Willingness to participate in advance care planning among older adults with relatively high educational attainment in a continuing care retirement community of the Beijing-Tianjin-Hebei region: a qualitative study.

BACKGROUND: China is experiencing rapid population ageing, accompanied by changes in family structure, intergenerational relationships, and expectations regarding later-life care. As older adults become frail or lose cognitive and communicative capacity, they may receive end-of-life care that is inconsistent with their values and preferences. Advance care planning (ACP) may help older adults clarify and communicate their future medical and care preferences. However, ACP remains at an early stage of development in China, and evidence regarding ACP willingness among older adults living in Continuing Care Retirement Communities (CCRCs) is limited. This study aimed to explore willingness to participate in ACP among older adults with relatively high educational attainment living in a CCRC in the Beijing-Tianjin-Hebei region and to gain a deeper understanding of the factors shaping such willingness. METHODS: A qualitative study was conducted between July and September 2025 in a CCRC in the Beijing-Tianjin-Hebei region of China. Purposive and snowball sampling were used to recruit older residents, family members, healthcare professionals, and institutional administrators. Semi-structured interviews were conducted, and data were analyzed using thematic analysis guided by the Theory of Planned Behavior (TPB). RESULTS: Thirty-six participants were included, comprising 20 older adults, 4 family members, 5 doctors, 5 nurses, and 2 institutional administrators. Five themes were identified: attitudes toward ACP participation, subjective norms, perceived behavioral control, factors related to ACP participation, and willingness to participate in ACP. Most older adults expressed positive attitudes toward ACP, viewing it as a way to reduce suffering, maintain dignity and autonomy, and lessen family burden. However, family members and healthcare professionals expressed more concerns about preference stability, filial responsibility, implementation risks, and legal or procedural uncertainty. Willingness to participate in ACP was shaped not only by individual attitudes but also by family support, professional guidance, institutional processes, policy environments, and social networks within the CCRC setting. CONCLUSIONS: Among older adults with relatively high educational attainment living in Chinese CCRCs, willingness to participate in ACP appears to be shaped through the interaction of individual, familial, institutional, and broader social factors rather than by individual awareness alone. These findings contribute to a context-specific understanding of ACP willingness in Chinese CCRCs and suggest that future ACP implementation should combine public education with family communication, professional support, institutional preparedness, and supportive policy environments. Further research involving more diverse populations and care settings is needed to examine the transferability of these findings.