A longitudinal analysis of the association between the living arrangements and psychological well-being of older Chinese adults: the role of income sources

Psychological well-being (PWB), an important indicator of successful ageing, was conceptualized for assessing mental health across the dimensions of overall quality of life, positivity, perceived happiness, and lack of loneliness among older adults [1]. Studies have shown that improved PWB could be associated with improved quality of life [2], reduced risk of incident chronic diseases [3‐5], and prolonged lifespan [6, 7]. An increasing number of studies document an association of living arrangements with PWB among older adults [8‐10] . Such studies have mostly been from developed countries, with limited data from developing countries such as China, the country with the largest elderly population [11, 12]. The proportion of older Chinese adults aged 65 and over increased from 7% in 2000 to 10.8% in 2016 and is expected to reach 15.7% by 2030, according to the United Nations [13]. In China, older adults traditionally live with their adult children, typically their sons [14]. Family relationships were continually guided by filial piety, which emphasized physical care, emotional support, respect, and obedience to older adults. There are two hypotheses to explain the effect of living with family. One hypothesis is that older adults who live with family can more easily receive material support, such as assistance in daily life and financial support, and thus experience less isolation and loneliness. The competing hypothesis is that the potential irritations of family life may reduce any advantages of living with family [12].

However, the growing size of the older population, the one-child family planning policy, increased urbanization and massive rural-to-urban migration have significantly changed the traditional family structure [15, 16]. An increasing number of older adults are living by themselves or in senior care facilities, resulting in lower prevalence of traditional family care. Different findings from existing research on the associations between the PWB of older adults and living alone or in an institution show inconsistent evidence. Some studies indicated that those living alone are more depressed and less satisfied with life [17, 18] and more likely to develop disabilities [19]. However, other studies suggested the opposite [20]; elderly people who live alone are reportedly healthier (activities of daily living (ADL), cognitive functions) than those who live with family [21, 22]. In addition, research from Korea, Japan, the United States, and Canada showed that living in an institution, representing a loss of independence, was associated with less happiness and lower quality of life [23]. In China, given the long history of cultural norms and social stigma, institutionalized older adults face adjustment challenges after leaving their community [15]; however, institutions provide care and medical facilities, offering environments that are rich in social interaction and psychological comforts [24].

The relationship between living arrangements and PWB could be moderated by income sources. A recent study from Korea showed that older adults’ PWB was strongly associated with whether or not they received support [25] . Unlike most developed countries with an established pension and welfare system, China introduced its retirement system only three decades ago, and most older Chinese adults, including those living in rural areas, have to rely on either self-support or intergenerational support from children and children-in-law [26]. Furthermore, support from government through a minimum living standard guarantee programme or basic pension insurance has become the most important source of income for poor older adults in China [27, 28]. Different income sources may have different influences on people’s decision making and state of mind and subsequently affect their PWB. For example, older adults with financial self-support have autonomy and independence, which are highly valued in Western culture [29]. Those older adults are more self-reliant and able to make their own decisions while living with adult children. According to the cultural traditions of filial piety, older adults who are supported by children are likely to feel proud and grateful [30], but intergenerational financial support may increase the probability of withdrawal of informal support from their family, in turn decreasing the PWB that can result from living with family [31]. However, few studies have examined the moderating effect of income sources on the relationship between living arrangements and PWB.

Our aim was to examine whether living arrangements are associated with PWB and whether income sources moderate this association. We used a large representative survey of older Chinese adults to address this research question.

Table 1 lists the characteristics of the baseline sample by living arrangements. The mean age of the respondents was 86.39 years old. The majority (53.97%) of the respondents lived in rural areas, 57.39% were female, 5.59% were minority, and 10.48% had a professional occupation. A total of 80.59% of the older adults were financially sufficient, and 79.30% of those living in an institution were financially self-sufficient. The proportions of the respondents living with family, alone, and in an institution were 81.91, 13.48 and 4.61%, respectively. Most respondents were supported by their adult children (65.22%), while 28.03% were financially independent. Specifically, the main resource of those living alone and living with family was support from their adult children, and only 23.30% of those living alone were financially independent. Moreover, 48.04% of those living in an institution were supported by the government, and fewer than 1/3 were supported by their children. The institutionalized older adults had poorer physical health than those living alone. The average PWB score was 22.80, and the participants living alone had the lowest average scores.

The analysis results of the coefficients estimated from the random-effects ordinal probit model for PWB are presented in Table 2. The significant evidence from likelihood ratio (LR) tests (P < .001) indicates that the fit of the models can significantly improve the estimation and control for individual heterogeneity. Model 1 indicates a significantly positive association between PWB and living with family or in an institution compared to living alone. Older adults supported by children or the government scored significantly lower than those who were financially independent (model 2). Model 3 indicates that older adults living with family (β = .29, p < .001) and those living in an institution (β = .34, p < .001) had stronger PWB than those living alone; moreover, support from children (β= −.08, p < .05) or from the government (β= −.24, p < .001) has a negative effect on PWB compared to the effect of financial self-support. Moreover, the LR test for interaction terms showed that the interacting effects of income sources play a significant role in the relationship between living arrangements and PWB (LR χ²(4) = 14.41, P < 0.01). Living in an institution with support from children (β= −.22, p < .05) led to lower PWB than living alone with financial self-support, and living with family with support from children also led to lower PWB, but this effect was nonsignificant. The opposite result was observed for older adults living with their family and supported by the government (β = .16, p < .05). Figure 1 shows the interaction between living arrangements and PWB. The results of a stratified analysis by income sources also confirmed the interacting effects of income sources [see Additional file 1: Table S1].

Regarding the effect of the control variables, better PWB was observed for older adults who were older, urban, male, married, and educated; those who had a professional occupation; those who were financially self-sufficient; and those who had social support. Currently, smoking, drinking, regularly exercising, and living with children and siblings were significantly associated with better PWB, while having diseases led to negative feelings. In addition, cognitively impaired adults felt significantly better than normal, which might be the result of their caregivers helping them answer the questions. The coefficients of the variables were mostly robust among the three models [Table 2 near here]. The results of sensitivity analyses indicated that there was no significant change after adjustment for the dummy variable indicating an individual was deceased or lost to follow-up or after limiting the data for respondents who answered the survey question without any help from others [see Additional file 2: Sensitivity analyses].

Using four waves of longitudinal data from the CLHLS sample of older Chinese adults, this study found that living arrangements were significantly associated with PWB. Older adults living with family or in an institution had better PWB than their counterparts living alone. In addition, we provided new evidence that these relationships were moderated by income sources after adjusting for socio-demographic factors, health behaviours and health status.

Our findings were consistent with other research [11, 36‐38]. Both today and in the past, living with family is important because of the support that family provides and the influence of this support on the well-being of older individuals. Living with family usually refers to residing with a spouse, children or both. A spouse was considered to contribute more to the emotional well-being of their partner. Adult children were found to play a more important role in improving the well-being of a parent whose spouse has passed away [39]. Adult children were responsible for taking care of their parents [40] and assumed a strong role in providing their parents instrumental, emotional and financial support in the traditional Confucian culture [41]. By living with family, adult parents obtain not only daily care but also emotional nurturing from their families. Indeed, grandchildren have been an important part of the traditional family in China, especially in rural areas. With the progress of labour migration, left-behind children were naturally being cared for by their grandparents, which may also provide emotional comfort for older adults. Therefore, despite population migration and social transformation, living with family was still a popular pattern and was beneficial for the PWB of older Chinese adults.

In contrast with developed countries [15], residing in an institution was better than living alone for older Chinese adults. Institutionalized older adults, especially those who are very sick and disadvantaged, preferred to reside in the institution, as the availability of institutionalized care and facilities, which were evaluated positively by older adults, promoted their PWB. For those with limited or no family support, institutionalization may be beneficial to mitigate feelings of loneliness from social isolation and social shame [24].

We found that living alone was harmful to older adults’ PWB, which was inconsistent with other studies [21, 42, 43]. Those living alone were younger and most of them had better health status than their counterparts in our study. Lack of financial support, emotional comfort and care services are the three main problems for these persons [44]. Since mental health is a determinant of life satisfaction for older adults [45], society should pay more attention to these people.

Our study showed that income sources were significantly associated with the PWB of older Chinese adults. The results indicated that older adults supported by children or the government had lower PWB scores than those who were financially self-sufficient. Furthermore, older adults living with family and supported by the government had significantly higher PWB scores. This finding suggests that financial support from the government can increase older adults’ PWB resulting from living with family. Government support through Dibao could meet the basic needs of older adults by establishing a security net and mitigating the tensions among household members due to poverty [28]. In addition, being supported by their children was worse than supporting themselves for those living in an institution. In a culture emphasizing filial piety, adult children might be regarded as unfilial if they send their parents to an institution. However, most of those who were living in an institution and receiving support from the government were the “three-no” older adults, defined as having little or no income, no living children or relatives, and no physical ability to work [15], Because of shifts in family size, pension structure and funding, the demand for such institutions will gradually increase, and the government should increase the number of public institutions to supply more beds and promote private pensions to provide more choices for older adults.

Several limitations of this study should be noted. First, a potential bias may arise from sample attrition. Respondents were lost to follow-up when they were male, had a higher education level, and lived in an urban area. Most of those characteristics are positively associated with PWB. The results of sensitivity analysis showed that the estimated relationship between living arrangements and PWB remained nonsignificant, with adjustment for the dummy variable indicating death or loss to follow-up. Second, although random effects were added to the ordinal probit model, the self-selection problem regarding living arrangements for different PWB was not completely addressed. Third, although we used longitudinal data from the CLHLS, we should be cautious about causal inferences. Additional studies are warranted to examine the mechanisms of why living arrangements can affect PWB. Fourth, although we adjusted for as many available covariates as possible, the data limitations restricted us from including some potential confounders, such as wealth or family relationships, which may be associated with PWB.

Despite these limitations, our analysis provides a significant contribution to the existing literature on the relationship between living arrangements and PWB in China. Understanding how living arrangements may affect PWB is critical in China, a society with the largest older population in the world. We recognize that living with family or in an institution leads to better PWB than does living alone. In addition, financial support from the government can moderate this association. Our study encourages future research to investigate the causal mechanisms through which living arrangements affect PWB.