Introduction
Day care centres represent a core community-based long-term care service for frail older adults. This type of service is aimed to sustain and preserve the functioning of frail older people, allowing them to age in place and meet some of their long-term care needs (Anetzberger Reference Anetzberger2002; Krout Reference Krout1995). It is believed that attendance at adult day care centres can promote older adults' quality of life (Bilotta et al. Reference Bilotta, Bergamaschini, Spreafico and Vergani2010). Quality of life among older people has become a major focus for research and a driver of social policy.
Indeed, some of the reasons for day-care participation are related to social interactions and friendships that are facilitated by day care centres and thus promote the wellbeing of the participants, reducing their levels of depression, buffering stress and increasing levels of life satisfaction (Garcia-Martin et al. Reference Garcia-Martin, Gomez-Jacinto and Martimportugues-Goyenechea2004; Valadez et al. Reference Valadez, Christine Lumadue, Gutierrez and de Vries-Kell2006; Williams and Roberts Reference Williams and Roberts1995). Baumgarten et al. (Reference Baumgarten, Lebel, Laprise, Leclerc and Quinn2002), for example, found that participation in social activities was associated with a decrease in feelings of anxiety and depression. In a literature review, Gaugler and Zarit (Reference Gaugler and Zarit2001) found that adult day care centres did not affect functional outcomes, but they did have a positive effect on the subjective wellbeing of the participants. A study conducted in India (Jacob et al. Reference Jacob, Abraham, Abraham and Jacob2007) found that participation in adult day care improved the quality of life of rural older adults. An Italian study (Bilotta et al. Reference Bilotta, Bergamaschini, Spreafico and Vergani2010) found that a greater frequency of weekly attendance at day care centres improved the quality of life of older adults suffering from depression. Another study conducted in the United States of America (USA) (Schmitt et al. Reference Schmitt, Sands, Weiss, Dowling and Covinsky2010) found that users of day care health centres reported higher levels of two domains of health-related quality of life: physical and emotional, compared to their counterparts who did not use this type of service. Another study (Hashizume and Kanagawa Reference Hashizume and Kanagawa1996) found that use of day care centres had a positive effect on quality of life among female users but no correlation was found between day care use and quality of life among male users. However, comparative studies that included matched samples of users and non-users of day care centres and the relation of day-care use on the various domains of quality of life are still scant.
It is therefore hypothesised that day care centre attendance can improve quality of life in various domains. However, study of the psychosocial benefits of adult day services to participants has been neglected and there is a paucity of studies that examined the effect of day-care attendance on visitors' wellbeing (Dabelko and Zimmerman Reference Dabelko and Zimmerman2008). Further, studies that examined the effects of day care centre use yielded inconsistent findings. Baumgarten et al. (Reference Baumgarten, Lebel, Laprise, Leclerc and Quinn2002), for example, found no evidence of any effect of day centre attendance on the client's anxiety, depression or functional status, while other studies (e.g. Emami et al. Reference Emami, Torres, Lipson and Ekman2000) found that attendance in day care centres was positively connected with health-related quality of life and alleviated depression and stress (Valadez et al. Reference Valadez, Christine Lumadue, Gutierrez and de Vries-Kell2006). Therefore, more research is needed in order to learn about the outcomes of day care centre use and their effectiveness in promoting the quality of life of their users compared to non-users of this type of service.
Day care centres in Israel
There are several models of adult day care centres: social, medical and integrated (Dabelko and Zimmerman Reference Dabelko and Zimmerman2008; Van Beveran and Hetherington Reference Van Beveren and Hetherington1998; Weissert Reference Weissert1976). The medical model includes assessment, care and rehabilitation, while the social model focuses on socialisation and prevention. The integrated model includes two elements from each model. In addition, there are adult day care centres that serve specific population groups of older persons such as cognitively impaired or physically disabled but cognitively intact. In the USA, for example, 37 per cent of the adult day care centres operate according to the social model (20 per cent of them serve cognitively impaired patients), 42 per cent operate according to the integrated model, and only about 21 per cent operate according to the medical model (Nadash Reference Nadash2003; Robert Wood Johnson Foundation 2003).
Day care centres are a core community-based service for frail older persons that started to develop in Israel in the early 1980s. After the enactment of the Long-Term Care Insurance Law in 1986 many new day care centres were established, aimed at enabling disabled elderly persons to age in place. To date there are approximately 180 day care centres that serve approximately 16,000 people (Brodsky, Shnoor and Be'er Reference Brodsky, Shnoor and Be'er2010) with most of them focusing on providing social and recreational activities and personal services. Studies (Be'er Reference Be'er1994; Iecovich and Carmel Reference Iecovich and Carmel2011) conducted in Israel found that most adult day care centres follow the social model and for the most part serve older persons who are moderately frail and who have a lower socio-economic status, while severely disabled older adults barely use this type of service although it is optional to all frail older persons regardless of their ethnicity or socio-economic status. Only a very few adult day care centres in Israel aim to serve cognitively impaired older persons, compared to 52 per cent in the USA (National Adult Day Services Association 2011).
Most of the centres operate five days a week, five to six hours a day, but there are also a few day care centres that operate six days a week and are open eight hours a day. The day care centres in Israel are heterogeneous in terms of their physical size, number of participants, characteristics of the participants, variety of services, auspices and operators. Most of the expenses are covered by the long-term care benefits to which disabled older persons are entitled under the Long-Term Care Insurance Law. This enables the participants to replace two to three hours of home-care services per day with a daily visit to a day care centre. Thus, people who are entitled to receive 10–18 weekly hours of home-care can replace that with day-care visits five days a week. The centres provide transportation and two meals a day (breakfast and lunch) for which the participants co-pay about $5 a day. For each participant, an individual care plan is prepared and provided by a multidisciplinary team. The core services provided at the day care centres include personal care, social activities, health promotion, meals, physical activities and laundry. No medical services are provided within the day care centres.
Methods
Sample
We used a quasi-experimental design to recruit respondents. The sample included 400 dyads of users of day care centres for functionally disabled older adults and 400 non-users. In addition, 17 users were included but without matched non-users. The sample of users was recruited through 12 day care centres in the southern region of Israel that serve altogether about 1,000 registered frail older adults. Inclusion criteria were: age over 60, speak Hebrew or Russian (about a third of the respondents were immigrants from former Soviet Union countries who immigrated to Israel after the collapse of the Soviet regime in 1989), disabled in terms of having difficulties in performing activities of daily living (ADL) but cognitively intact, and members of Clalit Health Service Organization, which is the largest health maintenance organisation (HMO) in Israel.
In Israel there are four HMOs that operate under the national health insurance law enacted in 1994 and provide universal health-care services to all its citizens. The Clalit HMO provides health-care services to more than half of the population in Israel and the vast majority of older adults are insured in this organisation (Bendelac Reference Bendelac2010). Only those who met the inclusion criteria and gave their consent to be interviewed were included in the study. Thus among the users of day care centres, 417 were interviewed, 165 refused, 75 were not members of the Clalit HMO, 40 were cognitively impaired, 29 could not be interviewed due to language barriers, and the remainder were unavailable. The 400 non-users composed the comparison group and were matched with users by gender, age (same age or up to five years difference between user and non-user), functional status, and same family physician to control for treatment approaches of the family physician. Family physicians were asked to include only those who received long-term care services under the long-term care insurance law (Schmid Reference Schmid2005), suggesting that they were disabled in terms of having difficulties in performing daily activities, and who were cognitively intact. At first, users of day care centres were interviewed and were asked who their family physician was. The family physicians were asked to provide for each of their patients who were users of a day care centre, lists of non-users who met the inclusion criteria. In case the non-user was unavailable or reluctant to participate in the study, the physician was asked to provide another name that met the same criteria. Thus, 400 non-users were interviewed, 111 refused, 65 were unavailable, 17 were cognitively impaired, 74 were unable to be interviewed due to language barriers, and seven died. For 17 users no matched non-users could be found.
Data collection
A letter was sent to the directors of the 13 day care centres explaining the goals of the study and asking their permission for the reviewers to present the research goals to the users of the day care centres. Thereafter, visitors of the day care centre were approached by interviewers and were asked to volunteer to be interviewed. Those respondents who gave their consent and were Clalit HMO patients were given explanations on the research goals; if they agreed to be interviewed they were asked to sign a consent form. Interviews were conducted in one of the rooms at the day care centre to assure confidentiality. After completing the data collection at each day care centre and receiving lists from each physician, a pre-notification letter was sent to the patients explaining to them the goals of the study, asking their consent to be interviewed, assuring them of confidentiality, and notifying them that an interviewer would contact them the next week via telephone. A week later interviewers telephoned the older persons and asked their consent to be interviewed. Once they agreed, appointments were made at the homes of the participants.
Data were collected during 2009–10 through face-to-face interviews, using a structured questionnaire. All interviewers were trained to interview older people and in use of the specific questionnaire. Those respondents who gave their consent and were Clalit HMO members underwent a mini-mental screening test (Folstein et al. Reference Folstein, Folstein and McHugh1975) that included 13 questions related to memory and orientation to make sure that there were no cognitively impaired participants; if they gave three or more incorrect answers (e.g. date of birth, age, what day is it today, who is the current prime minister, who was the former prime minister, etc.) the interview was stopped. After completing the mini-mental test the respondents were given explanations of the research goals and if they agreed to be interviewed they were asked to sign a consent form. The study underwent review by an institutional review board and was approved by the ethics committee of the Clalit HMO and the University Medical Centre. Informed consent was obtained from all subjects.
Measures
Outcome variable
The World Health Organization Quality of Life (WHOQOL) – Brief was used to assess participants' quality of life. This tool, which was developed by World Health Organization (WHO), serves to self-appraise quality of life of healthy populations, as well as those who are in distress due to care-giving tasks (Ben-Yaakov and Amir Reference Ben-Yaakov and Amir2001). The original measure includes 100 items, but the shorter version of 26 items was used in the present study. This measure encompasses four major domains of quality of life: physical health (seven items – e.g. to what extent do you feel that physical pain prevents you from doing what you need to do; how much do you need any medical treatment to function in your daily life), mental health (six items – e.g. how much do you enjoy life; to what extent do you feel your life to be meaningful), social relationships (three items – e.g. how satisfied are you with your personal relationships; but one item: ‘how satisfied are you with your sex life’ was excluded because most participants refused to answer this question); and environment (eight items – e.g. how safe do you feel in your daily life; how healthy is your physical environment). In addition, the measure includes two items that relate to the general quality of life and to the general health status of the respondent (how would you rate your quality of life; how satisfied are you with your health). Scores for each item range from one to five, with a higher score indicating better quality of life. A score for each domain was calculated and the total sum of scores indicates a person's overall quality of life. The score for the domain of physical health ranged from four to 20, for mental health four to 20, for social relationships four to 20, and for environment five to 20. The total score ranged from 22 to 89. This tool has been translated into many languages, including Hebrew, has been used in Israel in several studies, and internal consistency (Cronbach alpha) ranged from 0.74 to 0.92 (Ben-Yaakov and Amir Reference Ben-Yaakov and Amir2001). In this study the internal consistency (Cronbach alpha) was 0.93.
Independent variables
Instrumental activities of daily living: Fillenbaum's (Reference Fillenbaum1985) measure was used to examine the ability to perform instrumental activities of daily living (IADL). The measure includes eight items relating to home chores, laundry, cooking, etc. Scores for each item ranged from one (no difficulty at all) to five (very much difficulty). The final index was based on the sum of scores, ranging from eight to 40. The internal consistency (Cronbach's alpha) was 0.94.
Activities of daily living: ADL was measured by using the measure of Katz et al. (Reference Katz, Downs, Cash and Grotz1970) which includes eight items (washing, dressing, toileting, indoor mobility, eating, etc.), with scores for each item ranging from one (no difficulty at all) to five (very much difficulty). The sum of scores produced an index ranging from eight to 40. The internal consistency (Cronbach's alpha) was 0.91.
Self-rated health: The respondents were asked to rate their present health status with scores ranging from 1 (excellent) to 6 (very poor).
Co-morbidity: Based on the Cross-sectional and Longitudinal Aging Study (CALAS) study (Modan et al. Reference Modan, Fuchs, Blumstien, Chetrit, Lusky, Novikov, Gindin, Habot and Walter-Ginzburg2002), comorbidity was measured by the number of self-reported chronic health conditions, such as: ‘Do you suffer from or has a physician ever told you that you suffer from …’ and a list of 14 major medical conditions were read. The 14 conditions included: cancer, diabetes, high blood pressure, heart attack, other heart disease, cardiovascular accident, circulatory, respiratory, gastrointestinal, osteoporosis, Parkinson, thyroidism, arthritis, and nephrologic problems. Score for each condition was 1=yes and 0=no. Scores were summed with higher scores indicating more morbidity.
Day care use: Respondents were divided into two groups – those who visited day care centres (=1) and those who did not (=0). Those who visited day care centres were asked how many times a week they visited the day care centres with answers ranging from 1 (once a week) to 6 (six times a week) and for how long have they been attending the day care centre (in months).
Economic status: The respondents were presented with seven categories of income and were asked to choose the category that was relevant to them. Thus, 1 indicated the lowest monthly income, which was the poverty line in Israel, while 7 indicated the highest level of income. In addition, respondents were asked to rate their perceived economic status with scores ranging from 1 (very good) to 5 (very poor).
Co-variates
Co-variates included age, gender, education (included seven categories ranging from 1=partial elementary school to 7=graduate degree and above), ethnicity (coded as 1=Europe/America, 2=Asia/Africa, 3=born in Israel), marital status (coded 1=married, 0=unmarried), living arrangements (coded 1=live alone, 2=otherwise), number of children, number of children living in proximity, household size, and length of time living in Israel.
Analyses
A range of descriptive analyses (percentages, means and standard deviations) were initially performed to present the characteristics of the respondents and the dependent and independent variables. t-Test/χ 2 were carried out, respectively, to examine the associations between the dependent and independent variables, specifically to examine difference in quality of life of users and non-users of day care centres. In addition, correlation coefficients were calculated to probe the association between duration and frequency of weekly visits to day care centres and quality of life among users of day care centres. To test the research hypotheses and examine the extent to which utilisation of day care centres was significant in explaining quality of life, two linear regressions were run: one included the entire sample with a dichotomous variable of users and non-users of the day care centres and the second regression analysis included only users of the day care centres. The second equation included frequency of weekly visits and length of use of the day care centres. Both regression analyses included respondents' socio-demographics, health status (self-rated health and co-morbidity), functional (ADL and IADL) status, and economic status (perceived economic status and monthly income). For each regression analysis, data storage and analysis were performed using SPSS package version 17.
Results
Participants' characteristics
Respondents' characteristics by day care utilisation are presented in Table 1. The findings show that the vast majority (about 76 per cent) were women with an average age of about 78. No significant differences were found between users and non-users of day care centres in functional status in terms of ability to perform ADL and IADL tasks. Also, no significant differences were found between the two groups of respondents in the number of children living in near proximity and perceived economic status. Significant differences were found between the two groups of respondents in ethnicity, marital status, level of education, number of children, living arrangements, household size, length of stay in Israel, monthly income, and health status (self-rated health and co-morbidity). Among those who attended day care centres there were significantly more widowed persons, with lower levels of education, born in Asian/African countries, living alone with good to moderate levels of self-rated health compared to their counterparts in the control group, many more of whom were married, highly educated, lived with somebody, were born in European/American countries but rated their health status as poorer. In addition, users of day care centres had significantly more children, lived longer in Israel, lived in smaller households, had a lower monthly income, and reported less co-morbidity compared to their peers in the control group. In other words, those who visited day care centres were of lower socio-economic status compared to non-users. Among those who attended day care centres the average length of time of visiting the day care centre was 49.17 months (SD=50.35) and the average number of weekly visits was 3.83 (SD=1.23).
Table 1. Characteristics of respondents by use of day care centres
Notes: ADL: activities of daily living. IADL: instrumental activities of daily living. QoL: quality of life. SD: standard deviation.
Significance levels:
* p<0.05,
** p<0.01,
*** p<0.001.
Significant differences were found between the two groups of respondents in terms of physical and emotional quality of life, social relationships, and overall quality of life: those who were users of day care centres reported significantly higher levels of quality of life in all dimensions and overall quality of life compared to their peers who did not use day care centres, except for environmental quality of life where no significant difference was found between the two groups of respondents.
Table 2 presents the linear regression analyses of variables explaining quality of life of users and non-users of day care centres and among users only. The findings show that for the entire sample several variables were significant in explaining quality of life: use of day care centres, health status (self-rated health and comorbidity), functional status (IADL), socio-economic status (perceived economic status and education), household size, age and ethnicity. This suggests that those reporting better quality of life were users of day care centres; had better health, functional and economic status; lived in larger households; were older; and were born in European/American countries or in Israel. All the variables included in the equation explained 56 per cent of the variance in quality of life.
Table 2. Variables explaining quality of life among users and non-users of day care centres
Notes: 1.
1 =Asia/Africa, 0=otherwise.
2. Lower scores indicate better health and economic status. ADL: activities of daily living. IADL: instrumental activities of daily living. SE: standard error.
Significance levels:
* p<0.05,
** p<0.01,
*** p<0.001.
For those who attended day care centres the findings show that only self-rated health, functional status (IADL) and perceived economic status were significant in explaining quality of life, suggesting that better self-rated health and functional status in terms of IADL, and better perceived economic status were connected with increased quality of life among users of day care centres. However, the number of weekly visits as well as length of attendance in the day care centre were found to be insignificant in explaining quality of life among users of day care centres. All the variables included in the equation explained 51 per cent of the variance in quality of life.
Discussion
In brief, the findings show that the level of quality of life was moderate among users and non-users of day care centres alike. This is consistent with previous studies that found quality of life among functionally dependent older persons to be fair (e.g. Bowling et al. Reference Bowling, Seetai, Morris and Ebrahim2007; Xavier et al. Reference Xavier, Ferraz, Marc, Escosteguy and Moriguchi2003). It was hypothesised that use of day care centres will improve the quality of life of their users and that longer and more frequent use will be connected with improved quality of life among users of this type of service. The findings show that users of day care centres reported significantly higher quality of life compared to their counterparts who did not use this service. Furthermore, except for environmental quality of life, users of day care centres reported significantly improved quality of life in all spheres of life: physical, psychological and social, compared to their counterparts who were non-users. This suggests that using this type of service can have a positive effect on most aspects of an individual's life and therefore can be an important means to promote the wellbeing of disabled older adults. However, length and frequency of visitation were not significantly related to the improvement in quality of life of the day care centres' users. Thus, only, the first part of the hypothesis was confirmed, whereas the findings refute the second part of the hypothesis.
Consistent with previous studies (e.g. Blane et al. Reference Blane, Higgs, Hyde and Wiggins2004; Bowling et al. Reference Bowling, Gabriel, Banister and Sutton2003), health and functional and economic status were found to be crucial and predominant factors affecting quality of life of older people. Yet, use of day care centres was found to be significantly associated with quality of life. It might be that in spite of the poor health, functional and economic circumstances, the use of day care centres can still contribute to the promotion of quality of life of disabled older adults. In this case it can be concluded that day care centres do have a positive effect on the level of quality of life among users of this service. However, it might also be that those who actually visit day care centres experience a priori higher levels of quality of life than their counterparts who are non-users, so that day care centres actually have no effect on quality of life. Therefore, day care centres should offer more programmes that are focused on health promotion, prevention, restoration of functional status or enablement programmes (Alpert Reference Alpert2010; Cartwright et al. Reference Cartwright, Cosgrave, Gooden and Carpenter2009; Resnick Reference Resnick, Foreman, Milisen and Fulmer2010) that can improve perceived health and functional status and consequently improve quality of life. It might be that there is cyclical connection between these variables; that is, those who experience improved quality of life visit day care centres that in turn enhance their quality of life even more. This issue merits further investigation to find the causal association between these two variables by using before and after research designs to probe this causal relationship.
Relating to the group of users, the findings indicate that frequency of day care centre use and length of use had no cumulative significant impact on quality of life, although it might have been expected that more frequent and longer use would be related to higher quality of life. This can be because quality of life is mostly influenced by self-assessments of health and economic status; thus the frequency and duration of use of day care centres have no effect on the quality of life of its users. However, this is in contrast to findings from a recent Italian study (Bilotta et al. Reference Bilotta, Bergamaschini, Spreafico and Vergani2010) that greater weekly attendance at day care centres was related to a better quality of life among older patients suffering from depression. One possible explanation for these findings is that because the day care centres in Israel operate according to the social model, they do not provide health and rehabilitation services. The findings indicate that health and functional (IADL) status were significantly connected with quality of life. Therefore, it might be that transforming the day care centres into a more integrated model whereby more emphasis is put on providing programmes that are aimed to enhance and improve health and functional status, such as health promotion and prevention programmes, may demonstrate a greater impact on users' quality of life in the long run. However, this issue merits further examination on the expectations of older persons from this type of service.
More in-depth studies are necessary to detect weaknesses in the current programmes of day care centres in order to make them more effective in achieving the goal of increasing quality of life among frail older adults. In addition, the findings show that the variables mostly explaining quality of life were subjective (self-rated health and perceived economic status) rather than objective factors (e.g. morbidity, monthly income). This suggests that interventions aimed to change attitudes and to address subjective feelings should be offered to day care users in order to help them promote quality of life.
Limitations
There are several limitations to this study; first, the study is cross-sectional, thus a causal relationship between quality of life and utilisation of day care centres is warranted. In fact, it might be that those who attend day care centres may be a selected group who were ‘better off’ from the very start. Further investigation and evaluation studies that will include longitudinal as well as quasi-experimental designs to examine differences in quality of life before and after attending day care centres can throw more light on this issue. This can enable better understanding of the association between these variables and identify factors that can make day care centres more effective in improving quality of life. Second, generalisation of the findings is limited because the sample and the sampling procedure do not guarantee representativeness of all visitors in day care centres on a national level. This is because the sample was not randomly selected and included only day care centres in the southern region of Israel. Furthermore, since there were relatively many refusals (165) among the users of day care centres, mainly because they refused to sign a consent form, this may have biased the findings of the study. However, we have no data on those who refused to participate in the study to know if they significantly differed from those who agreed to participate in the study. Third, as noted above, the day care centres in Israel operate according to the social model, whereas in other countries there are models that either follow the medical model or are integrated. Therefore, the findings of this study may apply only to those adult day care centres that follow the social model. Despite these limitations, the study adds to our knowledge and understanding of frail older adults and points to the need for further research in order to understand how adult day care centres can be more effective in achieving their goal to promote quality of life. Thus, longitudinal and quasi-experimental study designs that will enable examination of causal relationships between use and non-use of adult day care centres can provide better insight on the effectiveness of this type of service in promoting the quality of life of its users. Furthermore, comparisons between users of different models of day care centres can provide indications for the model that best improves quality of life.
Acknowledgements
This study was funded by the Israel National Institute for Health Policy Research.
