The Association Between Trajectories of Perceived Unmet Needs for Home and Community-Based Services and Life Satisfaction Among Chinese Older Adults: The Moderating Effect of Psychological Resilience

Abstract

This study examined whether trajectories of perceived unmet needs for Home and Community-Based Services (HCBS) were associated with life satisfaction among Chinese older adults and whether the association was moderated by psychological resilience. Data came from five waves (2005-2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Latent class growth analysis revealed three distinct trajectories of perceived unmet HCBS needs: “increasing” (n = 977, 36.24%), “persistent” (n = 570, 21.14%), and “decreasing” (n = 1149, 42.62%). Multiple regression estimates showed that the increasing group was associated with lower life satisfaction, and the association was moderated by psychological resilience, especially for older adults who were male, living in rural, and oldest-old. Results indicate that inequalities in cumulative exposure to perceived unmet HCBS needs may further lead to increasing inequalities in life satisfaction. Interventions focused on minimizing the provision-need gap of HCBS and enhancing personal resilience should be considered to improve the life satisfaction of older adults.

Keywords

unmet needs home and community-based service life satisfaction resilience

Introduction

According to the seventh Population Census of China, the number of Chinese older people aged 65 and older was 190 million in 2020 (National Bureau of Statistics of PRC, 2021) and is projected to reach 258 million in 2030 and further reach 394 million in 2050 (United Nations, 2022). Meanwhile, increasing life expectancy and the number of older people with chronic diseases and functional impairments will lead to a considerable increase in the need for healthcare and social care services. However, the small-size of family structure, the mobility of adult children, and changes in the value of filial piety have fundamentally eroded the traditional family-centered long-term care pattern for Chinese older adults (Ding & Hesketh, 2006, Lei et al., 2016). It has posed a great challenge for the Chinese government to meet the rapidly growing needs of older population in healthcare and social care services.

Home and Community-Based Services (HCBS), as a supplement to family care, are designed by the Chinese government to achieve the goal of meeting various service needs and ultimately improving the well-being of older people (Xu & Chow, 2011). The Chinese central government has encouraged HCBS to cover a broad range of services for older adults since 2008, including daily care, medical care, emotional support, social services, and other services (Ministry of Civil Affairs of China, 2008). Over the past decades, a series of plans and policies have been implemented by Chinese national and local governments to promote HCBS development. The availability of HCBS has significantly increased in China (Zhang et al., 2018). However, empirical evidence indicates that the increasing availability of HCBS does not meet the needs of older adults (Lu et al., 2021). The insufficient service provision and provision-need mismatch have led to a failure or low efficiency in satisfying older adults’ needs and inequality in access to HCBS across regions and urban-rural populations (Ding & Qu, 2019, Zhang & Li, 2019). A recent cross-sectional study has found a high prevalence (51.3%–55.5%) of perceived unmet needs for HCBS among Chinese urban older adults (Meng et al., 2021).

The issue of unmet care needs in older population is prevalent across many countries and has become a global concern because of its adverse consequences on health and well-being (Allen et al., 2014, Kalánková et al., 2021). It is worth noting that the formation of unmet needs is a dynamic process, resulting from the matching between services provision and individuals’ diverse needs over time. A longitudinal analysis of HCBS provision-need patterns is vital for understanding the formation and development of unmet needs. Further, while some unmet needs may occur given the constrain of public and private resources (Allin et al., 2010), what is of particular concern is whether the distribution of unmet needs is inequitable or systematically related to sociodemographic characteristics of certain populations (Smith & Connolly, 2020), and whether inequality in unmet needs would further lead to inequality in well-being outcomes.

Therefore, using nationally representative longitudinal data of Chinese older adults from 2005 to 2018, the current study aims to address the following four questions. (1) Whether Chinese older adults’ perceived needs have been satisfied along with the increasing availability of HCBS, (2) who experiences persistent or increasing perceived unmet needs for HCBS, (3) whether the persistence or increase in perceived unmet HCBS needs is further related to a lower level of life satisfaction in later life, and (4) whether the relationship varies by different population subgroups. Findings about these questions can provide policy implications about the adequacy, effectiveness, and equality of HCBS provision over time, help develop targeted interventions and strategies for those at risk of serious or increased perceived unmet needs, optimize resource allocation, and ultimately improve the well-being of older population.

Literature Review

Life satisfaction, which refers to a cognitive global evaluation of one’s life, has been identified as an important indicator of older adults’ subjective well-being (Diener, 2013). Community environment has been identified as a critical factor for older adults’ life satisfaction (Santos et al., 2022), as many older adults are confined within their community and home due to physical function and cognitive impairments. Community-based support and services are particularly important for older adults’ life satisfaction, especially in some situations where families cannot provide the needed services (Zhang et al., 2017). Evidence from China showed that the increasing perceived availability of HCBS significantly improved life satisfaction among older adults (Zhang et al., 2018), whereas Shen and Yeatts (2013) did not find a significant association between the number of community service organizations and life satisfaction. The inconsistency could be partly attributed to the single-point-in-time measure, which might underestimate the neighborhood effect (Murray et al., 2010). More importantly, those studies did not take the pertinence of HCBS provision into consideration. A recent study argued that HCBS cannot improve recipients’ life satisfaction if they are mismatched with the specific needs of older adults (Lu et al., 2021).

Unmet needs for HCBS could enhance or extend our knowledge about the relationship between community-based services and life satisfaction. In most previous studies, an unmet need was defined when individuals did not receive the needed service or received inadequate services (Casado et al., 2011; Depalma et al., 2013; Mitra et al., 2011; Vlachantoni et al., 2021). Some studies focus on the perceived unmet needs for HCBS, which is defined as the perceived gap between services availability and needs (Lu et al., 2021, Meng et al., 2021), thus indicating the perceived efficacy of the HCBS delivery system in providing needed services. Although the unmet need is a complex multi-faceted concept (Smith & Connolly, 2020, Vlachantoni et al., 2011) and measured in different ways in previous studies, it has been consistently identified as a risk factor for health and well-being (Allen et al., 2014, Beach et al., 2020, Chong et al., 2021). Specifically, unmet needs for assistance in activities of daily living (ADLs) or instrumental activities of daily living (IADLs) can lead to lower levels of health-related quality of life (Bouldin et al., 2021), higher risks of hospital readmission and mortality (DePalma et al., 2013, He et al., 2015), and higher levels of depressive symptoms (Choi & McDougall, 2009). In addition, perceived unmet needs for HCBS are negatively associated with life satisfaction (Lu et al., 2021), while older adults with met home care needs report higher levels of life satisfaction and lower levels of loneliness and perceived life stress (Kadowaki et al., 2015). However, the majority of prior studies considered unmet needs within cross-sectional study designs or time-averaged values and thus failed to investigate the trajectory of unmet needs over time and its associations with life satisfaction.

Recently, a few studies have called for increased attention on the trajectory of unmet needs given changes in service availability and personal needs over time (Smith & Connolly, 2020). Longitudinal studies have shown that considerable change and heterogeneity exist in the level of unmet needs. For example, drawing on longitudinal data from community-dwelling older people in England, Hu et al., (2022) identified heterogeneous trajectories of care needs (low, medium, and high) and utilization (low, medium, and high), and found individuals with multiple functional limitations and no spouse/partner faced an acute and enduring risk of inadequate care and unmet needs. Vlachantoni et al. (2021) explored the changing patterns of unmet social care needs for bathing or dressing in England, showing a significant proportion of older people experienced persistent unmet needs, particularly those who were younger, with no spouse/partner, or with increased ADLs limitations. Huang et al., (2022) further found that changing patterns of unmet ADL needs were associated with life satisfaction among older adults with functional disabilities, and a fulfillment of unmet ADL needs leads to an increase in life satisfaction. However, little attention has been focused on the change of unmet needs for HCBS. No longitudinal study, to our knowledge, has investigated trajectories of unmet HCBS needs that Chinese older adults have experienced, and how those trajectories are related to life satisfaction.

It is likely that Chinese older adults may experience distinct trajectories of unmet HCBS needs (e.g., persistent low/high, increasing, or declining) since both HCBS availability and individual needs vary over time. From a life-course perspective, the accumulation of risk model can be applied to understand the association between unmet HCBS needs trajectories and life satisfaction. The accumulation of risk model centers on the influence of accumulated exposures over time (Ben-Shlomo & Kuh, 2002). It posits that disadvantaged exposures experienced at different life stages contribute to an overall cumulative impact on later health and well-being (Pudrovska & Anikputa, 2013), emphasizing the importance of considering both the extent and duration of exposure to risks. Evidence has demonstrated that persistent exposure to disadvantaged socioeconomic conditions is particularly detrimental to health and well-being (Clarke et al., 2014, Kahn & Pearlin, 2006). Additionally, cumulative exposure to poor housing conditions has been linked to diminished life satisfaction among older adults (Park & Kim, 2022).

Hence, this study focuses on the accumulation of perceived unmet needs for HCBS (a main risk factor for older adults) over a 13-year period. Following a previous study (Dirlam & Zheng, 2017), this accumulation is conceptualized using a person-centered approach (group-based trajectory modeling) that simultaneously profiles the timing, magnitude, and duration of exposures to the primary risk factor (perceived unmet HCBS needs). It is reasonable to posit that older adults persistently exposed to disadvantaged communities with insufficient resources might report enduring or increasing unmet HCBS needs, potentially leading to more negative perceptions of their quality of life.

In addition, it is necessary to examine the population heterogeneity in the association between trajectories of unmet HCBS needs and life satisfaction. The expectation of HCBS seems to vary across older populations. For example, since the likelihood of functional deterioration and mobility limitation increases with age, the oldest-old may report higher attachment to their communities (Wiles et al., 2012) and thus are more vulnerable to unmet HCBS needs than younger older adults. Given the traditional norm of women with caregiving roles (Chen et al., 2021, Miller & Cafasso, 1992), it is possible that older men show higher expectations for HCBS due to their lower self-care abilities than older women. Further, there exist substantial rural-urban disparities in terms of socioeconomic, medical, and social care resources in China (Ding & Qu, 2019). In comparison to urban residents, rural older adults may have more needs for HCBS due to the lack of accessible and affordable alternatives. Evidence from China has shown that the effect of HCBS on life satisfaction is more pronounced in rural areas than in urban areas (Wang et al., 2020).

There is also a paucity of research exploring protective factors that may buffer the negative effect of unmet needs on life satisfaction among older adults. One of the potential protective factors is psychological resilience, which is defined as the ability to navigate adversities through positive adaptation to maintain physical and psychological well-being (Manning et al., 2006, Southwick & Charney, 2012). The protective model of resilience suggests that psychological resilience, as an internal positive psychological asset, would buffer the negative effects of risk exposure (Fergus & Zimmerman, 2005). Prior studies have shown that psychological resilience is positively associated with life satisfaction among older adults (Reyes et al., 2020, Smith & Hollinger-Smith, 2015) and have well-documented the protective role of psychological resilience in the face of aging-related risk exposures, such as poverty, illness, and disability (Lim et al., 2015; Manning et al., 2016; Wang et al., 2020b). Resilient individuals tend to show high levels of optimism, self-efficacy, and ability to seek help and integrate individual and social resources to cope with aging-related stress and challenges (Fontes & Neri, 2015). Thus, it is expected that older adults with high levels of psychological resilience might have a high ability to cope with the aging-related exposure to unmet HCBS needs (a main risk for older adults) so that they can ultimately maintain their life satisfaction. However, to our knowledge, the moderating effect of psychological resilience between trajectories of unmet HCBS needs and life satisfaction has not been examined empirically.

Thus, based on the existing theoretical and empirical evidence, the current study aims to fill the gaps in the literature by (1) identifying the changing trends and heterogeneous trajectories of perceived unmet needs for HCBS over a 13-year period, (2) examining the association between perceived unmet HCBS needs trajectories and life satisfaction, (3) exploring whether the observed association between perceived unmet HCBS needs trajectories and life satisfaction is moderated by psychological resilience, and (4) investigating the age, gender and urban-rural differences in the main and interaction effects of perceived unmet HCBS needs trajectories and psychological resilience on life satisfaction among Chinese older adults.

Methods

Data

Data for this study were derived from the Chinese Longitudinal Health Longevity Survey (CLHLS), which was conducted by Peking University and Duke University every two/three years since 1998. Follow-up surveys were conducted in 2000, 2002, 2005, 2008, 2011, 2014, and 2018. The CLHLS is a nationwide population-based longitudinal study that was conducted in half of the cities and counties in 22 of China’s 31 provinces through a multistage cluster sampling approach. Rich information such as socio-demographic characteristics, family and household conditions, lifestyles, and health conditions of participants were collected. More detailed information and data quality about this survey have been documented elsewhere (Duke Aging Center, 2022).

In the current study, five most recent waves (from 2005 to 2018) of CLHLS were used for data analysis, because information on HCBS was unavailable in previous waves. Supplementary Figure 1 shows the flow chart of the CLHLS (2005-2018), attrition, and the sample selection progress in the current study. The 2005 wave included 15638 respondents. The following four waves added 9842 respondents in 2008, 1532 in 2011, 1126 in 2014, and 12411 in 2018, respectively. Attrition was prevalent: 8166 participants dropped out due to death or the loss of follow-up in 2008, 8532 in 2011, 3699 in 2014, and 3773 in 2018, respectively.

To explore trajectories of unmet needs for HCBS among community-dwelling older adults, respondents who met the following criteria were included in this study: (a) 65 years old and above; (b) community-dwelling; (c) having complete information on perceived unmet HCBS needs for at least three waves; and (d) be survived in the 2018 wave. According to these criteria, 2,696 eligible respondents were included to identify trajectories of perceived unmet HCBS needs, among which 47.4% participated in five waves, and 36.9% in four waves, and 15.6% in three waves. A detailed analysis of sample attrition (as shown in Supplementary Table 4) reveals that individuals who were female, not living alone, reporting lower levels of self-rated financial status, and having fewer children were more likely to be excluded from this analysis.

Among the 2696 follow-up respondents, the prevalence of missing data on the study variables was less than 5%, except for perceived unmet HCBS needs (5.9%), life satisfaction (8.6%), psychological resilience (14.8%), self-rated health (8.3%), and medical insurance (5.4%). For certain time-invariant variables (such as years of schooling, ethnic group, and primary occupation), we imputed their missing values using available data from prior waves. We also employed the Multiple Imputation by Chained Equations techniques with 20 imputed datasets to estimate missing values for psychological resilience and other covariates (Murray, 2018). However, 231 cases were excluded from the regression models through listwise deletion due to missing values in life satisfaction (a dependent variable). No significant differences in sample characteristics were detected between the 2465 respondents included in the regression models and the 231 excluded cases. The variable distribution of the data after multiple imputation was also consistent with the data before imputation.

Measurement

Life Satisfaction

Life satisfaction was measured by a single-item question in 2018 wave. Participants were asked “How do you rate your life at present?”, which was assessed using the 5-point scale responses (5 = very good, 4 = good, 3 = fair, 2 = bad, and 1 = very bad).

Perceived Unmet Needs for HCBS

Both measures of needs based on self-reported ADLs/IADLs limitations (Allen et al., 2014; Depalma et al., 2013; Vlachantoni et al., 2021) and perceived needs reported/felt by individuals (Casado et al., 2011, Meng et al., 2021, Mitra et al., 2011) were used in prior studies, and they provided important information in understanding the actual needs for services among older adults (Cohen-Mansfield & Frank, 2008).

This study focused on perceived needs for community services. In line with previous studies with CLHLS data (Lu et al., 2021, Meng et al., 2021), perceived unmet needs for HCBS was defined as the perceived gap between availability and need of HCBS. It was measured by the combination of two questions: “Do you expect your community to provide the following services?” (need) and “Are these services available in your community?” (availability). The services included (1) personal daily care services, (2) in-home medical visits, (3) psychological consulting, (4) daily shopping, (5) social and recreational activities, (6) legal consulting services, (7) health education, and (8) neighborhood relations. All items were coded dichotomously (yes/no). For each service, we generated a new binary variable: a perceived unmet need (coded as 1) was identified when the service was reported need but not available in their communities, and the other answers were coded as 0. Then, the total perceived unmet needs for HCBS were calculated as the number of services that were reported need but not available in their communities, ranging from zero to 8, with higher scores indicating higher perceived unmet needs for HCBS.

Psychological Resilience

In line with previous studies (Lou et al., 2023, Yang & Wen, 2015), psychological resilience was measured in the 2018 wave by a scale based on five items, including ‘Do you feel the older you get, the more useless you are?’; ‘Do you always look on the bright side of things?’; ‘Do you often feel fearful or anxious?’; ‘Do you often feel lonely and isolated?’; and ‘Can you make your own decisions concerning your personal affairs?’. Each item was assessed on a five-point Likert scale ranging from 1 (always) to 5 (never), with items 2 and 5 reversely recoded. Then the total values of five items were summed up, ranging from 5 to 25, with a higher score indicating a higher level of psychological resilience. The scale of psychological resilience had good reliability with a Cronbach’s alpha coefficient equaling to .872 in this study.

Covariates

According to the socio-ecological theory, individuals are embedded within broader social systems, and their well-being is influenced by the interplay of individual, interpersonal, and environmental factors (Clarke & Nieuwenhuijsen, 2009, Stokols, 1996). Guided by the social-ecological theory and drawing on evidence from previous studies (Ng et al., 2017, Zhang & Liu, 2007), this study measured individual factors (demographic characteristics, health condition, and socioeconomic status), interpersonal factors (marital status, living arrangement, number of children, and intergenerational support), and environmental factors (current location, region, and social insurance) associated with older adults’ life satisfaction in 2018. These factors were selected as covariates in the current study.

Demographic characteristics included age, gender, years of schooling, and ethnicity (Han/others). Socioeconomic status included primary occupation (unemployed/housework, agriculture, and others), per capita household income, and self-rated financial status (very rich, rich, regular, poor, and very poor). Health condition variables included self-rated health status (very good, good, regular, poor, and very bad), having chronic diseases (no/yes), and functional status. Functional status was measured by asking participants whether they required assistance for each of the six ADLs: bathing, dressing, toileting, transferring, continence, and eating. The responses “no assistance”, “partial assistance”, and “full assistance” were scored as 3, 2, and 1, respectively. The total score ranged from 6 to 18, with a higher score indicating a better functional status. Intergenerational support included financial, instrumental, and emotional support. Specifically, financial support was measured by the amount of money that older adults received from their children and grandchildren. Instrumental support was evaluated by the primary caregiver when older adults needed assistance in daily activities or encountered difficulties. Emotional support was assessed by the person to whom older adults talked frequently in daily life and to whom they talked first when they wanted to share thoughts. Answers on adult children, grandchildren, and spouses of children/grandchildren were recognized as receiving support (coded as 1), and others were coded as 0. Marital status (married, not married), current location (rural, urban), region (eastern, central, and western), and living arrangement (living alone, living with others) were categorical variables. Social insurance included medical insurance and old-age insurance. Those with “Public Old-age Insurance,” “Retirement Pension,” or “Commercialized Old Age Insurance” were regarded as having old-age insurance (coded as 1), and those with “Public Free Medical Services,” “The Cooperative Medical Insurance for Urban Workers and Residents,” “The New Rural Cooperative Medical Insurance,” or “Commercial Medical Insurance” were regarded as having medical insurance (coded as 1). The other answers were coded as 0.

Analytic Strategy

In the first step, we conducted a descriptive analysis to summarize the trends of the needs, provisions, and perceived unmet needs for HCBS among Chinese older adults over time.

Secondly, Latent Class Growth Modeling (LCGM) was used to identify distinct trajectories of perceived unmet HCBS needs from 2005 to 2018, using Mplus 7.0. This technique (Andruff et al., 2009, van der et al., 2020) combines latent class analysis and growth curve modeling and could cluster individuals into a finite number of subgroups based on both initial levels (intercept) and changes (slope). For perceived unmet HCBS needs, one-class, two-class, three-class, and four-class trajectory models were tested, correspondingly. Then the best-fitting model was selected by comparing recommended indices in previous studies (Jung & Wickrama, 2008, Nylundet al., 2007, Wickramaet al., 2016). LCGM estimates the parameters of latent trajectories using the Full Information Maximum Likelihood (FIML) approach in the Mplus software, thereby accommodating incomplete longitudinal data (Schafer & Graham, 2002). Chi-square analyses and t tests were applied to compare socio-demographic characteristics among different trajectories of perceived unmet HCBS needs.

Then, multiple regressions through three-step modeling were applied to examine the association between trajectories of perceived unmet HCBS needs and life satisfaction, as well as the moderating effect of psychological resilience. Model 1 only included trajectories of perceived unmet HCBS needs adjusted for potential confounders. Model 2 added psychological resilience, and then interactions between trajectories of perceived unmet HCBS needs and psychological resilience were included in Model 3.

Finally, we further conducted a series of multiple regression models to examine the population heterogeneity in the main effect of perceived unmet HCBS needs trajectories and the moderating effect of psychological resilience on life satisfaction with controlling potential confounders.

Results

Changing Trends in the Needs, Provisions, and Perceived Unmet Needs for HCBS

Figure 1 presents trends in the needs, provisions, and perceived unmet needs for HCBS among Chinese older adults over time. In general, it shows a volatile upward trend of the HCBS needs over the provisions since 2008, and the provisions were far from sufficient for the high needs. As to the perceived unmet needs for HCBS, its average had started to decline gradually since 2011, but remained at a high level. A considerable HCBS provision-need gap was persistently observed over the 13-year period, although there was a significant increase in the HCBS availability, indicating that HCBS provisions were insufficient for older adults’ needs.

Figure 1.

The Average Number of the Needs, Provisions, and Perceived Unmet Needs for HCBS from 2005 to 2018. Source: 2005, 2008, 2011, 2014, and 2018 Chinese Longitudinal Health Longevity Survey.

Specifically, as shown in Supplementary Figure 2, psychological consulting, personal daily care, and in-home medical visits were consistently reported as having high perceived unmet needs (persistently above 50%), while neighborhood relations were reported as having the lowest perceived unmet needs (persistently above 40%). Perceived unmet needs for in-home medical visits and health education experienced a sharp decline since 2008, whereas other services showed a slight decline since 2011.

Identification of Perceived Unmet HCBS Needs Trajectories

According to the results of latent class growth modeling (details can be found in Supplementary Table 1 and Supplementary Table 2), a 3-class model was identified as the best-fit model for perceived unmet HCBS needs trajectories. Figure 2 shows the three latent classes identified in the perceived unmet HCBS needs trajectories: (1) Class 1 (36.24%), which was named “increasing perceived unmet needs,” represents a medium initial score (intercept = 4.348, p < .001) and a significant upward trend (slope = .192, p = .001); (2) Class 2 (21.14%), which was named “persistent perceived unmet needs,” represents a medium initial score (intercept = 4.305, p < .001) and maintaining this level over time (slope = −.042, p < .001); (3) Class 3 (42.62%), which was named “decreasing perceived unmet needs,” represents a medium initial score (intercept = 4.386, p < .001) and a rapid decline (slope = −.230, p < .001).

Figure 2.

Latent Classes of Perceived Unmet HCBS Needs Trajectories of Chinese Older Adults.

Trajectories of Perceived Unmet HCBS Needs and Class Members’ Characteristics

As shown in Table 1, most of the sample characteristics in 2018 under investigation were significantly associated with the class membership of perceived unmet HCBS needs trajectories. Specifically, members of the increasing perceived unmet needs group were more likely to be older, ethnic minorities, live in eastern and rural areas, and report significant disadvantages in socioeconomic status, as these members reported a lower proportion of having old-age insurance and lower self-rated financial status, household income, and family financial support compared with those in the persistent and decreasing unmet needs groups. In contrast, members of the decreasing perceived unmet needs group were more likely to be Han ethnic, have old-age insurance, and report higher levels of self-rated financial status, family financial support, and self-rated health status than members of other groups. In addition, members of the decreasing perceived unmet needs group also reported higher levels of life satisfaction and psychological resilience than members of other groups. Members of the persistent perceived unmet needs group were more likely to be younger, have chronic diseases, and report a significantly higher household income than members in the increasing and decreasing groups.

Table 1.

Sample Characteristics in 2018 and Univariate Analysis With Trajectories of Perceived Unmet HCBS Needs.

			The increasing class (n = 977)	The persistent class (n = 570)	The decreasing class (n = 1149)	F/χ²	Pr
Age			85.76 (9.24)	84.65 (7.87)	85.22 (8.33)	3.06	.047
Gender						.78	.677
		Male	48.62%	47.19%	46.75%
		Female	51.38%	52.81%	53.25%
Ethnic group						12.57	.002
		Han	91.24%	92.11%	95.02%
		Other	8.76%	7.89%	4.98%
Years of schooling			2.72 (3.59)	2.68 (3.43)	3.04 (3.88)	2.85	.058
Self-rated financial status			3.034 (.65)	3.11 (.61)	3.20 (.63)	19.44	.000
Household income per capita			13087.72 (18242.61)	17162.91 (19134.47)	16718.90 (18210.06)	11.33	.000
Chronic diseases						22.45	.000
		Yes	65.53%	74.65%	74.14%
		No	34.47%	25.35%	25.86%
Functional status			17.12 (2.28)	17.21 (2.11)	17.00 (2.47)	1.61	.120
Self-rated health			3.36 (.90)	3.37 (.90)	3.49 (.93)	5.93	.003
Marital status						4.24	.120
		Married	45.98%	42.18%	41.70%
		Not married	54.02%	57.82%	58.30%
Number of children			3.75 (1.66)	3.77 (1.67)	3.67 (1.68)	.85	.428
Intergenerational financial support			2795.36	3478.15	3660.04	4.37	.013
Intergenerational financial support			(5767.99)	(6352.1)	(7393.44)	4.37	.013
Intergenerational instrument support						5.37	.068
		Yes	89.01%	92.63%	90.2%
		No	10.99%	7.37%	9.8%
Intergenerational emotional support						5.04	.080
		Yes	82.77%	87.06%	84.76%
		No	17.23%	12.94%	15.24%
Living alone						.40	.818
		Yes	18.78%	17.81%	19.08%
		No	81.22%	82.19%	80.92%
Current location						16.76	.000
	Rural		51.38%	41.05%	49.87%
	Urban		48.62%	58.95%	50.13%
Region						16.04	.003
	Eastern		65.92%	59.12%	58.40%
	Central		24.26%	28.95%	27.85%
	Western		9.82%	11.93%	13.75%
Medical insurance						.16	.921
	Yes		82.28%	82.55%	82.97%
	No		17.72%	17.45%	17.03%
Old-age insurance						31.66	.000
	Yes		35.18%	43.93%	47.35%
	No		64.82%	56.07%	52.65%
Psychological resilience			19.00 (3.12)	18.95 (2.80)	19.73 (2.99)	17.74	.000
Life satisfaction			3.77 (.81)	3.92 (.78)	4.01 (.74)	23.95	.000

The Association Between Trajectories of Perceived Unmet HCBS Needs and Life Satisfaction

As shown in Table 2, the regression estimates in model 1 suggest that trajectories of perceived unmet HCBS needs were significantly associated with life satisfaction (coefficient = −.126, p < .001). Compared with older adults with decreasing perceived unmet needs for HCBS, older adults with increasing perceived unmet needs for HCBS reported significantly lower life satisfaction. When psychological resilience was included in model 2, the association between increasing unmet needs for HCBS and life satisfaction remained statistically significant (coefficient = −.108, p < .01). Psychological resilience was positively associated with life satisfaction (coefficient = .041, p < .001). When we further added the interaction terms between trajectories of perceived unmet HCBS needs and psychological resilience in model 3, the interaction term between the increasing trajectory of perceived unmet HCBS needs and psychological resilience was significantly and positively associated with life satisfaction (coefficient = .030, p < .01), which implies that psychological resilience moderated the association between increasing perceived unmet needs for HCBS and life satisfaction. For older adults with higher psychological resilience, the negative effect of increasing perceived unmet needs for HCBS on life satisfaction became weaker.

Table 2.

Multiple Regression Results for the Association Between Trajectories of Perceived Unmet HCBS Needs, Psychological Resilience, and Life Satisfaction.

	Life satisfaction
	Model 1	Model 2	Model 3
Trajectories of perceived unmet HCBS needs (Ref: Decreasing class)
Persistent class	−.012 (.036)	.009 (.035)	.001 (.035)
Increasing class	−.126*** (.031)	−.108** (.031)	−.114** (.031)
Psychological resilience		.041*** (.005)	.027** (.007)
Psychological resilience* persistent perceived unmet needs for HCBS			.018 (.012)
Psychological resilience*Increasing perceived unmet needs for HCBS			.030** (.010)
Age	−.001 (.002)	−.001 (.002)	.001 (.002)
Gender (Ref: Female)	−.062* (.030)	−.073* (.030)	−.075* (.030)
Ethnic group (Ref: Han)	.037 (.053)	−.003 (.053)	−.008 (.052)
Years of schooling	.003 (.004)	.001(.004)	.001(.004)
Primary occupation (Ref: Unemployed/housework)
Agriculture	−.001 (.056)	−.028 (.056)	−.029 (.054)
Others	.025 (.063)	−.014 (.063)	−.015(.062)
Self-rated financial status	.228^*** (.023)	.208^*** (.023)	.204^*** (.022)
Per capita household income	.023* (.009)	.022^* (.009)	.022^* (.009)
Self-rated health	.342^*** (.016)	.297^*** (.017)	.295^*** (.017)
Functional status	−.001 (.008)	−.009 (.008)	−.008 (.008)
Chronic diseases (Ref: no)	.070* (.031)	.065^*(.031)	.065* (.031)
Marital status (Ref: Not married)	.015 (.032)	−.005 (.032)	−.005 (.032)
Number of children	.008 (.009)	.009 (.009)	.009 (.009)
Intergenerational instrument support	−.015 (.061)	−.020 (.060)	−.029(.063)
Intergenerational financial support	.006 (.004)	.006 (.004)	.006 (.004)
Intergenerational emotional support	−.059(.049)	−.048 (.049)	−.047(.049)
Living arrangement (Ref: Living with others)	−.163*** (.037)	−.153*** (.036)	−.156*** (.036)
Current location (Ref: Urban)	−.002 (.029)	−.021 (.028)	−.023 (.029)
Regions (Ref: Central)
Eastern	.103^** (.032)	.104^** (.031)	.107^** (.036)
Western	.096 (.048)	.067 (.047)	.067 (.048)
Old-age insurance (Ref: no)	.110^*** (.030)	.101^** (.029)	.099^** (.028)
Medical insurance (Ref: no)	−.072 (.036)	−.072 (.036)	−.074 (.036)

Constant	1.915^***(.271)	1.454^***(.274)	1.698^***(.287)
R ²	.29	.308	.310
N	2465	2465	2465

Note. *p < .05; **p < .01; ***p < .001.

Heterogeneity Analysis

Table 3 reports the results of heterogeneity analysis on the main effect and moderating effect with adjustment of potential confounders. Stratified analysis confirmed that there were gender and rural-urban differences in the effect of perceived unmet HCBS needs trajectories on life satisfaction. The negative association between the increasing trajectory of perceived unmet HCBS needs and life satisfaction was only significant among older men (coefficient = −.149, p < .01) and rural older adults (coefficient = −.161, p < .001). However, both young-old (< 85 years old) and oldest-old (>= 85 years old) respondents with increasing perceived unmet needs for HCBS reported significantly lower levels of life satisfaction than their correspondents (coefficient = −.098, p < .05; coefficient = −.110, p < .05, respectively).

Table 3.

Heterogeneity Analysis on the Main and Moderating Effect of Perceived Unmet HCBS Needs’ Trajectories and Psychological Resilience.

	Female	Male	Male	Urban	Rural	Rural	<85 years old	<85 years old	> = 85 years old	> = 85 years old
Trajectories of perceived unmet HCBS needs (Ref: Decreasing class)
Persistent class	.032 (.050)	−.015 (.051)	−.033 (.051)	.051 (.048)	−.031 (.053)	−.041 (.053)	.004 (.046)	.005 (.047)	.019 (.055)	.014 (.055)
Increasing class	−.063 (.044)	−.149** (.044)	−.172*** (.045)	−.047 (.044)	−.161*** (.044)	−.168*** (.044)	−.098* (.041)	−.110* (.041)	−.110* (.049)	−.091 (.049)
Psychological resilience	.042*** (.007)	.039*** (.008)	.023 (.011)	.044*** (.008)	.036*** (.007)	.022 (.010)	.028*** (.007)	.018 (.010)	.055*** (.008)	.036** (.011)
Psychological resilience* persistent perceived unmet needs for HCBS			.025 (.019)			.007 (.017)		.018 (.017)		.017 (.018)
Psychological resilience* increasing perceived unmet needs for HCBS			.031* (.015)			.037** (.014)		.019 (.014)		.049** (.015)

Constant	1.512*** (.387)	1.387** (.408)	1.671*** (.431)	1.435** (.399)	1.589** (.380)	1.837*** (.396)	2.271*** (.529)	2.432*** (.540)	1.062* (.461)	1.430** (.476)
Control variables	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
N	1260	1205	1205	1272	1193	1193	1440	1440	1025	1025

Note. *p < .05; **p < .01; ***p < .001.

Because the association between the increasing trajectory of perceived unmet HCBS needs and life satisfaction was not significant in older women and urban older adults, the moderating effect of psychological resilience on the association was not examined in the two sub-groups. As Table 3 shows, psychological resilience was significantly associated with life satisfaction across all six sample subgroups, which was consistent with the findings in the total sample. Its moderating effect on the association between increasing trajectory of perceived unmet HCBS needs and life satisfaction was also statistically significant among older men (coefficient = .031, p < .05), rural older adults (coefficient = .037, p < .01), and oldest-old (coefficient = .049, p < .01). However, the negative effect of increasing perceived unmet HCBS needs on life satisfaction of young-old was not significantly moderated by psychological resilience.

Sensitivity Analysis

To evaluate the potential impact of sample selection on the trajectory analyses, we limited the sample to participants with complete information on perceived unmet HCBS needs for at least two waves (n = 3272) and conducted a sensitivity analysis. This sensitivity analysis identified three trajectory classes (as illustrated in Supplemental Figure 4), aligning with the presently reported findings. The increasing trajectory of perceived unmet HCBS needs exhibited a negative correlation with life satisfaction, and this association was moderated by psychological resilience, after adjusting for all covariates (as shown in Supplementary Table 4). Additionally, another sensitive analysis, performed on the complete-case samples (without multiple imputation), yielded results consistent with the currently reported findings (results available upon request). All of these sensitivity analyses collectively underscore the robustness of our findings.

Discussion

Drawing on nationally representative longitudinal data, this study identified distinct trajectories of perceived unmet HCBS needs over a 13-year period among Chinese older adults, and examined the association between perceived unmet HCBS needs and life satisfaction. In addition, the moderating role of psychological resilience in the association between perceived unmet HCBS needs trajectories and life satisfaction was also examined.

A slight decline was observed in the overall level of perceived unmet HCBS needs among Chinese older adults from 2005 to 2018. However, in line with previous studies (Lu et al., 2021; Meng et al., 2021), we found a considerable provision-need gap in HCBS, especially in psychological consulting, personal daily care, and in-home medical visits. Considering the sample attrition and significant differences between the samples that dropped out and those that remained in our study, the provision-need gap may have been underestimated. Longitudinal findings indicate that the increasing availability of HCBS was persistently insufficient for older adults' needs. More importantly, our results further show that the inter-individual divergence of unmet HCBS needs was increasing over the 13-year period. Three distinct trajectories (increasing, persistent, and decreasing) of perceived unmet HCBS needs were identified, which supported the heterogeneity in the development of perceived unmet needs for healthcare and social care services (Hu et al., 2022; Smith & Connolly, 2020; Vlachantoni et al., 2021). The increasing availability of HCBS did effectively satisfy some (the group with decreasing unmet needs, 42.64%) older adults’ needs over time, while others experienced persistent (21.13%) or even increasing (36.22%) perceived unmet needs for HCBS. These distinct trajectories indicate that inequality in meeting HCBS needs has exacerbated over time, which could partly be attributed to the insufficient and uneven distribution of HCBS resources across regions and rural-urban populations (Ding & Qu, 2019, Zhang & Li, 2019).

Knowledge of the perceived unmet HCBS needs trajectory and its associated factors may provide policy implications for developing targeted services and programs to meet the needs of older population. The current study found that significant differences existed in socio-demographic characteristics among class members of trajectories of perceived unmet HCBS needs. It is noteworthy that older adults with increasing perceived unmet HCBS needs tend to be the vulnerable group with the fewest economic resources for old-age support (significant disadvantages in old-age insurance, self-rated financial status, household income, and family financial support). Members of this vulnerable group were more likely to be older, ethnic minorities, and living in eastern and rural areas. In contrast, members of the decreasing group reported greater economic resources for old-age support than others. It seems that the increasing availability of HCBS helps to meet the needs of older population who enjoy advantaged economic resources rather than those being in economic disadvantages.

Although previous studies have well documented the negative effect of unmet needs on health and well-being (Allen et al., 2014, DePalma et al., 2013, He et al., 2015, Xu et al., 2012), this study further contributes to the literature by providing evidence for the association between cumulative exposure to perceived unmet HCBS needs and life satisfaction. It was found that older adults who experienced increasing perceived unmet HCBS needs reported lower levels of life satisfaction, compared with those reporting decreasing perceived unmet HCBS needs. This finding is consistent with a prior study that indicated that negative changes in unmet ADL needs were associated with decreases in life satisfaction among functionally disabled older adults (Huang et al., 2022). Our findings highlight the importance of long-term exposures to perceived unmet HCBS needs in reducing older adults’ life satisfaction in later life. In addition, the association between trajectories of perceived unmet HCBS needs and life satisfaction was only significant among male and rural older adults. A possible explanation is that males are more likely to report unmet needs and rely on others’ care than females (Chen et al., 2021, Miller & Cafasso, 1992) and therefore are more vulnerable to increasing perceived unmet HCBS needs. The rural-urban disparities can be explained by disadvantages in socioeconomic conditions and availability of care resources in rural areas than that in urban areas of China, which cause more dependence of rural older adults on HCBS.

Another contribution of the current study was that we found the moderating role of psychological resilience in the association between trajectories of perceived unmet HCBS needs and life satisfaction. In previous studies, the protective role of psychological resilience has been demonstrated in the face of aging-related stressors and adversities, such as poverty, illness, and disability (Lim et al., 2015; Wang et al., 2020b). The current study found that psychological resilience was positively associated with life satisfaction and buffered the negative effect of increasing perceived unmet HCBS needs on life satisfaction, further extending our understanding of psychological resilience in aging process. Older adults with high psychological resilience usually possess high levels of optimism and self-efficacy and more effective problem-solving skills (Fontes & Neri, 2015, Southwick & Charney, 2012), all of which help them cope with increasing perceived unmet needs for HCBS and thus promote their life satisfaction. In addition, the buffering effect of psychological resilience was found significant among older adults who were males, living in rural areas, and oldest-old. We did not examine the moderating effect of resilience in older women and urban older adults, because the association between trajectories of perceived unmet HCBS needs and life satisfaction was not significant in the two sub-groups. Results showed that psychological resilience was a significant moderator for the oldest-old but not for the young-old. A possible explanation is that the oldest-old suffer more age-related loss in health and social resources and might rely more on internal psychological resources to cope with unmet needs. In comparison, the young-old are more active in society and have higher ability to integrate individual and social resources to deal with unmet needs.

Findings from the present study have valuable implications for developing community-based old-age support and intervention programs to promote older adults’ well-being. Older adults have a strong preference for aging in place. It is critical to develop HCBS and person-centered care to meet their needs. The distinct trajectories of perceived unmet HCBS needs underline an increasing inequality in unmet needs over time, which would further lead to inequality in life satisfaction. Hence, minimizing the provision-need gap of HCBS, especially the psychological consulting, personal daily care, and in-home medical visits, is urgent for local governments to promote healthy aging. To promote social equality, basic support and care services should be efficiently delivered to those particular vulnerable groups, who not only have limited economic resources but also suffer increasing unmet HCBS needs. In addition, the significant moderating effect of psychological resilience highlights the need to develop and implement effective interventions that help foster and strengthen psychological resilience, especially for older adults who are male, living in rural, and oldest-old (>= 85 years old).

There are several limitations of this study. First, the measure of needs (‘do you expect your community to provide the services’) may partly reflect personal attitude towards the function of community not necessarily personal needs. However, evidence from China shows that older adults’ expectations or attitudes towards social care services (e.g., old-age support) are driven by self-interest and generally reflect their own actual needs (Yang et al., 2019), indicating the measure bias is acceptable. This measure is able to capture both the expected contents and sources (community vs. others) of services, addressing which services older adults are looking for from their communities. Further, in line with prior studies (Lu et al., 2021, Meng et al., 2021), this study focused on the perceived unmet needs due to perceived unavailability of needed services, regardless of the actual availability or utilization of services due to data limitation. It might underestimate the actual provision condition and does not capture unmet needs due to other reasons (e.g., inaccessible, unaffordable, unacceptable). However, perceived availability is a premise of service use and is more effective in predicting unmet needs than actual availability (Hwang et al., 2017, Tang & Pickard, 2008). Our findings shed light on the perceived gap between service needs and provision, thus providing an indicator of the perceived efficacy of HCBS delivery system in providing needed services. Future studies are needed to further capture other dimensions of unmet needs for HCBS by considering the utilization and quality of services, if data are available.

Second, only participants who provided complete information on perceived unmet HCBS needs for at least 3 waves and survived in 2018 were included in this study. These participants may represent relatively healthier older Chinese population. Consequently, this study might have underestimated unmet HCBS needs. Third, this study exclusively focused on the number of perceived unmet needs for HCBS over time. Future studies should further investigate the association between trajectories of different types of perceived unmet HCBS needs (with regard to the services provided) and life satisfaction. Fourth, although the five-item scale of psychological resilience is acceptable and reliable (Lou et al., 2023, Yang & Wen, 2015), developing a psychological resilience scale targeting older adults is needed to further explore the role of psychological resilience in this association.

Conclusion

Despite these limitations, the current study provides the first longitudinal analysis that examined the association between accumulative exposure to perceived unmet HCBS needs and life satisfaction, and the moderating role of psychological resilience on this association. Meeting the growing needs of HCBS for old-age has become a major policy issue as the rapidly aging of Chinese population. Three distinct trajectories (increasing, persistent, and decreasing class) of perceived unmet HCBS needs over the 13-year period have been identified and are found to be significantly associated with life satisfaction in later life. Moreover, psychological resilience could buffer the negative effect of the increasing trajectory of perceived unmet HCBS needs on life satisfaction, and the moderate effect is more pronounced in older adults who are males, living in rural areas, and oldest-old. Findings can be used to identify older adults at greater risk of experiencing persistent or increasing perceived unmet needs for HCBS and the transition risk of perceived unmet HCBS needs to lower life satisfaction. Future interventions could focus on the reduction of unmet HCBS needs and the improvement of psychological resilience to improve older adults’ psychological well-being.

Supplemental Material

Supplemental Material - The Association Between Trajectories of Perceived Unmet Needs for Home and Community-Based Services and Life Satisfaction Among Chinese Older Adults: The Moderating Effect of Psychological Resilience

Supplemental Material for The Association Between Trajectories of Perceived Unmet Needs for Home and Community-Based Services and Life Satisfaction Among Chinese Older Adults: The Moderating Effect of Psychological Resilience by Hui Wang, Huijun Liu, Bei Wu and Lun Hai in Research on Aging

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Social Science Foundation of China (21ZDA103).

ORCID iD

Hui Wang

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Hui Wang is a PhD Candidate from the Institute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University. Her research interests include aging and health policy, social care services and unmet needs, and health inequality.

Huijun Liu is a Full Professor from the Institute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University. Her research interests include aging and health policy, gender imbalance and social risk governance, and control of HIV Transmission.

Bei Wu is Dean’s Professor in Global Health and Vice Dean for Research at the Rory Meyers’ College of Nursing, New York University (NYU). She is also co-director of the NYU Aging Incubator. Her research interests include long-term care, cognitive impairment, dementia caregiving, and oral health.

Lun Hai is a PhD Candidate from the Institute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University. Her research interests include long-term care and healthy aging.

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