Abstract
This study examined differences in sociodemographics, health, participation, and quality of life among older adults from ethnic majority versus minority groups.
Participation is defined as involvement in a life situation (World Health Organization [WHO], 2001), which occurs when individuals carry out purposeful and meaningful daily activities (American Occupational Therapy Association, 2020). It encompasses both objective and subjective aspects. The objective aspect encompasses frequency, duration, and diversity. The subjective aspect encompasses occupational experience, including autonomy (independence and choice), belongingness, challenge, engagement (motivation and involvement), mastery (achievement and competence), and meaning (Ginis et al., 2017; Hammell, 2004). Participation in activities is vital for older adults, who may be vulnerable to functional deterioration because of biopsychosocial factors (Jessen-Winge et al., 2018). Sustaining engagement in meaningful activities and relationships is essential for healthy aging, which involves preserving functional ability for well-being in older age (WHO, 2017). This underscores the importance of a proactive, holistic approach to maintaining a high quality of life (QoL) among older adults (WHO, 2015).
QoL is defined as a person’s perception of their position in life in the context of their surrounding culture and value system, and it relates to their goals, expectations, standards, and concerns (WHOQOL Group, 1995). It has been shown that QoL in older ages is degraded by impaired functional ability, loneliness, and depression rather than by the aging process itself (Brett et al., 2019). Conversely, it was found that older people’s involvement in lifelong activity significantly contributes to their health, well-being, and QoL (Stav et al., 2012).
Previous studies have shown a significant correlation between participation and QoL among older adults, indicating that participation in socially productive and leisure activities was associated with QoL (Araújo et al., 2021; Segev-Jacubovski & Shapiro, 2022) and that participation in physical activities improves their perceived mental health, resulting in better health-related QoL (Yen & Lin, 2018). Two conceptual models support this relationship. The first is the International Classification of Functioning, Disability and Health (ICF; WHO, 2001), which emphasizes the biopsychosocial synergy of participation in activities across various life domains as crucial in fostering health, well-being, and QoL. The second is the do-live-well (DLW) occupation-based health promotion framework (Moll et al., 2015), which highlights the impact of engagement in various activities (physical, cognitive, sensory, and social) on health and well-being. This framework focuses on the range and nature of occupational experiences, reflecting the subjective aspect of participation. According to this framework, personal and social contexts can affect the ability to engage in health-promoting activities, affecting health and wellness outcomes. These contexts encompass demographic characteristics (e.g., age, socioeconomic status, and ethnicity) and social forces in the physical, institutional, or sociocultural environments, which can either facilitate or hinder optimal activity engagement.
Social and cultural contextual factors shape opportunities or form barriers to meaningful occupations, thereby promoting or hindering occupational justice. Occupational justice argues that people have unique occupational capacities, needs, and routines within the context of their environment and that they have the right to actualize their capacities to promote and sustain their health and QoL (Durocher et al., 2014). Occupational justice is served when conditions allow people to engage in occupations that are consistent with their culture and beliefs in an effort to bridge the gap between well-being and restrictive social conditions (Hocking, 2017). It emphasizes creating opportunities for participation in meaningful occupations to enhance the health and QoL of older adults by supporting the principles of fairness, equity, and empowerment (Lewis & Lemieux, 2021).
In the Israeli population, there are two main ethnic groups: a Jewish majority and an Arab minority, which constitutes approximately 21% of the population (Israeli Central Bureau of Statistics; ICBS, 2022). These two populations differ in primary language (Hebrew versus Arabic) and religious affiliation (Jewish versus Christian or Muslim). Most Israeli Arabs attend separate educational frameworks and live in separate residential communities, which often leads to social segregation (Damri & Litwin, 2016). Additionally, their communities are ranked at the low end of the Israeli socioeconomic index of localities (ICBS, 2022) and often lack public infrastructure for social participation (Rozani, 2022; Yazdanpanahi & Woolrych, 2023). The two groups differ in poverty rate, which is higher among the Arab households, along with multiple health disparities, such as life expectancy (Chernichovsky et al., 2017), self-rated health (Rozani, 2022), and depression (Schorr et al., 2021).
Only a few studies have specifically compared participation and QoL among older adults from Arab and Jewish ethnic groups. For example, it was found that older Arab adults participated in physical activities less often than their Jewish peers (Rozani, 2022). Additionally, a previous study found that the QoL of older Jewish people was higher than that of their Arab peers (Vitman-Schorr & Khalaila, 2022) and that declining QoL was more apparent among minorities, including Arabs, than among the Jewish majority (Damri & Litwin, 2016). More such comparisons can provide valuable insights into the unique challenges facing older adults in minority cultures and foster a more informed approach to address their specific requirements. Such careful evaluation through the lens of equity and justice is essential in occupational therapy (Johnson et al., 2024) for creating caring communities (Suarez-Balcazar et al., 2023).
Given this knowledge gap, our study focused on participation in daily activity and QoL among community-dwelling older individuals from these two ethnic groups. The study aimed to explore the differences between community-dwelling older adults from minority (Arab) and majority (Jewish) populations. Our objectives were to compare participation (objective and subjective) and QoL between these groups and to examine the relationships between sociodemographics, health-related variables, and participation with QoL in each group. The study hypotheses were lower participation and QoL scores in the minority group, compared with those in the majority group, and significant correlations between sociodemographics, health-related variables, and participation with QoL in both groups.
Method
Study Design and Participants
The study was designed as a quantitative, descriptive, comparative, and correlative cross-sectional study. We recruited participants using a stratified sample, resulting in 496 men and women divided into two groups: 90 Arab and 406 Jewish participants, on the basis of their proportions in the Israeli population (ICBS, 2022). The inclusion criteria included individuals ages 65 yr and older who had not been hospitalized the previous month. A final sample of 190 (90 Arab, 100 Jewish) participants was generated by matching Arab and Jewish participants by gender and financial adequacy level to eliminate confounding factors (for sociodemographic information, see the Results section). The sample size was determined using G*Power software (level of .9), with a medium effect size (d = .5) and an anticipated significance of .05. The minimum required sample was 86 participants for each group.
Measures
Background Questionnaire
This self-report questionnaire was developed for the present study to collect sociodemographic information (age, gender, marital status, living conditions, level of education, financial adequacy, and general health status) on a scale ranging from 0 (worst possible) to 100 (best possible).
Four-Item Patient Health Questionnaire for Anxiety and Depression
The four-item Patient Health Questionnaire for Anxiety and Depression (PHQ–4; Kroenke et al., 2009) self-report questionnaire uses a two-item depression scale and a two-item anxiety scale, rated on a 4-point scale ranging from 0 (never) to 3 (almost constantly), yielding total scores ranging from 0 to 12. Each score is categorized as normal (0–2), mild (3–5), moderate (6–8), or severe (9–12). The PHQ–4 has displayed good internal consistency and validity in measuring depression and anxiety symptomatology (Löwe et al., 2010). The present study also observed good internal consistency (α = .88).
Experiencing Day-to-Day Life Questionnaire
The Experiencing Day-to-Day Life Questionnaire (EDLQ; Budman, 2020) was developed to assess the self-reported occupational experiences of adults. It was modified for people over age 65 for the present study by replacing financial security with the housekeeping category, adding examples of activities, and adding a frequency scale. The adapted questionnaire included questions related to seven occupational categories: taking care of physical needs, housekeeping management, spirituality, pleasure and joy, connecting with others, contributing to the community and society, and developing and expressing capabilities (Appendix 1). The adapted questionnaire assesses objective participation (frequency) on a scale ranging from 1 (not at all) to 6 (every day) and subjective participation (satisfaction, importance, and competence) on a scale ranging from 1 (not at all) to 5 (completely). Two mean-score scales are calculated: one for objective participation and one for subjective participation. The internal consistency of the scales was found to be good in the original tool (α = .64–.81; Budman et al., 2023), as well as in the adapted version (objective: α = .78; subjective: α = .93).
World Health Organization Quality of Life–Brief Version
This self-administered brief version of the 100-question World Health Organization Quality of Life questionnaire (WHOQOL–BREF; WHO, 1996) assesses self-perceptions of QoL in the context of one’s cultural values and personal goals, expectations, standards, and concerns. The WHOQOL-BREF contains 26 items that assess physical health, psychological health, social relationships, and environment. Items are measured on a 5-point scale, yielding a transformed total score range of 0–100, with higher scores indicating higher QoL. It has good discriminant validity, internal consistency, and test–retest reliability in the general population and among older adults (Goes et al., 2021). The internal consistency in our sample was excellent (α = .92).
Procedure
We obtained research ethics approval from the Faculty of Medicine at Hebrew University before beginning the study. Candidates who met the inclusion criteria were requested to read the study information, which included a guarantee of anonymity and a consent form to be signed. Participants were asked to complete the questionnaires manually or online using Qualtrics software; they could choose Hebrew or Arabic. Occupational therapy graduate students were available to assist with questionnaire completion or to address any technical or accessibility issues.
Data Analysis
Data analysis was conducted using IBM SPSS Statistics (Version 29). We conducted Cronbach’s α tests to measure the internal consistency of the questionnaires. Descriptive statistics were applied to the demographic variables to determine the means, standard deviations, and percentages. We conducted chi-square analyses to examine the differences between the groups, with a p value of .05 considered statistically significant. The assessment of normality revealed that the health-related variables and objective participation were not normally distributed for the Jewish group, as indicated by skewness and kurtosis Z scores exceeding ±2.58. Additionally, subjective participation was not normally distributed for the Arab group, on the basis of the same criteria. Consequently, nonparametric statistical tests were used for the analysis.
To compare the study measures between groups, we used the Mann–Whitney U test. We used Spearman’s correlation coefficient in each group to examine the correlations among the study measures. False discovery rate (FDR) correction by means of the Benjamini–Hochberg method (Benjamini & Hochberg, 1995) was also applied to adjust for multiple correlations. For all analyses, r <.3 was considered a small effect, .3 ≤ r <.5 was considered a medium effect, and r ≥.5 was considered a large effect.
Results
Of the 190 community-dwelling older people who participated in this study, 100 (52.6%) were Jewish and 90 (47.4%) were Arab. Significant differences between the two groups were found in education levels and health-related variables (Table 1). Most of the Jewish group (79.0%) reported having a professional or academic education, whereas more than half (65.2%) of the Arab group reported not completing high school. The majority of the Jewish participants (92.9%) reported a high level of health, in contrast to 72.4% of the Arab participants. Additionally, the Arab group exhibited a higher prevalence of moderate to severe depression and anxiety symptoms (32.2%), compared with the Jewish group (7.0%). We conducted Mann–Whitney U tests to compare the groups in participation and QoL. The results (Table 2), indicated significant differences, with small and medium effect sizes, between Arabs and Jews in all measures. Jews reported higher levels of participation and higher QoL.
Sociodemographics and Health-Related Differences Between the Two Study Groups
Note. PHQ–4 = Four-item Patient Health Questionnaire for anxiety and depression.
***p < .001.
Differences in Participation and QoL by Group
Note. Mdn = median; QoL = quality of life; WHOQOL-BREF = World Health Organization Quality of Life–Brief Version. **p < .01. ***p < .001.
To further investigate the differences in activity patterns between the groups, we conducted Mann– Whitney U tests for each of the seven occupational categories. As shown in Table 3, the Jewish group exhibited higher means in most categories, with significant differences identified in four of them and small effect sizes. Although the Arab group had a higher mean in the spirituality category, this difference was not statistically significant.
Differences in the Frequency of Participation in Different Occupational Categories by Group
Note. Mdn = median.
*p < .05. ***p < .001.
We calculated Spearman’s correlation coefficient to discover any correlations between socio-demographics, health-related variables, and participation with QoL. FDR correction was applied to adjust for multiple testing. In both groups, all measures (Table 4) excluding age, demonstrated significant correlations with QoL. Making ends meet more easily, higher education levels, better health status, lower levels of anxiety and depression, and increased objective and subjective participation were all associated with better QoL. A higher correlation was found between subjective participation and QoL among the Arab group (r = .63).
Spearman Correlational Analyses Between Sociodemographic Variables, Health-Related Variables, and Participation (Objective and Subjective) With QoL in Both Groups
Note. All reported p values were adjusted using the false discovery rate correction. PHQ–4 = four-item Patient Health Questionnaire for anxiety and depression; QoL = quality of life; WHOQOL-BREF = World Health Organization Quality of Life–Brief Version.
*p < .05. ***p < .001. Both p values are one-tailed.
Discussion
In this study, we aimed to compare participation (objective and subjective) and QoL among community-dwelling older adults from two ethnic groups: Jews (the majority group) and Arabs (the minority group). Additionally, we examined the relationships between sociodemographics, health-related variables, and participation with QoL of each group.
The comparison of the sample characteristics revealed significant differences between the two groups in education levels and health-related variables. The Arab group reported lower education levels, lower self-rated health status, and a higher prevalence of depression and anxiety symptoms, compared with the Jewish group. These findings support previous studies that indicated higher levels of distress and depressive symptoms among minority groups (Kimhi et al., 2020; Schorr et al., 2021). It also aligns with the findings of Rozani (2022), who linked the lower self-rated health scores, including depression, among Arab elderly people to socioeconomic factors such as ethnicity, low income, and education. These results can be explained by a lack of adequate accessible health care services in districts with high percentages of Arab residents (Chernichovsky et al., 2017).
The first study hypothesis, anticipating lower participation, in both subjective and objective aspects, and lower QoL scores in the minority group compared with the majority group, was confirmed. Moreover, significant differences were found in the frequency of participation in most occupational categories (taking care of physical needs, pleasure and joy, connecting with others, and developing and expressing capabilities). Group differences in participation can be explained by health-related factors, such as the higher levels of depressive symptoms in the Arab group, and socioeconomic factors, such as the higher likelihood of minority elders living in poverty or remote areas, with limited public infrastructure and opportunities for participation in various activities, such as social participation (Yazdanpanahi & Woolrych, 2023) or adequate public transportation (Avivi et al., 2021).
Additionally, low participation rates in health-promoting and physical activities can be attributed to the lower education levels among people in the minority group (Rozani, 2022; Sebastião et al., 2021), and the lack of accessible health care services in minority neighborhoods (Chernichovsky et al., 2017). Although no significant differences were found in the spirituality category, the Arab group reported higher scores, likely because of the more collectivistic and traditional nature of Arab society compared with the general Jewish society (Damri & Litwin, 2016). The significant differences in both objective and subjective participation between the majority and minority groups highlight the disparities in opportunities for participation in various activities between these two groups, which can be attributed to social factors. This underscores the importance of occupational justice and the significance of addressing inequalities that affect marginalized communities’ engagement and participation in meaningful activities (Lewis & Lemieux, 2021). Although our two groups were matched in their ability to make ends meet, about half of the older adults reported some financial difficulties, indicating that subjective perceptions of financial security may not represent objective socioeconomic status.
Our results showed that the minority group experienced significantly lower QoL, compared with the majority group, which can be also explained by socioeconomic and health-related factors. These findings support the findings of previous studies, which indicated that lower education levels (Chen et al., 2017), lower socioeconomic status, and perceived health issues, including high levels of depression (Damri & Litwin, 2016), are associated with lower QoL scores. Our results also support the interconnectedness of financial security and QoL among older adults (WHO, 2015).
The second study hypothesis anticipated significant correlations between sociodemographics, health-related variables, and participation with QoL in both groups. This was also confirmed, indicating that making ends meet more easily, higher education levels, better health status, lower levels of anxiety and depression, and increased objective and subjective participation were all associated with better QoL of older adults, in both the minority and majority groups. The link between the sociodemographics and health-related variables with older adults’ QoL was mentioned earlier (Chen et al., 2017; Damri & Litwin, 2016). The main focus of this study was the significant correlations between participation and QoL, which align with previous studies showing positive links between participation in meaningful activities (Araújo et al., 2021), socially productive activities (Segev-Jacubovski & Shapiro, 2022), and physical activities (Phillips et al., 2013) with older adults’ QoL. This is also supported by Stav et al. (2012), whose systematic review found that participating in activities positively affects health and QoL of older adults. Additionally, our study’s finding that subjective participation is associated with QoL supports the findings of Antunes et al. (2023), who reported that subjective aspects of participation are more closely associated than its objective aspects with general well-being and QoL among adults with disability. Another study by Eakman et al. (2010) highlighted that participation in personally meaningful activities affects well-being and health-related QoL more than participation in less meaningful activities, which underscores the importance of engagement in meaningful activities for successful aging.
Despite the significant differences between groups in both objective and subjective participation and QoL, these measures significantly correlated in both groups, regardless of majority or minority affiliation. Notably, we found a higher correlation between subjective participation and QoL among participants in the minority group. This result underscores the importance of occupational justice, which encourages practices and policies that address inequalities to enable marginalized communities, such as minority groups, to participate in meaningful occupations (Lewis & Lemieux, 2021; Suarez-Balcazar et al., 2023). This is essential for advancing and sustaining health and QoL among older adults (Durocher et al., 2014).
Overall, the link between participation and contextual factors with well-being and QoL supports theoretical models such as the ICF framework (WHO, 2001), where activity and participation are key factors for older adults’ QoL (Chen et al., 2020); and the DLW framework, which suggests that wellness and health improve through occupational experiences, and are also affected by personal and social factors, such as demographics and sociocultural environment (Kim et al., 2022; Moll et al., 2015). Our findings could thus broaden the perspectives of interventions for older adults from all ethnic backgrounds.
Limitations
This study used self-reported questionnaires among older adults from two specific ethnic groups. Although differences in different occupational categories were compared, the effect sizes were small. Future research should explore differences between groups across additional activities, including health-promoting occupations, and should incorporate qualitative methods for more in-depth exploration of older adults’ experiences within their sociocultural environment. Evaluating additional objective social factors (e.g., income and family support), physical and cognitive functioning, and health-related status among these groups is recommended. Further studies should also include more diverse groups of older adults from other ethnic minority groups.
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice: The study provides evidence for the link between both objective and subjective participation in daily activities and QoL among older adults, regardless of ethnic identity. It highlights the importance of evaluating both objective and subjective participation and of encouraging older adults to participate in meaningful activities that may foster their QoL. Occupational therapists should consider tailoring interventions that focus on both aspects of participation for enhancing the QoL of older adults, especially among minorities. Intervention programs should allocate resources to underserved communities and increase opportunities for participation in meaningful activities to promote occupational justice and accessibility, especially for older adults from minority groups.
Conclusion
In this study, we aimed to compare participation and QoL among older adults from a majority group (Jews) and a minority group (Arabs); we also examined the associations that linked sociodemographics, health-related variables, and participation with QoL in both groups. Significantly lower scores emerged in the Arab group, compared with the Jewish group, in both objective and subjective aspects of participation and QoL. This disparity underscores the need for more equitable responses to the needs of older adults in minority groups. Significant correlations were common to both groups, whereas subjective participation correlated higher among adults in the minority group. These findings thus underscore the potential of subjective participation for enhancing the QoL of older adults, especially among minority groups, and the necessity of addressing inequalities through the lens of occupational justice. The results also support existing theoretical models linking participation and contexts to QoL, adding to the growing awareness of the need for both objective and subjective participation among diverse older adults.
Footnotes
Acknowledgments
We are grateful to all the participants for their invaluable contributions and to the research team of occupational therapist graduate students (Shira Zecharia, Noa Wities, and Miriam Frankl) for their dedicated involvement. This research was partially supported by the Minerva Center on Intersectionality in Aging (No. 49478) and by the Israel National Institute for Health Policy Research (No. 2021/92).