1
EFFECT OF STRUCTURED NURSING INTERVENTION
ON ANXIETY, DEPRESSION AND QUALITY OF LIFE
AMONG SENIOR CITIZENS
Thesis submitted in partial fulfilment for the Award of
Degree of Doctor of Philosophy in Nursing
By
Pavithran Rayaroth
VINAYAKA MISSIONS UNIVERSITY
SALEM, TAMILNADU, INDIA
2015
2
VINAYAKA MISSIONS UNIVERSITY
DECLARATION
I, Pavithran Rayaroth, declare that the thesis entitled Effect of
Structured Nursing Intervention on Anxiety, Depression and
Quality of Life among Senior Citizens, submitted by me for the
Degree of Doctor of Philosophy in Nursing is the record of work
carried out me during the period from April 2008 to March 2015
under the guidance of Dr. Sr. Anne Jose and has not formed the
basis for the award of any degree, diploma, associateship,
fellowship, titles in this or any other University or other similar
institution of higher learning.
Place:
Kozhikode
Date:
Signature of the Candidate
Pavithran Rayaroth
3
VINAYAKA MISSIONS UNIVERSITY
CERTIFICATE BY THE GUIDE
I, Dr. Sr. Anne Jose, certify that the thesis entitled EFFECT OF
STRUCTURED
NURSING
INTERVENTION
ON
ANXIETY,
DEPRESSION AND QUALITY OF LIFE AMONG SENIOR
CITIZENS, submitted for the Degree of Doctor of Philosophy in
Nursing by Mr. Pavithran Rayaroth is the record of research work
carried out by him during the period from April 2008 to March
2015 under my guidance and supervision and that this work has
not formed the basis for award of any degree, diploma, associateship, fellowship or other titles in this University or any other
University or institution of higher learning.
Signature of the Supervisor with designation
Place:
Date:
Kozhikode
4
ACKNOWLEDGEMENT
The investigator would first like to thank his mother Madhavi
Amma Rayaroth, without her continuous support and encouragement,
he never would have been able to achieve his goals.
The investigator is extremely thankful to Dr. Rajendran V. R.,
Vice Chancellor and Dr. Lakshmi Rana, Dean (Nursing), Vinayaka
Missions University, Salem for giving an opportunity to conduct this
study.
The investigator expresses the deep sense of gratitude to
Dr. Sr. Anne Jose, Former Professor, College of Nursing, Calicut for
her timely advice, excellent guidance, moral support and constant
encouragement for the completion of the dissertation. The investigator
considers it is a great privilege to work under her guidance.
The investigator is obligated to Prof. Salomy George, Director,
SIMET and Former Deputy Director of Nursing Education, Trivandrum
for her timely guidance and support.
It is his pleasure to offer genuine thanks to Dr. Kochuthersmia
Thomas, Ex. Registrar, Kerala Nurses and Midwifery Council and
Ex. Deputy Director of Nursing Education, Trivandrum; Prof. Prasanna
Kumari, Former Principal, Government College of Nursing, Trivandrum
and present Deputy Director of Nursing Education, Trivandrum;
Prof. Chandra Kanthi, Former INC president,
Prof. Valsa Panikar,
5
Principal
Government
College
of
Nursing,
Trivandrum;
Dr. Survanalatha, Dr. Rema Devi, and Dr. Betsy, Former Professor,
Government College of Nursing, Trivandrum for their scholarly remarks
and valuable suggestions and inspirations.
The investigator also expresses his
heartfelt thanks
to
Dr. Vedaguru Ganesan, Dean, Annamalai University, Chennai for his
scholarly suggestions, inspiring criticisms and encouragement in the
beginning stage of the study.
The investigator expresses his thankfulness to Director of Social
Welfare Department, Government of Kerala for giving administrative
sanction to conduct the study in various government old age homes in
North Kerala.
The investigator is highly indebted to the Project Officers of
Government Old age homes, Calicut and Palakkad for giving sanctions
for the study.
He extends his immense gratitude to Yoga Acharya Unniramman
Master, Director of Pathanajali Yoga Research Centre, Calicut;
Musician and singer Kovoor Vijayan Master and Mr. Balan Master,
Director of Institute of Music, Thalasserry for their constructive and
critical guidance and generous support for the preparation of the tool.
Gratefully the investigator remembers all the experts who
willingly gave their time for content validation.
6
He expresses his heartfelt thanks to all the faculty members and
students of SIMET College of Nursing, Mundur and Government
College of Nursing, Calicut for their active support and encouragement.
The investigator is obliged to Directors of Mercy home and
Karuna Bhavan, Calicut; Crescent and Sneha Jyothy old age homes,
Palakkad for granting permission and providing facilities for the study.
He is grateful to Dr. Girish S, Department of Statistics,
Government Arts and Science College, Calicut for spending his
valuable time in analyzing the data and in rendering expert opinion and
recommendations in the data processing section of this dissertation.
The investigator gratefully recalls the help provided by the library
staff of Government College of Nursing, Calicut, Vinayaka Missions
University, Salem, SIMET College of Nursing, Mundur and Manipal
University, Manipal.
He extends his sincere thanks and gratitude to inmates of Mercy
home, Karuna Bhavan and Government Old age homes, Calicut;
Crescent, Sneha Jyothy and Government old age homes, Palakkad for
their cooperation and participation who forms the core in his study.
He expresses his deep sense of gratitude from the heart to all his
family members especially his wife Mrs. Beena P Rayaroth, daughter
Ms. Manjeeth P Rayaroth and son Mr. Karnan P Rayaroth for their
sincere support, constant encouragement and sacrifices which helped
him to undertake this endeavour successfully.
7
He is thankful to all friends for the generous help; he has
received throughout this study.
Above all, he owes his success to God Almighty.
Pavithran Rayaroth
8
ABSTRACT
The population of senior citizens are tremendously increasing all
over the world. Living condition of majority of them was very pathetic.
Therefore, it is the responsibility of the civilized society to evaluate and
improve the quantum of care rendered to them in old age homes and
modify the care regime through research.
The present study aims to evaluate the effect of a structured
nursing intervention (SNI) designed by the researcher on anxiety,
depression and quality of life (QOL) among senior citizens in the
selected old age homes of North Kerala.
Objectives of the study were
1. To evaluate the effect of SNI on anxiety, depression and QOL
among institutionalized senior citizens
2. To identify the association between anxiety, depression and QOL
and selected socio-demographic variables among institutionalized
senior citizens
3. To find out the relationship between anxiety, depression and QOL
among institutionalized senior citizens
The study based on Roy‘s adaption model. The sample consists
of 312 senior citizens, who selected by multiphase random sampling
technique. Data collected by semi structured interview method and
standardized tools (WHOQOL-BREF, Hamilton Anxiety Rating and Beck
9
Depression Inventory II scale). The researcher himself developed SNI
consisting of simple warming up exercises, breathing exercises,
progressive muscle relaxation and guided imaginary under the
background of music composed in Anantha Bhairavi and Sindhu bhairavi
ragas was used. The study conducted in government as well as private
old age homes of Calicut and Palakkad.
The major findings of the study were
1. SNI was effective in reducing depression and anxiety and improving
QOL among senior citizens.
2. There was no significant association between anxiety, depression
and QOL and selected socio-demographic variables of senior
citizens in one hand but on the other hand there was significant
association between certain domains of QOL and selected sociodemographic variables.
3. There was negative relationship between QOL and both depression
and anxiety among senior citizens.
4. There was positive relationship between depression and anxiety
among senior citizens.
The study highlights the role of nurse in the use of independent SNI
in improving the quality of care to senior citizens for promotion of
mental health and QOL in hospital and community settings.
10
TABLE OF CONTENTS
CHAPTERS
PAGE NO.
I
INTRODUCTION
1-10
II
REVIEW OF LITERATURE
11-65
III
METHODOLOGY
66-83
IV
ANALYSIS AND
INTERPRETATION
84-130
V
DISCUSSION
131-135
VI
SUMMARY AND CONCLUSION
136-145
 BIBLIOGRAPHY
146
 APPENDIX
175
11
LIST OF TABLES
SL.NO.
1
2
3
4
5
6
7
8
9
10
11
12
13
TABLE
Details of sample collected from selected old age
homes
Details of data collection instruments used in the
study
Frequency and percentage distribution of sample
based on age
Frequency and percentage distribution of sample
based on marital status
Frequency and distribution of sample based on
educational status
Frequency and percentage distribution of sample
based on type of family
Frequency and percentage distribution of sample
based on physical support
Frequency and percentage distribution of sample
based on social support
The t value computed between mean pre test and
post test anxiety scores among senior citizens
The t value computed between mean pre test and
post test depression scores among senior citizens
The t value computed between mean pre test and
post test QOL scores among senior citizens
Level of anxiety among senior citizen before and
after SNI
Level of depression among senior citizen before
and after SNI
PAGE NO.
71
73
85
87
87
88
89
90
92
93
94
95
96
12
SL.NO.
14
15
16
17
18
TABLE
Level of overall QOL among senior citizen before
and after SNI
The F value computed between pretest anxiety
scores and sex among senior citizens
The F value computed between pretest anxiety
scores and age among senior citizens
The F value computed between pretest anxiety
scores and religion among senior citizens
The F value computed between pretest anxiety
scores and marital status among senior citizens
PAGE NO.
96
99
99
100
101
The F value computed between pretest anxiety
19
scores and educational status among senior
101
citizens
The F value computed between pretest anxiety
20
scores and previous occupation among senior
102
citizens
21
22
23
The F value computed between pretest anxiety
scores and type of family among senior citizens
The F value computed between pretest anxiety
scores and financial support to senior citizens
The F value computed between pretest anxiety
scores and physical support to senior citizens
103
103
104
The F value computed between pretest anxiety
24
scores and psychological support to senior
105
citizens
25
The F value computed between pretest anxiety
scores and social support to senior citizens
105
13
SL.NO.
TABLE
PAGE NO.
The F value computed between pretest anxiety
26
scores and duration of stay in old age homes
106
among senior citizens
27
28
The
F
value
computed
between
pretest
depression scores and sex among senior citizens
The
F
value
computed
between
pretest
depression scores and age among senior citizens
The
29
F
value
computed
between
108
108
pretest
depression scores and religion among senior
109
citizens
The
30
F
value
computed
between
pretest
depression scores and marital status among
109
senior citizens
The
31
F
value
computed
between
pretest
depression scores and educational status among
110
senior citizens
The
32
F
depression
value
computed
scores
and
between
previous
pretest
occupation
111
among senior citizens
The
33
F
value
computed
between
pretest
depression scores and type of family among
111
senior citizens
The
34
F
value
computed
between
pretest
depression scores and financial support to senior
112
citizens
The
35
F
value
computed
between
pretest
depression scores and physical support to senior
citizens
113
14
SL.NO.
TABLE
The
36
F
value
computed
PAGE NO.
between
pretest
depression scores and psychological support to
113
senior citizens
The
37
F
value
computed
between
pretest
depression scores and social support to senior
114
citizens
The
38
F
value
computed
between
pretest
depression scores and duration of stay in old age
115
home among senior citizens
39
40
41
42
The F value computed between pretest QOL
scores and sex among senior citizens
The F value computed between pretest QOL
scores and age among senior citizens
The F value computed between pretest QOL
scores and religion among senior citizens
The F value computed between pretest QOL
scores and marital status among senior citizens
116
117
118
119
The F value computed between pretest QOL
43
scores and educational status among senior
120
citizens
The F value computed between pretest QOL
44
scores and previous occupation among senior
121
citizens
45
46
The F value computed between pretest QOL
scores and type of family among senior citizens
The F value computed between pretest QOL
scores and financial support to senior citizens
47
The F value computed between pretest QOL
scores and physical support to senior citizens
122
123
124
15
SL.NO.
TABLE
PAGE NO.
The F value computed between pretest QOL
48
scores and psychological support to senior
125
citizens
49
The F value computed between pretest QOL
scores and social support to senior citizens
126
The F value computed between pretest QOL
50
scores and duration of stay in old homes among
127
senior citizens
Correlation coefficients computed on combined
51
scores
of
anxiety
and
depression
among
129
institutionalized senior citizens.
Correlation coefficients computed on combined
52
scores of anxiety and QOL among institutionalized
129
senior citizens.
Correlation coefficients computed on combined
53
scores
of
depression
and
institutionalized senior citizens.
QOL
among
130
16
LIST OF FIGURES
SL. NO.
1
2
3
FIGURE
Percentage of world population over 65 years,
1950-2050
Percentage of senior population in India
Conceptual framework based Roy‘s adaptation
model
PAGE NO.
3
7
63
4
Schematic representation of design of the study
67
5
Percentage distribution of sample based on sex
86
6
7
8
9
10
11
Percentage distribution of sample based on
religion
Percentage distribution of sample based on
previous occupation
Percentage distribution of sample based on
source of income
Percentage distribution of sample based on
psychological support
Percentage distribution of sample based on
duration of stay in old age home
Distribution of mean pre test and post test score
of QOL in fours domains
86
88
89
90
91
97
17
LIST OF APPENDICES
S. No
A
Appendix
Tool-I: Semi structured interview schedule to collect sociodemographic data among senior citizens
B
Tool-II: Hamilton Anxiety Rating Scale
C
Tool-III: Beck Depression Inventory II Scale
D
Tool-IV: WHO Quality of Life BREF Scale
E
Audio CD of Structured Nursing Intervention (SNI)
18
CHAPTER I
INTRODUCTION
Aging is a universal phenomenon and silent process of life
cycle that the experience cannot be avoid by living organism. It is an
inevitable phase in one‘s life. The term ‗elderly or old age‘ represents
ages that nearing or surpassing the average life span of human beings
at a given time (Wikepedia). The boundary of old age cannot be
defines exactly because it has different meaning in different societies.
National policy on Older Persons (1999) defines ‗senior citizen‘ as a
person who is 60 years old or above (Jeyalakshmi, Chakrabarti and
Gupta Nivedita, 2011).
According to Indian tradition, life cycle of individual divided
into four stages or Ashramas– First stage is Brahmacharya ashram,
which consists of period upto 20-25 years; second one is Grhasthya
Ashram consists of period 25-55year; the third is Vanaprastha Ashram
consist of period 55-60years and fourth one is Sannyas Ashram
consists of period above 60years of one‘s life.
Among these,
Vanaprastha Ashram is the most crucial one where individual gradually
abandon worldly pleasures and initiates preparation to enter the
sannyas Ashram. Sannyas is the last phase where he wishes to obtain
freedom from all sort of worldly affairs, totally spent his time in
identification for the inner self and pure consciousness. Among these
19
phases, Vanaprastha and Sannyas are coming under the heading old
age (Sremath Bagavatham, Padmapoornam). According to Indian
tradition, senior citizens are the respected and worshipful category of
people in the society. As such, their welfare and protection was being
actively granted in all Indian civilization irrespective of time and place.
Followed by the decline of value system and matrilineal
system of inheritance, joint family system collapsed in India. After the
collapse of matrilineal system of inheritance and starting of a new
system, named patrilineal system of inheritance came into practice in
society because of these changes, the life of senior citizen become
worse and pathetic (History of ancient and medieval India, 2002). The
repercussion of these changes could be observed in similar societies of
other countries also. This is because of large-scale migration of
youngsters to urban centres for seeking employment and education.
The life of senior citizens who were compelled to live alone in villages
becomes very horrible in the absence of needed support. Their
conditions become more deplorable after the loss of spouse. In
accordance with the decline of physical health, their productivity also
deteriorates gradually becomes a burden to the society.
20
According to WHO, the world's population of senior
citizens has doubled since 1980 and is forecast to reach 2 billion by
2050 (World Health Organization, 2012). Ageing of population affected
due to downward trends in fertility and mortality i.e. due to low birth
rates coupled with long life expectancies. The number of senior citizens
has tripled over the last 50 years; it will again triple over the next 50
years(Situational Analysis of The Elderly in India, 2011).
Figure 1: Percentage of world population over 65 years, 1950-2050
Source: UN world population prospect, 2008
In 1950, there were 205 million senior citizens throughout the
world. At that time, only three countries had more than 10 million senior
citizens: China (42 million), India (20 million), and the USA (20 million).
In 2000, the number of countries with more than 10 million people aged
60 or over increased to 12, including 5 with more than 20 million senior
citizens: China (129 million), India (77 million), USA (46 million), Japan
(30 million) and the Russian Federation (27 million) (World Population
21
Aging, UN, 2009). By 2020, of the ten countries with the largest elderly
populations in the world, five will be in the developing world: China
(230 million), India (142million), Indonesia (29 million), Brazil (27
million) and Pakistan (18 million)(WHO, 2010).
The population of senior citizen is growing faster than the
total population in practically all regions of the world and the difference
in growth rates is increasing. By 2025-2030, projections indicate that
the population of senior citizens will be growing 3.5 times as rapidly as
the total population (2.8 per cent compared to 0.8 per cent). As the
senior citizens population has grown faster than the total population,
the proportion of senior citizens relative to the rest of the population
has increased considerably. At the global level, one in every twelve
individuals was at least 60 years of age in 1950, and one in every
twenty was at least 65. By the year 2000, those ratios had increased to
one in every ten aged 60 years and one in every fourteen aged 65 or
older. By the year 2050, more than one in every five persons
throughout the world is project to be senior citizens, while nearly one in
every six is project to be at least 65 years old. Almost one fifth of the
population in the more developed regions, but only 8 per cent in the
less developed regions was senior citizens in 2000, up from 12 per
cent and 6 per cent respectively in 1950. Although the regional
differences in the percentage of senior citizens expected to decrease
over the next 50 years, the difference will remain large through mid-
22
century. By 2050, one in every three persons living in the more
developed regions is likely to be 60 or older and about one in every
four is project to be 65 or older. In the less developed regions, nearly
one in every five is projected to be senior citizens, while one in every
seven is projected to be over 65(World Population Aging, UN, 2009).
The senior citizens population is growing at a faster rate in the
less developed regions. In contrast with the slow process of population
ageing experienced in the past by most countries in the more
developed regions, the ageing process in most of the less developed
regions is taking place in a much shorter period, and it is occurring on
relatively larger population bases (Situational Analysis of the Elderly in
India, 2011). In 1950-1955, the average annual growth rate of persons
aged 60 years or over was practically the same in the more and in the
less developed regions (near 1.8 per cent). Currently, the average
annual growth rate of the population of senior citizens in the less
developed regions (2.5 per cent) is almost three times that of the more
developed regions (0.9 per cent). Over the second quarter of this
century, the growth rate of people over 60 is expected to decline in
both more and less developed regions. The number of senior citizens
will increase by about 70 per cent, from 231 million in 2000 to 395
million in 2050. In contrast, in the less developed regions the senior
citizens populations will more than quadruple during this same period,
from 374 million to 1.6 billion. By 2050, nearly four fifths of the world‘s
23
senior citizens population will be living in the less developed regions
(World Population Aging, UN, 2009).
Census trends show that India is entering the age of aging.
India has the second largest senior citizens population in the world
constitutes 7percentage. In 2000, the number of Indians over 60 years
of age stood at nearly 80 million, or roughly 8 percent of the population.
According to UN forecasts, number will reach nearly 170 million by
2025 and 325 million or 20 percent of the population by 2050. The size
of India‘s senior citizens population is expected to increase from 71
million in 2001 to 179 million in 2031, and further to 301 million in 2051
(Rajan, Sarma, & Mishra, 2003). As of 2004, India accommodated 75
million senior citizens people, second only to China - representing 7.5
percent of the total population. Among them, one fifth was from urban
areas and only one-fourth are literate. Among senior citizens women,
54 percent of them are young old (60-69 years), 67 percent of old-old
(70-79 years) and 70 percent, of oldest old (80 and above) and mostly
are widows (Liebig and Irudaya Rajan, 2003).
According to 2001 census, in India there are 100 million
senior citizens that is about 7.4 percentage of total population. Among
the state proportion of senior citizens in total population vary from
around 4 percentage in small states like Dadra and Nagar Haveli,
Nagaland, Arunachal Pradesh, Meghalaya to more than 8 percentage
in Maharashtra, Tamil Nadu, Punjab, Himachal Pradesh and 10.5% in
24
Kerala. By 2020, 9percent population will be senior citizens in India. As
per analysis of census data and projections, senior citizens population
sex ratio is in favour of female senior citizens. As per the census 2001,
whereas for total Indian population sex ratio is in favour of male
population in ratio 940:1000, for senior citizens at (60+) population it is
in favour of senior citizens women by1022:1000. According to the
2001census, 33.1 % of the senior citizens in India live without their
spouses.
Figure 2: Percentage of senior population in India
Source: Helpage, country data 2012
The expectation of life gives a good idea about the general
health status of the people. According to world data bank, the life
expectancy at birth for total years increased from 63 years in 2002 to
65years in 2011. The life expectancy at birth for females has been
increasing continuously and during 2002-2006, it was 64.2 for females
as against 62.6 years for males (RGI, 2008). Life expectancy is
25
generally considerably higher among urban people (68.8years) than
among rural ones (62.1years). The expectation of life at birth is highest
in Kerala (70.9years for males and 76yeas for females) during 20012003 (Directorate of health services, 2007).The aged dependency ratio
increased from 11.6 in 1971, 14.41 in 1981, 14.4 in 1991, 15.06 in
2001, and 16.40 in 2011 respectively and estimated to increase 21.39
in 2021 (Rajan and Aliyar Sabu 2004).
Kerala had 31 lakhs senior citizens representing around 10
percent of the total population in 2001. Kerala ranks the highest state
with the senior citizens forming with 10.5% of its population (Indian
Journal of Medical Research, 2006). Their numbers expected to
increase 53 lakhs in 2021 and 110 lakhs in 2051 and the proportion is
likely to reach 30 percent in 2051. Between 1999 and 2004, the
proportion of the senior citizens to the total population in Kerala has
increased from 11 to 14 during the last five years. In 2004, the highest
proportion of senior citizens were found in Pathanamthitta followed by
Kottayam, Ernakulum, Alappuzha and Thiruvananthapuram districts of
Kerala (above the state average) and the lowest is in Wayanad.
However, 12 out of 14 districts in Kerala have already crossed 10
percent mark, with Pathanamthitta district showing the maximum of
21percent - double than the Malappuram figure. Districts, which were
the forerunners in fertility and mortality transition, have reported higher
proportion of the senior citizens (Guilmoto and Irudaya Rajan, 2004). In
26
2004, almost all the districts of Kerala have reported more proportion of
female senior citizens than males, except Kollam, Idukki and
Malappuram (Rajan S Irudaya and Sabu Aliyar, 2005).
In that context, only mushrooming of old age homes can
be view. More and more old age home are arising in the cities as well
as in villages for accommodating of our senior citizens. Government
also initiating various steps and adopting policies to improve the life of
this most neglected, abandoned, crucified group comprises a major
segment of all population.
In India, there are 1018 geriatric homes during 2011. Out
of which, 427 homes are free of cost while 153 are on payment and
stay basis, 146 homes have both free as well as pay and stay facilities
and detailed information is not available for 292 homes (Banker,
Prajapati and Kedia, 2011). About 52% of total old age homes in
country confined to only four states namely Kerala, Tamil Nadu,
Karnataka and Andhra Pradesh (Rajan, 2000). Old age homes are
functioning under the control of social welfare department, Government
of Kerala. Department directly manages at least one old age home in
each district. Non-government as well as charitable trust also owned
old age homes. Kerala State led the rest of the country with more than
420 old age homes, followed by Tamil Nadu and Maharashtra .One out
of every 10 old age homes in India is located in Kerala (Irudaya Rajan,
2006).
27
A descriptive study conducted among 192 institutionalized
senior citizens of Maharashtra. The researcher explored the reason for
admission and their perception regarding care provided by old age
homes. The findings revealed that neglect from the family members,
poverty and absence of care givers in home setup for the reason for
admission and also found that majority of senior citizens were
emotionally upset ( Dhanajay, Balram, Paswan and Bansod, 2006).
When the elders were transfer from the family to the old
age homes, they face numerous psycho physiological problems. The
sudden separations from society, financial loss, loss of prestige,
chronic illness, loss of spouse etc make their life very deplorable
(Dubey et al, 2011). To manage these problems, respective institutions
should improve the living condition; modernize the care regimens and
policies (Soodan, 2006). The major reason for not getting quality care
to elderly is that care providers are not seriously taking into
consideration psychological constrains of them. As such, total
pleasurable environment could not provide in old age homes. It is
possible
only
by
introducing
evidenced
based
interventional
programmes, which give relief to inmates (Lin, Wang and Huang,
2007).
28
CHAPTER II
REVIEW OF LITERATURE
Review of literature is the key step in a research process.
The major goal of the review of literature is to develop a strong
knowledge base to carry out research and other non-research scholarly
activities in educational and clinical practice settings. In educational
area, such knowledge enhances the writing of scholarly papers by
students and faculty.
In the present study, the related literature was reviewed,
categorized and organized under the following headings,
The problems of institutionalized senior citizens
A. Anxiety and senior citizens
B. Depression and senior citizens
C. QOL among senior citizens.
Selected interventions and its effects on anxiety, depression and
QOL among senior citizens
A. Music therapy
B. Guided imagery
C. Yoga and breathing exercises
D. Progressive muscle relaxation
29
The problems of institutionalized senior citizens
The population of senior citizens are increasing day by day.
In accordance with the advancement of age, the individual become more
and more incapacitated. It is a fact that family is the best place for
everybody for spending his later part of his life and living with children
and their grandchildren‘s are the most preferred living arrangement for
the senior citizens.
Until and unless proper support is established, their life
becomes pathetic, irrespective of the place where they accommodated.
When age advances, physical strength declines and paved way for the
outbreak of chronic aliment; situation makes the person an unproductive
one and burden to the society. They label as deprived group and become
depended to others. Hormone and enzyme production declines and
affects the sensory and motor functions of individual. Ageing affects the
cognitive and psychomotor functions of individual (Deary et al., 2009).
In the early days, there were family to meet all the needs and
the expectations. The current trend is that institutions are incorporate with
facilities to accommodate and meet the needs of senior citizens. Senior
citizens throwing out from the home and community find the shelter in
institution like old age homes, retirement homes or care homes. Currently
these old age homes are facing many problems as understaffing,
unskilled staffing and inadequate facilities (Bussp, 2009). The care
providers working in the old age home are to be equipped with current
30
knowledge and skill in accordance with science and technology. Just the
help on empirical basis are not sufficient to meet the challenges they are
facing (Bvant and Osgood, 1991).
Archarrya (2012) investigated on depression, loneliness and
insecurity feeling among 75 senior citizens female living in old age homes
of Agartala by using Beck‘s Depression Inventory, Revised UCLA
Loneliness scale, and Maslow‘s security-insecurity test. From the study,
the researcher acknowledges the senior citizens women who are residing
in old age homes have much depression, loneliness and insecurity
feeling than the senior citizens who live with their families.
A descriptive study conducted by Asadullah (2012) to assess
the socio-demographic profile, pattern of morbidities and QOL of 90
senior citizens inmates in old age homes in Udupi district, Karnataka by
using a pre-structured and pre-tested questionnaire and WHOQOL-BREF
Scale. The study findings revealed that the respondents showed highest
QOL score in environmental domain and least score in social relationship
domain. The study concludes that there is a need to address the issue of
social
negligence
of
senior
citizens
from
family
and
society;
organisational care and support is essential for health and wellbeing of
senior citizens.
A cross sectional study conducted by Purna A. Singh (2012)
to compare the prevalence and pattern of psychiatric disorders in 120
senior citizens in old age homes and communities of Khammam district in
31
Andhra Pradesh by using Mini Mental Status Examination and Brief
Psychiatric Rating Scale. The result of the study concludes that the age
group of >80 years have more prevalence of psychiatric disorders (44%),
followed by those who are in the age groups of 60 to 69 years (33.3%)
and 70 to 79 years (28.9%). The prevalence of psychiatric illnesses was
more among the individuals living in the community (38.3%) than in the
people living in old age homes (30%). Depression was the most common
psychiatric disorder in the general population (21.7%) and in those living
in old age homes (25%), followed by anxiety disorders (5.8%), substance
use-related disorders (4.2%), and organic disorders (0.9%).
Anitha R. (2012) conducted a cross sectional study to assess
the morbidity profile of 210 inmates in old age homes in Chennai. The
finding in the study reveals that the overall prevalence of central nervous
system disorders and mental illness among the senior citizens studied
and found to be 20.5%. Due to the more number of senior citizens with
mental illness institutionalized because of difficulty in caring them at
home.
A cross sectional study was conducted by Dubey, Bhasin,
Gupta, and Sharma (2011) to understand the feelings of 60 senior
women residing in the old age home and within the family setup in
Jammu. Purposive sampling technique used to select the samples for
this study. The study reveals that most of the subjects felt the attitude of
the younger generation is unsatisfactory.
32
An exploratory study was conducted by Tiwari
(2010) to
assess mental health problems among 45 inhabitants of old age homes
at Lucknow by using Survey Psychiatric Assessment Schedule (SPAS),
Mini Mental State Examination (MMSE), Mood Disorder Questionnaire
(MDQ), and SCAN-based clinical interviews. The finding in this study
shows that depression (37.7%) found to be the most common mental
health problem followed by anxiety disorders (13.3%) and dementia
(11.1%).
A cross-sectional study conducted by Vishal (2010) on
depression among 105 senior citizens living in old age homes, affluent
and slums of Surat city, Gujarat using Geriatric Depression Scale (GDS).
The findings in this study shows that the prevalence of depression was
34.9% for men and 41.9% for women and also found that the senior
citizens people those living in old age homes (25.71%) requires an
institutional treatment.
Varma, Kusuma, and Babu (2010) conducted a study to
assess the health related QOL of senior citizens living in rural community
and old age homes in Vishakhapatnam by using SF 36 health survey.
The findings of the study concluded that residents living in old age homes
have better QOL compared to rural community.
A cross sectional study was conducted by Nagaraj (2010) on
psychiatric morbidity among 100 senior citizens people living in old age
homes and in the communities of Mysore by using on Mini Mental Status
33
Examination (MMSE), Informant Questionnaire on Cognitive Decline in
Senior citizens (IQCODE), Brief Psychiatric Rating Scale (BPRS) and
QOL visual analogue scale. The finding of the study shows that
depression was present in 22% of people in the community and 36% of
old age home inmates. This study concludes that psychiatric morbidity is
high in senior citizens irrespective of the setting in which they live.
A study conducted by Bussup (2009) on home health care
vs. old age home and QOL among the senior citizens. The findings
reveals that home health care eliminate problems of senior citizens in old
age homes such as inadequate nursing staffing, medication errors and
senior citizens having to share bathrooms and other infrastructure in
other words home health care agencies maintain the QOL of senior
citizens. This study concludes that QOL may not guarantee in an old age
home.
A study was conducted by Hegde (2008) on determine the
frequency of psychiatric and physical morbidity among 245 residents of
old age home of Mangalore using Mini-International Neuropsychiatric
Interview (MINI), social support scale, disability scale and Hindi Mental
Status Examination. The finding in this study shows the average
prevalence of psychiatric disorders found to 58.2% depressive disorders,
30% dysthymia, 8.2% psychotic disorders and 2.7% generalized anxiety
disorder and 40% of residents had moderate to good social support.
34
A cross sectional study was conducted by Lin, Wang, and
Huang (2007) to examine the depressive symptoms of 138 senior
citizens who are residents at nursing homes located in southern Taiwan
by using Socio-demographic Inventory, the Center for Epidemiological
Studies Depression Scale, Social Support Scale, and Chronic Condition
Checklist. The finding from this study shows that 81.8% senior citizens
who were residing in nursing homes have depression. Length of
residency, number of chronic conditions, perceived health status and the
amount of social support from their family and relatives are major causes
for their depression. This study suggests that health care providers at
nursing homes should develop an effective health promotion programme
for these groups.
A comparative study conducted by Yogendra (2007) on
perceived health problems and subjective well- being status of 60 senior
citizens living with their families and old age homes at Mangalore. The
study finding shows that health problems and the subjective well- being
status of the senior citizens living with their families were lower than that
of the senior citizens living in old age homes.
A cross-sectional study conducted by Aravind (2007) to
identify the prevalence and correlation of depressive symptoms among
randomly selected 210 inmates of 25 old age homes in Kottayam,
Keralaby using Geriatric Depression Scale, modified Barthel Activities of
Daily Living Index and Lubben Social Network Scale. The study shows
35
that a prevalence of 44.5% depressive symptoms in old age homes and
none of the inmates were under the treatment for depression.
Dhanajay, Bansod, Balram and Paswan (2006) conducted a
descriptive study among 192 senior citizens by including six old age
homes of Maharashtra. The survey method used for exploring the reason
for coming to old age home and perception of senior citizens about care
provided at old age home. Investigator indicates that neglect from family
members,
poverty,
and
no
caregiver
were
the
reason
for
institutionalization. Majority of senior citizens were emotionally upset and
had suicidal ideation at old age home.
Triple P. (2006) conducted a study to identify the psychiatric
morbidity among senior citizens attending the psychiatric services of
Institute of Medical Sciences and geropsychiatric patients of Mumukshu
Bhavan (old age home) in Varanasi. The finding of the study reveals that
depressive disorders were the most common psychiatric illnesses.
Objective social support was moderate for the majority of patients but
perceived social support was poor. This study concludes that people
living in the old age home felt better than those who live with family.
A cross sectional study was conducted by Jongenelis (2004)
on prevalence and risk indicators of depression among 333 senior
citizens patients from 14 nursing home of Netherlands using Geriatric
Depression Scale (GDS). The study findings show that the prevalence of
major depression, minor depression and sub-clinical depression are
36
8.1%, 14.1%, and 24% respectively. Significant risk indicators for
depression among senior citizens were pain, functional limitations, visual
impairment, stroke, lack of social support, negative life events, loneliness
and perceived inadequacy of care.
A comparative study done by Yadidya (2003) on QOL among
100 senior citizens living in old age homes and family set up in Bangalore
city by using the modified WHO standardized tool. The finding shows that
the QOL of senior citizens living in selected homes for the aged is less
than the family set up.
Reena, Thandavan, and Manikaraj (2000) conducted a
correlation study among sixty senior citizens institutionalized (30) and
non-institutionalized (30) in the aspect of physical, social, financial and
emotional
areas
institutionalized
at
Tamil
senior
Nadu
citizens
in
have
India.
more
The
study
problems
reveals
than
non-
well-being
and
institutionalized in all dimensions.
Chada(1994)
studied
psychological
depression among institutionalized and non-institutionalized senior
citizens in India. The result indicates that senior citizens in noninstitutionalized setting have lower level of depression as compared to
institutionalized settings. Family support found to be the important factor
for psychological well-being.
37
Anxiety and senior citizens
An anxiety is a pervasive feeling of dread, apprehension and
impending disaster. It is response to an unidentified or unknown threat,
which may be due to unconscious conflict or insecurity (like undergoing
surgery) (Dr. Bimala Kappor, 2012). Prevalence of anxiety was higher
among persons in institutionalized like retired home or old age home
(Janel G., 2001). Most often senior citizen has anxiety and depression
goes hand in hand. It is common illness among senior citizens, affecting
10-20% of their population, though it is often undiagnosed. Usually
anxiety occurs not proportional to the challenges of life from part of
individual, object or situation. Many senior citizens worry about the
health, possible problems related with physical care they get in future
from part of relatives. Intense form of anxiety causes significant
impairment of social and family functioning (Geriatric Mental Health
Foundation, 2009).
Death anxiety is another type of anxiety common among
senior citizens. Gradually, they recognize the fact that the date of death is
very nearing. The life experience of senior citizens witnessing the death
of significant others, relatives friends etc every day, made them to think
that one day he also have to leave this world and gradually, they mentally
prepared for this unavoidable happening.
Senior citizens with anxiety disorders often go untreated for a
number of reasons. Some of them may not seek treatment as they have
38
suffered symptoms of anxiety for most of their live and believe the
feelings are normal. Both clients and physicians often miss a diagnosis of
anxiety because of other medical conditions and drug use or situations
that the client is coping with. Untreated anxiety can lead to cognitive
impairment, disability, poor physical health and poor QOL. Fortunately,
anxiety is treatable with drugs and psychosocial therapy (Geriatric Mental
Health Foundation, 2009).
A cross sectional study was conducted by Kumar et al,
(2010) to assess the prevalence of anxiety and depression symptoms
among 65 senior citizens of Nepal by using Nepalese version of Beck
depression Inventory II and Beck Anxiety Inventory. The study result
reveals that very high prevalence of depression and anxiety among
hospitalized geriatric medical inpatients as compared to the healthy
community dwellers in Nepal. The study concludes that the presence of
anxiety and depression can further exacerbate the physical illness,
slowing down recovery and adversely affecting a wide range of
outcomes. Such a high amount of psychiatric morbidity in this population
needs to be addressed by appropriate mental health interventions.
Kirmizioglu (2009) conducted a study to determine current
and lifetime prevalence of anxiety disorders among 462 senior citizens
living in the Sivas province of Turkey using standardized tool Anxiety
Module of SCID-I. The finding of this study states that the prevalence for
all types of anxiety disorder was 17.1% overall and the lifetime
39
prevalence was 18.6%. The lifetime prevalence of specific phobia
amongst the senior citizens is higher than that of general population.
A study conducted by Smalbrugge et al, (2005) to assess the
co-morbidity of depression and anxiety among 313 nursing home
residents of Netherlands by using Schedules for Clinical Assessment in
Neuropsychiatry (SCAN) and GDS. The result of the study denotes that
prevalence of depression was 17.1% and anxiety 4.8%. The study
concludes that co morbidity of anxiety and depression is most prevalent
in the more severe depressive and anxious nursing home residents.
A cross sectional study was conducted by Hout Van et al
(2004) to determine anxiety and risk of death in 3107 senior citizens in
Netherland. The result of the study reveals that men have increased
mortality risk with diagnosed anxiety disorders.
Mehta et al (2003) conducted a cross sectional study to
determine the prevalence and correlates of anxiety symptoms in absence
of depression in 3041 senior citizens by using Hopkins Symptoms
checklist. The result of the study shows that prevalence of anxiety
symptoms is common in depressed and non-depressed senior citizens.
The anxiety symptoms are higher among senior citizens with poor
psychosocial functioning, low personal mastery and need of more
emotional support.
A comparative study conducted by Barrowclough (2001) to
assess the effectiveness of cognitive-behavioural therapy and supportive
40
counselling for anxiety symptoms in senior citizens adults by using semi
structured self-rating scale on anxiety and depression. The findings in
this study elicits that cognitive-behavioural therapy gave better
improvement in depression and anxiety level than supportive counselling.
Anu, Sara, and Paniyadi Nandakumar (2009) conducted a
comparative
study
on
stress,
coping
strategies
and
QOL
of
institutionalized and non-institutionalized elderly in Kottayam district,
Kerala by coping inventory, Stress rating scale and WHOQOL-BREF
scale. The findings of study denotes that institutionalized elderly have
more stress and less QOL compared to non institutionalized ones.
Depression and senior citizens
Depression is a state associated with affect (mood) of a
person. It is a pathological mood disturbances characterized by feeling,
attitudes and beliefs the person has about self and his environment
(Dr. Bimla Kapoor, 2012). National Institute of Mental Health and
Neurosciences reported that the incidence rate of depression was 29.8%
among senior citizens. The major causes of depression among senior
citizens are adjusting mental problems related to retirement, financial
crisis and death of spouse as well as variety of physical illness. Society is
often ignorant about psycho physiological changes associated with
normal ageing process. As there is tendency of social isolation, physical
and psychological harassments as well as denial of information to these
people, sum total of these factors make them sad, lonely and irritable.
41
Often they have feeling of worthlessness, hopelessness, powerlessness
and helplessness. These manifested problems often misdiagnosed and
undertreated because of misconception that symptoms are part of ageing
process and treatment is not necessary.
Overall sadness of these
groups of people affects the day today life and makes them more
dependent to others. More than that the depression affect the QOL of
seniors very inversely irrespective of environment, they are accumulated.
Suicide is second major cause of death among senior
citizen. They are the vulnerable group of suicide, second to adolescents.
Increasing the number of suicides is prevalence among these groups
caused by depression associated with over dependence of others related
with decline of physical and mental health. Among senior citizens, there
are between two to four suicide attempts for every completed attempt
(Miller, Segal, & Coolidge, 2001). However, the suicide completion rate of
senior citizens is 50% higher than the population as a whole. Reasons for
suicide among senior citizens are physical and psychiatric illnesses,
unbearable
psychological
pain,
cognitive
construction,
indirect
expressions, inability to adjust, interpersonal relations, rejectionaggression, alcohol abuse, identification-egression, visual impairment,
neurological disorders, malignant disease, CVDs, and musculoskeletal
disorders (Weaver & Koenig, 2001).
Javed (2013) conducted a cross sectional study to
investigate the rate of prevalence of depression in various demographic
42
variables among 310 senior citizens from twin cities (Rawalpindi and
Islamabad) of Pakistan using 15-item Geriatric Depression Scale (GDSSF). The result of the study shows that the prevalence of depression
among senior citizens was 42%. Depression are more common among
females (54.61%) compared to males (29.75%); the unmarried (78%)
compared to the married (22.38%); the senior citizens who lived in
nuclear family system (48.42%) compared to those who lived in joint
family system (31.66%) and the unemployed (57%) compared to the
employed (19.23%).
A study conducted by Renku Sharma and Rahul Sharma
(2012) to assess the magnitude of depression and its socio-demographic
correlates among 121senior citizens in rural areas of Delhi by using
Geriatric Depression Scale. In the study, it is found that depression was
less common among those who had positive approach including doing
exercise daily (p=0.03) and yoga (p=0.026). The study concludes that
there are several important risk factors such as poor sleep at night,
tension at home, poor perception of health, not receiving any financial
support in the form of pension for self or spouse and poor nutritional
indicators were associated with depression. By identifying these factors
among senior citizens at higher risk for depression can help to plan for
better care for them.
Maulik and Dasgupta (2012) conducted a cross sectional
study on depression and its determinants among 82 senior citizens from
43
Singur of West Bengal by using Bengali translated geriatric depression
scale (short form). The finding of the study reveals that the prevalence of
depression was 53.7%. The risk factors of depression were female sex,
illiteracy, poor Per Capita Income, absence of personal income, and
staying without spouse.
Barua Ankur., and Kar Nilamadhab (2010) conducted a cross
sectional study to assess the prevalence of depression among senior
citizens of rural areas of Udupi district. Simple random sampling
technique used. The result indicates that the prevalence of depression
among senior citizens was determined to be 21.9%. The prevalence
rates of depression among males and females were 19.9% and 22.6%
respectively.
Kojin and Youn Ho investigated the effects of laughter
therapy on depression, cognitive function, QOL and sleep pattern among
109 subjects aged over 65 in China using Geriatric Depression Scale
(GDS), Mini-Mental State Examination (MMSE), Short-Form Health
Survey-36 (SF-36), Insomnia Severity Index (ISI) and Pittsburgh Sleep
Quality Index (PSQI). The finding of the study shows that laughter
therapy is an easily accessible, useful and cost effective intervention that
has positive effect on depression, QOL and sleep pattern among senior
citizens.
A cross sectional study conducted by Rajkumar (2009) to
examine the nature and prevalence of geriatric depression. Sample
44
collected from Kaniyambadi block of Vellore district of Tamil Nadu by
using the following structured assessment tools: Geriatric Mental State,
Community Screening Instrument for Dementia, Modified CERAD 10
word list learning task, History and Aetiology Schedule Dementia
Diagnosis and Subtype, WHO Disability Assessment Scale II, and
Neuropsychiatric Inventory. From the study, the researcher denotes that
geriatric depressions are more prevalent in rural south India. Poverty and
physical ill health are risk factors for depression among senior citizens.
A cross sectional study was conducted by Taqui (2007) to
determine the relationship between the type of family system and
depression among 400 senior citizens visiting in a tertiary care hospital
Karachi, Pakistan by using 15-item Geriatric Depression Scale. The study
shows that the prevalence of depression was 19.8%. Multiple logistic
regression analysis reveals that the independent predictors of depression
are nuclear family system, female sex, being single or divorced/widowed,
unemployment, and having a low level of education. The senior citizens
living in a nuclear family system were 4.3 times more likely to suffer from
depression than those living in a joint family system.
A study conducted by Sood (2006) to evaluate the profile of
psychiatric disorders among 528 senior citizens admitted to various
departments of the teaching hospital attached to the Government Medical
College, Amritsar by using psycho-geriatric assessment scales (PAS)
and mental status examination. The result of this study shows that 260
45
(49%) had psychiatric disorders. The most common psychiatric disorder
was depression (25.94%), followed by adjustment disorders (11%),
anxiety disorders (4.54%), dementias (3.6%), delirium (3%), bipolar
disorders (0.8%), and substance-related disorders (0.4%). This study
emphasises on a coordinated approach of the geriatric and psychogeriatric services along with medical consultants for providing better
health services to geriatric inpatients.
A cross sectional study was conducted by Sherina (2005) to
determine the prevalence of depression and its associated factors among
300 senior citizens in Selangor of Malaysia using 30-item Geriatric
Depression Scale (GDS) questionnaire. The researcher acknowledges
that 6.3% of the senior citizens have depression. Important factors that
contribute for depression among senior citizens are gender, ethnicity, and
presence of chronic illness, functional disability and cognitive impairment.
Bennett, Smith, and Hughes (2005) conducted a cross
sectional study to investigate the relationship between depressive feeling
and coping among widowed senior citizens by using symptoms of anxiety
and depression scale (SAD) and the Hospital Anxiety and depression
Scale (HADS). The result shows that depressive feelings are associated
with non-coping in senior citizens who are widowed.
A study was conducted by Alpass and Neville (2003) to
assess the relation between loneliness, health, and depression in 217
older men (> 65 years) residing in New Zealand. The study shows that
46
depression is higher in those who are lonelier. Social isolation also
influences the experience of depression. Age-related losses such as loss
of professional identity, physical mobility and the inevitable loss of family
and friends can affect a person's ability to maintain relationships and
independence, which in turn may lead to a higher incidence of depressive
symptoms.
QOL among senior citizens
Everyone has an opinion about their QOL, but no one knows
precisely what it means in general (Netuveli and Bland, 2008). The
discussion about QOL was started more than two millennia ago by
Aristotle, but we are still arguing about what it means. According to
Aristotle, good life is not only something to live for but also something to
live by. This is true in older ages where life can described in terms of
strategies for maintaining QOL. The use of the term "QOL" relates with
the values and perceptions of clients has created doubt, confusion, and
misunderstanding among practitioners, researchers, policymakers, and
clients. The principal reason for this state of affairs is that a clear
conceptual basis for quality-of-life measures is lacking (Hunt, & Leplege,
1997). In the last decades of the 20th century, it also became the province
of psychometricians, health services researchers, and health policy
makers, who have tried to translate and construct into one or more scales
to measure the deliberate outcomes of health interventions or
47
consequences of health care. QOL is sometimes contrasts with more
narrow outcomes (Kane, 2003).
From literature reviews, QOL is a multidimensional concept,
which cannot be explains in medical terms alone. It only makes sense if
considered in a holistic context. It also contains both subjective and
objective elements; therefore, there is a need to take account of both
when measuring the concept. These include objective domains such as
the physical and care environment, physical and mental health, level of
functioning and socioeconomic status; and subjective domains such as
psychological well-being, autonomy/independence, purposeful activity,
social relationships, spirituality and identity/sense of self citizen (Murphy
et al, 2006). The QOL of senior citizens has become relevant with the
demographic shift that has resulted in greying population. Most of QOL
measures are not develop for senior citizens, although they are capable
of thinking and talking about their QOL (Netuveli and Bland, 2008). The
majority of the senior citizens evaluate their QOL positively based on
comparison with others, social contacts especially with family and
children, health, material circumstances and activities. Minority of them,
evaluate QOL negatively on dependency and functional limitations,
unhappiness and reduced social contacts through death of friends and
family members. The emergence of these domains confirms the complex,
interrelated and multidimensional nature of QOL for senior citizen
(Murphy et al, 2006).
48
QOL is difficult to define and to measure. It is a collection of
interacting objective and subjective dimensions, which may change over
time in response to life and health events and experiences (Bowling et
al., 2003). Some authors have avoided giving any definition of QOL or
associated concepts, thus adding to the confusion and ambiguity
surrounding the term (Farquhar, 1995a; 1995b, Haas, 1999a; 1999b).
Others provide precise definitions, such as Lawton (1991) who defines
QOL as : the multidimensional evaluation, by both intra-personal and
social-normative criteria, of the person-environment system of an
individual in time past, current and anticipated. The WHO (1996) defined
QOL as individual‘s 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. It is a broad ranging concept
affected in a complex way by the persons‘ physical health, psychological
state, level of independence, social relationships, and their relationship to
salient features of their environment.
QOL for senior citizen should be of concern to all citizens.
Regulations dealing with standards of care in long-stay facilities are
necessary but they are not enough. We must think about maximising the
potential of dependent senior citizens wherever they live. This report is
concerned with QOL in residential care, but QOL is equally important for
dependent their living at home (Murphy et al, 2006). Important initiatives
have undertaken to raise awareness about QOL within long-care centres
49
and formulation of a voluntary Code of Practice for Nursing Homes. As a
result, more attention paid to quality deficits and the need to develop and
strengthen quality assurance mechanisms. However, the measurement
of QOL in residential care settings remains overshadowed by the
importance placed on care structures and health outcomes as indicators
of quality. While these are, of course, important, they do not tell the whole
story about life in an institutional care setting. However, assessment of
quality of care is much difficult to assess than QOL. The focus of
attention in long-term care centres has shifted to a holistic interpretation
of the ‗good life‘ to quality of care.
Qadri et al, (2013) conducted a cross sectional study to
determine the pattern of physical morbidity in rural 660 elderly population
and to study HRQOL using WHOQOL BREF scale and its utilization of
health services among them. Simple random sampling technique used
for sample collection. The findings of the study revealed that QOL was
better in males, married, graduated, living in extended families and highclass caste.
Vagetti et al, (2013) conducted a study to explore association
between socio-demographic variables and health conditions and QOL
domains among 1806 female participants in the ―Elde
rs in Movement‖
program using WHOQOL BREF and OLD scales. The finding of the study
denotes that socio-demographic factors and health conditions were
associated with QOL among elderly women.
50
An exploratory study was conducted by Top and Dikmetaş
(2012) on QOL and attitudes to ageing of120 senior citizens in old age
homes in Turkey by using The World Health Organization QOL
Instrument-Older Adults Module (WHOQOL-OLD) and the WHOAttitudes to Ageing Questionnaire (AAQ). The study finding shows that
the highest significant relationship is between psychological growth
subscale of attitudes to ageing and sensory abilities subscale of QOL
(r = 0.579; P < 0.01). Overall QOL and overall attitudes to ageing had a
significant and positive relationship (r = 0.408; P < 0.01). This study
suggests that QOL is a complex, multidimensional concept that should be
study at different levels of analysis in developing countries.
A cross sectional study was conducted by Sowmiya and
Nagarani (2012) on QOL of 476 senior citizen residing in Mettupalayam,
a rural area of Tamil Nadu by using WHOQOL-BREF questionnaire. The
findings of this study shows that 50% of senior citizens were falling in
moderate score of QOL and very few (3.8%) individuals were having
good QOL. The investigator recommends that traditional role of
respecting and caring elders should be reinforced at school level and
interventions from the primary level.
Erkal, Sahin, and Surgit (2011) conducted a study to assess
the QOL of 121 senior citizens living in nursing homes in Ankara by using
WHOQOL OLD scale. The finding of the study reveals that there are
significant relationship between QOL and selected demographic
51
characteristics such as age, gender, marital status, monthly income and
educational level.
A study was conducted by Tawatchai Apidechkul (2011) to
assess the QOL, mental and physical health among 247 senior citizens
living in rural and suburban areas of northern Thailand by using Thai
General health questionnaire, WHOQOL-BREF(Thai version) and history
and physical examination. The sample selected by using a cluster
random sampling technique. The result of the study reveals that the
subjects from suburban areas had a higher QOL in aspect to physical
health (p = 0.011), mental health (p = 0.025), and social relationships (p
= 0.012). Social relationships among females from difference areas were
significantly different (p=0.01). Subjects from rural areas had better
mental health than those from suburban (p = 0.0001).
A
cross
sectional
survey
conducted
by
Naing,
Nanthamongkolchai, and Munsawaengsub (2010) to assess the factor
related to QOL of 209 elderly people in Einne Township, Myanmar by
using WHOQOL BREF scale and structured interview technique. The
findings of the study reveals that the factors that contributes the QOL
were educational level, current illness, self esteem, family income, family
relationship and social support.
Shobha, (2009) conducted a study on life style factors and
QOL of senior citizens by using the Pac Horale Scale. The study reveals
that the majority of the senior citizens involved themselves in various
52
activities ranging from walking, yoga, meditation and other activities like
watching TV, reading newspaper and talking to friends. The study shows
that majority of the respondents were actively involved in household work
and care of grant children. Senior citizens respondent in the higher age
group of 70-79yrs and female respondent found to have lower level of life
satisfaction.
An exploratory study conducted by Kalfoss and Halvorsrud
(2009) to describe the importance given to 38 areas of QOL among 379
Norwegian senior citizens and to identify differences in importance
ratings by age, gender, marital and health status by using WHO QOL
scale. The findings of the study reveals that highest mean importance
was assigned to activities of daily living, mobility, sensory abilities, health
and home environment. Least important was sex life, adequate social
help, chance to learn new skills, body image and appearance and free of
dependence on medications and treatment. There are significant
differences in the importance given to various aspects of QOL by
younger old and older old and for women and men. The study emphasis
on further research to assess the importance ratings vary in other senior
citizens populations and cultures.
Netuveli and Gopalakrishnan (2008) investigated predictors
of QOL of senior citizens by analysis of English longitudinal study of
aging in a sample of 11,234 numbers. The study reveals that QOL
reduced by depression, poor perceived financial situation, limitations in
53
mobility and long standing illness. Study also found that QOL improved
by trusting relationship with family and friends, frequent contacts with
others, living in good neighbourhood.
A descriptive study was conducted by Lin, Yen and Fetzer
(2008) to identify and describe predictors of QOL of randomly selected
192 Taiwanese senior citizens living alone by using WHO-QOL-BREF,
Social Support Scale and Centre for Epidemiological Studies Depression
Scale (CES-D). This study shows that senior citizens who live in rural
areas and suffer from depression are at high risk for a low QOL. This
study emphasis on nursing assessment of QOL indicators and
implementation of strategies for increased social support needed for
high-risk senior citizens.
A descriptive study conducted by Figueira et al (2008) to
evaluate QOL of the Family Health Programme senior citizens as ageing
progress in Brazil by using WHOQOL-OLD. From this study, it is clear
that as ageing progresses the QOL decreases which explained by losses
in autonomy, future present and past activities plus social participation.
Ashish G (2008) conducted a study to assess the impact of
old age home design an aging and QOL of senior citizens. Rapid
transition in social structure and breakdown of traditional joint family
system increase demand for old age care in India. The results states that
QOL influenced by staying in free situation, marital status, living with their
spouses, higher education, subjective feeling of being healthy, regular
54
exercise habits, higher functionality, better cognition, and pressure of
regular activity schedule.
A cross sectional study was conducted by Mudey et al
(2008) to assess QOL among rural and urban senior citizens population
of Wardha District, Maharashtra. The study reveals that the senior
citizens living in the urban community reported significant lower level of
QOL in the domains of physical and psychological than the rural senior
citizens populations. The rural senior citizens population reported
significant lower level of QOL in the domain of social relation and
environmental than urban population. The difference between the QOL in
rural and urban senior citizens population is due to the difference in the
socio-demographic factors, social resource, lifestyle behaviours and
income adequacy.
A study conducted by Rance (2008) on impact of health
education on health related QOL among senior citizens persons using
HRQOL scale. Intervention includes the physical activity, advice on
healthy food intake and other aspects of management. This study
concludes that provision of community based health education
intervention might be a potential public health initiative to enhance the
QOL in senior citizens.
Kabir (2006) conducted a cross sectional study on social
capital and QOL in 1135 senior citizens at rural Bangladesh. The result
reveals that advanced age, poorhouse hold economic states and low
55
social capital at individual and community levels were significant
determinants of poor QOL among the senior citizens. This population
study provided empirical evidences that social capital both at individual
and community levels were directly associated with quality of senior
citizens.
Rashmi (2006) conducted a study on QOL of old age home
residents in Bangalore. The sample consisted of 60 old age home
residents, 60 community residents and 32-day centre attendees, in the
age group of 68 to 72 years. The QOL assessed using the Philadelphia
Geriatric Centre Multilevel Assessment Instrument (PGC-MAI). The
finding reveals that the old age home residents had the highest mean
scores on the physical health, adjustment and environmental domains.
Day centre attendees had the highest mean scores on mobility, and
community residents had highest mean scores on cognitive, activities of
daily living, time use and social domains.
A cross sectional study was conducted by Barua et al (2005)
to examine the QOL of 70 senior citizens visiting Dr. T. M. A Pai Rotary
Hospital, Karnataka by using WHOQOL-BREF tool. The result of this
study reveals that there was significant difference in the mean scores in
the physical (p=0.004), psychological (p=0.001) and social (p=0.016)
domains, and on total scores (p=0.006) among those in the age groups
of ≥60–69 years and ≥70 years. There was a significant difference in the
mean scores in the social (p=0.002) and environmental (p=0.012)
56
domains, and on total scores (p=0.016) among single and married
subjects.
Rafati et al (2004) conducted a cross sectional study to
assess HRQOL and relating factors in 202 institutionalized elderly living
in Kahrizak Charity Institution for elder people in Iraq using Iranian
version of SF-6 questionnaire. The finding of the study established that
QOL of elderly was poor.
Chow (2002) conducted a study on confirmed positive
relationship between friendship and successful ageing and QOL.
Researcher suggests that larger the number of close relatives and the
more frequent contact with friends in the living arrangement are some of
the important factors of social support. It is critically important to the
senior citizens the QOL and the wellbeing.
A study conducted by Gupta (2003) to assess the QOL of
institutionalized senior citizens in selected 22 old age homes (867
inmates) of Delhi. Data collected using a Profile sheet of respondents
and questionnaire for QOL-BREF (WHO-2001). Most of respondents
were between 60-70 years of age group, males, educated up to class
ten/graduation, in service, married, childless, widowed, staying in old age
homes for three to five years duration and high and middle-income group.
The QOL of residents in physical, psychological and in the domain of
social-relationship was not satisfactory in selected old age homes
57
whereas in the domain of environment the QOL was to the level of
satisfaction.
Selected interventions and its effects on anxiety, depression and
QOL among senior citizens
A. Music therapy
Music therapy is an interpersonal process in which a trained
music therapist uses music and all of its facets—physical, emotional,
mental, social, aesthetic, and spiritual-to help clients to improve or
maintain their health. Music therapists primarily help clients improve their
observable level of functioning and self-reported QOL in various
domains.
A study conducted by Erkkila (2011) to determine the
efficacy of music therapy added to standard care compared with standard
care only in the treatment of depression among 76 working-age people.
Clinical measures included depression, anxiety; general functioning and
QOL assessed. The findings of this study reveals that participants
receiving music therapy plus standard care showed greater improvement
than those receiving standard care only in depression symptoms, anxiety
symptoms and general functioning at 3-month follow-up.
A literature review has done by Adigun (2011) on the
benefits of music therapy on QOL among elderly people. The finding of
the study establishes that music has a very great impact on QOL among
elderly people.
58
Lee (2010) conducted a study to the effect of music on the
QOL of 66 senior citizens in Hong Kong. QOL was analyzed in terms of
physical (PCS) and mental (MCS) component summaries and its eight
subscale. The study indicates that music listening is an effective nursing
intervention in improving QOL of senior citizens. It implicates that music
can help nurses to build therapeutic relationships with senior citizens.
Nurses are encouraged to use music as part of their holistic caring for
senior citizens.
A randomized controlled study conducted by Chan (2009) to
determine the effect of music on depression levels in 47 senior citizens of
Hong Kong. The findings of study reveals that in the music group, there
were statistically significant decreases in depression scores (P < 0.001)
and blood pressure (P = 0.001), HR (P < 0.001), and RR (P < 0.001)
after 1 month. The investigator of this study suggests that nurses may
utilize music as an effective nursing intervention for patients with
depressive symptoms in the community setting.
A study conducted by Watkins (2008) on music therapy:
proposed physiological mechanisms and clinical implications. They
concludes the findings from clinical research suggesting that music may
facilitate a reduction in the stress response include decreased anxiety
levels, decreased blood pressure and heart rate, and changes in plasma
stress hormone levels.
59
Sherry Baker, (2008) proved in his study music therapy
shows promise in treating high blood pressure. The researchers studied
at 48 patients aged between 45 yrs and 70 yrs and all diagnosed with
mild hypertension and were on medications for their high blood pressure.
Of these, 28 patients aged between 45 and 69, listened to 30 minutes of
classical, Celtic and raga music per day while conducting slow, controlled
abdominal breathing exercises. The result reveals a significant reduction
in systolic blood pressure (the top number in a blood pressure reading
that represents the pressure when the heart is resting between beats) in
those patients who had been listening to music daily. However, those in
the control group only experienced non-significant blood pressure
changes.
Ziv (2008) conducted a comparative study on the effect of
music relaxation versus progressive muscular relaxation on insomnia,
anxiety and depression in 15 senior citizens and their relationship to
personality traits in Israel. The study finding shows that music relaxation
was more efficient than progressive muscular relaxation in improving
sleep and reduction in anxiety and depression among senior citizens.
Hays and Minichiello (2005) conducted a study to explore the
contribution of music on QOL among 45 senior citizen of Australia. The
result of the study reveals that music promotes QOL by contributing to
positive self-esteem, by helping people feel competent and independent,
and by lessening feelings of isolation and loneliness. The study emphasis
60
that music can be used to maintain and promote a better QOL for senior
citizens.
Ronnberg Lisa (1997) conducted a quazi experimental study
on effect of mental stimulation by audiovisual programme among QOL in
nursing home residents of Stockholm using Nottingham Health profile.
The result shows that QOL increased among residents who received
intervention.
B. Guided imagery
Guided imagery is a program of directed thought and
suggestions that guide your imagination towards a relaxed, focused
state. We can use an instructor, tapes or scripts to help for this process.
Guided imagery has many uses. It can promote relaxation, which can
lower blood pressure and reduce other problems related to stress.
Guided imagery sometimes known as visualization is a technique in
which a person imagines pictures, sounds, smells and other sensations
associated with reaching a goal. Imagining being in a certain environment or
situation can activate the senses, producing a physical or psychological
effect.
Paula Ford Martin (2004) defined guided imagery is the use of
relaxation and mental visualization to improve mood and or physical wellbeing. The investigator states that some therapist also uses guided imagery
in-group setting. It is a two-part process; the first component involves
reaching a state of deep relaxation through breathing and muscle relaxation
technique. The second component of the exercise is imagery or
61
visualization. In a typical guided imagery session, the therapist will use one
of a variety of guided imagery that will lead you through imagined
experiences in your mind. Usually the therapist will guide your imagination
to places or situations that will make you peaceful, safe, relaxed and secure.
The therapist may use gentle background music to create a relax
atmosphere and help to avoid distractions. You will ask to imagine
something such as a warm healing light on the area where the cancer was
or images of your immune system attacking cancer cells. The therapist will
describe sounds, smells, taste, or other sensations that might accompany
what you are imaging.
A study has conducted by Baird and Sands (2006) to assess
the effect of guided imaginary with relaxation on HRQOL in 28 old women
with osteoarthritis for 12 weeks. The findings of the study suggest that the
effects of guided imaginary with relaxation are not limited to improvement in
pain and mobility, but also improvement in QOL.
Hamlin Lind (2002) states that in the clinical research it
demonstrated that guided imagery is single form of relaxation could reduce
pre operative anxiety and post operative pain among surgical patients.
C. Yoga and breathing exercises
Yoga is a form of exercise that adapts to needs and abilities.
Even senior citizens can do it. The word yoga means "union" in Sanskrit,
"yoga" can more accurately described by the Sanskrit word asana, which
refers to the practice of physical postures or many people think that yoga
is just stretching. It is the practice of breathing, stretching, light exercising
62
and meditation holistically making a person healthier in mind, body and
spirit. In the physical aspect, yoga improves flexibility muscle tone,
strength and blood circulation, on the spiritual and emotional level; it
creates a sense of wellbeing and calmness. Scientists say that yoga
works like other body mind therapies to reduce stress and other believe
that yoga promotes the release of endorphin (natural painkiller) from the
brain. Yoga is also beneficial in the prevention and control of common
health and emotional problems that linked with old age. It could offer a
low cost, and minimally invasive treatment protocol, which is easy to
deliver to senior citizens in-group format.
Four basic principles underlie the teachings and practices of
yoga's healing system. The first principle is the human body is a holistic
entity comprised of various interrelated dimensions inseparable from one
another and the health or illness of any one dimension affects the other
dimensions. The second principle is individuals, their needs are unique
and therefore must approach in a way that acknowledges this
individuality, and their practice must tailor accordingly. The third principle
is yoga is self-empowering; the student is his or her own healer. Yoga
engages the student in the healing process; by playing an active role in
their journey toward health, the healing comes from within, instead of
from an outside source and a greater sense of autonomy is achieves.
The fourth principle is that the quality and state of an individual‘s mind is
crucial to healing. When the individual has a positive mind-state, healing
63
happens more quickly, whereas if the mind-state is negative, healing may
prolong.
Breath is the most vital process of the body. It influences
activities of each cell and most importantly, it linked with performance of
the brain. Breathing intimately linked to all aspects of human experience.
Most people breathe incorrectly using only a small part of vital capacity of
lungs. Rhythmic, deep and slow respiration stimulates and stimulated by
calm, content state of mind. Breathing establishes the natural relaxed
rhythm of the body and mind. Although breathing is unconscious process,
conscious control of it may take at many times. Proper breathing
influences QOL of people. Improving the quality of breathing improves
the general health of individual and as such improves the QOL
(Saraswathi Satyananda Swami, 1996).
Nadi Shodhana Breathing exercise is a practice of breathing,
where the individual seated in comfortable position, and directed to inhale
and exhale in a controlled fashion. Take inhalation through one nostril
and exhale through other nostril by alternately opening and closing each
nostril. This exercise generates energy (Saraswathi Satyananda Swami,
1996).
Woodyard (2011) conducted a literature review on exploring
the therapeutic effects of yoga and its ability to increase QOL. The results
of the study shows that yogic practices enhance muscular strength and
body flexibility, promote and improve respiratory and cardiovascular
64
function, promote recovery from and treatment of addiction, reduce
stress, anxiety, depression, and chronic pain, improve sleep patterns,
and enhance overall well-being and QOL.
A comparative study conducted by Gururaja, Harano,
Toyotake (2011) to find the effect of yoga on mental health between
young and senior people in Japan. The result of the study shows that
reduction in State and Trait anxiety score signifies that yoga has both
immediate as well as long-term effect on anxiety reduction. Thus, yoga
helps to improve psychological health of senior citizens.
Chen (2010) conducted a quazi experimental study to test
the effects of a 6-month yoga exercise program in improving sleep quality
and decreasing depression in transitional frail senior citizens living in
assisted living facilities. The finding of the study reveals that the yoga
exercise programme has improved the sleep quality and decreased
depression in institutionalized senior citizens.
A comparative study conducted by Shahidi (2010) to assess
the effectiveness of Kataria's Laughter Yoga and group exercise therapy
in depression in 60 older women of a cultural community of Tehran, Iran.
The finding of the study shows that laughter yoga is as effective as group
exercise program in improvement of depression and life satisfaction of
depressed older women.
A study conducted by Kozasa (2008) on Siddha Samadhi
Yoga among 22 adult volunteers with anxiety complaints by usingState-
65
Trait Anxiety Inventory, the Beck Depression Inventory, Tension Feelings
Self-evaluation Scales, and the Well-being Self-evaluation Scales. The
result of study shows that there is a significant reduction in scores on
anxiety, depression, and tension found in yoga group, as well as an
increase in well-being in comparison with the control group.
A study was conducted by Bonura (2007)on impact of yoga
on psychological health in 98 senior citizens living in North Florida. The
study finding reveals that yoga participants improved more than both
exercise and control participants, in anger, anxiety, depression, wellbeing, general self-efficacy, and self-efficacy for daily living and also selfcontrol is proposed as a mechanism underlying the impact of yoga on
psychological health.
A quazi experimental conducted by Javnbakht (2007) to
evaluate the influence of yoga in relieving symptoms of depression and
anxiety in 65 women who were referred to a yoga clinic by using a
personal information questionnaire and Beck and Spielberger tests. The
findings in the study reveals that women who participated in yoga classes
showed a significant decrease in state anxiety (p=0.03) and trait anxiety
(p<0.001). The investigators suggest that yoga could consider as a
complementary therapy or an alternative method for medical therapy in
the treatment of anxiety disorders.
Shapiro (2007) acknowledges that yoga has beneficial
effects in emotional, biological and psychological effects on depressive
66
client. Thus, the study concludes that Yoga appears to be a promising
intervention for depression.
Krishnamurthy and Telles (2007) conducted a comparative
study on yoga and Ayurveda treatment modalities on institutionalized 69
senior citizens by using 15-item Geriatric Depression Scale. The finding
of this study reveals that depression symptom scores significantly
decreased among senior citizens those participated in yoga program
comprising physical postures, relaxation techniques, regulated breathing,
devotional songs, and lectures.
A study conducted by Oken (2006) to determine the effect of
yoga on cognitive function, fatigue, mood, and QOL among 135 healthy
senior citizens. The result of the study shows that yoga intervention
produced improvements in physical measures as well as a number of
quality-of-life measures related to sense of well-being and energy and
fatigue compared to controls.
A randomized comparative study conducted by Smith (2006)
on yoga and relaxation technique among 131adults with anxiety in South
Australia by using State Trait Personality Inventory sub-scale anxiety,
General Health Questionnaire and the Short Form-36. The finding of the
study shows that yoga is more effective than relaxation in reducing
stress, anxiety and improving physical health among adults.
67
Progressive muscle relaxation technique
Progressive muscle relaxation (PMR) originally designed by
Jacobson to guide people through successive tensing and relaxation of
the body muscle groups from toe to head to achieve overall body
relaxation. This process is easy to learn and teach, safe, non-threatening
and non-competitive.
Guedes et al (2011) conducted a study to investigate the
association between physical activity and QOL among 1204 Brazilian
older adults using WHOQOL and International Physical Activity
questionnaire. The finding of the study indicates that increased levels of
physical activity had contributed to improvement in QOL of older adults.
Ayers and Sorrell (2007) of university of California conducted
a literature review on evidence-based psychological treatments for latelife anxiety by using specific coding criteria and identified 17 studies that
met criteria for evidence-based treatments. This study reflects that
efficacy for relaxation training and cognitive–behavioural therapy (CBT)
has support for treating subjective anxiety symptoms and disorders.
Conrad and Roth (2007) investigated on progressive muscle
relaxation technique among patients with anxiety disorders. The result of
the study shows that progressive muscle relaxation technique is effective
in improving generalized and panic anxiety disorders.
Morone and Greco (2007) conducted a structured review on
eight mind–body interventions on senior citizens with chronic non-
68
malignant pain. Review of articles supports only for progressive muscle
relaxation technique and guided imaginary are effective in reducing
chronic pain among senior citizens.
Doris (2007) conducted a study to examine the effects of
relaxation therapy and exercise training on psychological outcomes and
disease-specific QOL of older heart failure patients in china. The result
shows that the relaxation and exercise groups reported a significantly
greater improvement in psychological and various disease-specific QOL
outcomes (dyspnoea, fatigue, and emotion) compared with those who
received the attention placebo.
A quazi experimental study conducted by Giju Thomas
(2006) to determine the effectiveness of progressive muscle relaxation
technique on anxiety among 40 senior citizens inmates of Sarvodaya old
age home, Bangalore. Data collected by using Standard State Trait
Anxiety Inventory Scale. The result of the study reveals that progressive
muscle relaxation technique is effective in reducing anxiety on senior
citizens.
A cross sectional study conducted by Binhosen (2003) to
investigate physical activity and health related QOL among 350 senior
citizens residing in the municipal area of Muang district, Chiang Mai
Province by using Physical Activity Scale for the Elderly (PASE) and
HRQOL-
Questionnaire.
The
investigator
strongly
suggests
that
household activity was an alternative strategy to enhance physical
69
activity resulting in the improvement of health related QOL among senior
citizens.
From the detailed review of research and non-research
literature, it is clear that inadequate care, protection, feeling of insecurity
etc will leads to serious health related problems and issues among senior
citizens. The related review also reflects strong relationship between
various nursing interventions and anxiety, depression and QOL among
senior citizens. The literature review helps the investigator to design and
work overall research process.
Need and significance of the study
There is no doubt that the joint family system prevalent in
India had provided much stability and protection of our senior citizens. In
that system the youngsters extended support, love and respect to the
senior citizens. The socio-economic shifts within origin of nuclear families
affect inversely the ability of the family to continue the traditional care to
senior citizens. The problems related to the fulfilment of basic
requirement such as social needs, nutrition and accommodation are
added to old age health problems; certain arrangements is inevitable to
meet the problem. Provisions of old age homes will helped to solve the
problem up to certain extend.
In 20th century, the proportion of population aged 60 or over
increased in all the countries of the world. About 600 million people in the
world were senior citizens at the turn of the new millennium and their
70
number expected to increase further due to substantial improvement in
life expectancy throughout the world. The grey population, which
accounted for 6.7% of total population in 1991, increased to more than
10% by the year 2012 (United Nations Population Challenges and
Development Goals, 2005). This is particularly due to improvement in
public health and medical advances and prevention of many deadly
epidemic diseases. Therefore, government needs to initiate appropriate
programme and policy intervention to ensure life dignity for senior
citizens of the country.
In this context, QOL that is related to individual enjoying the
happiness life of high quality during old age, draws attention as a
comprehensive and universal approach (Rawat, S, 2007). Therefore,
numerous institutions, which take care of senior citizens managed by
Government, voluntary organization and Christian missionaries, came
into existence. The life satisfaction among the institutionalized senior
citizens found to be significantly lower than that of the noninstitutionalized senior citizens (Mathew, S. 1997).
The experience of an old age person in an institution is very
different from of an individual in a family. Living in an institution demands
specific adjustmental task to cope up with the problems. Some
individuals make good adjustment and some find it difficult. The health
status that may cause loss of independence and dignity are strongly
associated with health related QOL of institutionalized senior citizens.
71
Institutionalized senior citizens subjected to psychosocial problems like
depression, anxiety, feeling of insecurity, loneliness, behavioural
problems, social problems, low self-esteem. Poor adjustmental are
responsible for the worsening of health and related physical and
psychosocial problems. The absence of family care and surrounding
induce feeling of loneliness among residents of old age home (Avdesh
Sharma, 2009).
The facilities as well as number of care provider available for
the senior citizens are not sufficient and limited resources are available to
meet the physical needs. Psychological parameters totally neglected and
not taken into consideration for making the life stress free and improve
the
quality of
their
life.
Specific
programmes
cooperated
with
psychological studies conducted on yoga (Oken et al, 2006), transidential
mediation,
cognitive
behavioural
therapy
(Serfaty
et
al,
2009),
rehabilitations therapy, group therapy, etc has proven very effective for
their well-being as well as to improve the QOL. Studies suggested that a
planned interventional programme given to them on daily basis including
yoga (Hariprasad et al., 2013), music (Eckl, 2012), guided imaginary,
muscle relaxation (Baird and Sands, 2006) etc would yield good result in
improvement of QOL among senior citizen in old age homes.
Gerontological nursing is a new branch of nursing. It is slowly
gaining importance in the profession of nursing (Harper and Hogstel,
2001). Unfortunately, much cost effective intervention programme to
72
meet the physical, psychological problems not incorporated with current
nursing curriculum.
If the nurses given proper instructions about this
programme, even without formal training, nurses working in this sector
can revolutionalize the quality of care of senior citizens.
The researcher who is postgraduate scholar in nursing and
psychology had more than 30 years of experience in nursing as well as
community social services. He had always shown much consideration to
the patient‘s in chronic wards with full of destitute senior citizens of
District Hospital, Kannur; General Hospital, Thalasserry; Government
Taluk Hospital, Vythry, Wayanad, and Sanatorium of Chest diseases,
Pariyaram. He is an admirer of Indian tradition have much compassion
and love towards seniors. It was his pleasure to visit old age homes and
spend time with them. This frequent visit helped him to understand the
heartfelt problems of them. He had vivid life experiences on the problems
of senior citizens both institutionalized and non-institutionalized in the
country. This understanding motivated him to formulate a planned
intervention programme that should applicable to both institutionalized
and non-institutionalized seniors in future.
Intervention could do miraculous changes in anxiety,
depression and QOL among senior citizens. On the light of this
background, the present study ―toassess the effect of structured nursing
intervention on anxiety, depression and QOL among senior citizens
73
admitted in the old age homes of North Kerala‖ could make radical
changes in the comfort of life of our grey population.
Statement of problem
Effect of structured nursing intervention on anxiety, depression and QOL
among senior citizens of North Kerala.
Title of the study
EFFECT OF STRUCTURED NURSING INTERVENTION ON ANXIETY,
DEPRESSION AND QUALITY OF LIFE AMONG SENIOR CITIZENS
Objectives of the study
1. To find out the effect of Structured Nursing Intervention (SNI) on
anxiety, depression and QOL among senior citizens.
2. To
find
out
the
association
between
anxiety
and
selected
demographic variables among senior citizens
3. To find out the association between depression and selected
demographic variables among senior citizens
4. To find out the association between QOL and selected demographic
variables among senior citizens
5. To find out the relationship among anxiety, depression and QOL
among senior citizens
Hypothesis
H1- There is a significant difference in anxiety, depression and QOL
among senior citizens before and after Structured Nursing Intervention
74
H2- There is a significant association between anxiety and selected
demographic variables among senior citizens.
H3-There is a significant association between depression and selected
demographic variables among senior citizens.
H4-There is a significant association between QOL and selected
demographic variables among senior citizens.
H5- There is a significant relationship among anxiety, depression and
QOL among senior citizens.
Operational definition
Senior citizen- Senior citizens are adults above 60 years of age who are
inmates of old age homes of North Kerala.
North Kerala – North Kerala are the regions in Kerala, which constitute
the districts of Kasargod, Kannur, Wayanad, Kozhikode, Malappuram
and Palakkad.
SNI- SNI is a 50 minutes programme comprising of general warming up
and
breathing
exercises,
progressive
muscle
relaxation,
guided
imaginary and group interaction section. Interventions conducted in the
background of music in Sindhu Bhairavi and Anand Bhairavi ragas
designed by the researcher with an idea to improve the QOL, reduction in
anxiety and depression among senior citizens admitted in old age homes.
Effect- Effect is the significant changes in anxiety, depression and QOL
among
senior
intervention.
citizen
who
have
undergone
structured
nursing
75
Anxiety –Anxiety is a worried, uncertain state of mind a senior citizens
experience due to aging process, admission to old age homes and
separation of family members as measured by the Hamilton anxiety
rating scale.
Depression- Depression is the general sadness experienced by the
senior citizens admitted in old age homes as measured by Beck
depression inventory II scale.
QOL- QOL is the degree of satisfaction experienced by senior citizens
admitted
in
old
age
homes
in
physical,
psychological,
social,
environmental, economic and spiritual domains assessed by WHOQOL
BREF scale.
Selected demographic variables- in this study select demographic
variable refer to the age, sex, marital status, previous occupation, source
of income, financial support, social support, psychological support and
duration of the stay in old age homes.
Conceptual framework
The theoretical framework for the present study based on
Callista Roy‘s adaptation model (RAM). Sr. Callista Roy considers a
person as holistic adaptive system characterized by input, control, out-put
and feedback process. Input is the stimuli and output is the adaptive and
maladaptive response. The person is a bio psychosocial being in
constant interaction with changing environment.
76
As an open living system person receives input or stimuli
from both environment and self. A stimulus can be focal, contextual and
residual in nature and is a unit of information, matter or energy. A focal
stimulus is the change most immediately challenging the person‘s
adaption. The factor precipitates behaviour. Contextual stimuli exist in
situations that strengthen effect of focal stimulus. Residual stimuli are the
factors affect the focal stimulus but whose effects are unknown. Person
continuously scan the environment for stimuli, so he can respond and
ultimately adapt. The result is the attainment of an optimum level of
wellness.
There are two interrelated subsystem in Roy‘s model. The
primary functional or control process subsystem consists of a regulator
and cognator. The secondary effecter subsystem consists of four
adaptive modes, physiological mode, self-concept mode, role function
mode and interdependence mode. Coping taking place in these two
subsystems. A regulator is a subsystem coping mechanism, which
responds automatically through neural chemical endocrine process. A
cognator is a subsystem coping mechanism, which responds through a
complex process of perception and information processing, learning,
judgement and emotion. Roy proposes that behavioural responses of
these subsystems can observed in four adaptive modes.
77
Physiological adaptive mode involves body‘s basic needs
like oxygenation, fluid electrolyte balance, nutrition, elimination, activity
and rest. Physiological integrity is the adaptive response of this mode.
Self-concept mode refers to psychological and spiritual
characteristics of the person. It incorporates two components, personal
self and social self. Psychic integrity is the goal of self-concept mode.
Interdependence mode refers to the ability to cope with
others. It involves previous relation with significant others and support
system. Affectional adequacy is the goal of this mode.
The role function adaptive mode involves behaviour based
on person‘s position in society. It also depends on how person integrates
with others in a given situation, can classify as primary, secondary or
tertiary role. Social integrity is the goal of role function mode.
Output may be adaptive or maladaptive responses. Adaption
occurs when the person respond positively to the environmental
changes. This adaptive response promotes the integrity of the person,
which leads to health. Maladaptive responses to stimuli lead to disruption
of the integrity of the person.
Roy‘s goal of nursing is to help man adapt to changes in his
four modes during health and illness. She uses the nursing processassessment, making nursing diagnosis, goal settings, intervention and
evaluation to facilitate the adaptive of the person.
78
In the present study, senior citizens are the person who
forms an adaptive system with different stimuli. The focal stimuli are
institutionalization, familial separation, functional decline, dependency,
low esteem and loneliness. Contextual stimuli include socio-economic
status, education, attitudes of senior citizens towards service and lack of
social support. The residual stimuli include past life experience,
expectation of society from the senior citizens and cultural belief towards
aging.
In the control phase, the adaptive levels to these stimuli
modulated through regulator and cognator subsystem. Response of this
subsystem expressed through four modes of control process.
In physiological mode, it expressed as indigestion, distaste,
altered bowel and bladder pattern, poor intake of food, reduced sleep and
inactivity.
Self-concept level response expressed by senior citizen is
low esteem, lack of confidence, dependency and frustration.
Role performance inadequacy is expressed are poor
acceptability, unwanted feeling, loneliness, role confusion, and losing
power.
Interdependence
mode
expressed
by
lack
of
trust,
suspiciousness, poor adaptability to change, loneliness and loss of
relationship.
79
In control phase, institutionalized senior citizen is facing
difficulty in adapting positively to stimuli. It‘s evidenced through their
perceived decline in QOL.
Response to this subsystem expressed through four modes.
A senior citizen who enjoys QOL and decreases in anxiety and
depression level is the expression of adaptive response.
In physiologic mode, it is express as taking adequate food,
rest, obtaining adequate sleep and keeping active, which would promote
physiological integrity.
The response in self-concept mode is the achievement of
psychic integrity, which expressed as increase in self-concept, selfesteem, functional ability and independence.
In role performance mode the adaptive responses are
behaviours that demonstrate design to fulfil social integrity, which include
adaption to changed situation and positive communication.
The adaptive response in interdependence mode is the
behaviour that promotes a healthy relationship with inmates‘ and
significant others in the old age homes which promote the affection
adequacy of senior citizens which include optimism, healthy outlook
towards life and realistic expectation.
80
OUTPUT
CONTROL
INPUT
ADAPTION
S
T
I
M
U
L
I
Focal stimuli
 Institutionalization
SENIOR CITIZEN
 Familial separation
QOL
STRUCTURED NURSING INTERVENTION
A
D
A
P
T
A
T
I
O
N
 Functional decline
 Low self esteem
 Loneliness
Contextual stimuli
 Education
 Attitude towards
service
 Lack of social
support
 Loss of economy
Residual stimuli
 Expectation of society
 Socio-personal factors
 Family factors
 Cultural factors
FEEDBACK
Figure 3: Conceptual framework based on Roy’s adaptation model
Depression
Anxiety
Anxiety
Depression
QOL
MALADAPTION
81
In the output, there is adaption positive or negative
manifested as improved or degraded QOL and increased or decreased
anxiety and depression. In negative adaption, stimuli are takes back
again to control process for adaption through feedback.
According to Roy, the goal of nursing is to help man to adapt
changes in his four modes during health and illness. This model served
as a useful tool for systemic gathering of responses regarding adaption
problem by assessing the behaviour of senior citizen and assessing the
stimuli.
Nursing
action
planned
in
form
of
―
structured
nursing
interventional‖ which manipulates senior citizen subsystem. This
technique helps institutionalized senior citizen to make adaption in four
modes and thus improve QOL and reduction in anxiety and depression.
Assumptions
a) SNI will improve the QOL of senior citizens.
b) Senior citizens admitted in old age home will have depression and
anxiety.
c) Senior citizens will cooperate in SNI
Delimitation
a) The study was conducted only in old age homes of northern part of
Kerala
b) The study design adopted is one group pretest –post test design
c) SNI is administered through audio CD.
82
Summary
This chapter presents a brief account of the literature
search related with the present study. Contemporary available
research findings shows that nursing interventional programmes of any
type, which has component of group activities yield good results.
Literature search for the cognitive behavioural therapy, music therapy,
remembrance therapy etc reviewed in detail. Available different studies
support the interventional programme formulated by investigators. At
same time, it may me emphasise that number of studies exclusively
conducted for QOL of seniors are comparatively limited in and out of
country.
83
CHAPTER III
METHODOLOGY
The third chapter deals with the research methodology
adopted for the study. The success of the research is depending upon
the selection of correct research methodology, which systematically
solves the research problem, and testing the hypothesis. It includes the
step of research approach, research design, research setting,
population, sampling, research tool, pilot study, data collection process
and plan for data analysis.
Research approach
The core objective of the study was to assess the effect of
structured nursing intervention on anxiety, depression and QOL among
senior citizens of North Kerala. The contributory objectives of the study
were to assess the level of anxiety, depression and QOL among senior
citizens of North Kerala. Therefore,
the
investigator
adopted
a
quantitative approach for the study. As such in the present study,
investigator decided to conduct the study without control group and
subjects acted as their own control.
84
Purpose
To improve QOL, to reduce depression and to relieve
anxiety.
Design
One group pre test- post test design
Setting
Old age homes of Calicut and Palakkad
Target population
Senior citizens of old age homes
Sample
320 inmates of old age homes of Calicut and Palakkad
Data collection instruments
Semi structured interview schedule
WHOQOL- BREF
Hamilton anxiety rating scale
Beck‘s depression inventory II
Pre-test
Structured Nursing Intervention (SNP)
Post test
Data analysis
SPSS version
Report
Descriptive and inferential statistics
Figure 4: schematic representation of design of the study
85
Research design
The design selected for the study was one group pre test –
post test design. This is a suitable design to conduct such a study to
assess the effect of nursing intervention programme in the setting like
an old age home.
Schematic representation of the study
O1 X O2
Key
O1 - Pre test to assess anxiety, depression and QOL among
institutionalized senior citizens
X– Structured nursing intervention
O2- Post test to assess anxiety, depression and QOL among
institutionalized senior citizens
Variables
In the study, dependent variables are anxiety, depression
and QOL of senior citizens. Independent variable is structured nursing
interventions
Setting of the study
The study conducted in two districts of North KeralaCalicut and Palakkad. Government old age home, Vellimandukundu
86
coming under Social Welfare Department, Kerala has nearly 150
inmates during the course of the study. There are wards separated for
males and females. Mercy home and Karuna Bhavan are institutions
run by charitable missionary organizations. Both the old age homes
has sufficient subjects to conduct the study. In Palakkad district,
Government old age home, Kodamaloor and Private old age homes
such as Crescent old age home, and Sneha Jyothy old age home
selected for this study. These two old age homes run by the charitable
trust. The subjects selected as per criteria given below.
Population and sample
In the study, population refers senior citizens residing at
Mercy home, Karuna Bhavan, and Government old age home, Calicut;
Crescent old age home, Sneha Jyothy old age home and Government
old age home, Palakkad.
The sample consisted of 320 senior citizens who meet
criteria, listed below.
Inclusion criteria
Senior citizen who is:
1. 60 years and up to 80 years
2. Male and female
3. Able to do activity of daily living (ADL)
87
Exclusion criteria
Senior citizens who is:
1. Critically ill
2. Bed ridden
3. Dumb and deaf
4. Taking treatment for mental illness
Sampling technique
Multiphase random sampling techniques is used for
selecting sample as per availability and fulfilment of inclusion criteria
In the first phase, Calicut and Palakkad districts selected
by lottery method from the six districts of north Kerala i.e Palakkad,
Malappuram, Calicut, Wayanad, Kannur and Kasargod.
In second phase, institution selected according to simple
random technique.
In third phase, subjects selected through lottery method. At
the same time, intervention provided to subjects who wanted to
undergo the programme by their own will.
88
Table 1: Details of sample collected from selected old age homes
District
Calicut
No. of inmates
Samples
who met criteria
selected
Mercy Home
90
45
Karuna Bhavan
86
43
144
72
148
74
Crescent old age home
84
42
Sneha Jyothy old age
88
44
Old age home
Govt. old age home,
Vellimandukundu
Govt. old age home,
Palakkad
Kodamaloor
Data collection instruments
The technique used for the investigation consists of interview.
Tool: I-Semi structured interview schedule on socio demographic
data of senior citizens
Semi structured interview schedule was used to collect
socio-demographic data of senior citizens residing in selected old
homes. It consisting of 12 items as sex, age in years, religion, marital
status, educational status, previous occupation, type of family, financial
support, psychological support, physical support, family support and
duration of old age home stay.
Tool was prepared in English and translated to Malayalam
by a language expert. This tool later re-translated to English by another
89
language expert and found to be similar to the English version. For the
content validity, the tool submitted to the various experts in fields of
three psychologists, two psychiatrics and five nursing along with criteria
for evaluation. In corporate with suggestions from various experts tool
were modified and got 100% agreement.
Tool: II-Hamilton Anxiety Rating Scale
Hamilton Anxiety Rating Scale (HAM-A) is standardized tool to
assess the anxiety among senior citizens. It consists of 14 items.
Participants were instructed to rate the symptoms according to intensity
of symptoms. Each item contains five responses are rated as 0, 1, 2, 3
and 4 where 0 stands for absent of symptoms and 4 stands for
symptoms that are incapacitating. Total score is 30. According to
author of this tool, level of anxiety classified as
<17: mild; 18–25: moderate; > 25: severe.
The tool was prepared in English and translated to Malayalam by
a language expert. This tool later re-translated to English by another
language expert and found to be similar to the English version.
90
Table 2: Details of data collection instruments used in the study
S.
No
Selected/
Name of the tool
Variables measured
developed by
investigator
No. of
items
Reliability
Validity
-
Content
α-0.77-0.92
Construct
(test-retest)
Concurrent
α-0.91
Construct
(test-retest)
Concurrent
α-0.63-0.84
Construct
(test-retest)
Concurrent
Age, sex, religion, marital status,
Socio1
Demographic
Performa
educational status, previous occupation,
type of family, financial support,
Developed
12
Anxiety
Selected
14
Depression
Selected
21
Domains of QOL
Selected
26
psychological support, physical support,
family support and duration of stay in old
age homes
2
3
4
Hamilton anxiety
rating scale
Beck Depression
inventory II scale
WHO QOL BREF
91
Tool: III- Beck Depression Inventory II scale
Beck Depression Inventory II scale is standardized tool with 21
items to assess the depression of senior citizens. Each item contains
four responses. Total score is 50. According to author of this scale,
depression classified as follows
Classification
Score
Level of depression
Normal
1-10
Normal ups and down
Mild
11-16
Mild mood disturbance
Borderline
17-20
Borderline depression
Moderate
21-30
moderate depression
Severe
Over 30
Severe depression
The tool was prepared in English and translated to Malayalam by
a language expert. This tool later re-translated to English by another
language expert and found to be similar to the English version.
Tool: IV-WHO QOL BREF Scale
WHO QOL BREF Scale used to assess the QOL of senior
citizens. This scale consists of 26 items, which grouped under four
domains. The physical domain has seven items, which include; pain
and discomfort, dependence on medication, energy and fatigue,
mobility, sleep and rest, activities of daily living and working capacity.
The psychological wellbeing domain has six items, which include;
positive feelings, negative feelings, spirituality, thinking, learning,
memory and concentration, body image and self-esteem. The social
domain has three items including; personal relationship, sexual activity
92
and social support. The environment domain has eight items including;
physical safety and security, physical environment, financial resources,
information and skills, recreational and leisure, home environment,
access to health and social care and transport. Each item rated on a
five-point scale. The raw score for each domain was calculated and
then transferred into a range between 0-100. Higher scores suggest
higher QOL. Beyond this, two items are general one that relates with
individual perception on their QOL (WHOQOL scale, 1996). The
researcher has categorizes the QOL into three levels<33- low QOL
34-66- average QOL >66 – high QOL from the
transformed data 0-100
A language expert translated the tool to Malayalam. This tool
later re-translated to English by another language expert to ensure
language validity.
Structured nursing intervention
The structured nursing intervention is an intervention
designed by the researcher aiming to reduce anxiety, depression and
to improve the QOL of senior citizens admitted in the old age homes. It
is a 50 minutes interventional package. The intervention has four parts.
All the parts designed in such a way that the participants can perform
in an easy way without any strain. The intervention developed based
on one of the principles of yoga of balancing and harmonizing the
body, mind and emotion. The intervention consists of simple, gentle
93
and comfortable activities that are quite suitable for the senior citizens
of all age groups. The four sessions of interventions are:
1. Warming up exercises (5minutes)
2. Relaxation training (30minutes)
3. Structured group interaction session (5 minutes)
4. Recreational session (10minutes)
1. Warming up exercises- it includes simple range of motion
exercises that can be performed by the senior citizen without
tiresome which is given for 5 minutes, followed by resting period of 2
minutes
2. Relaxation training : relaxation training consists of
A. Breathing exercisesa) Simple breathing – it is a mode of relaxation exercises by
controlling the rate and depth of respiration. It is given for 5
minutes. The steps are
 Sit comfortably or lie supine with arms and legs straightened
 Inhale gently, but deeply through nose and push air down
abdomen
 Hold the breath for a moment, and then pull the shoulders back
whilst gently letting it go.
 Squeeze all the air out of the lungs by contracting the abdomen
 Repeat it for 2 minutes.
94
b) Nadi shodana breathing- Sit in a comfortable posture (those who
can sit can sit against a wall with legs out stretched or in a chair
which has straight back). Keep the head and spine upright. Relax
the whole body and close the eyes. Hold the fingers of the right
hand in front of the face. Rest the index finger and middle fingers
gently on the eye brows centre. Both fingers should be relaxed. The
thumb is above the nostril and the ring finger above the left. These
two digits control the breath in the nostril by alternately pressing on
the nostril, blocking the flow of breath and the other. Close the right
nostril with the thumb. Inhale and exhale through the left nostril
5times. The rate of inhalation/ exhalation should be normal. Beware
of each breath. After 5 breathe release the pressure of the thumb on
the right nostril press the left nostril with the ring finger, blocking the
flow of air. Inhale and exhale through the right nostril5 time, keeping
the respiration rate normal. Lower the hand and breathe 5 times
through both nostrils together. This is one round, practice it 5
rounds.
c) Bhastrika breathing- sits in any comfortable position. Keep the head
and spine straight, keep the whole body relaxed. Take a deep
breath in/out forcefully through the nose. Do not strain. During
inhalation, the diaphragm descents and the abdomen moves
outwards. During exhalation the diaphragm moves inwards.
Continue in this manner counting 10 breaths. This is one round,
95
practice up to 5 rounds. Keep the breath rhythmical. Inhalation and
exhalation must be equal.
B. Progressive muscle relaxation- lie flat on the back with the arms
15cm away from the body. Palms facing upwards. Let the fingers
curl up slightly. Move the feet slightly apart to a comfortable position
and close the eyes. The head and spine should be in straight line.
Relax the whole body and stop all physical movements, concentrate
on breathing and count the breath from no 27 to backward to 0.
Relax the body from the leg to the head mentally by giving
concentration to different parts. Once the whole body is relaxed give
a gap for 3 minutes guided imagery session starts.
C. Guided imagery – in the relaxed position, direct the person to a
dream world by asking to focus attention to the command. You will
feel that you can see each object closely and clearly before you just
imagine an existing day break. Can‘t you head the birds chirping
and twittering in the branches (background music). Look at those
lovely hilltops, fog pierced by the golden rays of the rising sun. You
will certainly enjoy the marvelous spectacle which lifts you to the
ecstatic world of blissfulness (background music).
Now turn the eyes on to the stream which cascades down
the hills splashing drops like pearls and see how it gently moves
along the valley, purling to the pebbles it flows over. Sauntering
along the bank of the stream, you are now entering an open grass
96
gland. Stay there for awhile, charmed by a beautiful sights and
sounds nature lays before you for your delight and enjoyment (back
ground music). Listen to amours chant of the feathered choir and
the murmurs buzz of butterflies. And from you are now entering
beautiful garden arrays with rows of fragments flowers. Exhilarated
by exiting spectacle of the golden drops of dew trickling down the
petals and colorful butterflies dancing around the flowers, you are
now moving forward(background Music). You reached to a lake and
now you are on the shore of that lake. Your eyes now meet the
blooming lotuses, swans that swim about and the golden fishes
(back ground music).
D. Audio of a varna in flute (Anantha Bhairavi raga) 3min- (give a
pause of three minutes) now focus on your own body. Don‘t you feel
that each organ of your body now experiences a condition of
ecstasy? In fact this is a very serene and blissful state. Now you are
provided with enough oxygen in your entire limp. Both the mind and
body experience a condition of extreme relaxation. Pray that you
may transmit this pleasant experience to other individuals also. Now
descents from this euphoric world of imagination into your own
works a day world and very slowly rise up.
97
3. Structured group interactive sessions (5 minutes)
a. News paper reading- all the senior citizens sit in a circle and one
among them read the news paper of the day aloud, while others
listen
b. Group discussions- here senior citizens participates in the
discussions on the main news of the day moderated by the
researcher
4. Recreational session(10 minutes)- in this session the senior
citizen were made to participate in the recreational activities such as
passing a ball and music chair on alternate days and singing of
songs daily. Followed by the national anthem, the intervention of
that day finishes.
Structured nursing intervention submitted to experts in the
field of five psychologists, two psychiatrics, seven nursing, three
musicians and two yoga Acharayas, along with objectives and criteria
for validity. There was 99% agreement for this tool.
Data collection procedure
The data collection period was from March 2012 to August 2012.
Formal administrative sanctions obtained from Social
welfare Department, Government of Kerala and various directors of old
age homes of Palakkad and Calicut. The data collection periods were 6
months that is three months each in each district. The investigator
explains the purpose of study and obtained informed consent from
98
participants who met the inclusion criteria. The investigator gives a
detailed orientation programme on structured nursing intervention. The
data collected directly from the subjects of respective old age homes.
Average time taken for data collection is about 45 minutes.
All the participants requested to seat in a hall comfortably and
audio CD played with help of adequate number of speakers. They
requested to follow the instructions and perform accordingly.SNI
administered every alternative day with a minimum of three
programmes per week. The intervention implemented in all Sundays,
Wednesday and Friday for a period of three months. It arranged
between 7.30 am to 10.30 am and 4.30 pm to 6.30pm, without
interrupting the daily routine of the institution, so that each group will
get 36 days of treatment. A post-test conducted with the help of Tool II,
III and IV, after 20 days of programme.
Eight-drop outs reported during post test data collection due to
illness and death of participants.
Ethical consideration and human right protection
The problem presented in front of the Ethical committee of
Government Medical College, Calicut and committee approved and
issued the ethical clearance certificate. Subsequently Directorate of
medical education, Government of Kerala provide No Objection
Certificate to conduct the study.
99
In every study, protection of human rights is responsible of
the investigator. Here human right protected with provision of informed
consent. All the subjects were given free hand to withdraw from the
study at any time as when they like and also they were given chance to
contact the investigator at any time during the study by providing the
his mobile number. For conducting study at Government, old age
homes
administrative
sanctions
from
director,
social
welfare
department, Trivandrum. Other old age homes sanctions obtained from
the respective institutions.
Pilot study
Pilot study conducted from an old age home at Palakkad
for a period from November 2011 to February 2012. A pre–test
administered to 32 subjects who conformed to the selection criteria
after obtaining informed consent. Structured nursing intervention
implemented for 3 months. After 20 days, post-test conducted. Data
tabulated by using descriptive and inferential statistics and found the
data were amenable to the statistical analysis. The study found to be
feasible and practicable.
Plan for data analysis
Collected data will be analyzed by descriptive and
inferential statistics by using statistical software (SPSS-version 17).
1. Socio-demographic data will be analyzed using descriptive statistics
and expressed in tables and graphs.
100
2. Effect of SNI on anxiety before and after intervention will be analyzed
by paired ‗t‘ test at 5% level of significance.
3. Effect of SNI on depression before and after intervention will be
analyzed by paired ‗t‘test at 5% level of significance.
4. Effect of SNI on QOL before and after intervention will be analyzed by
paired ‗t‘ test at 5% level of significance.
5. The association between anxiety, depression and QOL and selected
socio-demographic variables will be assessed by one way ANOVA at
5% level of significance.
6. Relationship between anxiety, depression and QOL before and after
SNI will be assessed by Karl Pearson coefficient at 5% level of
significance.
101
CHAPTER IV
ANALYSIS AND INTERPRETATION
The chapter deals with the analysis and interpretation of
collected data. Data collected from three hundred and twelve
institutionalized senior citizens of selected Old age homes of North
Kerala were tabulated, analyzed and interpreted using descriptive and
inferential statistics with the help of SPSS version 17.
Objectives of the study
1. To find out the effect of Structured Nursing Intervention (SNI) on
Anxiety, Depression and QOL among senior citizens.
2. To find out the association between anxiety and selected
demographic variables among senior citizens
3. To find out the association between depression and selected
demographic variables among senior citizens
4. To find out the association between QOL and selected demographic
variables among senior citizens
5. To find out the relationship among anxiety, depression and QOL
among senior citizens
102
Data tabulated and analyzed under the following headings:
Section I:
Sample characteristics of senior citizens
Section II:
Effect of structured nursing intervention
Section III: Level of anxiety, depression and QOL
Section IV: Association
between
selected
socio-demographic
variables and anxiety, depression and QOL among
senior citizens
Section V:
Relationship between anxiety, depression and QOL
among senior citizens
SECTION I:
Sample characteristics of senior citizens
Table 3: Frequency and percentage distribution of sample based
on age
n=312
Age in years
f
%
60 – 65 years
138
44.23
66 – 70 years
143
45.83
71 – 75 years
22
7.05
76 – 80 years
9
2.88
Data on the Table 3 indicates that 45.8% senior citizens
belonged to age group of 66-70years and only 2.88% of samples were
in age group of 76-80 years.
103
Female
40.57%
Male
59.43%
Male
Female
Figure 5: Percentage distribution of sample based on sex (n=312)
In figure 5, 59.43 % sample was males and 40.57% were females.
Christian
26.40%
Hindu
48.20%
Muslim
25.40%
Figure 6: Percentage distribution of sample based on religion
(n=312)
Figure 6 indicates that 48.2% sample were Hindus,
Christian (26.40%) and Muslims (25.40%)
104
Table 4: Frequency and percentage distribution of sample based
on marital status
n=312
Marital Status
f
%
Married
171
54.81
Unmarried
46
14.74
Divorced
38
12.18
Deserted
57
18.27
According to Table 4 point outs that majority of senior
citizens 54.81% were married, 18.27% were deserted, 14.74% were
unmarried and 12.18 % were divorced.
Table 5: Frequency and percentage distribution of sample based
on educational status
n=312
Educational Status
f
%
Illiterate
78
25.0
Up to 4th class
165
52.89
Up to 10th class
66
21.15
Up to Degree
3
0.96
From the above table, it is revealed that majority of sample
had education upto fourth standard (52.89%) and a very few sample
had graduate level of education.
105
36.4
35.9
40
Percentage
35
30
18.6
25
20
9.1
15
10
5
0
Previous occupation
Skilled labourer
Private Employee
Self employed
Unemployed
Figure 7: Percentage distribution of sample based on previous
occupation (n=312)
Figure 7 denotes that 35.90% sample was skilled
labourers, 36.40% were unemployed, 18.60% were private employers
and remaining (9.10%) were self-employed.
Table 6: Frequency and percentage distribution of sample based
on type of family
n=312
Type of family
f
%
Nuclear family
199
63.78
Joint family
75
24.04
Extended
38
12.18
Table 6 reveals that 63.78% of senior citizens were lived in
nuclear families, 24.04% were in joint family and 12.18% were in
extended family.
106
Pension
6.8%
Wife/Husband
6.8%
Widow/Old
age pension
22.3%
Son/Daughter
48.6%
Friends/Others
15.5%
Figure 8: Percentage distribution of sample based on source of
income (n=312)
From above figure, it is clear that 48.60% sample had
source of income from their own son or daughter
Table 7: Frequency and percentage distribution of sample based
on physical support
n=312
Physical Support
f
%
Brothers/Sisters
34
10.90
Wife/Husband
51
16.35
Son/Daughter
84
26.92
Friends/Others
143
45.83
Data from the Table 7 point out that 45.83% of the senior
citizens had physical support from friends/ others, 26.92% from
107
son/daughter, 16.35% from wife or husband and remaining (10.90%)
from brothers or sisters.
37.3
40
35
30.9
Percentage
30
brothers,/ sisters
22.7
25
wife/husband
20
son/daughter
15
friends/others
9.1
10
5
0
Figure
Psychological support
9:
Percentage
distribution
of
sample
based
on
psychological support (n=312)
It is evident from figure 9 that 37.3% of sample getting
psychological support from son/ daughter, whereas 30.90% receives
support from friends/ others and only 9.1% receives psychological
support from their spouse.
Table 8: Frequency and percentage distribution of sample based
on social support
n=312
Social Support
f
%
Brothers/Sisters
40
12.82
Wife/Husband
72
23.08
Son/Daughter
56
17.95
Friends/Others
144
46.15
108
Data on Table 8 shows the social support of senior
citizens. 46.15% had social support from friends/brothers/sisters
socially supported others, 23.08% from wife/husband, 17.95% from
son/daughter and 12.82% senior citizens.
38.6
40
31.8
35
30
25
21.8
20
15
7.7
10
5
0
Below 1 year
1 - 3 years
3 - 5 years
Above 5 years
Figure 10: Percentage distribution of sample based on duration of
the stay in old age home (n=312)
Figure 10 illustrates that 38.6% of senior citizens stayed in
old age home for 1-3 years, 31.8% stayed for 3-5years, 21.8% stayed
for below 1year and 7.7% stayed above 5years.
SECTION II
Effect of structured nursing intervention
This section deals with:
A. Effect of SNI on anxiety among senior citizens
B. Effect of SNI on depression among senior citizens.
C. Effect of SNI on QOL among senior citizens
109
A. Effect of structured nursing intervention on anxiety among
senior citizens
To identify the effect of SNI on anxiety among senior
citizens the following hypothesis formulated and tested at 5% level of
significance.
H01 – there is no significant difference in mean scores of
anxiety among senior citizens before and after SNI.
In order to find out the significance difference in mean
score of anxiety, the data subjected to paired ‗t‘test.
Table 9: The t value computed between mean pretest and posttest
anxiety scores among senior citizens
Variable
Anxiety
Test
Mean
Pre test
40.66
4.13
Post test
18.38
3.14
SD
n=312
Mean
Paired t
Difference
value
22.28
79.91
p value
0.0001***
*** Significant at p< 0.001 level
Table 9 presents that the mean, SD, mean difference, t
and p values of pre and post tests anxiety scores among senior
citizens. The findings shows that there is significant difference in their
mean pretest and post test scores of anxiety [t(311)=79.91, p<0.001].
Hence, the null hypothesis H01is rejected and it interpreted that the SNI
was effective in reducing anxiety among senior citizens.
110
B. Effect of structured nursing intervention on depression among
senior citizens
To identify the effect of SNI on depression among senior
citizens the following hypothesis formulated and tested at 5% level of
significance.
H02 – there is no significant difference in mean scores of
depression among senior citizens before and after SNI
In order to find out the significance difference in mean
score of depression, the data were subjected to paired‗t‘ test.
Table 10: The t value computed between mean pre test and post
test depression scores among senior citizens
Variable
Depression
Test
Mean
SD
Pre test
42.87
5.18
Post test 24.35
4.82
n=312
Mean
Paired t
Difference
value
18.53
45.11
p value
0.0001***
*** Significant at p< 0.001 level
The findings in table 10 shows that there is significant
difference in mean pretest and post test score of depression among
senior citizens [t(311)=45.11, p<0.001]. Hence, the null hypothesis
H02is rejected and it interpreted that the SNI was effective in reducing
depression among senior citizens.
111
C. Effect of structured nursing intervention on QOL among senior
citizens
To identify the effect of SNI on QOL among senior citizens
the following hypothesis formulated and tested at 5% level of
significance.
H03 – There is no significant difference in mean scores of
overall QOL among senior citizens before and after SNI
In order to find out the significance difference in mean
score of QOL, the data were subjected to paired ‗t‘ test.
Table 11: The t value computed between mean pre-test and posttest QOL scores of senior citizens
Variable
QOL
Test
Mean
SD
Pre test
54.53
4.252
Post test
92.29
3.808
n=312
Mean
Paired
Difference t value
37.76
115.76
p value
0.0001***
*** Significant at p< 0.001 level
Data in table 11 shows that the t value is significant,
(t(311)=115.76, p<0.001). The mean post test QOL scores among
senior citizens is significantly higher than their mean pre test score.
Based on this finding, null hypothesis H03 is rejected and it is
interpreted that the senior citizens who have undergone the SNI scored
significantly higher in their post test on QOL compared to their pre test.
Hence, SNI was effective in enhancing the QOL among senior citizens.
112
SECTION III:
Level of anxiety, depression and QOL among senior citizens
This section deals with
A. Level of anxiety among senior citizens before and after SNI
B. Level of depression among senior citizens before and after SNI
C. Level of overall QOL among senior citizens before and after SNI
D. Mean scores of domains of QOL among senior citizens before and
after SNI
E. Mean score of anxiety, depression and QOL among senior citizens
before SNI
Table 12: Level of anxiety among senior citizen before and after
SNI
n=312
Pre test
Post test
Level of anxiety
F
%
f
%
< 17 (mild)
53
16.99
171
54.81
102
32.69
84
26.89
157
50.32
57
18.27
18 – 25
(moderate)
Over 25 (severe)
Data from table 12 points out that 50% senior citizen has
severe level of anxiety before SNI. After SNI, percentage of senior
citizens having severe anxiety dropped from 50% to 18%.
113
Table 13: Level of depression among senior citizen before and
after SNI
n=312
Pre test
Level of depression
Post test
F
%
f
%
11 – 16 (mild)
18
5.77
130
41.67
17 – 20 (borderline)
41
13.14
78
25.00
21 – 30(moderate)
94
30.12
54
17.31
159
50.96
50
16.03
Over 30(severe)
According to Table 13 depicts that 51% of senior citizens
have severe level of depression before SNI and 16% senior citizen
have severe level of depression after SNI.
Table 14: Level of overall QOL among senior citizens before and
after SNI
n=312
Pre test
Level of QOL
< 33 (Low)
34 – 66
(average)
>67 (High)
Post test
f
%
f
%
165
52.89
39
12.50
106
33.97
79
25.32
41
13.14
194
62.18
The data presented in table 14 shows that 13.14 % senior
citizen has high level of QOL before SNI. After SNI, percentage of
114
senior citizens having high level of QOL increased from 13.14% to
62.18%
80
70
Mean score
60
66.6
63.05
59.58
69.65
50
40
Pre test
Post test
30
20
35.45
29.23
10
23.85
24.46
0
Physical
health
Psychological
health
Social
relationship
Envirnoment
Figure 11: Distribution of mean pretest and post test score level of
QOL in four domains.
Figure 11 shows mean pretest and posttest score level of
QOL in four domains. It is clear that there is remarkable increase of posttest score of mean QOL from that of pre test score. The mean score of
QOL in pre test was highest for the physical health domain (35.45) and
lowest for social relationship domain (23.85). The mean score of QOL in
post test was highest for environment domain (69.65) and lowest for
physical health domain (59.58).
115
SECTION IV:
Association between selected socio-demographic variables and
anxiety, depression and QOL among senior citizens
A. Association between selected socio-demographic variables
and anxiety among senior citizens
This section deals with significance of association between
anxiety and following socio demographic variables among senior
citizens: a) Sex b) Age c) Religion d) Marital status e) Educational
status f) Previous occupation g) Type of family h) financial support
i) Physical support
j) Psychological
support k) Social
support
l) Duration of the stay
To identify the association between anxiety and selected
demographic variables of senior citizens, the following hypothesis was
formulated and tested at 5% level of significance.
H04 – there is no significance of association between anxiety and
following socio demographic variables of senior citizens: : a) Sex
b) Age c) Religion d) Marital status e) Educational status f) Previous
occupation g) Type of family h) financial support i) Physical support
j) Psychological support k) Social support l) Duration of the stay
In order to find out the significance of association between
selected demographic variables and anxiety, the data were subjected
one way ANOVA test.
116
Table 15: The F value computed between pretest anxiety scores
and sex among senior citizens
n=312
Sex
Mean
SD
Male
40.98
4.36
Female
41.80
F value
p value
1.015
0.953NS
4.66
NS-Not Significant at p= 0.05 level
Data presented in table 15 shows that there is no significant
difference in mean pretest anxiety scores and sex among senior
citizen. Based on these findings, the null hypothesis H 04 (a) is
accepted. It interpreted that there is no significant association between
anxiety and sex among senior citizens.
Table 16: The F value computed between pretest anxiety scores
and age among senior citizens
n=312
Age in years
Mean
SD
60-65yrs
40.93
4.15
66-70yrs
40.48
4.02
71-75yrs
40.92
4.01
76-80yrs
38.29
5.94
NS-Not Significant at p= 0.05 level
F value
p value
1.083
0.356NS
117
Data presented in table 16 shows that there is no
significant difference in mean pretest anxiety scores and age among
senior citizens. Based on these findings, the null hypothesis H04(b) is
accepted. It interpreted that there is no significant association between
anxiety and age among senior citizens.
Table 17: The F value computed between pretest anxiety scores
and religion among senior citizens
Religion
Mean
S. D
Hindu
41.05
3.841
Muslim
40.24
4.256
Christian
40.52
4.386
n=312
F value
p value
0.760
0.469NS
NS-Not Significant at p= 0.05 level
Table 17 depicts that there is no significant difference in
mean pretest anxiety scores and religion among senior citizens. Based
on these findings, the null hypothesis H04(c) is accepted. It interpreted
that there is no significant association between anxiety and religion
among senior citizens.
118
Table 18: The F value computed between pretest anxiety scores
and marital status among senior citizens
Marital
status
Mean
S.D
Married
43.05
5.113
Unmarried
43.65
5.583
Divorced
41.97
5.732
Deserted
42.13
4.594
n=312
F value
p value
1.151
0.329NS
NS-Not Significant at p= 0.05 level
Data presented in table 18 shows that there is no
significant difference in mean pretest anxiety scores and marital status
among senior citizens. Based on these findings, the null hypothesis
H04 (d) is accepted. It interpreted that there is no significant association
between anxiety and marital status among senior citizens.
Table 19: The F value computed between pretest anxiety scores
and educational status among senior citizens n=312
Educational
status
Mean
S.D
Illiterate
39.78
3.986
Up to 4th
41.76
5.654
Up to 10th
40.98
4.478
Up to degree
40.30
4.872
NS-Not Significant at p= 0.05 level
F value
p value
0.206
0.89NS
119
It is infers from table 19 that there is no significant
difference in mean pretest anxiety scores and educational status
among senior citizens. Based on these findings, the null hypothesis
H04 (e) is accepted. It interpreted that there is no significant association
between anxiety and educational status among senior citizens.
Table 20: The F value computed between pretest anxiety scores
and previous occupation among senior citizens
Previous
occupation
Mean
S. D
Skilled labourer
41.98
5.204
Private employee
43.30
5.213
Self-employed
42.48
5.140
Unemployed
43.59
5.082
n=312
F value
p value
2.031
0.109NS
NS-Not Significant at p= 0.05 level
Data presented in table 20 shows that there is no
significant difference in mean pretest anxiety scores and previous
occupation among senior citizens. Based on these findings, the null
hypothesis H04 (f) is accepted. It interpreted that there is no significant
association between anxiety and previous occupation among senior
citizens.
120
Table 21: The F value computed between pretest anxiety scores
and type of family among senior citizens
Type of
family
Mean
Std. Deviation
Nuclear
41.04
3.931
Joint
40.06
4.487
Extended
40.22
4.108
n=312
F value
p value
1.265
0.284NS
NS-Not Significant at p= 0.05 level
According to table 21 shows that there is no significant
difference in mean pretest anxiety scores and type of family among
senior citizens. Based on these findings, the null hypothesis H04(g) is
accepted. It interpreted that there is no significant association between
anxiety and type of family among senior citizens
Table 22: The F value computed between pretest anxiety scores
and financial support to senior citizens
Financial
support
Mean
S. D
Wife/
husband
41.33
2.320
Son/daughter
40.23
4.300
Friend/others
41.13
4.418
Widow/old
age pensions
40.68
4.118
Pensions
42.64
2.649
NS-Not Significant at p= 0.05 level
n=312
F value
p value
1.317
0.265NS
121
Data presented in table 22 shows that there is no significant
difference in mean pretest anxiety scores and financial support to
senior citizens. Based on these findings, the null hypothesis H04 (h) is
accepted. It interpreted that there is no significant association between
anxiety and financial support to senior citizens
Table 23: The F value computed between pretest anxiety scores
and physical support to senior citizens
Physical
support
Mean
Std. Deviation
Brothers/sisters
41.48
3.930
Wife/husband
41.12
3.487
Son/daughters
39.94
4.336
Friends/others
40.94
4.191
n=312
F value
p value
1.318
0.269NS
NS-Not Significant at p= 0.05 level
From the table 23, it is clear that there is no significant
difference in mean pretest anxiety scores and physical support to
senior citizens. Based on these findings, the null hypothesis H04 (i) is
accepted. It interpreted that there is no significant association between
anxiety and physical support to senior citizens.
122
Table 24: The F value computed between pretest anxiety scores
and psychological support to senior citizens
Psychological
support
Mean
Std.
Deviation
Brothers/sisters
41.08
3.746
Wife/husband
41.84
2.292
Sons/daughters
40.10
4.375
Friends/others
40.83
4.355
n=312
F value
p value
1.238
0.297NS
NS-Not Significant at p= 0.05 level
Data presented in table 24 shows that there is no
significant difference in mean pretest anxiety scores and psychological
support to senior citizens. Based on these findings, the null hypothesis
H04 (j) is accepted. It interpreted that there is no significant association
between anxiety and psychological support to senior citizens.
Table 25: The F value computed between pretest anxiety scores and
social support to senior citizens
Social
support
Mean
Std. Deviation
Brothers/sisters
43.40
4.224
Wife/husband
42.49
4.573
Son/daughter
43.09
5.543
Friends/others
42.34
5.634
n=312
F value
p value
0.702
0.551NS
NS-Not Significant at p= 0.05 level
Data presented in table 25 shows that there is no
significant difference in mean pretest anxiety scores and social support
123
to senior citizens. Based on these findings, the null hypothesis H04(k) is
accepted. It is interprets that there is no significant association between
anxiety and social support to senior citizens
Table 26: The F value computed between pretest anxiety scores
and duration of stay in old age homes among senior citizens
n=312
Duration of
stay
Mean
Std. Deviation
Below 1 year
42.73
5.279
1-3 years
43.07
4.534
3-5 years
42.67
4.534
Above 5
years
42.67
5.865
F value
p value
0.135
0.939NS
NS-Not Significant at p= 0.05 level
Data presented in table 26 shows that there is no significant
difference in mean pretest anxiety scores and duration of stay in old
age homes among senior citizens. Based on these findings, the null
hypothesis H04(l) is accepted. It is interprets that there is no significant
association between anxiety and duration of stay in old age homes
among senior citizens.
124
B. Association between selected socio-demographic variables
and depression among senior citizens
This section deals with significance of association between
depression and following socio demographic variables among senior
citizens: a) Sex b) Age c) Religion d) Marital status e) Educational
status f) Previous occupation g) Type of family h) financial support
i) Physical support j) Psychological support k) Social
support
l) Duration of the stay
To identify the association between depression and
selected demographic variables among senior citizens, the following
hypothesis formulated and tested 5% level of significance.
H05 – there is no significance of association between
depression and following socio demographic variables among senior
citizens: a) Sex b) Age c) Religion d) Marital status e) Educational
status f) Previous occupation g) Type of family h) financial support
i) Physical support j) Psychological support k) Social
support
l) Duration of the stay
In order to find out the significance of association between
selected demographic variables and depression, the data were
subjected to one way ANOVA test
125
Table 27: The F value computed between pretest depression
scores and sex among senior citizens
Sex
Mean
Std.
Deviation
Male
42.91
4.82
Female
43.11
5.70
n=312
F value
p value
0.279
0.780NS
NS-Not Significant at p= 0.05 level
Data presented in table 27 shows that there is no significant
difference in mean pretest depression scores and sex among senior
citizens. Based on these findings, the null hypothesis H05(a) is
accepted. It is interprets that there is no significant association between
depression and sex among senior citizens.
Table 28: The F value computed between pretest depression
scores and age among senior citizens
Age in
years
Mean
Std. Deviation
60 – 65
42.66
5.287
66 – 70
43.35
5.109
71 – 75
41.48
5.413
76 – 80
42.00
3.618
n=312
F value
p value
1.160
0.325NS
NS-Not Significant at p= 0.05 level
Data presented in table 28 shows that there is no
significant difference in mean pretest depression scores and age
126
among senior citizens. Based on these findings, the null hypothesis
H05 (b) is accepted. It is interprets that there is no significant
association between depression and age among senior citizens.
Table 29: The F value computed between pretest depression
scores and religion among senior citizens
Religion
Mean
Std. Deviation
Hindu
43.15
4.996
Muslim
43.20
5.395
Christian
42.53
5.387
n=312
F value
p value
0.314
0.731NS
NS-Not Significant at p= 0.05 level
Data presented in table 29 shows that there is no significant
difference in mean pretest depression scores and religion among
senior citizens. Based on these findings, the null hypothesis H 05(c) is
accepted. It is interprets that there is no significant association between
depression and religion among senior citizens.
Table 30: The F value computed between pretest depression
scores and marital status among senior citizens
Marital
status
Mean
Std. Deviation
Married
43.05
5.113
Unmarried
43.65
5.579
Divorced
41.97
5.734
Deserted
42.13
4.587
NS-Not Significant at p= 0.05 level
n=312
F value
p value
1.151
0.329NS
127
Data presented in table 30 shows that there is no significant
difference in mean pretest depression scores and marital status among
senior citizens. Based on these findings, the null hypothesis H05(d) is
accepted. It is interprets that there is no significant association between
depression and marital status among senior citizens.
Table 31: The F value computed between pretest depression
scores and educational status among senior citizens
Educational
status
Mean
Std. Deviation
Illiterate
41.80
4.138
Up to 4th
40.56
3.877
Up to 10th
41.89
4.401
Up to degree
41.40
5.688
n=312
F value
p value
0.286
0.78NS
NS-Not Significant at p= 0.05 level
Data presented in table 31 shows that there is no
significant difference in mean pretest
depression scores and
educational status among senior citizens. Based on these findings, the
null hypothesis H05(e) is accepted. It is interprets that there is no
significant association between depression and educational status
among senior citizens.
128
Table 32: The F value computed between pretest depression
scores and previous occupation among senior citizens
Previous
occupation
Mean
S. D
Skilled labourer
41.98
5.209
Private employee
43.30
5.214
Self-employed
42.48
5.729
Unemployed
43.59
5.085
n=312
F value
p value
2.034
0.109NS
NS-Not Significant at p= 0.05 level
Data presented in table 32 shows that there is no
significant difference in mean pretest depression scores and previous
occupation among senior citizens. Based on these findings, the null
hypothesis H05 (f) is accepted. It is interprets that there is no significant
association between depression and previous occupation among
senior citizens.
Table 33: The F value computed between pretest depression
scores and type of family among senior citizen n=312
Type of
family
Mean
Std. Deviation
Nuclear
42.96
5.509
Joint
43.16
4.671
Extended
42.85
4.622
F value
p value
0.037
0.963NS
NS-Not Significant at p= 0.05 level
Data presented in table 33 shows that there is
no significant difference in mean pretest depression scores and type of
129
family among senior citizens. Based on these findings, the null
hypothesis H05 (g) is accepted. It is interprets that there is no significant
association between depression and type of family among senior
citizens.
Table 34:The F value computed between pretest depression
scores and financial support to senior citizens
Financial support
Mean
S. D
Wife/ husband
42.67
4.776
Son/daughter
43.24
5.221
Friend/others
44.19
4.254
Widow/old age pensions 42.21
5.763
Pensions
41.50
n=312
F value
p value
1.044
0.386NS
5.170
NS-Not Significant at p= 0.05 level
Data presented in table 34 shows that there is no
significant difference in mean pretest depression scores and financial
support to senior citizens. Based on these findings, the null hypothesis
H05 (h) is accepted. It is interprets that there is no significant
association between depression and financial support to senior
citizens.
130
Table 35: The F value computed between pretest depression scores
and physical support to senior citizens
Physical
Mean
Std. Deviation
Brothers/sisters
43.26
5.618
Wife/husband
42.85
4.210
Son/daughters
43.00
5.524
Friends/others
42.99
5.310
support
n=312
F value
p value
0.030
0.993NS
NS-Not Significant at p= 0.05 level
Data presented in table 35 shows that there is no significant
difference in mean pretest depression scores and physical support to
senior citizens. Based on these findings, the null hypothesis H05(i) is
accepted. It is interprets that there is no significant association between
depression and physical support to senior citizens.
Table 36: The F value computed between pretest depression
scores and psychological support to senior citizens
n=312
Psychological
support
Mean
Std. Deviation
F value
p value
Brothers/sisters
43.73
4.241
Wife/husband
41.95
4.441
Sons/daughters
43.02
5.538
0.636
0.593NS
Friends/others
42.72
5.605
NS-Not Significant at p= 0.05 level
131
Data presented in table 36 shows that there is no
significant difference in mean pretest
depression scores and
psychological support to senior citizens. Based on these findings, the
null hypothesis H05 (j) is accepted. It is interprets that there is no
significant association between depression and psychological support
to senior citizens.
Table 37: The F value computed between pretest depression
scores and social support to senior citizens
Social
Mean
Std. Deviation
Brothers/sisters
43.40
4.215
Wife/husband
42.49
4.575
Son/daughter
43.09
5.544
Friends/others
42.34
5.628
support
n=312
F value
p value
0.702
0.551NS
NS-Not Significant at p= 0.05 level
Data presented in table 37 shows that there is no
significant difference in mean pretest depression scores and social
support to senior citizens. Based on these findings, the null hypothesis
H05(k) is accepted. It is interprets that there is no significant association
between depression and social support to senior citizens.
132
Table 38:The F value computed between pretest depression
scores and duration of stay in old age home among senior
citizens
n=312
Duration of
stay
Mean
Std.
Deviation
Below 1 year
42.73
5.287
1-3 years
43.07
4.529
3-5 years
42.67
5.864
Above 5 years
43.04
5.345
F value
p value
0.135
0.939NS
NS-Not Significant at p= 0.05 level
Data presented in table 38 shows that there is no
significant difference in mean pretest depression scores and duration
of stay in old age home among senior citizens. Based on these
findings, the null hypothesis H05(l) is accepted. It is interprets that there
is no significant association between depression and duration of stay in
old age home among senior citizens.
C. Association between selected socio-demographic variables
and QOL among senior citizens
This section deals with significance of association between
QOL and following socio demographic variables among senior
citizens: a) Sex b) Age c) Religion d) Marital status e) Educational
status f) Previous occupation g) Type of family h) financial support
i) Physical support j) Psychological
l) Duration of the stay
support
k) Social
support
133
To identify the association between selected sociodemographic variables and QOL among senior citizens, the following
hypothesis formulated and tested 5% level of significance.
H06 – there is no significance of association between QOL
and following socio demographic variables among senior citizens:
a) Sex b) Age c) Religion d) Marital status e) Educational status
f) Previous occupation g) Type of family h) financial support i) Physical
support j) Psychological support k) Social support l) Duration of the
stay.
In order to find out the significance of association between
selected socio-demographic variables and QOL, the data were
subjected to one-way ANOVA test.
Table 39: The F value computed between pretest QOL scores and
sex among senior citizens
Domain
n=312
Sex
Mean
S. D
Male
35.14
8.07
Female
35.90
7.82
Male
28.90
6.01
Female
29.70
6.30
Male
23.43
6.87
Female
24.46
6.58
Male
24.72
8.35
Female
24.08
7.86
Male
45.51
3.67
Female 45.45
NS-Not Significant at p= 0.05 level
3.35
PHYSICAL HEALTH
PSYCHOLOGICAL
HEALTH
SOCIAL
RELATIONSHIP
ENVIRONMENT
OVERALL
F value
p value
-0.676
0.500NS
-0.941
0.348NS
-1.090
0.277NS
0.562
0.575NS
0.114
0.909NS
134
Data presented in table 39 shows that there is no
significant difference in mean pretest QOL scores and sex among
senior citizens. Based on this findings, the null hypothesis H06(a) is
accepted. It is interprets that there is no significant association between
QOL and sex among senior citizens.
Table 40: The F value computed between pretest QOL scores and
age among senior citizens
n=312
Domain
Age in
years
PHYSICAL HEALTH
60 – 65
66 - 70
71 - 75
76 - 80
45.48
45.87
34.20
30.00
PSYCHOLOGICAL
HEALTH
60 - 65
66 - 70
71 - 75
76 - 80
Mean
S.D
F value
p value
9.89
6.21
6.98
4.39
0.968
0.39NS
39.22
39.31
48.00
31.40
7.15
5.88
6.41
7.77
0.342
0.74NS
SOCIAL
RELATIONSHIP
60 - 65
66 - 70
71 - 75
76 - 80
43.22
24.31
34.93
23.80
6.60
7.93
7.35
5.02
0.495
0.65NS
ENVIRONMENT
60 - 65
66 - 70
71 - 75
76 - 80
53.85
34.10
48.33
31.20
7.31
7.22
10.15
11.63
2.57
0.05**
60 - 65
53.99
4.07
66 - 70
54.82
4.51
Overall
1.583
0.193NS
71 - 75
55.44
3.89
76 - 80
55.86
2.04
NS-Not Significant at p= 0.05 level ** Significant at p=0.05 level
135
Data presented in table 40 shows that there is no
significant difference in mean pretest QOL scores and age among
senior citizens except for environment domain. Based on this findings,
the null hypothesis H06(b) is accepted. It is interpreted that there is no
significant association between QOL and age among senior citizens
except for environment domain as p=0.05.
Table 41: The F value computed between pretest QOL scores and
religion among senior citizens
n=312
Domain
Religion
Mean
S.D
F value p value
PHYSICAL HEALTH
Hindu
Muslim
Christian
35.24
35.80
35.45
8.13
7.82
7.92
0.086
0.917NS
PSYCHOLOGICAL
HEALTH
Hindu
Muslim
Christian
29.39
29.06
29.10
6.08
6.31
6.15
0.068
0.935NS
SOCIAL
RELATIONSHIP
Hindu
Muslim
Christian
22.79
23.83
25.71
7.60
6.44
4.98
3.501
0.032**
ENVIRONMENT
Hindu
Muslim
Christian
25.44
23.94
23.24
8.99
7.92
6.55
1.490
0.228NS
Hindu
54.43
4.22
Overall
Muslim
54.35
3.96 0.498
Christian
55.05
4.54
NS-Not Significant at p= 0.05 level ** Significant at p=0.05 level
0.608NS
Data presented in table 41 shows that there is no
significant difference in mean pretest QOL scores and religion among
senior citizens except for social relationship. Based on these findings,
136
the null hypothesis H06(c) is accepted. It is interpreted that there is no
significant association between QOL and religion among senior citizens
except for social relationship domain as p<0.05.
Table 42: The F value computed between pretest QOL scores and
marital status among senior citizens
n=312
Domain
Marital
status
PHYSICAL HEALTH
Married
Unmarried
Divorced
Deserted
36.10
34.70
35.26
34.22
8.39
6.43
7.69
8.08
0.640
0.590NS
PSYCHOLOGICAL
HEALTH
Married
Unmarried
Divorced
Deserted
29.04
28.49
29.85
30.06
5.90
7.17
5.86
6.17
0.509
0.677NS
SOCIAL
RELATIONSHIP
Married
Unmarried
Divorced
Deserted
23.12
26.27
24.07
23.83
7.81
4.44
6.27
4.49
1.898
0.131NS
ENVIRONMENT
Married
Unmarried
Divorced
Deserted
24.70
24.49
24.85
23.36
8.30
7.66
8.78
7.77
0.270
0.847NS
Married
Unmarried
Divorced
Deserted
54.60
54.98
54.74
53.73
4.65
4.19
3.85
3.00
0.846
0.470NS
Overall
Mean
S.D
F value p value
NS-Not Significant at p= 0.05 level
Data presented in table 42 shows that there is no
significant difference in mean pretest QOL scores and marital status
among senior citizens. Based on these findings, the null hypothesis
137
H06(d) is accepted. It is interpreted that there is no significant
association between QOL and marital status among senior citizens.
Table 43: The F value computed between pretest QOL scores and
educational status among senior citizens
Domain
PHYSICAL
HEALTH
Educational status
Mean
S.D
Illiterate
Up to 4th class
34.65
36.20
7.87
7.98
Up to 10th class
34.36
8.17
Up to degree
36.00
6.27
29.27
28.57
6.67
6.19
30.62
5.19
Up to degree
32.75
3.50
Illiterate
Up to 4th class
23.56
23.69
6.51
7.29
Up to 10th class
24.55
5.61
Up to degree
25.00
6.93
Illiterate
Up to 4th class
26.14
23.94
9.58
7.79
Up to 10th class
23.74
7.29
Up to degree
25.00
4.90
Illiterate
55.47
4.57
54.86
4.34
54.24
3.98
53.76
3.79
Illiterate
th
PSYCHOLOGICAL Up to 4 class
HEALTH
Up to 10th class
SOCIAL
RELATIONSHIP
ENVIRONMENT
th
OVERALL
n=312
Up to 4 class
th
Up to 10 class
Up to degree
NS-Not Significant at p= 0.05 level
F value p value
0.780
0.506NS
1.614
0.187NS
0.238
0.870NS
1.006
0.391NS
1.963
0.159NS
Data presented in table 43 shows that there is no significant
difference in mean pretest QOL scores and educational status among
senior citizens. Based on these findings, the null hypothesis H06 (e) is
138
accepted. It is interprets that there is no significant association between
QOL and educational status among senior citizens
Table 44: The F value computed between pretest QOL scores and
previous occupation among senior citizens
Domain
Previous
occupation
Mean
Skilled labourer
35.35
Private employee 36.32
Self employed
35.37
Unemployed
35.12
PHYSICAL
HEALTH
Skilled labourer
29.29
PSYCHOLOGICAL Private employee 30.68
HEALTH
Self employed
29.21
Unemployed
28.39
SOCIAL
RELATIONSHIP
ENVIRONMENT
Skilled labourer
24.12
Private employee 25.12
Self employed
24.63
Unemployed
22.73
Skilled labourer
25.53
Private employee 23.42
Self employed
22.79
Unemployed
24.38
S.D
8.16
8.04
5.81
8.28
n=312
F value
p value
0.210
0.890NS
6.53
6.14
1.258
5.48
5.83
6.92
5.69
6.63
7.09
8.28
7.07
5.73
8.98
0.290NS
1.323
0.268NS
0.929
0.428NS
Skilled labourer
55.44
4.64
Private employee 54.52
3.96
OVERALL
3.191
Self employed
54.24
4.08
Unemployed
53.72
3.92
NS-Not Significant at p= 0.05 level ** Significant at p=0.05 level
0.024**
Data presented in table 44 shows that there is significant
difference in mean pretest QOL scores and previous occupation
among senior citizens. Based on these findings, the null hypothesis
H06 (f) is rejected. It is interprets that there is significant association
between QOL and previous occupation among senior citizens.
139
Table 45: The F value computed between pretest QOL scores and
type of family among senior citizens
Type of
family
Domain
Mean
n=312
S.D
F value p value
PHYSICAL HEALTH
Nuclear
Joint
Extended
34.64
37.02
36.52
7.49
8.58
8.72
1.943
0.146NS
PSYCHOLOGICAL
HEALTH
Nuclear
Joint
Extended
29.09
29.51
29.37
6.47
5.48
5.70
0.095
0.910NS
SOCIAL
RELATIONSHIP
Nuclear
Joint
Extended
24.22
23.51
22.67
6.54
6.84
7.72
0.682
0.507NS
ENVIRONMENT
Nuclear
Joint
Extended
24.79
23.49
24.63
8.40
7.06
8.85
0.476
0.622NS
OVERALL
Nuclear
Joint
Extended
54.59
54.37
54.93
4.15
4.18
4.87
0.150
0.861NS
NS-Not Significant at p= 0.05 level
Data presented in table 45 shows that there is no
significant difference in mean pretest QOL scores and type of family
among senior citizens. Based on these findings, the null hypothesis
H06(g) is accepted. It is interprets that there is no significant association
between QOL and type of family among senior citizens.
140
Table 46: The F value computed between pretest QOL scores and
financial support to senior citizens
Domain
Mean
S.D
Wife/husband
Son/ daughter
Friends/others
Widow/old age
pensions
Pension
34.00
36.10
33.94
5.89
8.02
8.43
35.64
7.61
34.93
9.78
Wife/husband
Son/ daughter
PSYCHOLOGICAL Friends/others
HEALTH
Widow/old age
pensions
Pension
28.73
29.08
29.07
6.12
6.27
6.57
29.00
6.30
32.00
2.54
Wife/husband
Son/ daughter
Friends/others
Widow/old age
pensions
Pension
26.60
23.82
23.19
3.56
7.23
6.78
23.92
6.83
22.43
5.11
PHYSICAL
HEALTH
SOCIAL
RELATIONSHIP
Source of income
n=312
Wife/husband
Son/ daughter
Friends/others
ENVIRONMENT
Widow/old age
pensions
Pension
Wife/husband
Son/ daughter
Friends/others
OVERALL
Widow/old age
pensions
Pension
NS-Not Significant at p= 0.05 level
25.00 7.17
23.71 7.07
26.68 10.45
25.72
F
value
p
value
0.595 0.667NS
0.775 0.543NS
0.848 0.496NS
2.056 0.088NS
9.18
20.29 5.36
56.33 5.024
54.47 4.28
54.35 4.28
54.94
4.14
52.86
2.69
1.354 0.251NS
141
Data presented in table46 shows that there is no
significant difference in mean pretest QOL scores and financial support
to institutionalized senior citizens. Based on these findings, the null
hypothesis H06(h) is accepted. It is interprets that there is no significant
association between QOL and financial support to institutionalized
senior
citizens,
but
there
is
significant
association
between
environment domain and financial support theoretically.
Table 47: The F value computed between pretest QOL scores and
physical support to senior citizens
Domain
Physical support
n=312
Mean
S.D
F value p value
PHYSICAL HEALTH
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
35.78
35.54
35.69
35.09
9.55
7.32
7.97
7.91
0.088
0.967NS
PSYCHOLOGICAL
HEALTH
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
30.65
28.78
29.27
29.00
4.68
5.86
6.43
6.40
0.520
0.669NS
SOCIAL
RELATIONSHIP
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
23.61
23.32
24.24
23.86
7.22
6.77
6.99
6.51
0.171
0.916NS
Brothers/ sisters
Wife/ husband
ENVIRONMENT
Son/ daughter
Friends/ others
Brothers/ sisters
Wife/ husband
OVERALL
Son/ daughter
Friends/ others
NS-Not Significant at p= 0.05
22.91
24.02
23.41
26.12
54.04
54.56
54.55
54.78
5.89
8.20
6.55
9.71
3.67
4.43
4.45
4.15
1.795
0.149NS
0.179
0.910NS
142
Data presented in table 47 shows that there is no
significant difference in mean pretest QOL scores and physical support
to senior citizens. Based on these findings, the null hypothesis H06(i) is
accepted. It is interprets that there is no significant association between
QOL and physical support to senior citizens.
Table 48: The F value computed between pretest QOL scores and
psychological support to senior citizens
Psychological
support
Domain
Mean
n=312
S.D
F value
p value
Brothers/ sisters
Wife/ husband
PHYSICAL HEALTH
Son/ daughter
Friends/ others
35.02
34.74
36.25
34.98
9.34
6.21
7.88
7.48
0.438
0.726NS
PSYCHOLOGICAL
HEALTH
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
29.38
28.58
29.12
29.44
5.44
5.94
6.29
6.58
0.112
0.953NS
SOCIAL
RELATIONSHIP
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
21.10
25.00
24.56
24.69
7.78
4.47
6.73
6.09
3.573
0.015**
Brothers/ sisters
23.31
8.50
Wife/ husband
23.74
6.81
ENVIRONMENT
2.190
Son/ daughter
23.61
6.43
Friends/ others
26.61
9.77
Brothers/ sisters
53.48
4.35
Wife/ husband
54.95
4.44
OVERALL
1.680
Son/ daughter
54.62
4.26
Friends/ others
55.25
3.98
NS-Not Significant at p= 0.05 level ** Significant at p=0.05 level
0.900NS
0.172NS
Data presented in table 48 shows that there is no significant
difference in mean pretest QOL scores and psychological support to
143
senior citizens except for domain social relationship. Based on these
findings, the null hypothesis H06(j) is accepted. It is interpreted that there
is no significant association between QOL and psychological support to
senior citizens except for domain social relationship as p<0.05.
Table 49: The F value computed between pretest QOL scores and
social support to senior citizens
Domain
Social support
n=312
Mean
S.D
F value p value
PHYSICAL
HEALTH
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
34.96
34.68
36.41
34.98
9.43
6.20
7.93
7.48
0.574
PSYCHOLOGICAL
HEALTH
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
29.34
27.52
29.54
29.44
5.49
6.44
6.04
6.58
0.740
SOCIAL
RELATIONSHIP
Brothers/ sisters
Wife/ husband
Son/ daughter
Friends/ others
20.89
23.48
25.10
24.69
7.72
6.76
6.20
6.09
4.431
Brothers/ sisters
23.15
8.51
Wife/ husband
25.28
8.15
ENVIRONMENT
2.663
Son/ daughter
23.18
5.80
Friends/ others
26.61
9.77
Brothers/ sisters
53.15
4.12
Wife/ husband
54.49
4.70
OVERALL
3.846
Son/ daughter
54.77
4.20
Friends/ others
55.33
4.04
NS-Not Significant at p= 0.05 level ** Significant at p=0.05 level
0.632NS
0.529NS
0.005**
0.049**
0.010**
Data presented in table 49 shows that there is significant
difference in mean pretest QOL scores and social support to senior
citizens except for domains physical and psychological health. Based on
144
these findings, the null hypothesis H06(k) is rejected. It is interprets that
there is significant association between QOL and social support to senior
citizens except for domains physical and psychological health.
Table 50:The F value computed between pretest QOL scores and
duration of stay in old homes among senior citizens
Duration of
stay
Below 1yr
1-3yrs
PHYSICAL HEALTH
3-5yrs
Above 5 yrs
Domain
PSYCHOLOGICAL
HEALTH
Below 1yr
1-3yrs
3-5yrs
Above 5 yrs
Mean
S.D
n=312
F value p value
36.39
35.35
36.04
30.47
8.06
8.45
7.40
5.85
2.349
0.074NS
29.30
29.35
28.65
30.93
5.55
5.83
6.70
6.95
0.600
0.615NS
Below 1yr
22.39
7.92
1-3yrs
23.25
6.92
SOCIAL
2.322
RELATIONSHIP
3-5yrs
25.50
5.75
Above 5 yrs
24.20
5.00
Below 1yr
23.61
7.44
1-3yrs
23.22
7.21
ENVIRONMENT
2.703
3-5yrs
25.60
8.92
Above 5 yrs
28.73
9.87
Below 1yr
54.17
4.21
1-3yrs
54.12
4.53
OVERALL
1.395
3-5yrs
55.19
4.20
Above 5 yrs
54.88
2.63
NS-Not Significant at p= 0.05 level ** Significant at p=0.05 level
0.076NS
0.047**
0.244NS
Data presented in table 50 shows that there is no
significant difference in mean pretest QOL scores and duration of stay
in old age homes among senior citizens except for domains
environment. Based on these findings, the null hypothesis H 06(l) is
accepted. It is interprets that there is no significant association between
145
QOL and duration of stay in old age homes among senior citizens
except for domain environment, but there is significant association
between physical health and social relationship domains and duration
of stay in old age homes of theoretically.
SECTION V:
Relationship among anxiety, depression and QOL among senior
citizens
This section deals with significance of relationship between
following variables among senior citizens.
a) Anxiety and depression among senior citizens
b) Anxiety and QOL among senior citizens
c) Depression and QOL among senior citizens
To identify the relationship between anxiety, depression
and QOL among senior citizens, the following hypothesis formulated
and tested 5% level of significance.
H07 – there is no significance of relationship between
following variables among senior citizens.
a) Anxiety and depression among senior citizens
b) Anxiety and QOL among senior citizens
c) Depression and QOL among senior citizens
In order to find out the significance of relationship between
anxiety, depression and QOL, the data subjected to Karl Pearson
coefficient.
146
Table 51: Correlation coefficients computed on combined scores of
anxiety and depression among senior citizens.
Variables
Depression and Anxiety
n=312
Co efficient of correlation
Pre test
Post test
-0.026
Combined (pre test and post test)
-0.073
+0.829
< 0.001***
p value
*** Significant at p=0.01 level
Data presented in table 51 shows that the combined
(pretest and post test) scores on depression and anxiety (r = +0.831,
p<0.001) among senior citizens have significant positive correlation.
Hence, null hypothesis H07(a) is rejected. It is interpreted that
depression and anxiety are directly proportional each other.
Table 52: Correlation coefficients computed on combined scores of
anxiety and QOL among senior citizens.
Variables
Anxiety and QOL
Combined (pre test and post test)
p value
*** Significant at p=0.01 level
n=312
Co efficient of correlation
Pre test
Post test
+0.002
+0.084
-0.927
< 0.001***
147
According to table 52, the combined (pretest and post test)
scores on anxiety and QOL(r = -0.927, p<0.001) among senior citizens
have significant negative correlation. Hence, null hypothesis H07(b) is
rejected. It is interpreted that anxiety and QOL are inversely proportional
each other.
Table 53: Correlation coefficients computed on combined scores of
depression and QOL among senior citizens.
Variables
Depression and QOL
Combined (pre test and post test)
n=312
Co efficient of correlation
Pre test
Post test
-0.115
+0.003
-0.868
< 0.001***
p value
*** Significant at p=0.01 level
Table 53 indicates that the combined (pretest and post
test) scores on depression and QOL(r = -0.868, p<0.001) among senior
citizens have significant negative correlation. Hence, null hypothesis
H07(c) is rejected. It is interpreted that depression and QOL are
inversely proportional each other.
148
CHAPTER V
DISCUSSION
This chapter deals with discussion, which gives a brief
account of the result of investigation and shows how better way the
investigation results could be utilize by society. Discussions are
discuses mainly on basis on the objectives formulated for the study.
1. Evaluate the effect of SNI on anxiety, depression and QOL among
senior citizens
The present study elicits that SNI reduce the anxiety level, as
there are significant differences in the mean pre test scores of
anxiety with mean posttest scores among senior citizens, which
supported by the study conducted by Giju Thomas (2006) and
Conard and Roth (2007) to determine effectiveness of progressive
muscle relaxation technique on anxiety among elderly. Sung et al
(2010) found that listening music intervention among elderly living
in old age homes has positive impact for reducing anxiety. Antall
and Kresevic (2004) revealed that the use of guided imaginary
intervention was effective for reducing anxiety among elderly.
The present study establishes that SNI reduces the
depression level as there are significant differences in the mean
pre test scores of depression with mean post test scores among
senior citizens. This finding is in concordance with the findings of
149
Vakylabad et al (2013). They identified that guided imaginary
technique is effective on the reduction of depression among
elderly. The finding of the present study greatly supported by
Antunes et al (2005) in which they found that aerobic exercises
intervention helps to reduce depression among elderly.
In the present study, it found that SNI was very effective on
QOL among senior citizens. Senior citizens who were in low and
moderate QOL mean scores before structured nursing intervention
found high QOL mean scores after structured nursing intervention.
This finding of present study supported by the study conducted by
Sampaio and Ito Emi (2012) on community dwelling older adults in
Japan. The findings found that QOL of senior citizens was highly
influenced by physical activity, art activity, social activity, reading
and writing activity.
2. Identify the association between anxiety, depression and anxiety
and selected socio-demographic variables among senior citizens
The findings of the present study revealed that there is no
significant association between anxiety and selected sociodemographic variables among senior citizens at 5% level of
significance. The findings are supported by Giju Thomas (2006)
found that there are significant association between anxiety and
selected socio-demographic variables except for religion.
150
The present study denoted that there is no significant
association between depression and selected socio-demographic
variables among senior citizens at 5% level of significance. It is
comparable to the findings of Akhtar-Danesh N. and Landeen
Janet (2007). The contemporised findings was found by study
conducted by Majdi et al (2010)
It is evident from the present study that there is no significant
association
between
QOL
and
selected
socio-demographic
variables among senior citizens at 5% level of significance. These
findings are supported by the studies conducted by Gureje et al
(2008) ;Reklaitiene, Baceviciene, and Andrijauskas (2009). At the
same time, a study conducted by Vagetti et al (2013) and Erkal,
Sahin and Surgit (2011) showed that socio-demographic factors
and health conditions of elderly women influences the QOL. The
findings of these studies are not congruent to the results of present
study.
Kerala Model Economy is a par with modern developed
economies. Per capita income is low in Kerala, but standard of life,
health standards are a par with developed economies. This is quiet
against the trends in Indian economy (Parayil, 2000; Franke,
Richarda and Barbara 1999).
151
3. Find out the relationship between quality life, depression and
anxiety among senior citizens
From the present study finding, it is clear that there is positive
relationship between depression and anxiety among senior citizens
by using Karl Pearson‘s Coefficient at 1% level of significance.
These findings are consistent with the findings of study conducted
by Van der Weele et al (2008) and supported by study conducted by
Porzych et al (2005).
The present revealed that there is negative relationship
between depression and QOL among senior citizens by using Karl
Pearson‘s coefficient at 1% level of significance. This finding is in
concordance with the findings of Chang Yu-San et al (2006); Ishak
et al (2011); Akyol et al (2010); Naumann and Byrne (2004). The
findings of this study denoted that QOL is strongly correlates with
severity of depression. The study conducted by Gonzalez and
Gomez (2012) strongly supports this finding by revealing QOL and
depression were negatively correlates to each other among
Mexican older adults.
It is evident from the present study that there is negative
relationship between anxiety and QOL among senior citizens by
using Karl Pearson‘s coefficient at 1% level of significance. The
findings are in tune with the findings of Gregurek et al (2009) and
Henning et al (2007)
152
4. Assess the level of QOL, depression and anxiety among senior
citizens
The present study findings reveals that majority of senior citizens
have severe level of anxiety and depression. It is comparable with
the findings of the studies conducted by Minghelli et al (2013), John
Abin (2012), Ghafari et al (2012) and Prina et al (2011).
From the present findings of the study shows that majority
of senior citizens have moderate level of QOL. The findings are
supported by studies conducted by Naing, Nanthamongkolchai,
and Munsawaengsub (2010); and Sola et al (2008).
153
CHAPTER VI
SUMMARY AND CONCLUSION
A quantitative study undertaken among senior citizens
above 60years of age in North Kerala with an objective to assess the
effect
of
SNI
(general
warming
exercise,
breathing
exercise,
progressive muscle relaxation, guided imaginary under the background
of music) on anxiety, depression and QOL. The study also emphasizes
to assess the relationship with anxiety, depression and QOL among
senior citizens.
In the present study, the data collected from 312 senior
citizens residing on government and private old age homes of Calicut
and Palakkad by using semi structured interview schedule. Sample
was selected based on multi phase random sampling.
The major findings of the study were
1. Sample characteristics of senior citizens
a) Most of the subjects (45.83% and 44.23 %come under age group of
66-70 years and 60-65 years respectively. Only 2.88% of the
sample fall in age group 76-80 years
b) Majority of sample (59.43 %) were males and 40.57% were females.
c) Nearly half of sample is Hindus (48.20%)
154
d) Most of sample (54.81%) was married, 18.27% were deserted,
14.74% were unmarried and 12.18 % were divorced.
e) Maximal sample of senior citizen come under the educational status
up to 4th standard (52.89%) and (0.96%) minimal sample have
graduate level of educational level.
f) 35.90% of sample was skilled labourers, (36.40%) was unemployed,
(18.60%) was private employers and remaining (9.10%) was selfemployed.
g) Majority of sample senior citizens (63.78%) were lived in nuclear
families, (24.04%) were in joint family and (12.18%) were in
extended family.
h) Most of the senior citizens (48.60%) source of income is from their
own son or daughter.
i) 45.83 % of the senior citizens got physical support from friends/
others, (26.92%) got support from son/ daughter, (16.35%) from
wife or husband and remaining (10.90%) got from brothers or
sisters.
j) Psychological support for the sample got mainly from son/ daughter
(37.30%), then from friends/ others (30.90%), (22.70%) from
bothers/sisters and remaining from wife/husband (9.10%).
k) 46.15% of sample got social support from friends/others, (23.08%)
got from wife/husband, (17.95%) got from son/daughter and the
remaining got from brothers/sisters (12.8%).
155
l) 38.6 % of senior citizens stayed 1-3 years, (31.8%) stayed for 35years, (21.8%) stayed for below 1year and (7.7%) stayed above
5years.
2. Effect of structured nursing intervention
a) Among the senior citizen, 50% had severe level of anxiety before
SNI. After SNI, percentage of senior citizens having severe anxiety
was dropped from 50% to 18%. There is significant decrease in
anxiety level among senior citizens after SNI.
b) 51% senior citizens have severe level of depression before SNI and
16% senior citizen have severe level of depression after SNI. The
level of depression was statistically decreased among senior
citizens after SNI.
c) 13.14 % senior citizen has high level of QOL before SNI. After SNI,
percentage of senior citizens having high level of QOL was
increased from 13.14% to 62.18%. Therefore, structured nursing
intervention is effective in improving QOL among senior citizens.
3. Association between selected demographic variables and
anxiety, depression and QOL among senior citizens
A. Anxiety
There is no significant association between anxiety and
age, sex, religion, marital status, educational status, type of family,
source of income, physical support, psychological support, social
156
support and duration of stay in old age home at 5% level of
significance.
B. Depression
There is no significant association between depression
and age, sex, religion, marital status, educational status,
previous occupation, type of family, source of income, physical
support, psychological support, social support and duration of
stay in old age home at 5% level of significance.
C. Quality of Life
a) There is no significant association between domains of QOL
and
sex,
marital
status,
educational
status,
previous
occupation, type of family, source of income, and physical
support at 5% level of significance.
b) There is no significant association between domain of QOL and
age, social support and duration of stay
at 5% level of
significance except for domain environment
c) There is no significant association between QOL and religion,
social support and psychological at 5% level of significance
except for domain social relationship.
d) There is significant association between overall score of QOL
and previous occupation and social support at 5% level of
significance.
157
4. Relationship among the anxiety, depression and QOL in senior
citizens
a) There is positive relationship between depression and anxiety
among senior citizens at 1% level of significance.
b) There is negative relationship between QOL and both depression
and anxiety among senior citizens at 1% level of significance.
Recommendations
1) SNI is a cost effective intervention for senior citizens, which can be
practiced with minimal assistance.
2) Social welfare department of the state can direct all projects
officers of old age homes to include this intervention in the day to
day activities of inmates.
3) In the community, Public Health Nurses can conduct this
intervention in the sub-center level.
4) Non–Government
Organizations
(NGO)
can
propagate
this
intervention to improve the QOL among senior citizens.
5) Nursing administrators should setup a wing of nurses with positive
attitude exclusively for the care of the old age people and they
must be given basic training to implement this intervention.
Suggestions
1) Similar study can be conducted on a larger sample in different
setting
2) The study can be conducted with longer period of time and duration
158
3) The study can be conducted in psychiatric settings
4) The study can be conducted with control group for the prediction of
effectiveness of intervention
5) Comparative study can be conducted in institutionalized and non
institutionalized senior citizens
6) Comparative study can be conducted in rural and urban
institutionalized senior citizens
7) Comparative study can be conducted in rural and urban non
institutionalized senior citizens.
Limitations
1) Sample collected only from the inmates admitted in old age homes.
2) Majority of senior citizens staying in houses where not obtained the
chance of become a study subjects.
3) There is no control group for the study as the investigator observed
that keeping a group away from intervention section is violation of
ethical principle.
4) Even though, subjects are selected based on inclusion criteria, but
some subjects expressed tiredness initially.
Strength of the study
Structured nursing intervention is a package developed by
the researcher based upon the traditional exercises and Carnatic
music, which is cost effective. Senior citizens of all age groups can
easily practice the interventions, which are included in SNI. Sample
159
collected from different old age homes of two districts of North Kerala.
The subjects were voluntarily attended the intervention regularly which
indicates that it is highly beneficial and help them to forget their
miseries and pain in life at least for the period of one hour in a day and
adapted a positive thinking.
Nursing implication
The investigation to reduce anxiety, depression and improve the
QOL among senior citizens conducted with the SNI designed by the
researcher is a milestone in development of gerontological nursing. It
has implications in nursing practise, nursing research, nursing
education and nursing administration. As far as gerontological nursing
is concerned, the study gives valuable contribution to practice of it.
Nursing practice: Prevention of illness, promotion of health, restoration
of health and rehabilitation of health of people are the components of
nursing. As far as gerontological nursing is concerned, these
dimensions had equal value. They are most vulnerable group becomes
victims of varieties of illness due to decline of health and emaciation.
They are most deprived, neglected group in society. Therefore, in the
last stages, quality of nursing care is required to them. Therefore, they
rely mostly on quality of nursing services compared to other group of
people. Residents of old age homes experience a variety of
psychological
problems.
So
the
intervention
incorporated
with
breathing exercises, music, muscle relaxation programme etc will boost
160
morale of people. More than that, the group activity will help them to
develop ‗we feel‘. From the study, it was found that QOL considerably
increased in one hand and anxiety and depression are considerably
decreased in other hand. This SNI must integrate with procedure of
nursing service in future so that by cost effective way, senior citizens in
both institutionalized and non-institutionalized can be cared.
Nursing education: Nursing education is undergoing tremendous
changes. Gerontological nursing is a new branch of nursing. At
present, curriculum of gerontological nursing is mixed with other
branches. Much nursing intervention are not incorporated with the
curriculum of gerontological nursing. SNI is a programme developed by
the researcher that is found to be very cost effective to improve the
QOL, decreased depression and anxiety level among senior citizens.
Much old age homes are mushrooming as result of silent social
changes and polarization of families exclusively for the care of senior
citizens. If a cost effective programme like SNI, which developed by the
researcher, include in the training programme for nurse who are
working in various old age homes all over the world, which will have
miraculous effect in the quantum of service that they are rendering to
them. Training of the nurse getting can utilize in community setup as
well as home setup. SNI programme includes simple steps like general
warming up exercises, breathing exercises, muscle relaxation and
guided imaginary under the background of music that can practiced by
161
common people under minimal assistance from health personnel
during initial stages. These extra activities will make an individual
happy and improves his QOL irrespective of age.
Nursing administration: Home for senior citizens and special wards of
general hospitals exclusively for senior citizens and chronically ill
patients deserve special attention. In Kerala, most of the general
hospitals and district hospitals have special wards for senior citizens
and chronically ill patients. In missionary hospitals and cooperative
hospitals, there is also provision to admit senior citizens and chronically
ill patients. Unfortunately, this is fact that they get less service due to
staff shortage and lack of training of available staff willing to work in
this area. They are most deprived, neglected and abundant individuals
of the society. So nursing administrators should provide special
attention to improve QOL of senior citizens by giving importance to
alternative therapies like structured nursing interventional programmes,
which found cost effective. In service education and continuing
education, programmes should be conduct in the aspect of alternative
therapies especially focusing SNI programme to improve the quality of
care and life of senior citizens. Nursing administrator should encourage
nurses to undergo training programme on alternative therapy for senior
citizens and provide practical training of these programmes to improve
the care to senior citizens.
162
Nursing research: Though gerontological nursing is a very important
branch of nursing, it is fact that very limited studies conducted in this
area. This interventional study will open the eyes of nursing
researchers in this field and motivate them to conduct researches in
different
setting
and
with
different
interventional
programmes.
Researcher will focus their attention towards various psychosocial
issues of senior citizens and initiate steps to resolve them. Considering
the emerging trends of geriatric population and psychosocial issues of
contemporary societies, present research will pave way for a bettersatisfied society.
Conclusion
Structured
nursing
intervention
programme
is
a
package
incorporated with traditional values and practices of our country, which
found that it has tremendous impact upon anxiety, depression and
QOL of our senior citizens. This cost effective intervention is a new
trend in the Geronotological nursing. The most deprived, neglected and
abandoned segment of our society can be help in a cost effective way
with this intervention to achieve the improvement in QOL, thus relieving
anxiety and depression.
163
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