Preparation for future care moderates the relationship between loneliness and depression among Chinese rural older adults: A cross-sectional study

Background: Loneliness and depression are common mental health concerns among older adults in rural China. Loneliness has been identified as a risk factor for depressive symptoms, while preparation for future care can be a protective factor. Little is known about the complex relationships among these factors in rural older adults. This study aimed to explore whether preparation for future care moderated the association between loneliness and depressive symptoms. Methods: A total of 481 rural older adults aged 60 years and above were recruited in Shandong, China. Loneliness, preparation for future care, and depressive symptoms were measured. Statistical analyses included d escriptive analysis, univariate analyses, and moderating effects analyses. Results: Our findings showed that preparation for future care and its related dimensions of gathering information, making decisions, and concrete planning can moderate the relationship between loneliness and depression. When the level of preparation for future care and its dimensions were higher, the effect of loneliness on depressive symptoms was weaker. Conclusions: As the first study on how preparation for future care moderates the relationship between loneliness and depression in rural older adults, the findings are significant. Preparation for future care should be taken into consideration when interventions are being developed to reduce depressive symptoms in older adults.

an urban environment, leaving behind a great number of older adults in rural areas [9]. Rural older adults, owing to such factors as poor living conditions, "empty-nest syndrome," and lack of social interactions [9], may also experience more serious health problems.
Depression, is one of the most prevalent mental health issues among older adults [10], and it is becoming a central public health concern. Depression is characterized by low mood, lack of energy, and/or somatic symptoms [11]. As the body ages, mental cognition and physical functioning decline, which may be related to depression [12,13]. Previous studies indicated that depression could influence physical and mental health, quality of life [4], and suicidal tendencies [14]. However, depression in old age is often seen as a normal part of aging and neglected by doctors [12]. Thus, it is vital to identify and assess depression and its related factors among older adults.
Loneliness is a subjective emotion related to not having many or good interpersonal relationships [9], and is often experienced by older adults, especially in rural areas. Traditional Chinese culture values filial piety, and older adults have often been taken care of by their adult children in the home.
However, as their adult children find jobs and move to urban areas, rural older adults are experiencing empty-nest syndrome, and suffer from more loneliness than older adults in urban areas [9]. A previous cross-sectional study reported that 78.1% of the older population in Anhui Province experienced moderate to severe loneliness [15]. Previous research reported that loneliness could predict depression among older populations [3,16]. However, as not all older adults who experience loneliness also suffer from depression, some protective factors might exist.
As people age, they face a decline in physical functioning, an increase in chronic diseases, and frailty; thus, preparation for future care (PFC) is necessary to cope with increasing care needs. PFC is a concept developed by Sörensen and Pinquart [17], and is a health-promotion activity that encompasses both thoughts and actions. It includes five factors: awareness of future care needs, gathering information, make decisions, concrete planning, and avoidance of care planning. Older adults who engage in PFC have been shown to have better health outcomes and greater life satisfaction [18]. Sörensen et al. [19] explored whether PFC was related to subsequent mental health (e.g., depression and anxiety), and a two-year longitudinal study indicated that failure to engage in PFC is a remarkable risk factor for depression and anxiety among older populations. It was proposed that the PFC model was based on proactive coping, which could buffer the stress older adults experience from the aging process [20]. Loneliness is a mental stressor [21] often experienced by older adults, and PFC might buffer the negative outcomes of loneliness. However, whether PFC could also moderate the relationship between loneliness and depression among rural older populations has scarcely been explored.
Considering this background, the present study aimed to explore the relationships among loneliness, depression, and PFC in community-dwelling older adults in rural China. Additionally, we examined the moderating effects of PFC on the path from loneliness to depression. Therefore, we first hypothesized that loneliness is a risk factor (H1), whereas PFC is a protective factor (H2), for depression.
Subsequently, we also hypothesized that PFC would moderate the relationship between loneliness and depression (H3) among Chinese rural older populations ( Figure 1).

Participants
This was a cross-sectional study with older adults living in rural communities in Shandong, China, which is a typical northern Chinese province and has one of the largest aging populations in China.
Data were collected between March and May, 2015. Household surveys were conducted by trained research assistants, who also read questionnaires to participants if they were illiterate. Individuals included in the study fulfilled the following criteria: (1) aged ≥ 60 years, (2) had the physical and mental abilities to participate in interviews, and (3) were willing to participate in the study and sign an informed consent form. Individuals who were younger than 60 years old or has serious physical or mental health issues were excluded. Ultimately, a total of 481 participants were recruited. This study was approved by the institutional review board of the School of Nursing, Shandong University (approval number: 2017-R-105).

Sociodemographic and physical health characteristics
Participants' gender, age, marital status, living status, educational background, self-rated financial status, and medical insurance were obtained in this study.
We also collected participants' physical health information by assessing for a number of illnesses and healthy lifestyle indicators (including smoking, drinking, and exercise). As for illnesses, we selected medical disorders reported to be prevalent among older adults and asked participants whether they had experienced one or more of the following medical conditions during the previous year: diabetes mellitus, hypertension, osteoarthritis, liver disorders, kidney disorders, cancer, congestive heart failure, chronic obstructive pulmonary disease, heart attack, gastrointestinal disorders, hearing problems, or ophthalmologic disorders [22].

Loneliness
Loneliness was assessed with the Chinese version of the UCLA Loneliness Scale (ULS; Version 3) [23].
The ULS consists of 20 items and measures feelings of loneliness using a 4-point Likert scale, ranging from 0 ("never") to 4 ("often"). When summing the item scores, items 1,5,6,9,10,15,16,19, and 20 are reverse scored. The scores in the present study ranged between 20-80, with higher scores signifying more intense feelings of loneliness. Cronbach's α of the scale was 0.893 in the current study.

Preparation for future care
The short-form of the Preparation for Future Care Needs (PFCN) scale [24,17] was used in this study.
The PFCN short-form has 15 items and 5 dimensions to assess the process of care planning, namely awareness of future care needs (AW), avoidance of care planning (AV), gathering information (GA),

Depression
Depression was evaluated using the Patient Health Questionnaire-9 (PHQ-9) [25], which was developed according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). The PHQ-9 has been widely used in depression screening, and showed good validity, with a Cronbach's α of 0.866 in the current study. It comprises nine items, with higher scores indicating more serious depressive symptoms.

Statistical analyses
Descriptive analyses, independent t-tests, and a one-way analysis of variance (ANOVA) were performed to describe basic patient characteristics and compare the distribution of depression. The correlations of main variables (loneliness, depression, total PFC, and each dimension of PFC) were analyzed using Pearson correlation analyses. The moderating effects were analyzed using the PROCESS macro for SPSS [26]. The bias-corrected 95% confidence interval (CI) was calculated with 5,000 bootstrapping re-samples. If the 95% CI did not contain 0, it indicated that the mediating effect was significant. Likewise, if the 95% CI of the interaction did not contain 0, a significant moderating effect could be established. All statistical analyses were conducted using SPSS22.0. Statistical significance was defined as a two-tailed p-value < 0.05. Additionally, all moderating models were controlled for covariates which significantly correlated with depression in univariate analyses, and the study variables were standardized.

Basic characteristics and depression levels of participants
A total of 481 older adults were recruited into the study; however, 45 participants were excluded for having over 15% of the data missing on the PFCN, PHQ-9, or ULS. Thus, data were collected from a total of 436 participants in this study, with a mean age of approximately 70.77 years. A majority of the participants were female (52.3%) and/or had at least one illness (66.5%). Four participants (9.1%) were illiterate. More information is provided in Table 1.
The distribution of depression among participants is also shown in Table 1. By comparison of the means using an independent t-test and ANOVA, we found that participants who were female, aged ≥ 80 years, illiterate, lived alone, had a poor self-rated financial status, seldom exercised, and/or had two or more illnesses presented higher depression scores. Table 2 shows the means, SDs, and correlations among the main variables. Bivariate correlations revealed that loneliness was positively correlated with depression (r = 0.407, p < 0.001). Total PFC scores and scores for each dimension were positively correlated with each other. However, contrary to our hypothesis, except for MD, the total PFC score and each dimension of PFC were not significantly correlated with depression or loneliness. Thus, H1 was supported, while H2 was not. Note: AW = awareness of future care needs, AV= avoidance of care planning, GA = gathering information, MD = making decision, CP = concrete planning, and PFC = preparation for future care; * p < .05, ** p < .01, *** p < .001.

The moderating effect of PFC on loneliness and depression
As shown in Table 3 Figure 2.
Furthermore, the significant moderating model was further tested by analyzing the effects of loneliness on depression at different levels of PFC. We divided the total PFC, GA, MD, and CP into three levels: low (mean minus one SD), medium (the mean), and high (mean plus one SD). As shown in Table 4, the effect of loneliness on depression was most severe in the low-level total PFC group, and least severe in high-level group, which was also shown for GA, MD, and CP. The results of a simple slope analysis (Figure 3) also clearly depicted the relationship between loneliness and depression at different levels of total PFC, GA, MD, and CP; thus, the lower the PFC, the stronger the impact of loneliness on depression (the higher the slope).

The main findings
To our knowledge, this study is the first to explore the relationships among loneliness, depressive symptoms, and PFC among older adults in rural China. This study found that older adults in rural China often experience some degree of loneliness and depression. Loneliness was positively correlated with depressive symptoms, and total PFC, as well as the GA, MD, and CP dimensions of PFC, were shown to moderate the relationship between loneliness and depression. Thus, these findings indicate that older adults who are well-prepared for future care are less likely to develop depressive symptoms due to loneliness than those who are not well-prepared.
Many previous studies have reported that loneliness is a significant risk factor for depressive symptoms in older populations [27], and our results support the positive correlation between loneliness and depressive symptoms in older adults in rural China. With the rapid development of urbanization in China, a large number of the young rural labor force flows to cities, leading many rural older adults to experience empty-nest syndrome [28], which may be one of the reasons why rural older adults often feel lonely. Compared with the rich and colorful community activities available to older adults in urban areas, the construction of spiritual civilization in rural areas is relatively backward, and the social activities of older adults in rural areas are relatively poor [29], which may be another reason for the high rates of loneliness in rural older populations. Since loneliness is a risk factor for developing depressive symptoms, special attention should be paid to the mental health care of lonely older adults.
Previous studies have found that adequate PFC is a protective factor for depression, and inadequate PFC increases the risk of depression [19]. However, previous studies have not explored the mechanism of how PFC affects depression. The current study found that although PFC is not directly related to depression, it can moderate the relationship between loneliness and depression, which can, to some extent, prevent lonely older adults from developing depressive symptoms. The income of older adults in rural areas mainly comes from farming. As these individuals age, their decreased physical functioning impairs their ability to farm; thus, they lose their primary source of income, and struggle to remain self-sufficient. Traditional Chinese Confucian culture emphasizes filial piety, which means older adults mainly rely on their adult children for their support and care [30]. As a result, rural older adults whose children work in cities often feel there is no one they will be able to rely on in the future. The absence of a source of income and caregivers makes these individuals worry about how they will be able to look after themselves in the future, which can lead to depressive symptoms.
Adequate PFC can enable older adults to have a better sense of control over their lives as they age and alleviate their worries about future care. Therefore, depressive symptoms can be prevented to some extent. Furthermore, PFC is essentially a positive coping style for possible difficulties in the future [20], which is widely known to be a buffer between stressors (e.g., loneliness) and adverse outcomes (e.g., depression) [31].
PFC includes five aspects: awareness of future care needs (AW), avoidance of care planning (AV), gathering information (GA), making decisions (MD), and concrete planning (CP). Among them, AW and AV describe thoughts, while GA, MD, and CP describe actions [17]. By analyzing the moderating effects of each aspect, we found that GA, MD, and CP could buffer depression, while AW and AV could not. Therefore, it is not enough for older adults to simply realize the importance of PFC, they must also take specific actions, including collecting relevant information, making decisions, and formulating specific future care plans to truly eliminate worries about their future as they age and prevent depressive symptoms.

Implications
The results of this study have many important implications. Chinese older adults in rural areas often experience poor living conditions, empty-nest syndrome, and a lack of social interactions [9], which can exacerbate feelings of loneliness and depressive symptoms in older people. Depression can lead to a number of adverse health outcomes and even suicide [14].TheChinese government spends a lot of money every year on the prevention and treatment of depression in the older population [2]. The present study found that PFC could reduce the impact of loneliness on depression, which suggests that education on, and improved public awareness of, PFC in rural areas could help more older adults prepare for care in advance, and thus prevent loneliness from developing into depression. Compared with the large amount of funds invested by the government every year for depression prevention and treatment, PFC education and publicity is relatively simple, easy to operate, and cost-effective, which has important practical significance and provides novel insight for the prevention and treatment of depression in the rural older population of China. Notably, PFC education should not only make older adults aware of the importance of PFC but also teach them how to collect information, make decisions, and make specific plans.
Although the population samples in this study were from China, previous studies in other countries have also found that PFC is an important protective factor for mental health [19]. Therefore, the findings of this study may have international implications for mental health promotion in older populations.

Limitations
This study has some limitations. First, although we have reported the relationships among loneliness, depression, and PFC, the study had a cross-sectional design; thus, we cannot confirm the causal relationships between variables. For example, loneliness may be a risk factor for depression, but conversely, depressive symptoms may be a predictor of loneliness [32]. Therefore, future research needs to use longitudinal study designs to further explore the causal relationships between variables.
Second, in this study, the PHQ-9 was chosen as a measure of depression, which is only a screening tool for depressive symptoms, not the "gold standard" for diagnosing depression. At the same time, all the measurements used were self-report scales, which may cause report bias and recall bias.
Third, the geographically may be limited because of the small sample size, and all participants are from just one rural region in Shandong Province. Therefore, multi-center, large-sample studies are needed in the future to ensure the representativeness and generalization of research findings.

Conclusion
This study found that older adults in rural China often experience some degree of loneliness and depression, and PFC can moderate the relationship between loneliness and depression; when the level of PFC and its dimensions were higher, the effect of loneliness on depressive symptoms was weaker. As a result, older adults who are well-prepared for future care may be less likely to develop depressive symptoms due to loneliness. As the first study on how PFC moderates the association between loneliness and depression in rural older adults, the findings are significant. Although PFC is a protective factor for mental health, the current situation regarding the frequency of use of PFC in rural areas is not optimistic. In the future, health education on PFC in rural areas may be an effective way to increase the use of PFC among rural older adults, and thus promote their mental health.   Note: Covariates (gender, age, education, number of illnesses, living status, exercise, and self-rated financial status) were controlled. PFC = preparation for future care, AW = awareness of future care needs, AV= avoidance of care planning, GA = gathering information, MD = making decision, and CP = concrete planning; B = unstandardized regression coefficient, SE = standard error, LLCI = lower level of confidence interval, ULCI = upper level of confidence interval. * p < .05, ** p < .01, *** p < .001.  The final moderating model Moderating effects of PFC on the relationship between loneliness and depression Note: low (the mean minus one SD), medium (the mean), and high (the mean plus one SD). PFC = preparation for future care, GA = gathering information, MD = making decision, and CP = concrete planning.