INTRODUCTION
According to Statistics Korea [1], Korea will become a super-aged society by 2025, with the proportion of adults aged ≥65 years projected to reach 20%, and continue to increase. As life expectancy increases, older adults commonly face physical and mental health challenges, making the promotion of healthy and meaningful aging a key public health priority [2,3]. Quality of life (QoL) is a subjective evaluation of an individual's overall well-being. In the revised Wilson and Cleary model, Ferrans et al.[4] identified self-rated health status as a direct determinant of health-related QoL, a finding supported by previous studies [5,6]. Self-rated health status integrates physiological, psychological, and functional perceptions that cannot be captured using objective indicators alone [4].
Previous domestic and international studies identified several determinants of self-rated health status in older adults, including sex, age, marital status, family status, presence of chronic diseases, smoking, and regular physical activity [7-11]. These results suggest that self-rated health status reflects a comprehensive subjective evaluation that integrates sociodemographic, socioeconomic, health-related, and behavioral factors. Furthermore, depression [7,9-12], social activities [7,11,12], and subjective social status [5,8] have been identified as key determinants of self-rated health status.
Depression is a key factor shaping the subjective health status of older adults, influencing not only emotional wellbeing, but also physical, cognitive, and social functioning [10,13]. In old age, experiences such as bereavement, reduced social roles, isolation, and accumulation of chronic illnesses can heighten vulnerability to depressive symptoms, which in turn diminish individuals’ evaluations of their own health [14]. Notably, previous research has shown that even among older adults with comparable physical health conditions, those with higher levels of depressive symptoms consistently rate their health more negatively than their less-depressed counterparts [15]. This pattern suggests that subjective health perceptions are deeply intertwined with psychological states, beyond the influence of objective health indicators. Therefore, depression represents a critical psychological determinant of subjective health status and should be carefully addressed when seeking to enhance older adults’ overall well-being and QoL.
Notably, social activities have been reported to have a more substantial impact on self-rated health status than on physical health [12]. Older adults who actively participate in social activities tend to perceive their subjective health positively and report higher health satisfaction [16]. Social activities promote interactions with others and foster a sense of belonging, self-esteem, and purpose in life, serving as psychological buffers that help individuals perceive themselves as healthy [17,18]. Consequently, active social participation encourages health-promoting behaviors such as regular outings, balanced nutrition, and physical activity, thereby enhancing self-efficacy and ultimately improving subjective health perception.
Subjective social status refers to an individual's perception of their socioeconomic position within society, reflecting not only objective indicators such as income, education, and occupation, but also personal evaluations in comparison with others [18]. Subjective social status captures a person's relative social position by integrating both material circumstances and psychological perceptions, serving as an important measure for understanding how social inequality affects health, well-being, and QoL [8,19,20]. Individuals who perceive their social position as relatively higher tend to evaluate their health more positively, suggesting that subjective social status is associated not only with health perception but also with overall life satisfaction [8,20].
Previous research has shown that both emotional factors, such as depression, and social factors influence subjective health status [5,7-12]. Greater engagement in social activities was associated with lower levels of depressive symptoms and better self-rated health status [11]. Furthermore, depression itself is powerfully shaped by social environment and resources, as documented in previous studies [21]. Given that depression is closely intertwined with social conditions, it is plausible that social variables, such as participation in social activities and subjective social status, may buffer or exacerbate the impact of depression on subjective health status. Therefore, we hypothesized that social activity and subjective social status may serve as moderating factors in the relationship between depression and subjective health status in older adults.
This study aimed to examine the effect of depression on self-rated health status among adults aged ≥65 years and to assess the moderating effects of key social variables, thereby providing foundational evidence for developing nursing interventions aimed at improving subjective health. The following hypotheses were developed:
• Hypothesis 1. Higher levels of depression will be associated with poorer self-rated health status among older adults.
• Hypothesis 2. Higher levels of formal social activity will be associated with better self-rated health status among older adults.
• Hypothesis 3. Higher levels of subjective social status will be associated with better self-rated health status among older adults.
• Hypothesis 4. Formal social activity will moderate the association between depression and self-rated health status.
• Hypothesis 5. Subjective social status will moderate the association between depression and self-rated health status.
METHODS
1. Study Design
This descriptive cross-sectional study was conducted using data from the 9th Korean Longitudinal Study on Aging (KLoSA). Based on the revised Wilson and Cleary model proposed by Ferrans et al. [4], the theoretical framework of this study was developed by focusing on the pathway from symptoms (depression) to general health status (self-rated health status) and by examining the moderating roles of formal social activity and subjective social status in this relationship.
2. Study Participants
The KLoSA is a biennial panel survey, initiated in 2006, that provides foundational data for developing socioeconomic policies in response to Korea's transition to a super-aged society. The survey targeted adults aged ≥45 years residing in Korea (excluding Jeju Island) and used a stratified sampling method based on the 2005 Population and Housing Census. Households were randomly sampled from 1,000 sample survey districts selected based on regional population distribution. The 9th wave, completed in 2022, was used in this study, and individuals aged <65 years (n=1,566) and those with missing data on key variables (n=4) were excluded using a complete-case analysis approach (Figure 1).
3. Measurements
1) Demographic characteristics
Age, gender, final education, marital status, and employment status were used as the demographic characteristics. Age was divided into 65 to 74 years old, 75 to 84 years old, and 85 years old or older [22]. Educational level was classified as elementary or lower, middle school, high school, or higher. Marital status was categorized by the presence of a spouse and employment status according to current employment.
2) Health status characteristics
The number of chronic diseases was calculated by adding the total number of chronic conditions diagnosed, including hypertension, diabetes, cancer, chronic pulmonary disease, liver disease, heart disease, cerebrovascular disease, and rheumatoid disease. The number of chronic diseases was categorized into three groups based on the count of diagnosed chronic conditions: no disease (0), single disease (1), and multiple (≥2).
Activities of daily living (ADL) were assessed based on the past week using seven items: dressing, washing one's face, bathing, eating, mobility, toilet use, and bowel and bladder control. Each item evaluated whether the participant was able to perform the activity independently or required partial or complete assistance from another person [23]. Based on previous studies [24], each item was scored as 1 when partial or complete assistance was required and 0 otherwise. Total scores were then dichotomized: 0 indicated "no difficulty in daily life," and ≥1 indicated "difficulty in daily life."
3) Health-related behaviors
This study analyzed various health-related behaviors, including smoking, alcohol use, exercise routines, and medical checkups within past 2 years. Smoking use was categorized into two groups: those who did not smoke (encompassing individuals who had never smoked and former smokers) and current smokers. Similarly, alcohol consumption was divided into non-drinkers (including lifelong abstainers and those who stopped drinking) and current drinkers. Regular physical activity was defined as the participation in exercise at least once per week. Preventive health practices were assessed by determining whether individuals had undergone a free basic health check within the past two years.
4) Subjective social status
Subjective social status was measured using a single-item question asking respondents, "Where do you think your socioeconomic status belongs?" Responses were recorded on a reverse-coded 6-point scale (1=low to 6=high), with higher scores indicating a higher perceived status.
5) Formal social activities
Formal social activities were assessed by adding participation across seven groups (e.g., religious, social, leisure/sports, alumni/hometown, volunteer, political/civic, and other associations). Based on previous studies [25], each group was scored as 1 (yes) or 0 (no), producing a total score ranging from 0 to 7, with higher scores indicating greater social engagement.
6) Depression
Depression was assessed using the Korean version of the CES-D 10 [26]. Participants reported how often they had experienced specific feelings during the past week on a 4-point scale (1=rarely to 4=most of the time). Two positive items were reverse-coded, and the total scores were summed, with higher scores indicating greater depressive symptoms. Cronbach's ⍺ was .91 in the original validation [26] and .78 in this study, demonstrating good internal consistency.
7) Self-rated health status
Self-rated health status was assessed using the question, "How would you rate your own health?" using a 5-point scale. In this study, based on a previous study [27], to increase statistical power and the accuracy of interpretations, responses were reverse-coded. Then they recatego-rized into a binary variable: "Very poor" and "Poor"=0 (poor health), and "Fair," "Good," and "Very good"=1 (good health).
4. Statistical Analysis
Participants’ general and health-related characteristics were summarized using descriptive statistics, presenting unweighted counts (N) and weighted percentages to reflect the population distribution. Differences in self-rated health status were examined using survey-weighted x2 tests, and statistical significance was determined using p-values. For logistic regression analyses, statistical significance was assessed based on whether the 95% confidence intervals (CIs) of the odds ratios included the value of 1.
To identify factors associated with self-rated health status, survey-weighted hierarchical multiple logistic regression analyses were performed. Model 1 included sociodemographic and health-related variables (gender, age, education level, marital status, employment status, number of chronic diseases, activities of daily living, smoking, alcohol drinking, regular exercise, and regular medical checkups), as well as depression. In Model 2, Formal social activity and subjective social status were added to Model 1.
To examine the moderating effects of formal social activity and subjective social status on the association between depression and self-rated health status, interaction terms (depression × formal social activity and depression × subjective social status) were added separately to Model 2, and weighted logistic regression models were fitted. Conditional effects (simple slopes) of depression on self-rated health status were estimated at the mean and ±1 standard deviation levels of the moderators to facilitate interpretation of the moderation effects.
All analyses were conducted using R (version 4.4.1), taking into account the complex survey design, which includes stratification, clustering, and sampling weights.
RESULTS
Women accounted for the largest proportion (56.2%) of the study population aged 65 years and older. Most were aged 65∼74 years (58.1%) and had a high school education level or higher (41.9%). Most of the participants lived with their spouses (69.2%) and were not employed (72.8%). A large proportion of patients reported having two or more chronic diseases (45.9%) and no difficulty with ADL (94.6%). Additionally, most participants were non-smokers (92.5%), non-drinkers (73.2%), did not engage in regular exercise (51.2%), and had undergone a medical checkup within the past two years (84.3%).
1. Self-rated Health Status by Participants’ Characteristics
Analysis of self-rated health status across sociodemographic, socioeconomic, health status, and health-related behavioral characteristics showed statistically significant differences by gender (p<.001), age (p<.001), education level (p<.001), marital status (p<.001), employment status (p <.001), the number of chronic disease (p <.001), ADL (p<.001), smoking status (p=.012), alcohol drinking status (p<.001), exercise (p<.001), and medical checkup within the past two years (p<.001) (Table 1).
Table 1.
Differences in Self-rated Health Status according to Characteristics (N=4,487)
2. Influencing Factors for Self-rated Health Status
In Model 1, compared with older adults aged 65∼74 years, the likelihood of reporting good self-rated health status was lower among those aged 75∼84 years (odds ratio [OR]=0.77, 95% CI=0.65 to 0.92) and those aged ≥85 years (OR=0.50, 95% CI=0.37 to 0.67). Individuals with ADL limitation were less likely to report good self-rated health status than those without (OR=0.34, 95% CI=0.21 to 0.54). Compared to those without chronic disease, participants with a single chronic disease (OR=0.53, 95% CI=0.43 to 0.64) or multiple chronic diseases (OR=0.35, 95% CI= 0.29 to 0.42) were less likely to report good self-rated health status. Higher levels of depression were associated with lower odds of reporting good self-rated health (OR= 0.94, 95% CI=0.92 to 0.97). Conversely, older adults with a high school education or above were more likely to report good self-rated health status than those with an elementary school education or below (OR=1.23, 95% CI=1.01 to 1.49). Participants who engaged in regular exercise were also more likely to report good self-rated health status than those who did not engage in regular exercise (OR= 1.24, 95% CI=1.05 to 1.45). In Model 2, formal social activity and subjective social status —key study variables—were added to Model 1. Higher levels of formal social activity (OR=1.42, 95% CI=1.29 to 1.56) and higher subjective social status (OR=1.57, 95% CI=1.45 to 1.71) were also associated with increased odds of reporting good self-rated health status. However, the association between regular exercise and self-rated health status was no longer statistically significant after the inclusion of formal social activity and subjective social status in Model 2. Accordingly, Hypotheses 1∼3 were supported, demonstrating significant associations between depression, formal social activity, subjective social status, and self-rated health status (Table 2).
Table 2.
Factors Influencing Self-rated Health Status (N=4,487)
ADL=activities of daily living; CI=confidence interval; OR=odds ratio; ref.=reference; SRH=self-rated health-status; SSS=subjective social status. The variance inflation factor values of the variables in Model 2 ranged from 1.02 to 1.24. All models were analyzed using complex-sample multiple logistic regression.
3. Moderating Effect of Formal Social Activity
In the third step (Model 3-1), which included the interaction term between depression and formal social activity, the model fit significantly improved (Wald x2=9.75, p= .002). Formal social activity moderated the relationship between depression and self-rated health status. Although the predicted probability of reporting good self-rated health status decreased as depression increased across all levels of formal social activity, the rate of decline differed depending on the level of formal social activity. At low level of formal social activity (mean [M]-1 standard deviation [SD]), the slope associated with depression was the steepest (B=-0.09, 95% CI: −0.13 to −0.05), whereas at high level of formal social activity (M+1 SD), the association was attenuated and not statistically significant (B=-0.01, 95% CI: −0.05 to 0.02) (Table 3). A similar pattern was observed in the interaction plot (Figure 2), indicating differential slopes of depression across levels of formal social activity. These findings are consistent with Hypothesis 4, suggesting that the association between depression and self-rated health status varies according to levels of formal social activity.
4. Moderating Effect of Subjective Social Status
In the third step (Model 3-2), which included the interaction term between depression and subjective social status, the model fit significantly improved (Wald x2=9.32, p=.002). Although the predicted probability of reporting good self-rated health status decreased as depression increased across all subjective social status levels, the decline rate differed depending on the subjective social status level. At low subjective social status (Mean −1 SD), the slope associated with depression was the steepest (B= −0.10, 95% CI: −0.14 to −0.06), whereas at high subjective social status (Mean +1 SD), the slope was the most gradual (B=-0.01, 95% CI: −0.05 to 0.02) (Table 4). A similar pattern was observed in the interaction plot (Figure 3), indicating differential slopes of depression across levels of subjective social status. These findings are consistent with Hypothesis 5, suggesting that the association between depression and self-rated health status varies according to levels of subjective social status.
DISCUSSION
This study identified several key factors that influence self-rated health status among older adults. Advancing age, ADL limitations, presence of chronic diseases, and higher levels of depression were associated with lower odds of reporting good self-rated health status. In contrast, greater participation in formal social activities and higher subjective social status were associated with more favorable self-rated health perception. This study's main findings were that higher levels of formal social activity and subjective social status functioned as moderators in the association between depression and self-rated health status. Especially among individuals with higher levels of formal social activity and higher subjective social status, the slope of depression in relation to self-rated health status was attenuated and not statistically significant.
In this study, the self-rated health status of community-dwelling older adults aged ≥65 years was 2.15 out of 5, which is lower than the average of 2.80 reported in the 8th wave of the Korean Longitudinal Study of Aging [28] and an average of 2.74 from the Survey of Health, Ageing, and Retirement in Europe conducted among adults aged ≥50 years [13]. These results indicate that older adults in this study perceived their self-rated health status as more negative. This may be partly explained by the timing of the data collection—the 9th wave of the KLoSA was conducted in 2022 during the COVID-19 pandemic. Previous research has shown that prolonged social distancing, increased depression and anxiety, and lifestyle changes related to indoor living during the pandemic contributed to a 29.4% worsening in self-rated health status among older adults [29]. Given that self-rated health status was identified as a predictor of mortality in a systematic review [30], more in-depth research on how older adults perceive their health in the post-pandemic context is warranted.
In this study, younger age, the absence of difficulties in performing ADLs, and fewer chronic diseases were associated with higher odds of reporting good self-rated health status. These findings are consistent with previous studies indicating that younger age [8,10,11,31] and fewer chronic conditions [7,10,11,31] have a higher likelihood of reporting good self-rated health status. Altogether, these results suggest that self-rated health status is influenced by a complex interplay of physical, sociodemographic, socioeconomic, and behavioral factors, not by physical status alone. Therefore, high-risk groups, such as the oldest old and those with multiple chronic diseases, should be prioritized in intervention programs to enhance self-rated health status in community-dwelling older adults.
A significant association was observed between formal social activity and self-rated health status. This finding is consistent with previous research, which has reported that individuals with higher levels of social activity perceive their health more positively [7,11,17]. Szwarcwald et al. [28] demonstrated that social distancing during the COVID-19 pandemic was significantly associated with a deteriorating self-rated health status. Notably, Dawson-Townsend [17] found that only those who actively participated in both formal and informal social activities maintained a significantly higher self-rated health status, even after controlling for other variables. Given that the level of social participation among community-dwelling older adults likely declined after the COVID-19 pandemic, there is a need to strengthen intervention programs and social support systems that promote both formal (e.g., volunteer activities and employment participation) and informal (e.g., senior center engagement and peer interactions) social activities. Furthermore, Kim and Choi [11] identified senior center participation, leisure activities, cultural activities, sports activities, alumni gatherings, and family gatherings as social activities significantly associated with self-rated health status. Therefore, designing intervention programs that focus on senior centers, leisure, cultural, and sports facilities, and actively involving family members may be an effective strategy for promoting self-rated health status among older adults.
A significant association was observed between subjective social status and self-rated health status. Subjective social status is significantly associated with self-rated health status. This finding is consistent with previous research that reported that older adults with higher levels of subjective social status perceive their health more positively [8]. Subjective social status serves as an integrated indicator of multidimensional socioeconomic status [19] and can be improved through social support and the provision of social resources [8]. Furthermore, individuals with lower subjective social status face greater barriers to accessing medical services and other essential resources [8], which negatively affects their perception of self-rated health and may lead to physical functional decline [19]. Based on previous studies, individuals with lower educational attainment, unmarried status, low income, or chronic illnesses may be more likely to have lower subjective social status and limited access to social resources [19], suggesting the potential value of considering targeted social support in future research and policy discussions.
In this study, depression was significantly associated with self-rated health status. This finding is consistent with that of previous research demonstrating that higher levels of depression are associated with more negative perceptions of health [7,9,10,31]. In a previous study conducted among Korean adult women [9], higher levels of depressive symptoms were associated with more negative perceptions of self-rated health status. This pattern is consistent with the present findings and suggests that depressive symptoms may be related to more negative appraisals of one's self-rated health status. These results highlight the potential value of early screening and management of depression among community-dwelling older adults, not only as a mental health strategy but also in relation to self-rated health status.
The negative association between depression and self-rated health was more pronounced in the low-level formal social activity group. In contrast, this association was attenuated and not statistically significant in the high level of formal social activity group. These findings suggest that the association between depression and self-rated health varies according to the level of formal social activity. However, in this study, social activity was restricted to formal social activities. Consequently, informal social resources such as interactions with friends, family gatherings, and neighborhood relationships were not captured, which should be considered when interpreting the findings. Furthermore, previous research [18] has demonstrated that formal social participation is closely linked to self-rated health status, whereas informal social participation is more strongly associated with mental health. Therefore, future research is needed to further explore the associations of both formal and informal social activities with self-rated health by examining these domains separately.
Furthermore, in the low subjective social status group, the negative association between depression and self-rated health was more pronounced. In contrast, this association was attenuated and not statistically significant in the high subjective social status group. This pattern suggests that the association between depression and self-rated health status varies according to the level of subjective social status. Previous research has reported that low subjective social status among community-dwelling older adults is associated with higher levels of psychological stress and lower access to healthcare services [8,20]. While the present study measured only societal-level subjective social status, Sumerlin et al. [20] distinguished between subjective social status at the societal level, reflecting perceived socioeconomic position, and subjective social status at the community level, reflecting perceived social standing within one's immediate social networks. They found that community-level subjective social status, such as perceptions of status among family, friends, and peer groups, had a significant impact on health-related QoL. These findings suggest that, beyond socioeconomic position, perceptions of social status formed within community networks may be relevant to physical and mental health. Accordingly, attention to social support, resource availability, and perceived belonging within the community may be important considerations when examining subjective social status. In particular, future research may further explore how social participation and social support are associated with subjective social status and self-rated health among older adults with higher levels of depressive symptoms.
Based on the present findings, these results may inform future discussions regarding the identification of potentially vulnerable subgroups among community-dwelling older adults, such as the oldest old and those with chronic conditions. In addition, consideration of both formal and informal social participation, including interactions with family, friends, and neighbors within the community, may be relevant in future community-based research and program planning.
This study had several limitations. First, although the KLoSA is a longitudinal panel survey, this analysis was based on data from a single wave and was therefore conducted as a cross-sectional study. Consequently, it was not possible to establish clear causal pathways among depression, formal social activity, subjective social status, and self-rated health status. Future studies should employ longitudinal analyses to examine causal relationships better. Second, because the KLoSA relies on interviewer-administered, self-reported data, variables such as depression, formal social activity, subjective social status, and self-rated health status may be subject to self-report bias, including potential over- or underestimation, due to the inherent limitations of self-reported measures. Third, because this study utilized secondary data, key variables such as self-rated health status and subjective social status were measured using single-item measures, which may limit measurement precision and reliability; therefore, the findings should be interpreted with caution. Future research should employ multi-item scales to more comprehensively and precisely assess these constructs. Fourth, due to the nature of secondary data analysis, only a limited set of variables that may influence self-rated health status was included in the analytical model. In particular, formal social activity was measured solely based on participation in formal social activities, which may not have fully captured informal social activities, the influence of social networks, or differences in participation frequency. In addition, regular exercise was measured using a single-item question, which may not have adequately captured variations in the frequency, intensity, and duration of physical activity. Despite these limitations, the KLoSA is a nationally representative longitudinal panel survey that includes a wide range of sociodemographic and health-related variables, thereby ensuring high reliability and external validity. Importantly, this study used large-scale national data to examine the moderating effects of formal social activity and subjective social status on the relationship between depression and self-rated health status.
CONCLUSION
This study utilized nationally representative data from KLoSA to examine the moderating roles of formal social activity and subjective social status in the association between depression and self-rated health status among community-dwelling older adults. The KLoSA is a large-scale panel survey conducted by the Korean government among adults aged 45 years and older, systematically collecting comprehensive information on sociodemographic characteristics, health status, and social participation. The survey instruments are periodically reviewed and validated by expert panels to ensure high reliability and validity. Moreover, the use of data collected during the COVID-19 pandemic in 2022 adds academic value by enabling exploration of factors associated with self-rated health status in this population.
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