Concerns of seniors living in rural elderly care facilities

By GUO QI et al. / 06-13-2024 / Chinese Social Sciences Today

A doctor provides free medical service at an elderly care center in Xingtai, Hebei Province, on Nov. 13, 2023. Photo: CNSphoto

China is transitioning into a “silver society,” as its population ages, with rural areas facing higher aging levels than urban regions. The number of elderly population in rural areas has steadily increased, prompting farmers, governance bodies, and rural communities to prioritize elderly care, as both a concept and an institutional form. The government introduced several policies to support rural elderly care, making the development of an inclusive, efficient, and sustainable elderly care service system a central focus in rural civil affairs work. Many regions have gradually established a comprehensive elderly care service system centered on home care, supported by community services, and reinforced by institutional care. 

However, while the model of elderly care is functional, issues remain with rural understandings of elderly care and the unique, deep-seated notions held by elderly people. These cultural insights should be included in the construction of a new socialist countryside and a rural elderly care service system. 

This article, based on comprehensive data from field investigations, analyzes the institutional reasons for the elderly to enroll in elderly care facilities in one sample county. This study investigates the multiple dimensions of deep-seated family values as reflected in adaptation and maladaptation in the process of adjusting to elderly care. It also explores the root causes of survival anxiety, expressed in varying degrees by the elderly in these elderly care facilities. Research results are then analyzed to recommend specific systems and measures which promote elderly services in rural areas.

Individual dilemmas

Village-run elderly apartments primarily accommodate elderly people who still have the ability to care for themselves, while most residents in nursing homes receive the “Five Guarantees” [the state guarantee to provide proper food, clothing, medical care, housing, and funeral expenses for at-risk residents] or are too old or cognitively impaired to be cared for by their children. Cited reasons for elderly residents who decided to “leave home” included: the redistribution of homestead land, concentrated redevelopment of farmhouses, and the implantation of urban housing models into rural areas.

Due to the size of the population and limited spatial resources, land for construction is in short supply, and concentrated farmhouse redevelopment has relatively uniform requirements. These factors, in addition to the “one household, one house” policy that villages strictly enforce, have deprived elderly residents of the right to allocate homestead land at will. The demolition and reconstruction of old houses results in the disappearance of familiar living spaces and activity scenes, which the elderly have known for a lifetime. Shrinking homestead areas, and the restructuring of farmhouses to mimic urban housing, have put an end to the traditional family spatial division patterns. Such phenomena—where generational differences are amplified and conflicts escalate,  which can lead to disharmony between in-laws due to the inability to separate households—are common in rural areas. 

Due to the inability to separate households, some elderly people attempt to rebuild demolished homes and auxiliary buildings, resulting in illegal constructions. These actions reflect widespread beliefs regarding family living arrangements among rural elderly: they have their own lifestyle, need an independent living space, and need to maintain an appropriate distance from the next generation. The redistribution of homestead land and concentrated redevelopment of farmhouses makes household separation practices a difficult transition for many rural families. Still, the application of urban spatial models and living concepts to rural areas makes household separation increasingly indispensable. The collision of these opposing forces exacerbates the marginalization of the elderly, leaving some who still have the ability to care for themselves “homeless,” forcing them to find shelter in elderly apartments or nursing homes.

Elderly apartments

Elderly apartments provide a concentrated living place for the elderly and alleviate the pressure of house demolition and reconstruction. Most elderly people do not feel forced to relocate; instead, they repeatedly claim that they chose to live in elderly apartments. As long as they have an apartment and can control their living and activity space, rural elderly are generally willing to leave “home” because they are content to be “on their own.” 

The emergence of elderly apartments, although possibly obscuring the many helpless aspects of their daily lives, gives older residents the control to choose household separation and pursue greater personal freedom. This provides them with the opportunity to maintain their daily habits and have freedom in their personal space. The desire for a stable space of their own is unshakeable for Chinese people. Rural elderly people, having dedicated all their energy and money to their children, are seeing their old homes leveled during farmhouse redevelopment. Despite the reconstruction, they still long for the familiarity of their own “nest” in the second half of their lives. Although elderly apartments are modest, they are well-equipped and better suited to the living habits of rural elderly.

Elderly apartments are not merely places for seniors to passively await the end of their lives; they are also spaces for production and social livelihoods. The residents of these apartments are often quite busy. Older individuals may take on simple industrial processing tasks, while those who are younger and healthier might take on village sanitation work, or continue farming. The elderly residents of these apartments have known each other since they were young, and living together in close proximity strengthens their bonds.

Elderly apartments, as a localized institution, provide a viable option for rural elderly in the context of urbanization and concentrated farmhouse redevelopment, offering a way to mitigate generational conflicts. First, the elderly residents can maintain their own small households while still being part of a larger family unit shared with their children and grandchildren, without the physical distance being too far or too near. Second, these apartments have a rental system that grants elderly residents long-term usage rights, providing them with psychological stability and a sense of security. Third, the apartments are not fundamentally different from farmhouses, so the elderly can continue their work and not merely live as passive residents. In essence, elderly apartments and the course of rural social life are interwoven, forming a relatively organic whole. The residents are not abandoned by their families; rather, they can demonstrate their agency and pursue their freedom.

Nursing homes

Though standardized architectural layouts and interior designs provide a pleasant living environment, they remove the ability to interact with living spaces, eliminating the possibility to personalize these spaces. Often, the medical cleanliness of nursing homes comes at the cost of personal privacy. Seniors’ schedules, activity spaces, and meals are standardized and fixed, which starkly contrasts with their previous autonomous lives. Living in a professional nursing home means leaving behind their families and kinship networks. These institutions are usually located far from the residents’ original homes and their children’s residences. More importantly, when children send their parents to nursing homes and pay monthly fees, it subconsciously signals a transfer of caregiving responsibility to the institution, often leading to a reduced frequency of visits and care from the children.

For rural seniors, “dying a natural death at home” is a lifelong concern. They believe that only by passing away at home can they be properly buried and avoid becoming wandering spirits. For this reason, many rural seniors insist on returning home to die, even if they have been receiving medical treatment in hospitals. Nursing homes, despite offering professional care, cannot replace the homes that seniors have shaped over the years. The sense of detachment between nursing homes and a personal home is particularly evident in outdoor spaces. Staff work tirelessly on landscaping, while seniors nearby remain indifferent and unengaged. Most seniors accept and adapt, silently altering the nursing home’s rules, schedules, and spatial arrangements as they adjust. This gradual transformation suggests that nursing homes may slowly shift from objective, professional institutions to spaces infused with subjectivity and emotional resonance. However, due to the professional setting and strict rules in nursing homes, these changes are inherently limited.

In short, elderly apartments provide rural seniors with a sense of independence and community, aligning closely with their lifestyle preferences and family structures. In contrast, nursing homes, despite their high-quality professional care, often feel impersonal and distant, highlighting the need for more nuanced and emotionally resonant elder care. It is thus essential to incorporate deep-seated family and spatial concepts into the development of senior care services to create more effective and compassionate care environments.

Private care facilities

In-depth interviews reveal that these private nursing homes cater to local farmers’ lifestyles and habits, therefore the elderly residents feel truly at home. The lives of elderly residents appear pleasant, leisurely, and free, and these private establishments offer a more genuine sense of “home” compared to professional nursing homes. This authenticity can be attributed to their low fees, low operational costs, and lack of professionalization, inadvertently preserving the natural lifestyle of rural homes. In addition, the alignment of the facility directors’ own lifestyles with the rural elderly care centers’ operations also plays a significant role.

What is home

When asked why they chose to live in care facilities and how their lives are, the elderly frequently use words like “freedom,” “lack of freedom,” “having no choice,” and “home” within their interviews. This shows that the concept of home serves as a concrete source of social life and a holistic and foundational metaphor for Chinese people, as evidenced by numerous empirical studies and theoretical reflections. These studies often focus on family relationships and their extensions.

A home consists of family members who embody traditional Chinese values such as filial piety and love between spouses, and the ideal of multiple generations living under one roof. These values still hold strong today. For the elderly, separating their personal living spaces from the extended family signifies individual freedom. They can return to a family members’ household without having to consider themselves a burden to other family members and can shed the economic and domestic responsibility of maintaining a large family. This sense of freedom not only stems from the love and longing generated by distance between family members but also from the return to a two-person world after raising children, with the personal house being a crucial pillar.

The primary difference in cultural concepts of home, between rural and urban elderly, is not in relationships with family members or the house but in the sense of homeland. In urban areas, moving is a routine that only signifies a change in homeownership. However, in rural areas, a strong attachment to the land is both a social governance system and a lifestyle. While understandings of home involve family members, the house, and the homeland, with subtle balances in shifting family dynamics, “home” is generally centered on family members. Family members are interconnected and support each other, forming a holistic concept of home that resides in the subconscious of rural elderly. This concept is the core of their fundamental beliefs and spiritual disposition.

True respect for the elderly involves adapting elder care environments to their needs rather than the other way around. Prioritizing the needs of the elderly is essential to ensure their fundamental security, alleviate their survival anxiety, and establish a new ethical society. Thus, elder care policies and practices must consider and integrate the importance of deep-seated concepts such as family and home, ensuring that care environments resonate with their intrinsic values and provide a sense of continuity and stability.

Guo Qi, Xiao Ying (professor), Wang Donghui, and Fu Jiajia are from the School of Sociology at Shanghai University.

Edited by YANG XUE