The mediating and moderating role of social support on the relationship between psychological well-being and burdensomeness among elderly with chronic illness: community nursing perspective

Psychological well-being in the elderly is a multi-faceted construct that includes emotional regulation, life satisfaction, and the absence of significant mental health issues. Chronic illnesses often threaten this well-being by introducing persistent stressors related to health deterioration, reduced functional capacity, and increased dependency on others. These stressors can lead to feelings of burdensomeness, where individuals perceive themselves as a burden to their family and friends. Such perceptions are linked to increased depressive symptoms, lower self-esteem, and even suicidal ideation [8, 10].

Social support plays a pivotal role in alleviating the psychological burdens associated with chronic illnesses. It helps individuals cope with stress by providing emotional comfort, practical assistance, and a sense of stability. The presence of a supportive network can significantly reduce the feelings of isolation and loneliness that often accompany chronic illnesses, thereby enhancing overall well-being [9, 11, 12].

The sources and effectiveness of social support can vary significantly across different cultural contexts. For example, in Chinese culture, family support is often the primary source of social support for the elderly, driven by strong filial piety norms. In contrast, in Western cultures, friend support and community networks might play a more substantial role. Understanding these cultural nuances is essential for designing effective support interventions tailored to specific populations [13, 14].

The significance of social support in Arab culture is deeply rooted in its collectivist nature, which emphasizes family cohesion and community interconnectedness. Research indicates that elderly individuals in Arab societies often depend on extended family networks for both emotional and practical support, a practice that is culturally endorsed and expected. Religious and cultural norms further reinforce the importance of caring for the elderly, viewing it as a moral and spiritual duty [15, 16].

However, cultural stigmas surrounding the pursuit of external help can create challenges. Feelings of shame or dishonor may prevent the elderly from fully utilizing available support systems. For example, studies conducted in various Arab countries highlight the reliance on family as the primary source of elder care, while also noting socio-demographic changes that may hinder this traditional support system. By integrating examples from specific regions, such as the study by Hussein and Ismail, we can gain a more comprehensive understanding of these cultural dynamics [17, 18].Hussein and Ismail’s study underscores the urgent need for comprehensive policies to support the ageing population in Arab countries. It highlights the critical role of family caregivers, particularly women, and the challenges they face due to socio-demographic changes, emphasizing the importance of community-based support systems and social policies to enhance elderly care [18].

Several theoretical models explain how social support influences psychological well-being. The stress-buffering hypothesis and self-determination theory (SDT) theoretical frameworks are acknowledged, but their direct application to the study’s focus on burdensomeness and social support requires further justification. These models were selected because they uniquely address the nuanced dynamics between perceived burdensomeness and social support in psychological well-being.

The stress-buffering hypothesis [19, 20] highlights how social support mitigates the adverse effects of stress by providing emotional, informational, instrumental, and appraisal support. This is particularly relevant to burdensomeness, as emotional support may alleviate feelings of being a burden, while appraisal support can help individuals reframe such perceptions in a more positive light. Informational and instrumental support further contribute by offering tangible assistance and practical guidance, reducing the stressors that may exacerbate burdensomeness.

SDT [21, 22] focuses on fulfilling the basic psychological needs of autonomy, competence, and relatedness. These needs are particularly critical in the context of burdensomeness. For example, social support that fosters autonomy can empower individuals to feel less dependent and burdensome. Support that enhances competence can counter feelings of inadequacy while fostering relatedness directly addresses the need for connection, which is often strained when individuals perceive themselves as burdensome.

These frameworks were chosen over others because they comprehensively capture the mechanisms by which social support can influence burdensomeness and psychological well-being. The stress-buffering hypothesis provides a lens to understand how support mitigates stress-related outcomes, whereas SDT offers insights into how support satisfies fundamental psychological needs. Together, they provide a multidimensional perspective, emphasizing both the reduction of stress and the promotion of intrinsic well-being [19‐22].

This study aims to elucidate the complex relationships between social support, psychological well-being, and burdensomeness among the elderly with chronic illnesses. By examining both mediating and moderating pathways, it seeks to provide a comprehensive understanding of how social support can mitigate the negative psychological impacts of chronic illness. Given the aging global population and the increasing prevalence of chronic illnesses, such insights are vital for public health strategies and policies aimed at supporting this vulnerable demographic. This study aims to investigate the mediating and moderating role of social support on the relationship between psychological well-being and burdensomeness among elderly with chronic illness.

Participants eligible for this study were adults aged 60 years and older who have been diagnosed with at least one chronic illness, such as diabetes, hypertension, or arthritis. They were required to be able to communicate effectively, willing to provide informed consent, and could be of any gender. Exclusion criteria encompassed individuals below the age of 60 years, those without a diagnosed chronic illness, and individuals experiencing severe cognitive impairment that could impair their ability to participate meaningfully or comprehend study procedures. Additionally, participants unable to communicate proficiently even with assistance, were excluded. Refusal or inability to provide informed consent also led to exclusion from the study to maintain ethical standards and ensure voluntary participation.

A power analysis for a two-tailed one-sample t-test indicated that the minimum sample size to yield a statistical power of at least 0.95 with an alpha of 0.05 and a medium effect size (d = 0.2) is 327 [23].However, The final sample included 311 older adults. While our original calculation required a sample of 327 participants, the final sample of 311 participants still meets the threshold for adequate statistical power. Using G*Power software, we recalculated the power for our mediation and moderation analysis, accounting for the reduced sample size. The updated power analysis indicated that, with a sample of 311 participants, the study maintains sufficient power (above 0.80) to detect medium effect sizes (f² = 0.15) at a 5% significance level.

Purposive sampling was employed in this study to align with its research objectives, which necessitated the recruitment of older adults possessing specific characteristics pertinent to the study variables. This approach ensured the inclusion of participants who met the predefined criteria essential for examining the relationship between psychological well-being, burdensomeness, and social support. Initially, 327 older adults were invited to participate. Of these, three declined, and 13 were excluded for not meeting the inclusion criteria. The final sample included 311 older adults, whose responses were analyzed for the study (Fig. 1).

The study involved multiple variables and their interactions, each contributing to the understanding of the factors influencing psychological well-being in elderly individuals with chronic diseases. Burdensomeness, as the independent variable, was measured using the Perceived Burdensomeness Scale (PBS), which evaluates the degree to which individuals perceive themselves as a burden to others. Comorbidities were assessed through a checklist of chronic conditions reported by the participants and were included as a control variable due to their potential influence on both psychological well-being and social support. Social support, serving as a mediator variable, was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS), which measures perceived support from family, friends, and significant others. This variable was included to explore its mediating role in the relationship between burdensomeness and psychological well-being. In addition, the subdimensions of social support, family support, friends support, and significant other support were analyzed separately within the broader social support framework. Psychological well-being, the dependent variable, was measured using Ryff’s Psychological Well-Being Scale (PWBS), which assesses various aspects of well-being, including autonomy, personal growth, self-acceptance, life purpose, mastery, and environmental mastery. Finally, family type, categorized as nuclear or extended, was included as a control variable to account for any potential influence of family structure on psychological well-being.

This form covers a wide range of aspects, including socio-demographic information such as age, gender, education level, marital status, residence, family structure, employment status, and income. It also explores medical history, including types of chronic diseases and duration of diagnosis. Additionally, lifestyle factors such as exercise habits and risk taking behaviors like smoking are assessed.

The Geriatric Feelings of Burdensomeness Scale (GFBS), developed by [24], measures feelings of burdensomeness specifically among elderly populations. The scale comprises 25 items rated on a five-point Likert scale, from strongly disagree 1 to strongly agree 5. Total scores range from 25 to 125, with higher scores indicating greater feelings of burdensomeness. The scale has demonstrated high internal consistency, with a Cronbach’s alpha of 0.97. Construct validity was confirmed through exploratory and confirmatory factor analyses, establishing the GFBS as a reliable and valid measure for assessing burdensomeness among the elderly. In this study, the GFBS also showed strong reliability, with a Cronbach’s alpha of 0.824. After translating the scale from English to Arabic, an exploratory factor analysis was conducted to validate the instrument. The factor loadings ranged from 0.442 to 0.829 before rotation and improved to a range of 0.580 to 0.953 after varimax rotation, all exceeding the 0.35 threshold and collectively explaining 68.606% of the total variance.

This scale is a widely used psychometric instrument designed to measure perceived social support from three distinct sources: family, friends, and significant others. Developed by [12], the MSPSS has been validated and utilized in various research and clinical settings due to its strong psychometric properties. The MSPSS comprises 12 items, with four items allocated to each of the three subscales: Family Support, Friends Support, and Significant Other Support. Each item is rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree).The total score of the MSPSS ranges from 12 to 84, with higher scores indicating greater perceived social support. Each subscale score ranges from 4 to 28, allowing for the assessment of specific support sources. The Multidimensional Scale of Perceived Social Support (MSPSS) categorizes the level of perceived social support into three distinct ranges based on the total score obtained from the 12 items. Scores ranging from 12 to 35 indicate a low level of perceived support. Scores between 36 and 60 reflect a medium level of perceived support, .Lastly; scores from 61 to 84 denote a high level of perceived support. These categories help in understanding the extent to which individuals feel supported by their social networks and can guide interventions to enhance social support where needed. The scale demonstrates high internal consistency, with Cronbach’s alpha values typically exceeding 0.90 for the overall scale and each subscale. Construct validity has been confirmed through factor analysis, supporting the three-factor structure of the MSPSS. Additionally, the MSPSS has shown strong convergent validity, correlating well with other measures of social support, and discriminant validity, indicating that it measures distinct constructs. In the present study, the Multidimensional Scale of Perceived Social Support (MSPSS) demonstrated strong reliability, with a Cronbach’s alpha of 0.88. After translating the scale into Arabic, content validity was assessed through exploratory factor analysis, which revealed satisfactory loadings both before and after varimax rotation. These factors collectively accounted for 78.151% of the total variance, confirming the robust construct validity of the scale. Additionally, the Kaiser-Meyer-Olkin measure and Bartlett’s test of sphericity supported the suitability of the data for factor analysis, further endorsing the scale’s validity for Arabic-speaking populations.

The 18-item version of Ryff’s Psychological Wellbeing Scale, originally developed by Ryff and Keyes in 1995, has been adapted into a streamlined Swedish version by [25]. This adaptation focuses on assessing various dimensions of psychological well-being using both Classical Test Theory (CTT) and Item Response Theory (IRT). The scale includes 18 items distributed across six subscales: Positive Relations with Others (3 items), Environmental Mastery (3 items), Self-Acceptance (3 items), Autonomy (3 items), Personal Growth (3 items), and Purpose in Life (3 items). Each item is rated on a Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). The scale comprises ten positively scored items 1, 3, 4, 5, 6, 8, 11, 12, 13, 15 and eight negatively scored items 2, 7, 9, 10, 14, 16, 17, 18. The total score ranges from 18 to 108, with higher scores indicating greater well-being. The Swedish version of the scale has demonstrated acceptable reliability, with Cronbach’s alpha coefficients ranging from 0.48 to 0.80 across the subscales and 0.79 for the total scale [26]. In the current study, the scale exhibited excellent internal consistency, with a Cronbach’s alpha coefficient of 0.88. Additionally, after translating the scale into Arabic, the researchers conducted an exploratory factor analysis to assess its validity. The factor loadings ranged from 0.442 to 0.829 before rotation and improved to a range of 0.580 to 0.953 after varimax rotation. All factor loadings exceeded the 0.35 threshold, collectively explaining 68.606% of the total variance.

The data collection process began with a comprehensive orientation provided to all participants, outlining the study’s objectives and emphasizing the voluntary nature of their involvement. Researchers addressed any questions or concerns promptly and reinforced the confidentiality measures in place to foster trust in the research.

Data collection was carried out by a team of trained researchers from June to August 2024. The researchers underwent detailed training to ensure that interviews with older adults, particularly those with chronic illnesses, were conducted with sensitivity and empathy. The training covered ethical considerations, such as obtaining informed consent and maintaining confidentiality; effective communication skills, including empathetic listening and building rapport; and strategies for managing emotional distress that participants might experience during the interview process. Additionally, the training emphasized the importance of respecting participants’ autonomy, addressing sensitive topics related to chronic illness and burdensomeness, and ensuring that all interactions were supportive and respectful. Researchers were also trained to refer participants to appropriate resources if needed. This approach ensured a safe and comfortable environment for participants throughout the data collection process.

Prior to participation, each participant provided written informed consent. To maintain anonymity, participants were instructed not to include any personal identifiers on the questionnaires. Participation was entirely voluntary, and participants were free to withdraw from the study at any point. Data collection was conducted through interviews in the waiting areas of the clinics. Each interview, lasting 20 to 30 min, was scheduled between 10 a.m. and 2 p.m. from Saturday to Thursday. Recognizing the varying needs of elderly participants with chronic illnesses, we prioritized flexibility in the schedule. The chosen time window was initially designed to accommodate the participants’ availability, but we also ensured flexibility by offering alternative times outside the primary schedule for those with medical appointments or other conflicting obligations. This approach was designed to maximize participation while minimizing the disruption to the participants’ routines.

Approval for the study was granted by the Research Ethics Committee of the Faculty of Nursing, El Minia University, Egypt (REC202471). In addition, permission was secured from the directors of the participating clinics after a thorough explanation of the study’s objectives. The research was conducted in full accordance with the ethical standards outlined in the Declaration of Helsinki, ensuring the protection of participants’ rights and well-being. Before participation, all individuals were provided with a clear, detailed explanation of the study’s aims, and written informed consent was obtained. Special care was taken to ensure that participants, particularly elderly individuals, understood the study procedures, with research assistants available to clarify any questions. For participants with potential cognitive impairments, additional safeguards were implemented. If needed, caregivers or family members were involved in the consent process to ensure that participants were capable of making informed decisions.

To protect participants’ privacy, all data were handled with the strictest confidentiality. Personal identifiers were removed, and data were stored in a secure, password-protected system accessible only to the research team. For additional security, physical records were kept in locked cabinets. Participants were also made fully aware of their right to withdraw from the study at any point without facing any consequences. These measures were designed to ensure ethical compliance, safeguard participant privacy, and provide protection for those in vulnerable groups, such as the elderly.

Before entering the data into the computer, it was verified for accuracy. Data analysis and tabulation were conducted using IBM SPSS Statistics version 25.0. Descriptive statistics were employed to characterize both study participants and variables. Mean scores were calculated for numerical values. A statistically significant level was considered when p ≤ 0.001, and the significance level was set at p < 0.05. A path analysis model was created for mediation analysis using SPSS-AMOS version 26. Parametric tests were utilized as the data exhibited normal distribution according to the Kolmogorov-Smirnov test, Inter-Quartile Range, and an assessment of residual plots [27]. In IBM SPSS, outliers were adjusted to their closest normal value using Winsorizing method. Outliers for this study referred to outside the fence of Q1 – (1.5 × Interquartile range [IQR]) and Q3 + (1.5 × IQR). Multicollinearity among variables was assessed. Tolerance values were confirmed to be greater than 0.1, and the Variance Inflation Factor (VIF) was less than 3. Specifically, both social support and burdensomeness had a VIF not exceding 1.693, which is below the threshold of 3, indicating no significant multicollinearity. Homoscedasticity was assessed using standardized residual plots. All assumptions were satisfactorily met, validating the robustness of our findings. Pearson’s correlation was used to analyze bivariate correlations between the study variables and their sub-dimensions. Furthermore, Andrew F. Hayes’ Process Macro was utilized as a data analysis approach. This approach is based on ordinary least squares regression and the bias-corrected bootstrapping method developed by [28]. It is recognized for its superior statistical power compared to other confidence interval analyses [29].

The findings of this study have significant implications for nursing education, practice, and research, particularly in the context of elderly patients with chronic illnesses.

This study has several strengths that enhance the validity and reliability of its findings. Firstly, the use of established and validated measurement tools, such as the Geriatric Feelings of Burdensomeness Scale and the Multidimensional Scale of Perceived Social Support, ensures that the constructs of interest were accurately assessed. The rigorous translation and validation processes for these scales into Arabic further contribute to their cultural relevance and applicability within the study population. Additionally, the cross-sectional design, while limiting in some respects, allows for a snapshot of the relationships between perceived social support, feelings of burdensomeness, and psychological well-being in older adults with chronic illnesses, providing valuable insights into their current experiences.

Despite its strengths, this study also has notable limitations. The cross-sectional design of this study limits the ability to draw causal inferences about the relationships between the variables. Since data were collected at a single point in time, it is not possible to determine the directionality or temporal sequence of the observed associations. While this design allows for the identification of correlations, it does not allow for the establishment of cause-and-effect relationships. Future research utilizing longitudinal or experimental designs would be necessary to explore potential causal pathways.

Another limitation relates to the use of Western-based instruments to measure constructs like social support. While efforts were made to translate and validate these tools for the local context, there remains a possibility of cultural bias. Certain dimensions of social support may be conceptualized or experienced differently in non-Western populations, potentially affecting the accuracy of the findings. Addressing this limitation in future research could involve the development or adaptation of culturally specific tools to better capture the lived experiences of older adults in diverse contexts.

Additionally, self-reported measures may be subject to biases, as participants could provide socially desirable responses rather than honest reflections of their feelings and experiences. Furthermore, the study was conducted in a specific clinical setting, which may limit the generalizability of the findings to broader populations or different contexts. Lastly, while the sample size was adequate for statistical analysis, it may not fully capture the diverse experiences of all older adults with chronic illnesses, necessitating future research that includes longitudinal designs and a more varied demographic to enhance understanding of these dynamics.

Finally, our results are likely most applicable to elderly individuals with chronic illnesses in similar clinical settings. Extrapolating these findings to healthier elderly populations or those in different care environments may not be appropriate due to the distinct challenges faced by our sample. Moreover, the relatively homogeneous nature of our sample limits the findings’ applicability. Factors such as socio-economic status, cultural background, and individual coping mechanisms can vary widely among broader populations, potentially leading to different experiences regarding perceived burdensomeness and social support.