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Factors associated with the utilization of community-based health services among older adults in China—an empirical study based on Anderson’s health behavior model

Factors associated with the utilization of community-based health services among older adults in... Taking the modified Anderson health behavior model as the analysis framework and relying on 1136 empirical research data of S District in Foshan City, Guangdong Province of China, this study explores the influence of predis- posing factors, enabling factors and need factors on the utilization of community-based health services among older adults in China. The results show that three variables have a significant impact on the use of family health services, which are whether the pension is the main source of living, income surplus, and major expenditure items. Seven vari- ables have a significant impact on the use of preventive health services, which are household registration type, the basic endowment insurance coverage, the nature of the working unit before retirement, the self-rated health status, chronic diseases, self-care ability in daily life, and preventive health care needs. Keywords: Community-based health services, Influencing factors, Anderson model, Healthy aging What is known about the topic Introduction China is the country with the largest elderly population in the world. By the end of 2019, there were 253.88 mil- • Anderson health behavior model is widely used to lion people aged 60 and above, accounting for 18.1% of predict and explain individual choice and the total population [1]. With the rapid growth of the elderly population, elderly health issues require urgent use of health services. attention. The National Medical and Health Service Sys- tem Planning Outline (2015–2020) officially made it clear What does this paper adds that the elderly care service should be fully integrated with the concept of health, and the support of health ser- • Some predisposing, enabling and need factors have vices should be strengthened. Besides, community-based a significant impact on the use of community-based health services should be developed, and the capac- health services among older adults in China. ity of community-based health service organizations should be improved to provide daily care, chronic dis- *Correspondence: dhyuan@jnu.edu.cn ease management, rehabilitation, health education and Common Prosperity and National Governance Institute, Jinan University, consultation, and traditional Chinese medicine health No.601, Huangpu Dadao Xi, Guangzhou, Guangdong Province, China Full list of author information is available at the end of the article care services for older adults. Since 2016, contracts with © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Lin et al. BMC Primary Care (2022) 23:99 Page 2 of 10 general practitioner services have developed in urban study attempts to investigate the utilization of commu- areas of China [2]. Hospital institutions were encouraged nity-based health services and analyze factors affecting to extend nursing services to households. The Decision of service utilization. Considering that specific community the Fourth Plenary Session of the 19th Central Commit- health service types are distinct in different provinces tee of the Communist Party of China also pointed out that or cities in China, this study analyzes two basic types of it is necessary to speed up the construction of an elderly community health service programs in terms of family care service system, in which the older adults are pro- health services and preventive health services in the S vided with home care, taken care of by community and District of Foshan City. supported by social services. A healthy aging strategy that focuses on improving the quality of life of the elderly, Literature review shortening the survival period with diseases, and extend- The Anderson’s health behavior model was developed in ing healthy life expectancy is China’s way to actively and the West countries, and had been widely tested [4–19]. effectively respond to the rapid development of popula - In recent years, Anderson’s health behavior model has tion aging. gradually been used to explain elderly care and medical China has established primary health care agencies in decision-making behavior [6, 16, 20–23]. Some scholars urban and rural communities. In urban China, commu- have pointed out that the utilization rate of community nity health care centers or stations are the main health health services in China is not high [24–27]. Chen and care providers. In rural areas, township hospitals or vil- Chen claimed that the utilization of medical support ser- lage clinics are major health care providers. There were vices was the highest in Q street, Putuo District, Shang- 970,036 primary health care agencies in urban and rural hai, but the utilization rate was only about 30% among all communities of China by the end of 2020. Among these community residents with demands4. primary health care agencies, there were 35,365 commu- Liu et  al. conducted logistic regression analysis on the nity health service centers or stations, 35,762 township demand of health care service among older adults living hospitals, 608,828 village clinics, and 289,542 outpatient in the community based on Anderson’s health behavior departments [1]. The primary health care agencies pro - model, finding that age, the number of children, conveni - vide basic public health services for community resi- ence for medical treatment, social support, the preva- dents. Basic public health services include disease and lence of chronic diseases, cognitive level, as well as the emergency prevention services, family health services, degree of fragility and depression were factors influenc - family rehabilitation, hospice and other medical services, ing older adults’ demand for health and nursing care health care services, and health education services. Chi- services [16]. Based on the 2014 Chinese Longitudinal nese residents can get access to these public health ser- Healthy Longevity Survey (CLHLS), Chen and Wang vices with support from government funding, universal observed that loneliness, community-based life care ser- health insurance coverage, and the basic public health vices, and chronic diseases were the influencing factors of service program [3]. In urban communities, community- unmet care needs [25]. Peng et al. used Anderson’s health based health services for older adults mainly include behavior model to analyze the related factors affecting daily care, chronic disease management, rehabilitation, the use of long-term care services for the disabled elderly health education and consultation, and traditional Chi- in China [22]. The study showed that enabling factors nese medicine health care services. Some services such and need factors had a significant impact on the choice as health education and consultation services are free for of services, while the predisposing factors had not passed older adults, and some services such as daily care are not the significance test. free but the partial fees could be covered by health insur- In recent years, with the implementation of the policy ance. Some disadvantaged older adults can get access to of “Combining Medical Care with Nursing Care into the these public services covered by social assistance pro- Community”, the health services are incorporated into grams or by community charitable endowment funds. the community-based care system. But health services In rural China, some developed areas have established are not exactly the same as existing services such as daily community service provision systems providing similar care services. The existing literature used the Anderson’s types of community services as in urban areas. The less- health behavior model to discuss health service utiliza- developed rural areas mainly provide disease treatment tion in hospitals, but ignored the health service utiliza- services due to the paucity of public finance. tion in the community settings. To fill the identified But at present, there are still few empirical studies on knowledge gap, this study adopts the modified Ander - the efficiency and the effectiveness of community-based son health behavior model as the analysis framework to health service utilization. Taking the S District of Foshan analyze a survey data from the elderly population in S City, Guangdong Province of China as an example, this District of Foshan City, Guangdong Province of China, Lin  et al. BMC Primary Care (2022) 23:99 Page 3 of 10 aiming to identify key factors that affect older adults variable. Considering the quadratic effect of age, the using two types of community-based health services. square of age was used as the independent varia- This study uses the modified Anderson’s health behav - ble.③ The household registration type was a multi- ior model as the theoretical framework, and classifies classification variable (1 = agricultural household various individual factors that may affect the older adults’ registration, 2 = non-agricultural household reg- use of community-based health services as independ- istration, 3 = unified household registration), with ent variables. In order to better apply Anderson’s health “agricultural household registration” as the refer- behavior model in China, it is necessary to supplement ence group.④ The education level was divided into the indicators. The social insurance variables (the insured three levels (1 = no schooling, 2 = primary school, situation of basic endowment insurance and basic medi- 3 = junior high school and above), with “no school- cal insurance), the variable of working unit (the nature of ing” as the reference group.⑤ Marital status was a the working unit before retirement), the traditional vari- dummy variable (0 = unmarried, 1 = married). This able of family culture (the number of people living with study classified unmarried, divorced and widowed the family and the living conditions with their families) into “unmarried” category. are supplemented. This study investigates the influence (2) Enabling factors.① Basic endowment insurance, as of Chinese cultural tradition, social insurance system, a classification variable, “retirement pension system and other factors on the utilization of community-based of government and institution” was taken as a ref- health services among older adults in China, which erence group.② Basic medical insurance, as a clas- also makes the Anderson’s health behavior model more sification variable, with “public medical system of comprehensive. institutions” as the reference group.③ The nature of the working unit before employment or retire- Research design ment was a dummy variable (0 = no working unit, Data sources including farming; 1 = having a working unit).④ The data used in this paper came from the community The average monthly income was divided into six elderly care service survey conducted by S District Social levels (1 = 1000 RMB and below, 2 = 1001–2000 Innovation Center entrusted by the Party Committee and RMB, 3 = 2001–3000 RMB, 4 = 3001–4000 RMB, Government Office of S District in Foshan City, Guang- 5 = 4001–5000 RMB, 6 = 5001 RMB and above), dong Province in 2017. The survey samples cover 4 street with “1000 RMB and below” as the reference communities and 5 township communities in S District, group.⑤ Income surplus is divided into three levels and the respondents were elderly people over 60 years (1 = make ends meet, 2 = basically enough, 3 = sur- old. The sample was selected by using the multistage plus), with “make ends meet” as the reference sampling method. The survey was conducted in person. group.⑥ Whether pension is the primary source of A total of 1136 questionnaires were collected, of which living is a dummy variable (0 = no, 1 = yes).⑦ The 1061 were valid. The response rate was around 93.4%. main expenditure items were classified variables, with “daily diet and clothing consumption” as the Variable selection reference group.⑧ The number of family members Dependent variable living together was a continuous variable.⑨ Living The dependent variables of this study are the use of conditions were classified variables (1 = living with community-based health services among older adults, husband, wife and other family members, 2 = liv- including the use of family health services (family doc- ing with family members without the respondent’s tors, family beds, family appointment visits, family reha- husband and wife, 3 = living with husband and wife bilitation guidance and other personalized services) only, 4 = living alone). and the use of preventive health services (e.g., physical (3) Need factors.① Health status: the data was examination, chronic disease prevention, health records). obtained through the self-rated health status of the The three dependent variables are binary variables. The interviewees. There were five options in the ques - elderly who used these community-based health services tionnaire: “very healthy, relatively healthy, general, in the past 12 months were defined as 1, and those who relatively unhealthy and very unhealthy”. In this did not use were defined as 0. study, “very healthy and relatively healthy” was defined as “good health”, which was assigned as 1, Independent variable and the remaining three options were defined as “poor health” with a value of 0.② Patients with chronic disease were dummy variables (0 = no, (1) Predisposing factor.① Gender is a dummy vari- 1 = yes).③ Self-care ability of daily life was a able (0 = female, 1 = male).② Age is a continuous Lin et al. BMC Primary Care (2022) 23:99 Page 4 of 10 demand is also significantly associated with service utili - dummy variable (0 = no difficulty, 1 = difficulty). zation (χ 2 = 492.916, P < 0.001). Eight questions were set up in the questionnaire to ask the respondents whether they could indepen- dently carry out daily activities (ADL: including eat- Regression analysis ing, bathing, defecation and indoor activities) and Table  3 reports the diagnosis results of multicollinearity instrumental daily activities (IADL: including cook- of independent variables. The variance expansion factor ing, washing clothes, shopping, taking public trans- (VIF) of each variable is far less than 10, indicating that portation) to assess the living ability of the respond- the problem of multicollinearity between independent ents. If any of the activities of daily life were difficult variables is not serious. (choose “need some help” or “completely”), it was Table  4 presents the results of regression models. The defined as “having difficulty in self-care ability in three logistic regression models constructed in this daily life”.④ The need for health care for the elderly study all passed the significance test, that is, Model 1 (χ was a dummy variable (0 = no need, 1 = need). 2 = 67.486, P < 0.001), Model 2 (χ 2 = 629.777, P < 0.001), and Model 3 (χ 2 = 487.097, P < 0.001) were statistically significant. Statistical analysis The influence of predisposing factors The dependent variable in this paper is a binary variable, The two models showed that the type of household reg - which is suitable for the binary logistic regression model. istration had a significant influence on the use of pre - u Th s, three binary logistic regression models were used ventive health care services. The results showed that to predict the utilizations of family health services and compared with agricultural household registration, the preventive health services. This study used descriptive elderly with non-agricultural household registration statistics to described the characteristics of all variables. (β = − 0.702, P < 0.01) and unified household (β = − 0.791, Thereafter, two Chi-Square tests were used to examine P < 0.01) were less likely to use preventive health care ser- the relationship between service demand and service uti- vices. There was no significant effect on the use of family lization. And then two regression models were employed health services by the elderly. to predict service utilization. The statistical software package SPSS 24.0 (International Business Machines The influence of enabling factors Corp: Beijing, China) was applied for all data analyses. The empirical results showed that the basic endowment insurance coverage of the elderly, the nature of the work- Results ing unit before retirement, average monthly income, Descriptive statistics whether the pension is the main source of living, income The basic information of the sample is shown in Table  1. surplus, major expenditure items, and living condi- The situation of elderly people using family health ser - tions had a significant impact on whether the elderly use vices in terms of family doctors, family beds, family community-based health services. In terms of the use of appointment visits, rehabilitation guidance, and other family health services, compared with the elderly who family medical and health services was not well. The did not rely on pension as the main source of living, the demand rate was 20.7% among all respondents, while elderly people with pension as the main source of income the utilization rate was only 0.8% in total sample. The were more likely to use family health services (β = 3.556, demand rate of preventive health care services such as P < 0.1). The effect of income surplus on the use of family physical examination, chronic disease treatment, and health services is negative, that is, the elderly with “ make health records reached 66.6%, and the utilization rate was ends meet “ are more likely to use family medical services 52% in total sample. than those with “basically sufficient income” (β = − 4.55, P < 0.05). The possible explanation for this statisti - Chi‑Square tests cal result is that there is a reverse causal relationship Table  2 indicates the relationship between service between the income surplus and whether the elderly use demand and service utilization. Among the respond- family health services. Because of the large proportion ents with the demand for family health service, only 4% of medical expenditures and the high amount of medical of them had used this type of service. 75.3% of respond- expenditures, this part of the elderly “cannot make ends ents with demand for preventive health care services had meet”. Taking the elderly whose main expenditure items used this type of service. The relationship between family were daily diet and clothing consumption as the refer- health service demand and the utilization is significant (χ ence group, the elderly whose main expenditure items 2 = 34.462, P < 0.001). The preventive health care service were “water, electricity, property, transportation and Lin  et al. BMC Primary Care (2022) 23:99 Page 5 of 10 Table 1 Descriptive statistics of variables (n = 1061) Variable Mean (SD) or Per cent Dependent variable Family health medical services (Use) 0.8% Preventive health services (Use) 52% Predisposing factors Gender (Male) 44.4% Age (Mean / SD) 71.48/1.705 Household registration Agricultural household registration 63.7% Non agricultural household registration 20% Unified household registration 16.3% Education level No formal education (illiterate) 18.9% Primary school 58.8% Junior high school and above 22.3% Marital status (married) 72.7% Demand factors Self rated health (good health) 50.2% Suffering from chronic diseases (yes) 57.4% Self care ability in daily life (yes) 90.2% Demand for health-related services Family health service (No) 79.3% Preventive health care services (No) 33.4% Enabling factors The nature of the working units before the current employment or retirement (Having 50.40% working units) Basic endowment insurance Retirement pension system of government and institution 4.5% Basic endowment insurance for urban employees 34.5% Basic endowment insurance for urban and rural residents 40.9% Did not participate in any social endowment insurance 20.1% Basic medical insurance Public medical system of government and institution 3.9% Basic medical insurance for urban employees 32.2% Basic medical insurance for urban and rural residents 55.9% No social medical insurance 8% Average monthly income 1000 RMB and below 31.3% 1001–2000 RMB 28.7% 2001-3000RMB 20.5% 3001-4000RMB 12.9% 4001-5000RMB 3.3% 5001RMB and above 3.2% Income surplus Make ends meet 24.9% Basically enough 64.7% Lin et al. BMC Primary Care (2022) 23:99 Page 6 of 10 Table 1 (continued) Variable Mean (SD) or Per cent There is a surplus 10.5% Pension as the main source of living (Yes) 51.5% Major expenditure items Daily diet and clothing consumption 75.6% Water, electricity, property, transportation and communication 5.3% See a doctor / buy health products 16.5% Rehabilitation nursing / professional nursing service fee 0.7% Domestic service 0.4% Cultural and entertainment consumption 1.5% Number of CO residents (Mean / SD) 4.15/0.06 Living conditions Living with husband, wife and other family members 50.5% Living with family members without the respondent’s husband and wife 26.8% Living with husband and wife only 15.2% Living alone 7.5% communication” (β = 6.647, P < 0.05) and “seeing a doctor Table 3 Collinearity diagnosis / purchasing health care products” (β = 3.982, P < 0.05) were more likely to use family health services. Independent variable Family Preventive health health Concerning the use of preventive health care ser- service services vices, compared with the elderly who enjoyed the VIF VIF retirement pension treatment of government insti- tutions, the elderly who participated in the basic Gender 1.198 1.199 endowment insurance of urban and rural residents Age 1.027 1.027 (β = − 2.461, P < 0.1) and those who did not partici- Registered residence 1.350 1.350 pate in any social endowment insurance (β = − 2.511, Marital status 1.387 1.384 P < 0.05) were less likely to use preventive health Education level 1.367 1.366 care services. At present, the pension of govern- Basic endowment insurance 3.493 3.479 ment institutions is higher than that of employees, Basic medical insurance 2.779 2.775 Nature of working unit before retirement 1.673 1.657 Average monthly income 2.019 2.000 Table 2 Relationship between health service demand and Pension as the main source of living 1.720 1.721 service utilization (n = 1061) Income surplus 1.353 1.351 Family health medical Preventive health services Major expenditure items 1.083 1.088 services Number of co-residents 2.039 2.027 Not having Having Not having Having Living conditions 2.299 2.292 demand demand demand demand Self rated health 1.344 1.353 Suffering from chronic diseases 1.230 1.284 Did not use 885 224 355 186 Self care ability in daily life 1.142 1.132 Use 0 9 19 566 Demand for family health services 1.053 Chi-square 34.462*** 492.916*** Demand for preventive health services 1.091 *p < 0.1, **p < 0.05, ***p < 0.01 Lin  et al. BMC Primary Care (2022) 23:99 Page 7 of 10 Table 4 Logistic regression result Variable Family health service Prevention health service β value Exp(B) β value Exp(B) Constant −59.995 0.000 −1.577 0.207 Gender (Reference group: Female) 2.266 9.643 −0.122 0.885 Age 0.902 2.464 0.009 1.009 Age squared −0.006 0.994 0 1 Household registration (Reference group: Agricultural household registration) Non agricultural household registration −2.45 0.086 −0.702*** 0.496 Unified household registration − 22.152 0.000 −0.791*** 0.453 Marital status (Control group: Unmarried) 0.042 1.043 0.228 1.257 Education level (Reference group: No formal education) Primary school 1.915 6.788 0.054 1.055 Junior high school and above −15.743 0.000 −0.304 0.738 Basic endowment insurance (Reference group: Retirement pension system of government and institution) Basic endowment insurance for urban employees −11.606 0.000 −1.941 0.144 Basic endowment insurance for urban and rural residents −8.958 0.000 −2.461* 0.085 Did not participate in any social endowment insurance −4.544 0.011 −2.511** 0.081 basic medical insurance (Reference group: Public medical system of government and institution) Basic medical insurance for urban employees 3.231 25.313 0.354 1.424 Basic medical insurance for urban and rural residents 2.544 12.73 0.157 1.17 No social medical insurance 5.385 218.195 0.67 1.954 Nature of unit before retirement (Reference group: No working unit) −0.212 0.809 0.473* 1.605 Average monthly income 1.962 7.11 −0.134 0.875 Pension as the main source of living (Reference group: No) 3.556* 35.04 −0.263 0.769 Income surplus (Reference group: Make ends meet) Basically enough −4.45** 0.012 −0.167 0.846 There is a surplus −13.527 0 −0.085 0.918 Major expenditure items (Reference group: Daily diet and clothing consumption) Water, electricity, property, transportation and communication 6.647** 770.587 −0.265 0.767 See a doctor / buy health products 3.982** 53.63 0.393 1.482 Rehabilitation nursing / professional nursing service fee −21.364 0 −20.758 0 Domestic service −14.113 0 −0.748 0.473 Cultural and entertainment consumption 8.52 5016.197 0.602 1.826 Number of CO residents −0.365 0.694 0.053 1.054 Living conditions (Reference group: Living with husband, wife and other family members) Living with family members without the respondent’s husband and wife 0.576 1.779 0.172 1.187 Living with husband and wife only −4.098 0.017 0.247 1.281 Living alone 3.062 21.376 −0.224 0.799 Self rated health(Reference group: Poor health) −0.75 0.721 −0.355* 0.701 Suffering from chronic diseases (Reference group: No) 0.848 2.334 0.397** 1.488 Self care ability in daily life (Reference group: No difficulty) 2.451 11.595 −1.052*** 0.349 Family health service demands (Reference group: no demand) 21.391 1.95E+ 09 / / Preventive health service demands (Reference group: no demand) / / 4.357*** 78.03 Chi‑square (df ) 67.486 (32)*** 629.777 (32)*** *p < 0.1, **p < 0.05, ***p < 0.01 and the pension of employees is higher than that of services. Compared with the elderly who enjoy the residents. The level of pension to a large extent repre- retirement treatment of government institutions, the sents the economic ability of the elderly, thus affecting elderly who did not participate in any social endow- whether the elderly groups use preventive health care ment insurance were the least likely to use preventive Lin et al. BMC Primary Care (2022) 23:99 Page 8 of 10 health care services. Before retirement, the elderly Compared with the elderly without chronic diseases, with working units were more likely to use preventive the elderly with chronic diseases used more preventive health services than those without (including farming) health services (β = 0.397, P < 0.05). With the decline of (β = 0.473, P < 0.1). Similar to the above explanation health status, the elderly with chronic diseases have a of the possibility of participating in the basic endow- stronger demand for prevention and health care, which ment insurance, the old people who have a working is consistent with the research of Li [11]. The disease is unit before retirement enjoy the retirement treat- a major adverse factor that perplexes the elderly in their ment of government and public institutions or receive later years, and the elderly diseases are mainly cardiovas- employee pension, which may be more secure in terms cular and cerebrovascular diseases (hypertension, coro- of source of living than the elderly without a unit nary heart disease, and cerebral apoplexy), diabetes, and (including farming). The difference like the working other common chronic diseases. The elderly with chronic units before retirement is also reflected in the aspect diseases are more likely to use community preventive of health security. The retirees of some working units health care services because they need to pay attention enjoy the benefits of public medical treatment of gov- to and investigate their own health problems at all times, ernment institutions or basic medical insurance for so as to reduce the potential risks. The elderly with pre - urban workers, while the retirees without a unit can ventive care needs were more likely to use services than only participate in the basic medical insurance for those without (β = 4.357, P < 0.01). urban and rural residents, or even not participate in In terms of family health services, although the ena- any basic medical insurance. Regardless of whether it bling factors had not passed the significance test, it is is outpatient or inpatient, the level of protection and found that the elderly with poor health status, chronic strength of the above two is quite different. There- diseases, difficulties in daily life and family health service fore, the nature of the pre-retirement working unit is demand were more likely to use family health services. more likely to affect the elderly’s attitude toward seek- With the growth of age, the physical health status of the ing medical care in the economic dimension, as well elderly gradually deteriorates, and the risk of chronic dis- as their medical actions-whether to use preventive eases continues to increase. In addition, daily self-care health services. ability is declining and health problems are prominent. As a result, the possibility of using family health services will increase. The influence of need factors The empirical results showed that the health status of Discussion need factors, chronic diseases, self-care ability of daily The results show that among the 18 independent vari - life, and service need had a significant influence on ables, three variables have a significant impact on the use whether the elderly use community-based health ser- of family health services, which are whether the pension vices. In terms of preventive health care services, the is the main source of living, income surplus and major impact of self-rated health status and self-care abil- expenditure items. Seven variables have a significant ity of daily life on the use of services is negative, that impact on the use of preventive health services, which is, the elderly with poor health status are more likely are household registration type, the basic endowment to use preventive health care services than those with insurance coverage, the nature of the working unit before good health status (β = − 0.355, P < 0.1), which is simi- retirement, the self-rated health status, chronic dis- lar to the research conclusion of Chen and Ma [14]. The eases, self-care ability in daily life, and preventive health worse the physical condition of the elderly, the higher care needs., Several predictors such as social support, the demand for health services, thus, the more likely the prevalence of chronic diseases, and degree of fragil- they are to use preventive health services. The elderly ity are similar to the findings of Liu et  al. [16] who used with no difficulties in daily life were more likely to use Andersen’s model to predict community health and nurs- preventive health services than those with difficul - ing services’ demands. Based on the findings, this study ties (β = − 1.052, P < 0.01). The possible explanation for provides the following suggestions for improving the use this statistical result is that the elderly people who take efficiency of community-based health services. care of themselves are more sensitive and free in walk- First, the government should pay attention to the eco- ing, daily activities, eating, and defecation, and so on, nomic income of the elderly, and improve the health care so they take the initiative to participate in the physical service subsidy system. The results show that economic examination and chronic diseases provided by the com- variables such as basic endowment insurance, average munity. Another possibility is that people using preven- monthly income, whether the pension is the main source tive health services are healthier and less likely to have of living, income surplus, main expenditure items, and difficulties in daily life. Lin  et al. BMC Primary Care (2022) 23:99 Page 9 of 10 other economic variables have a significant impact on elderly care services based on the health needs of the whether the elderly use health care services. Some lower- elderly, deepen the quality of services, and further income elderly people may be difficult to purchase and enhance the sense of acquisition and satisfaction of the use community-based health services because of their elderly. insufficient ability to pay. The government should further Last but not the least, the Chinese government improve the classification of the elderly’s health status should strengthen the capacity of community health and economic income evaluation mechanism, formulate service provision agencies in urban and rural areas. detailed and reasonable service subsidy standards, and The Chinese government should further promote the provide appropriate subsidies for the purchase of health development mode of combining medical care with and elderly services for low-income elderly people who nursing care into the community, actively develop do have a demand for health and elderly care services healthy elderly care service projects, and improve the and lack financial capacity. By doing this, service provi - professionalism of health care services and the acces- sion organizations can transform potential demands into sibility and convenience of elderly access to services. At actual demands and increase service utilization rate [11]. the community level, we should strengthen the public- At the same time, differentiated government subsidies and ity of health care services through multiple channels, the scope of government-purchased services can be estab- improve the overall cognitive level of the elderly on lished according to different types and levels of health and the health care service projects, cultivate the positive elderly care services, and the threshold for enjoying gov- aging concept of the elderly, and enhance the cognition, ernment-purchased services can be appropriately relaxed, acceptance and participation of the elderly in the com- so that more needy elderly people can enjoy free services. munity service model. Second, the government should establish a unified Although the survey sample is representative of the evaluation mechanism of community home-based care elderly population in the study area, the findings can - services. The results of this study show that the utili - not be generalized to all aged population in China con- zation rate of community-based health services in S sidering community health services are heterogeneous District is not high, which may be due to the insuffi - in different cities. Regarding the representativeness of cient supply of health care services and the mismatch Guangdong province, the economic and social develop- between supply and need. Logistic regression results ment of S District of Foshan City is lined up in front confirmed that there were differences in the influenc - of Guangdong Province, thus S District can represent ing factors of different types of service use, and the the developed areas of Guangdong Province, but can- elderly with health care service needs were more likely not represent the whole Guangdong Province. In addi- to use health service items. Therefore, the service sup - tion, this study did not include all types of community ply should respond to the health demands of the elderly health services for older adults due to the lack of data. to achieve the balance of supply and need of commu- Nevertheless, this study contributes to understanding nity-based health services. It is necessary to establish the application of Andersen’s model in community- a unified health status classification and needs assess - based health service utilization among older adults in ment mechanism, and establish an elderly information the Chinese context. database to comprehensively integrate and evaluate the Acknowledgements information of the elderly, such as age, physical health Not applicable. status, self-care ability, family situation, and economic Authors’ contributions status. According to the health status and needs assess- LWY designed this study. LWY analyzed and interpreted the data. LWY was ment results of the elderly, accurately identify service a major contributor in writing the manuscript. YWX and YDH made a major needs, flexibly and accurately provide different kinds contribution to revise the manuscript. LWY read and approved the final manu- script. The author(s) read and approved the final manuscript. of community-based health services for different older adults, and allocate community medical and health Funding resources and pension service resources fairly and This article was funded by National Philosophy and Social Science Foundation of China ( Title: Research on the integration of technology and practical effects effectively. Service providers should accurately identify in the smart elderly care service system, No: 21B[GL0031]1) and Guangdong service needs based on the health status of the elderly Province Philosophy and Social Science Planning Project ( Title: The formation and the results of needs assessments, flexibly and mechanism, influence and intervention of structural stigma of major sudden acute infectious diseases, No: GD20CGL02). The funders had no role in the accurately delivering differentiated and personalized design of the study, the collection, analysis and interpretation of data. community health and elderly care services to service targets. Community health resources and elderly care Availability of data and materials The datasets used and/or analysed during the current study available from the service resources should be allocated fairly and effec - corresponding author on reasonable request. tively [9]. At the same time, we will continue to expand Lin et al. 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Factors associated with the utilization of community-based health services among older adults in China—an empirical study based on Anderson’s health behavior model

BMC Primary Care , Volume 23 (1) – May 2, 2022

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Abstract

Taking the modified Anderson health behavior model as the analysis framework and relying on 1136 empirical research data of S District in Foshan City, Guangdong Province of China, this study explores the influence of predis- posing factors, enabling factors and need factors on the utilization of community-based health services among older adults in China. The results show that three variables have a significant impact on the use of family health services, which are whether the pension is the main source of living, income surplus, and major expenditure items. Seven vari- ables have a significant impact on the use of preventive health services, which are household registration type, the basic endowment insurance coverage, the nature of the working unit before retirement, the self-rated health status, chronic diseases, self-care ability in daily life, and preventive health care needs. Keywords: Community-based health services, Influencing factors, Anderson model, Healthy aging What is known about the topic Introduction China is the country with the largest elderly population in the world. By the end of 2019, there were 253.88 mil- • Anderson health behavior model is widely used to lion people aged 60 and above, accounting for 18.1% of predict and explain individual choice and the total population [1]. With the rapid growth of the elderly population, elderly health issues require urgent use of health services. attention. The National Medical and Health Service Sys- tem Planning Outline (2015–2020) officially made it clear What does this paper adds that the elderly care service should be fully integrated with the concept of health, and the support of health ser- • Some predisposing, enabling and need factors have vices should be strengthened. Besides, community-based a significant impact on the use of community-based health services should be developed, and the capac- health services among older adults in China. ity of community-based health service organizations should be improved to provide daily care, chronic dis- *Correspondence: dhyuan@jnu.edu.cn ease management, rehabilitation, health education and Common Prosperity and National Governance Institute, Jinan University, consultation, and traditional Chinese medicine health No.601, Huangpu Dadao Xi, Guangzhou, Guangdong Province, China Full list of author information is available at the end of the article care services for older adults. Since 2016, contracts with © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visithttp:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Lin et al. BMC Primary Care (2022) 23:99 Page 2 of 10 general practitioner services have developed in urban study attempts to investigate the utilization of commu- areas of China [2]. Hospital institutions were encouraged nity-based health services and analyze factors affecting to extend nursing services to households. The Decision of service utilization. Considering that specific community the Fourth Plenary Session of the 19th Central Commit- health service types are distinct in different provinces tee of the Communist Party of China also pointed out that or cities in China, this study analyzes two basic types of it is necessary to speed up the construction of an elderly community health service programs in terms of family care service system, in which the older adults are pro- health services and preventive health services in the S vided with home care, taken care of by community and District of Foshan City. supported by social services. A healthy aging strategy that focuses on improving the quality of life of the elderly, Literature review shortening the survival period with diseases, and extend- The Anderson’s health behavior model was developed in ing healthy life expectancy is China’s way to actively and the West countries, and had been widely tested [4–19]. effectively respond to the rapid development of popula - In recent years, Anderson’s health behavior model has tion aging. gradually been used to explain elderly care and medical China has established primary health care agencies in decision-making behavior [6, 16, 20–23]. Some scholars urban and rural communities. In urban China, commu- have pointed out that the utilization rate of community nity health care centers or stations are the main health health services in China is not high [24–27]. Chen and care providers. In rural areas, township hospitals or vil- Chen claimed that the utilization of medical support ser- lage clinics are major health care providers. There were vices was the highest in Q street, Putuo District, Shang- 970,036 primary health care agencies in urban and rural hai, but the utilization rate was only about 30% among all communities of China by the end of 2020. Among these community residents with demands4. primary health care agencies, there were 35,365 commu- Liu et  al. conducted logistic regression analysis on the nity health service centers or stations, 35,762 township demand of health care service among older adults living hospitals, 608,828 village clinics, and 289,542 outpatient in the community based on Anderson’s health behavior departments [1]. The primary health care agencies pro - model, finding that age, the number of children, conveni - vide basic public health services for community resi- ence for medical treatment, social support, the preva- dents. Basic public health services include disease and lence of chronic diseases, cognitive level, as well as the emergency prevention services, family health services, degree of fragility and depression were factors influenc - family rehabilitation, hospice and other medical services, ing older adults’ demand for health and nursing care health care services, and health education services. Chi- services [16]. Based on the 2014 Chinese Longitudinal nese residents can get access to these public health ser- Healthy Longevity Survey (CLHLS), Chen and Wang vices with support from government funding, universal observed that loneliness, community-based life care ser- health insurance coverage, and the basic public health vices, and chronic diseases were the influencing factors of service program [3]. In urban communities, community- unmet care needs [25]. Peng et al. used Anderson’s health based health services for older adults mainly include behavior model to analyze the related factors affecting daily care, chronic disease management, rehabilitation, the use of long-term care services for the disabled elderly health education and consultation, and traditional Chi- in China [22]. The study showed that enabling factors nese medicine health care services. Some services such and need factors had a significant impact on the choice as health education and consultation services are free for of services, while the predisposing factors had not passed older adults, and some services such as daily care are not the significance test. free but the partial fees could be covered by health insur- In recent years, with the implementation of the policy ance. Some disadvantaged older adults can get access to of “Combining Medical Care with Nursing Care into the these public services covered by social assistance pro- Community”, the health services are incorporated into grams or by community charitable endowment funds. the community-based care system. But health services In rural China, some developed areas have established are not exactly the same as existing services such as daily community service provision systems providing similar care services. The existing literature used the Anderson’s types of community services as in urban areas. The less- health behavior model to discuss health service utiliza- developed rural areas mainly provide disease treatment tion in hospitals, but ignored the health service utiliza- services due to the paucity of public finance. tion in the community settings. To fill the identified But at present, there are still few empirical studies on knowledge gap, this study adopts the modified Ander - the efficiency and the effectiveness of community-based son health behavior model as the analysis framework to health service utilization. Taking the S District of Foshan analyze a survey data from the elderly population in S City, Guangdong Province of China as an example, this District of Foshan City, Guangdong Province of China, Lin  et al. BMC Primary Care (2022) 23:99 Page 3 of 10 aiming to identify key factors that affect older adults variable. Considering the quadratic effect of age, the using two types of community-based health services. square of age was used as the independent varia- This study uses the modified Anderson’s health behav - ble.③ The household registration type was a multi- ior model as the theoretical framework, and classifies classification variable (1 = agricultural household various individual factors that may affect the older adults’ registration, 2 = non-agricultural household reg- use of community-based health services as independ- istration, 3 = unified household registration), with ent variables. In order to better apply Anderson’s health “agricultural household registration” as the refer- behavior model in China, it is necessary to supplement ence group.④ The education level was divided into the indicators. The social insurance variables (the insured three levels (1 = no schooling, 2 = primary school, situation of basic endowment insurance and basic medi- 3 = junior high school and above), with “no school- cal insurance), the variable of working unit (the nature of ing” as the reference group.⑤ Marital status was a the working unit before retirement), the traditional vari- dummy variable (0 = unmarried, 1 = married). This able of family culture (the number of people living with study classified unmarried, divorced and widowed the family and the living conditions with their families) into “unmarried” category. are supplemented. This study investigates the influence (2) Enabling factors.① Basic endowment insurance, as of Chinese cultural tradition, social insurance system, a classification variable, “retirement pension system and other factors on the utilization of community-based of government and institution” was taken as a ref- health services among older adults in China, which erence group.② Basic medical insurance, as a clas- also makes the Anderson’s health behavior model more sification variable, with “public medical system of comprehensive. institutions” as the reference group.③ The nature of the working unit before employment or retire- Research design ment was a dummy variable (0 = no working unit, Data sources including farming; 1 = having a working unit).④ The data used in this paper came from the community The average monthly income was divided into six elderly care service survey conducted by S District Social levels (1 = 1000 RMB and below, 2 = 1001–2000 Innovation Center entrusted by the Party Committee and RMB, 3 = 2001–3000 RMB, 4 = 3001–4000 RMB, Government Office of S District in Foshan City, Guang- 5 = 4001–5000 RMB, 6 = 5001 RMB and above), dong Province in 2017. The survey samples cover 4 street with “1000 RMB and below” as the reference communities and 5 township communities in S District, group.⑤ Income surplus is divided into three levels and the respondents were elderly people over 60 years (1 = make ends meet, 2 = basically enough, 3 = sur- old. The sample was selected by using the multistage plus), with “make ends meet” as the reference sampling method. The survey was conducted in person. group.⑥ Whether pension is the primary source of A total of 1136 questionnaires were collected, of which living is a dummy variable (0 = no, 1 = yes).⑦ The 1061 were valid. The response rate was around 93.4%. main expenditure items were classified variables, with “daily diet and clothing consumption” as the Variable selection reference group.⑧ The number of family members Dependent variable living together was a continuous variable.⑨ Living The dependent variables of this study are the use of conditions were classified variables (1 = living with community-based health services among older adults, husband, wife and other family members, 2 = liv- including the use of family health services (family doc- ing with family members without the respondent’s tors, family beds, family appointment visits, family reha- husband and wife, 3 = living with husband and wife bilitation guidance and other personalized services) only, 4 = living alone). and the use of preventive health services (e.g., physical (3) Need factors.① Health status: the data was examination, chronic disease prevention, health records). obtained through the self-rated health status of the The three dependent variables are binary variables. The interviewees. There were five options in the ques - elderly who used these community-based health services tionnaire: “very healthy, relatively healthy, general, in the past 12 months were defined as 1, and those who relatively unhealthy and very unhealthy”. In this did not use were defined as 0. study, “very healthy and relatively healthy” was defined as “good health”, which was assigned as 1, Independent variable and the remaining three options were defined as “poor health” with a value of 0.② Patients with chronic disease were dummy variables (0 = no, (1) Predisposing factor.① Gender is a dummy vari- 1 = yes).③ Self-care ability of daily life was a able (0 = female, 1 = male).② Age is a continuous Lin et al. BMC Primary Care (2022) 23:99 Page 4 of 10 demand is also significantly associated with service utili - dummy variable (0 = no difficulty, 1 = difficulty). zation (χ 2 = 492.916, P < 0.001). Eight questions were set up in the questionnaire to ask the respondents whether they could indepen- dently carry out daily activities (ADL: including eat- Regression analysis ing, bathing, defecation and indoor activities) and Table  3 reports the diagnosis results of multicollinearity instrumental daily activities (IADL: including cook- of independent variables. The variance expansion factor ing, washing clothes, shopping, taking public trans- (VIF) of each variable is far less than 10, indicating that portation) to assess the living ability of the respond- the problem of multicollinearity between independent ents. If any of the activities of daily life were difficult variables is not serious. (choose “need some help” or “completely”), it was Table  4 presents the results of regression models. The defined as “having difficulty in self-care ability in three logistic regression models constructed in this daily life”.④ The need for health care for the elderly study all passed the significance test, that is, Model 1 (χ was a dummy variable (0 = no need, 1 = need). 2 = 67.486, P < 0.001), Model 2 (χ 2 = 629.777, P < 0.001), and Model 3 (χ 2 = 487.097, P < 0.001) were statistically significant. Statistical analysis The influence of predisposing factors The dependent variable in this paper is a binary variable, The two models showed that the type of household reg - which is suitable for the binary logistic regression model. istration had a significant influence on the use of pre - u Th s, three binary logistic regression models were used ventive health care services. The results showed that to predict the utilizations of family health services and compared with agricultural household registration, the preventive health services. This study used descriptive elderly with non-agricultural household registration statistics to described the characteristics of all variables. (β = − 0.702, P < 0.01) and unified household (β = − 0.791, Thereafter, two Chi-Square tests were used to examine P < 0.01) were less likely to use preventive health care ser- the relationship between service demand and service uti- vices. There was no significant effect on the use of family lization. And then two regression models were employed health services by the elderly. to predict service utilization. The statistical software package SPSS 24.0 (International Business Machines The influence of enabling factors Corp: Beijing, China) was applied for all data analyses. The empirical results showed that the basic endowment insurance coverage of the elderly, the nature of the work- Results ing unit before retirement, average monthly income, Descriptive statistics whether the pension is the main source of living, income The basic information of the sample is shown in Table  1. surplus, major expenditure items, and living condi- The situation of elderly people using family health ser - tions had a significant impact on whether the elderly use vices in terms of family doctors, family beds, family community-based health services. In terms of the use of appointment visits, rehabilitation guidance, and other family health services, compared with the elderly who family medical and health services was not well. The did not rely on pension as the main source of living, the demand rate was 20.7% among all respondents, while elderly people with pension as the main source of income the utilization rate was only 0.8% in total sample. The were more likely to use family health services (β = 3.556, demand rate of preventive health care services such as P < 0.1). The effect of income surplus on the use of family physical examination, chronic disease treatment, and health services is negative, that is, the elderly with “ make health records reached 66.6%, and the utilization rate was ends meet “ are more likely to use family medical services 52% in total sample. than those with “basically sufficient income” (β = − 4.55, P < 0.05). The possible explanation for this statisti - Chi‑Square tests cal result is that there is a reverse causal relationship Table  2 indicates the relationship between service between the income surplus and whether the elderly use demand and service utilization. Among the respond- family health services. Because of the large proportion ents with the demand for family health service, only 4% of medical expenditures and the high amount of medical of them had used this type of service. 75.3% of respond- expenditures, this part of the elderly “cannot make ends ents with demand for preventive health care services had meet”. Taking the elderly whose main expenditure items used this type of service. The relationship between family were daily diet and clothing consumption as the refer- health service demand and the utilization is significant (χ ence group, the elderly whose main expenditure items 2 = 34.462, P < 0.001). The preventive health care service were “water, electricity, property, transportation and Lin  et al. BMC Primary Care (2022) 23:99 Page 5 of 10 Table 1 Descriptive statistics of variables (n = 1061) Variable Mean (SD) or Per cent Dependent variable Family health medical services (Use) 0.8% Preventive health services (Use) 52% Predisposing factors Gender (Male) 44.4% Age (Mean / SD) 71.48/1.705 Household registration Agricultural household registration 63.7% Non agricultural household registration 20% Unified household registration 16.3% Education level No formal education (illiterate) 18.9% Primary school 58.8% Junior high school and above 22.3% Marital status (married) 72.7% Demand factors Self rated health (good health) 50.2% Suffering from chronic diseases (yes) 57.4% Self care ability in daily life (yes) 90.2% Demand for health-related services Family health service (No) 79.3% Preventive health care services (No) 33.4% Enabling factors The nature of the working units before the current employment or retirement (Having 50.40% working units) Basic endowment insurance Retirement pension system of government and institution 4.5% Basic endowment insurance for urban employees 34.5% Basic endowment insurance for urban and rural residents 40.9% Did not participate in any social endowment insurance 20.1% Basic medical insurance Public medical system of government and institution 3.9% Basic medical insurance for urban employees 32.2% Basic medical insurance for urban and rural residents 55.9% No social medical insurance 8% Average monthly income 1000 RMB and below 31.3% 1001–2000 RMB 28.7% 2001-3000RMB 20.5% 3001-4000RMB 12.9% 4001-5000RMB 3.3% 5001RMB and above 3.2% Income surplus Make ends meet 24.9% Basically enough 64.7% Lin et al. BMC Primary Care (2022) 23:99 Page 6 of 10 Table 1 (continued) Variable Mean (SD) or Per cent There is a surplus 10.5% Pension as the main source of living (Yes) 51.5% Major expenditure items Daily diet and clothing consumption 75.6% Water, electricity, property, transportation and communication 5.3% See a doctor / buy health products 16.5% Rehabilitation nursing / professional nursing service fee 0.7% Domestic service 0.4% Cultural and entertainment consumption 1.5% Number of CO residents (Mean / SD) 4.15/0.06 Living conditions Living with husband, wife and other family members 50.5% Living with family members without the respondent’s husband and wife 26.8% Living with husband and wife only 15.2% Living alone 7.5% communication” (β = 6.647, P < 0.05) and “seeing a doctor Table 3 Collinearity diagnosis / purchasing health care products” (β = 3.982, P < 0.05) were more likely to use family health services. Independent variable Family Preventive health health Concerning the use of preventive health care ser- service services vices, compared with the elderly who enjoyed the VIF VIF retirement pension treatment of government insti- tutions, the elderly who participated in the basic Gender 1.198 1.199 endowment insurance of urban and rural residents Age 1.027 1.027 (β = − 2.461, P < 0.1) and those who did not partici- Registered residence 1.350 1.350 pate in any social endowment insurance (β = − 2.511, Marital status 1.387 1.384 P < 0.05) were less likely to use preventive health Education level 1.367 1.366 care services. At present, the pension of govern- Basic endowment insurance 3.493 3.479 ment institutions is higher than that of employees, Basic medical insurance 2.779 2.775 Nature of working unit before retirement 1.673 1.657 Average monthly income 2.019 2.000 Table 2 Relationship between health service demand and Pension as the main source of living 1.720 1.721 service utilization (n = 1061) Income surplus 1.353 1.351 Family health medical Preventive health services Major expenditure items 1.083 1.088 services Number of co-residents 2.039 2.027 Not having Having Not having Having Living conditions 2.299 2.292 demand demand demand demand Self rated health 1.344 1.353 Suffering from chronic diseases 1.230 1.284 Did not use 885 224 355 186 Self care ability in daily life 1.142 1.132 Use 0 9 19 566 Demand for family health services 1.053 Chi-square 34.462*** 492.916*** Demand for preventive health services 1.091 *p < 0.1, **p < 0.05, ***p < 0.01 Lin  et al. BMC Primary Care (2022) 23:99 Page 7 of 10 Table 4 Logistic regression result Variable Family health service Prevention health service β value Exp(B) β value Exp(B) Constant −59.995 0.000 −1.577 0.207 Gender (Reference group: Female) 2.266 9.643 −0.122 0.885 Age 0.902 2.464 0.009 1.009 Age squared −0.006 0.994 0 1 Household registration (Reference group: Agricultural household registration) Non agricultural household registration −2.45 0.086 −0.702*** 0.496 Unified household registration − 22.152 0.000 −0.791*** 0.453 Marital status (Control group: Unmarried) 0.042 1.043 0.228 1.257 Education level (Reference group: No formal education) Primary school 1.915 6.788 0.054 1.055 Junior high school and above −15.743 0.000 −0.304 0.738 Basic endowment insurance (Reference group: Retirement pension system of government and institution) Basic endowment insurance for urban employees −11.606 0.000 −1.941 0.144 Basic endowment insurance for urban and rural residents −8.958 0.000 −2.461* 0.085 Did not participate in any social endowment insurance −4.544 0.011 −2.511** 0.081 basic medical insurance (Reference group: Public medical system of government and institution) Basic medical insurance for urban employees 3.231 25.313 0.354 1.424 Basic medical insurance for urban and rural residents 2.544 12.73 0.157 1.17 No social medical insurance 5.385 218.195 0.67 1.954 Nature of unit before retirement (Reference group: No working unit) −0.212 0.809 0.473* 1.605 Average monthly income 1.962 7.11 −0.134 0.875 Pension as the main source of living (Reference group: No) 3.556* 35.04 −0.263 0.769 Income surplus (Reference group: Make ends meet) Basically enough −4.45** 0.012 −0.167 0.846 There is a surplus −13.527 0 −0.085 0.918 Major expenditure items (Reference group: Daily diet and clothing consumption) Water, electricity, property, transportation and communication 6.647** 770.587 −0.265 0.767 See a doctor / buy health products 3.982** 53.63 0.393 1.482 Rehabilitation nursing / professional nursing service fee −21.364 0 −20.758 0 Domestic service −14.113 0 −0.748 0.473 Cultural and entertainment consumption 8.52 5016.197 0.602 1.826 Number of CO residents −0.365 0.694 0.053 1.054 Living conditions (Reference group: Living with husband, wife and other family members) Living with family members without the respondent’s husband and wife 0.576 1.779 0.172 1.187 Living with husband and wife only −4.098 0.017 0.247 1.281 Living alone 3.062 21.376 −0.224 0.799 Self rated health(Reference group: Poor health) −0.75 0.721 −0.355* 0.701 Suffering from chronic diseases (Reference group: No) 0.848 2.334 0.397** 1.488 Self care ability in daily life (Reference group: No difficulty) 2.451 11.595 −1.052*** 0.349 Family health service demands (Reference group: no demand) 21.391 1.95E+ 09 / / Preventive health service demands (Reference group: no demand) / / 4.357*** 78.03 Chi‑square (df ) 67.486 (32)*** 629.777 (32)*** *p < 0.1, **p < 0.05, ***p < 0.01 and the pension of employees is higher than that of services. Compared with the elderly who enjoy the residents. The level of pension to a large extent repre- retirement treatment of government institutions, the sents the economic ability of the elderly, thus affecting elderly who did not participate in any social endow- whether the elderly groups use preventive health care ment insurance were the least likely to use preventive Lin et al. BMC Primary Care (2022) 23:99 Page 8 of 10 health care services. Before retirement, the elderly Compared with the elderly without chronic diseases, with working units were more likely to use preventive the elderly with chronic diseases used more preventive health services than those without (including farming) health services (β = 0.397, P < 0.05). With the decline of (β = 0.473, P < 0.1). Similar to the above explanation health status, the elderly with chronic diseases have a of the possibility of participating in the basic endow- stronger demand for prevention and health care, which ment insurance, the old people who have a working is consistent with the research of Li [11]. The disease is unit before retirement enjoy the retirement treat- a major adverse factor that perplexes the elderly in their ment of government and public institutions or receive later years, and the elderly diseases are mainly cardiovas- employee pension, which may be more secure in terms cular and cerebrovascular diseases (hypertension, coro- of source of living than the elderly without a unit nary heart disease, and cerebral apoplexy), diabetes, and (including farming). The difference like the working other common chronic diseases. The elderly with chronic units before retirement is also reflected in the aspect diseases are more likely to use community preventive of health security. The retirees of some working units health care services because they need to pay attention enjoy the benefits of public medical treatment of gov- to and investigate their own health problems at all times, ernment institutions or basic medical insurance for so as to reduce the potential risks. The elderly with pre - urban workers, while the retirees without a unit can ventive care needs were more likely to use services than only participate in the basic medical insurance for those without (β = 4.357, P < 0.01). urban and rural residents, or even not participate in In terms of family health services, although the ena- any basic medical insurance. Regardless of whether it bling factors had not passed the significance test, it is is outpatient or inpatient, the level of protection and found that the elderly with poor health status, chronic strength of the above two is quite different. There- diseases, difficulties in daily life and family health service fore, the nature of the pre-retirement working unit is demand were more likely to use family health services. more likely to affect the elderly’s attitude toward seek- With the growth of age, the physical health status of the ing medical care in the economic dimension, as well elderly gradually deteriorates, and the risk of chronic dis- as their medical actions-whether to use preventive eases continues to increase. In addition, daily self-care health services. ability is declining and health problems are prominent. As a result, the possibility of using family health services will increase. The influence of need factors The empirical results showed that the health status of Discussion need factors, chronic diseases, self-care ability of daily The results show that among the 18 independent vari - life, and service need had a significant influence on ables, three variables have a significant impact on the use whether the elderly use community-based health ser- of family health services, which are whether the pension vices. In terms of preventive health care services, the is the main source of living, income surplus and major impact of self-rated health status and self-care abil- expenditure items. Seven variables have a significant ity of daily life on the use of services is negative, that impact on the use of preventive health services, which is, the elderly with poor health status are more likely are household registration type, the basic endowment to use preventive health care services than those with insurance coverage, the nature of the working unit before good health status (β = − 0.355, P < 0.1), which is simi- retirement, the self-rated health status, chronic dis- lar to the research conclusion of Chen and Ma [14]. The eases, self-care ability in daily life, and preventive health worse the physical condition of the elderly, the higher care needs., Several predictors such as social support, the demand for health services, thus, the more likely the prevalence of chronic diseases, and degree of fragil- they are to use preventive health services. The elderly ity are similar to the findings of Liu et  al. [16] who used with no difficulties in daily life were more likely to use Andersen’s model to predict community health and nurs- preventive health services than those with difficul - ing services’ demands. Based on the findings, this study ties (β = − 1.052, P < 0.01). The possible explanation for provides the following suggestions for improving the use this statistical result is that the elderly people who take efficiency of community-based health services. care of themselves are more sensitive and free in walk- First, the government should pay attention to the eco- ing, daily activities, eating, and defecation, and so on, nomic income of the elderly, and improve the health care so they take the initiative to participate in the physical service subsidy system. The results show that economic examination and chronic diseases provided by the com- variables such as basic endowment insurance, average munity. Another possibility is that people using preven- monthly income, whether the pension is the main source tive health services are healthier and less likely to have of living, income surplus, main expenditure items, and difficulties in daily life. Lin  et al. BMC Primary Care (2022) 23:99 Page 9 of 10 other economic variables have a significant impact on elderly care services based on the health needs of the whether the elderly use health care services. Some lower- elderly, deepen the quality of services, and further income elderly people may be difficult to purchase and enhance the sense of acquisition and satisfaction of the use community-based health services because of their elderly. insufficient ability to pay. The government should further Last but not the least, the Chinese government improve the classification of the elderly’s health status should strengthen the capacity of community health and economic income evaluation mechanism, formulate service provision agencies in urban and rural areas. detailed and reasonable service subsidy standards, and The Chinese government should further promote the provide appropriate subsidies for the purchase of health development mode of combining medical care with and elderly services for low-income elderly people who nursing care into the community, actively develop do have a demand for health and elderly care services healthy elderly care service projects, and improve the and lack financial capacity. By doing this, service provi - professionalism of health care services and the acces- sion organizations can transform potential demands into sibility and convenience of elderly access to services. At actual demands and increase service utilization rate [11]. the community level, we should strengthen the public- At the same time, differentiated government subsidies and ity of health care services through multiple channels, the scope of government-purchased services can be estab- improve the overall cognitive level of the elderly on lished according to different types and levels of health and the health care service projects, cultivate the positive elderly care services, and the threshold for enjoying gov- aging concept of the elderly, and enhance the cognition, ernment-purchased services can be appropriately relaxed, acceptance and participation of the elderly in the com- so that more needy elderly people can enjoy free services. munity service model. Second, the government should establish a unified Although the survey sample is representative of the evaluation mechanism of community home-based care elderly population in the study area, the findings can - services. The results of this study show that the utili - not be generalized to all aged population in China con- zation rate of community-based health services in S sidering community health services are heterogeneous District is not high, which may be due to the insuffi - in different cities. Regarding the representativeness of cient supply of health care services and the mismatch Guangdong province, the economic and social develop- between supply and need. Logistic regression results ment of S District of Foshan City is lined up in front confirmed that there were differences in the influenc - of Guangdong Province, thus S District can represent ing factors of different types of service use, and the the developed areas of Guangdong Province, but can- elderly with health care service needs were more likely not represent the whole Guangdong Province. In addi- to use health service items. Therefore, the service sup - tion, this study did not include all types of community ply should respond to the health demands of the elderly health services for older adults due to the lack of data. to achieve the balance of supply and need of commu- Nevertheless, this study contributes to understanding nity-based health services. It is necessary to establish the application of Andersen’s model in community- a unified health status classification and needs assess - based health service utilization among older adults in ment mechanism, and establish an elderly information the Chinese context. database to comprehensively integrate and evaluate the Acknowledgements information of the elderly, such as age, physical health Not applicable. status, self-care ability, family situation, and economic Authors’ contributions status. According to the health status and needs assess- LWY designed this study. LWY analyzed and interpreted the data. LWY was ment results of the elderly, accurately identify service a major contributor in writing the manuscript. YWX and YDH made a major needs, flexibly and accurately provide different kinds contribution to revise the manuscript. LWY read and approved the final manu- script. The author(s) read and approved the final manuscript. of community-based health services for different older adults, and allocate community medical and health Funding resources and pension service resources fairly and This article was funded by National Philosophy and Social Science Foundation of China ( Title: Research on the integration of technology and practical effects effectively. Service providers should accurately identify in the smart elderly care service system, No: 21B[GL0031]1) and Guangdong service needs based on the health status of the elderly Province Philosophy and Social Science Planning Project ( Title: The formation and the results of needs assessments, flexibly and mechanism, influence and intervention of structural stigma of major sudden acute infectious diseases, No: GD20CGL02). The funders had no role in the accurately delivering differentiated and personalized design of the study, the collection, analysis and interpretation of data. community health and elderly care services to service targets. Community health resources and elderly care Availability of data and materials The datasets used and/or analysed during the current study available from the service resources should be allocated fairly and effec - corresponding author on reasonable request. tively [9]. At the same time, we will continue to expand Lin et al. 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Journal

BMC Primary CareSpringer Journals

Published: May 2, 2022

Keywords: Community-based health services; Influencing factors; Anderson model; Healthy aging

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