By the end of 2021, the number of people in China aged 60 years and over had reached 267.36 million, accounting for 18.9% of the total population (National Health Commission of the People’s Republic of China, 2022). In 2005 the average annual growth rate of older adults (60 years and over) in China from 2000 to 2050 was expected to be around 4.4% (United Nations, Department of Economic and Social Affairs, Population Division, 2006). According to projections made in 2022, the number of people aged 60 years and above was expected to exceed 300 million in 2024, 500 million in 2048, and reach a peak of 524 million in 2052, and the number of people aged 65 years and above was expected to exceed 300 million in 2033, exceed 400 million in 2050, and reach a peak of 436 million in 2057 (W. Chen, 2022, as cited in Du, 2023). The steady increase in the proportion of the population in this age group has heightened public attention to the health of older adults.

 

Self-rated health (SRH) is widely used to assess overall health status among older adults. Self-evaluation of physical health serves as a cumulative proxy for stressors, social support, health behaviors, personal attitudes, chronic conditions, functional limitations, and medical history (Kaplan & Baron-Epel, 2003). SRH evaluation shows strong consistency with both subjective and objective health measures, is more stable than physician assessments (Idler & Benyamini, 1997), and reliably predicts morbidity and mortality (Lee, 2000). Environmental support is vital for achieving healthy aging (Denstel et al., 2023). Choi (2020) found that neighborhood characteristics, including social infrastructure and accessibility, provide essential support for adults aged over 50 years. Social factors, such as health insurance and community services, are also associated with older adults’ health (Chang, 2009). Our focus in the current study was on examining the impact of the community environment on the health of older adults, and the underlying mechanisms in this relationship.

 

Community services provided for older adults in China include daily living assistance, psychological support, and home nursing services (Xia, 2020). The 2018 wave of the Chinese Longitudinal Healthy Longevity Survey collected information on eight types of service including personal care, home medical care, spiritual comfort and chatting, daily shopping assistance, social and recreational activities, legal aid, health education, and neighborhood relationship services. We defined the categories of personal care and daily shopping assistance as daily care, classed spiritual comfort and chatting along with social and recreational activities as spiritual recreation, categorized home medical care and health education as medical services, and defined legal aid and neighborhood relationship services as legal aid (Xia, 2020).

 

The Chinese government has been promoting the development of community services to expand capacity and meet the care needs of the growing population of older adults. Even so, there remains a substantial level of unmet needs (Lu et al., 2021). Thus, we took community services and unmet needs as entry points to explore the impact of the community environment on older adults who use these services. Previous studies have largely focused on the health effects of community services. This study extended the scope to explore the mediating role of self-determination. Our aim was to contribute to understanding of the psychological mechanisms through which community services affect the health of older adults.

 

Well-developed community-based care services play a vital role in meeting the needs of older adults, enhancing their autonomy and quality of life as they age, and slowing down the onset of physical disabilities (Xia, 2020). Self-determination theory (Deci & Ryan, 2000) has been applied to human motivation in domains such as health, education, work, and sport. According to this theory, autonomy is a basic human need that, when supported, promotes more self-directed behavior in the health domain. Researchers have also shown that people living in communities that are (vs. are not) cohesive and supportive experience influences that are more positive, which, in turn, promotes better health (e.g., Wacker & Roberto, 2016). Some scholars have examined the impact of socioeconomic conditions or psychological cohesion on the health of people in community subsets (Wen & Gu, 2011). Community-based care services for older adults are conducive to improving physical health and reducing the risk of chronic diseases (Lv & Zhang, 2022; Yang et al., 2021). Studies have shown that appropriate use of community services by older adults is effective in reducing emergency hospitalizations (Wallace et al., 2016), preventing hospitalization and inpatient treatment (Tomita et al., 2010), reducing the burden on caregivers (Sussman & Regehr, 2009), and enhancing well-being (Q. Chen et al., 2019). Therefore, we proposed our first hypothesis:

Hypothesis 1: Community services will be positively associated with the health of older adults.

 

An unmet need is a necessity or requirement in a specific area of an individual’s life where the support provided is insufficient, inadequate, or unavailable (van der Roest et al., 2007). The issue of unmet care needs for older adults is prevalent in many countries and has become a global concern because of its negative impacts on health and well-being (Kalánková et al., 2021). Unmet needs of older adults are important clinical and research indicators that may lead to reduced quality of life, increased anxiety and depression (Sachs-Ericsson et al., 2005; J. Zhang et al., 2021), and even an increase in the mortality rate (Blazer et al., 2005). Unmet needs can also lead to negative events, such as emergency room visits, placement in a nursing home, and hospitalization (Long et al., 2005). Estimates of unmet needs can serve as an indicator of the future demand for long-term care services (Long et al., 2005). Therefore, we proposed our second hypothesis:

Hypothesis 2: Unmet community service needs will be negatively associated with the health of older adults.

 

Wehmeyer (2005) defined self-determined behavior as “acting as the primary causal agent in one’s life and making choices and decisions regarding one’s quality of life free from undue external influence or interference” (p. 117). Self-determination theory describes the process whereby an individual’s social environment generates the satisfaction of their psychological needs, which, in turn, generates intrinsic (or internalized) motivation and/or positive influence, both of which have a significant impact on behavior (Deci & Ryan, 2000). Satisfied needs provide resources for positive motivation and behavior (Sheldon & Gunz, 2009). Breitholtz et al. (2013) found that even when older adults were dependent on others for their daily activities, they still expressed the need to exercise their right to self-determination in their daily life. Self-determination has become a particularly crucial psychosocial determinant of healthy aging. Ng et al. (2012) showed in a meta-analysis that enhanced self-determination is consistently associated with improvements in the psychological and physical health of older adults. Wehmeyer and Bolding (2001) found that those who lived and worked in a community environment, as opposed to a clustered noncommunity environment, had higher self-determination, enjoyed greater autonomy, had more opportunities for choice, and were more satisfied. When their psychological needs are met, individuals experience more self-determined motivation and a higher level of well-being (Deci & Ryan, 2000). Philippe and Vallerand (2008) confirmed that a supportive environment can fulfill psychological needs, which, in turn, leads to better psychological adjustment for older people living in a nursing home. Interventions that enhance autonomy have been found to be associated with improved quality of life and reduced mortality in people living in a senior citizens’ home (Hwang et al., 2006). Ryan et al. (2008) also reported finding that supporting patients’ needs for autonomy, competence, and relatedness during medical interventions can improve long-term outcomes. In addition to the physical benefits, self-determination helps to enhance mental health outcomes (Soenens & Vansteenkiste, 2010), including reduction in depression, and increases in self-esteem and life satisfaction (Ben-Zur, 2002). Therefore, we proposed the following hypotheses:

Hypothesis 3: Self-determination will mediate the relationship between community services and the health of older adults.

Hypothesis 4: Self-determination will mediate the relationship between unmet needs for community services and the health of older adults.

We used data from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which is one of the most extensive and longest running surveys in China’s social sciences, covering 22 Han Chinese provinces, and is conducted every 3 years. Core variables in the analysis included community services, self-determination, and SRH. Following previous studies, we selected potential influencing factors of SRH for correlation analysis: gender, age, level of education, marital status, annual household income, presence or absence of children, sleep duration, and chronic diseases (Cui et al., 2021; Frange et al., 2014; Mansyur et al., 2008; Murata et al., 2006). To ensure data quality, we cleaned missing values in the core variables, and to avoid compromising reliability, excluded observations with key information missing. Values missing in control variables were imputed using median interpolation. Specifically, among the original 16,954 observations in the 2018 CLHLS dataset, we excluded 15,206 because information was missing on at least one of the core variables. As a result, the final sample consisted of data from 1,748 survey respondents. The respondents ranged in age from 70 to 116 years (M = 84.2, SD = 7.63), and there were 808 (46.2%) men and 940 (53.8%) women.

The availability of community services was measured with the CLHLS question “Are there any services for older adults available in your community?” Eight categories were provided as response options: (a) personal daily care, (b) daily shopping assistance, (c) home medical care, (d) health education, (e) spiritual comfort and chatting, (f) social and recreational activities, (g) legal aid, and (h) mediation for family or neighborhood disputes. We grouped these eight items into four categories: daily care, medical services, spiritual recreation, and legal aid, with each category comprising two services. To evaluate the level of community services available for older adults, all items were dichotomously coded (0 = no, 1 = yes), and positive responses were summed to generate a composite score (range = 0–2).

 

To measure need for community services, we used the question “Would you like the community to provide the following social services for older adults?” Response options were as follows: (a) personal care, (b) home medical care, (c) spiritual comfort and chatting, (d) daily shopping assistance, (e) social and recreational activities, (f) legal aid, (g) health education, and (h) neighborhood relationship services. Community service needs were coded based on positive responses (0 = not needed, 1 = needed). Similarly, we coded responses to the question “What community services are available in your community for older adults?” according to service provision (0 = not provided, 1 = provided). We constructed a new variable that we labeled community unmet needs, by subtracting service supplied from service need on an item-by-item basis (i.e., need minus provided). A result of 0 indicated a met need, 1 indicated an unmet need, and −1 indicated the absence of a need. Unmet needs were further categorized into four domains: daily care, medical services, spiritual recreation, and legal aid.

 

To assess self-determination among the respondents, we used the question “Are you in charge of your own affairs?” This question reflects the personal control and decision-making capacity of older adults in daily life and serves as a key indicator of self-determination. The variable was treated as continuous. In the original coding, the responses were coded on a 5-point Likert scale ranging from 1 = always to 5 = never. So that higher scores indicated a higher level of self-determination, we reversed this coding so that 1 = never, 5 = always. Thus, higher scores reflected a higher level of self-determination.

 

We measured SRH using the question “How do you feel with your own health right now?” For this question we also reversed the coding used in the original survey, and participants’ responses were scored on a 5-point scale (1 = very bad, 5 = very good), with higher scores indicating better perceived health.

We used SPSS 22.0 to calculate descriptive statistics and conduct a correlation analysis, and estimated two multiple mediation models in Mplus 7.0 to assess the relationships among community services, unmet needs, self-determination, and SRH of older adults.

We performed a Pearson correlation analysis of the study variables (see Table 1). The community services of daily care and spiritual recreation were positively associated with SRH. Unmet needs for daily care, medical services, spiritual recreation, and legal aid were all negatively associated with SRH. Daily care, medical services, spiritual recreation, and legal aid were all positively associated with self-determination. Unmet needs for daily care, medical services, spiritual recreation, and legal aid were all negatively associated with self-determination. Self-determination was positively associated with SRH. Annual household income, presence or absence of children, sleep duration, and chronic diseases were included as control variables in the subsequent model.

To test Hypotheses 1 and 3, we used Mplus 7.0 to examine both the direct effect of the community services categories on older adults’ SRH and the mediating role of self-determination in this relationship. The model fit was acceptable, χ²/df = 2.217, root-mean-square error of approximation (RMSEA) = .026, comparative fit index (CFI) = .981, Tucker–Lewis index (TLI) = .920. As shown in Figure 1, daily care provision was positively associated with SRH and negatively associated with self-determination. Medical services were not significantly associated with SRH, but were positively associated with self-determination. The association of spiritual recreation with SRH was nonsignificant, but there was a positive association with self-determination. Legal aid was not significantly associated with either SRH or self-determination. Self-determination was positively associated with SRH.

 

We tested individual mediation effects using the bias-corrected bootstrapping method with 5,000 resamples and 95% confidence intervals (CIs). As shown in Table 2, the indirect paths from the community services of daily care, medical services, and spiritual recreation to SRH via self-determination were significant, as the 95% CI for each did not include zero. The indirect path from legal aid to SRH via self-determination was not significant, with the 95% CI including zero.

To test if unmet needs for community services were negatively associated with older adults’ SRH (Hypothesis 2), and if self-determination mediated the relationship between unmet needs for community services and SRH (Hypothesis 4), we performed mediation analysis using Mplus 7.0. The model fit was acceptable, χ²/df = 2.49475, RMSEA = .029, CFI = .984, TLI = .932. As set out in Figure 2, unmet need for daily care services was negatively associated with SRH, but not significantly associated with self-determination. Unmet need for medical services was not significantly associated with SRH, but was negatively associated with self-determination. Unmet need for spiritual recreation was not significantly associated with SRH, but did have a significant negative association with self-determination. Further, unmet need for legal aid was not significantly associated with either SRH or self-determination. Self-determination was significantly and positively associated with SRH.

 

We tested each mediating effect using bias-corrected bootstrapping with 5,000 resamples. As shown in Table 3, the indirect paths from unmet needs for daily care and medical services to SRH via self-determination did not include zero, indicating significant mediation effects. The indirect paths from unmet needs for spiritual recreation and legal aid included zero, suggesting nonsignificant mediation.

We based our study on self-determination theory (Ryan & Deci, 2000) and examined the complex relationships among the health of older adults in China, the community services provided for them, and unmet needs. Our findings partially supported the proposed hypotheses, offering new insights for understanding the underlying mechanisms in these relationships.

 

We found that daily care and spiritual recreation services were significantly associated with better SRH, which aligns with the finding of previous research (Yang et al., 2021), but the association of medical and legal aid services with SRH was nonsignificant. Daily care services likely benefit SRH by covering essential needs such as assistance with grocery shopping and personal care. Such services help older adults to maintain their physical health, and promote their emotional well-being by ensuring support in daily life for physical needs, while also providing stability to reduce anxiety. Social interaction through spiritual recreation services helps alleviate loneliness and reduce stress, anxiety, and depression (Nezlek et al., 2002). Positive social experiences help older adults feel supported and accompanied, which contributes to better health outcomes. The nonsignificant associations of medical and legal aid services with SRH may be because medical services do not align well with older adults’ needs in terms of content, timing, or accessibility (Qiao et al., 2024). Thus, the effects of the medical services on health may emerge over time and may not be captured by short-term SRH measures.

 

Unmet need for community services was negatively associated with older adults’ SRH. Unmet daily care needs (e.g., assistance with daily shopping, personal care) were also negatively associated with SRH. This result is consistent with that of a previous study (Y. Zhang et al., 2021). Daily care services support independent living; the absence of these services may disrupt basic routines (e.g., dietary safety, hygiene) and pose health risks. For example, without assistance, older adults with limited mobility may be at risk of malnutrition or their hygiene may be poor, leading to increased incidence of disease and lower SRH (Wang et al., 2020). The direct effect of unmet needs for medical services, spiritual recreation, and legal aid on SRH was nonsignificant, but the results of the mediation analysis suggest that there may be possible indirect pathways. Older adults are often chronically ill; delays in receiving care may increase stress and lower subjective health ratings. Limited social activities may lead to loneliness and negative emotions, affecting mental health (Fadila & Elhameed, 2019). The nonsignificant association for legal aid may reflect the limited need that older adults have for legal help in their daily life. Traditional family values in China lead older adults to seek help with legal matters within the family. Thus, legal aid plays a minor role in their problem-solving strategies.

 

We also explored the mediating role of older adults’ self-determination in the relationship between the community services available and their SRH. We found that certain community services were associated with better SRH through enhanced self-determination. Specifically, medical and spiritual recreation services enhanced their self-determination, which, in turn, supported SRH. This result aligns with self-determination theory in the health context (Ng et al., 2012), by emphasizing the impact of need for autonomy on behavior and psychological well-being. Community services are associated with better health outcomes through their support for the fulfillment of higher order psychological needs (autonomy, competence, and relatedness). For example, health education may improve an individual’s confidence in managing a chronic condition (competence), and recreational activities foster a sense of belonging through social engagement (relatedness). When community services offer choices (e.g., frequency of checkups, types of activities), they fulfill autonomy needs and enhance individuals’ sense of control over life (Deci & Ryan, 2000). Supportive communities facilitate self-determination through choices in aspects such as service type and timing (Andrew & Meeks, 2018), which strengthens perceived control over life—a key factor in older adults’ health (Rodin, 1986). When they can participate in deciding the form of spiritual and recreational activities, and can independently choose the timing and content of medical services, older adults gain a sense of control over their life, which supports both their physical and mental health.

 

Although unmet needs for medical services were not directly related to SRH, there was a significant indirect effect mediated by self-determination. According to self-determination theory (Ryan & Deci, 2000), unmet needs for medical services undermine control over health management (e.g., lack of choice over timing or rehabilitation plans), leading to frustration of autonomy needs, which reduces perceived health control and lowers SRH ratings (Deci & Ryan, 2008). For instance, a lack of medical guidance may lead to anxiety because of reduced control over illness. This highlights the psychological empowerment role of medical services: beyond treatment, the provision of these services enhances a sense of control over one’s health through participation in decision making. Similarly, unmet needs for spiritual recreation were negatively associated with self-determination, and the mediating effect was at a significant level. In other words, unmet needs influenced health through self-determination, indirectly leading to poorer self-rating of health. In line with self-determination theory (Deci & Ryan, 2000), gaps in spiritual recreation services frustrate autonomy and relatedness needs, lowering the individual’s self-evaluation of health. For instance, when older adults cannot choose the form or timing of social activities (e.g., being required to take part in activities arranged for a group at a set time), their sense of control over life diminishes. The absence of activities, such as chat groups, also limits social interaction, reducing the sense of belonging and increasing loneliness and emotional isolation (Fadila & Elhameed, 2019).

 

Our study has some limitations. First, because the data are cross-sectional, we could not establish causality, highlighting the need for longitudinal designs to track changes in the relationship between community services and health. Second, as we drew the data from a national survey of older adults conducted in China in 2018, the generalizability of the findings to populations in this age range in other countries may be limited. Because the data are now 8 years old, this may limit the study’s reflection of the more recent context. In future studies, researchers could consider incorporating updated data. Third, we measured self-determination using a single indicator; in future studies, multidimensional scales could be applied (e.g., autonomy, competence, relatedness) to better capture the underlying mechanisms. Finally, we did not examine potential moderators such as family support. Future researchers could explore how social networks interact with community services to clarify the pathways to healthy aging.

 

This study has contributed to the growing body of research on aging and health by highlighting the differentiated effects of community services and unmet needs on older adults’ SRH. By introducing self-determination as a mediating mechanism, this study provides theoretical insight into possible pathways through which psychological needs relate to the health outcomes of older adults. The results also offer practical implications for optimizing the design of community services to support healthy aging.

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