For centuries, Taiwanese cultural values were derived from a long tradition of rural surroundings emphasizing cohesive human relationships in small communities. Traditional Chinese individuals still cling to the value that it is the responsibility of family members to take care of their ill family members. However, with urbanization and changing life styles, family members have a dilemma. Individuals who maintain responsibility for their family members are faced with having to send a family member to a nursing home or long-term care facility to assure their health and care needs are met. Thus, Taiwanese society may realize nursing homes are replacing traditional family-member caregivers.
Increasing population, lengthening of life span, changes in illness patterns, and changes in family life make providing health care for elderly individuals a serious problem in Taiwan (Lee, 1981; Lin, 1991; Yang, 1988). For the past 20 years, the elderly population, defined as those 65 years of age or older, has increased significantly from 3.1% of the total population in 1972 to 7.6% in 1995. According to one official estimate, 2.86% of Taiwanese older adults will live in a long-term health care facility by the year 2020. In the same time period, the elderly population is projected to comprise 12.95% of the total Taiwanese population (Department of Directorate General of Budget, Accounting, and Statistics, the Executive Yuan, 1990). Based on these data, one can postulate that the needs for long-term care are becoming more and more urgent in Taiwanese society. Another significant change occurring in Taiwan is the lengthening of life expectancy. In 1950, life expectancy was 53 years for men and 56 years for women, while in 1995 the life expectancy jumped to 72 years for men and 78 years for women (Ministry of Interior, the Executive Yuan, 1996). People in Taiwan are living longer and that alone suggests that more health care services will be needed to serve the steadily increasing elderly population.
In addition, the causes of death in Taiwan have changed. In 1952, the majority of the 10 leading causes of death were various infectious diseases, such as gastroenteritis, pneumonia, and tuberculosis (Department of Health, the Executive Yuan, 1953). While in comparison, the leading causes of death in 1995 were the chronic conditions of malignant neoplasms, cerebrovascular diseases, and cardiac diseases (Department of Health, the Executive Yuan, 1996). Reasons given for the change in these illness patterns are generally attributed to changes in lifestyle, the professionals' ability to treat infectious disease, and an increase in the incidence of vaccinations (Yang, 1988).
Other changes have also taken place within the family structures. For the past 20 to 30 years, family life has experienced decreasing family size, declining family cohesion, changes in relationship between husbands and wives, and changes in family caregiver roles (Lee, 1981; Lin, 1991). It is more and more common that a twogeneration, or core family, lives in an urban area while their elderly family members reside in a rural area. Additionally, the relationship between husbands and wives has changed from one of inequality to equality. More and more women are now working to provide financial support for the family. For example, in 1956, 17.4% (n = 452,400) of the total employed population were women (Lin, 1991); this percentage increased to 36.8% (n = 3,389,280) in 1986. Increasing employment significantly affects a woman's ability to be a family caregiver and, therefore, diminishes the availability of family care providers for older adults.
Unfortunately, nursing homes in Taiwan are insufficient in number, generally of low quality, require private payment, and receive lower priority for government regulation. In spite of these facts, studies support an argument that nursing homes would be used if available (Chiou & Wang., 1987; Hon, 1993; Hurng, 1987; Jung, Tsai, & Lin, 1990; Lan & Shiung, 1993; Lee, Wang, & Jung, 1990; Wei, Yang, & Wu, 1993; Wu, 1993). The personnel requirements for a legally registered nursing home in Taiwan are (Department of Health, the Executive Yuan, 1994):
* At least one nurse per 1 0 nursing beds.
* At least one nurse assistant per six nursing home beds.
* Nurses should provide care under the supervision of physicians.
* At least one social worker, if the total nursing home beds are greater than 100.
* Other optional personnel. Ideally, it is expected that services provided in nursing homes conform to or exceed legal regulations and meet the expectations of the service consumers. However, regulating nursing homes in Taiwan is still a new phenomenon. Only 11 nursing homes were legally registered as of July 1996 in Taiwan (Long Term Care Professional Association of ROC, 1996). These licensed nursing homes provide 1,925 beds for a population of approximately 21 million. In addition, the geographic distribution of these legally registered nursing homes is problematic. The licensed nursing homes are located near acute hospitals in the urban area and do not serve the population equally (Lan et ai, 1993), thus this distribution severely limits accessibility to services for the rural areas. There are also a large number of unlicensed nursing homes in Taiwan. For example, Wu and Chang (1995) have identified at least 125 unlicensed nursing homes in Taipei City while only two nursing homes legally registered. Lee, Wang, and Jung (1990) concluded that 80% of unlicensed nursing home facilities deliver low quality care. To make matters worse, the private-pay economic system definitely continues to limit accessibility to nursing home services.
Several studies have identified an insufficient number of nursing homes as a major long-term care problem for elderly individuals in Taiwan (Chiou et al, 1987; Hon, 1993; Hurng, 1987; Jung et al., 1990; Wu, 1993). However, what nursing home services are needed and whether these services would actually be used remains unknown. Thus, it is of significance to the community that a needs assessment be conducted to examine what types of nursing home services are needed and what types of services would be used (Blum, 1974; Neuber, 1980; Soriano, 1995; Warheit, Bell, & Schwab, 1977; Witkin & Altschuld , 1995; Zaura, Brachrach, & Hess, 1983). The importance of conducting studies such as this also relates to identifying the types of services that customers expect and identifying the services available to reduce the risk of market failure. Thus, the purposes of this community needs assessment study were to directly assess factors associated with nursing homes and the perception of need for nursing home services in community settings.
The research design for this community needs assessment was a descriptive study using a mailed questionnaire approach with crosssectional and stratified random sampling techniques. Ten towns in the northwest of Taiwan were included in the study. Three of the selected communities were suburban and the remainder was rural. The participants were randomly selected from each town. The general inclusion criteria for participation was:
* Residing in the target community for at least 6 months.
* Age 20 years or older.
* Ability to read and write.
The Perception Evaluation Tool (PET) was used in the study to collect information from the general public and key informants in each community. A cover letter; a survey questionnaire (the PET); and a stamped, self- addressed return envelope were mailed to the participants who were willing to participate, as indicated by the telephone screening. A thank-you letter was sent to participants who responded. Two weeks after the initial mailings, nonrespondents were contacted by telephone to inform them that the questionnaire had not been received and requested its return. A followup letter, as a friendly and courteous reminder was sent to these participants who had not returned their questionnaires, 2 weeks after the telephone follow-up. Results of the survey were combined to assess the perceptions of need for nursing homes in Taiwan.
The psychometric properties of the PET were evaluated and demonstrated appropriate stability reliability, internal consistency reliability, content validity, construct validity, convergent validity, and discriminant validity (Chen, 1997; 2000). The PET was designed to identify the perception of:
* Need for nursing home services in a community.
* If needed, what services should be provided within nursing homes.
* Potential willingness of individuals to use services provided within nursing homes.
The PET consisted of 59 closedended items and was restructured into two sections: Section I: Factors (item n = 42) and Section II: Perception (item n - 17).
A final sample of 319 individuals was obtained for the study for an overall response rate of 69%. Most of the participants were general community individuals (52.7%) followed by health care providers (19.4%), social leaders (15.3%), and political leaders (12.6%). Overall, the sample contained 188 males and 131 females, ranging in age from 20 to 83 (M = 44.8, SD = 14.8). Most participants indicated their annual household incomes ranged from adequate (52.8%) to more than adequate (36.7%). Approximately half of the participants (42.8%) indicated they had some religious preference at the time of survey. Approximately half of the participants reported there was one (33.9%) to two (16.3%) elderly family members living with them, and 48% of the participants indicated there was not an older family member in their household. A summary of study results of associated factors and perceptions of need for nursing home services is shown in the Table.
Data generated from the 319 participants indicated their awareness level of nursing home services was ranked as follows: nursing (46%), rehabilitation (41%), medical (40%), social work (34%), dietary (33%), environmental (32%), recreational (31%), laundry (30%), hospice (26%), and religious (24%). On average, the participants were aware of 3 of 10 nursing home services listed above. Participants who indicated higher awareness level were women (df= 317, t = -2.6, p < 0.05), key community informants (df= 317, t = -5.5, p < 0.0001), individuals having more than an adequate income (F (2,302) =5.9, p <0.01), or individuals having heard of nursing homes prior to the survey (df= 317, t = -16.2, p < 0.0001). Based on the results of the Pearson correlation coefficient tests, the higher the participants' awareness level, the greater their perception of need for nursing home services (r = 0.33, p < 0.0001) and the greater their potential for use of the services (r = 0.25, p < 0.0001).
Participants also were asked whether they or their family members had experienced any of the 10 listed nursing home services. The percentage of participants who had experienced nursing home services were as follows: nursing (7%), medical (6%), dietary (5%), rehabilitation (4%), social work (4%), recreational (4%), environmental (3%), laundry (3%), religious (3%), and hospice (2%). On average, the participants indicated they or their family members experienced approximately 0.4 of the 10 listed services. Participants who had heard of nursing homes prior to the survey experienced more nursing home services than those who had never heard of nursing homes before (df = 317, t = -4.3, p < 0.0001).
The top 10 reasons for individuals entering a nursing home as identified by participants were someone in the same household who was age 65 or older (52%), had hypertension (25%), had diabetes (18%), had heart diseases (8%), had a stroke (6%), lived alone (6%), were in poor general physical health (5%), were widowed (4%), were unable to bathe themselves (3%), and were unable to walk (3%). Participants whose education level was less than junior high school (F (2,313) = 4.3, p < 0.05) were also at a higher risk level for nursing home entry. Interestingly, it was found that only two of the 319 participants indicated that "poor family enjoyment" was a reason for a family member's admission to a nursing home.
ASSOCIATED FACTORS AND PERCEPTION OF NEED FOR NURSING HOME SERVICES
The most needed nursing home services as reported by the participants were social work service, rehabilitation service, and environmental service (Table). It was also found that participants who were men (df= 317, t = - 2.7, p <0.01), age 65 or older (F (2,316) = 6.5, p <0.01), educated with less than a junior high school (F (2,315) = 9.2, p <0.0001), or had never heard of a nursing home prior to the study (df = 317, t = -3.7, p < 0.0001), indicated a lower need for nursing home services than other participants.
Many Chinese individuals are family oriented. Accordingly, it was found in this study that when family care was available, the participants tended not to use nursing home services. Otherwise, the potential to use nursing home services ranged from "not sure" to "would probably use nursing home services." Participants who were educated at least at a college level (F (2,315) = 3.8, p < 0.05) or who had heard of nursing homes prior to the study (df= 317, t = -2.9, p < 0.01), indicated higher potential for use of nursing home services. In addition, moderate to strong correlations were found between their potential for use and their service needs (r = 0.41, p < 0.0001), potential for use and awareness level (r = 0.25, p < 0.01), and potential for use and personal experience (r = 0.19, p < 0.01).
The survey participants' awareness level and personal experience for nursing home services were considerably low (Table). This supports the need for the development of educational programs to increase customers' awareness level of nursing home services, and facilitate the identification of services needed. The programs would ultimately serve to increase the potential of nursing home use. The low personal experience for nursing home services might be because there were no licensed nursing homes in the towns surveyed. As indicated in the Table, all of the listed nursing home services, except religious services, were reported as either probably needed or needed. These results indicated the need for nursing home services was generally high. An interesting outcome was that religious services (i.e., a place for nursing home residents or their family members to pray) was the least needed service to be provided within a nursing home among the 319 participants. This might be because of the way the main religions in Taiwanese societies, such as Buddhism and Taoism, are practiced.
In this study, 15% of the elderly participants had heard of nursing homes prior to the study in comparison the Hon study in 1993, which showed only 7.6% of the elderly individuals had an understanding of what a nursing home was. This almost two-fold percentage increase in 4 years in elderly awareness level for nursing home services might be the result of commonly seen advertisements and the growing number of nursing homes established in contemporary Taiwanese societies. Although the elderly individuals' awareness level for nursing homes increased over the years, most of elderly individuals in this study did not know what a nursing home was or the services provided in nursing homes. In addition, the large percentage of participants who had never heard of nursing homes may be a result of the lack of information being disseminated about comprehensive long-term care programs and the fact that there are still very limited numbers of licensed nursing homes in Taiwan.
This study also provided evidence of the impact of social change on the perceptions of society in the areas of nursing home care. It is of interest to observe the increasing need and willingness to use nursing home services. In Hon's study (1993), only 47.9% of the participants thought it was either necessary or very necessary to provide nursing home services within their communities. In the current study, 84% of the participants indicated it was necessary or very necessary to provide nursing home services in the survey towns. Survey participants specifically reported that 9 of 10 listed nursing home services were to be either needed or probably needed (Table). Another indicator of change is the individuals' willingness to live in a nursing home. In 1993, Wu found only 43.1% of individuals were willing to live in a nursing home, while the current study showed 71 % of participants would want to live in a nursing home, if they were not able to care for themselves. The reason they would be willing to live in a nursing home was they did not want to become a burden to their families.
Jung et al. (1990) found that 41.4% of primary caregivers of bedridden family members would be willing to place them in a long-term care institution (N = 41). While in the current study, approximately 67% of the participants reported they would place their family members in a nursing home if the family members could not care for themselves. These findings indicate changes in perception of nursing homes in Taiwan.
It is important for nurses to provide input in the development of a more comprehensive health service system. The approach of the current study demonstrated a systematic set of procedures undertaken for the purpose of setting priorities and making decisions when the emphasis is on identified needs. After these needs are clearly identified, service programs can be developed and evaluated more rationally. Therefore, nurses who already provide nursing home services may apply the concepts and methods of this study to their client population. It is expected that the results from the community needs assessment can help nurses develop plans and strategies to improve their existing nursing home services. For example, in the current study (Table), the awareness level of nursing home services among survey participants was considerably low. It was recommended that service providers develop educational programs to help their clients understand the services provided within nursing homes. For policy implication, policy makers who plan or develop long-term health care programs for the survey areas might consider increasing the number of nursing home beds. The results of the survey indicated that the need for nursing home services was high, as was the potential for use.
Additional information, which had direct implications for nursing, was obtained from the participants. The participants in this study were asked to record their suggestions related to the services they thought should be provided within nursing homes (e.g., psychosocial consultation, management of personal events, transportation services, interaction with families of nursing home residents and encouragement of family members to visit the residents, customer information services, education programs related to disease prevention, health promotion, availability of outdoor facilities, public payment system). Nurses should consider these expectations in planning and providing services for Taiwanese older adults.
In addition to identifying an insufficient number of nursing homes in Taiwan as previous studies have found, this study investigated exactly what types of nursing home services were needed and whether these services would actually be used. Based on the findings generated from the 319 participants, the current study contributes to the field of long-term care in Taiwan and serves as a model of how nurses can conduct a needs assessment to identify community perceptions of service need.
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ASSOCIATED FACTORS AND PERCEPTION OF NEED FOR NURSING HOME SERVICES