J Cross Cult Gerontol (2014) 29:37–51 DOI 10.1007/s10823-013-9219-0 ORIGINAL ARTICLE
Psychological Distress of Older Chinese: Exploring the Roles of Activities, Social Support, and Subjective Social Status Wei Zhang & Min Chen
Published online: 22 December 2013 # Springer Science+Business Media New York 2013
Abstract The goal of this research is to examine if the long neglected correlates such as social and leisure activities, social support, and subjective social status contribute to variations in psychological distress among older Chinese. Using data collected in one of the most developed areas in China—Suzhou city, Jiangsu province, the authors find that engaging in various exercises, living with both spouse and adult children, perceived availability of social support from others as well as believing in the importance of caring for other family members are particularly beneficial for mental health whereas the perception of relative deprivation and low life quality is detrimental to mental health for older Chinese. This work is among the first studies that comprehensively examined various important correlates of psychological distress and indicate the unique patterns of distress among the elderly in the most developed area in the contemporary China. Keywords Distress . Activities . Older Chinese . Social support . Subjective social status
Introduction Chinese population is aging rapidly. According to the figures provided by the National Bureau of Statistics of China and China National Population Development Strategy Research Group, there were 124.26 million or 10.46 % of adults aged 60 years or older in China. This number is projected to increase up to 234 million or 16.00 % of the total population in 2020 (Li et al. 2011). As number of older adults continues to increase significantly, close attention needs to be paid to the health and well-being of this population segment. A limited but growing number of studies have started to examine the prevalence and correlates of mental health problems such as depression, the most common psychiatric condition in older people (Chen et al. 2004), among older Chinese (Li et al. 2011, 2012; See Lim et al. 2011 for review). Findings suggest W. Zhang (*) Department of Sociology, University of Hawaii at Manoa, 2424 Maile Way, Saunders Hall, Room 204, Honolulu, HI 96822, USA e-mail: [email protected] M. Chen College of Social Sciences, Suzhou Vocational University, Suzhou, People’s Republic of China
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that the prevalence of self-reported depressive symptoms among Chinese older adults can be as high as 40 % (Yu et al. 2012) and, compared to their rural counterparts, the depression rate for urban older adults is substantially higher (Li et al. 2011). Despite the abovementioned efforts in understanding the mental health of older Chinese, two major limitations remain in the literature. First, most studies have conceptualized depression as a dichotomized problem rather than a continuum and have often neglected another major aspect of psychological status—anxiety. Our study focuses on psychological distress, an unpleasant state that takes two major forms—both depression and anxiety (Mirowsky and Ross 2003). Distress is also measured as a continuous variable with higher levels of well-being on one end and high levels of distress on the other (Mirowsky and Ross 2003). We believe that this continuous measure not only captures more variations in mental health for older Chinese, but also avoids social stigmatization in Chinese culture that treats mental disorder as a diagnosed problem. Second, to date, many existing studies have focused on a limited number of factors that might be associated with mental health of older Chinese, primarily including education (Ross and Zhang 2008), filial piety (Cheng and Chan 2006; Li et al. 2011), family support and health status (Yu et al. 2012). Given that older Chinese are embedded in various social relations and are engaged in a variety of social activities, it is essential to comprehensively identify the potential social factors that might contribute to preventing distress or alleviating its symptoms within this population segment. Focusing on one of the most developed areas in China— Suzhou, Jiangsu Province, this study examines how social and leisure activity participation, various aspects of social support, and subjective social status, in addition to the previously examined socio-demographic factors, are associated with variation in psychological distress among the elderly in China.
Theoretical Background One critical component of successful aging is active engagement (Rowe and Kahn 1997). According to Rowe and Kahn (1997), maintaining close interpersonal relations and participating in productive activities are two important forms of active engagement. Interpersonal relations “involve contacts and transactions with others, exchange of information, emotional support, and direct assistance” (Rowe & Kahn, p. 433–434) and productive activities are activities that create social value such as caring for family members or working as a volunteer in organizations. Their theoretical emphasis on the productive and social aspects of activity for successful aging is empirically supported by evidence disclosing that older adults who actively participate in social and meaningful leisure activities usually report positive well-being (Adams et al. 2011). Pathways linking those activities and individual well-being often include physical benefits from body movement, social support from social interactions and the consequent positive psychological status such as a sense of belonging, a sense of identity, and a sense of personal mastery (Adams et al. 2011). This study considers social engagement as a multi-dimensional concept and examines its three aspects among older Chinese. The first aspect is an engaged lifestyle indicated by participating in social and leisure activities. The second aspect is social integration indicated by individual involvement with family, groups or community. It should be noted that the resulted social support and sense of belonging from social integration may mediate the effect of social and leisure activities on individual well-being. The third aspect is subjective social status indicated by individual self-perception of life quality and social status compared to others. According to the comparative reference group theory, when individuals compare their
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own situations upward with those of others in better situations, their feelings of relative deprivation will be provoked (Merton 1968). We argue that those socially engaged older adults are more likely to be aware of the existing social inequality and their relative location in society if they are actively interacting with others and are exposed to the latest news in media. In the following subsections, we will discuss how these three aspects are related to psychological distress. Social and Leisure Activities and Distress Engagement in meaningful social and leisure activities can be considered as an important aspect of healthy lifestyle to directly affect one’s psychological well-being. For instance, as one important indicator of lifestyle, exercise has both preventive and therapeutic psychological benefits because it has antidepressant effects through physiological, psychological, and neural pathways (Walsh 2011). Studies conducted in mainland China and in Taiwan have started to show that engaging in leisure-time physical exercises is significantly associated with better cognitive performance (Ku et al. 2012), a reduced level of distress (Ross and Zhang 2008) and depression (Chen et al. 2012) among older Chinese. In addition, leisure activities may also indirectly affect psychological well-being through pathway of social support because they often take place within social groups (Coleman 1993). This study focuses on two indicators of social and leisure activity participation—exercises and religious participation. Rather than jogging or running alone, older Chinese like doing exercises that are collective in nature such as doing activities on squares where a group of elderly follow a teacher to perform dances, Tai-qi and other movements or stretches collectively. In this sense, exercise is not only a physical activity that promotes one’s sense of fulfillment and enjoyment, but also a routine social event that develops one’s social network and sense of belonging. As an indicator of social activities (Glass et al. 1999, 2006), religious participation increases social resources (Ellison and George 1994), which in turn, promotes individual mental health. A limited number of studies have started to show that religious participation predicts longevity among older adults in China (Sun and Liu 2006; Zeng et al. 2011; Zhang 2008). Other studies suggest that religious participation is beneficial for mental health in various cultural contexts. One study by Lampinen et al. (2006) found that leisure activity (indicated by involvement in associations, religious activities, etc.) is associated with better mental health among older adults in Finland. Another study (Chiao et al. 2011) disclosed that continuously participating or initiating participation in social activities (including participating in hobby-related clubs, religious or church groups, political groups, etc.) is significantly associated with lower levels of depression among older Taiwanese adults. This study examines if the mental health benefit of religious participation remains for older adults in Suzhou, China. Social Support and Distress This study considers three forms of social support: living arrangements (that provide the context for family support), perceived social support from others, and believing in the importance of providing support to other family members. While the relationship between social support and beneficial health outcomes is well established in Western society (House et al. 1988), relatively fewer studies have examined this relationship in a non-Western setting among the elderly. For older Chinese, social exchanges may take on greater meaning because they are more likely to be retired, to be financially dependent, and have fewer social ties (Liang et al. 1992). Available studies in China revealed that emotional support (Leung et al. 2007),
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perceived social support (Krause et al. 1998; Li and Liang 2007) and filial support (Huang 2012) are important to the mental health of older Chinese. This study examines if the relationship between perceived social support—subjective evaluations of supportive exchanges (Barrera 1986) that gauges the availability of both instrumental and emotional support from others—and distress holds for the elderly in Suzhou city. Recent studies also suggest that giving may be as important as receiving social support in affecting health of the elderly (Liang et al. 2001). Brown et al. (2005) revealed that giving, not receiving, a higher level of social support is associated with lower morbidity in an ethnically diverse sample of community-dwelling older adults in New York. Similarly, Brown et al. (2003) found that mortality is significantly reduced for older married adults providing instrumental support to others. Their findings indicate that giving or altruism may be an evolved biological indicator of successful aging and benefit health due to positive mental statuses such as sense of meaning, purpose, mastery, and belonging, which in turn, lead to happiness and less depression. While Western literature shows beneficial health effect of providing social support to others, there is virtually no study available that examines whether this relationship holds true for older Chinese. Poulin et al. (2010) found that active helping predicted greater caregiver positive effect when controlling for care recipient illness status and functional impairment. Their finding indicates that the health benefits of helping behavior might be greatly enhanced when there is a strong sense of dependence between caregivers and those helped. Given that most retired older Chinese are likely to be care givers for their loved ones (including spouses, adult children and grandchildren) and at the same time to be care recipients by their family members when needed, we expect to identity lower levels of distress among older Chinese who believe that it is important to care for their family members. Living arrangements are also likely to be associated with health and well-being of older Chinese because they may greatly affect the amount of social support the elderly receive from their family members (Chou et al. 2006). Due to the combined effect of rapid population aging, drastic economic reforms, strict family planning policies, and large-scale internal migration, the long lasting norms on filial piety has started to erode due to practical limitations in the contemporary China (Sun et al. 2011). As a result of these social changes, the proportion of empty-nested households (i.e. households with one older adult living alone or living with only his or her spouse) has already increased to 27.9 % in 2007 and is estimated to increase up to 90 % by 2030 from 16.7 % in 1993 (Sun et al. 2011). Given that household in China has been historically considered as the primary unit for providing support to its older adults due to the long-lasting norms on filial piety, living alone is empirically found to be associated with increased levels of depression for older Chinese (Chou et al. 2006). Our study differentiates various types of living arrangements and links them to levels of distress among the elderly. Compared to other living arrangements, we predict that living with both spouse and children is associated with a better mental health outcome for older Chinese because it provides a context of reciprocal family support and mutual benefits: it not only meets the filial expectations and needs of the elderly, but also fulfill the necessities of caring for the offspring of their adult children. Taken together, we examine the following three aspects of social support: living arrangements, perceived availability of support from others, and believing in the importance of providing support to other family members. Subjective Social Status and Distress Despite the increasing significance of subjective social status (Operario et al. 2004; SinghManoux et al. 2003), its effect on mental health has not yet been closely explored in mainland China. Therefore, another focus of this study is to examine the mental health consequences of
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subjective social status that assesses individual self-perception of social status relative to others. Multiple studies conducted in the U.S. among Asian Americans (Gong et al. 2012; Leu et al. 2008), U.K. (Demakakos et al. 2008; Singh-Manoux et al. 2003), Japan (Sakurai et al. 2010), and Taiwan (Collins and Goldman 2008; Hu et al. 2005) demonstrated that perceived social status has a strong and independent effect on health once traditional measures of socioeconomic status (SES), like education, income and occupation, have been taken into consideration. In many ways, subjective social status, in comparison to traditional measures of SES, could be a more appropriate indicator of SES and more relevant to the health and well-being of older Chinese. For instance, most Chinese older than 60 years are likely to be retired and rely on limited sources of income. In addition, many older Chinese, women in particular, have had little or low level of education (Ross and Zhang 2008). As a result, those conventional measures of SES may not comprehensively capture their current social status and living circumstances. This study focuses on two measures of subjective social status—relative deprivation (i.e. feelings of less well-off compared to others) and self-reported life quality. Feeling of relative deprivation is empirically found to be negatively associated with health through psychosocial stress and related behaviors (Eibner and Evans 2005; Mangyo and Park 2011; Subramanyam et al. 2009; Wilkinson and Pickett 2006). In summary, using data from the largest Asian country where cultures, norms and values are very different from those of Western societies, this study intends to comprehensively explore the important correlates of psychological distress among the elderly in China. We made several predictions on the basis of the aforementioned literature. We predict that active engagement in life, indicated by doing exercises, religious participation, various aspects of social support and subjective social status, is associated with psychological distress. We further expect that the effects of these correlates on distress remain when we adjust for individual background variables, physical health, and chronic conditions. The conceptual model of our work is summarized in Fig. 1.
Methods Data The study participants include 292 older adults in Suzhou city, Jiangsu province, China. Selection of Suzhou as the study site is determined by (1) its geographic and economic position as a well-developed large city in the southeastern part of China; (2) its high population
Various exercises
Participation in
Religious participation
leisure activities
social and
Living arrangements Perceived social support
Various aspects
Psychological
of social support
distress
Importance of providing support to family Perceived relative deprivation
Subjective social
Perceived life quality
status
Fig. 1 Conceptual model linking psychological distress and correlates
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density and long life expectancy; (3) its thick and rich history, and (4) its openness, which collectively, have great academic merits. Specifically, first, it is located at the heart of the Yangtze River Delta, which is the most developed part in China. Second, it is adjacent to Shanghai and has an advanced network of railways, highways, waterways, and skyways. Due to its convenient transportation, the city has embraced a wide range of cultures, including that from other parts of China and abroad. Third, it has more than 2,500 years of history and is the cradle of Wu culture, and is the oldest town in the Yangtze Basin. In this place, Chinese traditions and cultures are successfully maintained and carried on. Most importantly, people residing in Suzhou live substantially longer life compared people from other parts of China. For instance, the life expectancy in Suzhou is around 81.56 years in 2010 according to the statistics provided by the local Center for Disease Control (CDC), which is the highest in Jiangsu province and comparable to the life expectancy of residents in Shanghai (which is slightly over 82.51 years according to the Statistics provided by Shanghai Health Bureau). In sum, Suzhou is the center of both Asian traditions and the Western cultures, thus, it is unique in terms of the diversity and richness in many aspects, including lifestyle, living arrangements, as well as health and well-being. Among various districts in Suzhou area, Pingjiang district is often the representative of Suzhou city given its convenient public transportation, prosperous economy, garden assembly, and developed culture and well-preserved ancient features. It has an area of 22 km2 and has a population of 27 million in 2010. This study focuses on Pingjiang district in Suzhou and applied non-probability sampling design. To reach older respondents with diverse socioeconomic background, the data were collected from community clinics (where free medical check-ups were taking place among seniors), senior college, and community dwelling areas from five different neighborhoods and areas in Pingjiang district from June to July, 2012. Given that many older adults may have difficulty in reading and writing because of poor vision and low levels of education, face-to-face interview was adopted with questionnaire composed primarily of close-ended questions. Oral consent was obtained from the participants and anonymity and confidentiality were emphasized to encourage honest responding. In the analysis, only four cases were excluded due to missing data. This study was approved by the Institutional Review Board with which the first author is affiliated. Variables Dependent Variable The focal dependent variable is psychological distress, which is measured by five items that gauge symptoms of anxiety (anxiety and fear) and depression (lonely, useless and hopeless) as well as indicator of well-being end of the psychological continuum (happiness). Specifically, respondents were asked how often they felt (a) fearful or anxious, (b) hopeless, (c) lonely and isolated, (d) useless, and (e) happy. Responses to the first four distress items were coded 1 (never), 2 (seldom), 3 (sometimes), or 4 (often), and responses to feeling happy were coded in reverse. The index is the mean response to these five items. All items load on a single factor above 0.4; the alpha reliability is 0.85, and the mean is 1.83, with a standard deviation of 0.73. The correlation of each item with the overall distress scale is 0.83 for fearful and anxious, 0.78 for hopeless, 0.82 for lonely and isolated, 0.78 for useless, and 0.44 for happy (scored in reverse). Other scholars (Wu and Schimmele 2006; Ross and Zhang 2008; Zhang and Liu 2007) applied similar measures to construct psychological well-being and psychological disposition scales for older Chinese. These studies confirm that those items are valid measures to gauge psychological status of older Chinese.
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Major Independent Variables We used two indicators, exercise and religious participation, to assess social and leisure activity participation. Exercise is measured in response to a question: “How often do you do exercise?” Responses were coded 1 (never), 2 (seldom), 3 (sometimes), or 4 (often). Almost 43.2 % of the sample reported exercising at least sometimes. In the analysis, exercise was dichotomized to contrast individuals doing exercise sometimes or often with others. In the follow-up open-ended questions, respondents were further probed by the types of exercises they were engaging in sometimes or often. Most respondents mentioned that they were doing exercises that are collective in nature such as square dancing, square Tai-qi, climbing mountains or hills with friends, and walking or jogging with friends. In this sense, exercise is considered a form of collective activity in this study. Besides exercise, respondents were also asked: “How often (never, seldom, sometimes, or often) do you participate in any religious activities?” Around 31.2 % of the sample reported to participate in religious activities at least sometimes. Variable on religious participation was also dichotomized in the multivariate analysis. In the open-ended question, we got to know that only those respondents who regularly visited temple and burned joss sticks (i.e. at least two times a month) considered themselves as religiously active. Others who simply worshiped ancestors or visited temple occasionally during travelling would not consider themselves as religious. Most religious respondents are Buddhists and only two are Christians. We consider three aspects of social support: living arrangements, perceived social support, and believing in the importance of providing support to other family members. Living arrangements were assessed by several dummy variables: living with spouse only (51.7 % of the sample), living with adult children only (11.3 %), living with both spouse and adult children (24.7 %), and living with others (the reference category) including living alone (10.65 %), living with parents (1.4 %) and living in the senior center (0.3 %). Perceived social support was assessed by asking respondents how often they will have someone who (a) provides sick care; (b) loves them and cares for them; (c) listens to their worries; (d) helps them solve problems; and (e) companies them to do happy things. Responses to these items were coded 1 (never), 2 (sometimes), or 3 (always). The index is the mean response to these five items, scored 1 to 3. All items load on a single factor above 0.8; the alpha reliability is 0.87, and the mean is 2.57, with a standard deviation of 0.52. Believing in the importance of providing support to other family members was assessed by asking respondents: “How important (not important, so-so, or important) is it for an older person like you to care for other family members?” Over 59 % of the sample reported that being able to caring for other family members is important. Subjective social status was gauged by two separate questions. Self-perception of relative deprivation was coded in response to a question: “How often (never, seldom, sometimes, or often) do you feel that other people live a better life than you?” A dummy variable was created to contrast individuals reporting sometimes or often to those reporting never or seldom. Over 35 % of the sample reported feeling relative deprivation at least sometimes. The second measure is self-reported general life quality, which is coded in response to a question: “How good is your general life quality?” It is scored 1 (very bad), 2 (bad), 3 (so-so), 4 (good), and 5 (very good). Over 46 % of the respondents reported having good or very good life quality. Control Variables We controlled for three sets of variables. The first set of variables include indicators of objective SES such as education (illiterate, less than high school, high school, and some
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college or more) and family monthly income (=RMB 5,000, equivalent to around $820) is a protective factor against distress. There is a substantial and significant negative association between self-rated good or very good physical health and distress with an adjustment for age, gender, marital status, education, family income, and chronic disease counts. Exercise, added in Model 2, is significantly and negatively related to distress and it partially mediates the effect of self-rated physical health, highest family income and age. For instance, part of the reason why individuals with highest family income are mentally healthy compared to others is because they are more likely to engage in various exercises. Inconsistent with our expectation, however, religious participation is not related to a significant reduction in distress. Models 3-5 progressively added the second set of important correlates of theoretical interest—various aspects of social support. Results demonstrate that, compared to seniors living with others (primarily those living alone), seniors living with both spouse and adult children show a significant mental health benefit. And seniors who recognize the importance of caring for other family members as well as those who perceive more social support from others are more likely to report significant lower levels of distress. Indicators of subjective social status were added in Model 6. Both relative deprivation and self-reported life quality are significantly associated with distress but in opposite direction. Noticeably, the effect of both self-rated health and high family income is further reduced in the final model, suggesting that their effect on distress is greatly mediated by subjective social status and other proposed independent variables.
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Table 1 Descriptive statistics, older Chinese, 2012 (n=288)
Except for rounding error, percentages sum to 100.0 %. For continuous variables such as psychological distress, age, perceived social support, and number of chronic diseases, means are reported and standard deviations (SD) are in parentheses
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Variables
PCT/mean
Psychological distress Social and leisure activity participation Exercises % Never/seldom (reference) % Sometimes/often Religious participation % Never/seldom (reference) % Sometimes/often Various forms of social support Living arrangements % Living with others (reference) % Living with spouse % Living with children % Living with spouse and children Importance of providing support to family % So-so/not important (reference) % Important Perceived social support Subjective social status Perceived relative deprivation % Never/seldom (reference) % Sometimes/often Perceived life quality % Very bad/bad/so-so (reference) % Good/very good Education levels % Illiterate (reference) % Less than high school % High school % Some college or higher Family income %=RMB 5,000 Socio-demographics Age Gender % Female % Male Marital status % Married % Others Self-reported health % Very bad/bad/so-so (reference) % Good/very good Number of chronic diseases
1.83 (0.73)
56.8 43.2 68.8 31.2
12.3 51.7 11.3 24.7 40.8 59.2 2.57 (0.52)
64.7 35.3 53.8 46.2 9.6 52.7 28.1 9.6 31.8 46.6 21.6 69.89 (8.13) 60.6 39.4 78.8 21.2 64.4 35.6 1.53 (1.18)
0.197 (0.128)
Married
Less than high school
−0.288† (0.150)
0.173† (0.090)
Female
Education (illiteratea)
0.011† (0.006)
Age
Control variables
Good/very good
Sometimes/often Perceived life quality (very bad/bad/so-soa)
Perceived relative deprivation (never/seldoma)
Subjective social status
Perceived social support
Important
Importance of providing support to family (so-so/not importanta)
Living with spouse and children
Living with spouse Living with children
Living arrangements (living with othersa)
Various forms of social support
Sometimes/often
Religious participation (never/seldoma)
Sometimes/often
Exercise (never/seldoma)
Social and leisure activity participation
Model 1
−0.253† (0.148)
0.199 (0.126)
0.185* (0.090)
0.008 (0.006)
−0.088 (0.090)
−0.269*** (0.083)
Model2
−0.214 (0.148)
0.610* (0.245)
0.187* (0.089)
0.008 (0.006)
−0.564* (0.252)
−0.586* (0.254)
−0.256† (0.148)
0.632** (0.243)
0.183* (0.088)
0.008 (0.006)
−0.225** (0.086)
−0.386 (0.249) 0.069 (0.167)
−0.037 (0.090)
−0.259** (0.083)
Model 4
−0.389 (0.252) 0.024 (0.168)
−0.086 (0.089)
−0.274*** (0.083)
Model3
−0.244† (0.146)
0.691** (0.241)
0.165† (0.087)
0.008 (0.006)
−0.158 (0.130)
0.408† (0.215)
0.087 (0.078)
0.007 (0.005)
−0.217* (0.087)
0.651*** (0.077)
−0.160* (0.076) −0.193** (0.072)
−0.232** (0.081)
−0.390† (0.222)
−0.330 (0.218) 0.037 (0.147)
0.055 (0.080)
−0.138† (0.074)
Model 6
−0.186* (0.086)
−0.527* (0.249)
−0.381 (0.246) 0.095 (0.166)
−0.025 (0.089)
−0.238** (0.082)
Model 5
Table 2 Psychological distress regressed on socio-demographic characteristics, self-rated heath and disease counts (Model 1), exercise and religious participation (Model 2), living arrangements (Model 3), importance of providing support to family (Model 4), perceived social support (Model 5), and subjective social status (Model 6), older Chinese, 2012 (n=288)
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−0.264** (0.090)
0.144
1.500
0.033 (0.036)
a
Reference group
Shown are metric coefficients with standard errors in parentheses †p
Psychological Distress of Older Chinese: Exploring the Roles of Activities, Social Support, and Subjective Social Status Wei Zhang & Min Chen
Published online: 22 December 2013 # Springer Science+Business Media New York 2013
Abstract The goal of this research is to examine if the long neglected correlates such as social and leisure activities, social support, and subjective social status contribute to variations in psychological distress among older Chinese. Using data collected in one of the most developed areas in China—Suzhou city, Jiangsu province, the authors find that engaging in various exercises, living with both spouse and adult children, perceived availability of social support from others as well as believing in the importance of caring for other family members are particularly beneficial for mental health whereas the perception of relative deprivation and low life quality is detrimental to mental health for older Chinese. This work is among the first studies that comprehensively examined various important correlates of psychological distress and indicate the unique patterns of distress among the elderly in the most developed area in the contemporary China. Keywords Distress . Activities . Older Chinese . Social support . Subjective social status
Introduction Chinese population is aging rapidly. According to the figures provided by the National Bureau of Statistics of China and China National Population Development Strategy Research Group, there were 124.26 million or 10.46 % of adults aged 60 years or older in China. This number is projected to increase up to 234 million or 16.00 % of the total population in 2020 (Li et al. 2011). As number of older adults continues to increase significantly, close attention needs to be paid to the health and well-being of this population segment. A limited but growing number of studies have started to examine the prevalence and correlates of mental health problems such as depression, the most common psychiatric condition in older people (Chen et al. 2004), among older Chinese (Li et al. 2011, 2012; See Lim et al. 2011 for review). Findings suggest W. Zhang (*) Department of Sociology, University of Hawaii at Manoa, 2424 Maile Way, Saunders Hall, Room 204, Honolulu, HI 96822, USA e-mail: [email protected] M. Chen College of Social Sciences, Suzhou Vocational University, Suzhou, People’s Republic of China
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that the prevalence of self-reported depressive symptoms among Chinese older adults can be as high as 40 % (Yu et al. 2012) and, compared to their rural counterparts, the depression rate for urban older adults is substantially higher (Li et al. 2011). Despite the abovementioned efforts in understanding the mental health of older Chinese, two major limitations remain in the literature. First, most studies have conceptualized depression as a dichotomized problem rather than a continuum and have often neglected another major aspect of psychological status—anxiety. Our study focuses on psychological distress, an unpleasant state that takes two major forms—both depression and anxiety (Mirowsky and Ross 2003). Distress is also measured as a continuous variable with higher levels of well-being on one end and high levels of distress on the other (Mirowsky and Ross 2003). We believe that this continuous measure not only captures more variations in mental health for older Chinese, but also avoids social stigmatization in Chinese culture that treats mental disorder as a diagnosed problem. Second, to date, many existing studies have focused on a limited number of factors that might be associated with mental health of older Chinese, primarily including education (Ross and Zhang 2008), filial piety (Cheng and Chan 2006; Li et al. 2011), family support and health status (Yu et al. 2012). Given that older Chinese are embedded in various social relations and are engaged in a variety of social activities, it is essential to comprehensively identify the potential social factors that might contribute to preventing distress or alleviating its symptoms within this population segment. Focusing on one of the most developed areas in China— Suzhou, Jiangsu Province, this study examines how social and leisure activity participation, various aspects of social support, and subjective social status, in addition to the previously examined socio-demographic factors, are associated with variation in psychological distress among the elderly in China.
Theoretical Background One critical component of successful aging is active engagement (Rowe and Kahn 1997). According to Rowe and Kahn (1997), maintaining close interpersonal relations and participating in productive activities are two important forms of active engagement. Interpersonal relations “involve contacts and transactions with others, exchange of information, emotional support, and direct assistance” (Rowe & Kahn, p. 433–434) and productive activities are activities that create social value such as caring for family members or working as a volunteer in organizations. Their theoretical emphasis on the productive and social aspects of activity for successful aging is empirically supported by evidence disclosing that older adults who actively participate in social and meaningful leisure activities usually report positive well-being (Adams et al. 2011). Pathways linking those activities and individual well-being often include physical benefits from body movement, social support from social interactions and the consequent positive psychological status such as a sense of belonging, a sense of identity, and a sense of personal mastery (Adams et al. 2011). This study considers social engagement as a multi-dimensional concept and examines its three aspects among older Chinese. The first aspect is an engaged lifestyle indicated by participating in social and leisure activities. The second aspect is social integration indicated by individual involvement with family, groups or community. It should be noted that the resulted social support and sense of belonging from social integration may mediate the effect of social and leisure activities on individual well-being. The third aspect is subjective social status indicated by individual self-perception of life quality and social status compared to others. According to the comparative reference group theory, when individuals compare their
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own situations upward with those of others in better situations, their feelings of relative deprivation will be provoked (Merton 1968). We argue that those socially engaged older adults are more likely to be aware of the existing social inequality and their relative location in society if they are actively interacting with others and are exposed to the latest news in media. In the following subsections, we will discuss how these three aspects are related to psychological distress. Social and Leisure Activities and Distress Engagement in meaningful social and leisure activities can be considered as an important aspect of healthy lifestyle to directly affect one’s psychological well-being. For instance, as one important indicator of lifestyle, exercise has both preventive and therapeutic psychological benefits because it has antidepressant effects through physiological, psychological, and neural pathways (Walsh 2011). Studies conducted in mainland China and in Taiwan have started to show that engaging in leisure-time physical exercises is significantly associated with better cognitive performance (Ku et al. 2012), a reduced level of distress (Ross and Zhang 2008) and depression (Chen et al. 2012) among older Chinese. In addition, leisure activities may also indirectly affect psychological well-being through pathway of social support because they often take place within social groups (Coleman 1993). This study focuses on two indicators of social and leisure activity participation—exercises and religious participation. Rather than jogging or running alone, older Chinese like doing exercises that are collective in nature such as doing activities on squares where a group of elderly follow a teacher to perform dances, Tai-qi and other movements or stretches collectively. In this sense, exercise is not only a physical activity that promotes one’s sense of fulfillment and enjoyment, but also a routine social event that develops one’s social network and sense of belonging. As an indicator of social activities (Glass et al. 1999, 2006), religious participation increases social resources (Ellison and George 1994), which in turn, promotes individual mental health. A limited number of studies have started to show that religious participation predicts longevity among older adults in China (Sun and Liu 2006; Zeng et al. 2011; Zhang 2008). Other studies suggest that religious participation is beneficial for mental health in various cultural contexts. One study by Lampinen et al. (2006) found that leisure activity (indicated by involvement in associations, religious activities, etc.) is associated with better mental health among older adults in Finland. Another study (Chiao et al. 2011) disclosed that continuously participating or initiating participation in social activities (including participating in hobby-related clubs, religious or church groups, political groups, etc.) is significantly associated with lower levels of depression among older Taiwanese adults. This study examines if the mental health benefit of religious participation remains for older adults in Suzhou, China. Social Support and Distress This study considers three forms of social support: living arrangements (that provide the context for family support), perceived social support from others, and believing in the importance of providing support to other family members. While the relationship between social support and beneficial health outcomes is well established in Western society (House et al. 1988), relatively fewer studies have examined this relationship in a non-Western setting among the elderly. For older Chinese, social exchanges may take on greater meaning because they are more likely to be retired, to be financially dependent, and have fewer social ties (Liang et al. 1992). Available studies in China revealed that emotional support (Leung et al. 2007),
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perceived social support (Krause et al. 1998; Li and Liang 2007) and filial support (Huang 2012) are important to the mental health of older Chinese. This study examines if the relationship between perceived social support—subjective evaluations of supportive exchanges (Barrera 1986) that gauges the availability of both instrumental and emotional support from others—and distress holds for the elderly in Suzhou city. Recent studies also suggest that giving may be as important as receiving social support in affecting health of the elderly (Liang et al. 2001). Brown et al. (2005) revealed that giving, not receiving, a higher level of social support is associated with lower morbidity in an ethnically diverse sample of community-dwelling older adults in New York. Similarly, Brown et al. (2003) found that mortality is significantly reduced for older married adults providing instrumental support to others. Their findings indicate that giving or altruism may be an evolved biological indicator of successful aging and benefit health due to positive mental statuses such as sense of meaning, purpose, mastery, and belonging, which in turn, lead to happiness and less depression. While Western literature shows beneficial health effect of providing social support to others, there is virtually no study available that examines whether this relationship holds true for older Chinese. Poulin et al. (2010) found that active helping predicted greater caregiver positive effect when controlling for care recipient illness status and functional impairment. Their finding indicates that the health benefits of helping behavior might be greatly enhanced when there is a strong sense of dependence between caregivers and those helped. Given that most retired older Chinese are likely to be care givers for their loved ones (including spouses, adult children and grandchildren) and at the same time to be care recipients by their family members when needed, we expect to identity lower levels of distress among older Chinese who believe that it is important to care for their family members. Living arrangements are also likely to be associated with health and well-being of older Chinese because they may greatly affect the amount of social support the elderly receive from their family members (Chou et al. 2006). Due to the combined effect of rapid population aging, drastic economic reforms, strict family planning policies, and large-scale internal migration, the long lasting norms on filial piety has started to erode due to practical limitations in the contemporary China (Sun et al. 2011). As a result of these social changes, the proportion of empty-nested households (i.e. households with one older adult living alone or living with only his or her spouse) has already increased to 27.9 % in 2007 and is estimated to increase up to 90 % by 2030 from 16.7 % in 1993 (Sun et al. 2011). Given that household in China has been historically considered as the primary unit for providing support to its older adults due to the long-lasting norms on filial piety, living alone is empirically found to be associated with increased levels of depression for older Chinese (Chou et al. 2006). Our study differentiates various types of living arrangements and links them to levels of distress among the elderly. Compared to other living arrangements, we predict that living with both spouse and children is associated with a better mental health outcome for older Chinese because it provides a context of reciprocal family support and mutual benefits: it not only meets the filial expectations and needs of the elderly, but also fulfill the necessities of caring for the offspring of their adult children. Taken together, we examine the following three aspects of social support: living arrangements, perceived availability of support from others, and believing in the importance of providing support to other family members. Subjective Social Status and Distress Despite the increasing significance of subjective social status (Operario et al. 2004; SinghManoux et al. 2003), its effect on mental health has not yet been closely explored in mainland China. Therefore, another focus of this study is to examine the mental health consequences of
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subjective social status that assesses individual self-perception of social status relative to others. Multiple studies conducted in the U.S. among Asian Americans (Gong et al. 2012; Leu et al. 2008), U.K. (Demakakos et al. 2008; Singh-Manoux et al. 2003), Japan (Sakurai et al. 2010), and Taiwan (Collins and Goldman 2008; Hu et al. 2005) demonstrated that perceived social status has a strong and independent effect on health once traditional measures of socioeconomic status (SES), like education, income and occupation, have been taken into consideration. In many ways, subjective social status, in comparison to traditional measures of SES, could be a more appropriate indicator of SES and more relevant to the health and well-being of older Chinese. For instance, most Chinese older than 60 years are likely to be retired and rely on limited sources of income. In addition, many older Chinese, women in particular, have had little or low level of education (Ross and Zhang 2008). As a result, those conventional measures of SES may not comprehensively capture their current social status and living circumstances. This study focuses on two measures of subjective social status—relative deprivation (i.e. feelings of less well-off compared to others) and self-reported life quality. Feeling of relative deprivation is empirically found to be negatively associated with health through psychosocial stress and related behaviors (Eibner and Evans 2005; Mangyo and Park 2011; Subramanyam et al. 2009; Wilkinson and Pickett 2006). In summary, using data from the largest Asian country where cultures, norms and values are very different from those of Western societies, this study intends to comprehensively explore the important correlates of psychological distress among the elderly in China. We made several predictions on the basis of the aforementioned literature. We predict that active engagement in life, indicated by doing exercises, religious participation, various aspects of social support and subjective social status, is associated with psychological distress. We further expect that the effects of these correlates on distress remain when we adjust for individual background variables, physical health, and chronic conditions. The conceptual model of our work is summarized in Fig. 1.
Methods Data The study participants include 292 older adults in Suzhou city, Jiangsu province, China. Selection of Suzhou as the study site is determined by (1) its geographic and economic position as a well-developed large city in the southeastern part of China; (2) its high population
Various exercises
Participation in
Religious participation
leisure activities
social and
Living arrangements Perceived social support
Various aspects
Psychological
of social support
distress
Importance of providing support to family Perceived relative deprivation
Subjective social
Perceived life quality
status
Fig. 1 Conceptual model linking psychological distress and correlates
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density and long life expectancy; (3) its thick and rich history, and (4) its openness, which collectively, have great academic merits. Specifically, first, it is located at the heart of the Yangtze River Delta, which is the most developed part in China. Second, it is adjacent to Shanghai and has an advanced network of railways, highways, waterways, and skyways. Due to its convenient transportation, the city has embraced a wide range of cultures, including that from other parts of China and abroad. Third, it has more than 2,500 years of history and is the cradle of Wu culture, and is the oldest town in the Yangtze Basin. In this place, Chinese traditions and cultures are successfully maintained and carried on. Most importantly, people residing in Suzhou live substantially longer life compared people from other parts of China. For instance, the life expectancy in Suzhou is around 81.56 years in 2010 according to the statistics provided by the local Center for Disease Control (CDC), which is the highest in Jiangsu province and comparable to the life expectancy of residents in Shanghai (which is slightly over 82.51 years according to the Statistics provided by Shanghai Health Bureau). In sum, Suzhou is the center of both Asian traditions and the Western cultures, thus, it is unique in terms of the diversity and richness in many aspects, including lifestyle, living arrangements, as well as health and well-being. Among various districts in Suzhou area, Pingjiang district is often the representative of Suzhou city given its convenient public transportation, prosperous economy, garden assembly, and developed culture and well-preserved ancient features. It has an area of 22 km2 and has a population of 27 million in 2010. This study focuses on Pingjiang district in Suzhou and applied non-probability sampling design. To reach older respondents with diverse socioeconomic background, the data were collected from community clinics (where free medical check-ups were taking place among seniors), senior college, and community dwelling areas from five different neighborhoods and areas in Pingjiang district from June to July, 2012. Given that many older adults may have difficulty in reading and writing because of poor vision and low levels of education, face-to-face interview was adopted with questionnaire composed primarily of close-ended questions. Oral consent was obtained from the participants and anonymity and confidentiality were emphasized to encourage honest responding. In the analysis, only four cases were excluded due to missing data. This study was approved by the Institutional Review Board with which the first author is affiliated. Variables Dependent Variable The focal dependent variable is psychological distress, which is measured by five items that gauge symptoms of anxiety (anxiety and fear) and depression (lonely, useless and hopeless) as well as indicator of well-being end of the psychological continuum (happiness). Specifically, respondents were asked how often they felt (a) fearful or anxious, (b) hopeless, (c) lonely and isolated, (d) useless, and (e) happy. Responses to the first four distress items were coded 1 (never), 2 (seldom), 3 (sometimes), or 4 (often), and responses to feeling happy were coded in reverse. The index is the mean response to these five items. All items load on a single factor above 0.4; the alpha reliability is 0.85, and the mean is 1.83, with a standard deviation of 0.73. The correlation of each item with the overall distress scale is 0.83 for fearful and anxious, 0.78 for hopeless, 0.82 for lonely and isolated, 0.78 for useless, and 0.44 for happy (scored in reverse). Other scholars (Wu and Schimmele 2006; Ross and Zhang 2008; Zhang and Liu 2007) applied similar measures to construct psychological well-being and psychological disposition scales for older Chinese. These studies confirm that those items are valid measures to gauge psychological status of older Chinese.
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Major Independent Variables We used two indicators, exercise and religious participation, to assess social and leisure activity participation. Exercise is measured in response to a question: “How often do you do exercise?” Responses were coded 1 (never), 2 (seldom), 3 (sometimes), or 4 (often). Almost 43.2 % of the sample reported exercising at least sometimes. In the analysis, exercise was dichotomized to contrast individuals doing exercise sometimes or often with others. In the follow-up open-ended questions, respondents were further probed by the types of exercises they were engaging in sometimes or often. Most respondents mentioned that they were doing exercises that are collective in nature such as square dancing, square Tai-qi, climbing mountains or hills with friends, and walking or jogging with friends. In this sense, exercise is considered a form of collective activity in this study. Besides exercise, respondents were also asked: “How often (never, seldom, sometimes, or often) do you participate in any religious activities?” Around 31.2 % of the sample reported to participate in religious activities at least sometimes. Variable on religious participation was also dichotomized in the multivariate analysis. In the open-ended question, we got to know that only those respondents who regularly visited temple and burned joss sticks (i.e. at least two times a month) considered themselves as religiously active. Others who simply worshiped ancestors or visited temple occasionally during travelling would not consider themselves as religious. Most religious respondents are Buddhists and only two are Christians. We consider three aspects of social support: living arrangements, perceived social support, and believing in the importance of providing support to other family members. Living arrangements were assessed by several dummy variables: living with spouse only (51.7 % of the sample), living with adult children only (11.3 %), living with both spouse and adult children (24.7 %), and living with others (the reference category) including living alone (10.65 %), living with parents (1.4 %) and living in the senior center (0.3 %). Perceived social support was assessed by asking respondents how often they will have someone who (a) provides sick care; (b) loves them and cares for them; (c) listens to their worries; (d) helps them solve problems; and (e) companies them to do happy things. Responses to these items were coded 1 (never), 2 (sometimes), or 3 (always). The index is the mean response to these five items, scored 1 to 3. All items load on a single factor above 0.8; the alpha reliability is 0.87, and the mean is 2.57, with a standard deviation of 0.52. Believing in the importance of providing support to other family members was assessed by asking respondents: “How important (not important, so-so, or important) is it for an older person like you to care for other family members?” Over 59 % of the sample reported that being able to caring for other family members is important. Subjective social status was gauged by two separate questions. Self-perception of relative deprivation was coded in response to a question: “How often (never, seldom, sometimes, or often) do you feel that other people live a better life than you?” A dummy variable was created to contrast individuals reporting sometimes or often to those reporting never or seldom. Over 35 % of the sample reported feeling relative deprivation at least sometimes. The second measure is self-reported general life quality, which is coded in response to a question: “How good is your general life quality?” It is scored 1 (very bad), 2 (bad), 3 (so-so), 4 (good), and 5 (very good). Over 46 % of the respondents reported having good or very good life quality. Control Variables We controlled for three sets of variables. The first set of variables include indicators of objective SES such as education (illiterate, less than high school, high school, and some
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college or more) and family monthly income (=RMB 5,000, equivalent to around $820) is a protective factor against distress. There is a substantial and significant negative association between self-rated good or very good physical health and distress with an adjustment for age, gender, marital status, education, family income, and chronic disease counts. Exercise, added in Model 2, is significantly and negatively related to distress and it partially mediates the effect of self-rated physical health, highest family income and age. For instance, part of the reason why individuals with highest family income are mentally healthy compared to others is because they are more likely to engage in various exercises. Inconsistent with our expectation, however, religious participation is not related to a significant reduction in distress. Models 3-5 progressively added the second set of important correlates of theoretical interest—various aspects of social support. Results demonstrate that, compared to seniors living with others (primarily those living alone), seniors living with both spouse and adult children show a significant mental health benefit. And seniors who recognize the importance of caring for other family members as well as those who perceive more social support from others are more likely to report significant lower levels of distress. Indicators of subjective social status were added in Model 6. Both relative deprivation and self-reported life quality are significantly associated with distress but in opposite direction. Noticeably, the effect of both self-rated health and high family income is further reduced in the final model, suggesting that their effect on distress is greatly mediated by subjective social status and other proposed independent variables.
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Table 1 Descriptive statistics, older Chinese, 2012 (n=288)
Except for rounding error, percentages sum to 100.0 %. For continuous variables such as psychological distress, age, perceived social support, and number of chronic diseases, means are reported and standard deviations (SD) are in parentheses
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Variables
PCT/mean
Psychological distress Social and leisure activity participation Exercises % Never/seldom (reference) % Sometimes/often Religious participation % Never/seldom (reference) % Sometimes/often Various forms of social support Living arrangements % Living with others (reference) % Living with spouse % Living with children % Living with spouse and children Importance of providing support to family % So-so/not important (reference) % Important Perceived social support Subjective social status Perceived relative deprivation % Never/seldom (reference) % Sometimes/often Perceived life quality % Very bad/bad/so-so (reference) % Good/very good Education levels % Illiterate (reference) % Less than high school % High school % Some college or higher Family income %=RMB 5,000 Socio-demographics Age Gender % Female % Male Marital status % Married % Others Self-reported health % Very bad/bad/so-so (reference) % Good/very good Number of chronic diseases
1.83 (0.73)
56.8 43.2 68.8 31.2
12.3 51.7 11.3 24.7 40.8 59.2 2.57 (0.52)
64.7 35.3 53.8 46.2 9.6 52.7 28.1 9.6 31.8 46.6 21.6 69.89 (8.13) 60.6 39.4 78.8 21.2 64.4 35.6 1.53 (1.18)
0.197 (0.128)
Married
Less than high school
−0.288† (0.150)
0.173† (0.090)
Female
Education (illiteratea)
0.011† (0.006)
Age
Control variables
Good/very good
Sometimes/often Perceived life quality (very bad/bad/so-soa)
Perceived relative deprivation (never/seldoma)
Subjective social status
Perceived social support
Important
Importance of providing support to family (so-so/not importanta)
Living with spouse and children
Living with spouse Living with children
Living arrangements (living with othersa)
Various forms of social support
Sometimes/often
Religious participation (never/seldoma)
Sometimes/often
Exercise (never/seldoma)
Social and leisure activity participation
Model 1
−0.253† (0.148)
0.199 (0.126)
0.185* (0.090)
0.008 (0.006)
−0.088 (0.090)
−0.269*** (0.083)
Model2
−0.214 (0.148)
0.610* (0.245)
0.187* (0.089)
0.008 (0.006)
−0.564* (0.252)
−0.586* (0.254)
−0.256† (0.148)
0.632** (0.243)
0.183* (0.088)
0.008 (0.006)
−0.225** (0.086)
−0.386 (0.249) 0.069 (0.167)
−0.037 (0.090)
−0.259** (0.083)
Model 4
−0.389 (0.252) 0.024 (0.168)
−0.086 (0.089)
−0.274*** (0.083)
Model3
−0.244† (0.146)
0.691** (0.241)
0.165† (0.087)
0.008 (0.006)
−0.158 (0.130)
0.408† (0.215)
0.087 (0.078)
0.007 (0.005)
−0.217* (0.087)
0.651*** (0.077)
−0.160* (0.076) −0.193** (0.072)
−0.232** (0.081)
−0.390† (0.222)
−0.330 (0.218) 0.037 (0.147)
0.055 (0.080)
−0.138† (0.074)
Model 6
−0.186* (0.086)
−0.527* (0.249)
−0.381 (0.246) 0.095 (0.166)
−0.025 (0.089)
−0.238** (0.082)
Model 5
Table 2 Psychological distress regressed on socio-demographic characteristics, self-rated heath and disease counts (Model 1), exercise and religious participation (Model 2), living arrangements (Model 3), importance of providing support to family (Model 4), perceived social support (Model 5), and subjective social status (Model 6), older Chinese, 2012 (n=288)
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−0.264** (0.090)
0.144
1.500
0.033 (0.036)
a
Reference group
Shown are metric coefficients with standard errors in parentheses †p
