Impact of Socioeconomic status on depression of Elderly in Punjab, Pakistan

Background/ Objectives: The present study explores the impact of socioeconomic status on the depression of the elderly. The study has been conducted on 800 respondents in Punjab, Pakistan. The main objective of the research was to examine the impact of socioeconomic status on geriatric depression of the elderly. Methods/ Statistical analysis: Questionnaires were used to collect data. Survey research designwas used. Simple randomsampling technique was used for the particular research. Findings: The results showed that socioeconomic has a significant negative correlation with the level of depression. This shows that thosewhohave higher level of socioeconomic status tended to have lower level of depression. The ability to do routine activities in daily life is based on socioeconomic status was the most prevailing factor of having good mental health in old age. Novelty/Applications : The scholarship recommended that socioeconomic status is related to mental health and has a negative effect on people overall mental health in old age. Based on the findings, it is recommended that governmentmay develop programs such as social security for the elderly people that will help them in maintaining their socioeconomic status. Mental health practitioners must focus on the interventions that will recognize the importance of mental health in later ages.


Introduction
Socioeconomic status of all ages plays an important role in Pakistan. It becomes more prominent as one gets older. People of high income status and education tend to be happier and less likely to suffer from depression and other psychiatric disorders than people with low socioeconomic status (1)(2)(3)(4) . The increasing older population needs to be given considerable attention to this issue. As Pakistan, is in the united nations list of some Asian nations where the elderly population is increasing to its limit by 2025 (5) . The older populace is expanding, especially in the creating nations of the world. There were progressively matured (over 60 years or more) universally as compared to the youngsters https://www.indjst.org/ under 5 years as per the 2012 report of the United Nations Population Fund (UNPF), in 2000. Likewise, it is considered that the world will have more matured individuals than the kids under 15 years in 2050. The primary purpose for this developing pace of the old populace is the decrease in death rate because of the progressions made in the fields of medication and nourishment whereby maturing, somewhat, can be anticipated or deferred. This improved future has eventually expanded the quantity of more seasoned individuals and can live long because of better sustenance, cleanliness and medicinal services (6) .
Pakistan is an underdeveloped country where the problems of finances are very significant. Low socioeconomic status is associated with morbidity of depression most prominently in old age. As people age their depression increases due to many factors and low socioeconomic status is one of them. In countries like Pakistan there is no welfare support for lower SES groups they also faced less favorable access to health care and less likely to use specific mental care. Depression exhibits an association with socioeconomic status among all psychiatric disorders (7) .
In the same manner, senior residents have better added to the improvement of the general public during their gainful time. Like youngsters and ladies there are no privileges for more established individuals (8) . Be that as it may, keeping in account the life-changing administrations concentrated by the old in various limit, the United Nations pronounced fifth October to be seen as an International Day of the more established people over the globe (9) . The present populace of Pakistan is 191,326,717 and this is proportional to 2.57% of the all-out total populace as indicated by the United Nations appraises. Among these we have almost 18 million of old matured 60 or more (10) . The state is answerable for the arrangement of fundamental wellbeing offices, for example nourishment, cover, wellbeing, yet sadly this isn't useful in Pakistan because of the lack of ability of the state. For the older populace specifically, the absence of state and cultural help has been routinely remunerated by the occurrence of a solid and genuine family support. Be that as it may, the old-style joint family framework is adjusted to family unit and because of this failure in the structure of the family money related and Psychological Problems of the Senior Citizens of Pakistan, the strength of the old is crumbled since in family unit old guardians consume pretty much nothing or even no power and their consideration and backing is disregarded.
Furthermore, another major problem of the older adults is lack of getting help for their problems due to financial issues (11) . Numerous nongovernmental associations have been developed for the welfare of the older populace for example Women Partnership, Pakistan Senior Citizens Association (Karachi based), Pakistan Association of Gerontology and Association for the Welfare of the Retired Persons (Islamabad based) but in any case, these associations couldn't prevail in their point since these associations either had money related constraints or their endeavors didn't improve the enormous number of the old populace.
There are not many studies with the context of socioeconomic status of the elderly. The main reason is that depression among the elderly is considered as a normal part of aging and the factor of socioeconomic status is neglected. So, the main goal of the research is to focus on the importance of socioeconomic status and its role in the well-being of the individual. The foremost purpose of the current research is to see the impact of socioeconomic status on geriatric depression in the elderly.
Previously, the findings of the relationship between socioeconomic status and depression in old age have been remarkably inconsistent. The negative relationship of socioeconomic status (SES) with mental illness is one of the most consistently replicated findings in the social sciences The lower the SES of an individual, the higher is his or her risk of mental illness. Though, unraveling the SES-mental illness, relationship there has been such limited progress in the last decade. But now, the importance of this issue is growing. The lack of state mental health programs has emphasized the need for aiming assets to those areas with the utmost requirement rather than relying on old expenditure forms (12) .
Moreover, a strong opposite relationship has been confirmed by several recent studies between SES and mental disorder. It is proven by many research publications that regardless of the changes in definitions and measurements of SES, the possibility of depression in the lowest SES group is as much as twice that found in the highest SES group. People with low socioeconomic status are more likely to have psychiatric disorders than those with higher socioeconomic status. Several epidemiological studies of depression in Canada and United States found differences in the prevalence rates of depression based on SES factors (13)(14)(15)(16)(17) .
From the above mentioned literature, additionally it is stated that, low socioeconomic status not only affects older people mental health, but also on the well-being of an individual socially. As lack of finance limited their social gathering. They do not participate in any activity which is related to money. So, they live a lonely life and this loneliness takes them towards depression in old age. In this globalized world, ' A feeling of emptiness after the last kid left home' isn't only a Western marvel, the more youthful age has enabled it to make advances into the eastern culture too. In Pakistani social setting, numerous individuals work past their retirement age (60 years in Pakistan) fundamentally because of convincing conditions to bring home the bacon. Additionally, the progressive breaking down of the hundreds of years old joint family framework, the development of the family unit framework and independence conceit have disintegrated the channels of care for the old and has exiled them to segregation without risk of punishment (18) . https://www.indjst.org/ Further, research uncovers that 33 percent of Pakistani, populace is living beneath the destitution line and this expansion in the degree of neediness has without a doubt influenced the lives of the old populace. Destitution has broadened their monetary requirements and prompts mental issues like sorrow. If there should arise an occurrence of work, they are terminated by the businesses due to their less ready to take an interest in the financial exercises adequately. The annuity framework is planned so as to give the older or people who misfortune procuring limit during mature age, passing of breadwinner in the family and episode of incapacity. In contrast to the senior residents in many created states far and wide, older in Pakistan wear not get benefits rather government annuity plans are accessible for the individuals who are utilized in the administration area or working in sorted out division as it were (19) .
In any case, notwithstanding of the annuity, the greater part of the senior residents can't discover elective wellsprings of pay as benefits can't meet their subsistence necessities and in this way they become reliant on others for money related help. In numerous enterprises in Pakistan, older is dealing with contract premise and they are not qualified for an annuity. In spite of the fact that they are qualified for the equivalent on noncontributory premise, in any case, they are not in any case thought qualified for contributory framework and subsequently after their retirement, they are denied of annuity (20,21) .

Sample
The study was cross-sectional in nature. All respondents enlisted were from the biggest state Punjab of Pakistan. Elderly population data were taken from the Pakistan Statistical Department, Islamabad, Pakistan. A structured questionnaire was used for the respondents' scrutiny. The eligibility of the respondents was, they must be Pakistani and residing in Punjab state and have the age of 55 to 74 years of age and they must not be cognitively impaired. The Mini Mental Status Examination (MMSE)was used to check the cognitive impairment of the respondents. Many questions in MMSE were asked to check the time, age, name and place orientation.

Data collection procedure
The questionnaire of the study has an informed consent, a cover letter. The aim of the research and privacy were elucidated to participants. About 876 individuals, both male and female were approached at their homes. A total of 800 elderly adults were selected (based on MMSE screening) to take part in the research having a response rate of 91.32%.

Socio-economic status
In the present-day research, the socioeconomic status was determined by using Ansari and Siddiqui (2003) (22) . They reported three levels of socioeconomic status. They are Low, Middle and High on the basis of a survey conducted by the Federal Bureau of Statistics. Low socioeconomic status is considered when a monthly income of the household is Rs. 14000 and below; middle socioeconomic status is when monthly income is 14000 to 30000; and high socioeconomic status is considered as when the monthly income is of 30000 and above.

Geriatric depression
Geriatric depression was measured by using (23) . Geriatric Depression Scale (GDS). It has been extensively used for measuring depression in older people. Short form of geriatric depression scale (Urdu) was used in the present research. It consists of 15 items, so, it is easy for older people to answer. Scores for normal condition is 0-4, depending on education, age, and complaints; 5-8 score for mild depression; 9-11 score for moderate depression; and 12-15 score for severe depression. The Cronbach's alpha was 0.83.

Data analysis
The data analysis has done by using Statistical Package for Social Sciences (SPSS) version 21 was used. Before data analysis begins data cleaning has been done. Descriptive statistics were calculated by using SPSS. To examine the relationship between socioeconomic status and geriatric depression, cross tabulation and multiple regression were used in the study. https://www.indjst.org/

Results
A total number of 800 male and female were involved in this study. The profile of the respondents is given below. There are three demographic variables in this study are gender, age, and socioeconomic status. Each demographic variable is divided into different categories that is explained in the Table 1.

Discussion
The present study tries to improve the pragmatic linkage of socioeconomic status and geriatric depression. Socioeconomic status has been stated to have a negative impact on geriatric depression. In the present research, the associations between socioeconomic status and geriatric depression are studied in a sample of older adults in one of the biggest state in Pakistan. Generally, the results determine that socioeconomic status has negative effect on geriatric depression.
The maximum number of the respondents has geriatric depression from mild to moderate (49% and 34%, respectively) as shown in Table 2. This means that more than 83% of respondents were having mild to moderate depression. This also indicates older people have mild to moderate depression in their old age. It is due to this fact that in old age there are no health benefits for older people in Pakistan. One of the important factor is socioeconomic factor as the treatment of mental disorder is expensive and people with low socioeconomic status cannot afford. Another reason is that depression is considered as a normal part of aging, no one cares about the older people. Government does not provide any facility in hospitals and clinics to older people. That's why socioeconomic status is very important for the well-being of older people in their old age.
The results of the study show that the majority of the respondents (40%) belongs to middle class as shown in Table 1, as Pakistan is a low income country, where the middle class is the prominent class. This result shows that socioeconomic status is very important for the wellbeing of an individual. As Pakistan is a poor country, and the majority of its earning depends on agriculture. The people are independent and in their later ages when they have no power to work their source of income reduces and they become dependent on their children, the government has not planned yet for these older people any benefits in old age. This leads them towards depression in old age. Therefore, it is evident from the discussion that socioeconomic status has a very important role in the life of older people. Our results supported by the previous researches such as (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) . In the Table 1, the respondents are divided into two categories on the basis of their gender. The gender is equally distributed to see the gender differences in the present study 400females and 400males. Concerning age, the study classified them into five age groups. These age groups are 50years to 54years old, 55 years to 59years old, 60 years to64 years old, 65years to 69years old and 70 years to 74years old. The majority of respondents falls in the group 56years to 60years old which are (304; 38%). On the other hand, the smallest percentages of respondents are in the age group of 65years to 69years old which are (37; 4.63%) respectively. While the second highest age group is 50 years to 54years old which has (235; 29.37%). The respondents in the age group of 60years to 64years old were 224 with a percentage of 28% correspondingly. Mean age of the respondents was 57 years with standard deviation of 1.29, the age range was between 55 years to 59 years old.
Socioeconomic status of the respondents is divided into three classes lower, middle and upper on the basis of the research by (Ansari, 2003, Siddique, 2003, Federal bureau of statistics, 2001). The table shows that the most of the respondents (320; 40%) https://www.indjst.org/ belong to middle class and others (288; 36%) are in the upper class. The remaining respondents (192; 24%) lie in the lower class. Socioeconomic status of the respondents in category two it shows most of the respondents belong to the middle class which is the most common class in Pakistan.
Whereas, Table 2, represents the profile of the level of depression of the respondents. In general majority of the respondents have mild depression. This shows that elderly people have a great chance of having depression in their old age.  Socio-economic status and geriatric depression are negatively correlated. Which shows that as the socio-economic status increases geriatric depression in older people of Pakistan decreases. As Pakistan is an underdeveloped low income country, so in old age, income and finance is a crucial issue. Pakistan has no such policies for older people that make them secure in their later lives. This is the main cause of having depression in old age.
However, Table 4 describes the relationship between socioeconomic status and geriatric depression was also analyzed by using cross tabulation. The main purpose of the cross tabulation was to determine the relationship of independent variable toward the dependent variable i.e. socioeconomic status and geriatric depression. Analysis was described by the cross tabulation table. The Table 4 of cross tabulation depicted the impact of socio-economic status categories on the geriatric depression of the older people of Pakistan. The socio-economic status has been divided into three classes based on their monthly income. While geriatric depression has four levels on the bases of their scores. The lower socio-economic status category illustrated that people having low socioeconomic status are more prone to depression as in the first category of low socio-economic status https://www.indjst.org/ with geriatric depression showed that no depression respondents are only (3; 0.4%) as compared to other classes of geriatric depression. Similarly, as the socio-economic status increases the level of depression also decreases as in the case of middle socio-economic status there are (20; 2.5%) respondents in no depression. Which shows that as the socio-economic status of older people of Pakistan rises their depression decreases. Correspondingly, the people having high socio-economic status the number of respondents in no depression category is (39; 4.9%). Which showed that as the older people of Pakistan have high socioeconomic status they have more chances to have no depression in life.
Moreover, Table 5 explains the summary of multiple regression analysis of socioeconomic status and geriatric depression. The model parameters give the estimates for Beta values that indicates the individual contribution of each predictor to the model as seen in Table 5. The Beta value in the above Table 5 explained the relationship between geriatric depression and each of the predictor variables. The sign of the Beta indicates the direction of the relationship, where a positive parameter indicates a positive relationship between the predictor and the outcome variable and a negative coefficient represents a negative relationship between the dependent and the independent variable. The Beta value of socioeconomic status is negative as seen in Table 5 with a value of -0.061. This means that, there is a negative relation between the socioeconomic status of the people in Pakistan and geriatric depression of old people in Pakistan. Therefore, the higher the socioeconomic status of older people the lower the geriatric depression of the people in Pakistan. The parameter found is said to be significant since the p-value is less than 5% of the variable. This means that socioeconomic status has a negative relation with geriatric depression. The higher the socioeconomic status the lower the depression of older people. Similarly, F-statistics value of the model is 25.055 with corresponding p-value is 0.000 (p< 0.05) which means that it is significant at 5%. From this we can interpret that the above model is significantly predicted the outcome variable which is geriatric depression. Correspondingly, going by the R-square result of the Model as seen in Table 5 therefore, the value is 0.30, which means that socio-economic status accounts for 3.0% of the variation in geriatric depression. This shows that the independent variable explained the variation in geriatric depression by 30%. The adjusted R 2 explained the amount accounted for by dependent variable as well as the number of observations for the model and its generalization. Its values were very close to the value of R 2 . So, the better the adjusted R-square the better the fitness of the model.
The beck cognitive theory also postulates that low socioeconomic status (SES) affects older people cognitive thoughts they become negative and this negativity leads them towards many psychological problems and depression is one of them. As it is evident from the literature that low income countries have poor mental health facilities, therefore, poor people have less chance to get benefits from the services and remain in depression throughout their life. So, it is necessary for social workers, Nongovernmental organization and Government to provide older people with the facilities of having free medical checkups, so they may be able to get benefits from them.

Conclusion
Overall, the analysis in the current scholarship exhibited that socioeconomic status has a negative effect on geriatric depression. The result is consistent with the previous researches and in line with the theory. The theory states that cognitive thinking plays an important role in determining the psychological health of an individual. If the older people are free from money constraints they may be better able to perform activities of their life. Additionally, it should have a progressive influence on the life, emotional and social well-being of the older adults. Consequently, it is imperious for social workers and psychologists to recognize these important factors when successfully treating psychological well-being problems among older adults. https://www.indjst.org/

Implications for Psychological practices
The significance of socioeconomic status in evaluating the psychological health of elderly patients has been emphasized. In the current research, contentment towards socioeconomic constraints leads to better psychological well-being. The ability to do daily activities with satisfaction had affirm effect on the psychological well-being of the elderly. The results of the research have important academic and practical implications not only for psychologists and social workers but also for governmental organization.
So, the present research provides evidence to make plans by introducing small packages and reforms for older people. This creates harmony and growth in the country like Pakistan, who is a low income country. Unlike, big countries such as the United Kingdom, Canada and America, in a smaller country such as Pakistan the resolution of issues of the older population can deem to be a real starter not just an academic exercise in her policy strategies. In order to enhance mental health in the country on a large scale, small incentives for older people in the financial sector of Pakistan should be globally competitive.
This study also has limitations, the most important limitation of the research was related to the geriatric depression construct and its measurement. The researcher experienced difficulty in finding available research material applicable to the study that focused on depression on old age specially with context to Pakistan. Research studies and measuring instruments of individual wellbeing were found to focus only on certain aspects of depression. Respondents of these studies were also not relevant as they are not old people. Wellbeing research on the older population in general was also lacking in Pakistan. This resulted in a limitation of having to base local research needs on previous studies of western culture influenced individual wellbeing.
In concluding, the study revealed that socioeconomic status plays a significant part in well-being of older people. Elderly people with secure income were accomplished their psychological health better and with ease. It is suggested that every hospital and clinic have special arrangements for elderly. Furthermore, to rise the generalizability of this research future research is endorsed at the national level.