Asian Nursing Research 9 (2015) 96e103

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Asian Nursing Research

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Research Article

A Study on Body Image, Sexual Quality of Life, Depression, and Quality

of Life in Middle-aged Adults
Jeong Sun Kim, PhD, RN, 1, * Sook Kang, MD, RN 2
1
College of Nursing, Chonnam National University, Gwangju, South Korea
2
Department of Nursing, Chunnam Techno University, Gokseong, South Korea

a r t i c l e i n f o s u m m a r y

Article history: Purpose: The purpose of this study was to examine the correlations of body image, sexual quality of life
Received 13 January 2014 (SQOL), depression, and quality of life, and to identify the influencing factors on quality of life of middle-
Received in revised form aged adults in the community.
16 December 2014
Methods: The participants of this study were 367 middle-aged adults. Data were collected through
Accepted 26 December 2014
personal interviews using a questionnaire. Data were analyzed using descriptive statistics, t tests, one-
way analysis of variance, Pearson's correlation coefficients, and stepwise multiple regression.
Keywords:
Results: Body image, SQOL, depression, and quality of life according to the general characteristics and
body image
depression
health-related characteristics commonly showed significant differences in age, level of education,
middle aged duration of marriage, living arrangement, occupation, monthly income, presence of disease, exercise,
quality of life stressor, frequency of sexual intercourse with spouse, and degree of deep sleep. Quality of life showed
significant positive correlations with body image and SQOL, but a significantly negative correlation with
depression. Body image, depression, education level, SQOL, and stressor, which accounted for 42.0% of
the variance, were significant predictors influencing quality of life in middle-aged adults in the
community.
Conclusions: To improve quality of life in middle-aged adults ahead of old age, an assessment of their
body image, depression, SQOL should be made and a variety of nursing interventions should be followed
to improve their positive body image, depression, and SQOL.
Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

Introduction Their negative body image in middle age has made them feel shame
and anxiety compared with other people's body [5], while a posi-
Middle-aged adults are facing a turning point in their life in that tive image of their body has a great effect on improving their
they are experiencing physical and psychological aging with the quality of life [3].
changes in their social roles [1]. At this stage of life, they prepare for These changes of body image in middle age also produce a
old age and tend to think about the meaning of death more negative effect on sexual satisfaction, for they tend to avoid sexual
frequently [2], so they can expect to improve their quality of life in activities as a result of their declining physical attraction [6]. The
middle age when they cope with the overall changes in their lives degrees of middle-aged couples' sexual life satisfaction are affected
[3]. greatly by the expectation of sexual function, the level of education,
Most middle-aged adults in the aging process are experiencing and the relationships with their spouses as well as sexual
changes of body image and have feelings of anxiety as they become dysfunction [7]. However, as most of the studies on middle-aged
conscious of their declining, physical attraction [2]. In particular, adults focus only on their physical aspects, it is difficult to eval-
the physical changes of middle-aged adults connected with the uate their sexual quality of life (SQOL).
aging process have complex and multifaceted characteristics [4]. Middle-aged adults feel more and more depressed as they
grow older [8]. Depression in menopausal women is especially
influenced by their body image as well as poor physical functions
[9]. Moreover, depression in middle-aged adults is the most
* Correspondence to: Jeong Sun Kim, PhD, RN, College of Nursing, Chonnam
National University, 5 Hak-dong, Dong-gu, Gwangju, 501-746, South Korea. powerful factor affecting their perceived subjective quality of life
E-mail address: [email protected] [10]. Therefore, it is suggested that the depression in middle-aged

http://dx.doi.org/10.1016/j.anr.2014.12.001
p1976-1317 e2093-7482/Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
 J.S. Kim, S. Kang / Asian Nursing Research 9 (2015) 96e103 97

adults is concerned with body image, sexual matters, and quality Measurements
of life.
While research on middle-aged adults has been conducted for General and health-related characteristics
middle-aged women thus far [3,6,11e16], neither studies on men General characteristics of the participants included gender, age,
nor women in middle age are sufficient. Most studies have mainly education level, religion, duration of marriage, living arrangement,
examined if they have any relations with various physical and occupation, and monthly income. Health-related characteristics
psychosocial factors [17e21] centering on experimental studies included disease, exercise, stress, stressor, frequency of sexual in-
that can improve quality of life and concepts concerned with tercourse with spouse, presence of sleep disorder, and degree of
health-related quality of life through a variety of program in- deep sleep.
terventions [22e26]. Therefore, for those in middle age, who
experience climacteric symptoms and aging, and are adapting to Body image
the physical changes, it is difficult to clearly grasp how much their Body image was measured using the tool modified by [28] from
body image or SQOL has an effect on their quality of life. the original Body Self-image Questionnaire developed by [29]. This
Thus, this study intended to provide basic data of strategy tool uses a 5-point Likert scale and has 23 questions. Scores on this
development for the improvement of quality of life by examining tool range from 23 to 115 points, with higher scores meaning a
the relationship between body image, SQOL, depression, and the more positive view of their body image. The Cronbach's alpha
quality of life, and the influence factors on the quality of life, which for the previous study was .75 [28], and that of the current study
would enable middle-aged adults to cope positively with the was .86.
various changes, and to actively adapt to the elderly life ahead. To
do this, first, this study identified the levels of middle-aged adults' SQOL
body image, SQOL, depression, and quality of life. Second, this study The tool used here to measure SQOL was the Korean language
investigated the differences of middle-aged adults' body image, version of SQOL by [30]; modified from the original SQOL devel-
SQOL, depression, and quality of life as they relate to general oped by [31] to suit the Korean culture. The tool of this study uses a
characteristics, and health-related characteristics. Third, the study 6-point Likert scale and has 18 questions. Scores on this tool range
examined the correlations amongst body image, SQOL, depression, from 18 to 108 points, with higher scores indicating higher levels of
and quality of life of middle-aged adults. Lastly, the study identified SQOL. The Cronbach's alpha for the previous study was .87 [30], and
the various influencing factors on quality of life in middle-aged that of the current study was .91.
adults.
Depression
Methods Depression was measured using the integrated Korean language
version of Center for Epidemiologic Studies-Depression Scale
Study design standardized by [32] from the original version by [33]. The tool of
this study consists of 20 questions using a 4-point Likert scale.
This study was a cross-sectional descriptive survey examining Scores on this tool range from 0 to 60 points, with higher scores
the correlations among middle-aged adults' body image, SQOL, signifying higher levels of depression. The Cronbach's alpha for the
depression, and quality of life. This study also aimed to identify previous study was .91 [32], and that of the current study was .89.
factors that influence the quality of life within this population.
Quality of life
Setting and samples To evaluate quality of life, the tool used here is the Korean lan-
guage version of World Health Organization Quality of Life Scale-
The participants for this study were selected by convenient Brief (WHOQOL-BREF) standardized by [34] from the original by
purposive sampling among the adult population that registered at WHOQOL Group [35]. The tool of this study uses a 5-point Likert scale
five culture centers in Gwangju one of the six metropolitan cities in and has 26 questions, with scores ranging from 26 to 130 points.
Korea. The standards of selection for the participants of this study Higher scores mean higher quality of life. The Cronbach's alpha for
are as follows: (a) aged 45e60 years; (b) people without disorders the previous study was .86 [34], and that of the current study was .94.
such as breast cancer, cervical cancer, or sexual dysfunction which
can have a negative influence on sexual life; (c) people in normal Data collection
marital status excluding those who were divorced or bereaved as it
could be difficult to evaluate their SQOL; (d) people who did not Data for this study were collected from July to December 2012.
have mental diseases and who could communicate with each Data collection was conducted by one-to-one interview using a
other; (e) people who understood the purpose of this study and structured questionnaire survey. The participants who understood
gave written consent to participate in this study. The minimum the purpose of this study and agreed to participate in this survey
sample size was calculated to be 160 when the multiple regression signed his or her name on a consent form. The questionnaire survey
analysis was conducted using G*Power 3.1.2 analysis software with was conducted by researchers and three assistant researchers who
predictor variables set at 8, level of significance at .05, effect size had been trained in advance. It took approximately 15e20 minutes
at .15, and test power calculation at .95 [27]. Therefore, the 367 to complete the questionnaire.
participants who participated in this research, excluding the 10
whose responses were insufficient among the 377 through docu- Data analysis
ment investigation, was considered suitable.
Data were analyzed using SPSS version 20.0 (IBM SPSS Statistics,
Ethical considerations Chicago, IL, USA). General characteristics and health-related char-
acteristics of the participants were presented in real numbers,
This study was approved by the Chonnam National University percentages, means, and standard deviations. The differences
Hospital Institutional Review Board for ethical consideration ac- among body image, SQOL, depression, and quality of life according
cording to the Declaration of Helsinki (IRB No. CNUH-2012-012). to general characteristics and health-related characteristics were
 98
Table 1 Differences in Body Image, Sexual Quality of Life, Depression and Quality of Life according to Demographic Characteristics (N ¼ 367).

Characteristics Categories n (%) Body image Sexual quality of life Depression Quality of life
M ± SD
M ± SD t/F p (post hocy) M ± SD t/F p (post hocy) M ± SD t/F p (post hocy) M ± SD t/F p (post hocy)

Gender Female 186 (50.7) 68.58 ± 11.26 0.79 .428 72.91 ± 13.95 1.91 .057 15.66 ± 7.84 0.90 .371 79.60 ± 14.85 0.77 .440
Male 181 (49.3) 69.48 ± 10.57 75.62 ± 13.24 14.92 ± 7.84 80.77 ± 14.13
Age (yr) 45e50 (a) 121 (33.0) 71.36 ± 10.84 6.17 .002 80.19 ± 13.32 25.30 < .001 14.02 ± 7.74 6.05 .003 81.65 ± 13.92 6.84 .001

J.S. Kim, S. Kang / Asian Nursing Research 9 (2015) 96e103

51e55 (b) 115 (31.3) 69.30 ± 10.11 (c < a) 74.33 ± 12.31 (c < b < a) 14.50 ± 7.60 (a, b < c) 82.78 ± 15.20 (c < a, b)
56e60 (c) 131 (35.7) 66.62 ± 11.25 68.69 ± 12.81 17.16 ± 7.83 76.53 ± 13.72
52.77 ± 4.56
Education Elementary school (a)
17 (4.6) 56.35 ± 8.25 16.18 < .001 64.88 ± 12.20 17.45 < .001 21.41 ± 6.02 6.45 < .001 69.59 ± 16.24 40.64z < .001
level Middle school (b) 47 (12.8) 64.17 ± 10.23 (a < b < c, d) 63.68 ± 11.49 (a, b < c, d) 17.94 ± 7.47 (b, c, d < a) 72.30 ± 11.41 (a, b < c, d)
High school (c) 214 (58.3) 69.53 ± 9.91 75.64 ± 12.34 14.51 ± 7.48 80.24 ± 12.72
 College (d) 89 (24.3) 72.78 ± 11.51 78.28 ± 14.59 14.61 ± 8.44 86.21 ± 16.57
Religion None (a) 161 (43.9) 67.75 ± 11.06 4.39 .002 73.52 ± 13.86 3.60 .007 16.06 ± 8.71 11.23z .024 79.84 ± 14.91 2.12 .078
Buddhism (b) 100 (27.2) 67.33 ± 10.86 (a, b < e < c, d) 71.51 ± 12.23 (b < e) 16.03 ± 7.39 (d < e) 77.61 ± 15.03
Protestant (c) 76 (20.7) 72.16 ± 10.51 76.89 ± 13.53 13.99 ± 6.85 82.70 ± 13.07
Catholic (d) 27 (7.4) 74.19 ± 8.50 80.15 ± 15.51 11.52 ± 5.31 84.85 ± 12.86
Other (e) 3 (0.8) 68.00 ± 9.85 84.33 ± 5.86 16.67 ± 2.31 78.33 ± 5.67
Duration of 1e20 (a) 79 (21.5) 70.06 ± 11.11 4.25 .015 81.20 ± 14.43 45.02z < .001 13.43 ± 6.85 6.28 .002 81.57 ± 13.85 4.96 .008
marriage (yr) 21e30 (b) 188 (51.3) 70.02 ± 10.60 (c < a, b) 74.96 ± 12.60 (c < b < a) 14.95 ± 8.36 (a, b < c) 81.64 ± 14.79 (c < a, b)
31e40 (c) 100 (27.2) 66.33 ± 11.01 67.42 ± 11.77 17.42 ± 7.10 76.33 ± 13.84
Living With spouse (a) 65 (17.7) 64.25 ± 12.37 15.24z < .001 68.71 ± 14.32 8.59 < .001 18.20 ± 8.52 5.59 .004 74.66 ± 14.39 5.89 .003
arrangement With spouse and 283 (77.1) 70.02 ± 9.83 (a < b, c) 75.06 ± 12.93 (a < b < c) 14.69 ± 7.54 (b, c < a) 81.40 ± 13.93 (a < b, c)
children (b)
Other (c) 19 (5.2) 70.53 ± 16.27 81.11 ± 16.45 14.32 ± 7.99 80.89 ± 19.05
Occupation Yes 307 (83.7) 70.01 ± 10.61 4.00 < .001 75.65 ± 13.13 4.59 < .001 14.53 ± 7.32 3.70 < .001 81.22 ± 13.97 3.16 .002
No 60 (16.3) 63.97 ± 11.16 67.05 ± 14.12 19.20 ± 9.21 74.83 ± 16.00
Monthly <200 (a) 68 (18.5) 64.78 ± 10.67 7.18 < .001 68.29 ± 12.97 6.45 < .001 18.50 ± 8.31 5.96 .001 72.82 ± 12.95 13.01 < .001
income 200e399 (b) 175 (47.7) 68.82 ± 10.53 (a < b, c < d) 74.53 ± 13.45 (a < b, c, d) 15.02 ± 7.76 (b, c, d < a) 79.98 ± 13.84 (a < b, c < d)
(10,000 KRW) 400e599 (c) 96 (26.2) 70.70 ± 10.07 77.04 ± 13.32 14.44 ± 6.94 82.65 ± 13.35
 600 (d) 28 (7.6) 74.82 ± 13.09 77.39 ± 13.82 12.18 ± 8.01 90.86 ± 17.16
y
Duncan's multiple test.
z
Kruskal wallis statis.
 J.S. Kim, S. Kang / Asian Nursing Research 9 (2015) 96e103 99

analyzed using t tests and one-way analysis of variance; post hoc

p (post hocy)

(a < b, c, d)
test was made through Duncan's test. The levels of body image,

.007

< .001

.012

.010

.001

.008

.001
SQOL, depression, and quality of life were presented in means and

(d < a)
(a < c)
standard deviations. The correlations among body image, SQOL,
depression and quality of life were analyzed through Pearson's

Quality of life

2.72

3.69

2.53

3.37

5.76

2.65

5.67
correlation coefficients. To identify the factors that influenced

t/F
quality of life, stepwise multiple regression analysis was conducted,
and categorical variables were analyzed as dummy variables.

14.78
14.20
14.61
13.69
14.24
14.86
14.09
15.30
12.68

72.80 ± 10.03

14.68
14.59
13.83
14.78
13.34
13.15
15.21
14.96
14.73
12.53
10.20
M ± SD
Results

±
±
±
±
±
±
±
±
±

±
±
±
±
±
±
±
±
±
±
±
76.93
81.46
82.43
76.84
79.14
83.64
71.27
80.46
81.32

77.07
74.66
80.65
82.39
83.78
77.85
81.88
85.25
80.93
75.91
71.89
Level of body image, SQOL, depression and quality of life

p (post hocy)

(d < b < a)
The participants’ mean scores for body image, SQOL, depression,

.001

< .001

.002

.094

< .001

< .001

< .001
(a < d)
and quality of life were 69.02 ± 10.92 (range, 23e115), 74.25 ± 13.65
(range, 18e108), 15.29 ± 7.84 (range, 0e60), and 80.18 ± 14.49
(range, 26e130) respectively.

Depression

z
3.24

4.52

3.14

2.01

9.92

3.98

25.60
t/F
Differences in body image, SQOL, depression and quality of life
according to demographic characteristics

19.73 ± 10.17

10.19
17.38 ± 8.23
14.47 ± 7.53
13.76 ± 6.95
17.57 ± 8.52

13.24 ± 6.49

15.22 ± 7.38
15.13 ± 7.95

15.20 ± 5.55

8.72
8.61
7.89
6.62
6.33
7.95
7.48
5.91
7.76
7.73
15.91± 8.11
M ± SD

±
±
±
±
±
±
±
±
±
±
±
As to the participants’ scores for body image, there were signifi-

17.19
18.85
15.48
13.32
12.65
17.16
13.93
12.25
14.69
18.26
20.67
cant differences statistically, according to age (F ¼ 6.17, p ¼ .002),
education level (F ¼ 16.18, p < .001), religion (F ¼ 4.39, p ¼ .002),
duration of marriage (F ¼ 4.25, p ¼ .015), living arrangement

(a < b < c, d)
p (post hocy)
Table 2 Differences in Body Image, Sexual Quality of Life, Depression and Quality of Life according to Health-related Characteristics (N ¼ 367).

.003

< .001

.906

.002

< .001

.074

.018
(F ¼ 15.24, p < .001), occupation (t ¼ 4.00, p < .001), and monthly

(a < c, e)

(d < a)
income (F ¼ 7.18, p < .001). The scores of SQOL showed significant
Sexual quality of life

differences statistically, according to age (F ¼ 25.30, p < .001), edu-

cation level (F ¼ 17.45, p < .001), religion (F ¼ 3.60, p ¼ .007), duration

54.72z
3.04

5.05

0.12

4.31

1.79

3.40
of marriage (F ¼ 45.02, p < .001), living arrangement (F ¼ 8.59,
t/F

p < .001), occupation (t ¼ 4.59, p < .001), and monthly income

(F ¼ 6.45, p < .001). The degrees of depression showed significant
13.41
13.54
13.65
12.54
14.14
11.98
18.65
12.68
13.53

67.10 ± 10.34

14.48
13.13
11.72
11.83
16.12
14.31
13.08
12.51
13.65
14.07
9.57
differences statistically, according to age (F ¼ 6.05, p ¼ .003), edu-
M ± SD

±
±
±
±
±
±
±
±
±

±
±
±
±
±
±
±
±
±
±
±
cation level (F ¼ 6.45, p < .001), religion (F ¼ 11.23, p ¼ .024), duration
70.84
75.60
77.11
70.01
74.29
74.09
65.00
73.63
77.04

75.26
67.13
72.13
79.06
83.55
72.76
75.33
78.96
74.35
71.80
68.33
of marriage (F ¼ 6.28, p ¼ .002), living arrangement (F ¼ 5.59,
p ¼ .004), occupation (t ¼ 3.70, p < .001), and monthly income
(a < b, c, d, e)

(F ¼ 5.96, p ¼ .001). Quality of life also showed significant differences

p (post hocy)

(a < b, c, d)
< .001

< .001

.225

.002

.001

.002

.002
statistically, according to age (F ¼ 6.84, p ¼ .001), education level

(c, d < a)
(F ¼ 40.64, p < .001), duration of marriage (F ¼ 4.96, p ¼ .008), living
arrangement (F ¼ 5.89, p ¼ .003), occupation (t ¼ 3.16, p ¼ .002), and
Body image

monthly income (F ¼ 13.01, p < .001) (Table 1).

3.55

4.57

1.22

4.49

5.76

3.15

4.94
t/F

Differences in body image, SQOL, depression and quality of life

11.61
10.39
10.54
10.77
11.08
10.31
13.16

10.49

12.65
11.26
10.63

12.90
10.54
10.96
10.52
10.95
10.11
12.02
according to health-related characteristics
9.59

67.30 ± 8.14

9.39
M ± SD

±
±
±
±
±
±
±
±
±

±
±
±
±
±
±
±
±
±
±
±
The participants’ body image showed significant differences
65.86
70.27
71.11
65.94
68.64
70.28
61.00
67.89
71.30

68.17
64.88
69.51
71.35
69.53
66.95
70.54
72.31
69.69
65.47
66.00
statistically, according to presence of disease (t ¼ 3.55, p < .001),
exercise (t ¼ 4.57, p < .001), stressors (F ¼ 4.49, p ¼ .002), frequency
(28.3)
(71.7)
(59.7)
(40.3)
(76.8)
(23.2)

(25.1)
(28.3)

(14.7)
(21.8)
(39.0)
(28.3)
(10.9)
(42.2)
(57.8)
(13.0)
(62.7)
(21.8)

of sexual intercourse with spouse (F ¼ 5.76, p ¼ .001), presence of

(6.0)

10 (2.7)

(2.5)
n (%)

sleep disorder (t ¼ 3.15, p ¼ .002), and degree of deep sleep

104
263
219
148
282
85
22
92
104

54
80
143
104
40
155
212
48
230
80
9

(F ¼ 4.94, p ¼ .002). SQOL also showed significant differences sta-

tistically, according to disease (t ¼ 3.04, p ¼ .003), exercise
Children problem (b)
Marital problem (a)

(t ¼ 5.05, p < .001), stressors (F ¼ 4.31, p ¼ .002), frequency of sexual

Parental support
Categories

intercourse with spouse (F ¼ 54.72, p < .001), and degree of deep

1e2 times (b)
3e4 times (c)
 5 times (d)

Very good(a)
<1 times (a)

sleep (F ¼ 3.40, p ¼ .018). The degree of depression showed sig-

Occupation

problem (d)

Very bad(d)
problem (c)

Other (e)

nificant differences statistically, according to disease (t ¼ 3.24,

Good(b)
Bad(c)

p ¼ .001), exercise (t ¼ 4.52, p < .001), presence of stress (t ¼ 3.14,

Yes

Yes

Yes

Yes
No

No

No

No

p ¼ .002), frequency of sexual intercourse with spouse (F ¼ 9.92,

Duncan's multiple test.

p < .001), presence of sleep disorder (t ¼ 3.98, p < .001), and degree
Degree of deep sleep
Frequency of sexual

Kruskal wallis statis.

intercourse with
spouse (month)

of deep sleep (F ¼ 25.60, p < .001). Quality of life showed significant

sleep disorder
Characteristics

differences statistically, according to disease (t ¼ 2.72, p ¼ .007),

Presence of

exercise (t ¼ 3.69, p < .001), presence of stress (t ¼ 2.53, p ¼ .012),

(n ¼ 282)
Exercise

Stressor
Disease

stressors (F ¼ 3.37, p ¼ .010), frequency of sexual intercourse with

Stress

spouse (F ¼ 5.76, p ¼ .001), presence of sleep disorder (t ¼ 2.65,

p ¼ .008), and degree of deep sleep (F ¼ 5.67, p ¼ .001) (Table 2).
y
z
100 J.S. Kim, S. Kang / Asian Nursing Research 9 (2015) 96e103

Table 3 Factors Influencing Quality of Life (N ¼ 367). proper measurement tools that can reflect the essence of body
image in middle-aged adults. SQOL was consistent with the result
Factors Standardized b t p Adjusted F p
of [30] which showed a middle level in married women in their
R2
20se60s, but the results differed from that of [7] which showed
Body image .32 6.83 < .001 .42 53.74 < .001
their general satisfaction in more than half of subjects in middle-
Depression .32 6.48 < .001
Education level .15 3.58 < .001 aged and elderly couples. There are some limits in comparing the
Sexual quality of life .11 2.32 .021 result of this study with that of the Son et al. study [7]. While SQOL
Stressor .08 2.05 .042 was measured merely in the aspect of sexual satisfaction with one
item in the Son et al. study [7], this study examined it in various
aspects such as sexual self-esteem, psychological, and emotion
state about sexual life including relationship with spouse. Depres-
Correlations among body image, SQOL, depression and quality of life
sion was in concordance with the result of Choi's study [12] which
reported a low level of depression in middle-aged adults. However,
Body image of the study participants was positively correlated
in light of the result of Chung and Koo's study [37] which showed
with SQOL (r ¼ .41, p < .001) and quality of life (r ¼ .54, p < .001), but
the degree of depression becoming increasingly higher as people
it had a negative correlation with depression (r ¼ .45, p < .001).
grew older from middle age, it is necessary that researchers and
SQOL was negatively correlated with depression (r ¼ .51, p < .001),
nurses develop intervention strategies to prevent depression in
but it was positively correlated with quality of life (r ¼ .44, p < .001).
middle age. Quality of life measured in our study was consistent
Depression was negatively correlated with quality of life (r ¼ .52,
with the result of [12] which reported a middle level of quality of
p < .001).
life in middle-aged adults. However, based on Oh and Oh's report
[38]; life satisfaction in middle-aged adults was influenced nega-
Factors influencing quality of life tively by their sense of crisis in middle age. Thus, further studies
should explore the factors that interfere with the quality of life in
In order to identify the factors influencing quality of life, a middle-aged adults.
stepwise multiple regression analysis was conducted with signifi- In terms of body image according to the participants' general
cant variables from general characteristics and health-related and health-related characteristics surveyed by education level in
characteristics, and significant variables from the correlation this study, the scores of body image were higher in high school
analysis. The correlation coefficients between the independent graduates than those of middle school graduates. The result in our
variables ranged from a .52 to .54; because they did not exceed study was similar to that of Gavin, Simon, and Ludman's study [39]
.80, we confirmed that they were independent of each other. The which showed that the women who graduated from college were
Durbin-Watson statistic was 1.790, because it was so close to 2, we more satisfied with their body image than those who did not. This
decided that there was no autocorrelation. In addition, we checked meant that if middle-aged adults' education level were higher, they
for multicollinearity and found the following results: tolerance was would think more positively about their body image. In terms of the
.73e.96, which was considerably greater than .10; the variation age of participants, the result of this study was similar to that of a
inflation factor was 1.03e1.36, which did not surpass the standard study by [36] which showed that adults over 50 years of age had
value of 10; and the condition index was less than 30. According to lower scores in body image than those below age 49 suggesting
these statistics, there was no problem of multicollinearity. This that as people grew older, they thought more negatively about their
analysis confirmed that the data meet on the assumptions of re- body image. However, body image by gender did not show any
siduals, linearity, normality, and the homoscedasticity of error significant differences in this study, while it did show significant
terms. Cook's distance values for examining individual data points differences in the study by Davison and McCabe [7]. Women in
never exceeded 1.00. middle age are constantly making efforts in managing their
Factors influencing quality of life of middle-aged adults in this appearance and recovering their physical attractiveness so as to
study were body image, depression, education level, SQOL, and eliminate body-related stress, and to have self-contentment and
stressor, and the explanatory power of these factors was 42.0% psychological stability [40]. However, they develop negative rec-
(Table 3). ognitions of their body image when they face realistic difficulties in
having ideal body shapes [28]. On the other hand, while middle-
Discussion aged men's body image is concerned with their social and sexual
functions, they do not express their changes of body image directly,
This study was conducted to prepare grounds for nursing as- and are also more positive about their body image than women are
sessments and intervention strategies to improve quality of life for [36]. Based on these facts, adults' recognitions of their body image
middle-aged adults by examining the correlations among their in middle age differ by gender due to their different physical
body image, SQOL, depression, and quality of life, as well as the characteristics. However, our discussions of different studies are
factors influencing quality of life in this group. limited due to varying measurement tools, age range, and gender.
Body image, SQOL, and quality of life of participants showed Therefore, follow-up exploratory studies are necessary for identi-
intermediate levels of scores, and depression showed low levels of fying the various factors influencing body image in middle-aged
scores. The result for body image was different from that of [3] adults. On the other hand, in the aspect of exercise, the result of
which was measured by adjective meaning measure and showed body image gained by a meta-analysis was supported by Hausen-
a high level, whereas our result was similar to that of [36] which blas and Fallon's assertion [41] that exercise had a positive effect on
was measured by subcategory such as physical attractiveness, body body image. Therefore, exercise for health management in middle
image satisfaction, body image importance, body concealment, age had a great influence on developing a positive body image.
body improvement, social physique anxiety, and appearance With regard to SQOL, as a result of investigating predictive
comparison and showed a middle level in the ages of 30e49 years. factors affecting SQOL of married women aged 20e60 years, this
As the results of body image assessment show differences by the study showed a similar result with that of [30] which identified that
measurement tools, genders, and range of ages of participants, this age, duration of marriage, monthly income, and the frequency of
study suggested that further studies are necessary by developing sexual intercourse are factors affecting SQOL. The finding of this
 J.S. Kim, S. Kang / Asian Nursing Research 9 (2015) 96e103 101

study was also similar to that of Barrientos and Pa ez's study [42]; in adult who made use of sports facilities to enjoy sports had a
which the researchers found that adults' satisfaction with sexual higher quality of life than a person who did not. Through the study
life showed significant differences by educational, social and eco- by Giannouli et al., [49] the researchers verified that exercise was
nomic levels, and frequency of sexual intercourse. However, this closely connected with a middle-aged woman's quality of life. In
study showed some differences when compared with Yang's study Lee and Choi's study [51]; the researchers proved that a middle-
[30] and Barrientos and Pa ez's study [42]. In Yang's study [30], aged adult whose cognition degree of stress had a higher quality
SQOL did not show significant differences according to education of life. From all these findings, we summarized that if a middle-
level, while in Barrientos and Pa ez's study [42], satisfaction with aged person was younger, had a higher education level, a higher
their sexual life showed significant differences according to gender. monthly income, a more stable occupation, no disease, less stress,
Based on these facts, we suggested that middle-aged adults were and exercised, the person would show a higher quality of life.
enjoying higher SQOL when they were younger and in shorter Therefore, for adults in middle age who are going through physical,
duration of marriage, had higher social and economic levels and psychological, and socioeconomic changes in their life, it is essen-
more frequent sexual intercourse. However, concerning education tial that research investigate the deterrent factors that prevent
level and gender, the results of each study had some differences. them from enjoying high quality of life and plan preventative
Therefore, it is necessary to conduct more in-depth follow-up strategies in order to prepare them for their elderly life.
studies to identify the reasons why these differences exist. On the With regards to the correlations among body image, SQOL,
other hand, the subjects of this study felt lower SQOL when they depression and quality of life, the result of this study is consistent
lived with their spouse alone than those that lived with their with that of Kim and Choi's study [3] which confirmed that if a
children together. This finding had something to do with Jeong's middle-aged woman had a positive body image, her quality of life
assertion [2] that middle-aged couples' marital satisfaction reached improved. The result of this study is also in concordance with the
the lowest level compared with couples in other life cycles, due to result of Choi's study [12] which found that the lower the degree of
factors coming from long marital life, general physical and mental depression in a middle-aged adult, the higher the quality of life
changes of middle age, and their grownup children. Therefore, they would have. The result of this study was similar to that of
evaluation of middle-aged adults' SQOL should not focus on sexual Woloski-Wruble et al.’s study [16] in that if a middle-aged woman
satisfaction through physical contacts, but on general sexual life felt more satisfaction with her SQOL, her satisfaction with daily life
including various emotional factors such as sexual self-esteem would be greater. The result was also similar to that of Gavin et al.’s
perceived through sexual intercourse, psychological and study [39]; which found that if a middle-aged woman had higher
emotional fitness, as well as consideration and general feelings for dissatisfaction with her body image, she experienced more severe
spouse [30]. depression. Hence, all of these results strongly indicate that it is
In terms of depression, middle-aged women's depression in our necessary to map out the strategies for increasing positive body
study was similar to that of Kim and Kim's study [43]; which image and sexual satisfaction, and relieving depression in order to
showed significant differences statistically, according to age, edu- improve the quality of life of middle-aged adults. However, as most
cation level, religion, monthly income, duration of marriage, and studies focus on middle-aged women, and the measuring tools and
presence of disease. This study's findings were similar to findings contents are different from study to study, it is difficult to compare
from previous studies [39,44e46]. Gavin et al. asserted that if a and interpret the results with the middle-aged adults in our study.
subject's level of education were low, she would likely experience Therefore, more in-depth follow-up studies are needed to provide
more depression at the ages of 40e65 years [39]. Tanaka et al., [46] enough relevant grounds to be applied to both men and women
identified that an adult with a chronic disease was at a higher risk considering middle-aged adults' characteristics.
of experiencing depression. Lee and Choi [45] confirmed that The findings from analyzing the predictors affecting quality of
middle-aged women's depression was related to their level of stress life in middle-aged adults by dividing adulthood into three stages of
[45], while verified that postmenopausal women who had chronic age group, namely, 18e39, 40e64, and over 65, partly coincided
disease suffered from more depression as the frequency of sexual with Han and Choo's study [52]; in which the authors confirmed
intercourse with spouse increased [44]. Taken together, middle- that the factors affecting a middle-aged adult's quality of life were
aged adults' degrees of depression appeared higher in those with depression, religion, monthly income, and occupation, having 28%
lower educational and economic levels. This study also confirmed of explanation power. The findings were also in partial agreement
that middle-aged adults were likely to go through more depression with Choi's study results [12] which found that a middle-aged
when they have disease or stress, or less frequent sexual inter- adult's depression, education level, and exercise had 24% of
course. Thus, in order to investigate middle-aged adults' depression explanation power. All these results indicate that depression is a
tendency, proper nursing assessments should be made by taking common factor influencing a middle-aged adult's quality of life. Lim
the above general characteristics into consideration. and Auh's study [10] confirmed that depression was the most
The result of this study on quality of life was also similar to that powerful factor influencing middle-aged adults' quality of life.
of the study conducted by [47]. In their study, the researchers Therefore, it is very important to make a primary assessment and
confirmed that the adults' quality of life at the ages of 20e59 years monitor the symptoms of depression continuously, while devel-
had significant differences, according to age, education level, oping intervention strategies that relieve depression. On the other
monthly income, occupation, and presence of disease. The results of hand, in this study, body image was a potent predictor influencing
this study turned out to be similar to those obtained by the studies the quality of life in middle-aged adults, suggesting that perception
of [12,48e50]; and Lee and Choi [51]. Choi's study [12] found that of one's body image can strongly influence quality of life. Adults in
participants with junior college education and above showed middle age commonly tend to have a negative body image as their
higher quality of life than that of a high school graduate, and a physical attraction decreases on the account of the aging process
person who exercised had a higher quality of life than a person who and climacteric symptoms. For this reason, women in middle age
did not during middle age. In Chung's study [48]; the researcher are constantly making efforts in managing their appearance and
found that a middle-aged woman who graduated from college, or recovering their physical attractiveness so as to eliminate body-
whose economic situation was good showed a higher quality of life related stress, and to have self-contentment and psychological
than a woman who graduated from only high school or who was stability [40]. On the other hand, middle-aged men's efforts for
poor, respectively. Han's study [50] confirmed that a middle-aged their appearance focus on maintaining masculine appearance and
102 J.S. Kim, S. Kang / Asian Nursing Research 9 (2015) 96e103

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