Research Analysis

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Quality of Life Research (2024) 33:691–703 https://doi.org/10.1007/s11136-023-03555-2

The effects of community‑based home health care on the physical and mental health of older adults with chronic diseases

Shuyan Gu1  · Cangcang Jia2 · Fangfang Shen3 · Xiaoyong Wang4 · Xiaoling Wang5 · Hai Gu1

Accepted: 28 October 2023 / Published online: 30 November 2023 © The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023

Abstract Purpose This study aimed to explore the effects of community-based home health care (HHC) on the physical and mental health of older adults with chronic diseases in China. Methods The study data were retrieved from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey. Ordinary least squares regression model was used to assess the effects of community-based HHC on the health. Entropy balancing was used to test the robustness of the regression results. Results A total of 5571 older adults with chronic diseases were included. The results showed that older adults who had received community-based HHC reported significantly better self-rated health (coefficient = 0.051, 95%CI [0.004, 0.098]), less physical discomfort (coefficient = − 0.021, 95%CI [− 0.042, − 0.001]), lower depression scores (coefficient = − 0.263, 95%CI [− 0.490, − 0.037]), and lower anxiety scores (coefficient = − 0.233, 95%CI [− 0.379, − 0.088]) compared with those who had not received community-based HHC. Overall, community-based HHC conferred greater positive effects on the health of rural older adults, older adults with multiple chronic diseases, and older adults with low incomes. Conclusion Community-based HHC was beneficial for improving self-rated health and reducing physical discomfort, depres- sion, and anxiety in older adults with chronic diseases, thus improving their quality of life. It is important to promote its development nationwide in China.

Keywords Older adults · Chronic disease · Community-based home health care · China

Plain English summary

Population aging is a global challenge, and healthy aging has been prioritized to improve the well-being of older adults. Home health care (HHC) as health care services provided by medical staff to improve the supply and quality of health care services for older adults at their home, has been expanding rapidly worldwide. Older adults with chronic diseases are its main users. Previous studies in other countries have pro- posed that HHC reduces the physical pain and mental illness of older adults. However, its effects on Chinese older adults have not been determined. Therefore, this study explored the effects of community-based HHC on the physical and mental health of Chinese older adults. It was found that com- munity-based HHC significantly improved self-rated health and reduced physical discomfort, depression, and anxiety in Chinese older adults with chronic diseases, thus improv- ing their quality of life. Rural older adults, older adults with multiple chronic diseases, and older adults with low incomes benefited more from community-based HHC. China

* Shuyan Gu [email protected]

* Hai Gu [email protected]

1 Center for Health Policy and Management Studies, School of Government, Nanjing University, 163 Xianlin Road, Nanjing 210023, Jiangsu, China

2 School of Health Policy and Management, Nanjing Medical University, Nanjing, Jiangsu, China

3 General Practice Department, Daguang Road Community Healthcare Center, Nanjing, Jiangsu, China

4 Health Insurance Office, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China

5 Department of Endocrinology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China

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as the country with the largest older population and uneven distribution of medical resources and economic develop- ment, promoting community-based HHC is important in its context. The government should provide more policy and resource supports for developing it. The media should pub- licize its necessity to nudge its utilization. HHC providers should provide services of the highest quality.

Introduction

Population aging is a global challenge. China, as the coun- try with the largest older population, faces much greater challenges. There were 190.6 million older adults aged 65 and above in China in 2020, accounting for 13.5% of the total population [1]. Aging is the primary driver of chronic diseases [2]. A total of 76.3% of older adults suffer from chronic diseases [3]. Deaths induced by chronic diseases account for 88.5% of total deaths in China [4]. Due to their features of difficulty in curing, a long course, progressivity, and requiring ongoing medical attention, chronic diseases not only impact the health and damage the self-care abil- ity of older adults but also increase the economic and care burden of their families. Families with older members with chronic diseases were reported to incur 37%-45% higher additional annual inpatient costs and 2.4%-3.3% lower labor force participation than those without such members in China [5]. Thus, the health of older adults is tied not only to themselves and their families but also to health care sys- tems and social labor supplies.

However, traditional care provided by family members is often insufficient and of poor quality because of small family sizes and unprofessional care in China, which is not conducive to meeting the needs of older adults [6]. When care needs are not met, the physical functions and quality of life of older adults may continue to deteriorate, evok- ing psychological issues such as depression and anxiety, which ultimately undermine their mental health [7–10]. To cope with unmet needs, in 2015, the State Council of China proposed extending health care services to communities and households by providing health care services for older adults with mobility difficulties in the community [11]. Sub- sequently, a series of policies were issued to clearly define and promote community-based home health care (HHC) in China. Community-based HHC is defined as a series of health care services provided by medical staff of health care institutions in the community to older adults with mobility difficulties, chronic diseases, or convalescent/end-stage ill- nesses at their homes by regular home visits, family doctor contracts, and family beds [12]. Health care services include regular checkups, medical care, drug delivery, rehabilitation care, pharmaceutical services, and hospice care [12]. The purpose of community-based HHC is to improve the supply

and quality of health care services for older adults at their homes to help support their independence, improve their quality of life, and reduce unnecessary hospitalization, thus achieving healthy aging.

HHC is expanding rapidly worldwide. Older adults with chronic diseases are its main users [13]. Studies in other countries have proposed that HHC can decrease physical pain and mental illness in older adults [14–16]. However, in China, community-based HHC is a relatively novel health care model. Previous studies have mainly focused on explor- ing its implementation status, service models, development paths, and demands and associated factors among older adults. Its effects on the health of older adults with chronic diseases have not been determined. Therefore, this study aimed to explore the effects of community-based HHC on the health of older adults with chronic diseases and inves- tigate its heterogeneous effects on the health between rural and urban older adults, older adults with single and multiple chronic diseases, and older adults with low and high incomes in China.

Methods

Data and sampling

The study data were retrieved from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) conducted by Center for Healthy Aging and Development at Peking University [17]. The CLHLS is a nationally repre- sentative follow-up survey covering 23 provinces and munic- ipalities across China. The survey recruited older adults aged 65 and above by using a multistage stratified sampling strategy, and was conducted at the respondents’ home. It was approved by the Ethics Committee of Peking University (IRB00001052-13074). The 2018 wave is the latest wave of follow-up data containing 15,874 participants from 450 urban/rural communities and 150 counties/districts. The collected information includes demographic and socioeco- nomic characteristics, family background and social ties, health, and lifestyle. This study aimed to explore the effects of community-based HHC on the health of older adults with chronic diseases. The chronic diseases included hyperten- sion, diabetes, dyslipidemia, heart disease, cataracts, arthri- tis, stroke, bronchitis (Online Resource 1 Table S1). We removed the data of respondents who did not answer the question related to community-based HHC and who did not have chronic diseases. Respondents with missing data were also omitted from this study.

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Variables

Dependent variables

The health indicators included overall health, physical health, and mental health.

Overall health was measured by self-rated health (SRH), which is considered a health indicator reflecting respondents’ overall appraisal of physical, mental, and social well-being [18]. Respondents were asked “How do you rate your health at present?”. The response was coded from 1 (very poor) to 5 (very good). Higher scores repre- sented better health.

Physical health was evaluated by the item “Have you felt any physical discomfort in the past two weeks?”. If the response was “yes,” we considered the respondents to have physical discomfort and coded them as 1; otherwise, we considered the respondents to have no physical discomfort and coded them as 0.

Mental health was evaluated by depression and anxiety. Depression was measured by the 10-item Center for Epide- miologic Studies Short Depression Scale (CESD-10). The CESD-10 includes 10 items regarding respondents’ nega- tive experiences such as feeling bothered, having trouble concentrating, and positive feelings about future life and happiness within the past week [19]. Each negative item was scored as 0 (rarely or none of the time), 1 (some or a little of the time), 2 (occasionally or a moderate amount of the time), or 3 (most or all of the time). The positive items were reverse-coded. Total depression scores ranged from 0 to 30, with higher scores indicating more severe depres- sion. Anxiety was measured by the 7-item Generalized Anxiety Disorder Scale (GAD-7). The GAD-7 comprises seven items asking respondents to self-rate the frequency of each anxiety symptom over the past two weeks [20]. Each item was scored as 0 (never), 1 (several days), 2 (more than half of days), or 3 (almost every day). Total anxiety scores ranged from 0 to 21, with higher scores indicating more severe anxiety.

Independent variable

Community-based HHC was evaluated by the item “Dose your community provide you with regular home visit ser- vices to provide medical care and drug delivery?”. If the response was “yes,” we considered the respondents to have received community-based HHC and classified them as the HHC group and coded them as 1; otherwise, we con- sidered the respondents to have not received community- based HHC and classified them as the non-HHC group and coded them as 0.

Control variables

We controlled for the following variables: gender (female, male), age group (young-old, oldest-old), region of birth (rural, urban), marital status (single, married), education level (illiterate, primary school, middle school, high school or above), annual household income (low, high), region of current residence (rural, urban), living arrangements (liv- ing alone, living with household members), activities of daily living (ADLs), instrumental activities of daily living (IADLs), chronic diseases (single, multiple), body mass index (BMI) group (underweight, normal weight, over- weight, obese), smoking (no, yes), drinking (no, yes), and physical exercise (no, yes).

According to the World Health Organization and previous studies, the age of 80 years was used as the cutoff age for distinguishing young-old from oldest-old individuals [17, 21, 22]. Single referred to separated, divorced, widowed, or never married. Education level was assessed by years of schooling, divided into 0 (illiterate), 1–6 years (primary school), 7–9 years (middle school), and ≥ 10 years (high school or above). Annual household income was divided into low income and high income based on its median [23]. ADLs were measured by six items covering respondents’ basic self-care ability. Respondents were asked if they could independently bathe, dress, go to the toilet, etc. [24]. IADLs were measured by eight items representing respondents’ adaptation to the surrounding environment. Respondents were asked if they could independently visit neighbors, go shopping, cook, etc. [25]. Each ADL or IADL item was scored from 1 (complete independence) to 3 (complete dependence). Higher scores indicated worse activity ability. Multiple chronic diseases referred to two or more types of chronic diseases. Underweight referred to a BMI < 18.5 kg/ m2, normal weight referred to 18.5 ≤ BMI < 24 kg/m2, over- weight referred to 24 ≤ BMI < 28 kg/m2, and obese referred to a BMI ≥ 28 kg/m2 [26].

Statistical analysis

A descriptive analysis was performed to investigate the ini- tial differences, including means and standard deviations (SD) for continuous variables and numbers and percentages for categorical variables. A two-sample t test was used to test group differences among continuous variables, with a Pearson χ2 test used for categorical variables. Ordinary least squares regression model was used to assess the effects of community-based HHC on the health of older adults. In case there may be mutual causality between community-based HHC and health, entropy balancing was used to obtain a weighted comparison to adjust for intergroup differences, thus testing the robustness of the regression results [27]. Moreover, the method of replacing the health indicator was

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additionally used to reinforce the robustness of the results, where health changes were used as an alternative health indi- cator. Health changes were evaluated by the item “Have you felt any changes in your health since last year?”. Stata SE 15.1 software (Stata Corp LP, College Station, TX, USA) was used to conduct all analyses. A p value < 0.05 indicated statistical significance.

Results

Characteristics of the respondents

A total of 5571 older adults with chronic diseases were included, with an average age of 81.92 (SD 10.68) years and a female proportion of 53.2%. There were 1940 older adults who had received community-based HHC, and 3631 had not received community-based HHC. Those who had received community-based HHC, on average, had better health than those who had not received community-based HHC, as evidenced by slightly better SRH (3.41 vs 3.37), less physical discomfort (16.65% vs 18.48%), lower depres- sion scores (7.24 vs 7.36), and lower anxiety scores (1.32 vs 1.51). However, only anxiety scores showed significant differences (p = 0.011). In addition, those who received community-based HHC were more likely to be born in rural areas (p < 0.001), have low education (p = 0.009) and low incomes (p = 0.030), and not participate in physical exercise (p < 0.001) (Table 1).

Effects of community‑based home health care on health and its heterogeneity

The regression results showed that older adults who had received community-based HHC reported significantly better SRH (coefficient = 0.051, 95%CI [0.004, 0.098], p = 0.034), less physical discomfort (coefficient = − 0.021, 95%CI [− 0.042, − 0.001], p = 0.043), lower depression scores (coefficient = − 0.263, 95%CI [− 0.490, − 0.037], p = 0.023), and lower anxiety scores (coefficient = − 0.233, 95%CI [− 0.379, − 0.088], p = 0.002) compared with those who had not received community-based HHC. This meant that community-based HHC had a significantly positive effect on SRH and negative effects on physical discomfort, depression, and anxiety in older adults with chronic diseases (Table 2).

The heterogeneous effects of community-based HHC on health were explored. In the subgroups of region of resi- dence, community-based HHC contributed to a significant enhancement in SRH (p = 0.016) and a significant decrease in anxiety scores (p = 0.033) for rural older adults, but only conferred a significant decrease in anxiety scores (p = 0.032) for urban older adults. In the subgroups of chronic diseases,

community-based HHC promoted the mental health of older adults with multiple chronic diseases, with significant decreases in depression scores (p = 0.007) and anxiety scores (p < 0.001), but did not significantly benefit those with a single chronic disease. In the subgroups of income, com- munity-based HHC significantly increased SRH (p = 0.026) and decreased anxiety scores (p = 0.006) for those with low incomes, but reduced physical discomfort (p = 0.004) for those with high incomes. Overall, community-based HHC conferred greater positive effects on the health of rural older adults, older adults with multiple chronic diseases, and older adults with low incomes (Table 3).

Robustness test

Entropy balancing was first conducted. After the entropy balancing step, the means in the reweighted non-HHC group matched those in the HHC group. The entropy balancing results were consistent with the regression results, indicat- ing that the potential endogeneity between community- based HHC and health did not affect the regression results (Table 2). Then, an additional test was performed by using health changes as an alternative health indicator and found that community-based HHC had a significantly positive effect on health changes in older adults (p = 0.012) (Online Resource 1 Table S2). Both tests reinforced the robustness of the regression results, verifying the health benefits of com- munity-based HHC on older adults with chronic diseases.

Discussion

This study is the first to use the nationally representative data from the CLHLS to evaluate the effects of commu- nity-based HHC on the physical and mental health of older adults with chronic diseases in China. The results showed that community-based HHC conferred positive effects on improving SRH and reducing physical discomfort, depres- sion, and anxiety in older adults with chronic diseases, thus improving their quality of life.

HHC refers to health care services provided at individu- als’ homes, satisfying their daily care needs without leav- ing home. It is especially useful for individuals who have poor accessibility to hospitals. Globally, needs for HHC have largely increased due to the growth of the older popu- lation and the increases in chronic diseases and disabilities requiring continuous care [28]. It has been reported that 70.5% of patients who need HHC are older adults [28], and 90% who receive HHC are chronically ill [13]. There are various HHC models available worldwide, serving a varied patient case mix. A study in Brazil proposed that HHC reduced physical pain, loneliness, and depression in older adults through regular home visits and systematic

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Table 1 Characteristics of the respondents

Variables Total (N = 5571) HHC groupa (N = 1940)

Non-HHC groupb (N = 3631)

p

Mean/n SD/% Mean/n SD/% Mean/n SD/%

SRHc 3.39 0.89 3.41 0.88 3.37 0.90 0.156 Physical discomfort 0.089  No 4577 82.16 1617 83.35 2960 81.52  Yes 994 17.84 323 16.65 671 18.48

Depression scored 7.32 4.47 7.24 4.15 7.36 4.64 0.301 Anxiety scoree 1.44 2.73 1.32 2.54 1.51 2.82 0.011 Gender 0.829  Female 2964 53.20 1036 53.40 1928 53.10  Male 2607 46.80 904 46.60 1703 46.90

Age groupf 0.775  Young-old 2510 45.05 869 44.79 1641 45.19  Oldest-old 3061 54.95 1071 55.21 1990 54.81

Region of birth < 0.001  Rural 3628 65.12 1414 72.89 2214 60.97  Urban 1943 34.88 526 27.11 1417 39.03

Marital status 0.890  Single 2761 49.56 959 49.43 1802 49.63  Married 2810 50.44 981 50.57 1829 50.37

Education level 0.009  Illiterate 2175 39.04 802 41.34 1373 37.81  Primary school 1986 35.65 694 35.77 1292 35.58  Middle school 688 12.35 224 11.55 464 12.78  High school or above 722 12.96 220 11.34 502 13.83

Annual household income 0.030  Low 2810 50.44 1017 52.42 1793 49.38  High 2761 49.56 923 47.58 1838 50.62

Region of current residence < 0.001  Rural 2226 39.96 922 47.53 1304 35.91  Urban 3345 60.04 1018 52.47 2327 64.09

Living arrangements 0.492  Living alone 922 16.55 312 16.08 610 16.80  Living with household members 4649 83.45 1628 83.92 3021 83.20

ADL scoreg 6.57 1.64 6.62 1.74 6.55 1.58 0.125 IADL scoreh 12.12 5.29 12.21 5.33 12.07 5.27 0.342 Chronic diseases 0.809  Single 2456 44.09 851 43.87 1605 44.20  Multiple 3115 55.91 1089 56.13 2026 55.80

BMI groupi 0.548  Underweight 644 11.56 222 11.44 422 11.62  Normal weight 2782 49.94 954 49.18 1828 50.34  Overweight 1590 28.54 556 28.66 1034 28.48  Obese 555 9.96 208 10.72 347 9.56

Smoking 0.754  No 4721 84.74 1640 84.54 3081 84.85  Yes 850 15.26 300 15.46 550 15.15

Drinking 0.450  No 4754 85.33 1646 84.85 3108 85.60  Yes 817 14.67 294 15.15 523 14.40

Physical exercise < 0.001

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care [14]. Frailty among older adults was found to be strongly associated with HHC utilization in Belgium [29]. The systolic and diastolic blood pressure of frail older adults receiving HHC were observed to decrease by 8.97 and 15.78 mmHg and 2.92 and 5.01 mmHg after 4-year and 8-year follow-ups, respectively, in Korea, demonstrat- ing its short- and long-term benefits [30]. In the USA, HHC was reported to lower the rehospitalization risk by 48–82% for older adults, and sufficient HHC services may avoid rehospitalization [15]. A total of 63.9% of older adults receiving HHC reported no anxiety, and only 3.6% reported mild or moderate anxiety [31]. HHC recipients were more likely to report preventable adverse events than those who did not receive HHC, suggesting an opportunity to improve patient safety [32]. HHC utilization was asso- ciated with increased older adult-caregiver mutuality and reduced caregiving burden and depression [33]. Previous studies in foreign populations have confirmed that HHC improves the quality of life, physical health, and mental health of older adults [16].

In China, the government has been promoting com- munity-based HHC in recent years. However, it is still a new model in China. Most health care institutions can only provide part of the services required by the government. For example, the services in this study involved only regu- lar home visits. Older age and chronic diseases are often accompanied by more health issues and irreversible decline in physical functions [34]. This study showed that 59.4% of older adults with chronic diseases reported any disability in IADLs. Disability is mostly degenerative, and its damage to health is usually serious. Based on Chinese practice, current community-based HHC is mostly used as an intermediate bridge between home care and hospital treatment for older adults. Although it may not be sufficient to substantially change the natural decline of physical functions, it plays a certain role in alleviating physical discomfort. In addi- tion, medical staff as the gatekeepers of health may have a certain authority and trust among older adults; thus, their HHC services may not only address physical discomfort but also provide psychological comfort to older adults to

The means and SDs were presented for continuous variables. The numbers and percentages were presented for categorical variables a HHC group included older adults with chronic diseases who had received community-based HHC. Com- munity-based HHC was evaluated by the item “Dose your community provide you with regular home visit services to provide medical care and drug delivery?” b Non-HHC group included older adults with chronic diseases who had not received community-based HHC c SRH was measured by the item “How do you rate your health at present?”, reflecting respondents’ overall appraisal of physical, mental, and social well-being. The scores ranged from 1 to 5, with higher scores indi- cating better health [18] d Depression was measured by the CESD-10, which comprises 10 items regarding respondents’ negative experiences such as feeling bothered, having trouble concentrating, and positive feelings about future life and happiness. The scores ranged from 0 to 30, with higher scores indicating more severe depression [19] e Anxiety was measured by the GAD-7, which comprises seven items asking respondents to self-rate the frequency of each anxiety symptom. The scores ranged from 0 to 21, with higher scores indicating more severe anxiety [20] f Young-old referred to older adults aged 65–79  years, and oldest-old referred to those aged ≥ 80  years according to the World Health Organization [21] g ADL was measured by six items covering respondents’ basic self-care ability such as bathe, dress, go to the toilet. The scores ranged from 6 to 18, with higher scores indicating worse activity ability [24] h IADL was measured by eight items representing respondents’ adaptation to the surrounding environment such as visit neighbors, go shopping, cook. The scores ranged from 8 to 24, with higher scores indicating worse activity ability [25] i Underweight referred to BMI < 18.5 kg/m2, normal weight referred to 18.5 ≤ BMI < 24 kg/m2, overweight referred to 24 ≤ BMI < 28 kg/m2, and obese referred to ≥ 28 kg/m2 based on the Chinese criteria [26] ADL activities of daily living, BMI body mass index, CESD-10 10-item Center for Epidemiologic Studies Short Depression Scale, GAD-7 7-item Generalized Anxiety Disorder Scale, HHC home health care, IADL instrumental activities of daily living, SD standard deviation, SRH self-rated health

Table 1 (continued) Variables Total (N = 5571) HHC groupa (N = 1940)

Non-HHC groupb (N = 3631)

p

Mean/n SD/% Mean/n SD/% Mean/n SD/%

 No 3406 61.14 1266 65.26 2140 58.94  Yes 2165 38.86 674 34.74 1491 41.06

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698 Quality of Life Research (2024) 33:691–703

1 3

Ta bl

e 2

(c on

tin ue

d)

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bl es

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m fo

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ty sc

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f [ 95

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I] p

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699Quality of Life Research (2024) 33:691–703

1 3

Ta bl

e 2

(c on

tin ue

d)

Va ria

bl es

O rd

in ar

y le

as t s

qu ar

es re

gr es

si on

m od

el En

tro py

b al

an ci

ng m

et ho

d

SR H

a Ph

ys ic

al d

is co

m fo

rt D

ep re

ss io

n sc

or eb

A nx

ie ty

sc or

ec SR

H a

Ph ys

ic al

d is

co m

fo rt

D ep

re ss

io n

sc or

eb A

nx ie

ty sc

or ec

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

C oe

f [ 95

% C

I] p

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0. 18

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1

a SR H

w as

m ea

su re

d by

th e

ite m

“ H

ow d

o yo

u ra

te y

ou r h

ea lth

a t p

re se

nt ?”

, r efl

ec tin

g re

sp on

de nt

s’ o

ve ra

ll ap

pr ai

sa l o

f p hy

si ca

l, m

en ta

l, an

d so

ci al

w el

l-b ei

ng . T

he s

co re

s ra

ng ed

fr om

1 to

5 ,

w ith

h ig

he r s

co re

s i nd

ic at

in g

be tte

r h ea

lth [1

8] b D

ep re

ss io

n w

as m

ea su

re d

by th

e C

ES D

-1 0,

w hi

ch c

om pr

is es

1 0

ite m

s r eg

ar di

ng re

sp on

de nt

s’ n

eg at

iv e

ex pe

rie nc

es su

ch a

s f ee

lin g

bo th

er ed

, h av

in g

tro ub

le c

on ce

nt ra

tin g,

a nd

p os

iti ve

fe el

in gs

ab

ou t f

ut ur

e lif

e an

d ha

pp in

es s.

Th e

sc or

es ra

ng ed

fr om

0 to

3 0,

w ith

h ig

he r s

co re

s i nd

ic at

in g

m or

e se

ve re

d ep

re ss

io n

[1 9]

c A nx

ie ty

w as

m ea

su re

d by

th e

G A

D -7

, w hi

ch c

om pr

is es

se ve

n ite

m s a

sk in

g re

sp on

de nt

s t o

se lf-

ra te

th e

fr eq

ue nc

y of

e ac

h an

xi et

y sy

m pt

om . T

he sc

or es

ra ng

ed fr

om 0

to 2

1, w

ith h

ig he

r s co

re s

in di

ca tin

g m

or e

se ve

re a

nx ie

ty [2

0] d Y

ou ng

-o ld

re fe

rr ed

to o

ld er

a du

lts a

ge d

65 –7

9  ye

ar s,

an d

ol de

st- ol

d re

fe rr

ed to

th os

e ag

ed ≥

80  y

ea rs

a cc

or di

ng to

th e

W or

ld H

ea lth

O rg

an iz

at io

n [2

1] e A

D L

w as

m ea

su re

d by

s ix

it em

s co

ve rin

g re

sp on

de nt

s’ b

as ic

s el

f- ca

re a

bi lit

y su

ch a

s ba

th e,

d re

ss , g

o to

th e

to ile

t. Th

e sc

or es

ra ng

ed fr

om 6

to 1

8, w

ith h

ig he

r s co

re s

in di

ca tin

g w

or se

a ct

iv ity

ab

ili ty

[2 4]

f IA D

L w

as m

ea su

re d

by e

ig ht

it em

s re

pr es

en tin

g re

sp on

de nt

s’ a

da pt

at io

n to

th e

su rr

ou nd

in g

en vi

ro nm

en t s

uc h

as v

is it

ne ig

hb or

s, go

s ho

pp in

g, c

oo k.

T he

s co

re s

ra ng

ed f

ro m

8 to

2 4,

w ith

hi

gh er

sc or

es in

di ca

tin g

w or

se a

ct iv

ity a

bi lit

y [2

5] g U

nd er

w ei

gh t r

ef er

re d

to B

M I <

18 .5

 k g/

m 2 , n

or m

al w

ei gh

t r ef

er re

d to

1 8.

5 ≤ B

M I <

24  k

g/ m

2 , o ve

rw ei

gh t r

ef er

re d

to 2

4 ≤ B

M I <

28  k

g/ m

2 , a nd

o be

se re

fe rr

ed to

≥ 28

 k g/

m 2 b

as ed

o n

th e

C hi

- ne

se c

rit er

ia [2

6] AD

L ac

tiv iti

es o

f d ai

ly li

vi ng

, B M

I b od

y m

as s i

nd ex

, C ES

D -1

0 10

-it em

C en

te r f

or E

pi de

m io

lo gi

c St

ud ie

s S ho

rt D

ep re

ss io

n Sc

al e,

C I c

on fid

en ce

in te

rv al

, C oe

f c oe

ffi ci

en t,

G AD

-7 7

-it em

G en

er -

al iz

ed A

nx ie

ty D

is or

de r S

ca le

, H H

C h

om e

he al

th c

ar e,

IA D

L in

str um

en ta

l a ct

iv iti

es o

f d ai

ly li

vi ng

, S RH

se lf-

ra te

d he

al th

700 Quality of Life Research (2024) 33:691–703

1 3

decrease their anxiety or depression caused by illness. Our study confirmed this hypothesis, as it found positive associa- tions between community-based HHC and improved SRH and decreased physical discomfort, depression, and anxiety in older adults with chronic diseases. Our study supported and supplemented the previous findings in other populations.

Considering the uneven distribution of medical resources and economic development between rural and urban China, this study explored the rural–urban differences in health benefits of community-based HHC. It was found that com- munity-based HHC conferred greater health benefits on rural older adults. This may be partly because rural older adults have poorer accessibility to health care services than urban older adults. In rural China, even mobile older adults may be less likely to have regular doctor visits due to long trips to hospitals and high medical costs, as most of them are farmers with lower incomes [22]. In addition, with a mass of laborers migrating to cities for work, the number of left behind and empty nest rural older adults has increased, triggering more health issues due to less family support. They are more likely to report unmet care needs. There- fore, community-based HHC may bring more benefits to

rural older adults by ensuring timely and affordable use of health care services. Older adults are at high risk of chronic diseases. Because of the long course and multiple patho- genic factors associated with chronic diseases, older adults may often suffer from multiple chronic diseases, triggering more severe health issues [35]. Thus, this study estimated the differences between older adults with single and multiple chronic diseases and found that community-based HHC had greater health benefits for those with multiple chronic dis- eases. Older adults with multiple chronic diseases may suffer from physical discomfort more frequently than those with a single chronic disease [36]. They may also face mental ill- ness, whose risks increase with the increase in the number of chronic diseases [37]. Thus, older adults with multiple chronic diseases are more likely to prefer and benefit from community-based HHC. Older adults with different eco- nomic statuses have different access to medical resources. Those with low incomes may be more sensitive to medical costs and in an inferior position in accessing health care resources. There are more cases of missed or delayed health care when they are sick. This study found that older adults with low incomes benefited more from community-based

Table 3 Heterogeneous effects of community-based home health care on the health of older adults with chronic diseases

a SRH was measured by the item “How do you rate your health at present?”, reflecting respondents’ overall appraisal of physical, mental, and social well-being. The scores ranged from 1 to 5, with higher scores indicating better health [18] b Depression was measured by the CESD-10, which comprises 10 items regarding respondents’ negative experiences such as feeling bothered, having trouble concentrating, and positive feelings about future life and happiness. The scores ranged from 0 to 30, with higher scores indicating more severe depression [19] c Anxiety was measured by the GAD-7, which comprises seven items asking respondents to self-rate the frequency of each anxiety symptom. The scores ranged from 0 to 21, with higher scores indicating more severe anxiety [20] CESD-10 10-item Center for Epidemiologic Studies Short Depression Scale, CI confidence interval, Coef coefficient, GAD-7 7-item Generalized Anxiety Disorder Scale, SRH self-rated health

SRHa Physical discomfort Depression scoreb Anxiety scorec

Coef [95%CI] p Coef [95%CI] p Coef [95%CI] p Coef [95%CI] p

Panel 1: by region of current residence

 Rural 0.088 [0.017, 0.160] 0.016 − 0.015 [− 0.047, 0.017]

0.351 − 0.294 [− 0.638, 0.050]

0.094 − 0.238 [− 0.456, − 0.019]

0.033

 Urban 0.017 [− 0.046, 0.080]

0.602 − 0.024 [− 0.051, 0.003]

0.078 − 0.190 [− 0.492, 0.112]

0.217 − 0.212 [− 0.407, − 0.018]

0.032

Panel 2: by chronic diseases

 Single 0.061 [− 0.007, 0.129]

0.081 − 0.021 [− 0.048, 0.005]

0.117 − 0.074 [− 0.399, 0.252]

0.657 − 0.100 [− 0.312, 0.112]

0.353

 Multiple 0.046 [− 0.019, 0.112]

0.166 − 0.022 [− 0.052, 0.009]

0.168 − 0.436 [− 0.752, − 0.120]

0.007 − 0.367 [− 0.569, − 0.164]

< 0.001

Panel 3: by annual household income

 Low 0.075 [0.009, 0.142] 0.026 − 0.001 [− 0.031, 0.029]

0.952 − 0.296 [− 0.626, 0.034]

0.079 − 0.313 [− 0.536, − 0.089]

0.006

 High 0.030 [− 0.037, 0.098]

0.377 − 0.041 [− 0.069, − 0.014]

0.004 − 0.244 [− 0.556, 0.068]

0.125 − 0.152 [− 0.337, 0.034]

0.109

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HHC than those with high incomes. This may be somewhat attributed to the lower costs associated with community- based HHC relative to those in hospitals.

Regarding the health benefits of community-based HHC for older adults with chronic diseases, it is essential to pro- mote its development in China. Additionally, community- based HHC can help divert a mass of older adults away from overcrowded hospitals to alleviate the difficulties of seeing a doctor [36]. Therefore, community-based HHC is important in the Chinese context. Given that it is still in the primary stage with low resource investment, simple ser- vice, and low quality. The government should provide more policy provisions and resource supports for developing it to improve its sustainability, adequacy, equity, and universal accessibility, especially for populations at great probability of benefiting from it. The mass media needs to publicize its necessity among the public to nudge its utilization. Evidence has shown that the health benefits of HHC on older adults depend on its quality. When its quality meets the needs of older adults, their physical discomfort and mental illness can be eased, otherwise, they may deteriorate [38]. There- fore, HHC providers should strive to promote their com- munication skills with older adults and family caregivers, and provide services of the highest possible quality, espe- cially ensuring that the services are safe, effective, low-cost, timely, efficient, and person-centered [39].

This study had several limitations. First, cross-sectional data may have difficulty capturing the long-term dynamic health benefits of community-based HHC on older adults. Second, the community-based HHC services involved in this study were merely regular home visits and did not include services such as family beds. Thus, our results may have underestimated its health benefits. Third, the estimates of SRH, physical discomfort, depression, and anxiety were based on self-reports of older adults, which may have been impacted by individuals’ feelings and health conditions at the time they were interviewed. Recall bias may also have somewhat impacted the accuracy of the findings.

Conclusion

This study found that community-based HHC conferred positive effects on improving SRH and decreasing physi- cal discomfort, depression, and anxiety in older adults with chronic diseases, thus improving their quality of life in China. Rural older adults, older adults with multiple chronic diseases, and older adults with low incomes were found to benefit more from community-based HHC. It is important to promote its development nationwide in China. The govern- ment should provide more policy and resource supports to develop community-based HHC to improve its sustainabil- ity, equity, and accessibility, especially for populations with

a high probability of benefiting from it. The media should publicize its necessity to nudge its utilization. HHC provid- ers should strive to provide services of the highest quality.

Supplementary Information The online version contains supplemen- tary material available at https:// doi. org/ 10. 1007/ s11136- 023- 03555-2.

Acknowledgements Not applicable.

Author contributions SG contributed to study design, statistical analy- sis, data interpretation, and writing and review of the manuscript. CJ and FS contributed to statistical analysis and data interpretation. XW and XW contributed to data interpretation and review of the manu- script. HG contributed to study design, data interpretation and review of the manuscript. All authors read and approved the final manuscript.

Funding This study was funded by National Natural Science Founda- tion of China (72104102) and Jiangsu Planning Office of Philosophy and Social Science (20JD001).

Data availability Data are available in a public, open access repository. Researchers can download the datasets free of charge from the fol- lowing website: https:// opend ata. pku. edu. cn; Peking University Open Access Research Database.

Declarations

Competing interests The authors have no relevant financial or non- financial interests to disclose.

Ethics approval This study involves human participants and was approved by the Ethics Committee of Peking University (IRB00001052-13074). All participants or their proxy respondents provided written informed consent to participate in the study before taking part.

Consent to participate Informed consent was obtained from all indi- vidual participants included in the study.

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