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Neighborhood support network, perceived proximity to community facilities and depressive symptoms among low socioeconomic status Chinese elders ab

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Yan-Yan Chen , Gloria H.Y. Wong , Terry Y. Lum , Vivian W.Q. Lou , Andy H.Y. Ho , Hao b

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Luo & Tracy L.W. Tong a

Department of Social Work, Fudan University, Shanghai, China

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Sau Po Center on Ageing, The University of Hong Kong, Hong Kong, China

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Department of Social Work and Social Administration, Sau Po Center on Ageing, The University of Hong Kong, Hong Kong, China d

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Division of Psychology, School of Humanities and Social Sciences, Nanyang Technological University, Singapore Published online: 16 Mar 2015.

To cite this article: Yan-Yan Chen, Gloria H.Y. Wong, Terry Y. Lum, Vivian W.Q. Lou, Andy H.Y. Ho, Hao Luo & Tracy L.W. Tong (2015): Neighborhood support network, perceived proximity to community facilities and depressive symptoms among low socioeconomic status Chinese elders, Aging & Mental Health, DOI: 10.1080/13607863.2015.1018867 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1018867

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Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1018867

Neighborhood support network, perceived proximity to community facilities and depressive symptoms among low socioeconomic status Chinese elders Yan-Yan Chena,b*, Gloria H.Y. Wongb, Terry Y. Lumb,c, Vivian W.Q. Louc, Andy H.Y. Hod, Hao Luob and Tracy L.W. Tongb a

Department of Social Work, Fudan University, Shanghai, China; bSau Po Center on Ageing, The University of Hong Kong, Hong Kong, China; cDepartment of Social Work and Social Administration, Sau Po Center on Ageing, The University of Hong Kong, Hong Kong, China; dDivision of Psychology, School of Humanities and Social Sciences, Nanyang Technological University, Singapore

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(Received 13 September 2014; accepted 6 February 2015) Objectives: Depressive symptoms are common in older people; most previous research on elderly depression focused on individual-level characteristics or neighborhood socioeconomic status. Modifiable neighborhood characteristics of older people dwelling in low-income communities are under-studied. This study aims to identify potentially modifiable social and physical neighborhood characteristics that influence depressive symptoms independent of individual-level characteristics among older Chinese. Method: Data came from a cross-sectional survey conducted in four low-income public rental housing estates in Hong Kong in 2012. We interviewed a total of 400 elderly residents. The structured questionnaire covered demographics, activities of daily living, recent fall history, neighborhood support networks, and perceived proximity by walk to community facilities. Multiple regression was used to test whether inclusion of neighborhood factors in addition to individual characteristics increases model fit in explaining depressive symptoms in elders with low socioeconomic status. Results: At individual level, activities of daily living and income significantly predicted depressive symptoms. Receiving support from friends or neighbors is associated with fewer depressive symptoms. However, participants who received organizational support had a 1.17 points of increase on the 15-item Geriatric Depression Scale (GDS-15). At-ease walkable proximity to medical facilities was positively associated with a better GDS score. Conclusion: Neighborhood support networks and perceived proximity by walk to community facilities contribute significantly to depressive symptoms among low-income elders. Programs and policies that facilitate neighborhood support and commuting or promote facility accessibility may help ameliorate depressive symptoms common among lowincome elders. Keywords: neighborhood; support networks; perceived walkability; depressive symptoms; low-SES elders

Introduction Elderly depression is common in the community. Among community-dwelling elders, prevalence of clinically relevant depression is approximately 13.5%, and that of depressive symptoms can be as high as 49% (Beekman, Copeland, & Prince, 1999; Copeland et al., 2004; Djernes, 2006). Elders with low socioeconomic status (SES) and those living in deprived areas are particularly impacted (Koster et al., 2006), as depression is a significant cause of disability and dependence (Lenze et al., 2001), financial burden and suffering (Hall & Wise, 1995), negative emotion such as loneliness (Dahlberg, Anderssonc, McKee, & Lennartsson, 2015), and increased odds of mortality in late life (Blazer, 2003). Much efforts have been made to identify and target its risk factors (e.g., see reviews by Cole & Dendukuri, 2003; Djernes, 2006). In particular, identification of modifiable risk factors will inform the design of effective measures to reduce the burden of elderly depression. Modifiable risk factors include individual-level and macro-level factors. Previous research on depression mostly focused on the former (Blazer, 2003; Blazer & Hybels, 2005; Cole & Dendukuri, 2003; Luppa et al., *Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis

2012), which are clinically informative for guiding individualized treatment. Macro-level factors, on the other hand, are warranted for developing public health strategies (Kim, 2008), with far-reaching impact on long-term health and social care systems. According to the ecological model, environmental context has a critical role in mental health (U.S. Department of Health and Human Services, 2000). Research on neighborhood features and depression or depressive symptoms in the general population has burgeoned in recent years. Neighborhood refers to ‘the bundle of spatially based attributes associated with clusters of residences, sometimes in conjunction with other land uses’ (Galster, 2001). It consists of structural, infrastructural, demographical, class status, tax/public service package, environmental, proximal, political, social-interactive, and sentimental characteristics. Among these, characteristics contributing directly to daily functioning are more relevant to depression (Julien, Richard, Gauvin, & Kestens, 2012). For example, informal alliances with neighbors may have buffering effects (Ross & Jang, 2000), and presence of health-related care and amenities can affect social interactions and health behaviors, exerting an effect on

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depression through moderating social and physical health (Kim, 2008). Much remains unknown, however, about the effect of neighborhood environment on depression in the elderly population, despite the fact that neighborhood characteristics appeared to have a stronger impact on older people than in adult populations (Mair, Roux, & Galea, 2008). This is particularly true among low-income elders who are more likely to be confined by their immediate environment because of commuting costs (Newman, 2003). We also know very little about the role of neighborhood environment on depression in Chinese communities, which may differ from that in western societies given the Chinese cultural values. To explore these knowledge gaps, this study examined the associations of social and physical characteristics of the neighborhood with depressive symptoms among low-income Chinese elders in Hong Kong. In particular, we evaluated the association of two potentially modifiable macro-level factors, namely neighborhood support network and perceived walkability to neighborhood facilities, with depression in this population.

Neighborhood characteristics and elderly depression According to the ecological theory of aging (Lawton, 1999), the health of older adults is a function of personenvironment fit. Neighborhood environment has important impact on older persons, who tend to spend a large proportion of their daily lives in the neighborhood due to retirement and reduced mobility, have stayed in and thus been exposed to their neighborhood for many years, and are more vulnerable to environmental stressors owing to decreasing competencies (Glass & Balfour, 2003; Lawton, 1977). A 2012 review on neighborhood characteristics and depressive mood among elders aged 65 years or above included 19 studies with sample sizes ranging from 301 to 77,930 (Julien et al., 2012). The vast majority of these studies were done in western societies, whilst the two available Taiwan studies reported conflicting results (Julien et al., 2012). In essence, the impact of neighborhood characteristics on depression among Chinese elders is largely unexplored. The 19 studies showed that older people living in with neighborhood socioeconomic disadvantage, higher population density, higher perceived neighborhood problems, lower collective efficacy were more likely to be depressed, while those who lived in a more walking-friendly neighborhood and in neighborhood with higher social capital were less likely to be depressed (Julien et al., 2012). These results, however, were not consistently replicated across studies. Such inconsistency is similar to that found in studies in the general population, the majority of which used indicators derived from census data, and focused on neighborhood socioeconomic composition. In two reviews published in 2008 (Kim, 2008; Mair et al., 2008), a total of 58 cross-sectional and longitudinal studies were identified, with sample sizes ranging from 103 to 4,516,787 (cohort and population-based register). In both reviews,

only half of the studies found an association between lower neighborhood SES and depression. While most previous studies used readily available data (e.g., census data), results were more consistent among studies that used a theoretical approach. More refined theoretical driven research that examines specific neighborhood characteristics and their association with depression is called for (Kim, 2008; Mair et al., 2008). For example, in the general population, only four studies investigated the effects of built environment (e.g., quality of housing areas, walking environment) and they unanimously found an association with depression; most studies that investigated positive social interaction in the neighborhood found it to be protective against depression (Mair et al., 2008). To date, few theoretically driven empirical research has been done on the association between specific neighborhood characteristics and elderly depression. On the other hand, most of the previous studies focused on objective measures of neighborhood features and defined neighborhood using administrative or statistical spatial boundaries. These approaches sacrifice measures that may be more meaningfully related to mood (Julien et al., 2012). Particularly among low-income elders who are more likely to suffer from poor health and physical dysfunction, the boundary of neighborhood may be much smaller (Syddall, Evandrou, Cooper, & Sayer, 2009). Non-concordance between objective and perceived neighborhood walkability may also be a problem among older adults (Arvidsson, Kawakami, Ohlsson, & Sundquist, 2012). As these elders have difficulty traveling beyond their physical proximity and tend to interact more with their immediate physical environment (Glass & Balfour, 2003) and close neighbors (Thom
ese & van Tilburg, 2000), alternative methods such as exposure-specific and self-reported measures may better reflect the effects of neighborhood characteristics (Coulton, Korbin, Chan, & Su, 2001; Julien et al., 2012). Neighborhood support network Recent research in western societies increasingly recognizes the role of neighborhood support network (neighbors, friends, and organizations) in elderly depression (Fiori, Antonucci, & Cortina, 2006; Golden, Conroy, & Lawlor, 2009; Litwin, 2011). Those who have more diverse network, friend network (composed of friends and acquaintances), and congregant network (religious or other group gatherings) have fewer depressive symptoms (Litwin, 2011). The role of neighborhood support network in elderly depression in Chinese communities may differ in the context of strong filial value and family cohesion. In traditional Chinese culture, family (especially adult children) assumes a major role in old-age care and support. Chinese elders who receive instrumental aid from their children are less likely to have depressive symptoms (Chi & Chou, 2001). With demographic and social changes in modernized Chinese cities like Hong Kong (e.g., decline in fertility, reduced family size, increase in elderly households), however, traditional values of filial piety have eroded (Chow & Lum, 2008). The hierarchical

Aging & Mental Health compensatory model of support network suggests neighbors and formal organizations become crucial when families fail to provide care (Cantor, 1979). Neighborhood support may relate to a weakened family support and, in the Chinese context, its relationship with elderly depression is thus complex. Empirical studies taking into account support from neighbors, friends, organizations, and family in modern Chinese societies are lacking.

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Perceived neighborhood walkability A walkable neighborhood enables residents to perform daily activities without the use of a car, with implications on social capital (Leyden, 2003). Studies in western societies found that elders who reported higher perceived walkability to key services and amenities are more likely to participate socially (Kruger, Reischl, & Gee, 2007; Richard, Gauvin, Gosselin, & Laforest, 2009); Conversely, elders who perceived their community amenities to be poor have fewer social activities (Bowling & Stafford, 2007). Supportive social ties and social capital are known to be beneficial in reducing depressive symptoms (Berke, Gottlieb, Moudon, & Larson, 2007). Accessible community amenities (e.g., parks) also facilitate physical activities in older adults such as walking (Nagel, Carlson, Bosworth, & Michael, 2008), which is negatively related to depressive symptoms in elders (Lampinen, Heikkinen, & Ruoppila, 2000). Those who perceive greater accessibility to community facilities and services also have a higher sense of mastery towards the environment (Jang, Kim, & Chiriboga, 2006; Knight, Davison, McCabe, & Mellor, 2011). In Hong Kong, a metropolitan Chinese city, accessible community amenities (e.g., recreational space, shops, and pedestrian infrastructure) have also been shown to relate positively to within-neighborhood walking (Cerin, Sit, Barnett, Cheung, & Chan, 2013; Cerin et al., 2014). Hong Kong elders with a lower SES (particularly those who are less educated) were less likely to engage in within-neighborhood walking, partly due to the physical barriers to walking in the neighborhood (Cerin, Mellecker, et al., 2013). As elderly depression in Chinese may be more closely related to family support and instrumental aid (Chi & Chou, 2001), however, it is unknown whether perceived walkability to community facilities has similar effects on depression among Chinese elders as observed in the West. Knowledge gaps and this study At present, very little is known about the relationship between neighborhood characteristics and depression in Chinese elders. Most of the above-mentioned evidence was from western societies, with very different cultural values than those of Chinese communities (e.g., filial piety) that may impact on depression. The role of neighborhood characteristics as experienced by elders of lower SES, as opposed to objective neighborhood characteristics, is also relatively understudied despite their relevance in this particular population. Research is needed to demarcate the association between neighborhood support (including neighbors, organizations, friends, and family),

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perceived walkability to community facilities of different nature (e.g., social, recreational, instrumental), and depressive symptoms in Chinese elders with lower SES. Evidence generated from such research will inform public mental health strategies targeting elders in Chinese communities, such as the potential values in promoting neighborhood support network and measures to improve accessibility of neighborhood facilities by walk, from a person-center perspective of the elder with low SES. This study was designed as a first step in addressing these knowledge gaps, by investigating the associations of experienced social and physical characteristics of the neighborhood with depressive symptoms among Chinese elders with lower SES in Hong Kong. Hong Kong is a fast-aging metropolitan city. The elderly population is expected to grow from 13% in 2011 to 30% by 2041 (Census and Statistics Department, 2012). Prevalence of clinically relevant depression among community-dwelling elders is estimated to be 9.7% (Sun, Xu, Chan, Lam, & Schooling, 2012). Taking into account known individuallevel factors including activities of daily living (ADL) and SES, we tested the association of the following experiential neighborhood characteristics with depressive symptoms: (1) neighborhood support network, under the categories of family living together, relatives, neighbors and friends, and organizations; and (2) perceived walkability, as defined by reported accessibility/proximity to neighborhood facilities, including recreational, medical, daily necessities, dining, and others by walk.

Methods Design and sampling frame This is a cross-sectional study conducted in four lowincome public rental housing estates in Hong Kong. Data were collected between August and October 2012. A total of 400 elders aged 60 years or above residing in these estates (n D 100 per estate) were recruited and interviewed face-to-face. The estates were high-rise buildings in urban areas built between 1958 and 1970, and have elderly concentrations ranging from 31% to 37%. To ensure enough variation in the sample’s frailty levels, we provided a free community health screening during participant recruitment. Trained occupational therapists assessed the activities of daily living (ADL) and instrumental activities of daily living (IADL) of all participants, who were then stratified into healthy (i.e., no ADL/IADL limitation), moderately frail (i.e., some ADL/IADL limitations but not requiring community-based LTC services), and high frailty (i.e., ADL/IADL limitations requiring community-based LTC services to stay in the community) groups with equal representation. Elders who were cognitively incapable for interviewing were excluded.

Measures Depressive symptoms We assessed depressive symptoms using the Hong Kong Chinese version of the 15-item Geriatric Depression Scale

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(GDS-15). The total score ranges from 0 to 15, with higher scores indicating higher depressive symptoms. A cutoff point of 8 is commonly used to indicate clinically significant depression (Lee, Chiu, Kowk, & Leung, 1993; Sun et al., 2012). The scale has been validated in Hong Kong with good reliability and validity (Chan, 1996; Lee et al., 1993; Mui, Kang, Chen, & Domanski, 2003). In our sample, the Cronbach’s alpha was 0.821.

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Neighborhood support network We used a name-generator method to assess the neighborhood support network of elderly participants. Following the exchange approach, we asked participants to name the persons who they relied on for help in buying groceries and daily necessities, and escorting to medical appointments (McCallister & Fischer, 1978), without setting a limit on the number of people they named. Each person named was classified into family living together (i.e., coresiding family members), family and relatives (i.e., nonco-residing family and extended relatives), friends (i.e., neighbors, friends), and organizations (i.e., health care or social service organization that offered support). We created four dummy-coded variables for each category of neighborhood support network. Perceived neighborhood walkability Based on the Leyden Walkability Instrument (Leyden, 2003), we measured perceived walkability to community facilities with items modified according to the Hong Kong context. The Leyden Walkability Instrument was developed as a simplified way in measuring perceived walkability, by direct questioning of individuals on their perception of traveling to various locations on foot from home. This self-reported method has been shown to generate results that associate with social engagement, trust, and faith in the neighborhood (Leyden, 2003). In our study, participants rated their perceived walkability as high (i.e., can walk with ease), low (i.e., cannot walk with ease), or not applicable (i.e., no such facility or participant is bed-bound) to the following five categories: recreational (i.e., parks and recreational facilities); medical (i.e., clinics, pharmacies, hospitals); necessities (i.e., grocery stores, wet markets, supermarkets); dining (i.e., restaurants, canteens); and others (i.e., banks, hair salons, government offices). Individual-level characteristics To control for individual-level characteristics related to depressive symptoms, we recorded age, gender, income, ADL, recent fall history, marital status, and education level. Monthly income was categorized into welfare (i.e., recipients of means-tested welfare benefits of about HK$3000 (US$1 HK$7.8)), HK$0 1999; HK$2000 3999; HK$4000 5999; HK$6000 7999; and HK$8000 or above. In Hong Kong, elders receiving means-tested welfare must provide a signed document by his/her children, commonly known as the ‘bad son statement’, declaring that they lack

the financial means to support their parents. This group is therefore separated in our analysis from other low-income groups, the latter of whom have opted to live in poverty to protect their children’s reputation as violating the filial norm (Lum et al., 2014). ADL was measured using the Barthel index (Mahoney & Barthel, 1965), with a possible range between 0 and 100 where higher scores indicate higher levels of functioning. Recent fall history was assessed by the question ‘Have you fell in your home in the past year?’ (Yes/no). Education was categorized into ‘uneducated/kindergarten’, ‘primary school’, and ‘secondary or above’.

Analysis Descriptive statistics were calculated for the prevalence of depressive symptoms and individual-level characteristics. We used multiple regression to model whether depressive symptoms are associated with perceived walkability to community facilities and neighborhood support network, controlling for estates and individual-level characteristics. Stata 13.1 (College Station, TX) was used to conduct the data analysis.

Results Descriptive statistics The average age of all participants (n D 400, 43.5% women) were 80.2 years (SD, 7.5), with slightly more than half (55.3%) being married. They generally had good ADL (mean, 93.1; SD, 14.0), although 23.5% had fallen in the past year. Education was limited with only 20.8% having attained secondary school or above. The majority had monthly income below HK$8000, with 32% on welfare. In terms of support network, 43.3% and 47.0% of the participants received help from family living together and family and relatives not living together, respectively. Only 11.5% received organizational help. The levels of perceived walkability were generally high in all the five domains, with the percentages ranging from 68.5% to 72.8%. The average score of GDS-15 was 4.3 (SD, 3.5). Using 8 as the cutting point in GDS-15, the prevalence of clinically significant depressive symptoms in our sample was 17.8%. Table 1 shows the sample characteristics.

Multiple regression model of depressive symptoms Table 2 shows the result of the multiple regression model. The model explained 31% of the variance of depressive symptoms (F(24,343) D 6.49, p < 0.001). Participants living in Estate D scored 1 point lower than those in Estate A. Physical functioning was negatively associated with depressive symptoms each point of increase on ADL reduced a score of 0.07 on GDS-15. Compared with elders receiving welfare, those with a monthly income of HK$4000 5,-999, HK$6000 7999, and HK$8000 or above scored 1.02, 1.66, and 1.94 points lower on GDS15, respectively. Elders who received support from organizations scored 1.17 point higher on GDS-15 compared with those

Aging & Mental Health Table 1. Characteristics of the study sample (n D 400).

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Characteristics Age (mean, SD) Gender, men ADL (range, 0–100) (mean, SD) Fallen in the past year Married Education attainment Uneducated/kindergarten Primary Secondary or above Monthly income Welfare HK$0–$1999 HK$2000 3999 HK$4000 5999 HK$6000 7999 HK$8000 or above Support network Family living together Family and relatives Neighbors and friends Organizations Perceived proximity by walk Recreational, can walk with ease Medical, can walk with ease Necessities, can walk with ease Dinning, can walk with ease Other, can walk with ease GDS-15 (range, 0–15) (mean, SD) Depressive symptoms (GDS 15 >D 8)

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Table 2. Regression model of depressive symptoms.

N (or mean)

% (or SD)

80.2 174 93.1 94 221

7.5 43.5 14.0 23.5 55.3

128 189 83

32.0 47.3 20.8

118 28 54 70 48 51

32.0 7.6 14.6 19.0 13.0 13.8

173 188 35 46

43.3 47.0 8.8 11.5

290 284 284 274 291 4.3 71

72.5 71.0 71.0 68.5 72.8 3.5 17.8

who received no support from organizations. Elders who received support from friends or neighbors scored 1.1 point lower compared with those who received no support from friends or neighbors. Elders who could walk to medical facilities with ease scored 2.31 points lower compared with those who could not.

Discussion Elderly depression is a major health concern due to its close association with dementia and other morbidity, suicide, and all-cause mortality (Diniz, Butters, Albert, Dew, & Reynolds, 2013; Fiske, Wetherell, & Gatz, 2009). Elders living in poverty are particularly impacted (Koster et al., 2006). In this study, we found that 17.8% of lowincome elders had significant depressive symptoms. This nearly doubled the prevalence found in a populationbased research (9.7%) of Hong Kong elders using the same measurement (Sun et al., 2012), and is higher than the approximate prevalence rates of 9.5% to 13.5% among western community-dwelling elders (Copeland et al., 2004; Djernes, 2006). This finding is alarming even when comparing with other low-income older populations; for

Constant Estate1 Estate 2 Estate 3 Estate 4 Age Male gender ADL Recent fall history Monthly income2 HK$0 $1999 HK$2000 $3999 HK$4000 $5999 HK$6000 $7999 HK$8000 or above Married Education3 Primary School No education Support network Family living together Family and relatives Neighbors and friend Organizations Perceived proximity Recreational Medical Necessities Dinning Others F R-square Adjusted R-square

b (standardized coef.)

B

SE

12.53

2.58

0.42 0.53 1.00 0.01 0.48 0.07 0.73

0.47 0.46 0.44 0.02 0.36 0.01 0.38

0.05 0.07 0.13 0.01 0.07 0.27 0.09

0.65 0.80 1.02 1.66 1.94 0.08

0.63 0.50 0.46 0.51 0.52 0.40

0.05 0.08 0.12 0.16 0.20 0.01

0.19 0.07

0.37 0.49

0.03 0.01

0.46

0.43

0.07

0.13

0.35

0.02

1.10

0.55

0.09

1.17

0.51

0.11

0.14 2.31 0.37 0.62 0.58 6.49 (df D 24, 343) 0.31 0.26

0.76 0.87 0.80 0.70 0.81

0.02 0.30 0.05 0.08 0.08

Note: reference group used in the analysis were 1Estate 1; 2welfare; and 3 secondary school or above.  p < 0.05; p < 0.01; p < 0.001.

example, the prevalence of mild depression among lowincome elders in the United States was less than half of our results, at 8.2% (Lum et al., 2013). This finding clearly warrants an urgent need for large-scale preventive interventions for reducing the burden of depressive symptoms among local low-SES Chinese elders. To explore potential intervention targets at a macro level, we studied the association of specific neighborhood social and physical characteristics and depressive symptoms among Chinese elders with low SES. We found that perceived proximity to community facilities by walk and neighborhood support network are correlated with depressive symptoms, independent to individual-level factors of ADL, recent fall history, and income.

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Support network of neighbors and friends Social support as a protective factor against stress and mood problems is well established both in western cultures and some Asian societies (Chao, 2014; Lin, Ye, & Ensel, 1999). The importance of neighbors and organizations as a source of social support, relative to that of family, is less investigated in Chinese societies. In a westernized Chinese city where the traditional values of filial piety and family support have weakened, with increasing numbers of single and couple elderly households (Census and Statistics Department, 2013), our results showed that support from neighbors and friends are associated with fewer depressive symptoms. Whereas greater family support appeared related to reduced depressive symptoms in our model, it did not reach statistical significance. This finding echoed that of western studies of neighborhood support network and elderly depression (Golden et al., 2009; Litwin, 2011). For example, compared with those who receive support from neighbors and friends but little family support, elders who have family support but lack support from friends and neighbors are more likely to have depressive symptoms (Fiori et al., 2006). Similarly, higher levels of social engagement, but not family support, is associated with lower levels of depression (Golden et al., 2009). A recent study based on a random sample from Shanghai, mainland China, also indicated the increasing role of the neighborhood in lowering depression for older people (Ye & Chen, 2014). While Ye and Chen (2014) measured neighborhood identity, we focused on neighborhood support, thus our findings are complementary to highlight the importance of different aspects of neighborhood associated with Chinese elderly depression. According to the hierarchical compensatory model of support network, when family is unavailable, formal health care and social service organizations become crucial (Cantor, 1979). While this may be the case in care provision, however, participants in our sample who received formal support had more depressive symptoms. As Chinese elders often seek informal support first and view professional help as the last resort (Hwang, 1977; Shek, 1998), it is quite possible that elders who are receiving formal organizational support lack informal support from families and friends, and are thus experiencing a higher level of depression. Our post hoc analysis suggests that elders receiving organizational support were less likely to have support from family living together but more likely to receive support from friends and neighbors (results not shown). From a social policy perspective, these findings shed light on programs and services that foster mutual support among neighbors, which may be related to depression among low-income Chinese elders. Older people living in a naturally occurring retirement community, as is the case in this study, have generally known each other for decades. An older person who receives instrumental support from the acquaintances that they meet on a daily basis, but not those who receive support from paid workers, are

less depressed. Therefore, in Chinese societies similar to Hong Kong, whether resources allocated to deliver direct elderly services by professional caregivers may be more effectively used in supporting the established social relationships among elderly neighbors should be considered. For example, a community partnership model between informal helpers and professionals, such as the Naturally Occurring Retirement Community with Supportive Service Program (NORC-SSP) model, may be considered. The NORC-SSP is an aging-in-place model that promotes partnership among formal and informal neighborhood stakeholders to create a coordinated package of services to support independent living of elders. It takes advantages of the skills and experiences of elders in the community, which aims to reduce social isolation and create strong, healthy communities, in which elders can remain independent living, with increased security and quality of life through improved communication and collaboration among community service providers.

Medical facilities within walkable distance Interestingly, among the various types of amenities and services measured, only medical facilities correlated with depressive symptoms. Existing theories posit that community facilities contribute to depressive symptoms through three pathways: physical activity, social participation, and sense of mastery. Given the nature of medical facilities, the former two pathways may be less relevant it is unlikely that access to medical facilities may promote physical activities or provide a context for social ties. On the other hand, an ability to reach medical care independently when needed may give rise to a higher sense of mastery. We postulated that with increasing frailty level, proximity to different types of neighborhood facilities may impose different degrees of pressure on the elder. While low accessibility to amenities and daily living necessities (e.g., grocery store, banks) is more readily compensated by formal and informal support, the inability to visit a nearby medical facility unaccompanied in case of emergency may be a major cause of stress, leading to a sense of out of control. On the other hand, as elderly depression is commonly presented as preoccupations with physical illnesses (Georgotas, 1983), it is possible that easier access to clinics may help identify and intervene ‘masked depression’ at an earlier stage. This may be especially true in Chinese culture where physical illnesses are perceived as more acceptable than mental disorders. Our finding contrast with that of Kubzansky et al. (2005). Using investigator ratings of neighborhood service density, they did not find any relationship between accessibility to healthcare or other services and depressive symptoms in the elderly. Apart from the different study sample and culture, the use of objective measurement of neighborhood services availability may partially explain for the difference. Depending on individual health and functioning level, facilities and services available in the community may not be equally accessible to the older residents. As elders with low SES are less able to afford

Aging & Mental Health

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transportation and more confined within their walkable environment, whether the facilities are perceived as within walkable distance may be a more sensitive measure of the person’s physical neighborhood environment. Apart from the accessibility of medical facilities, we found that elders in Estate D were less depressed than those from Estate A. While the relatively higher income and higher perceived proximity of medical facilities of Estate D than those of Estate A may account for the difference, further research is needed to examine more factors beyond the individual level that related to depressive symptoms of Chinese low SES elders. Limitations and conclusion This is a first study that investigated the association between specific social and physical neighborhood characteristics to depressive symptoms among low-SES Chinese elders, independent to individual-level factors. We provided initial evidence of the link between supports from neighbors and availability of medical facilities within a perceived walkable distance. We adopted a cross-sectional design because of the exploratory nature of the study. We also measured neighborhood support and facility accessibility as experienced by the person instead of using objective environmental markers. Some caveat should be borne in mind when interpreting our findings. First, the directionality of the associations found in our models is unknown. We cannot rule out the possibility that less support from neighbors and perceiving a lack of medical facilities within walkable distance is a consequence to depressive mood; although this interpretation would be less in line with other longitudinal, general population studies that largely confirmed a contribution of neighborhood characteristics to depression and depressive symptoms (Mair et al., 2008). Second, although the use of objective markers is less sensitive in capturing neighborhood characteristics that may impact a person’s health and mental health (Weden, Carpiano, & Robert, 2008; Wen, Hawkley, & Cacioppo, 2006), our assessments of perceived walkability and naming of support network are limited by a self-report method. It is possible that respondents’ of perceived walkability rating were partly based on their own physical health or disability. The fact that our sample has good overall ADL, and that ADL and recent fall history have been included as control variables in the regression model, should provide some confidence while we interpret the results with caution. Reporting bias is also possible for people who are already depressed to perceive less support and greater difficulty in accessing neighborhood facilities. If this is the case, however, we would expect a similar correlation direction across sources of neighborhood support and types of facilities. This is not the case in our study, as it is difficult to explain how reporting bias would result in more depressed people reporting more support from organizations. Third, we had not adjusted certain individual-level characteristics, such as chronic conditions, which could influence depressive symptoms. Future study can test the respective role of other known and theoretical factors at individual and

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environmental levels with specific hypotheses to allow more refined understanding. Taken together, our findings resonated theoretical and empirical efforts to orient research, services, and policies to the place of residence of our older population (World Health Organization, 2007). Few previous studies have reported similar information about the unique contribution of neighborhood-level characteristics independent to individual-level characteristics. Such information would be useful to inform planning of effective and cost-effective public health intervention strategies in reducing depressive symptoms in low-SES Chinese elderly populations. For example, professionals may promote elderly community empowerment through developing naturally occurring groups, and identifying community leaders to run peer activity groups for elders so as to expand social network and social capital. Urban planners should also consider choosing the right location for community facilities to enhance accessibility. For newly designed senior housing, availability of established medical facilities should be a consideration in the choice of site for location. In established, naturally occurring retirement communities, incentives from urban planners can be provided to attract development of medical facilities, which can include pharmacies, clinics, and community hospital. Although it may be possible that perceived proximity to medical facilities can be a proxy for that to other types of destinations, our results suggest that medical facilities may have a specific role compared with other types of facilities. Further research using longitudinal design and combined use of objective neighborhood characteristic markers, such as by means of geographic information systems, will provide more definite evidence. As the Chinese saying goes, it is better to have near neighbor than kin afar. To help improve the mental health of low-SES elders who spend much of their time interacting with their neighborhood, we need to sustain and strengthen neighborhood support in terms of both social and physical environment.

Disclosure statement No potential conflict of interest was reported by the authors.

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