A multilevel analysis of the role of the family and the state in self-rated health of elderly Chinese

Do Health and Housing Attributes Motivate Residential Moves Among Older Chinese Adults? Evidence From an 8‑Year Follow‑up Study

Background and Objectives

Despite the widespread belief in aging-in-place as the preferred housing arrangement for older adults, they are increasingly embracing moving. The person-environment fit theory explains that environmental changes due to residential moves can pose health risks, discouraging older people from moving. However, it also suggests that moves may be suitable when living conditions no longer meet their physical needs. The correlation between older people's health, housing, and their subsequent moving or staying actions in China remains underexplored.

Research Design and Methods

Using alternative operating variables of key concepts and the China Family Panel Studies 2012-2018 data sets, this study examines the effects of health and housing status on older people's residential moves in China. The study outlines changes in health indicators and housing characteristics during multiple moves, as well as examines the relationship between the health and housing status of older adults and moving over a relatively long period of time using both regression models with lagged explanatory variables and fixed effects binary choice models.

Results

The results reveal that: (1) higher rates of subsequent moves were observed among older adults with better self-rated health, positive self-rated health changes, and no ADL impairment, but no significant associations were found between most health variables and moving; and (2) the correlation between older persons' house ownership/type and their residential moves was significant and consistent over time, steady and lasting.

Discussion and Implications

Potential mechanisms explaining the association between specific housing types and ownership statuses on moving are discussed. The findings encourage a focus on the positive benefits of moving in later life and how to provide additional housing options for older individuals.

The role of family support in the self-rated health of older adults in eastern Nepal: findings from a cross-sectional study

BACKGROUND

Nepal's low fertility rate and increasing life expectancy have resulted in a burgeoning older population. For millennia, filial piety shaped family cohesion and helped Nepali older adults achieve positive outcomes, but recently, it has been eroding. Furthermore, there are not enough institutional support options or alternatives to family-based care to deal with the biosocial needs of older adults. This study explored the association between family support and self-rated health among Nepali older adults.

METHODS

A community-based cross-sectional survey in eastern Nepal's two districts, Sunsari and Morang, interviewed 847 older adults (≥ 60 years). The final analytical sample was 844. Participants were asked whether they received assistance with various aspects of daily life and activities of daily living from their families. Multivariable logistic regression examined the association between family support and self-rated health.

RESULTS

Participants who received support with various aspects of daily life had 43% higher odds of good health, but after adjusting for control variables, the result only approached statistical significance (p = 0.087). Those who received family assistance with activities of daily living had nearly four times higher odds (OR: 3.93; 95% CI: 2.58 - 5.98) of reporting good health than participants who lacked this support.

CONCLUSIONS

Given the important role of family support in Nepali older adults' health, government programs and policies should create a conducive environment to foster family-based care until more comprehensive policies for older adults' care can be put into effect. The results of this study can also help shape the global aging environment by highlighting the need for family support in older care, particularly in low-income nations with declining traditional care systems and weak social security policies.

To what extent do disparities in economic development and healthcare availability explain between-province health inequalities among older people in China?

Background

Uneven economic development has led to substantial health inequalities between Chinese provinces. The extent of, and factors underlying, between-province health inequalities have received little attention.

Methods

Data from 15,278 respondents in Wave 2 (2013) of the China Health and Retirement Longitudinal Study (CHARLS) were used to investigate inequalities among people aged ≥50 years in five health outcomes between 27 Chinese province-level administrative units. After characterizing the between-province differences and the relevance of province effects, proportional change in variance between unadjusted and adjusted models was calculated to determine the percentage of between-province variance in health outcomes explained by province-level variables including measures of economic development and healthcare availability.

Results

Although province effects explained <10% of overall variance in health outcomes, they underpinned large between-province inequalities among people aged ≥50 years. Gross Regional Product per capita was more important than doctor density in explaining between-province variance in health outcomes, particularly depression symptoms and instrumental activities of daily living impairment.

Conclusion

Policy efforts, including more equal distribution of healthcare personnel, may be warranted to reduce between-province health inequalities.

Ethnic Differences in Social Support for Elderly Individuals in Rural Southern China: A Cross-sectional Survey

This study investigated ethnic differences in social support received by the rural elderly population and the effect of ethnic culture, socioeconomic status, and contextual variables on their social support. We determined social support received by 6451 elderly individuals from the rural Guangxi region. Children and spouses represented the most important sources of social support for this population. The Jing and Zhuang, and the Yao and Dong ethnic groups received the maximum and minimum support from the children, respectively. The overall mean social support score was 35.5, and the Jing had the highest and the Maonan had the lowest score. Amid the variation in social support received by different ethnic groups, contextual effects on social support received at the household level are more important than those at the village level among rural elderly individuals. Modern Chinese society should try to narrow the social gap.

Are there gender differences in the trajectories of self-rated health among chinese older adults? an analysis of the Chinese Longitudinal Healthy Longevity Survey (CLHLS)

BACKGROUND

Self-rated health (SRH) is a good predictor of morbidity and mortality. Extensive research has shown that females generally report poorer SRH than males but still tend to live longer. Previous studies used cross-sectional or pooled data for their analyses while ignoring the dynamic changes in males' and females' SRH statuses over time. Furthermore, longitudinal studies, especially those that focus on older adults, typically suffer from the incompleteness of data. As such, the effect of dropout data on the trajectories of SRH is still unknown. Our objective is to examine whether there are any gender differences in the trajectories of SRH statuses in Chinese older adults.

METHODS

The trajectories of SRH were estimated using the pattern-mixture model (PMM), a special latent growth model, under non-ignorable dropout data assumption. We analyzed the Chinese Longitudinal Healthy Longevity Survey (CLHLS) data of 15,613 older adults aged 65 years and above, collected from 2005 to 2014.

RESULTS

The results demonstrated the effect of non-ignorable dropout data assumptions in this study. The previous SRH score was negatively associated with the likelihood of dropping out of the study at the next follow-up survey. Our results showed that both males and females in China perceive their SRH as decreasing over time. A significant gender difference was found in the average SRH score (female SRH was lower than male SRH) in this study. Nonetheless, based on the results obtained using the PMM, there are no gender differences in the trajectories of SRH at baseline as well as in the rate of decline among the total sample. The results also show that males and females respond to SRH predictors similarly, except that current drinking has a more pronounced positive effect on males and healthcare accessibility has a more pronounced positive effect on females.

CONCLUSIONS

Our results suggest that missing data have an impact on the trajectory of SRH among Chinese older adults. Under the non-ignorable dropout data assumptions, no gender differences were found in trajectories of SRH among Chinese older adults. Males and females respond to SRH predictors similarly, except for current drinking habit and healthcare accessibility.

Association between socioeconomic welfare and depression among older adults: Evidence from the China health and Retirement Longitudinal Study

This study aims to examine the association between province-level socioeconomic welfare factors and depression symptoms among older adults in China. Province-level socioeconomic characteristics were merged with microdata for respondents over 65 years from the 2018 China Health and Retirement Longitudinal Study (CHARLS) Wave 4 (N = 6657). Principal component analysis (PCA) was used to extract three socioeconomic welfare factors constructed from 14 province-level variables. A Bayesian mixed-effects logistic model was applied to measure the association between the three socioeconomic welfare factors and depression symptoms while controlling for socio-demographic variables. The PCA showed that economic welfare, medical resource welfare, and social service welfare together explained 72.2 percent of the total variance of the 14 province-level variables. It was found that increasing economic welfare was significantly associated with a lower probability of depression symptoms (OR = 0.806, 95%CI: [0.674, 0.967]), while medical facilities were associated with a higher probability of depression symptoms (OR = 1.181, 95%CI: [1.029, 1.354]) among Chinese older adults. Uncertainty existed as to whether having access to social welfare (OR = 0.941, 95%CI: [0.835, 1.060]) was associated with prevalence of depression. Thus, improved socioeconomic welfare systems for older adults (which possibly require an increase in spending) are necessary to contribute further to reduced depression risk in China. Policymakers should also improve the utilization of medical resources to mitigate the incidence of depression among the elderly in China.

Exploring the association between urbanisation and self-rated health of older adults in China: evidence from a national population sample survey

OBJECTIVES

This study investigated the association between urbanisation and self-rated health of older adults in China, particularly how different dimensions, rate and level of urbanisation are related to older people's health. Additionally, it examined the moderating effect of education on the association between each of the four dimensions of urbanisation and older people's health.

DESIGN

The study uses a cross-sectional survey design.

PARTICIPANTS

This study analysed 236 030 individuals (aged 60-79 years) nested within 267 prefecture-level cities from 2005 China's 1% population sample survey.

OUTCOME MEASURES

Self-rated health was the outcome variable. Four groups of predictors assessed prefectures' level and rate of urbanisation: land-use conversion, economic growth, population concentration and health services. Multilevel logistic regression was used to examine the association between self-rated health and the level and rate of urbanisation, after adjusting for individual-level covariates. Multiplicative interactions explored variations by education.

RESULTS

The odd of reporting fair or poor health was negatively associated with the level and rate of population concentration (OR 0.93,95%CI 0.87 to 0.99 and 0.74,95%CI 0.59 to 0.93, respectively) and positively associated with the level of health services (OR 1.12, 95% CI 1.06 to 1.19). Land-use conversion, economic growth and health service improvements (the forms of rate of urbanisation) were not significantly associated with self-rated health. Education had a moderating effect on the association between urbanisation and self-rated health.

CONCLUSIONS

Older people living in more densely populated areas and areas undergoing rapid population concentration were less likely to report fair or poor health. This result supports healthy migration and 'salmon bias' hypotheses. No urban health penalty was observed for the older adults in China; therefore, the following pathways linking urbanisation to health are unclear: lifestyle changes, environmental pollution and cultivated land reduction.

Mediating effect of social support on the associations between health literacy, productive aging, and self-rated health among elderly Chinese adults in a newly urbanized community

With the growing urbanization of China, which has changed older adults' living conditions, lifestyle, and the source of support, coupled with rapid population aging, the health status of the elderly should be paid attention to. In addition to objective indicators such as the decline of function, specific factors, such as social support, health literacy, and productive aging, also have an impact on the health outcomes of the elderly. However, the interrelationships among these factors and their potential mechanisms in the context of urbanization remain unclear. Thus, this study was the first to explore the interrelationships among social support, health literacy, productive aging, and self-rated health in older adults living in a newly urbanized community in China.We aimed to investigate the mediating effect of social support on the associations between health literacy, productive aging, and self-rated health among elderly Chinese adults in a newly urbanized community to provide reference data for future health interventions for the elderly.This cross-sectional study was conducted between June and August 2013. Questionnaires on social support, health literacy, productive aging, and self-rated health were administered to 992 elderly residents. Structural equation models were used to examine the relationships among these 4 variables. Statistical analyses were performed using IBM SPSS Statistics 21.0 and Mplus 7.0.The mean scores for social support, health literacy, productive aging, and self-rated health were 34.5 ± 5.8, 13.6 ± 4.4, 11.3 ± 3.0, and 3.4 ± 0.7, respectively. Social support was directly related to self-rated health (β=0.119, 95% confidence interval [CI]: 0.041-0.198), while productive aging and health literacy had indirect associations with self-rated health via social support (β=0.071, 95% CI: 0.054-0.216; β=0.049, 95% CI: 0.066-0.183). Both productive aging (β=0.214, 95% CI: 0.047-0.381) and health literacy had direct associations with social support (β=0.327, 95% CI: 0.175-0.479), while health literacy had a direct association with productive aging (β=0.676, 95% CI: 0.604-0.748). Productive aging mediated the relationship between health literacy and social support.Overall, improving health outcomes among older adults requires enhancement of social support, along with consideration of productive aging and health literacy.

Understanding the Wellbeing of the Oldest-Old in China: A Study of Socio-Economic and Geographical Variations Based on CLHLS Data

Empirical studies of the socio-economic determinants of the wellbeing of the oldest-old in China including the role of geography and spatial factors are rare. This paper applies binary logistic regression analysis to data on the oldest-old aged 80 years old and higher from the 2011 Chinese Longitudinal Healthy Longevity Study (CLHLS). Socioeconomic determinants of the self-reported quality of life (QoL) and self-reported health (SRH) of the oldest-old population are explored, with special attention paid to the role of residence and region. The results indicate that, after controlling for individual demographic and health behavior variables, both economic status and social welfare have a significant effect on self-reported QoL and SRH. There are also significant differences in self-reported QoL among cities, towns and rural areas, with the oldest-old respondents living in Central rural, Western town and Western rural areas being significantly less likely to report good QoL, compared to the oldest-old living in Eastern cities. Significant differences in SRH exist among Eastern China, Western China and Northeastern China, with the oldest-old from Western towns being significantly less likely to report good health, and the oldest-old from Northeastern cities being significantly more likely to report good health than those from Eastern cities. The results of this study indicate that socioeconomic factors that explain self-reported QoL and SRH of the older population are in general factors that explain the self-reported QoL and SRH of the oldest-old cohorts. The interaction effect of residence and region matters more than each of the individual factors, in providing us with more detailed information on the role of geography in explaining QoL and health of the oldest-old. At a time when the oldest-old cohorts in China are at the beginning of their projected growth, these findings are vital for providing policy makers with more information on the urgency of making more geographically targeted policy to improve more effectively the self-reported QoL and SRH of the oldest-old population.

Geographical variations in self-rated health and functional limitations among older Chinese in eight WHO-SAGE provinces

BACKGROUND

The proportion of population ageing in China will grow significantly in the next few decades but the pace of population ageing and social change vary considerably across regions. Notably, Eastern coastal areas are economically more advanced compared to the Western region. These economic disparities could result in differing adverse health outcomes.

METHODS

We investigate geographical variations in self-rated overall health and functional limitations in a national representative sample of Chinese aged 50 years and older (n = 13,175) using the WHO Study on global AGEing and adult health (WHO SAGE). We used multivariable logistic regression to investigate urban-rural inequalities across regions, adjusting for sociodemographic and health covariates. Two main outcomes were self-rated overall health and functional limitations based on the WHO Disability Assessment Schedule 2.0 for a range of daily activities.

RESULTS

The largest urban-rural differences in adverse health outcomes were in Shandong (AORs for urban versus rural of 6.32 [95% Confidence Interval 4.53-8.82] for poor or very poor self-rated overall health and 5.14 [CI 3.55-7.44] for functional limitations), followed by Jilin (AORs 2.71 [CI 2.04-3.61] and 4.72 [CI 3.43-6.49]), and Hubei (AORs 2.36 [CI 1.82-3.07] and 4.11 [CI 2.80-6.04]), respectively. Covariates significantly associated with both adverse health outcomes were older age, poor income, no health insurance, and increasing number of chronic diseases.

CONCLUSION

Our study reveals substantial disparities between urban and rural areas observed in both the well-developed areas (eg Shandong) and also the lower end of the economic spectrum (eg Hubei and Jilin). Targeted economic development policy and systematic health prevention and healthcare policies could be beneficial in improving health in later life whilst minimising geographical inequalities.

Childlessness and vulnerability of older people in China

Background

the number of childless older people is increasing in China, but relatively little is known about the role of childlessness in health outcomes. This study investigates the relationship between childlessness and three health outcomes: difficulty with Instrumental Activities of Daily Living (IADLs), self-rated health and depression.

Methods

this study includes 13,171 individuals aged 50 and above from national survey data of the second wave of the China Family Panel Study (2012). Binary/multinomial logistic and ordinary least squares regression models are presented.

Results

childless individuals whose children have all died exhibit worse health outcomes than individuals with children, but this effect is influenced by demographic characteristics, socio-economic status and social security. On the other hand, individuals who are childless due to other reasons (involuntary or voluntary) are less likely to report difficulty with IADLs and to report depression than older people with all children alive after controlling for demographic and socio-economic and social security factors.

Conclusions

the death of a child has an adverse effect on people's health for both childless people whose children have all died and those who have lost a child but have other children alive. These two groups are in the most vulnerable position, which could also suggest that their children have died because they grew up in a vulnerable family. The government needs to improve the social security for these two groups and provide social services (particularly mental health services) to older people who have lost a child; these could contribute to alleviating some of the adverse effects of the death of a child.

Association of empty nest with depressive symptom in a Chinese elderly population: A cross-sectional study

BACKGROUND

Empty nest has been becoming the main family pattern among old people, and influencing the traditional family providing for the aged in China. This study aimed to investigate the association of empty nest with depressive symptom in a Chinese elderly population.

METHODS

Our study was based on the baseline investigation of Zhejiang Major Public Health Surveillance which was conducted in 2014. The final analyzed sample consisted of 9215 participants aged no less than 60 years. Subjects completed a questionnaire including demographic characteristics, living arrangements, behavioral risk factors, health status, subjective assessments, and Patient Health Questionnaire-9 scale.

RESULTS

More than half of the participants were empty nest elders (57.4%). The overall prevalence of depressive symptom was 10.3%, while it was higher in empty nest group than in non-empty nest group (11.6% vs. 8.6%, P<0.001). A positive association was found between empty nest and depressive symptom, the OR (95%CI) was 1.223(1.045, 1.431). After stratified by gender/age/education level/employment status, this association was just prominent in participants of male, 70 years old and above, primary school education, and retirees. No matter living with spouse or living alone, empty nesters were more likely to have depressive symptoms than non-empty nesters.

LIMITATIONS

Cross-sectional study could not make a causation conclusion. The social supports of participants were not been investigated in detail.

CONCLUSIONS

Empty nest elders, especially those who are male, 70 years old and above, primary school education, and retired, are more vulnerable to depressive symptom.

Challenges for the Aging Family in the People’s Republic of China

La République populaire de Chine a la plus grande population de personnes âgées de tous les pays du monde. Il est une nation qui a subi d'énormes changements économiques, sociaux et démographiques au cours des dernières trois et demi-décennies. Traditionnellement, la famille a fourni le soutien social principal pour les personnes âgées; sous le socialisme précoce, cela a changé quelque peu, mais au cours des dernières années, l'importance du soutien de la famille a été réaffirmé. Cet article examine quatre questions essentielles (changements démographiques, le système du hukou, le réforme économique, et les caractéristiques générales entourant la modernisation) qui ont peu à peu changé la capacité des familles à fournir un soutien pour leur membres plus âgés. Domaines de recherche et orientations de politique publique sont considérés en vertu de lesquelles l'État pourrait prendre quelques responsabilités de la famille, soutenir la capacité des soins, et aussi améliorer la qualité et la quantité de l'aide pour les citoyens âgés.

An exploratory discrete-time multilevel analysis of the effect of social support on the survival of elderly people in China

This study undertakes a survival analysis of elderly persons in China using Chinese Longitudinal Healthy Longevity Survey 2002-2008. Employing discrete-time multilevel models, we explored the effect of social support on the survival of elderly people in China. This study focuses on objective (living arrangements and received support) and subjective activities (perceived support) of social support, finding that the effect of different activities of social support on the survival of elderly people varies according to the availability of different support resources. Specifically, living with a spouse, financial independence, perceiving care support from any resource is associated with higher survival rates for elderly people. Separate analysis focusing on urban elderly and rural elderly revealed broadly similar results. There is a larger difference between those perceiving care support from family or social service and not perceiving care support in urban areas comparing to those in rural areas. Those who cannot pay medical expenses are the least likely to survive. The higher level of economic development in province has no significant effect on the survival of elderly people for the whole sample model and the elderly people in urban areas; however, there is a negative influence on the survival of the rural elderly people.

Individual and province inequalities in health among older people in China: evidence and policy implications

This paper uses multi-level modelling to analyse data from the nationally-representative Chinese Health and Retirement Longitudinal Study (CHARLS) in order to investigate the characteristics associated with poor health among older people, including individual and household characteristics as well as the characteristics of the provinces in which the older person lives (contextual effects). The results show that older Chinese women, rural residents, those with an education level lower than high school, without individual income sources, who are ex-smokers, and those from poor economic status households are more likely to report disability and poor self-rated health. Differentials in the health outcomes remain substantial between provinces even after controlling for a number of individual and household characteristics.