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IJHCQA
23,1 Quality of life and wellbeing of the
elderly in Lebanese nursing
homes
72
Jacqueline Doumit
Faculty of Natural and Applied Sciences, Notre Dame University, Zouk Mosbeh,
Received 25 February 2008
Revised 7 September 2008 Lebanon, and
Accepted 28 September Ramzi Nasser
2008
Center of Educational Development and Research, Qatar University,
Doha, Qatar

Abstract
Purpose – The purpose of this paper is to assess quality of life in relation to wellbeing among
Lebanese nursing home elderly residents. The study attempts to understand the impact of structures,
processes and skills on elderly health status.
Design/methodology/approach – In this paper, 220 normally functioning elderly respondents
from 33 nursing homes were studied. A quasi-experimental approach measured psychological and
health-related factors using the Geriatric Depression Scale, Activity of Daily Living, EuroQol EQ-5D
and the Mini-Nutritional Assessment (MNA) instruments.
Findings – A relatively high level of mild depression among elderly residents and a lack of mobility
were found. Generally, normally functioning elderly residents were well nourished and had moderate
daily activity levels.
Originality/value – The study is original in the sense that it assesses elderly residents’
psychological and physical health status in relation to institutional structures, processes, and skills.
Keywords Elderly people, Quality of life, Lebanon, Nursing homes
Paper type Research paper

Introduction
Lebanon’s elderly population is estimated to exceed 10 per cent by 2025 (Sibai et al.,
2004). Many elderly are now living alone because of greater emigration among young
people, decreased mortality rates, major breakthroughs in healthcare and social change
among the young. It is expected that a greater demand for elderly nursing homes and
subsidized care will be needed in the face of elderly demographic changes.
Worldwide interest in successful ageing is now concerned with how to maintain
people in homes or the community (Jones and Peters, 1992). The demand for adequate
healthcare in either private, charity, non-profit and publicly funded homes, plays a
major role in providing elderly care in Lebanon. Such needs include economic
maintenance, psychosocial and health related aspects. Thus, our study assesses the
International Journal of Health Care
institution status by incorporating structures, processes and skills before relating them
Quality Assurance to wellbeing. Our purpose was to improve elderly quality of life including autonomy,
Vol. 23 No. 1, 2010
pp. 72-93 cognitive, nutritional and psychological states.
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526861011010695 This study was funded by World Health Organization Grant #EM/07/05649.
 Elderly healthcare services have been a powerful ingredient for national healthcare Quality of life of
policy decision makers. The basic assumption for any future policy underscores elderly the elderly
people’s quality of life and the progress from dependency to independency and
wellbeing. We consider two main perspectives; first, medical intervention for the
purpose of elderly longevity and second, bio-psychological, which takes account of
biological, psychological and social wellbeing. This latter perspective reflects generally
the policy “faithfully” outlined by the World Health Organization (WHO, 1993) and 73
considers promoting a healthy living and lifestyle changes in elderly care nursing
homes ENH by nutritional, physical and psychological support programmes (O’Boyle,
1997). There are however, considerable debates about what succeeds and what policy
makers will decide for the betterment of elderly lives.
Schmid (1991) says that health, physical, cognitive, social and sexual activities decline
considerably with age for which drugs and other treatments are used to compensate.
Even as ageing requires physical dependence and increased mobility, eating, dressing,
toileting and bathing assistance (Stone et al., 1987), the elderly will face a rise in medical
treatment that continues until death. Thus, devising a comprehensive healthcare
strategy for the elderly offers preventive measures, guiding procedures and standards
for elderly care homes that maintain a sustainable elderly wellbeing healthcare program.
Quality of life measures have obvious implications for cognitive, affective and
functional abilities, which are significant to the overall elderly wellbeing (O’Boyle,
1997). Some measurements can detect old age related health problems that cause
disease or impairment but easily remediable or prevented if activity or nutritional
programmes are implemented. Bowling et al. (1993) suggest that the most important
wellbeing domains are health lack of illness and functional status as opposed to social
networks or social support. The assumptions that drive this work are that knowing
specific elderly conditions provides pre-emptive programs that can be devised to
reduce ENH illness risks (Paunonen and Häggman-Laitila, 1990).
Evidence suggests that there is an impetus to improve elderly people’s quality of life.
The recent seminar on Ageing in Lebanon: Research and Policies held in 2007 and
funded by the WHO as a pre-implementation research program for the semi-independent
elderly in Lebanon, intended to improve institutional care. The concepts underlying
quality of life are multidimensional and include various institutional conditions,
processes and healthcare skills (O’Boyle, 1997). Our understanding of elderly quality of
life in relation to wellbeing suggests a comprehensive evaluation covering key domains:
.
physical health;
.
emotional life, i.e. depression; and
.
nutritional status (Beck et al., 1984).
Additionally, a general drive for quality improvement and an “institutional standards”
culture could promote different service quality aspects generated by customer values
and expectations (Smith and Swinehart, 2001). A measurable aspect of this quality is
based on outcomes (Donabedian, 1988), specifically, the impact of care on outcomes. At
the policy level, the Ottawa Charter for Health Promotion (World Health Organization,
1986) and Vienna Recommendations on Health Promoting Hospitals (World Health
Organization, 1997) suggest among other things strengthening health promotion to
improve service quality as a golden standard and a hospital’s obligation when
assessing patient needs and wellbeing (Groene et al., 2005).
IJHCQA Lebanese elderly healthcare system
23,1 Lebanon is a small country around 10,000 sq. km. With a society made up of
multi-confessional entities Christians, Muslims and Druze. The first Lebanon elderly
care home was known as the Saint George, established in 1874 in Beirut, the capital of
Lebanon. Following the colonial French departure, 72 years later, a second home was
established (El Bcheraoui and Chapuis-Lucciani, 2007). In the last 40 years most other
74 homes have branched out from hospitals. Currently, Lebanon has 46 homes: 25
Christian; seven Muslim, one Druze, and 13 secular funded by Christian
philanthropists that serve mainly Christian dominations. Several homes are
ethnically oriented and confessional. For instance, the Dar Yassouh El Malak admits
only elderly from the Christian clergy, the Kahel Center for Armenian Handicapped
admits mainly Armenians who settled in Lebanon in the past century, fearing
persecution in their native homes.
According to Abyad (2001), most nursing homes are understaffed and lack
specialists. Abyad states that three nursing homes: Markaz Riaayat El Mousineen-Ain
Wizen, Saint George home – Beirut, and Dar al Alajaza Al Islamia – Beirut provide
comprehensive services including rehabilitative, preventive and curative services.
These elderly homes have affiliate universities, which educate nursing and medical
students. The Lebanese University the only public has an agreement with Markaz
Riaayat El Mousineen-Ain Wizen, while the University of Balamand links with Saint
George hospital to educate medical residents for one month in geriatrics. Only Ain
Wizen has accreditation from the Arab Board of Psychiatry (Abyad, 2001).
The Lebanon health system is largely run by private institutions that benefit from
public funds. For instance, three curative services required in old age:
(1) Kidney dialysis;
(2) Open-heart surgery; and
(3) Cancer treatment

are financed by the Ministry of Public Health (Sibai et al., 2004).

Per capita expenditure on health is one of the highest in the Middle East (World
Health Organization, 2004). The National Society Security Fund NSSF adapted from
the French system was established in 1964. In the early years, it included separate old
age benefits and various programs allowing all Lebanese citizens to subscribe to
different benefits. However, after 20 plus years of civil war, few NSSF programs
remained intact, with only services provided to public servants. Ironically, individuals
covered by the NSSF lose their health insurance on retirement from work leaving the
Lebanon elderly with no substantial support once they reach early old age. The
institutionalized elderly are either dependent on family members or rely on limited
funds from either the Ministry of Social Affairs or the Ministry of Public Health. The
National Health Insurance scheme run by the Ministry of Public Health covers
healthcare monthly bills up to $300 per month, while the Ministry of Social Affairs
monthly gives each elderly person up to $80. A number of ENHs operate with a deficit
budget seeking philanthropic aid from Christian or Islamic, national and regional
sources or through nongovernmental organizational funds. However, these funds are
unevenly distributed among different communities, especially outside the capital
Beirut (Sibai et al., 2004).
Engagement model and objectives Quality of life of
All Lebanese ENHs are private and for profit or non-profit. Government requirements the elderly
for obtaining a nursing home license, standard guidelines and control are basically
absent. Although the Ministry of Public Health allocates funds for the number of beds
designated in the original licensing agreement, many ENHs seeking to expand remain
unsupported by both Ministries of Public Health and Social Affairs.
Few elderly studies emerge in Lebanon (Sibai et al., 2004). Some specifically 75
examine elderly health through validity studies (Chahine et al., 2007; Sabbah et al.,
2003) but few examine the relation between institutions and elderly wellbeing. Our
study assesses the structures, processes and skills as a quality of life measure that may
impact elderly wellbeing. Data from elderly residents on one hand, merged with
institutional data on the other, reflect the engagement model applied in academic and
educational settings (Nora and Cabrera, 1996). The model emphasizes a unique
interaction between elderly residents and the institution, influenced by a variety of
elements producing a connection i.e. engagement. Simply explained, as the elderly
enter ENHs, they bring with them distinct health problems, all-life experiences,
financial matters, nutritional problems and specific psychosocial factors developed at
home and life in general. The ENH staff have a unique role providing a comfortable
environment for elderly residents facing drastic changes from life in independent
settings to ENHs. Pillemer (1988) suggested that ENH structures, processes and staff
skills combine to affect elderly wellbeing.

Methods
Investigators approached 44 Lebanon elderly care homes providing long-term
assistance rather than temporary shelter or kitchen/food services. From 33 ENHs,
which agreed to take part in the study. Field researchers encountered problems in two
sites discontinued data collection. In both cases the administrators interfered and
interrupted data collection. This behaviour arose from possible trepidation, such that
data might reveal sensitive information and be conceived as a possible threat to their
organizational strategies.
Fieldwork was distributed among regions. Consequently, seven field researchers
moved from one region to another starting in the north before moving to the south,
east, Mount Lebanon and Beirut. Questionnaires were used to assess ENH structures,
procedures and elderly wellbeing. These assessments were non-invasive, relying
exclusively on questionnaires, inventories and interviews to measure key elderly
health dimensions and indicators. The first questionnaire compiled an institution
inventory:
(1) Bed number.
(2) Aggregated elderly health status.
(3) Staff education.
(4) Medical support.
(5) Elderly activities.
(6) ENH activity areas.
(7) Financial assistance.
(8) Deaths.
IJHCQA (9) Employee numbers.
23,1 (10) Geriatric subspecialty.
(11) Food quantity and quality.
The second questionnaire solicited information from nurses, caregivers or assistants
and included:
76 (1) Socio-demographic and socio-economic information.
(2) Satisfaction with what the ENH offers the elderly.
(3) Relation with peers and supervisors.
(4) Elderly care home perceptions.
(5) Staff-resident relationships.
The third questionnaire dealt with:
(1) Elderly residents’ socio-demographic and socio-economic information.
(2) Health status, diseases and disabilities.
(3) Smoking and drinking behaviour.
(4) Prescribed and non-prescribed drugs.
(5) Sleeping behaviour.
(6) Financial support.
(7) Activities and social involvement.
(8) Frequency contacting relatives and friends visits and phone calls.
(9) In and outside visits.
Anthropometric measurements and other physiological data or weight, height and
blood pressure were recorded and written into the elderly questionnaire. Data were
collected through a checklist, inventories, measurements and questionnaires.

Elderly inclusion and exclusion criteria

Five criteria excluded elderly residents from the project:
(1) Institutionalized less than three months.
(2) Suffering terminal disease.
(3) Blind and/or deaf.
(4) Cognitive impairment measured through the Arabic mini-mental state
examination.
(5) Below 60 years.
The advantage of including selected residents allowed candid and precise wellbeing
data. Field researchers, through interview and probing procedures, solicited all
responses from the elderly residents. A detailed medical history was obtained by
checking each resident’s medical dossier. Our study, therefore, included only residents
physically and mentally capable of interacting with the interviewer.
Measures and instruments Quality of life of
Quality of life data were collected through questionnaires administered among the elderly
administrators, staff, and information from elderly dossiers. Wellbeing data were
collected from the elderly. Six exogenous factors adapted from Pillemer’s (1988, p. 231)
model indicated elderly quality of life:
(1) Custodial orientation or level, based on independence, movement in and outside
the ENH, communicating freely and making decisions (Tobin, 1974; Tobin and 77
Lieberman, 1976).
(2) Care level, resulting from low or high nursing expertise, training/supervision,
according to Pillemer (1988), results in possible elderly maltreatment, i.e. lower
wellbeing levels.
(3) Size, the number of ENH beds is related to service quality (Tobin, 1974; Lee, 1984).
(4) Elderly pay rates indicate that pay is directly related to expenditure per ENH
patient. Higher expenditure i.e. cost, means better the quality of care (Ullman,
1981; Tobin, 1974; Kosberg, 1974).
(5) Higher staff-patient ratios i.e. higher staff per patient numbers means better
service quality (Ullman, 1981).
(6) Physical activity within the ENH includes activities provided by ENH staff for
the able elderly to improve their quality of life and wellbeing (Acree et al., 2006).
These exogenous variables were crossed with elderly wellbeing measures using
standardized nutritional status, depression, daily activity and overall health indicators.
The general aim of our study was to assess how exogenous factors that deal with
institutions, impact the affective, nutritional and physical status of the elderly. All well
being questionnaires and inventories reflected health-related dimensions:
(1) Physical functioning.
(2) Psychological functioning.
(3) Nutritional and overall wellbeing.
Analysis was based on person-centred care by integrating psychological and nutritional
information, as well as aggregating information on institutional needs and outcomes:
(1) The Mini Mental State Examination MMSE Arabic version was used to
evaluate cognitive function.
(2) The Adapted Mini Mental State Examination AMMSE inventory, adapted from
the MMSE was used to identify dementia. The adapted form makes the
questions easy to follow among illiterate individuals. The items that demanded
writing, reading and arithmetical knowledge were changed so that an illiterate,
elderly person could answer the exam verbally. Those elderly who scored less
than 20 on the AMMSE were excluded from the study.
(3) The Mini Nutritional Assessment MNA inventory is a screening tool to assess
nutritional status (Guigoz et al., 1996; Rubenstein et al., 1999) and has 18
questions. Its score ranged from 0 to 30. It is subdivided into four parts:
.
Anthropometric measurements.
.
General status.
IJHCQA .
Diet information.
23,1 .
Subjective assessment (Guigoz et al., 1996). The MNA has six pre-qualifying
questions and if the resident scores 12-14 points then s/he is classified as
normal or well nourished. Those scoring between 12 and 14 in the first six
items were recoded into percentage scores: 12 indicated 85.7 per cent; 13
indicated 92.86 per cent and 14 indicated 100 per cent. Those who scored less
78 than 12 points completed the remaining MNA items. A score of less than 17
points out of 30 is regarded as an indication of malnutrition. A score 17-23.5
indicates a malnutrition risk and greater, and equal to 24 points indicates
that the resident is normal or well nourished. Higher percentages meant
better nutritional status.
(4) The Activities of Daily Living ADL inventory measures the ability to perform
routine activities (Katz et al., 1970). Labelled as the “Index of independence in
activities of daily living”, it was used to study overall performance:
.
bathing;
.
dressing;
.
going to the toilet;
.
transferring movement;
.
continence; and
.
eating and drinking.
The questionnaire uses an ordinal scale ascending from 0 to 6; where 6 means
independence and 0 dependence. The index components are highly ordered
thus, the loss of independence occurs first through bathing, then dressing, going
to the toilet, movement, continence, and finally eating and drinking. The
response format for each of the components is binary. Thus, a score of 0 on each
component means dependence while 1 means independence. The responses on
the Arabic ADL were transformed from a binary 0 and 1 response to 0, half and
1. A half indicates that the resident can be partially independent. Thus, giving
the option of scoring the ADL on a continuous scale. The ADL was scored from
0 to 6. A mean percentage score was calculated, thus higher ADL percentages
indicated higher individual activity/autonomy.
(5) The Geriatric Depression Rating Scale GDS inventory is a screening instrument
for older adults. It provides measures for depressive symptoms and their
severity in the elderly (Yesavage et al., 1983). It was introduced in 1983, initially
as a user-friendly 30-item, self-rated instrument for use with minimal
interviewer training. The 30-item GDS was subsequently reduced to 15 items
(Sheikh and Yesavage, 1986). The instrument has been translated into Arabic
and validated by Al-Shammari and Al-Subaie (1999) in Saudi Arabia and by
Chaaya et al. (2008), in Lebanon. A score $ 11 points out of 15 is regarded as an
indication of severe depression, 6-10 indicates a mild to moderate depression
and # 5 points indicate that the person is normal. The GDS was re-coded in
reverse order, such that all depression indicators were scored 0 and
non-depression indicators 1. Thus, higher scores meant lower depression.
The GDS was transformed into a mean percentage score.
 (6) The EuroQol 5-Domains EQ-5D Brooks, 1996 is based on five elements each Quality of life of
scored from 1 to 3 such that lower scores indicated extreme problems; the elderly
conversely higher scores indicated no problems. The five dimensions mobility,
self-care, usual activity, pain/discomfort, anxiety/depression, with each having
three possibilities, gives 35 ¼ 243 responses. With EQ-5D comes an EQ-VAS,
which is a vertical graduated 20 cm scale ranging from 0 worst case to 100 no
problems at all and elderly give an overall self-rated health assessment through 79
the scale. The EQ-VAS was a percentage score. In some cases, elderly were
assisted in their self-assessment by providing explanations. Each dimension in
the EQ-5D was validated and analyzed separately.
The MMSE instrument, Arabic version, provided by Folstein et al. (2001), went
through an adaptation process rather than translation. The high levels of elderly
illiteracy (see Table I) essentially required simplifying to provide factual information
relevant for the elderly. The Chronbach alpha reliability came to 0.91 for the adapted
version. For MMSE, Chronbach alpha reliability score was 0.89. The correlation
between the AMMSE and MMSE came to a meritorious 0.94 (Ary et al., 2002). Two
instruments were translated into Arabic. These were the Activities of Daily Living
ADL and Mini Nutritional Assessment MNA instruments. The translation went
through the foreword-translation procedure, which involved three translations from
source to target language and then three raters/graders judged whether the
foreword-translated version was similar to the source. The translations are adequate to

Dataset Mean/n SD/%

Age mean 78.47 7.66

Male 82 34
Marital status
Married 19 8
Widowed 111 46
Divorced 12 5
Never married 100 41
Education
Low 138 57
Intermediate 71 29
High 18 7
Occupational status
Low 70 29
Intermediate 37 15
High 9 4
Notes: Percentages do not add to 100 per cent because missing values are not shown in the tables.
Low education includes those who had no education or terminated their education at elementary
school. Intermediate education is those who completed secondary school but may not have received a
degree, and high education is those who had a university degree including graduate studies. A low
occupation includes those with low-paying job, such as a farmer or labourer; an intermediate
occupational status is a person who had a mid-level job, a craftsman, or a small-scale businessman.
Lastly, a high occupational status is a person who owned his own business, had a white-collar job, or Table I.
owned a large farm Sample characteristics
IJHCQA the target when all judges agree on the translation. The inter-rater/grader consistency
23,1 comparing the proportion of times judges have similar ratings came to 0.85. Based on
the translated version’s operational constructs, a review of the document by
investigators provided a semi-finalized version. A final instrument was then
consensually assessed by the translators and used for the pilot study. All instruments
were piloted among eight cognitively able elderly. Minor changes rewording and
80 modifying response format were made to the instruments based on the pilot results.
The exogenous factors were considered quality of life measures that underlined the
study’s engagement model. They were measured through institutional and staff
questionnaires and observational recordings made by each field researcher. The
custodial measure was based on the level of independence experienced by elderly as
judged by field researchers who asked nurses about elderly on two respective scales:
(1) Ability to move freely.
(2) Interact with others within and outside the ENH.
Care level was measured by four items:
(1) Number of ENH employees.
(2) Number of employees that take care of the elderly.
(3) Number of years employed in the ENH.
(4) Years’ experience.
These four items were aggregated to obtain a mean score. Bed number was used to
determine institution size. Elderly pay rates measured “in terms of dues”, source of
finances and monthly expenditure on each resident. The staff-patient ratio was
calculated by dividing the number of residents by the number of staff available.
Last, institutional data of all activity types provided by the Ministry of Social
Affairs whether cognitive or physical including reading, games, kitchen work,
cleaning, etc. were summed into an aggregate score as a measure of institutional
activities.
Measurements were based on a standard protocol that we devised. One investigator
taught field researchers to use the MMSE, AMMSE, ADL and GDS instruments. A
dietitian showed field researchers how to use the MNA, 24-hour food recall instruments
and how to take anthropometric measurements. Field researchers were unaware of
each instrument’s nature and purpose to improve objectivity. Pilot testing instruments
performed on non-institutionalized residents incurred minor modifications.
The study started with six field researchers and one coordinator. A single
coordinator dealt with all regions. Five field researchers dealt with inventories and
questionnaires MMSE, AMMSE, ADL and GDS, two other field researchers/dieticians
dealt with inventories, diet-related questionnaires MNA and 24-hour food recall and
anthropometric measurements; while the coordinator handled the questionnaires for
ENH administrators and staffs. All data were integrated within one database, tagged
and then related through query pointers.

Ethical considerations
A World Health Organization, Eastern Mediterranean Regional Office research grant
review committee granted approval to carry out the study, which was supported by the
Ministry of Social Affairs, Ministry of Public Health and the National Association of
Elderly Affairs. The study was partially funded by WHO through contract Quality of life of
EM/07/0564956. An ethics committee did not exist at the national level or where the elderly
both authors work. The investigators presented consent forms describing the project to
ENH administrators. The consent form asked for approval to enter the home, check
medical files and administer self-rated questionnaires and anthropometric
measurements. Administrators were told all information would be kept
anonymously. Once approval was garnered, administrators identified cognitively 81
able elderly who could participate in the study.
Field researchers described the project verbally to each elderly resident and waited
for his/her agreement. Residents choosing to participate in the study were given the
AMMSE to determine their cognitive abilities. Those receiving a score above 20 were
included in the study. The remaining instruments described previously were then
administered. Duress was not used on the elderly residents and the field researchers
respected elderly rights and needs. Staff and residents in each home were given a code
and a key number to merge datasets and to assure anonymity.

Sample
Out of 2,018 elderly residents, in 33 nursing homes visited, 340 were recognized, by
administrators, as cognitively able. Ultimately, 220 participants with a score of 20 and
above on the AMMSE were included in the study. Demographic characteristics are
presented in Table I. Participating residents’ mean age was 78.5 years. In total, 66 per
cent were female and 46 per cent widowed. The majority emerged from low income and
low education backgrounds.

Results
Ordinal levels of each of the six exogenous factors were run against elderly wellbeing
measures GDS, ADL, MNA, EQ-VAS and EQ-5D. Thus, all instruments were re-scored
such that the higher scores provided a positive wellbeing measure. Table II describes
the recoded wellbeing indicators.
For GDS, ADL, MNA and EQ-VAS, a mean score appeared previously the 50th
percentile, indicating scores above the median level. Activities of Daily Living and
Mini Nutritional Assessment were the highest among ENH residents. The lowest
percentages appeared on the Geriatric Depression Scale GDS, with an average score of
56.38, which indicates that residents were depressed to some extent higher
scores ¼ depression. Considering GDS norms and classifications, we found 50.5 per
cent were mildly to moderately depressed and 11.9 per cent had severe depression (see
Table II). The EQ-5D expressed higher and significant wellbeing levels p , 0:001.
Excepting those who expressed anxiety/depression, more people thought they had
problems, than those that did not, nor had extreme problems. This result corroborated
the GDS findings.
Owing to the number of borderline-mildly demented residents, we ran an analysis to
see if there were any differences between those who scored 20 to 24 and those who
scored above 24 on the AMMSE. We ran a t-test to compare the two groups’ GDS, ADL,
MNA, and EQ-VAS scores (see Table III). No differences were detected except for the
ADL. However, this difference established the AMMSE’s validity; in that demented
residents have restricted mobility and maybe their movement is limited in and outside
the ENH. To cross-validate this hypothesis we ran a two-way ANOVA using
IJHCQA
Mean SD Range (%) n
23,1
GDS 56.38 23.35 0-100 195
ADL 77.47 26.93 0-100 216
MNA 84.75 14.99 25-100 63
EQ-VAS 64.13 23.25 1-100 210
82 No problems Some Extreme
EQ-5D n (%) n (%) n (%) Chi-square
Mobility 162 73.3 44 19.9 15 6.8 30.61 * *
Self-care 106 48 71 32.1 43 19.5 62.11 * *
Usual activity 133 60.2 58 26.2 129 13.1 78.56 * *
Pain/discomfort 112 50.7 88 39.8 20 9 27.17 * *
Anxiety/depression 80 36.2 103 46.6 37 16.7 164.59 * *
Well-
MNA Malnourished At risk nourished
17 #
MNA , 17 MNA $ 23.5 MNA . 23:5
n (%) n (%) n (%)
7 3.2 49 22.3 149 67.7 155.76 * *
Mild
Normal depression Severe
6 $ GDS $ 11 $ GDS $
Table II. GDS 0 # GDS $ 5 10 15
GDS, ADL, MNA, EQ-5D n (%) n (%) n (%)
and EQ-VAS description 73 37.6 98 50.5 23 11.9 45.01 * *

20 # AMMSE , 24 AMMSE $ 24
Mean SD Mean SD t-value df

GDS 53.17 21.93 57.34 23.74 1.014 192

ADL 61.17 29.60 81.89 24.38 4.906 213 * *
Table III. MNA 65.95 9.48 67.22 11.13 0.387 60
Mean, SD and t-values for EQ-VAS 63.71 27.45 64.82 23.33 0.387 207
AMMSE classifications
and wellbeing measures Note: * * Significant at p , 0:001

institutional custodial levels crossed with the two AMMSE groups on the mean ADL
score. We did not expect to find significant interaction effects between mildly
demented, high custodial levels and ADL. In fact the hypothesis was confirmed. No
interaction effect was found between the two variables F ¼ 0:95df ¼ 2; 209; p . 0:05.
To determine exogenous effects on elderly wellbeing, six main factors were
identified and described in the method section. Custodial level, bed number, care level,
elderly pay rates, staff-patient ratio and activity levels were all re-coded into high,
middle and low values based on: the thirtieth percentile; between the thirtieth and
sixtieth inclusive percentile; and above the sixtieth percentile score, respectively and
run on each of the GDS, ADL, MNA, EQ-VAS and EQ-5D wellbeing measures. A
one-way Analysis of Variance ANOVA was run on these four measures as wellbeing
indicators. Table IV reports the means and F-ratios.
 Quality of life of
GDS ADL MNA EQ-VAS
Mean SD Mean SD Mean SD Mean SD the elderly
Custodial level
Low 57.71 24.02 81.42 24.50 85.80 14.83 64.23 22.9
High 53.08 19.91 65.86 33.43 86.41 8.96 64.87 29.58
F-value df 0.92 158 3.0 * * 177 0.21 167 0.13 172 83
Level of care
Low 54.53 24.94 82.77 21.67 88.52 13.91 64.46 21.47
Middle 56.48 22.05 81.67 18.98 82.17 11.61 63.08 22.45
High 53.64 24.19 64.49 33.26 84.61 17.42 62.98 20.35
F-value df 0.15 2.116 7.12 * * 2.127 2.566 2.118 0.07 2.125
Beds
Low 59.88 24.63 85.92 19.70 83.85 14.71 62.80 23.74
Middle 55.26 22.84 80.19 24.59 85.91 15.05 67.02 23.12
High 55.18 22.75 67.03 30.35 82.75 15.05 64.36 25.99
F-value df 0.74 2.169 9.18 * * 2.184 0.68 2.176 0.097 2.53
Rates elderly pay
Low 55.76 22.91 77.34 26.70 85.90 13.80 63.74 23.98
Middle 53.12 23.38 73.23 26.74 81.66 16.58 62.15 23.25
High 60.21 25.96 80.32 25.98 82.31 17.43 68.56 26.41
F-value df 0.74 2.177 0.62 2.194 1.49 2.185 0.72 2.190
Patient to staff ratio
Low 59.19 22.72 72.59 28.86 86.90 14.20 71.69 29.10
Middle 55.20 24.72 74.13 27.99 81.11 15.60 60.83 21.81
High 55.76 21.83 80.95 24.38 85.47 14.68 65.27 23.91
F-value df 0.35 2.160 1.54 2.175 2.30 2.167 2.5 2.173
Activities
Low 52.99 23.83 71.83 29.15 82.25 16.33 61.62 23.34
Middle 58.16 23.50 80.95 25.85 84.92 15.46 64.65 20.73
High 58.61 23.86 77.13 26.04 85.24 13.64 66.23 26.92 Table IV.
F-value df 1.05 2.175 1.63 2.195 0.76 2.186 0.65 2.191 Six exogenous factors
crossed with wellbeing
Note: * * Significant at p , 0:001 indicators

The first analysis showed that high custodial levels appeared to be significantly
different than lower custodial levels on daily activity measures; i.e. tighter control of
elderly independence explains lower activity. Additionally, a significant difference was
found between care level and ADL percentages. Scheffe’s post-hoc analysis showed
significant differences between low and high classification care level on the ADL mean
difference ¼ 18.28, p , 0:001. Also, a significant difference mean difference ¼ 17.12,
p , 0:05 was found between middle and high care levels; thus, lower care levels
generated higher daily activity.
A significant difference was found between beds and ADL scores. Scheffe’s post-hoc
analysis showed significant differences between low and high bed numbers mean
difference ¼ 18.37, p , 0:05. The highest difference between low and high
classification mean difference ¼ 18.89, p , 0:001 and a significant difference was
found between the middle and high classification mean difference ¼ 13.16, p , 0:05.
Thus, lower bed numbers generated higher ADL scores.
IJHCQA Care levels showed moderate MNA differences. As such, moderate levels produced
23,1 better nutritional results. No significant differences were found between the levels of all
other exogenous institutional factors on the GDS, ADL, MNA, and EQ-VAS indicators.
The final analysis used six exogenous factors on five EQ-5D dimensions. We used a
non-parametric chi-square test to study the relationship between the six factors and
EQ-5D. Thus, each of the exogenous factors crossed with the EQ-5D dimensions. Each
84 of the EQ-5D dimensions had three attributes:
(1) Extreme problems.
(2) Some problems.
(3) No problems.
We found significant differences between custodial level, mobility, care level, bed numbers
and patient to staff ratio. There were more elderly with no mobility problems in low than in
high custodial situations; thus, lower care levels meant higher mobility. Extreme mobility
problems also appeared when there were a high number of ENH beds when staffing ratios
were lower. Thus, it appeared that residents enjoy mobility if there was a low level of care,
because ENH staff were more custodial in their dealings with elderly, which is a possibly a
lack of independence indicator. It appeared that more ENH beds meant greater problems;
showing that is, individual care and mobility seemed to be lacking.
Chi-square test results indicated a significant relation between high care levels and
extreme self-care problems. Similarly, ENHs with high bed numbers were different to
ENHs with extreme problems with self-care 55.3 per cent compared to those with no
problems 28 per cent. Finally, elderly who showed high activity levels 63.2 per cent felt
pain/discomfort compared to those who were at middle levels 46.9 per cent and lower
levels 36.4 per cent. Table V reports the exogenous factor results.

Discussion
We related different exogenous factor levels to elderly wellbeing. Although the
independent variables, i.e. exogenous are not exhaustive, they presented to some
extent, a measure of institutional structure, processes and skills in relation to elderly
health. The basic assumption that drives this study can be expressed through Nora
and Cabrera’s (1996) engagement model, which suggests a close connection between
quality of life, specifically in the context and structure of the organization and general
elderly wellbeing (Paunonen and Häggman-Laitila, 1990).
There is consensus among administrators, elderly caregivers and the general public
for a better, meaningful and an active life for elderly living within ENHs. There is no
consensus regarding elderly quality of life measurement (Lundh and Nolan, 1996).
Certainly, quality of life is a complex and multidimensional (O’Boyle, 1997) issue leading
to disagreements in ways to assess wellbeing. According to Bowling (1993), assessment
is variegated and subjective, it entails evaluating several key domains such as:
.
symptoms;
.
activity;
.
health;
.
distress;
.
social, sexual and cognitive functioning.
 Extreme problems Some problems No problems
Datasets Frequency Row % Column % Frequency Row % Column % Frequency Row % Column % Chi-square
Mobility
Custodial level
Low 4 2.6 26.7 27 17.9 61.4 120 79.5 74.5 21.66 * *
High 7 22.6 46.7 5 16.1 11.4 5 61.3 11.8
Level of care
Low 0 0 0.0 6 13.3 23.1 39 80.7 39.8 15.79 * *
Middle 1 2.4 11.1 9 21.4 34.6 32 76.2 32.7
High 8 17.4 88.9 11 23.9 42.3 27 58.7 27.6
Beds
Low 2 3.2 15.4 10 16.1 24.4 50 80.6 36.2 14.62 *
Middle 1 1.6 7.7 12 19.7 29.3 40 78.7 34.8
High 10 14.5 76.9 19 27.5 46.3 40 58 29.0
Rates elderly pay
Low 9 7 25 19.4 95 73.6 3.59
Middle 1 2.9 11 31.4 23 65.7
High 3 8.1 6 16.2 28 75.7
Patient to staff ratio
Low 7 18.4 53.8 9 23.7 22.5 22 57.9 16.9 11.23 *
Middle 5 6.2 38.5 18 22.2 45.0 58 71.6 44.6
High 1 1.6 7.7 13 20.3 32.5 50 78.1 38.5
Activity
Low 5 7.6 17 25.85) 44 66.7 5.89
Middle 1 2.0 13 26 36 72
High 8 9.2 13 14.9 66 75.9
Self-care
Custodial level
Low 23 15.3 52 34.7 75 50.0 6.03
High 10 32.3 8 25.8 13 41.9
Level of care
Low 6 13.3 22.2 16 35.6 34.8 23 51.1 39.0 13.42 * *
Middle 4 9.8 14.8 19 46.3 41.3 18 43.9 30.5
High 17 37 63.0 11 23.9 23.9 18 39. 30.5
(continued)
the elderly

crossed with the EQ-5D

Table V.
Exogenous factors
85
Quality of life of
 86
23,1

Table V.
IJHCQA

Extreme problems Some problems No problems

Datasets Frequency Row % Column % Frequency Row % Column % Frequency Row % Column % Chi-square
Beds
Low 5 8.2 13.2 4 34.4 35.0 35 57.4 37.6 11.3 *
Middle 12 19.7 31.6 17 27.9 28.3 32 52.5 34.4
High 21 30.4 55.3 22 31.9 36.7 26 37.7 28.0
Rates elderly pay
Low 24 18.8 38 29.7 66 57.6 3.64
Middle 9 25.7 14 40 12 34.3
High 6 16.2 13 35.1 18 48.6
Patient to staff ratio
Low 10 26.3 10 26.3 18 47.4 4.50
Middle 17 21 31 38.3 33 40.7
High 12 19 16 35.4 35 55.6
Activity
Low 18 27.7 23 35.4 24 36.9 4.90
Middle 8 16 15 30 27 54
High 15 17.2 32 36.8 40 46
Usual activity
Custodial level
Low 18 12.0 39 26 93 62 0.68
High 5 16.1 8 25.8 18 58.1
Level of care
Low 5 11.1 9 20 31 68.9 5.89
Middle 5 11.9 11 26.2 26 61.9
High 10 21.7 15 32.6 21 45.7
Beds
Low 6 9.7 14 22.6 42 67.7 9.31
Middle 4 6.6 18 29.5 39 63.9
High 15 21.7 20 29 34 49.3
Rates elderly pay
Low 16 12.4 36 27.91 77 59.7 0.64
Middle 4 11.4 9 35.7 22 62.7
High 5 13.5 8 21.6 24 64.9
(continued)
 Extreme problems Some problems No problems
Datasets Frequency Row % Column % Frequency Row % Column % Frequency Row % Column % Chi-square
Patient to staff ratio
Low 5 13.2 10 26.3 23 60.5 2.88
Middle 14 17.3 22 27.2 45 55.6
High 5 7.8 19 29.7 40 62.5
Activity
Low 11 16.7 18 27.3 37 56.1 4.15
Middle 8 16 17 34 25 50
High 9 10.5 20 23.3 57 66.3
Pain/discomfort
Custodial level
Low 12 8 62 41.3 76 50.7 1.41
High 4 12.9 10 32.2 17 54.8
Level of care
Low 6 13.13 15 33.3 24 53.3 8.81
Middle 0 0 21 50 21 50
High 0 17.4 18 39.1 20 43.5
Beds
Low 4 6.6 29 47.5 28 45.9 6.27
Middle 3 4.9 29 47.5 29 47.5
High 10 14.5 23 33.3 36 52.2
Rates elderly pay
Low 13 10.2 53 41.4 62 48.4 3.87
Middle 4 11.4 17 48.6 14 40
High 2 5.4 12 32.4 23 62.2
Patient to staff ratio
Low 4 10.5 10 26.3 24 63.2 7.37
Middle 10 12.3 37 45.7 34 42
High 3 4.8 29 46 31 49.2
Activity
Low 6 9.1 31.6 36 54.5 44.4 24 36.4 23.5 15.26 *
Middle 3 6.1 15.8 23 46.9 28.4 23 46.9 22.5
High 10 11.5 52.6 22 25.3 27.2 55 63.2 53.9
(continued)
the elderly

Table V.
87
Quality of life of
 88
23,1

Table V.
IJHCQA

Extreme problems Some problems No problems

Datasets Frequency Row % Column % Frequency Row % Column % Frequency Row % Column % Chi-square
Anxiety/depression
Custodial level
Low 22 14.6 76 50.3 53 35.1 9.11
High 3 9.7 15 48.4 13 41.9
Level of care
Low 9 20 21 46.7 15 33.3 3.57
Middle 5 12.2 21 51.2 15 36.6
High 13 28.3 18 39.1 15 32.6
Beds
Low 9 14.8 31 50.8 21 34.4 1.65
Middle 11 18 31 50.8 19 31.1
High 13 18.8 29 42 27 39.1
Rates elderly pay
Low 24 18.8 58 45.3 46 35.9 3.00
Middle 4 16.4 21 60 10 28.6
High 8 21.6 16 43.2 13 35.1
Patient to staff ratio
Low 8 21.1 12 31.6 18 97.4 6.68
Middle 18 22.5 36 45 26 32.5
High 8 12.5 35 54.7 21 32.8
Activity
Low 14 21.5 34 52.3 17 26.7 4.74
Middle 8 16 24 48 18 36
High 12 13.8 38 43.7 37 42.5
Notes: For significant Chi-Squares, row and column percentages are presented. *Significant at p , 0:05; * *Significant at p , 0:001
We selected four main dimensions to measure elderly wellbeing: Quality of life of
(1) Daily activities functional. the elderly
(2) Nutritional status.
(3) Depression affective.
(4) Overall health using inventories, questionnaires and interviews.
These dimensions were studied in relation to exogenous variables adapted from
89
Pillemer (1988) and maltreatment measures found in ENHs. The approach is
characterized by an engagement model that merges ENH structures, processes and
skills with elderly wellbeing measures. The main impetus is to recommend quality of
life improvements for residents, leading to independent living for the elderly. Although
the study is not exhaustive, it is a step towards understanding some of the variables
conducive to elderly wellbeing.
It is clear from our results that service developments are needed. Our findings show
there is a moderate level of able elderly less than 15 per cent who are active in their
daily lives, have fair levels of nutrition and a decent ENH life. However, a majority had
mild depression measured through GDS. Many expressed loneliness, bereavement and
dependence as they moved into an ENH. Additionally, depression/anxiety among
elderly found by Sabbah et al. (2003) had a strong relationship to the SF-36 health
survey physical scale. Thus, it could be that depression is related to mobility shown by
the significant relationship between the EQ-5D first dimension i.e. mobility with the
fifth depression/anxiety, x 2 ¼ 11:46; df ¼ 4; 219; p , 0:05. It was evident that a
higher percentage having mobility problems 33.3 per cent also had problems with
depression/anxiety 16.3 per cent. The onset of depression leads to somatic complaints
(McElhaney, 2003) as we found a strong relationship between high physical activities
and pain see Table V. There also appears to be a level of confinement that limits
activities. For instance, the custodial levels appeared to show significantly lower levels
of daily functioning expressed in bathing, dressing, toileting, transferring and eating.
Increased care by staff leading to lower aggregated ADL levels or increased
dependence in daily functioning. Thus, over-exertion by ENH staff can do more harm
than good, in some cases stifling elderly independence and determination.
Elderly care research suggests that activities independently have no substantive
affect on mental health (Acree et al., 2006; Brown et al., 1995). On the other hand,
Rejeski and Mihalko (2001) show that physical activity among elderly is positively
associated with mental health. Importantly, they influence physical, mental, and social
wellbeing. The literature corroborates our results. For example, we found that
exogenous measures:
.
custodial level;
.
care level; and
.
bed numbers
were significantly related to mobility conditions as expressed through the EQ-5D.
Additionally, staff’s higher care levels led to self-care problems found in EQ-5D.
Simply, lower patient-staff ratios lead to a higher care level, which reverses the effect
and view that it helps self-sustenance and movement, but in fact stifles independence.
Recommendations to balance these care aspects are a matter of education and training.
IJHCQA Generally, ENH staff has to explore best practices in terms of mobility and
23,1 psychological care. The kind of care needed to improve elderly resident’s situation and
calls for better ENH standards.

Study limitations
The major methodological difficulty in a study of this kind is the large number of
90 resident quality of life factors. Hence, other studies will do well to analyze data through
confirmatory path analyses. Additionally, a major limitation is that only a few elderly
residents have the cognitive functional ability to interact with researchers leaving out
the much-needed support that demented people may need. Also, with the extensive use
of objective questionnaires, using tools and instruments to understand elderly health
status does not reflect elderly resident priorities and is generally difficult for elderly to
provide self-ratings (McCartan-Quinn et al., 1996). It is significant then to understand
elderly concerns through qualitative observations not easily elicited by questionnaires
devised for this study. For instance, field researchers observed elderly residents living
conditions. In some ENHs they were pampered, in other situations living conditions
were abysmal; specifically the absence of heating or proper lighting. Thus, these
aspects are not easily measured objectively and qualitative research approach
observing interactions would offer a richer picture of elderly living conditions.

Recommendations
A phenomenological approach to research focuses on the elderly views of life (O’Boyle,
1994), through naturalistic and qualitative methods, is a much needed research
approach to understand ENH residents’ needs. Carefully examining elderly
maltreatment as an aspect of residence quality of care and life requires better data
and criteria collected from ENHs. According to one quality assurance model
(Fleishman et al., 1996), an annual ENH surveillance can help to obtain a complete
picture of institutional quality care and understand Lebanese elderly residents’ quality
of life. The Social Affairs and Public Health Ministries are currently focussing on acute
care and fatal illnesses. Such programs and policies do not cover elderly healthcare
provisions or those suffering from chronic illnesses. Establishing institutionalized
healthcare policies and standards is highly recommended. It is possible that a set of
operationally defined ENH standards can be devised by a group of experts, by which
ENH managers align structures, processes and skills to these standards before an
operating license is granted. Currently, there are no valid operational standards to
evaluate ENHs. There are also no Lebanese ENH licensing procedures and many
organizations run without the Ministry of Public Health surveillance. It is high time
that ENH standards are established to assure elderly residents’ wellbeing and that
these standards become quality benchmarks.

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Corresponding author
Ramzi Nasser can be contacted at: ramzin@qu.edu.qa

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