Factors Related to Self-Confidence to Live Alone in Community-Dwelling Older Adults: A Cross-Sectional Study

The number of older adults living alone has risen and is expected to increase, particularly in Western and developed countries, including South Korea [1, 2]. Notably, these individuals are a vulnerable group that can face serious challenges to successfully ageing in place (AIP) because they tend to be socially isolated, feel lonelier [3], have poor health status [4], and lower life satisfaction [5]. Nevertheless, a majority of them strongly prefer to live in their own home, even in cases of age-related issues in physical movement, regardless of their cultural background [6, 7].

AIP has emerged as a key concept in the field of gerontology, reflecting an increase in the ageing population, and their living preferences [8]. It is defined as ‘meeting the desire and ability of people, through the provision of appropriate services and assistance, to remain living relatively independently in the community in his or her current home or an appropriate level of housing’ [9]. As many researchers have asserted a positive impact on self-identity, autonomy, and well-being, AIP has become an important strategy to overcome the challenges that we encounter [10, 11]. However, recent studies have pointed out that all stakeholders need to be alert about the ‘stuck-in-place’ issues that accompany living with a shortage of financial, physical, and social resources necessary to live independently [12].

For older adults living in the community, independent living means to live in their own homes with a sense of control and freedom of decision and movement [13]. Sense of control has been considered a ‘status’ goal in many studies [14]. However, as successful AIP is an eventual process of balancing and adapting to both personal and environmental changes in the way of ageing [15], previous concepts such as sense of control are limited to reflecting dynamic interactions between a person and their environment. A previous qualitative study focussing on the concept of AIP emphasised that it is a process rather than a constant state, and studied the perception of one’s ability as a feature of a successful AIP [16]. In addition, previous qualitative studies have demonstrated that a salient attribute of a person ageing successfully is their faith and trust to live independently and adapting to any circumstances even with physical discomfort; this can be defined as self-confidence [17‐19]. Therefore, successful AIP can be considered as ageing with confidence in one’s ability to live independently with a sense of control [17]. However, self-confidence to live alone, as a pioneering concept for AIP, has not yet been explored. Thus, we need to comprehensively examine the factors that influence this, along with the accumulated knowledge of factors for AIP and independent living.

According to previous studies, regarding demographic characteristics, women and old people (≥75 years old) are less likely to AIP [17], while having religion, a higher income, independent earning, higher educational level, and satisfaction with the condition of housing, facilitates AIP [6, 20]. Many previous studies related to residential spaces have been concerned with ‘age-friendly modification’ such as basic housing facilities [21]. In fact, the World Health Organization [22] reported the prevalence of indoor dampness estimated at 10–50% worldwide. In addition, 20–30% of the older adults who were at risk of poverty in Europe, reported experiencing leaky roofs, dampness, and broken windows or rotten frames, as was the case in South Korea [23, 24]. Thus, it is necessary to explore the effect of mould exposure and wall cracks at home on individuals’ self-confidence to live alone.

Daily living difficulties like health-related characteristics, disabilities, and other instrumental activities hinder independence negatively and affect independent living and AIP [25, 26]. In addition, those with more chronic conditions and depressive symptoms are less likely to live independently [6, 26]. According to a qualitative study that explored the experience of AIP by interviewing older women with physical discomfort living alone, ‘falling’ was one of the biggest challenges they faced in daily living [19]. Due to a decline in physical, sensory, and cognitive functions, older adults experience the highest risk of fall-related deaths or severe injuries [27], and approximately 33.7% injured by falls, visit the emergency department (ED) [28]. In particular, older adults who live alone experience helplessness because there is no one to help them in the event of a fall, which leads to feelings of fear and lack of safety [29]. Despite the emphasis on health-related safety for AIP, it has rarely been addressed to the best of our knowledge [30].

Concerning social characteristics, participation in social activities [19, 21]; interaction with friends, neighbours, and family [21]; and social support, positively affects AIP [17]. However, loneliness affects AIP negatively in older adults [17]. Even though the importance of community-based services has been emphasised [10], a longitudinal study demonstrated that older adults who used community-based services were less likely to age in place [6]. Thus, the effect of public service on older adults living alone needs to be further explored.

Inferring from previous studies, some general characteristics (religion, income, educational level, condition of house, participation in economic activity), social networks, and social support can promote self-confidence to live alone, whereas other general characteristics (female, old age), decreased function (disability, IADL), physical condition (number of comorbidities), mental health (depressive symptoms), and loneliness can hinder it. Further exploration is needed with regard to wall cracks and mould exposure at home, falls, ED visits, and public service utilisation.

Therefore, it is necessary to identify the factors influencing the self-confidence to live alone, comprehensively, with respect to general, health-related, and social characteristics.

In the present study, mould exposure at home, IADL, depression, ED visits, interactions with family members, public service utilisation, social support, and loneliness were significant predictive factors for self-confidence in living alone.

The concept of self-confidence to live alone was introduced for the first time to promote successful AIP among older adults living alone, and the influencing factors were identified by comprehensively considering the characteristics of ageing. Self-confidence is a familiar and handy indicator that can consider various statuses, coping skills, competence, and knowledge [18]. Therefore, the findings of this study may be evidence that self-confidence to live alone could be a new practical index in the field of health and ageing to screen for successful AIP among older adults living alone.

The average self-confidence to live alone was 6.59 points, slightly higher than the medium score of 5. While refraining from drawing hasty conclusions, it is possible to speculate the reasons for the current findings based on a previous study demonstrating that the proportion of vulnerable groups who responded as ‘very confident to live in place’ was higher than that of the non-vulnerable group [45]. Older adults living alone are a relatively vulnerable residential group among all older adults. According to a prospective study, although baseline states of mental health and physical function were lower in older women living alone than in those who live with a spouse, older women living alone were not at risk for declining in functional status longitudinally [46]. It can be assumed that as older adults living alone try to adapt and balance changes by themselves (e.g. functional, social, and environmental changes), they might be able to perceive their potential power affirming control over their own life, which is more important than actualising it for successful AIP [16].

Interaction with family members, public service utilisation, social support, and loneliness were predictive factors in the aspect of social characteristics. Participants in the current study were more isolated from family members than those in a previous study conducted in the United States (mean age = 67 years). The results originated from the properties of single living. Nevertheless, it has several implications in terms of familial interactions being an important factor to instil confidence to live alone among these older adults. First, consistent with a previous study [21], it was identified that family is still an essential social network for healthy AIP, despite older adults living alone being significantly more isolated from family than those living with others [3]. This finding strengthens the importance of familial networks for older adults living alone.

Similarly, a second implication is the health providers’ and policy makers’ need to pay attention to familial networks for solitary living older adults to promote social networks. Despite the importance of familial connectedness, according to a previous study that reviewed interventions for social connectedness, many studies have focussed on improving contacts with groups or individuals rather than with family members (e.g. peer-group support or community-based programmes) [47]. Research evidence shows that technology-assisted interventions improve social connectedness and belongingness [48], and technological strategies are helpful in promoting familial networks for older adults living alone.

Interestingly, those who use public services showed lower self-confidence to live alone in the current study. Contrary to our results, a generous utilisation of welfare and public services was positively associated with both living alone and actualisation of AIP [6, 25]. This difference could be due to shortcomings in the quantity and quality of services, as inferred from previous studies. Solitary living older adults stated the need for public services to live independently [19] but mentioned limited time [19] and provider-oriented services as disadvantages [49].

In addition, this study shows that social support is an important factor in instilling self-confidence for living alone. This can be linked to the results of existing studies that show social support as essential to maintain independent AIP among older adults living alone. In previous qualitative studies, older adults living alone emphasised that informal social supports were crucial sources of emotional as well as instrumental support such as meal preparation, housework, and hospital visits [17, 19]. In particular, these individuals had significantly lower social support and daily housework support when they were sick than those living with others [50]. Therefore, strengthening a community-based social support system can improve self-confidence to live alone and further enhance independent living for older adults living alone. However, one limitation of this cross-sectional research is that this association must be further explored in prospective studies. The negative relationship between loneliness and self-confidence to live alone found in this study is consistent with a previous study that revealed a negative correlation between loneliness and self-esteem mediated by positive coping strategies [51]. In particular, according to a previous study, older adults living alone experienced more emotional loneliness than those living with others [3]. Therefore, reducing the emotional loneliness of older adults living alone and improving strategies for positive coping skills can increase confidence in living alone and can lead to successful AIP.

With respect to health-related factors, IADL and depression were important for self-confidence to live alone as demonstrated in many studies. IADL and depression are factors that share several important aspects of independent living for older adults. According to a previous study on these individuals, the declining capability of IADL increases their difficulties in daily living, such as household affairs, shopping, gardening, and household maintenance, which makes it harder for them to live independently and increases feelings of depression [52, 53]. In other aspects, difficulties in IADL hinder social activities, making older adults depressed, and eventually impairing their sense of mastery over their own life [54]. Therefore, for older adults to live independently, it is necessary to examine those who have difficulties with IADL, to identify domains requiring support in the IADL, and to establish an easily accessible social daily living assistance system. In addition, in-depth evaluation of the causes of depression is required for the elderly living alone with low confidence in AIP, and tailored interventions based on that can lead to successful AIP.

History of ED visits was a significant factor in lowering self-confidence to live alone. Most older adults living alone require emergency support services, especially for safety [55]. This means that people living alone must confront and handle any life-threatening situation without immediate help, which may make them anxious. This experience of helplessness in a life crisis situation can negatively affect self-confidence in living alone and can even lead to dependency upon others. Therefore, reducing the incidence of emergency situations among older adults living alone could increase their self-confidence to live alone.

Finally, exposure to indoor microbial pollutants is a well-known health hazard that causes many symptoms and diseases [23]. It can be assumed that long-term exposure to such an adverse environment leads to chronic pain and decline in health, resulting in poor quality of life and, consequently, reducing the confidence to live alone. Therefore, periodic inspection of the residential conditions of older adults living alone is necessary, alongside health education on the importance of home management methods.

Despite these findings, the current study has some limitations. First, since this study was the first to measure the confidence to live alone, the concept was defined as evidenced in previous studies related to AIP, independent living, and healthy and successful ageing. For a more consistent implementation of the concept in the field, further conceptual analysis is necessary. Second, self-confidence to live alone was measured using a simple and convenient NRS scale considering the characteristics of older adults, however, it is not a structured tool. Thus, future studies need to develop a standardised measurement and present clinimetric properties. Third, this study comprehensively encompasses many variables based on previous studies, but there were limits to exploring related factors in-depth due to secondary data analysis. Further research needs to explore factors with their constituent domains and their pathways. Fourth, though the original data were collected by trained assistants, interpretation of the results should be done with caution as this study could potentially be impacted by self-report bias.

Self-confidence to live alone—a new and practical indicator for screening successful AIP among older adults living alone—was slightly higher than the mean value of the scale. To increase self-confidence to live alone, intervention measures must focus on improving interactions with family members, public service utilisation, social support, loneliness, IADL, depression, ED visits, and mould exposure at home. The findings have scope for fostering independent living and successful AIP among older adults living alone.