Graphical abstract

Introduction

The United Nation’s Decade of Healthy Ageing (2030) highlights a concerted action in response to global population aging. It is also closely linked with the Sustainable Development Goal 3, which seeks to “ensure healthy lives and promote well-being for all at all ages” [1]. By 2050, more than 40% of the Korean population will be aged ≥65 years, a sharp rise from 10.8% in 2010 [2]. With a rapidly ageing population, healthy ageing and care for older people have become major concerns in the Republic of Korea.

According to the National Statistical Office, the proportion of older persons living alone in the Republic of Korea was 16.0% in 2000, increasing to 19.6% in 2020 [3]. It has been reported that older people living alone have significantly poorer physical and mental health, health behaviors, and worse quality of life than those living with a family member [4,5]. Furthermore, older people living alone are more likely to present with self-reported illness and use health services when they are sick [6]. As age advances, older people tend towards multi-morbid diseases and are likely to have more complex care needs [7]. Understanding the health status of the older population in each country is important so that effective national health and social service plans can be formulated. However, little is known about the epidemiological characteristics of older people living alone and whether living alone itself is associated with health-related quality of life (HRQoL) after adjusting for age and other socioeconomic variables.

The 3-level version of the European Quality of Life 5-Dimensional Questionnaire (EQ-5D-3L) is a suitable instrument to measure health status among older populations and has been used in a number of studies [8]. The EQ-5D-3L questionnaire is also known as a useful predictor of mortality and of first hospitalization among older populations [9].

The main purpose of this study was to determine the HRQoL of older people according to their living arrangement status using the EQ-5D-3L. The specific aims were (1) to investigate the prevalence of different living arrangements according to the subjects’ sociodemographic characteristics, (2) to compare the EQ-5D-3L index scores by sociodemographic characteristics according to living arrangements, (3) to compare the EQ-5D-3L by gender and living arrangement, (4) to determine whether living arrangements are associated with quality of life after adjusting for sociodemographic variables.

Materials and Methods

Data Sources and Participants

We conducted a secondary analysis of data obtained from the seventh Korean National Health and Nutrition Examination Survey (KNHANES VII, 2016 to 2018) [10]. The KNHANES is a nationwide periodic cross-sectional survey of the health and nutrition of a nationally representative sample of community residents. Further details on the KNHANES VII are described in the raw data use guidance of the KNHANES VII[10]. From 31,689 randomly sampled individuals, 24,269 people participated in this national survey across all ages (a response rate of 76.6%). For the present study, 6,153 KNHANES participants aged ≥60 years were included for analysis based on demographic characteristics, health behaviors, health status, and the EQ-5D-3L.

Measurements

HRQoL: EQ-5D-3L

The KNHANES uses the EQ-5D-3L to assess health status. The EQ-5D-3L was developed by the EuroQol Group and has been widely used as a concise, generic instrument for measuring, comparing, and valuing health status across disease areas [11]. The EQ-5D-3L consists of the 5 dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression and has 3-level answers (“no problem”, “some problems”, and “severe problems”) for each dimension. The EQ-5D-3L is easy to apply as a self-administered survey. A Korean version of the EQ-5D-3L was developed, and its reliability and validity were tested according to a procedure recommended by the EuroQol group [12]. Lee et al. [13] established a population-based preference weighting for the Korean EQ-5D-3L using a representative population sample [13], and the Korean EQ-5D-3L index scores were calculated using these population weightings. A higher score typically represents a better health status [14].

In this study, the sociodemographic characteristics included gender, age, living arrangement (living with others or living alone), region (urban or rural), education level (elementary, middle school, or high school), marital status (never married, married, or divorced/separated), and income (low, lower-medium, upper-medium, or high). Current smoking status (yes or no), high-risk drinking (yes or no), and walking over 30 minutes daily (yes or no) were included as health behavior variables. Perceived stress (little or much) and perceived health status (1, very poor; 2, poor; 3, moderate; 4, good; 5, very good) were included as health status variables.

Statistical Methods

Statistical analyses were conducted using SAS software ver. 9.4 (SAS Institute Inc.). Survey procedures for the complex sampling design were applied to estimate nationally representative statistics. The chi-square test was used to compare the general characteristics and EQ-5D-3L index scores according to living arrangement, and multiple linear regression analysis was conducted to investigate if living arrangements influenced the EQ-5D-3L index scores after adjusting for covariates. A p-value less than 0.05 indicated statistical significance.

Ethics Statement

This study was approved by the Institutional Review Board (IRB) of Jeju National University (IRB No: JJNU-IRB-2022-078). Informed consent was waived by the IRB since this secondary analysis used anonymized data.

Results

Living Arrangement by Sociodemographic Characteristics

Of the 18.0% of respondents who lived alone, the prevalence was higher in women and in older age groups (p<0.001): 11.70% in men (11.1% 60–64 years, 32.0% >80 years) and 23.0% in women (11.9% 60–64 years, 41.2% >80 years) (Table 1). More participants in lower income brackets lived alone (30.3%) than those with higher incomes (5.5%, p<0.001), and a higher percentage of rural residents lived alone (22.4%) than urban residents (16.7%, p<0.001).

HRQoL by Living Arrangement

The comparison of HRQoL (measured by EQ-5D-3L index score) according to living arrangement is presented in Table 2. Overall, the HRQoL was lower in groups living alone than in groups living with others. The HRQoL decreased in both groups as age advanced. The HRQoL was significantly lower in those aged ≤74 years and living alone than in those aged ≤74 years and living with others. However, for those ≥75 years, there were no significant differences in HRQoL between the 2 groups. The HRQoL in men was higher than in women, though the scores were significantly lower for those living alone in both genders (p<0.001). According to marital status, those who had never married and lived alone showed the lowest HRQoL. However, the scores were not significantly different based on living arrangement in the subgroups of marital status. Lower education levels were associated with lower HRQoL scores, and mean scores were significantly lower in the group living alone than in the group living with others for the same education-level subgroups. Income levels followed a pattern much like the levels for education. Those who lived alone in rural areas had lower HRQoL scores than those living alone in urban areas. However, in both urban and rural dwellers, the mean HRQoL scores of those living alone were significantly lower than those living with others.

The Prevalence of Health Problems in the EQ-5D-3L By Living Arrangement

The EQ-5D-3L index scores according to living arrangement are shown in Figure 1. Older people living alone showed higher impairments in all dimensions of the EQ-5D-3L than those living with others including mobility (p<0.001), self-care (p<0.001), usual activities (p<0.001), pain/discomfort (p<0.001), and depression/anxiety (p<0.001). For respondents living alone, problems with mobility were most prevalent (42.8%), followed by pain/discomfort (41.9%). Conversely, for those living with others, pain/discomfort was the most common problem (32.7%), followed by mobility (28.2%). In both groups, respondents reporting problems in self-care were in the lowest percentage (13.0% for living alone; 7.1% for living with others). Overall, pain/discomfort was the most frequently reported complaint (total 34.3%, men 25.4%, women 41.4%), followed by mobility (total 30.8%, men 22.7%, women 37.3%). Relatively few respondents had problems with self-care (total 8.2%, men 6.2%, women 9.8%).

Factors Influencing HRQoL

Multiple regression was used to evaluate the impact of living arrangement on HRQoL using EQ-5D-3L index scores (Table 3). After adjusting for the significant variables of HRQoL (age, gender, education, exercise, perceived stress, and perceived health status), living arrangement was a significant influencing factor for HRQoL. Living alone was significantly associated with a lower HRQoL (b=–0.048, p<0.001). Age was also significantly associated with a lower HRQoL (b=–0,171, p<0.001), and women showed a significantly lower HRQoL than men (b=–0.044, p<0.001). Those with a lower education level had a lower HRQoL than those with a higher education (b=–0.054, p=0.004). People who walked >30 minutes daily showed a higher HRQoL than those who did not. Perceived stress and subjective health status were also significantly associated with EQ-5D-3L index scores (p<0.001) (Table 3).

Discussion

In this study, 18.0% of people over 60 years of age reported living alone (women, 23.0% vs. men, 11.7%). As urbanization and nuclearization of the family have increased in the Republic of Korea, the overall number of households has increased steadily, with single household occupancy being the most prevalent household type (30.2%) in 2019 [3].

Globally, the percentage of people living alone varies by both age and gender [15]. Across Europe and North America, there are much larger differences in the incidence of living alone in later life (75–79 years old) with Switzerland, the Netherlands, and the United Kingdom recorded as the highest. The incidence of living alone is reported to be 2 to 3 times higher in women than in men [15]. Understanding the distribution and trends in living alone among older people by age and gender can contribute to better estimations of long-term care needs and inform policies that meet the evolving needs of older people.

Living alone had a significant association with HRQoL as measured by EQ-5D-3L index scores. Nearly half of people aged ≥60 years reported having health problems, and those living alone demonstrated significantly lower EQ-5D-3L index scores than those living with others. Using multiple regression analysis, living arrangements were found to be significantly associated with EQ-5D-3L index scores. The impact of living arrangements on long-term care needs has been previously reported [16]. Previous studies have also presented evidence that those who belong to single-person households experience lower health status [4]. Living with a spouse in the household provided the greatest health protection [16], and living alone had the most negative effect on health for older people [17]. The lower quality of life for older people living alone may be due to a lack of social support. Previous studies have found that older people with poor social support showed a lower quality of life or psychological health [18], while those living with family fared better than older people living alone in terms of subjective health status, depression, and life satisfaction [19]. Living arrangements can be related to both social support and social networks as well as care support [20]. Older people living alone may be a vulnerable population, and that should be taken into consideration when making policies for long-term care and interventions. Older people obtain emotional and social support primarily through family and community; therefore, raising the level of social support for those living alone by strengthening the community support system can be a solution.

This study found that EQ-5D-3L index scores decreased rapidly with advancing age and that the prevalence of health problems across all dimensions of the EQ-5D-3L was higher in men than in women, regardless of the living arrangement. Previous studies also reported a significant decline in HRQoL with age [16,21], and that the HRQoL was higher in men with poorer health status and greater mobility limitations than in women [22]. The proportion of women living alone increases with age, presumably because women live longer than men. Mouodi et al. [17] suggested that the influence of living arrangements on health differed by gender, demonstrating that health problems were higher in older people who lived alone, and that health status according to living arrangement was different for men and women. This study found that women living alone had a lower quality of life; thus efforts to target interventions more specifically to them are needed.

As previously reported by Mangen et al. [8], the most common health-related complaints identified in the present study were pain/discomfort and mobility problems. Therefore, it is necessary to prioritize pain management and mobility support services for the growing older population. Previous studies found that the prevalence of health problems reported in the EQ-5D-3L increased with age, and that mobility problems occurred most frequently in the eldest population [8]. Anxiety and depression were reported more frequently in this study than in other European studies, which found anxiety/depression to be the least prevalent [21]. One reason for the higher prevalence of anxiety/depression in the Republic of Korea might be poverty. The old-age poverty rate in the Republic of Korea has been reported highest among the Organization for Economic Co-operation and Development (OECD) countries in 2016 at >45% [23]. Depression and suicide mortality were also serious challenges, with the Republic of Korea demonstrating the highest suicide mortality rate among the OECD countries at 24.6 per 100,000 persons in 2017 [24]. The high old-age poverty rate in the Republic of Korea might also be related to the fact that the pension system has not fully matured, and it is hoped that various social systems will mature to reduce poverty over time.

Multiple regression analysis of the EQ-5D-3L index scores suggested a need to target future health and well-being interventions towards women, older people living alone, those with lower education and poor perceived health status, those with poor health behavior (notably those not walking >30 minutes a day), and those with perceived high levels of stress. Previous studies also found that gender, age, stress, perceived health, and physical activity were significant factors affecting quality of life [25,26]. Perceived health status had the greatest effect on HRQoL in this study. Among the sociodemographic variables, the effect of age on HRQoL was much greater than gender or the level of education, as demonstrated in previous studies [27]. Understanding older people as a potentially vulnerable population may lead to developing more responsive and better-integrated policies and interventions. Preventive and supportive community care services that enhance quality of life can have a positive impact and better support older people.

A strength of this study was the relatively large sample; thus, the results can be seen as representative of the general older population of the Republic of Korea. In addition, the data was collected by well-trained interviewers for the KNHANES. However, some limitations should be considered. First, we cannot attribute a causal relationship to the findings because the study design was based on a cross-sectional survey. Second, there might be recall bias because the data were collected retrospectively using questionnaires. Third, although the EQ-5D-3L focused on 5 dimensions of HRQoL, it did not measure all dimensions of quality of life. Further studies are recommended to expand on this aspect. In addition, because the EQ-5D-3L is a generic questionnaire for assessing quality of life, any correlations between existing disease and quality of life were not investigated in this study. Fourth, the EQ-5D-3L index scores in this study may have been overestimated in relation to the actual life quality of older Koreans since older people living in residential facilities were not included in the KNHANES. Fifth, because this study used data from the Republic of Korea only, it cannot be generalized to the populations of other countries.

Conclusion

Approximately 1 in 5 older people in this sample were living alone, and the HRQoL was lower in groups living alone than in groups living with others. Living alone was negatively associated with the HRQoL after adjusting for age, gender, education, exercise, perceived stress, and perceived health status. Therefore, it is important to take living arrangements into consideration when formulating policies on healthy aging. Devising innovative living arrangements, especially those that enhance interactions between older and younger populations, can play an essential role in healthy aging and improve the HRQoL for older people.

HIGHLIGHTS

Various factors contribute to well-being late in life, including “ageing in place” and with whom one ages. This study found that living alone was associated with poorer health-related quality of life, including higher rates of pain, depression, and anxiety as well as greater limitations on mobility, self-care, and routine activities. The findings of this study emphasize that, when planning care for older people, living arrangements should be considered and social and health services strengthened for those living alone.

Article information

Ethics Approval

This study was approved by the IRB of Jeju National University (No: JJNU-IRB-2022-078) and was performed in accordance with the principles of the Declaration of Helsinki.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

This research was supported by the 2022 scientific promotion program funded by Jeju National University.

Availability of Data

The datasets generated and/or analyzed during the current study are available in the Korean National Health and Nutrition Examination Survey (KNHANES VII) repository (https://knhanes.kdca.go.kr/knhanes/eng/index.do).

Authors’ Contributions

Conceptualization: all authors; Data curation: EP; Formal analysis: EP; Funding acquisition: EP; Investigation: all authors; Methodology: all authors; Project administration: all authors; Resources: all authors; Software: EP, PL; Supervision: all authors; Validation: all authors; Visualization: EP; Writing–original draft: EP; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Figure 1.

The prevalence of health problems (EQ-5D-3L index scores) according to gender and living arrangement in older Korean adults. EQ-5D-3L, 3-level version of the European Quality of Life 5-Dimensional Questionnaire.

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Figure & Data

References

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