Illness acceptance and community self-efficacy mediate the relationship between social isolation and loneliness among elderly people with Parkinson's Disease

Illness acceptance and community self-efficacy mediate the relationship between social isolation and loneliness among elderly people with Parkinson's Disease | 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 Article Illness acceptance and community self-efficacy mediate the relationship between social isolation and loneliness among elderly people with Parkinson's Disease Yuanrong Wu, Qin Li, Manxuan Shen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5645836/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Scientific Reports → Version 1 posted 8 You are reading this latest preprint version Abstract Objective: In this study, we investigated the status quo of illness acceptance, community self-efficacy, and social isolation in elderly patients with Parkinson’s disease (PD). We explored the effects of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in patients with PD based on the self-regulation theory model. Methods: We selected elderly patients with PD from the outpatient department of two Grade iii-A hospitals in Guangdong Province through convenience sampling. We collected data using a general information questionnaire. We used the Lubben Social Network Scale, UCLA Loneliness Scale, Community’s Self-Efficacy Scale, and Acceptance of Illness Scale. Data were analyzed using descriptive statistics, Pearson’s correlation coefficient, and bootstrap sampling to test the multiple mediation model. Results: We recruited 142 elderly patients with PD. Their mean age was 69.30 years (standard deviation = 5.34, range from 60 to 89 years). Approximately 55.6% (n = 79) were male. The mean scores for community self-efficacy, social network, and illness acceptance were 11.03 ± 6.21, 13.29 ± 5.4, and 23.56 ± 6.871, respectively. Loneliness was negatively associated with illness acceptance (r = -0.536, p < 0.001) and community self-efficacy (r = -0.654, p < 0.001). The results of multiple mediation analysis indicated that illness acceptance (effect: -0.172, 95% confidence interval (CI) [-0.297, 0.067]) and community self-efficacy (effect: -0.271, 95% CI [-0.446, -0.115]) individually and collectively influenced the relationship between social isolation and loneliness (effect: -0.055, 95% CI [-0.105, -0.017]). The direct effect and mediating effect values accounted for 59.6% and 40.4% of the total effect value, respectively. Conclusion: Illness acceptance and community self-efficacy mediate the association between social isolation and loneliness. Interventions that help facilitate mutuality, illness acceptance, and community self-efficacy may help minimize the level of loneliness in patients with PD. Health sciences/Neurology/Neurological disorders/Parkinsons disease Biological sciences/Psychology/Human behaviour Parkinson’s Disease (PD) Social isolation Loneliness Illness acceptance Community self-efficacy Mediator Figures Figure 1 1. Introduction Parkinson's disease (PD) is a common neurodegenerative disorder among the elderly, primarily characterized by bradykinesia, muscle rigidity, resting tremors, akinesia, postural instability, sleep disorders, and hypoesthesia [1]. Age is associated with an increase in PD risk. The prevalence of PD was found to increase from 18% for individuals aged 65–70 years to 36% for individuals aged 80–85 years[2]. The prevalence of PD among individuals aged 65 years and above in China was 1.60%, and the burden of PD has been found to increase every year[3][4]. Elderly patients with PD often perceive themselves as socially isolated and lonely[5]. Symptoms such as dyskinesia, hypophonia, dysarthria, and facial masking further contribute to stigma and social withdrawal [6] [7]. Social isolation and loneliness are frequently used interchangeably; however, they are distinct terms. Social isolation is an objective condition characterized by the restricted participation of individuals in activities, a dearth of social relationships, or infrequent social interactions [8]. It is typically measured using objective and quantifiable means, such as the frequency of social contact, the expanse of one’s social network, and factors such as household composition, marital status, and friendships. Indicators of social isolation include living alone, having limited social network connections, and engaging in minimal social interactions [9][10]. Among the elderly, social isolation is strongly correlated with fewer social network ties and a weak socioeconomic status. It acts as a predictor of adverse outcomes, including morbidity and mortality [11], cognitive decline, and depressive symptoms [12]. Conversely, loneliness is a subjective emotional state of feeling unloved and distant from significant others, close friends, and family [8]. Individuals experiencing loneliness often perceive the world more negatively and anticipate unpleasant social interactions, which can result in the retention of negative social information [13]. One can experience social isolation without feeling lonely, and they may experience loneliness even if they are socially well-connected. Findings from numerous studies have underscored the prevalence of social isolation and loneliness among older adults. Social isolation impacts approximately 24% of the elderly population. The prevalence of loneliness ranges from 0.2–25%, depending on the context and measurement criteria [14][15][16]. Although social isolation can increase the likelihood of loneliness, the two phenomena exert distinct effects. Nevertheless, both have significant consequences on the physical and mental health of individuals with PD, exacerbating existing symptoms and contributing to poorer health outcomes[17]. Self-management is crucial for handling chronic diseases as it enables patients to control symptoms and mitigate the impact of the disease on their health, psychosocial well-being, and lifestyle[18][19]. Community self-efficacy is a strong predictor of the self-management ability of patients with PD and positively influences social participation and social capital in older adults[20]. Illness acceptance, which reflects a patient's ability to adapt to their condition, is influenced by disease severity, treatment options, personal resilience, family support, and socioeconomic status[21]. Illness acceptance, community self-efficacy, and loneliness were found to be negatively correlated with social isolation[22]. Greater community self-efficacy and illness acceptance enhance self-management, assist in regulating negative emotions, and reduce social isolation among the elderly[23]. The self-regulation theory was proposed by Bandura and is derived from the social cognition theory [24]. According to the social cognition theory, self-regulation comprises three fundamental processes: self-observation, self-judgment, and self-reaction [25]. Individuals make self-judgments based on personal standards through self-observation and then self-react (either negatively or positively) based on their self-judgments. Their self-reaction subsequently influences their observation and judgment in the subsequent stage. These three processes occur cyclically. Thus, the self-regulation theory is of vital importance in the process of human adaptation and growth through the regulation of emotion, behavioral consciousness, and desire [26]. Social symptoms of PD, such as dysarthria, facial masking, and emotion recognition problems, often directly lead to feelings of loneliness and social isolation[27]. While social isolation and loneliness in elderly patients with PD were found to be linked in some studies, only a limited number of studies have investigated the interaction between social isolation and loneliness[28]. In this study, using the self-regulation theory model, we operationalized illness acceptance and community self-efficacy as self-awareness. In this study, patients with PD made self-judgments based on illness acceptance and community self-efficacy and self-reacted to provide feedback. The objectives of the present study were as follows: (i) investigate the status of illness acceptance, community self-efficacy, social isolation, and loneliness in patients with PD; (ii) determine the relationship between illness acceptance, community self-efficacy, social isolation, and loneliness; (iii) examine the multiple mediating roles of illness acceptance and community self-efficacy in the link between social isolation and loneliness in patients with PD. The findings from this study will provide important insights into the development of effective interventions for reducing loneliness in patients with PD. 2. Materials and methods 2.1. Study design and participants We used a cross-sectional descriptive study design using a questionnaire survey. Using convenience sampling, we recruited elderly patients with PD from the outpatient departments of two Grade iii-A hospitals in the Guangdong Province. The inclusion criteria were as follows: (1) confirmed diagnosis of PD; (2) age above 60 years, (3) presence of clear consciousness and ability to complete the questionnaire; (4) ability to provide signed informed consent. The exclusion criteria were as follows: (1) presence of severe hearing impairment and inability to communicate; (2) inability, for mental-health-related reasons (such as cognitive impairment or dementia), to complete the questionnaire; (3) presence of other serious diseases as complications. We diagnosed PD using the Clinical Diagnostic Criteria for Parkinson's Disease in China (2016)[29] based on three signs and symptoms: “bradykinesia” and at least “resting tremor” or “myotonia.” We examined all symptoms according to the methodology described in the Uniform Parkinson's Disease Assessment Scale (UPDRS)[30]. 2.2. Sample size determination We calculated the sample size using the G*Power version 3.1 software[31]. With a significance level α of 0.05, a power (1-ß) of 95%, and an effect size of 0.28 (medium effect size), the desired sample size was 129. Considering a potential invalid questionnaire rate of 10%, we arrived at a sample size of 142. 2.3. Ethics This study protocol was reviewed and approved by the Ethics Committee of Nanfang College Guangzhou (Ethics Approval No: NF2022052702). 2.4. Instrumentation We evaluated demographic and clinical variables such as sex, age, marriage, educational level, place of residence, number of living children, monthly income, living arrangement, social media use, social participation, and clinical stage of PD. A professional neurologist used the modified Hoehn and Yahr (HY) Scale for PD Staging (HY-5) to categorize the disease into clinical stages. The Lubben Social Network Scale (LSNS-6) comprises three items that assess family ties and a comparable set of three items that evaluate friendship-related ties. It enquires about the frequency of contact and emotional closeness [32]. Each item is scored on a scale of 0 (no relatives/friends) to 5 (nine or more relatives/friends) points. The total score for the scale ranges from 0 to 30, with lower scores indicating a weaker social network. We classified respondents with scores less than 12 points as being at risk of social isolation. Respondents with a score of less than 6 points on the family subscale or friends subscale were considered to be at risk of family or friend isolation [32]. The Cronbach alpha value of the scale was 0.805 [33]. In this study, the Cronbach alpha value was 0.803. The UCLA Loneliness Scale (Version 3) comprises 20 items that are used to assess loneliness. Each item is rated on a scale ranging from 1 (i.e., “never”) to 4 (i.e., “always”). Nine items were reverse-coded to ensure the same directionality as that of the remaining items. The total score ranges from 20 to 80. A greater total UCLA score indicates a higher level of loneliness [34][35]. This instrument exhibited satisfactory reliability and validity in a previous study conducted in China [36]. In this study, the Cronbach alpha value was 0.901. The Community’s Self-Efficacy Scale (CSES) is a self-administered questionnaire developed based on Bandura’s self-efficacy theory. This scale is used for assessing a community’s self-efficacy to aid in preventing social isolation among older people[37]. Jin translated the CSES into Chinese and validated the Chinese version [38]. The scale has two dimensions: community network and neighborhood watch, with four items in each dimension. Each item is scored on a 4-point Likert scale, from level 0 (not confident) to 3 (confident), and the total score ranges from 0 to 24. The higher the score, the stronger the community’s self-efficacy. The Cronbach alpha value of the scale was 0.910 in the Chinese version [38]. In this study, the Cronbach alpha value was 0.911. The Acceptance of Illness Scale (AIS) is a tool used to assess how a patient copes with their illness. The tool comprises eight questions that focus on the consequences of poor health, specifically, limitations caused by an illness, lack of self-sufficiency, a sense of dependence on others, and lowered self-esteem. In response to each statement, the patient defines their present status using a 5-point Likert scale, where 1 point indicates “strongly agree” and 5 points indicate “strongly disagree”. A score of 1 point indicates negative illness adaptation and that of 5 points indicates illness acceptance. The respondent can achieve a total score of 8 to 40 points. A low score indicates a lack of illness acceptance, whereas a high score indicates a good adaptation to the illness. The results are grouped into three ranges: scores less than 20 points represent “poor acceptance” of the illness, scores from 20 to 30 points represent “average acceptance,” and scores greater than 30 points indicate “good acceptance” of the illness [39]. The Cronbach’s reliability index was 0.868 for studies that used the Chinese version[40]. In this study, the Cronbach alpha value was 0.901. 2.5. Data collection Before collection, the researcher communicated with relevant departments of the hospital, familiarized them with the research purpose and content, and obtained support and consent from the nursing department of the hospital. From November 2021 to April 2022, we conducted a questionnaire survey in the outpatient department of two Grade III-A hospitals in Guangdong Province. We distributed the questionnaire samples on-site. Before we conducted the investigation, we explained the purpose and content of the study to patients and obtained the informed consent of the patients and their families. We conducted the survey anonymously. During the survey, the researcher read out each question, requested the participants to provide their responses, and completed the questionnaire truthfully. After we collected the answers to the questions, we performed a timely check for missing items, which were then supplemented. All data were entered into the database. 2.6. Statistical analysis We used SPSS version 26.0 to perform all statistical analyses. We applied the Bootstrap method using the SPSS macro program PROCESS V3.4.1. We described the demographic and clinical characteristics using descriptive statistics. We tested statistically significant differences between socio-demographic and clinical factors using ANOVA for continuous variables and the Chi-square test for categorical variables. We analyzed the relationships among illness acceptance, community self-efficacy, and social isolation using the Pearson correlation. P-values less than 0.05 were considered statistically significant. We used Hayes’ PROCESS procedure (model 6) in SPSS with bootstrap sampling (5000 samples) to test the multiple mediation model. Social isolation was set as X, loneliness as Y, illness acceptance as Mediator 1 (M1), and community self-efficacy as Mediator 1 (M2). The first indirect effect of X on Y via M1 was a1b1. The second indirect effect of X on Y via M2 was a2b2. The third indirect effect of X on Y via M1 and M2 serially was a1a3b2. The sum of all indirect effects was equal to the total indirect effect, i.e., a1b1 + a1a3b2 + a2b2. The coefficient c’ was the direct effect of X on Y. The direct effect and total indirect effect constitute the total effects (c), i.e., c = c’+ a1b1 + a2b2 + a1a3b2. All variables were standardized (Z-values) before the mediation analyses. We evaluated the point estimates and 95% confidence interval (CI) of the indirect, direct, and total effects using bootstrapping with 5000 simulations. The results were considered significant if the 95% CI did not contain zero. 3. Results 3.1. Demographic characteristics We included 142 elderly patients with PD; their mean age was 69.30 years (SD = 5.34, range 60-89). Approximately 55.6% of the participants (n=79) were male. Table 1 shows the demographic characteristics of the study population. 3.2. Mean scores and correlation coefficients of the study variables The mean scores of social isolation, loneliness, illness acceptance, and community self-efficacy in elderly patients with PD are shown in Table 2. Correlation analysis showed that a poorer social network was correlated with higher degrees of loneliness (r = -0.677, P < 0.001), and loneliness was negatively correlated with illness acceptance (r = -0.536, p < 0.001) and community self-efficacy (r = -0.654, p < 0.01) (Table 2). 3.3. Multiple mediation effects of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in elderly patients with PD As shown in Table 3 and Figure 1, the direct effect of social isolation on loneliness was statistically significant (c’ = -0.736, 95% CI [-0.988, -0.483]), and the total indirect effect of social isolation on loneliness was statistically significant (a1b1 + a1a3b2 + a2b2 = -0.498, 95% CI [-0.689, -0.319]). Social isolation exerted an indirect effect on loneliness through illness acceptance (a1b1 = -0.172, 95% CI [-0.297, -0.067]), and community self-efficacy (a2b2 = -0.271, 95% CI [-0.446, -0.115]), accounting for 13.9% and 22.0% of the total indirect effect, respectively. Furthermore, social isolation exerted an indirect effect on loneliness through illness acceptance and community self-efficacy in combination (a1a3b2 = -0.055, 95% CI [-0.105, -0.017]), accounting for 4.5% of the total indirect effect. This effect was statistically significant as no zeros were found in the 95% CI. 4. Discussion In this study, we used the LSNS-6 to measure social isolation among elderly patients with PD. We observed that 33.0% of elderly patients with PD exhibited social isolation, which was greater than that reported by the U.S. Health and Retirement Study, according to which 24% of community-dwelling adults aged 65 years and older in the USA (approximately 7.7 million people) were socially isolated and 4% (approximately 1.3 million people) were severely socially isolated [41]. Risbridger et al.[42] reported that 28% of elderly people in Malaysia experience social isolation. This might be because, in contemporary China, factors such as population migration have fragmented family units, urbanization has weakened mutual support through geographical ties, and the predominance of nuclear families has exacerbated social isolation among the elderly[43]. We found that elderly patients with PD experiencing a high degree of social isolation also demonstrated a low level of illness acceptance. This might be attributed to the fact that symptoms of exhaustion caused by diseases or treatment side effects make patients with PD less inclined to engage in social interactions, which further results in lower illness acceptance. Moreover, patients with PD with a lower illness acceptance experience significantly higher levels of mental stress. They feel angry, hurt, and discriminated against, which in turn leads to social isolation[44]. Conversely, patients with a high degree of illness acceptance tend to adopt an optimistic approach to coping with the disease and regain a sense of personal accomplishment by accepting the physical limitations and unpredictability of their illnesses[45]. Guiding patients with PD to accept the disease through social networks and health education, which may help them understand the clinical manifestations and prognosis of the disease, may reduce their risk of social isolation. Patients with a high degree of social isolation tend to have low levels of community self-efficacy. This is because active social participation increases the depth and breadth of social connections, helps patients adapt to changes in their lives, and makes them more confident about social interaction[46][47]. We used the self-regulation theory model to explore the effect of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in patients with PD. The results of multiple mediation effects analysis indicated that social isolation directly exacerbates loneliness. This might be attributed to the fact that social relationships mirror the economic resources and social capital of the elderly. Strong social relationships offer more avenues for the elderly to participate in society and provide a platform conducive to the realization of self-worth, life satisfaction, and subjective well-being. However, PD disrupts social connectedness and affects social interaction. Elderly patients with PD who are socially isolated have limited social connectedness and interpersonal relationships[48]. They do not receive support and care from family, friends, neighbors, and others and cannot actively seek resources to deal with disease-related events and their corresponding emotional reactions, which intensifies their negative psychological reactions[49]. Strengthening social connectedness by increasing social participation through community activities and information and communication technology is a good method to reduce social isolation and loneliness [50][51]. We found that social isolation exerted a significant indirect effect on loneliness through illness acceptance and community self-efficacy, accounting for 13.9% and 22.0% of the total indirect effect, respectively. Moreover, social isolation exerted an indirect effect on loneliness through illness acceptance and community self-efficacy, accounting for 4.5% of the total indirect effect. Illness acceptance and social self-efficacy influence the relationship between social isolation and loneliness, which is consistent with the hypothesis stipulating the multiple mediating roles of illness acceptance and social self-efficacy. Interventions that target loneliness from the perspective of illness acceptance and community self-efficacy can help individuals enhance disease acceptance and develop a positive self-efficacy to overcome disease manifestations. Therefore, strengthening family, community, and social support networks can enhance illness acceptance in patients with PD. This fosters positive adjustment and reintegration into daily life while reducing feelings of loneliness among patients. The “internet + integrated medical and elderly care” model provides access to an age-friendly digital society, through which social network support can be leveraged to alleviate social isolation and enhance disease acceptance and self-efficacy[52]. 5. Limitations This study had certain limitations. First, we selected participants only from the outpatient departments of two Grade iii-A hospitals in China, and only 142 participants were included. Consequently, the generalizability of our findings is somewhat limited. In future studies, participants should be recruited from a range of centers. Second, we used self-reported measures in this study. Hence, the response bias was unavoidable. However, the instruments we used had good reliability and validity. Third, some participants required assistance to complete their questionnaires. This could, to some extent, affect the results, even though we took countermeasures to ensure credibility. Lastly, some participants exhibited a strong sense of vigilance toward certain questions in the questionnaire. They feared the invasion of their privacy and refused to participate in the survey. This may have undermined the credibility and completeness of the questionnaire. Therefore, in future studies, researchers can focus on improving their communication skills and obtaining the trust and informed consent of research participants to ensure the credibility of the research. Despite these limitations, this study adopted a theoretical exploratory approach to offer new perspectives on the relationship between social isolation and loneliness in elderly patients with PD. 6. Conclusion In conclusion, our findings demonstrated that the relationship between social isolation and loneliness was partially mediated by illness acceptance and community self-efficacy. Interventions aimed at promoting mutuality, illness acceptance, and community self-efficacy will help reduce the level of loneliness among elderly patients with PD. Declarations Data Availability Statement Data are provided in the supplementary information files. Ethics Statement This study strictly followed the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of Nanfang College Guangzhou (Ethics Review Approval Number: NF2022052702). Written informed consent was obtained from all participants before the study was conducted. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding Statement This article was funded by The 2019 Guangdong University Humanities and Social Science Research project (2019KQNCX206). Authors’ contributions Manxuan Shen designed and directed the study. Yuanrong Wu and Qin Li recruited the participants and obtained the data. Yuanrong Wu and Qin Li conducted the data analysis. Yuanrong Wu and Qin Li drafted the manuscript. All authors revised the paper and approved the final version. References Armstrong, M. J. & Okun, M. S. Diagnosis and Treatment of Parkinson Disease: A Review. JAMA 323, 548-560, doi:10.1001/jama.2019.22360 (2020). Ben-Shlomo, Y. et al. The epidemiology of Parkinson's disease. Lancet 403, 283-292, doi:10.1016/s0140-6736(23)01419-8 (2024). Song, Z. et al. Prevalence of Parkinson's Disease in Adults Aged 65 Years and Older in China: A Multicenter Population-Based Survey. Neuroepidemiology 56, 50-58, doi:10.1159/000520726 (2022). Zheng, Z., Zhu, Z., Zhou, C., Cao, L. & Zhao, G. Burden of Parkinson Disease in China, 1990-2019: Findings from the 2019 Global Burden of Disease Study. Neuroepidemiology 57, 51-64, doi:10.1159/000527372 (2023). Vardanyan, R., König, H. H. & Hajek, A. Association between Parkinson's Disease and Psychosocial Factors: Results of the Nationally Representative German Ageing Survey. J Clin Med 11, doi:10.3390/jcm11154569 (2022). Maffoni, M., Giardini, A., Pierobon, A., Ferrazzoli, D. & Frazzitta, G. Stigma Experienced by Parkinson's Disease Patients: A Descriptive Review of Qualitative Studies. Parkinsons Dis 2017, 7203259, doi:10.1155/2017/7203259 (2017). Ahn, S., Springer, K. & Gibson, J. S. Social withdrawal in Parkinson's disease: A scoping review. Geriatr Nurs 48, 258-268, doi:10.1016/j.gerinurse.2022.10.010 (2022). National Academies of Sciences, E. et al. in Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System (National Academies Press (US) Copyright 2020 by the National Academy of Sciences. All rights reserved., 2020). Coyle, C. E. & Dugan, E. Social isolation, loneliness and health among older adults. J Aging Health 24, 1346-1363, doi:10.1177/0898264312460275 (2012). Stafford, M., Gardner, M., Kumari, M., Kuh, D. & Ben-Shlomo, Y. Social isolation and diurnal cortisol patterns in an ageing cohort. Psychoneuroendocrinology 38, 2737-2745, doi:10.1016/j.psyneuen.2013.07.002 (2013). Kotwal, A. A. et al. The epidemiology of social isolation and loneliness among older adults during the last years of life. J Am Geriatr Soc 69, 3081-3091, doi:10.1111/jgs.17366 (2021). Shankar, A., McMunn, A., Demakakos, P., Hamer, M. & Steptoe, A. Social isolation and loneliness: Prospective associations with functional status in older adults. Health Psychol 36, 179-187, doi:10.1037/hea0000437 (2017). Prell, T., Schönenberg, A. & Heimrich, K. G. The impact of loneliness on quality of life in people with Parkinson's disease: results from the Survey of Health, Ageing and Retirement in Europe. Front Med (Lausanne) 10, 1183289, doi:10.3389/fmed.2023.1183289 (2023). Cudjoe, T. K. M. et al. The Epidemiology of Social Isolation: National Health and Aging Trends Study. J Gerontol B Psychol Sci Soc Sci 75, 107-113, doi:10.1093/geronb/gby037 (2020). Vancampfort, D. et al. Physical activity and loneliness among adults aged 50 years or older in six low- and middle-income countries. Int J Geriatr Psychiatry 34, 1855-1864, doi:10.1002/gps.5202 (2019). Zhang, J. et al. Loneliness and Health Service Utilization among the Rural Elderly in Shandong, China: A Cross-Sectional Study. Int J Environ Res Public Health 15, doi:10.3390/ijerph15071468 (2018). McDaniels, B. & Subramanian, I. Social isolation, loneliness and mental health sequelae of the Covid-19 pandemic in Parkinson's disease. Int Rev Neurobiol 165, 197-227, doi:10.1016/bs.irn.2022.03.003 (2022). Cybulski, M., Cybulski, L., Krajewska-Kulak, E. & Cwalina, U. Illness acceptance, pain perception and expectations for physicians of the elderly in Poland. BMC Geriatr 17, 46, doi:10.1186/s12877-017-0441-4 (2017). van Riel, P., Zuidema, R. M., Vogel, C. & Rongen-van Dartel, S. A. A. Patient Self-Management and Tracking: A European Experience. Rheum Dis Clin North Am 45, 187-195, doi:10.1016/j.rdc.2019.01.008 (2019). Tadaka, E. et al. Development of a community's self-efficacy scale for preventing social isolation among community-dwelling older people (Mimamori Scale). BMC Public Health 16, 1198, doi:10.1186/s12889-016-3857-4 (2016). Gu, Z., Li, M., Liu, L., Ban, Y. & Wu, H. The moderating effect of self-efficacy between social constraints, social isolation, family environment, and depressive symptoms among breast cancer patients in China: a cross-sectional study. Support Care Cancer 31, 594, doi:10.1007/s00520-023-08063-0 (2023). Zhang, X., Li, X., Luo, W., Zhao, H. & Liu, Y. Validation of the Chinese Version Community's Self-Efficacy Scale in Community-Dwelling Older Adults. Patient Prefer Adherence 16, 1061-1070, doi:10.2147/ppa.S359459 (2022). Bandura, A. Social Foundations of Thought & Action: A Social Cognitive Theory. The Academy of Management Review 12, 169 (1987). Bandura, A. Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes 50, 248-287, doi:https://doi.org/10.1016/0749-5978(91)90022-L (1991). Tougas, M. E., Hayden, J. A., McGrath, P. J., Huguet, A. & Rozario, S. A Systematic Review Exploring the Social Cognitive Theory of Self-Regulation as a Framework for Chronic Health Condition Interventions. PLoS One 10, e0134977, doi:10.1371/journal.pone.0134977 (2015). Prenger, M. T. M., Madray, R., Van Hedger, K., Anello, M. & MacDonald, P. A. Social Symptoms of Parkinson's Disease. Parkinsons Dis 2020, 8846544, doi:10.1155/2020/8846544 (2020). Wang, W. W. et al. Status quo of social isolation in patients with Parkinson′s disease. Chinese General Practice Nursing 21, 1046-1051 (2023). Chen, Y. P. & Shang, H. F. Introduction of clinical diagnostic criteria for Parkinson's disease in China (2016). Chinese Journal of Practical Internal Medicine 37, 124-126, doi:10.19538/j.nk2017020110 (2017). Martinez-Martin, P. Instruments for holistic assessment of Parkinson's disease. J Neural Transm (Vienna) 120, 559-564, doi:10.1007/s00702-013-1005-1 (2013). Faul, F., Erdfelder, E., Buchner, A. & Lang, A. G. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41, 1149-1160, doi:10.3758/brm.41.4.1149 (2009). Lubben, J. et al. Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations. Gerontologist 46, 503-513, doi:10.1093/geront/46.4.503 (2006). Chang, Q., Sha, F., Chan, C. H. & Yip, P. S. F. Validation of an abbreviated version of the Lubben Social Network Scale ("LSNS-6") and its associations with suicidality among older adults in China. PLoS One 13, e0201612, doi:10.1371/journal.pone.0201612 (2018). Russell, D. W. UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure. J Pers Assess 66, 20-40, doi:10.1207/s15327752jpa6601_2 (1996). Lin, C. Y. et al. Psychometric Evaluation of Three Versions of the UCLA Loneliness Scale (Full, Eight-Item, and Three-Item Versions) among Sexual Minority Men in Taiwan. Int J Environ Res Public Health 19, doi:10.3390/ijerph19138095 (2022). DengFeng, W. The reliability and validity of Russell Loneliness Scale. Chinese Journal of Clinical Psychology, 23-25 (1995). Tadaka, E. et al. Development of a community's self-efficacy scale for preventing social isolation among community-dwelling older people (Mimamori Scale). BMC Public Health 16, 1198, doi:10.1186/s12889-016-3857-4 (2016). Jin, J. Z., H. Reliability and validity of the Chinese version of Community's Self-efficacy Scale in communitydwelling older people. Chinese General Practice 20(29), 3665-3668 (2017). Felton, B. J., Revenson, T. A. & Hinrichsen, G. A. Stress and coping in the explanation of psychological adjustment among chronically ill adults. Soc Sci Med 18, 889-898, doi:10.1016/0277-9536(84)90158-8 (1984). Wang, W., Cui, H., Zhang, W., Xu, X. & Dong, H. Reliability and Validity of the Chinese Version of the Scale for Assessing the Stigma of Mental Illness in Nursing. Front Psychiatry 12, 754774, doi:10.3389/fpsyt.2021.754774 (2021). Blazer, D., Lustig, T. & Kearney, M. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. TR news: Transportation research (2021). Risbridger, S. et al. Social Participation's Association with Falls and Frailty in Malaysia: A Cross-Sectional Study. J Frailty Aging 11, 199-205, doi:10.14283/jfa.2021.31 (2022). Liu, Y., Dijst, M., Faber, J., Geertman, S. & Cui, C. Healthy urban living: Residential environment and health of older adults in Shanghai. Health Place 47, 80-89, doi:10.1016/j.healthplace.2017.07.007 (2017). Polański, J., Misiąg, W. & Chabowski, M. Impact of Loneliness on Functioning in Lung Cancer Patients. Int J Environ Res Public Health 19, doi:10.3390/ijerph192315793 (2022). Bandura, A. Self-efficacy and health. Behaviour Research & Therapy 23, 437-451 (1985). Schwarzer, R. & Jerusalem, M. Measures in health psychology: a users portfolio. (1995). Soleimani, M. A., Negarandeh, R., Bastani, F. & Greysen, R. Disrupted social connectedness in people with Parkinson's disease. Br J Community Nurs 19, 136-141, doi:10.12968/bjcn.2014.19.3.136 (2014). Wickramaratne, P. J. et al. Social connectedness as a determinant of mental health: A scoping review. PLoS One 17, e0275004, doi:10.1371/journal.pone.0275004 (2022). Giebel, C. et al. Enabling middle-aged and older adults accessing community services to reduce social isolation: Community Connectors. Health Soc Care Community 30, e461-e468, doi:10.1111/hsc.13228 (2022). Thangavel, G., Memedi, M. & Hedström, K. Customized Information and Communication Technology for Reducing Social Isolation and Loneliness Among Older Adults: Scoping Review. JMIR Ment Health 9, e34221, doi:10.2196/34221 (2022). Phang, J. K. et al. Digital Intergenerational Program to Reduce Loneliness and Social Isolation Among Older Adults: Realist Review. JMIR Aging 6, e39848, doi:10.2196/39848 (2023). Tables Table 1. Demographic characteristics of elderly patients with PD (N = 142) Variables (mean ± SD)/Frequency (percentage) Age 69.30±5.34 Gender Male 79（55.6） Female 63（44.3） Place of residence Countryside 58（40.8） City 84（59.1） Educational level Junior high school or below 101（71.1） Senior high school or above 39（28.8） Marital status Single (single/divorced/widowed) 27（19） Married/cohabiting 115（80.9） Living Arrangement Living alone/Nursing Home 13（9.1） Live with family 129（90.8） Monthly income <3000 yuan 70（49.2） ≥3000 yuan 72（50.7） Number of living children ≤1 4（2.8） ≥2 138（97.1） Social media use Yes 60（42.2） No 82（57.7） Social participation Yes 64（45） No 78（54.9） Clinical stage of PD 0 9 (6.3) 1 62 (43.7) 1.5 31 (21.8) 2 20 (14.1) 2.5 7 (4.9) 3 6 (4.2) 4 4 (2.8) 5 3 (2.1) Table 2. Mean scores and correlation coefficients of study variables (N = 142) Variable Mean±SD 1 2 3 4 1. Social isolation 13.29±5.40 1 2. Loneliness 43.33±9.84 -0.677** 1 3. Illness acceptance 23.56±6.87 0.387** -0.536** 1 4. Community self-efficacy 11.03±6.22 0.621** -0.654** 0.471** 1 Note: *P ＜ 0.01，**P ＜ 0.001 Table 3. Multiple mediation effects of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in elderly patients with Parkinson’s disease (N = 142) Effect Pathway Effect value 95% Confidence Interval Frequency Lower Upper Direct effect X→Y -0.736 -0.988 -0.483 59.6% Indirect effect X→M1→Y -0.172 -0.297 -0.067 13.9% X→M2→Y -0.271 -0.446 -0.115 22.0% X→M1→M2→Y -0.055 -0.105 -0.017 4.5% Total indirect effect -0.498 -0.689 -0.319 40.4% Total effect -1.234 -1.458 -1.009 100% Note: X, social isolation; Y, loneliness; Mediator 1 (M1), illness acceptance; Mediator 2 (M2), community self-efficacy; 95% CI, 95% confidence interval Additional Declarations No competing interests reported. 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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-5645836","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":448661686,"identity":"fe9244a8-5ed5-4378-b464-0e99980b27de","order_by":0,"name":"Yuanrong Wu","email":"","orcid":"","institution":"NANFANG COLLEGE·GUANGZHOU","correspondingAuthor":false,"prefix":"","firstName":"Yuanrong","middleName":"","lastName":"Wu","suffix":""},{"id":448661687,"identity":"fcd7d0d1-3d8e-466f-8573-1d1ea603e343","order_by":1,"name":"Qin Li","email":"","orcid":"","institution":"the First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Qin","middleName":"","lastName":"Li","suffix":""},{"id":448661688,"identity":"0055d430-69a4-4f1a-ae70-4bf8017777ec","order_by":2,"name":"Manxuan Shen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYDACCQST8UFChQ1pWpgNHpxJI00Lm+TDtkOEdcjPbj726EbNncQNx88eq0hgO8DA396dgFeLwZ1j6cY5x54ZG5zJS7uRwHOHQeLM2Q34tUjkmEnnsB2WMziQY3YjQeIZUCQXvxb5GfnfpHP+HeYxOP/GrCDB4DBhLQw3ctikc9uAttzIMWNISCBCi8GNNDPp3L7DxpI33hhLJBxI4yHoF/kZyc+kc74dTuw7n2P48ec/Gzn+9l4CDkMHPKQpHwWjYBSMglGAFQAAzSxMAvtlu4MAAAAASUVORK5CYII=","orcid":"","institution":"the First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Manxuan","middleName":"","lastName":"Shen","suffix":""}],"badges":[],"createdAt":"2024-12-15 04:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5645836/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5645836/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-07890-x","type":"published","date":"2025-07-01T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82044220,"identity":"55a1fdcf-0cb4-4b44-813a-45a45eda5ebc","added_by":"auto","created_at":"2025-05-06 09:29:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61645,"visible":true,"origin":"","legend":"\u003cp\u003eThe multiple mediation model of illness acceptance and community self-efficacy depicting the relationship between social isolation and loneliness in elderly patients with Parkinson's disease (N= 142). Note: *P\u003cem\u003e＜\u003c/em\u003e0.01，**P\u003cem\u003e＜\u003c/em\u003e0.001\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5645836/v1/0bad779f069637575fe5cb74.jpg"},{"id":86179866,"identity":"593a0fbb-abf0-4574-9f14-f2792de8a564","added_by":"auto","created_at":"2025-07-07 16:20:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":748016,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5645836/v1/0048c497-f7eb-4705-87b2-324a237ad43e.pdf"},{"id":82048113,"identity":"832e13c1-87a8-4cb6-ad23-3f4b5e3cf4ec","added_by":"auto","created_at":"2025-05-06 09:45:20","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":58077,"visible":true,"origin":"","legend":"","description":"","filename":"Data.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-5645836/v1/adee6be4018f670c24788a2f.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Illness acceptance and community self-efficacy mediate the relationship between social isolation and loneliness among elderly people with Parkinson's Disease","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eParkinson's disease (PD) is a common neurodegenerative disorder among the elderly, primarily characterized by bradykinesia, muscle rigidity, resting tremors, akinesia, postural instability, sleep disorders, and hypoesthesia [1]. Age is associated with an increase in PD risk. The prevalence of PD was found to increase from 18% for individuals aged 65\u0026ndash;70 years to 36% for individuals aged 80\u0026ndash;85 years[2]. The prevalence of PD among individuals aged 65 years and above in China was 1.60%, and the burden of PD has been found to increase every year[3][4]. Elderly patients with PD often perceive themselves as socially isolated and lonely[5]. Symptoms such as dyskinesia, hypophonia, dysarthria, and facial masking further contribute to stigma and social withdrawal [6] [7].\u003c/p\u003e \u003cp\u003eSocial isolation and loneliness are frequently used interchangeably; however, they are distinct terms. Social isolation is an objective condition characterized by the restricted participation of individuals in activities, a dearth of social relationships, or infrequent social interactions [8]. It is typically measured using objective and quantifiable means, such as the frequency of social contact, the expanse of one\u0026rsquo;s social network, and factors such as household composition, marital status, and friendships. Indicators of social isolation include living alone, having limited social network connections, and engaging in minimal social interactions [9][10]. Among the elderly, social isolation is strongly correlated with fewer social network ties and a weak socioeconomic status. It acts as a predictor of adverse outcomes, including morbidity and mortality [11], cognitive decline, and depressive symptoms [12].\u003c/p\u003e \u003cp\u003eConversely, loneliness is a subjective emotional state of feeling unloved and distant from significant others, close friends, and family [8]. Individuals experiencing loneliness often perceive the world more negatively and anticipate unpleasant social interactions, which can result in the retention of negative social information [13]. One can experience social isolation without feeling lonely, and they may experience loneliness even if they are socially well-connected. Findings from numerous studies have underscored the prevalence of social isolation and loneliness among older adults. Social isolation impacts approximately 24% of the elderly population. The prevalence of loneliness ranges from 0.2\u0026ndash;25%, depending on the context and measurement criteria [14][15][16]. Although social isolation can increase the likelihood of loneliness, the two phenomena exert distinct effects. Nevertheless, both have significant consequences on the physical and mental health of individuals with PD, exacerbating existing symptoms and contributing to poorer health outcomes[17].\u003c/p\u003e \u003cp\u003eSelf-management is crucial for handling chronic diseases as it enables patients to control symptoms and mitigate the impact of the disease on their health, psychosocial well-being, and lifestyle[18][19]. Community self-efficacy is a strong predictor of the self-management ability of patients with PD and positively influences social participation and social capital in older adults[20]. Illness acceptance, which reflects a patient's ability to adapt to their condition, is influenced by disease severity, treatment options, personal resilience, family support, and socioeconomic status[21]. Illness acceptance, community self-efficacy, and loneliness were found to be negatively correlated with social isolation[22]. Greater community self-efficacy and illness acceptance enhance self-management, assist in regulating negative emotions, and reduce social isolation among the elderly[23].\u003c/p\u003e \u003cp\u003eThe self-regulation theory was proposed by Bandura and is derived from the social cognition theory [24]. According to the social cognition theory, self-regulation comprises three fundamental processes: self-observation, self-judgment, and self-reaction [25]. Individuals make self-judgments based on personal standards through self-observation and then self-react (either negatively or positively) based on their self-judgments. Their self-reaction subsequently influences their observation and judgment in the subsequent stage. These three processes occur cyclically. Thus, the self-regulation theory is of vital importance in the process of human adaptation and growth through the regulation of emotion, behavioral consciousness, and desire [26].\u003c/p\u003e \u003cp\u003eSocial symptoms of PD, such as dysarthria, facial masking, and emotion recognition problems, often directly lead to feelings of loneliness and social isolation[27]. While social isolation and loneliness in elderly patients with PD were found to be linked in some studies, only a limited number of studies have investigated the interaction between social isolation and loneliness[28]. In this study, using the self-regulation theory model, we operationalized illness acceptance and community self-efficacy as self-awareness. In this study, patients with PD made self-judgments based on illness acceptance and community self-efficacy and self-reacted to provide feedback. The objectives of the present study were as follows: (i) investigate the status of illness acceptance, community self-efficacy, social isolation, and loneliness in patients with PD; (ii) determine the relationship between illness acceptance, community self-efficacy, social isolation, and loneliness; (iii) examine the multiple mediating roles of illness acceptance and community self-efficacy in the link between social isolation and loneliness in patients with PD. The findings from this study will provide important insights into the development of effective interventions for reducing loneliness in patients with PD.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design and participants\u003c/h2\u003e \u003cp\u003eWe used a cross-sectional descriptive study design using a questionnaire survey. Using convenience sampling, we recruited elderly patients with PD from the outpatient departments of two Grade iii-A hospitals in the Guangdong Province. The inclusion criteria were as follows: (1) confirmed diagnosis of PD; (2) age above 60 years, (3) presence of clear consciousness and ability to complete the questionnaire; (4) ability to provide signed informed consent. The exclusion criteria were as follows: (1) presence of severe hearing impairment and inability to communicate; (2) inability, for mental-health-related reasons (such as cognitive impairment or dementia), to complete the questionnaire; (3) presence of other serious diseases as complications. We diagnosed PD using the Clinical Diagnostic Criteria for Parkinson's Disease in China (2016)[29] based on three signs and symptoms: \u0026ldquo;bradykinesia\u0026rdquo; and at least \u0026ldquo;resting tremor\u0026rdquo; or \u0026ldquo;myotonia.\u0026rdquo; We examined all symptoms according to the methodology described in the Uniform Parkinson's Disease Assessment Scale (UPDRS)[30].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Sample size determination\u003c/h2\u003e \u003cp\u003eWe calculated the sample size using the G*Power version 3.1 software[31]. With a significance level α of 0.05, a power (1-\u0026szlig;) of 95%, and an effect size of 0.28 (medium effect size), the desired sample size was 129. Considering a potential invalid questionnaire rate of 10%, we arrived at a sample size of 142.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Ethics\u003c/h2\u003e \u003cp\u003e This study protocol was reviewed and approved by the Ethics Committee of Nanfang College Guangzhou (Ethics Approval No: NF2022052702).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Instrumentation\u003c/h2\u003e \u003cp\u003eWe evaluated demographic and clinical variables such as sex, age, marriage, educational level, place of residence, number of living children, monthly income, living arrangement, social media use, social participation, and clinical stage of PD. A professional neurologist used the modified Hoehn and Yahr (HY) Scale for PD Staging (HY-5) to categorize the disease into clinical stages.\u003c/p\u003e \u003cp\u003eThe Lubben Social Network Scale (LSNS-6) comprises three items that assess family ties and a comparable set of three items that evaluate friendship-related ties. It enquires about the frequency of contact and emotional closeness [32]. Each item is scored on a scale of 0 (no relatives/friends) to 5 (nine or more relatives/friends) points. The total score for the scale ranges from 0 to 30, with lower scores indicating a weaker social network. We classified respondents with scores less than 12 points as being at risk of social isolation. Respondents with a score of less than 6 points on the family subscale or friends subscale were considered to be at risk of family or friend isolation [32]. The Cronbach alpha value of the scale was 0.805 [33]. In this study, the Cronbach alpha value was 0.803.\u003c/p\u003e \u003cp\u003eThe UCLA Loneliness Scale (Version 3) comprises 20 items that are used to assess loneliness. Each item is rated on a scale ranging from 1 (i.e., \u0026ldquo;never\u0026rdquo;) to 4 (i.e., \u0026ldquo;always\u0026rdquo;). Nine items were reverse-coded to ensure the same directionality as that of the remaining items. The total score ranges from 20 to 80. A greater total UCLA score indicates a higher level of loneliness [34][35]. This instrument exhibited satisfactory reliability and validity in a previous study conducted in China [36]. In this study, the Cronbach alpha value was 0.901.\u003c/p\u003e \u003cp\u003eThe Community\u0026rsquo;s Self-Efficacy Scale (CSES) is a self-administered questionnaire developed based on Bandura\u0026rsquo;s self-efficacy theory. This scale is used for assessing a community\u0026rsquo;s self-efficacy to aid in preventing social isolation among older people[37]. Jin translated the CSES into Chinese and validated the Chinese version [38]. The scale has two dimensions: community network and neighborhood watch, with four items in each dimension. Each item is scored on a 4-point Likert scale, from level 0 (not confident) to 3 (confident), and the total score ranges from 0 to 24. The higher the score, the stronger the community\u0026rsquo;s self-efficacy. The Cronbach alpha value of the scale was 0.910 in the Chinese version [38]. In this study, the Cronbach alpha value was 0.911.\u003c/p\u003e \u003cp\u003eThe Acceptance of Illness Scale (AIS) is a tool used to assess how a patient copes with their illness. The tool comprises eight questions that focus on the consequences of poor health, specifically, limitations caused by an illness, lack of self-sufficiency, a sense of dependence on others, and lowered self-esteem. In response to each statement, the patient defines their present status using a 5-point Likert scale, where 1 point indicates \u0026ldquo;strongly agree\u0026rdquo; and 5 points indicate \u0026ldquo;strongly disagree\u0026rdquo;. A score of 1 point indicates negative illness adaptation and that of 5 points indicates illness acceptance. The respondent can achieve a total score of 8 to 40 points. A low score indicates a lack of illness acceptance, whereas a high score indicates a good adaptation to the illness. The results are grouped into three ranges: scores less than 20 points represent \u0026ldquo;poor acceptance\u0026rdquo; of the illness, scores from 20 to 30 points represent \u0026ldquo;average acceptance,\u0026rdquo; and scores greater than 30 points indicate \u0026ldquo;good acceptance\u0026rdquo; of the illness [39]. The Cronbach\u0026rsquo;s reliability index was 0.868 for studies that used the Chinese version[40]. In this study, the Cronbach alpha value was 0.901.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data collection\u003c/h2\u003e \u003cp\u003eBefore collection, the researcher communicated with relevant departments of the hospital, familiarized them with the research purpose and content, and obtained support and consent from the nursing department of the hospital. From November 2021 to April 2022, we conducted a questionnaire survey in the outpatient department of two Grade III-A hospitals in Guangdong Province. We distributed the questionnaire samples on-site. Before we conducted the investigation, we explained the purpose and content of the study to patients and obtained the informed consent of the patients and their families. We conducted the survey anonymously. During the survey, the researcher read out each question, requested the participants to provide their responses, and completed the questionnaire truthfully. After we collected the answers to the questions, we performed a timely check for missing items, which were then supplemented. All data were entered into the database.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical analysis\u003c/h2\u003e \u003cp\u003eWe used SPSS version 26.0 to perform all statistical analyses. We applied the Bootstrap method using the SPSS macro program PROCESS V3.4.1. We described the demographic and clinical characteristics using descriptive statistics. We tested statistically significant differences between socio-demographic and clinical factors using ANOVA for continuous variables and the Chi-square test for categorical variables. We analyzed the relationships among illness acceptance, community self-efficacy, and social isolation using the Pearson correlation. P-values less than 0.05 were considered statistically significant.\u003c/p\u003e \u003cp\u003eWe used Hayes\u0026rsquo; PROCESS procedure (model 6) in SPSS with bootstrap sampling (5000 samples) to test the multiple mediation model. Social isolation was set as X, loneliness as Y, illness acceptance as Mediator 1 (M1), and community self-efficacy as Mediator 1 (M2). The first indirect effect of X on Y via M1 was a1b1. The second indirect effect of X on Y via M2 was a2b2. The third indirect effect of X on Y via M1 and M2 serially was a1a3b2. The sum of all indirect effects was equal to the total indirect effect, i.e., a1b1\u0026thinsp;+\u0026thinsp;a1a3b2\u0026thinsp;+\u0026thinsp;a2b2. The coefficient c\u0026rsquo; was the direct effect of X on Y. The direct effect and total indirect effect constitute the total effects (c), i.e., c\u0026thinsp;=\u0026thinsp;c\u0026rsquo;+ a1b1\u0026thinsp;+\u0026thinsp;a2b2\u0026thinsp;+\u0026thinsp;a1a3b2. All variables were standardized (Z-values) before the mediation analyses. We evaluated the point estimates and 95% confidence interval (CI) of the indirect, direct, and total effects using bootstrapping with 5000 simulations. The results were considered significant if the 95% CI did not contain zero.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1.\u0026nbsp; Demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe included 142 elderly patients with PD; their mean age was 69.30 years (SD = 5.34, range 60-89). Approximately 55.6% of the participants (n=79) were male. Table 1 shows the demographic characteristics of the study population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.\u0026nbsp; Mean scores and correlation coefficients of the study variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean scores of\u0026nbsp;social isolation, loneliness, illness acceptance, and community self-efficacy in elderly patients with PD are shown in Table 2. Correlation analysis showed that a poorer social network was correlated with higher degrees of loneliness (r = -0.677, P \u0026lt; 0.001), and loneliness was negatively correlated with illness acceptance (r\u0026nbsp;= -0.536,\u0026nbsp;p\u0026nbsp;\u0026lt; 0.001) and community self-efficacy (r\u0026nbsp;= -0.654, p\u0026nbsp;\u0026lt; 0.01) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Multiple mediation effects of illness acceptance and community self-efficacy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eon the relationship between social isolation and loneliness\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;in elderly patients with PD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3 and Figure 1, the direct effect of social isolation on loneliness was statistically significant (c\u0026rsquo; = -0.736, 95% CI [-0.988, -0.483]), and the total indirect effect of social isolation on loneliness was statistically significant (a1b1 + a1a3b2 + a2b2 = -0.498, 95% CI [-0.689, -0.319]). Social isolation exerted an indirect effect on loneliness through illness acceptance (a1b1 = -0.172, 95% CI [-0.297, -0.067]), and community self-efficacy (a2b2 = -0.271, 95% CI [-0.446, -0.115]), accounting for 13.9% and 22.0% of the total indirect effect, respectively. Furthermore, social isolation exerted an indirect effect on loneliness through illness acceptance and community self-efficacy in combination (a1a3b2 = -0.055, 95% CI [-0.105, -0.017]), accounting for 4.5% of the total indirect effect. This effect was statistically significant as no zeros were found in the 95% CI.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, we used the LSNS-6 to measure social isolation among elderly patients with PD. We observed that 33.0% of elderly patients with PD exhibited social isolation, which was greater than that reported by the U.S. Health and Retirement Study, according to which 24% of community-dwelling adults aged 65 years and older in the USA (approximately 7.7\u0026nbsp;million people) were socially isolated and 4% (approximately 1.3\u0026nbsp;million people) were severely socially isolated [41]. Risbridger et al.[42] reported that 28% of elderly people in Malaysia experience social isolation. This might be because, in contemporary China, factors such as population migration have fragmented family units, urbanization has weakened mutual support through geographical ties, and the predominance of nuclear families has exacerbated social isolation among the elderly[43].\u003c/p\u003e \u003cp\u003eWe found that elderly patients with PD experiencing a high degree of social isolation also demonstrated a low level of illness acceptance. This might be attributed to the fact that symptoms of exhaustion caused by diseases or treatment side effects make patients with PD less inclined to engage in social interactions, which further results in lower illness acceptance. Moreover, patients with PD with a lower illness acceptance experience significantly higher levels of mental stress. They feel angry, hurt, and discriminated against, which in turn leads to social isolation[44]. Conversely, patients with a high degree of illness acceptance tend to adopt an optimistic approach to coping with the disease and regain a sense of personal accomplishment by accepting the physical limitations and unpredictability of their illnesses[45]. Guiding patients with PD to accept the disease through social networks and health education, which may help them understand the clinical manifestations and prognosis of the disease, may reduce their risk of social isolation. Patients with a high degree of social isolation tend to have low levels of community self-efficacy. This is because active social participation increases the depth and breadth of social connections, helps patients adapt to changes in their lives, and makes them more confident about social interaction[46][47].\u003c/p\u003e \u003cp\u003eWe used the self-regulation theory model to explore the effect of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in patients with PD. The results of multiple mediation effects analysis indicated that social isolation directly exacerbates loneliness. This might be attributed to the fact that social relationships mirror the economic resources and social capital of the elderly. Strong social relationships offer more avenues for the elderly to participate in society and provide a platform conducive to the realization of self-worth, life satisfaction, and subjective well-being. However, PD disrupts social connectedness and affects social interaction. Elderly patients with PD who are socially isolated have limited social connectedness and interpersonal relationships[48]. They do not receive support and care from family, friends, neighbors, and others and cannot actively seek resources to deal with disease-related events and their corresponding emotional reactions, which intensifies their negative psychological reactions[49]. Strengthening social connectedness by increasing social participation through community activities and information and communication technology is a good method to reduce social isolation and loneliness [50][51]. We found that social isolation exerted a significant indirect effect on loneliness through illness acceptance and community self-efficacy, accounting for 13.9% and 22.0% of the total indirect effect, respectively. Moreover, social isolation exerted an indirect effect on loneliness through illness acceptance and community self-efficacy, accounting for 4.5% of the total indirect effect. Illness acceptance and social self-efficacy influence the relationship between social isolation and loneliness, which is consistent with the hypothesis stipulating the multiple mediating roles of illness acceptance and social self-efficacy. Interventions that target loneliness from the perspective of illness acceptance and community self-efficacy can help individuals enhance disease acceptance and develop a positive self-efficacy to overcome disease manifestations.\u003c/p\u003e \u003cp\u003eTherefore, strengthening family, community, and social support networks can enhance illness acceptance in patients with PD. This fosters positive adjustment and reintegration into daily life while reducing feelings of loneliness among patients. The \u0026ldquo;internet\u0026thinsp;+\u0026thinsp;integrated medical and elderly care\u0026rdquo; model provides access to an age-friendly digital society, through which social network support can be leveraged to alleviate social isolation and enhance disease acceptance and self-efficacy[52].\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study had certain limitations. First, we selected participants only from the outpatient departments of two Grade iii-A hospitals in China, and only 142 participants were included. Consequently, the generalizability of our findings is somewhat limited. In future studies, participants should be recruited from a range of centers.\u003c/p\u003e \u003cp\u003eSecond, we used self-reported measures in this study. Hence, the response bias was unavoidable. However, the instruments we used had good reliability and validity.\u003c/p\u003e \u003cp\u003eThird, some participants required assistance to complete their questionnaires. This could, to some extent, affect the results, even though we took countermeasures to ensure credibility.\u003c/p\u003e \u003cp\u003eLastly, some participants exhibited a strong sense of vigilance toward certain questions in the questionnaire. They feared the invasion of their privacy and refused to participate in the survey. This may have undermined the credibility and completeness of the questionnaire. Therefore, in future studies, researchers can focus on improving their communication skills and obtaining the trust and informed consent of research participants to ensure the credibility of the research.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study adopted a theoretical exploratory approach to offer new perspectives on the relationship between social isolation and loneliness in elderly patients with PD.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eIn conclusion, our findings demonstrated that the relationship between social isolation and loneliness was partially mediated by illness acceptance and community self-efficacy. Interventions aimed at promoting mutuality, illness acceptance, and community self-efficacy will help reduce the level of loneliness among elderly patients with PD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are provided in the supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study strictly followed the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of Nanfang College Guangzhou (Ethics Review Approval Number: NF2022052702). Written informed consent was obtained from all participants before the study was conducted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article was funded by The 2019 Guangdong University Humanities and Social Science Research project (2019KQNCX206).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManxuan Shen designed and directed the study. Yuanrong Wu and Qin Li recruited the participants and obtained the data. Yuanrong Wu and Qin Li conducted the data analysis. Yuanrong Wu and Qin Li drafted the manuscript. All authors revised the paper and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArmstrong, M. J. \u0026amp; Okun, M. S. Diagnosis and Treatment of Parkinson Disease: A Review. JAMA 323, 548-560, doi:10.1001/jama.2019.22360 (2020).\u003c/li\u003e\n\u003cli\u003eBen-Shlomo, Y. et al. The epidemiology of Parkinson's disease. Lancet 403, 283-292, doi:10.1016/s0140-6736(23)01419-8 (2024).\u003c/li\u003e\n\u003cli\u003eSong, Z. et al. Prevalence of Parkinson's Disease in Adults Aged 65 Years and Older in China: A Multicenter Population-Based Survey. Neuroepidemiology 56, 50-58, doi:10.1159/000520726 (2022).\u003c/li\u003e\n\u003cli\u003eZheng, Z., Zhu, Z., Zhou, C., Cao, L. \u0026amp; Zhao, G. Burden of Parkinson Disease in China, 1990-2019: Findings from the 2019 Global Burden of Disease Study. Neuroepidemiology 57, 51-64, doi:10.1159/000527372 (2023).\u003c/li\u003e\n\u003cli\u003eVardanyan, R., K\u0026ouml;nig, H. H. \u0026amp; Hajek, A. Association between Parkinson's Disease and Psychosocial Factors: Results of the Nationally Representative German Ageing Survey. J Clin Med 11, doi:10.3390/jcm11154569 (2022).\u003c/li\u003e\n\u003cli\u003eMaffoni, M., Giardini, A., Pierobon, A., Ferrazzoli, D. \u0026amp; Frazzitta, G. Stigma Experienced by Parkinson's Disease Patients: A Descriptive Review of Qualitative Studies. Parkinsons Dis 2017, 7203259, doi:10.1155/2017/7203259 (2017).\u003c/li\u003e\n\u003cli\u003eAhn, S., Springer, K. \u0026amp; Gibson, J. S. Social withdrawal in Parkinson's disease: A scoping review. Geriatr Nurs 48, 258-268, doi:10.1016/j.gerinurse.2022.10.010 (2022).\u003c/li\u003e\n\u003cli\u003eNational Academies of Sciences, E. et al. in Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System (National Academies Press (US)\u003c/li\u003e\n\u003cli\u003eCopyright 2020 by the National Academy of Sciences. All rights reserved., 2020).\u003c/li\u003e\n\u003cli\u003eCoyle, C. E. \u0026amp; Dugan, E. Social isolation, loneliness and health among older adults. J Aging Health 24, 1346-1363, doi:10.1177/0898264312460275 (2012).\u003c/li\u003e\n\u003cli\u003eStafford, M., Gardner, M., Kumari, M., Kuh, D. \u0026amp; Ben-Shlomo, Y. Social isolation and diurnal cortisol patterns in an ageing cohort. Psychoneuroendocrinology 38, 2737-2745, doi:10.1016/j.psyneuen.2013.07.002 (2013).\u003c/li\u003e\n\u003cli\u003eKotwal, A. A. et al. The epidemiology of social isolation and loneliness among older adults during the last years of life. J Am Geriatr Soc 69, 3081-3091, doi:10.1111/jgs.17366 (2021).\u003c/li\u003e\n\u003cli\u003eShankar, A., McMunn, A., Demakakos, P., Hamer, M. \u0026amp; Steptoe, A. Social isolation and loneliness: Prospective associations with functional status in older adults. Health Psychol 36, 179-187, doi:10.1037/hea0000437 (2017).\u003c/li\u003e\n\u003cli\u003ePrell, T., Sch\u0026ouml;nenberg, A. \u0026amp; Heimrich, K. G. The impact of loneliness on quality of life in people with Parkinson's disease: results from the Survey of Health, Ageing and Retirement in Europe. Front Med (Lausanne) 10, 1183289, doi:10.3389/fmed.2023.1183289 (2023).\u003c/li\u003e\n\u003cli\u003eCudjoe, T. K. M. et al. The Epidemiology of Social Isolation: National Health and Aging Trends Study. J Gerontol B Psychol Sci Soc Sci 75, 107-113, doi:10.1093/geronb/gby037 (2020).\u003c/li\u003e\n\u003cli\u003eVancampfort, D. et al. Physical activity and loneliness among adults aged 50 years or older in six low- and middle-income countries. Int J Geriatr Psychiatry 34, 1855-1864, doi:10.1002/gps.5202 (2019).\u003c/li\u003e\n\u003cli\u003eZhang, J. et al. Loneliness and Health Service Utilization among the Rural Elderly in Shandong, China: A Cross-Sectional Study. Int J Environ Res Public Health 15, doi:10.3390/ijerph15071468 (2018).\u003c/li\u003e\n\u003cli\u003eMcDaniels, B. \u0026amp; Subramanian, I. Social isolation, loneliness and mental health sequelae of the Covid-19 pandemic in Parkinson's disease. Int Rev Neurobiol 165, 197-227, doi:10.1016/bs.irn.2022.03.003 (2022).\u003c/li\u003e\n\u003cli\u003eCybulski, M., Cybulski, L., Krajewska-Kulak, E. \u0026amp; Cwalina, U. Illness acceptance, pain perception and expectations for physicians of the elderly in Poland. BMC Geriatr 17, 46, doi:10.1186/s12877-017-0441-4 (2017).\u003c/li\u003e\n\u003cli\u003evan Riel, P., Zuidema, R. M., Vogel, C. \u0026amp; Rongen-van Dartel, S. A. A. Patient Self-Management and Tracking: A European Experience. Rheum Dis Clin North Am 45, 187-195, doi:10.1016/j.rdc.2019.01.008 (2019).\u003c/li\u003e\n\u003cli\u003eTadaka, E. et al. Development of a community's self-efficacy scale for preventing social isolation among community-dwelling older people (Mimamori Scale). BMC Public Health 16, 1198, doi:10.1186/s12889-016-3857-4 (2016).\u003c/li\u003e\n\u003cli\u003eGu, Z., Li, M., Liu, L., Ban, Y. \u0026amp; Wu, H. The moderating effect of self-efficacy between social constraints, social isolation, family environment, and depressive symptoms among breast cancer patients in China: a cross-sectional study. Support Care Cancer 31, 594, doi:10.1007/s00520-023-08063-0 (2023).\u003c/li\u003e\n\u003cli\u003eZhang, X., Li, X., Luo, W., Zhao, H. \u0026amp; Liu, Y. Validation of the Chinese Version Community's Self-Efficacy Scale in Community-Dwelling Older Adults. Patient Prefer Adherence 16, 1061-1070, doi:10.2147/ppa.S359459 (2022).\u003c/li\u003e\n\u003cli\u003eBandura, A. Social Foundations of Thought \u0026amp; Action: A Social Cognitive Theory. The Academy of Management Review 12, 169 (1987).\u003c/li\u003e\n\u003cli\u003eBandura, A. Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes 50, 248-287, doi:https://doi.org/10.1016/0749-5978(91)90022-L (1991).\u003c/li\u003e\n\u003cli\u003eTougas, M. E., Hayden, J. A., McGrath, P. J., Huguet, A. \u0026amp; Rozario, S. A Systematic Review Exploring the Social Cognitive Theory of Self-Regulation as a Framework for Chronic Health Condition Interventions. PLoS One 10, e0134977, doi:10.1371/journal.pone.0134977 (2015).\u003c/li\u003e\n\u003cli\u003ePrenger, M. T. M., Madray, R., Van Hedger, K., Anello, M. \u0026amp; MacDonald, P. A. Social Symptoms of Parkinson's Disease. Parkinsons Dis 2020, 8846544, doi:10.1155/2020/8846544 (2020).\u003c/li\u003e\n\u003cli\u003eWang, W. W. et al. Status quo of social isolation in patients with Parkinson\u0026prime;s disease. Chinese General Practice Nursing 21, 1046-1051 (2023).\u003c/li\u003e\n\u003cli\u003eChen, Y. P. \u0026amp; Shang, H. F. Introduction of clinical diagnostic criteria for Parkinson's disease in China (2016). Chinese Journal of Practical Internal Medicine 37, 124-126, doi:10.19538/j.nk2017020110 (2017).\u003c/li\u003e\n\u003cli\u003eMartinez-Martin, P. Instruments for holistic assessment of Parkinson's disease. J Neural Transm (Vienna) 120, 559-564, doi:10.1007/s00702-013-1005-1 (2013).\u003c/li\u003e\n\u003cli\u003eFaul, F., Erdfelder, E., Buchner, A. \u0026amp; Lang, A. G. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41, 1149-1160, doi:10.3758/brm.41.4.1149 (2009).\u003c/li\u003e\n\u003cli\u003eLubben, J. et al. Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations. Gerontologist 46, 503-513, doi:10.1093/geront/46.4.503 (2006).\u003c/li\u003e\n\u003cli\u003eChang, Q., Sha, F., Chan, C. H. \u0026amp; Yip, P. S. F. Validation of an abbreviated version of the Lubben Social Network Scale (\"LSNS-6\") and its associations with suicidality among older adults in China. PLoS One 13, e0201612, doi:10.1371/journal.pone.0201612 (2018).\u003c/li\u003e\n\u003cli\u003eRussell, D. W. UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure. J Pers Assess 66, 20-40, doi:10.1207/s15327752jpa6601_2 (1996).\u003c/li\u003e\n\u003cli\u003eLin, C. Y. et al. Psychometric Evaluation of Three Versions of the UCLA Loneliness Scale (Full, Eight-Item, and Three-Item Versions) among Sexual Minority Men in Taiwan. Int J Environ Res Public Health 19, doi:10.3390/ijerph19138095 (2022).\u003c/li\u003e\n\u003cli\u003eDengFeng, W. The reliability and validity of Russell Loneliness Scale. Chinese Journal of Clinical Psychology, 23-25 (1995).\u003c/li\u003e\n\u003cli\u003eTadaka, E. et al. Development of a community's self-efficacy scale for preventing social isolation among community-dwelling older people (Mimamori Scale). BMC Public Health 16, 1198, doi:10.1186/s12889-016-3857-4 (2016).\u003c/li\u003e\n\u003cli\u003eJin, J. Z., H. Reliability and validity of the Chinese version of Community's Self-efficacy Scale in communitydwelling older people. Chinese General Practice 20(29), 3665-3668 (2017).\u003c/li\u003e\n\u003cli\u003eFelton, B. J., Revenson, T. A. \u0026amp; Hinrichsen, G. A. Stress and coping in the explanation of psychological adjustment among chronically ill adults. Soc Sci Med 18, 889-898, doi:10.1016/0277-9536(84)90158-8 (1984).\u003c/li\u003e\n\u003cli\u003eWang, W., Cui, H., Zhang, W., Xu, X. \u0026amp; Dong, H. Reliability and Validity of the Chinese Version of the Scale for Assessing the Stigma of Mental Illness in Nursing. Front Psychiatry 12, 754774, doi:10.3389/fpsyt.2021.754774 (2021).\u003c/li\u003e\n\u003cli\u003eBlazer, D., Lustig, T. \u0026amp; Kearney, M. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. TR news: Transportation research (2021).\u003c/li\u003e\n\u003cli\u003eRisbridger, S. et al. Social Participation's Association with Falls and Frailty in Malaysia: A Cross-Sectional Study. J Frailty Aging 11, 199-205, doi:10.14283/jfa.2021.31 (2022).\u003c/li\u003e\n\u003cli\u003eLiu, Y., Dijst, M., Faber, J., Geertman, S. \u0026amp; Cui, C. Healthy urban living: Residential environment and health of older adults in Shanghai. Health Place 47, 80-89, doi:10.1016/j.healthplace.2017.07.007 (2017).\u003c/li\u003e\n\u003cli\u003ePolański, J., Misiąg, W. \u0026amp; Chabowski, M. Impact of Loneliness on Functioning in Lung Cancer Patients. Int J Environ Res Public Health 19, doi:10.3390/ijerph192315793 (2022).\u003c/li\u003e\n\u003cli\u003eBandura, A. Self-efficacy and health. Behaviour Research \u0026amp; Therapy 23, 437-451 (1985).\u003c/li\u003e\n\u003cli\u003eSchwarzer, R. \u0026amp; Jerusalem, M. Measures in health psychology: a users portfolio. (1995).\u003c/li\u003e\n\u003cli\u003eSoleimani, M. A., Negarandeh, R., Bastani, F. \u0026amp; Greysen, R. Disrupted social connectedness in people with Parkinson's disease. Br J Community Nurs 19, 136-141, doi:10.12968/bjcn.2014.19.3.136 (2014).\u003c/li\u003e\n\u003cli\u003eWickramaratne, P. J. et al. Social connectedness as a determinant of mental health: A scoping review. PLoS One 17, e0275004, doi:10.1371/journal.pone.0275004 (2022).\u003c/li\u003e\n\u003cli\u003eGiebel, C. et al. Enabling middle-aged and older adults accessing community services to reduce social isolation: Community Connectors. Health Soc Care Community 30, e461-e468, doi:10.1111/hsc.13228 (2022).\u003c/li\u003e\n\u003cli\u003eThangavel, G., Memedi, M. \u0026amp; Hedstr\u0026ouml;m, K. Customized Information and Communication Technology for Reducing Social Isolation and Loneliness Among Older Adults: Scoping Review. JMIR Ment Health 9, e34221, doi:10.2196/34221 (2022).\u003c/li\u003e\n\u003cli\u003ePhang, J. K. et al. Digital Intergenerational Program to Reduce Loneliness and Social Isolation Among Older Adults: Realist Review. JMIR Aging 6, e39848, doi:10.2196/39848 (2023).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Demographic characteristics of elderly patients with PD (N = 142)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"561\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 378px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)/Frequency (percentage)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 378px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e69.30\u0026plusmn;5.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e79（55.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e63（44.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003ePlace of residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eCountryside\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e58（40.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eCity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e84（59.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eEducational level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e101（71.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eSenior high school or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e39（28.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eSingle (single/divorced/widowed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e27（19）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eMarried/cohabiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e115（80.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eLiving Arrangement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eLiving alone/Nursing Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e13（9.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eLive with family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e129（90.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eMonthly income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u0026lt;3000 yuan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e70（49.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u0026ge;3000 yuan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e72（50.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eNumber of living children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u0026le;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e4（2.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u0026ge;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e138（97.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eSocial\u0026nbsp;media\u0026nbsp;use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e60（42.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e82（57.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 163px;\"\u003e\n \u003cp\u003eSocial participation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e64（45）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e78（54.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" style=\"width: 163px;\"\u003e\n \u003cp\u003eClinical stage of PD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e9 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e62 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e31 (21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e20 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e7 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e6 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e4 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003e3 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Mean scores and correlation coefficients of study variables (N = 142)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"561\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eMean\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1. Social isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e13.29\u0026plusmn;5.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e2. Loneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e43.33\u0026plusmn;9.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-0.677**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e3. Illness acceptance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e23.56\u0026plusmn;6.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.387**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-0.536**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4. Community self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e11.03\u0026plusmn;6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.621**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-0.654**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.471**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: *P\u003cem\u003e＜\u003c/em\u003e0.01，**P\u003cem\u003e＜\u003c/em\u003e0.001\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Multiple mediation effects of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in elderly patients with Parkinson\u0026rsquo;s disease (N = 142)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"561\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePathway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 88px;\"\u003e\n \u003cp\u003eEffect value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e95% Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003eFrequency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eDirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eX\u0026rarr;Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e-0.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.988\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e59.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eIndirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eX\u0026rarr;M1\u0026rarr;Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e-0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e13.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eX\u0026rarr;M2\u0026rarr;Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e-0.271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e22.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eX\u0026rarr;M1\u0026rarr;M2\u0026rarr;Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e-0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eTotal indirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e-0.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.689\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e40.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e-1.234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-1.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-1.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: X, social isolation; Y, loneliness; Mediator 1 (M1), illness acceptance; Mediator 2 (M2), community self-efficacy; 95% CI, 95% confidence interval\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Parkinson’s Disease (PD), Social isolation, Loneliness, Illness acceptance, Community self-efficacy, Mediator","lastPublishedDoi":"10.21203/rs.3.rs-5645836/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5645836/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e In this study, we investigated the status quo of illness acceptance, community self-efficacy, and social isolation in elderly patients with Parkinson’s disease (PD). We explored the effects of illness acceptance and community self-efficacy on the relationship between social isolation and loneliness in patients with PD based on the self-regulation theory model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe selected elderly patients with PD from the outpatient department of two Grade iii-A hospitals in Guangdong Province through convenience sampling. We collected data using a general information questionnaire. We used the Lubben Social Network Scale, UCLA Loneliness Scale, Community’s Self-Efficacy Scale, and Acceptance of Illness Scale. Data were analyzed using descriptive statistics, Pearson’s correlation coefficient, and bootstrap sampling to test the multiple mediation model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e We recruited 142 elderly patients with PD. Their mean age was 69.30 years (standard deviation = 5.34, range from 60 to 89 years). Approximately 55.6% (n = 79) were male. The mean scores for community self-efficacy, social network, and illness acceptance were 11.03 ± 6.21, 13.29 ± 5.4, and 23.56 ± 6.871, respectively. Loneliness was negatively associated with illness acceptance (r = -0.536, p \u0026lt; 0.001) and community self-efficacy (r = -0.654, p \u0026lt; 0.001). The results of multiple mediation analysis indicated that illness acceptance (effect: -0.172, 95% confidence interval (CI) [-0.297, 0.067]) and community self-efficacy (effect: -0.271, 95% CI [-0.446, -0.115]) individually and collectively influenced the relationship between social isolation and loneliness (effect: -0.055, 95% CI [-0.105, -0.017]). The direct effect and mediating effect values accounted for 59.6% and 40.4% of the total effect value, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIllness acceptance and community self-efficacy mediate the association between social isolation and loneliness. Interventions that help facilitate mutuality, illness acceptance, and community self-efficacy may help minimize the level of loneliness in patients with PD.\u003c/p\u003e","manuscriptTitle":"Illness acceptance and community self-efficacy mediate the relationship between social isolation and loneliness among elderly people with Parkinson's Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 09:29:15","doi":"10.21203/rs.3.rs-5645836/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-06T05:54:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-05T11:47:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-30T09:25:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197586928642452937347388881016127954153","date":"2025-04-27T16:46:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305332906454817755584453160545833750075","date":"2025-04-27T07:47:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-25T10:08:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-24T13:34:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-09T03:12:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"70ea43de-deb8-41d6-b8d2-a333f3752565","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":47744459,"name":"Health sciences/Neurology/Neurological disorders/Parkinsons disease"},{"id":47744460,"name":"Biological sciences/Psychology/Human behaviour"}],"tags":[],"updatedAt":"2025-07-07T16:11:32+00:00","versionOfRecord":{"articleIdentity":"rs-5645836","link":"https://doi.org/10.1038/s41598-025-07890-x","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-07-01 15:57:55","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-05-06 09:29:15","video":"","vorDoi":"10.1038/s41598-025-07890-x","vorDoiUrl":"https://doi.org/10.1038/s41598-025-07890-x","workflowStages":[]},"version":"v1","identity":"rs-5645836","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5645836","identity":"rs-5645836","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}