Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 221 (Online Publication: Dec., 2018) BIBECHANA A Multidisciplinary Journal of Science, Technology and Mathematics ISSN 2091-0762 (Print), 2382-5340 (0nline) Journal homepage: http://nepjol.info/index.php/BIBECHANA Publisher: Research Council of Science and Technology, Biratnagar, Nepal Quality of life of elderly people living with family and in old age home in Morang District, Nepal Menuka Shrestha1*, Heera KC2, Prem Bhattarai3, Anjali Mishra4, Surya B. Parajuli4,5 1Department of Nursing, Purbanchal University, College of Medical and Allied Health Sciences, Gothgaun, Nepal 2Department of Nursing, Purbanchal University, Birat Health College, Biratnagar, Nepal 3Department of Physiology, Kathmandu University, Birat Medical College & Teaching Hospital, Tankisinuwari, Nepal 4Department of Community Medicine, Kathmandu University, Birat Medical College & Teaching Hospital, Tankisinuwari, Nepal 5Nepal Medical Volunteer Society, Biratnagar, Nepal *E-mail: mennusb@gmail.com Article history: Received 16 September 2018; Accepted 10 November 2018 http://dx.doi.org/10.3126/bibechana.v16i0.21643 This work is licensed under the Creative Commons CC BY-NC License. https://creativecommons.org/licenses/by-nc/4.0/ Abstract Introduction: Nepal like many other developing countries in the world is witnessing the rapid ageing of population. Quality of life (QOL) of elderly people is becoming even more relevant towards an ageing society. In Nepal, less is known regarding special needs and quality of life of elderly people either in familial situations or in old age residences. Objectives: The present study was undertaken to assess and compare the quality of life of elderly living with the family and in old age home. Methodology: A Cross sectional descriptive study was conducted from October 2016 to April 2017 among elderly population aged 60 years and above. A total of 50 elderly people were enrolled from old age home (OAH) using total enumeration sampling technique and equal number of sample was selected from the family setting. QOL of elderly was assessed using WHOQOL-BRIEF questionnaire after taking informed consent from the participants. Data was analyzed using SPSS. Results: The mean scores of QOL domains were better among the age group 60-70 years, males, married, literates and who had children. The mean scores of QOL in physical, psychological and environmental domains were better in elderly living with the family than living in OAH. Low scores were found on social domain among elderly compared to other domain irrespective of their residence. Conclusion: QOL score among elderly is average, while social relationship domain of QOL scores was found to be low. Social activities should be expanded for these residents in order to promote social health. The QOL which each individual possesses is very important in all aspects be it physical, psychological, social & environmental. Furthermore, programs that help elderly people live in their own homes and social environments should be promoted. Keywords: Humans; Homes for the Aged; Quality of Life. http://nepjol.info/index.php/BIBECHANA mailto:mennusb@gmail.com http://dx.doi.org/10.3126/bibechana.v16i0.20960 https://creativecommons.org/licenses/by-nc/4.0/ Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 222 (Online Publication: Dec., 2018) 1. Introduction Ageing is inevitable developmental facts that bring along a number of changes in the physical, psychological, hormonal and social status. Most of these changes are expected to affect quality of life of the elderly [1]. One of the greatest challenges to public health is to improve the quality of later years of life as life expectancy continues to rise [2]. WHO defines the concept Quality of Life (QOL) as ‘individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns [3]. Quality of life elderly people (QOL) is becoming even more relevant with demographic shift happening towards an ageing population. There are signals that concerns related to QOL in elderly people are different from that of other general population. In Nepalese society, there is very low awareness about special needs of elderly and caretakers are yet to understand the vitals of elderly care (physical and mental, psychological and social needs). Additionally, among elderly there is difference between those living in old age homes and those living in community [4]. Nepal like many other developing countries in the world is observing the rapid ageing of people. The urbanization, modern character, tendencies and values and world integration have led to change in the weakening of social values, economic structure, the erosion of societal values, and social structure such as the joint family. In this changing economic and social environment, the younger age group is searching for new identities about economic independence and redefined social roles inside, as well as outside the family. The shifting economic structure has reduced the dependence of rural families on land which has provided strength to tie between generations [5]. The problem has broad social, economic, political and health implications and is viewed as a concern by many different people-administrators, health professionals and general public. Care of the elderly is also one of the priority areas in Nepal. The Government of Nepal has also recently adopted National Policy on Ageing since its 9th long-term plan. Above all, not much research work has been carried out in this topic in Nepal, though it is a topic of concern. We believe the research will help administrators and policy makers to plan and implement necessary changes to address the special needs of elderly. The main objective of this study was to assess and compare the quality of life of elderly living with family and old age home. 2. Methodology This is a cross sectional study was carried out in an Old age home at Birateswhor Bridhashram, Biratnagar and home setting at Sundar Haraincha Municipality from October 2016 to April 2017. Total Sample size was 100; 50 elderly people were taken from old age home using total enumeration sampling technique and equal number of sample was taken from the home setting. Elderly people aged 60 years and above were included but those elderly who were suffering from mental illness were excluded from the study. Data were collected through face to face interview method. Informed consent was taken from each participant and ethical approval was taken from Purbanchal University Department of research. Quality of life was measured with the validated World Health Organization Quality of Life Instrument-Brief Version (WHOQOL-BREF). It evaluates perceived quality of life using 26 items categorized into Physical domain (7 items), Psychological domain (6 items), Social Relations domain (3 items), and Environment domain (8 items). Two items evaluates perception of general health and quality of life. Each item is ranked on a 5-point Likert scale. Higher scores indicate higher quality of life. The physical health domain includes items on mobility, daily activities, Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 223 (Online Publication: Dec., 2018) functional capacity, energy, pain and sleep. The psychological domain measures include self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory concentration, religion, and the mental status. The social relationships domain contains questions on personal relationships, social support, and sex life. The environmental health domain covers issues related to financial resources, safety, health and social services, living physical environment, opportunities to acquire new skills and knowledge, recreation, general environment (noise, air pollution, etc.) and transportation. 3. Results Hundred elderly people participated in the study where 50 participants from OAH and 50 from the family. More than half (52% and 58%) were in the age group 60- 70 years in the OAH and in the family setting respectively. The mean age of the respondents living in OAH was 70.42±8.33 years while the mean age of respondents living with the family was 71.08±8.08 years. Majority of the respondents were male, Hindus and Brahmin/Chhetri in both the places. In OAH both male and female were more or less equal in number. In OAH most of the respondents (70%) were widow/widower while in the family setup 72% of the respondents were married and living together with their spouses. There were no unmarried and separated persons in the family setup. Most of the respondents (68%) were found to be illiterate in the family in comparison to those living in OAH (20%). In OAH, most of the respondents (74%) had children while in family setup all the respondents had children (table1). Age is significantly associated with the physical domain as compared to other domain. As the age increases the mean QOL scores were decreasing in other domains too but it was not found to be statistically significant. The mean QOL scores of psychological and environmental domains were significantly less in females as compared to males. The mean QOL scores of physical and social domains were also less among females. Education and marital status were significantly associated with the physical, psychological and environmental domains of quality of life. Significant association was found between the elderly who had the child and psychological and environmental domains (table 2). The mean scores and comparison of QOL (domain wise) between elderly people living in old age home and within family setup. Significant association was found in terms of physical, psychological and environmental health among elderly people living in old age home and within family setup at p value <0.001. The mean score of physical health between elderly people living with the family (21.88±4.37) was better than the elderly people living in old age home (16.50±4.11). Also, the mean score of psychological health of elderly people living with family (20.80 ±3.8) was better than those living in old age home (12.82 ±3.15). It indicates that elderly people living with the family had better psychological health than elderly people living in old age home. Similarly, the mean score of environmental health of elderly living with the family (26.18±3.52) was better than those living in old age home (20.64±3.63). The mean score of QOL between elderly people living with family (79.08±11.16) was better than the elderly people living in old age home (60.06±10.70). It indicates that elderly people living with family had better QOL than the elderly people living in old age home (table 3). Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 224 (Online Publication: Dec., 2018) Table 1: Distribution of Socio-Demographic Characteristics of elderly people (n=100). Variable Old age home (n=50) Family (n=50) n (%) n (%) Age in years 60-70 years >70years 26 (52) 24(84) 29(58) 21(42) Mean age in years ± SD 70.42±8.33 71.08±8.08 Gender Male Female 26(52) 24(48) 39(78) 11(22) Caste/Ethnic Group Dalit Janajati Madhesi Brahmin/Chhetri 8(16) 12(24) 6(12) 24(48) 1 (2) 18(36) - 31(62) Religion Hindu Buddhist 43(86) 7(14) 46(92) 4(8) Marital status Unmarried Married Widow/Widower Divorced/Separated 3(6) 7(14) 35(70) 5(10) - 36(72) 14(28) - Have children Yes No 37(74) 13(26) 50(100) - Table 2: Association of Socio demographic characteristics with domains of QOL scores (n=100). Variable Physical (Mean ±SD) Psychological (Mean ±SD) Social (Mean ±SD) Environment (Mean ±SD) Age 60-70 years >70years P value 20.75 (4.44) 17.29 (5.06) <0.001 17.04 (5.01) 16.53 (5.74) 0.641 10.29 (1.21) 10.00(1.39) 0.268 23.80 (4.14) 22.93 (4.94) 0.343 Sex Male Female P value 19.62 (5.21) 18.40 (4.58) 0.25 18.08 (5.33) 14.46 (4.53) <0.001 10.31 (1.40) 9.89 (1.05) 0.122 24.51 (4.52) 21.37 (3.79) <0.001 Education status Illiterate Literate P value 17.68 (4.63) 21.11 (4.87) <0.001 14.64 (4.70) 19.57 (4.82) <0.001 9.98 (1.13) 10.39 (1.46) 0.123 21.32 (3.97) 26.07 (3.73) <0.001 Marital status Unmarried Married Divorced Separated P value 20.67 (4.93) 21.98 (3.70) 16.52 (4.92) 19.40 (2.19) <0.001 15.67 (1.52) 20.00 (4.01) 14.15 (5.27) 15.00 (0.70) <0.001 10.33 (0.57) 10.48 (1.40) 9.83 (1.22) 10.40 (.548) 0.117 20.67 (0.57) 25.66 (3.46) 21.67 (4.81) 22.00 (2.00) <0.001 Religion Hindu Buddhist P value 19.33 (4.92) 18.09 (5.82) 0.444 16.99 (5.20) 15.36 (6.39) 0.343 10.16 (1.33) 10.18 (0.98) 0.95 23.64 (4.50) 21.55 (4.39) 0.148 Have children Yes No P value 19.47 (5.04) 17.31 (4.53) 0.148 17.38 (5.39) 13.00 (2.82) 0.005 10.18 (1.36) 10.00 (0.81) 0.637 23.97 (4.48) 19.69 (2.75) <0.001 Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 225 (Online Publication: Dec., 2018) Table 3: Comparisons of Domains of QOL by Their Place of Living (n=100) Variable (QOL Domains) Group P value Old age home (n=50) Mean ± SD Family set up (n=50) Mean ± SD Physical (mean ±SD) 16.50±4.11 21.88±4.37 <0.001 Psychological (mean ±SD) 12.82±3.15 20.80±3.87 <0.001 Social relationship (mean ±SD) 10.10±1.01 10.22±1.54 0.647 Environment (mean ±SD) 20.64±3.63 26.18±3.52 <0.001 Total QOL 60.06±10.70 79.08±11.16 <0.001 4. Discussion The mean score was found higher in environmental (23.41±4.52) and physical domain (19.19±5.01) as compared to social (10.16±1.30) and psychological domain (16.81±5.33) of quality of life of elderly. Overall mean score of QOL was found to be good but mean score for social relationship and psychological domain was comparatively lower than other domains which are similar to the other study where the physical domain of quality of life had the highest mean score 14.3 (±2.7), while the social domain had the lowest mean score 10.8 (±3.4) [6]. Another study conducted in India also reported lowest score in the social domain [7]. This could be due to the growing number of elderly that face abandonment and neglect. However, other studies have reported lower scores in the physical domain compared to other domains. [8, 9]. The study revealed that age was significantly associated with physical domain. This is because the older age group had more functional limitations compared to the younger age group. Similar findings was found in a study which reported impaired physical health among older age groups [6]. As growing age increases the probability of developing physical problems like musculoskeletal problems, so age was significantly associated with physical domain. Women had a significantly lower quality of life in all domains compared to men. This could be because the women perceive ageing more negatively than the men. Other studies reported that low quality of life scores among women and recognized their findings to feelings of unattractiveness among elderly women, which could lead to low self-esteem and also add to negative perception of ageing among elderly women [9]. Marital status was significantly associated with quality of life in this study except in social domain. This is perhaps because married residents live in their homes with their spouses in the home setting. Previous studies reported contradictory findings [10]. Level of education was significantly associated with the physical, psychological and environmental domains of quality of life. Evidence from studies suggests that people with higher level of education are more likely to engage in healthy behaviors which could improve physical health compared to those with lower level of education [11]. In addition higher level of education can improve psychological spirit, coping mechanisms [12] and social relationships [13]. Higher level of education also had higher scores in the environment domain of quality of life. Previous studies [14] have reported significantly better quality of life among people with higher level of education compared to those with lower level or no education, further highlighting the positive impact of higher education on quality of life. The mean score of physical (21.88±4.37), psychological (20.80±3.87) and environmental (26.18±3.52) Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 226 (Online Publication: Dec., 2018) health domain was found higher among the elderly living with family than those elderly living in old age home with physical (16.50±4.11), psychological (12.82±3.15) and environmental (20.64±3.63) health domain. This finding was supported by a study which revealed that institutionalized elderly showed low level of quality of life compared to non-institutional [15]. This finding is in contrast to the study titled “quality of life between elderly people living in old age home and within family setup” where physical, psychological and environmental domain mean score was reported high among elderly living in old age home than elderly living with family [16]. Similar findings was found in previous study [17]. The total mean score of QOL between elderly people living with family (79.086±11.16) was better than the elderly people living in old age home (60.06±10.70) at p value <0.001. It indicated that elderly people living with family had better QOL than the elderly living in old age home which was contradicted with the previous study [18] which observed that people living in old age home had good QOL. Social health domain’s mean score was found lowest among QOL domain in both places and it was not statistically significant with residence. Similar findings were revealed by other studies done in rural area of South India7and Tamilnadu [19] 5. Conclusion QOL score among elderly was average, while social relationship domain of QOL scores was found to be low. The physical health, psychological health and environmental health domains of QOL were better in the people living with family than the elderly living in old age home. QOL of elderly decreases as the age increases. The social relation domain revealed very poor among elderly living in both places. The QOL which each individual possesses is very important in all aspects be it physical, psychological, social & environmental. Only if they have fulfillment in all these aspects of life they have a high QOL. Recommendations Despite some limitations, this community based cross-sectional study gives valuable information on the QOL and its associated factors among elderly population. Health education related to activity and environmental modification as well as increase in the social relationship may help in improving the QOL of elderly people. Further analytical studies will help in understanding the association of factors influencing QOL. Additionally, programs that help elderly people live in their own homes and social environments should be developed. Social activities should be diversified for these residents in order to compensate for their lack of freedom. Limitation of the Study Small sample size is the limitation of study. Under reporting of chronic diseases in elderly, which has impact on QoL is another limitation. We could not include some factors like mental health status, complications of chronic morbid conditions of the elderly. Acknowledgement We would like to acknowledge all respondents for their cooperation, time and participation. We appreciate director of Birateswor Bridhasram for granting the permission and cooperation during the study. We would also like to thank Purbanchal University, department of research for financial support for the successful completion of this study. Conflict of Interest We declare no conflict of interest. Menuka Shrestha et al. / BIBECHANA 16 (2019) 221-227: RCOST p. 227 (Online Publication: Dec., 2018) Financial Disclosure Faculty grant received from Research department of Purbanchal University. References [1] J. Singh Dr, Comparative study of Quality Of Life in Aged persons. Indian J of Applied Research 4 (2014) 1-3. [2] S. Hameed, K. R. Brahmbhatt, D. C. Patil, Quality of life among geriatric population in a rural area of Dakshina Kannada, Karnataka, India, Global J Med and public health 3(2014)1-5. [3] The WHOQOL Group, The World Health Organization Quality of Life Assessment (WHOQOL), Position paper from the World Health Organization, SocSci Med 41 (1995) 1401–1409. [4] A. Gupta, U. Mohan, S.C. Tiwari, S. K. Singh, V. K. Singh, Dimensions and determinants of quality of life among senior citizen of Lucknow, India, Int J Med and public health 4 (2014) 477-481. [5] K. Gormal, Aged in India. Mumbai, Tiss Publishers, 2003. [6] O.F. Onunkwor, A.S. Radman, P.P. George, J. Arokiasamy, H.Y. A. Barua, Shuaibu H.O. A cross- sectional study on quality of life among the elderly in non-governmental organizations’ elderly homes in Kuala Lumpur, Health and Quality of Life Outcomes 14 (2016) 6. [7] S.G. Kumar, A. G. P. Majumdar, Quality of life (QOL) and its associated factors using WHOQOL- BREF among elderly in urban Puducherry, India, Journal of Clinical and Diagnostic Research: JCDR 8(1) (2014) 54-7. [8] M. Tajvar, M. Arab, A. Montazeri, Determinants of health-related Quality of Life in elderly in Tehran, Iran, BMC Public Health 8(1) (2008) 323. [9] L. Vitorino, L. Paskulin, L. Vianna, Quality of Life among older adults resident in long-stay care facilities, Latin Am J Nurs. 20(6) (2012) 1186–95. [10] E. Luleci , W. Hey, F. Subasi, Assessing selected Quality of Life factors of nursing home residents in Turkey, Arch GerontolGeriatr. 46(1) (2008) 57–66. [11] F. Van Oort , F. van Lenthe, J. Mackenbach, Cooccurrence of lifestyle risk factors and the explanation of education inequalities in mortality: results from the GLOBE study, Prev Med. 39 (6) (2004)1126–34. [12] U. Christensen, L. Schmidt, M. Kriegbaum, C. Orsted Hougaard, B.E. Holstein, Coping with Unemployment: Does educational attainment make any difference? Scand J Public Health 34 (2006) 363–70. [13] C. Lasheras, A.M. Patterson, C. Casad, Effects of education on the quality of life, diet, and cardiovascular risk factors in an elderly Spanish community population, Exp Aging Res. 27 (3) (2001) 257–70. [14] S. Qadri , S. Ahluwalia, A. Ganai, P. Shalender, F. Wani, H. Bashir, An epidemiological study on QOL among rural elderly population of northern India, Int J Med Sci Public Health 2(3) (2013) 514–22. [15] M.A. Mathew, S.L. George, N. Paniyad, Comparative Study on Stress, Coping Strategies and Quality of Life of Institutionalized and non-institutionalized in Kottayam District, Keral, Indian Journal of Gerontology 23(1) (2013) 79- 89. [16] R. Panday, M. Kiran, P. Srivastava, S.A. Kumar, study on quality of life between elderly people living in old age home and within family setup, Open J Psychiatry Allied Sci. 6 (2015) 127-31. doi: 10.5958/2394-2061.2015.00010.5 [17] S. Chandrika Dr, P. Radhakumari Dr, B. Devi Madhavi Dr, Quality of Life of Elderly Residing in Old Age Homes and Community in Visakhapatnam City, IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) 14 (10) (2015) 27-31. [18] M. Asadullah, K. Kuvalekar,B. Katarki, S. Malamardi, S. Khadka, S. Wagle, et al. A study on morbidity profile and quality of life of inmates in old age home in Udupi district, Karnataka, India, International Journal of Basic and Applied Medical Sciences 2012. [19] V. Praveen, A.M. Rani, Quality of life among elderly in a rural area, Int J Community Med Public Health 3 (2016) 754-757.