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Nursing and Health Sciences (2014), 16, 381–386
Research Article
Gender differences in the relationship between physical functioning and depressive symptoms in low-income older adults living alone Eun Ju Lim, RN, PhD Red Cross College of Nursing, Chung-Ang University (CAU), Seoul, Korea
Abstract
This study examined gender differences in the relationship between physical functioning and depressive symptoms in low-income older adults living alone in Korea, and the variables influencing these symptoms. Data from a total of 317 older adults in the 2011 Korean National Survey were used. Upper limb mobility, lower limb mobility, activities of daily living, instrumental activities of daily living, and depressive symptoms were measured. Data were analyzed using multiple regression analysis. Low-income older men and women living alone experienced depressive symptoms. Regression analysis showed that lower limb mobility and age together explained 35.4% of the variance in depressive symptoms in men. Subjective health status explained 16.7% of the same in women. These findings suggest that low-income older adults living alone should be carefully monitored by public healthcare managers to improve their physical and mental health, considering gender-specific elements.
Key words
depression, depressive symptoms, Korea, older people, physical functioning.
INTRODUCTION
than those living with their families (Nahcivan & Demirezen, 2005). According to a survey of 7040 older adults living alone in Brazil (Blay et al., 2007), depressive symptoms were highly prevalent in individuals with poor self-reported physical health and low participation in daily physical activity. However, almost no study has examined the correlation between physical health status and depressive symptoms in low-income older adults living alone. Older adults tend to be classified based on age; however, physical functioning and depressive symptoms vary based on a range of sociodemographic features (Chen et al., 2005; Lee & Park, 2008; Lin & Wang, 2011; van Milligen et al., 2011) including gender (Park, 2004). To effectively estimate and satisfy the health service demands of low-income older adults living alone, it is necessary to analyze their characteristics. This study provides the basic data for establishing a community-level intervention strategy to improve and maintain the health of vulnerable older adults by assessing the relationship between physical functioning and depressive symptoms, using a representative sample of low-income older adults living alone in Korea.
Low-income older adults living alone are vulnerable because of social and economic deprivation (Kim & Choi, 2011). In Korea, 12.3% of older adults are recipients of the National Basic Livelihood Security support, which is a public assistance program for individuals in a low-income bracket: of these recipients, 51.9% live alone (Ministry for Health and Welfare Affairs, 2009). The 2012 statistical survey of older adults in Korea showed that they experienced financial problems (40.2%), health problems (39.8%), and loneliness (4.1%) (Korean National Statistical Office, 2012). Low-income older adults living alone had more physical and mental health problems compared to higherincome older adults living with others (Park & Ha, 2004). Therefore, the former require social and financial support, as they have a relatively high probability of developing depressive symptoms. In accordance with epidemiological survey results on risk factors of depressive symptoms in older adults in rural areas of China, a high prevalence of depressive symptoms was reported among low-income older adults living alone (Chen et al., 2005). In another study, older adults living alone were 3.3 times more likely to experience depressive symptoms
Literature review
Correspondence address: Eun Ju Lim, CAU Healthcare System, Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-ro Dongjak-gu, Seoul 156-756, Korea. Email: [email protected] Received 3 June 2013; revision received 27 October 2013; accepted 24 November 2013
Aging people experience a decline in physical functioning and independence due to reduced mobility resulting from biological senescence and changes in the musculoskeletal system. Physical functioning implies the physical ability to independently and safely engage in daily activities without
© 2014 Wiley Publishing Asia Pty Ltd.
doi: 10.1111/nhs.12119
382
feeling fatigued (Rikli & Jones, 2001). It is an important reflection of the health status of an older person (Lee & Park, 2008). Older adults’ self-reported subjective physical functioning is highly correlated with actual measurements of physical functioning (Lee et al., 2002). Physical functioning enables independence in old age, decreased risk of medical disorders, and sufficient energy balance for metabolism (Chodzko-Zajko et al., 2009). A reduction in physical functioning in older adults can, through an interaction with depression, lower mental and physical health (Huang et al., 2011). Depression is the most frequently-occurring mental illness among older people (van Milligen et al., 2012). It can reduce a person’s feelings of control over his or her surrounding environment, self-esteem, and ultimately, quality of life (Lee et al., 2005). Depressive symptoms are influenced by biological factors, such as age, and physical factors, including physical functioning, number of chronic diseases, and amount of medication (Blay et al., 2007). Furthermore, depressive symptoms are influenced by psychological factors, including perceived health status and financial satisfaction (Blay et al., 2007), and socioeconomic factors, such as income and marital status (Mechakra-Tahiri et al., 2010). A previous correlation analysis between depression and physical functioning in a prospective cohort study of adults from four European countries demonstrated that lower physical functioning was associated with depressive symptoms (Stegenga et al., 2012). Adults with depressive symptoms demonstrated a lower level of physical functioning than healthy adults (Brenes, 2007; van Milligen et al., 2012), which in turn increased the severity of depressive symptoms (Brenes, 2007). These previous findings support a relationship between physical functioning and depressive symptoms. This study investigated gender differences between physical functioning and depressive symptoms among low-income older adults living alone in Korea, and the variables influencing their depressive symptoms.
METHODS Design A cross-sectional descriptive survey design was used in this study.
Data collection and participants Cross-sectional survey data were obtained from the Korean Elderly Adults Survey conducted by the Korea Institute for Health and Social Affairs (KIHASA), and organized by the Ministry of Health and Welfare in 2011. Written approval was obtained from KIHASA for the use of the survey data. Original data were stratified by the seven metropolitan cities and nine provinces of Korea. The nine provinces were further divided into 18 classes by division into dongs (neighborhoods) and eups/myeons (towns/townships). The Korean Elderly Adults Survey is conducted every three years. The scope of the 2011 survey was determined by responses from a panel of households surveyed in 2008. Data © 2014 Wiley Publishing Asia Pty Ltd.
E. J. Lim
were collected through three telephone surveys and one faceto-face interview. Those who died or were admitted to hospitals or long-term care facilities from April 2011 to April 2012 were excluded. Thus, out of a total of 10,674 communitydwelling, older adults, 2094 lived alone, and of these, 317 belonged to low-income households. These adults formed the final sample. Individuals classified as “low income” (≤ $US479.50/month) qualified for, and received, a basic livelihood allowance from the government, and fulfilled its criteria for absolute poverty status. Those who met all of the inclusion criteria (i.e. lived alone, 65 years of age or older, belonged to a low-income household) numbered 317 and were the eventual participants for the study.
Measurement Physical functioning Physical functioning items were divided into mobility and self-care. Mobility was further divided into upper limb mobility (ULM) and lower limb mobility (LLM). Self-care comprised activities of daily living (ADL) and instrumental activities of daily living (IADL). Mobility. Mobility was assessed using the Physical Functioning Scale (Lee et al., 2002), which consists of five questions (two for ULM and three for LLM). ULM was determined by measuring the flexibility and muscular power of shoulder joints. LLM was determined by assessing endurance, balance, and walking ability, as well as flexibility of lower limbs. The items were scored from zero (unable to do without help) to three (can do with no difficulty). The total score was divided by the number of questions and by three. The ULM score was then multiplied by 40, and the lower limb score was multiplied by 60, to make the total possible scores on ULM and LLM questions equal 100 points. Higher scores indicated better functioning. This measure has been validated in a community-dwelling older sample (Lee et al., 2005; Lee & Park, 2008). Cronbach’s α was 0.87 in the study that developed this scale, and 0.88 in the present study. Cronbach’s α coefficients for ULM and LLM were 0.70 and 0.85, respectively. Self-care. ADL and IADL were assessed using the tools developed by Katz et al. (1963) and Lawton and Brody (1969), respectively. In this study, the tool translated by Won et al. (2002), which is widely used and accepted in Korea due to its validity and reliability, was modified and applied. The ADL measure comprised seven questions, rated using a Likert scale (1 = complete independence; 3 = complete dependence). Total scores ranged from seven to 21 points. Higher scores indicated greater impairment in ADL. Cronbach’s α was 0.94 at the time the scale was developed, and 0.81 in this study. To assess IADL, 10 questions were modified, such that they could be answered on a Likert scale (1 = complete independence; 3 = complete dependence). Total scores ranged from 10 to 30. Higher scores indicated greater impairment in IADL. Cronbach’s α was 0.94 at the time of scale development, and 0.93 in this study.
Physical functioning and depression
383
Table 1. Sociodemographic characteristics (n = 317)
Variable Age (years) 65–74 ≥ 75 Mean ± standard deviation Subjective health status Good Moderate Poor No. chronic diseases
Nursing and Health Sciences (2014), 16, 381–386
Research Article
Gender differences in the relationship between physical functioning and depressive symptoms in low-income older adults living alone Eun Ju Lim, RN, PhD Red Cross College of Nursing, Chung-Ang University (CAU), Seoul, Korea
Abstract
This study examined gender differences in the relationship between physical functioning and depressive symptoms in low-income older adults living alone in Korea, and the variables influencing these symptoms. Data from a total of 317 older adults in the 2011 Korean National Survey were used. Upper limb mobility, lower limb mobility, activities of daily living, instrumental activities of daily living, and depressive symptoms were measured. Data were analyzed using multiple regression analysis. Low-income older men and women living alone experienced depressive symptoms. Regression analysis showed that lower limb mobility and age together explained 35.4% of the variance in depressive symptoms in men. Subjective health status explained 16.7% of the same in women. These findings suggest that low-income older adults living alone should be carefully monitored by public healthcare managers to improve their physical and mental health, considering gender-specific elements.
Key words
depression, depressive symptoms, Korea, older people, physical functioning.
INTRODUCTION
than those living with their families (Nahcivan & Demirezen, 2005). According to a survey of 7040 older adults living alone in Brazil (Blay et al., 2007), depressive symptoms were highly prevalent in individuals with poor self-reported physical health and low participation in daily physical activity. However, almost no study has examined the correlation between physical health status and depressive symptoms in low-income older adults living alone. Older adults tend to be classified based on age; however, physical functioning and depressive symptoms vary based on a range of sociodemographic features (Chen et al., 2005; Lee & Park, 2008; Lin & Wang, 2011; van Milligen et al., 2011) including gender (Park, 2004). To effectively estimate and satisfy the health service demands of low-income older adults living alone, it is necessary to analyze their characteristics. This study provides the basic data for establishing a community-level intervention strategy to improve and maintain the health of vulnerable older adults by assessing the relationship between physical functioning and depressive symptoms, using a representative sample of low-income older adults living alone in Korea.
Low-income older adults living alone are vulnerable because of social and economic deprivation (Kim & Choi, 2011). In Korea, 12.3% of older adults are recipients of the National Basic Livelihood Security support, which is a public assistance program for individuals in a low-income bracket: of these recipients, 51.9% live alone (Ministry for Health and Welfare Affairs, 2009). The 2012 statistical survey of older adults in Korea showed that they experienced financial problems (40.2%), health problems (39.8%), and loneliness (4.1%) (Korean National Statistical Office, 2012). Low-income older adults living alone had more physical and mental health problems compared to higherincome older adults living with others (Park & Ha, 2004). Therefore, the former require social and financial support, as they have a relatively high probability of developing depressive symptoms. In accordance with epidemiological survey results on risk factors of depressive symptoms in older adults in rural areas of China, a high prevalence of depressive symptoms was reported among low-income older adults living alone (Chen et al., 2005). In another study, older adults living alone were 3.3 times more likely to experience depressive symptoms
Literature review
Correspondence address: Eun Ju Lim, CAU Healthcare System, Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-ro Dongjak-gu, Seoul 156-756, Korea. Email: [email protected] Received 3 June 2013; revision received 27 October 2013; accepted 24 November 2013
Aging people experience a decline in physical functioning and independence due to reduced mobility resulting from biological senescence and changes in the musculoskeletal system. Physical functioning implies the physical ability to independently and safely engage in daily activities without
© 2014 Wiley Publishing Asia Pty Ltd.
doi: 10.1111/nhs.12119
382
feeling fatigued (Rikli & Jones, 2001). It is an important reflection of the health status of an older person (Lee & Park, 2008). Older adults’ self-reported subjective physical functioning is highly correlated with actual measurements of physical functioning (Lee et al., 2002). Physical functioning enables independence in old age, decreased risk of medical disorders, and sufficient energy balance for metabolism (Chodzko-Zajko et al., 2009). A reduction in physical functioning in older adults can, through an interaction with depression, lower mental and physical health (Huang et al., 2011). Depression is the most frequently-occurring mental illness among older people (van Milligen et al., 2012). It can reduce a person’s feelings of control over his or her surrounding environment, self-esteem, and ultimately, quality of life (Lee et al., 2005). Depressive symptoms are influenced by biological factors, such as age, and physical factors, including physical functioning, number of chronic diseases, and amount of medication (Blay et al., 2007). Furthermore, depressive symptoms are influenced by psychological factors, including perceived health status and financial satisfaction (Blay et al., 2007), and socioeconomic factors, such as income and marital status (Mechakra-Tahiri et al., 2010). A previous correlation analysis between depression and physical functioning in a prospective cohort study of adults from four European countries demonstrated that lower physical functioning was associated with depressive symptoms (Stegenga et al., 2012). Adults with depressive symptoms demonstrated a lower level of physical functioning than healthy adults (Brenes, 2007; van Milligen et al., 2012), which in turn increased the severity of depressive symptoms (Brenes, 2007). These previous findings support a relationship between physical functioning and depressive symptoms. This study investigated gender differences between physical functioning and depressive symptoms among low-income older adults living alone in Korea, and the variables influencing their depressive symptoms.
METHODS Design A cross-sectional descriptive survey design was used in this study.
Data collection and participants Cross-sectional survey data were obtained from the Korean Elderly Adults Survey conducted by the Korea Institute for Health and Social Affairs (KIHASA), and organized by the Ministry of Health and Welfare in 2011. Written approval was obtained from KIHASA for the use of the survey data. Original data were stratified by the seven metropolitan cities and nine provinces of Korea. The nine provinces were further divided into 18 classes by division into dongs (neighborhoods) and eups/myeons (towns/townships). The Korean Elderly Adults Survey is conducted every three years. The scope of the 2011 survey was determined by responses from a panel of households surveyed in 2008. Data © 2014 Wiley Publishing Asia Pty Ltd.
E. J. Lim
were collected through three telephone surveys and one faceto-face interview. Those who died or were admitted to hospitals or long-term care facilities from April 2011 to April 2012 were excluded. Thus, out of a total of 10,674 communitydwelling, older adults, 2094 lived alone, and of these, 317 belonged to low-income households. These adults formed the final sample. Individuals classified as “low income” (≤ $US479.50/month) qualified for, and received, a basic livelihood allowance from the government, and fulfilled its criteria for absolute poverty status. Those who met all of the inclusion criteria (i.e. lived alone, 65 years of age or older, belonged to a low-income household) numbered 317 and were the eventual participants for the study.
Measurement Physical functioning Physical functioning items were divided into mobility and self-care. Mobility was further divided into upper limb mobility (ULM) and lower limb mobility (LLM). Self-care comprised activities of daily living (ADL) and instrumental activities of daily living (IADL). Mobility. Mobility was assessed using the Physical Functioning Scale (Lee et al., 2002), which consists of five questions (two for ULM and three for LLM). ULM was determined by measuring the flexibility and muscular power of shoulder joints. LLM was determined by assessing endurance, balance, and walking ability, as well as flexibility of lower limbs. The items were scored from zero (unable to do without help) to three (can do with no difficulty). The total score was divided by the number of questions and by three. The ULM score was then multiplied by 40, and the lower limb score was multiplied by 60, to make the total possible scores on ULM and LLM questions equal 100 points. Higher scores indicated better functioning. This measure has been validated in a community-dwelling older sample (Lee et al., 2005; Lee & Park, 2008). Cronbach’s α was 0.87 in the study that developed this scale, and 0.88 in the present study. Cronbach’s α coefficients for ULM and LLM were 0.70 and 0.85, respectively. Self-care. ADL and IADL were assessed using the tools developed by Katz et al. (1963) and Lawton and Brody (1969), respectively. In this study, the tool translated by Won et al. (2002), which is widely used and accepted in Korea due to its validity and reliability, was modified and applied. The ADL measure comprised seven questions, rated using a Likert scale (1 = complete independence; 3 = complete dependence). Total scores ranged from seven to 21 points. Higher scores indicated greater impairment in ADL. Cronbach’s α was 0.94 at the time the scale was developed, and 0.81 in this study. To assess IADL, 10 questions were modified, such that they could be answered on a Likert scale (1 = complete independence; 3 = complete dependence). Total scores ranged from 10 to 30. Higher scores indicated greater impairment in IADL. Cronbach’s α was 0.94 at the time of scale development, and 0.93 in this study.
Physical functioning and depression
383
Table 1. Sociodemographic characteristics (n = 317)
Variable Age (years) 65–74 ≥ 75 Mean ± standard deviation Subjective health status Good Moderate Poor No. chronic diseases
