Determinant Factors of Quality and Life Satisfaction of the Older People

Older people’s health care is carried out by involving the family as a support group. If done optimally, the support provided will help maintain the health of older people. The purpose of the study was to analyze the determinant factors (family support and burden) on the quality and satisfaction of life the older people. This descriptive correlational research was the second stage of previous research related to the identification of caregivers' burden when caring for older people. A sample of 104 respondents was taken through simple random sampling. The results showed that the family support and family burden affected the older people's quality of life (< 0.05), but did not affect the older people's life satisfaction (> 0.05). Family support and burdens affect the QoL for older people, which is due to the family's ability in caring for older people and the need for long-term services at home. Recommendations for health workers, especially nurses, are to focus not only on the elderly but also to the family's physical, psychological, and financial burdens to increase family support.


Introduction
Globally, in 2020, the number of people with ages 65 years or over has risen to 727 million people. This number is projected to double to 1.5 billion by 2050. Over the past fifty years, the percentage of the elderly population in Indonesia has increased from 4.5% to around 10.7% in 2020. This figure is projected to continue to increase and will reach 19.9 percent in 2045 (Statistics Indonesia, 2022). This increase is in accordance with the life expectancy (LE) as a result of improving health quality. The data show that in the period 2010-2035, the LE population of Indonesia reached 69.8 and will increase to 72.4 in 2035. This figure is predicted to continue to increase until the LE of Indonesia's population reaches 77 years in 2050 (Ministry of Health Republic of Indonesia, 2018). The increase in the older people population affects health and quality of life (QoL) problems that are more critical than at other population group. As a person gets older, they tend to face complex health problems, that could become their most difficult condition (Kim & Ko, 2018). Issues that occur in older people include diseases, such as diabetes, heart disease, kidney disease, stroke and blood vessel disorders as well as health problems caused by decreased body functional problems, such as the risk of disability. These conditions would result in a reduced level of independence for the older people, which will ultimately affect the QoL (Andriyanto et al., 2019).
QoL is one of the most important concepts and has become the focus of attention of international organizations, such as the World Health Organization (WHO). WHO has interpreted QoL as an individual's understanding of their conditions and situations in life, such as their culture, value systems, life goals, life expectancy, standards, and priorities (Bahramnezhad et al., 2017). One of the factors that play a role in the care process for older people is support from the closest family (Sari et al., 2018). Family members as caregivers play a central role in managing all aspects of care. Family caregivers who care for older people are likely to face various problems in terms of physical, social, and economic during the treatment process, whereas the home care system is not adequate, and thus, informal care is broader than formal care. In general, the responsibility in caring for the older people who are at home rest with their spouse, children, relatives, or friends (Pessotti et al., 2018).
Previous research has found that the caregiver burden associated with subjective demands increased significantly over time. Perceived skill preparedness was high at baseline, but decreased over time. The overall QoL was moderate at the baseline, and decreased significantly over time (Grant et al., 2013). Other studies have consistently shown that an increased caregiver burden will result in decreased mental and physical health (Turkoglu & Kilic, 2012). Health problems and decreased body function in older people occur because of the aging process and are exacerbated by accompanying risk factors, causing physical and cognitive health problems (Saifullah et al., 2020). Various effects due to aging, such as decreased health status and chronic disease make older people a vulnerable population. Changes in various body systems can lead to the emergence of degenerative diseases in older people, such as dementia, osteoarthritis, heart disease, hypertension, stroke, and diabetes (Chin et al., 2014). Older people need support in carrying out health care to overcome these problems.
Therefore, a comprehensive approach to the older people should be considered including family support, and the health needs of the older people group, so that health workers can improve care through the development of a family nursing intervention model (Prazeres & Santiago, 2016). Families who do not understand how to care for older people will feel the burden of caring for older people, and the increasing burden of care will reduce the family's ability to provide care for older people (Turkoglu & Kilic, 2012). Family training is needed to support the basic needs of older people at home. In addition, families must also be able to increase empowerment by motivating older people to routinely carry out their health checks at the nearest service (Andriyanto et al., 2020). The results of the research in the previous stage indicate the existence of a relationship between caregiver burden in caring for older people and the QoL (Rekawati et al., 2020b). The QoL of older people will increase if the family provides support in care. The support provided by the family in the care of older people can also affect the life satisfaction of the elderly themselves. Further steps are needed to identify other factors (family support and burden) that affect the QoL and life satisfaction of older people. The purpose of the study is to analyze the determinant factors (family support and burden) on the quality and satisfaction of life the older people.

Methods
This research is descriptive correlational research. It is a stage 2 development in identifying other factors that influence the quality and life satisfaction of older people. A number of 104 respondents was taken through simple random sampling with the Slovin formula from a population of 140 respondents. The inclusion criteria were older people who live with family, have a non-communicable disease and are cooperative. The exclusion criteria comprise older people who have a chronic disease with complications and cannot read and write.
The instrument in this study used two questionnaires. The first questionnaire focuses on family support in older people's care with the validity test results ranging in value from 0.374 to 0.748 and a reliability value of 0.923 (Rekawati et al., 2020a). The second questionnaire is the modified Quality of Life (WHOQOL)-BREF, which was translated into Indonesian, with the results of the validity test of the value range of 0.638 to 0.879 and a reliability value of 0.9 (Vinsalia & Handajani, 2021).
The data collection process started by identification of respondents, and then providing instruments to the respondents. The univariate analysis were used to describe the respondents' age, gender, education, occupation, and health history of parents and family. Bivariate analysis was used to determine the relationship between family support and caregiver burden on the quality and life satisfaction of older people using the Chi-square test with a significance value of p-value < 0.05. The study received ethical clearance from the Faculty of Nursing, Universitas Indonesia. Principles in research ethics include respecting hu-man dignity, principles of justice and harmlessness, and benefits obtained.

Results
Characteristics of Respondents. The characteristics of respondents in this study include respondents' age, sex, education, profession, and history of the disease. Table 1 shows that the majority of respondents in the older people category were female, had primary education background, and hypertension history. While for ca-regivers, most of them aged 60-74 years, unemployed, and had secondary education.
The results of research related to family support, family burden, QoL, and life satisfaction of older people can be seen in Table 2. The majority of bad family support, good family burden, good QoL, and indicated that older people do not experience life satisfaction.
The results showed the existence of a relationship between family support and burden with the QoL for older people (0.046) and (0.028). There is no relationship between family support and burden with life satisfaction of the older people (0.082) and (0.252) (see Table 3).

Discussion
The findings show that family support and burdens in caring for older people affect the QoL of older people. These findings support previous research that has focused specifically on caregivers for lung cancer patients and indicated a high perceived caregiver burden led to decreased QoL (Grant et al., 2013). For the family burden factor dimension, caregivers experience high levels of stress, as evidenced by the results of the questionnaire. The emotional impact of care responsibilities weighs heavily on caregivers. The family is the main support system for older people in maintaining their health and the most effective place to provide care for older people with non-communicable diseases to maintain a good QoL (Rekawati et al., 2020b). The role of the family in older people's care includes looking after and caring for them, maintaining and improving their mental status, anticipating socio-economic changes, providing motivational support, and facilitating the spiritual needs of older people (Ishak et al., 2017). High family support can reduce morbidity and mortality, which in turn will improve the QoL of older people (Prazeres & Santiago, 2016).
Caring for older people with non-communicable diseases will create a feeling of burden or strain on the caregiver, which can affect the QoL of the family itself (Maryam et al., 2012). The burden of caring is a multidisciplinary response to physical, psychological, social, and financial stressors associated with family experiences in caring for clients (Pessotti et al., 2018). Increasing the burden of caring for older people is significantly related to low QoL, especially the health of older people (Turkoglu & Kilic, 2012   Based on the results of other studies, caregiver burden associated with subjective demands experienced increased psychological stress over time. The QoL decreased significantly over time (Grant et al., 2013). Families experience a high burden in caring for older people, namely psychological burdens identified through verbal characteristics such as stress, crying, and guilt because they have to leave the older person to earn a living and changes in the emotions of clients who are often angry and behave badly. Meanwhile, the physical load can be seen in facial expressions of fatigue, expressions of feeling tired and bored.
In addition, family difficulties in caring for older people include dividing time between caring and other roles, and economic burdens related to their medical costs (Maryam et al., 2012). Family members are an important component because they are the main source of care and support for older people (Widmer et al., 2018). Several studies have shown that family relationships have a protective effect on the individual, which is directly related to reducing individual stress and positively affecting the physical and psychological health of the individual. However, well-meaning family support does not necessarily improve the well-being of older people because it often causes more stress than comfort (Getanda et al., 2015). Indeed, if family support is perceived as too distracting, controlling, or dominating, it can generate resentment, resistance to behavior change, and stress (Turkoglu & Kilic, 2012). Previous research supports the results that family conflict relationships affect the level of individual stress that is felt in relation to psychological health (Widmer et al., 2018). Therefore, families must minimize the occurrence of conflicts by carrying out their roles carefully to enable older people to feel better life satisfaction because older people constantly require assistance in their activities. The lack of adequate coping strategies to deal with the demands of caregiving has a negative effect on caregivers' mental health and well-being and caregiver performance, sometimes leading to neglect of care (Sarabia-Cobo & Sarriá, 2021).
Indonesia is an Asian country that still upholds traditional and cultural values related to the assumption that parents need to be respected and protected. The results of research observations in Depok, families who care for their parents consider this a gift, a trial, a blessing, and a means of making themselves role models for others. The observations are also in accordance with previous research, which describes a child who takes care of his parents as a reward for the care given when he was young (Rekawati et al., 2020b). If a child or family is sincere in caring for their parents, it does not make up for the burdens of parenting. It will have a major impact on the QoL and parents have satisfaction in living their lives. The life satisfaction of older people is influenced by the chronic disease factors they suffer (Hu et al., 2016). Parenting is time-consuming and results in a great physical and mental burden. However, we also know that parenting has positive aspects and results in satisfaction (Sarabia-Cobo & Sarriá, 2021).
The perceived satisfaction and QoL of older people can be assessed based on their daily experiences. As they become older, older people will need more attention, support, care, and appreci-ation. The results showed that 14 caregivers were older people, and some were older couples. Thus, in providing support for older people's care, support is carried out together and they give attention to one another. The attention received by older people can be in the form of social support provided by family, relatives, or closest people (Pessotti et al., 2018;Rekawati et al., 2020b). The results showed that life satisfaction in older people is not related to family support and burdens in caring for older people. These results do not agree with previous studies that there is a relationship between family reward support and life satisfaction in the older people in Depok, West Java (Rekawati et al., 2020b).
Award support is one of the four types of family social support. Family appreciation support refers to the feedback that families give to individuals to help them evaluate themselves or assess a situation (Wiliyanarti & Muhith, 2019). Several limitations need to be recognized. Several chronic health problems were selected based on importance, and excluded patients with complications and comorbidities (Maryam et al., 2012). The current study did not consider the severity of any chronic health problems. Sample selection bias due to the possibility of nonconsecutive patient recruitment should also be considered. These results forced us to consider the role of workload as a contributor to life satisfaction, as highlighted by several authors in studies on life satisfaction (Esteban et al., 2022).

Conclusion
The determinant factor that affects the QoL for older people is the support and burden of the family, which can be attributed to the level of the family's skills in caring for older people and the need for long-term services at home. Further research could focus on developing a model of nursing intervention in overcoming health problems of older people that involves the family as a support system. Health workers, especially nurses, can pay attention to what the family felt in relation to the physical, psychological, and financial burdens so that health services for older people and their families can be carried out optimally. Health services in providing services to older people need to involve the family as the care support provider.