Disability is a key measure used by policymakers to estimate care needs among older populations. In various countries, including China, difficulties in bathing and toileting tend to have the higher prevalence rates among older adults than other ADLs. Although these two activities are highly environment-based, there has been less effort in the field to examine how environmental factors, especially built environment, matters in the disabilities of bathing and toileting, though the role of environment is well established for health and well-being of later years [41–44]. Based on the data from the TVS 2014, through examining the difficulties of bathing and toileting of Chinese rural seniors, this paper revealed the significant roles of environment factors in determining ADL disability, such as geographic location, neighbourhood conditions and built environment. To our knowledge, this is the first study on this important topic.
We found significant regional disparities in bathing and toileting limitations among older Chinese adults. This result is consistent with previous studies which have highlighted that ADL disabilities tend to be more prevalent in the Northern region . Since a substantial proportion of older adults in rural China go outdoors for bathing (about 15%) and toileting (about 40%), the climate directly influences their ability to perform these tasks. Another possible explanation for the observed regional patterns is the uneven economic development in China. Eastern and Southern provinces in China usually have better economies than their northern and western counterparts , and older adults in affluent regions may have better resources to cope with barriers of daily life.
This study also confirms that the important role of neighbourhood and community factors in explaining differences in bathing and toileting limitations. A number of recent studies have found that neighbourhood amenities and conditions such as lighting, good traffic, security, sanitation, and public services etc. are positively associated with health and wellbeing of older residents [46–48]. Along this line of work, our study further demonstrated that good neighbourhood amenities also reduced difficulty in bathing and toileting of Chinese rural older adults, for many of whom, these activities are not home-bounded, but in public facilities of the community.
Importantly, we examined in detail the built environment of bathing and toileting for older adults, an aspect that is largely omitted in existing literature. Unlike seniors from developed societies, rural Chinese older adults have various built environment of bathing and toileting. For bathing, showering indoors at home as the modern and convenient way of bathing was only adopted by about 40% of rural seniors. As expected, older people using the other bathing methods encountered more difficulties. They may have to carry additional tasks such as preparing hot water and visiting a place beyond home, deal with unexpected contingencies, and suffer a situation without surveillance of family members [25, 49].
Patterns of toileting use is rather intriguing among older Chinese adults in rural areas. A substantial proportion of these older adults (about 40%) still reported doing toileting outdoors rather than indoors, and about 30% of the sample reported doing toileting by squatting indoors. The remainder, who used bucket indoors and pedestal pan indoors for toileting, reported the most difficulty in toileting. This is somewhat counterintuitive since the bucket and pedestal pan are supposed to make toileting easier. We believe one possible explanation could be that when squatting becomes harder for some frail older adults, devices such as pedestal pan seats and bucket seat toilets are often installed to mitigate the issue and lower the risk of falls [50, 51]. This is consistent with the environmental proactivity hypothesis, that is, older persons in ill health tend to make positive changes to their environment [52, 53]. Therefore, older persons using bucket indoors and pedestal pan indoors for toileting are likely those who in poorer health.
There is good corroborating evidence for this explanation. For example, we observed that the use of bucket and pedestal pan for toileting indeed increased with age (see Table 1). Additionally, compared with solo-living older adults in rural China, those who lived with their adult children were much more likely to experience difficulties in bathing and toileting (see Table 3). Similar to the logic of the environmental proactivity hypothesis, Chinese rural older adults with health declines often chose to live with children for help, as is a norm of old-age care in China [54, 55]. Lastly, how this interesting scenario did not happen for bathing? A partial reason, we think, is that many older adults in rural China may avoid bathing if their health status disallowing, instead of actively seeking for countermeasures. In the additional analysis on bathing in wintertime of Chinese older adults, we found that seniors of poor self-reported health had much less bathing in wintertime than those with good self-reported health. Based on the discussion of both bathing and toileting as above, we propose that the association between environment and disability of old age is not unidirectional, but interactive.
Our findings in this paper confirmed the significant impact of built environment on old-age disability, and thus provided good support for the speculation on the puzzling disability trends of Chinese older adults, as raised by Zeng and colleagues (2017). That is, improvement in facilities and infrastructures of the older adult living environment could effectively reduce their disability, even if their intrinsic functional limitations become worsened . Such a conclusion has important policy implications for societies of population aging. That is, even though the population aging could lower down the general population health, there is always room for us to reverse this negative trend through modifying the built environment towards more age-friendly designs and solutions. For the Chinese rural older adults specifically, this study clearly spotted the urgencies to promote the use of showering facilities and pedestal pans for toileting.
This study also reminds us about the complicacy of the disablement process, which is not a purely biomedical issue, but heavily affected by external barriers and facilitators. One direct implication is thus to put caution on the comparability of the routine disability measures such as ADL across nations. Societies with different developmental stages often have diversified contexts for older adults to perform daily activities. Direct comparisons could be misleading, as the results are often mixed with both intrinsic body limitations and external factors. For efforts to clarify these intertwining relations, as suggested by our results, it is also needed to go beyond regional- and neighbourhood-level factors to pay attentions to the built environment.
There are a number of limitations in this study. While we classified a few major types of built environment for toileting and bathing of older adults in rural China, there is surely room of improvement for further research to refine these important measurements. The neighbourhood amenity score is also not an validated index, though with a good face validity by covering major old-age-related characteristics of Chinese rural communities. We thus expect the development of a good measurement scheme for the community environment of older adults in China. Lastly, a part of the sample of TVS 2014 did not come from national PPS sampling, but from the fieldwork of the SUFE students of the rural areas. However, these students came from all of China with quite even chance of being admitted to SUFE, and we thus perceived the sampling bias not to be severe.