Multiple chain-mediating effects of physical frailty and loneliness on family health and social frailty in hospitalized old patients with heart failure: a cross-section study

Multiple chain-mediating effects of physical frailty and loneliness on family health and social frailty in hospitalized old patients with heart failure: a cross-section study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Multiple chain-mediating effects of physical frailty and loneliness on family health and social frailty in hospitalized old patients with heart failure: a cross-section study Junting Huang, Xiaobo Liu, Duolao Wang, Xiaorong Luan, Wanxia Yao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6574616/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The elderly population in China is about to exceed 300 million, and heart failure (HF) is a significant public health problem that seriously endangers the physical and mental health of the elderly. Hospitalized HF patients often suffer from social and physical frailty, and the family is the principal place of care for the elderly, in addition to the hospital and community. Loneliness is a psychological problem that coexists in both developed and developing countries. There is a lack of research on the relationship between family health, physical frailty, loneliness and social frailty in elderly HF inpatients. Objective This study explores the level of social frailty and the factors that influence elderly HF inpatients. It also examines the correlation between family health, physical frailty, loneliness, and social frailty and verifies the chain mediating role of physical frailty and loneliness in the relationship. Method This cross-sectional study collected four hundred sixty-three questionnaires from Northeast China, Northwest China and South China. The research assessment tools include the FRAIL scale (physical frailty), Family APGAR index (family health), LSNS-6 (loneliness), and HALFT scale (social frailty). Data analysis was performed using multiple regression analysis and the SPSS PROCESS Macro plug-in Model 6. Results Age (B = 0.423, p < .001), number of hospitalizations (B = 0.256, p < .001), and education level (B = 0.116, p = 0.004) were risk factors for social frailty in elderly HF inpatients. Social frailty was found to be at a medium-high level, negatively correlated with family health (r=-.540, p < 0.01) and loneliness scores (r=-.732, p < 0.01), and positively correlated with physical exhaustion (r = .549, p < 0.01). Loneliness and physical frailty played a chain-mediating role between family health and social frailty, with an indirect effect of 18.62%, 59.47%, and 13.4%, respectively, all partial mediation. Conclusion The level of social frailty in elderly HF patients is moderately high, negatively affected by age, the number of hospitalizations and education level; interacts with family health, physical frailty and loneliness; and physical frailty and loneliness chain-mediate family health and social frailty. It is recommended that healthcare professionals should care about the physical, mental and social health of elderly HF inpatients. heart failure elderly inpatients social frailty physical frailty family health loneliness Figures Figure 1 Figure 2 Highlights Hospitalized old patients with heart failure have medium-highly levels of social frailty and physical frailty. Age, number of hospitalizations, and education level are risk factors for social frailty in hospitalized old patients with heart failure. Physical frailty and loneliness chain-mediated on family health and social frailty, is a partial mediation. Introduction Heart failure (HF) is a clinical syndrome caused by primary myocardial damage and abnormalities, leading to dysfunction of ventricular systole or diastole(Abovich et al., 2023 ). It is estimated that the number of people suffering from HF worldwide has exceeded 64.3 million and is increasing with the ageing population(Hollenberg et al., 2024 ). In addition, improving medical technology and extending patients' survival time also contribute to the high prevalence of HF(Suksatan et al., 2022 ). Due to the structural changes in the heart of HF patients, the high frequency of episodes, high readmission and mortality rates impose a heavy financial burden on families and societies. Studies pointed out that more than 90% of HF patients are often accompanied by somatic symptoms such as shortness of breath, fatigue, sleep apnoea, oedema, chest pain, etc., which have a profound impact on patients' health outcomes(Aïdoud et al., 2023 ; Hu, 2024 ). Frailty is an adverse clinical state caused by a variety of factors, and the level of frailty spikes during stressful states in older adults, inducing adverse cardiovascular health outcomes, of which social and physical frailty are common in patients with HF(K. Nagai et al., 2020 ; H. Wang et al., 2024 ). Physical frailty is a common predictor of disability, hospitalization and death, and social frailty is also strongly associated with disability and mortality rates(Qi & Li, 2022 ; Y. Wang et al., 2024 ; Zhang et al., 2019 ). The combination of physical and social frailty further increases the risk of developing disability. A study showed that 21% of older people aged 65 years and over were frail, with a higher proportion of women(Wang et al., 2022 ). Another study showed that about 48% of older adults were pre-frail(Y. Wang et al., 2024 ). However, the prevalence of frailty in hospitalized elderly patients ranges between 27% and 80%(Wang et al., 2022 ). Social frailty is the lack of a person's ability to access social resources. The social frailty rate among older people in Spain is 8.9%, while in Japan, it is 23.26%(Yu et al., 2023 ). However, the social frailty rate among hospital older adults is as high as 53.13%(Qi et al., 2023 ). A study noted that participants with social frailty at baseline had a four-fold higher risk of physical or pre-existing frailty four years later than those without(Ma et al., 2018 ). Another study claimed that physical frailty affects social frailty after conducting a longitudinal analysis that verified that reduced walking speed and muscle strength, which constitute physical frailty, are important risk factors for future declines in social functioning(Koutatsu Nagai et al., 2020 ). Family health (FH) is a promising family-oriented health strategy. The family is the meeting place for the health of each family member and their material, social, emotional, economic and medical resources(Alonso et al., 2022 ). In social relationships, the family is considered the most critical first-level relationship. China's elderly population will exceed 300 million, and healthy ageing is inevitable (Chen et al., 2022 ). The family is the primary source of care for older people, and the presence of the family is the primary source of social support while also helping to motivate older people to participate in daily activities and improve self-esteem(Dehi Aroogh & Mohammadi Shahboulaghi, 2020 ). Studies have shown that effective family communication can help depressed older people gain more social support and alleviate their depressive symptoms(Song et al., 2024 ). Older people who feel that the social support provided by their offspring and intimate partners is insufficient are more likely to experience depression, comorbidities and cognitive decline. Another study found that family health was negatively associated with the prevalence of frailty and pre-frail(Li et al., 2023 ). This association could be mediated by health literacy and specific health behaviours (e.g. not smoking, sleeping longer, eating breakfast daily). Intimate and kinship relationships are strongly associated with older people's health. Berkman's theory states that every family has its functions and systems, which aim to fulfil and coordinate its essential functions to suit its membership and tendencies by realistically responding to the dangers and opportunities prevalent in the social environment. There are differences in all psychosocial variables associated with physical frailty. The relationship between physical and social frailty emphasizes the importance of psychosocial factors in detecting physical frailty(Misu et al., 2023 ). Physical frailty (PF), loneliness and social frailty (SF) are all prospectively associated with adverse outcomes such as mortality in older people(Sun et al., 2023 ; Zhang et al., 2019 ). In addition, early studies investigated the beneficial effect of psychosocial resources on frailty outcomes. For frail older people living in institutions, psychosocial resources may buffer against various adverse outcomes. Associations between loneliness and depression, anxiety, stress, sleep and cognition have been identified. Loneliness predicts higher vulnerability in Fried's vulnerability phenotype. Suggesting that the higher the degree of social isolation, the higher the vulnerability index and the higher the vulnerability risk. Physically frail people have poorer cardiovascular health and biological functioning. Lonely people are thought to have poorer health behaviours (i.e. poorer lifestyles and nutrition, more smoking and drinking, and less exercise) than non-lonely people. A lack of social relationships may lead to unmet care needs and increase the likelihood of poor health. Second, lonely or socially isolated frail older people may also be those with less favourable personality traits, such as low self-esteem and a lack of control. This makes it more difficult for them to cope with stress and increases the risk of mortality. Finally, loneliness may also have more direct physiological effects on older people, manifesting as neuroendocrine and immune responses and various diseases. For example, Loneliness is associated with depression and cardiovascular disease, both of which are associated with mortality. Another hypothesized mechanism for the relationship between loneliness and frailty is slower gait speed and poorer mobility, both of which have been associated with loneliness and are likely to predispose individuals to sarcopenia, an age-related reduction in muscle mass that is a risk factor for frailty. Objectives and hypotheses China is facing unprecedented challenges due to one of the fastest ageing populations in the world. Therefore, the prevention and management of social and physical frailty is both necessary and urgent in China, and family health may be an effective intervention target. This study explores whether and how family health can reduce the risk of frailty in older adults. We propose two hypotheses: (1) family health can independently predict social frailty; (2) family health, physical frailty, loneliness and social frailty are interrelated; (3) physical frailty and loneliness mediate the relationship between family health and social frailty. Figure 1 shows the chain mediation model of physical frailty and loneliness between family health and social frailty. In addition, we also intend to investigate the current situation of social frailty and its influencing factors in elderly HF inpatients. Methods Setting and sample This study is cross-sectional research from October 2023 to June 2024 using convenient sampling of old HF patients. Participants were admitted to the Cardiology Departments of three tertiary Grade A hospitals in Shandong Province (northeast), Shaanxi Province (northwest), and Guizhou Province (south) in China. Inclusion criteria included a diagnosis of CHF according to heart failure guidelines; age 60 years and above; no severe hearing or visual impairments; no neurological diseases (e.g., dementia, stroke, epilepsy, etc.); no severe psychiatry disorders (e.g., schizophrenia, bipolar disorder, etc.); no other advanced diseases (e.g., leukaemia, breast cancer, etc. ); fluency in speaking, listening, reading, and writing; and voluntary participation in the study. A rough sample size estimation method was used, which requires the sample size to be 10–20 times that of the study variables. This study included 14 variables, and the sample size should be 140–280 participants. The sample size was increased by 20% to 168–336 participants considering invalid questionnaires. Four hundred sixty-three CHF patients were invited to complete questionnaires; Fig. 2 shows the flowchart process of participant recruitment. Measurements Independent variable = Social frailty Social frailty was assessed using the HALFT scale (Help, Participation, Loneliness, Financial, and Talk, HALFT)(Ma et al., 2018 ). The HALFT scale consists of five items and five dimensions: being unable to help others, limited social participation, loneliness, financial difficulties, and having no one to talk to. Five items: Item 1: Have you helped friends or family this past year? Item 2: Have you participated in social or leisure activities in the past year? Item 3: Have you felt lonely in the past week? Item 4: Was your income last year sufficient to cover your living expenses for one year? Item 5: Do you have someone to talk to every day? One point is calculated for 'no' answers to items 1, 2, 4, and 5 but for 'yes' answers to item 3. The total scores of the HALFT scale ranged from 0 to 5 points; the higher the scores were, the higher the social frailty level was. The Cronbach's alpha coefficient of the HALFT scale is 0.736. Mediator 1 = Family health Family health was assessed by the Family APGAR Index (Adaptation, Partnership, Growth, Affect, and Resolve, APGAR)(Sirgy, 1986 ). The Family APGAR Index consists of five items and five dimensions. Each item is scored by a three-point Likert scale ranging from 0(not at all) to 2(always). The total score is 0–10 points, with the lower scores indicating the higher family health level. The Cronbach's alpha coefficient of the Chinese version of the Family APGAR Index is 0.91(Zhu et al., 2024 ). Mediator 2 = Loneliness Loneliness was assessed by the LSNS-6 (Lubben Social Network Scale-6, LSNS-6)(Gray et al., 2016 ). The LSNS-6 consists of 6 items and two dimensions: family network (3 items) and friends’ network (3 items). Each item is scored by a six-point Likert scale (0 = none, 1 = one, 2 = two, 3 = three to four, 4 = five to eight, and 5 = nine and above). The total scores range from 0 to 30, with higher scores indicating a lower level of loneliness. The Cronbach's alpha coefficient of the Chinese version of the LSNS-6 is 0.83(Guan et al., 2024 ). Dependent variable = Physical frailty Physical frailty was assessed by the FRAIL scale. The FRAIL scale includes five items and dimensions(Gleason et al., 2017 ; Ng et al., 2024 ). Fatigue: Are you fatigued? Resistance: Cannot walk up 1 flight of stairs? Aerobic: Cannot walk one block? Illnesses: Do you have more than five illnesses? Loss of weight: Have you lost more than 5% of your weight in the past 6 months? Scoring 0 means robust, 1–2 points means prefrail and 3–5 points is frail. The Cronbach's α of the Chinese version of the FRAIL scale is 0.67(Zhao et al., 2020 ). Covariates Covariates included age, gender, marital status, residence, education level, monthly household income, number of hospitalizations, the NYHA (New York Heart Association, NYHA) classes, and number of chronic diseases. The coding of the category variables is as follows: gender (1 = female, 2 = male), marital status (1 = married, 2 = divorced/widowed/single), education level (1 = primary school or illiterate, 2 = secondary school, 3 = college or above), residence (1 = rural, 2 = urban), monthly household income (1 = less than 1,000 yuan, 2 = 1,000 yuan to 2,999 yuan, 3 = 3,000 yuan to 5,999 yuan, 4 = 6,000 yuan or above), NYHA classes (1 = Class I, 2 = Class II, 3 = Class III, 4 = Class IV), number of chronic diseases (1 = none or one, 2 = two or more). Ethical and research approval This study strictly abides by the Declaration of Helsinki and has been approved by the School of Nursing and Rehabilitation Ethics Review Committee of Shandong University (Approval No.: 2023-R-004; Approval Date: 3 February 2023). Data was collected using face-to-face interviews by a trained researcher. Each interview and questionnaire completion took approximately 20–25 minutes. All participants signed an informed consent form before completing the questionnaire and were told they had the right to withdraw from the study without affecting subsequent treatment. All data were processed anonymously and destroyed after the end of the study. Statistical analysis IBM SPSS Statistics Version 26.0 (IBM, Armonk, NY, USA) was applied for data analysis. Category variables are described as frequencies and percentages. Numerical variables are expressed as means (M) and standard deviations (SD). Considering the lack of normal distribution of some variables based on skewness-kurtosis tests, Spearman correlation analysis opted to explore the relationships of variables. An independent sample t-test and ANOVA were used to perform univariate analysis. Regression analysis was used for multiple-factor analysis. The variance inflation factor (VIF) is less than 5, so there is no multicollinearity. In the regression analysis, the covariates that were significant in the univariate analysis were included in Model 1, family health in Model 2, and physical frailty and loneliness in Model 3. Multiple mediation effects were tested using the SPSS PROCESS macro Model 6 developed by Preacher and Hayes(Hayes, 2017 ). Family health was set as X; physical frailty was set as M 1 ; loneliness was set as M 2 , and social frailty was set as Y. The indirect effects in this model include (1) through physical frailty (a 1 b 1 ), (2) through loneliness (a 2 b 2 ), and (3) through physical frailty and loneliness (a 1 d 21 b 2 ). The sum of indirect effects = a 1 b 1 + a 2 b 2 + a 1 d 21 b 2 . If M 1 and M 2 are not present, the direct effect of X on Y is c’. The total effect of X on Y (c) is the direct effect + indirect effects: c = c’ + a 1 b 1 + a 2 b 2 + a 1 d 21 b 2 . All covariates were controlled in the mediation model. A bootstrap 95% confidence interval (CI) based on 5000 samples was applied to assess the significance of direct and indirect effects. Bootstrap results were considered significant if the 95% CI did not contain zeros. Results Participants’ characteristics Five hundred questionnaires were distributed for this study, of which 17 were lost, 12 participants were withdrawn, and eight were invalid. Four hundred sixty-three valid questionnaires were returned for a valid response rate of 92.6%. Figure 2 shows the flowchart process of participant recruitment. The main characteristics of the study participants are shown in Table 1. The mean age of the participants was 67.41 years (SD=5.173), and the majority were female (63.5%). Approximately 11.7% of the participants were divorced, widowed, or single; 62.2% had an education level of primary school or below; 279 people had two or more chronic diseases; 237 people were living in rural areas; the mean of the number of hospitalizations was 1.71(SD=0.974); and 103 people had a monthly household income of 3,000 to 5,999 yuan. There were 108, 123, 122, and 110 people with NYHA classes I-IV, respectively. Single-factor analysis of SF Independent sample t-test showed that gender (t=-2.27, p=0.024) and marital status (t=-4.093, p<.001) influence SF. ANOVA results showed that household monthly income (F=7.819, p<.001) and education level (F=14.32, p<.001) are controlling factors of SF. Spearman correlation analysis showed that number of hospitalizations (r=.458, p<0.01) and age (r=.582, p<0.01) is an influencing factor of SF. Table 2 gives the details about comparison of differences between social frailty in demographic and disease-related information. Correlation of FH, PF, loneliness, and SF The mean level of FH is 6.89(SD=3.221), the mean level of PF is 2.56(SD=1.481), the mean level of loneliness is 14.11(SD=8.601), and the mean level of SF is 2.25(SD=1.354). Spearman correlation analysis indicated that FH (r=-.540, p<0.001) and loneliness (r=-.732, p<0.001) were negatively correlated with SF. It also revealed that PF (r=.549, p<0.01) was positively associated with SF. Table 3 gives the details about the correlations between social frailty, physical frailty, loneliness, and family health. Multiple-factor analysis of SF The multiple stepwise regression analysis results showed in model 1, adjusted R 2 is 0.371, indicating that age, the number of hospitalizations, and education level can predict SF, with an explanation of 37.1%. In model 2, adjusted R 2 is 0.577, indicating that FH can significantly expect SF, with a net explanation of 20.6%. In model 3, R 2 is 0.709, indicating that PF and loneliness can predict SF, with a net explanation of 13.2%. The main effect of FH on SF is significantly reduced, suggesting that PF and loneliness may mediate between FH and SF. Table 4 gives the details about the regression analysis of social frailty. Mediation analysis of PF and loneliness between FH and SF The bootstrap results indicated that the path standardized coefficient of FH on PF (path a1) was -.3069 (95% CI: -.1820,-.1002), the path standardized coefficient of PF on SF (path b1) was .1511 ( 95% CI: .0822,.1941), the path standardized coefficient of PF on loneliness (path d21) was -.2895 (95%CI: -2.1296, -1.2316), the path standardized coefficient of FH on loneliness (path a2) was .3938 (95%CI:.8441,1.2591), the path standardized coefficient of loneliness on SF (path b2) was -.3762 (95%CI:-.0702,-.0483). The total effect (path c) and direct effect (path c') of FH on SF were -.4772 (95% CI: -.2284, -.1729) and -.2492 (95% CI: -.1318, -.0778), respectively. The total indirect effect of FH on SF (path a1*b1+path a1*d21*b1+path a2*b2) is -.2280 (95% CI: -.2775, -.1788). The indirect impact of sequential multiple mediating effects of PF and loneliness is 13.38%, calculated by (path a1*d21*b1)/ (path c'), and is a partial mediation. The mediating effect size of PF is 18.62%, calculated by (path a1*b1)/ (path c’). And the mediating effect size of loneliness is 59.47%, calculated by (path a2*b2)/ (path c’). Table 5 gives the details about the mediation analysis of family health, physical frailty, loneliness, and social frailty. Discussion This is the first study to analyze the relationship between family health, physical frailty, loneliness and social frailty using sample data collected in Northeast China, Northwest China and South China. This study verified the independent predictive role of family health on social frailty; it also verified the interactions between family health, physical frailty, loneliness and social frailty. In addition, physical frailty and loneliness mediate between family health and social frailty. Through multiple-factor analysis, we also found that age, number of hospitalizations and education level are risk factors for SF in elderly inpatients with HF. In this study, the older the age, the higher the risk of social frailty in the elderly, which is consistent with the results of other studies(H. Wang et al., 2024 ; Yu et al., 2023 ). Age is an important indicator of physiological ageing. Ageing can lead to the degeneration of various body functions, and the elderly are prone to an increased risk of disease, which seriously threatens their health and thus reduces their ability to participate in society. In this study, the higher the level of education, the greater the likelihood of social frailty, which is inconsistent with other researcher results (Qi et al., 2023 ; Sun et al., 2023 ). The possible reason is the need for more cultural background and assessment tools. Considering that highly educated older people have a higher degree of social frailty, as they have lower social participation after hospitalization, have difficulty adapting to their role as patients and suffer from high psychological stress. This study found that older people with a higher number of hospitalizations were at a higher risk of social frailty, which is consistent with the results of a European study(Odaci Comertoglu et al., 2024 ; Ragusa et al., 2022 ). When older people suffer from chronic diseases, their physical fitness often declines, and the number of hospitalizations increases. Heart failure patients usually have reduced physical flexibility, which affects their ability to perform daily activities and is not conducive to their participation in social activities. Physical frailty and social frailty are positively correlated. According to the theory of ageing free radicals, the damage caused by reactive oxygen species to macromolecules such as oxygen due to ageing leads to a decline in the function of the body's tissues and organs, a decrease in muscle mass and strength, and an accelerated progression of physical frailty, which poses a serious threat to the daily activity function of older people(Aïdoud et al., 2023 ). Dong et al. pointed out that older adults with physical frailty are more likely to experience social frailty(Dong et al., 2024 ), consistent with this study. Decreased physical function limits the mobility and range of motion of older people, reducing the frequency of outdoor activities and contact with the outside world, ultimately leading to social disconnection(Noguchi et al., 2021 ; Park et al., 2023 ). Healthcare professionals should inform older people of the importance of gradually developing exercise. Exercise can delay muscle ageing, and good physical fitness can promote older people's active participation in social activities and reduce social frailty. Family health is negatively correlated with social frailty. Family health is directly correlated with social frailty and can also have an indirect effect on social frailty through depression. According to the 'main effect model' in social support theory, family health, as a protective factor, can promote individuals to have a positive self-evaluation, keep the levels of brain energy metabolites and amino acids stable, reduce the risk of depression in older people, have a positive and optimistic attitude, increase the elderly's belief in actively participating in activities, and reduce the occurrence of social frailty(Slavich et al., 2023 ). The main reason is that older people with a high level of family health who regularly participate in physical exercise can help improve their disease resistance and adaptability to maintain a dynamic balance in energy metabolism(Angulo et al., 2020 ). In addition, regular activity will cause the brain to secrete beta-endorphins, increase neurotransmitters, and generate positive emotional experiences so that older people can maintain good physical and mental health and integrate into society. This study found a negative correlation between loneliness scores and social dysfunction scores, meaning that loneliness positively correlates with social frailty. Related studies have shown that loneliness is a common problem among heart failure patients(Goodlin & Gottlieb, 2023 ; Zhang et al., 2024 ). Their limited physical activity objectively causes social isolation, reduced social participation, and a subjective sense of being excluded by others. This conflicts with their internal desire to socialize with the outside world, which, over time, hurts their perception and experience of the social environment, leading to social frailty. Patients with a sense of loneliness accompanied by severe depressive mood are more likely to experience social frailty, which is consistent with the results of multiple studies(Ge et al., 2022 ; Hanlon et al., 2024 ; Li et al., 2024 ). Patients with heart failure often suffer from depression and loneliness, and the physical and mental factors mutually reinforce each other, creating a vicious cycle. Patients with severe feelings of loneliness usually feel tired, lose their appetite, lose interest in things, and reduce the number of times they go out and communicate with others. The lack of social pleasure is one of the main symptoms of loneliness, which means that patients have lower motivation to socialize, reduce social activities or even avoid them(Park et al., 2023 ). The economic and care burden that the disease places on the family makes patients feel guilty and self-blame, which leads to a reduction in communication with their family members and even voluntary isolation from them. They are less likely to seek medical treatment, unwilling to trouble others and enter a state of self-isolation, impairing their ability to use resources. Even though resources are sufficient, social frailty is likely to occur. The results of this study show that when older people lack family health and are accompanied by physical frailty and loneliness, they are prone to high levels of social frailty and have a higher risk of adverse health outcomes. After controlling for covariates such as age, number of hospitalizations and education level, we found that physical frailty and loneliness mediate between family health and social frailty. This shows that family health in elderly HF inpatients not only directly affects social frailty but also indirectly through physical frailty and loneliness. Asejeje et al. also pointed out that as people age, they experience changes in their role functions(Asejeje & Ogunro, 2024 ). Suppose older people receive financial support, emotional support and care from their families. In that case, they will face their old age with an optimistic and cheerful attitude, creating a positive family health environment and reducing the incidence of social frailty. In addition, studies have shown that loneliness can affect neuroendocrine function and is associated with poorer sleep patterns and less sleep time, further exacerbating the social decline of patients(Deng et al., 2023 ; Sun et al., 2024 ). It is suggested that medical staff should develop personalized exercise plans for older people in poor physical and mental health to improve their physical fitness and immunity. In addition, they should establish good communication with older people, encourage family members to patiently listen to their feelings and needs, and promote family health. Limitation This study has some limitations. First, this was a cross-sectional and exploratory study, it was impossible to make firm causal relationship or long-term dynamic changes between variables. Future research could pay attention to longitudinal research to explore merit confirmation of the mechanism and provide more accurate information for intervention. Second, the data collected in the form of self-report questionnaires in this study may cause recall bias due to distorted or incomplete memory; in addition, social frailty may be more sensitive in the social environment, a format based on self-report questionnaires may mask the severity of the psychosocial damage that social frailty inflicts on old HF patients.Therefore, future studies should attempt to conduct structured clinical interviews to accurately and in-depth assess the psychosocial health threat posed by social frailty to old HF patients. Third, we only verified psychosocial variables as mediating variables and ignore demographic and disease-related data, future studies can explore the mechanism function of gender, marital status, and the number of chronic diseases as mediating variables on social frailty. Forth, the sample size of our study was small and limited in China, which could limit the generalizability of these findings. Therefore, future studies can include conduct in different countries and validate the applicability of in other culture populations. Implication for practice Our findings are of practical significance. They suggest that a multidimensional and personalized approach should be adopted to reduce social frailty and its negative impact on elderly inpatients with HF. When providing care or designing interventions for elderly HF patients with social frailty, physic-psycho-social factors such as social frailty, physical frailty, family health and loneliness should be considered, not only to prevent mortality but also to reduce adverse health outcomes. It is expected that during the 14th Five-Year Plan period, China's elderly population will exceed 300 million. The elderly have a long average survival period with illness, and many of them suffer from chronic heart failure. Therefore, the construction and urban and rural coverage of a comprehensive and integrated 'hospital-community-home' health service platform is urgently needed. Finally, medical staff and family members should provide 'dual-heart' care for heart failure patients, reduce their level of loneliness, give full play to the health-promoting function of the family, and reduce the level of physical and social frailty in elderly HF patients. Conclusions The level of social frailty in elderly HF patients is moderately high, were negatively affected by age, the number of hospitalizations and education level; and physical frailty and loneliness play a chain-mediation effect between family health and social frailty. It is recommended that healthcare professionals should care about the physical, mental and social health of elderly HF inpatients. Declarations Consent for publication Not applicable. FUNDING INFORMATION The study is supported by the Shaanxi Provincial Science and Technology Department Research Project (No. 2023-JC-YB-806). CONFLICT OF INTEREST STATEMENT All the authors declared no conflicts of interest. DATA AVAILABLE STATEMENT Supporting the data available by contacting the corresponding authors. ETHICAL CONSIDERATIONS This study has been approved by the School of Nursing and Rehabilitation Ethics Review Committee of Shandong University (Approval No.: 2023-R-004; Approval Date: 3 February 2023). All participants signed an informed consent form before completing the questionnaire and were told they had the right to withdraw from the study without affecting subsequent treatment. All data will only be used for scientific research and paper publication. CLINICAL TRIAL NUMBER Not applicable. CONSENT FOR PUBLICATION Not applicable. Author Contribution JTH was responsible for the methodology, data analysis, and writing of the first draft. JTH, WXY, and XBL were accountable for managing the data. DLW was responsible for data analysis. JTH and XRL were answerable for the study design. WXY and XRL were accountable for supervising writing, reviewing, and editing. The authors read and approved the final draft. Acknowledgement none Data Availability Data are available on request by contacting the author upon reasonable request. Ethical approval and consent to participate The research design was reviewed and approved by the School of Nursing and Rehabilitation Ethics Review Committee of Shandong University (Approval No.: 2023-R-004; Approval Date: 3 February 2023). All methods were carried out in accordance with the Declaration of Helsinki and relevant national and institutional guidelines. In strict adherence to the principle of informed consent, all data were collected anonymously after obtaining the permission and informed consent signed by respondents. References Abovich A, Matasic DS, Cardoso R, Ndumele CE, Blumenthal RS, Blankstein R, Gulati M. The AHA/ACC/HFSA 2022 Heart Failure Guidelines: Changing the Focus to Heart Failure Prevention. Am J Prev Cardiol. 2023;15:100527. https://doi.org/10.1016/j.ajpc.2023.100527 . Aïdoud A, Gana W, Poitau F, Debacq C, Leroy V, Nkodo JA, Poupin P, Angoulvant D, Fougère B. High Prevalence of Geriatric Conditions Among Older Adults With Cardiovascular Disease. J Am Heart Association. 2023;12(2):e026850. https://doi.org/doi:10.1161/JAHA.122.026850 . Alonso MAM, Barajas MES, Ordóñez JAG, Ávila Alpirez H, Fhon JRS, Duran-Badillo T. Quality of life related to functional dependence, family functioning and social support in older adults. Rev Esc Enferm USP. 2022;56:e20210482. https://doi.org/10.1590/1980-220X-REEUSP-2021-0482en . Angulo J, El Assar M, Álvarez-Bustos A, Rodríguez-Mañas L. Physical activity and exercise: Strategies to manage frailty. Redox Biol. 2020;35:101513. https://doi.org/https://doi.org/10.1016/j.redox.2020.101513 . Asejeje FO, Ogunro OB. Deciphering the mechanisms, biochemistry, physiology, and social habits in the process of aging. Archives Gerontol Geriatr Plus. 2024;1(1):100003. https://doi.org/https://doi.org/10.1016/j.aggp.2023.100003 . Chen X, Giles J, Yao Y, Yip W, Meng Q, Berkman L, Chen H, Chen X, Feng J, Feng Z, Glinskaya E, Gong J, Hu P, Kan H, Lei X, Liu X, Steptoe A, Wang G, Wang H, Zhao Y. The path to healthy ageing in China: a Peking University-Lancet Commission. Lancet. 2022;400(10367):1967–2006. https://doi.org/10.1016/s0140-6736(22)01546-x . Dehi Aroogh M, Mohammadi Shahboulaghi F. Social Participation of Older Adults: A Concept Analysis. Int J Community Based Nurs Midwifery. 2020;8(1):55–72. https://doi.org/10.30476/ijcbnm.2019.82222.1055 . Deng M, Qian M, Lv J, Guo C, Yu M. The association between loneliness and sleep quality among older adults: A systematic review and meta-analysis. Geriatr Nurs. 2023;49:94–100. https://doi.org/https://doi.org/10.1016/j.gerinurse.2022.11.013 . Dong Q, Bu X, Wang T, Liu M, Zhong F, Liu C. Profiles of physical frailty, social frailty, and cognitive impairment among older adults in rural areas of China: a latent profile analysis. Front Public Health. 2024;12:1424791. https://doi.org/10.3389/fpubh.2024.1424791 . Ge L, Yap CW, Heng BH. Associations of social isolation, social participation, and loneliness with frailty in older adults in Singapore: a panel data analysis. BMC Geriatr. 2022;22(1):26. https://doi.org/10.1186/s12877-021-02745-2 . Gleason LJ, Benton EA, Alvarez-Nebreda ML, Weaver MJ, Harris MB, Javedan H. FRAIL Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients. J Am Med Dir Assoc. 2017;18(12):1082–6. https://doi.org/10.1016/j.jamda.2017.07.005 . Goodlin SJ, Gottlieb SH. Social Isolation and Loneliness in Heart Failure: Integrating Social Care Into Cardiac Care. JACC Heart Fail. 2023;11(3):345–6. https://doi.org/10.1016/j.jchf.2023.01.002 . Gray J, Kim J, Ciesla JR, Yao P. Rasch Analysis of the Lubben Social Network Scale-6 (LSNS-6). J Appl Gerontol. 2016;35(5):508–28. https://doi.org/10.1177/0733464814560468 . Guan Z, Zwi AB, Sun M, Poon AWC. Validation and reliability of the Chinese version of the Friendship Scale (FS-C) in family caregivers of people with severe mental illness. Arch Psychiatr Nurs. 2024;53:95–101. https://doi.org/https://doi.org/10.1016/j.apnu.2024.10.006 . Hanlon P, Wightman H, Politis M, Kirkpatrick S, Jones C, Andrew MK, Vetrano DL, Dent E, Hoogendijk EO. The relationship between frailty and social vulnerability: a systematic review. Lancet Healthy Longev. 2024;5(3):e214–26. https://doi.org/https://doi.org/10.1016/S2666-7568(23)00263-5 . Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford; 2017. Hollenberg SM, Stevenson LW, Ahmad T, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Morris AA, Page RL, Siddiqi HK, Storrow AB, Teerlink JR. 2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure Focused Update. J Am Coll Cardiol. 2024;84(13):1241–67. https://doi.org/doi:10.1016/j.jacc.2024.06.002 . Hu SS. Heart failure in China: epidemiology and current management. J Geriatr Cardiol. 2024;21(6):631–41. https://doi.org/10.26599/1671-5411.2024.06.008 . Li H, Wu Y, Bai Z, Xu X, Su D, Chen J, He R, Sun J. The Association Between Family Health and Frailty With the Mediation Role of Health Literacy and Health Behavior Among Older Adults in China: Nationwide Cross-Sectional Study. JMIR Public Health Surveill. 2023;9:e44486. https://doi.org/10.2196/44486 . Li Z, Gu J, Li P, Hu J, Wang S, Wang P, Zhou L, Yun Y, Shi Y, Wang P. The relationship between social frailty and loneliness in community-dwelling older adults: a cross-sectional study. BMC Geriatr. 2024;24(1):73. https://doi.org/10.1186/s12877-024-04666-2 . Ma L, Sun F, Tang Z. Social Frailty is Associated with Physical Functioning, Cognition, and Depression, and Predicts Mortality. J Nutr health aging. 2018;22(8):989–95. https://doi.org/https://doi.org/10.1007/s12603-018-1054-0 . Misu Y, Katayama O, Lee S, Makino K, Harada K, Tomida K, Morikawa M, Yamaguchi R, Nishijima C, Fujii K, Shimada H. Reciprocal relationship between physical and social frailty among community-dwelling older adults. Arch Gerontol Geriatr. 2023;114:105066. https://doi.org/10.1016/j.archger.2023.105066 . Nagai K, Tamaki K, Kusunoki H, Wada Y, Tsuji S, Itoh M, Sano K, Amano M, Hayashitani S, Yokoyama R, Yonezawa R, Kamitani T, Shinmura K. Physical frailty predicts the development of social frailty: a prospective cohort study. BMC Geriatr. 2020;20(1):403. https://doi.org/10.1186/s12877-020-01814-2 . Nagai K, Tamaki K, Kusunoki H, Wada Y, Tsuji S, Itoh M, Sano K, Amano M, Hayashitani S, Yokoyama R, Yonezawa R, Kamitani T, Shinmura K. Physical frailty predicts the development of social frailty: a prospective cohort study. BMC Geriatr. 2020;20(1):403. https://doi.org/10.1186/s12877-020-01814-2 . Ng YX, Cheng LJ, Quek YY, Yu R, Wu XV. The measurement properties and feasibility of FRAIL scale in older adults: A systematic review and meta-analysis. Ageing Res Rev. 2024;95:102243. https://doi.org/10.1016/j.arr.2024.102243 . Noguchi M, Kubo H, Kanai M, Nozoe M, Shimada S. Relationship between pre-stroke frailty status and short-term functional outcome in older patients with acute stroke–A mediation analysis. Arch Gerontol Geriatr. 2021;94:104370. https://doi.org/https://doi.org/10.1016/j.archger.2021.104370 . Odaci Comertoglu E, Ozturk Y, Hafizoglu M, Kahyaoglu Z, Cavusoglu C, Balci C, Dogu BB, Halil M, Aki E, O., Cankurtaran M. The effect of social frailty on mental health and quality of life in older people: a cross-sectional study. Eur Geriatr Med. 2024;15(2):453–61. https://doi.org/10.1007/s41999-024-00931-0 . Park J, Cho A, Lee S, Lee H. Association of nutrition management status, frailty, and social contact frequency with life satisfaction in older adults: A moderated mediation model. Arch Gerontol Geriatr. 2023;113:105019. https://doi.org/https://doi.org/10.1016/j.archger.2023.105019 . Qi X, Li J. The Relationship between Social Frailty and Depressive Symptoms in the Elderly: A Scoping Review. Int J Environ Res Public Health. 2022;19(24). https://doi.org/10.3390/ijerph192416683 . Qi X, Li Y, Hu J, Meng L, Zeng P, Shi J, Jia N, Zeng X, Li H, Zhang Q, Li J, Liu D. Prevalence of social frailty and its associated factors in the older Chinese population: a national cross-sectional study. BMC Geriatr. 2023;23(1):532. https://doi.org/10.1186/s12877-023-04241-1 . Ragusa FS, Veronese N, Smith L, Koyanagi A, Dominguez LJ, Barbagallo M. Social frailty increases the risk of all-cause mortality: A longitudinal analysis of the English Longitudinal Study of Ageing. Exp Gerontol. 2022;167:111901. https://doi.org/10.1016/j.exger.2022.111901 . Sirgy MJ. A Quality-of-Life Theory Derived from Maslow's Developmental Perspective. Am J Econ Sociol. 1986;45(3):329–42. https://doi.org/https://doi.org/10.1111/j.1536-7150.1986.tb02394.x . Slavich GM, Roos LG, Mengelkoch S, Webb CA, Shattuck EC, Moriarity DP, Alley JC. Social Safety Theory: Conceptual foundation, underlying mechanisms, and future directions. Health Psychol Rev. 2023;17(1):5–59. https://doi.org/10.1080/17437199.2023.2171900 . Song Y, Wang M, Zhu M, Wang N, He T, Wu X, Shi Z, Chen M, Ji T, Shen Y. Benefit finding among family caregivers of patients with advanced cancer in a palliative treatment: a qualitative study. BMC Nurs. 2024;23(1):397. https://doi.org/10.1186/s12912-024-02055-z . Suksatan W, Tankumpuan T, Davidson PM. Heart Failure Caregiver Burden and Outcomes: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221112584. https://doi.org/10.1177/21501319221112584 . Sun J, Zhou N, Zhang H, Wu H, Wang F, Luo Y. Longitudinal analysis of the mediating role of self-perception of aging in the relationship between frailty and intrinsic capacity: A cross-lagged mediation model. Arch Gerontol Geriatr. 2024;120:105336. https://doi.org/https://doi.org/10.1016/j.archger.2024.105336 . Sun QQ, Tan K, Tang HY, Liu YY, Zhu H, Qin H, Xia X, Zhang M, Chen YY, Nie SS, Wang S. Incidence and predictive value of social frailty among community-dwelling older adults in Southwest China: A prospective cohort study. Front Public Health. 2023;11:1103651. https://doi.org/10.3389/fpubh.2023.1103651 . Wang H, Chen X, Zheng M, Wu Y, Liu L. Research status and hotspots of social frailty in older adults: a bibliometric analysis from 2003 to 2022. Front Aging Neurosci. 2024;16:1409155. https://doi.org/10.3389/fnagi.2024.1409155 . Wang Y, Li J, Fu P, Jing Z, Zhao D, Zhou C. Social support and subsequent cognitive frailty during a 1-year follow-up of older people: the mediating role of psychological distress. BMC Geriatr. 2022;22(1):162. https://doi.org/10.1186/s12877-022-02839-5 . Wang Y, Zheng F, Zhang X. (2024). The Impact of Social Participation on Frailty among Older Adults: The Mediating Role of Loneliness and Sleep Quality. Healthcare , 12 (20), 2085. https://www.mdpi.com/2227-9032/12/20/2085 Yu S, Wang J, Zeng L, Yang P, Tang P, Su S. The prevalence of social frailty among older adults: A systematic review and meta-analysis. Geriatr Nurs. 2023;49:101–8. https://doi.org/https://doi.org/10.1016/j.gerinurse.2022.11.009 . Zhang J, Xiang X, Yang X, Mei Q, Cheng L. The effect of self-disclosure on loneliness among patients with coronary heart disease: The chain mediating effect of social support and sense of coherence. Heart Lung. 2024;64:74–9. https://doi.org/https://doi.org/10.1016/j.hrtlng.2023.11.013 . Zhang X, Tan SS, Franse CB, Alhambra-Borrás T, Durá-Ferrandis E, Bilajac L, Markaki A, Verma A, Mattace-Raso F, Voorham AJJ, Raat H. Association between physical, psychological and social frailty and health-related quality of life among older people. Eur J Pub Health. 2019;29(5):936–42. https://doi.org/10.1093/eurpub/ckz099 . Zhao M, Mou H, Zhu S, Li M, Wang K. Cross-cultural adaptation and validation of the FRAIL-NH scale for Chinese nursing home residents: A methodological and cross-sectional study. Int J Nurs Stud. 2020;105:103556. https://doi.org/10.1016/j.ijnurstu.2020.103556 . Zhu W, Wang Y, Tang J, Wang F. Sleep quality as a mediator between family function and life satisfaction among Chinese older adults in nursing home. BMC Geriatr. 2024;24(1):379. https://doi.org/10.1186/s12877-024-04996-1 . Tables Table 1.The demographic and disease-related information (n=463) Variables Frequency(%)/Mean(SD) Age 67.41(5.173) Number of hospitalizations 1.71(0.974) NYHA Classes Class I 108(23.3%) Class II 123(26.6%) Class III 122(26.3%) Class IV 110(23.8%) Number of chronic diseases None or one 184(39.7%) Two or more 279(60.3%) Gender Female 294(63.5%) Male 169(36.5%) Residence Rural 237(51.2%) Urban 226(48.8%) Education level Primary school or illiterate 288(62.2%) Secondary school 141(30.5%) College or above 34(7.3%) Marital status Single 54(11.7%) Married 409(88.3%) Household monthly income Less than 1,000 RMB 103(22.2%) 1,000 RMB to 2,999 RMB 157(33.9%) 3,000 RMB to 5,999 RMB 103(22.2%) Above 6,000 RMB 100(21.6%) Table 2. Comparison of differences between social frailty in demographic and disease-related information (n=463) Variables Social frailty Mean(SD) t/F/r value P value Age 2.25(1.354) .582 <0.01 Number of hospitalizations 2.25(1.354) .458 <0.01 NYHA Classes 1.811 0.144 Class I 2.05(1.314) Class II 2.41(1.471) Class III 2.35(1.075) Class IV 2.16(1.512) Number of chronic diseases 1.157 0.248 None or one 2.31(1.373) Two or more 2.16(1.325) Gender -2.27 0.024 Female 2.36(1.37) Male 2.07(1.31) Residence -0.198 0.843 Rural 2.24(1.333) Urban 2.27(1.379) Education level 14.32 <.001 Primary school or illiterate 2.01(1.282) Secondary school 2.55(1.386) College or above 3.03(1.314) Marital status -4.093 <.001 Single 1.56(1.355) Married 2.34(1.329) Household monthly income 7.819 <.001 Less than 1,000 RMB 2.1(1.354) 1,000 RMB to 2,999 RMB 2.08(1.169) 3,000 RMB to 5,999 RMB 2.13(1.202) Above 6,000 RMB 2.82(1.617) Tables 3.The correlations between social frailty, physical frailty, loneliness, and family health (n=463) Variables Mean(SD) Social frailty Physical frailty Loneliness Family health Social frailty 2.25(1.354) 1 Physical frailty 2.56(1.481) .549** 1 Loneliness 14.11(8.601) -.732** -.499** 1 Family health 6.89(3.221) -.540** -.367** .576** 1 Table 4.The regression analysis of social frailty (n=463) Variables The first layer The second layer The third layer Standardized Beta P value Standardized Beta P value Standardized Beta P value Covariates Age 0.423 <.001 0.32 <.001 0.224 <.001 Number of hospitalizations 0.256 <.001 0.159 <.001 0.12 <.001 Female 0.049 0.217 0.043 0.183 0.038 0.156 Secondary school 0.116 0.004 0.039 0.246 0.032 0.257 College or above 0.096 0.016 0.029 0.375 0.03 0.276 Married 0.068 0.075 0.083 0.009 0.064 0.015 1,000 RMB to 2,999 RMB -0.03 0.531 -0.013 0.743 -0.064 0.057 3,000 RMB to 5,999 RMB -0.048 0.317 -0.084 0.035 -0.107 0.001 above 6,000 RMB 0.097 0.059 0.037 0.378 -0.04 0.262 Independent Variables Family health -0.498 <.001 -0.254 <.001 Mediators Physical frailty 0.155 <.001 Loneliness -0.385 <.001 Adjusted R 2 0.371 0.577 0.709 F 31.239 <.001 64.115 <.001 94.652 <.001 Table 5. The mediation analysis of family health, physical frailty, loneliness, and social frailty (n=463) Model path Standardized Effect BootSE BootLLCI BootULCI Path a1 Family health → physical frailty -.3069 .0208 -.1820 -.1002 Path b1 Physical frailty → social frailty .1511 .0285 .0822 .1941 Path a2 Family health → loneliness .3938 .1056 .8441 1.2591 Path b2 Loneliness → social frailty -.3762 .0056 -.0702 -.0483 Path d21 Physical frailty → Loneliness -.2895 .2285 -2.1296 -1.2316 Total effect (path c) Family health → social frailty -.4772 .0141 -.2284 -.1729 Direct effect (path c’) Family → Social frailty -.2492 .0137 -.1318 -.0778 Indirect effect (a1*b1 ) -.0464 .0111 -.0699 -.0256 Indirect effect (a2*b2) -.1482 .0196 -.1873 -.1104 Indirect effect (a1*d21*b1) -.0334 .0076 -.0497 -.0201 Total indirect effect (a1*b1 + a2*b2+a1*d21*b1) -.2280 .0249 -.2775 -.1788 Additional Declarations No competing interests reported. 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00:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6574616/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6574616/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88643430,"identity":"45e91760-6512-4420-b1d6-e17842b426a8","added_by":"auto","created_at":"2025-08-08 16:15:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":629732,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6574616/v1/b6d3e832913b6f88a1a0b1b0.jpeg"},{"id":88643428,"identity":"19db17a9-77a2-49b8-96c1-84f457dd556f","added_by":"auto","created_at":"2025-08-08 16:15:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33760,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6574616/v1/43fd0b720c8a6948e02570d0.png"},{"id":101303884,"identity":"95f26ea6-a4cd-497f-bd86-ff86eda2e90d","added_by":"auto","created_at":"2026-01-28 10:00:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1351082,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6574616/v1/4f18603d-038c-46a9-9313-370b3ebd0dec.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multiple chain-mediating effects of physical frailty and loneliness on family health and social frailty in hospitalized old patients with heart failure: a cross-section study","fulltext":[{"header":"Highlights","content":"\u003cp\u003eHospitalized old patients with heart failure have medium-highly levels of social frailty and physical frailty.\u003c/p\u003e\u003cp\u003eAge, number of hospitalizations, and education level are risk factors for social frailty in hospitalized old patients with heart failure.\u003c/p\u003e\u003cp\u003ePhysical frailty and loneliness chain-mediated on family health and social frailty, is a partial mediation.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eHeart failure (HF) is a clinical syndrome caused by primary myocardial damage and abnormalities, leading to dysfunction of ventricular systole or diastole(Abovich et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It is estimated that the number of people suffering from HF worldwide has exceeded 64.3\u0026nbsp;million and is increasing with the ageing population(Hollenberg et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In addition, improving medical technology and extending patients' survival time also contribute to the high prevalence of HF(Suksatan et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Due to the structural changes in the heart of HF patients, the high frequency of episodes, high readmission and mortality rates impose a heavy financial burden on families and societies. Studies pointed out that more than 90% of HF patients are often accompanied by somatic symptoms such as shortness of breath, fatigue, sleep apnoea, oedema, chest pain, etc., which have a profound impact on patients' health outcomes(Aïdoud et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hu, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFrailty is an adverse clinical state caused by a variety of factors, and the level of frailty spikes during stressful states in older adults, inducing adverse cardiovascular health outcomes, of which social and physical frailty are common in patients with HF(K. Nagai et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; H. Wang et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Physical frailty is a common predictor of disability, hospitalization and death, and social frailty is also strongly associated with disability and mortality rates(Qi \u0026amp; Li, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Y. Wang et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The combination of physical and social frailty further increases the risk of developing disability. A study showed that 21% of older people aged 65 years and over were frail, with a higher proportion of women(Wang et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Another study showed that about 48% of older adults were pre-frail(Y. Wang et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, the prevalence of frailty in hospitalized elderly patients ranges between 27% and 80%(Wang et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Social frailty is the lack of a person's ability to access social resources. The social frailty rate among older people in Spain is 8.9%, while in Japan, it is 23.26%(Yu et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, the social frailty rate among hospital older adults is as high as 53.13%(Qi et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). A study noted that participants with social frailty at baseline had a four-fold higher risk of physical or pre-existing frailty four years later than those without(Ma et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Another study claimed that physical frailty affects social frailty after conducting a longitudinal analysis that verified that reduced walking speed and muscle strength, which constitute physical frailty, are important risk factors for future declines in social functioning(Koutatsu Nagai et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFamily health (FH) is a promising family-oriented health strategy. The family is the meeting place for the health of each family member and their material, social, emotional, economic and medical resources(Alonso et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In social relationships, the family is considered the most critical first-level relationship. China's elderly population will exceed 300\u0026nbsp;million, and healthy ageing is inevitable (Chen et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The family is the primary source of care for older people, and the presence of the family is the primary source of social support while also helping to motivate older people to participate in daily activities and improve self-esteem(Dehi Aroogh \u0026amp; Mohammadi Shahboulaghi, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Studies have shown that effective family communication can help depressed older people gain more social support and alleviate their depressive symptoms(Song et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Older people who feel that the social support provided by their offspring and intimate partners is insufficient are more likely to experience depression, comorbidities and cognitive decline. Another study found that family health was negatively associated with the prevalence of frailty and pre-frail(Li et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This association could be mediated by health literacy and specific health behaviours (e.g. not smoking, sleeping longer, eating breakfast daily). Intimate and kinship relationships are strongly associated with older people's health. Berkman's theory states that every family has its functions and systems, which aim to fulfil and coordinate its essential functions to suit its membership and tendencies by realistically responding to the dangers and opportunities prevalent in the social environment. There are differences in all psychosocial variables associated with physical frailty. The relationship between physical and social frailty emphasizes the importance of psychosocial factors in detecting physical frailty(Misu et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePhysical frailty (PF), loneliness and social frailty (SF) are all prospectively associated with adverse outcomes such as mortality in older people(Sun et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In addition, early studies investigated the beneficial effect of psychosocial resources on frailty outcomes. For frail older people living in institutions, psychosocial resources may buffer against various adverse outcomes. Associations between loneliness and depression, anxiety, stress, sleep and cognition have been identified. Loneliness predicts higher vulnerability in Fried's vulnerability phenotype. Suggesting that the higher the degree of social isolation, the higher the vulnerability index and the higher the vulnerability risk. Physically frail people have poorer cardiovascular health and biological functioning. Lonely people are thought to have poorer health behaviours (i.e. poorer lifestyles and nutrition, more smoking and drinking, and less exercise) than non-lonely people. A lack of social relationships may lead to unmet care needs and increase the likelihood of poor health. Second, lonely or socially isolated frail older people may also be those with less favourable personality traits, such as low self-esteem and a lack of control. This makes it more difficult for them to cope with stress and increases the risk of mortality. Finally, loneliness may also have more direct physiological effects on older people, manifesting as neuroendocrine and immune responses and various diseases. For example, Loneliness is associated with depression and cardiovascular disease, both of which are associated with mortality. Another hypothesized mechanism for the relationship between loneliness and frailty is slower gait speed and poorer mobility, both of which have been associated with loneliness and are likely to predispose individuals to sarcopenia, an age-related reduction in muscle mass that is a risk factor for frailty.\u003c/p\u003e\u003cp\u003eObjectives and hypotheses\u003c/p\u003e\u003cp\u003eChina is facing unprecedented challenges due to one of the fastest ageing populations in the world. Therefore, the prevention and management of social and physical frailty is both necessary and urgent in China, and family health may be an effective intervention target. This study explores whether and how family health can reduce the risk of frailty in older adults. We propose two hypotheses: (1) family health can independently predict social frailty; (2) family health, physical frailty, loneliness and social frailty are interrelated; (3) physical frailty and loneliness mediate the relationship between family health and social frailty. Figure\u0026nbsp;1 shows the chain mediation model of physical frailty and loneliness between family health and social frailty. In addition, we also intend to investigate the current situation of social frailty and its influencing factors in elderly HF inpatients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSetting and sample\u003c/p\u003e\u003cp\u003eThis study is cross-sectional research from October 2023 to June 2024 using convenient sampling of old HF patients. Participants were admitted to the Cardiology Departments of three tertiary Grade A hospitals in Shandong Province (northeast), Shaanxi Province (northwest), and Guizhou Province (south) in China. Inclusion criteria included a diagnosis of CHF according to heart failure guidelines; age 60 years and above; no severe hearing or visual impairments; no neurological diseases (e.g., dementia, stroke, epilepsy, etc.); no severe psychiatry disorders (e.g., schizophrenia, bipolar disorder, etc.); no other advanced diseases (e.g., leukaemia, breast cancer, etc. ); fluency in speaking, listening, reading, and writing; and voluntary participation in the study. A rough sample size estimation method was used, which requires the sample size to be 10–20 times that of the study variables. This study included 14 variables, and the sample size should be 140–280 participants. The sample size was increased by 20% to 168–336 participants considering invalid questionnaires. Four hundred sixty-three CHF patients were invited to complete questionnaires; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the flowchart process of participant recruitment.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMeasurements\u003c/p\u003e\u003cp\u003eIndependent variable = Social frailty\u003c/p\u003e\u003cp\u003eSocial frailty was assessed using the HALFT scale (Help, Participation, Loneliness, Financial, and Talk, HALFT)(Ma et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The HALFT scale consists of five items and five dimensions: being unable to help others, limited social participation, loneliness, financial difficulties, and having no one to talk to. Five items: Item 1: Have you helped friends or family this past year? Item 2: Have you participated in social or leisure activities in the past year? Item 3: Have you felt lonely in the past week? Item 4: Was your income last year sufficient to cover your living expenses for one year? Item 5: Do you have someone to talk to every day? One point is calculated for 'no' answers to items 1, 2, 4, and 5 but for 'yes' answers to item 3. The total scores of the HALFT scale ranged from 0 to 5 points; the higher the scores were, the higher the social frailty level was. The Cronbach's alpha coefficient of the HALFT scale is 0.736.\u003c/p\u003e\u003cp\u003eMediator 1 = Family health\u003c/p\u003e\u003cp\u003eFamily health was assessed by the Family APGAR Index (Adaptation, Partnership, Growth, Affect, and Resolve, APGAR)(Sirgy, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e1986\u003c/span\u003e). The Family APGAR Index consists of five items and five dimensions. Each item is scored by a three-point Likert scale ranging from 0(not at all) to 2(always). The total score is 0–10 points, with the lower scores indicating the higher family health level. The Cronbach's alpha coefficient of the Chinese version of the Family APGAR Index is 0.91(Zhu et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMediator 2 = Loneliness\u003c/p\u003e\u003cp\u003eLoneliness was assessed by the LSNS-6 (Lubben Social Network Scale-6, LSNS-6)(Gray et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The LSNS-6 consists of 6 items and two dimensions: family network (3 items) and friends’ network (3 items). Each item is scored by a six-point Likert scale (0 = none, 1 = one, 2 = two, 3 = three to four, 4 = five to eight, and 5 = nine and above). The total scores range from 0 to 30, with higher scores indicating a lower level of loneliness. The Cronbach's alpha coefficient of the Chinese version of the LSNS-6 is 0.83(Guan et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDependent variable = Physical frailty\u003c/p\u003e\u003cp\u003ePhysical frailty was assessed by the FRAIL scale. The FRAIL scale includes five items and dimensions(Gleason et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ng et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Fatigue: Are you fatigued? Resistance: Cannot walk up 1 flight of stairs? Aerobic: Cannot walk one block? Illnesses: Do you have more than five illnesses? Loss of weight: Have you lost more than 5% of your weight in the past 6 months? Scoring 0 means robust, 1–2 points means prefrail and 3–5 points is frail. The Cronbach's α of the Chinese version of the FRAIL scale is 0.67(Zhao et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCovariates\u003c/p\u003e\u003cp\u003eCovariates included age, gender, marital status, residence, education level, monthly household income, number of hospitalizations, the NYHA (New York Heart Association, NYHA) classes, and number of chronic diseases. The coding of the category variables is as follows: gender (1 = female, 2 = male), marital status (1 = married, 2 = divorced/widowed/single), education level (1 = primary school or illiterate, 2 = secondary school, 3 = college or above), residence (1 = rural, 2 = urban), monthly household income (1 = less than 1,000 yuan, 2 = 1,000 yuan to 2,999 yuan, 3 = 3,000 yuan to 5,999 yuan, 4 = 6,000 yuan or above), NYHA classes (1 = Class I, 2 = Class II, 3 = Class III, 4 = Class IV), number of chronic diseases (1 = none or one, 2 = two or more).\u003c/p\u003e\u003cp\u003eEthical and research approval\u003c/p\u003e\u003cp\u003e This study strictly abides by the Declaration of Helsinki and has been approved by the School of Nursing and Rehabilitation Ethics Review Committee of Shandong University (Approval No.: 2023-R-004; Approval Date: 3 February 2023). Data was collected using face-to-face interviews by a trained researcher. Each interview and questionnaire completion took approximately 20–25 minutes. All participants signed an informed consent form before completing the questionnaire and were told they had the right to withdraw from the study without affecting subsequent treatment. All data were processed anonymously and destroyed after the end of the study.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eIBM SPSS Statistics Version 26.0 (IBM, Armonk, NY, USA) was applied for data analysis. Category variables are described as frequencies and percentages. Numerical variables are expressed as means (M) and standard deviations (SD). Considering the lack of normal distribution of some variables based on skewness-kurtosis tests, Spearman correlation analysis opted to explore the relationships of variables. An independent sample t-test and ANOVA were used to perform univariate analysis. Regression analysis was used for multiple-factor analysis. The variance inflation factor (VIF) is less than 5, so there is no multicollinearity. In the regression analysis, the covariates that were significant in the univariate analysis were included in Model 1, family health in Model 2, and physical frailty and loneliness in Model 3.\u003c/p\u003e\u003cp\u003eMultiple mediation effects were tested using the SPSS PROCESS macro Model 6 developed by Preacher and Hayes(Hayes, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Family health was set as X; physical frailty was set as M\u003csub\u003e1\u003c/sub\u003e; loneliness was set as M\u003csub\u003e2\u003c/sub\u003e, and social frailty was set as Y. The indirect effects in this model include (1) through physical frailty (a\u003csub\u003e1\u003c/sub\u003eb\u003csub\u003e1\u003c/sub\u003e), (2) through loneliness (a\u003csub\u003e2\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e), and (3) through physical frailty and loneliness (a\u003csub\u003e1\u003c/sub\u003ed\u003csub\u003e21\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e). The sum of indirect effects = a\u003csub\u003e1\u003c/sub\u003eb\u003csub\u003e1\u003c/sub\u003e + a\u003csub\u003e2\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e + a\u003csub\u003e1\u003c/sub\u003ed\u003csub\u003e21\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e. If M\u003csub\u003e1\u003c/sub\u003e and M\u003csub\u003e2\u003c/sub\u003e are not present, the direct effect of X on Y is c’. The total effect of X on Y (c) is the direct effect + indirect effects: c = c’ + a\u003csub\u003e1\u003c/sub\u003eb\u003csub\u003e1\u003c/sub\u003e + a\u003csub\u003e2\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e + a\u003csub\u003e1\u003c/sub\u003ed\u003csub\u003e21\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e. All covariates were controlled in the mediation model. A bootstrap 95% confidence interval (CI) based on 5000 samples was applied to assess the significance of direct and indirect effects. Bootstrap results were considered significant if the 95% CI did not contain zeros.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants\u0026rsquo; characteristics\u003c/p\u003e\n\u003cp\u003eFive hundred questionnaires were distributed for this study, of which 17 were lost, 12 participants were withdrawn, and eight were invalid. Four hundred sixty-three valid questionnaires were returned for a valid response rate of 92.6%. Figure 2 shows the flowchart process of participant recruitment. The main characteristics of the study participants are shown in Table 1. The mean age of the participants was 67.41 years (SD=5.173), and the majority were female (63.5%). Approximately 11.7% of the participants were divorced, widowed, or single; 62.2% had an education level of primary school or below; 279 people had two or more chronic diseases; 237 people were living in rural areas; the mean of the number of hospitalizations was 1.71(SD=0.974); and 103 people had a monthly household income of 3,000 to 5,999 yuan. There were 108, 123, 122, and 110 people with NYHA classes I-IV, respectively.\u003c/p\u003e\n\u003cp\u003eSingle-factor analysis of SF\u003c/p\u003e\n\u003cp\u003eIndependent sample t-test showed that gender (t=-2.27, p=0.024) and marital status (t=-4.093, p\u0026lt;.001) influence SF. ANOVA results showed that household monthly income (F=7.819, p\u0026lt;.001) and education level (F=14.32, p\u0026lt;.001) are controlling factors of SF. Spearman correlation analysis showed that number of hospitalizations (r=.458, p\u0026lt;0.01) and age (r=.582, p\u0026lt;0.01) is an influencing factor of SF. Table 2 gives the details about comparison of differences between social frailty in demographic and disease-related information.\u003c/p\u003e\n\u003cp\u003eCorrelation of FH, PF, loneliness, and SF\u003c/p\u003e\n\u003cp\u003eThe mean level of FH is 6.89(SD=3.221), the mean level of PF is 2.56(SD=1.481), the mean level of loneliness is 14.11(SD=8.601), and the mean level of SF is 2.25(SD=1.354). Spearman correlation analysis indicated that FH (r=-.540, p\u0026lt;0.001) and loneliness (r=-.732, p\u0026lt;0.001) were negatively correlated with SF. It also revealed that PF (r=.549, p\u0026lt;0.01) was positively associated with SF. Table 3 gives the details about the correlations between social frailty, physical frailty, loneliness, and family health.\u003c/p\u003e\n\u003cp\u003eMultiple-factor analysis of SF\u003c/p\u003e\n\u003cp\u003eThe multiple stepwise regression analysis results showed in model 1, adjusted R\u003csup\u003e2\u003c/sup\u003e is 0.371, indicating that age, the number of hospitalizations, and education level can predict SF, with an explanation of 37.1%. In model 2, adjusted R\u003csup\u003e2\u003c/sup\u003e is 0.577, indicating that FH can significantly expect SF, with a net explanation of 20.6%. In model 3, R\u003csup\u003e2\u003c/sup\u003e is 0.709, indicating that PF and loneliness can predict SF, with a net explanation of 13.2%. The main effect of FH on SF is significantly reduced, suggesting that PF and loneliness may mediate between FH and SF. Table 4 gives the details about the regression analysis of social frailty.\u003c/p\u003e\n\u003cp\u003eMediation analysis of PF and loneliness between FH and SF\u003c/p\u003e\n\u003cp\u003eThe bootstrap results indicated that the path standardized coefficient of FH on PF (path a1) was -.3069 (95% CI: -.1820,-.1002), the path standardized coefficient of PF on SF (path b1) was .1511 ( 95% CI: .0822,.1941), the path standardized coefficient of PF on loneliness (path d21) was -.2895 (95%CI: -2.1296, -1.2316), the path standardized coefficient of FH on loneliness (path a2) was .3938 (95%CI:.8441,1.2591), the path standardized coefficient of loneliness on SF (path b2) was -.3762 (95%CI:-.0702,-.0483). The total effect (path c) and direct effect (path c\u0026apos;) of FH on SF were -.4772 (95% CI: -.2284, -.1729) and -.2492 (95% CI: -.1318, -.0778), respectively. The total indirect effect of FH on SF (path a1*b1+path a1*d21*b1+path a2*b2) is -.2280 (95% CI: -.2775, -.1788). The indirect impact of sequential multiple mediating effects of PF and loneliness is 13.38%, calculated by (path a1*d21*b1)/ (path c\u0026apos;), and is a partial mediation. The mediating effect size of PF is 18.62%, calculated by (path a1*b1)/ (path c\u0026rsquo;). And the mediating effect size of loneliness is 59.47%, calculated by (path a2*b2)/ (path c\u0026rsquo;). Table 5 gives the details about the mediation analysis of family health, physical frailty, loneliness, and social frailty.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to analyze the relationship between family health, physical frailty, loneliness and social frailty using sample data collected in Northeast China, Northwest China and South China. This study verified the independent predictive role of family health on social frailty; it also verified the interactions between family health, physical frailty, loneliness and social frailty. In addition, physical frailty and loneliness mediate between family health and social frailty. Through multiple-factor analysis, we also found that age, number of hospitalizations and education level are risk factors for SF in elderly inpatients with HF.\u003c/p\u003e\u003cp\u003eIn this study, the older the age, the higher the risk of social frailty in the elderly, which is consistent with the results of other studies(H. Wang et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yu et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Age is an important indicator of physiological ageing. Ageing can lead to the degeneration of various body functions, and the elderly are prone to an increased risk of disease, which seriously threatens their health and thus reduces their ability to participate in society. In this study, the higher the level of education, the greater the likelihood of social frailty, which is inconsistent with other researcher results (Qi et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sun et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The possible reason is the need for more cultural background and assessment tools. Considering that highly educated older people have a higher degree of social frailty, as they have lower social participation after hospitalization, have difficulty adapting to their role as patients and suffer from high psychological stress. This study found that older people with a higher number of hospitalizations were at a higher risk of social frailty, which is consistent with the results of a European study(Odaci Comertoglu et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ragusa et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). When older people suffer from chronic diseases, their physical fitness often declines, and the number of hospitalizations increases. Heart failure patients usually have reduced physical flexibility, which affects their ability to perform daily activities and is not conducive to their participation in social activities.\u003c/p\u003e\u003cp\u003ePhysical frailty and social frailty are positively correlated. According to the theory of ageing free radicals, the damage caused by reactive oxygen species to macromolecules such as oxygen due to ageing leads to a decline in the function of the body's tissues and organs, a decrease in muscle mass and strength, and an accelerated progression of physical frailty, which poses a serious threat to the daily activity function of older people(A\u0026iuml;doud et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Dong et al. pointed out that older adults with physical frailty are more likely to experience social frailty(Dong et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), consistent with this study. Decreased physical function limits the mobility and range of motion of older people, reducing the frequency of outdoor activities and contact with the outside world, ultimately leading to social disconnection(Noguchi et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Park et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Healthcare professionals should inform older people of the importance of gradually developing exercise. Exercise can delay muscle ageing, and good physical fitness can promote older people's active participation in social activities and reduce social frailty.\u003c/p\u003e\u003cp\u003eFamily health is negatively correlated with social frailty. Family health is directly correlated with social frailty and can also have an indirect effect on social frailty through depression. According to the 'main effect model' in social support theory, family health, as a protective factor, can promote individuals to have a positive self-evaluation, keep the levels of brain energy metabolites and amino acids stable, reduce the risk of depression in older people, have a positive and optimistic attitude, increase the elderly's belief in actively participating in activities, and reduce the occurrence of social frailty(Slavich et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The main reason is that older people with a high level of family health who regularly participate in physical exercise can help improve their disease resistance and adaptability to maintain a dynamic balance in energy metabolism(Angulo et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, regular activity will cause the brain to secrete beta-endorphins, increase neurotransmitters, and generate positive emotional experiences so that older people can maintain good physical and mental health and integrate into society.\u003c/p\u003e\u003cp\u003eThis study found a negative correlation between loneliness scores and social dysfunction scores, meaning that loneliness positively correlates with social frailty. Related studies have shown that loneliness is a common problem among heart failure patients(Goodlin \u0026amp; Gottlieb, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Their limited physical activity objectively causes social isolation, reduced social participation, and a subjective sense of being excluded by others. This conflicts with their internal desire to socialize with the outside world, which, over time, hurts their perception and experience of the social environment, leading to social frailty. Patients with a sense of loneliness accompanied by severe depressive mood are more likely to experience social frailty, which is consistent with the results of multiple studies(Ge et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hanlon et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Li et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Patients with heart failure often suffer from depression and loneliness, and the physical and mental factors mutually reinforce each other, creating a vicious cycle. Patients with severe feelings of loneliness usually feel tired, lose their appetite, lose interest in things, and reduce the number of times they go out and communicate with others. The lack of social pleasure is one of the main symptoms of loneliness, which means that patients have lower motivation to socialize, reduce social activities or even avoid them(Park et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The economic and care burden that the disease places on the family makes patients feel guilty and self-blame, which leads to a reduction in communication with their family members and even voluntary isolation from them. They are less likely to seek medical treatment, unwilling to trouble others and enter a state of self-isolation, impairing their ability to use resources. Even though resources are sufficient, social frailty is likely to occur.\u003c/p\u003e\u003cp\u003eThe results of this study show that when older people lack family health and are accompanied by physical frailty and loneliness, they are prone to high levels of social frailty and have a higher risk of adverse health outcomes. After controlling for covariates such as age, number of hospitalizations and education level, we found that physical frailty and loneliness mediate between family health and social frailty. This shows that family health in elderly HF inpatients not only directly affects social frailty but also indirectly through physical frailty and loneliness. Asejeje et al. also pointed out that as people age, they experience changes in their role functions(Asejeje \u0026amp; Ogunro, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Suppose older people receive financial support, emotional support and care from their families. In that case, they will face their old age with an optimistic and cheerful attitude, creating a positive family health environment and reducing the incidence of social frailty. In addition, studies have shown that loneliness can affect neuroendocrine function and is associated with poorer sleep patterns and less sleep time, further exacerbating the social decline of patients(Deng et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sun et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). It is suggested that medical staff should develop personalized exercise plans for older people in poor physical and mental health to improve their physical fitness and immunity. In addition, they should establish good communication with older people, encourage family members to patiently listen to their feelings and needs, and promote family health.\u003c/p\u003e\u003cp\u003eLimitation\u003c/p\u003e\u003cp\u003eThis study has some limitations. First, this was a cross-sectional and exploratory study, it was impossible to make firm causal relationship or long-term dynamic changes between variables. Future research could pay attention to longitudinal research to explore merit confirmation of the mechanism and provide more accurate information for intervention. Second, the data collected in the form of self-report questionnaires in this study may cause recall bias due to distorted or incomplete memory; in addition, social frailty may be more sensitive in the social environment, a format based on self-report questionnaires may mask the severity of the psychosocial damage that social frailty inflicts on old HF patients.Therefore, future studies should attempt to conduct structured clinical interviews to accurately and in-depth assess the psychosocial health threat posed by social frailty to old HF patients. Third, we only verified psychosocial variables as mediating variables and ignore demographic and disease-related data, future studies can explore the mechanism function of gender, marital status, and the number of chronic diseases as mediating variables on social frailty. Forth, the sample size of our study was small and limited in China, which could limit the generalizability of these findings. Therefore, future studies can include conduct in different countries and validate the applicability of in other culture populations.\u003c/p\u003e\u003cp\u003eImplication for practice\u003c/p\u003e\u003cp\u003eOur findings are of practical significance. They suggest that a multidimensional and personalized approach should be adopted to reduce social frailty and its negative impact on elderly inpatients with HF. When providing care or designing interventions for elderly HF patients with social frailty, physic-psycho-social factors such as social frailty, physical frailty, family health and loneliness should be considered, not only to prevent mortality but also to reduce adverse health outcomes. It is expected that during the 14th Five-Year Plan period, China's elderly population will exceed 300\u0026nbsp;million. The elderly have a long average survival period with illness, and many of them suffer from chronic heart failure. Therefore, the construction and urban and rural coverage of a comprehensive and integrated 'hospital-community-home' health service platform is urgently needed. Finally, medical staff and family members should provide 'dual-heart' care for heart failure patients, reduce their level of loneliness, give full play to the health-promoting function of the family, and reduce the level of physical and social frailty in elderly HF patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe level of social frailty in elderly HF patients is moderately high, were negatively affected by age, the number of hospitalizations and education level; and physical frailty and loneliness play a chain-mediation effect between family health and social frailty. It is recommended that healthcare professionals should care about the physical, mental and social health of elderly HF inpatients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConsent for publication\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFUNDING INFORMATION\u003c/h2\u003e\u003cp\u003eThe study is supported by the Shaanxi Provincial Science and Technology Department Research Project (No. 2023-JC-YB-806).\u003c/p\u003e\u003cp\u003eCONFLICT OF INTEREST STATEMENT\u003c/p\u003e\u003cp\u003eAll the authors declared no conflicts of interest.\u003c/p\u003e\u003cp\u003eDATA AVAILABLE STATEMENT\u003c/p\u003e\u003cp\u003eSupporting the data available by contacting the corresponding authors.\u003c/p\u003e\u003cp\u003eETHICAL CONSIDERATIONS\u003c/p\u003e\u003cp\u003e This study has been approved by the School of Nursing and Rehabilitation Ethics Review Committee of Shandong University (Approval No.: 2023-R-004; Approval Date: 3 February 2023). All participants signed an informed consent form before completing the questionnaire and were told they had the right to withdraw from the study without affecting subsequent treatment. All data will only be used for scientific research and paper publication.\u003c/p\u003e\u003cp\u003eCLINICAL TRIAL NUMBER\u003c/p\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003cp\u003e CONSENT FOR PUBLICATION\u003c/p\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJTH was responsible for the methodology, data analysis, and writing of the first draft. JTH, WXY, and XBL were accountable for managing the data. DLW was responsible for data analysis. JTH and XRL were answerable for the study design. WXY and XRL were accountable for supervising writing, reviewing, and editing. The authors read and approved the final draft.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003enone\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are available on request by contacting the author upon reasonable request.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003cp\u003e The research design was reviewed and approved by the School of Nursing and Rehabilitation Ethics Review Committee of Shandong University (Approval No.: 2023-R-004; Approval Date: 3 February 2023). All methods were carried out in accordance with the Declaration of Helsinki and relevant national and institutional guidelines. In strict adherence to the principle of informed consent, all data were collected anonymously after obtaining the permission and informed consent signed by respondents.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbovich A, Matasic DS, Cardoso R, Ndumele CE, Blumenthal RS, Blankstein R, Gulati M. The AHA/ACC/HFSA 2022 Heart Failure Guidelines: Changing the Focus to Heart Failure Prevention. Am J Prev Cardiol. 2023;15:100527. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajpc.2023.100527\u003c/span\u003e\u003cspan address=\"10.1016/j.ajpc.2023.100527\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eA\u0026iuml;doud A, Gana W, Poitau F, Debacq C, Leroy V, Nkodo JA, Poupin P, Angoulvant D, Foug\u0026egrave;re B. High Prevalence of Geriatric Conditions Among Older Adults With Cardiovascular Disease. J Am Heart Association. 2023;12(2):e026850. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/doi:10.1161/JAHA.122.026850\u003c/span\u003e\u003cspan address=\"doi:10.1161/JAHA.122.026850\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlonso MAM, Barajas MES, Ord\u0026oacute;\u0026ntilde;ez JAG, \u0026Aacute;vila Alpirez H, Fhon JRS, Duran-Badillo T. Quality of life related to functional dependence, family functioning and social support in older adults. Rev Esc Enferm USP. 2022;56:e20210482. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1980-220X-REEUSP-2021-0482en\u003c/span\u003e\u003cspan address=\"10.1590/1980-220X-REEUSP-2021-0482en\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAngulo J, El Assar M, \u0026Aacute;lvarez-Bustos A, Rodr\u0026iacute;guez-Ma\u0026ntilde;as L. Physical activity and exercise: Strategies to manage frailty. Redox Biol. 2020;35:101513. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.redox.2020.101513\u003c/span\u003e\u003cspan address=\"10.1016/j.redox.2020.101513\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAsejeje FO, Ogunro OB. Deciphering the mechanisms, biochemistry, physiology, and social habits in the process of aging. Archives Gerontol Geriatr Plus. 2024;1(1):100003. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.aggp.2023.100003\u003c/span\u003e\u003cspan address=\"10.1016/j.aggp.2023.100003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen X, Giles J, Yao Y, Yip W, Meng Q, Berkman L, Chen H, Chen X, Feng J, Feng Z, Glinskaya E, Gong J, Hu P, Kan H, Lei X, Liu X, Steptoe A, Wang G, Wang H, Zhao Y. The path to healthy ageing in China: a Peking University-Lancet Commission. Lancet. 2022;400(10367):1967\u0026ndash;2006. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0140-6736(22)01546-x\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(22)01546-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDehi Aroogh M, Mohammadi Shahboulaghi F. Social Participation of Older Adults: A Concept Analysis. Int J Community Based Nurs Midwifery. 2020;8(1):55\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.30476/ijcbnm.2019.82222.1055\u003c/span\u003e\u003cspan address=\"10.30476/ijcbnm.2019.82222.1055\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeng M, Qian M, Lv J, Guo C, Yu M. The association between loneliness and sleep quality among older adults: A systematic review and meta-analysis. Geriatr Nurs. 2023;49:94\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.gerinurse.2022.11.013\u003c/span\u003e\u003cspan address=\"10.1016/j.gerinurse.2022.11.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDong Q, Bu X, Wang T, Liu M, Zhong F, Liu C. Profiles of physical frailty, social frailty, and cognitive impairment among older adults in rural areas of China: a latent profile analysis. Front Public Health. 2024;12:1424791. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2024.1424791\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1424791\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGe L, Yap CW, Heng BH. Associations of social isolation, social participation, and loneliness with frailty in older adults in Singapore: a panel data analysis. BMC Geriatr. 2022;22(1):26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-021-02745-2\u003c/span\u003e\u003cspan address=\"10.1186/s12877-021-02745-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGleason LJ, Benton EA, Alvarez-Nebreda ML, Weaver MJ, Harris MB, Javedan H. FRAIL Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients. J Am Med Dir Assoc. 2017;18(12):1082\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jamda.2017.07.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jamda.2017.07.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoodlin SJ, Gottlieb SH. Social Isolation and Loneliness in Heart Failure: Integrating Social Care Into Cardiac Care. JACC Heart Fail. 2023;11(3):345\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jchf.2023.01.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jchf.2023.01.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGray J, Kim J, Ciesla JR, Yao P. Rasch Analysis of the Lubben Social Network Scale-6 (LSNS-6). J Appl Gerontol. 2016;35(5):508\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0733464814560468\u003c/span\u003e\u003cspan address=\"10.1177/0733464814560468\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuan Z, Zwi AB, Sun M, Poon AWC. Validation and reliability of the Chinese version of the Friendship Scale (FS-C) in family caregivers of people with severe mental illness. Arch Psychiatr Nurs. 2024;53:95\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.apnu.2024.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.apnu.2024.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHanlon P, Wightman H, Politis M, Kirkpatrick S, Jones C, Andrew MK, Vetrano DL, Dent E, Hoogendijk EO. The relationship between frailty and social vulnerability: a systematic review. Lancet Healthy Longev. 2024;5(3):e214\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/S2666-7568(23)00263-5\u003c/span\u003e\u003cspan address=\"10.1016/S2666-7568(23)00263-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHollenberg SM, Stevenson LW, Ahmad T, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Morris AA, Page RL, Siddiqi HK, Storrow AB, Teerlink JR. 2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure Focused Update. J Am Coll Cardiol. 2024;84(13):1241\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/doi:10.1016/j.jacc.2024.06.002\u003c/span\u003e\u003cspan address=\"doi:10.1016/j.jacc.2024.06.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHu SS. Heart failure in China: epidemiology and current management. J Geriatr Cardiol. 2024;21(6):631\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.26599/1671-5411.2024.06.008\u003c/span\u003e\u003cspan address=\"10.26599/1671-5411.2024.06.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi H, Wu Y, Bai Z, Xu X, Su D, Chen J, He R, Sun J. The Association Between Family Health and Frailty With the Mediation Role of Health Literacy and Health Behavior Among Older Adults in China: Nationwide Cross-Sectional Study. JMIR Public Health Surveill. 2023;9:e44486. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/44486\u003c/span\u003e\u003cspan address=\"10.2196/44486\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Z, Gu J, Li P, Hu J, Wang S, Wang P, Zhou L, Yun Y, Shi Y, Wang P. The relationship between social frailty and loneliness in community-dwelling older adults: a cross-sectional study. BMC Geriatr. 2024;24(1):73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-024-04666-2\u003c/span\u003e\u003cspan address=\"10.1186/s12877-024-04666-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMa L, Sun F, Tang Z. Social Frailty is Associated with Physical Functioning, Cognition, and Depression, and Predicts Mortality. J Nutr health aging. 2018;22(8):989\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1007/s12603-018-1054-0\u003c/span\u003e\u003cspan address=\"10.1007/s12603-018-1054-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMisu Y, Katayama O, Lee S, Makino K, Harada K, Tomida K, Morikawa M, Yamaguchi R, Nishijima C, Fujii K, Shimada H. Reciprocal relationship between physical and social frailty among community-dwelling older adults. Arch Gerontol Geriatr. 2023;114:105066. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.archger.2023.105066\u003c/span\u003e\u003cspan address=\"10.1016/j.archger.2023.105066\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNagai K, Tamaki K, Kusunoki H, Wada Y, Tsuji S, Itoh M, Sano K, Amano M, Hayashitani S, Yokoyama R, Yonezawa R, Kamitani T, Shinmura K. Physical frailty predicts the development of social frailty: a prospective cohort study. BMC Geriatr. 2020;20(1):403. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-020-01814-2\u003c/span\u003e\u003cspan address=\"10.1186/s12877-020-01814-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNagai K, Tamaki K, Kusunoki H, Wada Y, Tsuji S, Itoh M, Sano K, Amano M, Hayashitani S, Yokoyama R, Yonezawa R, Kamitani T, Shinmura K. Physical frailty predicts the development of social frailty: a prospective cohort study. BMC Geriatr. 2020;20(1):403. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-020-01814-2\u003c/span\u003e\u003cspan address=\"10.1186/s12877-020-01814-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNg YX, Cheng LJ, Quek YY, Yu R, Wu XV. The measurement properties and feasibility of FRAIL scale in older adults: A systematic review and meta-analysis. Ageing Res Rev. 2024;95:102243. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arr.2024.102243\u003c/span\u003e\u003cspan address=\"10.1016/j.arr.2024.102243\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoguchi M, Kubo H, Kanai M, Nozoe M, Shimada S. Relationship between pre-stroke frailty status and short-term functional outcome in older patients with acute stroke\u0026ndash;A mediation analysis. Arch Gerontol Geriatr. 2021;94:104370. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.archger.2021.104370\u003c/span\u003e\u003cspan address=\"10.1016/j.archger.2021.104370\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOdaci Comertoglu E, Ozturk Y, Hafizoglu M, Kahyaoglu Z, Cavusoglu C, Balci C, Dogu BB, Halil M, Aki E, O., Cankurtaran M. The effect of social frailty on mental health and quality of life in older people: a cross-sectional study. Eur Geriatr Med. 2024;15(2):453\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s41999-024-00931-0\u003c/span\u003e\u003cspan address=\"10.1007/s41999-024-00931-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePark J, Cho A, Lee S, Lee H. Association of nutrition management status, frailty, and social contact frequency with life satisfaction in older adults: A moderated mediation model. Arch Gerontol Geriatr. 2023;113:105019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.archger.2023.105019\u003c/span\u003e\u003cspan address=\"10.1016/j.archger.2023.105019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQi X, Li J. The Relationship between Social Frailty and Depressive Symptoms in the Elderly: A Scoping Review. Int J Environ Res Public Health. 2022;19(24). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph192416683\u003c/span\u003e\u003cspan address=\"10.3390/ijerph192416683\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQi X, Li Y, Hu J, Meng L, Zeng P, Shi J, Jia N, Zeng X, Li H, Zhang Q, Li J, Liu D. Prevalence of social frailty and its associated factors in the older Chinese population: a national cross-sectional study. BMC Geriatr. 2023;23(1):532. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-023-04241-1\u003c/span\u003e\u003cspan address=\"10.1186/s12877-023-04241-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRagusa FS, Veronese N, Smith L, Koyanagi A, Dominguez LJ, Barbagallo M. Social frailty increases the risk of all-cause mortality: A longitudinal analysis of the English Longitudinal Study of Ageing. Exp Gerontol. 2022;167:111901. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.exger.2022.111901\u003c/span\u003e\u003cspan address=\"10.1016/j.exger.2022.111901\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSirgy MJ. A Quality-of-Life Theory Derived from Maslow's Developmental Perspective. Am J Econ Sociol. 1986;45(3):329\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1111/j.1536-7150.1986.tb02394.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1536-7150.1986.tb02394.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSlavich GM, Roos LG, Mengelkoch S, Webb CA, Shattuck EC, Moriarity DP, Alley JC. Social Safety Theory: Conceptual foundation, underlying mechanisms, and future directions. Health Psychol Rev. 2023;17(1):5\u0026ndash;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/17437199.2023.2171900\u003c/span\u003e\u003cspan address=\"10.1080/17437199.2023.2171900\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong Y, Wang M, Zhu M, Wang N, He T, Wu X, Shi Z, Chen M, Ji T, Shen Y. Benefit finding among family caregivers of patients with advanced cancer in a palliative treatment: a qualitative study. BMC Nurs. 2024;23(1):397. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12912-024-02055-z\u003c/span\u003e\u003cspan address=\"10.1186/s12912-024-02055-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuksatan W, Tankumpuan T, Davidson PM. Heart Failure Caregiver Burden and Outcomes: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221112584. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/21501319221112584\u003c/span\u003e\u003cspan address=\"10.1177/21501319221112584\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSun J, Zhou N, Zhang H, Wu H, Wang F, Luo Y. Longitudinal analysis of the mediating role of self-perception of aging in the relationship between frailty and intrinsic capacity: A cross-lagged mediation model. Arch Gerontol Geriatr. 2024;120:105336. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.archger.2024.105336\u003c/span\u003e\u003cspan address=\"10.1016/j.archger.2024.105336\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSun QQ, Tan K, Tang HY, Liu YY, Zhu H, Qin H, Xia X, Zhang M, Chen YY, Nie SS, Wang S. Incidence and predictive value of social frailty among community-dwelling older adults in Southwest China: A prospective cohort study. Front Public Health. 2023;11:1103651. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2023.1103651\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2023.1103651\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang H, Chen X, Zheng M, Wu Y, Liu L. Research status and hotspots of social frailty in older adults: a bibliometric analysis from 2003 to 2022. Front Aging Neurosci. 2024;16:1409155. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fnagi.2024.1409155\u003c/span\u003e\u003cspan address=\"10.3389/fnagi.2024.1409155\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Y, Li J, Fu P, Jing Z, Zhao D, Zhou C. Social support and subsequent cognitive frailty during a 1-year follow-up of older people: the mediating role of psychological distress. BMC Geriatr. 2022;22(1):162. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-022-02839-5\u003c/span\u003e\u003cspan address=\"10.1186/s12877-022-02839-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Y, Zheng F, Zhang X. (2024). The Impact of Social Participation on Frailty among Older Adults: The Mediating Role of Loneliness and Sleep Quality. \u003cem\u003eHealthcare\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(20), 2085. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mdpi.com/2227-9032/12/20/2085\u003c/span\u003e\u003cspan address=\"https://www.mdpi.com/2227-9032/12/20/2085\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu S, Wang J, Zeng L, Yang P, Tang P, Su S. The prevalence of social frailty among older adults: A systematic review and meta-analysis. Geriatr Nurs. 2023;49:101\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.gerinurse.2022.11.009\u003c/span\u003e\u003cspan address=\"10.1016/j.gerinurse.2022.11.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang J, Xiang X, Yang X, Mei Q, Cheng L. The effect of self-disclosure on loneliness among patients with coronary heart disease: The chain mediating effect of social support and sense of coherence. Heart Lung. 2024;64:74\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.hrtlng.2023.11.013\u003c/span\u003e\u003cspan address=\"10.1016/j.hrtlng.2023.11.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang X, Tan SS, Franse CB, Alhambra-Borr\u0026aacute;s T, Dur\u0026aacute;-Ferrandis E, Bilajac L, Markaki A, Verma A, Mattace-Raso F, Voorham AJJ, Raat H. Association between physical, psychological and social frailty and health-related quality of life among older people. Eur J Pub Health. 2019;29(5):936\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/eurpub/ckz099\u003c/span\u003e\u003cspan address=\"10.1093/eurpub/ckz099\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao M, Mou H, Zhu S, Li M, Wang K. Cross-cultural adaptation and validation of the FRAIL-NH scale for Chinese nursing home residents: A methodological and cross-sectional study. Int J Nurs Stud. 2020;105:103556. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijnurstu.2020.103556\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2020.103556\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhu W, Wang Y, Tang J, Wang F. Sleep quality as a mediator between family function and life satisfaction among Chinese older adults in nursing home. BMC Geriatr. 2024;24(1):379. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-024-04996-1\u003c/span\u003e\u003cspan address=\"10.1186/s12877-024-04996-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1.The demographic and disease-related information (n=463)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFrequency(%)/Mean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e67.41(5.173)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eNumber of hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e1.71(0.974)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eNYHA Classes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eClass I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e108(23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eClass II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e123(26.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eClass III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e122(26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eClass IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e110(23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eNumber of chronic diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eNone or one\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e184(39.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eTwo or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e279(60.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e294(63.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e169(36.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e237(51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e226(48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eEducation level\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003ePrimary school or illiterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e288(62.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e141(30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e34(7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e54(11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e409(88.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003eHousehold monthly income\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLess than 1,000 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e103(22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e1,000 RMB to 2,999 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e157(33.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e3,000 RMB to 5,999 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e103(22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAbove 6,000 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e100(21.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Comparison of differences between social frailty in demographic and disease-related information (n=463)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eSocial frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003et/F/r value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2.25(1.354)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eNumber of hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2.25(1.354)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eNYHA Classes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1.811\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003eClass I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.05(1.314)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003eClass II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.41(1.471)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003eClass III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.35(1.075)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003eClass IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.16(1.512)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eNumber of chronic diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eNone or one\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.31(1.373)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eTwo or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.16(1.325)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e-2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.36(1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.07(1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.843\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.24(1.333)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.27(1.379)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eEducation level\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e14.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003ePrimary school or illiterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.01(1.282)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.55(1.386)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3.03(1.314)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e-4.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1.56(1.355)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.34(1.329)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eHousehold monthly income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e7.819\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eLess than 1,000 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.1(1.354)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e1,000 RMB to 2,999 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.08(1.169)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e3,000 RMB to 5,999 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.13(1.202)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eAbove 6,000 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2.82(1.617)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTables 3.The correlations between social frailty, physical frailty, loneliness, and family health (n=463)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eSocial frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003ePhysical frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eLoneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eFamily health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eSocial frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e2.25(1.354)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePhysical frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e2.56(1.481)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e.549**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eLoneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e14.11(8.601)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e-.732**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e-.499**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eFamily health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e6.89(3.221)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e-.540**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e-.367**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e.576**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4.The regression analysis of social frailty (n=463)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 25px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003eThe first layer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003eThe second layer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 25px;\"\u003e\n \u003cp\u003eThe third layer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eStandardized Beta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eStandardized Beta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003eStandardized Beta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 100px;\"\u003e\n \u003cp\u003eCovariates\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.423\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eNumber of hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.276\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e1,000 RMB to 2,999 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e3,000 RMB to 5,999 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eabove 6,000 RMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eIndependent Variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 49px;\"\u003e\n \u003cp\u003eFamily health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 100px;\"\u003e\n \u003cp\u003eMediators\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 74px;\"\u003e\n \u003cp\u003ePhysical frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 74px;\"\u003e\n \u003cp\u003eLoneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e-0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eAdjusted R\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003e0.371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e31.239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e64.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e94.652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5. The mediation analysis of family health, physical frailty, loneliness, and social frailty (n=463)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eModel path\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eStandardized Effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eBootSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eBootLLCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eBootULCI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ePath a1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eFamily health \u0026rarr; physical frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.3069 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0208 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.1820 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.1002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ePath b1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003ePhysical frailty \u0026rarr; social frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e.1511 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0285 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.0822 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e.1941\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ePath a2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eFamily health \u0026rarr; loneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e.3938 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.1056 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e.8441 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1.2591\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ePath b2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eLoneliness \u0026rarr; social frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.3762 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0056 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.0702 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.0483\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ePath d21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003ePhysical frailty \u0026rarr; Loneliness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.2895 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.2285 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-2.1296 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-1.2316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eTotal effect (path c)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eFamily health \u0026rarr; social frailty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.4772 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0141 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.2284 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.1729\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eDirect effect (path c\u0026rsquo;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eFamily \u0026rarr; Social frailty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.2492 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0137 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.1318 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.0778\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eIndirect effect (a1*b1 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.0464 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0111 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.0699 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.0256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eIndirect effect (a2*b2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.1482 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0196 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.1873 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.1104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eIndirect effect (a1*d21*b1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.0334 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0076 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.0497 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.0201\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eTotal indirect effect (a1*b1 + a2*b2+a1*d21*b1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e-.2280 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e.0249 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e-.2775 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-.1788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"heart failure, elderly inpatients, social frailty, physical frailty, family health, loneliness","lastPublishedDoi":"10.21203/rs.3.rs-6574616/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6574616/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cdiv id=\"ASec1\" class=\"AbstractSection\"\u003e\u003cdiv class=\"Heading\"\u003eBackground\u003c/div\u003e\u003cp\u003eThe elderly population in China is about to exceed 300\u0026nbsp;million, and heart failure (HF) is a significant public health problem that seriously endangers the physical and mental health of the elderly. Hospitalized HF patients often suffer from social and physical frailty, and the family is the principal place of care for the elderly, in addition to the hospital and community. Loneliness is a psychological problem that coexists in both developed and developing countries. There is a lack of research on the relationship between family health, physical frailty, loneliness and social frailty in elderly HF inpatients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"ASec2\" class=\"AbstractSection\"\u003e\u003cdiv class=\"Heading\"\u003eObjective\u003c/div\u003e\u003cp\u003eThis study explores the level of social frailty and the factors that influence elderly HF inpatients. It also examines the correlation between family health, physical frailty, loneliness, and social frailty and verifies the chain mediating role of physical frailty and loneliness in the relationship.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"ASec3\" class=\"AbstractSection\"\u003e\u003cdiv class=\"Heading\"\u003eMethod\u003c/div\u003e\u003cp\u003eThis cross-sectional study collected four hundred sixty-three questionnaires from Northeast China, Northwest China and South China. The research assessment tools include the FRAIL scale (physical frailty), Family APGAR index (family health), LSNS-6 (loneliness), and HALFT scale (social frailty). Data analysis was performed using multiple regression analysis and the SPSS PROCESS Macro plug-in Model 6.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"ASec4\" class=\"AbstractSection\"\u003e\u003cdiv class=\"Heading\"\u003eResults\u003c/div\u003e\u003cp\u003eAge (B\u0026thinsp;=\u0026thinsp;0.423, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), number of hospitalizations (B\u0026thinsp;=\u0026thinsp;0.256, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and education level (B\u0026thinsp;=\u0026thinsp;0.116, p\u0026thinsp;=\u0026thinsp;0.004) were risk factors for social frailty in elderly HF inpatients. Social frailty was found to be at a medium-high level, negatively correlated with family health (r=-.540, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and loneliness scores (r=-.732, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and positively correlated with physical exhaustion (r\u0026thinsp;=\u0026thinsp;.549, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Loneliness and physical frailty played a chain-mediating role between family health and social frailty, with an indirect effect of 18.62%, 59.47%, and 13.4%, respectively, all partial mediation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"ASec5\" class=\"AbstractSection\"\u003e\u003cdiv class=\"Heading\"\u003eConclusion\u003c/div\u003e\u003cp\u003eThe level of social frailty in elderly HF patients is moderately high, negatively affected by age, the number of hospitalizations and education level; interacts with family health, physical frailty and loneliness; and physical frailty and loneliness chain-mediate family health and social frailty. It is recommended that healthcare professionals should care about the physical, mental and social health of elderly HF inpatients.\u003c/p\u003e\u003c/div\u003e","manuscriptTitle":"Multiple chain-mediating effects of physical frailty and loneliness on family health and social frailty in hospitalized old patients with heart failure: a cross-section study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-08 16:15:44","doi":"10.21203/rs.3.rs-6574616/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fae1579b-0deb-47c7-87ec-15437fbec2f4","owner":[],"postedDate":"August 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T09:49:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-08 16:15:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6574616","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6574616","identity":"rs-6574616","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}