The health utility value, which is a preference-based index measure of HRQoL predicted on the EQ-5D instrument, was found to be 0.944 in this study. This score surpasses those documented in analogous investigations conducted in urban(0.907) and rural (0.861) regions of China among middle-aged and older adults [61]. Furthermore, it slightly deviates from the reported value for the general population in China (0.946)[62]. Importantly, it exceeds recent findings from select high-income and upper middle-income countries, including the United States (0.851)[63], Germany (0.880)[64], Poland (0.888)[65], Bulgaria (0.942)[66] and New Zealand (0.847)[67]. These results are plausibly attributable to the multi-ethnic settlement dynamics of Yunnan province where ethnic minority groups exhibit relatively enhanced resilience, thereby engendering a subjectively higher HRQoL[68, 69]. Additionally, these findings convey that Health Program for Poverty Alleviation implemented over recent years has effectively ameliorated the health status of middle-aged and elderly populations, as well as individuals grappling with chronic conditions within the precincts of Yunnan Province[38].
Consistent with previous findings, this study also underscores the observation that individuals afflicted by NCDs commonly report diminished HRQoL. Moreover, our study reveals a progressive deterioration in HRQoL commensurate with an increase in the number of concurrent NCDs. This phenomenon can be attributed to the dual burden of physiological and psychological distress encountered by patients with NCDs. The deleterious impact on overall health and HRQoL attributed to NCDs stems from several facets. Firstly, many NCDs are associated with constant pain [70], limitations in functional abilities[71], and, in some cases, the development of disability[72], which collectively contribute to a compromised physical well-being. Moreover, NCDs typically exhibit a protracted and gradual progression, necessitating continuous medical treatment[4]. Apart from the psychological distress deriving from disease symptoms and treatment side-effects, individuals contending with NCDs often grapple with social and psychological challenges, including feelings of isolation, perceived burdensomeness on others, and the stigma attached to their conditions, all of which can detrimentally affect patients’ HRQoL[73, 74]. It is worth noting that in contrast to experiencing a solitary NCD, the acquisition of multimorbidity can further exacerbate patients’ HRQoL[75]. This exacerbation can be attributed to the coexistence of multiple NCDs, which prompts a more severe clinical scenario characterized by an increasing burden of diseases and their clustering patterns, thereby yielding inferior HRQoL outcomes[75]. One plausible explanation for this is that worsened conditions lies in the fact that aggravated health conditions not only generate heightened physical distress but also necessitate intricate therapeutic interventions. This, in turn, engenders challenges such as detrimental polypharmacy and overwhelming financial burdens associated with intensified medical care and potential unemployment[75–77].
Previous studies have posited an association between NCDs and heath lifestyle. Generally, individuals embracing healthier lifestyles are less prone to the onset of NCDs[78]. In the current study, significant correlations were discerned in the prevalence of NCDs among individuals engaging in diverse health-related behaviors. Additionally, a positive relationship emerged between the number of NCDs and health lifestyle. Specifically, smoking status, alcohol consumption, physical examination attendance and physical activity all exhibited positive association with the number of NCDs. These findings provide two significant insights. Firstly, it is arguable that individuals may modify their previously unhealthy behaviors in response to the progression of acquired NCDs[79, 80], prompting them to engage more frequently with healthcare services and adopt compliant medical behaviors[81]. This result further underscores the imperative of furnishing health management services to individuals aged 35 and above with chronic conditions through initiatives like the National Basic Public Health Services Project in China. Secondly, although being diagnosed with NCDs can potentially serve as a catalyst for unhealthy behavioral modifications, the effective transition to and sustained adoption of a healthy lifestyle at a younger age remains an ongoing challenge for patients[80, 82]. Initiating a healthy lifestyle at an early stage confers substantial benefits to individual health and represents a cost-effective intervention approach[83]. Therefore, it is prudent to prioritize the promotion of healthy lifestyles, particularly among economically disadvantaged populations, such as rural communities.
Based on the data presented in Table 2 of this study, no significant correlation was discerned between health utility value and health lifestyle score. Nonetheless, it is noteworthy that the health utility value demonstrated a negative association with scores pertaining to smoking status and alcohol consumption, while exhibiting positive correlations with scores related to sleep duration and physical activity. These results are consistent with several other investigations conducted across diverse populations. For instance, a cross-sectional study involving 1,920 community-dwelling elderly individuals in Korea reported lower HRQoL among participants who abstained from alcohol consumption, yet elevated HRQoL among those engaged in physical activity [25]. Similarly, another cross-sectional study comprising 2,037 community-dwelling adults in Japan identified insufficient physical activity and inadequate sleep as factors linked to lower HRQoL, while individuals with alcohol consumption habits exhibited higher HRQoL [17]. Moderate alcohol consumption and regular physical activity have been shown to enhance self-perceived happiness in various studies[84, 85]. However, it is crucial to provide tailored recommendations regarding optimal levels of alcohol consumption and physical activity for distinct age groups.
To date, although pairwise correlations between NCDs, HRQoL, and health lifestyle have been extensively examined, the moderating role of health lifestyle in the relationship between the number of NCDs and HRQoL remained a relatively unexplored area of inquiry. Firstly, this study confirmed that the adoption of a healthy lifestyle negatively moderates the relationship between the number of NCDs and HRQoL among middle-aged and older adults. In other words, the maintenance of a health-promotion lifestyle can act as a protective factor mitigating the adverse impacts of NCDs and promoting an enhanced state of HRQoL. Moderation effect analyses of each behavior further indicated that several specific behaviors, namely sufficient sleep duration, regular physical examinations, and engagement in physical activity significantly, moderate the relationship between the number of NCDs and HRQoL. The incongruities noted in the influence of smoking status and alcohol consumption on this relationship remain enigmatic but may be imputable to a diminished statistical power from a lower prevalence of these behaviors within our study sample[86]. Consequently, a pressing need exists for further research endeavors to comprehensively clarify the intricate interplay between specific behavioral factors and their influence on the relationship between the number of NCDs on HRQoL. Overall, the adoption of a healthy lifestyle emerges as a potentially effective mechanism linking NCDs with improved HRQoL.
Our findings propose a novel perspective on the promotion of HRQoL among middle-aged and older adults in rural areas, particularly those with chronic conditions. It is recommended to implement targeted healthy lifestyle interventions for individuals within this population. The current results highlight distinct focal points compared to previous intervention strategies, with particular emphasis on three specific health-related behaviors: sleep duration, physical examination attendance, and physical activity.
As for sleep, it is pertinent to recognize that both the aging process and the presence of NCDs can adversely affect the sleep patterns of older adults. Therefore, efforts to ameliorate the sleep quality of this population should not be overlooked[87]. Additionally, long-term agricultural labor may lead rural residents to neglect regular physical activity in their daily lives[88]. Hence, there is a pressing need to enhance health education and promote healthy lifestyle within rural areas by encouraging residents to engage in scientifically appropriate physical activities beyond their occupational work and cultivate good sleep habits. Furthermore, regular physical examinations assume a pivotal role in the early detection and treatment of NCDs among middle-aged and older adults. Over the years, while Chinese Government has made commendable strides in offering complimentary physical examinations for individuals aged 65 and above through the National Basic Public Health Service Project, the needs of middle-aged individuals have been underestimated. Given the vulnerability of rural populations in terms of economic capacity and disease incidence, it is recommended to further advance and expand this provision to encompass middle-aged adults residing in rural areas.
Two principal limitations warrant acknowledgment in this study. Firstly, our assessment of participants’ chronic disease status relied on a count of NCDs as an indicator. However, this counting method does not account for the specific types of NCDs, thereby precluding a nuanced understanding of the individual diseases’ distinct impacts on HRQoL. Secondly, our data collection was reliant upon self-reported questionnaires, a methodology susceptible to memory bias during the interview process.