The relationship between self-assessment living standard and mental health among the elderly in rural China: the mediating role of sleep quality

doi:10.21203/rs.3.rs-1539692/v1

Objective: Psychological problems are the main cause of anxiety, depression and happiness reduction in the elderly. Mental health imbalance not only has a direct impact on physical health, but also has an indirect impact on social support, quality of life, and brings a huge burden of disease. The purpose of this study was to explore the relationship between self- assessment living standard and mental health and the mediating role of sleep quality among the elderly in rural areas of China.

Methods: Using typical field sampling method, Mengcheng County, Anhui Province was selected as the investigation site, and a total of 1223 respondents were selected. With the help of questionnaires, face-to-face interviews were used to collect data. Self- assessment living standard can be divided into five subjective dimensions. Mental health was evaluated by 12 Items General Health Questionnaire (GHQ-12). Sleep quality was measured by Pittsburgh Sleep Quality Scale (PSQI). Bootstrap test was used for data analysis.

Results: The results showed that 24.7% of the elderly had a tendency to have mental health problems, which was similar to 18.5%-24.47% of the general elderly population. 59.3% of the elderly had a general self-assessment living standard (average score was 2.89 ± 0.726). The average sleep quality score was (6.97 ± 4.066), and 2.5% of the respondents reported serious sleep problems. Elderly with low self- assessment living standards were more likely to report a higher propensity for psychological problems (β=0.420, P < 0.001) and poorer sleep quality (β= 0.608, P < 0.001) than elderly with high self- assessment living standards. Mental health of the elderly may be related to sleep quality (β= 0.117, P < 0.001). In addition, the effect of self- assessment living standard on mental health was significantly mediated by sleep quality (β= 0.071, P < 0.001).

Conclusions: Mental health is associated with self-assessment living standard, with this association mediated by sleep quality. A reasonable mechanism needs to be established to improve self-assessment living standard and sleep quality.

Self-assessment

Living standard

Mental health

Sleep quality

Elderly

According to the results of China's seventh census, the number of Chinese aged 60 and above has reached 264 million, accounting for 18.70% of the total population. The population aged 65 and above is about 190 million, accounting for 13.50% [1]. With the deepening of the aging degree in China, the psychological problems of the elderly have become increasingly prominent due to the changes in social and family structure, physical aging, the influence of diseases, and inadequate support system [2]. The data showed that the proportion of the elderly with mental problems in various regions of China ranged from 2.26–69.68% [3], Among them, the proportion of the elderly in rural areas with mental health problems is 1.76 times that of the elderly in urban areas [4], meanwhile, the life security, physical function and social support of the elderly in rural areas are significantly lower than those in urban areas. WHO defines health as a state of complete physical, mental and social adaptation, not just no disease or infirmity. Psychological imbalance not only has a direct impact on physical health, but also has an indirect impact on social support and quality of life, bringing a huge burden of disease.

Studies have shown that the aged’s age, economic status, physical status, social support, social role and lifestyle change are the main factors affecting their mental health [5,6]. Jiang Haochen’s research proved that compared with the elderly with a more affluent living standard, the elderly with a poorer living standard reported worse mental health [7], and reveal the self- assessment living standards may have an important impact on the mental health of the elderly population. Research pointed out that in addition to the objective measurement of economic level, people's subjective economic pressure measurement on the personal happiness and satisfaction occupy more important position [8], of the living standards of their subjective evaluation mainly from compare yourself with other living conditions, especially in rural areas of China the elderly by education degree is generally low, less mental recreation makes it easier to compare oneself with others. If one continues to believe that his or her standard of living is below the average or reference level, this long-term gap will indirectly affect his or her mental health. At present, China has achieved comprehensive poverty alleviation, and absolute poverty, which is measured by meeting basic survival needs, has been eliminated. However, the identification of relative poverty, which reflects the gap between individual economy, living conditions and local average living standards, has received little attention [9]. In addition, relevant studies on the living standards of the elderly in rural China focus more on objective evaluation of living standards, and less on subjective evaluation [10].

Sleep quality usually declines gradually with age [11], and some elderly people may suffer from sleep disorders. The incidence of sleep disorders among the elderly over 60 years old in China is 30% ~ 40% [12]. Sleep disorders are mainly manifested as difficulty in falling asleep and maintaining sleep, which leads to sleep deficiency and fatigue, and patients find it difficult to recover from sleep [13]. Studies have shown that there is a significant correlation between sleep quality and mental health, and sleep disorders (such as insomnia, narcolepsy, sleep apnea and circadian complaints) have a high comorbidity rate with depression and anxiety [14]. Optimizing sleep quality can promote mental health [15]. A large number of studies have shown that poor sleep quality will not only increase the occurrence of chronic diseases, but also increase the risk of death [16–18]. Meanwhile, the elderly with poor sleep quality are more likely to suffer from hypertension, depression and other diseases [19], and sleep is also associated with the risk of mental health and other psychiatric diseases [20]. At present, there are many studies on the influencing factors of sleep disorders in the elderly in China. For example, moderate exercise is beneficial to improve the sleep quality of the elderly [21]. Interpersonal relationship can affect the sleep quality of the elderly by affecting their mood [22]. However, the potential causes of sleep quality among the elderly in China have not been fully appreciated.

The pathway by which self-assessment of living standards affects the mental health of the elderly remains controversial. In the context of the rapid development of aging society has become the basic national conditions of China, the mediation of the impact of self-assessment of living standards on mental health has become an issue that needs to be studied in the prevention of psychological abnormalities in the elderly. Therefore, we conducted a cross-sectional study to uncover the relationship between self-assessment living standards and mental health among elderly people in rural China, and to consider the role of sleep quality in this study.

Study design and data collection

From July to September 2021, we conducted a cross-sectional survey in Mengcheng County, Anhui Province, central China. Mengcheng county is a pilot county of compact county medical community ( Figure 1 ). The local county and village medical and health service system is sound and relevant departments have strong coordination, providing good external conditions for the research work.

Two towns in Mengcheng County were randomly selected, and 5 villages were randomly selected in each town. The elderly ≥ 60 years old in the villages were investigated. Exclusion criteria included sensory or cognitive impairment, contraindications to physical activity, a medical diagnosis of a primary sleep disorder (for example, sleep apnea or primary insomnia), or any other confounding condition. Before the investigation, all subjects were told the purpose and procedure of the study orally. The investigators were all postgraduates from Anhui Medical University who had received unified training and doctors from local township health centers. Each subject was visited and interviewed face-to-face. A total of 1223 elderly people were surveyed, of whom 1188 completed the survey, with an effective response rate of 97.14% (1188/1223).

Measurement of Self-assessment Living Standard

This study used self-assessment living standard to measure the living standard of the elderly. The respondents were asked "What is your living standard in the local area?" , the answers were divided into five levels: "very good", "good", "average", "poor" and "very poor", with a value of 1, 2, 3, 4 and 5 respectively. The higher the score was, the lower the self-assessment living standard. Since this entry is subjective, we will not combine the answers to avoid increasing errors.

Measurement of Sleep Quality

The Pittsburgh Sleep Quality Scale (PSQI) was used in this study. PSQI was developed by Buysse et al. in 1989 for self-assessment of sleep in the past 1 month. The scale consists of 7 dimensions, including subjective sleep quality, sleep time, sleep time, sleep efficiency, sleep disorders, sleep drugs, and daytime dysfunction. Each dimension is 0 ~ 3 points, and the cumulative score is the total score. The lower the score, the better the sleep [23]. The Cronbachα coefficient of the scale was 0.77, the half-fold reliability was 0.83, and the structural validity was 0.63-0.91, indicating that the scale had good reliability and validity and was widely used [24,25].

Measurement of Mental Health

Mental health was measured using the 12 Items General Health Questionnaire (GHQ-12), a self-assessment screening tool that has been successfully applied to the Chinese sample. There are 12 items in the questionnaire, and the answers to each item are divided into four options. The first two items are counted as 0 points, and the last two items are counted as 1 point. The total score ranges from 0 to 12 points. The higher the GHQ-12 score, the higher the risk of developing psychological disorders[26]. The Cronbach’s alpha coefficient of GHQ-12 was 0.793.

Statistical analysis

First, we used the Chi-square test to examine differences in mental health among older adults with different living standards and quality of sleep. Rates and percentages are used to describe the demographic characteristics of different groups of subjects.

Next, Pearson correlation analysis was used to test the correlation between variables. In order to further explore the specific role path of sleep quality in the mediating effect of self-rated living standard on mental health, this study adopted the mediating effect test method proposed by Hayes [27], taking self-assessment living standard as independent variable, mental health as dependent variable and sleep quality as intermediary variable to test the significance of the mediating effect. Mediation test Model 4, developed by Hayes based on the SPSS macro program PROCESS, uses the non-parametric percentage Bootstrap method with bias correction to extract an estimated 95% confidence interval repeatedly for 5000 times. When the confidence interval of each path coefficient does not include 0, it indicates that the mediation effect is significant. According to the test results, the mediation effect path analysis model is drawn, as shown in Figure 2.

Characteristics of participants

Table 1 describes the general demographic characteristics of the respondents. The study involved 1,188 participants, of whom 895 had good mental health and 293 had poor mental health. There were good or poor differences between the two groups in gender, education level, living status, working status and other basic demographic characteristics, the incidence of chronic diseases, hospitalization, and sleep quality. Among the 895 subjects with good mental health, 50.72% (454/895) were male, 36.65% (328/895) were aged between 60 and 69, 21.90% (196/895) lived with their spouse, and 85.70% (767/895) had not seen a doctor in the last two weeks. 60.56% (542/895) had not been hospitalized in the past one year.

Table 1

General characteristics of the respondents (N = 1188)

	Total (N=1188)	Mental health		c²	p-value
	Total (N=1188)	Good(N=895)	Poor(N=293)	c²	p-value
Gender				5.269	0.022
Male	580（49.3）	454(50.73)	126(43.00)
Female	608（50.7）	441(49.27)	167(57.00)
Age(years)				0.027	0.986
60–69	4359(36.6)	328(36.65)	107(36.52)
70–79	55(47.0)	421(47.04)	137(46.76)
≥80	195(16.4)	146(16.31)	49(16.72)
Married status				1.613	0.656
Married	841(70.8)	642(71.73)	199(67.92)
Divorced	8(0.7)	6 (0.67)	2(0.68)
Widowed	289(24.3)	21(2.3)	79(26.96)
Others	50(4.2)	37(4.13)	13(4.44)
Education level				11.561	＜0.001
Primary and below	974（81.7）	712(79.55)	259(88.40)
Junior and above	217（18.3）	183(20.45)	34(11.60)
Employment status				34.228	＜0.001
Normal work	265（22.3）	197(22.01)	68(23.21)
Half work	380（32.0)	309(34.53)	71(24.23)
Housework	316(26.6)	250(27.93)	66(22.53)
Don’t work	224(18.9)	137(15.31)	87(29.69)
Other	3(0.3)	2(0.22)	1(0.34)
Living style				7.868	0.020
Living alone	250（21.0）	485(54.19)	145(49.49)
Living with spouse	630（53.0）	196(21.90)	54(18.43)
Other	308（25.9）	214(23.91)	94(32.08)
Living standard				27.189	＜0.001
Good	282(23.7)	239(26.70)	44(15.02)
Common	705(59.3)	529(59.11)	176(60.07)
Bad	308(25.9)	128(14.30)	73(24.91)
Chronic diseases				7.688	0.006
Yes	915(77.0)	672(75.08)	243(82.94)
No	273(23.0)	223(24.92)	50(17.06)
Physical discomfort				9.265	0.002
(Within two weeks)
Yes	996(83.8)	767(85.70)	229(78.16)
No	192(16.2)	128(14.30)	6(2.05)
Hospitalization				12.490	＜0.001
(Within a year)
Yes	685(57.7)	524(58.55)	143(48.81)
No	503(42.3)	353(39.44)	150(51.19)
Sleep quality				50.395	＜0.001
Very good	493(14.50)	416(46.48)	77(26.28)
Not too bad	420(35.35)	304(33.97)	116(39.59)
Common	221(18.60)	148(16.54)	73(24.91)
Very bad	29(2.44)	12(1.34)	17(5.80)

The relationship between Living standard, Sleep quality and Mental health

Pearson correlation analysis was conducted on the data of self- assessment living standard, sleep quality and mental health scales, and the results are shown in Table 2. The score of mental health status is significantly positively correlated with the score of self- assessment living standard and sleep quality.

In Table 3, bootstrap test analysis results showed that self-assessment living standard had a significant direct impact on mental health (β=0.420, 95%CI 0.273 - 0.567). Elderly people with higher self-assessment living standards are likely to report higher levels of mental health. Meanwhile, self-assessment living standard was significantly associated with sleep quality: higher self-assessment living standard was associated with better sleep quality compared with lower self-assessment living standard (β=0.608, 95%CI 0.282 - 0.933). There is also a link between sleep quality and mental health. Higher sleep quality scores were associated with higher mental health level (β=0.117, 95%CI 0.091 - 0.142). Based on the results, a path map of self-assessment living standards, sleep quality and mental health was drawn, as shown in Figure 2.

Table 2

Correlation analysis of subjective evaluation of living standard, sleep quality and mental health

	Self-assessment of living standards	Sleep quality	Mental health
Self-assessment of living standards	1
Sleep quality	0.107***	1
Mental health	0.178***	0.265***	1

Table 3

Bootstrap test of self- assessment living standard, sleep quality and mental health

Dependent variable	Predictive variable	Standardized regression coefficient	SE	T	95%CI		R²	F	P
Dependent variable	Predictive variable	Standardized regression coefficient	SE	T	LLCI	ULCI	R²	F	P
Sleep quality	Living standard	0.608	0.166	3.662	0.282	0.933	0.012	13.411	0.000
Mental health	Sleep quality	0.117	0.013	8.807	0.091	0.142	0.095	60.463	0.000
Mental health	Living standard	0.420	0.077	6.377	0.273	0.567	0.340	40.67	0.000

Mediating effect analysis of self-rated living standard, sleep quality and mental health

Sleep quality was a potential mediator in the association between self-assessment living standards and mental health (β=0.071, 95%CI 0.021 - 0.099). Bootstrap test results showed that the 95%CI of direct and indirect effects of self-assessment living standard on mental health score did not include 0. The results indicate that sleep quality plays a partial mediating role in the relationship between the self-rated living standard and mental health of the elderly in rural areas, and the partial mediating effect value is 0.071, accounting for 14.46% of the total effect. The specific results are shown in Table 4.

Table 4

The mediating effect of sleep quality on self-rated living standard and mental health

	Effect	Boot SE	95%CI
The total effect	0.491	0.077	0.339	0.642
Direct effect	0.420	0.075	0.273	0.567
Indirect effect	0.071	0.023	0.029	0.119

This study proved the relationship among self-assessment living standard, mental health and sleep quality among the elderly in rural areas of Anhui Province. The results showed that self-assessment living standard was closely related to mental health, and the elderly with low self-assessment living standard had a higher risk of psychological problems. However, this correlation occurs through both direct and indirect effects. Sleep quality played a significant partially mediating role between self-assessment living standard and mental health.

Rural elderly Self-assessment living standard, Sleep quality and Mental health status

Among the 1,188 respondents, 705 (59.34%) thought their living standard was average, 201 (16.92%) thought their living standard was poor or even very poor, and 282 (23.74%) thought their living standard was good, among which the proportion of self-assessment was average or poor was significantly higher than the research results of Jiang Haochen [28]. The reason may be that the regional distribution of the survey objects and the total number of samples are different. Meanwhile, the economic status and medical level of rural areas are lower than the national level. Some studies have classified the lifestyle of the elderly in China into four types: survival type, healthy type, risk type and mixed type, with 45%, 25%, 13% and 17% respectively. The life style of the elderly in rural Areas of China is mainly subsistence lifestyle [29]. They control the living cost and have few social participation behaviors, mostly watching TV and listening to radio, and less intake of fresh fruits and fish in daily life, which may be an important reason for their low self-assessment of living standard.

The results of this study show that 24.7% of the rural elderly have a tendency to have mental health problems, which is similar to 18.5%~24.47% of the general elderly population [30-32]. Compared with the urban elderly, the rural elderly in China have less financial resources, social support, family companionship, etc., and relatively overlapping living environment, which may have a negative impact on their mental health [33]. Gender, education level and working state have statistical significance to mental health difference, which is consistent with the research conclusions of Liang Xiaoli ; Zhang Pei et al. [34,35]. In addition, 21.5% of participants with PSQI scores above 11, and 2.5% of participants reported serious sleep problems, which was higher than the results of Ding Kunxiang's study [36].

The effect of Self-assessment living standard on Mental health

Previous studies have observed a correlation between self-assessment living standards and mental health [37]. Previous studies have revealed the impact of poverty on the mental health of the elderly. For example, Bayapa et al. (2012) found that poverty was significantly correlated with cognitive impairment and depression in the elderly in India [38]. Wen Xingxiang (2017) et al.’s study on the elderly in rural China shows that the mental health status of the elderly in poor families is worse [39]. Jiang Haochen et al. (2021) conducted a study on the elderly aged 65 and above in China, which verified that the elderly with lower self-rated living standards had more severe negative psychological emotions [40]. The negative impact of lower living standards on mental health may come from the negative impact of less economic foundation and resources on individuals' physical health and social behavior, or the poverty-related living environment may lead to more stress and negative emotions, thus affecting mental health [41]. In addition, social comparison theory believes that social comparison is intra-group and inter-group comparison, and the latter has a more obvious impact on individual psychological development [42]. However, these studies use different participant groups (e.g., young adults) or analytical methods (e.g., traditional regression and correlation). Although those studies differed from ours in terms of specific details, the results regarding the negative relationship between self-assessment living standard and mental health were consistent, which confirms the results of our study.

Self-assessment of the impact of Living standards on Sleep quality

This study found that self-assessment living standard was associated with an increased likelihood of high sleep quality among the elderly in rural areas in Anhui province. A study conducted in Yunnan Province, China, showed that older people in rural areas with lower family property have a higher likelihood of sleep disorders [43]. It may be related to their sensitive emotions. The elderly with lower living standards are more likely to have negative thoughts and to have random thoughts before going to sleep, which affects their sleep. Low level of self-reported life means not only a single economic sources, less material resources, and poor living environment, also means that more stressful life events and negative mood [44], which will result in its sleep problems obviously increased, low level of self-reported life will bring such as difficulty falling asleep, wake up, wake up at night and having nightmares and other sleep problems.

The mediating role of Sleep quality in Self-assessment living standard and Mental health

The results of this study show the correlation between low sleep quality and high tendency of mental health problems, which is consistent with the results of previous investigations on employees of public institutions [45]. The analysis also found that sleep quality was the mediating variable between the self-rated living standard and mental health of the rural elderly, playing a partial mediating role, accounting for 14.46% of the total effect. As a mediating factor, sleep quality is correlated with self-rated living standard and mental health. Self-rated living standard can indirectly affect mental health by acting on sleep quality, that is, the lower the self-rated living standard is, the worse the sleep quality is, and the lower the mental health level is. Earlier studies have also confirmed this conclusion. Jeffrey J. Kim et al found in a study of German communities and students that when individuals' sleep quality and mental health are not healthy, measures to improve sleep can better promote the improvement of mental health [46]. Lu Jiehua confirmed that there is a positive correlation between sleep quality and mental health of Chinese elderly in his evitable investigation of longitudinal data of Chinese elderly. Su Y's study found that poor sleep quality is associated with increased incidence of violations, aggression, depression and anxiety [47]. Possible explanations for this result is that although China has comprehensive poverty alleviation, rural residents general living standards improve gradually, but the income of the rural elderly people in China still is generally low, cultural life still relatively monotonous and boring [48], coupled with the decline in physiological function, relative lack of medical resources, children migrant workers and other factors, It will have a negative impact on their economic status and living standards for a long time. Over time, they are easy to fall into sleep difficulties, easy to wake up, nightmares and other sleep disorders, leading to their inability to relieve mental stress through sleep, resulting in psychological problems. The study of Jiang Guanghui et al.[49] shows that when the proportion of children going out is high, the negative time loss effect is dominant, which is not conducive to the improvement of parents' health. This survey found that 70.1% of the elderly live alone or only with their partners, and the proportion of children going out is high. Previous studies have found that cognitive behavioral therapy is particularly effective in improving individual sleep quality and mental health outcomes [50,51]. Therefore, China can help prevent sleep and psychological problems in the elderly by strengthening the training of primary medical workers in this therapy.

Advantages and Limitations

Advantages: First, the effective response rate of this study is 99.00% (1188/1223), as we all know, studies with higher effective response rates were more reliable. Secondly, we used internationally recognized measurement questionnaires to make objective measurements of the study subjects. In addition, this is the first study to examine the relationship between the three variables and the mediating role of sleep quality in the elderly population in Anhui Province.

However, this study also has the following limitations: First, self-rated living standards, sleep quality, and mental health were measured through questionnaires, which means that self-reported biases may affect the results. Second, since this study is a cross-sectional study, although there is a correlation between self-rated living standards, sleep quality and mental health, it is difficult to determine the causal association. Finally, the investigation objects of this study only cover rural areas of Anhui Province, and the extensibility of the results of this study is limited by factors such as economic development and cultural background.

Our research shows that self-assessment low living standards and poor sleep quality can exacerbate psychological problems. In addition, sleep quality mediates the relationship between self-assessment living standards and mental health. Our study explores possible pathways between self-assessment living standards and mental health, and may have implications for reducing mental health among rural elderly. Ultimately, our results may help alleviate psychological problems and improve sleep quality of rural elderly, and provide information for clinical prevention of diseases.

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of Anhui Medical University. All participants were fully informed about the study purpose and methods. Before conducting the survey, explain the purpose and procedures of the research to all interviewees, and ensure that all interviewees have informed consent to this research. For the illiterate interviewees, the informed consent of the guardian was also obtained.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated during the study are not publicly available due to an ethical restriction but are available from the corresponding author on reasonable request.

Conflicts of interest

The authors declare that they have no conflict of interest.

Funding

This research was funded by Research Projects of Humanities and Social Sciences in Colleges and Universities of Anhui Province (No. SK2018A0165) and Doctoral Fund Project of Anhui Medical University (No. XJ201545). The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Author’s contributions

BBZ conceptualized the study. XW, SL, MZ, contributed to the study design, data collection and data processing and statistical analysis. XR contributed to the literature review. BBZ wrote the article. BBZ, XW and WZ revised the article. All authors reviewed the manuscript and approved the final manuscript.

Acknowledgements

The authors would like to appreciate the involvement of the participants who joined this study. Author details

¹Department of Health Service Management, School of Health Management, Anhui Medical University, Anhui, China.

² School of Public Health and Health Management, Anhui Medical College, Hefei, Anhui, China

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No competing interests reported.

The relationship between self-assessment living standard and mental health among the elderly in rural China: the mediating role of sleep quality

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