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Geriatr Gerontol Int 2015; 15: 457–464
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Self-rated health and associated factors among older people living alone in Shanghai Yu Chen,1 Alison E While2 and Allan Hicks2 1 School of Nursing, Fudan University, Shanghai, China; and 2Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
Aim: Self-rated health is a reliable and important health measure related to older people’s mortality and quality of life. Few studies regarding the self-rated health of older people living alone have been carried out in Mainland China. The present study aimed to investigate the self-rated health of older people living alone in Shanghai and its associated factors. Methods: A stratified random cluster sample of 521 community-dwelling older people living alone in Shanghai completed structured questionnaires through face-to-face interviews. The data collected included self-rated health, physical health, depression, functional ability, physical activity, health services satisfaction, loneliness, social support and sociodemographic variables. Results: More than two-fifths of the participants (43.2%) reported good self-rated health. Multinomial logistic regression analyses found that chronic disease, acute disease, functional ability, satisfaction with health services, depression and age were predictors of self-rated health. Conclusions: Identifying factors associated with the self-rated health of older people living alone could inform the delivery of appropriate health and social care interventions to promote older people’s health. Geriatr Gerontol Int 2015; 15: 457–464. Keywords: aging, associated factors, China, living alone, self-rated health.
Introduction China, as a developing country with a population of 1.3 billion, is undergoing dramatic population aging with approximately 13.3% of the total population being aged 60 years and older.1 The annual growth rate of older people is 3.3%, fivefold of the rate of the national population.2 It is estimated that the number of Chinese older people will increase by 200 million every 12–13 years, equivalent to the total population of some populated countries.3 The rapid growth rate is about to catch up with Japan, which has the fastest aging rate in the world.3 Additionally, changes in living arrangements due to the migration of younger people, improvement in
Accepted for publication 11 March 2014. Correspondence: Mrs Yu Chen BSc MSN PhD, School of Nursing, Fudan University, no. 305 Fenglin Road, Xuhui District, Shanghai 200032, China. Email: [email protected]
© 2014 Japan Geriatrics Society
living conditions, and changes in lifestyle and family values have resulted in an increase in the number of older people living alone.4 Population aging brings about major challenges to health and social care, because older people have a progressive, generalized impairment of function with aging resulting in a growing risk of age-associated diseases.5 Health plays a dominant role in influencing older people’s life satisfaction, happiness and quality of life.6,7 Understanding the health status of this population is important to inform the development of disease prevention and health promotion programs, and the delivery of appropriate health and social services to older people. There are different measures in assessing older people’s health, among which self-rated health (SRH) has been regarded as a practical, reliable and important measure of the general state of health.8 It is commonly used in health surveys, because it is easily obtained, offers much more information than other measures and allows comparisons of people’s state of health across different countries.9 Furthermore, it is a significant predictor of doi: 10.1111/ggi.12298
| 457
Y Chen et al.
morbidity, mortality, health services utilization and the quality of life of older people.10–12 Extensive literature has documented the factors that are associated with older people’s SRH. Health-related factors, such as physical health, mental health and functional ability, have been identified as principal determinants of SRH.9,13,14 Lifestyle factors are also reported to have effects on SRH with older people adopting a proactive lifestyle being more likely to report better health despite various lifestyle variables being used across different studies.15 Additionally, psychosocial factors, such as social support, distress and self-esteem, are considered to play a role in SRH.16,17 Identifying these associated factors could help to recognize groups vulnerable to poor health and high-risk individuals in prodromal stages for the development of adverse health events to inform the priorities in health and social care of older people.9 Older people living alone are a unique group requiring specific attention. Many studies in Western countries have found that older people who live alone are more likely to be physically or mentally ill, require outside help in the case of illness or disability, require long-term care services and be institutionalized.18–21 In light of the great burden this places on health and social care, the SRH of older people living alone needs to be studied. Furthermore, SRH has been shown to be culturally and socially sensitive.22 Traditionally, interdependence and group harmony are emphasized in China.23 Therefore, intergenerational coresidence is very common, which gives Chinese older people a sense of pride as well as instrumental and emotional support.24 Different living arrangements are salient to and have great consequences for Chinese older people’s SRH.24 Considering the vulnerability of older people living alone and the differences of cultural norms between China and Western countries, it is important to explore the SRH of older people living alone in China. However, most studies of SRH in China have focused on older people regardless of their living arrangements. Older people living alone in China are an understudied population and little is known about their SRH. Therefore, the present study was designed to investigate the SRH of older people living alone in Shanghai and its associated factors to inform initiatives to promote healthy aging.
Chongming. In China, the term “older people” refers to those aged 60 years and older, which was described in the “Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly.”27 Living alone in the present study refers to a state of a oneperson household; that is, staying and sleeping alone in one’s dwelling with no-one else sharing the dwelling.28 The sample inclusion criteria were older people living alone, being able to communicate in Mandarin or Chongming dialect and having no major cognitive impairment indicated by a score of under 6 on the Short Portable Mental Status Questionnaire (SPMSQ).29 The exclusion criteria were having hearing, language and communication difficulties; and having moderate or severe cognitive impairment as evidenced by the results of cognitive function tests. A stratified random cluster sampling procedure was applied to recruit the sample. Two towns (one town with high socioeconomic status and the other with low socioeconomic status) were randomly selected. Nine communities (high socioeconomic status: n = 5; low socioeconomic status: n = 4) were randomly selected from these two towns. All older people living alone (n = 640) in these nine communities were invited to participate in the study. A total of 18 trained data collectors who were community committee staff or community residents distributed information sheets to the 640 potential participants during door-to-door visits in November 2011. After one week, they contacted potential participants again to ascertain their wishes regarding participation. A total of 618 older people agreed to participate in the study and were offered a face-to-face interview in their homes or community committee offices. During the interview, the SPMSQ29 was administered to assess the potential participants’ cognitive function. A total of 97 older people were excluded from further participation because of poor cognitive function. The remainder (n = 521) were given an informed consent form. Once consent was gained, the structured questionnaires were completed either with the data collectors or independently and took approximately 45 min to complete. Therefore, the response rate was 95.9% (521 out of 543 eligible subjects). This study was approved by the University Research Ethics Committee.
Methods
The dependent variable, namely SRH, was measured using a single-item question of “How would you rate your current health status?” with five possible responses: very good, good, neutral, poor and very poor. Some variables that have been reported to influence the SRH of older people in previous studies were selected as independent variables in the present study, including physical health, depression, functional ability, physical activity, health services satisfaction, loneliness
Study population and data collection The present study was carried out in Chongming County of Shanghai, which is China’s most populous city with 3.7 million older people and 233 500 older people living alone.25,26 The target population was community-dwelling older people living alone in 458 |
Study variables
© 2014 Japan Geriatrics Society
SRH of older people living alone
and social support.9,14–16 Physical health was measured by asking the participants whether they had experienced acute diseases in the previous 4 weeks and chronic diseases. The 15-item Geriatric Depression Scale (GDS) was used to measure depression.30 Each item was rated on a dichotomous scale of “yes” or “no” with one point being assigned to a response indicating a depressive symptom. The total score ranged from 0–15, and a score of equal to or greater than 8 suggested having depression. The Cronbach’s α coefficient of the scale in the current study was 0.82, and the 2-week test–retest reliability coefficient was 0.81. The Activity of Daily Living (ADL) Scale was used to measure functional ability.31 It includes 14 items with two components; that is, Physical Self-Maintenance Scale (6 items) and Instrumental Activity of Daily Living Scale (8 items), to assess people’s basic and high-level physical functioning.31 The Chinese version of the ADL Scale is a four-point rating scale from carrying out an activity totally independently to being totally dependent, with a total score of 14–16, 17–21 and 22+ indicating a high, moderate and low level of functional ability, respectively.32 In the present study, the Cronbach’s α coefficient of the scale was 0.92, and the 2-week test– retest reliability coefficient was 0.88. Physical activity was measured using the reported frequency of recreational and household activities, and their intensity per week drawing on relevant literature.33,34 The participants who reported undertaking a minimum of 30 min of moderate/strenuous physical activity on at least 5 days per week were categorized as having undertaken adequate physical activity.35 A single item was used to measure global health services satisfaction, namely: “On the whole, how satisfied are you with your health services?” with a five-point scale from “very satisfied” to “very dissatisfied.” A single item is a commonly used method to assess people’s overall perceptions of their health services when the focus is global satisfaction with services rather than specific experiences related to individual services at different points in time.36,37 A single item is recommended, because participants find it easier to understand and minimize the research burden.38 The UCLA Loneliness Scale version 3 was used to measure loneliness.39 It is a four-point rating scale comprising 20 items. The total score ranged from 20–80, with a score of 20–34, 35–49, 50–64 and 65–80 indicating a low, moderate, moderately high and high level of loneliness, respectively.40 The Cronbach’s α coefficient and 2-week test–retest reliability coefficient of this scale in the present study was 0.89 and 0.68, respectively. The Social Support Rate Scale was used to assess social support.41 The total score ranged from 12–65, with a higher score indicating a higher level of social support. The scale was modified with one item regard© 2014 Japan Geriatrics Society
ing living arrangements being deleted, considering the participants’ characteristics of living alone. The modified scale had a Cronbach’s α coefficient of 0.76, and a 2-week test–retest reliability coefficient of 0.70. The participants were divided into three groups according to the frequency distribution of total score. Those who scored the lowest 27.0% were categorized into the low level group, and those who scored the highest 27.0% were categorized into the high level group.42 The remainder were categorized into the moderate level group. Data relating to age, sex, education level, previous occupation, economic level and residential area were also collected.
Statistical analysis Data were analyzed using SPSS 16.0 (SPSS, Chicago, IL, USA). Descriptive statistics were used to examine the participants’ SRH, sociodemographic characteristics, chronic disease, acute disease, depression, functional ability, physical activity, health services satisfaction, loneliness and social support. In order to identity the associated factors, SRH was categorized into three groups as “good,” “neutral” and “poor,” with the participants who rated their health as good or very good being categorized into the “good” group, whereas those who rated their health as poor or very poor were categorized into the “poor” group. The χ2-test was used to explore the relationships between SRH and the independent variables. The variables that were significant in the bivariate analyses were entered into the multinomial logistic regression models to identify the predictors of SRH using poor SRH as the reference category.
Results Overall, more than two-fifths of the participants (n = 225, 43.2%) rated their health as good, and less than one-sixth (n = 79, 15.2%) rated their health as poor. Table 1 presents the relationships between SRH and each independent variable. Older people’s SRH was significantly associated with age, education level, previous occupation, economic level, chronic disease, acute disease, depression, functional ability, physical activity, health services satisfaction, loneliness and social support. There were no significant differences across the participants of different sexes and from different residential areas. The results of the multinomial logistic regression analyses are presented in Table 2. Chronic disease, acute disease, functional ability and health services satisfaction were statistically significant across the two models. The participants who did not have chronic diseases were more likely to report better health (good vs | 459
Y Chen et al.
Table 1 Bivariate relationships between self-rated health and independent variables
Age (years)
Sex Education
Previous occupation†
Economic level‡
Residential area Chronic disease Acute disease Depression Functional ability
Physical activity Health services satisfaction§ Loneliness
Social support
60–69 70–79 80+ Male Female No formal education Primary school Junior high school and above Peasant Blue-collar worker Non-manual employee Low level Medium-low level Medium-high level High level Rural Urban No Yes No Yes No Yes Low level Moderate level High level Inadequate Adequate Dissatisfied Satisfied Low level Moderate level Moderately high level Low level Moderate level High level
n
Good n %
Neutral n %
Poor n %
χ2
P
126 200 195 177 344 244 213 64
80 100 45 80 145 89 90 46
63.5 50.0 23.1 45.2 42.2 36.5 42.3 71.9
43 76 98 67 150 102 100 15
34.1 38.0 50.2 37.9 43.6 41.8 46.9 23.4
3 24 52 30 49 53 23 3
2.4 12.0 26.7 16.9 14.2 21.7 10.8 4.7
70.17
Geriatr Gerontol Int 2015; 15: 457–464
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Self-rated health and associated factors among older people living alone in Shanghai Yu Chen,1 Alison E While2 and Allan Hicks2 1 School of Nursing, Fudan University, Shanghai, China; and 2Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
Aim: Self-rated health is a reliable and important health measure related to older people’s mortality and quality of life. Few studies regarding the self-rated health of older people living alone have been carried out in Mainland China. The present study aimed to investigate the self-rated health of older people living alone in Shanghai and its associated factors. Methods: A stratified random cluster sample of 521 community-dwelling older people living alone in Shanghai completed structured questionnaires through face-to-face interviews. The data collected included self-rated health, physical health, depression, functional ability, physical activity, health services satisfaction, loneliness, social support and sociodemographic variables. Results: More than two-fifths of the participants (43.2%) reported good self-rated health. Multinomial logistic regression analyses found that chronic disease, acute disease, functional ability, satisfaction with health services, depression and age were predictors of self-rated health. Conclusions: Identifying factors associated with the self-rated health of older people living alone could inform the delivery of appropriate health and social care interventions to promote older people’s health. Geriatr Gerontol Int 2015; 15: 457–464. Keywords: aging, associated factors, China, living alone, self-rated health.
Introduction China, as a developing country with a population of 1.3 billion, is undergoing dramatic population aging with approximately 13.3% of the total population being aged 60 years and older.1 The annual growth rate of older people is 3.3%, fivefold of the rate of the national population.2 It is estimated that the number of Chinese older people will increase by 200 million every 12–13 years, equivalent to the total population of some populated countries.3 The rapid growth rate is about to catch up with Japan, which has the fastest aging rate in the world.3 Additionally, changes in living arrangements due to the migration of younger people, improvement in
Accepted for publication 11 March 2014. Correspondence: Mrs Yu Chen BSc MSN PhD, School of Nursing, Fudan University, no. 305 Fenglin Road, Xuhui District, Shanghai 200032, China. Email: [email protected]
© 2014 Japan Geriatrics Society
living conditions, and changes in lifestyle and family values have resulted in an increase in the number of older people living alone.4 Population aging brings about major challenges to health and social care, because older people have a progressive, generalized impairment of function with aging resulting in a growing risk of age-associated diseases.5 Health plays a dominant role in influencing older people’s life satisfaction, happiness and quality of life.6,7 Understanding the health status of this population is important to inform the development of disease prevention and health promotion programs, and the delivery of appropriate health and social services to older people. There are different measures in assessing older people’s health, among which self-rated health (SRH) has been regarded as a practical, reliable and important measure of the general state of health.8 It is commonly used in health surveys, because it is easily obtained, offers much more information than other measures and allows comparisons of people’s state of health across different countries.9 Furthermore, it is a significant predictor of doi: 10.1111/ggi.12298
| 457
Y Chen et al.
morbidity, mortality, health services utilization and the quality of life of older people.10–12 Extensive literature has documented the factors that are associated with older people’s SRH. Health-related factors, such as physical health, mental health and functional ability, have been identified as principal determinants of SRH.9,13,14 Lifestyle factors are also reported to have effects on SRH with older people adopting a proactive lifestyle being more likely to report better health despite various lifestyle variables being used across different studies.15 Additionally, psychosocial factors, such as social support, distress and self-esteem, are considered to play a role in SRH.16,17 Identifying these associated factors could help to recognize groups vulnerable to poor health and high-risk individuals in prodromal stages for the development of adverse health events to inform the priorities in health and social care of older people.9 Older people living alone are a unique group requiring specific attention. Many studies in Western countries have found that older people who live alone are more likely to be physically or mentally ill, require outside help in the case of illness or disability, require long-term care services and be institutionalized.18–21 In light of the great burden this places on health and social care, the SRH of older people living alone needs to be studied. Furthermore, SRH has been shown to be culturally and socially sensitive.22 Traditionally, interdependence and group harmony are emphasized in China.23 Therefore, intergenerational coresidence is very common, which gives Chinese older people a sense of pride as well as instrumental and emotional support.24 Different living arrangements are salient to and have great consequences for Chinese older people’s SRH.24 Considering the vulnerability of older people living alone and the differences of cultural norms between China and Western countries, it is important to explore the SRH of older people living alone in China. However, most studies of SRH in China have focused on older people regardless of their living arrangements. Older people living alone in China are an understudied population and little is known about their SRH. Therefore, the present study was designed to investigate the SRH of older people living alone in Shanghai and its associated factors to inform initiatives to promote healthy aging.
Chongming. In China, the term “older people” refers to those aged 60 years and older, which was described in the “Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly.”27 Living alone in the present study refers to a state of a oneperson household; that is, staying and sleeping alone in one’s dwelling with no-one else sharing the dwelling.28 The sample inclusion criteria were older people living alone, being able to communicate in Mandarin or Chongming dialect and having no major cognitive impairment indicated by a score of under 6 on the Short Portable Mental Status Questionnaire (SPMSQ).29 The exclusion criteria were having hearing, language and communication difficulties; and having moderate or severe cognitive impairment as evidenced by the results of cognitive function tests. A stratified random cluster sampling procedure was applied to recruit the sample. Two towns (one town with high socioeconomic status and the other with low socioeconomic status) were randomly selected. Nine communities (high socioeconomic status: n = 5; low socioeconomic status: n = 4) were randomly selected from these two towns. All older people living alone (n = 640) in these nine communities were invited to participate in the study. A total of 18 trained data collectors who were community committee staff or community residents distributed information sheets to the 640 potential participants during door-to-door visits in November 2011. After one week, they contacted potential participants again to ascertain their wishes regarding participation. A total of 618 older people agreed to participate in the study and were offered a face-to-face interview in their homes or community committee offices. During the interview, the SPMSQ29 was administered to assess the potential participants’ cognitive function. A total of 97 older people were excluded from further participation because of poor cognitive function. The remainder (n = 521) were given an informed consent form. Once consent was gained, the structured questionnaires were completed either with the data collectors or independently and took approximately 45 min to complete. Therefore, the response rate was 95.9% (521 out of 543 eligible subjects). This study was approved by the University Research Ethics Committee.
Methods
The dependent variable, namely SRH, was measured using a single-item question of “How would you rate your current health status?” with five possible responses: very good, good, neutral, poor and very poor. Some variables that have been reported to influence the SRH of older people in previous studies were selected as independent variables in the present study, including physical health, depression, functional ability, physical activity, health services satisfaction, loneliness
Study population and data collection The present study was carried out in Chongming County of Shanghai, which is China’s most populous city with 3.7 million older people and 233 500 older people living alone.25,26 The target population was community-dwelling older people living alone in 458 |
Study variables
© 2014 Japan Geriatrics Society
SRH of older people living alone
and social support.9,14–16 Physical health was measured by asking the participants whether they had experienced acute diseases in the previous 4 weeks and chronic diseases. The 15-item Geriatric Depression Scale (GDS) was used to measure depression.30 Each item was rated on a dichotomous scale of “yes” or “no” with one point being assigned to a response indicating a depressive symptom. The total score ranged from 0–15, and a score of equal to or greater than 8 suggested having depression. The Cronbach’s α coefficient of the scale in the current study was 0.82, and the 2-week test–retest reliability coefficient was 0.81. The Activity of Daily Living (ADL) Scale was used to measure functional ability.31 It includes 14 items with two components; that is, Physical Self-Maintenance Scale (6 items) and Instrumental Activity of Daily Living Scale (8 items), to assess people’s basic and high-level physical functioning.31 The Chinese version of the ADL Scale is a four-point rating scale from carrying out an activity totally independently to being totally dependent, with a total score of 14–16, 17–21 and 22+ indicating a high, moderate and low level of functional ability, respectively.32 In the present study, the Cronbach’s α coefficient of the scale was 0.92, and the 2-week test– retest reliability coefficient was 0.88. Physical activity was measured using the reported frequency of recreational and household activities, and their intensity per week drawing on relevant literature.33,34 The participants who reported undertaking a minimum of 30 min of moderate/strenuous physical activity on at least 5 days per week were categorized as having undertaken adequate physical activity.35 A single item was used to measure global health services satisfaction, namely: “On the whole, how satisfied are you with your health services?” with a five-point scale from “very satisfied” to “very dissatisfied.” A single item is a commonly used method to assess people’s overall perceptions of their health services when the focus is global satisfaction with services rather than specific experiences related to individual services at different points in time.36,37 A single item is recommended, because participants find it easier to understand and minimize the research burden.38 The UCLA Loneliness Scale version 3 was used to measure loneliness.39 It is a four-point rating scale comprising 20 items. The total score ranged from 20–80, with a score of 20–34, 35–49, 50–64 and 65–80 indicating a low, moderate, moderately high and high level of loneliness, respectively.40 The Cronbach’s α coefficient and 2-week test–retest reliability coefficient of this scale in the present study was 0.89 and 0.68, respectively. The Social Support Rate Scale was used to assess social support.41 The total score ranged from 12–65, with a higher score indicating a higher level of social support. The scale was modified with one item regard© 2014 Japan Geriatrics Society
ing living arrangements being deleted, considering the participants’ characteristics of living alone. The modified scale had a Cronbach’s α coefficient of 0.76, and a 2-week test–retest reliability coefficient of 0.70. The participants were divided into three groups according to the frequency distribution of total score. Those who scored the lowest 27.0% were categorized into the low level group, and those who scored the highest 27.0% were categorized into the high level group.42 The remainder were categorized into the moderate level group. Data relating to age, sex, education level, previous occupation, economic level and residential area were also collected.
Statistical analysis Data were analyzed using SPSS 16.0 (SPSS, Chicago, IL, USA). Descriptive statistics were used to examine the participants’ SRH, sociodemographic characteristics, chronic disease, acute disease, depression, functional ability, physical activity, health services satisfaction, loneliness and social support. In order to identity the associated factors, SRH was categorized into three groups as “good,” “neutral” and “poor,” with the participants who rated their health as good or very good being categorized into the “good” group, whereas those who rated their health as poor or very poor were categorized into the “poor” group. The χ2-test was used to explore the relationships between SRH and the independent variables. The variables that were significant in the bivariate analyses were entered into the multinomial logistic regression models to identify the predictors of SRH using poor SRH as the reference category.
Results Overall, more than two-fifths of the participants (n = 225, 43.2%) rated their health as good, and less than one-sixth (n = 79, 15.2%) rated their health as poor. Table 1 presents the relationships between SRH and each independent variable. Older people’s SRH was significantly associated with age, education level, previous occupation, economic level, chronic disease, acute disease, depression, functional ability, physical activity, health services satisfaction, loneliness and social support. There were no significant differences across the participants of different sexes and from different residential areas. The results of the multinomial logistic regression analyses are presented in Table 2. Chronic disease, acute disease, functional ability and health services satisfaction were statistically significant across the two models. The participants who did not have chronic diseases were more likely to report better health (good vs | 459
Y Chen et al.
Table 1 Bivariate relationships between self-rated health and independent variables
Age (years)
Sex Education
Previous occupation†
Economic level‡
Residential area Chronic disease Acute disease Depression Functional ability
Physical activity Health services satisfaction§ Loneliness
Social support
60–69 70–79 80+ Male Female No formal education Primary school Junior high school and above Peasant Blue-collar worker Non-manual employee Low level Medium-low level Medium-high level High level Rural Urban No Yes No Yes No Yes Low level Moderate level High level Inadequate Adequate Dissatisfied Satisfied Low level Moderate level Moderately high level Low level Moderate level High level
n
Good n %
Neutral n %
Poor n %
χ2
P
126 200 195 177 344 244 213 64
80 100 45 80 145 89 90 46
63.5 50.0 23.1 45.2 42.2 36.5 42.3 71.9
43 76 98 67 150 102 100 15
34.1 38.0 50.2 37.9 43.6 41.8 46.9 23.4
3 24 52 30 49 53 23 3
2.4 12.0 26.7 16.9 14.2 21.7 10.8 4.7
70.17
