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. 2021 May 7;8(6):3566–3574. doi: 10.1002/nop2.906

The mediating effect of self‐efficacy on the relationship between family functioning and quality of life among elders with chronic diseases

Yuan Yuan 1,3, Hui‐wen Xu 1,3, Song Zhang 1, Ying Wang 2, Akio Kitayama 3, En Takashi 3, Wei‐juan Gong 1,✉, Jing‐yan Liang 4
PMCID: PMC8510730  PMID: 33960735

Abstract

Aim

To explore whether self‐efficacy has any positive or negative mediating effects between family functioning and quality of life among elders with chronic diseases.

Design

A cross‐sectional study.

Methods

Questionnaires were collected from 516 community‐dwelling elderly individuals with chronic diseases using a convenience sampling method. The questionnaires included the Self‐efficacy for Managing Chronic Disease Six‐Item Scale, the Family Adaptation Partnership Growth Affection Resolve Index and the MOS 36‐Item Short Form Health Survey.

Results

Family functioning and self‐efficacy impacted the quality of life of community‐dwelling elderly individuals with chronic diseases. Family functioning was mediated by self‐efficacy and had an indirect impact on quality of life. The mediating effect accounted for 62.50% of the total effect.

Keywords: chronic diseases, elders, family functioning, quality of life, self‐efficacy

1. INTRODUCTION

With the ageing of the global population, the number of community‐dwelling elderly individuals with chronic diseases is increasing (Sun et al., 2019; Zhou et al., 2016). It was reported that the four most common non‐communicable chronic diseases (NCDs) among elderly individuals were cancer, diabetes, cardiovascular disorders and lung disease. The four major NCDs and a handful of other chronic conditions were responsible for two‐thirds of mortality globally in 2016 (Nugent, 2019). In China, the Study of Global AGEing and Adult Health (SAGE)‐China Wave 1 cross‐sectional study reported that half of the elderly individuals in China had at least one chronic illness (Zhao et al., 2018). In 2015, the China Family Development Report (2015) released by the National Health and Family Planning Commission showed that half of all elderly people were living without children (Croll et al., 2019), and the proportion was higher in rural areas than in urban areas; additionally, their family functioning was poor. Because of the characteristics of chronic diseases in the elderly population, such as long disease duration, difficult self‐healing, complex aetiology, many complications, and high cost of treatment, coupled with retirement syndrome and other family and social factors, physical and psychological diseases are common in the elderly population and seriously affect patients's quality of life (Botes et al., 2018; Maresova et al., 2019). Additionally, chronic diseases place a heavy burden on the family and society, attracting the focus of medical services (Nurchayati et al., 2019; Wu et al., 2019).

Bandura defined self‐efficacy as the conviction that one can successfully execute the behaviour required to produce an outcome (Bandura, 1977). In other words, self‐efficacy is the perceived confidence that a person has the ability to accomplish something. Self‐efficacy is thought to be an important factor in initiating and maintaining physical activity and is therefore believed to improve quality of life through its effects on both positive affect and negative affect (Hager et al., 2019; Lee et al., 2016; Yeung & Lu, 2014). Previous studies have verified that self‐efficacy has certain influences on the quality of life of patients with chronic diseases (Du et al., 2018; Selzler et al., 2020; Zhang, Gilmour, et al., 2020; Zhang, Xue, et al., 2020). Lee's study demonstrated that self‐efficacy, anxiety and depression play major roles in determining the perception of quality of life in cancer patients (Lee et al., 2016). Omran's research showed that health‐related quality of life in patients with type 2 diabetes is related to self‐efficacy, self‐care activities and health literacy (Omran & McMillan, 2018).

Family is the core of society and provides not only material support but also spiritual and emotional support. Family functioning, in which the family is regarded as a system, refers to interactions with family members that involve physical, emotional, and psychological activities and affects many aspects of family life (Wang et al., 2015; Wei et al., 2020). Family functioning plays a crucial role in the growth of individuals, and if the family does not operate in such a way that it performs its basic functions, family members will have a variety of problems (Zhang, Gilmour, et al., 2020; Zhang, Xue, et al., 2020). In recent years, nursing professionals have expanded the focus of their attention from the patient alone to the patient and the family (Fjortoft et al., 2020). Good family support has a major impact on the patients' recovery from disease and on the improvement of self‐efficacy and quality of life (Konradsen et al., 2018). Previous studies have shown that family functioning can improve self‐efficacy (Puspasari et al., 2018; Wu & Sheng, 2019). Additionally, previous studies have demonstrated that family functioning has certain influences on the quality of life of patients with chronic diseases (Andrade et al., 2020). For example, Azmoude's paper showed that good family functioning associated with better quality of life in diabetics (Azmoude et al., 2016).

In Summary, previous studies have shown that family functioning has been separately associated with self‐efficacy and quality of life. Additionally, self‐efficacy has been found to be a major variable that affects the quality of life of patients with chronic diseases. Self‐efficacy may be involved in the psychological mechanism underlying the relationship between family functioning and quality of life in people with chronic diseases. However, to the best of our knowledge, no study has been conducted with a focus on the mediating effects of self‐efficacy between family functioning and quality of life in community‐dwelling elderly individuals with chronic diseases. Thus, the research questions of this study were as follows: (a) What are the levels of family functioning, self‐efficacy and quality of life among elderly individuals with chronic diseases? (b) What are the relationships among family functioning, self‐efficacy and quality of life? (c) To what extent, if at all, does self‐efficacy mediate the association between family functioning and quality of life in community‐dwelling elderly individuals with chronic diseases?

2. METHODS

2.1. Participants and sampling

Elderly individuals from different communities in Jiangsu Province (eastern China), Yunnan Province (southwestern China), Hunan Province (central China) and Shanxi Province (northern China) were selected by convenience sampling. The inclusion criteria were as follows (Kuhirunyaratn et al., 2019): (a) community‐dwelling people aged 60 years and older; (b) the presence of one or more chronic diseases such as hypertension or diabetes or others; and (c) ability to communicate normally and cooperate with investigation and evaluation. The exclusion criteria were as follows: (a) participants with obvious mental disorders or obvious cognitive impairment; and (b) participants with acute respiratory, circulatory or digestive diseases or injuries. Verbal informed consents were obtained from all participants, and they could withdraw from the study at any time.

2.2. Measurements

2.2.1. Questionnaire on sociodemographic characteristics

The questionnaire was designed by the researchers themselves and included sociodemographic characteristics and general features of their diseases (type of disease, duration of disease, etc.).

2.2.2. Self‐efficacy for managing chronic disease 6‐item scale (SECD6)

The SECD6 was created by Lorig (Lorig et al., 2001) and includes 6 items in total. Each item has 10 response categories ranging from ‘No confidence at all’ (1 point) to ‘With absolute confidence’ (10 points); thus, the average item score ranges from 1–10, where higher average scores indicate better self‐efficacy. The Chinese version of SECD6 has good internal consistency with a Cronbach's alpha of 0.91 (Jiang et al., 2020).

2.2.3. Family adaptation, partnership, growth, affection and resolve (APGAR) index

The APGAR index was designed by Good according to the characteristics of family functioning. The APGAR includes five items: adaptation, partnership, growth, affection and resolve. All of the items are positive items, and each one includes three options: often = 2, sometimes = 1, and almost never = 0. Total scores on this scale can range from 0–10; a score of 0–3 indicates severe family dysfunction, 4–7 indicates moderate family dysfunction, and 8–10 indicates good family functioning. The Chinese version of the APGAR has been used widely in China, and it has been found to have good validity and reliability (Sun et al., 2011).

2.2.4. MOS 36‐Item short form health survey (SF‐36)

The SF‐36, translated by the School of Medicine, Zhejiang University, includes 36 items (Dong et al., 2017). The score conversion formula is as follows: conversion score = (actual score − the lowest possible score in this aspect)/(the difference between the highest possible score and the lowest possible score in this aspect) × 100. The higher the score, the better the quality of life. The scale consists of nine dimensions: general health, physiological function, role physiological, body pain, role emotional, mental health, vitality, social function and health transition. The scale can be divided into two subscales: the physical component summary and the mental component summary. The Cronbach's alpha values for the internal consistency reliability were 0.72 and 0.88, respectively. The 2‐week test–retest reliability coefficients were 0.66 and 0.94, respectively (Hsu et al., 2018). The mental component summary includes vitality, social function, role emotional and mental health. The physical component summary includes physiological function, role physiological, body pain and general health. The total score on the SF‐36 is the sum of all items except health transition.

2.3. Data collection

Data were collected from 01 January–31 December 2019. After training and passing an examination, five nursing students began to conduct the investigation. Investigators went to community meeting sites or participants' homes, explained the purposes and methods of the study to the elderly individuals and then sent out questionnaires with their consent. While meeting face to face with the elderly participants, the researchers explained the meaning of each item clearly, and the participants could ask the researchers questions at any time if they could not understand the questionnaire. A total of 519 questionnaires were sent out. However, there questionnaires had unanswered questions and therefore invalid. Thus, a total of 516 valid questionnaires were collected, for an effective rate of 99.42%.

2.4. Data analysis

Data were analysed using SPSS 20.0 and AMOS 20.0. Frequencies and descriptive statistics were used to describe the data. Pearson correlation analysis was used to verify the correlations among the participants' self‐efficacy, family functioning and quality of life. A structural equation model was applied to determine the intermediary effects of self‐efficacy between family functioning and quality of life, and statistical significance was defined as p < .05.

2.5. Ethical consideration

The study was reviewed and approved by the Ethics Committee of School of Nursing, Yangzhou University (YZUHL2019001). The study was carried out in compliance with the tenets of the Declaration of Helsinki. Verbal informed consents were obtained from all participants. All personal information was encrypted.

3. RESULTS

3.1. Sociodemographic characteristics, self‐efficacy, family functioning and quality of life of the participants

A total of 516 community‐dwelling elderly people took part in this study; the sociodemographic characteristics of the respondents are presented in Table 1. The distribution of participants' chronic disease types is presented in Figure 1.

TABLE 1.

Distribution of respondents' sociodemographic characteristics (N = 516)

Characteristics Observation (N) Percentage (%)
Gender
Female 255 49.42
Male 261 50.58
Age group (years)
60–69 207 40.12
70–79 210 40.70
80 and above 99 19.19
Education level
Illiterate or barely literate 192 37.21
Primary school 156 30.23
Junior high school 87 16.86
Senior high school or technical secondary school 42 8.14
Junior college diploma or higher 39 7.56
Residence
Urban residents 165 31.98
Rural residents 264 51.16
Urban–rural fringe area 87 16.86
Current living conditions
Living alone 54 10.47
With spouse 279 54.07
With children and grandchildren 180 34.88
With others 3 0.58
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FIGURE 1.

FIGURE 1

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Distribution of participants' chronic disease types

The average scores for self‐efficacy and family functioning were 6.219 ± 2.059 and 8.035 ± 2.248, respectively. The average scores for general health, physiological function, role physiological, body pain, role emotional, mental health, vitality and social function were 55.878 ± 17.937, 68.576 ± 26.470, 61.773 ± 44.293, 74.581 ± 20.036, 72.674 ± 40.500, 68.256 ± 17.384, 66.337 ± 16.720 and 47.929 ± 11.879, respectively. The average scores for the physical component summary and the mental component summary were 260.808 ± 88.584 and 255.196 ± 72.876, respectively. The average total score for the 8 dimensions was 516.004 ± 151.884, and the average health transition score was 48.256 ± 21.517.

3.2. Correlation analysis of the participants' self‐efficacy, family functioning and quality of life

The results of the correlation analysis of self‐efficacy, family functioning and the quality of life of the community‐dwelling elders with chronic diseases are shown in Table 2. All variables were positively correlated and had statistical significance (all p < .01).

TABLE 2.

Correlation analysis of self‐efficacy, family functioning and the quality of life of the community‐dwelling elders with chronic diseases

SECD6 APGAR General health Physiological function Role physiological Body pain Role emotional Mental health Vitality Social function Physical component summary Mental component summary SF‐36
SECD6 1
APGAR 0.462** 1
General health 0.625** 0.320** 1
Physiological function 0.605** 0.355** 0.518** 1
Role physiological 0.507** 0.247** 0.526** 0.584** 1
Body pain 0.416** 0.347** 0.477** 0.523** 0.487** 1
Role emotional 0.431** 0.382** 0.425** 0.581** 0.694** 0.392** 1
Mental health 0.515** 0.394** 0.446** 0.509** 0.436** 0.370** 0.562** 1
Vitality 0.543** 0.330** 0.531** 0.524** 0.484** 0.431** 0.516** 0.762** 1
Social function 0.474** 0.342** 0.499** 0.644** 0.531** 0.587** 0.551** 0.591** 0.610** 1
Physical component summary 0.655** 0.373** 0.728** 0.814** 0.891** 0.723** 0.695** 0.544** 0.604** 0.692** 1
Mental component summary 0.564** 0.438** 0.546** 0.670** 0.687** 0.501** 0.898** 0.822** 0.797** 0.750** 0.768** 1
SF‐36 0.653** 0.428** 0.687** 0.796** 0.850** 0.662** 0.836** 0.712** 0.735** 0.763** 0.952** 0.928** 1
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Abbreviations: APGAR, Family Adaptation, Partnership, Growth, Affection and Resolve; SECD6, Self‐efficacy for Managing Chronic Disease 6‐item Scale.

**

p < .01.

3.3. Analysis of the mediating effects of self‐efficacy

In order to test whether self‐efficacy mediated the relationship between family functioning and quality of life, regression analysis was employed. The first step evaluated whether family functioning (as an independent variable) predicted quality of life (as a dependent variable). The second step tested the relationships between family functioning (as an independent variable) and self‐efficacy (a mediator). In step 3, when self‐efficacy was induced in the model, family functioning was found to have a significant impact on quality of life. The results are all displayed in Table 3. The mediation model is displayed in Figure 2, and the model was demonstrated to fit well by the following indicators: goodness‐of‐fit index (GFI) = 0.978, adjusted goodness‐of‐fit index (AGFI) = 0.964, standardized root mean square residual (SRMR) = 0.026, root mean square error of approximation (RMSEA) = 0.038, normal fit index (NFI) = 0.985, and incremental fit index (IFI) = 0.993. Similarly, the results regarding whether self‐efficacy is a mediator of the relationship between family functioning and the physical component summary or mental component summary are shown in Tables 4 and 5. The mediation models are displayed in Figure 3 and both models were demonstrated to fit well: GFI = 0.968 and 0.977, AGFI = 0.954 and 0.944, SRMR = 0.036 and 0.040, RMSEA = 0.037 and 0.039, NFI = 0.965 and 0.971, and IFI = 0.983 and 0.984, for the physical component summary and mental component summary, respectively. The results showed that self‐efficacy played a partial intermediary role between family functioning and quality of life, and the ratio of intermediary effects to total effects was calculated as 0.462 × 0.579/0.428 × 100% = 62.500%. Additionally, self‐efficacy played a partial intermediary role between family functioning and both the physical component summary and the mental component summary, the ratios of intermediary effects to total effects were calculated as 0.462 × 0.614/0.373 × 100% = 76.050% and 0.462 × 0.461/0.438 × 100% = 48.626%, respectively.

TABLE 3.

The mediating effects of self‐efficacy on family functioning and quality of life

Step Independent variable Dependent variable Adjusted R 2 F β t p
Step1 Family functioning Quality of life .181 115.014 0.428 10.724 <.01
Step2 Family functioning Self‐efficacy .212 139.425 0.462 11.808 <.01
Step3 Family functioning Quality of life .444 206.918 0.160 4.325 <.01
Self‐efficacy 0.579 15.632 <.01
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FIGURE 2.

FIGURE 2

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Mediation model of the effects of self‐efficacy on the relationship between family functioning and quality of life. **p < .01

TABLE 4.

The mediating effects of self‐efficacy on family functioning and physical component summary

Step Independent variable Dependent variable Adjusted R 2 F β t p
Step1 Family functioning Physical component summary .138 83.193 0.373 9.121 <.01
Step2 Family functioning Self‐efficacy .212 139.425 0.462 11.808 <.01
Step3 Family functioning Physical component summary .433 197.886 0.090 2.401 .017
Self‐efficacy 0.614 16.406 <.01
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TABLE 5.

The mediating effects of self‐efficacy on family functioning and mental component summary

Step Independent variable Dependent variable Adjusted R 2 F β t p
Step1 Family functioning Mental component summary .190 121.675 0.438 11.031 <.01
Step2 Family functioning Self‐efficacy .212 139.425 0.462 11.808 <.01
Step3 Family functioning Mental component summary .356 143.265 0.225 5.635 <.01
Self‐efficacy 0.461 11.554 <.01
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FIGURE 3.

FIGURE 3

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Mediation model of the effects of self‐efficacy on the relationship of family functioning with physical component summary or mental component summary. *p < .05, **p < .01

4. DISCUSSION

In this study, a total of 333 elderly individuals were ‘living alone’ or ‘living with their spouses’; that is, the proportion of participants living without children was 64.53% (higher than shown by national data), which may be related to the growing proportion of elderly individuals living without children and the large rural population in this study. In this study, the top four chronic disease types were hypertension (300, 58.14%), osteoarthropathy (195, 37.79%), hyperlipidemia (132, 25.58%) and chronic gastrointestinal diseases (132, 25.58%). Although the study was carried out in communities and inpatients were not included, the incidence of each type of chronic disease was still high. Hypertension and other chronic diseases have a high incidence in the elderly population in China. If the situation cannot be resolved properly and in time, it will lead to serious social and economic problems (Cao et al., 2017; Zhao et al., 2018).

In this study, the participants' average SECD6 score was 6.219 ± 2.059, which is at a moderate value and indicates that the self‐efficacy of the participants needs to be improved. This result was similar to that of a previous study (Fan & Lv, 2016). The average APGAR score was 8.035 ± 2.248, indicating that family functioning was relatively good. The average total score on the eight main dimensions of the SF‐36 was 516.004 ± 151.884, which was consistent with a study in China showing that the quality of life of elderly individuals based on the community nursing model was higher than the quality of life of elderly individuals based on the family and institutional nursing model. This may be because there was no strict separation between community nursing and family nursing in this study and because the basic characteristics of the participants were slightly different.

Self‐efficacy refers to people's subjective judgment and inner experience of whether they can successfully complete a certain behaviour. Quality of life is determined by an individual's physiological function, psychological status and other factors (Tuluce & Kutluturkan, 2018). In this study, self‐efficacy and quality of life were positively correlated and had a significant relationship. Research by Chirico et al. (2017) showed a positive relationship between self‐efficacy for coping with cancer and quality of life. Additionally, research findings from Son and Won (2017) demonstrated that the self‐efficacy of elderly patients with hypertension could affect their quality of life directly and could act as an intermediary variable influencing the effects of other variables on quality of life. The results of these prior studies were in accordance with the results of the present study.

In a study of the relationship between family functioning and quality of life, researchers found that people with better family functioning had higher quality of life, and correlation analysis showed that quality of life and family functioning had a strong positive correlation (Lu et al., 2017). This means that the low family functioning of elderly patients with chronic diseases was an important factor affecting their quality of life. In the present study, family functioning had a significant positive correlation with each dimension of quality of life, which was in agreement with the previous research results. Caregiving by family members has an extremely important impact on the quality of life of elderly individuals.

In this study, there was a statistically significant between self‐efficacy and family functioning. It is suggested that caregivers should help patients establish a systematic social and family support network and pay additional attention to family members, especially spouses and children, to help them participate in patients' disease management. Doctors and nurses can teach family members how to care for patients properly and can give supervision and full support in terms of emotion and action, which plays an extremely important role in improving patients' self‐efficacy, prolonging the stable period of disease and promoting patients' recovery.

To test the intermediary effects of self‐efficacy between family functioning and quality of life, we can use the intermediary effects test procedure summarized by Wen (Wen & Fan, 2015). If self‐efficacy has intermediary influences on family functioning and quality of life, the following three conditions should be met: (a) family functioning (as an independent variable) significantly predicts quality of life (as a dependent variable); (b) family functioning (as an independent variable) significantly predicts self‐efficacy (as an intermediary variable); and (c) family functioning and self‐efficacy jointly predict quality of life. When self‐efficacy (the intermediary variable) is added, if the influences of family functioning on quality of life are not significant, the intermediary variable shows a full intermediary effect, and if the influences of family functioning on quality of life are significant, the intermediary variable shows a partial intermediary effect. We found that self‐efficacy played a partial mediating role between family functioning and quality of life according to the above conditions, and the ratio of mediating effects to total effects was 62.500% in this study. Similarly, self‐efficacy also played a partial mediating role between family functioning and both the physical component summary and mental component summary, and the ratios of mediating effects to total effects were 76.050% and 48.626%, respectively. The proportions of the mediating effects of self‐efficacy were relatively large, especially between family functioning and the physical component summary. The findings suggested that higher family functioning was associated with more positive self‐efficacy, which, in turn, was associated with better quality of life. This finding demonstrated that effective family functioning can improve the ability of community‐dwelling elderly patients with chronic diseases to cope with their disease and control their emotions; additionally, it is conducive to cultivating the self‐efficacy of the patients. A strong sense of self‐efficacy can strengthen elderly people's capacity for self‐attribution and self‐adjustment, enabling them to take note of the combination of internal and external factors, which plays an important role in the health management of chronic diseases. Self‐efficacy can mobilize the subjective initiative of the patients so that they fully participate in self‐management of the disease, which is of great significance in improving their quality of life. Consequently, self‐efficacy, as a mediator, plays a key role in the process of behaviour change and is an important factor in maintaining and improving quality of life.

4.1. Strengths

To the best of our knowledge, this is the first representative analysis of the mediating effect of self‐efficacy in the association between family functioning and quality of life in community‐dwelling elderly individuals with chronic diseases. In addition, a variety of statistical methods (descriptive analysis, Pearson's correlation analysis and structural equation modelling) were employed to investigate the relationship among family functioning, self‐efficacy and quality of life.

4.2. Limitations

This study has a few limitations. First, we used a cross‐sectional design, with data being collected at only one point in time. Therefore, the study could not identify the changes and trends over time and, as such, might provide weak evidence of correlations among self‐efficacy, family functioning and quality of life. Second, the convenience sample may not be representative of the targeted population, and the results may be biased. In the future, we need to expand the sample size and use stratification and random sampling to enrich the research results and make them more representative.

5. CONCLUSION

This study demonstrated that family functioning, self‐efficacy and quality of life are closely related in community‐dwelling elderly individuals with chronic diseases. Family functioning, with self‐efficacy as the intermediary, has certain impacts on quality of life. This suggests that medical and health personnel should increase their focus on the indirect impacts of family functioning in the care process of community‐dwelling elderly patients with chronic diseases to enhance the patients' self‐efficacy and improve their quality of life.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AUTHOR CONTRIBUTIONS

Yuan Yuan and Hui‐wen Xu contributed equally to this work. Wei‐juan Gong and Jing‐yan Liang contributed equally to this work. Yuan Yuan, Hui‐wen Xu, Wei‐juan Gong and Jing‐yan Liang : Study design, study conduction, collection and analysis of data and manuscript draft preparation. Akio Kitayama and En Takashi: Data collection, statistical analysis and manuscript draft preparation. Song Zhang, Ying Wang: Data collection. All authors read and approved the final manuscript.

ACKNOWLEDGEMENT

The authors would like to thank the participants for their supports in making this study possible.

Yuan Y, Xu H‐W, Zhang S, et al. The mediating effect of self‐efficacy on the relationship between family functioning and quality of life among elders with chronic diseases. Nurs Open. 2021;8:3566–3574. 10.1002/nop2.906

Funding information

This work was supported by the National Natural Science Foundation of China (81570392); the National Key R&D Program of China (2016YFE0126000); the National 2018 local universities science, education, culture and health introduction project – high‐end foreign experts project (GDW20183200386); the Key R&D projects of Yangzhou (YZ2020097) and the Open project of Key Laboratory of zoonosis in Jiangsu Province (HX20014).

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

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