BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from
BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available.
When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to.
The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript.
BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay- per-view fees (http://bmjopen.bmj.com).
If you have any questions on BMJ Open’s open peer review process please email [email protected]
http://bmjopen.bmj.com/ on September 30, 2021 by guest. Protected copyright. BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open
Quality of Life and Loneliness Among Elderly Chinese: A Cross-Sectional Study of the Elderly in Liaoning Province, China
ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-021822
Article Type: Research
Date Submitted by the Author: 19-Jan-2018
Complete List of Authors: Zhu, Yaxin; China Medical University, Department of Social Medicine, School of Public Health Liu, Jie; China Medical University, Department of Health Statistics, School of Public Health Yi, Zhe; China Medical University, Department of Prothodontics, School of Stomatology Qu, Bo; China Medical University, Department of Health Statistics, School of Public Health
Keywords: quality of life, elderly, loneliness
http://bmjopen.bmj.com/
on September 30, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 1 of 15 BMJ Open
1 2 3 Quality of Life and Loneliness Among Elderly Chinese: A Cross-Sectional Study 4 of the Elderly in Liaoning Province, China 5 Yaxin Zhu1, Jie Liu2, Zhe Yi3*, Bo Qu2, 6 1 7 Department of Social Medicine, School of Public Health, China Medical University, 8 Shenyang, Liaoning Province, People’s Republic of China 9 2Department of Health Statistics, School of Public Health, China Medical University, 10 Shenyang, Liaoning Province, People’s Republic of China 11 3Department of Prothodontics, School of Stomatology, China Medical University, 12 13 Shenyang, Liaoning Province, People’s Republic of China 14 15 * Correspondence to: Zhe Yi, Department of Prothodontics, School of Stomatology, 16 China MedicalFor University, peer No. 117 Nanjingreview North Street, only Heping District, Shenyang 17 18 110001, People’s Republic of China. 19 Tel: 86 13238866438 20 E mail: [email protected] (ZY) 21 22 Keywords: quality of life; loneliness; elderly 23 24 Word counts: 2836 25 26 27 28 29 30
31 http://bmjopen.bmj.com/ 32 33 34 35 36 37 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 2 of 15
1 2 3 4 Abstract 5 Objectives: The aim of the study was to learn more about the loneliness, 6 7 health related characteristics, and QOL in a sample of elderly; and to examine the 8 relationships among these variables. 9 Design: Cross sectional study. 10 Setting: Communities in Dandong city of Liaoning province, China. 11 Participants: Sample of 732 elderly Chinese, aged 60 and older, living in Dandong, 12 13 Liaoning Province, China. 14 Methods: A questionnaire was administered face to face to the participants. The 15 questionnaire contained four sections: demographic characteristics, heath information, 16 the EQ 5D scale,For and peer the UCLA Lonelinessreview Scale. The only t test, F test, and multiple 17 18 linear regression analyses were performed to individually test associations between 19 the demographic data, health related factors, loneliness, and QOL. 20 Results: Chronic diseases, loneliness, age, and smoking status were negatively 21 associated with QOL (p < 0.05). The standardized coefficients (β) for chronic disease 22 and loneliness were –0.250 and –0.175, respectively. Satisfaction with health services, 23 24 income, and physical activity were positively associated with QOL (p < 0.05). 25 Conclusions: Loneliness predicted poorer QOL among elderly. Health professionals 26 should acknowledge the great negative impact loneliness has on elderly’s QOL and to 27 realize the importance of routine screening for loneliness and offering treatment. 28 29 Strengths and limitations of this study 30 1. This study will provide reference for better promoting QOL in elderly Chinese.
31 http://bmjopen.bmj.com/ 32 2. The knowledge gained in this study is a critical step forward in understanding how 33 loneliness relate to QOL for elderly. 34 35 3. A longitudinal design might further confirm causal relationships between factors 36 37 possibly associated with QOL. 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 3 of 15 BMJ Open
1 2 3 4 Introduction 5 The global population is aging rapidly [1]. In 1950, only 8% of the global 6 7 population was ≥60 years of age [2]. The HelpAge Global Network 2015 review 8 reported that 12% of the global population was ≥60 years of age [3] and that by 2050 9 this percentage would double [1,3]. The People’s Republic of China has the largest 10 population ≥60 years old (hereafter denoted as elderly) in the world and in 2014 11 accounted for 14.4% of the total Chinese population [4]. The percentage of elderly 12 13 Chinese is expected to reach 33.9% by 2050 [3]. In addition, elderly Chinese currently 14 constitute one fifth of the total worldwide elderly population [2]. Notably, the elderly 15 are more vulnerable to chronic diseases [5], and given the rapid growth of the aging 16 population, For the prevalence peer of chronic review diseases is expected only to increase among the 17 18 elderly [5]. Hence, the aging population should have a profound impact on healthcare 19 systems and economic growth in China and worldwide [1,2]. 20 Maintaining the elderly in good health positively impacts both them and society in 21 general, as the availability of human and social resources for the aged depends greatly 22 on their health status [1]. However, healthy aging involves more than the absence of 23 24 disease [1]. A report by the World Health Organization (WHO) has suggested that 25 improving quality of life (QOL) for older people should be the outcome of realizing 26 the policy framework of “active ageing” [6]. QOL is an assessment of health status 27 based on a medical model that reflects an individual’s physical, psychological, and 28 29 sociological health [7]. In addition, it has been recommended that disease centered 30 curative health systems embrace integrated care focusing on the needs of elderly [1].
31 Thus, assessment of QOL is seen as an essential element in the care of the elderly http://bmjopen.bmj.com/ 32 [8,9,10], and improving their QOL has become a prioritized element in their medical 33 care [6]. Identifying the factors associated with QOL is needed if new interventions 34 35 that will lead to improved QOL among elderly are to be developed. 36 Loneliness among the elderly is common [11] and a serious problem [12]. A 37 longitudinal cohort study found that the risk of Alzheimer disease was more than 38 twice that for elderly who felt lonely as compared with those who did not feel so [13].
39 on September 30, 2021 by guest. Protected copyright. 40 In addition, loneliness may have deleterious effects on their psychological states. A 41 5 year longitudinal study conducted among older male and female Americans 42 indicated that the degree to which the subjects were lonely positively correlated with 43 subsequent changes in their depressive states [14]. Another study reported that lonely 44 individuals were more likely to partake in health damaging behaviors, e.g., physical 45 46 inactivity [15]. 47 The relationship between loneliness and health has been recognized within the past 48 decade, with loneliness being related to adverse physical and mental health outcomes 49 [11,13,14]. However, QOL as a good measure of overall health has also been reported 50 51 to be influenced by loneliness in long term psychiatric patients [16] and stroke 52 survivors [17], the relationship between QOL and loneliness among elderly Chinese 53 has not been fully assessed. Emerson and colleagues suggested that early intervention 54 of loneliness might be able to decrease morbidity and mortality rates among elderly 55 [18]. Therefore, the purpose of the study reported herein was to investigate the 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 4 of 15
1 2 3 association of loneliness with QOL among elderly Chinese. 4 5 Materials and Methods 6 7 Ethics statement 8 9 The Bioethics Advisory Commission of the China Medical University approved 10 this study. The participants were informed about the purpose of the study and, prior to 11 the start of the study, were assured that their privacy would be protected. All 12 13 participants provided written informed consent before participating in the study. 14 15 Study population and procedures 16 This cross sectionalFor peer study included review 784 elderly of ageonly ≥60 years from Dandong, 17 18 Liaoning Province, who had been randomly selected. The participants were from a 19 number of communities in Dandong. Compared with other cities in China, Dandong 20 has more elderly. In 2014, those ≥60 years of age accounted for 21.6% of the 21 Dandong population, and this elderly population ranked third in Liaoning Province. A 22 questionnaire was administered face to face to the participants from 2017 February to 23 24 July. When, a participant did not answer >20% of the questions, the associated 25 questionnaire was not included in the study. Valid questionnaires were collected from 26 732 participants (valid response rate, 93.4%). 27 28 Measurements 29 30 The questionnaire contained four sections: demographic characteristics,
31 heath related information, and the EQ 5D and the UCLA Loneliness scales. The http://bmjopen.bmj.com/ 32 demographic characteristics were age, gender, marital status, education, monthly 33 income, place of residence (urban or rural), and living arrangement (empty or 34 35 non empty nester). Empty nesters were elderly who never had children or whose 36 children had left home, so that empty nesters were defined as those living alone or 37 with only a spouse [19]. 38 Health related information consisted of smoking status, physical activity status,
39 on September 30, 2021 by guest. Protected copyright. 40 chronic disease status, and satisfaction with their health services. To assess the level 41 of physical activity, participants were asked if they exercised at least six times a week 42 [20]. Respondents were defined as having a chronic disease(s) if they had ever been 43 so diagnosed by a health professional(s). Satisfaction with health services was 44 evaluated using one item from WHOQOL BREF [21], in which respondents rated the 45 46 scale from 1 (very dissatisfied) to 5 (very satisfied). 47 The EQ 5D was used to evaluate QOL of the participants, which is a generic tool 48 developed by the EuroQol Group [22]. The EQ 5D contains five items covering 49 different dimensions (mobility, self care, usual activities, pain/discomfort, and 50 51 anxiety/depression). Each item has three possible responses (no problem, moderate 52 problem, or extreme problem). A single EQ 5D summary index score ranging from 53 –0.149 to 1.0 was calculated using the Chinese time trade off model [22]. Higher 54 values imply better QOL. In addition, the EQ 5D also contains the visual analogue 55 scale (VAS). The VAS was used to assess the respondents’ own perception of their 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 5 of 15 BMJ Open
1 2 3 health status on a scale from 0 (worst) to 100 (best). The EQ 5D has been shown to be 4 applicable in China and for elderly Chinese [20,23 25]. The reliability of the EQ 5D 5 for our study was acceptable, with a Cronbach’s alpha equaling 0.82. 6 7 Loneliness in the elderly was assessed with the use of the UCLA Loneliness Scale 8 [26], which has 20 items rated on a 1 to 4 point, Likert type scale. The total UCLA 9 score ranges from 20 to 80, with greater scores defining greater degrees of loneliness. 10 The scale ranges are: 20–34, a low loneliness level; 35–49, a moderate loneliness 11 level; 50–64, a moderately high loneliness level; and 65–80, a high loneliness level 12 13 [26]. We found the scale to be reliable, as the Cronbach’s alpha was 0.84. 14 15 Statistical Analyses 16 The Student’sFor t test, peer the F test, review and multiple linear only regression analyses were 17 18 performed to determine the association between QOL and the demographic data, 19 health related factors, and the UCLA Loneliness scale. All variables found to be 20 significant according to the t and F tests were analyzed according to a multivariate 21 regression model. Data were analyzed using SPSS version 21.0 (SPSS Inc., Chicago, 22 IL, USA) for Windows. A p value < 0.05 was considered to be statistically significant. 23 24 25 Results 26 27 Participant Characteristics 28 29 The demographic characteristics of the participants are described in Table 1. A total 30 of 375 women (51.2%) and 357 men (48.8%) participated. Their ages ranged from 60
31 to 96 years, with a mean age of 71.34 ± 7.73 years (standard deviation); 241 of the http://bmjopen.bmj.com/ 32 participants (32.9%) lived in rural areas. Approximately one half of the participants 33 (341, 46.6%) were empty nesters. The F or t tests revealed that there were significant 34 35 differences in the QOL scores for participants of different ages, residences, living 36 arrangements, monthly incomes, and education levels (p < 0.05). Participants who 37 were younger, lived in an urban area, or were not empty nesters had higher QOL 38 scores (Table 1).
39 on September 30, 2021 by guest. Protected copyright. N 40 Table 1. The relationship between demographic characteristics and QOL ( = 732). 41 Variable Number of EQ 5D F/t 42 participants index score 43 (%) 44 Ageb 45 46 60–69 289 (39.5%) 0.95 ± 0.10 8.149** 47 70–79 345 (47.1%) 0.92 ± 0.12 48 ≥80 98 (13.4%) 0.90 ± 0.15 49 Gendera 50 51 Male 357 (48.8%) 0.93 ± 0.12 0.301 52 Female 375 (51.2%) 0.93 ± 0.12 53 Residencea 54 Rural 241 (32.9%) 0.92 ± 0.12 –2.333* 55 Urban 491 (67.1%) 0.94 ± 0.12 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 6 of 15
1 2 3 Living arrangementa 4 Empty nester 341 (46.6%) 0.92 ± 0.13 2.221* 5 Non empty nester 391 (53.4%) 0.94 ± 0.11 6 b 7 Marital status 8 Single 18 (2.4%) 0.97 ± 0.10 2.304 9 Married 688 (94.0%) 0.93 ± 0.12 10 Divorced/Widowed 26 (3.6%) 0.89 ± 0.14 11 Monthly incomeb 12 13 <2000 367 (50.1%) 0.90 ± 0.14 21.722** 14 2000–3000 194 (26.5%) 0.95 ± 0.08 15 >3000 171 (23.4%) 0.97 ± 0.09 16 b EducationFor peer review only 17 18 Primary school or below 323 (44.1%) 0.92 ± 0.13 3.236* 19 Junior high school 294 (40.2%) 0.95 ± 0.10 20 Senior high school 89 (12.2%) 0.94 ± 0.11 21 College and above 26 (3.5%) 0.92 ± 0.12 22 at test; bF test; *p < 0.05; **p < 0.01 23 24 Regarding health related characteristics (Table 2), the majority of the participants 25 (559, 76.4%) suffered from a chronic disease(s), and approximately one half (436, 26 59.5%) were satisfied or very satisfied with the health services that they received. For 27 the heath related characteristics, the F or t tests results showed that significant 28 29 differences existed in the QOL scores as related to chronic disease status, smoking 30 status, physical activity, and satisfaction with health services (p < 0.05). Those who
31 had a chronic disease(s), smoked, were not physically active, or were dissatisfied with http://bmjopen.bmj.com/ 32 their health services had lower QOL scores (Table 2). 33 N 34 Table 2. The relationship between health-related characteristics and QOL ( = 732). 35 Variable Number of EQ 5D index F/t 36 participants score 37 (%) 38 Chronic diseasea
39 on September 30, 2021 by guest. Protected copyright. 40 Yes 559 (76.4%) 0.87 ± 0.15 –7.158** 41 No 173 (23.6%) 0.95 ± 0.10 42 Smoking statusa 43 Yes 220 (30.1%) 0.92 ± 0.13 –1.984* 44 45 No 512 (69.9%) 0.94 ± 0.11 a 46 Physical activity 47 No 633 (86.5%) 0.93 ± 0.12 –2.631** 48 Yes 99 (13.5%) 0.95 ± 0.09 49 Health servicesb 50 51 Very dissatisfied 20 (12.7%) 0.83 ± 0.21 29.230** 52 Dissatisfied 53 (22.3%) 0.86 ± 0.14 53 Neither satisfied nor 223 (15.5%) 0.89 ± 0.13 54 dissatisfied 55 56 Satisfied 353 (38.2%) 0.96 ± 0.08 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 7 of 15 BMJ Open
1 2 3 Very satisfied 83 (11.3%) 0.97 ± 0.09 4 at test; bF test; *p < 0.05; **p < 0.01 5 6 QOL 7 8 The mean EQ 5D index score for the participants was 0.93 ± 0.12 (range, 9 0.22–1.00). The mean VAS score was 81.25 ± 14.38 (range, 0–100). The distribution 10 of the EQ 5D scale score presented in Table 3. The most prevalent health related 11 12 problem reported by the participants was pain/discomfort (196, 26.8% had moderate 13 or extreme pain/discomfort). 14 Table 3. Distribution of EQ-5D index score (N = 732). 15 Dimension No problem Moderate problem Extreme problem 16 MobilityFor peer678 (92.6%) review 53 (7.2%) only1 (0.1%) 17 18 Self care 713 (97.4%) 14 (1.9%) 5 (0.7%) 19 Usual activities 677 (92.5%) 55 (7.5%) 0 (0%) 20 Pain/discomfort 536 (73.2%) 193 (26.4%) 3 (0.4%) 21 Anxiety/depression 610 (83.3%) 121 (16.5%) 1 (0.1%) 22 23 Loneliness 24 25 The mean UCLA loneliness score was 40.73 ± 8.73 (range, 20–64). According to 26 their loneliness scores, 547 participants (74.7%) had a moderate or a moderately high 27 28 loneliness score (Table 4). A significant difference was found for the QOL scores for 29 groups with different degrees of loneliness (p = 0.00). Participants with moderately 30 high loneliness scores had lower QOL scores (0.86 ± 0.17) compared with
31 participants in the other two groups. The relationships between their QOL and http://bmjopen.bmj.com/ 32 loneliness scores are listed in Table 4. 33 N 34 Table 4. The relationship between loneliness and QOL ( = 732). 35 Loneliness level Number of EQ 5D index F 36 participants score 37 (%) 38 Low 185 (25.3%) 0.97 ± 0.07 33.889** 39 on September 30, 2021 by guest. Protected copyright. 40 Moderate 449 (61.3%) 0.93 ± 0.11 41 Moderately high 98 (13.4%) 0.86 ± 0.17 42 **p < 0.01 43 44 Relationships between the demographic data, health-related 45 46 47 factors, loneliness, and QOL 48 Seven factors were included in the regression model significantly (Table 5). Having 49 50 a chronic disease(s), being lonely, the age of the participant, and smoking were 51 negatively associated with QOL (p < 0.05), with chronic disease and loneliness status 52 having standardized coefficients of –0.250 and –0.175, respectively. Satisfaction with 53 health services, a higher income, and being physically activity were positively 54 55 associated with the QOL of the participants (p < 0.05). 56 Table 5. Multiple linear regression showing factors associated with QOL (N = 732). 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 8 of 15
1 2 3 Unstandardized Standardized 4 Factor coefficient coefficient t 5 B SE β 6 f ** 7 Chronic disease .069 .009 .250 7.479 8 Health service satisfactioni .029 .005 .220 6.277** 9 Lonelinessj .034 .007 .175 5.042** 10 Smokingg .019 .008 .076 2.333* 11 h * 12 Physical activity .025 .011 .073 2.182 a * 13 Age .013 .006 .077 2.271 14 Incomed .015 .005 .107 3.029** 15 Educatione .002 .005 .016 .436 16 ResidenceForb peer.005 review .009 only.021 .567 17 c 18 Living arrangement .008 .008 .033 .983 19 *p < 0.05; **p < 0.01; SE, standard error; B, regression coefficient 20 a60–69, 1; 70–79, 2; ≥80 21 b Rural, 1; Urban, 2 22 c 23 Non empty nester, 1; Empty nester, 2 d 24 <2000, 1; 2000–3000, 2; >3000, 3 25 ePrimary school or below, 1; Junior high school, 2; Senior high school, 3; College and above, 4 26 fNo, 1; Yes, 2 27 gNo, 1; Yes, 2 28 h 29 No, 1; Yes, 2 30 iVery dissatisfied, 1; Dissatisfied, 2; Neither satisfied nor dissatisfied, 3; Satisfied, 4; Very satisfied,
31 5 http://bmjopen.bmj.com/ 32 j Low, 1; Moderate, 2; Moderately high, 3 33 34 35 Discussion 36 This study contributes to our knowledge concerning the relationship between QOL 37 and loneliness among elderly Chinese living in Dandong, Liaoning Province, China 38 based on their responses and by identifying factors that could potentially influence 39 on September 30, 2021 by guest. Protected copyright. 40 QOL. Having a chronic disease(s) had the greatest impact on their QOL (β = –0.250, 41 p < 0.05). How satisfaction with health services affected QOL was somewhat less a 42 concern for our participants than that of chronic diseases, as the β for health service 43 satisfaction was 0.220. Loneliness affected QOL even less, although it correlated 44 45 negatively with QOL (β = –0.175, p < 0.05). Furthermore, income, physical activity, 46 age, and smoking status also had significant influences on the QOL of our participants 47 (p < 0.05). 48 Our results indicate that the pain/discomfort facet of QOL was the most prevalent 49 50 problem among the participants. This finding is in line with previous studies on 51 Chinese [23,24] and Vietnamese elderly [27]. One population based study revealed 52 that more than one half of older Americans had been bothered by pain in the month 53 prior to being questioned [28]. The elderly often experience chronic pain [29], which 54 is a disability that can cause decreased mobility and depression [28]. These factors 55 56 may increase healthcare costs and may decrease productivity [29]. Bhattarai and 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 9 of 15 BMJ Open
1 2 3 colleagues suggested that cost efficient intervention strategies for management of the 4 pain in the elderly should be a priority for healthcare providers [29]. 5 We found loneliness to be significantly correlated with the QOL of our participants, 6 7 and those who had a greater degree of loneliness also reported a poorer QOL. 8 Loneliness may impair the immune and cardiovascular systems [11]. The negative 9 effects of loneliness on the physical and psychological health of the elderly have been 10 widely documented [11,14]. Lonely individuals are also more likely to engage in 11 behavior that results in poor health outcomes [15]. These factors may all contribute to 12 13 and impair QOL for the elderly [8]. We found that 74.7% of our participants 14 experienced a moderate or moderately high level of loneliness. The prevalence of 15 loneliness found by us is comparable with that found for elderly in other Chinese city, 16 Shanghai [8,26]For but ispeer much greater review than that reported only in the developed country 17 18 Finland [30]. The substantial social and economic changes occurring in China, along 19 with the increase in the number of elderly, increases the likelihood that more elderly 20 will be lonely [26,31]. There is, therefore, an urgent need to routinely assess 21 loneliness in elderly Chinese [18] and to carry out interventions that will mitigate 22 their loneliness [8]. 23 24 Consistent with other studies [32,33], suffering from a chronic disease(s) was an 25 important risk factor for QOL among elderly. Monitoring and ameliorating a chronic 26 disease(s) may reduce their negative impact on the QOL of the elderly [2]. However, 27 representative data from six countries, including China, have indicated that effective 28 29 healthcare coverage among elderly with chronic diseases is between 20.7% and 48.2% 30 [34]. Given the continuous nature of chronic care, it should be more effective to
31 provide the elderly with healthcare services in community based settings, e.g., http://bmjopen.bmj.com/ 32 primary healthcare centers [2]. The WHO study also urged that permanent 33 mechanisms be established that would expand healthcare coverage for the elderly 34 35 with chronic conditions [34,35]. 36 We found that the QOL of our participants positively correlated with their 37 satisfaction with health services, which is consistent with a related study [8]. The 38 elderly who are more satisfied with their health services are more prone to regard the
39 on September 30, 2021 by guest. Protected copyright. 40 healthcare they receive as effective and hence adhere to the recommended 41 treatment(s), which consequently may further improve their physical and mental 42 health [8]. This may explain why the elderly who reported a greater degree of 43 satisfaction with their healthcare also reported a better QOL. However, only half of 44 our participants (49.5%) were satisfied or very satisfied with their health services. 45 46 Poor quality, high costs, and poor accessibility to healthcare may be reasons for 47 dissatisfaction with health services in China [8,36]. 48 Our study has several limitations. First, the study was conducted in only one 49 Chinese city, which may partly limit representation of elderly Chinese. Additional 50 51 studies in other areas of China will help determine whether our findings can be 52 generalized. Second, using cross sectional data limited our ability to confirm causal 53 relationships between factors possibly associated with QOL. However, our study 54 identified multiple factors that may influence QOL in the elderly that can be 55 addressed separately and in depth in the future. 56 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 10 of 15
1 2 3 4 Conclusions 5 Our study provides information about the QOL and loneliness of elderly Chinese, 6 7 and demonstrates that loneliness is a crucial problem for elderly. It points out that 8 loneliness predicted poorer QOL among elderly. To address the findings of this study, 9 it is of great importance for health professionals to acknowledge the great negative 10 impact loneliness has on elderly’s QOL and to realize the importance of routine 11 screening for loneliness and offering treatment. In addition, improving the quality of 12 13 health services is also of great need to improve the QOL of elderly Chinese. 14 15 Acknowledgments 16 The authors Forwish to thank peer Xia Min forreview help with samp leonly collection. We thank all the 17 18 elderly participants in this study. 19 20 Competing Interests 21 The authors declare that they have no competing interests. 22 23 Funding 24 25 This work was supported by National Natural Science Foundation of China, grant 26 number 71473269 and 71673301. The funders had no role in study design, data 27 collection and analysis, decision to publish, or preparation of the manuscript. 28 29 30 Author contributions
31 http://bmjopen.bmj.com/ 32 33 YZ wrote the manuscript. YZ and JL participated in the data collection and analysis. 34 ZY collected the data. ZY and BQ designed the study. BQ obtained funding. All 35 authors read and approved the final manuscript. 36 37 38 Ethics approval
39 on September 30, 2021 by guest. Protected copyright. 40 Ethical protocol was obtained from the Bioethics Advisory Commission of China 41 Medical University. All participants provided written informed consent before 42 participating in the study. 43 44 45 Data sharing statement 46 No additional unpublished data. 47 48 References 49 50 1. World Health Organization. WHO World Report on Health and Ageing, 2015. 51 Accessed in 10 Oct 2017. 52 http://101.96.8.164/apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng. 53 pdf?ua=1. 54 55 2. Shanghai Municipal Center for Disease Control & Prevention (SCDC). Study on 56 global AGEing and Adult Health Wave 1 China National Report (2012). Accessed in 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 11 of 15 BMJ Open
1 2 3 01 Oct 2017. 4 https://www.researchgate.net/publication/277305920_China_Study_on_global_AGEi 5 ng_and_adult_health_SAGE_Wave_1_National_Report. 6 7 3. HelpAge International. HelpAge International Annual review 2015 (2015). 8 Retrieved online 08 Oct 2017. 9 http://www.helpage.org/who we are/annual review 2015/#looking forward. 10 4. HelpAge International. Global Age Watch Index (2014). Retrieved online 14 Oct 11 2017. http://www.helpage.org/global agewatch/about/about global agewatch/. 12 13 5. Wang Z, Li X, Chen M. Catastrophic health expenditures and its inequality in 14 elderly households with chronic disease patients in China. Int J Equity Health 15 2015;14: 8. 16 6. World HealthFor Organization. peer Active review ageing: a policy framework only (2002). Accessed in 17 18 01 Oct 2017. 19 http://apps.who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf. 20 7. Zhang Y, Zhou Z, Gao J, et al. Health related quality of life and its influencing 21 factors for patients with hypertension: evidence from the urban and rural areas of 22 Shaanxi Province, China. BMC Health Serv Res 2016;16:277. 23 24 8. Chen Y, Hicks A, While AE. Quality of life and related factors: a questionnaire 25 survey of older people living alone in Mainland China. Qual Life Res 26 2014;23(5):1593 602. 27 9. Bélanger E, Ahmed T, Vafaei A, et al. Sources of social support associated with 28 29 health and quality of life: a cross sectional study among Canadian and Latin American 30 older adults. BMJ Open 2016;6(6):e011503.
31 10. Cerin E, Sit CH, Zhang CJ, et al. Neighbourhood environment, physical activity, http://bmjopen.bmj.com/ 32 quality of life and depressive symptoms in Hong Kong older adults: a protocol for an 33 observational study. BMJ Open 2016;6(1):e010384. 34 35 11. Luanaigh CO, Lawlor BA. Loneliness and the health of older people. Int J Geriatr 36 Psychiatry 2008;23(12):1213 21. 37 12. Liu LJ, Guo Q. Loneliness and health related quality of life for the empty nest 38 elderly in the rural area of a mountainous county in China. Qual Life Res
39 on September 30, 2021 by guest. Protected copyright. 40 2007;16(8):1275 80. 41 13. Wilson RS, Krueger KR, Arnold SE, et al. Loneliness and risk of Alzheimer 42 disease. Arch Gen Psychiatry 2007;64(2):234 40. 43 14. Cacioppo JT, Hawkley LC, Thisted RA. Perceived social isolation makes me sad: 44 5 year cross lagged analyses of loneliness and depressive symptomatology in the 45 46 Chicago Health, Aging, and Social Relations Study. Psychol Aging 47 2010;25(2):453 63. 48 15. Hawkley LC, Thisted RA, Cacioppo JT. Loneliness predicts reduced physical 49 activity: cross sectional & longitudinal analyses. Health Psychol 2009;28(3):354 63. 50 51 16. Borge L, Martinsen EW, Ruud T, et al. Quality of life, loneliness, and social 52 contact among long term psychiatric patients. Psychiatr Serv 1999;50(1):81 4. 53 17. Theeke L, Horstman P, Mallow J, et al. Quality of life and loneliness in stroke 54 survivors living in Appalachia. J Neurosci Nurs 2014;46(6):E3 15. 55 18. Emerson KG, Jayawardhana J. Risk Factors for Loneliness in Elderly Adults. J 56 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 12 of 15
1 2 3 Am Geriatr Soc 2016;64(4):886 7. 4 19. Cheng P, Jin Y, Sun H, et al. Disparities in prevalence and risk indicators of 5 loneliness between rural empty nest and non empty nest older adults in Chizhou, 6 7 China. Geriatr Gerontol Int 2015;15(3):356 64. 8 20. Tan Z, Liang Y, Liu S, et al. Health related quality of life as measured with EQ 5D 9 among populations with and without specific chronic conditions: a population based 10 survey in Shaanxi Province, China. PLoS One 2013;8(7):e65958. 11 21. The WHOQOL Group. Development of the World Health Organization 12 13 WHOQOL BREF quality of life assessment. Psychol Med 1998;28:551 8. 14 22. Liu GG, Wu H, Li M, et al. Chinese time trade off values for EQ 5D health states. 15 Value Health 2014;17(5):597 604. 16 23. Sun S, ChenFor J, Johannessonpeer M, review et al. Regional differencesonly in health status in 17 18 China: population health related quality of life results from the National Health 19 Services Survey 2008. Health Place 2011;17(2):671 80. 20 24. Zhang T, Shi W, Huang Z, et al. Influence of culture, residential segregation and 21 socioeconomic development on rural elderly health related quality of life in Guangxi, 22 China. Health Qual Life Outcomes 2016;14:98. 23 24 25. Deng X, Dong P, Zhang L, et al. Health related quality of life in residents aged 18 25 years and older with and without disease: findings from the First Provincial Health 26 Services Survey of Hunan, China. BMJ Open 2017;7(9):e015880. 27 26. Chen Y, Hicks A, While AE. Loneliness and social support of older people living 28 29 alone in a county of Shanghai, China. Health Soc Care Community 30 2014;22(4):429 38.
31 27. Hoi le V, Chuc NT, Lindholm L. Health related quality of life, and its http://bmjopen.bmj.com/ 32 determinants, among older people in rural Vietnam. BMC Public Health 2010;10:549. 33 28. Patel KV, Guralnik JM, Dansie EJ, et al. Prevalence and impact of pain among 34 35 older adults in the United States: findings from the 2011 National Health and Aging 36 Trends Study. Pain 2013;154(12):2649 57. 37 29. Bhattarai P, Phillips JL. The role of digital health technologies in management of 38 pain in older people: An integrative review. Arch Gerontol Geriatr 2017;68:14 24.
39 on September 30, 2021 by guest. Protected copyright. 40 30. Routasalo PE, Savikko N, Tilvis RS, et al. Social contacts and their relationship to 41 loneliness among aged people a population based study. Gerontology 42 2006;52(3):181 7. 43 31. Chen Y, Hicks A, While AE. Loneliness and social support of older people in 44 China: a systematic literature review. Health Soc Care Community 2014;22(2):113 23. 45 46 32. Venturelli M, Cè E, Limonta E, et al. Effects of endurance, circuit, and relaxing 47 training on cardiovascular risk factors in hypertensive elderly patients. Age (Dordr) 48 2015;37(5):101. 49 33. Cadore EL, Izquierdo M. Exercise interventions in polypathological aging patients 50 51 that coexist with diabetes mellitus: improving functional status and quality of life. Age 52 (Dordr) 2015;37(3):64. 53 34. Goeppel C, Frenz P, Tinnemann P, et al. Universal health coverage for elderly 54 people with non communicable diseases in low income and middle income countries: 55 a cross sectional analysis. Lancet 2014;384:S6. 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 13 of 15 BMJ Open
1 2 3 35. Trivedi AN, Moloo H, Mor V. Increased ambulatory care copayments and 4 hospitalizations among the elderly. N Engl J Med 2010;362(4): 320 8. 5 36. Eggleston K, Ling L, Qingyue M, et al. Health service delivery in China: a 6 7 literature review. Health Econ 2008;17(2):149 65. 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30
31 http://bmjopen.bmj.com/ 32 33 34 35 36 37 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 14 of 15 NA 4 4 5 5 1 1
NA 4,5 4,5 4 4 NA 4 4 4 4
3,4 3,4 3 3
4,5 4,5 4,5 4,5 NA Reported on page # Reported on page 2 2 4 4
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only ) Indicate study’s) the designcommonlywith used a in term ortitlethe abstract the ) ) theGive eligibility criteria, and sourcesthe methodsand of of selection participants ) ) statisticalDescribe all methods, thoseincluding confoundingusedforcontrol to ) ) Describe any methods used subgroups examine to interactionsand ) If ) applicable, describe methodsanalytical taking account of sampling strategy ) ) in theProvide abstract informativean and balanced summary of what was donewhat wasand found ) Describe) sensitivity any analyses ) how Explain missing data were addressed a a a b e d c b For eachof interest, For variable sourcesdatagive of and details of methods of assessment (measurement). Describe comparability of of comparability assessment methods isthanthere more if one group ( ( why why
applicable collection collection ( ( ( ( Recommendation cross-sectional studies of cross-sectional reports in be included should that items of Statement—Checklist (v4) 2007 STROBE
6 1 ( 3 specific objectives, State including prespecified any hypotheses 5 the setting, Describe locations, relevantand dates, including periods exposure,of recruitment, follow-up, data and 9 any Describe efforts to address sourcespotential of bias 7 define Clearly outcomes,all exposures,predictors, potential confounders,effect and modifiers. diagnostic Give criteria, if 4 key Present of studyelements in thedesign early paper 8* 10 10 how Explain studythe size was arrived at # Item Item Results
Statistical Statistical methods 12 ( Quantitative variables 11 how Explain quantitative were handledvariables in analyses.the If applicable, describe which chosengroupings were and Study size Bias Data sources/Data measurement Variables Participants Setting Study design Methods Objectives Background/rationale 2 thebackground Explain scientific for rationale investigation the and being reported Introduction Title andTitle abstract Section/Topic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from 8,9 8,9 5-7 5-7 NA
8,9 8,9 9 9 8 8
5-8 5-8 NA NA 4 4 5-8 5-8 5-8 5-8 10 10 NA NA
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright.
For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml ) Report) boundaries category when continuous variables were categorized ) ) unadjustedGive estimates if applicable, and, confounder-adjusted estimates their and precision95% (eg, confidence ) If ) relevant, If consider translating estimatesrelativerisk of into absolute for risk meaningfulperioda time c b a similar studies,similar and other relevant evidence confounders magnitude of magnitude potential biasany confirmed eligible,confirmed included in study, the completing follow-up, analysed and interval). Make interval). clear confounderswhich were adjusted they why and for were included which the presentthe which is based article
( ( number Indicate (b) of participants missingwith eachfor data of interest variable Consider (c) diagram use flow of a reasons Give (b) non-participationfor each at stage 18 18 results Summarise key to reference withstudy objectives 16 16 ( 22 22 sourcethe Give of funding and role the of fundersthe thefor studypresent if and, applicable, originalthe for study on 19 19 Discuss of study, the takinglimitations into sourcesaccount biasof potential imprecision.or Discussboth direction and 13* 13* Report (a) numbers of individuals each at stage of study—eg numbers eligible, potentially examinedfor eligibility, An Explanation and Elaboration article discussesitem each checklist and gives backgroundmethodological and published examples of transparent reporting. The STROBE checklist is best used in this(freelywith conjunction available onarticle sites the Medicine of PLoS http://www.plosmedicine.org/,Web at Annals of Internal Medicine at http://www.annals.org/, http://www.epidem.com/).Epidemiology at and Information on InitiativeSTROBE the is www.strobe-statement.org.available at information*Give separately cases for and controls studiesin forcase-control applicable, if and, exposedunexposed and groups in cohort and studies.cross-sectional Note: Funding Other information Generalisability 21 Discuss(external generalisabilitythe of studythe validity) results Interpretation 20 cautious Give interpretationa of resultsoverall considering limitations, objectives, multiplicity of resultsanalyses, from Limitations Key Key results Discussion Other analyses 17 other Report analyses done—eg analyses of subgroups sensitivity interactions, and and analyses
Main resultsMain Outcome Outcome data 15* numbers Report of outcome events or summary measures
Descriptive data 14* characteristicsGive (a) participantsof study (eg demographic, social) clinical, and information on exposures potential and
Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 15 of BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open
Quality of Life and Loneliness Among Elderly Chinese: A Cross-Sectional Study of the Elderly in Liaoning Province, China
ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-021822.R1
Article Type: Research
Date Submitted by the Author: 11-May-2018
Complete List of Authors: Zhu, Yaxin; China Medical University, Department of Social Medicine, School of Public Health Liu, Jie; China Medical University, Department of Health Statistics, School of Public Health Qu, Bo; China Medical University, Department of Health Statistics, School of Public Health Yi, Zhe; China Medical University, Department of Prothodontics, School of Stomatology
Primary Subject Public health Heading: http://bmjopen.bmj.com/ Secondary Subject Heading: Geriatric medicine
Keywords: quality of life, elderly, loneliness
on September 30, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 1 of 16 BMJ Open
1 2 3 Quality of Life and Loneliness Among Elderly Chinese: A Cross-Sectional Study 4 of the Elderly in Liaoning Province, China 5 Yaxin Zhu1, Jie Liu2, Bo Qu2*, Zhe Yi3*, 6 1 7 Department of Social Medicine, School of Public Health, China Medical University, 8 Shenyang, Liaoning Province, People’s Republic of China 9 2Department of Health Statistics, School of Public Health, China Medical University, 10 Shenyang, Liaoning Province, People’s Republic of China 11 3Department of Prothodontics, School of Stomatology, China Medical University, 12 13 Shenyang, Liaoning Province, People’s Republic of China 14 15 * Corresponding author: 16 Zhe Yi, DepartmentFor peer of Prothodontics, review School of Stomatology,only China Medical 17 18 University, No. 117 Nanjing North Street, Heping District, Shenyang 110001, 19 Liaoning Province, People’s Republic of China. 20 Tel: 86 13238866438 21 E mail: [email protected] (ZY) 22
23 24 Zhe Yi and Bo Qu contributed equally to this paper. 25 26 Keywords: quality of life; loneliness; elderly 27 Word counts: 3613 28 29 30
31 http://bmjopen.bmj.com/ 32 33 34 35 36 37 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 2 of 16
1 2 3 4 Abstract 5 Objectives: The aim of the study was to learn more about the loneliness, 6 7 health related characteristics, and QOL in a sample of elderly; and to examine the 8 relation among these variables. 9 Design: Cross sectional study. 10 Setting: Communities in Dandong city of Liaoning province, China. 11 Participants: Sample of 732 elderly Chinese, aged 60 and older, living in Dandong, 12 13 Liaoning Province, China. 14 Methods: A questionnaire was administered face to face to the participants. The 15 questionnaire contained four sections: demographic characteristics, heath information, 16 the EQ 5D scale,For and thepeer UCLA Loneliness review Scale. The t test,only F test, and multivariable 17 18 linear regression analyses were performed to individually test associations between 19 the demographic data, health related factors, loneliness, and QOL. 20 Results: Chronic diseases, loneliness, age, and smoking status were negatively 21 associated with QOL (p < 0.05). Satisfaction with health services, income, and 22 physical activity were positively associated with QOL (p < 0.05). 23 24 Conclusions: Loneliness was an important factor related to low QOL among elderly 25 Chinese. The findings indicate that reducing loneliness may help improve the QOL 26 for elderly. 27 Strengths and limitations of this study 28 29 1. In this study, we investigated the relation between QOL and loneliness, which 30 could provide some implication for proposing new interventions on improving QOL
31 among Chinese elderly. http://bmjopen.bmj.com/ 32 33 2. This study was an observational investigation employing a cross sectional design to 34 explore the relation between QOL and loneliness, which may limit the ability to 35 36 confirm causal relation. 37 38 3. The recruitment of participants from communities stratified by districts will
39 improve the sample representativeness. on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 3 of 16 BMJ Open
1 2 3 4 Introduction 5 The global population is aging rapidly [1]. In 1950, only 8% of the global 6 7 population was ≥60 years of age [2]. The HelpAge Global Network 2015 review 8 reported that 12% of the global population was ≥60 years of age [3] and that by 2050 9 this percentage would double [1,3]. The People’s Republic of China has the largest 10 population ≥60 years old (hereafter denoted as elderly) in the world and in 2014 11 accounted for 14.4% of the total Chinese population [4]. The percentage of elderly 12 13 Chinese is expected to reach 33.9% by 2050 [3]. In addition, elderly Chinese currently 14 constitute one fifth of the total worldwide elderly population [2]. Notably, the elderly 15 are more vulnerable to chronic diseases [5], and given the rapid growth of the aging 16 population, For the prevalence peer of chronic review diseases is expected only to increase among the 17 18 elderly [5]. Hence, the aging population should have a profound impact on healthcare 19 systems and economic growth in China and worldwide [1,2]. 20 Maintaining the elderly in good health positively impacts both them and society in 21 general, as the availability of human and social resources for the aged depends greatly 22 on their health status [1]. However, healthy aging involves more than the absence of 23 24 disease [1]. A report by the World Health Organization (WHO) has suggested that 25 improving quality of life (QOL) for older people should be the outcome of realizing 26 the policy framework of “active ageing” [6]. Adding “quality” to older people’s life to 27 improve their health, social function, independence, and activity has become the goal 28 29 of a prolonged life [7]. QOL is an assessment of health status based on a medical 30 model that reflects an individual’s physical, psychological, and sociological health [8].
31 In addition, it has been recommended that disease centered curative health systems http://bmjopen.bmj.com/ 32 embrace integrated care focusing on the needs of elderly [1]. Thus, assessment of 33 QOL is seen as an essential element in the care of the elderly [9 11], and improving 34 35 their QOL has become a prioritized element in their medical care [6]. Identifying the 36 factors associated with QOL is needed if new interventions that will lead to improved 37 QOL among elderly are to be developed. 38 Loneliness among the elderly is common [12] and a serious problem [13]. The
39 on September 30, 2021 by guest. Protected copyright. 40 relation between loneliness and health has been recognized within the past decade, 41 with loneliness being related to adverse physical and mental health outcomes 42 [12,14,15]. A longitudinal cohort study found that the risk of Alzheimer disease was 43 more than twice that for elderly who felt lonely as compared with those who did not 44 feel so [14]. In addition, loneliness may have deleterious effects on their 45 46 psychological states. A 5 year longitudinal study conducted among older male and 47 female Americans indicated that the degree to which the subjects were lonely 48 positively correlated with subsequent changes in their depressive states [15]. Another 49 study reported that lonely individuals were more likely to partake in health damaging 50 51 behaviors, e.g., physical inactivity [16]. 52 Although QOL as a good measure of overall health has also been reported to be 53 influenced by loneliness among the elderly in some countries like Sweden [17] and 54 Netherlands [18], the relation between QOL and loneliness among elderly Chinese 55 has not been fully assessed [13]. Compared with these developed country, China has 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 4 of 16
1 2 3 the unique national conditions and culture. Due to social and economic change in 4 China recently, younger people have migrated or emigrated to relatively economically 5 developed area to seek employment and a better life [19]. And China is a country that 6 7 values the culture of collectivism and filial piety. Older people still expected to get the 8 care provided by their children. Therefore, the perception of the gap between expected 9 and actual amount of support that the older people derived from their families would 10 be stronger for elderly [13]. This would be the reason why Chinese elderly had 11 serious problem of loneliness. Emerson and colleagues suggested that early 12 13 intervention of loneliness might be able to decrease morbidity and mortality rates 14 among elderly [20]. Hence, the relation between QOL and loneliness should be fully 15 investigated to provide some implication for proposing new interventions on 16 improving QOLFor among peer Chinese elderly. review The purpose of onlythe study reported herein was 17 18 to learn more about the loneliness, health related characteristics, and QOL in a sample 19 of elderly; and to examine the relation among these variables. 20 21 Materials and Methods 22 23 Ethics statement 24 25 The Bioethics Advisory Commission of the China Medical University approved 26 this study. The participants were informed about the purpose of the study and, prior to 27 the start of the study, were assured that their privacy would be protected. All 28 29 participants provided written informed consent before participating in the study. 30 Study sample and procedures 31 http://bmjopen.bmj.com/ 32 This study employed a cross sectional design with a stratified random sampling 33 method on elderly of age ≥60 years in Dandong, Liaoning Province. Compared with 34 35 other cities in China, Dandong has more elderly. In 2014, those ≥60 years of age 36 accounted for 21.6% of the Dandong population, and this elderly population ranked 37 third in Liaoning Province. 38 Dandong has six districts. One community in each district was randomly selected to
39 on September 30, 2021 by guest. Protected copyright. 40 achieve the required sample size, which was determined by the criterion that the 41 sample size should be 20 times the number of variables. In this study, the 42 questionnaire contained 36 variables, and the required sample size was 720. Inclusion 43 criteria were age ≥60 years, residence in Dandong, providing the written informed 44 consent, and able to understand the questionnaire and communicate. Those who 45 46 refused to participate in the study and have severe physical conditions affecting daily 47 life were excluded. During this survey, a questionnaire was administered by 48 face to face interview to the participants by the trained investigators from 2017 49 February to July. If the participants have any problem with completing the survey, the 50 51 investigators will assist them. 52 In total, 784 eligible subjects were included in this survey, and 764 completed 53 questionnaires were returned (response rate 97.4%). When a participant did not 54 answer >20% of the questions, the associated questionnaire was not included in the 55 study. After exclusion of 32 invalid questionnaires, 732 questionnaires were identified 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 5 of 16 BMJ Open
1 2 3 as valid. 4 5 Measurements 6 7 The questionnaire contained four sections: demographic characteristics, 8 heath related information, and the EQ 5D and the UCLA Loneliness scales. The 9 demographic characteristics were age, gender, marital status, education, monthly 10 income, place of residence (urban or rural), and living arrangement (empty or 11 non empty nester). Empty nesters were elderly who never had children or whose 12 13 children had left home, so that empty nesters were defined as those living alone or 14 with only a spouse [21]. 15 Health related information consisted of smoking status, physical activity status, 16 chronic diseaseFor status, peerand satisfaction review with their health only services. To assess the level 17 18 of physical activity, participants were asked if they exercised at least six times a week 19 [22]. Respondents were defined as having a chronic disease(s) if they had ever been 20 so diagnosed by a health professional(s). Satisfaction with health services was 21 evaluated using one item from WHOQOL BREF [23], in which respondents rated the 22 scale from 1 (very dissatisfied) to 5 (very satisfied). 23 24 The EQ 5D was used to evaluate QOL of the participants, which is a generic tool 25 developed by the EuroQol Group [24]. The EQ 5D contains five items covering 26 different dimensions (mobility, self care, usual activities, pain/discomfort, and 27 anxiety/depression). Each item has three possible responses (no problem, moderate 28 29 problem, or extreme problem). A single EQ 5D summary index score ranging from 30 –0.149 to 1.0 was calculated using the Chinese time trade off model [24]. Higher
31 values imply better QOL. In addition, the EQ 5D also contains the visual analogue http://bmjopen.bmj.com/ 32 scale (VAS). The VAS was used to assess the respondents’ own perception of their 33 health status on a scale from 0 (worst) to 100 (best). The EQ 5D has been shown to be 34 35 applicable in China and for elderly Chinese [22,25 27]. The reliability of the EQ 5D 36 for our study was acceptable, with a Cronbach’s alpha equaling 0.82. 37 Loneliness in the elderly was assessed with the use of the UCLA Loneliness Scale 38 [28], which has 20 items rated on a 1 to 4 point, Likert type scale. The total UCLA
39 on September 30, 2021 by guest. Protected copyright. 40 score ranges from 20 to 80, with greater scores defining greater degrees of loneliness. 41 The scale ranges are: 20–34, a low loneliness level; 35–49, a moderate loneliness 42 level; 50–64, a moderately high loneliness level; and 65–80, a high loneliness level 43 [28]. We found the scale to be reliable, as the Cronbach’s alpha was 0.84. 44 45 Statistical Analyses 46 47 The Student’s t test, the F test, and hierarchical linear regression analysis were 48 performed to determine the association between QOL and the demographic data, 49 health related factors, and the UCLA Loneliness scale. In Block 1, demographics 50 51 characteristic (age, gender, marital status, education, monthly income, place of 52 residence, and living arrangement) were put in the model. Health related 53 characteristics (smoking status, physical activity status, chronic disease status, and 54 satisfaction with their health services) were added in Block 2. In Block 3, loneliness 55 was added. Variances of QOL explained by different groups of independent variables 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 6 of 16
1 2 3 were examined by △R2 (R squared change). Data were analyzed using SPSS version 4 21.0 (SPSS Inc., Chicago, IL, USA) for Windows. A p value < 0.05 was considered to 5 be statistically significant. 6 7 Patient and public involvement 8 9 No participated elderly were involved in setting the research question or the 10 outcome measures, nor were they involved in developing plans for design or 11 implementation of the study. The participants were informed that the results were to 12 13 be published in an open access journal. 14 15 Results 16 For peer review only 17 Participant Characteristics 18 19 The demographic characteristics of the participants are described in Table 1. A total 20 of 375 women (51.2%) and 357 men (48.8%) participated. Their ages ranged from 60 21 to 96 years, with a mean age of 71.34 ± 7.73 years (standard deviation); 241 of the 22 participants (32.9%) lived in rural areas. Approximately one half of the participants 23 24 (341, 46.6%) were empty nesters. The F or t tests revealed that there were significant 25 differences in the QOL scores for participants of different ages, residences, living 26 arrangements, monthly incomes, and education levels (p < 0.05). Participants who 27 were younger, lived in an urban area, or were not empty nesters had higher QOL 28 29 scores (Table 1). 30 Table 1. The relationship between demographic characteristics and QOL (N = 732).
31 Variable Number of EQ 5D F/t http://bmjopen.bmj.com/ 32 participants index score 33 (%) 34 b 35 Age 36 60–69 289 (39.5%) 0.95 ± 0.10 8.149** 37 70–79 345 (47.1%) 0.92 ± 0.12 38 ≥80 98 (13.4%) 0.90 ± 0.15 39 a on September 30, 2021 by guest. Protected copyright. 40 Gender 41 Male 357 (48.8%) 0.93 ± 0.12 0.301 42 Female 375 (51.2%) 0.93 ± 0.12 43 Residencea 44 Rural 241 (32.9%) 0.92 ± 0.12 –2.333* 45 46 Urban 491 (67.1%) 0.94 ± 0.12 47 Living arrangementa 48 Empty nester 341 (46.6%) 0.92 ± 0.13 2.221* 49 Non empty nester 391 (53.4%) 0.94 ± 0.11 50 b 51 Marital status 52 Single 18 (2.4%) 0.97 ± 0.10 2.304 53 Married 688 (94.0%) 0.93 ± 0.12 54 Divorced/Widowed 26 (3.6%) 0.89 ± 0.14 55 Monthly incomeb 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 7 of 16 BMJ Open
1 2 3 <2000 367 (50.1%) 0.90 ± 0.14 21.722** 4 2000–3000 194 (26.5%) 0.95 ± 0.08 5 >3000 171 (23.4%) 0.97 ± 0.09 6 b 7 Education 8 Primary school or below 323 (44.1%) 0.92 ± 0.13 3.236* 9 Junior high school 294 (40.2%) 0.95 ± 0.10 10 Senior high school 89 (12.2%) 0.94 ± 0.11 11 College and above 26 (3.5%) 0.92 ± 0.12 12 a b 13 t test; F test; *p < 0.05; **p < 0.01 14 Regarding health related characteristics (Table 2), the majority of the participants 15 (559, 76.4%) suffered from a chronic disease(s), and approximately one half (436, 16 59.5%) wereFor satisfied orpeer very satisfied review with the health services only that they received. For 17 18 the heath related characteristics, the F or t tests results showed that significant 19 differences existed in the QOL scores as related to chronic disease status, smoking 20 status, physical activity, and satisfaction with health services (p < 0.05). Those who 21 had a chronic disease(s), smoked, were not physically active, or were dissatisfied with 22 23 their health services had lower QOL scores (Table 2). 24 Table 2. The relationship between health-related characteristics and QOL (N = 732). 25 Variable Number of EQ 5D index F/t 26 participants score 27 (%) 28 a 29 Chronic disease 30 Yes 559 (76.4%) 0.87 ± 0.15 –7.158**
31 No 173 (23.6%) 0.95 ± 0.10 http://bmjopen.bmj.com/ 32 a Smoking status 33 34 Yes 220 (30.1%) 0.92 ± 0.13 –1.984* 35 No 512 (69.9%) 0.94 ± 0.11 36 Physical activitya 37 No 633 (86.5%) 0.93 ± 0.12 –2.631** 38 Yes 99 (13.5%) 0.95 ± 0.09
39 on September 30, 2021 by guest. Protected copyright. b 40 Health services 41 Very dissatisfied 20 (12.7%) 0.83 ± 0.21 29.230** 42 Dissatisfied 53 (22.3%) 0.86 ± 0.14 43 Neither satisfied nor 223 (15.5%) 0.89 ± 0.13 44 45 dissatisfied 46 Satisfied 353 (38.2%) 0.96 ± 0.08 47 Very satisfied 83 (11.3%) 0.97 ± 0.09 48 at test; bF test; *p < 0.05; **p < 0.01 49 50 QOL 51 52 The mean EQ 5D index score for the participants was 0.93 ± 0.12 (range, 53 0.22–1.00). The mean VAS score was 81.25 ± 14.38 (range, 0–100). The distribution 54 of the EQ 5D scale score presented in Table 3. The most prevalent health related 55 56 problem reported by the participants was pain/discomfort (196, 26.8% had moderate 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 8 of 16
1 2 3 or extreme pain/discomfort). 4 Table 3. Distribution of EQ-5D index score (N = 732). 5 Dimension No problem Moderate problem Extreme problem 6 7 Mobility 678 (92.6%) 53 (7.2%) 1 (0.1%) 8 Self care 713 (97.4%) 14 (1.9%) 5 (0.7%) 9 Usual activities 677 (92.5%) 55 (7.5%) 0 (0%) 10 Pain/discomfort 536 (73.2%) 193 (26.4%) 3 (0.4%) 11 Anxiety/depression 610 (83.3%) 121 (16.5%) 1 (0.1%) 12 13 14 Loneliness 15 The mean UCLA loneliness score was 40.73 ± 8.73 (range, 20–64). According to 16 their lonelinessFor scores, peer 547 participants review (74.7%) had a moderateonly or a moderately high 17 18 loneliness score (Table 4). A significant difference was found for the QOL scores for 19 groups with different degrees of loneliness (p = 0.00). Participants with moderately 20 high loneliness scores had lower QOL scores (0.86 ± 0.17) compared with 21 participants in the other two groups. The relationships between their QOL and 22 23 loneliness scores are listed in Table 4. 24 Table 4. The relationship between loneliness and QOL (N = 732). 25 Loneliness level Number of EQ 5D index F 26 participants score 27 (%) 28 29 Low 185 (25.3%) 0.97 ± 0.07 33.889** 30 Moderate 449 (61.3%) 0.93 ± 0.11
31 Moderately high 98 (13.4%) 0.86 ± 0.17 http://bmjopen.bmj.com/ 32 **p < 0.01 33 34 35 Relation between the demographic data, health-related 36 37 factors, loneliness, and QOL 38 Hierarchical linear regression analyses of the factors associated with QOL are 39 on September 30, 2021 by guest. Protected copyright. 40 presented in Table 5. In Block 1, age, income, education, living arrangement, and 41 marital status were significantly associated with QOL (p < 0.05). When health related 42 characteristics were added in Block 2, age, income, chronic disease(s), health service 43 satisfaction, smoking and physical activity were significantly associated with QOL (p 44 45 < 0.05). In Block 3, among these demographic and health related characteristics, 46 having a chronic disease(s), the age of the participant, and smoking were negatively 47 associated with QOL (p < 0.05), with chronic disease having standardized coefficients 48 of 0.234. Satisfaction with health services, a higher income, and being physically 49 50 activity were positively associated with the QOL of the participants (p < 0.05). In 51 addition, loneliness was significantly and negatively associated with QOL 52 (level = moderate: β = 0.190, p < 0.05; level = moderately high: β = 0.260, p < 0.05; 53 reference group: level = low). The loneliness explained 5.2% of the variance of QOL. 54 Table 5. Hierarchical linear regression analyses of the factors associated with QOL (N = 55 732 56 ). 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 9 of 16 BMJ Open
1 2 3 Factor Block 1 (β) Block 2 (β) Block 3 (β) 4 Agea 5 70–79 6 0.081* 0.074* 0.079* 7 ≥80 0.077 .043 0.050 8 Incomeb 9 2000–3000 0.157* 0.094* 0.097* 10 >3000 11 0.205* 0.108* 0.103* 12 Gender Female 0.009 .048 0.045 13 Educationc 14 Junior high school 0.083* 0.037 0.034 15 Senior high school 0.052 0.027 0.031 16 For peer review only 17 College and above 0.012 0.028 0.031 18 Residence Urban 0.061 0.021 0.002 19 Living arrangement Empty nester 0.086* 0.061 0.030 20 d Marital status 21 22 Married 0.079 0.064 0.057 23 Divorced/Widowed 0.109* 0.066 0.054 24 Chronic disease Yes 0.239* 0.234* 25 Health service satisfactione 26 27 Dissatisfied 0.088 0.086 28 Neither satisfied nor dissatisfied 0.225* 0.196* 29 Satisfied 0.524* 0.453* 30 Very satisfied 0.307* 0.258*
31 http://bmjopen.bmj.com/ 32 Smoking Yes 0.116* 0.110* 33 Physical activity Yes 0.078* 0.078* 34 Lonelinessf 35 Moderate 0.190* 36 37 Moderately high 0.260* 38 F 6.007 12.874 15.246 2 39 R 0.091 0.256 0.308 on September 30, 2021 by guest. Protected copyright. 40 2 △R 0.091 0.165 0.052 41 42 *p < 0.05; **p < 0.01; β, standardized regression coefficient 43 a: reference group = 60 69; b: reference group = <2000; c: reference group = primary school or 44 below; d: reference group = Single; e: reference group = very dissatisfied; f: reference group = 45 low. 46 47 Discussion 48 49 This study contributes to our knowledge concerning the relationship between QOL 50 and loneliness among elderly living in Dandong, Liaoning Province, China. Our 51 results indicate that the pain/discomfort facet of QOL was the most prevalent problem 52 53 among the participants. This finding is in line with previous studies on Chinese [25,26] 54 and Vietnamese elderly [29]. One population based study revealed that more than 55 one half of older Americans had been bothered by pain in the month prior to being 56 questioned [30]. The elderly often experience chronic pain [31], which is a disability 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 10 of 16
1 2 3 that can cause decreased mobility and depression [30]. These factors may increase 4 healthcare costs and may decrease productivity [31]. Bhattarai and colleagues 5 suggested that cost efficient intervention strategies for management of the pain in the 6 7 elderly should be a priority for healthcare providers [31]. 8 We found loneliness to be significantly correlated with the QOL of our participants, 9 and those who had a greater degree of loneliness also reported a poorer QOL. 10 Loneliness may impair the immune and cardiovascular systems [12]. The negative 11 effects of loneliness on the physical and psychological health of the elderly have been 12 13 widely documented [12,15]. Lonely individuals are also more likely to engage in 14 behavior that results in poor health outcomes [16]. These factors may all contribute to 15 and impair QOL for the elderly [9]. We found that 74.7% of our participants 16 experienced For a moderate peer or moderately review high level of loneliness.only The prevalence of 17 18 loneliness found by us is comparable with that found for elderly in other Chinese city, 19 Shanghai [9,28] but is much greater than that reported in the developed country 20 Finland [32]. The substantial social and economic changes occurring in China, along 21 with the increase in the number of elderly, increases the likelihood that more elderly 22 will be lonely [19,28]. There is, therefore, an urgent need to carry out interventions 23 24 that will mitigate their loneliness [9]. 25 Consistent with other studies [33,34], suffering from a chronic disease(s) was an 26 important risk factor for QOL among elderly. Monitoring and ameliorating a chronic 27 disease(s) may reduce their negative impact on the QOL of the elderly [2]. However, 28 29 representative data from six countries, including China, have indicated that effective 30 healthcare coverage among elderly with chronic diseases is between 20.7% and 48.2%
31 [35]. Given the continuous nature of chronic care, it should be more effective to http://bmjopen.bmj.com/ 32 provide the elderly with healthcare services in community based settings, e.g., 33 primary healthcare centers [2]. The WHO study also urged that permanent 34 35 mechanisms be established that would expand healthcare coverage for the elderly 36 with chronic conditions [35,36]. 37 We found that the QOL of our participants positively correlated with their 38 satisfaction with health services, which is consistent with a related study [8]. The
39 on September 30, 2021 by guest. Protected copyright. 40 elderly who are more satisfied with their health services are more prone to regard the 41 healthcare they receive as effective and hence adhere to the recommended 42 treatment(s), which consequently may further improve their physical and mental 43 health [8]. This may explain why the elderly who reported a greater degree of 44 satisfaction with their healthcare also reported a better QOL. However, only half of 45 46 our participants (49.5%) were satisfied or very satisfied with their health services. 47 Poor quality, high costs, and poor accessibility to healthcare may be reasons for 48 dissatisfaction with health services in China [9,37]. 49 Our study has several limitations. First, the study was conducted in only one 50 51 Chinese city, which may partly limit representation of elderly Chinese. Additional 52 studies in other areas of China will help determine whether our findings can be 53 generalized. Second, this study employed a cross sectional design, which may limit 54 the ability to confirm causal relation between QOL and loneliness. The further study, 55 applying more effective design like case control design or cohort design, would be 56 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 11 of 16 BMJ Open
1 2 3 carried out to establish the casual relation between loneliness and QOL. Last, the 4 unique use of self report response may cause some bias like consistency motif, 5 acquiescence bias, and social desirability. The two primary ways through the design 6 7 of the study’s procedures and statistical controls should be carried out to control for 8 these method biases in the future research [38]. In addition, our study identified 9 multiple factors that may influence QOL in the elderly that can be addressed 10 separately and in depth in the future. 11 12 Conclusions 13 14 Our study provides information about the QOL and loneliness of elderly Chinese, 15 and demonstrates that loneliness is a crucial problem for elderly. It points out that 16 loneliness wasFor negatively peer associated reviewwith QOL among elderly. only To address the findings 17 18 of this study, it is suggested that we may need to be aware of the loneliness of elderly, 19 and take action in the care for the elderly to minimize the loneliness and improve the 20 QOL. 21 22 Acknowledgments 23 24 The authors wish to thank Xia Min for help with sample collection. We thank all the 25 elderly participants in this study. 26 27 Competing Interests 28 29 The authors declare that they have no competing interests. 30 Funding 31 http://bmjopen.bmj.com/ 32 This work was supported by National Natural Science Foundation of China, grant 33 number 71473269 and 71673301. The funders had no role in study design, data 34 35 collection and analysis, decision to publish, or preparation of the manuscript. 36 37 38 Author contributions
39 on September 30, 2021 by guest. Protected copyright. 40 YZ wrote the manuscript. YZ and JL participated in the data collection and analysis. 41 ZY collected the data. ZY and BQ designed the study and revised the manuscript. BQ 42 43 obtained funding. All authors read and approved the final manuscript. 44 45 46 Ethics approval 47 Ethical protocol was obtained from the Bioethics Advisory Commission of China 48 49 Medical University. All participants provided written informed consent before 50 participating in the study. 51 52 Data sharing statement 53 No additional unpublished data. 54 55 56 References 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 12 of 16
1 2 3 1. World Health Organization. WHO World Report on Health and Ageing, 2015. 4 Accessed in 10 Oct 2017. 5 http://101.96.8.164/apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng. 6 7 pdf?ua=1. 8 2. Shanghai Municipal Center for Disease Control & Prevention (SCDC). Study on 9 global AGEing and Adult Health Wave 1 China National Report (2012). Accessed in 10 01 Oct 2017. 11 https://www.researchgate.net/publication/277305920_China_Study_on_global_AGEi 12 13 ng_and_adult_health_SAGE_Wave_1_National_Report. 14 3. HelpAge International. HelpAge International Annual review 2015 (2015). 15 Retrieved online 08 Oct 2017. 16 http://www.helpage.org/who we are/annual review 2015/#looking forward.For peer review only 17 18 4. HelpAge International. Global Age Watch Index (2014). Retrieved online 14 Oct 19 2017. http://www.helpage.org/global agewatch/about/about global agewatch/. 20 5. Wang Z, Li X, Chen M. Catastrophic health expenditures and its inequality in 21 elderly households with chronic disease patients in China. Int J Equity Health 22 2015;14:8. 23 24 6. World Health Organization. Active ageing: a policy framework (2002). Accessed in 25 01 Oct 2017. 26 http://apps.who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf. 27 7. Ann B. The psychometric properties of the older people’s quality of life 28 29 questionnaire, compared with the CASP 19 and the WHOQOL OLD. Curr Gerontol 30 Geriatr Res 2009;2009(2):298950.
31 8. Zhang Y, Zhou Z, Gao J, et al. Health related quality of life and its influencing http://bmjopen.bmj.com/ 32 factors for patients with hypertension: evidence from the urban and rural areas of 33 Shaanxi Province, China. BMC Health Serv Res 2016;16:277. 34 35 9. Chen Y, Hicks A, While AE. Quality of life and related factors: a questionnaire 36 survey of older people living alone in Mainland China. Qual Life Res 37 2014;23(5):1593 602. 38 10. Bélanger E, Ahmed T, Vafaei A, et al. Sources of social support associated with
39 on September 30, 2021 by guest. Protected copyright. 40 health and quality of life: a cross sectional study among Canadian and Latin American 41 older adults. BMJ Open 2016;6(6):e011503. 42 11. Cerin E, Sit CH, Zhang CJ, et al. Neighbourhood environment, physical activity, 43 quality of life and depressive symptoms in Hong Kong older adults: a protocol for an 44 observational study. BMJ Open 2016;6(1):e010384. 45 46 12. Luanaigh CO, Lawlor BA. Loneliness and the health of older people. Int J Geriatr 47 Psychiatry 2008;23(12):1213 21. 48 13. Liu LJ, Guo Q. Loneliness and health related quality of life for the empty nest 49 elderly in the rural area of a mountainous county in China. Qual Life Res 50 51 2007;16(8):1275 80. 52 14. Wilson RS, Krueger KR, Arnold SE, et al. Loneliness and risk of Alzheimer 53 disease. Arch Gen Psychiatry 2007;64(2):234 40. 54 15. Cacioppo JT, Hawkley LC, Thisted RA. Perceived social isolation makes me sad: 55 5 year cross lagged analyses of loneliness and depressive symptomatology in the 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 13 of 16 BMJ Open
1 2 3 Chicago Health, Aging, and Social Relations Study. Psychol Aging 4 2010;25(2):453 63. 5 16. Hawkley LC, Thisted RA, Cacioppo JT. Loneliness predicts reduced physical 6 7 activity: cross sectional & longitudinal analyses. Health Psychol 2009;28(3):354 63. 8 17. Jakobsson U, Hallberg IR. Loneliness, fear, and quality of life among elderly in 9 Sweden: a gender perspective. Aging Clin Exp Res 2005;17(6):494 501. 10 18. Ilona V, Ros Wynand J G, Bas S, de Wit NJ. Ethnicity does not account for 11 differences in the health related quality of life of Turkish, Moroccan, and Moluccan 12 13 elderly in the Netherlands. Health Qual Life Outcomes 2014;12(1):138. 14 19. Chen Y, Hicks A, While AE. Loneliness and social support of older people in 15 China: a systematic literature review. Health Soc Care Community 16 2014;22(2):113 123.For peer review only 17 18 20. Emerson KG, Jayawardhana J. Risk Factors for Loneliness in Elderly Adults. J 19 Am Geriatr Soc 2016;64(4):886 7. 20 21. Cheng P, Jin Y, Sun H, et al. Disparities in prevalence and risk indicators of 21 loneliness between rural empty nest and non empty nest older adults in Chizhou, 22 China. Geriatr Gerontol Int 2015;15(3):356 64. 23 24 22. Tan Z, Liang Y, Liu S, et al. Health related quality of life as measured with EQ 5D 25 among populations with and without specific chronic conditions: a population based 26 survey in Shaanxi Province, China. PLoS One 2013;8(7):e65958. 27 23. The WHOQOL Group. Development of the World Health Organization 28 29 WHOQOL BREF quality of life assessment. Psychol Med 1998;28:551 8. 30 24. Liu GG, Wu H, Li M, et al. Chinese time trade off values for EQ 5D health states.
31 Value Health 2014;17(5):597 604. http://bmjopen.bmj.com/ 32 25. Sun S, Chen J, Johannesson M, et al. Regional differences in health status in 33 China: population health related quality of life results from the National Health 34 35 Services Survey 2008. Health Place 2011;17(2):671 80. 36 26. Zhang T, Shi W, Huang Z, et al. Influence of culture, residential segregation and 37 socioeconomic development on rural elderly health related quality of life in Guangxi, 38 China. Health Qual Life Outcomes 2016;14:98.
39 on September 30, 2021 by guest. Protected copyright. 40 27. Deng X, Dong P, Zhang L, et al. Health related quality of life in residents aged 18 41 years and older with and without disease: findings from the First Provincial Health 42 Services Survey of Hunan, China. BMJ Open 2017;7(9):e015880. 43 28. Chen Y, Hicks A, While AE. Loneliness and social support of older people living 44 alone in a county of Shanghai, China. Health Soc Care Community 45 46 2014;22(4):429 38. 47 29. Hoi le V, Chuc NT, Lindholm L. Health related quality of life, and its 48 determinants, among older people in rural Vietnam. BMC Public Health 2010;10:549. 49 30. Patel KV, Guralnik JM, Dansie EJ, et al. Prevalence and impact of pain among 50 51 older adults in the United States: findings from the 2011 National Health and Aging 52 Trends Study. Pain 2013;154(12):2649 57. 53 31. Bhattarai P, Phillips JL. The role of digital health technologies in management of 54 pain in older people: An integrative review. Arch Gerontol Geriatr 2017;68:14 24. 55 32. Routasalo PE, Savikko N, Tilvis RS, et al. Social contacts and their relationship to 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 14 of 16
1 2 3 loneliness among aged people a population based study. Gerontology 4 2006;52(3):181 7. 5 33. Venturelli M, Cè E, Limonta E, et al. Effects of endurance, circuit, and relaxing 6 7 training on cardiovascular risk factors in hypertensive elderly patients. Age (Dordr) 8 2015;37(5):101. 9 34. Cadore EL, Izquierdo M. Exercise interventions in polypathological aging patients 10 that coexist with diabetes mellitus: improving functional status and quality of life. Age 11 (Dordr) 2015;37(3):64. 12 13 35. Goeppel C, Frenz P, Tinnemann P, et al. Universal health coverage for elderly 14 people with non communicable diseases in low income and middle income countries: 15 a cross sectional analysis. Lancet 2014;384:S6. 16 36. Trivedi For AN, Moloo peer H, Mor V.review Increased ambulatory only care copayments and 17 18 hospitalizations among the elderly. N Engl J Med 2010;362(4): 320 8. 19 37. Eggleston K, Ling L, Qingyue M, et al. Health service delivery in China: a 20 literature review. Health Econ 2008;17(2):149 65. 21 38. Podsakoff PM, Mackenzie SB, Lee JY, et al. Common method biases in 22 behavioral research: a critical review of the literature and recommended remedies. J 23 24 Appl Psychol 2003;88(5):879 903. 25 26 27 28 29 30
31 http://bmjopen.bmj.com/ 32 33 34 35 36 37 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from NA 4 4 5 5 1 1
NA 4,5 4,5 4 4 NA 4 4 4 4
3,4 3,4 3 3
4,5 4,5 4,5 4,5 NA Reported on page # Reported on page 2 2 4 4
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only ) Indicate study’s) the designcommonlywith used a in term ortitlethe abstract the ) ) theGive eligibility criteria, and sourcesthe methodsand of of selection participants ) ) statisticalDescribe all methods, thoseincluding confoundingusedforcontrol to ) ) Describe any methods used subgroups examine to interactionsand ) If ) applicable, describe methodsanalytical taking account of sampling strategy ) ) in theProvide abstract informativean and balanced summary of what was donewhat wasand found ) Describe) sensitivity any analyses ) how Explain missing data were addressed a a a b e d c b For eachof interest, For variable sourcesdatagive of and details of methods of assessment (measurement). Describe comparability of of comparability assessment methods isthanthere more if one group ( ( why why
applicable collection collection ( ( ( ( Recommendation cross-sectional studies of cross-sectional reports in be included should that items of Statement—Checklist (v4) 2007 STROBE
6 1 ( 3 specific objectives, State including prespecified any hypotheses 5 the setting, Describe locations, relevantand dates, including periods exposure,of recruitment, follow-up, data and 9 any Describe efforts to address sourcespotential of bias 7 define Clearly outcomes,all exposures,predictors, potential confounders,effect and modifiers. diagnostic Give criteria, if 4 key Present of studyelements in thedesign early paper 8* 10 10 how Explain studythe size was arrived at # Item Item Results
Statistical Statistical methods 12 ( Quantitative variables 11 how Explain quantitative were handledvariables in analyses.the If applicable, describe which chosengroupings were and Study size Bias Data sources/Data measurement Variables Participants Setting Study design Methods Objectives Background/rationale 2 thebackground Explain scientific for rationale investigation the and being reported Introduction Title andTitle abstract Section/Topic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 15 of 16 BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 16 of 8,9 8,9 5-7 5-7 NA
8,9 8,9 9 9 8 8
5-8 5-8 NA NA 4 4 5-8 5-8 5-8 5-8 10 10 NA NA
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright.
For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml ) Report) boundaries category when continuous variables were categorized ) ) unadjustedGive estimates if applicable, and, confounder-adjusted estimates their and precision95% (eg, confidence ) If ) relevant, If consider translating estimatesrelativerisk of into absolute for risk meaningfulperioda time c b a similar studies,similar and other relevant evidence confounders magnitude of magnitude potential biasany confirmed eligible,confirmed included in study, the completing follow-up, analysed and interval). Make interval). clear confounderswhich were adjusted they why and for were included which the presentthe which is based article
( ( number Indicate (b) of participants missingwith eachfor data of interest variable Consider (c) diagram use flow of a reasons Give (b) non-participationfor each at stage 18 18 results Summarise key to reference withstudy objectives 16 16 ( 22 22 sourcethe Give of funding and role the of fundersthe thefor studypresent if and, applicable, originalthe for study on 19 19 Discuss of study, the takinglimitations into sourcesaccount biasof potential imprecision.or Discussboth direction and 13* 13* Report (a) numbers of individuals each at stage of study—eg numbers eligible, potentially examinedfor eligibility, An Explanation and Elaboration article discussesitem each checklist and gives backgroundmethodological and published examples of transparent reporting. The STROBE checklist is best used in this(freelywith conjunction available onarticle sites the Medicine of PLoS http://www.plosmedicine.org/,Web at Annals of Internal Medicine at http://www.annals.org/, http://www.epidem.com/).Epidemiology at and Information on InitiativeSTROBE the is www.strobe-statement.org.available at information*Give separately cases for and controls studiesin forcase-control applicable, if and, exposedunexposed and groups in cohort and studies.cross-sectional Note: Funding Other information Generalisability 21 Discuss(external generalisabilitythe of studythe validity) results Interpretation 20 cautious Give interpretationa of resultsoverall considering limitations, objectives, multiplicity of resultsanalyses, from Limitations Key Key results Discussion Other analyses 17 other Report analyses done—eg analyses of subgroups sensitivity interactions, and and analyses
Main resultsMain Outcome Outcome data 15* numbers Report of outcome events or summary measures
Descriptive data 14* characteristicsGive (a) participantsof study (eg demographic, social) clinical, and information on exposures potential and
Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open
Quality of Life and Loneliness among Older People in Liaoning Province, China: A Cross-Sectional Study
Journal: BMJ Open ManuscriptFor ID peerbmjopen-2018-021822.R2 review only Article Type: Research
Date Submitted by the 25-Jun-2018 Author:
Complete List of Authors: Zhu, Yaxin; China Medical University, Department of Social Medicine, School of Public Health Liu, Jie; China Medical University, Department of Health Statistics, School of Public Health Qu, Bo; China Medical University, Department of Health Statistics, School of Public Health Yi, Zhe; China Medical University, Department of Prothodontics, School of Stomatology
Primary Subject Public health Heading:
Secondary Subject Heading: Geriatric medicine http://bmjopen.bmj.com/
Keywords: quality of life, loneliness, older people
on September 30, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 1 of 16 BMJ Open
1 2 3 Quality of Life and Loneliness among Older People in Liaoning Province, China: 4 A Cross-Sectional Study 5 Yaxin Zhu1, Jie Liu2, Bo Qu2*, Zhe Yi3* 6 1 7 Department of Social Medicine, School of Public Health, China Medical University, 8 Shenyang, Liaoning Province, People’s Republic of China 9 2Department of Health Statistics, School of Public Health, China Medical University, 10 Shenyang, Liaoning Province, People’s Republic of China 11 3Department of Prothodontics, School of Stomatology, China Medical University, 12 13 Shenyang, Liaoning Province, People’s Republic of China 14 15 * Corresponding author: 16 Zhe Yi, DepartmentFor peer of Prothodontics, review School of Stomatology,only China Medical 17 18 University, No. 117 Nanjing North Street, Heping District, Shenyang 110001, 19 Liaoning Province, People’s Republic of China. 20 Tel: 86 13238866438 21 E mail: [email protected] (ZY) 22
23 24 Zhe Yi and Bo Qu contributed equally to this paper. 25 26 Keywords: quality of life; loneliness; older people 27 Word counts: 3613 28 29 30
31 http://bmjopen.bmj.com/ 32 33 34 35 36 37 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 2 of 16
1 2 3 4 Abstract 5 Objectives: The aim of the study was to learn more regarding loneliness, 6 7 health related characteristics, and quality of life (QOL) in a sample of older people 8 and to examine the relations among these variables. 9 Design: Cross sectional study. 10 Setting: Communities in Dandong city, Liaoning province, China. 11 Participants: Sample of 732 older people aged 60 and older who were living in 12 13 Dandong, Liaoning province, China. 14 Methods: A questionnaire was administered to the participants face to face. The 15 questionnaire contained four sections: demographic characteristics, heath information, 16 the EQ 5D scale,For and thepeer UCLA Loneliness review Scale. The t test,only F test, and multivariable 17 18 linear regression analyses were performed to individually test associations between 19 the demographic data, health related factors, loneliness, and QOL. 20 Results: Chronic diseases, loneliness, age, and smoking status were negatively 21 associated with QOL (p < 0.05). Satisfaction with health services, income, and 22 physical activity were positively associated with QOL (p < 0.05). 23 24 Conclusions: Loneliness was an important factor related to low QOL among older 25 people in China. The findings indicate that reducing loneliness may help to improve 26 the QOL for older people. 27 28 29 Strengths and limitations of this study 30 1. Hierarchical linear regression analysis was performed to provide a conceptual and
31 statistical mechanism for investigating and drawing conclusions regarding the http://bmjopen.bmj.com/ 32 different levels of associated factors (loneliness, heath related characteristics, and 33 demographic information) of QOL among older people. 34 35 36 2. A stratified random sampling design was used in this study to improve the sample’s 37 representativeness. 38
39 3. Standardized instruments (EQ 5D and UCLA) assessing the QOL and loneliness on September 30, 2021 by guest. Protected copyright. 40 were used to make the results more reliable. 41 42 4. This study was an observational investigation employing a cross sectional design to 43 44 explore the relation between QOL and loneliness, which may limit the ability to 45 confirm a causal relation. 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 3 of 16 BMJ Open
1 2 3 4 Introduction 5 The global population is ageing rapidly [1]. In 1950, only 8% of the global 6 7 population was ≥60 years of age [2]. The HelpAge Global Network 2015 review 8 reported that 12% of the global population was ≥60 years of age [3] and that by 2050, 9 this percentage would double [1,3]. The People’s Republic of China has the largest 10 population ≥60 years old (hereafter designated older people) in the world and in 2014 11 accounted for 14.4% of the total Chinese population [4]. The percentage of older 12 13 people in China is expected to reach 33.9% by 2050 [3]. In addition, the Chinese older 14 population currently constitutes one fifth of the total worldwide older people 15 population [2]. Notably, older people are more vulnerable to chronic diseases [5], and 16 given the rapidFor growth peer of the aging reviewpopulation, the prevalence only of chronic diseases is 17 18 expected to increase among older people [5]. Hence, the aging population should have 19 a profound impact on healthcare systems and economic growth in China and 20 worldwide [1,2]. 21 Maintaining older people’s good health positively impacts both them and society in 22 general, as the availability of human and social resources for the aged strongly 23 24 depends on their health status [1]. However, healthy aging involves more than the 25 absence of disease [1]. A report by the World Health Organization (WHO) has 26 suggested that improving quality of life (QOL) for older people should be the 27 outcome of realizing the policy framework of “active ageing” [6]. Adding “quality” to 28 29 older people’s life to improve their health, social function, independence, and activity 30 has become the goal of a prolonged life [7]. QOL is an assessment of health status
31 based on a medical model that reflects an individual’s physical, psychological, and http://bmjopen.bmj.com/ 32 sociological health [8]. In addition, it has been recommended that disease centred 33 curative health systems embrace integrated care focusing on the needs of older people 34 35 [1]. Thus, assessment of QOL is seen as an essential element in the care of older 36 people [9 11], and improving their QOL has become a prioritized element in their 37 medical care [6]. Identifying the factors associated with QOL is needed if new 38 interventions that will lead to improved QOL among older people are to be developed.
39 on September 30, 2021 by guest. Protected copyright. 40 Loneliness among older people is a common [12] and serious problem [13]. The 41 relation between loneliness and health has been recognized within the past decade, 42 with loneliness being related to adverse physical and mental health outcomes 43 [12,14,15]. A longitudinal cohort study found that the risk of Alzheimer disease was 44 more than twice that for older people who felt lonely compared with those who did 45 46 not [14]. In addition, loneliness may have deleterious effects on their psychological 47 states. A 5 year longitudinal study conducted among older male and female 48 Americans indicated that the degree to which the participants were lonely was 49 positively correlated with subsequent changes in their depressive states [15]. Another 50 51 study reported that lonely individuals were more likely to partake in health damaging 52 behaviours, e.g., physical inactivity [16]. 53 Although QOL, as a good measure of overall health, has also been reported to be 54 influenced by loneliness among older people in certain countries, such as Sweden [17] 55 and the Netherlands [18], the relation between QOL and loneliness among older 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 4 of 16
1 2 3 people in China has not been fully assessed to date [13]. Compared with these 4 developed countries, China has unique national conditions and culture. Due to recent 5 social and economic changes in China, younger people have migrated or emigrated to 6 7 relatively economically developed areas to seek employment and a better life [19]. 8 Also, China is a country that values the culture of collectivism and filial piety. Older 9 people are still expected to be provided with care by their children. Therefore, the 10 perception of the gap between expected and actual amounts of support that older 11 people received from their families would be stronger for older people [13]. This 12 13 perceived gap would be the reason why Chinese older people had serious problems of 14 loneliness. Emerson and colleagues suggested that early intervention regarding 15 loneliness might be able to decrease morbidity and mortality rates among older people 16 [20]. Hence,For the relation peer between QOL review and loneliness shouldonly be fully investigated to 17 18 provide implications for proposing new interventions on improving QOL among 19 Chinese older people. The purpose of the study described in this report was to learn 20 more concerning the loneliness, health related characteristics, and QOL in a sample of 21 older people and to examine the relations among these variables. 22 23 Materials and Methods 24 25 26 Ethics statement 27 The Bioethics Advisory Commission of the China Medical University approved 28 29 this study. The participants were informed regarding the purpose of the study and, 30 prior to the start of the study, were assured that their privacy would be protected. All
31 participants provided written informed consent before participating in the study. http://bmjopen.bmj.com/ 32 33 Study sample and procedures 34 35 Older age is generally defined in relation to retirement from paid employment and 36 receipt of pensions [21]. The age of 60 is roughly equivalent to retirement ages in 37 China. In this study, 60 years of age was chosen as the cut off point for defining older 38 people. This study employed a cross sectional design with a stratified random
39 on September 30, 2021 by guest. Protected copyright. 40 sampling method on older people of age ≥60 years in Dandong city, Liaoning 41 province. Compared with other cities in China, Dandong has more older people. In 42 2014, those aged ≥60 years accounted for 21.6% of the Dandong population, and this 43 percentage ranked third in Liaoning province. 44 Dandong has six districts. One community in each district was randomly selected to 45 46 achieve the required sample size, which was determined by the criterion that the 47 sample size should be 20 times the number of variables. In this study, the 48 questionnaire contained 36 variables, and the required sample size was 720. Inclusion 49 criteria were age ≥60 years, residence in Dandong, having provided the written 50 51 informed consent, and ability to understand the questionnaire and communicate. 52 Those who refused to participate in the study were excluded. Additionally, older 53 people who were determined by the clinician to have severe physical conditions 54 affecting daily life and unsuitable to take part in the study were also excluded. During 55 this survey, a questionnaire was administered by face to face interview by trained 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 5 of 16 BMJ Open
1 2 3 investigators with the participants from February 2017 to July 2017. If the participants 4 had any problem with completing the survey, the investigators assisted them. 5 In total, 784 eligible participants were approached in this survey, and 764 6 7 completed the questionnaires (completion rate 97.4%). When a participant did not 8 answer >20% of the questions, the associated questionnaire was not included in the 9 study. After exclusion of 32 invalid questionnaires, 732 questionnaires were identified 10 as valid. 11 12 Measurements 13 14 The questionnaire contained four sections: demographic characteristics, 15 heath related information, and the EQ 5D and the UCLA Loneliness scales. The 16 demographicFor characteristics peer were age,review gender, marital only status, education, monthly 17 18 income, place of residence (urban or rural), and living arrangement (empty or 19 non empty nester). Empty nesters were older people who never had children or whose 20 children had left home such that empty nesters were defined as those living alone or 21 with only a spouse [22]. 22 Health related information consisted of smoking status, physical activity status, 23 24 chronic disease status, and satisfaction with health services. To assess the level of 25 physical activity, participants were asked if they exercised at least six times a week 26 [23]. Respondents were defined as having a chronic disease(s) if they had been 27 diagnosed by a health professional(s). Satisfaction with health services was evaluated 28 29 using one item from WHOQOL BREF [24], in which respondents rated the scale 30 from 1 (very dissatisfied) to 5 (very satisfied).
31 The EQ 5D was used to evaluate QOL of the participants, which is a generic tool http://bmjopen.bmj.com/ 32 developed by the EuroQol Group [25]. The EQ 5D contains five items covering 33 different dimensions (mobility, self care, usual activities, pain/discomfort, and 34 35 anxiety/depression). Each item has three possible responses (no problem, moderate 36 problem, or extreme problem). A single EQ 5D summary index score ranging from 37 –0.149 to 1.0 was calculated using the Chinese time trade off model [25]. Higher 38 values implied better QOL. In addition, the EQ 5D also contains the visual analogue
39 on September 30, 2021 by guest. Protected copyright. 40 scale (VAS). The VAS was used to assess the respondents’ own perceptions of their 41 health status on a scale of 0 (worst) to 100 (best). The EQ 5D has been shown to be 42 applicable in China for Chinese older people [23,26 28]. The reliability of the EQ 5D 43 for our study was acceptable with a Cronbach’s alpha of 0.82. 44 Loneliness in older people was assessed with the use of the UCLA Loneliness Scale 45 46 [29], which has 20 items rated on a 1 to 4 point, Likert type scale. The total UCLA 47 score ranges from 20 to 80, with greater scores defining greater degrees of loneliness. 48 The scale ranges are the following: 20–34, a low loneliness level; 35–49, a moderate 49 loneliness level; 50–64, a moderately high loneliness level; and 65–80, a high 50 51 loneliness level [29]. We found the scale to be reliable, as the Cronbach’s alpha was 52 0.84. 53 54 Statistical Analyses 55 The Student’s t test, F test, and hierarchical linear regression analysis were 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 6 of 16
1 2 3 performed to determine the association between QOL and the demographic data, 4 health related factors, and the UCLA Loneliness scale. In Block 1, demographic 5 characteristics (age, gender, marital status, education, monthly income, place of 6 7 residence, and living arrangement) were included in the model. Health related 8 characteristics (smoking status, physical activity status, chronic disease status, and 9 satisfaction with health services) were added in Block 2. In Block 3, loneliness was 10 added. Variances of QOL explained by different groups of independent variables were 11 examined by △R2 (R squared change). Data were analysed using SPSS version 21.0 12 13 (SPSS Inc., Chicago, IL, USA) for Windows. A p value < 0.05 was considered to be 14 statistically significant. 15 16 Patient andFor public peer involvement review only 17 18 No participating older people were involved in setting the research questions or the 19 outcome measures, nor were they involved in developing plans for the design or 20 implementation of the study. The participants were informed that the results were to 21 be published in an open access journal. 22 23 Results 24 25 26 Participant Characteristics 27 The demographic characteristics of the participants are described in Table 1. A total 28 29 of 375 women (51.2%) and 357 men (48.8%) participated in the study. Their ages 30 ranged from 60 to 96 years with a mean age of 71.34 ± 7.73 years (standard deviation);
31 241 of the participants (32.9%) lived in rural areas. Approximately one half of the http://bmjopen.bmj.com/ 32 participants (341, 46.6%) were empty nesters. The F or t tests revealed that there 33 were significant differences in the QOL scores for participants of different ages, 34 35 residences, living arrangements, monthly incomes, and education levels (p < 0.05). 36 Participants who were younger, lived in an urban area, or were not empty nesters had 37 higher QOL scores (Table 1). 38 Table 1. Relationship between demographic characteristics and QOL (N = 732).
39 on September 30, 2021 by guest. Protected copyright. 40 Variable Number of EQ 5D F/t 41 participants index score 42 (%) 43 Ageb 44 60–69 289 (39.5%) 0.95 ± 0.10 8.149** 45 46 70–79 345 (47.1%) 0.92 ± 0.12 47 ≥80 98 (13.4%) 0.90 ± 0.15 48 Gendera 49 Male 357 (48.8%) 0.93 ± 0.12 0.301 50 51 Female 375 (51.2%) 0.93 ± 0.12 52 Residencea 53 Rural 241 (32.9%) 0.92 ± 0.12 –2.333* 54 Urban 491 (67.1%) 0.94 ± 0.12 55 Living arrangementa 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 7 of 16 BMJ Open
1 2 3 Empty nester 341 (46.6%) 0.92 ± 0.13 2.221* 4 Non empty nester 391 (53.4%) 0.94 ± 0.11 5 b Marital status 6 7 Single 18 (2.4%) 0.97 ± 0.10 2.304 8 Married 688 (94.0%) 0.93 ± 0.12 9 Divorced/Widowed 26 (3.6%) 0.89 ± 0.14 10 Monthly incomeb 11 <2000 367 (50.1%) 0.90 ± 0.14 21.722** 12 13 2000–3000 194 (26.5%) 0.95 ± 0.08 14 >3000 171 (23.4%) 0.97 ± 0.09 15 Educationb 16 PrimaryFor school peer or below review323 (44.1%) 0.92 only± 0.13 3.236* 17 18 Junior high school 294 (40.2%) 0.95 ± 0.10 19 Senior high school 89 (12.2%) 0.94 ± 0.11 20 College and above 26 (3.5%) 0.92 ± 0.12 21 at test; bF test; *p < 0.05; **p < 0.01 22 23 Regarding health related characteristics (Table 2), the majority of the participants 24 (559, 76.4%) suffered from a chronic disease(s), and approximately one half (436, 25 59.5%) were satisfied or very satisfied with the health services that they received. For 26 the heath related characteristics, the F or t tests results showed that significant 27 differences existed in the QOL scores as related to chronic disease status, smoking 28 29 status, physical activity, and satisfaction with health services (p < 0.05). The 30 participants who had a chronic disease(s), smoked, were not physically active, or were
31 dissatisfied with their health services had lower QOL scores (Table 2). http://bmjopen.bmj.com/ 32 Table 2. Relationship between health-related characteristics and QOL (N = 732). 33 34 Variable Number of EQ 5D index F/t 35 participants score 36 (%) 37 Chronic diseasea 38 Yes 559 (76.4%) 0.87 ± 0.15 –7.158**
39 on September 30, 2021 by guest. Protected copyright. 40 No 173 (23.6%) 0.95 ± 0.10 41 Smoking statusa 42 Yes 220 (30.1%) 0.92 ± 0.13 –1.984* 43 No 512 (69.9%) 0.94 ± 0.11 44 a 45 Physical activity 46 No 633 (86.5%) 0.93 ± 0.12 –2.631** 47 Yes 99 (13.5%) 0.95 ± 0.09 48 Health servicesb 49 Very dissatisfied 20 (12.7%) 0.83 ± 0.21 29.230** 50 51 Dissatisfied 53 (22.3%) 0.86 ± 0.14 52 Neither satisfied nor 223 (15.5%) 0.89 ± 0.13 53 dissatisfied 54 Satisfied 353 (38.2%) 0.96 ± 0.08 55 56 Very satisfied 83 (11.3%) 0.97 ± 0.09 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 8 of 16
1 2 3 at test; bF test; *p < 0.05; **p < 0.01 4 5 QOL 6 7 The mean EQ 5D index score for the participants was 0.93 ± 0.12 (range, 8 0.22–1.00). The mean VAS score was 81.25 ± 14.38 (range, 0–100). The distribution 9 of the EQ 5D scale scores is presented in Table 3. The most prevalent health related 10 problem reported by the participants was pain/discomfort (196, 26.8% had moderate 11 or extreme pain/discomfort). 12 N 13 Table 3. Distribution of EQ-5D index score ( = 732). 14 Dimension No problem Moderate problem Extreme problem 15 Mobility 678 (92.6%) 53 (7.2%) 1 (0.1%) 16 Self careFor peer713 (97.4%) review 14 (1.9%) only5 (0.7%) 17 18 Usual activities 677 (92.5%) 55 (7.5%) 0 (0%) 19 Pain/discomfort 536 (73.2%) 193 (26.4%) 3 (0.4%) 20 Anxiety/depression 610 (83.3%) 121 (16.5%) 1 (0.1%) 21 22 Loneliness 23 24 The mean UCLA loneliness score was 40.73 ± 8.73 (range, 20–64). According to 25 their loneliness scores, 547 participants (74.7%) had a moderate or a moderately high 26 loneliness score (Table 4). A significant difference was found for the QOL scores for 27 groups with different degrees of loneliness (p = 0.00). Participants with moderately 28 29 high loneliness scores had lower QOL scores (0.86 ± 0.17) compared with 30 participants in the other two groups. The relationships between their QOL and
31 loneliness scores are listed in Table 4. http://bmjopen.bmj.com/ 32 Table 4. Relationship between loneliness and QOL (N = 732). 33 34 Loneliness level Number of EQ 5D index F 35 participants score 36 (%) 37 Low 185 (25.3%) 0.97 ± 0.07 33.889** 38 Moderate 449 (61.3%) 0.93 ± 0.11
39 on September 30, 2021 by guest. Protected copyright. 40 Moderately high 98 (13.4%) 0.86 ± 0.17 41 **p < 0.01 42 43 Relation between the demographic data, health-related 44 45 46 factors, loneliness, and QOL 47 Hierarchical linear regression analyses of the factors associated with QOL are 48 presented in Table 5. In Block 1, age, income, education, living arrangement, and 49 50 marital status were significantly associated with QOL (p < 0.05). When health related 51 characteristics were added in Block 2, age, income, chronic disease(s), health service 52 satisfaction, smoking and physical activity were significantly associated with QOL (p 53 < 0.05). In Block 3, among these demographic and health related characteristics, 54 having a chronic disease(s), age of the participant, and smoking were negatively 55 56 associated with QOL (p < 0.05), with chronic disease having standardized coefficients 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 9 of 16 BMJ Open
1 2 3 of 0.234. Satisfaction with health services, higher income, and being physically 4 active were positively associated with the QOL of the participants (p < 0.05). In 5 addition, loneliness was significantly and negatively associated with QOL 6 7 (level = moderate: β = 0.190, p < 0.05; level = moderately high: β = 0.260, p < 0.05; 8 reference group: level = low). Loneliness explained 5.2% of the variance of QOL. 9 Table 5. Hierarchical linear regression analyses of the factors associated with QOL (N = 10 732). 11 Factor Block 1 (β) Block 2 (β) Block 3 (β) 12 a 13 Age 14 70–79 0.081* 0.074* 0.079* 15 ≥80 0.077 .043 0.050 16 Incomeb For peer review only 17 18 2000–3000 0.157* 0.094* 0.097* 19 >3000 0.205* 0.108* 0.103* 20 Gender Female 0.009 .048 0.045 21 Educationc 22 23 Junior high school 0.083* 0.037 0.034 24 Senior high school 0.052 0.027 0.031 25 College and above 0.012 0.028 0.031 26 Residence Urban 27 0.061 0.021 0.002 28 Living arrangement Empty nester 0.086* 0.061 0.030 29 Marital statusd 30 Married 0.079 0.064 0.057
31 http://bmjopen.bmj.com/ Divorced/Widowed 32 0.109* 0.066 0.054 33 Chronic disease Yes 0.239* 0.234* 34 Health service satisfactione 35 Dissatisfied 0.088 0.086 36 Neither satisfied nor dissatisfied 0.225* 0.196* 37 38 Satisfied 0.524* 0.453*
39 Very satisfied 0.307* 0.258* on September 30, 2021 by guest. Protected copyright. 40 Smoking Yes 0.116* 0.110* 41 Physical activity Yes 0.078* 0.078* 42 f 43 Loneliness 44 Moderate 0.190* 45 Moderately high 0.260* 46 F 6.007 12.874 15.246 47 2 48 R 0.091 0.256 0.308 2 49 △R 0.091 0.165 0.052 50 *p < 0.05; **p < 0.01; β, standardized regression coefficient 51 a: reference group = 60 69; b: reference group = <2000; c: reference group = primary school or 52 53 below; d: reference group = Single; e: reference group = very dissatisfied; f: reference group = 54 low. 55 56 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 10 of 16
1 2 3 4 Discussion 5 This study contributed to our knowledge concerning the relationship between QOL 6 7 and loneliness among older people living in Dandong city, Liaoning province, China. 8 Our results indicated that the pain/discomfort facet of QOL was the most prevalent 9 problem among the participants. This finding is in line with previous studies on 10 Chinese [26,27] and Vietnamese older people [30]. One population based study 11 revealed that more than one half of older Americans had been bothered by pain in the 12 13 month prior to being questioned [31]. The older people often experience chronic pain 14 [32], which is a disability that can cause decreased mobility and depression [31]. 15 These factors may increase healthcare costs and may decrease productivity [32]. 16 Bhattarai andFor colleagues peer suggested review that cost efficient only intervention strategies for 17 18 management of the pain in the older population should be a priority for healthcare 19 providers [32]. 20 We found loneliness to be significantly correlated with the QOL of our participants, 21 and those who had a greater degree of loneliness also reported a poorer QOL. 22 Loneliness may impair the immune and cardiovascular systems [12]. The negative 23 24 effects of loneliness on the physical and psychological health of the older people have 25 been widely documented [12,15]. Lonely individuals are also more likely to engage in 26 behaviour that results in poor health outcomes [16]. These factors may all contribute 27 to and impair QOL for older people [9]. We found that 74.7% of our participants 28 29 experienced a moderate or moderately high level of loneliness. The prevalence of 30 loneliness found by us is comparable with that found for older people in other Chinese
31 cities, such as Shanghai [9,29], but is considerably greater than that reported in the http://bmjopen.bmj.com/ 32 developed country Finland [33]. The substantial social and economic changes 33 occurring in China along with the increase in the number of older people increases the 34 35 likelihood that more older people will be lonely [19,29]. Therefore, there is an urgent 36 need to perform interventions that will mitigate their loneliness [9]. 37 Consistent with other studies [34,35], suffering from a chronic disease(s) was an 38 important risk factor for QOL among older people. Monitoring and ameliorating a
39 on September 30, 2021 by guest. Protected copyright. 40 chronic disease may reduce its negative impact on the QOL of the older population[2]. 41 However, representative data from six countries, including China, have indicated that 42 effective healthcare coverage among older people with chronic diseases is between 43 20.7% and 48.2% [36]. Given the continuous nature of chronic care, it should be more 44 effective to provide the older people with healthcare services in community based 45 46 settings, e.g., primary healthcare centres [2]. The WHO study also urged that 47 permanent mechanisms be established that would expand healthcare coverage for 48 older people with chronic conditions [36,37]. 49 We found that the QOL of our participants was positively correlated with their 50 51 satisfaction with health services, which is consistent with the results of a related study 52 [8]. The older people who are more satisfied with their health services are more prone 53 to regard the healthcare they receive as effective and hence adhere to the 54 recommended treatment(s), which consequently may further improve their physical 55 and mental health [8]. This finding may explain why the older people who reported a 56 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 11 of 16 BMJ Open
1 2 3 greater degree of satisfaction with their healthcare also reported a better QOL. 4 However, only half of our participants (49.5%) were satisfied or very satisfied with 5 their health services. Poor quality, high costs, and poor accessibility to healthcare may 6 7 be reasons for dissatisfaction with health services in China [9,38]. 8 Our study had several limitations. First, the study was conducted in only one 9 Chinese city, which may partly limit representation of Chinese older people. 10 Additional studies in other areas of China will help determine whether our findings 11 can be generalized. Second, this study employed a cross sectional design, which may 12 13 limit the ability to confirm a causal relation between QOL and loneliness. A future 14 study, applying a more effective design, such as a case controlled design or cohort 15 design, should be conducted to establish the casual relation between loneliness and 16 QOL. Last, For the unique peer use of a self reportreview response only may cause bias, such as a 17 18 consistency motif, acquiescence bias, and social desirability. The two primary ways to 19 control for these method biases through the design of the study’s procedures and 20 statistical controls should be undertaken in future research [39]. In addition, our study 21 identified multiple factors that may influence QOL in older people; these factors can 22 be addressed separately and in depth in the future. 23 24 25 Conclusions 26 Our study provides information regarding the QOL and loneliness of Chinese older 27 people and demonstrated that loneliness is a crucial problem facing the elderly. This 28 29 study indicated that loneliness was negatively associated with QOL among older 30 people. To address the findings of this study, it is suggested that we may need to be
31 aware of the loneliness of older people and take action to minimize loneliness and http://bmjopen.bmj.com/ 32 improve QOL. 33 34 Acknowledgments 35 36 The authors wish to thank Xia Min for help with sample collection. We thank all of 37 the participants in this study. 38
39 Competing Interests on September 30, 2021 by guest. Protected copyright. 40 41 The authors declare that they have no competing interests. 42 43 Funding 44 This work was supported by the National Natural Science Foundation of China, grant 45 46 number 71473269 and 71673301. The funders had no role in study design, data 47 collection and analysis, decision to publish, or preparation of the manuscript. 48 49 50 Authors’ contributions 51 52 YZ wrote the manuscript. YZ and JL participated in the data collection and analysis. 53 54 ZY collected the data. ZY and BQ designed the study and revised the manuscript. BQ 55 obtained funding. All authors read and approved the final manuscript. 56 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 12 of 16
1 2 3 4 Ethics approval 5 Ethical protocol was obtained from the Bioethics Advisory Commission of China 6 7 Medical University. All participants provided written informed consent before 8 participating in the study. 9 10 Data sharing statement 11 No additional unpublished data. 12 13 14 References 15 1. World Health Organization. WHO World Report on Health and Ageing, 2015. 16 Accessed in For10 Oct 2017. peer review only 17 18 http://101.96.8.164/apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng. 19 pdf?ua=1. 20 2. Shanghai Municipal Center for Disease Control & Prevention (SCDC). Study on 21 global AGEing and Adult Health Wave 1 China National Report (2012). Accessed in 22 01 Oct 2017. 23 24 https://www.researchgate.net/publication/277305920_China_Study_on_global_AGEi 25 ng_and_adult_health_SAGE_Wave_1_National_Report. 26 3. HelpAge International. HelpAge International Annual review 2015 (2015). 27 Retrieved online 08 Oct 2017. 28 29 http://www.helpage.org/who we are/annual review 2015/#looking forward. 30 4. HelpAge International. Global Age Watch Index (2014). Retrieved online 14 Oct
31 2017. http://www.helpage.org/global agewatch/about/about global agewatch/. http://bmjopen.bmj.com/ 32 5. Wang Z, Li X, Chen M. Catastrophic health expenditures and its inequality in 33 elderly households with chronic disease patients in China. Int J Equity Health 34 35 2015;14:8. 36 6. World Health Organization. Active ageing: a policy framework (2002). Accessed in 37 01 Oct 2017. 38 http://apps.who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf.
39 on September 30, 2021 by guest. Protected copyright. 40 7. Ann B. The psychometric properties of the older people’s quality of life 41 questionnaire, compared with the CASP 19 and the WHOQOL OLD. Curr Gerontol 42 Geriatr Res 2009;2009(2):298950. 43 8. Zhang Y, Zhou Z, Gao J, et al. Health related quality of life and its influencing 44 factors for patients with hypertension: evidence from the urban and rural areas of 45 46 Shaanxi Province, China. BMC Health Serv Res 2016;16:277. 47 9. Chen Y, Hicks A, While AE. Quality of life and related factors: a questionnaire 48 survey of older people living alone in Mainland China. Qual Life Res 49 2014;23(5):1593 602. 50 51 10. Bélanger E, Ahmed T, Vafaei A, et al. Sources of social support associated with 52 health and quality of life: a cross sectional study among Canadian and Latin American 53 older adults. BMJ Open 2016;6(6):e011503. 54 11. Cerin E, Sit CH, Zhang CJ, et al. Neighbourhood environment, physical activity, 55 quality of life and depressive symptoms in Hong Kong older adults: a protocol for an 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 13 of 16 BMJ Open
1 2 3 observational study. BMJ Open 2016;6(1):e010384. 4 12. Luanaigh CO, Lawlor BA. Loneliness and the health of older people. Int J Geriatr 5 Psychiatry 2008;23(12):1213 21. 6 7 13. Liu LJ, Guo Q. Loneliness and health related quality of life for the empty nest 8 elderly in the rural area of a mountainous county in China. Qual Life Res 9 2007;16(8):1275 80. 10 14. Wilson RS, Krueger KR, Arnold SE, et al. Loneliness and risk of Alzheimer 11 disease. Arch Gen Psychiatry 2007;64(2):234 40. 12 13 15. Cacioppo JT, Hawkley LC, Thisted RA. Perceived social isolation makes me sad: 14 5 year cross lagged analyses of loneliness and depressive symptomatology in the 15 Chicago Health, Aging, and Social Relations Study. Psychol Aging 16 2010;25(2):453 63.For peer review only 17 18 16. Hawkley LC, Thisted RA, Cacioppo JT. Loneliness predicts reduced physical 19 activity: cross sectional & longitudinal analyses. Health Psychol 2009;28(3):354 63. 20 17. Jakobsson U, Hallberg IR. Loneliness, fear, and quality of life among elderly in 21 Sweden: a gender perspective. Aging Clin Exp Res 2005;17(6):494 501. 22 18. Ilona V, Ros Wynand J G, Bas S, de Wit NJ. Ethnicity does not account for 23 24 differences in the health related quality of life of Turkish, Moroccan, and Moluccan 25 elderly in the Netherlands. Health Qual Life Outcomes 2014;12(1):138. 26 19. Chen Y, Hicks A, While AE. Loneliness and social support of older people in 27 China: a systematic literature review. Health Soc Care Community 28 29 2014;22(2):113 123. 30 20. Emerson KG, Jayawardhana J. Risk Factors for Loneliness in Elderly Adults. J
31 Am Geriatr Soc 2016;64(4):886 7. http://bmjopen.bmj.com/ 32 21. World Health Organization. Definition of an older or elderly person, 2010. 33 Accessed in 06 Jun 2018. 34 35 http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html 36 22. Cheng P, Jin Y, Sun H, et al. Disparities in prevalence and risk indicators of 37 loneliness between rural empty nest and non empty nest older adults in Chizhou, 38 China. Geriatr Gerontol Int 2015;15(3):356 64.
39 on September 30, 2021 by guest. Protected copyright. 40 23. Tan Z, Liang Y, Liu S, et al. Health related quality of life as measured with EQ 5D 41 among populations with and without specific chronic conditions: a population based 42 survey in Shaanxi Province, China. PLoS One 2013;8(7):e65958. 43 24. The WHOQOL Group. Development of the World Health Organization 44 WHOQOL BREF quality of life assessment. Psychol Med 1998;28:551 8. 45 46 25. Liu GG, Wu H, Li M, et al. Chinese time trade off values for EQ 5D health states. 47 Value Health 2014;17(5):597 604. 48 26. Sun S, Chen J, Johannesson M, et al. Regional differences in health status in 49 China: population health related quality of life results from the National Health 50 51 Services Survey 2008. Health Place 2011;17(2):671 80. 52 27. Zhang T, Shi W, Huang Z, et al. Influence of culture, residential segregation and 53 socioeconomic development on rural elderly health related quality of life in Guangxi, 54 China. Health Qual Life Outcomes 2016;14:98. 55 28. Deng X, Dong P, Zhang L, et al. Health related quality of life in residents aged 18 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 14 of 16
1 2 3 years and older with and without disease: findings from the First Provincial Health 4 Services Survey of Hunan, China. BMJ Open 2017;7(9):e015880. 5 29. Chen Y, Hicks A, While AE. Loneliness and social support of older people living 6 7 alone in a county of Shanghai, China. Health Soc Care Community 8 2014;22(4):429 38. 9 30. Hoi le V, Chuc NT, Lindholm L. Health related quality of life, and its 10 determinants, among older people in rural Vietnam. BMC Public Health 2010;10:549. 11 31. Patel KV, Guralnik JM, Dansie EJ, et al. Prevalence and impact of pain among 12 13 older adults in the United States: findings from the 2011 National Health and Aging 14 Trends Study. Pain 2013;154(12):2649 57. 15 32. Bhattarai P, Phillips JL. The role of digital health technologies in management of 16 pain in olderFor people: An peer integrative review.review Arch Gerontol only Geriatr 2017;68:14 24. 17 18 33. Routasalo PE, Savikko N, Tilvis RS, et al. Social contacts and their relationship to 19 loneliness among aged people a population based study. Gerontology 20 2006;52(3):181 7. 21 34. Venturelli M, Cè E, Limonta E, et al. Effects of endurance, circuit, and relaxing 22 training on cardiovascular risk factors in hypertensive elderly patients. Age (Dordr) 23 24 2015;37(5):101. 25 35. Cadore EL, Izquierdo M. Exercise interventions in polypathological aging patients 26 that coexist with diabetes mellitus: improving functional status and quality of life. Age 27 (Dordr) 2015;37(3):64. 28 29 36. Goeppel C, Frenz P, Tinnemann P, et al. Universal health coverage for elderly 30 people with non communicable diseases in low income and middle income countries:
31 a cross sectional analysis. Lancet 2014;384:S6. http://bmjopen.bmj.com/ 32 37. Trivedi AN, Moloo H, Mor V. Increased ambulatory care copayments and 33 hospitalizations among the elderly. N Engl J Med 2010;362(4): 320 8. 34 35 38. Eggleston K, Ling L, Qingyue M, et al. Health service delivery in China: a 36 literature review. Health Econ 2008;17(2):149 65. 37 39. Podsakoff PM, Mackenzie SB, Lee JY, et al. Common method biases in 38 behavioral research: a critical review of the literature and recommended remedies. J
39 on September 30, 2021 by guest. Protected copyright. 40 Appl Psychol 2003;88(5):879 903. 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from NA 4 4 5 5 1 1
NA 4,5 4,5 4 4 NA 4 4 4 4
3,4 3,4 3 3
4,5 4,5 4,5 4,5 NA Reported on page # Reported on page 2 2 4 4
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only ) Indicate study’s) the designcommonlywith used a in term ortitlethe abstract the ) ) theGive eligibility criteria, and sourcesthe methodsand of of selection participants ) ) statisticalDescribe all methods, thoseincluding confoundingusedforcontrol to ) ) Describe any methods used subgroups examine to interactionsand ) If ) applicable, describe methodsanalytical taking account of sampling strategy ) ) in theProvide abstract informativean and balanced summary of what was donewhat wasand found ) Describe) sensitivity any analyses ) how Explain missing data were addressed a a a b e d c b For eachof interest, For variable sourcesdatagive of and details of methods of assessment (measurement). Describe comparability of of comparability assessment methods isthanthere more if one group ( ( why why
applicable collection collection ( ( ( ( Recommendation cross-sectional studies of cross-sectional reports in be included should that items of Statement—Checklist (v4) 2007 STROBE
6 1 ( 3 specific objectives, State including prespecified any hypotheses 5 the setting, Describe locations, relevantand dates, including periods exposure,of recruitment, follow-up, data and 9 any Describe efforts to address sourcespotential of bias 7 define Clearly outcomes,all exposures,predictors, potential confounders,effect and modifiers. diagnostic Give criteria, if 4 key Present of studyelements in thedesign early paper 8* 10 10 how Explain studythe size was arrived at # Item Item Results
Statistical Statistical methods 12 ( Quantitative variables 11 how Explain quantitative were handledvariables in analyses.the If applicable, describe which chosengroupings were and Study size Bias Data sources/Data measurement Variables Participants Setting Study design Methods Objectives Background/rationale 2 thebackground Explain scientific for rationale investigation the and being reported Introduction Title andTitle abstract Section/Topic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 15 of 16 BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 16 of 8,9 8,9 5-7 5-7 NA
8,9 8,9 9 9 8 8
5-8 5-8 NA NA 4 4 5-8 5-8 5-8 5-8 10 10 NA NA
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright.
For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml ) Report) boundaries category when continuous variables were categorized ) ) unadjustedGive estimates if applicable, and, confounder-adjusted estimates their and precision95% (eg, confidence ) If ) relevant, If consider translating estimatesrelativerisk of into absolute for risk meaningfulperioda time c b a similar studies,similar and other relevant evidence confounders magnitude of magnitude potential biasany confirmed eligible,confirmed included in study, the completing follow-up, analysed and interval). Make interval). clear confounderswhich were adjusted they why and for were included which the presentthe which is based article
( ( number Indicate (b) of participants missingwith eachfor data of interest variable Consider (c) diagram use flow of a reasons Give (b) non-participationfor each at stage 18 18 results Summarise key to reference withstudy objectives 16 16 ( 22 22 sourcethe Give of funding and role the of fundersthe thefor studypresent if and, applicable, originalthe for study on 19 19 Discuss of study, the takinglimitations into sourcesaccount biasof potential imprecision.or Discussboth direction and 13* 13* Report (a) numbers of individuals each at stage of study—eg numbers eligible, potentially examinedfor eligibility, An Explanation and Elaboration article discussesitem each checklist and gives backgroundmethodological and published examples of transparent reporting. The STROBE checklist is best used in this(freelywith conjunction available onarticle sites the Medicine of PLoS http://www.plosmedicine.org/,Web at Annals of Internal Medicine at http://www.annals.org/, http://www.epidem.com/).Epidemiology at and Information on InitiativeSTROBE the is www.strobe-statement.org.available at information*Give separately cases for and controls studiesin forcase-control applicable, if and, exposedunexposed and groups in cohort and studies.cross-sectional Note: Funding Other information Generalisability 21 Discuss(external generalisabilitythe of studythe validity) results Interpretation 20 cautious Give interpretationa of resultsoverall considering limitations, objectives, multiplicity of resultsanalyses, from Limitations Key Key results Discussion Other analyses 17 other Report analyses done—eg analyses of subgroups sensitivity interactions, and and analyses
Main resultsMain Outcome Outcome data 15* numbers Report of outcome events or summary measures
Descriptive data 14* characteristicsGive (a) participantsof study (eg demographic, social) clinical, and information on exposures potential and
Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open
Quality of Life, Loneliness, and Health-related Characteristics among Older People in Liaoning Province, China: A Cross-Sectional Study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-021822.R3
Article Type: Research
Date Submitted by the 09-Aug-2018 Author:
Complete List of Authors: Zhu, Yaxin; China Medical University, Department of Social Medicine, School of Public Health Liu, Jie; China Medical University, Department of Health Statistics, School of Public Health Qu, Bo; China Medical University, Department of Health Statistics, School of Public Health Yi, Zhe; China Medical University, Department of Prothodontics, School of Stomatology
Primary Subject Public health
Heading: http://bmjopen.bmj.com/
Secondary Subject Heading: Geriatric medicine
Keywords: quality of life, loneliness, older people
on September 30, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 1 of 16 BMJ Open
1 2 3 Quality of Life, Loneliness, and Health-related Characteristics among Older 4 People in Liaoning Province, China: A Cross-Sectional Study 5 Yaxin Zhu1, Jie Liu2, Bo Qu2*, Zhe Yi3* 6 1 7 Department of Social Medicine, School of Public Health, China Medical University, 8 Shenyang, Liaoning Province, People’s Republic of China 9 2Department of Health Statistics, School of Public Health, China Medical University, 10 Shenyang, Liaoning Province, People’s Republic of China 11 3Department of Prothodontics, School of Stomatology, China Medical University, 12 13 Shenyang, Liaoning Province, People’s Republic of China 14 15 * Corresponding author: 16 Zhe Yi, DepartmentFor peer of Prothodontics, review School of Stomatology,only China Medical 17 18 University, No. 117 Nanjing North Street, Heping District, Shenyang 110001, 19 Liaoning Province, People’s Republic of China. 20 Tel: 86-13238866438 21 E-mail: [email protected] (ZY) 22
23 24 Zhe Yi and Bo Qu contributed equally to this paper. 25 26 Keywords: quality of life; loneliness; older people 27 Word counts: 3000 28 29 30
31 http://bmjopen.bmj.com/ 32 33 34 35 36 37 38
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 2 of 16
1 2 3 4 Abstract 5 Objectives: The aim of the study was to examine the relations among quality of life 6 7 (QOL), loneliness, and health-related characteristics in a sample of Chinese older 8 people. 9 Design: Cross-sectional study. 10 Setting: Communities in Dandong city, Liaoning province, China. 11 Participants: Sample of 732 older people aged 60 and older who were living in 12 13 Dandong, Liaoning province, China. 14 Methods: A questionnaire was administered to the participants face-to-face. The 15 questionnaire contained four sections: demographic characteristics, health-related 16 characteristics,For the EQ-5D peer scale, and review the UCLA Loneliness only Scale. The t-test, F-test, 17 18 and multivariable linear regression analyses were performed to individually test 19 associations between the demographic data, health-related characteristics, loneliness, 20 and QOL. 21 Results: Chronic diseases, loneliness, age, and smoking status were negatively 22 associated with QOL (p < 0.05). Satisfaction with health services, income, and 23 24 physical activity were positively associated with QOL (p < 0.05). 25 Conclusions: Loneliness, chronic diseases, and health service satisfaction were 26 important factors related to low QOL among older people in China. The findings 27 indicate that reducing loneliness, managing chronic diseases, and improving the 28 29 health service may help to improve the QOL for older people. 30
31 Strengths and limitations of this study http://bmjopen.bmj.com/ 32 1. Hierarchical linear regression analysis was performed to provide a conceptual and 33 statistical mechanism for investigating and drawing conclusions regarding the 34 35 different levels of associated factors (loneliness, heath-related characteristics, and 36 demographic characteristics) of QOL among older people. 37 38 2. A stratified random sampling design was used in this study to improve the sample’s
39 representativeness. on September 30, 2021 by guest. Protected copyright. 40 41 3. Standardized instruments (EQ-5D and UCLA) assessing the QOL and loneliness 42 43 were used to make the results more reliable. 44 45 4. This study was an observational investigation employing a cross-sectional design to 46 explore the relation between QOL and loneliness, which may limit the ability to 47 confirm a causal relation. 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 3 of 16 BMJ Open
1 2 3 4 Introduction 5 The global population is ageing rapidly [1]. In 1950, only 8% of the global 6 7 population was ≥60 years of age [2]. The HelpAge Global Network 2015 review 8 reported that 12% of the global population was ≥60 years of age [3] and that by 2050, 9 this percentage would double [1,3]. The People’s Republic of China has the largest 10 population ≥60 years old (hereafter designated older people) in the world and in 2014 11 accounted for 14.4% of the total Chinese population [4]. The percentage of older 12 13 people in China is expected to reach 33.9% by 2050 [3]. In addition, the Chinese older 14 population currently constitutes one-fifth of the total worldwide older people 15 population [2]. Notably, older people are more vulnerable to chronic diseases [5], and 16 given the rapidFor growth peer of the aging reviewpopulation, the prevalence only of chronic diseases is 17 18 expected to increase among older people [5]. Hence, the aging population should have 19 a profound impact on healthcare systems and economic growth in China and 20 worldwide [1,2]. 21 Maintaining older people’s good health positively impacts both them and society in 22 general, as the availability of human and social resources for the aged strongly 23 24 depends on their health status [1]. However, healthy aging involves more than the 25 absence of disease [1]. A report by the World Health Organization (WHO) has 26 suggested that improving quality of life (QOL) for older people should be the 27 outcome of realizing the policy framework of “active ageing” [6]. Adding “quality” to 28 29 older people’s life to improve their health, social function, independence, and activity 30 has become the goal of a prolonged life [7]. QOL is an assessment of health status
31 based on a medical model that reflects an individual’s physical, psychological, and http://bmjopen.bmj.com/ 32 sociological health [8]. In addition, it has been recommended that disease-centred 33 curative health systems embrace integrated care focusing on the needs of older people 34 35 [1]. Thus, assessment of QOL is seen as an essential element in the care of older 36 people [9-11], and improving their QOL has become a prioritized element in their 37 medical care [6]. Identifying the factors associated with QOL is needed if new 38 interventions that will lead to improved QOL among older people are to be developed.
39 on September 30, 2021 by guest. Protected copyright. 40 Some health-related characteristics, such as chronic diseases and physical activity, 41 associated with QOL among older people have been well documented [12,13]. 42 Loneliness among older people is a common [14] and serious problem [15]. The 43 relation between loneliness and health has been recognized among older people 44 within the past decade, with loneliness being related to adverse physical and mental 45 46 health outcomes [14,16,17]. Due to recent social and economic changes in China, 47 younger people have migrated or emigrated to relatively economically developed 48 areas to seek employment and a better life [18]. Also, China is a country that values 49 the culture of collectivism and filial piety. Older people are still expected to be 50 51 provided with care by their children. Therefore, the perception of the gap between 52 expected and actual amounts of support that older people received from their families 53 would be stronger for older people [15]. This perceived gap would be the reason why 54 Chinese older people had serious problems of loneliness. 55 Although QOL, as a good measure of overall health, has also been reported to be 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 4 of 16
1 2 3 influenced by loneliness among older people in certain countries, such as Sweden [19] 4 and the Netherlands [20], the relation between QOL and loneliness among older 5 people in China has not been fully assessed to date [15]. It is also suggested that 6 7 interventions on lonely older people may improve well-being and lengthen life [21]. 8 Hence, the relation between QOL and loneliness should be fully investigated to 9 provide implications for proposing new interventions on improving QOL among 10 Chinese older people. The purpose of the study was to examine the relations among 11 quality of life (QOL), loneliness, and health-related characteristics in a sample of 12 13 Chinese older people. 14 15 Materials and Methods 16 For peer review only 17 Ethics statement 18 19 The Bioethics Advisory Commission of the China Medical University approved 20 this study. The participants were informed regarding the purpose of the study and, 21 prior to the start of the study, were assured that their privacy would be protected. All 22 participants provided written informed consent before participating in the study. 23 24
25 Study sample and procedures 26 Older age is generally defined in relation to retirement from paid employment and 27 receipt of pensions [22]. The age of 60 is roughly equivalent to retirement ages in 28 29 China. In this study, 60 years of age was chosen as the cut-off point for defining older 30 people. This study employed a cross-sectional design with a stratified random
31 sampling method on older people of age ≥60 years in Dandong city, Liaoning http://bmjopen.bmj.com/ 32 province. Compared with other cities in China, Dandong has more older people. In 33 34 2014, those aged ≥60 years accounted for 21.6% of the Dandong population, and this 35 percentage ranked third in Liaoning province. 36 Dandong has six districts. One community in each district was randomly selected to 37 achieve the required sample size, which was determined by the criterion that the 38 sample size should be 20 times the number of variables. In this study, the
39 on September 30, 2021 by guest. Protected copyright. 40 questionnaire contained 36 variables, and the required sample size was 720. Inclusion 41 criteria were age ≥60 years, residence in Dandong, having provided the written 42 informed consent, and ability to understand the questionnaire and communicate. 43 Those who refused to participate in the study were excluded. Additionally, older 44 people who were determined by the clinician to have severe physical conditions 45 46 affecting daily life and unsuitable to take part in the study were also excluded. During 47 this survey, a questionnaire was administered by face-to-face interview by trained 48 investigators with the participants from February 2017 to July 2017. If the participants 49 had any problem with completing the survey, the investigators assisted them. 50 51 In total, 784 eligible participants were approached in this survey, and 764 52 completed the questionnaires (completion rate 97.4%). When a participant did not 53 answer >20% of the questions, the associated questionnaire was not included in the 54 study. After exclusion of 32 invalid questionnaires, 732 questionnaires were identified 55 as valid (response rate 93.4%). 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 5 of 16 BMJ Open
1 2 3 4 5 Measurements 6 7 The questionnaire contained four sections: demographic characteristics, 8 heath-related characteristics, and the EQ-5D and the UCLA Loneliness scales. The 9 demographic characteristics were age, gender, marital status, education, monthly 10 income, place of residence (urban or rural), and living arrangement (empty or 11 non-empty nester). Empty nesters were older people who never had children or whose 12 13 children had left home such that empty nesters were defined as those living alone or 14 with only a spouse [23]. 15 Heath-related characteristics consisted of smoking status, physical activity status, 16 chronic diseaseFor status, peer and satisfaction review with health services. only To assess the level of 17 18 physical activity, participants were asked if they exercised at least six times a week 19 [24]. Respondents were defined as having a chronic disease(s) if they had been 20 diagnosed by a health professional(s). Satisfaction with health services was evaluated 21 using one item from WHOQOL-BREF [25], in which respondents rated the scale 22 from 1 (very dissatisfied) to 5 (very satisfied). 23 24 The EQ-5D was used to evaluate QOL of the participants, which is a generic tool 25 developed by the EuroQol Group [26]. The EQ-5D contains five items covering 26 different dimensions (mobility, self-care, usual activities, pain/discomfort, and 27 anxiety/depression). Each item has three possible responses (no problem, moderate 28 29 problem, or extreme problem). A single EQ-5D summary index score ranging from – 30 0.149 to 1.0 was calculated using the Chinese time trade-off model [26]. Higher
31 values implied better QOL. In addition, the EQ-5D also contains the visual analogue http://bmjopen.bmj.com/ 32 scale (VAS). The VAS was used to assess the respondents’ own perceptions of their 33 health status on a scale of 0 (worst) to 100 (best). The EQ-5D has been shown to be 34 35 applicable in China for Chinese older people [24,27-29]. The reliability of the EQ-5D 36 for our study was acceptable with a Cronbach’s alpha of 0.82. 37 Loneliness in older people was assessed with the use of the UCLA Loneliness Scale 38 [30], which has 20 items rated on a 1- to 4-point, Likert-type scale. The total UCLA
39 on September 30, 2021 by guest. Protected copyright. 40 score ranges from 20 to 80, with greater scores defining greater degrees of loneliness. 41 The scale ranges are the following: 20–34, a low loneliness level; 35–49, a moderate 42 loneliness level; 50–64, a moderately high loneliness level; and 65–80, a high 43 loneliness level [30]. We found the scale to be reliable, as the Cronbach’s alpha was 44 0.84. 45 46 Statistical Analyses 47 48 The Student’s t-test, F-test, and hierarchical linear regression analysis were 49 performed to determine the association between QOL and the demographic data, 50 51 health-related factors, and the UCLA Loneliness scale. In Block 1, demographic 52 characteristics (age, gender, marital status, education, monthly income, place of 53 residence, and living arrangement) were included in the model. Health-related 54 characteristics (smoking status, physical activity status, chronic disease status, and 55 satisfaction with health services) were added in Block 2. In Block 3, loneliness was 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 6 of 16
1 2 3 added. Variances of QOL explained by different groups of independent variables were 4 examined by △R2 (R squared change). Data were analysed using SPSS version 21.0 5 (SPSS Inc., Chicago, IL, USA) for Windows. A p-value < 0.05 was considered to be 6 7 statistically significant. 8 9 Patient and public involvement 10 No participating older people were involved in setting the research questions or the 11 outcome measures, nor were they involved in developing plans for the design or 12 13 implementation of the study. The participants were informed that the results were to 14 be published in an open access journal. 15 16 Results For peer review only 17 18 Participant Characteristics 19 20 The demographic characteristics of the participants are described in Table 1. A total 21 of 375 women (51.2%) and 357 men (48.8%) participated in the study. Their ages 22 ranged from 60 to 96 years with a mean age of 71.34 ± 7.73 years (standard deviation); 23 24 241 of the participants (32.9%) lived in rural areas. Approximately one-half of the 25 participants (341, 46.6%) were empty nesters. The F- or t-tests revealed that there 26 were significant differences in the QOL scores for participants of different ages, 27 residences, living arrangements, monthly incomes, and education levels (p < 0.05). 28 29 Participants who were younger, lived in an urban area, or were not empty nesters had 30 higher QOL scores (Table 1).
31 Table 1. Relationship between demographic characteristics and QOL (N = 732). http://bmjopen.bmj.com/ 32 Variable Number of EQ-5D F/t 33 participants index score 34 35 (%) 36 Ageb 37 60–69 289 (39.5%) 0.95 ± 0.10 8.149** 38 70–79 345 (47.1%) 0.92 ± 0.12
39 on September 30, 2021 by guest. Protected copyright. 40 ≥80 98 (13.4%) 0.90 ± 0.15 41 Gendera 42 Male 357 (48.8%) 0.93 ± 0.12 0.301 43 Female 375 (51.2%) 0.93 ± 0.12 44 a 45 Residence 46 Rural 241 (32.9%) 0.92 ± 0.12 –2.333* 47 Urban 491 (67.1%) 0.94 ± 0.12 48 Living arrangementa 49 Empty nester 341 (46.6%) 0.92 ± 0.13 2.221* 50 51 Non-empty nester 391 (53.4%) 0.94 ± 0.11 52 Marital statusb 53 Single 18 (2.4%) 0.97 ± 0.10 2.304 54 Married 688 (94.0%) 0.93 ± 0.12 55 Divorced/Widowed 26 (3.6%) 0.89 ± 0.14 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 7 of 16 BMJ Open
1 2 3 Monthly incomeb 4 <2000 367 (50.1%) 0.90 ± 0.14 21.722** 5 2000–3000 194 (26.5%) 0.95 ± 0.08 6 7 >3000 171 (23.4%) 0.97 ± 0.09 b 8 Education 9 Primary school or below 323 (44.1%) 0.92 ± 0.13 3.236* 10 Junior high school 294 (40.2%) 0.95 ± 0.10 11 Senior high school 89 (12.2%) 0.94 ± 0.11 12 13 College and above 26 (3.5%) 0.92 ± 0.12 14 at-test; bF-test; *p < 0.05; **p < 0.01 15 Regarding health-related characteristics (Table 2), the majority of the participants 16 (559, 76.4%)For suffered peer from a chronic review disease(s), and approximatelyonly one-half (436, 17 18 59.5%) were satisfied or very satisfied with the health services that they received. For 19 the heath-related characteristics, the F- or t-tests results showed that significant 20 differences existed in the QOL scores as related to chronic disease status, smoking 21 status, physical activity, and satisfaction with health services (p < 0.05). The 22 23 participants who had a chronic disease(s), smoked, were not physically active, or were 24 dissatisfied with their health services had lower QOL scores (Table 2). 25 Table 2. Relationship between health-related characteristics and QOL (N = 732). 26 Variable Number of EQ-5D index F/t 27 participants score 28 29 (%) 30 Chronic diseasea
31 Yes 559 (76.4%) 0.87 ± 0.15 –7.158** http://bmjopen.bmj.com/ 32 No 173 (23.6%) 0.95 ± 0.10 33 a 34 Smoking status 35 Yes 220 (30.1%) 0.92 ± 0.13 –1.984* 36 No 512 (69.9%) 0.94 ± 0.11 37 Physical activitya 38 No 633 (86.5%) 0.93 ± 0.12 –2.631**
39 on September 30, 2021 by guest. Protected copyright. 40 Yes 99 (13.5%) 0.95 ± 0.09 41 Health servicesb 42 Very dissatisfied 20 (12.7%) 0.83 ± 0.21 29.230** 43 Dissatisfied 53 (22.3%) 0.86 ± 0.14 44 45 Neither satisfied nor 223 (15.5%) 0.89 ± 0.13 46 dissatisfied 47 Satisfied 353 (38.2%) 0.96 ± 0.08 48 Very satisfied 83 (11.3%) 0.97 ± 0.09 49 a b 50 t-test; F-test; *p < 0.05; **p < 0.01 51 52 QOL 53 The mean EQ-5D index score for the participants was 0.93 ± 0.12 (range, 0.22– 54 1.00). The mean VAS score was 81.25 ± 14.38 (range, 0–100). The distribution of the 55 56 EQ-5D scale scores is presented in Table 3. The most prevalent health-related 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 8 of 16
1 2 3 problem reported by the participants was pain/discomfort (196, 26.8% had moderate 4 or extreme pain/discomfort). 5 6 N 7 Table 3. Distribution of EQ-5D index score ( = 732). 8 Dimension No problem Moderate problem Extreme problem 9 Mobility 678 (92.6%) 53 (7.2%) 1 (0.1%) 10 Self-care 713 (97.4%) 14 (1.9%) 5 (0.7%) 11 12 Usual activities 677 (92.5%) 55 (7.5%) 0 (0%) 13 Pain/discomfort 536 (73.2%) 193 (26.4%) 3 (0.4%) 14 Anxiety/depression 610 (83.3%) 121 (16.5%) 1 (0.1%) 15 16 LonelinessFor peer review only 17 18 The mean UCLA loneliness score was 40.73 ± 8.73 (range, 20–64). According to 19 their loneliness scores, 547 participants (74.7%) had a moderate or a moderately high 20 loneliness score (Table 4). A significant difference was found for the QOL scores for 21 groups with different degrees of loneliness (p < 0.001). Participants with moderately 22 23 high loneliness scores had lower QOL scores (0.86 ± 0.17) compared with 24 participants in the other two groups. The relationships between their QOL and 25 loneliness scores are listed in Table 4. 26 Table 4. Relationship between loneliness and QOL (N = 732). 27 Loneliness level Number of EQ-5D index F 28 29 participants score 30 (%)
31 Low 185 (25.3%) 0.97 ± 0.07 33.889*** http://bmjopen.bmj.com/ 32 Moderate 449 (61.3%) 0.93 ± 0.11 33 34 Moderately high 98 (13.4%) 0.86 ± 0.17 35 ***p < 0.001 36 37 Relation between the demographic data, health-related 38
39 factors, loneliness, and QOL on September 30, 2021 by guest. Protected copyright. 40 41 Hierarchical linear regression analyses of the factors associated with QOL are 42 presented in Table 5. In Block 1, age, income, education, living arrangement, and 43 marital status were significantly associated with QOL (p < 0.05). When health-related 44 45 characteristics were added in Block 2, age, income, chronic disease(s), health service 46 satisfaction, smoking and physical activity were significantly associated with QOL (p 47 < 0.05). In Block 3, among these demographic and health-related characteristics, 48 having a chronic disease(s), age of the participant, and smoking were negatively 49 50 associated with QOL (p < 0.05), with chronic disease having standardized coefficients 51 of -0.234. Satisfaction with health services, higher income, and being physically 52 active were positively associated with the QOL of the participants (p < 0.05). In 53 addition, loneliness was significantly and negatively associated with QOL 54 (level = moderate: β = -0.190, p < 0.05; level = moderately high: β = -0.260, p < 0.05; 55 56 reference group: level = low). Loneliness explained 5.2% of the variance of QOL. 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 9 of 16 BMJ Open
1 2 3 4 5 6 N = 7 Table 5. Hierarchical linear regression analyses of the factors associated with QOL ( 8 732). 9 Factor Block 1 (β) Block 2 (β) Block 3 (β) 10 Agea 11 12 70–79 -0.081* -0.074* -0.079* 13 ≥80 -0.077 -.043 -0.050 14 Incomeb 15 2000–3000 0.157* 0.094* 0.097* 16 >3000 For peer review only 17 0.205* 0.108* 0.103* 18 Gender-Female 0.009 -.048 -0.045 19 Educationc 20 Junior high school 0.083* 0.037 0.034 21 Senior high school 22 0.052 0.027 0.031 23 College and above -0.012 -0.028 -0.031 24 Residence-Urban 0.061 0.021 0.002 25 Living arrangement-Empty nester -0.086* -0.061 -0.030 26 Marital statusd 27 28 Married -0.079 -0.064 -0.057 29 Divorced/Widowed -0.109* -0.066 -0.054 30 Chronic disease-Yes -0.239* -0.234*
31 http://bmjopen.bmj.com/ Health service satisfactione 32 33 Dissatisfied 0.088 0.086 34 Neither satisfied nor dissatisfied 0.225* 0.196* 35 Satisfied 0.524* 0.453* 36 Very satisfied 37 0.307* 0.258* 38 Smoking-Yes -0.116* -0.110*
39 Physical activity-Yes 0.078* 0.078* on September 30, 2021 by guest. Protected copyright. 40 Lonelinessf 41 Moderate 42 -0.190* 43 Moderately high -0.260* 44 F 6.007 12.874 15.246 2 45 R 0.091 0.256 0.308 46 △R2 0.091 0.165 47 0.052 48 *p < 0.05; β, standardized regression coefficient 49 a: reference group = 60-69; b: reference group = <2000; c: reference group = primary school or 50 below; d: reference group = Single; e: reference group = very dissatisfied; f: reference group = 51 low. 52 53 54 Discussion 55 This study contributed to our knowledge concerning the relation between QOL, 56 loneliness, and health-related characteristics among older people living in Dandong 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 10 of 16
1 2 3 city, Liaoning province, China. Our results indicated that the pain/discomfort facet of 4 QOL was the most prevalent problem among the participants. This finding is in line 5 with previous studies on Chinese [27,28] and Vietnamese older people [31]. One 6 7 population-based study revealed that more than one-half of older Americans had been 8 bothered by pain in the month prior to being questioned [32]. The older people often 9 experience chronic pain [33], which is a disability that can cause decreased mobility 10 and depression [32]. These factors may increase healthcare costs and may decrease 11 productivity [33]. Bhattarai and colleagues suggested that cost-efficient intervention 12 13 strategies for management of the pain in the older population should be a priority for 14 healthcare providers [33]. 15 We found loneliness to be significantly correlated with the QOL of our participants, 16 and those whoFor had apeer greater degree review of loneliness alsoonly reported a poorer QOL. 17 18 Loneliness may impair the immune and cardiovascular systems [14]. The negative 19 effects of loneliness on the physical and psychological health of the older people have 20 been widely documented [14,17]. Lonely individuals are also more likely to engage in 21 behaviour that results in poor health outcomes [34]. These factors may all contribute 22 to and impair QOL for older people [9]. We found that 74.7% of our participants 23 24 experienced a moderate or moderately high level of loneliness. The prevalence of 25 loneliness found by us is comparable with that found for older people in other Chinese 26 cities, such as Shanghai [9,30], but is considerably greater than that reported in the 27 developed country Finland [35]. The substantial social and economic changes 28 29 occurring in China along with the increase in the number of older people increases the 30 likelihood that more older people will be lonely [18,30]. Therefore, there is an urgent
31 need to perform interventions that will mitigate their loneliness [9]. http://bmjopen.bmj.com/ 32 Consistent with other studies [12,36], suffering from a chronic disease(s) was an 33 important risk factor for QOL among older people. Monitoring and ameliorating a 34 35 chronic disease may reduce its negative impact on the QOL of the older population 36 [2]. However, representative data from six countries, including China, have indicated 37 that effective healthcare coverage among older people with chronic diseases is 38 between 20.7% and 48.2% [37]. Given the continuous nature of chronic care, it
39 on September 30, 2021 by guest. Protected copyright. 40 should be more effective to provide the older people with healthcare services in 41 community-based settings, e.g., primary healthcare centres [2]. The WHO study also 42 urged that permanent mechanisms be established that would expand healthcare 43 coverage for older people with chronic conditions [37,38]. 44 We found that the QOL of our participants was positively correlated with their 45 46 satisfaction with health services, which is consistent with the results of a related study 47 [8]. The older people who are more satisfied with their health services are more prone 48 to regard the healthcare they receive as effective and hence adhere to the 49 recommended treatment(s), which consequently may further improve their physical 50 51 and mental health [8]. This finding may explain why the older people who reported a 52 greater degree of satisfaction with their healthcare also reported a better QOL. 53 However, only half of our participants (49.5%) were satisfied or very satisfied with 54 their health services. Poor quality, high costs, and poor accessibility to healthcare may 55 be reasons for dissatisfaction with health services in China [9,39]. 56 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 11 of 16 BMJ Open
1 2 3 Our study had several limitations. First, the study was conducted in only one 4 Chinese city, which may partly limit representation of Chinese older people. 5 Additional studies in other areas of China will help determine whether our findings 6 7 can be generalized. Second, this study employed a cross-sectional design, which may 8 limit the ability to confirm a causal relation between QOL and loneliness. A future 9 study, applying a more effective design, such as a case-controlled design or cohort 10 design, should be conducted to establish the casual relation between loneliness and 11 QOL. Last, the unique use of a self-report response may cause bias, such as a 12 13 consistency motif, acquiescence bias, and social desirability. The two primary ways to 14 control for these method biases through the design of the study’s procedures and 15 statistical controls should be undertaken in future research [40]. In addition, our study 16 identified multipleFor factors peer that may influencereview QOL in olderonly people; these factors can 17 18 be addressed separately and in depth in the future. 19 20 Conclusions 21 Our study provides information regarding the relation among QOL, loneliness, and 22 health-related characteristics of Chinese older people. Loneliness is a crucial problem 23 24 facing the elderly. This study indicated that loneliness was negatively associated with 25 QOL among older people. To address the findings of this study, it is suggested that we 26 may need to be aware of the loneliness of older people and take action to minimize 27 loneliness and improve QOL. Furthermore, managing chronic diseases and improving 28 29 the health service may contribute to better QOL for older people. 30 Acknowledgments 31 http://bmjopen.bmj.com/ 32 The authors wish to thank Xia Min for help with sample collection. We thank all of 33 the participants in this study. 34 35 36 Competing Interests 37 The authors declare that they have no competing interests. 38
39 Funding on September 30, 2021 by guest. Protected copyright. 40 41 This work was supported by the National Natural Science Foundation of China, grant 42 number 71473269 and 71673301. The funders had no role in study design, data 43 collection and analysis, decision to publish, or preparation of the manuscript. 44 45 46 Authors’ contribution 47 48 YZ wrote the manuscript. YZ and JL participated in the data collection and analysis. 49 ZY collected the data. ZY and BQ designed the study and revised the manuscript. BQ 50 obtained funding. All authors read and approved the final manuscript. 51 52 53 Ethics approval 54 55 Ethical protocol was obtained from the Bioethics Advisory Commission of China 56 Medical University. All participants provided written informed consent before 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 12 of 16
1 2 3 participating in the study. 4 5 Data sharing statement 6 7 No additional unpublished data. 8 9 References 10 1. World Health Organization. WHO World Report on Health and Ageing, 2015. 11 Accessed in 10 Oct 2017. 12 13 http://101.96.8.164/apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng. 14 pdf?ua=1. 15 2. Shanghai Municipal Center for Disease Control & Prevention (SCDC). Study on 16 global AGEingFor and Adult peer Health Wave review 1 China National only Report (2012). Accessed in 17 18 01 Oct 2017. 19 https://www.researchgate.net/publication/277305920_China_Study_on_global_AGEi 20 ng_and_adult_health_SAGE_Wave_1_National_Report. 21 3. HelpAge International. HelpAge International Annual review 2015 (2015). 22 Retrieved online 08 Oct 2017. 23 24 http://www.helpage.org/who-we-are/annual-review-2015/#looking-forward. 25 4. HelpAge International. Global Age Watch Index (2014). Retrieved online 14 Oct 26 2017. http://www.helpage.org/global-agewatch/about/about-global-agewatch/. 27 5. Wang Z, Li X, Chen M. Catastrophic health expenditures and its inequality in 28 29 elderly households with chronic disease patients in China. Int J Equity Health 30 2015;14:8.
31 6. World Health Organization. Active ageing: a policy framework (2002). Accessed in http://bmjopen.bmj.com/ 32 01 Oct 2017. 33 http://apps.who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf. 34 35 7. Ann B. The psychometric properties of the older people’s quality of life 36 questionnaire, compared with the CASP-19 and the WHOQOL-OLD. Curr Gerontol 37 Geriatr Res 2009;2009(2):298950. 38 8. Zhang Y, Zhou Z, Gao J, et al. Health-related quality of life and its influencing
39 on September 30, 2021 by guest. Protected copyright. 40 factors for patients with hypertension: evidence from the urban and rural areas of 41 Shaanxi Province, China. BMC Health Serv Res 2016;16:277. 42 9. Chen Y, Hicks A, While AE. Quality of life and related factors: a questionnaire 43 survey of older people living alone in Mainland China. Qual Life Res 44 2014;23(5):1593-602. 45 46 10. Bélanger E, Ahmed T, Vafaei A, et al. Sources of social support associated with 47 health and quality of life: a cross-sectional study among Canadian and Latin American 48 older adults. BMJ Open 2016;6(6):e011503. 49 11. Cerin E, Sit CH, Zhang CJ, et al. Neighbourhood environment, physical activity, 50 51 quality of life and depressive symptoms in Hong Kong older adults: a protocol for an 52 observational study. BMJ Open 2016;6(1):e010384. 53 12. Cadore EL, Izquierdo M. Exercise interventions in polypathological aging patients 54 that coexist with diabetes mellitus: improving functional status and quality of life. Age 55 (Dordr) 2015;37(3):64. 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 13 of 16 BMJ Open
1 2 3 13. Barile JP, Thompson WW, Zack MM, Krahn GL, Horner-Johnson W, Bowen SE. 4 Multiple chronic medical conditions and health-related quality of life in older adults, 5 2004-2006. Prev Chronic Dis 2013;10:E162. 6 7 14. Luanaigh CO, Lawlor BA. Loneliness and the health of older people. Int J Geriatr 8 Psychiatry 2008;23(12):1213-21. 9 15. Liu LJ, Guo Q. Loneliness and health-related quality of life for the empty nest 10 elderly in the rural area of a mountainous county in China. Qual Life Res 11 2007;16(8):1275-80. 12 13 16. Wilson RS, Krueger KR, Arnold SE, et al. Loneliness and risk of Alzheimer 14 disease. Arch Gen Psychiatry 2007;64(2):234-40. 15 17. Cacioppo JT, Hawkley LC, Thisted RA. Perceived social isolation makes me sad: 16 5-year cross-laggedFor analysespeer of loneliness review and depressive only symptomatology in the 17 18 Chicago Health, Aging, and Social Relations Study. Psychol Aging 19 2010;25(2):453-63. 20 18. Chen Y, Hicks A, While AE. Loneliness and social support of older people in 21 China: a systematic literature review. Health Soc Care Community 22 2014;22(2):113-123. 23 24 19. Jakobsson U, Hallberg IR. Loneliness, fear, and quality of life among elderly in 25 Sweden: a gender perspective. Aging Clin Exp Res 2005;17(6):494-501. 26 20. Ilona V, Ros Wynand J G, Bas S, de Wit NJ. Ethnicity does not account for 27 differences in the health-related quality of life of Turkish, Moroccan, and Moluccan 28 29 elderly in the Netherlands. Health Qual Life Outcomes 2014;12(1):138. 30 21. Luo Y, Waite LJ. Loneliness and mortality among older adults in China. J
31 Gerontol B Psychol Sci Soc Sci. 2014;69(4):633-45. http://bmjopen.bmj.com/ 32 22. World Health Organization. Definition of an older or elderly person, 2010. 33 Accessed in 06 Jun 2018. 34 35 http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html 36 23. Cheng P, Jin Y, Sun H, et al. Disparities in prevalence and risk indicators of 37 loneliness between rural empty nest and non-empty nest older adults in Chizhou, 38 China. Geriatr Gerontol Int 2015;15(3):356-64.
39 on September 30, 2021 by guest. Protected copyright. 40 24. Tan Z, Liang Y, Liu S, et al. Health-related quality of life as measured with EQ-5D 41 among populations with and without specific chronic conditions: a population-based 42 survey in Shaanxi Province, China. PLoS One 2013;8(7):e65958. 43 25. The WHOQOL Group. Development of the World Health Organization 44 WHOQOL-BREF quality of life assessment. Psychol Med 1998;28:551-8. 45 46 26. Liu GG, Wu H, Li M, et al. Chinese time trade-off values for EQ-5D health states. 47 Value Health 2014;17(5):597-604. 48 27. Sun S, Chen J, Johannesson M, et al. Regional differences in health status in 49 China: population health-related quality of life results from the National Health 50 51 Services Survey 2008. Health Place 2011;17(2):671-80. 52 28. Zhang T, Shi W, Huang Z, et al. Influence of culture, residential segregation and 53 socioeconomic development on rural elderly health-related quality of life in Guangxi, 54 China. Health Qual Life Outcomes 2016;14:98. 55 29. Deng X, Dong P, Zhang L, et al. Health-related quality of life in residents aged 18 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from BMJ Open Page 14 of 16
1 2 3 years and older with and without disease: findings from the First Provincial Health 4 Services Survey of Hunan, China. BMJ Open 2017;7(9):e015880. 5 30. Chen Y, Hicks A, While AE. Loneliness and social support of older people living 6 7 alone in a county of Shanghai, China. Health Soc Care Community 8 2014;22(4):429-38. 9 31. Hoi le V, Chuc NT, Lindholm L. Health-related quality of life, and its 10 determinants, among older people in rural Vietnam. BMC Public Health 2010;10:549. 11 32. Patel KV, Guralnik JM, Dansie EJ, et al. Prevalence and impact of pain among 12 13 older adults in the United States: findings from the 2011 National Health and Aging 14 Trends Study. Pain 2013;154(12):2649-57. 15 33. Bhattarai P, Phillips JL. The role of digital health technologies in management of 16 pain in olderFor people: An peer integrative review.review Arch Gerontol only Geriatr 2017;68:14-24. 17 18 34. Hawkley LC, Thisted RA, Cacioppo JT. Loneliness predicts reduced physical 19 activity: cross-sectional & longitudinal analyses. Health Psychol 2009;28(3):354-63. 20 35. Routasalo PE, Savikko N, Tilvis RS, et al. Social contacts and their relationship to 21 loneliness among aged people-a population-based study. Gerontology 22 2006;52(3):181-7. 23 24 36. Venturelli M, Cè E, Limonta E, et al. Effects of endurance, circuit, and relaxing 25 training on cardiovascular risk factors in hypertensive elderly patients. Age (Dordr) 26 2015;37(5):101. 27 37. Goeppel C, Frenz P, Tinnemann P, et al. Universal health coverage for elderly 28 29 people with non-communicable diseases in low-income and middle-income countries: 30 a cross-sectional analysis. Lancet 2014;384:S6.
31 38. Trivedi AN, Moloo H, Mor V. Increased ambulatory care copayments and http://bmjopen.bmj.com/ 32 hospitalizations among the elderly. N Engl J Med 2010;362(4):320-8. 33 39. Eggleston K, Ling L, Qingyue M, et al. Health service delivery in China: a 34 35 literature review. Health Econ 2008;17(2):149-65. 36 40. Podsakoff PM, Mackenzie SB, Lee JY, et al. Common method biases in 37 behavioral research: a critical review of the literature and recommended remedies. J 38 Appl Psychol 2003;88(5):879-903.
39 on September 30, 2021 by guest. Protected copyright. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from NA 4 4 5 5 1 1
NA 4,5 4,5 4 4 NA 4 4 4 4
3,4 3,4 3 3
4,5 4,5 4,5 4,5 NA Reported on page # Reported on page 2 2 4 4
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only ) Indicate study’s) the designcommonlywith used a in term ortitlethe abstract the ) ) theGive eligibility criteria, and sourcesthe methodsand of of selection participants ) ) statisticalDescribe all methods, thoseincluding confoundingusedforcontrol to ) ) Describe any methods used subgroups examine to interactionsand ) If ) applicable, describe methodsanalytical taking account of sampling strategy ) ) in theProvide abstract informativean and balanced summary of what was donewhat wasand found ) Describe) sensitivity any analyses ) how Explain missing data were addressed a a a b e d c b For eachof interest, For variable sourcesdatagive of and details of methods of assessment (measurement). Describe comparability of of comparability assessment methods isthanthere more if one group ( ( why why
applicable collection collection ( ( ( ( Recommendation cross-sectional studies of cross-sectional reports in be included should that items of Statement—Checklist (v4) 2007 STROBE
6 1 ( 3 specific objectives, State including prespecified any hypotheses 5 the setting, Describe locations, relevantand dates, including periods exposure,of recruitment, follow-up, data and 9 any Describe efforts to address sourcespotential of bias 7 define Clearly outcomes,all exposures,predictors, potential confounders,effect and modifiers. diagnostic Give criteria, if 4 key Present of studyelements in thedesign early paper 8* 10 10 how Explain studythe size was arrived at # Item Item Results
Statistical Statistical methods 12 ( Quantitative variables 11 how Explain quantitative were handledvariables in analyses.the If applicable, describe which chosengroupings were and Study size Bias Data sources/Data measurement Variables Participants Setting Study design Methods Objectives Background/rationale 2 thebackground Explain scientific for rationale investigation the and being reported Introduction Title andTitle abstract Section/Topic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 15 of 16 BMJ Open: first published as 10.1136/bmjopen-2018-021822 on 13 November 2018. Downloaded from Page 16 of 8,9 8,9 5-7 5-7 NA
8,9 8,9 9 9 8 8
5-8 5-8 NA NA 4 4 5-8 5-8 5-8 5-8 10 10 NA NA
http://bmjopen.bmj.com/ BMJ Open on September 30, 2021 by guest. Protected copyright.
For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml ) Report) boundaries category when continuous variables were categorized ) ) unadjustedGive estimates if applicable, and, confounder-adjusted estimates their and precision95% (eg, confidence ) If ) relevant, If consider translating estimatesrelativerisk of into absolute for risk meaningfulperioda time c b a similar studies,similar and other relevant evidence confounders magnitude of magnitude potential biasany confirmed eligible,confirmed included in study, the completing follow-up, analysed and interval). Make interval). clear confounderswhich were adjusted they why and for were included which the presentthe which is based article
( ( number Indicate (b) of participants missingwith eachfor data of interest variable Consider (c) diagram use flow of a reasons Give (b) non-participationfor each at stage 18 18 results Summarise key to reference withstudy objectives 16 16 ( 22 22 sourcethe Give of funding and role the of fundersthe thefor studypresent if and, applicable, originalthe for study on 19 19 Discuss of study, the takinglimitations into sourcesaccount biasof potential imprecision.or Discussboth direction and 13* 13* Report (a) numbers of individuals each at stage of study—eg numbers eligible, potentially examinedfor eligibility, An Explanation and Elaboration article discussesitem each checklist and gives backgroundmethodological and published examples of transparent reporting. The STROBE checklist is best used in this(freelywith conjunction available onarticle sites the Medicine of PLoS http://www.plosmedicine.org/,Web at Annals of Internal Medicine at http://www.annals.org/, http://www.epidem.com/).Epidemiology at and Information on InitiativeSTROBE the is www.strobe-statement.org.available at information*Give separately cases for and controls studiesin forcase-control applicable, if and, exposedunexposed and groups in cohort and studies.cross-sectional Note: Funding Other information Generalisability 21 Discuss(external generalisabilitythe of studythe validity) results Interpretation 20 cautious Give interpretationa of resultsoverall considering limitations, objectives, multiplicity of resultsanalyses, from Limitations Key Key results Discussion Other analyses 17 other Report analyses done—eg analyses of subgroups sensitivity interactions, and and analyses
Main resultsMain Outcome Outcome data 15* numbers Report of outcome events or summary measures
Descriptive data 14* characteristicsGive (a) participantsof study (eg demographic, social) clinical, and information on exposures potential and
Participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60