Gender differential on the structural relationship between ...jssm.umin.jp/report/no31-2/31-2-09.pdf177,648,705 older adults aged 60 years old or over, accounting for 13.26 percent

社会医学研究．第 31 巻 2 号．BulletinofSocialMedicine,Vol.31（2）2014

― 79 ―

ABSTRACTObjective:Thepurposeof thisstudywastoexplorethestructuralrelationshipbetweensocioeconomicstatus(SES),mentalhealthandneedforlong-termcare(NLTC),withthegoalofprovidingusefulinformationtopreventtheNLTC.Method:1,836 (39.8%ofmale,60.2%of female)respondentswereconducted inLhasaandShigatsecityinTibetfromJulytoAugustin2009.Descriptiveanalysis,factoranalysisandstructuralequationmodelingwereperformedtoidentifytheassociationbetweenSES,mentalhealthandNLTC.Results:PositivecorrelationbetweenSESandmentalhealthwasobservedamongtheTibetanelderly,whileitwasslightlystrongerfortheTibetanfemaleelderly.ThereisanegativecorrelationbetweenmentalhealthandtheNLTCamongtheTibetanelderly,and itwas littlestrongeramongtheTibetanmaleelderly.SESof theTibetanelderlywouldnotonlyhaveadirectimpactontheNLTC,butalsohaveanindirectimpactontheNLTCthroughmentalhealth,andbothoftheeffectsarenegative.Conclusions:SlightgenderdifferentialwerefoundonthestructuralassociationbetweenSES,mentalhealthandNLTC.Theresultshighlighttheimportanceofenhancingtheindividual’sSESandtheirmentalhealth.

抄　録目的：本研究の目的は、社会経済要因、精神的健康と要介護度との関連構造を明らかにすることにより、要介護人口を減少するために活用される科学的エビデンスを提供することである。方法：2009 年の 7 月から 8 月まで、チベットのラサ市とシガツェ市にて調査を行った。1,836 人（男性 39.8％、女性 60.2％）の回答を収集した。記述分析、要因分析と構造方程式モデリングで社会経済要因、精神的健康と要介護度との関連構造を分析した。結果：チベット高齢者では、社会経済要因と精神的健康との正相関が明らかになり女性の正相関は、男性より強いことが示された。また、チベット高齢者では、精神的健康と要介護度との負の相関が明らかになり男性の負相関は、女性より強いことが示された。チベット高齢者の要介護度は、社会経済要因からの直接的な影響の他に、精神的健康を経由する間接的な効果が示され、直接効果と間接効果は共にマイナス効果になっていた。結論：本研究により社会経済要因、精神的健康と要介護度との関連構造が明らかになり、性別差異が示された。要介護予防のためには、個人の社

原　著

Genderdifferentialonthestructuralrelationshipbetweensocioeconomicstatus,mentalhealthandneedforlong-termcare:

Across-sectionalstudyamongtibetanelderly

社会経済要因、精神的健康と要介護度との関連構造―チベット高齢者における横断調査

FanleiKong1）,BinAi2）,ShuoWang1）,TanjiHoshi1）

孔　凡磊 1）、艾　斌 2）、王　碩 1）、星　旦二 1）

1）GraduateSchoolofUrbanEnvironmentScience,TokyoMetropolitanUniversity,Japan2）SchoolofEthnologyandSociology,MinzuUniversityofChina,China

1）首都大学東京　都市環境科学研究科2）中央民族大学　民族学と社会学学部


― 80 ―

1．Introduction1.1 Population aging in China

　UnitedNationsdefinestheagedsocietyas: if thepopulationaged60yearsoldandaboveaccountsformorethan10%of thetotalpopulation inacountry(or region), or thepopulationaged65yearsoldorover accounts for 7%of the total population, thecountryor regioncouldberecognizedasentryoftheagedsociety1）.According to thereportof the1%population sampling surveywhich conductedin2005bytheNationBureauofStatisticsofChina,therewere144.08millionolderpersonswhoaged60orover,accountingfor11.03percentofthetotalChinesepopulation.As for thepopulationaged65andmore,thetotalnumberreachedto10,045million,constituting7.69percentof the totalpopulation2）.Fromthisperspective,Chinahasenteredtheagedsociety in2005.Moreover,accordingto thedataofthesixthnationalcensusofChinain2010,therewere177,648,705olderadultsaged60yearsoldorover,accounting for13.26percentof the totalpopulation(ofwhich 118,831,709 aged 65 years or over andabout 8.87 percent of the total population)3）. Itmeans,duringthesefiveyears, thepopulationaged60yearsoroverhasincreasedbyabout3,356people(thepopulationaged65andabovehas increasedbyabout 1,838million). Suchanumber is equivalentto the totalpopulationofCanada in20114）.As theaging trendproceed, researcherspredict that theproportionoftheelderlyaged65yearsormorewillreach14.3percent in2025,andwill furtheramountto26percentin20505）.

1.2　Literature review1.2.1 Relationship between socioeconomic

status (SES) and need for long-term care (NLTC)

　McKevittetal.showedthat,amongthe1,251UKelderlywhocaught thestroke, theelderly living in

poverty-strickenareasreportedarelativelyhigherunmet care needs than the other groups6）.Hoile et al. studied thedeterminants of theVietnamelderly aged 60 years or over and the resultsshowedthatSES, suchaseducation level,workingstatus,household incomeaffects theNLTCamongtheelderlyrespondents7）.Laporteetal. foundthatthe individual in the lower SEShaving a higherpropensityand intensityof careneedsamong theCanadahome-caring elderly8）.A long-termstudyamong the 35,926Finnish elderly conducted byMartikainen et al. suggests that the elderly in alower SES aremore likely to use theLTC; andshowstheimpactofSESontheentryofinstitutionalcare isstrongeronthewomenthanmen. Itshouldbe noted that the possibility ofwomen into thepensionagencyreceiving long-termcare thanmenbecauseoftheirageandthelargerlivingalonehaveahigherlikelihood9）.

1.2.2 Association between mental health and NLTC

　Previousresearchesshowedthat thesickor frailpopulations, suchas strokepatients10）, thosewithmentalretardation11）ortheelderlywithdementia12）are suffering higher likelihood ofmental illness(suchastensionanddepression),areinhigherneedforLTC. Inaddition to thegeneralpopulation, theresearchersstudied theveteransa lot.Sorrell andDurhamfoundthatthelong-termcarefacilitieswhichunder theUnitedStatesDepartment ofVeteransAffairscannotmeettheneedsofthoseveteranswithcognitivedeclineandhomecaringservice, theneedto investmore resources in order tomeet futurecaringneedsof an increasingnumberofveteransisurgent13）.Samuelssonetal. followedup the192elderlywhoreceivedhomecareorinstitutionalcarein southernSweden for25yearsandshowed thatamongtheseolderpersons,53percentofthemwere

会経済要因と精神的健康の重要性が明らかになった。

　Keywords：SES,mentalhealth,NLTC,genderdifferential,Tibetanelderly　キーワード：社会経済要因、精神的健康、要介護度、性別差異、チベット高齢者


― 81 ―

withdementia,34percentofthemwithmoreorlessmental illnessandonly12percentof themwere innormallymentalconditions14）.

1.2.3 Correlation between SES and mental health

　Existingstudiesconsistentlyshowedthatthere isannegative relationshipbetweenSESandmentalhealth, namely, the individualswith a lowerSEShad ahigherpossibility of suffering frommentalhealth problems15）. In otherwords, peoplewiththe lowerSEShad thehigher likelihood of beingwithmental illness16, 17）. Specifically, individualswithhigher incomes, compared to those of lowerincome individuals,hadabettermentalhealth18,19）;thosewhowere inemploymentwould inabetterself -reported mental health than that of outof employment20）. In addition, concerning therelationshipbetweeneducationandmentalhealth,a studyconductedamong theJapanesepopulationshowedthat there isasignificant linearcorrelationbetweentheeducationofthefemaleandtheirmentalhealth,whilesuchanassociationdoesnotexistintheJapanesemale21）.

1.3　Summary of the literature and the objective　In aword, the previous researches examinedthe relationship betweenSES andmental healthis relatively atmost, followedby the researchesfocusedontherelationshipbetweenSESandNLTC,while thestudiesclarified theassociationbetweenthementalhealthandNLTCwas relatively least.However, todate, there isstillnoresearchclarifiedthe relationshipbetweenSES,mental health andNLTCatthesametime.　Basedonthesummaryofthepreviousresearches,thepurpose of this study canbe summarized asfollow:1）TowhatextenttheNLTCoftheTibetanurban

elderlyissatisfied?2）Toexplore the relationshipbetween theSES,

mentalhealthandNLTCamongtheTibetanurbanelderly;and,whether there isgenderdifferentialontheassociationsabove.

2．Method2.1　Hypotheses of the research

　Basedontheliteraturereviewandtheobjectives,thefollowinghypothesesareproposed:　Hypothesis 1:ThereisastrongpositivecorrelationbetweenSESandmentalhealthamong theTibeturbanelderly.Thatis,abettersocioeconomicstatusofaTibeturbanelderlywouldgenerallypredictabetterstatusofhismentalhealth.Moreover,genderdifferencewillbefound.　Hypothesis 2:Anegative relationshipwouldbeobservedbetweenmentalhealthandNLTCamongtheTibetanurbanelderly,whichmeans abettermentalhealthof theTibeturbanelderly,willhavethe lower need for LTC.What ismore, genderdifferentialwillbeobserved.　Hypothesis 3:SEScouldnotonlyaffecttheNLTCdirectly, but also exert an indirect effect on theNLTCthrough thementalhealth.Here, thedirectand indirecteffects shouldbenegative.Moreover,genderdifferencewillbefound.

2.2　Study location and subjects　TibetAutonomousRegion has one prefecture-levelcity,sixregionsand73counties.Aprefecture-levelcityisalsothecapitaloftheTibetAutonomousRegion -Lhasacity.Inaddition,acounty-levelcity --Shigatse city is concluded in Shigatse region.Concretely, seven counties, one region (namedChengguanDistrict, include seven sub-districtofficesand28communitycommittee) isunder thejurisdictionofLhasa;whileShigatsecityincludes10townships, two sub-district offices (10 communitycommittee).Dataused in this studywascollectedfromlateJulytolateAugustin2009,whilesubjectsincluded in thesurveywas theurbanelderlyaged60 years or over in the two cities of theTibetAutonomousRegion--thecityofLhasaandShigatse.

2.3　Sampling method　Asfor thesamplingmethod,firstly,wecollectedthe listofall communitycommittees inLhasaandShigatse, including 28 communities in the formercityand10inthelattercity.These38communities


― 82 ―

arethenarranged frommoreto less inaccordancewith thenumberof thepopulation.Thirdly,outof9 from28communities inLhasa, outof4 from10communities in the city of Shigatse,with a totalof 13 communitieswere selected at randombyusingcluster samplingmethod.Theagedpersonswhowere 60years old and above from these 13communitieswereallconcludedas theparticipantsof this study. Specifically, therewere 1437 olderpersons inLhasa,and571olderadults inShigatse,withatotalnumberof2,008elderlypeople inthese13communitiesoftwocities.Weaimedtocollecteddata fromthese2008olderpersonsand issuedonequestionnairetoeacholderperson,eventually,atotalof 1836questionnaireswereeffectively recovered,withthevalidresponserateof91.4%.　This study employed both the staffs of thecommunitycommitteeandthecollegestudentswhosemother language isTibetan as thequestionnaireinvestigator.All of them can expertly use boththeTibetan andChinese, and switch these twolanguageseasily,inordertoensurethatthelanguagetranslationhadno impacton theauthenticityandcorrectnessof thequestionnaire.Meanwhile,beforethestartofthesurvey,investigatorswereconductedaunified training to increase theirknowledgeandunderstandingabout thepurpose andcontents ofthesurvey, thestructureof thequestionnaireandskillsandmasteryonconductingasurvey.Duringthe survey, the investigatormainlyconducted theface-to-facequestionnairesurvey inhouseholds,andrecordedtruthfullyinaccordancewiththeresponsesandanswersof theelderly. In somecommunities,therespondentsweregatheredtogethertofillinthequestionnaire.

2.4　Measurement of the variables　The indicatorsofSES, in thepresent study,areeducationandhousehold income.Theanswers foreducationincludes:① illiterate;② elementaryschool;③ juniormiddleschool ; ④ seniormiddleschool;⑤ vocational college and above.Options for thehousehold incomesare: ① lessthan1,000RMB(147USD,astheaverageexchangerateoftheyear2009;

thesamebelow); ② 1,000―2,999RMB(147―440USD);③ 3,000―5,999RMB(441―881USD);④ 6,000RMB(881USD)andabove.　The indicators for thementalhealthused in thisstudyare fromthe“ThreeHealthFactors”,whichwascreatedbyProf.Hoshi andconcludeda totalof nine indicators to evaluate themental health,physical health and social health separately22―25）.The“ThreeHealthFactors” index systemwasfirstlyoriginated fromtheanalysisof thedatabaseaboutthehealthconditionsoftheTokyoelderly,andwasalso foundtobeequallyapplicable toevaluatetheelderly fromothercities in Japan, suchas theHannocity,SaitamaPrefecture26）.Concretely,asforthe indicatorsofmentalhealth, threequestionsareincluded: 1）Howaboutyourhealthcondition thisyear?2）Isyourhealthstatusasgoodaslastyear?3）Areyousatisfiedwithyourcurrentlives?Inthepresent study, 1）and3）will beusedas the twoindicatorsofmentalhealth.　As stated previous, the quantitative studiesfocusedon theLTC issueswere relatively few inChina;althoughtheempiricalresearchesstudiedtheLTCissueswererelativelymore, the indicators fortheNLTCweredifferent fromone toanother. Inthisstudy, threequestionswillbeusedtomeasuretheneed forLTC: 1）thecaring timeof the firstcare provider; 2）the caring time of the secondcareprovider;3）thecaring timeof the thirdcareprovider.Thesameoptionsaregiventothesethreequestions,namely:①carejustwhenneeded;②2―3hoursperday;③halfdayperday;④almostalldaylong;⑤others.

2.5　Statistical approach　SPSS 17.0was employed to present the basicdistribution of the socioeconomic status,mentalhealthandtheneedforLTCoftheTibetanelderly,specifically, about their absolute numbers andpercentage.　Amosversion17.0statisticalsoftwarepackageforWindowswasusedtoperformtheSEM,inordertoobtain themaximum-likelihoodestimatesofmodel


― 83 ―

parametersandprovidegoodness-of-fit indices. Inotherwords,whether the structural relationshipbetween socioeconomic status,mental health andthe need for LTC among theTibetan elderly iscorrespondedwiththehypothesesstatedpreviouslywillbeclarifiedthroughtheAmos.　Assessmentof themodel fitnesscalculateshowtheproposedmodelmightbe consistentwith theempirical data.Maximum-likelihood estimation isusedtoestimatethebest-fittingmodelinthisstudy.χ2 test,TLI, IFI,CFIandRMSEAwerereportedforthemodelfitness.ThemodelareregardedtobegoodfittedwhenTLI>0.9027）;IFIvaluecloseto128）;CFIvalue>0.9029）andRMSEA<0.0530）.

3．Results3.1　Characteristics of the subjects

　Table1shows theneed forLTCof theTibetanurbanelderly.Amongthetotalnumberofthe1,836elderly included in the survey, 1,310 of themarefromLhasa,with the remaining of 526 are fromShigatse.Of thosewhoweresurveyed,more thanhalfarefemale(60.2%).Ontheagedistribution,58.7%of thesubjectsareaged from60 to69.As for thenationality, 99.0%of theparticipants areTibetanelderly.Perhaps it is related to theenvironmental

factors inTibet, suchas thehighaltitudeand thehighlandclimate,which forces theelderlyofothernationalities (Hannationalityorothernationalities)toreturnto theEasternChina (or theirhometownotherthanTibet)aftertheirretirement.

3.2　NLTC of the Tibetan elderly3.2.1 The primary provider of the six basic

needs for LTC　Table2presents thedistributionof theprimaryprovidersof thesixbasicneeds forLTC.Wecouldacknowledge the important role of the familymembersoncaringtheelderlybasedoninformationinthetable.　Spouseisalwaysthemostimportantprimarycareprovideronanytypeofthesesixbasiccaringneeds.Onthe itemofbeingcaredwhensick,38.2percentofitwasprovidedbythespouse,accountingfortherelativelyhighestproportionamongalltheproviders.Asonekindoftheinformalcareproviders,althoughtheproportionof itsprovisiontothecashorthingsdecreased to 19.2percent, but still play themostimportantrole.　Son takes the secondary role on satisfying theneeds of“Caredwhen sick” (20.1%),“Cash orthings” (19.2%) and“Discuss important things”

Table 1. Characteristic of the Subjects


― 84 ―

(17.3%)fortheelderly.Thesepercentagesarelowerthan the spouse’s, buthigher than thedaughter’s,inspiteofthegaponpercentagebetweensonsanddaughtersisnotlargeonthesethreeitems(20.1%vs17.9%;19.2%vs16.2%;17.3%vs15.9%).　Comparing with the son, daughter plays amore important role on satisfying the needs of

“Housework”(19.4%),“Talkheartily”(17.4%),“Goingoutside together” (15.7%).Particularly, thegapontheprovision of“Housework” (19.4%vs 13.4%) issignificantlygreater than that of“Talkheartily”(17.4%vs16.3%)and“Goingoutsidetogether”(15.7%vs13.1%).　Compared to these threemain informal careproviders, the role of other careprovidersas theprimaryprovider (suchas theBrothersor sisters,otherrelatives) isrelatively loweramongallof therespondents.

3.2.2 The satisfaction of the six basic needs for LTC

　Amongthesesixbasicneeds forLTC, including“Caredwhensick”,“Housework”,“Cashorthings”,“Talk heartily”,“Discuss important things”and“Goingoutside together”, thepercentageof theirbeing“always”satisfiedwas 71.2%, 60.1%, 40.5%,

54.7%,58.2%,55.8%respectively(Table3).Therefore,except“Cashorthings”,morethanhalfofotherfivekindsofneedsforLTCcouldbe“always”satisfied.　Althoughthepercentageoftheneedfor“Cashorthings”being“always”satisfiedwaslowerthanhalf(27.0%),but intermofbeing“Frequently”satisfied,itsproportionisthehighest.Asforotherfivekindsofneeds forLTC, includingthe“Caredwhensick”,

“Housework”,“Talkheartily”,“Discuss importantthings”and“Goingout together”, theirproportionwas19.3%,21.6%,24.4%,21.6%,20.4%separately.AscouldbeseenfromtheTable3,comparingwiththe needs could be“Always”and“Frequently”sat is f ied , the remain ing four ones , namely

“Sometimes”,“Seldom”,“Never”and“Notneeded”separately, their proportion is relatively low.Tosome extents, this represents the satisfaction ofthe sixbasicneeds forLTC is in relativelygoodconditionamongtheTibetanelderly.

3.3 Gender differential on the structural relationship between SES, mental health and NLTC among the Tibetan urban elderly

3.3.1 Factor analysis　Table4 shows theresultsof the factoranalysisof thecorrespondingvariables.After theprincipal

Table 2. Distribution of the first care provider of the six basic needs for LTC


― 85 ―

component analysis byusing orthogonal rotation,the sevenvariables, including“Caring timeof thethirdcareprovider”,“Caringtimeofthesecondcareprovider”,“Caringtimeof the firstcareprovider”,

“Lifesatisfaction,“Subjectivehealth”,“Education”,“Household income”,weredivided into threemainfactorswith a cumulative contribution rate of79.850%.　Here,we named these threemain factors as

“need forLTC” (including threevariables:Caringtime of the third care provider, Caring time ofthe second careprovider andCaring timeof thefirstcareprovider),“mentalhealth” (including twovariables:Life satisfaction, Subjectivehealth) and

“Socioeconomic status” (including two variables:Education,Householdincome).

3.3.2 Fitness of the hypothetical model　Themodel fitness indiceswereshown inFigure1andFigure2.ThecalculatedvalueofCFI,TLIandIFIwere0.992,0.984and0.992respectively.Allof themwerehigher than therecommended level,withtheabsolutevalueof0.9.Thecalculatedvalueof theRMSEAwas 0.040,whichwas lower thantherecommended levelof0.05.Allof these indicesindicated thehypotheticalmodel fit theempiricaldataideally.　Concerning the p-value of the chi-square test

Table 3. The satisfaction of the six basic needs for LTC

Table 4. Factor Analysis of Observed Variables


― 86 ―

in this study, the relatively largenumbers of theparticipants concluded in this study resulting ina small value of it (with the value of p<0.001).Consequently, itwouldnotbeusedas the fitnessindices in this study, although itwas reportedasotherresearchersdid.

3.3.3 Gender difference on the relationship between mental health and NLTC

　ThegenderdifferenceontherelationshipbetweenmentalhealthandNLTCamongtheTibetanelderlywaspresented inTable5,Figure1andFigure2.MentalhealthexertednegativeanddirecteffectontotheNLTCboth for theTibetanmale elderly andfemale elderly.Concretely, the total standardizedeffectofmentalhealthontotheNLTCwasslightlystronger for theTibetanmale elderly (with thevalueof -0.250)thantheir femalecounterparts (with

thevalueof-0.203),althoughbothoftheeffectwerefairlyweak.

3.3.4 Gender difference on the association between SES and NLTC

　As illustrated inTable5,Figure1andFigure2,SEScouldnotonlyinfluencetheNLTCdirectly,butalsoexertedtheindirecteffectontotheNLTCbothfor theTibetanmale elderly andTibetan femaleelderly.Specifically, thedirect standardizedeffectfromSESupontheNLTCwas-0.172fortheTibetanmale elderly and -0.136 for theTibetan femaleelderly,while the indirect standardizedeffectwas-0.122forthemaleand-0.112forthefemale.　Itmeansboththedirectand indirecteffect fromSESupontheNLTCwasslightlystrongeramongtheTibetanmaleelderlythantheirfemalecounterparts.Consequently, thetotalstandardizedeffectwasalso

Table 5 Structural relationship between SES, Mental Health and NLTC by gender among the Tibetan elderly

Figure 1 Structural relationship between the SES, mental

health and NLTC among the Tibetan male elderly

Figure 2 Structural relationship between the SES, mental

health and NLTC among the Tibetan female elderly


― 87 ―

slightly strongeramong theTibetanmale elderly(withacoefficientof-0.294)thanthefemaleones(withacoefficientof-0.248).

3.3.5 Gender difference on the correlation between SES and mental health

　ThecorrelationbetweenSESandmentalhealthwaspresented inTable5,Figure1andFigure2.Positiveand relatively strongeffect exerted fromtheSESontomentalhealthwasobservedboth fortheTibetanmaleelderlyand femaleelderly.WhiletheassociationbetweenSESandmentalhealthwasfoundedtobeslightlystrongeramongtheTibetanfemaleelderly (with thevalueof 0.552) than theirmalecounterparts(withthevalueof0.489).

3.3.6 Critical Ratios for Differences between Parameters

　CriticalRatiosforDifferencesbetweenParameters(CRdiff)indicatestheratiosbetweentheparametersdifference and the estimated standard error ofthis difference.TheCRdiff value squared is anapproximation for howmuch the chi-square testwouldincreaseifoneimposedtheconstraintonthemodelparameters.TheCRdiff testscanbeappliedwhen testing equality constraints between twopreviously freeparameters. If ¦CRdiff¦<1.96, thetestisstatisticallynon-significant( α =0.05),whichmeansthattwoparametersareequalandcannotrejectthehypothesis that the twovariancesareequal in thepopulation.　Inthisstudy,theCRdiffvaluefortherelationshipbetweenSES andNLTC, betweenmental healthandNLTC among theTibetanmale and femaleelderlywere9.755and2.250separately.As for theassociationbetweenSESandmentalhealthamongtheTibetanmale and female elderly, itsCRdiffvaluewas2.720.AllofthesethreeCRdiffvaluesaregreater than1.96, indicating that thedifferenceonthethreeaboverelationshipsbetweenTibetanmaleandfemaleelderlywasstatisticallysignificant.

3.4　Discussion3.4.1 Relationship between mental health and

NLTC　Negativecorrelationbetweenmentalhealthandtheneed forLTC is themost important findingofthis study;because thereareonly fewresearchesexploredtherelationshipbetweenmentalhealthandtheNLTCandnoexistingstudieshadexaminedthegenderdifferentialontheassociation.Manyexistingstudieshadmainly investigated theNLTCof theelderlywhosuffered fromphysicaldisability, suchasWolfeetal.conducteda10-year follow-upstudyontheNLTCofthestrokepatientsinsouthLondonofUK10）.Among the few studies involving therelationshipbetweenmentalhealthandtheNLTC,researchersjustintroducedthedistributionofNLTCof the elderly,without exploring the relationshipbetweenmentalhealthandneed forLTC.Suchas,Kimetal. studied theNLTCof thepatientswithdementia12）;Reidetal. investigatedthe influencingfactorsof thementaldisordersand theNLTCbythe adult patients11）. In addition, the study alsoexplainswhytherewere53percentof thepatientswith dementia, 34 percentwithmental healthproblemsandonly12percentwere ingoodmentalhealthamongthepatientswhowereusingthehomecareand institutionalnursingcareservices inonestudy,thisisbecausethereisanegativecorrelationbetweenmentalhealthandtheNLTC.

3.4.2 Correlation between SES and NLTC　Negative correlationwas observed betweenSES and theNLTC among theTibetan elderly,whichmeans that the higher of the individual’ssocioeconomicstatus, the lessofhisneed forLTC;while for thosewith lower socioeconomic status,theirneedforLTCishigher.Hoileetal.conducteda surveyon the2,240Vietnameseelderlyaged60yearsoroverandfoundoutthatthesocioeconomicstatusof theelderly (suchaseducation,householdincome) could affect their needs for LTC7）, theresultsofhisstudywerealmostsametothisstudy.TheresultsofthisstudyalsoexplainedtheresidentsofOntario,Canada,whosesocioeconomicstatuswerelower tended tohave ahigher intention of beingcaredandusecaringservicesmorefrequently8）.In


― 88 ―

addition,toacertainextent,theresultsalsoexplicatewhythose fromtheunderdevelopedareasreportedmore unmet care needs among the 1,251Britishstrokepatients6）.

3.4.3 Association between SES and mental health

　TherelationshipbetweenSESandmentalhealthwasfoundtobepositiveamongtheTibetanelderly.Theresultindicatesthatthehigherleveloftheone’ssocioeconomicstatus,thebetterstatusofhismentalhealth;while for thosewith lower socioeconomicstatus, theirmental health areworse. Positivecorrelationbetweensocioeconomicstatusandmentalhealth is the same to the results of thepreviousstudies: 1)peoplewith lowersocioeconomicstatustendtoexperiencemorementalhealthproblems15）;2) individuals fromthehighersocioeconomicstatusgroups aremore likely to have a bettermentalhealth16,17）.

3.4.4 Structural relationship between SES, mental health and NLTC

　Usingthestructuralequationmodeling,thisstudyexplored the relationship among socioeconomicstatus,mental health and the need forLTC.Asshownintheresults,thesocioeconomicstatuscouldnotonlyhaveadirect impactontheneedforLTC,butalsocouldindirectlyinfluencetheneedforLTCviamentalhealth.Italso,tosomedegree,showstheimportanceofsocioeconomicstatus.　Existing studies consistently showed that thereis a positive correlation between the individual’s socioeconomic statusand theirhealth (includingmental health ) , which means that a h ighersocioeconomicstatusoftheindividual,hishealthwillberelativelybetter31―34）.Specifically,thedifferenceonsocioeconomicstatususuallymeans thedifferencesof the ability on obtaining themedical services,occupational risks, social support, and life stress.These differences ultimately led to the differentlevel of individual’s health35）. Some researchersalsogiveasimilarexplanationasbelow: thosewhohavehigher socioeconomic status aremore likely

toobtainmedicalservices,moreeasilytobuildandmaintaintheirsocialrelationshipsandmorelikelytoliveingoodcommunities,suchgroupwilleventuallyhave a higher level of health36, 37）. It should beemphasized that, from amacro perspective, theimpactofindividual’ssocioeconomicstatusonhealthisnotsimplycausedbysocioeconomicstatusonly,but causedbyvarious factors combined together,including the individual’s lifestyle, environmentalfactors and the social factors and so on38, 39）.Ofcourse, there are also researchers believe thatecological factorsalsoplayan importantrole intheprocess40）.　The influence of socioeconomic status on thehealthnarratedabove,combiningwiththestructuralanalysis of theassociationbetweensocioeconomicstatus,mentalhealthandtheneed forLTCamongtheolderpersons in this study, theprocessof thesocioeconomicstatusexerting itseffectontheneedforLTC can be further specifically summarizedas follows: those elderlywho are on differentsocioeconomicstatus live indifferentcommunities,theyhavedifferent lifestyle,owningdifferentabilitytoobtainmedical servicesandvariousdegreesofsocial support.All of these lead to theirdifferentmentalhealthconditions,andeventually, theyhavedifferentlevelsoftheneedforLTC.

3.5　Main conclusions　Firstly,membersare themajorprovidersof thesixbasicneeds forLTC in this study.Thespouseisthemost importantprimarycareprovider inanykindof thebasicneeds.Sons, followingthespouse,take thesecondaryroleonsatisfying theneedsof

“Caredwhensick”,“Cashor things”and“Discussimportant things” for the elderly.While for thedaughters, followingthespouse, takethesecondaryrole on satisfying the needs of“Housework”,

“Talkheartily”and“Going outside together” forthe elderly. Comparingwith these threemaininformal careproviders, the role of others as thecareproviders is relatively loweramongallof therespondents.　Secondly, among these sixbasicneeds forLTC,


― 89 ―

including“Caredwhensick”,“Housework”,“Cashorthings”,“Talkheartily”,“Discuss importantthings”and“Goingoutsidetogether”,thepercentageoftheirbeing“always”satisfiedwas 71.2%, 60.1%, 40.5%,54.7%, 58.2% and 55.8% respectively.Therefore,exceptthe“Cashorthings”,morethanhalfofotherfivekindsofneedsforLTCcouldbealwayssatisfied.Comparingwith theneedscouldbe“Always”and

“Frequently” satisfied, the remaining four ones,namely“Sometimes”,“Seldom”,“Never”,“Notneeded”,theirproportionisrelativelylow.　Thirdly, there is apositive correlationbetweensocioeconomic status andmental health both fortheTibetanmaleand femaleelderly.That is, thehigher socioeconomic statusof theTibetanurbanelderly, thebetterof theirmentalhealth; the lowersocioeconomicstatusof theTibetanurbanelderly,theworseof theirmentalhealth.Slightdifferencewas observed on the correlation between SESandmental health,while itwas slightly strongeramong theTibetan femaleelderly than theirmalecounterparts.　Fourthly, there isanegativecorrelationbetweenmentalhealthand theNLTCboth for theTibetanmale and female elderly.Namely, bettermentalhealthof theTibetanurbanelderlywouldmainlyindicate their fewerNLTC;while for thosewhosementalhealthisworse,theirNLTCwouldbemore.Subtledifferencewas foundabout therelationshipbetweenmentalhealthand theNLTC,and itwaslittlestrongeramongtheTibetanmaleelderlythanthefemaleones.　Fifthly,Tibetanmale and female elderlywouldnotonlyhaveadirect impactontheneedforLTC,but alsohavean indirect impact on theneed forLTC throughmental health, andboth the directand indirecteffectarenegative.That is tosay, thehigher socioeconomic statusof theTibetanurbanelderly, the lesstheirneeds fortheLTC;the lowersocioeconomic statusof them, themoreneeds fortheLTC.Minor distinctionwas observed on theassociationbetweenSESand theNLTC,while thetotaleffectwasslightlystrongeramongtheTibetanmaleelderlythantheirfemalecounterparts.

References:1）LinXu.Socialwelfareproblemsandthestrategy

in thedeprivedareasofChina.Xi’an,People’sPressofShanxiProvince,1998：98.

2）NationalBureau of Statistics of thePeople’sRepublicofChina.Reportof the1%populationsamplingsurveyofChinain2005.2006.

3）NationalBureau of Statistics of thePeople’sRepublicofChina.Reportof theSixthNationalPopulationCensusin2010（no.1）.2011.

4）GovernmentofCanada.2011Census:PopulationandDwellingCounts.2012.

5）AnXie.Thestatus,trendsandcharacteristicsofChina’spopulationageing.StatisticalResearch,2004；08）：50―53.

6）C.Mckevitt,N.Fudge, J.Redfern, et al. Self-reported long-termneedsafter stroke.Stroke,2011；42（5）：1398―403.

7）V.HoiLe,P.Thang,L.Lindholm.Elderlycareindaily living in ruralVietnam:needand itssocioeconomic determinants. BMCGeriatr,2011；11：81.

8）A. Laporte, R. Croxford, P. C. Coyte. Can apublicly fundedhomecaresystemsuccessfullyallocate service based on perceived needrather thansocioeconomicstatus?ACanadianexperience.HealthSocCareCommunity,2007；15（2）：108―19.

9）P.Martikainen,H.Moustgaard,M.Murphy,et al.Gender, livingarrangements, and socialcircumstancesasdeterminantsofentryintoandexit from long-term institutional careatolderages: a 6-year follow-up studyof olderFinns.Gerontologist,2009；49（1）：34―45.

10）C.D.Wolfe,S.L.Crichton,P.U.Heuschmann,et al.Estimates of outcomesup to tenyearsafterstroke:analysisfromtheprospectiveSouthLondonStrokeRegister.PLoSMed,2011；8（5）：e1001033.

11）K.A.Reid,E.Smiley,S.A.Cooper.Prevalenceandassociationsofanxietydisorders inadultswith intellectualdisabilities. J IntellectDisabilRes,2011；55（2）：172―81.

12）Nae-HwaKim,GeorgesElHoyek,DianeChau.


― 90 ―

Long-TermCareof theAgingPopulationwithIntellectualandDevelopmentalDisabilities.ClinGeriatrMed,2011；27（2）：291―300.

13） J.M.Sorrell, S.Durham.Meeting thementalhealthneedsof theagingveteranpopulation.JPsychosocNursMentHealthServ,2011；49（1）：22―5.

14）G.Samuelsson,G.Sundstrom,O.Dehlin, et al.Formalsupport,mentaldisordersandpersonalcharacteristics: a 25-year follow-up studyof atotal cohort of olderpeople.HealthSocCareCommunity,2003；11（2）：95―102.

15）F. Gong, J . Xu, D. T. Takeuchi . Beyondconventional socioeconomic status: examiningsubjectiveandobjectivesocialstatuswithself-reported health amongAsian immigrants. JBehavMed,2012；35（4）：407―19.

16）G. V. Mavrinac, D. M. Sersic, A. Mujkic.Cardiovascular and behavioral risk factorsin relation to self-assessedhealth status.CollAntropol,2009；33Suppl1：99―106.

17）F.Sani,M.E.Magrin,M.Scrignaro, et al. In-group identificationmediates the effects ofsubjectivein-groupstatusonmentalhealth.BrJSocPsychol,2010；49（Pt4）：883―93.

18）T.Huijts,T.A.Eikemo,V. Skalicka. Income-related health inequalit ies in the Nordiccountries: examining the role of education,occupationalclass,andage.SocSciMed,2010；71（11）：1964―72.

19） I.Theodossiou,A.Zangelidis.Thesocialgradientin health: the effect of absolute income andsubjective social status assessment on theindividual’shealth inEurope.EconHumBiol,2009；7（2）：229―37.

20）O.Baron-Epel,G.Kaplan.Can subjective andobjectivesocioeconomicstatusexplainminorityhealthdisparities inIsrael?SocSciMed,2009；69（10）：1460―7.

21）K.Honjo,N.Kawakami,T.Takeshima, et al.Socialclass inequalities inself-ratedhealthandtheirgenderandagegroupdifferencesinJapan.JEpidemiol,2006；16（6）：223―32.

22）TanjiHoshi.Healthpromotion for thepeople

with focusing on the personal dream andthought. JapaneseJournalofHealthEducationand Promotion, 2012；20（4）：307―312（inJapanese）.

23）Tanji Hoshi, Naoko Sakurai. Social supportsetworks andhealth.TheQuarterly of SocialSecurityResearch, 2012；48（3）：304―318（inJapanese）.

24）T.Hoshi, C.Takagi, N. Inoue, et al. Causaleffectofsocioeconomicvariablesonthe“threehealth factors”amongelderlyurbandwellers.Japanese Journal of Health education andpromotion.JapaneseJournalofHealthEducationand Promotion, 2012；20（3）：159―170（inJapanese）.

25）MikiKubo.Astructureanalysisofsocioeconomicfactorsandhealthstates for theurbanelderlydwellerswithcardiovasculardiseases.Bulletinof SocialMedicine, 2012；30（1）：13―24（inJapanese）.

26）Naoko Inoue.The chronological trend of thebedridden status andpreventive factors andcumulativesurvival rateduring threeyears inthe Japaneseurbanelderlydwellers.Bulletinof SocialMedicine, 2012；30（1）：1―12（inJapanese）.

27）L.―T.Hu,P.M.Bentler.Cutoff criteria for fitindexes in covariance structure analysis:Conventional criteriaversusnewalternatives.StructuralEquationModeling:AMultidisciplinaryJournal,1999；6（1）：1―55.

28）PeterMBentler,DouglasGBonett.Signi?cancetests and goodness of fit in the analysis ofcovariance structures. Psychological bulletin,1980；88（3）：588―606.

29）Tai.Sheng.Rong.AmosandResearchMethod.Secondeditioned.Chongqing,ChongqingUniversityPress,2010：128（inChinese）.

30）MichaelWBrowne, Robert Cudeck. Singlesample cross-validation indices for covariancestructures.MultivariateBehavioralResearch,1989；24（4）：445―455.

31）D.S.Brennan,K.A.Singh.Dietary,self-reportedoralhealthandsocio-demographicpredictorsof


― 91 ―

generalhealthstatusamongolderadults.JNutrHealthAging,2012；16（5）：437―41.

32）D.Fiorillo,F. Sabatini.Quality andquantity:the role of social interactions in self-reportedindividualhealth.SocSciMed,2011；73（11）：1644―52.

33）M. J.Hwang,D.P.Yoon,W.Shim, et al.Theimpact of social status and riskbehaviors onhealthstatusamongelderlyindividualsinKorea.SocWorkPublicHealth,2010；25（2）：223―36.

34）A.Wengler.The health status of first- andsecond-generation Turkish immigrants inGermany.IntJPublicHealth,2011；56（5）：493―501.

35） S.Kagamimori,A.Gaina,A.Nasermoaddeli.SocioeconomicstatusandhealthintheJapanesepopulation.SocSciMed,2009；68（12）：2152―60.

36）E.C. Bird, P. Conrad,A.M.(Eds.) Fremont J.Mirowsky,C.E.Ross,J.Reynolds.Linksbetweensocial status and health status.Handbook ofmedical sociology.Upper Saddle River,NewJersey,Prentice-Hall.2000：47―67.

37）E.C.Bird,P.Conrad,A.M.(Eds.)FremontS.A.Robert, J.S.House. Socioeconomic inequalitiesin health:An enduring sociological problem.Handbookofmedical sociology.UpperSaddleRiver,NewJersey,Prentice-Hall.2000：79―97.

38）LisaFBerkman, IchiroKawachi.AHistoricalFramework forSocialEpidemiology.NewYork,OxfordUniversityPress,2000.

39）MichaelMarmot, RichardWilkinson. Socialdeterminants of health. NewYork, OxfordUniversityPress,1999.

40） I.Kawachi,B.P.Kennedy.Health and socialcohesion:why care about income inequality?BMJ,1997；314（7086）：1037―40.


― 92 ―

Documents

Gender differential on the structural relationship between ...jssm.umin.jp/report/no31-2/31-2-09.pdf177,648,705 older adults aged 60 years old or over, accounting for 13.26 percent