The Relationship Between Geriatric Depression and Health-Promoting Behaviors Among Community-Dwelling Seniors

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1 ORIGINAL ARTICLE The Journal of Nursing Research h VOL. 21, NO. 2, JUNE 2013 The Relationship Between Geriatric Depression and Health-Promoting Behaviors Among Community-Dwelling Seniors Chyong-Fang Chang 1 & Mei-Hsiang Lin 2 & Jeng Wang 3 & Jun-Yu Fan 4 Li-Na Chou 5 & Mei-Yen Chen 6 * 1 BSN, RN, Graduate Nursing Student, College of Nursing, Chang Gung University of Science and Technology & 2 EDd, RN, Associate Professor, College of Nursing, Chang Gung University of Science and Technology & 3 PhD, RN, Associate Professor and Director, Department of Gerontological Care and Management, Chang Gung University of Science and Technology & 4 PhD, RN, Associate Professor, College of Nursing, Chang Gung University of Science and Technology & 5 PhD, RN, Associate Professor, School of Nursing, National Tainan Institute of Nursing & 6 PhD, RN, Professor, College of Nursing, Chang Gung University of Science and Technology. ABSTRACT Background: People older than 65 years old account for about 10.9% of Taiwan_s total population; it is also known that the older adults experience a higher incidence of depression. Public health nurses play an important role in promoting community health. Policymaking for community healthcare should reflect the relationship between health-promoting behavior and depression in community-dwelling seniors. Therefore, the encouragement of healthy aging requires strategic planning by those who provide health promotion services. Objective: This study was designed to elicit the health-promoting behaviors of community seniors and investigate the relationship between geriatric depression and health-promoting behaviors among seniors who live in rural communities. Methods: We used a cross-sectional, descriptive design and collected data using a demographic information datasheet, the Health Promotion for Seniors and Geriatric Depression Scale short forms. Results: The study included 427 participants. Most were women; mean age was 75.8 years. Most were illiterate; roughly half engaged in a limited number of health-promoting activities. The Geriatric Depression Scale score was negatively associated with health-promoting behavior. Social participation, health responsibility, self-protection, active lifestyle, and total Health Promotion for Seniors score all reached statistical significance. Multivariate analysis indicated that geriatric depression and physical discomfort were independent predictors of healthpromoting behavior after controlling the confounding factors. Conclusions/Implications for Practice: Participants practiced less than the recommended level of health-promoting behaviors. We found a negative correlation between the geriatric depression score and health-promoting behavior. Results can be referenced to develop strategies to promote healthy aging in the community, especially with regard to promoting greater social participation and increased activity for communitydwelling older adults experiencing depression. KEY WORDS: community health nursing, depression, elderly, health promotion. Introduction Health promotion and mental health are important global health issues, with health promotion and the prevention of mental disorders in later life becoming critical health policy priorities (World Health Organization [WHO], 2012a, 2012b). At the end of 2011, people over 65 years old accounted for 10.9% of the total population in Taiwan (Ministry of Interior, Department of Statistics, Taiwan, ROC, 2012). A rising population of elderly persons means rising numbers within this population who experience depression. Some studies showed that the prevalence of geriatric depression in Taiwan is 21.4%Y24.2% (Lin, Chen, & Lin, 2010; Shih et al., 2005). Among older adults, depressive mood often affects people resulting in lower quality of life, fewer social activities, and poorer health status (Chan, Chiu, Chien, Thompson, & Lam, 2006; Liu, 2009; Veenstra, 2000). Systematic reviews indicate that some clinicians and healthcare providers provide suboptimal depression management and care (Barley, Murray, Walters, & Tylee, 2011). In 2012, the WHO defined health promotion as a process involving the improvement of self-management behaviors that leads to reduced morbidity and mortality. Increased compliance with health-promoting behavior such as eating breakfast and exercising regularly has been found to correlate positively Accepted for publication: November 30, 2012 *Address Correspondence to: Mei-Yen Chen, No. 2, Chia-pu Rd. West Sec., Putz City, Chiayi County 61363, Taiwan, ROC. Tel: +886 (5) ext. 2201; Fax: +886 (5) ; meiyen@gw.cgust.edu.tw doi: /jnr.0b013e fc9 75

2 The Journal of Nursing Research Chyong-Fang Chang et al. with improved health status in the older adults (McPhee, Johnson, & Dietrich, 2004; Woo, Ho, & Yu, 2002). Kim (2009) indicated that better physical and mental health helped older adults develop healthy aging expectations; implementation of health-promoting behaviors helped to achieve this outcome. Many studies have shown an association between practicing health-promoting behaviors and decreased incidence of depression in older adults. A decreased incidence of depression has been observed among the older adults involved in regular community activities compared with those who do no partake in these activities. In addition, Harrington et al. (2009) reported that compliance with health-promoting behaviors led to improved mental health, enhanced quality of life, and longer working careers. Accordingly, the preliminary conclusion was that greater participation by the older adults in health-promoting behaviors would be associated with the beneficial effects of reduced geriatric depression and enhanced mental health. However, the basic but simple concepts obtained from the published literature relating to health-promoting behaviors showed inconsistency and limited efficacy in Taiwan. In addition, different concepts of what health-promoting behaviors among older adults exist across various academic fields. We retrieved relevant literature from OVID, CINAHL, PubMed, ProQuest, and Chinese Electronic Periodical Services. Articles published between 1995 and February 2012 were selected using keywords that included elderly people, health behavior, health-promoting behavior, and depression. There were 16 articles investigating relationships between depression and elderly health in terms of nutrition, exercise, oral hygiene, and social participation (Blake, Malik, & Thomas, 2009; Harrington et al., 2009; Jung & Shin, 2008; Yip et al., 2007). However, we found that there were differences in the scope of health-promoting behaviors among recently published articles. For example, health responsibility, stress management, and social support were included in health-promoting behaviors reported by Yu and Chen (2010). Chen et al. (1997), however, assumed that health-promoting behaviors should include six dimensions for the adult population: self-actualization, health responsibility, interpersonal support, exercise, stress management, and nutrition. Wang and Hsu (1997) designated health-promoting behaviors as contributing to mental health, sleep, diet, healthcare utilization, and self-care. Furthermore, prevention of chronic diseases, nutrition, and exercise have also been considered parts of health promotion (Huang, Chen, Yu, Chen, & Lin, 2002). Hence, our objectives were to understand the health-promoting behaviors of community seniors in disadvantaged areas and investigate the relationship between practicing health-promoting behaviors and depression in participants. Methods Study Design and Subjects This is a partial project and the first phase report for the Public Health Nurse-Led Health Promotion for Community Seniors project supported in 2010 by the Bureau of Health, Chiayi County. A cross-sectional descriptive study design was applied. Participants were selected by convenience sampling at four community centers in the two townships with the highest ratio of older adults. Selection criteria included subjects who were (a) older than 65 years old, (b) able to communicate in Hokkien or Mandarin, and (c) willing to participate. Exclusion criteria were (a) serious mental problems, including dementia; (b) inability to communicate cogently; and (c) inability to walk to the local health center. Public health nurses subjectively assessed participant mental states. G-Power version 3.1 estimated a required sample size of 260 participants (effect size =.35,! =.05, and power =.8). Data Collection During the study period, data were collected both through a self-administered questionnaire and interviews led by 10 research assistants after the study purpose and procedure had been explained to participants. Public health nurses obtained informed consent from all participants from March to October Research assistants were senior nursing students who all held registered nursing licenses and had received three preparatory training sessions (total: 6 hours, 2 hours each session). In session 1, we introduced the study background and questionnaire contents. Each research assistant conducted a rehearsed session as an interviewer, posing all interview questions in Hokkien (the Taiwanese dialect of Chinese). As necessary, the primary investigator corrected the research assistant s phrasing of questions to improve accuracy and clarity. In sessions 2 and 3, the 10researchassistantswere separated into five pairs. Each pair role-played the role of an elderly interviewee and the interviewer. After that, the most confusing items were discussed to make sure all research assistants fully understood each question. The most confusing items included I have checked my blood cholesterol this year and I eat a balanced diet each day. Therefore, we invited two older adults to help us clarify their understanding of the Hokkien meanings of each item. Research assistants were then divided into two groups to interview each elder; a 90% correct response rate was confirmed among the five. The questionnaire consisted of three sections described below. 1. Demographic data included gender, age, level of education, living arrangement, physical conditions, and masticatory problems. 2. Health-promoting behavior: This study used a preliminary Health Promotion Scale for seniors (HPS). Questions addressing elderly health-promoting behaviors were designed in accordance with our review of the literature. A content validity index was computed using the proportion of experts who were in agreement on item relevance. The content validity index was.89 after evaluation by five nursing experts holding a master s or doctoral degree in the field of elderly care. Internal reliability was measured by a value of Cronbach s! =.86, and construct validity was established using factor analysis. The 76

3 Geriatric Depression and Health-Promoting Behaviors VOL. 21, NO. 2, JUNE 2013 simplified version of the HPS consisted of five dimensions of behavior, including social participation (four items, e.g., participation in township/village activities), health responsibility (four items, e.g., measuring blood sugar or blood pressure), healthy diet (four items, e.g., daily minimum intake of one and a half bowls of vegetables), self-protection (four items, e.g., wearing nonslip shoes), and active life (four items, e.g., 30-minute daily cumulative exercise). A 21-item Likert-type scale was established for the HPS that explained 59.9% of total variance. A 4-point Likert scale was used to score the frequency of performed behavior (Table 2). Scores of 1 to 4 indicated the responses of never, sometimes, usually, and always, respectively, with higher scores indicating more health-promoting behavior. 3. Geriatric Depression Scale (GDS): The GDS short form included 15 questions designed to determine the degree of depression (Sheikh & Yesavage, 1986). The GDS is a structured questionnaire developed via modification of the GDS-30 (Yesavage et al., 1983). The Chinese version was translated and prepared by Liao, Yeh, Ko, Luo, and Lu (1995). The GDS was found to have 92% sensitivity and 89% specificity. Tool validity and reliability have been supported through both clinical practice and research. In a validation study comparing the long and short forms of the GDS for self-rating of symptoms of depression, both were successful in differentiating depressed from nondepressed adults with a high degree of correlation (r =.84,p G.001; Sheikh & Yesavage, 1986). The questionnaire consists of items involving emotional, cognitive, and behavioral symptoms. Examples of questions include the following: Are you basically satisfied with your life?, Do you often get bored?, Do you feel full of energy?, and Do you prefer to stay at home rather than going out and doing new things? Questions are answered by yes/no response, with a total possible score range of 0Y15 and higher scores correlating with higher levels of depression. Optimal sensitivity (94%) and specificity (82%) were also shown with the use of a cutoff score of 5 (Hoyl et al., 1999). Any positive score above 5 on the GDS short form should prompt an in-depth psychological assessment and evaluation for suicide. The Kuder Richardson coefficient of reliability (KR-20) for this study was Ethical Considerations and Data Analysis This study started after the approval of the institutional review board (No B). Interviewers explained the study objectives and obtained consent from enrolled participants before face-to-face interviews were conducted. Data were analyzed by independent t test, Pearson productymoment correlation coefficient, and stepwise regression using SPSS version 18.0 (SPSS, IBM, Inc., Armonk, NY, USA). Missing values were excluded. p G.05 indicated statistical significance. Results Demographic Characteristics and Health-Promoting Behaviors Four hundred twenty-seven community seniors participated in this study (Table 1). More than two thirds of participants (64.9%) were women. Mean age was 75.8 years (SD =6.0 years). More than two thirds (67.0%) were either illiterate or had a low level of education, 22.2% lived alone, 48.5% reported physical discomforts, and 30.4% reported masticatory difficulties. Mean scores of 1Y2 were observed in two habit categories, indicating that the frequency ranged between never and sometimes (Table 2). Frequencies of sometimes and usually were performed for 10 habits, including involvement of township-held activities, receiving regular blood cholesterol checkups, receiving regular blood sugar checkups, making annual dental visits, brushing teeth daily after meals, participation in community activities, and participation in physical exercise classes and activities. The Relationships Between Demographic Data, Depression, and Health-Promoting Behaviors One-way ANOVA was applied to analyze factors influencing participant performance in each HPS subscale. More social participation was found in participants who were literate (p G.01), without reported physical discomfort (p G.001), and with lower reported masticatory difficulties (p G.05). In terms of performing health responsibility, scores for participants without reported physical discomfort (p G.05) or masticatory difficulties (p G.05) were higher compared with their counterparts. Lower healthy diet scores were observed in participants living alone when compared with their counterparts living with others (p G.05). For questions pertaining to an active life, those without reported physical discomfort (p G.01) had higher scores than other groups. Total scores of HPS were higher among literate participants (p G.05) and in those without reported physical discomfort (p G.001). Table 3 shows that higher scores in social participation (p G.001), health responsibility (p G.05), self-protection (p G.01), active life (p G.01), and total HPS (p G.001) all had a significant negative correlation with GDS. Although lacking statistical significance, a healthy diet also correlated negatively with GDS. We further analyzed predictors affecting the health-promoting behaviors of participants. Healthpromoting behavior was used as the dependent variable, whereas geriatric depression, education, living alone, physical discomfort, and masticatory difficulty were used as independent variables for multiple regression analysis. Among healthpromoting behavior predictors, only geriatric depression and physical discomfort were important explanatory factors of health-promoting behaviors. These two variables accounted for 9% of total variance (Table 4). 77

4 The Journal of Nursing Research Chyong-Fang Chang et al. TABLE 1. Demographic Characteristic Associated With Health-Promoting Behaviors (N = 427) SP HR Variable M SD n % M SD t M SD t Gender j Female Male Age (years) È R Education j3.03** j0.85 Illiterate Literate Living alone 0.29 j1.33 Yes No Physical discomfort 4.16*** 2.49* No Yes Masticatory difficulties 2.36* 2.35* No Yes Note. SP = social participation; HR = health responsibility; HD = healthy diet; SP = self-protection; AL = active life; HPS = (total score of) health promoting for seniors. *p G.05. **p G.01. ***p G.001. TABLE 2. Health-Promoting Behaviors, Frequency of Practice (N = 427) Never Sometimes Usually Always Variable Mean SD n % n % n % n % Social participation 1. Township-held activities Religious activities Healthcare program Local health agency Health responsibility 5. Check blood cholesterol Check blood sugar Check blood pressure Dental visits Brushing teeth after meals Healthy diet bowls of vegetables Half bowl of fruit Varied diet Drink water of 1500 cc Self-protection 14. Wearing fit shoes Wearing nonslip shoes Enough sleep Three regular meals Active life 18. Exercise 3 times/week Cumulative 30 minutes Community activity Exercise class

5 Geriatric Depression and Health-Promoting Behaviors VOL. 21, NO. 2, JUNE 2013 HD SP AL HPS M SD t M SD t M SD t M SD t 0.43 j j j0.16 j j0.96 j1.17 j1.72 j2.30* j2.10* j j ** 3.86*** j TABLE 3. Relationship Between Depression Score and Health-Promoting Behaviors (N = 427) Variable SP HR HD SP AL HPS GDS j0.35*** j0.12* j0.08 j0.24** j0.13** j0.26*** Note. SP = social participation; HR = health responsibility; HD = healthy diet; SP = self-protection; AL = active life; HPS = (total score of) health promoting for seniors; GDS = (total score of) Geriatric Depression Scale. *p G.05. **p G.01. ***p G.001. TABLE 4. Multiple Regression Analysis of Factors Associated With Health-Promoting Behavior (N = 427) Variable B R 2 SE " t 95% CI VIF Constant *** [61.00, 64.60] Geriatric depression j j0.23 j4.79*** [j1.60, j0.67] 1.06 Physical discomfort (yes = 1) j j0.13 j2.65** [j5.63, j0.84] 1.06 Note. CI = confidence interval; VIF = variance inflation factor. *p G.05. **p G.01. ***p G

6 The Journal of Nursing Research Chyong-Fang Chang et al. Discussion Three key findings emerged from this study. First, the practice of health-promoting behaviors among community seniors was generally suboptimal. Second, older adults with reported geriatric depression and physical discomfort practiced fewer health-promoting behaviors. According to the statistics, average life expectancies are 76 years old for men and 83 years old for women in Taiwan. These numbers approximate those in developed countries (Department of Health, Executive Yuan, Taiwan, ROC, 2012). However, we concluded that many health-promoting behaviors such as attendance at healthcare programs, community activities, and dental visits as well as tooth brushing were performed less among our participants. Quality of life may be negatively affected by lower daily performance of health-promoting behaviors according to a previous report (Harrington et al., 2009). Analyzing each individual dimension of health-promoting behavior, we found the lowest average score to be that for active life, which included 30 minutes of exercise three times every week (or a cumulative 30 minutes of exercise daily), participation in community activities, and involvement in exercise classes or activities. These findings echoed official reports that say only 14% of Taiwanese older adults regularly participate in social activities (Ministry of Interior, Department of Statistics, Taiwan, ROC, 2012). In our study, participants who reported never participating in community activities or exercise classes accounted 51.1% and 54.8%, respectively. It may be attributable to the lack of organized activities in rural areas or of information related to official or civil activities not being available. Furthermore, participants who are illiterate (67%) likely face difficulties in effectively accessing community resources. Living in a rural setting also likely impedes access to medical resources. We also found very low scores for social participation (involvement in village activities) and health responsibility (annual dental visits and brushing teeth after meals). These findings may provide significant insights for rural health policy decision makers. A study in Korea (Jung & Shin, 2008) showed that older adults with less than 10 real teeth accounted for 30.2%; 31.3% of the participants still had 10Y19 teeth. However, our study found 74% of participants with less than 10 real teeth. Only 17.1% had more than 20 of their original teeth, and most (63.9%) had more than 20 artificial teeth or dentures. The findings clearly indicate that community-dwelling older adults living in rural areas have inadequate oral hygiene. This deserves further investigation to identify contributing factors such as lack of awareness, ignorance of oral hygiene since childhood, and low access to dental clinics. Furthermore, the findings indicate that it is necessary to start healthpromoting programs for community senior s oral hygiene. Studies have indicated that depression affects millions of people worldwide, is a major cause of disability and distress, and is expected to become the second most common cause of loss of disability-adjusted life years in the world by 2020 (WHO, 2012b). Nonetheless, management efficacy for depression has been found to be suboptimal (Barley et al., 2011). This study examined the relationship between practicing health-promoting behaviors and depression in older adults. Further research on evidence-based health-promoting activities should be conducted on community-dwelling seniors residing in rural areas. This study indicated that factors associated with seniors performing health-promoting behaviors included depression and physical discomfort. This phenomenon may be because of older adults living alone (22.2%) and the high percentage of older adults reporting physical discomfort (48.5%). Less social support and physical discomfort limited their social participation and overall health promotion performance. However, only 9% of the total variance was found in this study. This means factors associated with practicing healthpromoting behaviors among seniors may be explained by multiple factors. Such a possibility should be explored to initiate effective health promotion programs for communitydwelling seniors. Some studies indicated that social participation can help protect against morbidity and mortality (Holmes & Joseph, 2011). This is consistent with studies that found a higher prevalence of depressive mood among adults who did not engage in health-promoting behavior and exhibited poor health. Meanwhile, older adults who participated less in social activities were more likely to be depressed compared with those with regular involvement (Ganatra, Zafar, Qidwai, & Rozi, 2008; Liu, 2009; Veenstra, 2000). Therefore, we recommend providing individualized support for older adults (e.g., to access geriatric care, dental services, etc.), especially those with physical discomforts and masticatory difficulties. To continue enhancing older adults participation in community activities, we suggest the development of a health promotion framework in communities by integrating the efforts of primary healthcare providers and community resources. Limitations Limitations of this study include the following considerations. Participants were invited by nonrandom sampling, and most were in lower socioeconomic strata as evidenced by demographic variables such as education. Furthermore, selection and recall bias should be considered. This limitation in our study may limit the generalizability of findings. The cross-sectional design used reflected participant status only at the time of the survey. This severely limits the inferences we can make from results and causal explanations. Therefore, further studies should establish the evidence-based health-promoting activities for community rural seniors. In addition, longitudinal and empirical study designs are also suggested to explore the relationship between elderly healthpromotion activities and depression. Conclusions Assuming that frequency of practice is usually associated with good behavior (Chen, Chang Liao, Liao, & Chou, 1994), 80

7 Geriatric Depression and Health-Promoting Behaviors VOL. 21, NO. 2, JUNE 2013 we found that 12 habits were performed less frequently in 21 of the healthy lifestyle patterns. Higher scores for health-promoting behavior generally correlate with lower geriatric depression scores in the older adults. To achieve good health-promoting behavior and reduce the incidence of depression, it is recommended that more activities for the older adults be planned in communities, especially in rural areas. References Barley, E. A., Murray, J., Walters, P., & Tylee, A. (2011). Managing depression in primary care: A meta-synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Family Practice, 12, 47. doi: / Blake, H., Mo, P., Malik, S., & Thomas, S. (2009). How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review. Clinical Rehabilitation, 23(10), 873Y887. doi: / Chan, S. W. C., Chiu, H. 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8 The Journal of Nursing Research VOL. 21, NO. 2, JUNE * % * meiyen@gw.cgust.edu.tw 82