Comparison of self-esteem and quality of life between residents of old people ' s home and the elders living at home Primerjava samospoštovanja in kakovosti življenja stanovalcev v domu za starejše in lastnem domu

Introduction: Research on self-esteem and quality of life has been so far predominantly focused on younger age groups. The aim of this cross-sectional study was to examine the differences regarding self-esteem and quality of life between the residents of old people's home and the elders living at home. Methods: A questionnaire used in the survey inquired about socio-demographic data and the respondents' activities. It included the respondents' self-esteem assessment, based on the Rosenberg Self-esteem Scale (RSES), the assessment of quality of life, based on the Satisfaction With Life Scale (SWLS) and the assessment of their functional abilities. The purposive sample included 204 respondents. The research was conducted from November 2012 to March 2013. Results: The respondents in both groups expressed equal satisfaction with life (p = 0.846). The respondents who live in their own home demonstrate higher self-esteem than those who live in old people's home (difference in mean scores of the RSES was 3.4; 95 % CI for the difference from 1.0 to 5.8; t-test for independent samples, p = 0.005). Results of the study suggest that the respondents with higher self-esteem are more satisfied with their life (p = 0.537, p < 0.001). Discussion and conclusion: Self-esteem has to be recognised as a factor associated with the quality of life and should therefore be included in the care of the elderly. Timely and adequate interventions may prevent the decline in quality of life, which requires adequate training of health personnel and family members, and the public awareness.


Introduction
The steady increase in life expectancy over the past centuries, attributed to higher standards of living, the improved healthcare and the long-term downtrends in fertility rate, caused that the aged population is currently the fastest growing age group in developed countries.The Republic of Croatia, with the proportion of 17.15 % of people aged 65 and over, belongs to the fourth group of countries with ''with the most aged populations'', according to the United Nations classification (Tomek-Roksandić & Čulig, 2004).
As life expectancy is rising, it is important that people experience these extra years of life in good health and in good functional state and not in a poor state of health (Železnik, et al., 2011).A review of the literature indicates that high levels of self-esteem, self-efficacy and social support would be elements of strength in the elderly, while, loneliness, depression and anxiety would be among the main elements of vulnerability mentioned in studies on wellbeing in the Third-Age (Gerino, et al., 2015).Functional ability is a critical indicator of quality of life and health in the elderly, sometimes even more important than the presence of a disease.Impaired functional abilities are the best predictor of mortality or of the need for institutional care.Socio-demographic factors, such as old age, female gender, poor social support, single life, lower education and lower income are associated with poorer functional abilities and lower probability of improvement of the decreased functional abilities.Change in one of the functions is associated with the change in general functional ability (Tomek-Roksandić, 2004).
Social activity has been recognised as the most important predictor for maintaining and stimulation of functional ability.Maintenance and stimulation of the social activity can help in self-maintenancethe activities of daily living and improvement of the quality of life of the elderly (Despot Lučanin, 2003).The foundations for healthy and active ageing, the preservation of functional ability and improvement of health in the very old age are established in the earlier years by one's own decisions and positive health behaviour.Non-smoking, appropriate diet, continuous physical, psychological and occupational activities, avoidance of negative health behaviour, are the most important factors in improving health and preserving functional ability in old age (Tomek-Roksandić, 2004).Changes related to ageing and disease affect self-esteem of older persons.In many people, the visible changes associated with ageing and the changed physical appearance may, by themselves, affect self-worth and self-esteem.Orth and colleagues (2010) suggested that changes in socioeconomic status and physical health account for the decline in selfesteem that occurs in old age.
Frequent health problems, physical and economic dependence in conjunction with other losses, effect a change in the elders' thinking and beliefs about their own abilities and self-esteem.Loss of self-respect and low self-esteem can cause serious problems, such as fear, anxiety, helplessness, hopelessness and depression (Pronk, et al., 2011).Self-esteem is related to better health, less criminal behaviour, lower levels of depression and, overall, greater success in life (Orth, et al., 2010).Epidemiological studies have demonstrated the effects of self-esteem on global health and life expectancy in normal aging.It has also been demonstrated that self-esteem may effect the basal regulation and reactivity of endocrine system as well as the age-related changes in cognitive performance and cognitive decline with aging.
According to Zimmerman and colleagues (2016), chronic exposure to stress has been shown to impact a wide range of health-related outcomes in older adults.Their findings provide evidence of a relationship between a direct indicator of psychological stress and specific hippocampal subfield volumes in elderly individuals.
Quality of life in old age, although associated with physical health and functioning, may not be directly dependent on health factors.Some older people live well despite poor health and vice versa.It has been established that psychological and social collateral factors have an important role in the ageing process (Suhonen, et al., 2005;Železnik, 2014).For no justifiable reason, the recent research on selfesteem and quality of life has been focused mainly on younger population, even though the percentage of elderly people in the general population is steadily increasing.The phenomenon of quality of life is manifold and complex, having many dimensions.The most important aspects of quality of life were for the residents to feel secure in the nursing home, have a place of their own where they could be alone with their thoughts, set their affairs in order and be prepared for death.Furthermore, it mattered to be recognized as an individual with his or her roots in their own respective family and doing meaningful things (Hjaltadóttir & Gústafsdóttir, 2007).
The studies that have dealt with the elderly were related to the pathology of ageing and testing of negative emotional states, but there are very few studies that examine successful ageing.Studies have proved that depression, anxiety, emotional instability, feelings of loneliness, social isolation, low self-esteem, are causes for lower estimation of quality of their life (Suhonen, et al., 2005).However, what makes one elderly person more satisfied and happier is rarely a subject of research.

Aim and objectives
The aim of this research is to examine the perception of self-esteem and quality of life of older people and to ascertain whether there is a difference between the self-esteem and quality of life of the older people who live in their own home and the residents of old people's homes.

Methods
A quantitative nonexperimental descriptive research was conducted.

Description of the research instrument
The questionnaire used in this cross-sectional study inquired about basic demographics (age, gender, housing, marital status, lifestyle, occupation until retirement, level of education); the activities of the respondents; the assessment of self-esteem, using the Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965); the assessment of quality of life, using the Satisfaction With Life Scale (SWLS) (Diener, et al.,1985), and the assessment of functional ability.Respondents were offered the choice of 16 activities and four degrees of frequency in these activities (daily, weekly, monthly, yearly).Respondents had the option of free entry of additional activities.
The Rosenberg Self-Esteem Scale is a 10-question scale that is presented with four response choices, ranging from strongly agree to strongly disagree (agree, partly agree, neither agree nor disagree, partially disagree, disagree).The first item included questions 1 through 3 and received a positive score if two or three of its questions were answered positively.Questions 4 and 5 and questions 9 and 10 were aggregated into two other items that were scored positively, if both questions in the item had positive answers.Questions 6 through 8 counted individually formed the final three items.For the negatively worded RSE questions, responses that expressed disagreement and, hence, were consistent with high self-esteem, were considered positive.The chosen items were awarded values from 1 to 5, where in the items of 1, 5, 7, 8 and 10 were encoded in a way that total agreement was assigned value 5, and total disagreement value 1. Answers to the items 2, 3, 4, 6 and 9 were awarded inverted values, so total agreement was awarded value 1, and total disagreement value 5.The higher RSES score corresponds to greater selfesteem.RSES internal consistency evaluated by the Cronbach alpha coefficient was 0.796.
The Satisfaction With Life Scale (SWLS) contained 5 items with answers which had the same choice as in the Rosenberg's scale wherein the total agreement was awarded value 5, and total disagreement value 1.The higher SWLS score, the higher life satisfaction.Cronbach alpha for SWLS was 0.786.
Assessment of functional ability was based on 12 questions and optional choices: I can do it independently and without difficulties; I can do it independently but with difficulties; I cannot do it independently.The choices were awarded values from 1 to 3, in the way that total independence was awarded value 1, to total dependence value 3, i.e. the higher the score, the lower functional ability.Cronbach alpha was 0.947.

Description of a sample
The research included 204 respondents aged 65 years and over, with preserved cognitive abilities, living in the city of Osijek.Community nurses and nurses who work in old people's homes selected the respondents who participated in the study.More than half of the respondents are widowed and most of them live alone.The majority of the respondents have completed secondary education.Detailed information about respondents is given in Table 1.

Description of the research procedure and data analysis
One part of the survey was carried out in the elders' homes in Osijek, and the second part in old people's homes.The survey was conducted by community nurses, and a structured interview was used.Each respondent had given their written consent to participate in the study and was clearly informed of the objectives, purpose and methods of the research.
Categorical data were presented by absolute and relative frequencies.Numerical data are described as mean and standard deviation.In case of asymmetric distribution of data, the median and the limits of interquartile range were used to assess mean and the variability of numerical data.Internal consistency of used scales was assessed by the Cronbach alpha coefficient.The difference in distribution of categorical variables between the observed groups was tested by χ 2 test, and if necessary, by the Fisher's exact test.Normality of the distribution of the numerical variables was tested by Kolmogorov-Smirnov test.Differences between numerical variables were tested by t-test for independent samples, and in the case of non-compliance, the Mann-Whitney U test was used.Bivariate correlation of total scores was assessed by Spearman coefficient ρ.All p values are two-sided.The level of significance was set at p < 0.05.The statistical program SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis.

Results
The study included 41 (20.1 %) men and 163 (79.9 %) women.The total of 101 respondents (49.5 %) live in their own homes, and 103 (50.5 %) respondents reside in old people's homes.The age of the respondents ranged from 65 to 96 years.Arithmetic mean of age was 76.8 years, and the standard deviation 7.1 years.Men and women were of the same age (Mann-Whitney U test, p = 0.234).
The largest number of respondents (n = 175, 85.8 %) daily watch TV, and a large proportion (67.2 %) read newspapers, books or solve crossword puzzles.The vast majority of respondents (77.9 %) take a walk, most of whom (82.4 %) do it on daily basis.Almost half of the respondents workout daily or weekly, and approximately 30 % of them go on a trip or travel.More than one fifth of the respondents (23 %) go to cinema, theatre, exhibitions or concerts at least once a year and a smaller percentage are included in creative workshops (10.8 %), and in cultural or artistic activities (8.8 %).Only two (1.0 %) of the respondents were not involved in any activity.
Assessment scores of the respondents' self-esteem were within the normal range; they were satisfied with their life and had good functional abilities.The arithmetic mean of total RSES score was 37.1 (s = 8.8).Median SWLS score was 20 (interquartile range from13 to 22), with a median total score of functional abilities 14 (interquartile range from 12 to 22).
The respondents who have higher self-esteem are more satisfied with life (r s = 0.537, p < 0.001).The improved functional capacity (expressed lower score) is associated with higher self-esteem (r s = -0.381,p < 0.001) and greater life satisfaction (r s = -0.203,p = 0.004).

Differences between groups of respondents regarding housing
With regard to housing, the shares of male and female respondents in the groups were similar (χ 2 test, p = 0.650).The respondents who live in old people's homes were older than those who live in their own homes (mean 80.0 vs. 73.7 years, mean difference 6.3 years, 95 % CI for the difference from 4.5 to 8.1 year; t-test for independent samples, p < 0.001).The distribution of marital status of the respondents differed significantly between the groups with respect to the housing (χ 2 test, p < 0.001).The majority of respondents who reside in their own homes live in a marriage or cohabitation, while in old people's homes widows/widowers prevail.The vast majority of the respondents (92.2 %) who reside in old people's homes are single.The distribution of the respondents' lifestyle differed significantly between the groups with respect to the housing (Fisher's exact test, p < 0.001).The distribution of the respondents' educational background differed significantly between the groups with respect to the housing (χ 2 test, p = 0.003).The share of respondents with a post high school education who live in old people's homes is less than 10 %, while in the group of respondents who live in their own home it is almost three times higher (Table 1).
The frequency of involvement in activities that require strenuous physical activity varies significantly between the two groups of respondents for all activities except for walking (Table 3).
None of the respondents who reside in an old people's home is involved in humanitarian work, political activities and activities in associations.Among other activities that do not require strenuous physical activity, respondents from both groups differ only in frequency and proportion of visits to cultural events (Table 4).

Discussion
The basic characteristics of the respondents in this study, such as age, marital status, lifestyle and distribution of educational attainment are very similar to the characteristics of the population of older persons in other studies (Brajković, 2010).The respondents assessed their self-esteem in the normal range; they are satisfied with life and have good functional capacity.Previous studies that have addressed the subjective quality of life and age, give inconsistent findings and show that the subjective quality of life in function of age may increase, decrease or stay the same.Elderly people can maintain the level of subjective quality of life by lowering their expectations, thus increasing their self-esteem and life satisfaction (Sok, 2010).
Respondents in the current study who have higher self-esteem are more satisfied with life.Improved Table 4: Frequency of the respondents' involvement in the activities that do not require strenuous physical activity according to housing Tabela 4: Pogostost vključitve anketirancev v aktivnosti, ki ne zahtevajo večjo fizično aktivnost, znotraj skupin anketirancev glede na prebivališče/vrsto nastanitve

Yearly/ Letno
Not at all/ Sploh ne Creative workshops In their own environment 4 (4.0) 6 (5.9) 1 (1.0) 1 (1.0) 89 (88.1) 0.833 In old people's home 3 (2.9)7 ( 6 In their own environment 0 (0.0) 9 (8.9) 5 (5.0) 1 (1.0) 86 (85.1) < 0.001 In old people's home 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 103 (100.0)Legend/Legenda: * Fisher's exact test/Fisherjev natančni preizkus; % -percentage/odstotki; n -number/število functional ability is associated with higher selfesteem and greater life satisfaction.Similar results were obtained in other studies of quality of life of the elderly population which show that functional capacity and high self-esteem are the main predictors of quality of life of older people.According to Gerino and collegues (2015) self-esteem plays an important role in the perception of one's overall state of health, constituting a factor that would affect the physical and psychological areas of quality of life, and the experiences related to the living environment.Functional capability that enables the fulfilment of basic needs, self-care and participation in activities has a positive impact on the quality of life (Železnik, 2014).Respondents residing in an old people's home were more advanced in age than the residents who live in their own home.The majority of respondents who live in their own home are married or live in cohabitation, while most of the respondents who live in old people's homes are widowed.These results can be explained by the assumption that older people decide to move to a residential facility at a later age, usually after losing their spouse (Železnik, et al., 2011).Social support in this case is a very important and major predictor of life satisfaction and a good indicator of health outcomes, especially in old age (Routasalo, et al., 2006;Pronk, et al., 2011).In the elderly, loneliness would be associated with low quality of life, especially in the mental domain (Dóci, et al., 2003).In fact, as stated in the international literature, loneliness, in connection with the fact that friends' social support, seems to determine the perception of maintaining satisfying social roles (Theeke, 2009;Charles, 2010;Pronk, et al., 2011;Theeke, et al., 2012;Rokach, 2012).Social relationships and health act as predictors of life satisfaction in advanced old age.Life satisfaction measures how people evaluate their life as a whole rather than their current feelings.When asked to rate their general satisfaction with life on a scale from 0 to 10, people across the Organisation for Economic Co-operation and Development (OECD) gave it a 6.5 grade.Life satisfaction is not evenly shared across the OECD however.Some countries -Hungary, Portugal and Turkey -have a relatively low level of overall life satisfaction, with average scores of 5.5 or less.At the other end of the scale, scores reach 7.6 in Norway and Switzerland.Slovenians gave it a 5.7 grade, lower than the OECD average of 6.5 (OECD, 2015).
There is a significant difference in the educational structure of respondents.The share of the respondents with post high school education in the group of the elderly who live in their own home is almost three times higher than those who stay in old people's homes.Assuming that people with less education have less income, this figure can be explained by the fact that life in an old people's home is much cheaper than living in one's own home, which can be a reason for the decision to move to an old people's home.The respondents in both groups expressed equal satisfaction with life.Only a small number of available studies have dealt with the issue how the move to an old people's home influences their life satisfaction (Netten, et al., 2002).Most of the research deals with the issues how life in old people's homes influences some variables related to satisfaction (e.g.: how living in an old people's home influences the sense of loneliness, the self-assessment of their health status and self-esteem, etc.), but none has explored how it influences life satisfaction itself (Prieto-Flores, et al., 2011).Social relationships and health as predictors of life satisfaction in advanced old age (Brajković, 2010).Quality of life is the individual's perception of his/her health status in relation to social, physical, psychological, economic and spiritual aspects (Gabriel, & Bowling, 2004;Gerino, 2014).
Respondents who live in their own home have higher self-esteem than the respondents who reside in old people's homes.Institutionalization enhances the effects of negative factors associated with self-esteem, such as stigmatization, decreased social interaction and loss of control over the environment (Taft, 1985).Reasons for lower assessment of self-esteem may be the fact that living in an old people's home was a decision made by only a small number of residents.More common causes include poor health, dependency on others, family's inability to take care of a weak person, letting children to live in their home, poor relations within the family, a sense of loneliness and abandonment (Pavot & Diener, 2008;Prieto-Flores, et al., 2011).Kermode and MacLean (2001) reported that older people experienced higher quality of life than people in other age groups.Variables contributing to higher quality of life include good relationships with their partner, with their children, and God.
Respondents residing in old people's homes have a significantly lower functional ability than the respondents who live in their own home.Similar results were obtained in other studies on functional ability as an indicator of the degree of dependence on the assistance of other persons.In older people living in their homes, there are no major limitations in the activities of daily life, but for the residents of old people's homes there are (Železnik, 2014).One of the reasons for accommodation in an old people's home may be a reduced functional ability, however, many studies mention the problem of "learned helplessness" as a result of institutionalisation. Traditionally, care for the elderly in an institution is directed towards working "for individuals".Taking care of the elderly individuals is task-oriented instead of being individualised and tailored to the older persons' needs.Oftentimes, the nurses and other staff in an old people's home take on tasks which could be performed by older people themselves if properly enabled.The elderly should be helped to improve self-care skills and move towards being as independent as possible.The fully compensatory system of providing healthcare discourages older people to perform activities by themselves which leads them into a state of increasing dependence.
In addition to research that addresses the deterioration in functional ability, lesser-known studies describe the possibility of recovering the lost abilities.People with preserved cognitive and physical functional and self-maintenance capacity become increasingly dependent on caregivers after institutionalisation.The same survey shows that the changed approach to nourishing can improve independence, competence and a sense of personal control along with higher self-esteem (Alaphilippe, 2008;Gothe, et al., 2011).Alaphilippe (2008) notes that the aging process does not necessarily result in self-esteem decrease, regardless of the decline in many areas of mental activity.Some other authors (An, et al., 2008) believe that life satisfaction, self-esteem, and perceived health status were strongly correlated with each other.Living arrangements significantly affected life satisfaction, self-esteem, and perceived health status.Women who live with their married son had the highest life satisfaction and self-esteem and perceived themselves to be healthier in comparison to their counterparts.
There is empirical evidence suggesting that personal autonomy and independence are of special importance in the care of older people, and that addiction is associated with low self-esteem and other mental problems such as depression (Clissett, et al., 2013).
The frequency of involvement in activities that require strenuous physical activity varies significantly across the two groups for all activities except walking.According to available studies, physical activity is significantly associated with the level of self-esteem, better self-assessment of health and quality of life of older persons (Lee, et al., 2010;Železnik, 2010;Gothe, et al., 2011;Železnik, 2012).Although exercise is an established component in the management of many chronic diseases associated with aging, activity levels tend to progressively decline with increasing age, which is a growing public health problem (Železnik, 2014).Given the growing proportion of older adults, these suboptimal levels of physical activity represent an increasing public health problem.Age-specific barriers and motivators unique to this cohort are relevant and must be acknowledged.The identification of reliable predictors of exercise adherence will allow healthcare providers to effectively intervene and change patterns of physical activity in sedentary elderly (Schutzer & Graves, 2004).

Conclusion
The results of the study support previous findings that there is a positive correlation between self-esteem and life satisfaction of the elderly.Self-esteem should be recognised as an important aspect of the adaptive processes in older adults.The long-stay care services should therefore help the residents to be as selfmanaging as possible and enable them to achieve their fullest possible potential.The staff in residential care can play a key and pivotal role in the prevention of the elders' disempowerment and consequently lower selfesteem and quality of life.It is therefore of importance that healthcare professionals and family members acquire adequate knowledge and skills to help preserve self-esteem and quality of life of the elderly.Furthermore, adequate educational and promotional strategies should be adopted to heighten the overall awareness of the issue in the general public.