Exploratory analysis of health-related quality of life among the empty-nest elderly in rural China: An empirical study in three economically developed cities in eastern China

Health issues of older people in rural China have caught the concern and interests of researchers¹. Currently, research results mainly focus on three aspects.

First, Depression or loneliness is common among older people in rural China. 78.1% of the elderly in rural Anhui had moderate to severe levels of loneliness[4]. 26.5% and 4.3% of older people in rural Shandong and Sichuan met the criteria for mild and severe depression, respectively[5]. Risk factors related to loneliness or depression among older people in rural China are family function and social support[4], living alone and low cognitive function[5], poor self-rated health and presence of chronic disease[6], financial status, living arrangements, and some demographic factors[7].

Second, Mental health is poor among older people in rural China. Older parents with more migrant children tended to have significantly more depression and lower life satisfaction[8]. Older adults consider family support agreement as necessary, thus rendering the elderly more in need of parental support but less likely to get it[9].

Third, The quality of life (QOL) of older people in rural China is worrisome. One report use the 36-item Short Form Health Survey (SF-36) to evaluate the QOL in the older Chinese in Zhejiang, and all scale scores of SF-36 in the rural population were significantly lower than those in the urban population, except for the general health domain[10]. The Chinese elderly in rural Anhui were found that 49.7% of them slept poorly; poor physical component summary (PCS) and poor mental component summary (MCS) are two predictors for poor sleep quality[11]. Another research further emphasized this worrisome situation: the over-65 age populations report the highest rate of completed suicide, reaching 44.3 to 200 per 100,000, which is four to five times higher than the general population, and the rural suicide rate is three to five times higher than the urban suicide rate[12].

The above literatures focused on the large population of the rural Chinese elderly. Existing literature suggests that the health of the rural Chinese elderly, especially the empty-nest elderly who are a more vulnerable group, is a cause for worry. The empty-nest elderly encounters problems in material deprivation and psychological issues. The empty-nest elderly will encounter difficulty in addressing this reality on their own. The problem of rural Chinese empty-nest elderly is not only a specific problem of individual family, but is also an extensive issue in the society. Thus, research is needed on the health of the rural Chinese empty-nest elderly.

As a more vulnerable group in China, the empty-nest elderly have been given great concern. The current studies are mainly focused on three aspects.

First, The living arrangements of the empty-nest elderly are worrisome. A study showed that majority of the Chinese elderly lived independently or in "empty nests,". Housing and community facilities for the elderly were also insufficient (particularly those serving the disabled)[13].

Second, Many empty-nest elderly suffer from loneliness or depression. A survey in a mountainous county found that the empty-nest elderly had lower life satisfaction, less social support, higher prevalence of chronic diseases, more feelings of depression and loneliness, and lower physical and mental health scores than not-empty-nest elderly. The empty-nest elderly were also likely to have mental health problems and dissatisfaction with life[14],[15]. The determined prevalence of depression of the empty-nest elderly was 74.46%, indicating a higher level[16]. Furthermore, if the empty-nest elderly were better supported and looked after, their negative mental issues might be prevented or at least relieved[17]. A geriatric depression scale was applied to investigate the empty-nest elderly in Hunan and found that the average score of the rural group is higher than that of the urban group, indicating a worse situation[18]. 30.11% of the empty-nest elderly in rural Sichuan showed anxiety-related symptoms of anxiety disorders and that depression[19].

Third, The health of the empty-nest elderly is deteriorating. One study on the Chinese elderly showed that living alone is associated with low subjective well-being, and living with immediate family is related with positive subjective well-being[20]. The empty-nest elderly in a mountainous area were less likely to call for doctor because they lack financial and social support[21]. And the empty-nest elderly in Shanghai were more likely to have lower social support and worse self-reported health than the non-empty-nest group[22]. Another study showed that the empty-nest elderly in Shanghai had less social support and higher prevalence of chronic diseases and had higher home care needs than the non-empty-nest elderly[23]. Some scholars used the SF-36 on the empty-nest elderly and found that scores of the scale and the psychological domain were significantly low[24].

The negative health of the empty-nest elderly should arouse our vigilance and strong attention. However, existing literature focuses on specific psychological health and living conditions with extensive meaning and does not explore the general aspects of health. In studying the issue of the empty-nest elderly, Chinese scholars are more concerned on the urban elderly than the rural ones[25]. This highlights the urgency to study the rural Chinese empty-nest elderly.

The HRQOL is related to both self-reported chronic diseases (e.g., diabetes, breast cancer, arthritics, and hypertension) and risk factors (e.g., body mass index, physical activities, and smoking status). Measuring the HRQOL can help determine the burden of preventable diseases, injuries, and disabilities. This measurement can help provide valuable new insights into the relationships between HRQOL and risk factors. Measuring the HRQOL can also help monitor progress in achieving the nation’s health objectives[26]. HRQOL can test the effects of various health changes and provide further references for clinical management and policy decisions[27]. Many scales can be used to measure the HRQOL[28]. Excellent standard lies in obtaining semantic, idiomatic, experiential, and conceptual equivalence in translation, pre-testing techniques, and re-examination of scores[29]. The scales used to measure Chinese HRQOL are SF-36[30, 31], World Health Organization Quality of Life BREF (WHOQOL-BREF)[32, 33], and others. Most of these measures have good applicability. This study uses the five-domainal European quality of health scale (EQ-5D) and the12-item Short Form Health Survey (SF-12).

EQ-5D is a handy, easy-to-use tool for measuring health outcomes that has been increasingly used in health services, economic analyses, pharmacies, and population health surveys. It is widely used to assess and test the quality and effectiveness of health services. The validity and reliability of EQ-5D have been tested in populations in mainland China[34‐37]. It has also been applied to many populations to measure their HRQOL[38],[39].

SF-12 is a subset of SF-36. They both help evaluate the quality of care in managed care plans and other health care applications. They have also been widely used and extensively validated in clinical settings and special populations[40]. Moreover, tests of reliability and validity have been taken, and the results show the practical significance of the SF-12 scale. SF-12 can be a practical alternative to the SF-36 for large group comparisons with a focus on overall physical and mental health outcomes[41‐43]. The SF-12 scale is popular as it improves efficiency and lowers the costs for profiles and summary scales. This study also uses the SF-12 scale as the samples in this study are large enough. Researches have indicated that Chinese version of SF-12 is an effective measurement tool to Chinese population[44]. It is feasible and credible[45].

Strong comparability exists between SF-12 and EQ-5D scales in measuring the health burden of chronic diseases, recent health problems, and social inequity[46]. Both measures can retain consistency when measuring the sociological demographic differences of population health[47]. However, EQ-5D has an important ceiling effect. A combination with SF-12 can provide more range in measuring health[48]. Considering that SF-12 and EQ-5D are internationally acknowledged mature scales and their combination produces an advantage, this study will simultaneously use SF-12 and EQ-5D to measure the HRQOL of the rural Chinese elderly.

This study takes the cities of Nanjing, Suzhou, and Wenzhou as examples. We use the EQ-5D and the SF-12 to measure the HRQOL of empty-nest elderly living in the rural areas of the three cities, which represent the economically developed areas in China. Research results may not only provide practical significance to the challenges of rural aging population but also further reference for other developed areas in China. Studying the HRQOL of empty-nest rural elderly and improving their HRQOL are of great practical significance as the HRQOL is an important part of building new socialist villages and is related to the creation of a harmonious society in rural China.

This study aims to (1) provide the basic information of the rural Chinese empty-nest elderly and detailed evidence of different domains of HRQOL as reference for future studies; (2) explore the social reasons that lead to the HRQOL situation of the rural Chinese empty-nest elderly to facilitate policy making for governmental and social organizations on how to improve the HRQOL; (3) compare the differences of the HRQOL measured by different scales and provide practical evidences of the application of SF-12 and EQ-5D on the rural Chinese empty-nest elderly population.

The study explores the HRQOL of the empty-nest elderly in rural China. A questionnaire investigation is conducted on the empty-nest rural elderly aged 60 and over in three cities: Nanjing, Suzhou, and Wenzhou. Creating a complete sampling frame without any mission is impossible because of the large jurisdiction areas of three cities with large numbers of empty-nest elderly. Therefore, we used the multi-stage sampling method. The sampling units used in China at the early stage are mainly the administrative units or organizations[49]. First, two counties/cities are randomly selected from each city. Gaochun County and Lishui County were chosen from Nanjing; Wujiang City and Taicang City were chosen from Suzhou; Pingyang County and Cangnan County were chosen from Wenzhou. Second, two towns are randomly selected from each county/city. Third, three villages are randomly selected from each town.

Finally, the amended sampling with Probability Proportionate to Size (PPS) is used to compensate for the errors or defects that may occur in the multi-stage sampling process[49]. The PPS sampling method ensures that the probability is proportional to the size of elements. This study used the PPS method to determine the sample size of each village according to the demographic data of the Villagers’ Committees or the local Civil Affairs Bureau because the distribution of the empty-nest elderly is not the same in different villages. The Villagers’ Committees or the local Civil Affairs Bureau provides the basic information of the empty-nest elderly, including their names and addresses. The investigators randomly chose the household that met the investigation requirement. The investigators visited their homes to ask for permission. The investigation will be conducted with their consent. If they refuse, the investigator will go to another family until enough respondents were found to satisfy the sample size determined by PPS method. The respondents verbally expressed their willingness to participate in the investigation.

All questionnaires were completed by the investigators according to the answers of the respondents through one-to-one live interview. Those who were unconscious or had slurred speech were excluded from the investigation. All investigators had to undergo uniform training prior to the investigation. During the investigation, the questionnaire used a unified guidance language and unified description of the ambiguous items. The questionnaires were completed anonymously and received on the spot. The investigation was conducted in the summer of 2013. A total of 1200 questionnaires were distributed and 967 valid ones were received. The effective rate was 80.58%.

The questionnaires include basic information of the empty-nest elderly: gender, age, and education. A total of 424 men participated in the survey, accounting for 44.3% of the total number, and 534 women participated, accounting for 55.7% of the total number. The minimum age of the respondents was 60 and the maximum age was 98. The mean value and standard deviation of the ages were 78.27 and 9.585, respectively. On the basis of the skewness and kurtosis values (kurtosis = -1.024; skewness = -0.162), the age distribution was negatively biased and not as steep as the standard normal distribution. In terms of education distribution, the illiteracy percentage of older empty-nest Chinese elderly was the highest, accounting for 39% of the total. Primary school ranked second at 36.4%. The Respondents with a high school education or above only accounted for 9.6% of the total.

Figure 2 shows the EQ-5D scores of the HRQOL of the empty-nest Chinese elderly. The respondents with "severe problems" accounted for the highest percentage, followed by those with "some problems." Only a few respondents chose "no problem." In the domain of mobility, 51.9% of the elderly could not ambulate, and 34% had inconvenience in some actions. Only 14.1% of the elderly choose "I have no problems in walking about;" this percentage is the smallest compared with those of the other four same-level items. In the domain of self-care ability, 53.1% of the respondents could not wash faces, take a bath, and dress themselves up, accounting for the greatest proportion among all same-level items. About 31.4% of the elderly had problems in self-care ability, and 15.5% had no problems.

In the domain of usual activities, 51.4% of the respondents could not conduct any usual activities, 32% had some problems, and 16.6% had no problems. In the pain/discomfort domain, 51.5% had severe pain/discomfort, 29.2% had some pain/discomfort, which is the lowest percentage among all same-level items, and 19.3% had no pain/discomfort, which is the highest percentage among all same-level items. Anxiety/depression reflects the mental condition of the empty-nest Chinese elderly. Among the respondents, 47.2% had severe anxiety/depression, which is the lowest percentage among all same-level items, 34.7% had some problems, and 18% had no symptoms of anxiety/depression. Overall, the HRQOL of the respondents was relatively low and the gap between the five domains was small.

Figure 3 shows the utility score curve based on the calculation of the EQ-5D sores of the empty-nest Chinese elderly using the Japanese scale utility systems. With a score of 0.848, "11111" denotes that the health condition of the elderly is the best. With a score of -0.111, "33333" indicates that the health condition of the elderly is the worst. As illustrated in Figure 3, the curve is U-shaped distributed, indicating that the health of the elderly shows polarization. Both of the best and the worst conditions account for the majority, and the figure indicating the respondents who considered themselves to have the worst health is large. Overall, the effective score curve declines with the scores. This result can be interpreted as the percentage of worst health condition being higher than that of the best health condition. This phenomenon is also obvious in the 0.47 score. Moreover, the utility score curve is steep in the score section of -0.111 to 0.47 and gentle in the scores section 0.47 to 0.848. Therefore, the gap in the respondents with the worst health condition is relatively large but has differences in the five domains. The gap in the respondents with the best health condition is relatively small and is positive in all five domains.

Figure 4 shows the SF-12 of the HRQOL of the respondents. H1 indicates "how do you feel your current health condition." The lightest color denotes very good health, and the darkest color indicates very poor state of health. As shown in the first column of Figure 4, 53.2% of the respondents reported very poor health condition, and only 10.1% were very satisfied with their health. H2 indicates "does your health limit the activities." The lightest color indicates no limit, and the darkest color denotes a large limit. As shown in the second column, 49.5% of the respondents could not do appropriate activities because of their physical health, and 16.9% had no limitation. H3 indicates "how many flights of stairs can you climb," H4 indicates "if you accomplish less work than you would like," H5 indicates "are limited in any kind of work or other activities," H6 indicates "cut down the amount of time you spend on work or other activities," H7 indicates "do not work or perform other regular daily activities as carefully as before," H8 indicates "have problems with your work or other activities as a result of your physical health in the past four weeks," H9 indicates "are calm and peaceful," H10 indicates "do you have a lot of energy," H11 indicates "are down hearted and depressed," and H12 indicates "how much has your physical health or emotional problem interfered with your social activities (e.g., visiting friends, relatives, etc.)." As shown in Figure 4, the poor situation accounts for a large proportion in all 12 items, and the good condition accounts for a small one. Thus, the HRQOL scores of the empty-nest Chinese elderly through the analysis of SF-12 scale are low.

With the rapid development of China's economy for the past 30 years, the problems of the empty-nest rural elderly are becoming increasingly exposed. This study takes the rural areas in Nanjing, Suzhou and Wenzhou as samples and uses the EQ-5D and SF-12 scales to measure the HRQOL of the empty-nest rural elderly. It aims to determine the appropriate and effective measure to help improve the HRQOL of the empty-nest rural elderly and resolve the urgent population aging issue. The main findings of this study are as follows:

Since the People’s Republic of China was founded in 1949, rural areas have experienced enormous changes. China has significantly accelerated its pace of urbanization. The urbanization rate increased from 17.9% in 1978 to 52.6% in 2012, with a sharp increase of 34.7% and an average annual increase of 1.0%. The total urban population has increased by 15,870,000 on average annually, and the total rural population has reduced by 4,350,000 on average annually. A large number of rural surplus labors have transferred to non-agricultural industries. In 2012, the number of rural-to-urban migrants in China reached 260,000,000[51]. A large number of young people leave their villages and work in the city. Therefore, many elderly are left in the villages, resulting in the prominent phenomenon of empty nest.

With the development of economy, people’s living standard has dramatically improved in the past decades. This change is also particularly noticeable after the reform and opening up policy was implemented. Accordingly, the levels of health service and people’s health awareness have greatly improved. The life expectancy of residents increased from 67.8 in 1981 to 74.8 in 2010[51]. However, their health conditions still deserve attention. The prevalence of mild cognitive impairment in the elderly in China was 9.6% and 14.7% in Eastern and Western China, respectively[52]. And the pooled prevalence of depressive symptoms in Chinese older adults is 23.6%, with single adults (i.e., divorced, unmarried, or widowed) having higher rate[53].

The growth of the Chinese elderly has brought many social problems, and its reasons and effects have attracted many discussions. Only a small percentage of healthy elderly did not work. Any true retirement is rare in rural China. In the lack of formal pension plans, older people must expend a great deal of effort to sustain the asset base of their own household and their children’s households. With the rapid increase in migration and increasing opportunities of households to move permanently to the city, older people have to work even more[54]. The one-child policy has a great impact on the growth of the elderly in China and is also producing profound many social and economic complications that require the development of appropriate policies[55‐58]. On one hand, in rural China, the challenges in caring for children and the elderly are becoming more urgent, as the number of the elderly is increasing and the young have fewer choices. Many families are structured as 4-2-1 as the first generation of only children has reached their marrying age. A young married couple has to take care of two sets of parents without help from siblings[59]. On the other hand, as the regional economic development in China is not balanced, many young people choose to leave their villages and work or settle down in towns. Such rural-to-urban migration has greatly influenced the fertility rate[60]. Family or social support have important impact on the health of rural elderly[61]. The elderly in rural areas lack care, and this inattention to their well-being affects their physical and mental health[62].

First, Upholding the traditional Chinese family arrangements (i.e., three generations in a family) may be the most effective solution. In other words, efforts should be made to prevent the elderly from suffering the empty-nest phenomenon[63]. Older parents living in three-generation households or with grandchildren in skipped-generation households have better psychological well-being. Receiving greater remittances from adult children and having stronger emotional cohesion with them. Both financial and emotional support improve their well-being of the elderly. Traditional family arrangements are beneficial in rural Chinese society because they indicate an achievement of a cultural ideal[64]. Some studies have also proved that rural grandparents who perceive their children as filial or their family as harmonious, those who receive instrumental support and less monetary support from their grandchildren are likely to have higher levels of life satisfaction or well-being than those who do not[65, 66]. The loneliness felt by older adults is even reduced by the affection for and from their children, and perceptions of attachment to their children increase their psychological well-being[67].

Second, The empty-nest elderly must be given financial support. Providing basic social security investments are crucial to improve the psychological well-being and life satisfaction of the elderly[68]. The elderly Chinese with low social status tend to negatively rate their health[69]. The empty-nest phenomenon undermine family support and lack of money reduce the self-care abilities of adults, and inadequate services weaken social support[70].

The government has an important function in the process of policy implementation. The Rural Mutual Health Care (RMHC) was a social experiment that was conducted in one of China’s western provinces from 2003 to 2006, and it had a positive effect on the health status of the participants aged over 55[71]. The New Rural Cooperative Medical Scheme (NRCMS) was established in 2003, and its coverage was high. By the end of 2012, a total of 2,566 counties in rural China carried out work on the NRCMS; the participation rate was 98.3%[51]. However, a study also showed that the coverage of NRCMS was high but not adequate to improve the access to in-patient care of the poor and the chronically ill[72]. Therefore, the current health schemes need to be improved. Moreover, the health of the elderly is not only affected by individual income but also by the income inequality[73]. China’s rural health crisis can be resolved through a fundamental rethinking of health provision across China, focusing specifically on the poorest, most remote parts of the nation[74]. Increased state investment in basic health provision should be more balanced.

Third, The capabilities of rural community care should be established[75],[76]. Having a community-based service delivery model is important. Social work practice will make China’s model more efficient and more sustainable[77]. We suggest that, first, the government should provide the extremely poor rural elderly with some basic community-based services (e.g., people who would provide services such as doing housework, haircutting, maintaining property, providing assistance to see a doctor, and doing shopping) with no charge. Second, the mutual potential of the rural community should be fully used. Neighbors and friends of the poor elderly are encouraged to help, and these people should be paid by the government. In this way, the poor elderly receive help from people they are familiar with, and they can save on expenses. Third, professional workers, such as rural doctors, plumbers, and barbers, can be included in the service system to provide more professional services for the elderly. Moreover, the poor elderly should be provided free services by the government, and the empty-nest elderly with good economic situation can also choose to avail of extra services with low pay.

This study has some limitations. First, the empty-nest elderly living in Nanjing, Suzhou, and Wenzhou were chosen. These three sampling cities are relatively economically developed in China. Therefore, the results in this study only provide reference for other developed areas in China. For poor areas, particularly those in Western China, further research is expected. Second, this study only focused on the HRQOL of the empty-nest elderly in rural China. Future studies are suggested to explore the factors related to or are affected by the HRQOL. Moreover, more research on the empty-nest elderly living in urban areas is needed. Third, the empty-nest elderly is a large vulnerable group in China. If future studies could focus on long-term HRQOL, they may have an important role in the adjustment of national policies and government work.