JMIR Publications

ABSTRACT

Background:

The global phenomenon of aging is advancing at an accelerated pace, which presents significant challenges for China. By the end of 2024, the individuals aged 60 and older in China reached 310 million, accounting for 22.0% of the total population, these individuals were characterized by a substantial base and rapid growth rate[1]. Older adults often experience a decline in physical capabilities, reduced social engagement, and adverse life events such as bereavement, which make them particularly vulnerable to mental health issues, including anxiety, depression, loneliness, loss, and distrust[2]. The incidence of moderate-to-severe anxiety among community-dwelling older adults was reported to be 56.3% (341 out of 606), and the prevalence of moderate-to-severe depression was 28.7% (174 out of 606)[3]. Approximately 90% of older adults in China rely on traditional home-based care as their primary model of elderly care[4], with intergenerational family interactions playing a crucial role in enhancing their mental health[5]. However, the rapid aging process, combined with declining fertility rates, have weakened the traditional family support system in China, complicating the ability to meet the increasing demand for elderly care services through familial care alone. As a result, a growing number of older adults, particularly those with disabilities[6] or those living independently[7], face challenges such as inadequate daily care and a lack of emotional support, which can negatively impact their mental health. In response to the declining birth rates, increased aging process, and smaller family sizes, home and community-based elderly care (HCEC) models enabled older adults to remain in familiar environments, sustain their social networks, and maintain familial connections. This approach not only alleviated feelings of helplessness and the risk of solitary death among empty-nest older adults but also diminished the loneliness and emotional detachment often associated with institutional care. Given its alignment with Chinese cultural values, public preferences, and cost-effectiveness, and narrowing health inequality, HCEC has emerged as a promising framework for elderly care[8]. Numerous studies have highlighted the significant demand for HCEC services among older adults, particularly in areas related to daily assistance and emotional support[9]. Furthermore, the care needs of the elderly are individualized and influenced by various factors, including level, health status, family environment, economic conditions, and social security[10]. Current research evaluated the effects of policy has primarily focused on health status, quality of life[10], and life satisfaction among older adults[11]. Enhancing the mental health of older adults is a critical objective in promoting healthy aging. To further maintain the physical and mental well-being of older adults and improve their quality of life, China's Ministry of Civil Affairs and Ministry of Finance issued the "Notice on Central Financial Support for Pilot Reforms of HCEC Services" in 2016. From 2016 to 2020, the central government allocated 5 billion yuan to support five batches of pilot regions, encompassing 203 cities (districts) across 31 provinces, which covered 60% of prefecture-level cities in China (Figure 1). Note: The first batch (end of 2016) included 26 pilot cities. The second batch (2017) included 28 pilot cities. The third batch (2019) included 35 pilot cities. The fourth batch (2020-2023) included 54 pilot cities. The fifth batch (2020) included 50 pilot cities. The white blocks indicate cities that were not included in the pilot programme. Despite these advancements, there is a lack of research examining the impact of HCEC pilot policies on the mental health of older adults, particularly concerning their medium- to long-term effects. Clarifying the influence of these policies aligns with the principles of active aging and healthy aging, and also addressing older adults' preferences for care and the concept of "aging within the community." This inquiry is of significant practical importance for promoting the high-quality development of the older adults. Therefore, this study aims to investigate the role of HCEC service reform pilots in the mental health of older adults, with a focus on exploring their internal mechanisms and medium- to long-term policy effects in depth.

Objective:

The study aims to examine the effects of pilot reform policies related to home and community-based care services on the mental health of older adults in China. This research has significant practical implications for achieving the goal of "well-being in aging" and leveraging the potential of the "silver economy."

Methods:

Utilizing data from the China Family Panel Studies (CFPS) collected between 2010 and 2022, this study examined the "home- and community-based elderly care service reform pilot" policy to conduct causal identification using the difference-in-differences (DID) methodology. It quantitatively evaluated the impact of integrating home-based and community-based care on the mental health of older adults.

Results:

The findings indicate that: (1) The pilot reform of home- and community-based elderly care services significantly reduced depression scores among older adults, and enhanced their mental health. (2) Improvements in physical health and the increased awareness of filial care serve as essential pathways through which the pilot policy positively impacted the mental health of older adults. (3) Heterogeneity analysis revealed that the policy's effects are particularly pronounced among individuals with lower educational level, female, and those with disabilities.

Conclusions:

The reform of home- and community-based elderly care services has the potential to significantly improve the mental health of older adults. These findings are not only important for the understanding of the integration of home-based and community-based elderly care services, but also provide valuable insights for the development of elderly care service systems in developing countries.