Enhancing Income as a Starting Point for Designing Sustainable Health Product-Service Systems for Chronically Ill Elderly in Rural Areas

Abstract

Insufficient income, inadequate healthcare resources, and insufficient chronic disease management awareness pose a fundamental obstacle to the sustained health maintenance of elderly individuals with chronic diseases in rural areas. In response to these challenges, this study adopted a research-through-design approach and introduced system design thinking by incorporating new stakeholders, experiential insights, and services. Initially, during the background research stage, a semi-structured interview was conducted to gain an understanding of the pains, needs, and potential opportunities of the target users. Subsequently, in the design model construction stage, desk research was carried out to refine and integrate the common components identified in various design models. In a focus group, these components were then incorporated into the development of a Sustainable Health Product-Service System Design Model tailored for rural elderly with chronic diseases after refining the pains, needs, and potential opportunities defined in the first stage. This design model encompassed elements including a background layer, a stakeholder layer, a funding layer, a product layer, a service layer, and an information layer. In the system design and design model validation stage, a design project aimed at health maintenance was launched within Liyang Town, with the design thinking method following a process of empathizing, defining, ideating, prototyping, and testing. Throughout the project, the established model guided the design process and facilitated the conceptualization and implementation of a Product-Service system. In conclusion, an investigation encompassing 15 elderly individuals was undertaken to analyze their income balance, health condition, health awareness, and their satisfaction with the health system. This analysis spanned the period both before and after their involvement in the project. The outcomes of this examination revealed notable enhancements across all three dimensions evaluated, highlighting the positive impact of the project on the elderly participants. Furthermore, the project’s social benefits were also comprehensively established.

1. Introduction

According to the World Health Statistics 2023 report, approximately 500 million individuals worldwide suffer from chronic diseases, with nearly 70% of this demographic surpassing the age of 60 [1]. Regions characterized by more significant economic disadvantages exhibit a higher prevalence of elderly people with chronic diseases [2]. In other words, these chronic conditions are significant and profound economic issues for any person, the healthcare system, and society as a whole [3,4]. Despite the remarkable advancements witnessed in evidence-based medicine for the treatment of major diseases in recent years, the number of elderly individuals affected by chronic diseases keeps increasing annually, especially in rural areas.

Through a literature review, this study identified several challenges surrounding the management of chronic diseases among the elderly population in rural areas. Firstly, the high prevalence of chronic diseases among the rural elderly can be directly attributed to their limited awareness of health maintenance, such as a lack of regular health check-ups and the adoption of unhealthy dietary patterns [5]. Secondly, the imbalanced allocation of healthcare resources between urban and rural settings has led to a deficiency of medical facilities, community clinics, and accessible family physicians [6]. Thirdly, a lack of income sources for the rural elderly coupled with inadequate health insurance coverage to address the expenses incurred in managing these ailments underscores a fundamental issue [7]. Among all three issues, low income and insufficient health insurance coverage emerge as the primary problems impeding the sustained health maintenance of elderly individuals grappling with chronic diseases. A field investigation carried out across five rural areas in China corroborated these aforementioned issues. Notably, the field investigation also uncovered some opportunities to support chronic disease management among the rural elderly. If elderly people retain a certain degree of physical mobility, this could enable them to undertake light domestic work. The natural environment in which the elderly reside presents potential opportunities for organic farming (agriculture, husbandry, or catering) with high economic value. However, there are currently a lack of suitable employment opportunities tailored to harness these prospects for the benefit of the rural elderly population.

Chronic diseases require a long period of treatment, which leads to an increase in demand for healthcare services [8,9,10,11]. Addressing the complex challenges surrounding public health demands a multidisciplinary approach integrating insights from various disciplines, including public health and management, through sustainable system design thinking. However, this kind of approach that effectively bridges the gap between low incomes and continuous expenses for chronic disease management among rural elderly populations remains limited. The primary objective of this study is to fill this gap in the rural areas in China by developing a Sustainable Health Product-Service System Design (PSSD) Model that considers augmenting the income of the elderly, optimizing the health service process, and effectively integrating social and medical resources.

This study examines the scope of chronic diseases in the following categories: (1) chronic cardiovascular diseases (hypertension, coronary heart disease, stroke, cerebral hemorrhage), (2) endocrine metabolic diseases (diabetes mellitus, hyperthyroidism), (3) chronic respiratory diseases (chronic bronchitis, asthma, chronic obstructive pulmonary disease), (4) digestive system disease, (5) neoplastic disease [12].

Current research related to “chronic disease” and “Design” primarily concentrates on product enhancement and improving user experiences, which may not adequately address the challenges faced by rural elderly individuals dealing with chronic illnesses. Some studies focus on the design of medical instruments, such as smart hemostats in conjunction with new technology [13], the development of a Mobile Monitoring and Feedback Tool [14], the design of intelligent medical aid products tailored to the needs of elderly users managing chronic diseases [15], and the creation of mobile applications [16]. Furthermore, certain research endeavors are dedicated to enhancing the user experience along the journey of “purchasing medicine—taking medicine—managing medicine” [17]. Additionally, there are studies delving into the exploration of innovative medical solutions, such as a Chronic Disease mHealth App Intervention Design Framework [18] for real-time interventions that can seamlessly connect individuals to healthcare teams. These collective efforts hold significance in various aspects, facilitating improvements in chronic disease management and offering valuable insights and experiences that inform our research on addressing the management of chronic illnesses among rural elderly populations.

The article is structured as follows. To begin with, Section 2 outlines the methodology employed in the study. Following this, the subsequent sections present the outcomes of the research. Section 3 introduces procedures for constructing the model, and Section 4 introduces the proposed Sustainable Health Product-Service System Design (PSSD) Model. Moreover, it offers insights into the practical implementation and testing of the model through its application within the project involving elderly participants from Liyang Town, Anhui Province, China (Section 5). In concluding the article, confirmation of the success of the sustainable health PSSD model is provided. Additionally, attention is drawn to the identified limitations, and potential avenues for further advancements in research are underscored.

2. Materials and Methods

This paper aims to develop a Sustainable Health Product-Service System Design Model to guide the design of the health system to be specifically tailored for rural elderly individuals suffering from chronic diseases. The primary research methods employed in this paper are outlined below (as depicted in Figure 1):

2.1. Phase 1: Background Research

The study conducted semi-structured interviews, with the aim of exploring two key aspects: (1) understanding the living conditions, pains, and needs of elderly individuals concerning the management of chronic diseases; and (2) identifying potential opportunities to address the challenges presented by this situation. To enhance the reliability of the study, we employed the triangulation approach, which involves using multiple methods of data collection and gathering information from various sources [19]. In this study, the triangulation principle was applied through both interviews and focus groups (in phase 2), involving selected individuals and groups, namely, local elderly residents, community staff, doctors, and designers.

Specifically, we conducted semi-structured interviews with 20 local elderly individuals who were living with chronic illnesses. These participants were recruited with the support of local governments, following specific criteria: (1) Participants had to be chronically ill elderly individuals aged equal to and over 60. (2) Both male and female participants were included. (3) Eligible participants had one or more chronic diseases falling within specified categories [12]. (4) Their living environment should be surrounded by rich local resources. The interviews were not rigidly structured but focused on key conversational topics related to living conditions, pains, and needs. Simultaneously, interviews were also conducted with local government staff and other relevant individuals, such as family members of the elderly participants. Each interview with an elderly person (or their family) typically lasted between 20 and 30 min, and conversations with community staff extended to 60–90 min. Given that the primary objective of these activities was to gain an understanding of the general situation, all data were collected by the reviewer with notes. The program details were clearly communicated, and informed consent was obtained from the 20 elderly individuals who participated.

Subsequently, the collected data were analyzed based on pre-defined topics, encompassing the pains, needs, and possibilities identified during the interviews. Statements were organized under each topic. After a comprehensive analysis and categorization of the data, we arrived at the results presented below.

2.2. Phase 2: Construction of a Sustainable Health Product-Service System Design Model for Chronically Ill Elderly in Rural Areas

Desktop research was conducted on the existing design models focusing on the product, service, user experience, or system design. Three design models were selected for analysis: the Double Diamond model [20], the FBS (Function-Behavior-Structure) model [21], and the Five Elements of User Experience model [22]. By studying the commonalities and differences among these design models, it was observed that they establish connections between the objective world, the interpreted world, and the intended world to describe design activities. Comparative qualitative analysis was employed to refine the critical elements encompassed by these design models. The Five Elements of User Experience model further classifies the design activities into Strategy, Scope, Structure, Skeleton, and Surface elements, providing a more comprehensive framework [23].

Following the initial stage of data collection, a focus group session was conducted involving a carefully selected group of individuals. The objectives of this focus group were twofold: (1) to gather their perspectives on the identified pains, needs, and potential opportunities established in the first stage; (2) to facilitate the development of a sustainable Health Product-Service System Design Model.

A total of 9 participants were involved in this activity, comprising 3 researchers, a Liyang government administrator, a doctor from Xiaode hospital, a poultry company manager, and 3 individuals living with chronic illnesses. The focus group session was facilitated by one of the researchers who served as the moderator. During the session, the moderator introduced key background information about the project, including its objectives, the overall process, and the expected duration of the session. He also presented the initial conclusions drawn from the first stage of the research, along with the findings from desk research on three general design models. The focus group session extended over a period of 4 h, allowing for in-depth discussions and insights from the diverse group of participants.

The next step was constructing the Sustainable Health Product-Service System Design Model with a deductive process based on the results obtained from the former stages. This model encompasses the shared aspects of the design models and addresses the challenges encountered by chronically ill elderly individuals in rural areas. Moreover, it rationalized integrating the emerging service model, focusing on “organic farming for income improvement” and “chronic disease management”.

2.3. Phase 3: Validation of the Sustainable Health Product-Services System Design Model within a Project

In the third phase, the model was implemented within the Liyang Town Health Design project in China to validate its real-world applicability. The project unfolded through a sequential design process encompassing background information research, the development of design proposals, and subsequent testing and refinement stages.

During the preliminary stage of background information research, a comprehensive analysis was undertaken involving the local natural environment, the financial dynamics of chronically ill elderly individuals, and the pivotal stakeholders within Liyang Town who could be integrated into the system.

After the background research, the study ventured into the design thinking stage, in which the six design layers proposed in the model were seamlessly incorporated. Following this integration, a Product-Service System (PSS) design proposal was formulated to cater to the needs of the locally residing chronically ill elderly individuals.

In the final stages, the design was refined, subject to a comparative assessment against the designated design objectives. This iterative procedure ensured that the ultimate system addressed the challenges unearthed in the earlier stages.

2.4. Phase 4: Empirical Demonstration of the Model’s Practical Value

In the fourth phase, the practical value of the Product-Service System (PSS) was empirically validated via comparative case analysis. The study delved into an investigation involving fifteen chronically ill elderly individuals from Liyang Town. Empirical comparisons were drawn on pre-participation and post-participation scenarios within the project, employing a combination of questionnaires and semi-structured interviews.

The empirical demonstration showcased the value of the sustainable health PSS across economic, health, and social dimensions through an examination encompassing the management of chronic diseases, income balance, and the satisfaction of user experiences before and after project participation. This comprehensive analysis also proves the effectiveness and impact of the Sustainable Health Product-Service System Design Model.

3. Model Construction

The literature highlighted that in rural areas of developing countries, the elderly population heavily relies on government or charitable organizations for financial support in managing chronic diseases [24]. However, the number of chronically ill elderly is rising, and the existing assistance methods are insufficient to adequately address the expenses associated with chronic diseases [25]. In response to the challenge of limited income for managing chronic conditions in rural Chinese areas, this paper presents a Sustainable Health Product-Service System Design Model. This model harnesses the potential of the natural environment that surrounds rural elderly individuals and their capability to participate in light physical activities.

3.1. Findings from the Semi-Structured Interview

The results yielded crucial insights into the elderly population. Firstly, their primary sources of income are subsistence allowances provided by the government and support from their adult children. Notably, a significant portion of their financial resources is allocated to purchasing medicines for managing chronic diseases. Despite their chronic conditions, 16 out of 20 elderly individuals are still able to engage in light work. Furthermore, most elderly individuals have convenient access to open natural resources, enabling them to engage in activities like organic agriculture, husbandry, or catering in close proximity to their homes. However, the limited availability of sales channels often leads to the sale of organic agricultural products at prices considerably lower than market rates for similar products.

Specifically, these elderly individuals face three primary challenges: (1) low health literacy, (2) lack of community care, and (3) insufficient staffing in local healthcare organizations. On the other hand, their expressed needs encompass: (1) universal chronic disease education, (2) the provision of medical expenses, and (3) access to medical resource support, as illustrated in Figure 1.

3.2. A Comparison of Three Design Models

Stanford University’s design school introduced a design model consisting of contextual architecture, functional architecture, and interaction architecture [26]. Building upon this framework, Jesse James Garrett proposed the Five Elements of the User Experience Model, which further divides UX design into five levels: strategy, scope, structure, skeleton, and surface [27]. However, these models may not be suitable for addressing the unique challenges faced in rural areas, particularly concerning the significant gap between income enhancement and health maintenance for elderly populations dealing with chronic diseases.

To bridge this gap and address similar practical challenges, this study took into account the common elements found in these design models and considered the specific context of managing chronic diseases among rural elderly individuals. Additionally, the study explored new stakeholders, experiential insights, and system content as potential opportunities. Through desk research, the shared components of these design models were refined and integrated into an emerging system model designed for managing chronic diseases in the elderly population. This culminated in the development of a sustainable solution tailored to the specific needs of this demographic.

3.3. Model Construction with the Focus Group

During the focus group discussions, participants reached a consensus regarding the nature of chronic illnesses, which progress slowly and require long-term medication. They recognized that inadequate financial resources present significant challenges in managing these conditions. As a response, the focus group proposed a system model that could bridge the gap between “income improvement through organic farming (agriculture, husbandry, or catering)” and “chronic disease management.”

One innovative aspect of this proposed solution is the introduction of an “intelligent traceable anklet” designed to be attached to poultry. This anklet aims to facilitate and enhance organic farming activities, potentially providing a sustainable source of income for the elderly population. The primary objective of this study is to establish a sustainable balance between “income enhancement through organic farming” and “chronic disease expenses” by reorganizing the relationships among all stakeholders within the system.

3.3.1. Organizing Stakeholders’ Interactions

To enhance the management of chronic diseases in rural areas, this paper introduced new stakeholders to the system. Conventionally, the management of chronic diseases involves two main stakeholders: the elderly and medical institutions [28]. However, through the focus group, this study has identified an opportunity to capitalize on untapped natural resources that can boost the income of the elderly population while considering their physical capabilities.

Drawing from home-based distributed light labor, this study introduces poultry enterprises as novel stakeholders, offering a range of services such as providing chicks and selling free-range chickens. Elderly individuals can generate income by tending to these free-range chickens. Additionally, another new stakeholder is introduced: the company that produces “smart traceable anklets” for poultry. These anklets monitor the entire organic free-range process, including hatching, feeding, health monitoring, and chicken processing, ensuring the sale of certified organic poultry at a premium price.

In conjunction with the traditional stakeholders like community clinics, hospitals, and regulatory institutions, this system model optimizes interactions between poultry companies, producers of the “smart traceable anklets” for poultry, and elderly individuals with chronic diseases. The emphasis lies in establishing a strong connection between income augmentation and covering chronic disease expenses. By identifying and refining interactions among these stakeholders, the overall management of chronic diseases in rural areas can be significantly improved.

3.3.2. Insight into the Experience

Stanford University’s design school introduced a design model consisting of contextual architecture, functional architecture, and interaction architecture [26]. During the focus group discussions, there was a unanimous consensus that the construction of the system model for rural elderly individuals with chronic diseases could be centered around three crucial perspectives: “context,” “touchpoints,” and “behavior.” From the “context” perspective, we explored the typical scenarios for managing chronic diseases among rural elderly individuals. We reframed the scenarios related to disease management, income enhancement, social care, and treatment. The study analyzed the interconnections among products, information, and stakeholders for these scenarios, using touchpoints as the starting point [29]. This analysis encompassed physical touchpoints involving interactions between the elderly individuals and products, information touchpoints involving interactions between the elderly individuals and information, as well as interpersonal touchpoints involving interactions between the elderly individuals and other stakeholders within the chronic disease management system. Moreover, the study adopted a “behavioral” perspective, delving into the behavioral characteristics of both elderly individuals and service providers. This analysis specifically focused on cognitive patterns, physiological factors, and behavioral constraints that come into play during these interactions.

3.3.3. System Content Coding

Drawing from design semiotics theory [30], the study employed coding to categorize all relevant elements within the system model, encompassing stakeholders, scenarios, products, and information. The coding process involved the following elements, as depicted in Figure 2:

(1) Stakeholder coding: the study identified and coded different stakeholder groups involved in the model, including:

• Stakeholders contributing to elderly income generation, such as poultry companies and a producer of smart traceable anklets.
• Stakeholders responsible for disease management payment, such as poultry companies and government institutions.
• Stakeholders engaged in disease management activities, comprising community clinics and hospitals.
• Stakeholders overseeing the overall process and regulations, including regulatory institutions that ensure the well-being of the elderly within the system.

(2) Scenario coding: The main scenarios in the system are the “organic farming to improve income scenario,” the “chronic disease maintenance scenario,” and the “payment scenario.” Sub-scenarios were further refined within each major category. The content of each scenario was coded using design semiotics principles.

(3) Product coding: The study coded the various products involved in the system model [31], such as organic poultry, the smart traceable anklet, chronic disease medicines, and other relevant items.

(4) Information coding: The information media utilized within the system model were also coded [32]. This encompasses chronic disease diagnosis and treatment information, physical examination information, electronic medical record information, and other relevant data.

In conclusion, this paper suggested that the Sustainable Health Product-Service System Design Model should encompass the following layers: a context layer, a stakeholder layer, a funding layer, a product layer, a service layer, and an information layer (as illustrated in Figure 3).

4. The Sustainable Health Product-Service System Design (PSSD) Model

4.1. The Background Layer

The natural environment, regional policies, and the distribution of chronic diseases among the elderly are crucial in constructing the PSSD Model. Examining this contextual knowledge aids in understanding the living environment, physical conditions, and behavioral preferences of rural elderly populations with chronic diseases. For instance, the rural natural environment can be utilized effectively for organic free-range farming. At the same time, considering the physical capabilities and behavioral preferences of the elderly, the number of free-range chickens to be raised should be adjusted. Economic income could cover the costs associated with chronic disease management.

4.2. The Stakeholder Layer

The stakeholder layer considers the service providers, service recipients, and regulators, as well as the interpersonal touchpoints within the Sustainable Health PSSD Model. Once all stakeholders in the service system have been identified, they are visually depicted using tools such as stakeholder blueprints and user portraits [33].

4.3. The Funding Layer

The funding layer addresses the income sources within the model, particularly focusing on the payment of chronic disease expenses and health check-ups. This layer is essential to the functioning of the system and directly relates to the economic viability of the system design model. Relying solely on assistance from the government or public institutions is insufficient for long-term healthcare financing [34]. The funding layer aims to establish a sustainable balance between “income improvement through organic farming” and “payment for chronic illnesses” by facilitating income improvement for the elderly through the model.

4.4. The Product Layer

The product layer includes products for income improvement and products for health maintenance within a system. Capitalizing on the natural environment of rural areas where the elderly reside, collaboration occurs between the poultry company and the elderly in raising the chicks. To ensure transparency and traceability, “intelligent traceability anklets” are attached to the chickens’ feet, capturing the entire organic free-range process from hatching and feeding to slaughter. Poultry companies purchase chickens that meet the required standards and have passed inspections. The income from the sale of these chickens would be used to purchase health maintenance products and services.

4.5. The Service Layer

The service layer encompasses various services within the sustainable health system, including services related to chronic disease management, poultry feeding, supervision, etc. These emerging service scenarios include: (1) Poultry companies provide chicks to the elderly and purchase mature free-range chickens. (2) Poultry companies utilize “intelligent traceability anklets” to monitor organic poultry breeding. (3) Poultry companies enable elderly individuals to care for free-range chickens in the natural rural environment. (4) Poultry companies purchase organic chickens from the elderly. (5) Local medical institutions and large hospitals offer health check-ups and medical treatment for elderly individuals. (6) The regulatory institutions regulate the whole process to protect the elderly individuals involved in the system. These scenarios, among others, contribute to the comprehensive service layer of the sustainable health system.

4.6. The Information Layer

The information layer serves as the connection between stakeholders and the product within the system, encompassing the information touchpoints of the model. Within the model, the information layer can be categorized into three main areas. First, there are information touchpoints focused on enhancing the income of the elderly. Second, there are information touchpoints related to chronic disease management and regular medical check-ups for the elderly. Third, there are information touchpoints facilitating communication among all stakeholders.

The information touchpoints within the Sustainable Health Service System Design Model encompass various aspects, including supporting data, data for visualization, and service features. The information layer plays a vital role in facilitating effective communication and decision making among stakeholders within the model.

In conclusion, the Sustainable Health Product-Service System Design Model for the chronically ill elderly in rural areas consists of six interconnected layers: the contextual layer, the stakeholder layer, the funding layer, the product layer, the service layer, and the information layer. Each layer addresses different elements to tackle the funding gap for chronic disease management through distributed home-based light work. The contextual and stakeholder layers serve as the foundational components of the model, involving design research, contextual analysis, and user research. The financial and product layers leverage the natural environment in rural areas to support poultry farming. Poultry companies utilize smart traceable anklets for poultry and provide financial support for chronic diseases. The service and information layers are designed to integrate income enhancement services, chronic disease management services, health information visualization services, and monitoring services. Sustainable service system design thinking guides the development of these layers, fostering a comprehensive approach to address the needs of the elderly population with chronic diseases.

5. The Evaluation of the System Design Model in a Real Case

Building upon the Chronic Disease Health Maintenance Programme for the Elderly in Liyang Township, Anhui Province, China, this study attempts to address the challenges faced by the chronically ill elderly in Liyang Town, a sustainable reformed village. The application of the Sustainable Health Product-Service System Model within Liyang Town led to the formulation of a sustainable health Product-Service System (PSS) tailored to meet the needs of the local chronically ill elderly. This effort pursued a dual objective: firstly, to establish a balanced and sustainable PSS by integrating the concepts of “organic farming for income enhancement” and “payment for chronic disease management” in Liyang Town. Secondly, by conducting a comparative analysis of participants’ health status, awareness, and satisfaction before and after their engagement with the system, the study aimed to evaluate the model’s effectiveness within a real-world scenario, ensuring its relevance in comparable settings. The practical steps undertaken to achieve these aims were as follows.

5.1. Case Design—Application of the System Design Model in Liyang Town

This project started by summarizing the background information. Firstly, an analysis of the natural environment and the distribution of chronically ill elderly individuals in Liyang Town was conducted. Field research revealed that approximately 1000 elderly in Liyang Town suffer from chronic illnesses. Common chronic diseases prevalent among the elderly in Liyang Town include diabetes, coronary heart disease, hypertension, and others. The government shoulders 60 percent of the medication and treatment expenses for chronically ill elderly in rural areas, with individuals paying the remaining 40 percent. Nevertheless, a substantial number of these elderly people still encounter financial difficulties when purchasing necessary chronic disease medications, often relying on welfare assistance. With regard to the natural environment, the village is situated in a mountainous region with rich natural resources, like vast under-utilized grasslands, woodlands, and natural water sources, rendering it conducive to organic farming. Notably, this on-site investigation reveals that despite their chronic health conditions, a significant proportion of the elderly can actively partake in light work activities, such as organic poultry feeding. Secondly, regarding potential stakeholders, the key stakeholders identified in this project were the elderly individuals, Liyang Town Clinic, Hexian Xiaode Hospital, and Hexian Poultry Company. Secondary stakeholders included the company that produced the “smart able anklet,” government institutions, regulatory authorities, and Hexian Natural Resources Planning Bureau, see Figure 4. In this context, the elderly with chronic diseases were the recipients of services, and the Liyang Town Clinic, Hexian Xiaode Hospital, Hexian Poultry Company, the “Smart Traceable Anklet” production company, and government institutions acted as the service providers.

The second stage involved design thinking. This project’s key contribution was to balance “income improving through organic Poultry” and “the costs of chronic disease management”. This stage integrated products, services, and information. Regarding the products, this project introduced the “smart traceable anklet” to be attached to the feet of chickens. This anklet records the organic free-range process, from hatching and feeding to fowling. As a vital component of the PSS, the “anklet” features functions including positioning, step tracking, and poultry health monitoring. With the support of Hexian Poultry Company and the “smart traceable anklet” company, the chronically ill elderly needed the natural environment for raising organic chickens, along with light feeding and everyday nighttime cage care.

The service layer encompassed three primary aspects: the organic chicken breeding service, the organic chicken purchasing and selling services, and the chronic disease management services funded by chicken selling. In the information layer, recordings were maintained along the entire process of eco-chicken breeding, incomes generated from the sale of eco-chickens, and the money allocation for chronic disease care, as well as comprehensive records of the elderly’s chronic disease situation. The “intelligent traceability anklet” tracked the steps by eco-chickens in the natural environment. Using big data, the anklet enabled complete traceability of the organic breeding process, from hatching and feeding to slaughtering. This facilitated transparency during organic poultry practices. The money obtained from the sale of eco-chickens was then allocated to cover health care costs for the chronically ill elderly. If the funds are insufficient to support the healthcare needs of certain individuals, adult children provide additional assistance, or they can choose to use fundamental medicines for chronic diseases rather than expensive ones. The design pathway for establishing a sustainable health PSS for the chronically ill elderly in Liyang Town is outlined below (see Figure 5).

5.1.1. Key Partnership Establishment

Hexian Poultry Company established collaborative arrangements with 15 chronically ill elderly individuals. Comprehensive assessments were conducted to evaluate the natural environment near each elderly person’s residence (poultry company and Hexian Natural Resources Planning Bureau), the individual’s physical capabilities (Liyang community clinic), and the expenses associated with chronic disease management (provided by the elderly). Based on these assessments, the suitable quantity of organic chicks for each elderly individual was determined. The chicks were delivered to the elderly’s homes, and the elderly were provided with guidance on organic farming practices.

5.1.2. Cooperation with the “Smart Traceable Anklet” Company

The “smart traceable anklet” production company collaborated with poultry companies to attach the anklets to the feet of each chicken. These anklets tracked the chickens’ free-range steps and monitored their health status. By integrating the IoT network, information would be displayed by scanning a QR code linked to each chicken. Once a chicken reached one million recorded steps and maintained normal health status, the information would be sent to Hexian Poultry Company. Hexian Poultry Company was responsible for collecting the eco-chickens that meet the necessary conditions for sale.

5.1.3. Sales and Financial Distribution

Hexian Poultry Company collaborated with online supermarkets and set up a dedicated area for selling eco-chickens at a higher price than conventionally raised chickens. The money from the sale of eco-chickens was used to cover the expenses of the poultry company and the rental fees of the “smart traceable anklet” production company. The remaining financial benefits were distributed to the health maintenance of the elderly participants.

5.1.4. Graded Treatment Model

The Liyang Town community clinic and the Hexian Xiaode Hospital adopted a graded treatment model to reduce inconvenience for the elderly when seeking medical care. The Liyang Town Community Clinic regularly conducts health check-ups for elderly individuals with chronic diseases and creates chronic disease profiles for elderly project participants, thereby visualizing the process of their chronic disease management.

Responsive to alterations in the elderly’s medical examination results, the Liyang Town Community Clinic communicates any changes in the elderly’s conditions to specialist doctors at Hexian Xiaode Hospital via online platforms. Based on the observed changes, specialist doctors schedule appointments in advance and develop medication plans for the elderly.

5.1.5. Cost Coverage

The money derived from participation in the organic farming project was used to cover the costs of managing the elderly’s chronic diseases. A few elderly individuals still had insufficient income to cover their healthcare expenses fully. Their adult children supported the shortfall.

The last stage involved refining the system design solutions. This project focused on improving the income of the elderly in Liyang Town and optimizing their experience in managing chronic diseases. The design solution was organic chicken-breeding programs tailored to each elderly individual in Liyang Town, considering the unique characteristics of their natural environment. At the same time, the chronic disease management model for the elderly is optimized based on the specific types of chronic diseases, making full use of the community clinic in Liyang Town. In the face of the limited medical resources in the larger hospitals in He County, this medical PSS links the community clinic in Liyang Town and larger hospitals in He County, reducing the inconvenience faced by the elderly when attending follow-up consultations.

In summary, the refinement stage involved optimizing various touchpoints within the PSS, including product touchpoints, behavioral touchpoints, and information touchpoints [35]. The aim was to achieve sustainable income enhancement for the elderly, enabling them to afford their chronic disease regimens.

5.2. Cross-Case Comparison

In comparison to the previous process, the development of the Product-Service System (PSS) system now begins with a comprehensive background investigation. This approach affords the opportunity to create a system that can be customized to meet the specific needs of the local population. In terms of stakeholders, the former process exclusively involved the elderly, the local clinic, and the local government. However, the newly developed PSS system has expanded its stakeholder base to include the following entities: elderly individuals, Liyang Town Clinic, Hexian Xiaode Hospital, and Hexian Poultry Company. Additionally, secondary stakeholders now encompass the company responsible for producing the “smart wearable anklet,” government institutions, regulatory authorities, and Hexian Natural Resources Planning Bureau. The inclusion of these new stakeholders has led to optimization in both product and service offerings tailored to the elderly population. The service layer of the PSS system encompasses three primary aspects: organic chicken-breeding services, organic chicken-purchasing and -selling services, and chronic disease management services. These services collectively enhance the experience of managing chronic illnesses among the elderly. Furthermore, new funding sources have been introduced to address the financial aspects of elderly disease management. Innovative products have been integrated into the system, including the “smart wearable anklet,” IoT facilitators, improved medications, and economical livestock. These additions provide additional support for funding sources and contribute to the improved management of chronic diseases. IoT technology has also been implemented to enhance communication efficiency, fostering connectivity among all stakeholders involved in the system.

The validation process centered on the Product-Service System (PSS) established through the sustainable health PSSD model. This validation enlisted the participation of fifteen elderly individuals with chronic illnesses from Liyang Town. Data were collected both before and after their involvement in the project. By comparing and analyzing this data, the study substantiates the viability of the sustainable health PSSD model and its corresponding system.

The PSS was demonstrated to possess substantial economic value. Between March 2023 and May 2023, the average monthly revenue generated from the sale of eco-chickens following the implementation of the project amounted to RMB 406.4 per person. Once accounting for the service fee paid to the poultry company and the rental fee paid to the producer of the “Smart Traceability Anklet,” the elderly participants experienced an average monthly income increment of RMB 239.5 yuan.

Prior to the project, only 26% (4 out of 15) of the elderly were capable of maintaining a balanced income after accounting for chronic illness expenses, leaving the remaining 74% (11 out of 15) with a negative income post-expenditures. After participating in the project, regular health check-ups and more targeted use of medications improved treatment quality, with cost improvement by an average of RMB 120. With the cost improvement, a significant 86% (13 out of 15) of the elderly could independently cover their chronic disease expenses (after health insurance) while sustaining a balanced income, representing a substantial 60% increase compared to their pre-project situation.

Overall, the project led to an improvement in the income of the elderly participants. Despite the notable increase in chronic disease-related expenditures, a significant 60% rise in the number of elderly individuals who could afford these costs themselves after accounting for health insurance was observed. This underscores the importance of a consistent income source in sustaining health services.

The social impact can be outlined as follows: Firstly, the Sustainable Health PSS, combining “organic poultry for income generation” and “payment for chronic disease management,” provides continuous financial support to the elderly in Liyang Town, effectively addressing the social challenge of insufficient funds for rehabilitating elderly individuals with chronic diseases. As a result of project participation, more than 80% of the elderly can now independently and consistently manage their chronic illnesses. This achievement not only reduces their financial burden but also generates increased social value for the elderly. This system empowers rural elderly individuals to access improved medical resources from larger hospitals. Regular check-ups and targeted medication ensure better health outcomes for the elderly. Additionally, collaboration among stakeholders is optimized through the involvement of the elderly in organic chicken breeding, thus providing the community with healthier poultry products.

The health-related outcomes encompass the following aspects: The Graded Treatment Model mitigates the necessity for elderly individuals to frequently travel to large hospitals by providing equal access to better medical resources through the application of the Internet of Things (IoT), which enhances communication efficiency. An examination of the health experiences of elderly individuals before and after their participation in the project revealed significant findings. Following their involvement in the project, the satisfaction rate of elderly individuals with their chronic disease management reached a substantial 87.3%. In contrast, those who utilized the conventional approach of personally visiting clinics for consultations and participated before the project exhibited a notably lower satisfaction rate of 29.1% in their health experiences.

In conclusion, this study proposed a Sustainable Health Product-Service System Design Model and constructed a PSS for rural elderly individuals with chronic diseases in Liyang Town. This study compared and evaluated the health maintenance outcomes of elderly individuals before and after participating in the sustainable health PSS. Through the empirical evaluation process, the economic, social, and health values of the Sustainable Health Service System Design Model for rural elderly chronic disease groups were elucidated based on the comparison of multiple datasets.

6. Conclusions and Discussion

The management of chronic illnesses among elderly individuals in rural areas is greatly impacted by inadequate healthcare resources and a lack of financial resources [36]. Reliance solely on social assistance or government financial support is not a sustainable long-term solution for rural elderly individuals with chronic illnesses [37]. This study introduced sustainable PSSD system design thinking to address this issue by incorporating new stakeholders, experiential insights, and service content coding. It aims to leverage the opportunities around these rural elderly individuals, striving for a balance between “organic poultry to improve income” and “payment for chronic disease rehabilitation.”

By analyzing the common elements covered by the existing design models and considering the context of chronic disease management among rural elderly individuals, the study constructed a Sustainable Health Product-Service System Design Model to guide practical implementation. The system design model is composed of several key elements, including a contextual layer, a stakeholder layer, a financial layer, a product layer, a service layer, and an information layer. The background and stakeholder layers serve as the foundational components, encompassing design research, background analysis, and user research. These elements provide the groundwork for the entire system. Moving up to the funding and product layers, the objective is to leverage the natural environment in which rural elderly individuals reside. This involves supporting poultry farming through poultry-breeding enterprises and the production of “smart traceability ankle bracelets” for poultry. These endeavors aim to generate income to cover the costs of chronic disease care. In the service and information layers, the focus is on integrating a multitude of service scenarios. This includes income enhancement services, chronic disease maintenance services, health information visualization services, and supervision services. These services are guided by sustainable service design principles. Each layer encompasses distinct contents, with the ultimate goal of establishing a sustainable and balanced service system that harmonizes “ecological farming for income enhancement” with “payment for chronic disease care.”

To validate the system design model, this study implemented a Product-Service System (PSS) within the context of the Chronic Disease Elderly Health Maintenance Project in Liyang Town. This project aimed to enhance the health management of chronically ill elderly individuals. Utilizing the framework of the Sustainable Health Product-Service System Model, the study developed a tailored PSS involving 15 chronically ill elderly participants. The subsequent empirical analysis examined and compared the outcomes of the elderly individuals’ chronic disease management before and after their engagement in the project. Through this analysis, the practical value of both the Sustainable Health Product-Service System Design Model and the final Product-Service System was demonstrated across economic, social, and health dimensions. Apart from these benefits, the system design model or the final PSS also raises awareness about chronic disease management among elderly individuals in rural areas, optimizes the health service process, and integrates social medical care.

There are certain limitations to this research. Though we followed the triangulation principle in the initial stage to enhance the study’s reliability, the sample size (20) may not be sufficiently large. This could potentially result in the developed model not being comprehensive enough. Currently, the study is primarily focused on rural areas in Anhui Province, China. However, we plan to expand the study area for broader nationwide replication and to tailor the practical application of the sustainability model according to local resource endowments. In the validation stage, we conducted a small group test due to the limited availability of supporting products and services for all chronically ill elderly individuals in Liyang Town. The system will undergo further refinement to be capable of supporting all potential participants. In the subsequent phases of the study, the number of participants will be increased. This will enable us to gather more objective data and practical results for the next phase of the design study, which will also lay a solid foundation for the broader adoption of the design model. In the future, the plan is to extend the PSS to encompass all elderly individuals in Liyang Town. Additionally, the model will be expanded to other rural areas, considering local conditions and specific needs.