The International Journal of Psychosocial Rehabilitation


Quality of Life of People with Long-Term Psychiatric Illness
Living in a Residential Home

 

Kim Wan Young (PhD in Social Work)
 University of Bristol, U.K.

 

Young, KW. (2004). Quality of Life of People with Long-Term Psychiatric Illness Living in a
 Residential Home.   International Journal of Psychosocial Rehabilitation. 9 (1),133-145.

 

Key words: Quality of Life, Residential care, Mental Illness

 Address for correspondence:
Kim Wan Young
Hong Kong Sheng Kung Hui Welfare Council, 1A, Lower Albert Road, Central, Hong Kong

Phone: +852-98500822; Fax  :+852-28733707

E-mail: dyoung@skhwc.org.hk


Abstract

This study aims at exploring the impact of a residential home on the quality of life of people with long-term menbtal illness after their discharge from mental hospitals. This research adopted a combined research methodology and QoL data were obtained from both quantitative and qualitative analysis. Results showed that residential home residents had better QoL, including overall life satisfaction, than that of hospital in-patients.  In sum, this study demonstrates that residential care could lead to a better QoL for people with long-term psychiatric illness.

 

Introduction

People with long-term psychiatric illness are so disabled and impaired that they are difficult to be placed in the community [1].  In the past few decades, several models of community care program for these people have been developed in the Western countries, especially in United Kingdom and United State, including: staffed community house [2], hospital hostels [3-4],  "Training in community living" model [5] and fostering care homes [6]. However, these community care models are not widely developed in the community. In fact, the majority of people with long-term psychiatric illness live in rather different settings such as hostels and residential homes. 

 
In the past, residential homes, such as nursing homes, hostels as well as board and care homes are often being criticized as “institutional like” and becoming another kind of “asylum” in the community [7-8]. In fact, institutional care does not depend on the type of residence nor residents’ mental state, but on the care giver’s management [9]. So not all residential services should be identified as “institution” as characterized by Knuze and Lamb [7-8]. Research studies often report different or even contradictory results in this area. For example, In U.S.A., Linn et al. [10], in a randomized control study on nursing home care for people with long-term psychiatric illness, reported that nursing home residents deteriorated significantly in self-care, behavioral problems, mental confusion, and depression. However, Timko et al. [11], in another randomized control study of nursing home care, reported that, as compared with the hospital in-patients, nursing home residents had better choice, control in policies, more social and recreational activities while their subjective life satisfactions remained positive and unchanged. Similarly, in Australia, Burdekin [12]described hostels and boarding houses as the “new institutions”, while Horan et al. [13] reported that residents of hostels and boarding houses were satisfied with their quality of life although they had negligible participation in daily activities, few family contacts and limited finances. So whether or not residential care has positive impacts on the life conditions of people with long-term psychiatric illness remained unanswered. Moreover,  Thronicroft et al. [14] have pointed out that the success of some community care programs may not be generalized to elsewhere due to a lot of reasons including cultural difference, and suggested the importance of exploring local experience of implementing community care programs.


 In Hong Kong, the government has adopted a policy of community care since 1970s [15]. However, after the incident of severe violent act of a psychotic outpatient on a public estate in 1982,  there was a strong “Anti-half way house movement” among local community residents who showed low acceptance towards people with mental illness [16]. Since then, due to the strong community opposition, the progress of the development of community-based rehabilitation services was largely limited.  On the other hand, in order to protect people with psychiatric illness from social stigmatization, community-based supportive services have become segregated and tended to be confined in large and institution-like [16]. In 1990s, several large residential homes, named long stay care home (below referred as LSCH), with each LSCH has about two hundred beds, have been established to support people with long-term psychiatric illness living in the community.  Despite the Hong Kong Government's keen interest in expanding this kind of residential home rapidly,  it is important to ensure that the life conditions of its residents are well maintained or even get improvement in the community.  This study attempts to explore the impact of residential home on the quality of life of people with long-term mental illness after they have discharged from mental hospitals and lived in the community.

 
In evaluating community care program, quality of life (below referred as QoL) is increasingly identified as a key outcome for evaluating community mental health services [17]. However, there is a disagreement on how quality of life should be defined [18]. The lack of agreement on its definition is due to a number of reasons [19].  In this study, quality of life is defined as individual’s subjective feeling of overall life satisfaction, as determined by the mentally alert individual whose life is being evaluated. 

 

Aims and research hypothesizes

The aim of this research study is to explore the QoL of people with long-term psychiatric illness after their discharge from mental hospitals and live in residential home (i.e. LSCH) in Hong King context.
 

 The research hypothesis is that people with long-term psychiatric illness would have a better QoL after they have discharged from hospital to LSCH. 

 

Research Design

 Settings

In this study, two groups of people with long-term psychiatric illness were included in the studied sample. One studied group came from a newly built LSCH with two hundreds beds which has been opened in 1996 in Hong Kong. Four to five residents lived in the same bedroom. It had a large occupational unit. Various kinds of professional and non-professional staff had been employed to provide 24-hour personal care services for its residents. Staff to resident ratio was about 1:3.  .


 Another studied group came from two traditional large mental hospitals in Hong Kong, which have been built in 1970s and 1980s respectively.    

 
Studied Sample

As the research objective is to examine the QoL of people with long-term psychiatric illness after their discharge from mental hospitals, the studied subjects were restricted to those who were discharged from mental hospitals and admitted into LSCH.  So only those LSCH residents, who were being assessed by registered psychiatric nurses and the author as mentally stable, had suitable cognitive and communicative skills for interview,  had discharged from mental hospitals and then lived at LSCH for more than one year, were eligible for being selected and invited to join in the research project.  Finally 45 residents had given their written consent and were interviewed by the author successfully. This group of people constituted the experimental group (below referred as LSCH group).

 Similarly, those hospital in-patients, who were identified by the hospital psychiatrists as suitable and ready for discharge into LSCH;  assessed by hospital psychiatric nurses and the author as mentally stable, had appropriate cognitive and communicative skills for interview, were eligible for being selected and invited to join in the research project.  Finally 43 hospital in-patients had given their written consent and were interviewed by the author successfully. This group of people constituted the control group (below referred as hospital group).

 
This study adopted a quasi-experiment research design, and the QoL of the experimental as well as the control group were compared. The QoL data of both studied groups were collected between April, 96 and December, 1997.

 

Data Collection

A) Quantitative Analysis

Quality of Life Interview

Lehman’s Quality of Life Interview [20] is adopted and modified in this study.  The reliability and validity of the scale are well established [20-21] and the scale has been widely used.  In this study, there is no modification in the sub-scales of overall life satisfaction and subjective QoL in various life domains. The only modification is the modification of the objective QoL indicators of living environment so as to suit the special living environment in mental hospitals and residential setting in Hong Kong.  In these settings, all basic facilities such as bed, food, electricity, air-conditioning, water-heater, etc, are provided by the residential home and mental hospitals with good conditions..  Thus the availability of these facilities is not respondents’ concern. Rather whether or not these living places are crowded and too restrictive are their main concerns. So items measuring the crowdedness and restriction were included in the objective QoL indicators of living environment. The scale has 56 items, and contains objective QoL indicators, subjective QoL indicators as well as overall life satisfaction.

 
In this study, the reliabilities of the subscales of the Quality of Life scale, as measured by means of internal consistency Cronbach’s alpha, are found to rank from 0.62 to 0.93. It shows that the reliabilities of these subscales have reached acceptable levels for statistical analyses purpose, and are comparable to that of original Quality of Life Interview [20].

 
B)  Qualitative Interview

In addition to the above quantitative data, some qualitative data are also collected to supplement the quantitative QoL data. Eight respondents were randomly selected  from a group of people who had appropriate communicative skills and going to be discharged to LSCH from mental hospitals. These people were followed up for more than one year before and after they had discharged from mental hospitals.  Sixteen semi-structured individual interviews were carried out for these eight persons. Eight interviews were carried out when respondents still lived in mental hospital several months before their discharge, while another eight interviews were carried out when they had lived in LSCH for about one year.  The conversations of these sixteen interviews were tape-recorded and transcribed.  The content of these scripts were then coded and analyzed.

 
In this study, qualitative data obtaining through semi-structural interview served two main functions. Firstly, qualitative QoL data could complement the quantitative QoL data obtained from the measuring scale so as to increases the understanding about respondents’ life situations in both mental hospitals and LSCH settings.  Secondly, qualitative QoL data was used to cross check the QoL data found by the quantitative analysis, and seek for convergence of research results.  To achieve these purposes, during qualitative interview, respondents were asked some open-end questions including:  respondents’ own evaluation of their overall life conditions at current living places; comparing their overall life conditions between long stay care home and mental hospitals; describing those life domains they concerned; describing whether they were satisfied or dis-satisfied with various life domains; and the reasons why they were satisfied or not satisfied in that life domain.

 

Characteristics of the research sample

Below describes the characteristics of the studied sample: LSCH group (n=45) and hospital group (n=43).  Results showed that these two groups of respondents did not differ in almost all demographic factors, except in sex ratio.  The Hospital group was predominately male while LSCH group was predominated female.

 Table 1 Demographic characteristic of the samples.

 

Hospital  group

(N =43)

LSCH

group

(N=45)

Test

significance

Gender (%male)

72

38

Chi-square

.001*

Age (mean year)

48

49

Student t-test

.701

Education

% none

% primary school

% secondary school

% higher education

 

10

52

34

5

 

11

56

27

6

Chi-square

.864

Marital status (% single, divorced or widow)

83

87

Chi-square

.562

Religion (% none)

69

71

Chi-square

.053

Financial Situation

% rely on governmental assistance

 

93

 

91

 

Chi-square

.

740

Diagnosis (% schizophrenic)

91

91

Chi-square

.946

Period of Illness (mean year)

19

21

Student t-test

.348

Number of hospitalizations (mean)

5

5

Student t-test

.755

Period of latest Hospital stay (mean year)

6

8

Student t-test

.158

* <.01                    **<.05


 Overall, the people with long-term psychiatric illness were predominately male, schizophrenic and single.  All of them were under 65 years of age (mean 48-49 years).  Most of them had reached primary school level or above, and did not have any religious affiliation. Just over half of them have at least one physical illness.  Almost all of them suffered from schizophrenia.  Their illnesses were so chronic that most of them had been ill for more than 20 years.  One half of patients had a latest continuous hospital stay for 1-4 year, while the other half 5 year and more. Most were single or divorced, and had few contacts with their families. They did not have any friends outside the hospitals and LSCH.  Most of them were lack of employable skills and attended some forms of vocational training. Almost all of them had to rely on governmental social security schemes to support their lives.


 Research Results

 As quality of life is a multi-dimensional concept, three kinds of quality of life indicators, including: traditional indicators, objective quality of life indicators and the  subjective quality of life indicators, are used in this study in order to get a holistic picture about the life conditions of the studied subjects.

 
A) Quantitative Analysis

Traditional Indicators

Basic information on the numbers of suicides, deaths, homeless patients, number of patients being charged for criminal offences and number of hospital re-admission rate between 1-4-96 and 31-12-97 were collected and supplied by the superintendent of the LSCH.

 During the 21 months period, none committed suicide, 2 out of 204 LSCH residents died because of physical illness (producing a mortality rate of 0.56% annually), none of them became homelessness, and none was arrested. In addition, 21 out of 204 LSCH residents had been re-admitted to hospital at least once during the 21 months period, producing a hospital re-admission rate of 10.3% annually.


 

Objective Quality of life Indicators

Table 2 Objective quality of life indicators of the studied groups

Objective QoL

(Mean Score)

Hospital gp

(N=43)

LSCH gp

(N=45)

 Student t-test Significance (2-tailed)

Living Situation

(Score between 1-4, with 1 have the best outcome)

1.9

1.9

.971

Daily Activities & Functioning

(Score between 0-1, with 1 have the best outcome)

0.6

0.8

.000 *

Family

(Score between 1-5, with 1 have the best outcome)

4.1

3.8

.726

Social Relationship

(Score between 1-5, with 1  have the best outcome)

3.9

3.4

.056

Finance

(Score between 0-1, with 1 the best outcome)

0.8

0.9

.415

Health

(Score between 1-5, with 1 have the best outcome)

2.5

2.3

.271

* significance <.01      ** significance <.05    

 
When comparing the objective QoL of LSCH group with that of hospital group, the following findings were found (data please refer to Table 2):

LSCH group had better objective QoL in daily activities & functioning (t-test =-4.221, d.f. =86, p<.000). As compared with hospital group, LSCH group used public transportation, went out for tea and shopping more frequently.

 LSCH group and hospital group did not differ in objective QoL in many life domains including: living environment, family relationships, social relationship, financial situation and personal safety etc.

 
Subjective Quality of Life

Both LSCH and Hospital group regarded most of their life domains as average to satisfactory, and more than two thirds of these two studied groups expressed satisfaction in each life domains.  In particular, they were most satisfied with living situation, while least satisfied with family and social relationships (please refer to Figure 1 for reference). 

 
Figure 1  Subjective Life Satisfaction




LSCH group were more satisfied with their overall life satisfaction (t-test=-2.756, d.f.=86, p=.007<.01), personal safety (t-test=-2.842, d.f.=86, p=.006<.01) and health (t-test=-3.046, d.f.=86, p=.003<.01) as compared with that of hospital group.

 

LSCH and hospital group were equally satisfied in most life domains, including: living situation, daily activities and functioning, family relationships, social relationship, and financial situation.

 

Table 3 Subjective Life Satisfaction of LSCH and hospital group

Subjective QoL in various life domains

(Score between 1-7 with 7 means most satisfactory)

Hospital gp

(N=43)

LSCH gp

(N=45)

 Student t-test Significance (2-tailed)

Average subjective satisfaction in living condition

5.442

(3.365)

5.417

(0.867)

.961

Average satisfaction in leisure

 

5.070

(1.442)

5.389

(1.027)

.233

Average satisfaction in family relationship

 

4.756

(1.894)

5.000

(1.739)

.530

Average satisfaction in social relationship

 

4.767

(1.315)

5.506

(1.226)

.291

Average satisfaction in financial situation

 

4.616

(1.683)

5.133

(1.375)

.117

Average satisfaction in personal safety

 

4.733

(1.841)

5.489

(0.997)

.006*

Average satisfaction in health condition

 

4.458

(1.461)

5.344

(0.910)

.003*

Global Subjective QoL

 

4.791

(1.604)

5.567

(0.975)

.008*

* significance < .01            * *significance < .05       ( )—standard deviation


 B) Qualitative Analysis

Data from qualitative interview also showed that most respondents were more satisfied with their lives at LSCH than at hospital. Below were some respondents’ accounts for their overall lives at LSCH as compared with that at hospital. Due to confidentiality, the names of the respondents and hospitals have changed to other labels.


 Better Overall Life

“Long stay care home is better than hospital because here provide better meal and more activities. Also residents here are better than hospital” (Ah Wing).


 “Long stay care home is better than hospital…When I lived at hospital, I did not have any money. Also I was not allowed to go out of hospital. I felt boring at hospital. Here, I have more freedom and can go out to have food and tea…After finishing I can have bath and then go to sleep whenever I want to” (Ah Fai).


 “I prefer to live at long stay care home. It has better living environment and more entertainment. The patients here are better. The staff here is better” (Ah Fun).


 “Here (LSCH) is better than Hospital B. It has a better living environment, better entertainment, better staff, better work environment, better personal safety, ….Living here, I can have a better health…... Here offer me more freedom” (Ah Ngan).


 “Last year, I have $100 per week. Now (at LSCH) I can have $200 per week. Now I have enough money to spend ... Here (LSCH) is good! It is better than Hospital A. Living here, my pocket money is being controlled. Apart from it, everything seems alright” (Ah Chong).


 “When comparing my life here with that at Hospital B, they are the same.…Both places are good. These two places have their own advantages and disadvantages. It was more convenient to see the doctor at hospital. Also if there is any problem, staff will take action quickly….Here (LSCH), I can enjoy more freedom. I can put on my own clothes. Also O.T. is not a hard job for me” (Ah Too).


 “Both settings are good. At hospital, I was allowed to walk around the garden. Here, I can go out (to nearby community) on Saturday and Sunday. However, here I am required to pack my own belongs all the time, and clean the floor, etc. These are difficult tasks. At hospital, I did not need to do any cleaning” (Ah Chung).


On the other hand, data from qualitative interview also showed that respondents  appreciated some life domains at LSCH including：residents behaving more properly, better staff attitude; and less restriction and more freedom, which were not reflected in the quantitative analysis. Below are some of the respondents’ personal accounts:

 

Residents behaved more properly at LSCH

“Hospital residents had complex social background. They always had quarrel, fighting and gambling. They also stole money and things from others…LSCH has better residents…. Here (LSCH), we don’t have any fighting,...If resident do something wrong, that resident will be sent back to hospital…They seldom have any conflict” (Ah Chong);


 “Here (LSCH), residents are better…….No one take advantages from me. No one ask me to give them money and cigarettes. No one steal my belongings…. It was difficult to get along with other patients of Hospital A…. These patients liked gambling, smoking, taking advantages from others” (Ah Wing).

 “Other patients are quite nice. They do not blame at me nor punch me…. No patients take advantage on me…. I like them” (Ah Too).

 

Better Staff Attitude

“Staff of LSCH is better. …They offer assistance such as escorting client to go out, buying things for us, and drawing money from the bank etc. Also they are more polite... Hospital patients were being shouted at, punched, restrained, given injection by staff. The staff of LSCH does not shout at residents” (Ah Chong).

 

 “Here (LSCH), staff treats me good. When I lost temper, they do not restrain me. Rather they just ignore me and let me clam down. Moreover, they listened to my unhappiness, which make me feel better” (Ah Chung).

 

 “Staff here is better than hospital staff. They offer me help.  For example, before going to picnic, they remind me whether I have got enough money. Also when I am sick, they show concern to me. Also they give me encouragement and support. They praise me whenever I have good performance in doing household duties, and in my work” (Ah Ngan).

 

Less Restriction and More Freedom at LSCH

“To me, restriction is loose (at LSCH). However, restriction is tight for others… The management of daily routine of Hospital A was more strict than here (LSCH). For example, the bathing time is more flexible here…Also, I can go out to have tea and shopping from 4:30pm to 5:30pm from Monday to Friday, and from 8:30 am to 5:30 pm on Saturday and Sunday….. LSCH provides more freedom.” (Ah Wing).


 “Other than going out, I can have freedom here…. the management of daily routine is not strict here (LSCH)” (Ah Too).


 “I have more freedom here (LSCH)…. I don’t think the management is strict here. Some resident refuse to have bath, or refuse to do O.T.. Staff just let them and do not punish them”  (Ah Fai).


 “The management of basic routine is quite strict here (LSCH). Anyway Hospital B is more strict in the basic routine….. There is no restriction about the bathing time, but the water heater is opened between 5:00 p.m. to 9:30 p.m.” (Ah Ngan).


 When I lived at hospital, I was allowed to go out once a month under the permission of my doctor… Here (LSCH), I am allowed to go out twice weekly, usually on Saturday and Sunday.  So, at LSCH, I have more chance to go out” (Ah Ming).


When comparing the QoL data from qualitative and quantitative analysis, data from qualitative interview supported the findings from quantitative analysis that: most LSCH residents viewed their overall life conditions as positive; and reported to have a better life at LSCH than that at mental hospitals.  In addition, data from qualitative interview showed that LSCH residents appreciated and satisfied with some life domains at LSCH which were not identified in the quantitative analysis, including: other residents behaving more properly, better staff attitude, less restriction and more freedom.


Based on the above discussion, it is found that findings from both quantitative and qualitative analysis converged in a number of areas.  This convergence supported the validity of finding that QoL at LSCH was better than that at mental hospitals.  In sum, this research study demonstrated that LSCH yield a better quality of life by improving residents’ overall life satisfaction,  subjective QoL in health and personal safety,  objective QoL in daily activities  than that at mental hospital.

Discussion


Reflection on Methodology and Research Strategy
This study highlights the limitation in using of Quality of Life Interview scale to measure subjective QoL.  It is found that this scale is not comprehensive enough and does not cover some QoL data mentioned and concerned by respondents during qualitative interview. These areas are: restrictions and freedom in daily routine,  residents’ behaviour, and staff attitude.  On the other hand, data from qualitative interview is proven to provide valuable information complementing the data measured by Quality of Life Interview scale.  Thus it would be useful to ask respondents some open-end questions including:  respondents’ own evaluation of their overall life conditions; comparing their overall life conditions between long stay care home and mental hospital; describing those life domains they concerned; describing whether they were satisfied or dis-satisfied with various life domains; and the reasons why they were satisfied or not satisfied in that life domain.
 
After acknowledging the limitation of Quality of Life Interview, it is recommended to use combined research methodology, i.e. the use of both qualitative and quantitative research methods in studying QoL.  In this study, a combined research methodology, i.e. pre-eminence of the quantitative over qualitative research, is adopted and is shown to provide a more thorough picture about the QoL of respondents.
 

Residential Care is a Positive Choice

In the past few decades, there are a dualistic view of residential and community care---residential care is “bad” while community care is “good”, which was regarded as an anti-residential care movement [25]. This anti-residential care bias was based on the influence of the “literature of dysfunction” in relation to residential care, which is both conceptually limited in its analysis and scientifically flawed in terms of methodology [25]. Research evidences tend to show that residential care has its own value and has numerous advantages [26]. So both residential service and other forms of community care facilities, such as family care, day care, etc, should be placed with equal weight of importance within an integrated network of community care system.
 

 This research study has demonstrated that residential home care, as one kind of community care program, can lead to a better quality of life, including both subjective and objective quality of life for people with long-term psychiatric illness.  This finding is supported by other research studies which have demonstrated that people with long-term psychiatric illness living a variety of community-based settings have positive and even better QoL after their discharge from mental hospitals [23, 24, 27-31].  Thus the research result in this study adds evidence to the fact that residential home care is a positive choice for its residents, as advocated by Wagner Report [32].


 Conclusion

This research study has demonstrated that residential home care can lead to a better quality of life, including both subjective and objective quality of life for people with long-term psychiatric illness, and adds evidence to the fact that residential home care is an important component of the integrated network of community care system. The study is based on a quasi-experiment research strategy, so that the QoL of LSCH group was compared with that of hospital group which was acted as a control group. In future, a large-scale longitudinal study should be carried out in order to confirm the above research findings.  

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