Estimation of factors associated with self-rated health among older adults living alone: A multilevel analysis of individual and regional determinants.

Purpose: This study was designed to reveal how individual-level characteristics and local-government policy factors associated with self-rated health (SRH) among older adults living alone. Methods: Data were drawn from the 2023 Korean Community Health Survey, including 21,677 adults aged 65 years and older who reported living alone. A multilevel regression analysis was conducted using four models: a null model, an individual-level model, a regional-level model, and a full model including cross-level interactions. Fixed and random effects were estimated. Results: The null model showed an intra-class correlation coefficient of 10.9%, indicating that regional-level factors explained a significant portion of the variance in SRH. In the full model, individual-level factors such as older age, being female, lower educational attainment, lower monthly income, current smoking, and depressive symptoms were significantly associated with lower SRH. Conversely, current alcohol use and greater physical activity were associated with better SRH. At the regional level, a higher older adults welfare budget and the number of healthcare and leisure welfare facilities were positively associated with better SRH. Cross-level interactions showed that the positive effect of regional welfare budgets was attenuated among older individuals and those with higher monthly income, but was amplified for individuals with a higher degree of physical activity. Conclusion: SRH among older adults living alone is related to individual and regional factors. Regional welfare interventions are essential, but their benefits are context-sensitive and vary depending on individual characteristics like age and physical activity level. Structural, context-sensitive interventions at the community level are essential to improving health equity and well-being in this population.