CLINICAL ISSUES

A comparison of physical health status, self-esteem, family support and health-promoting behaviours between aged living alone and living with family in Korea
Sohyune R Sok and Eun K Yun

Aims. This study examined and compared the physical health status, self-esteem, family support and health-promoting behaviours between aged living alone and the aged living with family. Background. As the Korean population ages, the number of older people living alone is steadily rising. Previous studies have been conducted to dene the factors affecting the health of older people. However, research studies focused on the impact of family support, which potentially affects the overall health of older people, have been rarely conducted. Design. This was a comparative descriptive design. Methods. The survey included a set of four questionnaires. All measures were self-administered. In the data analysis, descriptive statistics were used to analyse the demographic characteristics. The Chi-square test and independent t-test were used to examine the differences between the aged living alone and the aged living with family. Results. The physical health status (t = 4085, p < 0001), self-esteem (t = 2675, p < 0001), family support (t = 1646, p < 0001) and health-promoting behaviours, specically exercise (t = 1586, p < 0001) and nutrition (t = 1729, p < 0001), of the aged living with family were higher than that of the aged living alone. Conclusions. This study shows that the aged living with family exhibited better physical health status, self-esteem and healthpromoting behaviours than the aged living alone. Relevance to clinical practice. Clinical practice should be focused on emotional support with family or society for Korean aged, especially the aged living alone. Also, the practiceshould be adjusted to encourage the health-promoting behaviour for themas well. Key words: aged, community, family support, health, health-promoting behaviour, self-esteem
Accepted for publication: 14 August 2010

Introduction
Korea is facing an increasing social concern with the rapid growth of its ageing population. In 1960, the population aged 65 and over was 29%, then rose to 72% in 2000 and is projected to reach 14% by 2018. It is expected to take only 18 years from 2000 for the aged population in Korea to double, compared with a doubling period of 71 years in the United States and 115 years in France (Cho et al. 2004, Korea National Statistical Ofce 2009).
Authors: Sohyune R Sok, PhD, RN, Assistant Professor, College of Nursing Science, Kyung Hee University; Eun K Yun, PhD, RN, Full-time Lecturer, College of Nursing Science, Kyung Hee University, Seoul, Korea Correspondence: Sohyune R Sok, Assistant Professor, 415, College of Nursing Science, Kyung Hee University, #1, Heogi-dong,

Along with the rapid increase in the older population, living arrangements and family relations are also undergoing modications (Padoani et al. 1998). Korea National Statistical Ofce (2006) reported that the population of older people living alone in Korea has increased from 542,690 in 2000 to more than 833,072 in 2006, which is a sharp increase of 30% in only six years. In 2010, the population of older people living alone in Korea is expected to be over a million, which is 187% of the total older population. Also, the proportion of older women
Dongdaemun-gu, Seoul 130-701, Korea. Telephone: +82 2 961 9144. E-mail: 5977sok@khu.ac.kr

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living alone (877%) was more than that of older men living alone. With a growing population of older people who are living alone, considerable research studies have been conducted into their emotional well-being, quality of life and health status (Kawamoto et al. 2005, Lin et al. 2007, Kim et al. 2008). However, living arrangement issues related to health-promoting behaviours of older people have not been sufciently investigated. Older people living alone might be an at-risk group for high levels of mortality and morbidity, causing high demands on health and social services. The modication of living arrangements has progressed over the course of socio-economic development. In the past, the family was regarded as the primary source of care for older people. However, the role of social care is becoming increasingly emphasised as an alternative support measure. Therefore, the nurses role is to promote health by assessing individual lifestyles and to develop a programme to increase positive behaviour and minimise its negative concomitants (Chen et al. 2007). To identify fundamental ideas for the development of nursing intervention to enhance the health of older people from the social support perspective, this study examined the level of health-promoting behaviours of older people living alone and living with family. The specic aim of this study was to compare the physical health status, self-esteem, family support and health-promoting behaviours of older people based on their living conditions. The ndings from this study will help guide the development of health-promoting programmes for older people and ultimately enhance their quality of life.

Literature review
The Health Promotion Model (HPM) provides an organisational framework for this study. In recent years, attempts have been made to prevent diseases related to ageing and to facilitate overall improvement in health-promoting behaviours (Resnick 2003, Kim et al. 2006). The HPM represents a theoretical perspective that explores the factors and relationships contributing to health-promoting behaviour and therefore to the enhancement of health and quality of life. The HPM originally developed in the early 1980s by Pender denes health-promoting behaviour as a multidimensional pattern of self-initiated actions and perceptions that serve to maintain or enhance the level of wellness, selfactualisation and fullment of the individual (Pender 1996). Previous research has examined the issues and determinants of health-promoting behaviour (Rife et al. 1989, Felton et al. 1997).

The HPM includes three components: (1) individual characteristics and experiences, (2) behaviour-specic cognitions and affects and (3) behavioural outcomes. In this study, the following three variables were chosen from the current HPM variables. Self-esteem was derived as a personal psychological factor from the domain of individual characteristics. Family support was chosen as an interpersonal inuence from the domain of behaviour-specic cognition, and health-promoting behaviour was included as a behavioural outcome. Self-esteem refers to the degree to which one considers oneself worthy and capable (Rosenberg 1979). It can be dened as the affective component of the self (Seigley 1999). Health-related research studies have focused on self-esteem as one variable inuencing health-promoting behaviour (Volden et al. 1990, AbuSabha & Achterberg 1997, Wang et al. 2005). Individuals with high self-esteem have been shown to have better health and well-being than their counterparts with low self-esteem (Kinnunen et al. 2008). Familism is the term used to describe the importance of extended family ties as well as the strong identication and attachment of individuals to their families (Fange & Ivanoff 2009). Familism has been noted as an important value for many ethnic groups such as Asians, Latinos, African Americans, Asian Americans and American Indians (Varley & Blasco 2003, Edwards & Lopez 2006). Previous research on the role of the home for older people revealed that it is the most important locus in their lives (Fa nge & Ivanoff 2009). Kawamoto et al. (2005) investigated the relationship between living alone and well-being and determined the characteristics, physical health status, mental health status, social support and health needs of community-dwelling older people who are living alone in Japan. Family is an important source of support for older people. In cultures where family interdependence is highly valued, living with adult children in an extended family is common. Older people who received more family support were reported to have good selfperceived health and a low prevalence of psychological distress (Kotkamp-Mothes et al. 2005, Leung et al. 2007). Previous research has shown that the supportive role of the home during old age positively enhances well-being, autonomy and participation in valued activities among older people (Pietila & Tervo 1998, Song 2001, Kim 2007).

Methods
Design
A comparative descriptive design was used to compare and to examine the physical health status, the self-esteem, family
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support and the health-promoting behaviours between the aged living alone and the aged living with family. A crosssectional questionnaire survey was conducted using a convenient sampling from 1 March 200630 February 2007.

Cronbachs alpha coefcient of the original scale was 092. An internal consistency of 062 was reported in Juns (1974) research for older people. The alpha coefcient reliability of the scale was 078 for the current study. Family support The family support scale by Cobb (1976) was used to examine family support from emotional perspective. This scale was modied by Kang (1984). The scale is an 11-item, ve-point, Likert format for scoring. Possible scores are 11 55, with a higher score indicating better family support. Cronbachs alpha coefcient of the original scale was 084. The alpha coefcient reliability of the scale was 087 for this study. Health-promoting behaviours The Health-Promoting Lifestyle Prole (HPLP) developed by Walker et al. (1988) was used to measure health-promoting behaviours. The HPLP, a 47-item questionnaire, was modied and translated into Korean by Suh (1997, YO Suh, Kyung Hee University, Seoul, unpublished doctoral dissertation). The HPLP items were scored on a ve-point, Likert scale of responses, ranging from 1 (never) 5 (routinely). Among the six total subscales in Suhs Korean version of the HPLP (1997, unpublished doctoral dissertation), only the exercise and nutrition were used. This is because exercise and nutrition are related to self-efcacy and have repeatedly been good predictors of health-promoting behaviours of older people, sometimes explaining more than 50% of the variability (AbuSabha & Achterberg 1997). The internal consistency of the original HPLP scale was 092, and Cronbachs alpha coefcients for the subscales were 070090. The alpha reliability coefcient for Suhs Korean version of HPLP (1997, unpublished doctoral dissertation) was 090 and ranged from 073087 for the subscales. Cronbachs alpha coefcient in this study was 092. Cronbachs alpha coefcients of the two subscales were 085 in exercise and 082 in nutrition.

Sample
The study sample comprised older people living alone and living with family in communities of Seoul, Korea. The older people living in institutions, facilities, retirement communities etc. were excluded because institutions, facilities and retirement communities for older people are not prevalent in Korea. Eligibility criteria included being 65 years old or older; informed consent to engage in this study; independent living; a clear, conscious state of mind and complete verbal facility. After research approval from the university, the questionnaires were distributed to 280 eligible participants, who were divided into two groups the aged living alone and the aged living with family. Responses were received from 971% (135/140) of older people living alone and 920% (137/140) of older people living with family; however, only 133 and 134 responses, respectively, were included in the nal dataset because of incomplete data. As a result, only 267 total questionnaires were used. Sample size adequacy (n = 170) was estimated based on an alpha level = 005, number of groups = 2 (u = 1), conventional medium effect size = 025 and power = 090 (Cohen 1988). Therefore, the sample size in the study was adequate.

Instruments
Physical health status The Physical Health Status Scale by Hwang (2002, SK Hwang, Kyung Hee University, Seoul, unpublished Masters thesis) was used to measure physical health status. The scale is a nine-item, four-point, Likert format for scoring. Possible scores are 936, with a higher score indicating better physical health status. Cronbachs alpha coefcient of the original scale was 087. An internal consistency of 078 was reported in Hwangs (2002, unpublished Masters thesis) research for the older people. The alpha coefcient reliability of the scale was 083 for this study. Self-esteem The Self-Esteem Scale (RSES) by Rosenberg (1965) was used to measure self-esteem. This scale was translated into Korean by Jun (1974). The RESE is a brief, 10-item, four-point, Likert format that is dichotomised for scoring. Possible scores are 1040, with a higher score indicating higher self-esteem.
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Procedures
This study was approved by the Institutional Review Board of a University in Korea, who specically requested to remain anonymous. The researchers contacted participants and explained the purpose, sample criteria, participation details and instruments of this study. The researchers and two trained assistants received written permission from all the participants. The survey was a self-reported questionnaire with the help of the researchers and/or their assistants. The two assistants were trained on the interview methods by the researchers for ve hours. The inter-rater reliability was

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analysed by the Spearmans rank correlation coefcients between the researchers and two assistants for scales. Spearmans rank correlation coefcients were 086 (The Physical Health Status), 082 (The Self-Esteem), 091 (The Family Support) and 084 (The Health-Promoting Lifestyle Prole), respectively.

Data analysis
The data were analysed using the statistical package, SPSS/WIN Ver12.0. Descriptive statistics and Chi-square tests were performed to compare the demographic characteristics. Independent t-tests were performed to compare the physical health status, self-esteem, family support and healthpromoting behaviours between older people living alone and living with family.

Results
Comparison of demographic characteristics between the aged living alone and living with family is shown in Table 1. Eighty-four (632%) of older people living alone were female and also 84 (627%) of older people living with family were female. As far as age was concerned, 76 (571%) participants living along and 79 (590%) participants living with family were 6574 years old or younger, whereas those who were
Table 1 General characteristics, n = 267

75 years old and older consisted of 57 (429%) participants and 55 (410%) participants, respectively. Buddhism was the most common religion in both groups. Most of the participants graduated from elementary school in both groups. In the level of monthly monetary allowance, 500,000750,000 won or less was the most prevalent among 53 (398%) and 51 (381%) participants for the aged living alone and the aged living with family, respectively. Within the immediate household, 105 (789%) participants of the aged living alone had no spouse and 108 (806%) participants of the aged living with family had a spouse. There was only difference in the presence of a spouse, and there were no differences in the other items. Comparison of physical health status, selfesteem, family support and health-promoting behaviours between the aged living alone and living with family is shown in Table 2. The score of physical health status was 1377 for the aged living alone and 2503 for the aged living with family. This was a statistically signicant nding (t = 4085, p < 0001). The score of self-esteem was 2205 for the aged living alone and 3575 for the aged living with family. Thus, this was a statistically signicant nding (t = 2675, p < 0001). The score of family support was 2903 for the aged living alone and 4269 for the aged living with family. Also, this was a statistically signicant nding (t = 1646, p < 0001). The score of exercise in health-promoting behaviours was 853 for

Characteristics Gender Age (year)

Category Male Female 6569 7074 7579 80 above Protestant Catholic Buddhism Other None Elementary Middle High College above 250 below 250490 500740 750990 1000 above Yes No

Living alone (n = 133) n (%) 49 84 27 49 38 19 30 18 79 6 6 68 26 18 15 14 30 53 21 14 28 105 (368) (632) (203) (368) (286) (143) (226) (135) (594) (45) (45) (511) (195) (135) (113) (105) (226) (398) (158) (113) (211) (789)

Living with family (n = 134) n (%) 50 84 28 51 37 18 32 17 78 7 8 70 26 17 13 16 31 51 2 14 108 26 (373) (627) (209) (381) (276) (134) (239) (127) (582) (52) (61) (523) (194) (135) (97) (119) (231) (381) (164) (104) (806) (194)

v2 0006 0014

p 0936 0950

Religion

0003

0970

Education

0004

0985

Monthly allowance (1000 won)

0013

0961

Spouse

8142

<0001

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SR Sok and EK Yun Table 2 Differences of variables between two groups, n = 267 p <0001 <0001 <0001 <0001 <0001

Variable

Living alone Living with family (n = 133) (n = 134) M (SD) M (SD) t 4085 2675 1646 1586 1729

Physical health status 1377 (236) 2503 (214) Self-esteem 2205 (191) 3575 (559) Family support 2903 (285) 4269 (914) Exercise of health-promoting behaviour 853 (224) 1375 (306) Nutrition of health-promoting behaviour 737 (246) 1196 (183)

the aged living alone and 1375 for the aged living with family. This was another statistically signicant nding (t = 1586, p < 0001). The score of nutrition in healthpromoting behaviours was 737 for the aged living alone and 1196 for the aged living with family. Therefore, it was a statistically signicant nding (t = 1729, p < 0001).

Discussion
The focus of this study was to identify the differences of physical health status, self-esteem, family support and healthpromoting behaviours between the aged living alone and living with family. In this study, we found that older people living with family had higher levels of physical health status, self-esteem and family support. The results demonstrated the impact of emotional support from family members, which seems to positively affect the physical and psychological health of the aged population in Korea. This is consistent with Phillips et al.s (2005) study in Hong Kong, which conrmed that the environmental dwelling conditions mainly affect an older persons psychological well-being and, hence, most likely inuenced their opportunities for healthy ageing. However, previous research studies in this area reported mixed results. While most studies supported the relationship between living in an extended family setting and the psychological or physical health of older people (KotkampMothes et al. 2005, Okkonen & Vanhanen 2006), some studies did not (Gliksman et al. 1995, Gee 2000). It is often argued that there are cultural and also individual differences in evaluating well-being. In western countries, the most typical extended family setting is an independent residence, namely, older people and adult children live separately (Hays 2002). Nevertheless, the relationship and intimacy among family members living together has been regarded as an important value and mutual obligation in Asian ethnic countries. Therefore, we found that the aged living with family had higher self-esteem than the aged living alone. This is because of the fact that older people in Korea still consider the traditional Asian extended family setting as an important value in their lives and neglect the recent modications in the extended family living arrangement.
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We found that the aged living with family also had better health-promoting lifestyles than the aged living alone. This study found that the aged living with family exhibited better health-promoting behaviours than the aged living alone in the elds of exercise and nutrition. This result supports the assertion that when an older person is living with family, their positive self-evaluation facilitates health-promoting behaviours (Okkonen & Vanhanen 2006). The results of this study provide nurses with an effective means to enhance the health-promoting behaviours of aged people. This suggests that the designs and applications of health-promoting programmes should focus on family support in addition to a basic foundation in physical health promotion for older Korean people. Blazer (1982) studied social support and mortality in the older community and argued that older people with the greatest risk of dying were those with inadequate social support, followed by those with little to no social interaction with others and those with diminishing roles and attachments in the household. Previous studies discovered that positive relationships exist between perceived social support and positive health practices in older people (Padoani et al. 1998, Zunzunegui et al. 2001, Bergamini et al. 2007). Thus, for the aged living alone to cope with the lack of family support, nurses should plan to use various social supports system as a part of health-promoting programmes and help them to extend their social relationships with others.

Limitations
Selecting only two of six HPLP subscales may have a limitation in this study. Furthermore, it is difcult to generalise the results because of the small sample size. However, the main aim of this study was not to produce generalisable results; but rather, to provide information on which to build future investigations. Although, there were no differences in the eligibility and demographics between the groups collected on the survey, the list of potential differences between those living alone and living with family was not comprehensive.

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Conclusions
The results of this study demonstrated that the physical health status, self-esteem, family support and health-promoting behaviours (exercise and nutrition) of the aged living with family were higher than those of the aged living alone. As the Korean population ages, the number of the aged living alone is steadily rising. Derived from the understandings of different characteristics between old aged living alone and living with family, various nursing intervention strategies for the aged living alone should be developed to be focused on family or social support. To cope with the lack of family support, nurses should plan to use various social supports as a part of health-promoting programmes and help the aged living alone to extend their social relationships with others.

these ndings, clinical practice should be focused on emotional support with family or society for Korean aged, especially the aged living alone. Also, the practice should be adjusted to encourage the health-promoting behaviour for them as well. Future research studies should consider various characteristics including status of emotional support based on types of living arrangement of old aged and incorporate them into health-promoting programme along with social support.

Acknowledgements
The authors are grateful to all the participants who participated in the study.

Contributions Relevance to clinical practice

These ndings may help healthcare providers to provide basic data that shall serve as basis to explore nursing intervention to improve the physical health status, selfesteem, family support and health-promoting behaviours (exercise and nutrition) of the aged living alone. Considering Study design: SRS; data collection and data analysis: SRS and manuscript preparation: SRS, EKY.

Conict of interest
The authors declare they have no conict of interest.

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