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Article

Effect of Positive Mental Health on Elderly Patients with Chronic Diseases: The Chain-Mediated Effects of Gratitude and Forgiveness Tendencies at a Tertiary Hospital in Guangzhou

by
Hai-Cheng Liu
1,†,
Ying Zhou
1,2,*,†,
Chun-Qin Liu
1,
Xiao-Bing Wu
3,
Graeme D. Smith
4,
Thomas Kwok-Shing Wong
1,
Xin-Yang Hu
1,
Yi-Meng Liu
1,
Ying-Ying Qin
1 and
Wen-Jing Wang
1
1
School of Nursing, Guangzhou Medical University, Guangzhou 511436, China
2
Health Medical School, Guangzhou Huashang College, Guangzhou 511300, China
3
The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
4
School of Health Sciences, Saint Francis University, Hong Kong SAR, China
*
Author to whom correspondence should be addressed.
†
These authors have contributed equally to this work and share first authorship.
Healthcare 2025, 13(5), 444; https://doi.org/10.3390/healthcare13050444
Submission received: 16 January 2025 / Revised: 7 February 2025 / Accepted: 17 February 2025 / Published: 20 February 2025
(This article belongs to the Topic Exploring the Interplay of Psychology and Work-Related Health and Well-Being)
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Abstract

:
Background: This study aims to elucidate the mediating roles of gratitude and forgiveness tendency between mature happiness and positive mental health, seeking to reveal the significance of enhancing these psychological traits to enhance the well-being of this population, so as to provide a theoretical foundation for strategies aimed at promoting healthy aging and enhancing the happiness of elderly patients with chronic illness. Methods: From April to October 2024, elderly patients with chronic diseases in the geriatric department of a tertiary hospital in Guangzhou China were selected as subjects through convenience sampling. The study utilized the general information questionnaire, the Chinese Version of Mature Happiness Scale-Revised, the Positive Mental Health Scale, the Gratitude Questionnaire-6, and the Tendency to Forgive Scale for data collection. Results: A total of 319 valid questionnaires were obtained. The mature happiness, positive mental health, gratitude, and forgiveness tendency of elderly patients with chronic diseases were at a medium level. Correlation analysis indicated that mature happiness was positively associated with positive mental health, gratitude, and forgiveness tendency. Mediation analysis illuminated that positive mental health robustly predicted the extent of gratitude, which served as a pivotal predictor of mature happiness. Moreover, gratitude and forgiveness tendency together played a significant chain mediating role between mature happiness and positive mental health, accounting for 26.31% of the total effect (p = 0.246). Conclusions: Positive mental health has a significant positive impact on mature happiness amongst elderly patients with chronic diseases, mediated through the chain mediating effects of gratitude and forgiveness tendency. Consequently, fostering traits of gratitude and forgiveness in this population may enhance their mental health and mature happiness.

1. Introduction

Globally, the continuous growth of the elderly population has shifted the focus of public health towards promoting healthy aging. As life expectancy increases, the prevalence and burden of chronic diseases have escalated [1]. Chronic diseases are characterized by their repetitive nature, long duration, poor prognosis, numerous sequelae, and complications, and the associated economic and social burdens significantly impact the physical and mental health of the elderly [2]. Healthy aging encompasses not only physical health but also psychological well-being and happiness [3]. However, traditional psychological research on elderly patients with chronic diseases primarily emphasizes negative emotions such as depression, anxiety, and loneliness, often overlooking the crucial role of internal positive qualities and emotions in maintaining overall health. Studies indicate that enhancing well-being can help delay the progression of chronic diseases, alleviate negative emotions, and promote patient recovery [4].
In traditional positive psychology, happiness is frequently characterized as a fleeting and variable experience centered on positive emotions like satisfaction and pleasure [5]. Nonetheless, this definition possesses limitations. It rests upon a simplistic binary perspective that bifurcates emotions into positive and negative, disregarding the notion that the essence of happiness may lie in a dynamic equilibrium between these opposing emotional states, rather than the supremacy of a single emotion type. To a certain extent, this outlook inadequately accounts for individuals’ internal stability and adaptability when confronted with life’s complexities and uncertainties, nor does it proficiently elucidate how individuals attain enduring happiness amidst multifaceted and volatile life circumstances [6,7].
With the advancement of Existential Positive Psychology (EPP) [8], scholars have delved into the mechanisms by which individuals sustain enduring happiness despite facing adversities. EPP emphasizes the positive aspects of life and seeks a balance between negative and positive elements, moving beyond a simple binary view in order to cultivate a more flexible and mature happiness [9,10]. Compared to the traditional definition of happiness, mature happiness is a more persistent and profound state of well-being that focuses on the individual’s ability to maintain a positive attitude in the face of challenges [11]. It encompasses traits such as inner harmony, self-acceptance, and life satisfaction [12]. Furthermore, mature happiness stems from positive cognition and evaluations of oneself, others, and life, developed through continuous self-growth and adaptation over time [13]. Studies indicate that mature happiness is a stronger predictor of psychological distress, such as stress, anxiety, and loneliness, in comparison to traditional subjective happiness measures [14]. Consequently, investigating the internal mechanisms underlying well-being, particularly mature happiness, holds significant practical implications for elderly patients with chronic diseases.
Positive mental health serves as a fundamental pillar of psychological well-being and it can help to motivate individuals to pursue self-improvement in response to environmental changes [15], playing a crucial role in enhancing overall well-being and reducing anxiety and loneliness amongst elderly [16]. Gratitude, defined as the ability to perceive and appreciate positive aspects of life, encourages individuals to focus on the bright side of life, thereby effectively preventing the emergence of negative emotions [17]. Additionally, forgiveness tendency is an intrinsic and stable personality characteristic that enables individuals to transition from negative to positive states when confronted with interpersonal offenses or adverse situations [18].
Evidence has demonstrated that the psychological traits of gratitude and forgiveness can have a significant positive impact on individuals’ mental health and quality of life. Specifically, gratitude can enhance an individual’s positive emotions and life satisfaction [19], whilst forgiving others can help to reduce levels of psychological stress and negative emotions [20]. For patients with chronic illnesses, these psychological traits can facilitate mental health status improvement [21]. García-Vázquez [22] further revealed a positive correlation between tendencies toward gratitude and forgiveness, individuals with higher levels of gratitude are more likely to exhibit prosocial behaviors and be more inclined to forgive others. This combination of psychological traits plays a positive role in promoting individuals’ mental health and social interactions. Levine [23] noted that chronic disease patients often face physical and emotional fatigue, leading to increased negative emotions and decreased mental health, thereby lowering their overall happiness levels. However, high levels of gratitude can effectively mitigate the negative effects caused by chronic diseases. Additionally, Chen [24] demonstrated that with social and family support, individuals can explore the world through a grateful perspective, actively engage in healthy behaviors, and manage their health more effectively, thereby slowing disease progression and extending life expectancy. Furthermore, studies by Vosvick [25] and Charzyńska [26] indicated that when faced with poor health conditions, self-forgiveness, gratitude, and forgiveness towards others can provide psychological capital to improve patient well-being, enhancing their psychological resilience and adaptive capacity. According to PERMA theory [27] and the cognitive adaptation theory [28], positive mental health, gratitude, and forgiveness tendency act as critical psychological capital, enhancing positive emotions and facilitating cognitive remodeling. This process can enable patients to reframe chronic disease related challenges, promoting a sense of life engagement and meaning, which is crucial for improving mature happiness in elderly patients with chronic diseases.
However, to date, limited research exists on the correlation between mature happiness and positive mental health, gratitude, and forgiveness tendency in global, particularly amongst elderly patients with chronic diseases. This study aims to investigate these relationships to enhance the understanding of how positive mental states collaboratively promote mature happiness. By doing so, this research seeks to enrich the theoretical frameworks of positive psychology and geriatric psychology. These findings may provide insights into methods and strategies for enhancing the well-being of elderly patients with chronic diseases, thereby providing theoretical support for active aging. This study posits the following hypotheses, which are illustrated in Figure 1:
(1)
Demographic and disease-related factors may influence mature happiness in elderly patients with chronic diseases.
(2)
Positive mental health, gratitude, and forgiveness tendency are significantly associated with mature happiness in elderly patients with chronic diseases.
(3)
Positive mental health will influence mature happiness through the mediating effect of gratitude or forgiveness tendency.
(4)
Gratitude and forgiveness tendency play a chain mediating role in the influence of positive mental health and mature happiness.

2. Methods

2.1. Study Design

The study adhered to the STROBE guidelines for cross-sectional research and employed a descriptive cross-sectional design.

2.2. Participants

From May to September 2024, a convenience sampling method was employed to recruit elderly patients with chronic diseases from the geriatric department of a tertiary hospital in Guangzhou China for a questionnaire survey. Inclusion criteria: (1) Age ≥ 60 years old [29]; (2) Diagnosis of at least one chronic disease as defined by the International Classification of Diseases, 11th Revision (ICD-11) [30], including but not limited to chronic obstructive pulmonary disease, hypertension, and diabetes; (3) Normal language expression and comprehension abilities; (4) Provided informed consent and voluntarily participated in the study. Exclusion criteria: (1) Conditions indicative of critical health status or terminal phase, including but not limited to organ failure and severe traumatic injuries; (2) Severe mental illness or cognitive impairment precluding normal communication; (3) Suffering major changes within half a year.

2.3. Sample Size

Based on the sample size estimation method for quantitative studies [31], the required sample size was calculated to be 5–10 times the number of independent variables. Considering a potential 20% rate of invalid responses, the target sample size was determined to be between 163 and 325 participants. This study ultimately included 335 questionnaires, thereby meeting the sample size requirement.

2.4. Measuring Instruments

2.4.1. Demographics

A self-developed general information questionnaire was employed, encompassing demographic details including gender and age, as well as the status of chronic diseases.

2.4.2. The Chinese Version of the Mature Happiness Scale–Revised (MHS-R-CV)

The Mature Happiness Scale was originally developed by Wong [12], later revised by Carreno [14]. Our research team translated, sinicized, and cross-culturally adapted of the revised English version to create the MHS-R-CV. With a Cronbach’s α coefficient or 0.921, the MHS-R-CV demonstrates strong internal consistency and is well-suited for assessing mature happiness among Chinese residents. The scale comprises seven items that measure aspects such as inner harmony, calmness, acceptance, satisfaction, and overall life satisfaction using a 5-point Likert scale ranging from 1 (not at all) to 5 (all of the time). Total scores range from 7 to 35, with higher scores indicating greater mature happiness.

2.4.3. Positive Mental Health Scale (PMHS)

Originally developed by German scholars Lukat [32], the PMHS aims to assess the internal and external factors of individual positive mental health and consists of 9 items. It uses a Likert 4-point rating scale, with higher scores indicating higher levels of positive mental health. The scale has been validated and applied in several countries, including France, Germany, and Russia [33]. The Chinese adaptation of the PMHS was employed in this study, demonstrating a Cronbach’s α coefficient of 0.95 and a test–retest reliability of 0.69, indicating satisfactory psychometric properties within the Chinese population [34].

2.4.4. The Gratitude Questionnaire-6 (GQ-6)

The Gratitude Questionnaire-6 was developed by Emmons and McCullough [35]. It is used to evaluate the frequency and intensity of individuals’ feelings of gratitude, as well as the density and breadth of events that produce gratitude, so as to reflect individual differences in the characteristics of gratitude. The scale contains six affective, thought, or behavioral items related to gratitude. In our study, the Cronbach’s α coefficient of the Chinese version of the scale was 0.81 [36]. The Likert 7-point scoring method was used, in which 1 represented “strongly disagree” and 7 represented “strongly agree”. Items 3 and 6 needed to be scored in reverse. The total score spans from 6 to 42, with elevated scores signifying greater levels of gratitude traits in the individual.

2.4.5. Tendency to Forgiveness Scale (TTF)

This scale was developed by Brown [37] to assess the level of an individual’s tendency to forgive from the perspective of temperament. The scale contains 4 items and is scored on a 5-point Likert scale ranging from 1 “strongly disagree” to 5 “strongly agree”, with higher scores indicating a greater tendency to forgive. The scale showed good internal consistency reliability (α = 0.82) and test–retest reliability (r = 0.71). The Chinese version also shows good reliability (α = 0.61) and validity, and has been widely used for studies involving college students [38].

2.5. Research Methodology

In this survey design study, two professionally trained nursing graduate students served as investigators, and data were collected using structured questionnaires and face-to-face interviews. Before filling in the questionnaire, the investigator explained the purpose and significance of the study in detail to the elderly patients with chronic diseases who participated in the study, filled it in in an anonymous manner after obtaining the patient’s consent, and withdrew it immediately after completion. If the study participant had poor vision or low education, the investigator assisted in filling out the questionnaire based on the patient’s verbal responses. A total of 335 questionnaires were collected in this survey, including 16 invalid questionnaires and 319 valid questionnaires, with an effective recovery rate of 95.22%.

2.6. Statistical Analysis

SPSS 27.0 software was used for data analysis. Count data were described as frequency and percentage. The measurement data conforming to normal distribution were expressed as mean (M) and standard deviation (SD). Two independent sample t test, or analysis of variance was used for comparison between groups. Pearson correlation analysis was used to explore the correlation between mature happiness and positive mental health, gratitude and forgiveness tendency in elderly patients with chronic diseases. SPSS macro PROCESS 4.1 was used to test the mediation effect.

3. Results

3.1. Common Method Bias Test

In this study, Harman single factor was used to detect common method bias. The results showed that a total of four factors with eigenvalues greater than 1 were extracted, and the first factor explained 36.43% of the variance, which was lower than the critical standard of 40% [39]. Controlling for the effects of an unmeasured latent methods factor (ULMC) also corroborated this assertion. The comparison between the bifactor model (RMSEA = 0.062, CFI = 0.916, TLI = 0.906) and the model with only trait factors (RMSEA = 0.069, CFI = 0.893, TLI = 0.881) revealed no significant differences. The improvement in fit indices was minimal, with increases in CFI and TLI values less than 0.1 and a decrease in RMSEA value less than 0.05 [40]. Therefore, the common method bias in this study can be considered not to be a serious problem.

3.2. Sample Characteristics

This study included 319 elderly patients with chronic diseases aged between 60 and 91 years, with an average age of (68.33 ± 6.76) years. The highest proportion of patients was aged between 60 and 70 years (70.2%). There were 160 male patients (50.2%) and 159 female patients (49.8%). The majority of study participants were married (84.6%), and half (49.8%) lived with their spouses. The majority of patients had a monthly pension income of between CNY 2000 and 3999 (43.9%). One hundred and forty-two patients had a chronic disease history of over 10 years or more, and most patients took more than two medications daily (65.2%). More than half of the patients had two or more chronic diseases (66.8%). The univariate analysis and t test found that there were statistically significant differences in the MHS-R-CV scores of elderly patients with chronic diseases in terms of the three variables of current living style, marital status, and perceived health status (p < 0.05). Refer to Table 1 for details.

3.3. Descriptive Statistic and Correlation Analysis Among Variables

The scores of MHS-R-CV, PMHS, GQ-6, and TFF of 319 elderly patients with chronic diseases were (21.02 ± 6.77), (22.91 ± 5.01), (25.05 ± 5.61), and (13.14 ± 2.95), respectively. The results of correlation analysis showed that the mature happiness of elderly patients with chronic diseases was positively correlated with positive mental health, gratitude, and forgiveness tendency (r = 0.691, 0.612, 0.590, all p < 0.01), and positive mental health was positively correlated with gratitude and forgiveness tendency (r = 0.404, 0.373, all p < 0.01). Gratitude was positively correlated with forgiveness tendency (r = 0.729, p < 0.01). See Table 2.

3.4. Multiple Linear Regression Analysis of Influencing Factors of Mature Happiness in Elderly Patients with Chronic Diseases

Taking mature happiness as the dependent variable, three statistically significant variables in the univariate analysis and t test (p < 0.05), current living style, marital status and perceived health status, were used as control variables, and a silent variable was set. In addition, positive mental health, gratitude, and forgiveness tendency were used as independent variables, and multiple linear regression analysis was conducted by stepwise method. The independent variable assignment is shown in Table 3.
Through stepwise regression analysis, a total of three models were obtained. Ultimately, the variables of positive mental health, gratitude, and forgiveness tendency were included in the model, indicating that these three variables are the influencing factors of mature happiness of elderly chronic disease patients. The coefficient of determination R2 of the regression model was 0.633, adjusted R2 was 0.630, F was 181.105 (p < 0.001), suggesting that the model fits well, and the variables entered into the model can explain 63.0% of the total variance of mature happiness of elderly chronic disease patients. In addition, the tolerance value in this study was 0.449 to 0.823, and the variance inflation factor (VIF) was 1.215 to 2.228 < 10 [41], indicating that there is no serious multicollinearity problem among the variables, and the detailed results are shown in Table 4.

3.5. Analysis of the Chain Mediation Effect Between Mature Happiness and Positive Mental Health in Elderly Patients with Chronic Diseases

In order to deeply explore the positive effects of positive mental health, gratitude and forgiveness tendency on mature happiness and its internal mechanism, this study took positive mental health as the dependent variable (X), gratitude and forgiveness tendency as the mediating variable (M), and mature happiness as the independent variable (Y). Multivariate hierarchical regression analysis under Model 6 was performed using the PROCESS 4.1 macro program of SPSS software. The results showed that positive mental health had a significant positive predictive effect on gratitude and mature happiness (β = 0.453, 0.689, both p < 0.001). Positive mental health had a positive predictive effect on forgiveness tendency (β = 0.055, p = 0.025). In addition, gratitude showed a significant positive predictive effect on forgiveness tendency and mature well-being (β = 0.363, 0.295, both p < 0.001), and forgiveness tendency also had a significant positive predictive effect on mature happiness (β = 0.510, p < 0.001) (see Table 5).
Gratitude and forgiveness tendency had a chain mediating effect on positive mental health and mature happiness in elderly patients with chronic diseases, and the mediating effect value was 0.246, accounting for 26.31% of the total effect (0.935). Positive mental health affects mature happiness through the following four paths: (1) direct path: positive mental health → mature happiness; (2) indirect path 1: positive mental health → gratitude → mature happiness; (3) indirect path 2: positive mental health → forgiveness tendency → mature happiness; (4) indirect path 3: positive mental health → gratitude → forgiveness tendency → mature happiness. The relational model is shown in Figure 2.
A total of 5000 bootstrap samples were randomly and repeatedly selected from 319 elderly patients with chronic diseases to test the chain mediating effect of gratitude and forgiveness tendency between positive mental health and mature happiness of elderly patients with chronic diseases. The results showed that the 95% CI of the three indirect paths did not include 0, indicating that the independent mediating effect of gratitude and forgiveness tendency and the chain mediating effect of gratitude and forgiveness tendency were significant. The proportion of the three indirect path effects was 14.33%, 2.99%, and 8.98%, respectively, as detailed in Table 6.

4. Discussion

Quality of Life (QoL) is a comprehensive and holistic concept that encompasses an individual’s overall state and satisfaction across multiple dimensions, including physical health, psychological well-being, social relationships, environment, and economic status [42]. For elderly patients with chronic diseases, the long-term impact of illness not only leads to physical decline but also induces feelings of helplessness and despair. Moreover, it frequently gives rise to psychological issues such as loneliness, anxiety, and depression [43]. These psychological challenges further diminish their overall satisfaction and erode their quality of life. Therefore, addressing the psychological issues of elderly patients with chronic diseases is of paramount importance for alleviating the burden of illness and enhancing their quality of life. In this study, we have shown the interactions between positive mental health, gratitude, forgiveness tendencies, and mature happiness in older adults with chronic diseases. Preliminary results showed that the score of elderly patients with chronic diseases in MHS-R-CV was (21.02 ± 6.77) points, slightly higher than the median total score of 21 points, showing a medium level of mature well-being, which still needs to be further improved, similar to the research results of Carreno [14]. This may be due to the long-term existence of chronic diseases and the coexistence of multiple diseases, which make elderly face a higher risk of disability and the threat of a shortened health life span, potentially causing psychological distress, leading to decreased happiness [44]. Therefore, health care professionals need to have awareness of the importance of identifying and screening for mental health problems in elderly patients with chronic diseases as early as possible, to enable mental health interventions and management measures in order to improve their overall well-being.
Further correlational analyses revealed significant positive associations between mature happiness and high levels of positive mental health, gratitude, and forgiveness tendencies in older adults with chronic diseases, similar to previous findings [45,46]. This suggests that elderly patients with chronic diseases who have better positive mental health status and higher levels of gratitude and forgiveness tendency experience stronger mature happiness. This may be explained as those with personality traits often have better emotional stability and self-efficacy, a greater ability to quickly adjust their mindset to relieve the discomfort and stress caused by the disease, leading them to view the disease in a more positive perspective, be more self-focused, and have better recovery beliefs [47]. Secondly, gratitude can stimulate the positive emotional experience of elderly patients with chronic diseases, alleviate the pain caused by excessive attention to the disease, optimize their interpersonal relationships, build a more solid social support system, and thus enhance their mature happiness [48]. Finally, forgiveness tendency helps patients release negative emotions, reduce psychological burden, promote self-acceptance, enhance inner peace and tranquility, and further enhance happiness experience [49].
In exploring the relationship between positive mental health and mature happiness, this study revealed the mediating roles of gratitude and forgiveness tendencies. This finding holds significant implications for the clinical management of elderly patients with chronic illnesses. Mediation analysis indicated that gratitude and forgiveness tendencies significantly mediate the relationship between positive mental health and mature happiness, accounting for 26.31% of the total effect. These results suggest that a positive mental health state can indirectly enhance the level of mature happiness in elderly patients with chronic illnesses by increasing their tendencies towards gratitude and forgiveness.
In clinical practice, this may imply that psychological interventions such as gratitude training, forgiveness promotion activities, or mindfulness meditation can help patients focus more on self-awareness and acceptance, effectively improving their levels of positive mental health and better equipping them to face the challenges posed by chronic diseases [50,51]. These interventions not only improve emotional states but also may help to promote psychological maturity and well-being by enhancing gratitude and forgiveness tendencies, thereby playing an active role in chronic disease management [52]. Therefore, cultivating these traits can enhance patients’ psychological adaptability, increase their life satisfaction and vitality, and reduce negative emotions, such as depression and envy [53]. Additionally, the cultivation of gratitude and forgiveness can be achieved through narrative nursing, a method proven to effectively alleviate depression and anxiety symptoms in chronic disease patients, enhancing their quality of life and treatment adherence [54]. Through narrative nursing, patients are better able to understand their emotions and experiences, achieving psychological growth and maturity [55], which aligns with the concept of mature happiness. By considering these psychological tendencies comprehensively and incorporating them into treatment and care plans, the overall well-being of patients can be effectively enhanced.

Limitations

The limitation of this study is that only one tertiary hospital in Guangzhou was selected as the survey object, and the sample size was small and may be affected by regional differences. Therefore, it is necessary to expand the scope of investigation, increase the sample size, and construct more targeted and universal intervention programs in the future, so as to better evaluate the mature happiness level of this special population.

5. Conclusions

In conclusion, positive mental health not only directly affects mature happiness, but also indirectly promotes mature happiness by enhancing gratitude, and the chain mediating effect of gratitude and forgiveness tendency. Therefore, in the intervention to improve the mature happiness of elderly patients with chronic diseases, gratitude and forgiveness can be cultivated to improve their mature happiness. Future research can further explore the differences in mediating effects of gratitude and forgiveness on mature happiness in the elderly patients with chronic diseases under different cultural backgrounds to verify its universality. At the same time, long-term follow-up studies can be carried out to observe the lasting effects of interventions to cultivate gratitude and forgiveness tendency on mature happiness of the elderly patients with chronic diseases.

Author Contributions

H.-C.L. contributed to this article by coordinating data collection, elaborating the theoretical framework, and writing the manuscript. Y.Z. contributed to this article through the coordination of research design, data collection, the writing of the manuscript, financial support, and supervision. G.D.S. and T.K.-S.W. contributed to this article through a critical revision of the manuscript and English grammar modification and translation. C.-Q.L. participated in the design process of this study, assisted in statistical analysis of the data, and reviewed and revised the article. X.-B.W. provided clinical data collection resources for this study to ensure the smooth development of the investigation and solved problems in the clinical data collection process. X.-Y.H., Y.-M.L., Y.-Y.Q. and W.-J.W. assisted in clinical data collection and data management, as well as statistical analysis. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by The Key Discipline Project (Nursing) of Guangzhou Education Bureau, Grant/Award Number: 06-410-2108021, and the Academic Backbone Scientific Research Project for teachers in the School of Nursing, Guangzhou Medical University, Grant/Award Number: 2022.

Institutional Review Board Statement

This study was conducted in strict accordance with the Declaration of Helsinki. The Human Research Ethics Committee at Guangzhou Medical University approved this study (approval number: 202403006, approval date: 26 March 2024). The research was conducted in compliance with local legislative and institutional requirements.

Informed Consent Statement

All participants provided written informed consent to take part in the study.

Data Availability Statement

The data are available upon request from the corresponding author.

Acknowledgments

The authors would like to thank all participants of the study.

Conflicts of Interest

The authors declare no conflicts of interest.

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Healthcare 13 00444 g001
Figure 1. Hypotheses model.
Figure 1. Hypotheses model.
Healthcare 13 00444 g001
Healthcare 13 00444 g002
Figure 2. Chain mediation model of gratitude and forgiveness tendency in positive mental health and mature happiness of elderly patients with chronic diseases (Note: ** indicates p < 0.001, * indicates p < 0.05).
Figure 2. Chain mediation model of gratitude and forgiveness tendency in positive mental health and mature happiness of elderly patients with chronic diseases (Note: ** indicates p < 0.001, * indicates p < 0.05).
Healthcare 13 00444 g002
Table 1. Sample characteristics and univariate analysis (n = 319).
Table 1. Sample characteristics and univariate analysis (n = 319).
Variablen%MHS-R-CV Score
(Mean ± SD)		t/Fp
Gender −1.2080.228
Male16050.220.56 ± 6.61
Female15949.821.48 ± 6.92
Age (years) 2.8710.058
60–7022470.220.46 ± 6.80
71–797222.622.01 ± 6.78
≥80237.223.3 ± 5.82
Current living style 3.3630.036
Solitude278.517.89 ± 5.83
Cohabitation15949.821.10 ± 6.94
Live with children or relatives13341.721.56 ± 6.63
Marital status −2.3300.020
Married27084.621.39 ± 6.88
Not in marriage4915.418.96 ± 5.77
Degree of education 0.9270.449
Primary and below3711.620.70 ± 7.46
Middle school9128.521.95 ± 6.69
High school/technical secondary school1023221.16 ± 6.57
Diploma5517.220.16 ± 6.61
Bachelor degree or above3410.719.85 ± 7.10
Pension income (CNY/monthly) 2.4220.066
<2000351122.14 ± 7.15
2000–399914043.919.90 ± 6.74
4000–599910332.322.03 ± 6.83
≥60004112.921.34 ± 5.99
Perceived health status 6.0770.003
Good14043.922.28 ± 6.43
General13040.820.58 ± 6.69
Bad4915.418.57 ± 7.27
Self-care ability of daily living 0.0550.956
Yes30896.621.02 ± 6.80
No113.420.91 ± 6.40
Do you exercise every week? −0.5830.560
Yes8927.920.66 ± 7.09
No23072.121.16 ± 6.66
Duration of chronic disease 0.7520.472
<5 years6520.421.69 ± 6.98
5–10 years11235.120.45 ± 6.88
>10 years14244.521.16 ± 6.60
Number of daily doses 1.6550.099
≤1 type11034.521.87 ± 6.58
≥2 types20865.220.55 ± 6.86
Number of hospitalizations in the past year 1.1250.261
≤1 time24175.521.26 ± 6.75
≥2 times7824.520.27 ± 6.83
Number of chronic diseases 1.9570.051
1 type10633.222.07 ± 6.15
≥2 types21366.820.5 ± 7.02
Note: n = frequency, % = percentage, Mean = arithmetic mean, SD = standard deviation.
Table 2. Pearson correlation coefficient (n = 319).
Table 2. Pearson correlation coefficient (n = 319).
ScaleScore RangeMean ± SDMHS-R-CVPMHSGQ-6TFF
MHS-R-CV10–3321.02 ± 6.771.000
PMHS10–3622.91 ± 5.010.691 **1.000
GQ-614–3825.05 ± 5.610.612 **0.404 **1.000
TFF6–1913.14 ± 2.950.590 **0.373 **0.729 **1.000
Note: Mean = arithmetic mean, SD = standard deviation. ** indicates p < 0.01.
Table 3. Independent variable assignment description.
Table 3. Independent variable assignment description.
VariableAssignment Condition
Current living style1 = “solitude”; 2 = “cohabitation”; 3 = “live with children or relatives”;
Marital status1 = “married”; 2 = “not in marriage”
Perceived health status1 = “good”; 2 = “general”; 3 = “bad”;
Positive mental healthcontinuous variable
Gratitudecontinuous variable
Forgiveness tendencycontinuous variable
Table 4. Multiple linear regression analysis (n = 319).
Table 4. Multiple linear regression analysis (n = 319).
ModelRegression CoefficientSEStandard Regression CoefficienttpToleranceVIF
Quantity−8.8601.308/−6.773<0.001//
Positive mental health0.6890.0510.51013.546<0.0010.8231.215
Gratitude0.2950.0620.2444.798<0.0010.4492.228
Forgiveness tendency0.5100.1150.2224.417<0.0010.4622.166
Note: SE = standard error, VIF = variance inflation factor.
Table 5. Mediation effect of gratitude and forgiveness tendency on positive mental health and mature happiness in elderly patients with chronic diseases.
Table 5. Mediation effect of gratitude and forgiveness tendency on positive mental health and mature happiness in elderly patients with chronic diseases.
Regression EquationOverall Fit IndexRegression Coefficient
Outcome Variable (Y)Predictive Variable (X)RR2Fβt
GratitudePositive mental health0.4040.16461.998 **0.4537.874 **
Forgiveness tendencyPositive mental health0.7340.538184.203 **0.055 2.251 *
Gratitude 0.36316.522 **
Mature happinessPositive mental health0.7960.633181.105 **0.68913.546 **
Gratitude 0.2954.798 **
Forgiveness tendency 0.510 4.417 **
Note: ** indicates p < 0.001, * indicates p < 0.05.
Table 6. Total effect, direct effect, and intermediate effect results.
Table 6. Total effect, direct effect, and intermediate effect results.
Influence PathEffect SizeSE95%CIEffect Ratio (%)
LowerUpper
Total effect0.9350.0550.8271.043/
Direct effect0.6890.0510.5890.78973.69
Intermediate effect0.2460.0320.1840.31026.31
Positive mental health → Gratitude → Mature happiness0.1340.0300.0730.19214.33
Positive mental health → Forgiveness tendency → Mature happiness0.0280.0140.0030.0572.99
Positive mental health → Gratitude → Forgiveness tendency → Mature happiness0.0840.0210.0450.1288.98
Note: SE = standard error.
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Liu, H.-C.; Zhou, Y.; Liu, C.-Q.; Wu, X.-B.; Smith, G.D.; Wong, T.K.-S.; Hu, X.-Y.; Liu, Y.-M.; Qin, Y.-Y.; Wang, W.-J. Effect of Positive Mental Health on Elderly Patients with Chronic Diseases: The Chain-Mediated Effects of Gratitude and Forgiveness Tendencies at a Tertiary Hospital in Guangzhou. Healthcare 2025, 13, 444. https://doi.org/10.3390/healthcare13050444

AMA Style

Liu H-C, Zhou Y, Liu C-Q, Wu X-B, Smith GD, Wong TK-S, Hu X-Y, Liu Y-M, Qin Y-Y, Wang W-J. Effect of Positive Mental Health on Elderly Patients with Chronic Diseases: The Chain-Mediated Effects of Gratitude and Forgiveness Tendencies at a Tertiary Hospital in Guangzhou. Healthcare. 2025; 13(5):444. https://doi.org/10.3390/healthcare13050444

Chicago/Turabian Style

Liu, Hai-Cheng, Ying Zhou, Chun-Qin Liu, Xiao-Bing Wu, Graeme D. Smith, Thomas Kwok-Shing Wong, Xin-Yang Hu, Yi-Meng Liu, Ying-Ying Qin, and Wen-Jing Wang. 2025. "Effect of Positive Mental Health on Elderly Patients with Chronic Diseases: The Chain-Mediated Effects of Gratitude and Forgiveness Tendencies at a Tertiary Hospital in Guangzhou" Healthcare 13, no. 5: 444. https://doi.org/10.3390/healthcare13050444

APA Style

Liu, H.-C., Zhou, Y., Liu, C.-Q., Wu, X.-B., Smith, G. D., Wong, T. K.-S., Hu, X.-Y., Liu, Y.-M., Qin, Y.-Y., & Wang, W.-J. (2025). Effect of Positive Mental Health on Elderly Patients with Chronic Diseases: The Chain-Mediated Effects of Gratitude and Forgiveness Tendencies at a Tertiary Hospital in Guangzhou. Healthcare, 13(5), 444. https://doi.org/10.3390/healthcare13050444

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