Background
The self-perception of uselessness, a key component of one’s self-perception of aging, is the internalized feeling of one’s declining contribution and importance to others [
1,
2]. Recent studies have shown that self-perceived uselessness is a negative psychological disposition that is significantly associated with higher mortality risks in older adults [
1‐
10]. To date, however, much of the existing research is from developed counties and few studies consider how changes in perceptions of uselessness may impact mortality.
China is a developing country with a rapidly aging population and limited system of institutionalized care for its older adults [
11]. With among the largest number of older adults in the world, China has gained considerable attention by scholars to better understand the challenges of aging in the context of this nation’s unique social and cultural makeup. Recent studies have now begun to demonstrate an association between perceptions of uselessness and subsequent health and mortality outcomes among older adults in China [
11‐
13]. The research shows that older adults with high perceptions of feeling useless are more likely to exhibit poorer health and higher mortality risks than older adults with low (or no) perceptions of feeling useless [
11‐
13]. However, it is unclear whether and to what extent changes in perceived uselessness that may accompany aging are associated with mortality risks. To our knowledge, only one study has shown that short-term changes in self-perceptions of aging are associated with subsequent mortality in U.S. adults aged 70–79 [
2].
The current study is the first to use national longitudinal data of older adults (aged 65+) from China to examine the association between changes in perceived uselessness and subsequent mortality risks from 2005 to 2014. In addition, we examined whether factors related to (i) socioeconomic resources, (ii) family and support environment, (iii) health behaviors and lifestyle, and/or (iv) psychological and physical health status may contribute to the associations. The implications of these findings are discussed in the context of promoting successful aging in China.
Results
The sample distributions of the study variables are presented in Table
1. The upper-left panel of the table shows the distribution of changes in perceived uselessness over time in the CLHLS. More than one-quarter of the respondents (27.0%) had an increase in their level of feeling useless—changing from low to moderate levels or from moderate to high levels. Alternatively, we find that slightly less than one-quarter of the respondents (24.2%) reported a decline in their level of feeling uselessness over time—changing from high to moderate levels or from moderate to low levels. Approximately 6.5%, 10.7%, and 15.4% of respondents had persistent levels of high, moderate, and low perceptions of uselessness, respectively, during the three-year interval. Roughly 16.2% of respondents were unable to answer (i.e., having missing information on this measure; 90% was due to poor health, primarily cognitive impairment). With regard to subsequent mortality risks, CLHLS respondents with persistently high levels of perceived uselessness had the highest rate of dying (38.3%) during the three-year interval. Conversely, those with persistently low levels of perceived uselessness had the lowest rate of death (19.6%).
Table 1
Sample distributions of study variables for the period 2005–2011, CLHLS
Total (n) | 13,976 | 33.1 |
Changes in perceived uselessness | | |
High-high | 6.4 | 38.3 |
Low-moderate/moderate-high | 27.0 | 30.1 |
Moderate-moderate | 10.7 | 31.7 |
High-moderate / moderate-low | 24.2 | 26.2 |
Low-low | 15.4 | 19.6 |
High/moderate/low- unable to answer | 8.1 | 62.8 |
Unable to answer - high/moderate/low | 5.8 | 45.8 |
Persistently unable to answer | 2.4 | 75.3 |
Covariates | | |
Background Characteristics
| | |
Mean age (years) | 85.1 | − |
Ages 65–79a
| 36.0 | 10.9 |
Ages 80–89a
| 27.6 | 28.6 |
Ages 90–99a
| 25.2 | 53.3 |
Ages 100+a
| 11.1 | 69.4 |
Females | 54.6 | 34.3 |
Males | 45.4 | 31.5 |
Non-Han ethnicity | 11.0 | 29.5 |
Han ethnicity | 89.0 | 33.3 |
Socioeconomic Resources
| | |
Education, 0 year of schooling | 59.9 | 37.4 |
Education, 1–6 years of schooling | 29.5 | 27.3 |
Education, 7+ years of schooling | 10.6 | 23.2 |
Rural | 52.9 | 33.8 |
Urban | 47.1 | 32.0 |
Non-White collar occupation | 91.8 | 33.6 |
White collar occupation | 8.2 | 25.4 |
Economic dependence | 71.3 | 38.3 |
Economic independence | 28.7 | 19.5 |
Fair or poor family economic condition | 84.7 | 33.6 |
Rich family economic condition | 15.3 | 29.3 |
Family and Support Environment
| | |
Currently not married | 62.1 | 41.6 |
Currently married | 37.9 | 18.8 |
Family members are most frequent contacts | 75.6 | 32.0 |
Friends/relatives are most frequent contacts | 18.0 | 27.7 |
No one to contact | 6.4 | 58.7 |
No coresidence with children | 43.1 | 24.0 |
Coresidence with children | 56.9 | 39.6 |
Discordance in living arrangement | 26.4 | 35.6 |
Concordance in living alone/with spouse only | 30.1 | 20.3 |
Concordance in coresidence with children | 43.5 | 39.9 |
Not-receiving money/food from children | 21.5 | 33.0 |
Receiving money/food from children | 78.5 | 32.9 |
Not-giving money/food to children | 76.4 | 35.8 |
Giving money/food to children | 23.6 | 23.6 |
Health Behaviors and Lifestyle
| | |
Not currently smoking | 81.9 | 34.5 |
Currently smoking | 18.1 | 25.3 |
No current alcohol consumption | 82.8 | 34.2 |
Current alcohol consumption | 17.2 | 26.8 |
No regular exercise | 66.0 | 39.0 |
Regular exercise | 34.0 | 21.0 |
Leisure activity (low level) | 29.7 | 61.2 |
Leisure activity (medium level) | 30.9 | 29.2 |
Leisure activity (high level) | 39.4 | 14.4 |
Social participation (low level) | 75.3 | 38.2 |
Social participation (medium level) | 10.6 | 18.3 |
Social participation (high level) | 14.1 | 15.6 |
Psychological and Physical Health Status
| | |
ADL independent | 77.3 | 24.6 |
ADL dependent | 22.7 | 61.1 |
IADL independent | 36.4 | 11.6 |
IADL dependent | 63.6 | 45.1 |
Cognitively unimpaired | 63.7 | 20.3 |
Cognitively impaired | 36.3 | 55.0 |
Having no chronic disease | 39.3 | 33.8 |
Having 1+ chronic disease | 60.7 | 32.3 |
Not often as joyful as when younger | 64.2 | 35.9 |
Often as joyful as when younger | 35.8 | 27.5 |
Not often lonely | 93.1 | 32.5 |
Often lonely | 6.9 | 38.2 |
Not optimistic | 24.3 | 37.8 |
Optimistic | 75.7 | 31.3 |
No self-control | 41.7 | 42.7 |
Self-control | 58.3 | 25.9 |
Table
2 reports the HRs of mortality risk associated with changes in perceived uselessness for the CLHLS sample of older adults in China. Results show that mortality risks were higher in those with consistently high levels of perceived uselessness [HR = 1.80, 95% CIs: 1.57–2.08,
p < 0.001], increases to moderate/high levels [HR = 1.42, 95% CIs: 1.27–159,
p < 0.001], consistently moderate levels [HR = 1.50, 95% CIs: 1.32–1.71,
p < 0.001], and decreases to moderate/low levels [HR = 1.23, 95% CIs: 1.09–1.37] compared with those reporting consistently low levels of perceived uselessness when adjusting for background demographics (Model I). The associations are only slightly attenuated when socioeconomic resources (Model II) and family/support environment (Model III) were further taken into account. The associations were reduced to a greater extent when adjusting for behavioral and lifestyle factors (Mode IV)—with no significant increase in mortality for those with decreases to moderate/low levels of perceived uselessness. As expected, psychological and physical health status further accounted for the associations between changes in perceived uselessness and mortality (Model V). When all sets of factors were included (Model VI), the associations between changes in perceived uselessness and mortality further diminished: only the persistently high [HR = 1.16, 95% CIs: 1.00–1.35,
p < 0.05] and moderate [HR = 1.06, 95% CIs: 1.06–1.39,
p < 0.01] groups had significantly higher risks of mortality.
Table 2
Relative risk (RR) of mortality of dynamic changes in self-perceived uselessness, CLHLS 2005–2014, Ages 65+, unweighted
Changes in perceived uselessness |
High-high (vs. low-low) | 1.80 *** (1.57–2.08) | 1.68 *** (1.46–1.93) | 1.73 *** (1.50–1.99) | 1.39 *** (1.21–1.61) | 1.26 ** (1.09–1.46) | 1.16 * (1.00–1.35) |
Low-moderate / moderate-high (vs. low-low) | 1.42 *** (1.27–1.59) | 1.35 *** (1.21–1.51) | 1.40 *** (1.26–1.69) | 1.22 *** (1.09–1.36) | 1.12 * (1.00–1.25) | 1.07 (0.95–1.20) |
Moderate-moderate (vs. low-low) | 1.50 *** (1.32–1.71) | 1.44 *** (1.26–1.64) | 1.48 *** (1.30–1.69) | 1.33 *** (1.16–1.51) | 1.27 *** (1.12–1.46) | 1.22 ** (1.06–1.39) |
High-moderate / moderate-low (vs. low-low) | 1.23 *** (1.09–1.37) | 1.18 ** (1.05–1.32) | 1.21 ** (1.08–1.35) | 1.10 (0.98–1.23) | 1.08 (0.96–1.21) | 1.03 (0.92–1.15) |
Log pseudolikelihood | −41,087.8 | −41,056.3 | −41,020.5 | −40,761.4 | −40,701.5 | −40,565.9 |
Discussion
Perceived uselessness has received increasing attention in the literature and has been linked to significant increases in mortality [
1‐
11]. Although self-perceptions of aging (and usefulness) are generally internalized over the life course, recent research has shown that changes in perceptions of uselessness are common in older adults [
2]. Using a uniquely large nationally representative longitudinal dataset of older adults in China, we found that persistently high levels of perceived uselessness were associated with increased mortality risk; whereas persistently low levels of perceived uselessness was associated with reduced mortality risk. Controlling for more than two dozen socioeconomic, social support, behavioral, and health-related factors accounted for some, but not all of the associations.
Approximately 60% of CLHLS respondents reported changes in the frequency of feeling useless over a three-year interval—a rate that is somewhat higher than reported in the United States (40%) [
2]. Our data also showed that the proportions of study participants reporting changes in these perceptions were similar in direction (27% increase and 24% decrease) and consistent with U.S. research [
2]. Studies suggest that older adults in China often attribute more weight to family dynamics in rating the subjective quality of their aging [
24], and that interrelated changes in living arrangements [
25,
26] and health [
27] are increasingly common at old age. In this context, older adults may change their perceptions of usefulness to family members and others as these events occur over the latter life course. In addition, older adults’ feelings of uselessness may be influenced by the migration of children (for employment opportunities) and relocation/resettlement of children due to the rapid urbanization of both urban and rural areas in China. Future research is needed to further examine these and other factors associated with such changes in perceived uselessness in older adults.
To date, only one U.S. study has examined the association between changes in feelings of usefulness and mortality. Consistent with our findings, results from U.S. data show that persistently high levels of feeling useful to others was associated with significantly lower risk of mortality [
2]. In China, there is also evidence to suggest a significant association between perceived uselessness and mortality in older adults [
11]. The current study builds upon this literature by demonstrating an association between changes in perceived uselessness and mortality in a major developing country. In the context of China, resources for successful aging are limited compared with Western societies; and perceptions of aging are deeply rooted in cultural norms and expectations [
13,
28]. Our findings show that persistently high levels of feeling useless to others was associated with an 80% increased hazard ratio in mortality compared with those who report consistently low levels of feeling useless. Although adjustments for multiple covariates accounted for much of the association, older adults with high levels of perceived uselessness remain at elevated risk for mortality relative to their counterparts with low levels of perceived uselessness.
Existing literature suggests that older adults who frequently report high levels of uselessness often possess fewer social connections, lower self-efficacy and control, less social support, and lower levels of resilience and capacity compared with those who do not perceive themselves as useless [
1,
3]. Furthermore, there is evidence to indicate that perceived uselessness is also associated with engagement in fewer social activities [
29] and health-seeking behaviors [
30], which in turn, may precipitate or exacerbate health problems [
31]. From a physiological standpoint, exhibiting strong feelings of uselessness may cause dysregulation of the central nervous system, neurotransmitters, and/or immune system that may lead to the onset and progression of disease, disability, and other manifestations of aging [
32,
33]. Alternatively, positive feelings toward one’s aging and usefulness to others may promote positive lifestyles such as a healthy diet, routine medical check-ups, exercise, and more leisure-time activities that fulfill their expected social roles [
1]. In sum, older adults’ perceptions of usefulness or uselessness may impact their health through psychological, behavioral, and/or physiological pathways [
19,
20,
25].
Major strengths of the present study include its large sample size, longitudinal design, and the nationally representativeness of a non-Western society that includes more than 10,000 older adults observed over a 9-year period. Our findings also have potential implications for public health. The robust associations between high and moderate levels of uselessness and mortality suggest that older adults’ perceptions may have a direct impact on trajectories of health and longevity. These findings underscore the importance of maintaining positive self-perceptions with age and that it may never be too late to promote positive perspectives of aging. Studies show that older adults’ perception of usefulness may be influenced by the public [
34,
35]; therefore, public health interventions may consider promoting positive views on aging that target not only older adults, but also in the context of families, neighborhoods, and society [
1,
19,
33,
36]. Given recent evidence on the negative perceptions of aging among older adults in China [
37], such strategies are especially timely and needed to promote more successful aging.
Several limitations of the study are also acknowledged. First, we recognize that perceived uselessness was measured by a single question in the CLHLS, which may have measurement bias. Therefore, we encourage additional studies to further substantiate these findings using more sophisticated and multi-domain measures to better capture the complex nature of self-perceptions of aging and uselessness [
4,
11]. Second, we acknowledge that data were lacking on the length of self-perceived uselessness and the timing of changes in self-perceived uselessness. It is unclear whether and to what extend such individual variations would alter the results; therefore, more research is warranted to shed light on these dimensions perceived uselessness. Third, this study did not examine the underlying factors that may be contributing to changes in these perceptions. More research is needed to identify such factors—particularly those related to increased feelings of uselessness. Fourth, we did not investigate potential differences in the associations among subgroups (e.g., by age, urban/rural residence, etc.). We recognize that some segments of the population may internalize different perceptions of aging and usefulness [
13] and the subsequent link to mortality may not be universal. Therefore, we encourage future studies to consider possible subgroup variations in these findings—which may provide additional insights into how feelings of uselessness impact mortality [
11]. More generally, more empirical work is needed to better understand how self-perceptions of aging and one’s sense of usefulness influence survival in China and other nations.