1.1 Background
By the end of 2019, China's older adults population aged 60 and above reached 253.88 million, accounting for 18.1% of the total population, much higher than the UN's statistical standard of 10% of the population aging[1]. Relevant data show that China's population aged 60 and above is expected to exceed 300 million in 2025, 400 million in 2033, and will reach a peak of 487 million in 2053[2]. Along with the increasing number of older adults, the demand for older adults services is also expanding. At the same time, along with socialism with Chinese characteristics entering a new era, the demand for older adults services in China is constantly transforming and upgrading, showing a situation where basic physiological needs and spiritual and cultural needs are equally important[3]. As the older adults move from society to family after retirement, the change of environment and role has caused more and more older adults psychological quality to weaken and their demand for Cultural and Leisure Services to become more and more urgent[4]. The "Thirteenth Five-Year Plan" for the development of the national older adults and the construction of the older adults system points out that "to improve the older adults service system, enrich the spiritual and cultural life of the older adults, the development of older adults education, and the prosperity of older adults culture."
In recent years, along with the accelerated development of population aging in China, community older adults care services have received more and more attention from the government and the society. Under the guidance of government policies and market promotion, community older adults services in China have been developed rapidly, and some urban communities have even achieved full coverage of community older adults service sites[5]. Community older adults services include life care, medical care, cultural entertainment, spiritual comfort, active aging, and rights protection, which are all urgently needed to be satisfied for the older adults. However, the utilization level of community older adults services for the older adults is generally low, and the imbalance between supply and demand is becoming more and more serious, and so is the utilization of community cultural and leisure services[6]. First, the mismatch between service content and demand has led to the dilemma of "poor supply" and "poor demand" at the same time, and the supply of community cultural and leisure services mainly focuses on the most basic services such as chess and card activities, calligraphy and painting activities, and lacks senior classes, knowledge lectures, intelligent recreational activities[7]. Secondly, the services lack specialization and are difficult to meet the needs of the older adults. At present, most studies on the factors affecting the utilization of community older adults services discuss demand-side factors such as economic level, health status, family support, and lack discussions on supply-side factors such as service supply and service price, while studies on the utilization of community cultural and leisure services mainly stay at the theoretical level, with a lack of empirical studies[8]. Service supply and service demand are the prerequisites for effective service utilization, and thus determine whether service effectiveness can be generated. In order to better break the imbalance between supply and demand, improve the effectiveness of community older adults services, and promote the healthy and sustainable development of community older adults services, it is necessary to investigate the factors influencing the utilization of community cultural and leisure services from both the supply and demand sides[9].
Accordingly, this study draws on Anderson's model to construct an analytical framework for the factors influencing the utilization of community cultural and leisure services for the older adults. Based on the questionnaire survey data in Shaanxi Province, the Poisson regression method is used to empirically analyze the key factors influencing the utilization of community cultural and leisure services for the older adults from both the supply and demand sides, in order to draw insights for the future development of community cultural and leisure services.
1.2 literature review
Scholars have studied the factors influencing the utilization of community-based senior care services for older adults, focusing on overall community-based senior care service utilization, or the utilization of medical care services among them. In terms of overall community older adults service utilization, the factors that influence the utilization of older adults services are mainly gender, age, residence style, financial status, receipt of Medicaid, and health status[10][11][12][13][14]. Meanwhile, related studies show that older adults who receive support from informal caregivers such as children are more likely to use community older adults care services[15]; the more adequate social capital (social participation, volunteering, sense of belonging, social trust, etc.), the more likely older adults are to use older adults care services[16]; perceived service need and service knowledge/perception are important factors influencing older adults care service utilization[17][18]; service supply and service quality are the practical constraints for the elderly to use elderly care services[19]; socio-cultural factors may lead to urban-rural differences in the utilization of older adults care services, such as the perceptions of older adults towards community-based older adults care services and formal support[20].
In terms of health care utilization, scholars have mainly used the Anderson Health Care Utilization Model to analyze the factors influencing the utilization of health care services. Scholars' findings suggest that older adults with poorer health status (such as self-reported health, number of chronic diseases, overweight or obese) are more likely to use health care services [21][22][23][24]; the more intergenerational support (financial support, caregiving support, emotional support from children), the more older adults use health care services[25][26]; the economic level constrains older adults' use of health care services[27][28][29]; the type of health insurance has a significant impact on the level and frequency of health care services for older adults[30][31][32]; the accessibility of community health care facilities is an important factor influencing the use of health care services for older adults[33].
According to the literature, first of all, few scholars have studied the factors influencing the utilization of community-based Cultural and Leisure Services for the older adults. However, the demand for Cultural and Leisure Services of the older adults in China is becoming more and more prominent, and the demand for older adults services has changed from a single basic physical need to both basic physical needs and spiritual and cultural needs. Secondly, existing studies have focused on demand-side factors and relatively neglected the influence of supply-side factors on the service utilization of the older adults. Therefore, this study intends to focus on community cultural and leisure services and investigate the key factors affecting the utilization of community spiritual services for the older adults from both supply and demand side perspectives.
1.3 Analysis Framework
The Anderson model was created by American scholar Ronald Anderson in 1968 and was originally used to analyze the factors influencing the utilization of home health services. The fourth revision of the Anderson model in 2000 renamed the "environment" dimension and the "demographic" dimension as the "situational characteristics" dimension and the "personal characteristics" dimension, respectively, and expanded the "situational characteristics" dimension to be the same as the "personal characteristics" dimension. The "situational characteristics" dimension is expanded into the same structure as the "personal characteristics" dimension, i.e., dispositional factors, enabling resources, and need factors[34][35]. Thus, the Anderson model consists of four dimensions: situational characteristics, personal characteristics, medical behaviors, and medical outcomes, making the model more complex and complete. The situational characteristics dimension refers to the external environment. The personal characteristics dimension refers to the factors that predispose people to use medical services before the onset of disease, including demographic factors, social structural factors, and health beliefs; the enabling resources refer to the factors that ensure people's access to medical services, including personal resources, family resources, and community resources; and the need factors are the direct reasons for people to use medical services, including perceived health status and assessment of health status. Medical behavior dimension, including individual self-care, medical service process and medical service utilization. The medical outcome dimension, which includes perceived health status, assessed health status, and patient satisfaction, reflects the subjective evaluation of the individual's health care outcomes, and the health care outcomes have a negative impact on the individual's health care utilization behavior[35].
Anderson's model has become the most widely used theoretical model in health care utilization research[36] and is also applicable to analyze the influencing factors of psycho-cultural service utilization. It has been pointed out that, as a bridge between supply and demand of services, health care utilization is mainly influenced by supply-related and demand-related factors, in addition to individual characteristics[37][36]. This provides a more systematic approach to explore the determinants of health care service utilization and may overcome the shortcomings of Anderson's model. Therefore, this paper adopts this new perspective by reconstructing the Anderson model using the 2000 version of the Anderson model as the base model and considering only the individual characteristics, medical behavior, and medical outcome dimensions. In this study, the propensity factors are invariable and cannot be intervened[38][34], which can be used as control variables in this study[39], including demographic characteristics such as age and gender and social structural characteristics such as education level and household registration; community resources in the enabling factors are used as supply-side factors, resources of Cultural and Leisure Services for the older adults provided by the community, and are appropriately refined and extended, including service facility supply, service content; finally, the perceived service needs are used to measure the Cultural and Leisure Services needs of the older adults instead of the health status in the original model, and they are combined with the individual and family resources in the enabling factors and the satisfaction of the results in the "medical outcomes" in the original model as the demand-side factors, including Service need, service acceptability, economic level, and service satisfaction.
From the supply side, service supply is a prerequisite for the use of community cultural and leisure services for the older adults, including the supply of service facilities and the supply of service contents. On the basis of adequate service supply, scholars point out that the accessibility of service location and the reasonableness of service fees significantly affect the service utilization of the older adults[40][41][42]. Therefore, this paper proposes the following research hypotheses.
H1: Supply-side factors significantly affect the utilization of community cultural and leisure services for the older adults.
H1a: The supply of service facilities significantly and positively affects the use of community cultural and leisure services for the older adults.
H1b: The supply of service content significantly and positively affects the use of community cultural and leisure services for the older adults.
H1c: Service location accessibility significantly and positively affects the utilization of community cultural and leisure services for the older adults.
H1d: Reasonableness of service fees significantly and positively affects the utilization of community-based Cultural and Leisure Services for the older adults.
From the demand side, service need is the direct motivation for the older adults to utilize community cultural and leisure services, and at the same time, the conversion of this potential need into actual demand is also directly influenced by factors such as service acceptability, economic level, and the feedback influence of service satisfaction[43][44][45][18]. Therefore, this paper proposes the following research hypothesis.
H2: Demand-side factors significantly affect the utilization of community-based Cultural and Leisure Services for the older adults.
H2a: Service acceptability significantly and positively affects the use of community cultural and leisure services for the older adults.
H2b: Service satisfaction significantly and positively affects the use of community cultural and leisure services for the older adults.
H2c: Service need significantly and positively influences the utilization of community cultural and leisure services for the older adults.
H2d: Economic level significantly and positively influences the utilization of community cultural and leisure services for the older adults.
In summary, the Anderson model of health care service utilization was reconstructed from both the supply and demand sides to establish an analytical framework of factors influencing the utilization of community-based cultural and leisure services for the older adults, as shown in Fig. 1.