Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12851 Self-efficacy in older adults with depression: a qualitative study Tri Nurhidayati,1,2 Atika Alfia Rizki,2 Dewi Setyawati,2 Ah Yusuf,1 Retno Indarwati1 1Doctoral Program, Faculty of Nursing, Universitas Airlangga, Surabaya; 2Department of Nursing, FIKKES Universitas Muhammadiyah Semarang, Indonesia Abstract Older people suffering from depression often exhibit low self- efficacy, which causes them to quickly give up on challenges caused by various problems related to ageing, such as physical, social and mental aspects, including depression, which ultimately impact their quality of life and productivity. Depression in the elderly is caused by physical, psychological, and social interac- tions with other people, especially caregivers in nursing homes. This study employed a phenomenological approach to analyse self-efficacy among older adults suffering from depression through qualitative inquiries. The participants who met the inclu- sion criteria lived in nursing homes for more than one year and experienced depression. In-depth interviews were conducted using a structured guide with a general self-efficacy scale (GSES), Indonesian version. The study was conducted in an older adult nursing home in 2022 with 14 older adults. The results were divid- ed into four themes – accompanying performance, vicarious learn- ing, verbal encouragement and emotional states – and indicated that older adults with depression experienced poor self-efficacy and described how to cope with poor self-efficacy. Introduction Mental health problems that generally occur in older adults are depression, loneliness, stress, anxiety, and fear of death. Self- efficacy is an individual’s ability to cope with stress and depres- sion experienced in difficult and stressful situations. Self-efficacy influences individual motivation and plays an important role in depression, namely, in controlling the events that occur.1 Several provinces in Indonesia show data that they have entered an old population structure, including Central Java (14.17%) entering the old population structure number three after DI Yogyakarta (15.52%) and East Java (14.53), followed by North Sulawesi (12.74%), Bali (12.71%), South Sulawesi (11.24%), Lampung (10.22%), and West Java (10.18%).2 Moreover, as age increases, the incidence of depression will be higher. According to data from National Research in Indonesia, the prevalence of depression increased with age, the highest being age 75 and over years at 8.9%, 65–74 years at 8.0%, and 55–64 years at 6.5%.3 In addition, almost all older adults (31 older adults) who were in the nursing home experienced mild depression (70.5%), nine older adults experienced moderate depression (20.5%) and four older adults did not experience depression (9.1%).4 Depression is a mood disorder characterised by sadness, feel- ings of loneliness, low self-esteem, and hopelessness. It is usual- ly accompanied by signs of psychomotor retardation or some- times agitation, withdrawal and other cognitive disorders, such as insomnia and anorexia.5 The results of a study by Pae showed that the majority of older adults who live in nursing homes expe- rience moderate depression,6 and the majority of older adults who live at home with their families experience mild depression. This is because older adults living in nursing homes live far away from their families, so they do not have the opportunity to share their problems and sorrows. Loneliness arises when you are away from your family because there are no more people to live with and share everything with. When feelings of loneliness increase, the stress factor increases and causes depression in older adults. Depression in older adults is caused by physical, psychologi- cal, and social interactions that are mutually detrimental and reduce the quality of life and work productivity of older adults. Psychological factors are characterised by unresolved conflicts (anxiety, guilt), memory decline and personality disorders.7 Another impact we can see is how older adults feel about them- Correspondence: Tri Nurhidayati, Department of Nursing, FIKKES Universitas Muhammadiyah Semarang, Jalan Kedung Mundu Raya No. 18 Semarang, Indonesia. E-mail: tri.nurhidayati-2022@fkp.unair.ac.id Key words: self-efficacy, older adults, depression. Contributions: all Authors discussed the results. First and second author responbility following: previous study and design and data collection. The others contributed the final manuscript. Conflict of interest: the authors declare that they have no known compet- ing financial interests or personal relationships that could have appeared to influence the work Funding: we thank the Nurse Program at the University of Muhammadiyah Semarang for the grant support in this study. Availability of data and materials: the data of this study are available on request from corresponding author. Conference presentation: this work was presented at the 3rd International Nursing Scholar Congress 2023, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia. Acknowledgments: we would like to thank all the collaborators who are currently working on this research. Received: 25 July 2024. Accepted: 25 July 2024. Early access: 25 July 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12851 doi:10.4081/hls.2024.12851 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 650] [Healthcare in Low-resource Settings 2024;12:12851] Non -co mmerc ial us e o nly selves if depression is not handled properly because it can make older adults want to harm themselves or even end their lives. To prevent the effects of depression, older adults must have the confi- dence to overcome problems and dare to change from darkness to light.8 Self-efficacy is a person’s belief that they can overcome problems by controlling events that affect their lives.9 People with high self-efficacy can identify their problems and solve them using their skills; they have beliefs that can influence their thoughts, feel- ings and actions.10 Previous research has shown that there is a strong connection between self-efficacy and depression, where the direction of the relationship is negative and increasing self-efficacy increases an individual’s ability to view himself positively. Someone with high self-efficacy can overcome depression. Conversely, someone with low self-efficacy will give up on existing problems more efficient- ly. However, the reactions of older adults with depression differ significantly. Some people can respond effectively, so they can quickly reduce depression, but males find it challenging to reduce depression and prevent it from affecting their health. Differences in the ability to reduce depression are closely related to the level of self-efficacy. Older adults with depression tend to have low self- efficacy. That is, they give up more easily, while older adults who are not depressed have high self-efficacy and tend to be more resilient in dealing with problems. Based on the explanation above, the significance of self-effica- cy in the prevention and management of depression among older adults highlights the need for interventions aimed at bolstering self-efficacy and coping mechanisms to enhance mental well- being in this demographic group. Self-efficacy can also increase an individual’s ability to assess themselves in order to achieve the desired effect, namely, in overcoming depression. To explore more details about self-efficacy in older people with depression, researchers are interested in conducting this research using quali- tative methods, which is a different research method from previous research. Materials and Methods Design This study is qualitative research using phenomenological methods and involves a detailed and iterative process for selecting areas to address in interviews and crafting the final list of ques- tions. Phenomenology seeks to understand and describe the lived experiences of individuals, focusing on their subjective percep- tions and interpretations of phenomena. Participants and setting The participants were older adults with at least moderate depression, the ability to communicate well and cooperatively, liv- ing in nursing homes and having the willingness to be respondents. Depression was measured using the DASS questionnaire.11 The exclusion criteria were older adults who refused participa- tion, had hearing and speech impairments, were sick, had chronic illnesses and were under special care. This research was conducted at the Pucang Gading Older Adults Social Service House in Semarang. Ethical considerations This study was already granted ethical clearance from the Faculty of Nursing and Health Sciences, University of Muhammadiyah Semarang, number 0188/KEPK/VII/2023. The participants were explained what the study included and joined voluntarily; their identities were not disclosed in the research reports. Data collection Data were collected using interviews with structured guide- lines. Data analysis In-depth interviews were conducted using an Indonesian ver- sion of the General Self-Efficacy Scale (GSES).12 The questions were used as a guide and further explored key topics discussed by the respondents. Each interview with respondents lasted between 35 and 45 minutes. The collected data were then analysed using manual Interpretive Phenomenological Analysis (IPA). Data col- lection was carried out by the first author as a head researcher and research members 1 and 2. Data processing and data analysis were carried out by the lead researcher and research members 1 and 2. Trustworthiness To ensure the trustworthiness of the data, the researcher used four criteria – credibility, confirmability, dependability, and trans- ferability. The credibility of the data was confirmed through peer checks. The research team members independently analysed the interviews and compared the concepts, categories, and themes to confirm the findings of the second and third authors and care- givers. The research stages and processes were recorded and reported step by step to warrant the dependability of the conclu- sions. Finally, data transferability was ensured through deep descriptions of the context. In this study, the researchers used source triangulation, in which data credibility was tested by veri- fying the information obtained from several sources. These care- givers were at the Pucang Gading Older Adults Social Service Home in Semarang. Results Fourteen respondents, four female and ten males, were used for this study. Furthermore, they were aged 65–86 years old. Two respondents had a senior high school education, three respondents had an education up until junior high school, and the others had an elementary school education, as shown in Table 1. The transcrip- tion verbatim was analysed, and 10 sub-themes were used for four different themes, as shown in Table 2. Based on the study’s results, the respondents’ characteristics showed that most were in the older adults category – female, ele- mentary school education, and Muslim. Theme 1. Performance accomplishments The elderly make efforts to solve problems by praying and remaining silent to solve problems; they choose to avoid thinking about problems too deeply. “Just pray and pray.” (P3) “There’s no need to try anything, sis. It’s better to be quiet, even though you have lots of thoughts about sleeping well.” (P5) The participants also admitted that life when they were still married was the most memorable thing. Respondents 3 and 4 stat- ed the following: “When can I gather with my wife, family and talk together Article [Healthcare in Low-resource Settings 2024;12:12851] [page 651] Non -co mmerc ial us e o nly again.” (P3) “Yes, family, get together. If we celebrate Eid al-Fitr together, it’s delicious.” (P4) Theme 2. Vicarious experience All participants felt the difference between the past and the present, and the description of the difference also varied. All par- ticipants in this study claimed to have friends of varying numbers. However, all participants had more than one friend. There were differences in their relationships with their friends at the nursing home, where most older adults felt that they did not get along with their friends. The majority of the elderly people felt that they did not fit in with their friends, as stated by respondent 1: “I don’t feel right. My inner self doesn’t match at all because his behaviour doesn’t adhere to religion.” (P1) Some elderly people did feel happy when they were with their friends, namely, Respondent 3: “Yes, I’m happy, but it depends on the chat.” (P3) Theme 3. Social persuasion According to the interview results, 10 of the 14 participants, before living in the nursing home, used to live with their families. This shows that there is an effect of persuasion from the family, which may still leave an impression on the participants, as stated by Respondent 2: “Yes, between children and family.” (P2) However, some elderly people also admitted that before living in an institution, they used to live alone or had no family to accom- pany them. So they did not have another choice to live in an nurs- ing home. Respondent 1 also said the following: “In the past, I also lived with my family. Not long ago, I didn’t live anymore. I divorced my wife.” (P1) Theme 4. Physiological and emotional states All participants admitted that their families did not want to care for older adults. Although the reasons are unknown, all older adults acknowledged that their families did not want to care for them anymore, so they sent them to a different home. Respondents 4 and 6 admitted the following: “Because no one takes care of it; no one wants to take care of it.” (P4) “Because no one took care of me, my parents were gone, and my wife and children left me.” (P6) Article Table 1. Distribution of respondents based on age, gender, religion and education 2023 (n = 14). No Respondent's initials Age (years) Gender Religion Level of education 1 MM 86 Male Islam Elementary School 2 JS 75 Male Christianity Elementary School 3 M 61 Male Christianity Senior High School 4 Q 71 Male Christianity Senior High School 5 S 69 Male Islam Elementary School 6 MB 65 Male Christianity Junior High School 7 NA 70 Female Islam Elementary School 8 SE¬ 65 Female Islam Junior High School 9 N 76 Male Islam Junior High School 10 R 67 Male Islam Elementary School 11 NN 78 Female Islam Elementary School 12 J 80 Female Islam Elementary School 13 CA 68 Male Islam Elementary School 14 W 65 Male Islam Elementary School Table 2. Themes and sub-themes. Themes Sub-themes Performance accomplishments Active and responsible Learning from the past Vicarious experience Relationships with fellow seniors Daily activities Social persuasion Residence Physical state Physiological and emotional states Relationship with family Family abandonment Older adults’ feelings Positive outlook and religion Active and responsible [page 652] [Healthcare in Low-resource Settings 2024;12:12851] Non -co mmerc ial us e o nly The reason was validated by the caretaker of the nursing home room, who said that there were indeed older male adults in the nursing home who were placed in the care of their families. The families admitted that they were unable or unwilling to care for these older adults in their respective homes. Almost all older adults admit that they feel neglected by their families. However, one older adult did not answer the question of whether he felt neglected by his family. This is shown by snippets of conversation between Respondents 3 and 4, namely, the following: “Yes, actually, yes, sis, it’s not quite enough, miscommunica- tion. There’s no one to contact. It’s difficult for me to contact you.” (P3) “Yes, miss, I feel neglected.” (P4) Male older adults felt sad and resigned from leaving the nurs- ing home. They feel sad, either remembering the past, uncomfort- able or free and unable to do anything. As stated by Respondent 8, he feels resigned to having lived in a nursing home for many years. “...I gave up, but it made me feel at home here...” (P8) Even Respondent 1 admitted that he wanted to get out of the nursing home but could only give up because there wasn’t much he could do alone. “If I can get out, I want to get out, and it’s as if later, if I go out- side, what business do I want to do? The problem is that if you try, it’s possible that if Allah blesses you, you can. Here, I surrender the deck. This is how the cake is. Eat here is what it is.” (P1) The nursing home ’s caretaker confirmed that these older adults feel hopeless, resigned, and often look sad. The nursing home ’s caretaker said that older adults had residual sadness from past failures when they were young. However, they grew much more sincere and can accept or surrender to the situation. Almost all participants admitted to feeling pessimistic and doubtful about maintaining and achieving their current life goals. This illustrates that self-efficacy is still poor. “If it’s not here at all, I’m like a paralysed pessimist. I’m here. Just die or live.” “Not here at all, miss. Not receiving satisfaction at all, hope- less, pessimistic, negative thoughts all the time.” (P8) However, one participant said that he felt he could maintain and achieve his current life goals. “I’m sure it is. I can ask Allah to make it easier. If you are blessed, you can achieve it. My efforts are praying, praying, pray- ing, dhikr, dhikr and dhikr.” (P10) This was reinforced by the statement by the caretaker of the nursing home that male older adults in the nursing home felt resigned and pessimistic about achieving their goals in life. Discussion The attitudes of older adults in dealing with problems in this study varied. Some felt sad and anxious. Some were sincere in fac- ing problems. Older adults tend to have worse cognitive functions than younger adults. Even older adults without neurodegenerative diseases or cognitive disorders tend to make bad decisions. This was due to decreased brain function in the frontal lobe.13-15 Impaired cognitive function and worsening decisions could affect the attitudes of older adults in dealing with problems. In this study, feelings of sadness and anxiety can also be affected by depression experienced by older adults. According to previous research, feel- ings of fear, anxiety or sadness often appear in someone who is diagnosed with depression.16 So this is in line with the results of the study. In older adults with depression, there were symptoms of anxiety and sadness. In dealing with problems, the older adults in this study had var- ious ways, including praying and staying silent. At the same time, praying is said to be an intervention for solving spiritual problems. Praying can improve a person’s condition from a psychological perspective and improve how they control their emotions. Thus, praying can help older adults deal with the problems that occur to them because it has a psychological impact, especially on older adults in this study experiencing depressive disorders. Moreover, silent treatment, which is an attempt to avoid verbal communica- tion and ignore other people, can take a toll on the person being refused communication, which can cause social pain that even acti- vates the part of the brain that regulates physical pain. However, for someone who does engage in silent treatment, there is still a lack of data to show whether this is beneficial or detrimental from a psychological perspective.16 Some older adults in the Pucang Gading Semarang home care feel that there has been no significant change since living in the nursing home. However, some feel a change, even though they feel uncomfortable living in the nursing home. Some older adults resid- ing in nursing homes feel underappreciated and disempowered, resulting in feelings of alienation and increased powerlessness. They also felt limited in their activities and contact with family or friends. This perception of older adults can also affect their quality of life. In this study, the quality of life of older adults was disturbed because they felt less empowered and had limited activities and contact with family and friends.17 In addition, in this study, it was found that there were several conflicts in this nursing home, including incompatibility with fel- low friends in the nursing home; relationships with fellow resi- dents are associated with perceptions of social support.18 This means that good co-resident relations will increase the perception of social support for someone. In this study, older male adults did not have good relationships with fellow residents, which raised the risk of poor social support for those living in the Pucang Gading home care in Semarang. Older adults or the elderly are people over 60 years old. Some changes occur in older adults, both physically, mentally, and socially. Physical changes that occur include decreased physical strength, stamina, and appearance. This can cause some older adults to become sad, unhappy and depressed when they enter old age. Older adults also become ineffective in their daily work and social roles due to their energy or physical limitations.19 In addition, older adults also feel tired when they become older adults in an older adult home. Fatigue is a feeling of discomfort, weakness, extreme tiredness, and loss of control. Fatigue is also associated with decreased mobility, cognitive function, and the risk of hospitalization.20 One of the respondents felt fatigued, and he needed a walker. This can have an impact on the physical health experienced by older adults. Most older adults feel resigned to living in a nursing home, even though they feel uncomfortable. In this study, older adults lived in this nursing home because their families placed them there Article [Healthcare in Low-resource Settings 2024;12:12851] [page 653] Non -co mmerc ial us e o nly or there was no family to care for them. Some of the older adults in this study felt uncomfortable living in the Pucang Gading older adults’ social service home, Semarang. Older adults who live at home with their families have better psychological conditions compared to those who live in aged care homes.21 Similar to the results of previous research, older adults can feel resigned because they can no longer work optimally in aged care homes.11 The feel- ing of surrender or hopelessness in older adults is a form of nega- tive emotion that often occurs due to aging. It is faced negatively, such as not doing daily activities and avoiding social relationships with those around them. A sense of resignation is one of the causes of mental health problems, especially depression and suicidal ideation. Older adults face male mental problems, as in this study, where some older adults have family problems. The family plays a vital role in improving the quality of life of older adults. The fam- ily is part of the closest core community that can pay attention to and hear the complaints of older adults directly.24 If older adults have problems with the family, communication automatically becomes poor, and older adults do not have a place to complain or tell stories. No one pays any attention, either. When older adults are placed in a nursing home, many things happen or are felt by older adults. In this study, some older adults did not accept being placed in the nursing home, so they fought and felt uncomfortable living there. As a place of care for older adults, providing good (clinical) care and a home-like environment is a big challenge for older adults’ social service homes. Suppose the nursing home provides a sense of home or a feeling of being at home. In that case, older adults will feel at home and comfortable living at an older adults’ social service home and can carry out their daily activities with more enthusiasm. According to the study results, most respondents felt resigned from being placed in this social institution for older adults. Older adult neglect is the most common type of abuse or mis- treatment. In a systematic review of the prevalence of older adult maltreatment, researchers concluded that around 20% of all depen- dent older adults suffer from neglect.22 Neglect by the family caus- es older adults to experience feelings of loneliness. There is a cor- relation between a high loneliness score and the risk of mistreat- ment or abuse in older adults. Loneliness is a complex concept involving both psychological and social aspects. This also aligns with the research results, where all older adults feel lonely living in the Pucang Gading home care and feel like they do not have friends. Loneliness can affect phys- ical health, sleep quality, and mental health and can cause a risk of cardiovascular disease.22 Self-efficacy is an individual’s belief in their ability to perform the tasks entrusted to them. The higher the self-efficacy, the higher the confidence in an individual’s ability to achieve success. In dif- ficult situations, people with low self-efficacy will quickly reduce their efforts or give up.23 In this study, some older adults feel pes- simistic about achieving life goals, but some remain optimistic, trying and praying to maintain and achieve life goals. Older adults with lower self-efficacy tend to limit themselves to daily life activ- ities. Those with higher self-efficacy are more proactive in seeking health information, in self-care behaviour and in complying more with the treatment.24 Self-efficacy can have a two-way relationship with depressive symptoms based on Hammen’s theory of stress generation of depression and Bandura’s sociocognitive theory, where people who experience depressive symptoms generate more interpersonal stressors than healthy people.26 People feel they can- not deal with and solve interpersonal problems when faced with interpersonal stressors. In other words, people who have lower lev- els of emotional and social self-efficacy can lead to increased depressive symptoms.17,27 In this study, older adults tended to have low self-efficacy due to their perceived pessimism about achieving life goals. This can be caused by the depressive condition experi- enced by older adults and can also exacerbate depression. The researchers acknowledged that their study had certain lim- itations. One of the limitations is the presence of biased factors that may have influenced the self-efficacy of elderly people who suffer from depression, which were not taken into account during the study. Additionally, there may be some degree of subjectivity in interpreting the research results obtained through interviews with respondents. To minimise this, the researchers carried out source triangulation by cross-checking the data with facts obtained from informants and other research studies. The self-efficacy of older adults with depression at the Pucang Gading Older Adults social service home in Semarang was described through 4 themes – performance accomplishment, vicar- ious learning, verbal encouragement, and emotional states. Older adults who have low efficacy fail to achieve life goals and exacer- bate depression. Therefore, nurses can play a role in helping adults achieve success and fulfilment in different areas of their lives. 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