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Received: 5 November 2020    Revised: 14 May 2021    Accepted: 24 May 2021

DOI: 10.1111/jan.14940

ORIGINAL RESEARCH:
E M P I R I C A L R E S E A R C H – ­ Q U A N T I TAT I V E

Impact of sense of coherence, resilience and loneliness on

quality of life amongst older adults in long-­term care: A
correlational study using the salutogenic model

Jia Yi Tan1 | Wai San Wilson Tam2 | Hongli Sam Goh2 | Chee Chung Ow3 |

Xi Vivien Wu2

1
Singapore General Hospital, Singapore,
Singapore Abstract
Aims: This study aimed to identify the predicting factors of quality of life (QoL) from
2
Alice Lee Centre for Nursing Studies,
Yong Loo Lin School of Medicine, National
University of Singapore, Singapore,
a set of psychosocial, sociodemographic and clinical variables amongst older adults in
Singapore a long-­term care setting.
3
Kwong Wai Shiu Hospital, Singapore, Design: A cross-­sectional, descriptive correlational study.
Singapore
Method: The study was conducted in a nursing home and a day care centre from
Correspondence July to December 2019. Two hundred older adults were recruited. Guided by the
Xi Vivien Wu, Alice Lee Centre for Nursing
Studies, Yong Loo Lin School of Medicine, salutogenic model, the sense of coherence (SOC) scale, Connor–­Davidson resilience
National University of Singapore, Level 2, scale, de Jong Gierveld loneliness scale and World Health Organization quality of
Clinical Research Centre, Block MD 11, 10
Medical Drive, Singapore 117597. life instrument-­older adults (WHOQOL-­OLD) were used. The sociodemographic and
Email: [email protected] clinical profiles of participants were collected. Descriptive statistics, Pearson product-­
Funding information moment correlation coefficient, independent-­samples t test, one-­way analysis of vari-
This research did not receive any specific ance and stepwise regression were utilised in the analysis.
grant from funding agencies in the public,
commercial, or not-­for-­profit sectors. Results: The mean score for WHOQOL-­OLD was 94.42 ± 19.55. The highest mean
score was observed in the “Death and Dying” facet, while the lowest mean scores
were reflected in the “Autonomy” and “Intimacy” facets of QoL. Regardless of resident
type, most QoL scores were similar across different variables. Based on the stepwise
regression, higher manageability and meaningfulness in SOC, higher resilience, lower
social loneliness, lower emotional loneliness and hearing impairments are significantly
associated with higher QoL.
Conclusion: Manageability, meaningfulness and resilience should be enhanced while
ameliorating feelings of loneliness to improve the QoL amongst older adults receiving
long-­term care. Age, marital status, educational level, care arrangement, body mass
index, performance in activities of daily living, comorbidities and hearing and mobility
impairments could influence QoL and thus warrant more attention.
Impact: Future interventions can be conducted in group sessions to facilitate social
interaction and alleviate loneliness. More resources should be allocated to enhance
older adults’ care arrangements and coping mechanisms to provide them with the
support, as they face challenges in daily life due to mobility impairment and other
restrictions.

J Adv Nurs. 2021;00:1–19. wileyonlinelibrary.com/journal/jan© 2021 John Wiley & Sons Ltd     1 |
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2      TAN et al.

KEYWORDS
cross-­sectional research, loneliness, long-­term care, midwifery, nurses, nursing, older adults,
quality of life, resilience, salutogenesis, sense of coherence

1  |  I NTRO D U C TI O N Resilience is defined as the ‘person–­environment’ interaction which

allows one to adapt to stressors (coping mechanism; Bolton et al.,
Although different countries have defined the age for ‘older adults’ 2016; Egeland et al., 1993). Wild et al. (2013) added that more re-
differently based on the country's life expectancy, the World Health cent literature has shifted the focus to examine the influence of
Organization (WHO) considers people aged 60  years and older as systemic factors on one's adaptation process, thus reconceptualise
older adults (WHO, 2018). WHO has projected the global popu- resilience as a multidimensional concept, which includes the socio-­
lation of older adults to rise sharply over the next 30  years, from environmental, financial and mobility aspects. Despite the prolifera-
900  million in 2015 to 2 billion by 2050 (WHO, 2018). Like other tion in publication in the psychogeriatric field, most of these studies
developed countries, Singapore has forecasted a rising demand for have focused on resilience, rather than the outcome—­healthy ageing.
long-­term care (LTC) services due to its ageing population, increased Martinson and Berridge (2015) observed much heterogeneity in its
prevalence of chronic diseases and trend towards smaller family definition, with most of these studies focusing on the coping aspect.
units (Goh et al., 2018). Within the community, the LTC services can These observations were also made by Michel and Sadana (2017),
be classified into home-­based, centre-­based, and residential care who reported challenges in unifying the definition of healthy ageing
to support older adults who require assistance in their activities of and measurement due to sociocultural variability and relevance to
daily living (ADLs; Su & Wang, 2019). ageing. They reviewed 10 recently published papers and outlined
As the older adults face greater risks of developing chronic dis- the different domains of healthy ageing, such as daily functioning,
eases and functional limitations over time, this trend warrants an ur- personal perception and physiological outcomes. Michel and Sadana
gent need to revamp existing healthcare infrastructure and services, (2017) then proposed future research to examine the perceptions of
as well as promote the concept of healthy ageing. Healthy ageing is older adults towards healthy ageing and their coping mechanisms, in
defined as the process of establishing and conserving functional abil- different countries and contexts.
ity that enables well-­being in declining years (WHO, n.d.). Although Within medical sociology, Antonovsky's (1979) salutogenic model
the LTC settings aspire to promote healthy ageing, older adults re- remains a prominent guiding framework for examining one's coping
ceiving LTC often experience a lower quality of life (QoL) than their process with life stressors. The model assumes the ubiquitous na-
community-­dwelling peers (Siddiqui et al., 2019). This phenomenon ture of life stressors, of which disease is one of them and therefore
has piqued researchers’ interest to investigate the determinants of focuses on how people cope with them using intrinsic and extrin-
healthy ageing in LTC settings. sic resources (Drageset et al., 2017). Based on these assumptions,
Antonovsky proposed the concept of sense of coherence (SOC),
which comprises of three elements: (1) comprehensibility—­the extent
2  |  BAC KG RO U N D to which the stressors are perceived as predictable, ordered and ac-
countable (2) manageability—­the ability to cope using adequate re-
The review by Michel and Sadana (2017) reported that a plethora of sources at disposal; and (3) meaningfulness—­the degree to which the
studies in the literature have discussed the concept of ‘healthy ageing’, stressors are appraised as challenges worthy of investment and com-
since the 1950s. A paradigm shift is observed from a disease-­health mitment, rather than a burden (Wiesmann et al., 2017). Psychologists
continuum perspective to a more pragmatic one focusing on older recommended the adaptation of selection, optimisation and compen-
adults with pre-­existing medical conditions successfully adapting to sation as proactive strategies of life management (Freund & Baltes,
ADLs. To address the limitations of the disease-­oriented model, two 2002). Selection refers to developing and choosing goals, optimisa-
prominent fields have contributed to the ‘healthy ageing’ literature—­ tion to the application and refinement of goal-­relevant means and
resilience theory from the field of psychology and Antonovsky's compensation to the substitution of means when previous means are
(1979) salutogenic model from medical sociology. These develop- no longer available (Freund & Baltes, 2002). The process of selec-
ments have also led WHO to redefine the ‘healthy ageing’ concept to tion, optimisation and compensation focuses on setting clear goals,
its present statement, which recognises the roles of intrinsic capacity investing means into the pursuit of the goals and carrying these out
and compensatory extrinsic resources in maintaining their daily func- persistently even in the face of adversity, which is consistent with the
tions during the later years (Michel & Sadana, 2017). SOC concept (Freund & Baltes, 2002).
Within the resilience literature, Wild et al. (2013) synthesised The salutogenic model's contribution to the healthy ageing dis-
studies that examined the impact of resilience on healthy ageing course is its focus on meaningfulness, which considers the subjective
and observed its historical discourse from a personal traits-­based meaning and personal values that an older adult holds towards ageing,
approach to one focusing on the individual's intrinsic capacities and and the sociocultural context one is in Giglio et al. (2015). At the same
adaptation process in response to the situation and environment. time, Antonovsky's other concept, generalised resistance resources
TAN et al. |
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F I G U R E 1  Conceptual framework—­
salutogenic model. *GRRs, Generalised ↑ Resilience Coping Strategies
Resistance Resources; QoL, Quality of
Life; SOC, Sense of Coherence

↑ Emotional Emotional
loneliness Closeness
GRRs SOC
↑ Healthy
Knowledge and
behaviour
Intelligence

↑ Spousal
support QoL
Support System
↑ Social
loneliness

Healthy Ageing

(GRRs), outlines the multiple layers of resources beyond individual coping mechanism in SOC. Tan et al. (2016) conducted a mixed-­method
attributes, which account for systemic and extrinsic resources to study in Singapore to evaluate the feasibility of a salutogenic-­guided
help the individual cope with life stressors (Mittelmark et al., 2017). self-­care programme on community-­dwelling older adults and found
Although Windle (2011) argued that there were similarities between that the programme enhanced the participants’ comprehensibility and
resilience and SOC, protective factors with GRRs, Mittelmark et al. manageability, which in turn had a positive effect on their psychological
(2017) suggested otherwise. The salutogenic model defines resilience QoL. On the other hand, Martinez-­Martin et al. (2012) investigated the
as coping abilities and subsume it as one of the components of GRRs. determinants of HRQoL and global QoL amongst community-­dwelling
In other words, SOC entails the ability to not just cope with but also older adults and found that SOC was positively associated with global
analyse challenging situations and evaluate the motivation to mobilise QoL but not HRQoL.
diverse resources to overcome the stressors. This model also aligns Despite an increase in the number of salutogenic-­based studies
with Erikson's life stage theory, during the integrity versus despair on older adults, most of the studies were conducted on community-­
stage of development, whereby older adults are challenged with dwelling healthy adults and in the Western countries. There are only
declining functions and medical conditions (Dezutter et al., 2013). two known studies that utilised the salutogenic model to explore the
Resolution of stressors at this stage is postulated to maintain ego in- SOC amongst older adults in Singapore (Seah et al., 2019; Tan et al.,
tegrity characterised by wisdom, thus allowing individuals to attain a 2016). However, as both studies were conducted on healthy older
sense of closure and face death without fear (Dezutter et al., 2013). adults, who were postulated to have better GRRs than those based
Three systematic reviews have examined studies using the salu- within the LTC setting (Goh et al., 2018), it is unknown whether the
togenic model in different healthcare contexts and supported its use older adults living within the LTC setting with fewer GRRs would
due to its ability to incorporate a holistic and collective approach to- have better SOC and QoL than their healthy counterparts.
wards solving clinical issues arising in different populations (Álvarez
et al., 2020; Eriksson & Lindström, 2007; Shorey & Ng, 2021). These
reviews have demonstrated the positive correlations between SOC, 2.1  |  Conceptual framework
health outcomes and well-­being. Several other studies have also ex-
amined the use of salutogenic models on the older adults’ population In the salutogenic model, the concept of health is elucidated on a
and demonstrated a positive correlation between SOC and QoL (von continuum of ease and disease, with the assumption of life being
Humboldt et al., 2014; Wiesmann & Hannich, 2013; Wiesmann et al., inherently full of disturbances that may be perceived as stressors
2009). Von Humboldt et al. (2014) and Wiesmann et al. (2017) reported (Mittelmark et al., 2017). The core constructs of the salutogenic
that SOC served as the strongest predictor of well-­being amongst model include GRRs and SOC. GRRs are defined as the internal and
other predictors such as religion, income, education and social sup- external resources that can be utilised to overcome stressors and
port. Additionally, SOC was found to be associated with all subdimen- strengthen SOC (Mittelmark et al., 2017). GRRs facilitate coping and
sions of health-­related QoL (HRQoL; Drageset et al., 2017; Giglio et al., contribute to the development of SOC, while SOC can be strength-
2015). The resource-­mobilisation and resource-­pooling hypotheses ened by enhancing GRRs or increasing awareness of available re-
were attested in a study conducted by Wiesmann and Hannich (2013). sources (Mittelmark et al., 2017). In other words, there is a reciprocal
Resource-­mobilisation allows the spontaneous application of resources relationship between GRRs and SOC. By enhancing GRRs and SOC,
to cope with adverse events, whereas resource-­pooling assumes that older adults can move towards the ease end on the continuum and
SOC is shaped by resources over time. Both hypotheses explained the achieve healthy ageing.
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4      TAN et al.

GRRs include the following factors: (i) coping strategies, (ii) emo- 3.2  |  Design and setting
tional closeness, (iii) knowledge and intelligence and (iv) support sys-
tem (Figure 1). Of these factors, resilience and emotional closeness A cross-­sectional, descriptive correlational design was adopted in
have been postulated to contribute to internal resources for coping this study. This study was conducted from July to December 2019
(Mittelmark et al., 2017). Resilience refers to the ability to bounce at a charitable LTC facility located in the north-­eastern part of
back from adversity and reintegrate back into a satisfying life after Singapore. The nursing home had over 600 beds and provided medi-
difficult circumstances (Resnick, 2014). Psychological, physical and cal and nursing care for older adults. The day care centre provided
social aspects of resilience help to overcome age-­related adversi- centre-­based rehabilitation programmes with a range of activities
ties (Wild et al., 2013). With healthy personality and coping strate- for cognitive stimulation, body strengthening and balance training.
gies, psychological resilience is a process of using positive adaptive
behaviours when dealing with adversity (Resnick, 2014). Research
has shown that an individual with higher resilience demonstrates 3.3  |  Participants
an increased use of positive coping strategies to persist through ad-
versity (McClain et al., 2018). According to Weiss et al. (1973), emo- Nursing home residents and day care clients were recruited through
tional closeness is often lacking amongst lonely older adults and can convenience sampling. All older adults aged 60 years and above who
be classified into two types: (i) Emotional loneliness—­resulting from were able to read and/or speak in English and/or Chinese were eli-
the deprivation of emotional attachment to significant others and (ii) gible for the study. Older adults who were clinically diagnosed with
social loneliness—­characterised by the lack of an engaging social net- major psychiatric illness or moderate to severe cognitive impairment
work of people with common interests. were excluded.
The concept of SOC originated from Antonovsky in 1979 to ex-
plain why some people became sick under stress while others stayed
healthy. According to Mittelmark et al. (2017), increasing older 3.4  |  Sample size estimation
adults’ awareness and knowledge of available resources through ed-
ucation could ultimately help them achieve healthy ageing on the Convenience sampling was employed in the recruitment of study
conceptual health continuum, including SOC. Having higher educa- participants. It allowed maximal data collection within a limited
tion level increases the likelihood of engaging in healthy behaviour sampling frame (Polit & Beck, 2009). While nonprobability sampling
and improving coping mechanism and social relationship, which in could reduce generalisability, it was the most feasible and cost-­
turn leads to a better QoL (Onunkwor et al., 2016). Increased self-­ efficient sampling method due to time and resource constraints.
efficacy amongst educated older adults also helps them to stay The eligible population was expected to be 30% of the total 711
positive (Hedayati et al., 2014). Lastly, a strong support system is older adults at the study site. We derived the population variance
crucial as it promotes sense of security, peace and belonging, hence, from the standard deviation (SD) of QoL which ranged from 10.30
facilitating positive psychological adjustment when dealing with to 15.82 (Dogan & Goris, 2018; Şenol et al., 2013). Assuming a 95%
stressors. Hedayati et al. (2014) reported that married older adults confidence interval, 1 unit margin of error and a median SD of 13, a
had higher QoL than those who were bereaved or divorced and con- minimum of 161 participants was required for a population of 213
cluded that support systems could be enhanced by spousal relation- older adults.
ships. Guided by the salutogenic model (Figure 1), the main research
questions in this study were as follows:
3.5  |  Variables and measurements
1. What are the impacts of SOC, resilience and loneliness on
different domains of QoL amongst older adults in the LTC Participant's gender, age, marital status, educational level, ethnicity,
setting? religion, caregiver and care arrangements were recorded. We also
2. What are the predictive factors of QoL amongst older adults in gathered clinical data such as comorbidities, sensory and functional
the LTC setting? impairments, body height and weight. In addition to these self-­
reported data, the Barthel Index (BI) scores were retrieved by the site
principal investigator. In consideration of the majority Chinese popu-
3  |  TH E S T U DY lation and their limited English literacy at the study site, the Chinese
version of the questionnaire was included. Following the guidance
3.1  |  Aims of the salutogenic model (Antonovsky, 1979), four instruments, SOC
scale, Connor–­Davidson resilience scale, de Jong Gierveld loneliness
This study aimed to identify the predicting factors of QoL from a set scale and World Health Organization QoL instrument-­older adults,
of psychosocial, sociodemographic and clinical variables amongst were used to examine the impact of SOC, resilience and loneliness
older adults in a LTC setting. on different domains of QoL amongst older adults in LTC setting and
TAN et al. |
      5

identify the predictive factors of QoL from a set of psychosocial, Activities” (PPF); “Social Participation” (SOP); “Death and Dying”
sociodemographic and clinical variables. (DAD) and “Intimacy” (INT). Each facet consists of four items. There
are seven reverse-­scored items. The rating for positively scored
items was taken at face value, while scoring for reverse-­scored items
3.5.1  |  Sense Of Coherence scale (SOC-­13) was converted (i.e. a score of 5 was converted to 1).

SOC-­13 is a scale that assesses how people view life and seek to
identify how people use their resources to overcome resistance and 3.6  |  Data collection
maintain and develop their health (Mittelmark et al., 2017). SOC-­13
is derived from the original 29-­item scale. Antonovsky's scale has Potential participants were identified by the nurses after they per-
been translated and used in at least 49 different languages. SOC-­13 formed prudent assessments based on the selection criteria. The
is ranked on a 7-­point Likert-­t ype scale (1 = never to 7 = very often) researcher conducted a short briefing for the participants to inform
to measure perceived comprehensibility (five items), manageability them about the purpose of the study, the instruments used, esti-
(four items) and meaningfulness (four items). Low comprehensibility mated time required to complete the questionnaires, as well as the
is defined as ≤26 points, while low manageability and meaningful- potential risks and benefits of the research. Participants were also
ness are defined as ≤22 points. There are five reverse-­scored items. informed verbally that they reserved the right to refuse participa-
tion. All enquiries about the study were answered and the study
commenced after obtaining verbal consent. The survey was con-
3.5.2  |  Connor–­Davidson Resilience Scale (CD-­ ducted either at the bedside or a private space depending on the
RISC-­10) mobility status of the participants, while maintaining a conducive
environment for data collection.
CD-­RISC-­10 is a robust unidimensional scale in assessing resilience
(Cosco et al., 2016). Each item is rated on a 5-­point scale (0 = not true
at all to 4 = true nearly all the time). Scoring of the scale is based on 3.7  |  Ethical considerations
summing the total of all the items, each of which is scored from 0–­4.
For the CD-­RISC-­10, the full range is therefore 0 to 40, with higher Ethical approval was obtained from the Institutional Review Board
scores reflecting greater resilience. (IRB) of the National University of Singapore on 15 July 2019 with
the reference code S-­19-­209. A waiver of documented consent was
approved by the IRB. The researcher ascertained that the infor-
3.5.3  |  de Jong Gierveld Loneliness Scale (dJGLS-­6) mation about the study (i.e. anticipated risk and benefit, uncondi-
tional right of withdrawal, study duration, etc.) was complete and
Loneliness concerns the subjective evaluation of one's situation, adequately understood by the participants. Informed consent was
characterised by either a smaller than desirable number of relation- obtained verbally from the participants before the data collection.
ships with friends and colleagues (social loneliness) or situations Privacy and confidentiality was ensured throughout the entire
whereby the intimacy in confidant relationships one wishes for has course of research and thereafter.
not been realised (emotional loneliness; de Jong Gierveld & van
Tilburg, 2010). A shortened six-­item version of dJGLS-­6 was used
to measure social and emotional loneliness, with three items assess- 3.8  |  Data analysis
ing each component (de Jong Gierveld & van Tilburg, 2010). The re-
sponse categories included “yes”, “more or less” and “no”. Responses Data analysis was performed using IBM Statistical Package for
were translated into “yes” for a score of 1 point and “no” with no the Social Sciences (SPSS) Version 26.0. All data were summarised
score for negatively worded emotional loneliness. In both subscales, using descriptive statistics, namely, frequency and percentage for
a response of “more or less” earned 1 point. categorical data, mean and SD for continuous data. The Pearson
product-­moment correlation coefficient was performed to test
the relationship between QoL and the continuous variables, while
3.5.4  |  World Health Organization QoL instrument-­ independent-­samples t test and one-­way analysis of variance
older adults module (WHOQOL-­OLD) (ANOVA) with post hoc Bonferroni tests were applied to investigate
the differences in QoL amongst subgroups classified under different
The outcome variable was collected using WHOQOL-­OLD which is sociodemographic and clinical variables. Variables which had a p-­
a multidimensional measure of the QoL in older adults. WHOQOL-­ value of <.100 for the inferential tests were included in the stepwise
OLD consists of 24 questions answered on a Likert-­t ype scale regression to identify the predictors of QoL amongst variables with
(1  =  not at all to 5  =  completely) to assess six facets: “Sensory significant correlation or significant group differences. Statistical
Abilities” (SAB); “Autonomy” (AUT); “Past, Present and Future significance for all the tests was set at a p-­value of <.05.
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6      TAN et al.

TA B L E 1  Characteristics of participants
3.9  |  Validity, reliability and rigour
Total
The WHOQOL-­OLD, SOC-­13, CD-­RISC-­10 and dJGLS-­6 have been (N = 200)

well-­validated in previous research (Cosco et al., 2016; de Jong Demographic variable n (%)
Gierveld & van Tilburg, 2010; Eriksson & Lindstrom, 2005; Mick &
Gender
Silke, 2006). These instruments had been translated from English
Male 84 (42.0)
into Chinese and undergone validation in previous research as well.
Female 116 (58.0)
All the instruments demonstrated reasonable levels of reliability and
Age
validity. The WHOQOL-­OLD achieved a high Cronbach's alpha of
0.89 for its total score (Mick & Silke, 2006). The Chinese version <70 years old 29 (14.5)

yielded a Cronbach's alpha which ranged from 0.711 to 0.842 for 70–­79 years old 63 (31.5)

each domain (Liu et al., 2013). Its reliability and validity were also ≥80 years old 108 (54.0)
confirmed by an acceptable intraclass correlation coefficient (ICC) Mean (SD) 79.43 (8.25)
of more than 0.7, as well as good content and construct validity (Liu Marital status
et al., 2013). Single 46 (23.0)
SOC-­13  has generally shown acceptable reliability (α  =  0.70–­ Married 49 (24.5)
0.92 in a review of 127 studies), as well as criterion and construct Widowed 92 (46.0)
validity across different cultures (Eriksson & Lindstrom, 2005). The
Divorced 9 (4.5)
translated version has also demonstrated good reliability (α = 0.89;
Separated 4 (2.0)
Li et al., 2017).
Highest educational level
CD-­RISC-­10 has a good internal consistency, which is supported
No formal education 92 (46.0)
by Cronbach's alpha that ranged from 0.88 to 0.93 (Cosco et al.,
Primary 60 (30.0)
2016). Both Cronbach's alpha of 0.936 and a test-­retest reliability
coefficient of 0.665 were documented for the translated Chinese Secondary or highera  48 (24.0)

version of CD-­RISC-­10 (Meng et al., 2019). Ethnicity

The dJGLS-­6 has been tested in seven countries, and its reliabil- Chinese 194 (97.0)
b
ity and validity have been proven (de Jong Gierveld & van Tilburg, Non-­Chinese   6 (3.0)
2010). The translated version also showed good content validity and Religion
reliability, with ICC ranging from 0.98 to 1.00 and Cronbach's alpha Buddhism 122 (61.0)
at a satisfactory level of 0.76 (Leung et al., 2008). Christianity 39 (19.5)
c
Others   39 (19.5)
Primary caregiver
4  |  R E S U LT S
Self 98 (49.0)
Othersd  102 (51.0)
Two hundred and ten potential participants were preselected from
Care arrangement
711 participants in the LTC setting. Those with early stage demen-
Day care 76 (38.0)
tia were assessed by clinicians to ensure that they demonstrated
the cognitive capacity to complete the questionnaires. Of 210 eli- Nursing home (<24 months) 79 (39.5)

gible participants, 200 completed the questionnaire, while 10 de- Nursing home (≥24 months) 45 (22.5)
clined to participate in the study (response rate: 95.2%). Table 1 Body mass index
presents a summary of the sociodemographic and clinical charac- <18.5 kg/m2 38 (19.0)
teristics of the participants. The mean age of the participants was 18.5–­24.9 kg/m 2
124 (62.0)
79.43 ± 8.25 years. Most of the respondents were Chinese (n = 194, ≥25.0 kg/m2 38 (19.0)
97.0%), widowed (n  =  92, 46.0%), Buddhist (n  =  122, 61.0%) and Barthel index for ADL
had no formal education (n  =  92, 46.0%). More than half of the
≥80 (totally independent) 60 (30.0)
participants were female (n = 116, 58.0%), nursing home residents
60–­79 (minimally dependent) 36 (18.0)
(n = 124, 62.0%) and had a primary caregiver who was either a fam-
40–­59 (partially dependent) 51 (25.5)
ily member or helper (n = 102, 51.0%). In terms of clinical variables,
20–­39 (very dependent) 41 (20.5)
the mean body mass index (BMI) was 21.84 kg/m2 (SD = 3.90). The
<20 (totally dependent) 12 (6.0)
mean BI score was 59.65 (SD = 25.39). Most respondents were ADL-­
dependent, with a score below 80 (n = 140, 70.0%). A total of 140 Number of comorbidities

respondents (70.0%) reported having at least three comorbidities.

The most common comorbidity was hypertension (n = 143, 71.5%). (Continues)
TAN et al. |
      7

TA B L E 1  (Continued)
of 0–­1; 75 participants (37.5%) with a score of 2–­4 experienced mod-
Total erate loneliness, and 33 participants (16.5%) with a score above 4
(N = 200)
experienced severe loneliness. Good internal consistency of the in-
Demographic variable n (%) struments was also documented by Cronbach's alpha of >0.7.
Table 3 shows that all components of SOC, resilience and loneli-
0 0 (0.0)
ness were at least moderately correlated with QoL and its domains.
1 29 (14.5)
However, an exception of weak association was observed between
2 31 (15.5)
meaningfulness in SOC and DAD in QoL (r = 0.175, p = 0.013).
≥3 140 (70.0)
The comparison of mean scores of outcome variables amongst
Top five comorbidities
different socio-­demographic and clinical subgroups is illustrated in
Hypertension 143 (71.5) Table 4. Participants aged 70–­79 and ≥80 years had higher overall
Hyperlipidaemia 103 (51.5) QoL (F = 4.46, p = .013) and DAD scores (F = 6.37, p = .003) than their
Stroke 66 (33.0) younger counterparts. Participants who were divorced, separated
Type II diabetes mellitus 64 (32.0) or widowed scored significantly higher in AUT (F  =  4.75, p  =  .010)
Early stage of dementia 51 (25.5) and SOP (F  =  3.59, p  =  .029) than those who were never married.
e
Visual impairment   Significant higher scores in INT were also observed amongst the

Yes 37 (18.5) ever-­married participants in comparison with the single individuals,

while married participants scored significantly higher than those
No 163 (81.5)
who lost their spouse (F = 24.85, p < .001). In terms of overall QoL,
Hearing impairment
single participants scored significantly lower than the other groups
Yes 26 (13.0)
(F = 7.31, p = .001).
No 174 (87.0)
On the other hand, participants who received secondary or
Mobility
higher education scored lower in DAD (F = 3.55, p = .033) in com-
Impairedf  144 (72.0) parison to other groups. While a significant difference in SOP was
Normal 56 (28.0) observed (F = 3.87, p = .024), post hoc Bonferroni tests showed oth-
a
Secondary or higher: Received the equivalent of secondary or tertiary erwise. Nursing home residents scored significantly lower than day
education. Tertiary education includes those who received education care clients for the overall and all domains of QoL across different
from Junior College, Polytechnics, Institute of Technical Education or
demographic and clinical variables. The length of stay amongst nurs-
University.
b ing home residents did not affect the results.
Non-­Chinese comprises Malay, Indian and Eurasian participants.
c In terms of clinical variables, significant differences were ob-
Others include Taoism, Catholicism, Hinduism, Islam and Free thinker.
d
Others include helper or family members such as spouse, sibling, served amongst the different BMI groups. Underweight participants
children and grandchildren. scored significantly lower in SAB, SOP and total QoL, than those in
e
Visual impairment not corrected by glasses (e.g. glaucoma, cataract, the healthy weight range, while the overweight group scored sig-
blindness and diabetic retinopathy). nificantly higher in SOP and total QoL than the underweight group.
f
Impaired: Requires assistance, wheelchair-­bound or bedbound. However, post hoc tests showed no significant difference in AUT
between the BMI groups.
In addition, 37 respondents (18.5%) had visual impairments while 26 Furthermore, significant differences were observed across dif-
(13.0%) had hearing impairments. Most participants also reported ferent performances in ADL based on the BI scores. Participants
having mobility impairments (n = 144, 72.0%). who were very/totally dependent scored significantly lower in all
Table 2 reports the outcomes of the study. The overall WHOQOL-­ domains of QoL as compared to totally independent participants.
OLD scores ranged from 40 to 120; the overall mean score was Similarly, partially dependent participants had significantly lower
94.42  ±  19.55. Amongst the six domains, the highest mean score scores in most QoL domains compared to the totally independent
was observed in the DAD facet, while the lowest mean scores were ones, with exceptions in PPF and DAD. Minimally dependent partic-
reflected in the INT and AUT facets. The overall scores for SOC-­ ipants also scored higher in AUT, INT and total QoL in comparison
13 ranged from 24 to 91; the mean score was 71.80 ± 13.94. High with very/totally dependent participants.
comprehensibility (>26 points) and manageability (>22 points) but In terms of comorbidities, post hoc tests after ANOVA revealed
low meaningfulness (≤22 points) were observed amongst the partic- no significant difference amongst participants with different num-
ipants. Item 4 in meaningfulness had the lowest score (2.83 ± 2.34), bers of comorbidities. Amongst the top five comorbidities reported,
as participants expressed lack of clear goal and purpose in life. On hypertension was found to affect SAB (t = −2.36, p = .019); hyperlip-
the other hand, the overall scores for CD-­RISC-­10 ranged from 2 to idaemia was positively associated with AUT (t = 2.35, p = .020) and
40; the mean score was 28.64 ± 9.28. The overall scores for dJGLS-­6 SOP (t = 2.01, p = .046); stroke was negatively correlated with AUT
ranged from 0 to 6; the mean score was 2.10  ±  1.92. Ninety-­t wo (t = −2.00, p = .048) and total QoL (t = −2.12, p = .036); Type II diabetes
participants (46.0%) did not feel lonely, as demonstrated by a score mellitus was found to affect PPF (t = −2.28, p = .024), DAD (t = −2.42,
 |
8      TAN et al.

TA B L E 2  Mean, standard deviation and

Total (N = 200)
Cronbach's alpha of the scales
Cronbach's
Scale Subscales Mean (SD) alpha

WHOQOL-­OLD Sensory abilities (SAB) 17.39 (3.05)

Autonomy (AUT) 14.37 (4.35)
Past, present, and future activities (PPF) 14.86 (3.77)
Social participation (SOP) 15.31 (4.89)
Death and dying (DAD) 18.16 (3.60)
Intimacy (INT) 14.34 (4.66)
Overall mean 94.42 (19.55) 0.952
SOC-­13 Comprehensibility 29.75 (5.56)
Manageability 24.46 (4.95)
Meaningfulness 17.60 (5.96)
Overall mean 71.80 (13.94) 0.847
CD-­RISC-­10 Overall mean 28.64 (9.28) 0.934
dJGLS Social loneliness 1.31 (1.19)
Emotional loneliness 0.79 (1.00)
Overall mean 2.10 (1.92) 0.793

Abbreviations: AUT, autonomy; CD-­RISC-­10, Connor–­Davidson resilience scale; DAD, death and
dying; dJGLS-­6, de Jong Gierveld loneliness scale; INT, intimacy; PPF, past, present, and future
activities; SAB, sensory abilities; SOC-­13, Sense of coherence scale; SOP: Social participation;
WHOQOL-­OLD, World Health Organization quality of life instrument-­older adults module.

TA B L E 3  Correlation between continuous variables and study outcomes

Pearson correlation coefficient (p-­value)

Study variables SAB AUT PPF SOP DAD INT Total

** ** ** ** ** **
SOC—­comprehensibility .559 .623 .656 .620 .429 .548 .717**
** ** ** ** ** **
SOC—­manageability .656 .601 .625 .604 .574 .562 .748**
SOC—­meaningfulness .399** .662** .706** .697** .175* .585** .692**
** ** ** ** ** **
Resilience .562 .797 .834 .828 .436 .697 .879**
Social loneliness −.385** −.639** −.701** −.699** −.353** −.700** −.744**
** ** ** ** ** **
Emotional loneliness −.562 −.591 −.584 −.599 −.450 −.539 −.693**

Note: All correlations were significant at p < .001 except that between DAD and meaningfulness which was significant at .013.
Abbreviations: AUT, Autonomy; DAD, death and dying; INT, intimacy; PPF: past, present and future activities; SAB, Sensory abilities; SOP, social
participation.
*p < .05.; **p < .001.

p = .018) and total QoL (t = −2.06, p = .040); and early stage of demen- group, significant higher scores in QoL were observed for Chinese
tia was positively associated with AUT (t = 2.28, p = .024) and total older adults, those without hypertension, stroke, diabetes mellitus,
QoL (t = 2.06, p = .040). In addition, participants with hearing impair- mobility impairment and with higher BI.
ment were found to have lower scores in SAB (t = −4.16, p < .001). In the final regression analysis (Table 5), higher manageability
Mobility impairment was also found to be negatively associated with [β  =  0.80 (0.50, 1.09)], higher meaningfulness [β  =  0.34 (0.10, 0.58)],
all domains of QoL. higher resilience [β = 0.99 (0.80, 1.17)], lower social loneliness [β = −3.19
Table 4 illustrates the comparison of the overall QoL scores (−4.40, −1.98)], lower emotional loneliness [β = −2.42 (−3.82, −1.03)] and
across various demographic variables between the resident types: no hearing impairment [β = −3.80 (−6.81, −0.80)] were identified as sig-
day care and nursing home older adults. Regardless of resident type, nificant predictors for greater QoL, accounting for 87.3% of the variance
most QoL scores were similar across different variables. Significant between the expected and observed QoL scores. In addition, separate
higher QoL scores were observed for older adults with hypertension regression analyses for the day care and nursing home older adults were
or hyperlipidaemia for the day care group. As for the nursing home conducted and the results were illustrated in Table 5. For day care older
TA B L E 4  Comparison of mean scores of quality of life amongst different groups of sociodemographic and clinical characteristics

Mean (SD)
TAN et al.

Total Day care Nursing home

Demographic variable SAB AUT PPF SOP DAD INT n = 200 n = 76 n = 124

Gender
Male (n = 84) 17.6 (2.8) 14.1 (3.9) 14.7 (3.9) 14.7 (5.2) 18.1 (3.7) 14.4 (4.7) 93.5 (19.1) 102.5 (13.4) 88.8 (20.1)
Female (n = 116) 17.2 (3.2) 14.6 (4.7) 15.0 (3.7) 15.8 (4.6) 18.2 (3.5) 14.3 (4.7) 95.1 (19.9) 106.0 (12.6) 87.6 (20.6)
t/F statistic 0.97 −0.75 −0.58 −1.53 −0.26 0.01 −0.55 −1.18 0.33
p-­value .334 .457 .564 .128 .798 .989 .582 .241 .740
Age
<70 years old (n = 29) 16.3 (3.8) 12.8 (4.7) 14.2 (4.0) 13.6 (4.6) 15.0 (5.5) 12.8 (5.2) 84.6 (20.4) 95.6 (16.4) 80.4 (20.5)
70–­79 years old (n = 63) 17.9 (2.8) 14.4 (4.2) 14.8 (3.9) 15.1 (5.1) 18.5 (3.2) 14.7 (4.9) 95.5 (19.4) 105.5 (12.8) 88.9 (20.2)
≥80 years old (n = 108) 17.4 (2.9) 14.8 (4.3) 15.1 (3.7) 15.9 (4.8) 18.8 (2.7) 14.5 (4.4) 96.4 (18.8) 105.9 (11.9) 90.2 (20.0)
t/F statistic 2.82 2.57 0.57 2.69 6.37 1.92 4.46 2.28 1.90
** *
p-­value .062 .079 .569 .070 .003 .149 .013 .110 .154
Marital status
Single (n = 46) 16.7 (3.5) 12.8 (4.1) 13.8 (3.8) 14.0 (4.9) 17.0 (4.7) 10.9 (4.7) 85.0 (20.5) 98.0 (n.a.) 84.8 (20.6)
Married (n = 49) 17.8 (3.0) 14.3 (4.3) 15.1 (3.4) 14.8 (5.4) 18.4 (3.1) 16.8 (3.9) 97.1 (17.9) 103.6 (14.1) 89.2 (19.1)
Others (n = 105) 17.5 (2.9) 15.1 (4.4) 15.2 (3.9) 16.1 (4.5) 18.6 (3.2) 14.7 (4.1) 97.3 (18.8) 105.4 (12.4) 90.4 (20.5)
t/F statistic 1.82 4.75 2.39 3.59 2.16 24.85 7.31 0.313 1.01
* * ** **
p-­value .164 .010 .094 .029 .122 < .001 .001 .73 .369
Highest educational level
No formal education (n = 92) 17.4 (2.8) 15.0 (4.0) 15.5 (3.1) 16.3 (4.1) 18.8 (2.6) 14.6 (4.2) 97.5 (16.8) 103.8 (12.5) 91.8 (18.3)
Primary (n = 60) 17.5 (3.0) 13.7 (4.7) 14.2 (4.5) 14.5 (5.6) 18.5 (3.1) 14.2 (5.1) 92.5 (21.1) 107.4 (13.8) 86.6 (20.6)
Secondary or higher (n = 48) 17.3 (3.5) 14.0 (4.4) 14.5 (3.8) 14.4 (5.1) 16.7 (5.1) 14.1 (5.0) 90.9 (21.9) 104.2 (13.7) 84.9 (22.4)
t/F statistic 0.06 2.11 2.25 3.87 3.55 0.25 2.31 0.493 1.358
* *
p-­value .947 .125 .110 .024 .033 .782 .105 .613 .261
Ethnicity
Chinese (n = 194) 17.5 (2.8) 14.4 (4.3) 15.0 (3.7) 15.4 (4.9) 18.2 (3.5) 14.4 (4.6) 94.9 (18.8) 104.4 (12.9) 89.0 (19.5)
Non-­Chinese (n = 6) 12.8 (6.6) 12.7 (7.1) 12.0 (6.4) 14.0 (5.2) 16.5 (5.4) 11.8 (6.7) 79.8 (35.7) 116.5 (2.1) 61.5 (27.9)
t/F statistic 1.75 0.60 1.13 0.67 0.77 1.34 1.03 −1.320 2.737
p-­value .140 .572 .311 .507 .477 .182 .350 .191 .007*
Religion
Buddhism (n = 122) 17.6 (2.8) 14.8 (4.2) 15.0 (3.5) 15.7 (4.7) 18.4 (3.3) 14.7 (4.3) 96.1 (18.3) 103.5 (13.2) 90.6 (19.7)
|
      9

(Continues)
TA B L E 4  (Continued)
|

Mean (SD)
10     

Total Day care Nursing home

Demographic variable SAB AUT PPF SOP DAD INT n = 200 n = 76 n = 124

Christianity (n = 39) 17.4 (2.9) 12.9 (4.7) 14.0 (4.6) 14.3 (5.3) 17.7 (4.5) 13.2 (5.1) 89.4 (21.7) 109.7 (8.1) 85.7 (21.4)
Others (n = 39) 16.9 (3.9) 14.7 (4.1) 15.3 (3.7) 15.1 (5.1) 18.0 (3.5) 14.4 (5.2) 94.3 (20.7) 106.4 (13.3) 83.9 (20.4)
t/F statistic 0.73 3.02 1.05 1.29 0.58 1.40 1.76 0.837 1.208
p-­value .486 .051 .356 .277 .560 .254 .175 .437 .302
Primary caregiver
Self (n = 98) 17.6 (2.9) 14.7 (4.4) 15.0 (3.9) 15.3 (5.1) 18.4 (3.2) 14.1 (5.1) 95.2 (19.7) 105.7 (12.9) 83.8 (19.5)
Others (n = 102) 17.2 (3.2) 14.0 (4.3) 14.8 (3.6) 15.3 (4.7) 17.9 (4.0) 14.5 (4.2) 93.7 (19.5) 102.6 (12.9) 90.8 (20.4)
t/F statistic 1.08 1.11 0.40 0.02 1.04 −0.58 0.55 0.979 −1.874
p-­value .282 .267 .689 .986 .302 .561 .584 .331 .063
Care arrangement
Day care (n = 76) 18.4 (1.9) 16.7 (3.1) 16.2 (2.8) 17.5 (3.6) 19.0 (2.7) 16.9 (3.0) 104.7 (12.9)
Nursing home (<24 months; 17.2 (2.9) 13.1 (4.3) 14.1 (4.1) 14.3 (5.0) 17.7 (3.9) 13.3 (4.7) 89.6 (19.6)
n = 79)
Nursing home (≥24 months; 16.1 (4.2) 12.8 (4.7) 13.9 (4.2) 13.4 (5.3) 17.6 (4.3) 11.8 (5.0) 85.6 (21.4)
n = 45)
t/F statistic 9.32 24.24 10.09 16.06 4.24 28.91 24.79
** ** ** ** * **
p-­value <.001 <.001 <.001 <.001 .017 <.001 <.001**
Body mass index
<18.5 kg/m2 (n = 38) 16.2 (3.4) 12.7 (3.9) 13.8 (4.2) 13.2 (5.2) 16.8 (5.0) 13.2 (4.4) 86.0 (21.0) 94.3 (17.5) 85.0 (21.3)
18.5–­24.9 kg/m2 (n = 124) 17.8 (2.7) 14.7 (4.3) 15.2 (3.5) 15.6 (4.8) 18.4 (3.2) 14.6 (4.6) 96.3 (17.8) 104.4 (13.1) 90.6 (18.5)
≥25.0 kg/m2 (n = 38) 17.2 (3.6) 15.1 (4.7) 14.9 (4.0) 16.4 (4.5) 18.6 (3.0) 14.6 (5.2) 96.8 (21.8) 107.3 (11.0) 83.9 (25.0)
t/F statistic 3.72 3.52 2.08 4.65 1.99 1.52 4.52 1.800 1.305
p-­value .026* .032* .128 .011* .144 .222 .012* .173 .275
Barthel index
≥80 (totally independent; n = 60) 18.6 (1.8) 16.5 (3.3) 16.5 (2.7) 17.4 (3.9) 19.3 (2.0) 16.8 (3.2) 105.1 (13.4) 105.6 (13.1) 102.2 (15.4)
60–­79 (minimally dependent; 17.5 (2.8) 14.8 (4.5) 14.6 (3.6) 15.7 (4.5) 18.1 (3.8) 14.7 (3.8) 95.3 (18.6) 103.3 (12.5) 88.2 (20.5)
n = 36)
40–­59 (partially dependent; 17.0 (2.7) 13.8 (4.1) 14.8 (3.8) 14.8 (4.7) 17.9 (3.6) 13.5 (4.6) 91.7 (17.1) 101.6 (13.6) 90.7 (17.3)
n = 51)
<40 (very/ totally dependent; 16.4 (4.1) 12.3 (4.6) 13.4 (4.3) 13.1 (5.4) 17.2 (4.5) 12.1 (5.3) 84.4 (22.4) 102.7 (15.9) 83.3 (22.4)
n = 53)
TAN et al.

(Continues)
TABLE 4 (Continued)

Mean (SD)
TAN et al.

Total Day care Nursing home

Demographic variable SAB AUT PPF SOP DAD INT n = 200 n = 76 n = 124

t/F statistic 7.07 11.76 7.99 8.49 4.98 13.70 14.31 0.254 2.755
p-­value <.001** <.001** <.001** <.001** .003** <.001** <.001** .858 .045*
Number of comorbidities
1 (n = 29) 18.3 (2.0) 14.0 (3.5) 15.5 (3.0) 15.8 (4.2) 18.0 (3.5) 14.4 (4.9) 96.1 (16.3) 98.8 (17.3) 94.5 (16.0)
2 (n = 30) 18.0 (1.8) 14.0 (4.2) 14.6 (3.5) 15.2 (5.0) 18.6 (3.6) 14.2 (4.6) 95.5 (17.8) 102.3 (13.1) 89.4 (18.9)
≥3 (n = 141) 17.1 (3.4) 14.5 (4.6) 14.8 (4.0) 15.2 (5.0) 18.1 (3.6) 14.4 (4.7) 94.0 (20.6) 106.4 (11.6) 86.6 (21.2)
t/F statistic 4.13 0.29 0.54 0.19 0.27 0.01 0.14 1.879 1.181
p-­value .020* .745 .583 .826 .768 .989 .872 .160 .311
Hypertension
Yes (n = 143) 17.1 (3.4) 14.4 (4.6) 14.7 (3.9) 15.2 (5.0) 18.0 (3.8) 14.3 (4.8) 93.8 (20.7) 107.8 (10.4) 85.3 (20.9)
No (n = 57) 18.0 (2.0) 14.2 (3.7) 15.2 (3.3) 15.5 (4.6) 18.5 (3.1) 14.5 (4.4) 96.0 (16.2) 97.1 (15.4) 95.3 (16.9)
t/F statistic −2.36 0.35 −0.79 −0.30 −0.91 −0.39 −0.78 3.505 −2.501
* **
P-­value .019 .725 .432 .766 .365 .697 .436 .001 .014*
Hyperlipidaemia
Yes (n = 103) 17.2 (3.4) 15.1 (4.4) 15.1 (3.8) 16.0 (4.5) 18.2 (3.6) 14.8 (4.5) 96.4 (19.6) 107.8 (9.9) 88.2 (20.8)
No (n = 97) 17.6 (2.6) 13.6 (4.2) 14.6 (3.7) 14.6 (5.2) 18.1 (3.6) 13.8 (4.8) 92.3 (19.4) 100.6 (15.2) 88.1 (20.0)
t/F statistic −0.91 2.35 1.07 2.01 0.10 1.55 1.47 2.356 0.042
p-­value .364 .020* .287 .046* .921 .122 .143 .022* .966
Stroke
Yes (n = 66) 16.9 (3.6) 13.5 (4.7) 14.1 (4.2) 14.4 (5.1) 17.7 (3.8) 13.8 (5.1) 90.3 (21.4) 103.4 (13.2) 81.8 (21.5)
No (n = 134) 17.6 (2.7) 14.8 (4.1) 15.2 (3.5) 15.8 (4.7) 18.4 (3.5) 14.6 (4.4) 96.5 (18.3) 105.3 (12.8) 91.2 (19.1)
t/F statistic −1.65 −2.00 −1.85 −1.93 −1.41 −1.06 −2.12 −0.624 −2.457
* *
p-­value .100 .048 .066 .055 .161 .292 .036 .535 .015*
Type II diabetes mellitus
Yes (n = 64) 17.2 (3.5) 13.7 (4.9) 14.0 (4.0) 14.4 (5.1) 17.2 (4.4) 13.9 (4.7) 90.3 (21.6) 104.3 (11.2) 82.4 (22.0)
No (n = 136) 17.5 (2.9) 14.7 (4.1) 15.3 (3.6) 15.7 (4.7) 18.6 (3.0) 14.5 (4.7) 96.4 (18.3) 104.8 (13.7) 91.0 (18.9)
t/F statistic −0.58 −1.48 −2.28 −1.84 −2.42 −0.90 −2.06 −0.104 −2.262
p-­value 0.565 0.141 0.024* 0.068 0.018* 0.368 0.040* 0.917 0.025*
Early stage dementia
Yes (n = 51) 17.8 (2.9) 15.6 (4.3) 15.6 (3.8) 16.2 (4.6) 18.8 (2.6) 15.4 (4.2) 99.3 (18.7) 108.2 (13.3) 91.3 (19.4)
|
      11

(Continues)
 |
12     

TA B L E 4  (Continued)

Mean (SD)

Total Day care Nursing home

Demographic variable SAB AUT PPF SOP DAD INT n = 200 n = 76 n = 124

No (n = 149) 17.3 (3.1) 14.0 (4.3) 14.6 (3.7) 15.0 (5.0) 18.0 (3.9) 14.0 (4.8) 92.8 (19.6) 103.0 (12.5) 87.3 (20.6)
t/F statistic 1.08 2.28 1.52 1.44 1.74 1.95 2.06 1.641 0.914
* *
p-­value .280 .024 .131 .152 .084 .053 .040 .105 .363
Visual impairment
Yes (n = 37) 17.2 (2.3) 14.0 (4.2) 15.3 (4.0) 15.3 (5.1) 18.4 (3.2) 14.7 (4.1) 95.0 (17.5) 104.3 (12.1) 91.6 (18.0)
No (n = 163) 17.4 (3.0) 14.4 (4.4) 14.8 (3.7) 15.3 (4.9) 18.1 (3.7) 14.3 (4.8) 94.3 (20.0) 104.7 (13.1) 87.2 (20.9)
t/F statistic −0.31 −0.52 0.78 −0.06 0.51 0.62 0.20 0.097 −0.989
p-­value .755 .602 .436 .957 .611 .541 .842 .923 .325
Hearing impairment
Yes (n = 26) 15.2 (3.2) 13.6 (4.3) 13.7 (4.5) 14.2 (5.5) 18.2 (3.0) 13.1 (5.6) 88.0 (20.8) 101.5 (10.3) 83.9 (21.5)
No (n = 174) 17.7 (2.9) 14.5 (4.4) 15.0 (3.6) 15.5 (4.8) 18.2 (3.7) 14.5 (4.5) 95.4 (19.2) 104.9 (13.1) 89.0 (20.1)
t/F statistic −4.16 −0.99 −1.65 −1.25 0.11 −1.27 −1.82 0.624 1.019
**
p-­value <.001 .323 .102 .212 .915 .214 .071 .534 .310
Mobility
Impaired (n = 144) 16.9 (3.4) 13.6 (4.4) 14.2 (4.0) 14.5 (5.0) 17.7 (4.0) 13.5 (4.8) 90.5 (20.3) 102.3 (13.0) 85.9 (20.7)
Normal (n = 56) 18.7 (1.5) 16.3 (3.4) 16.5 (2.6) 17.4 (3.8) 19.3 (1.7) 16.4 (3.5) 104.6 (13.0) 107.3 (12.4) 99.7 (12.9)
t/F statistic −5.16 −4.61 −4.66 −4.45 −4.02 −4.60 −5.83 1.710 2.862
** ** ** ** ** ** **
p-­value <.001 <.001 <.001 <.001 <.001 <.001 <.001 .092 .005**

Note: The dependent variable is the total score of QoL. The summary statistics are presented as mean and SD.
Abbreviations: AUT: autonomy; DAD, death and dying; INT, intimacy; PPF, past, present, and future activities; SAB, sensory abilities; SOP, social participation.
*p < .05.; **p < .01.
TAN et al.
TAN et al. |
      13

TA B L E 5  Predictors of quality of life

Regression 95% confidence
Variables coefficient interval p-­value VIF

Overall
SOC—­manageability 0.80 (0.50, 1.09) <.001 2.215
SOC—­meaningfulness 0.34 (0.10, 0.58) .005 2.080
Resilience 0.99 (0.80, 1.17) <.001 2.995
Social loneliness −3.19 (−4.40, −1.98) <.001 2.108
Emotional loneliness −2.42 (−3.82, −1.03) .001 1.975
Hearing impairment −3.80 (−6.81, −0.80) .013 1.049
R2 0.873
Durbin–­Watson statistic 1.90
Day care
Resilience 0.91 (0.63, 1.18) <.001 2.02
Social loneliness −3.82 (−5.98, −1.67) .001 2.334
Emotional loneliness −3.44 (−5.39, −1.48) .001 1.331
Hypertension 4.720 (1.604, 7.801) .003 1.076
2
R 0.801
Durbin–­Watson statistic 2.05
Nursing home
SOC—­manageability 0.92 (0.54, 1.29) <.001 2.757
SOC—­comprehensibility −0.53 (−0.87, −0.18) .003 2.978
Resilience 1.36 (1.15, 1.57) <.001 2.714
Social loneliness −3.46 (−4.78, −2.13) <.001 1.687
Emotional loneliness −1.85 (−3.60, −0.11) .037 2.098
Ethnicity (Non-­Chinese vs. −11.85 (−19.48, −4.22) .003 1.178
Chinese)
R2 0.887
Durbin–­Watson statistic 2.02

Abbreviations: SOC, sense of coherence scale; VIF, variance inflation factor.

adults, higher resilience [β = 0.91 (0.63, 1.18)], lower social loneliness a Brazilian study reported overall mean scores ranging from 44.0 to
[β = −3.82 (−5.98, −1.67)], lower emotional loneliness [β = −3.44 (−5.98, 65.5 amongst older adults in day care centre and care home (Simeao
−1.67)] and hypertension [β = 4.720 (1.604, 7.801)] were identified as et al., 2018). The better overall mean score in Singapore could be at-
significant predictors for higher QoL score, accounting for 80.1% of the tributed to the focus of the Ministry of Health on providing quality,
variance between the expected and observed QoL scores. For nursing accessible and affordable care. Aside from just medical and nurs-
home older adults, higher manageability [β = 0.92 (0.54, 1.29)], lower ing care, the LTC providers in Singapore utilised a multidisciplinary
comprehensibility [β = −0.53 (−0.87, −0.18)], higher resilience [β = 1.36 team to provide comprehensive and person-­centred rehabilitation,
(1.15, 1.57)], lower social loneliness [β  =  −3.46 (−4.78, −2.13)], lower nutrition and various support services (Goh et al., 2018). This ho-
emotional loneliness [β = −1.85 (−3.60, −0.11)] and ethnicity [β = −11.85 listic approach in promoting healthy ageing might have contrib-
(−19.48, −4.22)] were identified as significant predictors for higher QoL uted to the higher QoL scores amongst Singaporean older adults.
score, accounting for 88.7% of the variance between the expected and Participants in this study generally had a high acceptance of death
observed QoL scores. (DAD). Conversely, the lowest mean score was observed in INT. This
corresponded with the high proportion of individuals who had lost
their spouse (McGee et al., 2011). Furthermore, social isolation can
5  |   D I S C U S S I O N also result in the loss of intimate relationships (McGee et al., 2011).
While Singapore remains a fairly conservative society, stigma per-
5.1  |  Discussion on the key variables meates late-­life intimacy and sexuality. Hence, older adults may not
be expressive in their needs and concerns. Moreover, there has been
The mean score of 94.42 for overall QoL was found to be higher limited attention on sexual health as this topic is often avoided or
than those reported in other studies. A Turkish study revealed a stereotyped (Milovich & Burleson, 2017). This could also contrib-
mean score of 50.15 in the LTC setting (Dogan & Goris, 2018) while ute to less satisfaction scores as observed in the INT. Additionally,
 |
14      TAN et al.

participants also scored low in AUT due to the nature of the LTC feelings of loneliness is pertinent in healthy ageing. Given the defini-
setting. tion of loneliness, interventions can focus on two aspects: improving
In terms of SOC, participants were generally equipped with the the quantity and quality of the support network and adapting expec-
ability to cope with stressful situations and believed that they had tations of interpersonal relationships to become more realistic ones
adequate resources to cope, as evidenced by high comprehensibly (de Jong Gierveld et al., 2018; Lee et al., 2020). According to Haugan
and manageability. In the salutogenic model, Antonovsky (1979) pro- et al. (2020, & 2021), the quality of the nurse–­patient interaction
posed that meaningfulness is the most crucial aspect of SOC as it can significantly improve older adults’ physical, emotional, social,
reflects the motivation to deal with stressors. However, participants functional, spiritual well-­being, joy-­of-­life and self-­transcendence in
generally scored low in this component and expressed the lack of the LTC. In addition, Kamalpour et al. (2021) proposed the use of an
clear goals and purposes in life. Goal attaining can be difficult for online community to provide the necessary social support, network
those with poor health and limited mobility, thus leading to goal dis- and resources to engage older adults meaningfully and reduce their
engagement (Saajanaho et al., 2016). Furthermore, the loss of job loneliness.
and spouse due to retirement and widowhood, respectively, can also The findings corroborated with the salutogenic model that sug-
result in a decline in purpose in life (Saajanaho et al., 2016). This can gests that resilience is a protective factor against stressors such as
be aggravated by the deprivation of personal choices and freedom declining sensory abilities (SAB) and fear of death (DAD). Successful
due to age-­related frailty (Riedl et al., 2013). Nonetheless, Resnick's coping in resilient older adults also enables them to maintain in-
(2014) resilience model emphasises making attainable goals and dependence (AUT) and lead an active lifestyle (SOP), while gain-
adapting positively after adversity. Encouraging older adults to ing satisfaction from achievements in life and looking forward to
adapt the selection, optimisation and compensation process to set things (PPF; MacLeod et al., 2016). Furthermore, mutual enjoyment
small and achievable goals could motivate them better (Freund & through shared activities in intimate relationships (INT) contributes
Baltes, 2002). As health-­related changes become more prevalent in to the positive effects in life and boost resilience. Individuals who
the lives of older adults, compensation mechanism should be more can make positive contributions to intimate relationships are also
typical at the later stage of life (Freund & Baltes, 2002). more likely to report satisfaction in INT. Conversely, lonely older
While there is no definite classification of CD-­RISC scores, it is adults have reduced GRRs to buffer against the impact of ageing,
noteworthy that the mean score (28.64) of this study is lower than resulting in a decline in all domains of QoL. SOC is highly dependent
the first quartile (29) of a community survey conducted in the United on the presence of GRRs, and it reflects the ability to utilise these
States (Campbell-­Sills et al., 2009). This finding supports the obser- resources. Therefore, older adults who view the world as compre-
vation that older adults in the LTC setting may be less resilient than hensible, manageable and meaningful can maintain high QoL with
the general population. Resilience is postulated to have strong as- GRRs at their disposal. This study confirmed the role of GRRs for im-
sociations with sense of purpose, ADL independence, mobility and proving SOC and resilience, while ameliorating feelings of loneliness
physical health; however, these were lacking amongst participants in healthy ageing. Two recent systematic reviews demonstrated the
in this study (MacLeod et al., 2016). Older adults in the LTC setting effectiveness of psychosocial interventions, such as reminiscence-­
tend to be less resilient than the general population due to various based intervention, in improving psychological well-­being and re-
factors, such as frailty and dependence (Saajanaho et al., 2016). The ducing loneliness of the older adults (Chow et al., 2020; Tam et al.,
factors that can influence resilience include (i) adaptive coping styles 2021).
and mental health (mental); (ii) social support, sense of purpose and While meaningfulness underpins the desire to live and the
community involvement (social); and (iii) ADL independence, mobil- motivation to embrace the inevitable demise, this is in contrast to
ity and physical health (physical; MacLeod et al., 2016). Ageing in the weak correlation observed between meaningfulness and DAD
place is a factor for building resilience through facilitating indepen- (Zhang et al., 2019). Meaningfulness is an elusive element, which was
dence (McClain et al., 2018). Living in a familiar environment pro- conceptualised as a single construct in the SOC scale. Therefore, it
motes sense of autonomy, provides safety and security, supports might not fully capture the other aspects of life meaning such as the
routines and mitigates health decline for ageing adults (Fänge & quest for it (Zhang et al., 2019). Furthermore, the lack of goal and
Ivanhoff, 2009). Engaging in daily activities at home and the commu- purpose might not necessarily result in a meaningless life, particu-
nity contributes to successful ageing and higher QoL (McClain et al., larly during old age. Hence, the association between meaningfulness
2018). Older adults ageing in place tend to be more physically able, and DAD might not be truly reflected.
have a higher QoL and achieve better clinical outcomes in compari- In this study, higher QoL was observed amongst the older
son to institutionalised older adults (Wang et al., 2012). groups, which could be attributed to their increased adaptation to
Our findings reported a loneliness prevalence of 54.0% amongst age-­related changes and stressors as age advances. This observation
nursing home older adults, which was considerably higher than also coincided with greater death acceptance (DAD) amongst the
those of other countries, Poland (39.6%) and China (40.3%; Su & older groups. However, the comparison between long-­ and short-­
Wang, 2019; Trybusinska & Saracen, 2019). The abundance of social stay nursing home residents on QoL was insignificant. A systematic
relationship may not necessarily eliminate loneliness as the quality review highlighted the trajectory of nursing home residence acting
of these relationships is more important than quantity. Alleviating as a proxy hospice for short-­stay residents approaching end-­of-­life
TAN et al. |
      15

(Moore et al., 2019). At the other end of the spectrum, nursing homes social participation can be compromised amongst underweight par-
are accommodating residents with cognitive impairments who may ticipants due to the positive association between functional limita-
survive for many years following admission (Moore et al., 2019). tion and nutritional status (Danielewicz et al., 2014).
Older adults may gain interest in spirituality and gerotranscendence When performance in ADL was investigated, participants with
and change their perspective from a materialistic and rational vision higher dependence generally scored worse in QoL. Similarly, ADL
to a more cosmic and transcendental one, thus leading to a positive was found to be positively associated with the physical and psy-
attitude towards ageing (Norberg et al., 2015). chological domains of QoL (Kwong et al., 2014). The findings in this
When marital status was taken into consideration, the ever-­ study also revealed no significant relationship between the number
married participants who had experienced love and a sense of of comorbidities and QoL. Nonetheless, older adults with high ac-
companionship had higher scores in INT. A similar outcome was ceptance of illness were able to experience good QoL despite hav-
also observed amongst the single participants who scored lower ing multiple comorbidities. When the association between common
in overall QoL, and this finding is consistent with a previous study chronic illnesses and QoL was examined, high dependence and re-
(Gondodiputro et al., 2018). The role of spousal relationship was cor- duced perceived autonomy (AUT) were observed amongst stroke
roborated based on the salutogenic model. According to Kamalpour patients as stroke-­related complications often manifest as func-
et al. (2021), many older adults might find themselves serving as in- tional limitations. On the other hand, complications of DM can af-
formal caregivers for their spouses or friends and losing access to fect older adults’ death attitude (DAD), satisfaction with present life
environmental resources due to aging-­related issues. However, par- and expectation of the future (PPF). In addition, mobility impairment
ticipation in caregiving does enhance the resilience of older adults by was related to all domains of QoL. This finding corroborated with
providing them with environmental resources through engagement the detrimental effect of functional limitation on QoL. In addition,
with the online health community. In fact, the more resources an auditory impairments hindered effective communication, leading
older adult is able to gain, the more resilient the individual is likely to to increased reliance, loneliness and frustration. Hence, it impedes
be (Resnick, 2014; Wister et al., 2016). Kamalpour et al. (2021) rec- healthy ageing. The final regression model accounted for 87.3% of
ommended establishing online health communities to support the the observed variation and corroborated with the conceptual frame-
caregivers, improve resilience in older adults’ and empower them, work. Nevertheless, a contrasting finding was observed on the asso-
enable aged-­care providers to engage their clients and consider new ciation between educational level and QoL. Furthermore, 13.1% of
healthcare delivery models. variance could not be accounted for, indicating that other possible
In contrast to previous studies (Hedayati et al., 2014; Onunkwor predictors have yet to be identified.
et al., 2016), this study did not report any significant positive asso-
ciation between educational level and QoL except the DAD facet,
in which where there was a significant difference. This finding 5.2  |  Implications for nursing practice
concurred with a previous study, which reported that death anx-
iety increased with higher educational level (Khawar et al., 2013). The findings have implications for resources allocation and inter-
Education attainment may lead to greater importance placed on self ventions that aim to improve QoL amongst older adults in the LTC
and life as it can be regarded in terms of social status, thus resulting setting. In general, future interventions can focus on three modifi-
in lower death acceptance (Ron, 2010). able areas in the salutogenic model: (i) enhancing manageability and
Finally, nursing home residents scored significantly lower than meaningfulness, (ii) boosting resilience and (iii) reducing loneliness to
the day care clients, who were homestayers, in all domains of QoL improve QoL. Firstly, since participants expressed their lack of pur-
except for DAD. Similar findings were reported by Nogueira et al. pose, goal setting should be encouraged to improve meaningfulness.
(2016). Sensory impairments (SAB) are more common amongst nurs- Due to age-­related changes, it is paramount for older adults to dis-
ing home residents, and they can affect the capacity of social par- engage from unattainable goals and replace them with more feasible
ticipation (SOP; Nogueira et al., 2016). Moreover, these limitations ones. Secondly, a multidimensional approach focusing on resilience-­
indicate higher dependence, leading to decreased autonomy (AUT) building should be considered to enhance the adaptive coping styles,
and diminished opportunities to seek more recognition and assets increase community involvement and encourage ADL independence
(PPF; Nogueira et al., 2016). Institutionalised older adults were also and physical health. Lastly, interventions can be conducted in group
more prone to diluting personal relationships due to social isolation sessions to facilitate social interaction and alleviate loneliness.
(INT). Nogueira et al. (2016) also documented higher death accep- A multicentred, longitudinal approach can be adopted in fu-
tance amongst institutionalised older adults due to desensitisation, ture studies to enhance the representativeness of the sample and
but this is contrasted in this study. strengthen the associations identified. More importantly, longitu-
In terms of BMI, underweight participants scored lower in SAB, dinal studies can explore further insights into variables that may
SOP and overall QoL as compared to those with healthy weight. change over time and circumstances, thus establishing causality
Similarly, a community-­based study revealed that being underweight between the study variables. Besides addressing the limitations of
posed higher risk for low QoL (You et al., 2018). Sensory impairment this study, future research should also consider implementing and
can directly impact food intake and nutritional status. Furthermore, evaluating concrete strategies to improve QoL.
 |
16      TAN et al.

5.3  |  Limitations E T H I C A L A P P R OVA L

Ethical approval (S-­19-­209) for the study was obtained from the
This study has several limitations due to the constraints in research National University of Singapore Institutional Review Board.
design. Firstly, the findings of a single-­site study can limit the gener-
alisability of the study. This is arguably important as the composition PEER REVIEW
of the study population, institutional protocols and staffing charac- The peer review history for this article is available at https://publo​
teristics differ across LTC settings. Secondly, the cross-­sectional de- ns.com/publo​n/10.1111/jan.14940.
sign of this study restricted the inference of causalities amongst the
study variables. Therefore, the reported relationships should only be DATA AVA I L A B I L I T Y S TAT E M E N T
treated as associations. In addition, exact inferences of the regression The data that support the findings of this study are available from
analysis could have been affected due to the violation of the normal- the corresponding author upon reasonable request.
ity assumption.
ORCID
Xi Vivien Wu  https://orcid.org/0000-0002-9264-3630
6  |  CO N C LU S I O N
T WITTER
The study findings contributed to the existing knowledge on factors Xi Vivien Wu  @WxvivienWu
influencing QOL for older adults in the LTC settings. Age, marital
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