Social Support Moderates the Effects of Self-esteem and Depression on Quality of Life Among Chinese Rural Elderly in Nursing Homes

HIGHLIGHTS

• Age, self-esteem, depression and social support can predict rural elderly's QoL.

• Social support can moderate self-esteem and QoL with depression controlled.

• Social support can moderate depression and QoL when self-esteem controlled.

• Family and others support are the moderators in the relation of self-esteem and QoL.

• Family support plays moderating effect in the association between depression and QoL.

Introduction

According to the dramatic ageing of population in the world, quality of life (QoL) among the elderly has acquired much more eye-catching and attention-grabbing. The World Population Ageing Report 2015 version reveals that elderly aged 60 years and above were increased by 48% in 2015, and will have been over tripled by 2050 compared with that in 2000 (UN, 2015a). Ageing of populations is seen as the only predictable challenge concerning health, which is rapidly increasing all over the world (WHO, 2015a). Influenced by one-child policy, the proportion of seniors in China has grown rapidly in the past decades and now China possesses the largest number of people aged 60 years and over (Lei et al., 2016, UN, 2015b).

Quality of life is conceptualized as individual's perception of their life status and position under the background of the value systems and local cultures and relates to their life goals, prospects, concerns and standards (WHO, 2007). The multidimensional construct contains physical, psychological and social domains. People with high QoL usually have good living conditions, the ability to live independently and enough friends from the perspective of objective dimension, while from the subjective well-being, they are satisfied with their lives and can perceive high degree of happiness. Many studies have focused on QoL of the aged people to predict demands of social care and to offer health-promoting interventions (Oguzturk, 2008, Sewo Sampaio et al., 2013). QoL is often reported decreased as age increasing (Netuveli, Wiggins, Hildon, Montgomery, & Blane, 2005), and gender, income, chronic disease as well as age are confirmed acting as potential factors to QoL in the older rural Chinese population (Zhou et al., 2011), while fewer social networks and more severe psychological distress are also conducted contributing to lower QoL (Lei et al., 2016, Oguzturk, 2008, Khalil and Abed, 2014). In fact, as the aged population continues to increase, coupling with the decrease of family caregivers, more dependent old people prefer to move in care homes (Gu et al., 2007, Underwood et al., 2013). Numerous studies, however, have made it convincing that it is considerably different in quality of life, depressive symptom, morbidity of disease and daily functioning between the elderly living in care homes and those in private houses (Drageset et al., 2008, Gu et al., 2007). According to a comparative study on nursing home residents aged 65–102 years with at least 6-month-residence and general citizens at the same age in Norway, it is stated that the nursing home residents usually undergo lower health-related quality of life in comparison with the general population, especially more severe bodily pain and worse physical and emotional role limitation (Drageset et al., 2008). For these aged care residents, especially those in rural counterparts, they are suffering more difficulties in quality of life limited by the backward economic level and deficient supportive policy. To enhance QoL of the institutional elderly, psychiatric nursing cannot be ignored. Psychiatric mental health nursing provider can assist with managing both somatic and mental problems, coordinating daily activity training, and finding interventions to releasing psychological problems. These measures are also essential steps to better QoL. In this climate, exploring risk factors of QoL and then implementing psychiatric nursing targetedly makes it much more effective so as to improve the QoL.

Depression is the most frequent psychiatric disease in aged life, and it is also one of the most common treated diseases in the primary care (Helvi et al., 2016, Park and Unützer, 2011). The occurrence and development of late-life depression is usually chronic. Furthermore, the depression among older populations has a high rate of relapse (Ismail, Fischer, & McCall, 2013). Studies are exploded to seek the associations between QoL and late-life depression while the latter is thought the most common reason for low mental and physical quality of life (Bodner and Bergman, 2016, Unalan et al., 2015). Unalan et al. found depression was negatively correlated with QoL, which was a protective factor on death and dying as well (Unalan et al., 2015). Compared with non-depressive elderly, the subjective quality of life is absolutely lower in the depressive cohort on Chinese people aged 65 and over (Chan, Chien, Thompson, Chiu, & Lam, 2006). Under the aggression of depression, the institutional elderly also suffer psychological distress. For example, there reported a prevalence of 43.4% of depressive symptoms in Taiwan care homes, while 65.4% in Hong Kong care homes (Tsai, Chung, Wong, & Huang, 2005). Polish researchers Mazurek et al., who conducted a survey with 300 residents in public nursing homes from three large cities, stated that the mean score of Geriatric Depression Scale was 7.27 ± 3.77 signifying moderate depression among the population (Mazurek et al., 2015). But most of the studies have focused mainly on the elderly in urban care facilities, little is known about the depression level among the rural institutional counterparts. All the characteristics of late-life depression described above illustrate that the psychiatric nursing for rural institutional older adults is pretty essential and also full of difficulties. For the reason of the administrators of the rural nursing homes do not take sufficient account of the psychological needs of older people (McCormack & Skatvedt, 2016), it comes to be necessary to pay more attention to these institutional residents in countryside.

Self-esteem is individual's attitude toward himself/herself which measures one's feelings of self-evaluation and self-acceptance, and reflects one's value, worth and respect built by perceived views across the significant surroundings (Rosenberg, 1965, Sullivan, 1953). Many of the studies have been published exploring self-esteem and QoL (Bozorgpour and Salimi, 2012, Li et al., 2015). In a cross-sectional study with cervical cancer survivors investigated, it was proved that a higher self-esteem was beneficial for dealing with stress related to cancer and could promote QoL (Li et al., 2015). Self-evaluation influences the interpretation of life satisfaction. Low self-esteem and negative assessment on self can both lead to students' poor life satisfaction (Bozorgpour & Salimi, 2012). However, it is unbalanced for the current situation that only a few studies have been conducted in the old, and even fewer in the elderly living in nursing homes. Seniors' health condition gradually turns to be fragile with age increasing, which can lead to a more negative self-evaluation. Considering that low self-esteem can weaken coping resources and promote suicidal ideation (Jang et al., 2014), the elderly population, as the potential high-risk individuals, deserve public attention.

It has been widely agreed that social support plays a crucial role in improving psychological well-being and maintaining mental health (Boen, Dalgard, & Bjertness, 2012). Strengthening social support from family and external interpersonal relationship is also illustrated useful in improving quality of life, as well as in decreasing depressive symptom and raising self-esteem (Li et al., 2015, Unalan et al., 2015). Across 148 studies, a meta-analytic review on social relationships and mortality risk illustrates that the likelihood of the survival increased by 50% for participants with more social support than those with weaker social support (Holt-Lunstad, Smith, & Layton, 2010). Acquiring support from others is helpful for dealing with difficulties and coping with stress, especially for people with limitations in routine activities (such as bathing, dining, going to the toilets) (Melchiorre et al., 2013). Also, sufficient support and good interpersonal relationship appear to be comfort in both physical and spiritual aspects for people in suffering. Social support is particularly significant among elderly. P. Lei et al., conducting a health survey on 9833 old adults aged 60 years and over, indicated that those with fewer social networks, for instance fewer visits from children, less connection with neighbors, showed more problems in various dimensions of health-related quality of life (Lei et al., 2016). Another study described the convincing association between depression, self-perceived health, chronic diseases and social support in elderly and found a highly prevalent of low social support in seniors living in poor area (Lino, Portela, Camacho, Atie, & Lima, 2013). Other than the direct effect, social support is also considered contributing to health outcomes through moderating effect (Chung, Moser, Lennie, & Frazier, 2013). Increasing and reinforcing social support has been verified positively associated with high self-esteem when coping with stress (Denissen, Penke, Schmitt, & van Aken, 2008). Despite many researches on the relationship between self-esteem, social support and quality of life, there is insufficient evidence on it after depression controlled, while it is a vital factor to health outcomes (Chung et al., 2013, Jang et al., 2014). In addition, a vast number of studies have confirmed the interacting effect of social support on depression and quality of life (Chung et al., 2013, Unalan et al., 2015). As the scar model assumes that the depressive symptoms could leave scars in one's mind which results in subsequent lower self-esteem (Steiger, Fend, & Allemand, 2015), it is also essential to explore the independently predictive power of depression to quality of life after controlling self-esteem.

Hence it seems reasonable to hypothesize that: H1, low self-esteem, high depression level, and insufficient social support are independent risk factors of high quality of life; H2, social support can moderate self-esteem and quality of life with depression controlled; H3, social support can moderate depression and quality of life when self-esteem controlled (Fig. 1). The current research aims to explore the roles of self-esteem, depression and social support on quality of life among Chinese rural elderly in nursing homes, and to examine the moderating effect of social support specifically in the association of self-esteem and depression with quality of life.