Population ageing has increased worldwide in the last decade, and Japan has become a super-ageing society with people aged ≥65 years accounting for 26.6% of the country's population (Cabinet Office, 2015). This percentage is the highest of all ≥65-year-old populations in other Asian countries, as well as compared to the US and Europe. Indeed, the rate of population ageing in Japan has been increasing every year and is predicted to reach 39.9% in 2060, with one in 2.5 people turning 65 years or older (Cabinet Office, 2015). According to estimates in the UK, the number of people aged 80 years or older will double in 30 years (Office for National Statistics (ONS), 2013). Further, the average life expectancy in the UK in 2014 was 79.2 years for men and 82.9 years for women (ONS, 2018). On the other hand, the average healthy life expectancy at age 65 years in the UK is 10.7 for men and 12.1 for women (ONS, 2014). For these reasons, it is suggested that older people will require support and nursing care for at least 5 years towards the end of their life. As in Japan, there is a global need for efforts towards supporting the health and wellbeing of older people.
Studies on quality of life (QOL) in old age have been conducted mainly in the US and Europe (Emmons and McCullough, 2003; Bishop et al, 2006). Subjective wellbeing, one of the concepts of QOL, first attracted attention in the 1940s, and ‘successful ageing’ proposed by Rowe and Kahn (1997) gained focus as a desirable way to lead life after retirement.
QOL is reportedly strongly associated with health in older people. A number of cohort studies (Iwasa et al, 2006) and meta-analyses (Cohen et al, 2016) have reported that people who find their lives worth living have a lower risk of mortality from stroke and cardiovascular diseases compared to those who do not. Moreover, there is a strong association between ‘loss of life goals’ and symptoms of depression in older people (Arean and Reynolds, 2005), and some studies have suggested that people who have life goals are less subject to stress compared to those do not (Bruce, 2002; Ohashi and Katsura, 2015). Thus, in considering the health of older people, providing support to improve their QOL (e.g. life goals and enhanced self-worth) could lead to better survival (Kaplan and Camacho, 1983).
Older people are more likely to lose track of their personal goals and lack self-worth because of changes in their circumstances and environment, for example, compulsory retirement, spouses' death and the independence of their children. Therefore, it is presumed that they are prone to depression (Ohashi and Katsura, 2018).
The authors of the present study proposed that by helping older people to re-set their personal goals and build self-worth, these individuals might be able to improve their QOL. In this study, QOL was defined as a mentally satisfying life in which older people find their life goals and their lives worth living for. The authors conducted an intervention programme designed to help older people find their life goals and the meaning of their existence. They then evaluated the effectiveness of the programme using QOL as the index.
Methods
Study design
This study used a randomised controlled design with a previously developed interventional programme. The programme was conducted once a month for 90 minutes over a period of 4 months, and changes in outcomes were compared between intervention and control groups. During the intervention period, participants in the control group led their normal lives. The programme was led by professional coaches who were trained by other professional coaches certified by the International Coach Federation. Details of the intervention were included in the form of a coaching protocol. The primary outcome was the Philadelphia Geriatric Center Morale Scale (PGC) score, and the secondary outcome was the General Health Questionnaire (GHQ) score. This study was conducted in accordance with the Consolidated Standards of Reporting Trial (CONSORT) statement. Figure 1 shows the CONSORT flowchart consisting of enrolment, allocation, follow-up and analysis.
Study location, enrolment and randomisation procedure
The participants in this study were residents of City A in western Japan who were ≥65 years old, not certified to receive long-term care, who lived independently at home and who scored ≥10 points on the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC). TMIG-IC scores ≥10 indicate independence in performing vital life functions (Saito et al, 2017). The researchers in charge of enrolment put up posters for recruitment in cooperating clubs and welfare facilities for older adults in City A. Among the participants who attended an orientation meeting, those with TMIG-IC scores ≥10 and who provided consent were finally enrolled in this study. After participant registration, a study assistant who was not involved in the intervention assigned an equal number of participants to the intervention and control groups, randomised using a computer algorithm.
Blinding
The coach was aware of group assignments and provided the regular coaching programme to participants assigned to the intervention group. It was not possible to blind the recipients to the fact that they were being provided coaching. Data collectors and those undertaking the data analysis were also aware of group assignments.
Theoretical basis of the programme
The transaction model of stress and coping (Folkman, 2010) and social cognitive theory (Bandura, 2001) formed the theoretical basis of this programme, based on the idea that clarifying one's own worth and re-setting personal goals could lead to emotional stability and adoption of healthy behaviours.
The transaction model takes into consideration the need for self-affirmation, self-worth and goal re-setting in the process of controlling one's emotions to cope with stress (Folkman, 2010). The social cognition theory suggests that healthy behaviours are adopted as a result of mutual influences among the following three factors: one's capabilities, such as emotion control and self-control; the ability to translate one's knowledge and skills into action; and environmental factors.
QOL improvement programme
Figure 2 shows the components of the four-part programme developed for the purpose of improving QOL in older people. The programme was conducted in a coaching class setting, as this method is suitable for self-reflection and realising one's latent potential (Barlow et al, 2002). Table 1 shows the framework of support aimed at improving participants' QOL.
| Needs | Theories used | Concepts | Intervention strategies | Actual intervention contents | Goals |
|---|---|---|---|---|---|
| QOL (acceptance of ageing, sense of ikigai, satisfaction in life) |
Transaction model of stress and coping |
Emotional control |
Personal goals |
Drawing one's dreams |
Improve QOL |
| Self-affirmation | Rediscovering one's own strengths | Identifying one's own strengths Image exercise | |||
| Skill acquisition | Providing skills to facilitate human relations Providing skills to solve problems | Exercise on listening skills Creating a personal history chart | |||
| Observation learning | Providing a role model | Sharing within the group |
Items, timing of evaluation and data collection
A self-administered questionnaire survey was conducted at two time points in the study: baseline (immediately before the programme was started, i.e., before the intervention) and follow-up (immediately after the programme was completed, i.e., after the intervention).
Data were collected through questionnaire forms, which were distributed to and collected from the enrolled participants by the study assistant at the time of the baseline survey (i.e., when the contents of the study were explained to the participants before they started the programme) and follow-up survey (i.e., immediately after the fourth session of the programme was completed). The evaluated items are described below.
PGC score
The PGC was developed by Lawton (1975) in his study on the psychological wellbeing of older people. A Japanese version has been created and achieved widespread use in Japan as a means to assess QOL among older people (Wataru et al, 1989). In the present study, the 17-item version was used, consisting of the following three factors: ‘lonely dissatisfaction’, ‘acceptance of own ageing’, and ‘agitation’. For scoring, each item of the PGC receives a score of 1 (if a positive choice is selected) or 0 (if other choices are selected), and the total score is obtained by simply adding these scores. The highest achievable score is 17 points, and the higher the score, the greater is the responder's self-assessed QOL. ‘High morale’ means that the person has basic satisfaction with themselves, has a sense of belonging and has accepted ageing.
GHQ score
The GHQ was used to assess the degree of mental health among the participants. This parameter has been suggested to be associated with subjective wellbeing (Iwasa et al, 2006). This GHQ questionnaire was developed by Goldberg et al (1998), who also reported its reliability and validity. It consists of 12 items, each of which is rated on a four-point scale, and the total score is calculated according to the GHQ scoring manual. The higher the score, the lower is the degree of mental health, and scores ≥5 indicate poor mental wellbeing.
TMIG-IC score
The TMIG-IC, an index developed by the Tokyo Metropolitan Institute of Gerontology (Tomioka et al, 2016), was used to assess higher physical activity levels in the community-dwelling older people who participated in this study. The higher physical activities assessed using this index included ‘independence in instrumental activities’, ‘intellectual activity’, and ‘social role’. TMIG-IC scores ≥10 have been reported to indicate independence in performing vital life functions (Saito et al, 2017). In this study, the TMIG-IC score was used for participant selection at the time of enrolment, wherein participants with scores <10 were excluded.
Analysis methods
Participants who attended all four classes were included in the final analysis. Data were analysed using the two-sample t-test to compare basic attributes as well as the scores of PGC, GHQ and TMIG-IC between the groups at baseline and before and after the intervention. When PGC scores showed significant differences between the groups after the intervention, comparisons of subscale scores before and after the intervention were performed using the paired t-test. All analyses were performed using Statistical Package for the Social Sciences version 24, with the level of significance set at <5%.
Ethical considerations
The study protocol was approved by the ethics committee of Kyoto Prefectural University of Medicine. Ethical processes were adhered to. This study was registered with the Japanese University Hospital Medical Information Network (UMIN) Center (UMIN registration no.: UMIN000021950).
Results
Participant details
Sixty-three people attended an information session regarding the study. Of these, 60 were enrolled as study participants; three with TMIG-IC scores <10 were excluded (Figure 1). All 60 participants were randomly assigned to either the intervention or control groups (n=30 each). In the intervention group, one participant was excluded from analysis for missing one class due to illness; the remaining 29 participants attended all four classes. In the control group, there were no dropouts, and all 30 participants were included in final analysis.
Table 2 shows the basic information of the participants. Age (intervention group: 71.8 ± 5.21 years; control group: 70.8 ± 5.61 years), sex, family structure and economic condition were similar between the groups. Moreover, no differences were observed between the groups in PGC, GHQ or TMIG-IC scores before the intervention.
| Intervention (n=29) | Control (n=30) | P value | |
|---|---|---|---|
| Men:women (N) | 10:19 | 13:17 | 0.486 |
| Family structure (N) | 0.618 | ||
| Single | 3 | 6 | |
| Husband and wife | 16 | 13 | |
| Three or more people | 10 | 11 | |
| Age (years) (mean±SD) | 71.8±5.21 | 70.8±5.61 | 0.497 |
| Economic condition1 (mean±SD) | 2.2±0.8 | 2.3±0.82 | 0.899 |
| ADL (mean±SD) | 12.3±1.12 | 12.5±1.52 | 0.728 |
| PGC score (mean±SD) | 12.10±2.84 | 12.53±2.58 | 0.546 |
| GHQ score (mean±SD) | 2.34±2.25 | 2.90±3.20 | 0.444 |
Comparisons between the groups were made using two-sample t-tests, X2-tests (sex and family structure) and the Mann-Whitney test (economic condition).
Economic condition (1–4): unfavourable=1, favourable=4.
SD: standard deviation; ADL: activities of daily living; PGC: Philadelphia Geriatric Center Morale Scale; GHQ: General Health Questionnaire
Comparisons between intervention and control groups after the intervention
The scores on the PGC, that is, the primary outcome, differed significantly between the groups (P<0.003). As shown in Table 3, the mean effect size for differences between the groups was 2.42 (95% confidence interval (CI): 0.62–2.94) for PGC, and -1.02 (95% CI: -2.36 to -0.01) for GHQ. The annualised effect size for PGC was 0.78 (95% CI: 0.24–1.30).
| Follow-up | Effect size mean [95% CI] | Annualised effect size Cohen's d [95% CI] | |||
|---|---|---|---|---|---|
| Intevention (n=29) mean±SD | Control (n=30) mean±SD | P value | |||
| PGC score | 15.31±1.75 | 13.53±2.60 | 0.003 | 2.42 [0.62–2.94] | 0.78 [0.24–1.30] |
| GHQ score | 1.38±1.35 | 2.57±2.89 | 0.049 | -1.02 [-2.36, -0.01] | 0.52 [0.00–1.04] |
Comparisons between the groups were made using two-sample t-tests.
SD: standard deviation; CI: confidence interval; PGC: Philadelphia Geriatric Center Morale Scale; GHQ: General Health Questionnaire
Changes in PGC scores before and after the intervention
Table 4 shows the comparison of scores for the three PGC factors, namely, ‘acceptance of own ageing’, ‘lonely dissatisfaction’, and ‘agitation’, before and after the intervention. The scores for ‘acceptance of own ageing’ and ‘lonely dissatisfaction’ showed significant improvements after the intervention compared to before (P<0.001).
| PGC factor | Baseline (n=29) mean±SD | Follow-up (n=30) mean±SD | P value |
|---|---|---|---|
| Acceptance of own ageing | 3.15±1.48 | 5.39±0.94 | <0.001 |
| Lonely dissatisfaction | 4.25±1.57 | 5.14±1.06 | <0.001 |
| Agitation | 4.22±1.66 | 4.36±1.62 | 0.258 |
The baseline and follow-up scores in the intervention group were compared using the paired t-test.
PGC: Philadelphia Geriatric Centre Morale Scale
Discussion
The findings of the present study confirmed that the developed programme was effective in improving QOL, which has been shown to be strongly related to healthy life expectancy (Kaplan and Camacho, 1983). Of the 30 participants who were assigned to the intervention group, 97.0% (n=29) attended all four classes. This high participation rate suggests that the contents of the programme were of interest to the participants (people aged ≥65 years). The mean TMIG-IC score was 12.4 in the participant group, which is similar to the national average of 12.5 among people in their 70s (Tomioka et al, 2017). With regard to family structure, most participants lived with their spouses, and this proportion was comparable to the national average (Cabinet Office, 2017). Thus, in terms of demographics, the participant group seemed representative of the general Japanese population in this age group.
The intervention programme was found to be significantly effective in improving PGC scores, compared to the control group (effect size=2.42; P<0.003). In addition, a significant intervention effect of the programme was suggested by the annualised effect size of 0.78 (95% CI: 0.24–1.30) for the PGC score. In particular, the programme was shown to be effective in improving ‘acceptance of own ageing’ and ‘lonely dissatisfaction’, among the three PGC factors. The intervention also significantly improved GHQ scores compared the control group (effect size=-1.02; P<0.049); however, no substantial effect was confirmed, with an annualised effect size of 0.52 (95% CI: 0.00–1.04).
The programme conducted in the present study urged participants to turn their thoughts inward, clarify their self-worth (part 4(1)) and attach positive meaning to their lives in the past, present (part 3) and future (part 4(2)). According to Diener et al (1999), cognitive evaluation of one's life increases subjective life satisfaction, which is a component of QOL. Moreover, positive valuation of life also reportedly increases mental wellbeing (Lawton, 2001). The findings of this study are consistent with those of these reports. According to Maslow's hierarchy of needs (1987), the desire to attach meaning to life corresponds to higher-level needs, such as those involving social belonging and esteem. Further, according to the concept of self-efficacy (Bandura, 2001), one way to increase confidence in oneself is to gain verbal affirmation from others (part 2 of the programme). In the classes in the QOL improvement programme, participants reflected on their past as a part of the exercise, which probably helped them accept the ageing process better by helping them gain an objective understanding of their lives (part 3). It could also be that, as participants rediscovered their strengths (part 2), set future life goals (part 4(2)) and clarified their self-worth (part 4(1)) through the workshop, they were able to re-confirm the meaning of their lives and existence; this might have contributed to the improvements in the ‘lonely dissatisfaction’ factor (Peterson, 2005).
The effect of this programme in improving GHQ scores was low, possibly due to the fact that all the participants had normal GHQ scores even before the intervention (mean score: 2.62±2.72). However, after the intervention, there was a 1.02-point decrease in the score relative to the control group, suggesting that the programme improved the participants' mental wellbeing to some extent.
Study limitations
The present study was conducted in a single provincial city with a small sample population recruited from clubs and welfare facilities. It also had a short follow-up period. Since one participant dropped out from the intervention group and was excluded from the analysis, the effects of the intervention may have been overestimated. Moreover, given that the group assignment was not blinded to the researchers or the participants, there is a possibility that some bias might have been introduced. Therefore, the observed effects of the programme may not be adequately generalisable.
Conclusions
As the ageing population grows worldwide, the need for interventions to improve the QOL of and prolong healthy life span in this demographic is increasing. Good health is closely tied to social wellbeing. The coaching programme described in the present article enhanced the QOL among community-dwelling older people by guiding them to reframe their life goals and re-assess the meaning of their existence. Further studies with a more diverse and larger sample size are warranted to better understand the effects of this programme and introduce improvements whereby it could be applicable to more older people from diverse backgrounds.