Changes in psychological well-being among older adults: a latent transition analysis from China | BMC Public Health

In this study, we identified the latent subtypes of psychological well-being and transition within these subtypes among Chinese older adults using LPTA. We examined the factors affecting membership and transition of each subtype by introducing covariates. From the same perspective of comprehensive measurement, Yang et al.’s research utilized the latent class model and latent growth mixture model to define three mental health states and four dynamic trends among Chinese older adults, based on four items [50]. Our results revealed four types according to eight indicators reflecting psychological well-being across various aspects, expecting to provide more precise classification and overall characterization. To our knowledge, this is the first study to explore latent transition patterns and related influencing factors targeting a Chinese population using the LPTA model.

The typical subtypes revealed provide empirical evidence for the theoretical model of the hedonic approach which focuses on happiness and defines well-being in terms of achieving pleasure and avoiding pain, including components such as happiness, life satisfaction, and positive/negative affects [51]. Under this perspective, well-being is described as a person’s emotional state and evaluation of current life circumstances, with personality and individual differences being most concerned [52]. In contrast, the eudaimonic approach emphasizes meaning and self-realization, defining well-being as the extent of an individual’s full functioning, which links to resilience, personal growth, and self-actualization from a long-term view [52]. Focusing on psychological well-being status and changes among older adults, this study employed the hedonic view for measurement. Despite differences in definitions and philosophies, these two theoretical perspectives, while to some degree overlapping, often pose distinct questions and thus enrich each other’s understanding, offering a comprehensive view of the various personal, contextual, and cultural elements involved in the essence and enhancement of well-being [53]. Future research could conduct empirical analyses from an integrated perspective.

In this study, the Mainly Unhappy Subtype had a high self-evaluation of QOL, few negative feelings, and many positive feelings like optimism but low happiness, which shares a number of similarities with the contradictory type in the previous study [50]. This also implied that QOL and happiness are correlated, yet a variety of factors influence both; for example, QOL is intimately connected to physical and material conditions, whereas professional pride and altruism play a more significant role in facilitating happiness [54,55,56]. Such explanations also correlate favorably with the case of the “happy poor” [57].

We also found the Mainly Unhappy Subtype, into which other unhealthy subtypes mainly transition and which easily interchanged with the Satisfied and Positive Subtype, accounted for the highest proportion, second only to the Satisfied and Positive Subtype. This may highlight the uniqueness of happiness among psychological elements, that is, poor psychological well-being might start with unhappiness, and eliminating unhappiness is a crucial step in recovering psychological health. Happiness is a personal feeling shaped by a person’s values, propensities, character, genes, and other factors; it transcends cheerfulness and contentment, representing a desirable yet elusive sense of inner equilibrium and balance [58]. Those who are not detected in psychopathology but report diminished subjective happiness or who are “pure languishing” in life need to be noticed [50].

Previous research has shown that the significant increase in feelings of uselessness among older adults in China is primarily driven by cultural shifts, family structure changes, and health decline, which together diminish their sense of societal and familial contribution [59,60,61]. Consistently, this study revealed the Resilient yet Useless Subtype, characterized by a typically high level of perceived uselessness. Notably, compared to the other subtypes, the Resilient yet Useless Subtype was most likely to transition to the Discontented and Negative Subtype with lower scores in life satisfaction and happiness and higher scores in uselessness and other negative feelings (i.e. loneliness and anxiety). This supports a prior finding that recurrent self-perceived uselessness can be a chronic stressor that influences people’s thoughts, feelings, and behaviors, which, in turn, may adversely impact their psychological and physiological well-being [62]. Concomitantly, we observed that the probabilities of the Resilient yet Useless Subtype transitioning to the other three subtypes were relatively close. Such great instability further suggests the Resilient yet Useless Subtype may serve as a crossroads for the deterioration or improvement of psychological health, emphasizing early intervention in self-perceived uselessness of Chinese older adults [63], and avoidance of turning into more negative states.

Self-perceived uselessness, a key aspect of self-perceived aging, represents a negative view of one’s declining contribution and importance to others [27]. This negative assessment of usefulness at older ages is a social process that reflects the internalization of culturally valued attributes [64]. Studies have indicated that Chinese older adults consider family dynamics heavily when assessing the quality of their aging [60], and interrelated changes in living arrangements [65] and health [66] are increasingly common as they age. Consequently, an individual’s feeling of usefulness within family and social contexts might fluctuate as these events occur over the latter life course [60]. For example, health-related reductions in social network size could limit the social and family roles where older adults feel valuable [67]. Environmental factors, particularly family/social support, correlate with perceived usefulness and cognitive health by offering emotional support, enhancing social connections, and a sense of participation of older adults [27, 68]. Data from a Chinese national sample also indicated that cultural environmental factors such as coresidence with children and intergenerational transfer decreased perceived uselessness of older adults [27]. Studies generally found that socioeconomic resources, particularly financial ones, correlated with reduced perceived uselessness, enabling access to better housing, healthcare, and social services, and promoting positive aging beliefs [63]. Thus, supporting policies for older adults with lower economic status are crucial for enhancing their sense of usefulness. Since previous longitudinal studies have shown that self-perceived uselessness among older adults can generalize to perceptions held by the wider public and can change over time, interventions should involve all stakeholders to better shape the discourse and perception of aging in society [62], including government efforts to cultivate a culture of care, encourage regular family contact, and refine elder care policies, such as labor leave improvements and integrated support services [69].

In general, psychological well-being among older adults tends to be unstable, as we found the proportion of older adults in any subtype who maintain their original category was less than or close to 50%. With some caution regarding the generalizability of such explorative results, these transitions could potentially mirror the interplay between emotions [12]. On the one hand, positive emotions have a buffering and suppressing effect on negatives, termed “emotion blunting” [14, 70]. As this study indicated, the Mainly Unhappy Subtype with higher optimism and conscientiousness mostly changed into the Satisfied and Positive Subtype; the Resilient yet Useless Subtype with moderate-high scores in positive feelings like optimism was more likely to turn into the Mainly Unhappy Subtype with lower scores in uselessness and loneliness. Multilevel analyses have shown that across nations, the experience of positive emotions was correlated more strongly with life satisfaction than the absence of negatives [10], suggesting cultivating positive emotions to optimize health and well-being in later life [14]. On the other hand, augmentation between negative emotions could be considered to play a role in the comorbidity of negative emotional symptoms in mood disorders [71]. In line with this, we revealed the Discontented and Negative Subtype, predominantly originating from the Mainly Unhappy Subtype, characterized by high levels of perceived uselessness, loneliness, and accompanying unhappiness.

Several studies have shown that demographic and socioeconomic characteristics, social support, lifestyle, and physical health are closely related to the psychological well-being of older adults [61, 72]. This study takes a step forward to explore the predictive factors of the change process of psychological well-being by estimating the influence of individual characteristics on membership and transition of latent subtypes. Previous studies have demonstrated the paradox of aging in life satisfaction and negative affect from a longitudinal and multidimensional perspective, yet across dimensions SWB change were more negative in old-old than in young-old age [73, 74]. Under a person-centered and comprehensive reconsideration, we found the paradox of aging existed in the memberships of the Mainly Unhappy Subtype and the Discontented and Negative Subtype. This is in accordance with the adaptation processes to age-associated losses that older individuals benefit from giving up blocked goals in terms of well-being [75]. Additionally, there may be some social factors, such as social support, which play a particularly strong role in the old-old as moderators of the relationships between age and loneliness, especially in countries that emphasize filial piety [76]. Compared to the young-old, it was more challenging for those aged 75 to 84 to recover from unhappiness and loneliness. Furthermore, there was a higher risk of transitioning from the Satisfied and Positive Subtype to the Mainly Unhappy Subtype in individuals aged 85 and older compared to the 65–74 age group, emphasizing the importance of prevention for specific psychological conditions in different age groups, particularly in relation to psychological well-being subtypes and the change process. Our findings also showed that male older adults in the Satisfied and Positive Subtype were less likely to transition to the Resilient yet Useless Subtype than females. This might be because in traditional Chinese culture, males often assume the leadership role in important decisions and act as the authority figures with regard to family and social issues [77], making male older adults more inclined to maintain a positive attitude towards life and a sense of self-worth.

We also found that older adults with higher educational levels had lower risks of membership in the three unhealthy subtypes. In particular, the relationship between education and loneliness is widely discussed, yet no consensus has been reached [78]. We found an eliminating effect of education on loneliness as the greater likelihood of transitioning to the Satisfied and Positive Subtype from the Discontented and Negative Subtype, which supports the view that a higher level of education acts as a protective factor against loneliness [79]. Possible explanations include that higher education can lead to a better perception of aging changes — such as physical, social, and professional—and enhance psychological adaptability concerning well-being [80].

In terms of family characteristics, we found that older adults with higher household incomes or who married and lived with a spouse were less likely to belong to the Resilient yet Useless Subtype or the Discontented and Negative Subtype. Initially classified as the Satisfied and Positive Subtype, they were also less likely to turn into the Discontented and Negative Subtype, and if they did, they tended to change more quickly. These findings underscore the critical role of culturally normative family traits in fostering well-being in old age [63], especially in the Chinese context where family obligations closely align with personal expectations and are vital for overcoming daily challenges [81, 82]. These findings also reinforce the notion that sharing life with a partner is a fundamental precondition of social integration [82], and the role of a spouse serves as a critical supportive factor to relieve life pressure and promote positive mental health development [83].

From a broader societal perspective, in Chinese society, Confucian values prioritize large families and co-residence, which are vital for maintaining communication, contact, understanding, and enhancing family solidarity [84]. This arrangement also allows older adults to contribute to families, which improves their sense of usefulness, health, and positive views on aging [85]. However, some studies have claimed that as societal modernization and individualization of younger generations progress, filial piety is fading away, and intergenerational support patterns are altered [86]. The feeling of uselessness may be exacerbated by children’s migration for employment and urbanization’s impact on family relocation and structure [60]. These changes also exacerbate feelings of loneliness, especially in the Chinese context that emphasizes collectivist culture [87]. In addition, a systematic review and meta-analysis on the influencing factors of loneliness among older adults in China has found that marital status, living arrangements, having children(or not), receiving family and social support, relationships with family members, and social activities are the main influencing factors of loneliness [88]. From these perspectives, it is necessary to coordinate the efforts of all sectors of society and form a system of coordinated advancement involving families, government, and society [69].

In this study, the effect of social support was found in the transitions of the Discontented and Negative Subtype, showing a greater likelihood of moving to either the Satisfied and Positive Subtype or the Mainly Unhappy Subtype. Possible underlying mechanisms involved in this transition during the period include: Social support partially mediates the relationship between loneliness and a broad range of mental health consequences, which could be explained by the Evolutionary Theory of Loneliness (ETL) [37]. Social support has a beneficial effect on health independent of stressors, providing individuals with socially rewarding roles that support positive affect and, consequently, promote mental health [89]. Furthermore, social support might promote physical health through emotionally-induced improvements in immune system functioning, thereby improving the mental health [90].

It is worth noting that different types of social support have varying impacts on the psychological well-being of older adults. For example, friend support is more important in reducing loneliness than other supports (i.e., family and significant other support) among older adults, since the importance of social support from specific sources varies across different developmental stages [91]. In comparison to those with non-integrated social network types, older adults with diverse social networks showed the highest score of self-rated quality of life [92]. Coresidence with adult children is linked to a lower risk for frequent self-perceived uselessness whereas receiving financial and instrumental support from children is associated with a high risk [27]. Nevertheless, social support is broad conception and was categorized by different dimensions in previous literatures. Some studies divided it into emotional and financial support, as well as living arrangements [31]. Others included formal/informal support [68], or instrumental (including financial support)/emotional support [93]. Some focused on family, relatives, and community, considering marriage, family structure, and community services [94]. In general, social support includes not only the structural characteristics of the social networks (the social context of the interactions) but also the functional aspects of the interactions between its members [38]. Future research should delve into social support with in-depth, systematic exploration and comparative analysis, especially regarding the change of older adults’ psychological well-being.

As this study showed, the impact of lifestyle on psychological well-being was all-encompassing, beyond the buffering effect against negative emotions, as discussed for other factors above, a healthy lifestyle demonstrated a significant correlation with happiness. For example, we found that exercise was associated positively with belonging to the Satisfied and Positive Subtype and with the transition from the Mainly Unhappy Subtype to the Satisfied and Positive Subtype. This is in good agreement with the previous view that regular exercise enhances life’s meaning and self-esteem, which are vital for older adults’ motivation to seek continued personal growth and happiness [95]. We also found that older adults who participated in more leisure activities were less likely to belong to the Discontented and Negative Subtype or the Resilient yet Useless Subtype. This value is barely distinguishable from Liddle et al. who indicated that leisure activities serve as a protective factor against depression by enhancing motivation and providing social support and meaning in life [96]. Additionally, our findings imply that leisure activities may help to avoid augmentation between negative emotions; specifically, those of the Mainly Unhappy Subtype or the Resilient yet Useless Subtype had a lower probability of transitioning into the Discontented and Negative Subtype with an overall decline in life satisfaction, positive emotions, and an increase in negative emotions. These findings highlight the importance of resources that promote physical exercise and leisure activities [16].

Physical health is generally considered crucial for mental health [3], and our findings underscore the significant impact of physical health on the initial state of psychological well-being. Both ADL disabilities and chronic illnesses were negatively related to feelings of loneliness and uselessness; ADL disabilities were also linked to unhappiness. Meanwhile, older adults in the Resilient yet Useless Subtype are more susceptible to the impact of chronic illnesses on their recovery to the Satisfied and Positive Subtype. Previous findings have suggested that chronic diseases and disabilities might be the most pronounced predictors of perceived uselessness among older adults in China [27], as these health issues directly affect daily living functions and independence, influencing behavior and self-perception [97], and are not conducive to eliminating the feeling of uselessness. The reciprocal relationships between physical health conditions and psychological well-being could be discussed more thoroughly. A multiple mediation analysis indicated that loneliness and social isolation have an indirect effect on cardiovascular disease and type 2 diabetes through both baseline psychological and health behavioral factors [67], as lonely and socially isolated individuals may cope less adaptively with stress, making them more prone to the pathogenic influence of stress [98].

Considering the generalizability of our findings, a systematic review has shown that marital status, social support, and activities of daily living are key factors affecting life satisfaction among older adults in Asia [99]. A survey in Great Britain identified the pattern of loneliness in older age groups, often resulting from the loss of social networks due to retirement or bereavement, living alone, or reduced mobility related to health conditions [100] which also supports our findings. A study across 24 countries also found that despite cultural and socioeconomic differences, certain core factors such as social support and the feeling of loneliness have a universal impact on the mental health of older adults worldwide [101]. Recognizing unique cultural factors in China, such as filial piety and family structure, as we discussed above, which may distinctly influence the psychological well-being of older adults, further empirical and comparative analyses should be conducted to explore the transition of psychological well-being states across different cultural and socioeconomic contexts.

The findings provide practical implications. For healthcare professionals, it is essential to value the interplay between emotions and to cultivate and enhance positive emotions, leveraging their buffering and protective effects against negative emotions. Prevention and management strategies targeting certain emotions, such as unhappiness and uselessness are critical, forming a significant component of full recovery and acting as the tipping point between recovery and decline. Resources for promoting physical exercise, which are crucial for the prevention and recovery of the Mainly Unhappy Subtype, should be considered an integral component of community-based interventions. As for the Resilient yet Useless Subtype, it is important to build a social atmosphere that encourages regular family contact and focuses on an older adult care culture in families and the maintenance of a holistic care environment. Policy design and support services should integrate labor leave improvements and family care assistance. In addition, policies to support older adults with limited financial resources (i.e., pension and medical insurance systems) are also important to improve their self-perceived usefulness. As modernization progresses, educating both older adults and young adults to be aware, understand, and accept such changes may improve positive attitudes toward aging and the perception of usefulness of older cohorts. As for the Discontented and Negative Subtype, which not only has a sense of uselessness, but also feelings of loneliness evident, it is necessary to coordinate the efforts of all sectors and form a system of coordinated advancement by families, government, and society. The integration of all social support resources, including financial, emotional, and instrumental support from family, friends, and community, is essential. As our findings underscore the significant impact of physical health on feelings of loneliness and uselessness, public health programs or medical interventions may target the Resilient yet Useless Subtype and the Discontented and Negative Subtype to reduce feelings of uselessness and social isolation among old adults in China. Health policies and treatments require a comprehensive approach that considers the psychological states of older adults, their physical function, chronic conditions, educational level, and the need for financial and environmental support.

This study has several vital strengths. To the best of our knowledge, this is the first to explore latent subtypes of psychological well-being among Chinese older adults in a large and representative sample size. Our study also contributes new knowledge about risk indicators and factors of psychological well-being by unveiling the patterns and the development from a constructivist and systematic perspective. For instance, we observed that the Resilient yet Useless was the least stable, with a relatively average rate of transitioning to any other subtype. In other words, older people with pronounced perceived uselessness require early attention to avoid further deterioration and even reverse the trend.

This study has some limitations. LTA, an exploratory data-based analysis, may require further validation for generalizability across different populations and settings. Measurement bias may exist as we only used self-reported data to assess psychological health; future studies should include objective measures. Data spanned only two time points, overlooking the annual change and complex situations. This lack of more frequent data made it difficult to determine whether the observed transitions are part of a larger, ongoing trend or if they are more episodic and variable over time. Given that the psychological well-being status of individuals may change more than once within a period, the conclusions drawn may be rough. This study relied on logistic regression to examine influencing factors. Caution should be exercised in comparing and explaining the psychological status and its change. Future research should employ longitudinal data to comprehensively understand the causal mechanism, accounting for individual and external factors. A more targeted and detailed examination of how certain factors, such as various forms of support, impact these psychological subtypes and their transitions would offer a clearer understanding of the underlying mechanisms.