The Relationship between Depression and Suicide Ideation Among Rural Elderly in South Korea: The Moderating Effects of Gender and Health Literacy

Background: South Korea has the highest suicide rate among OECD member countries. The elderly suicide rate (41.7) is higher than the OECD average (17.2), and the suicide attempt rate in rural areas (35.3%) exceeds that of urban areas (16.8%) (OECD, 2023; Ministry of Health & Welfare, 2018, 2022). This phenomenon is due to urbanization, aging, and a lack of health and welfare infrastructure. As depression predicts suicidal ideation (Beghi et al., 2021), this study investigates the moderating effects of gender and health literacy on the relationship between depression and suicidal ideation. Suicide prevention initiatives should incorporate gender differences, and health literacy is crucial for the elderly who face challenges in comprehending health-related information in rural areas.

Methods: This study analyzed the samples of 2,840 elderly 65 or older living in Chungcheongbuk-do from the 2021 Health Community Survey. Depression is assessed using the Patient Health Questionnaire (PHQ-9), which has a Cronbach's alpha of .8. Suicidal ideation (‘0 = no’ or ‘1 = yes’), gender (‘0 = male’ or ‘1 = female), and health literacy (‘0 = very easy or easy’ or ‘1 = very difficult or difficult’) are dummy coded. Moderation effects are analyzed using the PROCESS Macro Model 1 with 5,000 bootstrap samples.

Results: Of the sample, 15.5% reported depression symptoms, 11.4% reported experiencing suicidal ideation, and 31.1% showed low health literacy. Depression was significantly associated with suicidal ideation after four covariates (e.g., age, income). The relationship between depression and suicidal ideation was moderated by gender (B = -.14, p < .05) and health literacy (B = -.18, p < .01). The slope of suicidal ideation among females was significantly higher than that among males as the level of depression increased, and that among those with low health literacy was higher than those with high health literacy.

Implications: The results suggest that social welfare services should consider gender and health literacy when developing suicide prevention strategies among rural elderly. Prioritizing health literacy programs for the female elderly is imperative because their depression symptoms often manifest as changes in appetite and sleep patterns, and accessing psychiatric care is challenging due to low anonymity in rural communities. Intervention programs to enhance health literacy should also be actively linked with health and welfare agencies.

References

Beghi, M., Butera, E., Cerri, C. G., Cornaggia, C. M., Febbo, F., Mollica, A., ... & Lozupone, M. (2021). Suicidal behaviour in older age: A systematic review of risk factors associated to suicide attempts and completed suicides. Neuroscience & Biobehavioral Reviews, 127, 193–211. doi: 10.1016/j.neubiorev.2021.04.011

Ministry of Health and Welfare. (2018). 2018 National Survey on Suicide. Sejong: Republic of Korea.

Ministry of Health and Welfare, & Korea Foundation For Suicide Prevention. (2022). White paper suicide prevention. Seoul: Republic of Korea.

OECD (2023), Suicide rates (indicator). doi: 10.1787/a82f3459-en