Stress Relief, Living Arrangements, and Depression Among Community-Dwelling Older Adults in the Philippines

Abstract

The Philippines is transitioning into an aging population. This results in problems associated with the mental health of older people. However, despite studies of depression in later life, there has been limited literature on the experience of those from rural communities in low and middle-income countries. This study examines depression, stress and stress relief measures used, and living arrangements of older adults (≥ 60 years) living in rural areas in the Philippines and compares depressed older adults from those that are not depressed. A cross-sectional descriptive design was employed using interviewer-assisted surveys. Convenience sampling was conducted to obtain data from 410 older people seeking care at rural health clinics across the Philippines. Data were analyzed through frequencies and chi-squares. Those who were depressed accounted for 11.5% of the respondents, while 77.1% reported some level of stress. Their stress relief measures included eating regularly (82.9%), exercise (64.6%), praying (62%), hanging out with friends and family (22%), and getting massages (7.3%). Around a third of respondents lived alone. For overall life stress, those who were not depressed reported that their lives were somewhat stressful, significantly higher than their depressed counterparts. Respondents who answered that work and money were their causes of stress showed significant differences compared to those who experienced no work or money-related stress. For stress relief measures, those who performed exercise and identified hanging out with friends and family as measures to maintain good wellbeing were significantly less likely to report depression. There were no differences among those living alone or older adults living with either adults, children, or both. Depression is an area of concern for community-dwelling older people in rural municipalities. The results of our study suggest the need to develop primary care services such as depression screening, health education and promoting healthy lifestyles, spirituality, stress management, and creating activities that will promote social interaction and maintain a social network.

Graphical Abstract

Introduction

The Philippines is transitioning into an aging population. As of the latest census in 2015, 7.5 million Filipino older adults account for 7.5% of the total population (Philippine Statistics Authority, 2015). This results in problems associated with the mental health of older people. The nation comes in third in the countries with the most problems in mental health in the Western Pacific Region, with an estimated six million Filipinos who suffer from depression and/or anxiety (World Health Organization, 2017). There are 17% to 20% of adult Filipinos live with mental disorders (Department of Health, 2012), and high prevalence of suicide among older adult Filipinos due to their failure to adapt to rapid social and economic developments (Carandang et al., 2019).

Mental health issues are presently more prevalent in low-middle-income countries (LMICs) than their counterparts because of scarcity in resources and health care access (Rathod et al., 2017). About 80% or more people who are experiencing depression are living in the LMICs (Vigo et al., 2016). Recent studies suggest that depression is associated with older age (Flores et al., 2018). However, there is little known on late-life depression of older Filipinos, especially when associated with stress, stress relief, and living arrangements. Living alone when someone gets old is unconventional in the Philippines. It is a Filipino norm for parents to live in the households of their children, especially when they get older (Chen et al., 2017; Natividad & Cruz, 1997)

Our study aims to contribute to the research gaps that can be useful in formulating or revising national policies and interventions addressing depression among older adults. This study describes the prevalence of depression, stress and stress relief measures used, and living arrangements of older adults (≥ 60 years) living in rural areas in the Philippines and compares depressed older adults from those that are not depressed.

Method

A cross-sectional descriptive design was employed primarily using interviewer-assisted surveys. Convenience sampling was conducted to obtain data from 410 older people (aged 60 years old and above) who sought care at their village health center in rural areas across the Philippines. Those who gave verbal consent (the need for written informed consent was waived) completed individual face-to-face interviews to measure depression, stress, stress relief, and living arrangements. A detailed description related to the parent study is described elsewhere (Cacciata et al., 2021). The study was reviewed and approved by the Institutional Review Board at the University of California Irvine and the Research Ethics Board at the University of the Philippines Manila.

Measures

Depression was measured with seven items from the Hospital Anxiety and Depression Scale (HADS). Scores were categorized into normal, borderline, and depressed. For stress, the participants were asked with a single item on “how stressful is your life?” with possible responses ranging from not stressful, somewhat stressful, to very stressful. For sources of stress, the participants were asked a yes or no question if their source of stress is work, caring for family, and money. Living arrangement was measured with a question on whether the respondent lived alone or not. Finally, stress relief measures were asked with yes or no items on whether the respondents exercise, eat, get massages, pray/see a priest, and regularly hang out with family and friends to maintain health and wellbeing.

The demographic variables were collected using a standardized form. Age was measured as age at the last birthday. Marital status was categorized as single, married, widowed, and separated. Educational level was categorized as an elementary undergraduate, elementary graduate, high school undergraduate, high school graduate, college level, college graduate, and postgraduate degree.

Data Analysis

Data were summarized using descriptive analysis and differences in the categories of the HADS depression scale. A chi-square test was used to assess the association between the three categories of the HADS depression scale and the sociodemographic and economic characteristics, living arrangement causes of stress, and stress relief measures. Data analysis was performed using SPSS (Version 26). Statistical significance was set at a P value less than 0.05.

Results

Sociodemographic and economic characteristics

Table 1 reports the outcome variable depression according to sociodemographic and economic characteristics of older adults. Four hundred forty-five older adults were included in the survey. After excluding cases with missing data (n= 35; 7.9%), the final data set in the analysis was from 410 older adults. Nearly 12% of older adults were categorized with depression, with 10.5% at borderline. Older adults aged 60–69 years were significantly more depressed (83.3%) as compared to those belonging in the 80 years or above group (42.1%), a P-value = <0.001. Marital status did not report a significant difference among single, married, and divorced/widowed, like those living alone or older adults living with either adults, children, or both. Those who reported having an income of less than PHP 25,000 annually were significantly more depressed than those with higher annual incomes. The association between stress and depression was significant (p < 0.00). Respondents who answered that work (P = 0.03) and money (P = 0.01) were their causes of stress showed significant differences compared to those who experienced no work or money-related stress. Those who performed exercise and hung out with friends and family were significantly less likely to report depression (P = < 0.001 and 0.02, respectively).

Table 1.

Depression scale according to characteristics and stress relief measures of older adults (N = 410)

		Depression scale
		Depressed		Borderline		Normal
Variables	%	n	%	n	%	n	%	P
Overall		47	11.5	43	10.5	320	78.0
Age (years)								<0.001
60 – 69	61.5	20	83.3	22	8.7	210	7.9
70 – 79	29.3	11	9.2	13	10.8	96	80.0
80 or above	9.3	16	42.1	8	21.1	14	36.8
Sex								0.97
Male	35.6	16	11.0	15	10.3	115	78.8
Female	64.4	31	11.7	28	10.6	205	77.7
Marital status								0.46c
Single	7.1	5	17.2	4	13.8	20	69.0
Married	53.2	21	9.6	25	11.5	172	78.9
Widowed/Divorced	39.8	21	12.9	14	8.6	128	78.5
Education								0.40
HSa undergraduate	48.8	27	13.5	19	9.5	154	77.0
HSa graduate or higher	51.2	20	9.5	24	11.4	166	79.0
Income (PHPb per year)								0.03
< 25,000	18.0	15	20.3	9	12.2	50	67.6
25,000 – 50,000	38.3	15	9.6	19	12.1	123	78.3
50,001 – 75.000	18.5	7	9.2	11	14.5	58	76.3
> 75,000	25.1	10	9.7	4	3.9	89	86.4
Living alone								0.33
No	31.5	17	13.2	17	13.2	95	73.6
Yes	68.5	30	10.7	26	9.3	225	80.1
Life stress								< .001
Not stressful	22.9	1	0.2	10	2.4	83	20.2
Somewhat stressful	72.2	38	9.3	31	7.6	227	55.4
Very stressful	4.9	8	2.0	2	0.5	10	2.4
Cause of stress (work)								0.03
No	85.9	44	12.5	32	9.1	276	78.4
Yes	14.1	3	5.2	11	19.0	44	75.9
Cause of stress (family)								0.45
No	72.0	31	10.5	29	9.8	235	79.7
Yes	28.0	16	13.9	14	12.2	85	73.9
Cause of stress (money)								0.01
No	33.9	7	5.0	17	12.2	115	82.7
Yes	66.1	40	14.8	26	9.6	205	75.6
Stress relief – exercise								<0.001
No	35.4	31	21.4	18	12.4	96	66.2
Yes	64.6	16	6.0	25	9.4	224	84.5
Stress relief – eat								0.08
No	17.1	10	14.3	12	17.1	48	68.6
Yes	82.9	37	10.9	31	9.1	272	80.0
Stress relief – massage								0.29c
No	92.7	46	12.1	41	10.8	293	77.1
Yes	7.3	1	3.3	2	6.7	27	90.0
Stress relief – pray								0.07
No	38.0	14	9.0	11	7.1	131	84.0
Yes	62.0	33	13.0	32	12.6	189	74.4
Stress relief – friends								0.02
No	77.1	44	13.9	33	10.4	239	75.6
Yes	22.9	3	3.2	10	10.6	81	86.2

^aHS High School

^bPHP Philippine Peso

^cFisher’s Exact Test

Discussion

Depression and stress

Our results suggest that those who were not depressed experienced more stress than their counterparts who were either depressed or borderline. Older adults who were not depressed are vulnerable to depression once a major stressful life event occurs. These may include a death of a significant other, death of a close family member, financial difficulties, and health deterioration (Bellingtier et al., 2017). The association between depression and stress has been reported by many studies (Hammen, 2018; Monroe et al., 2019). However, there may be other factors that contribute to this relationship.

Furthermore, associations were found between depression and work and money as sources of stress. Older people in rural communities continue to engage in income-generating activities, especially in the agricultural areas. Stress from financial difficulties may result from the instability of income from agricultural yield and the absence of other sources of funds (i.e., pension).

Depression and living arrangements

Multiple studies suggest that those who live alone are most likely to report depression (Dean et al., 1992; Hu et al., 2012; Stahl et al., 2017) and a higher risk of early mortality (Holt-Lunstad et al., 2015) as compared to those who live with a significant other or family member. In addition, living alone poses a greater risk for social isolation because of a considerable lack of emotional support, increasing the risk of depression (Cacioppo & Hawkley, 2003). Despite these facts, our findings revealed that living arrangement was not associated with depression. Other factors present in rural communities may contribute to this. For example, community cohesion is very strong in rural areas, which stems from the need to help each other, trust, and closely-knit relationships (Skerratt et al., 2012). Living in a cohesive community also entails a good neighborhood. The neighborhood social quality modifies the association between living alone and depressed (Stahl et al., 2017). This can be attributed to enhancing supportive behaviors among neighbors, including assistance with household chores and transportation (Cramm et al., 2015), and may lessen the stresses of living alone (Robinette et al., 2013). Furthermore, a good neighborhood promotes community social activities for older adults, giving them the chance to meet other people and create and increase their social network (Elliott et al., 2014).

Depression and stress relief measures

The results of our study supported the results of previous studies that maintaining a healthy lifestyle reduces depression symptoms (Lucineide, 2019). Such health behaviors include exercise, eating a balanced diet, maintaining adequate social support, and spirituality. In addition, rural areas provide a conducive environment for physical activity due to more green spaces and walkable spaces (Stahl et al., 2017). The quality of food may also be healthier considering the preponderance of agricultural products over fast food. In addition, senior Filipino women who reported positive self-rated health and had higher psychological resilience and social interaction depicted a lower level of depressive symptoms (Carandang et al., 2019).

On the other hand, a higher level of depressive symptoms was noted in women with chronic diseases. As mentioned earlier, the culture in rural areas is characterized by closely-knitted relationships. People tend to know each other more in the provinces compared to the urban areas. Social support as a stress relief measure is consistent with a study conducted in Taiwan among older adults (Zimmer & Chen, 2012). The study showed that social support was a strong predictor of depression among those not depressed at baseline but have lesser change among those already in such condition. Less depressive symptoms among the community-dwelling older adults in Asia are associated with adequate general social support such as being with a spouse or partner, living with family, having a large social network, having more contact with family and friends, and having emotional and instrumental support (Tengku et al., 2019). Furthermore, our study suggests the role of praying and visiting a priest as a stress relief measure.

The Philippines is a predominantly Catholic country, is characterized by the strong influence of the church in daily life. In addition, older people are known to participate in many religious activities.

Recommendations

Development of primary care interventions for depressed older adults in rural settings

The results of this study suggest the need to develop interventions to address depression among older adults. This is particularly challenging within the Philippine context as primary care services are specific to the geriatric population, and mental health services are limited in rural settings. Moreover, mental health services may not be routinely delivered due to competing priorities with maternal and child health programs, tuberculosis control, and other conditions such as heart disease, lung disease, and diabetes. Nonetheless, service packages that include a routine assessment of mental health problems, referrals to a psychiatrist, psychosocial and healthy lifestyle interventions may be warranted. In addition, other activities in the communities that promote mental health may include strengthening the local senior citizens association as a venue of socialization and maintaining social support.

Strengthen policies such as the Philippine Plan of Action for Older Persons

Depression among older adults remains a public health issue that leads to impaired functioning in daily life. Unfortunately, depression is underdiagnosed, and the plan of care receives little attention in primary care settings, which necessitates evidence-based interventions and health promotion programs to be developed to avoid overlooking symptoms that leave depression untreated among older adults. The results of this study can serve as evidence for policy recommendations on the advancement of health and wellbeing in the older age, development of supportive environments and can also focus on improving mental health and instituting systems that support the needs of older adults. Mental health care in the community consists of training health workers with issues related to aging and implementing long-term care of older adults diagnosed with depression, emphasizing education, training, and support to the caregivers. It is also important to ensure that mental health services be made available to the community and residential care centers. The National Health Insurance Programs must include care packages for mental health services to promote the accessibility of health care that is responsive to the needs of older adults.

Limitations

The responses of the older adults on their mental health may be affected by stigma and the culture of keeping to one-self when adversities in life are experienced. As a result, there may be a pre-dilection to report more positive health behaviors, including their stress relief measures.

Conclusion

Depression is an area of concern for community-dwelling older people in rural municipalities. The results of our study suggest the need to develop primary care services such as depression screening, health education and promoting healthy lifestyles, spirituality, stress management, and creating activities that will promote social interaction and maintain social networks.