| Backgrouds and ObjectivesAging of population is an outstanding and global problem that is occurring currently and will last for a long period of time. As a developing country with the largest population in the world, China will have to face the problems caused by aging of population. Meanwhile it will be affected by many other social and economic factors, such as the dual structure of economy and society in urban and rural areas, etc. As a result, aging of population in China will develop in fast speed based on the immense population, and with more advanced age population and marked difference from one area to the another one. With speeding up of aging, a series of problems including change of family structure and living arrangements will arise and effect of the change on health of the elderly has been a focus in public health.Health is a status that can be embodied from multi-aspects, including physiological, psychological status and social adaptability, etc. Health status could be affected by many factors, such as genetic characteristics, environmental factors, lifestyle and behavioral habits and health service, and so on. Therefore how to assess health status of the elderly and its relation to living arrangements and the other factors has been a scientific and practicable issue. Especially, the associations between health status of the elderly and living arrangements need to be explored by further studies.Objective of the present study is to discover the biological and social-demographic characteristics; evaluate the physiological and psychological health status and quality of life of the elderly living with different arrangements; find out the main factors that associate with health status and quality of life of those living with different arrangements in rural and urban areas. Multi-factor model was constructed and adopted to find out the potential factors that affected physiological and psychological health of the elderly with different living arrangements in rural and urban areas. The factors that play key roles in causing the change in health status and quality of life of the elderly will be distinguished and elucidated in a longitudinal study.Materials and MethodsThe investigations in urban and rural areas were carried out in Gongshu district in Hangzhou city and Wuyicounty in Jinhua city, respectively. Two-stage stratified cluster sampling method was adopted and the study were carried out among those aged not less than60years and inhabited for not less than6months. Eventually,2554urban and2441rural participants in the first stage in2007and1498urban and2793rural participants in the second stage in2011had been recruited in the study.A structured questionnaire was adopted and the information including social-demographic characteristics, physiological and psychological health status, lifestyle-related factors, health condition, social activities and participation was collected by face to face interview. Quality of life of the subjects had been evaluated with SF-36scales in the first stage carried out from October to November in2007. Based on the first stage study, activities of daily life (physiological functions) and depression status (psychological functions) of the participants were assessed with activities of daily living (ADL, including BADL, IADL) and GDS scales in the second stage study carried out from May to August. Based on the two-stage study, longitudinal comparison had been performed and the change trend in quality of life and its influencing variables had been investigated.Reliability analysis and factor analysis were conducted to evaluate the reliability and validity of the ADL and GDS scales. One-Way ANOVA, Chi-square test, multiple linear regression and multi logistic regression were adopted in the study. Difference of physiological and psychological health status of the elderly with different characteristics was compared. ADL, depression status and quality of life and the differences among those living with different arrangements in rural and urban areas had been evaluated.Statistical models based on multi-linear regression and multiple classification analysis (MCA) had been performed to explore the factors that associated with physiological and psychological health status of the elderly with different living arrangements in rural and urban areas. Health related factors models had been constructed based on linear regression and MCA and the common factors and specific factors that associated with psychological and physiological health had been investigated. Changes in quality of life and their impact factors had been evaluated with multivariate analysis of variance.Results1Quality of life for the elderly living alone and non-living alone in rural and urban areas2157and2073validated questionnaires in the first stage, and1165and2609validated questionnaires in the second stage had been acquired from urban and rural areas, respectively. The ratios of those living alone in rural and urban areas were10.4%and25.1%in the first stage, respectively; the ratios became11.9%and22.6%in second stage. 1.1Horizontal comparison of quality of life The PF (physical functioning), VT (vitality) and MH (mental health) scores for the older adults living alone were lower than those non-living alone in urban area in the first stage, while difference in quality of life showed no significance between the two groups in the second stage. In rural area, no significant difference was detected in quality of life between those living alone and non-living alone in the first stage, however, all the four scores of physiology and SF score of psychology for those living alone in second stage were higher than those non-living alone.1.2The factors associate with living alone Having no spouse was the first cause of living alone and advanced age ranked second. Lower income was a factor that associated with living alone among the elderly in rural area.1.3Longitudinal comparison of quality of life Increased scores in PF, GH (general health) and MH but decreased one in VT for the elderly in urban area were observed. In, rural area, increased scores in RP (role limitations due to physical problems) and RE (role limitations due to emotional problems) and decreased scores in PF, BP (bodily pain), GH, VT and SF (social functioning) were detected. The scores in RP and RE for those living alone and non-living alone increased, while that in VT decreased. For those none-living alone, the score in SF became lower.1.4Change in quality of life Significant change in overall quality of life among the elderly was observed. The scores in GH and MH were higher, while those in PF, RP, and RE were lower in urban than those in rural. No significant difference in quality of life was detected between different genders and among different age groups. The significant change between advanced age and younger groups only appeared in PF score.2Living arrangements and their relations to social and biological characteristicsSignificant differences in term of social-demographic characteristics, lifestyle factors, psychological behaviors, prevalence rates of chronic diseases, accessibility to social support and social communication between the participants from rural and urban areas were detected in second of the study.Compared with the rural elderly, those living in urban area showed to be less frequent to live alone and engaged in bad psychological behaviors and lifestyles, and had higher income and were better educated. In addition, prevalence rate of chronic diseases among the urban elderly was higher than that among those in rural area (77.5%vs.38.5%, P=0.001), but the elderly living in urban area had more chances to participate in social communication and obtain social support. Those living alone tended to be older (76.60in urban and76.03in rural areas), female (81.30%in urban and65.30%in rural areas), and illiterate (37.0%in urban and82.2%in rural areas). Furthermore, those living alone had more difficulty to acquire material and psychological support and communicated with their relatives, family members, and neighbors less frequently; had more tendency to be unhappy, lacking sensation of happiness and life satisfaction in rural areas.3Associations between living arrangements and physiological health3.1Comparisons of BADL and IADL scores After adjustment in MCA model, the elderly living alone get lower ADL scores (6.27in urban and6.54in rural areas), but those living only with their children get higher scores (7.58in urban and7.19in rural areas). Correspondingly, those living alone in urban area get lower IADL score (9.42), while those live only with their children get higher IADL score (11.87).3.2Difference of the factors affecting ADL between rural and urban areas Living arrangements, age, lacking physical exercise, having difficulty to acquire support, number of the attacked chronic diseases and frequencies of communicating with their neighbors and friends are common factors that can affect physical activities of daily life. Lack of the sensation of happiness is a special factor for the elderly in urban area, but having difficulty to acquire psychological support, living with their parents or children and communicating with their neighbors and friends less frequently are specific factors associate with ADL.3.3Effect of living arrangements on ADL The common factors that associated with lower ADL for those living alone and non-living alone were advanced age, being worse educated, lack of physical exercise in urban area. For those living alone in urban area, lacking physical exercise and low educational level were the factors that associated with lower ADL ranking first and second, respectively. For those non-living alone in urban area, the factors ranking first and second were having difficulty to get material support and lacking physical exercise; in rural area, the factors were having difficulty to acquire psychological support and communicating with their relatives, neighbors and friends more frequently.4Associations between living arrangements and psychological health4.1Comparison of GDS scores After adjustment for age and gender, the elderly in rural area get higher GDS score than those in urban area (10.02vs.5.92). The elder living with their spouse and children get higher GDS score in urban area (6.54). In rural area, the GDS score for those living alone (10.35) were higher than those living only with their spouses (9.71), living with spouse and children (9.09), but lower than those living only with their children (12.44).4.2Factors affecting depressions of the elderly The common factors associate with depression were advanced age, being not engaged in tea consumption, lack of physical exercise, having difficulty to acquire material assistance, suffering more chronic diseases, poor health status, and living arrangements.In urban area, the factors that associate with depression of the elderly were having difficulty to get material assistance, poor overall health status, lacking sensation of happiness and living arrangements, while in rural area the factors were lacking sensation of happiness, poor health status, communicating with neighbors and friends more frequently and living arrangements. 4.3Factors affecting depressions of those living with or without spouse In urban area, the factors associated with depression of those living with spouses were lacking sensation of happiness, having difficulty to acquire material assistance and poor health status. For those living without spouse, the factors were having difficulty to acquire material assistance, poor health status, and suffering more chronic diseases.In rural area, the factors affecting depression of those living with spouses were lack of sensation of happiness, poor health status and advanced age, and the factors for those living without spouse were lack of sensation of happiness, poor health status and communicating with neighbors and friends more frequently.Conclusions(1) For the elderly living and non-living alone, the changes in quality of life of are inconsistent at different time point. Degree and trend of the longitudinal change are different from rural to urban areas, and the quality appears to became better in urban, while became worse in rural areas. The changes in quality of life for those living and non-living alone keep in same trend and can't be affected by age, living arrangements and gender.(2) Living alone of the elderly could be affected by many factors, including socio-demographic characteristics, psychosocial and lifestyle behaviors, health status and social support, etc. Among the factors included, having no spouse is the most important factor, followed by age. In addition, low income is also the important factors of rural elderly living alone. There is no significant difference in ADL between the rural and urban elderly. The elderly living alone appear to be better in ADL, while those living only with children appear to be worse, especially in urban area. Depression level of the rural elderly is higher than that of those in urban area. The elderly living with spouses and children in urban area and those living with children and living alone appear to be more depressed in rural area. (3) The factors affecting the ability of self-governing of the elderly are having difficulty to acquire material support, living with children and lacking sensation of happiness and physical exercise in urban area; the factors in rural area are having difficulty to acquire psychological support, advanced age and communicating with parents and children more frequently but less frequently with relatives, in urban area, for the elderly living alone, the factors ranking first and second that affect ADL are lacking physical exercises and low educational level, while for those non-living alone are having difficulty to acquire material support. The factors ranking first and second that affect ADL of the rural elderly living and non-living alone are having difficulty to acquire psychological support and communicating with the children and parents more frequently.(4) The factors impacting depressive symptoms of the urban elderly are having difficulty to acquire material support, poor health status, lacking sensation of happiness, living with spouse and living only with their children, respectively. For the rural elderly, the factors are lacking sensation of happiness, poor health status, communicating with neighbors and friends more frequently, and living with their children and living alone.In urban area, the factors that associate with highly depressive symptoms are lacking sensation of happiness, having difficulty to acquire material support and poor health status for the elderly living with spouses; for those living without spouse, the factors are having difficulty to acquire material support, poor health status and suffering more chronic diseasesIn rural area, the factors associate with highly depressed symptoms are lacking sensation of happiness, poor health status and advanced age for those living with their spouses; for those living without spouse, the factors are lacking sensation of happiness, poor health status and communicating more frequently with neighbors and friends.
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