Life quality and daily life activities of elderly people in rural areas, Eskişehir (Turkey)

Life quality and daily life activities of elderly people in rural areas, Eskişehir (Turkey)

Archives of Gerontology and Geriatrics 48 (2009) 127–131 Contents lists available at ScienceDirect Archives of Gerontology and Geriatrics journal ho...

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Archives of Gerontology and Geriatrics 48 (2009) 127–131

Contents lists available at ScienceDirect

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Life quality and daily life activities of elderly people in rural areas, Eskis¸ehir (Turkey) ¨ nsal, Selma Metintas, Filiz Koc, Ali Arslantas Didem Arslantas *, Aleattin U Eskisehir-Osmangazi University, Medical Faculty, Deparment of Public Health, Meselik-Eskisehir 26480, Turkey



Article history: Received 19 June 2007 Received in revised form 27 November 2007 Accepted 29 November 2007 Available online 22 January 2008

Certain difficulties in daily life activities appear and quality of life (QoL) begins to deteriorate with old age. This study aimed at determining QoL and activities of daily living (ADL) of elderly people in rural areas of Eskis¸ehir, and at identifying applicable factors in this regard. Cross-sectional study managed to reach 1301 (81.3%) of elderly people. Face-to-face interviews and the WHOQOL-BREF QoL scale and questionnaire were applied to evaluate daily life activities, as well as instrumental activities all of which contained sociodemographic features. WHOQOL-BREF life quality scale comprised of four domains with grades between 0 and 20. Those who received help from others in the execution of these activities were labelled as ‘‘dependent’’, those who received partial aid during the execution of these activities were labelled as ‘‘partially dependent’’, and those who did not receive any help in their daily activities were labelled as ‘‘independent’’ individuals. Average age of 1301 people contacted was 71.52  5.18 (ranging 65–91 years); 675 of them were women (51.9%), 626 were men (48.1%). Three hundred and eighty-seven of these elderly people (29.7%) had no medically diagnosed illnesses, whereas 18 of them (1.4%) were bedridden. With older age, with the exception of social and environmental areas, life quality got even worse in women, widows, illiterates, bedridden and those with medically diagnosed diseases. As women were more dependent on issues such as housework, shopping, traveling, transporting and bathing, men were more dependent on areas such as meal preparation. No distinction between men and women were identified in areas such as dressing, toilet use, urine and bowel continence and eating. As a conclusion, in cases where medically diagnosed diseases were present, quality of life in women that were dependent somehow in daily activities was worse. It was concluded that medicosocial services for the elderly would be prioritized and studies on chronic diseases would be re-evaluated. ß 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Quality of life during aging Daily and instrumental activities Cross-sectional study WHOQOL-BREF questionnaire

1. Introduction One of the most important developments in the last century was the increase in life expectancy. Factors such as decrease in birth rates and improvement of treatments for chronic diseases have affected the aging of societies, and finally the number of elderly people increased (Lloyd-Sherlock, 2000). Today, elderly people constitute 14.3% of developed countries. According to WHO estimations, elderly people are expected to constitute 30–40% of the society in 2025–2050 (WHO, 1999a). The increase of the elderly population in Turkey is also evident. For example, the ratio of people of 65 years of age or above was 4.3% in 1990, it reached 5.9% in 1998 (Ministry of Health, 1999). The main objective of the preventive health services offered to the elderly people is to improve their QoL, allowing independent

* Corresponding author. Tel.: +90 2222392979; fax: +90 2222293049. E-mail addresses: [email protected], [email protected] (D. Arslantas). 0167-4943/$ – see front matter ß 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2007.11.005

living and preventing the handicaps. The basis of the preventive health services is the identification of risk factors for dependency and the possible reduction of these risk factors. To this end, a comprehensive evaluation is required (Stuck et al., 2002; Samuel, 2002). Aging causes health- and social problems. This means that elderly people find themselves in a situation, where they have to continue their lives with certain obstacles and problems. As one gets older, some difficulties arise in daily activities and QoL begins to deteriorate. The term ‘‘QoL’’ covers physical health, level of independency, social activities and environmental factors. Moreover, the term is also effected by health condition, care and unattended requirements of elderly people (Fidaner et al., 1999; Chantal and Holtkamp, 2000). Generally, if someone is not capable of meeting his/her own needs such as clothing, self-care and nutrition, he/she is defined as dependent. Thus, if we wish to ensure health, independence and mobility of the elderly subjects, we have to determine the best way to protect the elderly from diseases and handicaps. The best available


D. Arslantas et al. / Archives of Gerontology and Geriatrics 48 (2009) 127–131

indicators of handicaps are daily activities and mobility (Sonn, 1996). A real measurement of daily activities can provide more useful information than the determination of liberty with regards to precautions to be taken. This study describes an effort to determine QoL, ADL-related and other factors concerning the elderly people in the rural areas of Eskis¸ehir. 2. Materials and methods Sectional study was undertaken in Alpu, Sivrihisar district center and Kaymaz sub-district which fall within the research area of Eskis¸ehir Osmangazi University Public Health Department in Faculty of Medicine. Listing the name and address data collected from clinical records, we could contact 1301 of these elderly people, representing 81.3% of the total number of them. The WHOQOL-BREF form (Turkish version) with sociodemographic features and ADL questionnaire, as well as the instrumental ADL (IADL) items were also applied to elderly people in form of face-to-face interviews at their homes. The WHOQOL-BREF is a QoL scale, developed by the World Health Organization. The four domains applied in this questionnaire cover the following items.  Domain I. Physical characteristics (ADL, dependence on medicines and medical aids, energy and fatigue, mobility, pain and discomfort, sleep and rest, working capacity).  Domain II. Psychological aspects (self-image of body and appearance, negative feelings, positive feelings, thinking, learning, memory and concentration).  Domain III. Social relationships (personal relationships, social support, sexual activity).  Domain IV. Environmental circumstances (financial resources, freedom, physical safety and security, health and social care: accessibility and quality, home environment opportunities for acquiring new information and skills, participation in and opportunities for recreation/leisure activities, physical environment, transport). The scale was evaluated according to the guidelines developed by the WHO. As each domain relates to the QoL within the framework of its own contents, domain scores were calculated separately. Domain scores varied between 0 and 20. Higher scores indicated higher QoL. Eser et al. (1999) validated the Turkish version of the scale, and assured its reliability. On the other hand, the everyday activities were also examined using the ADL and IADL scales. ADL scale includes self-care behavior such as eating, clothing, bathing, self-care, mobility between the chair and the bed, use of lavatories, intestinal and bladder control, walking and use of stairs; activities one has to do everyday. The IADL scale includes activities such as preparation of food, housework, purchasing medications, accomplish tasks outside, financial management and use of telephones; activities one has to undertake in order to survive as an individual in society (Sonn, 1996). Elderly people who received help from others in the execution of entire ADL and/or IADL functions were classified as dependent. Those who received only partial help from others, were classified as partially dependent and those who received no help were classified as independent from others. The interviewed elderly people were also asked, if they had any medically diagnosed chronic diseases. Ethical approval: Procedures in this study were in accordance with the Helsinki Declaration of 1975. The study protocol was approved by the local ethics board.

Table 1 Distribution of the sociodemographic features in the study group Parameters


Number of the pool = 1301 Sex Male Female

48.1 51.9

Age (years) 65–69 70–74 75–79 80+

43.7 29.7 16.9 9.7

Marital status Married Single Widow

67.4 – 32.6

Education status Illiterate Primary–secondary graduate High school +

33.3 66.6 0.1

Social security No Yes

8.9 91.9

Living the person Alone With a partner With children Other

18.9 65.0 15.4 0.7

Data collected were computer evaluated. x2 as a statistical test, variance analysis and t-test were used, as well. 3. Results The gender distribution of our study pool was 675 women (51.9%) and 626 men (48.1%), making a total of 1301 people. The average age (S.D.) was 71.52  5.18 years (range: 65–91 years). Sociodemographic characteristics of this pool are shown in Table 1. Almost one third, 387 (29.7%) of the elderly people had no medically diagnosed chronic disease, while the three most frequently occurring chronic diseases were identified as hypertension (33.5%), rheumatism-related diseases (26.1%) and diabetes (14.2%). As regards their dependency, only 18 of them (1.4%) were bedridden. The occurrence of medically diagnosed chronic diseases and dependency data are summarized in Table 2. Sociodemographic distribution of the WHOQOL-BREF scores concerning QoL are shown in Table 3. In domains I and II the scores as well as QoL parameters were deteriorated with older age. Women had lower average scores in

Table 2 The distribution of the diagnosed chronic diseases and dependency Parameters


Number of the pool = 1301 Diagnosed chronic disease None Hypertension Rheumatic diseases Diabetes Coronary disease Heart failure Cerebro-vascular disease

29.7 33.5 33.5 14.2 13.2 9.3 5.3 2.7

Dependent in daily activities Outside home independent Inside home independent Bedridden

77.4 21.2 1.4

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Table 3 General QoL and health distribution and domain scores (mean  S.D.) Scores








Age (years) 65–69 70–74 75–79 80+ F p

3.28  0.71 3.17  0.75 3.13  0.79 2.96  0.86 7.09 <0.0001

3.23  0.87 3.12  0.87 3.10  0.89 3.00  0.95 3.03 <0.02

14.06  2.45 13.24  2.56 13.20  2.68 12.31  2.82 20.34 <0.0001

14.15  2.26 13.71  2.15 13.69  2.37 13.10  2.48 8.64 <0.0001

13.76  3.67 13.74  3.60 14.13  3.51 13.67  4.09 0.69 <0.55

13.73  2.13 13.71  2.18 13.86  2.13 13.31  1.93 1.89 <0.12

Sex Male Female t p

3.33  0.72 3.07  0.76 6.29 <0.0001

3.35  0.85 3.00  0.86 7.38 <0.0001

14.35  2.59 12.76  2.42 11.45 <0.0001

14.32  2.28 13.41  2.22 7.23 <0.0001

13.86  3.81 13.76  3.53 0.46 <0.64

14.03  2.09 13.41  2.12 5.32 <0.0001

Marital status Married Widow t p

3.31  0.70 2.97  0.80 7.51 <0.0001

3.28  0.85 2.95  0.88 6.35 <0.0001

13.98  2.52 12.57  2.59 9.26 <0.0001

14.18  2.16 13.16  2.41 7.41 <0.0001

13.75  3.58 13.92  3.84 0.77 <0.44

13.91  2.01 13.29  2.23 4.83 <0.0001

Education Illiterate Primary–secondary High school+ F p

2.95  0.68 3.32  0.76 3.55  0.52 38.51 <0.0001

2.96  0.84 3.28  0.87 3.33  0.86 19.52 <0.0001

12.73  2.43 13.89  2.62 16.76  1.66 37.02 <0.0001

13.71  2.24 13.90 15.85  1.62 4.38 <0.01

13.56  3.35 13.94  3.83 13.59  1.11 1.55 <0.20

13.28  2.17 13.90  2.08 15.61  1.26 16.02 <0.0001

all domains, except for the domain III. Illiterate widows had the lowest score averages in all domains. The further distributions of the WHOQOL-BREF scores in correlation with various parameters are shown in Table 4. In cases of the bedridden elderly people all domain scores were lower, if they lived with medically diagnosed chronic diseases, whereas the scores were higher if they lived with their spouses. The distribution of ADL and IADL scores is listed Table 5. In the dependency, eating in ADL, and shopping in IADL identified as the most outstanding items. Women were more dependent in terms of housework, shopping, traveling, bathing and transferring, while the men were more dependent in terms of meal preparation. In terms of dressing, toilet use, urine and bowel continence, and eating no differences between men and women were identified. Independency in terms of ADL and IADL functions was inversely proportional to the age:

independency was the lowest in the age group of 80-year-old or more. 4. Discussion and conclusions The problems due to old age are not only health problems but also a loss in the overall QoL is evident. Our studies revealed that factors such as sociodemographic ones, level of dependency in ADL, level of help received, and the socio-environmental factors can affect the overall QoL (Hellstro¨m et al., 2004). In terms of QoL, one should feel that his/her life, as a whole, is proceeding towards a better one. What is then decisive at this point is the actual situation of the particular person, and the actual expectations of the person regarding this situation. For the elderly, another target parallel to this one is ‘Healthy Aging’ that is one of European Health Targets for the 21st century (WHO, 1999b).

Table 4 Distribution of overall health, QoL and domain averages related to presence of diagnosed chronic diseases, daily dependency and the living style Scores




Living the person Alone With a partner With children Other F p

3.01  0.83 3.33  0.70 2.92  0.73 2.70  0.67 25.09 <0.0001

2.96  0.89 3.29  0.85 2.94  0.88 2.90  0.87 15.41 <0.0001

Level of dependency Bedridden Outside home dependent Outside home independent F= p

1.72  0.82 2.87  0.72 3.32  0.70 81.86 <0.0001

Presence of disease No Yes t= p

3.48  0.64 3.08  0.77 9.49 <0.0001





12.86  2.61 13.97  2.54 12.52  2.57 12.28  1.96 25.28 <0.0001

13.06  2.30 14.25  2.16 13.14  2.43 13.60  2.31 25.98 <0.0001

13.77  3.59 14.48  3.70 13.20  3.85 12.93  3.72 4.87 <0.002

12.99  2.24 13.95  2.05 13.54  2.14 14.00  1.58 13.88 <0.0001

1.55  0.85 2.82  0.85 3.29  0.83 68.12 <0.0001

8.85  3.30 11.83  2.42 14.07  2.38 128.39 <0.0001

10.14  3.47 13.28  2.33 14.07  2.17 38.92 <0.0001

10.90  3.96 12.72  3.60 14.16  3.60 23.04 <0.0001

12.08  2.12 13.36  2.10 13.83  2.12 10.92 <0.0001

3.66  0.69 2.96  0.86 15.43 <0.0001

15.33  2.06 12.76  2.46 19.33 <0.0001

14.84  1.99 13.43  2.28 11.12 <0.0001

14.11  3.68 13.68  3.65 1.91 <0.05

12.28  1.96 13.46  2.15 6.74 <0.0001


D. Arslantas et al. / Archives of Gerontology and Geriatrics 48 (2009) 127–131

Table 5 Distribution (%) of dependency according the ADL and IADL items List of activities

Performs independently

Performs with assistance

ADL Bathing Dressing Toilet use Urine and bowel continence Transferring Eating

91.9 95.0 95.9 95.8 92.7 71.9

5.9 3.0 2.5 2.7 5.6 25.1

2.2 2.0 1.5 1.5 1.7 3.1

IADL Shopping Traveling Meal preparation Housework

68.6 70.2 72.6 77.5

18.1 21.5 16.6 16.6

13.3 8.3 10.8 5.9

In this study, 29.7% of the elderly people had no medically diagnosed chronic diseases. The most frequent diseases were hypertension, rheumatisms and diabetes. In another study in Taiwan it was revealed that 10% of the elderly people had no medically diagnosed diseases and the most frequent diseases were reported as hypertension, stroke, musculo-skeletal diseases and diabetes (Lai et al., 2005). Yet, in another study realized three Asian countries (Indonesia, Japan and Vietnam) mostly encountered chronic diseases were hypertension, osteoartropathy, coronary diseases and stroke (Wada et al., 2005). Another study in China identified hypertension as the most frequent chronic disease (Beydoun and Popkin, 2005), quite similarly to our results. Considering that cardiovascular diseases are the primary reasons of death in the world, the finding that hypertension is the most frequent health problem was not a surprise. Of the elderly people, 18.9% lived alone, and 1.4% was declared entirely bedridden in terms of activities. In a Swedish study (Hellstro¨m et al., 2004) 31.5% of the elderly people lived alone. This percentage was 17.7% (Castillon et al., 2005) in Spain, 4.2% (Beydoun and Popkin, 2005) in China and 31.3, 6.3 and 10.0% in the three Asian countries, Indonesia, Vietnam and Japan, respectively (Wada et al., 2005). While in Taiwan 1.2% of elderly people were bedridden, the same figure in a nation-wide study was 2.8% (Arslan and Kutsal, 1999; Hwang et al., 2003). Despite being a rural area, the numbers of elderly people who lived alone are still high. Elderly people having to live alone is but an expected result of urbanization and migration to cities. Yet, rural areas are places where people still cherish traditional values more. In addition, expectancy in rural areas is heavier on pursuit of life with children. Considering QoL, WHOQOL-BREF domain averages increased parallel with the age except for social and environmental domains. In studies it was reported that average scores for domains decreased similarly as QoL decreases with increasing age (Hwang et al., 2003; Skevington et al., 2004). Scores for all domains were lower in women, widows and the illiterate group, except for the social domain. We can say that social domain is not effected by age, civil status and education in rural areas. On the other hand, presence of chronic diseases, dependency in daily activities and lifestyles affect the social domain. In those with diseases and the bedridden social domain scores were the lowest, whereas they were highest in those who lived with their spouses. In another study performed in Nigeria, it was reported that degradation in the QoL increases parallel to dependency and that dependency decreased all domain averages in WHOQOL-BREF (Gureje et al., 2006). A sectional study in China revealed that WHOQOL-BREF total scores were higher in cases where elderly people had better social support. Lower social support is interpreted as indicative of loss of traditional perception of the family concept, shrinking of families and children leaving their families as they grow up (Chan et al., 2006).

Unable to perform

Environmental domain included many domains such as financial resources, physical security, access to health services, home environment, recreation opportunities, rest, physical environment and transportation. As age did not affect this domain, in widows, in those who lived alone, in women, in bedridden, in illiterate and in those with medically diagnosed chronic diseases, the average score for environmental domain was the lowest. Considering the higher level of illiteracy and higher number of widows in rural areas, the issues such as financial constraints, reduced access to health services and lower security are very likely also present. A study performed in Taiwan informed us that in a group with chronic diseases all domains are affected except the environmental domain, while in a study of Nigeria, physical dependency affected all domains (Arslan and Kutsal, 1999; Hwang et al., 2003; Skevington et al., 2004; Gureje et al., 2006). With old age, the execution of daily activities are extensively affected. In many activities people become more and more dependent as opposed to the independency they enjoyed before. Increase in dependency affects negatively the QoL. When ADL and IADL functions were considered in our study, it was found that eating and shopping were the two activities leading to dependency at most, however, the dependency in all activities increased with the age. Cleaning, shopping, transportation, bathing are activities where women are more dependent, whereas men were more dependent in food preparation. No gender differences in terms of dependency were identified in activities such as toileting, continence and eating. The study made in Nigeria revealed that dependency in all activities increased parallel with the age, and that women were more dependent than men (Gureje et al., 2006). Yet, in a study in China it was reported that as a result of socioeconomical status, health and nutritional factors affected the decline in both ADL and IADL functions (Beydoun and Popkin, 2005). In a society-based study conducted in I˙zmir, the three functions of the highest levels of dependency were the bladder control, use of stairs and bathing. In the present study we have also seen that women were more dependent in all of these activities and dependency trends were parallel to the older age. In another study conducted again in I˙zmir, no differences were seen between men and women with regard to activities, and the dependency increased more after 80 years of age (Kesiog˘lu et al., 2003; Ulusel et al., 2004). Higher levels of dependency in women may be attributed to more additional diseases they undergo and to lower socioeconomical status, especially in rural women. Our study has some limitations. Considering that depression is directly related to QoL and living activities in the elderly, depression should have also been analyzed in another study. A study involving the body mass index (BMI) could have revealed the eventual effects of malnutrition, as a defect leading to dependency.

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