The current study aims to investigate the relationship between the meaning of life, psychological well-being, self-care, and social capital with depression and death anxiety through the mediating role of loneliness in the elderly living in nursing homes. The pathway analysis indicated that the model proposed by this study properly fits in the studied sample. According to the obtained results, in addition to the direct effect of meaning of life, social capital, self-care and psychological well-being on death anxiety and depression, the indirect effect of them on death anxiety and depression through the mediating role of loneliness was confirmed. Accordingly, all hypotheses of this study were confirmed.
The Relationship of Meaning of Life and Depression Through Loneliness
The first hypothesis stating that the meaning of life is correlated with depression through loneliness was confirmed. In other words, individuals with a high level of meaning of life are less likely to feel loneliness, which in turn, leads them to experience lower level of depression. Although there is no study addressing this path, the finding of this study are consistent with that of previous studies (23,43,44,50,52,77) in terms of the constituent relationships of this pathway. Regarding the interpretation of this finding, Kleftaras and Psarra (77) pointed out that individuals experiencing the high meaning of life, have usually a positive perception of their personal health level, experience lower level of anxiety and sleep disorder and, most importantly, have higher social performance, all of which will lead to lower level of depression. Besides, Steptoe and Fancourt (43) believe that individuals with a higher level of meaning and value in their life are probably more in touch with their friends, and are more likely to participate in social and cultural events. The idea that they feel they are doing valuable things not only is the result of this social participation but also makes them stay involved in personal and social relationships, thus experiencing a lower feeling of loneliness. Ultimately, conducting a 12-year longitudinal study on the relationship between loneliness and depression, Lee et al. (2021) stated in the interpretation of the mentioned relationship that loneliness can lead to cognitive dysfunction, such as increased vigilance towards threatening social stimuli and negative cognitive bias. Lonely individuals are more likely to expect negative social interactions, reminiscence negative social memories, and negatively evaluate themselves and their social context. Loneliness can lead to negative thoughts about self and is accompanied by depression. Experiencing meaningful companionship, belonging, and communication has lots of advantages, and a reduced level of each leads to depression. Loneliness can also have biological effects on responding stress, such as disruption in the immune system and hypothalamic-pituitary-adrenal (HPA) axis, which, in turn, may contribute to depression. In general, it can be concluded that a high level of meaning in life reduces the risk of depression in the elderly, keeping them involved in meaningful and valuable social relationships and improving the physiological performance of their body.
The Relationship of Psychological Well-Being and Depression Through Loneliness
The second hypothesis stating that psychological well-being is correlated with depression through loneliness was confirmed. In other words, individuals with high psychological well-being are less likely to experience feeling of loneliness, which in turn, leads them to experience lower level of depression. Even though no study has investigated this path, the finding of this study are consistent with that of previous studies (25,26,45,46) in terms of the constituent relationships of this pathway. In interpretation of this finding, Hemingway & Jack (45) believe that three important parts of the elderly’s well-being are maintained and developed in social communications. Hemingway and Jack believe that self-esteem, quality of life, and empowerment in old age may be increased through participating in communities and avoiding loneliness. They believe that the presence of the elderly in the community and avoiding isolation and loneliness are related to high well-being through the development of factors, such as collective and individual identity, taking a role in society, providing and receiving social support, friendship, inclusivity, and social connection. In addition, Dhara & Jogsan (25) stated that the relationship of the elderly with their family members seems to be of the essential factors in the relationship between depression and well-being. They believe that due to the lack of proper caring conditions by family members and being ignored by caregivers, the well-being of the elderly can be threatened which may lead to physical and mental problems, such as depression. To put it differently, they believe that a warm family atmosphere along with hospice care is necessary. Accordingly, it can be concluded that suitable social and family space as one of the essential elderly’s well-being factors is related to the feeling of loneliness, which in turn, may be associated with lower level of depression.
The Relationship of Self-Care and Depression Through Loneliness
The third hypothesis of this study stating that self-care is correlated with depression through loneliness was confirmed. In other words, individuals with a high level of self-care are less likely to experience the feeling of loneliness, which in turn, may cause them to experience lower level of depression in them. Although no study has investigated this path, the finding of this study are consistent with that of previous studies (28,47) in terms of the consistent relationships of this pathway. Regarding the interpretation of this finding, Canjuga et al. (78) believe that the elderly who have adequate knowledge and ability in self-care and an effective support system, are capable enough to increase their emotional, religious, and physical health, and to independently maintain their social participation, which in turn, lead them to experience a lower feeling of loneliness. According to Giardini et al. (79), however, insufficient self-care has some implications, such as reducing the level of health in individuals and may result in an increased level of disappointment, as the central core of depression. This type of disappointment usually reduces the incentive and tendency of individuals to do their desired activities and participate in social events, which leads to depression. This issue might lead to the formation of a downward spiral circle in which depression reduces self-care behaviors, which in turn increase the depression. In support of this claim, Iovino et al. (80) indicated that depression symptoms, such as tiredness, reduced energy level, disappointment, along with reduced incentive, lead to loss of interest and desire to do things (tasks pertinent to self-care) that must be done to maintain health.
The Relationship of Social Capital and Depression Through Loneliness
The fourth hypothesis of this study, stating that social capital is related to depression through loneliness, was confirmed. In other words, individuals with high social capital are less likely to feel loneliness which, in turn, lead them to experience lower levels of depression. Although no study has investigated this path, the finding of this study are consistent with that of previous studies (30–32,48,49) in terms of the consistent relationships of this pathway. Regarding the interpretation of this finding, Bai et al. (48) believe that elderly with a low level of social capital are more likely to experience loneliness due to lower functional ability, lower level of trust in others, and lower level of participation and communication. Similarly, Nyqvist et al. (49) stated that the elderly have a lower chance of maintaining their own social capital due to the higher risk of losing their friends and spouse. They believe that aging and loss of cognitive ability and functional limitation do not directly lead to loneliness but bring about depression, which per se results in the feeling of loneliness. In their points of view, there is a circular causality between depression and loneliness, because the feeling of loneliness probably brings about depression. They believe that the important factor in the reduced social capital, which leading to loneliness and depression is the loss of social participation among the elderly. In support of this interpretation, Sun et al. (31) also expressed that the most important reason behind higher social capital in the elderly (below 80 years old) is their ability for social interaction leading to the lower feeling of depression. Furthermore, in investigating the relationship between social capital and depression, Han et al. (32) have pointed out the important effect of trust and reciprocity and took advantages of the main effect model and the stress-buffering model for explaining this relationship. According to the main effect model, living in a highly trusting community leads individuals to have more loyalty to other members of the community, like neighbors and companions. In such a community, the tendency to help others can lay a foundation for a positive psychological condition via creating the feeling of safety, being accepted by the community, and self-worth, which per se decreases the probability of getting affected by depression. Besides, according to the stress-buffering model, the existence of social capital (trust and reciprocity) can prevent or alleviate negative emotional and cognitive responses to stressful incidents of life through a benign appraisal of the incidents. Such being the case will lead to lower mental health damage and a decreased probability of getting affected by depression.
The Relationship of Meaning of Life and Death Anxiety Through Loneliness
The fifth hypothesis of this study, stating that Meaning of life is correlated with death anxiety through the loneliness was confirmed. In other words, individuals with a higher meaning of life have a lower feeling of loneliness, which in turn, lead them to experience a lower death anxiety.
Although no study has investigated this path, the finding of this study are consistent with that of previous studies (34,53,54) in terms of the consistent relationships of this pathway. Regarding the interpretation of this finding, Moore et al. (81) expressed that it seems that individuals with a higher meaning of life understand the high meaning life clearly, explain the essence of life based on their own personal values, and are capable of recognize goals and values of survival and life, and for this reason, they can have a more realistic perspective, accept the death and the its pertinent issues easily, and experience lower death anxiety. According to the meaning management theory (82), the best way to alleviate death anxiety appears to be searching for the meaning of life. This model also states that individuals aspire to live a more meaningful life, and focusing on positive growth seems better than searching for a defense mechanism against death anxiety. In other words, if individuals believe that their life is meaningful and they play an important part in their community, they will probably not experience being threatened with an inevitable death. In addition, according to the Terror Management Theory (83), the elderly with higher feelings of loneliness have lost their bonding with the common values of their own culture, which In turn leads the elderly to feel that the world is not particularly ordered and have no meaningfulness, which may make them vulnerable to death anxiety.
The Relationship of Psychological Well-Being and Death Anxiety Through Loneliness
The sixth hypothesis stating that psychological well-being is correlated with death anxiety through loneliness was confirmed. Indeed, individuals with higher psychological well-being have a lower feeling of loneliness, which in turn caused them to feel lower level of death anxiety. Although no study has investigated this path, the finding of this study are consistent with that of previous studies (45,46,53,54,84) in terms of the consistent relationships of this pathway. Regarding the interpretation of this finding, we can say that based on the existentialism theory (85), the awareness of an individual regarding the death issue is the most important factor in the highest level of psychological well-being. According to this theory, individuals with a higher level of psychological well-being focus more on the awareness of being alive when encountering the death issue. In this case, instead of thinking that life is a perpetual and immortal essence and being engrossed in it, they are aware that they are living and can take advantages of being alive. According to what was mentioned before (45), the elderly with higher well-being are present in society and have a more social role. In this case, we can probably assert that this the concentration on being alive, increases the tendency to use life properly, as well as the tendency to social participation among the elderly, and maintains the bonding with the common values of their own culture, and for these reasons, decrease their death anxiety.
The Relationship of Self-Care and Death Anxiety Through Loneliness
The seventh hypothesis of this study stating that self-care is correlated with death anxiety through loneliness was confirmed. Indeed, individuals with higher self-care have a lower feeling of loneliness, which in turn causes them to experience lower death anxiety. Although no study has investigated this path, the finding of this study are consistent with that of previous studies (37,53,54) in terms of the consistent relationships of this pathway. In interpretation of this finding, we again refer to Canjuga et al. (78), based on which, individuals with higher self-care have the required ability to maintain emotional, religious, and physical health, which can be correlated with their awareness of being alive and using this mortal essence. In addition, individuals with lower self-care can experience consequences like decreased health that can convey the meaning of forthcoming death in their minds. Thereby, such individuals are less likely to experience death anxiety, which leads to lower level of depression among them.
The Relationship of Social Capital and Death Anxiety Through Loneliness
The eighth hypothesis of this study, stating that social capital is related to death anxiety through loneliness, was confirmed. To put it differently, individuals with high self-care have a lower feeling of loneliness, which lead them to experience lower death anxiety. Although no study has investigated this path, the finding of this study are consistent with that of previous studies (38,53,54) in terms of the consistent relationships of this pathway. In interpreting this finding, we can again refer to the previously provided interpretations. In this case, individuals with lower social capital are less able to experience social interaction, trust, and reciprocity, and will probably have a more feeling of loneliness. Such loneliness deprives them of engaging in a social condition, feeling alive, and living a life as a mortal essence, which in turn leading to a higher experience of death anxiety.
The Implications of the Current Study for Therapy
Taking a glance at the aforementioned interpretations, we can find out a fundamental common issue among all of them, which is social participation, the opposite point of feeling loneliness. As indicated, the meaning of the elderly’s life is formed by maintaining the social function, peer relationships, companionship, belonging, and connection. Their social well-being consisting of self-esteem, quality of life, and empowerment is satisfied thanks to their social relations, social participation, and receiving social support. Meanwhile, their self-care is closely correlated with maintaining the social participation, and their social capital is satisfied thanks to mutual trust, reciprocity, and social participation. Therefore, one of the fundamental variables in identifying and preventing depression and death anxiety is loneliness among the elderly, which could only be improved by elevating their social participation. For this reason, the current study can convey a clear message for the experts and therapists working with the elderly. This message is nothing but the application of interventions and therapeutic methods assuring the presence of the elderly in communities and their participation in different social issues.
One of the most effective therapies in this field can be reminiscence therapy. Reminiscence therapy includes discussion about activities, events, and past experiences with an individual or a group of people, and is usually conducted using reminder stimuluses like a picture, video, cooking appliances, etc. (3). Different studies have demonstrated that the participation of the elderly in meetings where they can reminisce their memories may increase their happiness (86) and decrease their depression (87,88) and death anxiety (89). Hence, holding social events where the elderlys are encouraged to tell their past memories, authorities can help the elderly to increase their meaning of life and well-being and provide them with social capital, and incentivize them for taking care of themselves for having a sufficient potential to take part in these social programs. Doing so, an important step can be taken towards decreasing depression and death anxiety in the elderly through alleviating their feeling of loneliness.
The Limitations of the Current Study
One of the limitations of this study is about the data collection method that was done using self-report questionnaires. Although providing useful information, sometimes, these questionnaires can reduce the validity of the obtained results. Besides, although path analysis is used in this study, the nature of the obtained relations is of correlative, not causal type. Due to the utilized statistical method and cross-sectional study, casual interpretation of this type of study is not appropriate. In addition, this study was conducted on Iranians, and due to the profound cultural difference between the eastern and western communities, some considerations should be considered in generalizing these findings to other communities.
Suggestions for Future Studies
According to the mentioned limitations in the current study, it is proposed that future studies use highly precise tools under a condition with controlling disruptive variables for investigating the mentioned relationship in this study. Moreover, future studies could use a longitudinal design to consider the relationship between these psychological structures. In addition, re-conducting such studies in different cultural contexts will help to obtain more universal and exact findings in this field.