Barriers to providing long-term care insurance services by direct care workers: a qualitative study in Shandong Province, China

Barriers to providing long-term care insurance services by direct care workers: a qualitative study in Shandong Province, China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers to providing long-term care insurance services by direct care workers: a qualitative study in Shandong Province, China Jing Gao, Jia Yin, Qiang Sun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4108108/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background China's long-term care insurance (LTCI) system plays a crucial role in addressing the challenges posed by an aging population, while simultaneously placing higher demands on the quantity and quality of long-term care (LTC) services. However, LTCI-designated facilities still face challenges in terms of recruiting and retaining care workers. There is limited knowledge regarding the barriers to service delivery for direct care workers in the context of LTCI. Objectives To analyze the barriers faced by direct care workers in providing LTC services from their perspectives and to explore possible reasons. Methods Based on Herzberg's two-factor theory, face-to-face semi-structured interviews were conducted with 31 direct care workers. Thematic framework analysis method was used to generate qualitative codes and identify themes. Results Direct care workers in designated LTCI facilities faced barriers to meeting motivation and hygiene factors. The motivation factors included three themes: intense and difficult work, tedious and boring work content, and difficulty in gaining recognition and fulfillment at work. Hygiene factors included four themes: difficulty communicating with patients or family members, depressing work environments, incomplete service processes, and inadequate safety measures for home care. Conclusions The conditions of people with disabilities or dementia covered by LTCI are complicated, which causes many difficulties and obstacles to the work of direct care workers. We recommend that in the development of the LTCI system, more emphasis should be placed on service providers as the mainstay of policy practice so that both the hygiene and motivation factors of direct care workers are met and put into effect together. Systems related to LTCI assessment and service provision should be optimized to alleviate the stress of direct care workers and eliminate barriers to their work. direct care workers long-term care insurance services barriers China Figures Figure 1 Introduction Population aging is a global challenge affecting human development. According to united nations projections, the proportion of the world's population aged ≥65 years will reach 16% by 2050[ 1 ]. China has been an aging society since 1999, and the total number of older people is large and aging rapidly[ 2 ]. China is expected to become a fully aging society by 2040, when the population aged ≥60 years will increase to 402 million[ 3 ]. As fertility rates decline and life expectancy increases, many older adults can no longer rely on their children as providers of long-term care (LTC) services and will rely primarily on the Social Security system[ 4 ]. However, the significant increase in the cost of LTC in China has placed a huge burden on both individuals and families[ 5 ]. China issued the "Guidance on the Piloting of Long-term Care Insurance System" in 2016 to launch the piloting of long-term care insurance (LTCI). LTCI is often considered as the "sixth insurance" in addition to social insurance, such as pension, medical, work injury, unemployment, and maternity[ 6 ]. The implementation of LTCI can replace hospitalization for long-term disabled patients, reduce health insurance costs[ 7 ], mitigate the burden of care on family caregivers[ 8 ], and have a positive impact on the quality of life of the disabled elderly[ 9 ]. However, since the late development of LTCI in China, it is still relatively immature in terms of population coverage, funding model, access criteria, and service provision[ 10 ]. In terms of service delivery, although the predictability of LTCI funding creates stable market conditions and serves as a stimulus for the development of designated service providers[ 11 ], LTCI-designated service providers still face some difficulties and challenges in recruiting and retaining care workers[ 12 ]. Current care teams in China are far from meeting the demands of LTC services for the disabled in terms of quantity and quality[ 13 ], and most care workers are uncertified or less qualified[ 14 ]. Care workers play an important role in the sustainability of the LTCI system as direct providers of LTC services. Apart from family members, direct care workers have the closest relationship with older adults with disabilities, and their work behaviors are most likely to affect their quality of care and quality of life of older adults[ 15 ]. However, work exhaustion and stress are significantly associated with job satisfaction among LTC workers[ 16 ]. Job satisfaction has a significant negative impact on turnover intention[ 17 ]. Owing to the importance of worker stability in reducing organizational costs and increasing productivity, it is necessary to have an in-depth understanding of the work barriers and difficulties of LTC workers[ 18 ]. This study defines care workers as those who directly provide LTC services to older people with disabilities who are entitled to LTCI, such as those who provide daily care in designated institutions or in the homes of disabled older people under China's LTCI service system. Current research on China's LTCI policy is mostly focused on policy analysis and evaluation of implementation effects, with less empirical research on service providers in the policy context. There is a lack of research explaining the barriers to direct care workers' work in providing LTC services from their perspectives. Therefore, this study adopted a qualitative research approach based on two-factor theory to analyze in depth the barriers they face in providing LTC services and the reasons for them from the perspective of direct care workers to provide references for improving the quality of LTC services and optimizing the LTCI system in China and countries in similar situations. Methods Study design and setting Our study was conducted from November 2020 to January 2021 in eight cities in Shandong Province, China. Based on the size of the institution and the type of service, each city selected 3–4 designated LTCI facilities of medium to high size in the locality, which provided institutional or home care. Shandong Province is located on the eastern coast of China and has 16 cities and 136 counties. The Seventh China Population Census in 2020 showed that Shandong Province has a population of 101,527,500, which is one of the two provinces with a population of more than 100 million in China. Meanwhile, 20.90% of the population was aged ≥60 years, including 15.13% of the population aged ≥65 years. The aging process in Shandong is faster than the national average[2]. Qingdao, a city in Shandong, was the first city in China to introduce an LTCI scheme. By the end of 2019, all other cities in Shandong had launched an LTCI policy. Participants From each designated LTCI institution, 1–2 direct care workers were selected for in-depth interviews. The inclusion criteria for the participants were (1) providing formal LTC services to disabled older people who were entitled to LTCI; (2) working in their current institution for 2 consecutive years or more; (3) informed consent, high willingness to confide, and good communication skills; and (4) ability to speak Mandarin. Data collection procedure Data were collected through face-to-face semi-structured in-depth interviews between November 2020 and January 2021. The interview volume was determined based on when the interview data reached saturation. We developed an interview outline for use by the interviewer based on open-ended and unstructured questions aimed at exploring how care workers feel about their work as well as the intensity, stress, and difficulties of their work. We drew on American psychologist Frederick Herzberg's two-factor theory to develop interview questions to better guide the respondents' answers. Two-factor theory, also known as "motivation-hygiene theory", provides a novel research perspective to relieve care workers' stress, eliminate work hindrances, and improve the efficiency of LTC management. The theory points out that hygiene factors mostly cover the objective external environment, such as policies, management measures, work environment and conditions, and interpersonal relationships, which can prevent employees from losing their jobs owing to dissatisfaction and eliminate their dissatisfaction. Motivation factors mostly come from the work itself, such as the challenge of the work content, work responsibilities, and importance of the work itself. Improving these factors can stimulate employees’ motivation and enthusiasm and improve the efficiency of their work[ 19 ]. Prior to meeting the respondent, the interviewer contacted the institutional manager to explain the research situation. After informed consent and trust were obtained, an appointment was made with each interviewee. Formal, semi-structured, in-depth interviews were conducted in the respondents’ office or conference room. Six trained members of the subject team served as interviewers. Each interview lasted for approximately 20–60 min. During the interviews, the interviewers maintained a respectful and neutral attitude and encouraged interviewees to fully express their views and ideas. The interview data were transcribed, replacing each participant's name with a unique code. Data analysis This study used a thematic framework analysis to analyze the interview data. At the end of each interview, raw data, such as audio recordings and notes, were transcribed and organized verbatim by each group of researchers. The researchers read the data carefully, coded, categorized, summarized, and analyzed the recurring elements. Finally, the motivation and hygiene factors in the two-factor theory were used as two themes, and the corresponding subthemes were distilled to form a preliminary coding framework. For divergent themes, all subject members were discussed until a consensus was reached. All data were analyzed using NVivo 11 (QSR International, Melbourne, Australia) and Microsoft Excel (Microsoft Corporation, Redmond, WA). Throughout the data analysis process, we consulted qualitative research experts outside of the subject group members. Results Demographic characteristics Details of the participants’ demographic characteristics are presented in Table 1. Thirty-one eligible care workers completed the interviews, and over 90% of them were female (n=28). Approximately half of the participants were aged 40–49 years, with an average age of 43 years. Approximately 75% of the interviewees had an education level lower than a specialty (n=23), and only one had a bachelor's degree. More than 70% of the participants had worked for 2–5 years, with an average of 4.61 years. The employment nature of the respondents was mainly contractual, while the remainder were temporary workers. Table 1 Characteristics of direct care workers No. Sex Age Education Years of work in the LTC field Employment nature P1 Female 43 Middle School 3 Contract system P2 Female 46 Elementary School 8 Contract system P3 Female 47 Elementary School 8 Contract system P4 Female 49 Middle School 2 Contract system P5 Female 42 High school 4 Contract system P6 Female 50 Middle School 5 Contract system P7 Female 44 College 4 Contract system P8 Female 46 Middle School 7 Contract system P9 Female 47 Middle School 3 Contract system P10 Male 53 Middle School 4 Contract system P11 Female 27 College 3 Contract system P12 Female 50 Middle School 7 Contract system P13 Male 42 High school 6 Contract system P14 Female 41 Middle School 4 Contract system P15 Male 48 College 5 Contract system P16 Female 55 Middle School 7 Contract system P17 Female 52 Middle School 10 Temporary workers P18 Female 49 Middle School 5 Contract system P19 Female 45 Elementary School 2 Temporary workers P20 Female 30 College 2 Contract system P21 Female 28 College 9 Contract system P22 Female 29 Bachelor’s degree 3 Contract system P23 Female 24 College 4 Contract system P24 Female 38 Middle School 4 Contract system P25 Female 38 Middle School 2 Contract system P26 Female 45 Middle School 5 Contract system P27 Female 35 Middle School 7 Contract system P28 Female 32 College 4 Contract system P29 Female 52 High school 2 Contract system P30 Female 52 Elementary School 2 Contract system P31 Female 49 No education 2 Contract system Themes Based on two-factor theory, the following seven hindrances to the provision of LTCI services by care workers were summarized in terms of both motivation and hygiene factors (Figure 1): M otivation factors Intense and difficult work As patients covered by LTCI are in a state of disability or disability combined with dementia, their conditions are relatively severe and unstable. They often need to perform operations, such as pressure sore care, assisting patients to turn and get in and out of bed, caring for tracheotomized patients with cannula, and suctioning. This makes the work of the nursing staff more difficult, especially at the beginning of their careers, when they are unfamiliar with the patient's condition and the tasks involved. See the following examples. "It is very tiring to do every task by hand, for example, to keep turning the elderly during bathing. Once I was cutting an elderly person's nails, and I only touched them with my hand before I started to cut them, but the elderly person thought they were cut , and cursed. Some operations are highly specialized and technical, which is more difficult for us, such as pressure sore care, which should be operated by nurses, but the latest policy is that caregivers can do it too." (P15) "Patients with LTCI are more seriously ill and stay in bed, requiring them to be turned every two hours, which is more strenuous to serve for patients who weigh a lot. Also, some patients need extra meals, and it takes more time to care for them." (P25) Tedious and boring work content According to care workers, the fact that most clients are older people who cannot take care of themselves leads to busy and boring daily care work that requires constant work. Caregivers often have to work 24 h in a row before they can work shifts and have fewer holidays, which leads to irregularity and a lack of rest. Moreover, a busy work schedule limits the social interactions of care workers to a certain extent, reducing the time spent with family and friends. In short, all of these reduce care workers' enthusiasm and motivation for their work. Difficulty in gaining recognition and fulfillment at work Some older people despise the social status of care workers and often misunderstand or blame them during their work. Simultaneously, patients sometimes distrust the professional competence and personal qualities of care workers, causing them to feel aggrieved and helpless. This leads to a lower evaluation of the meaning and value of work, and a lack of fulfillment among care workers. "Some patients feel that they have to pay to stay here and we have to serve them all day long, so they can't be negligent. But we are not just responsible for one patient, we cannot be there for one person every step of the way. Once there is negligence, they will complain, and this time will be very stressful, bad mood, cannot laugh. The old people will also ask why they are stern-faced when they see it, making me feel quite difficult sometimes." (P10) H ygiene factors Difficulty communicating with patients or family members Some older people with dementia and deafness are unable to communicate properly with care workers and have difficulty expressing their needs clearly. Some patients with dementia even scolded care workers, making it difficult for care workers to provide services. In addition, some family members often make harsh demands, especially during the Newcastle pneumonia epidemic, when they are unable to visit the older people in the hospital due to the relevant control measures and are dissatisfied with or misunderstand the work of the care workers. The excessive demands and lack of understanding from patients and families led to difficulties for care workers in dealing with related issues and led to conflicts and reduced motivation among care workers. As shown in the following extracts: "The elderly were occasionally in an abnormal mood, some hitting or cursing, and when I could not do my job , the dean would feel that I was not doing my job well, leaving me a little stressed. At the same time, the words of some elderly family members gave us chills, and they expressed their inability to understand when they could not see the elderly during the COVID-19" (P2) "Many elderly people with dementia cannot communicate with us, and when the care worker feeds them , they say they didn't, so it's easy for the family to misunderstand. There are also some elderly people who are violent and we are worried about them hurting other elderly people. Difficulty in communicating with patients leads to an inability to get a good understanding of the patient's specific situation." (P13) D epressing work environments Direct care workers report that their own state of mind and psychological condition often leads to high levels of work stress and that psychological conditions are closely related to the patient's condition. Care workers become attached to patients over time, but the seriousness or rapid deterioration of many disabling patients creates a sense of anxiety and urgency for care workers. Simultaneously, the fact that terminally ill patients often pass away makes care workers feel emotionally drained. "There are times when the elderly suddenly become ill, mentally unstable and so on, which can make us stressed." (P30) "It feels like a rather depressing atmosphere to work in when you see the elderly seriously ill in bed." (P17) Incomplete service process Owing to the short pilot period of China's LTCI and other reasons, the construction of the service system is not sound, the specific implementation rules are not perfect, and the development of information technology lags. Care workers state that there are currently more papers that require handwritten records. Simultaneously, the LTCI policy requires monthly billing, and patients need to be discharged and admitted, resulting in a cumbersome process. This adds to the workload and complexity of the care workforce. This is illustrated in the following example: "There are too many paper record forms, such as care plans, service records, and dynamic assessment forms, resulting in a heavy workload for us." (P11) "LTCI system requires discharging patients and then readmitting them after each month's billing, and the procedure is too cumbersome." (P22) Inadequate safety measures for home care When providing home care, families with long distances or scattered addresses result in longer travel times for healthcare workers. Most institutions do not have uniform transportation for caregivers, and safety measures are not in place. Caregivers often need to use their own transportation, such as cars or electric vehicles. The lack of uniform and standardized management in the purchase, use, and maintenance of transportation tools leads to a high level of safety risks, as care workers face various accidental risks on their way to the doorstep. Discussion Although the LTCI policy positively impacts both the demand for institutional care for the older people and the supply of nursing beds in designated institutions through the reimbursement of LTC costs[ 20 ], the demand for direct care workers is even greater. Coupled with the more complex conditions of patients with higher levels of disability or dementia, more specific and higher demands are placed on the service capacity and quality of direct care. Focusing on our research perspective on direct care workers, we found that the barriers faced by care workers in providing LTCI services include seven aspects: intense and difficult work, tedious and boring work content, difficulty in gaining recognition and fulfillment at work, difficulty communicating with patients or family members, depressing work environments, incomplete service process, and inadequate safety measures for home care. A study of LTCI services in Japan showed that the undersupply of care workers, high turnover, and low skill levels were mainly due to low wage levels and poor working conditions, which also had a potential negative impact on the quality of care[ 21 ]. A Korean study analyzed the reasons for willingness to leave among care workers providing direct services under the LTCI system and found that harsh working conditions, discordant relationships with supervisors, and their own health status were the main reasons for their departure[ 22 ]. A study of South African LTC workers showed that caregivers' motivation to provide quality care is hindered by role ambiguity, harsh employment conditions, negative interpersonal relationships at work, and role overload. These unfavorable conditions are created by policy deficits and a lack of structural support[ 23 ]. A study in Hangzhou, China, showed that low education level, long working hours, and low compensation of care workers were barriers to the development of LTC services[ 24 ]. These findings are generally consistent with those of our study. Therefore, first, there are obstacles faced by direct care workers in terms of work content, environment, and other aspects. It is necessary to protect the legitimate rights and interests of care workers, such as the salaries and benefits of working hours; optimize scheduling and leave patterns; and provide scientific and flexible scheduling for care workers. Human resources should be reasonably allocated to reduce work intensity and avoid fatigue. Professional psychological guidance and education should be regularly arranged to focus on and maintain the physical and mental health of care workers. The professional skills training should be increased and practical exercises should be strengthened in response to the specific conditions of disabled and demented people. The comprehensive quality of care workers should be continuously improved and the construction of an LTC talent echelon should be promoted. Second, in response to obstacles, such as difficulty in obtaining recognition, a sense of achievement for care workers, and the difficulty of interpersonal communication, it is necessary to create a good and harmonious interpersonal atmosphere and invite patients' families to participate in internal activities. The feedback from patients and their families should be paid attention to and a service satisfaction evaluation system and service quality evaluation mechanism should be established. Research and development should be carried on for a care application (APP) that can be used by designated LTCI facilities and care workers and evaluation functions must be set up for patients and family members to use online. The evaluation results can be linked to the assessment of care workers. By organizing activities, such as the regular selection of excellent care workers, giving them tangible incentives such as bonuses, and intangible incentives such as publicity and reporting, the professional honor and social awareness of care workers should be enhanced. In addition, our study showed that inadequate LTCI policies and insufficient safety measures for home care are major barriers faced by caregivers. This may be related to the relatively short period of time for formal implementation of the LTCI pilot in China. Inadequate service specifications and assessment processes cause inconvenience to caregivers in providing services. The shortage of care workers to provide home care[ 25 ], despite the wide and convenient audience for home care services, may also be related to factors, such as inadequate security safeguards. These are prerequisites for ensuring the success of direct care workers. In response to these obstacles, we recommend optimizing LTCI assessment and service policies and improving service processes and management systems. Emphasis should be placed on standardized management, good service process management, and standardization of LTCI service behavior. Information technology support should be strengthened; the construction of home hospital beds, smart wards, and electronic medical records should be promoted; and the LTCI service model should be innovated. The technical support of information technology should be strengthened; the construction of home beds, smart wards, and electronic medical records should be promoted; and the nursing service model should be innovated. Service records that can be comprehensively recorded in the care APP cannot be filled in paper record forms. For home care, it is necessary to equip a specialized management team and improve supervision and administration. The safety guarantee of home care should be strengthened and the safety hazards should be reduced. Limitations This study has several limitations. First, participants were recruited only from Shandong Province, which has certain geographical limitations and is not representative of all direct care workers in the LTCI service delivery field. Some contextual characteristics, such as location, agency size, structure, and local environment, may differ from those of other care settings. The extrapolation of the findings from this study to other settings still needs to be contextualized. Second, a potential bias is the lower number of male care workers included in our study, which may have resulted in a lack of information from their perspective. Further research should explore job perceptions and stress factors when dealing with patients at different stages, levels of disability, and types of care, and identify ways to enable care workers to better provide LTC services. Conclusion In conclusion, although LTC workers play a critical role in supporting the needs of people with disabilities and their families, they face several dilemmas and barriers. LTC is characterized by extreme vulnerability, especially during the coronavirus disease 2019 pandemic, and workers endure moral distress and emotional exhaustion, which have a dramatic impact on both physical and mental health and well-being[ 26 ]. Only when hygiene and motivation factors of direct care workers are met and work together can enthusiasm for work be mobilized can stress effectively be relieved and barriers to work eliminated. Improving the service capacity of care workers while reducing staff turnover would improve the quality and efficiency of LTCI services. Declarations Acknowledgements The authors would like to acknowledge the officials of the local health agencies and staff at the study sites for their cooperation. Funding This work was supported by the Shandong Province Social Science Planning Research Project (18CZKJ20). Authors' contributions Jing Gao was responsible for designing the study, conducting the interviews, interpreting the data and drafting the manuscript. Jia Yin was responsible for conducting the interviews and interpreting the data. Qiang Sun critically revised the manuscript for important intellectual content and grammar mistakes. All authors read and approved the final version of the manuscript. Ethics approval and consent to participate Informed consent was obtained from all participants included in the study. All participants were informed of the study purpose, risks and benefits. Availability of data and materials The datasets used during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Consent for publication Not applicable. 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A qualitative examination of policy and structural factors driving care workers' adverse experiences in long-term residential care facilities for the older adults in Cape Town. BMC Geriatr. 2019;19(1):97. Hong S, Yu P, Chen X, et al. Long-term care services and care workers in Hangzhou City, China: A cross-sectional survey. J Nurs Manag. 2019;27(7):1546-1553. Xiao F, Cao S, Xiao M, et al. Patterns of home care and community support preferences among older adults with disabilities in China: a latent class analysis. BMC Geriatr. 2023;23(1):117. Boamah SA, Weldrick R, Havaei F, et al. Experiences of Healthcare Workers in Long-Term Care during COVID-19: A Scoping Review. J Appl Gerontol. 2023;42(5):1118-1136. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4108108","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280867429,"identity":"2c1095bb-7bf2-4523-a80e-a343bcc53434","order_by":0,"name":"Jing Gao","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Gao","suffix":""},{"id":280867430,"identity":"813e486a-02eb-4343-935c-af39ea7a62bf","order_by":1,"name":"Jia Yin","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Yin","suffix":""},{"id":280867431,"identity":"66494393-a561-4595-9ac1-565d3d36837e","order_by":2,"name":"Qiang Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYDACZjBpw8BwAEjxkKAljRQtEHCYBC18x5mfPfzy57w9340Exgdv2xjkzQlpkTzMZm4s23Y7ceaNBGbDuW0MhjsbCGgxOMxgJi3ZcDvB4EYCmzRvG0OCwQGCWti/SUv8OWcP1ML+m0gtPGaSH9gOMG4A2sJMlBbJwzxl0oxtyYkzzzxslpxzTsJwAyEtfOePb5P88cfOnu948sEPb8ps5AnaAooOZkh0MDYACQlC6iFaGH8QoW4UjIJRMApGMAAAiENBVIiMd7cAAAAASUVORK5CYII=","orcid":"","institution":"Shandong University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2024-03-15 13:12:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4108108/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4108108/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53194200,"identity":"d8febce6-7779-40dd-b951-c7afd50f1298","added_by":"auto","created_at":"2024-03-21 18:10:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96076,"visible":true,"origin":"","legend":"\u003cp\u003eThemes of barriers for direct care workers in the data analysis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4108108/v1/882adb3dd059e4ae765fa933.png"},{"id":53558672,"identity":"50b62fc1-da85-40f4-8e45-f1b69fc2aafa","added_by":"auto","created_at":"2024-03-27 13:07:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":423569,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4108108/v1/bc1676f0-8bce-4019-9c4e-5ee8fa615127.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to providing long-term care insurance services by direct care workers: a qualitative study in Shandong Province, China","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePopulation aging is a global challenge affecting human development. According to united nations projections, the proportion of the world\u0026apos;s population aged \u0026ge;65 years will reach 16% by 2050[\u003csup\u003e1\u003c/sup\u003e]. China has been an aging society since 1999, and the total number of older people is large and aging rapidly[\u003csup\u003e2\u003c/sup\u003e]. China is expected to become a fully aging society by 2040, when the population aged \u0026ge;60 years will increase to 402 million[\u003csup\u003e3\u003c/sup\u003e]. As fertility rates decline and life expectancy increases, many older adults can no longer rely on their children as providers of long-term care (LTC) services and will rely primarily on the Social Security system[\u003csup\u003e4\u003c/sup\u003e]. However, the significant increase in the cost of LTC in China has placed a huge burden on both individuals and families[\u003csup\u003e5\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eChina issued the \u0026quot;Guidance on the Piloting of Long-term Care Insurance System\u0026quot; in 2016 to launch the piloting of long-term care insurance (LTCI). LTCI is often considered as the \u0026quot;sixth insurance\u0026quot; in addition to social insurance, such as pension, medical, work injury, unemployment, and maternity[\u003csup\u003e6\u003c/sup\u003e]. The implementation of LTCI can replace hospitalization for long-term disabled patients, reduce health insurance costs[\u003csup\u003e7\u003c/sup\u003e], mitigate the burden of care on family caregivers[\u003csup\u003e8\u003c/sup\u003e], and have a positive impact on the quality of life of the disabled elderly[\u003csup\u003e9\u003c/sup\u003e]. However, since the late development of LTCI in China, it is still relatively immature in terms of population coverage, funding model, access criteria, and service provision[\u003csup\u003e10\u003c/sup\u003e]. In terms of service delivery, although the predictability of LTCI funding creates stable market conditions and serves as a stimulus for the development of designated service providers[\u003csup\u003e11\u003c/sup\u003e], LTCI-designated service providers still face some difficulties and challenges in recruiting and retaining care workers[\u003csup\u003e12\u003c/sup\u003e]. Current care teams in China are far from meeting the demands of LTC services for the disabled in terms of quantity and quality[\u003csup\u003e13\u003c/sup\u003e], and most care workers are uncertified or less qualified[\u003csup\u003e14\u003c/sup\u003e]. Care workers play an important role in the sustainability of the LTCI system as direct providers of LTC services. Apart from family members, direct care workers have the closest relationship with older adults with disabilities, and their work behaviors are most likely to affect their quality of care and quality of life of older adults[\u003csup\u003e15\u003c/sup\u003e]. However, work exhaustion and stress are significantly associated with job satisfaction among LTC workers[\u003csup\u003e16\u003c/sup\u003e]. Job satisfaction has a significant negative impact on turnover intention[\u003csup\u003e17\u003c/sup\u003e]. Owing to the importance of worker stability in reducing organizational costs and increasing productivity, it is necessary to have an in-depth understanding of the work barriers and difficulties of LTC workers[\u003csup\u003e18\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eThis study defines care workers as those who directly provide LTC services to older people with disabilities who are entitled to LTCI, such as those who provide daily care in designated institutions or in the homes of disabled older people under China\u0026apos;s LTCI service system. Current research on China\u0026apos;s LTCI policy is mostly focused on policy analysis and evaluation of implementation effects, with less empirical research on service providers in the policy context. There is a lack of research explaining the barriers to direct care workers\u0026apos; work in providing LTC services from their perspectives. Therefore, this study adopted a qualitative research approach based on two-factor theory to analyze in depth the barriers they face in providing LTC services and the reasons for them from the perspective of direct care workers to provide references for improving the quality of LTC services and optimizing the LTCI system in China and countries in similar situations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study was conducted from November 2020 to January 2021 in eight cities in Shandong Province, China. Based on the size of the institution and the type of service, each city selected 3\u0026ndash;4 designated LTCI facilities of medium to high size in the locality, which provided institutional or home care. Shandong Province is located on the eastern coast of China and has 16 cities and 136 counties. The Seventh China Population Census in 2020 showed that Shandong Province has a population of 101,527,500, which is one of the two provinces with a population of more than 100 million in China. Meanwhile, 20.90% of the population was aged \u0026ge;60 years, including 15.13% of the population aged \u0026ge;65 years. The aging process in Shandong is faster than the national average[2]. Qingdao, a city in Shandong, was the first city in China to introduce an LTCI scheme. By the end of 2019, all other cities in Shandong had launched an LTCI policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom each designated LTCI institution, 1\u0026ndash;2 direct care workers were selected for in-depth interviews. The inclusion criteria for the participants were (1) providing formal LTC services to disabled older people who were entitled to LTCI; (2) working in their current institution for 2 consecutive years or more; (3) informed consent, high willingness to confide, and good communication skills; and (4) ability to speak Mandarin.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through face-to-face semi-structured in-depth interviews between November 2020 and January 2021. The interview volume was determined based on when the interview data reached saturation. We developed an interview outline for use by the interviewer based on open-ended and unstructured questions aimed at exploring how care workers feel about their work as well as the intensity, stress, and difficulties of their work. We drew on American psychologist Frederick Herzberg\u0026apos;s two-factor theory to develop interview questions to better guide the respondents\u0026apos; answers. Two-factor theory, also known as \u0026quot;motivation-hygiene theory\u0026quot;, provides a novel research perspective to relieve care workers\u0026apos; stress, eliminate work hindrances, and improve the efficiency of LTC management. The theory points out that hygiene factors mostly cover the objective external environment, such as policies, management measures, work environment and conditions, and interpersonal relationships, which can prevent employees from losing their jobs owing to dissatisfaction and eliminate their dissatisfaction. Motivation factors mostly come from the work itself, such as the challenge of the work content, work responsibilities, and importance of the work itself. Improving these factors can stimulate employees\u0026rsquo; motivation and enthusiasm and improve the efficiency of their work[\u003csup\u003e19\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003ePrior to meeting the respondent, the interviewer contacted the institutional manager to explain the research situation. After informed consent and trust were obtained, an appointment was made with each interviewee. Formal, semi-structured, in-depth interviews were conducted in the respondents\u0026rsquo; office or conference room. Six trained members of the subject team served as interviewers. Each interview lasted for approximately 20\u0026ndash;60 min. During the interviews, the interviewers maintained a respectful and neutral attitude and encouraged interviewees to fully express their views and ideas. The interview data were transcribed, replacing each participant\u0026apos;s name with a unique code.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used a thematic framework analysis to analyze the interview data. At the end of each interview, raw data, such as audio recordings and notes, were transcribed and organized verbatim by each group of researchers. The researchers read the data carefully, coded, categorized, summarized, and analyzed the recurring elements. Finally, the motivation and hygiene factors in the two-factor theory were used as two themes, and the corresponding subthemes were distilled to form a preliminary coding framework. For divergent themes, all subject members were discussed until a consensus was reached. All data were analyzed using NVivo\u0026nbsp;11\u0026nbsp;(QSR\u0026nbsp;International, Melbourne, Australia) and Microsoft Excel (Microsoft Corporation, Redmond, WA). Throughout the data analysis process, we consulted qualitative research experts outside of the subject group members.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDetails of the participants\u0026rsquo; demographic characteristics are presented in Table 1. Thirty-one eligible care workers completed the interviews, and over 90% of them were female (n=28). Approximately half of the participants were aged 40\u0026ndash;49 years, with an average age of 43 years. Approximately 75% of the interviewees had an education level lower than a specialty (n=23), and only one had a bachelor\u0026apos;s degree. More than 70% of the participants had worked for 2\u0026ndash;5 years, with an average of 4.61 years. The employment nature of the respondents was mainly contractual, while the remainder were temporary workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e Characteristics of direct care workers\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of work in the LTC field\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment nature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n 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\u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eTemporary workers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eTemporary workers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eElementary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003eP31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.408163265306122%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\"\u003e\n \u003cp\u003eContract system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on two-factor theory, the following seven hindrances to the provision of LTCI services by care workers were summarized in terms of both motivation and hygiene factors (Figure 1):\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003cstrong\u003eotivation factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntense and difficult work\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs patients covered by LTCI are in a state of disability or disability combined with dementia, their conditions are relatively severe and unstable. They often need to perform operations, such as pressure sore care, assisting patients to turn and get in and out of bed, caring for tracheotomized patients with cannula, and suctioning. This makes the work of the nursing staff more difficult, especially at the beginning of their careers, when they are unfamiliar with the patient\u0026apos;s condition and the tasks involved. See the following examples.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It is very tiring to do every task by hand, for example, to keep turning the elderly during bathing. Once I was cutting an elderly person\u0026apos;s nails, and I only touched them with my hand before I started to cut them, but the elderly person thought they were cut\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;and cursed. Some operations are highly specialized and technical, which is more difficult for us, such as pressure sore care, which should be operated by nurses, but the latest policy is that caregivers can do it too.\u0026quot; (P15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Patients with LTCI are more seriously ill and stay in bed, requiring them to be turned every two hours, which is more strenuous to serve for patients who weigh a lot. Also, some patients need extra meals, and it takes more time to care for them.\u0026quot; (P25)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTedious and boring work content\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to care workers, the fact that most clients are older people who cannot take care of themselves leads to busy and boring daily care work that requires constant work. Caregivers often have to work 24 h in a row before they can work shifts and have fewer holidays, which leads to irregularity and a lack of rest. Moreover, a busy work schedule limits the social interactions of care workers to a certain extent, reducing the time spent with family and friends. In short, all of these reduce care workers\u0026apos; enthusiasm and motivation for their work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifficulty in gaining recognition and fulfillment at work\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome older people despise the social status of care workers and often misunderstand or blame them during their work. Simultaneously, patients sometimes distrust the professional competence and personal qualities of care workers, causing them to feel aggrieved and helpless. This leads to a lower evaluation of the meaning and value of work, and a lack of fulfillment among care workers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Some patients feel that they have to pay to stay here and we have to serve them all day long, so they can\u0026apos;t be negligent. But we are not just responsible for one patient, we cannot be there for one person every step of the way. Once there is negligence, they will complain, and this time will be very stressful, bad mood, cannot laugh. The old people will also ask why they are stern-faced when they see it, making me feel quite difficult sometimes.\u0026quot; (P10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eH\u003c/strong\u003e\u003cstrong\u003eygiene factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifficulty communicating with patients or family members\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome older people with dementia and deafness are unable to communicate properly with care workers and have difficulty expressing their needs clearly. Some patients with dementia even scolded care workers, making it difficult for care workers to provide services. In addition, some family members often make harsh demands, especially during the Newcastle pneumonia epidemic, when they are unable to visit the older people in the hospital due to the relevant control measures and are dissatisfied with or misunderstand the work of the care workers. The excessive demands and lack of understanding from patients and families led to difficulties for care workers in dealing with related issues and led to conflicts and reduced motivation among care workers. As shown in the following extracts:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The elderly were occasionally in an abnormal mood, some hitting or cursing, and when I could not do my job\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;the dean would feel that I was not doing my job well, leaving me a little stressed. At the same time, the words of some elderly family members gave us chills, and they expressed their inability to understand when they could not see the elderly during the COVID-19\u0026quot; (P2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Many elderly people with dementia cannot communicate with us, and when the care worker feeds them\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;they say they didn\u0026apos;t, so it\u0026apos;s easy for the family to misunderstand. There are also some elderly people who are violent and we are worried about them hurting other elderly people. Difficulty in communicating with patients leads to an inability to get a good understanding of the patient\u0026apos;s specific situation.\u0026quot; (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003cstrong\u003eepressing work environments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDirect care workers report that their own state of mind and psychological condition often leads to high levels of work stress and that psychological conditions are closely related to the patient\u0026apos;s condition. Care workers become attached to patients over time, but the seriousness or rapid deterioration of many disabling patients creates a sense of anxiety and urgency for care workers. Simultaneously, the fact that terminally ill patients often pass away makes care workers feel emotionally drained.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There are times when the elderly suddenly become ill, mentally unstable and so on, which can make us stressed.\u0026quot; (P30)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It feels like a rather depressing atmosphere to work in when you see the elderly seriously ill in bed.\u0026quot; (P17)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncomplete service process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOwing to the short pilot period of China\u0026apos;s LTCI and other reasons, the construction of the service system is not sound, the specific implementation rules are not perfect, and the development of information technology lags. Care workers state that there are currently more papers that require handwritten records. Simultaneously, the LTCI policy requires monthly billing, and patients need to be discharged and admitted, resulting in a cumbersome process. This adds to the workload and complexity of the care workforce. This is illustrated in the following example:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There are too many paper record forms, such as care plans, service records, and dynamic assessment forms, resulting in a heavy workload for us.\u0026quot; (P11)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;LTCI system requires discharging patients and then readmitting them after each month\u0026apos;s billing, and the procedure is too cumbersome.\u0026quot; (P22)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInadequate safety measures for home care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen providing home care, families with long distances or scattered addresses result in longer travel times for healthcare workers. Most institutions do not have uniform transportation for caregivers, and safety measures are not in place. Caregivers often need to use their own transportation, such as cars or electric vehicles. The lack of uniform and standardized management in the purchase, use, and maintenance of transportation tools leads to a high level of safety risks, as care workers face various accidental risks on their way to the doorstep.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough the LTCI policy positively impacts both the demand for institutional care for the older people and the supply of nursing beds in designated institutions through the reimbursement of LTC costs[\u003csup\u003e20\u003c/sup\u003e], the demand for direct care workers is even greater. Coupled with the more complex conditions of patients with higher levels of disability or dementia, more specific and higher demands are placed on the service capacity and quality of direct care. Focusing on our research perspective on direct care workers, we found that the barriers faced by care workers in providing LTCI services include seven aspects: intense and difficult work, tedious and boring work content, difficulty in gaining recognition and fulfillment at work, difficulty communicating with patients or family members, depressing work environments, incomplete service process, and inadequate safety measures for home care.\u003c/p\u003e\n\u003cp\u003eA study of LTCI services in Japan showed that the undersupply of care workers, high turnover, and low skill levels were mainly due to low wage levels and poor working conditions, which also had a potential negative impact on the quality of care[\u003csup\u003e21\u003c/sup\u003e]. A Korean study analyzed the reasons for willingness to leave among care workers providing direct services under the LTCI system and found that harsh working conditions, discordant relationships with supervisors, and their own health status were the main reasons for their departure[\u003csup\u003e22\u003c/sup\u003e]. A study of South African LTC workers showed that caregivers\u0026apos; motivation to provide quality care is hindered by role ambiguity, harsh employment conditions, negative interpersonal relationships at work, and role overload. These unfavorable conditions are created by policy deficits and a lack of structural support[\u003csup\u003e23\u003c/sup\u003e]. A study in Hangzhou, China, showed that low education level, long working hours, and low compensation of care workers were barriers to the development of LTC services[\u003csup\u003e24\u003c/sup\u003e]. These findings are generally consistent with those of our study.\u003c/p\u003e\n\u003cp\u003eTherefore, first, there are obstacles faced by direct care workers in terms of work content, environment, and other aspects. It is necessary to protect the legitimate rights and interests of care workers, such as the salaries and benefits of working hours; optimize scheduling and leave patterns; and provide scientific and flexible scheduling for care workers. Human resources should be reasonably allocated to reduce work intensity and avoid fatigue. Professional psychological guidance and education should be regularly arranged to focus on and maintain the physical and mental health of care workers. The professional skills training should be increased and practical exercises should be strengthened in response to the specific conditions of disabled and demented people. The comprehensive quality of care workers should be continuously improved and the construction of an LTC talent echelon should be promoted. Second, in response to obstacles, such as difficulty in obtaining recognition, a sense of achievement for care workers, and the difficulty of interpersonal communication, it is necessary to create a good and harmonious interpersonal atmosphere and invite patients\u0026apos; families to participate in internal activities. The feedback from patients and their families should be paid attention to and a service satisfaction evaluation system and service quality evaluation mechanism should be established. Research and development should be carried on for a care application (APP) that can be used by designated LTCI facilities and care workers and evaluation functions must be set up for patients and family members to use online. The evaluation results can be linked to the assessment of care workers. By organizing activities, such as the regular selection of excellent care workers, giving them tangible incentives such as bonuses, and intangible incentives such as publicity and reporting, the professional honor and social awareness of care workers should be enhanced.\u003c/p\u003e\n\u003cp\u003eIn addition, our study showed that inadequate LTCI policies and insufficient safety measures for home care are major barriers faced by caregivers. This may be related to the relatively short period of time for formal implementation of the LTCI pilot in China. Inadequate service specifications and assessment processes cause inconvenience to caregivers in providing services. The shortage of care workers to provide home care[\u003csup\u003e25\u003c/sup\u003e], despite the wide and convenient audience for home care services, may also be related to factors, such as inadequate security safeguards. These are prerequisites for ensuring the success of direct care workers. In response to these obstacles, we recommend optimizing LTCI assessment and service policies and improving service processes and management systems. Emphasis should be placed on standardized management, good service process management, and standardization of LTCI service behavior. Information technology support should be strengthened; the construction of home hospital beds, smart wards, and electronic medical records should be promoted; and the LTCI service model should be innovated. The technical support of information technology should be strengthened; the construction of home beds, smart wards, and electronic medical records should be promoted; and the nursing service model should be innovated. Service records that can be comprehensively recorded in the care APP cannot be filled in paper record forms. For home care, it is necessary to equip a specialized management team and improve supervision and administration. The safety guarantee of home care should be strengthened and the safety hazards should be reduced.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, participants were recruited only from Shandong Province, which has certain geographical limitations and is not representative of all direct care workers in the LTCI service delivery field. Some contextual characteristics, such as location, agency size, structure, and local environment, may differ from those of other care settings. The extrapolation of the findings from this study to other settings still needs to be contextualized. Second, a potential bias is the lower number of male care workers included in our study, which may have resulted in a lack of information from their perspective. Further research should explore job perceptions and stress factors when dealing with patients at different stages, levels of disability, and types of care, and identify ways to enable care workers to better provide LTC services.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, although LTC workers play a critical role in supporting the needs of people with disabilities and their families, they face several dilemmas and barriers. LTC is characterized by extreme vulnerability, especially during the coronavirus disease 2019 pandemic, and workers endure moral distress and emotional exhaustion, which have a dramatic impact on both physical and mental health and well-being[\u003csup\u003e26\u003c/sup\u003e]. Only when hygiene and motivation factors of direct care workers are met and work together can enthusiasm for work be mobilized can stress effectively be relieved and barriers to work eliminated. Improving the service capacity of care workers while reducing staff turnover would improve the quality and efficiency of LTCI services.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the officials of the local health agencies and staff at the study sites for their cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Shandong Province Social Science Planning Research Project (18CZKJ20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJing Gao was responsible for designing the study, conducting the interviews, interpreting the data and drafting the manuscript. Jia Yin was responsible for conducting the interviews and interpreting the data. Qiang Sun critically revised the manuscript for important intellectual content and grammar mistakes.\u0026nbsp;All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants included in the study. All participants were informed of the study purpose, risks and benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e Yang Y, Zheng R, Zhao L. Population Aging, Health Investment and Economic Growth: Based on a Cross-Country Panel Data Analysis. Int J Environ Res Public Health. 2021;18(4):1801. \u003c/li\u003e\n\u003cli\u003e Li SJ, Li YF, Song WM, et al. 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J Appl Gerontol. 2023;42(5):1118-1136.\u003cstrong\u003e \u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"direct care workers, long-term care insurance services, barriers, China","lastPublishedDoi":"10.21203/rs.3.rs-4108108/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4108108/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChina's long-term care insurance (LTCI) system plays a crucial role in addressing the challenges posed by an aging population, while simultaneously placing higher demands on the quantity and quality of long-term care (LTC) services. However, LTCI-designated facilities still face challenges in terms of recruiting and retaining care workers. There is limited knowledge regarding the barriers to service delivery for direct care workers in the context of LTCI.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo analyze the barriers faced by direct care workers in providing LTC services from their perspectives and to explore possible reasons.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBased on Herzberg's two-factor theory, face-to-face semi-structured interviews were conducted with 31 direct care workers. Thematic framework analysis method was used to generate qualitative codes and identify themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDirect care workers in designated LTCI facilities faced barriers to meeting motivation and hygiene factors. The motivation factors included three themes: intense and difficult work, tedious and boring work content, and difficulty in gaining recognition and fulfillment at work. Hygiene factors included four themes: difficulty communicating with patients or family members, depressing work environments, incomplete service processes, and inadequate safety measures for home care.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe conditions of people with disabilities or dementia covered by LTCI are complicated, which causes many difficulties and obstacles to the work of direct care workers. We recommend that in the development of the LTCI system, more emphasis should be placed on service providers as the mainstay of policy practice so that both the hygiene and motivation factors of direct care workers are met and put into effect together. Systems related to LTCI assessment and service provision should be optimized to alleviate the stress of direct care workers and eliminate barriers to their work.\u003c/p\u003e","manuscriptTitle":"Barriers to providing long-term care insurance services by direct care workers: a qualitative study in Shandong Province, China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 18:10:33","doi":"10.21203/rs.3.rs-4108108/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ede45d5-703c-4bf7-b9e1-79480220e79f","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-27T12:58:59+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-21 18:10:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4108108","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4108108","identity":"rs-4108108","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}