This study demonstrated that there were urban-rural disparities in the use of HCBSs and that there was an association between HCBSs utilization and levels of disabilities among Chinese older adults with disabilities. Differences were found between urban and rural older adults with disabilities in HCBSs utilization, with urban older adults with disabilities being inclined to use HCBSs relative to their rural counterparts. Levels of disabilities among older adults with disabilities were found to be statistically significantly associated with HCBSs utilization throughout China and in urban areas, but not in rural areas.
The results of this study indicate that urban older adults with disabilities have an increased likelihood of using HCBSs compared to their rural counterparts. Studies conducted in America, Japan, and South Korea showed urban-rural disparities in HCBSs utilization among older adults[27-29]. This study, with a focus on older adults with disabilities, drew the corresponding conclusion. Issues related to urban-rural disparities in HCBSs utilization have become a worldwide concern, prompting a search for effective ways to address these problems.
Levels of disabilities were significantly related to HCBSs utilization among the total number of older adults with disabilities and urban older adults with disabilities. This finding accords with previous studies showing that the extent of older adults’ levels of disabilities appears to stimulate HCBSs utilization[30, 31]. However, this study’s unexpected finding was that the levels of disabilities among rural older adults with disabilities were not significantly correlated with HCBSs utilization. This result was sustained in both bivariate and multivariate logistic analyses, possibly due to the low utilization of HCBSs by older adults with disabilities in rural areas.
A question, therefore, arises as to why HCBSs have been underutilized by rural older adults with disabilities when the need for HCBSs is higher among them[17, 18]. To explore this phenomenon further, we modified our conceptual framework based on a study by Levesque et al.[32], as shown in Figure 2. This revised conceptual framework of HCBSs utilization explained why rural older adults with disabilities could not easily use HCBSs from supply-side and demand-side perspectives. There are three reasons: unawareness of existing HCBSs, difficulties in seeking HCBSs, and difficulties in accessing HCBSs.
First, even though rural older adults with disabilities need HCBSs, they can be unaware of their existence. Supply-side barriers to being aware of HCBSs refer to inadequate publicity concerning HCBSs. In contrast, demand-side barriers refer to constraints related to traditional cultural attachments and being isolated from information sources. In terms of confronting the supply-side barriers, efforts by the Chinese government have led to HCBSs beginning to appear in rural areas. However, there is still inadequate publicization of HCBSs information compared to urban areas[33]. 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. Rural older adults with disabilities, therefore, prefer informal care provided by their children[34, 35]. Within this context, rural older adults with disabilities tend to have limited awareness of the existence of HCBSs. In addition, information isolation has profound implications for being aware or otherwise of HCBSs. 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 HCBSs in rural areas[36]. Given these factors, rural older adults with disabilities may not be aware of HCBSs and, hence, do not use HCBSs.
Second, even when there is awareness of HCBSs, rural older adults with disabilities may experience difficulties in seeking these HCBSs. Supply-side barriers to seeking HCBSs include insufficient participation by relevant parties and limited geographical accessibility to HCBSs. 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 HCBSs 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 HCBSs[14]. Despite improvements in rural transport facilities, limited or non-existent transportation in remote rural areas is likely to inhibit attempts to seek HCBSs, contributing to urban-rural disparities in HCBSs access[12]. In terms of the demand-side barriers, rural older adults with disabilities may not be able to go outside because of limited mobility. Furthermore, rural hollowing out is increasing as young and middle-aged workforce at home move to urban areas in large numbers[37]. Therefore, family support that enables rural older adults with disabilities to reach HCBSs physically has become increasingly inadequate in rural areas, resulting in fewer people seeking HCBSs relative to their urban counterparts. Given these challenges in seeking HCBSs, rural older adults with disabilities often cannot use HCBSs easily.
Third, assuming that rural older adults are successful in finding HCBSs facilities, access difficulties may also be encountered in rural areas. Supply-side barriers to accessing HCBSs relate to inadequate specific HCBSs for older adults with disabilities and lower quality HCBSs, whereas a more limited ability to pay creates a demand-side barrier. To address the supply-side barriers, the government has increased funding for HCBSs in rural areas, but fewer services are focused on older adults with disabilities compared with urban areas, as exemplified by the small number of beds provided for older adults with disabilities in rural happiness homes (xin-fu-yuan)[38, 39]. Moreover, related low-quality HCBSs in rural areas, which can involve unprofessional and unsustainable care from HCBSs providers, can foster a reluctance to access HCBSs by older adults with disabilities[38]. Concerning the demand-side barriers, an ability to pay refers to the capacity to acquire financial resources through income, savings, borrowings, and loans[32]. Although most HCBSs are free of charge or require limited payments[40], 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[17]. 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 HCBSs[41, 42]. For these reasons, rural older adults tend to be restricted in their ability to access HCBSs and eventually may not be able to use them.
In summary, HCBSs are more likely to be used among urban older adults with disabilities than their rural counterparts, and the higher the level of disabilities, the higher HCBSs utilization. However, the relationship between levels of disabilities and HCBSs utilization was significant in urban areas but not in rural areas.