Archives of Gerontology and Geriatrics 59 (2014) 415–421
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Quality of life of older adults in Turkey Naile Bilgili a,*, Fatma Arpacı b a b
Gazi University, Health Science Faculty, Department of Nursing, Besevler, Ankara, Turkey Gazi University, Vocational Educational Faculty, Department of Family Economics Education, Besevler, Ankara, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 January 2014 Received in revised form 1 July 2014 Accepted 3 July 2014 Available online 12 July 2014
The purpose of this study was to examine the factors affecting the quality of life of the elderly people in Turkey. Three-hundred community-dwelling older adults (Mage = 68.35, SD = 5.80 years) participated in this study. The quality of life was examined through World Health Organization Quality of Life Questionnaire-Older Adults Module Turkish Version (WHOQOL-OLD Turkish). Analysis of Variances (ANOVA) showed significant age differences in sensory abilities, social participation, and intimacy sub-scale scores. Post hoc Scheffe Test results indicated that elderly people aged 75 years and over differed from other age groups; although their scores in social participation and intimacy were lower; they had higher scores in sensory abilities than those aged 60–65 and 66–74 years. There were significant differences between the educational levels of these elderly people in sensory abilities, autonomy, past-present-and-future activities, social participation, and death-and-dying subscales. The autonomy, past-present-and-future activities, social participation, and death-and-dying scores of those with high school education were higher than that of those with secondary school or less education except in sensory abilities scores. There were differences found between the variable of with whom the elderly people lived and of QOL sub-scales of the elderly people’s sensory abilities, past-today-and-future activities, death-and-dying, social participation, and intimacy. In addition, the total average score of the QOL sub-scales with the sufficiency of income of the elderly people were interconnected. In conclusion, the findings revealed that gender, age, education, marital status, childbearing, social insurance, health status, living arrangement and income variables are the determinant to improving the quality of life of elderly people. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Elderly Quality of life WHOQOL-OLD Turkish older adults
1. Introduction The rapid increase in the elderly people population is a known fact. A reduction in childhood diseases, lower maternal mortality, and women’s achievements in the control of their own fertility are considered to be responsible for this increase (World Health Organization Centre for Health Development, 2012a). Although the number of people over the age of 60 was 600 million in the year 2000, it is expected to be 1.2 billion by 2025 and 2.0 billion by 2050 (World Health Organization Centre for Health Development, 2012b). The age group of 65-and-over today, accounts for about 7.3% of the Turkey’s population (Turkish Statistical Institute, 2011). However, it is foreseen to reach 10% by 2023 (Koc, Eryurt, Adalı, & Seckiner, 2010).
* Corresponding author. Tel.: +90 05327984600; fax: +90 312 216 26 36. E-mail addresses: [email protected], [email protected] (N. Bilgili). http://dx.doi.org/10.1016/j.archger.2014.07.005 0167-4943/ß 2014 Elsevier Ireland Ltd. All rights reserved.
The increase in life expectancy at birth is another indicator of the level of the states’ welfare. On the other hand, this increase brings comes with problems such as the uncontrollable growing numbers of severe health issues, declining functional abilities, economic difficulties and changes in social status, and loss of spouse and friends (Flood & Phillips, 2007). Services provided to the elderly people were aimed to enable such individuals to physically act as independently as possible, to have high cognitive and intellectual levels, to sustain active lives, and to be satisfied with their lives (to maintain a good quality of life). However, a longer lifespan does not always mean quality survival for elderly people; due to increased longevity and life expectancy, quality of life (QOL) has been considered an important issue, which has attracted the researchers’ attention (Hall, Opio, Dodd, & Higginson, 2011). The World Health Organization Quality of Life Group defines QOL as follows: ‘‘Quality of life is the individuals’ perception of their position in life in the context of the culture and the value systems in which they live in relation to their goals, expectations,
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standards and concerns. It is a broad concept affected in a complex way in which the persons’ physical health, psychological state, level of independence and social relationships are salient features of their environment’’ (World Health Organization Quality of Life [WHOQOL] Group, 1995). In general, QOL is a subjective and complex concept; its most important component is the healthrelated QOL (Tuzun & Eker, 2003). How an individual physically feels about himself/herself and the extent to which the individual is capable of fulfilling his/her daily work and efforts are examples of health-related qualities of life. In addition, health-related QOL, in the psychological sense, it is being able to feel and express emotions such as anger, resentment, fear, and happiness (Peel, Bartlett, & Marshall, 2007). On the other hand, the concept of health-related QOL is often used to assess the impact of illness on QOL (Ware, 2003). Health, functional status and social support, especially family and friends’ support, and social relations are among the important factors affecting the QOL of elderly people (Pinquart & Sorensen, 2000; Sparks, Zehr & Painter, 2004). Furthermore, sufficient economic resources, personal houses, and suitable physical environment are other factors affecting QOL (Knesebeck, Wahrendorf, Hyde, & Siegrist, 2007; Low and Molzahn, 2007). Dragomirecka et al. (2008) showed that the most important factor affecting the QOL of elderly people was depressive emotional status. In another study reported that the factors affecting QOL were health status, economic status and the meaning of life (Low & Molzahn, 2007). Robinson and Molzahn (2007) stated that the most important factors, which explain the difference in the QOL of elderly people, are personal relations, health status, and sexual activity. QOL requires a critical consideration in both national and international healthcare policies and decisions in each country. Therefore, it is important to determine and analyse factors influencing QOL in this study population. Relatively, few researches had examined the QOL of older adults across cultures and countries. Majority of the recent QOL studies of older adults have focused on the instrument of validation and/or of cultural adaptation (Paskulin & Molzahn, 2007). A number of studies have used the WHO Quality of Life Assessment for Older Adults (WHOQOL-OLD) assessments with community-dwelling Turkish older people. It is important to understand the determinants of QOL of various subgroups of older adults to support the evidencebased policy guidelines, the program development and the policy decisions in the Turkish health and social systems. Therefore, the purpose of this research was to determine the QOL and the factors affecting QOL of a group of elderly people living in their own homes in Ankara, Turkey. 2. Methods 2.1. Study design The current study is a cross-sectional study of the QOL of older adults and factors influencing life quality. A survey approach was used for data collection. 2.2. Sample and data collection The study was conducted among 300 community-dwelling elderly people aged 60 years and over. A door-to-door household survey of elderly adults from a large metropolitan area of central Turkey was utilized for data collection. Fifty out of the one hundred and twenty district streets were randomly selected; with 10 elderly people living on each street by random selection, the side and section of each street were sought. The selected participants were interviewed. Forty-eight refused to participate; 22 elderly
adults were unable to respond to the interview questions, while a response rate of 76.6% were collated. The study inclusion criteria were as follows: individuals performing activities of daily living independently, capable of communication and social activity, capable of reading and writing in Turkish and volunteering to participate in the study. One of the criteria for participating in the survey was being at or over 60 years of age. The reason for choosing the age of 60 is that most of the surveys and studies have been applied on the elderly at or over the age of 60 (Chachamovich, Fleck, Trentini, & Power, 2008; Halvorsrud, Kalfoss, & Diseth, 2008; Heydari, Khani, & Shahhosseini, 2012; Low and Molzahn, 2007; Lucas-Carrasco, Laidlaw, & Power, 2011; Paskulin & Molzahn, 2007; Top, Eris, & Kabalcıoglu, 2012). 2.3. Measurements The data were collected using the personal information form, which consist of descriptive information about the older adult and WHOQOL-OLD Turkish used to evaluate their QOL. The personal information form was designed as a document consisting of 18 questions about the older adult’s socio-demographical background (such as age, gender, health status, education level, marital status and income). They were asked whether they had illness or had not assessed their health status; those that declared a history of illness were regarded as having illnesses. In the case of economic status, they were asked whether they had an income or not; if they had, then they were asked whether this income was sufficient for them to meet their needs. In the end, the economic difficulty status of the elderly people was classified as follows: None/Little, Moderate, Much/Extreme. To determine the QOL of the elderly people, the WHOQOL-OLD Turkish version was used. The WHOQOL-OLD Scale of Life Quality, developed by the World Health Organization, a new instrument recently developed and tested in 22 countries. This instrument is an add-on module for the WHOQOL measures to be used for older adults (Power et al., 2005). Among the 22 study centers, the Turkish (Izmir) Centre simultaneously developed the Turkish version of the scale. The WHOQOL-OLD is the first generic QOL measure for the elderly developed in Turkey. A Turkish validity and reliability study of the WHOQOL-OLD Scale of Life Quality was conducted by Eser et al. (2010). The WHOQOL-OLD Module consists of 24 items and a 5-point Likert-type scale assigned to six facets: sensory abilities (items 1, 2, 10, and 20); autonomy (items 3, 4, 5, and 11); past, present, and future activities (items 12, 13, 15, and 19); social participation (items 14, 16, 17, and 18); death and dying (items 6, 7, 8, and 9); and intimacy (items 21, 22, 23, and 24). Possible facet scores range from 4 to 20. A total score can also be calculated by adding each of the individual item values. Higher scores indicate higher QOL. In the case of Sensory Abilities questions assessed the effects of visual, auditory, sensory, and taste and appetite changes on the quality of life were assessed. Autonomy questions examined independence, respect, general control over life, ability to make free decisions, and the effects of these factors on QOL. In the case of Past-Present-and-Future Activities, successes achieved in the past and satisfaction with these successes, recollections of the past, and feelings and opinions about the future were analyzed. In the case of Social Participation, opinions about the use of time and the state of taking part in crucial activities were examined. In the case of Death-and-Dying, opinions about the acceptance of death, its inevitability, and its meaning were questioned. Finally, in the case of Intimacy, relationship with other people and social support were examined. Eser et al. (2010) reported that Alpha values for the facets and the overall scale (range: 0.68–0.88) (>0.70), and the item total
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correlations and the overall scale success were satisfactory. As a measure of the construct validity of the scale, confirmatory factor analysis showed very high comparative fit index (CFI) values (range: 0.936–0.999) for each of the domains (Eser et al., 2010). The Chronbach’s alpha values calculated for reliability were 0.48 for sensory faculties, 0.78 for autonomy, 0.76 for past-present-andfuture activities, 0.81 for social participation, 0.88 for death-anddying, and 0.88 for intimacy. The alpha value of the reliability coefficient for the overall scale structure was found to be 0.69.
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An examination of the state of the elderly people dependency in daily activities shows that 29.3% were partially dependent on doing housework, whereas 12.7% were partially dependent on activities outside the home (e.g., arranging personal travel and shopping); 14.3% were partially capable of dispensing their medication, while 7.3% were completely not capable of dispensing their medication. 3.2. Quality of life and factors affecting quality of life of the elderly people
2.4. Ethical consideration Ethical approval was obtained from the ethical committee by Gazi University Institutional Review Board committee overseeing the project. Participation was voluntary. All respondents were informed about the purpose of the study, and their oral consent was obtained before initiating the interview. 2.5. Data analysis ANOVA was conducted to detect age, education, living arrangement and financial difficulties differences on quality of life. Scheffe test was used for post hoc comparisons. In addition, gender, marital status, childbearing, social security, and history of the present illness differences were analysed using t test. The correlation between sub-scale scores of the WHOQOL-OLD Turkish version and age, education, living arrangement, financial difficulties was analyzed by Pearson Product Moment Correlation coefficient. 3. Results 3.1. Demographic characteristics of study participants The participants included were approximately equal numbers of men and women. The mean age of the participants was 68.35 5.80 years, and 67.3% of the elderly people were graduates of a primary school or had lower education. Nearly half of them (49.3%) were married. Among these participants, 74.3% had an illness. The majority of the elderly people (92.0%) had children, and 29.4% were living alone. In addition, 90% of the elderly people had their own income, and 42.3% perceived their income as being moderate (Table 1).
Table 2 shows the mean values of the sub-scales scores of the WHOQOL-OLD. The mean values of the sub-scales scores of the WHOQOL-OLD were as follows: sensory abilities – 10.78 2.63; autonomy – 13.73 2.80; past, present, and future activities – 13.25 2.92; social participation – 12.61 3.13; death and dying – 14.74 2.92; and intimacy – 11.36 4.22. Death-and-dying subscales had the highest mean; while sensory abilities had the lowest sub-scales score, followed by intimacy. Table 3 compares the demographic characteristics of the elderly people with the main areas of WHOQOL-OLD. Elderly men had higher average scores in the sub-scales of sensory abilities, autonomy, past-present-and-future activities, social participation, and death-and-dying, whereas elderly women had higher average scores in the intimacy sub-scales and total average score. An examination of the effect of gender variables on sub-scales shows the difference in the sub-scales of autonomy (t = 4.67; p < 0.01), past-present-and-future activities (t = 2.29; p < 0.05), and intimacy (t = 3.96; p < 0.01) to be statistically significant. When the relationship between marital status and the QOL of the elderly people was examined, married elderly people had higher scores in the sub-scales of autonomy, past-present-andfuture activities, social participation, and death-and-dying, whereas unmarried elderly people had higher scores in the sub-scales of sensory abilities and intimacy. A significant differences between marital status and mean scores of the sub-scales of past-presentand-future activities (t = 2.36; p < 0.05), social participation (t = 2.57; p < 0.05), and death-and-dying (t = 2.00; p < 0.05) were found. The total score shows that married elderly people had higher scores, and there were significant differences found between the groups (t = 2.03; p < 0.05). In the case of the differences between elderly people having a child and quality of life, it was seen that the elderly people having
Table 1 Demographic characteristics of study participants (N = 300). n Gender Female Male Age (year) 60–65 66–74 75 Education Primary school or less (5 years or less) Secondary school (8 years) High school (11 years) Marital status Married Single + widow/widower Duration of marriage (year) 40 41–50 51 Present Presence of chronic illness Yes No
%
145 155
48.3 51.7
94 172 34
31.3 57.4 11.3
202 65 33
67.3 21.7 11.0
148 152
49.3 50.7
63 59 26
42.6 39.8 17.6
223 77
74.3 25.7
Having a child Yes No Number of Children (n = 276) 3 4 5 Living arrangement Spouse Spouse and children Alone Income Yes No Financial difficulties (n = 270) None/little Moderate Much/extreme Social security Yes No
n
%
276 24
92.0 8.0
142 72 57
53.3 26.0 20.7
112 100 88
37.3 33.3 29.4
270 30
90.0 10.0
144 114 12
53.3 42.3 4.4
288 12
96.0 4.0
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Table 2 Distribution of the mean scores on the WHOQOL-OLD Turkish (N = 300). Sub-scales
Minimum
Maximum
Mean
Median
Standard deviation
Sensory abilities Autonomy Past-present-and-future activities Social participation Death-and-dying Intimacy Total scores
5.00 4.00 4.00 4.00 5.00 4.00 50.00
18.00 20.00 20.00 20.00 20.00 20.00 103.00
10.78 13.73 13.25 12.61 14.74 11.36 75.79
11.00 14.00 13.00 12.00 16.00 11.00 75.79
2.63 2.80 2.92 3.13 2.92 4.22 8.52
WHOQOL-OLD Turkish: Turkish version of the World Health Organization Quality of Life Instrument-Older Adults Module.
a child had higher scores in the sub-scales of sensory abilities and death-and-dying; while elderly people without a child had higher scores in other sub-scales. Considering the QOL and the state of having social security, the elderly people with social security had higher scores in the sub-scales of autonomy (t = 3.39; p < 0.01), past-today-and-future activities (t = 3.06; p < 0.01), social participation (t = 1.98; p < 0.05), and death-and-dying (t = 4.23; p < 0.01). The difference between the groups was statistically significant. The total score showed that the elderly people with social security had higher scores. The difference between the groups was significant (t = 3.54; p < 0.01). The elderly people with diseases had higher scores in the subscales of sensory abilities, and there was a significant difference between the groups (t = 4.46; p < 0.01). The elderly people without disease had higher scores in the sub-scales of autonomy (t = 2.96; p < 0.01), past-today-and-future activities (t = 3.51; p < 0.01), and social participation (t = 7.26; p < 0.01). The difference between the groups was also statistically significant. A statistically significant difference was found between the average total score of quality of life and the state of having a disease (t = 4.20; p < 0.01). ANOVA showed age significant differences only in sensory abilities (F = 25.14; p < 0.01), social participation (F = 12.49; p < 0.01), and intimacy sub-scales (F = 6.68; p < 0.01). Post hoc Scheffe Test results indicated that elderly people aged 75 years and over differed from the other age groups in these sub-scales. Their scores of the social participation and intimacy sub-scales were
lower, but had higher scores in sensory abilities than those aged 60–65 and 66–74 years. ANOVA yielded significant differences between education levels of elderly people in sensory abilities (F = 18.84; p < 0.01), autonomy (F = 15.51; p < 0.01), past-present-and-future activities (F = 13.58; p < 0.01), social participation (F = 32.89; p < 0.01), and death-and-dying (F = 3.13; p < 0.05) sub-scales. Scheffe post hoc comparisons showed that the high school graduate elderly people were significantly different from the other groups. The autonomy, past-present-and-future activities, social participation, and deathand-dying scores of those with high school education were higher than those with secondary school or less education except sensory abilities sub-scale scores. A differences was found between the variable of with whom the elderly people lived and of QOL sub-scales of the elderly of sensory abilities (F = 18.84; p < 0.01), past-today-and-future activities (F = 3.95; p < 0.05), death-and-dying (F = 6.67; p < 0.01), social participation (F = 3.31; p < 0.05), and intimacy (F = 4.74; p < 0.01). There was a difference between the income levels of the elderly people and the sub-scales of autonomy (F = 16.41; p < 0.01), pasttoday-and-future activities (F = 16.21; p < 0.01), social participation (F = 11.94; p < 0.01), death-and-dying (F = 10.93; p < 0.01), and intimacy (F = 5.79; p < 0.01). The total average score of the QOL sub-scales of the elderly people was connected with the sufficiency of their income (F = 11.77; p < 0.01). Scheffe post hoc comparisons showed that much/extreme financial difficulties of
Table 3 The comparison of demographic characteristics of the elderly with the sub-scales of WHOQOL-OLD Turkish (N = 300). Sensory abilities
Autonomy
Past-present-and-future activities
Social participation
Death-and-dying
Intimacy
Total scores
M SD
M SD
M SD
M SD
M SD
M SD
M SD
Gender Female Male t
10.71 2.58 10.84 2.68 0.420
12.97 2.96 14.44 2.45** 4.673
12.85 2.94 13.62 2.87* 2.294
12.13 3.03 12.20 3.24 0.190
14.47 2.72 15.00 3.09 1.553
12.33 4.10** 10.44 4.14 3.969
75.24 8.39 76.30 8.64 1.078
Marital status Married Single + widow/widower t
10.49 2.73 11.06 2.50 1.890
13.87 2.77 13.59 2.84 0.862
13.65 2.87* 12.86 2.93 2.364
12.63 3.15* 11.71 3.06 2.576
15.08 2.78* 14.41 3.03 2.001
11.29 4.05 11.42 4.39 0.280
76.80 8.70* 74.81 825 2.030
Having a child Yes No t
10.86 2.60 9.79 2.81 1.931
13.65 2.79 14.66 2.80 1.697
13.19 2.89 13.87 3.31 1.084
12.04 3.11 13.58 3.16* 2.323
14.68 2.87 15.50 3.50 1.315
11.30 4.16 12.04 4.91 0.823
75.47 8.44 79.54 8.48* 2.259
Social security Yes No t
10.74 2.66 11.75 1.71 1.299
13.84 2.75** 11.08 2.84 3.399
13.35 2.87** 10.75 3.16 3.064
12.23 3.10* 10.41 3.60 1.982
14.88 2.78** 11.33 4.16 4.236
11.30 4.25 12.66 3.39 1.093
76.14 8.29** 67.41 9.95 3.542
13.45 2.59 14.54 3.24** 2.969
12.91 2.63 14.24 3.48** 3.517
11.45 2.72 14.23 3.34** 7.262
14.56 2.69 15.27 3.48 1.835
11.33 4.22 11.44 4.27 0.196
74.61 7.63** 79.22 9.98 4.200
Variable
History of the present illness Yes 11.17 2.51** No 9.66 2.66 t 4.466 * **
p < 0.05. p < 0.01.
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Table 4 Analysis of variance of sub-scales results of WHOQOL-OLD Turkish with age, education, living arrangements, economic status (N = 300). Sensory abilities
Autonomy
Past-present-andfuture activities
Social participation
Death-and-dying
Intimacy
Total scores
M SD
M SD
M SD
M SD
M SD
M SD
M SD
Age (yr) 60–65 66–74 75 p F
9.56 2.48 11.03 2.45 12.88 2.23 0.000** 25.147
13.64 3.17 13.85 2.50 13.38 3.21 0.628 0.467
13.39 3.34 13.16 2.73 13.29 2.71 0.834 0.182
12.86 3.37 12.24 2.72 9.85 3.40 0.000** 12.495
14.39 3.32 14.94 2.72 14.73 2.73 0.346 1.066
12.48 4.41 11.07 3.96 9.67 4.33 0.001** 6.682
76.09 9.72 76.08 8.32 73.50 6.57 0.249 1.395
Education Primary school or less (5 years or less) Secondary school (8 years) High school (11 years) p F
11.37 2.41 9.89 2.64 8.93 2.65 0.000** 18.843
13.19 2.70 14.40 2.74 15.75 2.41 0.000** 15.514
12.74 2.78 13.75 2.59 15.36 3.34 0.000** 13.582
11.31 2.88 13.24 2.46 15.24 3.28 0.000** 32.895
14.58 277 14.64 3.09 15.93 3.33 0.045* 3.130
11.20 4.21 12.27 3.93 10.48 4.69 0.094 2.388
74.11 8.00 78.01 8.31 81.72 8.59 0.000** 15.489
Living arrangement Spouse Spouse and children Alone p F
10.41 2.75 11.59 2.53 10.32 2.39 0.001** 7.362
14.10 2.62 13.63 2.62 13.38 3.18 0.177 1.740
13.83 2.63 13.06 2.77 12.72 3.33 0.020* 3.956
12.64 3.01 11.55 3.09 12.26 3.24 0.038* 3.312
15.39 2.43 14.77 2.82 13.89 3.39 0.001** 6.670
10.92 3.94 10.83 4.32 12.51 4.28 0.009** 4.748
77.10 7.94 75.08 8.40 74.94 9.23 0.120 2.133
Financial difficulties None/little Moderate Much/extreme p F
10.36 2.47 11.15 2.66 11.00 3.69 0.053 2.962
14.47 2.56 13.35 2.49 10.25 5.15 0.000** 16.415
14.04 2.76 12.78 2.60 9.91 4.01 0.000** 16.219
12.98 3.04 11.50 2.77 9.83 3.78 0.000** 11.949
15.52 2.58 14.00 3.03 13.41 3.08 0.000** 10.930
10.68 4.01 11.45 4.21 14.75 4.37 0.003** 5.792
77.86 7.52 73.96 8.13 69.50 10.7 0.000** 11.775
Variable
* **
p < 0.05. p < 0.01.
the elderly people were significantly different from the other income groups. The autonomy, past-present-and-future activities, social participation, and death-and-dying scores of those with much/extreme financial difficulties were lower than those with the other income groups except intimacy sub-scale scores (Table 4). Pearson correlation analysis showed that there was significant relationship between age and sensory abilities (r = 0.37; p < 0.01). There were weak and negative relationships between age and social participation and intimacy scores (r = 0.24, 0.20; p < 0.01, respectively). In addition, there were weak relationships between education [r(300) = 0.307; p < 0.01], financial difficulties [r(300) = 0.284; p < 0.01] and the total average score of the QOL sub-scales. 4. Discussion The mean scale score of the elderly people who participated in the research was 75.79. The average score was similar to those in the studies conducted by Ozyurt et al. (2007) in Manisa, Top and Dikmetas (2012), Top et al. (2012), and Ercan (2010) in nursing homes in Ankara with the same scale. The average score obtained from the reliability and validity study of the Eser et al. (2010) WHOQOL-OLD quality of life scale was lower (56.02). In the present study, the death-and-dying sub-scale had the highest average score. ‘‘Intimacy’’ in the studies of Ozyurt et al. (2007) and Top and Dikmetas (2012) and ‘‘sensory abilities’’ in the studies of Ercan (2010) and Top and Dikmetas (2012) were the sub-scales that had the highest averages. When the average score of gender of the elderly people was compared with their average QOL score, men had higher scores in all sub-scales except intimacy. The QOL of men was higher than that of women in most studies using the same scale or different QOL scales (Arslantas, Metintas, Unsal, & Kalyoncu, 2006; Calıstır, Dereli, Ayan, & Canturk, 2006; Drageset et al., 2008; Hsu, 2007; Kaya et al., 2008; Kirchengast & Haslinger, 2008; Ozyurt et al.,
2007). Men have better QOL, which likely stems from the fact that they are more educated, have more income, are more active in decision-making than women, and their interaction with the external environment is much more than that of women. However, some studies have shown that there is no statistical difference in the points of life quality of elderly men and women (Bowling, Banister, Sutton, Evans, & Windsor, 2002; Eser et al., 2010; Power et al., 2005; Top et al., 2012; Top & Dikmetas, 2012; Wiggins, Higgs, Hyde, & Blane, 2004). Married elderly people had higher mean scores in the subscales of autonomy, past-today-and-future activities, social participation, and death-and-dying, whereas unmarried elderly had higher mean scores in the sub-scales of sensory abilities and intimacy. It can be seen from the total score that married elderly had higher QOL than unmarried elderly (p < 0.05). Life quality of widowed elderly people was lower, which was similar to the study of Ozyurt et al. (2007). Alexandre, Cordeiro, and Ramos (2009) found that marital status affected the quality of life in a study conducted with WHOQOL-BREF to determine the life quality of the elderly people in Brazil. Lee, Kom, and Leey (2005) and Heydari et al. (2012) found that married participants had a higher average score of QOL than the singles, the divorced, the widows, and the widowers. The relationship between marital status and QOL could not be determined in similar studies conducted by Ercan (2010) in Turkey and Tseng and Wang (2001) in Taiwan to examine the life quality of the elderly people living in nursing homes. Social support and variables pertaining to social networks (family-children and friends) are also important factors related to the QOL of older adults. The elderly people having a child were found to have higher mean scores than those without a child in the sub-scales of sensory abilities and death-and-dying. The elderly people without a child had higher mean scores in other sub-scales. Living with family and having children could increase the life quality of an elderly individual by providing social and psychological support. In a meta-analysis, Pinquart and Sorensen (2000)
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examined 286 studies and found a positive relation among the social status of the elderly people, social relations, competence and well-being. Similarly, Sparks et al. (2004) found that social interaction is the only factor that explains life satisfaction when health status and social status are stable. Chappell (2003) also found that social support and health contributed significantly to the variance of subjective QOL. The present study showed that the elderly people with social security had higher mean scores in the sub-scales of autonomy (p < 0.01), the past-today-and-future activities (p < 0.01), social participation (p < 0.05), and death-and-dying (p < 0.01); in addition, they had higher average scores in total. It was also found in the study conducted by Calıstır et al., 2006, using the 14 SF-36 scale of life quality, that the elderly people with social security had a higher quality of life; however, could not find any statistically significant relationship between quality of life and the social security variance, although the elderly people without social security had a lower average life quality scores in the studies conducted by Ercan (2010) using WOQOL-OLD and by Luleci, Hey, and Subası (2008) using WOQOL-BREF. It might be thought that having social security could have a positive impact on life quality of the elderly people since it would facilitate benefiting from health services. Health status is an important factor directly affecting QOL. Health-related life quality includes the individual’s perception of his/her health status, being active in physical, social and psychological terms. Studies have shown a significant relationship between the health status of the elderly and QOL (Cheung, Kwan, Chan, & Ngan, 2005; Paskulin & Molzahn, 2007; Tseng & Wang, 2001). In the present study, a statistically significant difference was found between the state of having a disease and the average total score of life quality. Ozyurt et al. (2007) support the findings of our study. However, no differences could be found between the presence of chronic disease and QOL in the studies of Ercan (2010) and Luleci et al. (2008). In the present study, it was found that as age increases, the QOL mean scores decrease. It is a widely known fact that quality of life points usually decrease as age increases. When elderly individuals are divided according to age variants such as ‘‘
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Quality of life of older adults in Turkey Naile Bilgili a,*, Fatma Arpacı b a b
Gazi University, Health Science Faculty, Department of Nursing, Besevler, Ankara, Turkey Gazi University, Vocational Educational Faculty, Department of Family Economics Education, Besevler, Ankara, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 January 2014 Received in revised form 1 July 2014 Accepted 3 July 2014 Available online 12 July 2014
The purpose of this study was to examine the factors affecting the quality of life of the elderly people in Turkey. Three-hundred community-dwelling older adults (Mage = 68.35, SD = 5.80 years) participated in this study. The quality of life was examined through World Health Organization Quality of Life Questionnaire-Older Adults Module Turkish Version (WHOQOL-OLD Turkish). Analysis of Variances (ANOVA) showed significant age differences in sensory abilities, social participation, and intimacy sub-scale scores. Post hoc Scheffe Test results indicated that elderly people aged 75 years and over differed from other age groups; although their scores in social participation and intimacy were lower; they had higher scores in sensory abilities than those aged 60–65 and 66–74 years. There were significant differences between the educational levels of these elderly people in sensory abilities, autonomy, past-present-and-future activities, social participation, and death-and-dying subscales. The autonomy, past-present-and-future activities, social participation, and death-and-dying scores of those with high school education were higher than that of those with secondary school or less education except in sensory abilities scores. There were differences found between the variable of with whom the elderly people lived and of QOL sub-scales of the elderly people’s sensory abilities, past-today-and-future activities, death-and-dying, social participation, and intimacy. In addition, the total average score of the QOL sub-scales with the sufficiency of income of the elderly people were interconnected. In conclusion, the findings revealed that gender, age, education, marital status, childbearing, social insurance, health status, living arrangement and income variables are the determinant to improving the quality of life of elderly people. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Elderly Quality of life WHOQOL-OLD Turkish older adults
1. Introduction The rapid increase in the elderly people population is a known fact. A reduction in childhood diseases, lower maternal mortality, and women’s achievements in the control of their own fertility are considered to be responsible for this increase (World Health Organization Centre for Health Development, 2012a). Although the number of people over the age of 60 was 600 million in the year 2000, it is expected to be 1.2 billion by 2025 and 2.0 billion by 2050 (World Health Organization Centre for Health Development, 2012b). The age group of 65-and-over today, accounts for about 7.3% of the Turkey’s population (Turkish Statistical Institute, 2011). However, it is foreseen to reach 10% by 2023 (Koc, Eryurt, Adalı, & Seckiner, 2010).
* Corresponding author. Tel.: +90 05327984600; fax: +90 312 216 26 36. E-mail addresses: [email protected], [email protected] (N. Bilgili). http://dx.doi.org/10.1016/j.archger.2014.07.005 0167-4943/ß 2014 Elsevier Ireland Ltd. All rights reserved.
The increase in life expectancy at birth is another indicator of the level of the states’ welfare. On the other hand, this increase brings comes with problems such as the uncontrollable growing numbers of severe health issues, declining functional abilities, economic difficulties and changes in social status, and loss of spouse and friends (Flood & Phillips, 2007). Services provided to the elderly people were aimed to enable such individuals to physically act as independently as possible, to have high cognitive and intellectual levels, to sustain active lives, and to be satisfied with their lives (to maintain a good quality of life). However, a longer lifespan does not always mean quality survival for elderly people; due to increased longevity and life expectancy, quality of life (QOL) has been considered an important issue, which has attracted the researchers’ attention (Hall, Opio, Dodd, & Higginson, 2011). The World Health Organization Quality of Life Group defines QOL as follows: ‘‘Quality of life is the individuals’ perception of their position in life in the context of the culture and the value systems in which they live in relation to their goals, expectations,
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standards and concerns. It is a broad concept affected in a complex way in which the persons’ physical health, psychological state, level of independence and social relationships are salient features of their environment’’ (World Health Organization Quality of Life [WHOQOL] Group, 1995). In general, QOL is a subjective and complex concept; its most important component is the healthrelated QOL (Tuzun & Eker, 2003). How an individual physically feels about himself/herself and the extent to which the individual is capable of fulfilling his/her daily work and efforts are examples of health-related qualities of life. In addition, health-related QOL, in the psychological sense, it is being able to feel and express emotions such as anger, resentment, fear, and happiness (Peel, Bartlett, & Marshall, 2007). On the other hand, the concept of health-related QOL is often used to assess the impact of illness on QOL (Ware, 2003). Health, functional status and social support, especially family and friends’ support, and social relations are among the important factors affecting the QOL of elderly people (Pinquart & Sorensen, 2000; Sparks, Zehr & Painter, 2004). Furthermore, sufficient economic resources, personal houses, and suitable physical environment are other factors affecting QOL (Knesebeck, Wahrendorf, Hyde, & Siegrist, 2007; Low and Molzahn, 2007). Dragomirecka et al. (2008) showed that the most important factor affecting the QOL of elderly people was depressive emotional status. In another study reported that the factors affecting QOL were health status, economic status and the meaning of life (Low & Molzahn, 2007). Robinson and Molzahn (2007) stated that the most important factors, which explain the difference in the QOL of elderly people, are personal relations, health status, and sexual activity. QOL requires a critical consideration in both national and international healthcare policies and decisions in each country. Therefore, it is important to determine and analyse factors influencing QOL in this study population. Relatively, few researches had examined the QOL of older adults across cultures and countries. Majority of the recent QOL studies of older adults have focused on the instrument of validation and/or of cultural adaptation (Paskulin & Molzahn, 2007). A number of studies have used the WHO Quality of Life Assessment for Older Adults (WHOQOL-OLD) assessments with community-dwelling Turkish older people. It is important to understand the determinants of QOL of various subgroups of older adults to support the evidencebased policy guidelines, the program development and the policy decisions in the Turkish health and social systems. Therefore, the purpose of this research was to determine the QOL and the factors affecting QOL of a group of elderly people living in their own homes in Ankara, Turkey. 2. Methods 2.1. Study design The current study is a cross-sectional study of the QOL of older adults and factors influencing life quality. A survey approach was used for data collection. 2.2. Sample and data collection The study was conducted among 300 community-dwelling elderly people aged 60 years and over. A door-to-door household survey of elderly adults from a large metropolitan area of central Turkey was utilized for data collection. Fifty out of the one hundred and twenty district streets were randomly selected; with 10 elderly people living on each street by random selection, the side and section of each street were sought. The selected participants were interviewed. Forty-eight refused to participate; 22 elderly
adults were unable to respond to the interview questions, while a response rate of 76.6% were collated. The study inclusion criteria were as follows: individuals performing activities of daily living independently, capable of communication and social activity, capable of reading and writing in Turkish and volunteering to participate in the study. One of the criteria for participating in the survey was being at or over 60 years of age. The reason for choosing the age of 60 is that most of the surveys and studies have been applied on the elderly at or over the age of 60 (Chachamovich, Fleck, Trentini, & Power, 2008; Halvorsrud, Kalfoss, & Diseth, 2008; Heydari, Khani, & Shahhosseini, 2012; Low and Molzahn, 2007; Lucas-Carrasco, Laidlaw, & Power, 2011; Paskulin & Molzahn, 2007; Top, Eris, & Kabalcıoglu, 2012). 2.3. Measurements The data were collected using the personal information form, which consist of descriptive information about the older adult and WHOQOL-OLD Turkish used to evaluate their QOL. The personal information form was designed as a document consisting of 18 questions about the older adult’s socio-demographical background (such as age, gender, health status, education level, marital status and income). They were asked whether they had illness or had not assessed their health status; those that declared a history of illness were regarded as having illnesses. In the case of economic status, they were asked whether they had an income or not; if they had, then they were asked whether this income was sufficient for them to meet their needs. In the end, the economic difficulty status of the elderly people was classified as follows: None/Little, Moderate, Much/Extreme. To determine the QOL of the elderly people, the WHOQOL-OLD Turkish version was used. The WHOQOL-OLD Scale of Life Quality, developed by the World Health Organization, a new instrument recently developed and tested in 22 countries. This instrument is an add-on module for the WHOQOL measures to be used for older adults (Power et al., 2005). Among the 22 study centers, the Turkish (Izmir) Centre simultaneously developed the Turkish version of the scale. The WHOQOL-OLD is the first generic QOL measure for the elderly developed in Turkey. A Turkish validity and reliability study of the WHOQOL-OLD Scale of Life Quality was conducted by Eser et al. (2010). The WHOQOL-OLD Module consists of 24 items and a 5-point Likert-type scale assigned to six facets: sensory abilities (items 1, 2, 10, and 20); autonomy (items 3, 4, 5, and 11); past, present, and future activities (items 12, 13, 15, and 19); social participation (items 14, 16, 17, and 18); death and dying (items 6, 7, 8, and 9); and intimacy (items 21, 22, 23, and 24). Possible facet scores range from 4 to 20. A total score can also be calculated by adding each of the individual item values. Higher scores indicate higher QOL. In the case of Sensory Abilities questions assessed the effects of visual, auditory, sensory, and taste and appetite changes on the quality of life were assessed. Autonomy questions examined independence, respect, general control over life, ability to make free decisions, and the effects of these factors on QOL. In the case of Past-Present-and-Future Activities, successes achieved in the past and satisfaction with these successes, recollections of the past, and feelings and opinions about the future were analyzed. In the case of Social Participation, opinions about the use of time and the state of taking part in crucial activities were examined. In the case of Death-and-Dying, opinions about the acceptance of death, its inevitability, and its meaning were questioned. Finally, in the case of Intimacy, relationship with other people and social support were examined. Eser et al. (2010) reported that Alpha values for the facets and the overall scale (range: 0.68–0.88) (>0.70), and the item total
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correlations and the overall scale success were satisfactory. As a measure of the construct validity of the scale, confirmatory factor analysis showed very high comparative fit index (CFI) values (range: 0.936–0.999) for each of the domains (Eser et al., 2010). The Chronbach’s alpha values calculated for reliability were 0.48 for sensory faculties, 0.78 for autonomy, 0.76 for past-present-andfuture activities, 0.81 for social participation, 0.88 for death-anddying, and 0.88 for intimacy. The alpha value of the reliability coefficient for the overall scale structure was found to be 0.69.
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An examination of the state of the elderly people dependency in daily activities shows that 29.3% were partially dependent on doing housework, whereas 12.7% were partially dependent on activities outside the home (e.g., arranging personal travel and shopping); 14.3% were partially capable of dispensing their medication, while 7.3% were completely not capable of dispensing their medication. 3.2. Quality of life and factors affecting quality of life of the elderly people
2.4. Ethical consideration Ethical approval was obtained from the ethical committee by Gazi University Institutional Review Board committee overseeing the project. Participation was voluntary. All respondents were informed about the purpose of the study, and their oral consent was obtained before initiating the interview. 2.5. Data analysis ANOVA was conducted to detect age, education, living arrangement and financial difficulties differences on quality of life. Scheffe test was used for post hoc comparisons. In addition, gender, marital status, childbearing, social security, and history of the present illness differences were analysed using t test. The correlation between sub-scale scores of the WHOQOL-OLD Turkish version and age, education, living arrangement, financial difficulties was analyzed by Pearson Product Moment Correlation coefficient. 3. Results 3.1. Demographic characteristics of study participants The participants included were approximately equal numbers of men and women. The mean age of the participants was 68.35 5.80 years, and 67.3% of the elderly people were graduates of a primary school or had lower education. Nearly half of them (49.3%) were married. Among these participants, 74.3% had an illness. The majority of the elderly people (92.0%) had children, and 29.4% were living alone. In addition, 90% of the elderly people had their own income, and 42.3% perceived their income as being moderate (Table 1).
Table 2 shows the mean values of the sub-scales scores of the WHOQOL-OLD. The mean values of the sub-scales scores of the WHOQOL-OLD were as follows: sensory abilities – 10.78 2.63; autonomy – 13.73 2.80; past, present, and future activities – 13.25 2.92; social participation – 12.61 3.13; death and dying – 14.74 2.92; and intimacy – 11.36 4.22. Death-and-dying subscales had the highest mean; while sensory abilities had the lowest sub-scales score, followed by intimacy. Table 3 compares the demographic characteristics of the elderly people with the main areas of WHOQOL-OLD. Elderly men had higher average scores in the sub-scales of sensory abilities, autonomy, past-present-and-future activities, social participation, and death-and-dying, whereas elderly women had higher average scores in the intimacy sub-scales and total average score. An examination of the effect of gender variables on sub-scales shows the difference in the sub-scales of autonomy (t = 4.67; p < 0.01), past-present-and-future activities (t = 2.29; p < 0.05), and intimacy (t = 3.96; p < 0.01) to be statistically significant. When the relationship between marital status and the QOL of the elderly people was examined, married elderly people had higher scores in the sub-scales of autonomy, past-present-andfuture activities, social participation, and death-and-dying, whereas unmarried elderly people had higher scores in the sub-scales of sensory abilities and intimacy. A significant differences between marital status and mean scores of the sub-scales of past-presentand-future activities (t = 2.36; p < 0.05), social participation (t = 2.57; p < 0.05), and death-and-dying (t = 2.00; p < 0.05) were found. The total score shows that married elderly people had higher scores, and there were significant differences found between the groups (t = 2.03; p < 0.05). In the case of the differences between elderly people having a child and quality of life, it was seen that the elderly people having
Table 1 Demographic characteristics of study participants (N = 300). n Gender Female Male Age (year) 60–65 66–74 75 Education Primary school or less (5 years or less) Secondary school (8 years) High school (11 years) Marital status Married Single + widow/widower Duration of marriage (year) 40 41–50 51 Present Presence of chronic illness Yes No
%
145 155
48.3 51.7
94 172 34
31.3 57.4 11.3
202 65 33
67.3 21.7 11.0
148 152
49.3 50.7
63 59 26
42.6 39.8 17.6
223 77
74.3 25.7
Having a child Yes No Number of Children (n = 276) 3 4 5 Living arrangement Spouse Spouse and children Alone Income Yes No Financial difficulties (n = 270) None/little Moderate Much/extreme Social security Yes No
n
%
276 24
92.0 8.0
142 72 57
53.3 26.0 20.7
112 100 88
37.3 33.3 29.4
270 30
90.0 10.0
144 114 12
53.3 42.3 4.4
288 12
96.0 4.0
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Table 2 Distribution of the mean scores on the WHOQOL-OLD Turkish (N = 300). Sub-scales
Minimum
Maximum
Mean
Median
Standard deviation
Sensory abilities Autonomy Past-present-and-future activities Social participation Death-and-dying Intimacy Total scores
5.00 4.00 4.00 4.00 5.00 4.00 50.00
18.00 20.00 20.00 20.00 20.00 20.00 103.00
10.78 13.73 13.25 12.61 14.74 11.36 75.79
11.00 14.00 13.00 12.00 16.00 11.00 75.79
2.63 2.80 2.92 3.13 2.92 4.22 8.52
WHOQOL-OLD Turkish: Turkish version of the World Health Organization Quality of Life Instrument-Older Adults Module.
a child had higher scores in the sub-scales of sensory abilities and death-and-dying; while elderly people without a child had higher scores in other sub-scales. Considering the QOL and the state of having social security, the elderly people with social security had higher scores in the sub-scales of autonomy (t = 3.39; p < 0.01), past-today-and-future activities (t = 3.06; p < 0.01), social participation (t = 1.98; p < 0.05), and death-and-dying (t = 4.23; p < 0.01). The difference between the groups was statistically significant. The total score showed that the elderly people with social security had higher scores. The difference between the groups was significant (t = 3.54; p < 0.01). The elderly people with diseases had higher scores in the subscales of sensory abilities, and there was a significant difference between the groups (t = 4.46; p < 0.01). The elderly people without disease had higher scores in the sub-scales of autonomy (t = 2.96; p < 0.01), past-today-and-future activities (t = 3.51; p < 0.01), and social participation (t = 7.26; p < 0.01). The difference between the groups was also statistically significant. A statistically significant difference was found between the average total score of quality of life and the state of having a disease (t = 4.20; p < 0.01). ANOVA showed age significant differences only in sensory abilities (F = 25.14; p < 0.01), social participation (F = 12.49; p < 0.01), and intimacy sub-scales (F = 6.68; p < 0.01). Post hoc Scheffe Test results indicated that elderly people aged 75 years and over differed from the other age groups in these sub-scales. Their scores of the social participation and intimacy sub-scales were
lower, but had higher scores in sensory abilities than those aged 60–65 and 66–74 years. ANOVA yielded significant differences between education levels of elderly people in sensory abilities (F = 18.84; p < 0.01), autonomy (F = 15.51; p < 0.01), past-present-and-future activities (F = 13.58; p < 0.01), social participation (F = 32.89; p < 0.01), and death-and-dying (F = 3.13; p < 0.05) sub-scales. Scheffe post hoc comparisons showed that the high school graduate elderly people were significantly different from the other groups. The autonomy, past-present-and-future activities, social participation, and deathand-dying scores of those with high school education were higher than those with secondary school or less education except sensory abilities sub-scale scores. A differences was found between the variable of with whom the elderly people lived and of QOL sub-scales of the elderly of sensory abilities (F = 18.84; p < 0.01), past-today-and-future activities (F = 3.95; p < 0.05), death-and-dying (F = 6.67; p < 0.01), social participation (F = 3.31; p < 0.05), and intimacy (F = 4.74; p < 0.01). There was a difference between the income levels of the elderly people and the sub-scales of autonomy (F = 16.41; p < 0.01), pasttoday-and-future activities (F = 16.21; p < 0.01), social participation (F = 11.94; p < 0.01), death-and-dying (F = 10.93; p < 0.01), and intimacy (F = 5.79; p < 0.01). The total average score of the QOL sub-scales of the elderly people was connected with the sufficiency of their income (F = 11.77; p < 0.01). Scheffe post hoc comparisons showed that much/extreme financial difficulties of
Table 3 The comparison of demographic characteristics of the elderly with the sub-scales of WHOQOL-OLD Turkish (N = 300). Sensory abilities
Autonomy
Past-present-and-future activities
Social participation
Death-and-dying
Intimacy
Total scores
M SD
M SD
M SD
M SD
M SD
M SD
M SD
Gender Female Male t
10.71 2.58 10.84 2.68 0.420
12.97 2.96 14.44 2.45** 4.673
12.85 2.94 13.62 2.87* 2.294
12.13 3.03 12.20 3.24 0.190
14.47 2.72 15.00 3.09 1.553
12.33 4.10** 10.44 4.14 3.969
75.24 8.39 76.30 8.64 1.078
Marital status Married Single + widow/widower t
10.49 2.73 11.06 2.50 1.890
13.87 2.77 13.59 2.84 0.862
13.65 2.87* 12.86 2.93 2.364
12.63 3.15* 11.71 3.06 2.576
15.08 2.78* 14.41 3.03 2.001
11.29 4.05 11.42 4.39 0.280
76.80 8.70* 74.81 825 2.030
Having a child Yes No t
10.86 2.60 9.79 2.81 1.931
13.65 2.79 14.66 2.80 1.697
13.19 2.89 13.87 3.31 1.084
12.04 3.11 13.58 3.16* 2.323
14.68 2.87 15.50 3.50 1.315
11.30 4.16 12.04 4.91 0.823
75.47 8.44 79.54 8.48* 2.259
Social security Yes No t
10.74 2.66 11.75 1.71 1.299
13.84 2.75** 11.08 2.84 3.399
13.35 2.87** 10.75 3.16 3.064
12.23 3.10* 10.41 3.60 1.982
14.88 2.78** 11.33 4.16 4.236
11.30 4.25 12.66 3.39 1.093
76.14 8.29** 67.41 9.95 3.542
13.45 2.59 14.54 3.24** 2.969
12.91 2.63 14.24 3.48** 3.517
11.45 2.72 14.23 3.34** 7.262
14.56 2.69 15.27 3.48 1.835
11.33 4.22 11.44 4.27 0.196
74.61 7.63** 79.22 9.98 4.200
Variable
History of the present illness Yes 11.17 2.51** No 9.66 2.66 t 4.466 * **
p < 0.05. p < 0.01.
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Table 4 Analysis of variance of sub-scales results of WHOQOL-OLD Turkish with age, education, living arrangements, economic status (N = 300). Sensory abilities
Autonomy
Past-present-andfuture activities
Social participation
Death-and-dying
Intimacy
Total scores
M SD
M SD
M SD
M SD
M SD
M SD
M SD
Age (yr) 60–65 66–74 75 p F
9.56 2.48 11.03 2.45 12.88 2.23 0.000** 25.147
13.64 3.17 13.85 2.50 13.38 3.21 0.628 0.467
13.39 3.34 13.16 2.73 13.29 2.71 0.834 0.182
12.86 3.37 12.24 2.72 9.85 3.40 0.000** 12.495
14.39 3.32 14.94 2.72 14.73 2.73 0.346 1.066
12.48 4.41 11.07 3.96 9.67 4.33 0.001** 6.682
76.09 9.72 76.08 8.32 73.50 6.57 0.249 1.395
Education Primary school or less (5 years or less) Secondary school (8 years) High school (11 years) p F
11.37 2.41 9.89 2.64 8.93 2.65 0.000** 18.843
13.19 2.70 14.40 2.74 15.75 2.41 0.000** 15.514
12.74 2.78 13.75 2.59 15.36 3.34 0.000** 13.582
11.31 2.88 13.24 2.46 15.24 3.28 0.000** 32.895
14.58 277 14.64 3.09 15.93 3.33 0.045* 3.130
11.20 4.21 12.27 3.93 10.48 4.69 0.094 2.388
74.11 8.00 78.01 8.31 81.72 8.59 0.000** 15.489
Living arrangement Spouse Spouse and children Alone p F
10.41 2.75 11.59 2.53 10.32 2.39 0.001** 7.362
14.10 2.62 13.63 2.62 13.38 3.18 0.177 1.740
13.83 2.63 13.06 2.77 12.72 3.33 0.020* 3.956
12.64 3.01 11.55 3.09 12.26 3.24 0.038* 3.312
15.39 2.43 14.77 2.82 13.89 3.39 0.001** 6.670
10.92 3.94 10.83 4.32 12.51 4.28 0.009** 4.748
77.10 7.94 75.08 8.40 74.94 9.23 0.120 2.133
Financial difficulties None/little Moderate Much/extreme p F
10.36 2.47 11.15 2.66 11.00 3.69 0.053 2.962
14.47 2.56 13.35 2.49 10.25 5.15 0.000** 16.415
14.04 2.76 12.78 2.60 9.91 4.01 0.000** 16.219
12.98 3.04 11.50 2.77 9.83 3.78 0.000** 11.949
15.52 2.58 14.00 3.03 13.41 3.08 0.000** 10.930
10.68 4.01 11.45 4.21 14.75 4.37 0.003** 5.792
77.86 7.52 73.96 8.13 69.50 10.7 0.000** 11.775
Variable
* **
p < 0.05. p < 0.01.
the elderly people were significantly different from the other income groups. The autonomy, past-present-and-future activities, social participation, and death-and-dying scores of those with much/extreme financial difficulties were lower than those with the other income groups except intimacy sub-scale scores (Table 4). Pearson correlation analysis showed that there was significant relationship between age and sensory abilities (r = 0.37; p < 0.01). There were weak and negative relationships between age and social participation and intimacy scores (r = 0.24, 0.20; p < 0.01, respectively). In addition, there were weak relationships between education [r(300) = 0.307; p < 0.01], financial difficulties [r(300) = 0.284; p < 0.01] and the total average score of the QOL sub-scales. 4. Discussion The mean scale score of the elderly people who participated in the research was 75.79. The average score was similar to those in the studies conducted by Ozyurt et al. (2007) in Manisa, Top and Dikmetas (2012), Top et al. (2012), and Ercan (2010) in nursing homes in Ankara with the same scale. The average score obtained from the reliability and validity study of the Eser et al. (2010) WHOQOL-OLD quality of life scale was lower (56.02). In the present study, the death-and-dying sub-scale had the highest average score. ‘‘Intimacy’’ in the studies of Ozyurt et al. (2007) and Top and Dikmetas (2012) and ‘‘sensory abilities’’ in the studies of Ercan (2010) and Top and Dikmetas (2012) were the sub-scales that had the highest averages. When the average score of gender of the elderly people was compared with their average QOL score, men had higher scores in all sub-scales except intimacy. The QOL of men was higher than that of women in most studies using the same scale or different QOL scales (Arslantas, Metintas, Unsal, & Kalyoncu, 2006; Calıstır, Dereli, Ayan, & Canturk, 2006; Drageset et al., 2008; Hsu, 2007; Kaya et al., 2008; Kirchengast & Haslinger, 2008; Ozyurt et al.,
2007). Men have better QOL, which likely stems from the fact that they are more educated, have more income, are more active in decision-making than women, and their interaction with the external environment is much more than that of women. However, some studies have shown that there is no statistical difference in the points of life quality of elderly men and women (Bowling, Banister, Sutton, Evans, & Windsor, 2002; Eser et al., 2010; Power et al., 2005; Top et al., 2012; Top & Dikmetas, 2012; Wiggins, Higgs, Hyde, & Blane, 2004). Married elderly people had higher mean scores in the subscales of autonomy, past-today-and-future activities, social participation, and death-and-dying, whereas unmarried elderly had higher mean scores in the sub-scales of sensory abilities and intimacy. It can be seen from the total score that married elderly had higher QOL than unmarried elderly (p < 0.05). Life quality of widowed elderly people was lower, which was similar to the study of Ozyurt et al. (2007). Alexandre, Cordeiro, and Ramos (2009) found that marital status affected the quality of life in a study conducted with WHOQOL-BREF to determine the life quality of the elderly people in Brazil. Lee, Kom, and Leey (2005) and Heydari et al. (2012) found that married participants had a higher average score of QOL than the singles, the divorced, the widows, and the widowers. The relationship between marital status and QOL could not be determined in similar studies conducted by Ercan (2010) in Turkey and Tseng and Wang (2001) in Taiwan to examine the life quality of the elderly people living in nursing homes. Social support and variables pertaining to social networks (family-children and friends) are also important factors related to the QOL of older adults. The elderly people having a child were found to have higher mean scores than those without a child in the sub-scales of sensory abilities and death-and-dying. The elderly people without a child had higher mean scores in other sub-scales. Living with family and having children could increase the life quality of an elderly individual by providing social and psychological support. In a meta-analysis, Pinquart and Sorensen (2000)
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examined 286 studies and found a positive relation among the social status of the elderly people, social relations, competence and well-being. Similarly, Sparks et al. (2004) found that social interaction is the only factor that explains life satisfaction when health status and social status are stable. Chappell (2003) also found that social support and health contributed significantly to the variance of subjective QOL. The present study showed that the elderly people with social security had higher mean scores in the sub-scales of autonomy (p < 0.01), the past-today-and-future activities (p < 0.01), social participation (p < 0.05), and death-and-dying (p < 0.01); in addition, they had higher average scores in total. It was also found in the study conducted by Calıstır et al., 2006, using the 14 SF-36 scale of life quality, that the elderly people with social security had a higher quality of life; however, could not find any statistically significant relationship between quality of life and the social security variance, although the elderly people without social security had a lower average life quality scores in the studies conducted by Ercan (2010) using WOQOL-OLD and by Luleci, Hey, and Subası (2008) using WOQOL-BREF. It might be thought that having social security could have a positive impact on life quality of the elderly people since it would facilitate benefiting from health services. Health status is an important factor directly affecting QOL. Health-related life quality includes the individual’s perception of his/her health status, being active in physical, social and psychological terms. Studies have shown a significant relationship between the health status of the elderly and QOL (Cheung, Kwan, Chan, & Ngan, 2005; Paskulin & Molzahn, 2007; Tseng & Wang, 2001). In the present study, a statistically significant difference was found between the state of having a disease and the average total score of life quality. Ozyurt et al. (2007) support the findings of our study. However, no differences could be found between the presence of chronic disease and QOL in the studies of Ercan (2010) and Luleci et al. (2008). In the present study, it was found that as age increases, the QOL mean scores decrease. It is a widely known fact that quality of life points usually decrease as age increases. When elderly individuals are divided according to age variants such as ‘‘
![[Religiousness and health-related quality of life of older adults].](/assets/img/hold.png)
