社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

原著

The mediating effect of social interaction on the association between

socioeconomic status and health status among Chinese elderly in Tibet
中国チベット高齢者における社会経済的要因と健康に対する社会関係性の媒介効果
Shuo Wang1）, Bin Ai2）, Fanlei Kong1）, Tanji Hoshi1）王碩 1），艾

斌 2），孔凡磊 1），星旦二 1）1）Graduate School of Urban Environmental Science, Tokyo Metropolitan University2）Department of Ethnology and Sociology, MinZu University of China
1）首都大学東京

都市环境科学研究科

2）中央民族大学

民族学m社会学研究科

Abstract
Objectives: This study aimed to determine the structure between socioeconomic status (SES), social interaction
and health status among elderly urban community-dwellers in Tibet. Methods: A self-administered questionnaire
was distributed to 1,979 elderly who were selected by cluster sampling method in 2009, giving a response rateof 93.2%. Structural equation modeling were used to perform the data. Results: In the structural model, SES
had not only a direct effect, but also an indirect effect on health status by means of social interaction; comparedwith the indirect effect, SES exerted a larger direct impact on health status, especially on psychological health.
Conclusions: People with higher SES are more likely to have better health status. In addition, social interaction
plays a mediating role on the association between SES and health status. Therefore, improving social interactionof elderly people may decrease socioeconomic differentials in health status among urban community-dwellingelderly in Tibet.
抄

録

目的：本研究は、中国チベット高齢者における社会経済的要因、社会相互作用と健康状況を把握し、それらの相互関連性を構造的に明確にすることを目的とする。方法：2009 年にクラスタ・サンプリング法によって選出した 1,979
名の高齢者に自己申告アンケートを配布し、93.2％の回答が与えられた。分析方法は、構造方程式モデリングを用いた。結果：健康状態に対する社会経済要因は、直接的影響だけでなく、社会的相互作用を経由する間接的な効果がみられた。社会経済的要因は健康状態、とりわけ精神的要因に対して大きな直接的影響を及ぼしていた。結論：
社会経済地位が高ければ高いほど、よりよい健康状況を持っている可能性が高いことが示された。また、社会的相互作用が、社会経済地位と健康状態との関連に対して媒介効果がみられた。よって、高齢者の社会的相互作用を向上させることによって、チベット都市在住高齢者の社会経済的格差から健康状態の影響を減少させる可能性が示唆された。
Key words：socioeconomic status; health status; social interaction; mediating effect.
キーワード：社会経済地位；健康状況；社会相互作用；媒介効果― 69 ―

社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

Ⅰ．INTRODUCTION

level, the better his or her physical functioning, but

In China, the average life expectancy continues tothe more his or her diseases, by using data from

improve due to advancements in medical technology

research on living conditions and health in Wuhan

and improvements in living standards, but thecity in 1991 11）. Zimmer and Kwong suggested all

fertility rate continues to decline, both of which

education years, average annual household income,accelerate population aging. According to the sixth

pension eligibility, bank deposits, and the number

national census of China in 2010, the proportion ofof valuables possessed by household had impacts

elderly people aged 60 years and over accounted foron self-rated health, functional health and diseases

13.26% of the total population, which was an increase

among Chinese elderly in 1992 12）. A longitudinalof 2.93% compared with the fifth national census instudy on health among Chinese oldest-old elderly,

2000; the number of elderly aged 65 years and overfrom 1998 to 2000, demonstrated birthplace (urban/

1，
2）

.

rural), ethnic identity, marital status, and occupation

Similar to other cities in China, the Tibet

before retirement affected mortality to some degree,

has reached 8.87%, an increase of 1.91% from 2000

Autonomous Region (TAR) is experiencing population

while the main source of income was not statisticallyaging and urbanization, despite it being located insignificant13）. The use of different SES and healtha sparsely-populated plateau area. The percentage

indicators may be a reason for inconsistent resultsof the Tibetan population aged 60 years and above

across studies7）. Accordingly, it is very unclear towhich participated in the census numbered overwhat extent SES affect health.

220,000, constituting 8% of the entire population in

Besides socioeconomic condition, there are several

2007, while the percentage of urban elderly people

other social factors in determining health. Based on

in Lhasa City and Shigatse City was more than 10%,the causal relation with health, social determinants

indicating that the urban area in Tibet has takenof health fall into three levels: 1）distal factors,

3）

the lead into an aging society . On the one hand,such as SES; 2）mid-range factors, including social

this phenomenon reflects the economic and social

interaction and relation; and 3）proximal factors,

development of Tibet in recent years; on the otherwhich consist of health- related lifestyle andhand, it also brings many challenges to the economy,

behaviors 14） . The mediating influence of healthgovernment policies, and society, particularly withbehaviors has been increasingly recognized between

respect to traditional ways of supporting the aged

SES and health15，16）. In addition, a substantial bodyin Tibet. Therefore, how to maintain and improveof research identified the relationship between social

health status among urban elderly in Tibet is ainteraction and health17―19）, but no study examined

crucial issue for the government and academia.

the role which social interaction plays between     Socioeconomic status (SES) is a crucial factor to

SES and health among Chinese elderly. Since social

4）

determine health status . The relationship between

structures shape individual values and behaviors,

SES and health status is well-recognized in western

the association between social interaction and healthcountries, regardless of whether SES is assessedshould be taken into individual's structural position.

5―9）. Individuals

Therefore, this study aimed to: 1) identify thewith more privileged SES have better health status

extent to which SES and health status are related

than their unfavorable counterpart. However, few

in urban areas of Tibet; 2) determine the structurestudies have examined the association between SES

between SES, social interaction and health status

and health in developing country, particularly at old

among urban community-dwelling elderly.

by income, education, or occupation

ages

10）

. Existing literature showed that the healthstatus of Chinese elderly was related to SES, but

Ⅱ．METHODS

no consistent conclusions were found. Liang et al.

1．Samplepointed out that the higher an individual's educational

The urban elderly in Tibet were considered as― 70 ―

社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

the research population of this study. The definition

status20）. Measuring the SES of older adults needsof "city" employed was that of the administrative

multidimensional indicators, since different SES

divisions of China, rather than the dictionary

facets have different meanings and indicate accessdefinition of the word. In the Tibet Autonomous

to different resources7）. SES has traditionally been

Region, there is one prefecture-level city – the capitaldefined by education, income, and occupation. Givencity, Lhasa – and six prefectures: Shigatse, Qamdo,

the majority of elderly people have left their work

Shannan, Ngari, Nagqu and Nyingchi. In addition,

long time ago, this survey employed education

Shigatse, as a country-level city, is located in Shigatseand household income as indicators of SES, since

Prefecture. As such, there are two cities in Tibet,

education indicates the ability to get the informationaccording to administrative divisions, so all of theon health and health-related behaviors, while income

elderly in 28 communities from 7 sub-districts ofsuggests the ability to gain access to health services.

Lhasa City, and 10 communities from 2 sub-districts

Education is perhaps the most basic SESof Shigatse City, constituted the research objects.

component, as it can shape occupational opportunities

All the communities in Lhasa and Shigatse wereand earning potential, and it plays an important rolearranged by increasing population. Nine communities

in predicting SES in developing countries21）. In thein Lhasa and four communities in Shigatse werestudy, educational level was a seven-level ordinalthen selected by cluster sampling method, including

variable: 1 = No education, 2 = One to three years

1,979 elderly aged 60 years and above, as of Augustin primary school, 3 = Four to six years in primary

1, 2009. All of them received our questionnaire, andschool, 4 = Junior high school, 5 = High school, 6 =1,846 elderly answered, giving a response rate of

Junior college, and 7 = University or higher.

93.2%; 732 respondents were men, and the rest (1,114)

Household income was defined as the sum of thewere women. Approximately 58.5% were aged 60 tomonthly income of each individual member of the69, 32.2% were between 70 to 79 years old, and thosefamily and the income received by the household

aged 80 and over made up 9.32 % (Table 1).

overall. Respondents were asked to choose one ofeleven categories that best corresponded to their

Table 1．Study subjects by age and genderhousehold annual income in Chinese Yuan (1 USD
6 Chinese Yuan): 1 = less than 1,000 yuan, 2 =1,000-1,999 yuan, 3 = 2,000-2,999 yuan, 4 = 3,000-3,999
yuan, 5 = 4,000-4,999 yuan, 6 = 5,000-5,999 yuan, 7 =6,000-6,999 yuan, 8 = 7,000-7,999 yuan, 9 = 8,000-8,999
yuan, 10 = 9,000-9,999 yuan, and 11 = more thanThe purpose and design of this survey were

10,000 yuan.
2）Social interaction

approved by the government of the Tibet
Autonomous Region of China. The retrieved data

Social interaction was assessed by frequency andwere confidential and were only utilized for researchscale from objective perspectives, and satisfaction

and analysis. All the participants were also fully

from a subjective perspective. Regarding frequency

informed of the nature of the survey, and providedof social interaction, the elderly were asked, "Howtheir consent.

often do you contact people with whom you do notlive with, such as children, siblings, other relatives,

2．Data Collection

friends and neighbors, respectively?" with 1 =The study consisted of three measurement indices:

Never, 2 = Seldom, 3 = Sometimes, 4 = Often, and
5 = Every day. Their scale of social interaction was

SES, social interaction and health status.
1）SES

obtained by asking, "How many people (children,

SES is the most fundamental cause of healthsiblings, other relatives, friends and neighbors) do― 71 ―

社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

you have contact with, freely and comfortably?" ona five-point Likert scale, with 1 = None, 2 = One
to three people, 3 = Four to six people, 4 = Sevento nine people, and 5 = More than ten people. In
addition, the elderly were asked to describe theextent to which they were satisfied with their social
interaction. Response options were categorized into

Figure 1．Hypothesized model between SES, social interaction
and health status among Tibetan elderly citizens

five different levels: Very dissatisfied, Dissatisfied,Fair, Satisfied, and Very satisfied. The participants
were assigned one to five points, respectively, based

4．Statistical Analysis

on their chosen response.

A two-step approach to structural equation3）Health status

modeling (SEM) was carried out to assess theAs with SES, it has long been recognized thatmeasurement model and structural model between

health status is a multidimensional construct. In thisSES, social interaction and health status by using

study, both physical and psychological health were

Amos 17.0 for Windows. The maximum likelihood

used to indicate a person's health status. All scales

estimation method was applied to estimate theof health status were measured using a five-point

parameters in the model. Significance of the path

Likert-type scale (1 = Very bad / Every day; 5 =coefficient was set to a 0.05 level for two-tailed tests.

Very good / Never). Physical health was evaluated

All three kinds of goodness-of-fit indices, consistingby six items: energy, sleep, diet, hearing, seeing, andof absolute fit, incremental fit, and parsimony fit

activity. Psychological health was assessed by asking:indices, were utilized to evaluate overall model fit 22）.

"Do you feel lonely?" (loneliness); "Do you think what

The chi-squared test was used to assess the

you have done are not going well?" (dissatisfaction);

hypothesized model and its improvement from the"Do you feel very sad?" (sadness); "Do you think otherindependence model23）. Normalized Fit Index (NFI),

people do not like you?" (unpopularity); "Do you think

the Incremental Fit Index (IFI), the Root Meanyou do not have enough energy to do anything?"

Square Error of Approximation (RMSEA) were also(passiveness); "Do you think everyone is not friendly

obtained. For a good model, NFI and IFI should be

to you?" (unfriendliness); "Do you think your whole

greater than 0.90, and RMSEA was recommended

life has failed?" (failure); "Have you ever cried?"under 0.0524）.

(crying).
Ⅲ．RESULTS
3．Hypothesized model

1．Measurement Model

It was hypothesized that (Figure 1): 1) SES

Confirmatory factor analysis (CFA) was applied

associates with health status positively; 2) SES has

to evaluate measurement reliability and validity ina positive impact on social interaction; 3) social

this study. The item reliability, construct reliability

interaction exerts a positive impact on health status;(CR) and average variance extracted (AVE) were4) social interaction plays a mediating role on SES-

employed to verify that the estimated constructs

health status.

are valid, consist and applicable to study thecharacteristics that they wanted to measure 22）.
Table 2 lists the CFA results.

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社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

Table 2．Evaluation of measurement model

two variables. Path coefficients suggest whether
the relationship between two variables is positiveor negative and how great the relationship is.
Considering that many main variables (frequency
of social interaction, scale of social interaction,satisfaction of social interaction, some items ofphysical health, and some items of psychologicalhealth) had no significant differences between elderly
men and women, in addition, the structural model bygender displayed something wrong, only the whole
population was analyzed in this model. As presented
in Figure 2, seven latent variables were included instructural analysis between SES, social interaction
and health status among Chinese communitydwelling elderly. Of these variables, 'SES', 'social
interaction' and 'health status' were considered as
primary latent variables, while 'frequency' and 'scale'were regarded as secondary latent variables of social
interaction, and 'physical health' and 'psychologicalhealth' were regarded as secondary latent variables

A factor loading could be used as an indicatorof 'health status'. The fit indices for the model were:in interpreting the role each item plays in defining

NFI= 0.921 > 0.900, IFI= 0.935 > 0.900, and RMSEA=

each construct. Factor loadings are in essence the0.049 < 0.05. These results showed that all fit indicescorrelation of each item to their underlying factor.

met the requirements for a good model.

Kim and Muller suggested factor loading of 0.30 asa cut-off for significance25）. The standardized factor
loadings ranged from 0.40 to 0.83. And all factor
loadings in the model were significant (P < 0.05).
The construct reliability (CR) evaluated whether theindicators consistently represent the same latentvariable. In this study, the CR estimates ranged from0.67 to 0.84, exceeding the recommended value of 0.60
by Fornell and Larcker26）. They also suggested AVE
had better exceed 0.50, which determines whether
the set of indicators represent the latent variables26）.
With the exception of social interaction and physicalhealth, the average variances extracted (AVE) of

Figure 2．Structural analysis between SES, social interaction
and health status among Tibetan elderly citizens

SES and psychological health were 0.51 and 0.60.
2．Structural Model

The model depicted the underlying way from SES

Following the tradition of Amos analysis, observed

to health status by means of social interaction andvariables are represented by rectangles, latentsatisfaction of social interaction. Health status wasvariables are represented by circles, and a straight

positively and significantly associated with SES andarrow indicates the direction of relationship betweensocial interaction, since all the path coefficients were

― 73 ―

社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

positive. The results indicated that social interaction

Ⅳ．DISCUSSION

had both direct (0.29) and indirect (0.07) effects on

This population-based cross-sectional study

health status. Analogously, SES not only had direct

investigated the structure between SES, social

effects on health status (0.51), but also affectedinteraction and health status among urban

health status indirectly (0.08). By comparison, SES,

community-dwelling elderly in Tibet. In general, it

social interaction and satisfaction exerted slightly

was found that people with higher levels of education

greater impact on psychological health (0.57) thanand income would like to communicate with their

physical health (0.53). This meant that individuals

children, siblings, relatives, friends, and neighbors;with higher education and income could contact their

to some extent, people who connected with others

children, siblings, relatives, friends and neighborfrequently and had many people to contact weremore frequently, had more people to communicate

more likely satisfied with their social interaction. All

with, and would have better satisfaction of social

these factors may then allow the elderly to improve

interaction. These elderly people were found to havetheir health status, especially their psychologicalimproved physical and (especially) psychologicalstatus.
Like studies in western countries, SES was foundhealth.
According to standardized total effects, it is

to have significant influence on health status, be it

worth pointing out that SES demonstrated much

physical or psychological. The higher an individual's

larger impacts on health status (0.59) than social

SES, the better his or her health status. The resultsinteraction did (0.36) (Table 3). SES was more

showed that household income exerted greater

important for personal health status. Furthermore,

effects on health status than education, indicating thehousehold income contributed more in determining

importance of income. Liang and colleagues pointed

health status (0.83) than educational level (0.57). It

out that education was the best indicator to reflectis also worth noting that social interaction played a

SES of elderly people11）. This is because education

mediating role in the relationship between SES and

can increase employment opportunities, which canhealth status: that is, socioeconomic inequalities inlead to higher-paying jobs 27, 28）. In addition, thehealth could be explained by social interaction.

principal advantage of utilizing education level as
an indicator of SES is that educational attainment isTable 3．Standardized direct, indirect and total effects

generally stable across an individual's lifespan and iseasily recorded10, 29）. In contrast, however, Braveman
and his fellows insisted that educational level could
not represent the key aspects of economic status30）.
Zimmer and House also found income predicatedfunctional health better 31）. With the increase inage, the elderly need more and more medical

Social interaction had weak correlation withresources and care, which are largely dependent

satisfaction of social interaction (0.17), whileon financial capacity. Considering that China is asatisfaction had moderate relationship with healthdeveloping country, the government can only afford

status (0.38). In other words, not everyone witha small amount of medical expenses for the generalhigher frequency and larger scale social interaction

population: most of the costs are supported bycould be satisfied with their social interaction, but

companies and/or individuals. This is why household

satisfaction did enhance the influence of socialincome plays such a pivotal role in determining

interaction on health status.

health status of Chinese elderly.
Another main finding of this study was that social
interaction had a mediating role on association― 74 ―

社会医学研究．第 31 巻 2 号．Bulletin of Social Medicine, Vol.31（2）2014

between SES and health status. Higher levels of

and it was subject to the problem that bothsocial interaction provide elderly people with more

dependent and independent variables were based on

opportunities to go outside. For example, they may

self-rated data. The cross-sectional nature of the data

use the chance to get some exercise, even justset limits the interpretation of the results, rather

walking; or, they may use the chance to sociallythan their causal relationship. In general, longitudinalinteract with others, helping mediate a bad mood or

studies are preferable for investigating the causal

loneliness. Decline in physical health with age is anrelationship between SES, social interaction andirreversible process. However, the elderly can still

health status. Second, only registered citizens in

get along very well with others, given the chance,

Lhasa City and Shigatse City were selected as

and feel that life is worth living. We feel that this isresearch population, excluding those who lived in

why SES and social interaction demonstrated morecommunities without a census register.

influence on psychological health than physical health.

Despite these limitations, our analysis provided

Moreover, satisfaction of social interaction could

additional evidence on the role of social interaction

enhance the effects of social interaction on healthin SES-health status in a developing country. In

status. The existing literature has not identified

addition, we paid special attention to elderly people,

the consistent mediating effect of social interaction

who accounted for the majority of people with healthon the relationship between SES and health status.

status, as the proportion of elderly people is growing

In line with the findings of a study among older

rapidly.

Malaysians, having daily contact with adult children
moderates the effect of low SES on self-rated
32）

Ⅴ．CONCLUSIONS. Two German studies also observed

In conclusion, the study revealed that SES had

4，33）

.

positive and significant impacts on health status

However, Klein et al. did not specifically focus onamong elderly urban people in Tibet. People

elderly people, who consist of the majority with

with higher SES are more likely to have better

health problems. They realized that self-rated

health status. In addition, social interaction plays ahealth, which was the only indicator they used for

mediating role on the association between SES andthe measurement of health status, may generate

health status. Satisfaction of social interaction canbias; thus, physical health and psychological healthenhance the effects of SES on health status. This

were applied to evaluate health status in our study.

study lead us to conclude has some implications that

Another German study suggested the mediating

improving social interaction of elderly people may

effect of social interaction on SES-health status wasdecrease socioeconomic differentials in health status.

health status

the mediating effect of social interaction

very weak possibly due to the small size of theresearch population (682 older people)34）. A Danish

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