Abstract
What is already known about this topic?
In the context of rapid population ageing and over represented disabilities among the elderly, healthcare services for the elderly persons with disabilities are one of the most urgent and important population and public health issues. Previous studies indicated that the weighted prevalence rate of lifetime healthcare service use was 36.6% (95% CI: 35.6–37.5) among persons with disabilities aged 60 years and above in 2006.
What is added by this report?
We found that the lifetime utilization rate of auxiliary aids among elderly with disabilities increased significantly from 4.96% in 1987 to 9.07% in 2006 (ptrend<0.001), and the utilization rate of healthcare service in the last 12 months increased significantly from 18.6% in 2007 to 56.9% in 2014 (ptrend<0.001) among total elderly with disabilities.
What are the implications for public health practice?
The arduous achievement indicated the success of social, economic, and medical reforms as well as health equity improvement of China. However, more sound policies and action are needed to further reduce the unmet needs in healthcare services.
As the nation with the largest population, China has also been the country with the fastest aging speed. Providing healthcare services for the elderly persons with disabilities is one of the most urgent and important population and public health issues and also presents a major challenge for the government. Using data from the first and second China National Sample Survey on Disability (CNSSD) in 1987 and 2006, respectively, as well as the consecutive follow-up investigations once a year from 2007 to 2014, we investigated the healthcare service utilization among China’s elderly with disabilities from 1987 to 2014. Significant increases in the use of healthcare service were found, but the utilization rate in China was still lower than some high-income countries. These findings may provide information for further action and policymaking on healthcare service for the elderly, especially those living with disabilities.
The two CNSSDs were conducted to understand the prevalence, causes, and severity of various disabilities in the household population in the of mainland China. Nationally representative samples were derived by multistage, stratified random cluster sampling with probability proportional to size. The follow-up surveys aimed to investigate the living conditions, environment, and healthcare of people with disabilities in a sub-sample of those living with disabilities that were randomly selected from the second CNSSD. Standardized quality control systems including interviewer training and crosschecking of returned responses, and consistent approaches were conducted during the CNSSDs and the follow-up survey operations. More details about the surveys can be found in our previous work (1–2). For the purposes of this study, only survey respondents at and above 65 years-of-age were considered. A flowchart about the derivation of study samples was presented in a Supplementary File ( Supplementary Figure S1 available in http://weekly.chinacdc.cn/).
In the surveys, disabilities referred to one or more abnormalities in anatomical structure or the loss of a particular organ or function, either physical or psychological, that affected a person’s ability to carry out a normal activity and to participate fully in study, work, and community and social life (1). Healthcare service use in the surveys was self-reported by the respondents. In the two CNSSDs, the lifetime healthcare service use was investigated. In the 1987 survey, only the information of auxiliary aids use was investigated; in the 2006 survey, information of the rehabilitation therapy and training services use was available. In the follow-up surveys, healthcare service use was focused on the use during the past 12 months, and the health services widely involved rehabilitation therapy and training, auxiliary aids, medical diagnosis and needs assessment, psychological counseling, home service, day care and nursing, follow-up and evaluation service, rehabilitation knowledge education and so on.
In the 1987 and 2006 surveys, we constructed sample weights using standard weighting procedures allowing for complex sampling design to estimate the population weighted numbers and prevalence with 95% confidence intervals (CIs) of disability among the elderly. Population numbers and rate of healthcare service use in the utilization of healthcare service among the elderly with disabilities were calculated where appropriate. A chi-square test was used to determine the difference in utilization of healthcare service by age, sex, and residence. Wald tests of linear trend were used to determine differences in the utilization of rehabilitation services over the time series. STATA 13 (STATA Corp, College Station, TX, USA) was used for data analysis above. Annual percent change (APC) and average annual percent change (AAPC) with 95% CIs were calculated by Joinpoint Regression models with Joinpoint software (Depuy Orthopaedics Inc, IN, USA) among total elderly with disabilities and sub-population by age, sex, and residence. Details of the AAPC calculation method were shown in the supplementary file. A two-sided p-value of less than 0.05 was identified as statistically significant in all statistics of the present study.
In 1987, it was estimated that a weighted number of 16.87 million elderly were living with disability, accounting for 27.64% (95% CI: 27.34%–27.94%) of the total elderly aged 65 years old and above according to the first CNSSD, and the weighted number and proportion increased to 38.26 million and 29.42% (95% CI: 29.23%–29.61%) according to the second CNSSD, respectively. Considering the age structure of the elderly in the 2010 population census, the age-standardized prevalence of disability among elderly in 1987 and 2006 was 30.24% and 30.14%, respectively.
Table 1 presented the lifetime healthcare service use among the elderly with disabilities in 1987 and 2006. The utilization rate of auxiliary aids increased significantly from 4.96% in 1987 to 9.07% in 2006 (ptrend<0.001). The stratified analyses showed that the growth of auxiliary aids use was significant in the sub-population by age, sex, and residence (allptrend<0.001). In addition, the utilization rate of auxiliary aids in 1987 was lower in older elderly aged 80 years old and above (3.57%), female elderly (4.00%), and rural elderly (4.96%); however, the difference between age group was not found in 2006 (allptrend>0.05).
Table 1. The lifetime healthcare service use of elderly with disabilities in China, 1987–2006.
| Group | Elderly with disabilities (n) | Lifetime healthcare service use | ||||||||
| Auxiliary aids (n, %) | Rehabilitation therapy (n, %) | Any healthcare service (n, %) | ||||||||
| 1987 | 2006 | 1987 | 2006 | p trend | 2006 | 2006 | ||||
| Note: Participants were categorized by age (young elderly aged 65–79 years or super elderly aged 80 years and above), sex (male or female), and residence (rural areas or urban areas). | ||||||||||
| Total | 24,682 | 72,401 | 1,224 (4.96) | 6,570 (9.07) | <0.001 | 27,254 (37.64) | 28,300 (39.09) | |||
| Age (years) | ||||||||||
| 65–79 | 19,245 | 53,345 | 1,030 (5.35) | 4,803 (9.00) | <0.001 | 20,583 (38.58) | 21,297 (39.92) | |||
| ≥80 | 5,437 | 19,056 | 194 (3.57) | 1,767 (9.27) | <0.001 | 6,671 (35.01) | 7,003 (36.75) | |||
| p | <0.001 | 0.267 | <0.001 | <0.001 | ||||||
| Sex | ||||||||||
| Male | 10,617 | 33,548 | 662 (6.24) | 3,313 (9.88) | <0.001 | 12,547 (37.40) | 13,115 (39.09) | |||
| Female | 14,065 | 38,853 | 562 (4.00) | 3,257 (8.38) | <0.001 | 14,707 (37.85) | 15,185 (39.08) | |||
| p | <0.001 | <0.001 | 0.210 | 0.978 | ||||||
| Residence | ||||||||||
| Urban | 7,053 | 21,828 | 543 (7.70) | 3,255 (14.91) | <0.001 | 11,030 (50.53) | 11,414 (52.29) | |||
| Rural | 17,629 | 50,573 | 681 (4.96) | 3,315 (6.55) | <0.001 | 16,224 (32.08) | 16,886 (33.39) | |||
| p | <0.001 | <0.001 | <0.001 | <0.001 | ||||||
As shown in Table 2, the utilization rate of healthcare services during the last 12 months in elderly with disabilities increased significantly from 18.6% in 2007 to 56.9% in 2014 (ptrend<0.001), with a significant AAPC of 17.7% (95% CI: 9.3%–26.8%). The growth was also found in the sub-population by age, sex, and residence (allptrend<0.001). A joinpoint was found in 2012 in the stratified analyses by sex and residence, i.e. the APC increased significantly during 2007 to 2012 and maintained a relatively stable level after 2012 without significant APC ( Supplementary Table S1, available in http://weekly.chinacdc.cn/). Higher AAPCs were found in elderly aged 65−79 years old (18.0), female elderly (19.2), and rural elderly (23.1) when compared with their counterparts but not significant (all p>0.05).
Table 2. The healthcare service use during the last 12 months of elderly with disabilities in China, 2007–2014.
| Group | Total | Age (years) | Sex | Residence | |||||
| 65−79 | ≥80 | Male | Female | Urban | Rural | ||||
| Abbreviation: EWD=elderly with disabilities; HSU=healthcare service use. | |||||||||
| 2007 | |||||||||
| EWD, n | 9,871 | 7,191 | 2,680 | 4,543 | 5,328 | 2,685 | 7,186 | ||
| HSU, n (%) | 1,832 (18.6) | 1,356 (18.9) | 476 (17.8) | 853 (18.8) | 979 (18.4) | 810 (30.2) | 1,022 (14.2) | ||
| 2008 | |||||||||
| EWD, n | 9,211 | 6,580 | 2,631 | 4,255 | 4,956 | 2,514 | 6,697 | ||
| HSU, n (%) | 2,095 (22.7) | 1,495 (22.7) | 600 (22.8) | 963 (22.6) | 1,132 (22.8) | 926 (36.8) | 1,169 (17.5) | ||
| 2009 | |||||||||
| EWD, n | 15,515 | 10,829 | 4,686 | 7,193 | 8,322 | 3,957 | 11,558 | ||
| HSU, n (%) | 3,462 (22.3) | 2,417 (22.3) | 1,045 (22.3) | 1,639 (22.8) | 1,823 (21.9) | 1,410 (35.6) | 2,052 (17.8) | ||
| 2010 | |||||||||
| EWD, n | 14,474 | 9,907 | 4,567 | 6,696 | 7,778 | 3,685 | 10,789 | ||
| HSU, n (%) | 5,382 (37.2) | 3,673 (37.1) | 1,709 (37.4) | 2,483 (37.1) | 2,899 (37.3) | 1,775 (48.2) | 3,607 (33.4) | ||
| 2011 | |||||||||
| EWD, n | 12,869 | 8,541 | 4,328 | 5,979 | 6,890 | 3,225 | 9,644 | ||
| HSU, n (%) | 6,091 (47.3) | 3,979 (46.6) | 2,112 (48.8) | 2,810 (47.0) | 3,281 (47.6) | 1,833 (56.8) | 4,258 (44.2) | ||
| 2012 | |||||||||
| EWD, n | 11,979 | 7,873 | 4,106 | 5,568 | 6,411 | 3,237 | 8,742 | ||
| HSU, n (%) | 6,685 (55.8) | 4,381 (55.6) | 2,304 (56.1) | 3,104 (55.7) | 3,581 (55.9) | 2,057 (63.5) | 4,628 (52.9) | ||
| 2013 | |||||||||
| EWD, n | 11,261 | 7,191 | 4,070 | 5,215 | 6,046 | 2,991 | 8,270 | ||
| HSU, n (%) | 6,647 (59.0) | 4,271 (59.4) | 2,376 (58.4) | 3,092 (59.3) | 3,555 (58.8) | 1,950 (65.2) | 4,697 (56.8) | ||
| 2014 | |||||||||
| EWD, n | 10,439 | 6,624 | 3,815 | 4,848 | 5,591 | 2,716 | 7,723 | ||
| HSU, n (%) | 5,935 (56.9) | 3,727 (56.3) | 2,208 (57.9) | 2,745 (56.6) | 3,190 (57.1) | 1,738 (64) | 4,197 (54.3) | ||
| p trend | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | ||
DISCUSSION
Based on two large, representative population-based cross-sectional surveys covering all provincial-level administrative divisions (PLADs) of China, we found the number of the elderly with disabilities was rising in China. Since there was no significant change in the age-standardized prevalence between 1987 and 2006, the increase of number of the elderly with disabilities may be mainly caused by population aging. According to the latest statistics, there were 166.58 million elderly aged 65 years old and above in China in 2018, accounting for 11.9% of the total population (3–4). Therefore, the size of elderly with disabilities increased along with the number of the total elderly. Currently, the living population in the world was an estimated 7.8 billion in 2020, among which 9.3% were elderly aged 65 years and above (5). Global ageing had a major influence on the trend of global disability prevalence, which increased from 10% in the 1970s to 15% in the 2010s and continued to rise (6). By the 31st World Population Day, we need to focus on the wellbeing and healthcare services for the 725.4 million elderly (3), especially the elderly with disabilities in the ageing world.
This study found increases in healthcare service use among the elderly with disabilities for the first time. This is an important supplement to our previous research that reported that the weighted prevalence rate of lifetime healthcare service use among persons with disabilities aged 60 years old or more in 2006 (7). The increases found in this study were also consistent with previous studies in younger population including children and adolescents (8). These findings indicated the major progress China had achieved in providing healthcare for the elderly with disabilities in recent decades, especially after the reform and opening up. This achievement can be attributed to multi-sectoral efforts including increased access to medical resources and the improvement of medical insurance coverage following more than ten years of medical reform in China.
Additionally, the gap between different sub-populations in healthcare service use is narrowing. Specifically, the shortcomings in auxiliary aids use among the older elderly in 1987 were not found in 2006, and the average annual rise was higher in rural areas compared with urban areas but the rise was not significant. However, a gap in health service use remained between urban and rural areas, which may be caused by the low level of access to health resources in rural areas as well as health behaviors differences (9). More effort and strategies should be taken to improve the health resources, staffing, and education in rural areas.
There were still unmet needs for elderly with disabilities in healthcare service use and the total utilization rate was still lower than some high-income countries according to previous studies (10). The implementation of rehabilitation-related policies at the grass-roots level should be strengthened, better rehabilitation programs specialized for the elderly should be designed in rehabilitation institutions, and more residential/community-care should also be carried out for elderly with disabilities to improve their utilization.
This study was subject to several limitations. First, the healthcare service use was self-reported by the participants, so the results may be underestimated because of possible recall bias. Second, underestimates may also be caused by cases lost to follow up each year. Third, the elderly living in institutions such as hospitals were not represented in this community-based survey. In addition, the surveys could not cover all types of healthcare services, and we did not calculate the utilization by different types of disability, which should be explored in future studies.
In conclusion, this study showed increases with high AAPC of nationwide healthcare service use among the elderly with disabilities in China. However, more sound policies and actions are needed to in the new era to further to further narrow the gap in the healthcare service use among elderly with disabilities between China and high-income countries.
Funding: This work was funded by National Social Science Foundation of China (No. 18CRK005).
Conflict of interests: The authors declare no competing interests.
Acknowledgments
We thank all the medical workers, investigators, and all relevant staff in the two CNSSDs and follow-up surveys.
Contributor Information
Xiaoying Zheng, Email: xzheng@pku.edu.cn.
Linhong Wang, Email: linhong@chinawch.org.cn.
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