How Common Self-Treatment Is and What Influences It Among Older Adults Living Alone or With Family in Shandong, China

The number of older population over 60 years was 250 million at the end of 2018, accounting for 17.9% of the total population in China. People above the age of 65 are projected to represent 26% of China’s population by 2050 according to a report by the World Bank [1,2]. China is inevitably under the pressure of rapid aging. A major feature of China’s population aging is the transition of elderly household patterns. Living with children is the typical Chinese traditional family pattern for older people [3]. But due to many factors, such as the one-child parents entering the elderly, the imbalance of economic development, the acceleration of urbanization, and population migration, the proportion of elders living alone or living with their spouse continues to rise. These elders are called “empty nesters” [3,4,5,6]. The estimated number of empty nester households will account for 90% of the elderly households by 2030 [7]. Due to the lack of affection and spiritual comfort from their children for a long period, the empty nest elderly might have a worse health status. With the increasing number of empty nest elderly, the demand on health services for the elderly has become a major challenge facing us.

When ill, individuals can seek professional health care, self-treat, or do nothing [8]. Self-treatment refers to treating oneself without professional help to alleviate an illness or a condition [9], including self-medication or massage, hot compress or other auxiliary therapy. The definition of self-treatment differs across different publications [8,10,11]. In developing countries, self-treatment is increasing rapidly. A systematic review showed that the prevalence of self-medication among the elderly varies from 20% to 60% in most studies [12]. An Iranian study indicated that 80% of patients chose self-treatment [11]. In China, the fourth National Health Service Survey released that 38.0% of patients did not go to see a doctor, of which 70.0% used self-treatment [13]. The data of the China Health and Retirement Longitudinal Study (CHARLS) in 2013 showed that the prevalence of self-treatment among the middle-aged and elderly patients with non-communicable chronic diseases was 64.04% [14]. Compared with other professional hospital-based healthcare approaches (inpatient and outpatient treatments), correct self-treatment can be helpful for both individuals and medical health system, such as convenience, accessibility, lower medical costs, complementing the health care system, and relieving the burden of limited medical services. It can effectively alleviate the problems of difficulty and expense when seeing a doctor [8,15], and appropriate self-treatment can also avoid some unnecessary waste of medical resources [16]. But the negative effects of incorrect self-treatment cannot be ignored either. Irrational self-treatment, such as false self-diagnosis, drug abuse, missing optimal treatment, side effects or interaction with other drugs, can cause serious clinical consequences and unnecessary economic loss [15,17].

Older adults may be more likely to choose self-treatment due to the overall worse health status [18,19]. Previous studies have examined the potential determinates of self-treatment among the elderly. The decision to choose self-treatment involves a complex mechanism and is influenced by various factors, including individual, household, accessibility and medical insurance system factors [10,20]. Few studies, however, exist to date in China focusing on the roles of social changes and living arrangements in the use of self-treatment. Empty nesters may have a higher prevalence of self-treatment due to low socioeconomic status. Consequently, there is a clear need to evaluate nest status in the intensity of using self-treatment.

To extend the literature, the aims of this study are to identify the difference between empty and non-empty nesters in self-treatment behavior and comparatively evaluate the risk factors, respectively. This aims to provide a reference for formulating targeted interventions to improve self-treatment effectively.

The study showed that the prevalence of self-treatment among the elderly who reported the presence of illness during the two-week period before they were interviewed in Shandong, China, was 79.9%, which was higher than other similar studies [19,22]. It is difficult to compare with other studies due to the use of different definitions of self-treatment in each study. With the development of the economy and society, the access channels for health information is becoming more and more diversified, which plays a certain role in promoting self-treatment behavior.

Our results showed that the prevalence of self-treatment in empty nesters was lower than that in non-empty ones (74.0% vs. 83.3%), and the difference was significant after adjusting variables for social-economic and health-related factors. It is inconsistent with our hypothesis that the empty nesters may have a higher prevalence of self-treatment due to the poorer socioeconomic status. The possible explanation may be that China has improved the accessibility and equality for health services effectively in the past few years. A previous study [3] conducted in Shandong, China in 2011 showed that the empty nesters have a higher non-use rate of healthcare services than non-empty ones due to the fact that the higher demand for health services cannot be met equally, but another study conducted in Sinan county, China, in 2018 was inconsistent with it, which found that the empty nesters were less likely to choose self-treatment. After the ‘healthy China 2030’ plan released by the central government in 2016, a series of health poverty alleviation projects were implemented with the goal of strengthening financial risk protection against illness for the financially backward population [23,24,25]. A study indicated that more than 4.2 million poor patients with serious or chronic diseases have been treated due to the health poverty alleviation project [26]. Another important explanation for non-empty nesters having a higher prevalence of self-treatment than empty ones is that the family caregivers are often equipped with some knowledge and common skills of healthcare tasks due to the increased frailty of the elderly, and the non-empty nesters would usually deal with their discomfort with the support of their adult children [20].The results suggests that it is important to strengthen health education for elderly and family caregivers to make them understand the risks of improper self-treatment.

However, our separate analysis of empty and non-empty nesters showed that the effect of the socio-economic status on the behavior of self-treatment is significant for the empty nesters, but is not for the non-empty nesters. Among the empty nesters, the elderly who reported better economic status were more likely to use self-treatment. On the one hand, our view is that the targeted health poverty alleviation policy effectively improved the utilization of health services for the poorer population [27,28,29]. On the other hand, the possible explanation is that the elderly in poverty may have difficulty self-purchasing drugs with out-of-pocket money, which cannot be covered by medical insurance [20], and the elderly with higher affordability have more access to medical resources outside hospitals. In addition, education was negatively associated with self-treatment in empty nesters, educational level is related to the ability to access health information, elderly who with higher education usually have higher health literacy. However, even though our results showed a statistical significance between education and behavior, the clinical significance of the self-treatment rate of three groups of education level in Table 3, 77.9% in the least education and 70.8% in the most education, does not seem too impressive. We will further explore the relationship between education and self-treatment in the following research.

Regarding the non-empty nesters, there was no significant difference in using self-treatment among the elderly with different economic status. Except for the fact that empty nest elders are given more attention and social support than non-empty nesters due to their special physical and psychological needs, the health poverty alleviation project may be more significant in improving their health service utilization [30,31,32,33,34]. Furthermore, according to the need theory, the basic material needs must be fulfilled, and then additional economic resources may affect subjective behaviors with respect to non-material needs, but to a lesser degree [35,36]. This study used self-reported economic status, rather than objective income measures. It is subjective and can measure a person’s evaluation of their own socio-economic conditions more accurately that those less affected by the external factors. Compared with empty nesters, non-empty nesters have a higher demand for economic satisfaction and less additional economic resources to affect their medical behavior. However, insurance and employment were associated with self-treatment among non-empty nesters. URRBMI increased the likelihood of self-treatment compared with other types of commercial insurance. In addition, being unemployed was a predictor to self-treatment also. The findings suggest that after meeting basic material needs, relative income levels are negatively correlated with self-treatment among non-empty nesters.

Consistent with other similar studies [8,19,37,38], our results showed that chronic diseases was one common predictor of self-treatment among both empty and non-empty nesters. It should be noted that our study population include the elderly who had one or more chronic diseases but in a relatively stable status and need long-term medication, which may cause a higher prevalence of self-treatment among the elderly with chronic diseases.

There are some limitations in this study. First, this is a cross-sectional study and, therefore, the resulting factors associated with self-treatment behavior cannot determine causality. Second, the data were self-reported, and there might be a possible recall bias for most questionnaire data. Third, as for the definition of self-treatment, we only explained to the respondents before the survey that self-treatment refers to “the scenario where a person takes medication (including over-the counter drugs or prescribed drug already in family) or other approaches, such as massage, hot compress or other auxiliary therapy, to cope with illness conditions without professional help”, and it cannot be defined in detail. For example, it is not clear that whether it was self-treatment when they did exercises to relieve neck pain even though the exercises were recommended by a physical therapist. Therefore, this situation may cause potential additional biases. Finally, there may be more confounding factors than those available for consideration in this study. In addition, our study did not involve the self-treatment rate of single diseases, and the next step of our research can explore the diseases with the highest prevalence of self-treatment and find the priority management of diseases.

The prevalence of self-treatment among the elderly in Shandong, China, was 79.9%. Non-empty nest elderly had a higher prevalence of self-treatment than empty nesters. Our result showed that empty nesters with better socioeconomic status were more likely to use self-treatment, while non-empty nesters with relatively poorer socioeconomic status were more inclined to self-treatment. The findings from our study could provide the government with some information about the use of self-treatment among empty and non-empty nesters. Interventions targeting identified at-risk subgroups should be developed to maximize the effectiveness of self-treatment and reduce health risks.