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Module 3 | Part 3: 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 disease
s
Shuyan Gu1 · Cangcang Jia2 · Fangfang Shen3 · Xiaoyong Wang4 · Xiaoling Wang5 · Hai Gu
1
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
gushuyan@nju.edu.cn
* Hai Gu
ghai1008@vip.sina.com
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
http://orcid.org/0000-0002-2362-1251
http://crossmark.crossref.org/dialog/?doi=10.1007/s11136-023-03555-2&domain=pdf
692 Quality of Life Research (2024) 33:691–703
1 3
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.
693Quality of Life Research (2024) 33:691–703
1 3
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 variabl
e
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
694 Quality of Life Research (2024) 33:691–703
1 3
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
695Quality of Life Research (2024) 33:691–703
1 3
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 0.08
9
No 4577 82.16 1617 83.35 2960 81.52
Yes 994 17.84 323 16.65 671 18.4
8
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 60.9
7
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
696 Quality of Life Research (2024) 33:691–703
1 3
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
HH
C
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
697Quality of Life Research (2024) 33:691–703
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nx
ie
ty
sc
or
ec
C
oe
f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
oe
f [
95
%
C
I]
p
C
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f [
95
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C
I]
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f [
95
%
C
I]
p
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f [
95
%
C
I]
p
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f [
95
%
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I]
p
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f [
95
%
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I]
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ni
ty
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0.
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0.
00
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0.
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0.
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−
0.
49
0,
−
0.
03
7]
0.
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−
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37
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0.
08
8]
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0.
01
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−
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0.
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-0
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−
0.
09
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0.
00
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G
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de
r
(r
ef
:
fe
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01
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−
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−
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4]
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−
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−
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−
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0.
01
6]
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44
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−
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0.
03
1]
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08
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-0
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34
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−
0.
17
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0.
00
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ge
g
ro
up
d
(r
ef
:
yo
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g-
ol
d)
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ld
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t-
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0.
16
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0.
10
3,
0.
21
9]
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−
0.
07
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−
0.
02
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−
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26
8]
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0.
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60
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−
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79
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0.
41
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-0
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−
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82
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0.
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1
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56
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−
0.
76
6,
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0.
36
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0.
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on
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rth
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ef
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ru
ra
l)
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rb
an
0.
07
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0.
01
0,
0.
14
4]
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02
5
−
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00
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−
0.
03
5,
0.
02
3]
0.
68
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46
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−
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78
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13
5]
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−
0.
47
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−
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03
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0.
10
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−
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02
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−
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07
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−
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49
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−
0.
05
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re
f:
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−
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0.
10
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−
0.
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0.
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6]
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12
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09
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−
0.
20
4,
0
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87
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0.
54
4
0.
10
3[
−
0.
08
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0.
28
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27
5
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14
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−
0.
20
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0.
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04
7]
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15
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−
0.
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0.
38
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60
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−
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35
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11
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f:
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05
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−
0.
02
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0.
03
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73
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36
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−
0.
65
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06
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−
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39
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−
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5,
0.
05
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−
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0.
03
4]
0.
66
7
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0.
41
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−
0.
71
7,
−
0.
11
9]
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6
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−
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10
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−
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2
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−
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56
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58
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−
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−
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59
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01
3
A
nn
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us
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ho
ld
in
co
m
e
(r
ef
:
lo
w
)
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ig
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0.
07
3[
0.
02
0,
0.
12
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−
0.
60
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26
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0.
02
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−
0.
06
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4]
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00
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−
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94
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42
5]
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39
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−
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56
3,
−
0.
22
3]
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0.
00
1
698 Quality 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
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En
tro
py
b
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ng
m
et
ho
d
SR
H
a
Ph
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d
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co
m
fo
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D
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n
sc
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nx
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ty
sc
or
ec
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H
a
Ph
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d
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co
m
fo
rt
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ss
io
n
sc
or
eb
A
nx
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ty
sc
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ec
C
oe
f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
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f [
95
%
C
I]
p
C
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f [
95
%
C
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p
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cu
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ef
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13
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699Quality of Life Research (2024) 33:691–703
1 3
Ta
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a SR
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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
701Quality of Life Research (2024) 33:691–703
1 3
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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Abstract
Purpose
Methods
Results
Conclusion
Plain English summary
Introduction
Methods
Data and sampling
Variables
Dependent variables
Independent variable
Control variables
Statistical analysis
Results
Characteristics of the respondents
Effects of community-based home health care on health and its heterogeneity
Robustness test
Discussion
Conclusion
Acknowledgements
References
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