ABSTRACT
Introduction:
Elderly people have a higher probability of suffering from multiple health disorders due to reduced physical and mental functions, thus affecting their quality of life (QOL). Better understanding of QOL might help to identify ways to improve the delivery of health services to elderly people.
Objective:
To assess the QOL and its various sociodemographic determinants among elderly residing in a town of south-east district of the National Capital Region.
Methods:
A cross-sectional study among 400 elderly individuals was conducted in the field practice area of Urban Health Training Centre (UHTC) of a medical college. The WHOQOL-BREF questionnaire was used to assess the QOL of the study participants. Data was analysed using the Statistical Package for Social Sciences (SPSS). Unpaired t-test/analysis of variance (ANOVA) was performed for univariate analysis, and multivariate linear regression was used to identify the predictors of QOL across four domains.
Result:
The mean QOL score for physical, psychological, social and environmental domains was 48.9, 47.1, 53.6 and 48.7, respectively. QOL score was 4.04 points (physical domain) and 5.31 points (psychological domain) lower among those who were more than 70 years, compared to those who were in the age group of 60–64 years. For the social relationship domain, the score was 4.24 points higher among 65–69 years old participants compared to 60–64 years.
Conclusion:
Poor QOL score among the elderly in the present study highlights the need for focused interventions that cater to this older cohort. Structured integration of the elderly health care programmes with the National Program for non-communicable diseases at the local level will help in catering to their health care needs and further QOL.
Keywords: Elderly health, quality of life, WHOQOL-BREF
Introduction
Ageing is an inevitable and irreversible phenomenon. The projected proportion of the elderly has shown a rising trend, with 761 million elderly in the year 2021 to 1.6 billion by the year 2025 across the globe.[1] Coupled with the problem of failing health is the crisis of emotional insecurity, neglect and abuse. Many older persons either lack the opportunity and/or the capacity to be as productive as they were. Elderly people have a higher probability of suffering from multiple health disorders due to reduced physical and mental functions, which can seriously affect their quality of life (QOL).
WHO defines QOL as ‘an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concern.[2]’ In measuring QOL, therefore, the WHOQOL Group takes the view that it is important to know how satisfied or bothered people are by important aspects of their life, and this interpretation will be a highly individual matter.
Use of QOL Measurement Systems is still largely limited to developed nations, and there is a huge scope for it in countries like India, where the objective scales to measure disease burden in the community are still not widely used. With the addressal of elderly health care as a component of Comprehensive Primary Health Care under the umbrella of Aayushman Bharat Program, understanding the health needs of the elderly can help in early identification and timely management of morbidities, along with improvement of their QOL. A better understanding of QOL might help to identify ways to improve health service delivery to elderly people, at a time when the WHO predicts the burden of morbidity on health care services from the elderly will increase, specifically in the South-East Asian region.
Thus, the present study aims to assess the QOL and its various sociodemographic determinants among the elderly residing in a town of south-east district of the National Capital Region.
Methods
A cross-sectional study was conducted in the field practice area of the Urban Health Training Centre (UHTC) under the Department of Community Medicine of a Medical College in Delhi, between November 2024 and February 2025. The UHTC is located in Pul Prahladpur, South East Delhi, which serves a population of approximately 70,000. Pul Prahladpur is divided into the blocks including A to F, HR, T, U, R, S, RZ-A, RZ, GA, GB, GC and GD.
Consenting elderly (more than 60 years of age) residents of the field practice area of UHTC were included in the study. Critically ill participants, elderly individuals with pre-existing mental illness, and those who were not able to comprehend and answer the questionnaire were excluded from the study.
The sample size was calculated using the Lwanga and Lemeshow formula[3] which requires the following information: (a) the proportion of the population; (b) the significance level; and (c) absolute accuracy. The sample size calculation was based on the proportion of 30% of the elderly whose self-perception of their QOL was good,[4] with a 5% significance level and an absolute error of five percentage points. The sample size was 322. Considering that the sampling method was cluster sampling, a design effect 1.2 was estimated to reach an effective sample of 386 study subjects, which was rounded off to 400.
The study subjects were selected by cluster sampling from the study area, which has a total of 17 blocks. The inter- and intra-cluster homogeneity analysis was performed, and it was noted that there was inter-cluster homogeneity and intra-cluster heterogeneity; therefore, it was decided to take eight clusters and 50 elderly people in each cluster. These eight clusters were randomly selected by cluster technique, and 50 consecutive elderly subjects were studied in each cluster. A central point in each cluster was identified, and the direction of the first house was selected by flipping a coin in the centre of a cluster. The process helped in selecting the first house. Subsequently, a house-to-house search was performed, and if any elderly person was found in the house, s/he was included in the survey.
Ethical clearance was obtained from the Institutional Ethics Committee of the Medical College. The subjects selected for the study were contacted personally at their homes. To begin with, a good rapport was built with the study participants. Before the initiation of the interview, the aim and purpose of the study were explained to each participant, and written informed consent was taken. The study was conducted in accordance with the principles expressed in the Declaration of Helsinki.
Information regarding the sociodemographic characteristics was collected using a pre-tested, semi-structured, semi-open-ended questionnaire. To study various domains of QOL, the Hindi version of the WHOQOL-BREF questionnaire was used.[2] This tool was already validated and pilot tested in Hindi in India by the WHOQOL team. It takes into consideration four domains of QOL, that is, physical, psychological, environmental and social relationship, which had 26 questions and the mean score of items within each domain was used to calculate the domain score. The total score of the WHOQOL-BREF questionnaire was 100 in all four domains, namely physical health, psychological, social relationships and environment.
Participant’s details recorded were entered in an MS Excel spreadsheet, and cleaned. The data were analysed using MS Excel, and Statistical Package for Social Sciences (SPSS) version 26. The normality of the data was examined. To examine the association between the participants’ characteristics and their QOL, univariate statistical tests, including T-tests and one-way analysis of variance (ANOVA), were performed. Independent predictors were found using linear regression models. All tests were two-tailed, and a P value of less than 0.05 was considered as statistically significant.
Results
The sociodemographic details of the study participants are presented in Table 1. The mean QOL score for physical, psychological, social, and environmental domains was 48.9, 47.1, 53.6, and 48.7, respectively [Table 2].
Table 1.
Sociodemographic profile of the study participants
| Sociodemographic determinants | n (%) | |
|---|---|---|
| Age | 60–64 years | 183 (45.8%) |
| 65–69 years | 108 (27.0%) | |
| 70 years and above | 109 (27.2%) | |
| Sex | Male | 154 (38.5%) |
| Female | 246 (61.5%) | |
| Religion | Hindu | 375 (93.8%) |
| Muslim | 25 (6.3%) | |
| Occupational status | Employed | 138 (34.5%) |
| Unemployed | 262 (65.5%) | |
| Education | Illiterate | 245 (61.3%) |
| Literate | 155 (38.8%) | |
| Marital status | Married | 246 (61.5%) |
| Unmarried/widowed/separated | 154 (38.5%) | |
| Living arrangement | Living with spouse | 148 (37.0%) |
| Living with children | 175 (43.8%) | |
| Living alone/others | 77 (19.3%) | |
| Source of income | Present | 218 (54.5%) |
| Absent | 182 (45.5%) | |
| Chronic morbidity | Present | 358 (89.5%) |
| Absent | 42 (10.5%) | |
Table 2.
QOL scores across various domains according to WHOQOL-BREF
| Domain of QOL | Physical | Psychological | Social relationship | Environmental |
|---|---|---|---|---|
| Mean±SD | 48.94±12.83 | 47.14±13.81 | 53.67±21.46 | 48.78±15.28 |
| Median (IQR) | 50 (38–56) | 44 (38–56) | 56 (44–69) | 50 (38–56) |
| Minimum | 13 | 6 | 0 | 6 |
| Maximum | 100 | 94 | 100 | 94 |
On univariate analysis, the QOL scores for the physical domain were significantly higher among males (P value: 0.009), married (P value: 0.03), and those who did not have any chronic morbidity (P value: <0.001). Significant association was observed between age and QOL score across physical (P value: 0.003), psychological (P value: <0.001) and social relationship (P value: 0.02) domains. Marital status (P value: 0.001) and presence of chronic morbidity (P value: <0.001) were also significantly associated with the QOL scores across the psychological domain. The score for the social relationship domain was significantly higher among males (P value: <0.001), those who were literate (P value: 0.001), married (P value: <0.001), and those who had chronic morbidity (P value: 0.004). For the environmental domain, the score was significantly higher among literate (P value: 0.02) and those who had chronic morbidity (P value: <0.001). Also, a significant association was seen with the living arrangement and QOL score for the environmental domain (P value: 0.02) [Table 3].
Table 3.
Association between QOL scores across physical domain and sociodemographic determinants of the study participants
| Sociodemographic determinants | QOL score (mean±SD) across various domains | ||||
|---|---|---|---|---|---|
|
| |||||
| Physical | Psychological | Social relationship | Environment | ||
| Age | 60–64 years | 49.54±11.62* | 48.67±12.80* | 54.45±20.68 | 49.79±15.26 |
| 65–69 years | 51.15±13.62^ | 48.85±14.89^ | 56.57±22.28^ | 48.25±15.48 | |
| 70 years and above | 45.71±13.52*^ | 42.78±13.56*^ | 49.47±21.51^ | 47.55±15.13 | |
| P | 0.003 | <0.001 | 0.028 | 0.393 | |
| Sex | Male | 50.95±12.35 | 47.95±13.62 | 59.70±20.38 | 49.93±16.82 |
| Female | 47.71±12.99 | 46.64±13.92 | 50.00±21.30 | 48.09±14.25 | |
| P | 0.009 | 0.327 | <0.001 | 0.213 | |
| Occupational status | Unemployed | 48.56±12.67 | 46.96±13.83 | 52.25±22.05 | 48.96±14.46 |
| Employed | 49.70±13.17 | 47.50±13.79 | 56.53±19.97 | 48.43±16.86 | |
| P | 0.374 | 0.692 | 0.045 | 0.728 | |
| Education | Illiterate | 48.43±12.99 | 46.20±13.84 | 51.14±21.39 | 47.60±14.06 |
| Literate | 49.84±12.53 | 48.80±13.63 | 58.16±20.90 | 50.88±17.08 | |
| P | 0.262 | 0.053 | 0.001 | 0.028 | |
| Marital status | Married | 49.90±12.24 | 48.70±13.41 | 63.07±17.39 | 50.01±15.86 |
| Unmarried/widowed/separated | 47.27±13.68 | 44.44±14.11 | 37.46±17.86 | 46.66±14.02 | |
| P | 0.035 | 0.001 | <0.001 | 0.024 | |
| Living arrangement | Living with spouse | 49.05±12.73 | 48.29±13.73 | 62.07±16.41* | 48.46±15.65 |
| Living with children | 47.71±13.28 | 45.32±14.58 | 43.07±19.63*^ | 47.30±15.24^ | |
| Living alone/others | 51.25±11.86 | 48.64±11.92 | 59.11±24.45^ | 52.46±14.17^ | |
| P | 0.095 | 0.061 | <0.001 | 0.028 | |
| Source of income | Present | 48.70±13.28 | 48.04±13.26 | 51.91±22.53 | 48.34±15.12 |
| Absent | 49.20±12.33 | 46.13±14.36 | 55.64±20.06 | 49.28±15.48 | |
| P | 0.679 | 0.142 | 0.064 | 0.514 | |
| Presence of chronic morbidity | Present | 48.19±12.55 | 46.08±13.33 | 52.71±21.26 | 47.80±14.42 |
| Absent | 55.56±13.45 | 56.50±14.55 | 62.23±21.53 | 57.50±19.58 | |
| P | <0.001 | <0.001 | 0.004 | <0.001 | |
For physical and psychological domain: P<0.01-*60–64 years vs. 70 years and above, ^65–69 years vs. 70 years and above. For social relationship domain: P<0.01-^65–69 years vs. 70 years and above and *Living with spouse vs. Living with children ^Living with children vs. living alone. For environmental domain: P<0.001-^Living with children vs. living alone
On multivariate linear regression, the QOL score was 4.04 points (physical domain) and 5.31 points (psychological domain) lower among those who were more than 70 years, compared to those who were in the age group of 60–64 years. For the social relationship domain, the score was 4.24 points higher among participants aged 65–69 years compared to those aged 60–64 years. Although marital status was significantly associated with QOL score for the physical domain on univariate analysis, no significant association was seen on multivariate analysis. Also, sex was significantly associated with QOL score for the social relationship domain on univariate analysis; no significant association was seen on multivariate analysis [Table 4].
Table 4.
Linear regression analysis of significant predictors of QOL across various domains
| Sociodemographic determinants | Regression coefficient (95% CI) | ||||
|---|---|---|---|---|---|
|
| |||||
| Physical | Psychological | Social relationship | Environment | ||
| Age | 60–64 years | 1 | 1 | 1 | 1 |
| 65–69 years | 1.41 (–1.42 to 4.25) | 0.315 (–2.69 to 3.32) | 4.24 (0.29 to 8.19)* | –1.32 (–4.71 to 2.06) | |
| 70 years and above | –4.04 (–6.94 to 1.14)* | –5.31 (–8.39 to –2.24)* | 0.77 (–3.27 to 4.81) | –1.60 (–5.07 to 1.86) | |
| Sex | Male | 3.82 (–6.93 to 0.69)* | 0.44 (–2.865 to 3.743) | 1.55 (–2.79 to 5.89) | 1.40 (–2.32 to 5.13) |
| Female | 1 | 1 | 1 | 1 | |
| Occupational status | Unemployed | 0.61 (–3.60 to 2.37) | 1.29 (–1.87 to 4.46) | –0.18 (–4.34 to 3.99) | 1.96 (–1.61 to 5.53) |
| Employed | 1 | 1 | 1 | 1 | |
| Education | Illiterate | 0.20 (–2.90 to 2.50) | –1.77 (–4.63 to 1.09) | –3.82 (–7.58 to 0.06)* | –3.39 (–6.62 to –0.17)* |
| Literate | 1 | 1 | 1 | 1 | |
| Marital status | Married | 1.61 (–2.03 to 5.24) | 3.94 (0.09 to 7.79)* | 24.96 (19.90 to 30.03)* | 3.33 (–1.01 to 7.67) |
| Unmarried/widowed/separated | 1 | 1 | 1 | 1 | |
| Living arrangement | Living with spouse | 1 | 1 | 1 | 1 |
| Living with children | 1.95 (–1.87 to 5.77) | 1.95 (–2.09 to 6.00) | 1.56 (–3.96 to 6.88) | 2.74 (–1.83 to 7.30) | |
| Living alone/others | 3.76 (0.44 to 7.08)* | 2.95 (–0.57 to 6.47) | 2.99 (–1.63 to 7.62) | 5.52 (1.55 to 9.49)* | |
| Source of income | Present | 0.60 (–1.89 to 3.10) | –2.29 (–4.94 to 0.35) | 4.11 (0.63 to 7.59)* | 0.75 (–2.23 to 3.73) |
| Absent | 1 | 1 | 1 | 1 | |
| Presence of chronic morbidity | Present | 1 | 1 | 1 | 1 |
| Absent | 7.89 (4.05 to 11.74)* | 10.33 (6.26 to 14.40)* | 7.96 (2.61 to 13.32)* | 10.53 (5.94 to 15.12)* | |
*P-value: <0.05
Discussion
The rising longevity among the elderly has made them vulnerable to declining QOL owing to the higher unmet health needs, social seclusion, financial dependence and poor accessibility to health care. The WHOQOL-BREF is a validated tool which has been widely used across the globe to understand the QOL among the elderly across four domains including physical, psychological, social and environmental. The present study was conducted among 400 urban poor elderly to explore their QOL, which can help in identifying their health care needs.
The mean age of the study participants in the present study was 65.81 ± 5.8 years. The most common age group was 60–64 years, which included 45.8% of the study participants, followed by 65–69 years (27%), and ≥70 years (27%). Almost a similar age distribution was reported in the studies by Singh et al.,[5] Kumar et al.,[6] Raj et al.,[7] and Krishnappa et al.[8]Click or tap here to enter text. The majority of the study participants in the present study were females. Similar sex distribution was reported in the study by Kumar et al.,[6] Krishnappa et al.,[8] and Trivedi et al.[9] However, the study by Singh et al.,[5] Raj et al.,[7] and Singh et al.[10] had male preponderance. The distribution differences could be due to variability in the sex ratio in the studied community or timing of interview or variability in the distribution of the consenting participants.
The majority of the study participants were Hindus. Similar distribution was reported in the study by Trivedi et al.[9] and Krishnappa et al.[8] 63.5% of the study participants were married and 36.7% were either unmarried or widowed or separated. Similar findings were reported in the study by Raj et al.[7] and Singh et al.[5] Twenty per cent of the participants were living alone, and the rest were either living with their spouse or with their children. 45.3% of the participants were living in a joint family in the study by Singh et al.[5] However, more than half of the study participants were living in a nuclear family in the study by Trivedi et al.[9] Almost 80% of the participants had some form of chronic morbidity.
The mean QOL across physical, psychological, social relationship and environmental domains was 48.94, 47.14, 53.67, and 48.78, respectively. Similar findings were reported in the study by Singh et al.[5] Mean QOL score for physical, psychological, social relationship and environmental domains were 56.7, 50.8, 38.3 and 58.9, respectively, in the study conducted by Singh et al.[10] Kasaudhan et al.[11] reported better QOL scores across all domains in their study, which was conducted among 931 individuals in the age group 20–75 years. However, the study also reported similar QOL scores across all four domains among the elderly. A higher mean QOL score for each domain was reported in the study by Krishnappa et al.[8] conducted in Bangalore, which reported a mean score of 57.4, 58.6, 64.6 and 60, respectively, across physical, psychological, social relationship and environmental scores. Also, a study conducted in North Delhi among the elderly reported a higher QOL scores across all four domains.[12] Health is a state subject in India. The higher QOL score in their study could be attributed to better elderly care facilities in the studied region.[13] Although the study by Thadathil et al.[14] reported almost similar QOL scores across physical, social relationship, and environmental domains, but the QOL score in the psychological domain was reported to be only 26.95 in their study. This difference could be attributed to the difference in the sociodemographic structure of the studied population in the two studies. A better QOL score across all domains except social relationship was reported in the study by Kumar et al.[6] conducted in urban Puducherry. A better QOL score for the social relationship domain was reported to be higher among the elderly residing in old-age care facilities.[15] The differences in the QOL scores across different studies could be due to variability in the associated sociodemographic profile of the study participants.
The mean QOL score for physical domain was significantly lower among the older elderly who were 70 years or older, compared to those in the age group of 60–64. The QOL score was found to be poorer among those who had some chronic morbidity. Kumari et al.[16] also reported a significant association between age, sex, and marital status and the mean QOL for the physical domain. However, no significant association was reported between QOL and the presence of chronic morbidity among the study participants. Gender, marital status, age and education were significant predictors of QOL scores in the study by Singh et al.[10] A statistically significant association was reported between the presence of chronic morbidity and QOL score for the physical domain in the study by Trivedi et al.[9] Education, gender and financial dependence were significant predictors of QOL score for physical domain in the study by Thadathil et al.[14] For physical health domain, significant factors affecting QOL were age, gender, marital status, education, socio-economic status, type of family and presence of chronic comorbidity in the study by Singh et al.[5]
For the psychological domain, the QOL score were significantly lower among those who had some chronic morbidity, as compared to those who had no chronic morbidity (P value: <0.01). Barua et al.[17] also reported a significant association between age and the QOL score for the psychological domain. For the psychological health domain, significant correlates were age, gender, education, socio-economic status and presence of chronic morbidity in the study by Singh et al.[5] Thadathil et al.[14] reported age, sex, education, occupation, income, marital status, family type and presence of morbidity as significant correlates of QOL scores for the psychological domain. Education was reported to be a significant predictor of psychological domain in the study by Krishnappa et al.[8]
The mean QOL score for the social relationship domain was significantly higher among males (P value: 0.01) and married participants (P value: <0.01). The QOL score was found to be poorer among those who had some chronic morbidity (P value: 0.04). Also, the QOL score was significantly poorer among those who were living with their children when compared to those either living alone or living with their spouse (P value: <0.01). Age and religion were significant predictors of QOL score for the social relationship domain in the study by Kumari et al.[16] Only the socio-economic status was reported to be a significant predictor of QOL for the social domain in the study by Trivedi et al.[9] For the social domain, education, gender, and living status were significant predictors of QOL scores in the study by Krishnappa et al.[8]
For the environmental domain, the QOL score was significantly lower among those who had some chronic morbidity, as compared to those who had no chronic morbidity (P value: 0.01). Kumari et al.[16] reported a significant association between the QOL score for the environmental domain and sex, marital status and education level. However, these factors were not found to be significant predictors of QOL in the present study. Sex was reported to have a significant association with the QOL score for the environment domain in the study by Trivedi et al.[9] Education, gender and occupational status were significant predictors of QOL scores for the environmental domain in the study by Krishnappa et al.[8]
Sex, marital status, age and education were reported to be significant predictors of QOL scores for all four domains in the study by Singh et al.[10] Age, marital status, education, socioeconomic status and presence of chronic morbidity were significant factors for the social relationship domain and the environmental domain in the study by Singh et al.[5] Economic independence has been reported to be one of the factors affecting the QOL among the elderly.[18] However, the same was not observed in our study. Also, education has been reported as one of the significant predictors of QOL, owing to the better knowledge and understanding of the age-related changes and preventive and treatment interventions required.[16,19,20] However, the same was not reported in our study, which could be due to the small sample size taken in the study.
The strength in our study lies in the fact that the data collection was conducted using a standardised tool with established validity and reliability, and was done by a single investigator. As the study was conducted in the field practice area of the UHTC, the findings lack external validity. Also, the effect of sociodemographic factors on the QOL could not be assessed due to the cross-sectional nature of the study design.
Conclusion and Recommendation
Various studies performed across the country showed variability in the significant predictors of the QOL scores across all four domains which could be multifactorial including the sociodemographic structure of the studied population, differences in the assessment methodology including the sample size considered in these studies. Poor QOL scores among older individuals in the present study highlight the need for focused interventions catering to this older cohort. The elderly are vulnerable to multimorbidity, and the presence of chronic morbidity was seen as a significant predictor of poor QOL scores across all four domains. Thus, structured integration of the elderly health care programmes with the National Program for non-communicable diseases at the local level will help in catering to their health care needs and further QOL. Also, the study will help in creating targeted interventions based on the identified QOL deficits among the elderly attending the UHTC, catering to the study area. Implement guidelines and protocols to improve the diagnosis and management of chronic morbidities at the primary health care level.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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