Aging is characterized by the accumulation of changes that the organism undergoes over time. Changes in the structure and functions of the organism are most often manifested by a decrease in the individual's performance, polymorbidity and increased vulnerability [1]. In addition, aging affects the subjective perception of the social situation of seniors themselves, as well as their quality of life (QOL) [2]. The need to investigate the quality of life of older adults and the identification of factors that influence their life stems from the increase in the average life expectancy of the world population, which is one of the most important problems of public health and state policy. A concurrent problem is the necessity to ensure good living conditions for older people and to maintain the quality of life even in older age groups [3].
The basic definition of quality of life is the definition of the World Health Organization from 1996, which describes QOL as an individual's subjective perception of his position in life in the context of the culture and values of the society in which he lives, in relation to his goals and expectations. This perception is influenced by his physical and psychological health, level of independence, relationships, but also environmental factors and personal beliefs [4]. In general, the quality of life is understood as the interaction of many factors - social, health, economic, environmental, which together affect individuals and populations [5]. Because QOL intersects with several disciplines and has many dimensions, or areas, the quality of life may be satisfactory in certain areas, but insufficient in others [6].
Home health care increases the quality of life by enabling seniors to live in home conditions, which is significantly preferred over nursing care in institutions such as facilities for seniors. Seniors can thus live a better and happier life, since they are in their familiar home environment [7]. In the case of deterioration of the health of the senior citizen and subsequent dependence on the help of others, or after the exhaustion of other possibilities of help, institutional care comes into play. Maintaining the highest possible quality of life even in old age should be the primary goal of facilities that provide the necessary care to seniors [8].
COVID-19 was especially severe in the elderly, who, in addition to old age, have several comorbidities that increase the risk of a severe course of the disease and serious complications due to SARS-CoV-2 infection [9]. Walle-Hansen et al. (2021) examined the long-term consequences of overcoming COVID-19 on HRQOL (health-related quality of life). More than half of study participants age 60 and older reported a decline in quality of life six months after being admitted to the hospital. The most frequently reported changes were impaired ability to perform activities of daily living, decreased mobility, increased pain and discomfort. Up to 43% of participants experienced a negative change in cognitive functions compared to the period before hospitalization due to the illness of COVID-19 [10].
The aim of the contribution is to verify satisfaction with the quality of life and health of older adults (60+) living at home and in social facilities before the pandemic, during the COVID-19 pandemic, or during the lockdown and currently (at the time the respondent fills out the questionnaire).
Material and methodology
Data collection. For data collection, we used the Quality of Life Questionnaire for seniors, which was created as part of the AURORA project - Active aging-healthy lifestyle - an international trilateral collaboration with Palacky University in Olomouc and Rovira i Virgili University in Spain. Completing the questionnaire was voluntary and completely anonymous. Only questionnaires that indicated the age and gender of the respondent were included in the database. The resulting sample consisted of respondents over the age of 60. In the questionnaire, we monitored demographic data, lifestyle changes, quality of life and health. Questions related to quality of life components were formed into three time periods: before the pandemic, during the lockdown and after the end of the lockdown (currently). We collected data in the form of online distribution of questionnaires (google forms) using the Association of Universities of the Third Age from April 2022 to the beginning of June 2022. The respondents attending UTV in our sample represent the older adult population living in their own home. The second phase of collection took place from July to November 2022 directly in social facilities where seniors are accommodated, or in the senior leisure center. The resulting cohorts consisted of respondents living at home and in facilities for the elderly (ZPS).
Questionnaire type and description. To assess satisfaction with quality of life and health, respondents had Likert-type items at their disposal: very dissatisfied - dissatisfied - neither satisfied nor dissatisfied - satisfied - very satisfied. Since we did not work with standardized Likert scales, we worked with individual items as ordinal variables using non-parametric statistics. In the event that the respondent did not indicate or did not want to indicate an answer to a certain type of question, we worked with the given number of answers, which is why there are also different total numbers in some parameters.
Statistical data processing. We processed the database in the IBM SPSS Statistics program. We verified the differences between individual periods (before the pandemic, during the lockdown, currently) of the tested variables (satisfaction with health and quality of life) with the Friedman test followed by the Wilcoxon test. To verify differences in the independent variable (place of residence), we used the Mann-Whiteney U test.
Results
Research sample. The resulting research sample consists of 436 questionnaires from seniors visiting UTV, a leisure center and seniors living in social facilities. Out of the total number of 436 respondents, 330 were women and 96 were men (Table 1). The average age of the respondents is 72 years (SD 7.34), of which the average age for women is 71.95 (SD 7.42; min 60; max 99) and for men 72.18 (SD 7.07; min 61; max 93). The highest share was made up of persons with secondary education (46.8%) and with university education (39.2%). 62.8% of respondents lived in a partnership (married, partnership); 37.2% were single (single, living separately, divorced, widowed). More than two-thirds of the respondents (68.1%) still lived in their home environment, and 31.9% lived in a social institution (Table 1).
Table 1 Characteristics of the research sample
Quality of life. We found out whether during the lockdown there was a deterioration in satisfaction with the quality of life and health among seniors, and whether satisfaction with the quality of life and health among seniors is currently better than during the lockdown. The results of the Friedman test (Table 2) for satisfaction with the quality of life revealed to us that there is a statistically significant difference between the periods (QOL before the pandemic > currently > during the lockdown; mean rating 2.41 > 2.05 > 1.54; p=0.000). Follow-up testing showed that significant differences in satisfaction with quality of life were present between all three periods. The differences in satisfaction with the quality of life before the pandemic, during the lockdown and now are statistically significant (p=0.000). Our analysis confirmed that there was indeed a worsening of satisfaction with the quality of life during the lockdown, and its subsequent improvement in the present, but not to the level before the pandemic (Table 3).
Table 2 Results of the Friedman test for satisfaction with quality of life and health
Health. The analysis showed (Table 2) that differences in health satisfaction before the pandemic, during the lockdown and now are present (Health before the pandemic > now > during the lockdown; average score 2.24 > 1.91 > 1.86; p=0.000). A follow-up test revealed statistically significant differences only between the pre-pandemic-in-lockdown and pre-pandemic-current periods. Differences in health satisfaction between lockdown and now were statistically insignificant. As expected, subjective satisfaction with health decreased during the lockdown (p=0.000), and subsequently increased now, but the result is not significant (p=0.075). At the same time, health is currently rated significantly lower than before the pandemic (Table 3).
Table 3 Wilcoxon test for satisfaction with quality of life and health before the pandemic, during the lockdown and now
Place of residence. We compared satisfaction with the quality of life and health in individual periods among older adults also according to whether they live at home (alone or with family) or in a facility for the elderly (ZPS) (Table 4). Quality of life appeared to differ significantly by location only before the COVID-19 pandemic (p=0.000), in favor of living in one's home environment. During the lockdown (p=0.369) and currently (p=0.571) differences were not present.
However, the respondents' health assessment differed significantly in all three periods (p=0.000 and p=0.011, respectively). Seniors who lived at home rated their health better than those who live in a social facility for seniors (Table 4).
Table 4 Results of the Mann-Whiteney U-test for differences in satisfaction with quality of life and health among older adults living at home and in a nursing facility
Discussion and Conclusion
Our assumptions were only partially confirmed. We hypothesized that satisfaction with QOL changed for the worse during the lockdown, and subsequently improved in the present. This was indeed confirmed, the respondents indicated worse satisfaction with the quality of life during the lockdown than before the pandemic, as well as at present. However, the quality of life at present has not improved to the level of satisfaction before the pandemic.
Subjective health assessment changed during individual periods. Satisfaction with health significantly changed for the worse during the lockdown. And even if it has slightly improved compared to the lockdown, the result is not statistically significant. However, the health assessment also differs significantly between the pre-pandemic and current periods, as current health has not improved back to pre-pandemic levels.
Similar conclusions were reached by Colucci et al. (2022), lockdown during COVID-19 had a negative impact on older people's quality of life, perceived health and well-being [11]. According to Cocuzzo et al. (2022) the lockdown also had many negative consequences for the quality of life of the elderly, and despite vaccines, we are still far from being able to guarantee the QOL of the elderly as before the COVID-19 pandemic[12].
Furthermore, we hypothesized that QOL would be statistically significantly different in seniors living in social facilities and in seniors living at home. However, this was only true for pre-pandemic QOL. Quality of life was not statistically significantly different between older adults living in their home environment and in institutional care during the lockdown or now.
We interpret the results so that the impact of the place of residence on the quality of life is probably less for our respondents than the impact of the lockdown during the COVID-19 pandemic. Therefore, when assessing satisfaction with QOL during the pandemic, the place of residence was probably not a significant determining factor for our respondents. The negative impact of anti-pandemic measures may have overshadowed the potential negative impact of place of residence. However, it is questionable why this assessment is not different nowadays. This may be related to the lingering consequences of impaired QOL and health, which have not yet returned to their original levels.
Also Kubíčková et al. (2019) observed that the life satisfaction of Czech seniors depends on the individual's place of residence, specifically, a stay in a facility for the elderly or in a social facility has a negative impact. In addition, whether they live alone is an important factor. The worst off are those individuals who live in social facilities and live alone[13] . Trybusińska, Saracen (2019) report that up to 40% of nursing home residents feel lonely, and the greater the loneliness, the lower the quality of life [14].
According to Talarská et al. (2018) factors such as difficulty moving outside the home, urinary incontinence and forgetfulness influenced the need for 24-hour care, degree of independence, risk of falls and quality of life [15] . From this perspective, it is understandable that quality of life may be worse for older adults living in institutional care than for those who live at home and are in better health. Conversely, a senior who is in good health does not need 24-hour care or living in a nursing home. In our sample, health satisfaction was rated worse among older adults living in a nursing home than at home in all three periods.
Despite the fact that the difference in the quality of life between senior men and women living at home and in a social facility was confirmed only before the pandemic, it is necessary to examine which determinants are responsible for this happening and to implement interventions to reduce inequalities, as it is not excluded that these inequalities still persist. Since our research was a cross-sectional study, we cannot assess whether the worse quality of life in the ZPS was caused by the worse health and living conditions that determined the transfer of the senior to the ZPS, or whether the QOL worsened only during the stay in the ZPS.
Our results showed that, consistent with other studies, satisfaction with quality of life and with health worsened during the COVID-19 pandemic. It is necessary to introduce such measures during crisis situations that would ensure the highest possible stability of the quality of life and health of the older adult population.
Limitations
The main limitation of our work is the cross-sectional design of the study, which could have caused a distortion in the statements of the respondents due to the need for retrospective reflection on the period during the lockdown and before the pandemic. In addition, several lockdowns were announced in Slovakia, and the questionnaire did not allow for a specific specification of this period. Another disadvantage is that respondents did not have to answer every question, or each period, and therefore different numbers of answers arise during the analysis.
The study is approved by the Ethics Committee of the Faculty of Health Sciences of the Palacký University in Olomouc and the Ethics Committee of the UPJŠ in Košice.
Authors: Mgr. Lívia Kaňuková, Institute of Public Health and Hygiene, UPJŠ in Košice prof. MUDr. Kvetoslava Rimárová, CSc., Institute of Public Health and Hygiene, UPJŠ in Košice Work supported by 2 KEGA grant projects of the Ministry of Education, Science, Research and Sport of the SR KEGA: KEGA 001 UPJŠ-4/2024; KEGA 003 UPJŠ-4/2024.
List of bibliographic references
[1] DVOŘÁČKOVÁ, D. Quality of life of seniors in homes for seniors. Grada Publishing a. s., Prague, 2012. 1st edition. 112 pages. ISBN 978-80-247-4138-3. [2] GUIDA, C., CARPENTIERI, G. Quality of life in the urban environment and primary health services for the elderly during the Covid-19 pandemic: An application to the city of Milan (Italy), Cities, Volume 110, 2021, 103038, ISSN 0264-2751, doi.org/10.1016/j.cities.2020.103038. [3] DE MELO, R.L.P., DA SILVA JÚNIOR, E.G., SOUTO, R.Q. et al. Psychometric properties of the complete version of the World Health Organization Quality of Life Assessment (WHOQOL-OLD): reduced response scale. Psychol. Refl. Crit. 31, 4 (2018). doi.org/10.1186/s41155-018-0084-1 [4] WHO. 1996. What quality of life? World Health Forum: 17, 1996. p.354-356. Available: https://apps.who.int/iris/bitstream/handle/10665/54358/WHF_1996_17%284%29_p354-356.pdf?sequence=1&isAllowed=y. [5] PAYNE, J. et al. Quality of life and health. Triton, Prague, 2005. 1st edition. 629 pages. ISBN 80-7254-657-0. [6] LESKOVÁ, A. 2018. The story of old age or the life of a senior through the lens of social vulnerability. Slovak views: 10, 2018, p. 29-33. Available: http://matica.sk/wp-content/uploads/2018/10/SP-10_2018_Leskov%C3%A1_str_29-33.pdf. [7] NORTON, E.C. Chapter 16 - Health and Long-Term Care, Handbook of the Economics of Population Aging, North-Holland, Volume 1, 2016, Pages 951-989, ISSN 2212-0076, ISBN 9780444634054, doi.org/10.1016/bs.hespa.2016.06.001. [8] KOHÚTOVÁ, K. Quality of life of seniors in institutionalized care. In Alumni II. Conference of Graduates: a collection of contributions from the second scientific and professional conference of graduates studying psychology at the FF KU in Ružomberok. Ružomberok: Catholic University in Ružomberok. Verbum, 2018, p. 47-59. ISBN 978-80-561-0526-9. [9] WALLE-HANSEN, M.M., RANHOFF, A.H., MELLINGSÆTER, M. et al. 2021. Health-related quality of life, functional decline, and long-term mortality in older patients following hospitalization due to COVID-19. BMC Geriatrics 21, 199 (2021). doi.org/10.1186/s12877-021-02140-x. [10] BIDZAN-BLUMA, I., BIDZAN, M., JUREK, P., et al. 2020. A Polish and German Population Study of Quality of Life, Well-Being, and Life Satisfaction in Older Adults During the COVID-19 Pandemic. Frontiers in psychiatry, 11, 585813. doi.org/10.3389/fpsyt.2020.585813. [11] COLUCCI E, NADEAU S, HIGGINS J, et al. COVID-19 lockdowns' effects on the quality of life, perceived health and well-being of healthy elderly individuals: A longitudinal comparison of pre-lockdown and lockdown states of well-being. Arch Gerontol Geriatr. 2022 Mar-Apr;99:104606. doi: 10.1016/j.archger.2021.104606. [12] COCUZZO B, WRENCH A, O'MALLEY C . Effects of COVID-19 on Older Adults: Physical, Mental, Emotional, Social, and Financial Problems Seen and Unseen. Cureus 2022, 14(9): e29493. doi:10.7759/cureus.29493 [13] KUBÍČKOVÁ L, HAJKO V, HAZUCHOVÁ N, RAŠTICOVÁ M. Life satisfaction of Czech seniors: What actually matters? Scientific papers of the University of Pardubice. Series D, Faculty of Economics and Administration. 46/2019. ISSN 1211-555X (Print). Available: https://dk.upce.cz//handle/10195/74247 [14] TRYBUSIŃSKA D, SARACEN A. Loneliness of the context of quality of life of nursing home residents. Open Medicine: vol 14, 1, 2019. p. 354-361. doi.org/10.1515/med-2019-0035 [15] TALARSKA D, TOBIS S, KOTKOWIAK M, STRUGAŁA M, STANISŁAWSKA J, WIECZOROWSKA-TOBIS K. Determinants of Quality of Life and the Need for Support for the Elderly with Good Physical and Mental Functioning. Med Sci Monit. 2018 Mar 19;24:1604-1613. doi: 10.12659/msm.907032.