The association between living arrangements and health-related quality of life in Korean older people: a nationwide repeated cross-sectional study

Article information

Osong Public Health Res Perspect. 2024;.j.phrp.2023.0273

Publication date (electronic) : 2024 April 1

doi : https://doi.org/10.24171/j.phrp.2023.0273

Eunok Park¹, Philip Larkin², Zee-A Han^,3

¹College of Nursing, Jeju National University, Jeju, Republic of Korea

²Palliative and Supportive Care Service and Institute of Higher Education and Research in Healthcare, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

³Department of Rehabilitation Medicine, Uijeongbu Eulji Medical Center, College of Medicine Eulji University, Uijeongbu, Republic of Korea

Corresponding author: Zee-A Han Department of Rehabilitation Medicine, Uijeongbu Eulji Medical Center, College of Medicine, Eulji University, 712 Dongil-ro, Uijeongbu 11759, Republic of Korea E-mail: hanzeea@gmail.com

Received 2023 October 3; Revised 2024 February 13; Accepted 2024 February 16.

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

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).

Table 1.

Distribution of the general characteristics of older Korean adults according to living arrangement

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.

Table 2.

Health-related quality of life in older Korean adults (as measured by EQ-5D-3L index scores) according to living arrangement

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%).

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.

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).

Table 3.

Multiple regression analysis of the impact of living arrangement (alone vs. with others) on HRQoL using EQ-5D-3L index scores

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.

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