Utilization willingness of institutional care between disabled and non-disabled seniors: evidence from Jiangsu, China

As the world’s most populous country with the largest number of aging population [1], China has experienced an unprecedented aging process because of extending life expectancy and reducing mortality. In 2016, 16.7% of Chinese population (230.86 million) were aged 60 and above [2]. The older adults are predicted to account for 33% of the total population in China by 2050 [3]. With increasing and aging population, it is a persistent challenge for China to take better care of elders, especially disabled seniors. The disabled seniors refer to those older adults with activity of daily living (ADL) disability, which is assessed by instruments using the International Classification of Functioning, Disability, and Health framework [4]. A nation-wide sample survey indicated that there were 40.63 million disabled seniors in 2015, accounting for 18.3% of the total older adults in China [5].

Despite the increasing percentage of elders, supportive functions of family are diminishing. Filial piety is the basic norm in the Confucian doctrine [6], which means that adult children have responsibility to take care of older people. However, supportive functions of family to take care of older adults are immensely weakened due to decreasing family size and increasing demographic shift [7, 8]. “4:2:1”family structure (four grandparents, two adult children, and one grandchild) poses a dilemma for the adults who have to look after four parents and take care of one child at the same time [9]. The phenomenon is likely to become even more pressing in the near future with the implementation of universal two-child policy.

Due to diminishing supportive functions of family and rapid growth of older adults, especially the increasing percentage of disabled seniors in China [10], exploring the willingness of institutional care and its influential factors are of high priority. Several previous studies have identified determinants of willingness for institutional care, such as age [11, 12], gender [13], income [11], education [12, 14], marital status [11, 12], living arrangements [11‐13], non-communicable disease (NCDs) [15], and insurance [16]. However, few studies have explored the willingness of institutional care among disabled seniors [17], and no studies have compared such willingness between disabled and non-disabled seniors in China [18]. To remedy the situation, this study aims to explore the disparity in utilization willingness of institutional care between disabled and non-disabled seniors in China. To do so, we have following specific objectives. First, we will compare the preference for institutionalized care between disabled and non-disabled seniors. Second, we will identify influential factors of the willingness for institutional care among disabled and non-disabled seniors separately.

Based on the cross-sectional study conducted in Jiangsu,, our study compared the willingness of institutional care between disabled and non-disabled seniors in China and explored determinants in two subgroups separately. To our knowledge, it is the first study that focuses on the research subject above. Our findings showed that the willingness for institutional care among disabled seniors was significantly higher than non-disabled old adults.

Our study found that 14.2% of seniors chose institutional care. The percentage was lower than 45% which was reported in America [27] and 16.7% demonstrated in Taiwan [28]. Compared with studies of other provinces, the proportion was also lower than Beijing (30%) [29], Henan (16.1%) [16] and Guizhou (38.5%) [14]. However, it was higher than Shandong (8.5%) [30] and Zhejiang province [31]. In different circumstance, there is a large disparity of preference for institutional care among the seniors.

Consistent with other studies [32, 33], the result of our study demonstrated there was a significant difference in willingness of institutional care between two subgroups. The proportion of disabled and non-disabled seniors who preferred institutional care was 22.6 and 12.6% separately. However, another study [18] which revealed that disabled seniors were less likely to choose institutional care. One possible explanation is that attitudinal changes towards institutional care is happening in China in recent years [34]. More and more aging adults, especially disabled seniors recognize that institutional care is a good option for them because of the poor physical status, diminishing family size and reducing care functions [17, 32]. Another explanation may be the improvement of institutional service for seniors. Particularly, integrated care in some nursing home which combined medical care with nursing services is preferred by disabled seniors with high household income. Furthermore, the support of government is a favorable objective factor. This finding suggests that it is urgent to make and modify different supporting policy for disabled and non-disabled seniors separately.

Similarly, the finding in this study was that household income level significantly determined the utilization willingness of institutional care both in disabled older adults whose household income was corresponding to Q3 and non-disabled seniors whose household income belonged to Q2. There are two possible explanations for such output. First, older adults with high household income would pay more attention to health status and quality of life, so the institution with better medical care and nursing service [35, 36] is favored by older adults, especially the disabled ones with poor mental and physical condition. However, disabled seniors with higher household income which are enough to afford private professional care may have other options other than institutional care [37]. Second, many poor seniors have to give up their idea of institutional care because of financial insolvency, but if older people are the poorest ones, the willingness of institutional care may increase because the country is guaranteeing the rights of them through policy orientation. The finding indicates that maybe the government should pay special attention to the willingness of institutional care among middle-income seniors, which is an important question worthy of further exploration.

Furthermore, the study demonstrated that the preference for institutional care of disabled seniors was also found to be significantly related to three indicators including age, living arrangement, and education, which was consistent with previous studies [17, 18]. Education exerts a statistically positive effect on the willingness. The seniors with better education are open-minded, who will be easily to accept the new idea in view of diminishing family size and increasing geographic mobility [35]. In addition, disabled seniors living alone were more likely to choose institutional care because they find it hard to obtain informal support [30, 38].

Interestingly, age had a negative impact on the willingness for institutional care among disabled seniors. Essentially, with the growth of age, physical and psychological health of old adults become poor, leading to high demand and willingness of institutional care. However, the result of the study is opposite, which may be explained by Chinese traditional culture and changes of family structure [39]. Most of the oldest old tend to reject institutional care because of traditional family norms, intense loneliness, and extreme insecurity causes. Meanwhile, the young older people are more likely to accept the concept of modern pension institution [40]. The findings should, therefore, give an impetus to attach importance to the traditional culture and family concept in the study of willingness to live in eldercare institution.

Parallel to other studies [15, 18], we found that the non-disabled seniors who suffered from NCDs were more likely to prefer institutional care. The possible reason is that some NCDs are strongly related to worse physical condition which needs professional institutional service, including dementia, cardiovascular diseases and arthritis [41, 42]. According to the WHO Global Status Report (2010), NCDs are the leading causes of mortality and disability globally [43]. China, as the most populous developing country, has experienced the heavy burden of NCDs, accounting for 70% of total disease burden and 80% of total death [44]. However, for disabled seniors, 94.3% among them had NCDs according to the sample, leading to the possibility of neglecting the effect of NCDs. The finding shows that it is urgent to do further research to have a better understanding of epidemiology of NCDs among older adults.

This study has some limitations. Firstly, the information including the economic status and willingness of institutional care were self-reported, leading to the possibility of bias. Secondly, a cross-sectional design was adopted in our study to illustrate the relationship between willingness of institutional care and ADL disability difference rather than causality. Thirdly, some important variables are unavailable in the current study, such as the understanding of the institutional care [45], information of the offspring [17] and the psychological status [13, 16], which are the research directions in the future..

This study showed that the willingness for institutional care among disabled seniors was significantly higher than that among non-disabled ones. Household income was found to be an important determinant for the willingness in both disabled and non-disable seniors. Additionally, age, living arrangement, and education were predictors for willingness among disabled seniors. Non-disabled seniors who had NCDs were more likely to choose institutional care. According to the findings, several countermeasures should be put forward. Targeting policies should be made or modified to satisfy various demands of the disabled and non-disabled seniors separately.