The moderating effect of family socioeconomic status in the relationship between health-related behaviors and quality of life among the Hakka older adults in Fujian, China

The quality of life (QOL) serves as a pivotal reference for assessing human health. However, there is a notable dearth of research focusing on the QOL of specific populations, particularly older adults. Prior studies have highlighted the significance of various health-related behaviors in influencing overall well-being and disease prevention. Within the Hakka population in China, different traditions and practices may shape their health-related behaviors, potentially impacting their QOL. In this study, we have explored the relationship between health-related behaviors and QOL among Hakka older adults, considering the moderating effect of family socioeconomic status (SES). This study indicates that specific health-related behaviors, the number of healthy behaviors and behavior patterns are associated with QOL. The insights from this study encourage further research into health-related behaviors approaches in the context of QOL.

The global trend of population ageing presents critical challenges worldwide, with China being no exception to this demographic transformation. The projected steep increase in the number of Chinese older adults (aged 60 and above), from 254 million in 2019 to 402 million in 2040, highlights the urgency of this issue. This substantial growth represents a formidable 28% of the total population aged 60 or above [1]. China has already entered an ageing society and will continue to age rapidly in the future [2]. In analogous situations, most developed countries have implemented vigorous measures to address the issues arising from an ageing population. Chinese policymakers and society need to adapt promptly to this demographic shift. The prospect of continued rapid ageing highlights the importance of necessitating preventive actions aimed at safeguarding well-being. The transition from focusing “how to live longer” to prioritizing “how to live better” marks a crucial juncture in the current ageing process in China. Improving the quality of life (QOL) of older adults is of key significance for raising healthy life expectancy [3].

Studies have suggested that the QOL of older adults differs significantly from that of the general population [4], thereby highlighting their unique needs and challenges. Hakka older adults not only face health and QOL challenges similar to those of other aging populations but are also deeply influenced by their unique cultural background and family socioeconomic status (SES). There are approximately 80 million Hakka people worldwide, with 50 million residing in China. The term “Hakka” not only refers to this ethnic group but also represents a rich cultural heritage developed over thousands of years [5], particularly about wine culture. Due to the humid climate of their traditional settlements, Hakka people have developed Hakka wine, which is believed to dispel cold and nourish the blood, making it a common part of daily life. During festivals, wine serves as a customary gift and plays a vital role in honoring gods and ancestors. It is an essential medium for expressing affection and strengthening social bonds. Notably, Hakka older adults place great importance on preserving and practicing this cultural tradition. Despite extensive exploration of QOL dynamics across diverse age groups, including younger [6], children and adolescents [7, 8], and specific special populations [9, 10], a notable gap persists in understanding of QOL specifically among older adults, particularly in the context of family SES. Recognizing the paramount significance and frequently overlooked aspect of QOL deprivation in older adults, it is imperative to delve into the modifiable factors that can positively influence and raise their living standards. Family SES plays a crucial role in shaping health-related behaviors, which contribute significantly to an individual’s overall health status [11, 12]. Moreover, the efficacy of interventions designed to modify these behaviors exhibits a distinct population-specific profile [13, 14], emphasizing the necessity for tailored strategies. Research focusing on older adults has demonstrated that targeted interventions aimed at health-related behaviors can effectively improve their QOL and overall health status [15], thereby underscoring their potential for a positive shift.

Despite extensive inquiry into the individual associations between specific health-related behaviors and QOL, including physical exercise [16], a healthy diet [17], and sleeping [18]. These available studies have focused on the relationship between specific health-related behaviors and QOL, overlooking the comprehensive impact of multiple health-related behaviors on QOL. Importantly, various health-related behaviors are interconnected and mutually influence each other, not occurring in isolation [19].

Therefore, this research endeavors to bridge the existing gaps by meticulously exploring the associations between specific health-related behaviors, the number of healthy behaviors, behavior patterns, and QOL, considering the moderating effect of family SES.

In this study, the association between specific health-related behaviors, the number of healthy behaviors, and behavior patterns and QOL were examined in Hakka older adults (aged 60 +). Sleep regularity and physical exercise were positively associated with QOL. The number of healthy behaviors (from 4 to 5) served as a protective factor for QOL. Compared with the moderate-health pattern, the risk-selective pattern and family SES were positively related to QOL. And the family SES exclusively moderated the risk-selective pattern on QOL.

Healthy diet [17], sleep regularity [31], and physical exercise [32] significantly improve QOL among older adults. Prior research found a positive correlation between healthy dietary patterns and QOL [33]. Dietary patterns of healthful plant-based food were considered a protective factor for cognitive ability [34]. Sleep may positively influence QOL among older adults with type 2 diabetes [35]. Light physical activity has been associated with improved overall cognitive function among older adults, particularly in domains such as orientation, attention, concentration, and language abilities [36], and is beneficial to older adults’ physical well-being [37]. Importantly, our findings showed the accumulation of health-related behaviors was positively correlated with higher QOL. Interaction roles in multiple health-related behaviors, affecting each other, not isolation [19]. For example, eating habits influence sleep quality [38], such as the Mediterranean diet, a widely acknowledged beneficial dietary pattern [39, 40], has been associated with high-quality sleep [41]. The combination of healthy eating and physical activity exhibits a preventive effect against certain diseases [42, 43]. Meanwhile, appropriate physical exercise has been demonstrated to improve sleep quality [44], leading to a higher QOL [45]. The findings of this study were also confirmed in the Hakka older adults: participants with a higher number of healthy behaviors scored higher on the QOL domain (from 3.13 ± 0.32 to 3.74 ± 0.78), and were more likely to develop higher QOL (P < 0.05).

In this study, there was no significant correlation between smoking and QOL, but it is worth noting that there was a significant positive correlation between smoking and SAB in QOL among Hakka older adults, which is consistent with previous studies [46]. The age-related physical limitations in smokers are more pronounced compared to those in non-smokers, and the disparity increases with age [47]. Notably, drinking was negatively related to with SAB in QOL. That is, the lower the probability of drinking, the more sensory abilities is affected, which is consistent with previous research [48, 49]. Some studies also reported health benefits of moderate drinking [50, 51], this notion remains controversial in the global literature [52]. For example, drinking has been linked to improved mental health [53], especially among those experiencing anxiety. On the other hand, excessive drinking has been associated with significant health risks, including higher alcohol consumption, episodic binge drinking, and the intake of high-alcohol-content beverages, all of which have been linked to increased mortality rates [54]. In China, alcohol (such as Chinese Baijiu, Huangjiu, and Rice wine) plays a unique cultural role. In the cultural context, individuals tend to drink to alleviate their anxiety [55]. In Hakka areas, in which malaria prevalence contributes to the custom of wine-making and medicinal ingestion. Moreover, health policies in China do not prohibit drinking, and the Chinese Centre for Disease Control and Prevention (CDC) indicates that moderate drinking (1–2 standard drinks/day) may confer health benefits, including a reduced risk of ischemic heart disease, stroke, and diabetes mellitus, among adults (aged 40 +). In summary, this policy framework aligns with our findings, which indicate a positive relationship between drinking and higher QOL, supporting the notion that moderate alcohol consumption may have health-promoting effects. When formulating drinking-related policies, it is essential to enhance public awareness by promoting moderate drinking. Additionally, improving the packaging and labeling of alcoholic beverages with clear guidelines on responsible consumption can help mitigate risks. Lastly, preserving local and traditional drinking cultures while balancing public health concerns is crucial. Policymakers should consider regional and ethnic drinking customs to ensure that regulations both protect public health and respect cultural heritage.

In SAB, family SES significantly buffered the negative impact of risk-selective pattern. These results align with previous research suggesting that higher SES can buffer the adverse consequences of health-risk behaviors through resource accumulation [56, 57]. Our results suggest that family SES negatively moderated the positive effect of risk-selective pattern on PPF. The rewarding effect of alcohol temporarily enhances an individual’s sense of self-affirmation, especially when recognized as a “drinker status” in social interactions [58]. A large number of studies have also demonstrated the positive effects of alcohol on mental health [59, 60]. The negative moderating effect of family SES can be thought of as an alternative reward mechanism in social learning theory [61], whereby high SES groups derive satisfaction from occupational achievements, social activities, etc., thus reducing alcohol dependence [62].

In this study, family SES negatively moderated the positive effect of risk-selective pattern on SOP as well as INT, and past research suggests that alcohol consumption may act as a social enjoyment good that enhances social ties and interactions among people [63]. Individuals who also had regular drinking places had more emotionally supportive friends and a stronger sense of community belonging [64]. These findings are consistent with our findings. High SES individuals typically have broader and more diverse social networks that include not only family and friends, but also community leaders, educational institutions, and business executives, etc., and as a result, they show higher levels of motivation in social participation [65]. Drinking behaviors high SES individuals are perceived negatively in some settings, which can reduce their effective participation and exert a negative effect [66].On the other hand, our study showed that family SES buffered the negative effect of paradoxical-health pattern on INT. Consistent with our results, it has been shown that individuals who smoking and drinking for a long period of time have a higher rate of chronic diseases, require frequent medical or home recuperation, and have fewer opportunities to socialize [66]. In contrast, high SES individuals often have access to higher quality healthcare services, including more advanced medical equipment, more professional healthcare teams, and more comprehensive treatment plans [67], which can provide physiological safeguards for sustained social participation.

The results of this study suggest that family SES negatively moderated the positive effect of risk-selective pattern on DAD. Individuals with higher family SES who engage in smoking and drinking may mitigate the physical damage caused by these habits through access to better medical treatment [68]. Consequently, despite these bad habits, their fear of death may not be significantly diminished [69]. For total score, family SES primarily functioned as a risk buffer rather than a health amplifier, further reinforcing its role as a “buffer” against risky behaviors rather than an “amplifier” for health behaviors. This finding is consistent with the core mind of the Social Determinants of Health (SDH) theory which posits that SES improves overall well-being by reducing health disparities [70]. The nonsignificant moderation of the paradoxical-health pattern implies that socioeconomic resources alone cannot resolve intrinsic behavioral contradictions.

This study explored health-related behaviors and QOL among Hakka older adults. TCA was used to identify the behavior patterns, which overcomes the limitations of traditional analytical approaches. Combined with regression analysis, this approach provides valuable insights for future studies. However, this study had some limitations: (1) omission of social or health security factors: key determinants like health insurance coverage and healthcare infrastructure were not rigorously analyzed, limiting insights into systemic drivers of health disparities. (2) methodological constraints: the cross-sectional design precluded causal inference, while convenience sampling within a single region reduced generalizability. Additionally, the use of a self-administered questionnaire may have introduced response bias, potentially leading to inaccurate data. Misinterpretations of questions could further compromise the reliability of the findings. (3) incomplete health metrics: critical indicators (e.g., body weight, hygiene) were absent, potentially obscuring biopsychosocial pathways linking behaviors to quality of life. (4) age categorization granularity: broad age intervals may mask nuanced lifespan variations and restricts the ability to conduct more detailed age-specific analyses. Therefore, the conclusions of this study should be used with caution.

This study examined the relationship between health-related behaviors and QOL among Hakka older adults. Our findings showed that specific health-related behaviors were associated with QOL, with a higher number of healthy behaviors corresponding to a higher QOL score. Notably, compared with the moderate-health pattern, risk-selective pattern and family SES were positively related to QOL. And the family SES exclusively moderated the risk-selective pattern on QOL. These findings underscore the importance of promoting health-related behavior to enhance QOL in older adults, particularly when considering multiple health-related behaviors simultaneously. To support this, we recommend the following strategies: (1) developing community-based health promotion programs: implement targeted initiatives that encourage healthy behaviors among older adults, fostering a supportive environment for positive lifestyle changes; (2) conducting personalized health assessments: provide individualized health assessments to tailor interventions based on specific needs, thereby enhancing their effectiveness; (3) implementing education and awareness campaigns: increase public awareness about the impact of healthy lifestyles on QOL through structured educational initiatives; (4) integrating health services: expand health promotion efforts to include mental health support, such as stress management programs and coping strategies, ensuring a more comprehensive approach to well-being.