effect of structured nursing intervention …2 vinayaka missions university declaration i, pavithran...

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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

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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

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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, associate-

ship, fellowship or other titles in this University or any other

University or institution of higher learning.

Signature of the Supervisor with designation

Place: Kozhikode

Date:

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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,

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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.

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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.

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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

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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

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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 socio-

demographic 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.

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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

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LIST OF TABLES

SL.NO. TABLE PAGE NO.

1 Details of sample collected from selected old age

homes 71

2 Details of data collection instruments used in the

study 73

3 Frequency and percentage distribution of sample

based on age 85


based on marital status 87

5 Frequency and distribution of sample based on

educational status 87


based on type of family 88


based on physical support 89


based on social support 90

9 The t value computed between mean pre test and

post test anxiety scores among senior citizens 92


post test depression scores among senior citizens 93


post test QOL scores among senior citizens 94

12 Level of anxiety among senior citizen before and

after SNI 95

13 Level of depression among senior citizen before

and after SNI 96

12


14 Level of overall QOL among senior citizen before

and after SNI 96

15 The F value computed between pretest anxiety

scores and sex among senior citizens 99


scores and age among senior citizens 99


scores and religion among senior citizens 100


scores and marital status among senior citizens 101

19

The F value computed between pretest anxiety

scores and educational status among senior

citizens

101

20


scores and previous occupation among senior

citizens

102


scores and type of family among senior citizens 103


scores and financial support to senior citizens 103


scores and physical support to senior citizens 104

24


scores and psychological support to senior

citizens

105


scores and social support to senior citizens 105

13


26


scores and duration of stay in old age homes

among senior citizens

106

27 The F value computed between pretest

depression scores and sex among senior citizens 108

28 The F value computed between pretest

depression scores and age among senior citizens 108

29

The F value computed between pretest

depression scores and religion among senior

citizens

109

30


depression scores and marital status among

senior citizens

109

31


depression scores and educational status among

senior citizens

110

32


depression scores and previous occupation


111

33


depression scores and type of family among

senior citizens

111

34


depression scores and financial support to senior

citizens

112

35


depression scores and physical support to senior

citizens

113

14


36


depression scores and psychological support to

senior citizens

113

37


depression scores and social support to senior

citizens

114

38


depression scores and duration of stay in old age

home among senior citizens

115

39 The F value computed between pretest QOL

scores and sex among senior citizens 116


scores and age among senior citizens 117


scores and religion among senior citizens 118


scores and marital status among senior citizens 119

43

The F value computed between pretest QOL

scores and educational status among senior

citizens

120

44


scores and previous occupation among senior

citizens

121


scores and type of family among senior citizens 122

46


scores and financial support to senior citizens 123


scores and physical support to senior citizens 124

15


48


scores and psychological support to senior

citizens

125


scores and social support to senior citizens 126

50


scores and duration of stay in old homes among

senior citizens

127

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Correlation coefficients computed on combined

scores of anxiety and depression among

institutionalized senior citizens.

129

52


scores of anxiety and QOL among institutionalized

senior citizens.

129

53


scores of depression and QOL among


130

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LIST OF FIGURES

SL. NO. FIGURE PAGE NO.

1 Percentage of world population over 65 years,

1950-2050 3

2 Percentage of senior population in India 7

3 Conceptual framework based Roy‘s adaptation

model 63

4 Schematic representation of design of the study 67

5 Percentage distribution of sample based on sex 86

6 Percentage distribution of sample based on

religion 86


previous occupation 88


source of income 89


psychological support 90


duration of stay in old age home 91

11 Distribution of mean pre test and post test score

of QOL in fours domains 97

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LIST OF APPENDICES

S. No Appendix

A Tool-I: Semi structured interview schedule to collect socio-

demographic 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)

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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

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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.

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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

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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-

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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

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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

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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

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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 2001-

2003 (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

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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).

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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).

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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

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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

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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.

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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 at Tamil Nadu in India. The study reveals

institutionalized senior citizens have more problems than non-

institutionalized in all dimensions.

Chada(1994) studied psychological well-being and

depression among institutionalized and non-institutionalized senior

citizens in India. The result indicates that senior citizens in non-

institutionalized 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, rejection-

aggression, 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 (GDS-

SF). 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 psycho-

geriatric 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.


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 high-

class 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 ―Elders 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 WHO-

Attitudes 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

http://www.ncbi.nlm.nih.gov/pubmed?term=Top%20M%5BAuthor%5D&cauthor=true&cauthor_uid=23240580

http://www.ncbi.nlm.nih.gov/pubmed?term=Dikmeta%C5%9F%20E%5BAuthor%5D&cauthor=true&cauthor_uid=23240580

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


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 well-

being. 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

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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

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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

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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

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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-

http://www.ncbi.nlm.nih.gov/pubmed/?term=Gururaja%20D%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Harano%20K%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Toyotake%20I%5Bauth%5D

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, well-

being, general self-efficacy, and self-efficacy for daily living and also self-

control 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

http://diginole.lib.fsu.edu/do/search/?q=author_lname%3A%22Bonura%22%20author_fname%3A%22Kimberlee%22&start=0&context=1950990

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.

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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 late-

life 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-

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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 non-

institutionalized 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.

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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

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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 ―to assess 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


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


Hypothesis

H1- There is a significant difference in anxiety, depression and QOL

among senior citizens before and after Structured Nursing Intervention

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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


H4-There is a significant association between QOL and selected


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 citizen who have undergone structured nursing

intervention.

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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.

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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.

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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 process-

assessment, 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.

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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, self-

esteem, 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.

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ADAPTION SENIOR CITIZEN

MALADAPTION

FEEDBACK

Anxiety

QOL

Depression

Anxiety

Depression

QOL

ADAPTATION STIMULI

Focal stimuli

Institutionalization

Familial separation

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

ST

RU

CT

UR

ED

NU

RS

ING

IN

TE

RV

EN

TIO

N

INPUT CONTROL OUTPUT

Figure 3: Conceptual framework based on Roy’s adaptation model

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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.

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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

Figure 4: schematic representation of design of the study

Purpose To improve QOL, to reduce depression and to relieve

anxiety.

Design One group pre testpost 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

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


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 Kerala-

Calicut 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 Old age home No. of inmates

who met criteria

Samples

selected

Calicut

Mercy Home 90 45

Karuna Bhavan 86 43

Govt. old age home,

Vellimandukundu 144 72

Palakkad

Govt. old age home,

Kodamaloor 148 74

Crescent old age home 84 42

Sneha Jyothy old age 88 44

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

Name of the tool Variables measured Selected/

developed by investigator

No. of items

Reliability Validity

1

Socio-

Demographic

Performa

Age, sex, religion, marital status,

educational status, previous occupation,

type of family, financial support,

psychological support, physical support,

family support and duration of stay in old

age homes

Developed 12 - Content

2 Hamilton anxiety

rating scale Anxiety Selected 14

α-0.77-0.92

(test-retest)

Construct

Concurrent

3 Beck Depression

inventory II scale Depression Selected 21

α-0.91

(test-retest)

Construct

Concurrent

4 WHO QOL BREF Domains of QOL Selected 26 α-0.63-0.84

(test-retest)

Construct

Concurrent

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 exercises-

a) 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


3. To find out the association between depression and selected


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


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


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

Figure 5: Percentage distribution of sample based on sex (n=312)

In figure 5, 59.43 % sample was males and 40.57% were females.

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%)

Male59.43%

Female40.57%

Male Female

Hindu48.20%

Muslim25.40%

Christian26.40%

104


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.


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

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.


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.

05

10152025303540

35.9

18.6

9.1

36.4

Perc

enta

ge

Previous occupation

Skilled labourer Private Employee Self employed Unemployed

106

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


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

Wife/Husband6.8%

Son/Daughter48.6%Friends/Others

15.5%

Widow/Old age pension

22.3%

Pension6.8%

107

son/daughter, 16.35% from wife or husband and remaining (10.90%)

from brothers or sisters.

Figure 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.


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

0

5

10

15

20

25

30

35

40

22.7

9.1

30.9

37.3

Perc

enta

ge

Psychological support

brothers,/ sisters

wife/husband

son/daughter

friends/others

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.

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

0

5

10

15

20

25

30

35

40

Below 1 year 1 - 3 years 3 - 5 years Above 5 years

21.8

38.6

31.8

7.7

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 n=312

Variable Test Mean

SD Mean

Difference Paired t

value p value

Anxiety Pre test 40.66 4.13

22.28 79.91 0.0001*** Post test 18.38 3.14

*** 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


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 n=312

Variable Test Mean SD Mean

Difference Paired t

value p value

Depression Pre test 42.87 5.18

18.53 45.11 0.0001*** Post test 24.35 4.82


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


score of QOL, the data were subjected to paired ‗t‘ test.

Table 11: The t value computed between mean pre-test and post-

test QOL scores of senior citizens n=312

Variable Test Mean SD Mean

Difference Paired t value

p value

QOL Pre test 54.53 4.252

37.76 115.76 0.0001*** Post test 92.29 3.808


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

Level of anxiety

Pre test Post test

F % f %

< 17 (mild) 53 16.99 171 54.81

18 – 25

(moderate) 102 32.69 84 26.89

Over 25 (severe) 157 50.32 57 18.27

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

Level of depression Pre test 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

Over 30(severe) 159 50.96 50 16.03

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

Level of QOL

Pre test Post test

f % f %

< 33 (Low) 165 52.89 39 12.50

34 – 66

(average) 106 33.97 79 25.32

>67 (High) 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%

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 post-

test 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).

35.4529.23

23.85 24.46

59.5863.05

66.669.65

0

10

20

30

40

50

60

70

80

Physical health

Psychological health

Social relationship

Envirnoment

Mea

n sc

ore

Pre testPost test

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 F value p value

Male 40.98 4.36 1.015 0.953NS

Female 41.80 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 H04 (a) is

accepted. It interpreted that there is no significant association between

anxiety and sex among senior citizens.


and age among senior citizens n=312

Age in years Mean SD F value p value

60-65yrs 40.93 4.15

1.083 0.356NS 66-70yrs 40.48 4.02

71-75yrs 40.92 4.01

76-80yrs 38.29 5.94


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


anxiety and age among senior citizens.


and religion among senior citizens n=312

Religion Mean S. D F value p value

Hindu 41.05 3.841

0.760 0.469NS Muslim 40.24 4.256

Christian 40.52 4.386


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


118


and marital status among senior citizens n=312

Marital status Mean S.D F value p value

Married 43.05 5.113

1.151 0.329NS Unmarried 43.65 5.583

Divorced 41.97 5.732

Deserted 42.13 4.594 NS-Not Significant at p= 0.05 level


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.


and educational status among senior citizens n=312

Educational status Mean S.D F value p value

Illiterate 39.78 3.986

0.206 0.89NS Up to 4th 41.76 5.654

Up to 10th 40.98 4.478

Up to degree 40.30 4.872


119

It is infers from table 19 that there is no significant

difference in mean pretest anxiety scores and educational status


H04 (e) is accepted. It interpreted that there is no significant association

between anxiety and educational status among senior citizens.


and previous occupation among senior citizens n=312

Previous occupation Mean S. D F value p value

Skilled labourer 41.98 5.204

2.031 0.109NS Private employee 43.30 5.213

Self-employed 42.48 5.140

Unemployed 43.59 5.082



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


and type of family among senior citizens n=312

Type of family Mean Std. Deviation F value p value

Nuclear 41.04 3.931

1.265 0.284NS Joint 40.06 4.487

Extended 40.22 4.108


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


anxiety and type of family among senior citizens


and financial support to senior citizens n=312

Financial support Mean S. D F value p value

Wife/ husband 41.33 2.320

1.317 0.265NS

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


121


difference in mean pretest anxiety scores and financial support to

senior citizens. Based on these findings, the null hypothesis H04 (h) is


anxiety and financial support to senior citizens


and physical support to senior citizens n=312

Physical support Mean Std. Deviation F value p value

Brothers/sisters 41.48 3.930

1.318 0.269NS Wife/husband 41.12 3.487

Son/daughters 39.94 4.336

Friends/others 40.94 4.191


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


anxiety and physical support to senior citizens.

122


and psychological support to senior citizens n=312

Psychological support Mean Std.

Deviation F value p value


1.238 0.297NS Wife/husband 41.84 2.292

Sons/daughters 40.10 4.375




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 n=312

Social support Mean Std. Deviation F value p value


0.702 0.551NS Wife/husband 42.49 4.573





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


and duration of stay in old age homes among senior citizens

n=312

Duration of stay Mean Std. Deviation F value p value

Below 1 year 42.73 5.279

0.135 0.939NS 1-3 years 43.07 4.534

3-5 years 42.67 4.534 Above 5

years 42.67 5.865



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


124

B. Association between selected socio-demographic variables

and depression among senior citizens


depression and following socio demographic variables among senior





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






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 n=312

Sex Mean Std. Deviation F value p value

Male 42.91 4.82 0.279 0.780NS

Female 43.11 5.70



difference in mean pretest depression scores and sex among senior

citizens. Based on these findings, the null hypothesis H05(a) is


depression and sex among senior citizens.


scores and age among senior citizens n=312

Age in years Mean Std. Deviation F value p value

60 – 65 42.66 5.287

1.160 0.325NS 66 – 70 43.35 5.109

71 – 75 41.48 5.413

76 – 80 42.00 3.618



significant difference in mean pretest depression scores and age

126


H05 (b) is accepted. It is interprets that there is no significant

association between depression and age among senior citizens.


scores and religion among senior citizens n=312

Religion Mean Std. Deviation F value p value

Hindu 43.15 4.996

0.314 0.731NS Muslim 43.20 5.395




difference in mean pretest depression scores and religion among

senior citizens. Based on these findings, the null hypothesis H05(c) is


depression and religion among senior citizens.


scores and marital status among senior citizens n=312

Marital status Mean Std. Deviation F value p value

Married 43.05 5.113

1.151 0.329NS Unmarried 43.65 5.579

Divorced 41.97 5.734

Deserted 42.13 4.587 NS-Not Significant at p= 0.05 level

127


difference in mean pretest depression scores and marital status among

senior citizens. Based on these findings, the null hypothesis H05(d) is


depression and marital status among senior citizens.


scores and educational status among senior citizens n=312

Educational status Mean Std. Deviation F value p value


0.286 0.78NS Up to 4th 40.56 3.877

Up to 10th 41.89 4.401

Up to degree 41.40 5.688



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


128


scores and previous occupation among senior citizens n=312

Previous occupation Mean S. D F value p value


2.034 0.109NS Private employee 43.30 5.214

Self-employed 42.48 5.729

Unemployed 43.59 5.085



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.


scores and type of family among senior citizen n=312

Type of family Mean Std. Deviation F value p value

Nuclear 42.96 5.509

0.037 0.963NS Joint 43.16 4.671

Extended 42.85 4.622

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 n=312

Financial support Mean S. D F value p value

Wife/ husband 42.67 4.776

1.044 0.386NS


Friend/others 44.19 4.254

Widow/old age pensions 42.21 5.763

Pensions 41.50 5.170



significant difference in mean pretest depression scores and financial


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 n=312

Physical

support Mean Std. Deviation F value p value


0.030 0.993NS Wife/husband 42.85 4.210

Son/daughters 43.00 5.524




difference in mean pretest depression scores and physical support to

senior citizens. Based on these findings, the null hypothesis H05(i) is


depression and physical support to senior citizens.


scores and psychological support to senior citizens n=312

Psychological support Mean Std. Deviation F value p value


0.636 0.593NS Wife/husband 41.95 4.441

Sons/daughters 43.02 5.538



131


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.


scores and social support to senior citizens n=312

Social

support Mean Std. Deviation F value p value


0.702 0.551NS Wife/husband 42.49 4.575





significant difference in mean pretest depression scores and social


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 F value p value

Below 1 year 42.73 5.287

0.135 0.939NS 1-3 years 43.07 4.529

3-5 years 42.67 5.864

Above 5 years 43.04 5.345 NS-Not Significant at p= 0.05 level


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


QOL and following socio demographic variables among senior





133

To identify the association between selected socio-

demographic 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.


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 n=312

Domain Sex Mean S. D F value p value

PHYSICAL HEALTH Male 35.14 8.07

-0.676 0.500NS

Female 35.90 7.82

PSYCHOLOGICAL HEALTH

Male 28.90 6.01 -0.941 0.348NS

Female 29.70 6.30

SOCIAL RELATIONSHIP

Male 23.43 6.87 -1.090 0.277NS

Female 24.46 6.58

ENVIRONMENT Male 24.72 8.35

0.562 0.575NS

Female 24.08 7.86

OVERALL Male 45.51 3.67 0.114 0.909NS

Female 45.45 3.35 NS-Not Significant at p= 0.05 level

134


significant difference in mean pretest QOL scores and sex among

senior citizens. Based on this findings, the null hypothesis H06(a) is


QOL and sex among senior citizens.


age among senior citizens n=312

Domain Age in years Mean S.D F value p value

PHYSICAL HEALTH

60 – 65 45.48 9.89

0.968 0.39NS 66 - 70 45.87 6.21 71 - 75 34.20 6.98 76 - 80 30.00 4.39


60 - 65 39.22 7.15

0.342 0.74NS 66 - 70 39.31 5.88 71 - 75 48.00 6.41 76 - 80 31.40 7.77

SOCIAL RELATIONSHIP

60 - 65 43.22 6.60

0.495 0.65NS 66 - 70 24.31 7.93 71 - 75 34.93 7.35 76 - 80 23.80 5.02

ENVIRONMENT

60 - 65 53.85 7.31

2.57 0.05** 66 - 70 34.10 7.22 71 - 75 48.33 10.15 76 - 80 31.20 11.63

Overall

60 - 65 53.99 4.07

1.583 0.193NS 66 - 70 54.82 4.51 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


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.


religion among senior citizens n=312

Domain Religion Mean S.D F value p value

PHYSICAL HEALTH Hindu 35.24 8.13

0.086 0.917NS Muslim 35.80 7.82 Christian 35.45 7.92


Hindu 29.39 6.08 0.068 0.935NS Muslim 29.06 6.31


SOCIAL RELATIONSHIP

Hindu 22.79 7.60 3.501 0.032** Muslim 23.83 6.44


ENVIRONMENT Hindu 25.44 8.99


Overall Hindu 54.43 4.22




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.


marital status among senior citizens n=312

Domain Marital status Mean S.D F value p value

PHYSICAL HEALTH

Married 36.10 8.39

0.640 0.590NS Unmarried 34.70 6.43 Divorced 35.26 7.69 Deserted 34.22 8.08


Married 29.04 5.90


SOCIAL RELATIONSHIP

Married 23.12 7.81


ENVIRONMENT

Married 24.70 8.30


Overall

Married 54.60 4.65




significant difference in mean pretest QOL scores and marital status


137

H06(d) is accepted. It is interpreted that there is no significant

association between QOL and marital status among senior citizens.


educational status among senior citizens n=312

Domain Educational status Mean S.D F value p value

PHYSICAL HEALTH


0.780 0.506NS Up to 4th class 36.20 7.98 Up to 10th class 34.36 8.17 Up to degree 36.00 6.27




SOCIAL RELATIONSHIP



ENVIRONMENT



OVERALL





difference in mean pretest QOL scores and educational status among

senior citizens. Based on these findings, the null hypothesis H06 (e) is

138


QOL and educational status among senior citizens


previous occupation among senior citizens n=312

Domain Previous occupation Mean S.D F value p value

PHYSICAL HEALTH


0.210 0.890NS Private employee 36.32 8.04 Self employed 35.37 5.81 Unemployed 35.12 8.28




SOCIAL RELATIONSHIP



ENVIRONMENT



OVERALL


3.191 0.024** Private employee 54.52 3.96 Self employed 54.24 4.08 Unemployed 53.72 3.92


Data presented in table 44 shows that there is significant

difference in mean pretest QOL scores and previous occupation


H06 (f) is rejected. It is interprets that there is significant association

between QOL and previous occupation among senior citizens.

139


type of family among senior citizens n=312

Domain Type of family Mean S.D F value p value

PHYSICAL HEALTH Nuclear 34.64 7.49

1.943 0.146NS Joint 37.02 8.58 Extended 36.52 8.72


Nuclear 29.09 6.47 0.095 0.910NS Joint 29.51 5.48

Extended 29.37 5.70

SOCIAL RELATIONSHIP

Nuclear 24.22 6.54 0.682 0.507NS Joint 23.51 6.84

Extended 22.67 7.72

ENVIRONMENT Nuclear 24.79 8.40


OVERALL Nuclear 54.59 4.15




significant difference in mean pretest QOL scores and type of family


H06(g) is accepted. It is interprets that there is no significant association

between QOL and type of family among senior citizens.

140


financial support to senior citizens n=312

Domain Source of income Mean S.D F value

p value

PHYSICAL HEALTH

Wife/husband 34.00 5.89

0.595 0.667NS

Son/ daughter 36.10 8.02 Friends/others 33.94 8.43 Widow/old age pensions 35.64 7.61

Pension 34.93 9.78



0.775 0.543NS

Son/ daughter 29.08 6.27 Friends/others 29.07 6.57 Widow/old age pensions

29.00 6.30

Pension 32.00 2.54

SOCIAL RELATIONSHIP


0.848 0.496NS


Pension 22.43 5.11

ENVIRONMENT


2.056 0.088NS


Pension 20.29 5.36

OVERALL


1.354 0.251NS


Pension 52.86 2.69 NS-Not Significant at p= 0.05 level

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.


physical support to senior citizens n=312

Domain Physical support Mean S.D F value p value

PHYSICAL HEALTH

Brothers/ sisters 35.78 9.55

0.088 0.967NS Wife/ husband 35.54 7.32 Son/ daughter 35.69 7.97 Friends/ others 35.09 7.91




SOCIAL RELATIONSHIP



ENVIRONMENT



OVERALL



NS-Not Significant at p= 0.05

142


significant difference in mean pretest QOL scores and physical support

to senior citizens. Based on these findings, the null hypothesis H06(i) is


QOL and physical support to senior citizens.


psychological support to senior citizens n=312

Domain Psychological support Mean S.D F value p value

PHYSICAL HEALTH






SOCIAL RELATIONSHIP


3.573 0.015** Wife/ husband 25.00 4.47 Son/ daughter 24.56 6.73 Friends/ others 24.69 6.09

ENVIRONMENT



OVERALL





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.


social support to senior citizens n=312

Domain Social support Mean S.D F value p value

PHYSICAL HEALTH





0.740 0.529NS

Wife/ husband 27.52 6.44 Son/ daughter 29.54 6.04 Friends/ others 29.44 6.58

SOCIAL RELATIONSHIP



ENVIRONMENT



OVERALL




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 n=312

Domain Duration of stay Mean S.D F value p value

PHYSICAL HEALTH

Below 1yr 36.39 8.06

2.349 0.074NS 1-3yrs 35.35 8.45 3-5yrs 36.04 7.40 Above 5 yrs 30.47 5.85


Below 1yr 29.30 5.55


SOCIAL RELATIONSHIP

Below 1yr 22.39 7.92


ENVIRONMENT

Below 1yr 23.61 7.44

2.703 0.047** 1-3yrs 23.22 7.21 3-5yrs 25.60 8.92 Above 5 yrs 28.73 9.87

OVERALL

Below 1yr 54.17 4.21




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 H06(l) is


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. n=312

Variables Co efficient of correlation

Pre test Post test

Depression and Anxiety -0.026 -0.073

Combined (pre test and post test) +0.829

p value < 0.001***

*** 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.


anxiety and QOL among senior citizens. n=312


Pre test Post test

Anxiety and QOL +0.002 +0.084

Combined (pre test and post test) -0.927

p value < 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.


depression and QOL among senior citizens. n=312


Pre test Post test

Depression and QOL -0.115 +0.003

Combined (pre test and post test) -0.868

p value < 0.001***


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 socio-

demographic 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 self-

employed.

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 3-

5years, (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


6) Comparative study can be conducted in rural and urban


7) Comparative study can be conducted in rural and urban non


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 better-

satisfied 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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