Urban–Rural Disparities in the Association Between Home- and Community-Based Service Utilization and Levels of Disability Among Chinese Older Adults With Disabilities

Abstract

Home- and community-based services (HCBS) are optimal ways to deal with disability problems among older adults. This study aims to analyze urban–rural disparities in the relationship between HCBS utilization and levels of disability among Chinese older adults with disabilities, so as to meet the long-term care needs of them. In applying the Andersen Behavioral Model, bivariate analysis and multivariate regression models were employed using data from 843 older adults with disabilities from the 2018 China Longitudinal Aging Social Survey (CLASS). After adjusting covariates, disability levels among Chinese older adults with disabilities were significantly correlated with HCBS utilization in urban areas but not in rural areas. The urban–rural disparities may be due to the low utilization of HCBS in rural areas (only 11.2%) among older adults with disabilities compared with their urban counterparts (22.7%).

Keywords

urban–rural disparities home- and community-based services utilization levels of disability older adults with disabilities

What this paper adds?

• The higher the levels of disability are, the more HCBS are used by urban older adults with disabilities.

• Disability levels among older adults with disabilities were significantly associated with HCBS utilization in urban areas but not in rural areas.

Applications of study findings

• More attention should be paid to older adults with disabilities in rural China.

• The government should combine the supply-side and demand-side perspectives to fundamentally address urban–rural disparities in using HCBS among Chinese older adults with disabilities.

Background

In the face of seemingly irreversible aging and resultant healthcare challenges worldwide, disability issues that most old adults with disabilities live in developing countries should be taken more seriously, especially in China (Affairs, 2020; Mcclain-Nhlapo, 2018). According to relevant forecasts, the quantity of Chinese older adults with disabilities stands a chance of reaching 76.11 million in 2030, possibly surging to 120 million in 2050, among whom older adults with mild and moderate disabilities would form the largest group (Ge et al., 2020). The expression of “older adults with disabilities” mainly refers to those who have lost the ability to take care of themselves due to vulnerability, frailty, illness, mental handicap, and so on. However, in China, there is no uniformity in the assessment of older adults with disabilities, and it is hard to effectively identify the level and type of their disability (Xizhe Peng, 2018). In applying Katz activities of daily living (ADL) scale, the worldwide standardized scale, older adults with one or more ADL limitations, which involve activities such as bathing, dressing, and eating, are defined as older adults with disabilities (Katz et al., 1963). In China, the Katz scale can be also used to define older adults with disabilities (Xiao et al., 2023). Given the fact that the number of older adults with disabilities in China will increase year by year, the issue of caring for them needs urgently addressing.

Home- and community-based services (HCBS) are considered optimal approaches to resolving issues related to caring for older adults with disabilities, aiming at helping them live and age well in their homes (Chum et al., 2022). HCBS in China started later than in many Western countries (Xu et al., 2023). As early as the 1980s, the promotion of HCBS to meet the needs of older adults has been carried out in Denmark and the United States (Birnbaum et al., 1984; Stuart & Weinrich, 2001). In China, the policies related to HCBS originated in 2000 (Huang et al., 2024). Chinese government struggled hard and developed HCBS, encompassing diversified services and support, mainly including health care, daily care, legal advice, and spiritual comfort, all of which have been promoted nationally since 2008 (China, 2008). By 2018, the supply coverage of HCBS in China had reached 62.02%, at a relatively high level (Xu et al., 2022). However, China’s HCBS still need to further improve in terms of availability and personnel specialization of the services. Older adults with disabilities may prefer health care, daily care, and spiritual comfort services, which play a critical role in maintaining mental and physical health while mitigating the risk involved in moving to nursing homes and alleviating the financial burden on their families (Weaver & Roberto, 2017; Yu et al., 2021). HCBS can effectively help meet the long-term care needs of community-dwelling older adults with disabilities (Liu et al., 2022).

Furthermore, there is well-recognized urban–rural divides in the use of HCBS due to inequitable HCBS allocation in China. Previous studies have suggested that uneven financial investment in urban and rural areas as well as inadequate social financing in rural areas may lead to urban–rural disparities in quantity and quality of HCBS as well as HCBS utilization. (Liu et al., 2007; Wang & Qi, 2021). A study pointed out that urban–rural disparities in public service utilization is most likely a result of the better-developed and -resourced healthcare systems available in urban, primarily in terms of human, material, and financial resources as well as information technology (Zhang et al., 2020). Similarly, there are urban–rural differences in the use of HCBS as part of public services (Wang & Qi, 2021).

Several studies have shown that levels of disability among older adults usually go hand in hand with using HCBS based on a certain utilization rate. Van Cleve and Degenholtz (2022) suggested that older adults with higher ADL limitations were less likely to receive home-delivered meals with relatively low utilization (28.9%) of meal delivery services (Van Cleve & Degenholtz, 2022). Alkema et al. (2006) found that ADL impairments affected HCBS utilization and older adults with higher ADL limitations were more likely to use HCBS with a relatively high utilization rate of 72.3% (Alkema et al., 2006). It can be seen that differences in HCBS utilization rates are likely to lead to inconsistent results. However, the relationship between levels of disabilities and HCBS utilization remains unclear in China.

Theoretically, there should be a close correlation between the use of HCBS and levels of disabilities, but the correlation is affected by the quantity and quality of HCBS provision. Coupled with the fact of urban–rural disparities in the quality and quantity of the services provision in China, this study, with a focus on Chinese older adults with disabilities, also seeks to find out whether there are urban–rural differences in the relationship between HCBS utilization and levels of disabilities. This study can also provide strong reference value for subsequent elderly policy formulation concerning older adults with disabilities, such as recommendations for enhancement in publicity, quantity, and quality of the services.

Method

Data Source

Data in this study was from the 2018 Chinese Longitudinal Aging Social Survey (CLASS) for research and analysis. The CLASS is a nationally representative and large-scale social tracking survey conducted by the National Survey Research Center, Renmin University of China, and conducted in 28 provinces (including municipalities and autonomous regions) in China, excluding Hong Kong, Macao, Taiwan, Hainan, Xinjiang, and Tibet, involving a stratified and multi-stage probability sample of older adults aged 60 and above. The survey questionnaire covered key demographic characteristics, health status, socioeconomic status, and family and child status in relation to older adults. Overall, 11,419 older adults aged 60 or above completed face-to-face questionnaires alongside professional investigation teams who had received relevant training before the survey.

The term “urban–rural disparities” refers to the discrepancies in economic, cultural levels, and socioeconomic relations between urban and rural areas. Unlike urban areas, rural areas are places where people are engaged in agriculture. In China, the disability phenomenon among older adults is more severe in rural areas. People living in rural areas are more likely to rely on a single economic source and experience deficient living conditions, requiring more social attention than those in urban areas (Jiang et al., 2021). The urban–rural continuum is a particular space that has evolved from a predominantly rural peri-urban area to one characterized by combined urban and rural characteristics, as urban industrial and residential areas continue to spread to the city’s outskirts. Therefore, it can neither be classified separately as an urban area nor as a rural area (Xu et al., 2023). Based on this, the process of data screening was two-step: the first step was to screen out older adults with disabilities from the total elderly population, including 947 participants who had one or more ADL limitations; the second step was to exclude unusable and invalid data, and participants were excluded if they (a) lived in the urban–rural continuum (71), (b) were unable to respond to SRH (self-rated health) (9), (c) and missed data on the number of children (24). Eventually, 843 participants were included in the study. More details are presented in Figure 1.

Figure 1.

Flow diagram of target population screening.

Measurements

The Anderson Behavioral Model can be used to explain the factors that influence the service use, including predisposing factors, enabling factors, and need factors. Predisposing factors are pre-existing features of an individual, influencing their behavior related to using the services (e.g., age, gender, marital status, and education). Enabling factors are individual, family-based, and community-based resources that promote or hinder the service use (e.g., economic resources). Need factors include an individual’s perceived and objective need for services. Therefore, this study applied the Anderson Behavioral Model to incorporate confounders and control for other variables that may affect the use of HCBS among older adults with disabilities, making the results more precise (Andersen, 1995; Andersen, 2008).

The Andersen Behavioral Model is commonly used in research on public service utilization. Many studies on public service utilization among older adults have been guided by the model. Robinson et al. applied the model to explore the relationship between informal support and HCBS utilization among older adults (Robinson et al., 2021). Robison et al. examined the effect of birth cohort and gender on schedules of long-term services and supports using the Anderson Behavioral Model (Robison et al., 2014).

Dependent Variable: HCBS Utilization

In this study, participants were inquired whether the following HCBS for older adults were being used: (a) in-home visits, (b) helpline services for older adults, (c) escort services, (d) help with daily shopping, (e) legal assistance, (f) in-home housekeeping, (g) senior dining table or meal delivery, (h) daily care stations or nurseries, and (i) psychological counseling. The participants were categorized as “Any HCBS” if they reported using one or more of the services mentioned above and as “No HCBS” if no services were reported as used.

Independent Variable: Levels of Disability

ADL indexes reflect the most basic functions that enable older adults to live at home and in the community, which have been used extensively to assess the levels of disability (Gao et al., 2018; Han et al., 2021; Katz et al., 1963). Levels of disability in this study were evaluated using the internationally recognized Katz ADL index (Chiu et al., 2021; Peng et al., 2020). This ADL scale includes six items also used in the CLASS: bathing, dressing, eating, going to the toilet, getting in and out of bed, and walking around the room. Participants with at least one or more limitations were defined as older adults with disabilities (He et al., 2015; Xiao et al., 2023). Participants who needed some assistance or were unable to undertake the required movements in relation to each item were scored 1, whereas participants who needed no help were scored 0. Overall scores for the ADL indexes range from 0 to 6, indicating three levels of disability (1 or 2, participants with mild disabilities; 3 or 4, participants with moderate disabilities; 5 or 6, participants with severe disabilities).

Covariates

Covariates can be classified into three parts in terms of the Andersen Behavioral Model: (a) predisposing factors, including gender (male, female), age (60–75 years old, 75–85 years old, and 86 years old or over), education level (literate, illiterate), and marital status (married, single); (b) enabling factors, including living ways (living with families, living alone), residence (rural or urban), social insurance (yes, no), income (yes, no), and number of children (0–3, over 3); and (c) need factors, including chronic diseases (yes, no) and self-rated health (very good, good, fair, poor, and very poor).

Statistical Analysis

First, descriptive analyses were performed according to frequencies and percentages to present the overall features of participants. We then used chi-square tests to compare the key characteristics of urban and rural participants and of older adults with disabilities who did or did not utilize HCBS in urban and rural areas. In applying the Anderson Behavioral Model, multivariate logistic regression models were used to determine the situation in relation to the urban–rural disparities in the association between HCBS utilization and levels of disability among Chinese older adults with disabilities. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp) software.

Results

Basic Characteristics

This study included a sample of 843 older adults with disabilities, of whom 458 (54.3%) were urban residents and 385 (46.7%) were rural residents. The HCBS utilization variable among Chinese older adults with disabilities showed significant urban–rural differences. Older adults with disabilities who used HCBS accounted for 22.7% and 11.2% of those living in urban and rural areas, respectively, which indicated a low level of utilization. Table 1 presents more details on each characteristic.

Table 1.

Differences Between Basic Characteristics of Chinese Older Adults With Disabilities in Urban and Rural Areas (n= [%]).

Variable		Urban (n = 458)	Rural (n = 385)	χ ²
Predisposing factors
Gender	Male	201 (43.9%)	176 (45.7%)	0.283
Gender	Female	257 (56.1%)	209 (54.3%)	0.283
Age	60–75 years old	175 (38.2%)	165 (42.9%)	2.181
	75–85 years old	217 (47.4%)	164 (42.6%)
	86 years old or over	66 (14.4%)	56 (14.5%)
Education level	Literacy	344 (75.1%)	164 (42.6%)	92.327^***
Education level	Illiteracy	114 (24.9%)	221 (57.4%)	92.327^***
Marital status	With a spouse	247 (53.9%)	194 (50.4%)	1.051
Marital status	No spouse	211 (46.1%)	191 (49.6%)	1.051
Enabling factors
Living ways	Live with families	430 (93.9%)	347 (90.1%)	4.091^*
Living ways	Live alone	28 (6.1%)	38 (9.9%)	4.091^*
Social insurance	Yes	423 (92.4%)	334 (86.8%)	7.173^**
Social insurance	No	35 (7.6%)	51 (13.2%)	7.173^**
Income	Yes	31 (6.8%)	72 (18.7%)	27.769^***
Income	No	427 (93.2%)	313 (81.3%)	27.769^***
Number of children	0–3	339 (74.0%)	208 (54.0%)	36.691^**
Number of children	Over 3	119 (26.0%)	177 (46.0%)	36.691^**
Need factors
Chronic diseases	Yes	409 (89.3%)	332 (86.2%)	1.851
Chronic diseases	No	49 (10.7%)	53 (13.8%)	1.851
Self-rated health	Very good and good	90 (19.7%)	70 (18.2%)	0.293
Self-rated health	Fair, poor, and very poor	368 (80.3%)	315 (81.8%)	0.293
Level of disabilities	Mildly disabled	303 (66.2%)	247 (64.2%)	0.794
	Moderately disabled	71 (15.5%)	58 (15.1%)
	Severely disabled	84 (18.3%)	80 (20.8%)
Dependent variable
HCBS utilization	Yes	104 (22.7%)	43 (11.2%)	19.343^***
HCBS utilization	No	354 (77.3%)	342 (88.8%)	19.343^***

Note. Data in this table are presented as frequencies (percentages); HCBS, home- and community-based services.

*p < .05. **p < .01. ***p < .001.

Bivariate Results

As is shown in Table 2, bivariate analysis was used to examine discrepancies between HCBS users and non-users living in urban and rural areas. As for predisposing factors, urban older adults with disabilities aged 60–75 and 75–85 years are more likely to use HCBS and rural older adults with disabilities aged 60–75 years are more inclined to use HCBS. In urban and rural areas, enabling factors did not affect HCBS utilization. With regard to need factors, levels of disability among older adults with disabilities showed significant differences between HCBS users and non-users in urban areas and that older adults with mild and severe disabilities were more likely to utilize HCBS. However, apart from predisposing factors, no variables were significantly correlated with HCBS utilization in rural areas.

Table 2.

General Characteristics of HCBS Users and Nonusers in Urban and Rural Areas Among Chinese Older Adults With Disabilities.

Variable	Urban n (%)			Rural n (%)
Variable	Any HCBS	No HCBS	χ²	Any HCBS	No HCBS	χ²
Predisposing factors
Gender			3.529			0.046
Male	54 (51.9%)	147 (41.5%)		19 (44.2%)	157 (45.9%)
Female	50 (48.1%)	207 (58.5%)		24 (55.8%)	185 (54.1%)
Age			7.843^*			8.414^*
60–75 years old	28 (26.9%)	147 (41.5%)		19 (44.2%)	146 (42.7%)
75–85 years old	56 (53.8%)	161 (45.5%)		12 (27.9%)	152 (44.4%)
86 years old or over	20 (19.2%)	46 (13.0%)		12 (27.9%)	44 (12.9%)
Education level			0.001			0.011
Literacy	78 (75.0%)	266 (75.1%)		18 (41.9%)	146 (42.7%)
Illiteracy	26 (25.0%)	88 (24.9%)		25 (58.1%)	196 (57.3%)
Marital status			1.750			0.012
With a spouse	62 (59.6%)	185 (52.3%)		22 (51.2%)	172 (50.3%)
No spouse	42 (40.4%)	169 (47.7%)		21 (48.8%)	170 (49.7%)
Enabling factors
Living ways			1.205			0.907
Live with families	100 (96.2%)	330 (93.2%)		37 (86.0%)	310 (90.6%)
Live alone	4 (3.8%)	24 (6.8%)		6 (14.0%)	32 (9.4%)
Social insurance			2.747			3.112
Yes	100 (96.2%)	323 (91.2%)		41 (95.3%)	293 (85.7%)
No	4 (3.8%)	31 (8.8%)		2 (4.7%)	49 (14.3%)
Income			0.758			0.187
Yes	95 (91.3%)	332 (93.8%)		36 (83.7%)	277 (81.0%)
No	9 (8.7%)	22 (6.2%)		7 (16.3%)	65 (19.0%)
Number of children			0.068			0.525
0–3	78 (75.0%)	261 (73.7%)		21 (48.8%)	187 (54.7%)
Over 3	26 (25.0%)	93 (26.3%)		22 (51.2%)	155 (45.3%)
Need factors
Chronic diseases			0.165			0.813
Yes	94 (90.4%)	315 (89.0%)		39 (90.7%)	293 (85.7%)
No	10 (9.6%)	39 (11.0%)		4 (9.3%)	49 (14.3%)
Self-rated health			0.518			0.246
Very good and good	23 (22.1%)	67 (18.9%)		9 (20.9%)	61 (17.8%)
Fair, poor, and very poor	81 (77.9%)	287 (81.1%)		34 (79.1%)	281 (82.2%)
Level of disabilities			26.02^***			2.539
Mildly disabled	48 (46.2%)	255 (72.0%)		25 (58.1%)	222 (64.9%)
Moderately disabled	22 (21.2%)	49 (13.8%)		10 (23.3%)	48 (14.0%)
Severely disabled	34 (32.7%)	50 (14.1%)		8 (18.6%)	72 (21.1%)

Note. Data in this table are presented as frequencies (percentages); HCBS, home- and community-based services; *p < .05. **p < .01. ***p < .001.

Multivariate Regression Results

Table 3 presents the results for the two multivariate regression models: Model 1 (urban participants) and Model 2 (rural participants). Regarding the association between HCBS utilization and levels of disability among Chinese older adults with disabilities, the results presented in Model 1 (moderately disabled: odds ratio [OR] = 2.421, p < .01; severely disabled: OR = 3.675, p < .001) show that urban older adults with moderate disabilities used HCBS more than twice as often as urban older adults with mild disabilities, while older adults with severe disabilities used HCBS more than three times more often than older adults with mild disabilities. However, no significant association was found in Model 2 between the levels of disability among rural older adults with disabilities and the use of HCBS (moderately disabled: OR = 1.580, p > .05; severely disabled: OR = 0.957, p > .05).

Table 3.

Logistic Regression: Factors Affecting HCBS Utilization Among Chinese Older Adults With Disabilities.

Variable	Model 1: Urban (n = 458)		Model 2: Rural (n = 385)
Variable	OR	95% CI	OR	95% CI
Predisposing factors
Gender (ref. = male)	0.779	0.478–1.271	1.161	0.588–2.291
Age (ref. = 60–75 years old)
75–85 years old	1.891^*	1.098–3.259	0.553	0.239–1.276
86 years old or over	1.944	0.940–4.023	2.185	0.807–5.914
Education level (ref. = illiteracy)	1.067	0.609–1.872	1.063	0.517–2.187
Marital status (ref. = no spouse)	1.311	0.781–2.200	1.612	0.709–3.661
Enabling factors
Living ways (ref. = live with families)	0.667	0.208–2.142	1.945	0.678–5.577
Social insurance (ref. = no)	2.469	0.821–7.442	2.946	0.677–13.008
Income (ref. = no)	1.356	0.530–3.472	0.750	0.293–1.919
Number of children (ref. = 0–3)	0.873	0.501–1.524	1.269	0.630–2.554
Need factors
Chronic diseases (ref. = no)	1.091	0.485–2.454	1.563	0.510–4.789
Self-rated health (ref = very good and good)	1.608	0.876–2.949	1.538	0.657–3.604
Levels of disability (ref. = mildly disabled)
Moderately disabled	2.421^**	1.312–4.467	1.580	0.679–3.678
Severely disabled	3.675^***	2.072–6.516	0.957	0.400–2.290

Note. HCBS, home- and community-based services; OR, odds ratio; 95% CI, 95% confidence interval.

*p < .05. **p < .01. ***p < .001.

Discussion

Based on the current situation of urban–rural differences in the use of HCBS, this study confirmed the hypothesis that there is an urban–rural difference in the relationship between HCBS utilization and the levels of disabilities among Chinese older adults with disabilities, which furnishes strong policy references. Levels of disability among older adults with disabilities were found to be statistically significantly associated with HCBS utilization in urban areas but not in rural areas.

Based on the Anderson Behavioral Model, we found that among the predisposing factors, age was significantly linked to HCBS utilization among urban participants. Regarding the enabling factors, no variables were significantly associated with HCBS utilization among urban or rural participants. Concerning the need factors, levels of disability were significantly associated with HCBS utilization among urban participants. The main findings of the study are discussed in detail below.

Levels of disability were significantly related to HCBS utilization among urban older adults with disabilities. This finding accords with the studies conducted out of China showing that the extent of older adults’ levels of disability appears to stimulate HCBS utilization (Alkema et al., 2006; Ewen et al., 2017). However, this study’s unexpected finding was that the levels of disability among rural older adults with disabilities were not significantly correlated with HCBS utilization. This result was sustained in both bivariate and multivariate logistic analyses, possibly due to the extremely low utilization of HCBS by older adults with disabilities in rural areas.

A question, therefore, arises as to why HCBS have been underutilized by rural older adults with disabilities when the need for HCBS is higher among them (Zhang et al., 2020). To explore this phenomenon further, we supposed three reasons to explain the result: unawareness of existing HCBS, difficulties in seeking HCBS, and difficulties in reaching HCBS (Levesque et al., 2013).

First, even though rural older adults with disabilities need HCBS, they can be unaware of their existence. Supply-side barriers to being aware of HCBS refer to inadequate publicity concerning HCBS. In contrast, demand-side barriers refer to constraints related to traditional cultural attachments and being insulated from information sources. In terms of confronting the supply-side barriers, efforts by the Chinese Government have led to HCBS beginning to appear in rural areas. However, there is still inadequate publicization of HCBS information compared to urban areas (Xu & Chow, 2011). Regarding the demand-side barriers, conventional cultural perceptions of filial piety in family support are more deeply rooted in the Chinese countryside than in urban areas. Community-dwelling rural older adults with disabilities, therefore, prefer informal care provided by their children and feel ashamed to be cared for by others (Chou, 2011; Feng et al., 2012). Within this context, rural older adults with disabilities tend to have limited awareness of the existence of HCBS. In addition, information isolation has profound implications for being aware or otherwise of HCBS. It is difficult for rural older adults with disabilities to obtain external information because of their limited mobility and the absence of publicized information on HCBS in rural areas (Casado et al., 2011). Given these factors, rural older adults with disabilities may not be aware of HCBS and, hence, do not use HCBS.

Second, even when there is awareness of HCBS, rural older adults with disabilities may experience difficulties in seeking these HCBS. Supply-side barriers to seeking HCBS include insufficient participation by relevant parties and limited geographical accessibility to HCBS. Demand-side barriers are related to restrictions in mobility and a lack of family support. According to the supply-side barriers, although the government has actively mobilized and organized the participation of all sectors of society in rural construction, the issue of insufficient participation by multiple relevant parties (such as non-governmental organizations, social enterprises, the HCBS workforce, and volunteering groups) remains to be dealt with in some rural areas, which is likely to negatively affect rural older adults with disabilities in seeking HCBS (Wang & Qi, 2021). Despite improvements in rural transport facilities, limited or non-existent transportation in remote rural areas is likely to inhibit attempts to seek HCBS, contributing to urban–rural disparities in HCBS access (Treiman, 2012). In terms of the demand-side barriers, rural older adults with disabilities may not be able to go outside on account of limited mobility. Furthermore, rural hollowing out is increasing as young and middle-aged workforce at home move to urban areas in large numbers (Liu, Zhang, Lin, & Li, 2019). Therefore, family support that enables rural older adults with disabilities to reach HCBS physically has become increasingly inadequate in rural areas, resulting in fewer people seeking HCBS relative to their urban counterparts. Given these challenges in seeking HCBS, rural older adults with disabilities often cannot use HCBS easily.

Third, assuming that rural older adults are successful in seeking HCBS facilities, access difficulties may also be encountered in rural areas. Supply-side barriers to reaching HCBS relate to inadequate HCBS provision and lower-quality HCBS, whereas a more limited ability to pay creates a demand-side barrier. To address the supply-side barriers, the government has increased funding for HCBS in rural areas, but the HCBS provision is still insufficient. Besides, fewer services are focused on older adults with disabilities than urban areas, as exemplified by the small number of beds provided for older adults with disabilities in rural happiness homes (xin-fu-yuan) (Feng et al., 2020; Li et al., 2013). Moreover, related low-quality HCBS in rural areas, involving unprofessional and unsustainable care from HCBS providers, can foster a reluctance to access HCBS by older adults with disabilities (Feng et al., 2020). Concerning the demand-side barriers, an ability to pay refers to the capacity to acquire financial resources through income, savings, borrowings, and loans (Levesque et al., 2013). Although most HCBS are free of charge or require limited payments (Harrington et al., 2011), rural older adults with disabilities are more in need of long-term professional and fee-based home care services than their urban counterparts, as their children tend to work away from home (Zhang et al., 2020). Furthermore, most rural older adults with disabilities have low income and consumption level compared to their urban counterparts, resulting in a reduced ability to access HCBS (Chen et al., 2015; Wang et al., 2013). For these reasons, rural older adults tend to be restricted in their ability to access HCBS and eventually may not be able to use them.

In summary, the relationship between levels of disability and HCBS utilization was significant in urban areas but not in rural areas.

Limitations

Several limitations appeared in this study. In the first place, the cross-sectional design of this research restricted the determination of causal relationships among the variables. Longitudinal research should be conducted to further evaluate the urban–rural disparities in the association between HCBS utilization and disability levels among older adults with disabilities. Second, this study did not specify the different categories of HCBS. Future studies should consider specific types of HCBS in relation to their utilization. Finally, the predisposing, enabling, and need factors were all based at the individual level and—likely due to restrictions of the survey data—did not include contextual characteristics. Future studies we conduct will consider this issue and provide depth to this work.

Conclusions

The results of this study manifest that levels of disability among Chinese older adults with disabilities are significantly positively correlated with the use of HCBS in urban areas but not in rural areas.

It is well-advised that the government should combine the supply-side and demand-side perspectives to fundamentally address urban–rural disparities in using HCBS among Chinese older adults with disabilities. First, local governments should increase the level of publicity concerning HCBS in rural areas, strengthen health education, and raise the acceptance and awareness of HCBS among rural older adults with disabilities and their families through relevant knowledge dissemination. Second, the government urgently needs to advance the construction of transport infrastructure in rural areas and introduce relevant incentivizing policies to encourage the participation of pluralistic actors in HCBS provision so that older adults with disabilities in rural areas can access HCBS more easily. The government also needs to increase financial investment in HCBS for rural older adults with disabilities, narrow the gap between the content of HCBS in urban and rural communities and promote rational allocation of HCBS while considering local conditions, and improve the quality of HCBS.

Abbreviations

HCBS

Home- and community-based services

CLASS

Chinese Longitudinal Aging Social Survey

ADL

Activities of daily living

SRH

Self-rated health.

Footnotes

Acknowledgments

Zishuo Huang contributes greatly to this work. The authors thank the CLASS team for their hard work and unselfish sharing of survey data. We also acknowledge Editage editorial team for their English editing.

Author Contributions

Xiangyang Zhang, Zixia Wang, and Zishuo Huang conceived and designed the study. Zixia Wang and Zishuo Huang participated in acquisition of the data. Zishuo Huang and Chun Chen contributed to data analysis. Zishuo Huang and Zixia Wang wrote the original draft. Zishuo Huang took charge of the submission. Zixia Wang, Zishuo Huang, Xiangyang Zhang, Chun Chen, Rujia Zhang, Xiaoyi Wang, Qingren Yang, Jun Ye, Tingke Xu, Yunyun Huang, Xinxin Zhang, Shanshan Wang, and Lei Tang contributed greatly to the concept and design of the study and substantively revised the manuscript. All authors have read and approved the final manuscript and agreed to be responsible for all aspects of the study in ensuring that questions related to the accuracy or integrity of any part of the study are appropriately investigated and resolved.

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 National Natural Science Foundation of China (72274141), Natural Science Foundation of Zhejiang Province, China (LY22G030006), Philosophy and Social Science Project of Zhejiang Province, China (22NDJC104YB), 2023 Joint Project of Science and Technology Department of National Administration of Traditional Chinese Medicine and Zhejiang Administration of Traditional Chinese Medicine (GZY-ZJ-KJ-23084), and Philosophy and Social Science Planning of Zhejiang Province in 2022, “Youth Theory and Research Special Topics of Zhijiang River” (22ZJQN55YB).

Ethical Statement

ORCID iD

Chun Chen

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