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OR I GI NAL AR T I C L E

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
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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.
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