Population aging, resulting from lower mortality, longer life expectancies, and decreasing fertility, is a worldwide phenomenon (United Nations, 2017). By 2050, one in five individuals will be age ≥60, compared to 2017 when one in eight people were age ≥60 (United Nations, 2017). In 2016, 230.86 million adults in China were age ≥60, accounting for 16.7% of the total population (National Bureau of Statistics of the People's Republic of China, 2017). Simultaneously, the development of the economy, fast-paced urbanization, and the change in family structure have contributed greatly to the proportion of older adults living alone (Peng & Wang, 2010). According to the Sixth National Census Report in 2010, 16.4% of older adults age ≥65 lived alone in China (Chen, 2014). The proportions of older adults living alone in larger cities are even higher (e.g., 34% in Beijing, 37% in Tianjin, 30% in Guangzhou) (Sun, 2009).
Depression is prevalent among older adults (Forsman, Nordmyr, & Wahlbeck, 2011), which can result in compromised quality of life and the rise of morbidity (Wada et al., 2004). It is estimated that the prevalence of depressive symptoms among Chinese older adults ranges from 10.8% to 30.8% (Chou & Chi, 2005; Gao et al., 2009; Li et al., 2011). Older adults who live alone are more vulnerable to poorer physical and psychological well-being, lower self-esteem, and less social support (Lee & Hong, 2016; Lim, 2014). Accordingly, they are more likely to experience depressive symptoms and commit suicide (Conejero, Olié, Courtet, & Calati, 2018). In a study conducted among 1,049 older adults in the United States, older adults who lived alone were found to report higher levels of depression compared to those living with family members (Stahl, Beach, Musa, & Schulz, 2017). Another study also demonstrated that a much higher prevalence of depression was found among older adults who live alone (31.8%) compared to their counterparts who live with others (18.5%) (Fukunaga et al., 2012). Various factors have been identified from previous studies to be associated with depression among older adults, including advanced age (Demura & Sato, 2003; Woo et al., 1994), female gender (Chen et al., 2005; Woo et al., 1994), lower educational level (Lin & Wang, 2011), poorer economic status (Chen et al., 2005; Zhang et al., 1997), and more chronic diseases (Lin & Wang, 2011; Vink, Aartsen, & Schoevers, 2008). In addition, older adults with cognitive impairment, functional decline (Vink et al., 2008), or inadequate social support (Mechakra-Tahiri, Zunzunegui, Préville, & Dube, 2009; Yu, Li, Cuijpers, Wu, & Wu, 2012) were more likely to experience depressive symptoms. Although the influencing factors of depression among older adults have been widely studied, limited studies have been conducted specifically in older adults living alone, especially in the Chinese older population. Therefore, the current study focuses on the perspective of Chinese older adults living alone.
From a cultural perspective, the relationship between living alone and psychological well-being may be stronger and more prominent in certain ethnic groups (e.g., the Chinese population) (Alexander, Rubinstein, Goodman, & Luborsky, 1992). In traditional Chinese cultural, older adults normally prefer and are expected to live with their children and enjoy a multi-generational family life (Chou, Ho, & Chi, 2006). However, along with the influence of rapid development of China's economy, and the impact of Western culture, more and more younger adults are forced to leave their familial home for employment opportunities. As the one-child generation, younger Chinese individuals prefer living independently and moving away from their parents. Remitting money to their parents is a common way to fulfill their filial piety (Hu, 2015). Therefore, Chinese older adults living alone may experience more negative social stigma compared to their counterparts in Western countries (So, 2008). Many of these individuals reported unhappiness and depression (Leandro & Castillo, 2010).
Living alone may also have a stronger negative impact on Chinese older adults than their counterparts in Western countries due to different cultural expectations. In mainland China, few studies have been specifically conducted to target older adults living alone, although some studies investigated depression and its risk factors among Chinese older adults living alone in Hong Kong and Taiwan (Chou et al., 2006; Lin & Wang, 2011). Therefore, the objectives of the current study were to investigate the prevalence of depression and identify its associated factors among older adults living alone in mainland China. The study findings may provide further references for health care professionals to design effective interventions specifically for older adults living alone in mainland China to help them retain high quality of life.
Study Design and Sample
The current study reports data collected from a large-scale questionnaire survey that aimed to investigate the health status and psychosocial well-being of older adults living alone in Jiangsu province, mainland China. The details of the sampling method and data collection process have been reported elsewhere (Yu, Gu, Jiao, Xia, & Wang, 2019). In brief, a cross-sectional questionnaire survey study was conducted in three communities in Nanjing city in mainland China. Convenience sampling was used to recruit participants. Inclusion criteria were community-dwelling adults who (a) were age ≥60, (b) had been living alone for >1 year, and (c) were able to communicate in Chinese Mandarin or the Nanjing dialect. Older adults who had end-stage physical disorders (e.g., advanced cancer, end-stage renal failure) or moderate to severe cognitive impairment, as assessed using the Short Portable Mental Status Questionnaire (SPMSQ) (Chen, Hicks, & While, 2014), were excluded from the study.
The study sample size was calculated using the binary logistic regression analysis. Based on literature review, eight factors (i.e., sex, age, educational level, economic status, number of chronic illnesses, cognitive function, functional ability, and social support network) are associated with depression (Chen et al., 2005; Lin & Wang, 2011; Vink et al., 2008; Woo et al., 1994; Yu et al., 2012). By including the eight factors as independent variables in the regression model, 107 participants would be needed to achieve a medium effect size of 80% power and significance level of 0.05 (Cohen, 1992). A total of 195 older adults living alone were initially approached, of whom 13 declined to participate and 10 were excluded due to moderate to severe cognitive impairment (response rate = 93.3%). A total of 172 participants completed the questionnaire survey and were included in the data analysis.
The 15-item Geriatric Depression Scale-Short Form (GDS-15) was used to measure depression (Yesavage & Sheikh, 1986). Responses for each item in this scale are yes (1) or no (0). Total score ranges from 0 to 15, with higher scores indicating more severe depression. In the current study, the cut-off score was 8; therefore, participants with scores ≥8 were considered to have depression (Boey, 2000). The Chinese version of the GDS-15 has good reliability and validity, with a Cronbach's alpha of 0.82 (Mei, 1999).
Cognitive function was measured using the SPMSQ (Pfeiffer, 1975). This scale comprises 10 items measuring orientation, working memory, and calculation. Correct answers are given 1 point and incorrect answers are given a 0. Total score ranges from 0 to 10. A participant who scores 8 to 10, 6 to 7, 3 to 5, or 0 to 2 is considered to have intact cognitive function, mild cognitive impairment, moderate cognitive impairment, or severe cognitive impairment, respectively. The Chinese version of the SPMSQ has been demonstrated to have good reliability with a Cronbach's alpha of 0.77, and test-retest reliability coefficient of 0.94 (Chen, 2007).
Functional ability was measured using the Activities of Daily Living (ADL) scale (Lawton & Brody, 1969). The scale comprises 14 items, which are grouped into two parts: the Physical Self-Maintenance (PSM) scale (six items) and the Instrumental Activities of Daily Living (IADL) scale (eight items). The PSM scale rates basic functional abilities such as bathing, feeding, dressing, grooming, toileting, and transferring. The IADL scale rates more complicated abilities: washing clothes, using a telephone, cooking, using public transportation, shopping, handling one's own money, doing housework, and taking medicine. Each item is rated on a 4-point Likert scale (1 = totally independent to 4 = totally dependent). An adjusted score of 14 indicates normal functional ability, 15 to 21 indicates mild impairment of functional ability, and 22 to 56 indicates severe impairment of functional ability (Zhang, 2014). The Chinese version of the ADL scale has good reliability with a Cronbach's alpha of 0.85 (Chen, 2007).
Social support network was assessed using the abbreviated version of the Lubben Social Network Scale (LSNS-6) (Lubben et al., 2006). The LSNS-6 comprises six items that evaluate family social support network (three items) and friend social support network (three items). Each item is rated on a 6-point Likert scale regarding the number of relatives and friends whom older adults feel close to or ask for support (0 = none, 1 = one, 2 = two, 3 = three to four, 4 = five to eight, and 5 = nine or higher). Total score ranges from 0 to 30. In the current study, 12 was used as the cut-off point (Lubben et al., 2006), and participants who scored <12 were considered at risk of social isolation. This scale was translated into Chinese by the current authors' research team according to Brislin's (1986) model, and Cronbach's alpha was 0.78 for the current study.
The human ethics research committee of the Nanjing University of Chinese Medicine approved the study protocol. Permission was also obtained from the community committees of the study settings. The community committees are the governmental administrative organizations that manage the social affairs of residents in the community. Staff who helped with recruitment of participants were members of the committees and familiar with residents' living status.
A total of 195 older adults living alone were approached, and an information sheet containing the study design and aims was given to each participant by researchers, who were accompanied by a staff member of the respective resident committee. Face-to-face interviews were conducted by trained data collectors with older adults who were willing to take part in the study either at their homes or at the community centers from September 2017 to April 2018. After consent forms were collected from participants, the SPMSQ was administered to eligible participants to determine their cognitive function. Individuals with SPMSQ scores <6 were excluded from the study. A total of 172 older adults living alone signed consent forms and completed all questionnaires. Sociodemographic data, including gender, age, educational level, monthly income, and number of chronic illnesses, were also collected. Common chronic illnesses, including hypertension, diabetes mellitus, arthritis, cataract or glaucoma, stroke, Parkinson's disease, coronary heart disease, and chronic obstructive pulmonary disease, were listed for participants to choose based on their physicians' diagnosis.
SPSS version 24.0 soft ware was used to analyze the data. Participants' characteristics were described using descriptive statistics including mean (SD), frequency (%), and median (interquartile range). Bivariate (chi-square test) and multivariate (binary logistic regression analysis) analyses were performed. Categorical variables were transferred into dummy variables. The no depression group was coded 0, whereas the depression group was set at 1. The potential contributing factors were selected based on the results of univariate analysis with p ≤ 0.2 according to the recommendation of Mickey and Greenland (1989).
One hundred ten (64%) participants were female. Mean participant age was 74.92 (SD = 6.63 years), ranging from 60 to 92 years. A total of 41 (23.8%) participants did not receive any education, and 69 (40.1%) participants had primary education levels. Ninety-seven (56.4%) participants reported that their monthly income was <1,500 RMB. Twenty (11.6%) participants did not have any chronic illnesses, whereas 48.3% reported having one to two chronic illnesses. Approximately 18.6% of participants had mild cognitive impairment, and more than one half (52.3%) of participants had functional impairments. Forty-six (26.7%) participants were at risk of social isolation. Detailed information is presented in Table 1.
Participant Characteristics (N = 172)
Prevalence of Depression Among Older Adults Living Alone
Thirty-two older adults living alone scored ≥8 on the GDS-15, indicating a depression prevalence of 18.6%. The median of the GDS-15 total score was 3, and the interquartile range was 4.
Associated Factors of Depression Among Older Adults Living Alone
The chi-square test showed that cognitive function, functional ability, and social support network had significant correlations (p < 0.05) with depression (Table 2), and these three factors were included in the regression model. The results of the binary logistic regression model showed that social support network and functional ability were significantly associated with depression for older adults living alone (Table 3). The possibility of depression among older adults with social isolation risk was 2.59 times higher than older adults without such risks (odds ratio [OR] = 2.59, 95% confidence interval [CI] [1.13, 5.96], p = 0.03). Compared with individuals with normal functional abilities, the possibility of depression was 3.31 times higher in older adults with mild functional impairment (OR = 3.31, 95% CI [1.25, 8.75], p = 0.02) and 4.72 times higher in those with severe functional impairment (OR = 4.72, 95% CI [1.50, 14.84], p = 0.01).
Chi-Square Test of Participants by Presence of Depression
Risk Factors of Depression According to the Binary Logistic Regression (Forward Method)
Depression negatively affects every aspect of older adults' lives and has been documented as a significant risk factor for suicide in late life (Conwell, Duberstein, & Caine, 2002). Older adults living alone are most vulnerable, and without the company of spouses/partners and children, they are more likely to experience negative emotions (e.g., loneliness), which often accompany depression (Cacioppo, Hughes, Waite, Hawkley, & Thisted, 2006; Chou et al., 2006). China is a country that holds harmony and filial piety as traditional virtues, and children are always expected to take care of their parents socially and legally. However, family structure has transformed, and the traditional value of filial responsibility has changed with the evolving socioeconomic context of China. These trends weaken the traditional family support network of older adults. In addition, although friends and neighbors may provide support to older adults living alone, these are usually emotional supports or daily living assistances, which are intermittent and short-term (Liu, 2018; Stahl et al., 2017). Accordingly, older adults living alone are at risk for developing depression.
Few studies have reported the prevalence of depressive symptoms in Chinese older adults living alone. The current study showed that 18.6% of older adults living alone had depressive symptoms, which is higher than the 10.8% prevalence in general older adults in China (Li et al., 2011). The study results provide further evidence that older adults living alone are vulnerable and susceptible to depression. However, compared with studies conducted in other countries, the prevalence of depression in the current study sample is lower than that of Japan (31.8%) (Fukunaga et al., 2012), Korea (25%) (Lee et al., 2017), and the United Kingdom (21%) (Wilson, Mottram, & Sixsmith, 2010). The discrepancies may be due to the various instruments/measures applied in different studies, and the different cut-off points used to determine depressive symptoms. In addition, the mean age of the current study sample is younger than participants reported in the other studies, and age has been identified as a factor that influences depression (Demura & Sato, 2003; Woo et al., 1994).
The current study also identified that functional ability was a significant associated factor of depression in Chinese older adults living alone, with those having greater functional impairments reporting higher incidences of depressive symptoms, which is in agreement with previous studies (Chi et al., 2005; Li et al., 2011). Impairments in functional abilities in older adults can lead to difficulties in maintaining basic and more complicated everyday tasks (Akosile et al., 2018) and a loss of independence (Gell, Wallace, LaCroix, Mroz, & Patel, 2015). Having good functional abilities can help older adults maintain social contacts and promote engagement in social activities (Lee, 2005). Thus, functional ability status is an important health indicator for older adults as the impairment of such abilities can hamper quality of life (Akosile et al., 2018). Having good functional abilities is important for older adults living alone to maintain their routines and independent lives. Several studies demonstrated that impairments of functional abilities contributed to occurrences and developments of depressive symptoms (Chiu, Chen, Huang, & Mau, 2005; Gayman, Turner, & Cui, 2008).
The current study found that older adults living alone who had less social support networks were more likely to be depressed. Having a social support network is a vital environmental factor that can enhance health, security, and social participation for older adults (Yeh & Lo, 2004). In traditional Chinese culture, family support is one of the social capitals that has a central role in supporting older adults. Accordingly, living alone may be a detrimental factor, which may contribute to depression in Chinese older adults (Chou et al., 2006). The current work identifies that older adults living alone may have inadequate emotional and instrumental social support from their family members and close friends because of limited social support networks. Furthermore, they may experience difficulties in managing unexpected life events, such as accidents or acute diseases. The presence of a social support network is a significant protective factor against depressive symptoms for older adults living alone (Lin & Wang, 2011). Consequently, depression, owing to lack of social support networks, occurs in and exists among older adults living alone. In China, community services have not been well-developed to provide care and support for those who live alone. Adequate attention from the government, social organizations, and health care systems should be paid to older adults living alone regarding their special living statuses and depression.
Cognitive function was found to be associated with depressive symptoms through the chi-square test, although it was not a significant factor influencing depression in the final logistic regression model. This result is consistent with a previous study conducted in Hong Kong (Chi et al., 2005). Although the association between cognitive function and depression has been observed in several previous studies (Lee et al., 2017; Lindesay, Briggs, & Murphy, 1989), the direction of causation remains ambiguous. On one hand, depression in older adults may increase risk of cognitive impairments, whereas on the other hand, cognitive impairment may also result in deficient self-care abilities and depression (Liu et al., 1997).
Surprisingly, number of chronic diseases was not associated with depression in the current study, which is contrary to previous studies (Lin & Wang, 2011; Vink et al., 2008). One explanation might be the diverse treatment of data. In the current study, number of chronic diseases was treated as categorical data, whereas other studies regarded it as continuous data. Another reason might be that the relationship between number of chronic diseases and depression is mediated or influenced by other possible variables, such as personal characteristics, attitudes toward health and disease, and duration of disease. More evidence regarding the relationship of number of chronic diseases and depression and its mediating factors is necessary.
All sociodemographic variables, such as age, gender, marital status, educational level, and economic status, were not found to be associated with depressive symptoms among older adults living alone. This result is consistent with results of previous studies of older adults living alone, including research conducted among community-dwelling older adults in Singapore (Li, Theng, & Foo, 2015).
The current study has some limitations. First, the study sample was recruited from three communities of a district in Nanjing city; thus, the study sample does not represent various ethnic and racial populations in China. Therefore, the findings may not be generalizable to other older adults living alone in other settings, especially those living in rural areas of China. Second, the LSNS was translated by the current authors' research team, and only a preliminary psychometric assessment was performed on its content validity and internal consistency. A future full-scale study is needed to test the psychometric properties of the Chinese version of the LSNS. Lastly, the questionnaire survey relied mainly on self-report from older adults, who may have provided responses that are socially desirable. In addition, recall bias cannot be totally avoided in self-reported data.
The current study focused on depression in community-dwelling older adults living alone in mainland China. Depression is a common psychological problem among Chinese older adults living alone, although its prevalence is deemed lower compared to their counterparts in other developed countries. Functional ability and social support network are identified as two main factors significantly associated with depression among Chinese older adults living alone. Therefore, community health care providers should regularly assess for depression in older adults living alone, and interventional programs should consider the significant influencing factors of functional ability and social support network. One approach to support these solitary older adults is to increase community care services so that those with functional impairments can be better cared for in their own communities. Services to strengthen the social support networks of those older adults are also essential, such as home visit programs, peer support groups, and education programs. Hopefully, the results of the current study can provide further references for health care professionals to design effective interventions and services to help solitary older adults have a better quality of life. Finally, larger scale investigations that involve not only older adults living alone in urban communities, but also those in rural areas, are suggested to obtain a full understanding of depression among older adults living alone in China.
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Participant Characteristics (N = 172)
| 60 to 69||34 (19.8)|
| 70 to 79||98 (57)|
| ≥80||40 (23.3)|
| Female||110 (63.6)|
| Male||62 (36)|
| Illiterate||41 (23.8)|
| Primary schoola||69 (40.1)|
| Junior high school and aboveb||62 (36)|
|Monthly income (RMB)c|
| <1,500||97 (56.4)|
| 1,500 to 3,499||56 (32.6)|
| ≥3,500||19 (11)|
| Normal||140 (81.4)|
| Mild cognitive impairment||32 (18.6)|
| Normal||82 (47.7)|
| Mild impairment||64 (37.2)|
| Severe impairment||26 (15.1)|
|Social support network|
| Normal||126 (73.3)|
| Isolation risk||46 (26.7)|
|No. of chronic illnesses|
| 0||20 (11.6)|
| 1 to 2||83 (48.3)|
| 3 to 5||54 (31.4)|
| ≥6||15 (8.7)|
Chi-Square Test of Participants by Presence of Depression
|Variable||n (%)||χ2||p Value|
| 60 to 69||27 (19.3)||7 (21.9)|
| 70 to 79||81 (57.9)||17 (53.1)|
| ≥80||32 (22.9)||8 (25)|
| Male||51 (36.4)||11 (34.4)|
| Female||89 (3.6)||21 (65.6)|
| Illiterate||33 (23.6)||8 (25)|
| Primary school||54 (38.6)||15 (46.9)|
| Junior high school and above||53 (37.9)||9 (28.1)|
| Lower||77 (55)||20 (62.5)|
| Middle||46 (32.9)||10 (31.2)|
| Upper||17 (12.1)||2 (6.2)|
| Normal||126 (90)||23 (71.9)|
| Mild cognitive impairment||14 (10)||9 (28.1)|
| Normal||75 (53.6)||7 (21.9)|
| Mild impairment||48 (34.3)||16 (50)|
| Severe impairment||17 (12.1)||9 (28.1)|
|Social support network||8.13||<0.001|
| Normal||109 (77.9)||17 (53.1)|
| Isolation risk||31 (22.1)||15 (46.9)|
|No. of chronic illnesses||7.45||0.06|
| 0||19 (13.6)||1 (3.1)|
| 1 to 2||71 (50.7)||12 (37.5)|
| 3 to 5||40 (28.6)||14 (43.8)|
| ≥6||10 (7.1)||5 (15.6)|
Risk Factors of Depression According to the Binary Logistic Regression (Forward Method)
|Variable||B||SE||Wald||p Value||OR||95% CI|
|Social support network|
| Social isolation risks vs. normal social support network||0.95||0.43||5.04||0.03||2.59||[1.13, 5.96]|
| Mild impairment vs. normal functional ability||1.20||0.50||5.81||0.02||3.31||[1.25, 8.75]|
| Severe impairment vs. normal functional ability||1.55||0.59||7.04||0.01||4.72||[1.50,14.84]|