Chapter 4

DISCUSSION & INTERPRETATION

Analysis of the obtained results indicated significant positive correlation between

helping attitude and the Quality of Life in older living with their families. However, the

correlation between helping attitude and the other dimensions of psychological well-being

(viz., autonomy, environmental mastery, personal growth, positive relations with others and

self-acceptance) were not found to be significant in older living with their families.

Moreover, in case of older living in old age homes, the correlations between helping attitude

and the six dimensions of psychological well-being were not found to be significant. The

significant positive correlation between helping attitude and the Quality of Life in older

living with their families may be an indication of their underlying sense of belongingness and

the motivation to do something for their family members. According to Reker (2000),

purpose in life may emerge from enduring values or ideals, humanistic concerns, helping

behaviour, relationship with nature, traditions and culture, personal relationships, creative

activities, leisure activities, financial security, and meeting basic needs in individuals.

Helping behaviours, such as volunteer work, act like a roleidentity which gives a sense of

meaning and purpose in life, which in turn may enhance the wellbeing of an individual.

The present study also revealed significant differences between older living with their

families and those living in old age homes with respect to the dimensions of environmental

mastery and self-acceptance. In other words, the older living with their families scored higher

on the dimensions of environmental mastery and selfacceptance than the older living in old

age homes. However, no significant differences were observed between the two groups with

respect to the dimensions of helping attitude, autonomy, personal growth, positive relations

with others and purpose in life. The higher scores of older living with their families on the

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dimension of environmental mastery may be accounted for by the fact that these women have

been living in a known environment where they are reasonably well adjusted. They live in a

place which has been their „home‟ for many years.

Hence, these women are able to select or generate, with relative ease, environments

suited to their needs. Likewise, the older living with their families scored higher on the

dimension of self-acceptance. As these women live with their loved ones, they enjoy a feeling

of belongingness. Also, more often than not, grandchildren are a source of love and happiness

that in turn fosters the older people sense of worthiness and acceptance of self (Ryff& Essex,

1991). Moreover, living with their children and grandchildren, and being able to be a part of

their happiness, probably enhances their acceptance of their past life. Thus, older who live

with their families tend to have overall positive attitudes toward themselves.

Broadly speaking, this study tends to indicate that irrespective of whether they live

with their families or in old age homes, the older have secured reasonably high scores on

helping attitude and the six dimensions of psychological well-being. Schwartz et al. (2003)

have found that older females are more likely to help people when compared to other

individuals. Researchers have determined that as people grow older, they tend to have more

mature goals which in turn lead to greater well-being. This is in accordance with the findings

of Ryff and her colleagues that purpose, autonomy, growth, and meaning play an important

role in the older adults‟ not only adapting but also being able to thrive in later life and also in

their well-being. Though old age is usually viewed as a period of decline and degeneration

(Herzog et al., 1982; Pfeiffer, 1977), the present study has shown that older adults tend to

exhibit prosocial behaviour (helping) and also enjoy a high level of psychological well-being,

regardless of where they live. While there are differences in helping attitude and

psychological well-being of older living with their families and those living in old age homes,

the differences are not enough to determine which is better for the well-being of older , living

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with family or living in old age homes, as other factors such as socio-economic status, locus

of control, quality of life, etc. may also affect the well-being of individuals.

Regarding restrictions experienced in very old age, there were a variety of them. Most

of the restrictions experienced could not have been controlled by the older individual, thus,

they occurred independent of the individual’s influence. These include the death of loved

ones, declining health of one’s own and of the network members, the ability to move around,

retirement, one’s own age, relatives and friends living far away and the busy lives of

relatives. Some of the restrictions were also related to the feelings of loneliness. Although

individuals themselves can, to some extent, influence their own health and ability to function,

catching an illness, in the end, occurs rather arbitrarily. Therefore, the only restrictions that

clearly could have been influenced by the individual were one’s own self-centeredness and

losing interest in social life.

These results indicate that, in very old age, restrictions to social relationships are

manifold, and most often the older individuals themselves cannot influence, whether the

restrictions occur or not. It seems, however, that although the restrictions are experienced as

unfortunate, the Old Age people also find their restrictions, such as the death of loved ones,

as an understandable part of their lives as oldest old persons. Therefore, the Old Age people

in this study, as oldest old persons in other studies, seem to accept the realities of their lives.

Weakening or restricted social convoy seems to be the reality for the Old Age people

in this study. As was the case among the Old Age people in the study of Neville et al. (2016),

also the Old Age people in this study had experienced changes that influenced their social

networks, death of loved ones and health issues being the major obstacles for maintaining

social relationships. As the Old Age people in this study also felt that their own age restricts

them from having social relationships and that establishing relationships with younger

persons might not be easy, it can be argued, that weakening of the social convoy is, to some

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extent, inevitable for Old Age people. Difficulties in finding a suitable and meaningful friend

have been experienced by other older persons as well. Furthermore, weakening social convoy

through death of loved ones and due to moving to another area away from old friends, have

been found causing loneliness to elderly persons as was found in this study as well.

Furthermore, all of the other restrictions mentioned by the Old Age people have also potential

to make an individual susceptible to loneliness.

Regarding the significance of social relationships for very old individuals, three major

categories were created: “company”, “help” and “source of joy, grief and lifelong lessons”.

Old Age people were provided with company by their social networks, formed by children,

grandchildren, other relatives and friends. Having social contact with children and

grandchildren was commonly described in the interviews and other relatives and friends were

also met, but not that often. The meetings most often happened in the home of the

nonagenarian. Neighbors were an important social contact because they were described being

always present. For many participants, telephone was an important way to stay connected

with friends and relatives who lived far away. These findings indicate that the social

engagement of Old Age people mostly happens in the place where the nonagenarian lives: in

their home and neighborhood. Those living farther away were brought closer to the

nonagenarian by telephone calls. Nevertheless, Old Age people stayed socially connected

also outside their home and neighborhood by taking part in association activities.

Home has been found to be an important place for the very old and an important place to

meet relatives and friends (Fänge & Ivanov, 2008). Keeping company and staying connected

with family and friends, both face-to-face and via telephone, was found as an important part

of the social lives of the very old also in the study of Neville et al. (2016). They also found,

that for some participants, telephone had become more important means to stay socially

connected over time. Telephone calls were also found to be a significant predictor of

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valuation of life in very old age (Jopp, Rott & Oswald, 2008). The suggestion of technology

playing a central role in ensuring the oldest old to stay socially connected (Neville et al.,

2016), is supported by the findings of this study, since the Old Age people in this study often

described using the telephone in order to be in contact with family and friends, and, for some,

telephone was the only way to be in contact with social network members.

Help was a common topic in the interviews and informal social relationships were an

important source of help for Old Age people. Mostly children and grandchildren were

described helping the participant with everyday life chores, such as cooking and cleaning.

Neighbors mostly helped with outdoor chores. Old Age people also described that their

family and their neighbors help them by taking care of them in general, that is, helping with

everything needed or calling or visiting just to make sure everything is all right. In addition,

Old Age people gave help to others, mostly friends that had poorer health than they had

themselves, and helping others was expressed to be important and a way to feel necessary.

Experiences of caring for spouse were also described and the importance of taking care of the

spouse at home, even at the expense of one’s own well-being, was brought out. Although

receiving help was commonly described, also the importance, or for some, the necessity, of

being independent was brought forward.

Considering the limitations to one’s health and ability to function experienced in very old age

(Helminen et al., 2012; Jylhä, Enroth & Luukkaala, 2013), it is no surprise, that getting help

is commonly discussed topic among Old Age people. The importance of informal support for

the oldest old was also found in the study of Boerner et al. (2016) where children were found

to most often provide help for the centenarians. Moreover, in the same study, participants

mentioned receiving help with chores related to everyday life, but also with everything they

might need help with, as was the case in this study as well. The importance of the help of

neighbors for Old Age people with outdoor chores, but also with everything needed, was

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found also in the study of Neville et al. (2016). Not only describing concrete help, but also

helping in the form of “taking care” and receiving help with everything one might need help

with, indicates that, for the oldest old, it is not only important to receive help with major,

easily identifiable, tasks, such as cleaning and outdoor chores, but that there is also someone

to help with all of the little problems one might encounter in life.

Similarly to findings of van Tilburg (1998) giving help was not as common in the interviews

as getting help. In addition, relatives seem to play a more important role, at least in regards to

instrumental support, than friends in the lives of the Old Age people (van Tilburg, 1998).

Nevertheless, Old Age people also regarded helping others important in their lives and felt

necessary when they were able to give help. Therefore, it can be argued, that the reciprocity

of relationships is important. Thus, for the oldest old individuals, it is not only important to

receive help, but also to be able to give help.

In addition, although Old Age people told about receiving help for their tasks, they

also brought out the importance of being independent and did not want to be patronized.

Independence was also experienced as an important factor in the successful ageing of Old

Age people (Nosraty et al., 2015). Furthermore, staying independent and not being a burden

was found to be important for oldest old men. For them, this wish had caused feelings of

loneliness. (Ness et al., 2014b.) Old Age people in this study did not, however, talk about

independence in this context. Some of the Old Age people also had to be independent,

because there was no-one to help. Thus, independence was not always a choice, but a

necessity. It is also noteworthy, that the dependencies in the lives of older persons, such as

dependence on help of others, may actually enable independence, for example, by enabling

the person to still live in one’s own home in the fourth age (Tanner, 2016).

Social relations can bring joy and happiness, but also grief and disappointment into one’s life.

This was the case of the social relationships of Old Age people in this study as well. The

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participants described especially their grandchildren bringing joy and enrichment to their

lives. In addition friends and neighbors were described as a source of happiness in one’s life.

Death and illness of a child and disappointment caused by own child caused grief to Old Age

people. Some also felt sad about their relatives not remembering them and keeping in contact.

Other people’s wrongdoings towards the participants and mistreatment in childhood were

also described. On the other hand, also the positive impact of childhood families for one’s life

was brought out in the interviews.

Older individuals have been found to describe various positive aspects related to being a

grandparent and they appreciate their relationships with their grandchildren (Mansson, 2016).

Moreover, troubling childhood experiences and unpleasant issues related to social

relationships, such as loss of a child and troubles with a child, have been found to cause

loneliness to older persons (Tiilikainen & Seppänen, 2017). As the life-course perspective

(Dannefer & Settersten, 2010) suggests, life experiences of an individual strongly affect one’s

present life. This could be recognized in this study, since the Old Age people’ current lives

were connected to the experiences they had had in the past. As the participants in this study

explained, their way of life, life choices and attitude towards life had been influenced by

social relationships in their past, reaching as far as their childhood. Therefore, the findings

indicate that significant social relationships are not only those the person has in the exact

moment, but also those that have strongly influenced the person during their life-course.

Naturally, the influence can be both positive and negative as was found in this study.

Lastly, when considering aspects related to social relationships that are valued by Old

Age people, based on the findings of this study, it is clear that Old Age people value having

social relationships and not being alone. The importance of the family – one’s own children,

grandchildren and spouse – and their success and well-being was highlighted, as was having

a good and peaceful relationship with one’s spouse. In addition, having friends was

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important, but also having social relationships in the first place. Indeed, being social,

meaning, being surrounded by people and talking to people, was deemed important and, on

the contrary, being alone and lonely was experienced as undesirable. Old Age people valued

harmonious relationships, that is, getting along with others and not having arguments. In

addition, and most likely in connection to the appreciation of harmoniousness, also accepting

and acknowledging others was described as being important. Loneliness and being alone

were undesirable, although being alone did not always mean being lonely. Table 4

summarizes the findings of valued aspects of social relationships in very old age.

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4.2 Theoretical Framework

Theoretical frameworks prove their validity by guiding and structuring research, and

it should be emphasized that the PoW framework—even though the framework was not

subjected to test in a strict sense—provided a very fruitful base focusing on the different

objectives and tasks of the project. As a “meta model” it gave a systematic place to issues of

crQoL as “final outcome” of care, and to issues of professional care and care management as

“intermediate” outcomes (or outputs), as well as to practical development of instruments and

tools. Our starting point was an understanding of QoL as a multi-dimensional concept, but the

question was whether we should rely on some general model of QoL, or develop specific

models of QoL for different client groups. Along the lines of previous research, our own

early explorations specified nine conditions and input factors important for the subjective

QoL in old age, namely: demographic factors; socio-economic factors; physical-functional

competence and subjective need of help; psychological well-being; social wellbeing,

networks and participation; life style and leisure activities; housing and living environment;

traumatic life events and acute illnesses; and care, including satisfaction with care (see

Chapter 1, Fig. 3). Based on this, we assumed that also for care-dependent old people, the

four dimensions of QoL as reflected in the WHOQOL-measure would apply, that is, we

assumed the basic dimensions to be the same for all groups. However, we also assumed that

within these common dimensions, the variables would vary, reflecting the circumstances and

special situations of being dependent on external help, and depending on whether the person

is living at home or in an institution.

To investigate the validity of this assumption, the QoL model by Lawton (1983, 1991)

proved to be adequate theoretical starting point to capture the situation of frail older persons

receiving care, and the special circumstances of cognitive impairment due to dementia.

Lawton proposed four basic dimensions of life quality (functional competence,

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environmental resources, life satisfaction, psychological well-being), which correspond quite

well with the dimensions of the QoL model of the WHO (physical, psychological, social,

environmental; see Skevington, Lotfy, O’Connell, & The WHOQOL Group, 2004). These

again were comparable with the “four qualities of life” of Veenhoven (2000), and could be

generalized to develop a corresponding four-dimensional framework for the QoC and care

management (see Chapters 4 and 6). To achieve this, the model had to be modified and

elaborated by a more consistent interpretation grounded on social system theory, but the

approach to search for a generic model to be adapted to specific groups and care settings was

generally supported by the fact that “key indicators” coul be organized in this four-

dimensional model of crQoL, and that only more specific indicators distinguished between

groups and care settings (in homecare and institutional care).

The theoretical discussions had to take up a number of issues, which plague the

concept of QoL, and we suggest avenues of solving them in a comprehensive model of care-

related QoL (crQoL), which we differentiated into three sub-models, each mirroring the QoL

in care-dependent and frail old people from different angles: a structural model, a production

model and a normative model. One issue is also the distinction of subjective and objective

QoL, frequently considered of basic theoretical importance and characterizing distinct

approaches. Although the distinction of subjective and objective aspects of QoL is certainly

relevant, we suggest treating this distinction primarily as a methodological issue concerning

access to information by way of self-reports (interviews) or professional assessments

including behavioral observations. Subjective QoL is, then, seen as a “core” within a more

comprehensive concept of QoL, which integrates, moreover, emotions giving them a role in

affective regulation and as indicators of QoL based on observation, again structured in the

four dimensions of the model.

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4.3 Recommendations

A. Future studies can be conducted with a larger sample and involve other factors which

affect well-being such as locus of control, attributional style, hope, quality of life, and

the like.

B. Since the present study includes only, a study can also be conducted on the helping

attitude and psychological well-being of older females whose spouses are alive and

also on the helping attitude and psychological well-being of older men.

C. Further studies can be conducted to determine if helping attitude and psychological

wellbeing varies between older men and older women.

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