Quality of Life Research

https://doi.org/10.1007/s11136-020-02571-w

Activities of daily living, life orientation, and health‑related

quality of life among older people in nursing homes: a national
cross‑sectional study in China
Junling Li1 · Xueying Xu1 · Jinbin Sun1 · Weijie Cai1 · Tiantian Qin1 · Mingcheng Wu1 · Hongbo Liu1

Accepted: 26 June 2020

© Springer Nature Switzerland AG 2020

Abstract
Purpose This study aimed to explore the current status of activities of daily living (ADLs), life orientation, and health-related
quality of life (HRQoL) among older people in nursing homes and to further examine the mediating role of life orientation
in the impact of ADLs on HRQoL.
Methods A national cross-sectional study was conducted among older people aged 60 and above in nursing homes by the
randomly stratified cluster sampling method. The status of ADLs, life orientation and HRQoL were measured using an ADL
scale, a life orientation scale and the SF-12v2 scale, respectively. Multiple linear regression models were used to identify
explanatory factors associated with ADLs, life orientation, and HRQoL. The potential mediating role of life orientation in
the relationship between ADL and HRQoL was explored by mediation analysis.
Results The overall prevalence of ADL disability was 52.67%, and 84.37% of older people in nursing homes had a negative
life orientation. The mean scores of physical health and mental health among older people in nursing homes were 45.44 ± 6.46
and 42.67 ± 8.48, respectively. Some sociodemographic characteristics were associated with poor physical health and mental
health. After adjustments were made for covariates, the life orientation score mediated 13.81% of the total effect of the ADL
score on physical component score of HRQoL and mediated 45.33% of the mental component score of HRQoL.
Conclusion A sizeable proportion of older people had ADL disability and negative life orientation, and HRQoL was poor
among older Chinese people in nursing homes. Life orientation partially mediates the relationship between ADLs and
HRQoL.

Keywords Activities of daily living · Life orientation · Health-related quality of life · Older people · Nursing homes

* Hongbo Liu Background

hbliu@cmu.edu.cn
Junling Li In China, the proportion of the population aged 60 years
jlli@cmu.edu.cn old or over is increasing rapidly, accounting for 209 mil-
Xueying Xu lion individuals (15.2% of the total population) in 2015
bangjunjun@163.com and projected to comprise 358 million (25.3% of the total
Jinbin Sun population) in 2030 [1]. Additionally, decreasing fertil-
jbsun@cmu.edu.cn ity is ushering in unprecedented rapid population aging
Weijie Cai [2]. Accompanied by changes in demographic structure,
wjcai@cmu.edu.cn more medical and health services are in demand and carry
Tiantian Qin considerable social burdens [3, 4]. Consequently, the fam-
920927803@qq.com ily-based support system alone is inadequate to meet the
Mingcheng Wu considerable demands of medical and health services in
mcwu@cmu.edu.cn China [5]. Thus, a growing number of older people have
1 to choose to live in nursing homes for assisted living and
School of Public Health, China Medical University, 77 Puhe
Road, Shenyang North New Area, Shenyang, Shenyang, health care, especially older people with no partner or off-
Liaoning Province 110122, People’s Republic of China spring, multimorbidity, functional impairment, etc [6–8].

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This phenomenon may lead to differences between older
people living in nursing homes and community-dwelling
older people with respect to physical health, mental health,
and other factors [9]. In 2016, the Chinese government
reviewed and approved the plan for Healthy China 2030,
and one of the health policy goals was to improve the
mechanisms of nursing homes to promote healthy aging
[10]. Therefore, it is important and necessary to under-
stand the health status of older people in nursing homes
and explore effective measures for promoting their physi-
cal and mental health.
Health-related quality of life (HRQoL) is a subjec-
tive and multidimensional concept that consists of physi-
cal health and mental health and is a key indicator of a
person’s overall health status [11]. Studies have shown
that sociodemographic characteristics, social support,
and physical and psychological factors may influence the
HRQoL of older people [12–14]. The HRQoL of widowed
older people is lower than that of married older people
[15]. In particular, physical functioning seems to be a fun-
damental factor of HRQoL for nursing home residents,
and activities of daily living (ADLs) are associated not
only with the physical dimension but also with the psy-
chological dimension of HRQoL in China [16]. ADLs
address the essential activities that an individual performs
to live independently within society. Dysfunction in ADLs
is a major aging issue [17]. Positive life orientation, as
an inner health resource among older people, is closely
related to emotional vitality, optimism, positive emotion,
etc. [18]. Life orientation is associated with the major-
ity of the domains of health-related quality of life, and
pessimism could contribute to poorer mental health [19].
Furthermore, our previous research has indicated that
independence in basic activities of daily living (BADLs)
and instrumental activities of daily living (IADLs) was
related to positive life orientation among older Chinese
people in nursing homes [5].
Since dependency in ADLs could contribute to poor
HRQoL, positive life orientation, as a positive factor of
HRQoL, may play a mediating role in the relationship
between ADLs and HRQoL. The results from recent stud-
ies are still inaccurate in examining the mediating role of life
orientation in the effect of ADLs on HRQoL among older
people, particularly among older Chinese people in nurs-
ing homes. Therefore, based on the previous literature, we
hypothesized that both ADL function decline and negative
life orientation would have a significant negative impact on
HRQoL, and life orientation mediates the effect of ADLs
on HRQoL among older Chinese people in nursing homes.
Studies exploring such mediation effects are lacking. This
mediation analysis will enrich our understanding of HRQoL
and aid in the development of effective interventions to pro-
mote HRQoL among older people in nursing homes.
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Quality of Life Research
Methods
Study design
A cross-sectional study was carried out in China with a
multistage sampling design. First, based on geographic
divisions, China comprises five regions (eastern, west-
ern, southern, northern, and central), and each region has
several provinces or municipalities. Four provinces were
randomly selected in each region, and four municipalities
were also selected. Second, five cities (including munici-
palities) were randomly selected from each chosen prov-
ince (including neighboring municipalities). Third, based on
the type of ownership and control, the nursing homes were
divided into public nursing homes, private nursing homes,
and public–private nursing homes in China. Three nurs-
ing homes (including three types) were randomly selected
from each chosen city. All older people living in the chosen
nursing home were identified and recruited in our study if
they (1) were aged ≥ 60 years, (2) had lived in a nursing
home ≥ 3 months, (3) could communicate with the inves-
tigator, or (4) volunteered to participate in this survey. To
obtain more accurate data and comply with medical ethics,
our exclusion criteria include (1) a severe physical disease or
mental illness, (2) severe cognitive impairment, (3) inability
to communicate with the investigator, and (4) refusal to par-
ticipate in this survey. Considering the low educational level
of older people in China, face-to-face communication was
used to collect data in this survey. Before face-to-face com-
munication and with the consent of the management staff
of nursing homes, the trained investigators introduced the
purpose of this survey to participants and assured that their
information would be confidential. After obtaining informed
consent, our investigators completed questionnaires while
engaging in face-to-face communications.
Calculating the sample size
According to the distribution of the physical component
score and mental component score of quality of life among
older people in nursing homes, the sample size was calcu-
lated by the cluster sampling method [20], and a higher sam-
ple size was taken.
The following formula (1) was used to estimate the num-
bers for simple random sampling, in physical health and
mental health:
)2
z𝛼∕2 CV
(
n= (1)
𝜀
where Zα/2 denotes the αth quantile of the Z distribution
(given α = 0.05); CV denotes the variable coefficient; and
Quality of Life Research

ε denotes the relative error (given ε = 0.04, to control the deffphysical health = 1 + 0.522 × (300 − 1) = 157.07 ≈ 157
permissible error within 2 points both physical and mental
health scores). )2
7.35
Considering intraclass correlation coefficient between each
(
1.96 × 42.75
group, we calculated the design effect on physical health and nmental health = = 70.97 ≈ 71
0.04
mental health. The formula is as follows.
deff = 1 + 𝜌(M − 1) (2) ( 7.35 )2
1.96 × 42.75
where ρ denotes the intraclass correlation coefficient and M nmental health = = 70.97 ≈ 71
0.04
denotes the number of listing units sampled in each cluster.
Finally, the formula of sample size for cluster randomized
studies is N = n × deff . In this equation, the n is calculated deffmental health = 1 + 0.502 × (300 − 1) = 151.09 ≈ 151
sample size for simple random sampling, and deff denotes
The estimated sample size in physical health was 10,205,
design effect [21].
and in mental health, it was 10,721. We chose the higher
In our pilot survey, the mean physical component score and
sample size. Finally, considering a 10% nonresponse rate,
the standard deviation among older people in nursing homes
N = n/(1–0.1) = 10,721/0.90 = 11,912; therefore, we inves-
were 44.41 and 7.29, respectively. The mean mental compo-
tigated 12,000 older people.
nent score and the standard deviation among older people in
nursing homes were 42.75 and 7.35, respectively. In addition,
Sampling procedure
the intraclass correlation coefficients of the physical and men-
tal groups were 0.522 and 0.502, respectively, and an average
Figure 1 shows the sample enrollment procedure. Before
of 300 people of each group (nursing home) were determined
the formal investigation of our study, we conducted a pilot
according to our design.
survey of older people in three local (Shenyang) nursing
(
1.96 × 7.29 )2 homes, and a total of 159 older people were surveyed. In our
nphysical health = 44.41
= 64.70 ≈ 65 formal investigation, 267 questionnaires were not returned,
0.04 and 936 questionnaires with missing values for more than
10% of the items were regarded as invalid questionnaires.

Fig. 1  Participant enrollment

procedure 5 regions (Eastern, Western, Southern, Northern, and Central) in China

4 provinces selected randomly from each region

5 cities (including municipalities) selected randomly from each chosen province

3 nursing homes (public, private, and public-private nursing homes) from 100
cities (including 4 municipalities) (300 nursing homes, 12,000 older people)

267 participants were non-responsive

11,733 returned

936 invalid questionnaires

7

10,797 valid questionnaires

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Therefore, we collected 10,797 valid questionnaires, and the
effective response rate was 90.0%.
Basic characteristics of individuals, families,
and nursing homes
Based on the literature review [22–26], we considered three
aspects that may be related to quality of life in older people,
namely, sociodemographic characteristics, participants’ fam-
ilies, and nursing homes. In China, most of the older people
living in nursing homes are widowed or have no partner or
offspring. Considering the actual situation of older people,
families, and nursing homes in China, we chose the follow-
ing variables. Five sociodemographic characteristics were
chosen: age, gender, education status, marital status, and
pension. The variables pertaining to participants’ families
included the number of children, the status of the children’s
job, and the frequency of family visits. The variables per-
taining to nursing homes where participants lived included
the type of nursing home, nursing home expenses (RMB),
type of living room, nursing home evaluation, and frequency
of participatory social activities. Among these variables, age
was divided into three categories (< 75 years, 75–90 years,
and ≥ 90 years), according to the age division of older people
by the World Health Organization. In addition, we consid-
ered that older people lived in a nursing home because they
had no children, or their children were unable to support
them while they had 1–2 children. However, while they had
3 or more children, there were other reasons for living in a
nursing home, such as wanting to live in a nursing home.
We divide the variable into the following categories: none,
1 ~ , and 3 ~ .
Measurement of HRQoL
In this study, we used the SF-12v2, which is one of the
most widely used instruments for assessing self-reported
HRQoL [27]. The SF-12v2 consists of 12 items covering
eight dimensions: physical functioning, role physical, bod-
ily pain, general health, vitality, social functioning, role
emotional, and mental health. These items can be scored to
provide a physical component summary (PCS12) score and
a mental component summary (MCS12) score. These scores
were computed using norm-based methods to standardize
the scores (0–100) with a mean of 50 and a standard devia-
tion (SD) of 10 compared to the general US population [28].
The Chinese SF-12 has been demonstrated as a reliable and
valid instrument among the Chinese community of older
people [29]. The Cronbach’s alpha coefficients in this study
for physical health and mental health were 0.77 and 0.76,
respectively.
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Quality of Life Research
Measurement of the activities of daily living
Functional status was assessed using the basic activities of
daily living (BADLs) and instrumental activities of daily
living (IADLs) [30, 31]. The BADL scale assessed 6 func-
tions: bathing, dressing, feeding, showering, toileting, and
mobility (rising from a chair and walking). The IADL scale
assessed 8 functions: use of telephone, shopping for grocer-
ies, preparation of a meal, housekeeping, laundering, tak-
ing medications as prescribed, transportation, and manag-
ing finances. This scale included 14 items, and each item
is scored on a four-point scale ranging from 1 to 4, with
scores corresponding to independence, having some trouble,
needing help, and not being able to perform a given task.
The overall score ranges from 14 to 56, with a higher score
indicating a higher level of dependency. Any 2 or more items
(including BADLs and IADLs) with a score ≥ 3 points or a
total score ≥ 22 points indicated ADL disability (ADL dis-
ability was defined as a need for assistance in one or more
ADLs [32]), a total score equal to 14 points indicated nor-
mal function, and other scores indicated functional decline.
The questionnaire has been culturally adapted and translated
into Chinese, and it has been reported to have high validity
and reliability among older Chinese adults in nursing homes
[33]. The Cronbach’s alpha coefficient of the scale was 0.94
in this study.
Measurement of life orientation
Life orientation was measured by the Positive Life Orienta-
tion Scale (LOS) [34]. To be categorized as having a posi-
tive life orientation, one had to answer “positively” to all
the following questions (yes/no): (1) Are you satisfied with
your life? (yes = 0, no = 1); (2) Do you have zest for life?
(yes = 0, no = 1); (3) Do you feel needed? (yes = 0, no = 1);
(4) Do you have plans for the future? (yes = 0, no = 1); (5)
Do you suffer from loneliness? (seldom or sometimes = 0,
often or always = 1); and (6) Do you feel depressed? (seldom
or never = 0, often or always = 1). The sum of the scores for
these six questions (ranging from 0 to 6) yielded the life
orientation score (LOS), with a score of 0 representing a
positive life orientation and 1 representing a negative life
orientation [35]. The Positive Life Orientation Scale has
been demonstrated as a reliable and valid instrument among
older people [19]. In the present study, the Cronbach’s alpha
for the scale was 0.68.
Statistical analysis
Statistical analyses were performed in SAS 9.4. Numerical
variables were expressed as means and standard deviations
(SDs); categorical variables were expressed as frequen-
cies and percentages. Comparisons of means between the
Quality of Life Research
groups were made by independent t-tests or analysis of
variance. The factors associated with ADLs, life orienta-
tion and HRQoL were assessed by three separate multiple
linear regression models, using the total score for ADLs,
life orientation, the PCS12, and the MCS12 as the depend-
ent variables. Then, mediation analysis was conducted to
explore both the direct and indirect effects of ADLs on
HRQoL. The mediation analyses were first run without any
covariates (model 1); they were then adjusted for age and
sex (model 2), and finally, they were adjusted for educa-
tional level, marital status, pension, number of children,
status of children’s job, frequency of family visits, nursing
home expenses, type of living room, nursing home evalua-
tion, and frequency of participatory social activities (model
3). Bootstrap models was used to estimates bias-corrected
confidence intervals for various effects and percentages of
total effects (NBOOT = 1000, SEED = 20,200,622). For all
statistical tests, two-tailed p values < 0.05 were considered
statistically significant.
Results
Demographic characteristics of participants
A total of 5623 males and 5174 females participated. The
mean age of the participants was 74.60 ± 7.27 years, with a
range from 60 to 104 years old. The education level of the
subjects was generally low, with nearly 80% of participants
below the level of high school. A total of 8165 (75.62%)
of the participants were in separated/widowed/single; only
39.13% of the respondents’ monthly pension exceeded
1500 RMB. Over half of the participants had more than
two children, but most of their sons or daughters were busy
(56.39%), and 75.48% of their families visited them at least
once a month. Most older people live in double rooms, and
only a small proportion (14.19%) of the sample had expenses
of more than 2000 RMB for nursing homes every month.
A total of 55.15% of participants thought highly of their
nursing homes; 50.75% of participants sometimes chatted or
played chess or cards with the older people in their nursing
home. More information is provided in Table 1.
The status of ADLs, LOS, and HRQoL
The status of ADLs, life orientation, and HRQoL (PCS12
and MCS12) by different characteristics are presented in
Table 2. Their mean scores among the older people were
22.89 ± 8.48, 2.27 ± 1.70, 45.44 ± 6.46 an,d 42.67 ± 8.48,
respectively. After the ADL scores and LOS scores were
recoded into classification variables, the proportion of
participants with normal functioning, declines in ADLs
and ADL disability were 21.61%, 25.72%, and 52.67%,
respectively; furthermore, 84.37% had a negative life orien-
tation. Table 2 shows that physical health decreased with age
but increased with the frequency of family visits. In addi-
tion, married older people had better levels of both mental
health and physical health than separated/widowed/single
older people had.
Explanatory factors associated with ADLs, LOS
and HRQoL
In the multiple regression analysis, age, educational level,
number of children, type of nursing home, nursing home
expenses, nursing home evaluations, and frequency of par-
ticipatory social activities were associated with ADL scores.
Marital status, pension, frequency of family visits, nursing
home evaluation, and frequency of participatory social
activities were associated with life orientation scores. Edu-
cational level, marital status, and type of living room were
associated with physical health scores, while gender, mari-
tal status, number of children, nursing home expenses, and
nursing home evaluation were associated with mental health
scores (Table 3).
Mediation analysis
LOS as a mediator of the ADL‑PCS12 association
Table 4 and Fig. 2a (model 3) present the findings from
mediation analysis, exploring the ADL-LOS-PCS12 path-
way using the LOS score as the mediator. In the unadjusted
model (model 1), the ratio of the indirect effect of ADLs
to the total effect through LOS was 16.29%. In the final
adjusted model (model 3), the LOS score mediated 13.81%
of the total effect of ADLs on PCS12.
LOS as a mediator of the ADL—MCS12 association
Table 5 and Fig. 2b (model 3) present the findings from
mediation analysis, exploring the ADL-LOS-MCS12 path-
way using the LOS score as the mediator. In the unadjusted
model (model 1), the ratio of the indirect effect of ADLs
to the total effect through LOS was 44.85%. In the final
adjusted model (model 3), the LOS score mediated 45.33%
of the total effect of ADLs on MCS12.
Discussion
Given the enormous burden that the family living arrange-
ments place on families, the shift from the family mode
to the institutional mode will be an overwhelming trend
[9]. In addition, older people living in nursing homes are
more likely to be presented with health-promoting behavior
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Table 1  Demographic Variables Male (n = 5623) n(%) Female (n = 5174) n(%) Total (n = 10,797) n(%)
characteristics of participants
(%) Age
60 ~ 2902 (51.61)* 2534 (48.98) 5436 (50.35)
75 ~ 2608 (43.38) 2515 (48.61) 5123 (47.45)
90 ~ 113 (2.01) 125 (2.42) 238 (2.20)
Educational level
Illiterate 1671 (29.72)* 1973 (38.13) 3644 (33.75)
Primary/secondary school 2689 (47.82) 2302 (44.49) 4991 (46.23)
High school and above 1263 (22.46) 899 (17.38) 2162 (20.02)
Marital status
Married 1423 (25.31)* 1209 (23.37) 2632 (24.38)
Separated/widowed/single 4200 (74.69) 3965 (76.63) 8165 (75.62)
Pension (RMB)
None 1721 (30.61)* 1963 (37.94) 3684 (34.12)
1~ 1523 (27.09) 1365 (26.38) 2888 (26.75)
1500 ~ 1448 (25.75) 1247 (24.10) 2695 (24.96)
2500 ~ 931 (16.56) 599 (11.58) 1530 (14.17)
Number of children
None 170 (3.02)* 114 (2.20) 284 (2.63)
1~ 1728 (30.73) 1540 (29.76) 3268 (30.27)
3~ 3725 (66.25) 3520 (68.03) 7245 (67.10)
Status of children’s jobs
Very busy 3219 (57.25) 2869 (55.45) 6088 (56.39)
General 2119 (37.68) 2018 (39.00) 4137 (38.32)
Not busy 285 (5.07) 287 (5.55) 572 (5.30)
Frequency of family visits
No less than one time/month 4185 (74.43)* 3965 (76.63) 8150 (75.48)
One time/1–6 months 1087 (19.33) 942 (18.21) 2029 (18.79)
One time/more than 6 months 351 (6.24) 267 (5.16) 618 (5.72)
Nursing home expenses (RMB)
0~ 2649 (47.11) 2344 (45.30) 4993 (46.24)
1000 ~ 2186 (38.88) 2086 (40.32) 4272 (39.57)
2000 ~ 788 (14.01) 744 (14.38) 1532 (14.19)
Type of living room
Single room 1139 (20.26)* 894 (17.28) 2033 (18.83)
Double room 2712 (48.23) 2638 (50.99) 5350 (49.55)
Mixed dormitory 1772 (31.51) 1642 (31.74) 3414 (31.62)
Evaluation of nursing home
Very good 3056 (54.35) 2899 (56.03) 5955 (55.15)
General 2340 (41.61) 2069 (39.99) 4409 (40.84)
Not good 227 (4.04) 206 (3.98) 433 (4.01)
Frequency of activities
Never 465 (8.27) 448 (8.66) 913 (8.46)
Sometimes 2826 (50.26) 2654 (51.29) 5480 (50.75)
Always 2332 (41.47) 2072 (40.05) 4404 (40.79)

*p < 0.05

interventions to improve their quality of life [36]. Thus, the of ADLs on HRQoL through life orientation. This knowl-
main contribution of our study is to provide more extensive edge may be useful in the design of effective public health
knowledge on the factors that are associated with HRQoL strategies and the improvement in the quality of nursing
among older people in nursing homes and the indirect effect homes to enhance quality of life in older people.

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Quality of Life Research

Table 2  The status of ADLs, Variables ADL LOS PCS12 MCS12

life orientation and HRQoL by
different characteristics Total 22.89 ± 8.48 2.27 ± 1.70 45.44 ± 6.46 42.67 ± 8.48
Gender
Male 23.02 ± 8.64 2.24 ± 1.70* 45.49 ± 6.49 42.84 ± 8.43*
Female 22.75 ± 8.29 2.31 ± 1.70 45.39 ± 6.43 42.48 ± 8.52
Age
60 ~ 21.95 ± 8.03* 2.17 ± 1.70* 46.06 ± 6.25* 42.66 ± 8.15
75 ~ 23.69 ± 8.63 2.36 ± 1.70 44.84 ± 6.59 42.72 ± 8.76
90 ~ 27.29 ± 11.34 2.71 ± 1.60 44.08 ± 6.89 41.64 ± 9.49
Educational level
Illiterate 24.02 ± 8.76* 2.56 ± 1.70* 44.56 ± 6.49* 42.36 ± 8.58*
Primary/secondary school 22.45 ± 8.20 2.21 ± 1.68 45.73 ± 6.32 42.67 ± 8.31
High school and above 22.02 ± 8.44 1.94 ± 1.67 46.25 ± 6.57 43.18 ± 8.66
Marital status
Married 22.06 ± 7.98* 2.03 ± 1.66* 46.28 ± 6.64* 43.37 ± 8.29*
Separated/widowed/single 23.16 ± 8.61 2.35 ± 1.71 45.17 ± 6.38 42.44 ± 8.53
Pension (RMB)
None 23.14 ± 8.47* 2.61 ± 1.74* 44.97 ± 6.57* 42.80 ± 8.59*
1~ 23.04 ± 8.20 2.22 ± 1.69 45.59 ± 6.31 42.61 ± 8.11
1500 ~ 22.60 ± 8.81 2.08 ± 1.64 45.55 ± 6.39 42.06 ± 8.56
2500 ~ 22.55 ± 8.40 1.92 ± 1.58 46.12 ± 6.53 43.51 ± 8.67
Number of children
None 21.00 ± 7.81* 2.81 ± 1.69* 45.45 ± 5.75* 41.29 ± 7.60*
1~ 22.51 ± 8.69 2.19 ± 1.74 45.70 ± 6.40 42.75 ± 8.34
3~ 23.14 ± 8.39 2.29 ± 1.68 45.32 ± 6.51 42.68 ± 8.57
Status of children’s jobs
Very busy 22.99 ± 8.72* 2.20 ± 1.71* 45.49 ± 6.52* 43.05 ± 8.56*
General 22.62 ± 8.11 2.37 ± 1.69 45.27 ± 6.31 42.28 ± 8.27
Not busy 23.91 ± 8.31 2.32 ± 1.61 46.13 ± 6.78 41.40 ± 8.89
Frequency of family visits
No less than one time/month 22.91 ± 8.51* 2.16 ± 1.66* 45.53 ± 6.44* 42.87 ± 8.35*
One time/1–6 months 23.11 ± 8.31 2.60 ± 1.75 45.21 ± 6.47 41.81 ± 8.59
One time/more than 6 months 22.00 ± 8.59 2.72 ± 1.87 44.99 ± 6.65 42.82 ± 9.55
Type of nursing home
Public 22.06 ± 7.94* 2.32 ± 1.75* 45.58 ± 6.40* 42.63 ± 8.31
Private 23.74 ± 9.05 2.20 ± 1.66 45.19 ± 6.57 42.78 ± 8.78
Public–private 23.36 ± 8.02 2.39 ± 1.57 45.90 ± 6.19 42.33 ± 7.86
Nursing home expenses (RMB)
0~ 21.54 ± 7.57* 2.30 ± 1.68* 45.61 ± 6.43* 43.43 ± 8.54*
1000 ~ 23.79 ± 8.60 2.31 ± 1.68 45.35 ± 6.43 42.09 ± 8.30
2000 ~ 24.79 ± 10.09 2.07 ± 1.79 45.16 ± 6.65 41.79 ± 8.56
Type of living room
Single room 22.60 ± 8.73* 2.32 ± 1.75* 46.01 ± 6.79* 42.47 ± 8.73*
Double room 22.30 ± 8.14 2.21 ± 1.64 45.57 ± 6.39 43.03 ± 8.32
Mixed Dormitory 24.00 ± 8.74 2.34 ± 1.76 44.89 ± 6.32 42.21 ± 8.55
Nursing home evaluation
Very good 22.31 ± 8.27* 1.96 ± 1.53* 45.82 ± 6.65* 44.36 ± 8.39*
General 23.29 ± 8.58 2.59 ± 1.81 45.00 ± 6.14 40.75 ± 8.07
Not good 26.85 ± 8.91 3.30 ± 1.77 44.71 ± 6.69 38.87 ± 8.42
Frequency of activities
Never 27.13 ± 10.92* 3.02 ± 1.78* 44.04 ± 6.91* 39.72 ± 9.27*
Sometimes 24.03 ± 8.63 2.53 ± 1.74 44.99 ± 6.31 40.90 ± 8.05
Always 20.60 ± 6.95 1.79 ± 1.50 46.30 ± 6.44 45.48 ± 8.02

A t-test or analysis of variance was used to analyze the differences between subgroups
*p < 0.05

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 Quality of Life Research

Table 3  Factors associated with ADLs, life orientation, and HRQoL

ADL LOS PCS12 MCS12
b P value b P value b P value b P value

Intercept 42.82 < 0.01 6.29 < 0.01 58.21 < 0.01 55.19 < 0.01
Gender (Reference = Male) – – 0.04 0.18 −0.30 0.04
Age (Reference = 60 ~)
75 ~ 0.91 < 0.01 0.07 0.01 −0.56 < 0.01 0.47 < 0.01
90 ~ 3.45 < 0.01 0.09 0.34 −0.28 0.49 0.68 0.18
Educational level (Reference = Illiterate)
Primary/secondary school −0.87 < 0.01 −0.07 0.06 0.45 < 0.01 0.19 0.27
High school and above −1.01 < 0.01 −−0.06 0.19 0.61 < 0.01 0.30 0.21
Marital status (Reference = Married) −0.10 0.55 0.10 < 0.01 −0.55 < 0.01 −0.59 < 0.01
Pension (RMB) (Reference = None)
1~ 0.40 0.03 −0.28 < 0.01 0.06 0.71 −0.62 < 0.01
1500 ~ −0.28 0.17 −0.36 < 0.01 −0.32 0.06 −1.53 < 0.01
2500 ~ −0.15 0.55 −0.33 < 0.01 0.09 0.68 −0.42 0.11
Number of children (Reference = None)
1~ 1.18 0.01 −0.22 0.02 −0.05 0.89 1.35 0.01
3~ 1.41 < 0.01 −0.18 0.05 −0.09 0.80 1.32 0.01
Status of children’s jobs (Reference = Very busy)
General −0.86 < 0.01 0.08 0.01 −0.14 0.24 −0.17 0.26
Not busy 0.20 0.53 −0.01 0.84 0.81 < 0.01 −0.71 0.03
Frequency of family visits (Reference = No less than one time/month)
One time/1–6 months −0.18 0.33 0.23 < 0.01 −0.01 0.97 −0.34 0.07
One time/more than 6 months −1.01 < 0.01 0.38 < 0.01 −0.31 0.23 0.50 0.13
Type of nursing home (Reference = Public)
Private 0.89 < 0.01 0.16 0.01 0.66 0.01 – –
Public–private 1.22 < 0.01 −0.04 0.15 −0.13 0.30 – –
Nursing home expenses (RMB) (Reference = 0 ~)
1000 ~ 1.87 < 0.01 −0.06 0.05 0.04 0.78 −0.72 < 0.01
2000 ~ 3.06 < 0.01 −0.31 < 0.01 −0.30 0.12 −1.40 < 0.01
Type of living room (Reference = Single room)
Double room 0.02 0.92 −0.12 < 0.01 −0.56 < 0.01 0.16 0.41
Mixed dormitory 1.23 < 0.01 −0.17 < 0.01 −0.72 < 0.01 −0.07 0.75
Nursing home evaluation (Reference = Very good)
General −0.42 0.01 0.30 < 0.01 −0.41 < 0.01 −2.27 < 0.01
Not good 1.71 < 0.01 0.72 < 0.01 0.59 0.05 −2.61 < 0.01
Frequency of activities (Reference = Never)
Sometimes −2.07 < 0.01 −0.19 < 0.01 0.01 0.97 0.29 0.29
Always −3.75 < 0.01 −0.45 < 0.01 0.27 0.28 3.15 < 0.01
ADLs – – 0.03 < 0.01 −0.24 < 0.01 −0.12 < 0.01
LOS 0.87 < 0.01 – – −0.78 < 0.01 −1.49 < 0.01
HRQoL
PCS12 −0.37 < 0.01 −0.05 < 0.01 – – −0.15 < 0.01
MCS12 −0.12 < 0.01 −0.06 < 0.01 −0.09 < 0.01 – –

b unstandardized coefficient; In our model, we adjusted for nursing home

In our study, activities of daily living, life orientation an empirical study found that the ADLs of older adults in
and health-related quality of life of older people in nurs- nursing homes in China were poor, and the physical and
ing homes were poor, and the levels were lower than those mental health scores were all moderate [33]. A large pro-
of community-dwelling older people [9, 36]. However, portion of older people had ADL disability and negative

13
Quality of Life Research

Table 4  Mediation analysis for Model 1 Model 2 Model 3

the association between ADLs
and PCS12, mediated by LOS b CI b CI b CI

Total effect, c −0.28* (−0.29, −0.27) −0.27* (−0.28, −0.26) −0.27* (−0.28, −0.25)
Direct effect, c’ −0.23* (-0.25, −0.22) −0.23* (−0.24, −0.21) −0.23* (−0.25, −0.21)
Indirect effect, ab −0.05* (−0.05, −0.04) −0.04* (−0.05, −0.04) −0.04* (−0.04, −0.03)
Ratio of indirect to 16.29% 16.26% 13.81%
total effect medi-
ated (ab/c)
Ratio of indirect 19.47% 19.43% 16.04%
to direct effect
(ab/c’)

Model 1 Unadjusted model, Model 2 Adjusted for age and sex, Model 3 Adjusted for age, sex, educational
level, marital status, pension, number of children, status of children’s job, frequency of family visits, nurs-
ing home expenses, type of living room, nursing home evaluation, and frequency of activities, b unstand-
ardized coefficient
*p < 0.05

Fig. 2  Mediation model of HRQoL. a Association between ADLs
and PCS12, mediated by LOS; b association between ADL and
MCS12, mediated by LOS (X independent variable, Y outcome vari-
able, M mediator variable, a: association between independent vari-
able (X) and potential mediator (M); b association between potential
mediator (M) and outcome variable (Y), controlling for independent
variable (X); c total effect of the independent variable (X) on out-
come variable (Y); c’ direct effect (unmediated) of independent vari-
able (X) on outcome variable (Y)). *p < 0.05

Table 5  Mediation analysis for Model 1 Model 2 Model 3

the association between ADLs
and MCS12, mediated by LOS b CI b CI b CI

Total effect, c −0.24* (−0.26, −0.22) −0.25* (−0.27, −0.23) −0.17* (−0.20, −0.16)
Direct effect, c’ −0.13* (−0.15, −0.12) −0.14* (−0.16, −0.12) −0.10* (−0.12, −0.08)
Indirect effect, ab −0.11* (−0.12, −0.10) −0.11* (−0.12, −0.10) −0.08* (−0.09, −0.07)
Ratio of indirect to 44.85% 43.52% 45.33%
total effect medi-
ated (ab/c)
Ratio of indirect 81.30% 77.09% 82.93%
to direct effect
(ab/c’)

Model 1 unadjusted model, Model 2, adjusted for age and sex. Model 3, Adjusted for age, sex, educational
level, marital status, pension, number of children, status of children’s job, frequency of family visits, nurs-
ing home expenses, type of living room, nursing home evaluation, and frequency of activities, b unstand-
ardized coefficient
*p < 0.05

13

life orientation, which should attract the attention of nursing
home policymakers. Although aging naturally leads to ADL
disability, management staff of nursing homes can improve
this issue by providing more opportunities for social activi-
ties and physical rehabilitation exercises [37, 38]. The older
people living in nursing homes are more likely to feel that
their lives have lost its meaning or to feel lonely because of
insufficient family support, which can lead to a negative life
orientation [11]. Therefore, we call on family members to
often visit older people in nursing homes, especially adults
aged more than 90 years, who have poor daily living ability
and negative life orientation. Under the influence of the tra-
ditional Chinese concept of older-age care, the quality of life
of older people in nursing homes is lower than that of older
people in the community, which is consistent with Scocco’s
research results [9]. Compared with an elderly community-
dwelling population in Shanghai, the population in nursing
homes had lower physical and mental component summary
scores in our study [39]. In our results, the mental health
of older people in nursing homes was lower than physical
health, so we should pay more attention to the mental health
of older people. The results of univariate analysis showed
that older people with a good evaluation of nursing homes
had better HRQoL, especially mental health. Thus, manage-
ment staff of nursing homes could improve the satisfaction
of older people through various measures to improve their
mental health. In addition, we found that having a higher
educational level, being married, and living in a single room
were associated with good physical health, while being male,
being married, having more children, having lower nursing
home expenses, and having a better evaluation of nursing
homes were associated with good mental health [40–43].
It is worth noting that the widowers, accounting for a large
proportion of the older people in nursing homes, had poorer
mental health and physical health than married older people
[44]. Therefore, given that marital status is hard to change,
we should pay more attention to widowed older people both
physically and mentally. These conclusions provide policy-
makers with indicators regarding the rational allocation of
health resources.
To the best of our knowledge, this was the first attempt
to examine the mediating role of life orientation in the rela-
tionship between ADLs and HRQoL, which revealed that
ADLs have an indirect effect on HRQoL through life ori-
entation. The mediation effect of life orientation on mental
health was greater than that on physical health. However,
we are more focused on the mediation effect on physical
health because physical health is harder to change than men-
tal health. In the current study, many older people with ADL
disability are more likely to be depressed and unsatisfied
with life, which can lead to a negative life orientation [45].
Likewise, life orientation was found to be a significant fac-
tor associated with physical health, and interestingly, the
13
Quality of Life Research
effect of life orientation on mental health was greater than
the effect of ADLs on physical health [19]. In previous stud-
ies, ADLs and life orientation were independently associated
with physical health among older people [46]. This finding
provided a possible mechanism by which ADLs influenced
HRQoL. Given that ADL disability is hard to change, spe-
cific measures for promoting positive life orientation should
be made among older people in nursing homes considering
their particular characteristics. Suggested measures include
encouraging offspring to contact older people regularly,
introducing professional medical staff to nursing homes, and
organizing social activities to help older people have positive
relations with others.
This study is subject to some limitations. First, due
to our cross-sectional study design, no inferences can be
made regarding the causal relationships between ADLs,
life orientation, and HRQoL. Second, the ADL–life ori-
entation–HRQoL model was the first to be examined, this
hypothesis was based on limited theories and research expe-
rience, and the life orientation–ADL–HRQoL model cannot
be ruled out. Therefore, more prospective studies will be
needed to confirm these preliminary findings in the future.
Third, in the current study, the internal consistency of ADLs
was high, but that of the LOS was relatively low (Cronbach’s
alpha for the scale was 0.68). Finally, the possibility of selec-
tion bias and residual confounding cannot be ruled out.
For example, a person was excluded if there was a severe
physical disease or mental illness, and some older people
with worse ADLs were likely to be unable to complete the
questionnaire or participate in the survey, which resulted in
missing data or bias.
Conclusion
There was a high prevalence of ADL disability and a low
degree of positive life orientation, and HRQoL was poor
among older Chinese people in nursing homes. Lower edu-
cational level, separated/widowed/single status, and living
in a double room or mixed dormitory were associated with
poor physical health, while being male, being married, hav-
ing more children, having lower nursing home expenses,
and living in nursing homes with better evaluations were
associated with good mental health. Life orientation played
a mediating role in the relationship between ADLs and
HRQoL. These findings provide an integrated understand-
ing of the practical implications for developing interventions
to promote HRQoL among older Chinese people in nursing
homes.
Acknowledgements We wish to thank the participants, advisors, man-
agement staff of nursing homes, and collaborators of this study for their
valuable contributions.
Quality of Life Research
Author contributions All authors contributed to the study concep-
tion and design. Material preparation, data collection, and analysis
were performed by JL, JS, WC, TQ, and MW. The first draft of the
manuscript was written by JL, and all authors commented on previous
versions of the manuscript. All authors read and approved the final
manuscript.
Funding This study was funded by the Social Sciences Foundation of
Liaoning Province (No. L18ATJ001).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicts of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Individual privacy was not involved in our questionnaire. The study
protocol was in accordance with the ethical standards and was approved
by the Ethics Committee of China Medical University (CMU6206-
1004).
Informed consent Considering the age of the participants and the lack
of written ability, we obtained oral consent from the older adult par-
ticipants, meanwhile we obtained written informed consent about the
process from our study nursing home. Besides, our investigators would
provide information to the older adults orally and make them fully
aware of the purpose of our study, and those who did not agree to be
investigated were excluded.
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