Preamble

The Concept and Dimensional Characteristics of Spiritual Support for Older Adults in Contemporary China

FAN Yunge, MA Zijuan, LIN Weishi, ZHANG Rui, WANG Dongfang, FAN Fang
(School of Psychology and Center for Studies of Psychological Application, South China Normal University, Guangzhou 510631, China)

Abstract

As the material living standards of China's elderly population continue to improve, their spiritual needs have become increasingly prominent, making spiritual support a critical issue in addressing contemporary population aging. However, the connotation, characteristic dimensions, and measurement tools for spiritual support among today's older adults remain underexplored. This study combines theoretical analysis with empirical research to deepen understanding of the mechanisms underlying spiritual support. Through qualitative interviews, grounded theory analysis, and questionnaire surveys, we examined the core components of spiritual support for older adults. The results indicate that spiritual support encompasses five dimensions: health security (sense of security), social interaction (sense of belonging), cultural activities (sense of competence), independence and freedom (sense of autonomy), and existential meaning (sense of value). Based on these findings, we developed a measurement questionnaire. Three empirical studies involving a total of 1,354 older adults validated the reliability and validity of the questionnaire, clarified the five characteristic dimensions of spiritual support, and confirmed its long-term predictive effect on the physical and mental health of older adults. In summary, this study clarifies the connotation and structure of spiritual support for contemporary Chinese older adults, provides an effective measurement tool for assessing perceived spiritual support, and offers an empirical basis for future theoretical research and practical interventions.

Keywords: spiritual support, spiritual needs, older adults, physical and mental health

Population aging has become a severe challenge facing human society. Rapid aging not only places enormous pressure on socioeconomic development but also raises new ethical demands regarding moral behavior and social norms (Chen et al., 2022). As the material living standards of China's elderly population have improved in recent years, their spiritual needs have become increasingly prominent, making spiritual support a crucial issue in responding to contemporary aging society (Zhao & Yang, 2020). Article 14 of China's Law on the Protection of the Rights and Interests of the Elderly stipulates: "Supporters shall fulfill their obligations to provide financial support, daily care, and spiritual comfort to the elderly, and attend to their special needs." However, the current public understanding in China tends to view eldercare solely in terms of material support, neglecting spiritual care. Furthermore, the absence of a unified standard regarding the connotation and characteristic dimensions of spiritual support for contemporary older adults makes it difficult to quantitatively assess the level of spiritual support perceived by the elderly, which in turn leads to neglect of their spiritual needs by caregivers.

1.1 The Connotation of Spiritual Support

Spiritual support is a multidimensional concept with both broad and narrow definitions (Antonucci et al., 2014). Broadly defined, spiritual support refers to comprehensive care and support for older adults at the emotional, cognitive, psychological, and social levels, extending beyond direct care from family members to include multifaceted spiritual support from society, communities, and cultural institutions. The narrow definition primarily refers to spiritual care within families or intimate relationships, focusing particularly on direct support for the emotional and psychological needs of older adults. This form emphasizes emotional companionship, psychological comfort, and social interaction in daily life, typically provided by children, spouses, or other family members (Litwin & Shiovitz-Ezra, 2011). With continuous progress and changes in production and lifestyle patterns in China, particularly under the influence of economic development and population policies, the number of older adults living apart from their children has expanded, and the population of "empty-nest elderly" has gradually increased, making it difficult for spiritual support provided solely by family members to meet the growing psychological needs of older adults (Zhao & Yang, 2020). Therefore, compared with the narrow definition, the broad definition of spiritual support is better suited to modern society, encompasses more comprehensive spiritual needs of older adults, and facilitates the integration of resources and efforts from families, society, and government to provide a more complete spiritual support system (Antonucci et al., 2014).

Generally speaking, spiritual support involves meeting the spiritual needs of older adults, which is not only crucial for their quality of life and psychological well-being but also represents an important manifestation of social civilization and progress that can promote social harmony and advancement (Chen, 2016). In recent years, spiritual support has also been regarded as an important pathway to successful aging. According to Rowe & Kahn's (1998) theory of successful aging, three core dimensions are essential: low risk of disease and disability, high physical and cognitive functioning, and active social engagement. Higher levels of spiritual support can enhance the frequency of social interaction and life participation among older adults, strengthen their social connections, enrich daily life content, and thereby increase life satisfaction (Jadidi et al., 2021; Jadidi et al., 2022). Simultaneously, spiritual support can help older adults maintain a sense of control over their lives, alleviate feelings of loneliness and meaninglessness, and thus promote their psychological health (Inoue et al., 2020). Existing research indicates that the absence of spiritual support is one of the important factors leading to psychological problems such as depression and anxiety among older adults, and may even accelerate cognitive decline and increase the risk of dementia (Nakanishi et al., 2024).

The connotation of spiritual support continues to expand and deepen with the development of the times and social culture. However, research on spiritual support in China started relatively late, and there is still no unified and clear conceptual definition of spiritual support for contemporary Chinese older adults. In the past, the emotional needs of older adults primarily depended on care from family members, particularly their children. With the transformation of family structures and social relationships, the spiritual needs of older adults are also adapting to new intergenerational relationships, showing more diverse and dynamic trends. For example, contemporary older adults can also obtain emotional comfort from friends, neighbors, and even strangers (Paquet et al., 2023). Therefore, it is particularly critical and urgent to deeply explore the rich connotation of spiritual support for older adults that aligns with the times.

1.2 Similarities and Differences Between Spiritual Support and Related Concepts

Spiritual support shares considerable overlap with concepts such as emotional support, emotional comfort, and subjective well-being, and is closely related to emotional connection, psychological comfort, and life satisfaction. Specifically, emotional support emphasizes emotional understanding and social response, forming the foundation of external support resources for spiritual support among older adults (Sun & Shi, 2020). Emotional comfort focuses on care and empathy within intimate relationships, reflecting the core mechanism of internal emotional connection in spiritual support (You, 2015). Subjective well-being, meanwhile, reflects individuals' overall positive evaluation of life and serves as an important psychological indicator for measuring the effectiveness of spiritual support (Inoue et al., 2020; Nakanishi et al., 2024). High-level spiritual support often enhances older adults' subjective well-being and life satisfaction by strengthening external emotional connections, fulfilling internal senses of meaning, and enhancing self-worth. Therefore, spiritual support not only addresses the higher-level spiritual needs of older adults but also integrates multiple dimensions including emotional support, social participation, and value identification, demonstrating its comprehensive and systematic nature. In terms of functional structure, emotional support and emotional comfort can be regarded as core pathways to achieving spiritual support, while subjective well-being represents the ultimate outcome of spiritual support's effects.

1.3 The Relationship Between Spiritual Needs and Spiritual Support in Older Adults

There is a close relationship between the spiritual needs of older adults and spiritual support; spiritual needs constitute an important component of psychological health for older adults, while spiritual support serves as a crucial pathway to meeting these needs. The essence of spiritual support is to satisfy the spiritual needs of older adults (Mu, 2004; Zhao & Yang, 2020). Therefore, clarifying the spiritual needs of contemporary older adults will help elucidate the connotation and characteristic dimensions of spiritual support. According to Maslow's Hierarchy of Needs, individual need satisfaction follows a hierarchical pattern, which can be divided into five levels from low to high: physiological needs, safety needs, social needs, esteem needs, and self-actualization needs (Cui et al., 2021). Based on this, some researchers have theoretically proposed that the spiritual needs of older adults should include five levels from low to high: emotional needs, cultural and entertainment needs, educational needs, interpersonal interaction needs, political needs, and self-actualization needs, with different levels potentially being interdependent and overlapping (Shi et al., 2021; Zhou, 2005). You (2015), drawing on Maslow's hierarchy of needs and Erikson's theory of psychosocial development and considering the characteristics of China's elderly population, categorized older adults' spiritual needs into needs for emotion and belonging, needs for spiritual reliance and sustenance, needs for being loved and respected, and needs for peaceful departure. Additionally, Ming (2000), using Fei Xiaotong's "differential mode of association" theory as a background, pointed out that older adults' spiritual needs generally include emotional needs, entertainment needs, knowledge needs, interaction needs, and value needs, which spread outward like ripples, becoming broader as they extend. Through in-depth and comprehensive exploration of older adults' spiritual needs, we can clarify the pathways to achieving spiritual support from the perspective of the elderly themselves.

To meet the spiritual needs of older adults, researchers have proposed that spiritual support can be realized through emotional support, social activities, value realization, spiritual comfort, and self-actualization (Jadidi et al., 2021; Jadidi et al., 2022). Furthermore, Mu (2004), through an in-depth review and systematic study of existing literature, constructed a triangular structure of spiritual support for older adults: the needs for self-esteem, anticipation, and affection, corresponding to the "satisfactions" of personality respect, achievement reassurance, and emotional comfort. Meng and Wang (2022) noted that spiritual support should not only refer to older adults passively receiving help but also involve older adults actively initiating interactions. However, previous research has mostly analyzed older adults' spiritual needs from a theoretical perspective, lacking empirical validation, which may be insufficiently comprehensive and somewhat subjective.

1.4 Characteristic Dimensions of Spiritual Support for Older Adults

Eldercare for older adults includes both material and spiritual dimensions. Compared with material support, spiritual support for older adults possesses higher-level characteristics. Material support primarily meets survival needs such as food, clothing, housing, and transportation, whereas spiritual support focuses on the psychological state and happiness of older adults, representing more prominent needs that emerge after lower-level material needs are satisfied (Cui et al., 2021). Material support forms the foundation of spiritual support, yet spiritual support maintains its own independence; the two are complementary yet independent of each other (Liu, 2010). However, spiritual support carries greater uncertainty. While material support can typically be measured through concrete material carriers, spiritual support is achieved through verbal communication, emotional care, and empathic understanding, making it more abstract and difficult to quantify, relying primarily on the subjective feelings of older adults for evaluation (Lakey, 2014).

From an individual perspective, older adults possess certain self-support capabilities and can meet their own spiritual needs through self-adjustment and self-improvement (Meng & Wang, 2022). For example, older adults can maintain a positive and optimistic mindset and good mental state by cultivating hobbies, learning new knowledge and skills, and engaging in appropriate physical exercise. According to self-determination theory, individuals have three basic psychological needs: autonomy, competence, and relatedness (Deci & Ryan, 2000). Autonomy refers to the psychological freedom of engaging in activities according to one's own will and choices; competence refers to the sense of mastery and ability development in one's environment; and relatedness involves connecting with others and experiencing love and being loved. Older adults can satisfy their needs for autonomy and competence through active participation in various activities and helping others, thereby demonstrating their self-worth.

Family members and close friends can provide a guarantee for older adults' sense of relatedness. The family constitutes the main body of spiritual support, while friend support is also an important source of spiritual support for older adults (Shi et al., 2021; Mu, 2004). Socioemotional selectivity theory posits that as individuals age, their information processing and social goals continuously adjust (Carstensen et al., 2003). Older adults, aware of limited time, tend to focus on maintaining intimate relationships with family members to pursue life satisfaction (Dang et al., 2024). Additionally, older adults typically place particular emphasis on satisfying emotional and affective needs, tending to invest more time in interactions with familiar and rewarding social partners. This selective narrowing of social interaction maximizes positive emotional experiences and minimizes emotional risks during aging (Nikitin et al., 2024). Therefore, older adults are more inclined to meet their emotional needs through interactions with children and emotionally meaningful social companions.

Social culture also plays a multifaceted role in the spiritual support of older adults by shaping values, providing mental health resources, and constructing social networks. According to ecological systems theory, individuals live within multi-layered environmental systems (such as family, society, and culture) that jointly influence older adults' spiritual support through direct and indirect means (Bronfenbrenner, 1977). As social mobility in China continues to expand and multicultural integration accompanies it, new challenges have emerged for older adults' social adaptation (Yang, 2021). Communities and institutions should actively organize various activities to provide platforms for communication and interaction, respect the cultural traditions and beliefs of older adults, enhance their sense of social belonging, and create inclusive environments for their spiritual support (Nagao-Sato et al., 2023).

In summary, we believe that spiritual support for older adults is a multidimensional concept involving individuals, families, friends, culture, and society. In the process of meeting older adults' spiritual and emotional needs through spiritual support, older adults possess both subjective agency and dependence on external environmental support and attention. The concept of spiritual support not only exhibits high-level and independent characteristics but also involves uncertainty and complexity, primarily manifested in the lack of systematic and quantifiable measurement tools that can comprehensively capture the multidimensional features and dynamic changes of spiritual support.

1.5 Core Issues of This Study

As older adults accumulate life experience, their emotional lives become richer. Although they may not be as passionate and outgoing as younger people, their emotions become more delicate and sensitive, with stronger desires for spiritual need satisfaction. They particularly hope to receive care and affection from others, yearning to be valued and to gain self-worth (Lu et al., 2019; Li & Wang, 2022). In recent years, as the population aging process has accelerated, researchers from different fields have gradually begun to pay attention to the spiritual needs and spiritual support of older adults (Jadidi et al., 2022; Zhang et al., 2022). However, the scope of spiritual support is broad and involves diverse subjects. Currently, scholars have not reached a unified standard regarding the connotation and dimensions of spiritual support, and quantitative indicators for assessing the level of spiritual support perceived by older adults are still lacking. Previous research has mostly explored the connotation and characteristic dimensions of spiritual support through theoretical construction, which carries strong subjectivity and may limit the generalizability of findings.

Therefore, this study employs empirical methods to explore the connotation and characteristic dimensions of spiritual support for contemporary older adults, develops a spiritual support scale based on the perspective of older adults themselves, and validates the scale's reliability and validity across samples, thereby providing theoretical foundations and effective tools for future exploration of spiritual support implementation in the context of aging.

Study 1: Qualitative Exploration of the Connotation and Dimensions of Spiritual Support

2.1 Research Purpose

This study aims to employ qualitative research methods to explore the connotation and characteristic dimensions of spiritual support for older adults. Using grounded theory analysis, we conducted in-depth interviews with older adults living at home and in institutions, their children, and caregivers to obtain first-hand materials regarding perceptions and understanding of spiritual support for older adults. We further coded the textual data to explore the connotation and characteristic dimensions of spiritual support for contemporary older adults.

2.2 Method

2.2.1 Interview Participants

This study adopted an intensity sampling strategy (Chen, 1999), selecting older adults living at home and in institutions, their children, and caregivers as interview participants. Based on the research approach of "elderly-centered with diverse supplementary perspectives," we selected a total of 81 interview participants, including 52 older adults (32 living at home and 20 in institutions), 18 adult children (13 children of home-based older adults and 5 children of institution-based older adults), and 11 caregivers in institutional settings. The inclusion of children or caregivers aimed to provide supplementary information sources, offering peripheral perspectives on the cognition, implementation pathways, and obstacles of spiritual support for older adults. All participating older adults were in good physical health, free from major physical diseases, and capable of self-care. Their demographic information is presented in [TABLE:1].

2.2.2 Data Collection and Interview Process

This study primarily used interviews to collect data. To ensure that participants could clearly and accurately understand the interview content, the research team (comprising 2 doctoral supervisors, 1 master's supervisor, and 1 psychology postgraduate) developed a preliminary interview outline through discussion before formal interviews. Two participants were selected for pilot interviews, and based on the interview situations and participants' suggestions, the preliminary outline was revised to form the final interview outline (see [TABLE:2]). Formal interviews were semi-structured, with researchers conducting face-to-face in-depth interviews based on the interview outline and flexibly adjusting questions as appropriate. Interviews concluded when information saturation was reached—that is, when continued interviews could no longer provide new valuable content. Subsequently, interview content was transcribed verbatim, and data analysis was conducted using grounded theory.

2.2.3 Data Analysis

As no unified operational definition exists for the connotation of spiritual support for contemporary older adults, this study employed grounded theory to theoretically code the collected interview content, aiming to explore the connotation and characteristic dimensions of spiritual support. Grounded theory is a systematic qualitative research method that constructs theories reflecting social phenomena by collecting and analyzing qualitative data grounded in textual materials, combining inductive and deductive approaches in a bottom-up manner (Chen, 1999). The data analysis process based on grounded theory includes open coding (first-level coding), axial coding (second-level coding), and selective coding (third-level coding). To ensure consistency in the coding process, researchers repeatedly read all interview materials before formal coding to establish a preliminary coding framework. During coding, similar content across interview materials was continuously compared, the applicability of codes was cross-validated, and a stable coding system was formed through iterative revision (Nowell et al., 2017). Additionally, two scholars experienced in qualitative research reviewed some coded content to further enhance the rationality and scientific nature of the interpretations. To ensure coding completeness, the study employed the constant comparative method, coding and comparing all interview materials segment by segment until theoretical saturation was achieved. Throughout this process, researchers continuously compared statements from different participants, inductively forming stable and comprehensive thematic categories (Corbin & Strauss, 2008). This study utilized QSR Nvivo 20.0 qualitative analysis software to organize, edit, code, and statistically analyze the collected interview data. By importing Chinese interview texts, the software enabled indexing, searching, and theorizing of unstructured and non-numerical textual data to construct indices, logical relationships, and generate theories.

2.3 Results

2.3.1 Open Coding

The purpose of open coding is to deconstruct original data sentence by sentence, extract key concepts, and form preliminary categories. Based on careful reading and full understanding of participants' discourse meanings, textual content was broken down, and core meanings of each sentence were annotated to extract initial concepts (Chen, 2000). Before open coding, researchers assigned corresponding codes to each interview participant (e.g., FLR1 for the first home-based older adult, OLR2 for the second institution-based older adult, FZN3 for the third child of a home-based older adult, OZN4 for the fourth child of an institution-based older adult, and OHL5 for the fifth caregiver of an institution-based older adult). Subsequently, focusing on the core question of "the connotation of spiritual support for older adults," researchers continuously searched for and compared recurring meaning units, setting them as different nodes and inductively classifying similar concepts to form preliminary categories. Throughout this process, researchers maintained openness and flexibility, adjusting, merging, and refining categories as needed. This study extracted a total of 67 codes, involving 362 reference points (see [TABLE:3]).

2.3.2 Axial Coding and Selective Coding

Based on the initial categories extracted through open coding, axial coding and selective coding were further conducted on the textual materials focusing on "the connotation of spiritual support for older adults." Axial coding involves deeply classifying, synthesizing, and organizing textual materials based on initial categories extracted through open coding, searching for codes with semantic relationships and constructing logical connections between categories to deepen understanding of the data (Chen, 1999). In this study, since the 67 codes obtained through open coding represented a list of different meaning units, after further organization, analysis, and comparison, these 67 codes were categorized into 16 more refined codes. Selective coding involves further abstractly integrating and refining existing categories, generating and exploring main categories around the theme, and thereby establishing connections between categories (Chen, 1999). In this study, based on these 16 codes, five new nodes were established around the theme of "the connotation of spiritual support for older adults": "health security (sense of security)," "independence and freedom (sense of autonomy)," "cultural activities (sense of competence)," "existential meaning (sense of value)," and "social interaction (sense of belonging)" (see [TABLE:3]).

Specifically, social interaction emerged as the core category of spiritual support for older adults, with high frequency of mention by participants. Intimate relationships and social interaction are important pathways to meeting the emotional needs and sense of belonging among contemporary older adults. Intimate relationships (such as emotional support from children and spouses) provide stable emotional anchors and psychological comfort, while social interaction (such as interactions with friends and participation in community activities) expands their social connections and prevents loneliness. Second, participation in cultural activities organized by communities or institutions not only promotes social interaction and enhances sense of belonging but also provides opportunities for older adults to demonstrate their abilities and social connections, strengthening their sense of competence. From the individual subjective perspective of older adults, an independent and free lifestyle grants them more choices, allowing them to autonomously decide which social activities to participate in and generate a sense of control over their lives. With the development of the times, due to the improvement of China's pension system and increased savings among older adults, they can maintain a certain degree of economic autonomy, and older adults increasingly emphasize their independence and decision-making power in life. Furthermore, the sense of belonging and competence gained through interpersonal interaction and cultural activities further enables older adults to feel respected and recognized, enhancing their existential meaning and self-worth. When older adults feel their value is recognized, it in turn promotes their social participation and maintenance of a positive mindset. Health security forms the foundation of spiritual support for older adults, relying on comprehensive support from policies, technology, and communities. As age increases, older adults universally face physiological and psychological issues related to aging. A comprehensive health security system can provide emotional comfort and psychological security. Therefore, providing health security for older adults at the government level constitutes important support and a key foundation for realizing their spiritual support. Examples of interview data for each dimension are presented in [TABLE:4].

2.4 Theoretical Model Construction

Based on the hierarchical coding results of grounded theory and thorough analysis of interview materials, we constructed a bottom-up theoretical model of the connotative structure of spiritual support for contemporary older adults. As shown in [FIGURE:1], spiritual support can be integrated into a multidimensional structural system composed of three layers: basic support, relational interaction, and meaning construction, encompassing five interrelated characteristic dimensions: health security, social interaction, cultural activities, independence and freedom, and existential meaning. These five dimensions respectively address five categories of core emotional needs among older adults: sense of security, sense of belonging, sense of competence, sense of autonomy, and sense of value, collectively constituting the complete connotation of spiritual support. At the theoretical integration level, Maslow's hierarchy of needs theory and self-determination theory were organically integrated to construct a hierarchical structure of spiritual support. Health security serves as the basic dimension, corresponding to older adults' fundamental expectations for a stable and safe living environment, and constitutes the prerequisite for realizing other dimensions. Its sources of support are not limited to family children but also include community services and government policy guarantees, reflecting the objectivity and institutional dependency of spiritual support. At the middle level, social interaction, cultural activities, and independence and freedom constitute the core activity space for the spiritual lives of older adults, focusing on meeting their needs for social participation and environmental control. Social interaction, in particular, is widely recognized by older adults as having dual functions of emotional connection and psychological comfort, representing the core category through which they obtain a sense of belonging and existential confirmation. Cultural activities are not only ways to continue hobbies but also important carriers for achieving social participation and role transformation, helping older adults maintain a sense of "usefulness" and competence. Independence and freedom reflect older adults' insistence on autonomous living; whether this is respected by families and society directly affects their psychological dignity and life satisfaction. Based on self-determination theory, human health development and intrinsic motivation stem from the satisfaction of three basic psychological needs: autonomy, competence, and relatedness (Deci & Ryan, 2000). Existential meaning, as a higher-order dimension of spiritual support, emphasizes how older adults reconstruct life goals and sense of value after experiencing the fading of family roles and transformation of social identity. This dimension theoretically responds to the requirement of "active engagement" in Rowe & Kahn's (1998) framework of "active aging" and injects a more culturally sensitive psychosocial support pathway into existing successful aging theories.

Overall, spiritual support for contemporary older adults is based on health security guaranteed by social and family support, with social interaction as the core category. Emotional support is obtained through intimate interactions with family members, especially children, and exchanges with friends and neighbors. At the community level, diverse cultural activities serve as important carriers for older adults to achieve valuable social connections and interpersonal interactions. Furthermore, in the daily lives of older adults, it is necessary to accept and respect their autonomy and independence, encouraging them to actively arrange and control their personal lives, thereby promoting their acquisition of existential meaning and sense of value. Therefore, implementing spiritual support for contemporary older adults requires the participation of multiple subjects, integrating resources and efforts from older adults themselves, families, communities, and the government to provide a comprehensive support system. Spiritual support for contemporary older adults exhibits characteristics of subjectivity, objectivity, relationality, and higher-order nature. In summary, this study preliminarily proposes the following definition of spiritual support for contemporary older adults: Based on health security and using cultural activities as an important medium, spiritual support promotes meaningful social interaction and interpersonal exchange while fully respecting older adults' autonomy, gradually enhancing their existential value and psychological satisfaction.

2.5 Summary

This study conducted qualitative analysis of interview materials and used grounded theory to construct the conceptual connotation and theoretical explanatory framework of spiritual support for contemporary older adults. The results identified five characteristic dimensions: health security, social interaction, cultural activities, independence and freedom, and existential meaning, corresponding to older adults' emotional needs for security, belonging, competence, autonomy, and value. Specifically, spiritual support for contemporary Chinese older adults is based on health security provided by the government and families, with social interaction as the core. Emotional support is obtained through intimate interactions with family members, particularly children, and exchanges with friends and neighbors. At the community level, diverse cultural activities serve as important carriers for promoting social connections and interpersonal interactions among older adults. Additionally, accepting and respecting the autonomy and independence of older adults and encouraging them to actively arrange and control their lives helps enhance their existential meaning and sense of value. In conclusion, the connotation of spiritual support for contemporary Chinese older adults is a complex concept involving multiple subjects, characterized by the coexistence of subjectivity, objectivity, relationality, and higher-order nature.

Study 2: Development and Validation of the Spiritual Support Scale

3.1 Research Purpose

Based on the characteristic dimensions of spiritual support for older adults extracted through grounded theory in Study 1, this study developed a questionnaire to measure perceived spiritual support among older adults, aiming to create a localized assessment tool for spiritual support among Chinese older adults and further clarify the characteristic dimensions of spiritual support for contemporary older adults.

3.2 Method

3.2.1 Scale Development

Based on the five dimensions of spiritual support obtained in Study 1—health security (sense of security), cultural activities (sense of competence), social interaction (sense of belonging), independence and freedom (sense of autonomy), and existential meaning (sense of value)—we initially drafted items for the Perceived Spiritual Support Questionnaire for Older Adults by referencing existing mature scale items related to these dimensions. Subsequently, two health psychology experts and several psychology graduate students were invited to revise the drafted items word by word, eliminating items that clearly exceeded the comprehension range of older adults. This process resulted in a preliminary questionnaire containing 33 items: 4 items for health security (sense of security), 4 items for cultural activities (sense of competence), 16 items for social interaction (sense of belonging), 4 items for independence and freedom (sense of autonomy), and 5 items for existential meaning (sense of value), including 12 reverse-scored items to enhance data reliability and validity. To prevent response bias, the 33 items were randomly arranged to form the initial scale.

A pilot survey was conducted with 236 older adults over 60 years old in good physical health from a community in Guangzhou to preliminarily screen items. Based on item analysis and exploratory factor analysis results, 7 poorly fitting items were eliminated. Additionally, two dimensions contained only one item each, which does not meet basic psychometric requirements (Bollen, 1989; Hau et al., 1999), leading to the elimination of two more items. This resulted in a preliminary questionnaire containing 24 items. The 24-item preliminary scale was then administered to a larger sample of older adults to test its reliability and validity.

3.2.2 Participants

Sample 1: Using convenience sampling, we randomly selected one community each from Baiyun District and Conghua District in Guangzhou and invited older adults over 60 years old in good physical health who had long resided in these communities to participate. Trained administrators conducted individual testing, collecting 473 questionnaires. After excluding questionnaires that did not meet age criteria, the final valid sample comprised 472 participants, with an effective response rate of 99.8%. The sample included 296 females (62.7%), aged 65–99 years (Mage = 73.28 ± 5.81 years). Regarding education level, 10.2% had no formal education, 58.9% had primary school or below, 22.0% had junior high school, 6.6% had high school/vocational school/technical school/specialized secondary school, and 1.5% had college or above. This sample was used for item analysis and exploratory factor analysis. With a sample size more than 10 times the number of test items, it meets the requirements for stable factor structure in exploratory factor analysis (Wu, 2010).

Sample 2: We selected one community each from Conghua District and Haizhu District in Guangzhou and invited older adults over 60 years old in good physical health who had long resided in these communities to participate. Trained administrators conducted individual testing, collecting 644 questionnaires. After excluding questionnaires that did not meet age criteria, showed patterned responding, or contained logical contradictions, the final valid sample comprised 519 participants, with an effective response rate of 80.6%. The sample included 301 females (58.0%), aged 60–98 years (Mage = 72.36 ± 5.93 years). Regarding education level, 5.2% had no formal education, 31.2% had primary school or below, 25.8% had junior high school, 22.4% had high school/vocational school/technical school/specialized secondary school, and 9.3% had college or above. This sample was used for confirmatory factor analysis, criterion-related validity testing, and reliability analysis, with a sample size more than 10 times the number of test items, meeting the requirements for confirmatory factor analysis (Wu, 2010).

Two weeks later, 224 participants were selected for retesting within a specified time frame, yielding 223 valid matched pairs, with an effective matching rate of 99.6%. Among the valid matched data, 136 were female (61.0%), aged 66–99 years (Mage = 73.05 ± 5.61 years).

3.2.3 Measures

(1) Perceived Spiritual Support Questionnaire for Older Adults
The 24-item Perceived Spiritual Support Questionnaire for Older Adults was used, including five dimensions: health security (e.g., "I worry about my current or future health status"), cultural activities (e.g., "I am satisfied with the cultural and recreational activities I currently participate in"), social interaction (e.g., "I can maintain long-term harmonious relationships with old friends in my own way"), independence and freedom (e.g., "I can freely choose my lifestyle"), and existential meaning (e.g., "I can find appropriate opportunities to realize my value"). The questionnaire used a 4-point scoring scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree), with higher scores indicating better perceived spiritual support.

(2) Loneliness Scale
The 8-item short-form UCLA Loneliness Scale (ULS-8) developed by Hays and DiMatteo (1987) was used to measure loneliness among older adults. This scale is one of the most widely used self-report loneliness measures, containing 8 items such as "I feel a lack of companionship." Each item used a 4-point rating scale (1 = never; 2 = rarely; 3 = sometimes; 4 = always), with higher scores indicating stronger loneliness. In this study, the scale's Cronbach's α coefficient was 0.70.

(3) Depression Scale
The 9-item Patient Health Questionnaire (PHQ-9) developed by Kroenke et al. (2001) was used to assess depressive symptoms in older adults. This widely used scale demonstrates good reliability and validity and is a common tool for evaluating depression severity. The scale contains 9 items assessing the frequency of each described symptom in the past two weeks using a 4-point scale: "not at all" = 0, "several days (no more than 7 days)" = 1, "more than half the days (7–10 days)" = 2, and "nearly every day" = 3. Higher scores indicate more severe depressive symptoms. In this study, the scale's Cronbach's α coefficient was 0.94.

(4) Anxiety Scale
The 7-item Generalized Anxiety Disorder Scale (GAD-7) developed by Spitzer et al. (2006) was used to assess anxiety symptoms in older adults. This scale demonstrates good reliability and validity and is a common tool for evaluating anxiety. The scale contains 7 items assessing the frequency of each symptom in the past two weeks using the same 4-point scale as the PHQ-9. Higher scores indicate more severe anxiety symptoms. In this study, the scale's Cronbach's α coefficient was 0.95.

3.2.4 Statistical Methods

SPSS 26.0 was used for descriptive statistics, item analysis, exploratory factor analysis, criterion-related validity testing, and reliability analysis. AMOS 24.0 was used for confirmatory factor analysis.

3.3 Results

3.3.1 Item Analysis

Item analysis was conducted on Sample 1. First, the critical ratio method was used: based on the average scores of the 24 items of the Perceived Spiritual Support Questionnaire for Older Adults, high-level (top 27%) and low-level (bottom 27%) spiritual support groups were identified. Independent samples t-tests were performed on the scores of the 24 items between these two groups, revealing significant differences for all items. Next, Pearson correlation analysis was used to calculate correlations between each item and the total score and its respective factor score. Results showed that all item scores were significantly correlated with the total score (rs = 0.33–0.74, p < 0.001) and with their respective dimension scores (health security: rs = 0.33–0.54, p < 0.001; social interaction: rs = 0.51–0.73, p < 0.001; cultural activities: rs = 0.56–0.63, p < 0.001; independence and freedom: rs = 0.57–0.67, p < 0.001; existential meaning: rs = 0.35–0.51, p < 0.001).

3.3.2 Exploratory Factor Analysis

Exploratory factor analysis was conducted on Sample 1. Bartlett's test of sphericity (χ² = 4780.291, df = 231, p < 0.001) and the Kaiser-Meyer-Olkin test (KMO = 0.91) indicated that items likely shared underlying factors, making the data suitable for exploratory factor analysis. Principal component analysis with Promax rotation was used. The number of factors was determined based on eigenvalues ≥ 1 and scree plot inspection. Items were eliminated if they met either of the following criteria: (1) factor loading absolute value < 0.4 on any factor, or (2) difference in absolute loading values between any two factors < 0.15. Each time an item was eliminated, exploratory factor analysis was rerun until no items met these criteria. Based on these standards, 2 items were eliminated, retaining 22 items distributed across 5 factors, which cumulatively explained 63.82% of the variance. As shown in [TABLE:5], each item demonstrated substantial loadings on its respective factor, ranging from 0.55 to 0.85.

3.3.3 Confirmatory Factor Analysis

To further evaluate the appropriateness of the five-factor model obtained from exploratory factor analysis, confirmatory factor analysis was conducted on Sample 2. Comparison of model fit indices for one-factor, two-factor, three-factor, four-factor, and five-factor models revealed that the five-factor model offered superior representation of the internal structure of spiritual support for older adults (see [TABLE:6]). As shown in [FIGURE:2], all standardized factor loadings in the five-factor model were ≥ 0.39.

3.3.4 Criterion-Related Validity

Criterion-related validity was tested on Sample 2 using the Loneliness Scale, Depression Scale, and Anxiety Scale as criterion indicators. Pearson correlation analysis revealed that the total score and all factor scores of the Perceived Spiritual Support Questionnaire for Older Adults were significantly negatively correlated with total loneliness, depression, and anxiety scores, indicating that higher levels of spiritual support were associated with lower levels of negative psychological states, thus demonstrating good criterion validity. Notably, correlation coefficients ranged from -0.15 to -0.56, significant but moderate in strength (see [TABLE:7]), suggesting that while spiritual support is closely related to psychological health, it is not equivalent to traditional psychological distress indicators such as loneliness, depression, or anxiety. This "significant but not high" correlation reflects that spiritual support, as a comprehensive psychosocial support resource, operates through more multidimensional functional mechanisms. Spiritual support not only alleviates negative emotions but also emphasizes the construction of positive psychological resources such as autonomy, sense of value, cultural belonging, and social participation. Therefore, while maintaining moderate associations with traditional negative emotion indicators, the questionnaire also demonstrates relative independence and theoretical distinctiveness.

3.3.5 Reliability Analysis

Internal consistency reliability was tested on Sample 2. Results showed that the Cronbach's α coefficient for the Perceived Spiritual Support Questionnaire for Older Adults was 0.90, with dimension-specific coefficients of 0.66 (health security), 0.80 (social interaction), 0.80 (cultural activities), 0.75 (independence and freedom), and 0.75 (existential meaning). The overall test-retest reliability intraclass correlation coefficient (ICC) was 0.91, with dimension-specific ICC values of 0.74 (health security), 0.87 (social interaction), 0.79 (cultural activities), 0.75 (independence and freedom), and 0.65 (existential meaning).

3.4 Summary

Based on the qualitative analysis results from Study 1, this study developed and compiled a research tool to measure the degree of spiritual support perceived by older adults. Through exploratory factor analysis, a self-compiled 22-item Perceived Spiritual Support Questionnaire for Older Adults was extracted and identified. Subsequently, confirmatory factor analysis, criterion-related validity testing, and reliability analysis were conducted to systematically examine the scale's structural validity, convergent validity, and internal consistency. Results indicated that the questionnaire demonstrated stable psychological structure across different samples of older adults and effectively reflected the core characteristics of perceived spiritual support. Further analysis revealed that the questionnaire comprises five dimensions: health security (4 items), social interaction (7 items), cultural activities (4 items), independence and freedom (4 items), and existential meaning (3 items), consistent with the qualitative analysis results from Study 1. Although the retained items differed in number across dimensions, each effectively covered its core connotation. For example, "social interaction," as the most representative and diversely expressed dimension in spiritual support, was mentioned most frequently in interviews (accounting for 31.5% of reference points) and comprises 31.8% of total items. In contrast, "existential meaning," as a higher-order need, has a relatively concentrated content structure, with only 3 items adequately covering its key features while demonstrating good reliability and validity. In summary, this study not only further clarified the five core dimensions and their connotations of spiritual support for older adults but also revealed potential associations among dimensions, providing reliable measurement tools and theoretical support for subsequent theoretical deepening and empirical research on spiritual support.

Study 3: Longitudinal Predictive Effects of Spiritual Support on Health Outcomes

4.1 Research Purpose

This study utilized the Perceived Spiritual Support Questionnaire for Older Adults developed in Study 2 to examine the long-term predictive effects of spiritual support on older adults' physical and psychological quality of life, frailty, and cognitive function through longitudinal tracking, thereby investigating the relationship between perceived spiritual support and the physical and mental health of older adults.

4.2 Method

4.2.1 Participants

This study selected older adults over 60 years old in good physical health, with clear self-awareness and willingness to cooperate with assessments, from a community in Baiyun District, Guangzhou. Using G*Power (Faul et al., 2009), the minimum sample size required for multiple linear regression was calculated as 89 (Cohen's f² = 0.15 for medium effect size, α error probability = 0.05, power = 95%). A 6-month longitudinal follow-up survey was conducted. The first assessment (T1) took place from May to June 2024, with trained administrators conducting individual testing and collecting demographic information and perceived spiritual support levels. At T1, 237 valid questionnaires were collected, including 142 females (59.9%), aged 60–91 years (Mage = 73.07 ± 5.48 years). The second assessment (T2) occurred from November to December 2024, with 226 participants successfully followed up (retention rate = 95.4%), collecting data on quality of life, frailty, and cognitive function.

4.2.2 Measures

(1) Perceived Spiritual Support Questionnaire for Older Adults
The 22-item Perceived Spiritual Support Questionnaire for Older Adults developed in Study 2 was administered at T1 to measure spiritual support levels. The questionnaire includes five dimensions: health security (sense of security), social interaction (sense of belonging), cultural activities (sense of competence), independence and freedom (sense of autonomy), and existential meaning (sense of value). Using a 4-point scale (1 = strongly disagree to 4 = strongly agree), average scores across 22 items and each dimension were calculated for data analysis, with higher scores indicating better perceived spiritual support. In this study, Cronbach's α coefficients for the total questionnaire and its dimensions (health security, social interaction, cultural activities, independence and freedom, existential meaning) were 0.88, 0.75, 0.89, 0.87, 0.80, and 0.69, respectively.

(2) Quality of Life Scale
The 12-item Short-Form Health Survey (SF-12) developed by Ware et al. (1996) was administered at T2 to measure quality of life. The SF-12 contains 12 items covering physical and mental health-related quality of life dimensions. Dimension scores were calculated separately and converted to standard scores using formulas, with each dimension ranging from 0 to 100 and higher scores indicating better physical or mental quality of life. In this study, Cronbach's α coefficients for the physical and mental dimensions were 0.84 and 0.83, respectively.

(3) Frailty Scale
The Tilburg Frailty Indicator (TFI) developed by Gobbens et al. (2010) was administered at T2 to assess frailty status. The TFI contains 15 items comprising three dimensions: physical frailty, psychological frailty, and social frailty. The total score across 15 items (0–15) represented frailty severity, with higher scores indicating greater frailty. In this study, the scale's Cronbach's α coefficient was 0.75.

(4) Cognitive Function Scale
The 8-item Ascertain Dementia (AD-8) questionnaire developed by Hughes et al. (1982) was administered at T2 to assess cognitive function. This screening tool for early identification of cognitive impairment asks participants to respond to each item based on their actual situation, with "no" scored as 0 and "yes" scored as 1. Total scores range from 0 to 8, with higher scores indicating more severe cognitive impairment. In this study, the questionnaire's Cronbach's α coefficient was 0.63.

4.2.3 Statistical Methods

SPSS 26.0 was used for descriptive statistics, correlation analysis, and regression analysis. To avoid confounding effects of irrelevant variables on the relationships among main variables, demographic variables including age, gender, education years, marital status, physical disease status, and family economic status were controlled in regression analyses. Both uncontrolled and controlled model results are reported to comprehensively examine the relationships between perceived spiritual support and physical and mental health.

4.3 Results

4.3.1 Common Method Bias Test

Since questionnaire data were primarily collected through self-report from older adults, Harman's single-factor test was used to assess common method bias. The results revealed 16 factors with eigenvalues greater than 1, with the first factor explaining 19.39% of variance, below the 40% critical value, indicating no serious common method bias in this study.

4.3.2 Descriptive Statistics and Correlation Analysis

As shown in [TABLE:8], correlation analysis indicated that perceived spiritual support level was significantly positively correlated with physical quality of life (r = 0.27, p < 0.001) and mental quality of life (r = 0.22, p = 0.001). Specifically, health security (r = 0.29, p < 0.001), social interaction (r = 0.21, p = 0.002), cultural activities (r = 0.14, p = 0.042), and independence and freedom (r = 0.17, p = 0.013) were significantly positively correlated with physical quality of life, while health security (r = 0.15, p = 0.030), social interaction (r = 0.21, p = 0.002), and independence and freedom (r = 0.16, p = 0.018) were significantly positively correlated with mental quality of life. Perceived spiritual support level was significantly negatively correlated with frailty (r = -0.30, p < 0.001) and cognitive decline (r = -0.26, p < 0.001). Specifically, health security (r = -0.30, p < 0.001), social interaction (r = -0.23, p = 0.001), cultural activities (r = -0.20, p = 0.004), and independence and freedom (r = -0.17, p = 0.010) were significantly negatively correlated with frailty, while health security (r = -0.24, p < 0.001), social interaction (r = -0.22, p = 0.001), and independence and freedom (r = -0.15, p = 0.032) were significantly negatively correlated with cognitive decline.

4.3.3 Predictive Validity Test

Regression analysis results (see [TABLE:9]) showed that in the uncontrolled model, T1 perceived spiritual support level significantly predicted T2 physical quality of life (b = 6.35, SE = 1.52, 95% CI = [3.36, 9.34], β = 0.27, p < 0.001) and mental quality of life (b = 4.79, SE = 1.47, 95% CI = [1.90, 7.69], β = 0.22, p = 0.001), as well as frailty status (b = -1.84, SE = 0.40, 95% CI = [-2.63, -1.05], β = -0.30, p < 0.001) and cognitive decline (b = -1.06, SE = 0.27, 95% CI = [-1.60, -0.53], β = -0.26, p < 0.001).

After controlling for demographic variables, similar results were obtained: T1 perceived spiritual support level significantly predicted T2 physical quality of life (b = 4.77, SE = 1.52, 95% CI = [1.77, 7.77], β = 0.21, p = 0.002) and mental quality of life (b = 5.29, SE = 1.52, 95% CI = [2.29, 8.29], β = 0.24, p = 0.001), as well as frailty status (b = -1.61, SE = 0.42, 95% CI = [-2.44, -0.79], β = -0.26, p < 0.001) and cognitive decline (b = -1.00, SE = 0.28, 95% CI = [-1.55, -0.45], β = -0.24, p < 0.001).

4.4 Summary

This study employed a longitudinal design to systematically examine the long-term effects of perceived spiritual support on multidimensional health indicators, including quality of life, frailty status, and cognitive function among older adults. Results indicated that older adults with higher perceived spiritual support levels at baseline demonstrated better physical and mental quality of life, lower frailty levels, and better cognitive function six months later. After controlling for relevant demographic variables, the predictive effects of perceived spiritual support on all health indicators remained significant, demonstrating robust effects. These findings not only validate the predictive validity of perceived spiritual support for older adults' physical and mental health but also underscore the critical role of spiritual support in promoting overall health among older adults, providing empirical evidence for future eldercare policy development and intervention design.

General Discussion

This study employed interview and questionnaire methods to conduct three sequential substudies, thoroughly exploring and empirically validating the connotation and characteristic dimensions of spiritual support for older adults within contemporary Chinese sociocultural contexts. First, Study 1 used qualitative research methods to collect older adults' and caregivers' perceptions, experiences, and expectations of spiritual support through semi-structured interviews, analyzing core elements of perceived spiritual support from multiple perspectives. Using grounded theory to code interview data and construct theory, we preliminarily summarized the conceptual framework and structural characteristics of spiritual support, enriching and deepening its connotation at the theoretical level and expanding its applicability within contemporary Chinese society. Second, Study 2 employed psychometric methods to quantitatively investigate the characteristic dimensions of spiritual support for older adults. Based on qualitative analysis results from Study 1, we developed and compiled a spiritual support measurement questionnaire and systematically validated its reliability and validity. Results showed that spiritual support for older adults primarily includes five characteristic dimensions: health security, social interaction, cultural activities, independence and freedom, and existential meaning. This scale serves as an effective tool for measuring perceived spiritual support levels among older adults, providing a solid measurement foundation for subsequent research. Finally, Study 3 used a longitudinal design to examine the long-term effects of spiritual support on multidimensional health indicators among older adults. Findings demonstrated that perceived spiritual support levels not only positively predicted physical and mental quality of life but also exerted significant buffering effects on frailty status and cognitive decline. This further validates the importance of spiritual support in promoting overall health among older adults and provides scientific evidence for future eldercare intervention strategies.

This study systematically explored and clarified five characteristic dimensions of spiritual support for contemporary older adults—health security, social interaction, cultural activities, independence and freedom, and existential meaning—which respectively address key emotional needs for security, belonging, competence, autonomy, and value. Among these, social interaction is considered the core dimension of spiritual support, primarily comprising children's comfort and social engagement. Attachment theory posits that intimate relationships, especially with children, are important sources of emotional security (Hicks & Korbel, 2013). For older adults, children are typically regarded as the most direct and important responsible parties for providing support; their care and comfort not only provide psychological solace but also enhance sense of belonging, enabling older adults to better cope with uncertainties associated with aging. In contrast, social engagement emphasizes the breadth of interaction, with relatively weaker deep emotional dependence. Nevertheless, broad social interaction helps older adults construct existential meaning and enhances their motivation for daily life, thereby promoting spiritual support (Berlin & Perone, 2024).

Additionally, health security, as an important foundation of spiritual support, has often been insufficiently addressed in relevant research. However, with age, older adults face physiological decline that may generate health anxiety and aging-related fears (Yang et al., 2019). In this context, the government can enhance older adults' health security by improving the medical security system and optimizing eldercare service policies, while family members can also promote spiritual support by fostering healthy lifestyles and supportive family environments. Previous research has indicated that cultural activities play an important role in promoting spiritual support (Shi et al., 2021; Zhou, 2005). This study further reveals that diverse cultural activities organized with community support not only provide opportunities for social interaction but also promote competence enhancement through learning new knowledge and skills, thereby facilitating spiritual support.

Although recent scholars have begun to examine older adults' agency in spiritual support (Meng & Wang, 2022), systematic investigation of the role of independence and autonomy remains lacking, and it has not been widely incorporated as a core dimension of spiritual support. This study's results indicate that independence and autonomy have become important components of spiritual support for contemporary older adults. As China's pension system gradually improves, an increasing number of older adults can achieve economic independence, thereby reducing financial dependence on children, alleviating intergenerational burdens, and gaining greater autonomy in family decision-making. This shift not only reflects changes in older adults' spiritual support needs but also demonstrates the evolution of spiritual support approaches under social development—from traditional child-support models toward approaches emphasizing individual autonomy and dignity.

Finally, existential meaning, as a higher-order characteristic of spiritual support, was further validated in this study, consistent with previous research findings (Jadidi et al., 2021; Jadidi et al., 2022; Mu, 2004). Compared with younger populations, older adults are more likely to experience loss of life meaning due to retirement, declining physical and cognitive functions, and the successive loss of relatives and friends. Therefore, existential meaning not only concerns older adults' cognition and evaluation of their own life value but also involves their continued functioning and self-value realization within families, society, and groups. The establishment of this dimension indicates that spiritual support should extend beyond providing emotional support and security to address how to help older adults construct positive life meaning and enhance their overall sense of value.

The five characteristic dimensions of spiritual support and their total scores were all significantly positively correlated, indicating interactions among dimensions. Health security is the prerequisite for older adults' sense of security, primarily relying on external institutional support such as medical assistance, professional care, and family caregiving, providing basic protection for spiritual support (Bronfenbrenner, 1977). Good health status not only improves older adults' quality of life but also promotes social interaction. Through parent-child interaction, peer exchange, and social connections, older adults gain sense of belonging and social respect (Dang et al., 2024; Nikitin et al., 2024). Cultural activities provide opportunities for continuous learning and self-improvement while meeting social needs, enhancing older adults' sense of competence. Social interaction and cultural activities jointly promote social engagement, enabling older adults to satisfy internal needs through social connections and further facilitating independence and autonomy and existential meaning (Shi et al., 2021; Zhou, 2005; You, 2015). Positive social and activity experiences make it easier for older adults to develop positive cognitions about their abilities and life value, thereby enhancing overall spiritual support levels. Therefore, the five dimensions of spiritual support are both independent and interrelated, involving multi-subject interaction and demonstrating certain hierarchical and dynamic characteristics.

This study is the first to validate the long-term predictive effects of spiritual support on multidimensional health indicators (including physical and mental quality of life, frailty status, and cognitive function) among Chinese older adults and confirm its close associations with multiple mental health indicators (loneliness, depression, and anxiety). Spiritual support can serve as an important stress-buffering mechanism, enhancing older adults' stress resistance and adaptability through health security and strong interpersonal support systems, thereby reducing the incidence of chronic diseases and promoting physical health (Holt-Lunstad, 2024). At the mental health level, higher levels of spiritual support may exert positive effects through multiple mechanisms. According to self-determination theory (Deci & Ryan, 2000), spiritual support enhances psychological functioning and well-being by satisfying older adults' needs for autonomy, competence, and relatedness, thereby improving quality of life and overall mental health status. Additionally, the stable emotional connections and social participation opportunities provided by spiritual support help enhance older adults' emotion regulation abilities, alleviate loneliness, depression, and anxiety, increase life enthusiasm and sense of purpose, and reduce negative impacts of negative emotions on physical and mental health (Tsujimoto et al., 2024). Furthermore, spiritual support can continuously activate cognitive resources and promote positive self-cognition construction, generating positive feedback that further supports mental health development (McNamara & Gonzales, 2011). Notably, older adults with higher spiritual support levels are more likely to adopt positive health behaviors. For example, independence and autonomy make older adults more willing to actively seek medical resources, maintain regular routines, and eat healthily, while social interaction and cultural activity participation help increase physical activity levels, reduce chronic disease risks, and improve physical functioning (Teixeira et al., 2012). In summary, good spiritual support not only helps reduce the incidence of mental disorders but also mitigates negative impacts of negative emotions on physiological functions, promoting positive health cycles.

In traditional Chinese culture, the concept of "raising children to support one in old age" has long influenced societal perceptions of eldercare. However, with socioeconomic development and changes in family structure, face-to-face interaction time between older adults and their children has gradually decreased, making spiritual support issues increasingly prominent. Under the collision between traditional eldercare concepts and modern social realities, older adults on the one hand desire more companionship and care from their children, while on the other hand worry about becoming burdens on their children's career development and personal lives. This contradictory psychological state may weaken older adults' sources of emotional support, adversely affecting their mental and physical health. Therefore, conducting in-depth research on spiritual support holds not only important theoretical value but also provides practical guidance for solving real-world problems. The innovation and contributions of this study are mainly reflected in three aspects: First, it expands the psychosocial support dimension of successful aging theory. Rowe & Kahn's (1998) successful aging theory emphasizes three core elements: disease prevention, functional maintenance, and active participation, but pays insufficient attention to how social support can meet older adults' higher-level spiritual needs. This study emphasizes incorporating "spiritual support" into the successful aging framework, proposing that it is not only the psychological foundation for older adults' active social participation but also helps maintain their subjective well-being, identity, and life goals, expanding the theoretical boundaries of "active engagement" and "psychological autonomy" in this theory. Second, it constructs a localized theoretical model of spiritual support. This study proposes that spiritual support for contemporary Chinese older adults exhibits composite characteristics including subjectivity (older adults' expectations for respect and independence), relationality (psychological support based on intergenerational or social interaction), functionality (promoting physical and mental health), and higher-order nature (reflecting sense of value and existential meaning), innovatively defining it as a comprehensive elder support mechanism combining individual psychological appeals with social institutional support. This theoretical model not only aligns with China's unique cultural background but also provides new research perspectives and practical insights for international elder support theory and practice. Third, it advances empirical research and measurement tool construction for spiritual support. This study adopted a multi-stage research design, combining qualitative interviews with large-sample questionnaire surveys to identify and validate the core dimensions of spiritual support for Chinese older adults at the empirical level and develop an effective measurement tool. This tool not only provides quantitative foundations for subsequent empirical research but also can serve as a reference tool for spiritual support service indicators or older adult service quality assessment, helping improve the evaluation capacity of spiritual support systems and promote their institutionalization and standardization in eldercare services. In summary, through integrating theoretical and empirical analysis, this study not only deepens understanding of spiritual support mechanisms but also provides scientific foundations for eldercare policy and practice, contributing to constructing a spiritual support model more aligned with China's sociocultural background and promoting the physical and mental health and well-being of older adults.

Limitations and Future Directions

This study has several limitations. First, it has not examined the influencing factors of spiritual support among older adults. Future research could analyze mechanisms from individual, family, and societal levels, such as investigating how demographic characteristics, family structure, intergenerational interaction quality, and social policy support affect spiritual support. Second, the study sample was drawn from specific regions, which may limit the ecological validity of findings to some extent. Future studies could expand sampling ranges to compare differences in spiritual support among older adults across different regions and cultural backgrounds. Finally, although this study employed a longitudinal design, it only measured spiritual support and health status at two time points, making it difficult to fully reveal change trends over time. Given that older adults' spiritual support levels and health status may be influenced by multiple factors and exhibit dynamic changes, future research could employ multi-time-point tracking measurements over longer time spans to further explore long-term interactive effects and potential causal mechanisms between the two.

References

Antonucci, T. C., Ajrouch, K. J., & Birditt, K. S. (2014). The convoy model: Explaining social relations from a multidisciplinary perspective. Gerontologist, 54(1), 82−92.

Berlin, M., & Perone, A. K. (2024). Interactions, relationships and belonging: Comparing social connectedness and perceived isolation among older women living alone in private homes and in assisted living. Ageing and Society, 44(6), 1329−1353.

Bollen, K. A. (1989). Structural equations with latent variables. John Wiley & Sons.

Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32(7), 513−531.

Carstensen, L. L., Fung, H. H., & Charles, S. T. (2003). Socioemotional selectivity theory and the regulation of emotion in the second half of life. Motivation and Emotion, 27(2), 103−123.

Chen, F. (2016). The social support network for spiritual support of elderly people in rural northern Jiangsu. Chinese Journal of Gerontology, 36(14), 3585−3587.

Chen, X., Giles, J., Yao, Y., Yip, W., Meng, Q., Berkman, L., … Zhao, Y. (2022). The path to healthy ageing in China: A Peking university-Lancet commission. The Lancet, 400(10367), 1967-2006.

Chen, X. M. (1999). Grounded theory: Its train of thought and methods. Educational Research and Experiment, (4), 58−63+73.

Chen, X. M. (2000). Qualitative research method and social sciences research. Education Science Press, China.

Corbin, J., & Strauss, A. (2008). Basics of qualitative research (3rd ed.): Techniques and procedures for developing grounded theory. SAGE Publications, Inc.

Cui, L., Wang, Y., Chen, W., Wen, W., & Han, M. S. (2021). Predicting determinants of consumers' purchase motivation for electric vehicles: An application of Maslow's hierarchy of needs model. Energy Policy, 151, 112167.

Dang, M., Chen, Y., Ji, J. S., Zhang, Y., Chen, C., & Zhang, Z. (2024). The association between household and family composition and mental health of the elderly: Mediating role of lifestyle. BMC Public Health, 24(1), 2055.

Deci, E. L., & Ryan, R. M. (2000). The "what" and "why" of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227−268.

Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using GPower 3.1: Tests for correlation and regression analyses. Behavior Research Methods*, 41, 1149−1160.

Gobbens, R. J., Luijkx, K. G., Wijnen-Sponselee, M. T., & Schols, J. M. (2010). Towards an integral conceptual model of frailty. The Journal of Nutrition, Health and Aging, 14(3), 175−181.

Hays, R. D., & DiMatteo, M. R. (1987). A short-form measure of loneliness. Journal of Personality Assessment, 51(1), 69−81.

Hau, K., Cheng, Z. J., & Herbert, W. M. (1999). Confirmatory factor analyses: Number of items in questionnaires and small sample application strategies. Acta Psychologica Sinica, 31(1), 76−83.

Hicks, A. M., & Korbel, C. (2013). Attachment theory. In M. D. Gellman & J. R. Turner (Eds.), Encyclopedia of Behavioral Medicine (pp. 149−155). Springer New York.

Holt-Lunstad, J. (2024). Social connection as a critical factor for mental and physical health: Evidence, trends, challenges, and future implications. World Psychiatry, 23(3), 312−332.

Hughes, C. P., Berg, L., Danziger, W., Coben, L. A., & Martin, R. L. (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140(6), 566−572.

Inoue, Y., Wann, D. L., Lock, D., Sato, M., Moore, C., & Funk, D. C. (2020). Enhancing older adults' sense of belonging and subjective well-being through sport game attendance, team identification, and emotional support. Journal of Aging and Health, 32(7−8), 530−542.

Jadidi, A., Khodaveisi, M., Sadeghian, E., & Fallahi-Khoshknab, M. (2021). Exploring the process of spiritual health of the elderly living in nursing homes: A grounded theory study. Ethiopian Journal of Health Sciences, 31(3), 589−598.

Jadidi, A., Sadeghian, E., Khodaveisi, M., & Fallahi-Khoshknab, M. (2022). Spiritual needs of the Muslim elderly living in nursing homes: A qualitative study. Journal of Religion and Health, 61(2), 1514−1528.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606−613.

Lakey, B. (2014). Perceived social support and happiness: The role of personality and relational processes (S. David, Boniwell, I., Conley Ayers, A., Ed. Oxford Handbook of Happiness ed.). Oxford University Press.

Li, L. R., & Wang, J. (2022). The issue of elderly spiritual support from the perspective of China's traditional filial piety culture. Chinese Journal of Gerontology, 42(5), 1262−1265.

Litwin, H., & Shiovitz-Ezra, S. (2011). Social network type and subjective well-being in a national sample of older Americans. Gerontologist, 51(3), 379−388.

Liu, S. (2010). The old age support of rural elderly parents having complied with family planning. Population and Society, 26(4), 11−15.

Lu, J., Zhang, C., Xue, Y., Mao, D., Zheng, X., Wu, S., & Wang, X. (2019). Moderating effect of social support on depression and health promoting lifestyle for Chinese empty nesters: A cross-sectional study. Journal of Affective Disorders, 256, 495−508.

McNamara, T. K., & Gonzales, E. (2011). Volunteer transitions among older adults: The role of human, social, and cultural capital in later life. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 66(4), 490−501.

Meng, H., & Wang, Y., J. (2022). Spiritual care: A study of the aged care in ethnic minority areas of China in the perspective of embodiment. Journal of Yunnan Nationalities University (Social Sciences Edition), 39(2), 76−84.

Ming, Y. (2000). A "ripples" pattern of the mental demands of the elderly. South China Population, (02), 56−60+65.

Mu, G. Z. (2004). An analysis of the mental support for the elderly. Journal of Renmin University of China, (04), 124−129.

Nagao-Sato, S., Akamatsu, R., Karasawa, M., Tamaura, Y., Fujiwara, K., Nishimura, K., & Sakai, M. (2023). Associations between patterns of participation in community activities and social support, self-efficacy, self-rated health among community-dwelling older adults. Journal of Psychiatric Research, 157, 82−87.

Nakanishi, M., Yamasaki, S., Nakashima, T., Miyamoto, Y., Cooper, C., Richards, M., … Nishida, A. (2024). Association between dementia, change in home-care use, and depressive symptoms during the covid-19 pandemic: A longitudinal study using data from three cohort studies. Journal of Alzheimer’s Disease, 99(1), 403−415.

Nikitin, J., Luchetti, M., Alimanovic, N., Rupprecht, F. S., & Sutin, A. R. (2024). Are social interactions perceived as more meaningful in older adulthood? Psychology and Aging, 39(6), 599−607.

Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic analysis: Striving to meet the trustworthiness criteria. International Journal of Qualitative Methods, 16(1), 1609406917733847.

Paquet, C., Whitehead, J., Shah, R., Adams, A. M., Dooley, D., Spreng, R. N., … Dubé, L. (2023). Social prescription interventions addressing social isolation and loneliness in older adults: Meta-review integrating on-the-ground resources. Journal of Medical Internet Research, 25, e40213.

Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New York: Pantheon/Random House.

Shi, J., Hua, W., Tang, D., Xu, K., & Xu, Q. (2021). A study on supply-demand satisfaction of community-based senior care combined with the psychological perception of the elderly. Healthcare (Basel, Switzerland), 9(6), 643.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092−1097.

Sun, W. W., & Shi, D. N. (2020). The effect mechanism of social support and mental health of rural elderly. Sociological Review of China, 8(4), 77−87.

Teixeira, P. J., Carraça, E. V., Markland, D., Silva, M. N., & Ryan, R. M. (2012). Exercise, physical activity, and self-determination theory: A systematic review. The International Journal of Behavioral Nutrition and Physical Activity, 9, 78.

Tsujimoto, M., Saito, T., Matsuzaki, Y. & Kawashima, R. (2024). Role of positive and negative emotion regulation in well-being and health: The interplay between positive and negative emotion regulation abilities is linked to mental and physical health. Journal of Happiness Studies, 25, 25.

Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220−233.

Wu, M. L. (2010). Questionnaire statistical analysis practice—SPSS operation and application. Chongqing University Press, China.

Yang, H., Shao, J. J., Zhang, Q. H., Jiang, Y., Li, J. M., & Bai, X. J. (2019). Mediating role of security and perceived control on the relationship between fear of aging and older adults' vulnerability to fraud. Chinese Journal of Clinical Psychology, 27(5), 1036−1040.

Yang, J. H. (2021). Social adaptation of elderly migrants from the perspective of spatial theory. Sociological Studies, 36(3), 180−203.

You, W. B. (2015). The realistic dilemmas of spiritual support for the elderly in China and the construction of a support system. Chinese Journal of Gerontology, 35(12), 3479−3482.

Zhang, T., Liu, Y., Wang, Y., Li, C., Yang, X., Tian, L., … Li, H. (2022). Quality indicators for the care of older adults with disabilities in long-term care facilities based on Maslow’s hierarchy of needs. International Journal of Nursing Sciences, 9(4), 453−459.

Zhao, D. H., & Yang, P. P. (2020). The protection dilemma and realization path of spiritual support right under the background of aging. Study and Practice, (11), 103−112.

Zhou, S. B. (2005). Constructing concordant society and senile spiritual security. Northwest Population Journal, (06), 10−13.