The mediating role of anxiety and depressive symptoms on the relationship between physical limitations and cognitive impairment among older adults in China: differences based on religious perspective

The mediating role of anxiety and depressive symptoms on the relationship between physical limitations and cognitive impairment among older adults in China: differences based on religious perspective | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The mediating role of anxiety and depressive symptoms on the relationship between physical limitations and cognitive impairment among older adults in China: differences based on religious perspective Yi Zhang, Jinhua Guo, Lixia Lin, Min Peng, Jiaxi Huang, Yi Yang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6076160/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Physical limitationsand mental health may have a common effect on cognitive function. However, little is known about how religion influences these paths among older Chinese adults. Objective: This study investigated how anxiety and depressive symptoms mediate the association between physical limitations and cognitive impairment. Furthermore, we analyzed discrepancies in path models between participants with or without religious beliefs. Methods: This population-based, cross-sectional study involved 6656 adults aged ≥60 years in six cities in Guangdong Province, China. Participants were divided into two groups based on the presence of religious beliefs. All participants completed a general demographics questionnaire, the Chinese version of the Mini-Mental State Examination (MMSE), the Basic Activities of Daily Living (BADLs) scale, Generalized Anxiety Disorder-7 (GAD-7), and Health Questionnaire-9 (PHQ-9). Simple and serial multiple mediation models were then tested using SPSS PROCESS macro. Results: BADLs, anxiety symptoms, depressive symptoms, and cognitive impairment were significantly related (all P＜0.01). When adjusting for sociodemographic and health-related factors, BADLs limitations had a direct positive effect on cognitive impairment among participants with religious beliefs (effect=0.107, 95% confidence interval (CI): 0.095, 0.121), but also had indirect effect via independent masking of anxiety symptoms (effect=-0.005, 95%CI: -0.010,-0.002). For participants without religious belief, BADLs limitations had a direct positive effect on cognitive impairment (effect=0.135, 95%CI: 0.129, 0.140) as well as an indirect effect via three paths: an independent masking effect of anxiety symptoms (effect=-0.002, 95%CI: -0.004,-0.0001), independent mediation of depressive symptoms (effect=0.003, 95%CI: 0.002,0.004), and serial mediation of anxiety and depressive symptoms (effect=0.004, 95%CI: 0.003,0.006). Conclusions: Our findings highlight the need for health professionals to promote mental well-being to prevent cognitive decline prevention among older adults with physical limitations who do not have religious belief. These findings should be further confirmed by prospective studies utilizing other methods of assessing cognitive function and religiosity. cognitive impairment religious belief basic activities of daily life mental health mediating effect path analysis Figures Figure 1 Figure 2 Figure 3 Contributions to the literature 1.Pathway Modulation by Religious Beliefs: Religious beliefs uniquely modulate BADLs-cognitive impairment pathways, suppressing psychological mediation complexity 2.Multidimensional Risk in Non-Religious Populations: Non-religious older adults face direct and multifactorial indirect risks (anxiety masking, depressive mediation, anxiety-depression serial pathways) from BADLs limitations, amplifying cognitive decline. 3.Belief-Stratified Interventions: Findings advocate prioritized integration of anxiety-depression management in non-religious older adults with BADLs limitations and belief-specific prevention frameworks to counter cognitive deterioration. Introduction As global social structure changes, numerous countries, including China, are facing an aging problem and associated health issues [ 1 , 2 ] . Cognitive dysfunction is regarded as a normal neurological change that accompanies the physiological aging process [ 3 , 4 ] . However, persistent decline in cognitive function may develop into dementia or Alzheimer’s disease, leading to impaired self-care abilities and social interactions [ 3 , 5 , 6 ] and ultimately imposing a great burden on the public health system and healthcare financing [ 3 , 6 , 7 ] . At present, the prevalence of cognitive impairment in China is higher than that of other developed countries. In European countries, nearly 10% of older adults experience cognitive decline or dementia [ 8 , 9 ] . In China, various regional population-based surveys report a prevalence rate exceeding 20% [ 10 – 12 ] . Hence, there is an urgent need for comprehensive and active interventions for older adults with cognitive issues. Prior studies have investigated the association between physical function and cognitive impairment among older adult. In their prospective survey following older Japanese adults for 4 years, Sauvaget et al. [ 13 ] found that dementia was a strong predictor of limited basic activities of daily living (BADL) or instrumental activities of daily living (IADL) after adjusting for age, sex and history of stroke. The predictive value of changes in cognition to disability has been confirmed by several longitudinal studies. Exploration of the potential mechanism connecting cognitive impairment with physical function has become an important research topic. Wu et al. [ 14 ] reported that good baseline cognitive function decreased the risk of endpoint BADL disability over a 2-year follow-up period, and that depressive symptoms mediated the negative effect of cognitive function on BADLs. Using longitudinal data from the Chinese Longitudinal Healthy Longevity Surveys, Li et al. [ 15 ] found that 29.1% of older adults with cognitive impairment developed IADL disability in 6 years and that the correlation was fully mediated by lifestyle, social communication, and depressive status. Mental disorders are crucial mediators accelerating functional decline among older adults with limited cognitive competence [ 16 , 17 ] . This effect may be due to a synergistic link between cognitive impairment and depressive status, such that neuroinflammatory or morphological changes in the brain lead to impaired executive control and mood processing [ 18 , 19 ] . Mechanistic studies suggest that these effects might derive from bodily damage [ 16 ] , indicating a possible bidirectional correlation between physical and cognitive impairment via the same influencing path [ 20 ] . Moreover, Panza et al. [ 21 ] reported that mental diseases like depression may be a reaction in initial symptoms of cognitive decline and show similar behavior features of clinical function impairment, suggesting a vital overlap or interaction effect [ 22 , 23 ] . Based on this background, we hypothesized that mental disorders like anxiety or depression play an indirect role in the ADLs disability—cognitive function association. Several factors are recognized as possibly protective against cognitive decline, including healthy living habits [ 24 ] and dietary patterns [ 25 ] , positive or optimistic emotions [ 26 ] , frequent social activities [ 15 ] , and specific religious faiths or beliefs [ 27 ] . The effect of religiosity or religious practice on delaying cognitive development —particularly dementia — has attracted great research attention in the past decade. According to a systematic review of 17 studies [ 27 ] , a positive association between religious/spiritual practice and cognitive function was reported in 82% of studies. Nath et al. [ 28 ] also carried out a systematic review to explore the role of religion on cognitive maintenance, demonstrating significant consistency in the direction of the relationship between religion and memory, suggesting that region is a key element of cognitive protection among middle-aged and older adults. Prior studies have suggested several mechanisms to explain the positive impact of religion on cognitive deterioration. Some viewpoints argue that religious participation can improve the formulation of nonrepresentational concepts like moral sense and meaning of life, which are beneficial for stimulating and maintaining higher cortical functions and brain regions associated with memory [ 29 ] . Alternatively, religion can be linked to a positive effect on health by increasing social interactions that encourage individuals to consolidate friendships and expand social networks [ 30 , 31 ] , thus avoiding negative mental health consequences and cognitive deficits [ 32 ] . Social isolation has been shown to be a risk factor for cognitive decline in previous studies of older adults [ 33 , 34 ] . At the same time, the social characteristics of religious activity could strengthen cognitive reserve capacity and elevate mental tenacity [ 31 , 35 ] . There is a broad consensus that positive religious beliefs or involvement are an important coping resource for mental health. Compared to people without religious beliefs, individuals who believe in god or have higher religiosity may have greater self-control to seek divine forgiveness, which is a potential mechanism linking religion to psychological health [ 36 ] . The findings of a meta-analysis [ 37 ] investigating 79918 older adults living in communities and hospitals found that individuals with a high level of religious affiliation and internal religiosity report a lower prevalence of anxiety or depressive disorders. These findings are supported by increasing data from longitudinal studies [ 38 ] showing a significant association between religious belief and modest improvement of depressive symptoms over time. When religious-based approaches are fully considered by researchers when providing interventions for people with poor mental health, the results indicate a superior effect compared to usual psychological therapies [ 39 ] . The necessity to combine faith-adapted mental- and cognitive-related treatments with psychological interventions for depression patients has been emphasized in multiple studies [ 40 – 42 ] . However, because of differences between China and Western countries in terms of cultural background and the formal welfare system [ 43 , 44 ] , care for older adults in China is mainly based on a traditional family-based support model [ 44 ] . As a result, the impact of religiosity on mental health or cognitive function among older adults in China might be different from those reported in countries with a popular religious culture. Furthermore, there is a lack of research focusing on how religiosity affects the association between physical dysfunction and cognitive decline mediated by psychological factors [ 43 ] , limiting the understanding and applications of religious theories by healthcare professionals when handling cognitive issues. To address this research gap, the current study addressed two aspects. First, we explored the mediating or masking role of anxiety and depressive symptoms on the relationship between BADLS limitations and cognitive impairment among older Chinese adults after adjusting for sociodemographic and health-related factors. Second, we compared the discrepancy of two influencing paths among older adults without religious beliefs to develop a preliminary theoretical basis for psychological interventions for cognitive function in older adults based on religion. Methods Study design and participants This population-based, cross-sectional study used a multistage, stratified, cluster-sampling procedure and was conducted between June 2021 and December 2022. This study was carried out as part of the “Active health and technological response to aging” subproject carried out by the Ministry of Science and Technology of China. Four representative cities from the Pearl River Delta (Guangzhou, Shenzhen, Zhuhai, and Foshan), one city from the east region (Qingyuan), and one city from the west region of Guangdong Province (Maoming) were selected as the main study sites. Data collection was primarily conducted at hospitals, including 2–3 tertiary hospitals and 1 secondary hospital with a reputation for providing geriatric healthcare in each city. In view of the diversity of care models for older adults in China, we also collected data from community healthcare centers with the largest population attached to streets or hospitals, and 60–70 families recorded in community resident health files to avoid selection bias. The main inclusion criteria was being aged 60 years or older. Participants with a current or previous mental disease, serious organ dysfunction, or any acute disease, as well as participants who were unable to engage in normal communication, were excluded. Ultimately, a total of 6656 older adults from 15 tertiary hospitals, 6 secondary hospitals, 6 community healthcare centers, and 350 families in 6 cities were included in the analysis. This study was approved by the ethics committee of Guangdong Province People’s Hospital (KY-Z-2021-690-01) and all participants provided written informed consent. Measures General participant information General participant information was collected using a questionnaire developed based on previous studies and reviewed by two experts in a pilot study. This questionnaire included sociodemographic information (gender, age, body mass index (BMI), education level, type of residence, family income, etc.) and health-related information (chronic diseases, types of medication, drinking, smoking, regular physical examination, regular social activities, etc.). Religious beliefs We used a single question to assess religious beliefs: Do you believe in a religion (Christianity, Buddhism, Islam, etc.) or usually participate in individual or group religious-related activities? If participants answered “yes”, they were considered to have religious beliefs; otherwise, participants were considered to not have religious beliefs. Cognitive impairment Cognitive status was evaluated using the 30-item Chinese version of the Mini-Mental State Examination (MMSE). The MMSE was designed by Folstein [ 45 ] in 1975 and includes dimensions of orientation, memory, attention and calculation, recall, and language. The MMSE has a sensitivity up to 92.5% to detect cognitive impairment [ 46 ] . Correct responses were scored as 1, while incorrect or unclear responses were scored as 0. The MMSE is scored out of 30 points, with lower scores indicating more serious cognitive decline. BADLs Activities of daily living (ADLs) reflect essential activities performed by individuals living in medical institutions, communities, and families [ 47 ] . Because IADLs items might partially overlap with early cognitive decline, we use the BADLs rating scale for ADLs assessment. BADLs included eight basic movements and self-care activities: eating, bathing, combing, dressing, controlling urine, controlling excrement, walking, and walking up and down stairs [ 47 ] . Each item is evaluated at 2 to 4 level. The highest level is scored 15 points, and lowest level is scored 0 point. The BADLs rating scale is scored out of 100 points, with lower scores indicating worse self-care ablility, which means more serious physical limitations. Anxiety and depressive symptoms Anxiety and depressive symptoms were measured using the Generalized Anxiety Disorder-7 (GAD-7) and Health Questionnaire-9 (PHQ-9), respectively. Both scales are widely used instruments for assessing mental health. GAD-7 was used to evaluate the frequency of the following seven conditions over the previous 2 weeks: tension, uncontrollable worries, excessive worries, inability to relax, akathisia, irritability, and foreboding [ 48 ] . Each item was evaluated using a 4-point Likert scale with total scores ranging from 0 to 21. Anxiety symptoms were divided into four levels: mild (5–9), moderate (10–13), moderate-severe (14–18), and severe (19–21). PHQ-9 was used to evaluate the frequency of nine conditions over the previous 2 weeks: displeasure, appetite change, fatigue, worthlessness, guilt, decreased concentration, slow movement, restlessness, and suicidal tendency [ 49 ] . Each item was evaluated using a 4-point Likert scale with total scores ranging from 0 to 27. Depressive symptoms were divided into four levels: mild (5–9), moderate (10–14), moderate-severe (15–19), and severe (10–27). Data collection procedure Data were collected using the Wechat mini program called “Jingyice platform on the functional assessment of older adults”. Written permission was obtained by each of the selected hospitals and community study sites. Formal investigations were performed by specialized interviewer teams recommended by the hospitals and communities. For door-to-door data collection from families, interviewers were screened and trained by the corresponding communities. Unified guidelines were used when describing the study aims, obtaining informed consent, and carrying out face-to-face interviews. Consultations with caregivers or other family members chosen by subjects were allowed if older adults were unable to communicate with interviewers due to speech or hearing dysfunctions. All questionnaires were checked by the interviewers for missing data or errors. The data were stored in a secured file only accessible by authorized personnel. Data analysis Data analysis was performed using SPSS software version 26.0. Quantitative variables (such as MMSE scores) are reported as the mean ± standard deviation (SD), while qualitative variables (such as gender, age stratification, and education level) are reported as absolute values and percentages. We used the t test or chi-square test to compare differences in MMSE scores between groups based on sociodemographic or health-related factors. Pearson analysis was utilized to examine the correlation between cognitive impairment, BADLs, anxiety, and depressive symptoms among older adults with or without religious beliefs. Hayes’ (2013) SPSS PROCESS macro software (Model 4) [ 50 ] was employed to explore the independent indirect effect of anxiety and depressive symptoms on the association between BADLs limitations and cognitive impairment. To explore whether there is a serial multiple indirect effect of anxiety and depressive symptoms, we further used Hayes’ (2013) SPSS PROCESS macro (Model 6) [ 50 ] . We respectively established two path models for older adults with or without religious beliefs and then compared differences in the mediating or masking roles. Bootstrap confidence intervals (CI) at 95% and 5000 bootstrap samples were selected for the analysis. If the boundaries between the lower and upper values of the 95%CI did not cross zero, the models were regarded as significant at the 0.05 level. Results General participant characteristics Of the total 6656 participants, 943 (14.17%) reported having religious beliefs and 5713 (85.83%) reported no religious beliefs. The sample included 3106 males (46.66%) and 3550 females (53.34%). The average age was 71.97 ± 8.10 years; 46.06% of participants were in the range of 60–69 years old. The majority of participants (56.46%) had a standard BMI. More than half of participants had an education level of primary school or below (67.64%), more than three children (65.69%), were married (85.08%), and lived with family members (96.62%). Regarding region of residence, 53.80% and 46.20% of participants resided in urban and rural regions, respectively. Most participants received rural medical services (67.71%) and had a family income ranging from 2000–4000¥ per month (44.62%). Regarding health-related factors, nearly 20% and 10% of participants had more than three chronic diseases and took four types of medication, respectively. A small proportion of participants drank alcohol (6.51%), while the majority of participants smoked (87.58%). More than half of participants regularly participated in social activities (54.46%) and exercised (59.03%), while a small proportion (41.56%) regularly received physical examination by healthcare providers. As shown in Table 1 , univariate analysis indicated a significant discrepancy in cognitive function between subgroups of each general characteristic ( P <0.001) for older adults with religious beliefs except for dwelling state ( P = 0.056). There was also a significant discrepancy in cognitive function between subgroups without religious beliefs ( P <0.001). Table 1 Basic characteristics related to cognitive function among older adults with or without religious belief (n = 6656) Variables N (%) With religious belief (n = 943) Without religious belief (n = 5713) MMSE (Mean ± SD) t / F P value MMSE (Mean ± SD) t / F P value Gender −5.177 <0.001** 4.615 <0.001** Male 3106 (46.66) 14.35 ± 8.34 23.06 ± 6.40 Female 3550 (53.34) 17.20 ± 8.44 22.25 ± 6.77 Age, years old 84.239 <0.001** 466.624 <0.001** 60–69 3066 (46.06) 21.14 ± 8.68 24.64 ± 4.99 70–79 2305 (34.63) 14.94 ± 7.79 22.22 ± 6.42 ≥ 80 1285 (19.31) 12.64 ± 7.09 17.80 ± 8.15 BMI a , kg/m 2 42.840 <0.001** 92.139 <0.001** 28 416 (6.25) 24.52 ± 5.59 24.36 ± 4.95 Education level 87.801 <0.001** 172.728 <0.001** Primary school and below 4502 (67.64) 14.33 ± 7.92 21.33 ± 6.99 Junior high school 1156 (17.37) 25.86 ± 4.22 24.88 ± 5.06 Senior high school 792 (11.90) 25.66 ± 4.89 25.66 ± 4.99 College and above 206 (3.09) 26.40 ± 2.41 25.13 ± 5.54 Marital status 19.140 <0.001** 22.566 <0.001** Married 5663 (85.08) 15.35 ± 8.34 22.87 ± 6.48 Widowed 923 (13.87) 20.67 ± 8.40 21.21 ± 7.18 Other conditions b 70 (1.05) 22.11 ± 8.78 23.13 ± 7.12 Quantities of children 53.760 <0.001** 58.658 <0.001** None 141 (2.12) 19.72 ± 9.01 20.05 ± 7.48 1 564 (8.47) 24.19 ± 5.24 24.56 ± 5.87 2 1579 (23.72) 24.10 ± 5.70 23.96 ± 5.55 ≥ 3 4372 (65.69) 14.60 ± 8.15 21.88 ± 6.93 Types of residence −18.455 <0.001** −19.392 <0.001** Urban regions 3581 (53.80) 24.81 ± 4.92 20.64 ± 7.42 Rural regions 3075 (46.20) 13.77 ± 7.76 23.99 ± 5.62 Living alone or not 1.914 0.056 −2.670 0.008** Yes 225 (3.38) 19.21 ± 7.89 21.41 ± 7.26 No 6431 (96.62) 15.85 ± 8.51 22.68 ± 6.59 Types of insurance 68.747 <0.001** 62.889 <0.001** Rural medical service 4507 (67.71) 14.85 ± 8.26 21.91 ± 6.95 Urban medical service 1749 (26.28) 25.25 ± 4.51 23.91 ± 5.84 Other medical service 400 (6.01) 17.56 ± 7.49 24.09 ± 5.16 Family income per month, ¥ 163.306 <0.001** 106.605 <0.001** 4000 2600 (39.06) 24.27 ± 5.36 24.08 ± 5.74 Quantities of chronic diseases 15.543 <0.001** 9.088 <0.001** <3 5490 (82.48) 19.66 ± 8.31 22.93 ± 6.32 ≥ 3 1166 (17.52) 11.97 ± 6.75 20.53 ± 8.08 Types of medication 28.493 <0.001** 3.673 0.005** None 2738 (41.14) 16.79 ± 9.58 22.54 ± 6.76 1 1468 (22.06) 13.10 ± 7.05 22.69 ± 6.34 2 1189 (17.86) 19.53 ± 7.73 23.13 ± 6.14 3 615 (9.24) 19.56 ± 7.91 22.79 ± 6.61 ≥ 4 646 (9.70) 21.36 ± 6.74 21.88 ± 7.21 Drinking −4.936 <0.001** −7.389 <0.001** Yes 433 (6.51) 24.29 ± 5.51 24.95 ± 4.99 No 6223 (93.49) 15.71 ± 8.47 22.45 ± 6.69 Smoking −5.869 <0.001** −9.299 <0.001** Yes 5829 (87.58) 23.33 ± 5.81 24.65 ± 4.84 No 827 (12.42) 15.59 ± 8.46 22.31 ± 6.80 Regular physical examination −12.493 <0.001** −15.425 <0.001** Yes 2766 (41.56) 21.70 ± 5.96 24.11 ± 5.11 No 3890 (58.44) 14.15 ± 8.39 21.45 ± 7.40 Regular social activities −19.818 <0.001** −25.850 <0.001** Yes 3625 (54.46) 22.42 ± 6.14 24.46 ± 4.64 No 3031 (45.54) 12.65 ± 7.61 20.12 ± 7.67 Regular exercise −20.739 <0.001** −28.283 <0.001** Yes 3929 (59.03) 22.19 ± 6.44 24.42 ± 4.75 No 2727 (40.97) 12.30 ± 7.39 19.62 ± 8.06 a Body mass index b Other conditions mean spinsterhood or divorce ** P <0.01 Correlation analysis Table 2 presents the correlations between BADLs, anxiety symptoms, depressive symptoms, and cognitive function. For older adults with and without religious beliefs, the correlations between all variable pairs were significant (all P <0.001). BADLs were positively associated with cognitive function, while anxiety symptoms were positively related to depressive symptoms. Both BADLs and cognitive function were negatively associated with anxiety and depressive symptoms. Table 2 The correlation analysis between cognitive impairment, basic activities of daily living, anxiety symptoms and depressive symptoms among older adults with or without religious belief (n = 6656) Groups Variables Mean ± SD Cognitive impairment BADLs Anxiety symptoms Depressive symptoms With religious belief Cognitive impairment 15.93 ± 8.51 — 0.532** −0.538** −0.529** BADLs 80.92 ± 28.94 — −0.098** −0.095** Anxiety symptoms 7.64 ± 5.19 — 0.910** Depressive symptoms 9.55 ± 7.05 — Without religious belief Cognitive impairment 22.63 ± 6.61 — 0.665** −0.274** −0.343** BADLs 88.92 ± 25.83 — −0.271** −0.336** Anxiety symptoms 3.08 ± 4.10 — 0.850** Depressive symptoms 3.51 ± 4.92 — BADLs: Basic activities of daily living ** P <0.001 The masking effect of anxiety symptoms and mediating effect of depressive symptoms The PROCESS model 4 was used to explore the mediating or masking effect of anxiety and depressive symptoms on the correlation between BADLs and cognitive impairment. Gender, age, BMI, education level, marital status, number of children, residence type, living alone or not, insurance type, family income, quantities of chronic diseases, types of medication, drinking, smoking, regular physical examination, regular social activities, and regular exercise were included as covariates. For older adults with religious beliefs, the total, direct, and indirect effect models were significant ( P <0.001). BADLs were significantly associated with anxiety symptoms ( β = 0.019, SE = 0.005, P <0.001) and cognitive impairment ( β = 0.112, SE = 0.007, P <0.001). Anxiety symptoms were also significantly associated with cognitive impairment ( β =-0.341, SE = 0.043, P <0.001). Similarly, BADLs were significantly associated with depressive symptoms ( β = 0.029, SE = 0.007, P <0.001) and cognitive impairment ( β = 0.112, SE = 0.007, P <0.001). Depressive symptoms were also significantly associated with cognitive impairment ( β =-0.225, SE = 0.033, P <0.001). There was a masking role of anxiety ( β =-0.007, SE = 0.002, 95% CI : − .0011, -0.003) and depressive symptoms ( β =-0.007, SE = 0.002, 95% CI : − .011, -0.003) on the correlation between BADLs and cognitive impairment, each of which accounted for approximately 6.67% of variance in the total effect. The same approach was used to explore relationships between variables among participants without religious beliefs. The results showed that the total, direct, and indirect effect models were significant ( P <0.001). BADLs were significantly associated with anxiety symptoms ( β =-0.028, SE = 0.002, P <0.001) and cognitive impairment ( β = 0.138, SE = 0.003, P <0.001). Anxiety symptoms were also significantly associated with cognitive impairment ( β =-0.095, SE = 0.016, P <0.001). Similarly, BADLs were significantly associated with depressive symptoms ( β =-0.044, SE = 0.003, P <0.001) and cognitive impairment ( β = 0.135, SE = 0.003, P <0.001). Depressive symptoms was also significantly associated with cognitive impairment ( β =-0.118, SE = 0.014, P <0.001). Anxiety ( β = 0.003, SE = 0.006, 95% CI : 0.002, 0.004) and depressive symptoms ( β = 0.005, SE = 0.001, 95% CI : 0.004, 0.007) partially mediated the effect of BADLs on cognitive impairment, each of which accounted for approximately 2.14% and 3.57%, respectively, of variance in the total effect. Chained mediating or masking effect of anxiety and depressive symptoms A chained mediation effects model was established using PROCESS model 6. The regression analysis results are shown in Table 3 . For participants with religious beliefs, the direct effect of BADLs on anxiety symptoms ( β = 0.019, P <0.001) and cognitive impairment ( β = 0.107, P <0.001), and the effect of anxiety on depressive symptoms ( β = 1.121, P <0.001) and cognitive impairment ( β =-0.280, P <0.001), were significant. However, there was no significant impact of BADLs on depressive symptoms ( β = 0.006, P = 0.084), or of depressive symptoms on cognitive impairment ( β =-0.057, P <0.334). As shown in Table 4 and Fig. 1 , there was a significant total effect ( β = 0.101, SE = 0.007, 95% CI : 0.088, 0.0114) and direct effect ( β = 0.107, SE = 0.007, 95% CI : 0.095, 0.121) of BADLs on cognitive impairment. Anxiety symptoms played an independent masking role in the relationship between BADLs and cognitive impairment ( β =-0.006, SE = 0.002, 95% CI : -0.011, -0.003), whereas depressive symptoms did not mediate the path from BADLs to cognitive impairment. Table 3 The results of regression analysis in chained mediation effects model (n = 6656) a Groups Dependent variables Independent variables R R 2 F Standardized β β t P With religious belief Anxiety BADLs 0.673 0.453 42.450 0.103 0.019 3.645 <0.001** Depressive symptoms BADLs 0.919 0.844 262.568 0.026 0.006 1.729 0.084 Anxiety symptoms — — — 0.825 1.121 46.952 <0.001** Cognitive impairment BADLs 0.811 0.657 88.305 0.366 0.107 16.174 <0.001** Anxiety symptoms — — — −0.171 −0.280 −3.563 <0.001** Depressive symptoms — — — −0.047 −0.057 −0.966 0.334 Without religious belief Anxiety BADLs 0.355 0.126 45.755 −0.171 −0.027 −11.988 <0.001** Depressive symptoms BADLs 0.860 0.740 852.793 −0.088 −0.017 −11.122 <0.001** Anxiety symptoms 0.808 0.970 111.753 <0.001** Cognitive impairment BADLs 0.726 0.527 316.816 0.525 0.135 48.809 <0.001** Anxiety symptoms 0.040 0.064 2.271 0.023* Depressive symptoms −0.121 −0.162 −6.756 <0.001** a Final regression model adjusted for all covariates BADLs: Basic activities of daily living * P <0.05, ** P <0.01 Table 4 The relationship between basic activities of daily living and cognitive impairment with mediating or masking role of anxiety and depressive symptoms among older adults with our without religious belief (n = 6656) Groups Pathways effect Boot SE 95% CI Proportion of effect(%) With religious belief Total effect: BADLs→cognitive impairment 0.101* 0.007 (0.088, 0.114) 100.00 Direct effect: BADLs→cognitive impairment 0.107* 0.007 (0.095, 0.121) 105.94 Indirect effect: BADLs→cognitive impairment −0.006* 0.002 (−0.011,−0.003) 5.94 a Indirect effect 1: t BADLs→anxiety symptoms→cognitive impairment −0.005* 0.002 (−0.010,−0.002) 4.95 Indirect effect 2: BADLs→depressive symptoms→cognitive impairment −0.0004 0.001 (−0.002, 0.0004) 0.16 Indirect effect 3: BADLs→anxiety symptoms→depressive symptoms →cognitive impairment −0.001 0.001 (−0.004, 0.002) 0.83 Without religious belief Total effect: BADLs→cognitive impairment 0.140* 0.003 (0.134, 0.145) 100.00 Direct effect: BADLs→cognitive impairment 0.135* 0.003 (0.129, 0.140) 96.43 Indirect effect: BADLs→cognitive impairment 0.005* 0.001 (0.004, 0.007) 3.57 Indirect effect 1: BADLs→anxiety symptoms→cognitive impairment −0.002* 0.001 (−0.004,−0.0001) 1.43 b Indirect effect 2: BADLs→depressive symptoms→cognitive impairment 0.003* 0.001 (0.002, 0.004) 2.14 Indirect effect 3: BADLs→anxiety symptoms→depressive symptoms →cognitive impairment 0.004* 0.001 (0.003, 0.006) 2.86 a Indirect effect is regarded as masking effect calculated by |c’/c|. b Indirect effect 1 is regarded as masking effect calculated by |a 1 b 1 /c-c’| BADLs: Basic activities of daily living *Empirical 95% confidence interval dose not include zero. For participants without religious beliefs, the total and direct effects of BADLs on cognitive impairment remained significant ( P <0.05; Table 3 and Table 4 ). All of the indirect impacts, which differed from those for participants with religious beliefs, were statistically significant in the path from BADLs to cognitive impairment ( P <0.001; Table 4 and Fig. 2 ). Of the indirect effect, anxiety symptoms still played a masking effect in the association between BADLs and cognitive impairment ( β =-0.002, SE = 0.001, 95% CI : -0.004, -0.0001). Depressive symptoms partially mediated the effect of BADLs on cognitive impairment ( β = 0.003, SE = 0.001, 95% CI : 0.002, 0.004). The impact path from BADLs to cognitive impairment was sequentially mediated by anxiety and depressive symptoms ( β = 0.004, SE = 0.001, 95% CI : 0.003, 0.006). Discussion In this population-based, cross-sectional study of older Chinese adults, we found that, compared to participants without BADL limitations, those with BADL limitations reported significantly worse cognitive function regardless of whether they had religious beliefs. Furthermore, the multiple mediating effect model results revealed that the association between BADLs limitations and cognitive impairment may in part be attributed to depressive symptoms among older adults without religious beliefs, whereas a mediating effect of depression was not found among older adults with religious beliefs. Notably, anxiety and depressive symptoms sequentially mediated the association between BADL limitations and cognitive impairment. We also found that anxiety symptoms played an independent masking role on the effect of BADLs on cognitive decline among older adults with or without religious beliefs. There is a broad consensus that physical dysfunction is significantly related to cognitive decline [ 22 , 23 , 51 , 52 ] , although the mechanisms remain controversial [ 16 ] . Previous studies [ 53 – 56 ] have speculated that older adults with lower ADLs have worse physical activities and bodily function, which may be explained by impaired cardiopulmonary fitness, weakened neurotransmitters, and increased stress, ultimately leading to decreased cognitive function. Frailty or pre-frailty, which occurs with the aging process, has also been shown to be a predictive factor for physical impairment in prior studies [ 57 , 58 ] , which is considered one aspect of “cognitive frailty” [ 53 , 59 ] . Consistent with prior reports [ 16 , 60 – 62 ] , we found that a negative mental state like anxiety or depression is linked to cognitive impairment. This correlation is thought to share the same underlying pathophysiology mechanisms [ 60 , 63 ] , such as changes in white matter microstructure [ 64 ] , although more biomedical evidence is needed [ 16 ] . In conclusion, ADLs limitations and psychological disorders may be important predictive indexes of cognitive impairment with a similar influencing path, as proposed by Li et al [ 65 ] . Furthermore, our study explored the possible mechanism of the effect of BADL limitations on cognitive impairment from a psychological perspective. Although the current findings suggest that depressive disorders may aggravate cognitive function declines among older adults with basic physical activity restriction [ 14 , 16 , 22 ] , the proportion of explained variance in the total association was less than 5%, which was significantly lower than the proportions reported by Li et al. [ 15 ] and de Paula et al. [ 23 ] . A possible explanation of this difference is that the above two studies used multi-dimensional assessment methods to measure cognitive function, such as execution, memory, language, and visuospatial abilities, rather than single instrument, resulting in examination of more complex aspects of the association between mental health and cognitive impairment. Moreover, a 6-year longitudinal study by Li et al [ 15 ] fully confirmed the causal relationship between variables. This might also because the association between physical and cognitive function is mediated by diverse factors such as activity knowledge, skills, social network, social support, and multiple-disease states according to Human Capital Model [ 66 ] . However, only a part of these potentially influential factors were adjusted for in our study when established mediation effects model. Accordingly, we should adopt longitudinal design or measurement methods, including those of specific cognitive features, and explore the mediating effect from other individual or social factors, to broadly explain the effect of ADL limitations on cognitive impairment beyond the mental aspect. Despite the finding of a weak indirect effect of depressive symptoms in this study, the partial mediating role in pathway was significant. The mechanism underlying this association may be linked to the fact that older adults with physical limitations lack the energy to participate in external interactions with friends and nearby people [ 65 , 67 , 68 ] , leading to lower social communication and support. Previous studies [ 69 , 70 ] have found that older adults with lower social interactions report more negative mental health and may develop depression. Older people with psychological deficits are speculated to suffer brain structure and nerve function impairments, which can be explained by various hypotheses such as impaired neuroplasticity of the medial prefrontal cortex or hippocampus [ 18 ] , memory deficits, and the vascular hypothesis [ 19 ] , all of which increase the occurrence of cognitive impairment. Moreover, low social participation is predictive of emotional disturbance among older adults, which is related to functional status deterioration [ 71 ] . Our study also investigated the mediating effect of depressive symptoms on the correlation between physical and cognitive impairment among older adults with or without religious beliefs. The results suggest that individuals without religious beliefs who suffer basic self-care disability may experience a higher risk of cognitive decline through the negative influence of depressive status. In contrast, no significant effect of depressive symptoms was seen in the religious group. These findings suggest a crucial protective value of religious and spiritual beliefs on mental health, consistent with the findings of a meta-analysis of 102 observational studies [ 37 ] and a systematic review of 152 prospective studies [ 38 ] . There are several possible explanations for this finding. Firstly, religious activities might contribute to more positive social interactions and strengthen mental health, as discussed in similar studies [ 28 , 72 , 73 ] . Older adults who participate in religious activities more frequently show more self-confidence in coping with adverse life events by acquiring guidance from religious organizations or peer support [ 37 , 74 ] . Secondly, from an internal perspective, religion might relieve depressive symptoms by providing meaning and increasing psychological resilience when someone faces a dilemma, promoting a transcendent approach that changes one’s attention to other people’s happiness instead of excessively focusing on the self [ 75 ] . In addition, Maranges et al [ 36 ] found that religious beliefs might provide a connection between self-control and lower mental distress. Religion is traditionally regarded as a multidimensional construct dependent on the synthesis of beliefs [ 37 ] , public involvement [ 76 ] , private practices [ 72 ] , and intrinsic mental or cognitive aspects like religious coping and motivation [ 36 ] . However, the assessment of religious beliefs in our study was designed to single question and binary answers, which cannot fully consider the complex forms of religion. Numerous studies [ 43 , 77 ] examining the interrelation of religion and depression have reported considerable variation between continents or countries, highlighting the necessity to consider the effect of regional heterogeneity on religious connotation. For example, Chinese Buddhist culture has been proven to be valuable for relieving the adverse impact of perceived inequality and pressure from traditional social attributes on subjective well-being [ 78 ] . However, partial studies [ 79 , 80 ] conducted in western countries with a profound Christian culture or background have described a concept of negative religious coping, called “religious struggle”, which is associated with depression development. Therefore, future studies should focus on a common mechanism of psychological and cognitive disorder based on particular aspect of religion. Another major finding of our study is that anxiety symptoms play a significant masking role on the association between BADL limitations and cognitive impairment among older adults. A partial effect and a total masking effect in indirect effect, respectively, were found in the religious and non-religious groups. These different findings suggest that the indirect effect via anxiety symptoms might weaken the total direct effect of physical limitations on cognitive impairment. Compared to depressive symptoms, anxiety might alleviate the adverse impact of limited physical activities on cognitive impairment. These findings are inconsistent with prior reports in the psychosomatic field that mental disorders harm physical or cognitive health [ 81 , 82 ] . These differences could be due to the fact that anxiety, especially an early anxiety state, is presumed to be an adaptive strategy contributing to positive stress coping styles and adaptive behaviors [ 83 , 84 ] . Individuals often show adaptive effects during the early period of mild stress after a negative event, which is commonly described as hypervigilance and includes different manifestations like enhanced selective attention [ 85 ] , shorter response delay [ 86 ] , and stronger working memory [ 87 , 88 ] . This process may improve associative learning and adaptive feedback in the short term, and help advance disease management [ 89 ] . However, existing evidence does not show an overall beneficial influence of anxiety on pressure coping due to the complexity of mental health conditions intensity, measurements, and the environment in which stress experience [ 84 ] . Further research is needed to understand the evolutionary mechanism of psychologies inducing disease formulation in the future. Implications and limitations There is a lack of religious studies in China because of the low popularity of religious concepts in Chinese societies [ 43 ] . Individuals with religious beliefs may be considered to have social values deviating from the norm, and may be stigmatized or marginalized [ 43 ] . Hence, health professionals lack basic knowledge and experience in this field [ 90 ] , even though it may be essential for systematic disability management among older people. In light of this, the present study offers perspectives beyond existing research that religious belief has a direct impact on the association between mental health and disability status among older Chinese adults. These findings are encouraging and serve as a reminder that religious beliefs may play a more important role than originally thought, providing health professionals with new directions related to psychological management of disabled older adults. More attention should be paid to the role of depressive disorder in mediating the correlation between physical limitations and cognitive impairment among older adults without religious beliefs. Healthcare personnel should fully understand older adults’ religious beliefs and behaviors and seek the best approach to include religious elements in therapeutic strategies against the Chinese cultural background. Moreover, healthcare personnel should learn about religious cultures and forms to provide guidance for older adults. There are some limitations that restrict our findings. First, the cross-sectional design limits our ability to draw causal explanations or understand the temporal precedence in which variables interact. Prospective studies should be conducted to explore the causal relationship between related factors. Second, although we established a chained mediating effect model adjusted for probable confounding factors and found an indirect effect of anxiety and depressive symptoms on the association between ADL limitations and cognitive impairment, this accounted for a small proportion of the total effect. Thus, other variables may play a regulating role in the paths. Further research should include more variables to explore multiple mechanisms influencing disability according to a mature theoretical framework. Third, the current study only used a single question to identify participants with or without religious beliefs. Due to the complexity of religious categories and connotations, evaluation systems consisting of additional religion forms in accord with regional culture should be developed in the future. Fourth, only MMSE was used to assess cognitive impairment. A more comprehensive approach including systematic function aspects, such as language, memory, or execution function, and professional neurological examination is warranted to confirm diagnosis. Conclusion The findings of the current study suggest that physical limitations in older Chinese adults might influence cognitive function through the mediating role of depressive disorder and the masking role of anxiety. These paths were found to differ significantly between older adults with and without religious belief. Based on our findings, future therapeutic strategies aimed at addressing physical function and relieving mental health issues may aid in resolving cognitive concerns. Such treatments should focus on the prevention of depressive disorders, the potential positive effect of anxiety, and postponement of mental disorders and cognitive deterioration through religious thinking. Declarations Funding National Key Research and Development Program of China, 2020YFC2008500. Data availability Data is provided within the manuscript or supplementary information files. Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. 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Mild acute stress improves response speed without impairing accuracy or interference control in two selective attention tasks: Implications for theories of stress and cognition[J]. Psychoneuroendocrinology, 2019,108:78-86. Henckens M J, Hermans E J, Pu Z, et al. Stressed memories: how acute stress affects memory formation in humans[J]. J Neurosci, 2009,29(32):10111-10119. Yuen E Y, Liu W, Karatsoreos I N, et al. Acute stress enhances glutamatergic transmission in prefrontal cortex and facilitates working memory[J]. Proc Natl Acad Sci U S A, 2009,106(33):14075-14079. Shields G S, Sazma M A, Yonelinas A P. The effects of acute stress on core executive functions: A meta-analysis and comparison with cortisol[J]. Neurosci Biobehav Rev, 2016,68:651-668. Peteet J R, Zaben F A, Koenig H G. Integrating spirituality into the care of older adults[J]. Int Psychogeriatr, 2019,31(1):31-38. Additional Declarations No competing interests reported. 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Guo","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jinhua","middleName":"","lastName":"Guo","suffix":""},{"id":423834458,"identity":"e6790d77-7ee2-45dd-af7a-bf657bc032f3","order_by":2,"name":"Lixia Lin","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lixia","middleName":"","lastName":"Lin","suffix":""},{"id":423834459,"identity":"6d2ea8be-6a8e-4d7b-9f6d-357bfcd7b9ff","order_by":3,"name":"Min Peng","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Peng","suffix":""},{"id":423834460,"identity":"8eee8f95-5d3d-49e4-8146-37dc3d0a7f68","order_by":4,"name":"Jiaxi Huang","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiaxi","middleName":"","lastName":"Huang","suffix":""},{"id":423834461,"identity":"021dcca9-69f9-4e15-8862-55bffac02a2c","order_by":5,"name":"Yi Yang","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Yang","suffix":""},{"id":423834462,"identity":"bc32eb7d-dd65-47f9-80e9-5c763ce3a400","order_by":6,"name":"Tiemei Shen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFACxgYgIQFGDB8MbOxI08I4oyAtmQTbgFqYeT4cApuAF+i2N7d9ulFhkS8/u/nYYxuDA8wM7IePbsCnxezMwebZOWckLDfcOZZunGNwh4+BJy3tBl4tNxKbmXPbJAwMJHLMpHMMnjEzSPCY4ddy/yFQyz8JA/kZ+d+kLQwOMzYQ1HKDEailQcKA4UYOmzQDUVrOAB2WcwzosBtpZpI9BmnJbAT9cvz4Y+acmjqgw5KfSfz4Y2PHz374GF4tmICNNOWjYBSMglEwCrABANYER1InLl5FAAAAAElFTkSuQmCC","orcid":"","institution":"Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Tiemei","middleName":"","lastName":"Shen","suffix":""}],"badges":[],"createdAt":"2025-02-21 05:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6076160/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6076160/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78241647,"identity":"446d9e18-cf47-49fd-8c38-a8b6909327c5","added_by":"auto","created_at":"2025-03-11 09:05:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101353,"visible":true,"origin":"","legend":"\u003cp\u003eSelection process of the study population.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6076160/v1/01c0170ed46097839a6af576.png"},{"id":78241649,"identity":"23015c2a-2ec4-40b9-9d21-8f5ca98dadeb","added_by":"auto","created_at":"2025-03-11 09:05:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":105032,"visible":true,"origin":"","legend":"\u003cp\u003eFig.1 Chained mediation effects model of mediating or masking effect of anxiety and depressive symptoms on\u003c/p\u003e\n\u003cp\u003eassociation between BADLs and cognitive impairment among individuals who have religious belief\u003c/p\u003e\n\u003cp\u003ec=Total effect, c’=Direct effect, a\u003csub\u003e1\u003c/sub\u003e=Effect of BADLs on anxiety symptoms, a\u003csub\u003e2\u003c/sub\u003e=Effect of BADLs on depressive symptoms, b\u003csub\u003e1\u003c/sub\u003e=Effect of anxiety symptoms on cognitive impairment, b\u003csub\u003e2\u003c/sub\u003e=Effect of depressive symptoms on cognitive impairment, d\u003csub\u003e21\u003c/sub\u003e=Effect of anxiety on depressive symptoms\u003c/p\u003e\n\u003cp\u003eBADLs: Basic activities of daily living\u003c/p\u003e\n\u003cp\u003e**\u003cem\u003eP\u003c/em\u003e＜0.01\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6076160/v1/1866d8fcd6690ac6d7ced5c8.png"},{"id":78244910,"identity":"16b7460e-bbdd-406d-8a01-0203a99d6e46","added_by":"auto","created_at":"2025-03-11 09:21:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51984,"visible":true,"origin":"","legend":"\u003cp\u003eFig.2 Chained mediation effects model of mediating or masking effect of anxiety and depressive symptoms on association between BADLs and cognitive impairment among individuals who do not have religious belief\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ec=Total effect, c’=Direct effect, a\u003csub\u003e1\u003c/sub\u003e=Effect of BADLs on anxiety symptoms, a\u003csub\u003e2\u003c/sub\u003e=Effect of BADLs on depressive symptoms, b\u003csub\u003e1\u003c/sub\u003e=Effect of anxiety symptoms on cognitive impairment, b\u003csub\u003e2\u003c/sub\u003e=Effect of depressive symptoms on cognitive impairment, d\u003csub\u003e21\u003c/sub\u003e=Effect of anxiety on depressive symptoms BADLs: Basic activities of daily living *\u003cem\u003eP\u003c/em\u003e＜0.05, **\u003cem\u003eP\u003c/em\u003e＜0.01\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-6076160/v1/06797226296bbae60ae31a9b.png"},{"id":78247229,"identity":"cafaad21-d29a-4f31-b941-9236bbc91d33","added_by":"auto","created_at":"2025-03-11 09:38:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1864967,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6076160/v1/5d8a9c22-0483-4245-8e0a-1ccff0d1b7e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The mediating role of anxiety and depressive symptoms on the relationship between physical limitations and cognitive impairment among older adults in China: differences based on religious perspective","fulltext":[{"header":"Contributions to the literature","content":"\u003cp\u003e1.Pathway Modulation by Religious Beliefs: Religious beliefs uniquely modulate BADLs-cognitive impairment pathways, suppressing psychological mediation complexity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.Multidimensional Risk in Non-Religious Populations: Non-religious older adults face direct and multifactorial indirect risks (anxiety masking, depressive mediation, anxiety-depression serial pathways) from BADLs limitations, amplifying cognitive decline.\u003c/p\u003e\n\u003cp\u003e3.Belief-Stratified Interventions: Findings advocate prioritized integration of anxiety-depression management in non-religious older adults with BADLs limitations and belief-specific prevention frameworks to counter cognitive deterioration.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAs global social structure changes, numerous countries, including China, are facing an aging problem and associated health issues\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Cognitive dysfunction is regarded as a normal neurological change that accompanies the physiological aging process\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, persistent decline in cognitive function may develop into dementia or Alzheimer\u0026rsquo;s disease, leading to impaired self-care abilities and social interactions\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and ultimately imposing a great burden on the public health system and healthcare financing\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. At present, the prevalence of cognitive impairment in China is higher than that of other developed countries. In European countries, nearly 10% of older adults experience cognitive decline or dementia\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. In China, various regional population-based surveys report a prevalence rate exceeding 20%\u003csup\u003e[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Hence, there is an urgent need for comprehensive and active interventions for older adults with cognitive issues.\u003c/p\u003e \u003cp\u003ePrior studies have investigated the association between physical function and cognitive impairment among older adult. In their prospective survey following older Japanese adults for 4 years, Sauvaget et al.\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e found that dementia was a strong predictor of limited basic activities of daily living (BADL) or instrumental activities of daily living (IADL) after adjusting for age, sex and history of stroke. The predictive value of changes in cognition to disability has been confirmed by several longitudinal studies. Exploration of the potential mechanism connecting cognitive impairment with physical function has become an important research topic. Wu et al.\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e reported that good baseline cognitive function decreased the risk of endpoint BADL disability over a 2-year follow-up period, and that depressive symptoms mediated the negative effect of cognitive function on BADLs. Using longitudinal data from the Chinese Longitudinal Healthy Longevity Surveys, Li et al.\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e found that 29.1% of older adults with cognitive impairment developed IADL disability in 6 years and that the correlation was fully mediated by lifestyle, social communication, and depressive status. Mental disorders are crucial mediators accelerating functional decline among older adults with limited cognitive competence\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. This effect may be due to a synergistic link between cognitive impairment and depressive status, such that neuroinflammatory or morphological changes in the brain lead to impaired executive control and mood processing\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Mechanistic studies suggest that these effects might derive from bodily damage\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, indicating a possible bidirectional correlation between physical and cognitive impairment via the same influencing path\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Moreover, Panza et al.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e reported that mental diseases like depression may be a reaction in initial symptoms of cognitive decline and show similar behavior features of clinical function impairment, suggesting a vital overlap or interaction effect\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Based on this background, we hypothesized that mental disorders like anxiety or depression play an indirect role in the ADLs disability\u0026mdash;cognitive function association.\u003c/p\u003e \u003cp\u003eSeveral factors are recognized as possibly protective against cognitive decline, including healthy living habits\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e and dietary patterns\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e, positive or optimistic emotions\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e, frequent social activities\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, and specific religious faiths or beliefs\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. The effect of religiosity or religious practice on delaying cognitive development \u0026mdash;particularly dementia \u0026mdash; has attracted great research attention in the past decade. According to a systematic review of 17 studies\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e, a positive association between religious/spiritual practice and cognitive function was reported in 82% of studies. Nath et al.\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e also carried out a systematic review to explore the role of religion on cognitive maintenance, demonstrating significant consistency in the direction of the relationship between religion and memory, suggesting that region is a key element of cognitive protection among middle-aged and older adults. Prior studies have suggested several mechanisms to explain the positive impact of religion on cognitive deterioration. Some viewpoints argue that religious participation can improve the formulation of nonrepresentational concepts like moral sense and meaning of life, which are beneficial for stimulating and maintaining higher cortical functions and brain regions associated with memory\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Alternatively, religion can be linked to a positive effect on health by increasing social interactions that encourage individuals to consolidate friendships and expand social networks\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e, thus avoiding negative mental health consequences and cognitive deficits\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Social isolation has been shown to be a risk factor for cognitive decline in previous studies of older adults \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. At the same time, the social characteristics of religious activity could strengthen cognitive reserve capacity and elevate mental tenacity\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is a broad consensus that positive religious beliefs or involvement are an important coping resource for mental health. Compared to people without religious beliefs, individuals who believe in god or have higher religiosity may have greater self-control to seek divine forgiveness, which is a potential mechanism linking religion to psychological health\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. The findings of a meta-analysis\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e investigating 79918 older adults living in communities and hospitals found that individuals with a high level of religious affiliation and internal religiosity report a lower prevalence of anxiety or depressive disorders. These findings are supported by increasing data from longitudinal studies\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e showing a significant association between religious belief and modest improvement of depressive symptoms over time. When religious-based approaches are fully considered by researchers when providing interventions for people with poor mental health, the results indicate a superior effect compared to usual psychological therapies\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e. The necessity to combine faith-adapted mental- and cognitive-related treatments with psychological interventions for depression patients has been emphasized in multiple studies\u003csup\u003e[\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. However, because of differences between China and Western countries in terms of cultural background and the formal welfare system \u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e, care for older adults in China is mainly based on a traditional family-based support model\u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e. As a result, the impact of religiosity on mental health or cognitive function among older adults in China might be different from those reported in countries with a popular religious culture. Furthermore, there is a lack of research focusing on how religiosity affects the association between physical dysfunction and cognitive decline mediated by psychological factors\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e, limiting the understanding and applications of religious theories by healthcare professionals when handling cognitive issues.\u003c/p\u003e \u003cp\u003eTo address this research gap, the current study addressed two aspects. First, we explored the mediating or masking role of anxiety and depressive symptoms on the relationship between BADLS limitations and cognitive impairment among older Chinese adults after adjusting for sociodemographic and health-related factors. Second, we compared the discrepancy of two influencing paths among older adults without religious beliefs to develop a preliminary theoretical basis for psychological interventions for cognitive function in older adults based on religion.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThis population-based, cross-sectional study used a multistage, stratified, cluster-sampling procedure and was conducted between June 2021 and December 2022. This study was carried out as part of the \u0026ldquo;Active health and technological response to aging\u0026rdquo; subproject carried out by the Ministry of Science and Technology of China. Four representative cities from the Pearl River Delta (Guangzhou, Shenzhen, Zhuhai, and Foshan), one city from the east region (Qingyuan), and one city from the west region of Guangdong Province (Maoming) were selected as the main study sites. Data collection was primarily conducted at hospitals, including 2\u0026ndash;3 tertiary hospitals and 1 secondary hospital with a reputation for providing geriatric healthcare in each city. In view of the diversity of care models for older adults in China, we also collected data from community healthcare centers with the largest population attached to streets or hospitals, and 60\u0026ndash;70 families recorded in community resident health files to avoid selection bias. The main inclusion criteria was being aged 60 years or older. Participants with a current or previous mental disease, serious organ dysfunction, or any acute disease, as well as participants who were unable to engage in normal communication, were excluded. Ultimately, a total of 6656 older adults from 15 tertiary hospitals, 6 secondary hospitals, 6 community healthcare centers, and 350 families in 6 cities were included in the analysis. This study was approved by the ethics committee of Guangdong Province People\u0026rsquo;s Hospital (KY-Z-2021-690-01) and all participants provided written informed consent.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eGeneral participant information\u003c/h2\u003e \u003cp\u003eGeneral participant information was collected using a questionnaire developed based on previous studies and reviewed by two experts in a pilot study. This questionnaire included sociodemographic information (gender, age, body mass index (BMI), education level, type of residence, family income, etc.) and health-related information (chronic diseases, types of medication, drinking, smoking, regular physical examination, regular social activities, etc.).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReligious beliefs\u003c/h3\u003e\n\u003cp\u003eWe used a single question to assess religious beliefs: Do you believe in a religion (Christianity, Buddhism, Islam, etc.) or usually participate in individual or group religious-related activities? If participants answered \u0026ldquo;yes\u0026rdquo;, they were considered to have religious beliefs; otherwise, participants were considered to not have religious beliefs.\u003c/p\u003e\n\u003ch3\u003eCognitive impairment\u003c/h3\u003e\n\u003cp\u003eCognitive status was evaluated using the 30-item Chinese version of the Mini-Mental State Examination (MMSE). The MMSE was designed by Folstein\u003csup\u003e[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/sup\u003e in 1975 and includes dimensions of orientation, memory, attention and calculation, recall, and language. The MMSE has a sensitivity up to 92.5% to detect cognitive impairment\u003csup\u003e[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/sup\u003e. Correct responses were scored as 1, while incorrect or unclear responses were scored as 0. The MMSE is scored out of 30 points, with lower scores indicating more serious cognitive decline.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBADLs\u003c/h2\u003e \u003cp\u003eActivities of daily living (ADLs) reflect essential activities performed by individuals living in medical institutions, communities, and families\u003csup\u003e[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/sup\u003e. Because IADLs items might partially overlap with early cognitive decline, we use the BADLs rating scale for ADLs assessment. BADLs included eight basic movements and self-care activities: eating, bathing, combing, dressing, controlling urine, controlling excrement, walking, and walking up and down stairs\u003csup\u003e[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/sup\u003e. Each item is evaluated at 2 to 4 level. The highest level is scored 15 points, and lowest level is scored 0 point. The BADLs rating scale is scored out of 100 points, with lower scores indicating worse self-care ablility, which means more serious physical limitations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnxiety and depressive symptoms\u003c/h3\u003e\n\u003cp\u003eAnxiety and depressive symptoms were measured using the Generalized Anxiety Disorder-7 (GAD-7) and Health Questionnaire-9 (PHQ-9), respectively. Both scales are widely used instruments for assessing mental health. GAD-7 was used to evaluate the frequency of the following seven conditions over the previous 2 weeks: tension, uncontrollable worries, excessive worries, inability to relax, akathisia, irritability, and foreboding\u003csup\u003e[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/sup\u003e. Each item was evaluated using a 4-point Likert scale with total scores ranging from 0 to 21. Anxiety symptoms were divided into four levels: mild (5\u0026ndash;9), moderate (10\u0026ndash;13), moderate-severe (14\u0026ndash;18), and severe (19\u0026ndash;21). PHQ-9 was used to evaluate the frequency of nine conditions over the previous 2 weeks: displeasure, appetite change, fatigue, worthlessness, guilt, decreased concentration, slow movement, restlessness, and suicidal tendency\u003csup\u003e[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/sup\u003e. Each item was evaluated using a 4-point Likert scale with total scores ranging from 0 to 27. Depressive symptoms were divided into four levels: mild (5\u0026ndash;9), moderate (10\u0026ndash;14), moderate-severe (15\u0026ndash;19), and severe (10\u0026ndash;27).\u003c/p\u003e\n\u003ch3\u003eData collection procedure\u003c/h3\u003e\n\u003cp\u003eData were collected using the Wechat mini program called \u0026ldquo;Jingyice platform on the functional assessment of older adults\u0026rdquo;. Written permission was obtained by each of the selected hospitals and community study sites. Formal investigations were performed by specialized interviewer teams recommended by the hospitals and communities. For door-to-door data collection from families, interviewers were screened and trained by the corresponding communities.\u003c/p\u003e \u003cp\u003e Unified guidelines were used when describing the study aims, obtaining informed consent, and carrying out face-to-face interviews. Consultations with caregivers or other family members chosen by subjects were allowed if older adults were unable to communicate with interviewers due to speech or hearing dysfunctions. All questionnaires were checked by the interviewers for missing data or errors. The data were stored in a secured file only accessible by authorized personnel.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using SPSS software version 26.0. Quantitative variables (such as MMSE scores) are reported as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while qualitative variables (such as gender, age stratification, and education level) are reported as absolute values and percentages. We used the \u003cem\u003et\u003c/em\u003e test or chi-square test to compare differences in MMSE scores between groups based on sociodemographic or health-related factors. Pearson analysis was utilized to examine the correlation between cognitive impairment, BADLs, anxiety, and depressive symptoms among older adults with or without religious beliefs. Hayes\u0026rsquo; (2013) SPSS PROCESS macro software (Model 4)\u003csup\u003e[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/sup\u003e was employed to explore the independent indirect effect of anxiety and depressive symptoms on the association between BADLs limitations and cognitive impairment. To explore whether there is a serial multiple indirect effect of anxiety and depressive symptoms, we further used Hayes\u0026rsquo; (2013) SPSS PROCESS macro (Model 6)\u003csup\u003e[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/sup\u003e. We respectively established two path models for older adults with or without religious beliefs and then compared differences in the mediating or masking roles. Bootstrap confidence intervals (CI) at 95% and 5000 bootstrap samples were selected for the analysis. If the boundaries between the lower and upper values of the 95%CI did not cross zero, the models were regarded as significant at the 0.05 level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eGeneral participant characteristics\u003c/h2\u003e \u003cp\u003eOf the total 6656 participants, 943 (14.17%) reported having religious beliefs and 5713 (85.83%) reported no religious beliefs. The sample included 3106 males (46.66%) and 3550 females (53.34%). The average age was 71.97\u0026thinsp;\u0026plusmn;\u0026thinsp;8.10 years; 46.06% of participants were in the range of 60\u0026ndash;69 years old. The majority of participants (56.46%) had a standard BMI. More than half of participants had an education level of primary school or below (67.64%), more than three children (65.69%), were married (85.08%), and lived with family members (96.62%). Regarding region of residence, 53.80% and 46.20% of participants resided in urban and rural regions, respectively. Most participants received rural medical services (67.71%) and had a family income ranging from 2000\u0026ndash;4000\u0026yen; per month (44.62%). Regarding health-related factors, nearly 20% and 10% of participants had more than three chronic diseases and took four types of medication, respectively. A small proportion of participants drank alcohol (6.51%), while the majority of participants smoked (87.58%). More than half of participants regularly participated in social activities (54.46%) and exercised (59.03%), while a small proportion (41.56%) regularly received physical examination by healthcare providers. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, univariate analysis indicated a significant discrepancy in cognitive function between subgroups of each general characteristic (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) for older adults with religious beliefs except for dwelling state (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.056). There was also a significant discrepancy in cognitive function between subgroups without religious beliefs (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic characteristics related to cognitive function among older adults with or without religious belief (n\u0026thinsp;=\u0026thinsp;6656)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eWith religious belief (n\u0026thinsp;=\u0026thinsp;943)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eWithout religious belief (n\u0026thinsp;=\u0026thinsp;5713)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMMSE (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e/\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMMSE (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e/\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;5.177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3106 (46.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3550 (53.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.20\u0026thinsp;\u0026plusmn;\u0026thinsp;8.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e84.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e466.624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3066 (46.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.14\u0026thinsp;\u0026plusmn;\u0026thinsp;8.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2305 (34.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.94\u0026thinsp;\u0026plusmn;\u0026thinsp;7.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1285 (19.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.64\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e17.80\u0026thinsp;\u0026plusmn;\u0026thinsp;8.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003csup\u003ea\u003c/sup\u003e, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e92.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e582 (8.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.19\u0026thinsp;\u0026plusmn;\u0026thinsp;9.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e19.69\u0026thinsp;\u0026plusmn;\u0026thinsp;7.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.5\u0026ndash;23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3758 (56.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.01\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u0026minus;27.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1900 (28.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.13\u0026thinsp;\u0026plusmn;\u0026thinsp;8.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.23\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e416 (6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.52\u0026thinsp;\u0026plusmn;\u0026thinsp;5.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e172.728\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4502 (67.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.33\u0026thinsp;\u0026plusmn;\u0026thinsp;6.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1156 (17.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e25.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.88\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e792 (11.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e25.66\u0026thinsp;\u0026plusmn;\u0026thinsp;4.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e25.66\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e206 (3.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e26.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e25.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e22.566\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5663 (85.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.87\u0026thinsp;\u0026plusmn;\u0026thinsp;6.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e923 (13.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther conditions\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70 (1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.11\u0026thinsp;\u0026plusmn;\u0026thinsp;8.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuantities of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e58.658\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e141 (2.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.72\u0026thinsp;\u0026plusmn;\u0026thinsp;9.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e20.05\u0026thinsp;\u0026plusmn;\u0026thinsp;7.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e564 (8.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.19\u0026thinsp;\u0026plusmn;\u0026thinsp;5.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1579 (23.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4372 (65.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.60\u0026thinsp;\u0026plusmn;\u0026thinsp;8.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.88\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;18.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;19.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban regions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3581 (53.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e20.64\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural regions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3075 (46.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.77\u0026thinsp;\u0026plusmn;\u0026thinsp;7.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.99\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone or not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;2.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.008**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e225 (3.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6431 (96.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.85\u0026thinsp;\u0026plusmn;\u0026thinsp;8.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68.747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e62.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural medical service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4507 (67.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.85\u0026thinsp;\u0026plusmn;\u0026thinsp;8.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.91\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban medical service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1749 (26.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e25.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.91\u0026thinsp;\u0026plusmn;\u0026thinsp;5.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther medical service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e400 (6.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.09\u0026thinsp;\u0026plusmn;\u0026thinsp;5.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily income per month, \u0026yen;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e163.306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e106.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1086 (16.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.49\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2000\u0026ndash;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2970 (44.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.48\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.57\u0026thinsp;\u0026plusmn;\u0026thinsp;7.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2600 (39.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuantities of chronic diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5490 (82.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.66\u0026thinsp;\u0026plusmn;\u0026thinsp;8.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1166 (17.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.97\u0026thinsp;\u0026plusmn;\u0026thinsp;6.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e20.53\u0026thinsp;\u0026plusmn;\u0026thinsp;8.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.005**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2738 (41.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.79\u0026thinsp;\u0026plusmn;\u0026thinsp;9.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.54\u0026thinsp;\u0026plusmn;\u0026thinsp;6.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1468 (22.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.10\u0026thinsp;\u0026plusmn;\u0026thinsp;7.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.69\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1189 (17.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.53\u0026thinsp;\u0026plusmn;\u0026thinsp;7.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e23.13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e615 (9.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.79\u0026thinsp;\u0026plusmn;\u0026thinsp;6.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e646 (9.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.36\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;4.936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;7.389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e433 (6.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.29\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6223 (93.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.71\u0026thinsp;\u0026plusmn;\u0026thinsp;8.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.45\u0026thinsp;\u0026plusmn;\u0026thinsp;6.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;5.869\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;9.299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5829 (87.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e23.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.65\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e827 (12.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.59\u0026thinsp;\u0026plusmn;\u0026thinsp;8.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e22.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular physical examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;12.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;15.425\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2766 (41.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.70\u0026thinsp;\u0026plusmn;\u0026thinsp;5.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3890 (58.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.15\u0026thinsp;\u0026plusmn;\u0026thinsp;8.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e21.45\u0026thinsp;\u0026plusmn;\u0026thinsp;7.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular social activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;19.818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;25.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3625 (54.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.42\u0026thinsp;\u0026plusmn;\u0026thinsp;6.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3031 (45.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.65\u0026thinsp;\u0026plusmn;\u0026thinsp;7.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e20.12\u0026thinsp;\u0026plusmn;\u0026thinsp;7.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;20.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;28.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3929 (59.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e24.42\u0026thinsp;\u0026plusmn;\u0026thinsp;4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2727 (40.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e19.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003ea Body mass index\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eb Other conditions mean spinsterhood or divorce\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e** \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation analysis\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the correlations between BADLs, anxiety symptoms, depressive symptoms, and cognitive function. For older adults with and without religious beliefs, the correlations between all variable pairs were significant (all \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). BADLs were positively associated with cognitive function, while anxiety symptoms were positively related to depressive symptoms. Both BADLs and cognitive function were negatively associated with anxiety and depressive symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe correlation analysis between cognitive impairment, basic activities of daily living, anxiety symptoms and depressive symptoms among older adults with or without religious belief (n\u0026thinsp;=\u0026thinsp;6656)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith religious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.93\u0026thinsp;\u0026plusmn;\u0026thinsp;8.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.532**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.538**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.529**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e80.92\u0026thinsp;\u0026plusmn;\u0026thinsp;28.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.098**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.095**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.64\u0026thinsp;\u0026plusmn;\u0026thinsp;5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.910**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.55\u0026thinsp;\u0026plusmn;\u0026thinsp;7.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout religious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.665**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.274**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.343**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e88.92\u0026thinsp;\u0026plusmn;\u0026thinsp;25.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.271**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.336**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.850**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBADLs: Basic activities of daily living\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e**\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThe masking effect of anxiety symptoms and mediating effect of depressive symptoms\u003c/h2\u003e \u003cp\u003eThe PROCESS model 4 was used to explore the mediating or masking effect of anxiety and depressive symptoms on the correlation between BADLs and cognitive impairment. Gender, age, BMI, education level, marital status, number of children, residence type, living alone or not, insurance type, family income, quantities of chronic diseases, types of medication, drinking, smoking, regular physical examination, regular social activities, and regular exercise were included as covariates. For older adults with religious beliefs, the total, direct, and indirect effect models were significant (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). BADLs were significantly associated with anxiety symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019, SE\u0026thinsp;=\u0026thinsp;0.005, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.112, SE\u0026thinsp;=\u0026thinsp;0.007, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Anxiety symptoms were also significantly associated with cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.341, SE\u0026thinsp;=\u0026thinsp;0.043, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Similarly, BADLs were significantly associated with depressive symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029, SE\u0026thinsp;=\u0026thinsp;0.007, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.112, SE\u0026thinsp;=\u0026thinsp;0.007, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Depressive symptoms were also significantly associated with cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.225, SE\u0026thinsp;=\u0026thinsp;0.033, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). There was a masking role of anxiety (\u003cem\u003eβ\u003c/em\u003e=-0.007, SE\u0026thinsp;=\u0026thinsp;0.002, 95%\u003cem\u003eCI\u003c/em\u003e: \u0026minus;\u0026thinsp;.0011, -0.003) and depressive symptoms (\u003cem\u003eβ\u003c/em\u003e=-0.007, SE\u0026thinsp;=\u0026thinsp;0.002, 95%\u003cem\u003eCI\u003c/em\u003e: \u0026minus;\u0026thinsp;.011, -0.003) on the correlation between BADLs and cognitive impairment, each of which accounted for approximately 6.67% of variance in the total effect.\u003c/p\u003e \u003cp\u003eThe same approach was used to explore relationships between variables among participants without religious beliefs. The results showed that the total, direct, and indirect effect models were significant (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). BADLs were significantly associated with anxiety symptoms (\u003cem\u003eβ\u003c/em\u003e=-0.028, SE\u0026thinsp;=\u0026thinsp;0.002, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.138, SE\u0026thinsp;=\u0026thinsp;0.003, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Anxiety symptoms were also significantly associated with cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.095, SE\u0026thinsp;=\u0026thinsp;0.016, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Similarly, BADLs were significantly associated with depressive symptoms (\u003cem\u003eβ\u003c/em\u003e=-0.044, SE\u0026thinsp;=\u0026thinsp;0.003, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.135, SE\u0026thinsp;=\u0026thinsp;0.003, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Depressive symptoms was also significantly associated with cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.118, SE\u0026thinsp;=\u0026thinsp;0.014, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Anxiety (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003, SE\u0026thinsp;=\u0026thinsp;0.006, 95%\u003cem\u003eCI\u003c/em\u003e: 0.002, 0.004) and depressive symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005, SE\u0026thinsp;=\u0026thinsp;0.001, 95%\u003cem\u003eCI\u003c/em\u003e: 0.004, 0.007) partially mediated the effect of BADLs on cognitive impairment, each of which accounted for approximately 2.14% and 3.57%, respectively, of variance in the total effect.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eChained mediating or masking effect of anxiety and depressive symptoms\u003c/h2\u003e \u003cp\u003eA chained mediation effects model was established using PROCESS model 6. The regression analysis results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. For participants with religious beliefs, the direct effect of BADLs on anxiety symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.107, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and the effect of anxiety on depressive symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.121, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.280, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), were significant. However, there was no significant impact of BADLs on depressive symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.084), or of depressive symptoms on cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.057, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.334). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, there was a significant total effect (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.101, SE\u0026thinsp;=\u0026thinsp;0.007, 95%\u003cem\u003eCI\u003c/em\u003e: 0.088, 0.0114) and direct effect (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.107, SE\u0026thinsp;=\u0026thinsp;0.007, 95%\u003cem\u003eCI\u003c/em\u003e: 0.095, 0.121) of BADLs on cognitive impairment. Anxiety symptoms played an independent masking role in the relationship between BADLs and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.006, SE\u0026thinsp;=\u0026thinsp;0.002, 95%\u003cem\u003eCI\u003c/em\u003e: -0.011, -0.003), whereas depressive symptoms did not mediate the path from BADLs to cognitive impairment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe results of regression analysis in chained mediation effects model (n\u0026thinsp;=\u0026thinsp;6656) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDependent variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStandardized \u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith religious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3.645\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e262.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e46.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e16.174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;3.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;0.966\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout religious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;11.988\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e852.793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;11.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e111.753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBADLs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e316.816\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e48.809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.023*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;0.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;6.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.001**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003ea Final regression model adjusted for all covariates\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eBADLs: Basic activities of daily living\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e*\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05, **\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between basic activities of daily living and cognitive impairment with mediating or masking role of anxiety and depressive symptoms among older adults with our without religious belief (n\u0026thinsp;=\u0026thinsp;6656)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePathways\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eeffect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoot SE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%\u003cem\u003eCI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProportion of effect(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith religious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal effect:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.101*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.088, 0.114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDirect effect:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.107*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.095, 0.121)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e105.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;0.006*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(\u0026minus;0.011,\u0026minus;0.003)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.94\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect 1: t\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;anxiety symptoms\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;0.005*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(\u0026minus;0.010,\u0026minus;0.002)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect 2:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;depressive symptoms\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.0004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(\u0026minus;0.002, 0.0004)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect 3:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;anxiety symptoms\u0026rarr;depressive symptoms\u003c/p\u003e \u003cp\u003e\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(\u0026minus;0.004, 0.002)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout religious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal effect:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.140*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.134, 0.145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDirect effect:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.135*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.129, 0.140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.005*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.004, 0.007)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect 1:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;anxiety symptoms\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(\u0026minus;0.004,\u0026minus;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.43\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect 2:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;depressive symptoms\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.003*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.002, 0.004)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndirect effect 3:\u003c/p\u003e \u003cp\u003eBADLs\u0026rarr;anxiety symptoms\u0026rarr;depressive symptoms\u003c/p\u003e \u003cp\u003e\u0026rarr;cognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.004*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.003, 0.006)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ea Indirect effect is regarded as masking effect calculated by |c\u0026rsquo;/c|.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eb Indirect effect 1 is regarded as masking effect calculated by |a\u003csub\u003e1\u003c/sub\u003eb\u003csub\u003e1\u003c/sub\u003e/c-c\u0026rsquo;|\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBADLs: Basic activities of daily living\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Empirical 95% confidence interval dose not include zero.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor participants without religious beliefs, the total and direct effects of BADLs on cognitive impairment remained significant (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). All of the indirect impacts, which differed from those for participants with religious beliefs, were statistically significant in the path from BADLs to cognitive impairment (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of the indirect effect, anxiety symptoms still played a masking effect in the association between BADLs and cognitive impairment (\u003cem\u003eβ\u003c/em\u003e=-0.002, SE\u0026thinsp;=\u0026thinsp;0.001, 95%\u003cem\u003eCI\u003c/em\u003e: -0.004, -0.0001). Depressive symptoms partially mediated the effect of BADLs on cognitive impairment (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003, SE\u0026thinsp;=\u0026thinsp;0.001, 95%\u003cem\u003eCI\u003c/em\u003e: 0.002, 0.004). The impact path from BADLs to cognitive impairment was sequentially mediated by anxiety and depressive symptoms (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004, SE\u0026thinsp;=\u0026thinsp;0.001, 95%\u003cem\u003eCI\u003c/em\u003e: 0.003, 0.006).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this population-based, cross-sectional study of older Chinese adults, we found that, compared to participants without BADL limitations, those with BADL limitations reported significantly worse cognitive function regardless of whether they had religious beliefs. Furthermore, the multiple mediating effect model results revealed that the association between BADLs limitations and cognitive impairment may in part be attributed to depressive symptoms among older adults without religious beliefs, whereas a mediating effect of depression was not found among older adults with religious beliefs. Notably, anxiety and depressive symptoms sequentially mediated the association between BADL limitations and cognitive impairment. We also found that anxiety symptoms played an independent masking role on the effect of BADLs on cognitive decline among older adults with or without religious beliefs.\u003c/p\u003e \u003cp\u003eThere is a broad consensus that physical dysfunction is significantly related to cognitive decline\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/sup\u003e, although the mechanisms remain controversial\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Previous studies\u003csup\u003e[\u003cspan additionalcitationids=\"CR54 CR55\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/sup\u003e have speculated that older adults with lower ADLs have worse physical activities and bodily function, which may be explained by impaired cardiopulmonary fitness, weakened neurotransmitters, and increased stress, ultimately leading to decreased cognitive function. Frailty or pre-frailty, which occurs with the aging process, has also been shown to be a predictive factor for physical impairment in prior studies\u003csup\u003e[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]\u003c/sup\u003e, which is considered one aspect of \u0026ldquo;cognitive frailty\u0026rdquo;\u003csup\u003e[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/sup\u003e. Consistent with prior reports \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]\u003c/sup\u003e, we found that a negative mental state like anxiety or depression is linked to cognitive impairment. This correlation is thought to share the same underlying pathophysiology mechanisms\u003csup\u003e[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/sup\u003e, such as changes in white matter microstructure\u003csup\u003e[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]\u003c/sup\u003e, although more biomedical evidence is needed\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. In conclusion, ADLs limitations and psychological disorders may be important predictive indexes of cognitive impairment with a similar influencing path, as proposed by Li et al\u003csup\u003e[\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFurthermore, our study explored the possible mechanism of the effect of BADL limitations on cognitive impairment from a psychological perspective. Although the current findings suggest that depressive disorders may aggravate cognitive function declines among older adults with basic physical activity restriction\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e, the proportion of explained variance in the total association was less than 5%, which was significantly lower than the proportions reported by Li et al.\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e and de Paula et al.\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. A possible explanation of this difference is that the above two studies used multi-dimensional assessment methods to measure cognitive function, such as execution, memory, language, and visuospatial abilities, rather than single instrument, resulting in examination of more complex aspects of the association between mental health and cognitive impairment. Moreover, a 6-year longitudinal study by Li et al\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e fully confirmed the causal relationship between variables. This might also because the association between physical and cognitive function is mediated by diverse factors such as activity knowledge, skills, social network, social support, and multiple-disease states according to Human Capital Model\u003csup\u003e[\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]\u003c/sup\u003e. However, only a part of these potentially influential factors were adjusted for in our study when established mediation effects model. Accordingly, we should adopt longitudinal design or measurement methods, including those of specific cognitive features, and explore the mediating effect from other individual or social factors, to broadly explain the effect of ADL limitations on cognitive impairment beyond the mental aspect.\u003c/p\u003e \u003cp\u003eDespite the finding of a weak indirect effect of depressive symptoms in this study, the partial mediating role in pathway was significant. The mechanism underlying this association may be linked to the fact that older adults with physical limitations lack the energy to participate in external interactions with friends and nearby people\u003csup\u003e[\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/sup\u003e, leading to lower social communication and support. Previous studies\u003csup\u003e[\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/sup\u003e have found that older adults with lower social interactions report more negative mental health and may develop depression. Older people with psychological deficits are speculated to suffer brain structure and nerve function impairments, which can be explained by various hypotheses such as impaired neuroplasticity of the medial prefrontal cortex or hippocampus\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, memory deficits, and the vascular hypothesis\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, all of which increase the occurrence of cognitive impairment. Moreover, low social participation is predictive of emotional disturbance among older adults, which is related to functional status deterioration\u003csup\u003e[\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study also investigated the mediating effect of depressive symptoms on the correlation between physical and cognitive impairment among older adults with or without religious beliefs. The results suggest that individuals without religious beliefs who suffer basic self-care disability may experience a higher risk of cognitive decline through the negative influence of depressive status. In contrast, no significant effect of depressive symptoms was seen in the religious group. These findings suggest a crucial protective value of religious and spiritual beliefs on mental health, consistent with the findings of a meta-analysis of 102 observational studies\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e and a systematic review of 152 prospective studies\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. There are several possible explanations for this finding. Firstly, religious activities might contribute to more positive social interactions and strengthen mental health, as discussed in similar studies\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/sup\u003e. Older adults who participate in religious activities more frequently show more self-confidence in coping with adverse life events by acquiring guidance from religious organizations or peer support\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/sup\u003e. Secondly, from an internal perspective, religion might relieve depressive symptoms by providing meaning and increasing psychological resilience when someone faces a dilemma, promoting a transcendent approach that changes one\u0026rsquo;s attention to other people\u0026rsquo;s happiness instead of excessively focusing on the self\u003csup\u003e[\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]\u003c/sup\u003e. In addition, Maranges et al\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e found that religious beliefs might provide a connection between self-control and lower mental distress.\u003c/p\u003e \u003cp\u003eReligion is traditionally regarded as a multidimensional construct dependent on the synthesis of beliefs\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e, public involvement\u003csup\u003e[\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/sup\u003e, private practices\u003csup\u003e[\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]\u003c/sup\u003e, and intrinsic mental or cognitive aspects like religious coping and motivation\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. However, the assessment of religious beliefs in our study was designed to single question and binary answers, which cannot fully consider the complex forms of religion. Numerous studies\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]\u003c/sup\u003e examining the interrelation of religion and depression have reported considerable variation between continents or countries, highlighting the necessity to consider the effect of regional heterogeneity on religious connotation. For example, Chinese Buddhist culture has been proven to be valuable for relieving the adverse impact of perceived inequality and pressure from traditional social attributes on subjective well-being\u003csup\u003e[\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]\u003c/sup\u003e. However, partial studies\u003csup\u003e[\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]\u003c/sup\u003e conducted in western countries with a profound Christian culture or background have described a concept of negative religious coping, called \u0026ldquo;religious struggle\u0026rdquo;, which is associated with depression development. Therefore, future studies should focus on a common mechanism of psychological and cognitive disorder based on particular aspect of religion.\u003c/p\u003e \u003cp\u003eAnother major finding of our study is that anxiety symptoms play a significant masking role on the association between BADL limitations and cognitive impairment among older adults. A partial effect and a total masking effect in indirect effect, respectively, were found in the religious and non-religious groups. These different findings suggest that the indirect effect via anxiety symptoms might weaken the total direct effect of physical limitations on cognitive impairment. Compared to depressive symptoms, anxiety might alleviate the adverse impact of limited physical activities on cognitive impairment. These findings are inconsistent with prior reports in the psychosomatic field that mental disorders harm physical or cognitive health\u003csup\u003e[\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]\u003c/sup\u003e. These differences could be due to the fact that anxiety, especially an early anxiety state, is presumed to be an adaptive strategy contributing to positive stress coping styles and adaptive behaviors\u003csup\u003e[\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/sup\u003e. Individuals often show adaptive effects during the early period of mild stress after a negative event, which is commonly described as hypervigilance and includes different manifestations like enhanced selective attention\u003csup\u003e[\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]\u003c/sup\u003e, shorter response delay\u003csup\u003e[\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]\u003c/sup\u003e, and stronger working memory\u003csup\u003e[\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e]\u003c/sup\u003e. This process may improve associative learning and adaptive feedback in the short term, and help advance disease management\u003csup\u003e[\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e]\u003c/sup\u003e. However, existing evidence does not show an overall beneficial influence of anxiety on pressure coping due to the complexity of mental health conditions intensity, measurements, and the environment in which stress experience\u003csup\u003e[\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/sup\u003e. Further research is needed to understand the evolutionary mechanism of psychologies inducing disease formulation in the future.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplications and limitations\u003c/h2\u003e \u003cp\u003eThere is a lack of religious studies in China because of the low popularity of religious concepts in Chinese societies\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. Individuals with religious beliefs may be considered to have social values deviating from the norm, and may be stigmatized or marginalized\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. Hence, health professionals lack basic knowledge and experience in this field\u003csup\u003e[\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]\u003c/sup\u003e, even though it may be essential for systematic disability management among older people. In light of this, the present study offers perspectives beyond existing research that religious belief has a direct impact on the association between mental health and disability status among older Chinese adults.\u003c/p\u003e \u003cp\u003eThese findings are encouraging and serve as a reminder that religious beliefs may play a more important role than originally thought, providing health professionals with new directions related to psychological management of disabled older adults. More attention should be paid to the role of depressive disorder in mediating the correlation between physical limitations and cognitive impairment among older adults without religious beliefs. Healthcare personnel should fully understand older adults\u0026rsquo; religious beliefs and behaviors and seek the best approach to include religious elements in therapeutic strategies against the Chinese cultural background. Moreover, healthcare personnel should learn about religious cultures and forms to provide guidance for older adults.\u003c/p\u003e \u003cp\u003eThere are some limitations that restrict our findings. First, the cross-sectional design limits our ability to draw causal explanations or understand the temporal precedence in which variables interact. Prospective studies should be conducted to explore the causal relationship between related factors. Second, although we established a chained mediating effect model adjusted for probable confounding factors and found an indirect effect of anxiety and depressive symptoms on the association between ADL limitations and cognitive impairment, this accounted for a small proportion of the total effect. Thus, other variables may play a regulating role in the paths. Further research should include more variables to explore multiple mechanisms influencing disability according to a mature theoretical framework. Third, the current study only used a single question to identify participants with or without religious beliefs. Due to the complexity of religious categories and connotations, evaluation systems consisting of additional religion forms in accord with regional culture should be developed in the future. Fourth, only MMSE was used to assess cognitive impairment. A more comprehensive approach including systematic function aspects, such as language, memory, or execution function, and professional neurological examination is warranted to confirm diagnosis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of the current study suggest that physical limitations in older Chinese adults might influence cognitive function through the mediating role of depressive disorder and the masking role of anxiety. These paths were found to differ significantly between older adults with and without religious belief. Based on our findings, future therapeutic strategies aimed at addressing physical function and relieving mental health issues may aid in resolving cognitive concerns. Such treatments should focus on the prevention of depressive disorders, the potential positive effect of anxiety, and postponement of mental disorders and cognitive deterioration through religious thinking.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNational Key Research and Development Program of China, 2020YFC2008500.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript or supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ein accordance with the ethical standards of the institutional research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ecommittee and with the 1964 Helsinki declaration and its later amendments\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eor comparable ethical standards. This study was approved by the ethics committee of Guangdong Province People\u0026rsquo;s Hospital (KY-Z-2021-690-01) and all participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors agree to the publication in the present form and content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eQiao R, Jia S, Zhao W, et al. Prevalence and correlates of disability among urban-rural older adults in Southwest China: a large, population-based study[J]. BMC Geriatr, 2022,22(1):517.\u003c/li\u003e\n\u003cli\u003eHan Y, Zhang L, Fang Y. Multidimensional Disability Evaluation and Confirmatory Analysis of Older Adults in a Home-Based Community in China[J]. 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Int Psychogeriatr, 2019,31(1):31-38.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cognitive impairment, religious belief, basic activities of daily life, mental health, mediating effect, path analysis","lastPublishedDoi":"10.21203/rs.3.rs-6076160/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6076160/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Physical limitationsand mental health may have a common effect on cognitive function. However, little is known about how religion influences these paths among older Chinese adults.\u003c/p\u003e\n\u003cp\u003eObjective: This study investigated how anxiety and depressive symptoms mediate the association between physical limitations and cognitive impairment. Furthermore, we analyzed discrepancies in path models between participants with or without religious beliefs.\u003c/p\u003e\n\u003cp\u003eMethods: This population-based, cross-sectional study involved 6656 adults aged ≥60 years in six cities in Guangdong Province, China. Participants were divided into two groups based on the presence of religious beliefs. All participants completed a general demographics questionnaire, the Chinese version of the Mini-Mental State Examination (MMSE), the Basic Activities of Daily Living (BADLs) scale, Generalized Anxiety Disorder-7 (GAD-7), and Health Questionnaire-9 (PHQ-9). Simple and serial multiple mediation models were then tested using SPSS PROCESS macro.\u003c/p\u003e\n\u003cp\u003eResults: BADLs, anxiety symptoms, depressive symptoms, and cognitive impairment were significantly related (all P＜0.01). When adjusting for sociodemographic and health-related factors, BADLs limitations had a direct positive effect on cognitive impairment among participants with religious beliefs (effect=0.107, 95% confidence interval (CI): 0.095, 0.121), but also had indirect effect via independent masking of anxiety symptoms (effect=-0.005, 95%CI: -0.010,-0.002). For participants without religious belief, BADLs limitations had a direct positive effect on cognitive impairment (effect=0.135, 95%CI: 0.129, 0.140) as well as an indirect effect via three paths: an independent masking effect of anxiety symptoms (effect=-0.002, 95%CI: -0.004,-0.0001), independent mediation of depressive symptoms (effect=0.003, 95%CI: 0.002,0.004), and serial mediation of anxiety and depressive symptoms (effect=0.004, 95%CI: 0.003,0.006).\u003c/p\u003e\n\u003cp\u003eConclusions: Our findings highlight the need for health professionals to promote mental well-being to prevent cognitive decline prevention among older adults with physical limitations who do not have religious belief. These findings should be further confirmed by prospective studies utilizing other methods of assessing cognitive function and religiosity.\u003c/p\u003e","manuscriptTitle":"The mediating role of anxiety and depressive symptoms on the relationship between physical limitations and cognitive impairment among older adults in China: differences based on religious perspective","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 09:05:53","doi":"10.21203/rs.3.rs-6076160/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"343fd6a1-31a5-4585-ad39-8e9f5e232656","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-11T09:05:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-11 09:05:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6076160","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6076160","identity":"rs-6076160","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}