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Fear of COVID-19 and quality of life: the mediating role of loneliness among older Turkish adults

Published online by Cambridge University Press:  09 March 2022

Melih Altay Open the ORCID record for Melih Altay [Opens in a new window]  and
Azime Arisoy
Melih Altay*
Affiliation:
Ambassade de Turquie, Conakry, Guinea
Azime Arisoy
Affiliation:
Social Services and Consulting Department, Mehmet Akif Ersoy University, Burdur, Turkey
*
*Corresponding author. Email: [email protected]
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Abstract

The novel coronavirus (COVID-19) outbreak has affected living standards around the world, and pandemic anxiety has changed social habits. In this context, this paper investigates the relationship between fear of COVID-19 and quality of life, and assesses the mediating effect of loneliness on this relationship among a sample of older adults in Turkey. The study considers data from approximately 400 people, all of whom completed the CASP-19 Quality of Life Scale in Older People, the Loneliness Scale for the Elderly and the Fear of COVID-19 Scale. Confirmatory factor analyses were performed to confirm a one-factor structure for each instrument. Subsequently, mediation analysis, correcting for age as a continuous covariate, was performed to assess the nature of the relationship between fear and quality of life, and the extent to which that relationship is mediated by loneliness. Our study showed that there is a negative and direct relationship between loneliness and quality of life. Another important finding of our research is that fear of COVID-19 has a significant effect on loneliness. Finally, loneliness mediates the relation between fear of COVID-19 and quality of life. This finding strongly suggests that fear of COVID-19 influences quality of life via loneliness. This result is noteworthy, as we could not find any similar finding in the literature.

Keywords

older adultscoronavirusCOVID-19fear of COVID-19lonelinessquality of life
Type
Article
Information
Ageing & Society , Volume 44 , Issue 1 , January 2024 , pp. 1 - 16
Copyright
Copyright © The Author(s), 2022. Published by Cambridge University Press

Introduction

During the COVID-19 pandemic, many people have spent their time alone at home and have engaged in fewer social interactions, which can have a negative impact on physical and mental health (World Health Organization (WHO), 2021a). Since older individuals with chronic diseases are the group most affected by COVID-19 (Liu et al., Reference Liu, Chen, Lin and Kunyuan2020), social isolation of older populations has become mandatory during the COVID-19 pandemic (Fletcher, Reference Fletcher2021). Such social isolation may increase feelings of loneliness (Çam et al., Reference Çam, Atay and Işıklı2018) while reducing social activities and quality of life in older age (Gouveia et al., Reference Gouveia, Gouveia, Ihle, Kliegel, Maia, Badia and Freitas2017). Scientific studies on this subject are important in guiding social work actors in planning and implementing psychosocial services for older individuals. In this context, COVID-19 anxiety may affect feelings of loneliness and quality of life among individuals aged 60 years and older.

Studies to date have generally focused on the relationship between loneliness and quality of life (Weiner et al., Reference Weiner, Roe, Mashiach-Eizenberg, Baloush-Kleinman, Maoz and Yanos2010; Vuletić and Stapić, Reference Vuletić and Stapić2013; Gerino et al., Reference Gerino, Rollè, Sechi and Brustia2017; Szabo et al., Reference Szabo, Allen, Alpass and Stephens2019), while the role of fear of COVID-19 in this relation has not been examined. Moreover, prior research on these variables has largely focused on Western cultural contexts, although the criteria predicting older people's quality of life vary from society to society (Siedner, Reference Siedner2019). The adverse effects of loneliness may also vary depending on cultural characteristics. For example, Beller and Wagner (Reference Beller and Wagner2020) found that the effect of loneliness on health was stronger in collectivist countries than in individualist countries and suggested focusing on the effects of loneliness outside Western contexts. According to Hofstede's (Reference Hofstede2001) global study, Turkey's cultural classification differs from that of Western countries, as Turkey is a collectivist culture (Paşa et al., Reference Paşa, Kabasakal and Bodur2001; Kabasakal and Bodur, Reference Kabasakal, Bodur, Chhokar, Brodbeck and House2007). In sum, additional research needs to be conducted in non-Western societies such as Turkey.

COVID-19 should also be taken into consideration as a new area of focus, as the pandemic's effects on older communities have been felt deeply. For example, certain restrictions and measures have been implemented as a result of the pandemic that have isolated people from their environments. These policies may have especially affected sense of loneliness and quality of life among older people. Extending previous work, this study investigates the relationship between fear of COVID-19 and quality of life among Turkish individuals aged 60 years and older, and tests the mediating effect of loneliness in this relationship. First, we review the literature on older adults, fear of COVID-19, sense of loneliness and quality of life. Next, we examine data obtained from older people living in Burdur Province, Turkey. Finally, our findings are summarised and discussed in comparison with other research.

Literature review

Fear of COVID-19

As COVID-19 has spread across the world (Liu et al., Reference Liu, Chen, Lin and Kunyuan2020), health officials and governments have warned that older people face a greater risk of serious and potentially fatal diseases associated with COVID-19. The risk of death from COVID-19 for people in their sixties is 3.6 per cent, a figure that increases for those in their seventies, eighties and older (Brooke and Jackson, Reference Brooke and Jackson2020). Because the disease may be more severe and lead to an increased mortality rate among older people (Dhama et al., Reference Dhama, Kumar Patel, Kumar, Rana, Iqbal Yatoo, Kumar, Tiwari, Dhama, Natesan, Singh and Harapan2020; Yanez et al., Reference Yanez, Weiss, Romand and Treggiari2020), older adults may experience heightened fear of COVID-19.

In light of this, social isolation policies have been implemented for the older population globally. Such policies may include a number of measures, such as avoiding social contact with family members and friends, and maintaining physical distance from other people (Brooke and Jackson, Reference Brooke and Jackson2020). In response to COVID-19, the Ministry of the Interior in Turkey issued a circular imposing age-based lockdowns and certain other restrictions on citizens aged 65 years and older as well as individuals with chronic conditions (Republic of Turkey Ministry of Interior, 2020).

The pandemic brought not only the risk of death but also psychological pressure, anxiety and fear (Duan and Zhu, Reference Duan and Zhu2020; Duman, Reference Duman2020; Lin, Reference Lin2020; Xiao, Reference Xiao2020). Fear refers to an individual's normal subconscious responses – both physical and mental – to the possible harms associated with a given threat (Pappas et al., Reference Pappas, Kiriaze, Giannakis and Falagas2009). Infection has unique characteristics that explain the disproportionate degree of fear it incurs. The rapidity of the spread of COVID-19, the high rate of contraction of disease and morbidity, and psychosocial difficulties such as stigma, discrimination and loss of relatives to the disease could be expected to lead to widespread fear of COVID-19 (Pappas et al., Reference Pappas, Kiriaze, Giannakis and Falagas2009). The dramatic shift towards social distancing measures has posed significant challenges related to the health and wellbeing of older adults in the community, especially among those who are fragile, are very old or have multiple chronic diseases (Steinman et al., Reference Steinman, Perry and Perissinotto2020).

Loneliness

Social relationships are an integral part of human wellbeing (Gerst-Emerson and Jayawardhana, Reference Gerst-Emerson and Jayawardhana2015). Loneliness, lack of a mutual relationship with others, is experienced as a complex and subjective emotion that represents the gap between desired and actual social engagement (Victor et al., Reference Victor, Scambler, Bowling and Bond2005). Loneliness negatively affects older individuals’ lives, and increased loneliness among older people due to social isolation is a growing problem (Akbaş et al., Reference Akbaş, Taşdemir Yiğitoğlu and Çunkuş2020). According to a WHO report, approximately 15 per cent of adults aged 60 years and older experience mental health problems, which are associated with social isolation, loss of independence, loneliness and psychological distress (WHO, 2017). In light of this, the health and wellbeing consequences of social isolation and loneliness in older age have increasingly been monitored (Courtin and Knapp, Reference Courtin and Knapp2017).

In parallel with ageing, individuals’ social living spaces are shrinking (Willis et al., Reference Willis, Vickery and Jessiman2022). It is more difficult for older people to adapt to situations involving rapid changes in social structure, causing them to experience a sense of loneliness in response to social isolation more intensely than younger groups (Akbaş et al., Reference Akbaş, Taşdemir Yiğitoğlu and Çunkuş2020). Factors that cause an intense sense of loneliness among older individuals include sensory losses, physical limitations, the death of a spouse or friend, retirement, a change in roles, separation from home, chronic diseases, sociocultural conditions, economic difficulties, lack of social support systems and dependence on others (Akbaş et al., Reference Akbaş, Taşdemir Yiğitoğlu and Çunkuş2020).

Considering loneliness as a deficiency of social relationships (Koehn et al., Reference Koehn, Ferrer and Brotman2022), the decrease in older people's face-to-face interactions with their friends and family during the COVID-19 pandemic is an important factor in their increased feelings of loneliness (Pandya, Reference Pandya2020). In addition, social isolation among older adults is a known ‘serious public health concern’ due to the associated increased risks of cardiovascular, autoimmune, neurocognitive and mental health problems (Gerst-Emerson and Jayawardhana, Reference Gerst-Emerson and Jayawardhana2015; Armitage and Nellums, Reference Armitage and Nellums2020: 256). Social disconnection is also known to place older individuals at greater risk of depression and anxiety (Armitage and Nellums, Reference Armitage and Nellums2020).

Older people who are attempting to cope with health problems and have difficulty meeting their daily personal needs are worried about their futures. They may feel excluded due to social isolation during the COVID-19 pandemic and may experience an intense sense of loneliness (Gencer, Reference Gencer2019, Reference Gencer2020). Many studies have found that feelings of loneliness are associated with poor health outcomes, such as high blood pressure, cardiovascular disease, cognitive and functional decline, and depression (Knox and Uvnäs-Moberg, Reference Knox and Uvnäs-Moberg1998; Cacioppo et al., Reference Cacioppo, Hughes, Waite, Hawkley and Thisted2006; Hawkley et al., Reference Hawkley, Thisted, Masi and Cacioppo2010; James et al., Reference James, Wilson, Barnes and Bennett2011; Perissinotto et al., Reference Perissinotto, Stijacic Cenzer and Covinsky2012, cited in Zhang et al., Reference Zhang, Xu, Li, Sun, Ding, Qian, Jing, Zihang and Xie2018; Theeke and Mallow, Reference Theeke and Mallow2013).

Quality of life

As individuals live longer lives, health-enhancing behaviours become more important, especially with regard to quality of life (Lee et al., Reference Lee, Ko and Lee2006). Older adults’ lives involve not only health and dysfunction but also wellbeing and social exchanges (Lee et al., Reference Lee, Small and Haley2020). Quality of life refers to a person's state of wellbeing in a general sense, which includes being enthusiastic and happy (Eser, Reference Eser2006; Altay et al., Reference Altay, Çavuşoğlu and Çal2016). In the context of culture and value systems, the WHO defines quality of life as an individual's goals, expectations, standards and concerns regarding the perception of the position in that person's life (WHO, 2021b). ‘Quality of life’ became a frequently used term with the rapid development of the understanding of the welfare state after the Second World War (Musschenga, Reference Musschenga1997). The goals of social policy are expressed in terms such as ‘prosperity’, ‘happiness’ and ‘quality of life’, and with an intent to raise the quality of social life as much as possible. Social policies have thus played an important role in the development of quality of life in the field of health (Musschenga, Reference Musschenga1997).

Many factors affect quality of life, including financial situation, physical wellbeing, hobbies, participation in social life, relations with family and friends, psychological state and emotional state (Birtane et al., Reference Birtane, Tuna, Ekuklu, Uzunca, Akçi and Kokino2000; Altuğ et al., Reference Altuğ, Yağcı, Kitiş, Büker and Cavlak2009). Quality of life means different things in different periods of life and for different individuals. The criteria for determining quality of life may also vary with age. Culture, age, marital status, gender, economic status, leisure activities, educational attainment, chronic diseases, physical disabilities, social security, family relations and nursing home resident status are important variables affecting quality of life (Ercan Şahin, Reference Ercan Şahin2015). Receiving support for psychosocial needs also shows positive results with regard to perceived loneliness, quality of life and attitudes among older people (Esmaeilzadeh and Oz, Reference Esmaeilzadeh and Oz2020). According to the needs satisfaction approach, quality of life varies according to the number of satisfied needs, which can be either biological or social (Wiggins et al., Reference Wiggins, Higgs, Hyde and Blane2004). Danış (Reference Danış2009) explains that satisfaction with physical, spiritual and mental health and the state of enjoyment of life play a role in improving quality of life.

Relations among variables and hypotheses

The closeness of relationships with other individuals decreases among older people with increased health risks (Griffin et al., Reference Griffin, Williams, Mladen, Perrin, Dzierzewski and Rybarczyk2020). Parlapani et al. (Reference Parlapani, Holeva, Nikopoulou, Sereslis, Athanasiadou, Godosidis, Stephanou and Diakogiannis2020) found that, during the COVID-19 pandemic, older adults exhibited moderate to severe (84.5%) anxiety symptoms, moderate to severe depressive symptoms (81.6%) and sleep disturbances (37.9%). They also found that older women experienced greater fear of COVID-19, had more severe depressive symptoms and sleep disturbances, and exhibited greater intolerance to uncertainty, and those individuals living alone had greater feelings of loneliness than other participants in the study. Simon et al. (Reference Simon, Chang, Zhang, Ruan and Dong2014) found that older adults who had experienced adverse health changes in the previous year were more likely to experience a sense of loneliness. Grossman et al. (Reference Grossman, Hoffman, Palgi and Shrira2021) found that loneliness related to COVID-19 was associated with more sleep problems. Those with psychiatric diagnoses were more affected by loneliness during the implementation of social isolation measures to prevent the spread of COVID-19 (Hoffart et al., Reference Hoffart, Johnson and Ebrahimi2020).

  • • Hypothesis 1: Fear of COVID-19 among older adults is positively related to their sense of loneliness.

Since the isolation measures undertaken to counteract the spread of the pandemic have led to some problems related to the wellbeing and health of older adults (Korkmaz, Reference Korkmaz2019; Bozkurt et al., Reference Bozkurt, Zeybek and Aşkın2020; Steinman et al., Reference Steinman, Perry and Perissinotto2020), fear of COVID-19 may affect their quality of life. Dymecka et al. (Reference Dymecka, Gerymski and Machnik-Czerwik2022) found a significant association between life satisfaction and fear of COVID-19. According to Alyami et al. (Reference Alyami, de Albuquerque, Krägeloh, Alyami and Henning2021), fear of COVID-19 indirectly affects quality of life. Maslakçı et al. (Reference Maslakçı, Sürücü and Sesen2021) also identified close associations between these two variables. People's ways of life may change depending on isolation measures, and living apart from relatives and friends may lead to declines in quality of life.

  • • Hypothesis 2: Fear of COVID-19 is negatively related to older people's quality of life.

Quality of life is fed by emotional support (Doran et al., Reference Doran, Burden and Shryane2019). However, loneliness in older age may damage wellness and quality of life. For example, Morris (Reference Morris2020) proposed that reducing loneliness could mitigate the risk of depression. VanderWeele et al. (Reference VanderWeele, Hawkley and Cacioppo2012) identified mutual effects between loneliness and subjective wellbeing. Ekwall et al. (Reference Ekwall, Sivberg and Hallberg2005) found that loneliness was the most important factor predicting low quality of life among older people, and Çam et al. (Reference Çam, Atay and Işıklı2018) revealed that feelings of loneliness were more intense among older adults with insufficient social interaction (i.e. interactions in which psychosocial support, social bonds or emotional attachment could not be achieved). They emphasised that these individuals’ mental health and quality of life were negatively affected. The quality of life of older people living in nursing homes has been found to be significantly worse than that of those living at home (Göktaş, Reference Göktaş2006). A negative relationship has also been found between quality of life and loneliness (Weiner et al., Reference Weiner, Roe, Mashiach-Eizenberg, Baloush-Kleinman, Maoz and Yanos2010; Vuletić and Stapić, Reference Vuletić and Stapić2013; Faruk et al., Reference Faruk, Akkaya and Başıbüyük2019; Korkmaz, Reference Korkmaz2019; Szabo et al., Reference Szabo, Allen, Alpass and Stephens2019). In other words, loneliness may decrease quality of life (Gerino et al., Reference Gerino, Rollè, Sechi and Brustia2017; Faruk et al., Reference Faruk, Akkaya and Başıbüyük2019). In light of this, we propose the following relationship between loneliness and quality of life among those aged 60 years and older:

  • • Hypothesis 3: The sense of loneliness experienced by older individuals is negatively related to their quality of life.

The absence of social associations with friends and parents may lead to feelings of loneliness (Weiner et al., Reference Weiner, Roe, Mashiach-Eizenberg, Baloush-Kleinman, Maoz and Yanos2010). Moreover, fear of COVID-19 and social isolation measures may cause individuals to feel lonely (Hoffart et al., Reference Hoffart, Johnson and Ebrahimi2020; Grossman et al., Reference Grossman, Hoffman, Palgi and Shrira2021) and contribute to lower quality of life (Alyami et al., Reference Alyami, de Albuquerque, Krägeloh, Alyami and Henning2021; Maslakçı et al., Reference Maslakçı, Sürücü and Sesen2021). Considering that loneliness is a predictor of quality of life (Weiner et al., Reference Weiner, Roe, Mashiach-Eizenberg, Baloush-Kleinman, Maoz and Yanos2010; Vuletić and Stapić, Reference Vuletić and Stapić2013; Faruk et al., Reference Faruk, Akkaya and Başıbüyük2019; Korkmaz, Reference Korkmaz2019; Szabo et al., Reference Szabo, Allen, Alpass and Stephens2019), it may mediate the negative association between fear of COVID-19 and quality of life. Although there is little evidence of this mediation effect in the existing literature, we propose the following role of loneliness in the relationship between fear of COVID-19 and quality of life:

  • • Hypothesis 4: Loneliness mediates the relationship between fear of COVID-19 and quality of life among older adults.

Method

Research model

The research model prepared based on the hypotheses is shown in Figure 1. Data obtained from individuals aged 60 years and older were entered into a database and coded for subsequent analysis. Confirmatory factor analyses were conducted using AMOS. Cronbach's alpha reliability coefficients, correlations and multiple regressions were calculated using SPSS. The principles outlined by Baron and Kenny (Reference Baron and Kenny1986) were used as a reference framework when assessing the potential mediating role of loneliness. Sobel tests and Hayes's (Reference Hayes2017) PROCESS bootstrapping macro for SPSS were used to confirm the mediation effect.

Figure 1. Research model and hypotheses.

Notes: H1: Hypothesis 1. H2: Hypothesis 2. H3: Hypothesis 3. H4: Hypothesis 4. The mediating effect is shown in dash lines.

Sample

The sample in this research included older individuals living in Turkey. Individuals from the Burdur city centre and surrounding villages were selected using simple random sampling. A total of 267,092 people live in Burdur, 56,296 (21%) of whom are older adults (Table 1). Of the 540 surveys we distributed in February 2021, 397 were returned. Since outliers, which can be referred to as deviants (Aggarwal, Reference Aggarwal2017), can dramatically affect the inference results (Woolrich, Reference Woolrich2008), outlier analysis was conducted. As a result of the analysis, ten responses were excluded from the dataset. Participants’ average age was 69.5 years. Of the total sample, 46 per cent were female and 54 per cent were male; 40 per cent had graduated from primary or secondary school, 14 per cent from high school and 31 per cent from university, 7 per cent had a postgraduate education and the remaining 8 per cent were literate.

Table 1. Distribution of the older population in Burdur by gender

Source: TÜİK/MEDAS (2020).

Measures

Quality of Life Scale in Older People (CASP-19)

The 19-item CASP-19, developed by Hyde et al. (Reference Hyde, Wiggins, Higgs and Blane2003) to measure quality of life among older people, was used to determine participants’ levels of quality of life (see the Appendix). Answers are provided on a four-point Likert scale ranging from 0 (‘never’) to 3 (‘always’) (Hyde et al., Reference Hyde, Wiggins, Higgs and Blane2003). Sample items include ‘My age prevents me from doing the things I would like to’, ‘My health stops me from doing the things I want to do’ and ‘I feel that the future looks good for me’. The Turkish translation of the scale was created by Türkoğlu and Adıbelli (Reference Türkoğlu and Adıbelli2014). Confirmatory factor analysis was performed to test the CASP-19's sampling suitability and structural validity. Results showed that the values of goodness-of-fit indices were good in the analysis using a single-factor model (χ2/degrees of freedom (df) = 4.58, Goodness-of-Fit Index (GFI) = 0.91, Incremental Fix Index (IFI) = 0.95, Comparative Fit Index (CFI) = 0.95, Root Mean Square Error of Approximation (RMSEA) = 0.09). Factor loadings of items ranged from 0.57 to 0.91. Cronbach's alpha must be at least 0.70 for a scale to be considered reliable (Fields, Reference Fields2002; Neuman, Reference Neuman2007); the CASP-19's reliability coefficient was high (α = 0.96).

Fear of COVID-19 Scale (FCV-19S)

The seven-item FCV-19S developed by Ahorsu et al. (Reference Ahorsu, Lin, Imani, Saffari, Griffiths and Pakpour2020) was used to measure fear of COVID-19. Answers are provided on a five-point Likert scale ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’). Sample items include ‘It makes me uncomfortable to think about coronavirus-19’, ‘I am afraid of losing my life because of coronavirus-19’ and ‘I cannot sleep because I'm worrying about getting coronavirus-19’ (see the Appendix). The FCV-19S was translated into Turkish by Bakioğlu et al. (Reference Bakioğlu, Korkmaz and Ercan2020) and has high reliability (α = 0.88). Confirmatory factor analysis indicated that the FCV-19S's goodness-of-fit indices were good (χ2/df = 2.31, GFI = 0.98, IFI = 0.99, CFI = 0.99, RMSEA = 0.06). Factor loadings of items ranged from 0.44 to 0.81. As a result of the reliability analysis, it was determined that the reliability coefficient of the scale was high (α = 0.88).

Loneliness Scale for the Elderly (LSE)

The 11-item LSE developed by De Jong Gierveld and Kamphuis (Reference De Jong Gierveld and Kamphuis1985) and adapted by Van Tilburg and De Jong Gierveld (Reference Van Tilburg and De Jong Gierveld1999) was used to measure participants’ perceived feelings of loneliness (see the Appendix). Sample items include ‘I experience a general sense of emptiness’, ‘I miss the pleasure of the company of others’ and ‘I miss having people around’. Akgül and Yeşilyaprak (Reference Akgül and Yeşilyaprak2015) translated the LSE into Turkish and found that it had high reliability (α = 0.85). Confirmatory factor analysis indicated that the LSE's goodness-of-fit indices fit the single-factor structure (χ2/sd = 3.08, GFI = 0.94, IFI = 0.97, CFI = 0.97, RMSEA = 0.07). Factor loadings of items ranged from 0.47 to 0.90. The scale had high reliability (α = 0.93).

Findings

Because data must fit the normal distribution for parametric analysis tests (Yazıcıoğlu and Erdoğan, Reference Yazıcıoğlu and Erdoğan2004), analysis of normal distribution was performed and indicated that the data were normally distributed. Pearson's correlations were calculated to determine the relations among variables (Table 2). To assess the mediating role of loneliness in the relationship between fear of COVID-19 and quality of life, we followed Baron and Kenny's (Reference Baron and Kenny1986) procedure and used Sobel tests. According to this method, three conditions must be met to test the mediating effect of a variable. First, the independent variable should be significantly related to the mediator variable. Second, the independent variable should be related to the dependent variable. Third, the mediator should be included in the model. In this last stage, the mediating variables should be related to the dependent variables with the independent variables included in the equation. If the independent variables have no significant beta weights in the final stage, a full mediation effect is indicated. After these tests, we used bootstrapping to obtain a more robust p-value (Caron, Reference Caron2019). The analyses controlled for age as a possible covariate here for clarity.

Table 2. Means, standard deviations (SD) and correlations

Note: Alpha reliability coefficients are shown in parentheses.

Significance level: ** p ⩽ 0.01.

Regression analysis was conducted to test the hypotheses (Table 3). The beta weights for fear of COVID-19 and perceived quality of life were negative and significant (β = −0.23, p < 0.001). The beta weights for fear of COVID-19 and loneliness were also significant (β = 0.35, p < 0.001). In addition, loneliness was negatively and significantly related to quality of life (β = −0.61, p < 0.001). The R 2 values (Table 3) indicate that sense of loneliness explained 73 per cent of the variance in quality of life, a relatively high proportion in the statistical model. Thus, the first three hypotheses are supported.

Table 3. Mediating role of loneliness in the relationship between fear of COVID-19 and quality of life

Significance level: *** p < 0.001.

In the final step, fear of COVID-19 and the interaction of loneliness on quality of life were tested together. While the negative beta weight for the interaction between fear of COVID-19 and quality of life was not significant (β = −0.02, p > 0.05), the interaction between loneliness and quality of life was significant (β = −0.60, p < 0.001). In other words, when loneliness was added to the model as a mediator variable, the regression coefficient for fear of COVID-19 – which has a significant effect on quality of life (p < 0.001) – was reduced from −0.23 to −0.02, and the association lost its significance (p > 0.05). The predictor variables together explained 73 per cent of the variance in quality of life. Thus, we conclude that loneliness fully mediates the relation between fear of COVID-19 and quality of life. Sobel's test also showed that loneliness plays a mediating role in the relation between fear of COVID-19 and quality of life (z = −7.83, p < 0.001).

Since the bootstrapping method is free from statistical distribution assumptions (Caron, Reference Caron2019) and has more powerful statistical properties than the Sobel test with regard to indirect effect detection (Hayes, Reference Hayes2009), we also employed this method, using bias-corrected confidence intervals (CIs) (MacKinnon et al., Reference MacKinnon, Lockwood and Williams2004). The 95 per cent CI of the indirect effects was obtained using 5,000 bootstrap resamples (Caron, Reference Caron2019). Results indicated that fear of COVID-19 was negatively associated with quality of life (B = −0.39, t(386) = −8.47, p < 0.001) and positively related to loneliness (B = 0.34, t(386) = 10.36, p < 0.001). Finally, the mediator variable (i.e. loneliness) was negatively related to quality of life (B = −0.79, p < 0.001). When controlling for loneliness, the direct effect of fear of COVID-19 on quality of life became non-significant (B = −0.02, t(386) = −0.74, p < 0.001). Thus, it was confirmed that loneliness mediates the relationship between fear of COVID-19 and quality of life (B = −0.37; CI = −0.44 to −0.30). Hypothesis 4 is therefore supported.

Discussion

In this study, older adults’ fear of COVID-19, loneliness and quality of life were examined by collecting data from participants aged 60 years and older. Hypotheses regarding the relationship among fear of COVID-19, quality of life and loneliness were examined empirically. First, confirmatory factor analyses were performed to detect the factorial structure for each instrument. Subsequently, mediation analysis (controlling for age as a continuous covariate) was performed to assess the nature of the relationship between fear and quality of life and the extent to which that relationship is mediated by loneliness. Following Baron and Kenny's (Reference Baron and Kenny1986) procedure and using Sobel tests, we used bootstrapping to obtain a more robust p-value (Caron, Reference Caron2019).

We found a negative and direct relationship between loneliness and quality of life. Loneliness explained roughly 76 per cent of the variance in quality of life. This finding shows an overwhelming association that is consistent with other studies in the literature. As Ekwall et al. (Reference Ekwall, Sivberg and Hallberg2005) and Çam et al. (Reference Çam, Atay and Işıklı2018) have pointed out, loneliness affects quality of life. Although living alone does not necessarily equate to loneliness, people who live alone may have felt loneliness more intensely during the pandemic because of social isolation and limited social activities. In turn, older people's quality of life may have fallen over time as a result of living alone (Gouveia et al., Reference Gouveia, Gouveia, Ihle, Kliegel, Maia, Badia and Freitas2017). Likewise, quality of life decreases among older people if their feelings of loneliness are high (Gerino et al., Reference Gerino, Rollè, Sechi and Brustia2017; Faruk et al., Reference Faruk, Akkaya and Başıbüyük2019). Thus, loneliness is an important factor in older people's quality of life. We also found the effect of loneliness on quality of life to be higher in our sample than in some other studies conducted in individualist societies (Weiner et al., Reference Weiner, Roe, Mashiach-Eizenberg, Baloush-Kleinman, Maoz and Yanos2010; Szabo et al., Reference Szabo, Allen, Alpass and Stephens2019). As Beller and Wagner (Reference Beller and Wagner2020) have proposed, this result may show that collectivist communities assign more importance to loneliness than their individualist counterparts. Thus, feelings of loneliness may reduce older adults’ quality of life much more in collectivist cultures than in Western cultures.

Another important finding of our research is that fear of COVID-19 has a significant effect on loneliness. Specifically, as fear of COVID-19 increases, loneliness also increases. We believe that this result is valuable in that it has not previously been recorded in the literature. Since older adults are more strongly affected by COVID-19 (Griffin et al., Reference Griffin, Williams, Mladen, Perrin, Dzierzewski and Rybarczyk2020; Parlapani et al., Reference Parlapani, Holeva, Nikopoulou, Sereslis, Athanasiadou, Godosidis, Stephanou and Diakogiannis2020), they may be especially pushed to isolate themselves. We also found that fear of COVID-19 has a negative effect on quality of life, which likewise appears to be the first such finding in the literature. Given that the pandemic has affected the wellbeing of older people (Steinman et al., Reference Steinman, Perry and Perissinotto2020) and that fear of COVID-19 has an indirect effect on quality of life (Alyami, Reference Alyami, de Albuquerque, Krägeloh, Alyami and Henning2021), this conclusion is in line with other findings. Fear of COVID-19 leads individuals to isolate themselves and live apart from their relatives and friends, depriving them of physical and psychological support and interactions. This, in turn, may lead to a decrease in their quality of life.

Finally, loneliness mediates the relation between fear of COVID-19 and quality of life. This result is noteworthy, as we could not find any similar finding in the literature. This finding strongly suggests that fear of COVID-19 influences quality of life via loneliness. In other words, older people with high levels of fear of COVID-19 are at increased risk of experiencing high levels of loneliness, resulting in low quality of life. While fear of COVID and social isolation measures promote feelings of loneliness (Hoffart et al., Reference Hoffart, Johnson and Ebrahimi2020; Grossman et al., Reference Grossman, Hoffman, Palgi and Shrira2021) and indirectly affect quality of life (Alyami et al., Reference Alyami, de Albuquerque, Krägeloh, Alyami and Henning2021), loneliness leads to a decline in the quality of older adults’ lives (Weiner et al., Reference Weiner, Roe, Mashiach-Eizenberg, Baloush-Kleinman, Maoz and Yanos2010; Vuletić and Stapić, Reference Vuletić and Stapić2013; Faruk et al., Reference Faruk, Akkaya and Başıbüyük2019; Korkmaz, Reference Korkmaz2019; Szabo et al., Reference Szabo, Allen, Alpass and Stephens2019). Hence, fear of COVID-19 indirectly affects quality of life through loneliness. In line with the literature (Simon et al., Reference Simon, Chang, Zhang, Ruan and Dong2014; Dymecka et al., Reference Dymecka, Gerymski and Machnik-Czerwik2022), this result seems to indicate that people who are more afraid of a pandemic are not only exposed to a sense of loneliness but also experience a lower quality of life. This impact on quality of life can be ameliorated to some extent by having social and official support.

Limitations and recommendations for future research

Our research only examined fear of COVID-19, loneliness and quality of life. The inclusion of other variables that might impact quality of life would expand the scope of this research. In the model we created, only the mediating role of loneliness was tested and determined. We recommend examining the role of this variable as a moderator in similar models. Moreover, the scales used in this research measure individuals’ self-perceptions. Therefore, factors such as common method variance and social desirability bias should be taken into account when analysing our data. Finally, we used simple methods to test our hypotheses, which poses limitations: specifically, treating the responses as continuous rather than ordinal and directly using the loneliness score as a mediator, rather than using a complete ordinal structural equation model. Considering the novelty of this research, this may still be acceptable, but further analysis using different methods or statistical programs would deepen our results.

Conclusion and implications

Urgent action is needed to alleviate the problems that have arisen due to social isolation and fear of COVID-19. It is recommended that psychosocial support services should be strengthened in order to reduce fear of COVID-19. Since older people experience this feeling deeply as a result of their social isolation, the negative effects of loneliness within this population should be reduced using innovative solutions. In addition, public fear of COVID-19 should be addressed by increasing health literacy. To this end, a social support line could be established to provide a sense of belonging, and online support could be provided using new technologies.

Financial support

This research was not supported by any funding body or financial sponsors.

Conflict of interest

The authors declare no conflicts of interest.

Ethical standards

Ethical approval was received from the Mehmet Akif University Non-Interventional Clinical Research Ethics Committee (reference GO 2021/80). All participants indicated their consent to participate in the study prior to answering the questionnaire. All participants were fully anonymised.

Appendix

Quality of Life Scale in Older People (CASP-19)

  1. 1. My age prevents me from doing the things I would like to.

  2. 2. I feel that what happens to me is out of my control.

  3. 3. I feel free to plan for the future.

  4. 4. I feel left out of things.

  5. 5. I can do the things that I want to do.

  6. 6. Family responsibilities prevent me from doing what I want to do.

  7. 7. I feel that I can please myself what I can do.

  8. 8. My health stops me from doing the things I want to do.

  9. 9. Shortage of money stops me from doing the things that I want to do.

  10. 10. I look forward to each day.

  11. 11. I feel that my life has meaning.

  12. 12. I enjoy the things that I do.

  13. 13. I enjoy being in the company of others.

  14. 14. On balance, I look back on my life with a sense of happiness.

  15. 15. I feel full of energy these days.

  16. 16. I choose to do things that I have never done before.

  17. 17. I feel satisfied with the way my life has turned out.

  18. 18. I feel that life is full of opportunities.

  19. 19. I feel that the future looks good for me.

The Fear of COVID-19 Scale (FCV-19S)

  1. 1. I am most afraid of coronavirus-19.

  2. 2. It makes me uncomfortable to think about coronavirus-19.

  3. 3. My hands become clammy when I think about coronavirus-19.

  4. 4. I am afraid of losing my life because of coronavirus-19.

  5. 5. When watching news and stories about coronavirus-19 on social media, I become nervous or anxious.

  6. 6. I cannot sleep because I'm worrying about getting coronavirus-19.

  7. 7. My heart races or palpitates when I think about getting coronavirus-19.

Loneliness Scale for the Elderly (LSE)

  1. 1. There is always someone I can talk to about my day-to-day problems.

  2. 2. I miss having a really close friend.

  3. 3. I experience a general sense of emptiness.

  4. 4. There are plenty of people I can lean on when I have problems.

  5. 5. I miss the pleasure of the company of others.

  6. 6. I find my circle of friends and acquaintances too limited.

  7. 7. There are many people I can trust completely.

  8. 8. There are enough people I feel close to.

  9. 9. I miss having people around.

  10. 10. I often feel rejected.

  11. 11. I can call on my friends whenever I need them.

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Figure 0

Figure 1. Research model and hypotheses.Notes: H1: Hypothesis 1. H2: Hypothesis 2. H3: Hypothesis 3. H4: Hypothesis 4. The mediating effect is shown in dash lines.

Figure 1

Table 1. Distribution of the older population in Burdur by gender

Figure 2

Table 2. Means, standard deviations (SD) and correlations

Figure 3

Table 3. Mediating role of loneliness in the relationship between fear of COVID-19 and quality of life