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Original Article
The association between living arrangements and health-related quality of life in Korean older people: a nationwide repeated cross-sectional study
Eunok Park1orcid, Philip Larkin2orcid, Zee-A Han3orcid

DOI: https://doi.org/10.24171/j.phrp.2023.0273
Published online: May 23, 2024

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: October 3, 2023   • Revised: February 13, 2024   • Accepted: February 16, 2024

© 2024 Korea Disease Control and Prevention Agency.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • Objectives
    This study investigated the association between living arrangements and health-related quality of life (HRQoL) in older people.
  • Methods
    A secondary analysis was conducted of 6,153 participants (aged ≥60 years) from the seventh Korean National Health and Nutrition Examination Survey (2016 to 2018). HRQoL was measured using the 3-level version of the EuroQol 5-dimensional questionnaire. The chi-square test, t-test, and multiple regression were used, applying sampling weights for the analysis.
  • Results
    The proportion of respondents living alone was 18.0%, with a higher prevalence among women and older age groups (p<0.001). The overall HRQoL was lower in groups living alone than in groups living with others (p<0.001). Older people living alone showed higher impairments in all dimensions of the 3-level version of the European Quality of Life 5-Dimensional Questionnaire (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). Problems with mobility were most prevalent (42.8%), followed by pain/discomfort (41.9%) in respondents living alone. Living alone was significantly associated with a lower HRQoL index score (b=–0.048, p<0.001) after adjusting for age, gender, education, exercise, perceived stress, and perceived health status.
  • Conclusion
    Living alone was negatively associated with HRQoL. Based on this study, future care planning for older people should consider their living arrangements. The need to strengthen and expand care programs targeting those living alone should also be addressed.
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.
Data Sources and Participants
We conducted a secondary analysis of data obtained from the seventh Korean National Health and Nutrition Examination Survey (KNHANES VII, 2016 to 2018) [10]. The KNHANES is a nationwide periodic cross-sectional survey of the health and nutrition of a nationally representative sample of community residents. Further details on the KNHANES VII are described in the raw data use guidance of the KNHANES VII[10]. From 31,689 randomly sampled individuals, 24,269 people participated in this national survey across all ages (a response rate of 76.6%). For the present study, 6,153 KNHANES participants aged ≥60 years were included for analysis based on demographic characteristics, health behaviors, health status, and the EQ-5D-3L.
Measurements

HRQoL: EQ-5D-3L

The KNHANES uses the EQ-5D-3L to assess health status. The EQ-5D-3L was developed by the EuroQol Group and has been widely used as a concise, generic instrument for measuring, comparing, and valuing health status across disease areas [11]. The EQ-5D-3L consists of the 5 dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression and has 3-level answers (“no problem”, “some problems”, and “severe problems”) for each dimension. The EQ-5D-3L is easy to apply as a self-administered survey. A Korean version of the EQ-5D-3L was developed, and its reliability and validity were tested according to a procedure recommended by the EuroQol group [12]. Lee et al. [13] established a population-based preference weighting for the Korean EQ-5D-3L using a representative population sample [13], and the Korean EQ-5D-3L index scores were calculated using these population weightings. A higher score typically represents a better health status [14].
In this study, the sociodemographic characteristics included gender, age, living arrangement (living with others or living alone), region (urban or rural), education level (elementary, middle school, or high school), marital status (never married, married, or divorced/separated), and income (low, lower-medium, upper-medium, or high). Current smoking status (yes or no), high-risk drinking (yes or no), and walking over 30 minutes daily (yes or no) were included as health behavior variables. Perceived stress (little or much) and perceived health status (1, very poor; 2, poor; 3, moderate; 4, good; 5, very good) were included as health status variables.
Statistical Methods
Statistical analyses were conducted using SAS software ver. 9.4 (SAS Institute Inc.). Survey procedures for the complex sampling design were applied to estimate nationally representative statistics. The chi-square test was used to compare the general characteristics and EQ-5D-3L index scores according to living arrangement, and multiple linear regression analysis was conducted to investigate if living arrangements influenced the EQ-5D-3L index scores after adjusting for covariates. A p-value less than 0.05 indicated statistical significance.
Ethics Statement
This study was approved by the Institutional Review Board (IRB) of Jeju National University (IRB No: JJNU-IRB-2022-078). Informed consent was waived by the IRB since this secondary analysis used anonymized data.
Living Arrangement by Sociodemographic Characteristics
Of the 18.0% of respondents who lived alone, the prevalence was higher in women and in older age groups (p<0.001): 11.70% in men (11.1% 60–64 years, 32.0% >80 years) and 23.0% in women (11.9% 60–64 years, 41.2% >80 years) (Table 1). More participants in lower income brackets lived alone (30.3%) than those with higher incomes (5.5%, p<0.001), and a higher percentage of rural residents lived alone (22.4%) than urban residents (16.7%, p<0.001).
HRQoL by Living Arrangement
The comparison of HRQoL (measured by EQ-5D-3L index score) according to living arrangement is presented in Table 2. Overall, the HRQoL was lower in groups living alone than in groups living with others. The HRQoL decreased in both groups as age advanced. The HRQoL was significantly lower in those aged ≤74 years and living alone than in those aged ≤74 years and living with others. However, for those ≥75 years, there were no significant differences in HRQoL between the 2 groups. The HRQoL in men was higher than in women, though the scores were significantly lower for those living alone in both genders (p<0.001). According to marital status, those who had never married and lived alone showed the lowest HRQoL. However, the scores were not significantly different based on living arrangement in the subgroups of marital status. Lower education levels were associated with lower HRQoL scores, and mean scores were significantly lower in the group living alone than in the group living with others for the same education-level subgroups. Income levels followed a pattern much like the levels for education. Those who lived alone in rural areas had lower HRQoL scores than those living alone in urban areas. However, in both urban and rural dwellers, the mean HRQoL scores of those living alone were significantly lower than those living with others.
The Prevalence of Health Problems in the EQ-5D-3L By Living Arrangement
The EQ-5D-3L index scores according to living arrangement are shown in Figure 1. Older people living alone showed higher impairments in all dimensions of the EQ-5D-3L than those living with others including mobility (p<0.001), self-care (p<0.001), usual activities (p<0.001), pain/discomfort (p<0.001), and depression/anxiety (p<0.001). For respondents living alone, problems with mobility were most prevalent (42.8%), followed by pain/discomfort (41.9%). Conversely, for those living with others, pain/discomfort was the most common problem (32.7%), followed by mobility (28.2%). In both groups, respondents reporting problems in self-care were in the lowest percentage (13.0% for living alone; 7.1% for living with others). Overall, pain/discomfort was the most frequently reported complaint (total 34.3%, men 25.4%, women 41.4%), followed by mobility (total 30.8%, men 22.7%, women 37.3%). Relatively few respondents had problems with self-care (total 8.2%, men 6.2%, women 9.8%).
Factors Influencing HRQoL
Multiple regression was used to evaluate the impact of living arrangement on HRQoL using EQ-5D-3L index scores (Table 3). After adjusting for the significant variables of HRQoL (age, gender, education, exercise, perceived stress, and perceived health status), living arrangement was a significant influencing factor for HRQoL. Living alone was significantly associated with a lower HRQoL (b=–0.048, p<0.001). Age was also significantly associated with a lower HRQoL (b=–0,171, p<0.001), and women showed a significantly lower HRQoL than men (b=–0.044, p<0.001). Those with a lower education level had a lower HRQoL than those with a higher education (b=–0.054, p=0.004). People who walked >30 minutes daily showed a higher HRQoL than those who did not. Perceived stress and subjective health status were also significantly associated with EQ-5D-3L index scores (p<0.001) (Table 3).
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.
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.
Various factors contribute to well-being late in life, including “ageing in place” and with whom one ages. This study found that living alone was associated with poorer health-related quality of life, including higher rates of pain, depression, and anxiety as well as greater limitations on mobility, self-care, and routine activities. The findings of this study emphasize that, when planning care for older people, living arrangements should be considered and social and health services strengthened for those living alone.

Ethics Approval

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

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

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

Availability of Data

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

Authors’ Contributions

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

Figure 1.
The prevalence of health problems (EQ-5D-3L index scores) according to gender and living arrangement in older Korean adults. EQ-5D-3L, 3-level version of the European Quality of Life 5-Dimensional Questionnaire.
j-phrp-2023-0273f1.jpg
Table 1.
Distribution of the general characteristics of older Korean adults according to living arrangement
Characteristic Total (n=6,153)
Living with others (n=4,876, 82.0%)
Living alone (n=1,277, 18.0%)
Χ2 p
W % SE W % SE W % SE
Age (y) 171.52 <0.001
 60–64 31.2 0.8 88.5 1.0 11.5 1.0
 65–69 22.5 0.6 86.6 1.0 13.4 1.0
 70–74 17.4 0.5 82.0 1.3 18.0 1.3
 75–79 16.5 0.6 74.1 1.6 25.9 1.6
 ≥80 12.3 0.5 68.1 2.3 31.9 2.3
Gender 104.77 <0.001
 Man 44.5 0.6 88.3 0.8 11.7 0.8
 Woman 55.5 0.6 77.0 1.0 23.0 1.0
Marital status 2,304.14 <0.001
 Not married 0.9 0.1 18.8 5.6 81.2 5.6
 Married 70.1 0.8 97.0 0.3 3.0 0.3
 Divorced/separated 29.0 0.8 47.8 1.6 52.2 1.6
Education 87.24 <0.0001
 Elementary school 44.7 1.0 76.9 1.0 23.1 1.0
 Middle school 40.6 0.9 85.2 0.9 14.8 0.9
 High school 14.6 0.8 89.3 1.2 10.7 1.2
Income 317.13 <0.001
 Low 25.2 0.8 69.7 1.5 30.3 1.5
 Low middle 24.1 0.7 77.2 1.3 22.8 1.3
 Upper middle 24.8 0.7 86.0 1.0 14.0 1.0
 High 25.9 1.0 94.5 0.7 5.5 0.7
Region 13.82 <0.001
 Urban 78.4 2.0 83.3 0.8 16.7 0.8
 Rural 21.6 2.0 77.6 1.4 22.4 1.4

W %, weighted %, applied sampling weight; SE, standard error.

Table 2.
Health-related quality of life in older Korean adults (as measured by EQ-5D-3L index scores) according to living arrangement
Variable Category Living with others
Living alone
t p
n Mean±SE n Mean±SE
Age (y) 60–64 1,409 0.944±0.003 216 0.899±0.011 3.67 <0.001
65–69 1,228 0.924±0.004 229 0.888±0.010 3.08 0.002
70–74 977 0.902±0.005 259 0.860±0.012 3.48 0.001
75–79 760 0.867±0.007 302 0.836±0.013 1.73 0.084
≥80 502 0.835±0.010 271 0.808±0.014 1.43 0.154
Gender Man 2,317 0.932±0.003 349 0.896±0.009 4.01 <0.001
Woman 2,559 0.888±0.003 928 0.839±0.007 6.04 <0.001
Marital status Not married 11 0.875±0.050 47 0.777±0.042 1.24 0.215
Married 4,182 0.920±0.002 150 0.928±0.010 -0.42 0.677
Divorced/separated 682 0.854±0.007 1,080 0.849±0.006 0.62 0.534
Education Elementary school 2,079 0.872±0.004 758 0.820±0.008 5.49 <0.001
Middle school 2,038 0.931±0.003 402 0.901±0.007 4.35 <0.001
High school 725 0.950±0.004 106 0.931±0.010 1.61 0.109
Income Low 997 0.886±0.006 516 0.825±0.009 5.13 <0.001
Low middle 1,126 0.909±0.005 403 0.850±0.010 5.20 <0.001
Upper middle 1,277 0.915±0.004 248 0.911±0.009 0.92 0.360
High 1,452 0.920±0.004 104 0.906±0.016 1.01 0.314
Region Urban 3,676 0.914±0.003 892 0.867±0.006 7.22 <0.001
Rural 1,200 0.889±0.005 385 0.823±0.010 4.80 <0.001
Smoking No 4,345 0.908±0.003 1,112 0.854±0.006 8.11 <0.001
Yes 507 0.923±0.006 155 0.884±0.015 2.76 0.006
High-risk drinking No 4,555 0.907±0.003 1205 0.856±0.006 8.30 <0.001
Yes 296 0.932±0.008 63 0.894±0.018 1.90 0.058
Walking No 3,054 0.893±0.003 852 0.831±0.007 7.09 <0.001
Yes 1,786 0.938±0.003 407 0.907±0.007 4.73 <0.001
Perceived stress Moderate 3,906 0.925±0.002 1,007 0.882±0.006 7.02 <0.0001
High 941 0.844±0.007 258 0.761±0.015 4.78 <0.001
Perceived health status Very poor 378 0.716±0.014 181 0.660±0.017 2.17 0.030
Poor 962 0.849±0.005 303 0.778±0.012 4.74 <0.001
Moderate 2,416 0.933±0.003 591 0.916±0.005 3.11 0.002
Good 891 0.968±0.003 155 0.961±0.006 1.39 0.165
Very good 228 0.970±0.005 47 0.944±0.017 1.00 0.318

EQ-5D-3L, 3-level version of the European Quality of Life 5-Dimensional Questionnaire; SE, standard error.

Table 3.
Multiple regression analysis of the impact of living arrangement (alone vs. with others) on HRQoL using EQ-5D-3L index scores
Variable b beta t p
Age (y) –0.004 –0.171 –11.28 <0.001
Living arrangement (ref. with others) –0.018 –0.048 3.77 <0.001
Gender (ref. man) –0.013 –0.044 3.49 <0.001
Education
 High school Ref.
 Elementary –0.016 –0.054 –2.93 0.004
 Middle school 0.005 0.017 1.17 0.243
Health 0.058 0.374 23.46 <0.001
Walking
 Yes Ref.
 No 0.025 0.083 –7.62 <0.001
Stress
 Much Ref.
 Little –0.049 –0.133 9.09 <0.001

HRQoL, health-related quality of life; EQ-5D-3L, 3-level version of the European Quality of Life 5-Dimensional Questionnaire; ref., reference.

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