| BackgroundSuicide is a serious global public health problem,and The World Health Organization considers suicidal ideation as a crucial indicator for assessing suicidal behavior.In most countries of the world,suicidal ideation and the incidence of suicide among elderly individuals are among the highest in all age groups,especially among elderly individuals living alone,a special "vulnerable group" with a higher risk of suicide.Along with the development of nuclearized and miniaturized family structures in China,the group of elderly people living alone has become increasingly large and complex,making the prevention and control of suicide among this group of people a serious challenge.For over a century,suicide intervention research has been problem-oriented and focused on reducing risk factors.With the creation of the emerging field of Positive Suicidology,the focus of suicide intervention has shifted towards protective factors characterized by strength and potential.Protective factors have the ability to disrupt the relationship between risk factors and suicide,thereby reducing the risk of suicide.Based on the interpersonal theory of suicide,we identified the crucial distal risk factor of frailty and the key proximal risk factor of perceived burdensomeness/thwarted belongingness for suicidal ideation in community-dwelling older adults.Based on a developmental trajectory model of suicidal ideation,we proposed a critical risk pathway of "frailty→perceived burdensomeness/thwarted belongingness→suicidal ideation".Positive affect is a fundamental human force,and based on the broaden-and-build theory of positive affect,positive affect is unique in expanding momentary thinking and helping individuals rebound from stress.Therefore,Positive affect may play a buffering role in the pathway of stress-related risk factors to suicidal outcomes,i.e.,weakening or severing the relationship of "frailty(critical distal risk factors)→perceived burdensomeness/thwarted belongingness(critical proximal risk factors)→suicidal ideation",thus playing a protective role.Positive affect has become an emerging protective factor with great potential in suicide intervention research because of its unique "broaden-and-build" function.Positive affect interventions may alleviate stress and reduce suicidal ideation in a relatively short period through its instantaneous "broaden" function;through its "build" function,it may enhance the adaptive response to stress in individuals at high risk of suicide;and over time,Positive affect will form a "life" of their own,which may give individuals the potential to develop a "life"and a "life" of its own.With time,Positive affect will form their own "life" and may bring fundamental changes to individuals.The application of positive affect intervention in suicide prevention and control has achieved good results.However,as a newly emerging field,the relevant research is still minimal,and most of the research is conducted by foreign scholars in the adolescent group.Exploration in the elderly group is largely uncharted.Positive affect are a psychologically significant factor,particularly in relation to older adults.According to the socioemotional selectivity theory of aging,the pursuit of positive emotional experiences,which involves purposefully seeking positive affect experiences,is a prioritized social behavioral goal for older adults.Furthermore,in cognitive processing,older adults show a tendency to give priority to and engage with positive affect information.Based on this,it is urgently necessary to explore the protective pathways of positive affect on suicidal ideation in elderly individuals living alone in the community,revise the targeted positive affect intervention program based on the characteristics of elderly individuals living alone in the community with suicidal ideation and the local culture,and evaluate the impact of the intervention program.Purposes1.In investigating the protective function of positive affect on suicidal ideation among elderly individuals living alone in the community,and to explore whether positive affect serves as a moderator in the association between critical risk factors and suicidal ideation.(frailty--Perceived burdensomeness/Thwarted belongingness→suicidal ideation).2.Revision of the Positive Affect Intervention for Coping with Stress(PAICS)program developed by the Moskowitz team,taking into account the physical and psychological characteristics of elderly individuals living alone in the community with suicidal ideation and their local culture.3.To explore the effectiveness of the revised Positive affect Intervention Program in reducing suicidal ideation among elderly individuals living alone in the community,and to validate the protective effect of Positive affect against suicidal ideation found in cross-sectional studies.MethodThis study contains three parts:The first part was a cross-sectional research design in the form of a questionnaire survey,12 communities of elderly people living alone in Xintai City,Shandong Province,were selected from September 2021 to March 2022,and the demographic and sociological characteristics,frailty conditions,depressive symptoms,perceived burdensomeness,thwarted belongingness,positive affect and suicidal ideation were investigated.Data analysis was performed using SPSS 26.0.Univariate analysis and Pearson correlation analysis was utilized to examine differences in demographic information and scores on core variables between elderly individuals with and without suicidal ideation,and the correlations between core variables.The mediating effect was conducted using Model 4 in PROCESS 4.0,and Model 59 was used to establish a moderated mediation model of positive affect on suicidal ideation.Bootstrap resampling(N=5000)was applied to estimate sample statistics and 95%confidence intervals(C1),if the 95%CI does not cross 0,the effect was significant.Additionally,the study employed interactive visual technique and J-N diagram technique to further deconstruct the moderating effects of positive emotion.The second part was the revision of the positive affect intervention program,which introduced the positive affect Interventions for coping stress(PAICS)developed by Moskowitz’s team for,and combined the literature review method and the expert meeting method to revise the positive emotion intervention program in line with the characteristics of the study participants.The third part involved testing the intervention effects through a randomized controlled trial.The intervention study was conducted from May 2022 to November 2022.Before the intervention,a screening process was conducted on 139 community-dwelling older adults with suicidal ideation identified in the cross-sectional survey,applying inclusion and exclusion criteria,the results showed that six people did not have suicidal ideation at present,nine people chosed the duration of suicidal ideation as "brief,fleeting",and six people refused to participate.Ultimately,118 older adults participated in the study.A simple randomization method was adopted for sample grouping.A random sequence was generated by a person who did not participate in the intervention study using a Research Randomizer(Version 4.0).The generated random numbers were sorted in order from smallest to largest(the rank of random numbers generated).Then the random numbers corresponding to the subjects numbered 1～118 were placed into sealed,opaque envelopes labeled 1～118,and the odd numbers were designated as the control group and the even numbers as the intervention group,and the subjects were randomly assigned to the intervention group(59 people)and the control group(59 people)according to the numbers in the envelopes.The data collector is not aware of the grouping situation,which is blind to the evaluator.The elderly in the intervention group received 6-week individualized positive affect training,and the control group received health education,the intervention dose、intervention form and intervention duration of the control group were the same as those in the intervention group.The effect of the interventions on enhancing positive affect and reducing suicidal ideation was assessed at the baseline("T0"),immediately after intervention completion("T1"),one month after intervention completion("T2"),and three months after intervention completion("T3").The effect of intervention was exsamined using the GEE model,all analyses followed the principles of ITT analysis.Additionally,this study verified the model illustrating the protective impact of positive affect on suicidal ideation,as established in the cross-sectional study,through longitudinal tracking.The investigation explored the onset of intervention effects,as discussed in the results,without explicit reference to the initial aims and hypotheses.A moderated mediation model was established using PROCESS4.0,and the non-parametric statistical Bootstrap method(N=5000)was used to further verify the protective path of positive affect on suicidal ideation.ResultsI.Results of the first cross-sectional study:(1)A total of 893 elderly individuals living alone in the community were included in the study,with 15.67%(139 people)having suicidal ideal in the past week.(2)A moderated mediation model test:1)Perceived burdensomeness played an intermediary role between frailty and suicidal ideation.Frailty exhibited a notably impact on perceived burdensomeness(β=0.441,p<0.001,).The perceived burdensomeness also had a significant impact on suicidal ideation(β=0.186,p<0.001,).The perceived burdensomeness had a mediating effect with a 95%confidence interval of[0.123,0.249];2)The development path of "frailty→thwarted belongingness→suicidal ideation" among elderly individuals living alone in the community was not supported:frailty had a significant impact on thwarted belongingness(β=0.123,p<0.01,),while the influence of thwarted belongingnesson suicidal ideation did not reach statistical significance(p>0.05).The 95%confidence interval for the mediating effect of thwarted belongingness was[-0.319,0.737],and the confidence interval,encompassing 0,suggests that the mediating effect of thwarted belongingnesson was not significant;3)Positive affect had a moderating effect in the pathway of "frailty→suicidal ideation"(β=-0.113,95%Cl=[-0.160,-0.066]);they also had a moderating effect in the pathway of "perceived burdensomeness→suicidal ideation"(β=-0.152,95%CI=[-0.202,-0.102]);however,the moderating effect in the pathway of "frailty→perceived burdensomeness" is not significant(β=-0.034,95%Cl=[0.013,-0.034]).2.Results of the revised intervention program in the second part:Based on the cross-sectional univariate analysis of the physical and mental characteristics and local cultural characteristics of elderly individuals living alone in communities with suicidal ideation,preliminary revisions were made to the PAICS plan that did not fully consider the characteristics of the elderly and the actual practice content.This included adding audio guidance for elderly breathing meditation in Skill 4(mindfulness)and deleting informal mindfulness exercises;Skill 6(identifying and utilizing personal strengths)had been simplified and life-oriented,and the content of "advantage feedback" had been added in combination with local culture;for Skill 7(achievable goals),adopted a"selection optimization compensation" strategy dedicated to the selection,achievement,and maintenance of elderly goals related to successful aging to help elderly people manage their life goals.Through two rounds of expert meetings,a positive emotional intervention plan for suicidal ideation among elderly individuals living alone in the community had been developed,which was recognized by experts.The plan took the form of one-on-one,face-to-face intervention with a duration of 40-60 minutes once a week,divided into two stages.The first stage was a familiarization activity,and the second stage was a formal intervention activity.Six modules(each completed within one week)were used to teach the elderly eight positive emotional enhancement skills,After the intervention was completed,the elderly needed to list one or several skills that were most relevant or favorite to themselves,to continue practicing in daily life.3.Research results of the third part:(1)Verification of intervention plan results:1)There were no significant differences(all p>0.05)in key variables and general demographic information between the dropped participants and completed participants(all p>0.05).2)There were no significant differences in key variable scores and general information between the intervention and control groups at baseline(all>0.05),indicating that the two groups were comparable.3)The impact of the interventions on suicidal ideation:The results showed that the main effects of group and time were statistically significant(Wald χ2=5.435,p=0.020;Waldχ2=23.528,p<0.001),the group × time was statistically significant(Wald χ2=20.391,p<0.001).Inter-group comparison showed that the suicidal ideation score of the intervention group was significantly lower than that of the control group at T1 and T3 time points;within the intervention group,the mean difference between T1 and T0 was-5.534 scores(p<0.001).the mean difference between T2 and T0 was-4.208 scores(p<0.001);the mean difference between T3 and T0 was-5.420 scores(p<0.001);the mean difference between T3 and T2 was-1.540 scores(p=0.034).The differences were all significant.4)The effect of the intervention on perceived burdensomeness:Both group and time main effects were significant(Waldχ2=6.860,p=0.009;Waldχ2=10.779,p=0.013),and the group × time was also significant(Waldχ2=35.031,p<0.001).Intergroup comparison showed that the perceived burdensomeness score of the intervention group was significantly lower than that of the control group at T2 and T3 time points.Within the intervention group,the mean difference between T1 and T0 was(-3.328 scores,p=0.001);the mean difference between T2 and T0 was(-5.509 scores,p<0.001);the mean difference between T3 and T0 was(-5.940 scores,p<0.001),T2 and Tlwas(-2.019 scores,p=0.033);the mean difference between T3 and T1 was(-2.660 scores,p=0.002).All differences were statistically significant.5)The effect of the intervention on positive affect:Both group and time main effects were significant(Wald χ2=10.393,p=0.001;Wald χ2=28.517,p<0.001),and the group × time was also significant(Wald χ2=21.129,p<0.001).Intergroup comparison showed that the positive affect score of the intervention group was significantly higher than that of the control group at T1、T2 and T3 time points.Within the intervention group,the mean difference between T1 and T0 was(6.293 scores,p<0.001);the mean difference between T2 and T0 was(4.792 scores,p<0.001);the mean difference between T3 and T0 was(5.860 scores,p<0.001).All differences were statistically significant.(2)Verification of the protective effect of Positive affect on suicidal ideation after intervention completionThe study focuses on elderly individuals in the intervention group,with a focus on Δsuicide ideation(T1-T0 T2-T0 T3-T0)as the dependent variable,Δ frailty(T1-T0 T2-T0 T3-T0)as an independent variable,Δ perceived burdensomeness(T1-T0 T2-T0 T3-T0)as a mediating variable,Δ positive affect(T1-T0 T2-T0 T3-T0)as moderating variables,and moderated mediating effects being analyzed.The results showed that the protective effect of Positive affect on suicidal ideation was established in the T3-T0 model:1)There was a development path of "Δ frailty→Δ perceived burdensomeness→Δ suicidal ideation" in elderly individuals living alone in the community:"Δ frailty→Δ perceived burdensomeness"had a significant impact(β=0.455,p<0.01),"ΔΔ perceived burdensomeness →Δ suicide ideation" also had a significant impact(β=0.361,p<0.05).The the mediating effect of Δperceived burdensomeness in "Δ frailty and Δ suicidal ideation" was[0.030,0.321].2)The moderating effect of Δ positive affect in the pathway of“Δ frailty→Δ suicidal ideation" was significant 0.249,95%CI=[-0.475,-0.043]),in the pathway of“Δ perceived burdensomeness → Δ suicidal ideation”was also significant(β=-0.269,95%CI=[-0.479,-0.050]).Conclusion1.Positive emotions play a buffering role in the pathways from "frailty→ suicidal ideation" and "perceived burdensomeness → suicidal ideation," indicating that among community-dwelling older adults,positive emotions weaken or disrupt the relationship between key risk factors and suicidal ideation,thereby exerting a protective effect.2.The results of the randomized controlled trial indicate that the modified positive emotion intervention program in this study significantly impacts the primary outcome measure of suicidal ideation,as well as the secondary outcome measures of perceived burden and positive emotions.3.In the longitudinal data of the randomized controlled trial,the protective model of positive emotions on suicidal ideation,as explored in the cross-sectional study,is supported.This suggests that changes in positive emotions play a buffering role in the developmental pathways of "Δ frailty →Δ suicidal ideation" and"Δ perceived burdensomeness→suicidal ideation."... |
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