3.1▓Design
This research is a cross-sectional comparative study. In this study, elderly living in senior apartments, at home, or institution-based home, who fulfilled the inclusion criteria:
participants are more than 65 years old, and volunteered to participate, will be included. The bedridden and dementia elderly were excluded. The procedure of the study involved firstly the literature review, training interviewer, data collection, data analysis, and lastly writing up the conclusion.
The only senior apartment in the Kaohsiung City, institution-based home and home-dwelling elderly were selected for the survey. We recruit all the elderly people with those three different placements and those senior housing situated in Kaohsiung County with the same Medicare reimbursement or system, retirement system, for the elderly people, weather, and cultures. The three group elderly people participated the activity at least once a week. The home-dwelling people will either attend the course in the senior apartment or join the community activity at least once a week. They are either stay with their family member or live alone. They are active and independent. The elderly people in the senior apartment and institution-based may or may not have the assisted daily living care, or nurse care.
The interviewers were trained by the professional doctor for an hour in how to conduct the survey and skills of communicating with the elderly people. They were volunteering for this research. The consistencies of both interviewers are kept by having a discussion for any discrepancies encountered after each section of the survey questionnaires.
3.2▓Participants
In the study, elderly living in apartments, at home, or institution-based home, who
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fulfilled the inclusion criteria, which the participants are more than 65 years old, and volunteered to participate, would be included. The bedridden or with the scores of The Barthel Index of Activities of Daily Living (ADL) less than 80 and dementia elderly or answering the short portable mental status questionnaire (SPMSQ) with more than two errors would be excluded. Moreover, the hearing impairment participants or the participants who had language barriers would be excluded from the study which means they were not able to communicate.
The minimum number of participants to be recruited and attained the significant level 0.05 is calculated through the formula
For the significant level could be 0.05 or 0.01, the constant k=1.96 or 2.58
respectively, p=0.50. For the senior apartment, there are 100 eligible elderly people where
N=100, p=0.50, =0.05, k=1.96
Thus, the minimum participants to attain the significant level 0.05 are 79 elderly people.
For the institution-based and home-dwelling elderly people, we apply with the same method of recruiting.
For home-dwelling,
N=78, p=0.5, =0.05, k=1.96,
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Thus, n 65
For institution based,
N=40, p=0.5, =0.05, k=1.96,
Thus , n 36
For the home-dwelling elderly people who access the facility of the Senior Apartment of Kaohsiung County were recruited in this study. There were about 78 elderly people eligible for the study. To attain the significant level, at least 65 elderly people should be recruited.
For institutions based senior housing, we had selected the Ren-Ai institution-based senior home in Kaohsiung County. The maximum bed in their senior home is 50 and currently there are 40 elderly people staying in the home. For attaining the significant number of participants, at least 36 elderly people should be recruited. Figure 3-1 summarize the participants flow chart.
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Figure 3-1▓Participants Flow Chart
*: Poor cognition with SPMSQ > 2 errors. Participants did not meet the criteria during the survey period.
Home-dwelling (Xieheli) 78 Screened
Institution-based 40 Screened
Senior apartment 100 Screened
5< age 65 1 excluded* 26 refused 46 completed
2 hearing impairment 3 language barrier 3 excluded* 7 refused 25 completed
3 hearing impairment 1 excluded
17 refused* 80 completed
5< age 65 5 excluded 48 refused 151 completed
Completion rate 71.0%
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3.3▓Instrumental tools
Elderly characteristic will be assessed using six instrumental tools:
1. A 10-item short portable mental status questionnaire (SPMSQ) was used to assess the organic brain deficit in elderly people. Elderly people with the SPMSQ scores of with more than 2 errors will be excluded in this research (refer to Appendix 1). In distinguishing demented from non-demented subjects, sensitivity and specificity were 0.74 and 0.91 for the face-to-face test (Roccaforte, Burke, Bayer, Wengel, 1994).
2. The quality of life will be measured using the World Health Organization Quality of Life-BREF (WHOQOL-BREF- Taiwan version visual analogue scale) (refer to Appendix 2). The Taiwan version of the 28-item WHOQOL-BREF will be assessed using a Visual Analogue Scale. It is categorized into four domains: physical (7 items), psychological (6 items), social (4 items), and environmental (9 items). Cronbach’s α coefficients for internal consistence ranged from 0.73 to 0.79 (Chiu, , 2003). According to the Internal Consistency of the WHOQOL-BREF Domains: physical health 0.80, psychological 0.76, social relationship 0.66, and environment 0.80 (WHO, 1998).
3. Sociodemographic characteristics will be recorded on interview or via self-administered questionnaire (refer to Appendix C).
4. Elderly people's mobility and ability to perform daily self-care tasks will be assessed using The Barthel Index of Activities of Daily Living (ADL), (refer to Appendix D The Barthel Index of Activities of Daily Living (ADL) is a quick and reliable assessment of a person's mobility and ability to perform daily self-care tasks. It shows if disability is present and estimates its extent, and determines when a patient begins to need help. Originally developed for use during inpatient rehabilitation, this tool was used extensively in the clinical setting and it was equally applicable in this study. In addition, it can be administered periodically to assess a patient's improvement over time. Inter-rater reliability was reported as 'fair' to 'moderate' agreement for individual Barthel Index (BI) items, and a high percentage agreement for the total BI score (Sainsbury, Seebass, Bansal, Young, 2005).
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5. Instrumental Activities of Daily Living Scale (IADL) (Refer to Appendix E). The Lawton IADL scale was developed by Lawton and Brody in 1969 to assess the more complex ADLs necessary for living in the community. The Lawton IADL scale takes 10 to 15 minutes to administer and contains eight items. Inter-rater reliability was established at 0.85.
The correlations between the IADL scale and the other measures of functional status ranged between 0.40 and 0.61. The reproducibility coefficient (reproducibility is “the ability of the test to produce consistent results when repeated under the same conditions”18) was 0.96 for men and 0.93 for women (n = 97 and n = 168, respectively) (Carla, 2008; Lawton & Brody, 1969).
6. Elderly people’s depressive symptoms will be determined using the Taiwan Depression Questionnaire (TDQ) (refer to Appendix F). The 18-item Taiwanese Depression Questionnaire (TDQ) had a sensitivity of 0.89 and a specificity of 0.92 at a cutoff score of 19.Cronbach's alpha coefficient (0.90), concurrent validity, and the area under the ROC curves (0.92) are all quite satisfactory. The TDQ is a culturally relevant questionnaire, which is adaptable for screening depressive people in the local communities (Lee, Yang, Lai, Chiu, Chau, 2000).
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3.4▓Statistical analysis
Statistical analyses were performed using SPSS software, version 19.0 with authorization code given by IBM, Xi Shu Software, Taiwan. The analyses were stated as below:
1. Descriptive analysis: include the socioeconomic demographic characteristics with mean, standard deviation, and range values (for age) and percentages for relevant elderly people characteristics including the age, gender, income of family, individual income, education level, religion, marriage status, health status, life condition, functional status, emotional state (at home, senior apartment and institution-based home) were reported.
2. Manova and Posthoc Scheffe Analysis were performed (n=151) for the quality of life with different living arrangements.
3. The STATA program was performed to analysis the contribution of the relevant predictors such as age, gender, marriage status, depression state, level of dependence, income, and smoking, alcohol consumption to the outcome of quality of life (physical domain, psychological domain, social relationship domain and environment domain).
4. For the quality of life, the domain scores were calculated from items scores. The range of each domain was 4-20. The formula to calculate the scores of individual domains were summarized in table 3-1 (★the Taiwan localized questions, Yao, 2007). Two questions were added to the WHOQOL-BREF, which were question number 27: Do you feel respected by others, and questions 28: Do you usually able to get the food that you like to eat?
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Table 3-1: Equations for computing the scores of each domain
Equations for computing domain scores Transformed Score Domain 1 ((6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q18 /7) *4 b:
Domain 2 (Q5 + Q6 + Q7 + Q11 + Q19 + (6-Q26)/6)*4 b:
Domain 3 (Q20 + Q21 + Q22 +Q27★)/4*4 b:
Domain 4 ((Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q25+Q28★
/9)*4 b:
5. Analysis of covariance is a statistical technique with the analysis of regression and variance.
It can be helpful in non-randomized studies in drawing more accurate conclusions in reducing systematic bias (Steven, 2002). Analysis of covariate with the STATA program was chosen to determine the effect of covariate. In our study, there were several dependent variables (domain 1, 2, 3, 4) and several covariates. The covariate is any variable that is significantly correlated with the dependent variable. We selected three sets of covariate that are known to be related to QOL outcomes and might influence the different living
arrangements with QOL. The first set consisted of socioeconomic status represented by measures of age, gender, marriage, education, individual income and family income. The second set includes measures of physical illness, depression state, and the third set a measure of life condition and health status.
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3.5▓Ethical approval
The study was approved by the Institutional Board (IRB) of I-Shou University in October, 2010. The participant consent form was prepared. The participants were allowed to withdraw in any period of time without any penalty. A small gift key ring with torch light or anti-slippery mat was given as a souvenir to the participants after the completion of the questionnaire.
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