Leisure activities indirectly affect depression in older chinese adults through activities of daily living and self-rated health

Abstract

This study aims to explore interrelationships among leisure activities and depression and the mediating roles of activities of daily living (ADL) and self-reported health (SRH) among older adults in China. Data were extracted from 9,893 participants aged 50 and older from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) conducted in 2018. Pearson correlation analysis and multiple stepwise regression analysis were conducted by using SPSS, and the mediating effect was tested using the Process plugin. Leisure activities were negatively correlated with depression (r = − 0.169, P < 0.001), and positively correlated with ADL and SRH (r = 0.223, r = 0.123, P < 0.001). ADL and SRH were negatively correlated with depression (r = − 0.120, − 0.376, P < 0.001). Leisure activities can not only directly and negatively affect depression, but also can indirectly affect depression through positive effects on ADL and SRH. The mediating effect accounts for 30.79% of the total effect. ADL and SRH play mediating roles in the relationship among leisure activities and depression. The participation of elderly people in leisure activities reduces the risk of depression by increasing their level of daily activity ability and perceived health.

Introduction

In Globally, mental disorders were the seventh leading cause of disability attributing to 970 million prevalent cases in 2019; depressive and anxiety disorders being the leading contributors to this burden¹. Depression is ranked by WHO as the single largest contributor to global disability and is also the major contributor to suicide deaths². Depressive disorders, peaking in older adulthood, affect approximately 63 million people or 7% of the population aged 60 years and older worldwide³. As China has entered an aging society, the proportion of people aged 60 and over in China reached 18.70%, and the proportion of people aged 65 and over reached 13.50%, with a trend of increasing year by year⁴, and thus improving mental health and particularly preventing depression among older adults are gradually becoming serious public health issues in China, especially after experiencing the COVID-19 epidemic.

A growing body of research has emphasized the protective role of leisure activities in promoting successful aging and psychological well-being^5–7. Leisure activities-including physical, cognitive, intellectual, and social forms-are consistently linked to better health outcomes and reduced depression among older adults^8–12. According to the Activity Theory, active engagement in meaningful leisure roles supports life satisfaction and psychological adaptation in older age. The theory posits that maintaining social roles and active lifestyles helps preserve older adults’ mental well-being¹³.

Furthermore, the Health Belief Model suggests that an individual’s willingness to engage in health-promoting behaviors-such as leisure activity-is influenced by perceived susceptibility to illness, perceived benefits of the behavior, and self-efficacy¹⁴. In this context, older adults who perceive health benefits from physical and social engagement are more likely to adopt and maintain leisure behaviors that protect against depression.

Leisure activities has also been found to be significantly related to depression and quality of life⁸, able to prevent depression as well as anxiety in the elderly^10,15 and was a positive method to improve mental health^16–25. Specifically, physical activity is inversely related to incident depression and anxiety, with higher levels of PA leading to a lower risk of depression and anxiety, and depression and anxiety are probably causally related to physical inactivity^20,21; physical activity could reduce symptoms of depression and anxiety^16–19; successful leisure participation in old age helps in relieving psychological stress, improving life satisfaction and life quality²⁶ and associates with lowered all-cause mortality among older adults^27,28. Physical activity has thus been proposed as an adjunct treatment therapy for depression and anxiety^22,23,25.

ADL is an important indicator of the health of the elderly, and it is also their most basic self-care ability²⁹. As age increases, the body functions of the elderly gradually decline, and their ability to engage in daily activities is impaired, resulting in not only the loss of independent living skills, but also a decrease in their range of activities and social participation, which limits their interpersonal communication and leads to negative emotions such as depression³⁰. Studies have clearly shown that there is a close relationship between the ADL ability, social support, and depression status of elderly people³¹ and the worse the ADL ability, the higher the probability of depression in elderly people³².

SRH is a subjective indicator of health status containing biological, mental, social, and functional aspects of a person, including individual and cultural beliefs and health behaviors³³. Studies show that SRH is a significant predictor of various aspects of current health status³⁴, an important indicator of depression³⁵ and is also associated with quality of life and depression³⁶. Furthermore, depression has been shown to be associated with poor SRH as well as increased mortality in the general population³⁷, and fair or poor SRH at baseline to be predictive of a twofold increased risk for major depression at follow-up, even after adjusting for socio-demographic characteristics, lifestyle-related behaviors, disability and diabetes characteristics (OR = 2.05, 95% CI 1.20–3.48)³⁸.

Although many studies have been carried out to examine factors affecting depression among older adults, few studies have examined the relationships among those relevant factors simultaneously (e.g., leisure activities, ADL, SRH and depression) and there have been no studies to investigate the relationships between leisure activities and depression through mediating factors such as ADL or SRH. Therefore, t his study aims to explore interrelationships among leisure activities and depression and the mediating roles of ADL and SRH among older adults in China, using data from the CLHLS.

Materials and methods

Data source and samples

This study utilizes data from CLHLS conducted in 2018. The research was led by Professor Zeng Yi, Director of the Center for Healthy Aging and Family Studies at Peking University and covers 23 out of 31 provinces in China. The 2018 follow-up survey contains 15,874 respondents over 50 years of age and contains more than 750 questions including extensive data on demographics, socioeconomic conditions, psychological traits, social participation, and health conditions, and all data are collected via face-to-face interviews during inhome visits³⁹. The Ethics.

Committee of Peking University approved the CLHLS study (IRB00001052–13074)⁴⁰.More detailed information about the CLHLS and the detailsof the sampling design, response rates, attrition, and systematic assessments of data quality were available elsewhere⁴¹.

In the study, adults who met the following inclusion criteria were included: (a) complete information on variables of leisure activities, SRH and depression, (b) complete data related to variables such as age, sex, residence, education level, marital status, and economical status. A total of 15,874 participants were surveyed in the 2018 wave of the CLHLS. After excluding adults who did not meet the inclusion criteria, there were 9,893 older adults in the final analysis.

Assessment of leisure activities

A six-question index of activity was used to assess the participation in leisure activities of the participants. The participants were asked “ do you participate in the following activities? ”. The activities were provided as follows: (a) doing garden work, (b) reading newspapers or books, (c) playing cards or mahjong, (d) watching TV or listening to radio, (e) taking part in some social activities and (f) other outdoor activities (Tai Ji, square dance, visit and interact with friends, other outdoor activity). Responses for each activity in this study were recorded into a 5- frequency: “1. almost everyday ”, “ 2. not daily but at least once in a week ”, “ 3. not weekly but at least once in a month”, “4. not monthly but sometimes”, and “5. never”. Then we reverse 1–5 so that the higher the scores were, the higher level of participation in leisure activities. Total scores range from 6 to 30.

Assessment of activities of daily living

ADL was assessed by the ADL scale, including bathing, dressing, toileting, indoor transfers, continence, and feeding. Responses for each activity in this study were recorded into a 3 options: a score of 1 = without assistance, 2 = one part assistance or 3 = more than one part assistance. Then we reverse 1–3 so that the higher the scores were, the higher level of ADL. Total ADL score ranged from 6 to 18. Adequate properties of the scale have been reported in other studies among older adults in China⁴² and elsewhere⁴³.

Assessment of self-reported health

SRH was assessed by the question as follows: How do you rate your health at present? with answers “1. very good ” “ 2. good ” “ 3. so - so” “ 4. bad ” “ 5. very bad ”. Then we reverse 1–5 so that the higher the scores were, the healthier participants were.

Assessment of depression

Depression was measured using the 10-item Center for Epidemiological Studies Depression Scale (CESD-10), which has shown adequate reliability⁴⁴. For each item, participants were asked to rate “ how often you felt this way during the past week”. Responses were recorded on a five-point scale: 1 = always; 2 = often; 3 = sometimes; 4 = seldom; 5 = never. We reverse 1–5 so that the higher the scores were, the more severe in depression. Total scores range from 10 to 50. The Cronbach’s alpha for the CESD-10 in the study was 0.933.

Assessment of other variables

A number of factors related to demographics, socio-life status, and health were included in this study, as these may be risk factors for depression in older adults. They are age, sex, residence, education level, marital status, and economic status. Residence was divided into “urban” and “rural”. Education level was captured by asking participants their years of schooling.Marital status was categorized as “married and living with spouse”, “widowed”, and “others”. Economic status was divided into three groups, namely “Rich”, “so-so” and “poor”.

Statistical analysis

All analyses were conducted using SPSS 26.0 (SPSS Inc., Chicago, IL, USA) and the PROCESS macro (Version 3.5) developed by Andrew F. Hayes. Descriptive statistics and Pearson correlations were first calculated to explore relationships between variables. To examine the mediating roles of ADL and SRH in the relationship between leisure activities and depression, we employed Hayes’ PROCESS macro Model 4, which is specifically designed for testing parallel mediation models. This model allows for estimating multiple indirect effects from a single predictor through multiple mediators operating in parallel. We used 5,000 bootstrap samples to calculate bias-corrected 95% confidence intervals for the indirect effects. Mediation was considered statistically significant if the confidence intervals did not include zero.

Control variables including age, sex, residence, education level, marital status, and economic status were included in all regression models to account for potential confounding effects. Results are presented in terms of total, direct, and indirect effects with standardized coefficients.This analytic approach allows us to clarify the unique contribution of each mediator and assess whether ADL and SRH function as distinct, simultaneous pathways linking leisure activities to depression.

Results

Characteristics of the study population

Among the participants,45.7% were men (n = 4525) whereas 54.3% were women(n = 5368). Their average age is 83.2 years old, with an average education level of 3.7 years. 58.1% of the participants live in urban areas, 20.2% are rich, and 45.2% are married and living with spouse(Table 1).

Table 1.

The characteristics ofparticipants stratified by sex.

Item	All(n = 9893)	Men(n = 4525)	Women(n = 5368)
Age (yrs)	83.2 ± 11.4	81.9 ± 10.7	84.3 ± 11.8
Education level (yrs) Residence, n (%)	3.7 ± 4.4	5.3 ± 4.6	2.4 ± 3.8
Urban	5750(58.1)	2699(59.6)	3051(56.8)
Rural	4143(41.9)	1826(40.4)	2317(43.2)
Economical status, n (%)
Rich	2002(20.2)	1041(23.1)	961(17.9)
So-so	6912(69.9)	3055(67.5)	3857(71.9)
Poor	979(9.9)	429(9.4)	550(10.2)
Marital status, n (%)
Married and living with spouse	4468(45.2)	2704(59.7)	1764(32.9)
Widowed	5124(51.8)	1609(35.6)	3515(65.5)
Others	301(3.0)	212(4.7)	89(1.6)

Correlation analysis between depression, leisure activities, activities of daily living and self-reported health

Correlation analysis result indicated that depression and leisure activities are negatively correlated (r = −0.169, P < 0.001); depression had a negative correlation with ADL and SRH (r = − 0.120, − 0.376, P < 0.001); leisure activities had a positive correlation with ADL and SRH (r = 0.223, 0.123, P < 0.001). In the above analysis, sex, age, residence, education, marital status, and economic status are used as control variables.

An analysis of the mediating effect of activities of daily living and self-reported health

Leisure activities can not only directly and negatively affect depressive symptoms, but also can indirectly affect depressive symptoms through positive effects on ADL and SRH. The total mediating effect accounts for 30.79% of the total effect. Among them, the mediating effect of ADL accounts for 5.04% of the total effect, and the mediating effect of SRH accounts for 25.76% of the total effect. See Tables 2, 3 and 4, and Fig. 1.

Table 2.

Correlations among between depression, leisure activities, activities of daily living and self-reported health.

Constructs	1	2	3	4
1.Leisure activities 2.ADL 3.SRH 4.Depression	- 0.223*** 0.123*** −0.169***	- 0.156*** −0.120***	- −0.376***	-

Table 3.

Regression results across all models.

Predictor	Model 1: Depression (Total Effect) B (SE) p	Model 2: ADL B (SE) p	Model 3: SRH B (SE) p	Model 4: Depression (Direct & Indirect Effects) B (SE) p
Leisure Activities	−0.20 (0.012) < 0.001	0.25 (0.011) < 0.001	0.11 (0.012) < 0.001	−0.14 (0.011) < 0.001
ADL	-	-	0.14 (0.010) < 0.001	−0.04 (0.010) < 0.001
SRH	-	-	-	−0.35 (0.009) < 0.001
Age	0.01 (0.003) 0.021	−0.01 (0.003) 0.015	−0.02 (0.004) 0.005	0.01 (0.003) 0.018
Gender (Male = 1)	−0.15 (0.015) < 0.001	0.10 (0.014) 0.001	0.06 (0.015) 0.001	−0.12 (0.015) < 0.001
Marital Status (Married = 1)	−0.10 (0.014) 0.002	0.03 (0.012) 0.019	0.04 (0.013) 0.004	−0.06 (0.012) 0.002
Education (Years)	−0.03 (0.007) 0.001	0.02 (0.006) 0.002	0.03 (0.008) 0.001	−0.02 (0.006) 0.001
Economic Status (Higher = 1)	−0.08 (0.012) < 0.001	0.07 (0.011) < 0.001	0.08 (0.011) < 0.001	−0.06 (0.010) < 0.001
Residence (Urban = 1)	−0.05 (0.011) 0.004	0.04 (0.010) 0.007	0.05 (0.012) 0.002	−0.04 (0.011) 0.004
Chronic Conditions	0.09 (0.010) < 0.001	−0.06 (0.009) < 0.001	−0.07 (0.009) < 0.001	0.08 (0.010) < 0.001
Smoking (Yes = 1)	0.12 (0.013) < 0.001	−0.04 (0.010) < 0.001	−0.05 (0.011) < 0.001	0.10 (0.012) < 0.001
Social Activity Participation	−0.18 (0.012) < 0.001	0.08 (0.010) < 0.001	0.10 (0.012) < 0.001	−0.15 (0.011) < 0.001

Table 4.

Bootstrap test of the mediating role of activities of daily living and self-reported health.

Item	effect	S.E.	95% CI	effect (%)
Direct Effect	−0.1072	0.0087	(−0.1243,−0.0902)	69.21
Indirect Effect	−0.0477	0.0042	(−0.0560,−0.0396)	30.79
ADL	−0.0078	0.0023	(−0.0126, −0.0034)	5.04
SRH	−0.0399	0.0036	(−0.0468, −0.0331)	25.76
Total Effect	−0.1549	0.0091	(−0.1727, −0.1372)

Fig. 1.

Mediating Diagram of ADL and SRH in Leisure Activities and Depressive Symptoms.

*** p < 0.001.

Discussion

This study aims to explore interrelationships among leisure activities and depression and the mediating roles of ADL and SRH among older adults in China. The results showed that participation of leisure activities can not only reduce depressive symptoms directly but also can reduce depressive symptoms through the mediating effect of ADL and SRH.

The result demonstrated a negative relationship between leisure activities and depression among China older adults, consistent with the finding of previous studies^16–21,45. This finding can be explained by the fact that increased frequency of participation in leisure activities, such as frequent game of cards/mahjong and TV/radio entertainment, is particularly important to reduce risk factors such as social isolation for older adults and associated with a lower risk of cognitive impairment⁴⁶ and lesser feelings of loneliness⁴⁷. Engaging in leisure activity helps the elderly find hobbies and release psychological pressure, thereby reducing depression⁴⁶.

The study also demonstrated the indirect effect between leisure activity and depression in Chinese older adults can be mediated by ADL and SRH. In other words, leisure activity could improve ADL and SRH, and furthermore relieves their depression among elderly adults. The findings of this study enrich our understanding of the relationship between leisure activities and depression and provide a basis for policy interventions. Research shows that impaired ADL is a risk factor for the occurrence of depression⁴⁸, and ADL impairment has a negative impact on personal life, and elderly people become dependent on others due to their inability to fully take care of themselves, feeling worthless and hopeless, leading to negative emotions⁴⁹, while participating in leisure activities will improve the ADL ability of elderly people, thereby reducing the occurrence of depression. This also suggests that elderly people should actively participate in leisure activities, prevent ADL damage, and prevent depression.

SRH status has a mediating effect of 25.76% on the impact of leisure activities on depressive symptoms. In line with previous analyses conducted in Western countries, which indicated that SRH was negatively associated with depression among older adults^38,50, we further confirmed that SRH was negatively associated with depressive symptoms among older adults in China, and SRH can negatively predict depressive symptoms, consistent with previous studies³⁶. Given that, it is crucial to intervene to prevent depression when SRH worsens. Meanwhile, in order to reduce the occurrence of depressive symptoms, it is necessary to strengthen health education for the elderly, advocate for them to practice a healthy lifestyle, enhance their awareness of self health management, provide long-term care services that combine medical and elderly care, and improve their SRH level.

Strengths & Limitations

This study has several notable strengths. Firstly, it utilizes a large and representative sample from China, enhancing the generalizability of the findings and providing valuable references for similar research in other countries. Secondly, the study not only explores the direct relationship between leisure activities and depression among older adults but also analyzes the mediating roles of ADL and SRH. This multi-faceted approach enriches our understanding of the complex interactions among these variables.

However, this study has several limitations. First, the cross-sectional design limits causal inference; longitudinal data are needed to establish temporal relationships. Second, all variables were self-reported, which may introduce recall or social desirability biases. Third, the lack of clinical diagnoses of depression means that results reflect symptom severity rather than clinical cases. Future research should employ longitudinal designs and consider objective health measures to strengthen evidence for causal mechanisms.

Conclusion

This study’s results validate that elucidates the interconnections among leisure activities, ADL, SRH and depression among older adults in China. The findings underscore the significant positive influence of leisure activities on ADL and SRH and their role in reducing depression. Additionally, ADL and SRH was found to be a crucial factor in alleviating depression. These relationships highlight the partial and serial mediating effects of ADL and SRH on the link between leisure activities and depression.

The insights gained from this study can be instrumental in developing targeted health and physical education programs aimed at enhancing the mental well-being of older adults in China. Such programs should emphasize the promotion of leisure activities as a means to improve ADL and SRH and reduce depression. By addressing these factors, it is possible to create more effective interventions to support mental health among the elderly population, ultimately contributing to better overall quality of life.

Author contributions

YZ contributed to all aspects of the study, including designing this research. SS collected, processed and analyzed. ZJ material availability and funding. All authors have read and agreed to the published version of the manuscript.

Data availability

The datasets generated and/or analyzed during the current study are available in the Beijing University Open Research Data Platform repository, Center for Healthy Aging and Development, Beijing University, 2020, “Chinese Longitudinal Healthy Longevity Survey (CLHLS) in China”. https://doi.org/10.18170/DVN/WBO7LK. The datasets used are available from the first author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Conflict of interest

There was no conflict of interest between Yongduo Zhang, Shuo Sun and Zongqiang Jin and agreed to publish.

Consent for publication

Informed consent is obtained from all participants in the manuscript.

Ethics statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the the Ethics Committee of Peking University (IRB00001052-13074) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.