Association between elderly parents’ health status and adult children’ depression level among different caregiver roles in China: A multi-level mediation analysis

Association between elderly parents’ health status and adult children’ depression level among different caregiver roles in China: A multi-level mediation analysis | 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 Association between elderly parents’ health status and adult children’ depression level among different caregiver roles in China: A multi-level mediation analysis Yuan Yao, Qifeng Ma, Siyuan Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7455064/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective : This study examines the association between the health status of elderly parents and depression levels of their adult children, with a focus on differences in caregiving roles. It also investigates the mediating effect of social isolation among adult children, aiming to inform targeted mental health interventions. Methods : Utilizing data from the 2018, 2020, and 2022 China Family Panel Studies,this study employed multilevel linear models to investigate the relationship between the health status of elderly parents and the depression levels of their adult children. The multilevel mediation analysis was used to test the potential mediating role of social isolation. Results : Findings indicate that poor health status in elderly parents was associated with higher levels of depression in their adult children. This relationship differs depending on whether the adult children serve as caregivers, with a stronger and statistically significant association observed in the caregiver subgroup. Furthermore, social isolation was found to mediate the relationship between parental health status and depression only among caregivers. Conclusion : These results underscore the need to prioritize mental health support for adult children who serve as caregivers. Expanding and diversifying caregiver support services could help mitigate depressive symptoms, improve the balance between caregiving and social life, and promote the sustainability of family-based eldercare system. Depression Level Health Status The Elderly Caregiver Social Isolation Introduction Since the beginning of the 21st century, population aging has become a defining feature of China's demographic landscape. By the end of 2023, the population aged 60 and above reached 297 million, accounting for 21.1% of the total population. In response to this demographic shift, the Chineses government has introduced a range of strategic measures, such as the development of an age-friendly society, integration of medical and elderly care services, and reform of the pension insurance system. Despite these efforts, family-based care—where adult children provide informal support-remains the predominant form in China, underpinned by deeply rooted cultural norms of filial piety (Wang & Tang, 2023). However, members of the "sandwich generation" face dual pressures from parenting responsibilities and career demands (Lei et al., 2023), while also assuming caregiving roles for aging parents. These overlapping roles can result in significant psychological strain, role conflict, and energy depletion, increasing the risk of mental health challenges, particularly depression (Schulz et al., 2020). The relationship between elderly parents' health and adult children's depression and the underlying mechanisms from perspectives such as caregiving networks, social support levels, and social role conflicts have been widely explored in the previous studies (Escalante et al., 2020; Hamon, 1992; Wang et al., 2004). However, a critical mediating factor- adult children’s social isolation-has received comparatively less attention. Social isolation, defined as "a state in which individuals are isolated or detached from others and society" (Escalante et al., 2020), is recognized as a significant determinant of physical and mental health (Wister et al., 2016). (Soskolne et al., 2007)studies (2007) suggests that caregiving status moderates the psychological effects of parental health: adult children providing intergenerational care are more vulnerable to the adverse impacts of parental health decline than non-caregivers. Nevertheless, whether these findings are applicable to China’s distinct cultural context remains uncertain. This study aims to examine: (1) the association between health status of elderly parents and mental health of their adult children in China; (2) how this relationship varies depending on the caregiving role of the adult children; (3) the mediating effecs of social isolation in this association. By identifying key determinants of adult children’s mental health, the findings provide practical insights for the development of evidence-based public health interventions and the promotion of sustainable family caregiving. Moreover, by exploring the mechanisms through which elderly parents’ health affects depression outcomes, the study contributes to a deeper theoretical understanding of mental health disparities between caregivers and non-caregivers and informs the design of targeted support strategies. Background 2.1 Different Caregiver Roles in Elderly Parental Health and Adult Children's Depression Levels Over the years, scholars have proposed various theoretical models to explain the pathways linking elderly parental health to adult children's psychological well-being. Among these, the Stress Process Model (Pioli, 2010) is one of the most frequently cited frameworks for understanding caregiver burden, stress trajectories, and mental health outcomes. This model posits that health status of care recipients is key stressor directly impacting caregivers' psychological well-being. As caregiving for aging parents is considered a primary familial responsibility for adult children, the characteristics and health fluctuations of elderly parents significantly influence mental health of their adult-child caregivers. Fundamentally, caregiving is a dynamic process in which adult children continuously navigate stress and emotional demands (Barnett, 2013). According to this framework, declining parental health has a stronger negative impact on the caregiver’s psychological state, often leading to heightened mental health risks (Yi-meng & Qi-lin, 2021). Substantial empirical evidence supports the relationship between health status of elderly parents and psychological states of adult children. For example, (Amirkhanyan & Wolf, 2006) characterized caregiving as a stress process shaped by elder-specific factors—particularly health status—that profoundly affect adult children’s psychological outcomes. Similarly, other studies have found that higher levels of parental disability intensify caregiving demands, increasing stress and adversely impacting caregivers’ health (Yue et al., 2022). Amid the shifting paradigm of elder care—from traditional family-based models to more diverse and autonomous care alternatives—adult children are making divergent choices in fulfilling obligations. Constrained by socioeconomic pressures, some opt for institutional or community-based care options rather than assuming direct caregiving roles, resulting in variations in caregiver status. Under this circumstance, the impact of elderly parental health and adult children’s psychological well-being might differ according to the caregiving role adopted. According to role theory (Choi et al., 2007; Crittenden et al., 2022), caregivers—as opposed to non-caregivers—must juggle multiple social roles when providing care to elderly parents. This role multiplicity may lead to inter-role conflict and psychological distress. Empirical research has confirmed that family caregivers often experience poorer health than their non-caregiving counterparts. Notably, caregivers who persist in providing care despite work-family conflicts report significantly higher levels of depression (Lin et al., 2013). In China, the traditional culture norm of filial piety further obliges adult children to fulfill caregiving responsibilities. From a role theory perspective, internalizing this filial role can heighten caregiving intensity as parental health deteriorates, influencing multiple domains of the caregiver’s life, especially in mental health (Hamon, 1992). 2.2 The Mediating Effects of Social Isolation on the Relationship between Elderly Parents’ Health and Adult Children's Depression Levels Social isolation refers to an objective condition of disconnection resulting from deficiencies in an individual's social network. It is commonly categorized into two primary subtypes: family isolation and friend isolation (Jang et al., 2016). Social isolation has been significantly associated with impaired cognitive functioning and heighten feelings of loneliness. Chronic social isolation is widely recognized for its detrimental effects on both physical and mental health (Evans et al., 2019; Holt-Lunstad et al., 2015). According to the Family Stress Model (Choy et al., 2025), providing care for aging parents contributes to a decline in quality of life among adult-child caregivers. In parallel, the Stress Process Model suggests that the psychological impact of elderly parental health on adult children operates through multiple mediating mechanisms. Existing research has explored these pathways from various theoretical perspectives. For instance, a life-course study found that parental health influences offspring mental health via reduced leisure time and diminished income for caregivers (Yuan& Chen, 2019). Similarly, Malhotra et al. (2012) documented that access to formal care services and emotional support significantly moderate depressive symptoms among informal caregivers, especially spouses and adult children. However, few studies have examined the social isolation as a mediator in the relationship between parental health and adult children's depression, particularly across different caregiver roles. A substantial body of evidence indicate a strong association between caregiving for elderly parents with serious health problems and increased social isolation among caregivers (Musich et al., 2017). Within the Stress Process Model, the health status of elderly parents constitutes a primary stressor in caregiving contexts (Pearlin et al., 2005). The model’s central mechanism—stress proliferation—provides a theoretical foundation for understanding how caregiving stressors extend into other life domains (Li et al., 2021). Specifically, when health problems emerge and intensify, they exert broad biopsychosocial effects on caregivers via multiple pathways. Heightened social isolation is a salient manifestation of this stress proliferation process (Kim et al., 2017). Drawing on social role theory, adult children who internalize caregiving responsibilities often suppress their own needs—particularly social needs—while prioritizing the care of their aging parents. This role-based self-sacrifice increases their vulnerability to social isolation (Pope et al., 2022). At the same time, social relationships serve as critical buffers for emotional regulation, and the degree of isolation is strongly predicting depression trajectories (Luo, 2023). The well-established link between familial caregiving and social isolation is especially pronounced among caregivers experiencing prolonged isolation, whose fragile social networks limit opportunities for emotional exchange and exacerbates depressive symptoms through compounding psychosocial deprivation (Li et al., 2021). 2.4 Hypotheses Based on the theoretical frameworks and empirical findings presented in the preceding sections, this study proposes the following hypotheses: Hypothesis 1: Elderly parental health status will have a significant negative impact on depression levels of adult children. Hypothesis 2: The relationship between elderly parental health and adult children's depression will vary by caregiving roles, with caregivers exhibiting greater vulnerability to parental health deterioration compared to non-caregivers. Hypothesis 3: The relationships between elderly parental health and adult children's depression will be mediated by social isolation, such that poorer parental health increases social isolation, which in turn heightens depression levels. Methods 3.1 Data source The China Family Panel Studies (CFPS) is a nationally representative social survey administered by the Institute of Social Science Survey at Peking University. Launched with a baseline survey in 2010, it employs a biennial follow-up design using a stratified multistage probability sampling. The survey covers 25 provincial-level administrative units (provinces/municipalities/autonomous regions) across mainland China, excluding Xinjiang, Tibet, Ningxia, Qinghai, Inner Mongolia, Hainan, Hong Kong, Macao, and Taiwan. A key feature distinguishing CFPS from other large sample social surveys is its comprehensive documentation of kinship networks and detailed household member information (Yu et al., 2014). This design offers a significant methodological advantage by enabling the linkage of adult children with their elderly parents within the same households—an approach central to this study. In line with the research objectives, three caves of cross-sectional data from 2018, 2020, and 2022 were compiled, yielding an initial sample of 37,354 respondents. Using household identifiers and kinship codes, data from the adult questionnaire served as the master data. Elderly parents aged 60 and above were matched with their adult children in a one-to-many format, and subsequently integrated into a one-to-one parent-child matching sample. Cases with missing key variables were excluded, resulting in 12,960 valid matched pairs from 4,985 households retained for analysis. 3.2 Variables and measurement 3.2.1 Outcome: Depression level in Adult Children Following established methodologies (Stafford et al., 2011), this study measures adult children's depression levels using the revised short-form Center for Epidemiologic Studies Depression Scale (CES-D) (Silverstein et al., 2006). The 2018 CFPS includes an 8-item CES-D module, with each item rated on a 4-point Likert scaling. Response options include: "Rarely (< 1 day)" (scored 0); "Some days (1–2 days)" (scored 1); "Occasionally (3–4 days)" (scored 2); "Most of the time (5–7 days)" (scored 3), yielding total scores ranging from 0 to 24. Higher scores indicate greater depression severity. The scale demonstrated acceptable internal consistency in this study. 3.2.2 Predictor: Health status of Elderly Parents Self-rated health, a subjective assessment of one’s overall health, is widely recognized as a reliable indicator of an individual's health status. In this study, elderly parents’ health status is assessed using the CFPS question: “How do you rate your health status?”. Responses were coded on a 5-point scale: “very healthy” ( 5 ), “healthy” ( 4 ), “fairly healthy” ( 3 ), “average” ( 2 ), and “unhealthy” ( 1 ), with higher scores indicating higher health status. 3.2.3 Treatment group: Caregiver Role The caregiver role is identified using two CFPS questions “Do you do housework or take care of your father/mother?” and “Does the elderly person need care?”. Adult children who perform housework or caregiving tasks for elderly parents in need of care were classified as “caregivers” and assigned a value of 1. Others were categorized as “non-caregivers” and assigned a value of 0. 3.2.4 Mediator: The Level of Social Isolation of Adult Children To assess social isolation, this study uses the Social Isolation-Social Network Index (SNI) (Berkman & Syme, 2017), which capture four dimensions: marital status, organizational participation, religious involvement, and intimate relationships. The latter is further subdivided into family and friend relationships. Each dimension is scored as 1 if the individual is socially engaged and 0 otherwise, producing a total score from 0 to 5 points. Higher score reflects greater social isolation. 3.2.5 Covariates Control variables include demographic and socioeconomic characteristics of both generations. For adult children: age, gender, marital status, years of education, employment status, self-rated economic status, and self-rated health. For elderly parents: age, gender, marital status, and years of education. At the household level, urban-rural residence type and household size were also included. Table 1 summarizes all variable coding and descriptive statistics. Among the total of 12,960 paired samples, adult children had an average depression score of 5.54, a social isolation score of 2.86, an age of 40.26 years, and 7.09 years of education. Their average self-rated economic status and health score was 3.22. In total, 43% of adult children were caregivers, 79% were male, 82% were married, and 92% were employed. The elderly parents reported an average self-rated health score of 2.53, an average age of 68.92 years, and 3.03 years of education. Among them, 48% were male and 79% were married. Additionally, 53% of the households were urban (residing in towns/cities), with an average household size of 4.83 persons. Table 1 Description of variables and samples (n = 12,960) Variable Variable assignment Mean Standard Deviation Outcome Depression level 0 ~ 24 scores, the Depression level score of adult children 5.54 3.86 Predictor Health status 1 ~ 5 scores, self-rated health scores of elderly parents 2.53 1.27 Treatment Group Caregiver role Non-caregiver = 0, Caregiver = 1 0.43 0.50 Mediator Social isolation 0 ~ 5 scores, the degree of social segregation of adult children 2.86 0.85 Covariates Adult children Age 18 ~ 59 years old, the actual age of adult children 40.26 7.54 Gender Female = 0, male = 1 0.79 0.41 Marital status Currently not = 0, married = 1 0.82 0.38 Education 0 ~ 22 years, the actual number of years of education for adult children 7.09 5.21 Employment status Currently not = 0, employed = 1 0.92 0.28 Economic status 1 ~ 5 scores, self-rated of economic score of adult children 3.22 1.09 Health status 1 ~ 5 scores, self-rated of health score of adult children 3.22 1.10 Elderly parents Age 60 ~ 96years old, the actual age of elderly parents 68.92 7.13 Gender Female = 0, male = 1 0.48 0.50 Marital status Currently not = 0, married = 1 0.79 0.41 Education 0 ~ 19years, the actual number of years of education for elderly parents 3.03 4.14 Urban-Rural type Rural = 0, urban = 1 0.53 0.50 Family size 1 ~ 21, the size of the surveyed family 4.83 2.15 3.3 Statistical analysis First, Harman's single-factor test was conducted to assess common method bias. Six factors with eigenvalues greater than 1 were extracted. The first common factor accounted for 15.57% of the total variance, well below the conventional threshold of 40%. This suggests that common method bias was not a significant concern in the present study. Based on this test, Pearson correlation analysis was conducted on the main study variables. Secondly, considering the nested structure of the data—where multiple generational dyads are nested within the same household— the assumptions of homoscedasticity and independent distribution required for traditional linear regression were violated. To address this, we employed a two-level Hierarchical Linear Model (HLM) for regression analysis (Lei & Zhang, 2002). The model specifications are presented below: $$\:{Y}_{ij}={\beta\:}_{0j}+{{\beta\:}_{1j}X}_{ij}+{\sum\:}_{k}{\beta\:}_{jk}{C}_{kij}+{\lambda\:}_{t}$$ 1 $$\:{\beta\:}_{0j}={\eta\:}_{00}+{\sum\:}_{m}{\eta\:}_{0}m{Z}_{mj}+{\epsilon\:}_{0j}\:$$ 2 $$\:{\beta\:}_{jk}={\eta\:}_{j0}+{\sum\:}_{m}{\eta\:}_{jm}{Z}_{mj}\:$$ 3 In equations ( 1 )-( 3 ), \(\:{Y}_{ij}\) represents the depressive level of adult children in generation i within household j ; \(\:{X}_{ij}\) indicates the health status of elderly parents in generation i within household j . The regression coefficient for the core independent variable is \(\:{\beta\:}_{1j}\) , \(\:{C}_{kij}\:and\:{Z}_{{m}_{j}}\) represent control variables at the individual and household levels, respectively, with k and m being the number of control variables at each level. The regression coefficients for these control variables are \(\:{\beta\:}_{jk}\:and\:{\eta\:}_{jm}\) , respectively. \(\:{\beta\:}_{0j}\) denotes the random intercept, \(\:{\epsilon\:}_{0j}\) is the residual term at the household level, and \(\:{\lambda\:}_{t}\) is time fixed effects, which follows a normal distribution N (0, τ 00 ). Finally, building upon the HLM framework, this study employed split-sample regressions to analyze potential heterogeneity in caregiver roles and constructs a multilevel mediation model to examine the role of adult children's social isolation. Compared to single-level mediation models, the multilevel mediation approach enhances the explanatory power of mediation effects in nested data structures (Fang & Wen, 2018). Data management and statistical analyses were performed collaboratively using STATA 15 and SPSS 23 software. Results 4.1 The association between the health status of elderly parents and depression level of adult children The regression results of HLM model on the influence of elderly parents' health status on the depression level of adult children are shown in Table 2 . Model 1, the null model, is used to determine the necessity of using the HLM model in empirical analysis. This model does not include any predictors at either the first or second level; instead, it decomposes the regression equation into two components: intra-group variance σ 2 and inter-group variance τ 00 , which are used to calculate the intra-class correlation coefficient (ICC). According to the empirical rule (Fang et al., 2013), if the ICC value exceeds 0.059, it indicates that HLM analysis is necessary. The ICC value for Model 1 is significantly higher than this threshold, making the use of the HLM model in this study both appropriate and necessary. Model 2 introduced the core independent variable. Results indicated that each unit increase in elderly parents' health status was associated with an average decline of approximately 0.137 ( p< 0.001) in their adult children's depression levels. Building on this, Models 3 to 5 sequentially incorporated level-1 control variables (adult children's characteristics), level-1 parental control variables, and level-2 household control variables. The regression coefficient for parental health status decreased but remained statistically significant. Taking the full model (Model 5) as an example, results demonstrated that each unit increase in parental health corresponded to an average deterioration of 0.104 ( p <0.001) in offspring depression levels. These findings conclusively demonstrate that poor health among elderly parents exerts a negative impact on their adult children's depression levels, thereby supporting Research Hypothesis 1 . Table 2 The effect of elderly parents' health status on the depression level of adult children Variable (reference group) Model 1 Model 2 Model 3 Model 4 Model 5 Elderly parents' health status -0.137*** -0.103*** -0.106*** -0.104*** (0.023) (0.022) (0.022) (0.022) Adult children Age -0.028*** -0.024** -0.023** (0.006) (0.008) (0.008) Gender (Female) 0.043 0.044 0.016 (0.099) (0.099) (0.100) Marital status (currently not) -0.877*** -0.884*** -0.840*** (0.100) (0.100) (0.104) Education -0.084*** -0.089*** -0.081** (0.011) (0.011) (0.011) Employment status (currently not) -0.321*** -0.323** -0.331** (0.115) (0.115) (0.115) Economic status -0.312*** -0.312*** -0.313*** (0.032) (0.032) (0.032) Health status -0.746*** -0.746*** -0.748*** (0.030) (0.030) (0.030) Elderly parents Age 0.000 -0.000 (0.008) (0.008) Gender (Female) 0.009 0.004 (0.054) (0.054) Marital status (currently not) 0.158 0.179 (0.108) (0.108) Education 0.010 0.012 (0.009) (0.009) Urban-Rural type(rural) -0.366*** (0.088) Family size -0.029 (0.022) Constant 5.582*** 5.732*** 12.079*** 11.824*** 12.025*** (0.050) (0.081) (0.324) (0.506) (0.512) σ 2 5.896 5.863 5.736 5.737 5.736 τ 00 9.433 9.332 7.641 7.637 7.607 ICC 0.615 0.614 0.571 0.571 0.570 Observations 12,960 12,960 12,960 12,960 12,960 Number of groups 4,985 4,985 4,985 4,985 4,985 Note: *, ** and *** indicate significance at the 5%,1% and 0.1% levels, respectively, with standard error in parentheses. 4.2 Heterogeneity of caregiver role in the association between the health status of elderly parents and depression level of adult children Building upon the baseline regression, this study investigated potential heterogeneity in the relationship between elderly parents' health status and adult children's depression levels, conditional on caregiving roles. The results of this heterogeneity analysis are reported in Table 3 . After controlling for all level-1 and level-2 covariables, the regression results from Models 6 and 7 indicate the following: among non-caregivers, a one-unit improvement in elderly parents’ health status is associated with an average decrease of approximately 0.058 ( p < 0.05) in adult children’s depression level. Among caregivers, a one-unit improvement in elderly parents’ health status is associated with an average decrease of approximately 0.153 ( p < 0.001) in adult children’s depression level. These results suggest that the relationship between elderly parents’ health and adult children’s depression level varies by caregiving role. The significant association exists stronger in the caregiver subgroup supports Hypothesis 2 . Table 3 Heterogeneity in the relation between health status of elderly parents and depression level of adult children by caregiver roles Variable (reference group) Non-caregivers Caregivers Model 6 Model 7 elderly parents' health status -0.058* -0.153*** (0.028) (0.034) Covariates Under control Under control Constant 12.903*** 11.528*** (0.684) (0.721) σ 2 4.812 5.177 τ 00 8.464 8.086 ICC 0.638 0.610 Observations 7,353 5,607 Number of groups 3400 2,738 Note: *, ** and *** indicate significance at the 5%,1% and 0.1% levels, respectively, with standard error in parentheses. 4.3 Mediation role of social isolation between the association between the health status of elderly parents and depression level of adult children The corresponding regression estimates of multilevel mediation analysis are presented in Table 4 . Among non-caregivers, regression results from Models 8 and 9 reveal that while social isolation positively predicts depression levels ( p < 0.001), parental health status does not exert a significant effect on their social isolation. In contrast, among caregiver, Models 10 and 11 show that parental health status significantly and negatively predicts caregivers' social isolation ( p < 0.01), which in turn significantly increases theirs depression level ( p < 0.001). In summary, social isolation mediates the relationship between parental health and depression levels only within the caregiver subgroup, this mediation pathway is not observed among non-caregivers. The multilevel mediation analysis thus highlights social isolation as a key mechanism underlying caregiver-status heterogeneity, providing empirical support for Hypothesis 3 . Table 4 The mediation role of social isolation in the association between health status of elderly parents and depression level of adult children by different caregiver roles Variable (reference group) Non-caregivers Caregivers Social isolation Depression level Social isolation Depression level Model 8 Model 9 Model 10 Model 11 elderly parents' health status -0.011 -0.057* -0.021** -0.150*** (0.006) (0.028) (0.007) (0.032) Adult children's social isolation 0.410*** 0.315*** (0.063) (0.073) Covariates under control under control under control under control Constant 3.062*** 10.996*** 2.923*** 10.263*** (0.065) (0.743) (0.070) (0.777) σ 2 0.204 4.801 0.214 5.176 τ 00 0.431 8.365 0.361 8.016 ICC 0.679 0.635 0.627 0.608 Observations 7,353 7,353 5,607 5,607 Number of groups 3,400 3,400 2,738 2,738 Note: *, ** and *** indicate significance at the 5%,1% and 0.1% levels, respectively, with standard error in parentheses. Discussion This study constructs three-phase mixed cross-sectional data for 2018, 2020, and 2022 from the CFPS. Applying multilevel linear models and multilevel mediation analysis, we examined the relationship between elderly parents' health status and adult children's depression levels, with particular focus on heterogeneity by caregiver status and its underlying mechanisms. We found that elderly parents' health status significantly influenced on their adult children's depression levels. This association varies markedly by caregiver status. Social isolation among adult children's is a critical factor shaping caregiver-status heterogeneity in this relationship. The finding that poorer health among elderly parents associated with higher levels of depression level in adult children, aligning with prior evidence from single-wave cross-sectional studies (Li et al., 2021). Deteriorating parental health constitutes a significant stressor for caregiving adult children and may trigger depression level. Specifically, an initial decline in elderly parents' health can disrupts caregivers' psychological equilibrium, with emerging depressive symptoms constituting a salient adverse outcome. Empirical evidence consistently documents that progressive deterioration of parental health correlates with incremental exacerbation of depressive symptomatology among caregivers. Our analysis provides novel support for the applicability of the Stress Process Model in explaining depression among caregiving adult children facing parental health declines (Barnett, 2013) and highlights the potential negative psychological consequences of worsening parental health. These findings hold significant implications for developing empirically informed interventions aimed at safeguarding the psychological well-being of adult-child caregivers, effectively mitigating their depressive symptomatology, and fostering functional family dynamics—thereby generating actionable guidance for clinical and social service frameworks. Furthermore, this study innovatively indicated that compared with non-caregivers, parental health exerts a stronger and statistically significant effect on offspring depression levels. Caregivers usually experience multidimensional stressors during parental care provision, encompassing physiological, psychological, temporal, occupational, financial, and social domains (Ar & Karanci, 2019). Consequently, caregivers are more likely to encounter heightened role conflict and compromised role balance. Such cumulative role strain may increase psychological distress and depression risk (Rosa et al., 2025). These challenges not only affect caregivers' personal lives but also impair their psychological well-being and caregiving efficacy. Existing literature exhibits a critical empirical gap in stratified analyses based on adult children's caregiving status when examining the psychological consequences of declining parental health. This study addresses this gap through rigorous methodological design and empirical analysis, thereby providing a theoretical foundation for optimizing intra-familial care duty allocation and offering actionable frameworks for enhancing sustainable family functioning. Moreover, among non-caregivers, social isolation positively predicts depression level but is unrelated to parental health status. Among caregivers, however, social isolation demonstrates a significant mediator in the pathway linking parental health to depression. Assuming caregiving responsibilities often requires sacrificing personal time and social engagement to meet the complex needs of aging parents. As caregiving demands intensify, participation in social activities declines and personal time diminishes, leading to reduced involvement in social networks and greater social isolation. Notably, social isolation extends beyond physical solitude to include perceived emotional isolation and the contraction of social networks, both of which can have profound negative effects on caregivers' psychological well-being (Hamon, 1992). 6. Implications Based on the above research findings, this study puts forward three countermeasures from the health status of the elderly and the role of caregivers aspects. First, enhance the family's ability to manage health issues. This study reveals that the health status of elderly parents significantly impacts their children's depression level. To prevent and address these issues, at the community level, encouraging the establishment of psychological counseling services in communities and medical institutions to support family members' mental health; at the caregiver level, assisting family members in setting up health records for the elderly, conducting regular health check-ups, and promptly addressing any health issues. Additionally, through training and education, the study aims to improve the caregiving skills and knowledge of children, thereby enabling them to better care for the elderly. Second, to build a comprehensive support system to alleviate the burden of caregiving. This study finds that adult children caregivers experience more severe levels of depression compared to non-caregivers. When elderly parents face health issues, it can disrupt the family's balance and significantly impact the family's normal life. Adult children must balance their social roles with the additional responsibility of caring for elderly parents, which often leads to role conflicts. However, the deeply ingrained culture of filial piety makes it difficult for children to abandon their nurturing responsibilities. Therefore, it is essential to leverage the roles of multiple stakeholders, encouraging businesses, social organizations, and individuals to participate in the care of the elderly. This would foster a positive societal environment that cares about the health of the elderly, provide respite services for adult children, allowing them time to engage in social activities, thereby reducing the negative effects of social isolation and better balancing work and life. Third, enhance social participation and support to address the risks of social isolation. The study found that, compared to non-caregivers, social isolation plays a mediating role between the health status of parents who are child caregivers and their own levels of depression. The degree of social isolation significantly affects the depressive levels of child caregivers, which in turn impacts the normal life of their children. To ensure the well-being of caregivers, it is essential to provide them with mental health education and counseling, helping them understand and recognize depressive symptoms, and learn effective coping strategies. Encourage open and frequent communication among family members to strengthen connections and provide sufficient social support for caregivers. 7. Strengthens and Limitations This study uses data from the CFPS, which provides a large, nationally representative sample, linking elderly parents with their children through household-level information to explore their relationships and influencing factors. By constructing a tri-wave pooled cross-sectional dataset (2018, 2020, and 2022), the current study offers two critical methodological advantages. First, it captures temporal heterogeneity, enabling the detection of cohort-specific variations across key sociohistorical events, while controlling for period effects via time-fixed effects. Second, it reduced attrition bias, avoiding the sample loss typically associated with panel data and ensuring population representativeness with refreshed sampling in each wave. Furthermore, the current study employs a caregiving-status-stratified design (caregivers vs. non-caregivers) to examine the impact of elderly parents' health on adult children's psychological well-being, with social isolation as a critical mediator. By identifying this mediational pathway, our findings address a significant gap in understanding intergenerational health dynamics, providing robust empirical evidence for future theoretical refinement and policy interventions. However, self-rated health serves as the primary metric for assessing elderly parents’ health status, despite acknowledged limitations, such as subjective bias and measurement errors. While the scientific community recognizes inherent uncertainties in self-reported measures, the consistent use of self-rated health in large-scale epidemiological studies underscores its empirical utility. Given its capacity to holistically capture multidimensional health constructs, self-rated health remains a valuable tool in gerontological research. Declarations Funding declaration This research also received financial support from the Humanities and Social Sciences Youth Foundation, Ministry of Education (grant number 23YJCZH139) to Siyuan Liu. Competing interests The authors declare no conflicts of interest. Human ethics and consent to participate The study is a secondary analysis of the data from the China Family Panel Studies (CFPS), a collaborative project conducted by Peking University. The CFPS study was approved by the Research Ethics Committees of Peking University (No. IRB00001052-14010). All participants provided written informed consent. The study was conducted in accordance with internationally recognized ethical standards, such as the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials Data is available from https://www.isss.pku.edu.cn/cfps/. Acknowledgements We thank the support by the Big Data and Responsible Artificial Intelligence for National Governance, Renmin University of China Author contribution Yuan Yao, Qifeng Ma, and Siyuan Liu conceptualized the research topic. Yuan Yao analysed data and interpreted the findings. Yuan Yao and Siyuan Liu drafted and revised the text. All authors read the manuscript and approved the final version for submission. Clinical trial Not applicable References Amirkhanyan AA, Wolf DA. Parent care and the stress process: Findings from panel data. J Gerontol B Psychol Sci Soc Sci. 2006;61(5):S248-S255. doi:10.1093/geronb/61.5.S248 Ar Y, Karanci AN. Turkish adult children as caregivers of parents with Alzheimer's disease: Perceptions and caregiving experiences. Dementia (London). 2019;18(3):882-902. doi:10.1177/1471301217693400 Barnett AE. Pathways of adult children providing care to older parents. J Marriage Fam. 2013;75(1):178-190. doi:10.1111/j.1741-3737.2012.01022.x Berkman LF, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol. 2017;185(11):1070-1088. doi:10.1093/aje/kwx103 Choi NG, Burr JA, Mutchler JE, Caro FG. Formal and informal volunteer activity and spousal caregiving among older adults. Res Aging. 2007;29(2):99-124. doi:10.1177/0164027506296759 Choy JCP, Lum TYS, Yu DSF, Wong GHY. Application of family stress theory: Predicting wellbeing by demands, resources and perceptions among caregivers of older adults. Fam Process. 2025;64(1):e13100. doi:10.1111/famp.13100 Crittenden JA, Coleman RL, Butler SS. "It helps me find balance": Older adult perspectives on the intersection of caregiving and volunteering. Home Health Care Serv Q. 2022;41(4):291-309. doi:10.1080/01621424.2022.2034700 Escalante E, Golden RL, Mason DJ. Social isolation and loneliness: Imperatives for healthcare in a post-COVID world. JAMA Health Forum. 2020;1(12):e201597. doi:10.1001/jamahealthforum.2020.1597 Evans IEM, Martyr A, Collins R, Brayne C, Clare L. Social isolation and cognitive function in later life: A systematic review and meta-analysis. J Alzheimers Dis. 2019;70(s1):S119-S144. doi:10.3233/JAD-180501 Fang J, Qiu Z, Zhang M, Fang L. Review of the application of hierarchical linear modeling in psychological research from 2002 to 2011 in China. J Psychol Sci. 2013;36(5):1194-1200. doi:10.16719/j.cnki.1671-6981.2013.05.033 Fang J, Wen Z. A comparison of three methods for testing multilevel mediation. J Psychol Sci. 2018;41(4):962-967. doi:10.16719/j.cnki.1671-6981.20180430 Halpern J, Shroder MA, Citera M. Perceptions by adult children of elderly parents' needs. Psychol Rep. 1996;78(2):571-577. doi:10.2466/pr0.1996.78.2.571 Hamon RR. Filial role enactment by adult children. Fam Relat. 1992;41(1):91-96. doi:10.2307/585400 Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspect Psychol Sci. 2015;10(2):227-237. doi:10.1177/1745691614568352 Jang Y, Park NS, Chiriboga DA, Yoon H, Ko J, Lee J, Kim MT. Risk factors for social isolation in older Korean Americans. J Aging Health. 2016;28(1):3-18. doi:10.1177/0898264315584578 Kim MH, Dunkle RE, Lehning AJ, Shen HW, Feld S, Perone AK. Caregiver stressors and depressive symptoms among older husbands and wives in the United States. J Women Aging. 2017;29(6):494-504. doi:10.1080/08952841.2016.1223962 Lei L, Leggett AN, Maust DT. A national profile of sandwich generation caregivers providing care to both older adults and children. J Am Geriatr Soc. 2023;71(3):799-809. doi:10.1111/jgs.18138 Lei L, Zhang L. Principle and application of the hierarchical linear model. J Capital Normal Univ (Soc Sci Ed). 2002;02:110-114. Available from: https://gfgga60aabc7d15084b00scpqqfpxw9xcv6k0cfhaz.libproxy.ruc.edu.cn/kcms2/article/abstract?v=gPdQxwyUTL-8BX8qyJFfXDyv0Ox9Og6EqaUf-N7W7E22drfboZK2WA8isMRsM7aXU-eias7Zv1Cnm_WHPhIl4SaLt6OpSUqew7NCiCxYfIkwjuhiF-IvZe0j8c4HELx7baFtsWzA7MUssmjkr8U4s9NYzENNNCKaRQcCS90u7YdXGVUA2joc-IlGG5OFKtKW&uniplatform=NZKPT&language=CHS Li L, Wister AV, Mitchell B. Social isolation among spousal and adult-child caregivers: Findings from the Canadian Longitudinal Study on Aging. J Gerontol B Psychol Sci Soc Sci. 2021;76(7):1415-1429. doi:10.1093/geronb/gbaa197 Lin WF, Chen LH, Li TS. Adult children's caregiver burden and depression: The moderating roles of parent-child relationship satisfaction and feedback from others. J Happiness Stud. 2013;14(2):673-687. doi:10.1007/s10902-012-9348-0 Luo MS. Social isolation, loneliness, and depressive symptoms: A twelve-year population study of temporal dynamics. J Gerontol B Psychol Sci Soc Sci. 2023;78(2):280-290. doi:10.1093/geronb/gbac174 Malhotra C, Malhotra R, Ostbye T, Matchar D, Chan A. Depressive symptoms among informal caregivers of older adults: Insights from the Singapore Survey on Informal Caregiving. Int Psychogeriatr. 2012;24(8):1335-1346. doi:10.1017/s1041610212000324 Musich S, Wang SS, Kraemer S, Hawkins K, Wicker E. Caregivers for older adults: Prevalence, characteristics, and healthcare utilization and expenditures. Geriatr Nurs. 2017;38(1):9-16. doi:10.1016/j.gerinurse.2016.06.017 Pearlin LI, Schieman S, Fazio EM, Meersman SC. Stress, health, and the life course: Some conceptual perspectives. J Health Soc Behav. 2005;46(2):205-219. doi:10.1177/002214650504600206 Pioli MF. Global and caregiving mastery as moderators in the caregiving stress process. Aging Ment Health. 2010;14(5):603-612. doi:10.1080/13607860903586193 Pope ND, Baldwin PK, Gibson A, Smith K. Becoming a caregiver: Experiences of young adults moving into family caregiving roles. J Adult Dev. 2022;29(2):147-158. doi:10.1007/s10804-021-09391-3 Rosa CB, Holmes A, Wang W, Chang YP. The association between caregiving burden, the caregiving relationship, and caregiver health. J Gerontol Nurs. 2025;51(5):27-34. doi:10.3928/00989134-20250310-01 Schulz R, Beach SR, Czaja SJ, Martire LM, Monin JK. Family caregiving for older adults. In: Fiske ST, editor. Annu Rev Psychol. 2020;71:635-659. doi:10.1146/annurev-psych-010419-050754 Silverstein M, Cong Z, Li S. Intergenerational transfers and living arrangements of older people in rural China: Consequences for psychological well-being. J Gerontol B Psychol Sci Soc Sci. 2006;61(5):S256-S266. doi:10.1093/geronb/61.5.S256 Soskolne V, Halevy-Levin S, Ben-Yehuda A. The context of caregiving, kinship tie and health: A comparative study of caregivers and non-caregivers. Women Health. 2007;45(2):75-94. doi:10.1300/J013v45n02_05 Stafford M, McMunn A, Zaninotto P, Nazroo J. Positive and negative exchanges in social relationships as predictors of depression: Evidence from the English Longitudinal Study of Aging. J Aging Health. 2011;23(4):607-628. doi:10.1177/0898264310392992 Wang D, Tong Y, Zhou L, Shen J. Inner-mechanisms between intergenerational social support and subjective well-being of the elderly. Acta Psychol Sin. 2004;36(1):78-82. doi:10.1349/00338283003601008 Wang L, Tang Y. Changing trends and the effectiveness of informal care among rural elderly adults in China. Sage Open. 2023;13(4):21582440231202580. doi:10.1177/21582440231202580 Wister AV, Coatta KL, Schuurman N, Lear SA, Rosin M, MacKey D. A lifecourse model of multimorbidity resilience: Theoretical and research developments. Int J Aging Hum Dev. 2016;82(4):290-313. doi:10.1177/0091415016641686 Yi-meng Z, Qi-lin Z. The mental health of spouse caregivers for the disabled elderly and its influencing factors. Soc Sci Beijing. 2021;01:107-116. doi:10.13262/j.bjsshkxy.bjshkx.210111 Yu X, Jingwei H, Chunni Z. The China Family Panel Studies: Design and practice. Chin J Sociol. 2014;34(02):1-32. doi:10.15992/j.cnki.31-1123/c.2014.02.003 Yuan D, Chen T. The impact of family elder care on adult children's mental health: The mediating effect of time and income. South China Popul. 2019;34(06):50-64. Available from: https://gfgga60aabc7d15084b00scpqqfpxw9xcv6k0cfhaz.libproxy.ruc.edu.cn/kcms2/article/abstract?v=gPdQxwyUTL-tKcgGYjUZ9Dc3qbX1bIKvbjfVPzwaD7r3KtN3Q3ExmUMMjJRBw2iBqRtBTscxDtnU30FE1dDUleahzDBkkGBGqk6JFA5MSvAqon3NcYgVRd2NmXMVfDQQxi8dJXvW6ztm-8zpNLGNYpuqj0I02_exCu-QA5vwtn3MI74aiXuIxcJL-dbo0CBZs62oCTpTyyM=&uniplatform=NZKPT&language=CHS Yue L, Jia C, Hu B, Zhang Z, Bai M, Wang S, Yao N. Caregiving stress among family caregivers of older adults living with disabilities in China. Geriatr Nurs. 2022;47:226-231. doi:10.1016/j.gerinurse.2022.07.017 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 21 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviewers invited by journal 30 Sep, 2025 Editor invited by journal 05 Sep, 2025 Editor assigned by journal 02 Sep, 2025 Submission checks completed at journal 02 Sep, 2025 First submitted to journal 25 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7455064","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528166891,"identity":"aa9cbcc1-abcf-4408-88a1-1115b179cf84","order_by":0,"name":"Yuan Yao","email":"","orcid":"","institution":"Renmin University of China","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Yao","suffix":""},{"id":528166892,"identity":"c02d5514-4b58-45a7-bae1-b12e5eb2fde2","order_by":1,"name":"Qifeng Ma","email":"","orcid":"","institution":"Renmin University of China","correspondingAuthor":false,"prefix":"","firstName":"Qifeng","middleName":"","lastName":"Ma","suffix":""},{"id":528166893,"identity":"42b66cae-01d8-437b-a249-518a3cffcafa","order_by":2,"name":"Siyuan Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDACZjBpwcPA3gBmMTYQqUWCh4HnALFaIEACiBKI1CLfzmMm8XOHhIzBzbfPJH4w2MhuOMD87AE+LQaHecwke89I8BjcTjeT7GFIM95wgM3cAK8WZqAtvG0gLWls0gwMhxM3HOBhk8DrsGagLX9BWm4eA2n5T1gLA9Bh0mBbbrCBtBwgrMXgMFuxtSxQi+SZNGbLHoNk45mH2czwO6z/8Mabb9ts7PmOH2O88aPCTrbvePMz/A5j4EAOHhCbGb96IGB/QFDJKBgFo2AUjHAAAB67PPA4XRaCAAAAAElFTkSuQmCC","orcid":"","institution":"Renmin University of China","correspondingAuthor":true,"prefix":"","firstName":"Siyuan","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-08-25 15:08:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7455064/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7455064/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93408980,"identity":"408b9a3e-b8b4-4ca4-9714-d36607125e05","added_by":"auto","created_at":"2025-10-13 14:15:50","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":103986,"visible":true,"origin":"","legend":"","description":"","filename":"BMCmanuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-7455064/v1/5716c0c6289695fb9d1d936a.docx"},{"id":93408003,"identity":"ecfb321e-6deb-4c3d-99be-42893dc7f9a5","added_by":"auto","created_at":"2025-10-13 14:07:50","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5166,"visible":true,"origin":"","legend":"","description":"","filename":"edaaab46e88440068d580270ffe6a4e3.json","url":"https://assets-eu.researchsquare.com/files/rs-7455064/v1/1d00d65f2a54305e4535239c.json"},{"id":93408004,"identity":"c9727400-43f9-4aca-84a9-a8e66192f98d","added_by":"auto","created_at":"2025-10-13 14:07:50","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":133390,"visible":true,"origin":"","legend":"","description":"","filename":"edaaab46e88440068d580270ffe6a4e31enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7455064/v1/1e7cb20b82c70ea1d2f8c609.xml"},{"id":93408979,"identity":"8d1604e5-a16b-4adb-88cd-7c7e2973da5a","added_by":"auto","created_at":"2025-10-13 14:15:50","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":131117,"visible":true,"origin":"","legend":"","description":"","filename":"edaaab46e88440068d580270ffe6a4e31structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7455064/v1/47ad76594f2dd93da5b261ad.xml"},{"id":93408007,"identity":"3039c9b7-b93e-4ee8-a910-36bd1f13b56d","added_by":"auto","created_at":"2025-10-13 14:07:50","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":143697,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7455064/v1/d690cafb1d0e5d4527342268.html"},{"id":93410246,"identity":"ec96eeb6-cc31-4aff-a3a5-be5733d522f8","added_by":"auto","created_at":"2025-10-13 14:23:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1207609,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7455064/v1/9d285dc5-ac2d-4361-91b0-a451a7b9f210.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between elderly parents’ health status and adult children’ depression level among different caregiver roles in China: A multi-level mediation analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince the beginning of the 21st century, population aging has become a defining feature of China's demographic landscape. By the end of 2023, the population aged 60 and above reached 297 million, accounting for 21.1% of the total population. In response to this demographic shift, the Chineses government has introduced a range of strategic measures, such as the development of an age-friendly society, integration of medical and elderly care services, and reform of the pension insurance system. Despite these efforts, family-based care—where adult children provide informal support-remains the predominant form in China, underpinned by deeply rooted cultural norms of filial piety (Wang \u0026amp; Tang, 2023). However, members of the \"sandwich generation\" face dual pressures from parenting responsibilities and career demands (Lei et al., 2023), while also assuming caregiving roles for aging parents. These overlapping roles can result in significant psychological strain, role conflict, and energy depletion, increasing the risk of mental health challenges, particularly depression (Schulz et al., 2020).\u003c/p\u003e\n\u003cp\u003eThe relationship between elderly parents' health and adult children's depression and the underlying mechanisms from perspectives such as caregiving networks, social support levels, and social role conflicts have been widely explored in the previous studies\u0026nbsp;(Escalante et al., 2020; Hamon, 1992; Wang et al., 2004).\u0026nbsp;However, a critical mediating factor- adult children’s social isolation-has received comparatively less attention. Social isolation, defined as \"a state in which individuals are isolated or detached from others and society\"\u0026nbsp;(Escalante et al., 2020), is recognized as a significant determinant of physical and mental health\u0026nbsp;(Wister et al., 2016).\u0026nbsp;(Soskolne et al., 2007)studies (2007) suggests that caregiving status moderates the psychological effects of parental health: adult children providing intergenerational care are more vulnerable to the adverse impacts of parental health decline than non-caregivers. Nevertheless, whether these findings are applicable to China’s distinct cultural context remains uncertain.\u003c/p\u003e\n\u003cp\u003eThis study aims to examine: (1) the association between health status of elderly parents and mental health of their adult children in China; (2) how this relationship varies depending on the caregiving role of the adult children; (3) the mediating effecs of social isolation in this association. By identifying key determinants of adult children’s mental health, the findings provide practical insights for the development of evidence-based public health interventions and the promotion of sustainable family caregiving. Moreover, by exploring the mechanisms through which elderly parents’ health affects depression outcomes, the study contributes to a deeper theoretical understanding of mental health disparities between caregivers and non-caregivers and informs the design of targeted support strategies.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003e\u003cstrong\u003e2.1 Different Caregiver Roles in Elderly Parental Health and Adult Children's Depression Levels\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver the years, scholars have proposed various theoretical models to explain the pathways linking elderly parental health to adult children's psychological well-being. Among these, the Stress Process Model (Pioli, 2010) is one of the most frequently cited frameworks for understanding caregiver burden, stress trajectories, and mental health outcomes. This model posits that health status of care recipients is key stressor directly impacting caregivers' psychological well-being. As caregiving for aging parents is considered a primary familial responsibility for adult children, the characteristics and health fluctuations of elderly parents significantly influence mental health of their adult-child caregivers. Fundamentally, caregiving is a dynamic process in which adult children continuously navigate stress and emotional demands (Barnett, 2013). According to this framework, declining parental health has a stronger negative impact on the caregiver’s psychological state, often leading to heightened mental health risks (Yi-meng \u0026amp; Qi-lin, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubstantial empirical evidence supports the relationship between health status of elderly parents and psychological states of adult children. For example, (Amirkhanyan \u0026amp; Wolf, 2006) characterized caregiving as\u0026nbsp;a stress process\u0026nbsp;shaped by elder-specific factors—particularly health status—that profoundly affect adult children’s psychological outcomes. Similarly, other studies have found that\u0026nbsp;higher levels of parental disability\u0026nbsp;intensify caregiving demands, increasing stress and adversely impacting caregivers’ health (Yue et al., 2022).\u003c/p\u003e\n\u003cp\u003eAmid the shifting paradigm of elder care—from traditional family-based models to more diverse and autonomous care alternatives—adult children are making divergent choices in fulfilling obligations. Constrained by socioeconomic pressures, some opt for institutional or community-based care options rather than assuming direct caregiving roles, resulting in variations in caregiver status. Under this circumstance, the impact of elderly parental health and adult children’s psychological well-being might differ according to the caregiving role adopted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to role theory (Choi et al., 2007; Crittenden et al., 2022), caregivers—as opposed to non-caregivers—must juggle multiple social roles when providing care to elderly parents. This role multiplicity may lead to inter-role conflict and psychological distress. Empirical research has confirmed that family caregivers often experience poorer health than their non-caregiving counterparts. Notably, caregivers who persist in providing care despite work-family conflicts report significantly higher levels of depression (Lin et al., 2013).\u0026nbsp;In China, the traditional culture norm of filial piety further obliges adult children to fulfill caregiving responsibilities. From a role theory perspective, internalizing this filial role can heighten caregiving intensity as parental health deteriorates, influencing multiple domains of the caregiver’s life, especially in mental health\u0026nbsp;(Hamon, 1992).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 The Mediating Effects of Social Isolation on the Relationship between Elderly Parents’ Health and Adult Children's Depression Levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial isolation refers to an objective condition of disconnection resulting from deficiencies in an individual's social network. It is commonly categorized into two primary subtypes: family isolation and friend isolation (Jang et al., 2016). Social isolation has been significantly associated with impaired cognitive functioning and heighten feelings of loneliness. Chronic social isolation is widely recognized for its detrimental effects on both physical and mental health (Evans et al., 2019; Holt-Lunstad et al., 2015).\u003c/p\u003e\n\u003cp\u003eAccording to the Family Stress Model (Choy et al., 2025), providing care for aging parents contributes to a decline in quality of life among adult-child caregivers. In parallel, the Stress Process Model suggests that the psychological impact of elderly parental health on adult children operates through multiple mediating mechanisms. Existing research has explored these pathways from various theoretical perspectives. For instance, a life-course study found that parental health influences offspring mental health via reduced leisure time and diminished income for caregivers (Yuan\u0026amp; Chen, 2019). Similarly, Malhotra et al. (2012) documented that access to formal care services and emotional support significantly moderate depressive symptoms among informal caregivers, especially spouses and adult children.\u003c/p\u003e\n\u003cp\u003eHowever, few studies have examined the social isolation as a mediator in the relationship between parental health and adult children's depression, particularly across different caregiver roles. A substantial body of evidence indicate a strong association between caregiving for elderly parents with serious health problems and increased social isolation among caregivers (Musich et al., 2017). Within the Stress Process Model, the health status of elderly parents constitutes a primary stressor in caregiving contexts (Pearlin et al., 2005). The model’s central mechanism—stress proliferation—provides a theoretical foundation for understanding how caregiving stressors extend into other life domains (Li et al., 2021). Specifically, when health problems emerge and intensify, they exert broad biopsychosocial effects on caregivers via multiple pathways. Heightened social isolation is a salient manifestation of this stress proliferation process (Kim et al., 2017).\u003c/p\u003e\n\u003cp\u003eDrawing on social role theory, adult children who internalize caregiving responsibilities often suppress their own needs—particularly social needs—while prioritizing the care of their aging parents. This role-based self-sacrifice increases their vulnerability to social isolation (Pope et al., 2022). At the same time, social relationships serve as critical buffers for emotional regulation, and the degree of isolation is strongly predicting depression trajectories (Luo, 2023). The well-established link between familial caregiving and social isolation is especially pronounced among caregivers experiencing prolonged isolation, whose fragile social networks limit opportunities for emotional exchange and exacerbates depressive symptoms through compounding psychosocial deprivation (Li et al., 2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Hypotheses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the theoretical frameworks and empirical findings presented in the preceding sections, this study proposes the following hypotheses:\u003c/p\u003e\n\u003cp\u003eHypothesis 1: Elderly parental health status will have a significant negative impact on depression levels of adult children.\u003c/p\u003e\n\u003cp\u003eHypothesis 2: The relationship between elderly parental health and adult children's depression will vary by caregiving roles, with caregivers exhibiting greater vulnerability to parental health deterioration compared to non-caregivers.\u003c/p\u003e\n\u003cp\u003eHypothesis 3: The relationships between elderly parental health and adult children's depression will be mediated by social isolation, such that poorer parental health increases social isolation, which in turn heightens depression levels.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Data source\u003c/h2\u003e\u003cp\u003eThe China Family Panel Studies (CFPS) is a nationally representative social survey administered by the Institute of Social Science Survey at Peking University. Launched with a baseline survey in 2010, it employs a biennial follow-up design using a stratified multistage probability sampling. The survey covers 25 provincial-level administrative units (provinces/municipalities/autonomous regions) across mainland China, excluding Xinjiang, Tibet, Ningxia, Qinghai, Inner Mongolia, Hainan, Hong Kong, Macao, and Taiwan. A key feature distinguishing CFPS from other large sample social surveys is its comprehensive documentation of kinship networks and detailed household member information (Yu et al., 2014). This design offers a significant methodological advantage by enabling the linkage of adult children with their elderly parents within the same households\u0026mdash;an approach central to this study.\u003c/p\u003e\u003cp\u003eIn line with the research objectives, three caves of cross-sectional data from 2018, 2020, and 2022 were compiled, yielding an initial sample of 37,354 respondents. Using household identifiers and kinship codes, data from the adult questionnaire served as the master data. Elderly parents aged 60 and above were matched with their adult children in a one-to-many format, and subsequently integrated into a one-to-one parent-child matching sample. Cases with missing key variables were excluded, resulting in 12,960 valid matched pairs from 4,985 households retained for analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Variables and measurement\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Outcome: Depression level in Adult Children\u003c/h2\u003e\u003cp\u003eFollowing established methodologies (Stafford et al., 2011), this study measures adult children's depression levels using the revised short-form Center for Epidemiologic Studies Depression Scale (CES-D) (Silverstein et al., 2006). The 2018 CFPS includes an 8-item CES-D module, with each item rated on a 4-point Likert scaling. Response options include: \"Rarely (\u0026lt;\u0026thinsp;1 day)\" (scored 0); \"Some days (1\u0026ndash;2 days)\" (scored 1); \"Occasionally (3\u0026ndash;4 days)\" (scored 2); \"Most of the time (5\u0026ndash;7 days)\" (scored 3), yielding total scores ranging from 0 to 24. Higher scores indicate greater depression severity. The scale demonstrated acceptable internal consistency in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Predictor: Health status of Elderly Parents\u003c/h2\u003e\u003cp\u003eSelf-rated health, a subjective assessment of one\u0026rsquo;s overall health, is widely recognized as a reliable indicator of an individual's health status. In this study, elderly parents\u0026rsquo; health status is assessed using the CFPS question: \u0026ldquo;How do you rate your health status?\u0026rdquo;. Responses were coded on a 5-point scale: \u0026ldquo;very healthy\u0026rdquo; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), \u0026ldquo;healthy\u0026rdquo; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), \u0026ldquo;fairly healthy\u0026rdquo; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), \u0026ldquo;average\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and \u0026ldquo;unhealthy\u0026rdquo; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), with higher scores indicating higher health status.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3 Treatment group: Caregiver Role\u003c/h2\u003e\u003cp\u003eThe caregiver role is identified using two CFPS questions \u0026ldquo;Do you do housework or take care of your father/mother?\u0026rdquo; and \u0026ldquo;Does the elderly person need care?\u0026rdquo;. Adult children who perform housework or caregiving tasks for elderly parents in need of care were classified as \u0026ldquo;caregivers\u0026rdquo; and assigned a value of 1. Others were categorized as \u0026ldquo;non-caregivers\u0026rdquo; and assigned a value of 0.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4 Mediator: The Level of Social Isolation of Adult Children\u003c/h2\u003e\u003cp\u003eTo assess social isolation, this study uses the Social Isolation-Social Network Index (SNI) (Berkman \u0026amp; Syme, 2017), which capture four dimensions: marital status, organizational participation, religious involvement, and intimate relationships. The latter is further subdivided into family and friend relationships. Each dimension is scored as 1 if the individual is socially engaged and 0 otherwise, producing a total score from 0 to 5 points. Higher score reflects greater social isolation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e3.2.5 Covariates\u003c/h2\u003e\u003cp\u003eControl variables include demographic and socioeconomic characteristics of both generations. For adult children: age, gender, marital status, years of education, employment status, self-rated economic status, and self-rated health. For elderly parents: age, gender, marital status, and years of education. At the household level, urban-rural residence type and household size were also included.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes all variable coding and descriptive statistics. Among the total of 12,960 paired samples, adult children had an average depression score of 5.54, a social isolation score of 2.86, an age of 40.26 years, and 7.09 years of education. Their average self-rated economic status and health score was 3.22. In total, 43% of adult children were caregivers, 79% were male, 82% were married, and 92% were employed. The elderly parents reported an average self-rated health score of 2.53, an average age of 68.92 years, and 3.03 years of education. Among them, 48% were male and 79% were married. Additionally, 53% of the households were urban (residing in towns/cities), with an average household size of 4.83 persons.\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\u003eDescription of variables and samples (n\u0026thinsp;=\u0026thinsp;12,960)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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=\"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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVariable assignment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDepression level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;24 scores, the Depression level score of adult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026thinsp;~\u0026thinsp;5 scores, self-rated health scores of elderly parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver role\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-caregiver\u0026thinsp;=\u0026thinsp;0,\u003c/p\u003e\u003cp\u003eCaregiver\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMediator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial isolation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;5 scores, the degree of social segregation of adult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"14\" rowspan=\"15\"\u003e\u003cp\u003eCovariates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u0026thinsp;~\u0026thinsp;59 years old, the actual age of adult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u0026thinsp;=\u0026thinsp;0, male\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCurrently not =\u0026thinsp;0, married\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;22 years, the actual number of years of education for adult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCurrently not =\u0026thinsp;0, employed\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEconomic status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026thinsp;~\u0026thinsp;5 scores, self-rated of economic score of adult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026thinsp;~\u0026thinsp;5 scores, self-rated of health score of adult children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eElderly parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60\u0026thinsp;~\u0026thinsp;96years old, the actual age of elderly parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e68.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u0026thinsp;=\u0026thinsp;0, male\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCurrently not =\u0026thinsp;0, married\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;19years, the actual number of years of education for elderly parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban-Rural type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRural\u0026thinsp;=\u0026thinsp;0, urban\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026thinsp;~\u0026thinsp;21, the size of the surveyed family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Statistical analysis\u003c/h2\u003e\u003cp\u003eFirst, Harman's single-factor test was conducted to assess common method bias. Six factors with eigenvalues greater than 1 were extracted. The first common factor accounted for 15.57% of the total variance, well below the conventional threshold of 40%. This suggests that common method bias was not a significant concern in the present study. Based on this test, Pearson correlation analysis was conducted on the main study variables.\u003c/p\u003e\u003cp\u003eSecondly, considering the nested structure of the data\u0026mdash;where multiple generational dyads are nested within the same household\u0026mdash; the assumptions of homoscedasticity and independent distribution required for traditional linear regression were violated. To address this, we employed a two-level Hierarchical Linear Model (HLM) for regression analysis (Lei \u0026amp; Zhang, 2002). The model specifications are presented below:\u003cdiv id=\"Equ1\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ1\" name=\"EquationSource\"\u003e\n$$\\:{Y}_{ij}={\\beta\\:}_{0j}+{{\\beta\\:}_{1j}X}_{ij}+{\\sum\\:}_{k}{\\beta\\:}_{jk}{C}_{kij}+{\\lambda\\:}_{t}$$\u003c/div\u003e\u003cdiv class=\"EquationNumber\"\u003e1\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equ2\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ2\" name=\"EquationSource\"\u003e\n$$\\:{\\beta\\:}_{0j}={\\eta\\:}_{00}+{\\sum\\:}_{m}{\\eta\\:}_{0}m{Z}_{mj}+{\\epsilon\\:}_{0j}\\:$$\u003c/div\u003e\u003cdiv class=\"EquationNumber\"\u003e2\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equ3\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ3\" name=\"EquationSource\"\u003e\n$$\\:{\\beta\\:}_{jk}={\\eta\\:}_{j0}+{\\sum\\:}_{m}{\\eta\\:}_{jm}{Z}_{mj}\\:$$\u003c/div\u003e\u003cdiv class=\"EquationNumber\"\u003e3\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn equations (\u003cspan refid=\"Equ1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)-(\u003cspan refid=\"Equ3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Y}_{ij}\\)\u003c/span\u003e\u003c/span\u003erepresents the depressive level of adult children in generation \u003cem\u003ei\u003c/em\u003e within household \u003cem\u003ej\u003c/em\u003e; \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{X}_{ij}\\)\u003c/span\u003e\u003c/span\u003eindicates the health status of elderly parents in generation \u003cem\u003ei\u003c/em\u003e within household \u003cem\u003ej\u003c/em\u003e. The regression coefficient for the core independent variable is\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\beta\\:}_{1j}\\)\u003c/span\u003e\u003c/span\u003e,\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{C}_{kij}\\:and\\:{Z}_{{m}_{j}}\\)\u003c/span\u003e\u003c/span\u003erepresent control variables at the individual and household levels, respectively, with \u003cem\u003ek\u003c/em\u003e and \u003cem\u003em\u003c/em\u003e being the number of control variables at each level. The regression coefficients for these control variables are\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\beta\\:}_{jk}\\:and\\:{\\eta\\:}_{jm}\\)\u003c/span\u003e\u003c/span\u003e, respectively. \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\beta\\:}_{0j}\\)\u003c/span\u003e\u003c/span\u003edenotes the random intercept, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\epsilon\\:}_{0j}\\)\u003c/span\u003e\u003c/span\u003e is the residual term at the household level, and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\lambda\\:}_{t}\\)\u003c/span\u003e\u003c/span\u003e is time fixed effects, which follows a normal distribution \u003cem\u003eN\u003c/em\u003e (0, \u003cem\u003eτ\u003c/em\u003e\u003csub\u003e\u003cem\u003e00\u003c/em\u003e\u003c/sub\u003e).\u003c/p\u003e\u003cp\u003eFinally, building upon the HLM framework, this study employed split-sample regressions to analyze potential heterogeneity in caregiver roles and constructs a multilevel mediation model to examine the role of adult children's social isolation. Compared to single-level mediation models, the multilevel mediation approach enhances the explanatory power of mediation effects in nested data structures (Fang \u0026amp; Wen, 2018). Data management and statistical analyses were performed collaboratively using STATA 15 and SPSS 23 software.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.1 The association between the health status of elderly parents and depression level of adult children\u003c/h2\u003e\u003cp\u003eThe regression results of HLM model on the influence of elderly parents' health status on the depression level of adult children are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Model 1, the null model, is used to determine the necessity of using the HLM model in empirical analysis. This model does not include any predictors at either the first or second level; instead, it decomposes the regression equation into two components: intra-group variance \u003cem\u003eσ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e and inter-group variance \u003cem\u003eτ\u003c/em\u003e\u003csub\u003e\u003cem\u003e00\u003c/em\u003e\u003c/sub\u003e, which are used to calculate the intra-class correlation coefficient (ICC). According to the empirical rule (Fang et al., 2013), if the ICC value exceeds 0.059, it indicates that HLM analysis is necessary. The ICC value for Model 1 is significantly higher than this threshold, making the use of the HLM model in this study both appropriate and necessary.\u003c/p\u003e\u003cp\u003eModel 2 introduced the core independent variable. Results indicated that each unit increase in elderly parents' health status was associated with an average decline of approximately 0.137 (\u003cem\u003ep\u0026lt;\u003c/em\u003e0.001) in their adult children's depression levels. Building on this, Models 3 to 5 sequentially incorporated level-1 control variables (adult children's characteristics), level-1 parental control variables, and level-2 household control variables. The regression coefficient for parental health status decreased but remained statistically significant. Taking the full model (Model 5) as an example, results demonstrated that each unit increase in parental health corresponded to an average deterioration of 0.104 (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) in offspring depression levels. These findings conclusively demonstrate that poor health among elderly parents exerts a negative impact on their adult children's depression levels, thereby supporting Research Hypothesis \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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 effect of elderly parents' health status on the depression level of adult children\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=\"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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable (reference group)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModel 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModel 4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModel 5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElderly parents' health status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.137***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.103***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.106***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.104***\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\u003e(0.023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.022)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdult 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=\"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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.028***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.024**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.023**\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.006)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.008)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.008)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (Female)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.043\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.016\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.099)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.099)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status (currently 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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.877***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.884***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.840***\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.104)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.084***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.089***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.081**\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.011)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.011)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.011)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment status (currently 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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.321***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.323**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.331**\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.115)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.115)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.115)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEconomic 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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.312***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.312***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.313***\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.032)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.032)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.032)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth 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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.746***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.746***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.748***\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.030)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.030)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.030)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElderly parents\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=\"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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.000\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.008)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.008)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (Female)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.004\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.054)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.054)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status (currently 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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.179\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.108)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.108)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.012\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.009)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.009)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban-Rural type(rural)\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=\"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-0.366***\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\u0026nbsp;\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(0.088)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily size\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=\"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-0.029\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\u0026nbsp;\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(0.022)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.582***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.732***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.079***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.824***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.025***\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\u003e(0.050)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.081)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.324)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.506)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.512)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eσ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.896\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.863\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.736\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.737\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.736\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eτ\u003c/em\u003e\u003csub\u003e\u003cem\u003e00\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.433\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.641\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.607\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.614\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.571\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.571\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.570\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObservations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12,960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12,960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12,960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12,960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12,960\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of groups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4,985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4,985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4,985\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: *, ** and *** indicate significance at the 5%,1% and 0.1% levels, respectively, with standard error in parentheses.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e4.2 Heterogeneity of caregiver role in the association between the health status of elderly parents and depression level of adult children\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBuilding upon the baseline regression, this study investigated potential heterogeneity in the relationship between elderly parents' health status and adult children's depression levels, conditional on caregiving roles. The results of this heterogeneity analysis are reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eAfter controlling for all level-1 and level-2 covariables, the regression results from Models 6 and 7 indicate the following: among non-caregivers, a one-unit improvement in elderly parents\u0026rsquo; health status is associated with an average decrease of approximately 0.058 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in adult children\u0026rsquo;s depression level. Among caregivers, a one-unit improvement in elderly parents\u0026rsquo; health status is associated with an average decrease of approximately 0.153 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in adult children\u0026rsquo;s depression level. These results suggest that the relationship between elderly parents\u0026rsquo; health and adult children\u0026rsquo;s depression level varies by caregiving role. The significant association exists stronger in the caregiver subgroup supports Hypothesis \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003eHeterogeneity in the relation between health status of elderly parents and depression level of adult children by caregiver roles\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable (reference group)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-caregivers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCaregivers\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 6\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 7\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eelderly parents' health status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.058*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.153***\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\u003e(0.028)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.034)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCovariates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnder control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnder control\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.903***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.528***\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\u003e(0.684)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.721)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eσ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.177\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eτ\u003c/em\u003e\u003csub\u003e\u003cem\u003e00\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.464\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.086\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.638\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.610\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObservations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7,353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5,607\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of groups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3400\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2,738\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: *, ** and *** indicate significance at the 5%,1% and 0.1% levels, respectively, with standard error in parentheses.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e4.3 Mediation role of social isolation between the association between the health status of elderly parents and depression level of adult children\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe corresponding regression estimates of multilevel mediation analysis are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Among non-caregivers, regression results from Models 8 and 9 reveal that while social isolation positively predicts depression levels (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), parental health status does not exert a significant effect on their social isolation. In contrast, among caregiver, Models 10 and 11 show that parental health status significantly and negatively predicts caregivers' social isolation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), which in turn significantly increases theirs depression level (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eIn summary, social isolation mediates the relationship between parental health and depression levels only within the caregiver subgroup, this mediation pathway is not observed among non-caregivers. The multilevel mediation analysis thus highlights social isolation as a key mechanism underlying caregiver-status heterogeneity, providing empirical support for Hypothesis \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e3\u003c/span\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 mediation role of social isolation in the association between health status of elderly parents and depression level of adult children by different caregiver roles\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eVariable (reference group)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNon-caregivers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eCaregivers\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial isolation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDepression level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSocial isolation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDepression level\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 8\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 9\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModel 10\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModel 11\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eelderly parents' health status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.057*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.021**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.150***\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\u003e(0.006)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.028)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.007)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.032)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdult children's social isolation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.410***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.315***\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\u003e(0.063)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.073)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCovariates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eunder control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eunder control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eunder control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eunder control\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.062***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.996***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.923***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.263***\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\u003e(0.065)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.743)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.070)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.777)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eσ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.801\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.176\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eτ\u003c/em\u003e\u003csub\u003e\u003cem\u003e00\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.361\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.679\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.635\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.627\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.608\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObservations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7,353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7,353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5,607\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5,607\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of groups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,400\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,400\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2,738\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2,738\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: *, ** and *** indicate significance at the 5%,1% and 0.1% levels, respectively, with standard error in parentheses.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study constructs three-phase mixed cross-sectional data for 2018, 2020, and 2022 from the CFPS. Applying multilevel linear models and multilevel mediation analysis, we examined the relationship between elderly parents' health status and adult children's depression levels, with particular focus on heterogeneity by caregiver status and its underlying mechanisms. We found that elderly parents' health status significantly influenced on their adult children's depression levels. This association varies markedly by caregiver status. Social isolation among adult children's is a critical factor shaping caregiver-status heterogeneity in this relationship.\u003c/p\u003e\u003cp\u003eThe finding that poorer health among elderly parents associated with higher levels of depression level in adult children, aligning with prior evidence from single-wave cross-sectional studies (Li et al., 2021). Deteriorating parental health constitutes a significant stressor for caregiving adult children and may trigger depression level. Specifically, an initial decline in elderly parents' health can disrupts caregivers' psychological equilibrium, with emerging depressive symptoms constituting a salient adverse outcome. Empirical evidence consistently documents that progressive deterioration of parental health correlates with incremental exacerbation of depressive symptomatology among caregivers. Our analysis provides novel support for the applicability of the Stress Process Model in explaining depression among caregiving adult children facing parental health declines (Barnett, 2013) and highlights the potential negative psychological consequences of worsening parental health. These findings hold significant implications for developing empirically informed interventions aimed at safeguarding the psychological well-being of adult-child caregivers, effectively mitigating their depressive symptomatology, and fostering functional family dynamics\u0026mdash;thereby generating actionable guidance for clinical and social service frameworks.\u003c/p\u003e\u003cp\u003eFurthermore, this study innovatively indicated that compared with non-caregivers, parental health exerts a stronger and statistically significant effect on offspring depression levels. Caregivers usually experience multidimensional stressors during parental care provision, encompassing physiological, psychological, temporal, occupational, financial, and social domains (Ar \u0026amp; Karanci, 2019). Consequently, caregivers are more likely to encounter heightened role conflict and compromised role balance. Such cumulative role strain may increase psychological distress and depression risk (Rosa et al., 2025). These challenges not only affect caregivers' personal lives but also impair their psychological well-being and caregiving efficacy. Existing literature exhibits a critical empirical gap in stratified analyses based on adult children's caregiving status when examining the psychological consequences of declining parental health. This study addresses this gap through rigorous methodological design and empirical analysis, thereby providing a theoretical foundation for optimizing intra-familial care duty allocation and offering actionable frameworks for enhancing sustainable family functioning.\u003c/p\u003e\u003cp\u003eMoreover, among non-caregivers, social isolation positively predicts depression level but is unrelated to parental health status. Among caregivers, however, social isolation demonstrates a significant mediator in the pathway linking parental health to depression. Assuming caregiving responsibilities often requires sacrificing personal time and social engagement to meet the complex needs of aging parents. As caregiving demands intensify, participation in social activities declines and personal time diminishes, leading to reduced involvement in social networks and greater social isolation. Notably, social isolation extends beyond physical solitude to include perceived emotional isolation and the contraction of social networks, both of which can have profound negative effects on caregivers' psychological well-being (Hamon, 1992).\u003c/p\u003e\n\u003ch3\u003e6. Implications\u003c/h3\u003e\n\u003cp\u003eBased on the above research findings, this study puts forward three countermeasures from the health status of the elderly and the role of caregivers aspects. First, enhance the family's ability to manage health issues. This study reveals that the health status of elderly parents significantly impacts their children's depression level. To prevent and address these issues, at the community level, encouraging the establishment of psychological counseling services in communities and medical institutions to support family members' mental health; at the caregiver level, assisting family members in setting up health records for the elderly, conducting regular health check-ups, and promptly addressing any health issues. Additionally, through training and education, the study aims to improve the caregiving skills and knowledge of children, thereby enabling them to better care for the elderly.\u003c/p\u003e\u003cp\u003eSecond, to build a comprehensive support system to alleviate the burden of caregiving. This study finds that adult children caregivers experience more severe levels of depression compared to non-caregivers. When elderly parents face health issues, it can disrupt the family's balance and significantly impact the family's normal life. Adult children must balance their social roles with the additional responsibility of caring for elderly parents, which often leads to role conflicts. However, the deeply ingrained culture of filial piety makes it difficult for children to abandon their nurturing responsibilities. Therefore, it is essential to leverage the roles of multiple stakeholders, encouraging businesses, social organizations, and individuals to participate in the care of the elderly. This would foster a positive societal environment that cares about the health of the elderly, provide respite services for adult children, allowing them time to engage in social activities, thereby reducing the negative effects of social isolation and better balancing work and life.\u003c/p\u003e\u003cp\u003eThird, enhance social participation and support to address the risks of social isolation. The study found that, compared to non-caregivers, social isolation plays a mediating role between the health status of parents who are child caregivers and their own levels of depression. The degree of social isolation significantly affects the depressive levels of child caregivers, which in turn impacts the normal life of their children. To ensure the well-being of caregivers, it is essential to provide them with mental health education and counseling, helping them understand and recognize depressive symptoms, and learn effective coping strategies. Encourage open and frequent communication among family members to strengthen connections and provide sufficient social support for caregivers.\u003c/p\u003e\n\u003ch3\u003e7. Strengthens and Limitations\u003c/h3\u003e\n\u003cp\u003eThis study uses data from the CFPS, which provides a large, nationally representative sample, linking elderly parents with their children through household-level information to explore their relationships and influencing factors. By constructing a tri-wave pooled cross-sectional dataset (2018, 2020, and 2022), the current study offers two critical methodological advantages. First, it captures temporal heterogeneity, enabling the detection of cohort-specific variations across key sociohistorical events, while controlling for period effects via time-fixed effects. Second, it reduced attrition bias, avoiding the sample loss typically associated with panel data and ensuring population representativeness with refreshed sampling in each wave. Furthermore, the current study employs a caregiving-status-stratified design (caregivers vs. non-caregivers) to examine the impact of elderly parents' health on adult children's psychological well-being, with social isolation as a critical mediator. By identifying this mediational pathway, our findings address a significant gap in understanding intergenerational health dynamics, providing robust empirical evidence for future theoretical refinement and policy interventions.\u003c/p\u003e\u003cp\u003eHowever, self-rated health serves as the primary metric for assessing elderly parents\u0026rsquo; health status, despite acknowledged limitations, such as subjective bias and measurement errors. While the scientific community recognizes inherent uncertainties in self-reported measures, the consistent use of self-rated health in large-scale epidemiological studies underscores its empirical utility. Given its capacity to holistically capture multidimensional health constructs, self-rated health remains a valuable tool in gerontological research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research also received financial support from the\u0026nbsp;Humanities and Social Sciences Youth Foundation, Ministry of Education (grant number 23YJCZH139) to Siyuan Liu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman ethics and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is a secondary analysis of the data from the China Family Panel Studies (CFPS), a collaborative project conducted by Peking University. The CFPS study was approved by the Research Ethics Committees of Peking University (No.\u0026nbsp;IRB00001052-14010). All participants provided written informed consent. The study was conducted in accordance with internationally recognized ethical standards, such as the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available from https://www.isss.pku.edu.cn/cfps/.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the support by the Big Data and Responsible Artificial Intelligence for National Governance, Renmin University of China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYuan Yao, Qifeng Ma, and Siyuan Liu conceptualized the research topic. Yuan Yao analysed data and interpreted the findings. Yuan Yao and Siyuan Liu drafted and revised the text. All authors read the manuscript and approved the final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAmirkhanyan AA, Wolf DA. Parent care and the stress process: Findings from panel data. J Gerontol B Psychol Sci Soc Sci. 2006;61(5):S248-S255. doi:10.1093/geronb/61.5.S248\u003c/li\u003e\n \u003cli\u003eAr Y, Karanci AN. Turkish adult children as caregivers of parents with Alzheimer\u0026apos;s disease: Perceptions and caregiving experiences. Dementia (London). 2019;18(3):882-902. doi:10.1177/1471301217693400\u003c/li\u003e\n \u003cli\u003eBarnett AE. Pathways of adult children providing care to older parents. J Marriage Fam. 2013;75(1):178-190. doi:10.1111/j.1741-3737.2012.01022.x\u003c/li\u003e\n \u003cli\u003eBerkman LF, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol. 2017;185(11):1070-1088. doi:10.1093/aje/kwx103\u003c/li\u003e\n \u003cli\u003eChoi NG, Burr JA, Mutchler JE, Caro FG. Formal and informal volunteer activity and spousal caregiving among older adults. Res Aging. 2007;29(2):99-124. doi:10.1177/0164027506296759\u003c/li\u003e\n \u003cli\u003eChoy JCP, Lum TYS, Yu DSF, Wong GHY. Application of family stress theory: Predicting wellbeing by demands, resources and perceptions among caregivers of older adults. Fam Process. 2025;64(1):e13100. doi:10.1111/famp.13100\u003c/li\u003e\n \u003cli\u003eCrittenden JA, Coleman RL, Butler SS. \u0026quot;It helps me find balance\u0026quot;: Older adult perspectives on the intersection of caregiving and volunteering. Home Health Care Serv Q. 2022;41(4):291-309. doi:10.1080/01621424.2022.2034700\u003c/li\u003e\n \u003cli\u003eEscalante E, Golden RL, Mason DJ. Social isolation and loneliness: Imperatives for healthcare in a post-COVID world. JAMA Health Forum. 2020;1(12):e201597. doi:10.1001/jamahealthforum.2020.1597\u003c/li\u003e\n \u003cli\u003eEvans IEM, Martyr A, Collins R, Brayne C, Clare L. Social isolation and cognitive function in later life: A systematic review and meta-analysis. J Alzheimers Dis. 2019;70(s1):S119-S144. doi:10.3233/JAD-180501\u003c/li\u003e\n \u003cli\u003eFang J, Qiu Z, Zhang M, Fang L. Review of the application of hierarchical linear modeling in psychological research from 2002 to 2011 in China. J Psychol Sci. 2013;36(5):1194-1200. doi:10.16719/j.cnki.1671-6981.2013.05.033\u003c/li\u003e\n \u003cli\u003eFang J, Wen Z. A comparison of three methods for testing multilevel mediation. J Psychol Sci. 2018;41(4):962-967. doi:10.16719/j.cnki.1671-6981.20180430\u003c/li\u003e\n \u003cli\u003eHalpern J, Shroder MA, Citera M. Perceptions by adult children of elderly parents\u0026apos; needs. Psychol Rep. 1996;78(2):571-577. doi:10.2466/pr0.1996.78.2.571\u003c/li\u003e\n \u003cli\u003eHamon RR. Filial role enactment by adult children. Fam Relat. 1992;41(1):91-96. doi:10.2307/585400\u003c/li\u003e\n \u003cli\u003eHolt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspect Psychol Sci. 2015;10(2):227-237. doi:10.1177/1745691614568352\u003c/li\u003e\n \u003cli\u003eJang Y, Park NS, Chiriboga DA, Yoon H, Ko J, Lee J, Kim MT. Risk factors for social isolation in older Korean Americans. J Aging Health. 2016;28(1):3-18. doi:10.1177/0898264315584578\u003c/li\u003e\n \u003cli\u003eKim MH, Dunkle RE, Lehning AJ, Shen HW, Feld S, Perone AK. Caregiver stressors and depressive symptoms among older husbands and wives in the United States. J Women Aging. 2017;29(6):494-504. doi:10.1080/08952841.2016.1223962\u003c/li\u003e\n \u003cli\u003eLei L, Leggett AN, Maust DT. A national profile of sandwich generation caregivers providing care to both older adults and children. J Am Geriatr Soc. 2023;71(3):799-809. doi:10.1111/jgs.18138\u003c/li\u003e\n \u003cli\u003eLei L, Zhang L. Principle and application of the hierarchical linear model. J Capital Normal Univ (Soc Sci Ed). 2002;02:110-114. Available from: https://gfgga60aabc7d15084b00scpqqfpxw9xcv6k0cfhaz.libproxy.ruc.edu.cn/kcms2/article/abstract?v=gPdQxwyUTL-8BX8qyJFfXDyv0Ox9Og6EqaUf-N7W7E22drfboZK2WA8isMRsM7aXU-eias7Zv1Cnm_WHPhIl4SaLt6OpSUqew7NCiCxYfIkwjuhiF-IvZe0j8c4HELx7baFtsWzA7MUssmjkr8U4s9NYzENNNCKaRQcCS90u7YdXGVUA2joc-IlGG5OFKtKW\u0026amp;uniplatform=NZKPT\u0026amp;language=CHS\u003c/li\u003e\n \u003cli\u003eLi L, Wister AV, Mitchell B. Social isolation among spousal and adult-child caregivers: Findings from the Canadian Longitudinal Study on Aging. J Gerontol B Psychol Sci Soc Sci. 2021;76(7):1415-1429. doi:10.1093/geronb/gbaa197\u003c/li\u003e\n \u003cli\u003eLin WF, Chen LH, Li TS. Adult children\u0026apos;s caregiver burden and depression: The moderating roles of parent-child relationship satisfaction and feedback from others. J Happiness Stud. 2013;14(2):673-687. doi:10.1007/s10902-012-9348-0\u003c/li\u003e\n \u003cli\u003eLuo MS. Social isolation, loneliness, and depressive symptoms: A twelve-year population study of temporal dynamics. J Gerontol B Psychol Sci Soc Sci. 2023;78(2):280-290. doi:10.1093/geronb/gbac174\u003c/li\u003e\n \u003cli\u003eMalhotra C, Malhotra R, Ostbye T, Matchar D, Chan A. Depressive symptoms among informal caregivers of older adults: Insights from the Singapore Survey on Informal Caregiving. Int Psychogeriatr. 2012;24(8):1335-1346. doi:10.1017/s1041610212000324\u003c/li\u003e\n \u003cli\u003eMusich S, Wang SS, Kraemer S, Hawkins K, Wicker E. Caregivers for older adults: Prevalence, characteristics, and healthcare utilization and expenditures. Geriatr Nurs. 2017;38(1):9-16. doi:10.1016/j.gerinurse.2016.06.017\u003c/li\u003e\n \u003cli\u003ePearlin LI, Schieman S, Fazio EM, Meersman SC. Stress, health, and the life course: Some conceptual perspectives. J Health Soc Behav. 2005;46(2):205-219. doi:10.1177/002214650504600206\u003c/li\u003e\n \u003cli\u003ePioli MF. Global and caregiving mastery as moderators in the caregiving stress process. Aging Ment Health. 2010;14(5):603-612. doi:10.1080/13607860903586193\u003c/li\u003e\n \u003cli\u003ePope ND, Baldwin PK, Gibson A, Smith K. Becoming a caregiver: Experiences of young adults moving into family caregiving roles. J Adult Dev. 2022;29(2):147-158. doi:10.1007/s10804-021-09391-3\u003c/li\u003e\n \u003cli\u003eRosa CB, Holmes A, Wang W, Chang YP. The association between caregiving burden, the caregiving relationship, and caregiver health. J Gerontol Nurs. 2025;51(5):27-34. doi:10.3928/00989134-20250310-01\u003c/li\u003e\n \u003cli\u003eSchulz R, Beach SR, Czaja SJ, Martire LM, Monin JK. Family caregiving for older adults. In: Fiske ST, editor. Annu Rev Psychol. 2020;71:635-659. doi:10.1146/annurev-psych-010419-050754\u003c/li\u003e\n \u003cli\u003eSilverstein M, Cong Z, Li S. Intergenerational transfers and living arrangements of older people in rural China: Consequences for psychological well-being. J Gerontol B Psychol Sci Soc Sci. 2006;61(5):S256-S266. doi:10.1093/geronb/61.5.S256\u003c/li\u003e\n \u003cli\u003eSoskolne V, Halevy-Levin S, Ben-Yehuda A. The context of caregiving, kinship tie and health: A comparative study of caregivers and non-caregivers. Women Health. 2007;45(2):75-94. doi:10.1300/J013v45n02_05\u003c/li\u003e\n \u003cli\u003eStafford M, McMunn A, Zaninotto P, Nazroo J. Positive and negative exchanges in social relationships as predictors of depression: Evidence from the English Longitudinal Study of Aging. J Aging Health. 2011;23(4):607-628. doi:10.1177/0898264310392992\u003c/li\u003e\n \u003cli\u003eWang D, Tong Y, Zhou L, Shen J. Inner-mechanisms between intergenerational social support and subjective well-being of the elderly. Acta Psychol Sin. 2004;36(1):78-82. doi:10.1349/00338283003601008\u003c/li\u003e\n \u003cli\u003eWang L, Tang Y. Changing trends and the effectiveness of informal care among rural elderly adults in China. Sage Open. 2023;13(4):21582440231202580. doi:10.1177/21582440231202580\u003c/li\u003e\n \u003cli\u003eWister AV, Coatta KL, Schuurman N, Lear SA, Rosin M, MacKey D. A lifecourse model of multimorbidity resilience: Theoretical and research developments. Int J Aging Hum Dev. 2016;82(4):290-313. doi:10.1177/0091415016641686\u003c/li\u003e\n \u003cli\u003eYi-meng Z, Qi-lin Z. The mental health of spouse caregivers for the disabled elderly and its influencing factors. Soc Sci Beijing. 2021;01:107-116. doi:10.13262/j.bjsshkxy.bjshkx.210111\u003c/li\u003e\n \u003cli\u003eYu X, Jingwei H, Chunni Z. The China Family Panel Studies: Design and practice. Chin J Sociol. 2014;34(02):1-32. doi:10.15992/j.cnki.31-1123/c.2014.02.003\u003c/li\u003e\n \u003cli\u003eYuan D, Chen T. The impact of family elder care on adult children\u0026apos;s mental health: The mediating effect of time and income. South China Popul. 2019;34(06):50-64. Available from: https://gfgga60aabc7d15084b00scpqqfpxw9xcv6k0cfhaz.libproxy.ruc.edu.cn/kcms2/article/abstract?v=gPdQxwyUTL-tKcgGYjUZ9Dc3qbX1bIKvbjfVPzwaD7r3KtN3Q3ExmUMMjJRBw2iBqRtBTscxDtnU30FE1dDUleahzDBkkGBGqk6JFA5MSvAqon3NcYgVRd2NmXMVfDQQxi8dJXvW6ztm-8zpNLGNYpuqj0I02_exCu-QA5vwtn3MI74aiXuIxcJL-dbo0CBZs62oCTpTyyM=\u0026amp;uniplatform=NZKPT\u0026amp;language=CHS\u003c/li\u003e\n \u003cli\u003eYue L, Jia C, Hu B, Zhang Z, Bai M, Wang S, Yao N. Caregiving stress among family caregivers of older adults living with disabilities in China. Geriatr Nurs. 2022;47:226-231. doi:10.1016/j.gerinurse.2022.07.017\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Depression Level, Health Status, The Elderly, Caregiver, Social Isolation","lastPublishedDoi":"10.21203/rs.3.rs-7455064/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7455064/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/em\u003e: This study examines the association between the health status of elderly parents and depression levels of their adult children, with a focus on differences in caregiving roles. \u0026nbsp;It also investigates the mediating effect of social isolation among adult children, aiming to inform targeted mental health interventions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e: Utilizing data from the 2018, 2020, and 2022 China Family Panel Studies,this study employed multilevel linear models to investigate the relationship between the health status of elderly parents and the depression levels of their adult children. The multilevel mediation analysis was used to test the potential mediating role of social isolation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e: Findings indicate that poor health status in elderly parents was associated with higher levels of depression in their adult children. This relationship differs depending on whether the adult children serve as caregivers, with a stronger and statistically significant association observed in the caregiver subgroup. Furthermore, social isolation was found to mediate the relationship between parental health status and depression only among caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e: These results underscore the need to prioritize mental health support for adult children who serve as caregivers. Expanding and diversifying caregiver support services could help mitigate depressive symptoms, improve the balance between caregiving and social life, and promote the sustainability of family-based eldercare system.\u003c/p\u003e","manuscriptTitle":"Association between elderly parents’ health status and adult children’ depression level among different caregiver roles in China: A multi-level mediation analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-13 14:07:45","doi":"10.21203/rs.3.rs-7455064/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-21T05:47:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118728072118645690489012225643155220537","date":"2025-10-11T18:57:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-30T11:15:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-05T10:24:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-02T08:19:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-02T08:18:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-08-25T15:06:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7cbee786-2004-4564-9bdc-eab3b3a5a6b1","owner":[],"postedDate":"October 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T14:07:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-13 14:07:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7455064","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7455064","identity":"rs-7455064","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}