Long-term care for aged ethnic minority people in Yunnan, China:Understanding the situation

Kaining Zhang, David Zakus, Chuqun Gao

1. Yunnan College of Business Management, Kunming, Yunnan,China

2. Faculty of Community Services, School of Occupational and Public Health, Ryerson University, Toronto, Canada

3. Yunnan University of Traditional Chinese Medicine, Kunming, Yunnan, China

Long-term care for aged ethnic minority people in Yunnan, China:Understanding the situation

Kaining Zhang1, David Zakus2, Chuqun Gao3

1. Yunnan College of Business Management, Kunming, Yunnan,China

2. Faculty of Community Services, School of Occupational and Public Health, Ryerson University, Toronto, Canada

3. Yunnan University of Traditional Chinese Medicine, Kunming, Yunnan, China

Chinese governmental sectors have been investing lots of money in setting up new institutions for long-term care (LTC) in rural China to respond to the predicted increasing and urgent needs of the growing number of aging people. However, very few have identified that many ethnic minority groups have been enjoying their traditional home-based LTC systems, which are cost-effective and have been working really well for generations. This article reports on a study on LTC needs and provisions for the Dai, one of the ethnic minority groups in rural areas of southwest China, in Yunnan (Province). A randomized sample was drawn from 12 villages in Ruili, a county 752 km from Kunming, the capital city of Yunnan. Totally, 187 elderly persons were interviewed intensively.Activities of daily living were measured as the core indicator for understanding LTC. The research revealed that there is a significant disparity between the needs of the villagers and provisions from the different levels of government. There is an urgent need to reexamine the allocation of public resources for the aged. Traditional culture and practices of caring for the elderly, and practices in LTC of different ethnic groups, must be carefully considered.

Long-term care; Dai elderly; aging; rural; China

lntroduction

Many populations around the world are growing older, with an increasing number of persons in the elderly age groups. Given the fact that China is among the countries aging the fastest [1],Chinese governmental sectors have been investing substantial amounts of resources in setting up new institutions for long-term care (LTC) in rural China to respond to the predicted increasing and urgent needs of this growing number of aging people [2].

To better estimate the real needs for LTC of aged people in rural China, an investigation was undertaken by the Yunnan College of Business Management, supported by the Chinese National Social Sciences Fund. A comprehensive study was designed and then undertaken in Yunnan and two other provinces, Sichuan and Guizhou, focusing on three different ethnic groups in southwest China. This article reports on the findings of our first field study in Yunnan on elderly of the Dai ethnic group.

Background of the Dai ethnic group

Yunnan province is located in southwest China and has 26 ethnic groups. According to the Sixth National Population Census of the People’s Republic of China, Yunnan’s population totals 45,966,000, and of this population 33.4%, or 15,337,000, are from ethnic minority groups. Dai is one of the ethnic groups in Yunnan.

The Dai population in China is 1,261,311, of whom 1,222,836 (97%) live in Yunnan. Most of the Dai are farmers.For generation after generation, they have lived in the tropical areas, planting rice, bananas, coffee trees, rubber trees, and other tropical agricultural products [3]. Nearly all of the Dai people are Buddhists.

Methodology and sampling

To better understand the situation, multiple methods were used in this study to collect quantitative and qualitative data related to LTC. Existing data were collected from governmental sectors including the Committee for Aging, the Committee for Health and Family Planning, LTC institutions, and the health care system at the county, township, and village levels.Questionnaire surveys were conducted through visits to every house in the sample areas where there was at least one person aged 60 years or older. Our field study sites were in the rural areas near the Ruili county, which is 103 km from Mang City,the capital city of the Dehong Dai and Jingpo Autonomous Prefecture, and 752 kms west of Kunming, Yunnan’s capital city [4]. Administratively, within all of China’s 30 provinces,there are counties, townships, and villages in rural areas. In terms of sampling, three townships were first selected by randomized numbers from the six townships in Ruili. Then four villages were sampled from each of the three selected townships. In each of the 12 study villages, all of the villagers aged 60 years or older were interviewed one by one. Relatives, especially children of villagers aged 60 years or older, and any people who were LTC providers were interviewed. Participatory observations were undertaken where this was appropriate.On the basis of the participatory observations and in-depth interviews, true stories arose. The research team used case study methods to describe the aged people, their relatives, and friends, as well as the stories. Now the goal for 2014 has been fully achieved, and greater efforts are being made for achieving the goal for 2020. Activities of daily living (ADL) were measured using the Barthel Index which has been widely used to evaluate the self-care ability of the disabled persons, to measure the daily living abilities of each of the elderly people(defined as being older than 60 years) [5].

According to the international standard, a person was identified as severely disabled if the ADL score was 40 or less and of intermediate disability when the ADL score was greater than 40 but not more than 60 [6]. Health conditions were measured by a self-reporting method: Each aged person was requested to report her/his health conditions by showing the diagnosis booklets from township hospitals and health centers.If a person was too old to report, his/her family members were invited to show the diagnosis booklets. In other words, this study calculated the rate of health conditions, including hypertension, diabetes, and stroke, on the basis of self-reporting with confirmation from the diagnoses booklets.

As a result of sampling, three townships – Jiexiang,Longdao, and Mengmao – in Ruili county of Yunnan were selected. Two represented the traditional rural areas, whereas one township represented a rural area undergoing urbanization.In each township, all villages were numbered. The study villages were chosen by use of random number technology, and a detailed name list with the age and ethnicity of the villagers was obtained from the community leaders in each of the study villages. Finally, in each of the selected villages, the research team visited all households with villagers aged 60 years or older.

Within the households, one-to-one interviews were undertaken with the elderly, their relatives, and especially the caregivers. In Ruili county, 209 aged persons from 2325 Dai villagers living in seven villages were intensively interviewed.On the basis of the interviews, the research team found that among these elderly people, 12 had come from other ethnic minority groups but had married their Dai partners many years ago. Also, there were 10 aged persons who were nearly 60 years old, and were thought of by the community leaders as the “nearly 60 years.” To ensure study quality, the abovementioned 22 persons were excluded from data analysis. This resulted in a sample of 187 elderly persons (68 males and 119 females) aged 60–103 years, with an average age of 69.87 years (standard deviation 9.77 years). In addition to the aged people, 104 relatives, all caregivers, were interviewed. The relatives were family members who were living with the elderly.For elderly without children, ‘relatives’ normally means children of their brothers/sisters. Caregivers are those who daily provided the disabled elderly with assistance and simple care,such as day-to-day support in cooking and bathing. In addition, 36 case studies about aged people were organized and recorded, but these are not reported on here.

Major findings

In each of the three townships, surprising findings from this study revealed a serious disparity in the needs of villagers and the provision of LTC services as offered by the governmental sectors.

In Ruili county, from the government side, we found that more than 93% of LTC resources had been applied at the county level, with only 5% at the township level and less than 2% of the total budget for LTC applied at the village level. In contrast, from the demand side, our study showed that no Dai elderly villagers wish to use institutional LTC at all. All of the Dai elderly, including the disabled, are enjoying home-based care by their sons/daughters or grandsons/granddaughters, or their relatives or even nonrelatives if they have no supportive children. Moreover, during the in-depth interviews, in answering our question about assuming a situation if any aged people were totally disabled, less than 0.5% of the respondents said these old people might use the LTC institutions at the county or township level, whereas 98% said that the aged people should stay at home and use traditional home-based care, and 1.5%said these hypothetical elderly should accept village-level LTC. These figures also explain why in the Ruili County LTC Center, only 15 of its 115 beds for LTC have been occupied by senior citizens from all of the nearby villages. None of these 15 aged persons living in the Ruili County LTC Center come from the Dai ethnic group. Without a doubt, Dai people have been enjoying a totally different aging culture from the Han people,the majority ethnic group in China [7].

The field study in Ruili revealed that social support for the Dai elderly within the family and community is stronger and warmer than in the Han and Jingpo ethnic groups in the same county. One specific feature of Dai society has been the sex equality tradition, generation after generation. Indeed, unlike the Han and Jingpo ethnic groups in China, Dai people have no surname, and there is no preference for sons within Dai society [8]. Daughters assume the same roles as sons in caring for the aged. This provides parents with more opportunities in choosing with whom they will stay when they become very old and disabled. Meanwhile, the Buddhist books and chanting make each of the Dai villages a friendly community where the elderly are deeply respected by everyone [9]. If any senior citizen has no son or daughter, the young people in the village will assume the role of caregivers for them.

In every Dai village, there is a must: the village temple, the public space for all of the villagers. The village temple is important for aged people because it is the place where the elderly read Buddhist books, and chant and talk with each other. It is common that the village temple is also the place for aged people without relatives to receive food and clothing and to have opportunities to communicate with other people [10]. Moreover,our field study in Ruili illustrated that the newly implemented modest subsidy policy for senior citizens from governmental sectors since 2012 has enhanced the existing home-based care system. Those aged villagers interviewed and their caregivers said that the modest financial assistance, although only RMB50(less than USD10) per month per person, provides a real hearttouching warm feeling and modest support for the aged people.As a result of the above mentioned approaches, the elderly Dai generally enjoy a peaceful life within their communities.

Discussion

Although Yunnan local governments have made great efforts in increasing the number of LTC beds, only modest efforts have been made in development and involvement at the village level.Given the significant disparity between the needs of the villagers and the provision of LTC by Chinese governmental sectors,rethinking and reprioritizing governmental finance and other public resources for the elderly is recommended. Priority should be given to the essential services for the elderly at the village level, focusing on supporting home-based LTC within the villages, and primary health care for all of the community.

Our study findings showed that there was almost no local demand for local government LTC initiatives in Dai villages.The needs of the Dai people have not been correctly foreseen;not enough of local cultural practices for senior life have been taken into consideration. In fact, the culture of this ethnic minority group was in stark contrast with the beliefs and practices of the Han majority in rural China. In these rural ethnic minority communities, the elderly are respected by all residents. It is easy for any aged person to access LTC, even for those without any sons and daughters. When any elderly person dies, there is a funeral at which the deceased receives unique respect and blessings from all of the villagers. In contrast, if an elderly person dies outside the village (e.g., in a hospital in the county town or in a township health center),he or she does not receive that honor. The cultural beliefs and practices thus have a significant positive impact on the last life journey of all of the villagers.

At the national level, LTC beds for senior citizens in public institutions per 1000 elderly have become an indicator for national strategic planning for the aging. The Chinese government announced that the national average number of LTC beds per 1000 elderly should increase to 30 by the end of 2014, and then to 40 by the end of 2020. Obviously, it is good to set up this national indicator [11]. However, in many areas of Yunnan,this indicator makes no sense. Given the fact that in Yunnan 33.4% of the total population is from ethnic minority groups,and many of the other ethnic groups also have similar traditional culture and practices very different from those of the Han group, specifically with traditional home-based care for their elderly, efforts to increase the number of LTC beds obviously need to be reexamined. Unfortunately, led by faulty estimations of LTC bed needs in Yunnan, there has been increasing investment and larger-scale planning at the county and township levels for institutional LTC. As a result, the number of LTC beds in Yunnan started from less than 10 per 1000 elderly in 2001, reached 23 per 1000 elderly by 2014, but is still less than the national average of 27.5 per 1000 elderly [12]. Therefore Yunnan local governments are still endeavoring to put more money into increasing the number of beds, likely erroneously and thereby explaining the low occupancy rates.

From an epidemiological perspective, there has been an urgent need for health promotion in Dai communities in Ruili.Our study revealed that among the Dai elderly villagers there were high rates of health problems: the self-reporting prevalence of hypertension was 52.9%, that of diabetes was 18.2%,and that of stroke was as high as 14.4%. In Dai society every person is regarded as aged once he or she has his or her first grandchild. This person is then treated as a senior citizen within the family and the whole community, regardless of how young that person is, and all of that person’s agriculture working load is transferred to other family members. Meanwhile,as clearly stated in several published studies, there is a lack of nutrition knowledge and it is common for elderly villagers to consume too much meat and sugar [13]. Unfortunately, the villagers still lack primary health care knowledge. It is unusual for a villager to visit the village or township clinics just for hypertension or diabetes with unassuming symptoms. As a result, sequelae of hypertension or diabetes, such as stroke and consequent paralysis, were common. To make matters worse,health providers at the village and township levels usually lack fundamental knowledge and skills for common gerontological diseases. Therefore there are urgent needs in primary health care and health promotion for the ever-increasing number of elderly villagers, regardless of ethnicity.

On the basis of ADL measures for each of the individual elderly people, the rates of severe and intermediate disability by age and sex were calculated. This revealed that among the Dai aged villagers compared with Han people, there was a higher prevalence of severe and intermediate disability. For instance, the rates of severe and intermediate disability of the elderly reached 11.2%, with a 95% confidence interval as high as 9.8–12.7%. The high prevalence of hypertension, diabetes,stroke, and consequent paralysis in the field study may explain the high rates of severe and intermediate disability.

Conclusion

Because there has been misunderstanding of the needs for LTC institutions and staff in Ruili, public resources have been put into establishing more and more new LTC institutions, whereas the resources should have been targeted to village-level support systems. Increasingly, LTC institutions find it difficult to persuade the local elderly to come into their beautiful, quiet, and nice LTC facilities, even though they are totally free of charge.The high prevalence of hypertension, diabetes, stroke, and consequent paralysis in the study villages calls for more resources at the grassroots level to enhance primary health care, including health promotion. Therefore there is an urgent need to reexamine public resource allocations for the elderly. The real needs and demands of the villagers should be central. Traditional culture and practices of caring for the elderly, and practices in LTC of different ethnic groups, must be carefully considered.

Acknowledgments

We sincerely appreciate the genuine support from the Chinese National Social Sciences Fund.

Conflict of interest

The authors declare no conflict of interest.

Funding

This study is sponsored by the Chinese National Social Sciences Fund (CNSSF, grant No. 15BRK029).

1. Li B. Aging trend of the China’s rural population, impact and response. Western Forum 2015;25(2):73–81. [in Chinese].

2. Jiang YG. A primary study on strategies to strengthen the pension service institutions in rural China. Admin L 2011;33(3):74–6.[in Chinese].

3. Shen QF. The economic development and ethnic identity in Ruili Dai area. Guizhou Ethn Study 2015;363(3):142–6.[in Chinese].

4. Li H. The colorful traditional culture and customs of Dai people in Ruili. Ethn Group Today 2010;23(3):21–4. [in Chinese].

5. Gao XF, Yu WH. Using Barthel Index to assist in differentiating the sub-grading of nursing care for older adults admitted in department of geriatrics under treat-care mode. J Nurs Sci 2014;29(4):1–4. [in Chinese].

6. Li KC, Tang D. Renew of the application of Barthel Index and Modified Barthel Index in Mainland China. Chin J Rehabil Med 2009;24(8):737–1. [in Chinese].

7. Yang GC. A study on the linkage between marriage residence patterns and ageing care for Dai ethnic group in Xi Shuang Ban Na, Yunnan. Zhang KN et al. Healthy ageing: challenges and opportunities in China. Beijing: China Social Sciences Press;2014. pp. 476–7. [in Chinese].

8. Gao LS. The Dai nationality’s naming. J Central Univ Nat 1980;4(1):92–6. [in Chinese].

9. Zhang Y, Wang Y, Li CC. An investigation on the endowment pattern of ethnic minority groups – taking rural Yunnan as an example. Ideological F 2004;30(2):103–8. [in Chinese].

10. Shen QF. The Ravada Buddhism education and ethnic identity of Dai people in Ruili. Guizhou Ethn Study 2012;33(1):21–5.[in Chinese].

11. Mu GZ. Dilemma and strategic response for the development of China’s institutional care for the elderly. J Huazhong Norm Univ 2012;51(2):31–8. [in Chinese].

12. He XQ. Strengthen supportive measures to promote pension services development – interpretation of the Yunnan provincial government’s documents on development of pension services.Soc Welf 2015;36(1):30–1. [in Chinese].

13. Su MH, Yang YJ. Prevalence of hypertension and its influencing factors in ethnic area of southeast Asia border trade port, Yunnan.Mod Prev Med 2015;42(9):1537–42. [in Chinese].

Related lnformation

According to this article, Dai elderly prefer traditional home-based long-term care; this situation is common around the nation,and not particular to China. Many countries in Asia preferring the traditional methods of being cared for by younger generations of family members. Elderly care services encompass assisted living, adult day care, long-term care, residential care, hospice care, and home care. It cannot be limited to any one practice. Major topics of discussion include how to popularize diversified elderly care in different cultural context, and how to solve disparity between needs and provisions.

You can find the following articles relate to elderly care and elderly health published in Family Medicine and Community Health.

· Family structure and support for the oldest old: A cross-sectional study in Dujiangyan, China

http://www.ingentaconnect.com/content/cscript/fmch/2015/00000003/00000004/art00003

· Elderly healthcare service at the community health centers in the Pearl River Delta region, China

http://www.ingentaconnect.com/content/cscript/fmch/2013/00000001/00000001/art00006

· Challenges in the provision of community aged care in China

http://www.ingentaconnect.com/content/cscript/fmch/2013/00000001/00000002/art00007

· The Community Hub: a proposal to change the role of Residential Aged Care Facilities (RACFs)

http://www.ingentaconnect.com/content/cscript/fmch/2014/00000002/00000004/art00003

· Availability and social determinants of community health management service for patients with chronic diseases: An empirical analysis on elderly hypertensive and diabetic patients in an eastern metropolis of China

http://www.ingentaconnect.com/content/cscript/fmch/2015/00000003/00000001/art00003

Kaining Zhang, PhD

Yunnan College of Business Management, #55 Box, Yinhai Landscape, #748 Dianchi Road,Kunming, Yunnan 650228, China

E-mail: knzhang49@139.com

16 May 2016;

Accepted 24 June 2016

Family Medicine and Community Health 2016;4(3):64-68

www.fmch-journal.org DOI 10.15212/FMCH.2016.0119

© 2016 Family Medicine and Community Health