Social Interaction Using Spirituality Therapy to Improve the Quality of Life of the Elderly in the Community

Introduction

The impact of enhancements in science and technology, especially in the health section, has succeeded to reduce the rate of neonatal mortality, so that it has an impact on increasing the number of elderly. This increase in the number of elderly is also shadowed by a rise in life expectancy (1). Elderliness is a concept, the definition of which is broad, encompassing changes and losses in aging people. These changes include socioeconomic, environmental, educational, and nutritional factors. All systems in the body are affected by aging (2).

Psychological problems in the elderly are one of the aging processes that will be experienced by all elderly. These problems include short-term memory, frustration, loneliness, fear of losing freedom, fear of facing death, changes in desires, depression, and anxiety. Psychological problems in the elderly usually occur due to role transitions in the social environment, loss, physiological changes, and death (3). Aging causes various health problems, such as physical, mental, and intellectual weakness, various diseases, predisposing damages, decreased quality of life, as well as increased need for attention and  intensive care pattern (4). Changes in the quality of life experienced by the elderly commonly lead in a bad direction. Regularly, it is related to the socio-economic environment of the elderly such as retirement, loss of loved family members and friends, dependence on the necessities of life, and a decrease in a physical condition caused by aging. These changes are obstacles in determining the level of welfare of the elderly due to a decrease in meeting the needs of life (5). Quality of Life is a widespread concept and a combination of understanding physical, psychological, independence, social relations and interactions with the environment, personal beliefs and values. Low quality of life also causes depression, social isolation, and reduced daily activities (6).

Changes that occur in the elderly will result in a decrease in the social role of the elderly and also health status. As a result, the elderly will lose their jobs and feel incapable. It affects the social interaction of the elderly because they slowly withdraw from relationships with the surrounding community. Poor social interaction in the elderly can affect their quality of life and cause them to feel isolated, so that they like to be alone and depressed (7).  Since the elderly experience limitations and inability to perform activities, their quality of life will decline. Care is needed to improve the quality of life of the elderly where the role of the family is critical because it is the smallest unit of the community (8).

In Korea, quality of life represents a concept of subjective physical and psychological well-being, which serves as an important indicator for evaluating chronic diseases and predicting health outcomes such as mortality and morbidity. Among the various tools used for measuring Health-Related Quality of Life (HRQoL), the European Quality of Life-5 Dimensions (EQ-5D) questionnaire has been recognized as suitable for the general population. Although it has only a few questions, it is divided into various profifiles. Several previous studies showed that older adults who usually eat alone are unhappy and depressed,and have a lower HRQoL than those who eat together. However, few studies examined the association between the frequency of eating together and HRQoL (Health-Related Quality of Life) considering the demographic factors, socioeconomic status, health behaviors, and comorbidities in the adult population (9). Patient's knowledge based on training is very important to increase the needs of the elderly. Educational interventions can be considered as important factors for promotion of well-being and improvement of quality of life (4).

The quality of life is influenced by the relationship of the elderly with the surrounding environment, physical condition, psychosocial state, and level of independence (10). Psychological changes experienced by the elderly will cause them to slowly withdraw from relationships with the surrounding community, so that they can affect social interactions. Reduced social interaction in the elderly can cause feelings of isolation and depression, so that it can affect their quality of life (3). Social interaction arises because human apart from being an individual is a social being too. Humans as individual beings have the urge or motive to hold relationship with oneself, while humans are social creatures have the urge to hold relationships with others (11). Participation of the elderly in activities in a friendly environment is one of the key elements in improving their quality of life and general health and, consequently, reducing disability in old age. In addition to focusing on the rights of these people, this approach can be beneficial to maintain social order and improve the quality of life in this population group. The concept of quality of life has been considered an important indicator for evaluating individual health, judging the physical and mental health of the elderly, and finding the main problems in various aspects of their lives (12).

Social interaction is a social relationship which affects the individuals in a society and lasts throughout their life. Social interaction can have a positive impact on the quality of life because the elderly will not feel lonely by social interaction. One of the social interactions for the elderly is using spiritual therapy because in addition to developing human relationships, it also develops relationships between humans and God (13).Therefore, social interactions must be maintained and developed in the elderly group. The elderly who can continue to have good social interactions also can maintain their social status based on social skills. Good social interaction allows the elderly to get a feeling of belonging to a group so that they can share stories, interests, attention, and creative and innovative activities (14). One of the social interaction therapies for the elderly is using a spiritual sermon. The elderly who involved in Islamic activities have a higher level of happiness compared to others (15). Considering the importance of social interaction in the elderly, researchers are interested to investigate the effect of social interaction on the quality of life of the elderly in the community by conducting several educational course activities to improve the skills of the elderly and focuse on religious activities in the form of regular sermons. The present study was performed aimed to examine the effect of social interaction using spirituality therapy to improve the quality of life of the elderly in Gedongan Village, Baki District, Sukoharjo Regency, Indonesia.

Methods

This quasi-experimental study was performed with a pretest-posttest method and a control group design. The study was conducted from January to February 2022 in the Gedongan Village, Baki District, Sukoharjo City, Central Java Province. The population in this study was the elderly in the village of Gedongan. According to the Sugiyono's theory stating that for a simple experimental study with an experimental group and a control group, the sample size was between 10 and 20 in each group (16), so the researcher used 40 samples. Sampling was done by purposive sampling. The inclusion criteria were elderly aged 60 years, Muslim, women, not having a chronic disease, physically healthy condition, and ability to participate in activities conducted by the researchers. Meanwhile, the exclusion criteria were the elderly with total bed rest, not Muslim, and having chronic disease. The allocation of participants into the intervention or control groups was carried out by a research assistant using the technique of collecting data on participants in four Integrated Healthcare Center (posyandu) for the elderly in the village of Gedongan. There were a total of 114 participants in this study, but 74 respondents did not meet the inclusion criteria (16 participants were not Muslim, 14 were aged <60 years, 31 had chronic diseases, 4 were physically unhealthy, and 9 male participants). Therefore, 40 participants included in this study. The subjects were divided into 2 groups, namely the intervention group which received the social interaction using spiritual healing sermons with Islamic teacher and interaction with peers, and the control group only received the social interaction with peers. Participants were not informed about the groups, so that before the therapy the participants were asked to fill out a research agreement, then each therapy was carried out at a different place and time. In both groups, no individual was excluded during the follow-up. So, final analysis was done for 40 individuals (Figure 1).

The Social Interaction Intervention was completed separately between the intervention group and the control group to respect the ethical ethics. Then, participants were selected according to the inclusion criteria and a pretest was performed. Social interaction group used spirituality therapy in three 90-minute sessions (table 1). During the first 15 minutes of interaction with peers, participants were asked to tell about daily activities at home accompanied by cadres and there was motivation from cadres to improve daily activities. The next 15 minutes was related to reading verses from the Holy Quran. Next 50-minute session included participation in religious programs, spiritual healing sermons with Islamic teacher on the importance of socializing and getting closer to God and giving the spirit of the patient's quality of life. Social interaction interventions used spirituality therapy, namely religious events in the form of sermon activities or lectures led by an Islamic teacher (religious expert). Sermon activity is one way to strengthens relationships and friendships in the community. The sermon is communication conducted by one person or group of people intending to equate meaning in face-to-face situations. Communication in this study is a good relationship to promote, maintain, and increase relationships and do good things to fellow human beings, both relatives and the community. The last session included 10 minutes for discussion (13,17). The intervention was done two times a week for three weeks using group therapy. The control group was given social interaction therapy with peers for 30 minutes each session. A post-test was performed in both group one week after the end of the intervention. After the post-test was done between the two groups, the control group was given spiritual therapy.

Figure 1. The flowchart of the study

Table 1. Spiritual-religious intervention for the elderly (13,17).

The research instrument used the WHOQOL-BREF questionnaire, consisting of 26 questions which were divided into 24 questions based on the four aspects of quality of life and two questions regarding the overall quality of life and general health perceptions. This questionnaire was adopted from the WHOQOL-BREF questionnaire which was scored on a five-point Likert scale (1-5) and four kinds of answer choices. After scoring, all scores were summed up and then converted into a table so that it becomes a scale of 0-100. The score of 0 is the poorest quality of life while the scale of 100 represents the best quality of life. The components of quality of life questions included physical health (seven items), psychological (seven items), social (four items), environment (nine items), and general health (two items). Quality of life scores ranged from very poor (0-20), poor (21-40), moderate (41-60), good
(61-80), and very good (81-100). The WHOQOL-BREF questionnaire had been tested for validity in the Munawwaroh's study. The results of the validity test of the questionnaire were 0.818 and the reliability test used Cronnbracs Alpha with R-value = 0.891 (18). Moreover, the researcher conducted a content validity test which was a test of the contents of the lecture material through professional judgment on the lecture guide leaflet that would be delivered by the Islamic religious educator. The testers for content validity were an elderly programmer at the Baki Sukoharjo Community Health Center and a lecturer in Islamic religious education at the University of Muhammadiyah Surakarta. Univariate analysis uses descriptive statistical methods to determine the frequency distribution. Then, the GEE analysis with the Ordinal Logistic Regression model was used to see the effect of the time variable on changes in Quality of Life in elderly subjects. The Independent T-Test was also used to check the differences.

Results

This research was conducted at the Elderly Integrated Healthcare Center (Posyandu) in Gedongan Village, Baki District, Sukoharjo Regency with a total of 40 elderly respondents. The frequency distribution of the participants' characteristics is presented in Table 2. Most participants (n=19, 95%) in the treatment group and 15 participants (75%) in the control group was 60-74 years old (elderly). Marital status in the treatment group was balanced between the widow and married status with 10 participants (50%), while in the control group, 11 participants (55%) were married. The highest educational level in the treatment group was mainly graduated from elementary school with a total of nine participants (45%); in the control group, eight participants (40%) did not go to school (40%). The major profession in the treatment group was farmers with seven participants (35%), while in the control group, seven participants (35%) were unemployed (35%).

Table 2. Frequency distribution of demographic characteristics in the treatment and control groups

The distribution of participants based on the results of the pre-test was shown in Table 3. Accordingly, 13 respondents in the treatment group had a good quality of life (65%), and 7 respondents had a very good quality of life (35%), while in the control group, two respondents had a good quality of life (10%), and 18 respondents had a very good quality of life (90%). The results of post-test indicated that in the treatment group, 7 respondents had a good quality of life (35%), and 13 respondents had a very good quality of life (65%). However, the results of post-test in the control group were the same as the pre-test results.

The results of the two Treatment Difference Test in this study used the GEE Test which is a regression approach used on longitudinal data with correlated data. Longitudinal data itself is cross-sectional time series data, in which subjects (cross-sectional) are observed in two or more time periods (time series). In this study, pre-test and post-test were the two time periods. GEE analysis with the Ordinal Logistic Regression model was applied to evaluate the effect of time variables on changes in Quality of Life in elderly subjects. The results of the GEE test analysis revealed that the wald Chi-square in the treatment group was 1.744 with a P-value of 0.006 after the post-test, so the time variable has a significant effect on the model, so that the output regression results showed that social interaction using spirituality therapy improves the quality of life. However, the wald Chi-square in the control group was 8.690 with a P-value of 0.999 after the post-test, therefore, the time variable has no significant effect on the model. So the results of the regression output showed no effect. The control group showed a p-value of 0.999 > α=0.05 which indicates that the time variable has no significant effect on improving the quality of life of the respondents. Whereas in the treatment group p-value = 0.006 < α = 0.05 indicates that the time variable has a significant effect on improving the quality of life of the respondents.

Based on the results of the significant odds ratio value, only the treatment group proved that the time variable was included in the model. The logic model of the time variable that affects the quality of life in the elderly (in the treatment group) is as follows: The difference between very good QoL and good QoL, the elderly who have been intervened (post-test) tend to have a very good QoL of 0.29 times compared to the elderly who have not been intervened (pre-test).

Table 3. Frequency Distribution of Quality of Life in Pre-Test and Post-Test in the Treatment and Control groups

Discussion

The results of the current study showed that most participants in the treatment group and the control group aged 60-74 years (elderly). The elderly will experience psychosocial changes that affect their quality of life. The increasing age of the elderly can cause various problems both physically and mentally, and changes in social conditions that can result in a decrease in social roles (19). Elderly with excellent quality of life and health have the following characteristics: few diseases, good level of self-care, maintained physical and mental function, following physical activity, social participation, and high level of life satisfaction (20). High levels of family support and practice of daily activities of significantly contribute to a better quality of life and lower rates of depression in the elderly (21). Also, routine exercises for the elderly that can be applied in their homes or directly with supervision can improve their quality of life (22).

Based on the present study, the distribution of respondents based on the results of the pre-test revealed that the majority of the treatment group was in the good quality of life category. Meanwhile, the majority of the control group was in the very good quality of life category. Welfare is one of the parameters in describing a person's quality of life by achieving the four factors including physical, psychological, social, and environmental factors that affect the quality of life. In the level of quality of life, most of the respondents had a good to very good quality of life because the four factors of quality of life had not been achieved optimally in a prosperous state, so efforts still are needed to be made to improve the quality of life of elderly from good to very good (23). Aspects of the external environment in individuals generally include social and cultural backgrounds, social involvement, social activities, and physical sports that can improve cognitive function among the elderly. Another study explained that psychological stimulation such as religious therapy can prevent dementia (24).

Introversion, physically inactive, and reluctant to join in social activity, which are regarded as a natural course of old age, decrease the quality of life and may be the symptoms of depression. Researchers now have a better understanding of the benefits of physical activity for health and vitality. Regular physical activity plays a role in maintaining a healthy weight. It is also beneficial in increasing resistance to disease, and physical strength and flexibility. Also, it is widely recognized that regular physical activity reduces the risk of contracting the chronic diseases which are prevalent today (25). In other study, a decrease in the frequency of eating together was related to a lower HRQoL in the elderly.  Elderly who eat alone are susceptible to malnutrition, depression, and a poor HRQoL (9). Another study explained that improvements in quality of life may be also related to activity of daily living performance, which is a key determinant of quality of life. Although activity of daily living training was not effective on activity of daily living performance, maintenance was observed in the activity of daily living performance in the activity of daily living group, and a decline was observed in the care-as usual group. Although these differences were not significant, maintenance in the activity of daily living is considered a positive finding, as residents with dementia typically experience a decline in the activity of daily living performance over a 6-month period (25).

The World Health Organization Quality of Life (WHOQOL) suggested that quality of life is perceived as an individual's perception of social life in the context of culture and value systems as well as goals, expectations, standards, and concerns (26). If these needs are not met, the elderly experience problems in their life, which will diminish their quality of life (27). The elderly must have good social interactions to improve their quality of life so that they will not feel lonely (28).

Social activities in the form of regular sermons and training in the skills of making hulahoop doormats can improve the quality of life of the elderly. This success can also be influenced by the existence of tools in supporting these activities that facilitate the implementation of social activities. Study is one of the forms of religious activity done by Muslims. This activity is not mandatory but there are many activities like this of interest to the public. Recitation activities are often filled with listen to lectures, spiritual flush, learn more about As-Sunnah, and Tadarus (29). Spiritual counseling therapy can increase motivation to reduce anxiety and improve quality of life (30).

 This research is in line with Rohmah's research, which found that social factors affect the quality of life. Several things that support social relationships include the bonds which a person has to their social environment such as gathering with friends, having social relationships, being active in social interactions, and not experiencing obstacles in social relationships. Social and spiritual activities give the highest value to the elderly in finding meaning and a sense of self-worth (23). The ability of the elderly to continue social interactions is the key to maintain their social status based on their ability to socialize. Social interaction is highly crucial in improving the quality of life. Reduced social interaction in the elderly can cause feelings of isolation so that the elderly feel alone and experience social isolation and ultimately depressed; then, it can affect their quality of life (31).

This research is also in line with Samper's research, which confirmed that there is a relationship between social interaction and the quality of life of the elderly (7). Sanjaya explained that individuals who have limited social relationships experience loneliness, while individuals who have good social relationships do not experience loneliness and have good quality of life (7). Social activities such as joining individuals in a community or posyandu for the elderly will become an arena for exchanging ideas, sharing experiences, and caring for others. The number of activities completed by the elderly can facilitate the elderly's relationship with one another so that a good social reaction will be formed, which will ultimately affect the improvement of the quality of life of the elderly (20). In their study, Abizanda et al. reported that the physical exercise program applied to elderly improved their quality of life. They reported that the quality of life level of individuals decreases when they do not engage in physical activity (32).

In the present study, the results of the post test in the treatment group showed an increase in the quality of life levels of the elderly. The majority of the treatment group who were in the good quality of life category before treatment had very good quality of life after treatment. Meanwhile, the results of the post-test on the control group showed no change between the pre-test and post-test. It is suggested that the importance of increasing the social activities of the elderly be highlighted so that elderly health services can be maximized and visits to the elderly be done in the community. This study only analyzed the influence of social activities, other factors that may also influence the quality of life of the elderly are not observed, which is one of the limitations of the present study. One of the strength of the current study is that social interaction therapy which is focused on spiritual activities for the elderly in addition to developing relationships between humans also develops relationships between humans and God.

Implications for practice

The intervention of social interaction with spirituality therapy can improve the quality of life of the elderly. This intervention improves psychological health because recitation activities are one way to fortify relationships, friendships, and social involvement in the community. Knowledge and understanding related to spiritual healing need to be possessed and improved by nurses. This therapy can be used as a non-medical intervention and as additional knowledge for the elderly, families, and health cadres. It can also be performed independently and can be considered as a part of the holistic care program.

Acknowledgments

This research is resulted from the research of a team of lecturers from the community of nursing and gerontic department that was proposed to increase the number of research programs in nursing studies. The study was approved by the Ethics Committee of the Faculty of Medicine, University of Muhammadiyah Surakarta with ethics code No.2702/B.1/KEPK-FKUMS/XI/2020. The author would like to express their gratitude to the head of the Baki Sukoharjo Community Health Center and the Head of Gedongan Village who have provided consent to conduct the research. We would also thank Mrs. Lusi Hariyanti as the village midwife, Mrs. Parjiyem as the head of the Cadre, and the health cadres who helped to motivate the patients for therapy.

Conflicts of interest

The authors declared no conflict of interest.