Abstract
Widowhood represents a major life transition that can profoundly impact the mental health of older adults. However, limited research has explored how the duration of widowhood relates to depressive symptoms. This study examines the mediating roles of sleep duration and dietary diversity in the association between widowhood duration and depressive symptoms. Data were drawn from 2008 adults aged 65 and older participating in the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Linear regression-based mediation analysis was conducted to test the hypothesized pathways. Results revealed a significant positive association between widowhood duration and depressive symptoms. Specifically, among individuals widowed for more than 10 years, both sleep duration and dietary diversity served as mediators—albeit in gender-specific ways. Dietary diversity mediated the association in men, whereas sleep duration exhibited a suppression effect in women. These findings underscore the importance of tailored interventions to support the psychological well-being of widowed older adults. Family and community-based caregivers should prioritize improving dietary quality among long-term widowed men and enhancing sleep health among widowed women. Gender-sensitive strategies may be critical in mitigating the long-term psychological consequences of widowhood in later life.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10433-025-00873-x.
Keywords: Widowhood duration, Depressive symptoms, Sleeping duration, Dietary diversity
Introduction
Promoting healthy and active aging requires particular attention to the mental health of older adults. Depression is a common and debilitating mental disorder that significantly undermines well-being in later life. Cross-national data reveal considerable variation in the prevalence of depressive symptoms among older populations. For instance, Yan et al. reported CES-D-based prevalence rates of 17.8% in the UK, 19.5% in the US, and 37.7% in China. Similarly, Wang and Deng (2024) found that 32.9% of Chinese adults aged 45 and above exhibited depressive symptoms, with prevalence increasing with age. These figures suggest that older adults in China experience disproportionately higher rates of depressive symptoms compared to their international counterparts. The growing burden of late-life depression not only reduces quality of life (Orsolini et al. 2020) but also drives up healthcare costs (Schousboe et al. 2019). Identifying its risk factors through epidemiological research is therefore crucial for designing effective interventions and informing public health policy.
According to the most recent national census, approximately 50 million older adults in China are widowed. Specifically, 27.9% of adults aged 65 and above are widowed—16.0% of men and 38.6% of women (Guo et al. 2021). Projections indicate that by 2050, the number of widowed individuals aged 60 and above will reach around 118 million (Zhao & Li 2022). This demographic trend not only places pressure on family caregivers but also challenges the sustainability of China’s social welfare systems.
Widowhood is widely recognized as a major life stressor, consistent with stress theory. The transition to widowhood is often accompanied by financial hardship, disruption of daily routines, and social isolation (Scannell-Desch 2003). As widowhood progresses, individuals may follow divergent psychological trajectories. Some may gradually adapt to their new circumstances, developing resilience and reducing psychological distress over time (Huang et al. 2024). Others, however, may experience cumulative wear-and-tear effects from persistent stressors, resulting in health deterioration and worsening depressive symptoms (Li et al. 2023a, b). Thus, we hypothesize H1: Widowhood duration is positively associated with depressive symptoms, with the strongest effects observed during the early stages of bereavement.
According to the marital resource model, marriage provides access to critical psychological, social, and material resources that enhance well-being. The loss of a spouse interrupts these resources and adversely affects mental health (Jin & Chrisatakis 2009). In addition to financial resources, health-related behaviors such as sleep and diet are also essential components of well-being. Bereaved individuals often experience sleep disturbances—such as insomnia or fragmented sleep—especially within the first six months of spousal loss (Wu et al. 2021). Inadequate sleep is strongly associated with depressive symptoms in older widowed adults (Pan et al. 2022) and may also activate inflammatory pathways that further elevate depression risk (Irwin et al. 2023). Accordingly, we propose H2: Sleep duration mediates the relationship between widowhood duration and depressive symptoms, such that longer sleep is associated with fewer symptoms.
Dietary diversity, a proxy for dietary quality, reflects the range of different food groups consumed over a given period (Zhou et al. 2022). Evidence suggests that diet quality often deteriorates during the first two years of widowhood (Fagundes & Wu 2021). Interviews with bereaved older adults 6–15 months post-loss reveal reduced appetite and decreased dietary variety due to the absence of shared meals or social motivation to cook (Vesnaver et al. 2016). Conversely, greater dietary diversity has been shown to protect against depression (Li et al. 2022). Thus, we hypothesize H3: Dietary diversity mediates the association between widowhood duration and depressive symptoms, with higher diversity associated with lower symptom severity.
Role theory suggests that gendered family roles influence how men and women respond to widowhood (Strohschein 2016). Some studies report stronger mental health impacts for widowed men, often due to their lesser involvement in caregiving and domestic activities prior to spousal loss (Förster et al. 2019; Yu et al. 2021). Others argue that women—especially those who are economically dependent on their spouses—face heightened psychological and financial vulnerability following widowhood (Chen et al. 2020). For some women, spousal loss may also reduce caregiving burdens, potentially offering relief from long-standing emotional strain (Peña-Longobardo et al. 2021). We therefore propose H4: Gender moderates the relationship between widowhood duration and depressive symptoms.
Although a substantial body of research has explored the association between marital status and depression, most studies have concentrated on short-term widowhood (≤ 5 years), leaving the long-term effects underexplored. To address this gap, our study extends the analysis to include widowhood durations of up to 10 years, using longitudinal marital status data from the 2008–2018 China Longitudinal Healthy Longevity Survey (CLHLS). While prior studies have examined dietary diversity, sleep, or gender differences individually, few have integrated these variables into a comprehensive mediation framework. This study addresses that gap by investigating gender-specific mediating pathways linking widowhood duration to depressive symptoms—thus offering a more nuanced understanding of how to better support the mental health of widowed older adults (Fig. 1).
Fig. 1.
Research hypothesis
Methods
Study population
This study employs a cross-sectional analytical framework based on data from the latest wave (2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). The CLHLS is a nationally representative prospective cohort study using a multistage stratified random sampling approach, covering approximately 85% of Chinese older adults aged 65 years and above across 631 counties in 23 provinces. Ethical approval for the survey was obtained (IRB00001052-13074), and all participants provided written informed consent.
To establish our analytical sample, we dynamically tracked marital status across four survey waves (2008, 2011, 2014, and 2018). Initially, the baseline sample in 2008 included 16,467 respondents. We then sequentially merged data from the subsequent follow-up waves (2011, 2014, and 2018), continuously updating each individual’s marital status information. This dynamic tracking process enabled us to categorize widowhood duration accurately based on observed transitions in marital status across these waves.
Our final analytical sample (N = 2008) was drawn from respondents who remained continuously in the cohort from 2008 through the 2018 wave. Although our dependent variable (depressive symptoms), mediators (sleep duration and dietary diversity), and covariates were all measured cross-sectionally at the 2018 endpoint, the primary independent variable—widowhood duration—was derived from this dynamic longitudinal tracking approach. Figure 2 illustrates this dynamically tracked longitudinal data structure, clearly presenting the progressive integration of marital status data across waves, leading to the cross-sectional analytical dataset used in this study.
Fig. 2.
Sample selection
Measurement
Dependent variable
Depressive symptoms were assessed using the 10-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) (Silverstein et al. 2006), which measures the frequency of depressive symptoms experienced over the past week. This scale has been widely used in epidemiological studies and has demonstrated strong reliability and validity among older Chinese adults (Chen & Mui 2014). Response options range from 0 (“no”) to 3 (“always”), with total scores ranging from 0 to 30. Higher scores indicate more severe depressive symptoms. The Cronbach’s α for the current sample was 0.81.
Independent variable
We categorized widowhood duration into five groups: (1) married (reference group), (2) widowed for 0–4 years, (3) widowed for 5–7 years, (4) widowed for 8–10 years, and (5) widowed for more than 10 years. Specifically, “widowed for 0–4 years” included those who were married in all preceding waves (up to 2014) but reported being widowed in the last wave (2018). “Widowed for 5–7 years” referred to participants who reported being widowed in both the 2014 and 2018 waves, thus indicating at least 5 years of widowhood by 2018. “Widowed for 8–10 years” included those reporting widowhood in 2011, 2014, and 2018. Finally, “widowed for more than 10 years” applied to participants who had already been widowed in 2008 (and all subsequent waves).
Sleeping hours and dietary diversity, serving as mediators in this study, were measured using data from the 2018 wave of CLHLS. Dietary diversity was assessed based on the frequency of consumption across nine food groups (e.g., vegetables, meat, dairy, fruits, legumes), using a scale adapted from Krebs-Smith et al. (1987). Food items consumed daily or weekly were scored as 1, and others as 0, yielding a total score ranging from 0 to 9. Higher scores reflected better dietary diversity. The Cronbach’s α for this measure was 0.84. Sleep duration was self-reported and reflected the average number of hours slept per night.
Although widowhood duration was dynamically tracked across multiple waves (2008–2018), the mediators (sleeping hours and dietary diversity) and depressive symptoms were contemporaneously measured at the 2018 wave. This design rests on the theoretical assumption that prolonged widowhood status accumulates stressors that subsequently affect older adults’ lifestyle behaviors, such as sleep quality and dietary patterns, measured at the endpoint (2018). Thus, assessing mediators and depressive symptoms concurrently in 2018 captures the accumulated effects of widowhood duration on current health behaviors and mental health status.
Covariates
Based on prior literature, we included several covariates from the 2018 wave: gender (1 = male, 2 = female), age, education (0 = illiterate, 1 = literate), place of residence (0 = urban, 1 = rural), monthly income, self-rated health (1 = very bad to 5 = very good), chronic illness, number of children, co-residence status (0 = lives alone, 1 = lives with others), physical exercise (0 = no, 1 = yes), and financial support from children (0 = no, 1 = yes). Functional status was assessed using the Instrumental Activities of Daily Living (IADL) scale (Lawton & Brody 1969), comprising 8 items scored from 0 to 2. Higher scores indicate greater functional independence. The Cronbach’s α was 0.72.
Statistical analyses
We applied sampling weights (w_2018) to account for survey design and to produce population-representative estimates. Weighted descriptive statistics were used to characterize the sample. Linear regression models were employed to assess the direct and indirect effects of widowhood duration on depressive symptoms. Mediation analyses tested whether dietary diversity and sleep duration mediated this relationship. The Bootstrap method with 5000 resamples was used to estimate the indirect effects. Mediation was considered significant if the 95% confidence interval of the indirect effect excluded zero.
Results
Descriptive analysis
The mean depressive symptom score was lowest among married individuals ( 6.78), significantly lower than that of all widowed groups (Table 1). Older adults widowed for 0–4 years reported the highest depressive symptom scores and the shortest average sleep duration ( 6.6 h), indicating heightened psychological distress and sleep disturbances during the early phase of widowhood. Dietary diversity scores remained relatively stable across widowhood durations, with all groups reporting an average score of approximately 4.
Table 1.
Descriptive characteristics of the study participants
| Married (N = 828) | 0–4 years (N = 175) | 5–7 years (N = 103) | 8–10 years (N = 127) | 10 years above (N = 775) | p-value | |
|---|---|---|---|---|---|---|
| Depressive symptoms | 6.78 ± 4.06 | 8.39 ± 4.92 | 7.75 ± 4.58 | 7.75 ± 4.36 | 7.86 ± 4.22 | <0.001 |
| Sleep duration | 7.23 ± 2.06 | 6.61 ± 1.88 | 7.10 ± 1.90 | 7.19 ± 2.37 | 7.28 ± 2.38 | <0.05 |
| Dietary diversity | 4.95 ± 2.02 | 4.70 ± 2.05 | 4.21 ± 1.93 | 4.45 ± 1.99 | 4.31 ± 2.03 | <0.001 |
| Age | 78.0 ± 4.17 | 79.5 ± 4.89 | 80.6 ± 4.97 | 81.2 ± 4.47 | 81.5 ± 5.34 | <0.001 |
| Gender | <0.001 | |||||
| Male | 515 (62.20%) | 70 (40%) | 35 (33.98%) | 29 (22.83%) | 152 (19.61%) | |
| female | 313 (37.80%) | 105 (60%) | 68 (66.02%) | 98 (77.17%) | 623 (80.39%) | |
| Education level | <0.001 | |||||
| Illiterate | 685 (82.73%) | 130 (74.29%) | 75 (72.82%) | 101 (79.53%) | 561 (72.39%) | |
| Non-illiterate | 143 (17.27%) | 45 (25.71%) | 28 (27.18%) | 26 (20.47%) | 214 (27.61%) | |
| Place of residence | 0.237 | |||||
| Rural | 391 (47.22%) | 81 (46.28%) | 39 (37.86%) | 47 (37.01%) | 363 (46.84%) | |
| Urban | 437 (52.78%) | 94 (53.72%) | 64 (62.14%) | 80 (62.99%) | 412 (53.16%) | |
| Monthly income (Log) | 9.98 ± 1.45 | 9.79 ± 1.55 | 9.61 ± 1.77 | 9.73 ± 1.98 | 10.05 ± 1.53 | <0.001 |
| Self-rated health | <0.05 | |||||
| Very poor | 10 (1.21%) | 2 (1.16%) | 2 (2.29%) | 1 (0.79%) | 16 (2.14%) | |
| Poor | 96 (11.64%) | 9 (5.23%) | 14 (13.94%) | 24 (19.05%) | 73 (9.77%) | |
| Average | 309 (37.45%) | 79 (45.93%) | 50 (49.31%) | 42 (33.33%) | 303 (40.70%) | |
| Good | 309 (37.45%) | 70 (40.70%) | 27 (26.42%) | 44 (34.92%) | 269 (36.19%) | |
| Very good | 101 (12.25%) | 12 (6.98%) | 8 (8.04%) | 15 (11.91%) | 83 (11.19%) | |
| Chronic illness | 1.61 ± 1.59 | 1.75 ± 1.72 | 1.24 ± 1.60 | 1.47 ± 1.52 | 1.29 ± 1.35 | 0.324 |
| IADL | 6.46 ± 2.36 | 6.09 ± 2.62 | 5.87 ± 2.65 | 5.43 ± 2.51 | 5.21 ± 2.85 | <0.001 |
| Physical exercise | <0.001 | |||||
| No | 507 (62.69%) | 107 (63.90%) | 65 (63.72%) | 85 (68.75%) | 452 (62.72%) | |
| Yes | 301 (37.31%) | 61 (36.10%) | 37 (36.28%) | 38 (31.25%) | 269 (37.28%) | |
| Co-residence status | ||||||
| Lives Alone | 827(99.88%) | 154 (88.05%) | 93 (90.65%) | 116 (91.24%) | 707 (91.29%) | |
| Lives With Others | 1(0.12%) | 21 (11.95%) | 10 (9.35%) | 11 (8.76%) | 68 (8.71%) | |
| Number of Children | 3.65 ± 1.53 | 4.27 ± 1.77 | 4.52 ± 2.13 | 4.30 ± 1.40 | 4.56 ± 1.86 | <0.001 |
| Financial support | <0.05 | |||||
| No | 210 (25.32%) | 53 (30.35%) | 25 (24.44%) | 23 (18.02%) | 179 (23.11%) | |
| Yes | 618 (74.68%) | 122 (69.65%) | 78 (75.56%) | 104 (81.98%) | 596 (76.89%) |
Table reported M ± SD/N (%), categorical variables were described with N (%), and continuous variables were described with M ± SD. -value represented the correlation analysis between variables and widowhood duration
Direct effect of widowhood duration on depressive symptoms among older adults
Model 3 (Table 2) estimates the total effect of widowhood duration on depressive symptoms and reveals a significant positive association. The strongest association is observed among those widowed for 0–4 years ( 1.847), suggesting that psychological distress is most acute during the early stage of bereavement. Model 4 incorporates sleep duration and dietary diversity alongside widowhood duration and finds that widowhood remains significantly associated with depressive symptoms, indicating a lasting mental health impact. Additionally, both sleep duration and dietary diversity are negatively associated with depressive symptoms.
Table 2 .
Effects of dietary diversity, sleep duration, and widowhood duration on depressive symptoms
| Outcome variables | ||||
|---|---|---|---|---|
| Dietary diversity (Model 1) | Sleep duration (Model 2) | Depressive symptoms (Model 3) | Depressive symptoms (Model 4) | |
| Widowhood duration (reference group = married) | ||||
| 0–4 years |
− 0.116 [− 0.463, 0.230] |
− 0.311 [− 0.715, 0.093] |
1.847*** [1.122, 2.572] |
1.673*** [0.983, 2.363] |
| 5–7 years |
− 0.435 [− 0.883, 0.013] |
− 0.094 [− 0.616, 0.428] |
1.264** [0.327, 2.200] |
1.055* [0.163, 1.947] |
| 8–10 years |
− 0.396 [− 0.795, 0.002] |
0.166 [− 0.299, 0.630] |
1.164** [0.331, 1.997] |
1.078*** [0.284, 1.872] |
| More than 10 years |
− 0.551*** [− 0.761, − 0.341] |
0.303*** [0.058, 0.547] |
1.278*** [0.840, 1.716] |
1.188*** [0.767, 1.609] |
| Dietary diversity |
− 0.390*** [− 0.482, − 0.298] |
|||
| Sleep duration |
− 0.414*** [− 0.492, − 0.335] |
|||
| Covariates | Yes | Yes | Yes | |
Bold: ***p<0.001, **p<0.01, *p<0.05 (two-sided)
(1) All models were adjusted by age, gender, education level, place of residence, monthly income, self-rated health, chronic illness, IADL, physical exercise, financial support, co-residence status, and number of children. (2) The results reported coefficient and 95% CI based on Process in SPSS software
Mediation effect of sleeping duration and dietary diversity
Widowhood duration exceeding 10 years is significantly associated with reduced dietary diversity but increased sleep duration. In contrast, shorter durations (0–4, 5–7, 8–10 years) show no significant associations with either mediator (Models 1 and 2). After including the mediators, the effect of widowhood (especially 10 years) on depressive symptoms remains positive but attenuated, indicating potential mediation or suppression (Model 4). Specifically, dietary diversity mediates 16.8% of the total effect between long-term widowhood and depressive symptoms (Table 3). Sleep duration exhibits a suppression effect, accounting for 9.8% of the total effect—suggesting that longer sleep partially offsets the adverse psychological impact of prolonged widowhood.
Table 3 .
Indirect effects of widowhood duration on depressive symptoms
| Widowhood → dietary diversity → depressive symptoms | Widowhood → sleep hours → depressive symptoms | |
|---|---|---|
| Widowhood duration (reference group = married) | ||
| 0–4 years | 0.045 [− 0.096, 0.192] | 0.129 [− 0.038, 0.309] |
| 5–7 years | 0.170 [− 0.004, 0.342] | 0.039 [− 0.178, 0.252] |
| 8–10 years | 0.155 [− 0.005, 0.327] | − 0.069 [− 0.289, 0.151] |
| More than 10 years | 0.215 [0.123, 0.323] | − 0.125 [− 0.230, − 0.025] |
Bold: ***p<0.001, **p<0.01, *p<0.05 (two-sided)
(1) All models were adjusted by age, gender, education level, place of residence, monthly income, self-rated health, chronic illness, IADL, physical exercise, financial support, co-residence status, and number of children. (2) The results reported coefficient and 95% CI based on Process in SPSS software
For shorter durations of widowhood, neither dietary diversity nor sleep duration demonstrates statistically significant mediating or suppressing effects, though the direction of effects mirrors those seen in the > 10-year group. This implies that within the first 10 years of spousal loss, these lifestyle factors may not yet exert consistent or measurable influence on depressive symptoms. Among men widowed for more than 10 years, dietary diversity mediates 30.4% of the total effect, while among women, sleep duration suppresses 32.8% of the effect. These results highlight the differentiated pathways through which widowhood affects mental health across duration and gender (Appendices 1–4).
Discussion
To our knowledge, this is the first study explicitly examining the mediating roles of sleeping hours and dietary diversity in the relationship between widowhood duration and depressive symptoms among Chinese older adults. By focusing on this vulnerable group, the study enhances public understanding and underscores the need for improvements in primary healthcare services.
Consistent with our initial hypothesis (H1), we identified a significant positive association between widowhood duration and depressive symptoms, with the strongest psychological impact found during the initial 0–4 years of widowhood. This result aligns closely with existing literature indicating intense emotional distress and psychological vulnerability immediately after widowhood (Fagundes and Wu 2021; Kristiansen et al. 2019; Zheng and Yan 2024). However, our findings further demonstrate that adverse psychological effects remain substantial beyond 10 years of widowhood, highlighting the chronic nature of widowhood as a persistent stressor. This finding aligns well with previous research indicating prolonged exposure to stressors can lead to cumulative health deterioration and persistent depressive symptoms, consistent with the wear-and-tear hypothesis articulated in stress theory (Yu et al. 2021; Li 2007; Bi et al. 2021).
Regarding the mediation mechanisms (H2 and H3), we found significant mediating effects of dietary diversity and sleep duration only among individuals who experienced widowhood exceeding 10 years. One plausible explanation lies in the gradual depletion of marital resources over extended periods, as articulated by the marital resource model. In shorter widowhood durations, older adults may initially leverage coping strategies or social support networks, temporarily buffering against the negative impact on dietary and sleep patterns. Over the longer term, however, persistent social isolation, diminishing motivation for maintaining healthy lifestyles, and cumulative stress may substantially degrade dietary quality and disrupt sleep, resulting in more pronounced and detectable mediation effects on mental health (Freak-Poli et al. 2025; Tao et al. 2020; Li et al. 2023a, b).
Second, the chronic stress associated with prolonged widowhood may induce physiological changes (e.g., chronic inflammation or hormonal dysregulation), indirectly influencing health behaviors such as appetite and sleep, leading to greater susceptibility to depressive symptoms (Pasqualini et al. 2024). Third, older adults might increasingly neglect healthy lifestyle behaviors as widowhood prolongs due to the lack of shared meals or sleep routines that previously existed within marital relationships, thereby accentuating the mediating effects of dietary and sleep patterns on mental health (Fagundes & Wu 2021).
Moreover, our findings underscore notable gender differences (H4), highlighting that dietary diversity mediated depressive symptoms specifically in men, whereas sleep duration exerted a suppression effect for women. These gendered differences are consistent with role theory, suggesting men traditionally less involved in domestic tasks face greater dietary challenges following spousal loss, thereby significantly affecting their mental health (Del Río Lozano et al. 2017). Conversely, for women, prolonged widowhood might relieve them of caregiving roles, enabling better sleep patterns over time, thus partially buffering depressive symptoms, echoing prior findings (August 2022).
This selective mediation in long-term widowhood contrasts with previous studies primarily focusing on short-term widowhood effects. For instance, Noguchi et al. (2022) identified immediate dietary disruption following widowhood, whereas our study extends these findings by demonstrating that sustained dietary impairment becomes particularly influential over prolonged widowhood durations. Similarly, the relationship between improved sleep duration and mental health in long-term widowed women adds nuance to existing research emphasizing short-term sleep disturbances post-bereavement (Lancel et al. 2020; Wu et al. 2021).
This study focuses on older adults who remained continuously in the CLHLS from 2008 to 2018, which may introduce selection bias by excluding those who died or were lost to follow-up—potentially underestimating the impact of widowhood on more vulnerable individuals. Additionally, although widowhood duration was dynamically tracked, depressive symptoms and mediators were measured only in 2018, limiting the analysis to a cross-sectional design. While suitable for comparing different durations of widowhood at a fixed point, this approach restricts causal inference and overlooks changes over time. Future research could adopt fully longitudinal models or apply multiple imputation to address attrition and capture the dynamic effects of widowhood on mental health.
Based on the findings, several policy implications emerge. First, newly widowed older adults may benefit from targeted emotional support by family caregivers. Second, promoting balanced nutrition—such as through enriched meals—may improve mental health, though the feasibility of community canteens warrants further testing via pilot programs. Third, community-based health education can support older adults in developing and maintaining healthy eating habits.
Conclusion
This study examines the associations between widowhood duration, sleep duration, dietary diversity, and depressive symptoms among older adults. The results show that longer widowhood duration is linked to higher levels of depressive symptoms, with the most pronounced effects occurring within the first 0–4 years of bereavement. Furthermore, dietary diversity mediates the relationship between long-term widowhood (> 10 years) and depressive symptoms among men, whereas sleep duration serves as a mediator among women. These findings deepen our understanding of how the duration of widowhood affects mental health and highlight the need for tailored interventions for both recently and long-term widowed individuals. They also emphasize the relevance of dietary interventions, particularly for those widowed over a decade.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contribution
YM wrote the main manuscript text. JP, RW, ZL, and QL reviewed the manuscript.
Availability of data and materials
On reasonable request, these data may be made available from the corresponding author.
Declarations
Ethical approval and consent to participate
A written informed consent form was signed by each participant prior to being surveyed. The CLHLS data collection was approved by the Research Ethics Committee of Peking University (IRB00001052-13074).
Consent to publish
Not applicable.
Conflicts of interest
The authors declare no conflicts of interest.
Footnotes
This work was supported by the Suzhou University Humanities and Social Sciences Research Project [25XM1007].
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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