Loneliness and depression among the elderly in an agricultural
settlement: Mediating effects of social support Wan Mohd Yunus Wan Mohd Azam 1 BD, Normah Che Din 1 MD, Mahadir Ahmad 1 PhD, Shazli Ezzat Ghazali 1 MD, Norhayati Ibrahim 1 PhD, Zaini Said 1 MD, Ahmad Rohi Ghazali 3 PhD, Suzana Shahar 4 PhD, Rosdinom Razali 2 MD & T. Maniam 2 MPsychMed FAMM 1 Health Psychology Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2 Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 3 Biomedical Science Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 4 Dietetic and Nutrition Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Keywords depression, elderly, loneliness, rural community, social support Correspondence Normah Che Din MD, Health Psychology Program, Center of Health Care Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia. Tel: +603-26878182 Fax: +603-26878192 Email: norazman199@yahoo.com DOI:10.1111/appy.12061 Abstract Introduction: Loneliness has long been known to have strong association with depression. The relationship between loneliness and depression, however, has been associated with other risk factors including social support. The aim of this paper is to describe the role of social support in the association between loneliness and depression. Methods: This cross-sectional study examined the mediating effects of social support among 161 community-based elderly in agricultural settle- ment of a rural area in Sungai Tengi, Malaysia. Subjects were investigated with De Jong Gierveld Loneliness Scale, Geriatric Depression Scale and Medical Outcome Survey Social Support Survey. Data were analyzed using Pearson correlation, linear and hierarchical regression. Results: Results indicated that social support partially mediated the rela- tionship between loneliness and depression. Discussion: This suggests that social support affects the linear association between loneliness and depression in the elderly. Introduction The aging population in Asia has become a common phenomenon due to increasing longevity and declin- ing fertility. Based on the statistics from the Economic and Social Commission for Asia and the Pacic, the elderly in Asia are expected to increase more than twofold from 322 million in 2000 to 705 million in 2025 (Malaysian Institute of Economic Research, 2006). Malaysia also showed an increasing trend of elderly population. According to the Malaysian Department of Statistics (2003), the number of senior citizens almost tripled from 1960 to 1991 from 386,600 to 1,032,300. The elderly population contin- ues to increase with 1,398,500 in the year 2000. Based on the population projection, the number of senior citizens is expected to triple in the next 30 years to an estimated 4,933,400. The Federal Land Development Authority (FELDA) is a Malaysian government agency that relo- cates lower income residents of rural areas to newly developed areas to improve their economic status through large scale agricultural activities. The popula- tion of FELDA is growing older with the rst genera- tion in their 80s while the second generation is in their 50s. One of the FELDA settlements, FELDA Sungai Tengi, has 556 settlers with a total of 3,310 residents that includes their family members (Federal Land Development Authority, 2011). The FELDA settlers are well-provided with health-care facilities, and as a result, the infant mortality rate is decreasing while the lifespan of the settlers is increasing. However, the psy- chological well-being of the elderly in FELDA is not widely studied. The elderly commonly experience depression, loneliness, quality of life issues, as well as social isola- tion (Thomopoulou, Thomopoulou & Koutsouki, 2010). Depression has serious consequences such as the risk of suicide (Sherina et al., 2005). However, despite these negative effects, depression is usually bs_bs_banner Ofcial j ournal of the PacicRim College of Psychiatrists AsiaPacific Psychiatry ISSN 1758-5864 134 AsiaPacific Psychiatry 5 (2013) 134139 Copyright 2013 Wiley Publishing Asia Pty Ltd underdiagnosed and undertreated (Alexoupoulos et al., 2002; Simon et al., 1999). Pendleton (2008) also argued that while there are many other psychological illnesses in the elderly, depression was found to have the most negative adverse effects. Elderly people with high levels of loneliness expe- rience more depressive symptoms. Loneliness has long been identied as one of the risk factors for depression (Cacioppo et al., 2006). Buchman et al. (2010) found that loneliness was associated with inammation process and cardiovascular disease that can contribute to motor decline. Loneliness may also lead to fear, grief and anxiety along with loss of independence in elderly people (Aylaz et al., 2012). Social support, coping style, economic status, marital status and reli- gious belief were all signicant factors in predicting depression in the elderly (Xie et al., 2010). A recent study by Aylaz et al. (2012) also recommended that future study should focus on the relationship between loneliness and depression in the elderly because data in this area is rather scarce. Loneliness in the elderly usually does not directly lead to depression but the latter is mediated by other variables. Past studies on mediators of loneliness and depression focused more on adolescence or under- graduate students (Fontaine et al., 2009; Swami et al., 2007; Wei et al., 2005). Identifying variables that transmit the association between loneliness and depression is important from a theoretical viewpoint because these mediators expand our understanding of the process by which depression relates to loneliness. In addition, it is also benecial from a practical view- point in recognizing which aspects of the elderly per- sons life that need further assistance. The aim of this study was to identify the correlation between depres- sion and loneliness and further investigate the medi- ating effect of social support in the relationship between depression and loneliness. Methods Study design and sampling procedures In this cross-sectional study, sampling procedures involved four steps. First, FELDA Sungai Tengi was selected, as it had the largest elderly population in the rural area in the state of Selangor, Malaysia. Second, a preliminary study was conducted to identify house- holds with elderly residents in that area by providing a list of elderly subjects above 60 years old. Third, ques- tionnaires were distributed and administered orally based on the preference of the subjects. Fourth, all participants underwent assessments of general infor- mation with the Malay version of the mini-mental state examination (MMSE) for screening of cognitive functions, depressive symptoms using the Geriatric Depression Scale (GDS) and De Jong Gierveld Loneli- ness Scale for loneliness and Medical Outcome Survey (MOS) Social Support Survey for social support. Sample The study used the non-purposive sampling method, with an enrollment of 161 participants. Inclusion criteria were: aged 60 years and above; residing in FELDA Sungai Tengi; ambulatory; able to read, write and communicate; and were not known to have mental illness or a critical physical illness. Procedures Initially, approval from the village committees and the elderly were obtained with the agreement of the village leader. Second, trained research assistants dis- tributed and interviewed participants using the pro- vided questionnaires during our door-to-door eld survey. Upon completion, questionnaires were col- lected immediately. Of the 165 individuals enrolled, only 161 completed the questionnaires completely while three participants returned incomplete ques- tionnaires and one questionnaire was not usable. Therefore, the response rate was 97.58% (161/165). Measures Loneliness was assessed using the De Jong Gierveld Loneliness Scale which is specically developed for elderly people. The scale comprises two dimensions: negatively oriented emotional loneliness and posi- tively oriented social loneliness. The 15-item GDS was used in this study (Sheikh & Yesavage, 1986). According to Lesher and Berryhill (1994), the short version is able to function as a sat- isfactory substitution for the long version, having shown high correlation (r = 0.89) between the two. Social support was assessed using the MOS Social Support Survey which provides an assessment of several domains of perceived social support including tangible support, emotional/informational support, affective support and positive support (Sherbourne & Stewart, 1991). This assessment focuses on the functional support that refers to the degree to which interpersonal relationships serve particular functions. W.M.Y. Wan Mohd Azam et al. Loneliness and depression in rural elderly Malays 135 AsiaPacific Psychiatry 5 (2013) 134139 Copyright 2013 Wiley Publishing Asia Pty Ltd Data analysis Descriptive statistics were carried out for sociodemo- graphic data. Pearson correlation was used for association between loneliness and depression scores. Linear and hierarchical regressions were used to analyze the mediation effects of social support in the relationship between loneliness and depression. Addi- tionally, the Preacher and Hayes (2008) INDIRECT macros was used to calculate the indirect effect of social support as mediator. All data analysis was per- formed using the SPSS ver. 20 statistical analysis soft- ware package. Results The distribution of sociodemographic characteristics of the 161 subjects is shown in Table 1. The elderly who participated in this study were those aged 60 years and above. Table 2 illustrates the relationship between lone- liness and depression. The result indicated that social loneliness had a weak negative relationship with depression among the elderly, considering the posi- tively oriented items were not reversed. However, emotional loneliness was found to have a moderate positive relationship with depression. Depression was associated with being socially and emotionally lonely. In contrast, high emotional loneliness was related with high level of depression. Mediating effect of social support In the rst linear regression (path c), loneliness sig- nicantly predicts depression (b = 0.174, P < 0.001) (Table 3). However, the second regression (path a) indicated that loneliness signicantly predicts social support (b = 0.171, P < 0.01) in a negative direction, which means that when perceived social support decreased, the feeling of loneliness would increase. Table 1. Sociodemographic data of subjects Variables Frequency (%) Mean SD Sex Male 59 (36.6%) Female 102 (63.4%) Marital status Married 118 (73.3%) Divorced 2 (1.2%) Widowed 41 (25.5%) Education level Illiterate 24 (14.9%) Religious school 10 (6.2%) Primary school 111 (68.9%) Secondary school 12 (7.5%) Others 4 (2.5%) Occupation Not working 31 (19.3%) Housewife 69 (42.9%) Retired 30 (18.6%) Working 3 (1.9%) Working retiree 28 (17.4%) Age 64.94 3.83 Years of education 4.25 2.63 Total household monthly income (Rinngit Malaysia, RM) 1657.86 816.41 SD, standard deviation. Table 2. Pearson correlation analysis for loneliness and depression Depression Social loneliness 0.189 * Emotional loneliness 0.403 ** *P < 0.05. **P < 0.01. Table 3. Mediating effect of social support b R 2 R 2 change Analysis 1 Overall Path a: Loneliness depression 0.174 0.238* Analysis 2 Loneliness support 0.171 0.110* Analysis 3 Step 1: Path b: Social support depression 0.225 0.051*** Path c: Loneliness depression 0.311 0.097** 0.046 *P < 0.05. **P < 0.01. ***P < 0.001. Loneliness and depression in rural elderly Malays W.M.Y. Wan Mohd Azam et al. 136 AsiaPacific Psychiatry 5 (2013) 134139 Copyright 2013 Wiley Publishing Asia Pty Ltd Finally, hierarchical regression was performed to determine the effect of social support on depression (path b) and then the effect of loneliness on depres- sion (path c). In path b, social support explains 5% of the variance in depression (R 2 = 0.051, P < 0.01). In path c, loneliness adds signicantly to the variance which explains depression (R 2 change = 0.046, P < 0.01). In this case, the regression coefcient is still signicant at the nal step (P < 0.05). Therefore it can be inferred that loneliness is partially mediated by social support in the relationship with depression. The Sobel test was signicant, indicating an effect of mediation for social support between loneliness and depression (Sobel test statistic = 0.051, P < 0.05). Discussion Relationship between loneliness and depression Consistent with previous studies, it was found that loneliness is associated with depression (Aylaz et al., 2012; Cacioppo et al., 2006; Springer et al., 2003). Spe- cically, emotional loneliness is positively correlated with depression. This explains that the emotional effects caused by the loss or absence of a person or thing may predict depressive symptoms. In contrast, social loneliness is negatively correlated with depres- sion due to the positively oriented items in the De Jong Gierveld Loneliness Scale. Individuals experienc- ing loneliness may be deprived of social interactions, dependency and trust of others. This supports the theory that the experience of social isolation and lone- liness is an overall concept, including emotional and social loneliness, objective as well as subjective (Wenger et al., 1996). This study showed a relatively moderate relation- ship between loneliness and depression among the elderly in a FELDA settlement in Malaysia. Previous studies support this nding, also showing a moderate relationship between loneliness and depression among elderly residing in a community-based setting (Aylaz et al., 2012; Singh & Misra, 2009; Springer et al., 2003). This signies that high levels of social and emo- tional loneliness are related to depressive symptoms such as loss of interest, hopelessness, loss of self- worth, fatigue and emptiness. Mediating effect of social support Based on the Baron and Kenny (1986) test for full mediational models, it was found that part of loneli- ness is mediated by social support, but other parts directly or mediated by other variables not included in the model. Moreover, the current study also analyzed the size of the indirect effect and showed that the indirect effect of loneliness through social support is signicant. Most of the children of the elderly FELDA settlers have moved away to nd work elsewhere while many of settlers have lost their spouses. Despite living in a closely knit society, they may feel isolated and at the same time lack of social support from family members further contributes to depression. It is to be noted that family support is more effective in fostering a sense of well-being among elderly people compared to the support of friends (Lang & Carstenson, 1994). Gener- ally, the association between loneliness and depres- sion was somewhat affected when adjusting for social support, thereby backing the hypotheses of a partial mediator function of social support. Additionally, the negative effect of loneliness on depression was also due to how individuals perceive their social contact and support. It is likely that when a person feels iso- lated, they may perceive social support differently, further leading to depressive symptoms. These nd- ings support Lewinsohns theory of depression that depressed people experience reduction in reinforcers and increase in aversive events, which leads to their depression (Lewinsohn, 1974). In the current study, the experience of loneliness may be due to the reduc- tion of reinforcers such as social supports from the social circle which in turn predict the occurrence of depression. It is possible that there may be other vari- ables such as aversive experiences that may also affect the association between loneliness and depression, thereby contributing to our nding that social support is a partial mediator. Another plausible explanation may be that both measurements for loneliness and social support were assessing social constructs associated with the external social environment of the subjects. For instance, the social loneliness of the De Jong Gierveld Loneliness Scale measures items on the network of social rela- tionship that the person is part of, that shares common interests and activities (De Jong-Gierveld & Tilburg, 2010). Therefore, their experience of loneliness might have predicted how they perceived the social support that they received, whether tangible, emotional/ informational, affective or positive, that were assessed using the MOS Social Survey. Golden et al. (2009) also underlines that there is considerable overlap between loneliness and social networks, although both con- structs are distinct from each other. The result is also consistent with the study done by Boen et al. (2012) which suggests that lack of social W.M.Y. Wan Mohd Azam et al. Loneliness and depression in rural elderly Malays 137 AsiaPacific Psychiatry 5 (2013) 134139 Copyright 2013 Wiley Publishing Asia Pty Ltd support for individuals experiencing loneliness may further lead to increased psychological distress. This explains the direct effect of social support on depression found in this study. When a person is experiencing personal issues, the concern and attention of another person, whether a family member or friend, is important in diminishing the psychological distress (Boen, Dalgard & Bjertness, 2012). Depression, like many other mental disorders, evidences multiple causal chains involving environ- mental, social and biological risk factors that mediate the association with activity limitations (Carriere et al., 2009). This study demonstrates the role of social support as a partial mediator between loneliness and depression among the elderly. Limitations of this study There are a number of limitations in this study. First, the nature of this study does not allow us to elucidate the interrelationship between protective factors of perceived social support and the received social support. Thus, this study may not cover a complete perspective of social support. Second, because the study is cross-sectional, the results cannot establish a causal relationship between the variables. Third, the subjects represent a Malay ethnic community; there- fore, the ndings cannot be generalized to the multi- cultural population of Malaysia. Fourth, the study also did not account for the physiological or biochemical changes in the elderly that may inuence their con- dition. With these limitations, the conclusions of this study must be interpreted with caution. Conclusion Although past research has consistently identied linear relationships between indices of loneliness and depression, our results indicate that loneliness predicts depression through social support in a more complex way than previously hypothesized. It can be con- cluded that social support plays the role of a partial mediator in the relationship between loneliness and depression among the elderly. We suggest that social support is an important third variable that may inuence the emergence of depressive symptoms among the elderly. Therefore, it is important to provide enough social support in terms of emotional/ informational, physical and affective support to reduce the feelings of loneliness and depression in the elderly. Acknowledgement We are very thankful to all the FELDA elderly who participated in this study, the FELDA ofcers and the FELDA administrators. This study was supported by a CommunityUniversity Grant of the Universiti Kebang- saan Malaysia 2011 (KOMUNITI-2011-013). Conict of interest The authors declare no conict of interest. References Alexopoulos G.S., Borson S., Cuthbert B.N., et al. (2002) Assessment of late life depression. Biol Psychiatry. 52, 164174. Aylaz R., Akturk U., Erci B., Ozturk H., Aslan H. (2012) Relationship between depression and loneliness in elderly and examination of inuential factors. Arch Gerontol Geriatr. 55, 548554. Baron R.M., Kenny D.A. (1986) The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 5, 11731182. Boen H., Dalgard O.S., Bjertness E. 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