International Journal of Public Health Science (IJPHS)

Vol. 14, No. 2, June 2025, pp. 959~966

ISSN: 2252-8806, DOI: 10.11591/ijphs.v14i2.24703  959

Influence of community factors on formal care use among older

Chinese adults
Zihan Zhang, Chieko Kato
School of Information Sciences and Arts, Toyo University, Tokyo, Japan

Article Info ABSTRACT

Article history: Community plays a pivotal role in older adults' well-being and long-term
care issues. This study investigates how community factors, including
Received Mar 17, 2024 community support and social participation, with self-assessment of health
Revised Jul 30, 2024 as an intervening variable, influence the use of formal care. Further, how a
Accepted Nov 22, 2024 community contributes to older adults' well-being has also been discussed.
Data was collected from older adults (men 150, women 150, age>60 y/o)
and was analyzed by using structural equation modeling (SEM). This study
Keywords: used health as an intervening variable to investigate community factors'
influence on formal care use. The results find a significant negative
Formal care influence of social participation and self-assessment of health on the use of
Intervening variable formal care. While community support was not found to influence the use of
Long-term care formal care significantly, both community support and social participation
Older adults could negatively influence the use of formal care by positively influencing
SEM the self-assessment of health. Cohabitation has also been found to influence
community support significantly positively. In China, where formal care still
needs to be more developed, reducing over-reliance on formal care follows
Chinese cultural values and economic considerations. Moreover, older
people living alone need to be attended to by the community.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Zihan Zhang
School of Information Sciences and Arts, Toyo University
Tokyo, Japan
Email: [email protected]

1. INTRODUCTION
In line with the worldwide trend in population aging, the issue of long-term care for older adults has
become an important issue globally. It needs to be given high priority by governments, society, and families.
China has stepped into an aging society since 2000. The outstanding features of aging, including a large
proportion of the older population, rapid growth, dramatic expansion of the oldest-old, and uneven aging
distribution, have put China in a unique position [1], and dramatically increasing the need for long-term care
services in China [2].
As one of the primary forms of long-term care for older adults, formal care usually refers to paid
care services provided by a healthcare institution or staff for older adults in need. The rapid socio-economic
development and strict implementation of the revised family planning policy since 1980 have affected the
structure of families in China, with a weakening of traditional family support for older adults as a result [2].
Moreover, as society develops, more and more adult children leave their families for big cities with better
economic conditions [3]. Older Chinese adults, who have always had home care as the mainstream choice,
increasingly rely on formal care [4]. However, overreliance on formal care may also cause problems. For
instance, there are high economic costs [5], miscommunication, conflicts, risk of abuse [6], and lack of social
interaction [7], as formal care is relatively under-developed, and a comprehensive long-term care insurance

Journal homepage: http://ijphs.iaescore.com

960  ISSN: 2252-8806

system has not yet been established in China [8]. The issue of long-term care for older adults in China may
also reveal the necessity and urgency of long-term care for older adults around the world [9]. Addressing
these drawbacks requires a more holistic approach to elderly care that emphasizes community-based support
[10], promotes aging in place with adequate support services [11], and prioritizes the dignity and autonomy
of older adults [12]. This expresses both the motivation for this study to be pursued and the societal
implications and contributions that were expected.
Community factors have a significant impact on the health and well-being of older adults and may
promote a better life for them [13]. In this study, community factors included community support and social
participation. Community support refers mainly to local healthcare information and services, while social
participation refers mainly to community-based activities and social behaviors. The community provides an
essential social network for older adults, providing the necessary support and enhancing the interaction
between older adults and society. This alleviates isolation risk and enhances older adults' sense of belonging
to the community [14]. Interaction with others also promotes the maintenance and development of cognitive
abilities and slows the rate of cognitive decline [15]. Community support provides health knowledge,
education, and resources for older adults. For instance, some health promotion activities could help older
adults learn how to stay healthy, prevent diseases, and manage chronic conditions [16]. Safety measures in
the community can reduce the risk of crime and unintentional injuries in older adults [17]. In addition, good
neighborhoods can provide emergency assistance to older adults [18]. Further, the physical and mental health
and well-being of older adults also influence their use of and reliance on formal care [19].
This study investigated the influence of community support and social participation in the use of
formal care among older Chinese adults. It examined how these community factors influence the decision-
making process regarding formal care among older adults. Additionally, the study explored potential
interventions within communities aimed at reducing the dependence of older Chinese adults on formal care.
Recognizing the importance of promoting healthy aging environments, this research identified strategies that
communities could implement to alleviate the need for formal care among the elderly population. These
interventions aimed not only to alleviate the burden on formal care systems but also to enhance the health,
happiness, and overall well-being of older adults as they aged.
Previous studies have shown that community support is strongly associated with home care and
health among older adults [20]–[24], and social participation has been shown to be strongly associated with
health [25], [26]. Also, sufficient social support and social participation contribute to the physical and mental
health and quality of life of older adults [27]–[29]. In addition, studies indicate that social participation,
community support, and community belonging were positively associated [30]. Moreover, Zhang et al.
argues that older adults with better health status are less motivated to use formal care because they have no
urgent need for professional care services at the moment [31]. Furthermore, older adults living alone have
worse social participation and access to community support than those living with cohabitants [32]. Thus,
community support and social participation on the use of formal care are both hypothesized to significantly
influence the use of formal care through the intervening variable of self-assessment of health. Considering
that long-term care for older adults living alone has become an increasingly important issue in society, this
study used cohabitation as a control variable, and its effect on social factors was tested. The following
hypothesis was established in this study: i) Community support had a significant influence on the use of
formal care and social participation; ii) Social participation has a significant influence on the use of formal
care; iii) The self-assessment of health has a significant influence on the use of formal long-term care; iv)
Cohabitation has a significant influence on community support, and social participation.

2. METHOD
2.1. Sample and data collection
This study recruited 300 Chinese adults (150 males and 150 females) aged 60 years or older to
answer an online questionnaire in March 2022. In the current study, the sample was strictly restricted to
eliminate or minimize confounding variables. First, we considered that a physician's diagnosis of health may
influence the level of social engagement and use of long-term care. Therefore, all participants in this study
were not suffering from a medically diagnosed chronic condition. Second, to minimize the effect of large
differences in economic, medical, and long-term care systems between urban and rural areas in China,
especially in rural areas where formal care services may be inadequate, all participants in this study were
from urban areas in China. In addition, the experience of long-term care may also influence the motivation to
use care again. Therefore, all participants in this study were able to live independently without experience in
long-term care. This study was approved by the Research and Ethics Committee of the Graduate School of
Information Science and Arts at Toyo University (2022-01). The respondents were notified of the purpose

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and procedures of the study. They were also assured of their anonymity and confidentiality, protection of
personal information, data disposal, and the freedom to withdraw from the study at any time.
Researchers select samples representing the entire population, analyze the data from the selected
samples, and estimate the parameters of the entire population, making it very important to determine the
appropriate sample size to answer the research question. The G*power was used to calculate the sample size in
this study. Multiple linear regression analysis was selected for G*power due to its suitability for analyzing
different predictor variables as well as interaction effects. With the setting of effect size f2=0.15, a err
prob=0.05, power (1-ß err prob)=0.95, and number of predictors=4, a total sample size of 129 was calculated.
To obtain more precise and convincing results in addition to this criterion, 150 men and 150 women were used
as the final sample size for this study. As this survey was completed using an online questionnaire, the results
may be more representative of older Chinese people who have free access to the Internet. In addition, the age
groups were not evenly distributed because this study required a certain level of cognition and health.

2.2. Scale
Six items based on A, Inoue et al. were used to measure social participation [16], see
Table 1, it includes two sub-factors. [Community contributive activities], emphasize that older people have a
'role' in society, i.e., activities that contribute to other people, and the community. [Self-enlightenment
activities], emphasize activities in which older people make efforts to improve their purpose in life by doing
things that interest them. In the study, the number of factors and items, as well as the naming of the social
participation scale, were determined by exploratory factor analysis (EFA) and confirmatory factor analysis
(CFA). The fitness measures were GFI=0.992, AGFI=0.987, CFI=0.988, and RMSEA=0.026. The Cronbach
coefficient for the scale was 0.78, with 0.80 for factor 1 and 0.76 for factor 2, and reliability was determined.
Validity was determined by the positive correlations between the scale score and the external criteria.
Including the geriatric center morale scale (PGC) (attitude toward aging, mental fluctuation, and
loneliness/dissatisfaction, r=0.24, p<0.01), and frequency of going out of the home (r=0.20, p<0.01), and
frequency of attending regional activities (r=0.22, p<0.01). In addition, the participants were both older
people from East Asia. Therefore, this scale was considered appropriate in the current study.

Table 1. Items of social participation

Social participation The question and options
Factor1「Community contributive activities」 Have you ever engaged in any of the following activities in
1. Activities related to traffic safety and crime prevention. the past?
2. Activities related to community development or environmental 1= Never in the past;
beautification. 2= More than half a year ago;
3. Activities related to support for the older people. 3= Within the past six months.
Factor2「Self-enlightenment activities」
4. Physical activities such as gymnastics and sports.
5. Cultural activities such as hobby groups.
6. Get together with friends for dinner or drinks.

2.3. Statistical analysis

Data was analyzed using SPSS ver. 28.0. Factor analysis was conducted to confirm the reliability of
social participation. SEM was conducted to assess the variables' associations and test the hypothesized model.
Variables in the model included cohabitation, community support, social participation, self-assessment of
health, and use of formal care. Statistical significance was defined as *p<.05, **p<.01, ***p<.001.

3. RESULTS
3.1. Descriptive statistics
Table 2 shows the general characteristics of the respondents. There were equal numbers of male and
female respondents. The majority of respondents were aged between "60-75 years", "had cohabitants,"
felt that their health was "somewhat good," and felt that they were "sometimes" able to access community
support, see Table 2. Table 3 shows the descriptive statistics of social participation. The higher the mean
values, the higher the degree of the corresponding independent variables for the respondents, see Table 3.

3.2. Factor analysis

The absolute factor loadings of all items are larger than 0.4, which means the reliability was well
demonstrated. Results are displayed, where each domain is given factor loadings, communality values, and
alpha coefficients, see Table 4. Compared to the results of the reference, the composition of the questions for
the two sub-factors is consistent, but the items are not precisely in the same order. These differences may be
caused by differences in respondents' nationalities, living environments, and cultural habits.
Influence of community factors on formal care use among older Chinese adults (Zihan Zhang)
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Table 2. Characteristics of Chinese respondents (n=300)

Characteristics Categories n (%) SE
Gender Male 150 (50) 0.082
Female 150 (50)
Age 60~64 y/o 132 (44) 0.647
65~69 y/o 147 (49)
70~74 y/o 19 (6.3)
75~79 y/o 1 (0.3)
80~84 y/o 1 (0.3)
Cohabitants Yes 292 (97.3) 0.009
No 8 (2.7)
Self-assessment of health status Bad 3 (1) 0.819
Somewhat bad 16 (5.3)
Average 10 (3.3)
Somewhat good 159 (53)
Good 112 (37.3)
Support from the community Never 8 (2.7) 0.719
Seldom 26 (8.7)
Sometimes 152(50.7)
Often 114 (38)

Table 3. Descriptive statistics of assessment variables (n=268)

Variables Min. Max. Mean SD SE
Social participation 6 18 10 2.617 0.151

Table 4. Factor analysis of social participants (maximum likehood method and Promax rotation)
Item/activity description Factor loadings
Factor1 Factor2 Communality
「Community contributive activities」(L) (α＝0.75, Cumulative contribution ratio=35.52%)
2 Activities related to community development or environmental beautification.(O) 0.746 0.007 0.732
1 Activities related to traffic safety and crime prevention.(O) 0.604 0.036 0.521
3 Activities related to support for the older people.(O) 0.522 -0.053 0.499
「Self-enlightenment activities」(L) (α＝0.72, Cumulative contribution ratio=45.82%)
6 Get together with friends for dinner or drinks.(O) 0.135 0.827 0.312
4 Physical activities such as gymnastics and sports.(O) 0.116 0.494 0.561
5 Cultural activities such as hobby groups.(O) 0.282 0.418 0.594
Factor correlation
Factor1「Community contributive activities」 0.481
Factor2「Self-enlightenment activities」 0.481
Social participation (α＝0.79)

3.3. Test of hypothesized model and parameter estimate

SEM was used to assess the associations among variables in the hypothesized model. The model fits
the data well (GFI=0.995, AGFI=0.928, CFI=0.985, TLI=0.849, SRMR=0.074, and RMSEA=0.068).
Community support has a significant positive influence on social participation (β=8.55, p<.001). Social
participation significantly negatively influences the use of formal care (β=-2.22, p=.027). In addition, self-
assessment of health as an intervening variable significantly negatively influences the use of formal care (β=-
2.75, p=.006). Moreover, self-assessment of health is also positively influenced by health is shown to be an
intervening variable between community factors and the use of formal care. Furthermore, cohabitation
significantly positively influences community support (β=2.99, p=.003) and self-assessment of health (β=2.36,
p=0.018), respectively. However, community support was not found to influence the use of formal care
significantly. Cohabitation was not found to significantly influence social participation, either, see Figure 1.

Figure 1. Tested model of this study

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4. DISCUSSION
This study has illuminated the intricate interplay between community factors and their potential to
attenuate reliance on formal care services among older Chinese adults. Through a nuanced examination of
these dynamics, it becomes evident that community-level support mechanisms have a substantial direct and
indirect influence on the utilization of formal care mediated by the self-assessment of health among elderly
individuals. Notably, a key finding underscores the symbiotic relationship between community support and
social participation, wherein older adults receiving greater community support are more likely to engage in
social activities, thereby fostering a sense of belonging and well-being. Moreover, the presence of
cohabitants emerges as a significant determinant, as individuals residing with family members tend to
benefit from enhanced community support networks and exhibit superior self-assessed health status
compared to those living alone. This indirect pathway underscores the pivotal role of familial cohabitation
in facilitating access to community support services and promoting better health outcomes among older
adults, thereby mitigating the need for formal care interventions.
It was observed that older adults who actively engage in social participation tend to exhibit a
decreased reliance on formal care services and report better self-assessed health statuses. This correlation
underscores the importance of social connections in older adults’ lives. When an adult maintains a high
level of social participation, it signifies a robust connection with the local community [33]. Instead, older
people are more likely to choose autonomous living within their community facilitated by support networks
forged through social engagement. These networks not only provide companionship but also offer practical
assistance and emotional support, thereby fostering a sense of belonging and security. Moreover, active
involvement in social activities offers opportunities for older adults to cultivate meaningful relationships
and partake in fulfilling endeavors, contributing to a sense of purpose and overall life satisfaction [34].
These positive social interactions not only enhance the quality of life of older adults but also play a pivotal
role in maintaining their physical and emotional well-being, ultimately promoting healthy aging.
In addition, the correlation between higher levels of community support and increased social
participation coupled with improved self-assessment of health is particularly noteworthy among older
Chinese adults. The provision of robust community support services plays a pivotal role in facilitating
active engagement and fostering a sense of well-being among older adults [35]. By receiving ample support
from their communities, older adults are empowered to participate more fully in social activities, leading to
heightened life satisfaction and enhanced physical and mental health outcomes [36]. With familial
caregiving resources often stretched thin, older adults increasingly rely on community-based services to
address their healthcare needs and sustain their ability to live independently in their communities. Access to
essential healthcare services through community support mechanisms is therefore indispensable for older
adults seeking to maintain their autonomy and receive the care necessary to effectively manage their health
conditions. As such, fostering robust community support networks has emerged as a critical imperative in
ensuring the continued well-being and quality of life of China's aging population.
Moreover, the findings of this study underscore the pivotal role of better self-assessment of health
in mitigating the utilization of formal care services among older adults. Enhanced health status correlates
strongly with increased levels of independence, diminished reliance on formal care provisions, mitigated
risk of emergency medical incidents, and more effective management of chronic conditions [37]. Serving as
a mediating variable in this investigation, it was revealed that sufficient community support and heightened
social engagement positively influence the health outcomes of older adults. This revelation underscores the
primary objective of the study, emphasizing the vital role that communities play in nurturing the well-being
of their residents. By fostering supportive environments and facilitating opportunities for social
interactions, communities serve as catalysts for bolstering the physical and mental health of older adults,
thereby reducing their dependency on formal care services.
Furthermore, the study's findings highlight a significant association between the presence of more
cohabitants among older Chinese adults and enhanced levels of community support, along with better
overall health outcomes, thereby contributing to reduced reliance on formal care services. It is evident that
older adults living alone are more susceptible to inadequate social support, as highlighted by previous
research [38]. This demographic also tends to contend with a higher prevalence of chronic illnesses and
feelings of loneliness and depression compared to their counterparts who reside with family members [39].
The presence of cohabitants, often family members, confers several advantages that contribute to observed
outcomes. First, the presence of cohabitants expands older adults' access to informal community networks,
thereby fostering a sense of belonging and facilitating their participation in social activities. Second, in
instances where an older individual requires assistance because of health concerns, cohabitants are often
readily available to provide care and support, thus naturally mitigating the need for and utilization of formal
care services. In essence, the presence of cohabitants serves as a protective factor, bolstering the overall
well-being of older adults and enabling them to maintain their independence and quality of life within their
communities while reducing strain on formal care resources.
Influence of community factors on formal care use among older Chinese adults (Zihan Zhang)
964  ISSN: 2252-8806

Hence, it becomes apparent that community-level factors play a crucial role in mitigating the
utilization of formal long-term care services by exerting a positive influence on the intervening factor of
self-assessment of health [40]. Without robust community-based initiatives to support the health and well-
being of older adults, the burden on formal care services is bound to escalate, which is further compounded
by the urban-rural disparities. By strengthening community-level resources and promoting active engagement
among older residents, it becomes possible to empower individuals to take charge of their health and well-
being, thereby reducing strain on formal care services and fostering more sustainable models of elderly
care. Ultimately, prioritizing the development of community-based support systems represents a crucial
step towards ensuring the long-term health and vitality of aging populations in China and beyond.

5. CONCLUSION
The objective of this study was to investigate the influence of community factors on the utilization
of formal care services among older Chinese adults, and to elucidate the role of self-assessment of health as
an intervening factor in this relationship. Moreover, it aims to shed light on the unique characteristics and
potential risks faced by older individuals living alone in the Chinese context. In China, where the
development of formal care infrastructure lags behind, the imperative to reduce dependence on formal care
services aligns with deeply ingrained cultural values and economic considerations, while simultaneously
fostering community cohesion and facilitating personalized care. For instance, maintaining older adults
within familiar environments not only serves to assuage feelings of loneliness and insecurity, but also fosters
a heightened sense of belonging to the community. Moreover, reducing reliance on formal care services
preserves the autonomy of older adults, allowing them to maintain independence, and receive care tailored to
their unique backgrounds and needs. This personalized approach to care not only enhances the well-being of
older adults, but also reinforces their sense of agency and dignity. This study underscores the importance of
community-level factors in shaping the landscape of elder care in China and offers valuable insights into the
mechanisms through which community support and social participation can attenuate reliance on formal care
services among older adults.
This study presents a distinctive contribution to the field of elder care research in China by focusing
on the intricate relationship between community factors, self-assessment of health, and use of formal care
services among older adults. Additionally, this study's emphasis on the unique characteristics and risks faced
by older individuals living alone adds depth to the analysis, highlighting the need for targeted interventions
that address their specific needs and vulnerabilities. Furthermore, this study's exploration of how reducing
reliance on formal care services can preserve the autonomy and dignity of older adults underscores its
practical relevance in shaping policy and intervention strategies. Overall, this research not only expands our
theoretical understanding of elder care dynamics, but also offers practical insights that can inform the
development of more effective and culturally sensitive approaches to supporting older adults in China. While
this study provides valuable insights into the relationship between community factors and the use of formal
care among older Chinese adults, it is still important to recognize its limitations. One notable limitation is the
grouping of certain personal factors among respondents, which could have been made more discernible. This
lack of clarity may have influenced the study’s outcomes. Additionally, the prevalence of certain
characteristics among respondents, such as cohabitation, access to community support, and perceived good
health, might have inadvertently biased the results. In the future, concerted efforts should be made to address
and rectify these methodological shortcomings. This would contribute to a better understanding of the
interplay between community factors and the use of formal care, ultimately leading to more effective
interventions and support systems for older adults.

REFERENCES
[1] Y. Han, Y. He, J. Lyu, C. Yu, M. Bian, and L. Lee, “Aging in China: perspectives on public health,” Global Health Journal, vol. 4,
no. 1, pp. 11–17, Mar. 2020, doi: 10.1016/j.glohj.2020.01.002.
[2] Z. Feng et al., “Long-term care system for older adults in China: policy landscape, challenges, and future prospects,” The Lancet,
vol. 396, no. 10259, pp. 1362–1372, Oct. 2020, doi: 10.1016/S0140-6736(20)32136-X.
[3] S. Chen and C. Wang, “Impacts of the population ageing on the effects of the nationwide emission trading scheme in China,”
Science of The Total Environment, vol. 887, p. 164127, Aug. 2023, doi: 10.1016/j.scitotenv.2023.164127.
[4] S. Liu, Y. Wang, D. Zhou, and Y. Kang, “Two-step floating catchment area model-based evaluation of community care facilities’
spatial accessibility in Xi’an, China,” International Journal Environmental Research Public Health, vol. 17, no. 14, p. 5086, Jul.
2020, doi: 10.3390/ijerph17145086.
[5] E. Palm, “Who cares? moral obligations in formal and informal care provision in the light of ICT-based home care,” Health Care
Analysis, vol. 21, no. 2, pp. 171–188, Jun. 2013, doi: 10.1007/s10728-011-0199-3.
[6] O. Bífárìn et al., “Stressors and coping mechanisms of family care-givers of older relatives living with long-term conditions in
mainland China: a scoping review of the evidence,” Ageing Society, vol. 43, no. 4, pp. 952–989, Apr. 2023, doi:
10.1017/S0144686X21000817.

Int J Public Health Sci, Vol. 14, No. 2, June 2025: 959-966
Int J Public Health Sci ISSN: 2252-8806  965

[7] A. A. Scoglio, E. D. Reilly, J. A. Gorman, and C. E. Drebing, “Use of social robots in mental health and well-being research:
systematic review,” Journal Medical Internet Research, vol. 21, no. 7, p. e13322, Jul. 2019, doi: 10.2196/13322.
[8] K. B. Brewer et al., “Formal versus informal pathways to mental health care in China,” China Journal of Social Work, vol. 17,
no. 1, pp. 3–20, Jan. 2024, doi: 10.1080/17525098.2023.2252913.
[9] E. F. Fang et al., “A research agenda for ageing in China in the 21st century (2nd edition): Focusing on basic and translational
research, long-term care, policy and social networks,” Ageing Research Reviews, vol. 64, p. 101174, Dec. 2020, doi:
10.1016/j.arr.2020.101174.
[10] N. A. Spassiani, B. A. Meisner, M. S. Abou Chacra, T. Heller, and J. Hammel, “What is and isn’t working: Factors involved in
sustaining community‐based health and participation initiatives for people ageing with intellectual and developmental disabilities,”
Journal of Applied Research in Intellectual Disabilities, vol. 32, no. 6, pp. 1465–1477, Nov. 2019, doi: 10.1111/jar.12640.
[11] B. S. Fogel, “Psychological aspects of staying at home,” in Aging in Place, Routledge, 2019, pp. 19–28. doi:
10.4324/9781315227603-3.
[12] K. M. Gebremariam and R. Sadana, “On the ethics of healthy ageing: setting impermissible trade-offs relating to the health and
well-being of older adults on the path to universal health coverage,” International Journal Equity Health, vol. 18, p. 140, Dec.
2019, doi: 10.1186/s12939-019-0997-z.
[13] N. P. Gothe, D. K. Ehlers, E. A. Salerno, J. Fanning, A. F. Kramer, and E. McAuley, “Physical activity, sleep and quality of life in
older adults: influence of physical, mental and social well-being,” Behavioral Sleep Medicine, vol. 18, no. 6, pp. 797–808, Nov.
2020, doi: 10.1080/15402002.2019.1690493.
[14] J. Li and Y. Song, “Formal and informal care,” in Encyclopedia of Gerontology and Population Aging, Cham: Springer
International Publishing, 2019, pp. 1–8. doi: 10.1007/978-3-319-69892-2_847-1.
[15] W. LIN, “The relationship between formal and informal care among Chinese older adults: based on the 2014 CLHLS dataset,”
BMC Health Serv Res, vol. 19, p. 323, Dec. 2019, doi: 10.1186/s12913-019-4160-8.
[16] A. Inoue, E. Tadaka, K. Shiratani, A. Arimoto, E. Itoh, and A. Okochi, “Development of a scale of social activities among
community-dwelling elderly people,” Journal of Japan Academy of Community Health Nursing, vol. 19, no. 2, pp. 4–11, 2016, doi:
10.20746/jachn.19.2_4.
[17] B. Kennedy et al., “Epidemiology of homicide in community-dwelling older adults: a systematic review and meta-analysis,”
Trauma Violence Abuse, vol. 24, no. 2, pp. 390–406, Apr. 2023, doi: 10.1177/15248380211030250.
[18] D. R. Y. Gan, J. C. Fung, and I. S. Cho, “Neighborhood atmosphere modifies the eudaimonic impact of cohesion and friendship
among older adults: A multilevel mixed-methods study,” Social Science Medicine, vol. 270, p. 113682, Feb. 2021, doi:
10.1016/j.socscimed.2021.113682.
[19] Y. Lee, R. Barken, and E. Gonzales, “Utilization of formal and informal home care: how do older canadians’ experiences vary by
care arrangements?,” Journal of Applied Gerontology, vol. 39, no. 2, pp. 129–140, Feb. 2020, doi: 10.1177/0733464817750274.
[20] S. Artiga and E. Hinton, “Beyond health care: the role of social determinants in promoting health and health equity,” California,
2018. Accessed: November 13, 2023. [Online]. Available: https://files.kff.org/attachment/issue-brief-beyond-health-care.
[21] I. Ayano, T. Etsuko, S. Kae, A. Azusa, I. Eriko, and O. Ayako, “Development of a scale of social activities among community-
dwelling elderly people,” Journal of Japan Academy of Community Health Nursing, vol. 19, no. 2, pp. 4–11, 2016.
[22] E. Alnazly, O. M. Khraisat, A. M. Al-Bashaireh, and C. L. Bryant, “Anxiety, depression, stress, fear and social support during
COVID-19 pandemic among Jordanian healthcare workers,” PLoS One, vol. 16, no. 3, p. e0247679, Mar. 2021, doi:
10.1371/journal.pone.0247679.
[23] M. Qi et al., “The effect of social support on mental health in chinese adolescents during the outbreak of COVID-19,” Journal of
Adolescent Health, vol. 67, no. 4, pp. 514–518, Oct. 2020, doi: 10.1016/j.jadohealth.2020.07.001.
[24] I. Hombrados-Mendieta, M. Millán-Franco, L. Gómez-Jacinto, F. Gonzalez-Castro, M. J. Martos-Méndez, and A. García-Cid,
“Positive influences of social support on sense of community, life satisfaction and the health of immigrants in Spain,” Front
Psychol, vol. 10, Nov. 2019, doi: 10.3389/fpsyg.2019.02555.
[25] A. Wanchai and D. Phrompayak, “Social participation types and benefits on health outcomes for elder people: a systematic
review,” Ageing Int, vol. 44, no. 3, pp. 223–233, Sep. 2019, doi: 10.1007/s12126-018-9338-6.
[26] M. D. Aroogh and F. M. Shahboulaghi, “Social participation of older adults: a concept analysis,” International Journal of
Community Based Nursing and Midwifery, vol. 8, no. 1, pp. 55–72, Jan. 2020, doi: 10.30476/IJCBNM.2019.82222.1055.
[27] E. Choi et al., “Social participation and depressive symptoms in community-dwelling older adults: emotional social support as a
mediator,” Journal of Psychiatric Research, vol. 137, pp. 589–596, May 2021, doi: 10.1016/j.jpsychires.2020.10.043.
[28] D. S. Şahin, Ö. Özer, and M. Z. Yanardağ, “Perceived social support, quality of life and satisfaction with life in elderly people,”
Educational Gerontology, vol. 45, no. 1, pp. 69–77, Jan. 2019, doi: 10.1080/03601277.2019.1585065.
[29] L. da S. S. C. B. de Oliveira, E. C. Souza, R. A. S. Rodrigues, C. A. Fett, and A. B. Piva, “The effects of physical activity on
anxiety, depression, and quality of life in elderly people living in the community,” Trends in Psychiatry and Psychotherapy,
vol. 41, no. 1, pp. 36–42, Mar. 2019, doi: 10.1590/2237-6089-2017-0129.
[30] H. Tong, D. W. L. Lai, and C. A. Walsh, “Formal social participation and utilization of community-based services among urban
elderly chinese living alone in Shanghai, China,” Journal of Social Service Research, vol. 45, no. 4, pp. 520–529, Aug. 2019, doi:
10.1080/01488376.2018.1481172.
[31] Z. Zhang, C. Kato, and O. Yoshiomi, “Factors influencing the preferences of older japanese people for long-term care,” Home
Health Care Management & Practice, vol. 35, no. 4, pp. 253–261, Nov. 2023, doi: 10.1177/10848223231166114.
[32] A. F. Bolina, M. da C. Araújo, V. J. Haas, and D. M. dos S. Tavares, “Association between living arrangement and quality of life
for older adults in the community,” Revista Latino-Americana de Enfermagem, vol. 29, p. e3401, 2021, doi: 10.1590/1518-
8345.4051.3401.
[33] C. Marston, A. Renedo, and S. Miles, “Community participation is crucial in a pandemic,” The Lancet, vol. 395, no. 10238,
pp. 1676–1678, May 2020, doi: 10.1016/S0140-6736(20)31054-0.
[34] S. Kim, K. Choe, and K. Lee, “Depression, loneliness, social support, activities of daily living, and life satisfaction in older adults
at high-risk of dementia,” International Journal of Environmental Research and Public Health, vol. 17, no. 24, p. 9448, Dec. 2020,
doi: 10.3390/ijerph17249448.
[35] B. Macdonald and G. Hülür, “Well-being and loneliness in swiss older adults during the COVID-19 pandemic: the role of social
relationships,” Gerontologist, vol. 61, no. 2, pp. 240–250, Feb. 2021, doi: 10.1093/geront/gnaa194.
[36] H.-Y. An, W. Chen, C.-W. Wang, H.-F. Yang, W.-T. Huang, and S.-Y. Fan, “The relationships between physical activity and life
satisfaction and happiness among young, middle-aged, and older adults,” International Journal of Environmental Research and
Public Health, vol. 17, no. 13, p. 4817, Jul. 2020, doi: 10.3390/ijerph17134817.

Influence of community factors on formal care use among older Chinese adults (Zihan Zhang)
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[37] M. Sun et al., “Transition of care from hospital to home for older people with chronic diseases: a qualitative study of older
patients’ and health care providers’ perspectives,” Frontiers in Public Health, vol. 11, Apr. 2023, doi:
10.3389/fpubh.2023.1128885.
[38] R. Sakurai et al., “Poor social network, not living alone, is associated with incidence of adverse health outcomes in older adults,”
Journal of the American Medical Directors Association, vol. 20, no. 11, pp. 1438–1443, Nov. 2019, doi:
10.1016/j.jamda.2019.02.021.
[39] L. Gu, M. Yu, D. Xu, Q. Wang, and W. Wang, “Depression in community-dwelling older adults living alone in China: Association
of social support network and functional ability,” Research in Gerontological Nursing, vol. 13, no. 2, pp. 82–90, Mar. 2020, doi:
10.3928/19404921-20190930-03.
[40] National Academies of Sciences, Engineering, and Medicine, Social Isolation and Loneliness in Older Adults. Washington, D.C.:
National Academies Press, 2020. doi: 10.17226/25663.

BIOGRAPHIES OF AUTHORS

Zihan Zhang research topic focuses on long-term care for older adults in East
Asia. In particular, he analyzes and investigates the long-term care preferences of older
people in Japan and China, the factors that may significantly influence such preferences, and
the policies related to long-term care issues using different statistical methods. He can be
contacted at email: [email protected].

Chieko Kato qualifications include certified public psychologist, clinical

psychologist, art therapist, yoga therapist, and certified social researcher. She has been
involved in research related to the combined fields of psychology and information science,
aiming to create knowledge that can be used for psychological support, such as mental health
care for students and adults, and mental training for athletes. She can be contacted at email:
[email protected].

Int J Public Health Sci, Vol. 14, No. 2, June 2025: 959-966