5.1▓Important aspects of Quality of Life
Human beings are looking for a good life or enjoyment life. The quality of life assessment with the questionnaire WHOQOL is a good indicator. Few studies (Saxena, Carlson, Billington, 2001, Kalfoss & Halvorsrud, 2009) showed that the important issues for quality of life were included functional status, mobility, sensibility, home-like environment.
For their own perceptions on their physical status has a major contribution to the four facets of the quality of life. However, sex life, adequate social relationship, body image and appearance were the least important for the elderly people (Kalfoss & Halvorsrud, 2009). In our study, it showed that the health status were the major determinants of quality of life and also the age for physical domain, gender for social relationship, depression for psychological domain, and environment domain. At the beginning of our study, firstly we screened the participants with score of ADL more than 80 and secondly they participated in group activities at least once a week.
In terms of the living arrangement, the home dwelling residents had the best quality of life among those different living places arrangements. Health status was given highest priority especially the frail elderly (Puts, Shekary, Widdershoven, Heldens, Lips, Deeg, 2007) in QOL.
Our study was consistent with their findings, where health status contributes to major determinant of QOL especially in physical domain, psychological and environment domain.
The mean health status scores the highest in home-dwelling among these three types of different living arrangement and their four facets of QOL were also highest.
To address our study null hypothesis H1, the quality of life was different among elders living in institution-based home, senior apartment or staying at home with the different living arrangements.
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The quality of life is significantly different with the highest score found in the residents at home and lowest in the senior apartment with p-value <0.05. However, when we controlling the age, gender, health status and life conditions of the residents, the quality of life was not significant different among the three groups.
H2: The disability (Barthel Index of ADL), emotional state (depression scale), were significant different in the home-dwelling, institution-based home or in the senior apartment.
The hypothesis was rejected as in the ADL was not significant different among the three types of housing although the depression scores were significant different with the scores in the senior apartment was the highest, while the scores in institution based were second. The participants in senior apartment tended to have milder depression symptoms. Hypothesis H2:
The disability (Barthel Index of ADL), and emotional state (depression scale) vary accordingly to the quality of life in the different living places.
H3: The disability (Barthel Index of ADL) and emotional state (depression scale) contribute to the quality of life despite the different living arrangement.
Our findings showed that the ADL score did not determine the outcome of quality of life.
However, the determinants depression symptoms showed significant effect between subjects contribute to the quality of life of psychological domain and environment domain. Age, gender, life conditions, health status should be taken into considerations.
5.2▓Health status and Quality of Life
Health status has been identified as one of the important items to the quality of life.
Self-rated health statuses have a direct and independent effect of their own. Regardless of the presence or type of disease, there was a homogenous interrelation, significant correlation between health status and quality of life (Zuran, Persch, Tarso, Ioppi, Mezzich, 2000). Our findings confirmed the health status was the key factors for the overall experience of quality of life. There are several measurement of health status such as Personal Health Scale (PHS) with 10 items including sleep, mood, nervousness, fatigue and functional capacity, SF-36
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Health index and others. In our study, the sample population reported their health in a continuum from “very poor” to “very good”. However, the physical illness or disease presented did not determine the quality of life in our study. Thus, the self-reported health status is not an ideal indicator of health conditions. But, health status could be an accurate and a good predictor of subsequent ill health and mortality (Idler and Kasl, 1991; Idler and Benyamini, 1997).
According to Palloni’s (2000) United Nations report, the health status depends on two conditions 1) the access of the satisfactory of health and medical care, 2) the composition of population at any age according to risk profile including early childhood exposure, risk behavioral profile such as smoking and past purchase of health inputs. From our study, the access of satisfactory of health and medical care (Question 24: How satisfied are you with your access to health services?) was significantly correlated with health status with spearman rho coefficient = 0.248, p=.002, <0.01. The mean scores of the health status in senior apartment was 2.95, home-dwelling was 3.70 and institution-based was 3.52.
Health status is the major determinant for the quality of life and one of the elements involved the access of the satisfactory of health services. Between, the health and disability would also affect the choice of living especially when the health conditions require large expenditure care and health services. The elderly people will finally agree to transfer to the institution with the medical care needed or co-residence with family with the care provided.
5.3▓Depression and Quality of Life
Depression is a common disorder, affecting over 120 million people worldwide. Recent epidemiological surveys conducted in general populations have found that the lifetime prevalence of depression is in the range, from 4.3% in Shanghai to 26.4% in the United States, with a 9.1% to 16.9% inter-quartile range (IQR, the range after excluding the highest and lowest 4 surveys) ( Demyttenaere, Bruffaerts, Posada-Villa, et al., 2004). Depression is one of the global burden diseases. These disorders are not only affecting the social relationship but also the economics of the country. The severity of the depression has also increased the
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suicide or mortality risk. For the relapse or residual symptoms, especially cognitive impairment or social dysfunction can continue to reduce performance and cause considerable distress especial at work. The ever-present risk of relapse and recurrence also weighs heavily generally reducing the quality of life (Lépine and Briley, 2011).
Our findings showed that the depression symptoms assessed by Taiwan Depression Questionnaire (TDQ) is one of the important determinant to the quality of life especially the psychological domain and environment domain of quality of life.
One of the studies done by Golden, Conroy, Bruce et al. (2011) found that an increased prevalence of depression associated with the reduced quality of life where the elderly people with so much worries was significantly affecting their satisfaction of life. Quality of life is diminished among elderly patients in institutions and the most marked correlates were a diagnosis of major depression, worse performance in activities of daily living and worse cognitive function (Barca, Engedal, Laks, Selbæk, 2011).
Cummings (1997) reviewed the 27 definitions of the quality of life, of these domains, there were 85% include emotional well-being, 70% include health, 70% social and family connections, 59% material wealth or well-being, and 56% work or other productivity. He suggested the quality of life should have included all these in the domains. Emotional well-being was the most important for the domains of quality of life among the five domains.
Thus, mental health is important to gain a good quality of life especially with the good performance at work productivity. Elderly people should learn the way of gaining the free worries life in achieving the active retirement and good quality life.
5.4▓Other weighting factors of Quality of Life
Each domain of the quality of life should reflect the degree of satisfaction weighted by its level of perceived importance. However, there is evidence available indicating the hierarchy of domain relevance varies across groups according to gender and age, marital status. The impact of age and gender obtained in a general population shows that these variables must be considered when interpreting data on health related QOL for cancer patients
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as in psychological distress was higher in older patients. In particular, older women suffering from anxiety or depression had the greatest impairment in quality of life (Sampogna, Chren, Melchi, Pasquini, Tabolli, Abeni, and The Italian Multipurpose Psoriasis Research on Vital Experiences (Improve) Study Group, 2006). Another study done by Jörngården, Wettergen, Essen,(2006) also emphasized on the influence of gender and age in quality of life. The older adults reported the lower scores of quality of life and higher scores of depression and male had less depression symptoms compare to female. The QOL scores were then poorer in women than men, although most of this difference was accounted for by the difference in prevalence of mental disorders. Thus, it is important to take age and gender into consideration, both when planning studies and when comparing results from different groups was stressed.
Our study showed that the age had significantly influenced the physical domains of quality of life while the gender had influenced the social relationship where female more likely to involve in social activities.
Marital status, education level, and income are other weighting factors, which should be considered. Our results showed these factors had little or no direct effects on the quality of life.
However, other studies found that adults who are married or cohabitating reported a higher QOL than those living alone, or higher education level with better quality of life (Wahl, Rustoen, Hanested, Lerdal, Moum, 2004; Rustoen, Mount, Wiklund, Hanestead, 1999;
Kalfoss, Halvorsrud, 2009). Poverty in the population or staying alone is another factors contributing to the lower QOL (Palloni, 1999).
Lastly, other issues we have to take into consideration including 1) the role of preference, which is a thorn in the side of research on co-residence arrangements (Palloni, 1999), which it can rarely be identified; 2) the cultures, which probably influenced the choice of different living arrangement especially for most of the elderly people prefer to stay with their children.
However, shared living with children may not always lead to a higher likelihood of emotional satisfaction (Palloni, 1999); 3) physical environment which the elderly people prefer to have home–like decoration environment and; 4) care provided had met their needs especially when the needs of the elderly people were complex. The fact is that they require more personal and nursing care.
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5.5▓Limitation
This study involves several limitations when the survey was designed. Firstly, the sampling population is selected non-randomly where the availability of the elderly people is not possible. The selection of the participants could contribute to the selection bias. In Taiwan, currently there are four senior apartments with one situated in the southwest of Taiwan and the other three situated in the north part of Taiwan. We recruited the elderly people who participate in any activities at least once a week. The elderly person who never attended any activities or had no social activities was not recruited in our study. For the institution-based home, where it is different from nursing home is selected because the location is near to the xieheli. The three types of living arrangements will have the similar physical environment such as climate, resident milieu, and nature including natural, man-made elements such as houses, streets, safety. Kaohsiung is a city located in southwestern Taiwan, facing the Taiwan Strait on the west and it is divided into thirty-eight districts. Kaohsiung is the second largest city in Taiwan, with a population around 2.9 million (Kaohsiung official website, 2011). The climate is tropical wet and dry with average temperatures ranging from between 18.6 and 28.7 degrees Celsius, and average humidity between 60 and 81%. The climate influences the physical and sociology of the people. Heat-induced symptoms such as fatigue, lack of strength could possibly make elderly people less likely to involve in outdoor activities. The cold weather could easily trigger respiratory symptoms in asthmatic people or upper respiratory disease. Therefore, we attempted to recruit the participants in the same city.
However, there were individuals who chosen for the sample were unwilling or unable to participate in the survey. This could result in nonresponse bias when respondents differ in meaningful ways from non-respondents. Moreover, the response bias could also occur when the interviewer indicate the response to be satisfied, dissatisfied. The interviewers were trained to reduce these response biases by not giving respondent any options to express satisfaction or dissatisfaction. Besides, the social desirable would also contribute to the response bias as in most people like to present them in a favorable light, so they will be reluctant to admit to unsavory attitudes in a survey especially for the sexual activity question
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21. Instead, their responses may be biased toward what they believe is socially desirable. In addition, the face-to-face response might be different from the self-completed response.
The cross-sectional study design only involves the study of the different group of subjects at a specific point at a time. The longitudinal effects such as observe the disability over a time on the QOL in different living arrangements. All these issues should be regarded as sources of bias thus the results should be interpreted with caution.
A further qualitative study should be conducted in the future to investigate more details in the quality of life, or meaningful life, life satisfaction. The physical environment conditions should be explored in more detail on the relationship with the quality of life. The relevant data could be collected through the in-depth interviews.
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