Introduction
Population ageing has become a global issue and the situation in China is serious. A total of 264 million people aged 60 and above live in China in 2020, accounting for 18.7% of the total population, and this number is expected to reach a peak of 487 million in 2053 [
1]. As the older population grows and life expectancy increases, improving the health-related quality of life (HRQOL) has become one of the overarching goals of the World Health Organization’s (WHO) ‘Healthy People 2020’ framework and deserves a public health priority [
2]. HRQOL is a multidimensional indicator of health that includes physical function, mental health and an individual’s perceived socially relevant role over time [
3]. HRQOL has been shown to be associated with multiple adverse health events, for example, as HRQOL decreases, health service utilization increases significantly [
4]. Low HRQOL increases health care costs and economic burden [
5]. Meanwhile, HRQOL is also an important independent risk factor for mortality in the elderly [
6]. Therefore, exploring risk factors for HRQOL deserves more attention, which is essential for developing promising interventions to improve overall well-being of older people in later life.
The factors affecting HRQOL are also multifaceted, including age, chronic illness, average monthly income, and medical expenses [
7‐
9]. Of which, financial hardship is associated with deterioration in a range of health outcomes in later life, which exacerbates HRQOL [
10]. The financial hardship caused by high medical costs is often catastrophic. Catastrophic health expenditure (CHE) is defined as health expenditure that exceeds a predetermined percentage of a household’s ability to pay for health care [
11]. Previous studies have focused more on the relationship of CHE (or the financial burden of healthcare) with mental health [
12‐
14]. Some studies have shown that high medical expenditure was associated with poor quality of life in patients with type II diabetes [
15]. A study from Korea indicated that people who experienced CHE tended to report lower health utility values compared to those without CHE [
16]. Existing studies have mostly focused on the impact of chronic disease or health insurance on the relationship between CHE and HRQOL, and there is a lack of research on the role of caregivers of older adults. Although the association between CHE and HRQOL has been confirmed, the underlying mechanism is still unclear.
In China, as formal care services are not yet widely available, most older people have to rely heavily on informal care services provided by spouses, adult children or other family members [
17]. Previous research [
18] has shown that a network of caregivers, including adult children and friends, moderates the relationship between cancer-related financial difficulties and quality of life. The impact of this connection may vary according to the type of support provided, interpersonal dynamics, and other factors, where differences in the roles of different caregivers have not been clarified. Prior research confirmed that financial aid from their offspring played a vital role in the quality of life for parents [
19]. Tang et al. proposed that emotional support from adult children were effective in reducing the risk of CHE in middle-aged and older families [
20]. These studies found that the daily care provided by adult children has a positive effect on the health of the elderly, which can reduce the impact of financial difficulties and improve the quality of life of the elderly. However, care provided by other people may lead to different results. Older people may react negatively to the daily care provided by their spouse, and these negative reactions may affect HRQOL [
21]. The effect of the care services provided by community or professional nursing staff on HRQOL in older people may not be significant [
22]. Few studies have explored whether the caring role of adult children moderates the relationship between CHE and HRQOL in older adults, it remains an undervalued and understudied topic.
The objectives of this study are as follows. First, to examine the relationship between the experience of CHE and HRQOL in older people. Second, to explore whether the daily care provided by adult children is a moderator of the relationship between CHE and HRQOL. This study will provide new perspectives to improve the quality of life of older people.
Discussion
This study explored the association between CHE and HRQOL, and the role of daily care provided by adult children in moderating this relationship among older adults. The results of the study showed that the experience of CHE was associated with poorer HRQOL. Furthermore, the relationship between CHE and HRQOL is moderated when the primary caregiver of older people in their daily lives was their adult children. The daily care from adult children reduced the possibility for adverse health effects from CHE.
Our study showed that the incidence of CHE among older people in Shandong province was 60.5%, which was higher than that in previous studies in China. For example, a study using data from China’s Fourth National Health Services Survey (2008) found that the incidence of CHE was 13.0% [
33]. It was also higher than the incidence of CHE in a cross-sectional survey conducted in Shandong in 2012 with the prevalence of 44.9% [
34]. This may be due to the accelerated aging process and heavy use of health care services by more elderly people, who have lower incomes, thus resulting in an increased incidence of CHE. Another reason might be due to the conservative regional culture in Shandong area, especially in the elderly group. Faced with external investigators, the elderly were reluctant to disclose their real income and expenditure for reasons of personal privacy protection. They tended to underreport their income and overreport their expenditure, which would result in a high calculated CHE prevalence.
Our findings indicated that experiencing CHE is negatively associated with HRQOL in older adult. Respondents who experienced CHE scored significantly lower on each EQ-5D domain and had lower health utility scores than individuals who did not experience CHE. Similar to the previous study, research on the general population showed that people with CHE tended to have lower health utility values than those without CHE, and this association was more pronounced among people with chronic conditions [
16]. Some scholars had found that the presence of CHE was associated with poorer physical and mental health among both rural and urban older people in China [
14]. Older people who have experienced CHE bear greater subjective and objective financial burdens, and have increased risk of poverty, making them spend less on other aspects of their lives, or reduced the number of medical visits for fear of having to pay high medical costs again, which further lowered health utility values of older people [
35].
Our study also showed that the daily care from adult children moderated the association between the CHE and HRQOL. The influence of CHE on HRQOL was larger among older adults who were cared for by their adult children than those who were cared for by non-adult children. Specifically, caregivers appeared to buffer the relationship between CHE and HRQOL. Several possible explanations for this finding are as follows. First, increasing intergenerational contact with adult children not only promotes intra-family relationships, but also significantly improves HRQOL of older people [
36]. Second, adult children can provide financial and emotional support to their ageing parents. Transfer payment from adult children significantly reduce poverty among older people [
37]. Evidence from rural China suggested that financial support provided by adult children also improves the quality of life of the elderly [
38]. Emotional support from adult children can enhance the well-being of older people, improve their life satisfaction [
39] and therefore improve HRQOL levels [
40]. Third, adult children can share a lot of physical labor for their parents. They are younger and stronger and have more advantages in daily activities, which can help the elderly with heavy work, thus reducing the physical burden of older people [
41]. Other carers, such as spouses or relatives, may not be able to provide the desired level of care due to inadequate knowledge of disease management, excessive caregiving burden or disagreements with the older person [
42]. In conclusion, older people’s adult children are able to assist them to a large extent in their daily lives, both materially and emotionally. When CHE occur, adult children can compensate their parents financially to ease the financial burden and help them get through a difficult time in life as quickly as possible [
37]. Spiritually, adult children can provide emotional support to their parents [
43], reduce the psychological distress caused by CHE and improve the HRQOL in the elderly.
Table
1 showed that the incidence of CHE was higher among older adults who have purchased critical illness insurance (62.4%) compared with those who have not (37.6%). This may be because the starting payment line of critical illness insurance is relatively high, and the elderly cannot reach the reimbursement amount for a single medical treatment [
44]. Moreover, there is still inequality in medical insurance reimbursement level, services obtained or quality of care, so that the rights and interests of the elderly who have bought insurance have not been effectively protected [
45]. Secondly, due to the limited economic conditions or insufficient medical level in the area, the uninsured families actively or passively give up the medical treatment, and there are cases where they should have been hospitalized but were not, their medical needs are not met, so that the risk of CHE in this group of people is underestimated [
46].
Based on the findings of the study, we recommend that it is necessary for policy makers to develop intervention mechanisms to protect vulnerable groups from financial risks and thus reduce the incidence of CHE. Firstly, future health policy reforms should take greater account of the affordability of health services and reduce the price of treatment for major diseases and chronic conditions. Secondly, the proportion and scope of health insurance reimbursement should be increased to reduce out-of-pocket costs. For the common chronic diseases and the corresponding treatment drugs in the elderly population, the government should consider setting up reasonable reimbursement rules. Thirdly, as the primary caregivers of the elderly, adult children should pay timely attention to their parents’ physical and psychological status, increase emotional communication, and improve the living conditions, so as to improve the HRQOL of the elderly.
Several limitations of this study also need to be acknowledged. First, due to the possible reciprocal causal relationship between CHE and HRQOL, the cross-sectional data used in this study could not be investigated for rigorous causal studies. We therefore hope to test this relationship using better data and methodology in the future. Second, since self-reported health care expenditure and household income may lead to recall bias, especially in older adults, they are more inclined to overestimate their expenditure and report income to less. Third, this study was applied to older people in Shandong Province, China, and the applicability of the findings to other populations will need to be tested in future studies. Finally, due to the limitations of the sample data used in this study, we did not conduct a classification study of older adults without any caregivers, and in the future, we may screen these special populations on a national level.
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