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Meta analysis of anxiety of the elderly in traditional Chinese families and nursing homes

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  • Save American Journal of Sociological Research 2013, 3(3): 67-72 DOI: 10.5923/j.sociology.20130303.03 Anxiety among Chinese Older People Dwelling in Traditional Family versus Nursing Home: A Meta-analysis Feng Tong1,*, Hongbo Li2, Chenggang Yang1 1Southwestern University of Finance and Economics, Chengdu, 610074, China 2Nankai University, Tianjin, 300192, China Abstract Bac kground: In the aging china, there a re t wo ma in supporting models for e lderly, t raditional fa mily support, nursing home support. Object ive: to investigate the influence of an xiety statue in different resident places by combin ing the existing demographic variab les researches. Methods: totally 11 literatures selected in the Meta-analysis, demography background and health-related conditions data was extracted. An xiety was measured with SAS and STA I-Y respectively. Results: for the whole sample, there is no significant difference on the level of An xiety between the two groups. But the older age individuals reported higher level of anxiety in traditional family rather than in nursing home. Furthermo re, different demographic characteristic reported different an xiety levels within age, gender, educational experience, marital situation and so on. Conclusion: to benefit elderly mental health, higher age windowed individuals might be more suitable to live in nursing home, and there are some suggestions for elders liv ing in tradit ional family. Keywords Anxiety, Meta-analysis, Tradit ional Family Support, Nursing Ho me Support 1. Introduction A study in late 2012 found that there were 178 million people over 60 years-old in Ch ina, taking up 13.26% of the total population[1]. So me authors estimated that this proportion would increase to 20% by 2025 and 25% by 2050[2]. Thus, China is a rapid ly ag ing country both in terms of the over all proportion of elderly in the population and in terms of the rate of increase in the proportion of elderly. At the same t ime the one-child-policy has led to a rapid decrease in the size of urban families, so the traditional method of supporting the elderly is not the only way can solve. More and mo re institution supporting was accepted. But so far most the Chinese elderly willing to choose living on a traditional family support in the their own ho me or in their son’s and daughter’s home rather than nursing home or institution, because nursing home or institution are considered to be a poor condition liv ing, less support and may lead more mental problems. In this view, elderly have psychological resistance to enter the nursing home. Anxiety disorders in later life are very highly prevalent[3,4,5]. Prevalence estimates in later life range fro m 1.2% to 14.2%[6,7] depending on sampling procedure, * Corresponding author: (Feng Tong) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved age cut-offs for classificat ion as old and exclusion of anxiety cases due to general medical conditions. A Chinese research reported Chinese elderly thought that the nursing home can not meet their psychological needs[8], and may lead to even worse mental health and fewer positive emotions and so on. Some studies based on western data also found that the elders in institutions have higher incidence of depression and anxiety d isorders than which in the community and trad itional family[9, 10, 11]. There is a new research reports that the elders in Nursing ho me presented 28.1% depression prevalence rate, 27% anxiety disorders, much h igher than the elders in co mmunity and traditional family[12, 13]. In the late life, the medical disease is very frequent and several physical conditions such as respiratory, cardiac and vestibular p roblems may both be a source of an xiety and be exacerbated by anxiety[7]. And many previous studies reported various factors would affect the elderly mental health status, such as age[14, 15], gender[16], health[17], marriage status[16, 8, 18], economic status[16, 19], an xiety symptoms, chronic illness. functional limitations[20,21,22] as well as the social support models[19]. And of course there are many obvious significant differences between traditional family support and the nursing home support for elders in many aspects, which could lead to different elderly mental health status. The elderly average age is generally h igher which in the nursing home than in home[23] and the prevalence of various diseases is also worse than living 68 Feng Tong et al.: Anxiety among Chinese Older People Dwelling in Traditional Family versus Nursing Home: A M eta-analysis traditional family support[24, 10], but it may cause by the age of elder rather than the hygienic conditions of liv ing. However in a direct contrast research between the traditional family support and the nursing home support, reported that the difference was not significant[15]. And many researches about elderly an xiety symptom in d ifferent demography background reported very different consequences. Some factors result in vulnerability to disease and increased med ication use[25, 26]. So to properly appraisal the mental health status, the demography factors should be considered inevitably. In this study we review cu rrent relevant research and integrate the outcomes to evaluate the relationship between demography variable and mental health status in different social support, as well as appraisal the e xisting research by systematic revie w as well as quantity Meta-analysis, in order to reduce the research bias, and find out general reason of diverse mental health status between traditional family support and the nursing home support, help decision ma kers. 2. Methodology The first use of the concept of "meta-analysis" is an American scholar named Glass. His definition of meta-analysis is: to integrated discovery the already researches by comprehensive statistical analysis on the results of every single study[27]. Thus meta-analysis is a scientific, standardized and efficient secondary research methods, which can be largely overco me the limitations of traditional literature rev iew exists. In this paper the meta-analysis method is trying to apply in this research to analyze the an xiety intervention research, planning to use a descriptive analysis on existing researches and study, as well as quantity integrate those researches and study which match the Meta-analysis condition, in order to provide useful evidence for the elderly an xiety and psychological intervention by different support models. Meta-analysis is a way of merg ing the results of mult iple independent studies into a single effect size (effect size, ES), which uses a comb ined statistic reflects the combined effect of mu ltiple independent studies. Meta-analysis do not based on the original information, but by the existing statistical research results. There are two types of such results, one is test of hypothesis research, such as the t, , 2,P , etc.; Another one is the statistical values in each report, including the measurement data (continuous variables) and count data (discrete categorical variab les) The indicators of count data include: odds ratio(OR) 、 relat ive risk(RR ) 、 risk difference( RD)、hazard rat io(HR), etc. The indicators of measure ment data include: corre lation coefficient (r)、mean difference、weighted mean difference(WMD)、standardized mean difference(SMD),etc. The values used in this study is the weighted mean difference (WMD), Mark as‘d’. 3. Search Strategy In the research of e lderly mental health, we have to control the research background for reducing the research bias, so the literatures we chose are based on a same criterion: same age, gender, education level, marital status and other factors. Because the elderly in nursing home always have higher age and higher widowed rate, and those two key risk factors effecting elderly mental health[28], may create bias to the research of the supporting models on the elderly mental health. Studies were identified by searching the Cochrane Central Register of Controlled Trials (CENTRA L), Porquest, CNKI and WanFang databases fro m 1970 to 2013. We used a search string involving the MeSH term for an xiety disorders and combinations of ‘elderly an xiety disorder ’and ‘Tradit ional Family support’ or ‘Nursing home’ or ‘family support’ or ‘commun ity support ’ or ‘long term care’ or ‘dwelling support’ and the MeSH term for ‘support’ and combination of terms (‘care’ or ‘support’ or ‘interruption’ or ‘behaviors therapy’ or ‘feedback’ or ‘intervention’ or ‘counselling’) to maximize identification of relevant studies. Additional papers were identified fro m reference lists. We did not use studies in press or unpublished studies in this research. For this meta-analysis we included (a) published randomized controlled trial (RCTs);(b)case-controlled studies;(c) quasi-experimental studies (d)descriptive studies (e)single case experimental (f) experts opinion. Search criteria as following were tailored according to the database. Citation tracking was used to identify addit ional studies fro m the reference lists of previous relevant systematic rev iews . Records identified through database search Screened on article-title/key-words Records screened eligible Full-text articles asse ssed for eligibility Studies included in quantitative synthesis (m e ta -a n al ysi s) 4. The Meta-analysis of Anxiety Consistent with the aim of reviewing the effectiveness of support, comparative, experimental studies were selected. There are two highest frequency used scales in anxiety study: Zung's self-rating an xiety scale (SAS) and the State-Trait American Journal of Sociological Research 2013, 3(3): 67-72 69 Anxiety Inventory (the STAI-Y). SAS contains 20 items reflect the subjective feelings of an xiety, each item is divided into four rated in accordance with the frequency of symptoms, the Standard cut-off value is 50 points, 50-59 of which are d ivided into mild an xiety, 60-69 moderate an xiety, severe anxiety more than 69 points. STAI-Y has state anxiety and trait an xiety subscales, each of them has 20 questions, the former described a short-term unpleasant emot ional experience, such as stress, fear, an xiety, often accompanied by autonomic nervous sys tem hyperthyroidis m; latter is us ed to describe a relatively stable in mood, as a personality characteristic and tendency of individual differences in anxiety. Each topic scoring by four points, and the minimu m of each subscale is 20 points, the highest score is 80 points. As different health contexts, the experimental designs are often not possible or feasible, so study eligibility for inclusion in the review was assessed by two reviewers (Li and yang), with disagreements being resolved by consensus. And studies were categorised as having a theoretical basis if they cited a specific theory underlying their intervention design, or reported that the intervention was based on a broad theoretical approach. The Meta-analysis result of existing researches basing on those two questionnaires in three aspects as follows. 4.1. The Rate of El derly Anxiety under Differences Support Models There are 11 relevant literatures of the SAS Scale measurement results of trad itional family support elders, referring to 3163 people, and 887 people’s the standard points are over 50, calculat ing the elderly an xiety overall detection rate was 28.04%. there are five relevant literatures of the SAS Scale measurement results of nursing home elderly, referring to 2321 people, and 483 people’s the standard points are over 50, calculating the elderly an xiety overall detection rate was 29.87%. The whole percentage of anxiety disorder rates are very high among Chinese elderly, actually in the same level in those two supporting models, but a little better in traditional family elders. The better outcomes in the traditional family support group compared to those in the nursing home group might be due to the stronger social support network by family members. However, more prospective studies would be done as following to confirm that the results are not only due to circu mstances bias and reveal more correlation factors between those two models. 4.2. The Distinction of El derly Anxiety under Differences Support Models Because those SAS outcome measurements were not sufficient as literatures limitation, so the outcome of the STAI-Y measurement is adopted to measure elderly an xiety. Literature inclusion criteria: ① STAI-Y Scale as a measurement tool; ② the state and trait an xiety under different support models were to be measured; ③ the report provides each number of d ifferent support group, and the mean score and standard deviation. A total of 6 studies matched the inclusion criteria, referring to 2356 people. We set the nursing home support as "Treatment", setting the traditional family support as "control". Firstly we tested the homogeneity of the input data, when P over than 0.05 using a fixed effects model, when P less than 0.05 using a random effects model (the same way for the fo llo wing data). And test of homogeneity of the two sets of data reports P less than 0.05, wh ich means the study is heterogeneity, suggesting using the random effects model. Table 1. The overall level of The elderly anxiety comparison Items Z P 95% confidence d int erv al low high St ate anxiety < 4.93** 0.01 6.93 4.17 9.68 Trait anxiety 2.28* 0.02 2.36 0.33 4.38 *P<0.05,**P<0.01 As we can be seen from Tab le 1, the two d imensions both in state and trait anxiety level o f the nursing homes support model was significantly h igher than the traditional family support model, particu larly for the distinction of the state anxiety(P <0.01). That describes the emotional impact under this supporting of elders was more significant. The group living in their t raditional o wn or children’s homes, regardless of whether or not they receive effective services, report a h igher quality of life, better social support networks and less psychological symptoms than those living separately fro m their family members in nursing ho me facilit ies. Since elder subjects liv ing in their tradit ional homes may live with their spouse or with other family members. In this way elder get the additional family support report a stronger social support network than those who live in their place or with other family members who do not receive these services. In order to examine the active components between different elderly supporting models, dismantling studies should be conducted. We find that elders in nursing home had higher rate of an xiety sy mptom than in traditional fa mily. But in those selected studied, some shows there is no significant distinct among different elderly support models. So it is not clear whether our findings reflect differences between elderly support models and anxiety symptom patterns. Hence the further demography analysis should be applied to explain the different an xiety symptom patterns caused by methodological diffe rences. 4.3. The Correlati on between Demographic Variables and Anxiety Levels in Different Support Models The presence or absence of significant correlat ion between demographic variables and anxiety levels cause many researchers’ attentions, with many arguments. We select three most frequently used variables: gender (ma le, fe ma le), 70 Feng Tong et al.: Anxiety among Chinese Older People Dwelling in Traditional Family versus Nursing Home: A M eta-analysis age (<75, >75) and marriage (married, single), analy ze the STAI-Y results. Literature inclusion criteria (gender as an example): ① STAI-Y Scale as a measurement tool; ② state anxiety of men and female were to be measured; ③ The report provides the number of men and female groups, as well as the mean and standard deviation of the score. There are five literatures matched the standards of gender comparison, and two each of age and marriage. The Meta-analysis results of state anxiety and trait an xiety score are shown in Table 2 and Table Table 2. The elderly state anxiety score in different demographic ch aract erist ics 95% Sup p o rt in g models Items Z P d confidence int erv al low high Nursing Home Gender 1.77 0.08 - 0.62 - 1.31 0.07 Age 2.29* 0.02 - 1.27 - 2.36 -0.18 Marriage 0.50 0.62 - 0.97 - 4.76 2.82 Traditional Gender 1.52 0.06 - 0.51 - 1.82 0.03 Family Age 2.73* 0.03 - 1.27 - 1.82 -0.78 Marriage 3.52* 0.04 - 1.68 - 5.26 1.14 *P<0.05,**P<0.01 Meta-analysis in Table 2 showed that the different an xiety status of different ages, the lower age is accompanied by the lower level of state anxiety both in those two models, but there is an significant d istinction in marriage statue, single (widowed) elderly report a high level of state anxiety in traditional family rather than nursing home, and the distinction was very significant on statistic. However comparing with the some single study, this Meta-analysis research reports there is no correlation about gender, according to the 95% confidence interval (d ) of overall effect estimate on those two items, those can not be considered as significant difference. With respect to the other variables, some the demographic variables were significant in one or both anxiety groups. Our finding that that found that elderly an xiety increases with age, especially among traditional family environ ment. However, most diagnostic categories studies have found lower or similar rates among older indiv iduals. Also, in the studies about gender of o lder populations, we found that wo men were more likely to have an xiety sy mptom, although this result was not quite significant on an xiety, men were mo re likely reports positive mental health on an xiety disorder. With respect to the life events and achievement variables, consistent with other studies, we found lower inco me to be associated with elderly an xiety. Especially this estimation was taken place mo re co mmon among the family care anxious symptom group. Contrary to earlier reports, we found higher education to be associated with h igher an xiety levels, although this estimation attained more significance only among nursing home an xious group. For persons who with more education, always get more troublesome with neighbourhoods, in the same way, higher education person in nursing home may pay more attention on his personal circu mstances that could contribute to anxiety symptom. In addition to physical an xious symptoms, beyond those demography variab les, alcohol also can cause an xiety for some and relieve an xiety on individuals. Similarly acute stressors were also significant for both anxiety groups in some studies. So as two other vulnerability variables, past or current acute stress and alcohol abuse should be considered more in the family care group, since in nursing ho me institution, there is always strict regulation of those. However, there are still many other factors can impact anxiety symptom, but studies selected in this research contains various methodologies and different measurement standards that can not conduct to Meta-analysis. Given the cross-sectional nature of the study, it is not possible to prove a causal re lationship between the different forms of care, but fro m the better outcomes of the traditional family support group, we can see their demographic characteristics reports the younger elders have less anxiety disorder problem, the findings are quite suggestive that the provision of family care services does in fact improve the social support networks and some of the psychological symptoms of younger elderly urban residents. However the same age individual elder living in nursing home facilities are more isolated fro m their family members, but the older age individuals living in nursing home facilit ies assumes a better outcomes anxiety disorder statue. In another word, higher age with widowed elders report a lower an xiety statue than elderly under traditional fa mily support. That is to say, elderly who is the older and widowed is better to go to nursing home rather than traditional home, which may conducive to their mental health. That may cause by gaining new social support and relationships instead of original marriage statue. This proposals an opposite view against some previous research wh ich reports a poorer physical and mental hea lth condition in residential home care. In addition, before entering the residential home care, the elder is needed for a comprehensive physical examination, so some elders with d isease can not enter the residential home care. That is why the older elder in nursing home reports a lower prevalence rate. Ho wever, most of the nursing home elders are personally involved in the choice of supporting models, so the nursing home life for them, is not something completely forced, and thus may not be derived fro m a very negative emotions, such as many widowed elderly choose to go to residential home care, in order to make up the lack of communicat ion and social support. All in all, although the lower age elder with integrity family suit for living in traditional family support and the higher one with widowed more suit for liv ing in nursing home, the different outcomes between demographic characteristics and anxiety disorder in both group could be explained this point to some extend. 5. Limitation American Journal of Sociological Research 2013, 3(3): 67-72 71 This study has several limitations. To the first, although this meta-analysis included a relatively large number of studies, we did not have sufficient analysis to examine mo re specific subgroups, such as studies with windowed groups in which subjects were recruited fro m very different circu mstance. For the second, the quality of several studies was not optimal, and for some influence factors we only conducted describe analysis instead of intention to impact analyses. Third ly, the correlation factors in th is study considered and controlled is limited, In addition to elderly age, sex, marital status, social interaction, social support and so on[11,14], may also affect elderly mental health to some extent. Thus the conclusion of this study has some limitat ions in application and promotion process, look forward to a deeper and mo re comp rehensive study to test this conclusion. Despite these limitations, the present meta-analysis illustrates the influence and relat ionships between nursing home support and traditional fa mily support, analyze both advantages and disadvantages by demographic characteristics in those two group, and proposal that some mu lti-supporting model to remain stable to follow-up and may even improve somewhat. 6. Conclusions and Suggestion sample sizes. Our data suggests that providing more service options by demographic characteristic for the elderly which can improve their support networks and decrease some of their psychological symptoms, but much more work is needed refine these methods, to test their efficient, and to determine how best to adapt effective models to other communit ies, particularly rural co mmunit ies. Most importantly, the extent to wh ich social supporting models can actually improve social support, psychological health and the quality of life in elderly individuals will remain uncertain until more and more long-term prospective studies in relatively large samples are conducted. REFERENCES [1] Hong Z, CHEN S L, JI W Y, et al (2012), Comparison of the psychological status and quality of life of elderly urban Shanghai residents who receive different types of support services, Shanghai Archives of Psychiatry, Vol.23, No.2:79-86 [2] Liu L P, Jiang S Y, Xu D Y, et al (2008). Development trend o f old age service style in urban area. China Journal Community M edicine, 6 (7 ): 44-46. By co mprehensive analysis in above study, some suggestions could be discussed in final part, as the traditional family support model is the most common supporting so far in China, the suggestion mainly focus on improving this model by adapting mo re co mmunity supports, in order to develop a range of services to meet the different types of elderly needs; however, the nursing home support model, the research reports it is not so worse as people’s thinking and maybe suitable for some elderly population, such as widowed. According to advantages both in traditional family support and nursing home support, there are six target criteria may application for better mental health and providing high-quality life for the elder: 1) provide financia l support for all e lderly who have on or less resource of support in order to make them can choose dwelling what they want. 2) p rovide home meals services, mental care, day care centers, community cultural act ivity centers, and similar institutions that promoting elderly essential social communicat ion. 3) provide d iverse cultural and recreat ional collective act ivities to pro mote elderly social participation, especially for widowed elderly. 4) provide local health services to establish a med ical record for all elderly cit izens and provide regular follow-up of chronic conditions 5) create retired ad ministrative network form an aging services for the elder with dedicated full time staff 6) establish a legal consultation service for the elderly which is free of charge for those who can not afford the service in each local community or in nursing home. 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