A significant proportion of older people suffer from a long term condition / disability. This issue is of significant policy interest, as there is increasing recognition that there is a need to understand the different factors that contribute to quality of life in this population. Loneliness is an important potential factor in this context [1], but quality of life in older populations is affect by a wide range of other factors including social isolation [2], disability [3], long term conditions [4], living alone, or being a carer [5]. Rurality is another factor that may be associated with poorer health outcomes [6], but the picture is complicated, as there is also evidence that rural communities can provide each other with greater support [7]. Relatively little research has been undertaken to understand the interactions between these factors and they have therefore been incorporated in this study.
Measuring ‘quality of life’ as an outcome is complex, and it should be acknowledged that simplistic assumptions that a long term condition / disability inevitably leads to a poor quality of life is incorrect [8]. This may be because the components that constitute quality of life reflect changing life goals, and an inherent capacity to adjust to loss during the life course. Quality of life in the presence of a long term condition / disability may also be influenced by factors such as a sense of meaning, purpose, and a sense of being valued, which are incorporated in the model underpinning salutogenesis [9].
The capacity to cope in the face of adversity was studied by Antonovsky, who investigated holocaust survivors after the Second World War, and sought to understand the characteristics that had been most significant in those who survived [10]. He characterised these factors as ‘salutogenic’, and emphasised the importance of a personal sense of coherence.
A sense of coherence may be defined as, “The extent to which one has a pervasive, enduring though dynamic, feeling of confidence that one’s environment is predictable and that things will work out as well as can reasonably be expected” [11, 12]. Antonovsky suggested that sense of coherence is composed of three factors: comprehensibility, manageability, and meaningfulness. Expressed in greater detail, “comprehensibility is the extent to which events are perceived as making logical sense, that they are ordered, consistent, and structured. Manageability is the extent to which a person feels they can cope. Meaningfulness is how much one feels that life makes sense, and challenges are worthy of commitment” [13].
There are a wide range of concepts that overlap with sense of coherence including mastery, resilience and hardiness [14]. However, the concept of a sense of coherence has stood the test of time and has therefore been used in this paper. A range of studies have demonstrated that sense of coherence can have main, moderating, and mediating effects on health and quality of life [15], and this project therefore sought to assess any buffering effect that a sense of coherence might have on associations with quality of life, in the context of a population survey.
Population surveys need to be kept short to improve completion rates. It is therefore welcome that the original 29 item sense of coherence scale was later reduced to 13 items [16] and has more recently been reduced to a three item scale [17]. The three item sense of coherence scale has consequently been used in this study.
The geographical context for this study, NHS Highland, is very rural. NHS has a low population density, covering 41% of the land mass of Scotland, but with only a population of 320,000. There is one small city, a number of market towns, many small towns and villages, and 26 inhabited islands. The effect of rurality on the interplay between different factors affecting quality of life was therefore of interest to this study. Measuring rurality in Scotland is generally undertaken using an eight, six or three category index. For the purposes of this study, the index was collapsed into three categories, which is standard practice for this index [18].
The impact of disability, long term conditions, rurality, living alone, and being a carer on health has some evidence base, however, the extent to which these factors might be buffered by a strong SoC is unknown. To explore this, we hypothesised a model of physical, environmental and social factors, and sought to examine whether SOC buffers any of these factors, in terms of their impact on quality of life, in the context of older people (65+) in a rural Scottish Health Board (Fig. 1).