Sedentary behavior and psychological distress among Chinese rural older adults: the role of spouse loss and physical exercise

Abstract

Background

The moderating role of spouse loss and physical exercise remains understudied in the sedentary behavior - psychological distress relationship. We aimed to explore the association between sedentary behavior and psychological distress, as well as the role of spouse loss and physical exercise in this association among rural older adults.

Methods

The data came from the wave 3 of Shandong Rural Elderly Health Cohort (SREHC). A total of 3,235 rural older adults were included in the analysis. The linear regression model and marginal effects analysis were performed to examine the association of sedentary behavior with psychological distress, and the moderating effect of spouse loss and physical exercise in this association.

Results

After adjusting the confounders, sedentary behavior was significantly associated with psychological distress among rural older adults (β = 0.202, P < 0.001). Spouse loss may modify the relationship between sedentary behavior and psychological distress (β = 0.210, P = 0.033) and physical exercise also moderate this relationship (β = -0.265, P = 0.011).

Conclusions

Our findings highlighted that spouse loss and physical exercise moderated the association between sedentary behavior and psychological distress among Chinese rural older adults. These findings highlight the need to pay greater attention to older adults who have experienced spouse loss, and suggest that promoting physical exercise could be considered as a supportive approach to alleviate psychological distress associated with sedentary behavior in rural China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06478-4.

Introduction

Psychological distress in late life is a major public health issue, which is defined as a state of negative emotional suffering [1]. In China, it is estimated that over a third of older people were at risk of severe psychological distress, with a higher prevalence in rural than that in urban areas [2]. Rural residents are more likely to have lower socioeconomic status, reduced social participation and have less access to health services [3, 4]. Limited resources and opportunities may bring disadvantage in different life stages and further incur harmful consequences for mental health in later life. Previous research demonstrated that psychological distress was related to dementia, disability and mortality [5–7]. Psychological distress influences an individual’s physical health and also has an adverse effect on their well-being and life satisfaction [8]. Identifying potential influencing factors and the pathways to psychological distress are essential to improve mental health among rural older adults.

Unhealthy lifestyle was found to elevate the likelihood of psychological distress [9]. Sedentary behavior is particularly prominent in older adults and render them more susceptible to adverse health outcomes [10]. Older population is the most sedentary group, spending more than 60% of their awake time in a seated position [11]. Previous research further indicated that sedentary behavior was correlated with psychological distress based on a sample of adults [12]. To our knowledge, only a handful of preceding studies have assessed this association between sedentary behavior and psychological distress in older adults [13]. Therefore, we presume that the relationship between sedentary behavior and psychological distress still holds among older people in rural China. But the potential factors underlying this relationship also remains unclear. Examining the underlying mechanism on sedentary behavior and psychological distress may have crucial implications for health policy and public health.

Loss of marital role due to divorce or widowhood is a distressing life events and an inevitable transition in later life [14], which may reduce quality of life and general well-being [15]. A substantial body of evidence has indicated the health-regulatory functions of marital status. Precious study in Korea has investigated a significant association between spousal loss and sedentary behavior in later life, whereby older people experienced spousal loss reported more sedentary behavior [16]. Older people with spouse loss were particularly vulnerable to the negative effects of unhealthy behaviors [14]. Marital transitions may also diminish mental health. A previous study has demonstrated that older adults with spouse loss has greater levels of psychological distress than married group [17]. Theoretically, the relationship between marital status and health was usually approached from two perspectives, consisting of marital resource model and crisis model. The marital resource model emphasizes that married individuals may benefit from greater economic resources and social support, which are associated with maintaining health in later life [18]. The spouse is a resource of social regulation of health, and encourage and monitor each other to engage in healthy behaviors to boost health [19]. Compared with peers, married people are more likely to live longer and have lower incidence of health problems [20, 21]. According to crisis model, marital dissolution undermines health through entailing significant strains [18, 22, 23]. Spouse loss increases unhealthy behavior and poses health risks [14]. Compared to never-married and married, divorced and widowed individuals were more likely to be disadvantaged in mental health [19]. However, the role of spousal loss was rarely considered in earlier literature examining the link between sedentary behavior and psychological distress.

As a modifiable lifestyle, physical exercise is an effective approach to actively deal with population ageing and has been shown to closely associate with physical and mental health of individuals [24]. Distraction theory proposes that physical exercise may divert an individual’s attention from stressful events and painful stimulus to improve mood [25, 26]. Based on the cognitive behavioral theory, doing exercise may increase the confidence in one’s ability in physical exercise and further promote perceptions of physical ability, which in turn to spend more time in exercise [26]. Such positive thoughts and feelings may counteract negative ones and enhance mental health, as well as contribute to a healthy lifestyle. Some evidence supported that physical exercise might relieve psychological distress via improving psychological resilience [27]. People who engaged in physical exercise tend to have higher level of psychological health [28]. A body of research has found that physical exercise was strongly related to reduction in sedentary duration, namely, as the time spent in physical exercise increases, the duration of sedentary time decreases [29, 30]. While the association between physical exercise and psychological distress has been confirmed, the modifying role of physical exercise in the relationship between sedentary behavior and psychological distress remains unclear in rural older adults.

Despite growing evidence on the mental health risks associated with sedentary behavior among older adults, limited research has examined the potential moderating roles of spouse loss and physical exercise in rural Chinese contexts. Based on the abovementioned theoretical framework and empirical research, this research seeks to investigate the association between sedentary behavior and psychological distress, as well as to explore the moderating effects of spouse loss and physical exercise among rural older adults in China. We put forward the following hypotheses: (1) sedentary behavior is positively related to psychological distress; (2) the association between sedentary behavior and psychological distress would be stronger among those who had experienced spouse loss; and (3) physical exercise would buffer the negative impact of sedentary behavior on psychological distress. The conceptual moderation model is illustrated in Fig. 1. Gaining insight into the role of spouse loss and physical exercise in the association between sedentary behavior and psychological distress will provide scientific evidence about psychological distress prevention and active ageing.

Fig. 1.

Hypothesized moderation models. Notes: Model 1: testing the moderating effect of spousal loss on the effect of sedentary behavior on psychological distress. Model 2: testing the moderating effect of physical exercise on the effect of sedentary behavior on psychological distress

Materials and methods

Sample and study design

The present study used cross-sectional data from the second follow-up of the Shandong Rural Elderly Health Cohort (SREHC), conducted between July and August 2022 in Shandong Province. A total of 3,468 individuals aged 60 and above participated in the survey. The SREHC employed the multistage stratified random sampling strategy to ensure a representative sample. First, based on 2018 per capita GDP, all counties in Shandong were grouped into three economic tiers, from which one county was randomly selected per group. The final study counties—Rushan, Qufu, and Laoling—represented high, medium, and low economic levels, respectively [31]. Within each selected county, five townships were randomly chosen, followed by the random selection of four villages per township. Older residents aged 60 or above were then randomly recruited from each village.

Trained interviewers conducted face-to-face interviews using standardized questionnaires to ensure data reliability. Participants were eligible if they (1) were permanent residents aged 60 or older who had resided in the village for at least six months in the past year, and (2) provided informed consent and were cognitively capable of completing the interview independently. Participants were excluded from the study if they were unable to communicate clearly in Chinese, had been diagnosed with dementia or other psychiatric disorders, or expressed unwillingness to cooperate with the interview process. The data cleaning, analysis, and manuscript preparation were conducted between April and May 2024. For this study, we excluded those participants who was proxy-reported (n = 217) and who had missing information on key variable (n = 16). Eventually, 3,235 eligible older adults were included in our analysis. A detailed sample selection process is illustrated in Figure S1.

Measurements

Psychological distress

Psychological distress was measured using the 10-item Kessler Psychological Distress Scale (K10) [32], which has good reliability and validity [33]. The K10 included ten items characterized by depression and anxiety. Items scored on a 5-point scale from 1 (“none of the time”) to 5 (“all of the time”). The total score of the K10 ranged from 10 to 50, with higher scores indicating greater psychological distress. Several studies conducted in China have also supported the appropriateness of the K10 for use among older adults [34, 35]. In the present analysis, the scale exhibited the good reliability and validity with a Cronbach’s alpha of 0.907 and a KMO value of 0.921.

Sedentary behavior

Respondents were asked to recall the daily time spent in a sedentary position for each specified activity in the previous week. The activities include sitting at desk, using a computer, watching TV, traveling by motor vehicle or public transport, socializing, reading and other sedentary behaviors. In our analysis, sedentary behavior was measured using the total time spent on the above activities as a continuous variable in line with prior study [36].

Spouse loss

In this study, spouse loss was assessed with a dichotomous indicator by the question “What is your current marital status?”. If the answer was “divorced” or “widowed”, this was defined as “1 = yes” [31].

Physical exercise

Physical exercise was assessed based on participants’ self-reported frequency and duration of physical activity. Following previous studies and in accordance with national physical exercise guidelines [37, 38], we constructed a binary variable: participants were coded as 1 if they reported engaging in physical exercise at least three times per week and for at least 30 min each time. Those who did not meet both criteria were coded as 0.

Control variables

Several correlates of psychological distress were included as control variables in the analysis. The present study contained age, gender, education (illiteracy/primary school/middle school or above), household income per capita, living arrangement (non-empty-nest seniors/empty-nest seniors). Household income per capita was divided into four categories by quartiles. Of which, Q1 represented the lowest economic status group and Q4 represented the highest. In addition, the potential confounders also included current smoking status (yes/no), current drinking status (yes/no) and chronic conditions. Chronic conditions were measured by the number of self-reported chronic diseases and categorized as none, one chronic condition and multimorbidity.

Statistical analysis

Stata 15.0 (Stata Corp, College Station, TX, USA) were employed for statistical analysis and P < 0.05 (two-tailed) was considered statistically significant. Firstly, the mean (standard deviation) or frequency (percentage) was applied to describe the basic characteristics of the respondents. Subsequently, we carried out hierarchical multiple linear regression model to explore the association between sedentary behavior and psychological distress. Model 1 only included the sedentary behavior adjusting for all covariates. Model 2 further tested the association between sedentary behavior and psychological distress when two moderation variables was added. Then, we included the interaction terms (sedentary behavior × spouse loss and sedentary behavior ×physical exercise) in the regression model separately to test moderating effects of spouse loss and physical exercise. In addition, we used marginal effects analysis to illustrate the prediction of psychological distress by sedentary behavior, spouse loss, and physical exercise.

Ethics statement

The protocol for this study was approved by the Ethical Committee of School of Public Health, Shandong University (approval number, 20181228). We obtained the written informed consents from each respondents stating the study purposes, value, methods, and potential risks before the survey.

Results

Characteristics of participants

Table 1 showed the descriptive statistics about main study variables. Among the 3,235 respondents, mean age was 72.42 ± 5.91 years. The majority of participants were female (60.00%) and had the education status of primary school or below (78.39%). The mean times of sedentary behavior was 5.95 ± 2.64 h and the mean score of psychological distress was 15.42 ± 6.72. Of all respondents, 22.07% and 79.20% reported experiencing spouse loss and participating in physical exercise regularly, respectively.

Table 1.

Characteristics of rural older adults in Shandong, China, 2022 (N = 3,235)

Characteristics	N (%)
Age (years), mean (SD)	72.42 (5.91)
Gender
Male	1,294 (40.00)
Female	1,941 (60.00)
Education level
Illiterate	1,244 (38.45)
Primary school	1,292 (39.94)
Middle school and above	699 (21.61)
Household income per capitaa
Q1	809 (25.01)
Q2	811 (25.07)
Q3	807 (24.95)
Q4	808 (24.98)
Living arrangement
Non-empty-nest seniors	513 (15.86)
Empty-nest seniors	2,722 (84.14)
Chronic conditions
None	489 (15.12)
One chronic condition	855 (26.43)
Multimorbidity	1,891 (58.45)
Current smoking status
No	2,555 (78.98)
Yes	680 (21.02)
Current drinking status
No	2,410 (74.50)
Yes	825 (25.50)
Spouse loss
No	2,521 (77.93)
Yes	714 (22.07)
Physical exercise
No	2,271 (70.20)
Yes	964 (29.80)
Sedentary behavior (hours/day), mean (SD)	5.95 (2.64)
K10 scoreb, mean (SD)	15.42 (6.72)

^aQ1 was the poorest and Q4 was the richest

^bK10, Kessler Psychological Distress Scale

Association between sedentary behavior and psychological distress

The results of the hierarchical multiple linear regression analysis are displayed in Table 2. In Model 1, the degree of psychological distress was correlated to increased time of sedentary behavior (β = 0.232, P < 0.001). After adding possible moderators in Model 2, sedentary behavior was still significantly associated with psychological distress (β = 0.202, P < 0.001).

Table 2.

Association between sedentary behavior and psychological distress among rural older adults in Shandong, China, 2022 (N = 3,235)

Variables	Model 1 (without moderators)			Model 2 (with moderators)
	β	P-value	95% CI	β	P-value	95% CI
Sedentary behavior	0.232	< 0.001	0.145, 0.318	0.202	< 0.001	0.115, 0.289
Spouse loss (reference = No)				0.852	0.004	0.265, 1.439
Physical exercise (reference = No)				−1.059	< 0.001	−1.554, −0.565
Age	0.005	0.804	−0.034, 0.044	−0.016	0.457	−0.056, 0.026
Gender (reference = Male)	0.729	0.012	0.161, 1.297	0.570	0.052	−0.005, 1.145
Education (reference = Illiterate)
Primary school	−0.861	0.001	−1.385, −0.338	−0.791	0.003	−0.315, 0.268
Middle school and above	−1.919	< 0.001	−2.578, −1.260	−1.876	< 0.001	−2.534, −1.218
Household income per capita (reference = Q1)
Q2	−0.737	0.024	−1.375, −0.099	−0.763	0.019	−1.400, −0.125
Q3	−0.924	0.005	−1.568, −0.279	−0.952	0.004	−1.595, −0.309
Q4	−1.570	< 0.001	−2.222, −0.917	−1.569	< 0.001	−2.219, −0.919
Living arrangement (reference = Non-empty-nest seniors)	−1.173	< 0.001	−1.798, −0.548	−1.030	0.001	−1.662, −0.397
Chronic conditions (reference = None)
One chronic condition	0.998	0.007	0.274, 1.722	1.015	0.006	0.293, 1.736
Multimorbidity	2.536	< 0.001	1.876, 3.195	2.525	< 0.001	1.868, 3.182
Current smoking status (reference = No)	0.455	0.143	−0.154, 1.063	0.393	0.205	−0.215, 1.000
Current drinking status (reference = No)	−0.920	0.002	−1.516, −0.325	−0.952	0.002	−1.546, −0.359

The moderating role of spouse loss and physical exercise in the relationship between sedentary behavior and psychological distress

In Table 3, our findings indicated that spouse loss and physical exercise moderated links between sedentary behavior and psychological distress, respectively. Specifically, compared with the older adults without spouse loss, those with spouse loss had higher risk of psychological distress due to sedentary behavior (β = 0.210, P = 0.033). In order to show more visually the marginal effect of sedentary behavior in different spousal loss status, it can be seen in Fig. 2. Furthermore, if older adults participated in physical exercise, they were less likely to experience psychological distress even the more sedentary behavior (β = −0.265, P = 0.011). For a more visual representation of the marginal effects of sedentary behavior in different physical exercise situations, it can be seen in Fig. 3.

Table 3.

The interaction effects of sedentary behavior with spouse loss and physical exercise on psychological distress among rural older adults in Shandong, China, 2022 (N = 3,235)

Variables	Model 1 (Spouse loss as a moderator)			Model 2 (Physical exercise as a moderator)
	β	P-value	95% CI	β	P-value	95% CI
Sedentary behavior	0.148	0.004	0.048, 0.248	0.262	< 0.001	0.164, 0.361
Spouse loss (reference = No)	0.821	0.006	0.234, 1.409	0.817	0.006	0.229, 1.404
Physical exercise (reference = No)	−1.031	< 0.001	−1.526, −0.536	−1.168	< 0.001	−1.669, −0.667
Sedentary time × Spouse loss	0.210	0.033	0.017, 0.403
Sedentary time × Physical exercise				−0.265	0.011	−0.471, −0.060
Age	−0.016	0.456	−0.057, 0.026	−0.016	0.452	−0.057, 0.025
Gender (reference = Male)	0.564	0.054	−0.010, 1.139	0.576	0.050	0.001, 1.150
Education (reference = Illiterate)
Primary school	−0.795	0.003	−1.319, −0.272	−0.798	0.003	−1.321, −0.275
Middle school and above	−1.876	< 0.001	−2.534, −1.219	−1.862	< 0.001	−2.520, −1.204
Household income per capita (reference = Q1)
Q2	−0.735	0.024	−1.373, −0.098	−0.786	0.016	−1.423, −0.149
Q3	−0.938	0.004	−1.581, −0.295	−0.933	0.004	−1.575, −0.290
Q4	−1.525	< 0.001	−2.176, −0.875	−1.550	< 0.001	−2.199, −0.900
Living arrangement (reference = Non-empty-nest seniors)	−1.037	0.001	−1.669, −0.405	−1.034	0.001	−1.666, −0.402
Chronic conditions (reference = None)
One chronic condition	1.024	0.005	0.303, 1.745	0.995	0.007	0.274, 1.716
Multimorbidity	2.548	< 0.001	1.891, 3.205	2.515	< 0.001	1.858, 3.171
Current smoking status (reference = No)	0.380	0.220	−0.227, 0.987	0.387	0.211	−0.220, 0.994
Current drinking status (reference = No)	−0.944	0.002	−1.537, −0.351	−0.927	0.002	−1.520, −0.334

Fig. 2.

Interaction between sedentary behavior and spousal loss in the prediction of psychological distress

Fig. 3.

Interaction between sedentary behavior and physical exercise in the prediction of psychological distress

Discussion

This study examined the relationship between sedentary behavior and psychological distress among rural older adults and highlighted the moderating roles of spouse loss and physical exercise for the first time. Our study found that sedentary behavior was significantly associated with psychological distress among rural older adults, and that this association was intensified by spouse loss but mitigated by physical exercise.

The present study confirmed Hypothesis 1 by showing that sedentary behavior was positively associated with psychological distress among rural older adults, consistent with previous findings [12]. According to the displacement hypothesis, sedentary behavior might be at the expense of more active pursuits such as physical activity and other hobbies, which was shown to positively impact on mental health [39]. Biologically, large amounts of sedentary time have been found to altered cerebral blood flow, poor brain metabolism and decreased in serotonin, impacting negatively on psychological health [40]. As such, the greater the duration of sedentary time, the more likely psychological distress are experienced.

Consistent with Hypothesis 2, our results demonstrated that spouse loss significantly moderated the relationship between sedentary behavior and psychological distress. Spousal relationship is the most intimate and special relationships, which is protective for individual in the whole life [17]. Previous studies claimed that spouse loss disrupted social connectedness through losing a vital source of social support and inhibiting participation in community activities [41]. This transition in social relationship may loss passion for life and reduce life satisfaction [41], which increase unhealthy behaviors and further aggravate psychological distress [42, 43]. Based on the stress and coping theories, healthy lifestyle decreases the vulnerabilities of individuals to the negative influence of stress [44]. Spouse loss is the most stressful events in life, and unhealthy lifestyle like sedentary behavior may contribute to increase perceived stress and aggravate psychological distress [12, 45]. Furthermore, older adults with spouse loss tend to be more likely to have lower household income and fall into poverty [46], which restricted access to resources to maintain a healthy lifestyle and aggravate anxiety and depression in later life. Thus, spouse loss could increase the possibility of older adults with sedentary behavior suffering from psychological distress.

Our results confirmed Hypothesis 3, suggesting that physical exercise serves as a protective factor that mitigates the detrimental association between sedentary behavior and psychological distress. A body of evidence has demonstrated that physical exercise played a crucial role in breaking up prolonged sitting and improving adverse impact associated with sedentary behavior [30]. Several possible reasons are as follows. First, from a biological perspective, physical exercise contributes to positive mood and well-being through acting on hypothalamic–pituitary–adrenal axis and the sympathetic nervous system, as well as minimizing excessive inflammation [47]. Second, physical exercise also increases social participation and social interaction of older adults. During the physical exercise, older adults can share interest and goals as well as increase friendly conversation with participants, which help to reduce the willingness of sitting and mitigate the potential effects of sedentary behavior [48, 49]. Third, physical exercise has been proven to improve psychological resilience, which is essential in reducing anxiety and depression and protecting mental health in older people [50]. Physical exercise for older people may reinforce their ability to overcome challenges of daily life and to cope with stressful events, and induce positive psychological improvements [51]. Therefore, participating in physical exercise appears to decrease the opportunities to be sedentary and mitigate the adverse psychological health challenges and emotional suffering from sedentary behavior.

The findings of this study have important practical implications for policy-making and community-based interventions. A first powerful strategy might be to develop health education about “move more and sit less” and emphasize the adverse effect of sedentary behavior on older adults. Then, local governments and community committees should complete public service facilities and encourage older adults to participate in physical exercise according to their physical condition and interests. Moreover, it is also necessary to pay more attention to older adults suffered from spouse loss. Specifically, adult children and friends spend more time and patience on older person with spouse loss, and neighbors can visit more often with older people to sustain friendships and supportive connections. Moreover, promoting accessible and culturally appropriate physical exercise programs within rural communities may serve as an effective strategy to mitigate psychological distress. Policymakers and healthcare providers are encouraged to integrate psychological counseling and physical exercise promotion into existing older care services to enhance mental well-being.

Several limitations of the present study should be taken into account when construing the findings. Firstly, the inference of a causal relationship between sedentary behavior and psychological distress is limited by cross-sectional data. Secondly, although we collected information on sedentary time, sedentary activities and the company of children and friends were not available for analysis, which deserves further study in the future. Finally, sedentary behavior was measured using self-reports, which may introduce recall bias and measurement error. Future studies employing objective measures (e.g., accelerometers) are warranted to validate these findings, and longitudinal research is needed to further explore the temporal associations between sedentary behavior and psychological distress among older adults in rural China. It is worthwhile to examine the type of sedentary behavior and their influences on psychological distress, as well as the role of other loss experiences and frequency and duration of physical exercise in this association.

Conclusion

Our study provides a distinctive contribution to the available literature on sedentary behavior and psychological distress. The findings revealed that rural older adults with sedentary behavior were more likely to report psychological distress. Moreover, spouse loss was associated with a higher level of psychological distress in this group, while physical exercise appeared to be linked with lower levels of distress. The application of our findings may assist in health promotion activities to encourage older adults engage in physical exercise as an alternative to sedentary behavior. Moreover, it is appropriate that pay more attention to the lifestyle and social interaction among older adults with spouse loss, in order to improve psychological health.

Authors’ contributions

Study concept and design: CZ. Acquisition of data: CZ SC, XW, XW, JL, JL TG and DZ. Analysis and interpretation of data: SC, XW, XW, JL and JL. Drafting of the manuscript: SC. Critical revision of the manuscript for important intellectual content: CZ, DZ and TG. All authors reviewed the manuscript. And all authors have approved the submitted version of this manuscript and agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Funding

This work was supported by the National Science Foundation of China (grant numbers 72274109, 71774104, 71974117). The study sponsor has no role in study design, data analysis and interpretation of data, the writing of manuscript, or the decision to submit the paper for publication.

Data availability

The datasets used in the current study are not publicly available due to them containing information that could compromise research participant privacy but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The protocol for this study was approved by the Ethical Committee of School of Public Health, Shandong University (approval number, 20181228). We obtained the written informed consents from each respondents stating the study purposes, value, methods, and potential risks before the survey. All procedures were in accordance with the ethical standards of the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.