Han et al.

Health and Quality of Life Outcomes (2015) 13:31

DOI 10.1186/s12955-015-0225-5

RESEARCH Open Access

Psychosocial factors for influencing healthy aging

in adults in Korea
KyungHun Han1, YunJung Lee2, JaSung Gu3, Hee Oh3, JongHee Han3 and KwuyBun Kim3*

Abstract
Background: Healthy aging includes physical, psychological, social, and spiritual well-being in later years. The
purpose of this study is to identify the psychosocial factors influencing healthy aging and examining their
socio-demographic characteristics. Perceived health status, depression, self-esteem, self-achievement, ego-integrity,
participation in leisure activities, and loneliness were identified as influential factors in healthy aging.
Methods: 171 Korean adults aged between 45 and 77 years-old participated in the study. Self-reporting questionnaires
were used, followed by descriptive statistics and multiple regressions as inferential statistical analyses.
Results: There were significant differences between participants’ general characteristics: age, education, religion,
housing, hobby, and economic status. The factors related to healthy aging had positive correlation with perceived
health status, self-esteem, self-achievements, and leisure activities, and negative correlation with depression and
loneliness. The factors influencing healthy aging were depression, leisure activities, perceived health status, ego
integrity, and self-achievements. These factors were able to explain 51.9%.
Conclusions: According to the results, depression is the factor with the greatest influence on healthy aging. Perceived
health status, ego integrity, self-achievement, self-esteem, participation of leisure activities were also influential on
healthy aging as beneficial factors.
Keywords: Healthy aging, Depression, Perceived heath status, Self-esteem, Achievement, Ego-integrity, Leisure
activities, Loneliness

Background and mental wellness, independence, and quality of life,

Every person marks each stage of human development as well as enhancing successful life-course transitions
with certain achievements, and each stage is affected by [2]. This definition includes the physical, psychological,
the previous stage while additionally affecting the next social, and spiritual well-being of old adults. It also
one. Quality of life in old age is therefore influenced by signals an increasingly positive perspective on elderly
the individual’s lifestyle as an adult, and preparation for health and well-being. In recent studies, certain terms
senescence should be made during adulthood. But be- such as active aging, successful aging, positive aging, and
cause such preparation is crucial in determining the productive aging are used interchangeably to indicate
quality of life in old age and other health-related atti- healthy aging. For example, Kim and Chung uses
tudes, relevant education may play an important role “successful aging” synonymously with healthy aging
even from childhood [1]. Therefore, it is important to in- [3,4]. However, while successful aging is more of a goal
vestigate the recognition process of healthy aging and of old age, healthy aging can be considered as a series of
identify the influential factors in healthy aging at each processes for achieving successful aging, and is therefore
stage of life. a concept more pertinent to daily living [5]. Healthy
Healthy aging is a lifelong process of optimizing op- aging is what should be taken into consideration for
portunities for improving and preserving physical, social maintaining autonomy and independence towards suc-
cessful aging.
* Correspondence: [email protected] Nowadays, current trends indicate a populace unsatis-
3
College of Nursing Science, Kyung Hee University Seoul, Korea, 1
Hoegi-dong, Dongdaemun-gu 130-701Seoul, South Korea fied with just the basic necessities of life in elderly living
Full list of author information is available at the end of the article

© 2015 Han et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 2 of 10

(in other words, being merely disease- and disability- develop with integrating one’s life experience. Erikson also
free), showing instead a desire to maintain their current considered it as the result of seven stages of psychosocial
lifestyles, complete with all of their usual social and leis- development [20]. According to certain cross-sectional
ure activities. Healthy aging extends beyond the mere studies, generativity effects ego-integrity as an important
absence of disease or infirmity, and now includes phys- predictor, and Erikson’s prior stages are significantly cor-
ical, mental, and social well-being. The mental health of related to ego-integrity [21,22]. Torges et al. using a longi-
old people, consequently, also encompasses both positive tudinal dataset investigated how attaining successful
mental health as well as disease prevention. For this rea- generativity in midlife corresponds with higher levels of
son, much research on healthy aging related to mental ego-integrity in later life [23]. Psychological well-being ac-
health have focused more on identifying the psycho- quired through ego-integrity may also influence healthy
logical factors for active or successful aging or for psy- aging, but there are fewer studies examining ego-integrity
chological well-being, differing from previous studies as a factor influencing healthy aging.
that tended to concentrate on mental ill-health [6-8]. All the factors mentioned above affect healthy aging in
Consequently, many studies focus on the beneficial or correlation to each other, but many of the previous studies
risk factors for positive mental health, such as depres- investigate only one or two of these variables. In the
sion, self-esteem, self-efficacy, loneliness, and isolation, present study, we examined the above psychosocial factors
all factors that influence healthy aging. by including varying socio-demographic characteristics
In the present study, we propose to examine perceived and identifying the relative powers between the factors in-
health status, depression, self-esteem, self-achievement, fluencing healthy aging, with a final goal of facilitating so-
ego-integrity, participation in leisure activities, and lone- cial and clinical intervention for healthy aging. We also
liness as affecting factors on healthy aging. According to expanded the age range from 45 years-old, unlike previous
Mossey and Shapiro, well-being and mortality in old studies which tend to set their range from 60 or 65, due to
people are influenced by their belief in their own health studies on the aging process indicating that people tend to
as being good or poor, and old people who perceived commence practical preparation for old age approximately
their health more positively show higher well-being and in their 40s [24]. Koreans in particular may tend to be en-
less mortality [9]. Individual psychological resources gaged in healthy aging processes at this age due to their
such as self-esteem, self-achievement, and ego-integrity early retirement system.
are also important psychological factors for healthy
aging [6,10,11]. Several previous studies additionally in- Method
dicate that self-esteem is significantly correlated to our The present study investigated the psychosocial influ-
life outcomes such as human relationships, work, health, ence factors concerning the healthy using self-reporting
and healthy aging. However, the debate continues as to questionnaires examining with descriptive language,
whether self-esteem is a cause and/or consequence of followed by an analysis of the answers using inferential
healthy aging due to causal effect. A sense of self- statistics.
achievement also increases feelings of self-worth and
self-efficacy, improving positive mental health status as Subjects
well as the ability to have the psychological well-being The study sample consisted of 171 adults, aged between
necessary for healthy aging [11,12]. It seems that old 45 and 77. All participants were volunteers recruited
people possess a sense of self-achievement through the from institutions in the local community such as com-
participation of social or leisure activities; many studies munity centers, welfare centers, and church community
report leisure activities as a good indicator related to programs for adults. These adults were located in Seoul
healthy aging [13,14]. Other studies report that partici- and two other cities in Gyeonggi Province, South Korea.
pation in leisure activity relates to depression especially Two proctors visited and collected data at these places,
in old people [15,16]. Depression negatively correlates and gave more detailed information about the proce-
with mental health, with some studies reporting depres- dures of the study and asked to provide written in-
sion as a significant risk factor affecting healthy aging formed consent if they wished to enroll. We excluded
[17,18]. Loneliness and isolation among old people may people who have a history of alcoholism, and people
increase due to decreased personal relationships, with who were diagnosed with any psychiatric illnesses in-
such social isolation inducing or exacerbating geriatric cluding depression and dementia by a clinician and who
depression [19]. This study investigates the ego-integrity were under medical treatment. Regarding chronic dis-
affect on healthy aging because of how it can be a com- eases such as diabetes and hypertension, we included
pletion of psychological well-being in old age, according participants who were taking medication as outpatients
to Erikson’s psychosocial developmental theory [20]. but excluded adults who were hospitalized because of
Erikson’s concept of ego-integrity is complex for it may relevant diseases and needed the help of a caregiver.
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 3 of 10

Their demographic characteristics are reported in Perceived health status

Table 1. They were recruited according to the conveni- The Health Self Rating was used to measure self-
ence and snowball sampling methods. All participants perceived health status. The version used in the current
provided informed consent prior to the administration study was normalized for Koreans by Sung and Kim
of the procedure. Regarding sample size, a power ana- [27], and originally developed by Lawston, Moss, Fulcomer
lysis was conducted using the G*power 3.1 program and Kleben [28]. HSR consists of three items on a 5-point
[25]. Then, a minimum sample size was set for the scale: 1 item for current health states, another item for
present study at 153 (Cronbach’s alpha = .05, effect health status compared to peer group, and another item
size = .15, power (1-β) = .95, 7 independent variables). for comparing current status to the status of 6 months
Although the minimum sample size required was 153, prior. The reliability of the questionnaire was Cronbach’s
we collected data from 171 participants based on the ex- α = .79 [27], and the reliability in the study was Cronbach’s
pectation of missing data or error responses. α = .86.

Measures
Healthy aging Self-esteem
The Scale for Healthy Aging used for measuring healthy The normalized Korean version by Jeon of Rosenberg’s
aging was developed by Ko, consisting of 20 items on a Self-Esteem scale was used for measuring self-esteem in
5-point likert-scale [26]. This test measures mainly three the study [29]. This instrument consists of 10 items on a
different health factors: physical, cognitive-mental, and 5-point scale consisting of self-confidence, self-control,
social-supportive health. The range of scores is between and positive self-image. The scale is considered a reliable
20 and 100, and a higher score indicates a higher level of and valid quantitative tool for self-esteem assessment
healthy aging. The original reliability of the measure (Cronbach’s α = .85 by Jeon) and the reliability in the
is .89 (Cronbach’s α) and it was .88 in the present study. present study was Cronbach’s α = .79.
Table 1 Sociodemographic characteristics of respondents
Total N = 171
Variables Category N(%) M(SD) t or F p Post-hoc
Sex Male 74(45.4) 3.344(±0.533) −0.434 .664
Female 97(54.6) 3.365(±0.524)
Age (years) 45-60 66(39.6) 3.230(±0.490) 3.113 .015 b
61-70 77(45.0) 3.411(±0.543) b
>71 28(16.4) 3.381(±0.490) a
Education level Middle school 60(38.2) 3.279(±0.585) 6.828 .000 a
High school 85(45.0) 3.347(±0.497) a
College or above 26(20.8) 3.519(±0.461) b
Religion Yes 121(64.1) 3.436(±0.535) 4.682 .000
No 50(35.9) 3.210(±0.485)
Marital status Yes 158(78.9) 3.373(±0.528) 1.393 .163
No 13(21.1) 3.290(±0.529)
Residential status One’s own house 155(77.7) 3.400(±0.510) 4.266 .001
Rental house 16(22.3) 3.194(±0.542)
Avocation Yes 113(61.0) 3.519(±0.503) 9.290 .000
No 48(39.0) 3.098(±0.465)
Socioeconomic status High 9(5.2) 3.749(±0.558) 25.072 .000 a
Middle 107(62.6) 3.448(±0.472) b
Low 55(32.2) 3.167(±0.536) c
Income activity Yes 102(57.0) 3.394(±0.536) 1.845 .065
No 69(43.0) 3.306(±0.516)
Medication Yes 61(40.2) 3.301(±0.517) −1.128 .260
no 110(59.8) 3.384(±0.550)
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 4 of 10

Depression Data collection

For assessing depression, the Geriatric Depression Scale The present study was reviewed and approved by the
Short Form-Korea Version (GDSSF-K) normalized for ethics committee at KyungHee University (KHU 2012-
Koreans by Kee was used [30]. This scale was adapted S08) before collecting any data, and all subjects provided
for the purpose of the present study, reconstructed on a informed consent for study participation. We conducted
5-point likert scale consisting of yes/no alternative a pilot-survey for selecting the tools, randomly recruiting
choices for performing regression analysis. The tool is 50 sample subjects. In the main research, we distributed
specifically for assessing geriatric depression, consisting the self-reported form questionnaires with informed
of 15 items of the particular symptoms of geriatric de- consent after providing a proposal for utilizing the data
pression. The reliability of the tool in the research of from the research. We collected 180 samples with 171
Kee was Cronbach’s α = .88 [30], and the reliability in the samples being used in the study, excluding 9 inadequate
present study was Cronbach’s α = .86. samples from statistical analysis. 3 participants skipped
one or more page without marking and 2 participants
Ego integrity dropped out complaining that the questionnaire was too
Ego integrity was assessed using a tool invented by Kim long and 4 participants responded to questions without
[31] based on the theory of psychosocial development by sincerity such as making with one number on all ques-
Erikson. This questionnaire consisted of 31 items on a 5- tions and/or marking a repeated pattern of numbers.
point scale within 6 subscales: satisfaction of the current
life, wise living, attitude of life, acceptance of the past, ac- Data analysis
ceptance of aging, and acceptance of death. The original re- The collected data were analyzed using SPSS Statistics
liability of the questionnaire is Cronbach’s α = .91 [31], and 20.0 in accordance with the purpose of the study and
the reliability in the present study was Cronbach’s α = .92. the characteristics of the variables. The significance level
was set at P < 0.05 and post-hoc analyses were per-
Self-achievement formed where appropriate, with an effect size set at .15
For assessing self-achievement, we used Roh’s tool [32], for regression analysis.
consisting of 12 items on a 5-point scale. The higher the
score was, the higher the self-achievement. Self- 1) To calculate the differences in healthy aging
achievement measures the level of the subject’s belief, according to the demographic characteristics of the
confidence, and positive expectation of his or her own research subjects, t-tests and analyses of variance
potential, and concretely how the subject realized his or were conducted. For the post hoc analysis, Scheffe’s
her own value by satisfying life needs and goals. The reli- method was used.
ability verified by Roh was Cronbach’s α = .74 [32], and 2) The healthy aging of the subjects and relevant
the reliability in this study was Cronbach’s α = .81. variables, averages, and standard deviations were
measured.
Participation in leisure activities 3) For the correlations within the variables related to
Participation in leisure activities was assessed by Seok’s the healthy aging of the research subjects, Pearson’s
tool [33], consisting of 9 items on a 5-point scale with 3 product moment correlation coefficient was used to
different levels: at home with family, sports, and appreci- examine the relevance.
ation of art. The reliability of this questionnaire was 4) To examine and compare the factors influencing the
Cronbach’s α = .81 [33], and the reliability in our study healthy aging of the research subjects, a regression
was Cronbach’s α = .83. analysis was conducted on perceived health status,
self-esteem, depression, ego integrity, self-
Loneliness achievement, participation in leisure activities, and
The tool used for measuring loneliness was originally loneliness.
developed by Wythers [34]. The revised version for 5) Internal consistency of the tools was estimated by
Koreans used in this study that verified its validity and Cronbach’s alpha reliability coefficients.
reliability was developed by Maeng [35]. The tool con- 6) We divided the participants into 3 groups by age in
sists of 26 items on a 5-point scale. In the study, loneli- order to compare age difference: 45–60 years-old,
ness is a measure of the level of the subject’s negative 61–70 years-old, and 71 year-old over. According
feeling caused by isolation or lack of companionship, psychosocial development theories, Erikson sorted
and the failure of seeking personal and social relation- 40’s and 50’s into middle age and Havinghust et al.
ships. The reliability of the tool in Maeng’s research was also defined the middle aged to be from 30 to 60
Cronbach’s α = .96 [35], and the reliability of the tool in [36,37]. We followed a recent gerontology study’s
the present study was Cronbach’s α = .95. sub-grouping for our study, which distinguishes the
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 5 of 10

young old (60–69), the middle old (70–79), and the Correlations between healthy aging and psychosocial
very old (80 and over) recognizing the diversity of factors
old age, especially considering how the retirement The mean score of healthy aging was 3.36 (SD = .53).
age is comparatively earlier in Korea than in European The means of the other relevant variables were: self-
countries or the US (regular retirement starts from achievement [M = 3.66, SD = .55], self-esteem [M = 3.42,
55 years old in Korea) [38]. SD = .60], perceived health status [M = 3.28, SD = .68],
loneliness [M = 2.93 SD = 0.73], ego integrity [M = 2.85,
SD = .28], participation in leisure activities [M = 2.81,
Results SD = .74], and depression [M = 2.54, SD = .64]. We ex-
Demographic characteristics and healthy aging amined the correlation between healthy aging and psy-
The differences in the healthy aging by demographic chosocial factors for observing the correlation of the
characteristics of the research subjects were examined factors with each other (see Table 2). In the results, per-
by t-test and ANOVA, and Scheffe’s test was used for ceived health status [r = .448, p < .001], self-esteem [r =
the post hoc test (see Table 1). As a result, there was no 0.53, p < .001], self-achievement [r = 0.44, p < .001], and
significant difference between sex difference [t = −0.43, participation in leisure activities [r = 0.54, p < .001] had
p = .664]. In terms of age, healthy aging scores in the significantly positive correlation with healthy aging. Depres-
group of people 61–70 years-old was higher than in the sion [r = − .60, p < .001], and loneliness [r = − .19, p < .001]
group of people of 71 years-old or older, and the scores were negatively correlated to healthy aging at statis-
in the group of 45–60 years-old was lowest [F = 3.11 tically significant levels. Depression and loneliness
p = .015], but the group of 71 years-old or older differed negatively affected healthy aging in this study. Thus,
from the two groups of people 45–60 years-old and 61– depression and loneliness correlated positively with
70 years-old according to the results of the post hoc test. each other but they had negative correlation with other
People with higher educational backgrounds showed a all positive factors in the study. However, we could
higher degree of healthy aging [F = 6.82, p < .001). People not observe significant correlation between ego integ-
with religion showed a higher degree of healthy aging rity [r = − .002] and healthy aging.
than those without religion [t = 4.68, p < .001]. No dif-
ference was found between married and non-married Psychosocial factors influencing healthy aging
participants [t = 1.39, p = .163]. Regarding residential The Stepwise regression analysis was used for examining
types, home-owning subjects showed a higher degree of the psychosocial influence factors of the healthy aging.
healthy aging than those who rent property [t = 4.27, As a result (see Table 3), healthy aging was shown to be
p = .001]. People with a hobby presented a higher score significantly influenced by depression, participation in
of healthy aging than those who did not have one [t = leisure activities, perceived health status, ego integrity,
9.29, p < .001]. People with higher income levels showed self-achievement, and self-esteem (in that order). How-
having healthy aging [F = 2.51, p < .001]. Although people ever, loneliness did not seem to affect healthy aging. The
who were involved in economic activities showed a higher explanatory power of the final model was relatively high
score of healthy aging [mean = 3.39 ± 0.54], the result was [R2 = .526] and the final regression model was statisti-
not statistically significant [t = 1.85, p = .065]. Finally, treat- cally significant [F = 91.2, p < .001]. In addition, a vari-
ment with medications appears to have no influence on able with a higher tolerance limit is better because the
the degree of healthy aging [t = −1.13, p = .260]. tolerance limit is a variance in which the independent

Table 2 Correlation coefficients between healthy aging and variables

Healthy Perceived Self-esteem Depression Ego-integrity Self-achievement Participation of Loneliness
aging health status leisure activities
Healthy aging 1.000
Perceived health status .449*** 1.000
***
Self-esteem .525 .368*** 1.000
***
Depression -.595 -.421*** -.711*** 1.000
**
Ego-integrity -.002 -.061 -.144 .318*** 1.000
*** *** ***
Self-achievement .439 .229 .390 -.390*** .057 1.000
*** *** *** ***
Participation of .539 .333 .327 -.409 -.026 .385*** 1.000
leisure activities
Loneliness -.193*** -.201*** -.280*** .427*** .402*** -.147** -.215*** 1.000
*** **
: p < .001, < .01.
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 6 of 10

Table 3 Factors affecting healthy aging in the study samples

Variables B β t p Tolerance VIF Adj. R2 & F
A constant 1.652 5.944 .000 Adj. R2 = .526 F = 91.2 (p < .000)
Depression −0.273 −0.331 −6.613 .000 0.385 2.599
Participation of leisure activities 0.196 0.273 7.594 .000 0.744 1.344
Perceived health status 0.123 0.158 4.508 .000 0.781 1.280
Ego-integrity 0.242 0.129 3.820 .000 0.846 1.182
Self-achievement 0.113 0.117 3.236 .001 0.741 1.349
Self-esteem 0.101 0.114 2.523 .012 0.469 2.132

variable is not explained by other variables. Independent depression, participation in leisure activities, perceived
variables are statically valuable if VIF (variance inflation health status, ego integrity, self-achievement, and self-
factor) is less than 3. In the present model, all VIFs were esteem (in that order). These results were consistent
less than 3. We confirmed that the error terms also with previous studies reporting that depression nega-
showed a normal distribution examining the P–P plot of tively influences healthy aging [41,42]. In effect, several
error terms. studies reveal a similar result with our findings. Some
studies report that a higher perceived health status re-
Discussion sults in higher healthy aging [43-45], and another study
The purpose of the present study was to find the psy- points out the importance of psychological well-being
chosocial factors influencing healthy aging for assisting on healthy aging [46], while still other studies suggest
the preparation of active and successful aging, a socially that self-achievement and self-esteem relate to healthy
relevant issue as interest in and demand for healthy aging [47,48].
aging continues to increase due to the elongation of our In our study, depression was a more influential psy-
average lifespan and the growing elderly population. For chological factor on healthy aging. This finding means
this reason, we selected seven psychosocial influence fac- that not only physical health but also mental health is
tors of healthy aging suggested by previous studies, ob- very important to healthy aging and the life of old
serving how these factors affect healthy aging in tandem. people. Notably, Johnson and Barer report that people
A further goal of this study is to promote the develop- with good mental health are conscious of successfully
ment of psychosocial intervention that maintains and aging, even though their physical health status is consid-
promotes healthy life in old age. ered relatively poor [49]. In effect, many studies reveal
As we analyzed demographic characteristics, we found that good mental health can reduce depression as well
that age, religion, educational background, residential as a sense of alienation and loneliness by enhancing self-
status, economic level, and hobbies were influential in esteem due to increasing their participation in social ac-
healthy aging, with sex difference, spousal status, partici- tivities [40,43]. Old people tend to enjoy their daily lives
pation of income activities, and taking medication as more by maintaining their mental health and vitality of
having no effect. Linda suggests that the most influential life by doing leisure activities for stimulation and self-
social factors on healthy aging are family status and reli- development even if their activities are focused exclu-
gion [5], while some studies report that age, economic sively on work or income, and this is a trend of healthy
level, existence of a spouse, healthy and positive think- aging. However, loneliness did not influence healthy
ing, and hobbies are more important social influencing aging, and we could not find research that suggested any
factors in healthy aging [39,40]. Some of our results were direct influence, even though several researchers report
consistent with these previous studies but some results that loneliness is related to mental health and cognition,
were not, and the results of previous researchers are also and is also predictive of depressive symptoms. In our re-
not completely coherent. These discrepancies are prob- search, loneliness might be influenced by depression
ably due to differences in the socio-demographic factors during the regression analysis or simply was not a pri-
of the samples in each study and/or by territorial cul- mary influence factor on healthy aging.
tures and the current atmosphere of the samples’ Similar to previous studies, perceived health status,
societies. self-esteem, self-achievement, ego-integrity, and partici-
Most psychosocial influence factors selected in the pation in leisure activities positively affected healthy
present study affected healthy aging, according to the re- aging [6,9,11,43-45,47,48]. Hong pointed out that psy-
sults. In the regression analysis, the factors that signifi- chological well-being is very important in healthy aging
cantly influenced healthy aging were determined to be and for this reason, the psychological perspective, the
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 7 of 10

psychosocial, and the multidimensional model of healthy ego-integrity is a more stable factor that reflects the sta-
aging are regarded with more attention in recent healthy tus of psychological well-being in later life, which is in-
aging studies [46,50-54]. Belief in one’s own health as be- fluenced by one’s entire prior life according to Erikson’s
ing good or poor is very important for healthy aging. psychosocial development theory [59]. Erikson and col-
Mossey and Shapiro report that old people with more leagues already reported that successful balancing of a
positive perceived health show higher well-being and less development stage assists in facilitating the subsequent
mortality, while other studies report a positively perceived stage [60]. And many studies using both cross-sectional
health status affects healthy aging, consistent with our re- and longitudinal data report that achieving successful
sults [9,43-45]. The variables regarding individual psycho- generativity in mid-life facilitates attaining high levels of
logical resources such as self-esteem, self-achievement, ego-integrity in later life [21-23]. Ego-integrity does
and ego-integrity also consistently influence healthy aging seem to influence stability in our study as well. But there
in our findings as in previous studies [6,10,11]. However, are certain limits to discussing with our results how
we cannot know for sure whether self-esteem is a cause ego-integrity affects healthy aging, and therefore it
and/or consequence of healthy aging due to causal effects, would be worthwhile to observe how ego-integrity af-
even though many studies report that self-esteem influ- fects healthy aging independently through studies with
ences healthy aging. Self-esteem correlates significantly to diverse aspects.
our life outcomes in all age groups, not only for old age. There was no single-factor determinant of healthy
Not surprisingly, self-achievement also affects healthy aging. Many previous studies independently investigated
aging, as in previous studies [11,12]. The experience of healthy aging through biomedical or psychological per-
achievement may improve positive mental health status, spective studies [50,51]. Nowadays, the multidimensional
but old people have less opportunity to experience model of healthy aging is generally accepted because the
achievement. Participation in social or leisure activities factors of both perspectives are related reciprocally even
may enable a sense of self-achievement; leisure activities though they are theoretically dissimilar [52-54]. Interest-
was a positive factor on healthy aging, an observation con- ingly, we can observe similar outcomes in economically
sistent with previous studies, with some studies reporting developed countries in both the East and the West. Ng
that participation in leisure activities decreases depression et al. report that a multidimensional definition of suc-
particularly in old people [13-16]. As our results show, all cessful aging identifies more than the biomedical defin-
individual psychological resources correlate to social inte- ition in a Chinese-Singaporean sample that analyzes
gration because old people strengthen and improve their both cross-sectional and longitudinal data, and another
individual psychological resources through participating in cross-sectional study with Chinese elderly in Shanghai
social and leisure activities. However, as mentioned before, reported similar results as well [61,62]. According to a
old people tend to have less of a chance to participate, es- systematic review of Cosco et al., they report that
pecially after retirement. More public concern for increas- physiological factors such as physical status, disability,
ing the opportunities for their participation in social and and disease presence are more effective on healthy aging,
leisure activities is needed, in addition medical services but psychosocial factors such as affective status, social
and financial support. relations, and psychological well-being are more salient
Notably in our investigation, ego-integrity was in- similarly in all countries from studies analyzing 84 re-
cluded as an influencing factor by regression analysis, search articles published in between 2011 and 2013 in
but it did not significantly correlate with healthy aging. developed European, American, and Asian countries in-
According to many previous studies, ego-integrity is re- cluding South Korea [63]. Koreans generally had a nega-
lated to the factors of health status, social activities, self- tive perspective of retirement and aging because in the
esteem, self-efficacy, and social support, as well as other past, Korean old people tended to be physically and eco-
later life adjustment indexes such as life satisfaction, nomically dependent on their children and had to live
death anxiety, and sleep disturbance [55-58]. Consist- together. Therefore, their scope of life and social activ-
ently in our results, ego-integrity correlated significantly ities were relatively limited. In the last decade, the per-
with psychological factors such as depression, loneliness, ception of retirement and aging has changed more for
and self-esteem but not to perceived healthy status, par- the positive, but not as much as to the level of West-
ticipant leisure activities, and self-achievement. Accord- erners. According to a research report in 2010 from The
ing to our findings, ego-integrity may have an effect on Korea Institute for Health and Social Affairs, Korean old
healthy aging, but not directly (or primarily) because people spend more money on leisure activities, medical
healthy aging is inevitably influenced by physical health care, and exercise not only for maintaining physical sta-
in spite of the importance of mental health. However, it tus and avoiding diseases, but also for positive life-
is obvious that attainment of ego-integrity is an essential experiencing achievement, improving social relation-
task for old people as Guzman et al. mentioned because ships, avoiding depressive feelings, and integrating into
Han et al. Health and Quality of Life Outcomes (2015) 13:31 Page 8 of 10

society [64]. Recent studies from South Korea on healthy psychological factors that have not been assessed yet in
aging emphasize the importance of psychosocial factors recent healthy aging studies should be examined, as well
including ego-integrity, similarly to our study’s outcome, as the risk factors on healthy aging including more nega-
which were not regarded as important in studies on tive psychological factors. Additional research that dir-
healthy aging in the 90s [3,4,6,7,11]. ectly compares biomedical and psychosocial factors on
The maintenance of high levels of physical function is healthy aging are also needed, as the subject’s functional
still an important indicator of healthy aging. The level of capacity and health behaviors were not measured in the
physical activity and the functional status in old people present study.
correlates with psychosocial variables such as depression,
psychosocial skills, self-efficacy, and social support [65]. Conclusion
Some psychosocial factors for influencing healthy aging The present study investigates the psychosocial factors in-
that are found in our study, such as depression, per- fluencing healthy aging for promoting healthy living in old
ceived health status, and participation in leisure activ- age and developing socio-cultural care and support for old
ities, are related to physical activities in old adults. people. In light of the results, it can be inferred that de-
Several studies show that depression and poor perceived pression is the factor with the greatest influence on healthy
health status are risk factors in functional status decline aging. Factors such as participation in leisure activities,
in old people, and old people who have only a single perceived health status, ego-integrity, self-achievement,
chronic disease or were dependent on others for caregiv- and self-esteem also affect healthy aging with significant
ing had low self-esteem and experienced more depres- correlations between them. In particular, ego-integrity’s in-
sive feelings in their daily lives [66,67]. Inevitably, the fluence in completing psychological well-being in old age
status of physical function in old people was a more (according to Erikson’s psychosocial developmental theory)
basic fundamental factor on healthy aging interacting is an interesting finding of this study, meriting further in-
with psychological factors and built environmental fac- vestigation in the future. Finally, our findings make a step
tors on healthy aging. The strength of social relation- toward understanding healthy aging in terms of the psy-
ships of old people is related reciprocally to the status of chosocial perspective, and may help both society and indi-
physical function and psychological factors such as de- viduals in the planning of healthcare for old people.
pression and self-concept [68]. Old people may experi-
Competing interests
ence successful achievement, expand their social and The authors declare that they have no competing interests.
personal relationships, have more chance to increase
their physical activities participating in leisure activities, Authors’ contributions
KH and KB conceptualized the article, performed the analyses, interpreted
and consequently have less depression leading to more the results, drafted and revised the manuscript, and also incorporated the
vitality in life. According to the outcomes of previous comments from the co-authors. LJ, JS, H and JH contributed substantially to
studies, it is true that psychosocial, physical, and envir- the manuscript. All authors read and approved the final manuscript.
onmental factors interact reciprocally with healthy
Acknowledgements
aging [65,69,70]. This work was supported by the National Research Foundation of Korea
A major limitation of the study has to do with the re- Grant funded by the Korean Government [NRF-2009-351-H00002].
search sample and sample-size. It is still difficult to say
Author details
that our subject group is representative of Korean old 1
Behavioral Science Research Center, Korea University, Seoul, South Korea,
people as almost all of the participants live in major cit- 136-701, 1, 5-ka, Anam-dong, Sungbuk-ku, Seoul, South Korea. 2College of
ies, giving them more access to various socio-cultural Nursing, Seoul Women’s College of Nursing, 38 Ganhodae-ro, Seodae-
mun-gu, Seoul, South Korea. 3College of Nursing Science, Kyung Hee
benefits or support than people who live in smaller cities University Seoul, Korea, 1 Hoegi-dong, Dongdaemun-gu 130-701Seoul, South
or rural areas. Although the sample-size was satisfactory Korea.
under statistical analyses for examining the factors af-
Received: 9 October 2014 Accepted: 18 February 2015
fecting healthy aging, a still bigger sample is needed for
observing the difference or alteration of psychosocial
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