Abstract
Population aging has become an important social issue worldwide and the biggest challenge is improving older people’s quality of life. We aimed to determine the quality of life (QOL) of retired older adults in Tehran using the SF-36. About 321 men and 146 women, aged 60 to 69 (62%) and 70 or older (38%), participated. In the older group, the total QOL score was lower than in the younger group, but the older group scored higher in the mental domain. Education had a significant relationship with the mental domain of QOL, as did gender with the physical and mental domains. The income sufficiency state was significantly related to both domains of QOL. The findings can be useful in designing intervention studies that could eventually lead to application of strategies to promote QOL in retired older adults in Iran and other countries with similar sociocultural and economic backgrounds.
Introduction
Although having many positive impacts, increasing life expectancy and the aging of populations has become one of the important social issues in many countries in recent years. Populations are aging rapidly in both the developed and developing world, which places urgent demands on health care systems, many of which (particularly in the developing nations) are simply not prepared for the influx of the graying population. How this universal phenomenon—born out of improving life expectancy, better nutrition, standard of living, education—affects public policy and sustainable health care in the developing world is evident.
Available data show that like many other countries in Asia and the Pacific, which will experience a doubling of their older population in less than 50 years time (United Nations’ Economic and Social Commission for Asia and the Pacific, 2002), the ratio of the above-60-year-olds to the general population in Iran is also steadily increasing and is expected to rise from the 5.2% figure in 2000 to 10.3% by the year 2025 and to 21.7% in 2050 (United Nations’ Economic and Social Commission for Asia and the Pacific, 2002). These figures, derived from the Report on the Regional Survey on Aging of the United Nations’ Economic and Social Commission for Asia and the Pacific, can be considered challenging and dramatic in Iran. This is especially true due to the prevailing insufficient preventive and promotional programs for the older people in Iran, based largely on the lack of reliable and related data in official reports.
The dire situation has emerged despite clear mention in Iran’s Fourth Five-Year Social, Economic and Cultural Development Plan (2005-2009). The plan stipulates that a preventive and promotional strategy for physical and psychosocial well-being of all groups of people, especially those at risk, is a function of the government.
As the needs of this rapidly aging population multiply, it will exert more pressure on government funding and may demand a different concept of national budgeting in terms of health, medical, and rehabilitation services (United Nations Economic and Social Commission for Asia and the Pacific, 2004). At this juncture, one of the priorities of health-providing organizations in many countries is to uphold policy for increasing the years of “healthy aging,” or adding “life to years,” and decreasing the years that the older people spend in disease, disability, and consequently dependency. This rather new approach to aging may well have been influenced by World Health Organization’s (WHO) announcement of “Active Aging” as the theme of the 1999 World Health Day, which was followed by a global awareness-raising campaign on the same issue (WHO, 1998). According to WHO, the biggest challenge in the 21st century was to improve the quality of life of the older people (WHO, 1998).
The “health-related quality of life”(HR-QOL) as defined by the National Center for Chronic Prevention and Health Promotion (CDC) is “a person or group’s perceived physical and mental health over time,” and is an indicator of the health situation of people. By measuring the effects of numerous disorders and short- and long-term disabilities (National Center for Chronic Prevention and Health Promotion [CDC], 2009), it can help in better understanding the problems, shortcomings and challenges people face. The “retired” group of older people in Iran represents those who have been government employees and have somehow served the government in their younger active years. As such, the government is even more responsible for addressing their health care needs and engendering appropriate support systems to this end.
This is an especially challenging issue for the government because in the modern Iranian society, although the older adults are still highly respected, the former comprehensive care and support provided by children for their aged parents and grandparents seems to be gradually fading away. Also, further aggravating the situation is the fact that the majority of retired former government employees, surprisingly, seem to face hard economic conditions.
This study was undertaken to answer research questions concerning the HR-QOL score of this group of people, totally and in separate mental and physical domains, and also the relationship with such major demographic factors as education, gender, age group, and income state along with the comparison of results with findings of similar studies around the world. Our final intention was to contribute to appropriate prioritization and the more effective and evidence-based planning of policy makers in Iran in the interest of older people’s health, and especially for the prevention of undesired consequences of retirement.
For researchers in western countries, especially in Europe and North America, we intend to provide a broader outlook about the situation of retired older people in other parts of the world such as Iran; and to enhance the global pool of data on this issue, which may well be utilized for comparison studies. The data may also be applicable to retired older adults in societies with similar sociocultural backgrounds, namely, most Middle-Eastern countries and some ethnic groups with eastern origins living in the West.
Method
The study population consisted of people aged 60 and older, all of whom were retired from former governmental occupations. This age group was selected after the definition outlined in Iran’s Third Five-Year Social, Economic, and Cultural Development Plan (2000-2004), which officially defines old people as those 60 years old or older. The field researcher recruited the samples through a convenience sampling method. It consisted of those who had either personally referred to the “State Organization for Retirement” for dealing with different retirement issues during the year 2005 or who had sent someone else on their behalf.
After acquiring informed consent, participants were asked to complete the self-report Short Form Health Survey (SF-36) questionnaire. Also, questions were asked about age, gender, postretirement employment, and the participants’ sources of income and income sufficiency. The questions related to income sufficiency consisted of four Likert-type scale questions, each respectively questioning how the individual’s present income (from whatever sources) sufficed for his or her present expenses, in one of the four areas of “daily,” “medicine and medical care,” “unpredicted,” and “recreational” expenses. There were three response alternatives the participants could choose from: “income suffices,” “income relatively suffices” or “income does not suffice.” Cronbach’s alpha was calculated for the four questions related to income sufficiency, and the internal consistency was determined as 0.78. We determined a “total” expense status for each participant by scoring the response alternatives and categorizing them into three levels: “not sufficient,” “relatively sufficient” and “sufficient.”
For those who had not referred personally, the questionnaires were delivered to their living place through the same person who had referred on their behalf, only if consent could be acquired by phone. The questionnaires were a self-report type, and only in the case where the participants could not read because of missing glasses were the questions read to them.
It is noteworthy that the SF-36 questionnaire, a relatively popular questionnaire world-wide for assessing HR-QOL, has previously been standardized in the Iranian population (Montazeri, Goshtasebi, Vahdaninia, & Gandek, 2005). This is a universally well-known and acceptable questionnaire for assessing quality of life and consists of 2 main domains (physical health and mental health), each including four subdomains. The scoring scale is from 0 to 100, the former figure indicating the worst and the latter the best condition.
All data are presented as M ± SD. For comparison of groups, the t test was used for comparing age groups and gender groups. Analysis of variance (ANOVA) was used to determine whether there were significant QOL score differences among the different educational groups and the different income groups. Alpha was set at 0.05. Next, the Tukey HSD test (Tukey’s honestly significant difference test), was used as a post hoc test. Since sex and age group were two qualitative binominal variables, to control the effects of each on the total QOL scores as well as the income sufficiency states, multiple regression analysis was conducted.
Results
On the whole, 467 old people were sampled, of whom 321 were male (68.7%) and 146 were female (31.3%). As there were only few participants older than 80 (29 people or 6.2%), the participants were classified into two groups: the “60- to 69-year-olds” and the “70-year-olds or older.” There were 62.1% of the participants in the former age group and 37.9% in the latter.
In terms of education, 41.4% of the sample had a high school diploma as their highest degree, whereas 19.6% of the sample had not finished high school, 41.4% had a high school diploma as their highest degree, and the remaining 39% held university degrees. In terms of employment and economic situation, 461 (98.7%) were employed after retirement and 372 (79.7%) claimed that their retirement benefits had an insignificant role in providing for their expenses. About 425 (91%) participants declared that they received no economic support from their children or other relatives at the time of the study. The mean and standard deviation for the total quality of life score was 67.3 ± 17.7. Table 1 reports the quality of life (QOL) scores in the study group.
Age and Income Sufficiency of Older People in Tehran City in Terms of Sex
Table 1 shows that the number of women participants was lower than men in both age groups, but the difference in age distribution is more obvious in women (with 74.7% appearing in the 60 to 69 and 25.3% in the >70-year-old age groups in comparison to the 56.4% and 43.6% of men, respectively). In terms of income sufficiency, a higher percentage of women (88.4% as opposed to 82.6% of men) had nonsufficient income, while fewer women (2.1% in comparison to 6.2% of their male counterparts) considered their income to be sufficient.
As Table 2 shows, the frequency of income sufficiency in 60 to 69 and >70-year-old groups was similar. About 84.5% of 60- to 69-year-olds and 84.2% of >70-year-olds were in the nonsufficient income group, while 5.2% and 4.5% appeared in the sufficient income group, respectively.
Income Sufficiency States in Different Age Groups of Older People in Tehran City
As can be observed in Table 3, the overall QOL score was higher in the mental health domain (70.4 ± 18.6) than in the physical health domain (66.4 ± 21.6), with the highest score (76.6 ± 22.3) being in the “social functioning” subdomain of the mental health domain and the lowest score (56.3 ± 40.6) being in “role limitation due to physical problems,” which is a subdomain of the physical health domain.
SF-36 Quality of Life Scores in Retired Older People in Tehran City
Table 4 shows the QOL situation in terms of gender. As is observable, except for the “physical functioning” subdomain, men had a significantly higher QOL score in all other subdomains. The most prominent difference between the two groups were in the subdomains of “role limitation due to physical problems” (where men scored 60.6 ± 39.7 and women scored 47.1 ± 41.1) and “bodily pain” (men scored 79.5 ± 20.5 and women scored 63.8 ± 23.3). The QOL scores for men were also significantly higher in each of the main domains of physical health (p = .000) and mental health (p < .002) and for the total SF-36 score (p < .002).
SF-36 Quality of Life Scores in Retired Older People of Tehran City in Terms of Sex
Table 5 compares the QOL scores in the two different age groups. The total QOL score and the score for the “physical health” domain is significantly higher in the younger group, while the score for the “mental health” domain is significantly higher in the older age group, where in all subdomains, except for the “vitality” and “social functioning,” the differences between the two age groups are significant. In addition to other findings, posthoc testing showed that regardless of age range and gender, education had a significant relation with the mental domain of QOL (p = .000), but the same was not true about the physical domain.
SF-36 Quality of Life Scores in Retired Older People of Tehran City in Terms of Age Groups
Table 6 demonstrates QOL score in each of the main physical and mental domains, in different “income sufficiency for total expenses” groups, and significance of the relationship. ANOVA analysis showed a significant difference of both physical (0.002) and mental (0.009) QOL scores between those individuals who considered that their present income sufficed, relatively sufficed, or did not suffice their present “total expenses.” The post hoc analysis showed that the significant difference that was detected by the ANOVA test was between “nonsufficient” and “sufficient” and also between “relatively sufficient” and “sufficient” groups in terms of the physical component of QOL. However, the difference in the mental component of QOL was only statistically significant between the “not sufficient” and “sufficient” groups.
SF-36 Quality of Life Scores for the Physical and Mental Components, in Terms of Income Sufficiency State in Retired Older People of Tehran City
Note: One way ANOVA was used for determining the significance.
According to Table 7, by controlling the effect of each variable on the other, it was determined that quality of life was significantly related to all of the three variables (sex, income sufficiency, and age group).
Multiple Regression Analysis of Relation of Sex, Income Sufficiency, and Age Groups to Total SF-36 Quality of Life Scores
Note: The outcome variable: SF-36 total score; R2 = 0.06.
Discussion
This study was undertaken to determine the HR-QOL of Iranian older adults retired from former governmental occupations, totally and in mental and physical domains separately, as well as the relationship of QOL in this group of people with major demographic factors such as education, gender, age group, and income state. In terms of the first research question, the total QOL score in our study group was 67.3 ± 17.7. If we compare the results of the present study with another Iranian QOL study performed on the older people in the general population of Tehran, we find that Tajvar, Arab, and Montazeri (2008) have reported a PCS (Physical Component Summary) and an MCS (Mental Component Summary) of 55.01 ± 25.66 and 63.86 ± 23.86 respectively, using the SF-36, whereas the values achieved for the same items in the present study were 66.4 ± 21.6 and 70.4 ± 18.6 respectively. It seems that the total score as well as the score in either of the physical or mental domains are higher in our study (Tajvar et al., 2008).
Obviously, many factors may have played a role in and contributed to the higher scores in our study, but one key factor in this case is probably the education status of the older people in this research. Since our research population consisted of older people retired from governmental occupations being hired for the government in Iran, and a minimum degree of education is required in most of the careers, the differences in the QOL scores may be partly attributed to this factor. The relatively higher level of education in our study group is reflected in the fact that only 19.6% did not have a high school diploma and 39% held university degrees. Whereas in the study performed by Tajvar et al., 49.8% of the participants were illiterate, 4.5% had university education, and 45.8% were somewhere in between.
In answer to our other research question regarding the relationship of QOL with education, like many other studies (De Belvis et al., 2008; Devlin, Hansen, & Herbison, 2000; Goins, John, Hennessy, Denny, & Buchwald, 2006; Konig, Bernert, & Angermeyer, 2005; Lubetkin, Franks, & Gold, 2005; Luo, Johnson, Shaw, Feeny, & Coons, 2005; Ostir, Berges, Ottenbacher, Graham, & Ottenbacher, 2008; Tajvar et al., 2008; Zhou et al., 2010) we noticed a significant relationship between higher levels of education and QOL (although in our case only with the mental domain of QOL). This was an especially noticeable finding, in our relatively well-educated sample.
As for the QOL in terms of gender, our results are consistent with numerous other studies performed on QOL of old people, with diverse geographical and cultural backgrounds (Azpiazu Garrido et al. 2003; Borglin et al., 2005; Goins et al., 2006; Knurowski, Lazic, van Dijk, Geckova, & Tobiasz-Adamczyk, 2004; Lee et al., 2006; Lee & Shinkai, 2003; Tajvar et al., 2008; Tsai, Chi, Lee, & Chou, 2004; Walters, Munro, & Brazier, 2001; Zhou, 2010). All available studies determining health and HR-QOL in the Iranian older adults have shown similar gender differences (Montazeri et al., 2005; Tajvar et al., 2008; Tajvar & Farziyanpour, 2004; Vahdaninia, Goshtasebi, Montazeri, & Maftoon, 2005).
According to some authors, this may have roots in gender inequalities, such as inequalities in access to health, information, education, employment, resources, and an overall disadvantaged economic status and social positions in Iran (Tajvar et al., 2008). It is noteworthy that in some other studies women have reported significantly more problems than men on the overall age range with regard to pain/discomfort and self-care (Konig et al., 2005). Some studies have attributed the declining QOL scores in women to hormonal changes in old age (Chiu, Moore, Hsu, Liu, & Chuang, 2008; Deck, Kohlmann, & Jordan, 2002). However, Deck and Kohlmann (2002) have mentioned that men also experience similar hormonal problems.
Another explanation may be that women’s longevity entails greater disability and multimorbidity, which implies a longer period of frailty, incapacity, and dependency than for men (Borglin et al., 2005; Smith & Baltes, 1998). Other possible factors mentioned as responsible for the lower QOL in women are the women’s poorer health, worse-off economic situation, their widowhood, and higher age expectancy (Borglin et al., 2005). Among what has been proposed as explanations for the lower QOL of women in comparison to men, our data can support the possibility of worse economic situations, as demonstrated by Table 4, where a higher proportion of women are shown to have nonsufficient income (88.4%) and consequently a lower percentage have sufficient income (2.1%), as compared to their male counterparts (82.6% and 6.2% respectively). The women’s lower QOL is evidently not due to their longevity or higher age expectation in the present study, because according to Table 4, only 25.3% of women in our study were 70 years old or older, compared to 43.6% of men in that age range.
However in terms of our research questions regarding the QOL state in different age groups, one interesting and unexpected finding was that although the total QOL score and the score for the “physical health” domain was significantly higher in the 60 to 69 age group, the score for the “mental health” domain was significantly higher in the >70 age group, totally and in all subdomains, except for the “vitality” and “social functioning” subdomains. This finding is explainable in the light of some theories, models, and concepts derived from literature.
With many physical problems and disabilities emerging in old age, the prevalent misconception assumes that the mental and emotional aspects of health are also directly influenced (Rothermund & Brandtstadter, 2003). In fact, theoretically, at least two factors can interfere with the adaptation and coping process necessary for facing the challenges of getting older. First, the accumulation of chronic problems and second, the reduced potential to compensate for age-related losses due to cognitive decline and increase in frailty, which have been shown to exist in the 80+ age group (Baltes & Mayer, 1999).
However, this is not always the case. Some people irrespective of age maintain their well-being and good QOL despite poor physical functioning, disability, and apparently poor QOL to an outsider. This is called the “disability paradox” theory (Albrecht, 1994; Albrecht & Devlieger, 1999; Bowling, Seetai, Morris, & Ebrahim, 2007; Constanca, Sadlma, & Shah, 2007; Covinsky et al. 1999; Walker, 2004). Interestingly, according to some studies on the older people there is a considerable degree of stability or improvement (in contrast to decline) in measures of contentment with actual performance levels, life satisfaction, self-esteem (Rothermund & Brandtstadter, 2003), self-assessed measures of mental health (Haug et al., 1984), depression (Rothermund & Brandtstadter, 2003), and other psychiatric symptoms (Haug et al., 1984).
Another theory that can further explain the findings of the present study about the higher mental health score in the >70 age group despite the lower physical score in that same age range is the dual model of coping proposed by Brandtstadter (1989). According to the dual model of coping, older people adjust to their losses through two different coping processes: the “assimilative” coping, which acts through compensatory activities to counteract functional impairments, and the “accommodative” coping, characterized by lowering and adjusting personal goals, standards, and expectations, which thus buffers the negative effects of performance deficits. The former increases up to the age of 70 years and declines afterwards because of decreases in the resources required for successful compensation. From then on, the latter coping process surpasses the former (Constanca et al., 2007; Rothermund & Brandtstadter, 2003). It can thus be assumed that the accommodative coping is the cause of stability or even improvement observed in measures of life satisfaction (Rothermund & Brandtstadter, 2003) and quality of life (Constanca et al., 2007) in the oldest old.
However, it may also be argued that the relation is reversed, in that having positive emotions, itself the product of higher psychological resilience and other individual psychological traits, leads to psychological and physical well-being via more effective coping (Greer, Morris, Pettingale, & Haybittle, 1990; Mossey, Mutran, Knott, & Craik, 1989; Tugade, Fredrickson, & Barrett, 2004). Possibly, the older people surviving to an even older age have been the more emotionally positive ones and thus have a higher sense of well-being and QOL than the general group of younger older people.
All three theories can potentially explain the situation in our sample and we do not have enough evidence to fully accept or reject any.
It needs to be mentioned that working for the government in Iran is by no means an indication of a better economic or social situation, especially after retirement. This empirical evidence is reflected in the answers to three of our general questions about employment and sources of income after retirement, in that 461 participants (98.7%) were working after retirement to be able to afford a living, 372 participants (79.7%) claimed that their retirement salary had an insignificant role in providing for their total expenses at the time of the study. 394 participants thought that their income did not suffice their expenses. Fifty retirees perceived it as relatively sufficient and only for 23 it was sufficient.
To address our research question about the relationship between QOL and income state, as is presented in Table 7, it is apparent that both physical and mental QOL scores are significantly higher in those individuals who mention that their present income “suffices” to cover their present total expenses. Several other studies, mostly considering the overall economic status of the participants, have found a significant relationship between economic conditions and HR_QOL both in the older people (Breeze et al., 2004; Goins et al., 2006; Tajvar et al., 2008; Walker, 2004; Zhou, 2010) and in the general population (Konig et al., 2005; Lee, Ko, & Lee, 2006; Lubetkin et al., 2005).
It should also be noted that in this study the majority of participants, that is 461 individuals (98.7%), were employed after retirement. This may be an indication of insufficient retirement salaries for “making a living,” but on the other hand, employment per se has been demonstrated to have significant relationship with higher QOL in several studies conducted on the elderly (Goins et al., 2006; Salimzadeh, Eftekhar, Pourreza, & Moghim Beygi, 2007; Walker, 2004) or on the general population (Bhandari, Alpkokin, Kachi, Jia, & Kato, 2007; Devlin et al., 2000; Konig et al., 2005). This may also account for the overall relatively higher levels of QOL in our study.
There have been some limitations in this research, which can be considered in future studies to yield better results. Due to the intentions of our study and accordingly due to our sampling method, our sample was not representative of all Iranian older adults and, for example, did not take into account those who had not worked for the government, those with lower levels of education, those with no postretirement employment, those older than 80, those with severe comorbidities and so on. Although earlier studies in Iran have already addressed the health or health-related quality of life of the total population of older people (Montazeri et al., 2005; Tajvar et al., 2008; Tajvar & Farziyanpour, 2004), they are scarce and need to be confirmed and complemented by more in-depth research. Utilizing other QOL instruments, such as the WHO-QOL questionnaire for comparative reasons, and including other covariates such as comorbidities that may act as confounding variables, especially in terms of physical scores and which are included in many similar studies around the world, will also be good ideas for future studies in Iran. This would enable describing the study participants in more detail and could promote the use of more inferential statistics.
Conclusion
The mental aspect of quality of life seems to be in a better condition than the physical aspect in the Iranian older retired people. This is even more pronounced in the >70 group. The better mental and emotional conditions and lower psychological disorders in the older group of the old and the possible explanations and implications of this new and interesting topic can provide stimulus for further research. Considering the importance of mental aspects of quality of life, it is suggested that future interventional studies be conducted to assess the effect of mental health promotion programs, such as “coping skills education” for Iranians on the verge of retirement, on enhancing and promoting mental health and well-being in the younger group of old people, after which appropriate mental health interventional studies that are currently lacking or rare in the country can be implemented.
Footnotes
Acknowledgements
The authors acknowledge and appreciate the contribution made by the State Organization for Retirement for allowing the research to be conducted on its premises. They also are thankful to all the older people who shared their thoughts with them and participated in the study. Their special thanks go to Mr. Amin Sabuni for his sincere cooperation in terms of editing the manuscript.
The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
The author(s) received no financial support for the research and/or authorship of this article.