The findings from this study provide national information about unmet LTC needs among community-dwelling older adults and their expectations regarding eight types of community care services. The study demonstrates that the prevalence of unmet LTC needs among community-dwelling older adults in need of assistance in ADLs is high in China. Rural-urban differences exist in the influencing factors of unmet LTC needs and elderly individuals’ expectations regarding their needs for community care services.
Prevalence of unmet LTC needs
This study shows that nearly 23.56% of community-living older adults aged 65 and over are in need of long-term care for their basic activities of daily living, and 55.07% of them report their needs as unmet in China, which is a rate that is clearly higher than that of other countries. For instance, the proportion of unmet needs has been reported to be 22% among older adults aged 65 years or older living in communities in non-institutional housing in the USA . However, some studies have indicated this proportion may have been underestimated because respondents who received assistance were not asked whether that help was adequate or sufficient in the National Long-Term Care Survey in the USA [9, 23]. Another study reported that the prevalence of BADL disability among elderly people aged 65 and over in Brazil was 16.0% and that 47.0% of those people with disabilities had their needs met, while only 10.3% did not . In that study, unmet needs were defined as the presence of at least one unavailable need for BADLs. That is, in this 47.0% of the respondents, many might have been able to obtain help but were not fully satisfied. Moreover, some indicated that the prevalence of unmet needs among elderly people who required assistance in any of the six tasks for more than 3 months in China was even higher than that of this study, reaching 61.4%. Furthermore, older adults in rural areas had a higher rate of unmet needs than their urban counterparts, which is in line with other studies [16, 24]. Despite the different measures of unmet LTC needs, we can see that China, especially rural areas of China, faces great challenges in terms of unmet LTC needs among older people.
Rural-urban differences in the influencing factors of unmet LTC needs
The results of this study indicated that the willingness of caregivers and economic status were significantly important for both urban and rural residents, similar to the prior studies [3, 8, 25]. Regardless of the caregiver's identity, the willingness of caregivers to provide care is the most influential factor with the largest OR changes. The quality of care provided by unwilling caregivers is questionable. According to Maslow's hierarchy of needs theory, respect plays an important role in human needs. If elderly individuals need to be taken care of, but the caregiver is not willing to provide the service, the elderly individuals are likely to feel that they are not respected and not valued, especially in China where filial piety is valued. Consequently, care services are difficult to satisfy. That is, service attitudes remain important in elder care, although most of caregivers are elderly people’s children. In addition, elderly people with a good economic status generally have greater access to medical resources and are better able to pay for health care services, thus lowering their risk of having unmet needs[3, 13].
Feelings of loneliness were positively associated with the risk of having unmet needs, but living alone was not among urban older residents, which is different from prior studies [13, 27]. Loneliness is believed to be a common and serious problem for the elderly population; loneliness is defined as a deficiency between an individual’s actual and desired social relationships, resulting in feelings of distress, dissatisfaction or detachment [29-31]. Previous studies have shown that older people who live alone have a higher chance of having unmet needs because they lack the strongest support from family [13, 27]. That is, a lack of family support, rather than living alone, leads to unmet needs. After retirement, the social networks of urban residents narrow substantially, and their main caregivers, their children, are usually too busy to take care of them. Urban older adults are likely to feel lonely and consequently unsatisfied with their care services. Therefore, more attention should be paid to the loneliness of urban older adults, reducing it through the provision of more support.
In contrast to urban residents, rural-dwelling older adults who were unable to access timely medication or home visits, had severe ADL disability and had poor self-rated health were more likely to have unmet LTC needs, which is consistent with previous studies. Higher levels of dependency are associated with unmet needs [16, 32]; however, for rural disabled residents, the availability of both qualified formal and informal care services is inadequate to meet their needs. First, in China, compared to urban areas, rural areas have lower population densities, poorer infrastructure, fewer qualified hospitals and nursing homes. Although rural residents reported the availability of more home visit services, the service quality of rural community health centers is also not as good as that of urban community health centers. Therefore, it is difficult for rural residents to obtain good formal care services. Second, informal care has been decreasing due to rural-urban migration . Many working age adults flock to cities from the countryside for a better job or a more modern living environment, leaving elderly people behind; thus, more rural elderly people live alone than urban elderly people, as shown in Table 1.
Community care service needs and planning for the future
In accordance with the previous results, China is facing a growing gap between diversified LTC needs and provision, both in urban and rural areas [5, 34]. Although the resources and infrastructure for elderly care are limited, most Chinese elderly people prefer to age in place, either co-residing with children or living nearby. The findings from the study indicated that the quantity of the eight kinds of community care services, such as personal care and home visits, that were in demand from the participants was approximately 2 to 13 times the quantity supplied in 2014. Whether or not the LTC needs were satisfied, the supply of personal care and psychological consulting services were far below the demand. Home visit services were most needed, followed by healthcare education services, although both of these types of services were the most accessible. More emphasis should be placed on community care services, in partnership with family and institutional services.
In addition, rural older adults need more community care services than their urban counterparts, and their specific needs vary, similar to the findings of other studies . As reported above, for urban residents, loneliness is significantly associated with unmet needs, while for rural residents, available medical services and health are a greater problem. Therefore, to decrease the possibility of unmet needs, more psychological consulting services are needed in urban areas, while personal care, home visits, psychological consulting and healthcare education services are needed in rural areas.