Abstract
Abstract
Objectives
This study aimed to evaluate the factors associated with care modality among older adults with chronic disease and disability in rural China. We hypothesised that marital status, family structure, duration of disability and the number of chronic diseases would be significantly associated with care modality.
Design
This was a cross-sectional observational study using survey data to identify demographic and health-related factors associated with care modality.
Setting
The study was conducted in a rural mid-sized county in China and focused on older adults with chronic disease and disability.
Participants
A total of 608 older adults aged ≥60 years with chronic disease and disability residing in Qinghe County, Hebei Province, China, completed the survey. Eligible participants had at least one chronic disease and partial or complete loss of self-care ability.
Primary and secondary outcome measures
The primary outcome was care modality (home-based care vs institutional care). Secondary outcomes included specific chronic disease care needs.
Results
Of the participants, 18.59% received institutional care. Divorced, widowed or unmarried participants had higher odds of institutional care use (OR=3.113, 95% CI 2.01 to 4.82, p<0.0001), as did those with one child (OR=5.55, 95% CI 1.647 to 18.696, p=0.0057). Participants with a disability lasting 3 or more years had significantly lower odds of institutional care use (OR=0.353, 95% CI 0.186 to 0.667, p=0.0014). Individuals with three chronic diseases (OR=0.486, 95% CI 0.242 to 0.977, p=0.0429) or four or more (OR=0.412, 95% CI 0.183 to 0.928, p=0.0324) also had lower odds of institutional care use. The highest-priority chronic disease care needs were regular physical examinations, rehabilitation guidance, medication guidance, chronic disease management guidance and nutritional guidance. Participants receiving institutional care reported higher needs for digitally supported services such as online referral, medical record information sharing and remote data transmission.
Conclusions
Marital status, number of children, duration of disability and number of chronic diseases were significantly associated with care modality in this population. These findings highlight the need to improve institutional care quality and availability and to better address the chronic disease management needs of this population. Future research should focus on longitudinal studies to explore the evolving care needs of this growing demographic.
Keywords: Disabled Persons, Chronic Disease, Decision Making, Health Services
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This study studied older adults with chronic disease and disability living in rural China.
Structured questionnaires and the Barthel Index were used to collect data on chronic disease status, disability and care modality.
The cross-sectional design allowed for the identification of factors associated with care modality, but limited the ability to infer causal relationships.
Data were self-reported, which may have introduced recall bias and affected the accuracy of responses.
Introduction
The acceleration of global ageing has profound implications for healthcare systems worldwide. Among the nations experiencing this demographic shift, China stands out as having the largest older population in absolute terms.1 According to the National Bureau of Statistics of China, the population aged ≥60 years reached 310.31 million (22.0% of the total) by the end of 2024.2 Projections suggest that this demographic will expand significantly over the next 30 years, intensifying the demand for robust healthcare and social protection systems.3
Chronic diseases are highly prevalent in later life and are a major contributor to functional decline. Disability, commonly defined as limitations in activities of daily living, is also frequent among older adults in China, with pooled estimates suggesting a prevalence of approximately one quarter among older adults in China.4 5 Recent evidence further indicates that disability is more common among older adults with chronic conditions, with a pooled prevalence of 43.2%.6 In daily life, disability often requires sustained assistance with basic activities and the management of chronic conditions, placing substantial demands on family caregivers and local health services. These pressures underscore the need for coordinated, system-level approaches that integrate medical care with long-term care services.
In practice, translating system-level support into care delivery requires decisions about where care is provided and by whom. Accordingly, the choice between home-based and institutional care represents a pivotal point at which individual needs, family capacity and service availability converge. In rural China, institutional care is typically financed through a combination of out-of-pocket payment and government subsidies, although the level of support varies across localities. Prior work suggests that care-setting decisions are associated with living arrangements, age, education, income, employment and health status.7,12 While many studies on older-adult care in China have focused on ‘utilization willingness’,7,1113 14 defined as hypothetical preferences for institutional care, these investigations often fall short of capturing actual care decisions. Furthermore, much of the existing research has centred on institutional care in urban areas or broader provincial settings, with limited analysis of the care needs of older adults living in rural regions, where resources and access to care differ significantly. This disparity highlights a substantial gap in our understanding of the care requirements in rural and less affluent areas, where resource distribution is often uneven. Gaining a deeper understanding of the care needs and care-setting decisions in these regions is essential for the effective planning of healthcare workforce infrastructure and for ensuring that care delivery systems are responsive to these populations’ specific needs.
This study focused on older adults with chronic disease and disability in a mid-sized rural county in China. We aimed to examine factors associated with actual utilisation of institutional care and to characterise chronic disease care needs in this population, thereby informing service planning and resource allocation in similar rural contexts.
Methods
Study design and patient selection
This cross-sectional survey was conducted among older adults with chronic disease and disability in Qinghe County, Hebei Province, from August to December 2021. Eligible participants were aged ≥60 years, had partial or complete loss of self-care ability, had at least one chronic disease and were registered residents of Qinghe County. The Qinghe County Chronic Disease Management Center’s registry served as the sampling frame. This registry is a county-level database that supports chronic disease follow-up and monitoring within the county health system and also records disability status as part of routine care management. It is estimated to cover approximately 80% of local patients with chronic disease. Using registry filters based on these eligibility criteria, the study team identified residents aged ≥60 years with documented chronic disease and recorded disability status who were registered residents of Qinghe County; disability eligibility was further confirmed using the Barthel Index.15 From this eligible pool, 700 individuals were randomly selected for recruitment.
Village committees, community health service centres and local elderly care institutions assisted with participant contact by verifying residence and contact information and facilitating communication with families. All study invitations and explanations were provided by trained members of the research team. Each participant was invited at least once; if there was no response, follow-up contact was made by telephone or home visit. The questionnaire was administered in person by trained interviewers, who read each question aloud, explained it when necessary and recorded the responses on paper questionnaires. When participants were unable to respond independently, assistance was provided by a guardian or primary caregiver.
A total of 641 questionnaires were collected (response rate, 91.57%). Data cleaning involved double independent data entry, logical consistency checks and range checks. Questionnaires with >20% missing data or missing key variables required for the analyses (eg, care modality, age, gender, Barthel Index items and core covariates) were considered invalid and excluded. As a result, 608 questionnaires met the prespecified validity criteria and were included in the final analyses (valid response rate, 86.86%). All variables entered into the analyses were complete.
Study setting
Qinghe County is located in Xingtai City, Hebei Province, in North China. It is a moderately developed rural county with a stable local economic base, yet long-term care and specialist medical resources remain more constrained than in large urban centres. Nursing homes represent the main form of institutional long-term care locally and clinical care is delivered primarily through county hospitals and township health centres.
Measurement and outcome
The survey was administered in Chinese (Mandarin and local dialect as needed). The questionnaire was divided into three sections: basic information, degree of disability and chronic disease care needs. All study variables and their coding are summarised in table 1. Care modality was defined as the participant’s current care arrangement at the time of the survey and was categorised as home-based care versus institutional care; it did not capture willingness, preference or waiting status.
Table 1. Classification and coding of variables for basic information, chronic disease information and chronic disease care needs.
| Variables | Classification or scoring of variables |
|---|---|
| Basic information | |
| Household location | 0: rural village; 1: county seat (county town) |
| Gender | 0: female; 1: male |
| Age | 0: 60≤age <70 years; 1: 70≤age <80 years; 2: ≥80 years |
| Marital status | 0: married, spouse alive; 1: divorced/widowed/unmarried |
| Number of children | 0: none; 1: one; 2: two or more |
| Education level | 0: illiterate; 1: primary school; 2: middle school; 3: high school and above |
| Monthly income | 0: <¥1000; 1: ¥1000≤income <2000; 2: ¥2000≤income <3000; 3: ≥ ¥3000 |
| Duration of disability | 0: <1 year; 1: 1≤duration <3 years; 2: ≥3 years |
| Medical payment method | 0: urban employee medical insurance |
| 1: urban and rural residents medical insurance | |
| 2: other | |
| Number of hospitalisations per year | 0: 0 times; 1: 1 time; 2: 2 times; 3: 3 or more times |
| Degree of disability | 0: mild; 1: moderate; 2: severe |
| Care modality | 0: home-based care; 1: institutional care |
| Chronic disease information | |
| Number of chronic diseases | 0: 1; 1: 2; 2: 3; 3: ≥4 |
| Chronic disease care needs | |
| Online referral | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Medical record information sharing | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Remote data transmission | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Regular physical examination | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Medication guidance | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Wound care | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Catheter care | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Nutritional guidance | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Rehabilitation guidance | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Chronic disease management guidance | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Emotional support | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
| Social and entertainment activities | 0: not needed; 1: occasionally; 2: needed; 3: highly needed; 4: extremely needed |
Chronic diseases were defined as physician-diagnosed, non-communicable conditions lasting longer than 6 months and requiring long-term management or treatment. Diagnoses were based on medical records or prescription information issued by community health service centres or county-level hospitals. These conditions were recorded in the Qinghe County Chronic Disease Management Center registry and/or reported by participants (or their guardians) during the survey. They included, but were not limited to, hypertension, diabetes mellitus, coronary heart disease, stroke and chronic obstructive pulmonary disease. The number of chronic diseases was categorised for analysis as 1, 2, 3 or ≥4.
The degree of disability was assessed using the Barthel Index,15 which evaluates ten activities: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transferring, mobility and stair climbing, with a maximum possible score of 100. According to this classification, a score of 100 indicates no disability; 61–99 indicates mild disability; 41–60 indicates moderate disability; and ≤40 indicates severe disability. No included participant had a Barthel Index score of 100.
Chronic disease care needs were assessed using a 12-item Likert scale ranging from 1 to 5, with higher scores indicating greater perceived need. The items reflected common services delivered in community-based and institutional long-term care in this setting. ‘Online referral’ referred to assistance with arranging referrals through digital platforms. ‘Medical record information sharing’ referred to access to and exchange of clinical information between care providers. ‘Remote data transmission’ referred to transmitting health measurements to clinicians via digital tools. ‘Regular physical examination’ referred to routine check-ups and monitoring. ‘Medication guidance’ referred to medication reconciliation and adherence support, including explanation of indications and dosing schedules, monitoring for adverse effects and reminders or supervision when needed; in institutional settings, this support is typically provided by nursing staff, whereas in home-based care it is often delivered by family caregivers with support from primary care or community health workers. ‘Wound care’ and ‘catheter care’ referred to routine care and monitoring of wounds and indwelling catheters. ‘Nutritional guidance’ referred to diet counselling tailored to chronic conditions. ‘Rehabilitation guidance’ included functional training and mobility/exercise guidance. ‘Chronic disease management guidance’ referred to broader health education and self-management support for chronic conditions, including disease understanding, symptom monitoring, follow-up planning and guidance on lifestyle modification to support long-term health behaviour. ‘Emotional support’ and ‘social and entertainment activities’ referred to psychosocial support and organised social or recreational activities.
Statistical analysis
Categorical variables were presented as frequencies and proportions and were compared using the χ2 test or Fisher’s exact test, as appropriate. Variables that showed a statistically significant difference between the home-based care and institutional-care groups were subsequently entered into logistic regression analyses (except for monthly income, which was collected as personal income in a predominantly retired population and was highly skewed toward <¥1000; therefore, it was considered an imperfect proxy for household socioeconomic resources). Univariable logistic regression was performed first, followed by multivariable logistic regression to identify factors independently associated with institutional care utilisation. Cronbach’s alpha was calculated to assess the internal consistency of the 12-item scale measuring chronic disease care needs. The needs were analysed using the Kruskal-Wallis H test and the Mann-Whitney U test. A two-sided p value of less than 0.05 was considered statistically significant. All statistical analyses were conducted using SPSS (IBM Corporation, Armonk, New York, USA).
Patient and public involvement
None.
Results
Basic characteristics of the study participants
Of 700 individuals sampled, 641 returned questionnaires, and 608 valid questionnaires were included in the final analyses. As shown in table 2, among the 608 participants, 328 (53.95%) were female and 459 (75.49%) were aged 70 years or older. More than half (57.24%) had been living with disability for more than 3 years. Most participants had at least two chronic diseases and severe disability. Overall, 495 participants received home-based care and 113 (18.59%) received institutional care. There were no significant differences between the two groups in household location, gender, age group, education level or insurance/payment method. Participants who received institutional care were more likely to be divorced, widowed or unmarried, whereas those receiving home-based care tended to have poorer health, characterised by a greater number of chronic diseases, longer durations of disability, more frequent hospitalisations and a higher degree of disability.
Table 2. Characteristics of the study participants.
| All participants (n=608) | Home-based care (n=495) | Institutional care (n=113) | X2 | P value | |
|---|---|---|---|---|---|
| Household location | 2.057 | 0.151 | |||
| Rural village | 487 (80.1%) | 402 (81.21%) | 85 (75.22%) | ||
| County seat (county town) | 121 (19.9%) | 93 (18.79%) | 28 (24.78%) | ||
| Gender | 0.491 | 0.484 | |||
| Female | 328 (53.95%) | 264 (53.33%) | 64 (56.64%) | ||
| Male | 280 (46.05%) | 231 (46.67%) | 49 (43.36%) | ||
| Age (years) | 4.819 | 0.09 | |||
| 60≤age<70 | 149 (24.51%) | 129 (26.06%) | 20 (17.7%) | ||
| 70≤age<80 | 236 (38.82%) | 192 (38.79%) | 44 (38.94%) | ||
| ≥80 | 223 (36.68%) | 174 (35.15%) | 49 (43.36%) | ||
| Marital status | 29.899 | <0.0001 | |||
| Married, spouse alive | 358 (58.88%) | 315 (63.64%) | 43 (38.05%) | ||
| Divorced/widowed/unmarried | 250 (41.12%) | 180 (36.36%) | 70 (61.95%) | ||
| Number of children | 6.768 | 0.034 | |||
| 0 | 34 (5.59%) | 30 (6.06%) | 4 (3.54%) | ||
| 1 | 41 (6.74%) | 27 (5.45%) | 14 (12.39%) | ||
| ≥2 | 533 (87.66%) | 438 (88.48%) | 95 (84.07%) | ||
| Education level | 1.663 | 0.645 | |||
| Illiterate | 310 (50.99%) | 249 (50.3%) | 61 (53.98%) | ||
| Primary school | 184 (30.26%) | 150 (30.3%) | 34 (30.09%) | ||
| Middle school | 73 (12.01%) | 63 (12.73%) | 10 (8.85%) | ||
| High school and above | 41 (6.74%) | 33 (6.67%) | 8 (7.08%) | ||
| Monthly income (Chinese Yuan) | 7.885 | 0.048 | |||
| <1000 | 470 (77.3%) | 381 (76.97%) | 89 (78.76%) | ||
| 1000≤income<2000 | 30 (4.93%) | 21 (4.24%) | 9 (7.96%) | ||
| 2000≤income<3000 | 27 (4.44%) | 21 (4.24%) | 6 (5.31%) | ||
| ≥3000 | 81 (13.32%) | 72 (14.55%) | 9 (7.96%) | ||
| Duration of disability (years) | 21.144 | <0.0001 | |||
| ＜1 | 91 (14.97%) | 66 (13.33%) | 25 (22.12%) | ||
| 1≤duration<3 | 169 (27.8%) | 126 (25.45%) | 43 (38.05%) | ||
| ≥3 | 348 (57.24%) | 303 (61.21%) | 45 (39.82%) | ||
| Number of chronic diseases | 34.443 | <0.0001 | |||
| 1 | 92 (15.13%) | 72 (14.55%) | 20 (17.7%) | ||
| 2 | 229 (37.66%) | 165 (33.33%) | 64 (56.64%) | ||
| 3 | 185 (30.43%) | 165 (33.33%) | 20 (17.7%) | ||
| ≥4 | 102 (16.78%) | 93 (18.79%) | 9 (7.96%) | ||
| Medical payment method | 5.694 | 0.058 | |||
| Employee medical insurance | 76 (12.5%) | 60 (12.12%) | 16 (14.16%) | ||
| Residents medical insurance | 520 (85.53%) | 429 (86.67%) | 91 (80.53%) | ||
| Other | 12 (1.97%) | 6 (1.21%) | 6 (5.31%) | ||
| Number of hospitalisations per year | 12.716 | 0.005 | |||
| 0 | 39 (6.41%) | 30 (6.06%) | 9 (7.96%) | ||
| 1 | 171 (28.13%) | 126 (25.45%) | 45 (39.82%) | ||
| 2 | 128 (21.05%) | 108 (21.82%) | 20 (17.7%) | ||
| ≥3 | 270 (44.41%) | 231 (46.67%) | 39 (34.51%) | ||
| Degree of disability | 9.21 | 0.01 | |||
| Mild | 79 (12.99%) | 54 (10.91%) | 25 (22.12%) | ||
| Moderate | 81 (13.32%) | 69 (13.94%) | 12 (10.62%) | ||
| Severe | 448 (73.68%) | 372 (75.15%) | 76 (67.26%) | ||
Factors associated with institutional care utilisation
In this study, care modality referred to the participant’s current care arrangement at the time of the survey, categorised as home-based care versus institutional care. Table 3 presents the association between participant characteristics and institutional care utilisation. Univariable analysis showed that institutional care utilisation was significantly associated with marital status, number of children, duration of disability, number of chronic diseases and degree of disability. Specifically, divorced, widowed or unmarried individuals had higher odds of institutional care utilisation than married individuals (OR=2.885, 95% CI 1.961 to 4.243, p<0.0001). Those with one child had higher odds of institutional care utilisation than those without children (OR=3.59, 95% CI 1.201 to 10.725, p=0.0221), while those with two or more children showed no significant difference (OR=1.496, 95% CI 0.641 to 3.495, p=0.3517). Compared with participants with a disability duration of<1 year, those with disability duration of 3 or more years had lower odds of institutional care utilisation (OR=0.379, 95% CI 0.221 to 0.650, p=0.0004), whereas those with disability duration of 1–3 years did not differ significantly (OR=0.871, 95% CI 0.484 to 1.568, p=0.6447). Regarding chronic diseases, individuals with three chronic conditions (OR=0.451, 95% CI 0.248 to 0.821, p=0.0091) and those with four or more (OR=0.367, 95% CI 0.183 to 0.738, p=0.0049) had lower odds of institutional care utilisation than those with only one chronic disease. However, no significant difference was found for those with two chronic diseases (OR=1.413, 95% CI 0.806 to 2.476, p=0.2278). Individuals with moderate disability (OR=0.381, 95% CI 0.183 to 0.793, p=0.0099) and severe disability (OR=0.449, 95% CI 0.257 to 0.786, p=0.0051) had lower odds of institutional care utilisation than those with mild disability.
Table 3. Associations of demographic and health-related factors with institutional care utilisation.
| Univariable analysis | Multivariable analysis | |||
|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | |
| Marital status | ||||
| Married, spouse alive | Ref. | Ref. | ||
| Divorced/widowed/unmarried | 2.885 (1.961 to 4.243) | <0.0001 | 3.113 (2.01 to 4.82) | <0.0001 |
| Number of children | ||||
| 0 | Ref. | Ref. | ||
| 1 | 3.59 (1.201 to 10.725) | 0.0221 | 5.55 (1.647 to 18.696) | 0.0057 |
| ≥2 | 1.496 (0.641 to 3.495) | 0.3517 | 1.983 (0.762 to 5.162) | 0.1606 |
| Duration of disability (year) | ||||
| ＜1 | Ref. | Ref. | ||
| 1≤duration<3 | 0.871 (0.484 to 1.568) | 0.6447 | 0.841 (0.432 to 1.636) | 0.6099 |
| ≥3 | 0.379 (0.221 to 0.650) | 0.0004 | 0.353 (0.186 to 0.667) | 0.0014 |
| Number of chronic disease | ||||
| 1 | Ref. | Ref. | ||
| 2 | 1.413 (0.806 to 2.476) | 0.2278 | 1.774 (0.928 to 3.393) | 0.083 |
| 3 | 0.451 (0.248 to 0.821) | 0.0091 | 0.486 (0.242 to 0.977) | 0.0429 |
| ≥4 | 0.367 (0.183 to 0.738) | 0.0049 | 0.412 (0.183 to 0.928) | 0.0324 |
| Number of hospitalisations per year | ||||
| 0 | Ref. | Ref. | ||
| 1 | 1.148 (0.515 to 2.557) | 0.7356 | 1.126 (0.465 to 2.731) | 0.7923 |
| 2 | 0.595 (0.259 to 1.368) | 0.2216 | 0.95 (0.373 to 2.418) | 0.9144 |
| ≥3 | 0.538 (0.247 to 1.171) | 0.1181 | 0.784 (0.325 to 1.895) | 0.5892 |
| Degree of disability | ||||
| Mild | Ref. | Ref. | ||
| Moderate | 0.381 (0.183 to 0.793) | 0.0099 | 0.477 (0.208 to 1.096) | 0.081 |
| Severe | 0.449 (0.257 to 0.786) | 0.0051 | 0.863 (0.434 to 1.716) | 0.6746 |
In the multivariable analysis, marital status, having one child, duration of disability, and number of chronic diseases remained independently associated with institutional care utilisation. Divorced, widowed or unmarried participants had higher odds of institutional care utilisation (OR=3.113, 95% CI 2.01 to 4.82, p<0.0001), as did those with one child (OR=5.55, 95% CI 1.647 to 18.696, p=0.0057). Disability duration ≥3 years was associated with lower odds of institutional care utilisation (OR=0.353, 95% CI 0.186 to 0.667, p=0.0014). Additionally, individuals with three chronic diseases (OR=0.486, 95% CI 0.242 to 0.977, p=0.0429) or four or more (OR=0.412, 95% CI 0.183 to 0.928, p=0.0324) also had lower odds of institutional care utilisation. However, degree of disability was no longer a significant factor in the multivariable analysis.
Analysis of the importance of specific chronic disease care needs
Internal consistency of the 12-item chronic disease care needs scale was high (Cronbach’s α=0.939). Based on overall ratings, the needs were ranked from highest to lowest as follows: regular physical examinations, rehabilitation guidance, medication guidance, chronic disease management guidance, nutritional guidance, social and entertainment activities, emotional support, medical record information sharing, online referral, remote data transmission, catheter care and wound care. The Kruskal-Wallis H test showed significant differences across items (H=732.338, p<0.0001). Pairwise comparisons showed no statistically significant differences among the five highest-ranking items, indicating that these needs were perceived as equally important. However, these five items differed significantly from the remaining items, suggesting that they were the highest priorities for this population.
Compared with participants receiving home-based care, those receiving institutional care reported higher needs for online referral, medical record information sharing, remote data transmission and nutritional guidance (p=0.009, p=0.008, p=0.006, p<0.001, respectively) (table 4). No statistically significant differences were observed for the remaining eight items.
Table 4. Comparison of specific chronic disease care needs between home-based care and institutional care settings.
| Chronic disease care needs | Mann-Whitney U | Wilcoxon W | Z | P value |
|---|---|---|---|---|
| Regular physical examination | 26 667.5 | 40 362.5 | −0.913 | 0.361 |
| Rehabilitation guidance | 26 723.5 | 84 353.5 | −0.865 | 0.387 |
| Medication guidance | 26 163.5 | 83 793.5 | −1.259 | 0.208 |
| Chronic disease management guidance | 27 037.5 | 84 667.5 | −0.646 | 0.519 |
| Nutritional guidance | 22 674.5 | 36 369.5 | −3.682 | <0.001 |
| Social and entertainment activities | 26 877 | 84 507 | −0.751 | 0.452 |
| Emotional support | 25 983 | 83 613 | −1.36 | 0.174 |
| Medical record information sharing | 24 096.5 | 37 791.5 | −2.651 | 0.008 |
| Online referral | 24 198 | 37 893 | −2.618 | 0.009 |
| Remote data transmission | 23 957.5 | 37 652.5 | −2.751 | 0.006 |
| Catheter care | 26 224.5 | 39 919.5 | −1.304 | 0.192 |
| Wound care | 26 563.5 | 40 258.5 | −1.09 | 0.276 |
Discussion
As populations age globally, particularly in China, the demand for care management among older adults with chronic disease and disability has risen sharply. This study aimed to evaluate factors associated with care modality and to characterise the specific care needs of older adults with chronic disease and disability. In our study, 18.59% of participants received institutional care, while the rest received home-based care. In this sample, we did not observe evidence of differences in care modality by household location, gender, age group, education level or insurance/payment method. In the multivariable analysis, marital status, number of children, duration of disability and number of chronic diseases were significantly associated with care modality. Moreover, regular physical examinations, rehabilitation guidance, medication guidance, chronic disease management guidance and nutritional guidance were ranked as the highest-priority needs across participants. Participants receiving institutional care also reported higher needs for digitally supported services, including online referral, medical record information sharing and remote data transmission.
In the current study, family structure factors, including marital status and number of children, were significantly associated with institutional care utilisation. Participants who were divorced, widowed or unmarried had more than threefold higher odds of receiving institutional care than married participants. Furthermore, those from single-child families had the highest likelihood of institutional care utilisation (OR=5.55, p=0.0057), whereas no significant differences were observed among families with no children or with two or more children. Previous studies generally indicate that a lack of companionship increases the likelihood of institutional care use. Some have identified marital status as the key factor,8 16 17 while others have emphasised living alone without family support.79 13 18,20 Our findings on single-child families suggest a unique dynamic: although these families may have better financial resources compared with childless families, they may also face greater caregiving pressure because there is no additional sibling support, making institutional care more appealing for managing the needs of the study population.21 These results differ from prior studies, which have typically grouped all families with children together without distinguishing between single- and multiple-child households. This underscores the importance of considering diverse family structures in future research, as the complexity of living arrangements (eg, single with no child, with one child or with more children, married with no child, one or more children, living with them or alone), may have varying effects on care decisions.
An important consideration is the relatively low proportion of single-child families in the study population, as most participants had their children before the implementation of China’s one-child policy (1979–2015). In our study, less than 10% of families had only one child. However, as the cohort affected by the one-child policy ages, demand for institutional care may increase substantially. Without sibling support, single-child families may face greater challenges in providing sustained at-home care, leading to greater reliance on institutional services. These findings suggest that older adults from single-child families may represent an increasingly important group in future institutional care planning. Policymakers and healthcare systems should take this potential shift into account by expanding institutional care capacity and ensuring that sufficient resources are available to meet future demand.
Health-related characteristics were also associated with care modality. Interestingly, participants with a disability duration of 3 or more years were significantly less likely to receive institutional care (OR=0.353, p=0.0014), as were those with multiple chronic diseases. In particular, individuals with three chronic conditions (OR=0.486, p=0.0429) or four or more (OR=0.412, p=0.0324) had lower odds of institutional care utilisation than those with one chronic disease. This pattern differs from much of the existing literature, in which greater functional limitation and higher chronic disease burden are generally associated with increased institutional care use.714 22,26 In contrast, our findings suggest that, in this rural setting, longer disability duration and a higher number of chronic diseases were associated with lower institutional care utilisation. This unexpected finding may reflect several factors. In rural areas, facilities with the staffing, rehabilitation support and medical oversight required for long-term disability and complex chronic disease management may be limited, and families may perceive that institutional care cannot adequately meet these needs. In addition, the out-of-pocket costs of long-term institutional care may remain substantial, which may discourage admission or continued institutional care even when need is high.27 Finally, cultural expectations of family responsibility for caregiving (eg, filial piety) together with preferences for ageing in place, particularly toward the end of life, may make families more likely to provide intensive care at home rather than seek institutional placement. These results highlight a potential unmet need for institutional care among participants with more complex care needs, especially in rural areas where professional care resources are scarce. Previous studies have generally associated poorer health with a higher likelihood of institutional care, but few have explored the pattern observed here, which suggests a more complex relationship between health status and care modality. Because the sampling frame was based on documented chronic disease and disability, unmet needs may be even greater among older adults with similar conditions who remain undocumented and are therefore less likely to be identified through routine management systems. Evidence from chronic disease management more broadly suggests that nonadherence and underengagement with care are often associated with worse outcomes, greater acute care use, and higher overall healthcare costs,28 29 raising the possibility that this undocumented subgroup may face even greater unmet needs. Further research is necessary to validate these findings and to examine whether undocumented individuals face additional barriers to diagnosis, chronic disease management, and access to institutional care in rural settings.
In our analysis of chronic disease care needs, regular physical examinations, rehabilitation guidance, medication guidance, chronic disease management guidance and nutritional guidance were identified as the highest-priority needs in the study population. These findings are consistent with prior studies that have highlighted the demand for basic medical services across various care settings. For instance, Dong et al found that older adults in care homes prioritised medical care, physical exercise, and recreational activities,10 while Zhao et al emphasised the importance of regular check-ups and health seminars.14 Similarly, Huang et al mentioned the critical role of regular physical examinations in older-adult care.11 These results point to a clear and sustained need for foundational health services. In addition, our study identified a greater demand for specific digitally supported functions, including online referral, medical record information sharing, and remote data transmission, among participants receiving institutional care. This reflects the structured nature of institutional care, where coordination between multiple providers and the use of integrated technology systems are more common. Although previous studies have not specifically examined demand for these services, our findings align with broader health policy discussions that emphasise the integration of healthcare with long-term care services.27 Such integration is essential for managing chronic diseases and ensuring continuity of care, particularly for older adults with multiple comorbidities. In rural settings with constrained resources, these services may be scaled through phased implementation, beginning with low-cost functions (eg, standardised electronic summaries and referral templates), linkage with county hospitals and township health centres and targeted training for nursing home staff. Feasible models may also include shared regional information platforms, simplified mobile-based reporting for routine monitoring, and clear protocols for data privacy and interoperability. Collectively, these approaches could strengthen care coordination and improve access to timely clinical support in institutional care settings.
While numerous studies have explored the willingness of older adults to use institutional care,7,1113 14 this study focused on the factors associated with actual utilisation. This distinction provides more actionable evidence for policy and service design for the study population, particularly in rural settings where care resources and institutional capacity are often limited. In addition, findings from urban centres or province-wide analyses may not fully capture the service constraints and financing challenges faced by county-level rural areas. In rural China, institutional long-term care is commonly financed through a combination of out-of-pocket payment and government subsidies, with coverage varying across localities. In Hebei Province, a national programme provides monthly electronic vouchers for older adults assessed as having moderate or severe disability, with a maximum deduction of 800 yuan per month; these vouchers offset 50% of eligible home-based services and 40% of eligible institutional services. Against this background, we propose several policy recommendations for improving care for the study population in mid-sized, moderately developed rural counties such as Qinghe County. First, there is a need to expand institutional care capacity, with professional staff capable of managing severe disability and complex chronic disease. Second, strengthening the registry for older adults with chronic disease and disability and related digitally supported functions would help authorities and care providers better identify those most in need, support more timely coordination of services, and ensure that targeted assistance is delivered more effectively. It may also help reduce the number of individuals who remain undocumented despite having substantial care needs by improving case identification, follow-up, and linkage to available services. Third, long-term care financing should be strengthened and better aligned with need, including clearer benefit design and improved affordability for prolonged institutional care among those with substantial functional limitations; this may be further supported by the forthcoming expansion of long-term care insurance arrangements.30 Finally, improving communication between nursing homes and hospitals would facilitate better coordination of care and management of medical emergencies, ultimately improving outcomes for the study population. Although disability in this study was operationalised primarily as functional limitation using the Barthel Index, our findings suggest that care-setting decisions are shaped not only by functional impairment itself but also by contextual factors. Consistent with the International Classification of Functioning, Disability and Health,31 the strategies proposed here may help reduce structural and service-access barriers by improving the fit between individual needs and available supports.
Limitations
This study has several limitations. First, the data were self-reported, which may have introduced recall bias and affected the accuracy of the responses. Second, the cross-sectional design limits causal inference and does not allow assessment of temporality between potential determinants and care modality selection; longitudinal studies are needed to clarify causal pathways and changes in care utilisation over time. Third, the study lacked comprehensive data on important factors such as whether participants lived alone and household-level socioeconomic resources, both of which could significantly influence care decisions. Although personal monthly income was collected, this measure may not adequately capture socioeconomic status in a predominantly retired population and may not reflect household resources or the affordability of long-term institutional care. In addition, some potentially relevant factors could not be analysed because of missing data, including quality-related variables for home-based and institutional settings; therefore, differences in care quality between settings were not evaluated in the present study. Fourth, because the study was conducted in a mid-sized, moderately developed rural county and the sampling frame was based on a chronic disease management registry, the findings may not be generalisable to other rural counties with different service availability or to urban settings with substantially different long-term care resources. Older adults without documented chronic disease or disability were not captured and may therefore have been missed. Accordingly, the findings should be interpreted primarily in the context of older adults with documented chronic disease and disability in this setting. Future studies using multi-site designs and including diverse rural and urban regions, more comprehensive socioeconomic measures, and more complete quality-related data are warranted to assess regional variation and strengthen the external validity of these findings.
Conclusion
Marital status, having one child, duration of disability and number of chronic diseases were significantly associated with care modality in the study population. The findings indicate substantial demand for chronic disease care services, particularly regular physical examinations, rehabilitation guidance, medication guidance, chronic disease management guidance and nutritional guidance. Strengthening care delivery systems and reducing gaps in institutional care, especially for those with severe disability and complex needs, should be priorities in similar rural settings.
Footnotes
Funding: This work was supported by the 2021 Hebei Province Department of Science and Technology Soft Science Research Project, China, grant number 21557705D.
Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-095242 ).
Data availability free text: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Patient consent for publication: Not applicable.
Ethics approval: This study was approved by the Ethics Committee of the Central Hospital of Qinghe County (#2021011), which granted a waiver of written informed consent because this was a minimal-risk questionnaire survey and data were collected anonymously. Before participation, an information statement was provided, and verbal informed consent was obtained. For participants unable to provide consent because of cognitive or communication limitations, consent was obtained from a guardian (typically a family member or primary caregiver). Participation was voluntary, and participants could decline or withdraw at any time.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct or reporting, or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
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