This study was conducted to explore the impact of the developed need-based educational intervention on improving the QoL of activity-limited older adults. As a summary, statistical analysis of the results of the post-intervention between the intervention and control groups showed no significant difference in the overall QoL, while significantly higher values (p < 0.05) were observed in the QoL scores of the physical health and psychological domains in the intervention group compared to the control group. Comparison within the intervention and control groups indicates that the intervention conducted in this study has a statistically significant impact on maintaining the QoL of physical health, psychological, and environmental domains, and thereby, on the overall QoL of older adults with limitations of activities.
Impact of the developed intervention on the QoL of older adults with limitations in activities
The impact of the interventions towards improving QoL varied in different studies since many factors affect the QoL, and these factors are different in every society [33]. When considering the mean differences at baseline, no significant difference was observed between the two groups in the present study, similar to other studies [33, 34]. Conversely, Buss et al. wished to determine the effectiveness of educational nursing home visits on the QoL of older adults with impaired mobility and found that the baseline QoL of the control group was considerably lower than that of the intervention group that was at a standard level, and therefore the educational intervention was ineffective [35]. Therefore, studies including ours can claim that the impact of confounding factors was controlled.
Interventional studies have been conducted with a similar design to determine the effectiveness of need-based education and integrated care [33], the effectiveness of self-care educational programs [22], and healthy lifestyle programs [16, 36] on the QoL of older adults. All studies found a statistically significant improvement in the QoL with these interventions. When considering the individual impact of the intervention and control groups in the present study, the control group showed a significant difference between pre- and post-intervention results in all outcome variables, except for social relationships. However, although there is no significant difference between pre- and post-intervention results within the intervention group, there is a slight improvement in the overall QoL and domain-specific QoL. Similarly, Rana et al. conducted a community-based interventional study to determine the impact of health education on health-related QoL of older persons, and the study found that the deterioration of scores of most of the QoL dimensions was minimal in the intervention group when compared to the control group [16]. This may be due to the significant deterioration of QoL over time in the control group and not having much increase in the QoL in the intervention group, as exhibited in the post-intervention results within a shorter period of time. The reason for the deterioration of the QoL of the control group was probably multifactorial, which includes the increasing age of the caregivers, the emergence of disease-related complications, and caregiver burnout, which occurs naturally over six months. Further, although there was no significant improvement in the QoL of the older adults in the intervention group after six months, the intervention may have prevented the natural deterioration of the QoL to some extent in the intervention group compared to controls within the six months. Similarly, the overall mean scores of the QoL domains of the control groups in the study conducted by Khalili et al. decreased during the six months, with the deviation being statistically significant [33], similar to the present study. These similarities demonstrate that in the absence of proper planning of the related actions, the QoL of older adults would decrease over time. In addition, the length and the content of the educational intervention could affect the improvement in the QoL of the intervention group [31, 37].
The results of the current study found that the intervention had an impact on the overall QoL, physical health, psychological and environmental aspects, except for the social relationships of the older adults. The older adult’s level of QoL in social relationships had not deviated as much as in the other QoL aspects over the six months. However, when considering some of the studies that conducted health education interventions to improve a healthy lifestyle [16, 33, 36] found that mental health had significantly improved because of the involvement of family and social network support. Hekmatpou et al. report that, as most older adults had physical illnesses, the interventions helped improve their mental health when compared to physical health [36]. Such differences may be explained by the fact that the present study was conducted in the homes of older adults in community settings, while other studies were not explicitly conducted in similar settings.
Most studies have concluded that educating older adults about physical activity, adopting a healthy lifestyle, and providing psychological counseling and information related to caregiving of older adults with limitations in activities make a significant impact on improving the QoL of older adults [4, 16, 22, 32,33,34]. Moreover, there are reports that many factors could affect the QoL and that paying special attention to healthy lifestyles and self-care education provided to immobile older adults through interprofessional cooperation and public policies will improve the QoL of older adults [33]. Malekafzali et al. also highlight that educational interventions are suitable to promote the health of older adults, especially among women, due to their higher life expectancy and their vulnerability to disabilities [24]. Meanwhile, poor educational exposure, widowhood, living alone, and financial dependency need greater attention, as older adults are vulnerable to these risk factors [24]. Rana et al. mention that conducting community-based health education interventions will be a valued public health initiative in enhancing the QoL in old age [16]. Since there is an increase in the older adult population worldwide due to the higher life expectancy, the magnitude of older adults living with chronic non-communicable diseases is also high [14]. Therefore, there is a higher need for effective educational interventions to promote better health conditions and QoL [14]. Thus, Baraz et al. explained a paradigm shift in concepts of health and education in recent years that allows the expansion of actions in education for health [14]. In general, therapeutic interventions, such as education and psychotherapy, can provide the ground for improving both the physical and mental health of older adults [38]. Moreover, it is suggested to address the issues related to QoL through planning and policymaking [33]. Thereby, the healthcare workers can identify older adults with limitations in activities who need healthcare interventions and health education. The focus should not be confined to the QoL of older adults but also to improving the QoL of their caregivers. In conclusion, such involvement of healthcare workers would help reduce hospitalization rates and healthcare costs and improve public health in general.
While considering the study findings, such as improvements in the physical health, psychological, and environmental domains of QoL of older adults, it is important to reflect these effects over time to prevent further deterioration of QoL of older adults, which is common among activity-limited older adults. When focusing on the caregiver education in the Sri Lankan context, to ensure the long-term sustainability, it is important to have a continuous process of assessment of the needs of the older adults, regular follow-up sessions, monitoring, and reevaluating the caregiver training or education programs. Incorporating caregiver education certificate courses or training programs into existing public health, nursing curricula, or establishing technical colleges under the university system or public health institutions under the healthcare system are beneficial through national policy frameworks. Further, establishing collaborative partnerships between tertiary care hospitals, social service providers, and national or international non-governmental organizations can enhance resource mobilization. Particularly, scaling up the intervention for rural communities through resource persons such as nurses, community health workers, and social workers towards conducting mobile outreach education and training programs would increase the accessibility of older adults and caregivers of rural communities. Overall, the integration and expansion of caregiver education across the healthcare system can contribute to promoting healthy ageing, improving caregiver education, training, and ultimately enhancing the QoL of older adults in Sri Lanka.
Methodological considerations of the study
When focusing on the literature related to educational interventions intended to improve the QoL of the elderly population, there are many experimental clinical trials and a few quasi-experimental studies [39,40,41,42]. However, there has been a growing trend of quasi-experimental designs over the years [17]. Among them, some interventions conducted were aimed at improving the QoL of older adults [4, 16, 33,34,35, 39, 41, 43] or of their caregivers [31, 37, 44] whereas one study was conducted to improve the QoL of both older adults and their caregivers [26]. Most of the studies used differing QoL assessment tools such as the Health Survey Form (SF-36), Euro QoL-5D-5 L, and WHOQOL-OLD scales, and some used the WHOQOL-BREF scale [35, 44], which is similar to the present study.
Strengths and limitations of the study
The impact of the educational intervention was tested using a quasi-experimental study with a control group, using a pre- and post-intervention design, which is the most suitable design to address the study objective. Having a control group adds to the scientific strength of this quasi-experimental study and enables the applicability of the interventions and the impact of the interventions developed as per the study observations. As neither the participant nor the investigator was blinded in some interventional studies, the role of the researcher and participant in reporting outcomes can be challenged. However, to minimize this problem, the outcome was established before initiating the current study and measured as accurately and reliably as possible to avoid this problem. Compared to experimental research designs, quasi-experiments involve manipulation but do not use randomization [45]. To avoid this, adults were allocated to treatment groups by the investigator based on the predetermined study protocol.
When considering the limitations of quasi-experimental studies, this design has the potential for bias from confounding factors. For instance, the study may include the healthiest patients to ensure that the intervention optimizes the expected outcome. To minimize this factor, the researcher recruited participants who were of a similar age range and socio-demographic background with similar levels of limitations in activities. Some studies showed that imbalances in the socio-demographic factors of the participants between the intervention and control groups would affect the impact of the intervention on the outcome variables [16, 35]. To do this, as adopted in the present study, the investigator selected the participants based on the highest limitations in activity score using the list of participants with disabilities obtained from the social services division of each selected divisional secretariat. Furthermore, to avoid the introduction bias in this quasi-experimental study, the investigator randomly selected two of the thirteen divisional secretariats to conduct the intervention, and similarly for the control group. In addition, when allocating the sample to the intervention and control groups, subjects were allocated separately from two geographically separate divisional secretariats to minimize the risk of contamination. Moreover, just as in observational studies, there could be a possibility of influencing unmeasured confounders towards the study results, which is considered a limitation.
The present study analyzed covariates against all the outcome variables of the QoL of older adults to detect any effect on the impact. The results of the ANCOVA test revealed that there were no significant differences between the socio-demographic factors and other related confounding factors with the QoL dimensions of the two groups (p > 0.05), similar to the quasi-experimental study conducted by Khalili et al. [33]. Therefore, we conclude that the contribution of confounding factors towards the impact of the intervention was controlled appropriately. Thus, the results of this study are generalizable despite it being a quasi-experimental study.
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