The world’s population is ageing rapidly. According to the United Nations 1, the proportion of the world's population aged 65 years or older will grow from 9% in 2019 to 16% in 2050. In China, older adults will account for 26.1% of the population by 2050. There will be approximately 480 million old people aged 65 and above in China by 2050 2. Mental health is an important indicator of healthy ageing. Depressive symptoms are the most common mental health problems among old people 3. More than 300 million people suffered from depression in 2015, and the prevalence rate increases with age 4,5. Due to the different tools and samples, the prevalence rates of depression and depressive symptoms among older people varied across studies, ranging from 2.3–38.9% 6. Huang, et al. 7 and Haigh, et al. 5 reported that approximately 4.1% and 35% Chinese older adults experienced depression and depressive symptoms respectively. Individuals from low-income regions, rural areas and women have higher risk of depression symptoms than others 4,7.
Furthermore, depression is the major causes of both disability and suicide 4. Old people experiencing depression were more likely to have chronic diseases, such as asthma, coronary heart disease and rheumatoid arthritis 3 and higher risk of suicide 4,8,9. As the aged population grows, the number of depressed seniors will continue to increase. Although depression and depressive symptoms can be treated through psychological interventions or medications, 76–85% people in low- and middle-income countries still have no access to effective treatment 4,10. Therefore, reducing the prevalence of depressive symptoms is beneficial to promote older people’s mental and physical health, improve their life quality, and eventually achieve the goal of healthy ageing. Thus, it is important to examine the potential factors of depressive symptoms and develop corresponding effective policies and interventions.
Empirical studies have examined various factors of depressive symptoms among older people. These factors could be classified into a) sociodemographic characteristics, including gender, age, marital status 11–13; b) physical health, such as chronic diseases and disability 11,13; c) socioeconomic status (SES), such as income and education 9,11,14; d) social support 15 ; e) health behaviors, such as smoking and drinking 16, and social participation 17–19. In addition, some studies indicated that older people’s attitudes toward ageing (hereafter, ATA) were also modifiable social determinants of depressive symptoms 20–22. However, most existing studies examined the direct effects of ATA on depressive symptoms in western countries. And the interplay between ATA and social participation and their influence on depressive symptoms remains understudied. Therefore, it is necessary to examine the mechanisms linking ATA and social participation to depression among older Chinese people.
Theoretical Framework
The Active Ageing Framework highlighted that in order to maintain health, including physical health, mental health, and social well-being, old adults should be encouraged to participate in social activities, and be provided adequate protection, security and care when they needed. Active ageing refers to “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age (p.12)” 23. “Active” emphasize continued participation in social activities after retirement. At present, the promotion of social participation has become a key development strategy of active aging and a vital issue of public policy in all countries. In addition, according to Beck 24 cognitive theory of depression, people’s negative cognitions are the major causes of depression. Beck believed that the construct of schemata, which was defined as stored knowledge, would affect individual's understanding and processing of information. People with “depressogenic” schemata tend to explain all the events in a negative way. Individuals who engaged in this cognitive process were more likely to develop “negative cognitive triad”, which refers to negative views of oneself, the world, and the future 25. Beck hypothesized that these negative cognitions would increase the risk of depression. Therefore, older people who hold negative ATA may have a higher risk of suffering depression.
Furthermore, proponents of social psychology believed that behavior is associated with attitude. Self-perception theory indicated that people could infer their attitudes and emotions by observing their own behavior 26. Individual would change their attitudes to prove the rationality of behaviors and keep consonance of cognition. Thus, older people who engaged in activities actively were more likely to have positive ATA. Therefore, ATA may play a mediator role in the association between social participation and depressive symptoms among older people.
Social Participation and Depressive Symptoms
Social participation was defined as “a person’s involvement in activities that provide interaction with others in society or the community” (p.2148) 27. Empirical evidence indicated that engaging in social activities (e.g., political activities, volunteering activities, economic activities) was benefit to older people’s mental health, including reducing the risk of depressive symptoms 28–34. An intervention study found that established community group activities can influence the reduction of depression and suicide attention 18. A relevant systematic review also suggested that most of the research showed formal social participation had a positive impact on older people’s physical and psychosocial well-being 17. Moreover, some studies suggested that the effects of social participation varied from its type of activities, and high frequency of social participation was associated with low level of depressive symptoms 35,36. Older people who participated the single type of activities had a higher risk of depression than those who participated two or three types of physical, social, and religious activities 19.
The Mediator Role of ATA in the Association between Social Participation and Depressive Symptoms
ATA refers to older people's subjective evaluation and feelings to the process of ageing, including positive and negative attitudes, and it also can be measured by three dimensions: psychological loss, psychological growth, and physical change 37. Many relevant studies found that negative ATA was associated with higher level of depressive symptoms 21,38−41, while positive ATA was associated with lower risk of depression and anxiety symptoms, and higher level of life satisfaction 20,42−44 A systematic review reported negative ATA, ageism, and ageing stereotypes predicted higher level of depression and anxiety among older people in all the 12 studies 45. A cross-sectional study showed that people aged 80 and older had a more negative ageing attitudes than its younger counterpart group (aged 57 to 79). And positive ATA was associated with better quality of life 46. Meanwhile, one Chinese study reported that psychological loss had positive impact on depressive symptoms, while the effects of psychological growth on depressive symptoms was not significant 47. The inconsistent conclusions may result from different measurements and sample size in different countries.
Furthermore, empirical evidences suggested that older people’s social participation and health behaviors was associated with their ATA 46,48. Some studies indicated that social participation was an effective strategy to modify older people’s negative ATA. For example, a study on the relationship between older people’s ATA and cognitive function found that engaging in more social activities could reduce the impact of negative age stereotype on the decline of episodic memory 49. In addition, a randomized control trial study indicated that participating in physical activities could change older people’s ATA: Compared with two control groups, the behavior intervention combined with “views-on-ageing-component” had higher effects on the improvement of positive ATA 50. These findings indicated that encouraging older people to participate activities may be beneficial for fostering positive ATA, which could further reduce the risk of depressive symptoms.
Although previous studies had examined the effect of social participation and ATA on older people’s mental health, there still have some research gaps. First, existing studies are mainly based on Western countries, limited studies examined the relationship between ATA and depressive symptoms among older adults in China. ATA may be impacted and shaped by social and cultural determinants 51, therefore, it is important to understand the ageing attitudes and its effects on depressive symptoms in Chinese context. Secondly, previous studies have mostly examined the direct effects of ageing attitudes on depression and depressive symptoms, however, the underlying mechanisms have not been fully examined. To our knowledge, no studies have examined the mediation mechanisms among social participation, ATA and depressive symptoms in China. Based on a national survey data, this study would examine the mediation role of ATA on the relationship between social participation and depressive symptoms among older Chinese adults. Therefore, we proposed two hypotheses:
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1. Psychological loss mediates the association between social participation and depressive symptoms among older Chinese adults.
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2. Psychological growth mediates the association between social participation and depressive symptoms among older Chinese adults.