The Mechanism Of Depression Among Frail Older Women In Rural Areas Based Self-transcendence Theory And The Intervention Of Depression And Frailty

Objective:（1）To estimate the status of depressive symptoms among frail older women in rural areas.（2）Based on the self-transcendence theory,we aimed to analyze the mechanism of depression in the frail.（3）After the introduction and cultural adaptation of the instrumental reminiscence intervention program,we aimed to examine the influence of the intervention program on self-transcendence,depression and frailty,and to verify the role of self-transcendence as a target index in the influence of intervention on depression.Methods:（1）The survey of depressive symptoms of frail elderly women in rural areas:Between August and September 2020,there were 713potentially frail older women in rural communities of He’nan province on-site questionnaire survey,the information about their demographic sociology,frailty status,complications indexs,depressive symptoms,self-transcendence and cognitive function were collected,and the trend chi-square test and multiple linear regression method were used to examine the relationship between frailty scores and depressive symptoms rate and to examine the related factors of depressive symptoms,respectively.（2）The mechanism study of depressive symptoms among the frail based on the self-transcendence theory,and the sequential interpretation design with mixed methods was used:In the quantitative section,using the cross-sectional survey data,the traditional mediating effect analysis and the bootstrap method were used to examine the relationship between self-transcendence and frailty severity and depressive symptoms.In order to understand the quantitative results,a descriptive phenomenology method was used in September 2020,interviews were conducted with 12frail older women,and themes were extracted using the thematic analysis method.（3）The cultural adaptation of instrumental reminiscence program with Hong Kong version:Between October and November 2020,the FMAP guide of the psychological intervention was used,which includes five steps,namely,collaborate with stakeholders and generate information,integrate the information and culturally adaptate the program,the stakeholders conduct a review on the initial adaptation version and further revise it,test the culturally adapted intervention,integrate feedback and form the final version.（4）The intervention study:In this non-randomized,concurrent controlled study,47 frail older women with clinically significant depressive symptoms were included.Between December 2020 and April2021,the intervention group（n=23）was treated with the instrumental reminiscence therapy and the health education,which was performed once a week with about 120 minutes each time for 6 weeks,while the control group（n=24）with the health education once a week,about 60minutes each time,for 6 weeks.Data on depressive symptoms and self-transcendence were collected at baseline,3 weeks during the intervention,immediately after the intervention,3 months after the intervention,and the data on frailty at baseline,3 months after intervention were also collected.The effects of the intervention were analyzed using the generalized estimation equation,with the role of self-transcendence as a target index in the influence of intervention on depressive symptoms using the traditional mediating effect analysis.All analyses were performed using the per-protocol set.WPS excels and document were used for the input and storage of the above data,and SPSS 26.0,PROCESS V3.4.1 plug-in and Nvivo12 were used for the data analysis.Significance levelα=0.05 for all tests.Results:（1）Among 570 eligible samples,the overall rate of depressive symptoms among frail older women in rural areas was 51.9%.With the increase of frailty severity,the rate showed an increasing trend.The influencing factors of depressive symptoms included comorbidity index（β=0.204,p<0.001）,social support（β=-0.423,p<0.001）,physical conditi-on（β=0.201,p<0.001）,and frailty（β=0.156,p<0.001）.（2）In the quantitative section,only the interpersonal dimension mediated the relationship between frailty severity and depressive symptoms（β=0.617,p<0.001）.In the qualitative section,two themes and eight sub-themes were generated.The two themes were"connections outside of the present self"and"transcend one’s own limitations and inadequacies".The"transcend one’s own limitations and inadequacies"included six sub-themes,namely"frailty,being negative vs positive acceptance","daily life,the low level adjustment vs try one’s best to adjust","acceptance and adjustment of body function","concerns about the lack of caregivers as frailty worsens","life situation,dissatisfaction vs satisfaction","past gains and losses,care vs relief";The"connections outside of the present self"included two sub-themes,which were"social interaction,low level vs normal"and"negative life values".（3）Following five steps of the FMAP guide,the cultural adaptation was made to the Hong Kong version of instrumental reminiscence therapy,and the mainland version of the program was formed.（4）The GEE model analysis with depressive symptoms as the dependent variable showed that the main effect of time（p<0.001）and the interaction of group×time（p<0.001）were statistically significant.The intra-group comparison with marginal mean pairing showed that the depressive symptoms scores of the intervention group at T₁（mean difference=-1.04,p<0.001）,T₂（mean difference=-2.57,p<0.001）and T₃（mean difference=-3.35,p<0.001）were lower than those of T₀,with the scores at T₂（mean difference=-1.52,p<0.001）and T₃（mean difference=-2.30,p<0.001）lower than those at T₁,and the scores at T₃lower than those at T₂（mean difference=-0.78,p=0.018）.The depressive symptoms scores of the control group at T₁（mean difference=-0.29,p=0.002）and T₂（mean difference=-0.83,p<0.001）were lower than those at T₀,with the scores at T₂（mean difference=-0.54,p<0.001）lower than those at T₁,and the scores at T₃higher than those at T₂（mean difference=0.71,p<0.001）.The intergroup comparisons of marginal estimated mean pairs showed there were lower depressive symptoms scores in the intervention group than in the control group at T₂（mean difference=-2.68,p=0.036）and T₃（mean difference=-4.17,p=0.001）.The GEE model with self-transcendence as the dependent variable showed that the main effect of time（p<0.001）and group（p=0.001）,and the interaction of group×time（p<0.001）were all statistically significant.The intra-group comparison of marginal estimated mean pairing showed that self-transcendence scores of the intervention group at T₁（mean difference=0.83,p<0.001）,T₂（mean difference=2.04,p<0.001）and T₃（mean difference=2.48,p<0.001）were higher than those of T₀,with the scores at T₂（mean difference=1.22,p<0.001）and T₃（mean difference=1.65,p<0.001）higher than those at T₁,and the scores at T₃higher than those at T₂（mean difference=0.43,p=0.001）.The scores of the control group at T₁（mean difference=0.25,p=0.005）,T₂（mean difference=0.83,p<0.001）and T₃（mean difference=0.17,p=0.028）were higher than those of T₀,with the scores at T₂higher than those at T₁（mean difference=0.58,p<0.001）,while the scores at T₃lower than those at T₂（mean difference=-0.67,p<0.001）.The intergroup comparison of marginal estimated mean pairing showed that,although the self-transcendence scores of the intervention group at T₀（mean difference=3.02,p=0.012）were higher than those of the control group,the mean scores difference of self-transcendence between groups increased gradually at T₁（mean difference=3.60,p=0.003）,T₂（mean difference=4.23,p=0.001）,and T₃（mean difference=5.34,p<0.001）.The effect of the instrumental reminiscence intervention on depressive symptoms was partly caused by the self-transcendence index.In addition,the effect of instrumental reminiscence intervention on frailty was not statistically significant.Conclusion:（1）The rate of depressive symptoms among frail elderly women in rural areas is worrisome and deserves our attention.（2）The interpersonal self-transcendence mediates the relationship between frailty severity and depressive symptoms,that is,frail women with depressive symptoms tend to be deficient in self-acceptance and the adjustment to personal problems.（3）After the cultural adaptation,the instrumental reminiscence intervention program can significantly improve depressive symptoms and self-transcendence level,and the effect of intervention on depressive symptoms is partly caused by the improvement of self-transcendence level.