Our results showed that frailty in older subjects living alone had marked negative effects on the eight dimensions of the SF-36. Managing elderly people with chronic disease is complex because they commonly have multiple chronic conditions. Effective chronic disease management requires recognition of this complexity because there may be conflicts among management guidelines for the multiple conditions present [18
]. Older adults in rural areas of Shaanxi Province often have difficult pressures in life, including chronic diseases, ‘empty nest syndrome’, mental and physical disorders, serious psychological fatigue and psychological problems. The mental and physical disorders may in turn increase stress and lead to poor health and chronic diseases [19
]. In the present study, hypertension,,cardiac disease, chronic bronchitis, neurological disease and cancer were the major conditions that impacted HRQoL, and, in turn, the need for long-term care services. Elderly subjects living alone may have lower social status and income as well as depression related to their feelings of isolation and loneliness, compounded by the rural location of farms, the nature of farm work and children living away from home, which may partially explain the socioeconomic inequalities in health [2
]. This study indicated that we should focus on depression in the elderly, especially the empty-nest elderly in rural areas, to formulate effective measures to improve QoL. Chronic diseases were also associated with lower QoL, and perceived QoL was significantly correlated with self-rated health [21
In accordance with earlier studies [23
], education was a significant positive contributor to overall HRQoL. According to Lasheras et al. [25
], lower educational level is associated with unhappiness, poor social relationships, poor self-assessed health and sensory problems among the elderly. Education is an important indicator that may directly or indirectly influence HRQoL through its association with higher social class and economic status. Our survey suggests that education level is associated with better HRQoL and a lower need for long-term care services among empty-nest elderly subjects. This is consistent with other studies conducted in Nigeria and Iran [23
]. Where older adults with better education generally enjoy higher incomes and better social support. Medical costs are a huge burden for elderly subjects living alone because there is no universal health insurance in China, and may have a greater impact than in developed countries. Both education and income have a major influence on the QoL of the elderly in China. In our study, subjects reported higher physical functioning compared with perceived physical and emotional limitations, as reflected by scores on the SF-36. Furthermore, elderly people being able to live with their families is very important to health outcomes and has a positive effect on QoL [27
]. Good social relationships (including relationships with relatives and friends) are the most commonly reported factor influencing QoL in the elderly [26
]. There are fewer nursing homes in China than in developed countries. Policy-makers and health care providers should plan for the long-term care and health care delivery needs of the elderly, given that the placement of older adults in nursing homes is likely to increase in the coming years. Nursing homes will need to pay greater attention to the treatment of chronic diseases in older adults to improve their QoL. China has realized that expanding this area is not financially sustainable using only the government's resources. The current policy is to encourage private and foreign investors to participate in the nursing home business in China.
Our use of data from three regions in Shaanxi Province limited the applicability of our results to other provinces in China. Despite this, the results of the analysis provide an overall picture of the HRQoL and long-term care needs among older adults in rural Shaanxi Province, which may facilitate further prospective studies.