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Indian Journal of Science and Technology, Vol 8(25), DOI: 10.17485/ijst/2015/v8i25/80269, October 2015 ISSN (Print) : 0974-6846 ISSN (Online) : 0974-5645 Factors Influencing the Meaning in Life in the Old Age Su-Jin Lee1, Ok-Hee Ahn2* and Hye-Gyeong Cha3 Department of Nursing, Kunjang College, Kunsan-si, Jeollabuk-do - 573709, Republic of Korea; [email protected] 2 Department of Nursing, Woosuk University, Wanju-gun, Jeollabuk-do - 565701, Republic of Korea; 3 Department of Nursing, Namseoul University, Cheonan-si, Chungcheongnam-do - 331707, Republic of Korea 1 Abstract Purpose: This study purpose is to survey community-dwelling elders’ level in the meaning of life, to identify factors influencing their meaning of life holistically from the physical, psychological, social, and spiritual aspects, and to provide basic information for developing intervention programs with strategies to enhance community-dwelling elders’ meaning of life. Methods: This study is a descriptive research designed to investigate the influencing factors on the meaning in life among community-dwelling elders. The participants were 306 communicable elders (Age≥65). Data collected from April to October 2013 were analyzed using descriptive statistics, t-test, ANOVA, Pearson correlation coefficients, and stepwise multiple regression. Results: There were significant differences in the meaning in life between gender, age, residential area, educational level, employment status, extra-occupational activity, marriage status, family living arrangement, relationship with people living together, living type, monthly allowance, welfare center visiting times. Significant correlations were found between health promotion behavior (r=.648), social supports (r=.672), self-transcendence (r=.300) and loneliness (r=-.698). Significant predictors of the meaning in life were loneliness, health promotion behavior, subjective health, self-transcendence, social support, vocation status, and family living arrangement. Conclusion: The results of this study suggest that it is needed to develop integrative intervention program that can promoting the meaning in life and reduce the loneliness Keywords: Elder, Loneliness, Meaning in Life 1. Introduction Contemporary society is experiencing the rapid aging of the population as a result of the development of medicine and science and consequent extension of life expectancy. According to the 2013 Korean National Housing Census, elders aged over 65 occupy 12.2% of the whole population, and along with accelerated aging, the ratio is expected to reach 24.3% in 2030 and 37.4% in 20501. People in their old age, which is the last developmental stage of life, may go through developmental crises. Psycho-sociologist Erikson divided people’s development into eight stages, and said that each stage has its own crises and tasks to be experienced and overcome. The task to be achieved in the last stage of life is ego integration, which is looking back the past life, accepting the life without * Author for correspondence regret, and even admitting death peacefully. However, those in their old age experience poor health resulting from physical and physiological declines, and going further, they suffer retirement and the loss of roles and social associations. As a result, elders at this stage often think that their lives are meaningless and complain of low self-esteem, loneliness, isolation, etc2,3. In4, recognized the psychological state of uselessness, malaise, loneliness, anxiety, nihility and emptiness coming from the loss of the meaning of existence, meaning in life, and sense of purpose, and named the psychological state ‘existential vacuum’. In5 surveyed elders’ Meaning in life, and reported that 63.3% of the participants were in existential vacuum and only 4.2% discovered a clear Meaning in life. In6, who analyzed the relationship between the Meaning in life and death, reported that Factors Influencing the Meaning in Life in the Old Age elders with a solid Meaning in life were less likely to die than those without. These studies suggest the necessity of continuous research for supporting elders to find and solidify their Meaning in life. The Meaning in life is implementing the true essence of man in order to exist as a philosophically genuine human, and searching for significances in the present and past life with the belief that one’s own life is valuable and meaningful in association with the world where he/she belongs3,7,8. To help elders find or refine the Meaning in life, first of all, we need to identify factors that may influence elders’ Meaning in life. Although previous studies are explaining influential factors related to the Meaning in life at various developmental stages3,7,9-11, not many of them are dealing with elders’ Meaning in life in a way of integrating their physical, psychological, social, and spiritual aspects. Thus, this study aimed to survey the meaning in life level among elders living in an area, to examine related variables from the holistic aspect, and ultimately to provide basic information for strategies to promote elders’ Meaning in life. • • 2. Method 2.1 Design of the Research This study was a descriptive research that investigated elders’ Meaning in life level and factors influencing the level. 2.2 Subjects The subjects of this study were elders who were living in J Province, Korea, aged over 65, were able to communicate, and understood the purposes of this study and gave a written consent to participate in the research, and 306 questionnaires were used as valid data for this study. The required sample size was estimated using G*Power 3.1. With significance level 0.05, power of test 0.95, effect size 0.15, and the number of predictors 7, the minimum required sample size was 153. 2.3 Measurements • The Meaning in life level was measured with Elderly Meaning In Life (EMIL) developed by12. This measurement consists of 37 questions on a 4-point Likert scale from ‘Not at all’ (1) to ‘Absolutely yes’ (4), and its 2 Vol 8 (25) | October 2015 | www.indjst.org • • total score range is 37-148. A high score means a high Meaning in life level, and ten reverse questions were reversely converted. A Meaning in life score of 104 or lower indicates that the subject is losing the Meaning in life and in an existential vacuum state, and a score of 105-117 indicates that the subject has not found a clear Meaning in life and is pursuing the Meaning in life. Also, a score of 118 or higher means that the subject has discovered a clear Meaning in life. The reliability (Cronbach’s α) of this measurement was 0.91 in the study of12 and 0.90 in this study. Health promotion behavior was measured using the measurement prepared by13 based on the questionnaire on Korean elders’ health behavior developed by14 and adding contents related to eating life, drinking, weight, smoking, exercise and sleeping, which were found to be related with health level in the cohort analysis of Alameda County15. This measurement consists of 22 questions on a 5-point Likert scale from ‘Not at all’ (1) to ‘Absolutely yes’ (5), and the total score range is 22-110. A high score means a high level of health promotion behavior. The reliability (Cronbach’s α) of this measurement was 0.95 in13 and 0.87 in this study. Loneliness was measured with Korean-version RULS prepared by16 through translating the Revised UCLA Loneliness Scale (RULS) developed by17 and testing its reliability and validity. This measurement consists of 20 questions on a 4-point Likert scale from ‘Not at all’(1) to ‘Yes often’(4), and the total score range is 20-80. A high score means a high level of loneliness. In the measurement, ten items are positive questions and the other ten negative questions, and the scores of positive questions were reversely converted. The reliability (Cronbach’s α) of this measurement was 0.93 in 16 and 0.90 in this study. Social support was measured using the Multidimensional Scale on Perceived Social Support (MSPSS) developed by18 and translated by19. This measurement consists of 12 questions on a 5-point Likert scale from ‘Almost not’ (1) to ‘Almost yes’ (5), and the total score range is 12-60. A high score means a high level of social support. The reliability (Cronbach’s α) of this measurement was 0.8919 and 0.96 in this study. Self-transcendence was measured using questions on self-transcendence in the Temperament and Character Inventory (TCI) for adults developed by20 and translated by21, and its contents include creative self-forgetfulness, self-consciousness, oneness with all things in the universe, spiritual acceptance, and rational materialism. This measurement consists of 15 Indian Journal of Science and Technology Su-Jin Lee, Ok-Hee Ahn and Hye-Gyeong Cha questions on a 5-point Likert scale from ‘Not at all’ (0) to ‘Absolutely yes’ (4), and the total score range is 0-60. A high score means a high level of self-transcendence. The reliability (Cronbach’s α) of this measurement was 0.9321 and 0.95 in this study. 2.4 Data Collection Method Data were collected during the period from the 3rd to 26th of August, 2013. For the questionnaire survey, visiting nurses were recruited as research assistants, and before conducting the survey, they were educated by the researcher on the purpose of research, the contents of the questionnaire, and the survey method. Whether the questions in the questionnaire were asked in the same expressions to the subjects and whether the subjects’ answers were marked correctly on the answer sheet were tested, and differences among the research assistants and between the research assistants and the researcher were examined and corrected. The trained visiting nurses met each subject, explained the purposes of research, got his/her written consent, and then conducted the survey. Elders who were able to do self-reporting answered the questionnaire by themselves, and for those who had difficulty in self-reporting, the research assistant read and explained the questions slowly and marked their answers on the answer sheet. It took about 20-30 minutes for each to finish the survey. A total of 320 questionnaires were recovered, but with 14 of them excluded for incomplete answers, 306 were used as valid data in the analyzes. 2.5 Ethical Considerations for the Subjects Before it was started, this study was approved by the Institutional Review Board of W University Oriental Medicine Hospital (IRB No.: WSOH IRB 1307-03) for the ethical protection of the subjects. The subjects were given explanations about the purposes of research and informed that they could drop out anytime in the middle of research and private information would not be collected, and only community-dwelling elders who gave a written consent voluntarily were included in the survey. A gift was presented to each subject after the survey. 2.6 Data Analysis Collected data were analyzed using SPSS/WIN 20.0. Descriptive statistics was used to analyze the subjects’ general characteristics, Meaning in life, health Vol 8 (25) | October 2015 | www.indjst.org promotion behavior, loneliness, social support, and self-transcendence. T-test and one-way ANOVA were used to analyze differences in the Meaning in life, health promotion behavior, loneliness, social support, and self-transcendence according to the subjects’ general characteristics, and Scheffe’s test was used as a posthoc test. The correlations among the research variables were analyzed with Pearson’s correlation coefficient. Also, stepwise multiple regressions were performed to identify factors influencing the subjects’ Meaning in life. 3. Results 3.1 Meaning in Life According to General Characteristics The general characteristics of the subjects are shown in Table 1. Of the subjects, 15.0% were male, and 85.0% were female, and 44.4% of them were at the age of 6574. Also, 49.7% were unschooled, and 32.4% were elementary school graduates, showing that their academic qualification was generally low. As to religion, 31.7% were Christians and 43.5% were unbelievers. Moreover, 88.2% were unemployed, and 65% were bereaved or divorced and living alone and 35% were living with a spouse. As to household type, 43.5% of the subjects were of one-person household, and 27.8% were of elderly-couple household, showing that the percentage of elderly-couple households was relatively low. The subjects’ subjective health status was ‘Poor’ in 35% and ‘Good’ in 24.8%. Table 1 shows the Meaning in life level showed statistically significant differences according to the subjects’ gender (t=2.392, p=.017), age (F=4.166, p=.016), academic qualification (F=11.256, p<.001), occupation (t=4.130, p<.001), marital status (t=3.337, p=.001), and household type (F=4.656, p=.003). Specifically, the level was 104.91 in the male elders and 100.25 in the female ones, so the male elders’ Meaning in life level was statistically significantly higher than the female ones’. According to age, the level was 102.57 in those aged 6574, 100.59 in 75-84, and 96.00 in 85 or older, showing that the Meaning in life level decreased significantly with the increase in age. According to academic qualification, the Meaning in life level was lowest as 97.28 in unschooled elders and was 108.43 in high school graduates, showing that the Meaning in life level was significantly higher in those with high academic qualification. According to Indian Journal of Science and Technology 3 Factors Influencing the Meaning in Life in the Old Age Table 1. Meaning in Life according to General Characteristic (N=306) Characteristics Categories Gender Male Female Age(year) 65-74 a 75-84 b ≥85 c Education No education a level Elementary school b Middle school c ≥High school d Religion Protestant Catholic Buddhism None Other Occupation Yes NO Marital state Married Other Living Spouse, Family living a arrangement Nonspouse, Other living b Living with their spouse c Living alone d subjective health Very gooda Goodb Moderatec Badd Very bade p<.05 **p<.001 n(%) 046(15.0) 260(85.0) 136(44.4) 135(44.1) 035(11.4) 152(49.7) 099(32.4) 032(10.5) 023(7.5) 097(31.7) 022(7.2) 047(15.4) 133(43.5) 007(2.3) 036(11.8) 270(88.2) 107(35.0) 199(65.0) 026(8.5) 062(20.3) 085(27.8) 133(43.5) 013(4.25) 067(21.9) 108(35.30) 098(32.03) 020(6.54) Meaning in Life M ± SD F/t(p)/scheffe 104.91±10.31 2.392(.017)* 100.25±12.50 102.57±12.88 4.166(.016)* 100.59±11.62 a>c 096.00±11.32 097.28±10.64 11.256(<.001)** 103.23±11.97 c,d>a 105.91±15.22 108.43±11.92 101.77±12.77 1.860(.117) 097.86±14.20 104.51±12.09 099.72±11.29 098.57±15.99 108.69±10.87 4.130(<.001)** 099.91±12.12 104.09±12.26 3.337(.001)* 099.26±12.00 102.88±9.76 4.656(.003)* 100.27±11.23 c>d 104.61±12.67 098.54±12.46 112.00±11.88 17.544(<.001)** 107.94±11.77 a>d,e 101.36±11.06 095.93±10.85 092.70±10.32 * employment status, the level was 108.69 in employed elders, significantly higher than 99.91 in unemployed ones. According to marital status, the Meaning in life level was significantly higher in married elders with a spouse. According to household type, the Meaning in life level was lowest in elders of one-person household, and it was higher as 104.61 in those of elderly-couple household than in those living with other family members. Also, the differences were statistically significant. The Meaning in life level was not statistically significant according to religion (Table 1). 3.2 M eaning in Life, Health Promotion Behavior, Loneliness, Social Support, and Self-Transcendence Table 2 shows the level of Meaning in life, health promotion behavior, loneliness, social support, and selftranscendence of the subjects. The mean level of meaning 4 Vol 8 (25) | October 2015 | www.indjst.org in life the subjects of this study was 100.95±12, the lowest score was 67, and the highest score was 142. The mean level of health promotion behavior was 81.18±11.14, the lowest 46, and the highest 110. The mean level of loneliness was 43.34±8.66, the lowest 21, and the highest 72. The mean level of social support was 43.31±8.76, the lowest 18, and the highest 60. The mean level of self-transcendence was 24.37±11.21, the lowest 0, and the highest 60. Table 2. Meaning in Life, Health promotion behavior, Loneliness, Social support, Self-transcendence Variables Meaning in Life Health promotion behavior Loneliness Social support Self-transcendence Range 37-148 22-110 20-80 12-60 0-60 M±SD 100.95 ± 12.29 81.18 ± 11.14 43.34 ± 8.66 43.31 ± 8.76 24.37 ± 11.21 Min 67 46 21 18 0 Max 142 110 72 60 60 Table 3 shows a Meaning in life score of 104 or lower Indian Journal of Science and Technology Su-Jin Lee, Ok-Hee Ahn and Hye-Gyeong Cha indicates an existential vacuum state in which the subject is losing the Meaning in life, a score of 105-117 means that the subject has not found a clear Meaning in life and is currently pursuing the Meaning in life, and a score of 118 or higher means that the subject has discovered a Meaning in life. In this study, 194 (63.4%) of the subjects were at the stage of losing the Meaning in life, 86 (28.1%) at the stage of pursuing the Meaning in life, and 26 (8.5%) at the stage of having discovered the Meaning in life. Table 3. Meaning in Life According to Phases Variables Range Frequency Percentage Min Max Losing the Mean- ≤104 194 63.4 067 104 ing in Life Pursuing the 105-117 86 28.1 105 117 Meaning in Life Discovered the ≥118 26 08.5 118 142 Meaning in Life 3.3 C orrelations between the Meaning in Life and Major Variables The results of analyzing the correlations between the subjects’ Meaning in life level and other influential factors are shown in Table 4. The Meaning in life level was in a significant negative correlation with loneliness (r=-.70, p<.001), and in a significant positive correlation with health promotion behavior (r=.65, p<.001), social support (r=.67, p<.001), and self-transcendence (r=.30, p<.001). That is, the Meaning in life level increased statistically significantly when the loneliness level was low and when the levels of health promotion behavior, social support, and self-transcendence were high. 3.4 Factors Influencing the Meaning in Life In order to identify factors influencing the subjects’ Meaning in life as a dependent variable, this study conducted stepwise multiple regression analysis using health promotion behavior, loneliness, social support, and self-transcendence, and general characteristics such as subjective health status, employment status, and household type as independent variables. Employment status and household type were included in the regression equation as dummy variables. Linearity among the variables was confirmed through matrix plot graphs, and the hypotheses of regression analysis were tested through the auto-correlation of the dependent variable and multicollinearity among the independent variables. According to the results, Durbin-Watson statistic was 1.768, showing that there was not a major problem in the independence of the error terms. The tolerance limit of each variable was 0.363-0.950, higher than 0.1, and VIFs were 1.000-2.755, lower than 10, so the problem of multicollinearity was not observed among Table 4. Correlation among Variables Meaning in Life Health promotion behavior Loneliness Social support r (p) r (p) r (p) r (p) Meaning in Life 1 Health promotion behavior .65 (<.001)** 1 Loneliness -.70 (<.001)** -.58 (<.001)** 1 Social support .67 (<.001)** .68 (<.001)** -.73 (<.001)** 1 Self-transcendence .30 (<.001)** .27 (<.001)** -.17 (.002)* .23 (<.001)** Self-transcendence r (p) p<.05 **p<.001 1 * Table 5. Factors Influencing Meaning in Life Constant Loneliness Health promotion behavior Subjective health Self-transcendence Social support Occupation1 Live together2 B 41.873 00.525 00.268 -01.665 00.130 00.200 02.958 02.055 SE 4.574 0.074 0.055 0.498 0.040 0.081 1.382 0.982 β 0.370 0.243 -0.132 0.119 0.143 0.078 0.075 t (p) 9.154(<.001)** 7.108(<.001)** 4.856(<.001)** -3.346(.001)* 3.269(.001)* 2.461(.014)* 2.140(.033)* 2.092(.037)* adj R² 0.485 0.575 0.598 0.612 0.619 0.623 0.628 F= 72.408, p<.001 p<.05, **p<.001, Occupation1 : yes, live together2 : Living with their spouse * Vol 8 (25) | October 2015 | www.indjst.org Indian Journal of Science and Technology 5 Factors Influencing the Meaning in Life in the Old Age the independent variables. Also, the normality and equivariance of residuals were satisfied. With these conditions, multiple regression analysis was performed. Table 5 shows the subjects’ Meaning in life level was affected significantly by health promotion behavior (β=0.243), subjective health status (β=-0.132), selftranscendence (β=0.119), social support (β=0.143), employment status (β=0.078), and household type (β=0.075) (F=72.408, p<.001). Loneliness was the most influential variable with explanatory power of 48.5%, and the total explanatory power of loneliness, health promotion behavior, subjective health status, selftranscendence, social support, employment status, and household type was 62.8% . 4. Discussion This study was conducted to analyze elders’ Meaning in life level and factors influencing the level. In this study, loneliness was found to be the most influential factor for elders’ Meaning in life, which was followed by health promotion behavior, subjective health status, self-transcendence, social support, employment status, and household type. These variables explained 62.8% of the variance in the Meaning in life, and loneliness alone explained 48.5%. Loneliness is an emotion that people experience when they lack in personal relationships22, and it is experienced by a large number of people regardless of age. Loneliness experienced in childhood, adolescence and adulthood is usually temporary or lasts only for a short period23, but loneliness experienced in the old age is a much riskier phenomenon and a common type of stress causing physical diseases and psychological problems to elders24,25. In this study, the subjects’ level of loneliness was 43.34 point, slightly lower than 44.7 point reported by3, but higher than 41.3 point in the study of26 on livingalone female elders. These differences are probably because environments for exchanging social influences were different among community-dwelling elders, livingalone female elders, and elders participating in various activities such as welfare center programs or volunteer services. Loneliness showed a negative correlation not only with the Meaning in life but also with social support, health promotion behavior, and self-transcendence. This suggests the need of strategies to mitigate loneliness by raising the levels of social support, health promotion 6 Vol 8 (25) | October 2015 | www.indjst.org behavior, and self-transcendence to uplift elders’ Meaning in life level. Particularly because social support is helpful in reducing elders’ powerlessness27, improving their quality of life28, and easing their sense of isolation or loneliness23, and elders regard social relationship as a more important factor than physical health29, it is necessary to develop and execute various programs for expanding elders’ social network. In this study, the subjects’ Meaning in life level ranged between 67-142 point, and the mean score was 100.95 point, which is 68.21 point out of 100 points and slightly higher than the medium. This score corresponds to the stage of losing the Meaning in life, and is similar to 67.84 point reported by5. In30 that compared the Meaning in life between hospitalized and ordinary elders, however, the Meaning in life level was 66.02 point in hospitalized elders and 68.75 points in ordinary elders, and in the study of3 with elders using welfare centers, their Meaning in life level was 71.49 point, higher than that in this study with community-dwelling elders. What is more, the subjects’ Meaning in life level in this study was lower than 73.11 points in31 study with middle-aged subjects and 74.75 points in the study of32 with adolescents. These differences in the Meaning in life score are believed to come from the subjects’ background variables including age. That is, the Meaning in life level was lower in elders aged over 85 than in those aged 65-74, and according to subjective health status, it was significantly lower in those who answered “Poor” than in those who answered “Good.” Furthermore, the level was lower in those without a spouse due to bereavement or divorce than in those with a spouse, and it was much higher in those “Living with a spouse” than in those “Living alone.” These results are consistent with previous reports3,8,9. That is, elders living alone, those without a spouse, and those whose physical health status is poor may spend their old years full of regrets and complaints, and in order to help these elders losing the Meaning in life, namely, falling in an existential vacuum state find the Meaning in life, it is necessary to expand social network and, furthermore, to develop programs for finding and implementing the values of life according to4. According to general characteristics, what is more, the Meaning in life level was significantly higher in employed elders than in unemployed ones. Employed elders’ average meaning in life score was 108.69 point, which corresponds to the stage of pursuing the Meaning in life. This is consistent with the report of3 that the Meaning in life level Indian Journal of Science and Technology Su-Jin Lee, Ok-Hee Ahn and Hye-Gyeong Cha was higher in elders who were participating frequently in welfare center programs. Because the Meaning in life is in a high correlation with social support, it is necessary for various areas and classes to pay attention and consideration to elders so that they may continue selfefforts to find the Meaning in life and achieve values of life through social activities such as works, welfare center activities, volunteer services, various meetings of sameage people, etc. In conclusion, loneliness was found to be the most influential variable for elders’ Meaning in life, and also health promotion behavior, subjective health status, selftranscendence, social support, employment status, and household type were identified as influential variables to be considered. These findings suggest that priority should be given to interventions for loneliness to enhance elders’ Meaning in life level. Moreover, policies related to elders’ welfare centers should be promoted actively for providing elders with social support through active welfare services, elderly employment programs, companion services, etc. for community-dwelling elders. In addition, logo therapy for elders’ discovery of a Meaning in life, sports-for-all and public health education activities for health promotion, programs for forming and expanding social network, etc. may be utilized as direct and indirect interventions for upgrading elders’ Meaning in life. 5. Acknowledgment This paper has complemented and modified the master thesis of the first author Su Jin Lee. 6. References 1. Korea National Statistical Office. Korea: Population and Housing Census. 2013; Available from: http://census.go.kr/ dat/ysr/ysrList.do?q_menu=5&q_sub=7 2. Eun Y, Song KA, Park OH, Ko SH, Park MH, Kim JS, et al. Gerontological nursing. 2nd ed. Seoul, Korea: Hyunmoonsa; 2010. Chapter 1. 3. Gong SJ, Kim KH. 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