Association between self-esteem and health-related quality of life among elderly rural community, Northern Thailand

Abstract This study was aimed to investigate the association between self-esteem and health-related quality of life (HRQoL) among elderly rural community, Northern Thailand. A cross-sectional study was conducted with 299 elderly persons in the community in Phayao Province, Northern Thailand. The data were collected using the World Health Organization Quality of Life BREF—Thai (WHOQOL-BREF) questionnaires and the Rosenberg self-esteem questionnaires. The data were analyzed using descriptive statistics, multiple linear regression analysis, and correlation. The results showed that the mean age of the sample was 68.7 ± 7.7 years (mean ± SD). The study found that HRQOL in the elderly was at a moderate level (61.5%), while 58.5% of the participants exhibited low levels of self-esteem. Multiple linear regression analysis showed that an increase self-esteem was statistically significant with an increase HRQOL after adjustment for age, gender, monthly income, marital status, educational level, occupation, and congenital disease (B = 1.654, SE = 0.150, p < 0.001). In conclusion, the study findings suggest a strong correlation between self-esteem and HRQOL among the elderly population. Having a positive self-perception and feelings of self-value can improve an individual’s overall health and well-being during their later years.


Introduction
The global aging population is growing rapidly, and Thailand has been classified as an aging society since 2005 (Foundation of Thai Gerontology Research and Development Institute TGRI, 2021).As elderly, they become more vulnerable to illness and may require greater levels of support (Marengoni et al., 2011).Furthermore, aging can lead to changes in an individual's biology, psychology, emotions, and social functioning (Charles & Carstensen, 2010;Dziechciaz & Filip, 2014).These changes may increase the likelihood of developing underlying health conditions such as diabetes, obesity, high blood pressure, musculoskeletal disorders, dementia, and hearing impairments (Faulkner et al., 2007;Marengoni et al., 2011;Shang et al., 2022).
Deterioration of physiological or biological changes and imbalances of body systems causes various diseases in the elderly which affects the mind and emotions of the elderly (Dziechciaz & Filip, 2014;Galkin et al., 2022).As a result, the ability to do various activities affects the mind and mood of the elderly, feeling inferior, lonely, sad, indifferent (Galkin et al., 2022).It is also the age where the loss of a loved one, occupation, role, careers, and income affects the mind and emotions of the elderly as well.According to the results of the survey on the mental health of the elderly, mental changes in the elderly tend to be more severe statistics of suicide success are more which is a problem of mental change (Banerjee et al., 2021;Reynolds et al., 2022).
The self-esteem of the elderly is a self-assessment of their capabilities and how they perceive others' assessments based on the actions and behaviors displayed by others towards them (Potard, 2017).This self-assessment ultimately becomes a reflection of their preferences and opinions, leading to a sense of self-esteem and self-acceptance.Notably, elderly individuals often experience a decrease in self-satisfaction and may have low self-esteem (Chu & Koo, 2023;Szcześniak et al., 2020).
Self-esteem in the elderly is essentially a self-assessment regarding their competence and the recognition they receive from others through actions or behaviors directed towards them (Reitzes & Mutran, 2006;Van Osch et al., 2020).Two primary factors influence self-esteem: internal and external.Internal factors affecting self-esteem encompass physical characteristics such as height, weight, personality, strength, body shape, and general abilities.Additionally, mood disorders and other issues can impact self-esteem.On the other hand, external factors tied to one's environment, including social status, the composition of their social circle, and their relationships with family members, also play a significant role in shaping one's perception of self-worth (Campbell et al., 2010;Van Osch et al., 2020).
Studies have shown that self-esteem levels start declining between the ages of 60 and 70 (Orth et al., 2018;Robins & Trzesniewski, 2005;Robins et al., 2002).The Elderly's self-esteem declines in proportion to the changes in their lives, such as the passing of loved ones, poor physical and cognitive health, and a seeming loss of control.In addition, self-esteem is also considered an important indicator of mental health (Mann et al., 2004).A positive self-assessment reflects good mental health, and getting good care makes the elderly more confident that this will affect adaptation to changes in various areas (Reitzes & Mutran, 2006;Šare et al., 2021).
HRQOL is a comprehensive concept that encompasses both positive and negative aspects of an individual's life, includes subjective evaluations of physical, psychological, social, and functional aspects of health (Centers for Disease Control and Prevention CDC, 2018).Measuring HRQOL is important in supplementing public health measures of morbidity and mortality, particularly among the elderly population (CDC, 2018;Dumas et al., 2020).Research is essential to identify key factors contributing to health problems in this age group, which can significantly impact their quality of life.There are several factors associated with the HRQOL of the elderly, including socioeconomic status, lifestyle behaviors, and health conditions (Aung et al., 2022;Etxeberria et al., 2019;Geigl et al., 2023;Siqeca et al., 2022), as studied extensively.However, it's worth noting that self-esteem also plays a crucial role in influencing HRQOL.Self-esteem is a psychological dimension that can affect overall quality of life.
This study focuses on analyzing the association between self-esteem and HRQOL among the elderly in Phayao Province, located in the upper northern region of Thailand.The elderly population is at risk of experiencing a decline in self-esteem as a result of changing roles and interpersonal relationships.Consequently, the psychological dimension can be seen as a potential predictor of an improved quality of life (QoL), contributing to successful aging and overall happiness.This study will help to understand the self-esteem and HRQOL of the elderly in the community.

Study design, population, and sampling
The cross-sectional study was conducted between October and November 2022 in Mae Ka Subdistrict, Mueang District, Phayao Province, Northern Thailand.The study participants were at least 60 years old.During registration, the patients were informed about the study and asked whether they agreed to participate.Participation in the study was voluntary, and 299 participants were initially included.The subjects who provided written consent were asked to complete the questionnaire section containing questions related to the inclusion and exclusion criteria.
The sample size was calculated based on the finite population proportion method of quality of life at 68.5% (Hongthong et al., 2015).The equation used to obtain the sample size output: Where; size of population (N) is 1,500; p = 0.685, Delta (d) is 0.05; Alpha is 0.05, Z (0.975) is 1.960; and sample size (n) is 271.7.We added at least 10% more to the estimated sample size to allow for losses.Therefore, the sample size was required to be 299 subjects.The inclusion criteria were age ≥60 years and had signed consent forms.The exclusion criteria were people who could not verbally communicate in the Thai language or who had neuropathy.

Sociodemographic characteristics
The Sociodemographic characteristics included in the study were age, gender, education level, occupation, marital status, monthly income, and health data.The age of the respondents was categorized into 60-69, 70-79, and 80 years or older.

Rosenberg Self-Esteem Scale (RSES)
The self-esteem assessment used the Rosenberg self-esteem questionnaire that consists of ten items on the Likert scale from 1 to 4 (1=strongly disagree, 2=disagree, 3=agree, and 4=strongly agree).Items 2, 5, 6, 8, 9 are reverse scored (Rosenberg, 1965(Rosenberg, , 1979)).The possible range of results varies from 10 to 50 points.A high score reflects high self-esteem.The Rosenberg self-esteem questionnaire is a reliable and valid measure of global self-esteem.Cronbach's alpha was 0.794.

Health-Related Quality Of Life (HRQOL)
For the HRQOL, the WHOQOL-BREF scale was used (O'carroll et al., 2000).This scale includes four domains, physical health, psychological, social relationships and the environment, with 26 questions about QOL, health or other areas of life on the Likert scale from 1 to 5 points.Within these four domains, physical health addresses daily living activities, dependence on medical treatment, fatigue, sleep discomfort, mobility and workability.The psychological domain includes feelings, spirituality, bodily image, thinking, concentration, beliefs and memory.The social relationships domain includes social support, personal relationships and sexual activity, and the environment domain explains health and social care, financial resources, recreation, physical environment, freedom and physical safety.The 26 items WHOQOL-BREF scale was analyzed computing all domain scores.Quality of life was assessed by classifying the scores into three categories: low, moderate, and high.A greater score signifies an enhanced Health-Related Quality of Life (HRQOL).
The WHOQOL-BREF scale was already translated into the Thai language and used in Thailand (WHO, , 2020).The tools were pretested prior to administration, and the Cronbach's alpha was 0.945.
After the ethical approval from the Research Ethics Committee of University of Phayao University, Thailand (UP-HEC 1.2/008/65), the data were collected through a face-to-face interview technique with the pretested and valid structured tools.The researcher had collected data only after explaining the purpose of the study and obtaining the participants' written consent.The interviews lasted up to 30 min with a range of 20-30 min per participant.

Statistical analysis
The frequency, percentage, mean, and SD are described as characteristics of sample populations, self-esteem, and HRQoL.Mean and standard deviation were used to present the findings.The categorical data, including age, gender, monthly income, marital status, education level, occupation, smoking, alcohol and congenital disease, were compared using the independent samples t-test, Pearson correlation coefficient, an analysis of variance (ANOVA).The associations between self-esteem and HRQoL were made by using multiple linear regression analysis.

Factors related to self-esteem
On the RSES, the study group scored 31.18 ± 3.13 points, which indicates an average self-esteem according to the adopted distribution.A low self-esteem was found in 58.5% of the group.The majority of all the respondents had HRQoL score with moderate level that consists of physical health (83.9%), social relationships (77.6), overall QoL (61.5%) and psychological (56.9) while QoL score with high level was environmental domain (63.9%) (not shown in the table).Table 3 reveals that age and monthly income were associated with self-esteem (p = 0.047 and p = 0.026, respectively).There were significant differences between education, marital status, congenital disease with self-esteem (p < 0.0010, p = 0.004, p = 0.002, respectively).

Association self-esteem and HRQoL using multiple linear regression analysis
Multiple linear regression analysis showed that an increase self-esteem was statistically significant with an increase HRQoL after adjusting for age, gender, monthly income, marital status, educational level, occupation, congenital disease (B = 1.654,SE = 0.150, adjusted R square = 0.418, p < 0.001) (Table 5).

Discussion
Our findings support the association between self-esteem and HRQOL among older adults in rural communities.The study found that self-esteem levels among the elderly were low (58.5%), with a higher prevalence of low self-esteem observed among those aged 80 years and older.When considering the self-esteem scores of their own age groups, it was found that older adults tend to have lower selfesteem scores than younger seniors.It can be explained that age was an intrinsic factor affecting selfesteem due to physical changes such as height, weight, personality, strength, body shape, and general abilities, as well as mood disorders and other health issues (Jafari et al., 2015;Yazdani et al., 2018).
The study also found that elderly with congenital diseases tend to have lower self-esteem scores than those without any underlying diseases.It can be explained that illnesses or health issues can cause elderly to feel like they have no self-worth, especially given the changing societal roles they experience (Filej et al., 2018).It was observed that most of the sample population were unemployed, which may have contributed to the elderly feeling like they are no longer useful to society or their families, leading to a decrease in self-esteem (Jafari et al., 2015;Šare et al., 2021).
According to the research findings, older adults who have low monthly income, are unemployed, and are dealing with the underlying disease tend to have low self-esteem levels.Similarly, previous study found that older adults with a favorable financial situation exhibit higher levels of selfesteem compared to those with an unfavorable financial situation.Additionally, they noted that elderly individuals with no prior health issues had higher self-esteem than those with a history of health problems (Jafari et al., 2015).
Based on research studies, it has been found that HRQOL levels among the elderly were at a moderate level (61.5%), with females generally reporting higher scores in HRQOL than males.Similar findings were reported in a study conducted by Singh et al. (2022), which suggests that these results may be characteristic of rural elderly.Several factors may contribute to the higher HRQOL scores among females.For instance, females are more likely to seek healthcare services and engage in preventive health behaviors such as exercise and healthy eating (Lucas et al., 2000).They are also more likely to have better social support networks, which can positively impact their mental and emotional well-being (Kirkman et al., 2021).
The findings of the study indicate that elderly individuals who are young old, have higher monthly incomes, are in a couple relationship, and do not have congenital disease tend to report higher scores in terms of HRQOL.The study's results suggest that young old may have better physical and cognitive functioning, which can positively impact their HRQOL scores (Etxeberria et al., 2019;Song et al., 2023).Higher income levels may also provide greater access to healthcare and resources that can enhance an individual's HRQOL (Siqeca et al., 2022).Additionally, being in a couple relationship can provide social support, which is crucial for emotional well-being and HRQOL (Daely et al., 2022).
The study found that when considering each aspect of HRQOL, environmental quality of life was high while the quality of life on social relations was low level.It is assumed that rural areas often have access to nature that is conducive to outdoor activities and rural areas are less polluted, giving the elderly more freedom in their lives.Moreover, increased aging and poor communication skills makes getting into a social group becomes more and more difficult.The study of Praveen and M (2017) and Devraj and D'mello (2019) had reflected similar findings where high score was The study of factors related to self-esteem was found to be statistically significant at the < 0.005 level for educational level, single status, and the presence of congenital disease.Self-esteem refers to an individual's subjective evaluation of their own worth and is an important component of overall mental health and well-being.It may be that older people with lower levels of education may compare themselves to those who have even less education or who have faced greater challenges in life, which can also contribute to a sense of self-worth.It's worth noting that while some studies have found a correlation between lower levels of education and higher self-esteem in older adults, this relationship is not universal and may be influenced by a variety of factors, including cultural and societal norms, individual personality traits, and the specific circumstances of a person's life.
Regarding the factors that correlate with HRQOL in each aspect, the study found that age, marital status, and the presence of congenital disease were significant associated with HRQOL.HRQOL refers to an individual's perceived physical, emotional, social relation, and environmental to their health status (CDC, 2000).
The study also found a positive correlation between self-esteem and HRQOL, similar to other studies that also found a statistically significant association between self-esteem and HRQOL (Souza Júnior et al., 2022;Tavares et al., 2016).This suggests that individuals with higher levels of selfesteem may have better physical, emotional, and social functioning, leading to higher HRQOL scores.Higher self-esteem is associated with greater confidence, self-acceptance, and resilience in the face of life's challenges (Liu et al., 2021;Sharma et al., 2021;Timalsina et al., 2022).These factors may contribute to better physical health outcomes, as well as improved emotional and social functioning Several limitations of this study are (a) cross-sectional study conducted with older adults living in rural communities yielded results that were subject to bias and did not allow for the inference of causation; (b) comparative studies were not conducted in other groups, such as urban area group and (c) data of our study involved a self-reported questionnaire that may distort some information.However, the strength of this study is its holistic health assessment, considering not only physical health but also the psychological aspect (self-esteem) and their relationship to overall quality of life, providing a comprehensive view of well-being.This study has the potential to increase awareness about the importance of addressing mental health issues, including self-esteem, among rural elderly populations.

Conclusion
In conclusion, the results of the study indicate that there is a positive correlation between selfesteem and HRQOL.This suggests that individuals who have higher levels of self-esteem may experience better overall health and well-being.These findings highlight the importance of promoting positive self-esteem as a means of improving HRQOL, and may have implications for the development of interventions aimed at enhancing self-esteem and improving health outcomes.Further research is needed to explore the causal relationship between self-esteem and HRQOL, and to identify effective strategies for promoting self-esteem and improving overall quality of life.

Table 4 . Association between socio-demographic variables and HRQOL (n = 299) Associated factors Physical health p value Psychological p value Social relationships p value Environment p value Overall QoL p value
a Independent samples t-test, b Pearson correlation coefficient, c ANOVA, *p < 0.05, **p < 0.01, ***p < 0.001

Table 5 . Association self-esteem and HRQoL using multiple linear regression analysis
Note: adjust with age, gender, income, marital status, educational level, occupation, and underlying disease achieved in the environment domain and low score was observed for the social relationship domain which is rarely seen in other studies.