Urban Community Elderly Care Facility: Comparison
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如何应对人口老龄化已成为全世界关注的重要问题。随着经济和技术的发展，人类不再满足于预期寿命的增长，而是追求高质量的生活(QOL)。研究表明，老年人在集中的护理设施遭受抑郁症，高死亡率，低生活质量。建议就地老龄化是为了帮助老年人更好地老龄化。它是指在社区外部环境的支持下，延长居住时间，满足老年人对熟悉环境中老龄化的偏好。社区养老设施作为确保老龄化的重要环节，从设施功能设置与服务供给、设施空间分布与可达性、设施服务与财务安全等方面进行了研究。然而，关于 CECF 的影响因素以及每个因素如何影响和提高老年人生活质量的研究较少。译注:

How to deal with the aging population has become an essential issue for the whole world. With the development of the economy and technology, human beings are no longer satisfied with the increase in life expectancy; they are instead pursuing a high quality of life (QOL). Studies have shown that the elderly in centralized nursing facilities suffer from depression, high mortality rates, and low QOL. “Aging in place” is proposed to help the elderly age better. It refers to extending residence time and satisfying the preference of the elderly to age in a familiar environment, supported by the external environment of the community. As an essential link to ensure aging in place, community elderly care facilities (CECFs) have been studied in terms of facility functional setting and service supply, facility spatial distribution and accessibility, and facility service and financial security.

  • community elderly care facility (CECF)
  • quality of life (QOL)
  • structural equation model (SEM)
  • Shenzhen

1. Quality of Life (QOL)

1.1. Concept and Theory of QOL

The concept of QOL originates from economics and is defined as an indicator of people’s state of life and welfare [20][1]. It is the degree of superiority or inferiority of the population’s living conditions at a particular stage of economic development. It is the combined level of all social and natural conditions that satisfy people’s needs. Economists consider QOL as an objective concept describing the development of human society, while social psychologists believe it is a mixture of feelings of satisfaction of multiple needs. Combining subjective and objective perspectives, the World Health Organization (WHO) defines it as the experience of individuals with different cultures and values [21][2]. This definition reflects the development of material conditions in society. It emphasizes the subjective nature of QOL, which involves physical health, psychological behavior, social relationships, and the environment in which one lives, covering all aspects that affect QOL [22][3]. In addition, scholars believe that the QOL of the elderly is influenced by health status [23][4] and measured by life satisfaction, happiness, and social belonging [24,25,26][5][6][7]. In contrast, developing countries prefer measuring and defining it using objective indicators, such as material living standards, economic conditions, and medical and public services [27,28][8][9]. It is considered to be the sum of the objective state of the elderly in terms of material life, spiritual life, health status, and living environment, as well as self-perception.
On the basis of previous research, scholars have attempted to develop the theory of QOL. At first, using response transfer theory, Sprangers and Schwartz [29][10] constructed a model to reveal the influence of changes in physiological health status on the QOL of the elderly and to predict the changes in QOL. The meaning of health has subsequently expanded to include not only an absence of illness and pain, but also mental wellbeing and good social status. Scholars have realized the importance of mental and social health for the elderly and have refined the QOL theoretical model of the elderly using Maslow’s needs theory. Asadi-Lari, Hyde, and Wiggins et al. [30,31][11][12] adopted the need satisfaction model to discuss how physical health, psychological health, mobility, and social relationships affect the QOL of the elderly. Currently, the QOL model proposed by the World Health Organization (WHOQOL Model) in 2008 is the most widely used. This model draws on social ecology theory to decompose the factors and action mechanisms that influence QOL [21][2]. In addition to physical factors, other factors are examined in this model, such as psychological factors, the level of independence, social relationships, the environment, and spirituality factors. Therefore, it is applicable to QOL studies, because it not only concerns the individual dimension, but multiple dimensions, such as communities, cities, and society [32,33][13][14].

1.2. Influencing Factors of QOL

The WHOQOL Model highlights six factors affecting QOL: physiology, psychology, social relationships, level of independence, environment, and spirituality [21][2]. According to this model, the mechanisms and pathways of action of each factor affecting QOL and the interactions among the factors have been discussed extensively. Zikmund [34][15] found that, in addition to directly influencing QOL, psychological factors indirectly affect overall QOL through physical factors, social relationships, and the environment. Kiritz and Moos [35][16] argued that the environment is vital and affects physical QOL (Phys-QOL), psychological QOL (Psyc-QOL), and overall QOL. They also concluded that environmental factors have a high degree of influence on QOL. Fagerstrm et al. [36][17] confirmed these factors’ direct and potential role in the degree of independence and in physiological, psychological, and social relationships.
Many influencing factors are involved in the WHOQOL Model, and scholars in various fields have presented different research perspectives. In medicine and public health, scholars have considered physical factors, psychological factors, social relationships, and spirituality in overall health and discussed their role in influencing QOL. Jalenques et al. [37][18] concluded that health, age, relationship, and material and economic factors negatively influence the QOL of the elderly. Man et al. [38][19] used Anderson’s model to demonstrate that the health-related QOL (HRQOL) of the elderly is related to personal and social environmental factors, and that there is an interactive relationship among the factors. Studies have proven that the factors of age, literacy, income, and living ability significantly impact HRQOL in the elderly. In terms of geography and environmental behavior, scholars have interpreted the “degree of independence” as the purpose and ability of behaviors, and have also discussed the impact of aging behaviors on QOL. Using a regression analysis, Wang [39][20] confirmed that the behavioral purpose of the elderly directly affects the Phys-QOL, Psyc-QOL, and the social support of the elderly, subsequently having an impact on the overall QOL. Goulia and Ravulaparthy et al. [40][21] confirmed that the intensity of the elderly’s behavior directly affects their life satisfaction and QOL, and that QOL is usually higher for the elderly who travel long hours and distances, have a fixed routine of behavior, and have a regular travel period. Scholars have generally agreed that the physical and social environments influence the QOL of the elderly. Veerle et al. [41][22] proposed that promoting and improving the physical environment for neighborhood physical activity, community safety management, community relationship networks, and cohesiveness can effectively enhance the QOL of the elderly. The social environment, such as economic level, leisure activity opportunities, and social relationships, has a more significant effect on the QOL of the elderly. Mahapatra [42][23] put forward differences in the demand for community livability among the elderly of different economic levels and argued that the planning of the community environment and facilities should consider the affordability and adaptability of the elderly to effectively enhance the QOL. Santos and Silva et al. [43][24] considered that the role and mechanism of action of economic level and leisure activity opportunities influence the QOL of the elderly. In addition, good social relationships, such as those among spouses, children, relatives, and friends, significantly impact the QOL of the elderly.

1.3. Measurement Methods of QOL

There are two types of commonly used methods to measure QOL. Firstly, the multiscale combination measure evaluates QOL in terms of physical, psychological, life satisfaction, and environmental aspects. Typical scales include the Satisfaction with Illness Scale, the Life Satisfaction Scale, the Depression Self-Rating Scale, and the Social Support Scale [44,45,46,47][25][26][27][28]. Multiscale measures are mostly used in QOL and correlation studies on the influential factors. On the basis of the results of various scales, studies have explored the interactions among the factors through quantitative statistical methods. Secondly, the integrated measurement methods, including the SF-36 scale, WHOQOL-100 scale, and WHOQOL-BREF scale, cover all areas of QOL and can evaluate the overall QOL of residents. The WHOQOL-100 scale is universal and comprehensive, and it can be used in many applications after multiple empirical tests. The WHOQOL-100 scale includes six dimensions, 23 indicators, and 100 questions. The WHOQOL-BREF scale [48][29] is a streamlined version of the WHOQOL-100, using statistical methods to redivide the 23 indicators into four dimensions and refine 25 main questions from the original 100 questions (Table 1). The WHOQOL-BREF retains the key measurement capabilities of the WHOQOL-100 scale and reduces the difficulty of measurement; therefore, it is widely used.
Table 1. List of indicators of the WHOQOL-BREF Scale (Reprinted from [48]).
List of indicators of the WHOQOL-BREF Scale (Reprinted from [29]).
Goal Dimension Indicators
QOL Physical Pain and discomfort
Energy and fatigue
Sleep and rest
Mobility
Activities of daily living
Dependence on medication or treatments
Work capacity
Psychological Positive feelings
Thinking, learning, memory, and concentration
Self-esteem
Bodily image and appearance
Negative feelings
Spirituality
Social

relationships		 Personal relationships
Social support
Sexual activity
Environment Physical safety and security
Home environment
Financial resources
Health and social care: accessibility and quality
Participation in and opportunities for recreation leisure activities
Opportunities for acquiring new information and skills
Physical environment
Transport

2. Community Elderly Care Facilities (CECFs)

2.1. Functional Setting

Most previous studies on the functional setting of facilities focused on the type of facilities, as well as the service and the scale of facilities. From the perspective of long-term care (LTC), Curtis and Kiyak et al. [49][30] classified CECFs into adult family homes (AFH), adult residential care (ARC), and assisted living (AL), and they proposed that these three types of facilities mainly provide medical care, mental health, social support, and residential amenities for the elderly in the middle and late stages of aging with poor health conditions. Guihan et al. [50][31] studied the independence and privacy of the elderly in the three types of facilities. They found that better health conditions of the elderly and greater independence led to a higher demand for privacy. Since the privacy of the elderly is difficult to meet in all three types of care facilities, Guo [51][32] proposed new kinds of community retirement service facilities, such as daycares and senior centers in naturally occurring retirement communities. These facilities provide a place for activities and socialization for seniors in good health, meeting the need for privacy in their daily lives but excluding residential services. Nakanishi et al. [52][33] focused on the needs of the elderly in Japan and found that, except for the elderly with advanced age and poor health who require round-the-clock care, most of the elderly prefer daycare facilities and in-home senior care services due to the need for privacy and aging at home. Daycare centers mainly provide life care and social activity to help the elderly extend their stay in their original residence [53][34]. In addition, in Singapore, private clinics in and around the community often provide medical services for the elderly. Tan et al. [54][35] proposed building a CECF that integrates medical care and nursing care. Through the public healthcare system, CECFs are linked with community hospitals or large hospitals to provide professional care and medical services for the elderly. In addition, daycare facilities are built in the community to provide daytime activities for the elderly. Feng [55][36] suggested combining daycare centers and childcare facilities to promote intergenerational integration in the community. Feng et al. [56][37] encouraged community canteens to provide dining services for the elderly from an economic perspective. Community clinics and private general practices were also suggested to be embedded with elderly care service functions to provide in-home medical care services for the elderly.
In addition to the type of function of the facility, the scale of the CECF is also an essential element. Hannah Weihl [57][38] suggested through sample interviews that a larger facility would improve the wellbeing of the elderly, while Sikorska [58][39] indicated that the scale of the care facility should not be too large to take better care of the elderly. Shippee et al. [59][40] confirmed that the scale of the CECF has a significant intervention effect on the QOL of the elderly through a time-lapse study. It is difficult to determine a definite indicator of the scale of the CECF. Nevertheless, most scholars have agreed that the size of the facility has a significant relationship with the wellbeing and QOL of the elderly.

2.2. Planning and Layout

Planning and layout studies of CECFs have been carried out in two aspects. Firstly, through an analysis of the spatial distribution accessibility of CECFs, Yang et al. [60][41] analyzed the geographic accessibility between the elderly and healthcare facilities using GIS to make recommendations for policies regarding healthcare for the elderly. Grant [61][42] examined the effects of space and location on the elderly and their families, caregivers, and facilities and explored the spatial coupling of the elderly with facilities. Gibson et al. [62][43] explored the spatially equitable distribution of CECFs concerning the growth and distribution of the elderly by studying the distribution of facilities in four zones: capitals, other metropolitan areas, rural areas, and remote areas. Secondly, from the facility’s location, You [63][44] proposed increasingly converting vacant kindergartens into daycare centers for the elderly or adding elderly care functions by considering the current situation of negative population growth in Japan. He set up an enhanced spatial equity measurement to evaluate the satisfaction of the elderly with the distribution of existing facilities. He also constructed a potential evaluation model to assess the potential of kindergartens in the study area to be converted into CECFs. In addition, scholars have conducted substantial research on facility network construction. In Taiwan, a CECF hierarchical network called A–B–C was constructed on the basis of the LTC system. The A-level facility was considered the center, connecting the B-level and C-level facilities, and the travel time between each facility was within 30 min. The C-level facility provided in-home services within walking distance of users [64][45].

2.3. Operation and Management

Research on the operation and management of CECFs has mainly included measuring the service quality of the facility and developing policies to secure funding for the service. Xu [65][46] considered the quality of service in CECFs to be related to the number and professionalism of staff in the facilities. He also argued that strengthening staff training and standardizing the service charter could effectively improve the quality of elderly services in facilities. Chao [66][47] posited that service quality in facilities should be related to the perceptions of the elderly of their satisfaction with the facility’s elderly care services. Bravo [67][48] found that the elderly who continually used the facility for a more extended period were more satisfied with the service quality. Regarding the cost of services, Beland et al. [68][49] suggested that facilities only provide services for a fee in the traditional LTC system. The amount and type of care services seniors receive depend on their needs. They are tied to the amount and quantity of private insurance, Medicare, or Medicaid that they have. This means the elderly in this system have difficulty accessing needed services [69][50]. Hsu et al. [64][45] proposed setting a usage line for senior services to solve the problem. If the usage amount of elderly services exceeds the usage line, the elderly would need to pay the corresponding fee, whereas those within the usage line could do so free of cost. In addition, low-income families would receive a government subsidy to ensure that the elderly in need could use the facilities. Although the correlation between the quality of elderly services and the cost of elderly services has not been discussed explicitly, Bravo [67][48] discussed the satisfaction of the elderly with the quality of services in facilities using nonprofit facilities and profit facilities as examples.

3. Application of Structural Equation Modeling to CECFs

The structural equation model (SEM) originates from sociology, in which scholars aimed to find effective ways to understand the structure and interactions of underlying phenomena. On the basis of two-factor theory, Spelman constructed a measurement model for analyzing latent factors. Spelman’s [70][51] study is regarded as the origin of validated factor analysis in SEM, and numerous scholars have subsequently refined the study of measurement models of latent and observed variables in SEM. Wright [71][52] added path analysis to enhance the study of the causal structure between variables. He argued that, by constructing path diagrams, correlations among variables could be quickly decomposed into various causal sources to estimate the direct, indirect, and overall effects of one variable on another variable. SEM can be used to analyze multiple variables simultaneously and reveal the relationships between the effects of variables that are not directly measurable. Therefore, SEM is often applied in social sciences, such as sociology and psychology.
SEM is often used in studies related to QOL and aging to explore the intrinsic relationships of potential variables. Elosua [72][53] was the first to introduce SEM into QOL research. He proposed the Thurstonian model within the framework of SEM to assess the preferences of QOL dimensions in the elderly. On the one hand, he discussed the feasibility of SEM in QOL studies and concluded that housing conditions significantly impact the QOL of the elderly. Later on, Mu et al. [73][54] evaluated the relationship among architectural composition (AC), indoor environmental quality (IEQ), residential satisfaction (RS), and QOL in elderly housing using a large-scale questionnaire and SEM. They confirmed that IEQ and RS had the most significant effect on QOL and acted as mediating variables indirectly influencing the impact of AC on QOL. Dahlan [74][55] responded to the generally low QOL of the elderly in nursing homes and proposed using SEM that a comfortable physical environment and sufficient opportunities for activity participation are conducive to improving the QOL of the elderly. Since then, many scholars have also explored the influencing factors of QOL in terms of both physical and social environments. With the continuous development of SEM and the enrichment of relevant model assessment indicators, the role of SEM in research has been highlighted. In addition, to explore the causal relationship between variables, SEM has been applied to the multilayer analysis of covariates and the indirect influence path analysis. Mahmoodi [75][56] used gender as a covariate and found that gender factors influence the path of standard variables, such as mental health, education level, and accessibility of facilities, on the wellbeing of the elderly. Zhang et al. [76][57] developed a multi-moderator model of neighborhood environment and QOL for the elderly dwelling in the community. Using the multiple mediating effects of Phys-QOL, Psyc-QOL, and SR, recommendations were made for modifying a friendly neighborhood environment to be beneficial to the elderly. Most studies discussed the influence relationship or causality between CECFs and QOL using SEM. The restudyearch results can be used to propose construction strategies for CECFs. Fewer studies further analyzed the reasons for the differences in QOL among different groups according to the results obtained and clarified the aspects of CECFs that led to differences in QOL.

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