Background
Long-term care (LTC) needs primarily refer to the services and support that individuals may require for medical care or for assistance with the basic activities of daily living (ADLs) such as bathing, eating, and dressing. Unmet or under-met needs occur when LTC is unavailable or is insufficient to meet the needs of an individual [
1,
2]. In contrast to older adults who receive proper LTC, those who have unmet needs have a lower quality of life [
3], greater challenges and vulnerabilities associated with daily living activities [
4], more physician and emergency-room visits and more hospitalizations [
5], more hospital readmissions [
6], increased psychological stress [
7], and a higher rate of mortality [
8]. These findings suggest that the issue of unmet needs is important in the study of LTC, and that identifying factors associated with unmet needs is particularly crucial in reducing the risk of poor health outcomes.
Previous studies have examined factors associated with unmet needs in LTC [
1,
3,
5,
9-
13]. These studies have shown that low educational attainment, low income, not having a marital partner, living alone, ADL disabilities, cognitive impairment, and having fewer formal or informal resources available were factors associated with having more unmet LTC needs. These significant factors can be summarized by Andersen’s behavioral model of health services use [
14]. In this framework, factors that affect the use of health care services are classified into three broad categories: predisposing factors (demographics), enabling factors (resources), and need (e.g., illness level).
While previous studies have examined the factors described by Andersen’s model as well as other factors, some limitations exist. First, with a few exceptions [
1,
15], most previous studies were conducted in Western countries. Second, the few studies that have been conducted in mainland China (hereafter China) are very limited in depth and scope; in most cases the studies were not based on nationwide samples (e.g., studies conducted only in Shanghai) [
16], and the research design for most of the studies in China did not consider factors from all three of Andersen’s broad categories [
1]. Third, the sample size of the oldest old (age 80+), who tend to need the most care, was limited and therefore under-represented in previous studies. Fourth, potential differences in rural and urban areas of China have not been thoroughly examined. Research has shown that factors associated with the prevalence of ADL disabilities differ between rural and urban residents [
17]; thus, the unmet needs associated with ADLs may also differ for these two groups in China.
As a transitional developing country, China is facing acute challenges in providing the elderly with LTC services. These challenges have been attributed to the dramatic demographic, socioeconomic, and family structure changes over the last several decades [
16,
18]. The number of people aged 65 and older is projected to grow from 90 million in 2000 to 300 million in 2050 [
19]. It was estimated that, in 2005, there were about 5.7 million (5–6%) Chinese elderly aged 65+ who had at least one difficulty with ADLs and needed LTC; this number could reach 27 million in 2050 [
1]. Given these projections, it is imperative to find ways to provide LTC for this large and growing population. Analysis of recent longitudinal data is particularly important to produce results that may affect policies that address the challenges that the traditional family care system faces. Although China has launched some policy initiatives to improve the LTC system, institutionalized care, paid home care, and community-based care services still remain limited [
18]. Many of these services cannot provide professional and skilled nursing care [
16,
18].
The model of elderly care in China is based on the traditional norm of filial piety [
20]. In keeping with this tradition, LTC is predominantly provided by family members [
1]. However, the availability of potential caregivers is declining due to changing demographic trends, the weakening of traditional values, greater geographic mobility, and improved gender equality [
1,
16,
18,
19,
21]. First, declines in both mortality and fertility have not only accelerated population aging but also decreased the size of families. Second, Westernization, modernization, and individualization have eroded the core traditional value—filial piety. The impact of these changes has been to shift family structures from the traditional extended family to the nuclear family, decreasing the level of intergenerational support available. Finally, increased geographical mobility means fewer family members live nearby to support elders, and increased participation of women in the labor force means they are less available to be primary caregivers. Both of these changes have further contributed to the decline in the number of available caregivers and have made the informal elderly-care system even more vulnerable.
Rural–urban residency also plays an important role in LTC needs in China, given the substantial disparities in terms of socioeconomic, medical, and care resources between rural and urban areas. The household registration system (
Hukou), established in 1955, divided the Chinese population into rural and urban sectors, with policies favoring the urban sector [
22]. This system not only limited migration from rural to urban areas, but also limited job opportunities, housing opportunities, pension coverage, and access to medical resources for rural residents, thus creating large disparities between rural and urban areas [
23]. As a result, rural residents are less likely to be able to afford formal care such as institutionalized care or private care/services [
24]. Even if rural residents can afford formal services, availability is limited, and rural residents tend to be more comfortable following the traditional norms of filial piety [
1,
25]. Therefore, rural residents are more likely than urban residents to rely on family members to provide care, and thus are more likely to experience unmet care needs.
Given the large size and high growth rate of China’s elderly population; the fact that a sizable portion of LTC is provided by family members; the vast urban–rural differences in resources, availability, and accessibility; and the growing numbers of elderly in need of LTC [
1,
15], it is imperative that we gain a deeper understanding of unmet needs and their associated factors in this transitional country. By using a nationwide survey focusing on the oldest old population and employing Andersen’s framework, the present study aims to investigate: (1) the prevalence of unmet needs among the oldest old in China, (2) the factors associated with unmet needs in LTC, and (3) whether there are differences between urban and rural areas.
Discussion
Based on the 2005, 2008, and 2011 waves of the CLHLS, this study examined unmet needs in LTC and associated factors among the oldest old Chinese. The significant factors associated with unmet needs can be divided into three categories based on patterns for rural and urban residents: (1) factors significant for both rural and urban residents: economic status, timely medication, someone other than a family member as the primary caregiver, caregivers’ willingness to provide care, self-rated health, and self-rated life satisfaction, (2) factors significant only for rural residents: gender and cognitive impairment, and (3) factors significant only for urban residents: age, a son/daughter-in-law as the primary caregiver, expectation of access to community-based service, severe ADL disability, and optimism. We will highlight and discuss some important factors in each of these three categories below.
Common factors
Our results show that caregivers’ willingness, type of primary caregiver, and economic status were especially important for both rural and urban residents. Caregivers’ willingness to provide care was the most influential factor associated with unmet needs, a finding that is in line with previous studies [
15]. Clearly, caregivers’ willingness to provide care can influence care quality and thus indirectly impact the unmet needs of the oldest old. Receiving care from unwilling caregivers may make care recipients feel less satisfied with the care provided, and thus more likely to report unmet needs. The risk of having unmet needs was also higher if someone other than a family member was the primary caregiver (compared with a daughter/son-in-law as the primary caregiver). This is understandable because familiarity and trust are necessary for the oldest old to accept assistance in personal ADLs such as bathing and toileting [
15]. Further, because there is a lack of professional, skilled nursing care services in both rural and urban China [
16,
18], family members are still likely the best available care providers. Economic status was associated with both rural and urban residents’ risk of having unmet needs, which is consistent with previous studies [
3,
5,
9,
15]. Oldest old who are more financially secure generally have greater access to medical resources and are better able to pay for health care services, thus lowering their risk of having unmet needs.
Rural factors
Our findings show that being male and cognitively impaired were associated with more unmet needs among rural but not urban oldest old. Consistent with previous literature [
15], in rural areas men had a higher risk of having unmet needs than women. Research has found that women tend to receive fewer hours of care than men and are more likely to be caregivers even when they experience their own disability [
31]; this can be explained by sociocultural patterns such as the lower engagement of women in paid employment and the traditional association of women with caregiving roles [
31,
32]. This pattern is particularly strong in rural China. It is possible that rural women reported less unmet need because they had lower expectations for care and thus were more likely to be satisfied with the care they received.
We speculate that several factors that were not included in the analysis may explain why cognitive impairment was significant for rural but not for urban residents. First, diagnosis and treatment of cognitive impairment may be neglected in rural areas due to poor health literacy and limited access to medical services. Second, previous studies have suggested that lower caregiver education level is associated with lower quality of care [
33], thus increasing the likelihood of care recipients having unmet needs. Rural caregivers’ lower education [
34] may correlate with lack of caregiving knowledge, which might explain why there is a significant relationship between cognitive impairment and the risk of having unmet needs in rural areas.
Urban factors
The study found that several factors were associated with the risk of having unmet needs only for urban residents. These factors were type of primary caregiver, ADL disability, age, and optimism. Having a son/daughter-in-law as the primary caregiver was associated with greater odds of unmet needs compared to having a daughter/son-in-law as the primary caregiver in urban areas; in other words, daughters/sons-in-law provided better care than sons/daughters-in-law. A number of reasons could explain the advantage of daughters/sons-in-law as the primary caregivers in urban areas. Due to traditional divisions of labor and the nature of caregiving, women tend to take on more caregiving responsibilities [
31], and they also tend to be better caregivers than men [
35,
36]. Despite the fact that sons’ wives are women, parents tend to have a closer emotional tie with daughters than daughters-in-law [
36]; as a result, daughters are more likely to provide good care and parents are more likely to be satisfied with the care daughters provide. In contrast, the tension between daughters-in-law and mothers-in-law is the most frequent dispute in intergenerational relationships in China [
37]. Although daughters are predominately regarded as better caregivers, this study did not find that having a daughter as the primary caregiver was associated with a lower likelihood of having unmet needs in rural areas compared with having a son/daughter-in-law as the primary caregiver. This may be due to the rural oldest old’s suppression of needs [
38], because they may be used to hard living conditions and do not have or have limited access to community-based care services; thus, they are more likely to be satisfied with lower levels of care and make less of a distinction between the care they receive from a daughter/son-in-law or a son/daughter-in-law. In contrast, the urban oldest old tend to have higher expectations given their higher standards of living and thus are more likely to be satisfied with caregiving by a daughter.
Moreover, severe ADL disability was associated with a higher risk of unmet needs among urban residents but not rural residents. Supplementary data analyses (not shown here) revealed that the bivariate association between severe ADL disability and unmet needs was explained away by other health conditions and by regular exercise, especially the latter, in rural areas, but remained significant independent of regular exercise and other health conditions in urban areas. Further analysis showed that rural residents who regularly exercised were less likely to experience severe ADL disability compared with urban residents who regularly exercised. This study was not able to investigate why regular exercise would benefit rural residents more than urban residents because we lacked data on frequency, duration, and history of exercising. These uncontrolled factors should be considered in future studies.
Finally, age and optimism were both related to unmet needs for the urban oldest old. In contrast to previous studies [
1,
15], we found that older age was associated with a slightly lower risk of having unmet needs compared to younger age in urban areas. Older old residents, who may be less able to engage in daily activities, may require less assistance than younger old residents in urban areas. As discussed above, suppression of care needs and expectations in rural areas may explain why there was no age difference in unmet needs among rural oldest old. Likewise, optimism may be important for urban oldest old because they tend to have higher expectations for quality of life due to higher standards of living and community-based care services. In contrast, rural residents’ suppression of needs and lower expectations for receiving care likely negate the effects of optimism.
Limitations
The study has several limitations. First, availability of community-based care services is the only factor at the community level included in the study. Andersen and Davidson suggest that predisposing, enabling, and need factors should be measured at the community context level as well as the individual level in the framework of health care utilization [
39]. For example, lack of care resources in an area increases the risk for unmet needs among the elderly; if the dependency ratio of elders is high in an area, then the care resources in that area may be insufficient, resulting in more unmet needs. Therefore, given substantial regional variations in demographics, SES, medical resources, and health care resources in China, community-level variables related to demographics (e.g., proportion of elders with disabilities and dependency ratio of elders), SES (e.g., local government budgets for care services), and care resources (e.g., number of home service workers) should be included in future studies [
12].
Second, this study lacked data on care-resource factors such as the number of hours of care received and primary caregivers’ characteristics such as age and education. The effect of a caregiver’s age on the risk of having unmet needs is stronger in the case of the oldest old because their caregivers, mostly spouses or children, are also old or very old and may also need assistance with ADLs. Additionally, people with caregivers who have low levels of education are more likely to have low quality of care [
33], likely due to lack of knowledge and competence. Future studies should also include these variables as factors associated with unmet needs, especially when focusing on rural–urban differences.
Third, this study analyzed pooled data from the 2005, 2008, and 2011 waves of CLHLS. Given the rapid speed of urbanization in contemporary China, it is possible that some rural areas in 2005 had been transformed into urban areas by 2011. This possible change in the classification of residences may introduce a bias to the estimate of unmet needs in rural and urban areas. However, we do not think the major results are affected by this bias because the change in the classification of residences should not be large within a six-year period.
Conclusion
Many predisposing, enabling, and need factors in the Andersen model were significantly associated with unmet LTC needs among the oldest old in China. Economic status and caregivers’ willingness to provide care were the most important enabling factors for both rural and urban oldest old. Predisposing factors such as age and gender, enabling factors such as type of primary caregiver, and need factors such as ADL disability and cognitive impairment differed between urban and rural oldest old, which may be mostly explained by differing expectations for care which stem from differences in their standards of living and access to care resources.
These findings have important implications for policy makers. Since economic status plays an important role in shaping unmet needs among the oldest old, providing financial assistance or some insurance coverage would be an effective way to help elders meet their needs. Improved economic conditions would enable the elderly to have access to medical services, including timely medical treatment, and to more care resources such as paid home care, thus decreasing their unmet needs. This assistance is particularly important for rural residents as they have lower SES and a higher prevalence of unmet needs.
Given the decline in both willingness and availability of caregivers, it is imperative to increase the development of formal care services such as paid home-based care and community-based care services. Currently available formal care accounts for less than 10% of all LTC in China [
1]; moreover, the cost of formal care is unaffordable for most elders [
1,
24]. Therefore, formal care has not been able to replace or supplement family support [
1,
18]. As this study shows, willingness of caregivers is the strongest risk factor for unmet needs among the oldest old. Providing care for people at very old ages—the group who need the most care given their poor relative economic and health status compared to the younger old—can exert heavy physical, psychological, and financial burden on caregivers. Care burden can not only negatively affect caregivers’ quality of life and attitudes toward providing assistance, but also discourage potential caregivers from being willing to provide care. Nevertheless, although the willingness of caregivers to provide care is declining, family care will probably still prevail for the near future. Given the influence of filial piety, families may be reluctant to place their old family members in an institution where care is provided by strangers [
18]. Developing home-based and community-based services will help reduce the burden on informal caregivers while also contributing to the construction of a long-term care system.
Competing interests
The author declares that she has no competing interests.