Comparison of Stress Level and Quality of Life in Elderly

Who are Living with Chronic Illness in Bangkok and Surabaya

Ni Putu Wulan Purnama Sari

and Jintana Artsanthia

Faculty of Nursing, Widya Mandala Catholic University Surabaya (WMCUS), Jl. Raya Kalisari Selatan 1, Pakuwon City,

Surabaya, Indonesia

Faculty of Nursing, Saint Louis College (SLC), 19 Sathorn Road, Yannawa, Bangkok, Thailand

Keywords: Chronic Illness, Elderly, Quality of Life, Stress Level.

Abstract: Elderly with chronic illness, such as hypertension (HT) and diabetes mellitus (DM), was prone to stress that

potentially decrease quality of life (QOL). This study aimed to compare and analyze the differences of stress

level and QOL in hypertensive and/or diabetic elderly between Bangkok and Surabaya. This cross-sectional

study involved 100 and 96 elderly with HT and/or DM in communities of Bangkok and Surabaya

respectively (n=196). There were 60 DM, 68 HT, and 68 DM&HT cases compiled from both sites.

Instrument used were SPST-20 and WHOQOL-BREF. Independent sample T test and Kolmogorov-

Smirnov Z test were used for data analysis (α=.05). There were 6% and 0% mild stress, 64% and 29.17%

moderate stress, 24% and 67.71% high stress, 6% and 3.13% severe stress were found in Bangkok and

Surabaya respectively. Stress level was differ significantly between Bangkok and Surabaya (p=.000).

Coping strategy tends to be more adaptive in Bangkok. There were 25% and 0% poor QOL, 52% and

91.67% moderate QOL, 23% and 8.33% good QOL were found in Bangkok and Surabaya respectively.

QOL was also differ significantly between Bangkok and Surabaya (p=.000). Elderly in Surabaya had higher

stress level, but elderly in Bangkok had lower QOL.

1 BACKGROUND

Non-communicable disease (NCD) or chronic

diseases are not passed from person to person. They

are of long duration and generally slow progression.

The four main types of NCD are cardiovascular

disease (e.g. hypertension/HT), cancer, chronic

respiratory disease, and diabetes mellitus (DM).

80% of all NCD deaths occur in low- and middle-

income countries. Almost three quarters of NCD

deaths - 28 million - occur in low- and middle-

income countries. 16 million NCD deaths occur

before the age of 70; 82% of these "premature"

deaths occurred in low- and middle-income

countries (WHO, 2015).

In Thailand, the burden of disease is gradually

shifting from communicable diseases to NCD,

injuries, and mental illness. Greatest public health

benefits are gained through prevention of NCD

(particularly cardiovascular disease, cancer, and

DM), injuries, and mental health disorder. These

benefits can be achieved if risk factors are identified

and mitigated through appropriate interventions. If

NCD and mental illnesses are detected at an early

stage and appropriate controls initiated, their

severity can be significantly reduced. The burden of

NCD usually falls disproportionately on the lower

socio-economic groups who often face higher

exposure to risk factors and have limited access to

health services. Diseases such as DM, cancer, and

cardio-vascular diseases are often not detected until

they reach advanced levels (WHO Thailand, 2014).

In response to the increasing impact of NCD, the

Royal Thai Government has increasingly directed its

attention on prevention and control initiatives. The

Bureau of Non-Communicable Diseases is

responsible for NCD, injury prevention, tobacco and

alcohol control programs. The Bureau has made

steady progress in monitoring the burden of NCD

and injuries in addition to identify major behavioural

risk factors classified by province. The Bureau also

plans to improve the collection and analysis of NCD

and injury mortality and morbidity data. This is

being done in efforts to monitor trends and evaluate

the success of interventions. The Bureau of Policy

and Strategy notes that due to the unreliability of

incidence data for selected NCD, injuries, and

Sari, N. and Artsanthia, J.

Comparison of Stress Level and Quality of Life in Elderly Who are Living with Chronic Illness in Bangkok and Surabaya.

DOI: 10.5220/0008321201010109

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 101-109

ISBN: 978-989-758-336-0

101

mental illnesses, cases of hospitalization with more

accurate diagnosis are needed to ascertain trends as

well as strengths/weaknesses of current programs.

In Indonesia, the burden of disease is gradually

shifting from communicable diseases to NCD also.

Over the past decades, Indonesia has made

phenomenal progress. Per capita income has been

increasing at a blistering pace, up to around $3,000

per capita in 2010. At the same time, fertility has

dropped dramatically, while life expectancy has

increased steadily. From an individual perspective,

these developments are clearly welcome. DM is of

particular concern ‒ by 2030, the number of people

with DM will nearly double, from 7.6 million in

2013 to 11.8 million. With an annual growth in DM

prevalence of 6%, this far exceeds the country’s

overall annual population growth rate (Blueprint for

Change Program, 2013). The costs associated with

NCD in Indonesia are substantial. According to our

calculations, the five domains of NCD

(cardiovascular disease, cancer, chronic obstructive

pulmonary disease, DM, and mental illness) will

cost Indonesia $4.47 trillion (or $17,863 per capita)

from 2012 to 2030 (data for total health expenditure

is obtained from the Global Health Expenditure

Database (GHED) of WHO, updated in 2014).

Not only because of adjustment to the new role

as an elderly in the family and age-related physical

changes, elderly with NCD are also get stressors

from the disease burden, such as disturbing signs and

symptoms, diet restriction, continuous physical

exercise requirement, etc. Chronic illnesses or NCD

can create stress in elders, both physically and

psychologically. Apart from impairing physical and

mental health, chronic illnesses may also have

negative impact on occupational and social

functioning and thus affecting the quality of life

(QOL). Positive thinking and an optimistic attitude

are needed to increase the compliance to treatment

regime and can motivate them to adjust their lifestyle

(e.g. quit smoking and alcohol use, giving up fatty

foods), thus help to promote healthy living

This study aimed to compare and analyze the

differences of stress level and QOL in elderly who

are living with chronic illness especially HT and/or

DM between Bangkok and Surabaya.

2 METHODS

This was a comparative study involving 196 elderly

with Diabetes Mellitus (DM) and/or Hypertension

(HT) in communities in Surabaya and Bangkok.

There were 96 and 100 cases compiled from

Surabaya and Bangkok respectively. Sample

distribution between 2 sites is presented in Table 1.

Sample was chose by criteria then totally

included in the study (total sampling). Inclusion

criteria consist of (1) elderly who are willing to

participate in the study, and (2) consume medication

from medical doctor to treat the disease. Exclusion

criteria were cannot communicate using Pasa Thai or

Bahasa Indonesia.

Instrument used were valid and reliable

questionnaire. SPST-20 was used to measure stress

level (IOC=.78; Cronbach's Alpha=.94). It consisted

of 20 items assessed in Likert scale format: 1 = no

stress, 2 = mild stress, 3 = moderate stress, 4 = high

stress and 5 = severe stress. The category of stress

level was 0-23 = mild stress, 24-41 = moderate

stress, 42-61 = high stress, and >62 = severe stress.

WHOQOL-BREF was used to measure QOL

(IOC=.83; Cronbach's Alpha=.84). It consisted of 26

items assessed in Likert scale format from 1 to 5,

various terminologies were used to define the score

of Likert in each item. Transformation score of 0-

100 was used in this study context. The category of

QOL is presented in Table 2.

Descriptive statistic, independent sample T test,

and Kolmogorov-Smirnov Z test were used for data

analysis (α = .05). Ethical clearance was issued by

Ethical Committee of Saint Louis College (SLC),

Bangkok, Thailand (November 17

, 2016), Number:

E. 038/2559.

Table 1: Sample distribution

Case Bangkok Surabaya Total

DM 30 30 60

HT 35 33 68

DM&HT 35 33 68

Total 100 96 196

Table 2: Category of QOL

Domain Poor Moderate Good

Physical 7-16 17-26 27-35

Psychological 6-14 15-22 23-30

Social 3-7 8-11 12-15

Environment 8-18 19-29 30-40

Overview 26-60 61-95 96-130

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

102

3 RESULTS

In total, the study respondents composed of 15.82%

male and 84.18% female. Age range was 60 – 78

years old. The educational background of sample in

Bangkok was mostly primary school (53%), while in

Surabaya was mostly secondary school (64.58%).

The income of sample in Bangkok was mostly 43%

at THB 2000-6000 per-month (43%), while in

Surabaya was mostly less than IDR 800 thousand

per month (53.13%). In Bangkok, most respondents

has relative who suffered from DM/HT (66%), while

in Surabaya no family background was reported

(69.79%). Table 3 will explain demography

characteristic of study respondents.

There were 6% and 0% mild stress, 64% and

29.17% moderate stress, 24% and 67.71% high

stress, 6% and 3.13% severe stress were found in

Bangkok and Surabaya respectively. Majority, we

found moderate stress in Bangkok and high stress in

Surabaya. 25% and 0% poor QOL, 52% and 91.67%

moderate QOL, 23% and 8.33% good QOL were

found in Bangkok and Surabaya respectively.

Majority, we found moderate QOL in both site.

Table 4 and 5 will explain the result of descriptive

statistical analysis of measured variables.

The value of stress level in Bangkok was more

various than Surabaya. The data of stress level was

not normally distributed and not homogenous (p<α).

Kolmogorov-Smirnov Z test showed that there was

significant difference of stress level between

Bangkok and Surabaya (p=.000). After deeper

analysis of each item in SPST-20 instrument, there

were 11 items determined this significant difference.

They were item 1, 2, 4, and 5 about anxiety, 6 about

finance, 7 about muscular pain, 10 about appetite, 11

about headache, 14 about anger, 18 about

concentration, and 19 about fatigue.

The value of overview QOL was also more

various in Bangkok. All data of QOL was normally

distributed and homogenous (p>α). Independent

sample T test showed that there was significant

difference of QOL between Bangkok and Surabaya

(p=.000). After deeper analysis of each item in

WHOQOL-BREF instrument, there were 14 items

determined this significant difference. They were Q1

about overview QOL, Q2 about health satisfaction,

Q5 about enjoyment of life, Q6 about life meaning,

Q7 about concentration, Q9 about living environ-

ment, Q18 about working satisfaction, Q19 about

Table 3: Demography characteristic

Characteristic Bangkok

(

100

)

Surabaya

(

)

n % n %

Sex

Male

Female

11.45

88.54

Age (years old)

60-69

>70

78.13

21.87

Education

Primary school

Secondary school

Bachelor degree

No stud

26.04

64.58

9.38

Occupation

Farmer

Businessman

Government officer

Other (retire,

housewife)

12.50

1.04

86.46

Monthly income

THB <2,000

(IDR <800,000)

THB 2,000-6,000

(IDR 800,000-2.4

million)

THB 6,000-10,000

(IDR 2.41-4 million)

THB >10,000

(IDR >4 million)

53.13

32.29

10.42

4.17

Family background

of HT/DM

Yes

30.21

69.79

Table 4: Table of frequency and descriptive statistic of

Stress Level

Category Bangkok

(

100

)

Surabaya

(

)

n % n %

Mil

6 6 0 0

Moderate 64 64 28 29.17

High 24 24 65 67.71

Severe 6 6 3 3.13

Mean 36.82 48.42

Std. Deviation 13.29 8.89

Table 5: Table of frequency and descriptive statistic of

overview QOL

Category Bangkok

(100)

Surabaya

(96)

n % n %

Poo

25 25 0 0

Moderate 52 52 88 91.67

Goo

23 23 8 8.33

Mean 78.83 60.91

Std. Deviation 18.96 8.15

Comparison of Stress Level and Quality of Life in Elderly Who are Living with Chronic Illness in Bangkok and Surabaya

103

self-satisfaction, Q20 about personal/social relation-

ship, Q21 about sexual life, Q22 about social

support, Q24 about access to health care facility,

Q25 about transportation, and Q26 about negative

feeling. All domains was affected by the difference,

especially social domain in which all items were

affected (Q20, Q21, Q22), and psychological

domain (Q5, Q6, Q7, Q19, Q26).

4 DISCUSSION

4.1 Stress Level Differences

Results showed that there was significant difference

of stress level in elderly who are living with chronic

illness between Bangkok and Surabaya. This

difference was influenced by physical, psychology-

cal/emotional, and financial aspect. Physical aspect

relates to muscular pain, headache, appetite loss, and

fatigue. Psychological aspect relates to anxiety,

anger, and decreased concentration. Financial aspect

relates to low monthly income.

Muscular pain is frequently found in elderly.

Muscular pain in elderly usually happens because of

osteoporosis and osteoarthritis (Urban et al., 2010;

Camacho-Soto et al., 2011). An exploratory study in

Ghana showed that musculo-skeletal pain in elderly

is psychological, will worsen when they think too

much because of retirement, especially without a

house or enough money; also when the elderly left

alone at home and not doing anything, at times they

feel so bored (Aziato et al., 2016). The elderly

experience mild, moderate or severe pain and the

severity of pain increases with advancing age (Herr

et al., 2010). Pain also impairs sleep among the

elderly (Jacobson et al., 2009). Lack of sleep could

induce headache, along with hunger because of low

appetite. Chronic pain leads to a high incidence of

depression and anxiety among the elderly (Cino,

2014). Pain and aches were frequent stressors found

in elderly; therefore pain in various area of the body

could increase their stress level.

Appetite loss and the lack of hunger related to

aging have been termed as the anorexia of aging.

The etiology is multi-factorial and includes a

combination of physiological changes associated

with aging (decline in smell and taste, reduced

central and peripheral drive to eat, delayed gastric

emptying), pathological conditions (depression,

dementia, somatic diseases, medications and

iatrogenic interventions, oral-health status), and

social factors (poverty, loneliness). The anorexia of

aging is associated with protein-energy malnutrition,

sarcopenia, frailty, functional deterioration,

morbidity, and mortality. Loss of appetite may lead

to protein-energy malnutrition and weight loss

(Wysokinski et al., 2015). Appetite loss with weight

loss becomes a stressor for elderly because of its bad

consequences for health.

Fatigue is one of the most common symptoms

experienced by older people, both with and without

chronic disease. It is unpleasant and distressing and

can affect functioning and QOL (Egerton, 2013).

Fatigue can be an overwhelming and distressing

experience that constrains capacity for physical

functioning and social participation as well as

worsens morbidity and mortality outcomes (Yu et

al., 2010). A prospective study results focused on the

correlation between subjective fatigue, cognitive

function, and everyday functioning in elderly

showed that all domains of cognitive function and

everyday functioning declined significantly over

five years; and the decline rates differed by the latent

class of subjective fatigue. Except for the decreased

fatigue class, there were different degrees of

significant associations between the decline rates of

subjective fatigue and all domains of cognitive

function and everyday functioning in other classes of

subjective fatigue (Lin et al., 2013). Fatigue could be

a serious stressor for elderly because of its

consequences for everyday functioning impacted on

QOL.

The anxiety disorders are a prevalent mental

health problem in older age; it has a particular co-

morbidity and risk factor profile (Sami &

Nilforooshan, 2014). Anxiety disorders in the

elderly have been associated with neurotic

personality trait, cognitive decline, and increased

burden on physical health including frailty,

worsening physical functioning, increased disability

and increased taking of medications (Gale et al.,

2011; Ní Mhaoláin et al., 2012). Physical activity is

associated with lower levels of depression and

anxiety in elderly; female gender and lower

educational background had higher values of anxiety

and depression (Teixeira et al., 2013). Anxiety could

influence stress level in elderly because of its effect

on physical function in everyday life.

Anger could be an ordinary reaction to life

situations or indicative of emotional illness. Anger

can be healthy, and this should be recognized. For

some elders, anger correlates with good mental

health. Depression is regarded as an alternative to

anger – anger turned inward. Anger in elderly

correlates with the quality of their past relationships

with parents, siblings, children, and friends; conflict

management, coping strategy, work history, sexual

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

104

history, and life view. The elder’s anger response

has become conditioned over time. The elder could

be trying to gain attention or to distance himself

from others through the use of anger. The

rechanneling of anger in elderly can be promoted

through the use of physical activity, resident

councils, recreation activities, and other socially

acceptable means (McKinnon, 1998). By using these

means, coping strategy could be influenced.

Concentration is the ability to maintain attention

in a longer period. One of acute stress reaction is

concentration disorder (Idrus, 2016). A study

towards 74 elderly concluded that chronic stress and

coping strategies may be modulated by the presence

or absence of cognitive impairment, where memory

deficit awareness constitutes an additional potential

factor involved in high stress severity (Souza-

Talarico et al., 2009). Concentration disorder may

affect stress level in elderly because of its effect on

cognitive function impairment.

Financial problem is one of great stressor for

elderly, especially for those who had permanent job

previously. Study results showed that some elderly

already retire, and respondents in Surabaya had

lower monthly income than Bangkok. Financial

stress or strain which is presumably frequently

experienced by elderly in low socioeconomic status

or low income resulted in lower personal control

associated with distress (Caplan & Schooler, 2007).

Although financial strain is associated with actual

income and poverty, it is also associted with

cognitive capacity, depression, and self-esteem in

elderly, resulted in adverse effects on subjective

health (Angel et al., 2003). Economic security is the

key element that in a straightforward manner affects

people’s quality of life (Drobnic et al., 2010).

Financial problem in elderly needs to be addressed

by the family in which the elders live; therefore

stress level and subjective health status could be

perceived better.

During the aging process, there is evidence that

global perceived stress is associated with greater

reported exposure to daily stressor in older adults

(Stawski et al., 2008). These experiences of aging

and chronic illness symptoms may lead to

continuous anticipation of negative consequences,

triggering high levels of perceived stress symptoms

and cortisol levels. Stress symptomps are dependent

to coping strategy (Souza-Talarico et al., 2009). The

more adaptive coping strategy implemented, the

lower stress level perceived. Lower stress level

found in study respondents in Bangkok showed that

the elders there implemented more adaptive coping

strategy than the study respondents in Surabaya.

4.2 QoL Differences

Results showed that there was significant difference

of QOL in elderly who are living with chronic

illness between Bangkok and Surabaya. This

difference was mostly existed in psychological and

social domain of QOL. The difference was

influenced by working satisfaction (physical

domain); enjoyment of life, life meaning,

concentration, self-satisfaction, and negative feeling

(psychological domain); personal/social relationship,

sexual life, and social support (social domain);

living environment, access to health care facility,

and transportation (environmental domain).

Working satisfaction in elderly relates to physical

capacity needed for performing daily live activities

or household works; most study respondents already

retire, or being a housewife for now. Work is an

important economic, social, and psychological

ingredient of human life. Higher work intensity may

lead to deterioration of health and simultaneously

less likely to be able to afford the time needed for

health care due to work obligation (Zajc & Kohont,

2017). Time of health care in elderly with chronic

illness needs to be sufficient for monitoring their

health status and providing long-term vare needed

based on current health conditions. Less amount of

free time also affects life satisfaction, happiness,

depressed feeling, problem solving capacity, and

self-confidence of individual (Zajc & Kohont,

2017). Elderly needs sufficient free time and leisure

aktivities to increase their life satisfaction and QOL.

Enjoyment of life were found to be lesser in

individual with limiting and long standing illness,

such as DM and HT resulted in stroke, smoking,

physical inactivity, and alcoholic. Enjoyment of life

could predict a reduced risk of functional

impairment at older ages impacting QOL.

Independent predictors of functional impairment are

greater age, less wealth, having limiting – long

standing illness; baseline diabetes, arthritis, and

stroke; having a single impaired activity of daily

living at baseline, and physical inactivity (Steptoe et

al., 2014). Enjoyment in later life may also affect

cognitive health in elderly. Lack of cognitive health

in elderly results in decreased independence and

well-being, increrased health care costs, and

wellbeing, increased healthcare costs,

institutionalization and high levels of caregiver

burden (Hughes & Ganguli, 2009). Enjoymeny of

life needs to be adressed by elderly and the people

around them, along with adaptive coping strategy

implemented, so that better QOL could be achieved.

Comparison of Stress Level and Quality of Life in Elderly Who are Living with Chronic Illness in Bangkok and Surabaya

105

Life meaning, together with hope, have

significant correlation with positive mental health.

Life meaning explained 8% of variance of life

satisfaction. Life meaning is an independent

predictor of life satisfaction and self-esteem

(Halama & Dedova, 2007). For a single living older

woman, low living standard assessed by economic

and housing conditions seems to be a more serious

obstacle than poor health, making it difficult to

obtain a reasonable life satisfaction (Horstmann et

al., 2012). Generally, QOL is influenced by living

standard. Reasonable standard of living has changed

with time and cultural settings. In a society with

inequalities in living standard, there is elevated

stress level, especially in the lowest socio-economic

status, leading to poorer health and even lower life

satisfaction (Marmot, 2005). Poor QOL found in

Bangkok and lower QOL found in Surabaya

potentially because of inequalities in living standard

in the society, or unmatched status between

expectations and ambitions of respondents and the

possibility to reach their goals in life.

Self-satisfaction was associated with self-image.

Negative self-image is associated with various

psychological problems such as psychiatric

disturbance, low self-esteem, depression, and

behaviour problems. Self-image could predict

mental health in adulthood. The chronological age

influences the self-perception about self image. The

level of satisfaction indicates the assessment of the

quality of the resources that individuals hold in order

to face the challenges of age. Interpersonal

relationships and the reference cultural system,

where the individual acts, significantly contribute to

the definition of the idea of self (Diana et al., 2014).

Self-image in elderly is influenced by the construct

of self developed by values and culture in the family

and community. Better understanding of physical

changes and self-realization related to age could

promote positive self-image and psychological well-

being in elderly.

Negative feeling sometimes experienced by

elderly, such as loneliness and feeling abandon.

Loneliness was widespread among elderly widows.

Many felt isolated, dislocated from former social

circulation and missed being relevant (Nyanzi,

2011). A study conducted in rural Thailand towards

212 elderly showed that 9% were found to live

alone, 20% stated that they felt abandoned to some

degree. Feelings of abandonment do appear to result

in lower QOL in terms of psychological factors,

including one’s overall enjoyment of life, having a

meaningful life, and feelings of despair, anxiety or

depression (Sudnongbua et al., 2010). Abandonment

or loneliness of elderly, especially in rural area,

usually is a result of children emigration to other

area/city because of work and job obligations. But,

in city like Bangkok and Surabaya this condition

also exists, also mainly because of job obligations.

Adult children these days should pay more attention

to their elderly parents to promote better QOL.

Sexual life for elderly is difficult matter,

especially related to widower, negative body image,

depression, and erectile dysfunction due to chronic

illness. Sexuality impacts elderly’s QOL by

mechanism of spouse/family support, life

enjoyment, and secure feeling. Most study

respondents were women elderly, marital status and

widower were not identified. Post-menopausal

widows have less sexual appeal than younger

widows for whom reproduction is a viable outcome

of sexuality. Adult children usually control the

sexuality of their elderly parents often by

discouraging sexual liaisons. Adult children may

also arrange for new spouses with utilitarian value,

such as providing healthcare for ill elders (Nyanzi,

2011). QOL showed significant positive correlations

with body image and sexuality, but a significantly

negative correlation with depression. Body image,

depression, education level, sexuality, and stressor

were significant predictors influencing QOL in

middle-aged adults in the community (Kim & Kang,

2015). Erectile dysfunction was associated with

higher level of diabetes-specific health distress and

worse psychological adaptation to DM, related to

worse metabolic control. Erectile problem was also

associated with a dramatic increase in the prevalence

of severe depressive symptoms, less satisfactory in

sexual life, lower scores in the mental component of

QOL assessed by SF-36 (Berardis et al., 2002).

Social support gained from the family or

neighborhood is important to increase the value of

social domain of QOL in elderly because

communication with other person could add life

experiences that are stress relieving and cognitively

stimulating. A study in Turkey towards 108 older

adults concluded that QOL correlated with social

support from subgroups of family (spouse and

childrern), friends, and special friend (Unsar et al.,

2016). Social environment comprised of social

relationships and interpersonal interaction. Social

relationships can provide protection to life stresses

depression, loneliness, cognitive decline, risk of

institutionalization. Interpersonal interactions

promote psychological well-being and decreased

rates of morbidity and mortality (Smith &

Christakis, 2008). Socially active older adults tend to

have better cognition. Maintaining social networks

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

106

in later life may be beneficial as it provides several

social opportunities (Flatt & Hughes, 2013). Social

support gained from several social activities in later

life could promote cognitive health, life enjoyment,

adaptive coping strategy, and QOL.

Environmental factors also affect QOL. The

factors which are important in maintaining a good

QOL are being safe, overall living conditions,

having sufficient money, access to health services,

access to information for everyday living, leisure

activities, physical environment, and transport

(Sudnongbua et al., 2010). Living arrangement was

associated with health among older adults. Living

arrangement concordance increases the likelihood of

rating self-rated health as good, with concordance

having a greater impact for institutionalized elders

than for communityresiding elders (Sereny & Gu,

2011). Both living arrangement and home

modifications are important for promoting better

QOL in elderly who are having physical limitations.

Living environment is essential for elderly; it is

important to assure their safety, comfort, life

enjoyment, and condusive interpersonal relationship

with all family member.

Access to health care facility is essential for

elderly who are living with chronic illnesses,

sufficient time and proper health care service are

needed to promote routine check up of elderly’s

health condition. A poor, aging service design exerts

a negative effect on the QOL of elderly people. This

usually happens because government agencies have

limited resources, so that improvement items cannot

be implemented simultaneously. A comprehensive

aging place policy and increases effective use of

resources are needed to meet elderly people

demands, provide a clear design, and improve

service quality to match the demands and

expectations of elderly people (Chen, 2016).

Transportation is also important for promoting

better QOL in elderly. Currently, there are about 8.4

million senior citizens who depend on others for

their transportation. Shortly, the number of older

drivers will be more than double, making the issue

of senior transportation even more critical. In fact,

according to the Administration on Aging, by the

year 2030 the number of drivers over age 85 will be

4–5 times what it is today. The use of private vehicle

is not easy in older age, because of eye problems,

musculo-skeletal pain, tremor, and family

restriction; and because the skills and abilities

associated with driving tend to diminish with age—

viable alternate forms of transportation for the

elderly will continue to be an important issue for

years to come (FamilyCare America, 2018).

Therefore, elderly really need an easily accessible

public transportation developed by government or

private agencies to promote the use of medical care,

especially in urban life presented in Bangkok and

Surabaya.

5 CONCLUSIONS

There was significant difference of stress level in

elderly who are living with chronic illness between

Bangkok and Surabaya. This difference was

influenced by physical, psychological/emotional,

and financial aspect. Physical aspect relates to

muscular pain, headache, appetite loss, and fatigue.

Psychological aspect relates to anxiety, anger, and

decreased concentration. Financial aspect relates to

low monthly income. Coping strategy tends to be

more adaptive in Bangkok.

There was significant difference of QOL in

elderly who are living with chronic illness between

Bangkok and Surabaya. This difference was mostly

existed in psychological and social domain of QOL.

The difference was influenced by working

satisfaction (physical domain); enjoyment of life,

life meaning, concentration, self-satisfaction, and

negative feeling (psychological domain); personal/

social relationship, sexual life, and social support

(social domain); living environment, access to health

care facility, and transportation (environmental

domain). Inequalities in living standard tends to

happen in Surabaya’s society.

ACKNOWLEDGEMENTS

This study was funded by Saint Louis College (SLC)

and Widya Mandala Catholic University Surabaya

(WMCUS). This publication was supported by

Faculty of Nursing, WMCUS. We thanked all

respondents for participating in this study.

REFERENCES

Angel, R.J., Frisco, M., Anghel, J.L., Chiriboga,

D.A. 2003. Financial strain and health among

elderly Mexican-origin individuals. Journal of

Health and Social Behavior, 44: 536-551.

Aziato, L., Ohene, L.A., Norman, L. Antwi, H.O.

2016. Ageing with aches and pains’: lived

experiences of the elderly in Ghana.

Comparison of Stress Level and Quality of Life in Elderly Who are Living with Chronic Illness in Bangkok and Surabaya

107

International Journal of Caring Sciences, 9(2):

551-560.

Berardis, G.D., Franciosi, M., Belfiglio, M., Nardo,

B.D., Greenfield, S., Kaplan, S.H., Pellegrini, F.,

Sacco, M., Tognoni, G., Valentini, M.,

Nicolucci, A. Erectile dysfunction and quality of

life in type 2 diabetes patients. Diabetes Care,

25(2): 84-291.

Camacho-Soto, A., Sowa, G. & Weiner, D. K. 2011.

Chapter 58 - Geriatric pain. In: Candido, K et al.,

(ed.) Essentials of Pain Medicine (Third

Edition). Saint Louis: W.B. Saunders.

Caplan, L.J., Schooler, C. 2007. Socioeconomic

status and financial coping strategies: the

mediating role of perceived control. Social

Psychology Quarterly, 70(1): 43-58.

Cino, K. 2014. Aromatherapy hand massage for

older adults with chronic pain living in long term

care. Journal of Holistic Nursing, 32: 304-313.

Chen, S-H. 2016. Determining the service demands

of an aging population by integrating QFD and

FMEA method. Qual Quant., 50: 283–298.

Diana, P., Bottoni, G., Ferrari, G. 2014. Self-image

and self-satisfaction: a research among southern

Italian students using a battery of OSIQ items.

Italian Sociological Review, 2014, 4, 1, pp. 51-

70.

Drobnic, S., Beham, B., Prag, P. 2010. Good job,

Good life? Working conditions and quality of

life in Europe. Soc Indic Res., 99: 205–225.

Egerton, T. 2013. Self-reported aging-related

fatigue: a concept description and its relevance to

physical therapist practice. Physical Therapy,

93(10): 1403-1413.

Family Care America. (2018). Transportation and

The Elderly. Retrieved from:

http://www.caregiverslibrary.org/caregivers-

resources/grp-transportation/transportation-and-

the-elderly-article.aspx

Flatt, J.D., Hughes, T.F. 2013. Participation in social

activities in later life: does enjoyment have

important

implications for cognitive health?. Aging Health,

9(2): 149–158.

Gale, C.R. et al. 2011. Factors associated with

symptoms of anxiety and depression in five

cohorts of community-based older people: the

HALCyon (healthy ageing across the life course)

programme. Psychological Medicine, 41: 2057–

2073.

Halama, P., Dedova, M. 2007. Meaning in life and

hope as predictors of positive mental health: do

they explain residual variance not predicted by

personality traits. Studia Psychologica, 49(3):

191-200.

Herr, K., Titler, M., Fine, P., Sanders, S.,

Cavanaugh, J., Swegle, J., Forcucci, C. & Tang,

X. 2010. Assessing and treating pain in hospices:

current state of evidence-based practices. J Pain

Symptom Manage, 39: 803-19.

Horstmann, V., Haak, M., Tomsone, S., Iwarsson,

S., Gräsbeck, A. 2012. Life satisfaction in older

women in Latvia and Sweden—relations to

standard of living, aspects of health and coping

behaviour. J Cross Cult Gerontol., 27: 391–407.

Hughes, T.F., Ganguli, M. 2009. Modifiable midlife

risk factors for latelife cognitive impairment and

dementia. Curr. Psychiatry Rev., 5(2): 73–92.

Idrus, M.F. 2016. Stress-related disorder (in Bahasa

Indonesia). Retrieved from:

http://med.unhas.ac.id/kedokteran/wp-

content/uploads/2016/10/Gangguan-Terkait-

dengan-Stres.pdf

Jacobson, B. H., Boolani, A. & Smith, D. B. 2009.

Changes in back pain, sleep quality, and

perceived stress after introduction of new

bedding systems(). Journal of Chiropractic

Medicine, 8: 1-8.

Kim, J.S., Kang, S. 2015. A study on body image,

sexual quality of life, depression, and quality of

life in middle-aged adults. Asian Nursing

Research, 9, 96-103.

Lin, F., Chen, D-G., Vance, D.E., Ball, K.K.,

Mapstone, M. 2013. Longitudinal relationships

between subjective fatigue, cognitive function,

and everyday functioning in old age.

International Psychogeriatrics, 25(2): 275-285.

Marmot, M. 2005. Social determinants of health

inequalities. Lancet, 365: 1099–1104.

McKinnon, N. 1998. Caring for angry elders: what

makes them that way, and what you can do about

it. Nursing Homes, 47(11): 51-54.

Ní Mhaoláin, A.M. et al. 2012. Frailty, depression,

and anxiety in later life. International

Psychogeriatrics, 24: 1265–1274.

Nyanzi, S. 2011. Ambivalence surrounding elderly

widows’ sexuality in urban Uganda. Ageing Int.,

36: 378–400.

Sami, M.B., Nilforooshan, R. 2015. The natural

course of anxiety disorders in the elderly:a

systematic review of longitudinal trials.

International Psychogeriatrics, 27(7): 1061–

1069.

Sereny, M.D., Gu, D. 2011. Living arrangement

concordance and its association with self-rated

health among institutionalized and community-

residing older adults in China. J Cross Cult

Gerontol., 26: 239–259.

Smith, K.P., Christakis, N.A. 2008. Social networks

and health. Annu. Rev. Sociol., 34: 405–429.

Souza-Talaricoa, J.N., Chaves, E.C., Nitrini, R.,

Caramellic, P. 2009. Chronic stress is associated

with high cortisol levels and emotional coping

mechanisms in amnestic mild cognitive

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

108

impairment. Dement Geriatr Cogn Disord, 28: 465–

470.

Stawski, R.S., Sliwinski, M.J., Almeida, D.M.,

Smyth, J.M. 2008. Reported exposure and

emotional reactivity to daily stressors: the roles

of adult-age and global perceived stress. Psychol

Aging, 23(1): 52–61.

Steptoe, A., de Oliveira, C., Demakakos, P.,

Zaninotto, P. 2014. Enjoyment of life and

declining physical function at older ages: a

longitudinal cohort study. CMAJ, 186(4): 150-

156.

Sudnongbua, S., LaGrow, S., Boddy, J. 2010.

Feelings of Abandonment and Quality of Life

Among Older Persons in Rural Northeast

Thailand. J Cross Cult Gerontol., 25: 257–269.

Teixeira, C.M., Vasconcelos-Raposo, J.,

Fernandes, H.M., Brustad, R.J. 2013. Physical

activity, depression and anxiety among the

elderly. Soc Indic Res, 113: 307–318.

Unsar, S., Erol, O., Sut, N. 2016. Social support and

quality of life among older adults. International

Journal of Caring Sciences, 9(1): 249-257.

Urban, D., Cherny, N. & Catane, R. 2010. The

management of cancer pain in the elderly.

Critical Reviews in Oncology/Hematology, 73,

176-183.

World Health Organization (WHO). 2015. Non-

communicable Diseases Progress Monitor 2015

(September 2015). ISBN: 978 92 4 150945 9

WHO Thailand. 2014. Noncommunicable Diseases

(NCD) Country Profiles. Retrieved from:

www.who.int/nmh/countries/tha_en.pdf

WHO. 2014. WHO Global Health Expenditures

Atlas (September 2014). Retrieved from:

www.who.int/health-accounts/atlas2014.pdf

Wysokiński, A., Sobów, T., Kłoszewska, I., Kostka,

T., 2015. Mechanisms of the anorexia of aging—

a review. Age, 37:81.

Yu, D.S., Lee, D.T., Man, N.W. 2010. Fatigue

among older people: a review of the research

literature. Int J Nurs Stud., 47:216 –228.

Zajc, JC., Kohont, A. 2017. Impats of work intensity

on employees’ quality of work, life and health.

Teorija in Praksa, 54(2): 209-223.

Comparison of Stress Level and Quality of Life in Elderly Who are Living with Chronic Illness in Bangkok and Surabaya

109