Quality of life of rural poor elderly in Anhui, China.

This study is to explore the quality of life (QoL) of the rural poor elderly in central China (Anhui province) and the influencing factors.A multi-stage random sampling method was used to extract 3352 effective samples of the rural elderly in Anhui, including 1206 poor and 2146 non-poor elderly subjects. Euro QoL 5-dimension questionnaire (EQ-5D) was used for the measurement of QoL. Descriptive statistics and χ test were used to compare and analyze the sociodemographic characteristics and QoL scores between poor and non-poor elderly. Multiple linear regression was used to assess the influencing factors of QoL.There were significant differences in gender, age, education levels, professions, chronic diseases, physical discomfort within 2 weeks, hospitalization within 1 year, economic sources, and migrant workers between the rural poor and non-poor elderly groups. The QoL of rural poor elderly scored significantly higher than the non-poor elderly, in all these five dimensions. The average EuroQol Visual Analogue Scale (EQ-VAS) of poor elderly was 65.689, lower than the non-poor elderly (71.039). After controlling the confounding factors, there was a significant statistical difference in the total utility score of EQ-5D between the poor and non-poor elderly groups.The QoL of poor elderly in central China is lower than non-poor elderly, with the worst dimension of pain/discomfort. The QoL of rural poor elderly in this area could be affected by many factors, to which more attention should be paid.

Introduction

China has the largest elderly population in the world.[ According to the sixth national census in 2010, the population aged 60 years and over accounted for 13.26% and the people aged 65 years and over accounted for 8.87%, of the total population in China.[ Moreover, the United Nations (UN) Population Aging Report (2017) has shown that people aged 60 years and over in China will exceed one-third (35.1%) of the total population by 2050.[ With the accelerated aging process, the elderly's quality of life (QoL) needs more attention. According to the World Health Organization (WHO), QoL refers to the individual's experience of their standards, goals, expectations, concerns, and living conditions, in different cultures and values.[ Although the continuous rapid development of medical science and technology in China would prolong the life expectancy of the elderly, the overall health status of the elderly has still been worsening.[ In 2015, the UN has proposed 17 goals for sustainable development, including this one special goal for health, that is, ensuring and promoting the healthy life and well-being of people for all ages.[ However, the rising proportion of the elderly in China and the deterioration of health status would induce more challenges to achieve this goal.[ Therefore, the issues concerning aging and health have become the focuses of the related researchers and policy makers in China.[

Since 2015, the Chinese government has attached great importance to the poverty alleviation for the rural poor population. Specifically, in 2015, the Office of the Leading Group for Poverty Alleviation and Development of the State Council of China has issued the “Decision on Winning the Poverty Alleviation”, to ensure that more than 70 million poor people in the rural areas should and would be fully lifted out of poverty by the year of 2020,[ which represents an important part of China's realization of the well-off society. However, the poor economic levels of the elderly in the poor rural areas, as well as the inadequate old-age security mechanism, make the health of rural poor elderly in China a worrying issue. The health problem of the rural poor elderly populations in China is related to the implementation of the “Healthy China 2020” strategy.[ Therefore, assessment the QoL of poor rural elderly in China is an important public health issue, which provides not only corresponding suggestion for improving the health of the poor rural elderly, but also policy reference for establishing more reasonable old-age security mechanism.

In recent years, the QoL and related influencing factors of the elderly in China have been widely studied. However, the QoL of rural poor elderly is less studied. In a previous study, the 36-item Short Form Health Survey (SF-36) scale has been used to study the QoL of the elderly in Sichuan, China, showing that the QoL of rural males was higher than the rural females.[ However, another study has shown that there were no differences in the QoL of rural elderly between males and females.[ A group of Chinese empty-nest elderly have been subjected to the 12-item Short Form Health Survey (SF-12) and Euro QoL 5-dimension questionnaire (EQ-5D), and the results show that the QoL of these empty-nest elderly was lower than other residents.[ Furthermore, it has been found that the population with higher education levels generally has higher QoL levels, while the elderly people have lower QoL levels, in Chinese rural areas.[ Anxiety and depression have also been shown to reduce the QoL level of rural elderly.[ There have also been many in-depth studies concerning the psychological and social factors influencing the elderly's QoL.[ However, the related subjects have been special elderly populations with different living types, mainly in the communities and/or urban areas, and the assessment scales are primarily based on the SF-12 scale, SF-36 scale, and World Health Organization QoL Assessment Profile (WHOQoL-BREF).

Anhui province is one of the earliest provinces entering in the aging society in China. The proportion of the elderly aged 65 years and over has increased from 5.4% in 2000 to 10.2% in 2010. Moreover, by the end of 2017, the proportion of the elderly aged 60 years and over has reached 11.8874 million in Anhui, accounting for 18.16% of the total population.[ In 2016, Anhui has listed the precise poverty alleviation as one of the top ten poverty alleviation projects (the precise poverty alleviation is to accurately identify, assist, and manage the poverty alleviation goals in different poor families from different poverty-stricken areas).[ Meanwhile, as the first province to implement the comprehensive health care system reform in China, Anhui has a leading position in the health services compared with most provinces in western China.[ In this study, the QoL measure scale (EQ-5D) was used to assess the QoL of rural poor elderly in Anhui, China, and the reliability and validity of the scale was also tested. Moreover, the sociodemographic factors affecting the QoL of rural poor elderly were also identified, and the relevant improvements were proposed.

Methods

Study population

A representative sample of poor and non-poor elderly was collected from Anhui, China, from August 2017 to November 2017, by the multi-stage random sampling method. First, one county from each of the northern, central, and southern regions of Anhui Province was randomly selected according to the regional division. Second, two towns from each county were randomly selected, and totally six towns were selected (Fig. 1). Third, three villages from each town were also randomly selected, totaling 18 villages. Finally, 50 poor households from each village were randomly selected based on the list of poor households (a cardholder was established, and the poor households were identified based on the standard of per capita annual net income of <2736 CNY).[ In addition, 75 non-poor households from each village were randomly selected according to the 1:1.5 ratio. Residents aged 60 and older were the participants of the households surveyed. Under the assistance of local doctors and village committee members, the investigators entered the household to conduct the one-on-one inquiry. In the survey, the questionnaire had a unified guide and description. Inclusion criteria of the respondents included:

Figure 1

Location of the six sampling towns.

subjects aged 60 years and over (according to the Article 2 of the Law on the Protection of the Rights and Interests of the Elderly in China, which stipulates that the age for the elderly is 60 years);

subjects who had lived in the place for at least 1 year, at the time of survey.

In total, 2250 households (including 900 poor and 1350 non-poor households) and 3491 elders (including 1266 poor and 2225 non-poor elders) were surveyed, comprising 3352 effective participants (including 1206 poor and 2146 non-poor elders). The survey sample response rate was 96.01% (3352/3491).

This study was approved by the Ethics Committee of Anhui Medical University. All participants in the study understood the research objectives, procedures, and confidentiality through oral informed consent prior to participating in the study. The respondents voluntarily participated in or withdrew from the survey.

Measures

The questionnaire included the following two parts: the sociodemographic characteristics and the EQ-5D. On the basis of literature reviewing, the expert consultation method was used to design the survey of social demographic characteristics. The EQ-5D scale was used to assess the QoL levels,[ which consisted of the EQ-5D health status description (mobility, M; self-care, SC; usually activity, UA; pain/discomfort, PD; and anxiety/depression, AD) and EQ-VAS visual simulation score. For the EQ-5D health status description, each dimension included three levels of choices: 1, no problem; 2, moderate problem; and 3, extreme problem. Five dimensions coded with 1 (i.e., “11111”) suggested no problem for the respondents’ QoL, while “33333” represented the worst QoL status. Therefore, the EQ-5D could totally reflect 243 health conditions, plus two special health conditions, that is, the unconscious and death.[ On the other hand, the EQ-VAS is a 2-decimeter visual scale, with 100 and 0 points representing the best and worst health status of the day, respectively. Punctuation (0–100 points) points were obtained based on the self-assessment.

EQ-5D scoring

Considering the geographic regions and ethnic factors, the Japanese EQ-5D system was used herein,[ in which the total utility score was calculated according to the following formulation: U = 1 − (0.152 + 0.075 × M2 + 0.418 × M3 + 0.054 × SC2 + 0.102 × SC3 + 0.044 × UA2 + 0.133 × UA3 + 0.080 × PD2 + 0.194 × PD3 + 0.063 × AD2 + 0.112 × AD3), where 0.152 is the constant term; the M2, SC2, UA2, PD2 and AD2 denote the M, SC, UA, PD and AD levels in five dimensions 2 (assigned as 1), otherwise assigned as 0; and the M3, SC3, UA3, PD3 and AD3 denote the M, SC, UA, PD and AD levels in five dimensions 3 (assigned as 1), otherwise assigned as 0. Higher total utility value score indicated better QoL, while the higher dimension score suggested worse dimension. The total utility score U ranged over [−0.111, 1].[

Data analysis

Data were analyzed using the EpiData 3.1 and SPSS16.0 software. Descriptive statistics, χ2 test, and multiple linear regression were performed. The descriptive analysis reported the sociodemographic characteristics of the survey sample, and the one-factor χ2 test showed differences in the demographic characteristics and evaluated the differences in the utility scores and total utility value scores of EQ-5D between the poor and non-poor rural elderly groups. Multiple linear regression was used to compare the differences in the QoL between the poor and non-poor rural elderly groups, and to identify the social factors affecting the QoL of poor elderly people. In the multiple linear regression model, the total utility score of EQ-5D was used as the dependent variable, while the gender, age, education level, professions, chronic diseases, physical discomfort within 2 weeks, economic sources, living arrangements, and migrant workers were set as independent variables. Since, the independent variables were few, all the above independent variables were included in the regression equation by the forced introduction method (the standard of α = 0.05 was included, while the standard of α = 0.1 was excluded). P < .05 was considered statistically significant.

Results

Description of study subjects

The effective sample comprised 3352 respondents, including 1206 poor and 2146 non-poor elderly. Table 1 shows the demographic characteristics of the two groups. The age of the respondents ranged from 60 to 97 years (mean age 71.18 ± 7.098 years), with the average age of the poor group (71.74 ± 7.121 years) being higher than that of the non-poor group (70.86 ± 7.068 years). The proportion of men in the poor group (53.5%) was significantly higher than that in the non-poor group (46.8%). Overall, 66.1% of participants were illiterate and 64.1% were unemployed, while the proportions of illiterate or semi-literate (69.0%) and unemployed (71.0%) in the poor group were significantly higher than those in the non-poor group (64.6% and 60.3%, respectively).

Table 1

Frequency of socio-demographic characteristics of study subjects.

In total, 74.0% of participants had chronic diseases and the percentage of individuals with two, three, or more chronic diseases in the poor group were significantly higher than that in the non-poor group. Moreover, 63.4% of participants had physical discomfort within the 2 weeks preceding the survey, and this percentage in the poor group (68.6%) was significantly higher than in the non-poor group (60.6%). Furthermore, 19.7% of participants lived alone and 43.0% lived with their spouses, while there were no significant differences between the poor and non-poor groups in terms of living arrangements. In addition, 31.9% of participants were hospitalized during the year preceding the survey, and the percentage in the poor group (39.5%) was higher than in the non-poor group (27.6%). Finally, 57.5% of participants’ households had no migrant workers, and this percentage in the poor group (65.0%) was significantly higher than in the non-poor group (53.3%).

Description of EQ-5D dimensions

Table 2 shows the percentages of poor and non-poor elders who had problems in each of the EQ-5D dimensions. Compared to the non-poor group, the poor elderly presented higher percentages of moderate and extreme problems in all five dimensions. In the survey groups, the EQ-5D PD dimension comprised more moderate or extreme problems compared with the other four dimensions for both poor and non-poor groups.

Table 2

Percentages of poor and non-poor elders who have problems in each of the EQ-5D dimensions.

Because of the influence of confounding factors, we adopted the multiple linear regression method. After adjusting for the variables of gender, age, education level, occupation, chronic diseases, physical discomfort within the 2 weeks preceding the survey, hospitalization, economic sources, and migrant workers through multiple linear regression, we compared the utility scores of the dimensions with the total utility value of the two groups (Table 3). The average score of total QoL for the poor elderly was 0.663, which was significantly lower than the non-poor elderly (with the average score of 0.740) (P < .01). Moreover, the average scores of QoL with M, SC, UA, PD, and AD in the poor elderly group were significantly different than those in the non-poor elderly group (P < .01). The EQ-VAS self-rating showed that the average value for the rural poor group was 65.689, which was significantly lower than that in the non-poor elderly group (with the average score of 71.039) (P < .01).

Table 3

EQ-5D scale dimensions and total utility scores ().

Regression analysis

Multiple linear regression estimates were then reported on the association between the poverty and QoL in the elderly populations after controlling other covariates. As shown in Table 4, our results indicated that the QoL of poor elderly were significantly worse than the non-poor elderly (P < .01). However, no differences were observed in the EQ-5D utility score between the migrant workers and QoL of elderly. Moreover, almost all the covariates were significant influencing factors for the QoL of the elderly.

Table 4

Multiple linear regression model for overall EQ-5D utility score.

The multiple linear regression estimates of the overall EQ-5D utility scores for the poor elderly were shown in Table 5. Our results showed that, except for the education levels and economic sources, the other demographic characteristics (including the gender, age, professions, chronic diseases, physical discomfort within 2 weeks, hospitalization within 1 year, living arrangements, and migrant works) were the influencing factors for the QoL of poor elderly (all P < .01). Among these factors, the age of 80 years and above had the greatest impact on the QoL of poor elderly people (B = 0.098), while the gender and living arrangement (living with spouse) had the least impact on the QoL of poor elderly people (B = −0.032). However, as shown in Table 6, the education levels and economic resources were significant factors influencing the QoL of non-poor elderly people (P < .01), while the migrant workers did not represent influencing factor for the QoL of non-poor elderly. The factor with the greatest impact on the QoL of non-poor elderly was the age of 80 years and above, which was the same with the poor elderly people. The least influencing factors for the QoL were the education level and living arrangements (living with spouse) (B = 0.019).

Table 5

Multiple linear regression model for overall EQ-5D utility score of poor elderly.

Table 6

Multiple linear regression model for overall EQ-5D utility score of non-poor elderly.

Discussion

In the present study, the QoL of poor elderly people in central China (Anhui province) was investigated, in comparison with the non-poor elderly. Descriptive analysis showed that the proportion of rural poor males was higher than the elderly females, which was opposite to the gender composition of the non-poor elderly. These findings were in line with the gender composition of rural elderly in the central China as reported in the fifth health service survey in 2013, indicating that there were more males than females in the poor elderly population.[ Besides, the proportion of the elderly people having any problem of the poor elderly were higher than the non-poor elderly considering all the five dimensions, while the total utility quality scores were lower than the non-poor elderly, indicating that the QoL of poor elderly was lower than the non-poor elderly. In China, it is well known that the poor people have poor socioeconomic conditions, such as poor education level, low-income occupations and poor health services. Health status follows a socio-economic gradient, and the worse individual socioeconomic status might be related to worse health status. In addition, due to the rapid development of urbanization in China, young children would choose to settle down in the city, leaving the elderly stay in the countryside, shocking the old tradition and the happiness of the elderly. Chen et al[ have reported the poor QoL status of the rural elderly in poor areas, and shown that the ability of daily life in these elderly was significantly impaired, with, however, higher happiness levels.

By comparing the EQ-5D utility scores of the poor and non-poor elderly, our results showed that, in the five dimensions of QoL, the worst was the PD dimension (whether it was poor or non-poor), which was in line with previous findings.[ Poor elderly people may have poor PD dimensions due to poor economic conditions, and excessive labor-caused physical damages, which may also increase the chances of chronic diseases as the elderly people age.

After adjusting for confounding factors, our results from the multiple linear regression analysis showed that the poor status was related to the QoL of the elderly. Due to the historical and cultural reasons, there might still be some extent of gender discrimination in the elderly, the traditional concept of female weakness is maintained, and women have to take care of their spouses and children. At the same time, because women have to undergo a series of physiological processes (such as fertility), they are more likely to suffer from various diseases, resulting in a lower QoL level than men. Our results indicated that the elderly people aged 80 years and over had lower QoL levels. It has been shown that age is an important factor influencing the QoL of the elderly people.[ With the aging process, the functions of various organs in the elderly people would decline, and the ability to resist the external adverse factors would also decline, which might result in various chronic diseases such as hypertension, diabetes, and coronary heart diseases. Yang et al and Zhou et al[ have shown that chronic diseases have great influence on the QoL of the elderly. Besides, the social adaptability and role adaptability of the elderly would decline with aging, as well as the participation in social and collective activities, which adversely affect the QoL status. Urosević et al[ have shown that women were more likely to suffer from depression than men, probably due to loss of spouse, and chronic diseases. The regression showed that the QoL of poor elderly with physical discomfort within 2 weeks was low. Previous studies have shown that chronic disease is one of the important factors affecting the QoL of the older people.[ Our results showed that more chronic diseases were related to lower QoL in the poor elderly population. At the same time, with the increasing hospitalization times and duration within 1 year, the QoL of poor elderly was getting worse. Most chronic diseases are difficult to be cured, requiring long-term medical care, which might also induce complications, serious disorders of physical function, and frequent hospitalization. Hospitalization cost would increase not only the family's economic burden, but also the psychological burden of the elderly people themselves. It is shown that, with the increasing chronic physical diseases, the detection rate of depression in the elderly would also be increased, and the chronic physical illness is an important risk factor for the depression in the elderly.[ Our results showed that the QoL levels of the elderly people with professions and with three or more migrant workers in the family were higher than those without profession, which was in line with previous findings.[ This phenomenon might be explained by the fact that, for the elderly who work frequently, they can exercise properly, which might delay the decline of physical function, and alleviate the economic pressure, resulting in a positive psychological impact.

Our results showed that the older people living with spouses had lower QoL than the poor elderly living alone. However, previous findings have shown that the older people with spouses have higher QoL level.[ The reason for the inconsistency between the findings from our study and previous research may be that the elderly living alone would not encounter the family conflicts and/or chores, with probably more comfortable mood. On the other hand, the government gives the living allowance to those unmarried elderly people living alone.

Considering the main influencing factors for the QoL of rural poor elderly people, improving the QoL of poor elderly requires the efforts and supports from all the aspects. First of all, the government departments should improve the old-age security mechanism for the poor elderly in the rural areas, establish and improve the basic medical and health service facilities, and establish the leisure and recreational facilities, to enrich the spiritual life of the elderly. Secondly, Chinese traditional Confucian culture advocates that the children should support and raise the elderly. At the same time, they should also pay attention to the spiritual life of the elderly and encourage single elderly individual to find spouses. Furthermore, lifestyle is an important factor influencing the physical health. For the elderly people, it is necessary to develop a healthy lifestyle and participate in group activities, in order to maintain a positive and optimistic attitude. Finally, considering the rapidly growing aged population, government departments should formulate policies and regulations to alleviate the pressure, such as extending the retirement age of employees to provide more labor, and formulating incentives to encourage young couples to have two children.

There are many limitations of this study. First, the included sample was mainly from the Anhui province in central China, and samples from other provinces in China and other countries should be included in further in-depth studies in the future. Second, the QoL of poor elderly people was analyzed in this study, which was compared with the non-poor elderly people. Due to the limited number of survey samples, the overall situation of all poor and non-poor elderly people could not be described. Third, although a number of factors were controlled herein, there were still many potential confounding factors affecting the QoL of poor elderly people, such as smoking, drinking, and disabilities. Lastly, the relationship between the demographic characteristics and QoL could not be fully understood through a separate qualitative analysis. Quantitative analyses are still needed to make the interpretation of the results more convincing.

In conclusion, our results showed that the QoL of rural poor elderly in central China was lower than the non-poor elderly. The QoL of poor elderly was affected by many factors, including the age, gender, professions, chronic diseases, and living arrangements. Our findings herein might provide scientific evidence and basis for improving the QoL and social health services for the elderly in rural areas of China.

Author contributions

Conceptualization: Hong Ding.

Data curation: Jian Rong.

Formal analysis: Guimei Chen.

Investigation: Jian Rong, Hong Ding.

Methodology: Jian Rong.

Resources: Yanhong Ge, Tingting Xie, Nana Meng.

Software: Guimei Chen.

Writing – original draft: Jian Rong.