Social Support as a Mediator of Physical Disability and Depressive Symptoms in Chinese Elderly

Accepted Manuscript Social Support as a Mediator of Physical Disability and Depressive Symptoms in Chinese Elderly

Hui Xie, Wenjia Peng, Yang Yang, Dan Zhang, Yaoyao Sun, Menglian Wu, Jie Zhang, Jihui Jia, Yonggang Su PII: DOI: Reference:

S0883-9417(17)30288-1 doi:10.1016/j.apnu.2017.11.012 YAPNU 51025

To appear in:

Archives of Psychiatric Nursing

Received date: Accepted date:

5 June 2017 5 November 2017

Please cite this article as: Hui Xie, Wenjia Peng, Yang Yang, Dan Zhang, Yaoyao Sun, Menglian Wu, Jie Zhang, Jihui Jia, Yonggang Su , Social Support as a Mediator of Physical Disability and Depressive Symptoms in Chinese Elderly. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yapnu(2017), doi:10.1016/j.apnu.2017.11.012

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ACCEPTED MANUSCRIPT Social Support as a Mediator of Physical Disability and Depressive Symptoms in Chinese Elderly

Hui Xie, MS

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Doctoral Student, School of Nursing, Shandong University, Jinan 250012, Shandong,

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China, Phone: (86)013855210738. E-mail: [email protected]

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Associate Professor, School of Nursing, Bengbu Medical College, Bengbu 233030, Anhui, China, Phone: (86)5523178522

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Wenjia Peng, PhD

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Lecturer, Preventive Medicine department, Bengbu Medical College, Bengbu 233030, Anhui, China. E-mail: [email protected]

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Yang Yang, MS

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Doctoral Student, School of Nursing, Shandong University, Jinan 250012, Shandong, China. E-mail: [email protected]

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Dan Zhang, MS

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Doctoral Student, School of Nursing, Shandong University, Jinan 250012, Shandong, China. E-mail: [email protected] Yaoyao Sun, MS

School of Nursing, Shandong University, Jinan 250012, Shandong, China. E-mail: [email protected] Menglian Wu, MS School of Nursing, Shandong University, Jinan 250012, Shandong, China. E-mail:

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ACCEPTED MANUSCRIPT [email protected] Jie Zhang, PhD Professor, School of Public Health, Shandong University, Jinan 250012, Shandong, China.

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Professor, Department of Sociology, State University of New York Buffalo State,

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Buffalo, New York, USA. E-mail: [email protected]

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Jihui Jia, PhD

Professor, Shandong University, Jinan 250012, Shandong, China. E-mail:

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[email protected]

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Yonggang Su, PhD

Associate Professor, School of Foreign Languages and Literature, Shandong

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University, Jinan 250012, Shandong, China. E-mail: [email protected]

Correspondence: Yonggang Su, PhD, School of Foreign Languages and Literature,

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Shandong University, Jinan 250012, Shandong, P. R. China. Telephone:

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(86)53188382034; FAX: (86) 53188382034 .e-mail:[email protected]

Acknowledgements: We thank all the participants who volunteered to share data and peers who helped to proofread the manuscript.

Conflicts of interest statement: The authors declare that they have no competing interests.

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Funding: This work was supported by the Ministry of Education of China [grant numbers 14YJAZH068]; and Shandong Province Science and Technology

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Department [grant number 2015ZDXX0801A01].

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ACCEPTED MANUSCRIPT Social Support as a Mediator of Physical Disability and Depressive Symptoms in Chinese Elderly

Abstract

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The relationship between physical disability and depressive symptoms has been

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associated with social support. Different aspects of social support may play distinct

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roles in health-related quality of life. The aim of this study was to examine the mediation of social support in the relationship between physical disability and

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depressive symptoms among old people in Mainland China. Subjective support and

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utilization of support mediated the relationship between ADL and depressive symptoms, with the indirect effect of subjective support and utilization of support at

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0.038 and 0.030 respectively (the total effect was 0.180). Subjective support was

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negatively associated with depressive symptoms in independent elderly people, utilization of support was negatively associated with depressive symptoms in partially

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dependent elderly people, and utilization of support had a greater association with

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geriatric depressive symptoms than subjective support in severely dependent elderly people. Social support mechanism and positive psychological intervention should be established and introduced in accordance with the physical disability of the elderly people, to protect them from depressive symptoms.

Keywords: social support; mediator; activities of daily living (ADL); elderly; depressive symptoms

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ACCEPTED MANUSCRIPT Social Support as a Mediator of Physical Disability and Depressive Symptoms in Chinese Elderly

Introduction

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Researches reveal that geriatric depressive symptoms have become a public health

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problem with the gradual aging of the population (Lino et al., 2014). In China, the

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population aged 60 and above has reached 200 million, and will increase to 400 million within 10 years (Lu & Li, 2015). The prevalence of depressive symptoms in

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old people in China is on the rise, as reported by urban researches and rural-based

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studies, with rates varying from 5.91% to 54.3% (Li et al., 2015; Jee & Lee, 2013). Depressive symptoms are associated with a negative socio-economic impact, such as

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poverty, family disruption, emotional suffering, increased medical care expenses, and

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mortality (Alexopoulos, 2005).

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Physical disability, considered as the inability or diminished capacity to perform basic self-care tasks, undermines a person's ability to interact with the physical and

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social environment, hence increasing the risk of depressive symptoms (Bruce, 2001). Increased disability in activities of daily living (ADL) and instrumental activities of daily living (IADL) have been proven to be connected with depressive symptoms (Bowen & Ruch, 2015; Hybels, Pieper, & Blazer, 2009). Failure to carry out ADL had been positively associated with depressive symptoms in elderly people (Newsom & Schulz, 1996) and physical disability accounted for incidences of depressive symptoms in the elderly (Kennedy, Kelman, & Thomas, 1990). Furthermore, that 1

ACCEPTED MANUSCRIPT physical disability led to increased geriatric depressive symptoms over time has been supported by longitudinal researches (Lin & Wu, 2011). Given the influence of physical disability and depressive symptoms on the well-being of the elderly, it is

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urgent to find ways to deal with them.

Social support, defined as a range of supports accessible to an individual through

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his social interactions with other individuals (Cooke, Rossmann, Mccubbin, &

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Patterson, 1988), has received a great amount of attention for its function on

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alleviating or mediating the stress of life on mental health (Newsom & Schulz, 1996). It has been proved that social support can help to prevent negative effects of physical

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disability on mental health (Wan et al., 2013). Different dimensions of social support may play different roles in safeguarding health-related quality of life (Tang, Brown,

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Funnell, & Anderson, 2008). Social support can be divided into objective support, subjective support, and utilization of support, based on its nature (Xiao, 1994).

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Objective support refers to actual or visible support, including material aids, the availability of and participation in social networks, and team relations (Xiao, 1994).

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Subjective support, also known as perceived social support, refers to the experience of and, the degree of satisfaction with being understood, respected, and supported. Utilization of support is defined as the degree to which the available support is used (Xiao, 1994). Perceived social support or subjective support, compared with objective support, acts as a significant stress reducer and has been found more significantly related to depressive symptoms, and effective in mediating the relationship between disability and depressive symptoms (Taylor & Lynch, 2004; Yang, 2006). 2

ACCEPTED MANUSCRIPT Nevertheless, Krause found received social support to be generally protective against the effects of stressors for the elderly (Krause, 1986). Overall, relatively few studies discussed the effects of objective support, subjective support, and utilization of support as mediators in the relation between physical disability and depressive

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symptoms in Asian elderly. The influence of utilization of support on ADL and

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depressive symptoms in elderly people has been especially rarely researched on.

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Social support is typically conceptualized as one category of coping resource, while

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physical disability as a kind of chronic stressor (Verbrugge & Allan, 1994). Studies on life stress suggest that the effectiveness of any coping resource may depend on

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properties of the stressor (Thoits, 1995). So, it is necessary to examine what dimensions of social support associate with depressive symptoms in different ADL.

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The current study aimed to examine whether the relationship between physical disability and depressive symptoms can be mediated by social support among old

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people in Mainland China, and, if possible, to explore the role of objective support, subjective support, and utilization of support in relation to depressive symptoms in

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elderly people with different levels of ADL. This study first hypothesized that physical disability was associated with greater depressive symptoms (H1). Then, with the impairment of ADL as a stressor, this study also hypothesized that three dimensions of social support could mediate the relationship between ADL and depressive symptoms (H2) among Chinese elderly (seen in Figure 1). Furthermore, the present study specifically examined whether subjective support and utilization of support significantly were associated with 3

ACCEPTED MANUSCRIPT depressive symptoms more effectively than objective support (H3) was. The findings of the present research will be enlightening to identify the mediate effect of social support in affecting depressive symptoms, and will hopefully promote the mental health service in community medical centers.

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Depressive Symptoms

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Mediating Effect H2

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H1 (–)

Physical Disability (ADL)

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Social Support Objective Support (H3a) Subjective Support (H3b) Utilization of Support (H3c)

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Materials and Methods

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Figure 1. Theoretical model (H=hypothesis).

Participants

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A cross-sectional study was performed over 10 months in 2014 – 2015 with a

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convenience sample of 372 elderly adults qualified to participate from three community health centers in Bengbu, a medium-sized city in Anhui Province of China, . These participants met the study criteria: (1) the age (elderly 60 years of age and over, based on the reference set by the United Nations), (2) permanent local residents, (3) voluntary participation, and (4) ability to communicate in Chinese. The exclusion criteria were as follows: (1) documented with severe cognitive impairment (Mini-Mental State Examination score < 24) (Folstein, Folstein, & McHugh, 1975), (2)

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ACCEPTED MANUSCRIPT a terminal prognosis, and (3) impaired reality (e.g., severe hearing impairment, diagnosis of paranoia). In the process of recruitment, invitations were handed out to 419 families to invite eligible elderly people to participate in the research. Of these eligible referrals, 11%

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declined the invitation, mainly owing to lack of time or interest. Therefore, a sum of

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372 elderly people signed the informed consent and participated in the research.

Ethic statement

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The study (NO. 2014-25) was approved and granted permission by the Ethics

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Committee of Bengbu Medical College. All the participants were notified of the aim of the study and their right to attend or quit the investigation voluntarily, and they

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were provided with written informed consent agreements prior to the initiation of the

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study. During the research process, researchers ensured that participants’ private

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information would be kept secret, and that only aggregate data would be reported.

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Measurements

Depressive symptoms. The primary outcome variable, depressive symptoms of elderly people, was measured by the Geriatric Depression Scale-Long Form 30, which consists of 30 self-rating questions with “yes” or “no” options and a depressive symptoms-related score ranging from 0 to 30. A higher score suggests the presence of elevated depressive symptoms (Yesavage et al., 1982). The scale was particularly employed in monitoring and assessing the severity of depressive symptoms and has

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ACCEPTED MANUSCRIPT shown good reliability and validity (Liu et al., 2013). Cronbach’s α for the current sample was 0.724. Physical disability. The older adults’ physical disability was measured via the ADL Scale, including ADL subscales (Katz et al., 1963) and IADL subscales (Lawton &

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Brody, 1969). The ADL subscale assesses six types of ability: bathing, feeding,

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dressing, transferring, toileting, and continence. The IADL subscale evaluates the

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ability to perform eight types of more complex activities, like telephone using, transportation and shopping. Scores for performing activities range from 1 to 4 (1

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point for each activity performed without help and 4 points for each activity that the

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individual is unable to perform). The maximum score is 56 (higher scores indicating greater dependence). Edwards confirmed the ADL scales in a Brazilian study,

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showing a Cronbach’s α of 0.96 - 0.99 (Edwards, 1990). The elderly were grouped

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into three categories in accordance with degrees of dependence: independent (< 16 points), partially dependent (16–22 points), and severely dependent (a total score of >

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22 or more than two items with scores of ≥ 3) (Zhang & He, 2015). Cronbach’s α for

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the current sample was 0.93. Social support. Social support was evaluated by using the Social Support Rating Scale (Xiao, 1994), which has been widely used among different populations in China (Ma et al.,2015; Ke, Liu & Li, 2010). The Cronbach’s α and the validity are both satisfactory (Ma et al., 2015). It was examined from three dimensions: objective support (3 items), subjective support (4 items), and utilization of support (3 items). The total score of social support and scores for the objective, subjective, and

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ACCEPTED MANUSCRIPT utilization of support subscales range from 12 to 66, 1 to 22, 8 to 32, and 3 to 12, respectively. A higher score predicts more social support. The Cronbach’s α value for the whole scale and the three subscales in the study were 0.83, 0.86, 0.80, and 0.79, respectively. characteristics.

The socio-demographic characteristics

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Socio-demographic

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included gender, age, education level, marital status, residential status, chronic

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diseases (including hypertension, diabetes, coronary disease, cerebrovascular disease,

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osteoarthritis, and osteoporosis), and average monthly income.

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Data collection

Ethics approval was obtained from the three community health centers. Following

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participant enrollment, data were elicited via interviews with the elderly people

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conducted by researchers and research assistants trained in this respect and with bachelor’s degrees. The researchers and research assistants acquired the consent from

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the elderly people who were willing to participate and paid visits to the homes of

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these participants. The survey took 30 to 40 minutes, in the process of which the questionnaires were checked and the missing item responses were reconfirmed. Records of the diagnoses of chronic diseases were collected from patient charts.

Data analysis Data were double-entered by using the EpiData 3.1 software (EpiData Association, Odense, Denmark) and multiple logic checks were used to ensure quality. Statistical

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ACCEPTED MANUSCRIPT analyses were conducted by using SPSS 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were calculated to determine the distribution of the socio-demographic factors, number of chronic diseases, and residential status, and to calculate the prevalence proportions. The mean ( X ) and standard deviation (SD) were

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calculated for the scores of social support, ADL, and depressive symptoms. One-way

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analysis of variance was used to analyze continuous variables with the

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Student-Newman-Keuls test or independent t-test for post hoc multiple comparisons. The Pearson correlation coefficient was applied to measure the correlations between

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ADL, social support, and depressive symptoms.

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Multiple linear regression analysis was then performed to discover the contributions of ADL and social support to depressive symptoms. The depressive

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symptoms score was the dependent variable. The mediation effect was checked by

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using Model 4 in the PROCESS program (Hayes, 2013), with the depressive symptoms as an outcome, and social support as a mediator. Finally, three individual

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linear regression models were conducted by examining the relation between the type

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of social support and physical disability status (i.e., independent group, partially dependent group, severely dependent group). The significance level was set at 0.05.

Results Table 1 displays the socio-demographic and depressive symptoms data for the sample. The age of the participants ranged from 60 to 93 ( X = 71.7; SD = 6.2), and 47.3% were male, 64.5% married, 71.2% on a low level of income (< 1500 RMB), and

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ACCEPTED MANUSCRIPT 65.5% at the education level lower than elementary (primary) school. Furthermore, 75.3% lived with a spouse, and 16.7% lived on their own. Of the elderly people, 65.3% had one or two chronic diseases, including hypertension, diabetes, coronary disease, cerebrovascular disease, osteoarthritis, and osteoporosis.

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The study compared participants in terms of the variables of age, gender,

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educational level, residential status, marital status, average monthly income, and

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number of chronic diseases in relation to depressive symptoms. Gender, age, and number of chronic diseases did not significantly differ from each other in relation to

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depressive symptoms. Education level was significant for the scores of depressive

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symptoms; post hoc multiple comparisons indicated that depressive symptoms were significantly higher among those with elementary school education or less. In addition,

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single, widowed, and/or divorced participants scored significantly higher in

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depressive symptoms than married participants. Lastly, the participants whose average monthly income was < 1500 RMB had significantly higher scores of depressive

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symptoms compared with the participants with an average monthly income of ≥ 1500

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RMB. Although the number of chronic diseases does not produce significant influence, the elderly people with three or four chronic diseases had higher depressive symptoms scores than those with one or two chronic diseases (See Table 1). Table 2 illustrates the correlation coefficients among ADL, social support, three dimensions of social support, and depressive symptoms. The ADL and depressive symptoms were positively correlated (r = 0.226, P < 0.01), indicating that greater dependence of ADL in elderly people was positively relative to the higher level of

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ACCEPTED MANUSCRIPT depressive symptoms. Likewise, social support, objective support, subjective support, utilization of support, and depressive symptoms were negatively correlated (r = -0.369, -0.219, -0.340, -0.304, P < 0.01), suggesting that higher level of social support, objective support, subjective support, and utilization of support was positively relative

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to the lower level of depressive symptoms. Lastly, the study discovered a negative

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correlation between social support and ADL (r = -0.268, P < 0.01). Similarly, three

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dimensions of social support were negative correlation with ADL (r = -0.122, P < 0.05; -0.261, P < 0.01; -0.246, P < 0.01), indicating that greater dependence of ADL

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were relative to the lower level of objective support, subjective support, and

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utilization of support.

Socio-demographic factors that were significantly affecting depressive symptoms

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were included in the multiple linear regression analysis. Thus, the education level,

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marital status, residential status, and monthly income were regarded as confounding variables. With these variables were being controlled, the results (Table 3, R2 = 0.244,

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F = 11.673, P < 0.05) indicated that, as predicted (H1), ADL was positively associated

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with depressive symptoms (β = 0.171, P < 0.01), and lower dependence of daily functioning was associated with lower depressive symptoms among elderly people. In the regression model, subjective support (β = -0.220, P < 0.001) and utilization of support (β= -0.193, P < 0.001) were negatively associated with lower depressive symptoms among elderly people (H3b, H3c), while subjective support (β = -0.220) was more negatively associated with depressive symptoms than ADL (β = 0.171) and utilization of support (β = -0.193). However, objective support was not significant (β

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ACCEPTED MANUSCRIPT = 0.002, P = 0.979) in the study (H3a). The mediation effect is presented in Table 4. The indirect and direct effects of ADL and social support on depressive symptoms were studied with the usage of the SPSS macro created by Hayes (Hayes, 2013), which was conducted by means of

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bootstrapping strategy. Residential status and monthly income were set as covariates.

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The result showed that the overall models were significant (R2 = 0.149, 0.244, F =

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16.070, 16.779, P < 0.05).

Before social support was entered into the equation, impairment of ADL was

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strongly associated with depressive symptoms (B = 0.179, P < 0.01), whereas this

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effect was to be reduced (mediated to 0.112) by subjective support and utilization of support (B = -0.338, -0.548, P < 0.01, see Table 4). In this partial mediation model,

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the indirect effect of subjective support and utilization of support were 0.038

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(-0.112*-0.338) and 0.030 (-0.054*-0.548) respectively. The total effect was 0.180 (0.112 + 0.038 + 0.030). Consistent with prediction (H2), the results manifested that

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subjective support and utilization of support could mediate the relationship between

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ADL and depressive symptoms while objective support could not (Figure 2). It is important to notice that this is a partial mediating effect. Finally, multivariate linear regression models were applied to distinguish the contribution of objective support, subjective support, and utilization of support to the explained variance for physical disability. With the confounding demographic variables being controlled, it was revealed that in the independent elderly people, subjective support was negatively associated with depressive symptoms significantly

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ACCEPTED MANUSCRIPT (β = -0.215, P < 0.05). Utilization of support was negatively associated with depressive symptoms (β = -0.221, P < 0.05) in the partially dependent elderly people. In the severely dependent elderly people, subjective support and utilization of support were negatively associated with depressive symptoms, and utilization of support (β =

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-0.330, P < 0.05) had a greater association with geriatric depressive symptoms than

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subjective support (β = -0.285, P < 0.05, see Table 5).

Discussion

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The research simultaneously investigated the associations between ADL, social

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support, and depressive symptoms in elderly people, to examine whether objective support, subjective support, and utilization of support mediated the relationship

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between ADL and depressive symptoms. This study also took into account covariates,

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such as residential status and monthly income, which could possibly confound the relations among physical disability, social support, and depressive symptoms. In

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addition, by discovering the roles in which objective support, subjective support, and

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utilization of support played when they are associated with depressive symptoms, the study contributed to the understanding of the impact of different levels of ADL in elderly people.

It was found that subjective support and utilization of support were effective as a mediator between ADL and depressive symptoms. Subjective support was negatively associated with depressive symptoms significantly in the independent elderly people, utilization of support was negatively associated with depressive symptoms in the

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ACCEPTED MANUSCRIPT partially dependent elderly people, and utilization of support had a greater association with depressive symptoms in the severely dependent elderly people than subjective support did.

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Effects of ADL and social support on depressive symptoms

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The results demonstrated that impairment of ADL had a significant effect on

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depressive symptoms in the elderly, conforming with the findings of previous studies showing a relationship between activity limitations and psycho-social problems

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(Bowen & Ruch, 2015; Hybels, Pieper, & Blazer, 2009). Social support was found a

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positive association with depressive symptoms, and higher levels of depressive symptoms were closely related to lower levels of social support, as in some previous

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studies (Lewin, Jöbges & Werheid, 2013; Lino et al., 2013; Aksüllü & Doğan, 2004).

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Furthermore, this research discovered that subjective support and utilization of support play a role as a mediator between ADL and depressive symptoms. That is,

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when mediated by subjective support and utilization of support, less impairment of

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ADL is related to fewer depressive symptoms. Thus, it is important to notice the function of subjective support and utilization of support in relieving the negative consequences of ADL on depressive symptoms, which helps to understand the relative effectiveness of different dimension of social support as mediator in the relation between physical disability and depressive symptoms. In the case of physical disability characterized with slow rehabilitation, subjective support and utilization of support provide emotional comfort and positively affect elderly’ understanding and

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ACCEPTED MANUSCRIPT utilization of social contact and appraisals (Yang, 2006). The sense of security for knowing that tangible assistance is available (Newsom & Schulz, 1996), together with the ability of utilization of available support, can ease distress and ameliorate depressive symptoms.

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The finding that subjective support and utilization of support played a role as a

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mediator between ADL and depressive symptoms has important implications for care

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workers since social support is more amenable to manage. The participants in the present study were on a lower-income (71.2% had a monthly income of < 1500 RMB)

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and lower-education level (65.5% had elementary school education or less), and

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16.7% lived independently and 34.7% had three or four chronic diseases. The level of subjective support and utilization of support of the elderly people with less income

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and poorer education was lower than that of those with higher income and higher

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educational level since a higher average income can better meet material needs and, secure higher social status, indicating greater adaptability, self-adjustment, and utility

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of social support (Ma et al., 2015). Improving the perception of social relationships,

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strengthening ties with confidants, and especially improving the utilization of existing support, are more effective than providing other means of support in reducing risks for depression in elderly. It is also important to notice that this is a partial mediating effect, implying that those who have impairment of ADL will tend to develop depressive symptoms when they have no access to enough social support, but other mediating factors may get involved.

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Impact of subjective support, objective support, and utilization of support against depressive symptoms in elderly people with different levels of ADL An interesting discovery in this study is that subjective support was negatively

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associated with depressive symptoms in independent elderly people, utilization of

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support was negatively associated with depressive symptoms in partially dependent

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elderly people, and utilization of support had a greater association with depressive symptoms than subjective support in severely dependent elderly people.

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For independent elderly people, lower subjective support inferred lower level of

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satisfaction with social support (Ke, Liu, & Li, 2010). In a collectivistic culture, people prioritize group loyalty, cooperation and sense of belonging instead of

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individualism, social support is assumed as a matter of course (Hogg & Vaughan,

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2003). Chinese filial piety also advocates respecting and helping the elderly, when social support (objective support) for elder people can be taken as natural and may not

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get enough appreciation, and may not buffer the effects of pressures (such as

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disabilities) (Bozo, Toksabay, & Kürüm, 2009). The perceived reality is the psychological reality, which is an actual (intermediary) variable affecting people’s behavior and development (Thoits, 1983). Consequently, subjective support, a mediator variable that can influence personal behavior (Thoits, 1983), significantly predicted depressive symptoms more than actual or visible support in the independent elderly people. For the partially dependent and severely dependent elderly people, the inability to

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ACCEPTED MANUSCRIPT care for oneself might produce negative psychosocial influences, such as lower self-esteem, loss of perceived control, social activity restriction (Lenze, Rogers, & Martire, 2001) and inadequate positive evaluation of social support, which increases the requirement for social support and the susceptibility to depressive symptoms

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(Alexopoulos, 2005), but decreases the utilization of support. A possible explanation

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is that older people with physical disability are less likely to use support efficiently or

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actively even when they are offered much support. Furthermore, another reason might be related to the influence of Asian culture that emphasizes social harmony so that

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people can be dubious whether the pursuit of support might break the balanced

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distribution of resources in the community or burden the social networks (Chen, Hicks, & While, 2014). This necessitates a possible intervention that promotes the

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recognition of, and training in, the utilization of support, particularly for the

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partially dependent and severely dependent elderly people in the community. This study has twofold significance for health professionals. First, the concepts of

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social support should be clearly defined, and further researches are needed with more

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samples to measure the features of social support, including the amount, specific types and forms of utilization. Second, the mechanism of social support and positive psychological interventions should be established, to cater to physical disability of elderly individuals and to improve their psychological health as well.

Limitations A couple of limitations can be potential in this study. Firstly, the study only examined

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ACCEPTED MANUSCRIPT senior citizens as community residents, which was a restriction to the universality of its findings, while the rates of depressive symptoms were higher among institutionalized older people and hospitalized older persons. Therefore, the findings may not be generalized to apply to different subgroups of older people. Social support,

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in particular, may function differently in these subgroups. Secondly, cross-sectional

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analysis of this observational study cannot provide direct causal evidence; thus,

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further experimental or longitudinal studies are necessary to facilitate an evaluation of

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causality.

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Conclusion

The present study provides evidence that social support relieves the passive effects of

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ADL on the occurrence of depressive symptoms among elderly people. This is helpful

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for planning a possible avenue of preventive measures and for improving knowledge on the disposal of depressive symptoms, consequently constructive for promoting

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social support in community elderly population. Furthermore, the study, by exploring

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the roles that subjective support, objective support, and utilization of support play in preventing depressive symptoms, contributes to the understanding of the impact of different levels of ADL on elderly people. The mechanism of social support and positive psychological intervention should be established to protect elderly people from depressive symptoms.

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ACCEPTED MANUSCRIPT 355-372. Yesavage, J. A., Brink, T. L., Rose, T. L., et al. (1982). Development and Validation of a Geriatric Depression Screening Scale: a Preliminary Report. J Psychiatr Res, 17(1), 37-49. Zhang, M. Y., & He, Y. L. (2015). Rating Scales for Mental Health. Changsha: Hunan Science &

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Technology Press, 268.

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ACCEPTED MANUSCRIPT Table

1.

Comparison

of

depressive

symptoms

scores

among

different

socio-demographic variables Variables

N (%)

Depressive

F or t

P

symptoms score ( X ± SD)

176 (47.3)

10.80 ± 6.25

Female

196 (52.7)

11.16 ± 6.42

60 - 69

132 (35.5)

11.05 ± 7.02

70 - 79

137 (36.8)

11.22 ± 6.14

80 - 89

91 (24.5

≥ 90

12 (3.2)

11.76 ± 6.49

Junior or senior high school

101 (27.2)

9.74 ± 5.75

College or above

27 (7.3)

8.70 ± 5.86

240 (64.5)

10.40 ± 6.16

132 (35.5)

12.07 ± 6.52

62 (16.7)

13.21 ± 7.17

Living with spouse

280 (75.3)

10.75 ± 6.10

Living with others (children,

30 (8.0)

8.63 ± 5.43

< 1500

265 (71.2)

11.59 ± 6.43

≥ 1500

107 (28.8)

8.62 ± 5.43

132 (35.5)

10.44 ± 6.07

PT E

D

244 (65.5)

Married

CE

Single/widowed/divorced

0.996

5.655

0.004

-2.454

0.015

6.262

0.002

4.722

<0.001

1.546

0.202

10.25 ± 4.92

Elementary school or less

Marital status

0.021

10.65 ± 5.78

MA

Education level

0.577

NU

SC

Age group (years)

-0.559

RI

Male

PT

Gender

Residential status

AC

Living on their own

relatives, et al) Average monthly income (RMB)

Number of chronic diseases 1

21

ACCEPTED MANUSCRIPT 111 (29.8)

10.59 ± 5.95

3

73 (19.6)

12.25 ± 6.49

4

56 (15.1)

11.45 ± 7.29

AC

CE

PT E

D

MA

NU

SC

RI

PT

2

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ACCEPTED MANUSCRIPT Table 2. Descriptive and Pearson Correlation Analysis Range

Mean

SD

2

3

4

5

6

1 ADL

14 ~ 56

20.79

9.76

-0.268**

-0.122*

-0.261**

-0.246**

0.226**

2 Social

18 ~ 53

35.03

7.44

-

0.794**

0.880**

0.628**

-0.369**

1 ~ 17

7.91

3.00

-

-

0.527**

0.323**

-0.219**

11 ~ 29

19.67

4.17

-

-

-

3 ~ 12

7.45

2.21

-

-

1 ~ 29

10.99

6.33

-

3 Objective

PT

support

0.359**

-0.340**

-

-

-0.304**

-

-

-

4 Subjective

RI

support

5 Utilization

6 Depressive

Note.

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CE

PT E

D

SD=Standard Deviation. * P < 0.05; ** P < 0.01.

-

MA

symptoms

NU

of support

SC

support

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ACCEPTED MANUSCRIPT Table 3. Multiple linear regression Analysis on the depressive symptoms Dependent Variables:

Unstandardized

Standardized

Depressive Symptoms

Coefficients

Coefficients

B

SE

t

P

-0.341

0.733

β

Junior or senior high school

-0.257

0.753

-0.018

College or above

-0.457

1.326

-0.019

0.075

0.731

0.006

-0.345

0.730

0.103

0.918

-0.009

-0.137

0.891

-0.132

-2.384

0.018

RI

Marital status

PT

Education level (ref. elementary school or less)

SC

Residential status (ref. living on their own) -0.128

0.933

Living with others

-3.075

1.290

Average monthly income

-3.078

0.816

-0.220

-3.774

0.000

ADL

0.111

0.033

0.171

3.386

0.001

Objective support

0.003

0.119

0.002

0.027

0.979

Subjective support

-0.335

0.088

-0.220

-3.804

0.000

Utilization of support

-0.555

0.148

-0.193

-3.749

0.000

F

0.244 11.673*

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Ref=reference;

MA

D

PT E

R2

NU

Living with spouse

SE = Standard Error.

AC

* P < 0.05

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ACCEPTED MANUSCRIPT Table 4. Mediation Effect Analysis Based on PROCESS B

SE

t

P

LLCI

ULCI

Outcome: Depressive Symptoms ADL

0.179

0.032

5.646

0.000

0.117

0.242

-3.454

-0.179

Residential status (ref. living on their own) -1.817

0.833

-2.182

0.030

Living with others

-3.777

1.337

-2.825

0.005

-6.407

-1.148

-3.533

0.696

-5.075

0.000

-4.902

-2.164

R2

RI

Monthly income

PT

Living with spouse

SC

0.149

16.070*

F

0.000

0.119

0.003

0.997

-0.233

0.233

Subjective support

-0.338

0.087

-3.905

0.000

-0.508

-0.168

Utilization of support

-0.548

0.146

-3.764

0.000

-0.834

-0.262

ADL

0.112

0.032

3.530

0.001

0.050

0.174

-0.186

0.839

-0.222

0.825

-1.837

1.464

-3.082

1.273

-2.422

0.016

-5.585

-0.579

-3.276

0.669

-4.900

0.000

-4.590

-1.961

MA

Objective support

D

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Outcome: Depressive Symptoms

Living with spouse Living with others

CE

Monthly income R2

0.244 16.779*

AC

F Note:

PT E

Residential status (ref. living on their own)

SE = Standard Error;

LLCI = Lower Limit Confidence Interval; ULCI = Upper Limit Confidence Interval; Ref=reference; * P < 0.05.

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ACCEPTED MANUSCRIPT Table 5. Multivariate linear regression models to identify the predictors of depressive symptoms scores and the contribution of each predictor to the explained variance for different physical disability Independent group B (SE)

β

Partially dependent group P

B (SE)

β

P

0.006

0.954

-0.113

senior high

-0.148

-0.011

0.900

(1.175)

0.082

(1.969)

Marital

-2.001

status

(1.361)

0.850

-0.197

0.947

-0.298

(2.948) -0.124

0.143

0.006

1.224

-0.007

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above

0.017

0.080

0.952

(1.320)

MA

0.372

(1.396)

(1.408)

school College or

RI

or

B (SE)

SC

Education level (ref. elementary school or less) Junior

Severely dependent group

PT

Variable

β

P

-0.008

0.935

-0.013

0.897

0.101

0.333

-0.073

0.551

-0.136

0.267

-0.241

0.031

0.124

0.265

-0.285

0.014

-0.330

0.001

(2.298)

(1.257)

1.540

with

(1.627)

spouse 1.999

with others

(2.689)

Average

-2.542

monthly

(1.319)

AC

income

0.063

CE

Living

0.091

Objective

-0.329

support

(0.177)

Subjective

-0.321

support

(0.126)

Utilization

-0.206

of support

(0.227)

0.345

-0.377

(1.708)

0.458

-8.369

PT E

Living

D

Residential status (ref. living on their own)

-0.192

-0.165

0.056

-0.029

0.826

(1.617)

-0.390

0.000

(2.196) -2.701

0.183

-0.175

0.095

0.012

-0.291

0.092

0.407

0.365

-0.653 (0.297)

0.280 (0.249)

-0.190

0.108

(0.179) -0.073

-3.035 (1.384)

(0.220) -0.215

-2.387 (2.137)

(1.603)

0.066

-0.967

-0.450 (0.179)

-0.221

0.030

-0.910 (0.258)

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ACCEPTED MANUSCRIPT SE = Standard Error

PT

Objective support

0.000

Subjective support

0.112

NU

ADL

-0.054

Depressive symptoms

-0.548

MA

Utilization of support

-0.338

SC

-0.112

RI

-0.039

D

Figure 2. The estimation of the mediation effect of social support in affecting ADL

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and depressive symptoms among the elderly in China. (N = 372).

AC

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Note. Residential status and Monthly income were controlled as covariates.

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