INTRODUCTION
1. Background
The prominent changes in Korea’s demographic structure are the increase in age over 75, single-person households, and men [1]. With a rapidly growing number of older men living alone, this population brings social attention due to solitary death. Prior studies have revealed aged men living alone have relatively poor social resources [2], and a higher risk of depression, loneliness, suicidal thoughts, and decreased quality of life (QoL) [3]. Therefore, a comprehensive evaluation and approach are needed to improve their well-being.
Life satisfaction is the subjective evaluation of an individual’s overall well-being, indicating an integrated judgment of how the person’s life is going [4], and it has been weighed as a significant factor for successful aging. It is associated with multidimensional factors in older adults [2], which include individual factors, nutritional status, physical functions, and mental factors. To improve the life satisfaction of older men living alone, it would be the first step to explore the predictors of life satisfaction.
However, earlier studies mainly have compared life satisfaction and related factors by gender or living arrangement [2,5]. They have focused on specific factors rather than guided a theory with holistic perspectives. In addition, they might fail to represent the uniqueness of older men living alone because their portion is relatively small. Little has been known about life satisfaction and its related factors for older men living alone.
According to previous research, sociodemographic factors such as older age [2,3], living alone [2,6], lower education level [2,5,7], low income [8,9], unemployment [8,9], living in a small town or rural area [8], and multimorbidity [6,10] have negative impacts on life satisfaction in late life. The older adults who live alone, single, windowed, or divorced have a greater malnutrition risk [11]; their abnormal body mass index (BMI) and malnutrition have been known to lower life satisfaction [8,10]. Regarding physical functions, limitations in Instrumental Activities of Daily Living (IADL) [6,12], difficulty in physical movements [13], and impairment of vision or hearing [14] have also been identified as factors that decrease life satisfaction in previous studies. Mental factors, especially depression [5,8,12] and declined cognitive function [15] have been indicated predictors of life satisfaction in older people. Social relationships have strongly been supported as predictors of life satisfaction in old age, using various concepts such as social isolation [16], social resources [2,12], social frailty [15], social support [6,10], and social participation [5,6].
The preceding literature has provided other predictors of life satisfaction, including chronic pain [10], subjective health status [2,6,8], loneliness [3,6,12,16], and self-esteem [6]. To improve the life satisfaction of older men living alone, it would need to develop an integrated intervention strategy with theoretical guidance. The conservation model [17] guides how each unique individual regains wholeness and which nursing interventions help the adaptation process in the internal and external environment. According to Levine’s conservation model, four conservation principles (energy conservation, structural integrity, personal integrity, and social integrity) have been proven to quantify the effectiveness of individual assessment and nursing interventions in various healthcare settings, including the community [6,17]. The theoretical substruction of the current study and the hierarchical relationships are presented in Figure 1.
This study aims to investigate the predictors of life satisfaction among aged men living alone with well-established theoretical guides, and the findings of this study would provide a basis for establishing healthcare and welfare policies and developing nursing intervention strategies to improve life satisfaction.
METHODS
Ethic statement: This study was approved by the Institutional Review Board (IRB) of Korea Institute for Health and Social Affairs (IRB No. 2020-36) and Hanyang University (IRB No. HYUIRB-202204-004).
1. Study Design
This cross-sectional study identifies predictors of life satisfaction among older men living alone, analyzing the raw data from the 2020 NSOK [18]. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.
2. Participants
This study was conducted by analyzing data from the 2020 NSOK, which has been co-sponsored by the Ministry of Health and Welfare and the Korea Institute for Health and Social Affairs every 3 years since 2008 by law [18]. The sample was proportionally stratified from approximately 10,000 people aged 65 and over from 903 survey districts in 17 cities and provinces across South Korea, who were selected by area of residence, age, gender, education, marital status, and single-person households. Data were collected through face-to-face interviews using a tablet personal computer by well-trained surveyors. The raw data were used after approval from the Health and Welfare Portal site (https://data.kihasa.re.kr).
The data from 548 older men living alone out of the 10,097 participants in the 2020 NSOK were analyzed after the selection process to maintain the accuracy and representativeness of the data. The sample excluded 93 cases (14.5%) with missing main variables. The selection procedure was presented in Figure 2.
3. Measurement
1) Demographic Factors
Considering empirical findings [2,3,5-10], age (65~74, ≥75), education level (0~9 years, ≥9 years), income level (<standard median income [SMI], ≥SMI), current employment status (yes or no), area of residence (urban or rural areas), and the number of diagnosed chronic diseases (0~1, ≥2) were investigated. The chronic diseases were diagnosed by a physician in the past 3 months or more.
2) Nutritional Status
Energy conservation is the balance between the supply and demand of energy [17], which we defined as the nutritional status and measured using the BMI [19] and the Nutrition Screening Initiative (NSI) checklist [20]. The BMI was calculated by dividing weight (kg) by squared height (m²), which categorized survey participants into four groups following the Asia-Pacific BMI classifications presented by the World Health Organization [19]. We dichotomized normal and abnormal BMI ranges. Abnormal BMI ranges included underweight, overweight, and obese.
The NSI checklist consisted of 10 items and each item was rated on a scale from one to four [20]. A higher score indicated increased nutritional risk (range: 0~21). The scores were categorized as good (0~2 points), moderate risk (3~5 points), and high risk (6 points or more) [20]. In the present study, we considered participants with three points or more to be at nutritional risk in line with the prior research [15].
3) Physical Function
As the conservation of structural integrity refers to the ability of individuals to maintain their wholeness and restore function [17], we evaluated physical function using the Korean versions of Instrumental Activities of Daily Living (K-IADL) [21], motor ability scale [22], and self-reported visual and auditory difficulty [18]. IADL was measured using a 10-item K-IADL [21] (range: 10~37) and dichotomized into two categories. Limitation in IADL was defined as respondents who needed complete or partial help, and no limitation was defined as the case of no help needed [23]. Cronbach α was .94 in a previous study [23] and .96 in the current study.
The motor ability was measured using a 5-item physical performance scale developed by Lee et al. [22] (range: 0~100). We defined limitation in motor ability as cases where participants had difficulty with one or more physical movements, in line with the previous study [13]. Cronbach’s α value was .89 [22] and .92 in the current study.
Sensory function was evaluated using the 2020 NSOK self-reported vision and hearing difficulties in daily activities such as watching TV and communicating on the phone [18]. We classified declined and normal sensory functions according to the presence of either visual or auditory problems, as in the previous study [14,23].
4) Mental Health
As conservation of personal integrity is the process of restoring or maintaining self-identity and self-esteem to keep independence [17], we assessed depression and cognitive function. Depression was measured using a 15-item Korean version of the short form of the Geriatric Depression Scale (SGDS-K) [24]. The SGDS-K consists of 15 yes or no binary questions regarding feelings experienced in the past week. The score was calculated as the sum of yes (1 point) and no (0 points) responses together with five reverse-coded items (range: 0~15). We classified normal and depressive symptoms using a cutoff score of 8 points [23,24]. Cronbach’s α was .86 [24], and the Kuder–Richardson Formula 20 (KR-20) was .89 [23] in the previous studies. In this study, the value of KR-20 was .81.
Cognitive function was measured using the Korean version of the Mini-Mental State Examination for Dementia Screening, developed to screen for dementia by Kim et al. [25] (This article has been retracted due to originality issues however authors cited this because there are no alternatives.). Standardized normative cognitive function was established according to sex, age, and education period by Han et al. [26]. Higher scores implied better cognitive functioning (range: 0~30) [25]. Cronbach’s α was .83 [25]. KR-20 was .84 [23] and KR-20 was .88 in the current study.
5) Social Integrity
Individuals are defined by the community and the conservation of social integrity allows participation in diverse social groups [17]. We evaluated social networks using Berkman’s Social Network Index (SNI) [27,28] excluding marital status because all participants had no spouses in this study. We recategorized and calculated SNI using the following items: participation in church or religious activities (≥every few months=0, ≥once or twice a month=1); participation in group activities such as club, political group (participation=1, non-attendance=0); and close ties (0~2 friends and 0~2 relatives=0, all other scores=1) [27,28]. A higher SNI indicated a greater social network (range: 0~3). We defined an SNI score of 0 to 1 as social isolation and 2 to 3 as moderate social network, as in previous studies [27,28].
6) Wholeness
Integrity implies the wholeness of individuals and independence [17], and in this study, life satisfaction is defined as wholeness because it is a holistic and integrated concept. We evaluated life satisfaction using six items out of seven of the 2020 NSOK self-reported life satisfaction questionnaires [18]. We excluded the item related to satisfaction with the spousal relationship because participants of this study were single, widowed, or divorced. Scores were evaluated on a 5-point Likert scale, and the total life satisfaction score was calculated after reverse coding to facilitate interpretation [2]. A higher score indicated a higher level of life satisfaction [15] (score range: 6~30), we defined lower life satisfaction as cases where life satisfaction was less than the average of all participants. Cronbach’s α was .61 in the previous study [15] and was .89 in the current study.
4. Data Analysis
The statistical analysis was performed using Windows SPSS version 25.0 (IBM Corp.). Descriptive statistics on demographic characteristics, nutritional status, physical function, mental health, social networks, and life satisfaction were calculated and analyzed using error, mean and standard deviation, and percentage. Univariate and multivariate logistic regression analyses were conducted to identify predictors of life satisfaction in older men living alone. Odds ratios (ORs) with 95% confidence intervals (CIs) were presented. The significance level for all statistical analyses was set at a p-value of .05. The Hosmer–Lemeshow test was used to verify the good fitness of the logistic regression model where a p-value was greater than .05. Nagelkerke R2 was calculated for the explanatory power of the regression model.
5. Ethical Considerations
This study was approved by the Institutional Review Board (IRB) of Korea Institute for Health and Social Affairs (IRB No. No. 2020-36) and Hanyang University (IRB No. HYUIRB-202204-00). This study was exempted from informed consent acquisition since it is a secondary data analysis study.
RESULTS
1. Characteristics of the Participants
The participants’ characteristics are listed in Table 1. The mean age of the 548 participants was 74.35±6.59 years old. More than 60% of participants were below the standard median income (67.0%), and about half (48.7%) currently had a job. Most participants (70.6%) lived in urban areas, and approximately half (48.5%) of subjects had multimorbidity. Regarding energy conservation, 57.8% of the participants had an abnormal BMI, and about half (47.2%) were at risk of moderate or higher nutritional risk. In terms of structural integrity, most participants (91.2%) had no limitations in IADL, but more than 60% had limitations in motor skills (65.3%). Approximately 37% of participants had declined sensory function. As for personal integrity, 16.1% of the participants had major depression (SGDS-K≥8 points), and one-third (31.6%) had a cognitive function decline. The prevalence of social isolation was high (64.6%), and the average life satisfaction was 20.51±4.29 (score range: 6~30) (Table 1).
2. Predictors of Life Satisfaction of Older Men Living Alone
In univariate logistic regression analysis, income below SMI (OR=2.12, 95% CI=1.34~3.35, p=.001), being unemployed (OR=1.58, 95% CI=1.04~2.39, p=.033), moderate to severe nutritional risk (OR=2.02, 95% CI=1.36~2.98, p<.001), declined sensory function (OR=3.22, 95% CI=2.13~4.87, p<.001), depression (OR=1.89, 95% CI=1.03~3.48, p=.40), and social isolation (OR=1.60, 95% CI=1.06~2.43, p=.026) were associated with lower life satisfaction in older men living alone (Table 2). Furthermore, we performed multivariate logistic regression analyses applying the forward linear regression method. In the final model, income lower than SMI (OR=2.06, 95% CI=1.34~3.18, p=.001), being unemployed (OR=1.59, 95% CI=1.06~2.37, p=.025), living in a rural area (OR=1.55, 95% CI=1.01~2.36, p=.043), nutritional risk (OR=1.98, 95% CI=1.34~2.92, p<.001), declined sensory function (OR=3.29, 95% CI=2.20~4.93, p<.001), depression (OR=1.86, 95% CI=1.03~3.35, p=.040), and social isolation (OR=1.58, 95% CI=1.05~2.37, p=.027) were found to be significant predictors of lower life satisfaction among older men in South Korea. The Hosmer & Lemeshow test proved that the regression model fit well (χ2=2.741, degree of freedom=8, p=.950), and the explanatory power of the regression model was 28.0% (Nagelkerke R2=.280) (Table 3).
DISCUSSION
Based on Levine’s conservation model, this study aimed to provide a basis for establishing healthcare policy and developing nursing intervention strategies to improve life satisfaction among aged men living alone through assessing and identifying predictors. Comparing the degree of life satisfaction was difficult because each study had different tools and measuring systems [2,5-10,15].
As for individual factors, under SMI, being unemployment, and living in rural areas were significant predictors of life satisfaction, as supported by the previous research [8,10]. Interestingly, living in a rural area was insignificant in univariate logistic regression analysis, but was significant in multivariate logistic regression. The reason that residents in urban areas had higher life satisfaction would be more benefits than in rural areas related to better job opportunities and living conditions for older men living alone.
According to a multi-level modeling study, there were gender differences in the predictors of life satisfaction in 150 countries (N=952,739) [7]. Socio-political, employment-related, income, and education-related variables significantly impacted men, while marital status and interpersonal relationships were more essential determinants in women [7]. Therefore, the life satisfaction of older men living alone could be enhanced by providing economic support programs such as financial aid and good-quality job opportunities.
Regarding energy conservation, participants of the current study had a high prevalence of an abnormal BMI (57.8%) and nutritional risk (47.2%), which indicated participants of this study were at serious malnutrition risk. Nutritional risk appeared as a significant predictor of lower life satisfaction, and its effect was consistent with the findings of previous studies [8,10]. In Korea, the term ‘sik-gu’ refers to family members who eat together, and great value is traditionally placed on socializing during mealtimes. On the other hand, Korean older men in this generation were not familiar with household tasks such as grocery shopping or cooking due to the patriarchal cultural influence, and they experienced immense difficulties in preparing meals [5]. Thus, nutritional intervention programs for older men living alone should consider sociocultural characteristics and include comprehensive nutritional assessment for early detection of malnutrition. Custom-tailored nutrition-support programs based on personal needs would positively affect the life satisfaction of older men living alone. Improving the economic status and providing meal support and lifelong education (e.g., instruction in healthy eating, grocery shopping, and cooking) would help improve nutritional status, and low-cost shared dining facilities in the local communities would provide opportunities to socialize [11].
As for the conservation of structural integrity, our findings showed that IADL and motor ability were insignificant unlike previous studies [2,13]. A cross-sectional study conducted in community‐dwelling older adults in 17 European countries found that Activities of Daily Living and IADL disability had the most potent negative effect on life satisfaction for people in their 50s, and the impact of physical disability on life satisfaction decreased with aging [12]. This may explain insignificant relations among IADL, motor ability, and life satisfaction in this study. However, the sensory function decline was the strongest predictor of lower life satisfaction among Korean older adults living alone. This was similar to prior studies that dual sensory impairment markedly worsens life satisfaction [14] and lower QoL in older adults [29]. Moreover, sensory impairment was also associated with depression [14,23], cognitive decline [29], negative affect, loneliness, social isolation, self-esteem, and autonomy [14]. Accordingly, to improve life satisfaction in older men living alone, maintaining sensory function is essential to develop comprehensive interventions, including sensory function screening tests, financial support for assistance devices, and medical treatment.
Concerning personal integrity, the prevalence of depression of participants in this study (16.1%) was lower than in older women living alone (33.4%) [23]. As was expected, depression was a predictor of life satisfaction in aged men living alone, consistent with previous studies [5,10,12,14,15]. Since depression is related to suicidal thoughts in older men living alone [3], active nursing intervention is necessary. Nurses in primary care services and community healthcare personnel should focus on the early detection of depression and provide multidimensional support programs to improve life satisfaction in older men living alone.
In the current study, there was no association between cognitive decline and life satisfaction, which was different from the previous studies [3,15]. Ko et al. [3] found that cognitive function had a significant relation with QoL in older women living alone not in men. Furthermore, in American community-dwelling older adults (N=1,042), there was a gender difference in cognitive function [13]; however, cognitive function was not associated with life satisfaction. Therefore, the relation between cognitive function and life satisfaction by gender needs further investigation.
For social integrity, the prevalence of social isolation (64.6%) was notably high. Our finding found that social isolation had a negative association with life satisfaction among older men living alone. In a two-European country comparison study (N=7,149), social isolation was associated with decreased QoL [16]. Since social isolation was counted as predictive of mortality in men [27,28], preventing social isolation would be highly valued in older men.
Life satisfaction in older adults living alone is closely related to social relationships [2,5], and expanding social networks would be helpful by promoting social participation [9]. Since baby boomers have higher income and education levels than those in the past [1], using an information and communications technology-based intervention would be an alternative option. In addition, the public support system should be fortified to alleviate the social isolation of older adults living alone because the social relationships of Korean older adults are highly dependent on informal relationships such as those with children, friends, and neighbors.
A systematic review article presented that group, person-centered, and volunteering-based interventions on a long-term basis would help alleviate social isolation [30]. Those programs benefit the local community and might give opportunities to expand social networks and enhance their value among older men living alone. Therefore, the Korean government should put more effort into developing various types of social activity programs to meet individual needs.
A major strength of this study was that the logistic regression model was constructed based on theory and literature review to explore the predictors of life satisfaction in older adults living alone, who have been difficult to study in Korea. A good sample size and reliable and representative data were used. However, this study employed a cross-sectional design using secondary data and had limitations in interpreting and selecting measurement variables. First, in this study, a causal relationship cannot be confirmed due to the cross-sectional design, further longitudinal studies are necessary. Second, the measurement tools of the 2020 NSOK might not perfectly reflect the concept and construct of Levine’s conservation model, which explained the life satisfaction of older men living alone. Finally, the dropout rate was relatively high (14.5%), and most of the missing data were items related to relationships with children. This might be characteristic of Korean culture since they were reluctant to reveal negative responses regarding their children to others, and thorough consideration would be required in future research.
CONCLUSION
As the population of aged men living alone is rapidly growing, a strategy to improve their life satisfaction from the government and local districts is required. This study aimed to assess and identify predictors of life satisfaction in older men living alone based on Levine’s conservation model. The notable findings in this study were that the determinants of life satisfaction in aged men living alone were income, employment, place of residence, nutritional risk, sensory function, depression, and social isolation. Therefore, healthcare personnel should pay more attention to prevention and multidimensional interventions for malnutrition, visual and auditory function decline, depression, and social isolation. Comprehensive formal and informal support programs based on personal needs are required with holistic perspectives. The findings of this study are expected to be used as basic data when developing nursing interventions and establishing healthcare and welfare policies to enhance the life satisfaction of aged men living alone.
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