For disability in later years, difficulties in bathing and toileting often have high prevalence rates among older adults. Based on the data from the TVS 2014, this study investigated how difficulties of bathing and toileting of Chinese rural seniors are affected by environmental factors such as geographic location, neighbourhood condition and related facility. We found that environment plays an important role in bathing and toileting in later years, but the association of environment on disability is not unidirectional, but interactive. The disadvantaged environmental condition was highly related to more bathing difficulties of older adults; yet people with functional limitations tend to adjust environment to facilitate their toileting.
We found significant regional disparities in bathing and toileting limitations among older adults in rural China. 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. More research is clearly needed to shed light on this topic.
This study also confirms that the important role of neighbourhood factors in explaining differences in bathing and toileting limitations. A number of studies have found that neighbourhood conditions such as lighting, good traffic, security, sanitation, and public services etc. are positively associated with health and wellbeing of older residents [45-47]. Along this line of work, our study further demonstrated that good neighbourhood amenities were also related to less difficulty in bathing and toileting among Chinese rural older adults, many of whom still rely on non-home based or public facilities for bathing and toileting.
Importantly, we examined in detail the facilities 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 manners 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 in the early 2010s. 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, 48].
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 [49, 50]. This is consistent with the environmental proactivity hypothesis, that is, older persons with illness tend to make changes to their environment [51, 52], though our cross-sectional data could not directly test this. While some changes could be due to active adaptation, some could be involuntary when the health decline in old age limits the choice of older adults for toileting.
There is additional 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 [53, 54]. 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.
Our findings in this paper confirmed the significant impact of 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 lead to a decline in general population health, there could be room to reverse this negative trend through modifying environment towards more age-friendly designs and solutions. For the Chinese rural older adults specifically, this study highlighted the urgencies to promote the use of showering facilities and pedestal pans for toileting.
The importance of the role of environment in the later life, as shown in this study, is in line with a recent review on mechanism and framework of disability that highlights the role of environment in associating disability among older adults . And it also matches in line with the recent framework of healthy aging as proposed by WHO . In this new framework, capacity and ability of older adults are clearly separated so that intrinsic capacity defined as the composite of all physical and mental capacities of an individual is considered only a part of functional ability for older adults, for which “the environments they inhabit and their interaction with them are also major determinants of what older people can do” (p.2149). Therefore, healthy aging is essentially about interactions of older adults and their environment. our study is aligned with this general direction as we have demonstrated how environment matters for bathing and toileting, the two major types of disability in older adults.
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 related facilities.
There are a number of limitations in this study. Our data are cross-sectional, and thus findings of this study on the effect of environmental factors are associational rather than casual. The data was also about 6 years old in the year of 2020. Although rural China has witnessed noticeable changes within this period of time, the general situation in these areas, especially those in Central and Western China, has not been substantial . In addition, the study excluded those who could not communicate properly due to health issues, which constrained us from understanding the needs of severely unhealthy older adults, especially those with cognitive impairment. We thus encourage future studies to collect better data to address these limitations. In term of measurements, while we classified a few major types of facilities of toileting and bathing for 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 a validated index, though with a good face validity by covering major old-age-related characteristics of Chinese rural neighbourhood. We thus expect the development of a good measurement scheme for the neighbourhood 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.