Factors related to the internal social capital of elderly-caring social organizations: a cross-sectional study in Chongqing, China

This study was approved by the Biomedical Ethics Committee of Anhui Medical University (No. 20180181) and was officially launched in Chongqing from July to August 2022.

Chongqing is located in the southwestern part of China. In 2021, the population aged 65 and above in Chongqing was 5.70 million, accounting for 17.75% of the total population. This proportion is still on the rise, indicating a continuous deepening of population aging in the region [16]. In 2022, the Chongqing Municipal People 's Government issued the ' 14th Five-Year Plan for the Construction of Chongqing 's Pension Service System (2021–2025) ' to accelerate the construction of a multi-level pension service system comprising home-based care, community-based care, fully developed institutions, and medical care. First of all, we used a multi-stage stratified random sampling method. In the first stage, random sampling was conducted in 26 districts of Chongqing, and four districts (D, J, T and R) were selected as survey points. In the second stage, we randomly sampled 80 organizations from the list of ESOs provided by the local civil affairs bureau. At the third stage, we randomly selected a superintendent of an institution to conduct a more precise investigation of the organization's basic situation, thereby enhancing the accuracy of the study. The superintendent includes president, director, head, curator, and other personnel, who had a thorough understanding of the organization. The investigators are comprised of graduate students from Anhui Medical University and Chongqing Medical University. Regarding the questionnaire content, our investigators underwent professional training prior to commencing the survey. This training aimed to enhance their comprehension of the questionnaire, ensuring a smoother and more efficient survey process. The staff from the local Civil Affairs Bureau guided the research team to administer the questionnaire to the superintendent organization. Preceding this, the investigators introduced the basic content of the questionnaire, ensured that the content of the investigation would not be misunderstood, and obtained the informed consent of the respondents. We had rigorously managed and monitored the data collection and processing process, ensuring that each selected participant actively responded to our survey questionnaire or engaged in relevant data collection. After rigorous screening, all the responses from the selected sample were included in the data analysis.

In this study, we developed an internal social network scale by combining the social capital assessment tool developed by the World Bank and previous research. At the same time, experts reviewed and approved the content of the scale. The scale aims to reflect the basic characteristics of Elderly Service Organizations (ESOs) in Chongqing [17‐20]. The scale is comprised of two sections, focusing on both the organizational basic information and the internal social capital of ESOs. For the measurement of internal social capital, there were five dimensions: social trust, social support, social network, social norms, common language and common vision of which included 26items. In each item, we used the Likert five-point scale to measure and score, where 1 = “completely disagree”,2 = “not agree”,3 = “general”,4 = “partially agree”,5 = “completely agree”. To comprehensively reflect the status of internal social capital of ESOs, We calculate the total score of internal social capital (0–130) by summing up the scores from the five dimensions. In performing the binary logistic regression, we dichotomized the scores of total score and each dimension by taking the median as the cut-off: social support (high [≥ 25] and low [< 25]), social network (high [≥ 24] and low [< 24]), social trust (high [≥ 25] and low [< 25]), shared language and shared vision (high [≥ 25] and low [< 25]), social norm (high [≥ 25] and low [< 25])and total score (high [≥ 120] and low [< 120]). The overall Cronbach’s α coefficient for the scale was 0.915, indicative of good reliability and representativeness.

The basic situation of the organization we investigated included per capita floor area (≤ 50, > 50), founding time (≤ 2,3–8, ≥ 9 years), full-time staff (≤ 15, 16–30, ≥ 31),management employees (≤ 3, 4–6, ≥ 7), have volunteers (Yes, No), types of registration (1, > 1), operation pattern (public construction and operation, public construction and private operation,private construction and operation), types of services (≤ 3, 4–6, ≥ 7) self-care (Yes, No), total care (Yes, No), special care (Yes, No), home care service for older adults (Yes, No).

To ascertain potential influencing factors, we performed univariate analysis and binary logistic regression using IBM SPSS Statistics 26.0. Since the data did not conform to the properties of normal distribution, we used the composition ratio N (%), the median number and interquartile range to describe the basic composition of the data. Next, different single factor analysis methods were adopted according to whether the independent variables are binary variables. The two-category variables were tested by Mann–Whitney test to obtain the U value, and the three-category variables were tested by Kruskal–Wallis test to obtain the H value.

Studies had shown that a binary logistic model can still be used for analysis with a small sample size [21‐23]. Five meaningful factors in the univariate analysis were included in the binary logistic regression (Special care, Volunteer, Types of services, Management employees, full-time employees). According to the median of the five dimensions, they were divided into high and low categories.

Fundamental state and the results of univariate analysis of the ESOs are shown in Table 1. We surveyed 80 institutions in Chongqing, which consisted of 67(83.8%) A-type institutions and 13(16.3%) B-type institutions (A-type refers to social organizations engaged in elderly care services that have been filed or registered with civil affairs departments at all levels, providing comprehensive elderly care services. B-type refers to urban community elderly care service centers (stations) and rural township elderly care service centers, which only offer daily activities and dining services.). Among them, 49(61.3%) institutions covered an area of more than 50m².The institutions of ≤ 2 years were 33(41.3%), 21(26.3%) were established for 3–8 years, and residual 26(32.5%) were institutions ≥ 9 years. Most institutions 55(68.8%) had fewer full-time employees, about ≤ 15, and only a few institutions 9(11.3%) had more than 30 employees. For managerial roles, 49(61.3%) institutions had ≤ 3 managers, 20(25.0%) units had4-6 managers, and the remaining 11(13.8%) institutions had more than 6 managers. Additional descriptive analysis showed that on the types of services rendered, 57(71.3%) of the organizations offered more than 7 services, 25.0% offered 4–6, and the remaining provided only ≤ 3. More than half of the subjects 67(83.8%) had not recruited volunteers, and 67(83.75%) provided home care service for older adults and 67(83.8%) registered in various ways. Further analysis showed 22(27.5%) were in the category of public construction and operation type, 26(32.5%) were public construction and private operation, while 32(40.0%) were private construction and operation. The most common type of objects was self-care 79(98.75%), followed by total care 70(87.5%), and lastly by special care 35(43.75%).

In conducting the univariate analysis, the total score of internal social capital (the sum of the scores of the five dimensions) was held as the dependent variable, with the basic characteristics of the organization as the independent variables. It was observed that only full-time staff, managers, the number of volunteer services and professional care had a statistically significant association with internal social capital. As shown in Table 1.

To assess the relationship between the statistically significant independent variables from the univariate analysis and the derived dimensions of internal social capital, a binary logistic regression was performed. On the dimension of social trust, an improvement was seen in those institutions with receiving special care objects (p<0.001, OR = 0.047). Similarly with social norm, organizations which had special care objects (p<0.001, OR = 0.025), rendered 4–6 services (p<0.05, OR = 57.953) and hired 16–30 employees (p<0.01, OR = 24.247) showed more higher scores for social norms than else. In exploring the relationship between social support and significant variables from the univariate analysis, we found that providing special care (p<0.05, OR = 0.203) and the presence of volunteer staff (p<0.05, OR = 11.721) positively impacted social support score. ESOs that possessed 4–6 management employees were 52.422 times more likely to score high for social support (p<0.05, OR = 52.422). Accommodating special care objects and hiring 16–30 employees were significantly linked to the shared language and shared vision dimension (p<0.001, OR = 0.8) and (p<0.05, OR = 8.672), respectively. As shown in Table 2.

A positive correlation between specialized nurse and internal social capital was found. This interesting revelation to some extent provides explanation for previous studies which have observed that special care for reduced probability of negative events for older adults in nursing homes, such as physical injury (falls), malnutrition, constipation and incontinence, and chronic diseases. The results of our study proved the correctness of explaining the correlation from the perspective of internal social capital [24, 25]

ESOs which provide special care have higher requirements for staff than others. Special care is required to obtain relevant qualification certificates or receive professional training regularly. This perhaps explains the greater probability for quality care. Nevertheless, Jacob has argued in his research that there is a positive correlation between internal social capital within organizations and the quality of care provided by individual care workers, and that increasing manpower or the proportion of trained staff is not in itself a key factor [26]. Inspite of this, special care may play a certain role in improving social support. It is important to emphasize the fact that in ESOs who provide special care, due to the poor self-care ability of older adults, the proportion of caregivers is higher, which can bring spiritual and material support to older adults. Obviously, the provision of special care services is not a simple matter, he encouraged employees to continue to strengthen exchanges between, share experience, so as to better complete the work [27].

Our research suggests a connection between volunteer staff and internal social capital, and having volunteers often accompanies higher total scores of internal social capital. Dawn A. Marcus [28] argues in his paper that more than half of the volunteers will establish private contact with clients, which will also enhance the organization 's social support for older adults [28‐31]. In a qualitative study based on the SPIDER framework, it was shown that community health workers and volunteers can use their own social trust and social resources to do their work better. This was mainly attributed to the foreignness and sense of mission of volunteers. As ' outsiders ', volunteers can bring resources different from those within the organization, and older adults are more willing to share with them. Their participation has greatly enhanced the social support of the organization, and community support has an important impact on the long-term success of the organization [31].

Compared with organizations with ≤ 3 number of services, our research had shown that social norms and social capital score dimensions is high for institutions with 4–6 services. When ESOs provide 4–6 kinds of services, they will be more focused on implementing this service and specific operational specifications can be formulated for services within the organization. At the same time, due to the relatively small number of services provided, employees can focus on improving service quality and comply with organizational requirements. It has be identified that A previous survey we conducted in Anhui Province showed that the number of services provided by ESOs is also one of the determinants of the choice of nursing home for older adults [32]. This highlights the need for parity with respect to the number of services offered and the internal social capital of ESOs. A study based on China 's national conditions shows that ESOs need to balance the relationship between service quality and service type in their development, and gradually develop towards specialization, rather than blindly increasing full-time employees and service types [33]. This was partly consistent with our research results.

Institutions with 16–30 full-time employees were more likely to get higher scores on social norm, shared language and shared vision and total social capital compared to ESOs with less than 15 full-time employees. This finding contradicts previous studies have shown that there was no obvious relationship between full-time employees and social capital, while this paper revealed the hidden relationship between full-time employees and social capital [34]. This can be interpreted that when the number of employees in the ESOs is small, to accomplish tasks well, more communication and interaction between members are needed. While the organization exceeds a certain size, the more employees there are, the more detailed the division of labor will be, which reduces the opportunities for communication among the members of the organization.

The number of services and the number of full-time employees were two indicators reflecting the size of the company. In the field of enterprise efficiency, Dhawan has calculated and compared the average profit margins of small, medium and large companies with panel data of US listed companies from 1970 to 1989, and found that small and medium enterprises are more efficient [35]. And similar research results in the field of pension. A study based on China 's national conditions also shows that ESOs need to balance the relationship between service quality and service type in their development, and gradually develop towards specialization, rather than blindly increasing full-time employees and service types [33].

The core elements of internal social capital, including social networks, trust, support, norms, common language, and shared vision, are lacking in ESOs in the healthy aging service field. At the same time, internal social capital has the function of helping organizations acquire resources, improving organizational capabilities, and promoting organizational performance. Our study provides a new perspective and approach to explore strategies for ESOs to participate in healthy aging services. It also serves as an effective exploration in comprehensively addressing the various challenges faced by ESOs. By nurturing and enriching the stock of internal social capital in ESOs, promoting active and effective involvement of governments, multiple sectors, and ESOs in healthy aging services, it contributes to the positive interaction among governments, multiple sectors, and ESOs in achieving healthy aging objectives.