Associations and Impact Factors between Living Arrangements and Functional Disability among Older Chinese Adults
Liu H (2013) Associations and Impact Factors between Living Arrangements and Functional Disability among Older
Chinese Adults. PLoS ONE 8(1): e53879. doi:10.1371/journal.pone.0053879
Associations and Impact Factors between Living Arrangements and Functional Disability among Older Chinese Adults
Hui Wang 0
Kun Chen 0
Yifeng Pan 0
Fangyuan Jing 0
He Liu 0
Ulrich Thiem, Marienhospital Herne - University of Bochum, Germany
0 1 Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health , Hangzhou , China , 2 Zhejiang Provincial Centre for Disease Control and Prevention , Hangzhou , China
Objectives: To examine the association of living arrangements with functional disability among older persons and explore the mediation of impact factors on the relationship. Design: Cross-sectional analysis using data from Healthy Aging study in Zhejiang Province. Participants: Analyzed sample was drawn from a representative rural population of older persons in Wuyi County, Zhejiang Province, including 1542 participants aged 60 and over in the second wave of the study. Measurements: Living arrangements, background, functional disability, self-rated health, number of diseases, along with contemporaneous circumstances including income, social support (physical assistance and emotional support). Instrument was Activities of Daily Living (ADL) scale, including Basic Activities Daily Living (BADL) and Instrumental Activities of Daily Living (IADL). Results: Living arrangements were significantly associated with BADL, IADL and ADL disability. Married persons living with or without children were more advantaged on all three dimensions of functional disability. Unmarried older adults living with children only had the worst functional status, even after controlling for background, social support, income and health status variables (compared with the unmarried living alone, for BADL: 21.262, for IADL: 22.112, for ADL: 23.388; compared with the married living with children only, for BADL: 21.166, for IADL: 22.723, for ADL: 23.902). In addition, older adults without difficulty in receiving emotional support, in excellent health and with advanced age had significantly better BADL, IADL and ADL function. However, a statistically significant association between physical assistance and functional disability was not found. Conclusion: Functional disabilities vary by living arrangements with different patterns and other factors. Our results highlight the association of unmarried elders living with children only and functioning decline comparing with other types. Our study implies policy makers should pay closer attention to unmarried elders living with children in community. Community service especially emotional support such as psychological counseling is important social support and should be improved.
Funding: The source of funding that has supported our research is from Zhejiang Research Center on Aging. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
Living arrangements are defined by household composition or
the number and identity of the cohabitants. Household is a major
factor in determining the social roles of the elderly by providing
social integration, social support and interactions . The social
ties based on a persons household situation bring instrumental,
informational, and emotional supports from household members,
just as with any other social tie [2,3]. The social support theory,
addressing both the structure and the interactions in relationships,
proposes that strengthening social support can improve health and
mediate the negative effects of stress . Many previous studies
have shown that social support positively influences health and
reduces mortality .
However, social relations in household living arrangements are
different from other social relations. There are expectations and
obligations associated with family roles that shift over the course of
life. Household members provide each other personal care,
comfort and intimacy as well as aggravation and conflict .
Studies have reported that older adults with a concordance
between their needs and environment have higher morale .
Living arrangement concordance based on the family household is
closely connected with cohabitation status, living with/without
a partner and marital status. Cohabitation status and marital status
are important aspects of an individuals social relations but not
identical entities. Many studies separately use cohabitation status
and marital status as predictors in the analyses of the association
between living arrangements and health outcomes, but at present,
findings are conflicting . Thus, we argue that households
with different structures for the number and identity of members
make very different demands on the older adults in them and offer
very different resources. If so, we should also see patterned
differences in health among older persons living in various types of
households. Following our theoretical emphasis on the qualitative
differences in resources and demands among households of
different structures, we compared health among persons living in
different types of households in various combinations of
cohabitation and marital status.
Living arrangements are closely related to the health and
wellbeing of the older adults . The associations between living
arrangements and health outcomes, such as mortality, activities of
daily living (ADL) disability, self-rated health, and psychological
well-being have been reported by scholars . However, the
literature is not clear on the associations between living
arrangements and the health or well-being of older adults. In
China, there is a deep-seated tradition of coresidence with one or
more married children stemming from the Confucian ideals of
filial piety, but this tradition has declined over time as family sizes
have decreased due to the one-child policy along with other social
and economic changes . China is facing enormous challenges
of aging and the companying problem of services for the aged,
especially older adults with disabilities. Disability is prevalent and
costly among older adults. There are complex and multifactorial
reasons for the development of such disabilities among older adults
The purpose of this study was to investigate the association
between functional disability and living arrangements in a rural
sample of Chinese older adults in Zhejiang Province. In particular,
we aimed to answer the following questions: (1) What are the
relationships between living arrangements and basic activities daily
living (BADL) disability, instrumental activities of daily living
(IADL) disability, and activities of daily living (ADL) disability
among older adults? (2) Do some impact factors such as
sociodemographic characteristics, social support, self-rated health, and
number of diseases mediate the associations between living
arrangements and functional disability of older adults?
Participants and Procedure
Data for this paper were taken from the cross-sectional study on
Healthy Aging in Zhejiang Province. It was a multidimensional
survey of two random samples of the community-dwelling elderly
in Hangzhou City (urban area) and Wuyi County (rural area),
respectively. This study was approved by the Institutional Review
Board of Zhejiang University. The reference population for this
paper only included older adults registered at the family health
center of the town of Wangzhai and Baimu in Wuyi County, in the
southwestern region of Zhejiang Province. Data were collected
from May to August 2011. Older adults who volunteered to
participate in the study were selected according to the following
criteria: (a) age$60years and (b) living in Wangzhai or Baimu. All
older adults, a total of 1724, registered at the health center were
interviewed at home, informed regarding the objectives and
procedures of the study, and invited to participate in the study. A
total of 1565 older adults agreed to participate in the study by
signing the informed consent form and receiving a gift. There were
23 participants later excluded for uncompleted or unreliable
questionnaires, leaving a total of 1542 older adults, an effective
response rate of 89.4%.
Background. Socio-demographic variables included gender, age,
education (illiterate, primary school or more).
Living arrangements. In view of largely mixed results of
health benefits of living with others, particularly in regard to the
relative benefits of coresidence with children versus living alone,
the sample participants were classified into six types based on the
number and identity of the cohabitants: unmarried persons living
alone, married persons living alone, married persons living with
spouse only, unmarried persons living with children, married
persons living with children only, and married persons living with
spouse and children. Unmarried in this paper referred to
current status and included all types of non-married persons:
widowers, the divorced and the never married.
Health. Self-rated health was designed to capture respondents
subjective assessment of their own medical and functional status
. Respondents were asked to rate their health on a scale of poor,
fair, good, and excellent; Number of diseases was assessed from
reports noting what diseases from a list of 35 chronic diseases the
participant had been diagnosed with (e.g., hypertension, diabetes,
Functional disability. Respondents were asked to self-report
whether they had any difficulty with activities of daily living (ADL),
including the basic activities of daily living (BADL) and
instrumental activities of daily living (IADL) . The BADL
measure contained 6 items, including toileting, eating, dressing,
grooming, general movement, and bathing on a four-point scale
from no difficulty (1) to complete disability (4). The sum score
for BADL ranged from 6 to 24.The IADL scale consisted of eight
items: using the telephone, daily shopping, preparing meals, doing
housekeeping, doing laundry, taking the bus, taking medicine, and
handling personal finances. Each of these items was rated for the
difficulty using a scale similar to that used for BADL (range: 832).
The sum score for ADL reflecting global functional status  had
a range from 14 to 56, combining of BADL and IADL. Lower
scores indicated more intact functional abilities.
Contemporaneous circumstances. Yearly personal income was
recorded as,5000, $5000 and ,10000, or $10000 yuan per
year. We focused on perceived social support comprising two
subscales: physical assistance and emotional support. Physical
assistance was measured using the question: How much difficulty
do you currently have if in acquiring physical assistance (e.g.,
money, goods, daily care)? Emotional support was assessed by the
question: How much difficulty do you currently have if in need of
emotional support (e.g., expressions of care, concern, affection and
interest)? Each question had a trichotomous answer: no difficulty,
some difficulty, and severe difficulty.
Descriptive statistics were used for socio-demographic
characterization, social support and health by calculating the proportion
of distribution in each stratum of living arrangements. We used chi
square (x2) tests to identify group differences in proportions and
one-way ANOVA F-tests for continuous variables. One-way
ANOVA F-tests were applied to identify significant differences
between BADL, IADL, and ADL and living arrangements, then
an LSD post hoc multiple comparisons test was used to identify
specific differences in the functional disability. To compare
functional disability among the six types of living arrangements,
we performed multiple linear regression analyses in two models, in
which BADL disability, IADL disability and ADL disability served
as the dependent variables, respectively. Model 1 was analyzed for
each dependent variable, controlling for background variables
(gender, age and education). Then, health variables (number of
diseases and self-rated health) and contemporaneous
circumstances (yearly personal income, physical assistance and emotional
support) were added in Model 2 in addition to socio-demographic
variables. A P#0.05 was considered statistically significant. The
data were analyzed using the Statistical Package for the Social
Science (SPSS), version 17.0.
The descriptive characteristics of the study sample are shown in
Table 1. Of the participants, the proportions of unmarried persons
living alone, married persons living alone, older adults living with
spouse only, unmarried persons living with children only, married
persons living with children only, and the older adults living with
spouse and children were 25.3%, 5.3%, 52.1%, 7.1%, 2.3%, and
7.8%, respectively. The proportion of females was more than
double among unmarried persons living with children (75.5%)
when compared to older adults living with their spouse and
children (37.2%). Older adults living with a spouse and children
(67.7666.78 years) were significantly younger than unmarried
persons living alone (76.3267.62 years). Older participants living
with their spouse and children had a much higher education level
than married persons living with children only. The overwhelming
majority of unmarried persons living alone (93.5%) had less than
5000 yuan of yearly personal income compared to 42% of those
living with spouse and children. Many more married persons
living with children only (77.1%) than married persons living alone
(26.8%) had no difficulty in receiving physical assistance if in need.
In addition, a greater number of older adults living with spouse
and children (77.5%) than married persons living alone (31.7%)
had no difficulty in getting emotional support if in need. The
health status of unmarried persons living with children only was
significantly worse. Fewer older adults living with spouse and
children (37.8%) than unmarried persons living with children only
(67.3%) perceived their health as fair or poor, and 82.9% of
married persons living with children only had no chronic diseases
compared to 50.0% of unmarried persons living with children
Table 2 presents the means and standard deviations of the
continuous scores from the BADL, IADL, and ADL. Significant
associations of functional disability with living arrangements are
shown. Functional disability varied by living arrangements.
Unmarried persons living with children only had the lowest scores
on all three dimensions of functional disability. Furthermore,
married persons living with children only had significantly better
function than unmarried persons living alone, older adults living
with spouse only and both with spouse and children in regards to
IADL and ADL disability.
Table 3 reports the results of the multivariate analysis of the
associations between functional disability scores and living
arrangements. The figures in the table are coefficients from
multiple linear regressions of functional disability on sets of
The first panel presents the results for BADL disability. In
Model 1, being older and a low level of education were
independently associated with BADL disability. Unmarried
persons living alone, married persons living alone or with children
only, and older adults living with spouse only reported better
BADL ability than unmarried persons living with children only. In
Model 2, when controlling for contemporaneous circumstances,
background and health variables, the magnitude of the
associations did not change except that the coefficient for married persons
living with children only decreased from 21.646 to 21.166. These
results indicate that part of the association between living
arrangements and BADL disability was due to the confounding
effect of the added variables. The second panel presents the results
for IADL disability. Here again, unmarried persons living with
children only had significantly more IADL disability than older
people in other living arrangements except for older adults living
with spouse and children together. After controlling for other
covariates, the coefficient decreased from 23.730 to 22.723, but
the association still had statistical significance. In the third panel,
the results for ADL disability were similar to those for BADL and
IADL disability. In addition, the results in these three panels also
indicate that older adults who had no difficulty in receiving
emotional support and who were in excellent health have
significantly better BADL, IADL and ADL function.
In this paper, our results implicates that the social context
formed by the living arrangements based on family household has
been shown to be important social etiology for health. Living
arrangements are significantly related to functional disability
among older adults. Compared with other types of living
arrangements, unmarried persons including widowers, the
divorced and the never married, living with children only are
disadvantaged on all three dimensions of functional disability as
measured by the BADL, IADL and ADL. Married persons living
alone or with children only do appear to have better functionality.
Our study suggests that persons living alone did not report worse
functional status. In fact, an earlier study showed that urban older
adult living with children and without spouses had worse outcomes
as compared to those who lived alone . Our results also are
consistent with the findings of Hughes and Gove . However,
some previous studies found that living alone disadvantaged
individuals in regards to functional health [40,41] and other
measures of health . We explain this finding several ways.
First, functional disability preceded cohabitation and older adults
with functional disability may self-select to cohabitate with
children in the absence of the spouse. Second, functional disability
follows cohabitation status and unmarried adults may require
more support than they receive from children. Thus, unmarried
persons living with children experience demands that exceed their
coping resources and this imbalance ultimately affects their health
and even functional status.
Further, in our study living arrangements combining marriage
and cohabitation status do not merely seem to reflect alternative
status correlates with functional disability, respectively. Unmarried
persons living with children only do appear to be the least healthy
on all measures, which is partly consistent with the findings of
Hughes et al. who found the association only in women aged 51
61 . The findings in these two studies indicate that health can
be impacted both by cohabitation and marital status. A couple of
studies have reported on the independent effect of cohabitation
status and marital status [2,42].Our study implies that married
status may show positive association with functionality. Many
previous studies also reported having married persons experience
better health. There are several explanations, such as a direct
health promotional effect of the marriage, social support from
spouse [43,44], even the daily availability of health behaviors from
another person .
g d 2
in ie ) ) ) ) ) .6 ) ) ) ) ) ) ) ) ) )
liyvb rranUm(39=0n .(178821 .(672262 .(558912 .(442171 6.23767 .(858923 .()41145 .(932563 .)(4512 .)(014 .(442371 .(437061 .()26194 .(425761 .(419251 .()61126 .(523202 .(347431 .)(30105 .)(21174 .(350631 .(427661 .)(03104
(3) With spouse with children
(6) With spouse
*P-value is for One-way ANOVA F-tests between BADL, IADL, and ADL and living arrangements.
#P-value is for an LSD post hoc multiple comparisons test.
However, we see substantial variation in the extent to which
persons in the other living arrangements different from older
adults in unmarried status and living with children. Older persons
with similar marital status experience different functionality for
different cohabitation status. So a protective effect of marriage that
may be weakened by the identity and number of the partners. In
this study, an unmarried status, including being widowed, divorced
or never married reveals a passive single status. While, the
cohabitation of married persons was typed into two statuses, one
was living with spouse, the other was without spouse. In China,
living with adult children is traditional form, which was generally
replaced by living independently, or in empty nests. Married
persons living without spouse in our study may tend to be a more
active preference shaped not only by cultural norms but also by
education and exposure to new ideas . Some recent studies
indicated that elders living with children mainly for daily care, or
expectations that they serve younger generations . The
married elders living without spouse, but with children always play
the latter role. In addition, the reasons for living without a spouse
among married older adults also may be marital discord or
independent status. The preference reflects the congruence model
of the person-environment fit, with concordance of living
arrangements predicting better health . Anyhow, our results
suggest living arrangements based on household structure are
important beyond marital statusthat in certain circumstances
marriage does not protect health and being single does not
This study also provides evidence of association between
sociodemographic, contemporaneous circumstances and health factors
and functional disability. Emotional support as a type of social
supports in our study appears to exhibit a significantly positive
association with better functional status. It may contradict the
findings that persons living alone had better functional status
comparing with those who were unmarried elders living with
children. In fact, 67.3% of the unmarried and living with children
reported poor or fair self-rated health, while the proportion among
the living alone with unmarried and married status just were
53.0% and 48.8%, respectively. The results of association between
social support and functional status are in accordance with
previous evidence from other studies . However, few
studies have stratified social support into physical assistance and
emotional support. We think that the effects of physical assistance
and emotional support on health are different because perceptions
of emotional support tend to be correlated with marital status and
the social composition of the household [2,51,52]. Interestingly,
emotional support is positively associated with the functional status
of older adults. However, such an association cannot be found
between physical assistance and functional status. It is obvious that
higher age is associated with functional status decline for an
increase in disease. It is understandable that good ADL
functioning shows positive correlates with good self-rated health.
There are limitations to this study. One limitation might be its
cross-sectional design. We cannot draw conclusions of causality
between living arrangements and functional status. It is possible,
though unlikely, that the associations observed between unmarried
elders living with children and functioning decline, the living alone
and good functional status are a result of reverse causality. Second,
another limitation may be that data on social support in this study
relies on self-reported survey methods, not based on the
professional scales. It was measured by the two dimensions of physical
assistance and emotional support. Among previous studies, there is
a lack of consistence concerning the content of social support,
majority which is measured as a whole. In fact, four types of social
support: instrumental, informational, emotional and appraisal
support were defined by House . Further study could focus on
more exact classification and measurement. Third, living
arrangeWith spouse, children
Married, with children
primary school or more
Personalincome (yuan per year)
$5000 and ,10000
Number of diseases
ments in this study only reflect the current situation, did not have
information on the preference and satisfaction. Sarwariet al.
emphasized that the advantage of living alone may reflect
a preference. Because independent living expressed as a health
benefit in terms of decreased functional reliance on others .
Lawton et al. pointed out that any observed association between
living arrangements and health may have more to do with factors
and characteristics that are idiosyncratic to the individual and her
choice to live alone . The absence of information regarding
individual motivation limits our ability to identify the mechanism
relating living arrangements to health. So longitudinal study with
deep information -details of cohabitant children, individual
reference and maintenance time and so on- may clarify the
causality and mechanisms of association between living
arrangements and health.
In conclusion, functional disabilities vary by living arrangements
in different patterns and to different degrees. Our results highlight
the association of unmarried elders living with children only and
functioning decline comparing with other types. It implies policy
makers should pay closer attention to unmarried elders living with
children in community. Community service such as social support
also should be improved including life care, sanitary, day nursing
home, medical care, psychological counseling, rehabilitation and
Conceived and designed the experiments: HW KC. Performed the
experiments: HW YP FJ HL. Analyzed the data: HW. Contributed
reagents/materials/analysis tools: HW YP FJ HL. Wrote the paper: HW.
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