The Relationship Between Self-Care and Depression in Older People in the Post-COVID Period: The Mediating Role of Hopelessness and Social Support

Aging is an important issue in psychological health and quality of life. Older people are vulnerable members of the society, prone to mental disorders, especially depression. Therefore, the aim of the present study was to examine the relationship between self-care and depression through hopelessness and social support in older people in the post-COVID period. This was a correlational study, using structural equation modeling (SEM). The statistical population consisted of all older people in Tehran, Iran with a sample of 260 individuals selected through convenience sampling. The measures used in this study included the second edition of Beck’s depression inventory, Younesi Borojeni’s elderly self-care questionnaire, Zimet et al.’s multidimensional scale of perceived social support, and Beck’s hopelessness scale. The data obtained from the questionnaires were analyzed using Pearson’s correlation coefficient and SEM in SPSS-26 and AMOS-24 software. The results indicated that the relationship between self-care and depression was significant through hopelessness (P<0.001, β=-0.87), and the relationship between self-care and depression was also significant through social support (P<0.001, β=-0.126). Based on the findings and the clarification of the relationships between self-care and depression in older people through the mediation of hopelessness and social support, effective actions can be taken to reduce depression and its psychological consequences in pandemic periods for this population.
EXTENDED ABSTRACT 
Introduction
Older adults are among the vulnerable members of society and are prone to mental health disorders, particularly depression. Research indicates that depression is a significant predictor of impairment in interpersonal relationships and daily activities, including self-care, among older adults. Additionally, studies show a correlation between self-care behaviors and the incidence of depression in older individuals. Various factors influence self-care in older adults, with social support and hope being among the most critical. Research has demonstrated that self-care education can improve or reduce disabilities in older adults, thereby increasing their sense of hope and quality of life. The significance of this study lies in elucidating the role of self-care models through social support and hopelessness as mediating variables, which could lead to important findings in the prevention and control of depression among the growing older population. This understanding paves the way for precise and targeted intervention studies aimed at enhancing the mental health of older adults. Therefore, given the existing gaps in the literature, the present study aims to investigate the relationship between self-care and depression in older individuals, considering the mediating role of hopelessness and social support.
Method
This research was a correlational study using structural equation modeling (SEM). The statistical population comprised all individuals over 60 years old residing in Tehran, Iran. A sample of 260 individuals (108 men and 152 women) was selected through convenience sampling. The inclusion criteria were (1) age over 60 years, (2) physical ability to participate in the study, and (3) willingness to participate in the study. The exclusion criteria included (1) inability to respond to questions, (2) diagnosed psychological disorders, and (3) cognitive impairments or mental conditions limiting cognitive abilities. Participants completed Beck’s depression inventory, Younesi Borojeni’s elderly self-care questionnaire, Zimet et al.’s multidimensional scale of perceived social support, and Beck’s hopelessness scale. Upon obtaining the necessary permissions, the research was conducted in locations frequented by older individuals, such as parks and retirement centers. Participants meeting the inclusion criteria were invited to join the study. After explaining the objectives of the study and ensuring the confidentiality of participants’ information for them, we obtained consent, and distributed the questionnaires. Participants completed the questionnaires with the assistance and guidance from the researcher. Given the large number of questions (82) and the specific conditions of older individuals, most questionnaires were completed with the help of the researcher. The data collected from the questionnaires were analyzed using Pearson’s correlation coefficient and SEM in SPSS-26 and Amos-24.
Results
Before conducting data analysis, it was determined that the distribution of all variable scores was normal. Results indicated no correlation between errors and no multicollinearity among the variables. To test the research hypotheses, model fitting was assessed using SEM. Results of Pearson's correlation test showed a significant positive relationship between self-care and social support (P<.01, ɣ =.418) and between depression and hopelessness (P<.05, β=.195). Additionally, there was a significant negative relationship between self-care and hopelessness (P<.001, ɣ=-.458), self-care and depression (P<.05, ɣ = -.377), and social support and depression (P<.01, β=-.298). The model fit indices obtained were CMIN=111.15, CMIN/DF=2.85, RMSEA= .07, NFI = 0.90, TLI =.91, IFI =.93, and CFI =.93, indicating a good model fit. Results from the Sobel test showed that hopelessness had a significant mediating role in the relationship between self-care and depression (P<.05, Z=-2.57) and social support had a significant mediating role in the relationship between self-care and depression (P< .01, Z =-3.27).
Conclusion
The primary aim of this research was to explain the relationship among self-care, as the criterion variable, hopelessness and social support as mediators, and depression as the predictor variable in older adults during the post-COVID-19 period. This study found significant relationships between self-care and depression through hopelessness and social support in older adults. Additionally, social support and hopelessness were identified as mediators in the relationship between self-care and depression. Considering that older adults are a vulnerable segment of the population and are prone to mental health disorders, particularly depression, which significantly impairs their quality of life, understanding factors related to depression can help reduce unwanted consequences in older adults. For example, higher perceived social support is associated with better physical and mental health outcomes, increased well-being, and reduced symptoms of depression. Hopelessness, self-care, and perceived social support are predictors of depression that should be given special attention in older age. Older adults can reduce hopelessness and depression by enhancing self-care and social support. Ultimately, based on the results of this study, effective measures can be taken to improve the quality of life of older adults.
Ethical Consideration
Ethical Code
This research was authorized by the Research Deputy of Ardakan University for the Master’s thesis of Ms. Masoumeh Ebadi in General Psychology.
Financial Support
This research did not receive any financial support.
Authors’ Contributions
M.A: Conceptualization, Methodology, Software, Data Collection and Statistical Analysis; A.M: Project Administration, Supervision, Data Management; Z.M: Writing - Original Draft, Writing - Review & Editing
Conflict of Interest
The author had no conflicts of interest.
Acknowledgments
This article is derived from a Master’s thesis in General Psychology at Ardakan University. The researchers extend their gratitude to the Research Deputy of Ardakan University, all the older adults who participated in the research, and all individuals and institutions that facilitated the participation of older adults in this study.
References
Abbasi, M., Ghadampour, A., & Hojjati, M. (2017). The role of self-care, resilience, and hopelessness in depression among elderly patients with heart disease. Aging Psychology, 3(3), 181-188. https://doi.org/10.30473/hpj.2023.62887.5476 [Persian]
Assaran, M., Tatari, M., & Seyed-Mohrami, E. (2017). The relationship between self-efficacy and hopelessness in elementary school students: A preliminary study. Tanin-e Salamat Journal, 5(2), 49-55. [Persian]
Azari Qahferkhi, Z., Ansari Shahidi, M., & Shahzamani, M. (2023). The effectiveness of family based social support training on social adaptation and self-care behaviors of heart patients with depression symptoms (post open-heart surgery). Journal of Health Psychology, 12(45), 95-112. [Persian]
Azkhoush, M. (2008). Application of psychological tests and clinical diagnosis (3rd ed.). Ravan. [Persian]
Bagheri, H., Sadeghi, M., Esmaeili, N & Naeimi, Z. (2016). Relationship between spiritual health and depression and quality of sleep in the older adults in Shahroud. Journal of Gerontology (joge), 1(1), 55-62. [Persian]
Bakhtiari, M., Emami Naeini, M., Hatami, H., Khodakaram, S., & Sahaaf, R. (2017). Depression, perceived social support, and related factors in elderly residents of Tehran in 2014. Elderly: Iranian Journal of Gerontology, 12(2), 192-207. https://doi.org/10.21859/sija-1202192 [Persian]
Banjongrewadee, M., Wongpakaran, N., Wongpakaran, T., Ruktrakul, R., & Bunnag, P. (2020). The Role of perceived stress and cognitive function on the relationship between neuroticism and depression among the elderly: A structural equation model approach. BMC Psychiatry, 20(1), 25-35. https://doi.org/10.1186/s12888-020-2440-9
Beck, A. T., & Steer, R. A. (1988). Manual for the Beck Hopelessness Scale. San Antonio, TX: The Psychological Corporation. https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?ReferenceID=1162622.
Bruwer, B., Emsley, R., Kidd, M., Lochner, C., & Seedat, S. (2008). Psychometric properties of the Multidimensional Scale of Perceived Social Support in youth. Comprehensive Psychiatry, 49, 195–201. https://doi.org/10.1016/j.comppsych.2007.09.002
Choubfroushzadeh, A., Mohammadpanah-Ardakan, A., Behjati-Ardakan, F., & Ahmadi-Ardakani, Z. (2018). The effectiveness of life review on depression and life satisfaction of the elderly. Journal of Aging Psychology, 4(2), 155-164. [Persian]
Diener, E. (2009). Subjective well-being: The science of happiness and a proposal for a national index. American Psychologist, 55(1), 34–43. https://doi.org/10.1037/0003-066X.55.1.34
Erikson, E. (1963). Personality and development in old age. Harper & Row
Fathi, E. (2020). The phenomenon of population aging in Iran and its future. Research Report, Statistical Research Center of Iran. Retrieved May 25, 2022, from https://srtc.ac.ir/analytical-reports/ [Persian]
Folkman, S. (2013). Stress, hope, and coping: Effects on psychological well-being. Oxford University Press.
Friedman, H. S., & Brown, J. D. (2016). The role of self-esteem in mental health. Psychological Science, 27(1), 1–10. https://doi.org/10.1177/0956797615612260
García-Portilla Paz, L., de la Fuente Tomás, T., & Bobes-Bascarán, T. (2021). Are older adults also at higher psychological risk from COVID-19? Aging & Mental Health, 25(7), 1297-1304. https://doi.org/10.1080/13607863.2020.1805723
Ghorai, B. (1993). A study of some cognitive patterns in patients with comorbid anxiety and depression (Unpublished master's thesis). Institute of Psychiatry. [Persian]
Giardini, A., Pierobon, A., Callegari, S., Caporotondi, A., Stabile, M., Avvenuti, G., & Majani, G. (2017). Optimism may protect chronic heart failure patients from depressive symptoms: Relationships between depression, anxiety, optimism, pessimism, and illness perception. Psicoterapia Cognitiva e Comportamentale, 23(1), 27-39.
Hooman, H. A. (2005). Modeling of structural equations with LISREL software application (In Persian). Sāmte Organization.
Ioannou, M., Kassianos, A. P., & Symeou, M. (2019). Coping with depressive symptoms in young adults: Perceived social support protects against depressive symptoms only under moderate levels of stress. Frontiers in Psychology, 9. https://doi.org/10.3389/fpsyg.2018.02885
Isik, K., Başoğul, C., & Yildirim, H. (2021). The relationship between perceived loneliness and depression in the Elderly and influencing factors. Perspectives in Psychiatric Care, 57(1). 351-357. http://doi.org/10.1111/ppc.12572
Jokar, F., Asadollahi, A., Kaveh, M. H., Ghaemani, L., & Nazari, M. (2020). The relationship between social support and the quality of daily activities of elderly people in rural communities. Elderly: Iranian Journal of Gerontology, 15(3), 350-365. https://doi.org/10.32598/sija.10.15.3.2773.2 [Persian]
Kim, H., Kim, H. S., & Choi, Y. M. (2017). Depression, interpersonal relationship, daily living stress, daily activity disorder, and health-related quality of life from the participation of female elderly in health-promoting programs. Transylvanian Review, 1(2), 44-56.
Koç, Z., & Sağlam, Z. (2019). Determination of the effects of daily life activities and self-care capacity on depression of the elderly in Northern Turkey. Acta Clinica Croatica, 58(3), 516-522. https://doi.org/10.20471/acc.2019.58.03.16
Mohebi, S., Parham M., Sharifirad G., Gharlipour Z., Mohammadbeigi A., & Rajati F. (2018). Relationship between perceived social support and selfcare behavior in type 2 diabetics: A cross-sectional study. J Edu Health Promot, 7(48). https://doi.org/10.4103/jehp.jehp_73_17
Moghannloo, M., & Dadfar, H. (2024). The relationship between self-criticism and loneliness with depression in the elderly: The mediating role of rumination. Aging Psychology, 10(1), 89-110. [Persian]
Momeni, K., Amani, R., Janjani, P., Majzubi, M. R., & Hadian Hamdani, K. (2021). The relationship between attachment styles and positive and negative emotions in the elderly: The mediating role of reminiscence styles. Aging Psychology, 7(4), 407-422. [Persian]
Momeni, K., Amani, R., Janjani, P., Majzoobi, M. R., Forstmeier, S., & Nosrati, P. (2022). Attachment styles and happiness in the elderly: The Mediating role of reminiscence styles. BMC Geriatrics, 22, Article 349. https://doi.org/10.1186/s12877-022-03053-z
Moradi, Sh., & Ghodrati Mirkoohi, M. (2023). The relationship between resilience, hope, and depression in older adults. Journal of Gerontological Nursing, 9(3), 9-22. http://jgn.medilam.ac.ir/article-1-321- fa.html [Persian]
Nejati, V., and Ashairi, H. (2006). Investigating the relationship between cognitive disorders and depression in the elderly. Elderly, 1(2), 118-112. [Persian] https://sid.ir/paper/95069/en.
Ohayon, M.M., Carskadon, M.A., Guilleminault, C., Vitiello, M.V. (2004). Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep. 1, 27(7), 1255-1273. https://doi.org/10.1093/sleep/27.7.125 5
Oraki, M., Mahdizadeh, A., & Dertaj, E. (2019). The effectiveness of self-care empowerment training on life expectancy, happiness, and quality of life in elderly people in Iranian nursing homes in Dubai. Elderly: Iranian Journal of Gerontology, 14(3), 320-331.‎ https://doi.org/10.32598/sija.13.10.670 [Persian]
Pourmand, G., Dosh, L., Ahmadi, A., & Noori, M. (2020). An application of the theory of planned behavior to self-care in patients with hypertension. BMC Public Health, 20(1), 1290-1299. https://doi.org/10.1186/s12889-020-09385-y
Rajabi, S. (2018). Anxiety sensitivity, perfectionism, loneliness, and self-esteem in elderly individuals with obsessive-compulsive disorder and major depression. Journal of Aging Psychology, 4(2), 119-129. [Persian]
Rostami, S., & Ahmadnia, S. (2011). The role of perceived social support components in predicting social adjustment among high school girls in Kermanshah, Iran, 2009. Social Research, 11, 129-147. [Persian] http://noo.rs/tG59z
Rudnicka, E., Napierała, P., Podfigurna, A., Męczekalski, B., Smolarczyk, R., & Grymowicz, M. (2020). The World Health Organization (WHO) approach to healthy ageing. Maturitas, 139, 6-11. https://doi.org/10.1016/j.maturitas.2020.06.011
Sachs-Ericsson, N., Carr, D., Sheffler, J., et al. (2021). Cognitive reappraisal and the association between depressive symptoms and perceived social support among older adults. Aging & Mental Health, 25(3), 453-461. https://doi.org/10.1080/13607863.2019.1698516
Sadock, B., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences (10th ed.). Wolters Kluwer.
Saeidimehr, S., Geravandi, S., Izadmehr, A & Mohammadi, M. (2016). Relationship between the “quality of life” and symptoms of depression among older adults. Iranian Journal of Ageing, 11(1), 90-99. [Persian]
Salehi, L., & Kikavosi Arani, L. (2020). Application of the Beckman model in determining the dimensions of self-care and factors affecting it in the elderly in Tehran. Daily Internal Medicine, 26(4), 382-397. https://doi.org/10.32598/hms.26.4.325 [Persian]
Salimi, A., Azimehjoogar, B., & Nikpour, R. (2009). Internet communication in life: The role of perceived social support and loneliness in internet use. Psychological Studies, 5(3), 81-102. https://doi.org/10.22051/PSY.2009.1607 [Persian]
Sayyadi, E., Abedini, A., Abedini, S., Kamalzadeh, & Hesamoddin. (2023). Review of self-care and health literacy in elderly people in Iran. New Medical Information Journal, 9(1), 80-89. [Persian]
Seyyedi, M., Mohammadi, M., Omidi, M., & Habibnia, M. R. (2022). The role of self-care in cognitive ability among elderly women with diabetes. Applied Family Quarterly, 3(5 [continuing issue 14]), 196-208. [Persian]
Singh, M., Kaur, S., & Srivastava, P. (2017). Relationship between hopelessness and depression among persons with disabilities and their parents. Journal of Disability Management and Rehabilitation, 1(1), 32-34.
Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2021). The brief resilience scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15(3), 194–200. https://doi.org/10.1080/10705500802222972
Taheri Tanjani, P., Germaroodi, G., Azadbakhsh, M., Fekri Zadeh, Z., Hamidi, R., Fathi Zadeh, Sh., & Qaisvandi, E. (2015). Validity and reliability of the second version of the Beck Depression Inventory. Sabzevar University of Medical Sciences Journal, 21(4), 189-198. [Persian]
Thakur, U., Varma, A. R., & Varma, A. (2023). Psychological problem diagnosis and management in the geriatric age group. Cureus, 15(4). https://doi.org/10.7759/cureus.37644
Türkseven, E., Öner, C., & Şimşek, E. E. (2020). The relationship between geriatric depression and perceived social support in elderly: A field study. Turkish Journal of Family Medicine and Primary Care. https://doi.org/10.21763/tjfmpc.633760
Westerhof, G. J., Whitbourne, S. K., & Freeman, G. P. (2012). The aging self in a cultural context: The relation of conceptions of aging to identity processes and self-esteem in the United States and the Netherlands. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 67(1), 52-60. https://doi.org/10.1093/geronb/gbr075
Wong, S. Y. S., Zhang, D., Sit, R. W. S., Yip, B. H. K., Chung, R. Y. N., Wong, C. K. M., ... & Mercer, S. W. (2020). Impact of COVID-19 on loneliness, mental health, and health service utilisation: A prospective cohort study of older adults with multimorbidity in primary care. British Journal of General Practice, 70(700), e817-e824. https://doi.org/10.3399/bjgp20X713021
World Health Organization. (2019). Decade of healthy ageing 2020–2030: Zero draft 2019. Geneva: WHO.
Younesi Broujeni, J., Jadidi, M., & Ahmadrad, F. (2020). Development and standardization of the self-care scale for the elderly in Tehran. Quarterly Journal of Applied Psychological Research, 11(1), 185-208. https://doi.org/10.22059/japr.2020.280957.643266 [Persian]
Zal, A., Rezaei Jamalouei, H., & Taheri, M. (2022). A structural model of self-care based on self-transcendence with social support as a mediator in patients with diabetes. Daneshvar Medical Journal, 30(4 [continuing issue 161]), 11-22. https://doi.org/2022.16147.1204 [Persian]
Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52(1), 30-41. https://doi.org/10.1207/s15327752jpa5201_2