Preplanned Studies: Limited Social Support, but Comparable Health Literacy and Service Utilization, Among Elderly People Living Alone — Six PLADs, China, May–September 2020

As the world experiences an aging population, elderly individuals living alone have become a particularly vulnerable subgroup. Living alone is associated with feelings of loneliness and insecurity, as well as difficulties in daily living. It has been shown to be a risk factor for a range of adverse health outcomes, including physical and mental health (1). In this study, a nationally representative sample of 2,959 elderly people in China was selected using a stratified multi-stage random sampling method from May to September 2020. Each participant completed a cross-sectional questionnaire with the support of a local research assistant. The questionnaire consisted of validated scales measuring health literacy, service utilization, and social support. Descriptive statistics and chi-square tests were performed, adjusting for potential confounding factors. This study found that elderly individuals living alone in China have a lower registration rate with a general practitioner (GP), limited social support, but comparable health literacy and service utilization compared to elderly individuals living with family. Targeted and effective community care interventions should be developed to improve the quality of life of elderly individuals living alone.

The 2015 China Family Development Report found that around 10% of the elderly population in China lived alone, and these individuals often experienced loneliness, which limited their access to social support (2). However, current research on this topic has some limitations. First, existing data mostly focus on specific provincial-level administrative divisions (PLADs) or cities and lack national-level representation. Second, previous research has primarily examined the health and mental well-being of elderly people living alone. These assessments often focus on individual levels, while overlooking important factors such as health literacy, social support, and service utilization, especially community health education and public health services. These factors can be comprehensively evaluated from 3 aspects: individual capabilities, interpersonal skills, and service utilization, which can be modified through intervention programs. The aim of this study was to compare the differences in health status, service utilization, and social support between elderly people living alone and those living with family in China to inform medical resource allocation and policy decision-making.

A stratified, multistage, cluster sampling method was used to randomly select six PLADs in China from May to September 2020. First, two PLADs were randomly selected from the eastern, western, and central regions of Chinese mainland. Second, the provincial capital and another randomly selected cities/districts (below the median GDP) were selected from each PLAD. Overall, a total of 3,009 participants were selected from Zhejiang, Jiangxi, Chongqing, Gansu, Liaoning, and Beijing. The sampled cities were further stratified by urban and rural areas, and participants were randomly selected from household registration lists. According to the guidelines of the National Human Rights Action Plan (2016–2020), more than 90% of adults aged ≥60 years are registered at their local community health centers. The inclusion criteria were as follows: 1) aged ≥60 years; and 2) agreement to participate. Participants with dementia or mental disorders were excluded. Participants were recruited from community health centers with support from GPs. The methodology of this study has been described previously (3). This study was approved by the ethics committee of Peking University Health Science Center (ethical approval number: IRB00001052-19143). Informed consent was obtained from all participants.

The questionnaire was developed by a multidisciplinary research team and pilot tested before use. The measurements included socio-demographic information, health status (whether participants had chronic diseases, hospitalizations in the past year, and outpatient visit within two weeks), GP registration status, service utilization (regular physical examination, oral examination, regular blood pressure monitoring, and blood sugar measurement), health literacy, social support, and self-reported anxiety/depression status. Health literacy, with a full score of 26, was measured with reference to the Core Information on Elderly Health released by the National Health Commission of China (4). A health literacy questionnaire score of 80% or above was judged as high health literacy (5). The Social Support Rate Scale (SSRS) developed by Xiao (6) was used to measure social support. The SSRS has 10 items and a score range of 12–83. Descriptive statistics were calculated for all participant characteristics. Categorical variables are presented as frequency (n) and percentage (%). Differences between groups were examined using an independent-samples t-test. The comparison of categorical variables was examined using a chi-square test. Additional adjustments for potential confounders (gender, age, marital status, education level, and income) were made using covariate analysis or stratification analysis. The statistical significance level was P<0.05. All tests were two-tailed. Statistical analyses were conducted with SPSS (version 27, IBM Corp., Armonk, New York, United States).

In this cross-sectional study, a total of 3,009 participants over the age of 60 were approached for the survey, of which 50 (1.7%) were excluded due to incomplete or ambiguous answers. Among the 2,959 elderly people included in the analysis, 260 (8.8%) lived alone. Of the participants, 56.0% (1,657/2,959) were women, and 75.4% (2,230/2,959) were aged 65 and above. Nearly half of the participants (48.8%, 1,445/2,959) had attained primary school education or below, and 51.2% (1,515/2,959) were registered urban residents. Of all participants, 46.4% (1,374/2,959) were of low- and middle-income [600–3,500 Chinese Yuan (CNY) per month] (Table 1). Overall, 10.4% (309/2,959) had high health literacy. Furthermore, 59.7% (1,766/2,959) reported having a diagnosis of at least one chronic disease, 13.5% (399/2,959) had a hospitalization experience in the past year, and 72.9% (159/218) had an outpatient experience in the past two weeks (Table 2). Females accounted for 65.0% (169/260) among elderly living alone, while 55.1% (1,488/2,699) of the elderly living with family were female; the difference was statistically significant (P=0.002). Of the elderly living alone, 58.0% (151/260) were in the senior age group (70 and above), while 40.3% (1,088/2,699) of those living with family were over 70 years old. Overall, the elderly living alone were more likely to be in higher age groups (P<0.001) (Table 1).

After adjusting for confounding factors, there was no significant difference in the outpatient rate between older adults living alone (76.9%, 20/26) and those living with family (72.4%, 139/192) in the past 2 weeks. Furthermore, the GP coverage rate for older adults living with family was 47.8% (1,289/2,699), which was higher than the rate of 42.7% (111/260) for those living alone (P=0.024). The total social support score for older adults living alone was 33.1±8.1, compared to 39.3±7.5 for those living with family. The mean subjective social support (20.5±4.9 vs. 23.6±4.8) and objective social support (5.7±3.1 vs. 8.7±2.7) scores of older adults living alone were lower than those of older adults living with family (P<0.001). There was no significant difference in the utilization of social support between the two groups (6.8±2.4 vs. 7.1±2.3). The health literacy score of older adults living alone (12.1±5.6) was significantly lower than that of older adults living with family (13.1±5.6) (P<0.001). Only 6.2% (16/260) of older adults living alone had high health literacy, compared to 10.9% (293/2,699) of those living with family. However, the difference was non-significant in the adjusted analysis. In total, 85.8% (223/260) of older adults living alone and 89.3% (2,409/2,699) of older adults living with family reported no anxiety or depression. The differences were not statistically significant (Table 2).