Reasons for underutilization of community care facilities for the elderly in China

Abstract

Background

China’s government has invested a great deal of resources to improve the coverage rate of community care facilities for the elderly. However, the facilities that have been built are underutilized.

Methods

Referring to the Anderson model, a framework for analyzing the utilization of community care facilities for the elderly was constructed. Descriptive statistics on survey data from 17 communities demonstrated the status of the utilization, and binary logistic regression analysis examined the influencing factors of the utilization.

Results

Built community care facilities for the elderly are underutilized and there are significant differences in the influencing factors of the utilization between daily care facilities, medical care facilities, recreation facilities, and spiritual comfort facilities.

Conclusions

The main reasons for the underutilization can be delineated as follows: (1) The demand for community care facilities is outstripped by the supply, resulting in a surplus; (2) Complex constraints on demand for facilities due to insufficient enabling resources; (3) Inadequacy of community care facilities in meeting expectations. (4) High substitutability of community care facilities; (5) Bureaucratic pressure hindering facility development. To address the underutilization of community care facilities, it is recommended to clarify the community responsibility boundaries for elderly care and the role that the market plays in community care facilities for the elderly.

Introduction

Background

An aging population presents a shared challenge for the international community. China has the largest elderly population in the world, and the size of it is growing rapidly. In 2000, China had stepped into the aging society category with a population of 130 million aged 60 and above, accounting for more than 10% of the total population. By 2021, according to national census data, the population aged 60 and above in China was more than 264 million and accounted for 18.7% of the total population [1]. It is estimated that the proportion of the elderly population will reach 31% by 2050 in China and that this situation will continue until 2100 [2]. To meet the needs of the elderly, the Chinese government invested a large amount of funds to increase the coverage of community care facilities for the elderly.

Community care facilities are designed as relevant places or buildings which aim to provide services and carry out various activities for the elderly in the community. They are usually based on public–private partnerships in which local governments provide construction funds and professional institutions operate the community care facilities for the elderly [3]. In the 1970s, the United Kingdom government pioneered the promotion of community care facilities as a component of the Thatcher reforms. Through local government subsidies, community managers constructed facilities to offer respite care and day care services for older adults opting for aging in place [4,5,6]. During the period between the 1990s and 2000s, the roles of community care facilities underwent expansion. In developed nations such as the United States, community care facilities extended their services beyond catering to disabled older adults, to also providing “Home-Based Primary Care” for the entire older adult population [7,8,9]. In the 2010s, Japan amalgamated community care facilities with health care, nursing care, and livelihood support to establish the Community-based Integrated Care System Model [10]. The increasing diversification of content is a prevalent trend in community care facilities globally.

China has extensively adopted the models of community care facilities prevalent in developed nations. Thanks to the strong promotion of governments at all levels, the coverage rate of community care facilities for the elderly in China has rapidly increased. As of 2022, all urban communities and more than half of rural communities were equipped with community care facilities in the developed region of Eastern China, in cities such as Shanghai, or provinces such as Jiangsu [11]. Even in Western China, community care facilities have a high coverage rate. For example, Shaanxi province established more than 3000 community facilities that covered 90% of urban communities and 80% of rural communities. However, investigations found that most of the established community care facilities for the elderly are underutilized and unsustainable. Rapidly increasing the coverage of community care facilities requires a large amount of capital investment in the short term while the available funds are not sufficient. Since the outbreak of COVID-19, it is difficult for local governments to provide operating funds for community care facilities [12]. Meanwhile, the number of elderly people utilizing established community care facilities is much fewer than the capacity of the facilities. The lack of capital inflows led to the inability of most community care facilities to operate normally. At the same time, most elderly people who need community care do not use, or have never even heard of, community care facilities [3].

In the meantime, numerous articles continue to suggest that China increase the construction of community care facilities for the elderly [13], arguing that the coverage rate of community care facilities remains a limiting factor in the development of home-based elderly care services [14]. Previous studies have found that urban–rural differences [15], economic accessibility [16], and community supply quality [17] can affect the utilization of community care services by elderly people. However, most existing research has focused on community care services, and there is still little research on the influencing factors of elderly people’s use of community care facilities.

To fill this research gap and correct the low efficiency and unsustainable issues in the construction of community care facilities, this article describes the current utilization status of community care facilities for the elderly, examines the influencing factors of elderly people’s use of community care facilities to explore the reasons for underutilization, and provides countermeasures and suggestions for achieving effective utilization.

Analysis framework

The behavioral model of health services use, or the Anderson model for short, created by Odin Anderson in 1968, is the most commonly used analytical model to study the use of medical care services by the elderly [17, 18]. At the initial stage of the Anderson model, the family was taken as the fundamental analysis unit to explore the reasons for differences in the use of medical services by different families. Predisposing characteristics, enabling resources, and need, as the factors influencing the family’s use of health services, constitute the initial structure of the Anderson model. Predisposing characteristics refer to the reasons that lead to an increase or decrease in an individual’s service utilization tendency, including demographic, social structure, and health beliefs. Enabling resources are factors that promote service utilization, including personal or family resources and community resources. Need is a direct cause that affects service utilization, including perceived need and evaluated need [19, 20]. Predisposing characteristics pass through enabling resources and needs in sequence, ultimately affecting the use of health services [18].

Relative to alternative models, the Anderson model exhibits a superior degree of applicability for our research. Firstly, the flexibility inherent in the Anderson model permits its application beyond the analysis of health service utilization, enabling it to be tailored to the specific requirements of the population under investigation. Secondly, as a well-established analytical framework, the Anderson model has been extensively employed in research pertaining to services for the elderly in China. The utilization of the Anderson model facilitates a more comprehensive dialogue with existing research.

Based on the Anderson model, Zhang Wenjuan and Sun Lanying analyzed the influencing factors of urban elderly and rural elderly’s willingness to choose their manner of care [21, 22]; Peng Xizhe and others analyzed the influencing factors of disabled elderly using long-term care services [23]. Those studies have found that need has a significant impact on the utilization of care services for the elderly, and there is controversy over whether predisposing characteristics and enabling resources have a significant impact on utilization. Yu Zhao constructed an analysis framework of healthcare service utilization for both supply and demand, referencing the Anderson model, and found, based on the survey data, that service supply, service quality, service need, and knowledge of service are positively associated with the utilization of nonmedical community healthcare services among elderly Chinese [17]. Zhang Chi used the Anderson model as the basic explanatory framework to analyze the impact of social support for older people on the utilization of therapeutic healthcare services and found that social support has different impacts on urban and rural elderly people [15]. Nonetheless, these studies fail to distinctly differentiate between community service utilization and community facility utilization, or they solely scrutinize service utilization in isolation. The underutilization of community care facilities persists as a significant yet inadequately researched issue.

Distinct from medical services, community care facilities represent a quasi-public good, embodying both market and welfare characteristics. Sole reliance on the Anderson model for the analysis of community care facility utilization lacks rigor and necessitates logical reinforcement from public economics [24]. Our preliminary investigations have identified that the absence of effective demand constitutes a principal impediment to the progression of China’s aging industry [3]. Furthermore, the elements of “ability to pay” and “willingness to pay” within the effective demand theory align closely with “enabling resources” and “predisposing characteristics” within the Anderson model in terms of their implications and variables. Therefore, this paper introduces the effective demand theory of the elderly to reform the Anderson model. The effective demand theory holds that “need” forms “demand” and “demand” forms “effective demand”. “Need” comes from personal subjective perception and objective judgment, which is the subjective willingness of the subject to feel a certain lack and strive to obtain satisfaction. “Demand” refers to the need with “the ability to pay” and “effective demand” refers to the demand with “the willingness to pay” [3].

Based on this, we constructed an analysis model for the utilization of community care facilities for the elderly, as shown in Fig. 1.

Fig. 1

The analytical framework of the utilization of community care facilities

In the previous research, the factor of enabling resources was also a factor in the formation of elderly people’s ability to pay, which transforms need into demand [25]. The factors of predisposing characteristics, as a context of utilization, reflect the willingness to pay of the elderly and transform, ultimately, the demand into effective demand. In the context of China, social resources play a significant role [15]. Focusing solely on community resources while neglecting wider societal resources could lead to the omission of crucial variables, thereby potentially compromising the validity of the study. Therefore, we modified the model and replaced “community resources” with the broader meaning of “social resources”. We use this analytical framework to examine the influencing factors of the utilization of four types of community care facilities, including daily care facilities, medical care facilities, recreation facilities, and spiritual comfort facilities, to explore the reasons for the underutilization of community care facilities for the elderly.

Methods

Participant recruitment

The data for this study were obtained from the field research of the subject team, which was composed of 24 teachers, doctoral students, and master’s students from Xi’an Jiaotong University. We used a multistage stratified random sampling method to conduct field research in Shaanxi Province from July to August 2019. Yan’an City in the north of Shaanxi Province, Baoji City in the central, and Hanzhong City in the south were chosen as the first-layer samples. Then, based on the stratified random sampling method, one subdistrict and one township from each city were chosen for second-layer samples. Based on the structural sampling method, a total of 17 communities, including 10 urban communities and 6 rural communities, were used as third-layer samples. We used the random sampling technique to choose about 30 elderly people aged 60 years and above in each third-layer sample. To improve the response rate, we employed an interview-based questionnaire methodology. Investigators, operating in pairs, were escorted to the residences of elderly individuals by community workers. Upon securing the consent of the respondent, one investigator contacted a structured interview, systematically posing the questions outlined in the questionnaire, while the other investigator documented the responses. Upon complement of the questionnaire, a towel and a bar of soap were presented to the respondent as a gesture of gratitude.

To ensure that all questions in the questionnaire were answered as completely as possible, the investigators directly asked elderly people questions and filled in the questionnaire. The questionnaire was funded by the Research Foundation of China’s Ministry of Education (18JZD045) and its design adheres to the principles of rationality, precision, logic, non-induction, understandability, etc. The preliminary content was discussed and modified by experts many times; this paper uses the questionnaire’s basic personal information, utilization of community care, and other topics.

In the end, we obtained 538 valid questionnaires related to the theme, which is representative of the population. After 2 invalid questionnaires were eliminated through standardized inspection, we used 536 questionnaires that finally matched our research theme. The sampling process and result are shown in Table 1. We also conducted in-depth interviews with community leaders from 17 communities sampled in the third-layer to understand what care facilities are equipped with in each community.

Table 1 The sampling method of the survey

Measurement

Facilities’ utilization

The utilization of community care facilities was defined as a dependent variable in our analysis. The classification of community care facilities has undergone numerous alterations in Chinese policies between 2008 and 2021. To streamline academic research, Chinese scholars have amalgamated multiple policies into a four-category framework: daily care facilities, medical care facilities, recreation facilities, and spiritual comfort facilities [16, 17, 26,27,28]. Daily care facilities encompass day-care centers, mutual-help homes, canteens for older adults, and bathhouses for older adults. Medical care facilities comprise clinics, community pharmacies, community health centers, and rehabilitation units. Recreational facilities include fitness rooms for older adults, activity centers for older adults, chess rooms, reading rooms, painting and calligraphy rooms, and universities for older adults. Spiritual comfort facilities primarily consist of psychological counselling rooms.

This paper adopts the aforementioned four-category division. For each type of facility, we first asked community leaders whether they had such facilities in their community before the questionnaire. Then, we asked sampled elderly people four questions regarding whether they had used daily care facilities, medical care facilities, recreation facilities, or spiritual comfort facilities in the previous year. For each of the questions, the answers include “yes (1)” and “no (0)”. If the community provided a type of facility and the elderly had used it in the previous year, it was considered that the respondent utilized this type of community care facility, and we assign it a value of 1. Otherwise, we assigned a value of 0.

Predisposing characteristics

According to the analysis framework in Fig. 1 and the availability of data, the predisposing characteristics were measured from 7 variables. First, age and gender were used to reflect demographics. Age referred to the chronological age of the respondents in 2019. Gender was grouped as “male (0)” and “female (1)”. Second, marital status and cohabitation status were used to reflect the social structure. Marital status was grouped as “married (1)” and “single (0)”. The category “single” encapsulates individuals who identified as divorced, widowed, or never married, given that none of these groups have the potential to receive care from a spouse. Cohabitant status was grouped as “alone (1)”, “spouse (2)”, “children (3)”, and “others (4)”. We considered it as “children (3)” when the subject cohabitated with both children and a spouse or other person, because children are the most critical factor in family care [25]. Third, health management, exercise frequency, and health investment reflect health beliefs. The measurement of health management was carried out by listing a series of health management projects to the respondents in the questionnaire and asking them if they have accepted any of them. If the respondent had used any of the listed projects in the previous year, the response was considered as “yes (1)”; otherwise, the response was measured as “no (0)”. Weekly exercise frequency was based on the average weekly exercise frequency of the respondents. The measurement of health investment was carried out by listing a series of health investment products to the respondents in the questionnaire and asking them if they had purchased any of them. If the respondent had purchased any of the listed purchases in the previous year, the response was considered as “yes (1)”; otherwise, the response was measured as “no (0)”.

Enabling resources

Enabling resources were measured from six variables. First, personal resources were measured by the subject’s work before retirement, which was grouped as “civil servant (1)”, “employee of enterprises or institution (2)”, “self-employed (3)”, “farmer (4)”, “migrant worker (5)”, and “others (6)”. Second, the number of children and the annual household income were used to reflect family resources. Annual household income was obtained from the sum of various incomes of each family in 2018. To reduce the dimensional impact, the annual household income was logarithmically processed in the statistical model. Third, social resources were measured by the type of pension, health insurance, and type of residential community. Pension was grouped as “pension for public sector employees (1)”, “pension for private sector employees (2)”, “pension for residents (3)”, and “none (4)”. Health insurance was grouped as “health insurance for public sector employees (1)”, “health insurance for private sector employees (2)”, “health insurance for residents (3)”, and “none (4)”. The type of residential community was divided into rural community (0) and urban community (1) based on the actual community in which the respondents resided.

Need

According to the Anderson model, need includes two parts: perceived need and evaluated need. We measured perceived need by asking respondents if they required facilities; answers of “yes (1)” and “no (0)” were used. Most previous studies have used health status to respondents’ evaluated need [18]. Thus, we measured it in the same way, by asking the respondents how they felt in terms of health, and using a Likert scale with answers of “very poor (1)”, “poor (2)”, “average (3)”, “good (4)”, and “very good (5)”; the response can be considered as a continuous variable.

In summary, the measurements of variables are shown in Table 2.

Table 2 Measurement of variables

Reliability and validity of the questionnaire

The internal consistency of the questionnaire was evaluated utilizing Cronbach’s alpha coefficient. The cumulative Cronbach’s alpha for the questionnaire was 0.7119, with a range from 0.7 to 0.8, signifying satisfactory reliability.

To ascertain the construct validity, a Confirmatory Factor Analysis (CFA) was executed, and the results demonstrated acceptable data (χ²/df = 64.88, CFI = 0.861, TLI = 0.791, RMSEA = 0.084). Content validity was corroborated by a panel of five expert professors who scrutinized the questionnaire items for relevance and lucidity.

Statistics methods

Stata 15.1 (StataCorp, Texas, USA) was used in data analysis. First, the frequency distribution of equipment and utilization were used to report the current situation of underutilization of community care facilities. Second, means and frequency distribution was used to report the individual characteristics of respondents and independent variables. Third, we examined the effect of the influence factor on the utilization of community care facilities using binary logistic regression.

Result

Underutilization of community care facilities

The equipment and utilization of the community of four types of community care facilities are shown in Table 3; Fig. 2. In Table 3, “communities equipped” refers to the frequency of communities with such facilities among surveyed communities; “elderly covered” refers to the frequency of respondents who reside in communities equipped with such facilities; “utilization” refers to the number of respondents who have used such facilities in the previous year; and “utilization ratio” refers to the ratio of the number of elderly respondents in the community who have used such facilities to the total number of elderly respondents in the surveyed community with such facilities.

Table 3 Equipment and utilization of community care facilities (N = 536)

Fig. 2

Equipment and utilization of community care facilities (N = 536)

The construction of community care facilities for the elderly has achieved great results. Among the 17 communities surveyed, all have been equipped with medical care facilities; 16 of them were equipped with daily care facilities; 10 of them were equipped with recreation facilities; and 4 of them were equipped with spiritual comfort facilities. Our survey found that most community care facilities converted from community office rooms and are open to the elderly for free.

However, these equipped community care facilities are generally underutilized. Of the total, 20.71% of respondents had never used any community care facilities. More than half of the respondents in both communities had never used any community care facilities. Medical care facilities had the highest coverage and usage among the four types of facilities that covered all responders, and 61.57% of the respondents had used medical care facilities in the previous year. The annual free physical examination organized by the community was the main reason for this. Due to the relatively low construction and operation costs, recreation facilities covered 94.96% of respondents in their communities. However, 48.51% of respondents had not used recreation facilities, and 31.34% of the respondents were unaware that there were recreation facilities in their community. Daily care facilities covered 58.4% of the respondents, but only 27.16% of the respondents had used them. Only 1.68% of respondents had used spiritual comfort facilities, the lowest utilization rate of the four types of community care facilities.

Descriptive characteristics

Descriptive statistics of variables are shown in Table 4. The average age of the respondents was 70.32 years old. Female elderly people accounted for 60.26% of the total. According to the data from the 7th population census of Shaanxi Province, the average age of the elderly population was 69.55 years old, and the gender ratio was 95.26. The age structure of the sample was consistent with the census results, but the proportion of females was relatively high. This may be due to a systematic error caused by the survey process whereby females were more willing to accept interviews. The average score of respondents’ self-assessment of their health status was 3.46, with over half of respondents believing that their health status was good or relatively good, and 20.53% of respondents believing that their health status was poor or relatively poor. The respondents with rural-registered residences accounted for 53.54% of the total, which was slightly more than those with urban-registered residences. However, some of the elderly with rural-registered residences were living in cities. Only 37.31% of the elderly truly lived in rural areas. In terms of marital status, 70.9% of the elderly people had spouses, while 90.38% of the remaining single elderly people were single due to widowhood. In total, 81.16% of the elderly lived with their spouse or children. Most urban elderly people used to be employees of enterprises or institutions before retirement, while rural elderly people mostly engaged in agriculture before the age of 60. 6. The former employment of 53% of respondents was classified as “others” because they had no job or worked as full-time housewives before the age of 60. There was a significant income gap among the elderly. The average annual household income of respondents was CNY 33,600, with a median of CNY 22,600, and an income standard deviation of CNY 31,700. Of the total, 37.52% of respondents had a monthly income of less than CNY 1000, while the wealthiest 10% of respondents accounted for 31.4% of the total annual income of all respondents.

Table 4 Descriptive statistics of respondents’ characteristics (N = 536)

Logistic regression analysis

Table 5 presents the results from Logistic regression to examine influencing factors on the utilization of community care facilities. Each model has multiple variables with statistical significance OR values, and the P value of all models was not less than the inspection level (P > 0.05), which is meaningful. This study used Nagelkerker2 to measure the fit of the model; the closer the value, the better the fitness of the model. The R2 values of the four models were 0.145, 0.105, 0.135, and 0.346, which indicates that the model is average.

Table 5 Logistic regression analysis of influencing factors on the utilization of community care facilities (N = 536)

Utilization of daily care facilities

Among the predisposing characteristics, we found that age, marital status, and health investment had a significant impact on the utilization of daily care facilities. Consistent with existing research results, age was positively correlated with the daily care needs of the elderly. The likelihood of using daily care facilities increased by 6% for each year of increased age. Married elderly people with spouses were 63.9% less likely to use daily care facilities than single elderly people. Elderly people with health investments were 83.1% less likely to utilize community-provided daily care facilities than those without health investments.

Among the enabling resources, the residential community and the number of children had a significant impact on the utilization of daily care facilities. The likelihood of elderly people in rural areas using life care facilities was 79.2% higher than that of elderly people in urban areas. Elderly people with more children were less likely to use daily care facilities. For each additional child, the likelihood of elderly people using daily care facilities decreased by 25.8%.

The health status of elderly people, as evaluated by need and their perceived need for daily care facilities, had a significant impact on utilization. The likelihood of using the daily care facilities decreased by 20.5% for each level of improvement in self-assessment of health status. Elderly people with a perceived need for daily care facilities were 83% more likely to use them.

Utilization of medical care facilities

Among the predisposing characteristics, only gender had a significant impact on the utilization of medical care facilities. The likelihood of females using medical care facilities was 55.2% lower than that of males. Since the proportion of males with habits such as smoking and drinking was much higher than that of females, males were more likely to receive health management and monitoring services provided by the community. In terms of medical habits, female elderly people were more willing to prioritize community grassroots medical care. In total, 81.21% of surveyed female elderly people were willing to prioritize visiting community or street health service centers when facing diseases, while only 64.79% of surveyed male elderly people chose community or street health service centers.

Among the enabling resources, work before retirement, type of pension, type of medical insurance, residential community, and number of children had a significant impact on the utilization of medical care facilities. This article selected retired employees from enterprises and institutions as the reference object. Compared to retired employees of enterprises and institutions, the likelihood of elderly farmers using medical care facilities was 66.4% lower, while the likelihood of retired migrant workers using medical care facilities was 75.9% lower. Compared to elderly people who participated in the pension for private sector employees, elderly people who participated in the pension for residents were 224% more likely to use medical care facilities, and elderly people who participated in the pension for public sector employees were 428% more likely to use medical care facilities. Compared to the elderly who participated in the medical insurance for private sector employees, the likelihood of using medical care facilities was 84.3% lower for the elderly who participated in the medical insurance for public sector employees, and 84.2% lower for the elderly who did not participate in any medical insurance. For each additional child, the likelihood of elderly people using medical care facilities increased by 40.3%.

The health status and perceived needs of the elderly had a significant impact on the utilization of medical care facilities. The likelihood of using medical care facilities decreased by 18.4% for each level of improvement in self-assessment of health status. Elderly people with perceived needs for medical care facilities were 98% more likely to utilize them.

Utilization of recreation facilities

Among the predisposing characteristics, only health investment had a significant impact on the utilization of recreation facilities. Elderly people with health investments were 101.2% more likely to utilize recreation facilities than those without health investments.

Among the enabled resources, residential community, number of children, and annual family income had a significant impact on the elderly’s use of recreational facilities. The likelihood of elderly people in rural areas using recreation facilities was 181.9% higher than for those in urban areas. For each additional child, the likelihood of elderly people using recreation facilities decreased by 34.9%. For every unit of increase in household income, the likelihood of using recreation facilities increased by 29.3%.

The perceived needs of the elderly had a significant impact on the utilization of recreation facilities. The likelihood of elderly people utilizing recreation facilities increased by 97.4% if they perceived a need for it. The impact of the health status of elderly subjects on the utilization of recreation facilities was not significant.

Utilization of spiritual comfort facilities

Among the predisposing characteristics, gender and cohabitant had a significant impact on the utilization of spiritual comfort facilities. The likelihood of females using spiritual comfort facilities was 803.3% higher than that of males. Among the respondents, 88.89% of the elderly who used spiritual comfort services were female, and the overall mental health level of the surveyed females was slightly higher than that of the males. Elderly people living with their spouses were much more likely to use spiritual comfort facilities than those living alone, possibly because community spiritual comfort services have a mediating effect on family conflicts.

Among the enabling resources, only work before retirement had a significant impact on the utilization of spiritual comfort facilities. The likelihood of elderly people engaged in agricultural labor before retirement using spiritual comfort facilities was much higher than that of retired employees of enterprises and institutions. It should be noted that all spiritual comfort facilities in this survey were built in urban communities, and 77.78% of the elderly who used spiritual comfort facilities were elderly people who migrated from rural areas to urban areas after becoming elderly. It can be seen that the elderly migrant population is the main service target of community spiritual comfort facilities.

Neither evaluated need nor perceived need had a significant impact on the utilization of spiritual comfort facilities.

Discussion

Main findings

To understand the reasons for the underutilization of community care facilities for the elderly, this study constructed a framework for analyzing the utilization of community care facilities. The descriptive statistics on survey data from 17 communities prove that the built community care facilities for the elderly are underutilized. The logistic regression results indicate that there are significant differences in the influencing factors of the utilization between daily care facilities, medical care facilities, recreation facilities, and spiritual comfort facilities.

Underutilization of community care facilities for the elderly

Our findings indicate that all categories of community care facilities are underutilized, with the issue being more acute for daily care and spiritual facilities. This conclusion aligns with the majority of recent studies [16, 17, 24, 28]. However, some literature posits that community facilities providing care services for disabled older adults in China are remain inadequate [29]. This paper does not seek to contest this assertion. According to our survey, a significant majority of older adults with access to community care facilities (79.47%) reported having good health status, suggesting that disabled older adults constitute only a minor segment of users. Consequently, our findings propose that community care facilities are generally underutilized, rather than insufficiently constructed.

The demand for community care facilities is outstripped by the supply

The influence of older adults’ need for the four categories of community care facilities varies. Recent studies employing the Anderson model have separately examined the impact of older adults’ needs on their utilization of daily care facilities [17], medical facilities [15], and spiritual facilities [30]. While there is a consensus that the need for community care facilities is a prerequisite for their utilization, few studies have conducted a cross-sectional comparison. Our regression results indicate that older adults with a perceived need for daily care, medical care, and recreation were 83%, 98.1%, and 97.4% more likely, respectively, to utilize corresponding facilities compared to those who do not perceive a need. While 9.27% of elderly individuals do not require any daily care facilities, 30.22% do not require any medical care facilities; and 39.74% do not require any recreational facilities. This finding provides insight into the underutilization of these three categories of facilities.

However, the need for spiritual facilities among older adults does not significantly influence their usage. It has been suggested that older adults in developing countries like China do not sufficiently prioritize mental health and struggle to recognize their need for spiritual services [31]. Our survey corroborates this perspective. Despite the inspectors’ efforts to clarify, many respondents were unable to comprehend the concept of a spiritual facility, rendering the questionnaire item on the need for spiritual facilities less reliable.

Complex constraints on demand for facilities due to insufficient enabling resources

The majority of extant research has identified enabling resources as positive factors that underpin the utilization of community care facilities by older adults [16, 24, 26]. Specifically, numerous studies on the accessibility of community care facilities have underscored the significance of enabling resources [32,33,34]. While corroborating this perspective, our regression results further contend that the impact of enabling resources is not merely positive, but operates through a more intricate mechanism.

Firstly, diverging from existing studies that categorize household income as a categorical variable [16, 17], this paper analyzes household income as a continuous variable using logarithmic transformation. We discovered that household income significantly influences the utilization of recreational facilities only. During our interview-based questionnaire, many rural older adults who reported not requiring recreational facilities were engaged in labor to supplement household expenses. Similarly, urban older adults were often occupied with household chores and caring for their grandchildren, leaving them with limited leisure time for recreational activities. Therefore, the effect of annual household income on the utilization of community care facilities is likely indirect.

Secondly, while most studies propose that social benefits as formal support facilitate older adults’ use of community care facilities [15, 30], our research found that social benefits significantly affect the utilization of medical care facilities only. Older adults with pensions and health insurance for private sector employees are more likely to utilize community medical facilities than others. This discrepancy arises because some older adults have insufficient enabling resources, while others have excessive enabling resources. On one hand, the majority of older adults who participated in the pension for residents and those without medical insurance are agricultural or rural migrant workers. A manager of a medical care facility in a rural community explained in an interview: “When facing basic diseases, older adults usually opt for inexpensive drugs from pharmacies or folk remedies rather than seeking help from grassroots medical institutions.” On the other hand, retired older adults in the public sector have higher pension and medical insurance reimbursement amounts, leading them to seek treatment directly at large hospitals, rarely opting for community medical care facilities. For instance, one retired official we interviewed once spent RMB 10,000 a month on medical treatment, but was reimbursed more than 80% by his health insurance. As a result, only retired employees of urban enterprises are more inclined to choose community medical care facilities due to higher reimbursement rates and convenience.

Lastly, the question of whether older adults with a larger number of children are more likely to utilize community care facilities is a contentious issue in existing research [16, 17, 30]. Our regression analysis revealed that the influence of children on the utilization of different types of facilities by older adults is variable. Older adults with a larger number of children have relatively abundant family care resources but also shoulder more household responsibilities, such as caring for their grandchildren. Consequently, their propensity to use daily care facilities and recreational facilities is low. However, due to the enhanced ability of younger individuals to access information and their superior comprehension of the medical care facilities provided by the community, older adults with a larger number of children are more likely to utilize these facilities.

Inadequacy of community care facilities in meeting expectations

Policy analysis indicates that the development of community care facilities in China is intended to fulfill two primary objectives: (1) enhancing the quality of life for older adults, and (2) providing support for older adults who lack family care [3]. In the classical Anderson model, individuals exhibiting health investment behaviors demonstrate a willingness to utilize medical care services and facilities to augment their quality of life [18, 35]. However, our regression results reveal that older adults with health investment behaviors are less likely to utilize daily care facilities. One administrator of a community care facility noted in an interview that: “Due to our community’s limited construction capacity, the facility primarily provides venues and simple equipment, and seldom offers care services.” Therefore, a plausible explanation for our finding is that existing community care facilities are unable to satisfy the needs of older adults seeking to enhance their quality of life.

The construction of community care facilities has also failed to cater to the needs of older adults living alone. Studies have demonstrated that informal support from families influences the utilization of care services by older adults [30, 36]. Elderly individuals living alone, devoid of family care or companionship, should exhibit a higher propensity to utilize community care facilities [25]. However, our regression results showed no significant difference in the likelihood of older adults living alone, as compared to those with family companionship, utilizing facilities such as daily care, medical care, and recreational facilities. Many older adults living alone who were interviewed in our survey were unaware of the availability of care facilities in their community. In the absence of information and guidance, they tend to underutilize these facilities.

Interpretation

In the realm of public economics, community care facilities are typically classified as public goods [37]. It is somewhat reductionist to analyze the reasons for the underutilization of community care facilities solely from the perspective of the needs of older adults [17]. To ensure a more holistic analysis, this section expands upon the primary findings by investigating supply-side factors that contribute to the underutilization of community care facilities.

High substitutability of community care facilities

Governments have prioritized the acceleration of the construction of community care facilities, yet have overlooked the functional development of facilities that cater to the rigid needs of the elderly population. Consequently, these individuals are more inclined to opt for alternative methods.

Existing studies concur that there is a disparity in the utilization of community care facilities by older adults in rural and urban areas, albeit for varying reasons [15, 17, 28]. Our survey revealed that the quality of urban community care facilities significantly surpasses that of rural areas, yet the utilization of rural community care facilities is 8.31% higher than that of urban areas. We propose a novel explanation: urban elderly individuals have a wider array of choices. For instance, the elderly restaurant is a key focus in the construction of daily care facilities. Among the surveyed communities, four urban communities and three rural communities have elderly restaurants. Through field observations, we discovered that most elderly restaurants in urban communities do not significantly differ in terms of dish variety and service compared to regular restaurants, and the home delivery services of elderly restaurants are far less diverse and timely than those of other restaurants. Conversely, rural areas generally lack catering delivery services, resulting in a higher utilization rate of rural elderly restaurants compared to urban ones. Another example is that the hosting function of daytime care facilities is gradually being supplanted with the popularization of the Internet. Among the surveyed communities, five urban and five rural communities have daytime care facilities. With the increasing use of health bracelets, intelligent monitoring, and other devices in cities, relatives can access basic information about disabled elderly individuals in real time. Due to the lack of alternative choices for rural elderly, the utilization rate of daytime care facilities in rural areas surpasses that in urban communities.

Numerous studies have positively evaluated community recreation facilities in China [16, 28]. However, our field observations revealed that the established recreation facilities are also highly substitutable. Among the 17 communities surveyed, there are 16 card rooms and 15 reading rooms. Most of the card rooms are idle rooms equipped with several card tables, while the majority of the reading rooms are community meeting rooms where books, newspapers, magazines, and other reading materials are placed with strong propaganda. Through interviews with older adults, we further discovered that an increasing number of elderly individuals choose short videos as entertainment; these can satisfy their entertainment needs at home, eliminating the need to use recreation facilities.

Bureaucratic pressure hindering facility development

Over the years, numerous studies have concluded that the scarcity of mobile funds within the community hampers the implementation of operation and maintenance costs of community care facilities post-completion [3, 38]. Our survey corroborates that this issue remains prevalent. In remote urban and rural communities, care facilities can only be constructed and managed part-time by community management personnel. Consequently, due to their simplicity, low construction costs, short construction time, and ease of management, recreation facilities have been prioritized as construction projects.

This can be elucidated from an administrative perspective, where the top-down policy, driven by the bureaucratic system, results in limited choices for grassroots practical workers. During the interviews, some community leaders also acknowledged that their community care facilities are highly substitutable, expressing skepticism towards the current goal of emphasizing coverage. A grassroots civil servant conveyed to us that “governments at all levels have escalated their requirements for the construction speed and coverage of community care facilities from top to bottom, and the progress of construction tasks is directly linked to the performance evaluation of street offices and communities. When a facility is finally implemented in a community, it is often required to complete the construction of community care facilities within one assessment cycle. The method of assessment typically necessitates subordinate departments to regularly report their work to superiors in oral or written form, supplemented by photographs.” Many grassroots staff members have stated that few higher-level departments are conducting on-site inspections at home community elderly care service facilities, instead placing greater emphasis on work reports and statistics.

Limitations

Due to the availability of data and the progress of research, there are still some unresolved limitations in this article. Firstly, because community-level surveys are unstructured interviews, the collected data are difficult to quantify. Therefore, when constructing statistical models, the inclusion variables at the community level are relatively limited. In future research, further in-depth exploration on the analysis of community facilities construction and effective supply is required. Secondly, due to the items of the questionnaire, this study selects the original Anderson model to build a theoretical framework. Therefore, some new influencing factors in the improvement of the Anderson model have not been included in the analysis model of this article, and the selection of influencing factor variables needs to be further improved in the future. Thirdly, due to the impact of COVID-19, the period of this study is relatively long, which has a certain impact on the timeliness of the data. The basic data of this article come from the research group’s 2019 survey in Yan’an, Baoji, and Hanzhong in Shaanxi Province and from supplementary surveys in Baoji in 2021 and Yan’an and Hanzhong in 2022. The research conclusions are supported by interviews and informal discussions. However, the supplementary survey data are not included in the model due to their inconsistent caliber, and the timeliness of the quantitative analysis results is still limited. Lastly, to guarantee the accurate comprehension of the questions by the participants, we employed an interview-based questionnaire as opposed to a self-administered one. Furthermore, to surmount the obstacle of linguistic diversity and to safeguard the investigators, the process of investigation was conducted in the presence of community workers. This could potentially exert an influence on the responses to the questionnaire.

Conclusions and policy recommendations

Conclusions

Based on the Anderson model, this article constructed a framework for analyzing the utilization of community care facilities for the elderly and analyzed the reasons for the underutilization of community care facilities from predisposing characteristics, enabling resources, and needs. The main conclusions are as follows.

First, the descriptive statistics on survey data from 17 communities prove that the built community care facilities for the elderly are underutilized.

Second, the results of binary logistic regression analysis indicate that there are significant differences in the influencing factors of the utilization between daily care facilities, medical care facilities, recreation facilities, and spiritual comfort facilities.

Thirdly, the underutilization can be attributed to several factors: the demand for community care facilities is outstripped by the supply, the lack of sufficient enabling resources complexly constrains the demand for facilities, and the community care facilities’ inability to meet expectations.

Fourth, the supply reasons for the underutilization are that the community care facilities are highly substitutable and the pressure of bureaucracy restricts the development of facilities.

Policy recommendations

Clarify the community responsibility boundaries for elderly care

As a quasi-public sector, communities should prioritize meeting the basic needs of the elderly living at home, especially those who experiencing widowhood, loss of independence, disability, dementia, and disability. Due to the insufficient ability of the legal obligors of elderly people in difficulties to fully fulfill their legal obligations, social insurance and welfare do not provide adequate funds to make the cost of hiring caregivers affordable. Once elderly people in difficulties need daily care, accompanying medical treatment, emergency rescue, rehabilitation care, mental assistance, etc., it is difficult for them to receive necessary and timely assistance. The community should provide help to prevent the problems of thirst and hunger, sudden disease, solitary deaths, abuse, suicide, and other problems that may occur to the elderly in difficulty. Due to the limitations of resources in the community, the assistance provided to the elderly in need is limited. Therefore, the functional scope of the community in the construction of daily care facilities, medical care facilities, recreation facilities, and spiritual comfort facilities should be clearly defined, and the responsibility boundary of the community in the process of construction, management, and operation should be defined.

The construction of daily care facilities aims at providing all-weather nursing beds for the disabled elderly, providing short-term respite care services, and providing long-term care services if conditions permit. Elderly care service institutions with professional qualifications are the main operating entities of daily care facilities, operating independently, taking responsibility for their profits and losses under the support of corresponding policies, and subject to the supervision of government business regulatory departments. The community’s main responsibility is to provide facilities.

Medical care facilities rely on the medical and health system, leveraging the functions of grassroots health institutions to meet the basic medical care needs of the elderly for medication, medical treatment, and chronic disease management. More convenient and free physical examinations for elderly people in need should be provided. Elderly people who participate in medical insurance for residents should be granted a higher reimbursement ratio when seeking medical treatment at community care facilities.

The government can incentivize communities with conditions to build recreation facilities according to local conditions but should not include them in the performance evaluation of policy implementation. The government should give full play to the democratic expression, resource integration, and coordinated management functions of community autonomous organizations and adopt diversified entities, multiple fundraising programs, and various forms to build recreation facilities that meet the needs of the majority of elderly people in the community.

Most communities do not have the professional talents to provide psychological intervention. It is recommended to establish spiritual comfort facilities with professional psychological counselors and social workers in the town to visit and receive elderly people who have lost their independence, are widowed, live alone, and relocate from other places. We should utilize the advantages of community information and intermediary roles, promptly identify elderly people who need psychological intervention, and communicate with spiritual comfort facilities.

The role of the market in community care facilities for the elderly

The entry of enterprises or social organizations into communities plays an irreplaceable role in providing effective supply. Only by fully leveraging the role of the market and entrusting facilities’ operations and services to professional organizations can we better adapt to the diverse and multi-level needs of the elderly. Under policy guidance and government supervision, we should accelerate the introduction of market mechanisms into the supply of community care services and gradually achieve reasonable investment returns and operating profits for enterprises entering the community.

Firstly, market mechanisms for community care must be innovative. Community care services for the elderly do not fully possess the non-competitiveness and non-exclusivity of public goods. The market competition mechanism should be established where supply and demand determine prices, allowing professional institutions to better utilize community care facilities and provide higher quality elderly care services. Whether it is an enterprise or a non-governmental organization, they are equally entitled to unify preferential policies such as fund subsidies, tax exemptions, land supply, investment, and financing support. They independently determine targets, items, levels, prices, etc., use production factors equally by the law, and participate in market competition fairly. Community care facilities with public goods attributes should be transferred to professional institutions for free or at a low price. The institutions survive will be those that meet the challenges of the market mechanisms of consumer independent selection, evaluation, and fair competition, driving the continuous improvement of technology, cost reduction, quality improvement, and the effective supply of community elderly care services.

Secondly, we should ensure that institutions stationed in the community receive reasonable investment returns and operating profits. Institutions have dual goals of profitability and social benefits. On the one hand, it is permitted for institutions to charge necessary fees from service recipients that are suitable for their affordability. On the other hand, the government should effectively implement preferential policies, such as taxation and public utility prices, and provide public assistance subsidies for investment operators with “cost plus industry average profit”. The management philosophy and practice of artificially lowering the salaries of nursing staff in elderly care services should be changed. This will truly guide and attract social capital into the elderly care service industry, make elderly care a respected job, and lead to an increase in high-quality human resources invested in the industry for the elderly.

Thirdly, we should better leverage government functions such as top-level design, policy guidance, and supervision and management. We should build community care facilities for the elderly tailored to local conditions based on the diverse elderly care needs. The speed and scale of construction should be coordinated with economic and social context and should be in line with the actual situation of the community. We should improve the capacity of the community in distressed areas, maintain a fair and competitive market order, and optimize and implement preferential policies such as taxes, prices, and public subsidies. Furthermore, we should strengthen the supervision of the quality and price of community care services for the elderly.