ORIGINAL ARTICLE THE EFFECT OF A HEALTHY LIFESTYLE PROGRAM ON THE ELDERLY S HEALTH IN ARAK D. HEKMATPOU, M. SHAMSI 1, M. ZAMANI 2

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2 70 ORIGINAL ARTICLE THE EFFECT OF A HEALTHY LIFESTYLE PROGRAM ON THE ELDERLY S HEALTH IN ARAK D. HEKMATPOU, M. SHAMSI 1, M. ZAMANI 2 ABSTRACT BACKGROUND: Increasing life expectancy and decreasing birth rate have led to an increase in the elderly population worldwide so that the aging population is considered one of the biggest public health concerns in the present century which demands more attention to this vulnerable group. Therefore, the present study was done to determine the effect of a healthy lifestyle program on elderly s health in Arak. MATERIALS AND METHODS: This quasi experimental intervention study was carried out on 60 elderly citizens of Arak. The participants attended four instructional classes on nutrition, exercise, sleep hygiene, life skills, and personal hygiene over one month and they were followed for three months after the intervention. Data were collected through standard quality of life questionnaire (SF 36) and Katz standard ADLs in the elderly questionnaire before and three months after the completion of the study. RESULTS: The average age of the participants was ± 5.02 years. In terms of gender, the majority of the participants (60%) were male. In terms of quality of life before the instructional intervention, 13.3% of the participants were in low level, 30% in average level, 41.7% in good level, and 15% in the high level of quality of life. However, after the intervention, the majority of the participants were in good (38.3%) and high (45%) levels of quality of life which showed significant differences before and after the instructional intervention (P < 0.001). Moreover, there was a significant difference between Katz ADLs in the elderly before and after the intervention (P < 0.001). CONCLUSION: The comparison between the quality of life and ADLs in the elderly before and after the intervention showed that continuing instruction for the elderly based on a regular healthy lifestyle program is effective and holding different instructional classes for this population, that is often ignored, seems necessary. The findings of this study can help design proper instructional guidelines on healthy lifestyle in the elderly. Key words: Elderly, healthy lifestyle, quality of life Assistant Professor, Ph.D in Nursing, 1 Assistant Professor, Ph.D in Health Education, 2 Nursing Student, Research Committee, Arak University of Medical Sciences, Arak, Iran Address for correspondence: Dr. Mohsen Shamsi, Department of Health Education, School of Public Health, Arak University of Medical Sciences, Arak, Iran. E mail: dr.shamsi@arakmu.ac.ir Access this article online Quick Response Code: Website: DOI: / PMID: *****************************

3 HEALTHY LIFESTYLE PROGRAM ON THE ELDERLY S 71 INTRODUCTION Old age is a normal part of human social life which is remarkably different from the other stages of life. [1] According to the most recent UN studies, mortality and morbidity rates have significantly declined and the numbers of the elderly and mean life expectancy have increased. [2] In Iran, according to the last census in 2007, the population of people who are over 60 is approximately that forms 7.2% of the total population of this country which is estimated to reach nearly 10% of the population (10 million people) in [3] In 2006, UN estimated the total number of the elderly to be which is expected to increase to nearly two billion people in This indicates the fast growth of the world s aging population. [4] Since the elderly are considered the vulnerable class in society, they face a number of specific age related problems which can be prevented by lifestyle modifications and corrections. [5] Healthy lifestyle is defined as the type of lifestyle that provides, preserves, and enhances the level of health and welfare. [6] Although the right type of lifestyle should be adopted since the prenatal period, it is never too late for making modifications in lifestyle and creating the right habits that result in health and livelihood. [7] Noticing the role of lifestyle in preventing diseases, improving the quality of life, increasing life expectancy, and improving mental and physical health is of paramount importance. [6] Other studies have also shown a significant relationship between ADL (activities of daily living) and exercising or walking, consuming milk, dairy products, meat products, fresh fruits and vegetables, low fat foods, and low salt foods. [4] In this regard, Heiwe et al s study was indicative of the positive effect of exercise on the quality of life in elderly women [8] and Lapid et al s study indicated the positive impact of a continuous care program on the quality of life. [9] Lifestyle during old age should cover different economic, health/welfare, and medical aspects. [7] The basics of a healthy lifestyle include observing correct nutritional principles and healthy sleep, having sufficient daily physical activity, avoiding smoking, having regular periodic medical check ups, having mental health, and participating in social activities together with one s family. [10] Noticing the various studies done on the quality of life and health in old age, it seems that these studies have each examined one aspect of the healthy lifestyle in this age group. On the other hand, few studies have been carried out to examine the effect of thorough holistic programs on the healthy lifestyle (activity, exercise, nutrition, medical support, diet, and health habits, including personal and social hygiene and so on) in Iran. Therefore, we decided to design a thorough healthy lifestyle program and implement it among the elderly residents of Arak, Iran. In fact, the findings of this program were to be suggested as a practical guide to the health officials of Markazi Province and Iran in order to help them prevent chronic diseases or reduce the burden of these diseases on the elderly so that they can enjoy a healthy, high quality life and live with greater satisfaction. MATERIALS AND METHODS The present study was an intervention quasi experimental one which was conducted

4 72 INDIAN JOURNAL OF MEDICAL SCIENCES on 60 senior citizens of Arak. The inclusion criteria were their written consent, not having progressive age related diseases and having a good memory. The sample size was determined by Altman nomogram, A = 0.05 and B = 80% parameters, and a size effect equal to 50% of a sample size equal to 55 individuals in a single group study. Noticing the possible attrition, a sample size including 60 elderly individuals was chosen for this study. Sampling was done in several stages in five health centers that were randomly selected in five districts in the south, north, center, east, and west of Arak. Through random selection of family codes based on the files available in the health centers, elderly individuals in regions under the auspices of health centers were chosen. After obtaining their written consent in case of being willing to participate in the study and meeting the inclusion criteria, they were included in the study. During the study, two subjects were excluded from the study and eventually it was carried out on 58 subjects. The inclusion criteria were lack of cognitive disorders and physical limitations, whereas the exclusion criteria were developing cognitive and physical problems during the study or being absent in more than one instructional intervention session. For conducting the study, all participants were invited to refer to the health center in their neighborhood on a certain day. After explaining the objectives and the duration of the study, written consent for participating in the study was obtained from them. Then demographic and standard quality of life (SF 36) questionnaires were modified and validated by Montazeri et al., [11] and together with Katz ADL questionnaire [12] were administered to the participants. The demographic questionnaire included variables, such as gender, age, marital status, education, and income. SF 36 questionnaire included 8 scales each composed of a combination of 2 to 10 questions. These scales included physical performance, physical limitations, physical pain, general health, livelihood, social performance, and mental problems as well as brief assessments including physical health (physical performance, physical limitation, physical pain, and general health) and mental health (social performance, mental problems, mental health, and livelihood) scales. It is noteworthy that the points for some questions were recorded so that all scales had the same pints. Each scale was rated from 0 to 100; 0 indicating the worst and 100 indicating the best conditions. In terms of the quality of life (SF 36) index, one was seen as very poor, two as poor, three as average, four as good, and five as high indexes of quality of life. Katz questionnaire for the elderly was completed for the samples and healthy lifestyle program during old age was taught to the participants, in four two hour sessions through audio visual tools and other educational materials. The participants were surveyed and followed for three months. During this period, educational sessions were held and the problems and questions of the participants were dealt with. At the end of this period, following instructional intervention, the same questionnaires were administered to evaluate the participants

5 HEALTHY LIFESTYLE PROGRAM ON THE ELDERLY S 73 and the results were compared. Since two participants did not have regular attendance in the study and the instructional sessions, only data related to individuals present in instructional classes and both tests (pre test and post test) were used. Participants with Katz scores less than three were considered totally dependent in terms of doing daily activities whereas those with scores four to six were seen as relatively dependent and independent, respectively. A healthy lifestyle is defined as the kind lifestyle that provides, preserves, and enhances the individual s level of health and welfare. [6] In the present study, a healthy lifestyle was attributed to implementing the designed healthy lifestyle program which was to provide, preserve, and enhance the level of health and welfare in the elderly population under study. The topics discussed in the instructional invention were selected from reliable texts and The Guide to healthy lifestyle during old age published by the Ministry of Health and Medicine which emphasized nutrition, oral medicine, prevention of osteoporosis, prevention of accidents, physical activities in the elderly, respiratory system, ears, eyes, and cardiovascular system health, recommendations on urinary system in the elderly, and recommendations for sleep health. [13,14] It should also be mentioned that before launching the program, the current project was evaluated and approved by the Ethics Committee of Arak University of Medical Sciences and written consent was obtained from all participants. Moreover, throughout the study, all ethical issues in research were observed. Data were collected using SPSS software and through descriptive statistics and inferential tests such as Chi square and based on Kolmogorov Smirnov for the normality of the distribution, and Wilcoxon non parametric test for making pre test/post test comparisons between some variables. RESULTS Of the total 60 participants, 58 participants were present till the end of the study and completed the questionnaires. The mean age in this group was 67.6 ± 5.02 years. In terms of gender, 24 women (40%) and 36 men (60%) were present in the study. Of these, 1 (1.71%) participant was single, 45 (75%) participants were married, and 14 (23.3%) participants were widowed. In terms of education, 31 (51.7%) participants were illiterate, 28 (46.7%) had elementary school education, and 1 (1.71%) had secondary school education. According to the results, 19 (31.7%) participants had low income, 23 (38.3%) had average income, 12 (20%) had good income, and 6 (10%) had high income [Table 1]. In terms of quality of life before the instructional intervention, eight individuals (13.3%) were in low level, 18 (30%) were in average level, 25 (41.7%) were in good level, and 9 (15%) were in the high level of quality of life. However, after the intervention, none of the participants were in the low or very low quality of life level and 10 (16.7%) participants were in the average level, 23 (38.3%) in the good level, and 27 (45%) were in the high level of quality of life that based on Wilcoxon test showed significant

6 74 INDIAN JOURNAL OF MEDICAL SCIENCES differences before and after the instructional intervention (P < 0.001) [Table 2]. With regard to the results obtained from Katz ADL questionnaire, 5 (8%) of the participants Table 1: The demographic features of the elderly in this study Groups/Demographic variables N % Age (years) Sex Female Mail Marriage status Single Marriages Widow Level of education Illiterate Elementary Middle school Family income Weak Moderate Good Excellent 6 10 Chronic of disease Yes No were totally dependent, 12 (20%) of them were relatively dependent, and 43 (71.7%) of them were totally dependent; however, after the instructional intervention, 6 (10%) of the participants were relatively dependent and the rest 54 (90%) were independent in doing daily activities. According to Wilcoxon test, there was a significant difference between the elderly s ADLs before and after the instructional intervention (P < 0.001) [Table 2]. Based on Kolmogorov Smirnov, data on general health (P > 0.163), livelihood and mental health (P > 0.458), physical health (P > 0.281), and psychological health (P > 0.708) had a normal distribution. Therefore, for comparing the means before and after the intervention, paired t test was used which showed a significant difference following the instructional intervention [Table 3]. Regarding social health (P < 0.016) and physical pain (P < 0.025), Kolmogorov Smirnov test revealed lack of a normal distribution of data and the non parametric Wilcoxon test was utilized to make comparisons between the scores before and after the intervention in the parameters. The results revealed significant Table 2: The frequency distribution of quality of life and ADLs indexes of the elderly before and three months after the instructional intervention Educational intervention/ Indexes ADLs indexes (Katz) Before intervention Three month after intervention N % N % Test of Wilcoxon Complete dependence /001 Relative dependence Independence Quality of life indexes (SF 36) Very poor /001 Poor Average Good High indexes ADL=Activities of daily living

7 HEALTHY LIFESTYLE PROGRAM ON THE ELDERLY S 75 Table 3: The comparison between different dimensions of quality of life (SF 36) of the elderly in Arak before and three months after the instructional intervention Educational intervention Quality of life indexes (SF 36) Before intervention Three month after intervention Mean SD Mean SD Test of Wilcoxon General health /001 Livelihood /001 Physical performance /001 Mental health /001 Social performance /001 Physical pain /001 Total quality of life index /001 differences between different dimensions of quality of life before and three months after the intervention (P < 0.05) [Table 3]. DISCUSSION In the present study, the sample population of the elderly had a relatively suitable quality of life. The findings of the study showed that the sample population had reported a higher level of mental health in comparison with physical health which can be due to the support provided by family and social networks. On the other hand, the wide spectrum of physical ailments associated with old age influence this greater level of mental health compared with physical health in the study group. Furthermore, Keffe in his study on the status of rehiring retirees and their quality of life indices showed that these indices are of better conditions in working retirees than non working retirees. This can be due to the establishment of social relationships and the increased index of quality of life, especially in mental health. [15] Tabolli study, however, demonstrated that that the elderly s physical health was of a better condition than their mental health. [16] In the present study, after instructional sessions on how to have a healthy lifestyle and following the target group for three months after the instructional sessions, the elderly under study obtained a better quality of life. Habibi et al. in their study found a significant relationship between quality of life and such behaviors as exercising or walking, consuming milk, dairy products, foods rich in meat, fresh fruits, vegetables, low salt foods, and low fat foods, monitoring health conditions, and controlling blood pressure. [17] In the present study, following instructional intervention, the majorities of the elderly (90%) were empowered in terms of doing their daily activities and could do their personal tasks independently which indicated the efficacy of the educational programs in this area. Bazrafshan et al. in their study entitled The effect of exercise on the quality of life of elderly women in Shiraz, Iran found a significant difference in the quality of life before (50) and after (75) implementing an exercise program. [18] In the present study, implementing a regular instructional program with a follow up design eventually resulted in enhancing and importing the elderly s quality of life which was indicative of the efficacy of the intervention. Salar et al. in their quasi experimental study on the effect of a continuing care counseling program on the

8 76 INDIAN JOURNAL OF MEDICAL SCIENCES quality of life of the elderly in Zahedan, Iran, showed that after four months of follow up, the quality of life score increased from 40 before the intervention to 56.5 after it. This was indicative of the positive impact of the continuing care counseling program. [19] Naoto et al. in their quasi experimental studied the effects of a 12 Month Multicomponent exercise program on physical performance, Daily Physical Activity, and Quality of life in elderly people with minor disabilities. It was shown that applying such a program significantly increased the elderly s quality of life in different dimensions such as physical performance, playing roles, pain reduction, general health, livelihood and vitality, social performance, emotional performance, and mental health in comparison with the period before the intervention, whereas over the same period the control group did not experience a significant change in different dimension of quality of life. [20] CONCLUSION Noticing the findings of the present study which indicated the low quality of life in the elderly population in Arak, Iran, holding healthy quality of life classes can be a major step in improving the level of health and quality of life in this vulnerable group since the ultimate goal of health and medical care is health improvement in social groups. The need for such a program seems more urgent in the elderly as a growing population. REFERENCES 1. Lapid MI, Piderman KM, Ryan SM, Somers KJ, Clark MM, Rummans TA. Improvement of quality of life in hospitalized depressed elderly. Int Psychogeriatr 2011;23: Butler J, Ciarrochi J. Psychological acceptance and quality of life in the elderly. Qual Life Res 2007;16: Mina Majd. A nursing program. Printing, Ministry of Health, Medical Education, Department of Health, Office of Family Health and Population. Tehran, Iran: UNFPA; Robichaud L, Durand PJ, Bédard R, Ouellet JP. Quality of life indicators in long term care: Opinions of elderly residents and their families. Can J Occup Ther 2006;73: Lamping DL, Constantinovici N, Roderick P, Normand C, Henderson L, Harris S, et al. Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: A prospective cohort study. Lancet 2000;356: Lai KL, Tzeng RJ, Wang BL, Lee HS, Amidon RL, Kao S. Health related quality of life and health utility for the institutional elderly in Taiwan. Qual Life Res 2005;14: Doumit J, Nasser R. Quality of life and wellbeing of the elderly in Lebanese nursing homes. Int J Health Care Qual Assur 2010;23: Heiwe S, Tollbäck A, Clyne N. Twelve weeks of exercise training increases muscle function and walking capacity in elderly predialysis patients and healthy subjects. Nephron 2001;88: Lapid MI, Piderman KM, Ryan SM, Somers KJ, Clark MM, Rummans TA. Improvement of quality of life in hospitalized depressed elderly. Int Psychogeriatr 2011;23: Kim IK, Cheong K. Patterns of family support and the quality of life of the elderly. Soc Indic Res 2003;62: Montazeri A. Translation of the Persian instrument reliability and validity of the standard SF 36. Q Monit 2004;5: Meredith W, Mary S. Katz Index of Independence in Activities of Daily Living (ADL). Urol Nurs 2007;2:55 61.

9 HEALTHY LIFESTYLE PROGRAM ON THE ELDERLY S Salehi L, Ardebili H, Mohammad K. Facilitating factors and barriers to healthy lifestyle in elderly people: A qualitative study. J School Public Health Institute Public Health Res 2008;6: Hatami H. Public Health's comprehensive book. 2 nd ed. Ministry of health and education of medicine. Tehran: Samat Publication; p O'Keefe EA, Talley NJ, Zinsmeister AR, Jacobsen SJ. Bowel disorders impair functional status and quality of life in the elderly: A population based study. J Gerontol A Biol Sci Med Sci 1995;50: Sampogna F, Tabolli S, Mastroeni S, Di Pietro C, Fortes C, Abeni D; Italian Multipurpose Psoriasis Research on Vital Experiences (IMPROVE) study group. Abenia Quality of Life Impairment and Psychological Distress in Elderly Patients with Psoriasis. Dermatology 2007;215: Habibi A, Nikpour S, Seiedoshohadaei M, Haghani H. Health promotion behaviors and Quality of life among elderly people: A cross sectional survey J Ardabil Univ Med Sci Health Serv 2008;8: Bazrafshan MH. The effect of exercise on quality of life of elderly women a daily member Jahandydgan Shiraz. Sr J 2006;11: Salar A. Effect ongoing consultation on quality of life of elderly people in Zahedan in Tabib East 2002;5: Naoto T, Yasuki H, Shinichi I, Hiromi K, Keitaro T. Effects of a 12 Month Multicomponent Exercise Program on Physical Performance, Daily Physical Activity, and Quality of Life in Very Elderly People With Minor Disabilities: An Intervention Study J Epidemiol 2010;20:21 9. How to cite this article: Hekmatpou D, Shamsi M, Zamani M. The effect of a healthy lifestyle program on the elderly s health in Arak. Indian J Med Sci 2013;67:70-7. Source of Support: Nil. Conflict of Interest: None declared.