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Self-perception of aging and health among older adults in Korea
Journal of Aging Studies 18 (2004) 485 – 496 www.elsevier.com/locate/jaging
Self-perception of aging and health among older adults in Korea Yuri Jang a,*, Leonard W. Poon b, Soo-Young Kim c, Bok-Ki Shin d a
Department of Aging and Mental Health, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612-3889, USA b Gerontology Center, University of Georgia, USA c Department of Social Welfare, Kyungsung University, South Korea d Department of Social Welfare, Pusan National University, South Korea
Abstract The way that each individual perceives his or her own aging and health may be a key indicator of adaptation and well-being in old age. This study explored the determinants of self-perception of aging and health using 291 community-dwelling older adults in Korea (mean age = 69.9). Older individuals with lower levels of education and economic status and various types of health problems (more chronic conditions, greater disability, poorer vision, and greater numbers of sick days) were found to have more negative self-perception of aging and health. In addition, a significant role of psychological factors was observed. For self-perception of health, sense of mastery was found to be a significant factor, and for self-perception of aging, neuroticism was observed to be significant along with sense of mastery. The mediating role of self-perception of health was supported that positive perception of health intervened the adverse effects of health problems on self-perception of aging. The findings demonstrate the important roles of psychological resources and subjective perceptions and suggest a need to consider them when planning interventions. D 2004 Elsevier Inc. All rights reserved. Keywords: Self-perception of aging and health; Neuroticism; Mastery; Korea
1. Introduction Along with most other nations, Korea is undergoing a rapid growth of older populations with the increased life expectancies. In Korean society, reverence toward older generations has been strongly emphasized under the traditional Confucian values and collectivism. However, with socioeconomic development and modernization of the society, the cultural values, such as family solidarity and filial piety, have been modified (Cho, Hong, & Kim, 1999). In addition, values and beliefs of the elderly * Corresponding author. E-mail address: [email protected] (Y. Jang). 0890-4065/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jaging.2004.06.001
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themselves have been changing, and the contemporary older generations tend to have a stronger desire for autonomy and independence (Jang, Haley, Small, & Reynolds, 2000). In this changing society, it is important to explore the perspectives of older individuals on themselves and their life to better understand their adaptation in aging process. Regardless of the societal stereotypes of aging and life conditions that each individual is facing, self-perceptions play an essential role in determining wellbeing of older individuals. Under the various challenges in old age, the ability to preserve positive selfidentity may be a key for successful adaptation in aging. The importance of self-perception over objective situations has received an increasing attention in gerontological research. Studies have shown that positive self-perception of or attitude toward aging is beneficial for physical and emotional well-being (Maier & Smith, 1999). Furthermore, a recent longitudinal study reported that older individuals with more positive self-perception of aging survived 7.5 years longer than those with less positive self-perception of aging (Levy, Slade, Kunkel, & Kasl, 2002). Along the same line, self-perception of health has shown its significant ability to predict a variety of outcomes, including service utilization, emotional distress, morbidity, and mortality (Borawski, Kinney, & Kahana, 1996; Idler & Benyamini, 1997; Maier & Smith, 1999). Enhancement of positive self-perception has important practical implications because it is strongly connected with better adjustment to changes in old age and it leads to a higher quality of life regardless of objective life circumstances (Levy et al., 2002). The conceptual model for the present study is partially guided by the Health Belief Model (HBM; Rosenstock, 1974). The HBM, influenced by Kurt Lewin who believed that individuals’ perception determines what they will and will not do, has served as an important theoretical background in the area of health behaviors. The HBM can be summarized into three major components: objective (factual), subjective (belief-laden), and behavioral factors (Salazar, 1991). Objective factors, such as demographic characteristics and knowledge of disease, may shape perceptions of the seriousness of illness and perceived benefits and barriers to action. These perceptions predict and explain how each individual takes personal health behaviors. In the present study, the focus will be on subjective perception of both health and aging, identifying their determinants and connections between them. 1.1. Determinants of self-perception of aging and health One of the potential determinants of self-perception of aging and health is health-related factors. Physical health conditions, such as chronic disease, functional disability, sensory performance, and the number of sick days, may form an underlying basis for evaluation of aging and health status. However, in perceiving one’s own aging and rating physical health, people may use additional information that goes beyond a simple summing of their medical conditions or the level of disability. Indeed, studies have shown that individuals with equivalent levels of physical conditions have very different ratings of their health (Kahana et al., 1995; Schulz & Williamson, 1993). Given its subjective nature, it is important to acknowledge that self-perception of aging and health is not only influenced by objective health indicators, but also by psychological and social factors. Among various types of personality and psychological characteristics, neuroticism and sense of mastery are potential candidates that may influence self-perception of aging and health. Neuroticism, a global indicator of an individual’s tendency to experience negative and distressing emotions (Costa & McCrae, 1989), has widely known to be associated with heightened sensitivity to adversity and negative appraisals (Jang, Mortimer, Haley, & Graves, 2002; Watson & Pennebaker, 1989). These findings
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suggest that older individuals with a strong trait of neuroticism may have an increased susceptibility to negative perceptions of one’s own aging and health. On the other hand, sense of mastery which is defined as the extent to which a person feels that (s)he has control over life and environment (Pearlin & Schooler, 1978) may contribute to deriving a positive self-evaluations. The beneficial effects of sense of mastery in buffering stress and facilitating positive emotional states have been widely reported in studies with various populations (Lachman & Weaver, 1998; Roberts, Dunkle, & Haug, 1994), including older Koreans (Jang et al., 2000). In addition, social factors, such as networks with family and friends, are expected to promote positive self-perception of aging and health. Previous studies have shown that individuals with social resources have a more favorable perception of themselves and their situations (Krause, 1997). The existence of strong social ties and support from others may bolster older individuals’ self-esteem and positively influence self-perception of aging and health. 1.2. The mediating effects of self-perception of health In the connections between health-related factors and self-perception of aging, we expect that perception of health would have a mediating effect. The existence of health problems may not only have a direct effect on negative perception of aging but also have an indirect effect through negative perception of health. In other words, older individuals with poor health conditions may have negative perceptions of health, which in turn lead to a more negative perception of aging as a whole. Taken together, the present study is designed (1) to explore how health-related factors and psychosocial attributes determine self-perception of aging and health and (2) to test whether selfperception of health mediates the connections between health-related factors and self-perception of aging among older adults in Korea.
2. Method 2.1. Participants A survey was conducted in five Korean cities (Seoul, Pusan, Ulsan, Kwangju, and Sun-Cheon) in the winter of 2002. Participants were recruited through a variety of sources, including senior centers and clubs. Trained interviewers conducted face-to-face interviews with a total of 312 individuals aged 60– 90. For the present study, 21 participants who had missing data were discarded, so the final sample consisted of 291 respondents who had complete information. In the present sample, participants averaged 69.9 years of age (S.D. = 5.99). Gender distribution was nearly equal, and about 60% of the sample were married. Less than half of the sample received more than high school education and about 67% reported their economic status as ‘adequate.’ Descriptive information of the sample is shown in Table 1. 2.2. Measures A Korean version of the questionnaire was developed using a back translation method. The original instruments were translated into the Korean language by the first author and a careful review was
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Table 1 Descriptive characteristics of the sample and study variables (N = 291) Age Gender (female) Marital status (married) Education (z high school graduate) Perceived economic status Less than adequate Adequate More than adequate Chronic conditions Functional disability Vision Excellent Good Fair Poor Blind Hearing Excellent Good Fair Poor Number of sick days Neuroticism Mastery Network with family Network with friends Self-perception of health Self-perception of aging
M/S.D.
Range
69.9/5.99
60 – 90
%
a
50.2 59.1 47.6 21.8 67.1 11.1 1.45/1.14 1.95/3.32
0–5 0 – 22
.84 5.5 28.9 33.3 31.3 1.0 14.8 39.5 28.9 16.8
1.73/1.01 21.9/5.52 18.3/2.36 10.1/3.06 10.6/3.22 2.87/1.59 7.19/1.67
1–5 0 – 40 11 – 24 3 – 18 2 – 18 0–6 5 – 10
.72 .65 .70 .62 .65 .71
conducted with two persons bilingual in Korean and English. Another two bilingual persons translated the Korean version of the questionnaire into English to find any discrepancies between two versions of questionnaires. The refined version of the questionnaire was pretested with three Korean older adults who were representative of the anticipated sample in this study. 2.2.1. Chronic condition Individuals were asked to report whether they had specific diseases in the list on a yes/no format. The list of diseases was adopted from the Older Americans Resources and Services Questionnaire (OARS; Fillenbaum, 1988). It includes nine chronic diseases and conditions commonly found among older populations (e.g., arthritis, stroke, heart problems, diabetes, and cancer). The total number from the list was used for the analysis. 2.2.2. Disability Disability was assessed with 20 items from a composite measure of the Physical Activities of Daily Living (PADL; Fillenbaum, 1988), the Instrumental Activities of Daily Living (IADL; Fillenbaum,
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1988), Physical Performance Scale (Nagi, 1976), and Functional Health Scale (Rosow & Breslau, 1966). Items cover a wide range of activities, including eating, dressing, using the telephone, traveling, managing money, carrying a bag of groceries, and reaching out and above the head with the arms. Participants were asked to report whether they can perform each activity. The responses were coded as 0 (without help), 1 (with some help), or 2 (unable to do). Responses for individual items were summed for total scores. The possible range for disability was 0 (no disability) to 40 (severe disability). Reliability for the measure was shown to be satisfactory in the present sample (a=.84). 2.2.3. Sensory performance Individuals were asked to report their status of vision and hearing with help from assistive devices, such as glasses, contact lenses, and hearing aids, if they are needed. Responses were coded as blind or deaf (0), poor (1), fair (2), good (3), and excellent (4). 2.2.4. Number of sick days The number of sick days during the last 6 months was measured with five categories: none (1), less than a week (2), more than a week but less than a month (3), more than a month but less than 3 months (4), and more than 3 months (5). 2.2.5. Neuroticism Neuroticism was measured with 12 items from the NEO-Five Factor Inventory (NEO-FFI; Costa & McCrae, 1989). Participants were asked to indicate how they agreed with statements, such as ‘‘I rarely feel fearful or anxious’’ and ‘‘I often get angry at the way people treat me’’ using a five-point scale ranging from 0 (strongly disagree) to 4 (strongly agree). Responses were recoded and summed so that the higher total scores indicate higher neuroticism. Reliability was shown to be high in the present sample (a=.72). 2.2.6. Sense of mastery Sense of mastery was measured with the Pearlin and Schooler’s (1978) Mastery Scale. Respondents described their feelings about the seven items, such as ‘‘I cannot solve my problems’’ and ‘‘My future mostly depends on me,’’ on a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Responses to negatively worded items were reverse coded, and all responses were summed for the total score. Scores on the mastery scale range from 7 (low mastery) to 28 (high mastery). Reliability in the present sample was shown to be acceptable (a=.65). 2.2.7. Social network Networks with family and friends were measured with each three items from the Lubben’s Social Network Scale (Lubben, 1988). Measures included the number of relatives or friends seen at least once a month (0 to 9 or more), frequency of contact (less than monthly to daily), and the number of relatives or friends the participant felt close to (0 to 9 or more). Cronbach’s a was .70 for network with family and .62 for network with friends. 2.2.8. Self-perception of health Three items from the OARS (Fillenbaum, 1988) were selected to assess self-perception of health, including ‘‘How would you rate your overall health at the present time?’’ ‘‘How is your present health
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compared to five years ago?’’ and ‘‘How much do your health troubles stand in the way of your doing the things you want to do?’’ Total scores ranged from 0 (negative self-perception of health) to 7 (positive selfperception of health). Reliability for the scale based on the three items was shown to be acceptable (a=.63). 2.2.9. Self-perception of aging Self-perception of aging was measured with five items for the Attitude Toward Own Aging in the Philadelphia Geriatric Center Morale Scale (PGCMS; Lawton, 1975). The items include ‘‘Do things keep getting worse as you get older?’’ ‘‘Do you have as much pep as you had last year?’’ ‘‘Do you feel that as you get older you are less useful?’’ ‘‘As you get older, are things better than you thought?’’ and ‘‘Are you as happy now as you were when you were younger?’’ and they were asked with a yes/no format. Scores were recoded to indicate high scores more positive self-perceptions. The potential range for the scores was 5–10. Reliability for the scale in the present sample was satisfactory (a=.71). 2.2.10. Demographic variables Demographic information included age (in years), gender (0 = male, 1 = female), marital status (1 = unmarried, 2 = married), educational attainment (1 = < high school, 2 = z high school) and perceived economic status (1 = less than adequate, 2 = adequate, and 3 = more than adequate). 2.3. Analytic strategy To estimate predictability of physical and psychosocial factors on self-perception of health and aging, hierarchical regression analyses were conducted by entering independent blocks of predictors with (1) demographic variables, (2) physical health-related factors, and (3) psychosocial factors. For the regression model for self-perception of aging, self-perception of health was added as a potential predictor in the final step. Intercorrelations among study variables and variance inflation factors (VIF) were assessed to determine multicollinearity. In addition, the mediating effects of self-perception of health in the relationship between healthrelated factors and self-perception of aging were assessed following the Baron and Kenny (1986) criteria for mediation; (a) there is a significant association between independent variable and dependent variable, (b) there is a significant association between independent variable and presumed mediator, (c) there is a significant association between presumed mediator and dependent variable, and (d) a previously significant relationship between independent and dependent variables become nonsignificant or decreased when the mediator is controlled for. The mediating effects of self-perception of health were separately assessed with variables with significant direct effects.
3. Results 3.1. Descriptive information of the study variables As shown in Table 1, the average number of chronic conditions was 1.45 (S.D. = 1.14) and average score for functional disability was 1.95 (S.D. = 3.32). About 34% and 54% of the sample had either excellent or good status of vision and hearing, respectively. The average number of sick days was 1.73 (S.D. = 1.01). The mean scores for neuroticism, sense of mastery, network with family, and network with
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friends were 21.9 (S.D. = 5.52), 18.3 (S.D. = 2.36), 10.1 (S.D. = 3.06), and 10.6 (S.D. = 3.22), respectively. The mean scores for self-perception of health and aging were 2.87 (S.D. = 1.59) and 7.19 (S.D. = 1.67). 3.2. Correlations among study variables Bivariate correlation coefficients were assessed to understand underlying associations among study variables and are summarized in Table 2. More positive perception of aging and health was observed among those with younger age, fewer chronic conditions, less functional disability, better vision and hearing, and fewer sick days. Individuals with high neuroticism and low sense of mastery were more likely to have negative perception of aging and health. Networks with family and friends were positively associated with self-perception of aging but not with self-perception of health. Those who perceive their own health better were shown to have a more favorable perception of aging. 3.3. Regression models of self-perception of health and aging Table 3 summarizes the results of the hierarchical regression models of self-perception of health and aging. Demographic variables explained 11% of the variance of self-perception of health, with lower levels of education and economic status being significant predictors of more negative self-perception of health. Physical health-related factors explained an additional 23% of the variance. Those with more Table 2 Correlations among study variables (N = 291) 1 2
3
(1) Age – .01 .33*** (2) Chronic – .23*** condition (3) Functional – disability (4) Vision (5) Hearing (6). Number of sick days (7) Neuroticism (8) Mastery (9) Network with family (10) Network with friends (11) Self-perception of health (12) Self-perception of aging * P < .05. ** P < .01. *** P < .001.
4
5
6
7
8
9
10
11
12
.06 .11
.10 .05
.02 .20**
.09 .24***
.14* .20**
.27*** .14*
.15** .09
.16** .31***
.24*** .31***
.21***
.10
.23***
.19**
.33***
.23***
.18**
.37***
.22***
.43*** –
.16** .12* –
.26*** .08 .28***
.29*** .12* .24***
.11 .13* .11
.11 .12* .10
.34*** .16** .37***
.21*** .13* .28***
.53*** –
.17** .09 –
.11 .08 .56***
.37*** .41*** .09
.48*** .45*** .18**
.04
.13*
–
–
–
–
.48*** –
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Table 3 Regression models of self-perception of health and aging Predictor
Self-perception of health 2
b Age Gender Marital status Education Perceived economic status Chronic condition Functional disability Vision Hearing Number of sick days Neuroticism Mastery Network with family Network with friends Self-perception of health
.04 .01 .04 .23** .14* .18** .16** .22*** .01 .22*** .08 .17** .05 .07
Self-perception of aging 2
R
DR
.11***
.11***
.34***
.23***
.39***
.05**
b .11 .12 .01 .21** .22*** .29*** .13* .16** .03 .18** .23*** .22*** .00 .01 .23***
R2
DR2
.15***
.15***
.32***
.17***
.44***
.12***
.47***
.03***
* P < .05. ** P < .01. *** P < .001.
chronic conditions, more functional disability, poorer vision and greater numbers of sick days were found to perceive their health status more negatively. After controlling for background and health-related variables, psychosocial factors explained an additional 5% of the variance. Individuals with lower sense of mastery were likely to have negative perception of health. A total of 39% of variance of selfperception of health was accounted by the estimated model. In the model of self-perception of aging, predictors were found to function in the similar way with those of self-perception of health. More negative perception of aging was observed among older individuals with lower educational and economic status, more chronic conditions, greater disability, poorer vision, and greater numbers of sick days. In addition, psychosocial factors contributed 12% of the variance, identifying higher neuroticism and lower sense of mastery as significant predictors for negative perception of aging. In the final step, self-perception of health was entered as a predictor and accounted for additional 3% of the variance, resulting in a total of 47% of variance explained by the estimated model. Negative perception of health was a significant predictor of unfavorable perception of aging after controlling for health-related and psychosocial factors. 3.4. Mediating effects of self-perception of health Employing Baron and Kenny’s criteria, the mediating effects of self-perception of health was tested in the associations between health-related factors and self-perception of aging. Analyses were conducted after controlling for the effects of age, gender, marital status, education, and perceived economic status. The independent paths among independent variables (chronic condition, functional disability, vision, and the number of sick days), presumed mediator (self-perception of health), and dependent variable (selfperception of aging) were significant. When self-perception of health was controlled, the regression
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Fig. 1. Mediating effects of self-perception of health between health-related factors and self-perception of aging. The numbers in parentheses indicate the indirect effect of independent variables on self-perception of aging after controlling for the effects of self-perception of health. *P < .05, **P < .01, ***P < .001.
coefficients for each health-related factor on self-perception of aging either became nonsignificant or decreased. The direct effects of chronic condition on self-perception of aging (b = .31, P < .001) decreased (b = .21, P < .01) with a control for self-perception of health. The predictability of functional disability (b = .12, P < .05) and vision (b=.17, P < .01) became nonsignificant (b = .00, P>.05 for functional disability; b=.04, P>.05 for vision). The effect of the number of sick days (b = .25, P < .001) also decreased (b = 12, P < .05) after controlling for self-perception of health (see Fig. 1).
4. Discussion Given the importance of subjective perception over objective conditions in old age, the present study assessed the determinants of self-perception of aging and health and the connections between them using
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291 community-dwelling older adults in Korea. Findings from the analyses provided supportive evidence for the proposed hypotheses. In the regression models of self-perception of aging and health, lower levels of education and economic status and various health problems, such as more chronic conditions, greater disability, poorer vision, and greater numbers of sick days, were found to be common predictors of negative selfperceptions. The finding is consistent with previous research showing more negative outcomes in health and well-being among individuals with lower social class (Lachman & Weaver, 1998) and poorer physical health conditions (Borawski et al., 1996; Idler & Benyamini, 1997). It seems that the lack of socioeconomic resources and the existence of health problems make older individuals perceive their own aging and health status more negatively. After controlling for the effects of sociodemographic and health-related factors, psychosocial attributes accounted for a significant amount of variance of self-perception of aging and health. For self-perception of health, sense of mastery was found to be a significant factor, and for self-perception of aging, neuroticism was significant along with sense of mastery. Independent of health conditions, older individuals with a higher sense of mastery were likely to perceive their own health better. Negative perception of aging was found among those with high neuroticism and low sense of mastery. The findings indicate that psychological characteristics play an important role in shaping the ways of subjective perceptions and evaluations. The effects of social networks were shown to be nonsignificant mostly due to the small variance in the scales and confounding with psychological factors. The effect of neuroticism on self-perception of aging is consistent with studies showing negative appraisals of situations among those with high neuroticism (Watson & Pennebaker, 1989). Older individuals with high degrees of neuroticism tend to pay more attention to negative aspects of life and perceive situations as more stressful or threatening. Consequently, they may be more prone to negative changes and evaluate their health conditions and aging process in a more negative manner. The finding suggests that the personality trait of neuroticism is not only associated with negative perception of aging but also may lead to withdrawal from the society and hinder positive adaptation in aging. The present study highlighted the role of sense of mastery showing its beneficial effects on both selfperception of aging and health. Previous studies have shown that individuals with a strong sense of mastery are more likely to have positive attitudes and emotional states (Lachman & Weaver, 1998; Roberts et al., 1994). The mechanism of mastery and positive self-evaluation may not only be involved with subjective perception but also with behavioral aspects. That is, feelings in control may enable individuals to be actively engaged in health-promoting behaviors, such as nonsmoking and exercise, and in turn derive a positive perception of their own aging and health (Menec & Chipperfield, 1997). Following Baron and Kenny’s criteria, self-perception of health was evidenced to serve as a mediator in the connections between health-related factors and self-perception of aging. The predictability of chronic conditions, functional disability, vision, and the number of sick days, whose direct effects on self-perception of aging were significant, declined when controlling for self-perception of health. The existence of health problems seems to make older individuals perceive their own health status poorer and in turn lead to a more negative perception of aging. Thus, self-perception of health is an intervening step between those health-related factors and self-perception of aging. The finding implies that adverse effects of health problems on perception of aging can be reduced and that positive attitude toward aging can be reinforced by having an optimistic view of health. Linking our findings to the HBM, which advocates the connections between subjective perceptions and healthful behaviors, and other literature showing beneficial roles of positive perception in morbidity and mortality (Levy et al., 2002), special
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attention is needed to find strategies to preserve and promote positive outlooks among older populations. Some limitations to the present study need to be noted. Because the sample in the study is nonrepresentative, generalizability of the finding is limited. In addition, due to a cross-sectional design, caution must be exercised in drawing causal inference from the data. Another limitation is that all measures employed in the present study were self-reports. The use of objective testing for health-related variables would add strength to the study by contrasting the objective health conditions and subjective perceptions. In addition, future studies need to include various aspects of social resources, including the actual transaction of support exchange and the quality of or satisfaction with support along with the existence of social networks. Despite the aforementioned limitations, the present study has implications for research and practice. Given the importance of psychological factors and subjective perceptions, interventions need to focus on these factors and utilize them. Modification of negative perception of, or attitude toward, aging and health may facilitate successful adaptation in old age and maximize positive physical and mental health outcomes. Indeed, empirical evidence was found that with the self-stereotype of aging interventions tailored to alter negative perceptions and activate positive judgments about self, older individuals’ cognitive performance was considerably improved (Levy, 1996). Along with the individual level of interventions, efforts are needed to modify negative stereotypes of aging and the aged in the societal level. Acknowledgements This research was supported by Issues (SPSSI). Additional support The authors would like to thank possible. Special appreciation goes data entry task.
the grant from the Society for the Psychological Study of Social was provided by the Gerontology Center, University of Georgia. all study participants and interviewers who made this research to Emily Bower at the UGA Gerontology Center who conducted
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Self-perception of aging and health among older adults in Korea Yuri Jang a,*, Leonard W. Poon b, Soo-Young Kim c, Bok-Ki Shin d a
Department of Aging and Mental Health, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612-3889, USA b Gerontology Center, University of Georgia, USA c Department of Social Welfare, Kyungsung University, South Korea d Department of Social Welfare, Pusan National University, South Korea
Abstract The way that each individual perceives his or her own aging and health may be a key indicator of adaptation and well-being in old age. This study explored the determinants of self-perception of aging and health using 291 community-dwelling older adults in Korea (mean age = 69.9). Older individuals with lower levels of education and economic status and various types of health problems (more chronic conditions, greater disability, poorer vision, and greater numbers of sick days) were found to have more negative self-perception of aging and health. In addition, a significant role of psychological factors was observed. For self-perception of health, sense of mastery was found to be a significant factor, and for self-perception of aging, neuroticism was observed to be significant along with sense of mastery. The mediating role of self-perception of health was supported that positive perception of health intervened the adverse effects of health problems on self-perception of aging. The findings demonstrate the important roles of psychological resources and subjective perceptions and suggest a need to consider them when planning interventions. D 2004 Elsevier Inc. All rights reserved. Keywords: Self-perception of aging and health; Neuroticism; Mastery; Korea
1. Introduction Along with most other nations, Korea is undergoing a rapid growth of older populations with the increased life expectancies. In Korean society, reverence toward older generations has been strongly emphasized under the traditional Confucian values and collectivism. However, with socioeconomic development and modernization of the society, the cultural values, such as family solidarity and filial piety, have been modified (Cho, Hong, & Kim, 1999). In addition, values and beliefs of the elderly * Corresponding author. E-mail address: [email protected] (Y. Jang). 0890-4065/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jaging.2004.06.001
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themselves have been changing, and the contemporary older generations tend to have a stronger desire for autonomy and independence (Jang, Haley, Small, & Reynolds, 2000). In this changing society, it is important to explore the perspectives of older individuals on themselves and their life to better understand their adaptation in aging process. Regardless of the societal stereotypes of aging and life conditions that each individual is facing, self-perceptions play an essential role in determining wellbeing of older individuals. Under the various challenges in old age, the ability to preserve positive selfidentity may be a key for successful adaptation in aging. The importance of self-perception over objective situations has received an increasing attention in gerontological research. Studies have shown that positive self-perception of or attitude toward aging is beneficial for physical and emotional well-being (Maier & Smith, 1999). Furthermore, a recent longitudinal study reported that older individuals with more positive self-perception of aging survived 7.5 years longer than those with less positive self-perception of aging (Levy, Slade, Kunkel, & Kasl, 2002). Along the same line, self-perception of health has shown its significant ability to predict a variety of outcomes, including service utilization, emotional distress, morbidity, and mortality (Borawski, Kinney, & Kahana, 1996; Idler & Benyamini, 1997; Maier & Smith, 1999). Enhancement of positive self-perception has important practical implications because it is strongly connected with better adjustment to changes in old age and it leads to a higher quality of life regardless of objective life circumstances (Levy et al., 2002). The conceptual model for the present study is partially guided by the Health Belief Model (HBM; Rosenstock, 1974). The HBM, influenced by Kurt Lewin who believed that individuals’ perception determines what they will and will not do, has served as an important theoretical background in the area of health behaviors. The HBM can be summarized into three major components: objective (factual), subjective (belief-laden), and behavioral factors (Salazar, 1991). Objective factors, such as demographic characteristics and knowledge of disease, may shape perceptions of the seriousness of illness and perceived benefits and barriers to action. These perceptions predict and explain how each individual takes personal health behaviors. In the present study, the focus will be on subjective perception of both health and aging, identifying their determinants and connections between them. 1.1. Determinants of self-perception of aging and health One of the potential determinants of self-perception of aging and health is health-related factors. Physical health conditions, such as chronic disease, functional disability, sensory performance, and the number of sick days, may form an underlying basis for evaluation of aging and health status. However, in perceiving one’s own aging and rating physical health, people may use additional information that goes beyond a simple summing of their medical conditions or the level of disability. Indeed, studies have shown that individuals with equivalent levels of physical conditions have very different ratings of their health (Kahana et al., 1995; Schulz & Williamson, 1993). Given its subjective nature, it is important to acknowledge that self-perception of aging and health is not only influenced by objective health indicators, but also by psychological and social factors. Among various types of personality and psychological characteristics, neuroticism and sense of mastery are potential candidates that may influence self-perception of aging and health. Neuroticism, a global indicator of an individual’s tendency to experience negative and distressing emotions (Costa & McCrae, 1989), has widely known to be associated with heightened sensitivity to adversity and negative appraisals (Jang, Mortimer, Haley, & Graves, 2002; Watson & Pennebaker, 1989). These findings
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suggest that older individuals with a strong trait of neuroticism may have an increased susceptibility to negative perceptions of one’s own aging and health. On the other hand, sense of mastery which is defined as the extent to which a person feels that (s)he has control over life and environment (Pearlin & Schooler, 1978) may contribute to deriving a positive self-evaluations. The beneficial effects of sense of mastery in buffering stress and facilitating positive emotional states have been widely reported in studies with various populations (Lachman & Weaver, 1998; Roberts, Dunkle, & Haug, 1994), including older Koreans (Jang et al., 2000). In addition, social factors, such as networks with family and friends, are expected to promote positive self-perception of aging and health. Previous studies have shown that individuals with social resources have a more favorable perception of themselves and their situations (Krause, 1997). The existence of strong social ties and support from others may bolster older individuals’ self-esteem and positively influence self-perception of aging and health. 1.2. The mediating effects of self-perception of health In the connections between health-related factors and self-perception of aging, we expect that perception of health would have a mediating effect. The existence of health problems may not only have a direct effect on negative perception of aging but also have an indirect effect through negative perception of health. In other words, older individuals with poor health conditions may have negative perceptions of health, which in turn lead to a more negative perception of aging as a whole. Taken together, the present study is designed (1) to explore how health-related factors and psychosocial attributes determine self-perception of aging and health and (2) to test whether selfperception of health mediates the connections between health-related factors and self-perception of aging among older adults in Korea.
2. Method 2.1. Participants A survey was conducted in five Korean cities (Seoul, Pusan, Ulsan, Kwangju, and Sun-Cheon) in the winter of 2002. Participants were recruited through a variety of sources, including senior centers and clubs. Trained interviewers conducted face-to-face interviews with a total of 312 individuals aged 60– 90. For the present study, 21 participants who had missing data were discarded, so the final sample consisted of 291 respondents who had complete information. In the present sample, participants averaged 69.9 years of age (S.D. = 5.99). Gender distribution was nearly equal, and about 60% of the sample were married. Less than half of the sample received more than high school education and about 67% reported their economic status as ‘adequate.’ Descriptive information of the sample is shown in Table 1. 2.2. Measures A Korean version of the questionnaire was developed using a back translation method. The original instruments were translated into the Korean language by the first author and a careful review was
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Table 1 Descriptive characteristics of the sample and study variables (N = 291) Age Gender (female) Marital status (married) Education (z high school graduate) Perceived economic status Less than adequate Adequate More than adequate Chronic conditions Functional disability Vision Excellent Good Fair Poor Blind Hearing Excellent Good Fair Poor Number of sick days Neuroticism Mastery Network with family Network with friends Self-perception of health Self-perception of aging
M/S.D.
Range
69.9/5.99
60 – 90
%
a
50.2 59.1 47.6 21.8 67.1 11.1 1.45/1.14 1.95/3.32
0–5 0 – 22
.84 5.5 28.9 33.3 31.3 1.0 14.8 39.5 28.9 16.8
1.73/1.01 21.9/5.52 18.3/2.36 10.1/3.06 10.6/3.22 2.87/1.59 7.19/1.67
1–5 0 – 40 11 – 24 3 – 18 2 – 18 0–6 5 – 10
.72 .65 .70 .62 .65 .71
conducted with two persons bilingual in Korean and English. Another two bilingual persons translated the Korean version of the questionnaire into English to find any discrepancies between two versions of questionnaires. The refined version of the questionnaire was pretested with three Korean older adults who were representative of the anticipated sample in this study. 2.2.1. Chronic condition Individuals were asked to report whether they had specific diseases in the list on a yes/no format. The list of diseases was adopted from the Older Americans Resources and Services Questionnaire (OARS; Fillenbaum, 1988). It includes nine chronic diseases and conditions commonly found among older populations (e.g., arthritis, stroke, heart problems, diabetes, and cancer). The total number from the list was used for the analysis. 2.2.2. Disability Disability was assessed with 20 items from a composite measure of the Physical Activities of Daily Living (PADL; Fillenbaum, 1988), the Instrumental Activities of Daily Living (IADL; Fillenbaum,
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1988), Physical Performance Scale (Nagi, 1976), and Functional Health Scale (Rosow & Breslau, 1966). Items cover a wide range of activities, including eating, dressing, using the telephone, traveling, managing money, carrying a bag of groceries, and reaching out and above the head with the arms. Participants were asked to report whether they can perform each activity. The responses were coded as 0 (without help), 1 (with some help), or 2 (unable to do). Responses for individual items were summed for total scores. The possible range for disability was 0 (no disability) to 40 (severe disability). Reliability for the measure was shown to be satisfactory in the present sample (a=.84). 2.2.3. Sensory performance Individuals were asked to report their status of vision and hearing with help from assistive devices, such as glasses, contact lenses, and hearing aids, if they are needed. Responses were coded as blind or deaf (0), poor (1), fair (2), good (3), and excellent (4). 2.2.4. Number of sick days The number of sick days during the last 6 months was measured with five categories: none (1), less than a week (2), more than a week but less than a month (3), more than a month but less than 3 months (4), and more than 3 months (5). 2.2.5. Neuroticism Neuroticism was measured with 12 items from the NEO-Five Factor Inventory (NEO-FFI; Costa & McCrae, 1989). Participants were asked to indicate how they agreed with statements, such as ‘‘I rarely feel fearful or anxious’’ and ‘‘I often get angry at the way people treat me’’ using a five-point scale ranging from 0 (strongly disagree) to 4 (strongly agree). Responses were recoded and summed so that the higher total scores indicate higher neuroticism. Reliability was shown to be high in the present sample (a=.72). 2.2.6. Sense of mastery Sense of mastery was measured with the Pearlin and Schooler’s (1978) Mastery Scale. Respondents described their feelings about the seven items, such as ‘‘I cannot solve my problems’’ and ‘‘My future mostly depends on me,’’ on a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Responses to negatively worded items were reverse coded, and all responses were summed for the total score. Scores on the mastery scale range from 7 (low mastery) to 28 (high mastery). Reliability in the present sample was shown to be acceptable (a=.65). 2.2.7. Social network Networks with family and friends were measured with each three items from the Lubben’s Social Network Scale (Lubben, 1988). Measures included the number of relatives or friends seen at least once a month (0 to 9 or more), frequency of contact (less than monthly to daily), and the number of relatives or friends the participant felt close to (0 to 9 or more). Cronbach’s a was .70 for network with family and .62 for network with friends. 2.2.8. Self-perception of health Three items from the OARS (Fillenbaum, 1988) were selected to assess self-perception of health, including ‘‘How would you rate your overall health at the present time?’’ ‘‘How is your present health
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compared to five years ago?’’ and ‘‘How much do your health troubles stand in the way of your doing the things you want to do?’’ Total scores ranged from 0 (negative self-perception of health) to 7 (positive selfperception of health). Reliability for the scale based on the three items was shown to be acceptable (a=.63). 2.2.9. Self-perception of aging Self-perception of aging was measured with five items for the Attitude Toward Own Aging in the Philadelphia Geriatric Center Morale Scale (PGCMS; Lawton, 1975). The items include ‘‘Do things keep getting worse as you get older?’’ ‘‘Do you have as much pep as you had last year?’’ ‘‘Do you feel that as you get older you are less useful?’’ ‘‘As you get older, are things better than you thought?’’ and ‘‘Are you as happy now as you were when you were younger?’’ and they were asked with a yes/no format. Scores were recoded to indicate high scores more positive self-perceptions. The potential range for the scores was 5–10. Reliability for the scale in the present sample was satisfactory (a=.71). 2.2.10. Demographic variables Demographic information included age (in years), gender (0 = male, 1 = female), marital status (1 = unmarried, 2 = married), educational attainment (1 = < high school, 2 = z high school) and perceived economic status (1 = less than adequate, 2 = adequate, and 3 = more than adequate). 2.3. Analytic strategy To estimate predictability of physical and psychosocial factors on self-perception of health and aging, hierarchical regression analyses were conducted by entering independent blocks of predictors with (1) demographic variables, (2) physical health-related factors, and (3) psychosocial factors. For the regression model for self-perception of aging, self-perception of health was added as a potential predictor in the final step. Intercorrelations among study variables and variance inflation factors (VIF) were assessed to determine multicollinearity. In addition, the mediating effects of self-perception of health in the relationship between healthrelated factors and self-perception of aging were assessed following the Baron and Kenny (1986) criteria for mediation; (a) there is a significant association between independent variable and dependent variable, (b) there is a significant association between independent variable and presumed mediator, (c) there is a significant association between presumed mediator and dependent variable, and (d) a previously significant relationship between independent and dependent variables become nonsignificant or decreased when the mediator is controlled for. The mediating effects of self-perception of health were separately assessed with variables with significant direct effects.
3. Results 3.1. Descriptive information of the study variables As shown in Table 1, the average number of chronic conditions was 1.45 (S.D. = 1.14) and average score for functional disability was 1.95 (S.D. = 3.32). About 34% and 54% of the sample had either excellent or good status of vision and hearing, respectively. The average number of sick days was 1.73 (S.D. = 1.01). The mean scores for neuroticism, sense of mastery, network with family, and network with
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friends were 21.9 (S.D. = 5.52), 18.3 (S.D. = 2.36), 10.1 (S.D. = 3.06), and 10.6 (S.D. = 3.22), respectively. The mean scores for self-perception of health and aging were 2.87 (S.D. = 1.59) and 7.19 (S.D. = 1.67). 3.2. Correlations among study variables Bivariate correlation coefficients were assessed to understand underlying associations among study variables and are summarized in Table 2. More positive perception of aging and health was observed among those with younger age, fewer chronic conditions, less functional disability, better vision and hearing, and fewer sick days. Individuals with high neuroticism and low sense of mastery were more likely to have negative perception of aging and health. Networks with family and friends were positively associated with self-perception of aging but not with self-perception of health. Those who perceive their own health better were shown to have a more favorable perception of aging. 3.3. Regression models of self-perception of health and aging Table 3 summarizes the results of the hierarchical regression models of self-perception of health and aging. Demographic variables explained 11% of the variance of self-perception of health, with lower levels of education and economic status being significant predictors of more negative self-perception of health. Physical health-related factors explained an additional 23% of the variance. Those with more Table 2 Correlations among study variables (N = 291) 1 2
3
(1) Age – .01 .33*** (2) Chronic – .23*** condition (3) Functional – disability (4) Vision (5) Hearing (6). Number of sick days (7) Neuroticism (8) Mastery (9) Network with family (10) Network with friends (11) Self-perception of health (12) Self-perception of aging * P < .05. ** P < .01. *** P < .001.
4
5
6
7
8
9
10
11
12
.06 .11
.10 .05
.02 .20**
.09 .24***
.14* .20**
.27*** .14*
.15** .09
.16** .31***
.24*** .31***
.21***
.10
.23***
.19**
.33***
.23***
.18**
.37***
.22***
.43*** –
.16** .12* –
.26*** .08 .28***
.29*** .12* .24***
.11 .13* .11
.11 .12* .10
.34*** .16** .37***
.21*** .13* .28***
.53*** –
.17** .09 –
.11 .08 .56***
.37*** .41*** .09
.48*** .45*** .18**
.04
.13*
–
–
–
–
.48*** –
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Table 3 Regression models of self-perception of health and aging Predictor
Self-perception of health 2
b Age Gender Marital status Education Perceived economic status Chronic condition Functional disability Vision Hearing Number of sick days Neuroticism Mastery Network with family Network with friends Self-perception of health
.04 .01 .04 .23** .14* .18** .16** .22*** .01 .22*** .08 .17** .05 .07
Self-perception of aging 2
R
DR
.11***
.11***
.34***
.23***
.39***
.05**
b .11 .12 .01 .21** .22*** .29*** .13* .16** .03 .18** .23*** .22*** .00 .01 .23***
R2
DR2
.15***
.15***
.32***
.17***
.44***
.12***
.47***
.03***
* P < .05. ** P < .01. *** P < .001.
chronic conditions, more functional disability, poorer vision and greater numbers of sick days were found to perceive their health status more negatively. After controlling for background and health-related variables, psychosocial factors explained an additional 5% of the variance. Individuals with lower sense of mastery were likely to have negative perception of health. A total of 39% of variance of selfperception of health was accounted by the estimated model. In the model of self-perception of aging, predictors were found to function in the similar way with those of self-perception of health. More negative perception of aging was observed among older individuals with lower educational and economic status, more chronic conditions, greater disability, poorer vision, and greater numbers of sick days. In addition, psychosocial factors contributed 12% of the variance, identifying higher neuroticism and lower sense of mastery as significant predictors for negative perception of aging. In the final step, self-perception of health was entered as a predictor and accounted for additional 3% of the variance, resulting in a total of 47% of variance explained by the estimated model. Negative perception of health was a significant predictor of unfavorable perception of aging after controlling for health-related and psychosocial factors. 3.4. Mediating effects of self-perception of health Employing Baron and Kenny’s criteria, the mediating effects of self-perception of health was tested in the associations between health-related factors and self-perception of aging. Analyses were conducted after controlling for the effects of age, gender, marital status, education, and perceived economic status. The independent paths among independent variables (chronic condition, functional disability, vision, and the number of sick days), presumed mediator (self-perception of health), and dependent variable (selfperception of aging) were significant. When self-perception of health was controlled, the regression
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Fig. 1. Mediating effects of self-perception of health between health-related factors and self-perception of aging. The numbers in parentheses indicate the indirect effect of independent variables on self-perception of aging after controlling for the effects of self-perception of health. *P < .05, **P < .01, ***P < .001.
coefficients for each health-related factor on self-perception of aging either became nonsignificant or decreased. The direct effects of chronic condition on self-perception of aging (b = .31, P < .001) decreased (b = .21, P < .01) with a control for self-perception of health. The predictability of functional disability (b = .12, P < .05) and vision (b=.17, P < .01) became nonsignificant (b = .00, P>.05 for functional disability; b=.04, P>.05 for vision). The effect of the number of sick days (b = .25, P < .001) also decreased (b = 12, P < .05) after controlling for self-perception of health (see Fig. 1).
4. Discussion Given the importance of subjective perception over objective conditions in old age, the present study assessed the determinants of self-perception of aging and health and the connections between them using
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291 community-dwelling older adults in Korea. Findings from the analyses provided supportive evidence for the proposed hypotheses. In the regression models of self-perception of aging and health, lower levels of education and economic status and various health problems, such as more chronic conditions, greater disability, poorer vision, and greater numbers of sick days, were found to be common predictors of negative selfperceptions. The finding is consistent with previous research showing more negative outcomes in health and well-being among individuals with lower social class (Lachman & Weaver, 1998) and poorer physical health conditions (Borawski et al., 1996; Idler & Benyamini, 1997). It seems that the lack of socioeconomic resources and the existence of health problems make older individuals perceive their own aging and health status more negatively. After controlling for the effects of sociodemographic and health-related factors, psychosocial attributes accounted for a significant amount of variance of self-perception of aging and health. For self-perception of health, sense of mastery was found to be a significant factor, and for self-perception of aging, neuroticism was significant along with sense of mastery. Independent of health conditions, older individuals with a higher sense of mastery were likely to perceive their own health better. Negative perception of aging was found among those with high neuroticism and low sense of mastery. The findings indicate that psychological characteristics play an important role in shaping the ways of subjective perceptions and evaluations. The effects of social networks were shown to be nonsignificant mostly due to the small variance in the scales and confounding with psychological factors. The effect of neuroticism on self-perception of aging is consistent with studies showing negative appraisals of situations among those with high neuroticism (Watson & Pennebaker, 1989). Older individuals with high degrees of neuroticism tend to pay more attention to negative aspects of life and perceive situations as more stressful or threatening. Consequently, they may be more prone to negative changes and evaluate their health conditions and aging process in a more negative manner. The finding suggests that the personality trait of neuroticism is not only associated with negative perception of aging but also may lead to withdrawal from the society and hinder positive adaptation in aging. The present study highlighted the role of sense of mastery showing its beneficial effects on both selfperception of aging and health. Previous studies have shown that individuals with a strong sense of mastery are more likely to have positive attitudes and emotional states (Lachman & Weaver, 1998; Roberts et al., 1994). The mechanism of mastery and positive self-evaluation may not only be involved with subjective perception but also with behavioral aspects. That is, feelings in control may enable individuals to be actively engaged in health-promoting behaviors, such as nonsmoking and exercise, and in turn derive a positive perception of their own aging and health (Menec & Chipperfield, 1997). Following Baron and Kenny’s criteria, self-perception of health was evidenced to serve as a mediator in the connections between health-related factors and self-perception of aging. The predictability of chronic conditions, functional disability, vision, and the number of sick days, whose direct effects on self-perception of aging were significant, declined when controlling for self-perception of health. The existence of health problems seems to make older individuals perceive their own health status poorer and in turn lead to a more negative perception of aging. Thus, self-perception of health is an intervening step between those health-related factors and self-perception of aging. The finding implies that adverse effects of health problems on perception of aging can be reduced and that positive attitude toward aging can be reinforced by having an optimistic view of health. Linking our findings to the HBM, which advocates the connections between subjective perceptions and healthful behaviors, and other literature showing beneficial roles of positive perception in morbidity and mortality (Levy et al., 2002), special
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attention is needed to find strategies to preserve and promote positive outlooks among older populations. Some limitations to the present study need to be noted. Because the sample in the study is nonrepresentative, generalizability of the finding is limited. In addition, due to a cross-sectional design, caution must be exercised in drawing causal inference from the data. Another limitation is that all measures employed in the present study were self-reports. The use of objective testing for health-related variables would add strength to the study by contrasting the objective health conditions and subjective perceptions. In addition, future studies need to include various aspects of social resources, including the actual transaction of support exchange and the quality of or satisfaction with support along with the existence of social networks. Despite the aforementioned limitations, the present study has implications for research and practice. Given the importance of psychological factors and subjective perceptions, interventions need to focus on these factors and utilize them. Modification of negative perception of, or attitude toward, aging and health may facilitate successful adaptation in old age and maximize positive physical and mental health outcomes. Indeed, empirical evidence was found that with the self-stereotype of aging interventions tailored to alter negative perceptions and activate positive judgments about self, older individuals’ cognitive performance was considerably improved (Levy, 1996). Along with the individual level of interventions, efforts are needed to modify negative stereotypes of aging and the aged in the societal level. Acknowledgements This research was supported by Issues (SPSSI). Additional support The authors would like to thank possible. Special appreciation goes data entry task.
the grant from the Society for the Psychological Study of Social was provided by the Gerontology Center, University of Georgia. all study participants and interviewers who made this research to Emily Bower at the UGA Gerontology Center who conducted
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