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The Impacts of Unmet Needs for Long-Term Care on Mortality Among Older Adults in China
Abstract
The unmet needs of persons needing long-term care have recently drawn attention in China, the nation with the world’s largest elderly population. Using national panel data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we examined the 3-year mortality of 3,089 Chinese adults above the age of 65 years who required long-term care. Long-term care needs were measured by the inability to perform any of the following six activities of daily living for 3 months: eating, dressing, bathing, getting in/out of the bed, indoor transferring, and toileting. Exponential parametric hazard models were used to investigate the association between unmet care needs on subsequent mortality. Results showed that older adults with unmet needs had an approximately 10% increased risk of mortality compared with those whose needs were met when demographics were under control. The risks were particularly elevated among older women and among urban older adults. We conclude by discussing these findings and the importance of a national social insurance program (or additional programs) specialized for the provision of long-term care in China.
... Unmet ADL/IADL needs may be harmful to the health and well-being of older adults. Studies have found associations between unmet ADL/IADL needs and various health outcomes, such as more physician visits (Allen & Mor, 1997), higher fall rates (Marrero et al., 2019), and greater mortality (Zhen et al., 2015). However, there are great levels of heterogeneity among existing studies in terms of the regions and populations examined, study designs, and health outcomes found. ...
... In terms of participants' health conditions, eight studies included those who had difficulty with at least one ADL task (DePalma et al., 2013;Hass et al., 2017;He et al., 2015;Quail et al., 2007;Sands et al., 2006;H. H. Wang et al., 2016;Xu et al., 2012;Zhen et al., 2015), five studies selected those who had difficulty with at least one ADL or IADL task (Hu & Wang, 2019;Momtaz et al., 2012;Zuverink & Xiang, 2019), two studies screened participants through the use of a disability index (Allen & Mor, 1997;LaPlante et al., 2004), two studies concerned persons with dementia (Gaugler et al., 2005;Read et al., 2021), and one concerned terminal Allen et al. (2014), since they used a common data source from the National Health and Aging Trends Study. ...
... The definitions given for unmet needs for daily living assistance were different across studies. Most studies defined unmet need as a person receiving insufficient help (Allen et al., 2014;Allen & Mor, 1997;Chong et al., 2021;DePalma et al., 2013;Desai et al., 2001;Freedman & Spillman, 2014;Gaugler et al., 2005;Hass et al., 2017;He et al., 2015;Khatutsky et al., 2006;Komisar et al., 2005;LaPlante et al., 2004;Quail et al., 2007Quail et al., , 2011aQuail et al., , 2011bWolff et al., 2019;Zhen et al., 2015;Zuverink & Xiang, 2019). This definition covered two different circumstances: (a) participants did not receive any assistance but reported needing assistance, or (b) the participants were receiving assistance but reported needing greater assistance. ...
Many older adults are experiencing unmet needs for assistance with the activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Such unmet needs might threaten their physical and psychosocial well-being. We conducted a systematic review to provide a comprehensive picture of the health consequences of unmet ADL/IADL needs among older adults. Twenty-eight published articles were included for qualitative synthesis. We found that unmet ADL/IADL needs were consistently associated with higher health care utilization (e.g., hospitalization, medical spending) and adverse psychosocial consequences (e.g., anxiety, depression), while the findings of falls and mortality remain inconsistent. More studies are needed to draw firm conclusions and to allow for quantitative synthesis. This review advocates for more coordinated and comprehensive long-term care services for older adults. Future studies should explore how the adverse health outcomes identified in this review can be prevented or improved by adequately meeting older adults’ needs for assistance.
... Prior research used descriptive statistics to report that the prevalence of people experiencing adverse consequences, such as not being able to bathe or shower, not being able to put on clean clothes, falling out of bed or a chair, wetting or soiling oneself, or going hungry, was greater for those with unmet vs. met needs (9,10). Other longitudinal studies focusing on the adverse healthrelated consequences reported that unmet needs for assistance might increase the risk of death (11,12), hospitalizations (13,14), and rehospitalizations (15, 16), and also exacerbate depressive symptoms (17). Deterioration in health in turn will increase service uses and the risk of experiencing unmet needs (18,19). ...
... Previous studies have established the relationship between unmet needs and a set of single health indicators, mainly representing the biomedical level of health (11)(12)(13)(14)(15)(16)(17), but little is known about whether the absence or inadequate provision of LTC services and supports will prevent the aged population with disabilities from achieving a higher level of healthy aging. Understanding the relationship between unmet needs for assistance and different levels of healthy aging can provide evidences for incorporating unmet needs into the need assessment and establishing a precise LTC service supply and subsidy mechanism based on unmet needs, and also for developing an alternative health intervention that regards unmet needs as a risk factor. ...
... Our study has implications for health research. Previous studies have established the relationship between unmet needs and a set of single health indicators which mainly represented the biomedical level of health, such as mortality, hospitalizations, rehospitalizations, and depression (11)(12)(13)(14)(15)(16)(17). Indeed, healthy aging comprises of physiological, psychological, and social domains. ...
Background
Although there is a growing consensus around the world that long-term care services and supports are important to help the aged population with disabilities achieve healthy aging, a misallocation of care resources and inefficiency in care delivery still exist in China. The absence or inadequate provision of long-term care services and supports among older adults with disabilities results in a range of adverse health consequences. However, the negative influence of unmet needs for assistance on healthy aging, based on functional perspectives including physiological, psychological, and societal domains, has been underestimated. This study aimed to measure healthy aging based on a person-centered approach and examine the relationship between unmet needs for assistance and healthy aging among older adults with disabilities in China.
Methods
Based on the data from the Chinese Longitudinal Healthy Longevity Survey 2018, we used the latent profile analysis with three indicators to uncover distinctive types of older adults experiencing distinct levels of healthy aging, and applied the ordered logit regression to analyze the correlation between unmet needs for assistance and different levels of healthy aging. To further address the endogeneity bias, the robust test was conducted by the two-stage least-squares instrumental variable estimation and the conditional mixed process instrumental variable estimation.
Results
Three ordered latent classes were identified: a low level of healthy aging (42.83%), a middle level of healthy aging (47.27%), and a high level of healthy aging (9.90%). Disabled older adults with unmet needs had a lower probability of achieving the higher level of healthy aging (OR = 0.57, SE = 0.04, CI = 0.48–0.66, p < 0.001).
Conclusions
This study highlights the need to increase awareness among gerontological practitioners with respect to long-term care services and supports for disabled older adults as a potential for enhancing their healthy aging, and that unmet needs could be a basis for risk assessment and a means for determining the efficacy of long-term care interventions on maintaining health.
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter summarises available empirical knowledge concerning the consequences of care poverty. According to a growing body of research evidence, care poverty has many kinds of unwelcome consequences for older people’s health and well-being, and it also leads to an increased use of social and health care. Personal care poverty brings adverse consequences like wetting or soiling oneself, and together with socio-emotional care poverty, it also predicts depression. All domains of care poverty are associated with the incidence of emotional difficulties. Personal and socio-emotional care poverty predict health care use, and admissions in residential long-term care are more frequent among those in personal care poverty. Socio-emotional care poverty even predicts increased mortality. Thus, all domains of care poverty prove to have negative consequences for older people’s health and well-being. These consequences are not restricted to the individual level as care poverty also affects the use of health care and residential long-term care. The chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter introduces the concept of care poverty and suggests it as a key approach for research and policy-making on care for older people. The concept combines and connects three different strands of research literature: gerontological studies that focus on functional limitations and unmet needs, feminist social policy scholarship that has introduced concepts like care regimes and care deficit, and research on poverty and social inequality. The chapter describes how the concept of care poverty is also inspired by Raiz’s term of health care poverty. Care poverty is defined as the deprivation of adequate coverage of care needs resulting from interplay between individual and societal factors. It is further described as a situation where people in need of care do not receive sufficient assistance from either informal or formal sources. The mission of the concept of care poverty is to help identify inequalities in access to adequate care and to contribute to the creation of policies that can eradicate these inequalities. The chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter discusses the connections between care poverty and key dimensions of social inequalities (income, educational, gender, regional, ethnic, and racial inequalities). The findings are partly surprising and contradictory. A low income level is a risk factor for personal care poverty in some but not in all countries, while it is more systematically associated with practical care poverty and socio-emotional care poverty. A low level of education does not typically predict care poverty. Neither does gender, though at the same time the clear majority of older people in care poverty are women. Some studies identify an ethnic or racial gradient in care poverty, minorities being more likely to have unmet needs. However, several studies fail to show statistical significance for this difference. Concerning regional inequalities, there are major differences in care poverty rates across different areas, at least in geographically large countries, and in some cases also between rural and urban areas. The chapter ends by arguing that care poverty should be seen as a dimension of inequality in its own right. When some people receive adequate care while others do not, a new type of inequality emerges. This chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter discusses the relations between care poverty and long-term care systems of different countries. Comparative evidence on care poverty is still very weak, as reliable international datasets that have large enough samples of older respondents with care needs are not available. The few existing Europe-wide studies suggest high rates of care poverty especially in Eastern and Southern European countries, the evidence regarding Southern Europe being less consistent, though. A handful of two-country studies exist, and they support the importance of formal home care provisions in reducing care poverty, and this conclusion is echoed in local and national studies. Well-coordinated and well-resourced universal formal care systems (e.g. Sweden) seem to be the most effective way to eradicate care poverty. On the other hand, American studies show that the Medicaid programme has in the United States played a major role in cutting down care poverty, being targeted at older people who are at the highest risk. In the absence of a universal long-term care system, a targeted system can thus be a good second choice: it will not fully eradicate care poverty, but it can still succeed at substantially alleviating it. The chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This open access book (freely available from https://link.springer.com/book/10.1007/978-3-030-97243-1) turns the research attention of social policy scholars and long-term care researchers from comparative descriptions of care systems, focusing mostly on expenditures and volumes of long-term care services, to outcomes, and in particular to the question whether older people really receive the support that they need. Without knowledge about which needs and which social groups are currently inadequately covered, it is impossible to guide policy development.
The book puts forward a novel theoretical framework to guide future research work and public discussion on the issue of unmet long-term care needs, by broadening the current discussion so that inadequate care is seen in its societal and policy contexts, taking structural issues and policy designs into account. Kröger outlines three different domains of care poverty (personal care poverty, practical care poverty and socio-emotional care poverty) and differentiates between main methods how unmet needs are measured. This book summarises the existing knowledge on the prevalence, factors and consequences of unmet care needs and interprets these comparatively in the light of social inequalities and care policy models of different welfare states. It will be invaluable to students and scholars of social policy, social work, social gerontology, sociology and political science, and to all disciplines across the field of social sciences that study welfare state policies and care for older people.
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter outlines a framework around the concept of care poverty. This framework is based on three domains of care poverty and two measurement approaches. The three domains are personal care poverty, practical care poverty, and socio-emotional care poverty. Personal care poverty means inadequate support for personal care needs like bathing and toileting. Practical care poverty stands for a lack of help in meeting practical care needs like cleaning, shopping, and transportation. Socio-emotional care poverty is deprivation of support for emotional and social needs. Concerning measurement approaches, care poverty is measured mainly in two ways. The situation where an older person has care needs but does not receive any formal or informal support is called as absolute care poverty. Alternatively, if an older person with care needs self-reports (or is reported by proxy respondents) not to receive sufficient support, the situation is called relative care poverty, irrespective of whether the person receives informal or formal care or not. When combined, the three domains and the two measurement approaches produce six different categories of care poverty. The chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter sums up existing knowledge on factors of care poverty. The findings of earlier research are presented separately for different care poverty domains and measurement approaches. The factors are organised into three variable groups: (1) health and functional status, (2) socio-demographic background, and (3) the availability of informal and formal care. Health and functional status are found to be significantly associated with all three domains of care poverty. Despite some variation across socio-demographic factors, they generally prove not to be the strongest factors of care poverty, though in many studies income is associated with care poverty. Concerning the breadth of informal and formal support, living arrangement holds explanatory power in almost all domains of care poverty, but the findings are considerably less clear for the other variables. Overall, older people with major care needs who live alone and also have a low income level prove to be at highest risk for care poverty. The chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... The new millennium has seen Chinese researchers actively entering the field of unmet needs research. Their results are very similar to one another, showing a very high relative personal care poverty rate ranging between 55% and 61% (Zhen et al., 2015). However, the unanimity of their findings is not surprising as all these studies used the same CLHLS (Chinese Longitudinal Healthy Longevity Survey) dataset that originally focused on centenarians and only gradually extended to younger cohorts of people aged 65+. ...
... In China, Zhen et al. (2015) analysed whether unmet personal care needs influence the risk of mortality within three years for very old people (the mean age of the sample was 94.5 years). The results showed that older adults with unmet needs had an approximately 10% increased T. Kröger mortality risk, but unmet needs predicted mortality only in urban areas. ...
... As well, noticed that such consequences were more common among 'dual eligibles' than other Medicare users; having passed the strict Medicaid means test, the first group has lower incomes than the second group. A study from China observed that low economic status is a risk factor for mortality among those with unmet care needs (Zhen et al., 2015). The current evidence thus suggests that, even though a low level of income does not always predict care poverty, financial hardship is associated with the emergence of negative consequences among those who are in care poverty. ...
This chapter makes an inventory of earlier research on the prevalence of unmet care needs and summarises these findings under the term of care poverty rates. Care poverty rate is defined as the ratio of people, in a given group of people with care needs, whose care needs are not met. In the chapter care poverty rates are reported separately for different care poverty domains and measurement approaches. Findings are compared between different countries but also between the three care poverty domains and the two measurement approaches. Some countries (like Spain) show consistent results, while in other nations (like the United States) findings display large variations. The chapter also summarises findings on which care needs are most probable to be left unmet. In this respect, moving is found to be the most challenging personal care task and cleaning/housekeeping the most problematic practical care task. In general, the scarcity of research proves to pose the most substantial barrier to drawing conclusions about national levels of care poverty. The chapter is freely available at https://link.springer.com/book/10.1007/978-3-030-97243-1
... People needing LTC have therefore generally lower health than the rest of the population, since limitations due to health, lead to care dependency. Studies have shown that if LTC is inadequate health declines further (LaPlante et al. 2004, Zhen et al. 2015. Adequate LTC therefore, reduces the penalty care dependency has on health outcomes. ...
... Even so, pervious research on unmet LTC either focuses on what causes unmet care (Komisar et al. 2005) or is restricted to certain limitations causing care need (Gaugler et al. 2005, McDowell et al. 2010 or certain types of care provision (Casado et al. 2011). An overall study of the impact of unmet LTC needs on health outcomes has been done in china (Zhen et al. 2015), finding an increase in mortality rates if care needs are unmet. Previous research has found that LTC expenditure associates with coverage rates (Carrera et al. 2013, 40) and that unmet care leads to worse health outcomes (Zhen et al. 2015). ...
... An overall study of the impact of unmet LTC needs on health outcomes has been done in china (Zhen et al. 2015), finding an increase in mortality rates if care needs are unmet. Previous research has found that LTC expenditure associates with coverage rates (Carrera et al. 2013, 40) and that unmet care leads to worse health outcomes (Zhen et al. 2015). Nonetheless, to the best of my knowledge there has been no cross-country analysis investigating the impact of LTC financing on health outcomes. ...
Long term care (LTC) is a general life risk. Welfare states across Europe provide some kind of validation of this risk. However, care approaches differ significantly across countries. This research investigates the impact public financing expenditure has on health status of people needing LTC by analyzing data from the Survey of Aging and Retirement in Europe (SHARE) from 2013 to 2017. LTC needs where measured by functional limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Indicatory evidence shows, that an expansion of public LTC financing positively impacts health and decreases health inequality, however no significant effects could been identified. Unobserved variance between countries might explain insignificant findings, however the question whether this effect actually exists, remains unanswered.
... Long-term care needs primarily refer to a range of formal and informal aids and services that individuals may require for assistance or care with the basic activities of daily living (ADLs), such as eating, dressing and bathing [3,7]. It has been shown that nearly half of those with unmet needs may not be able to eat or may be burned or scarred while bathing, which could significantly diminish these individuals" quality of life [8]. ...
... It has been shown that nearly half of those with unmet needs may not be able to eat or may be burned or scarred while bathing, which could significantly diminish these individuals" quality of life [8]. Using national panel data, a study indicated that older Chinese adults with unmet needs had an approximately 10% increased risk of mortality compared with those whose needs were met when demographic data were controlled [7]. The presence of unmet needs also leads to negative events, such as emergency room visits, nursing home placement, and hospitalization [9,10]. ...
... The probabilities and correlates of unmet LTC needs among older adults have been a growing concern of many scholars. The overall proportion of unmet needs for the basic activities of daily living among elderly individuals aged 65 years or older was evaluated to be from 22% in the United States to 61.4% in China [7,12]. The rate among people aged 60 years and above in Brazil was 18%, which was slightly lower than the rate in the previous countries [13]. ...
Background: Estimates of unmet needs, as an indicator of future needs for long-term care (LTC) services, have become increasingly crucial policy concerns. This study aimed to examine the urban-rural differences in unmet needs and the demand for community care service among community-dwelling elderly people in China.
Methods: The data come from the 2014 Chinese Longitudinal Health Longevity Survey (CLHLS). A total of 1587 community residents aged 65+ with disabilities in the activities of daily living (ADLs) were included in this study. Based on the Andersen theoretical model, binary logistic regression was used to estimate the correlates of unmet needs in LTC. A chi-square test was used to examine the differences in expected needs for community-based LTC services between urban and rural areas.
Results: Over half (55.07%) of the participants reported their needs were unmet. Poor economic status and reluctant caregivers seriously affected elderly unmet needs. Among urban older adults, those who were male and lonely reported more unmet needs. Among rural ones, those with severe ADL disability and poor self-rated health reported more unmet needs. In addition, access to medication and home visit services were negatively associated with unmet needs. Living with children (69.12%) was viewed as the most desirable living arrangement among older adults, while living in a LTC facility seemed to be more accepted for rural residents with unmet needs than for other elderly respondents. Residents showed a high demand for community LTC care services, with 82.55% of them expecting to need home visits and 74.29% to healthcare education. Specifically, rural residents had greater expected needs for every community care service than their urban counterparts. However, only 4.66% to 36.42% of the respondents reported that all eight types of services were available, which was far below the demand for these services.
Conclusion: The risk of having unmet LTC needs is largely determined by elderly people’s economic status and caregivers’ willingness to provide care for both rural and urban elderly residents. More attention should be paid to psychological consulting services in urban areas, as well as personal care, home visits, psychological consulting and healthcare education services in rural areas.
... Long-term care needs primarily refer to a range of formal and informal aids and services that individuals may require for assistance or care with the basic activities of daily living (ADLs), such as eating, dressing and bathing [3,7]. It has been shown that nearly half of those with unmet needs may not be able to eat or may be burned or scarred while bathing, which could significantly diminish these individuals' quality of life [8]. ...
... It has been shown that nearly half of those with unmet needs may not be able to eat or may be burned or scarred while bathing, which could significantly diminish these individuals' quality of life [8]. Using national panel data, a study indicated that older Chinese adults with unmet needs had an approximately 10% increased risk of mortality compared with those whose needs were met when demographic data were controlled [7]. The presence of unmet needs also leads to negative events, such as emergency room visits, nursing home placement, and hospitalization [9,10]. ...
... The probabilities and correlates of unmet LTC needs among older adults have been a growing concern of many scholars. The overall proportion of unmet needs for the basic activities of daily living among elderly individuals aged 65 years or older was evaluated to be from 22% in the United States to 61.4% in China [7,12]. The rate among people aged 60 years and above in Brazil was 18%, which was slightly lower than the rate in the previous countries [13]. ...
Objective This study aimed to examine the urban-rural differences in unmet needs and the demand for community long-term care (LTC) services among community-dwelling elderly people in China.
Methods The data come from the 2014 Chinese Longitudinal Health Longevity Survey (CLHLS). A total of 1587 community residents aged 65+ with disabilities in the activities of daily living (ADLs) were included in this study. Based on the Andersen theoretical model, binary logistic regression was used to estimate the correlates of unmet needs in LTC. A chi-square test was used to examine the differences in expected needs for community-based LTC services between urban and rural areas.
Results Over half (55.07%) of the participants reported their needs were unmet. For both rural and urban residents, poor economic status and reluctant caregivers seriously affected unmet needs. In addition, among urban older adults, those who were male and lonely reported more unmet needs. Among rural elderly people, those with severe ADL disability and poor self-rated health reported more unmet needs. In addition, access to medication and home visit services were negatively associated with unmet needs. Living with children (69.12%) was viewed as the most desirable living arrangement among older people, while living in a LTC facility seemed to be more accepted for rural residents with unmet needs than for other elderly respondents. Residents showed a high demand for community LTC care services, with 82.55% of them expecting to need home visits and 74.29% to healthcare education. Specifically, rural residents had greater expected needs for every community care service than their urban counterparts. However, only 4.66% to 36.42% of the respondents reported that all eight types of services were available, which was far below the demand for these services.
Conclusion The risk of having unmet needs associated with ADL disability in LTC is largely determined by elderly people’s economic status and caregivers’ willingness to provide care for both rural and urban elderly residents. More attention should be paid to psychological consulting services in urban areas, as well as personal care, home visits, psychological consulting and healthcare education services in rural areas.
... To some extent, informal care improves the quality of life in older adults [16]. However, due to the lack of specialized care services and timely disease diagnosis, older adults with ADL limitations who received informal care may be at increased risk for health problems such as decreased physical functioning, chronic diseases, and depression [17][18][19], as well as a greater need to prevent diseases and improve health status through physical examination [20]. Several previous studies found an association between ADL limitations and the use of physical examination services [20][21][22][23]. ...
... This finding may be somewhat surprising, given that urban older adults in China have greater financial and medical resources than those in rural areas [26]. One possible reason for this finding is that the infrequent and low-quality care provided by informal caregivers, as well as ADL limitations, increase the risk of illness and financial burden for older adults [10,17,18]. Compared to households living in urban areas, rural households have lower financial incomes and limited disposable funds [46]. ...
Background
This study investigated the relationship between activities of daily living (ADL) limitations and the use of physical examination among older adults receiving informal care, and to further examine whether this relationship varies by gender and urban-rural areas.
Methods
The data in this study were obtained from the sixth Health Service of Shandong province, China. In total, 8,358 older adults aged 60 years or older who received informal care were included in the analysis. Binary logistic regression models were conducted to explore the association between ADL limitations and the use of physical examination and examine the differences between gender and urban-rural areas.
Results
The prevalence of limitations in ADL and physical examination utilization rate among older adults receiving informal care in Shandong Province were 14.12% and 72.31%, respectively. After adjusting for confounders, ADL limitations were negatively correlated with the utilization of physical examination services among older adults receiving informal care (OR = 0.74, 95% CI: 0.64, 0.87, P < 0.001), and there were gender and rural-urban differences. The association between ADL limitations and the use of physical examination was statistically significant in older women receiving informal care (OR = 0.65, 95% CI: 0.53, 0.80, P < 0.001). And only among urban older adults receiving informal care, those with ADL limitations had lower utilization of physical examination services than participants without ADL limitations (OR = 0.59, 95% CI: 0.47, 0.74, P < 0.001).
Conclusions
Our study suggested that the relationship between ADL limitations and the use of physical examination among older adults receiving informal care differed by gender and urban-rural areas in Shandong, China. These findings implied that the government should provide more health resources and personalized physical examination service programs, especially to meet the differential needs of women and urban old adults receiving informal care, to contribute to the implementation of healthy aging strategies.
... In addition, the rehospitalization rate of older people with unsatisfactory care experience is about 1.66 times higher than that of older people without unsatisfactory care experience [31]. According to a study, the death rate of older adults with disabilities with unsatisfied assistance experience increased by approximately 10% compared to those with a satisfied assistance experience [33]. ...
... (2021) [29] found that family care resources, household income, loneliness, and the number of ADLs affected the unmet needs for ADL assistance of older people with disabilities. In addition, economic status, having someone other than a family member as the primary caregiver, caring attitude of caregivers, timely medication, selfrated health, and self-rated life satisfaction impact unmet needs for ADL assistance [33]. In addition, when caregivers maintain a positive attitude, the likelihood of older individuals with disabilities encountering unmet needs diminishes by 78% in rural regions and 77% in urban areas. ...
Background
With a rapidly ageing population and a decline in the availability of family caregivers, the number of older adults with disabilities who have unmet long-term care needs is gradually increasing worldwide. However, whether there are gender differences in the association between primary caregivers or their attitudes and unmet needs for activities of daily living (ADL) assistance remains largely unknown.
Methods
This study used the latest 2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), containing the data of 1187 older adults with disabilities aged 65 and older, to identify gender differences in the attitudes of primary caregivers toward the unmet needs for ADL assistance among with disabilities adults in China. Binary logistic regression analysis was conducted to determine the effects of primary caregivers and their caregiving attitudes on the unmet care experiences of older adults with ADLs. In addition, a gender-stratified analysis was conducted to compare the differences based on older adults’ gender.
Results
The results revealed that the lack of positive attitudes from primary caregivers might create a situation of unmet needs for ADL assistance among older adults. When family members carry the main burden of care, older adults with disabilities, especially older women, have a lower level of unmet needs for ADL assistance. Therefore, it is important to consider gender-specific interventions to improve ADL assistance among older adults.
Conclusions
The findings suggest that the presence of a family member as a caregiver has a significant effect on unmet needs for ADL assistance in women, highlighting the importance of developing an emotional bond with the caregiver. Given that the availability of informal caregivers, such as family members, is declining, it is crucial to provide financial assistance and formal services, such as paid home services and community-based care services, and reduce the burden on family caregivers to address the unmet needs for ADL assistance among older adults with disabilities in China.
... Based on the Grossman model (11), socioeconomic inequity in access to care can arise from various channels, such as disparities in health literacy, income, time preference, and available time for producing health. Those unable to access the necessary care experience unmet needs, which could lead to negative health outcomes (12,13). Women, lower education, and worse economic status predict unmet needs for personal assistance in ADL among older adults (14,15). ...
... To calculate the descriptive differences in LTC utilisation across education and income groups, both indicators were divided into five categories. The category for education included lowest (<6), lowermiddle (6-9), middle (9-12), higher-middle (12)(13)(14)(15), and higher (16+). Despite different pre-and post-World War II educational systems, this categorisation roughly corresponded to the distinctions between elementary, secondary, high school, and university or higher. ...
Objectives
To assess the socioeconomic inequity in access to medical and long-term care (LTC).
Methods
We used data from Wave 6 (2002) through Wave 10 (2021) of the National Survey of the Japanese Elderly to assess gradients by income and education in access to medical care and LTC among Japanese individuals aged 60 years and above. Specifically, we assessed self-reported unmet needs for medical care and LTC, and public LTC use, and estimated the concentration indices (CI) to measure the degree of inequality and inequity. We standardised public LTC use by need and non-need variables. We analysed data derived from up to 1,775 person-wave observations from 1,370 individuals.
Results
The pooled incidence across waves of forgone medical care, self-reported unmet support for activities of daily living (ADL) or instrumental ADL (IADL), and those not certified for LTC services even with ADL or IADL limitations were 4.6%, 15.5%, and 62.5%, respectively. Public LTC use demonstrated pro-higher education and pro-rich distribution, whereas the gaps decreased for need-predicted use. Based on the CI estimates, no explicit inequality was found for forgone medical care. However, we observed inequity in standardised LTC use across education, indicating pro-higher education inequality, particularly among women and those aged ≥80 years.
Conclusions
Improving the understanding of available resources and strengthening the functions of health centres and communities are required to detect the needs of citizens and facilitate their access to necessary care.
... LTC is necessary for the wellbeing and safety of older people with functional and/or cognitive impairments [11]. Unmet needs for LTC have been associated with increased risk of hospital admission [12], hospital readmission [13], emergency department admission for falls and injuries [14], and mortality [15]. Therefore, it is necessary to identify who is not accessing care and uncover the reasons why so that policies and interventions can be tailored to protect the health of older persons at risk. ...
... Although there are many original studies that have examined unmet needs [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33], to the best of our knowledge, there has been no systematic review and metaanalysis of unmet needs for healthcare or LTC among older people. Since there is great variability in prevalence and reasons for unmet healthcare needs across studies [15,[33][34][35][36][37][38][39][40][41], our main objective is to provide a pooled estimate of unmet needs for healthcare among older people across countries and socio-demographic groups, as well as to identify the leading reasons for those unmet needs. In addition, our secondary objective is to estimate the proportion of unmet needs for LTC among the older population. ...
Background
The absolute number of older individuals needing medical care and long-term care (LTC) is increasing globally due to the growing ageing population. However, it is uncertain who and what proportion of the population has access to care. Therefore, a systematic review and meta-analysis of the prevalence and reasons for unmet needs for healthcare and long-term care among older people, 65 years old and above, across countries was conducted.
Methods
An information specialist performed a comprehensive search of four major databases (PubMed, EMBASE, Web of Science, and CINAHL) from inception to June 2020 without restrictions on language and date. We did random-effects meta-analysis to obtain pooled prevalence. We stratified the meta-analysis by reasons for unmet need categorized by barrier dimension (availability, accessibility, affordability, and acceptability), survey year, geographic location, and socio-demographic characteristics of the older individual.
Results
After screening 3912 articles, we included 101 studies published between 1996 and 2020. Of the 101 studies, 87 studies reported unmet healthcare needs and 14 studies reported unmet LTC needs. Overall, 10.4% (95% CI, 7.3–13.9) of the older population had unmet needs for healthcare. The common reasons for unmet healthcare needs were cost of treatment, lack of health facilities, lack of/conflicting time, health problem not viewed as serious, and mistrust/fear of provider. A significant variation in pooled prevalence of unmet healthcare needs due to cost was found by gender (male [10.9, 95% CI, 8.9–13.1] vs female [14.4, 95% CI, 11.8–17.3]), educational level (primary or less [13.3, 95% CI, 9.6–17.6] vs higher [7.5, 95% CI, 5.9–9.3]), self-reported health (poor [23.2, 95% CI, 18.8–27.8] vs good [4.4, 95% CI, 3.4–5.5]), insurance status (insured [9.0, 95% CI, 7.5–10.6] vs uninsured [27.7, 95% CI, 24.0–31.5]), and economic status of population (poorest [28.2, 95% CI, 14.1–44.9] vs richest [7.1, 95% CI, 3.8–11.3]). One in four (25.1, 95% CI, 17.1–34.2) older people had unmet needs in LTC. Rural residents had a higher prevalence of unmet needs in LTC compared to their urban counterparts.
Conclusion
With the population ageing globally, it is necessary to improve access to health care and LTC for older people. Ensuring affordability of health services, reducing geographical barriers, and improving acceptability, will be critical in reducing unmet need. Unmet needs for healthcare were concentrated in population with no education, poor economic group, outpatient health facility user, and uninsured group. With education and economic-based inequalities at the forefront, all countries should focus on improving access to health services by reducing the burden related to healthcare costs.
... For example, individuals with a shrinking social network might feel lonelier as a result, whilst others with a growing social network could also feel increasingly lonely if the quality of those relationships is poor. Adding to the challenge of understanding how different components of social connection are associated with adverse health outcomes is the numerous heterogeneous ways by which studies have operationalised and measured different aspects of each component [15,[24][25][26][27]. Prior studies have often focussed on a single-item measure, for example, showing that a 'sense of loneliness' (functional) or living alone (structural) is independently associated with a higher risk of all-cause mortality [28,29]. Alternatively, some studies have used composite scales or indices but still with a focus on a single component of social connection (e.g. ...
Background
Components of social connection are associated with mortality, but research examining their independent and combined effects in the same dataset is lacking. This study aimed to examine the independent and combined associations between functional and structural components of social connection and mortality.
Methods
Analysis of 458,146 participants with full data from the UK Biobank cohort linked to mortality registers. Social connection was assessed using two functional (frequency of ability to confide in someone close and often feeling lonely) and three structural (frequency of friends/family visits, weekly group activities, and living alone) component measures. Cox proportional hazard models were used to examine the associations with all-cause and cardiovascular disease (CVD) mortality.
Results
Over a median of 12.6 years (IQR 11.9–13.3) follow-up, 33,135 (7.2%) participants died, including 5112 (1.1%) CVD deaths. All social connection measures were independently associated with both outcomes. Friends/family visit frequencies < monthly were associated with a higher risk of mortality indicating a threshold effect. There were interactions between living alone and friends/family visits and between living alone and weekly group activity. For example, compared with daily friends/family visits-not living alone, there was higher all-cause mortality for daily visits-living alone (HR 1.19 [95% CI 1.12–1.26]), for never having visits-not living alone (1.33 [1.22–1.46]), and for never having visits-living alone (1.77 [1.61–1.95]). Never having friends/family visits whilst living alone potentially counteracted benefits from other components as mortality risks were highest for those reporting both never having visits and living alone regardless of weekly group activity or functional components. When all measures were combined into overall functional and structural components, there was an interaction between components: compared with participants defined as not isolated by both components, those considered isolated by both components had higher CVD mortality (HR 1.63 [1.51–1.76]) than each component alone (functional isolation 1.17 [1.06–1.29]; structural isolation 1.27 [1.18–1.36]).
Conclusions
This work suggests (1) a potential threshold effect for friends/family visits, (2) that those who live alone with additional concurrent markers of structural isolation may represent a high-risk population, (3) that beneficial associations for some types of social connection might not be felt when other types of social connection are absent, and (4) considering both functional and structural components of social connection may help to identify the most isolated in society.
... Rural overweight and obese older adults with ADL limitations are more likely to receive informal care from family members or other relatives. However, informal caregivers frequently lack specialized caregiving knowledge and skills, which can harm the health of the care recipients [55,56]. Thus, rural overweight and obese older adults with ADL limitations have a greater need for family physicians to provide them with specialized care services as well as skill training for their family caregivers, thereby improving their quality of life and well-being in later life [27]. ...
Background
The purpose of this study was to evaluate the relationship between activities of daily living (ADL) limitations and family doctor contract services among overweight and obese older adults, as well as to examine whether this association varies by urban-rural residence.
Methods
Data for the present study were obtained from the sixth Health Service of Shandong province, China. A total of 4,249 overweight and obese older adults were included in this study. Binary logistic regression models were used to evaluate the relationship between ADL limitations and family doctor contract services, to examine the potential differences between urban and rural areas.
Results
Of 4,249 overweight and obese older adults, the prevalence of limitations in ADL and family doctor service contracting rate in Shandong province were 12.47% and 66.46%, respectively. The results of the regression analyses revealed that overweight and obese older adults with ADL limitations were more likely to sign up for family doctor services than those without ADL limitations (OR = 1.27, 95%CI: 1.02–1.58, P = 0.033). Only among rural overweight and obese older adults, the relationship between ADL limitations and family doctor contract services was statistically significant (OR = 1.50, 95%CI: 1.13–1.99, P = 0.005).
Conclusions
Our study found a significant association between ADL limitations and family doctor contract services among overweight and obese older adults in Shandong, China. This relationship differed by urban-rural residence. To promote the positive development of the family doctor contract service system, the government should increase publicity, provide personalized contracted services, and prioritize the healthcare needs of overweight and obese older adults with ADL limitations, with special attention to rural areas.
... It has been argued that receiving support is beneficial for a person's health status, mortality risk (Tay et al., 2013;Zhen et al., 2013), and subjective well-being, as, in general, having social support contributes to an individual's quality of life (Bélanger et al., 2016;Landau & Litwin, 2001;Sirgy, 2012). However, the impact of this social support may depend on the individual characteristics of the caregivers and care recipients, the relationship between them, the expectations of the care recipients, the quantum and the quality of the support received, etc. (Carr et al., 2017;Maisel & Gable, 2009;Sirgy, 2012;Wolff & Agree, 2004). ...
A person’s health status is one of the strongest determinants of well-being. The negative impact of poor health on subjective well-being may be moderated by providing care to individuals in need. In this paper, we investigate the relationships between receiving informal care and the amount of care received and subjective well-being among people aged 65 or older in selected European countries. Our analysis of data from the 6th wave of the Survey of Health, Ageing and Retirement in Europe (SHARE) showed that receiving regular informal care was associated with higher subjective well-being among older people in Northern European countries, and with lower subjective well-being among older males in Southern European countries. Moreover, we found that the perception of the amount of help received affected the subjective well-being of older people, as those who reported that the support they received was either insufficient or met their needs had lower subjective well-being than those who were not in need of care. Our results also showed that receiving formal care was negatively related with subjective well-being among older adults in Northern Europe and Central and Eastern Europe. In the context of population ageing and the growing need for care, social policies that support both sides of the caregiving relationship could enhance subjective quality of life.
... 2020) [9]. Longitudinal studies have found that unmet healthcare needs can contribute to deterioration in future health and quality of life [10][11][12], therefore it is critical to identify populations that experienced greater levels of unmet need during the COVID-19 pandemic and implement interventions to reduce potential impacts. ...
Background:
The COVID-19 pandemic disrupted access to healthcare services in Canada. Research prior to the pandemic has found that depression and anxiety symptoms were associated with increased unmet healthcare needs. The primary objective of this study was to examine if mental health was associated with perceived access to healthcare during the pandemic METHODS: A cross-sectional study was conducted using data from 23,972 participants (aged 50-96) in the Canadian Longitudinal Study on Aging COVID-19 Exit Survey (Sept-Dec 2020). We used logistic regression to estimate how the presence of depression and anxiety symptoms, defined using scores of ≥10 on the Center for Epidemiologic Studies Depression Scale and ≥10 on the Generalized Anxiety Disorder Scale, were associated with the odds of reporting: 1) challenges accessing healthcare, 2) not going to a hospital or seeing a doctor when needed, 3) experiencing barriers to COVID-19 testing. Models were adjusted for sex, age, region, urban/rural residence, racial background, immigrant status, income, marital status, work status, chronic conditions, and pre-pandemic unmet needs.
Results:
The presence of depressive (aOR=1.96; 95% CI=1.82, 2.11) and anxiety symptoms (aOR=2.33; 95% CI=2.04, 2.66) compared to the absence of these symptoms were independently associated with higher odds of challenges accessing healthcare. A statistically significant interaction with sex suggested stronger associations in females with anxiety. Symptoms of depression (aOR=2.88; 95% CI=2.58, 3.21) and anxiety (aOR=3.05; 95% CI=2.58, 3.60) were also associated with increased odds of not going to a hospital or seeing a doctor when needed. Lastly, depressive (aOR=1.99; 95% CI=1.71, 2.31) and anxiety symptoms (aOR=2.01; 95% CI=1.58, 2.56) were associated with higher odds of reporting barriers to COVID-19 testing. There was no significantly significant interaction with sex for the latter two outcomes.
Conclusion:
The presence of depression and anxiety symptoms were strongly associated with perceived unmet healthcare needs during the COVID-19 pandemic. Interventions to improve healthcare access for adults with depression and anxiety during the pandemic may be necessary.
... Relative to older adults who receive appropriate LTC, those who have unmet needs are more likely to have a lower quality of life, 206 greater psychological stress, 207 more hospital admissions and readmissions, 208 and a higher rate of mortality. 209 These findings suggest that the availability and adequacy of care are especially important for older adults who need LTC. ...
Unlabelled:
Around the world, populations are ageing at a faster pace than in the past and this demographic transition will have impacts on all aspects of societies. In May 2020, the UN General Assembly declared 2021–2030 the Decade of Healthy Ageing, highlighting the importance for policymakers across the world to focus policy on improving the lives of older people, both today and in the future. While rapid population ageing poses challenges, China’s rapid economic growth over the last forty years has created space for policy to assist older persons and families in their efforts to improve health and well-being at older ages. As China is home to 1/5 of the world’s older people, China is often held up as an example for other middle-income countries. This Commission Report aims to help readers to understand the process of healthy ageing in China as a means of drawing lessons from the China experience. In addition, with the purpose of informing the ongoing policy dialogue within China, the Commission Report highlights the policy challenges on the horizon and draws lessons from international experience.
The uniqueness of china’s ageing society:
From a global perspective, China shares some of the economic and social challenges faced by other countries with rapidly ageing populations. China stands out, however, as it already has the world’s largest older population, and China’s ageing burdens will increase further as the ‘second baby boomers’ (those born between 1962 and 1975) start to enter retirement in 2022. In addition, China’s rapid demographic transition over the last four decades will lead to a dramatic decline in the number of living children for each older person in China and bring substantial challenges for both family-based care and social care. Compounding demographic changes, personnel planning in geriatric and rehabilitation medicine has not kept pace with the growth of the older age population, and there is a shortage of medical resources targeted at the ageing population. In Section 1, the report stresses the importance of achieving “healthy ageing” in light of socio-economic progress, urbanization and migration, and China’s demographic transition.
Health complexity and inequalities among china’s older population:
China completed its epidemiological transition from infectious diseases to non-communicable diseases (NCDs) during the past three decades. As in many other ageing countries, the upward trend in the incidence of NCDs and the presence of multimorbidity pose special challenges for China’s healthcare sector. Even as some older Chinese continue to suffer from such communicable diseases as hepatitis, tuberculosis, and sexually transmitted diseases, chronic conditions, such as cognitive impairments, mental disorders, and frailty, are becoming much more prominent. These chronic conditions are complex to treat and manage and are associated with more functional disability and greater care needs. Along with the emergence of NCDs, substantial gaps in health are apparent by gender, rural versus urban residence, ethnicity, and socio-economic status. Investments in healthy ageing, from promoting education in health literacy to improving access to health care, are promising means of improving the well-being of older adults and reducing the gaps in health across socioeconomic groups in China. Even as China’s population ages, investments in healthy ageing offer a path for older Chinese to play meaningful and productive social roles in society, while limiting burdens on their families. The latest facts on health status and health inequities among China’s older adults are presented in Section 2 of the report.
Modifiable factors of healthy ageing: evidence from china.:
Current evidence on the determinants of health and functioning status of China’s older population is summarized in Section 3. In China, as elsewhere, health at older ages results from the cumulative effects of behaviours and events that occur across the life cycle. These include exposures to unhealthy environments and parental decisions influencing in-utero and childhood health, later health behaviours as teenagers and adults (including decisions on educational investments, smoking, drinking, and physical activity), and decisions over food consumption which influence diet and nutritional status. Many of these decisions and behaviors are influenced by health literacy and socio-economic conditions, but they may also be influenced by policy (Section 5). Finally, Section 3 highlights the health benefits of social connections and participating in leisure activities such as square dancing and promoting age-friendly environments in China.
Integrating medical and social care for chinese older people.:
Older people require access to high-quality health services that include prevention, promotion, curative, rehabilitative, palliative and end-of-life care. An update on China’s policy initiatives regarding healthcare and social care relevant to the ageing population is provided in Section 4. In addition to achieving universal health insurance coverage, China has invested heavily in public health promotion and the consolidation of the primary healthcare system. Further, as the role of the family in providing care for older people is eroded by dwindling family size and changing living arrangements, especially with the outmigration of adult children, China is taking steps to build up institutional and community care infrastructure as both a substitute for, and complement to, family care. Furthermore, long-term care insurance (LTCI) has been piloted in many cities as a financing mechanism. China’s experience with the LTCI pilots suggests that it will be difficult to sustain LTCI under the current pay-as-you-go framework, and that there will be a considerable public financial risk as the population ages. Although China’s government has placed the integration of health care with long-term care (LTC) at the forefront of its policy agenda, the progress for the integration has been slow.
Lessons learned from china and implications for the future.:
An overview of the evidence presented earlier in the report is presented in Section 5, followed by policy recommendations for supporting healthy ageing in China. Policy recommendations outlined here can be generalized to other countries, especially low- and middle-income countries (LMICs). First, health promotion initiatives should focus on changing people’s behavior, especially smoking cessation, weight control, and health literacy education to reduce the incidence of NCDs and care burdens. Second, there is an urgent need to move away from disease-centred care to person-centred care and to increase the supply of health care workers, particularly in geriatric medicine, rehabilitation medicine, and hospice care. Third, innovative measures should be taken to remove obstacles to upgrading community and home environments and thus facilitate mobility and social engagement among older people. There are several other policy areas that should be addressed, given China’s unique institutional environment. These include regional segmentation of health insurance systems and the regulatory environment for healthcare delivery. Specifically, the report suggests that policy in China should focus on: (1) national integration of the health insurance system to eliminate the current segmentation across regions and occupations; (2) capping regionally segmented LTCI initiatives, and striving for a national scheme that is independently funded; (3) switching government subsidies in the aged care sector from subsidising providers to subsidising consumers to facilitate market competition and to help existing care facilities to meet safety regulations; (4) strengthing the capacity to regulate medical service providers, especially in screening for fraud against the national medical insurance schemes and reforming the healthcare delivery sector by lowering barriers to entry and facilitating choice. Older people are an important part of a family and an invaluable asset to society. Healthy ageing will not only enable older people to enjoy their later life to the fullest but has the potential to unleash the intellectual and vocational capacities of society as a whole. Recognizing that China’s older population will continue to grow, it is important to take their needs into account and prepare well in advance by creating an age-friendly environment for the ageing population. As China’s “second baby boomers” start to reach retirement age in 2022, it is imperative to take the window of opportunity afforded by China’s economic growth to make coordinated efforts across sectors to address the concerns of an ageing nation.
... with assistance with activities of daily living, to maintain their independence, and to enable them to better engage in social activities 27 . It has been confirmed that long-term unmet needs are more likely to lead to mental health problems 28 , readmission 29 , and high mortality rates 30 , which, in turn, lower individuals' SES and life satisfaction. Additionally, considering that China has a rural-urban dual system in which socioeconomic disparity is substantial and urbanization has been rapid in recent decades, the divide between rural and urban areas in terms of demographic structure, social norms, and economic development has widened. ...
This study aimed to examine the prevalence of unmet healthcare needs and clarify its impact on socioeconomic status (SES) and life satisfaction in a longitudinal cohort of the Chinese rural population. Data used in this study were obtained from a nationally representative sample of 1387 eligible rural residents from the Chinese Family Panel Studies. Generalized estimating equation (GEE) logistic regression models were used to examine the factors associated with unmet healthcare needs and the impact of unmet healthcare needs on respondents’ perceived SES and life satisfaction. Approximately 34.6% of respondents were male, 18.2% were ≤ 40 years, and 66.7% had completed primary education or below. Around 19% and 32.6% of individuals who healthcare needs were met reported an above average socioeconomic status and life satisfaction, respectively in the baseline survey. GEE models demonstrated that unmet healthcare needs were significantly associated with low perceived SES (Odds ratio = 1.57, p < 0.001) and life satisfaction (Odds ratio = 1.23, p = 0.03) adjusted by covariates. Respondents who were older, reported moderate or severe illness, and with chronic conditions were more likely to report the unmet healthcare needs.Unmet healthcare needs are longitudinally associated with low SES and life satisfaction among the Chinese rural population, the disparity in access to healthcare exists among this population.
... These unmet needs are associated with physical discomfort, psychological distress, and worse self-rated health (Quail et al., 2007). They also can lead to further health issues that increase health services utilization, such as hospitalization (Sands et al., 2006) and death (Zhen, Feng, & Gu, 2015). Therefore, maintaining the welfare of people with disabilities who need different types of health and personal care can be challenging if they lack adequate support Huenchuan & Rodríguez Velázquez, 2015;López-Ortega & Aranco, 2019). ...
The world’s population is aging rapidly, with the proportion of persons age 60 and older in the total population expected to increase from 12% in 2015 to 22% by 2050 (World Health Organization, 2017). Similarly, in Mexico, the proportion of persons age 60 and older is expected to increase from 11.0% in 2019 to 22.6% by the year 2050 (The World Bank, n.d.).
... Also worrisome is the decline of traditional role of the family in caring for older adults. Given smaller family sizes, many older Chinese may not have adult children around [17][18][19]. ...
Background: For older adults, difficulties in bathing and toileting are often the most prevalent in the index of Activities of daily living (ADL). This study aims to examine how environmental factors are associated with difficulty of bathing and toileting among older adults in rural China.
Method: The data are from the 2014 Thousand-Village Survey (TVS), a national survey of Chinese rural residents of old age. The sample consists of 10,689 subjects, 55 years or older, from 536 villages across all provinces of China. Logistic regressions were applied to examine how difficulty in bathing and toileting was related to environmental factors such as geographic location, neighbourhood amenity, and related facility of bathing and toileting.
Results: Older adults living in the southern regions of China had lesser difficulty in bathing and toileting than those living in Northern China, controlling on other confounders. Better neighbourhood conditions also reduced the likelihood of having such disabilities. Persons who bathed indoors without shower facilities, in public facility, and outdoors were significantly more likely to have bathing disability than those who showered indoors. Rural older adults who used pedestal pan and indoor bucket for toileting were more likely to have toileting disability than those who used indoor squatting facilities.
Conclusion: Environmental barriers were associated with functional disability among older adults in rural China, but these individuals may also change their environment to adapt to their functioning. Our findings suggest it is imperative to promote the use of showering facilities and pedestal pans for toileting in rural China
... Also worrisome is the decline of traditional role of the family in caring for older adults. Given smaller family sizes, many older Chinese may not have adult children around [17][18][19]. ...
Background
For older adults, difficulties in bathing and toileting are often the most prevalent in the index of Activities of daily living (ADL). This study aims to examine how environmental factors are associated with difficulty of bathing and toileting among older adults in rural China.
Method
The data are from the 2014 Thousand-Village Survey (TVS), a national survey of Chinese rural residents of old age. The sample consists of 10,689 subjects, 55 years or older, from 536 villages across all provinces of China. Logistic regressions were applied to examine how difficulty of bathing and toileting was related to environmental factors such as geographic location, neighbourhood amenity, and related facilities of bathing and toileting.
Results
Older adults living in the Southern regions of China had lesser difficulty in bathing and toileting than those living in Northern China, controlling for other confounders. Better neighbourhood conditions also reduced the likelihood of having such disabilities. Persons who bathed indoors without showering facilities, in public facilities, and outdoors were significantly more likely to have bathing disability than those who showered indoors with facility. Rural older adults who used pedestal pans and indoor buckets for toileting were more likely to have toileting disability than those who used indoor squatting facilities.
Conclusion
Environmental barriers were associated with functional disability among older adults in rural China, but the disabled individuals may change their environments to adapt to their functional capabilities. Our findings suggest that it is imperative to promote the use of showering facilities and pedestal pans for toileting in rural China.
... In the past 10 years, the population of Chinese older people aged 80 years and older has been growing at an average annual rate of 4.7%, which is significantly faster than the growth rate of older people aged 60 years and older [3]. In 2013, the number of Chinese older people over the age inadequate personal assistance in ADL (activities of daily living) are serious threats to the health status and life quality of older people with disabilities [40], including more limited ADL, emergency-room visits and hospitalizations [41][42][43], increased psychological stress [44], and higher rate of mortality [45]. Therefore, identifying the factors associated with the undermet care needs of the disabled oldest old people and taking appropriate interventions are particularly important. ...
We examined the influencing factors of the undermet care needs of the Chinese disabled oldest old people when their children are both caregivers and are themselves older people. Data were obtained from a cross-sectional survey: the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2018. The study participants included 1617 disabled oldest old people whose primary caregiver were their children or children-in-law and were aged 60 years and over. The results showed that the prevalence of undermet needs remained high, with 49.6% disabled oldest old people reporting undermet care needs. Binary logistic regression analysis revealed that living in a rural area (OR = 1.309, 95% CI = 1.133-1.513) and a higher frailty index (OR = 1.103, 95% CI = 1.075-1.131) were significantly positively associated with higher odds for undermet care needs, while a higher annual household income (OR = 0.856, 95% CI = 0.795-0.923), more financial support from children (OR = 0.969, 95% CI = 0.941-0.997), higher care expenditures (OR = 1.044, 95% CI = 1.002-1.088), better caregiver's performance (OR = 0.282, 95% CI = 0.196-0.407) and sufficient income to pay for daily expenses (OR = 0.710, 95% CI = 0.519-0.973) were significantly inversely associated with higher odds for undermet care needs. This evidence suggests the importance of policies to establish a community-based socialized long-term care system and supporting family caregivers of the disabled oldest old people.
... Also worrisome is the decline of traditional role of the family in caring for older adults given smaller family sizes, many older Chinese will not have any adult children around. Who will take care of disabled Chinese older adults has thus drawn serious attentions in literature [7][8][9]. ...
Background: For older adults, difficulties in bathing and toileting are often the most prevalent in the index of Activities of daily living (ADL). Few studies, however, have investigated how the built environment and other environmental factors affect bathing and toileting in later life. This study aims to fill this gap.
Method: The data are from the 2014 Thousand-Village Survey (TVS), a national survey of Chinese rural residents of old age. The sample consists of 10,689 subjects, 55 years or older, from 536 villages across all provinces of China. The multinomial logistic regressions were applied to examine how difficulty in bathing and toileting was related to environmental factors such as geographic location, community amenity, and built environment of bathing and toileting.
Results: Older adults living in the southern regions of China had lesser difficulty in bathing and toileting than those living in Northern China, controlling on other confounders. Better community conditions also reduced the likelihood of having such disabilities. Persons who bathed indoors without shower facilities, in public facility, and outdoors were significantly more likely to have bathing disability than those who showered indoors. Rural older adults who used pedestal pan and indoor bucket for toileting were more likely to have toileting disability than those who used indoor squatting facilities.
Conclusion: Environmental factors are strongly associated with functional disability among older adults, but the relationship is not unidirectional. Having a showering facility could reduce difficulties of bathing for rural Chinese. Very frail older persons may actively choose to change their environmental settings to suit their needs, for instance, by using a pedestal pan or bucket for toileting as an alternative to squatting. There is an urgent need to promote the use of showering facilities and pedestal pans for toileting in rural China.
... 7 There seems an increased mortality level of over 10% when compared with elderly persons reporting met needs. 8 Also, psychological distress was found to be more among the elderly population in a study in south India. It was attributed to the low socioeconomic status since it was a limiting factor for health care and they were unable to lead a life of dignity. ...
Background: The proportion of elderly population is on the increasing trend in India. Morbidity was found higher among the elderly population. About 10% increased risk of mortality was found among elderly people with unmet needs. The objective of the study was to assess the morbidity pattern and unmet health needs among elderly population in rural areas of Kancheepuram district, Tamil Nadu.Methods: This community based cross-sectional study was conducted for a period of 18 months in four selected villages in Kancheepuram district, Tamil Nadu, among 390 participants. EASY care standard (2010) questionnaire was used for assessment of health care needs. Frequency distribution of study variables and association using chi-square test were done using SPSS software version 23.Results: Out of 390 study participants, 51% were females. The most common morbidity was arthritis (40.5%), followed by diabetes and difficulty in hearing (29.5% each). Psycho-social issues such as loneliness (36.7%), little interest in doing things (30.8%), feeling hopelessness (30%) were noted among the study participants. The highest unmet health need was 11.8% for difficulty in hearing. The unmet health needs were associated with older age, widowhood, lower educational status, inability to work, low socio-economic status, absence of individual income, and absence of care taker of the study participants.Conclusions: The health needs of elderly are multi-faceted viz., medical, psycho-social, financial, etc. Since, family characteristics play a major role in meeting the health needs of elderly population, community-oriented services mainly involving family members will help for addressing the unmet needs of the elderly.
... As instrumental support from family care-givers is declining, unmet needs, which have been widely documented as leading to numerous adverse effects on health, are on the rise (Zhen et al., 2013). Gu and Vlosky (2008) found that nearly 60 per cent of older Chinese people reported having unmet needs in 2005. ...
Rapid demographic shifts and socio-economic changes are fuelling concerns over the inadequate supply of informal care – the most common source of care-giving for older people in China. Unmet long-term care needs, which are believed to cause numerous adverse effects on health, continue to increase. Drawing data from the 2015 wave of the China Health and Retirement Longitudinal Survey, this study explores the relationship between informal care provision and unmet long-term care needs among older people in China. We first examine the availability of informal care among older people with disabilities. We then analyse whether a higher intensity of informal care leads to lower unmet needs. Our findings suggest that the majority of older people with disabilities receive a low intensity of care, i.e. less than 80 hours per month. Besides, a higher intensity of informal care received could significantly lower the probabilities of unmet needs for the disabled older adults who have mainly instrumental activities of daily living limitations. Our study points out that informal care cannot address the needs of those who are struggling with multi-dimensional difficulties in their daily living. Our findings highlight a pressing need for the government to buttress the formal care provision and delivery systems to support both informal care-givers and disabled older people in China.
... Previous studies have offered different definitions of LTC needs. Most of the prior literature has focused on older adults with functional disabilities (Wu et al. 2009;Zhen et al. 2015), or "need aids for daily living" (Du 2015). ADL limitations have commonly been used as the primary measure for people who need LTC (Gu and Vlosky 2008;Peng et al. 2015;Stone et al. 1987), although a few others have used instrumental activities of daily living (IADL) limitations and disabilities for similar purposes (Hu et al. 2015). ...
This study analyses long-term care needs (LTC) in the context of older adults who face limitations in activities of daily living (ADL) or with cognitive impairment (CI), and thus need aids to fulfil daily activities. Drawing on data from three waves (2002, 2005, 2008/09) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), this study shows that the older adults aged 65 to 99 with ADL limitation declined over the years from 8% to 5% but those with CI increased from 11% to 17%. Overall, about 16% of the older adults reported LTC needs in the baseline year of 2002, and this subsequently increased to 20% in 2008/09. Results from random-effects parametric survival-time models indicate that social factors such as low income, inadequate medical services, a lack of social support and social activities as well as being spouseless tend to significantly increase the hazard of developing LTC needs for the Chinese older adults.
... H o w e v e r, t h e p r i m a r y i n t e r e s t o f this study was to find why not use and the influencing factors for the high rate of case closures in home service delivery found in this study. Previous research showed that greater unmet needs are predictive of nursing home placement, death, and loss to follow-up [19], while older adults with unmet needs had an approximately 10% increased risk of mortality compared with those whose needs were met when demographics were controlled for [25]. ...
Objectives: In order to develop person-centered service delivery in the community, it is important to understand the causal relationships among older adults' personal factors, service utilizations, and the ability to reside in the community from a longitudinal perspective. This study aimed to examine the profile of home services utilization and the reasons for case closures in two years, as well as the related influencing factors, among home service recipients in southern Taiwan. Methods: We analyzed the long-term care dataset of one southern metropolitan area from 2011-2015, and the records of 9,889 persons aged 50 and over who received home services with an initial need assessment (T0). The Cox Regression Analyses were used to examine the potential risk factors for leaving the services. Results: The high rates of case closures included death (20%) and drop-out (41%), mainly due to the need to search for caregiving resources within family networks. In terms of the influencing factors for leaving the services, those who with non-low household incomes, informal caregiving burden and moderate cognitive impairments were more likely to drop out. Conclusions: This study provides empirical evidence of the high dropout rate and the importance of further investigations to explore the service gap in this context, especially the need to give more attention to those service users who then drop out of the system. (Taiwan J Public Health. 2018;37(5):539-553)
... Using a sample of French residents, Dourgnon, Jusot, and Fantin (2012) found a detrimental impact on health 4 years after having declined care for financial reasons. Zhen, Feng, and Gu (2015) find an increase in 3-year mortality among the elderly with unmet needs in China. Our study builds on this work using a panel survey of Canadians that includes a shorter time between surveys (2 years), a more generic measure of unmet need and a longer period, enabling us to better capture the effect of unmet need on future health. ...
Utilization‐based approaches have predominated the measurement of socioeconomic‐related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access—self‐reported unmet need (SUN)—which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self‐reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization‐based approaches.
... Long-term care are the activities undertaken by informal (family, friend, or neighbors) or formal (health and social professionals or paraprofessionals) caregivers to ensure that people with or at risk of an ongoing loss of intrinsic capacity can maintain a level of functional ability and quality of life 2,3 . Accordingly, unmet need for personal assistance for activities of daily life is related to increased risk of mortality 4 and morbidity (e.g. falls, weight loss) 5 , hospitalization and re-hospitalization [6][7][8] , and psychological distress 9 . ...
OBJECTIVE
To estimate the proportion of unmet need for personal assistance for basic and instrumental activities of daily life and to evaluate socioeconomic inequalities related to the unmet need among community-dwelling Brazilian older adults.
METHODS
This was a cross-sectional study with data from the last National Health Survey in Brazil. Unmet need was considered as the presence of at least one unmet need for basic or instrumental activities of daily life among individuals reporting the need for assistance. Logistic regression models were used to assess the correlates and probabilities of unmet need.
RESULTS
The proportion of unmet need was 18% and 7.1% for basic and instrumental activities of daily life, respectively. Unmet need was significantly related to living arrangements and socioeconomic status. Individuals in the first quintile of wealth status had about 50% higher probability of having an unmet need. A family member was the most prevalent type of caregiver.
CONCLUSIONS
Long-term care policy is needed to reduce the proportion of unmet need, especially among socioeconomically disadvantaged groups. Future studies should address the availability, training, and remuneration of caregivers, as those are an indispensable labor force in an aging society.
Objective
This study sought to investigate mental disorder and mortality risks and medical utilization among various long-term care (LTC) services and examine the associated factors.
Methods
This retrospective cohort study used data from the National Health Insurance Research Database of the entire population of Taiwan recorded between 2006 and 2017. A total of 41,407 patients using LTC (study group) were identified and propensity score–matched with 41,407 LTC nonusers (control group) at a ratio of 1:1 according to sex, age, salary-based premium, comorbidity index score, and urbanization level. Patients were divided into four groups according to LTC service type. The age distribution was as follows: 50–60 years (10.47%), 61–70 years (14.48%), 71–80 years (35.59%), and 81 years and older (39.45%). The mean age was 70.18 years and 53.57% of female participants were included. The major statistical methods were the Cox proportional hazards model and the general linear model (GLM).
Results
Users of both institutional and inhome LTC services had the highest risk of mental disorder [adjusted hazard ratio (aHR) = 3.2]. The mean mortality rate in LTC nonusers was 46.2%, whereas that in LTC users was 90.4%, with the highest found among the users of both institutional and inhome LTC (90.6%). The institutional LTC users had the shortest survival time (4.1 years). According to the adjusted Cox model analysis, the odds of mortality was significantly higher among institutional LTC users than among inhome LTC users (aHR = 1.02). After the adjustment of covariates, adjusted GLM model results revealed that the annual medical expenditure per capita of LTC nonusers was NT$46,551, which was 1.6 times higher that of LTC users.
Conclusion
Users of both institutional and inhome LTC services have higher risk of mental disorder, shorter survival time, and lower medical utilization.
Background
The ageing population in China has led to a significant increase in the number of older persons with disabilities. These individuals face substantial challenges in accessing adequate activities of daily living (ADL) assistance. Unmet ADL needs among this population can result in severe health consequences and strain an already burdened care system. This study aims to identify the factors influencing unmet ADL needs of the oldest old (those aged 80 and above) with disabilities using six machine learning methods.
Methods
Drawing from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 2017–2018 data, we employed six machine learning methods to predict unmet ADL needs among the oldest old with disabilities. The predictive effects of various factors on unmet ADL needs were explored using Shapley Additive exPlanations (SHAP).
Results
The Random Forest model showed the highest prediction accuracy among the six machine learning methods tested. SHAP analysis based on the Random Forest model revealed that factors such as household registration, disability class, economic rank, self-rated health, caregiver willingness, perceived control, economic satisfaction, pension, educational attainment, financial support given to children, living arrangement, number of children, and primary caregiver played significant roles in the unmet ADL needs of the oldest old with disabilities.
Conclusion
Our study highlights the importance of socioeconomic factors (e.g., household registration and economic rank), health status (e.g., disability class and self-rated health), and caregiving relationship factors (e.g., caregiver willingness and perceived control) in reducing unmet ADL needs among the oldest old with disabilities in China. Government interventions aimed at bridging the urban–rural divide, targeting groups with deteriorating health status, and enhancing caregiver skills are essential for ensuring the well-being of this vulnerable population. These findings can inform policy decisions and interventions to better address the unmet ADL needs among the oldest old with disabilities.
Despite the well-established association between loneliness and all-cause mortality in older adults, it remains unknown whether this association holds for older adults of different sex and whether it is influenced by different samples and study characteristics. Thus, this meta-analysis aims to examine moderators of the association between loneliness and all-cause mortality in older adults. To this end, relevant literature was retrieved from the PubMed, Embase, PsycINFO, Web of Science, Chinese National Knowledge Infrastructure, Weipu, and Wanfang databases (inception to May 2023) and was processed in the Comprehensive Meta-Analysis 3.3 software. Moreover, subgroup analysis was performed to explore the sources of heterogeneity and further explore potential moderators. Funnel plots, Begg's test, and Egger's linear regression test were used to examine the publication bias, and sensitivity analysis was used to test the robustness of the results. Thirty-six studies involving 128,927 older adults were included in this meta-analysis. In general, loneliness was related to an increase in all-cause mortality in older adults (HR = 1.09, 95% CI = 1.06-1.12, I2 = 63.31%, p < 0.001). The overall effect size for older men was 1.18 (95% CI = 1.04-1.33, p = 0.010). The association between loneliness and all-cause mortality was found to be significantly influenced by the source country of the data, follow-up length, and covariates for chronic disease as moderators. In conclusion, loneliness among older adults deserves more attention, and services are needed to improve their mental health.
Background: China has the highest number of older adults with disabilities worldwide. Home and community-based services (HCBSs) are optimal ways to deal with disability problems. Studies have shown urban-rural disparities in the supply and demand of HCBSs in China and that disability levels are significantly associated with HCBSs utilization. However, what’s inconspicuous is whether there are urban-rural disparities in HCBSs utilization and whether HCBSs utilization and levels of disabilities are associated. This study is designed to analyze urban-rural disparities both in HCBSs utilization and in the relationship between HCBSs utilization and levels of disabilities among Chinese older adults with disabilities.
Methods: In applying the Andersen behavioral model, bivariate analysis and multivariate regression models were employed using data from 843 older adults with disabilities from the 2018 China Longitudinal Aging Social Survey.
Results: Urban older adults with disabilities used HCBSs over twice as often as their rural counterparts. Furthermore, older adults with moderate disabilities living in urban areas used HCBSs more than twice as often as older adults with mild disabilities, while older adults with severe disabilities residing in urban areas used HCBSs approximately three times more often than older adults with mild disabilities. However, regarding rural older adults with disabilities, the levels of disabilities were unrelated to HCBSs utilization.
Conclusion: Disability levels among Chinese older adults with disabilities were significantly correlated with HCBSs utilization throughout the country and in urban areas, but not in rural areas. The underlying reason for these disparities is the low utilization of HCBSs in rural areas among older adults with disabilities. The government should combine the supply-side and demand-side perspectives to fundamentally address urban-rural disparities in using HCBSs among Chinese older adults with disabilities.
Background
The absolute number of older individuals needing medical care and long-term care (LTC) is increasing globally due to the growing ageing population. However, it is uncertain who and what proportion of the population has access to care. Therefore, a systematic review and meta-analysis of the prevalence and reasons for unmet needs for healthcare and long-term care among older people, 65 years old and above, across countries was conducted.
Methods
An information specialist performed a comprehensive search of four major databases (PubMed, EMBASE, Web of Science, and CINAHL) from inception to June 2020 without restrictions on language and date. We did random-effects meta-analysis to obtain pooled prevalence. We stratified the meta-analysis by reasons for unmet need categorized by barrier dimension (availability, accessibility, affordability, and acceptability), survey year, geographic location, and socio-demographic characteristics of the older individual.
Results
After screening 3912 articles, we included 101 studies published between 1996 and 2020. Of the 101 studies, 87 studies reported unmet healthcare needs and 14 studies reported unmet LTC needs. Overall, 10.4% of the older population had unmet needs for healthcare. The common reasons for unmet healthcare needs were cost of treatment, lack of health facilities, lack of/conflicting time, health problem not viewed as serious, and mistrust/fear of provider. A significant variation in pooled prevalence of unmet healthcare needs due to cost was found by gender (male [10.9%] vs female [14.4%]), educational level (primary or less [13.3%] vs higher [7.5%]), self-reported health (poor [23.2%] vs good [4.4%]), insurance status (insured [9.0%] vs uninsured [27.7%]), and economic status of population (poorest [28.2%] vs richest [7.1%]). One in four (25.1%) older people had unmet needs in LTC. Rural residents had a higher prevalence of unmet needs in LTC compared to their urban counterparts.
Conclusion
With the population ageing globally, it is necessary to improve access to health care and LTC for older people. Ensuring affordability of health services, reducing geographical barriers, and improving acceptability, will be critical in reducing unmet need.
Introduction:
The COVID-19 pandemic led to the cancellation of healthcare appointments and to lower demand, which generated unmet healthcare needs. The aim of this study was to evaluate their prevalence and distribution in Portugal.
Material and methods:
Data came from the "Survey of Health, Ageing and Retirement in Europe". Between June and August 2020, 1118 Portuguese individuals aged 50 or over were inquired about unmet healthcare needs due to: i) fear of getting infected; ii) cancellation by the doctor/healthcare services; iii) unsuccessful consultation request. The analysis of the prevalence of unmet needs was complemented by the calculation of the concentration indices as a function of the variables: income, education and health status.
Results:
About 60% of respondents reported at least one unmet need, which was almost twice the European average. Motive ii) cancellation by the doctor/healthcare services was the most frequent. The prevalence of unmet needs differed depending on income level and health status. The indices evidence the concentration of unmet needs in individuals with the worst health status, although for the reason fear of infection the concentration occurred in those with higher levels of income and education.
Conclusion:
Our study showed a high prevalence of unmet needs and their concentration in individuals with worse health status. Given the association between unmet needs and the subsequent deterioration of health, these results should raise concerns about the near future.
Rapid aging and longer lives pose many health and social care policy challenges to countries in Latin America, such as Mexico. By 2050, 21.5% of the Mexican population will be 60 years or older, up from 10% in 2015 (González, 2015). Data from the SAGE study conducted between 2007 and 2010 found that life expectancy at age 50 was 32 years for women and 29 for men (Chirinda & Chen, 2017). Of these years, women could expect to live ten years and men six years with a severe disability (Chirinda & Chen, 2017).
Objective
To determine the prevalence of unmet need for primary healthcare and associated individual and household-level factors in Kenya.
Design
The data for this study are drawn from the 2016 Kenya Integrated Household Budget Survey (KIHBS). A multistage sampling technique involving a systematic selection of clusters at the national level and final selection of households was used.
Setting
This study was conducted in Kenya. The KIHBS is a nationally representative survey on a wide range of indicators to assess the progress made in improving the living standards of the population at the national level.
Participants
A total of 9447 households comprising 15 539 household members who reported a sickness or injury over the 4 weeks preceding this survey were included in this study. The study respondents comprised of the household heads.
Primary outcome measure
The primary outcome of this study is unmet need for primary healthcare defined as an unexpressed demand for primary healthcare following a reported sickness or injury over the 4 weeks preceding this survey.
Results
About one in every five study participants experienced an unexpressed demand for primary care. The odds of having unmet need for primary healthcare were 68% higher among participants without health insurance coverage compared with those with health insurance (adjusted OR 1.68; p<0.001; 95% CI 1.34 to 2.09) and 45% higher among households headed by single or unmarried persons compared with the those who were in a marital union (adjusted OR 1.45; p<0.05; 95% CI 1.06 to 1.98).
Conclusions
Our findings show that there is still a considerable unexpressed demand for primary care services despite widespread implementation of Universal Health Coverage (UHC) in Kenya, with households without a health insurance cover bearing the highest burden. Therefore, the design of UHC reforms in Kenya should focus on embedding social health protection to escalate the demand for primary healthcare services.
Using data from the Korean Longitudinal Study of Aging ( N = 3,356 participants aged 65 or older) and estimating Cox proportional hazard regression models, this study investigated the association between gender composition of children and parents’ mortality risk. This study showed that compared with having both daughters and sons, having exclusively daughters (but not exclusively sons) was associated with higher mortality risk. This association, however, was significant for mothers, but not for fathers. To shed light on source of this association, this study distinguished between mothers with only daughters who receive and do not receive regular financial support from children. Results showed that mothers had elevated mortality risk only if they do not receive regular financial support from their children. Traditional caregiving roles of sons for older parents in Korea may lead to a mortality disadvantage among mothers of daughters vis-à-vis a reduction in financial assistance from children.
The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O'Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n ¼ 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals' experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients' expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.
Objectives
This review aims to (1) examine existing definitions of omissions of care in the healthcare environment and associated characteristics and (2) outline adverse events that may be attributable to omissions of care among nursing home populations.
Design
Nonsystematic review. A literature search for published articles on care omissions in nursing home settings and related adverse events was performed using the databases PubMed, Web of Science, EBSCO Academic Search Premier, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) until January 2019. Articles were excluded if they were published in a language other than English or included samples that were not relevant to nursing home settings.
Settings and Participants
Adult samples in nursing home settings or settings likely to include nursing homes as part of the continuum of care.
Measures
Articles must provide a definition of missed or omitted care relevant to nursing home settings or include adverse events that can be attributed to care omissions.
Results
From a total of 2155 articles retrieved, 34 were retained for thematic synthesis. Key themes included broad agreement that any delay or failure of care is an omission; diverse views on including consideration of risks or occurrence of adverse events within the definition; diverse approaches to including components of care delivery systems in the definition; recognition that care in nursing homes includes both clinical and psychosocial care; and awareness that insufficient or inadequate resources to meet care demands can cause omissions. For research on adverse events attributable to omissions, 327 of 8385 articles were included for review. Nineteen adverse events were identified and omissions contributing to their incidence are highlighted.
Conclusions/Implications
Definitions of omissions of care for nursing homes vary in scope and level of detail. Substantial evidence connects omissions of care with an array of adverse events in nursing home populations.
Research investigating self-assessed unmet need (SUN) has taken the reports from surveys as given and subsequently attempted to discover patterns in inequality of access to healthcare. This requires the yet untested assumption that, given a certain level of care and demand, the likelihood of reporting unmet need does not vary across socioeconomic/demographic status (SEDS), be satisfied. Using an administrative dataset spanning 2001 to 2011 comprised of sufferers of a set of conditions that suggest unmet need (n = 3300) we evaluate the proposition that, given health status and care received, the propensity to report unmet need does not vary along SEDS. The results are further validated using the Canadian Community Health Surveys between 2001 and 2013 (n = 237,483). We find that the assumption of independence between reporting SUN and SEDS is not satisfied. Many of the groups found to have less access in previous studies may simply be more prone to interpret/answer the survey questions about unmet need in a certain way. The results of this research suggest that, in its present incarnation, survey data on self-assessed unmet need does not accurately measure what much of the academic literature has assumed it does.
Osoba w wieku starszym, geriatrycznym a tym samym bardzo często z niepełnosprawnością jest zbyt skąpo i niedostatecznie holistycznie zaopatrywana w realizację świadczeń zdrowotnych w środowisku domowym.
Jedną z form jaka funkcjonuje na rynku świadczeń zdrowotnych i dedykowanych osobom starszym i niepełnosprawnym jest pielęgniarska opieka domowa długoterminowa. Ten rynek świadczeń zdrowotnych od ponad 17 lat zorganizowały i prowadzą pielęgniarki jako samodzielna grupa zawodowa w oparciu o zawierane kontrakty z Narodowym Funduszem Zdrowia. Pomimo stale zwiększającego się zapotrzebowania na tego typu opiekę płatnik czyli Narodowy Fundusz Zdrowia traktuje te świadczenia jako limitowane. Świadczenia te są najtańszą formą opieki na rynku świadczeń zdrowotnych skierowaną do osób starszych i niepełnosprawnych. Wobec faktu, że społeczeństwo polskie starzeje się w bardzo szybkim tempie a tym samym zmaga się z wielochorobowością należałoby te świadczenia zdrowotne umieścić w świadczeniach gwarantowanych nielimitowanych.
Zmiana ta wprowadziłaby ogromne oszczędności w ochronie zdrowia. Osoba, która ze względu na stan zdrowia kwalifikuje się do realizacji świadczeń zdrowotnych typu pielęgniarska opieka domowa długoterminowa, a z powodu braku miejsc jest wpisywana na listę osób oczekujących.
Long-term care is receiving increasing attention as population aging increases the demand for long-term care services and boosts the cost of health expenditures. Although China’s old age support system has been studied, previous research has insufficiently examined the long-term care system and its related issues.This chapter systematically evaluates long-term care needs, costs, unmet needs, provisions, finances, and their associated factors among the Chinese elderly population. We mainly use the data from the 2005 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) including 15,593 elders aged 65 and older with over-sampling of the oldest-old to investigate these issues. Additional data were analyzed including a nationwide survey on the elderly and the 2000 census.We find that about 5-6% (or about 5.7 million) of the Chinese elderly needed long-term care in 2005 if the long-term care need was defined as a status in which a person has been disabled in any of six of activities of daily living for more than ninety days. That figure will reach 27 million in 2050 given the same age-sex-specific prevalence rates. Yearly long-term care expenditures reached 21 billion Yuan in 2005, accounting for 2.7% of total health expenditures. The proportion of unmet and undermet needs was nearly 60%. In other words, there were 3.5 million Chinese elders who needed long-term care services but could not access them. This number could climb to 16 million in 2050 given the same age-sex-specific rate.Our results revealed that more than 80% of long-term care services were provided by family and more than 50% of costs were paid for by family. Our results further revealed that care needs, costs, unmet and undermet needs, provisions, and sources of payments varied across regions and between urban and rural areas, and that individual socioeconomic status and family/social resources were associated with long-term care needs, provisions, and finances, although such associations did not follow the same patterns across subpopulations. These findings are useful in identifying target populations, assessing the long-term care needed, and initiating appropriate services given that rapid population aging and dramatic social and demographic changes will bring great pressure on and challenges to the long-term care system in China.
The health effects of marital status are frequently cited in the current debate on marriage promotion, but little is known about how marital health effects vary across groups. This article assembles the largest properly longitudinal and nationally representative dataset of elderly married couples in the United States (N = 410,272 couples) and provides strong evidence that the “widowhood effect”—how the death of a spouse increases the mortality of the survivor-varies substantially by race. The authors find that whites married to whites suffer a large and enduring widowhood effect. By contrast, blacks married to blacks do not suffer a detectable widowhood effect, possibly because they manage to extend the survival advantage of marriage into widowhood. For racially intermarried men, wife's race appears to dominate the size and presence of the widowhood effect entirely, regardless of husband's own race. These results likely arise from differences in the marital cultures and marital contexts of black and white couples. More generally, these results demonstrate that the health effects of social ties depend on the individual attributes of the actors they connect.
The authors explore the changing dynamics of gendered familial caregiving in urban China within the context of economic reforms and the continued cultural influence of xiao (filial piety). Data collected in China through interviews with 110 familial caregivers were used to examine cultural and structural influences on the caregiving behavior of adult children. Results from multiple regression analyses provide evidence of a gendered division of parental care tasks, a decline in the patrilocal tradition of caregiving, and a strong social pressure that influences caregiving behavior. Structural factors linked to caregiving performance included family size, lack of pensions for elders, and caregivers’ employment status and income. Findings portend deleterious effects for the women who are now caregivers as they are likely to live longer but be more financially dependent and have fewer children available to help them.
Based on unique data from a sample of nearly 9,000 people ages 80 to 105 interviewed in 22 provinces in 1998, we found that gender differentials in educational attainment among the Chinese oldest old are enormous: Many more women are illiterate. Oldest old women are more likely to be widowed and economically dependent, much less likely to have pensions, and thus more likely to live with their children and rely on children for financial support and care. The female oldest old in China are also seriously disadvantaged in activities of daily living, physical performance, cognitive function, and self-reported health, as compared with their male counterparts; these gender differences are more marked with advancing age. The large gender differentials among the Chinese oldest old need serious attention from society and government, and any old-age insurance and service programs to be developed or reformed must benefit older women and men equally.
This chapter assesses the reliability of mortality and self-reported morbidity in the first three waves of the Chinese Longitudinal
Healthy Longevity Survey (CLHLS). Results indicate that the observed rates of all-cause mortality reported in the CLHLS are
underestimated by 15–20 percent between 1998 and 2000 and by 5–20 percent for ages 80–90 when based on hazard-model estimates;
however, no such differences are found between the 2000 and 2002 waves. Our analyses further show that mortality rates over
age 90 in the CLHLS are more reliable than those obtained from the census. The quality of self-reported morbidity and its
population prevalence is generally quite good compared to other national data sets. However, the analyses suggest that information
collected from next-of-kin should be interpreted with caution. We find that cause-specific mortality rates estimated from
reports by the next-of-kin are substantially biased and that the prevalence of the decedents’ morbidity reported by the next-of-kin
is somewhat underestimated.
To develop a new classification method to describe incidence and prevalence of function and disability and their predictors in Chinese older adults.
Data were obtained from 16,020 older adults in the 2002 wave of Chinese Longitudinal Healthy Longevity Survey (CLHLS). The subtypes of function and disability were defined by combining physical performance (PP) tests and self-reported assessments of activities of daily living (ADL).
The most prevalent subtype involved PP limitations without ADL dependency. Rural living made it more likely that an individual with physical performance limitations would be independent in ADL, whereas city residence made dependence in ADL more likely, regardless of whether performance limitations were present.
Self-reported and performance-based tools can be used in combination to estimate conceptually different subtypes of function and disability, with different epidemiological rates of incidence and different social, medical, and environmental predictors.
China's one child per couple policy (OCP), with its depressive effects on fertility rates, was established in 1979. Since then numerous studies have documented the effects of the OCP on the aging of China's population. The increasing proportion of elderly in China is producing profound social and economic complications that require the development of appropriate policies. This article addresses this issue in a novel way, by focusing on the sandwich generation, i.e., those who oftentimes care for both younger and older generations. Qualitative data recently collected from diverse representatives of this generation are presented in an attempt to personalize the consequences of this demographic shift and to introduce possible solutions for lessening its effects. We determine that in urban areas many possibilities exist, while in rural areas challenges are more urgent given the proportionately larger number of elderly residents and the lack of options.
This study estimates the prevalence of unmet health care needs among the elderly of Barcelona, Spain, and analyzes the association between unmet needs and mortality.
Home interviews were conducted with 1315 elderly in Barcelona. Individuals were classified as having a "health services need" if they reported being in fair, poor, or very poor health; suffering from two or more chronic conditions; or being dependent in at least one basic activity of daily living. Need was considered unmet if no visits to or from a physician in the previous 12 months were reported. Mortality was assessed from census data in August 1991.
Between 10% and 25% of the elderly in need reported no use of health services. After a median of 60.3 months, those with unmet health care needs presented a higher risk of mortality, adjusted for several confounding factors: relative risk [RR] = 2.55 (95% confidence interval [CI] = 1.22, 5.32) for unmet activity of daily living dependency; RR = 1.80 (95% CI = 1.20, 2.70) for unmet comorbidity; and odds ratio = 1.10 (95% CI = 0.59, 2.05) for unmet poor self-rated health.
Noninstitutionalized elderly individuals with unmet health care needs are at increased risk of dying.
This article examines recent trends in self-reported unmet health care needs among the household population aged 12 or older, and explores various explanations for the increase observed.
The data are from the first half (September 2000 through February 2001) of data collection for cycle 1.1 of the Canadian Community Health Survey and from cross-sectional (1994/95 through 1998/99) household components of the National Population Health Survey.
Weighted frequencies and cross-tabulations were used to estimate the proportion of people aged 12 or older who reported that they did not receive health care when they thought they needed it. Estimates were also produced for the type of care sought, and specific reasons for unmet health care needs.
The percentage of people reporting unmet health care needs rose gradually between 1994/95 and 1998/99, then doubled (from 6% to over 12%) between 1998/99 and 2000/01. Long waiting time was the reason most frequently reported for unmet needs.
We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system.
We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse.
Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care.
Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs.
People who are dually eligible for Medicare and Medicaid are the focus of fiscal struggles between federal and state governments. Drawing on a survey of community-based elderly "dual eligibles," this paper examines how well their medical and long-term care needs are being met under the current combination of Medicare and Medicaid policies. While few people report difficulty getting medical care, 58% of people needing long-term care (help with activities of daily living) report unmet needs. As a result, many experience serious consequences, such as falls. Although unmet needs are substantial in all six states surveyed, we find the greater the use of paid home care in a state, the lower the likelihood of unmet needs, suggesting states' policies can make a difference.
China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.
Using survey data linked with Medicaid claims data, this study examines the consequences of unmet need for future health care use for a sample of disabled Medicaid beneficiaries in Westchester County, New York. Among other things, we find that individuals reporting unmet need in 1999 were more likely to use emergency room and hospital care in 2000 than those not reporting unmet need. Addressing the barriers to care that underlie unmet need could generate cost savings to Medicaid and provide better health outcomes for program beneficiaries.
Changes in the health and functioning of the Medicare-enrolled population aged 65+ are tracked by using the 1982–2004/2005 National Long-Term Care Surveys. We found a significant rate of decline in the prevalence of chronic disability that accelerated from 1982 to 2004. These declines are significant for both persons with less severe chronic disability, which might be compensated by modifying the built environment and providing assistive devices, and for persons with more serious disability, which may be affected by reductions in the incidence and severity of disease through biomedical interventions. Declines in chronic disability continued over the 22-year period at a rate fast enough (i.e., 1.52% per annum) to contribute significantly to the long-term fiscal stability of the Medicare (and Medicaid) programs. Changes in the rate and substance of disability declines seem consistent with the intentions of policy interventions in Medicare and Medicaid.
• Medicare
• National Long-Term Care Surveys (NLTCS)
• long-term care
• activities of daily living
• Medicaid
This article examines the changing demographics of China, with particular attention paid to the effect of the one‐child policy in relation to long‐term care of older people. It also examines the current state of health care for older people. Long‐term stays characterize hospital care. Most geriatric syndromes are less common in hospitalized older people (e.g., delirium, falls), but some (e.g., polypharmacy) are more common. A high volume of patients and brief targeted visits characterize outpatient care. Nursing homes exist in China, but relatively fewer than in the most developed countries.
Geriatric departments in university‐based hospitals primarily have developed out of a need to care for retired government officials and workers. There are no formal geriatric fellowships or national board certifications in geriatrics
Health care is primarily based on fee for service. Not all elderly have healthcare insurance. Although costs of health care and medications are less expensive than in the United States, they are relatively high for lower‐and middle‐class Chinese and have increased more quickly than has the standard of living in the past 20 years.
Family and community support for older people is strong in China. Some older people have one‐to‐one care from a baomu (literally “protection” ( bao ) “mother” ( mu )), a type of live‐in maid who also provides care for the older person. Some of the challenges facing China in the care of its aging population are how to increase geriatric research and training, how to care for the uninsured or underinsured, and how to handle the inevitable growth of disabled and frail older people.
Based on unique data from the largest-ever sample of the Chinese oldest-old aged 80 and older, our multivariate logistic regression analyses show that either receiving adequate medical service during sickness in childhood or never/rarely suffering from serious illness during childhood significantly reduces the risk of being ADL (activities of daily living) impaired, being cognitively impaired, and self-reporting poor health by 18%-33% at the oldest-old ages. Estimates of effects for five other indicators of childhood conditions are similarly positive but mostly not statistically significant. Multivariate survival analysis shows that better childhood socioeconomic conditions in general tend to reduce the four-year period mortality risk among the oldest-old. But after additional controls for 14 covariates are put into the model, the effects are not statistically significant, thus suggesting that most of the effects of childhood conditions on oldest-old mortality are indirect-at least to the point of affecting current health status at the oldest-old ages, which itself is strongly associated with mortality. While acknowledging limitations of the present analyses due to a lack of information on childhood illness, the oldest-olds'recollection errors, and other data problems, we conclude, based on this and other studies, that policies that enhance childhood health care and children's socioeconomic well-being can have large and long-lasting benefits up to the oldest-old ages.
Based on unique data from the largest-ever sample of the Chinese oldest-old aged 80 and older, our multivariate logistic regression analyses show that either receiving adequate medical service during sickness in childhood or never/rarely suffering from serious illness during childhood significantly reduces the risk of being ADL (activities of daily living) impaired, being cognitively impaired, and self-reporting poor health by 18%–33% at the oldest-old ages. Estimates of effects for five other indicators of childhood conditions are similarly positive but mostly not statistically significant. Multivariate survival analysis shows that better childhood socioeconomic conditions in general tend to reduce the four-year period mortality risk among the oldest-old. But after additional controls for 14 covariates are put into the model, the effects are not statistically significant, thus suggesting that most of the effects of childhood conditions on oldest-old mortality are indirect—at least to the point of affecting current health status at the oldest-old ages, which itself is strongly associated with mortality. While acknowledging limitations of the present analyses due to a lack of information on childhood illness, the oldest-olds’ recollection errors, and other data problems, we conclude, based on this and other studies, that policies that enhance childhood health care and children’s socioeconomic wellbeing can have large and long-lasting benefits up to the oldest-old ages.
Most major population surveys used by social scientists are based on complex sampling designs where sampling units have different probabilities of being selected. Although sampling weights must generally be used to derive unbiased estimates of univariate population characteristics, the decision about their use in regression analysis is more complicated. Where sampling weights are solely a function of independent variables included in the model, unweighted OLS estimates are preferred because they are unbiased, consistent, and have smaller standard errors than weighted OLS estimates. Where sampling weights are a function of the dependent variable (and thus of the error term), we recommend first attempting to respecify the model so that they are solely a function of the independent variables. If this can be accomplished, then unweighted OLS is again preferred. If the model cannot be respecified, then estimation of the model using sampling weights may be appropriate. In this case, however, the formula used by most computer programs for calculating standard errors will be incorrect. We recommend using the White heteroskedastic consistent estimator for the standard errors.
Summary European governments seek to ensure that their citizens have access to safe and effective health care. At the EU level, improving access to health care is among the priority objectives for promoting social inclusion and equal opportunities for all. The accessibility of health services is complex and depends on a multitude of factors that relate to the health system and also to the patients themselves. This research note critically assesses one indicator of access to health care: self-reported unmet need. This indicator is included in two international surveys: the Survey on Health, Ageing and Retirement in Europe (SHARE) of individuals aged 50 years and older, and the EU Survey of Income and Living Conditions (EU-SILC) of residents of private households aged 16 years and older. Across Europe there is quite a wide range in the proportion of the population who report an unmet need or who report to have forgone care in the past 12 months. When it is measured in an open-ended way, as in the EU-SILC, it is important to disaggregate the indicator by the reasons for unmet need in order to distinguish between those reasons that are more relevant to policymakers and those that reflect individuals' preferences and tastes. Perceived access problems would be expected to be greater among those with higher need for health care; indeed, in all countries (except Sweden) there is a relationship between reported forgone care and self-assessed health status. The few studies that have been conducted to examine unmet need in Europe have identified a strong association with both income and health whereby people who report unmet need tend to be in worse health and with lower income, after controlling for other measurable characteristics. To better understand this indicator and to examine how it relates to the health system, we analyze the relationships between reporting forgone health care and both the use of and expenditure for health services in 12 countries included in SHARE. We find some evidence of a positive association between forgoing health care and using health services; people who report to forgo care appear to be relatively higher users of the health system than those who do not report this access problem. Based on this analysis we would suggest that subjective indicators of access require careful attention, and that they should be combined with additional indicators such as actual utilization of health services, waiting times for treatment, and quality of care. In the effort to improve the design of surveys to elicit information on access to health care, it is important to include multiple questions and indicators. Such an approach would enable us to gain a better understanding of what unmet need means, and to what extent it represents barriers to access versus individual preferences. Interpretation of measures of unmet need requires a disaggregation of the indicator by the different reasons that are stated. Finally it is important to highlight that comparisons of subjective indicators across countries should be made cautiously; it is likely that some differences in the reporting of access problems relate to cultural differences, since perceived access problems depends on the recognition of a health problem, the individual's expectations and, ultimately, her experiences with the health system. This Research Note has been produced for the European Commission by Sara Allin and Cristina Masseria (Health and Living Conditions Network of the European Observatory on the Social Situation and Demography at LSE). The views expressed are those of the authors and do not necessarily represent those of the European Commission.
This research aims to further current understanding of gender differences in old age mortality. In particular, it assesses the relative importance of health behavior and baseline health conditions in predicting the risk of dying, and how their effects differ between elderly men and women. Data for this research came from a prospective study of a national sample of 2,200 older adults in Japan from 1987 to 1999. Hazard rate models were employed to ascertain the interaction effects involving gender and health behavior (i.e., smoking and drinking) and baseline health status. Gender differences in old age mortality in the Japanese are quite pronounced throughout all of our models. In addition, interaction effects of gender and smoking, functional limitation, and cognitive impairment, indicate that females in Japan suffer more from these risk factors than do their male counterparts. Failure to adjust for population heterogeneity may lead to a significant underestimation of female advantage in survival. The inclusion of health behavior and health status measures only offsets a limited proportion of this gender differential. The increased mortality risk due to smoking, functional limitation, and cognitive impairment among elderly Japanese women suggests that narrowing of gender gap in mortality may be due to not only changes in the levels of these risk factors but also their differential effects on men and women.
This chapter evaluates age reporting among the oldest-old, especially centenarians, in the Chinese Longitudinal Healthy Longevity
Survey (CLHLS) based on comparisons of various indices of elderly age reporting and age distributions of centenarians in Sweden,
Japan, England and Wales, Australia, Canada, China, the USA, and Chile. The analyses demonstrate that age reporting among
the oldest-old interviewees (Han and six minority groups combined) in the 22 provinces in China where the CLHLS has been conducted
is not as good as that in Sweden, Japan, and England and Wales, but is relatively close to that in Australia, more or less
the same as that in Canada, better than that in the USA (all race groups combined), and much better than that in Chile. As
indicated by the higher density of centenarians, age exaggeration exists in the six ethnic minority groups in the 22 Han-dominated
provinces, although we cannot rule out and quantify the potential impacts of past mortality selection and better natural environmental
conditions among these minority groups. We find that the age exaggeration of minorities in the CLHLS may not cause substantial
biases in demographic and statistical analyses using the CLHLS data, since minorities consist of a rather small portion of
the sample (6.8 percent at baseline and 5.5 percent in the grand total sample of the 1998, 2000, and 2002 waves).
This chapter provides a comprehensive review of data quality of the third wave of the Chinese Longitudinal Healthy Longevity
Survey (CLHLS) in 2002 in terms of proxy use, nonresponse rate, sample attrition, and reliability and validity of major health
measures. The results show that the data quality of the 2002 wave of the CLHLS is generally good. Some recommendations in
use of the dataset are provided.
To examine a new method of classifying disability subtypes by combining self-reported and performance-based tools to predict mortality in older Chinese adults.
Prospective cohort study.
Community-dwelling older adults.
Sixteen thousand twenty Chinese adults aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey (CLHLS).
Self-reported activities of daily living (ADLs) and physical performance (PP) tests (chair standing, lifting a book from floor, turning 360°) cross-classified to create mutually exclusive disability subtypes: subtype 0 (no limitations in PP or ADLs), subtype 1 (limitations in PP, no limitations in ADLs), subtype 2 (no limitations in PP, limitations in ADLs), and subtype 3 (limitations in PP and ADLs). Outcome was mortality over 3 years.
Cox proportional hazard models, controlling for sociodemographic variables, living situation, healthcare access, social support, health status, and life-style, showed that older adults without any limitations in ADLs or PP had significantly lower mortality risk than those with other disability subtypes and that there was a graded pattern of greater mortality according to subtype 1 (hazard ratio (HR)=1.31, 95% confidence interval (CI)=1.20-1.42), 2 (HR=1.39, 95% CI=1.23-1.59), and 3 (HR=1.88, 95% CI=1.72-2.05). When compared with the average survival curve in the cohort, subtypes of isolated performance deficits or self-reported disability did not substantially discriminate risks of death over 3 years.
Combined use of self-reported and PP tools is necessary when screening for mutually exclusive disability subtypes that confer significantly higher or lower mortality risks on a population of older adults.
China has the largest aging population in the world today. Despite the Chinese tradition of filial piety, economic, social,
cultural, and familial changes have made it increasingly difficult for older Chinese to receive support from adult children.
To ensure parental support, the Family Support Agreement (FSA) emerged from a local community in the mid-1980s. Since then,
the FSA has been promoted and monitored by the government. By the end of 2005, FSAs had been signed by more than 13 million
rural families across China and is now finding its way into cities. A voluntary contract between older parents and adult children
concerning parental provisions, the FSA represents an innovation to help meet the challenge of providing elder support. Although
the FSA’s moral persuasion is based on filial piety, violations of the FSA are subject to penalties by law. As the first systematic
and comprehensive exploratory study on the FSA, this article examines (a) the FSA’s emergence, content, legal foundation,
and implementation; (b) the role of the government and the legal system in promoting or monitoring FSAs; (c) the FSA’s strengths,
limitations, and challenges; (d) the FSA’s implications in light of Chinese history, intergenerational contract, filial piety,
and intergenerational relations; and (e) the future of the FSA as a social policy.
Studies of functional impairments in the U.S. elderly population have tended to rely on prevalence estimates from nationally representative health and institutional surveys. These prevalence estimates generally show higher rates of disability for females than males. Unfortunately, prevalence estimates can be misleading when one attempts to assess the risks of certain types of health event transitions for individuals. This study directly examined the individual transitions both into and out of functionally impaired states using longitudinal data from the 1982 and 1984 National Long Term Care Surveys (NLTCS). The data show that, even at very high levels of impairment, there are significant numbers of community residents who apparently manifest long-term improvement in functioning. The longitudinal data also show that the risks of becoming disabled are roughly the same for males and females. This suggests that sex differences in the national prevalence of disabilities arise from the greater longevity of females at any given level of age and functional impairment.
This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.
The Behavioral Model of Health Services Use was initially developed over 25 years ago. In the interim it has been subject to considerable application, reprobation, and alteration. I review its development and assess its continued relevance.
With the introduction of economic reforms, families in China are challenged by a variety of family-related problems. Demographic and social changes are affecting both the capacity and willingness of the family to provide care for the elderly. The Chinese Government is aware of the importance of the family in the welfare of its citizens, and has promulgated a series of laws and regulations prescribing family obligations. Yet formal services supporting families are extremely underdeveloped, and it is urgent that the government formulate an effective policy to facilitate, support, and maximize family care.
Although long-term care receives far less U.S. policy attention than health care does, long-term care matters to many Americans of all ages and affects spending by public programs. Problems in the current long-term care system abound, ranging from unmet needs and catastrophic burdens among the impaired population to controversies between state and federal governments about who bears responsibility for meeting them. As the population ages, the pressure to improve the system will grow, raising key policy issues that include the balance between institutional and noninstitutional care, assurance of high-quality care, the integration of acute and long-term care, and financing mechanisms to provide affordable protection.
It is widely recognized that social relationships and affiliation have powerful effects on physical and mental health. When investigators write about the impact of social relationships on health, many terms are used loosely and interchangeably including social networks, social ties and social integration. The aim of this paper is to clarify these terms using a single framework. We discuss: (1) theoretical orientations from diverse disciplines which we believe are fundamental to advancing research in this area; (2) a set of definitions accompanied by major assessment tools; and (3) an overarching model which integrates multilevel phenomena. Theoretical orientations that we draw upon were developed by Durkheim whose work on social integration and suicide are seminal and John Bowlby, a psychiatrist who developed attachment theory in relation to child development and contemporary social network theorists. We present a conceptual model of how social networks impact health. We envision a cascading causal process beginning with the macro-social to psychobiological processes that are dynamically linked together to form the processes by which social integration effects health. We start by embedding social networks in a larger social and cultural context in which upstream forces are seen to condition network structure. Serious consideration of the larger macro-social context in which networks form and are sustained has been lacking in all but a small number of studies and is almost completely absent in studies of social network influences on health. We then move downstream to understand the influences network structure and function have on social and interpersonal behavior. We argue that networks operate at the behavioral level through four primary pathways: (1) provision of social support; (2) social influence; (3) on social engagement and attachment; and (4) access to resources and material goods.
This study examined the prevalence, correlates, and negative consequences of unmet need for personal assistance with activities of daily living (ADLs) among older adults.
The authors analyzed cross-sectional data from the 1994 National Health Interview Survey's Supplement on Aging. Data were weighted to be representative of the noninstitutionalized population aged 70 years and older.
Overall, 20.7% of those needing help to perform 1 or more ADLs (an estimated 629,000 persons) reported receiving inadequate assistance; for individual ADLs, the prevalence of unmet need ranged from 10.2% (eating) to 20.1% (transferring). The likelihood of having 1 or more unmet needs was associated with lower household income, multiple ADL difficulties, and living alone. Nearly half of those with unmet needs reported experiencing a negative consequence (e.g., unable to eat when hungry) as a result of their unmet need.
Greater, targeted efforts are needed to reduce the prevalence and consequences of unmet need for ADL assistance in elderly persons.
The use of, and changes in the use of. formal (paid) and informal care by elderly persons who are chronically disabled and living in the community was studied.
Estimates were made of the sources and volume of home care use for persons reporting chronic disability in the 1982, 1989, and 1994 National Long Term Care Surveys. Comparisons were made across disability intensity, survey data, and age.
The analyses showed changes over time in the sources of home care services. Generally, the combined use of both paid and informal home health care increased, whereas the use of either source of care alone decreased. The amount spent on formal care increased with disability level and age.
Use of formal sources of care by community disabled elderly residents increased, likely because of changes in the Medicare home health care benefits in 1989. Increased use of home health care was associated with the concurrent use of informal care.
This study sought to increase knowledge about the impact of rater role on the assessment of in-home supportive care. The authors compared the perspectives of care recipients and professionals on one aspect of the broad concept of quality of care in home care-the sufficiency of the amount of care provided by informal and formal caregivers.
Sufficiency of home care was assessed through concurrent elderly persons' self-report through telephone interview and nurse clinical report based on in-home interviews with the elder. Care was assessed in terms of the sufficiency of the amount of informal and formal assistance received to meet functional dependency needs. Statistical analyses compared the ratings of elder and professional.
Professional ratings of the sufficiency of care were significantly lower than those of the elderly care recipients. From the perspective of both care recipients and professionals, sufficiency of care was significantly related to coresidence of elder and caregiver, and to caregiver health.
Consistent with previous literature, rater role was found to influence the assessment of the sufficiency of in-home care. Researchers and providers should recognize that care recipient and professional ratings are not interchangeable.
This study examined the effects of an early interventive social service program on the subjective well-being, permanent institutionalization, and mortality risk of low-income community-dwelling elders.
From a waiting list for community-based services, 105 "moderately at-risk" community-dwelling elders were recruited. Forty of these persons were randomly assigned to receive the intervention, and the remainder did not receive the intervention. Participants were interviewed every 3 months for 18 months. Primary outcome measures were depression, satisfaction with social relationships, environmental mastery, life satisfaction, permanent institutionalization, and mortality.
No significant differences in sociodemographic or health characteristics were found between the intervention and control groups at baseline. Those elders who received the intervention had significantly higher subjective well-being and were less likely to be institutionalized or die than those in the comparison group across the 18-month period.
The results make a strong case for the importance of community-based programs to the well-being of elders. Practitioners and policy makers should continue the search for community-based programs that are cost-effective and improve the quality of life for elders.
The aim of this study was to identify health-related changes occurring between 1983 and 1990 that characterize and differentiate 1996 long-term care outcomes (no services, home care, nursing home) among people aged 85 years and older.
Variables capturing health-related changes between 1983 and 1990 in a cohort (N = 616) of Aging in Manitoba Longitudinal Study participants aged 85 years and older were used in a series of logistic regression models to identify factors that best predicted the use of long-term care services in 1996, controlling for age and sex.
Factors predicting home care use relative to no services included changes in self-rated health, income adequacy, and railings outside of the house. Factors predicting nursing home use relative to home care included age and changes in general life satisfaction. Factors predicting nursing home use relative to no services included age; previous service use; length of time in the community; and changes in income adequacy, type of housing, and state of mind.
These findings challenge assumptions about the linearity of the continuum of long-term care services, because different factors were shown to predict home care use than were shown to predict nursing home use.
This study analyzes home- and community-based services (HCBS) use patterns and determines the costs of purchasing in-home services comparable to those offered by SCAN(R), a Social HMO. METHODS. Administrative data on 8,229 nursing home certifiable members were used to profile use patterns; a telephone survey gathered data on the market value of these services. RESULTS. Frail Social HMO members used a variety of HCBS to remain independent at home. These individuals would spend an average of $4,900 out of pocket per year to purchase equivalent HCBS, if they were not enrolled in the Social HMO. DISCUSSION. Findings suggest that the costs of maintaining a Social HMO member at home are modest and affordable, yet offer a substantial benefit, particularly to low- and moderate-income older people. With the aging of the population, an integrated medical and social program, such as the Social HMO, offers a viable policy solution.
We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily living (ADL) functioning in different age groups in the elderly population.
All 77+-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists, and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria for dementia. The Katz index of ADL was used to measure basic functional status.
After adjustment for socio-demographic characteristics, the oldest women (90+ years) had higher disability prevalence and a tendency for higher long-term disability incidence. Women aged 85+ years also had higher morbidity prevalence. Mortality among disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77-84 years).
We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival with slight disability earlier in adult life.
Both developing and major developed countries of the world are facing the global aging of their citizenry. The United States and the People's Republic of China each share in this phenomenon. The rapid growth of their aging populations comes as both countries are experiencing a sustained period of economic stability with an accompanying drop in fertility rates (Coale & Watkins 1986; Dyson & Murphy 1985). Together with longer expected life spans in both countries, these factors have caused a shift in the population structure which will result in increasingly large portions of the population who will potentially require assistance with ADL's and/or long term care (Olson 1990; Kennedy, LaPlante & Kaye 1997). The careful assessment and interpretation of available data to define the actual extent of need should be part of a process to help guide each country as they prepare for the future.
To determine how unmet needs for activity of daily living tasks influenced nursing home placement, death, or loss to follow-up in dementia.
An 18-month longitudinal design, with interviews administered every 6 months.
Eight catchment areas in the United States.
Five thousand eight hundred thirty-one dementia patients and their caregivers were included at baseline.
Measures of sociodemographic context of care; functional, cognitive, and behavioral status of care recipients; caregiver stress and well-being; and formal and informal resources served as covariates. The independent variables of interest were unweighted unmet care need scores and unmet need scores weighted by importance and severity in a prior sample of older consumers of long-term care. Outcomes included nursing home placement, death, and loss to follow-up.
Cox regression models suggested that greater unmet need was predictive of nursing home placement, death, and loss to follow-up. These results were apparent when the unweighted and the weighted scores for unmet need with activity of daily living dependencies were used.
Unmet need may be useful in identifying dementia care recipients at risk for nursing home placement and death. Further study of unmet need is needed to effectively assess and target intervention protocols during the course of dementia.
Although a relationship between marital status and mortality has long been recognized, no summary estimates of the strength of the association are available. A meta-analysis of cohort studies was conducted to produce an overall estimate of the excess mortality associated with being unmarried in aged individuals as well as to evaluate whether and to what degree the effect of marriage differs with respect to gender, geographical/cultural context, type of non-married condition and study methodological quality. All included studies were published after the year 1994, used multivariate analyses and were written in English. Pooling 53 independent comparisons, consisting of more than 250,000 elderly subjects, the overall relative risk (RR) for married versus non-married individuals (including widowed, divorced/separated and never married) was 0.88 (95% Confidence Interval: 0.85-0.91). This estimate did not vary by gender, study quality, or between Europe and North America. Compared to married individuals, the widowed had a RR of death of 1.11 (1.08-1.14), divorced/separated 1.16 (1.09-1.23), never married 1.11 (1.07-1.15). Although some evidence of publication bias was found, the overall estimate of the effect of marriage was robust to several statistical approaches and sensitivity analyses. When the overall meta-analysis was repeated with an extremely conservative approach and including eight non-significant comparisons, which were initially excluded because of data unavailable, the marriage protective influence remained significant, although the effect size was reduced (RR=0.94; 0.92-0.95). Despite some methodological and conceptual limitations, these findings might be important to support health care providers in identifying individuals "at risk" and could be integrated into the current programs of mortality risk estimation for the elderly.
This research aims to further current understanding of gender differences in old age mortality. In particular, it assesses the relative importance of health behavior and baseline health conditions in predicting the risk of dying, and how their effects differ between elderly men and women. Data for this research came from a prospective study of a national sample of 2,200 older adults in Japan from 1987 to 1999. Hazard rate models were employed to ascertain the interaction effects involving gender and health behavior (i.e., smoking and drinking) and baseline health status. Gender differences in old age mortality in the Japanese are quite pronounced throughout all of our models. In addition, interaction effects of gender and smoking, functional limitation, and cognitive impairment, indicate that females in Japan suffer more from these risk factors than do their male counterparts. Failure to adjust for population heterogeneity may lead to a significant underestimation of female advantage in survival. The inclusion of health behavior and health status measures only offsets a limited proportion of this gender differential. The increased mortality risk due to smoking, functional limitation, and cognitive impairment among elderly Japanese women suggests that narrowing of gender gap in mortality may be due to not only changes in the levels of these risk factors but also their differential effects on men and women.
The aim of this study was to examine the trend of hospitalisation amongst the elderly in urban China and analyse the main socio-economic factors which are affecting the use of inpatient care.
Data from the Chinese national household health interview surveys conducted in 1993, 1998 and 2003 were analysed. The following variables were selected: gender, health insurance coverage and household income.
Elderly people with insurance are more likely to use inpatient services than those who were not insured. Elderly people in the low income group are less likely than ones in the high income group to use inpatient services. Non-hospitalisation is more common amongst elderly women than elderly men and amongst the non-insured. The likelihood of elderly people in the low income groups not using inpatient services has increased dramatically from 12% in 1993 to 134% in 2003. Financial difficulty appeared to be the most common reason for not accessing inpatient care, particularly for elderly people without health insurance.
Elderly people with low income, without health insurance, and women appear to be more vulnerable in their access to inpatient care. Appropriate policies could be developed to protect these groups of people from high health care expenses.