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Sequential multiple mediating effect of loneliness and family health on physical frailty and willingness to age at home in older adults: a national survey in China

BMC Geriatrics volume 24, Article number: 919 (2024) Cite this article

Abstract

Background

With the rapid ageing of the global population, the number of older adults with physical frailty has been gradually increasing, making ageing at home a key strategy for coping with this demographic change. The opinions of older adults regarding their willingness to age at home deserve to be considered respectfully. As a result, this study aimed to investigate willingness to age at home and any associated underlying mechanisms involving physical frailty among older Chinese adults.

Methods

This study was a national cross-sectional survey. Stratified random and quota sampling were used before and after the individual level respectively. Willingness to age at home was compared between older adults with different characteristics using the Mann–Whitney U test and Kruskal–Wallis H test. A Spearman rank test was conducted to explore the correlations among physical frailty, loneliness, family health, and willingness to age at home. The path hypothesis that loneliness and family health influence the relationship between physical frailty and willingness to age at home among older adults was further tested through sequential multiple mediation analysis.

Results

A total of 3,837 older adults were included in this study. They returned a median score of 78 in terms of willingness to age at home. Physical frailty (β = − 0.044, P < 0.01) and loneliness (β = − 0.070, P < 0.001) were negatively associated, and family health (β = 0.275, P < 0.001) was positively associated with a willingness to age at home among older Chinese adults. Loneliness and family health played sequential multiple mediating role (β = − 0.018, Boot SE = 0.002, 95% CI = [–0.022, − 0.014]) between physical frailty and willingness to age at home.

Conclusions

Reducing physical frailty in older adults, reducing their sense of loneliness, and enhancing their family health is essential, as it can increase their levels of confidence with regard to ageing at home.

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Introduction

Population ageing has become a significant societal concern worldwide that is expected to increase in the near future. By 2030, the number of individuals over 60 years of age worldwide is projected to increase to 1.4 billion, thus comprising one-sixth of the world’s total population [1]. China is one of the most populous countries in the world, and its significant population of older adults is growing rapidly. According to China’s seventh population census [2], the number of older adults over 60 years of age reached 264 million in 2020, accounting for 18.70% of the country’s total population. The communique on the development of national undertakings for the aged in 2022 [3] showed that by the end of the year 2022, population aged ≥ 60 years had grown to 280 million. This number is expected to exceed 400 million by 2035, accounting for > 30%, indicating that China will have entered a stage of heavy population ageing. In the face of such a huge scale of older adults, there has been a consequent increase in the demand for long-term care. Influenced by the traditional Chinese ethics of filial piety, every generation in China takes children to support their parents as the obligation standard. As a result, ageing at home has been the main mode of care for older adults in China [4]. In the 1980s, China began to implement the one-child policy. As the post-1980s population begins to have children of their own, a “4-2-1” family—in which a couple takes care of four parents and one child—has gradually become commonplace, with adult children bearing a considerable burden of family old-age care [5]. Clearly, this model of ageing at home is now experiencing significant new challenges. To actively respond to the challenges of population ageing, the Chinese government adopted the new two-child policy in 2015 [6], and recently released a three-child policy to encourage childbirth [7]. However, the demographic benefits of the two-child policy will not be realised until after 2030 [6]. Therefore, at present, it remains a priority to address the needs of older adults in terms of home-based care [8].

With the changes in the country’s population structure, as well as in the conceptions around healthcare services, China’s undertakings for the aged has been encouraging diversified care service modes, leading to the emergence of new types of care for older adults, such as institutionalised long-term care facilities [9]. However, similarly to the situations in Japan, Finland, and other rapidly ageing countries [10, 11], 90% of older adults in China currently age at home [12]. Although there are many advantages to institutional nursing care services for older adults, it is unrealistic for China to build the large number of institutions it would require to house its entire population of older adults. In contrast, this would require the government to invest considerable funds, and the long training cycles needed to staff such institutions cannot be shortened. On the other hand, the resources currently owned by smaller home-based care may end up going to waste. Therefore, ageing at home remains the method of choice for older adults in China [8]. Thus, how to improve the existing mode of ageing at home and inject new energy is the challenge facing the Chinese government. However, the decision-making power related to this model often resides with caregivers, such as children and relatives, on behalf of the older adults they care for. This has resulted in a certain gap between decision-making power and the preferences of the older adults themselves, in terms of measures to facilitate ageing at home. Therefore, it is necessary to understand the views and attitudes of older adults themselves towards home-based care and explore the factors affecting their willingness to age at home to provide a more realistic reference for the construction and operation of China’s innovative family care system.

Physical frailty and willingness to age at home

As the population ages, the number of older adults with physical frailty will continue to increase. Physical frailty is a complex age-related disease state characterized by a decline in physical function, as well as a general loss of ability to cope with complex events and environmental stresses [13]. Physical frailty not only reduces the quality of life in older adults, increases the risks of adverse outcomes such as falls, unplanned hospital admissions, and death, but also increases the burdens placed on family members and society as a whole [14,15,16]. Physical frailty, as a transitional stage between health and disability, is now one of the major challenges faced by older adults in China [17]. Preventing physical frailty has become a central concern for clinicians, researchers, and policymakers [18]. The home, as an important place in which to care for older adults, is also a key place for identifying, preventing, and managing physical frailty. Recent studies have shown that willingness to age at home in older adults is related to physical health status [19]. Older adults with a poorer status were correlated with higher reluctance to choose home-based care because they believe that it cannot provide the healthcare services they expect, as well as professional forms of care such as long-term care, emergency calls [20]. Qiao et al. [21] explored the association between physical frailty in older adults and their intentions to choose institutional care. Their results showed that older adults with higher levels of physical frailty were more inclined to choose institutional care. Physical frailty is an important indicator of health status in older adults, and the relationship between physical frailty and willingness to age at home merits verification in a wider range of older adults. Moreover, the mechanisms behind how physical frailty affects willingness to age at home in older adults remain unclear.

Loneliness and family health as potential mediating factors

Older adults with physical frailty suffer from physical and psychological pains that may be caused by physical injuries and functional limitations. This pain is often difficult for others to understand, resulting in feelings of loneliness. Loneliness is a subjective feeling, and older adults with loneliness may feel a lack of intimate or adequate social relationships [22]. One study showed that loneliness was independently associated with physical frailty among community-dwelling older adults [23]. Loneliness in older adults can affect their attitudes toward home-based care, and older adults who experience more loneliness may have more negative attitudes toward this approach [24]. Therefore, we hypothesised that loneliness may serve as a mediating variable between physical frailty and willingness to age at home in older adults.

In addition to creating negative feelings in older adults themselves, physical frailty can also damage the physical health of their caregivers [25], causing the caregivers to develop negative mentalities such as subjective burdens and depression [26, 27] that are not conducive to the formation of a positive familial atmosphere [28]. In patients with chronic kidney disease, physical frailty has been shown to be associated with family function [29]. Considering that family function is only one aspect of family assessment, Weiss-Laxer et al. [30] proposed the term “family health” as a resource at the level of the family unit that develops from the intersection of the health of each family member, their interactions and capacities, as well as the family’s physical, social, emotional, economic, and medical resources. Family health integrates essential elements of concepts such as family structure, family function, and family social network. As in Western culture, blood or kinship has always been an important bond between family members in China. Their relationships with their family members can therefore significantly affect the choices that middle-aged and older adults make with regard to care modalities. More disharmonious familial relationships generally correlate with lower levels of preference for home-based care [31]. We chose family health as a comprehensive indicator in this study and hypothesised that it might mediate the relationship between physical frailty and willingness to age at home in older Chinese adults.

One study showed that loneliness correlates significantly with familial function [32]. According to Bowen’s family system theory, a family is a system in which members are interconnected and interdependent, and the negative emotions or experiences of one family member can cause strong impacts on the others [33]. Thus, loneliness in older adults may have a negative effect on family health. Taking all these notions into account, we hypothesised that physical frailty in older adults is sequentially related to increased loneliness, reduced family health, and ultimately a reduced willingness to age at home.

Theoretical framework

To explore the factors influencing the willingness to age at home in older adults, we followed Maslow’s hierarchy of needs theory to guide our study [34]. This theory emphasises that human motivation is determined by needs. It ranks human needs from low to high and divides them into five categories: physiological needs (such as food and health), safety needs (such as being protected), love and belonging (such as building relationships with others), respect (such as being respected by others), and self-actualisation (such as realising one’s goal). The needs of the various levels are interdependent and overlapping, developing in waves from low to high. The five needs may not exist at the same time, and the lower level needs only need to be partially satisfied to stimulate the higher level needs. The level of need and fulfilment at each level determines an individual’s motivation. Physical frailty, loneliness, and family health can be regarded in terms of the needs of older adults, and willingness to age at home can be examined in terms of motivation. When the physical frailty of older adults is secured to a certain extent, the fulfillment of their physiological needs will stimulate them to develop higher needs, and they may want to establish intimate relationships with others to weaken their sense of loneliness. After such intimate relationships are stabilized, older adults will further pursue the acquisition of economic, medical, and other resources in the family unit to meet the needs of ageing at home. Based on this, we proposed our hypothesis that physical frailty influences willingness to age at home in older adults, through the sequential multiple mediating effects of loneliness and family health.

It is necessary to listen to the voices of older adults. In general, our aim in this study was to examine the relationship between physical frailty, loneliness, family health, and willingness to age at home, through a largescale survey of a nationally-representative population of older adults in China. We also sought to explore whether loneliness and family health can continuously mediate the relationship between physical frailty and willingness to age at home. To the best of our knowledge, this is the first study to explore these intricate mechanisms between physical frailty and willingness to age at home in older Chinese adults. We hypothesised that:

  • 1) Physical frailty of older adults is related to their willingness to age at home;

  • 2) Loneliness can mediate the relationship between physical frailty and willingness to age at home in this population;

  • 3) Family health can also mediate the association between physical frailty and willingness to age at home in this population;

  • and 4) Loneliness and family health can sequentially mediate the relationship between physical frailty and willingness to age at home, in older Chinese adults.

Methods

Study design and participants

The data for this study came from the Psychology and Behavior Investigation of Chinese Residents (PBICR). This study surveyed residents in 148 cities, covering all provinces, autonomous regions, and municipalities in the Chinese mainland, between June 20 and August 31, 2022. Stratified random sampling was adopted at the provincial, municipal, district, county, and community/village levels; and non-equal probability (i.e., quota) sampling was adopted at the individual level. In the end, 30,505 valid questionnaires were collected. A total of 21,916 of these were pulled after adjusting for age, sex, and urban/rural distribution based on the results of China’s seventh population census in 2021. The study was conducted by trained investigators who distributed questionnaires to the participants one-on-one through an online platform (Questionnaire Star). The respondents were required to be able to understand or complete the questionnaire with the help of the investigator. All participants were required to sign an informed consent form prior to the survey. Those who were mentally abnormal, delirious, had cognitive dysfunction or were participating in other similar studies were excluded. All participants were anonymised. More details regarding the study’s protocol have been published previously [35].

This study was approved by the ethics review board of Shaanxi Health Culture Research Center (No. JKWH-2022-02) and was registered in the China Clinical Trials Registry (Registration No. ChiCTR2200061046. Date of registry:15/06/2022).

A total of 4,070 older adults aged ≥ 60 years were included, of whom eight were excluded because of missing information regarding physical frailty. Those with logical errors in their responses were also excluded. In the end, responses from 3,837 older adults were included in the study (Fig. 1).

Fig. 1
figure 1

Sample selection process

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Variables and instruments

Willingness to age at home

Ageing at home is a model of receiving care in the familiar home, which is centered on the family and is supported and cared for primarily by the older adults’ children and relatives. In order to discover more valuable information, after consulting with experts, we used a visual analogue scale (VAS) to indicate willingness to age at home. Older adults scored their willingness from 0 (unwilling) to 100 (very willing). Higher scores represented a stronger willingness of older adults to age at home. Older adults chose their scores to reflect their level of willingness. VAS can more accurately capture the actual feelings of research subjects, and is becoming increasingly popular in psychological tests such as public willingness and attitude [36].

Physical frailty

We used the FRAIL scale [37] to measure physical frailty, which includes five items related to fatigue, resistance (can’t go up a flight of stairs without any help), ambulation (have difficulty walking 500 m), and illnesses (≥ 5 diseases), as well as weight loss (a decline of more than 5% in a year). All five variables were coded as 0 (no) or 1 (yes), and the total scores were summed over a range of 0–5 points. Higher scores indicated poorer physical health among older adults. The FRAIL scale has been previously validated to perform well among older Chinese adults [38].

Loneliness

We used the Three-Item Loneliness Scale (T-ILS) [39] to measure the participants’ levels of loneliness. They were asked to indicate the frequencies with which the following questions applied to them: “How often do you feel left out?”, “How often do you feel isolated from others?”, and “How often do you feel that you lack companionship?”. The responses were rated on a three-point scale ranging from 1 (almost never) to 3 (often). It has a total score of 3–9, with a higher total score indicating greater loneliness. The T-ILS has been widely used in older adults [40].

Family health

We used the Family Health Scale-Short Form (FHS-SF) [28], which has been verified to perform well in the Chinese population, to evaluate family health [41]. The FHS-SF is a 10-item assessment scored on a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree). It has a total score of 10–50, with higher scores indicating better family health.

Sociodemographic characteristics

We obtained the participants’ characteristics—including age, sex, marital status, educational level, per capita monthly household income, medical insurance participation, and home quarantine status. Age and sex were self-reported. Marital status was categorised into married and single (unmarried/divorced/widowed). Educational level was a three-category variable: primary school and below, junior and senior high school, bachelor and above. Per capita monthly household income comprised four categories: ≤ 5,000, 5,001–9,000, 9,001–12,000, and ≥ 12,001 Chinese Yuan (CNY). Medical insurance participation was dichotomised into yes (including public health care, resident health insurance, employee health insurance, new agriculture cooperative medical insurance, and any commercial health insurance) or no. Home quarantine was classified into two categories by asking participants if they were quarantined in their homes due to COVID-19-related public restrictions at the time.

Statistical analysis

The normality of the data was assessed using the Kolmogorov–Smirnov test. Means and standard deviations were used to express normally-distributed continuous variables, whereas non-normally distributed continuous variables were expressed as medians and interquartile ranges (IQRs). Categorical variables were reported as numbers and percentages. Willingness to age at home was compared between groups divided according to their different sociodemographic characteristics using the Mann–Whitney U test and Kruskal–Wallis H test. We used the Spearman rank test to analyse the correlations among physical frailty, loneliness, family health, and inclination toward home-based care. Univariate and correlation analyses were performed using SPSS 27.0. The significance level of all hypothesis tests was set at two-sided P < 0.05. We applied model 6 of the PROCESS macro to test for the sequential multiple mediating effect of loneliness and family health. We used the Bootstrap method consisting of 5,000 replicate samples and set at 95% confidence intervals (CIs), to test the significance of these mediating effects. We considered the mediating effects to be significant if their 95% CIs did not contain zeros.

Results

Sample characteristics

Responses from a total of 3,837 older adults were included (Table 1). The median score in terms of willingness to age at home was 78. The average age of the respondents was 68.82 ± 6.28 years. Of these, 85.17% were married. Nearly half (48.45%) had educational levels of primary school and below. A proportion of 76.00% had a per capita household income of less than 5,000 CNY. The majority were able to cover part of the cost of their medical care through medical insurance (94.37%). Owing to the ongoing COVID-19 epidemic, 93.77% of the respondents had been quarantined at their homes at the time of the survey’s distribution.

Table 1 Sociodemographic characteristics of older adults (N = 3837)
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We then compared willingness to age at home among participants with different characteristics (Table 2). Our univariate analysis showed that there were significant differences in willingness to age at home among different age groups (P < 0.001). For older adults with per capita monthly household incomes of > 12,001 CNY, willingness to age at home was higher (P = 0.038). The difference in willingness to age at home among older adults with different home quarantine statuses was statistically significant (P < 0.001). There was no significant difference in willingness to age at home among older adults with different sexes, marital statuses, educational levels, and medical insurance participations (P > 0.05).

Table 2 Univariate analysis of willingness to age at home in older adults (N = 3837)
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Correlation

We conducted a pairwise correlation to explore the relationship between the four variables (Table 3). The results indicated that willingness to age at home was negatively correlated with physical frailty (r = − 0.120, P < 0.001) and loneliness (r = − 0.169, P < 0.001), and positively correlated with family health (r = 0.325, P < 0.001). Physical frailty was positively associated with loneliness (r = 0.323, P < 0.001) and negatively associated with family health (r = − 0.303, P < 0.001). Loneliness was negatively correlated with family health (r = − 0.317, P < 0.001).

Table 3 Correlations between physical frailty, loneliness, family health and willingness to age at home
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Sequential multiple mediating analyses

We used the bootstrap method to explore the roles of loneliness and family health in the relationship between physical frailty and willingness to age at home in our respondent cohort, controlling for age, sex, marital status, educational level, per capita monthly household income, medical insurance participation, and home quarantine status (Table 4).The results showed that physical frailty was positively correlated with loneliness (β = 0.294, P < 0.001) and negatively correlated with family health (β = − 0.198, P < 0.001). Loneliness was negatively correlated with family health (β = − 0.219, P < 0.001). We found that loneliness (β = − 0.070, P < 0.001) and family health (β = 0.275, P < 0.001) were significant negative and positive predictors, respectively, of willingness to age at home, after all other variables were included. When loneliness and family health were included in our regression analysis, the relationship between physical frailty and willingness to age at home remained significant (β = − 0.044, P < 0.01).

Table 4 Sequential multiple mediating models between physical frailty and willingness to age at home in older adults
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To further examine the relationship between physical frailty and willingness to age at home in older adults, a bias-corrected Bootstrap method was used. The mediating effects of loneliness (β = − 0.020, Boot SE = 0.005, 95% CI = [–0.030, − 0.011]), family health (β = − 0.054, Boot SE = 0.005, 95% CI = [–0.065, − 0.045]), and their sequential multiple mediation (β = − 0.018, Boot SE = 0.002, 95% CI = [–0.022, − 0.014]) were all found to be significant. These accounted for 14.60%, 39.42%, and 13.14% of the total effect, respectively. We found that the single mediating pathway of family health not only had a stronger mediating power than the single mediating pathway of loneliness but also a stronger mediating power than the multiple mediating pathways of loneliness combined with family health. However, there was no difference found between the single mediating pathway of loneliness and the multiple mediating pathways of loneliness combined with family health (Table 5).

Table 5 Comparison of mediation paths between physical frailty and willingness to age at home in older adults
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To visualize the relationship between the four main variables, we drew Fig. 2. Lower physical frailty, lower loneliness, and higher family health were associated with higher willingness to age at home. Each mediation path in Fig. 2 was valid that loneliness and family health can mediate, separately or together, the relationship between physical frailty and willingness to age at home.

Fig. 2
figure 2

Multiple mediating paths between physical frailty and willingness to age at home. Note: Each path reported a standardized coefficient. **P < 0.01，***P < 0.001

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Discussion

Although there have been several studies exploring the factors influencing the care preferences of older adults as they age [31, 42], their inclinations may be the result of multiple factors jointly mediated owing to the complexity of the health status and psychological needs in this demographic. Few studies in the literature have examined the factors that underlie the relationship between physical frailty and willingness to age at home in older adults. Based on Maslow’s hierarchy of needs theory, we proposed pathway hypotheses for how physical frailty affects willingness to age at home in older adults. In this study, we revealed the preference for ageing at home with a median score of 78 among older adults in mainland China. Their willingness to age at home was in the upper-middle range, but still had room to strengthen. We found that lower physical frailty, lower loneliness, and greater family health were associated with stronger willingness to age at home. Loneliness and family health partially mediated the relationship between physical frailty and willingness to age at home, respectively, in our cohort of older respondents. In particular, physical frailty may influence willingness to age at home in this demographic, through a chain-mediated effect involving loneliness and family health as well.

Direct effect of physical frailty on willingness to age at home

A negative correlation was observed between physical frailty and willingness to age at home. Physical frailty was found to be a direct predictor of willingness to age at home, constituting 32.12% of the total effect (Table 5). In other words, poorer physical health was correlated with an increased desire to age outside the home. In a study by Chen et al. [43], the researchers concluded that, while the majority of older adults preferred at-home or community-based ageing, those with disabilities showed a preference for institutional care vs. those without. This finding was similar to ours in this study. This demonstrates the pursuit of high quality of life in older adults as they age, and reflects the fact that home-based ageing is not yet able to fully meet the healthcare needs of some older adults in present-day China. In 2016, China began to implement a family doctor contracting system [44]; however, this system has not yet reached its full potential. The government needs to continue to improve the supervision and incentive mechanism behind this system, increase the input of medical resources into it, and improve the quality of the professionals staffing it [45], to increase the effective utilisation rate of family doctors and allow them to become primary decision-makers regarding healthcare in older adults. In recent years, with the support of the national government, some medical institutions have relied heavily on information technology to pilot “Internet hospitals”, “Internet nursing services”, and similar innovations to promote greater access to professional medical services in Chinese households. However, a significant portion of the older adults in the country are still unable to access these pilot resources. There remains a significant need to continue expanding the coverage of these pilot programs, enrich the content of the services they provide, optimise the service model, and improve its level of homogenization [46]. Therefore, convenient and high-quality medical services can better guarantee the health needs of older adults with physical frailty and increase their levels of confidence concerning ageing at home.

Mediating mechanism of loneliness

Old age has been regarded as a period of “loss” [47]. Even healthy older adults inevitably experience sensory and perceptual decline, as well as memory and cognitive loss [48] that can be further exacerbated by physical frailty [49]. The scope of available social activities is often significantly reduced in this demographic, and some older adults even have to face major life events such as the loss of a spouse and living alone. As various changes associated with old age take place, loneliness often develops unnoticed [50]. We found that physical frailty was positively associated with loneliness in the cohort of older adults surveyed in this study (Table 4; Fig. 2) This is consistent with the findings of previous related studies [51], which indicated that physical frailty can increase loneliness in older adults and that more severe physical frailty can further deepen feelings of loneliness. After controlling for sociodemographic factors, including age, sex, marital status, educational level, per capita monthly household income, medical insurance participation, and home quarantine status, multiple mediation analyses showed that loneliness mediated the relationship between physical frailty and willingness to age at home among older Chinese adults (Fig. 2). When physical frailty further increased feelings of loneliness in our cohort of respondents, they tended to show a decreased willingness to age at home. This may be attributable to the fact that older adults with physical frailty generally require more social and emotional support and have a reduced threshold for feeling lonely. If home-based care cannot meet their needs in these regards, these individuals are likely to seek out more beneficial ways of ageing, such as within institutionalised nursing facilities, where they perhaps find his bosom friend.

Mediating mechanism of family health

Our findings suggested that family health was positively correlated with willingness to age at home in older Chinese adults (Table 4; Fig. 2). Family health includes four dimensions: family/social /emotional health process, family healthy lifestyle, family health resources, and family external social support. Family is a key part of development in the lives of many individuals that provides not only a sense of security and emotional value but also personalised physical care and access to resources for family members [28]. As the range of activities available to an ageing individual decreases, their family may represent the most direct environment they have access to in their final years. If they perceive that at-home care can adequately meet their overall needs, older adults often indicate positive sentiments toward ageing at home. Our study also demonstrated that family health can mediate the relationship between physical frailty and willingness to age at home among older adults. Family health is dynamic in its development, changing as family members become ill and relationships break down [52, 53]. The physical frailty states of older adults can destabilise and reduce family health. When older adults do not receive adequate support in their family environments, their attitudes toward ageing at home can become negative. We found that the mediating effect of family health accounted for 39.42% of the total effect, which showed a clear advantage over the other two mediating pathways (Table 5). The family is essential to promoting the health of the general population in the 21st century [54]. Evidence has suggested that the valuation of care provided by families to their disabled and chronically ill members far exceeds the economic value contributed by the health care system [55]. Our findings may add evidence to support the notion of integrating family health into public health research and practice [56].

Mechanism behind the chain mediating effect of loneliness and family health

Several studies in the literature have reported on the relationship between physical health status and intention to age in place among older adults. Mair et al. [57] found less preference for home-based care after analysing the ageing preferences of middle-aged and older adults suffering from chronic diseases in 14 European countries. Our study came to a similar conclusion with regard to more severe degrees of physical frailty correlating with less willingness to age at home in older adults. However, few studies have investigated the mediating role of the individual and the family level in the relationship between health status and willingness to age at home. Our study found that loneliness and family health played a partial mediating role between physical frailty and willingness to age at home. The negative correlation that we found in our study between loneliness and family health in older adults validated the idea of family systems theory proposed by Bowen [33], and then we validated our last hypothesis. We propose the following explanation for this chain mediation effect. The willingness to age at home in older adults with more severe physical frailty can be weakened both by increased loneliness and a superimposed mediating effect of low family health. Older adults with higher levels of physical frailty are less resilient to stressors and less able to maintain internal homeostasis owing to declining physical functioning [13, 14]. These changes can easily lead to a significant sense of psychological unevenness [16], causing feelings of loneliness [58]. Older adults who feel lonely may have difficulty gaining empathy from family members, and they may become disappointed and marginalized, which manifests itself in less communication with family members. This chronically unhealthy family atmosphere may be related to older adults’ lower willingness to age at home. In addition, family members who grew up in families with poor family health may not give enough respect and care to older adults, which may also be associated to their low willingness to age at home.

There were several limitations to this study worth noting. First, as this was a cross-sectional study, we were unable to make firm causal conclusions. Therefore, the mechanisms we explored merit confirmation through related follow-up studies. Second, we collected survey responses from older adults through self-reported questionnaires that may have been inherently prone to subjective recall bias. Third, willingness to age at home among older Chinese adults will be affected by the cultural context such as “filial piety”. However, the database we used did not measure cultural variables which may make our findings have limited extrapolation. Future studies should consider incorporating cultural factors to further replicate our findings, and conducting them among older adults from different cultural backgrounds to improve the representativeness of the findings. Finally, marital status, as a control variable in this study, was divided into two categories: married and single. But this dichotomy may not be equivalent to the variable “widowed or not” and how much of a role widowhood plays on loneliness cannot be sure. Future research should consider a more detailed exploration of marital status, including widowed, divorced, or separated individuals, to better account for potential variations in loneliness.

Implications for practice

Our finding suggested that meeting the health and emotional needs of older adults while ageing at home by reducing physical frailty and loneliness and promoting their family health can increase their willingness to age at home. To continue promoting the fundamental role of ageing at home, we propose the following recommendations. The first step is to improve the accessibility and availability of primary health care resources. By accelerating improvements in facilities related to primary healthcare services, as well as training and importing relevant human resources, the scope and quality of primary healthcare services can be further expanded. Second, the Chinese government must accelerate the sinking of high-quality medical resources, further extend the scope of responsibilities doctors and nurses have in senior medical institutions, and support initiatives related to home visits by doctors and continuous nursing [59]. Third, healthcare institutions should focus on the early identification and prevention of physical frailty in older adults, as well as improve healthcare education and psychological services such as counselling for this demographic and their caregivers [60], in an effort to promote better family health. Barrier-free and age-adapted home environments for older adults with physical frailty would also likely be beneficial to enhancing their levels of comfort when ageing at home. Fourth, the government can alleviate the burden of family care through innovative care models, such as allocating some family care tasks to the centralised management of the community [61]. In addition to providing healthcare services, communities can organise substantial recreational and leisure activities to reduce loneliness in older adults [62, 63]. Finally, although it is unrealistic to pay informal caregivers directly, the reimbursement system for basic models of both urban and rural medical insurance and the old-age subsidy standard should be designed to be more equitable and beneficial to more Chinese citizens. The Chinese government should also support local industries throughout the country to provide more employment opportunities for workers and attract talent back to smaller towns while actively exploring a one-child care leave system to safeguard the manpower needed for family-based long-term care.

Conclusion

This study was a largescale national survey of willingness to age at home and the factors that influenced this sentiment, carried out in a nationally-representative sample of older adults in China. The confidence of willingness to age at home in Chinese older adults needed to be further strengthened. As was advocated in the WHO’s Decade of Healthy Ageing 2021–2030 document, it is essential to listen to the voices of older adults and consider their opinions meaningfully. Therefore, China must orient itself toward meeting the diverse care needs of older adults, reducing their physical frailty, and reduce their sense of loneliness. Family health may be a very important target for intervention in the future. China must support positive family health in home care environments, promote innovation in the home care service model, and thus ultimately achieve the goal of healthy ageing.

Data availability

The data sets generated and analyzed during this study are not publicly available as the data is still needed for other studies but are available from corresponding author WYB on reasonable request.

Abbreviations

VAS:

Visual Analogue Scale

FRAIL:

Fatigue, Resistance, Ambulation, Illnesses and Loss of weight

T-ILS:

Three-Item Loneliness Scale

FHS-SF:

Family Health Scale-Short Form

CNY:

Chinese Yuan

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Acknowledgements

We would like to thank all the participants who gave their valuable time to actively fill out the questionnaire.

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Authors and Affiliations

  1. School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, 44 Wenhua West Road, Jinan, Shandong Province, 250012, China

    Xuan Wang, Yifan Jiang, Zhiyong Xu & Lin Qi

  2. Department of Emergency Medicine, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan, Shandong Province, 250012, China

    Zhiyong Xu & Min Zhang

  3. Department of Nursing, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan, Shandong Province, 250012, China

    Zhiyong Xu, Lin Qi & Min Zhang

  4. Nursing Theory & Practice Innovation Research Center, Shandong University, 44 Wenhua West Road, Jinan, Shandong Province, 250012, China

    Zhiyong Xu, Lin Qi & Min Zhang

  5. Department of Surgery, Qilu Hospital of Shandong University, 107 Wenhua West Road, Jinan, Shandong Province, 250012, China

    Lin Qi

  6. School of Public Health, Peking University, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China

    Yibo Wu

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Contributions

WX and WYB provided ideas for research design. WX, JYF, and XZY analyzed the data. WX and QL interpreted the data. WX and ZM contributed to the drafting of the manuscript. All authors have approved the version to be released.

Corresponding authors

Correspondence to Yibo Wu or Min Zhang.

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This study was approved by the Shaanxi Health Culture Research Center ethics review board (No. JKWH-2022-02). Each participant fully understood the study and signed an informed consent form before the study.

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Not applicable.

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The authors declare no competing interests.

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Wang, X., Jiang, Y., Xu, Z. et al. Sequential multiple mediating effect of loneliness and family health on physical frailty and willingness to age at home in older adults: a national survey in China. BMC Geriatr 24, 919 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-024-05520-1

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BMC Geriatrics

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