Background
Worldwide, new digital technologies such as the Internet have changed how people connect and interact. The transition to web-enabled internet is occurring at a rapid rate, with an estimated reach of 4.9 billion individuals worldwide in 2021, up from 4.6 billion in the previous year [
1].
Several studies have claimed that Internet use can influence the health of older adults [
2,
3]. A literature review on social media use among older adults indicates that online communities are suitable for providing and receiving social support when people are confronted with difficult life situations, regardless of their geographical location or time. Further positive consequences include overcoming loneliness, relieving stress, and raising feelings of control and self-efficacy [
3]. Social media use can help individuals organize their work, increase availability, and stay connected with family and friends [
4]. Studies in China have indicated a significant positive relationship between social media use and the health of older adults [
2,
5]; the correlation was more significant for their mental health than their physical health [
2]. Data from a nationally representative sample of US Medicare beneficiaries aged 65 years and older also indicated that depressive and anxiety symptoms were negatively associated with Internet use [
6].
During the coronavirus disease 2019 (COVID-19) outbreak, Internet use also drew increasing attention for mental health care, especially among older adults who had been advised to avoid social activities. According to a scoping review conducted in European countries, the United States and Hong Kong, Internet use for communication was associated with improved mental health among older adults during the pandemic [
7].
However, Internet use is also known to have negative consequences. It may distract individuals from communicating face-to-face with other members of society [
8]. Research on the effects of Internet use on the mental health of older Chinese adults showed that Internet use had increased the incidence of depressive symptoms.
In Hong Kong, social media is a double-edged sword for mental health, and its roles varied across age groups during the COVID-19 pandemic; social media use had a significantly negative direct effect on depressive symptoms among older adults, but the effect mediated by posttraumatic stress disorder was significantly positive both among older and younger populations [
9].
Considering the increasing prevalence of Internet usage, examining whether Internet use positively or negatively impacts the mental health of older adults is imperative. In addition, because COVID-19 hinders direct connections with others, verifying the association between indirect connections via Internet use and mental health among older adults who are at a high risk of infectious diseases is important. In particular, research on older adults in low-income countries is essential because their living conditions, life situations, and Internet use will likely differ from those of the younger generation and those in high-income countries. To the best of our knowledge, no studies conducted in Myanmar explore the association between Internet use and health. However, since the military regime took control in Myanmar on February 1, 2021, there have been reports of the regime implementing restrictions on disseminating critical information. This restriction includes the imposition of increasingly severe blockades on the Internet and social media platforms [
10]. Although this study utilizes data collected before the military regime, we investigated the association between internet use and depressive symptoms among older adults in two regions of Myanmar.
Discussion
To the best of our knowledge, this is the first study to investigate whether Internet use is positively or negatively associated with depressive symptoms among older adults in a low income country, using data from urban and rural areas. Moreover, we conducted an interaction analysis between Internet use and subjective economic status. Overall, the model with adjusted potential confounding factors suggested that older adults who used the Internet were more likely to have lower GDS than those who did not. When examining the interaction effect, there were no significant interaction between Internet use and subjective economic status for GDS.
We found that Internet use among older adults in the two regions of Myanmar was still less common. Although it is thought that the rate was even lower after the two regions became military regime on February 1, 2021, the Internet use ratio of 17.5% in this study was low compared to the full data, which included people of other age groups in Myanmar (43.3% in 2021) [
23]. There are various possible reasons older adults were less likely to use the internet in this study. The popularity of Internet use is significantly affected by the level of economic development [
24]. In Myanmar, older adults are generally poor. According to the first national research on the situation of older adults in Myanmar in 2012, one-third of older adults live in homes without electricity and over half lack running water, and these situations are particularly common in rural areas [
25]. Because of the low economic status of older adults in Myanmar, the number of older adults using the Internet might be small. In addition, invisible obstacles might impede Internet adoption among older age groups. In a study in Israel, older adults often did not fully understand the specific benefits of using online health services, which led to them being less likely to use it [
26]. They often struggle with reduced reactivity, which made it harder to keep up with fast-paced technologies [
27]. According to Eurostat, 9% of adults in the EU aged 75 or over had severe visual impairments, and 18% had severe hearing limitations in [
27]. US statistics also indicated that 23% of older adults had a physical or health condition that made reading difficult or challenging [
28]. This may also be the reason for the low rate of Internet use among older adults in this study.
Consistent with the literature from middle- and high-income countries [
5,
6,
29‐
31], our study confirmed that older adults in Myanmar who used the Internet were less likely to be at higher risk of depressive symptoms, even after adjusting for some potential confounding variables, including frequency of meeting friends. Older adults in Myanmar may have used the Internet to contact family and friends to buffer isolation and reduce depressive symptoms, but it may not have reduced the frequency of meeting friends in Myanmar settings. According to a review of the impact of loneliness on the digital world using a theoretical model, the Internet was a useful tool for reducing loneliness when used as a station on the route to enhancing existing relationships and forging new social connections [
32]. However, when it was used to escape the social world, feelings of loneliness increased [
32]. In the case of older adults in Myanmar, Internet use seemed to function in the former capacity because, culturally, older adults in Myanmar typically hold high status and respect in their families, and family is essential [
33]. Moreover, the notion of family extends well beyond the nuclear family in Myanmar society [
34].
Although some studies conducted in middle- and high-income countries have identified an association between Internet use and depressive symptoms, no study conducted an interaction analysis between Internet use and subjective economic status, which provides an in-depth examination of the effect of Internet use on depressive symptoms among older adults. However, we found no significant interaction effect. It is possible to interpret that even older adults with poor subjective economic status are less prone to depressive symptoms as long as they are able to use the Internet. As there also may be a mediating effect rather than an interaction effect on depressive symptoms, we will examine which is appropriate in the future.
This study has several limitations [
13]. First, it is undeniable that the face-to-face interviews may have created a social desirability bias. This may have resulted in misreporting of depressive symptoms. Second, in this study, the measurement of depressive symptoms was based solely on the GDS score, and clinical diagnoses were not evaluated in determining depressive symptoms. Therefore, the results of this study do not necessarily apply to the diagnosis of clinical depressive symptoms. However, the GDS is a widely used and validated instrument for assessing depressive symptoms [
15‐
17]. Third, our estimates were based on a relatively small number of participants with difficult or very difficult subjective economic status among Internet users. There was a possibility that individual differences could affect the results. Fourth, Myanmar consists of seven regions and seven states, and the findings of this study cannot be generalized to Myanmar outside of Yangon and Bago. Ideally, this study should be extended to include surrounding areas in the future. Fifth, due to the cross-sectional design, it is undeniable that reverse causality may have occurred.
Acknowledgements
We would like to thank all the study participants and express our gratitude to Than Win Nyunt, from the Department of Geriatric Medicine, Yangon General Hospital, Yangon, Myanmar; Infectious Diseases Research Centre of Niigata University members, particularly Reiko Saito and Hisami Watanabe. In addition, we thank Saw Thu Nander, Yi Mynt Kyaw, and Myanmar Perfect Research team members, who were deeply involved in the project implemented to conduct the survey. We wish to express our gratitude to the Japan Gerontological Evaluation Study principal investigator, Katsunori Kondo, and core members Naoki Kondo, Jun Aida, Toshiyuki Ojima, and Masashige Saito, who provided helpful advice regarding the project; and Tomoko Manabe and Yumi Ito, who provided excellent secretarial support throughout the study.
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