Social Science & Medicine 72 (2011) 365e372
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Social Science & Medicine
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Aging, health and place in residential care facilities in Beijing, China
Yang Cheng a, b, *, Mark W. Rosenberg b, Wuyi Wang c, Linsheng Yang c, Hairong Li c
a
School of Geography, Beijing Normal University, 19 Xinjiekouwai Avenue, Beijing 100875, China
Department of Geography, Queen’s University, Kingston, Ontario K7L 3E6, Canada
c
Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Available online 26 October 2010
In recent years, residential care has become an alternative option for elder care in Beijing, China. Little is
known, however, about the well-being of elderly residents and the relationship between their health and
living in residential care facilities (RCFs). Hence this research aims to understand the well-being of
elderly residents in RCFs and how the environment of RCFs affects elderly people’s everyday activities
and health. The concepts of therapeutic landscapes, active aging, and well-being contribute to understanding the relationships among aging, health, and environment within RCF settings. Qualitative data
from 46 in-depth semi-structured interviews with RCF managers, elderly residents, and family members
in Beijing were transcribed and analysed using the constant comparative method. The results show that
most of the elderly residents are satisfied with their lives in RCFs, but a few of them feel isolated and
depressed after their relocation. Each RCF, as a place with its unique physical and social environment, has
a significant influence on the elderly residents’ physical and psychological well-being. Individual factors
such as characteristics of elderly residents, their attitudes on aging and residential care, and family
support also play important roles in their adaptation and well-being after relocation from home to RCFs.
Although this study focuses on residential care at the local level, it sheds light on future research on
geographical and socio-cultural meanings of elder care at local, regional, and national levels in China.
Ó 2010 Elsevier Ltd. All rights reserved.
Keywords:
Therapeutic landscapes
China
Aging
Residential care
Well-being
Introduction
The population is aging rapidly in China as a result of the
decrease in fertility and mortality in recent decades. Beijing, the
capital of China, has 2.2 million elderly people aged 60 and over,
which was 17.7 percent of its total population in 2008. The population aged 60 and over is expected to be 4.2 million by 2025,
which will be 30 percent of the total population (Beijing Municipal
Bureau of Statistics, 2000; Committee on Aging of Beijing, 2009).
The decreased availability of family caregivers providing day-today care for their elderly family members, the absence or shortage
of community care services, and the development of residential
care services facilitate the utilization of a variety of forms of residential care in recent years (Gu, Dupre, & Liu, 2007; Zhan, 2000). By
the end of 2008, there were 336 residential care facilities (RCFs)
with 39,994 beds in total, available for 1.8 percent of the elderly
population, and 62.9 percent of the beds were occupied (Beijing
Municipal Bureau of Civil Affairs, 2009).
* Corresponding author. School of Geography, Beijing Normal University, 19
Xinjiekouwai Avenue, Beijing 100875, China. Fax: þ86 10 64856504.
E-mail addresses: [email protected] (Y. Cheng), mark.rosenberg@
queensu.ca (M.W. Rosenberg), [email protected] (W. Wang), yangls@igsnrr.
ac.cn (L. Yang), [email protected] (H. Li).
0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.10.008
Since the late 1970s, a group of geographers have focused on the
elderly population, where they live, and their health within theoretical frameworks that link the mind, body, environment, and
society (Golant, 1984; Kearns & Andrews, 2005; Kearns & Gesler,
1998; Laws, 1993; Rowles, 1978). The existing theoretical and
empirical research emphasizes the importance of understanding
how embodied and emplaced experiences shape individuals’
identities and sense of place for the study of one’s well-being
(Kearns & Gesler, 1998). Much of the research focuses on elderly
people in the community and formal and informal home care
(Andrews & Phillips, 2005). Far less of the research is on residential
care. What research exists in English-speaking countries focuses on
not only the physical environment of RCFs including the natural
landscapes, building design, and amenities, but also on the social
relations, attitudes, behaviours, and sense of security and belonging
within the RCFs and their importance for the well-being of elderly
residents (Andrews & Phillips, 2005; Bernard, Bartlam, Sim, & Biggs,
2007; Gatrell, 2002; Hodge, 2008; Reed, Cook, Sullivan, & Buddidge,
2003; Reed, Payton, & Bond, 1998).
The studies in China are relatively limited compared to those in
English-speaking countries. Before the 1980s, RCFs in China only
provided services for elderly people without children, the disabled,
and orphans, and always put the three vulnerable groups under one
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Y. Cheng et al. / Social Science & Medicine 72 (2011) 365e372
roof. The services were limited to basic physical care without
consideration for social and emotional care needs (Zhan, Liu, Guan,
& Bai, 2006). In recent decades, RCFs started to accept self-funded
clients and provide various services to meet their social, emotional,
and spiritual needs (Zhan, Liu, & Guan, 2006). Existing research
focuses on attitudes toward residential care, the characteristics of
elderly people in RCFs, financial mechanisms of the residential care
industry, and the impact of filial piety culture on the decision
making for residential care (Di & Rosenbaum, 1994; Gu et al., 2007;
Guan, Zhan, & Liu, 2007; Shang, 2001; Zhan, Feng, & Luo, 2008;
Zhan, Liu, & Guan, 2006; Zhan, Liu, Guan, & Bai, 2006). Studies
show that elderly residents moved into RCFs mainly because of
their children’s busy work schedule and unavailability for care. The
majority of elder residents in RCFs expressed a preference to live in
RCFs and their living conditions improved compared to at home
(Zhan, Liu, & Guan, 2006). RCF residents were more likely to have
better psychological well-being and enjoy more social activities
than the elderly who live with their children (Zeng, Liu, Zhang, &
Xiao, 2005; Zhan, Liu, & Bai, 2005). With regard to families’ attitudes and support, female relatives, mostly daughters, were less
willing to place the elderly in RCFs compared to their male relatives,
mostly sons. Many of them expressed that if they had a choice they
would have preferred to care for their parents at home. Female
relatives were also more likely to provide physical care and visit
elderly residents after their relocation (Zhan, Liu, & Guan, 2006).
Regarding the relationship between elderly people’s well-being
and the living environment, a few studies confirm that the living
environment is an important determinant of elderly people’s wellbeing, especially psychological well-being (Gu et al., 2007; Phillips,
Siu, Yeh, & Cheng, 2005a, 2005b).
Little research, however, has been carried out concerning the
well-being of elderly residents and the relationships between
health and place in RCFs. What is also missing from the literature is
a multi-perspective analysis that takes into account the views of
elderly persons who move into RCFs, their families, and the RCF
managers.
Among major Chinese cities, Beijing has one of the largest and
most rapidly aging populations. Residential care as an alternative
choice to traditional family care has developed quickly in Beijing in
recent years. Taking Beijing as the study area, this research aims to
answer how the environment of RCFs affects elderly people’s
everyday activities and well-being. Related concepts, therapeutic
landscapes, active aging, and well-being, are explained in detail in
the second section of this paper. The third section focuses on the
methods of data collection and analysis of 46 in-depth semistructure interviews with elderly residents, family members, and
RCF managers in six RCFs in Beijing. The fourth part presents the
results from this research concerning the well-being of elderly
residents, the factors that affect elderly resident’s well-being, and
the link between elderly resident’s well-being and the RCF environment. The concluding part emphasizes the impact of the
physical and social environment in RCFs on elderly residents’ health
in the socio-cultural context of China, the importance of a multiperspective analysis, and the need for future studies of residential
care at various levels and in other areas of China.
The concepts of therapeutic landscapes and active aging
The geography of health emphasizes the importance of place,
the use of social theory (e.g., feminism and postmodernism) and
qualitative methods (e.g., in-depth interviews) (Cutchin, 1999,
2007; Dyck, 1999; Kearns & Andrews, 2005; Kearns & Moon,
2002; Laws, 1993, 1995, 1996; Rosenberg, 1998). The cultural turn
in health geography also calls for more theoretical development in
the study of elder care (Andrews & Phillips, 2005). Concepts such as
therapeutic landscapes (Gesler, 1992) and active aging (WHO,
2002) are suggested as ways of framing the study of elderly
people’s well-being in various settings.
The concept of “therapeutic landscapes” was first developed by
Gesler (1992) and increasingly used by health geographers. Originally, therapeutic landscapes referred to “places that have achieved
lasting reputations for providing physical, mental and spiritual
healing” (Kearns & Gesler, 1998, p. 8). The concept emphasizes the
power of place, and specifically how place interacts with a combination of physical, social, and individual factors to shape the
outcomes of health beliefs and the experiences of well-being. The
formation of therapeutic landscapes is a dynamic process shaped
by both social structures and human subjectivities (Gesler, 1992,
2003; Kearns & Gesler, 1998).
Already some studies have used the concept of therapeutic
landscapes to understand the role of physical, psychological, and
social meanings of place in elder care provision in various settings
such as hospitals, institutions, and homes in the U.K., New Zealand,
and Canada (Martin, Nancarrow, Parker, Phelps, & Regen, 2005;
Moon, Kearns, & Joseph, 2006; Williams, 1986). Kearns and
Andrews (2005) have argued how a residential care setting is
a place shaped by its physical and social environment for the care
and healing of its elderly residents. The environments of RCFs and
social relations within them have profound subjective meanings to
individuals and affect their health. The concept of therapeutic
landscapes has great potential to contribute to studies of elder care
in RCFs (Kearns & Andrews, 2005).
Ideas of active aging (World Health Organization [WHO], 2002)
and some similar concepts, such as successful aging (Rowe & Kahn,
1997), healthy aging (Bartlett & Peel, 2005), and positive aging
(Bowling, 1993), have been developed in response to rapid population aging and elderly people’s quality of life. The WHO (2002, p.
12) defines active aging as “the process of optimizing opportunities
for health, participation and security in order to enhance quality of
life as people age”. The models of active aging posit that the quality
of life of elderly people does not only depend on their physical and
psychological health but also on their morale, life satisfaction, and
engagement with life (Fisher, 1995; Guse & Masesar, 1999). Existing
research has studied the meaning of active aging for elderly people
at various stages, the crucial factors to enable active aging, and
empirical evidence on the role of leisure activities in promoting
health (Chong, Ng, Woo, & Kwan, 2006; Clarke & Warren, 2007;
Hutchinson, Yarnal, Staffordson, & Kerstetter, 2008). The term
“active” donates continual participation in physical, social, and
spiritual activities taking into account people’s capability as they
age (Andrews & Phillips, 2005). Active aging is not only a way of
understanding how elderly residents build up their feelings of selfesteem and self-worth and their engagement in the social environment of RCFs, but it is also a guide for the management of RCFs
to provide elderly residents with a healthy living environment.
The well-being of elderly residents is shaped by individuals’
perceptions and their sense of place. The determinants of wellbeing include the physical and social environments of RCFs,
capacity for self-care, satisfaction in services, sense of security,
social connections, and opportunities for leisure activities
(Andrews & Phillips, 2005; Center for Health Promotion, 2000;
Gatrell, 2002). The concepts of therapeutic landscapes and active
aging help us to understand the interaction between environment
and individual well-being in residential care settings.
Methods
To gain a multiple perspective from key actors in the process of
residential care of older people, in-depth semi-structured interviews were conducted among three groups of participants: elderly
Y. Cheng et al. / Social Science & Medicine 72 (2011) 365e372
residents, family members, and RCF managers. Elderly residents
were asked how they evaluate their health status and quality of life
selecting from excellent, very good, good, fair, or poor before and
after relocation, what their daily activities are, and what the
changes are after their relocation. Family members were asked
similar questions, while RCF managers were asked which types of
services they provide for elderly residents and what factors they
think are important for the well-being of elderly residents in RCFs
(for a complete list of questions for each group, please contact the
first author).
Interviews were carried out in six RCFs taking into account
their types of ownership and location. An experienced research
group in the Institute of Geographic Sciences and Natural
Resources Research at Chinese Academy of Sciences in Beijing
recommended one RCF as a study site, and the other five RCFs
were recommended by the manager from the first RCF. The six
RCFs are typical in Beijing in terms of their location and ownership. Three of the RCFs are located in the central districts of Beijing, and the other three are located in suburban areas. The types
of ownership were private, community, and publicly-owned
privately-run RCFs. All the six RCFs provide assistance to Activities
of Daily Living (ADLs) (e.g., bathing, dressing, eating, indoor
transferring, toileting, and continence), Instrumental Activities of
Daily Living (IADLs) (e.g., shopping, household chores, obtaining
health care, and traveling to these activities), and basic health care
for their residents. Four of the RCFs only accept residents with selfcare abilities and their residents are generally physically and
mentally healthy, while one community RCF and one publiclyowned privately-run RCF also accept residents with only some
self-care abilities who needs more assistance to their activities
(see more detailed information in Table 1). All six RCF managers
were contacted by phone first. After permission was given, time to
visit the RCFs was arranged. RCF managers helped recruit elderly
residents who were willing to participate. Based on the manager’s
knowledge of the residents, only those without cognitive impairments were selected. Both managers and residents helped recruit
family members as participants. In total, 27 elderly residents, 16
family members, and five RCF managers were interviewed in the
six RCFs. The length that the elderly participants stay in RCFs
varies from six months to three years which enables them to
provide reliable information on their experiences in RCFs (see
more detailed information in Table 2). The interviews were carried
out in private and quiet rooms or outdoors in the six RCFs. The
interviewer took notes and the interviews were audio recorded at
the same time. The interviews varied from 30 to 90 min. Mandarin
was the language used during the interviews because it is the
367
Table 2
Basic characteristics of elderly residents and family members interviewed.
Participants
Gender
Age
Elderly residents
Female (17)
60e69 (3)
70e79 (11)
80e89 (10)
Over 90 (3)
Mean age: 80
Male (10)
Family members
Gender
Relationship
with residents
Female (14)
Children (11)
Siblings (3)
Granddaughter (1)
Nephew (1)
Male (2)
official and everyday language in Beijing. Ethics approval for the
research project was obtained from the General Research Ethics
Board of Queen’s University in Canada.
The analysis of the data is based on the constant comparative
method (Glaser & Strauss, 1967). The content of the audio recordings was fully transcribed. The transcripts were read line-by-line
several times in order to mark the key points with a series of codes,
and similar codes were grouped into a concept. As concepts accumulated and their descriptions became more detailed, similar
concepts were rearranged by common themes and thematic categories were developed. Finally, the thematic categories were used
to define concepts and find associations between themes. Together
the thematic categories, concepts, and resulting associations were
used to provide explanations for the findings (Strauss & Corbin,
1990, 1998).
Results
The results show the general well-being of elderly residents in
RCFs in Beijing and identified the factors which affect residents’
well-being. The natural, built, and social environments of RCFs and
individual factors shaped by one’s attitudes, behaviours, and
experiences in RCFs are important to well-being. The results
contribute to understanding how therapeutic landscapes and the
active aging model of RCFs provide a healing function for elderly
residents and shape their personal and collective self-perceptions
and sense of place. The interaction between health and place in
RCFs helps to create a healthy living environment for elderly residents in RCFs.
Table 1
Basic characteristics of RCF research sites.
RCF
Location
Ownershipa
Eligible residents
Beds
Occupied rate
Charge
(Yuan/Month)
A
Suburban district
Private
With self-care ability
102
1420e2340
B
C
D
E
F
Central district
Central district
Central district
Suburban district
Suburban district
Community
Community
Publicly-owned privately-run
Community
Publicly-owned privately-run
With
With
With
With
With
25
32
76
80
712
Summer 100%
Winter 60%
100%
100%
100%
80%
35%
some self-care ability
self-care ability
self-care ability
self-care ability
some self-care ability
1150e1750
1000e1300
1675e2650
1000e1700
2000e2500
a
Note: currently, ownership of RCFs in Beijing is divided among government operated facilities, community facilities, private facilities, and publicly-owned and privatelyrun facilities. Government operated facilities include those operated and funded by local governments. Community facilities include those operated by city neighborhood
committees and village committees, and they are usually funded by local government and communities. Facilities operated by persons, companies, enterprises, and organizations are categorized as private facilities. The publicly-owned and privately-run facilities are a new type of ownership developed in recent years, which are set up and
funded by government, but managed by the private sector. The private sector does not own the properties nor need to pay rent, but assumes sole responsibility for the profits
or losses (Beijing Municipal Bureau of Civil Affairs, Beijing Municipal Commission of Development and Reform, Beijing Municipal Commission of Urban Planning, Beijing
Municipal Bureau of Finance, & Beijing Municipal Bureau of Land and Resources, 2008).
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Y. Cheng et al. / Social Science & Medicine 72 (2011) 365e372
Well-being of elderly residents in RCFs
Most of the elderly residents and family members interviewed
were satisfied with the residents’ lives in the RCFs. Some of the
elderly residents and family members reported significant
improvements in physical and mental health status and social skills
of the residents after relocation. Collective life in RCFs provides
elderly residents with more social opportunities and interaction
with their cohorts than living alone at home, which in turn enables
them to cope with the changes and challenges experienced as they
age. In many ways, elderly residents involve themselves in various
social activities and maintain their social connections within and
out of the RCF.
He (the interviewee’s father) gained some weight (he was too
thin when he was at home). The most important thing is that his
spiritual well-being has improved a lot. He used to avoid
socializing with others because of his poor hearing and sight.
Now he starts to gain back the willingness to socialize with
others after the relocation. (A family member)
The results, however, also show that a small proportion of
residents felt isolated and depressed after their relocation. They
had low levels of interest in participating in social activities, had
grown pessimistic about their futures, and worried about death.
They reported their mobility had become restricted because of
either the physical environment or social management mechanisms of the RCFs (see the next section). They felt that they had
gradually lost their social connections with the outside world and
with their former lives. They also reported a lack of emotional
support from the staff, their families, and friends had increased
their feeling of loneness living in the RCFs. No matter whether
elderly residents reported good or poor health status, their wellbeing was highly related to the physical and social attributes of the
RCF in which they lived.
Health and place in RCFs
Sense of place involves physical, social, and psychological
components (Rowles, 1983). In terms of residential care settings,
Andrews and Phillips (2005, p. 192) describe RCFs as places with
“objective place characteristics and subjective place experiences”,
which have significant influence on elderly residents’ well-being.
The results from this research confirmed the importance of the
physical and social environments of RCFs to elderly residents’
experience of place and their well-being. Apart from the above,
individual factors such as the socio-economic status of elderly
residents, their attitudes about aging and residential care, behaviours, and family support also play important roles in their level of
adaptation and well-being after the relocation from homes to RCFs.
Physical environment
The combination of natural and built landscapes within and
around the RCF, building design, and housing styles, as well as the
micro-environment of individual rooms have significant influence
on the well-being of elderly residents.
First, certain landscapes such as mountain areas, gardens, water,
and parks are reported as healthy landscapes with healing functions for elderly residents’ well-being, whereas the noisy city
environment, limited open space, and busy streets outside of the
RCFs were reported as unhealthy landscapes where elderly residents were more likely to have negative experiences.
I am tired of the noisy environment in the city. I felt depressed
and hopeless.. I decided to move to a pleasant environment..
The air is fresh, the water is clean, and the vegetables are organic
here.. I feel that my health gets improved. (An elderly resident)
Secondly, housing styles, building design, and the micro-environment of individual rooms, such as room location and design,
affect residents’ well-being and quality of care. Elderly residents
reported that bungalows and Beijing courtyards are much easier for
them to get around and socialize as compared to apartment
buildings. Common areas such as dining halls, gardens, and open
space facilitated social interactions among elderly residents. In
addition, room distribution and design such as single rooms or
shared rooms, room location and size, and the window directions of
rooms were reported as important factors for elderly residents’
choice of relocation and their well-being after moving.
I chose my room with a window facing to the south for some
sunshine and in the middle of the second row because the
rooms which are close to the central hall are noisy when people
are passing by, whilst the rooms at the end of the row are close
to the fence and have many bugs flying around. (An elderly
resident)
Thirdly, unhealthy landscapes were reported to be related to the
restriction of elderly residents’ mobility and negative experiences
that elderly residents have had. One of the study sites is located in
a bungalow surrounded by tall apartment buildings in a residential
area. The 32 beds within two-bed, three-bed, and four-bed units
offered in this RCF are relatively small for sharing among multiple
residents. Elderly residents with self care ability and those without
self care ability are mixed living in this bungalow. The smell of
disinfecting liquid often creates discomfort for the elderly residents. The lack of common areas and open space reduces social
opportunities for elderly residents. The hall is one of the few
common areas in the RCF. Some of the elderly residents, however,
spend hours everyday sitting alone on the benches in the hall and
seem reluctant to talk to others. They reported their health status
was declining and they felt isolated, depressed, and insignificant
after their relocation. Upon seeing the significant limitations and
challenges that entail with the incapacity to care for oneself, many
elderly residents often felt discouraged and depressed thinking of
their future. They viewed the RCF as a shelter in which to sleep and
eat instead of a place for receiving care and enjoying their elderly
life.
Social environment
The social aspects of RCF environment including the social
relations, social interactions, and subjective experiences that occur
in places are also significant to one’s well-being. Elderly residents
and RCFs managers reported that social activities, management
mechanisms, together with service quality and utilization were
important components of the social environment in an RCF and
influenced their health.
First, the social activities organized within and outside of RCFs
play an important role for elderly residents in maintaining their
social connections and in adapting to the relocation. The social
activities included taiechi, singing, calligraphy, painting, reading
groups, and weaving classes inside the RCFs, and short trips, visits
to schools or universities outside the RCFs. Volunteer groups from
various organizations and schools come to visit and perform for
elderly residents in the RCFs. The RCFs organized various symposia
for young people and are used as education bases by communities
and local governments. Some RCFs also provided special rooms for
practicing Buddhist and Christian religious activities to meet the
spiritual needs of elderly residents. Elderly residents can choose
among various activities in which to participate. The outcome of
Y. Cheng et al. / Social Science & Medicine 72 (2011) 365e372
these activities, either through the crafts they make or the role they
play in educating the young generation, provided them with
a therapeutic function improving their physical, social, and
psychological well-being.
We have the monthly birthday party at the first weekend of each
month.. We invite family members to get together, share
a birthday cake, make birthday wishes, and sing songs. We also
publish a monthly newspaper. All the manuscripts are
submitted by the elderly residents.. They write comments
about news, about their lives in the RCFs, all kinds of stuff. They
are really happy to see their words being published. (An RCF
manager)
Secondly, the management and staff members constitute an
important part of the social environment of RCFs and have significant impacts on elderly residents’ well-being. Most of the elderly
residents who were interviewed evaluated their lives in current
RCFs as being well organized with the freedom to participate in
activities that they prefer. There are, however, reports about some
RCFs where management and staff resorted to taking precautionary
actions to minimize elderly residents’ risks of the negative experiences, which restrict their level of independence and had negative
effects on their well-being (Li, Huang, & Dong, 2007). In this
research, some participants reported that they had negative experiences in other RCFs before, which caused them to relocate from
one RCF to another. Regarding the management and staff members,
the lack of professional training of staff members, their lack of
motivation and job satisfaction, and high frequency of labour
turnover in the industry affect the quality of service provided.
The chefs are paid very low. That’s why they don’t want to stay
long and we cannot have good meals.. There is not much
professional training of the staff members.. Two staff members
were sent to workshops for training last year, but they left for
a better pay in another RCF soon after they finished the training.
(An elderly resident)
Thirdly, access to services and service quality exert an important
influence on elderly people’s quality of life in RCFs. Taking the food
service as an example, it is one of the services mentioned most
frequently by elderly residents. The food service carries with its
social meanings that extend beyond the daily routine for many
residents. Some elderly people reported that they had difficulties
getting groceries and cooking and sometimes they skipped meals at
home before they moved to RCFs. The RCFs provide various kinds of
food for them to choose and change menus everyday taking into
account nutritional balance. They ate better in RCFs than at home
and gave highly positive evaluations of the quality of food they
were served. Other elderly participants were dissatisfied with the
food service provided. They complained about the poor quality of
food and the lack of choices. The satisfaction over the quality of
services affects elderly residents’ experiences and well-being in
RCFs.
To create a healthy living environment for elderly residents in
RCFs, it is important to provide a healing function through the
social relations and social practices within RCFs, which is a significant component of therapeutic landscapes in RCFs. Healthy physical
and social environments of RCFs are also crucial for providing
elderly residents with opportunities for active aging.
Individual factors e elderly residents
The inequality of experiences of elderly residents is affected by
institutional factors such as the physical and social environment of
RCFs, and also by individual factors such as elderly residents’
369
personal characteristics, health status, attitudes on aging and
residential care. The findings imply the importance of understanding that elderly people are not a homogenous group and
individual factors play significant roles in affecting their health
outcomes when improving equity of elder care. Efforts should be
made to provide the elderly with attractive options and give them
the opportunities to make their own choices.
First, individual characteristics including the personalities and
social skills of elderly residents have direct effects on their social
network within the RCF. Most elderly residents interviewed
reported that it was easier for them to live with those with similar
characteristics, life experiences, and socio-economic status. Once
elderly residents move to one RCF, many of them tend to stay there
for years unless the services provided cannot match their needs.
Secondly, the decline in elderly residents’ health status (e.g., the
decline of eye sight, hearing, and walking ability) limits their mobility
and reduces their opportunities to interact with other residents. The
social activities organized by RCFs have changed over time with
changes in elderly residents’ number, age structure, and health
status. At the time of the interviews, activities which had previously
been organized by the RCFs were no longer offered because of
declines in health status of some of the elderly residents or the
increasing costs of the activities. Elderly residents’ intensity of
engagement in activities is also affected by the changes in their health
status. Decreasing levels of strength and agility pose significant
constraints upon their movement, and occasional fainting spells and
decreased hearing ability affect their communication with others.
In the first few years here, we had more exercises together as
compared to now. We are getting old. Less and less people get up
to join in the morning exercises. Some of us just walk around in
the yard in the morning.. The RCF used to organize us to go to
golf course and fruit picking in orchards. This year we don’t have
any trips like that. (An elderly resident)
Thirdly, attitudes on aging and residential care, awareness of
self, and sense of control affect the self-evaluation of elderly residents’ well-being. Cultural values of filial piety and Confucianism
have played an influential role in shaping the long-standing
negative perceptions of residential care in Chinese society. Traditionally, elderly parents are cared for by their adult children. Society
used to disapprove of family members who relocated their elderly
parents to RCFs, casting it as a way of shrugging off their filial
obligations. With the socio-cultural changes in recent decades in
China, the stigma of residential care is gradually breaking down.
Notwithstanding these changes, certain members of the public,
including some elderly residents and their family members, still
have ambivalent attitudes towards residential care.
My mom told us she wanted to move into an RCF to enjoy her
elderly life.. We were not willing to do so.. She has five
children, two supported and the other three rejected. We had
concerns at the beginning. You know, the pressure from the
society is strong.. We came to an agreement eventually, and
we agreed to let her try, then she moved.. Only my families
know that mom moved into the RCF. We still keep it a secret to
our neighbours. We just tell them my mom went to visit her
daughter for some time.. We still feel the pressure from the
public. (A family member)
For some older people, residential care was a preferred choice to
enhance the quality of their elderly life, which they consider as
a way to relieve themselves from the heavy demands of housework
and spend more time on personal interests. Some elderly residents
chose residential care as a strategy to relieve the care-giving burden
on their family members, but some were reluctant to move and
resented being abandoned by their families.
370
Y. Cheng et al. / Social Science & Medicine 72 (2011) 365e372
The willingness to relocate and attitudes on collective life affect
the adjustment to the transition (Andrews, 2005). Active participation in various activities helps adaptation to relocation and
maintains or improves physical and psychological well-being.
Elderly residents also developed various strategies to manage their
lives in RCFs, such as searching for better RCFs if they were not
satisfied with the current one, hiring hourly caregivers to offer
additional services, and taking housekeeping chores as a form of
exercise to maintain their independence. Additionally, some elderly
residents participated in community services where the RCFs are
located and continued to contribute to society with their expertise
after the relocation.
I encourage other elderly residents to sing with me. I have
taught them more than 10 songs, including a song I wrote for
our RCF, and we perform some of them when people come to
visit or on festivals.. I also wrote a song for the school next to
our RCF and taught the music class there for a year. (An elderly
resident)
Rather than being passively “placed” in an RCF, some elderly
residents actually “live” in the RCF, where they make active choices,
decisions, and judgments about their living environment (Andrews
& Phillips, 2005).
Individual factors e family members
Both elderly residents and their family members’ attitudes
towards aging and residential care directly and indirectly affected
elderly residents’ well-being after relocation. In Asian societies,
the obligations to filial piety continue to persist even with the
recent dramatic socio-economic changes, albeit in an apparently
modified form (Ng, Phillips, & Lee, 2002). The attitude toward
residential care also varies among family members. Some of
them have positive attitudes toward residential care and
continue to provide all kinds of supports for their elderly parents
after the relocation, whereas some of them are negative about
residential care or choose to reduce their supports after the
relocation.
This research shows that most adult children continued to
support their elderly relatives in various ways after their relocation,
and the continued involvement influenced the quality of care
received by elderly residents. Family members engaged in a range
of physical care tasks such as bathing, laundering, and shopping.
They also undertook social care tasks, such as financial support,
visiting, and taking the elderly residents out for social activities or
to family events. Emotional support from family members was
valued as the most important form of support for elderly residents.
In addition, family members undertook an important monitoring
role checking on the quality of care given to the residents. Sometimes, family members also helped other residents they got to
know, which is especially significant for those who have few visitors. This phenomenon is similar to what others have found in other
cultural settings (see Gladstone, Dupuis, & Wexler, 2006; Milligan,
2006). With the cooperation of staff members, family members
contributed their knowledge and experience about the care needs
of elderly residents to improve their overall quality of care that
elderly residents received.
Every week, I bring her some magazines and newspapers when I
come to visit. Sometimes, I take her out for lunch or take her
home for a few days during the holidays. She likes me to come
and talk to her.. I help her do some laundry and wash her
hair.. I usually bring some extra food to share with other
elderly residents and staff when I come to visit. (A family
member)
All the family members interviewed reported that residential
care reduced their care-giving burden. Most family members,
however, were unable to visit their elderly relatives and care for
them everyday because of other social and family obligations. Some
of them developed strategies to maximise their support. For
example, adult children took turns to visit their elderly parents.
Some of them contributed more financial support, while others
provided more social and emotional support, depending on their
capabilities.
The active aging model emphasizes the role of individuals in
continuing to participate in social activities and engaging in their
lives. The examples of how changes in one’s health status affect the
ability to participate in social activities and how elderly residents
and family members develop strategies to meet the challenges they
face illustrate the dynamic attributes of sense of place and the
initiative of making place for adaptation. The individual experiences of social relations and social practices within the RCFs are
important when considering well-being and linking health to place.
Discussions and conclusion
This study is among the first studies on residential care in Beijing from the perspective of health geography. It uses a multiperspective analysis of the relationship between health and place
in RCFs. The results show that the majority of elderly residents are
satisfied with their lives in RCFs. It provides unique insights into the
physical and social environment of RCF life in Beijing as well as how
individual characteristics and attitudes are of vital importance to
elderly residents’ well-being. The meanings of therapeutic landscapes to individuals are shaped by the physical and built environment of RCFs, as well as the social environment which is
composed of social activities, social interactions, and management
mechanism within RCFs. The concepts of therapeutic landscapes
and active aging provide explanation on how the environment
affects the individual’s well-being and how individuals adapt to the
environment and aging process.
The rapid aging of the population in Beijing is creating many
challenges in terms of financial security, health care, and elder care
for elderly people. Residential care as an option for providing elder
care and creating a healthy living environment for elderly people is
attracting more and more elderly residents. Studies in this area are
urgently needed to contribute knowledge for both researchers and
policy makers. The analysis of how RCFs create healthy living
environments for elderly residents and how elderly residents
actively engage in the social life in RCFs is helpful to improve the
future planning and service quality of residential care.
The active aging model emphasizes individual responsibility in
terms of maintaining a healthy lifestyle and engaging in a life-long
preparation for old age and active participation. However, the role of
RCFs and government are also important for providing necessary
facilities, services, and management mechanisms to facilitate the
participation and increase the opportunities for elderly residents. In
the current context of China, the active aging model encourages the
people in the early stages of aging (60e79 years) to be important
care-giving resources both for the oldesteold and for young children
not only in families, but also in RCFs, the community, and society in
general. Building up elderly residents’ self-esteem, feelings of selfworth, and valuing their expertise is helpful in improving their
quality of life. The active aging model has a cumulative effect that
can provide mutual benefits to individuals and society. Additionally,
to engage family members in care-giving, especially emotional and
social support is necessary for improving the well-being of elderly
residents (Milligan, 2006).
There are some limitations to this research: the elderly residents
and family members interviewed are not matched within families
Y. Cheng et al. / Social Science & Medicine 72 (2011) 365e372
because of the difficulty in recruitment; all the elderly participants
have self-care abilities; and this paper does not address the variable
outcomes among RCFs in terms of their size and type of ownership.
For future research, more studies need to focus on the relationship
between place and health of elderly people with some or no selfcare abilities, and whether findings from this study would match
findings from other studies of the elderly population living in RCFs
in other parts of China.
Many of the findings parallel research on residential care for the
elderly in English-speaking countries in examining the impacts of
housing styles, building designs, access to services, and the quality
of care (Calkins, 2001; Hubbard, Tester, & Downs, 2003; Keen, 1989;
Netten, 1993; Traupmann, Eckels, & Hatfield, 1992); preference of
using on-site common areas to separated facilities (Bernard et al.,
2007); and impacts of on service quality due to low salaries, long
working hours, and poor working conditions for caregivers in RCFs
(Bartlett & Phillips, 1995; Matosevic, Knapp, Kendall, Henderson, &
Fernandez, 2007). There are, however many aspects to residential
care life in China that are a unique blend of Chinese tradition (e.g.,
room orientation) with the practical necessities of providing care.
There is also the particular tension created between elderly people,
their family members, and the community over whether residential care represents a break with tradition and the failure of children
to honour their responsibilities to their parents. Finally, there are
the specific issues of creating a residential care system quickly to
meet the rapid growth of an elderly population at an unprecedented scale in the complex environment of provision by services
representing a mix between public and private ownership.
Acknowledgements
All the authors gratefully thank the interviewees for participating in the research and Chinese Ministry of Science and Technology for financial support of this research through international
collaborative research project “Research on Environmental Change
and Health Security in BeijingeTianjin Megacity Area” (Grant
Agreement No. 2007DFC20180).
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