Abstract
Background
Loneliness in later life is common and is strongly associated with poorer quality of life (QoL). However, evidence from rural Egypt remains limited, particularly community-based studies that concurrently examine loneliness and QoL and their health, social, religious, and leisure-related determinants. This gap limits the development of culturally appropriate nursing and community interventions for rural older adults.
Objective
To assess the levels of loneliness and QoL and to identify their determinants among community-dwelling older adults in a rural Egyptian setting.
Methods
A cross-sectional descriptive study was conducted between July and September 2023 in a randomly selected rural village in Sharkia Governorate, Egypt. Using multistage probability sampling, 143 community-dwelling adults aged 60 years and older were recruited. Data were collected using structured and validated questionnaires. Descriptive statistics, Pearson correlation coefficients, and multiple linear regression analyses were performed.
Results
Participants had a mean age of 70.87 ± 8.50 years, and 52.4 percent were women. High loneliness was reported by 43.4 percent of participants, while 73.4 percent had low overall quality of life. Loneliness was strongly and inversely correlated with quality of life and was positively correlated with age and disease burden, while quality of life was negatively associated with age and number of chronic diseases and positively associated with education, income, social support, religious rituals, and leisure activities in bivariate analyses (all p <0.001). In exploratory multivariable analyses, quality of life was independently associated with age, education, current employment, number of chronic diseases, social support, and loneliness (R2 = 0.743), while loneliness was associated with age, number of visitors, religious rituals, and leisure activities (R2 = 0.451).
Conclusion
Loneliness and low quality of life are highly prevalent among community dwelling older adults in rural Egypt and are closely linked to aging, chronic disease burden, social resources, and engagement in meaningful activities. For nursing practice, these findings support the routine screening of loneliness and quality of life in primary and chronic care settings, the integration of social support and activity-based interventions into care plans, and collaboration with community and faith-based organizations to deliver culturally appropriate strategies aimed at reducing loneliness and enhancing quality of life among rural older populations.
Keywords: loneliness, quality of life, aged, rural population, social support, leisure activities, spirituality, cross-sectional studies, Egypt
Background
Egypt has the largest population in the Middle East and the third-largest in Africa, and it is experiencing steady growth in the proportion of older adults, a trend expected to continue in the coming decades (Sweed, 2016). As populations age, one issue consistently emerges as both common and consequential: loneliness (Joshi et al., 2018). Loneliness is an emotional and psychological state characterized by stress, sadness, low self-esteem, and hopelessness, and it occurs when the social relationships individuals desire do not match those they actually have (Dahlberg & McKee, 2014). At the global level, approximately one-third of older adults report experiencing loneliness (Beutel et al., 2017). Because loneliness is inherently subjective, its prevalence and expression vary within and across countries, shaped by individual characteristics, economic and policy contexts, population composition, and prevailing social expectations (Nzabona et al., 2016). For instance, Van Beljouw et al. (2014) reported that between 12 percent and 46 percent of older adults experienced loneliness at some point.
Gerontological research and practice face substantial challenges in addressing loneliness in later life. A wide range of often intersecting characteristics have been linked to loneliness, including advanced age, widowhood or being single, reduced income, poor health, functional limitations, depression, cognitive decline, and limited social support or networks (Trtica et al., 2023). From a psychosocial perspective, loneliness is among the most prevalent difficulties encountered by older adults and has been associated with male gender, unmarried status, lower educational attainment and income, and most strongly with living alone (Chow et al., 2021). These findings highlight the convergence of structural factors, such as income and living arrangements, with clinical characteristics, such as health status and cognitive functioning, in elevating the risk of loneliness.
Within this context, maximizing QoL, defined as an individual’s overall well-being and satisfaction with life, represents a central goal of elder care. The World Health Organization conceptualizes QoL as an individual’s perception of their position in life and the value they contribute to society (Cao et al., 2016; United States Census Bureau, 2022). QoL is multidimensional, subjective, and shaped by personal values. Key components in assessing QoL among older adults include autonomy, self-sufficiency, decision-making capacity, freedom from pain, preservation of sensory abilities, supportive social networks, financial security, and a sense of being valued by others (Soósová, 2016). QoL is influenced by a complex interplay of demographic factors such as age, gender, and ethnicity; socioeconomic factors including education, income, social status, and support; health-related factors such as disease burden, functional ability, and access to services; as well as cultural values and personal characteristics like coping strategies and self-efficacy (Lim et al., 2023). As individuals age, changes in health status, the need to adapt to new limitations, and shifts in family and social roles can substantially shape perceived QoL.
Loneliness is therefore not only widespread but also clinically significant among older adults, as it is closely linked to the multiple losses and disruptions in social relationships that often accompany aging (Mistry et al., 2022). An expanding body of evidence identifies loneliness as a significant public health concern, associating it with poorer physical and mental health outcomes, increased use of health care services, earlier institutionalization, cognitive decline, and higher mortality risk (McDaid & Park, 2024). Importantly, loneliness and poorer QoL are strongly interconnected. Social disconnection can undermine autonomy, purpose, and overall well-being, while diminished QoL can, in turn, intensify feelings of isolation, creating a reinforcing negative cycle (Mistry et al., 2022). Consequently, identifying predictors of both loneliness and QoL is essential to inform evidence-based prevention and intervention strategies that simultaneously address social, health, and environmental determinants (Nguyen et al., 2020).
Despite increasing attention to loneliness among older adults in Egypt, available local studies are largely urban or facility-based and do not simultaneously assess loneliness and QoL among rural, community-dwelling populations. For example, Sayied et al. (2012) examined loneliness alongside depression among attendees of geriatric clubs in Assiut City, relying on a convenience facility-based sample with limited generalizability to rural settings and without a concurrent measure of QoL. Similarly, Abdel-Aziz and El-Sebaie (2022) evaluated a nursing intervention using a nonrandomized before-and-after design to reduce depressive symptoms and loneliness. However, the study was not based on a probability-sampled rural community and did not assess QoL alongside loneliness. In contrast, international research consistently demonstrates a strong inverse association between loneliness and QoL in later life across diverse contexts, including China, Europe, and Southeast Asia (Beridze et al., 2020; Cao et al., 2016; Lim et al., 2023). Against this backdrop, the present study is positioned as a contextual contribution. It employs recent door-to-door, multistage probability sampling in a rural Egyptian village and assesses loneliness and QoL among the same participants, while modeling culturally salient engagement variables, such as religious rituals, leisure activities, and social support, alongside sociodemographic and health factors. This approach aims to generate locally relevant estimates and predictors to inform rural service planning, rather than to introduce conceptual novelty.
Accordingly, this study addresses the following research questions: 1) What are the levels of loneliness and QoL among community-dwelling older adults? 2) What factors influence loneliness and QoL among community-dwelling older adults? 3) What is the relationship between loneliness and QoL among community-dwelling older adults?
Methods
Study Design
A quantitative, cross-sectional descriptive design was adopted because the study objectives were to describe the burden of loneliness and QoL and to explore their sociodemographic, health, social, and religious determinants in a defined rural population, rather than to test an intervention. Cross-sectional surveys are well-suited for generating population-based estimates, such as the proportion of older adults experiencing high loneliness or low QoL, and for examining associations between variables measured at the same point in time. Accordingly, all observed relationships are interpreted as exploratory associations intended to inform future longitudinal and interventional research.
Setting
The study was conducted in a rural area (El Nakaria Village) in Sharkia Governorate, Egypt. El Nakaria is a large rural village located in the Zagazig district and has an estimated population of 2,300 older adults. The village is situated near Zagazig city, and multigenerational households are the most common family structure among residents. Livelihoods in the area depend primarily on agriculture. The village comprises approximately 8,000 houses, five schools, several pharmacies, and multiple mosques.
Sample/Participants
The sample size was calculated using the OpenEpi free software (Windows | Epi Info™ | CDC), assuming a total population of 2,300 older adults in the selected setting and an expected loneliness prevalence of 64 percent, based on a similar prior study (Susanty et al., 2022). At a confidence level of 80 percent, the minimum required sample size was approximately 130 participants. This number was increased by 10 percent, from 130 to 143, to account for nonresponse and ineligibility. The confidence level was set at 80% to balance statistical precision with feasibility constraints inherent in door-to-door data collection in a rural setting. This approach is consistent with exploratory community-based studies aimed at estimating prevalence and identifying potential correlates rather than testing definitive causal hypotheses. Accordingly, subsequent multivariable analyses were prespecified as exploratory and interpreted with caution.
A total of 143 community-dwelling older adults were recruited from the study setting. Eligible participants were aged 60 years or older, able to communicate, and free from diagnosed dementia or major psychiatric disorders. Older adults with psychiatric illness, dementia, severe sensory disabilities, or disabling diseases such as advanced cancer, as well as those residing in institutional settings such as nursing homes, were excluded.
The sample size calculation was designed to support descriptive estimation of loneliness prevalence in the village population. The multiple regression analyses were specified as secondary, exploratory assessments of associations and were not the basis for the a priori sample size determination. Consequently, the study may be underpowered to detect small partial effects in multivariable models, and results are therefore reported with an emphasis on effect sizes and 95 percent confidence intervals.
A multistage area or cluster sampling technique was used within one randomly selected rural village in Sharkia Governorate. First, one district (Zagazig city) was chosen from the 17 districts of Sharkia Governorate using simple random sampling based on the official district list and computer-generated random numbers. Second, a list of the 64 villages within the selected district was obtained, and one village (El Nakaria) was randomly chosen using the same method. Third, the residential area of El Nakaria was mapped and divided into clusters, from which clusters were randomly selected. Within each selected cluster, one street was randomly chosen. Fourth, along each selected street, a random starting household was identified, after which trained data collectors visited households consecutively. All residents aged 60 years or older in these households were screened for eligibility.
Eligible older adults were enrolled after providing consent. Individuals who met exclusion criteria were replaced by the next eligible household on the same street. Recruitment continued until the target sample size of 143 eligible and consenting participants was reached, and all completed the interview and constituted the final analytic sample.
Instruments
Several instruments were used in this study:
Participants’ Characteristics Form. A researcher developed the form to ensure cultural relevance for rural older adults. The instrument comprised five sections addressing sociodemographic characteristics, medical history and functional status, health habits and physical activity, psychological and spiritual support, and social and leisure engagement. Content validity was assessed by five experts in gerontological nursing and public health using a four-point relevance scale. Based on their feedback, minor revisions were made to wording and item order. A pilot test with 15 older adults from a similar setting confirmed clarity and an administration time of approximately 30 to 35 minutes. Pilot participants were excluded from the main study. Internal consistency in the study sample was acceptable, with a Cronbach’s alpha of 0.81. Content validity indices indicated strong validity, with item-level CVI values ranging from 0.80 to 1.00, a scale-level CVI average of 0.94, and a universal agreement CVI of 0.86.
UCLA Loneliness Scale, Version 3 (Arabic). Loneliness was assessed using the 20-item UCLA Loneliness Scale, Version 3, administered in Arabic (Russell, 1996). The scale measures subjective feelings of loneliness and social isolation (Trtica et al., 2023). Items are rated on a four-point scale ranging from never to always, yielding total scores from 20 to 80, with higher scores indicating greater loneliness. Common interpretive categories include low loneliness for scores from 21 to 40, moderate loneliness for scores from 41 to 60, and high loneliness for scores above 60. Categorical classifications are presented to aid interpretation of prevalence, whereas continuous scores were retained for correlation and regression analyses. Internal consistency in the present sample was excellent, with a Cronbach’s alpha of 0.913. Previous studies have demonstrated strong psychometric properties of the Arabic versions of the scale, including factor structure and validity in Arabic-speaking populations (Alateeq et al., 2021; AlNajjar & Dodeen, 2017). Use of the UCLA Loneliness Scale complied with guidance permitting non-profit research use, and confirmation was obtained from the developers.
WHO Quality of Life Instrument, Short Form (WHOQOL BREF). Quality of life was assessed using the WHOQOL BREF (Skevington et al., 2004). The instrument consists of 26 items. The first two items evaluate the overall QoL and satisfaction with health, while the remaining 24 items cover four domains: physical health, psychological health, social relationships, and environment. Responses are rated on a five-point Likert scale ranging from extremely dissatisfied or very poor to extremely satisfied or extremely good, with higher scores indicating better QoL. For descriptive purposes, QoL scores were categorized into low, moderate, and high levels using distribution-based thresholds consistent with prior community-based studies. These categorizations were used solely to facilitate the interpretation of prevalence estimates. All inferential and regression analyses were conducted using continuous WHOQOL-BREF scores to preserve statistical power and avoid information loss. In the present study, the WHOQOL BREF demonstrated excellent internal consistency, with a Cronbach’s alpha of 0.933. Multiple studies support the reliability and validity of the Arabic version of the WHOQOL BREF in both general and specific Arab populations (Dalky et al., 2017; Malibary et al., 2019; Ohaeri & Awadalla, 2009). Written authorization for use of the instrument was obtained from the World Health Organization prior to data collection (WHO, n.d.).
Pilot Testing and Item-Level Diagnostics. The pilot study with 15 participants confirmed the clarity of the items and the appropriate administration time, and the pilot data were not included in the main analysis. Within the study sample, internal consistency was further evaluated using item-level diagnostics to assess potential redundancy. The average inter-item correlation fell within the recommended range of 0.15 to 0.50, all corrected item total correlations exceeded acceptable minimum thresholds, and deletion of any single item did not result in a meaningful increase in Cronbach’s alpha. Collectively, these indicators support cohesive but non-duplicative content.
Data Collection
Data collection commenced after official permission to conduct the study was obtained. Fieldwork was carried out over three months, beginning in July 2023 and concluding in late September 2023. Each participant was interviewed in their home using the structured questionnaire, with interviews lasting approximately 30 to 35 minutes. Data collection was scheduled three days per week, from 8:00 a.m. to 3:00 p.m., on Saturday, Wednesday, and Friday.
Data were collected by a team of trained enumerators with backgrounds in nursing or public health who were recruited from the Faculty of Nursing at Zagazig University. Enumerators were required to have prior experience in community-based surveys or working with older adults and to be fluent in the local dialect. Before fieldwork, all enumerators completed a structured training program led by the principal investigator over two days. Training covered the study objectives and design, eligibility criteria, household recruitment procedures, verbal informed consent, standardized administration of all instruments, and strategies for responding to participants’ questions without introducing bias. Special emphasis was placed on respectful and sensitive interviewing of older adults, including clear communication, allowing sufficient time, and ensuring privacy. Training methods included demonstrations, detailed item-by-item reviews, role-playing, and mock interviews.
Following training, enumerators participated in the pilot study under direct supervision. Feedback from this phase was used to refine wording, sequencing, skip patterns, and interviewer consistency. During the main data collection phase, the principal investigator periodically accompanied enumerators in the field, reviewed completed questionnaires for completeness and accuracy, and provided immediate feedback to maintain data quality and protocol adherence.
Data Analysis
Data were analyzed using IBM SPSS Statistics, version 23. Continuous variables were summarized using means and standard deviations when normally distributed and medians with interquartile ranges when distributions were non-normal. Categorical variables were summarized using frequencies and percentages. Normality was assessed using the Shapiro-Wilk test and visual inspection of histograms. Group comparisons for categorical variables were conducted using chi-square or Fisher’s exact tests, as appropriate. Bivariate associations between continuous and ordinal variables were examined using Pearson’s correlation coefficient, given the presence of multiple ordered categories and approximately linear relationships.
Determinants of the two primary outcomes, the WHOQOL-BREF total score and the UCLA Loneliness Scale score, were examined using multiple linear regression. Separate models were specified for each outcome, incorporating sociodemographic, health-related, and social and engagement variables. Regression results are presented as unstandardized coefficients with standard errors, 95% confidence intervals, standardized coefficients, and p-values. Model fit was summarized using the coefficient of determination (R2) and the overall F statistic.
Assumptions of multiple linear regression were evaluated for both models. Linearity and homoscedasticity were assessed through inspection of residuals versus predicted value plots, and normality of residuals was examined using histograms and normal probability plots. Multicollinearity was evaluated using variance inflation factors (VIFs) and tolerance values. VIFs ranged from 1.34 to 2.05 in the QoL model and from 1.34 to 2.02 in the loneliness model, with tolerance values approximately 0.49 to 0.75 in both models. These values are below commonly accepted thresholds, indicating no evidence of problematic multicollinearity. Overall, diagnostic checks indicated that key regression assumptions were reasonably satisfied.
Given the modest sample size relative to the number of predictors, regression analyses were prespecified as exploratory. Findings are therefore interpreted as estimates of association rather than evidence of causality, with emphasis placed on effect sizes and 95% confidence intervals rather than statistical significance alone.
To assess the robustness of findings involving ordinal predictors (e.g., education, income, religious rituals, leisure activities), correlations and regression coefficients were examined for consistency in direction and magnitude across models and with bivariate associations. Results were stable, supporting the appropriateness of treating these variables as approximately continuous for analytic purposes. Similar approaches are widely used in epidemiological and gerontological research involving ordered categorical measures.
Ethical Considerations
The study protocol was approved by the Research Ethics Committee of the Faculty of Nursing, Zagazig University, Egypt, under code ID ZU Nur REC 0017 in June 2023. All participants were fully informed about the purpose of the study and provided verbal consent before participation. Participation was voluntary, and individuals were informed of their right to decline or withdraw at any time without consequence. Participants were assured that all data would be used solely for research purposes. Contact information for the researcher was provided, allowing participants to seek clarification or additional information at any time.
Results
Characteristics of the Study Participants
A total of 143 community-dwelling older adults participated in the study. As shown in Table 1, participants ranged in age from 60 to 97 years, with a mean age of 70.87 (SD = 8.50). Slightly more than half of the sample, 56.6%, were younger than 70 years. Females constituted 52.4% of the participants, and 46.9% were married. Nearly half of the sample, 47.6%, were illiterate. Regarding socioeconomic and living characteristics, 42.0% of participants lived with a spouse, while 18.2% lived alone. The majority, 82.5%, were not currently working, and pensions represented the main source of income for 72.7% of the participants. More than half, 55.9%, reported that their monthly income was sufficient to meet their needs.
Table 1.
Demographic characteristics of the participants (N = 143)
| Variable | Category | n | % |
|---|---|---|---|
| Age (years) | < 70 | 81 | 56.6 |
| ≥ 70 | 62 | 43.4 | |
| M ± SD | 70.87 ± 8.50 | ||
| Median (range) | 68 (60-97) | ||
| Gender | Men | 68 | 47.6 |
| Women | 75 | 52.4 | |
| Marital status | Married | 67 | 46.9 |
| Single | 6 | 4.2 | |
| Widowed | 54 | 37.8 | |
| Divorced | 16 | 11.2 | |
| Education | Illiterate | 68 | 47.6 |
| Read and write | 21 | 14.7 | |
| Basic education | 19 | 13.3 | |
| Secondary education | 5 | 3.5 | |
| University | 30 | 21.0 | |
| Current job | Working | 25 | 17.5 |
| Not working | 118 | 82.5 | |
| Crowding index | ≤ 1 | 74 | 51.7 |
| > 1 | 69 | 48.3 | |
| Income adequacy | Not enough | 52 | 36.4 |
| Enough | 80 | 55.9 | |
| Enough and saving | 11 | 7.7 | |
| Living arrangement | Alone | 26 | 18.2 |
| With spouse | 60 | 42.0 | |
| With one son | 55 | 38.5 | |
| With relatives | 2 | 1.4 | |
| Current income source | Pension | 104 | 72.7 |
| Help from sons | 7 | 4.9 | |
| Current work | 25 | 17.5 | |
| Property | 7 | 4.9 |
Loneliness and QoL
A high level of loneliness was reported by 43.4% of older adults, with a mean loneliness score of 55.64 (SD = 13.65). Moderate loneliness was reported by 41.9%, while 14.7% experienced low loneliness. With respect to QoL, the mean scores for the physical, psychological, social, and environmental domains were 18.33 (SD = 6.69), 15.43 (SD = 5.10), 7.24 (SD = 2.32), and 18.87 (SD = 6.10), respectively. Overall, 73.4% of participants were classified as having a low level of QoL. The total QoL mean score was 59.85 (SD = 17.20) (Table 2).
Table 2.
Loneliness and QoL scores among older adults (N = 143)
| Measure | M ± SD | Median (range) | High n (%) | Moderate n (%) | Low n (%) |
|---|---|---|---|---|---|
| Loneliness score (max = 80) | 55.64 ± 13.65 | 59 (20–80) | 62 (43.4) | 60 (41.9) | 21 (14.7) |
| Physical QoL (max = 35) | 18.33 ± 6.69 | 18 (7–35) | 21 (14.7) | 41 (28.7) | 81 (56.6) |
| Psychological QoL (max = 30) | 15.43 ± 5.10 | 15 (6–30) | 17 (11.9) | 44 (30.8) | 82 (57.3) |
| Social QoL (max = 15) | 7.24 ± 2.32 | 7 (3–15) | 9 (6.3) | 42 (29.4) | 92 (64.3) |
| Environmental QoL (max = 40) | 18.87 ± 6.10 | 18 (8–35) | 11 (7.7) | 27 (18.9) | 105 (73.4) |
| Total QoL (max = 120) | 59.85 ± 17.20 | 59 (24–100) | 14 (9.8) | 24 (16.8) | 105 (73.4) |
Correlates of Loneliness and QoL
As shown in Table 3, loneliness was strongly and inversely correlated with QoL (r = -0.693, p <0.001), indicating that higher loneliness was associated with poorer QoL. Age was negatively correlated with QoL (r = -0.472, p <0.001) and positively correlated with loneliness (r = 0.391, p <0.001). Greater disease burden was associated with worse outcomes, with more chronic diseases and treatments correlating negatively with QoL and positively with loneliness. Conversely, higher education and income correlated with better QoL and less loneliness. Social engagement, religious rituals, leisure activities, and social support were all associated with higher QoL and lower loneliness.
Table 3.
Correlations between QoL, loneliness, and selected variables
| Variable | QoL | Loneliness | ||
|---|---|---|---|---|
| r | p | r | p | |
| Loneliness score | -0.693 | <0.001 | — | — |
| Age (years) | -0.472 | <0.001 | 0.391 | <0.001 |
| Education | 0.291 | <0.001 | -0.277 | <0.001 |
| Income | 0.348 | <0.001 | -0.346 | <0.001 |
| Number of diseases | -0.550 | <0.001 | 0.323 | <0.001 |
| Number of treatments | -0.360 | <0.001 | 0.252 | 0.010 |
| Visiting others | 0.324 | <0.001 | -0.285 | 0.002 |
| Social support | 0.381 | <0.001 | -0.692 | <0.001 |
| Visitors | 0.231 | <0.001 | -0.219 | 0.010 |
| Religious rituals | 0.596 | <0.001 | -0.313 | <0.001 |
| Leisure activities | 0.494 | <0.001 | -0.308 | <0.001 |
Note. r = Pearson correlation coefficient.
Predictors of QoL
The multiple linear regression model presented in Table 4 accounted for a substantial proportion of variance in QoL (R2 = 0.743, adjusted R2 = 0.718; F (13, 130) = 28.95, p <0.001). After adjustment for all covariates, higher QoL was independently associated with current employment, greater social support, and lower loneliness, whereas older age, a higher number of chronic diseases, and lower educational attainment were associated with poorer QoL.
Table 4.
Multiple linear regression model predicting QOL (N = 143)
| Predictor | B | SE | β | t | p | 95% CI for B |
|---|---|---|---|---|---|---|
| Constant | 113.333 | 8.940 | 0.000 | 12.678 | <0.001 | 95.647, 131.019 |
| Age (years) | -0.289 | 0.123 | -0.143 | -2.352 | 0.020 | -0.531, -0.046 |
| Gender (male = 1) | -0.779 | 1.977 | -0.023 | -0.394 | 0.694 | -4.689, 3.132 |
| Education | -1.363 | 0.619 | -0.125 | -2.204 | 0.029 | -2.587, -0.140 |
| Current job (working = 1) | 10.671 | 2.612 | 0.236 | 4.085 | <0.001 | 5.503, 15.838 |
| Income | 1.224 | 1.800 | 0.043 | 0.680 | 0.498 | -2.336, 4.785 |
| Number of diseases | -3.357 | 0.743 | -0.284 | -4.518 | <0.001 | -4.827, -1.887 |
| Number of treatments | -0.322 | 1.277 | -0.015 | -0.252 | 0.802 | -2.847, 2.204 |
| Social support (f1–f8 sum) | 4.957 | 0.979 | 0.299 | 5.064 | <0.001 | 3.021, 6.893 |
| Visitors (number) | -0.656 | 0.730 | -0.053 | -0.899 | 0.371 | -2.099, 0.788 |
| Social visiting others | -0.534 | 0.664 | -0.041 | -0.804 | 0.423 | -1.848, 0.780 |
| Leisure activities (sport type) | -0.841 | 1.872 | -0.024 | -0.450 | 0.654 | -4.544, 2.861 |
| Religious rituals (praying frequency) | -0.662 | 0.375 | -0.097 | -1.763 | 0.080 | -1.405, 0.081 |
| Loneliness score | -0.555 | 0.076 | -0.438 | -7.302 | <0.001 | -0.705, -0.404 |
R2 = 0.743; adjusted R2 = 0.718; F(13, 130) = 28.95, p <0.001
Note. Gender coded 0 = female, 1 = male; employment coded 0 = not working, 1 = working. Higher scores for education, income, religious rituals, leisure activities, visiting, and social visiting indicate higher levels or more frequent engagement.
Specifically, older adults who were currently employed had WHOQOL-BREF scores approximately 10.7 points higher than those who were not employed (B = 10.671, p <0.001). Each additional type of social support (f1–f8) was associated with an increase of approximately 5.0 points in QoL (B = 4.957, p <0.001). Loneliness demonstrated a strong inverse association with QoL; for each one-point increase in the loneliness score, QoL decreased by approximately 0.56 points (B = -0.555, p <0.001), representing one of the largest standardized effects in the model (β = -0.438).
Age and health status were also independently associated with QoL. Each additional year of age was associated with a modest decline in QoL (B = -0.289, p = 0.020), and each additional chronic disease was associated with a reduction of approximately 3.4 points (B = -3.357, p <0.001). Education demonstrated a statistically significant negative coefficient (B = -1.363, p = 0.029), reflecting the study’s coding scheme in which higher numeric values corresponded to lower educational attainment; accordingly, lower education was independently associated with poorer QoL.
Gender, income, number of treatments, number of visitors, visiting others, leisure activities, and religious rituals were not independently associated with QoL in the fully adjusted model (all p > 0.05). Model diagnostics indicated acceptable stability, with tolerance values ranging from approximately 0.49 to 0.75 and variance inflation factor values ranging from 1.34 to 2.05.
The relatively high proportion of explained variance should be interpreted with caution. The WHOQOL-BREF and UCLA Loneliness Scale capture overlapping dimensions of subjective well-being and social connectedness, and shared conceptual variance likely contributed to the magnitude of R2. Accordingly, the model is best understood as describing co-occurring psychosocial correlates rather than providing a predictive or causal explanation of QoL.
Predictors of Loneliness
The multiple linear regression model presented in Table 5 accounted for a meaningful proportion of variance in loneliness scores (R2 = 0.451, adjusted R2 = 0.401; F(12, 131) = 8.98, p <0.001). Older age was independently associated with higher loneliness; each additional year of age was associated with an increase of approximately 0.46 points in loneliness score (B = 0.461, p = 0.001).
Table 5.
Multiple linear regression model predicting loneliness score (N = 143)
| Predictor | B | SE | β | t | p | 95% CI for B |
|---|---|---|---|---|---|---|
| Constant | 21.458 | 10.109 | -0.000 | 2.123 | 0.036 | 1.460, 41.456 |
| Age (years) | 0.461 | 0.135 | 0.289 | 3.407 | 0.001 | 0.193, 0.729 |
| Gender (male = 1) | 0.145 | 2.273 | 0.005 | 0.064 | 0.949 | -4.352, 4.642 |
| Education | 0.390 | 0.711 | 0.045 | 0.549 | 0.584 | -1.015, 1.796 |
| Current job (working = 1) | -1.163 | 3.002 | -0.033 | -0.387 | 0.699 | -7.103, 4.776 |
| Income | -0.435 | 2.069 | -0.019 | -0.210 | 0.834 | -4.529, 3.659 |
| Number of diseases | -0.372 | 0.854 | -0.040 | -0.436 | 0.664 | -2.062, 1.317 |
| Number of treatments | 2.077 | 1.457 | 0.121 | 1.426 | 0.156 | -0.805, 4.960 |
| Social support (f1–f8 sum) | -1.576 | 1.117 | -0.121 | -1.411 | 0.161 | -3.786, 0.634 |
| Visitors (number) | 3.074 | 0.795 | 0.315 | 3.867 | <0.001 | 1.501, 4.647 |
| Social visiting others | -0.726 | 0.761 | -0.071 | -0.954 | 0.342 | -2.231, 0.780 |
| Leisure activities (sport type) | -4.228 | 2.121 | -0.154 | -1.994 | 0.048 | -8.423, -0.033 |
| Religious rituals (praying frequency) | -1.042 | 0.422 | -0.194 | -2.468 | 0.015 | -1.877, -0.207 |
|
| ||||||
| R2 = 0.451, adjusted R2 = 0.401; F(12, 131) = 8.98, p <0.001 | ||||||
Note. Gender coded 0 = female, 1 = male; employment coded 0 = not working, 1 = working. Higher scores indicate higher levels or more frequent engagement.
The number of visitors received was positively associated with loneliness (B = 3.074, p <0.001). This finding should not be interpreted causally and may reflect reverse causation or a context-dependent association, whereby individuals experiencing greater loneliness or poorer health receive more care-related or obligation-driven visits that do not alleviate subjective feelings of loneliness. The reversal in direction relative to the bivariate correlation suggests a suppression effect, indicating that adjustment for age, health status, and engagement variables alters the observed association.
In contrast, greater engagement in leisure activities and more frequent religious rituals were independently associated with lower loneliness. Each unit increase in leisure activity was associated with a reduction of approximately 4.2 points in loneliness score (B = -4.228, p = 0.048), and each increase in praying frequency was associated with a reduction of approximately 1.0 point (B = -1.042, p = 0.015).
Gender, education, current employment, income, number of chronic diseases, number of treatments, social support, and visiting others were not independently associated with loneliness in the fully adjusted model (all p > 0.05). Model diagnostics indicated acceptable stability, with tolerance values ranging from approximately 0.49 to 0.75 and variance inflation factor values ranging from 1.34 to 2.02.
Discussion
This cross-sectional study of community-dwelling older adults in a rural Egyptian village found that loneliness was highly prevalent and QoL was generally low. Nearly half of the participants reported high loneliness, and almost three-quarters reported low overall QoL. Loneliness and QoL were strongly and inversely associated, and both outcomes showed systematic relationships with age, health burden, gender, socioeconomic position, and social, religious, and leisure engagement. Because all variables were measured at a single time point, these findings represent associations rather than causal relationships; the regression models identify factors that co-vary with loneliness and QoL in this rural context but do not establish temporal precedence or causation.
Several complementary theoretical perspectives help interpret these findings and situate them within the broader literature on aging and loneliness.
Theoretical Interpretation of Findings
First, the results are consistent with cognitive–discrepancy theories of loneliness, which conceptualize loneliness as arising from a perceived mismatch between desired and actual social relationships (Dahlberg & McKee, 2014; Yanguas et al., 2018). In this study, higher loneliness was associated with older age, greater multimorbidity and treatment burden, lower income, and weaker perceived social support. These conditions likely restrict mobility, social participation, and reciprocity, thereby widening the perceived gap between desired and available social connections. The strong inverse association between social support and loneliness, alongside the positive association between social support and QoL, aligns with evidence from Europe and other regions indicating that loneliness is more closely related to the perceived adequacy and emotional quality of relationships than to contact frequency alone (Beridze et al., 2020; Olaya et al., 2017).
Second, the observed pattern of associations accords with the social convoy model of aging, which emphasizes that individuals age within dynamic networks of close and peripheral relationships that provide emotional, instrumental, and informational support (Cohen-Mansfield et al., 2016; Yanguas et al., 2018). In our sample, greater disease burden and higher treatment load were associated with poorer QoL and higher loneliness, whereas visiting others, receiving visitors, and higher perceived social support were associated with better QoL and lower loneliness. Similar links between health status, functional limitations, social support, and loneliness have been documented in England, Spain, and China (Olaya et al., 2017; Trtica et al., 2023; Zhu et al., 2018). From a convoy perspective, chronic illness and disability may shrink or strain social networks, while supportive family and community ties can buffer the adverse emotional consequences of health decline.
Third, the associations observed between religious rituals, leisure activities, loneliness, and QoL are consistent with activity theory, which posits that continued engagement in meaningful roles and activities promotes well-being in later life. In this study, greater engagement in religious rituals and leisure activities was associated with higher QoL and lower loneliness in bivariate analyses, and both remained independently associated with lower loneliness in multivariable models. Comparable findings have been reported in Ghana, Sri Lanka, and Malaysia, where religious participation and leisure engagement predicted better QoL and lower loneliness among older adults (Attafuah et al., 2022; Lim et al., 2023; Wijesiri et al., 2023). In a rural Egyptian context, mosque attendance, Quran circles, and low-cost leisure or physical activities may provide structured opportunities for social contact, role continuity, and a sense of purpose—mechanisms emphasized by activity and resilience perspectives as central to successful aging (Cohen-Mansfield et al., 2016; Yanguas et al., 2018).
Taken together, these perspectives suggest that loneliness and QoL among rural older adults in Egypt are shaped by the interaction of health and functional constraints, the structure and quality of social convoys, and opportunities for engagement in socially, religiously, and personally meaningful activities. Although the present design cannot determine whether modifying any single factor would improve outcomes, it highlights key vulnerabilities and potential leverage points in this rural setting.
Loneliness, Health Burden, and QoL
The high prevalence of loneliness and low QoL observed in this study is consistent with reports from other low- and middle-income countries and from some high-income settings (Beutel et al., 2017; Ibáñez-del Valle et al., 2022; Susanty et al., 2022). Previous Egyptian studies have also documented substantial loneliness among older adults in both community and institutional contexts (Abdel-Aziz & El-Sebaie, 2022; Sayied et al., 2012). In contrast, lower prevalence estimates have been reported in some European samples (Olaya et al., 2017), suggesting the influence of welfare systems, service availability, and sociocultural norms on experiences of loneliness across countries (Beridze et al., 2020; Nzabona et al., 2016).
Within our sample, older age and a higher number of chronic conditions and treatments were associated with greater loneliness and poorer QoL, echoing findings from China and Europe linking multimorbidity and functional limitations to adverse psychosocial outcomes (Beridze et al., 2020; Trtica et al., 2023). From a stress-process perspective, chronic illness and polypharmacy may function as persistent stressors that restrict mobility, increase dependence, and reduce participation in valued activities, thereby amplifying perceived social disconnection (Cohen-Mansfield et al., 2016; Yanguas et al., 2018).
The strong inverse association between loneliness and QoL observed in this study is consistent with evidence from Turkey, Europe, and other regions, which shows that loneliness is closely linked to poorer physical and mental health and reduced well-being (Çam et al., 2021; McDaid & Park, 2024). In the QoL regression model, loneliness remained one of the strongest correlates after adjustment for age, disease burden, social support, and engagement variables. Nevertheless, the cross-sectional nature of the data precludes conclusions about directionality: loneliness may contribute to poorer QoL, declining QoL, and health may increase loneliness, or both may be driven by upstream social and economic determinants (Nguyen et al., 2020; Olaya et al., 2017). Longitudinal studies are required to disentangle these pathways.
Social Resources, Religious Engagement, and Leisure in a Rural Context
Consistent with prior reviews, our findings underscore the central role of social resources and participation in shaping loneliness and QoL in later life (Smale et al., 2022; Yanguas et al., 2018). Social support, visiting others, and receiving visitors were associated with better QoL and lower loneliness in bivariate analyses, aligning with studies from Canada, Nigeria, and Turkey (Ebimgbo et al., 2021; Smale et al., 2022). Although multigenerational households were common in this village, a notable proportion of older adults lived alone or were widowed. The social convoy perspective suggests that co-residence alone may be insufficient; the emotional quality, reciprocity, and perceived reliability of relationships appear more consequential than household structure per se (Dahlberg & McKee, 2014; Olaya et al., 2017).
Religious and leisure engagement emerged as particularly salient correlates in this rural setting. Frequent religious rituals were positively associated with QoL and inversely associated with loneliness, mirroring findings from Ghana, Sri Lanka, and Malaysia (Attafuah et al., 2022; Lim et al., 2023; Wijesiri et al., 2023). Religious participation may offer meaning, hope, and a sense of belonging that buffers the emotional impact of illness, bereavement, and economic hardship (Cohen-Mansfield et al., 2016; Yanguas et al., 2018). Leisure and sport activities may further support physical functioning, social interaction, and self-efficacy, consistent with activity theory and prior empirical work (Lim et al., 2023; Tzouvara & Kupdere, 2022).
An unexpected finding was the positive independent association between the number of visitors and loneliness in the multivariable loneliness model. Similar paradoxical associations have been reported elsewhere, where objective contact frequency does not necessarily correspond to subjective connectedness (Beutel et al., 2017; Yanguas et al., 2018). One interpretation is that lonelier individuals receive more obligation- or care-driven visits that do not meet emotional needs; another is that frequent visiting occurs in the context of illness or dependency, which may itself intensify feelings of isolation. This finding highlights the complexity of loneliness and suggests the need for qualitative research examining the meaning and perceived quality of social interactions among rural older adults.
Gender and Socioeconomic Differences
In bivariate analyses, men appeared more vulnerable to poorer QoL and higher loneliness; however, gender did not remain an independent predictor in the fully adjusted regression models. These findings are broadly consistent with evidence from rural Turkey and other contexts where gender differences in loneliness vary by social roles, marital status, and living arrangements (Ibáñez-del Valle et al., 2022; Susanty et al., 2022). From a convoy perspective, older men may experience more abrupt social network contraction following retirement or widowhood, whereas women often maintain broader kin and neighbor ties across the life course. Although mechanisms cannot be determined from the present data, the findings support the need for gender-responsive approaches in rural programs, such as proactively engaging older men in mosque-based or leisure activities and monitoring participation and outcomes by gender (Haney et al., 2017; Smale et al., 2022).
Higher education and income were associated with higher QoL and lower loneliness in bivariate analyses, consistent with international evidence that socioeconomic advantage facilitates better health, access to services, and social participation (Beridze et al., 2020; Lim et al., 2023; Wijesiri et al., 2023). In the QoL regression model, the negative coefficient for education (reflecting the coding scheme) indicates that lower educational attainment is independently associated with poorer QoL. Income did not remain significant after adjustment, suggesting shared variance with education, employment, and social support. Nonetheless, the overall pattern underscores socioeconomic position as an essential correlate of both loneliness and QoL among rural older adults, consistent with findings from Nigeria and Uganda (Ebimgbo et al., 2021; Nzabona et al., 2016).
Limitations
Several limitations should be considered. The cross-sectional design precludes causal inference, and the study was conducted in a single rural village, which may limit generalizability to other rural settings, districts, or governorates. The sample size (n = 143), while adequate for descriptive estimation and bivariate analyses, is relatively modest for multivariable regression models with multiple predictors, increasing the risk of overfitting and limiting power to detect small independent effects.
Although key regression assumptions were examined and multicollinearity was low (VIFs ranging from 1.34 to 2.05), the multivariable models were prespecified as exploratory and should be interpreted as estimates of association rather than predictive or causal models. Differences observed between bivariate and adjusted associations likely reflect shared variance and suppression effects inherent in multivariable modeling. Additionally, alternative model specifications (e.g., reduced predictor sets) may yield different effect estimates.
Future research should include larger, multi-village samples to improve generalizability and enable more parsimonious or penalized modeling approaches. Longitudinal and interventional studies are particularly needed to test causal pathways and to evaluate whether changes in health status, social support, religious engagement, or leisure participation lead to improvements in loneliness and quality of life. Qualitative research may further elucidate how older adults in rural Egypt experience loneliness and the emotional meaning of social, religious, and leisure activities.
Implications for Practice and Policy
Despite the inability to infer causality, the observed patterns, interpreted through cognitive–discrepancy, social convoy, and activity frameworks, have clear practical implications. Routine screening for loneliness and QoL using validated Arabic instruments could be integrated into chronic disease management and primary care visits. Identifying older adults at risk would facilitate referral to community- and mosque-based activities, befriending initiatives, or support groups, consistent with emerging social prescribing approaches.
Care plans for older adults with multimorbidity could explicitly incorporate social connection as a therapeutic goal alongside medical management. Multicomponent, culturally grounded interventions that combine health care, social engagement, religious participation, and practical supports (e.g., transportation) may be particularly relevant in rural settings. Programs should be gender- and poverty-sensitive to ensure equitable reach and benefit.
For nursing practice, these findings reinforce that loneliness and QoL are core gerontological concerns rather than peripheral social issues. Community and primary care nurses should routinely assess loneliness and QoL, view social connection as a therapeutic target, and collaborate with families, community organizations, and faith-based institutions to support meaningful engagement among older adults.
Conclusion
Older adults living in this rural Egyptian community experienced high levels of loneliness and low QoL, associated with health burden, socioeconomic factors, and social, religious, and leisure engagement. The findings support the development of community-based, culturally appropriate programs to enhance social interaction and reduce loneliness. Replication with larger, multi-site samples and longitudinal designs is recommended to strengthen the evidence base and guide effective interventions and policy responses for older adults in rural settings.
Acknowledgment
The authors would like to thank the older adults who participated in the study for their cooperation. This study was supported by Prince Sattam bin Abdulaziz University (PSAU/2024/R/1445).
Funding Statement
Funding The current study received no specific grants from public, commercial, or non- profit agencies.
Declaration of Conflicting Interest
No conflict of interest to declare in this study.
Author Contribution
Ayman Mohamed El-Ashry & Hassanat Ramadan Abdel Aziz: Conceptualization, preparation, and data collection; development of methodology; investigation; formal analysis; data examination; drafting the initial manuscript; manuscript writing; and editing. Ateya Megahed Ibrahim, Safia Gomaa Mohammed Metwalley: Methodology, investigation, formal analysis, data collection, writing manuscript, & editing. All authors reviewed the final version of the manuscript and accepted it for publication.
Author Biography
Hassanat Ramadan Abdel Aziz, PhD, RN, is an Assistant Professor at the Department of Nursing Administration and Education, College of Nursing, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia, and at the Gerontological Nursing, Faculty of Nursing, Zagazig University, Egypt.
Ayman Mohamed El-Ashry, PhD, RN, is a Lecturer at the Psychiatric and Mental Health Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt, and at the Nursing Department, College of Applied Medical Sciences, Al Qurayyat, Jouf University, Saudi Arabia.
Ateya Megahed Ibrahim, PhD, RN, is an Associate Professor at the Department of Nursing Administration and Education, College of Nursing, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia, and in the Family and Community Health Nursing, Faculty of Nursing, Port Said University, Egypt.
Safia Gomaa Mohammed, PhD, RN, is a Lecturer in the Gerontological Nursing, Faculty of Nursing, Zagazig University, Egypt.
Data Availability
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Declaration of Use of AI in Scientific Writing
The authors used Grammarly in the writing process to improve readability and remove grammatical errors. However, they took full responsibility for the content.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.