Role of Perceived Social Support on the Association between Physical Disability and Symptoms of Depression in Senior Citizens of Pakistan

Abstract

An emerging body of literature has implied that perceived social support is known as an upstream element of cognitive health. Various dimensions of perceived social support may have divergent influence on physical and cognitive health in later life. The present study aimed to investigate the mediating role of perceived social support on the relationship between physical disability and symptoms of depression in senior citizens of Pakistan. The data were collected from three metropolitan cities (Lahore, Faisalabad, Multan) in the Punjab province of Pakistan and 100 participants were approached from each city with a total sample size of 300. The results demonstrated that family support, friends’ support, and significant others’ support mediated the association between physical disability and symptoms of depression, with an indirect effect of 0.024, 0.058, and 0.034, respectively. The total direct and indirect effect was 0.493. Physical disability was directly associated with symptoms of depression and greater physical disability predicted a higher level of symptoms of depression. Perceived social support, including family support, friends’ support, and significant others’ support, showed an indirect association with symptoms of depression. Furthermore, family support and friends’ support were more significantly associated with symptoms of depression as compared to significant others’ support. The research discoveries have better implications for health care professionals, hospice care workers, and policy makers. A holistic approach is required to prevent senior citizens from late-life mental disorders.

Full text

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Int.J.Environ.Res.PublicHealth2020,17,1485;doi:10.3390/ijerph17051485www.mdpi.com/journal/ijerph
Article
RoleofPerceivedSocialSupportontheAssociation
betweenPhysicalDisabilityandSymptomsof
DepressioninSeniorCitizensofPakistan
AzamTariq1,TianBeihai1,*,NadeemAbbas2,SajjadAli3,WangYao4andMuhammadImran5
1DepartmentofSociology,CollegeofHumanitiesandSocialSciences,HuazhongAgriculturalUniversity,
Wuhan430070,China;azam_tariq@webmail.hzau.edu.cn
2InstituteofSocial&CulturalStudies,UniversityofthePunjab,Lahore54000,Pakistan;
nadeem544abbas@gmail.com
3CollegeofEconomicsandManagement,HuazhongAgriculturalUniversity,Wuhan430070,China;
sajjad@webmail.hzau.edu.cn
4DepartmentofSocialSecurity,CollegeofHumanitiesandSocialSciences,HuazhongAgricultural
University,Wuhan430070,China;18627064001@163.com
5DepartmentofComputerScienceandEngineering,ShanghaiJiaoTongUniversity,Shanghai200240,
China;Muhammad_imran@sjtu.edu.cn
*Correspondence:tianbeihai@mail.hzau.edu.cn;Tel.:+86‐189‐7156‐9599
Received:12January2020;Accepted:22February2020;Published:25February2020
Abstract:Anemergingbodyofliteraturehasimpliedthatperceivedsocialsupportisknownasan
upstreamelementofcognitivehealth.Variousdimensionsofperceivedsocialsupportmayhave
divergentinfluenceonphysicalandcognitivehealthinlaterlife.Thepresentstudyaimedto
investigatethemediatingroleofperceivedsocialsupportontherelationshipbetweenphysical
disabilityandsymptomsofdepressioninseniorcitizensofPakistan.Thedatawerecollectedfrom
threemetropolitancities(Lahore,Faisalabad,Multan)inthePunjabprovinceofPakistanand100
participantswereapproachedfromeachcitywithatotalsamplesizeof300.Theresults
demonstratedthatfamilysupport,friends’support,andsignificantothers’supportmediatedthe
associationbetweenphysicaldisabilityandsymptomsofdepression,withanindirecteffectof0.024,
0.058,and0.034,respectively.Thetotaldirectandindirecteffectwas0.493.Physicaldisabilitywas
directlyassociatedwithsymptomsofdepressionandgreaterphysicaldisabilitypredictedahigher
levelofsymptomsofdepression.Perceivedsocialsupport,includingfamilysupport,friends’
support,andsignificantothers’support,showedanindirectassociationwithsymptomsof
depression.Furthermore,familysupportandfriends’supportweremoresignificantlyassociated
withsymptomsofdepressionascomparedtosignificantothers’support.Theresearchdiscoveries
havebetterimplicationsforhealthcareprofessionals,hospicecareworkers,andpolicymakers.A
holisticapproachisrequiredtopreventseniorcitizensfromlate‐lifementaldisorders.
Keywords:perceivedsocialsupport;mediator;symptomsofdepression;physicaldisability;senior
citizens
1.Introduction
AccordingtotheUnitedNation,theglobalpopulationover60yearsofagewas962millionin
2017andisexpectedtobedoubleto2.1billionbytheyear2050.Two‐thirdsofthetotalolder
populationliveindevelopingcountries.Therapidprojectionsshowthatbytheyear2050,almost8
of10elderlypeoplewillberesidentsofdevelopingregions[1].Pakistanisadevelopingcountryand
thepopulationaged60oroverwas11.3millionin2017,anditisprojectedtoincreasetomorethan
43.3millionin2050,whichwillaccountfornearly16%oftheoverallpopulation[2].

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Thisrapiddemographictransitionhasledtoincreasedcomplicatedandinterconnected
problems,includingsocioeconomic,physical,social,andcognitivehealthproblemsofelderlypeople,
andpreviousstudiesdiscoveredthatdepressionintheelderlyhasbecomeaglobalpublichealth
problem[3–5].Aresearchrevealed16.52%life‐timeprevalenceofdepressioninelderlypeople.
However,theprevalenceofdepressionvariedamongcountries[6].InPakistan,theprevalenceof
depressioninseniorcitizensisrisingdaybyday,andmanystudieshavereported18%to66%inboth
ruralandurbansettings[7–10].Itisexpectedthatbytheyear2020,depressionwillbetheleading
burdenofdiseaseintheworld[11].Depressionisinterrelatedwithadversesocioeconomicoutcomes,
likeemotionalandcognitivesuffering,poverty,familyconflicts,riseinhealthcareexpenditure,and
deathrate[12].
Physicaldisabilityisdefinedasimpairmentsorlimitationsindailyactivitiesandrestrictedsocial
involvement[13].Theinabilitytoperformdailytasksofself‐careandlimitationsinanindividual’s
capacitytoparticipateinthesocialandphysicalenvironmentisalsoknownasphysicaldisability
[14].Thedeclineinphysicalhealthismostlyassociatedwithagingandactsasabigstressorinlater
life[15,16].Ithasbeenproventhatfailuretocarryoutactivitiesofdailyliving(ADL)and
instrumentalactivitiesofdailyliving(IADL)areassociatedwithdepressioninolderpeople[17,18].
Physicalorfunctionaldisabilityoftenleaveselderlypeoplevulnerabletodepression[19–22].Ithas
beenfoundthatanincreasedlevelofADLpredictsalowerlevelofdepression[23].Across‐sectional
studycarriedoutinChinawithasamplesizeof372elderlypeoplefoundthatlessdependencyin
activitiesofdailylivingwasassociatedwithlowerlevelofdepression[24].Furthermore,some
longitudinalstudiessupporttheargumentthatitleadstohighersymptomsinolderadults[25].The
giveninfluenceofphysicaldisabilityondepressionhighlightstheneedtofinddirectionstodealwith
it.
Socialsupportisoneofthefactorswhichinfluencessymptomsofdepressioninelderlypeople.
Socialsupportreferstotheseriesofaccessiblesupporttoapersonthroughtheirsocialrelationships
withotherpeople[26].Italsoincludesinformationorknowledge,emotionalaid,substantialhelp,
andself‐sufficiencythatindividualsgainthroughmutualrelationships[27].Perceivedsocialsupport,
alsoknownassubjectivesupport,isdefinedasthelevelofsatisfactionofbeingempathized,valued,
andsupportedinthesociety[28].Itrepresentshowmuchapersonfeelssafeandcompanionable[29].
Socialsupporthasreceivedsufficientattentionbecauseofitsfunctionofminimizingstressand
mentalhealthproblemsandpreventingtheharmfuleffectsofphysicaldisabilityonpsychological
well‐being[30].Perceivedsocialsupportplaystheroleofapowerfulstressreducerandhasbeen
foundtobeeffectiveinminimizingormediatingtheassociationbetweenphysicaldisabilityand
symptomsofdepression[31,32].AstudycarriedoutonTurkisholderpeoplewith102respondents
discoveredasignificanteffectofperceivedsocialsupportondepressionandfoundthatlower
perceivedsocialsupportwasassociatedwithgreaterdepression[29].Buildingupthisassociation,a
studyfoundthatsubjectivesupportmediatestherelationshipbetweenADLandsymptomsof
depressioninelderly[24].
Perceivedsocialsupportcanbefurtherdividedintothreedimensions,asfamilysupport,
friends’support,andsignificantothers’support[33].Accordingtothebestofourknowledge,there
havebeennostudiesdonetodiscovertheeffectsoffamilysupport,friends’support,andsignificant
others’supportontherelationshipbetweenphysicaldisabilityanddepressioninseniorcitizens
(peopleaged60orabove).
Accordingtothestress‐bufferinghypothesis,socialsupporthaspositiveeffectsonhealthand
well‐beingbyprotectingindividualsfromtheharmfuleffectsofstressors.Socialsupportisalso
consideredasacoppingsourceandphysicaldisabilityasastressor[34].So,itismandatorytofind
outwhatdimensionsofperceivedsocialsupportarelinkedwithphysicaldisabilityandsymptoms
ofdepression.
Theprimaryobjectiveofthepresentstudyistodiscoverwhetherperceivedsocialsupport
mediatestheassociationbetweenphysicaldisabilityandsymptomsofdepressioninseniorcitizens
livinginurbanareasoftheIslamicRepublicofPakistan.

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Thecurrentstudyfirsthypothesizesthatphysicaldisabilityissignificantlyassociatedwith
greatersymptomsofdepression(H1).Then,threedimensionsofperceivedsocialsupportcould
mediatetheassociationbetweenphysicaldisability(ADL,IADL)andsymptomsofdepression(H2).
Thisstudyfurtherhypothesizesthatfamilysupportisassociatedwithsymptomsofdepressionmore
significantlythanfriends’supportandsignificantothers’support(H3),asmentionedinthe
hypotheticalmodel(Figure1).Thediscoveriesofthisinvestigationwillhighlighttheroleof
perceivedsocialsupportonphysicaldisabilityandsymptomsofdepressionandisexpectedtobe
helpfulindevelopingpoliciestopromoteperceivedsocialsupportforthewell‐beingofsenior
citizens.

Figure1.Hypotheticalmodel.
2.MaterialsandMethods
2.1.StudyParticipants
Across‐sectionaldesignstudywascarriedoutoverfourmonthsin2018withasamplesizeof
300seniorcitizenparticipantsfromthreebigcities,includingprovincialcapitalcityLahore,
Faisalabad(industrialcity),andMultan,whichisthehistoricalcityandalsoknownasacityofsaints
inthePunjabprovinceofPakistan(Figure2).Theparticipantswereapproachedthroughapurposive
samplingtechniquetoperformaninterview‐basedquestionnairewiththehelpofthreeresearch
assistantswitharelevantfieldofstudy.Participantsaged60yearsorover(theagementionedin
PakistangovernmentseniorcitizenactandreferredbyUnitedNationsOrganization),witha
willingnesstoparticipateonavoluntarybasisandabilitytocommunicateinUrdu(nationallanguage
ofPakistan)wereincludedinthestudy.Seniorcitizenswithseverehearingandsightimpairment,
severephysicalinjuries,andterminalillnesswereexcludedfromthestudy.

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
Figure2.SurveymapofselectedcitiesinPunjabprovince,Pakistan(source:authors’own).
Allseniorcitizenswhowerewillingtoparticipateinthisinvestigationwereinformedaboutthe
objectivesofconductingresearch.Thepersonalandprivateinformationwasensuredtobekeptsecret
andaggregatedatawereused.
2.2.MeasurementTools
2.2.1.SymptomsofDepression
Theprimarydependentoutcomevariable“symptomsofdepression”inseniorcitizenswas
assessedviatheBeckdepressioninventory(BDI)scale[35].TheBDIscaleisastandardizedandself‐
reportedmeasurementtoolthatconsistsof21itemsrangingonafour‐pointscale,0to3,andahigher
scoreoftotal63scoresindicatesahigherlevelofsymptomsofdepression.Itisawidelyusedscale
forbothclinicalandresearchpurposesandmeasuresthepresenceofcognitive,vegetative,
psychomotor,andmotivationalfeaturesofdepression[7].TheBDIscalemeasuresthemoodof
subjectsfortheprevioustwoweeks[29].ThescalehasbeentranslatedintoUrdulanguage(Pakistan
nationallanguage)andhasbeenusedinpreviousresearchinthesamesetting[7].TheCronbach
alphaforthissamplewas0.86,whichindicatesitsreliability.
2.2.2.PhysicalDisability
Physicaldisabilitywasassessedthroughactivitiesofdailyliving(ADL),includingitssubscales
[36],andinstrumentalactivitiesofdailyliving(IADL)withsubscales[37].TheADLsubscale
measuressixtypesofabilities,includingtakingbaths,feeding,dressing,toileting,transferring,and
continence.TheIADLsubscaleisusedtomeasureeighttypesofcomplexactivities,liketelephone
use,goingshopping,transportation,financehandling,laundry,takingmedicine,foodpreparation,
andhousekeeping.Thescoresrangefrom1to4andtotalscoresare56.Thehigherobtainedscores
showgreaterphysicaldisability.TheCronbachalphaforthisstudywas0.85.
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2.2.3.PerceivedSocialSupport
Perceivedsocialsupportwasmeasuredbyusingamultidimensionalscaleofperceivedsocial
support(MSPSS)[38].Thisscalemeasurestheoverallscoreofperceivedsocialsupportincluding
threesubscales,Familysupport,Friendssupportandsignificantotherssupport.Thisscalehasbeen
translatedinUrdu.Furthermore,thisscalehasbeenusedinpreviousstudiesshowinggoodreliability
andpsychometricproperties[39,40].TheCronbachalphaforthecurrentsamplewas0.81.
2.3.AnalyticalTechniques
Thedataanalysiswascarriedoutthroughthestatisticalpackageforsocialsciences(IBMSPSS‐
21,IBMCorp.,Armonk,N.Y.,USA).Priortoexecutingkeyanalysis,descriptivestatisticswere
calculatedonsociodemographiccharacteristicstouncoverthedistributionofdifferentvariablesand
todetermineproportionsfortheprevalenceofdepression.Therange,mean(X),andstandard
deviation(SD)werefoundfortheperceivedsocialsupport,includingitssubscales(familysupport,
friends’support,significantothers’support),physicaldisability,andsymptomsofdepression.
Continuousvariableswereevaluatedthroughone‐wayanalysisofvariancewiththeStudent–
Newman–Keulstestforposthocmultiplecomparisons.Thecorrelationsbetweenphysicaldisability,
perceivedsocialsupport,includingitsdimensions(familysupport,friends’support,andsignificant
others’support),andsymptomsofdepressionweredetermined.
Multiplelinearregressionwasthenexecutedtodeterminethecontributionofphysicaldisability
andperceivedsocialsupport(familysupport,friends’support,significantothers’support)on
symptomsofdepression.Thesymptomsofdepressionwerekeptasadependentvariableinthis
analysis.PROCESSmodel‐4[41]wasusedtodiscoverthemediationeffectofthreedimensionsof
perceivedsocialsupportontheassociationbetweenphysicaldisabilityandsymptomsofdepression,
withsymptomsofdepressionasanoutcomevariable.
3.Results
Thesocio‐demographiccharacteristicsandsymptomsofdepressionforthecurrentsampleare
presentedinTable1.Themajorityoftheresearchparticipantsweremale(72%),theageofthe
respondentsrangedfrom60to90years,amongthem,51.6%werebetween60and69,33.6%were
between70and79years,andtheremaining14.6%were≥80yearsofage.Atotalof74.9%ofthe
respondentswereattheeducationlevelofhighschoolorless,whereasalmost25%oftherespondents
hadeducationabovehighschoollevel;55.6%participantsbelongedtoajointfamilysystem,38.6%
respondentshadafamilysizeofonetofourmembers,whereas48.6%hadfive–eight,and12.6%hada
familysizeof≥eightmembers;64.3%weremarried,39.3%werehouseholdhead,47.3%ofthe
respondentshadfamilyasasourceofincome,44%participantsbelongtothefamilywithtwoearning
hands;41.3%hadlessthan30,000PKR(PakistanRupees)andtheremainingrespondentshadmore
than30,000PKRmonthlyincome;27.6%oftherespondentswerelivingatadistancelessthan3Km
fromhospital,however,themajorityoftherespondents(52.6%)werelivingatthedistanceof4–7km
fromthehospital;14.6%oftherespondentswerenotsufferingfromanychronicdisease,whereas64.2%
hadatleastoneortwochronicdiseases,includingasthma,diabetes,andhypertension.Moreover,60%
oftheparticipantswerelivingwithaspouse,21.3%ofthemweredisabledbybirthorbecauseofan
accident,aseparateroomathomewasavailablefor52%oftheelderly,and62.6%oftherespondents
consideredtheirchildrenasfuturesecurity.
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Table1.Comparisonofdifferentsocio‐demographiccharacteristicswithdepressivesymptoms.
Socio‐DemographicVariablesNo.Percentage
(%)
Symptomsof
Depression
𝑿

± SD
Fp
Gender 
6.2860.013
Male2167233.14±8.67
Female842830.33±8.82
Age(Years) 
25.9280.000
60–6915551.629.58±8.72
70–7910133.633.60±7.70
80yearsorabove4414.639.25±6.85
Education 
10.9720.000
Primaryschoolorless5819.337.08±7.03
Middleschool8829.334.30±8.32
Highschool7926.329.07±7.94
Intermediateschool4113.629.14±10.20
Bachelor’sorabove3411.330.73±8.12
FamilyStructure 
1.2210.270Joint16755.631.85±8.55
Nuclear13344.332.98±9.07
FamilySize
3.9300.021
1–411638.632.59±8.95
5–814648.633.11±8.75
Above83812.628.71± 7.68
MaritalStatus
Married
Single/Divorced/Widowed

193
107

64.3
35.6

31.31±8.82
34.23±8.45
7.7490.006
Respondent’sStatus
IsHouseholdhead
IsnotHouseholdhead

118
182

39.3
60.6

31.23±8.76
33.08±8.76
3.1750.076
CurrentSourceofIncome
Salary
Pension
Agriculture/Property
Family

6459
35
142

21.3
19.6
11.6
47.3

29.93±8.25
29.67±8.29
33.34±8.40
34.31±8.85
6.2510.000
EarningHands
1
2
3

91
132
77

20.3
44
25.6

31.42±8.99
32.91±8.15
32.49±9.59
0.7830.458
MonthlyIncome
˂30,000
≥30,000

124
176

41.3
58.6

34.16±8.06
31.08±9.07
9.1440.003
DistancefromHospital
˂3km
4–7km
≥8km

83
158
59

27.6
52.6
19.6

31.71±9.03
33.09±8.88
31.28±8.14
1.2180.297
No.ofChronicdiseases
0
1
2
3

44
110
83
63

14.6
36.6
27.6
21

31.09±9.86
33.29±7.69
32.95±9.14
30.82±9.21
1.4890.218
Livingstatus
LivingwithSpouse
Livingwithother’s
(Children/Relatives)

180
120

60
40

29.68±8.96
36.35±6.81
47.9160.000
Physicaldisability(Birth/accidental)
Disabled
Non‐disabled

64
236

21.3
78.6

34.81±8.31
31.69±8.81
6.4610.012

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Smokinghabit
Smoker’s
Nonsmoker’s

130
170

43.3
56.6

32.45±8.68
32.28±8.90
0.0280.867
Childrenasafuturesecurity
Yes
No

188
112

62.6
37.3

30.51±8.75
35.44±7.98
23.7430.000
Separateroomathome
Available
Notavailable

156
144

52
48

31.50± 9.50
33.27±7.87
3.0590.081
Inresults,wecomparedthesocio‐demographicvariables,includinggender,age,levelof
education,familysystem,familysize,maritalstatus,respondentscurrentstatus,currentsourceof
income,totalearninghandsinfamily,monthlyhouseholdincome,distancefromhospital,number
ofchronicdiseases,livingstatus,physicaldisability,smokinghabit,separateroomathome,and
childrenasfuturesecurity,withthecriterionvariablesymptomsofdepression.Itwasfoundthatthe
familysystem,respondent’shouseholdstatus,totalearninghands,distancefromthehospital,
numberofchronicdiseases,smokinghabit,andhavingaseparateroomathomedidnotshow
significantassociationwithsymptomsofdepression.
Posthocmultiplecomparisonsfoundthatfemalerespondents,elderlyabovetheageof70years,
andtherespondentswithahighschoolorlowerlevelofeducationscoredsignificantlyhigheronthe
symptomsofdepressionscale.Therespondentswithafamilysizeofonetofour,
single/divorced/widowedstatus,andwithfamilyasthecurrentsourceofincomehadsignificantly
highersymptomsofdepression.Furthermore,therespondentswhosemonthlyincomewaslessthan
30,000PKR,livingwithothers(children/relatives),andinterestingly,non‐disabled,scoredhigheron
symptomsofdepression.Lastly,theparticipantswhoconsideredtheirchildrenasfuturesecurity
anddidnothaveaseparateroomathomescoredhighersymptomsofdepression.
Table2showsthePearsoncorrelationcoefficientanalysisamongphysicaldisability,perceived
socialsupport,familysupport,friends’support,significantothers’support,andsymptomsof
depression.Physicaldisabilityandsymptomsofdepressionweredirectlycorrelated(r=0.469,p<
0.01),signifyingthatgreaterphysicaldisabilityintheelderlywasdirectlyassociatedwithahigher
levelofsymptomsofdepression,whereasperceivedsocialsupport,familysupport,friends’support,
andsignificantothers’supportwereindirectlyassociatedwithsymptomsofdepression(r=−0.411,
−0.344,−0.343,−0.379,p<0.01),indicatingthatahigherlevelofperceivedsocialsupport,family
support,friends’support,andsignificantothers’supportwasassociatedwithalowerlevelof
symptomsofdepression.Thisstudyfoundanindirectcorrelationbetweenperceivedsocialsupport
andphysicaldisability(r=−0.432,p<0.01).Likewise,threedimensionsofperceivedsocialsupport
(familysupport,friends’support,significantothers’support)wereinverselycorrelatedwithphysical
disability(r=−0.177,−0.275,−0.263,p<0.01),suggestingthatgreaterphysicaldisabilitywas
associatedwithalowerleveloffamilysupport,friends’support,andsignificantothers’support.
Table2.DescriptivestatisticsandPearsoncorrelationanalysis.
VariablesRangeMeanSD
Perceived
Social
Support
Family
Support
Friends’
Support
Significant
Others’
Support
Symptoms
of
Depression
Physicaldisability
(ADL,IADL)22–5235.976.61−0.432**−0.177**−0.275**−0.263**0.469**
Perceivedsocial
support 21–7143.4410.03‐ 0.699**0.472**0.667**−0.411**
Familysupport4–2615.144.53‐ ‐0.231**0.480**−0.344**
Friends’support4–2613.035.34‐ ‐ ‐ 0.215**−0.343**
Significantothers’
support4–2615.723.95‐ ‐ ‐ ‐ −0.379**
Symptomsof
Depression15–5732.358.79‐ ‐ ‐ ‐ ‐
SD=Standarddeviation,**=Correlationissignificantat0.01level.

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Thesocio‐demographicvariableswithasignificantinfluenceonsymptomsofdepressionwere
involvedinamultiplelinearregressionmodel.Hence,thegender,age,levelofeducation,marital
status,whotheywerelivingwith,familysize,currentsourceofincome,averagemonthlyincome,
physicaldisability(birth/accidental),andchildrenasfuturesecuritywereconsideredconfounding
variablesandwerecontrolledinthecurrentanalysis.Priortorunningmultiplelinearregression,it
wasensuredthattherewasnoviolationofassumptionslikenormality,linearity,and
multicollinearity.Theresults(R2=0.452,F=10.935,p<0.01)showthesignificanceoftheregression
model.Adirectassociationwasfoundbetweenphysicaldisabilityandsymptomsofdepression(β=
0.244,p<0.01),aspredictedinH1,andalowerlevelofphysicaldisabilitywasassociatedwithalower
levelofsymptomsofdepressioninelderlypeople.Theresultsdemonstratethatfamilysupport(β=
−0.152,p<0.01),friends’support(β=−0.136,p<0.01),andsignificantothers’support(β=−0.120,p<
0.05)wereinverselyassociatedwithsymptomsofdepressionamongolderpeople.Moreover,family
support(β=−0.152)hadmorenegativeassociationwithsymptomsofdepressionascomparedto
friends’support(β=−0.136),andsignificantothers’support(β=−0.120)(Table3).


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Table3.Multiplelinearregressiononsymptomsofdepression.
DependentVariable:SymptomsofDepressionUnstandardizedCoefficientStandardizedCoefficient
B(SE)Β
Gender−2.503(0.944)−0.128**
Age(Years)(Ref.60‐69)
70–79
80orabove

−0.430(0.997)
2.899(1.480)

−0.023
0.117*
LevelofEducation(Ref.Primaryorless)
Middle(8Years)
Highschool(10years)
Highersecondaryschool(12years)
Bachelor’sorabove

0.977(1.268)
−3.074(1.313)
−2.749(1.507)
−1.207(1.731)

0.051
−0.154*
−0.108
−0.044
Maritalstatus −0.816(0.968)−0.045
Livingwith 1.516(1.064)0.085
Familysize(Ref.1–4members)
5–8
Above8

0.180(0.918)
−1.617(1.418)

0.010
−0.057
Currentsourceofincome(Ref.Salary)
Pension
Agriculture/property
Family

1.082(1.283)
2.191(1.536)
1.550(1.183)

0.049
0.080
0.088
Averagemonthlyincome(PKR)−1.478(0.855)−0.083
Physicaldisability(birth/accidental)−1.205(1.045)−0.056
Childrenasfuturesecurity0.617(0.915)0.034
Physicaldisability(ADL,IADL)0.325(0.078)0.244**
Familysupport−0.294(0.102)−0.152**
Friends’support−0.224(0.082)−0.136**
Significantothers’support−0.268(0.122)−0.120*
R20.452
F10.935**
Ref=Reference,SE=StandardError,**=p˂0.01,*=p˂0.05.
Themediatingeffectofthreedimensionsofperceivedsocialsupport(familysupport,friends’
support,significantothers’support)ontheassociationbetweenphysicaldisabilityandsymptomsof
depressionismentionedinTable4.PROCESSmacromodel‐4(v3.3)
(http://www.processmacro.org/download.html)wasusedtoanalyzethedirectandindirecteffectof
threedimensionsofperceivedsocialsupportandphysicaldisability[41].Thisanalysiswas
performedthroughbootstrappingstrategywith5000resamples.Statusofresidenceandaverage
monthlyincomewereusedascovariates.
Table4.MediationeffectanalysisbasedonPROCESS(Model4).
VariablesB(SE)LLCIULCI
Outcomevariable:Symptomsofdepression
Physicaldisability0.4952**(0.074)0.34830.6421
Averagemonthlyincome−2.7784**(0.883)−4.5172−1.0395
Statusofresidence3.4804**(1.005)1.50165.4591
R2
F
0.273
37.207**
Outcomevariable:Symptomsofdepression
Familysupport−0.296**(0.102)−0.498−0.094
Friends’support−0.287**(0.080)−0.445−0.128
Significantothers’support−0.331**(0.120)−0.568−0.093
Physicaldisability0.377**(0.071)0.2360.518
Averagemonthlyincome−2.621**(0.821)−4.238−1.004
Statusofresidence2.518**(0.948)0.6524.385
R2
F
0.379
29.902**
Ref=Reference,SE=StandardError,LLCI=Lowerlevelconfidenceinterval,ULCI=Upperlevel
confidenceinterval,**=p˂0.01.

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Theresultsindicatethesignificanceofoverallmodels(R
2
=0.273,0.379,F=37.207,29.902,p<
0.01).Itwasfoundthatphysicaldisabilitywasstronglyassociatedwithsymptomsofdepression(B
=0.495,p<0.01)beforeenteringperceivedsocialsupportintotheequation,whereasthiseffectwas
thenmediatedto(B=0.377,p<0.01)byfamilysupport(B=−0.296,p<0.01),friends’support(B=
−0.287,p<0.01),andsignificantothers’support(B=−0.331,p<0.01).Theindirecteffectoffamily
support,friends’support,andsignificantothers’supportwas0.024(−0.084×−0.296),0.058(−0.203×
−0.287),0.034(−0.103×−0.331),respectively.Thetotaldirectandindirecteffectwas0.493(0.377+
0.024+0.058+0.034).Theresultsdemonstrate,ashypothesizedinH2,thatthreedimensionsof
perceivedsocialsupport(familysupport,friends’support,significantothers’support)play
mediatingrolesontheassociationbetweenphysicaldisabilityandsymptomsofdepressioninsenior
citizens(Figure3).

Figure3.Mediatingeffectofperceivedsocialsupportaffectingphysicaldisabilityandsymptomsof
depressionamongseniorcitizensofPakistan(N=300).
4.Discussion
Thepresentresearchconcurrentlydiscoveredtheassociationsamongperceivedsocialsupport,
physicaldisability,andsymptomsofdepressionandexaminedthemediatingeffectoffamily
support,friends’support,andsignificantothers’supportontheassociationbetweenphysical
disabilityandsymptomsofdepressioninseniorcitizens.Controlvariableslikethestatusofresidence
andaveragemonthlyincome,ifnotincluded,couldperhapsconfusetheassociationsbetween
perceivedsocialsupport,physicaldisability,andsymptomsofdepression.
Thesociodemographiccharacteristicsthatweresignificantlyassociatedandshowedhigher
levelsofsymptomsofdepressionindicatethesecuresocialstatus,higherself‐adjustment,greater
adaptabilitytothesocialsituationsandtheproperutilizationofavailablesocialsupport.Hence,
unavailabilityofthesameleadstogreatermentaldistress[42].Therisksoflate‐lifedepressionmay
beminimizedbyimprovingsocialrelationships,strengtheningties,andmostimportantly,enhancing
theutilizationofexistingsocialsupportratherthanstipulatingotherresourcesofsupport[24].
Thecurrentstudydiscoveredasignificantdirectassociationbetweenphysicaldisabilityand
symptomsofdepressionbyconfirmingthepreviousresearchfindingsoftheassociationbetween
limitationsinactivitiesandsocio‐psychologicalproblems[17,24].AstudydoneinPakistanonrural
elderlypeoplewhichincluded146respondentsfoundadirectrelationshipbetweenphysical
disabilityanddepression[43].Furthermore,astudyfoundsimilarresultsthatlowerADL(activities
ofdailyliving)functioningwasassociatedwithagreaterlevelofdepressionintheelderly[29],and
ithasanegativeimpactoncognitivehealthandisafundamentalcauseofsocio‐psychological
problemsinolderpeople[19,21,22,44].

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Thethreedimensionsofperceivedsocialsupport(familysupport,friends’support,and
significantothers’support)werefoundtobeinverselyassociatedwithsymptomsofdepression.A
studycarriedonTurkishelderlywith102participantsfoundthathigherperceivedsocialsupport
predictedlowerlevelofdepression[29].Furthermore,subjectivesupport(perceivedsocialsupport)
showedaninverserelationshipbetweenactivitiesofdailylivinganddepressivesymptomsin
Chineseelderly[24].Inaddition,ourfindingsshowedthatfamilysupportandfriends’supporthave
moresignificantassociationswithsymptomsofdepressionascomparedtosignificantothers’
support.Citizenwelfaretrustconductedresearchanddiscoveredthatalmost98%ofthesenior
citizensofPakistanfavorlivingwithfamilyratherthanstayingatoldagehomesorsomewhereelse
[45].Sufficientliteratureisavailablesuggestingthatfamilysupportandinformalfriendsupportare
theprimarysourcesofemotionalsupportfortheelderly[46–48].Moreover,itwasfoundthatfamily
supportandfriends’supportisimportantforelderlypeopleofAsia[49–51].Conventionally,elderly
peoplemostlyseekcareandsupportfromthefamilymembers[52].
Thefindingsofthemediationeffectmodelshowthatfamilysupport,friends’support,and
significantothers’supportmediatedtheeffectontherelationshipbetweenphysicaldisabilityand
symptomsofdepression.Lowerphysicaldisabilitywassignificantlyassociatedwithalowerlevelof
symptomsofdepression.Astudyconductedon372Chineseelderlyfoundthatperceivedsocial
supportandutilizationofsupportmediatedtherelationshipbetweenimpairmentofADLand
depression[24].Ourresearchcontributestoexistingliteraturewithin‐depthdiscoveriesandhas
imperativeinferencesforgeriatricprofessionals,careproviders,andpolicyinterventions,as
perceivedsocialsupportismoreacquiescenttocope.Previousstudiesfocusedondifferent
dimensionsofsocialsupportandmostlycheckedthedirecteffect,buttherecentinvestigationis
uniqueonthebasisofitsobjectivesandmethodology.Ourfindingssuggestthatintheabsenceof
anyofthethreedimensionsofperceivedsocialsupport,seniorcitizenswithphysicaldisabilityhave
agreaterriskofsufferingfromsymptomsofdepressioninlateryearsoflife,andemphasizethe
significanceoftheperceivedsupportfromfamily,friends,andsignificantotherstopreventphysical
andcognitivehealthobstaclesinlatelife.
Thecurrentresearchhasstrengthsandsomelimitations.Accordingtoourknowledge,basedon
theexistingliterature,thisisthefirst‐everstudy,especiallyforthePakistancontext,whichhas
investigatedtheroleofperceivedsocialsupportontheassociationbetweenphysicaldisabilityand
depressioninseniorcitizensofthreemetropolitancitiesofthePunjabprovinceofPakistan.This
researchfilledtheliteraturegapfromadifferentpointofview,byfindingtheinfluenceofphysical
disabilityonsymptomsofdepressionratherthanfindingtheinfluenceofsymptomsofdepression
onphysicaldisability,asinpreviousstudies.Inlimitations,thedatawerecollectedfromthree
differentcities,whichmayaffectthegeneralizabilityofthefindings.Furthermore,thesamplesizeof
thestudymaybeconsideredasalimitation,andthecross‐sectionalapproachcanaffectthedirect
casualevidence;thus,furtherstudiesbasedonthelongitudinalapproachandwithalargersample
sizearerecommendedtodiscovercausality.
5.Conclusions
Thecurrentstudyattemptedtodiscovertheroleofperceivedsocialsupport(familysupport,
friends’support,significantothers’support)asamediatorontheassociationbetweenphysical
disabilityandsymptomsofdepressioninseniorcitizensofPakistan.Themajordiscoveriesinthis
researchmaynotbesurprising,becausePakistan’scultureisbasedoncollectivism,asacollectivist
culturereferstothestructureofsocietyinwhichindividualsgiveprioritytocommitment,
conformity,andgrouployalty,andpossessionofasenseofbelongingratherstayinginisolation[53].
Currently,rapiddemographicchangetoindividualismandthenuclearfamilysystemhasledsenior
citizenstosufferfromsocialisolation,withalackofperceivedsocialsupport.Ourfindingssuggest
thatallthreedimensions,familysupport,friends’support,andsignificantothers’support,of
perceivedsocialsupportareimportanttomediatetheassociationbetweenphysicaldisabilityand
symptomsofdepression.Thefindingsfacilitatetheevidencethatperceivedsocialsupport,including
itsdimensions,haspassiveconsequencesonphysicallimitationsandsymptomsofdepressionamong

Int.J.Environ.Res.PublicHealth2020,17,148512of14
seniorcitizens.Furthermore,itwasfoundthatalowerlevelofperceivedsocialsupportleadsto
greatersymptomsofdepression.
Inshort,themajordiscoveriesrevealedthatperceivedsocialsupportanditsdimensionsare
negativelycorrelatedwithsymptomsofdepression,whilephysicaldisabilityshowedadirect
associationwithsymptomsofdepressionandthethreedimensionsofperceivedsocialsupportplay
theroleofmediatorontheassociationbetweenphysicaldisabilityandsymptomsofdepression.The
findingsrevealthedifficultiesinthelivesfacedbyseniorcitizens.Developinginterventionpolicies
andprogramstosafeguardseniorcitizensfromdebilitatingeffectsintheabsenceofperceivedsocial
supportandprovidingbothmaterialandnonmaterialaidforindependentlivingtodiminishthe
vulnerabilitytophysicalandcognitivehealthdisordersinseniorcitizensarehighlyneededto
facilitatethemwithabetterqualityoflifeintheirlateyearsoflife.
AuthorContributions:Conceptualization,A.T.;datacuration,A.T.andW.Y.;formalanalysis,A.T.;
investigation,N.A.andS.A.;methodology,N.A.;software,W.Y.andM.I.;supervision,T.B.;validation,S.A.;
writing—originaldraft,A.T.;writing—reviewandediting,T.B.Allauthorshavereadandagreedtothe
publishedversionofthemanuscript.
Funding:Thisresearchreceivednoexternalfunding.
Acknowledgments:TheauthorsacknowledgeMuhammadZubair(CollegeofVeterinaryMedicine,Huazhong
AgriculturalUniversity,Wuhan,China)andMuhammadFaisal(PostdoctoralResearchscientist,TheOhioState
UniversityWexnerMedicalCenter,Ohio,Columbus,USA)fortheirguidanceandmoralsupportthroughout
theresearch.Furthermore,theauthorsaregratefultotheanonymousreviewersfortheirhelpfulcommentsand
suggestionsonanearliermanuscript.
ConflictsofInterest:Theauthorsdeclarednoconflictofinterestinthismanuscript.
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