long-term care resources, the impact of socioeconomic status, the significance of family relationships and social interaction, the influence of health status and mobility, and the role of mental health. Through triangulation, three meta-themes and nine meta-subthemes were identified as multidimensional factors influencing preparation for future care. These included predisposing factors (beliefs in filial piety, family structure, age, and health literacy), enabling factors (access to care resources, economic status, and social support), and need factors (physical health and mental health).

Discussions: Devising strategies is essential to address older individuals' beliefs regarding future care preparation, disease management, and psychological adjustment. Encouraging proactive conversations about future care within families, providing family support, and enhancing care resources through healthcare providers are crucial steps in supporting older adults in preparing for their future care needs.

Preparation for future care

Community-dwelling

Chronic disease

Convergent mixed method

Network analysis

The global population is aging rapidly, with an estimated 1.108 billion older adults worldwide[1]. By 2050, 22% of the world’s population will be over 60 years old[1]. In China, this proportion is expected to exceed 30% by 2035[2]. As people age, their capacity generally diminishes, but their susceptibility to chronic diseases increases[3]. Approximately 76.3% of older adults have at least one chronic condition[4], and about 1.3 billion people, or 16% of the global population, experience functional impairment[1], driving an increased demand for geriatric care services. Research predicted that around 91.4 million older adults in China will require care by 2050[5]. Despite Chinese traditional culture favoring home-based care[6], challenges arise from urbanization, shifting family structures, and increased participation of women in the workforce, making it difficult for families to meet the care needs of older adults[7]. Faced with this dilemma, older adults need to proactively utilize their resources and strengths to address future care risks.

Preparation for future care is a form of proactive coping, defined as “preparation for a future time when help with activities of daily living may be needed because of decrements in functional capacity”[8]. It is a sequential process encompassing initial awareness of future needs, gathering information on available resources, making decisions based on preferences, and taking concrete actions to ensure preparedness when required[9]. Preparation for future care positively impacts promoting a stronger sense of life control[10], reducing anxiety and depression, and improving alignment between older adults’ care desires and the care provided[11]. Moreover, it benefits prospective caregivers by offering guidance during emergencies[12]. However, despite its demonstrated benefits, a limited number of older adults engage in care preparation. A national survey by Tsinghua University revealed that 33% only of retired individuals in China had established a solid pension plan[13], highlighting the need to strengthen care planning and understand the contributing factors among Chinese community-dwelling older adults.

To date, most studies have examined factors influencing future care preparation by using single-method designs. A longitudinal study revealed a causal relationship among preparation for future care, depression, and anxiety[10]. Demographic characteristics (gender and educational level) and favorable attitudes towards planning have been identified as predictors[14]. Previous cross-sectional studies have highlighted factors, such as family support[8], social support[15], caregiving experience[16], and impaired daily living abilities[17], to be strongly associated with preparation for future care. Qualitative research has shown a positive correlation between life satisfaction and preparation for future care[18]. However, these relationships have not been clarified in older adults with chronic diseases, and a singular methodology may limit the interpretation of findings. Given the differences in cultural values and healthcare systems, particularly between China and developed countries, a convergent mixed-method study was conducted to comprehensively explore the influencing factors of future care preparation among community-dwelling older adults with chronic diseases in China. The convergent mixed-method approach provides a comprehensive understanding of the structure of influencing factors and explores the genuine grounds for future care preparation through the experiences of older adults, laying the groundwork for developing strategies to promote future care readiness for community-dwelling older adults with chronic diseases in China.

This study aimed to (1) identify influencing factors for future care preparation through quantitative research, (2) understand self-reported reasons for preparedness via qualitative interviews, and (3) examine multiple factors associated with future care preparation by integrating, quantitative and qualitative data, with a focus on community-dwelling older adults with chronic diseases in China.

Study Design

This study employed a convergent mixed-method design to capture information from community-dwelling older adults diagnosed with chronic diseases. The study included both quantitative and qualitative phases, with datasets handled equally without prioritizing one over the other. A parallel data analysis approach was used, with qualitative and quantitative data converging only during the interpretation stage. The study design and reporting followed the STROBE statement for observational studies[19], as shown in Supplementary 1, and the COREQ guideline for qualitative research[20], as shown in Supplementary 2.

Theoretical Framework

Andersen’s behavioral model of health service utilization[21] was used to guide this study. Recognized as a mainstream model for medical and health service research, it has been applied to long-term care research[22]. The model investigates three domains influencing long-term care transition: (a) predisposing factors, (b) enabling factors, and (c) need factors[23]. Predisposing factors include demographic characteristics, social and cultural structures, and attitudes/beliefs toward health services. Enabling factors refer to individuals' ability to obtain health services and available medical resources in communities and families. The need domain includes individuals’ perceived and actual service needs reflecting health problems.

Setting and Participants

Data were collected at five community hospitals in Zhejiang Province, China. The inclusion criteria for participants were: Chinese nationals aged 60 years or older, have more than 6 months of community residence, diagnosed with chronic diseases (e.g., coronary heart disease, stroke, hypertension, and diabetes), willing to participate, and possessing the cognitive capacity to understand each questionnaire item. Individuals with cognitive impairments were excluded.

Data Collection

Quantitative Data

Convenience sampling was used to collect data between May 2024 and July 2024 via an electronic questionnaire on the Wenjuanxing platform. To ensure data quality, the questionnaire was pre-tested on 30 older adults before the actual study. Researchers explained the study’s purpose, significance, methods, and privacy to participants, and obtained informed consent. Investigators used unified guidelines to ask questions individually and completed the questionnaire based on respondents’ answers, ensuring non-interference. Community workers, including neighborhood committee members or health service center personnel familiar with the local community, assisted in the preliminary screening of potential participants. Questionnaires were verified for completeness, and forms with missing or inaccurate sections were returned to participants for completion and verification. Low-quality questionnaires, such as those with standard responses or completed in less than one minute, were excluded from the analysis.

Preparation for future care was assessed using the Preparation for Future Care Needs (PFCN) scale, developed by Sörensen and Pinquart[9], and validated in China by Bai et al.[11]. The PFCN scale includes four dimensions with 14 entries: awareness, correct planning, decision-making, and avoidance, scored on a Likert 5-point scale. The total score ranges from 14 to 70, with higher scores indicating greater preparedness for future care. The Cronbach’s α for PFCN in this study was 0.971.

Various factors were considered based on Andersen’s model and prior research. Predisposing factors included age, gender, urban-rural distribution, and health literacy (HeLMS)[24]. Enabling factors included education level, income, marital status, number of adult children, living arrangements, type of medical insurance, caregiving experience, family function (APGAR)[25], and chronic illness resources (CIRS)[26]. Need factors included the number of chronic diseases, self-rated health status, life satisfaction, resilience (CD-RISC-10)[27], and illness perception (BIPQ)[28].

Qualitative Data

Data were collected in June 2024 through semi-structured interviews at five community hospitals. The maximum variation sampling method was applied. The interviewer (NQQ), a second-year PhD nursing student trained in qualitative research, asked four primary questions: (1) What chronic disease do you currently suffer from? Does this chronic disease affect your ability to take care of yourself in daily life? (2) What preparations or plans have you made for your future care needs? (3) What facilitates your preparation for future care? (4) What barriers do you face in preparing for future care? Interviews were audio-recorded and transcribed verbatim in Chinese using professional software (iFLYTEK). Two researchers independently listened to each recording to proofread and correct transcripts.

Sample size

The formula for calculating the sample size of the current situation survey is \(\:{n=\left(\frac{{\mu\:}_{\alpha\:/2}ơ}{{\delta\:}}\right)}^{2}\). By setting α = 0.05, = 1.96, and in Bai’s study[11], the ơ and δ were found to be 10.55 and 1.30, respectively. The minimum sample size calculated based on the above parameters is 328. In conclusion, a total of 370 questionnaires were distributed, and 362 valid questionnaires were returned, with an effective rate of 97.84%.

The sample size of the qualitative study was based on the principle that no new interview information appears until the information is saturated[29]. A total of 16 older adults with chronic diseases were recruited in the community to participate in face-to-face semi-structured interviews.

Statistical analyses

Quantitative data

Data analysis was conducted using SPSS 27.0 statistical software. Descriptive statistics for continuous variables were summarized using the mean and standard deviation (SD), while categorical variables were depicted using numbers and percentages. T-test or one-way ANOVA was utilized to investigate the association between sociodemographic factors and preparation for future care. Sociodemographic variables that demonstrated statistical significance at the P < 0.05 level were integrated into a multiple linear regression model, along with other variables derived from Andersen’s model for further investigation. Study variables that demonstrated statistical significance at the P < 0.05 level in the multiple linear regression model were incorporated into the network model, which was carried out using the R (version 2023.12.1 + 402) packages “bootnet” and “qgraph”[30]. The “EBICglasso” method was utilized as the default approach for the current models. The estimation of three widely used node centrality indices was estimated using the centrality plot function provided by the “qgraph” package. The stability of the network model was also assessed, with detailed methods described in Supplementary 3.

Qualitative Data

For qualitative data, deductive thematic analysis was employed[31]. Initial codes were independently generated by two coders and iteratively modified and reconciled through face-to-face discussions. Similar codes were collated into sub-themes and then mapped into three themes. Data analysis was performed using MAXQDA 2024.

Integration

To triangulate the findings from the quantitative and qualitative data, the convergence coding matrix was integrated[32]. Meta-subthemes were coded in accordance with the following criteria: (1) convergence: results of the two phases directly agree; (2) complementary: one phase offers complementary information to the other; (3) dissonance: the findings of one phase contradict those of the other; and (4) silence: themes arise from the study of one phase only.

Ethical Considerations

This study adhered to the tenets of the Declaration of Helsinki and received approval from the Ethics Research Committee of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (No. 2024-2228-01). All participants signed informed consent before participating in the study. The study was conducted anonymously to safeguard the privacy and confidentiality of the participants.

Quantitative research

Descriptive statistics

The demographic characteristics of the participants are presented in Supplementary 4. This study included 362 participants, with 188 (51.9%) males and 174 (48.1%) females. The mean age of the older adults was 71.30 years (SD = 6.80). The mean scores for health literacy, family function, resilience, chronic illness resources, illness perception, and total preparation for future care were 103.25 (SD = 16.15), 7.77 (SD = 3.06), 27.12 (SD = 7.76), 3.94 (SD = 0.68), 34.98 (SD = 10.43), and 43.87 (SD = 13.50), respectively.

Factors associated with preparation for future care

The univariate analysis is illustrated in Supplementary 5. Table 1 presents the results of the multiple linear regression analysis. Older adults who were older in age and reported more chronic diseases, higher levels of resilience, and greater chronic illness resources were significantly associated with higher preparation for future care. Conversely, having more adult children and higher levels of health literacy were associated with lower preparation for future care. These six variables explained 44.4% of the variation (adjusted R² = 0.418).

Table 1
Multiple linear regression analysis of associations between demographic variables and preparation for future care (n = 362).
Item	B	β	t	P	VIF
(Constant)	15.473		2.174	0.030
Age in year	2.152	0.107	2.379	0.018	1.244
Urban-rural distribution	-0.515	-0.018	-0.367	0.714	1.503
Education level	0.389	0.043	0.794	0.428	1.818
Number of adult children	-1.786	-0.107	-2.312	0.021	1.333
Medical insurance type (comparing the new rural cooperative medical insurance)
Self-pay	3.268	0.038	0.898	0.370	1.097
Resident basic medical insurance	-1.489	-0.050	-0.899	0.369	1.948
Employee basic medical insurance	-1.059	-0.037	-0.572	0.568	2.608
Personal per capita monthly income	0.151	0.019	0.325	0.745	2.108
Number of chronic diseases	2.552	0.147	3.415	< 0.001	1.150
Self-rated health status	0.588	0.034	0.668	0.505	1.654
Life satisfaction	-0.118	-0.006	-0.122	0.903	1.635
APGAR	-0.294	-0.067	-1.394	0.164	1.414
HeLMS	-0.470	-0.562	-7.668	< 0.001	3.329
CD-RISC-10	0.199	0.114	2.244	0.025	1.590
BIPQ	0.024	0.018	0.370	0.711	1.499
CIRS	17.008	0.854	9.053	< 0.001	5.512
F					17.188
P					< 0.001
R²					0.444
△R²					0.418

Network structure and centrality analysis

Figure 1 illustrates the network structure depicting the associations between factors and preparation for future care. Factors related to chronic illness resources demonstrated the strongest positive relationships with preparation for future care, while health literacy displayed the strongest negative relationships. Figure 2 presents the network centrality indicators. Chronic illness resources were identified as the most central factor node in the network. The Closeness values for chronic illness resources, preparation for future care, and health literacy were all high, indicating their proximity to other nodes in the network. Additionally, chronic illness resources and preparation for future care had the highest Betweenness values, suggesting they frequently appear in the shortest paths between other nodes. Conversely, nodes representing the number of chronic diseases, age, and resilience ranked the lowest in Strength, Closeness, and Betweenness values, respectively, placing them at the periphery of the network and making them the least central nodes in terms of their connections with other nodes. The results of network stability, edge weight, and strength centrality differences are presented in Supplementary 3.

Qualitative results

Descriptive statistics

Sixteen older adults were interviewed in this study, including 11 females and five males (Table 2). Each interview lasted between 20–30 minutes. The analysis yielded six main themes and thirteen sub-themes that elucidate the factors influencing preparation for future care among community-dwelling older adults with chronic diseases (Table 3).

Table 2

Characteristics of participants in qualitative interview (n = 16).
No.	Gender	Age	Education level	Marital status	Number of adult children	Living arrangements
1	Female	75	Junior high school	Married	One	With spouse
2	Female	74	Junior high school	Married	One	With spouse
3	Female	63	High school	Married	One	With spouse
4	Male	76	University	Widowed	One	Solitude
5	Female	71	High school	Married	One	With spouse
6	Female	80	Junior high school	Married	Two	With spouse
7	Female	88	Junior high school	Married	Two	With spouse
8	Female	72	Junior high school	Married	One	Solitude
9	Female	61	University	Married	One	With spouse and children
10	Male	65	University	Married	One	With spouse
11	Male	92	University	Married	Three	With spouse
12	Male	73	Junior high school	Married	One	With spouse and children
13	Male	70	High school	Married	One	With spouse and children
14	Female	67	University	Widowed	One	Solitude
15	Female	74	Primary school	Married	Two	With spouse
16	Female	80	University	Married	One	With spouse

Table 3

Qualitative themes.
Theme	Sub-theme
Theme 1: The Influence of Traditional Culture and Family Structure	Belief in Filial Piety Limits Initiative in Future Care Planning
	Single-Child Families Motivating Future Care Preparation
Theme 2: The Effects of Long-Term Care Resources	Positive Effects of Increased Care Resource Utilization on Future Care Planning
Theme 2: The Effects of Long-Term Care Resources	Challenges in Nursing Home Services
Theme 3: The Impact of Socioeconomic Status	Aging Encourages Proactive Future Care Planning
	Stable Economic Status Reinforces Future Care Planning
	Positive Impact of Higher Education on Future Care Planning
Theme 4: The Significance of Family Relationships and Social Interaction	Adequate Family Support Promotes Future Care Planning
	Social Interactions Drive Future Care Planning
Theme 5: Influence of Health Status and Mobility	Poor Health Status Facilitates Future Care Planning
Theme 5: Influence of Health Status and Mobility	Improved Mobility Impedes Future Care Planning
Theme 6: The Role of Mental Health	Healthy Mental State Catalyzes Future Care Planning
Theme 6: The Role of Mental Health	Enhanced Self-Esteem Postpones Future Care Planning

Theme 1: The Influence of Traditional Culture and Family Structure

Belief in Filial Piety Limits Initiative in Future Care Planning

Influenced by traditional Chinese beliefs, the concept of filial piety as a means to secure care in old age is prevalent among many respondents. Three older adults expressed a belief that their offspring serve as insurance against the challenges of aging, leading them to passively rely on their children for care arrangements rather than actively preparing for their future needs.

N8: "When I'm unable to exercise properly, I'll ask my son to take care of me. I should move in with him, or else consider going to a nursing home. I am unable to make this decision by myself."

N13: "My son will take care of me in the future. I don't need to think too much about it."

Single-Child Families Motivating Future Care Preparation

With nearly four decades since the nationwide enforcement of the one-child policy in China, family structures have undergone significant transformations. Some older adults in single-child households (n = 9) expressed diluted filial piety beliefs due to the burden on their single child. This burden has led these older adults to express concern about their future care needs, fearing they might hinder their children’s lives. Consequently, they feel compelled to take the initiative to prepare for their own care needs.

N1: "We are financially prepared and do not need to rely on our daughter for financial assistance. We do not want to burden her as she has her own family. I am over 70 years old and not afraid of passing away, but I worry about troubling my daughter."

N2: "I have only one son who is a busy teacher with a lot of work pressure. We are saving money for our future elderly care and do not want to rely on our child financially. "

Theme 2: The Effects of Long-Term Care Resources

Positive Effects of Increased Care Resource Utilization on Future Care Planning

Some older adults (n = 4) demonstrated proficiency in utilizing medical resources for health management, including purchasing medical resources, which further enhanced their level of preparedness in the health field.

N16: "There are five top-tier hospitals just a few bus stops away from us, making medical care very accessible to me. ...I have been undergoing cardiac rehabilitation through external counterpulsation for five years at the community hospital, three times a week, 40 minutes per session, and I have seen positive progress in my health condition."

Challenges in Nursing Home Services

Despite improvements in existing care resources, challenges, such as uneven distribution, unreasonable pricing, and low quality, persist. These issues contributed to a sense of hesitation among some participants (n = 5) regarding their preparation for future care needs.

N12: "To be honest, I don't want to go to a poor nursing home, but a good nursing home is too expensive, and I can't afford it."

N6: "I heard that the staff in the nursing home have a very bad attitude towards the elderly. Older adults went to the nursing home when they had no choice. It was not a matter of money, but the quality and morality of the nursing home and nursing staff."

Theme 3: The Impact of Socioeconomic Status

Aging Encourages Proactive Future Care Planning

Some older adults (n = 4) believed age influences preparation for future care. As individuals age, their independence wanes, resulting in a heightened demand for care services. This phenomenon necessitates the initiation of care preparations or the utilization of additional care resources, leading to more concrete planning for future care needs. Conversely, younger elderly individuals expressed a sense of not being ready for care and prioritized focusing on their current lives.

N11: "As I am getting older, I must consider my future care options. Most of my peers who came to Hangzhou with me have passed away, leaving only a few remaining, so I am prepared for what's to come."

N10: "This matter is still early. I am only 66 years old now. My wife has not retired yet. She is only 52 years old. We have not considered this issue now. We will at least think about it when we are about 70 or 80 years old."

Stable Economic Status Reinforces Future Care Planning

Older adults with stable retirement income, sufficient savings, and fixed assets; who can afford daily expenses; and who have additional savings are more inclined to invest in their health and future care. This financial security allows for more specific and comprehensive planning for future care needs.

N14: "I have a retirement income and have saved money. Generally, I don't have any significant financial issues. Now, I am considering where to settle down."

N15: "I plan to sell the house I live in now to support my elderly care."

Positive Impact of Higher Health Literacy on Future Care Planning

Older adults (N = 6) with higher health literacy exhibited a greater propensity to invest resources in maintaining their health. This proactive approach enabled them to better anticipate and address future care needs, thereby mitigating the risks associated with aging.

N16: "Both of us are intellectuals. We eat a light diet and have no bad habits. We know that the best preparation is to keep ourselves healthy."

Theme 4: The Significance of Family Relationships and Social Interaction

Adequate Family Support Promotes Future Care Planning

The disposition of spousal relationships exerts a substantial impact on the future care planning of respondents. Greater marital harmony correlates with higher levels of preparedness regarding care arrangements. Intergenerational support within families emerges as a pivotal factor because being supported by children and maintaining amicable relations can elevate the preparation for future care needs.

N2: "My husband primarily takes care of household responsibilities. We agreed that if one of us fell ill, we would consider moving to a nursing home together. For now, as long as one of us is healthy, we can continue living at home."

N15: "My son consistently advises us to prioritize our health and manage our finances wisely. He encourages us not to strain ourselves and offers to help with heavy tasks."

Social Interactions Drive Future Care Planning

Peers sharing mutual trust, interests, values, and cultural backgrounds, provide vital emotional reassurance, encouragement, and shared experiences to enhance mutual preparedness for future care arrangements. In addition, more and more older adults obtain health knowledge or care information through social media such as WeChat, Weibo, and TikTok to help better cope with complex health problems or unpredictable diseases they may face. Three older adults said that good use of social media improves their preparation for future care.

N1: "We have a nursing home nearby that costs 5000 yuan per month, where two acquaintances have already moved in. I would go there when I was no longer able to care for myself, considering the convenience and good environment there."

N7: I took part in an online nutrition course accessible via my mobile phone, attending three times a week. The program was led by a doctor specializing in nutrition, with a health consultant providing personalized recommendations for supplements."

Theme 5: Influence of Health Status and Mobility

Poor Health Status Facilitates Future Care Planning

Subjective health evaluation not only reflects the current health status of the interviewees but also leads to their demand for medical health services and institutional elderly care services. Interviewees (n = 3) who believe they are in poor health may worry about whether their current physical condition could support independent living and prepare for more future care.

N1: I had high blood pressure in my 30s, and diabetes started 18 years ago. Although I can take care of myself at present, I am under a lot of pressure. So many problems have caused difficulties in my life.

N2: I take dozens of medicines a day, and after taking them, I have a lot of side effects. I come to the hospital for acupuncture and physiotherapy every morning for half a day because I have pain all over.

Improved Mobility Impedes Future Care Planning

Participants (n = 4) with heightened mobility capacities and self-rated health status tended to exhibit avoidance behavior toward future care planning because they prefer self-reliance and independence.

N12: I am currently very active and can exercise without feeling fatigued. Even if you asked me to walk for hours, I could do it without hesitation. I have not yet thought about making care arrangements.

N13: While we are still independent and able to move around, we have not reached the point where we need outside assistance for care. We will consider making arrangements for care once we reach that stage.

Theme 6: The Role of Mental Health

Healthy Mental State Catalyzes Future Care Planning

Older adults (n = 4) with a healthy mental status demonstrated a propensity to adopt proactive coping strategies, creating a favorable environment for initiating future care preparations. However, respondents (n = 2) who experienced negative emotions often lacked a sense of control over their future lives, making them more focused on the present and reluctant to prepare for future care.

N2: "We have a practical outlook and understand that aging may eventually require us to be cared for by others. It's a natural part of life that we will have to face."

N5: "My heart disease can suddenly have a heart attack or cerebral infarction, so I don't know how long I live. This made me unable to prepare at all."

Enhanced Self-Esteem Postpones Future Care Planning

Additionally, respondents (n = 3) with increased self-esteem dismiss the notion that one's value diminishes with age, contributing to their active engagement in meaningful activities and sustained contributions to family and society, ultimately neglecting future care preparations.

N12: "I handle about 90% of the household chores, especially as my grandson is young and requires our care. With our children working, we take on the responsibility of cooking for them. Thus, I haven't given much thought to future care needs."

Integration of quantitative and qualitative data

In the triangulation process, the analysis yielded three main themes and nine sub-themes that elucidate the factors influencing preparation for future care among community-dwelling older adults with chronic diseases. Predisposing factors include beliefs in filial piety, family structure, age, and health literacy. Enabling factors comprise access to care resources, economic status, and social support. Need factors to address aspects of physical health and mental health (Table 4).

Table 4

Integration of quantitative and qualitative data.
Meta-themes	Meta-subthemes	Qualitative interviews	Quantitative data	Convergence assessment
Predisposing factors	Belief in filial piety	Older adults who influenced by filial piety beliefs are passively making preparation for their future care needs.	N/A	Silence
	Family structure	Some older adults in single-child households expressed adequate preparation for future care due to the burden on their single child.	Older adults who report more adults children associate with less preparation for future care.	Convergence
	Age	As individuals age, leading to more concrete planning for their future care needs.	Older adults who are older associate with higher preparation for future care.	Convergence
	Health literacy	Older adults with higher health literacy enable them to better anticipate future care needs.	Higher levels of health literacy associate with lower preparation for future care. Moreover, education level can not predict future care preparation.	Dissonance
Enabling factors	Access to care resources	Older adults who utilize more care resources are positively associate with better preparation for future care.	Older adults who report more chronic illness resources associate with higher preparation for future care.	Convergence
	Economic status	Older adults with stable retirement income, sufficient savings are better prepared for future care arrangements.	Personal monthly income is positively associated with preparation for future care.	Convergence
	Social support	Older adults who have greater marital harmony, more intergenerational support, and social interaction can elevate preparation for future care needs.	Family function can not predict preparation for future care.	Dissonance
Need factors	Physical health	Older adults with heightened mobility and health status avoid behaviors towards future care planning.	Older adults who report more chronic diseases significantly associate with the higher preparation for future care, but self-rated health status is not a predictor of preparation for future care.	Complementary
Need factors	Mental health	Older adults who reported healthy mental status and with low level of self-esteem fostering future care preparations.	Older adults who report higher levels of resilience significantly associate with the higher preparation for future care.	Complementary

To the best of our knowledge, this study was the first convergent mixed-method study examining the status and associated factors of preparation for future care among community-dwelling older adults with chronic diseases in China. By employing cross-sectional survey and semi-structured interviews, this research provides valuable insights into the variables impacting individuals' preparation for future care based on Andersen’s model.

Status of Preparation for Future Care

The investigation into the preparation for future care among community-dwelling older adults with chronic diseases has revealed insightful data. Older adults with chronic diseases showcased a higher level of preparation for future care compared to their healthy counterparts[14, 33]. This discrepancy could be attributed to the poorer health conditions experienced by individuals with chronic diseases, prompting a greater understanding of their future care needs and fostering a proactive approach to planning. The dimensions of awareness and decision-making emerged as particularly high among community-dwelling older adults with chronic diseases, echoing findings by Wang[34]. This finding may be due to the Chinese government's "14th Five-Year Plan for Healthy Aging," which aims to enhance the elderly's capacity for active health management and effectively address their health requirements[35]. By advocating for a shift towards a positive and proactive aging ideology, promoting correct attitudes towards aging, and emphasizing self-care concepts for older adults, these governmental strategies appear to have positively influenced preparedness levels in certain aspects.

Influencing Factors of Preparation for Future Care

Predisposing Factors

The interview showed that the belief in filial piety negatively influenced older adults’ preparation. Although this result was not mentioned in the quantitative analysis, it has been noted in previous studies[7, 11]. This may be intertwined with the enduring cultural expectations within the traditional Chinese society that places a significant emphasis on adult children fulfilling filial responsibilities towards their elderly parents[36]. This cultural context may inadvertently lead older adults to rely on their children for long-term care planning, potentially diminishing their motivation for independent planning and preparation[7, 8]. In the present mixed-method investigation, older adults who were only children showcased heightened preparedness for future care, consistent with the results of previous studies[15, 17]. Improving the correct understanding of future care preparation of older adults is necessary to prompt them to carry out future care preparation actions.

We found a dissonance between health literacy in quantitative data and qualitative interviews. Previous studies found similar results in qualitative interviews[34, 37], indicating that older adults with higher health awareness demonstrate better preparation for their future care needs. People with higher health literacy often have better health beliefs and awareness, promoting their participation in future care planning. However, the quantitative results indicated contradicting findings. This discrepancy may be due to the higher percentage of 60-69-year-old elderly in this study, who reported higher health literacy and less preparation for future care than older elderly individuals[8].

Both the quantitative and qualitative results indicated that older age is associated with more preparation for future care among community-dwelling older adults, which aligns with previous studies[15, 17]. Our study supports the notion that increasing age increases the odds of planning care for oneself, considering higher frailty, chronic health conditions, and dependency. It suggests that future care preparation interventions should adapt to different age groups of the elderly, especially to increase the attention of younger and older people to future care preparation.

Enabling Factors

Both qualitative and quantitative results emphasized the importance of high-quality and adequate care resources in fostering individuals' preparation for their future care needs. Previous studies mentioned that people were not confident that social care and support services, such as paid carers, would be able to understand and meet their needs; some also noted that care recipients were not treated with dignity[38]. In network analysis, chronic illness resources emerged as the key enabler of future care preparation. However, no previous research has thoroughly explored the relationship between chronic disease resources and future care preparation, warranting further attention in future research. By providing adequate chronic illness resources, healthcare providers, policymakers, and communities can collaboratively develop tailored interventions to enhance preparedness levels and promote the well-being of older adults.

The correlation between higher economic status and enhanced future care preparedness reinforces previous findings[17, 39], attributing increased preparedness to financial capabilities that afford access to diverse and superior care options, promoting successful aging[40]. To promote preparation for future care, communities can conduct financial lectures to help older adults understand the importance and necessity of health and financial preparation.

In qualitative interviews, the social context of planning is highly relevant, and family and friends may serve important functions in the planning process. Friends may exchange important information about specific planning actions or influence planning through normative behaviors. Enhanced overall family functioning (e.g., sharing thoughts, and collaborative problem-solving) increases the odds of discussions about future healthcare plans and preferences[41]. The exchange of emotional support may enhance emotional relationships, facilitating preparation for future care. Previous studies examined similar results[42]. Increased levels of social support predicted fewer negative beliefs about the usefulness of planning. However, in the present study, the quantitative data did not show a direct link between family functioning and future care preparation, which may be due to the high number of only-child older adults who receive less family support than those with many children but actively prepare for future care. Another reason may be that excessive family support increases the sense of dependence on families, leading individuals to assume that the need for a caregiver is already in place, thus negating the need to plan[15]. Future research should further explore the relationship between social relationships and future care preparation. Fully assessing the social support status of older adults, advocating for family members to communicate about future care preparation, and coordinating social support resources to encourage older adults to undertake future care preparation actions are necessary.

Need Factors

Both quantitative and qualitative results covered significant relationships between physical health and preparation for future care. Past studies demonstrated that loss of activities of daily living is a consistent predictor of preparation for care[43]. Increased chronic diseases and poor self-rated health status encourage older adults to plan for future care considering increased dependency[17]. However, a previous study found that people in poor physical health showed lower levels of preparation for future care[33]. This finding may be attributed to older people with poor health being more concerned about existing health problems and having no time to foresee future care needs, limiting their participation in future care preparations. Therefore, future research should incorporate comprehensive chronic disease assessments to discern the nuanced influence of disease type and severity on future care planning. Targeted future care preparation interventions should be carried out based on the number of diseases, the severity of the disease, and the ability to perform daily living activities in the elderly.

The quantitative and qualitative results exhibited a complementary. Yan et al.[44] pointed out that people with high levels of aging anxiety tend to avoid future care preparations. When mental health is well regulated, older people are more likely to adopt positive coping strategies, helping them prepare for future care. A previous study identified that people who reported low levels of self-esteem were associated with higher future care preparation[33]. Older adults with low self-esteem were highly sensitive to the threat of aging-related disabilities and were easily motivated to cope with the threat by promoting preparation for future care. By contrast, respondents with higher self-esteem are more willing to contribute to their families and society than to focus on their aging, leading to a lack of attention to care preparations[8]. Therefore, the important role of mental health in future care preparation needs to be emphasized, and aging adaptation and psychological adjustment should be important parts of future interventions.

Strengths and Limitations

While this study has provided valuable insights into the preparation for future care among older adults with chronic diseases, the accompanying limitations that warrant attention for future research endeavors must be acknowledged. First, the cross-sectional design of our study precludes establishing causal relationships between variables. Future research should prioritize longitudinal studies to uncover dynamic networks and delineate the variables that exert significant effects on preparation for future care. While the sample size in our study was adequate for analysis, the generalizability of our findings, particularly in Hangzhou, may be limited in extrapolation to a broader Chinese population. Future research initiatives should incorporate larger, more diverse, and representative samples to enhance the external validity of the study outcomes. Finally, certain factors potentially linked to preparation for future care, such as the utilization of electronic devices, activities of daily living, and biological determinants, were not integrated into the quantitative analysis. Future prospective studies should encompass comprehensive assessments of these variables to unravel the complex interplay between various determinants and their impact on preparation levels.

Overall, this study represents the first investigation into the preparation for future care and associated factors among community-dwelling older adults with chronic diseases in China. Through a convergent mixed-method analysis utilizing network analysis and semi-structured interviews, this research sheds light on the complex variables impacting individuals' preparation for future care within the framework of Andersen’s model. Considering these findings, healthcare providers, policymakers, and communities can collaboratively develop tailored interventions to enhance the preparation levels of community-dwelling older adults with chronic diseases.

Ethics approval and consent to participate

Consent for publication

Not applicable.

Availability of data and materials

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

Competing interests

The authors declare no competing interests.

Funding

This work was supported by the National Health Commission of the People’s Republic of China [WKJ-ZJ-2304 to YYZ].

Author Contributions

There are ten authors who have contributed to this article. As the first author, Qiqi Ni was responsible for the topic selection and paper writing. Li Wang, Weijing Sui, and Xiaoyan Gong helped with study conception and design, data interpretation, and technical editing. Junru Zhang, Zhenzhen Huang, Chuchu Zhang, Weilin Jiang, and Yunxia Shen contributed to data selection and statistical analyses. Yiyu Zhuang is the corresponding author, responsible for the revision and guidance of the article.

Acknowledgments

Not applicable.

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Determinants of Future Care Preparation Among Community-Dwelling Older Adults with Chronic Diseases: A Mixed-Method Study

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Abstract

Figures

Background

Methods

Study Design

Theoretical Framework

Setting and Participants

Data Collection

Sample size

Statistical analyses

Ethical Considerations

Results

Quantitative research

Qualitative results

Belief in Filial Piety Limits Initiative in Future Care Planning

Single-Child Families Motivating Future Care Preparation

Positive Effects of Increased Care Resource Utilization on Future Care Planning

Challenges in Nursing Home Services

Aging Encourages Proactive Future Care Planning

Stable Economic Status Reinforces Future Care Planning

Positive Impact of Higher Health Literacy on Future Care Planning

Adequate Family Support Promotes Future Care Planning

Social Interactions Drive Future Care Planning

Poor Health Status Facilitates Future Care Planning

Improved Mobility Impedes Future Care Planning

Healthy Mental State Catalyzes Future Care Planning

Enhanced Self-Esteem Postpones Future Care Planning

Integration of quantitative and qualitative data

Discussion

Status of Preparation for Future Care

Influencing Factors of Preparation for Future Care

Strengths and Limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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