We received support from Lingnan University and have no financial conflicts of interest to report [Grant number DR182B].

Introduction

2Literature on community care services focuses on the caregivers, care places, and care options of older persons, as well as the individual experiences of older persons (Yan, Gao, and Lyon 2014; Golant 2015; Li et al. 2022). Older persons receive both formal services from community care facilities and informal support from family, friends, and neighbours (Zhang et al. 2020; Zhou and Walker 2020). Older persons choose to utilise care services based on the comprehensive effects of social, psychological, economic, and health factors (Xie 2018; Ma, Shi, and Li 2019; Marinelli, Zhang, and Ying 2022). However, despite the rapid development of community care services in Beijing, the awareness and utilisation of these services remains relatively low (Sun, Hao, and Bo 2016). A questionnaire survey of 1,125 older persons living in three districts in Beijing found that only one fourth of the participants were informed of the social activities organised for them in their communities. A mere 11.2% of participants were aware of legal consultant services being provided, and an even smaller percentage knew about home care and assistance for grocery shopping available in their community (ibid.). The available care services are limited to basic daily life support and health care, while social activities and psychological consultations are insufficient. The needs of older persons, especially those with disabilities and chronic diseases, are inadequately considered in the development of community care services (Li et al. 2013; Gu, Rosenberg, and Zeng 2017; He and Yan 2021). Equally pressing is the shortage of care professionals. Insufficient income guarantees, high labour intensity, responsibility, and pressure, as well as low social status, have resulted in a serious “brain drain” of care service personnel (Dong, Wang, and Zhang 2020).

3“Ageing in place” makes communities beneficial places for older people to grow old. However, few studies focus on the dynamic interactions between structure and agency in shaping the provision and utilisation of community care services in Beijing. This study applies spatial statistics analysis and constant comparative method to analyse the spatial allocation of community care facilities and challenges in service provision and utilisation using statistics, interview data, and policy documents. Suggestions are provided to meet these challenges. The spatial and qualitative analysis of our data facilitates the understanding of the interaction of provision and utilisation of community care services, further pushing policy suggestions.

Conceptual framework

4The study uses the structuration theory as a framework to understand the complex interactions of service provision and utilisation. The British social theorist Anthony Giddens identified structuration theory, which recognises the duality of structure and human agency (1984). It has been widely applied in health geography to understand the interaction of care and place and identify challenges in service provision and utilisation (Wiles 2003; Wang et al. 2014; Zanin and Piercy 2019). It acknowledges that structures shape social practices and actions, while such practices and actions recreate social structures (Ngwira, Mayhew, and Hutchinson 2021). This study provides a more dynamic model for understanding the pathways and mechanisms linking social structures to service provision and utilisation (Oversveen et al. 2017) (Figure 1).

5Social structure refers to the rules and resources that enable and constrain decision, action, and thought. The rules in a society are either formal (policies in community care) or informal (cultural norms influencing individual actions). Resources refer to formal and informal care services and supports, while agency refers to the individual’s ability to take action, including managers and older individuals’ capability for action. Social structures and people’s actions are not separated as a dualism, but are viewed as a duality, inseparable and shaped by each other (Giddens 1984; Xiao et al. 2014). In terms of community care service provision and utilisation, agents (managers and older residents) employ structures (rules and resources) to guide their interactions. The structures are the medium of actions and the outcome of those actions. When agents interact to produce and reproduce social systems, they are not only enabled by the structures in place, but also constrained by them (Nunu et al. 2019).

Credit: authors.

Data and methods

7The research team conducted in-depth semi-structured interviews on six community care facilities in Beijing from June to July of 2019 (Figure 2). Three districts in the urban function extension areas and three in the urban new developing areas of Beijing were first randomly selected. Among these six districts, the communities with the highest population ageing rate in 2019 were chosen for conducting interviews. The basic information of the six selected communities is included in Table 1. Interviewees included four staff and two managers of the community care facilities and 28 older persons who were living in the communities. Participants were told that they could withdraw from the study at any time and were assured that their data would be confidential. All participants gave informed consent before the face-to-face interviews. Ethics approval was received from Beijing Normal University.

Source: authors.

Source: mapped by the authors.

8The staff and managers of the facilities were asked about the social and demographic characteristics of the community and the preferential policies related to the service’s provision. Information on the ownership and type of services was also collected. Questions on the operating costs and profits of community care facilities, the challenges of service provision, and suggestions for improving community care facilities were asked. The older persons were asked about their economic status, including enrolment in medical insurance, and their demands for and utilisation of community care services. The participants were interviewed for 20 to 60 minutes each.

9Nvivo Plus was used to process and code interview data. After classifying, coding, and collating the interview materials, it was used to check the relationship between the data. The constant comparative method was used to analyse the data. Two domains were defined from the data, namely, the demands for and the utilisation of community care services, and the service provision and challenges, which reflects the interaction of structure and agency in provision and utilisation of community care services among the older residents, governments, and the community care facilities.

Spatial inequity in community care services

Source: mapped by the authors.

11Figure 4 shows that nearly 70% of older persons in Beijing are living within 1 km of the nearest community care facilities. The proportion of older persons living within 2 km from the nearest community care facilities reaches 85%. Only 1.35% of older persons live more than 5 km from the nearest community care facilities. In Shunyi and Pinggu Districts, 56% and 39% of streets, respectively, have more than 60% of the older population living within 2 to 5 km from the nearest community care facilities. In addition, seven streets in Yanqing District and two streets in Mentougou District have more than 80% of the older population living more than 5 km away from the nearest facilities. In one township of the Huairou District, more than 60% of the older population live more than 5 km away from the facilities. The rapid growth of the older population and limited community care services in these suburban and exurban areas make the older residents living there more vulnerable compared to the older residents living in the central city of Beijing.

Source: mapped by the authors.

12The six selected communities have the highest population ageing rates in the urban function extension areas and the urban new developing areas of Beijing where the older population grows most rapidly. The distance to the nearest community care facilities of the three communities in the urban function extension area are less than 1 km, while the three communities in the urban new developing area have relatively low social economic status (SES) and longer distances to the nearest community care facilities (Table 1).

The demands for and utilisation of community care services

13With the increase in the number of older persons living alone, there is a great demand for community care services, such as emergency calls, meal service, and accompanying services. However, the current community service system for older persons does not fully meet their actual needs, which include daily life needs, emotional needs, and health service needs.

14The health status of older persons and whether their adult children and spouses are willing to provide care and emotional support, as well as their families’ ability to pay for community care services, and older persons’ need for services, are important. While adult children, spouses, and staff of community care facilities can provide daily life and health care support, older persons’ emotional support mainly depends on their family and friends. During the interviews, older persons and the staff of community care facilities frequently mentioned their need for adult children’s care and support. However, having a small number of adult children in a family, as well as the recent increase in the women’s workforce, has changed adult children’s attitude toward filial piety. The relationship between the parent and child/children has become less interactive and reciprocal (Zhan and Montgomery 2016). Adult children face challenges in providing care in person to their older parents due to their working and living conditions.

15Theoretically, community care services can effectively supplement the care provided by adult children to their ageing parents. However, in reality, community care services cannot adequately meet the diverse needs of older residents. Taking the need for catering services onsite as an example, each individual has different food regimens, due to personal preference and health status, adding to the complexity of service provision. Among the six community care facilities visited, there were great differences in the type, quality, and standard of charges for services. The needs of older persons are complex and diverse, resulting in a disconnect between the needs of older persons and the provision and quality of services. However, the greatest demand among all the facilities was for catering services, professional care service, and accompaniment appointments.

Of course, I hope that the community care facilities for older persons run well and that there is an option for us to use the services, but currently, some services are unable to meet my needs, and are not useful to me. (An older male in Community C, 24 June 2019)

16Older residents in the community generally know about community care facilities, but their knowledge of services varies from person to person. Older people who are willing to communicate with their friends and neighbours may receive more information on community care facilities during their social interactions. Those who are on the older end of the scale take the initiative to collect information on community care services because their health decline is more apparent to them.

There are advertisements for the community care facility. If you use a mobile phone, you will be notified of any activities they organise on WeChat. My neighbours also say it is very convenient, and the information on activities is quite timely. You don’t have to go there all the time to ask. (An older male in Community E, 1 July 2019)

17Even with the increasing demands of the older persons and growing government support for developing community care, the findings of this study show that the utilisation of community care services is still low. Older persons reported a sense of sadness and loss when using long-term care in the community because it seems like they are being abandoned by their families.

Generally speaking, when they are in poor health, it is their children who make decisions and send them to community care facilities for long-term care or short-term care. Most of the older persons feel socially excluded or even abandoned by their families. Like this old man, who is in his eighties and needs to be fed in a wheelchair. He is rich and his children are filial, but they are really unable to provide sufficient care for him at home. There are some challenges for the old man to live at home. He almost fell at home before he was sent here. His children often come to visit, but the old man is unhappy, and he often loses his temper and is not willing to stay here. However, it is true that there is no better choice, and community care needs a long time for older persons to accept it. (Manager of a community care facility in Community B, 22 June 2019)

18The other challenge comes in the form of conservative consumption values of older persons, their limited consumption capacity, and the high cost of community care services. Financial affordability affects older persons’ utilisation of community care services. Older persons expressed dissatisfaction with the prices of the services offered. Even though community care facilities have been supported by the government, older persons think the price of community care services remains high.

Personally, I would like to use the community care services, but I can’t afford it. As a retired worker, I depend on myself. I don’t want to put the burden on my children and ask for financial support from them. (An older male in Community E, 2 July 2019)

19In Community D, most older persons living in demolition housing are former farmers. They find that the care they need, such as day care, is unaffordable. This fact discourages them from learning more about the community care services. The knowledge and utilisation of community care services among low-income older persons are limited to free entertainment activities. This is significantly different from the perception and utilisation of community care services in Community F of Chaoyang District, a commercial housing community, where the per capita monthly income is relatively high. Older persons with better economic status are more willing to obtain information on community care services and purchase said services to improve their quality of life.

No one uses the chargeable community care services. We play cards at the community care centre. It is free, and I can’t afford a domestic worker. I have a pension of only 720 yuan a month. (An older female in Community D, 26 June 2019)

We all need to hire domestic workers to take care of older persons and children at home. The community care centre is just like a housekeeping company. The economic status of the residents here is quite good. They can afford the cost. (An older male in Community E, 2 July 2019)

Credit: photo taken by the authors.

20Community A, built in the 1980s, is a residential quarter with a total population of 5,580 residents in 1,943 households. People aged 60 and over account for 20% of the total, and many are veteran cadres and staff of state ministries or commissions. However, around 40% of those residents were relocated due to the redevelopment of their neighbourhood, leading to the creation of a community. A community care facility is located in the basement of the compound. The older persons prefer sitting in the recreation space to chat and enjoy the sunshine (Figure 5). They need community care services to support them and help them overcome difficulties in daily life. The mobility service is well-recognised among the community care services in Community A, and daily life needs are ranked highest among the community care needs. Transfer service is one of the many services provided by the community care facility. Older persons are willing to use it, even if a certain fee is required. Such a high-quality service carries with it an equally high degree of gratitude and desire for use.

The transfer service is good. We used it before. My husband can’t go downstairs when he gets sick. We asked the staff to take him downstairs in the wheelchair. This service costs 50 yuan. Is that OK? It’s helpful. The residents here are all old, the corridor is narrow, and people like to put sundries in the corridor. It was difficult to take my husband downstairs. It is tough. (An older female in Community A, 17 June 2019)

21When asked whether they have used other community care services, older residents discussed the discounts they were offered when community care services were first introduced. For example, the price and quality of catering services were good at the beginning, but over time, the quality declined and the prices increased. As a result, they lost interest in the catering service. Additionally, the provision of community care services was limited by personnel and space, as one interviewee pointed out:

The housekeeping service offers laundry and housekeeping for older persons. However, I am not confident about giving them my key to open my door. It costs three or four thousand yuan a year. How can you have the spare money to do so? No one uses the service. Have you visited the community care centre? It’s just a small room in the basement with no service. There were only two or three people in the room, usually only one young lady was there. It seems like she is just the keeper for the centre. (An older male in Community A, 18 June 2019)

Many old people like me come to lectures here, as there are always small gifts given out, such as rice, flour, grain, and cooking oil. When we come and listen to the lecture, we also learn something and get familiar with the community care facility. They often organise a sales pitch, but we don’t buy those products. (An older female in Community C, 24 June 2019)

22There are significant differences in the reimbursement of various types of medical insurance. For hospitalisation, more than 70% of medical expenses can be reimbursed by urban medical insurance, but only 50% of expenses can be reimbursed for those with rural medical insurance. Urban retirees are more open-minded, financially stable, and more willing to learn and use community care services than rural older persons. The general report is that medical expenses cannot be fully covered by medical insurance. The out-of-pocket portion increases with the number of medicines needed, and the upper limit is unknown. Saving for medical services becomes a necessity, and as a result, living costs are tightened. Both older persons and their children are willing to pay for community services if they are urgently needed, but the cost of community services remains unaffordable for most. This, in turn, makes it difficult for care services to make a profit. The delay of government subsidies, as well as the poor perception that has been acquired, increases the operating cost of community care facilities. Improving the delivery of subsidies, the medical insurance system, and social welfare have far-reaching impact on the provision of community care services.

23The utilisation of community care services is affected by both the price and the experience of using these services. The average monthly pension of older persons in Beijing is about 4,000 RMB. While the prices of community care services vary, generally speaking, the monthly cost is about 5,000 RMB if special care is needed. The disconnect between older persons’ demand, consumption capacity, the operation cost of community care facilities, and the cost of using the service also creates many challenges for providing community care services. The trust of older persons helps to increase their utilisation and address the challenges faced by the operation of community care facilities.

24Continuous improvement of policies will help to improve the acceptance and utilisation of community care services among older persons by standardising management and improving service quality. The utilisation of community care services by older persons also prompts the government and facilities to constantly adjust the formal and informal rules and resources.

Service provision and challenges

Credit: photo taken by the authors.

29The government is continuing its efforts to improve the types and quality of services and provide financial support for community care facilities. However, managers have reported difficulties in managing their funds due to the low revenue from service provision, as well as delays in receiving government subsidies. Along with the limited consumption capacity of older persons and other factors, many community care facilities are facing losses or suspension of business, making it difficult for the service provision to effectively meet the demands of older persons.

30Taking Community B as an example, there are 4,294 residents living in a total of 23 dormitory buildings and 1,473 households, and many of the residents are retired workers. While the community care facility is overseen by a private company, the manager stated that the income of the community care facility comes from three sources: payments from older persons (accounting for 40% of revenue), government subsidies (30%), and government purchases of community care services (30%). The residents’ payments are primarily for catering services and day care, while the government subsidies cover other expenses, such as rent, utility expenses, and staff salaries. The government also grants coupons to older residents for purchasing community care services. However, the specific types of community care facilities receive different levels of government subsidies, which can be implemented in various ways. The manager also mentioned inadequate government support and poor cash flow faced by the facility.

The government subsidies for private facilities are different from those for publicly funded facilities or those with public-private partnerships. While policy documents regulate rent and utility expense reductions, privately owned facilities renting a place for service provision are required to pay rent, which increases the cost of management. (The manager of the community care centre in Community B, 22 June 2019)

31The initial input cost of community care facilities varies from location to location. Some facilities are shared by subdistrict offices and state-owned enterprises, while others are fully supported by private enterprises. It is worth noting that the manager of Community B’s community care centre communicated with other managers of community care facilities in Beijing and found that in the past two years, they had experienced almost zero profit, and their line of business was becoming more of a public welfare system. These care facilities desperately need long-term development and are highly dependent on government subsidies. The managers and staff of the six research sites interviewed share a similar opinion that the cost recovery period of community care facilities is painfully long.

The residents in Community B are mostly veteran workers, and it is quite common for them to have a pension of a little more than 3,000 yuan per month. The community care centre offers beds for older residents, and the charge for beds ranges from 100 to 160 yuan per day. Depending on the physical condition of the older person, the expense is usually about 5,000 yuan per month. The vast majority of older persons can’t afford it, so our revenue is very poor. After all, there are operating costs such as staff salaries. (The manager of the community care centre in Community B, 23 June 2019)

32Despite the structural constraints, the managers have found ways to be proactive and meet these challenges. Various strategies have been developed to promote older residents’ utilisation of services and overcome the challenge of low revenue. Their actions help community care facilities survive within the structure of the current community care industry. For example, the community care facility in Community A jointly organises community activities with subdistrict offices, increases publicity for community care services, and has won a certain degree of trust and reputation with older residents. Promotional activities such as opening rewards, members’ relief, small gifts of rice, noodles, grain, and cooking oil, and discounts on meal services are effective in attracting older residents. Communication among older persons also helps disseminate information. The need for housekeeping and daily life care services convinces them to obtain information from community care facilities.

Last year or a few months ago, the community care facility just opened and cooperated with the canteen of my former workplace, offering discounts and selling affordable steamed buns, so all the older persons in the community bought food there. Then, we knew that the community care facility is here. (An older female in Community A, 17 June 2019)

The revenue situation of the facility in our community, how to say, public welfare long-term investment? I combined the facility for both older residents and the disabled, using the space for caring for the disabled to support service provision for older persons. Sharing staff and catering services can save some costs. The care facility needs rehabilitation equipment and special beds, as well as upfront investment for renovation. It cost me about one million yuan, and it is certainly impossible to cover the investment after just two years of operation. So, we really need the support of the government and community to gain the trust of older persons and improve their utilisation of the services. Actually, the older residents know enough about our centre, because we have provided domestic services before, but we still need publicity after ten years of working in the community care industry in Beijing. (The manager of the community centre in Community C, 25 June 2019)

34A review of the policy documents shows that the initial policy documents mainly focused on the establishment of a community service system and put forward the construction plan. With the progress of construction, combined with feedback from the operation of community service facilities, the government further put forward the implementation plan and detailed management measures to promote the development of community services. In view of the challenge of community care service management, the government issued measures to subsidise community care facilities. Subsequently, the introduction of the star ranking method for community care facilities has helped to standardise and ensure the quality of community services. The process of implementing these policies shows how agencies play an active role by providing feedback on operation and service use in forming the rules and increasing resources.

Discussion

35The number of community care facilities in Beijing has increased rapidly in recent years. Many of these facilities are concentrated in the central districts of Beijing, where the majority of older residents live within 1 km of the nearest community care facilities. In contrast, there are fewer community care resources located in suburban districts where the older population is growing most rapidly. The majority of older residents live within 2 to 5 km of the nearest facilities, while in suburban districts, older persons live more than 5 km away. The inequality in travel distance from older persons’ homes to community care facilities affects their willingness to utilise the services, as older persons prefer to have community care services accessible within walking distance on a daily base.

36Older residents reported their demand for community care services, namely catering services and daily care support. Financial cost is an obstacle to the utilisation of community care services. Families’ financial resources and the quality of services provided are two important factors in service utilisation. Those with good financial resources are more willing to spend money on services and purchase care services from community care facilities or domestic service companies. Older residents or communities with higher SES are in a position to be more agentic in meeting their elderly care needs, while lower SES individuals/communities are no less agentic in using different coping strategies.

37Private enterprises face the challenges of building trust and acceptance of older residents toward their services, as well as managing the facility with financial balance. The facilities put effort into developing information and publicity channels to obtain greater benefit, which has a positive effect on the long-term sustainable development of the community care service system. After several years of the development of community care services, the government has accumulated experience and learned lessons in the provision and utilisation of community services. The government has put forward regulations to standardise service provision and plays a positive role in financial support and management supervision of the community care services. Older residents are also actively collecting service information and carefully utilising services that are affordable and that effectively meet their care needs.

38The dynamic process of provision and utilisation of community care services reflects the impact of formal and informal rules and resources on older persons’ use of services and managers’ management of facilities. The feedback from service users and managers also affects the formulation and adjustment of relevant policies. The interaction of structure and agency promotes the development of community services. Suggestions are provided to address the challenges of service provision and relatively low utilisation of community care services from the perspectives of the government, private enterprises, social groups, and older residents (Chen et al. 2022).

39The government needs to make further efforts in the implementation of related policies, improving the social welfare of older residents and rational spatial allocation of community care facilities. Private enterprises can take the initiative to accept the supervision of the government, standardise the service market, and invigorate the operations. Social groups can widely participate in the dissemination of community care service information and act as a bridge between older residents, service facilities, and government departments. Older residents can improve their awareness of the utilisation of community care services and actively realise their needs. By doing all of this, the benefits of “ageing in place” can be better realised and the proper actions can finally be taken to sustain it as a form of living.

40This study has certain limitations. First, participants with disabilities and/or who were homebound may have been overlooked in this study. Second, the continuous development of community care services requires follow-up research in the future. Despite these limitations, this study provides insights into the challenges in the provision and utilisation of community care services in Beijing, which is important for the improvement of developing community care services.

Conclusion

41The findings of this study show that spatial inequity in access to community care services is created by the allocation of facilities. For those living in suburban districts, the lower availability of community care resources is a major concern. The analysis of the provision and utilisation of community care services is based on the structuration theory. Policy and organisational factors shape the challenges for service provision. The complex combination and internal relationship between these influencing factors, such as individual characteristics and the availability and quality of services, lead to differences in utilisation by older persons. The policies in community care provision and cultural norms of care utilisation shape the social practices of community care services. Such practices of managers, older residents, and the government reshape the rules and resources of community care service.

42This study provides insights for understanding the complex mechanisms linking social structures to service provision and utilisation. It offers a case study for understanding the interaction of structure and agency in community care services in the context of a developing country with rapid urbanisation and population ageing. The findings may be helpful in providing suggestions for the government, nonprofit organisations, and private enterprises to meet some of the challenges and improve the quality of community care services to support ageing in place in Beijing and similar cities.