Rehabilitation nursing with social support improves depression in elderly chronic disease patients based on advocacy promotion theory

Abstract

BACKGROUND

Depression in elderly patients with chronic diseases is a prevalent issue exacerbated by insufficient social support and traditional care models. While social support and rehabilitation nursing are recognized as beneficial, their integration under a motivational framework remains underexplored. Advocacy-promotion theory offers a structured approach to empower patients and mobilize multi-level support systems. This study hypothesizes that a rehabilitation nursing intervention, enhanced by social support and grounded in advocacy-promotion theory, will significantly improve depressive symptoms, self-efficacy, sleep quality, and overall quality of life in community-dwelling elderly patients with chronic diseases compared to conventional care.

AIM

To investigate the efficacy of advocacy-promotion-based rehabilitation nursing with social support on depression in elderly chronic disease patient.

METHODS

In this randomized controlled trial, 60 elderly patients with chronic diseases were randomly assigned to an observation group (n = 30) or a control group (n = 30). The control group received standard care and social support, while the observation group received an additional intervention based on advocacy-promotion theory. Outcomes included scores on the General Self-Efficacy Scale, Pittsburgh Sleep Quality Index, 17-item Hamilton Depression Rating Scale, World Health Organization Quality of Life for Older Adults module, and nursing satisfaction.

RESULTS

Compared to the control group, the observation group demonstrated significantly greater improvement in all measured outcomes. Post-intervention scores in the observation group were higher for self-efficacy (General Self-Efficacy Scale: 32.87 ± 8.96 vs 28.47 ± 7.60, P = 0.044) and quality of life (World Health Organization Quality of Life for Older Adults module: 80.14 ± 5.12 vs 74.67 ± 4.93, P < 0.001). Scores were lower for depression (17-item Hamilton Depression Rating Scale: 20.96 ± 4.68 vs 24.53 ± 4.49, P = 0.005) and sleep disturbance (Pittsburgh Sleep Quality Index: 8.75 ± 2.62 vs 10.93 ± 3.07, P = 0.005). Nursing satisfaction was also significantly higher in the observation group (93.33% vs 73.33%, P = 0.038).

CONCLUSION

Rehabilitation nursing integrated with social support and advocacy-promotion theory effectively improves self-efficacy, sleep quality, depressive symptoms, and overall quality of life in elderly patients with chronic diseases.

Key Words: Advocacy and promotion theory; Rehabilitation nursing; Chronic diseases of the elderly; Depression; Self-efficacy; Sleep quality; Quality of life

Core Tip: This study investigates the effectiveness of a rehabilitation nursing intervention, combining social support and advocacy-promotion theory, in reducing depressive symptoms among older adults with chronic conditions. It highlights the rising burden of age-related diseases, the intertwined relationship between chronic illness and mental health, and the urgent need for comprehensive interventions to improve elderly care and mental health outcomes. The findings aim to provide evidence for enhancing community health management and elderly care services.

INTRODUCTION

Healthy life expectancy has not increased in tandem with the significant increase in global life expectancy in recent decades, which has led to an increase in the burden of age-related diseases and an increased risk of chronic diseases for the elderly due to the chronic increase in underlying systemic inflammation[1,2]. The global rise in population aging has led to a significant increase in the incidence of age-related health conditions. Chronic illnesses - including cardiovascular and cerebrovascular disorders, diabetes, and Alzheimer’s disease - are particularly prevalent among older adults. These conditions not only impair physical well-being but also impose substantial psychological and emotional challenges, affecting overall quality of life and increasing the demand for comprehensive geriatric care[3]. Chronic diseases have multiple definitions, usually including the concepts of persistent illness, impact on daily life, and the need for continuous management[4]. Research shows that middle-aged and older adults with multiple chronic conditions face an increased risk of depression, creating a self-perpetuating cycle where poor mental health worsens physical health, and vice versa, complicating long-term management[5]. Therefore, how to effectively improve the depression of elderly patients with chronic diseases has become an important issue that needs to be urgently addressed in the current medical and social work fields.

Rehabilitation nursing, as an important means of promoting the physical and mental health of the elderly, plays an indispensable role in helping patients restore function and improve quality of life. In recent years, social support has become increasingly important as an important factor affecting the mental health of the elderly. Increased social support can prevent functional decline in the elderly, which is related to the increase of depressive symptoms[6]. At present, the routine community nursing model is often combined with basic social support, which usually includes health education, family communication and encouragement to participate in social activities. This traditional intervention model often focuses on one-way knowledge transmission and behavioral persuasion, which makes patients mostly in a passive compliance state, and their intrinsic management motivation and self-efficacy are difficult to be effectively activated. At the same time, the support provided is usually scattered and lacks system, and fails to fully integrate resources from multiple levels such as community, family and policy, resulting in insufficient coordination and sustainability of intervention. A deeper limitation is that its intervention focus is mostly on symptom relief and health knowledge dissemination, and fails to truly empower patients and their support networks to become active advocates and continuous participants in health management. These limitations may lead to limited effectiveness and insufficient sustainability of traditional support models in dealing with complex and persistent depressive moods.

The concept of advocacy is a relatively new concept proposed internationally in recent years. It has been successfully tried in solving many social problems. Its essence is to make appeals and promote action. From advocacy to mobilization to action, multiple specific actions constitute a continuous and comprehensive action to ultimately achieve a long-term goal. In order for nurses to effectively influence the quality of healthcare, they must contact policymakers and include nursing issues on the policy agenda[7]. Introducing advocacy theory into rehabilitation nursing is precisely to make up for the above-mentioned shortcomings of the traditional social support model. This theory emphasizes patient-centeredness. Through a systematic cycle of identification, mobilization and action, it not only provides support to patients but also strives to stimulate their own subjectivity and intrinsic motivation, build and integrate a multi-level support alliance from policy, community, family and professional institutions, and thus promote continuous and collaborative change from cognition to behavior. This model transforms patients from passive care recipients into active participants with self-management capabilities and the ability to mobilize resources, thereby potentially improving their psychosocial state more deeply and lastingly.

This study aimed to evaluate the efficacy of a rehabilitation nursing intervention, incorporating social support and guided by advocacy-promotion theory, in alleviating depressive symptoms among community-dwelling older adults with chronic conditions. Through this study, we hope to provide strong evidence to support mental health interventions for the elderly and offer practical guidance for the development of community health management and elderly care services.

MATERIALS AND METHODS

General information

This study protocol was reviewed and approved by the Shaoyang University Ethics Committee. The study was conducted from June 2022 to December 2024, randomly selecting 60 patients from community-based chronic disease records. Patients were randomly assigned to a control group and an observation group using a random number table, with 30 patients in each group.

Inclusion criteria: (1) Age ≥ 60 years; (2) Having at least one chronic disease; (3) Hamilton Depression Rating Scale [17-item Hamilton Depression Rating Scale (HAMD-17)] score ≥ 8; and (4) Patients volunteered and signed an informed consent form.

Exclusion criteria: (1) Patients with malignant tumors; (2) Patients with cognitive impairment; and (3) Patients who withdrew from the study.

Methods

The control group received conventional care combined with social support care. Conventional care included health education, diet, medication management, and exercise guidance. Social support involved explaining disease-related knowledge to patients, their families, and friends to help them understand the disease. This involved encouraging their friends and family to show concern and encouragement, affirmation, and participation in social activities, strengthening interpersonal relationships, alleviating patients’ sense of social deprivation, and boosting their confidence in treatment and recovery.

The observation group adopted rehabilitation care combined with social support care based on the advocacy and promotion theory. The advocacy and promotion theory includes four stages: Advocacy, alliance, publicity, and action: (1) Advocacy stage: In this stage, by analyzing the characteristics of the elderly in the pilot community, the key factors affecting their depression were identified and specific publicity and intervention measures were formulated accordingly; (2) Alliance stage: In this stage, a multi-level advocacy plan was formulated based on the core issues, covering policy, public and integrated advocacy, and a policy advocacy alliance and a public advocacy alliance were established. The former includes local governments, health departments, universities, research institutes and the Communist Youth League, while the latter includes project teams, community organizations, health centers, families and public welfare organizations. The project team will collaborate with the government and relevant organizations to hold a kick-off meeting in the pilot community, establish a special group, clarify the division of labor, and ensure organizational and personnel support for subsequent implementation; and (3) Publicity stage: This stage involves the formulation, release and dissemination of information. In the information formulation stage, based on the main health problems and issues identified by the pilot community, the core information and supporting content of health education for the elderly are designed to ensure that the content is scientific, easy to understand and has dissemination power. Information release and dissemination are carried out by the government and the public through the special group established in the alliance stage. Specific measures include the release of promotional videos, posters and free clinics by the Health and Family Planning Bureau or the Health Education Center through the media, community health service centers and other channels; the project team jointly organizes lectures, special events and regularly pushes information through WeChat public accounts with grassroots health personnel. By comprehensively covering core information, it stimulates the continued attention of the society and the elderly, thereby changing the public's cognition and handling of health issues; and (4) Action stage: In this stage, a series of health management activities are carried out mainly under the impetus of policy advocacy and public advocacy. First, holding special lectures and training, aiming to explain to government officials and managers how policies and governments can play a synergistic role in the creation of health zones, health education, health promotion and high-quality development of the health industry through policy advocacy goals, enhance the management awareness and capabilities of government personnel, and thus improve the quality of health services. Second, on the basis of basic public health services, strengthen collaborative management and provide personalized and precise health services and management. Third, conduct lectures based on personalized health management needs and major health issues in the pilot communities.

Observation indicators

Self-efficacy assessment: Self-efficacy was evaluated using the General Self-Efficacy Scale (GSES), a validated instrument comprising 10 items, each rated on a 4-point Likert-type scale. The composite score ranges from 10 to 40, with higher values indicating greater self-efficacy and lower scores reflecting diminished confidence in one’s ability to cope with challenges. A score toward the lower end of the scale suggests reduced perceived self-efficacy[8]. The study assessed patients’ confidence in managing their chronic disease and coping with depressive symptoms before and one week after the intervention.

Sleep quality assessment: Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), a widely utilized instrument comprising seven components, each rated on a 3-point scale[9]. The total score ranges from 0 to 21, with higher values indicating greater sleep disturbance and poorer overall sleep quality. Thus, an elevated PSQI score reflects more severe impairments in sleep patterns and related domains. The study evaluated the intervention’s effect on improving patients' overall sleep quality by comparing changes in the total PSQI score before and after the intervention.

Depression assessment: The severity of depressive symptoms was assessed using the HAMD-17, a clinician-administered instrument with a total possible score of 52[10]. This scale evaluates multiple dimensions of depression through 17 individual items, with higher composite scores indicating greater symptom severity. Therefore, an increase in the total score corresponds to a more pronounced level of depression. The study assessed patients before and after the intervention to quantify the degree of relief of core depressive symptoms.

Quality of life assessment: To evaluate the quality of life in older adults, the World Health Organization Quality of Life-Older Adults module (WHOQL-OLD) was employed[11]. This instrument comprises 24 items distributed across six domains, generating a total score ranging from 0 to 100. Higher scores reflect better perceived well-being and overall life satisfaction, with the scale specifically designed to capture age-related aspects of physical, psychological, and social functioning. Thus, a greater composite score indicates a higher quality of life. The study comprehensively evaluated the intervention's impact on the well-being of elderly patients in terms of physical, psychological, social relationships, and environmental aspects using this scale.

Nursing satisfaction: The satisfaction of the two groups of patients after receiving the nursing intervention was recorded. It was divided into very satisfied, basically satisfied, and dissatisfied. Satisfaction (%) = (very satisfied + basically satisfied)/total number of cases × 100%.

Statistical analysis

Using SPSS Data were analyzed using 25.0 software. Enumeration data are expressed as n (%) and analyzed using the χ² test; measurement data are expressed as mean ± SD and analyzed using the t test. P < 0.05 was considered statistically significant.

RESULTS

Comparison of general data

There were no significant differences in general characteristics such as gender, age, and degree of depression between the two groups (P > 0.05), indicating that the baseline data of the two groups were balanced and comparable (Table 1).

Table 1 Comparison of general information, n (%).

Characteristics	Control group (n = 30)	Observation group (n = 30)	χ2/t	P value
Gender			0.601	0.438
Male	17 (56.67)	14 (46.67)
Female	13 (43.33)	16 (53.33)
Age (year), mean ± SD	64.90 ± 2.85	65.13 ± 2.14	0.204	0.839
Depression level			0.501	0.778
Mild	21 (70.00)	23 (76.67)
Moderate	7 (23.33)	6 (20.00)
	2 (6.67)	1 (3.33)

Comparison of self-efficacy

Before the intervention, there was no significant difference in GSES scores between the two groups, but after the intervention, the GSES score of the observation group was significantly higher than that of the control group (P = 0.044) (Table 2).

Table 2 Comparison of self-efficacy, mean ± SD.

Group	GSES
	Before intervention	After intervention
Control group (n = 30)	21.27 ± 7.33	28.47 ± 7.60
Observation group (n = 30)	20.93 ± 7.05	32.87 ± 8.96
t	0.271	2.056
P value	0.787	0.044

GSES: General Self-Efficacy Scale.

Comparison of sleep quality

Before the intervention, there was no significant difference in PSQI scores between the two groups, but after the intervention, the PSQI score of the observation group was significantly lower than that of the control group (P = 0.005) (Table 3).

Table 3 Comparison of sleep quality, mean ± SD.

Group	PSQI
	Before intervention	After intervention
Control group (n = 30)	15.72 ± 3.44	10.93 ± 3.07
Observation group (n = 30)	16.13 ± 3.25	8.75 ± 2.62
t	0.497	2.932
P value	0.621	0.005

PSQI: Pittsburgh .

Comparison of depressive mood

Before the intervention, there was no significant difference in HAMD-17 scores between the two groups, but after the intervention, the HAMD-17 score in the observation group was significantly lower than that in the control group (P = 0.005) (Table 4).

Table 4 Comparison of depressive mood, mean ± SD.

Group	HAMD-17
	Before intervention	After intervention
Control group (n = 30)	33.04 ± 4.82	24.53 ± 4.49
Observation group (n = 30)	32.73 ± 4.06	20.96 ± 4.68
t	0.318	2.927
P value	0.752	0.005

HAMD-17: 17-item Hamilton Depression Rating Scale.

Comparison of quality of life

Before the intervention, there was no significant difference in WHOQL-OLD scores between the two groups, but after the intervention, the WHOQL-OLD score in the observation group was significantly higher than that in the control group (P < 0.001) (Table 5).

Table 5 Comparison of quality of life, mean ± SD.

Group	WHOQL-OLD
	Before intervention	After intervention
Control group (n = 30)	66.94 ± 5.72	74.67 ± 4.93
Observation group (n = 30)	67.29 ± 5.23	80.14 ± 5.12
t	0.304	4.204
P value	0.762	< 0.001

WHOQL-OLD: World Health Organization Quality of Life for Older Adults module.

Comparison of nursing satisfaction

After the intervention, the nursing satisfaction of patients in the observation group was significantly higher than that in the control group (93.33% vs 73.33%, P = 0.038) (Table 6).

Table 6 Comparison of nursing satisfaction, n (%).

Group	Very satisfied	Basically satisfied	Dissatisfied	Satisfaction
Control group (n = 30)	17 (56.67)	5 (16.67)	8 (26.67)	22 (73.33)
Observation group (n = 30)	20 (66.67)	8 (26.67)	2 (6.67)	28 (93.33)
χ2	-	-	-	4.320
P value	-	-	-	0.038

DISCUSSION

As the proportion of the elderly population in the population steadily increases, most elderly people are burdened with illness and disability in their later years. Therefore, it is necessary to develop global strategies and extensive research to address social and medical service challenges[12,13]. Chronic diseases in the elderly are wide-ranging, including cardiovascular and cerebrovascular diseases, respiratory diseases, digestive system diseases, neurological or memory-related diseases, etc[14]. The rising incidence of chronic illnesses among older adults due to global population aging has been identified as a significant factor contributing to depression, highlighting the critical intersection between physical and mental health in later life[15,16]. Depression not only exacerbates the course of chronic diseases, but also reduces patients’ self-management ability, compliance, and quality of life, thereby affecting the effectiveness of rehabilitation care. Therefore, exploring effective intervention measures to improve depression in elderly patients with chronic diseases has become one of the hot topics in modern geriatric nursing research.

Advocacy refers to the process of motivating, publicizing, and carrying out a series of actions to the general public or organizations on a hot social topic, thereby prompting changes in their cognition, attitudes, and behaviors toward the event, and thus promoting the realization of advocacy claims. Social support plays a crucial role in mitigating the impact of loneliness on depressive symptoms among older adults, with empirical evidence suggesting it significantly moderates the association between these factors, reducing the likelihood or severity of depression and promoting psychological resilience in the aging population[17]. Research indicates that older adults benefit significantly from receiving social support. Adequate and well-targeted support networks contribute to enhanced overall health, help mitigate risks to both physical and psychological well-being, and are associated with a range of positive outcomes, including improved emotional regulation, greater resilience to stress, and better management of chronic conditions[18]. These findings highlight the essential role of social connectedness in promoting healthy aging. Reduced levels of social support are associated with a heightened risk of difficulties in self-management, limitations in daily functioning, and increased reports of pain, discomfort, anxiety, and depressive symptoms. This relationship tends to strengthen over time, indicating a positive correlation between the duration of inadequate support and the worsening of these adverse health outcomes[19]. Building on these findings, the present study seeks to investigate the impact of a rehabilitation care intervention that integrates social support within the framework of advocacy-promotion theory. Specifically, it examines the effectiveness of this combined approach in alleviating depressive symptoms among community-dwelling older adults who are managing chronic illnesses.

First, this study found that the GSES score of the observation group increased to 32.87 ± 8.96 points after intervention, which was significantly higher than that of the control group 28.47 ± 7.60 points (P = 0.044), indicating that rehabilitation nursing based on advocacy facilitation theory can effectively enhance patients’ self-management ability and self-confidence. Self-efficacy, as the core psychological resource for chronic disease management[20], can be attributed to the empowering core of this theory: By accurately identifying individual needs in the advocacy stage and providing personalized health management in the action stage, patients are promoted from passive recipients to active managers, directly strengthening their positive beliefs. This role change not only enhances patients’ confidence in disease control and promotes their more active participation in self-monitoring and intervention[21], but also, through the combination with rehabilitation nursing and social support, further consolidates self-efficacy while providing emotional support, thereby forming a virtuous cycle of improving mood and health.

In this study, the PSQI score of the observation group decreased to 8.75 ± 2.62 points after intervention, which was significantly lower than that of the control group 10.93 ± 3.07 points (P = 0.005), indicating that rehabilitation nursing based on advocacy facilitation theory can significantly improve the sleep quality of patients. Sleep disorders and depressive mood are often mutually causal[22], and elderly patients with chronic diseases are particularly prone to falling into a vicious cycle of depression and insomnia due to physical discomfort or psychological stress. Intervention based on advocacy facilitation theory provides patients with stable emotional support and practical help through the construction of a multi-level social support alliance (family, community, professional institutions), effectively alleviating their loneliness and anxiety at night; at the same time, personalized nursing and the improvement of self-efficacy also enhance patients’ confidence in actively managing sleep and coping with discomfort, thereby promoting the improvement of sleep quality at both the physical and mental levels, and further laying the physiological and psychological foundation for the relief of depressive mood.

The core of this study is that it directly brought about a significant relief of depressive mood. The HAMD-17 score of the observation group dropped to 20.96 ± 4.68 points, which was more significant than that of the control group 24.53 ± 4.49 points (P = 0.005). This effect is a comprehensive manifestation of the aforementioned improvements. Depression, as a complex psychological disorder, is often manifested as symptoms such as low mood and loss of interest. In severe cases, it may even be accompanied by the risk of suicide[23]. The advocacy facilitation theory does not rely solely on psychological counseling, but rather uses a systematic “advocacy-alliance-advocacy-action” framework to improve self-efficacy at the individual level, strengthen social support at the interpersonal level, and create a caring atmosphere at the community level for multi-target intervention. Social support provides emotional comfort and practical help, reducing loneliness; enhanced self-efficacy promotes patients to face the disease positively. This multi-level, systematic support network can more comprehensively address the physical and mental needs of elderly patients with chronic diseases, fundamentally reduce their helplessness and despair, and thus effectively reduce the level of depression.

Furthermore, the comprehensive improvement of patients' quality of life is the logical necessity of this study. The WHOQL-OLD score of the observation group significantly increased from 67.29 ± 5.23 before intervention to 80.14 ± 5.12, which was better than that of the control group (74.67 ± 4.93) (P < 0.001), which strongly proved the overall effectiveness of this intervention model. Quality of life is a comprehensive reflection of physical and mental health and social function. When patients' self-efficacy, sleep quality and depressive mood are improved, their ability to participate in society and enjoy life will naturally be enhanced. Studies have shown that social support, positive emotion regulation and other factors are key to improving the quality of life of the elderly[24]. The advocacy facilitation theory promotes collaborative management and personalized services, which not only improves physical health, but also strengthens psychological state and social support network, thereby accurately meeting the diverse needs of elderly patients with chronic diseases, helping them maintain a positive attitude, enhance their confidence in life, reduce feelings of isolation and helplessness, and ultimately achieve an overall leap in quality of life.

In terms of nursing satisfaction, the observation group reached 93.33%, which was significantly higher than the control group’s 73.33%, indicating that rehabilitation nursing based on the advocacy facilitation theory combined with social support can effectively gain the recognition of patients. Nursing satisfaction not only reflects service quality but also indirectly demonstrates the positive impact of interventions on physical and mental health. High satisfaction is typically closely related to personalized care, emotional support, and tangible results. This intervention model emphasizes patient agency, using advocacy and facilitation theory to shift the nursing process from giving to collaboration. While providing emotional and practical assistance, it enhances patients' sense of participation, control, and trust. This patient-centered, comprehensive nursing model better meets the diverse needs of elderly patients with chronic diseases, improving not only the service experience but also laying a solid foundation for improved treatment adherence and long-term outcomes.

CONCLUSION

In summary, the results of this study indicate that rehabilitation nursing based on advocacy and facilitation theory, combined with social support, can effectively improve the depressive mood of elderly patients with chronic diseases in the community by enhancing self-efficacy, improving sleep, alleviating depressive mood, and improving quality of life and satisfaction. This demonstrates a comprehensive and personalized nursing philosophy and its practical significance and application prospects in geriatric care. While the randomized controlled design improved the reliability of the results, limitations remain: The samples were all from the same community, exhibiting high homogeneity, which may limit the general applicability of the conclusions in communities with different backgrounds. Future research could involve multicenter, large-sample randomized controlled trials to include more diverse populations, in order to verify the broad applicability, long-term benefits, and cost-effectiveness of this model. Furthermore, it could explore its differentiated effects and optimization pathways in patients with different chronic disease subtypes and different levels of depression, thereby providing more solid evidence for the improvement and promotion of this intervention model.