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The relationship of self-esteem and mental health among older adults with the mediating role of loneliness

BMC Geriatrics volume 25, Article number: 233 (2025) Cite this article

Abstract

Background

Mental health (MH) is one of the most important resources of human life, particularly during older adulthood. Self-esteem (SE) is related to mental health (MH), and loneliness may serve as a mediator in the relationship between SE and MH. However, the role of loneliness in this relationship is not well understood. This study aims to evaluate the association between SE and MH in older adults, specifically focusing on the mediating role of loneliness in this relationship.

Methods

This cross-sectional correlational study was conducted in 2023 using structural equation modeling. Participants were 357 older adults selected through quota sampling from comprehensive urban healthcare centers in Urmia, Iran. Data collection instruments included a demographic questionnaire, the University of California Los Angeles Loneliness Scale, the General Health Questionnaire, and the Rosenberg Self-Esteem Scale. Data were analyzed using the SPSS (v. 23.0) and the SmartPLS (v. 3.0) software.

Results

SE had a significantly weak positive association with MH (ß = 0.095; P < 0.001) and a significantly weak negative association with loneliness (ß = –0.288; P < 0.001). Additionally, loneliness had a significantly strong negative association with MH (ß = –0.632; P < 0.001). The study confirmed that loneliness acts as a mediator between SE and MH (β = –0.688, 95% CI: 0.1427, 1.2958; P < 0.001).

Conclusion

Health assessments and loneliness screening programs are essential for older adults to identify symptoms early and prevent mental health issues. Governments should strengthen social connections among older adults through services and education. Urban healthcare centers can reduce loneliness by organizing community activities, encouraging pet ownership, and promoting participation in senior centers.

Clinical trial number

Not applicable.

Peer Review reports

Introduction

Rapid aging is one of the greatest population changes in the twenty-first century [1, 2]. Aging is a critical stage in human life and a natural, physiological, and time-dependent process which influences individuals above sixty years [2]. In recent years, improved health conditions and life expectancy and reduced mortality rate have increased the number of older adults [3] and estimations show that the population of adults above sixty years will double till 2050 and will reach from 12% in 2015 to 22% in 2050 [2]. Aging has also started in Iran, and the statistics of the National Council of the Elderly show that the population of older adults in Iran will reach from 9.3% in 2016 to more than 20% in 2050 [4, 5]. Aging is associated with different consequences, including the increased risk of non-communicable diseases such as diabetes mellitus, cancer, cardiovascular disease [6], changes in social roles and family relationships, retirement, and loneliness due to children’s marriage and spousal death [7].

Age-related changes can negatively affect older adults’ mental health (MH) [8]. MH refers to the ability to perform social, mental, and physical roles and includes the ability to have coordinated relationships with others, change and correct the personal and social environments, and overcome conflicts and desires in an appropriate, logical, and fair manner [9]. Age-related changes and problems such as reduced self-confidence, reduced mobility, loss of friends and relatives, reduced autonomy, and affliction by chronic diseases put older adults at risk for MH disorders [10]. Statistics show that almost 14% of older adults above sixty years live with at least one MH disorder [11].

Self-esteem (SE) is a factor with potential effect on MH [12, 13]. By definition, SE is the subjective evaluation of self-worth and includes self-acceptance and positive self-attitude [14]. SE is an indicator of MH, maturity, and adaptation [15, 16]. When unpleasant feelings damage MH, great SE encourages adaptive behaviors and helps individuals take protective measures to reduce the immediate risk and promote their MH [17, 18]. Therefore, reduced SE may be harmful to MH [19]. SE has relationship with receiving and giving social support as well [13].

Loneliness is another influential factor on MH [13, 20, 21]. Loneliness is the lack of social relationships, not simply living alone, is an indicator of social well-being [21,22,23], and is felt when social interactions are quantitatively and qualitatively reduced [24]. Loneliness is an unpleasant, difficult, and painful personal experience [25]. It is a predisposing factor for physical disorders, immune dysfunction, altered nutrition, cardiovascular disease, sleep disorders [26], and most psychosocial problems such as depression, suicide, disappointment, social isolation, boredom, anxiety, distance from friends, self-care disorders, and SE disorders, and can be associated with serious physical and mental health problems [25, 27,28,29]. Loneliness and SE have close relationships with MH [30]. Evidence shows the high prevalence of loneliness [22]. For example, a study reported that the prevalence of moderate to severe loneliness among older adults was 36% [26].

A study showed that loneliness and SE mediated the relationship between intergenerational emotional support and MH [13]. Another study confirmed that loneliness and SE mediated the relationship of intergenerational emotional support and subjective well-being among elder migrants in China [31]. Moreover, a study reported the mediating role of loneliness in the relationship between well-being and relationship quality [32]. To our knowledge, none of the previous studies examined the relationship between SE and MH among older adults, specifically regarding the impact of loneliness. Thus, this study was conducted to assess the association between SE and MH in older adults, specifically focusing on how loneliness impacts this relationship in order to narrow this gap.

Conceptual framework & development of hypotheses

SE is a part of personality and a regulator of self-worth among all humans, particularly older adults [15, 33]. It is an indicator of maturity and adaptation with significant positive relationship with MH [16, 34]. Low SE has significant relationship with low self-worth, low life satisfaction, loneliness, depression, and anxiety [34]. Therefore, we hypothesized that “SE has significant relationship with MH”.

SE is a subjective criterion for interpersonal relationships among older adults. Older adults with greater SE have lower sense of loneliness. Different studies reported the significant relationship of SE and loneliness [21, 31, 35]. Low SE negatively affects older adults’ cognition and behavior, prevents social relationship development, and increases sense of loneliness, while high SE increases self-worth and social relationships and reduces loneliness [21, 33]. Accordingly, the second hypothesis of the study was, “SE has significant relationship with loneliness”.

Loneliness is associated with negative physical and mental health outcomes, particularly among older adults [36]. It can lead to senses of disappointment, distress, uselessness, and depression [37]. Studies show that loneliness has strong relationship with MH [13, 25, 27, 38] so that it can be considered as an independent health-related factor [27]. Thus, the third hypothesis of the study was “Loneliness has significant relationship with MH”.

There is growing evidence that loneliness is associated with a wide range of health-related outcomes in older adulthood such as altered daily functioning, reduced physical activity, lower MH, and lower physical health [39]. According to the sociometric theory, individuals who feel interpersonal isolation or seclusion have lower SE [40]. A study also reported that severer loneliness was associated with lower SE and poorer health [41]. Another study found that poor intergenerational emotional support can increase the sense of loneliness, reduce SE, and thereby, alter subjective well-being [36]. Therefore, we formulated the fourth study hypothesis as follows, “Loneliness has a positive/negative mediating role in the relationship of SE and MH.” Fig. 1 illustrates the conceptual framework.

Fig. 1
figure 1

Conceptual framework

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Material and methods

Design and participants

This cross-sectional correlational study was conducted in 2023 using structural equation modeling. Study setting was comprehensive urban healthcare centers in Urmia, Iran, and study population consisted of older adults covered by these centers. Participants were 357 older adults selected through quota sampling. Inclusion criteria were agreement for participation, orientation to time, place, and things, no history of hospitalization in psychiatric care settings, no history of significant losses during the past six months, no affliction by serious hearing or visual problems, mental disorders, psychosis, physical problems influencing MH (such as hypothyroidism), and cognitive problems, and receiving no treatment which could influence mental abilities, memory, and thinking. Sample size was determined based on the sample-to-item ratio. The data collection instruments of the study had 58 items and hence, with a sample-to-item ratio of 5:1 [42], at least 290 participants were determined to be needed for the study. Finally, sample size was increased to 357 considering a potential attrition rate of 20%.

Data collection instruments

Instruments were a demographic questionnaire, the University of California Los Angeles Loneliness Scale, the General Health Questionnaire, and the Rosenberg Self-Esteem Scale. The items of the demographic questionnaire were on age, gender, educational level, marital status, employment status, financial status, leisure-time activities, affliction by chronic diseases, number of children, and living arrangement.

The university of California Los Angeles loneliness scale

Developed by Russel et al. in 1980, this scale has twenty items, namely ten positively-worded and ten negatively-worded items. Scoring is performed on a four-point scale as follows: 1: “Often”; 2: “Sometimes”; 3: “Rarely”; and 4: “Never”. Ten items (i.e., items 1, 4–6, 9, 10, 15, 16, 19, and 20) are reversely scored. The possible total score of the scale is 20–80 and is interpreted as follows: scores 20–34: no or mild loneliness; scores 35–48: moderate loneliness; and scores more than 48: severe loneliness [23]. Russel et al. reported that the test–retest correlation coefficient of the scale was 0.89 [43]. The Cronbach’s alpha of the Persian version of the scale was also 0.89 [44].

The general health questionnaire

Developed by Goldberg and Hillier in 1979, this questionnaire has 28 items in four seven-item subscales, namely somatic symptoms (items 1–7), anxiety and insomnia (items 8–14), social dysfunction (items 15–21), and depression (items 22–28). Items are scored on a four-point Likert scale as follows: 3: “Much less than usual”; 2: “Less than usual”; 1: “Same as usual”; and 0: “Better than usual”. The possible total score of the questionnaire is 0–84 with a cutoff score of 23 which higher scores show poorer MH. A total score of more than 23 and subscale scores more than 6 show MH problems. This questionnaire has acceptable validity and reliability. Studies show that the coefficients of the correlations of its total score with its subscale scores were 0.72–0.87 and its Cronbach’s alpha was 0.90 [45, 46].

The rosenberg self-esteem scale

This ten-item scale has five positively worded items (items 1–5) and five negatively worded items (items 6–10). Items 1–5 are scored as follows: 1: “Completely disagree”; 2: “Disagree”; 3: “Agree”; and 4: “Completely agree”. Items 6–10 are reversely scored. The total score of the scale can range from 10 to 40 which higher scores show greater SE. Two studies showed that the Cronbach’s alpha of the scale was 0.78 [44] and 0.85 [47].

Ten faculty members assessed and confirmed the validity of these three instruments. Moreover, we conducted a pilot study to assess their reliability. Its results showed that the Cronbach’s alpha values of these three instruments were 0.83, 0.87, and 0.85, respectively.

Procedure

After getting ethical approval from a local university, participants were selected through quota sampling. Initially, we divided Urmia City into three hypothetical regions according to its residents' sociocultural and health characteristics. Three comprehensive urban health service centers with the largest populations of older adults were selected from each region using a simple random method with a random number table. Participants were then selected through quota sampling based on the proportion of older adults in each center. The necessary sample size of the study (i.e., 357) was divided by the total number of older adults covered by urban healthcare centers in Urmia city (i.e., 26,279). The result (i.e., 0.01358) was multiplied by the total number of older adults in each region to determine the number of participants from that region. Accordingly, 123 older adults from the first region (Saheeh Healthcare Center), 120 older adults from the second region (Velayat Healthcare Center), and 114 older adults from the third region (Razi Healthcare Center) were selected based on the inclusion criteria (Table 1) (Fig. 2). Participants with adequate literacy skills personally completed the study instruments, while we completed the instruments for participants with limited or no literacy skills through the interview method. Participants' completed instruments were checked for blank or ambiguous responses and returned to them to complete them. Finally, 357 participants completed 357 sets of instruments. Data collection lasted three months.

Table 1 The number of older adults participating in the study by healthcare center
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Fig. 2
figure 2

Study sample flow diagram

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Data analysis

IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA) and SmartPLS version 3.0 were used for data analysis. Numerical variables were described using mean and standard deviation (Mean ± SD) and categorical variables were described using absolute and relative frequencies (N (%)). The Fornell-Larcker method was used to assess the validity of the structural equation model and the internal consistency method (with Cronbach’s alpha) was used to assess its reliability. The conceptual model was also assessed through path (ß) and t coefficients. Bootstrapping macro was also employed to test the mediating role of the variables. The level of significance was set at less than 0.05.

Results

The mean of participants’ age was 68.65 ± 5.35 years. Most participants were married (77.9%) and retired (59.7%), lived with their spouses (51.3%), had two children or more (90.2%), and spent their leisure time a rest (53.5%). Almost half of the participants had an income which sufficed their expenses (47.6%) (Table 2).

Table 2 Participants’ demographic characteristics
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The conceptual model

The Cronbach’s alpha values of all variables were more than 0.7, confirming the acceptable reliability of the model (Table 3). The Fornell-Larcker criterion also confirmed the acceptable validity of the model (Table 4).

Table 3 Internal consistency reliability coefficients (Cronbach's alpha)
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Table 4 Fornell and Larker method (discriminant validity)
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A path coefficient indicates the direct relationship between one construct and another. Path coefficients greater than 0.6 suggest a strong predictive association of a latent variable with the dependent variable. Coefficients between 0.3 and 0.6 indicate a moderate association, while coefficients below 0.3 represent a weak association. Structural equation modeling revealed a significant weak positive relationship between SE and MH (ß = 0.095; P < 0.001). Additionally, a significantly weak negative relationship existed between SE and loneliness (ß = –0.288; P < 0.001), A significantly strong negative relationship was found between loneliness and MH (ß = –0.632; P < 0.001) (Fig. 3). The t statistic for the SE-MH and the SE-loneliness relationships was more than 1.96, denoting that these relationships had significant effects on each other at a confidence level of at least 0.95 (P < 0.001) (Fig. 3) (Table 5). As this study had a mediating variable, bootstrapping macro was used to assess the indirect relationships among variables. Results showed that the lower and the upper limits of the indirect relationship of SE and ME through the mediating role of loneliness did not include zero, denoting that this indirect path, i.e., the mediating effect of loneliness, was significant (P < 0.001) (Table 6).

Fig. 3
figure 3

The direct model (N = 357)

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Table 5 The results of structural equation modeling for the general conceptual model
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Table 6 Indirect Effects and Bootstrapping Results with mediation analysis
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Model goodness of fit

The root mean square error of approximation (RMSEA) was 0.093, which is less than 0.1 and hence, confirms the good model fit. Other model fit indices were shown in Table 7.

Table 7 Model goodness of fit indices
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Reverse model

The reverse model also showed a significant weak positive relationship between MH and SE (ß = 0.145; P < 0.001). It also revealed a significant strong negative relationship between MH and loneliness (ß = –0.658; P < 0.001). Also, a significant weak negative relationship was found between loneliness and SE (ß = –0.193; P < 0.001). The t statistic for the MH-loneliness and the loneliness-SE relationships was more than 1.96. Therefore, these relationships had significant effects on each other at a confidence level of at least 0.95. However, the MH-SE relationship in the reverse model was insignificant because its t statistic was less than 1.96 (Fig. 4).

Fig. 4
figure 4

The indirect model (N = 357)

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The bootstrapping test result showed that the lower and the upper limits of the indirect MH-SE relationship through the path of loneliness included zero, meaning that this indirect path was insignificant and hence, loneliness had no mediating role in the MH-SE relationship (Table 8).

Table 8 Indirect Effects and Bootstrapping Results with mediation analysis for reverse model
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Discussion

This study assessed the relationship between SE and MH among older adults, focusing on the mediating role of loneliness. Findings indicated a weak positive relationship between SE and their MH, denoting that older adult with higher SE had better MH. This confirms the first hypothesis of the study. In agreement with this finding, a study showed that SE had significant relationship with MH among older adults [36]. Another study found that adolescents’ SE had significant relationship with their physical and mental health [48]. SE is a mental state which is closely related to social support and MH [30]. Several studies reported that SE has a strong positive effect on MH and can moderately predict it [16, 36, 49,50,51]. People with greater SE are more optimistic in difficult situations [52] and have greater resilience [53]. Resilience in turn has strong relationship with MH [54]. SE is essential for successful relationships, effective occupational performance, and good health status [55].

Our findings also revealed a weak negative relationship between SE and loneliness, which supports the study's second hypothesis. Similarly, a study reported that SE and loneliness had significant inverse relationship, so that individuals with greater SE had lower sense of loneliness [21]. According to the social gauge theory, SE can reflect the emotional status of individuals in their interpersonal relationships. In other words, SE shows whether individuals have good interpersonal relationships and hence, it reflects emotional experiences [56]. Some studies also explain the SE-loneliness relationship from a cognitive view [31]. In this view, individuals with low SE show more internal symptoms and have inefficient self-schema in their memories. Low SE among older adults also leads to negative cognitions about interpersonal relationships and thereby, can lead to loneliness [21]. A study found that acceptance and social support had significant positive correlations with SE among older adults. In other words, older adult with greater acceptance and social support had greater SE than lonely older adult who had weak social support [13]. An explanation for the relationship of social support and SE is that compared with alone individuals with weak social support, individuals with strong social support have more positive self-perception because they use social resources to fulfill their needs [13].

We also found the strong negative relationship between loneliness and MH. Similarly, several previous studies indicated that loneliness can lead to depression and reduce social functioning among older adults [57,58,59]. A study indicated that loneliness causes MH problems (such as depression and anxiety) and increases the risks of suicidal thoughts, smoking, frequent medical visits, and intake of psychotropic agents [27]. Therefore, loneliness can be considered as an independent predictor of health [25, 27]. Encountering with different problems during older adulthood reduces older adult’s motivation and causes them to lose their sense of entity and purpose in life. Meanwhile, loneliness reduces their ability to establish and maintain effective interpersonal relationships. Lack of such relationships in turn negatively affects their MH [60]. On the other hand, social support can improve their emotional experience and physical conditions and thereby, improves their MH [13].

In this study, loneliness was a mediator in the relationship between self-esteem and mental health among older adults. This finding indicates that a greater sense of loneliness reduces SE in older adults, making them more vulnerable to mental health disorders. In agreement with our findings, a study on elderly migrants in China concluded that reduced emotional support and increased sense of loneliness undermine SE and thereby, alter MH [36]. The sociometric theory suggests that SE is an inner psychological system which measures the sense of seclusion by others and holds that greater sense of loneliness reduces SE [61]. Loneliness is associated with discomfort, low SE, and poor health [41].

One limitation of the study was the use of cross-sectional data, in which all variables were measured at the same time. It is generally inappropriate to conduct mediation analysis using cross-sectional data. Conducting longitudinal studies and utilizing their data to compare results can improve the interpretation of this study's findings. The social desirability and non-response biases related to self-reported questionnaires was another limitation. To minimize these biases, participants were encouraged to complete the questionnaires at their own pace and in a calm, anonymous environment. Researchers were present to address any questions and concerns. Cultural differences significantly affect feelings of loneliness and mental health, influencing how individuals perceive and express these emotions. Thus, measuring these variables in Iranian unique culture was another limitation of the study. Qualitative studies would be valuable and are recommended in this context.

Conclusion

This study concludes that older adults' SE positively relates to their MH and negatively relates to their loneliness. Furthermore, loneliness has a significant negative relationship with MH. Additionally, loneliness serves as a mediator in the relationship between SE and MH.

Health assessment and loneliness screening programs are recommended for older adults. Early detection of the symptoms of loneliness among older adults can help prevent its associated MH problems. Public health interventions to reduce older adults' loneliness and protect their MH are essential. Psychoeducational interventions to enhance social and interpersonal skills may help reduce loneliness and improve SE and MH in older adults.

Governments should use social services to enhance older adults' family and social relationships, promoting their mental health. Family education should also be encouraged to bolster support for them. Urban healthcare centers can utilize the study findings to create strategies to reduce loneliness in older adults. These strategies include organizing community and social activities, promoting pet ownership, encouraging hobbies, and facilitating participation in senior centers.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

MH:

Mental health

SE:

Self-esteem

UCLA:

The University of California Los Angeles

GHQ:

The General Health Questionnaire

RSES:

The Rosenberg Self-Esteem Scale

SPSS:

Statistical Package for the Social Sciences

RMSEA:

The Root Mean Square Error of Approximation

NNFI:

Non-Normed Fit Index

PNFI:

Parsimony Normed Fit Index

IFI:

Incremental Fit Index

GFI:

Goodness of Fit Index

NFI:

Normed Fit Index

CFI:

Comparative Fit Index

RFI:

Relative Fit Index

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Acknowledgements

This study is derived from a nursing project (record No. 9989). The authors thank the Research Deputy of the School of Nursing and Midwifery at Urmia University of Medical Sciences for its support. They also want to appreciate the participants' sincere cooperation.

Funding

This research received a grant (No. 053) from Urmia University of Medical Sciences to support the research in terms of study design, collection, analysis, interpretation of data, and the article's preparation.

Author information

Authors and Affiliations

  1. Patient Safety Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Urmia, Iran

    Mehri Alaviani

  2. School of Nursing & Midwifery, Campus Nazlu, 11 KM Road Seru, Urmia, Urmia, West Azerbaijan, 575611-5111, Iran

    Mehri Alaviani, Naser Parizad & Masumeh Hemmati Maslakpak

  3. Maternal and Childhood Obesity Research Center, Urmia University of Medical Sciences, Urmia, Iran

    Naser Parizad & Masumeh Hemmati Maslakpak

  4. Department of Biostatistics, Urmia University of Medical Sciences, Urmia, Iran

    Vahid Alinejad

  5. School of Medicine, Urmia University of Medical Sciences, Campus Nazlu, 11 KM Road Seru, Urmia, West Azerbaijan, Iran

    Vahid Alinejad

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  1. Mehri Alaviani
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  2. Naser Parizad
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Contributions

"M.A. and N.P. and M.H. designed the study and M.A., V.A., N.P., and M.H collected the data and MA., V.A., M.H., and N.P. prepared manuscript and MA., V.A. and N.P prepared Fig. 1–2 and MA. and V.A. prepared Tables 1–6 and V.A., MA. and N.P. analyzed and interpreted the data and MA., N.P., M.H. and V.A. revised and finalized the manuscript. All authors reviewed the manuscript."

Corresponding author

Correspondence to Vahid Alinejad.

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Ethics approval and consent to participate

This study was conducted in line with the regulations of the Declaration of Helsinki. Approval was granted by the Research Ethics Committee of Urmia University of Medical Sciences (Date: 13/05/2020/No: IR.UMSU.REC.1399.053). The purpose and procedures of the study were clearly explained to the participants. They were assured that their data would remain confidential and that participation was voluntary. All written consent forms were obtained through interviews, especially for illiterate participants. They were informed about their rights, the study's purpose, confidentiality, and the voluntary nature of their participation.

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Not applicable.

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The authors declare no competing interests.

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Alaviani, M., Parizad, N., Hemmati Maslakpak, M. et al. The relationship of self-esteem and mental health among older adults with the mediating role of loneliness. BMC Geriatr 25, 233 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-025-05810-2

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Keywords

BMC Geriatrics

ISSN: 1471-2318

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