Effect of home and community-based services on older adults’ depressive symptoms in China: a multilevel analysis

doi:10.21203/rs.3.rs-2501455/v1

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Research Article

Effect of home and community-based services on older adults’ depressive symptoms in China: a multilevel analysis

https://doi.org/10.21203/rs.3.rs-2501455/v1

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published 21 Jul, 2023

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Background

As the phenomenon of ageing continues to intensify, home and community-based services (HCBSs) have become of increasing importance in China. However, few studies have assessed the impact of HCBSs utilization on depressive symptoms among older adults. This study aimed to examine the association between HCBSs utilization and depressive symptoms in Chinese older adults.

Methods

This study included 7,787 older adults (≥ 60years old) who were recruited within the framework of the 2018 China Health and Retirement Longitudinal Study (CHARLS). Depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10). HCBSs utilization was assessed via the question, “What kind of HCBSs were being utilized in their community?”. Data were analyzed using generalized hierarchical linear models.

Results

Of the 7,787 participants, 20.1% (n = 1,567) reported they utilized HCBSs, and 36.7% (n = 2,859) were currently with depressive symptoms. After adjusting for individual- and province-level covariates, the HCBSs utilization was found to be associated with depressive symptoms (OR = 1.189, 95% CI:1.043–1.356, p < 0.01) among older adults. Additionally, the depressive symptoms were associated with gender, residence, educational level, marital status, number of chronic diseases, self-rated health, smoking, and provincial GDP per captia.

Conclusions

This study found HCBSs utilization might be a protective factor against depressive symptoms in Chinese older adults. It is important that the government provides targeted HCBSs at the community level to address the unmet care needs of older adults to reduce the occurrence of negative emotions and consequently the depressive symptoms.

depressive symptoms

home and community-based services

generalized hierarchical linear models

older adults

China Health and Retirement Longitudinal Study

Depression is a mental disorder characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities[1],which is different from short-term emotional reactions to everyday challenges as it lasts for a longer time period (i.e., minimum of 2 weeks as per clinical diagnostic criteria), with an estimated 5.0% of adults and 5.7% of older adults (≥ 60 years old) affected[2, 3]. In particular, with recurrent, moderate or severe intensity, depression may become a serious health threat. In the worst of cases, depression can lead to suicide. Rapid aging population has become a serious problem[4] and may lead to a higher prevalence of depression, causing a higher burden. Thus, it is important to take immediate action to address the specific concerns regarding older adults for alleviating depression[5].

China, the largest developing country, accounts for nearly 18% of the global population, and roughly 17% of the global disease burden of mental disorders[6]. In addition, the Chinese population is ageing dramatically[7]. In tandem with demographic transition, China is also undergoing a massive social transition and is witnessing key changes in family structure (e.g., decreases in family size, increases in family childlessness, and increases in the number of older adults living alone)[8, 9]. These shifts are challenging the traditional family-based care arrangement for older adults[10]. Thus, relying on the community and integrating various resources in the community, home and community-based services (HCBSs) was expanding and becoming critical components of elderly care. These services including daily care, health care, and entertainment not only retain the traditional form of caring modes but also reduce the daily care burden of their children, aiming to help older adults remain safely in their homes and avoid institutionalization[11, 12].

Depression in older adults is a serious public health issue globally, and may have a profound effect on every aspect of life, including school performance, work productivity, relationships with family and friends, and community involvement. The influence of individual factors on depressive symptoms among older adults have previously been examined by many researchers[13–19]. These factors encompass demographic characteristics (e.g., gender, age, level of education, marital status, and residence), health status (e.g., self-rated health (SRH) and chronic diseases), and lifestyle factors (e.g., drinking, smoking, and exercise). Moreover, depressive symptoms in older adults could be assumed to have a hierarchical structure, such that individuals are nested within the specific provinces where they are located, and thus, depression would not only be affected by individual factors, but also by provincial factors[20].

Some benefits of HCBSs on health status in older adults have been recognized previously, such as enhancing life satisfaction[21], promoting cognitive function[22], and reducing the risk of depression[23]. However, the most of studies only focused on HCBSs provision status and its effect on the health status of older adults instead of the impact of HCBSs utilization, which may lead to misjudgment of the role of HCBSs in healthy aging. However, to our knowledge, few studies have explored the association between HCBSs utilization and depressive symptoms in China.

Therefore, in this study, we aimed to (a) describe the current utilization of HCBSs, (b) examine depressive symptoms in Chinese older adults, and (c) explore the association between HCBSs utilization and depressive symptoms in China based on the 2018 China Health and Retirement Longitudinal Study (CHARLS) after adjusting for individual- and province-level covariates.

2.1. Study participants

Data were obtained from the fourth wave of survey data from the CHARLS, which is a survey of middle-aged and older adults in China based on a sample of households with members aged 45 years or above. With the aim of establishing a high-quality public database, it contained a wide range of information, ranging from socioeconomic status to health conditions, needed for scientific research on middle-aged and elderly adults.[24, 25]. To ensure sample representative, the survey followed strict randomization procedures and used a multi-stage sampling method. When sampling county and rural administrative units, a probability proportional to size (PPS) sampling method was adopted[26].

In this study, participants were excluded if they (1) were younger than 60 years old, or lacked data regarding (2) utilization of HCBSs, (3) 10-item Center for Epidemiological Studies Depression (CES-D-10), or (4) values in the main variables. A total of 19,816 participants completed the CHARLS in 2018. Crucially, 8,762 participants aged lower than 60 years, 35 participants lacking utilization of HCBSs data, 2,668 participants lacking CES-D-10 data, 530 participants with Memory-Related Disease or Emotional Problems, and 34 participants lacking values in main variables were excluded. Accordingly, the final study sample consisted of 7,787 participants.

2.2. Measures

2.2.1 Dependent variable

Depressive symptoms were assessed using the CES-D-10[27]. Ten of 20 items from the original version of the scale were grouped to the shortened CES-D-10 scale by its internal correlations[28]. This scale was widely used in older adults and showed high reliability and validity among Chinese older adults[29]. The CESD-10 comprised ten questions about depression, and the answers included four options: (1) rarely, (2) some days (1–2 days per week), (3) occasionally (3–4 days per week), and (4) most of the time (5–7 days per week)[30]. Among the ten questions, eight questions were negative statements, and two questions were positive statements. The answers were recorded as 0 (rarely) to 3 (most of the time) for the negative questions and were recorded as 3 (rarely) to 0 (most of the time) for the positive questions. The total score ranged from 0 to 30 points. A score ≥ 10 in the CES-D-10 was considered to indicate depressive symptoms, as validated by previous studies[28].

2.2.2. Independent variable

HCBSs utilization was measured by asking participants, “Have you ever received the following home and community care services?” The response options included: (a) day care centers, nursing homes, senior dining tables, etc.; (b) regular physical examinations; (c) on-site visits; (d) family beds; (e) community nursing; (f) health management; (g) entertainment; (h) other. If participants use one or more HCBS, they were classified as HCBSs utilization group, but if not, they were classified as HCBSs non-utilization group.

2.2.3. Covariates

Covariates were considered at individual and provincial levels[31–34]. Individual-level variables included sociodemographic characteristics, health status, and lifestyle. Sociodemographic characteristics included age, gender, marital status, educational level, residence, income, and health insurance; health status included the number of chronic diseases and self-rated health (SRH); lifestyle factors included smoking, drinking, and physical exercise. Further, the province-level variables included 2018 provincial GDP per capita and hospital beds per 10,000 persons, reflecting respectively economic and medical levels.

2.3. Statistical analysis

Descriptive statistics were used to analyze characteristics of the study participants. As discussed in the previous section, binary logistic regression was used to compare depressive symptoms risk across groups based on the categorical variables. Generalized hierarchical linear models were constructed using mixed model procedures, given that the data had a hierarchical structure composed of individuals (Level 1) nested within provinces (Level 2). A series of 2-level generalized hierarchical linear models with random intercepts and fixed slopes were used to examine whether depressive symptoms were associated with utilization of HCBSs among Chinese older adults. Data were analyzed using SPSS version 26.0. The level of significance was set at p < 0.05.

Table 1 presents the basic characteristics of the total sample included in this study. The final sample comprised 7,787 participants from 28 provinces, representing approximately 264 million Chinese residents aged ≥ 60 years. Of the 7,787 participants, 20.1% (n = 1,567) utilized HCBSs, and 36.7% (n = 2,859) with depressive symptoms. Majority of the respondents were male (n = 4,034, 51.8%), aged 60 – 69 (n = 5,074, 65.2%), partnered (n = 6,378, 81.9%), with an educational level of elementary school (n = 3,580, 46.0%), living in rural areas (n = 5,627, 72.3%), without income (n = 6,651, 85.4%), and without health insurance (n = 7,584, 97.4%). Additionally, a significant number of the respondents did not drink (n = 5,127, 65.8%) or smoke (n = 5,582, 71.7%), exercised (n = 7,041, 90.4%), had fair SRH (n = 3,897, 50.1%), or had three or more chronic diseases (n = 3,106, 39.9%). Most of the participants lived in the provinces with the third quartile of GDP per capita (n = 2,396, 30.8%) and provinces with the second quartile of hospital beds per 10,000 persons (n = 2,221, 28.5%).

Further, we analyzed the odds ratio for older adults with depressive symptoms (vs. non-depressive symptoms) for each predictor using binary logistic regression. The analysis showed that older adults who did not utilize HCBSs (OR = 1.167, 95% CI: 1.039–1.311, p = 0.009) had a greater risk of depressive symptoms than those who utilized HCBSs. In addition, older adults who were female, single, illiterate, living in rural areas, without income, with health insurance, with chronic diseases, with worse SRH, and who did not smoke, drink, or exercise had greater risk of depressive symptoms. For the province-level characteristics, older adults living in provinces with the fourth quartile of GDP per capita were less likely to suffer from depressive symptoms, and provinces with fourth quartile of hospital beds per 10,000 persons were more likely to be diagnosed with depressive symptoms.

[Insert Table 1 here] Table 1 Depressive symptoms by individual- and province-level variables among Chinese older adults in 2018

Table 2 summarizes the relationship between HCBSs utilization and depressive symptoms. Further, Model 1 identifies significant variations between provinces in the empty model (i.e., model without explanatory covariates included). The HCBSs utilization was significantly associated with depressive symptoms (OR = 1.154, 95% CI: 1.023–1.301, p < 0.05) in Model 2, which included HCBSs utilization as the only predictor. In Model 3, utilization of HCBSs was significantly associated with depressive symptoms (OR = 1.195, 95% CI: 1.049–1.362, p < 0.01) after controlling for other individual-level covariates. In Model 4, depressive symptoms were greatly associated with HCBSs utilization (OR = 1.189, 95% CI: 1.043–1.356, p < 0.01) after adjusting for individual-level and province-level variables. Older adults utilizing HCBSs were more likely to have a lower risk of depressive symptoms. Several covariates (i.e., gender, marital status, educational level, residence, number of chronic diseases, SRH, and smoking) were associated with depressive symptoms. In addition, provincial GDP per capita emerged as significant predictors of depressive symptoms.

[Insert Table 2 here] Table 2 HCBSs utilization associated with depressive symptoms among Chinese older adults in 2018

To the best of our knowledge, this is the first study to explore the association between HCBSs utilization and depressive symptoms among Chinese older adults using nationally representative survey data. Moreover, this study assessed the effects of individual- and provincial-level covariates on depressive symptoms among older adults. Results showed that older adults who utilized HCBSs were less likely to suffer from depressive symptoms, even after adjusting for sociodemographic characteristics, health status, lifestyle, and province-level covariates.

In the early 1980s, in the United States and Denmark, HCBSs provision systems were first established to match the demands of older adults[15, 35]. In China, the implementation of HCBSs occurred later than that in Western countries. However, since 2008, a series of policies have been implemented to not only encourage the provision of HCBSs at the national level, but also promote healthy ageing[19, 36, 37]. Due to the implementation and rapid promotion of national policies, the provision of HCBSs has increased dramatically from 26.10–62.01% in China[38]. However, the utilization rate of HCBSs was still low compared with the provision rate of HCBSs in China. This may be due to the large provision of HCBSs in the community resulting in an increase in the utilization rate; however, the provision of HCBSs cannot precisely match the demand of HCBSs for older adults, which causes the utilization rate to remain low.

The prevalence of depressive symptoms in older adults aged 60 years and above was 36.7% in 2018, which was significantly higher than that in 2015[5], despite the same measurement and cut-off points being used. In traditional Chinese society, positive family relations are beneficial to mental health and act as a social security system for older adults[39]. However, rapid industrialization and urbanization have shifted these traditional arrangements. Nowadays, older adults are less likely to live with younger generations and receive advice from them. This has direct implications on access to social care and financial security and even affects the mental health of older adults[40, 41].

The present study found that gender, marital status, educational level, residence, number of chronic diseases, SRH, and smoking might be associated with depressive symptoms, which is also in agreement with previous researches. Male participants had a lower risk of depressive symptoms compared to female participants[42]. Furthermore, older adults living with a partner were found to have a lower risk of depressive symptoms compared to older adults who were single[43]. Notably, older adults with higher educational levels[44], and living in urban areas[45] had a lower risk of depressive symptoms. Chronic diseases, in contrast, were found to increase the risk for depressive symptoms [46]. Finally, older adults with better self-rated health [47], and who were not smoking [48] had a reduced risk of depressive symptoms. Provincial factor (GDP per capita) was also found to be important factor influencing depressive symptoms in older adults in the present study, which is consistent with previous studies on the influence of provincial factors on health in older adults [49].

In other countries, the relationship between HCBSs and depressive symptoms has also been explored. As reported by one study from the United States, the utilization of outdoor HCBSs, such as church programs, transportation, and senior centers was associated with depressive symptoms, whereas the utilization of indoor HCBSs, such as home visits, personal care, and shopping assistance, was not associated with depressive symptoms[50]. Another study indicated that depressed older adults were more likely to utilize HCBSs than non-depressed older adults, which also confirmed that HCBSs will play a role in alleviating depressive symptoms in older adults[51]. In addition, a study in Germany indicated that services, such as daily care and health care, were significantly associated with depressive symptoms[52]. Finally, this study confirmed the HCBSs utilization to be a protective factor against depressive symptoms in older adults. While vigorously improving the provision of HCBSs, we should also pay attention to utilization of HCBSs to promote healthy aging.

Our findings support the hypothesis that HCBSs utilization has a positive effect on depressive symptoms in the aging population in China. First, the family’s ability to provide elderly care has been reduced following demographic shifts and socioeconomic changes[53], and older adults may feel a sense of loneliness or disappointment if they fail to receive care from their children[54]. However, the daily care services of HCBSs, such as day care centers, nursing homes, senior dining tables, etc., could be an alternative to accompanying children, reduce feelings of loneliness and marginalization, and protect older adults from depressive symptoms. Second, HCBSs include not only daily care services, but also health care services, such as regular physical examinations, onsite visits, family beds, community nursing, and health management, which are significant approaches to promote somatic symptoms and alleviate depressive symptoms in older adults to a certain extent[55]. Moreover, participation in the entertainment of HCBSs, such as Tai Chi, Table Tennis, and Mahjong, could provide an opportunity to interact with others and reduce negative affect among older adults who are alone at home[56], which is an essential protecting factor against depressive symptoms. Thus, providing targeted HCBSs at the community level could satisfy unmet elderly care needs and may reduce the incidence of adverse emotions and consequently lower the risk of depressive symptoms.

There are also some limitations to this study. First, due to the cross-sectional nature of the study, causal relationships between the utilization of HCBSs and depressive symptoms were not examined. Prospective studies should further examine these relationships. Second, the effects of specific types of HCBSs, such as daily care, health care, and entertainment, on depressive symptoms in older Chinese were not measured in this study. Further research is needed to examine the association between specific types of HCBS and depressive symptoms. Third, potential correlates, such as the accompanying family members and health service quality, were not measured in this study. Further research is needed to examine how HCBSs influence depressive symptoms.

This study shows that depressive symptoms were associated with utilization of HCBSs in China, even after adjusting for sociodemographic characteristics, health status, lifestyle, province-level GDP per captia and hospital beds per 10,000 persons. Better depressive symptoms are more prevalent among Chinese older adults with HCBSs utilization. In addition, gender, marital status, educational level, residence, number of chronic diseases, SRH, and smoking were associated with depressive symptoms. Significant associations were also identified between depressive symptoms and provincial GDP per captia. Notably, HCBSs may play an important role in preventing disease and improving mental health and quality of life. Therefore, the promotion of HCBSs is an important component of health education, patient management, and health promotion.

SRH

Self-Rated Health

HCBSs

Home and Community-Based Services (HCBSs)

CHARLS

China Health and Retirement Longitudinal Study

CES-D-10

10-item Center for Epidemiological Studies Depression Scale

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. The current study is a secondary analysis of public data of CHARLS. The ethical review committee of Peking University approved the conduct of CHARLS (Code of the ethical approval: IRB00001052-11015) and informed consents are signed by participants before their participation .

Consent for publication

Not applicable.

Availability of data and materials

All data used in this study were stored at http://charls.pku.edu.cn/ and available upon request.

Competing interests

The authors declare that they have no competing interests.

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].

Authors’ contributions

CC, XYZ, TKX and ZSH conceived and designed the study. TKX and ZSH participated in acquisition of the data. TKX and CC contributed to data analysis. TKX and ZSH wrote the original draft. TKX took charge of the submission. CC, XYZ, TKX, ZSH, YCH, YZ, DYC, and YTF substantively revised the manuscript. All authors have read and approved the final manuscript.

Acknowledgments

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.

WHO: Mental Health of Older Adults. In: World Health Organization. 2017.
Walker ER, McGee RE, Druss BG: Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis. JAMA Psychiatry 2015, 72(4):334-341.
WHO: Depression. In: World Health Organization. 2021.
Lutz W, Sanderson W, Scherbov S: The coming acceleration of global population ageing. Nature 2008, 451(7179):716-719.
Liao S, Zhou Y, Liu Y, Wang R: Variety, frequency, and type of Internet use and its association with risk of depression in middle- and older-aged Chinese: A cross-sectional study. J Affect Disord 2020, 273:280-290.
Liu S, Page A: Reforming mental health in China and India. The Lancet 2016, 388(10042):314-316.
Wang X-Q, Chen P-J: Population ageing challenges health care in China. The lancet 2014, 383(9920):870.
Yang W, Wu B, Tan SY, Li B, Lou VW, Chen Z, Chen X, Fletcher JR, Carrino L, Hu B: Understanding health and social challenges for aging and long-term care in China. Research on Aging 2021, 43(3-4):127-135.
Zhu Y, Österle A: China's policy experimentation on long‐term care insurance: Implications for access. The International Journal of Health Planning and Management 2019, 34(4):e1661-e1674.
Kalache A: Ageing in developing countries: are we meeting the challenge? Health Policy and Planning 1986, 1(2):171-173.
Low L-F, Yap M, Brodaty H: A systematic review of different models of home and community care services for older persons. BMC health services research 2011, 11(1):1-15.
Muramatsu N, Yin H, Hedeker D: Functional declines, social support, and mental health in the elderly: does living in a state supportive of home and community-based services make a difference? Social Science & Medicine 2010, 70(7):1050-1058.
Blazer DG: Depression in late life: review and commentary. The journals of gerontology series A: Biological sciences and medical sciences 2003, 58(3):M249-M265.
Chau R, Kissane DW, Davison TE: Risk factors for depression in long-term care: a systematic review. Clinical Gerontologist 2019, 42(3):224-237.
Chen Y, Hicks A, While AE: Depression and related factors in older people in China: a systematic review. Reviews in Clinical Gerontology 2012, 22(1):52-67.
Rodda J, Walker Z, Carter J: Depression in older adults. Bmj 2011, 343.
Steck N, Cooper C, Orgeta V: Investigation of possible risk factors for depression in Alzheimer's disease: A systematic review of the evidence. Journal of affective disorders 2018, 236:149-156.
Mohd TAMT, Yunus RM, Hairi F, Hairi NN, Choo WY: Social support and depression among community dwelling older adults in Asia: a systematic review. BMJ open 2019, 9(7):e026667.
Vink D, Aartsen MJ, Schoevers RA: Risk factors for anxiety and depression in the elderly: a review. Journal of affective disorders 2008, 106(1-2):29-44.
Li W, Liu E, Balezentis T, Jin H, Streimikiene D: Association between socioeconomic welfare and depression among older adults: Evidence from the China health and Retirement Longitudinal Study. Social Science & Medicine 2021, 275:113814.
Chen Q, Amano T, Park S, Kim B: Home and Community-based Services and Life Satisfaction among Homebound and Poor Older Adults. J Gerontol Soc Work 2019, 62(7):708-727.
Yu Y, Yuan C, Zhang Q, Song C, Cui S, Ye J, Zhang X, Chen C: Longitudinal association between home and community-based services provision and cognitive function in Chinese older adults: Evidence from the Chinese Longitudinal Healthy Longevity Survey. Health Soc Care Community 2021, 29(6):e288-e298.
Yu Y, Zhang J, Song C, Petrovic M, Pei X, Zhang WH: Perceived availability of home- and community-based services and self-reported depression among Chinese older adults: A cross-sectional study. Health Soc Care Community 2022, 30(5):e2827-e2837.
Zhao Y, Hu Y, Smith JP, Strauss J, Yang G: Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS). Int J Epidemiol 2014, 43(1):61-68.
Lei X, Sun X, Strauss J, Zhang P, Zhao Y: Depressive symptoms and SES among the mid-aged and elderly in China: evidence from the China Health and Retirement Longitudinal Study national baseline. Social Science & Medicine 2014, 120:224-232.
Feng XL, Pang M, Beard J: Health system strengthening and hypertension awareness, treatment and control: data from the China Health and Retirement Longitudinal Study. Bulletin of the World Health Organization 2013, 92:29-41.
Radloff LS: The CES-D scale: A self-report depression scale for research in the general population. Applied psychological measurement 1977, 1(3):385-401.
Andresen EM, Malmgren JA, Carter WB, Patrick DL: Screening for depression in well older adults: Evaluation of a short form of the CES-D. American journal of preventive medicine 1994, 10(2):77-84.
Chang S-H, Chen M-C, Chien N-H, Lin T-Y, Chang Y-Y: Gender differences in the relationship of lifestyle and depressive symptoms among Taiwanese older people. Collegian 2016, 23(3):249-255.
Amtmann D, Kim J, Chung H, Bamer AM, Askew RL, Wu S, Cook KF, Johnson KL: Comparing CESD-10, PHQ-9, and PROMIS depression instruments in individuals with multiple sclerosis. Rehabilitation psychology 2014, 59(2):220.
Liao S, Zhou Y, Liu Y, Wang R: Variety, frequency, and type of Internet use and its association with risk of depression in middle-and older-aged Chinese: a cross-sectional study. Journal of Affective Disorders 2020, 273:280-290.
Wang R, Chen Z, Zhou Y, Shen L, Zhang Z, Wu X: Melancholy or mahjong? Diversity, frequency, type, and rural-urban divide of social participation and depression in middle-and old-aged Chinese: A fixed-effects analysis. Social science & medicine 2019, 238:112518.
Feng Z, Li Q, Zhou L, Chen Z, Yin W: The relationship between depressive symptoms and activity of daily living disability among the elderly: results from the China Health and Retirement Longitudinal Study (CHARLS). Public Health 2021, 198:75-81.
Liu H, Fan X, Luo H, Zhou Z, Shen C, Hu N, Zhai X: Comparison of depressive symptoms and its influencing factors among the elderly in urban and rural areas: Evidence from the China Health and Retirement Longitudinal Study (CHARLS). International journal of environmental research and public health 2021, 18(8):3886.
Fiske A, Wetherell JL, Gatz M: Depression in older adults. Annual review of clinical psychology 2009, 5:363.
Tengku Mohd TAM, Yunus RM, Hairi F, Hairi NN, Choo WY: Social support and depression among community dwelling older adults in Asia: a systematic review. BMJ Open 2019, 9(7):e026667.
Steck N, Cooper C, Orgeta V: Investigation of possible risk factors for depression in Alzheimer's disease: A systematic review of the evidence. J Affect Disord 2018, 236:149-156.
Tingke Xu, Qinlan Zhao, Yin Chen, Yanhong Lu, Yunyun Huang, Qianru Zhai, Tingting Zhu, Chun Chen: Researches on the Spatial and Temporal Differences in the Provision of Home and Community － Based Pension Services in China Based on CLHLS (2008—2018) Longitudinal Data. The Chinese Health Service Management 2022, 39(03):170-172+195. (in Chinnese)
Lendon JP: The measurement, life course patterns, and outcomes of intergenerational ambivalence among parent-adult child dyads: University of Southern California; 2012.
Lim LL, Chang W, Yu X, Chiu H, Chong MY, Kua EH: Depression in Chinese elderly populations. Asia‐Pacific Psychiatry 2011, 3(2):46-53.
Mjelde-Mossey LA, Chi I, Lou VW: Relationship between adherence to tradition and depression in Chinese elders in China. Aging & Mental Health 2006, 10(1):19-26.
Thompson AH, Bland RC: Gender similarities in somatic depression and in DSM depression secondary symptom profiles within the context of severity and bereavement. Journal of Affective Disorders 2018, 227:770-776.
Hossain B, Yadav PK, Nagargoje VP, Vinod Joseph K: Association between physical limitations and depressive symptoms among Indian elderly: marital status as a moderator. BMC psychiatry 2021, 21(1):1-11.
Taple BJ, Chapman R, Schalet BD, Brower R, Griffith JW: The Impact of Education on Depression Assessment: Differential Item Functioning Analysis. Assessment 2022, 29(2):272-284.
Li LW, Liu J, Xu H, Zhang Z: Understanding rural–urban differences in depressive symptoms among older adults in China. Journal of aging and health 2016, 28(2):341-362.
Jiang CH, Zhu F, Qin TT: Relationships between Chronic Diseases and Depression among Middle-aged and Elderly People in China: A Prospective Study from CHARLS. Curr Med Sci 2020, 40(5):858-870.
Peleg S, Nudelman G: Associations between self-rated health and depressive symptoms among older adults: Does age matter? Social Science & Medicine 2021, 280:114024.
Weinberger AH, Kashan RS, Shpigel DM, Esan H, Taha F, Lee CJ, Funk AP, Goodwin RD: Depression and cigarette smoking behavior: a critical review of population-based studies. The American journal of drug and alcohol abuse 2017, 43(4):416-431.
Evandrou M, Falkingham J, Feng Z, Vlachantoni A: Individual and province inequalities in health among older people in China: Evidence and policy implications. Health & Place 2014, 30:134-144.
Lam BT, Cervantes AR, Lee WK: Late-life depression, social support, instrumental activities of daily living, and utilization of in-home and community-based services in older adults. Journal of human behavior in the social environment 2014, 24(4):499-512.
Pepin R, Leggett A, Sonnega A, Assari S: Depressive symptoms in recipients of home-and community-based services in the United States: are older adults receiving the care they need? The American Journal of Geriatric Psychiatry 2017, 25(12):1351-1360.
Stein J, Pabst A, Weyerer S, Werle J, Maier W, Heilmann K, Scherer M, Stark A, Kaduszkiewicz H, Wiese B: The assessment of met and unmet care needs in the oldest old with and without depression using the Camberwell Assessment of Need for the Elderly (CANE): Results of the AgeMooDe study. Journal of affective disorders 2016, 193:309-317.
Feng Z, Liu C, Guan X, Mor V: China’s rapidly aging population creates policy challenges in shaping a viable long-term care system. Health Affairs 2012, 31(12):2764-2773.
Wang D: Intergenerational transmission of family property and family management in urban China. The China Quarterly 2010, 204:960-979.
Yang L, Wang L, Di X, Dai X: Utilisation of community care services and self-rated health among elderly population in China: a survey-based analysis with propensity score matching method. BMC Public Health 2021, 21(1):1936.
Zhang Y, Yeager VA, Hou S: The impact of community-based supports and services on quality of life among the elderly in China: a longitudinal study. Journal of Applied Gerontology 2018, 37(10):1244-1269.

Table 1. Depressive symptoms by individual- and province-level variables among Chinese older adults in 2018

Variable	N (%)	Depressive Symptoms		OR (95% CI)	p-value
Variable	N (%)	No	Yes	OR (95% CI)	p-value
Total	7,787 (100.0)	4,928 (63.3)	2,859 (36.7)
Individual level
Utilization of HCBSs
Yes	1567 (20.1)	1,036 (66.1)	531 (33.9)	Ref
No	6220 (79.9)	3,892 (62.6)	2,328 (37.4)	1.167 (1.039, 1.311)	0.009
Gender
Male	4034 (51.8)	2,832 (70.2)	1,202 (29.8)	Ref
Female	3753 (48.2)	2,096 (55.8)	1,657 (44.2)	1.863 (1.697, 2.045)	<0.001
Age
60–69	5074 (65.2)	3,245 (64.0)	1,829 (36.0)	Ref
70–79	2252 (28.9)	1,392 (61.8)	860 (38.2)	1.096 (0.989, 1.214)	0.079
80–	461 (5.9)	291 (63.1)	170 (36.9)	1.036 (0.851, 1.263)	0.722
Marital status
Partnered	6378 (81.9)	4,158 (65.2)	2,220 (34.8)	Ref
Single	1409 (18.1)	770 (54.6)	639 (45.4)	1.554 (1.383, 1.747)	<0.001
Educational level
Illiterate	2011 (25.8)	1,072 (53.3)	939 (46.7)	Ref
Elementary school	3580 (46.0)	2,197 (61.4)	1,383 (38.6)	0.719 (0.644, 0.803)	<0.001
Middle school	1361 (17.5)	992 (72.9)	369 (27.1)	0.425 (0.366, 0.492)	<0.001
High school or higher	835 (10.7)	667 (79.9)	168 (20.1)	0.288 (0.238, 0.348)	<0.001
Residence
Urban	1630 (20.9)	1,211 (74.3)	419 (25.7)	Ref
Urban-rural continuum	530 (6.8)	361 (68.1)	169 (31.9)	1.353 (1.093, 1.676)	0.006
Rural	5627 (72.3)	3,356 (59.6)	2,271 (40.4)	1.956 (1.729, 2.212)	<0.001
Income
Yes	1136 (14.6)	848 (74.6)	288 (25.4)	Ref
No	6651 (85.4)	4,080 (61.3)	2,571 (38.7)	1.855 (1.609, 2.140)	<0.001
Health insurance
Yes	203 (2.6)	107 (52.7)	96 (47.3)	Ref
No	7584 (97.4)	2,763 (36.4)	4,821 (63.6)	0.639 (0.483, 0.845)	0.002
Number of chronic diseases
0	1186 (15.2)	931 (78.5)	255 (21.5)	Ref
1	1778 (22.8)	1,257 (70.7)	521 (29.3)	1.513 (1.274, 1.797)	<0.001
2	1717 (22.1)	1,097 (63.9)	620 (36.1)	2.063 (1.741, 2.446)	<0.001
≥3	3106 (39.9)	1,463 (47.1)	1,643 (52.9)	3.251 (2.783, 3.798)	<0.001
SRH
Very good	860 (11.0)	721 (83.8)	139 (16.2)	Ref
Good	917 (11.8)	726 (79.2)	191 (20.8)	1.365 (1.072, 1.738)	0.012
Fair	3897 (50.1)	2,651 (68.0)	1,246 (32.0)	2.438 (2.009, 2.959)	<0.001
Bad	1635 (21.0)	686 (42.0)	949 (58.0)	7.176 (5.837, 8.821)	<0.001
Very bad	478 (6.1)	144 (30.1)	334 (69.9)	12.031 (9.214, 15.709)	<0.001
Smoking
Yes	2205 (28.3)	1,472 (66.8)	733 (33.2)	Ref
No	5582 (71.7)	3,456 (61.9)	2,126 (38.1)	1.235 (1.114, 1.370)	<0.001
Drinking
Yes	2660 (34.2)	1,868 (70.2)	792 (29.8)	Ref
No	5127 (65.8)	3,060 (59.7)	2,067 (40.3)	1.593 (1.441, 1.761)	<0.001
Physical exercise
Yes	7041 (90.4）	4,518 (64.2)	2,523 (35.8)	Ref
No	746 (9.6)	410 (55.0)	336 (45.0)	1.468 (1.260, 1.709)	<0.001
Province level
GDP per capita
Q1	1706 (21.9)	1,013 (59.4)	693 (40.6)	Ref
Q2	2296 (29.5)	1,362 (59.3)	934 (40.7)	1.002 (0.882, 1.139)	0.970
Q3	2396 (30.8)	1,528 (63.8)	868 (36.2)	0.830 (0.731, 0.943)	0.004
Q4	1389 (17.8)	1,025 (73.8)	364 (26.2)	0.519 (0.445, 0.605)	<0.001
Hospital beds per 10,000 persons
Q1	2062 (26.5)	1,281 (62.1)	781 (37.9)	Ref
Q2	2221 (28.5)	1,529 (68.8)	692 (31.2)	0.742 (0.654, 0.842)	<0.001
Q3	1701 (21.8)	1,090 (64.1)	611 (35.9)	0.919 (0.805, 1.050)	0.216
Q4	1803 (23.2)	1,028 (57.0)	775 (43.0)	1.237 (1.087, 1.407)	<0.001

Note: Boldface indicates statistical significance (p<0.05)

Table 2. HCBSs utilization associated with depressive symptoms among Chinese older adults in 2018

Variables	Model 1 OR (95% CI)	Model 2 OR (95% CI)	Model 3 OR (95% CI)	Model 4 OR (95% CI)
Individual level
HCBSs (ref: yes)		1.154^* (1.023, 1.301)	1.195^ (1.049, 1.362)**	1.189^ (1.043, 1.356)**
Gender (ref: male)			1.700^* (1.489, 1.941)**	1.702^* (1.490, 1.943)**
Age (ref: 60–)
70–			0.916 (0.815, 1.030)	0.917 (0.816, 1.032)
80–			0.891 (0.710, 1.119)	0.896 (0.714, 1.125)
Marital status (ref: partnered)			1.302^* (1.138, 1.489)**	1.298^* (1.134, 1.485)**
Educational level (ref: illiterate)
Elementary school			0.897 (0.787, 1.022)	0.893 (0.784, 1.018)
Middle school			0.668^* (0.560, 0.797)**	0.664^* (0.556, 0.792)**
High school or higher			0.500^* (0.400, 0.624)**	0.500^* (0.400, 0.625)**
Residence (ref: urban)
Urban-Rural continuum			1.188 (0.942, 1.498)	1.185 (0.940, 1.494)
Rural			1.593^* (1.379, 1.840)**	1.593^* (1.379, 1.841)**
Income (ref: yes)			1.180^ (1.006, 1.385)**	1.166 (0.993, 1.369)
Health insurance (ref: yes)			0.809 (0.594, 1.102)	0.810 (0.595, 1.103)
Number of chronic diseases (ref: 0)
1			1.214^* (1.011, 1.459)	1.216^* (1.012, 1.460)
2			1.517^* (1.263, 1.822)**	1.514^* (1.261, 1.819)**
≥3			1.896 (1.591, 2.259)	1.888^* (1.585, 2.250)**
SRH (ref: very good)
Good			1.252 (0.974, 1.610)	1.249 (0.972, 1.606)
Fair			1.980^* (1.615, 2.427)**	1.973^* (1.609, 2.419)**
Bad			4.660^* (3.732, 5.820)**	4.637^* (3.713, 5.792)**
Very bad			7.666^* (5.763, 10.195)**	7.629^* (5.735, 10.149)**
Smoking (ref: yes)			0.826^ (0.723, 0.943)**	0.826^ (0.723, 0.944)**
Drinking (ref: yes)			1.024 (0.906, 1.156)	1.026 (0.908, 1.159)
Physical exercise (ref: yes)			1.178 (0.993, 1.399)	1.186 (0.998, 1.408)
GDP per capita (ref: Q1)
Q2				1.076 (0.786, 1.474)
Q3				0.899 (0.661, 1.221)
Q4				0.573^ (0.402, 0.818)**
Hospital beds per 10,000 persons (ref: Q1)
Q2				0.857 (0.627, 1.171)
Q3				0.930 (0.627, 1.171)
Q4				1.068 (0.762, 1.496)
Variance between provinces	0.183^**	0.184^**	0.093^**	0.058^*

Note: Boldface indicates statistical significance (^*p < 0.05, ^**p < 0.01, ^***p < 0.001).

No competing interests reported.

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Effect of home and community-based services on older adults’ depressive symptoms in China: a multilevel analysis

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Abstract

Background

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Results

Conclusions

1. Introduction

2. Methods

2.1. Study participants

2.2. Measures

2.2.1 Dependent variable

2.2.2. Independent variable

2.2.3. Covariates

2.3. Statistical analysis

3. Results

4. Discussion

5. Limitation

6. Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

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