---
title: "Multimorbidity and mental health in older Chinese adults: how family and social support modify risk"
id: "plos-one-23-chronic-disease-multimorbidity-and-mental-health-among-older-adults-in-china"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-23-chronic-disease-multimorbidity-and-mental-health-among-older-adults-in-china"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357259"
published_at: "2026-09-10T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Multimorbidity and mental health in older Chinese adults: how family and social support modify risk
## Provenance & Clinical Metadata
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- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357259)
- **Published At:** 2026-09-10T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This nationally representative cross-sectional study used data from the 2020 China Longitudinal Aging Social Survey (CLASS) to examine relationships among **multimorbidity**, **family support**, **social support**, and **mental health** in older adults in China. - Multimorbidity was defined as self-reported coexistence of two or more chronic conditions; mental health was assessed using survey measures reported in CLASS 2020. - Multivariate regression models with interaction terms tested both direct associations and moderating effects of family support and social support on the link between multimorbidity and mental health. - Findings: multimorbidity is significantly associated with poorer mental health among older adults in China. - Both **family support** and **social support** are independently associated with better mental health, but only **family support** significantly moderates the multimorbidity–mental health association. - Marginal effects analysis showed the negative association between multimorbidity and mental health became progressively stronger as levels of family support increased. - Age-stratified analyses revealed a U-shaped pattern for the direct association between family support and mental health across age groups (60–69, 70–79, 80+), while the moderating (interaction) effect of family support on the multimorbidity–mental health relationship weakened with advancing age and was not statistically significant among adults aged 80 and older. - The study situates results within the Stress-Buffering Hypothesis and Social Convoy Theory, distinguishing close family ties from broader social networks and emphasizing the unique caregiving and emotional roles of family in the Chinese context. - Data source, data access procedures, funding (none declared), and absence of competing interests were reported; limitations and suggestions for future research are noted in the original article.
## Clinical Analysis & Structured Key Points
Chronic disease multimorbidity and mental health among older adults in China: The moderating roles of family and social support | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Population aging has been accompanied by a growing prevalence of chronic disease multimorbidity among older adults, raising increasing concerns about its implications for mental health. Although previous studies have documented the negative association between multimorbidity and mental health, evidence regarding how support systems influence this relationship remains limited. Using nationally representative cross-sectional data from the 2020 China Longitudinal Aging Social Survey (CLASS), this study examined the association between self-reported multimorbidity and mental health among older adults in China, with particular attention to the moderating roles of family support and social support. Multivariate regression models incorporating interaction terms were employed to estimate both direct and interaction effects. The results indicate that, first, multimorbidity is significantly associated with poorer mental health among older adults. Second, although both social support and family support are positively associated with better mental health, only family support significantly moderates the association between multimorbidity and mental health. Third, marginal effects analysis shows that the negative association between multimorbidity and mental health becomes progressively stronger as the level of family support increases. Fourth, subgroup analysis reveals that the direct association between family support and mental health follows a U-shaped pattern across age groups, whereas its moderating effect on the relationship between multimorbidity and mental health gradually weakens with advancing age and becomes statistically insignificant among adults aged 80 years and above. These findings contribute to a more nuanced understanding of interpersonal resources in later life and highlight the need to integrate family-centered approaches into geriatric care and mental health interventions for older adults living with multimorbidity. Citation: Zong L, Zhou K (2026) Chronic disease multimorbidity and mental health among older adults in China: The moderating roles of family and social support. PLoS One 21(9): e0357259. https://doi.org/10.1371/journal.pone.0357259 Editor: Jiaci Lin, Nanjing University, CHINA Received: February 26, 2026; Accepted: August 14, 2026; Published: September 10, 2026 Copyright: © 2026 Zong, Zhou. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The data used in this study were obtained from the China Longitudinal Aging Social Survey (CLASS 2020), a nationally representative survey conducted by the Institute of Gerontology at Renmin University of China. The CLASS 2020 dataset is available to researchers for academic purposes upon formal application. Applicants are required to submit a research proposal outlining the purpose and study plan and to sign a data use agreement provided by the data distributor. Data requests can be directed to the designated contact email address, [ class_ruc@163.com ](mailto: class_ruc@163.com ), or submitted through the official CLASS data application portal: http://jkzgyjy.ruc.edu.cn/sjzy/CLASSsjsq/index.htm . Upon approval, the data will be provided according to the procedures specified by the data distributor. The authors had no special access privileges, and other researchers can obtain the data following the same application procedure. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Population aging has accelerated worldwide, making chronic non-communicable diseases one of the most important public health challenges affecting the health and well-being of older adults. The World Health Organization defines multimorbidity as the coexistence of two or more chronic conditions within the same individual [ 1 ]. Owing to the long-term, cumulative, and often irreversible nature of chronic diseases, multimorbidity not only increases the risks of functional disability, reduced quality of life, and healthcare utilization but also imposes persistent psychological burdens through continuous disease management, functional limitations, and reduced independence [ 2 ]. As population aging continues, multimorbidity has become increasingly common among older adults, making its psychological consequences an important issue for both researchers and policymakers. Multimorbidity is highly prevalent among older populations worldwide. For example, among U.S. adults with a mean age of 48.5 years, 51.0% of women have at least two cardiometabolic or kidney diseases, and 1.5% have three or more such conditions. Among older adults in the United States, the prevalence of multimorbidity reaches approximately 77.0%, while more than half of individuals aged 65–74 years live with multiple chronic conditions. In the United Kingdom, over 70% of adults aged 75 years and older experience multimorbidity [ 3 ]. China has likewise entered an era of rapid population aging, accompanied by a substantial increase in the prevalence of chronic diseases among older adults. National survey data indicate that 86.33% of community-dwelling older Chinese adults report having at least one chronic disease [ 4 ]. A growing body of evidence from both developed and developing countries consistently demonstrates that increasing numbers of chronic conditions are associated with higher levels of depression and anxiety, poorer subjective well-being, and lower psychological quality of life. Reflecting these concerns, the United Nations 2030 Agenda for Sustainable Development identifies the promotion of healthy lives and well-being for all ages (SDG 3) as a global priority, recognizing mental health in later life as an essential component of healthy aging and sustainable development [ 5 ]. Despite extensive evidence documenting the adverse association between multimorbidity and mental health, considerably less attention has been paid to the psychosocial resources that may alter this relationship [ 6 ]. To explain why the psychological consequences of multimorbidity differ across individuals, health psychology research has increasingly adopted the Stress-Buffering Hypothesis, which posits that psychosocial resources can intervene in the stress process and reduce the detrimental effects of stressful life events on mental health [ 7 ]. Within this framework, chronic disease burden represents a persistent health-related stressor, whereas informal support systems constitute important coping resources that may influence how individuals respond to disease-related challenges [ 8 ]. Consequently, the association between multimorbidity and mental health may vary according to the availability of supportive interpersonal resources. Importantly, informal support is not a homogeneous construct. According to Social Convoy Theory, individuals are surrounded by a dynamic network of social relationships organized into concentric circles according to emotional closeness and relationship quality [ 9 ]. The innermost circle primarily consists of family members, whereas the outer circles include friends, neighbors, and community members. Because these sources of support differ substantially in emotional intimacy, caregiving responsibility, and interaction frequency, they may exert distinct influences on psychological adaptation to chronic disease. Accordingly, this study conceptualizes informal support as two separate dimensions. Family support refers to emotional, instrumental, and financial assistance provided by close family members, particularly spouses and adult children, and is characterized by long-term commitment and intergenerational obligations. Social support, by contrast, refers to assistance obtained from broader interpersonal networks, including friends, neighbors, and community members. These operational definitions distinguish interpersonal support from broader sociological constructs such as generalized social capital or social participation [ 10 ]. This distinction is particularly relevant in the Chinese context. Although China is experiencing rapid population aging and continuous expansion of community-based support services, the family remains the cornerstone of elder care because of longstanding cultural norms emphasizing filial responsibility. Family support and broader social support therefore coexist but may play different roles in helping older adults cope with chronic disease. Nevertheless, existing evidence remains limited regarding whether these two forms of informal support differentially modify the association between multimorbidity and mental health. Moreover, little is known about whether these associations vary across different levels of support or across different stages of later life. To address these gaps, this study uses nationally representative data from the 2020 China Longitudinal Aging Social Survey (CLASS) to examine the association between self-reported multimorbidity and mental health among older adults in China. Specifically, we distinguish between family support and social support to investigate their respective moderating roles in the relationship between multimorbidity and mental health. Furthermore, marginal effects analyses are conducted to examine how the association between multimorbidity and mental health changes across different levels of support, while age-stratified analyses explore whether the moderating role of family support differs among adults aged 60–69 years, 70–79 years, and 80 years and above. This study contributes to the literature in three important ways. First, by distinguishing family support from social support, it extends the application of the Stress-Buffering Hypothesis and Social Convoy Theory to the study of multimorbidity and mental health among older adults. Second, beyond testing interaction terms, it employs marginal effects analyses to provide a more nuanced interpretation of how family support shapes the association between multimorbidity and mental health. Third, the age-stratified regression analysis indicates that the moderating association of family support differs across age groups, suggesting that the contribution of informal support may vary among older adults at different ages. These findings provide evidence for developing more targeted family-centered strategies to support healthy aging and psychological well-being among older adults living with multimorbidity. The remainder of this paper is organized as follows. The Literature Review and Analytical Framework section reviews the relevant literature and develops the research hypotheses. The Materials and Methods section describes the data, variables, and methodology. The Results section presents the empirical findings. The Discussion section discusses the main findings and their implications. The Conclusions section summarizes the main findings and policy implications. Finally, the Limitations and Future Work section outlines the study limitations and directions for future research. Literature review and analytical framework Literature review Multimorbidity and mental health in older adults. With the rapid acceleration of global population ageing, chronic disease multimorbidity has become the norm rather than the exception among older adults. The World Health Organization identifies multimorbidity as a central challenge to healthy ageing (WHO, 2022) [ 8 ]. Empirical evidence shows that hypertension, diabetes, arthritis, and cardio-cerebrovascular diseases are the most prevalent and commonly co-occurring chronic conditions in later life [ 1 ]. The burden of multimorbidity extends well beyond the simple accumulation of diseases, generating synergistic and compounding health effects [ 11 ]. A substantial body of research demonstrates that multimorbidity is a major risk factor for mental health problems such as depression and anxiety [ 12 , 13 ], and is strongly associated with more severe depressive symptoms, lower subjective well-being, and poorer overall mental health [ 14 ]. Certain chronic conditions (e.g., cerebrovascular diseases and thyroid disorders) are closely linked to neuroendocrine changes that may contribute to emotional disorders [ 15 ]. Moreover, declines in functional capacity, loss of social roles, and heightened uncertainty about future health can significantly undermine self-efficacy and increase feelings of stigma, thereby exacerbating psychological distress [ 16 ]. Consequently, the relationship between multimorbidity and mental health reflects a complex process shaped by biological, psychological, and social factors. Social support and mental health. Social support has long been recognized as a critical psychosocial resource for mental health [ 17 ]. Classical social support theory suggests that emotional, instrumental, and informational support are associated with greater perceived security, lower stress levels, and more adaptive coping behaviors, thereby contributing to better psychological well-being [ 9 ]. Empirical studies consistently show that higher levels of social support are related to lower risks of depression, greater life satisfaction, and better subjective well-being, both in the general population and among older adults [ 18 ]. In addition, social participation, neighborhood interactions, and access to community services have been found to show significant positive correlations with mental health in later life [ 19 ]. However, most existing studies treat “social support” as a homogeneous construct. According to the Social Convoy Theory (Antonucci, 1986), informal support systems are structured in concentric circles [ 9 ]. This perspective highlights the necessity to distinguish between family support (the inner circle)—typically rooted in kinship, emotional bonds, and normative obligations, and characterized by greater stability and intimacy—and broader social support (the outer circles), which is often more instrumental, selective, and geographically or interest-based [ 10 ]. In China, where Confucian values emphasize familial responsibility and intergenerational reciprocity, the family remains the primary unit of welfare provision, and family support plays an irreplaceable role in health protection for older adults [ 20 ]. Despite this, empirical research that systematically compares the relative moderating roles of family support and social support on the mental health consequences of multimorbidity among Chinese older adults remains scarce. Literature summary and research gaps. While the literature has reached broad consensus on the negative associations between chronic disease multimorbidity and older adults’ mental health, significant gaps remain regarding how different sources of support interact with this relationship. Specifically, few studies have distinguished between family support and social support within a unified analytical framework or examined their heterogeneous moderating patterns based on cross-sectional data from the Chinese context. Research hypotheses To address these gaps, this study draws upon the Stress-Buffering Hypothesis, which suggests that psychosocial resources may influence the relationship between health-related stressors and psychological well-being. Multimorbidity represents a major health stressor in later life, whereas informal support systems may shape how older adults experience and respond to this burden. Based on this theoretical framework, the following hypotheses are proposed: Hypothesis 1 (H1): Self-reported multimorbidity is negatively associated with mental health among older adults. Furthermore, according to the Convoy Model of Social Relations, family members and broader social networks occupy different positions within older adults’ support systems and may therefore play distinct roles in the relationship between multimorbidity and mental health. Accordingly, we propose the following hypotheses: Hypothesis 2 (H2): Social support moderates the association between multimorbidity and mental health. Hypothesis 3 (H3): Family support moderates the association between multimorbidity and mental health. Analytical framework This study developed a sequential empirical framework ( Fig 1 ) to systematically examine the association between multimorbidity and mental health among older adults and the underlying mechanisms. First, a baseline regression model was estimated to assess the direct association between multimorbidity and mental health. Building upon this analysis, social support and family support were introduced as moderating variables, and interaction models were estimated to examine whether these two forms of support differentially modify the association between multimorbidity and mental health. To further clarify the nature of the interaction effects, marginal effects analyses were conducted to estimate the association between multimorbidity and mental health at different levels of support, thereby illustrating how the relationship varies across support levels. Finally, to further examine whether the moderating role of family support differs across age groups, age-stratified regression analyses were conducted for three age groups (60–69 years, 70–79 years, and ≥80 years). This approach enabled us to assess variations in the moderating association of family support across different age groups in later life. Overall, the analytical framework follows a logical progression from main-effect estimation to moderation analysis, marginal-effects interpretation, and age-stratified regression analysis, providing a comprehensive assessment of the relationships among multimorbidity, support systems, and mental health in later life. Download: PNG larger image TIFF original image Fig 1. Analytical framework. https://doi.org/10.1371/journal.pone.0357259.g001 Materials and methods Data sources This study utilizes data from the fourth wave of the China Longitudinal Aging Social Survey (CLASS), conducted in 2020 by the Institute of Gerontology at Renmin University of China. CLASS is a nationally representative, longitudinal social survey that began with a baseline survey in 2014, followed by three follow-up waves in 2016, 2018, and 2020. The survey primarily targets older adults aged 60 and above within households, covering 28 provinces across China. The 2020 wave, the most recent follow-up, included 11,398 respondents. After excluding cases with missing values on key variables, the final analytical sample comprised 9,665 participants. Methods The study involving human participants was approved by the Ethics Committee of the National Survey Research Center, Renmin University of China. The study was conducted in accordance with local legislation and institutional requirements. Written informed consent for participation was not required from the participants or their legal guardians/next of kin in accordance with national legislation and institutional requirements. This study focuses on assessing the impact of chronic diseases on the mental health of older adults. By constructing a multidimensional indicator system and utilizing Stata 18 software, univariate descriptive statistical analysis was conducted, and regression models were developed to examine the relationships between the explanatory and dependent variables. In the empirical analysis, the Ordinary Least Squares (OLS) model was employed to evaluate the relationship between the comorbidity burden of chronic d
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