The relationship between home and community-based healthcare service utilization and depressive symptoms in older adults in rural China: A moderated mediation model

doi:10.21203/rs.3.rs-2471692/v1

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Research Article

The relationship between home and community-based healthcare service utilization and depressive symptoms in older adults in rural China: A moderated mediation model

https://doi.org/10.21203/rs.3.rs-2471692/v1

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published 30 May, 2023

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Background

Studies have shown a close association between home and community-based healthcare service (HCBHS) utilization and depressive symptoms in older adults. However, no studies have explored the underlying mechanism of this relationship in rural China. This research was designed to evaluate the roles of instrumental activities of daily living (IADL) and marital status in the association between HCBHS utilization and depressive symptoms in Chinese rural older adults.

Methods

Data were obtained from the 2018 China Health and Retirement Longitudinal Study, and 5981 rural respondents (≥ 60 years old) were included. Depression scores were calculated using the ten-item Center for Epidemiological Studies Depression Scale.

Results

HCBHS utilization had a direct and negative effect on depressive symptoms. Furthermore, marital status moderated the association between HCBHS utilization and IADL, which belonged to the indirect influence of the first half on the association between HCBHS utilization and depressive symptoms. HCBHS utilization was associated with IADL in single but not in married respondents.

Conclusion

The results demonstrated that marital status moderated the indirect relationship between HCBHS utilization and depressive symptoms, with HCBHS utilization negatively associated with IADL among single but not married respondents. The government should focus on older rural adults, especially those who are single and have poor IADL function, and improve the provision of HCBHS to alleviate depressive symptoms.

home and community-based healthcare service utilization

marital status

instrumental activities of daily living

depressive symptom

moderated mediation

Depression, a common mental illness worldwide, is often characterized by low mood (unhappiness, agitation, or loneliness), poor concentration, no interest in doing anything, and excessive guilt, which give rise to undue burdens of disease[1]. Approximately 5.7% of adults aged 60 years or over suffered from depressive symptoms globally as of 2021[1]. This may cause the affected older adults to behave in a dull state daily, such as being unable to eat, remaining in bed, or sitting on a stool all day without interacting with others [2, 3]. In the worst-case scenario, depressive symptoms can result in suicide. In China, approximately 36.14% of older adults were living with some extent of depressive symptoms in 2018 [4], which is more significant than in some European countries[5]. Moreover, Chinese rural older adults have an increased likelihood of suffering from depression relative to their urban counterparts [6–8]. Hence, mental health issues among rural Chinese older adults are not concerns that we can shrug off lightly.

Some studies have shown that home and community-based healthcare service (HCBHS) played a vital role in ameliorating mental health status by reducing depressive symptoms and loneliness among community-dwelling older adults[9, 10]. Although previous studies suggested that HCBHS were closely linked to depressive symptoms in older adults worldwide, the mechanisms underlying this association remain unclear. It is of utmost significance to explore the moderated mediation pathways between healthcare service utilization and depressive symptoms in Chinese rural older adults to develop effective interventions for depressive symptoms.

Studies have shown that rural older adults in China had lower socioeconomic status, poorer self-rated health, and an increased risk of instrumental activities of living (IADL) disabilities compared with their urban counterparts, which made rural older adults remain in stressful situation (e.g. low income and poor personal health status).[11–13]. Compared to basic activities of daily living (BADL), IADL, such as laundry, cooking, managing money, housekeeping, and transportation, is a more elaborate indicator of the competencies that rural older adults can utilize HCBHS and live in the community independently and socially [14–16], and higher IADL scores indicate higher risk of late-life depression [17, 18]. Furthermore, recent research also found that access to HCBHS might have a significantly negative correlation with IADL disabilities among rural community-dwelling older adults in China [19]. However, the relationship between HCBHS utilization, IADL, and depressive symptoms has not yet been conclusively established in China’s rural areas.

In the face of growing rural hollowing-out, the majority of the young or middle-aged workforce migrates to urban areas for work [20], thus rural older adults mainly rely on the companionship and care of their spouses for social support [21]. Married rural older adults tend to receive more financial, physical, emotional, and instrumental assistance, contributing to lower IADL disabilities compared with those without a spouse [22, 23]. Moreover, married rural older adults tend to use less HCBHS, as they receive relatively more social support. Is it possible that the fewer HCBHS are used, the less relief there is for IADL disabilities? Therefore, is there a moderating effect of marital status on the relationship between HCBHS utilization and IADL scores, which is an indirect influence of the relationship between HCBHS utilization and depressive symptoms in rural older adults in China?

This research concentrated on community-dwelling older adults in China’s rural areas and applied a moderated mediation model to examine the association between HCBHS utilization and depressive symptoms. We hypothesized that marital status moderates the mediating effect of IADL on the association between HCBHS utilization and depressive symptoms in community-dwelling older adults in rural China. This hypothesis is illustrated in Fig. 1.

[Figure 1 about here]

2.1 Data sources

The data used in the research were collected from the 2018 China Health and Retirement Longitudinal Study (CHARLS), a nationwide, ongoing and large-scale social survey project designed by the National Development Research Institute of Peking University and the China Social Science Research Centre of Peking University. The national baseline survey used a stratified multi-stage sampling method, with counties and districts (both urban and rural) as the primary sampling units, to investigate 19,816 middle-aged and elderly people aged 45 and above. The sample covered 450 villages and dwellings in 150 counties and districts in 28 provinces of mainland China, excluding Tibet. The response rate of respondents exceeded 80%, including 94% in rural areas and 69% in urban areas.

Respondents were excluded if they (a) were younger than 60 years old (8762), (b) lived in areas other than rural areas (2967), and did not match the data of (c) the ten-item Center for Epidemiological Studies Depression (CES-D-10) (2101) and (d) IADL (5). A final sample of 5,981 rural community-dwelling older adults in China was included in this study.

2.1.1 Materials

Dependent variable: Depressive symptoms

The CHARLS questionnaire applied a 10-question depression scale to measure respondents' psychological status, designed to follow the content of CES-D-10[24], which was evaluated using a four-point Likert scale [25]. We scored the frequencies of depressive symptoms produced by the participants in the past week as 0 (rarely), 1 (some days: 1 or 2 days per week), 2 (occasionally: 3 or 4 days per week), or 3 (most of the time: 5 or 7 days per week), of which eight items were negative and two items were positive emotions. After reversing the scores of the positive feelings items and summarizing the total items, the scores of depressive symptoms ranging from 0 to 30 manifest that with lower scores, lower levels of depressive symptoms.

Independent variable: Healthcare service utilization

Respondents were asked if they used the following healthcare services provided by the community: (a) regular physical examinations, (b) on-site visits, (c) family beds, (d) community nursing, and (e) health management. We classified respondents as “HCBHS utilization” if they utilized one or more service, and as “no HCBHS utilization” otherwise.

Moderating variable: Marital status

Respondents were asked, “What is your marital status?” The choices included: (a) married and cohabiting with a partner currently, (b) married but not cohabiting together due to work etc, (c) never married, (d) divorced, (e) widowed, and (f) separated. Respondents were stratified as “married” if they had a partner whether they are living together or not, and as “single” otherwise.

Mediating variable: IADL

The IADL reflects the basic competencies that older adults age and live in the community independently[26]. The IADL scale included five items in the CHARLS: cooking, grocery shopping, doing household chores, taking medicine, and managing finances, which were validated in previous studies [27, 28]. Respondents who did not have any difficulty in performing one scale of IADL were scored as 1, those who had difficulty but could still do it were scored as 2, those who had difficulty and needed help were scored as 3, and those who could not do it at all were scored as 4. The total IADL scores ranging from 5 to 20 manifest that the higher scores, more serious IADL disabilities.

Covariates

Based on extant literature, we selected confounding factors having an implication on depressive symptoms[29]. Socioeconomic characteristics included gender (male, female), age (60–75, 76–85, >86 years), education level (literacy, illiteracy), social insurance (yes, no), and wage and bonus income (yes, no). Covariates of health status included self-rated health (excellent, good, fair, poor, very poor). Health behaviors included drinking (yes, no), smoking (yes, no), and exercise (yes, no).

2.3 Statistical analysis

Frequencies, percentages, means, and standard deviations were used for the descriptive analyses. Stratified by marital status, Pearson’s correlation was applied to examine the relationship between distinct key variables in distinct marital statuses. Moderated mediation analysis was carried out applying Hayes' PROCESS macro (Model 7), which was based on bootstrapping (10000 bootstrap samples) using 95% confidence intervals. Gender, age, educational level, income, social insurance, self-rated health, smoking, drinking, and exercise were considered covariates. A moderated mediation model examined the impact of marital status on the mediated correlation between HCBHS utilization and depressive symptoms among the respondents. HCBHS utilization was regarded as the independent variable, depressive symptoms as the dependent variable, IADL as the mediated variable, and marital status as the moderated variable. All data analyses were performed applying IBM SPSS Statistics for Windows, version 26.0 (IBM Corp.).

[Table 1 about here]

Table 1

Descriptive statistics of the manifest variables
Variables	Total		Married		Single
Variables	N (%)	M ± SD	N (%)	M ± SD	N (%)	M ± SD
Gender		0.524 ± 0.500		0.560 ± 0.497		0.368 ± 0.482
Male	3134 (52.4%)		2731(55.9%)		403(36.8%)
Female	2847 (47.6%)		2155(44.1%)		692(63.2%)
Age		0.141 ± 0.371		0.101 ± 0.313		0.321 ± 0.526
60–75 years old	5184 (86.7%)		4409(90.2%)		775(70.8%)
76–85 years old	748 (12.5%)		460(9.4%)		288(26.3%)
>85 years old	49 (0.8%)		17(0.3%)		32(2.9%)
Education level		0.311 ± 0.463		0.285 ± 0.451		0.430 ± 0.495
Literate	4118 (68.9%)		3494(71.5%)		624(57.0%)
Illiterate	1863 (31.1%)		1392(28.5%)		471(43.0%)
Marital status		0.817 ± 0.387		--		--
Married	4886 (81.7%)		--		--
Unmarried	1095 (18.3%)		--		--
Income		0.149 ± 0.356		0.164 ± 0.370		0.081 ± 0.273
Yes	889 (14.9%)		800(16.4%)		89(8.1%)
No	5092 (85.1%)		4086(83.6%)		1006(91.9%)
Social insurance		0.969 ± 0.174		0.975 ± 0.157		0.942 ± 0.235
Yes	5794 (96.9%)		4763(97.5%)		1031(94.2%)
No	187 (3.1%)		123(2.5%)		64(5.8%)
Self-rated health		0.684 ± 0.465		0.695 ± 0.460		0.634 ± 0.482
Good, very good, fair	4092 (68.4%)		3398(69.5%)		694(63.4%)
Poor, very poor	1889 (31.6%)		1488(30.5%)		401(36.6%)
IADL	5981 (100%)	6.137 ± 2.446		6.048 ± 2.349		6.533 ± 2.803
Smoking		0.300 ± 0.459		0.311 ± 0.463		0.254 ± 0.435
Yes	1797 (30.0%)		1519(31.1%)		278(25.4%)
No	4184 (70.0%)		3367(69.0%)		817(74.6%)
Drinking		0.331 ± 0.471		0.351 ± 0.477		0.244 ± 0.430
Yes	1980 (33.1%)		1713(35.1%)		267(24.4%)
No	4001 (66.9%)		3173(64.9%)		828(75.6%)
Exercising		0.891 ± 0.311		0.899 ± 0.301		0.858 ± 0.350
Yes	5332 (89.1%)		4393(89.9%)		939(85.8%)
No	649 (10.9%)		493(10.1%)		156(14.2%)
HCBHS utilization		0.188 ± 0.391		0.181 ± 0.385		0.217 ± 0.413
Yes	1123 (18.8%)		885(18.1%)		238(21.7%)
No	4858 (81.2%)		4001(81.9%)		857(78.3%)
Depressive symptoms	5981 (100%)	9.357 ± 6.770		8.993 ± 6.618		10.981 ± 7.191

3.1 Descriptive statistics

This study included 5981 rural respondents aged 60 years or above in China, of whom 4886 (81.7%) were married and 1095 (18.3%) were unmarried. Rural community-dwelling older adults who used HCBHS accounted for 18.8% of the population. The respondents’ mean scores for depressive symptoms and IADL were 9.357 ± 6.770 and 6.137 ± 2.446, respectively. More details on the essential features of the respondents are displayed in Table 1.

3.2 Correlation analysis

[Table 2 about here]

Table 2

Descriptive statistics and correlations among key variables (n = 5981)
Variables	1	2	3	4
HCBHS utilization	1
Marital status	-0.036^**	1
IADL	-0.024	-0.077^***	1
Depressive symptoms	-0.034^**	-0.114^***	0.314^***	1

The means, standard deviations, and correlations among key research variables were calculated (Table 2). Married respondents had lower likelihood of using HCBHS compared to single ones (r=-0.036, p < 0.01). HCBHS utilization was not associated with IADL (r=-0.024, p = 0.059). HCBHS utilization was negatively linked to depressive symptoms (r=-0.034, p < 0.01). Married status was negatively related to IADL scores and depressive symptoms (r=-0.077, p < 0.001; r=-0.114, p < 0.001). Higher IADL scores were linked to more depressive symptoms (r = 0.314, p < 0.001).

3.3 Results of moderated mediation model

[Table 3 about here]

Table 3

Correlation between HCBHS utilization and depressive symptoms with IADL as a mediator and marital status as a moderator
Model pathways	R²	B	SE	t	95%CI
HCBHS utilization→IADL	0.187	-0.613	0.162	-3.781	(-0.930, -0.295)
Marital status→IADL		-0.199	0.086	-2.306	(-0.368, -0.030)
HCBHS utilization×Marital status→IADL		0.598	0.182	3.292	(0.242, 0.953)
IADL→Depressive symptoms	0.211	0.567	0.035	16.080	(0.498, 0.636)
HCBHS utilization→Depressive symptoms		-0.540	0.200	-2.696	(-0.932, -0.147)

[Figure 2 about here]

After adjusting for covariates, the pathway model of the moderated mediation analysis is shown in Fig. 2, corresponding to Table 3. The analysis indicated that HCBHS utilization (B=-0.613, t=-3.781, p < 0.001) and marital status (B=-0.199, t=-2.306, p < 0.05) were both negatively linked to IADL. The interaction effect of HCBHS utilization and marital status (B = 0.598, t = 3.292, p < 0.01) was positively correlated with IADL, demonstrating that the relationship between HCBHS utilization and IADL was moderated by marital status. Furthermore, IADL (B = 0.567, t = 16.080, p < 0.001) and HCBHS utilization (B=-0.540, t=-2.696, p < 0.01) were positively and negatively related to depressive symptoms, respectively.

[Table 4 about here]

Table 4

The impact of HCBHS utilization on IADL based on marital status
Marital status	B	SE	t	p	BootLLCI	BootULCI
Married	-0.015	0.082	-0.182	0.855	-0.176	0.146
Single	-0.613	0.162	-3.781	<0.001	-0.930	-0.295

[Figure 3 about here]

The outcome of the simple slope examination is presented in Table 4 and Fig. 3, which shows that HCBHS utilization was negatively linked to IADL among single respondents (B_simple=-0.613, t=-3.781, p < 0.001). However, among married respondents, HCBHS utilization (B_simple=-0.015, t=-0.182, p = 0.855) was not associated with IADL.

This was the first study to demonstrate that the mediating impact of IADL on the association between HCBHS utilization and depressive symptoms in rural community-dwelling older adults in China could be partially moderated by marital status. IADL did not mediate the association between HCBHS and depressive symptoms among married respondents; however, but IADL worked as a mediator among unmarried respondents. These findings shed light on the mechanisms underlying the relief of depressive symptoms in HCBHS and furnish a reference point for promoting the mental health of rural older adults with different marital statuses.

Literature out of China has shown that community-based healthcare services are closely correlated with depressive symptoms among older adults in the US and the Netherlands [30–32]. This study, focusing on Chinese rural older adults, concluded accordingly that HCBHS utilization has an increased likelihood of alleviating depressive symptoms. The circumstances that older adults in rural China might not be well cared for and have poor health status indicated that they have a higher need for HCBHS [33–35]. HCBHS can be effective in promoting the physical function and mental states of Chinese older adults in rural areas [36, 37], and then a sense of life satisfaction and safety will be planted at the bottom among their hearts, resulting in fewer depressive symptoms.

Furthermore, we concluded that IADL had a mediating effect on the association between HCBSHS utilization and depressive symptoms among single but not married respondents. Spouses, the basis of long-term social ties and networks, may act as a buffering mechanism when older adults live in rural areas [13, 38]. The buffering effect theory suggests that social support benefits individuals’ physical and mental health under stressful circumstances, such as living in rural areas. Figure 4 elaborates on the reasons for the marital status difference in the extent to which HCBSHS reduce IADL disabilities among rural community-dwelling older adults in China, from the perspective of spouses as a buffering mechanism.

[Figure 4 about here]

Not all rural older adults who use HCBHS are likely to reduce their IADL disabilities. Married rural older adults would get more attention, care, and resources than their single counterparts, and their spouse can supervise and correct incorrect health behaviors, such as preventing them from abusing alcohol and controlling their daily smoking, which can alleviate IADL disabilities [39]. Given relatively adequate social support from partners, rural married older adults would reduce the use of HCBHS, making HCBHS less effective in alleviating IADL disabilities. Therefore, HCBHS utilization was not associated with IADL disabilities among rural older adults within marital union.

The alleviation effect of HCBHS on depressive symptoms in single rural Chinese older adults was affected by IADL limitations. Single rural community-dwelling older adults lacked companionship and were more likely to remain in poorer physical and mental health and absent social participation than those with a partner [40]. In addition, rural community-dwelling older adults without a partner were more motivated to visit community-based healthcare facilities for health management and comprehensive care, use more HCBHS, and meet their interpersonal interaction needs, thus reducing IADL disabilities and alleviating depressive symptoms [41]. Therefore, HCBHS might not work to reduce IADL disabilities in married community-dwelling older adults living in rural areas compared with those who are single.

In summary, marital status was not only correlated with IADL disabilities but also moderated the mediating influence of IADL, in which HCBHS utilization was associated with IADL disabilities among unmarried but not married respondents.

This study had several limitations. First, the cross-sectional project of this study could not confirm the causal relationship among the variables. Longitudinal studies should further assess the underlying mechanisms of the association between the use of HCBHS and depressive symptoms. Second, the study only examined the mechanisms underlying the correlation between HCBHS utilization and depressive symptoms in older adults and did not consider other mental health-related factors, such as anxiety and loneliness. Future studies should include a more comprehensive analysis of psychological distress. Finally, in this study, physical function limitations only considered IADL, not BADL. Future studies should consider both IADL and BADL.

Overall, marital status moderated the mediating effect of IADL on the correlation between HCBHS utilization and depressive symptoms in community-dwelling older adults in rural China, with IADL partially mediating this association among unmarried but not married individuals. Therefore, the government should increase the provision of HCBHS to alleviate depressive symptoms in rural older adults effectively. For single rural older adults with IADL disabilities, the government should provide targeted HCBHS to lessen the level of IADL disabilities and depressive symptoms.

HCBHS

home and community-based healthcare service

IADL

instrumental activities of daily living

BADL

basic activities of daily living

CHARLS

China Health and Retirement Longitudinal Study.

Acknowledgements

The authors thank the CHARLS team for their hard work and unselfish sharing of survey data. We also acknowledge Editage editorial team for their English editing.

Authors’ contribution

Zishuo Huang, Tingke Xu, Chun Chen, and Xiangyang Zhang discovered and designed the study. Zishuo Huang and Tingke Xu participated in acquisition of the data. Zishuo Huang and Chun Chen contributed to data analysis. Zishuo Huang wrote the original draft. Zishuo Huang took charge of the submission. Zishuo Huang, Tingke Xu, Xinxin Zhang, Jiayun Zhang, Shanshan Wang, Qingren Yang, Yating Fu, Gui Jia substantively revised the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by Zhejiang Provincial Science and Technology Innovation Program (New Young Talent Program) for College Students [2022R413B053], Philosophy and Social Science Project of Zhejiang Province, China [22NDJC104YB], Zhejiang Provincial Natural Science Foundation [LY22G030006], and National Natural Science Foundation of China [72274141].

Availability of data and materials

The data are available at http://charls.pku.edu.cn.

Ethics approval and consent to participate

All procedures in this study were carried out in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study has been approved by Ethics Review Committee of Peking University and all participants in the cohort provided written informed consent. The IRB approval number for the main household survey, including the traditional household survey, was IRB00001052-11015.

Consent for publication

Not applicable.

Conflicts of interest

None declared.

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No competing interests reported.

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published 30 May, 2023

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The relationship between home and community-based healthcare service utilization and depressive symptoms in older adults in rural China: A moderated mediation model

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Abstract

Background

Methods

Results

Conclusion

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1. Introduction

2. Methods

2.1 Data sources

2.1.1 Materials

2.3 Statistical analysis

3. Results

3.1 Descriptive statistics

3.2 Correlation analysis

3.3 Results of moderated mediation model

4. Discussion

5. Limitations

6. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1