Shanghai, one of the largest cities by population in the world, is currently experiencing a record-setting increase in the aging population as well as the need for nursing home care. Elders aged 65 and over accounted for 25.7 % of the city’s overall 23.5 million population in 2012 (or about six million people; Shanghai Statistic Bureau 2013; Social Welfare Department of Shanghai Civil Affairs Bureau 2013). The average life expectancy in Shanghai in 2012 was 82.4 years, while the fertility rate has remained negative for the past 15 years (Shanghai Statistic Bureau 2013). Shanghai houses the largest and the “oldest” aging population in China (Shanghai Research Center on Aging 2014).
Recently, an increasing number of elders in Shanghai have moved into nursing homes to meet their needs for long-term care. The number of nursing homes in Shanghai has increased nearly 25 %, from 505 in 2006 to 631 in 2012 (Social Welfare Department of Shanghai Civil Affairs Bureau 2013). The number of nursing home beds has increased almost 50 %, from approximately 60,000 in 2006 to over 105,000 in 2012 (Social Welfare Department of Shanghai Civil Affairs Bureau 2013). The number of nursing home beds increased by almost 6000 in 2012 alone (Social Welfare Department of Shanghai Civil Affairs Bureau 2013). This shift, from family caregiving to nursing home care, constitutes a break with Chinese tradition and calls for an exploration of how Chinese baby-boomers and their elderly parents decide to institutionalize.
1.1 History of Chinese Sociodemographic Changes
China, the largest developing country in the world, is facing a rapidly growing aging population with overwhelming long-term care needs (Arnsberger et al. 2000) precipitated by increasing standards of living combined with the distorted demographic results of the one-child policy (Kissinger 2011). By 2050, more than 30 % of China’s population is projected to be 65 and older, which is roughly equivalent to the entire current population (316 million) of the USA (United States Census Bureau 2013; Hayutin 2008).
This demographic aging shift has a historical background. In 1949, when the Communists came to power, China’s total population was less than half of its current size, about 541.7 million (Zhang and Goza 2006). However, Mao Zedong believed that the larger the population, the more power the country would have to fight against capitalism (Kissinger 2011). Under the leadership of Mao, neo-Malthusians in China, who advocated for population control to ensure the availability of resources for future populations (Marsh and Alagona 2008), were stifled; and, as a result, the population nearly doubled over the next 25 years (Zhang and Goza 2006; Greenhalgh 2005). Between 1953 and 1964 alone, the country’s population swelled by an additional 112 million (Riskin 2000). The children born during the population influx of the 1950s and 1960s are now referred to as the Chinese baby-boomer generation (Greenhalgh 2005). As its baby-boomer generation begins to age in the approaching decade, China will face a glut of younger elders and middle-aged adults (Du 2013).
After Mao died, the next leader, Deng Xiaoping, initiated the Economic Reform, leading China to become the world’s second-largest economy (Kissinger 2011). Foreseeing the potential threat of the rapidly growing population to Chinese economic development, Deng adopted a strict family planning policy, known popularly as the one-child policy, in 1978 (Greenhalgh 2005; Zimmer and Kwong 2003). This policy was applied to the Han ethnic group, accounting for 92 % of the total Chinese population (Greenhalgh 2005). Consequently, China’s total fertility rate dropped from about 7.5 % in 1963 (Poston and Duan 2000) to 1.5 % in 2011 (Population Reference Bureau [PRB] 2011). Furthermore, in 2008, a total of 46 % of the Chinese population (including immigrants from rural areas) was concentrated in urban areas (Banister et al. 2010). Among them, 12.7 % were elders aged 65 and over (about 101.6 million), whereas in rural areas, the aging population was just 9.8 % (about 70.5 million; Banister et al. 2010). The proportion of older adults within the total population in urban China is expected to continue to grow over the urbanization process (PRB 2011; Banister et al. 2010; Arnsberger et al. 2000). This means that the long-term-care needs of the increasing aging population will also continue to grow in urban China.
The growing need for long-term care has also been directly impacted by the decreasing fertility rate. This, combined with the aging of Chinese baby-boomers, has created a “4-2-1” phenomenon in urban China (Sun 2004; Zimmer and Kwong 2003). That is, one child has to take care of his or her two parents and four grandparents. This “4-2-1” phenomenon may aggravate the difficulties in meeting the needs for elder care due to the fewer number of children in the family as well as disrupt the Chinese family caregiving tradition for the approaching “grey tsunami” of Chinese baby-boomers (China National Committee on Aging 2009; Zhan et al. 2008). By investigating how Chinese baby-boomers and their parents—the “2” and the “4”—deal with current changes in caregiving arrangements and make caregiving decisions we may inform the development of Chinese health-care policy aimed at meeting China’s increasing long-term care needs.
1.2 Long-Term Care in the USA and Urban China
Long-term care refers to a broad spectrum of paid and unpaid, medical and nonmedical care for people who have a chronic illness or disability (Kaiser Family Foundation 2011; Medicare.gov 2011a; Feder et al. 2000). Long-term care is different from acute care, which provides temporary, episodic services, but focuses on curing an illness or restoring an individual to a previous state of better health (Stone 2000; Kane et al. 1998). Long-term care is a way to integrate treatment and caregiving for elders and people with disabilities over time by incorporating health care into their daily lives (Stone 2000; Kane et al. 1998).
Declines in the ability to maintain activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) are the primary reasons elders need long-term care (Jones et al. 2009; Feder et al. 2000). ADLs are routine tasks of life, including eating, bathing, dressing, getting into and out of bed or a chair, and using the toilet (Gaugler et al. 2003; Feder et al. 2000). IADLs are additional activities necessary for independence, including walking around, laundry, housekeeping, phone use, preparing meals, shopping for groceries, going places outside of walking distance, and managing money (Gaugler et al. 2003; Feder et al. 2000). The National Long-Term Care Survey (NLTCS) in the USA defines the criteria for institutionalization as being disabled in any of six ADL tasks and any of eight IADL tasks for more than 90 days (Manton et al. 2006).
In the USA, at least eight types of long-term care exi...