Socioeconomic, health, and social connectedness factors associated with self-rated health of octogenarians and nonagenarians in South Korea: Urban and rural comparison

doi:10.21203/rs.3.rs-5012249/v1

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Research Article

Socioeconomic, health, and social connectedness factors associated with self-rated health of octogenarians and nonagenarians in South Korea: Urban and rural comparison

https://doi.org/10.21203/rs.3.rs-5012249/v1

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Background

The aging population, including octogenarians (aged 80–89) and nonagenarians (aged 90–99), is rapidly increasing. Understanding their self-rated health in urban and rural settings is vital for public health policy development. This study examined factors associated with self-rated health among octogenarians and nonagenarians across urban and rural areas of South Korea.

Methods

We analyzed data of 21,896 older adults (aged 80–99) from the 2023 Korea Community Health Survey. Self-rated health was assessed on a 5-point scale and categorized as "good" or "poor." Variables included age, residence area (urban/rural), sociodemographic characteristics, health behaviors, healthcare utilization, morbidity, and social interactions. Descriptive statistics were used to examine variable distributions, and logistic regression models identified factors associated with self-rated health in each age group and residential area.

Results

Among octogenarians, 18.7% in urban areas reported good self-rated health, compared to 15.0% in rural areas. In contrast, a smaller proportion of nonagenarians reported good self-rated health in urban areas (13.6%) than in rural areas (14.7%). Octogenarians in both rural and urban areas with higher education (urban odds ratio [OR] = 1.15, 95% CI = 1.07–1.24; rural OR = 1.15, 95% CI = 1.10–1.22) and higher income (urban OR = 1.18, 95% CI = 1.07–1.31; rural OR = 1.09, 95% CI = 1.01–1.18) reported better self-rated health. However, this association was less pronounced among nonagenarians. Characteristics such as regular walking (OR range 1.41 [95% CI = 1.23–1.62] among rural octogenarians to 2.25 [95% CI = 1.89–2.69] among urban nonagenarians), good self-rated oral health (OR range 2.48 [95% CI = 1.98–4.00] among rural nonagenarians to 3.50 [95% CI = 3.01–4.07] among urban octogenarians), and participation in social activities (OR range 1.24 [95% CI = 1.09–1.41] among rural nonagenarians to 1.67 [95% CI = 1.29–2.16] among urban octogenarians) were consistently associated with good self-rated health across all age groups in both rural and urban areas.

Conclusions

Characteristics associated with self-rated health differed significantly between octogenarians and nonagenarians in rural and urban areas. Public health strategies must support health-promoting behaviors such as regular walking, enhance oral health services, improve healthcare accessibility, reduce environmental stressors, and strengthen social support networks to promote health among octogenarians and nonagenarians.

Self-rated health

Octogenarians

Nonagenarians

Urban-rural comparison

Aging and well-being

As the global population ages, the number of individuals aged 65 years or older is increasing rapidly. In 2020, approximately 700 million people were in this age group, representing 9% of the total population [1]. This figure is projected to rise to 16% by 2050 [1]. Among this population, the number of octogenarians (80–89 years old) and nonagenarians (90–99 years old) are also growing significantly. By 2020, around 120 million people worldwide were aged 80 and older, which is expected to reach 430 million by 2050 [2]. In South Korea (hereafter referred to as Korea), the number of people in their 80s and 90s increased markedly between 2010 and 2020, from 1.4 million to 2.2 million and 200,000 to 400,000, respectively [3]. Life expectancy in Korea is projected to reach 86.7 years by 2030, the highest in the world [4]. Given the increasing size of this population, and the need to promote health among the oldest age groups,, addressing the needs of octogenarians and nonagenarians is essential for enhancing their quality of life and achieving Sustainable Development Goals [5]. Understanding these needs in Korea can provide valuable insights and strategies for global health policy development, benefiting other jurisdictions facing similar aging challenges.

Recently, octogenarians and nonagenarians have increasingly remained economically active after the traditional retirement age, typically in their 60s, or have maintained economic independence by starting their businesses [6]. As of 2023, 17% of individuals aged 80 and older were engaged in economic activities in Korea [7]. These individuals are engaged in various fields, including agriculture, self-employment, and casual labor [7]. Their economic participation contributes not only to their financial security but also to the economic vitality of society [8]. Octogenarians and nonagenarians also play significant social roles, such as raising grandchildren, passing on community wisdom, and advising younger generations [9]. Promoting health in these population groups will lead to more active economic and social participation, enhancing individual economic independence, family support, cultural continuity, and social solidarity [10].

Octogenarians and nonagenarians represent a significant segment of the older population, wih distinct health and policy needs that differentiate them from the overall population aged 65 and older group [11]. Public health research has often assumed uniformity in health status across older age groups, thereby overlooking the unique challenges faced by octogenarians and nonagenarians. These age groups encounter a broader range of health issues, including chronic conditions such as arthritis, cardiovascular diseases, diabetes, osteoporosis, cognitive decline, depression, and increased susceptibility to infections [12]. Effective management of chronic conditions and support for daily activities are crucial for maintaining their well-being [13]. Additionally, they face a greater risk of limited social engagement and feelings of isolation, highlighting the importance of robust social support networks [14]. Therefore, identifying and addressing the specific health needs that contribute to maintaining the health status of octogenarians and nonagenarians is a public health priority [15].

Self-rated health is a well-established indicator of the perceived health status of individuals, encompassing various factors such as medical diagnoses, conditions, symptoms, impairments, disabilities, and psychosocial issues [16]. Self-rated health is closely linked to overall population health and mortality, and is influenced by gender, household composition, education, income, health behaviors, stress, healthcare utilization, morbidity, and social participation, all of which shape self-assessments of health [17]. It is particularly critical for assessing the health of older adults, as it strongly predicts their quality of life and longevity [18]. Studies have indicated that individuals who rate their health as good are more likely to live longer than those who rate it poorly [19, 20]. Therefore, self-rated health assessment is essential for gerontological health research [21].

Urban and rural areas differ significantly in terms of access to healthcare, social resources, and environmental factors, leading to variations in self-rated health between and within individual countries [22]. Urban areas generally offer better access to healthcare and a more comprehensive range of health resources, which positively influence self-rated health [23]. However, high population density and environmental pollution in cities can adversely affect health [24]. Conversely, rural areas often benefit from a more natural environment and a strong sense of community but may face challenges such as limited healthcare access and social isolation [25].

In Korea, recent trends indicate that some older adults, including baby boomers, are moving from urban to rural areas in pursuit of quieter lifestyles and improved their quality of life [26]. Conversely, families with intergenerational caregiving responsibilities may relocate from rural to urban areas to gain better access to healthcare and educational resources [27]. Understanidng how these geographic and demographic shifts are associated with the health status of older adults in Korea is crucial [26]. Moreover, self-rated health varies across genders and age groups, highlighting the complexity of health assessments in diverse populations [22].

Previous studies have analyzed the factors associated with health status in older adults; however, detailed analyses specifically focusing on octogenarians and nonagenarians are lacking [28]. This gap is particularly notable in Korea, where the aging population is growing rapidly, and life expectancy is among the highest globally [3, 4]. The unique demographic and health characteristics of these age groups in Korea, including limited sample sizes in existing research and the rapid progression of age-related changes, underscore the need for focused research to address their specific health needs [29]. Although some research has examined the impact of urban versus rural environments on the health of older adults, it remains limited, often excluding the oldest age groups and relying on small, localized samples [29]. Addressing these gaps requires analyzing and comparing self-rated health and its associated factors among octogenarians and nonagenarians in urban and rural areas. This comparison will help identify how living environments affect the health of older adults and inform healthcare policies tailored to regional characteristics [30].

We aimed to identify the population distribution, the levels of good self-rated health among octogenarians and nonagenarians in Korea, and to analyze the factors associated with self-rated health. Our focus was on exploring how demographic factors, socioeconomic status, health behaviors and conditions, healthcare access, and social support are associated with self-rated health, with a focus on differences between urban and rural areas. These findings will inform targeted healthcare policies and support systems to improve the quality of life of the oldest Korean population and provide insights for other countries facing similar aging challenges.

Study design

We used the 2023 Korea Community Health Survey (KCHS) to assess self-rated health and its related factors in adults aged 80–99. The study sample consisted of 21,896 older adults aged 80–99 years. The KCHS is an annual nationwide survey conducted by the Korea Disease Control and Prevention Agency. It targets Korean residents aged 19 and older using a stratified multistage sampling method to ensure representativeness across urban and rural areas [31]. The survey achieved a high response rate, exceeding 90%, enhancing data reliability and validity [31]. Data for the 2023 KCHS were collected from May 16 to July 31, 2023, through computer-assisted personal interviews conducted by trained surveyors.

Variable definition and measurement

Outcome variable

The outcome variable was self-rated health, measured by the question, "How would you describe your general health?" Responses were recorded on a 5-point scale ranging from 1 (very good) to 5 (very poor). For the analysis, responses were dichotomized into good self-rated health (very good or good) and poor self-rated health (fair, poor, or very poor).

Stratification and adjustment variables

All analyses were stratified by age group (octogenarians and nonagenarians) and residential area (rural and urban). Age groups were classified based on the chronological age of the respondents. The residence area was categorized based on whether participants lived in rural (eup or myeon) or urban (dong) areas. We also considered other demographic and health-related characteristics that may influence self-rated health. These characteristics were selected based on previous research evaluating self-rated health according to residential area and age group [32].

Sociodemographic characteristics

Sociodemographic characteristics included sex, household composition, educational level, and household income. Household composition was categorized as single-generation (single person or couples), two-generation (with unmarried children or single parents with unmarried children), and three-generation households. Education levels were categorized as no formal education, elementary school, middle school, high school, and college graduate or higher. Household monthly income was grouped into four categories: less than 1 million Korean Won (KRW), 1 to less than 3 million KRW, 3 to less than 5 million KRW, and 5 million KRW or more.

Health behaviors and conditions

Health behavior and condition variables included current smoking status, monthly alcohol consumption, regular walking practice, self-rated oral health, and perceived stress level. Current smoking was defined as smoking at least five packs of cigarettes in a lifetime or currently smoking daily or occasionally. Monthly alcohol consumption was defined as consuming alcohol at least once per month in the past year. Regular walking practice was defined as walking for at least 30 minutes daily for five or more days in the past week. Self-rated oral health was classified as good if respondents rated it as 'very good' or 'good.’ Perceived stress level was considered high if respondents regularly reported feeling ‘very much’ or ‘a lot’ of stress.

Healthcare utilization and morbidity

Healthcare utilization and morbidity variables evaluated access to medical services and disease status. The unmet medical need was defined as the inability to visit a medical facility (excluding dental clinics) in the past year. Additionally, a diagnosis of hypertension or diabetes was defined as ever being diagnosed with either condition by a physician.

Social interaction and activities

Social interaction was defined as seeing or contacting relatives (including family members), neighbors, or friends at least once a week. Participation in social activities was defined as regular involvement in at least one of the following activities once a month: religious, social gatherings, leisure/recreational, or charitable activities.

Statistical analysis

Among the variables, missing values were identified as follows: self-rated health (n = 320, 1.46%), household income (n = 2,560, 11.7%), educational level (n = 1,120, 5.12%), walking (n = 300, 1.37%), monthly alcohol consumption (n = 180, 0.82%), current smoking (150, 0.68%), diabetes diagnosis (n = 100, 0.46%), and hypertension diagnosis (n = 90, 0.41%). Other variables had no missing values. Missing data were imputed using the multiple imputation method with the “mice” package in R.

All statistical analyses were weighted to ensure sample representativeness. Descriptive statistics examined the distribution of octogenarians and nonagenarians in rural and urban areas presented as unweighted frequencies and weighted percentages. Characteristics of those reporting good self-rated health were analyzed by age group and residential area. Differences between urban and rural areas within age groups were assessed using the chi-square test.

Following descriptive statistical analysis, logistic regression analyses were performed to identify characteristics associated with good self-rated health across age groups and residential areas. Odds ratios (ORs) and 95% confidence intervals (CIs) of the estimates were obtained after adjusting for the covariates above.

Sociodemographic characteristics of octogenarians and nonagenarians by residence area

Among the total sample (n = 21,896), 91.9% (n = 19,985) were octogenarians and 8.1% (n = 1,911) were nonagenarians (Table 1). Within the octogenarian group, 32.1% resided in rural areas, while 36.5% of nonagenarians lived in rural areas. In the octogenarian group, 58.9% were female, with a higher proportion of female in rural areas (61.5%) compared to urban areas (57.7%) (p < 0.001). Similarly, in the nonagenarian group, 68.9% were female, with a higher proportion in rural areas (72.0%) compared to urban areas (67.1%) (p < 0.05).

Regarding household composition, 69.9% of octogenarians lived in single-person households, with a higher prevalence in rural areas (76.9%) than in urban areas (66.6%) (p < 0.001). Among nonagenarians, single generation households were also the most common (51.4%), with a higher prevalence in rural areas (62.5%) compared to urban areas (45.1%). For this age group, two- and three-generation households were more prevalent in urban areas, compared to rural areas.

In terms of educational attainment, the highest percentage of octogenarians had no formal education (34.1%), with a significantly higher proportion in rural areas (48.5%) compared to urban areas (27.3%) (p < 0.001). For nonagenarians, the proportion without formal education was even higher at 47.1%, with a higher percentage in rural areas (64.1%) compared to urban areas (37.3%) (p < 0.001).

Regarding household income levels, the most common monthly household income range for octogenarians was between 1 million and 3 million KRW (40.4%), with urban residents generally having higher income levels than their rural counterparts (percentage of households with monthly income above 5 million KRW: rural 5.6%; urban 13.3%) (p < 0.001). Among nonagenarians, the largest proportion had a monthly household income below 1 million KRW (39.8%). Similar to octogenarians, nonagenarians in urban areas genereally had higher income levels than those in rural areas.

Table 1

Sociodemographic characteristics of octogenarians and nonagenarians by residence area
Characteristics	Octogenarians (people aged 80–89 years)			p	Nonagenarians (people aged 90–99 years)			p
	Total	Rural	Urban		Total	Rural	Urban
	n (%)	n (%)	n (%)		n (%)	n (%)	n (%)
Total	19,985 (-)	12,788 (32.1)	7,197 (67.9)	-	1,911 (-)	1,300 (36.5)	611 (63.5)	-
Sex
Female	12,581 (58.9)	8,222 (61.5)	4,359 (57.7)	***	1,413 (68.9)	984 (72.0)	429 (67.1)	*
Male	7,404 (41.1)	4,566 (38.5)	2,838 (42.3)	***	498 (31.1)	316 (28.0)	182 (32.9)	*
Household composition
Single-generation	15,359 (69.9)	10,311 (76.9)	5,048 (66.6)	***	1,173 (51.4)	866 (62.5)	307 (45.1)	***
Two-generation	3,451 (20.6)	1,959 (17.3)	1,492 (22.1)		592 (36.7)	369 (30.4)	223 (40.2)
Three-generation	1,175 (9.5)	518 (5.8)	657 (11.2)		146 (11.9)	65 (7.1)	81 (14.7)
Education level
None	8,939 (34.1)	6,745 (48.5)	2,194 (27.3)	***	1,117 (47.1)	870 (64.1)	247 (37.3)	***
Elementary	6,087 (30.5)	3,869 (30.8)	2,218 (30.3)		523 (30.2)	326 (25.8)	197 (32.7)
Middle	2,015 (12.6)	1,027 (9.1)	988 (14.2)		100 (7.1)	50 (4.8)	50 (8.4)
High	1,996 (14.5)	860 (8.3)	1,136 (17.4)		108 (9.2)	39 (4.1)	69 (12.1)
≥ University	948 (8.3)	287 (3.2)	661 (10.8)		63 (6.5)	15 (1.2)	48 (9.5)
Monthly household income (KRW)
< 1 million	9,714 (36.8)	7,280 (52.9)	2,434 (29.3)	***	1,005 (39.8)	784 (56.3)	221 (30.3)	***
[1 million, 3 million)	7,244 (40.4)	4,157 (33.6)	3,087 (43.7)		568 (34.8)	347 (29.6)	221 (37.8)
[3 million, 5 million)	1,711 (11.9)	827 (7.9)	884 (13.8)		190 (13.1)	99 (6.6)	91 (16.8)
≥ 5 million	1,316 (10.8)	524 (5.6)	792 (13.3)		148 (12.3)	70 (7.4)	78 (15.0)
* p < 0.05, p < 0.01, * p < 0.001; actual p-values are provided for p ≥ 0.05

Health-related characteristics of octogenarians and nonagenarians by residence area

Among octogenarians, urban residents reported a higher proportion of good self-rated health (18.7%) compared to rural residents (15.0%, p < 0.001). No significant differences in good self-rated health were observed between urban and rural nonagenarians (Table 2).

While smoking prevalence was uniformly low across all groups (≤ 5%), significant differences in walking practice were noted among octogenarians, with urban residents being more active (41.7%) than rural residents (30.4%, p < 0.001). Nonagenarians showed no significant differences in walking activity. Self-rated good oral health was significantly higher among urban octogenarians (14.6%) compared to rural octogenarians (12.0%; p < 0.001). Stress levels showed significant disparities only among octogenarians, with rural residents experiencing higher stress. Additionally, nmet medical needs were more prevalen among rural residents in both the octogenarian and nonagenarian groups. Diabetes prevalence was notably higher in urban octogenarians (26.8%) compared to rural (22.7%, p < 0.001). Social interactions were more frequent in rural residents among both octogenarians (rural 92.6%, urbal 80.7%) and nonagenarians (rural 91.5%, urban 75.3%), and social activity participation was significantly higher in urban areas for octogenarians (55.5%) compared to rural areas (48.0%, p < 0.001). No significant differences were found in alcohol consumption or hypertension diagnosis across any groups, suggesting that these factors are relatively uniform between urban and rural areas.

Table 2

Self-rated health and other health-related characteristics of octogenarians and nonagenarians by residence area
Characteristics	Octogenarians (people aged 80–89 years)			p	Nonagenarians (people aged 90–99 years)			p
	Total	Rural	Urban		Total	Rural	Urban
	n (%)	n (%)	n (%)		n (%)	n (%)	n (%)
Good self-rated health	3,115 (17.5)	1,829 (15.0)	1,285 (18.7)	***	257 (14.0)	174 (14.7)	83 (13.6)	0.57
Health behaviors and conditions
Current smoking	974 (4.9)	623 (5.0)	351 (4.9)	0.91	56 (3.8)	42 (4.6)	14 (3.3)	0.27
Monthly drinking	3,374 (18.1)	2,125 (17.3)	1,249 (18.5)	0.05	186 (10.4)	129 (11.1)	57 (9.9)	0.45
Regular walking	6,678 (38.1)	3,803 (30.4)	2,875 (41.7)	***	362 (20.7)	242 (19.4)	120 (21.4)	0.38
Good self-rated oral health	2,531 (13.7)	1,497 (12.0)	1,034 (14.6)	***	141 (7.1)	93 (7.0)	48 (7.2)	0.87
High-stress level	3,440 (17.2)	2,239 (18.5)	1,201 (16.6)	**	290 (16.5)	195 (14.9)	95 (17.5)	0.21
Healthcare utilization and morbidity
Unmet medical needs	1,232 (5.4)	896 (6.8)	336 (4.7)	***	170 (7.9)	130 (10.3)	40 (6.4)	**
Diagnosed with hypertension	12,657 (61.9)	8,207 (62.7)	4,450 (61.5)	0.14	1,248 (62.7)	864 (64.4)	384 (61.7)	0.30
Diagnosed with diabetes	4,786 (25.5)	2,829 (22.7)	1,957 (26.8)	***	323 (18.3)	206 (16.0)	117 (19.6)	0.06
Social interaction and activities
Social interactions	18,017 (84.5)	12,100 (92.6)	5,917 (80.7)	***	1,677 (81.2)	1,209 (91.5)	468 (75.3)	***
Social activities	9.971 (53.1)	6,072 (48.0)	3,899 (55.5)	***	657 (35.9)	442 (34.8)	215 (36.5)	0.51
* p < 0.05, p < 0.01, * p < 0.001; actual p-values are provided for p ≥ 0.05

Comparison of sociodemographic characteristics of octogenarians and nonagenarians with good self-rated health by residence area

Our analysis showed significant differences in the perception of good self-rated health across different sociodemographic variables based on residential area (Table 3). Among octogenarian females, a higher proportion of urban residents reported good self-rated health (15.0%) compared to rural residents (10.8%, p < 0.001). Conversely, nonagenarian males in rural areas reported a higher proportion of good self-rated health (23.2%) compared to those in urban areas (15.6%; p < 0.01).

In the octogenarian group, urban residents from single-generation (rural 15.3%, urban 19.5%; p < 0.001) and two-generation (rural 14.2%, urban 17.6%; p < 0.05) households perceived their health as good at higher rates than their rural counterparts. Additionally, among those with no formal education, urban octogenarians reported a higher proportion of good self-rated health (12.3%) compared to rural octogenarians (10.7%, p < 0.05).

Self-rated health differed by income level. Among octogenarians with a household income below 1 million KRW, those in urban areas reported a higher proportion of good self-rated health (14.2%) compared to those in rural areas (11.8%, p < 0.01). For nonagenarians with a monthly income between 1 and 3 million KRW, those in rural areas reported a higher proportion of good self-rated health (17.7%) compared to their urban counterparts (14.2%; p < 0.05).

Table 3

Proportion of octogenarians and nonagenarians reporting good self-rated health by sociodemographic characteristics
Characteristics	Octogenarians (people aged 80–89 years)		p	Nonagenarians (people aged 90–99 years)		p
	Rural	Urban		Rural	Urban
	n (%)	n (%)		n (%)	n (%)
Total	1,829 (15.0)	1,285 (18.7)	***	174 (14.7)	83 (13.6)	0.29
Sex
Female	884 (10.8)	624 (15.0)	***	112 (11.4)	53 (12.7)	0.16
Male	945 (21.6)	661 (23.6)	0.07	62 (23.2)	30 (15.6)	**
Household composition
Single-generation	1,497 (15.3)	937 (19.5)	***	113 (15.7)	42 (13.4)	0.07
Two-generation	261 (14.2)	239 (17.6)	*	55 (12.6)	30 (12.9)	0.89
Three-generation	71 (12.7)	109 (15.7)	0.15	6 (14.3)	11 (16.3)	0.75
Education level
None	709 (10.7)	252 (12.3)	*	98 (12.2)	32 (13.7)	0.13
Elementary	597 (15.7)	358 (16.0)	0.74	55 (18.9)	26 (13.2)	**
Middle	201 (19.2)	204 (20.0)	0.69	8 (17.2)	8 (19.5)	0.57
High	222 (25.9)	270 (25.0)	0.70	9 (23.3)	8 (8.5)	*
≥ University	100 (32.3)	201 (30.4)	0.60	4 (16.7)	9 (16.4)	0.96
Household income
< 100	853 (11.8)	345 (14.2)	**	87 (13.3)	24 (11.1)	0.06
[100, 300)	734 (18.7)	583 (19.9)	0.27	65 (17.7)	34 (14.2)	*
[300, 500)	146 (19.3)	194 (22.1)	0.18	13 (11.3)	16 (16.8)	0.13
≥ 500	96 (16.5)	163 (21.1)	0.08	9 (15.7)	9 (13.8)	0.77
* p < 0.05, p < 0.01, * p < 0.001; actual p-values are provided for p ≥ 0.05

Comparison of health-related characteristics of octogenarians and nonagenarians with good self-rated health by residence area

In our analyses, significant differences were observed in the perception of good self-rated health among octogenarians and nonagenarians based on residential areas and health-related characteristics (Table 4). Among octogenarians who smoked, a lower percentage of urban residents reported good self-rated health (18.5%) than their rural counterparts (20.3%, p < 0.001). This trend was reversed among octogenarians who consumed alcohol monthly; those in urban areas reported good self-rated health more frequently (28.6%) than those in rural areas (24.6%; p < 0.01).

Further distinctions were noted in physical activity levels. Both octogenarians and nonagenarians residing in urban areas reported higher percentages of good self-rated health related to regular walking practices, with urban octogenarians at 26.1% and nonagenarians at 24.5%, which were significantly higher than their rural counterparts at 20.6% and 19.1%, respectively (p < 0.001 for octogenarians, p < 0.05 for nonagenarians).

Self-rated health perceptions also differed by stress level. Nonagenarians experiencing high levels of stress in rural areas reported a better perception of self-rated health (9.7%) than those in urban settings (3.5%, p < 0.01). Similarly, octogenarians with conditions such as hypertension or diabetes reported better self-rated health in urban areas compared to rural areas.

Social engagement further influenced health perceptions among octogenarians. Those engaging in social interactions at least once a week and participating in social activities at least once a month reported higher rates of good self-rated health in urban areas (20.2% and 22.3%, respectively) than their rural counterparts (15.1% and 18.4%, p < 0.001 for both social interactions and activities).

Table 4

Proportion of octogenarians and nonagenarians having good self-rated health by health-related characteristics
Characteristics	Octogenarians (people aged 80–89 years)		p	Nonagenarians(people aged 90–99 years)		p
	Rural	Urban		Rural	Urban
	n (%)	n (%)		n (%)	n (%)
Total	1,829 (15.0)	1,285 (18.7)	***	174 (14.7)	83 (13.6)	0.29
Health behaviors and conditions
Current smoking	122 (20.3)	60 (18.5)	0.54	7 (19.7)	5 (42.2)	***
Monthly drinking	490 (24.6)	352 (28.6)	*	30 (26.2)	11 (22.5)	0.55
Regular walking	764 (20.6)	718 (26.1)	***	42 (19.1)	29 (24.5)	*
Good self-rated oral health	505 (35.9)	387 (38.5)	0.21	35 (35.2)	13 (33.7)	0.71
High-stress level	136 (7.1)	87 (7.2)	0.94	12 (9.7)	4 (3.5)	**
Healthcare utilization and morbidity
Unmet medical needs	64 (8.2)	24 (7.5)	0.65	13 (8.6)	1 (4.0)	**
Diagnosed with hypertension	983 (12.4)	682 (15.8)	***	107 (13.6)	42 (10.9)	*
Diagnosed with diabetes	288 (10.3)	245 (13.6)	**	23 (13.8)	17 (13.1)	0.81
Social interaction and activities
Social interactions	1,744 (15.1)	1,115 (20.1)	***	162 (14.7)	70 (15.3)	0.62
Social activities	1,057 (18.4)	848 (22.3)	***	78 (18.7)	40 (17.2)	0.39
* p < 0.05, p < 0.01, * p < 0.001; actual p-values are provided for p ≥ 0.05

Factors influencing good self-rated health among octogenarians and nonagenarians by residence area

We evaluated the association between participant characteristisc and perceptions of good self-rated health among older adults across different residential areas. Detailed results for each model are presented in Table 5.

For rural octogenarians, higher educational level (OR = 1.15, 95% CI [1.07, 1.24]) and household income (OR = 1.17, 95% CI [1.06, 1.30]) were associated with increased likelihood of reporting good self-rated health. Lifestyle factors, such as monthly alcohol consumption (OR = 1.59, 95% CI [1.35, 1.86]), regular walking (OR = 1.41, 95% CI [1.23, 1.62]), good self-rated oral health (OR = 3.50, 95% CI [3.01, 4.07]), and active social participation (OR = 1.40, 95% CI [1.22, 1.60]) were also positively associated with improved health perceptions. Conversely, being female (OR = 0.70, 95% CI [0.59, 0.82]), experiencing high levels of stress (OR = 0.48, 95% CI [0.37, 0.93]), having unmet medical needs (OR = 0.73, 95% CI [0.57, 0.93]), and having diagnosed with chronic conditions such as hypertension (OR = 0.70, 95% CI [0.61, 0.81]) or diabetes (OR = 0.63, 95% CI [0.53, 0.75]) were associated with lower odds of good self-rated health.

Similarly, in urban areas, octogenarians benefited from higher educational attainment (OR = 1.15, 95% CI [1.10, 1.21]) and income levels (OR = 1.10, 95% CI [1.01, 1.19]). Regular walking (OR = 1.77, 95% CI [1.56, 1.99]) and good self-rated oral health (OR = 2.73, 95% CI [2.37, 3.15]) showed even stronger positive associations with good self-rated health. However, those living in urban areas also faced reduced odds of good self-rated health due to high stress (OR = 0.38, 95% CI [0.31, 0.46]), unmet medical needs (OR = 0.58, 95% CI [0.42, 0.77]), hypertension (OR = 0.68, 95% CI [0.61, 0.77]) and diabetes (OR = 0.68, 95% CI [0.58, 0.79]).

For rural nonagenarians, regular activities such as walking (OR = 1.43, 95% CI [1.11, 1.85]), engaging in social activities (OR = 1.67, 95% CI [1.29, 2.16]), and good self-rated oral health (OR = 2.82, 95% CI [1.98, 4.00]) were significantly associated with a positive perception of good self-rated health. Conversely, female nonagenarians (OR = 0.49, 95% CI [0.35, 0.68]) were less likely to report good self-rated health.

In urban settings, smoking was significantly associated with higher odds of good self-rated health (OR = 5.33, 95% CI [3.77, 7.40]) among nonagenarians. Regular walking (OR = 2.25, 95% CI [1.89, 2.69]) and good self-rated oral health (OR = 2.48, 95% CI [1.98, 3.12]) also continued to positively be associated with health perceptions. However, high stress (OR = 0.22, 95% CI [0.11, 0.42]), unmet medical needs (OR = 0.33, 95% CI [0.29, 0.38]) and being diagonosed with hypertension (OR = 0.49, 95% CI [0.36, 0.66]) were associated with lower odds of reporting good self-rated health.

Table 5

Association between good self-rated health and participant characteristics by age group
Characteristics	Octogenarians (people aged 80–89 years)		Nonagenarians (people aged 90–99 years)
	Model 1 (rural)	Model 2(urban)	Model 3 (rural)	Model 4 (urban)
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Sociodemographic characteristics
Sex
Male	REF	REF	REF	REF
Female	0.70 (0.59, 0.82)	0.87 (0.75, 1.01)	0.49 (0.35, 0.68)	1.36 (0.85, 2.19)
Educational level	1.15 (1.07, 1.24)	1.15 (1.10, 1.21)	0.98 (0.85, 1.13)	0.90 (0.82, 1.00)
Household income	1.17 (1.06, 1.30)	1.10 (1.01, 1.19)	1.10 (0.84, 1.43)	1.04 (0.94, 1.16)
Household composition
Single-generation	REF	REF	REF	REF
Two-generation	0.93 (0.76, 1.14)	0.99 (0.82, 1.18)	0.75 (0.54, 1.05)	1.02 (0.66, 1.57)
Three-generation	0.71 (0.50, 1.00)	0.81 (0.62, 1.05)	0.78 (0.32, 1.90)	1.30 (0.90, 1.94)
Health behaviors and conditions
Current smoking	1.11 (0.85, 1.46)	0.86 (0.62, 1.19)	0.80 (0.50, 1.27)	5.33 (3.77, 7.40)
Monthly drinking	1.59 (1.35, 1.86)	1.50 (1.29, 1.75)	1.86 (1.21, 2.87)	1.19 (0.76, 2.01)
Regular walking	1.41 (1.23, 1.62)	1.77 (1.56, 1.99)	1.43 (1.11, 1.85)	2.25 (1.89, 2.69)
Good self-rated oral health	3.50 (3.01, 4.07)	2.73 (2.37, 3.15)	2.82 (1.98, 4.00)	2.48 (1.98, 3.12)
High-stress level	0.48 (0.37, 0.93)	0.38 (0.31, 0.46)	0.66 (0.36, 1.21)	0.22 (0.11, 0.42)
Healthcare utilization and morbidity
Unmet medical needs	0.73 (0.57, 0.93)	0.58 (0.42, 0.77)	0.65 (0.40, 1.05)	0.33 (0.29, 0.38)
Hypertension	0.70 (0.61, 0.81)	0.68 (0.61, 0.77)	0.87 (0.68, 1.10)	0.49 (0.36, 0.66)
Diabetes	0.63 (0.53, 0.75)	0.68 (0.58, 0.79)	1.07 (0.71, 1.61)	1.20 (0.87, 1.65)
Social interactions and activities
Social interactions	1.13 (0.83, 1.55)	1.57 (1.32, 1.86)	0.71 (0.51, 0.99)	1.38 (0.92, 2.07)
Social activities	1.40 (1.22, 1.60)	1.24 (1.09, 1.41)	1.67 (1.29, 2.16)	1.46 (1.10, 1.94)
Boldface indicates p < 0.05

We examined the levels of self-rated health and its associated factors among octogenarians and nonagenarians in urban and rural areas of Korea. In our study, 17.5% of octogenarians and 14.0% of nonagenarians reported their self-rated health as 'good' or 'very good,' which is significantly lower than the 24% reported by those aged 65 and older in Korea [33]. Notably, this figure for Korean adults aged 65 and over is nearly half of the 46% average reported among older adults in the 35 member countries of the Organisaiton for Economic Co-operation and Development [33]. Even when compared with those aged over 80 years from other countries [34, 35], the estimates for Korean older adults were substantially lower. While the significantly lower self-rated health among older adults in Korea compared to other countries is concerning, the steeper decline in self-rated health with age in Korea (− 0.408) compared to Germany (− 0.201) and Sweden (− 0.208) [36] is particularly alarming [36]. This steep decline underscores the need to identify the factors in Korea associated with self-rated health across various age groups among older adults. Disparities may exist between rural and urban areas, where differences in socioeconomic characteristics, behavior, social connectedness, and healthcare access could be associated with variations in self-rated health.

The distribution of older adults in rural areas (32% among octogenarians and 37% among nonagenarians) and urban areas (68% among octogenarians and 64% among nonagenarians) identified in this study, shows a higher proportion of older adults living in urban settings, consistent with trends observed in other high-income countries such as Poland [37] and the United States [38]. Older adults in rural areas represent a larger proportion than the overall population living in rural areas of Korea, which is just 8% [39]. This disproportionate concentration, highlights the need to understand the distribution and challenges across rural and urban areas to ensure healthy aging and promote health equity.

Substantial differences were observed in the characteristics of octogenarians and nonagenarians across rural and urban areas. While females were predominant across all age groups and residential areas, their proportion was higher in rural areas compared to urban areas. Additionally, older adults living in rural areas generally exhibited more disadvantaged characteristics compared to their urban counterparts, including lower education levels, lower income, and higher unmet medical needs. Regarding household composition, nearly 70% of octogenarians lived in single-generation households, indicating they often live alone or with a partner. This figure decreased to 51% among nonagenarians, with a corresponding increase in two- or three- generation households, particularly in urban areas. This shift between octogenarians and nonagenarians could be attributed to several factors, including the need for more accessible healthcare due to declining health and increased morbidities, as well as the need for daily living support from offspring living in urban areas [40–42]. However, given the preference of older adults to age in their own homes and communities, along with the time-related and financial burdens faced by caregivers [41], there is a growing need to enhance home-based support from formal caregivers and community services in rural areas. These services are currently often less accessible and less well-known in rural areas [43].

Moreover, the proportion of urban octogenarians reporting good self-rated health (18.7%) was higher compared to their rural counterparts (15.0%), whereas no significant difference was observed among nonagenarians across rural and urban areas. The lower self-rated health among rural older adults aligns with previous findings, which attribute this to factors such as lower accessibility to healthcare services and socioeconomic status [44, 45]. While our data is limited in explaining the lack of rural-urban differences among nonagenarians, insights could be gained from previous studies that have decomposed the dimensions of self-rated health among older adults [46]. Future research could focus specifically on octogenarians and nonagenarians, considering urban-rural differences.

The well-documented associations between education level and income with good self-rated health were also identified in this study among rural and urban octogenarians, which highlights the need for enhanced support for octogenarians with lower socioeconomic status. Intriguingly, this association did not hold among nonagenarians; in fact, higher education levels were slightly negatively associated with self-rated health among urban nonagenarians. The lack of association between socioeconomic status and self-rated health among the oldest old was similarly observed in a study conducted in the Nordic countries, where the positive influence of education level on self-rated health was significant only for the 75–84 age group and not in the 85–94 and 95 + groups [47]. Similarly, results from a study on Italian nonagenarians found no impact of socioeconomic status—measured as a latent variable including living conditions, education, and occupation—on self-rated health [48].

Several hypotheses could be tested in future research to explain the diminished impact of socioeconomic status on self-rated health among nonagenarians. One possibility is selective mortality, where those who faced greater socioeconomic disadvantages earlier in life may have had higher mortality rates, resulting in a study population that is relatively more advantaged [49]. Additionally, as biological and physiological limitations become more pronounced with age, the impact of socioeconomic status may become less influential. It is also important to consider the historical context of the nonagenarians in our study, who were born between 1924–1933 and grew up during a period when Korea was under Japanese colonization. During this time, access to resources, including education, was extremely limited, and with most of the population encountering challenges with socioeconomic conditions, a gradient in socioeconomic status may not have been perceived as more important than it is now. This is reflected in the overall lower education levels among nonagenarians; only 23% of nonagenarians received education beyond elementary school, compared to 35% among octogenarians. In contrast, over 80% of the current Korean population has completed high school or higher education [50]. As well as futures studies examining the different levels of self-rated health among urban and rural octogenarians and nonagenarians, longitudinal and qualitative research focusing on the self-rated health would help test these hypotheses.

Our results also highlighted disparities in self-rated health based on gender or residential area. For instance, rural women reported lower self-rated health than men, likely due to additional stress from traditional caregiving roles. This aligns with the role strain theory [51], which suggests that the multiple roles women often play can lead to increased stress and health issues. Targeted health management strategies, including women-specific health screenings and wellness programs, and stress reduction workshops, including relaxation techniques like meditation and respite care services, are essential to address these disparities.

Good self-rated oral health, regular walking, and engaging in social activities were consistently associated with reporting good self-rated health across all age groups in both rural and urban areas, highlighting the importance of these factors in promoting the health of octogenarians and nonagenarians. These findings align with previous research, including that of Ball et al. (2010) [52], which emphasized that social integration, healthy eating, and physical activity are crucial for maintaining good health in older adults. Their study showed that social norms significantly influenced health behaviors, suggesting that supportive social networks can enhance engagement in physical activity and healthy eating, promoting overall health. To promote these factors, community-based programs, such as walking clubs, can be established in urban and rural areas to encourage older adults to engage in regular physical activity together. Dental health initiatives, such as mobile dental clinics providing free check-ups in remote areas, can help maintain good oral health. Active social participation can be fostered through community events, such as monthly potluck dinners or hobby clubs, which offer opportunities for social engagement. These activities enhance physical health, provide emotional support, and help prevent social isolation.

Surprisingly, a strong positive association between current smoking and good self-rated health was found among urban nonagenarians, along with a positive association between monthly drinking and good self-rated health across all groups (although the odds ratio for urban nonagenarians was insignificant). While it melay seem counterintuitive that health-risk behaviors like smoking are associated with good self-rated health—especially since these behaviors are associated with poor self-rated health in younger populations [53]—similar findings have been reported in cross-sectional studies of older adults [54–55]. Longitudinal studies examining the trajectories of self-rated health with changes in health-risk behaviors, such as alcohol consumption and smoking, suggest a more complex relationship, as they have reported that those with poor self-rated health often stop engaging in health-risk behaviors like alcohol drinking and smoking [refs]. Therefore, our cross-sectional results should be interpreted with caution and should not be used as evidence to promote these behaviors among older adults. In fact, research indicates that even in advanced age, individuals can gain health benefits from abstaining from or reducing alcohol consumption [56] and quitting smoking [57].

This study has several limitations. First, the cross-sectional design restricts our ability to infer causality, as it does not account for changes over time. For instance, we were aunable to observe how household composition, influenced by migration patterns between urban and rural areas, affects the health of older adults over time. Second, the analysis did not include some variables that could be associated with self-rated health among older adults, such as built environment characteristics [58]. Moreover, while we aimed to identify sex differences in self-rated health by stratifying the analysis by sex across different age groups and residential areas, our small sample size limited our ability to do so. Additionally, the self-rated health measure may not accurately reflect relative health status for older adults with multiple health issues. Self-rated health is both influenced by the severity of existing health problems and changes in health relative to others or over time [19]. Another noteworthy point is the paradox observed in Japan and Korea, where high life expectancy coexists with low self-rated health, which has been attributed to high healthcare utilization. Although previous international studies have demonstrated that self-rated health is a robust predictor of morbidity and mortality, it may have limitations in predicting future health outcomes in Korea, compared to other jurisdictions [59].

Despite these limitations, this study provides crucial evidence for developing targeted interventions to improve the health of older adults. Our findings suggest that public health policies should address the specific needs of different age cohorts rather than treating older adults as a homogeneous group. Tailoring these inverventions can lead to improved self-rated health, which is a robust predictor for objective health outcomes. This study offers valuable insights into enhancing self-rated health among older adults and guiding effective policies in an aging society.

We identified that octogenarians and nonagenarians in Korea have substantially lower self-rated health compared to those aged 65 and over. Urban-rural differences in self-rated health were evident among octogenarians, with those in rural areas reporting lower self-rated health, likely due to factors such as lower education levels, lower income, poor oral health, reduced regular walking, higher unmet medical needs, and fewer opportunities to engage in social activities. Characteristics like good oral health, regular walking, and social activity engagement were consistently linked to better self-rated health across both age groups and regions. These findings underscore the need for policies that promote these factors and call for future longitudinal and qualitative research to further explore the context of self-rated health among octogenarians and nonagenarians.

Confidence interval

KDCA

Korea Disease Control and Prevention Agency

KCHS

Korean Community Health Survey

KRW

Korean Won

Odds ratio.

Ethics approval and consent to participate:

This study was exempt from ethical review by the first author's affiliated institution, as it utilized secondary data (IRB No. E2408/004-019). The data were anonymized and made publicly available, ensuring no personal information was included.

Consent for publication: Not applicable.

Availability of data and materials: The data supporting the findings of this study are available from the Korea Disease Control and Prevention Agency (KDCA). Access to the data is governed by the "Regulations on the Disclosure of Raw Data from the Korea Disease Control and Prevention Agency" (enforced on June 14, 2022, KDCA Notice No. 101). The data can be accessed publicly with appropriate permission from the KDCA.

Competing interests: The authors have no conflicts of interest to declare.

Funding: None.

Authors' contributions: HK contributed to the study design, data collection, analysis, and manuscript writing. DHK was involved in the study design, data analysis, and critical revision of the manuscript for important intellectual content. Both authors read and approved the final manuscript.

Acknowledgments: None.

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Socioeconomic, health, and social connectedness factors associated with self-rated health of octogenarians and nonagenarians in South Korea: Urban and rural comparison

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Abstract

Background

Methods

Results

Conclusions

Background

Methods

Study design

Variable definition and measurement

Outcome variable

Stratification and adjustment variables

Sociodemographic characteristics

Health behaviors and conditions

Healthcare utilization and morbidity

Social interaction and activities

Statistical analysis

Results

Sociodemographic characteristics of octogenarians and nonagenarians by residence area

Health-related characteristics of octogenarians and nonagenarians by residence area

Comparison of sociodemographic characteristics of octogenarians and nonagenarians with good self-rated health by residence area

Comparison of health-related characteristics of octogenarians and nonagenarians with good self-rated health by residence area

Factors influencing good self-rated health among octogenarians and nonagenarians by residence area

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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