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The significance of frailty in the relationship between socioeconomic status and health-related quality of life in the Korean community-dwelling elderly population: mediation analysis with bootstrapping

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Firstly, to investigate the prevalence of frailty and impact on health-related quality of life (HRQOL) in a Korean community-dwelling elderly population using the Fried frailty criteria; secondly, to investigate the associations among frailty, socioeconomic status (SES), and HRQOL of the Korean community-based population; and thirdly, to analyze the relationship between education, income, and frailty.


Nine hundred and sixty-four apparently heathy subjects from the Korean community-based population were enrolled in this prospective cross-sectional study. Using self-reported questionnaires, demographic data, SES, and HRQOL were evaluated. Frailty status was determined according to the Fried frailty criteria. After adjustment of covariates including age, sex, and BMI, multivariate linear regression analyses were conducted to assess each component of the proposed mediation models, and mediation was also verified by the bootstrapping technique.


Among the 964 participants, 530 (55.0%), 399 (41.4%), and 35 (3.6%) participants were classified into the robust, pre-frailty, and frailty group, respectively. The frail group demonstrated significantly lower HRQOL. Participants with lower income or education level had significantly higher chances of being frail. Frailty acted as a mediator in this association between low SES (education and income) and low HRQOL. Furthermore, income contributed most to the explanation of educational differences in frailty, suggesting full mediation.


Frailty has a significant negative influence on HRQOL in the community-based elderly population, and acts as a mediator between SES and HRQOL. As a mediator, income can explain educational difference related with the frailty.

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  1. Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K. (2013). Frailty in elderly people. Lancet, 381(9868), 752–762. doi:10.1016/s0140-6736(12)62167-9.

    Article  PubMed  Google Scholar 

  2. Tom, S. E., Adachi, J. D., Anderson, F. A., Jr., Boonen, S., Chapurlat, R. D., Compston, J. E., et al. (2013). Frailty and fracture, disability, and falls: A multiple country study from the global longitudinal study of osteoporosis in women. Journal of the American Geriatrics Society, 61(3), 327–334. doi:10.1111/jgs.12146.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., et al. (2001). Frailty in older adults: evidence for a phenotype. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 56(3), M146–M156.

    Article  CAS  Google Scholar 

  4. Chang, Y. W., Chen, W. L., Lin, F. G., Fang, W. H., Yen, M. Y., Hsieh, C. C., et al. (2012). Frailty and its impact on health-related quality of life: A cross-sectional study on elder community-dwelling preventive health service users. PLoS ONE, 7(5), e38079. doi:10.1371/journal.pone.0038079.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Hoogendijk, E. O., van Hout, H. P., Heymans, M. W., van der Horst, H. E., Frijters, D. H., Broese van Groenou, M. I., et al. (2014). Explaining the association between educational level and frailty in older adults: Results from a 13-year longitudinal study in the Netherlands. Annals of Epidemiology, 24(7), 538–544. doi:10.1016/j.annepidem.2014.05.002. e532.

    Article  PubMed  Google Scholar 

  6. Mulasso, A., Roppolo, M., & Rabaglietti, E. (2014). The role of individual characteristics and physical frailty on health related quality of life (HRQOL): A cross sectional study of Italian community-dwelling older adults. Archives of Gerontology and Geriatrics, 59(3), 542–548. doi:10.1016/j.archger.2014.08.012.

    Article  PubMed  Google Scholar 

  7. Kim, H. J., Kim, S. C., Kang, K. T., Chang, B. S., Lee, C. K., & Yeom, J. S. (2014). Influence of educational attainment on pain intensity and disability in patients with lumbar spinal stenosis: Mediation effect of pain catastrophizing. Spine (Phila Pa 1976), 39, E637–E644. doi:10.1097/BRS.0000000000000267.

    Article  Google Scholar 

  8. Kim, J. H., & Park, E. C. (2015). Impact of socioeconomic status and subjective social class on overall and health-related quality of life. BMC Public Health, 15, 783. doi:10.1186/s12889-015-2014-9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Lubetkin, E. I., Jia, H., Franks, P., & Gold, M. R. (2005). Relationship among sociodemographic factors, clinical conditions, and health-related quality of life: examining the EQ-5D in the U.S. general population. Quality of Life Research, 14(10), 2187–2196. doi:10.1007/s11136-005-8028-5.

    Article  PubMed  Google Scholar 

  10. Gobbens, R. J. J., Luijkx, K. G., & van Assen, M. A. L. M. (2013). Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty. Quality of Life Research, 22(8), 2051–2061. doi:10.1007/s11136-012-0341-1.

    Article  PubMed  Google Scholar 

  11. Bobak, M., Pikhart, H., Hertzman, C., Rose, R., & Marmot, M. (1998). Socioeconomic factors, perceived control and self-reported health in Russia. A cross-sectional survey. Social Science & Medicine, 47(2), 269–279.

    Article  CAS  Google Scholar 

  12. Anderson, N. B., & Armstead, C. A. (1995). Toward understanding the association of socioeconomic status and health: a new challenge for the biopsychosocial approach. Psychosomatic Medicine, 57(3), 213–225.

    Article  CAS  PubMed  Google Scholar 

  13. Seeman, T. E., & Crimmins, E. (2001). Social environment effects on health and aging: integrating epidemiologic and demographic approaches and perspectives. Annals of the New York Academy of Sciences, 954, 88–117.

    Article  CAS  PubMed  Google Scholar 

  14. Goldman, N. (2001). Social inequalities in health disentangling the underlying mechanisms. Annals of the New York Academy of Sciences, 954, 118–139.

    Article  CAS  PubMed  Google Scholar 

  15. Adler, N. E., & Newman, K. (2002). Socioeconomic disparities in health: pathways and policies. Health Affairs (Millwood), 21(2), 60–76.

    Article  Google Scholar 

  16. Park, S., Kim, H. J., Ko, B. G., Chung, J. W., Kim, S. H., Park, S. H., et al. (2016). The prevalence and impact of sarcopenia on degenerative lumbar spinal stenosis. Bone Joint J, 98-b(8), 1093–1098. doi:10.1302/0301-620x.98b8.37623.

    Article  CAS  PubMed  Google Scholar 

  17. Dolan, P. (1997). Modeling valuations for EuroQol health states. Medical Care, 35(11), 1095–1108.

    Article  CAS  PubMed  Google Scholar 

  18. Rabin, R., & de Charro, F. (2001). EQ-5D: a measure of health status from the EuroQol Group. Annals of Medicine, 33(5), 337–343.

    Article  CAS  PubMed  Google Scholar 

  19. Chun, M. Y. (2012). Validity and reliability of Korean version of international physical activity questionnaire short form in the elderly. Korean Journal of Family Medicine, 33(3), 144–151. doi:10.4082/kjfm.2012.33.3.144.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Gary, R. (2012). Evaluation of frailty in older adults with cardiovascular disease: incorporating physical performance measures. Journal of Cardiovascular Nursing, 27(2), 120–131. doi:10.1097/JCN.0b013e318239f4a4.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kim, M. H., Cho, Y. S., Uhm, W. S., Kim, S., & Bae, S. C. (2005). Cross-cultural adaptation and validation of the Korean version of the EQ-5D in patients with rheumatic diseases. Quality of Life Research, 14(5), 1401–1406.

    Article  PubMed  Google Scholar 

  22. Preacher, K., & Hayes, A. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, 36(4), 717–731. doi:10.3758/BF03206553.

    Article  Google Scholar 

  23. Preacher, K., & Hayes, A. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891. doi:10.3758/BRM.40.3.879.

    Article  PubMed  Google Scholar 

  24. Santos-Eggimann, B., Cuenoud, P., Spagnoli, J., & Junod, J. (2009). Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 64(6), 675–681. doi:10.1093/gerona/glp012.

    Article  Google Scholar 

  25. Syddall, H., Roberts, H. C., Evandrou, M., Cooper, C., Bergman, H., & Aihie Sayer, A. (2010). Prevalence and correlates of frailty among community-dwelling older men and women: findings from the Hertfordshire Cohort Study. Age and Ageing, 39(2), 197–203. doi:10.1093/ageing/afp204.

    Article  PubMed  Google Scholar 

  26. Jung, H. W., Kim, S. W., Ahn, S., Lim, J. Y., Han, J. W., Kim, T. H., et al. (2014). Prevalence and outcomes of frailty in Korean elderly population: comparisons of a multidimensional frailty index with two phenotype models. PLoS ONE, 9(2), e87958. doi:10.1371/journal.pone.0087958.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Bielderman, A., de Greef, M. H., Krijnen, W. P., & van der Schans, C. P. (2015). Relationship between socioeconomic status and quality of life in older adults: A path analysis. Quality of Life Research, 24(7), 1697–1705. doi:10.1007/s11136-014-0898-y.

    Article  CAS  PubMed  Google Scholar 

  28. Huguet, N., Kaplan, M. S., & Feeny, D. (2008). Socioeconomic status and health-related quality of life among elderly people: results from the Joint Canada/United States Survey of Health. Social Science and Medicine, 66(4), 803–810. doi:10.1016/j.socscimed.2007.11.011.

    Article  PubMed  Google Scholar 

  29. Dent, E., Kowal, P., & Hoogendijk, E. O. (2016). Frailty measurement in research and clinical practice: A review. European Journal of Internal Medicine, 31, 3–10. doi:10.1016/j.ejim.2016.03.007.

    Article  PubMed  Google Scholar 

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Ho-Joong Kim and Saejong Park contributed equally to the writing of this article. This study was supported by research grants from the Korea Sports Promotion Foundation. The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.


This study was funded by the Korea Sports Promotion Foundation.

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Correspondence to Jin S. Yeom.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all participants included in the study.

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Kim, HJ., Park, S., Park, SH. et al. The significance of frailty in the relationship between socioeconomic status and health-related quality of life in the Korean community-dwelling elderly population: mediation analysis with bootstrapping. Qual Life Res 26, 3323–3330 (2017).

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