The effect of perceived social support on frailty and depression: A multicategorical multiple mediation analysis


      • The cross-sectional study was conducted in rural areas of China.
      • Significant others' support mediated the relationship between frailty and depression.
      • The mediating effects of family support and friends support were not observed.
      • The daughter's support for the elderly should be valued.


      The mediating effects of three sources of perceived social support on frailty severity and depression were examined. Conducted in rural China, data on 570 frail older women were studied. Results showed that significant others' support (mainly daughters) (β = 0.177 for frailty score = 3) mediated the relationship between frailty severity and depression, and the 95 % bias-corrected bootstrap confidence intervals did not straddle zero (0.013–0.419), while the mediating effects of family support (mainly sons) and friends support were not observed. Support from daughters contributes to frail mothers' mental health.


      MMSE (Mini-Mental State Examination), GDS (Geriatric Depression Scale), MSPSS (Multidimensional Scale of Perceived Social Support), BMI (Body mass index), CCI (Charlson Comorbidity Index), CA-CCI (Combined Age Charlson Comorbidity Index), SD (Standard deviation), CI (Confidence interval)


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Psychiatric Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Antonucci T.C.
        • Fuhrer R.
        • Dartigues J.F.
        Social relations and depressive symptomatology in a sample of community-dwelling french older adults.
        Psychology and Aging. 1997; 12: 189-195
        • Bai X.
        • Lai D.W.L.
        • Guo A.
        Ageism and depression: Perceptions of older people as a burden in China.
        Journal of Social Issues. 2016; 72: 26-46
        • Balsamo M.
        • Cataldi F.
        • Carlucci L.
        • et al.
        Assessment of late-life depression via self-report measures: A review.
        Clinical Interventions in Aging. 2018; 13: 2021-2044
        • Baron R.M.
        • Kenny D.A.
        The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.
        Journal of Personality and Social Psychology. 1986; 51: 1173-1182
        • Bian F.J.
        • Logan Y.B.
        Intergenerational relations in urban China: Proximity, contact, and help to parents.
        Demography. 1998; 35: 115-124
        • Bisschop M.I.
        • Kriegsman D.M.
        • Beekman A.T.
        • et al.
        Chronic diseases and depression: The modifying role of psychosocial resources.
        Soc Sci Med. 2004; 59: 721-733
        • Bolger N.
        • Zuckerman A.
        • Kessler R.C.
        Invisible support and adjustment to stress.
        Journal of Personality and Social Psychology. 2000; 79: 953-961
        • Brown P.J.
        • Roose S.P.
        • O'Boyle K.R.
        • et al.
        Frailty and its correlates in adults with late life depression.
        The American Journal of Geriatric Psychiatry. 2020; 28: 145-154 2019.10.005
        • Brummel N.E.
        • Bell S.P.
        • Girard T.D.
        • et al.
        Frailty and subsequent disability and mortality among patients with critical illness.
        American Journal of Respiratory and Critical Care Medicine. 2017; 196: 64-72
        • Chappell N.L.
        • Kusch K.
        The gendered nature of filial piety-a study among Chinese Canadians.
        Journal of Cross-cultural Gerontology. 2007; 22: 29-45
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        Journal of Chronic Diseases. 1987; 40: 373-383
        • Chi I.
        • Chou K.L.
        Social support and depression among elderly Chinese people in Hong Kong.
        International Journal of Aging & Human Development. 2001; 52: 231-252 -G2UP-37QV
        • Chu J.H.
        Prenatal sex determination and sex-selective abortion in rural central China.
        Population and Development Review. 2001; 27: 259-281 -4457.2001.00259.x
        • Clegg A.
        • Young J.
        • Iliffe S.
        • et al.
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762
        • Cohen S.
        • McKay G.
        Social support, stress, and the buffering hypothesis: A theoretical analysis.
        in: Baum A. Taylor S.E. Singer J. Handbook of psychology and health. Erlbaum, Hillsdale, NJ1984: 253-268
        • Cohen S.
        • Wills T.A.
        Stress, social support, and the buffering hypothesis.
        Psychological Bulletin. 1985; 98: 310-357
        • Comman J.C.
        • Goldman N.
        • Weinstein M.
        • Lin H.
        Perception of elderly Taiwanese about the availability of social support.
        Princeton University, Princeton2001 (Accessed on 4 Sep 2021)
        • Cong Z.
        • Silverstein M.
        Intergenerational time-for-money exchanges in rural China: Does reciprocity reduce depressive symptoms of older grandparents?.
        Research in Human Development. 2008; 5: 6-25
        • Cong Z.
        • Silverstein M.
        Caring for grandchildren and intergenerational support in rural China: A gendered extended family perspective.
        Ageing and Society. 2011; 32: 425-450
        • Ding Y.
        Personal life satisfaction of China’s rural elderly: Effect of the new rural pension programme.
        Journal of International Development. 2016; 29: 52-66
        • Dong L.
        • Qiao X.
        • Tian X.
        • et al.
        Cross-cultural adaptation and validation of the FRAIL scale in Chinese community-dwelling older adults.
        Journal of the American Medical Directors Association. 2018; 19: 12-17
        • Ebenstein A.
        • Leung S.
        Son preference and access to social insurance: Evidence from China’s rural pension program.
        Population and Development Review. 2010; 36: 47-70
        • Feldman M.W.
        • Tuljapurkar S.
        • Li S.
        • et al.
        Son preference, marriage and intergenerational transfer in rural China.
        in: Gauthier A.H. Chu C.Y.C. Tuljapurkar S. Son preference, marriage and intergenerational transfer in rural China. Springer, Dordrecht, Netherlands2007: 139-162
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician.
        Journal of Psychiatric Research. 1975; 12: 189-198
        • Fritz M.S.
        • Mackinnon D.P.
        Required sample size to detect the mediated effect.
        Psychological Science. 2007; 18: 233-239
        • Gale C.R.
        • Cooper C.
        • Sayer A.A.
        Prevalence of frailty and disability: Findings from the English longitudinal study of ageing.
        Age and Ageing. 2015; 44: 162-165
        • Ghasemi S.
        • Mohammadi N.K.
        • Shahboulaghi F.M.
        • Ramezankhani A.
        Older adults’ perception of their needs in Tehran: A cry for emotional and social support.
        Global Journal of Health Science. 2016; 9: 134
        • Goldsmith D.J.
        • Dun S.A.
        Sex differences and similarities in the communication of social support.
        Journal of Social and Personal Relationships. 1997; 14: 317-337
        • Gui S.X.
        • Ni P.
        The “filling” theory of economic support for the elderly.
        Journal of Population Research. 1995; 19: 10-16
        • Hayes A.F.
        PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling [white paper].
        (Retrieved from)2012
        • Hayes A.F.
        • Preacher K.J.
        Statistical mediation analysis with a multicategorical independent variable.
        The British Journal of Mathematical and Statistical Psychology. 2014; 67: 451-470
        • He B.
        • Ma Y.
        • Wang C.
        • et al.
        Prevalence and risk factors for frailty among community-dwelling older people in China: A systematic review and meta-analysis.
        The Journal of Nutrition, Health & Aging. 2019; 23: 442-450
        • Hoogendijk E.O.
        • Muntinga M.E.
        • van Leeuwen K.M.
        • et al.
        Self-perceived met and unmet care needs of frail older adults in primary care.
        Archives of Gerontology and Geriatrics. 2014; 58: 37-42
        • Hoogendijk E.O.
        • Suanet B.
        • Dent E.
        • et al.
        Adverse effects of frailty on social functioning in older adults: Results from the longitudinal aging study Amsterdam.
        Maturitas. 2016; 83: 45-50
        • Horowitz L.M.
        • Krasnoperova E.N.
        • Tatar D.G.
        • et al.
        The way to console may depend on the goal: Experimental studies of social support.
        Journal of Experimental Social Psychology. 2001; 37: 49-61
        • Huang C.Y.
        • Lee W.J.
        • Lin H.P.
        • et al.
        Epidemiology of frailty and associated factors among older adults living in rural communities in Taiwan.
        Archives of Gerontology and Geriatrics. 2020; 87103986
        • Hubbard R.E.
        • Rockwood K.
        Frailty in older women.
        Maturitas. 2011; 69: 203-207
        • Ji L.
        • Qiao X.
        • Jin Y.
        • et al.
        Age differences in the relationship between frailty and depression among community-dwelling older adults.
        Geriatric Nursing. 2020; 41: 485-489
        • Jia F.
        • Shi X.
        • Li X.
        • Wang B.
        • Liu F.
        • Cao F.
        Physical frailty and the risk of major depressive disorder: The Irish longitudinal study on ageing.
        Journal of Psychiatric Research. 2020; 125: 91-95
        • Jin Y.
        • Si H.
        • Qiao X.
        • et al.
        Relationship between frailty and depression among community-dwelling older adults: The mediating and moderating role of social support.
        Gerontologist. 2020; 60: 1466-1475
        • Jing Z.
        • Li J.
        • Wang Y.
        • et al.
        The mediating effect of psychological distress on cognitive function and physical frailty among the elderly: Evidence from rural Shandong, China.
        Journal of Affective Disorders. 2020; 268: 88-94
        • Knodel J.
        • Chayovan N.
        Intergenerational relationships and family care and support for Thai elderly.
        Ageing International. 2009; 33: 15-27
        • Kunkel A.W.
        • Burleson B.R.
        Social support and the emotional lives of men and women: An assessment of the different cultures perspective.
        in: Canary D.J. Dindia K. Sex differences and similarities in communication. Erlbaum, Mahwah, NJ1998: 101-125
        • Kunkel A.W.
        • Burleson B.R.
        Assessing explanations for sex differences in emotional support: A test of the different cultures and skill specialization accounts.
        Human Communication Research. 1999; 25: 307-340
        • Liu D.
        • Xi J.
        • Hall B.J.
        • et al.
        Attitudes toward aging, social support and depression among older adults: Difference by urban and rural areas in China.
        Journal of Affective Disorders. 2020; 274: 85-92
        • Liu J.
        Ageing, migration and familial support in rural China.
        Geoforum. 2014; 51: 305-312
        • Liu J.
        Intimacy and intergenerational relations in rural China.
        Sociology. 2016; 51: 1034-1049
        • Luber M.P.
        • Hollenberg J.P.
        • Williams-Russo P.
        • et al.
        Diagnosis, treatment, comorbidity, and resource utilization of depressed patients in a general medical practice.
        International Journal of Psychiatry in Medicine. 2000; 30: 1-13
        • Luo B.
        • Zhan H.
        Filial piety and functional support: Understanding intergenerational solidarity among families with migrated children in rural China.
        Ageing International. 2011; 37: 69-92
        • Ma L.
        • Tang Z.
        • Zhang L.
        • et al.
        Prevalence of frailty and associated factors in the community-dwelling population of China.
        Journal of the American Geriatrics Society. 2018; 66: 559-564
        • McGivney S.A.
        • Mulvihill M.
        • Taylor B.
        Validating the GDS depression screen in the nursing home.
        Journal of the American Geriatrics Society. 1994; 42: 490-492 5415.1994.tb04969.x
        • Meadows S.O.
        Is it there when you need it?.
        Journal of Family Issues. 2009; 30: 1070-1097
        • Miller L.R.
        Definition of family.
        in: Encyclopedia of Family Studies. 1–7. 2016
        • Mitchell J.
        • Mathews H.F.
        • Yesavage J.A.
        A multidimensional examination of depression among the elderly.
        Research on Aging. 1993; 15: 198-219
        • Morley J.E.
        • Malmstrom T.K.
        • Miller D.K.
        A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.
        The Journal of Nutrition, Health & Aging. 2012; 16: 601-608
        • National Bureau of Statistics
        Major data from the seventh National census in 2020.
        (Retrieved from)2021
        Date accessed: May 10, 2022
        • O'Briena R.M.
        Caution regarding rules of thumb for variance inflation factors.
        Quality and Quantity. 2007; 41: 673-690
        • Ohrnberger J.
        • Fichera E.
        • Sutton M.
        The relationship between physical and mental health: A mediation analysis.
        Social Science & Medicine. 2017; 195: 42-49
        • Ross C.E.
        • Mirowsky J.
        Family relationships, social support and subjective life expectancy.
        Journal of Health and Social Behavior. 2002; 43: 469-489
        • Shimada H.
        • Lee S.
        • Doi T.
        • et al.
        Prevalence of psychological frailty in Japan: NCGG-SGS as a Japanese National Cohort Study.
        Journal of Clinical Medicine. 2019; 8: 1554
        • Silverstein M.
        • Cong Z.
        • Li S.
        Intergenerational transfers and living arrangements of older people in rural China: Consequences for psychological well-being.
        The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences. 2006; 61: S256-S266
        • Siriwardhana D.D.
        • Hardoon S.
        • Rait G.
        • et al.
        Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: A systematic review and meta-analysis.
        BMJ Open. 2018; 8e018195
        • Soysal P.
        • Veronese N.
        • Thompson T.
        • et al.
        Relationship between depression and frailty in older adults: A systematic review and meta-analysis.
        Ageing Research Reviews. 2017; 36: 78-87
        • Sun R.
        Worry about medical care, family support, and depression of the elders in urban China.
        Research on Aging. 2004; 26: 559-585
        • Tang D.
        • Lin Z.
        • Chen F.
        Moving beyond living arrangements: The role of family and friendship ties in promoting mental health for urban and rural older adults in China.
        Aging & Mental Health. 2020; 24: 1523-1532
        • Taylor S.E.
        Social support: A review.
        in: Friedman H.S. The Oxford handbook of health psychology. Oxford University Press, 2011: 189-214
        • Thoits P.A.
        Dimensions of life events that influence psychological distress: An evaluation and synthesis of the literature.
        in: Kaplan H.B. Psychosocial siress: Trends in theory and research. Academic Press, New York, NK1983: 33-103
        • Thoits P.A.
        Stress, coping, and social support processes: Where are we? What next?.
        Journal of Health and Social Behavior. 1995; 35: 53-79
        • Tse C.W.
        Migration and health outcomes of left-behind elderly in rural China.
        SSRN Elect J. 2013; (n. pag)
        • Turner R.J.
        • Turner J.B.
        Social integration and social support.
        in: Aneshensel C.S. Phelan J.C. Handbook of the sociology of mental health. Kluwer Academic, New York, NK1999: 301-319
        • Vaughan L.
        • Corbin A.L.
        • Goveas J.S.
        Depression and frailty in later life: A systematic review.
        Clinical Interventions in Aging. 2015; 10: 1947-1958
        • Wong O.M.
        Gender and intimate caregiving for the elderly in Hong Kong.
        Journal of Aging Studies. 2005; 19: 375-391
        • Woods N.F.
        • LaCroix A.Z.
        • Gray S.L.
        • et al.
        Frailty: Emergence and consequences in women aged 65 and older in the Women's Health Initiative observational study.
        Journal of the American Geriatrics Society. 2005; 53: 1321-1330
        • Xie Y.
        • Zhu H.
        Do sons or daughters give more money to parents in urban China?.
        Journal of Marriage and the Family. 2009; 71: 174-186
        • Yesavage J.A.
        • Brink T.L.
        • Rose T.L.
        • et al.
        Development and validation of a geriatric depression screening scale: A preliminary report.
        Journal of Psychiatric Research. 1982; 17: 37-49
        • Yi Z.
        • George L.
        • Sereny M.
        • Gu D.
        • Vaupel J.W.
        Older parents enjoy better filial piety and care from daughters than sons in China.
        American Journal of Medical Research. 2016; 3: 244-272
        • Zhan H.J.
        • Montgomery R.J.V.
        Gender and elder care in China: The influence of filial piety and structural constraints.
        Gender and Society. 2003; 17: 209-229
        • Zhang W.
        • Li S.
        • Silverstein M.
        The effects of inter-generational support on the mortality of older people in rural China.
        Asian Population Studies. 2005; 1: 325-338
        • Zhao Y.
        • Hu H.
        • Smith J.P.
        • Strauss J.
        • Yang G.
        Cohort profile: The China health and retirement longitudinal study (CHARLS).
        International Journal of Epidemiology. 2014; 43: 61-68
        • Zhou K.
        • Li H.
        • Wei X.
        • et al.
        Reliability and validity of the multidimensional scale of perceived social support in Chinese mainland patients with methadone maintenance treatment.
        Comprehensive Psychiatry. 2015; 60: 182-188 ch.2015.03.007
        • Zimet G.D.
        • Dahlem N.W.
        • Zimet S.G.
        • et al.
        The multidimensional scale of perceived social support.
        Journal of Personality Assessment. 1988; 52: 30-41