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Health care environment and life satisfaction in the elderly
HEALTH CARE ENVIRONMENT AND LIFE SATISFACTION IN THE ELDERLY MICHAEL J. SALAMON The Adult Development Center
This study examines the impact of where health care is received on the life satisfaction of older adults. Using a questionnaire, this study surveyed 241 individuals receiving care in six health care environments. Life satisfaction was assessed using the Life Satisfaction in the Elderly Scale. Results indicated that individuals residing in long-term care facilities have higher overall levels of well-being. Those receiving home health care had the lowest. Score patterns are reviewed and possible explunations discussed ABSTRACT:
Recent government policy has been in the direction of limiting the growth of nursing home bed capacity in the United States. Emphasis has instead been placed on providing a comparable level of health care services to older adults in their own homes. It has been assumed that a better and less costly form of care can be provided in one’s own home or apartment. A recent report by the General Accounting Office (GAO) (1982) has indicated that this shift of priorities to increased funding of home health services for the chronically ill elderly may not be a cost-effective alternative. Yet, while these findings are similar to those reported elsewhere (Kramer, Shaughnessy, and Pettigrew 1985; Weissert 1985; Weissert, Wan, Livieratas, and Katz 1980), the GAO study concluded that when professional health care services are provided in the home, the longevity of chronically ill older adults is improved and increases in selfreported levels of life satisfaction are recorded. The other authors have, however, pointed out that the comparisons between the chronicity of care in home versus nursing home are somewhat misleading as those in nursing homes may require either more or a different level of functional care. Therefore, longevity is not necessarily an outcome of placement. Direct all communicakms to: Michael Broadway,
Suite IA,
J. Salnmon. Executive Director, Woodmere, NY 11598.
The Adult Developmenr Center, 920
JOURNAL OF AGING STUDIES, Volume 1, Number 3, pages 287-297. Copyright @ 1987 by JAI Press, Inc. All rights of reproduction in any form reserved. ISSN: 08904065.
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It has also been suggested that older adults are generally happier receiving health care in their own homes (DeCrosta 1984). Several studies call this finding into question as well. Dunlop (1980), in his review, found cause to debate this assumption. His results indicated that home health care would not significantly reduce rates of institutionalization and decrease family stress, neither would it increase life satisfaction for the majority of those receiving such care. Similarly, Robinson (1983) reported that individuals receiving care in their own homes had lower levels of subjective wellbeing. Further, two other pilot studies found that life satisfaction is relatively high among older adults who reside in long-term health care facilities (Genhtrics 1983; Schwirian 1982). The measurement of subjective well-being, often referred to as life satisfaction, has been an issue of increasing relevance to gerontologists. Over the years, despite the technique used to assess subjective well-being, a number of variables have been shown to relate consistently to life satisfaction. Among these, socioeconomic status is one of the strongest correlates of life satisfaction. Those individuals with higher incomes have higher levels of life satisfaction (Edwards and Klemmack 1973; Larson 1978). There is also evidence suggesting that people who are married have higher levels of life satisfaction than those who are single, widowed, or divorced (Spreitzer and Snyder 1974). Other findings suggest that one’s race and affiliation with voluntary associations are also related to subjective well-being (Larson 1978; Salamon 1985a). Perhaps the most consistent finding is that older individuals who perceive themselves as being healthy report higher levels of life satisfaction (Campbell, Converse, and Rogers 1976; George and Lander-man 1984; Herzog and Rogers 198 1). While this finding may seem apparent it has implications beyond its simplicity. Perhaps the subjective reporting of physical well-being is mediated by other variables. One possible intervening variable is where older adults receive their health care. This study explores, in somewhat more detail, one of these issues. Specifically, the study was designed to explore whether life satisfaction is higher when the chronically ill elderly receive their health care in their own home as compared to other health settings. The rationale for this is based on the assumption that almost all of the variables that interact with life satisfaction may also interact with physical wellbeing (Zautra and Hempel 1984). There are a variety of health care settings where one may have health needs met. Each setting has its own characteristics. Some settings, such as residential care facilities or clinics attached to senior citizen centers, provide socialization and recreation programming in addition to basic health care. Physicians’ offices and acute care hospitals provide, almost exclusively, medical model health care. In these settings very little attention is given to patients’ other needs. Families are often called upon to provide case management and more direct care when an older adult relative requiring health care remains in the community (Koff 1982). When the older adult requires more intensive home health care their needs may serve to increase tension in the family and detract from the families ability to provide more appropriate social support (Dobroff and Litwak 1977; Smith and Bengston 1979). It is therefore possible that one of the settings along the health care continuum has, as a result of these factors, more of an impact on an older adult’s subjective well-being than the others.
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METHOD Sample The facilities surveyed in this study were sites of convenience, selected for the type of health care environment (HCE) they provided. The 6 HCEs were all located in the New York Metropolitan area and included 2 clinics affiliated with senior centers (clinic), 3 private physician’s offices (MD), 2 hospitals, 4 health-related or intermediate-care facilities (HRF), 3 skilled nursing facilities (SNF), and 2 health care service programs providing care to homebound elderly (HHC). Clinic sites at senior centers were diagnostic and treatment centers providing screening and health monitoring. These clinics were staffed full-time by a nurse and social worker supervised by a consulting physician. The 3 private physician offices belonged to 3 independent doctors. Despite the fact that two of the physicians specialized in gastroenterology, the third in oncology, all three reported that 90% of their practice was in general care for geriatrics. The two hospitals provided acute care and were both affiliated with major university medical schools. Both hospitals can be considered average in size, containing approximately 300 beds. The intermediate-care facilities provided supervision but limited direct medical intervention. Although the focus of care was considered medical, most programming was social and recreational. The skilled nursing facilities provided intensive nursing care within a medical model. The care, unlike that in a hospital, was not medically aggressive as the patients generally did not suffer acute distress. Home health care was similar to the care provided within an intermediate-care facility or skilled nursing facility setting. The major difference was the physical environment. A facility can never be like home, and, for the time that the care provider was in the patient’s house, the interaction was exclusively one on one. Within HCE categories, facilities were selected from different ethnic neighborhoods. This was done to gain as broad a representation as possible within each category. After securing approval from the facility or health care provider, study participants in the clinics, HRF, SNF, HHC, and HCEs were randomly selected from membership lists. Individuals at the MD and acute hospital sites were randomly drawn from those in attendance on a randomly selected day of the week. A total of 294 persons were individually contacted and asked to participate in the study, 60 at the clinic sites, 50 at the 2 hospitals, and 23 in the 2 HHC catchment areas.
Instrument This study used the Salamon-Conte Life Satisfaction in the Elderly Scale (LSES) (Salamon and Conte 1984) to measure subjective well-being. The LSES is a 40-item questionnaire that measures subjective well-being in 8 categories (Salamon and Conte 198 1). The first 5 of the 8 categories follow those hypothesized by Neugarten et al. (1961). The 3 additional categories were drawn from a review of the literature (Larson 1978). The LSES has been found to be a highly useful measure of life satisfaction. In addition to its psychometric properties it is one of the most complete measures of subjective well-being designed to measure 8 distinct categories shown to load into life satisfaction. The 8 categories that make up the LSES are: (1) Pleasure in daily activities
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(routine); (2) Goodness of fit between desired and achieved goals, a matching of the individual’s degree of satisfaction with their present stage of life relative to previous stages; (3) Meaning of life, a measure of the individual’s sense of usefulness and purpose in life; (4) Mood tone, general positive affect, happiness, or optimism; (5) Self-concept, the degree of personal self-regard and favorable self-appraisal; (6) Perceived level of health, the self-assessment of overall physical well-being; (7) Financial security, satisfaction with present and recent financial situations; and (8) Social contact, satisfaction with number and quality of social contacts. Factor analytic and clustering techniques support the validity of these 8 categories or factors (Salamon and Conte 1984). Each of the 8 categories contain 5 questions with 5 response options. Response options are coded numerically and scores in each of the 8 categories range from 0 to 25. The maximum total LSES score is 200. The higher the individual’s score the higher the individual’s level of life satisfaction. A variety of studies to assess the reliability and validity of the LSES indicate that it is a psychometrically sound instrument with coefftcient alphas ranging from (Y= .50 to (Y= .92 (Conte and Salamon 1982; Salamon 1983). In addition to the LSES, the survey instrument contained a variety of questions to assess demographic variables. These variables included age; marital status; socioeconomic status, measured by combining education, income, and occupational status; race; ethnicity; living environment; voluntary association; and health. Health was measured objectively by provider report and subjectively via self-report. The health care provider, who in almost all instances was a physician, was asked to rank the severity of the individual’s overall illess using the following scale: 1 = mild; 2 = moderate; 3 = severe. Findings reported elsewhere (Salamon 1985b) indicated high rates of agreement between self- and provider report.
Procedure The respondents were presented with a consent form and a questionnaire. A total of 294 survey questionnaires were individually distributed to patients in the HCEs. Respondents were asked to answer the questions as honestly and accurately as possible. They were informed that the questionnaire did not measure ability, neither did it affect the care they were receiving. Confidentiality was assured. They were informed, however, that objective ratings of physical health would be obtained from their health care provider. When necessary an assistant read the material to the subject but did not interpret the items or response choices.
Data Analysis In keeping with accepted procedures data were analyzed using traditional techniques. In particular, chi-square, a robust measure for differences among proportions, was used to examine the differences on demographic and background variables with general census. Following procedures often used in life satisfaction research, productmoment correlations were used to explore the strength and direction of relationships between life satisfaction and other variables. A series of one-way analyses of variance were also employed to determine if significant differences existed between means for HCEs.
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in the Elderly
RESULTS Fifty-two (87%) questionnaires were returned at the 2 clinic sites; 42 (78%) at the 3 MD sites; 47 (78%) at the 4 HRF sites; 40 (87%) at the 3 SNF sites; 40 (80%) at the 2 hospital sites; and 19 (83%) at the 2 HHC sites. Two hundred forty-one completed questionnaires were returned. As can be seen in Table 1 the subjects in the present study were not significantly different than the population at large. Those items for TABLE
1
Demographic Characteristics of Older Adults in the Present Study: Compared to Census Data (1982) Demographic
Characteristics
Percent
Census Data Percent
60-74 75-84 85+
60.0 23.2 6.2
68 24 8
Gender Male Female
35.0 64.0
38 62
Marital Status Married Divorced Widowed Separated Single
40.0 5.8 40.7 3.7 9.5
Occupational Status Professional Managerial Laborer
x2
df
1.37
2
.197
I
50 5 40 4 1
14.41*
4
17.0 32.4 24.9
25 45 20
7.29*
2
Income $2,399 2,400-3,599 3,600-5,999 6,000-9,999 1o,ooo+
23.2 13.3 19.5 10.0 21.2
18 30 I8 I5 I9
l2.85*
4
Education Completed High School College
42.7 12.0
41 I9
2.58
I
Race White Nonwhite
87.1 12.5
88 12
.30
I
Living Arrangements Alone With Spouse With Children Other (Including Institutions)
29.5 34.0 6.2 26.7
35 35 6 24
.94
3
Note:
*p < .OS.
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2
Biserial and Product Moment Correlations Between Total LSES Scores and Background Variables, p. r2 r
D
r2
Race
.I248
,020
.Ol56
Sex
.0293
,220
.0009
-.0007 .I863
.63 I ,002
.0347 .0347
Age Income
.oooo
.I863
.002
Total Club Affiliations
.I217
,030
,148
Total Number of Clubs Active in
.I010
.059
.OOlO
-.23 16
.ooo
.0536
-.0553
.I97
.0002
Years of Education
Total Self-Report
Completed
Ailments
Total Provider Report Ailments
which census data were available (Administration on Aging 1982) indicate that only in the areas of marital status, occupational status, and income levels were significant differences found. Those in the present study reported higher rates of being single, lower status occupations, and lower income rates than the norm. These differences may be related to the types of individuals receiving long-term health care and thus reflect an appropriate selection factor. As can be seen in Table 2, product-moment correlations show that socioeconomic status, affiliation with voluntary organizations, and perception of illness are related to overall well-being. For the purpose of this study both race and sex were coded categorically. White and male were each coded as 1. In the case of race, those who were white had higher LSES scores. In the case of gender, there was no significant difference between males and females. The remaining variables contained in Table 2 were coded continuously. Those respondents who had higher incomes, completed more years of formal schooling, and were affiliated with clubs, had higher LSES scores. The actual number of clubs in which an individual was active bordered on being significantly correlated with LSES scores. In the case of illness, the higher the total number of illnesses the more likely LSES scores would be low. This effect, however, was significant only for self-report and not for the provider report of total illnesses. In addition, it was found that individuals who have higher incomes and education levels, and are married are less likely to be in long-term care facilities and more likely to be receiving health care in a community setting. Location of health care is an additional factor that is related to life satisfaction. An analysis of the major contributing variable of HCE to level of life satisfaction is presented in Table 3. This table lists the mean LSES scores for the total and each of the 8 LSES categories for each HCE. In all of the LSES categories, except on the meaning of life subscale, those receiving home care had the lowest average scores. In all cases, those residing in an HRF or SNF had either the highest or among the highest averages. A one-way analysis of variance by HCE was performed for total LSES scores and the 8 LSES subscales, and results are also presented in Table 3. These results indicate that, in spite of limited sample size, there is significant difference between HCE scores on
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TABLE
3
Mean Physician Ranking of Illness Severity and Mean Scores on Total LSES and Subscales with F Values by Health Care Setting
Physician Ranking of Illness Severity* Total LSES Routine Goals Meaning of Life Mood Tone Self-concept Health Financial Security Social Contact Notes:
Clinic
MD
2.03 132.37 16.75 16.81 15.69 17.58 17.29 13.48 15.93 18.77
2.00 132.97 16.02 17.58 16.47 18.14 17.54 12.47 15.30 19.47
HRF
2.03 136.79 18.13 18.34 16.17 18.45 17.64 13.87 14.68 19.47
SNF
2.05 138.20 17.03 17.48 17.20 18.33 16.95 15.83 16.20 19.23
HosDital 2.07 133.25 16.60 16.78 15.88 17.50 17.25 13.88 15.80 19.58
HHC
2.05 118.74 12.47 14.53 15.95 16.26 15.53 11.21 14.46 18.21
F
,382 2.627** 6.788** 3.648** I.311 1.558 1.677 6.172** ,839 .608
*Based on a rank order: I = mild; 2 = moderate; 3 - wvere **Significant beyond p < .05.
LSES total and the LSES subcategories of routine goals and health. In those four instances, F tests were significant beyond the p < .05 level. Also listed in Table 3 is the mean physician severity ranking of illness level by health care setting. The one-way analysis of variance indicated no significant difference by HCE.
DISCUSSION Those individuals in the present study who were white, had higher levels of income, had completed more formal schooling, reported themselves affiliated with, although not necessarily active in, a number of clubs, and perceived themselves as healthy had higher levels of life satisfaction. These findings tend to concur with the results of other studies of life satisfaction, which also indicate significant correlations between life satisfaction and race, income, educational level completed, club affiliation, and selfperception of health (Campbell et al. 1976; Edwards and Klemmack 1973; Herzog and Rogers 198 1; Larson 1978; Salamon 1985a; Spreitzer and Snyder 1974; Zautra and Hempel 1984). In other words, those who are more advantaged have high life satisfaction, a not-too-surprising finding. These results also contribute to the validity of the LSES by indicating that it is accurate and sensitive to these variables. If, as suggested by the GAO report, individuals receiving health care at home consistently reported higher levels of well-being, it would be anticipated that the same results would have been found in the study. This, however, was not the case. The average life satisfaction scores in the present study were higher for those residing in an HRF or SNF. Those receiving health care at home had the lowest, or among the lowest, LSES scores. This appears to be a surprising finding, although it is consistent with other recent findings (Geriatrics 1983; Schwirian 1982). There are a variety of explanations that may help to clarify these results. It is possible that those respondents residing in an HRF or SNF were a select group of individuals who were actively involved in the daily routine and fairly alert, while those served by
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the HHC may have been more ill. Thus, different degrees of illness could explain the differences obtained. This is thought, however, to be unlikely given that both groups had similar types and mean number of illnesses (Salamon 1985b) as well as the fact that the average severity ranking by HCE resulted in an insigni~cant difference. A more plausible explanation may be derived from the pattern of LSES subscale differences. The routine subscale is a measure of pleasure in daily activities. HRFs and SNFs have staff dedicated to providing an ongoing variety of programs. Perhaps the greater amount of affiliation provided by a broad variety of programs is the important factor (Salamon and Nichol 1982). Those served by the HHC, while having their health needs cared for in their own homes, may be socially isolated and may not have their needs for daily activity and companionship met. Those in the present study receiving health care at home reported more frequent contact with relatives, however, these contacts may not meet their needs adequately. Further, without a variety of diversions, daily routine may become boring and life may begin to lose its meaning. The research on recreation and socialization activities suggests that they are important in acting as a buffer against stress and in overcoming loneliness and depression in the elderly (Kaplan, Campbell, and Gore 1977). The significant differences between HCEs and LSES health subscale score, while initially surprising, may also be better understood when examining the HCEs. While it is true that few, if any, individuals wish to move to a nursing home or even an intermediate-care facihty (Krause 19821, once they do Live there, their illness, a major factor contributing to the need for institutionalization, may no longer be a serious impediment. Limitations due to health may be less of a problem when individuals reside in a facility designed to help them cope better with their illness. Even when one has all the health and surgical supplies one needs in one’s own home, the basic environment may not be designed for easy access and ambulation. People can be inappropriately institutionalized in their own homes if staying there deprives them of services generally offered in an institution (Koff 1982). Furthermore, limitations of physical health tend, when in the community, to constitute a threat to one’s self-esteem. This is less likely in a facility. All of the residents have some form of physical limitation. Once an individual resides in an HRF or SNF and views others suffering health losses, their own health limitations may no longer be viewed as overwhelmingly negative (Myles 1978). When viewed from the perspective of equity theory, reasons for the differences in LSES goal subscale scores between HHC and HRF and SNF may become clearer. According to equity theory people who receive less than they feel they deserve experience distress. A major goal of well-being as individuals age may be to feel that they are receiving the care they require and are being properly cared for (Carp, Carp, and Millsap 1982). This feeling of being properly cared for may occur only at the HCE sites where total care is provided. This may indirectly result from the lessening of family tension when the older adult requiring health care is institutionalized (Smith and Bengston 1979). When an older adult is cared for in their own home the family is usually involved in patient care. This causes an increase in family tensions as family members are called upon to provide services they are unwilIing or unable to provide (Lipman 1979). The elder family member may feel uncomfo~ab~e recognizing that the family cannot provide the appropriate care, When an older adult is institutionalized the family may be freer to provide the necessary additional psychosocial supports, in the form of
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reminiscing and conversation, while staff of the facility provide the technical care (Dobroff and Litwak 1977). This adds to the older adults’ feeling of satisfaction with their expectation for care.
CONCLUSION There is a broader issue addressed by the findings reported here. The arguments for expanding home care services and placing increasingly less emphasis on nursing home care for the aged is based on three issues: cost, longevity, and personal satisfaction (or quality of life). As mentioned, there is considerable question regarding the cost-benefit of providing care to the infirm elderly in their own homes (GAO 1982; Weissert et al. 1980). Similarly, those studies that indicate that receiving health care in one’s own home contributes to longevity are contradicted by others that suggest that individuals receiving care in nursing homes are more functionally impaired and thus have a shorter life expectancy, making it improper to compare the two groups of individuals (Hughes 1985; Weissert 1985). Finally, the issue of happiness- satisfaction with life or life satisfaction being higher when care is provided in one’s own home as opposed to a nursing home-is called into question by this study. The results indicate that those receiving health care at home had the lowest levels of life satisfaction while those in HRF or SNF had the highest. If subjective levels of well-being are higher in a long-term care facility, and if residential long-term care is more cost effective and does not affect longevity, would it not be more beneficial to reexamine funding policies relevant to long-term care settings? We should not minimize the challenge of these findings to the new wave in health care, which is increasingly emphasizing the expansion of home care services. The participants of the present study were similar to the elderly population of the United States on most demographic factors. There were some differences found in marital and occupational status. This may, however, be due to where the respondents in the present study were located. While efforts were made to select participants without bias using random selection within facilities, the present study is somewhat limited as a result of both a relatively small sample size and the use of sites of convenience. Also the subjective measure of illness related to another subjective measure, LSES, while the objective measure of illness did not. Thus, there may be a need to develop or utilize a more objective measure of degree of severity of illness in order to control for it across settings in future studies. Despite these limitations, the results strongly suggest the need for further exploration. Additional types of facilities and home care programs, along with controls for related variables, as well as larger samples should be surveyed before further programming and policies regarding best methods of long-term care practices are written into stone. It would be unwise to commit to a program of care that is not beneficial in terms of cost, longevity, and life satisfaction. ACKNOWLEDGMENTS
Sylvia Mayer,
Allan
The author would like to thank doctors William Lundy, and Charles Levinthal
for their direction
Metlay, Bernard Ciorman, and support.
also wishes to thank Dr. Ruth Bennett for her constructive review of an earlier draft.
The author
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REFERENCES Administration on Aging. (1982). Facts About Older Americans: 1980-1981. Washington, DC.: Department of Health and Human Services. Campbell, A., P.E. Converse, and W.L. Rogers. (1976). The Quality of American Life. New York: Russell Sage Foundation. Carp, F.M., A. Carp, and R. Millsap. (1982). “Equity and Satisfaction Among the Aged.” Aging and Human Development 15: 15 I- 166. Conte, V.A., and M.J. Salamon. (1982). “An Objective Approach to the Measurement and Use of Life Satisfaction with Older Persons.” Journal of Measurement and Evaluation in Gutiiance 14: 194-200. DeCrosta, T. (1984). “Home Health Care: It’s Red Hot and Right Now.” Nursing Life 4: 53-60. Dobroff, R.D., and E. Litwak. (1977). Maintenance of Family Ties of Long-Term Care Patients. Bethesda, MD: NIMH. Dunlop, B.D. (1980). “Expanded Home-Based Care for the Impaired Elderly: Solution or Pipe Dream?” American Journal of Public Health 70: 5 15-549. Edwards, J., and L. Klemmack. (1973). “Correlates of Life Satisfaction: A Re-examination.” Journal of Gerontology 28: 497-502. General Accounting Offtce (GAO). (1982). The Elderly Should Benefit from Expanded Home Health Care But Increasing These Services Will Not Insure Cost Reduction GAO. IPE-83- 1, Gaitherburg, MD: Document Handling and Information Services Facility. George, L.K., and R. Landerman. (1984). “Health and Subjective Well-being: A Replicated Secondary Data Analysis.” Aging and Human Development 19: 133- 156. Geriatrics. (1983). “What’s New.” 38: 10-26. Herzog, A.R., and W.L. Rodgers. “Age and Satisfaction: Data from Several Large Surveys.” Research on Aging 3: 142-165. Hughes, S.L. (1985). “Apples and Oranges? A Review of Evaluation of Community-Based Long-Term Care.” Health Services Research 20: 46 l-488. Kaplan, B., J.C. Campbell, and S. Gore. (1977). ‘Social Support and Health.” Medical Care 25(Supplement): 47-58. Koff, T.H. (1982). Long-Term Care: An Approach to Serving the Frail Elderly. Boston: Little, Brown, Kramer, A.M., P.W. Shaughnessy, and M.L. Pettigrew. (1985). “Cost-Effectiveness Implications Based on a Comparison of Nursing Home and Home Health Care Mix.” Health Services Research 20: 387-406. Krause, D.R. (1982). Home Bittersweet Home: Old Age Institutkts in America Springfield, IL: Charles C. Thomas. Larson, R. (1978). “Thirty Years of Research on the Subjective Well-being of Older Americans.” Journal of Gerontology 33: 190-205. Lipman, A. (1979). “Impact of Demographic Changes on the Family.” Pp. 37-65 in Recent Advances in Gerontology. Excerpta Medica (Amsterdam, Netherlands). Myles, J.F. (1978). “Institutionalization and Sick Role Identification Among the Elderly.” American Sociological Review 43 1: 508-520. Neugarten, B.L., R.J. Havighurst, and S.S. Tobin. (196 1). “The Measurement of Life Satisfaction.” Journal of Gerontology 16: 134- 143. Robinson, B.C. (1983). Charactetistics of Housebound Elderly. Paper presented at the 36th Annual Meeting of the Gerontological Society of America, San Francisco. Salamon, M.J. (1983). Life Satisfaction and Health Care Environment. Paper presented at the 36th Annual Meeting of the Gerontological Society of America, San Francisco.
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. (1985a). “Sociocultural Theories in the Elderly: A Replication and Extension.“ Activities, Adaptation and Aging 7: 1 11- 122. ~. (1985b). “Medication Use and Illness: The Relationship Between Self and Provider Report.” Clinical Gerontologist 3: 17-22. Salamon, M.J., and V.A. Conte. (1981). 7’he Salamon-Conte Life Satisfaction in the Et&/y Scale and the Eight Categories of Life Satisfaction. Paper presented at the 34th Annual Meeting of the Gerontological Society of America, Toronto. -. (1984). The Life Satisfaction in the Elderly Scale. Odessa, FL: Psychological Assessment Resources. Salamon, M.J., and A. Nicol. (1982). “Rx for Recreation.” Aging 333-334: 18-22. Schwirian, P.M. (1982). “Life Satisfaction Among Nursing Home Residents.” Geriatric Nurstig 3: 111-114. Smith, K.F., and V.L. Bengston. (1979). “Positive Consequences of Institutionalization: Solidarity Between Elderly Parents and Their Middle-Aged Children.” The Gerontologist 19: 438-447.
Spreitzer, E., and E. Snyder. (1974). “Corelates of Life Satisfaction Among the Aged.” Journal of Gerontology 29: 454-458.
Weissert, W.G. (1985). “Seven Reasons Why it is so Difficult to Make Community-Based Long-Term Care Cost-Effective.” Health Services Research 20: 423-434. Weissert, W.G., T. Wan, B. Livieratos, and S. Katz. (1980). “Effects and Costs of Day Care Services for the Chronically Ill.” Medical Care 18: 567-584. Zautra, A., and A. Hempel. “Subjective Well Being and Physical Health: A Narrative Literature Review with Suggestions for Future Research.” Aging and Human Development 19: 95- 110.
This study examines the impact of where health care is received on the life satisfaction of older adults. Using a questionnaire, this study surveyed 241 individuals receiving care in six health care environments. Life satisfaction was assessed using the Life Satisfaction in the Elderly Scale. Results indicated that individuals residing in long-term care facilities have higher overall levels of well-being. Those receiving home health care had the lowest. Score patterns are reviewed and possible explunations discussed ABSTRACT:
Recent government policy has been in the direction of limiting the growth of nursing home bed capacity in the United States. Emphasis has instead been placed on providing a comparable level of health care services to older adults in their own homes. It has been assumed that a better and less costly form of care can be provided in one’s own home or apartment. A recent report by the General Accounting Office (GAO) (1982) has indicated that this shift of priorities to increased funding of home health services for the chronically ill elderly may not be a cost-effective alternative. Yet, while these findings are similar to those reported elsewhere (Kramer, Shaughnessy, and Pettigrew 1985; Weissert 1985; Weissert, Wan, Livieratas, and Katz 1980), the GAO study concluded that when professional health care services are provided in the home, the longevity of chronically ill older adults is improved and increases in selfreported levels of life satisfaction are recorded. The other authors have, however, pointed out that the comparisons between the chronicity of care in home versus nursing home are somewhat misleading as those in nursing homes may require either more or a different level of functional care. Therefore, longevity is not necessarily an outcome of placement. Direct all communicakms to: Michael Broadway,
Suite IA,
J. Salnmon. Executive Director, Woodmere, NY 11598.
The Adult Developmenr Center, 920
JOURNAL OF AGING STUDIES, Volume 1, Number 3, pages 287-297. Copyright @ 1987 by JAI Press, Inc. All rights of reproduction in any form reserved. ISSN: 08904065.
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It has also been suggested that older adults are generally happier receiving health care in their own homes (DeCrosta 1984). Several studies call this finding into question as well. Dunlop (1980), in his review, found cause to debate this assumption. His results indicated that home health care would not significantly reduce rates of institutionalization and decrease family stress, neither would it increase life satisfaction for the majority of those receiving such care. Similarly, Robinson (1983) reported that individuals receiving care in their own homes had lower levels of subjective wellbeing. Further, two other pilot studies found that life satisfaction is relatively high among older adults who reside in long-term health care facilities (Genhtrics 1983; Schwirian 1982). The measurement of subjective well-being, often referred to as life satisfaction, has been an issue of increasing relevance to gerontologists. Over the years, despite the technique used to assess subjective well-being, a number of variables have been shown to relate consistently to life satisfaction. Among these, socioeconomic status is one of the strongest correlates of life satisfaction. Those individuals with higher incomes have higher levels of life satisfaction (Edwards and Klemmack 1973; Larson 1978). There is also evidence suggesting that people who are married have higher levels of life satisfaction than those who are single, widowed, or divorced (Spreitzer and Snyder 1974). Other findings suggest that one’s race and affiliation with voluntary associations are also related to subjective well-being (Larson 1978; Salamon 1985a). Perhaps the most consistent finding is that older individuals who perceive themselves as being healthy report higher levels of life satisfaction (Campbell, Converse, and Rogers 1976; George and Lander-man 1984; Herzog and Rogers 198 1). While this finding may seem apparent it has implications beyond its simplicity. Perhaps the subjective reporting of physical well-being is mediated by other variables. One possible intervening variable is where older adults receive their health care. This study explores, in somewhat more detail, one of these issues. Specifically, the study was designed to explore whether life satisfaction is higher when the chronically ill elderly receive their health care in their own home as compared to other health settings. The rationale for this is based on the assumption that almost all of the variables that interact with life satisfaction may also interact with physical wellbeing (Zautra and Hempel 1984). There are a variety of health care settings where one may have health needs met. Each setting has its own characteristics. Some settings, such as residential care facilities or clinics attached to senior citizen centers, provide socialization and recreation programming in addition to basic health care. Physicians’ offices and acute care hospitals provide, almost exclusively, medical model health care. In these settings very little attention is given to patients’ other needs. Families are often called upon to provide case management and more direct care when an older adult relative requiring health care remains in the community (Koff 1982). When the older adult requires more intensive home health care their needs may serve to increase tension in the family and detract from the families ability to provide more appropriate social support (Dobroff and Litwak 1977; Smith and Bengston 1979). It is therefore possible that one of the settings along the health care continuum has, as a result of these factors, more of an impact on an older adult’s subjective well-being than the others.
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289
METHOD Sample The facilities surveyed in this study were sites of convenience, selected for the type of health care environment (HCE) they provided. The 6 HCEs were all located in the New York Metropolitan area and included 2 clinics affiliated with senior centers (clinic), 3 private physician’s offices (MD), 2 hospitals, 4 health-related or intermediate-care facilities (HRF), 3 skilled nursing facilities (SNF), and 2 health care service programs providing care to homebound elderly (HHC). Clinic sites at senior centers were diagnostic and treatment centers providing screening and health monitoring. These clinics were staffed full-time by a nurse and social worker supervised by a consulting physician. The 3 private physician offices belonged to 3 independent doctors. Despite the fact that two of the physicians specialized in gastroenterology, the third in oncology, all three reported that 90% of their practice was in general care for geriatrics. The two hospitals provided acute care and were both affiliated with major university medical schools. Both hospitals can be considered average in size, containing approximately 300 beds. The intermediate-care facilities provided supervision but limited direct medical intervention. Although the focus of care was considered medical, most programming was social and recreational. The skilled nursing facilities provided intensive nursing care within a medical model. The care, unlike that in a hospital, was not medically aggressive as the patients generally did not suffer acute distress. Home health care was similar to the care provided within an intermediate-care facility or skilled nursing facility setting. The major difference was the physical environment. A facility can never be like home, and, for the time that the care provider was in the patient’s house, the interaction was exclusively one on one. Within HCE categories, facilities were selected from different ethnic neighborhoods. This was done to gain as broad a representation as possible within each category. After securing approval from the facility or health care provider, study participants in the clinics, HRF, SNF, HHC, and HCEs were randomly selected from membership lists. Individuals at the MD and acute hospital sites were randomly drawn from those in attendance on a randomly selected day of the week. A total of 294 persons were individually contacted and asked to participate in the study, 60 at the clinic sites, 50 at the 2 hospitals, and 23 in the 2 HHC catchment areas.
Instrument This study used the Salamon-Conte Life Satisfaction in the Elderly Scale (LSES) (Salamon and Conte 1984) to measure subjective well-being. The LSES is a 40-item questionnaire that measures subjective well-being in 8 categories (Salamon and Conte 198 1). The first 5 of the 8 categories follow those hypothesized by Neugarten et al. (1961). The 3 additional categories were drawn from a review of the literature (Larson 1978). The LSES has been found to be a highly useful measure of life satisfaction. In addition to its psychometric properties it is one of the most complete measures of subjective well-being designed to measure 8 distinct categories shown to load into life satisfaction. The 8 categories that make up the LSES are: (1) Pleasure in daily activities
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(routine); (2) Goodness of fit between desired and achieved goals, a matching of the individual’s degree of satisfaction with their present stage of life relative to previous stages; (3) Meaning of life, a measure of the individual’s sense of usefulness and purpose in life; (4) Mood tone, general positive affect, happiness, or optimism; (5) Self-concept, the degree of personal self-regard and favorable self-appraisal; (6) Perceived level of health, the self-assessment of overall physical well-being; (7) Financial security, satisfaction with present and recent financial situations; and (8) Social contact, satisfaction with number and quality of social contacts. Factor analytic and clustering techniques support the validity of these 8 categories or factors (Salamon and Conte 1984). Each of the 8 categories contain 5 questions with 5 response options. Response options are coded numerically and scores in each of the 8 categories range from 0 to 25. The maximum total LSES score is 200. The higher the individual’s score the higher the individual’s level of life satisfaction. A variety of studies to assess the reliability and validity of the LSES indicate that it is a psychometrically sound instrument with coefftcient alphas ranging from (Y= .50 to (Y= .92 (Conte and Salamon 1982; Salamon 1983). In addition to the LSES, the survey instrument contained a variety of questions to assess demographic variables. These variables included age; marital status; socioeconomic status, measured by combining education, income, and occupational status; race; ethnicity; living environment; voluntary association; and health. Health was measured objectively by provider report and subjectively via self-report. The health care provider, who in almost all instances was a physician, was asked to rank the severity of the individual’s overall illess using the following scale: 1 = mild; 2 = moderate; 3 = severe. Findings reported elsewhere (Salamon 1985b) indicated high rates of agreement between self- and provider report.
Procedure The respondents were presented with a consent form and a questionnaire. A total of 294 survey questionnaires were individually distributed to patients in the HCEs. Respondents were asked to answer the questions as honestly and accurately as possible. They were informed that the questionnaire did not measure ability, neither did it affect the care they were receiving. Confidentiality was assured. They were informed, however, that objective ratings of physical health would be obtained from their health care provider. When necessary an assistant read the material to the subject but did not interpret the items or response choices.
Data Analysis In keeping with accepted procedures data were analyzed using traditional techniques. In particular, chi-square, a robust measure for differences among proportions, was used to examine the differences on demographic and background variables with general census. Following procedures often used in life satisfaction research, productmoment correlations were used to explore the strength and direction of relationships between life satisfaction and other variables. A series of one-way analyses of variance were also employed to determine if significant differences existed between means for HCEs.
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in the Elderly
RESULTS Fifty-two (87%) questionnaires were returned at the 2 clinic sites; 42 (78%) at the 3 MD sites; 47 (78%) at the 4 HRF sites; 40 (87%) at the 3 SNF sites; 40 (80%) at the 2 hospital sites; and 19 (83%) at the 2 HHC sites. Two hundred forty-one completed questionnaires were returned. As can be seen in Table 1 the subjects in the present study were not significantly different than the population at large. Those items for TABLE
1
Demographic Characteristics of Older Adults in the Present Study: Compared to Census Data (1982) Demographic
Characteristics
Percent
Census Data Percent
60-74 75-84 85+
60.0 23.2 6.2
68 24 8
Gender Male Female
35.0 64.0
38 62
Marital Status Married Divorced Widowed Separated Single
40.0 5.8 40.7 3.7 9.5
Occupational Status Professional Managerial Laborer
x2
df
1.37
2
.197
I
50 5 40 4 1
14.41*
4
17.0 32.4 24.9
25 45 20
7.29*
2
Income $2,399 2,400-3,599 3,600-5,999 6,000-9,999 1o,ooo+
23.2 13.3 19.5 10.0 21.2
18 30 I8 I5 I9
l2.85*
4
Education Completed High School College
42.7 12.0
41 I9
2.58
I
Race White Nonwhite
87.1 12.5
88 12
.30
I
Living Arrangements Alone With Spouse With Children Other (Including Institutions)
29.5 34.0 6.2 26.7
35 35 6 24
.94
3
Note:
*p < .OS.
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2
Biserial and Product Moment Correlations Between Total LSES Scores and Background Variables, p. r2 r
D
r2
Race
.I248
,020
.Ol56
Sex
.0293
,220
.0009
-.0007 .I863
.63 I ,002
.0347 .0347
Age Income
.oooo
.I863
.002
Total Club Affiliations
.I217
,030
,148
Total Number of Clubs Active in
.I010
.059
.OOlO
-.23 16
.ooo
.0536
-.0553
.I97
.0002
Years of Education
Total Self-Report
Completed
Ailments
Total Provider Report Ailments
which census data were available (Administration on Aging 1982) indicate that only in the areas of marital status, occupational status, and income levels were significant differences found. Those in the present study reported higher rates of being single, lower status occupations, and lower income rates than the norm. These differences may be related to the types of individuals receiving long-term health care and thus reflect an appropriate selection factor. As can be seen in Table 2, product-moment correlations show that socioeconomic status, affiliation with voluntary organizations, and perception of illness are related to overall well-being. For the purpose of this study both race and sex were coded categorically. White and male were each coded as 1. In the case of race, those who were white had higher LSES scores. In the case of gender, there was no significant difference between males and females. The remaining variables contained in Table 2 were coded continuously. Those respondents who had higher incomes, completed more years of formal schooling, and were affiliated with clubs, had higher LSES scores. The actual number of clubs in which an individual was active bordered on being significantly correlated with LSES scores. In the case of illness, the higher the total number of illnesses the more likely LSES scores would be low. This effect, however, was significant only for self-report and not for the provider report of total illnesses. In addition, it was found that individuals who have higher incomes and education levels, and are married are less likely to be in long-term care facilities and more likely to be receiving health care in a community setting. Location of health care is an additional factor that is related to life satisfaction. An analysis of the major contributing variable of HCE to level of life satisfaction is presented in Table 3. This table lists the mean LSES scores for the total and each of the 8 LSES categories for each HCE. In all of the LSES categories, except on the meaning of life subscale, those receiving home care had the lowest average scores. In all cases, those residing in an HRF or SNF had either the highest or among the highest averages. A one-way analysis of variance by HCE was performed for total LSES scores and the 8 LSES subscales, and results are also presented in Table 3. These results indicate that, in spite of limited sample size, there is significant difference between HCE scores on
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TABLE
3
Mean Physician Ranking of Illness Severity and Mean Scores on Total LSES and Subscales with F Values by Health Care Setting
Physician Ranking of Illness Severity* Total LSES Routine Goals Meaning of Life Mood Tone Self-concept Health Financial Security Social Contact Notes:
Clinic
MD
2.03 132.37 16.75 16.81 15.69 17.58 17.29 13.48 15.93 18.77
2.00 132.97 16.02 17.58 16.47 18.14 17.54 12.47 15.30 19.47
HRF
2.03 136.79 18.13 18.34 16.17 18.45 17.64 13.87 14.68 19.47
SNF
2.05 138.20 17.03 17.48 17.20 18.33 16.95 15.83 16.20 19.23
HosDital 2.07 133.25 16.60 16.78 15.88 17.50 17.25 13.88 15.80 19.58
HHC
2.05 118.74 12.47 14.53 15.95 16.26 15.53 11.21 14.46 18.21
F
,382 2.627** 6.788** 3.648** I.311 1.558 1.677 6.172** ,839 .608
*Based on a rank order: I = mild; 2 = moderate; 3 - wvere **Significant beyond p < .05.
LSES total and the LSES subcategories of routine goals and health. In those four instances, F tests were significant beyond the p < .05 level. Also listed in Table 3 is the mean physician severity ranking of illness level by health care setting. The one-way analysis of variance indicated no significant difference by HCE.
DISCUSSION Those individuals in the present study who were white, had higher levels of income, had completed more formal schooling, reported themselves affiliated with, although not necessarily active in, a number of clubs, and perceived themselves as healthy had higher levels of life satisfaction. These findings tend to concur with the results of other studies of life satisfaction, which also indicate significant correlations between life satisfaction and race, income, educational level completed, club affiliation, and selfperception of health (Campbell et al. 1976; Edwards and Klemmack 1973; Herzog and Rogers 198 1; Larson 1978; Salamon 1985a; Spreitzer and Snyder 1974; Zautra and Hempel 1984). In other words, those who are more advantaged have high life satisfaction, a not-too-surprising finding. These results also contribute to the validity of the LSES by indicating that it is accurate and sensitive to these variables. If, as suggested by the GAO report, individuals receiving health care at home consistently reported higher levels of well-being, it would be anticipated that the same results would have been found in the study. This, however, was not the case. The average life satisfaction scores in the present study were higher for those residing in an HRF or SNF. Those receiving health care at home had the lowest, or among the lowest, LSES scores. This appears to be a surprising finding, although it is consistent with other recent findings (Geriatrics 1983; Schwirian 1982). There are a variety of explanations that may help to clarify these results. It is possible that those respondents residing in an HRF or SNF were a select group of individuals who were actively involved in the daily routine and fairly alert, while those served by
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the HHC may have been more ill. Thus, different degrees of illness could explain the differences obtained. This is thought, however, to be unlikely given that both groups had similar types and mean number of illnesses (Salamon 1985b) as well as the fact that the average severity ranking by HCE resulted in an insigni~cant difference. A more plausible explanation may be derived from the pattern of LSES subscale differences. The routine subscale is a measure of pleasure in daily activities. HRFs and SNFs have staff dedicated to providing an ongoing variety of programs. Perhaps the greater amount of affiliation provided by a broad variety of programs is the important factor (Salamon and Nichol 1982). Those served by the HHC, while having their health needs cared for in their own homes, may be socially isolated and may not have their needs for daily activity and companionship met. Those in the present study receiving health care at home reported more frequent contact with relatives, however, these contacts may not meet their needs adequately. Further, without a variety of diversions, daily routine may become boring and life may begin to lose its meaning. The research on recreation and socialization activities suggests that they are important in acting as a buffer against stress and in overcoming loneliness and depression in the elderly (Kaplan, Campbell, and Gore 1977). The significant differences between HCEs and LSES health subscale score, while initially surprising, may also be better understood when examining the HCEs. While it is true that few, if any, individuals wish to move to a nursing home or even an intermediate-care facihty (Krause 19821, once they do Live there, their illness, a major factor contributing to the need for institutionalization, may no longer be a serious impediment. Limitations due to health may be less of a problem when individuals reside in a facility designed to help them cope better with their illness. Even when one has all the health and surgical supplies one needs in one’s own home, the basic environment may not be designed for easy access and ambulation. People can be inappropriately institutionalized in their own homes if staying there deprives them of services generally offered in an institution (Koff 1982). Furthermore, limitations of physical health tend, when in the community, to constitute a threat to one’s self-esteem. This is less likely in a facility. All of the residents have some form of physical limitation. Once an individual resides in an HRF or SNF and views others suffering health losses, their own health limitations may no longer be viewed as overwhelmingly negative (Myles 1978). When viewed from the perspective of equity theory, reasons for the differences in LSES goal subscale scores between HHC and HRF and SNF may become clearer. According to equity theory people who receive less than they feel they deserve experience distress. A major goal of well-being as individuals age may be to feel that they are receiving the care they require and are being properly cared for (Carp, Carp, and Millsap 1982). This feeling of being properly cared for may occur only at the HCE sites where total care is provided. This may indirectly result from the lessening of family tension when the older adult requiring health care is institutionalized (Smith and Bengston 1979). When an older adult is cared for in their own home the family is usually involved in patient care. This causes an increase in family tensions as family members are called upon to provide services they are unwilIing or unable to provide (Lipman 1979). The elder family member may feel uncomfo~ab~e recognizing that the family cannot provide the appropriate care, When an older adult is institutionalized the family may be freer to provide the necessary additional psychosocial supports, in the form of
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Health Care Environment and Life Satisfaction in the Elderly
reminiscing and conversation, while staff of the facility provide the technical care (Dobroff and Litwak 1977). This adds to the older adults’ feeling of satisfaction with their expectation for care.
CONCLUSION There is a broader issue addressed by the findings reported here. The arguments for expanding home care services and placing increasingly less emphasis on nursing home care for the aged is based on three issues: cost, longevity, and personal satisfaction (or quality of life). As mentioned, there is considerable question regarding the cost-benefit of providing care to the infirm elderly in their own homes (GAO 1982; Weissert et al. 1980). Similarly, those studies that indicate that receiving health care in one’s own home contributes to longevity are contradicted by others that suggest that individuals receiving care in nursing homes are more functionally impaired and thus have a shorter life expectancy, making it improper to compare the two groups of individuals (Hughes 1985; Weissert 1985). Finally, the issue of happiness- satisfaction with life or life satisfaction being higher when care is provided in one’s own home as opposed to a nursing home-is called into question by this study. The results indicate that those receiving health care at home had the lowest levels of life satisfaction while those in HRF or SNF had the highest. If subjective levels of well-being are higher in a long-term care facility, and if residential long-term care is more cost effective and does not affect longevity, would it not be more beneficial to reexamine funding policies relevant to long-term care settings? We should not minimize the challenge of these findings to the new wave in health care, which is increasingly emphasizing the expansion of home care services. The participants of the present study were similar to the elderly population of the United States on most demographic factors. There were some differences found in marital and occupational status. This may, however, be due to where the respondents in the present study were located. While efforts were made to select participants without bias using random selection within facilities, the present study is somewhat limited as a result of both a relatively small sample size and the use of sites of convenience. Also the subjective measure of illness related to another subjective measure, LSES, while the objective measure of illness did not. Thus, there may be a need to develop or utilize a more objective measure of degree of severity of illness in order to control for it across settings in future studies. Despite these limitations, the results strongly suggest the need for further exploration. Additional types of facilities and home care programs, along with controls for related variables, as well as larger samples should be surveyed before further programming and policies regarding best methods of long-term care practices are written into stone. It would be unwise to commit to a program of care that is not beneficial in terms of cost, longevity, and life satisfaction. ACKNOWLEDGMENTS
Sylvia Mayer,
Allan
The author would like to thank doctors William Lundy, and Charles Levinthal
for their direction
Metlay, Bernard Ciorman, and support.
also wishes to thank Dr. Ruth Bennett for her constructive review of an earlier draft.
The author
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