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Abstract

Facing the increasingly severe aging situation, China has started to implement the “integrated medical services and elderly care (IMSEC)” policy, which covers a variety of IMSEC models. However, there is currently little research on middle-aged and elderly people’s choice preference for these IMSEC models and their associated factors. Through the face-to-face questionnaire method, the choice preference of middle-aged and elderly people aged 45 years and over in Zhejiang Province, China, to the IMSEC model is explored. Through the multinomial logistic regression model, the influencing factors of choice preference are analyzed. A total of 1034 people are included in 2022. Their choice preference for the 4 major types of IMSEC models are Home IMSEC model (48.07%), Community IMSEC model (23.79%), Institutional IMSEC model (21.76%), and Internet Plus IMSEC model (6.38%). “C1. Home elderly care and contracted with a family doctor” is the most chosen subtype, accounting for 34.53%. The rural elderly are more likely to choose “Home IMSEC model” (OR(95%CI) = 2.977(1.343-6.601)). Elderly people with relatively large life care needs are more likely to choose “Institutional IMSEC model” (OR(95%CI) = 1.114(1.042-1.190)). Moreover, age, education, and self-reported health status are also influencing factors of choice preference. The government should focus on promoting the development of the “Home IMSEC model” and increase the promotion of “Internet Plus IMSEC model.” In addition, the life care service capacity and spiritual comfort capacity of IMSEC institutions, as well as the medical service capacity of the community, need to be enhanced.

Keywords

medical services elderly care elderly China choice preference

What do we already know about this topic?

Although some studies explore middle-aged and elderly people’s understanding and willingness to accept the “integrated medical services and elderly care (IMSEC)” policy, few studies have explored the choice preference of middle-aged and elderly people on different IMSEC models and related influencing factors.

How does your research contribute to the field?

This paper investigates the choice preference of middle-aged and elderly people on the IMSEC models and their influencing factors from the perspective of model selection of policy recipients. We have explored which models of IMSEC are popular with middle-aged and elderly people and what factors influence middle-aged and elderly people’s choice of these models.

What are your research’s implications toward theory, practice, or policy?

Our findings can be used as a reference for the government in China. For instance, the government should focus on promoting the development of the “Home IMSEC model” and increase the promotion of “Internet Plus IMSEC model.” In addition, the life care service capacity and spiritual comfort capacity of IMSEC institutions, as well as the medical service capacity of the community, need to be enhanced.

Introduction

In recent years, the aging situation in China has become increasingly severe. According to the seventh national census, as of 2020, China’s population aged ≥60 years is 264.02 million, accounting for 18.70%. Among them, the population aged ≥65 years is 190.64 million, accounting for 13.50%.¹ It is estimated that by 2025, China’s population aged ≥60 years will account for more than 20% of the total population, which marks the entry into a moderately aging society. The health status of the elderly is not optimistic. More than 78% of the elderly suffer from 1 or more chronic diseases, and the number of disabled elderly people continues to increase.² China’s aging is characterized by large scale, rapid speed, and heavy support burden. At present, China is facing enormous pressure on the elderly.

In China, elderly care service and medical service are under the jurisdiction of different departments. Among them, the elderly care service is under the jurisdiction of the Ministry of Civil Affairs. Traditional pension institutions cannot provide medical services for the elderly. Medical service is under the jurisdiction of the Health Commission. Most medical institutions cannot provide long-term care services for the elderly. The separation of medical service and elderly care service has caused great inconvenience to the elderly.³

In this regard, China proposed the concept of “integrated medical services and elderly care (IMSEC)” in 2013.^4,5 However, government documents do not give a clear definition of IMSEC. Some scholars believe that IMSEC is that “the government integrates medical resources and pension resources to meet the health needs of the elderly at different stages in the nursing process.”³ According to the “IMSEC Institutional Service Guideline (Trial)” issued by the Chinese government in 2019, the service content of “medical service” and “elderly care service” is clarified.⁶ “Medical service” includes regular rounds, disease diagnosis and treatment, emergency rescue, palliative care, nursing and rehabilitation, health education, and health management. “Elderly care service” includes life care and psychological support. There are 4 IMSEC models currently implemented in China: 1. “Elderly care service in hospital,” in which hospitals provide elderly care service; 2. “Constructing a hospital in elderly care institutions,” in which elderly care institutions provide medical service; 3. “Cooperation between Medical institutions and elderly care institutions,” in which elderly care institutions provide medical services according to needs; 4. “Home nursing,” in which family doctors provide medical services at home.⁷

Since it was first proposed in 2013, relevant policies of IMSEC have been gradually implemented. In 2015, 9 government departments collaborated to complete the implementation guidance of the policy. In more detail, it encourages medical and health institutions to cooperate with elderly care institutions, supports elderly care institutions in carrying out medical services, and promotes the extension of medical and health services to communities and families.⁸ By 2017, China had established 90 national-level IMSEC pilot cities.⁹ In 2022, the government put forward plans for the development of elderly care and the elderly care service system in the “14th Five-Year Plan,” which indicated that it would continue to enrich the service model of IMSEC and improve the service quality of IMSEC.¹⁰

Although China has invested a lot of human and material resources in promoting the IMSEC policy, it is not well understood. Current research in China can be divided into the following categories.¹¹ 1. Numerous studies explore how the government should optimize this policy from the perspective of policymakers.¹² For example, based on the experience of home elderly care in Japan, some research suggests that China should actively promote long-term care insurance and integrate elderly care service and chronic disease management services.¹³ 2. Relevant studies explore how IMSEC institutions should improve performance and introduce new models from the perspective of implementing agencies. For example, some studies have used the system dynamics model to evaluate the performance of IMSEC institutions, and found that the degree of policy support and the service level of IMSEC institutions are of great significance to the performance of institutions.¹⁴ In addition, some scholars have explored how to implement “TCM plus Smart Elderly Care” in the IMSEC model in institutions.¹⁵ 3. A few studies explore middle-aged and elderly people’s understanding and willingness to accept the policy from the perspective of policy recipients.^16,17 For example, the awareness rate of IMSEC policies among people over 60 years old is only 54.2%, and their willingness to participate is 66.3%. Influencing factors include age, number of children, and prevalence of chronic diseases.¹⁸ 4. From the perspective of the IMSEC model, a little of studies have explored the choice preference of middle-aged and elderly people on different IMSEC models and related influencing factors. It should be noted that this type of research is weak, and needs more attention.

Therefore, this paper investigates the choice preference of middle-aged and elderly people on the IMSEC model and its influencing factors from the perspective of model selection of policy recipients. The purpose of this paper is to explore which models of IMSEC are popular with middle-aged and elderly people and what factors influence middle-aged and elderly people’s choice of these models. This can provide an empirical basis for which type of IMSEC model the government will focus on launching next.

Methods

Study Design and Data

This paper adopts a cross-sectional research design. First, the choice preference of middle-aged and elderly people aged 45 years and older to the IMSEC model was described. Differences in choice preference among demographic characteristics were compared by univariate analysis. Then, a multinomial logistic regression model was used to explore the relevant factors affecting the choice preference of middle-aged and elderly people.

The questionnaire in this paper was self-designed. The designed questionnaire was formally used after pre-investigation and reviewed by 2 experts in epidemiology and biostatistics. The detailed questionnaire is attached in the Supplemental Materials. The questionnaire survey adopted a face-to-face paper format. The investigators were responsible for asking questions about the content of the questionnaire and then filling it out based on the responses of the elderly. Participants gave informed consent before conducting the questionnaire.

The inclusion criteria for this survey were as follows: 1. Permanent residents of Zhejiang Province, China; 2. Aged 45 years and above; 3. Voluntary participation in this survey; and 4. Clear awareness and able to understand and answer questions accurately.

This study is a cross-sectional study. Because the published studies did not show the probability of choosing the IMSEC models in middle-aged and elderly people, we can only calculate the sample size according to the formula n = 100 + 50×i, where i refers to the number of independent variables in the final model.¹⁹ There are 16 independent variables in the final logistic model. Therefore, the minimum sample size should be 900. Considering that some of the collected questionnaire information might be incomplete, we expanded the sample size to 1000. Finally, we collected 1034 valid questionnaires.

The survey adopted a sampling method combining probability sampling method and non-probability sampling method (Figure 1). Step 1: Through simple random sampling, 4 of the 11 prefecture-level cities in Zhejiang Province were selected as survey prefecture-level cities. The extraction results were Hangzhou City, Shaoxing City, Ningbo City, and Huzhou City. Step 2: According to the household registration or residence of the investigators, the target county-level cities (districts) in the above 4 prefecture-level cities were selected by convenience sampling method, and the investigators were assigned. Step 3: Through convenience sampling and snowball sampling methods, investigators conducted face-to-face questionnaire surveys in places with dense populations of middle-aged and elderly people (such as morning exercise parks, vegetable markets, and hospitals) in county-level cities (districts). The survey was carried out from June to November 2022. A total of 1100 questionnaires were collected. Due to the lack of key information such as gender and age in some questionnaires, the final number of valid questionnaires was 1034, with an effective rate of 94%.

Figure 1.

Sampling flowchart of data collection.

Research Variables and Measures

Choice preference (dependent variable) of the IMSEC model

According to the previous literature research,^20,21 4 categories of models of IMSEC in China are summarized. Some of these models are implemented currently, while others will be implemented in the future. The 4 major models are as follows: 1. Institutional IMSEC model; 2. Community IMSEC model; 3. Home IMSEC model; and 4. Internet Plus IMSEC model. Each category pattern can be subdivided into 3 subtypes. In other words, there are 12 subtypes of IMSEC patterns for middle-aged and elderly people in this survey. The definition of IMSEC models for each subtype is shown in Table 1.

Table 1.

IMSEC Models in China.

Type	Subtype	Description
A. Institutional IMSEC model: IMSEC services are provided by large-scale medical institutions or large-scale elderly care institutions (elderly are in large-scale institutions).	A1.Elderly care service in hospital	Set up a elderly care home in hospital.
	A2.Constructing a hospital in elderly care institutions	Set up infirmary and nursing stations in elderly care institutions.
	A3.Cooperation between Medical institutions and elderly care institutions	Medical institutions and elderly care institutions sign cooperation. The hospital provides disease diagnosis, treatment, and knowledge training for the elderly care institutions. The elderly care institutions can provide rehabilitation services for the discharged elderly.
B.Community IMSEC model: IMSEC services are provided by community (elderly are in IMSEC institutions of community).	B1.Nursing station in community elderly care station	Set up nursing station in the community elderly care station. The elderly in the community elderly care station can enjoy the services including basic nursing service, postoperative rehabilitation nursing, chronic disease daily rehabilitation, and so on.
	B2.Community health service centers and community day care centers	Set up a “community day care centers for elderly,” which is managed by community health service centers. It provides services such as living care and medical services for the elderly.
	B3.Professional elderly care institutions and community day care centers	Set up a “community day care centers for elderly,” which is managed by professional elderly care institutions.
C.Home IMSEC model: IMSEC services are provided by families and family doctors (elderly are at home).	C1.Home elderly care and contracted with a family doctor	The elderly are provided with living care at home by family members or nannies, and then receive health care services from family doctors.
	C2.Home elderly care and long-term care insurance	The elderly who participate in the long-term care insurance are provided with living care by their family members, and “home care” services by designated institutions of the long-term care insurance. The expenses are mainly from medical insurance funds.
	C3.Regular home visits by care providers/social workers	Regular rehabilitation care and other care services are provided at home by medically qualified elderly care providers/professional social workers.
D.Internet Plus IMSEC model: Apply Internet technology to the IMSEC services.	D1.Internet and wearable smart devices	“Home care” elderly people are equipped with wearable monitoring devices to monitor their physical condition.
	D2.Internet and IMSEC institutions	IMSEC institutions use Internet technology to provide online services for the elderly.
	D3. IMSEC service network platform	Develop smart IMSEC service network platform (such as website, mobile APP, and service hotline).The elderly or their families release needs information on the platform, and the platform responds to the needs by means of service order grabbing, order dispatching and offline service points.

The first question in the questionnaire is: “From the perspective of service space, which of the following IMSEC models do you most prefer?” This question identifies 4 broad categories of patterns for respondents. When the respondent chooses “A. institutional IMSEC model,” the corresponding next question is “Which type of institutional IMSEC model do you most like to choose?” In the end, the respondents will choose the preferred subtype (such as A1. Elderly care service in hospital).

Independent variables

First, the core variables of this study are selected from Andersen’s behavioral model,²² which has been widely used in many studies on health services, including predisposing factors, enabling factors, and demand factors. Based on the research content, the predisposing factors in this paper include age, gender, hukou, marital status, education, and occupation. Hukou is the information registered by individuals according to the type of residence, which is divided into urban hukou and rural hukou. Enabling factors include personal monthly income, pension insurance, whether there are medical staff/family doctors in the community, whether there are elderly care service stations/daytime care centers in the community, and whether it is convenient to seek medical treatment. Demand factors include self-assessment of health status and the number of chronic diseases.

Secondly, social support and loneliness are proven to have an impact on the self-care ability and health status of the elderly.^23,24 The elderly with poor health are more likely to receive IMSEC services.²⁵ Social support and health status will affect the living arrangement preference of the elderly.²⁶ Therefore, it is hypothesized that social support and loneliness will affect the choice preference of the elderly toward the IMSEC model. Therefore, social support and loneliness were selected as independent variables. It should be noted that the scales used to measure social support and loneliness of middle-aged and elderly people are all from literature. In addition, the Chinese version of the scale has been verified by Chinese scholars.^27,28 The perceived social support scale adopts Likert 7-level scoring, in which the higher the total score, the more social support. The loneliness scale adopts Likert 5-level scoring, and the higher the total score, the more loneliness.

Finally, the needs of the elderly are also included as independent variables. According to related studies, the needs of older adults influence their perception of the IMSEC model.^29,30 Based on Maslow’s hierarchy of needs theory, a scale is designed to measure the needs of the elderly. The scale has 19 items, including 5 dimensions of life care, medical care, spiritual comfort, safety, and rights protection. The need scale adopts Likert 5-level scoring, in which the higher the total score, the higher the degree of need.

Reliability and Validity of the Scales

KMO and Bartlett tests are used to judge whether the 3 scales are suitable for factor analysis. The results are shown in Supplemental Table 1. The KMO results of the 3 scales are all greater than 0.8, and the Bartlett tests are all less than 0.001, which indicates that the 3 scales can be used for factor analysis.

The factor analysis results of the perceived social support scale are shown in Supplemental Table 2. The scale has 12 items in total, which can extract 3 factor components, and the cumulative contribution rate is 81.91%. These 3 factors are called family support, friend support, and other support respectively.

As shown in Supplemental Table 3, there are 10 entries in the loneliness scale, which can extract 2 factor components, and the cumulative contribution rate is 61.01%. These 2 factors are named social loneliness and emotional loneliness respectively.

As shown in Supplemental Table 4, there are 19 items in the need scale, which can extract 5 factor components, and the cumulative contribution rate is 80.60%. These 5 factors are named life care needs, health care needs, spiritual comfort needs, security needs, and needs for safeguarding rights respectively.

Next, the reliability of the scale is measured, as shown in Supplemental Table 5. The Cronbach’s α coefficients of the 3 scales are all above .8, which indicates good reliability. The coefficients of the social support scales are all greater than .9, which indicates that the reliability is very good.

Statistical Analysis

First, the choice preference of middle-aged and elderly people for the IMSEC model is descriptively analyzed. The χ² test is used to compare the distribution of choice preference among various demographic characteristics. Group differences in scale scores are compared by analysis of variance. Among them, the SNK method is used for pairwise comparison. Then, multicollinearity among independent variables is tested. The results show that the variance inflation factor (VIF) is less than 10, which indicates that there is no collinearity between the independent variables. Finally, a multinomial logistic regression model is adopted to explore the influence factors of middle-aged and elderly people on the choice preference of the IMSEC model.

All statistical tests are 2-sided. P value <.05 is considered statistically significant. Statistical software is R software (version 3.6.3).

Results

A total of 1034 middle-aged and elderly people aged 45 years and above are included in this paper. Among them, women account for 59.86%, people over 60 years old account for 62.67%, married people account for 84.52%, people with urban hukou account for 57.54%, and people with middle school education or below account for 63.54%.

Middle-Aged and Elderly People’s Choice Preference for the IMSEC Model

As shown in Table 2, middle-aged and elderly people’s choice preferences for the 4 major types of IMSEC models are: “Home IMSEC model” (48.07%), “Community IMSEC model” (23.79%), “Institutional IMSEC model” (21.76%), and “Internet Plus IMSEC model” (6.38%). Among them, the “Home IMSEC model” is the most popular model for middle-aged and elderly people.

Table 2.

The Choice Preference of IMSEC Model Among Chinese Middle-Aged and Elderly (N = 1034).

Factor	Sample	IMSEC Models				P value
Factor	Sample	Institutional IMSEC model (N = 225)	Community IMSEC model (N = 246)	Home IMSEC model (N = 497)	Internet Plus IMSEC model (N = 66)	P value
Sex^a
Male	415	93 (22.41)	105 (25.30)	200 (48.19)	17 (4.10)
Female	619	132 (21.32)	141 (22.78)	297 (47.98)	49 (7.92)	.091
Age group (years)^b
45-59	386	72 (18.65)	108 (27.98)	158 (40.93)	48 (12.44)
60-69	272	52 (19.12)	56 (20.59)	153 (56.25)	11 (4.04)	<.001***
≥70	376	101 (26.86)	82 (21.81)	186 (49.47)	7 (1.86)
Hukou^a
Urban resident	595	165 (27.73)	155 (26.05)	225 (37.82)	50 (8.40)
Rural resident	439	60 (13.67)	91 (20.73)	272 (61.96)	16 (3.64)	<.001***
Marital status^a
Married	874	175 (20.02)	210 (24.03)	428 (48.97)	61 (6.98)
Others^d	160	50 (31.25)	36 (22.50)	69 (43.13)	5 (3.13)	.007**
Education^b
Middle school or below	657	125 (19.03)	145 (22.07)	370 (56.32)	17 (2.59)
High School	217	49 (22.58)	56 (25.81)	87 (40.09)	25 (11.52)	<.001***
College degree or above	160	51 (31.88)	45 (28.13)	40 (25.00)	24 (15.00)
Occupation^b
Farmer	247	22 (8.91)	51 (20.65)	167 (67.61)	7 (2.83)
Public servant	131	44 (33.59)	39 (29.77)	38 (29.01)	10 (7.63)
Enterprise staff	486	132 (27.16)	115 (23.66)	203 (41.77)	36 (7.41)	<.001***
Self-employed	170	27 (15.88)	41 (24.12)	89 (52.35)	13 (7.65)
Income(RMB)^b
<2000	211	21 (9.95)	41 (19.43)	145 (68.72)	4 (1.90)
2000-3000	188	19 (10.11)	41 (21.81)	112 (59.57)	16 (8.51)	<.001***
>3000	635	185 (29.13)	164 (25.83)	240 (37.80)	46 (7.24)
Pension^a
No	135	15 (11.11)	23 (17.04)	95 (70.37)	2 (1.48)
Yes^e	899	210 (23.36)	223 (24.81)	402 (44.72)	64 (7.12)	<.001***
Is there a health care provider /family doctor who can offer home visit in your community
Yes	393	96 (24.43)	111 (28.24)	159 (40.46)	27 (6.87)
No	641	129 (20.12)	135 (21.06)	338 (52.73)	39 (6.08)	.002**
Is there a nursing home/day care center in your community
Yes	357	88 (24.65)	90 (25.21)	157 (43.98)	22 (6.16)
No	677	137 (20.24)	156 (23.04)	340 (50.22)	44 (6.50)	.213
Is it convenient to see a doctor^b
Inconvenient	97	25 (25.77)	31 (31.96)	39 (40.21)	2 (2.06)
Moderate	143	31 (21.68)	36 (25.17)	62 (43.36)	14 (9.79)	.138
convenient	794	169 (21.28)	179 (22.54)	396 (49.87)	50 (6.30)
Chronic illness^b
None	482	100 (20.75)	105 (21.78)	240 (49.79)	37 (7.68)
1	333	69 (20.72)	82 (24.62)	162 (48.65)	20 (6.01)	.073
≥2	219	56 (25.57)	59 (26.94)	95 (43.38)	9 (4.11)
Self-reported general health status^b
Bad	50	19 (38.00)	10 (20.00)	17 (34.00)	4 (8.00)
Fair	319	90 (28.21)	82 (25.71)	126 (39.50)	21 (6.58)	<.001***
Good	665	116 (17.44)	154 (23.16)	354 (53.23)	41 (6.17)
Perceived social support^c
Family support	1034	225 (23.5 ± 5.2)	246 (23.5 ± 4.4)	497 (23.7 ± 4.1)	66 (24.0 ± 3.5)	.190
Friend support	1034	225 (19.6 ± 6.1)	246 (20.4 ± 5.2)	497 (20.2 ± 5.2)	66 (21.8 ± 4.2)	.847
Other support	1034	225 (20.8 ± 6.0)	246 (20.7 ± 5.1)	497 (21.4 ± 4.9)	66 (21.6 ± 4.6)	.027*
Loneliness^c
Social loneliness	1034	225 (15.4 ± 6.4)	246 (14.7 ± 6.5)	497 (13.3 ± 5.4)	66 (15.2 ± 5.4)	<.001***
Emotional loneliness	1034	225 (5.7 ± 2.7)	246 (6.2 ± 2.9)	497 (5.1 ± 3.0)	66 (5.8 ± 2.7)	<.001***
Need^c
Life care needs	1034	225 (16.4 ± 7.7)	246 (15.1 ± 7.1)	497 (11.4 ± 6.6)	66 (13.7 ± 6.4)	<.001***
Health care needs	1034	225 (13.9 ± 5.7)	246 (13.9 ± 5.4)	497 (11.2 ± 5.6)	66 (14.1 ± 5.0)	<.001***
Spiritual comfort needs	1034	225 (11.0 ± 5.2)	246 (11.2 ± 5.3)	497 (8.5 ± 4.9)	66 (12.6 ± 6.0)	<.001***
Security needs	1034	225 (10.9 ± 4.5)	246 (10.6 ± 4.4)	497 (8.2 ± 4.7)	66 (10.4 ± 4.3)	<.001***
Needs for safeguarding rights	1034	225 (7.7 ± 4.1)	246 (7.8 ± 4.3)	497 (6.2 ± 4.2)	66 (9.9 ± 4.7)	<.001***

These variable are unordered variables, expressed as N(%), and P value is the χ² test result.

hese variables are rank ordered variables, expressed as N(%), and P value is Kruskal-Wallis test result.

These variables are continuous variables, expressed as N(M ± S), and P value is the result of analysis of variance.

Include divorced, separated, widowed, and single

Include pension for urban and rural residents, pension for urban workers, and commercial endowment insurance.

P < .05. **P < .01. ***P < .001.

According to the univariate analysis (Table 2), there are differences between middle-aged and elderly people’s choice preferences among demographic characteristics such as age, hukou, marital status, education, and occupation (all P value of χ² test <0.05). For example, the elderly who are 60 to 69 years old, whose hukou is rural, have a middle school education or below, and are farmers, are more likely to choose the “Home IMSEC model.” Groups whose marital status is other (widowed and divorced) and whose occupation is staff in government institutions are more likely to choose the “Institutional IMSEC model.” In addition, younger people (45-59 years old) are more likely to choose the “Internet Plus IMSEC model” than older people.

Using analysis of variance, the scale scores were compared between the various models (Table 2). It can be found that middle-aged and elderly people who choose the “Internet Plus IMSEC model” get relatively more social support from other people (such as colleagues and leaders). According to the results of the SNK analysis, middle-aged and elderly people who choose the “Home IMSEC model” feel neither social loneliness nor emotional loneliness. Also, this group of people who choose the “Home IMSEC model” has relatively few needs in terms of life, medical care, spiritual comfort, safety, and rights protection.

In addition to middle-aged and elderly people’s choice preference for 4 major types of IMSEC models, the selection of 12 subtypes of IMSEC models was further analyzed (Supplemental Table 6). As shown in Figure 2a, the top 3 selection ratios in subtype are “C1. Home elderly care and contracted with a family doctor” (34.53%), “B2. Community health service centers and community day care centers” (12.19%), and “A2. Constructing a hospital in elderly care institutions” (10.06%). Middle-aged and elderly people whose hukou is rural, whose monthly income is less than 3000 RMB, and who have no pension insurance are more likely to choose “C1. Home elderly care and contracted with a family doctor,” with a proportion of more than 45%. Compared with other groups of people, middle-aged and elderly people whose hukou is urban hukou, who work for government institutions, and other marital status are more inclined to choose “A2. Constructing a hospital in elderly care institutions.” The group with poor self-reported health status prefers “A1. Elderly care service in hospital.”

Figure 2.

Choice Preference of Middle-Aged and Elderly People on 12 subtypes of IMSEC models: (a) The distribution of subtypes of IMSEC models among different factors. The brackets mean P-values for group comparison (univariate analysis). *P < .05, **P < .01, *** < .001. (b) Social support scale scores (class by subtypes of IMSEC models) (c) Loneliness scale scores (class by subtypes of IMSEC models), and (d) Need scale scores (class by subtypes of IMSEC models).

Elderly groups with different social support, loneliness, and needs have different choices for the 12 subtypes of the IMSEC model. Compared with other groups, the group who chose “C1. Home elderly care and contracted with a family doctor” has higher social support (Figure 2b), less social loneliness (Figure 2c), and lower various needs (Figure 2d). People with strong social loneliness are more likely to choose “A1. Elderly care service in hospital” (Figure 2c). Individuals who choose “D2. Internet and IMSEC institutions” also have higher needs in life care and spiritual comfort (Figure 2d).

Influencing Factors of Middle-Aged and Elderly People on the Choice Preference of the IMSEC Model

AFTER splitting into 12 subtypes, the sample size of each subtype is too small to be suitable for multivariate analysis. Therefore, this paper only discusses the factors affecting the selection of the 4 types of IMSEC models. Through the multinomial logistic regression model, the factors affecting the choice preference of middle-aged and elderly people to the IMSEC model are analyzed. The regression takes the “Internet IMSEC model” as a reference, and the results are shown in Table 3.

Table 3.

The Influencing Factors of the Choice Preference of IMSEC Model Among Chinese Middle-Aged and Elderly.

Factor	Institutional IMSEC model		Community IMSEC model		Home IMSEC model
Factor	OR	P value^a	OR	P value^a	OR	P value^a
Sex
Male	Reference		Reference		Reference
Female	0.796 (0.407-1.554)	.503	0.670 (0.348-1.290)	.231	0.766 (0.403-1.457)	.416
Age group (years)
45-59	Reference		Reference		Reference
60-69	2.596 (1.126-5.987)*	.025	1.592 (0.706-3.593)	.262	3.307 (1.503-7.280)**	.003
≥70	4.455 (1.526-13.009)**	.006	2.588 (0.903-7.419)	.077	5.385 (1.918-15.123)**	.001
Hukou
Urban resident	Reference		Reference		Reference
Rural resident	1.991 (0.858-4.616)	.109	1.865 (0.822-4.231)	.136	2.977 (1.343-6.601)**	.007
Marital status
Married	Reference		Reference		Reference
Others^b	1.481 (0.504-4.356)	.475	1.281 (0.434-3.781)	.654	1.329 (0.458-3.855)	.600
Education
Middle school or below	Reference		Reference		Reference
High School	0.326 (0.144-0.737)**	.007	0.376 (0.171-0.826)*	.015	0.305 (0.142-0.655)**	.002
College degree or above	0.339 (0.133-0.862)*	.023	0.342 (0.136-0.862)*	.023	0.245 (0.098-0.611)**	.003
Occupation
Farmer	Reference		Reference		Reference
Public servant	3.046 (0.677-13.699)	.147	1.338 (0.316-5.656)	.692	1.017 (0.247-4.187)	.981
Enterprise staff	2.817 (0.826-9.611)	.098	1.176 (0.370-3.740)	.783	1.479 (0.486-4.508)	.491
Self-employed	1.781 (0.486-6.528)	.384	1.105 (0.330-3.700)	.871	1.345 (0.420-4.306)	.618
Income (RMB)
<2000	Reference		Reference		Reference
2000-3000	0.289 (0.081-1.033)	.056	0.363 (0.111-1.183)	.093	0.350 (0.112-1.091)	.070
>3000	1.137 (0.331-3.909)	.839	0.712 (0.219-2.312)	.572	0.479 (0.153-1.504)	.208
Pension
No	Reference		Reference		Reference
Yes^c	0.979 (0.216-4.443)	.978	1.231 (0.284-5.329)	.781	1.095 (0.268-4.468)	.899
Is there a health care provider/family doctor who can offer home visit in your community
Yes	Reference		Reference		Reference
No	1.115 (0.546-2.277)	.765	1.008 (0.502-2.028)	.981	1.609 (0.807-3.204)	.176
Is there a nursing home/day care center in your community
Yes	Reference		Reference		Reference
No	0.940 (0.458-1.930)	.867	1.044 (0.516-2.112)	.906	1.029 (0.513-2.061)	.937
Is it convenient to see a doctor
Inconvenient	Reference		Reference		Reference
Moderate	0.325 (0.084-1.252)	.102	0.323 (0.086-1.214)	.094	0.619 (0.165-2.321)	.477
convenient	0.492 (0.145-1.674)	.257	0.398 (0.119-1.331)	.135	0.803 (0.241-2.670)	.720
Chronic illness
None	Reference		Reference		Reference
1	0.840 (0.416-1.698)	.628	1.391 (0.705-2.744)	.341	1.147 (0.589-2.231)	.687
≥2	1.100 (0.408-2.965)	.850	2.238 (0.848-5.906)	.104	1.807 (0.692-4.717)	.227
Self-reported general health status
Bad	Reference		Reference		Reference
Fair	2.744 (0.751-10.030)	.127	6.385 (1.663-24.518)**	.007	7.697 (2.100-28.215)**	.002
Good	1.559 (0.426-5.707)	.503	6.653 (1.742-25.413)**	.006	10.098 (2.798-36.441)***	<.001
Perceived social support
Family support	1.005 (0.922-1.095)	.914	0.992 (0.911-1.080)	.849	1.008 (0.926-1.096)	.859
Friend support	0.950 (0.851-1.060)	.360	1.004 (0.900-1.121)	.942	0.958 (0.860-1.066)	.433
Other support	1.047 (0.941-1.164)	.398	1.011 (0.910-1.122)	.845	1.073 (0.968-1.190)	.181
Loneliness
Social loneliness	1.035 (0.980-1.093)	.218	1.008 (0.956-1.064)	.761	0.989 (0.937-1.043)	.673
Emotional loneliness	1.013 (0.899-1.142)	.831	1.077 (0.960-1.209)	.208	1.046 (0.934-1.171)	.439
Need
Life care needs	1.114 (1.042-1.190)**	.002	1.065 (0.999-1.134)	.053	1.034 (0.972-1.100)	.293
Health care needs	0.935 (0.847-1.032)	.180	0.981 (0.892-1.079)	.691	0.973 (0.888-1.067)	.560
Spiritual comfort needs	0.945 (0.870-1.027)	.182	0.965 (0.891-1.045)	.386	0.915 (0.846-0.990)*	.026
Security needs	1.089 (0.971-1.220)	.144	1.078 (0.965-1.205)	.186	1.022 (0.918-1.137)	.693
Needs for safeguarding rights	0.903 (0.814-1.002)	.055	0.885 (0.800-0.979)*	.018	0.940 (0.852-1.038)	.220

Note. Take Internet Plus IMSEC Model as Reference.

Multinomial logistic regression model (take Internet Plus IMSEC model as reference) *P < .05, **P < .01, ***P < .001.

Include divorced, separated, widowed, and single

Include pension for urban and rural residents, pension for urban workers, and commercial endowment insurance.

Compared with other groups, middle-aged and elderly people who are 60 years old and above and have higher life care needs have a greater tendency to choose the “Institutional IMSEC model” (Age 60-69 years: OR = 2.596, 95% Confidence Interval (CI) = 1.126-5.987; age ≥ 70 years: OR (95%CI) = 4.455 (1.526-13.009); High life care needs: OR (95%CI) = 1.114 (1.042-1.190)). Compared with those with middle school education or below, the proportion of middle-aged and elderly people with higher education who choose the “Institutional IMSEC model” is less, with OR less than 1.

Compared with people with middle school education or below, middle-aged and elderly people with higher education have a smaller choice preference for the “Community IMSEC model” (High school education: OR (95%CI) = 0.376 (0.171-0.826); College degree or above: OR (95%CI) = 0.342 (0.136-0.862)). Compared with people with poor self-reported health status, middle-aged and elderly people with good self-reported health status are more inclined to choose the “Community IMSEC model,” with OR greater than 1.

In addition, factors that prompt middle-aged and elderly people to choose the “Home IMSEC model” include age 60 years and above, rural hukou, and good self-reported health status (with OR greater than 1). Compared with other groups, middle-aged and elderly people with higher education and higher spiritual comfort needs have a lower tendency to choose the “Home IMSEC model” (High school education: OR (95%CI) = 0.305 (0.142-0.655); College degree and above: OR (95%CI) = 0.245 (0.098-0.611); High spiritual comfort needs: OR (95%CI) = 0.915 (0.846-0.990)).

Unfortunately, no statistical association is found between social support, loneliness, health care needs, and the choice preference of middle-aged and elderly people in the multivariate analysis.

Discussion

This paper explores the choice preference of Chinese middle-aged and elderly people for various IMSEC models, and finds the relevant influencing factors. Foreign countries have long implemented similar IMSEC models (such as the PACE model in the United States,³¹ and the long-term care insurance model in Japan³²), which has certain reference significance for China. Although there have been some studies in China on “middle-aged and elderly people’s willingness to participate in IMSEC policies,” there is almost no research on the “choice preference of IMSEC model.” Therefore, the results also lack a basis for comparison among domestic provinces.

Among the 4 IMSEC models, the “Home IMSEC model” is the first choice for middle-aged and elderly people. Among them, the proportion of middle-aged and elderly people with rural hukou choosing this model is as high as 61.96%. From the perspective of old-age care, more than half of the elderly in China choose home elderly care,^33,34 especially in rural areas. Due to the limitations of personal economic conditions and regional elderly care services, 78.3% of the elderly in rural areas will choose home elderly care.³⁵ In the process of home elderly care, many elderly people hope to obtain some health services, including regular physical examinations, regular health lectures, and the establishment of health records.³³ Therefore, it is understandable why the highest choice preference in the results is “Home IMSEC model.” In addition, factors that promote middle-aged and elderly people’s choice of home elderly care include lower income, poorer medical insurance, lower education, more children, and better physical condition.³³ These factors are very similar to those found in this paper.

The “Community IMSEC model” is the second-ranked choice preference model. Educational background and physical health are influencing factors. Compared with the highly educated population, the elderly with low education are more likely to receive services provided by the community.³⁶ This may be one of the reasons why people with low education are more inclined to choose the “community IMSEC model.” In addition, the elderly who choose community care for the elderly have an urgent need for medical services. They worry that the community cannot provide adequate medical services.^35,37 Due to the limited medical conditions in the community, most middle-aged and elderly people who are willing to stay in the community for the elderly are in good health. In contrast, middle-aged and elderly people with poor physical condition are more inclined to choose other IMSEC models. Related research also shows that the elderly living alone are more likely to choose community care for the elderly.³⁵ Since this study does not include the independent variable of living conditions, relevant discussions can not be carried out.

Our results show 21.76% of middle-aged and elderly people chose the “Institutional IMSEC model.” Since the research topic “Institution IMSEC” is relatively new, there is no similar literature for comparison. Therefore, some literature on “institutional elderly care” is used for reference. In 2018, only 3.8% of the elderly in Zhejiang Province, China, chose institutional elderly care. Further, older people with higher educational backgrounds and younger ages are more inclined to choose institutional elderly care.³⁸ These results are quite different from those in this paper. In recent years, the publicity of IMSEC policies has played a huge role, making the elderly begin to understand the IMSEC model and gradually change their thinking. Therefore, the proportion of choosing the “institutional IMSEC model” is greatly increased. There is no definitive conclusion on the association between age and institutional elderly care. Some scholars do not find an association between the 2.³⁹ The findings of some scholars are consistent with the findings of this paper, that is, older people are more likely to choose institutional elderly care.⁴⁰ The older the elderly, the more they need, and the more they need professional institutions to provide various services. This is consistent with the results of this paper. This paper proposes that the increase in the need for life care is an important reason why the elderly tend to choose the “institutional IMSEC model.”

Among the 4 major models, the number of people who choose the “Internet Plus IMSEC model” is the lowest. In China, smart medical elderly care services relying on Internet technology are still a new field. About 63.8% of the elderly have never heard of this service.⁴¹ According to the description results, middle-aged and elderly people with high education and young age are more inclined to choose the “Internet Plus IMSEC model.” Therefore, before the “Internet Plus IMSEC model” is put into operation, the government needs to increase the utilization rate of this service by middle-aged and elderly people through more publicity and more advanced age-appropriate development.

Among the choice preference descriptions of the 12 subtypes, the proportion of choosing “C1. Home elderly care and contracted with a family doctor” is the highest. In addition, people who choose C1 have higher social support, less loneliness, and lower various needs. Therefore, it can be assumed that social support is one of the important factors affecting the choice preference of middle-aged and elderly people on the IMSEC model. Unfortunately, no statistical association between social support and choice preference is found, which needs to be further confirmed.

It is worth mentioning that many studies have confirmed that income is an important factor affecting the choice of elderly care methods. For example, low-income groups are more inclined to home elderly care,³³ while high-income groups are more inclined to institutional elderly care.⁴² However, this paper does not find the effect of income on choice preference in the IMSEC model. Due to insufficient discrimination of income levels in the questionnaire, most of the respondents are in the high-income group. The relationship between income and choice preference in the IMSEC model deserves further exploration.

Although there have been a large number of studies on the choice preference of Chinese middle-aged and elderly people for the elderly care model, there are few studies on the choice preference of the IMSEC model. Moreover, the published IMSEC model studies mainly focus on 1 or 2 specific IMSEC models. However, our study focused on 4 IMSEC models (12 subtypes) simultaneously. Therefore, our topic is indeed one of the highlights of this paper. It has to be admitted that this study also has shortcomings. First, this study adopts a cross-sectional survey research design, with limited causal inference ability. Second, the IMSEC models covered in this paper are not comprehensive. The subtypes of the IMSEC model are all amalgamations of 2 measures. However, there may also be a combination of 3 or more measures in reality, such as “Home elderly care + Family doctor contract model + Long-term care insurance.” In addition, the choice of IMSEC mode is not fixed, but changes dynamically with physical and economic conditions. For the selection of the IMSEC model, dynamic observation can better find relevant influencing factors.

The findings of this study may help to optimize the allocation and supply of the current integrated medical services and elderly care (IMSEC) resources. In other words, we can optimize the configuration based on the different model needs of different populations, making it more suitable for the current integrated medical services and elderly care needs. For example, firstly, the “Home IMSEC model” is the most popular IMSEC model among middle-aged and elderly people, which should be taken as the focus of IMSEC policy promotion with more resource input. Secondly, very few people choose the “Internet Plus IMSEC model.” For this model, the government needs to invest in more publicity and more advanced aging-friendly design. The elderly with high life care needs, other marital status (single, widowed, and divorced), and strong loneliness are more inclined to choose the “Institutional IMSEC model.” Therefore, the government should focus on improving the life care and spiritual comfort capabilities of IMSEC institutions. Finally, the elderly in good physical condition are more willing to choose the “community IMSEC model,” which indirectly shows that the medical service capacity of the community is still insufficient. Improving the medical service capacity of the community is also an important policy task.

Conclusion

This paper explores the choice preference of Chinese middle-aged and elderly people on the IMSEC model and its related influencing factors. Among the 4 models, the choice preference of middle-aged and elderly people is “Home IMSEC model,” “Community IMSEC model,” “Institutional IMSEC model,” and “Internet Plus IMSEC model.” Among the 12 subtypes, “C1. Home elderly care and contracted with a family doctor” is the most selected. In addition, the elderly in rural areas are more inclined to choose the “Home IMSEC model.” The elderly with high life care needs are more inclined to choose the “Institutional IMSEC model.” In addition, age, education, and self-reported health status are also important influencing factors of choice preference. In conclusion, our findings may contribute to improving the allocation and enhancing the supply efficiency of integrated medical services and elderly care resources in China.

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Footnotes

Acknowledgements

We would like to thank all the investigators who helped us with the survey.

Author Contributions

SQ conceived the idea and design of this study and he also dealt with data analysis. Y.C, M.Z, and J.Z performed the survey and further improved the quality of manuscript writing. YD performed the survey and wrote the manuscript. All authors contributed to the article and approved the submitted version.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This study was funded by Soft Science Research Program of Zhejiang Province [grant number: 2022C35064], General Project of the Department of Education of Zhejiang Province [grant number: Y202249243], Basic Scientific Research Funds of Department of Education of Zhejiang Province [grant number: KYQN202206], and Hangzhou High Level Talent Special Support Project [grant number: 4265C50622026]. The financial sponsor played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Ethical Approval

This study was approved by the Ethics Committee of Hangzhou Medical College (Ethics code: LL2022-18).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Consent for Publication

The authors declare no conflict of interest.

ORCID iDs

Shangren Qin

Ye Ding

Supplemental Material

Supplemental material for this article is available online.

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