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Health-related quality of life, occupation and prosthesis use in elderly people with lower extremity amputation in Taiwan

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Content HEALTH-RELATED QUALITY OF LIFE, OCCUPATION AND PROSTHESIS USE IN ELDERLY PEOPLE WITH LOWER EXTREMITY AMPUTATION IN TAIWAN Copyright 2003 by Yan-Hua Huang A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (OCCUPATIONAL SCIENCE) December 2003 Yan-Hua Huang R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. UM I Number: 3133282 Copyright 2003 by Huang, Yan-Hua All rights reserved. INFORMATION TO USERS The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. ® UMI UMI Microform 3133282 Copyright 2004 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. UNIVERSITY O F SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CALIFORNIA 90089-1695 This dissertation, w ritten by under the direction o f h <2.Y dissertation committee, and approved by all its m em bers, has been presented to and accepted by the D irecto r o f G raduate and Professional Program s, in partial fu lfillm en t o f the requirements fo r the degree o f DOCTOR OF PHILOSOPHY D irector D issertation Committee fYUU Chair ~ _ « / ’ T 0 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. ii ACKNOWLEDGEMENTS I am indebted to many people who have shared their knowledge and time with me. First, I wish to thank my committee chairperson, Dr. Ruth Zemke, for her sharing her rich knowledge so generously over the years. I am thankful for the opportunity to have worked with her and I am forever grateful for her support, encouragement, and guidance in both my academic and personal life. Her spirit inspired me, and will continue to be a model for me in the future. I also wish to thank my committee members. Dr. Mike Carlson for his guided and encouraged my dissertation process with his willingness to answer question and discuss quantitative research. I thank Dr. Florence Clark for the many useful suggestions for my study and providing me many references about the interview study. I also thank Dr. Jeanne Jackson for her encouragement and providing ideas about how to conduct the interview. Her class also provided me with many useful thoughts about occupation and the meaning o f prosthesis. I would also like to thank Dr. Shao-Yao Ying for his support and willingness to play an important role in my dissertation committee meeting. I thank Dr. Gelya Frank, for her ideas on the focus o f this dissertation during the beginning stage and providing me with much useful information about conducting quantitative and interview research studies. Her creative class provided me an opportunity to engage in a meaningful occupation, which improves my quality o f life and has provided me with many wonderful memories as an international student at use. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. iii I would like to thank other USC faculty members: Dr. Cheryl Mattingly, Dr. Mary Lawlor, Dr. Ann Neville-Jan, and Dr. Diana Parham from whom I learned much in my Ph.D classes and who provided me with many various aspects o f this dissertation. Dr. Donald Polkinghome offered me important ideas about qualitative research. I learned much about doing both quantitative and interview studies and writing about them for my dissertation. I also thank Dr. Elizabeth Yerxa, whose speech in Taiwan enlightened me and led me to USC. Most importantly, I would like to thank all the participants in my study for their willingness to spent their time and share their amputation and life experiences with me. They had taught me to view things from many different perspectives and enriched my life experience through sharing theirs. I am indebted to the Phi Beta Kappa National Honor Society for the Doctoral Scholarship Award. I wish also to thank the Veterans Affairs Commission of the Executive Yuan of the Republic o f China and the Chon-Ren and Jong-Chwen Prosthetic & Orthopedic Companies in Taiwan for their help in locating participants for my study. Also, my thanks go to Chun-ho Wang, Kent Chang, and Fu-Chai Hsiu, for their help and suggestions in data collection. I want to thank my friends Yi-Ju Tsai, Tzu-Hua Ho and Che-Yuan Sun who have supported me in many different ways over the years and who were always willing to discuss issues during the data collection and analysis. I would also like to thank my roommate Janice Silvemail for her care and sharing her creative home with me. Thanks to Vivian Sheehan, a pioneer in speech pathology, from whom I R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. iv learned many valuable lessons and to whose support I appreciate. Thanks to my classmates Amy, Christy, Chia-Ting, Eric, I-Shih, Ling, Peng, Sarinya, Susan, Tomomi, and Yen-Ta for their support. And last, but not least thanks to all my friends and relatives, especially my uncle, How-Yen Huang, for their encouraging me in their unique way in my academic and personal life. My family has provided me with much valuable and appreciated support. During these past years our family bond has been an extremely important support for me. My brother, Yi-Yang Huang provided computer assistance. My sister, Shi-Ting Huang offered draft reading and editing. Both o f them shared their experiences as international students with me and supported and encouraged me. Finally, my deepest appreciation goes to my parents, Yung-Fa Huang and Shiu-Lan Wu for their support for my study and for their endless love and care for my daily needs since I was bom. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. V TABLE OF CONTENTS ACKNOWLEDGEMENTS.............................................................................................. ii LIST OF TABLES AND FIGURES................................................................................ ix ABSTRACT....................................................................................... xi CHAPTER I - PROBLEM STATEMENT...................................................................... 1 Introduction..........................................................................................................................1 Rationale and Significance o f the Study.......................................................................... 1 Research Questions ....................................................................................................4 Research Design.................................................................................................................5 Hypotheses........................................................................................... 6 Assumptions.................................................................................................................. 7 Limitations...........................................................................................................................8 CHAPTER II - LITERATURE REVIEW........................................................................9 Occupation, Health and Amputation................................................................................9 The Origin o f Occupational Science and the Concepts o f Occupation.................9 Occupation, Health, and Quality o f Life.................................................................1 1 The Amputee in the Social World........................................................................... 14 Elderly People in Taiwan’s Society..................................................................... 15 Chaos and Continuity............................................................................................... 17 Constructing Self-concept and Self-identity Through Occupation.......................19 Self-Concept.....................................................................................................19 Self-Identity..................................................................................................... 20 Prosthesis as a Symbol of Hope for an Able-body or Total body........................ 21 Artifact, Self and Occupation.................. 22 Quality o f Life................................................. 23 The Definition of Quality of Life................................ ...23 Health-Related Quality o f Life................................................... 24 Different Views of Quality of Life.............................................................. 25 The Measurement of Quality o f Life..................................................................... 26 Cross-Cultural Quality o f Life Instrument. .......................................................... 28 SF-36 Health Survey............................. 28 SF-36 Taiwan Version................................................. 29 World Health Organization Quality o f Life Assessment (WHOQOL-lOO) ...................... 30 WHOQOL-BREF Quality of Life Assessment............................................ 31 WHOQOL-100-Taiwan Version.................................................................. 32 WHOQOL-BREF-Taiwan Version.............................................................. 35 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. The Difference Between the SF-36 Taiwan and WHOQOL-BREF Taiwan Version ..................................................................................................... 37 Occupations and Quality of Life in People with Amputation..................... 39 Variables Included in this Study.....................................................................46 Conclusion........................................................ 46 CHAPTER HI. METHODOLOGY................................................................................ 48 Research Design............................................................................................................. 48 Quantitative Approach..................................................................................................... 49 Participants................................................................................................................49 Demographic Description o f the Sample............................................ 51 Instruments............................................................................................................. ..54 Procedures.................................................................................................................59 Data Analysis.......................................................................................................... 60 Hypothesis 1.................................................................................... 60 Hypothesis 2 .....................................................................................................................61 Hypothesis 3 .....................................................................................................................61 Comparison Data from WHOQOL-BREF Taiwan version..................................62 Hypothesis 4 .....................................................................................................................63 Hypothesis 5 .....................................................................................................................63 Interviews Approach............... 63 Participants................................................................................................................63 Location and Time...................................... 64 Data Collection........................................................................................................ 65 Transcription........................................................ 65 Data Analysis and Coding........................... 66 Translation................................................................................................................ 66 CHAPTER IV . QUANTITATIVE RESULTS................................................................ 67 Descriptive Data.............................................................................................................67 Hypothesis 1.....................................................................................................................69 Hypothesis 2 ............................................................ .70 Hypothesis 3.....................................................................................................................71 Hypothesis 4 .....................................................................................................................77 Hypothesis 5 ............................................. 79 Summary ............ 83 CHAPTER V DISCUSSION OF QUANTITATIVE RESULTS ............... 84 Hypothesis 1........... 84 Hypothesis 2 .....................................................................................................................87 Hypothesis 3 ................ ..90 Hypothesis 4 ....................................................................................................................92 Hypothesis 5............................................... 93 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. vii CHAPTER VI. INTERVIEW FINDINGS.....................................................................96 Interview Analysis and Interpretation Procedure.......................................................... 96 Factors Influencing Quality o f Life............... 97 Life Attitude and Previous Life Experience..................... 97 Relationship with Family................................. 101 Introduction o f Veterans in Taiwan........................................................... 104 Material Life................................. 108 The Aging Process, Not only Amputation, Influences Quality o f Life.............110 How Amputation Changes Quality of Life and Occupation........................................I ll Mobility is a Basic Component for Occupation.................................................. 112 Leisure and Social Activities.................................................................................113 Relationships with Others......................................................................................115 How Prosthesis Usage Relates to Occupation.............................. 117 Activities of Daily Living...................................................................................... 117 Psychological Meaning.................................... 118 Security....................... 118 Self-esteem......................................................................................................118 CHAPTER VII. INTERVIEW FINDINGS RELATED TO QUANTITATIVE FINDINGS......................................................................... 121 CHAPTER VIII. IMPLICATIONS, RECOMMENDATIONS AND CONCLUSION................................................................................................ 127 Implications.................................................................................................................... 127 Elders with Amputation in Taiwan..................................................................... 127 Quality of Life Measures.......................................................................................132 Limitations...................................................................................................................... 133 Directions for Future Research......................................................................................134 Conclusion..................... 136 REFERENCES.................................................................................................... 137 APPENDICES Appendix A: SF-36 Taiwan, WHOQOL-BREF Taiwan, and Demographic Data Form - English Version.....................................................................................143 Appendix B: SF-36 Taiwan, WHOQOL-BREF Taiwan, and Demographic Data Form - Chinese Version.................................................... 157 Appendix C: Informed Consent Form - English Version.................................. 171 Appendix D: Informed Consent Form - Chinese Version.........................................175 Appendix E: Raw Score Mean + SD for WHOQOL-BREF and SF-36 Domains... 179 Appendix F: Final Regression Model for Predictors of WHOQOL-BREF Domains in Test of Hypothesis 1............................................................................... 182 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Appendix G : Correlations Between Domains of the WHOQOL-BREF Taiwan and the SF-36 Taiwan Version............................................... 186 Appendix H: Demographic Descriptions of Interview Participants...........................188 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. IX LIST OF TABLES AND FIGURES TABLES 1. Cultural Questions Added to WHOQOL-100........................................ 34 2. Items in SF-36 Taiwan Version Related to Occupation.................................... 38 3. Items in WHOQOL- BREF Taiwanese Version Related to Occupation 39 4. Demographic Characteristics of the Participants....................................................52 5. The Mean Age and Number o f Years Since Amputation o f the Participants 53 6. Participants’ Characteristics Related to Lower Extremity Amputation............... 54 7. Overview o f Independent Variables in Quantitative Data. ............................... 56 8. Overview o f Dependent Variables in Quantitative Data........................................ 58 9. Independent t - test for Comparing Groups by Veteran Status and Gender. 68 10. Summary of Standardized Beta Values and Significant Test Results o f Predictors o f WHOQOL Domains and SF-36 Physical and Mental Component Scales of Hypothesis 1.............................................................................................................70 11. Final Regression Model for Predictors o f Prosthesis Use o f Hypothesis2 71 12. Comparison of Male Group 1 data (50-59 yrs) in WHOQOL-BREF Taiwan Domains...................................................................................................... 73 13. Comparison of Male Group2 data (60-69 yrs) in WHOQOL-BREF Taiwan Domains. ............................................................... 73 14. Comparison of Female Group2 data (60-69 yrs) in WHOQOL-BREF Taiwan Domains.....................................................................................................................74 15. Comparison of Means o f Taiwanese Adults with Diabetes and Taiwanese Elders with Amputation in WHOQOL-BREF Taiwan Dom ains ...........75 16. Comparison o f Means o f Taiwanese Adults with Diabetes and Taiwanese Elderly Veterans with Amputation in WHOQOL-BREF Taiwan Domains...................... 76 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. X 17. Comparison o f Means o f Taiwanese Adults with Diabetes and Taiwanese Non-Veterans Male Elders with Amputation in WHOQOL-BREF Taiwan Domains......................................................................................................................76 18. Comparison of Means of Taiwanese Adults with Diabetes and Taiwanese Elderly Females with Amputation in WHOQOL-BREF Taiwan Domains...................... 77 19. Correlations between domains o f the WHOQOL-BREF Taiwan and the SF-36 Taiwan version.................................. 78 20. Item Analysis and Internal Consistency for the SF-36 Taiwan.............................80 21. Item Analysis and Internal Consistency for the WHOQOL-BREF Taiwan. 82 FIGURE 1. Overview of Planned Study........................................................................................6 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. xi ABSTRACT This study investigated quality o f life, occupation and prosthesis use among Taiwanese elders with lower extremity amputation from an occupational science and occupational therapy perspective. The research design involved quantitative instrument and semi-structured interviews. Quantitative descriptive and inferential statistical procedures with standard health-related quality of life measures, the SF-36 Taiwan and the World Health Organization Quality of Life Assessment -Taiwan short version, and a demographic data form investigated quality of life and prosthesis use among elderly amputees. Interviews gave insight into how amputation changed life quality, and occupation. The quantitative study included 90 participants with a mean age of 71.3. Multiple regressions revealed less social support correlating with reduced quality o f life. Higher level o f amputation, less prosthesis use, presence o f helper, and presence of other disease were associated with reduced scores on the quality o f life measures. No statistical relationship was found between socioeconomic status and quality o f life nor between age, gender, level o f amputation and prosthesis use. Non-hypothesized but significant relationships found that people living at home wore their prostheses significantly more than people living in institutions, and more years since amputation predicted more frequent prosthesis wearing. Independent-t tests found little significant difference in quality of life between the sample of elders with amputations and Taiwanese normative data. The two health-related quality o f R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. life measures correlated moderately, as expected, and demonstrated validity and reliability for use with this group. One-third o f the participants were interviewed. Results showed that life attitude, previous life experience, relationship with family, resources and aging related to their quality of life. Amputation influenced their mobility, leisure, social activities and relationships. Prosthesis use supported participation in daily activities and provided psychological meaning. Both quantitative results and interview findings demonstrate that more social support relates to higher quality o f life. Findings suggest that it is not only important that elderly amputees use prosthesis to maintain functional mobility, but also engage in occupations and maintain/obtain social relationships with family and society. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 Chapter 1 - Problem Statement Introduction Elderly people with lower extremity amputation are a special group of clients. Among elders with amputation, the interaction of complex medical problems and declining physiological functions that accompany the aging process results in reduced potential for successful rehabilitation and greater challenges in recovering their independence on the part of elderly patients as compared to younger adults (Bilodeau, Herbert, and Derosiers, 2000). The purpose o f this study was to look at the quality of life in elderly people in Taiwan who have had an amputation, especially in light of their use o f prostheses in relation to their engagement in occupations. This study sought to expand the knowledge base in occupational science by increasing our understanding o f the relationship between occupation and quality of life in an understudied population. It was also designed to help occupational therapists assist elderly people who have undergone lower extremity amputation to experience a better quality of life based on their occupational patterns. Rationale and Significance of the Study Due to the overall aging of the population and the increasing prevalence of diabetes and peripheral vascular disease, the number o f older persons with lower limb amputations is increasing. The population of elderly people will continue to grow worldwide and estimates show that from now until 2030, the elderly population will increase radically as the baby-boom generation ages into a 65 years and older group. As o f 1994,7.7% of the total population o f Taiwan was over the age of 65. In 2020, it R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 is estimated that 14.3% o f that population will be over 65 years (Department o f Health, 2000). As society is confronted with larger numbers of people living into old age, the manner through which we can promote quality o f life in elderly people is a necessary focus in medicine and occupational science. Diabetes was the fifth highest cause o f death among Taiwanese in 2000. People who died due to diabetes comprised 7.59% o f the number o f total deaths in 2000 (Department o f Health, 2000). Diabetes mellitus diagnosed in elderly persons has several forms. O f these, non-insulin dependent diabetes mellitus is most specific to elderly people. The effects o f any form uncontrolled diabetes include blindness, renal disease, vascular disease, and amputations. More than half o f all non-traumatie lower extremity amputations occur in persons with diabetes. Lower extremity disease is more prevalent among persons with diabetes than among persons without the disease and lower extremity amputation is a significant complication for older persons with diabetes (Centers for Disease Control and Prevention, 2000), with more amputations occurring among men than among women (Nielsen, 2000). The highest percentage of disease-related amputations occurs in those 61 to 70 years of age. Although there are some amputations due to peripheral vascular disease independent of diabetes, 50-70% o f disease-related amputations are related to complications resulting from diabetes. The prevalence of peripheral vascular disease among persons with diabetes is significantly greater than in those without diabetes (Nielsen, 2000). In spite o f improvements in medical and surgical care over the last several decades, the continued existence of amputation surgery and the risk of contra-lateral R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 3 amputation has changed very little (Custon & Bongiomi, 1996). Therefore, the need for lower extremity amputation and prosthesis usage continues in Taiwan. Prostheses are commonly used to restore function after amputation, but among elderly people, the rate o f prosthesis use has reportedly been low (Weiss et a l, 1990). The physical, psychological, and functional losses that patients experience after amputation influence their occupational patterns. Mobility is an important, if not an essential aspect of activities for most elderly people in Taiwan. Research shows that taking a walk and strolling around the streets is the second most frequent leisure activity in which elderly Taiwanese engage (watching TV is the most frequent leisure activity) (Bai, 1996). However, many people live in apartments without elevators that do not have a disability-friendly environment available in indoors or outdoors. Therefore, once elderly people have an amputation, their mobility and the range of possible occupation choices are limited. This study is based on the theoretical concept of occupational science that participating in occupation can positively influence one’s quality o f life, (hence, occupational science supports the practice of occupational therapy). Occupational science’s main focus is the study o f the person as an occupational being and how human beings realize their sense o f life’s meaning through purposeful activities (Yerxa et al., 1989). Occupational science research is designed to increase understanding of the form, function, and meaning of human occupation (Clark et al., 1991). Research from occupational scientists shows that an occupational therapy program designed from occupational science concepts and in which elderly people R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 4 engaged was effective in maintaining or improving their quality o f life (Clark et al., 1997). Very little data exist regarding the quality o f life and the occupations of elderly people with lower extremity amputation. In particular, the scarcity o f information about elderly Taiwanese with lower extremity amputation was obvious in the data that were reviewed by the writer. In fact, no study specifically addressed the quality of life of elderly Taiwanese with lower extremity amputation, much less in relation to their prosthesis use in occupations. Because this population has not previously been studied by occupational scientists and occupational therapists the goal of this study is to describe the quality of life of elderly Taiwanese with amputations and also focuses on the role o f prostheses in participation in occupation. It is the hope o f the author that knowing more about the relationship among occupation, the quality o f life and prosthesis use in elderly people with amputations will contribute to the development of occupational science. Furthermore, knowledge of this relationship will assist occupational therapists in their work with these elderly by enabling an understanding of the role o f participating in meaningful occupations as part of daily life and further helping elderly amputees to select and engage in occupations to have a satisfying life in spite o f amputation. Research Questions The research questions that were addressed in this study are: 1. What are the descriptive statistics regarding quality o f life (QOL) among elderly Taiwanese with lower extremity amputations? R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 5 2. What are the predictors of QOL scores for elderly Taiwanese with lower extremity amputation? 3. What are the predictors of how much elderly Taiwanese with lower extremity amputations will use their prosthesis? 4. Do elderly Taiwanese who experience amputation differ in mean QOL scores from (1) elderly people with diabetes who do not experience amputation and (2) healthy adults in Taiwan? 5. What are factors related to quality o f life for elderly Taiwanese with lower extremity amputation? 6. How does amputation change quality o f life and occupation? 7. How does the use o f prostheses relate to occupational patterns among elderly Taiwanese with a lower extremity amputation? Research Design This study has two components - a quantitative measurement component and an interview component Using descriptive and inferential statistical procedures, this research utilized two standard health related quality o f life (HRQOL) instruments and a demographic data form to look at the quality o f life and prosthesis use in elderly people with lower extremity amputation. The correlation between the two HRQOL measures and the psychometric properties o f these two measures were tested. Convenient sampling was used to select elders to be interviewed in an attempt to understand their quality o f life, occupation and prosthesis use (Figure 1). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 6 Quantitative study o f HRQOL in Taiwanese elders with lower extremity amputation Report Test HRQOL Examine Examine (1) descriptive difference predictors correlation matrix sample between subject o f HRQOL between WHOQOL statistics as sample (n=90) and and SF-36 QOL measured by and previous prosthesis scale and (2) the two HRQOL results for (1) use among internal consistency instruments Taiwanese Taiwanese as well as item-total (WHOQOL- adults’ elders with correlation o f each BREF and SF- normative data amputation measure in 36) and a (2) adults with (n=90) Taiwanese elders demographic diabetes without with amputation data amputation (n=90) questionnaire (n=90) Interview study Through interview, examine relationship between quality of life and amputation, how prosthesis use related to occupational patterns. Figure 1. Overview of planned study. Hypotheses 1. Low social support, high level of amputation, and low socioeconomic status predict reduced health-related quality of life (as measured by WHOQOL-BREF R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 7 Taiwan version: physical, psychological, social relationship, and environmental domains, and SF-36 Taiwan version: physical and mental domains) among elderly Taiwanese people with amputation. 2. Older age, female gender, and high level o f amputation predicts reduced prosthesis use among elderly Taiwanese people with amputation. 3. Quality o f life (as measured by WHOQOL-BREF Taiwan version) for elderly Taiwanese people with amputations is significantly lower than that o f adults’ with diabetes without amputation and Taiwanese adults’ normative data. 4. There is a positive correlation between scores of quality o f life on the SF-36 Taiwan version and the WHOQOL-BREF Taiwan version. 5. Both the SF-36 Taiwan version and the WHOQOL-BREF Taiwan version have acceptable internal consistency, as well as items that correlate acceptably with scale/domain totals, when used to assess elderly people with amputation. Assumptions 1. It is assumed that the participants would be able to follow the study procedures, understand the questionnaire administered to them, and would answer the questions to the best of their ability. 2. Quality of life of elderly Taiwanese with lower extremity amputations could be described using the two measures: WHOQOL-BREF Taiwan version and SF-36 Taiwan version. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 8 3. The elders in this study, with lower extremity amputation, were representative of the wider similar population of Taiwanese elders with lower extremity amputation. 4. The research scales had the same meaning or mathematical properties for the different subject groups. Limitations 1 . The results of this study are specific to elderly in Taiwan and may not be applicable to other age groups or cultural contexts. 2. The non-random sample may not adequately represent the population of the elderly with lower extremity amputation in Taiwan. 3. The historical control group (i.e., elderly adults with diabetes and healthy adults) may differ from the study sample due to considerations such as the use of different subject selection methods, or different study times. 4. Sequencing the interviews after the quantitative measures might have affected the content o f interviews. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 Chapter 2 - Literature Review Occupation. Health and Amputation In this chapter, the origin, definition and concept o f occupation will be discussed. The chapter will also include an approach to understanding how to improve health through occupation from an occupational science perspective. Important aspects of life with an amputation will be discussed, including amputees in the social world, attitudes toward elderly people in Taiwan, self identity and self concept through occupation, and the prosthesis as a symbol of hope and an artifact related to self and occupation from the perspective of Occupational Science. Additionally, the concept of quality o f life and the quality of life measurement that will be used in this study will be presented. The literature review will provide some direction for consideration of variables that might be important in the study of occupation and quality of life in this particular population (elderly people with amputations). Through integrating and discussing different ways of viewing this population, I hope to present a clear picture of why this study of the elderly Taiwanese amputee’s quality of life, occupation and prosthesis use was needed. The Origin of Occupational Science and the Concepts of Occupation The traditions and values of the occupational therapy profession provide the basic philosophy of occupational science (Yerxa, 1993). In the early 20th century, the founders o f the occupational therapy profession stated that occupation is important to health (Clark and Larson, 1993). For example, Dunton (1919), an early supporter o f occupational therapy, stated, “That occupation is as necessary to life as food and drink. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 10 That every human being should have both physical and mental occupation. That all should have occupations which they enjoy... That sick minds, sick bodies, sick souls, maybe healed through occupation” (p. 1). This statement reveals Dunton’s belief that human beings should engage in balanced and satisfying occupation, and consequently maintain and improve both their physical and mental health. Although its roots were broader, occupational therapy education historically was based on physical and mental health care concepts that were strongly influenced by the medical model. Occupational therapy students typically learned about anatomy, physiology, psychology and various types o f medical disorders as well as a range of treatment strategies and activities used to treat patients. The focus on the human need to engage in daily, satisfying occupation appears to have diminished (Wilcock, 1998). For that reason, in the 1960s, Mary Reilly advocated that occupational therapy should refocus to treat the person as a whole, rather than on organ system, and should return to its earlier emphasis on the value o f occupation. Reilly advocated holistic study of human occupation. In 1980, Yerxa suggested that occupation therapy should develop a science o f human occupation. It was her hope that beyond increasing the knowledge of occupation for occupational therapy practice, the development o f such a science would help find ways that all people can live a more meaningful life (Clark and Larson, 1993). The word “occupation” originates from the Latin root “occupacio” which means to seize or take control/possession (Yerxa et al., 1989). Occupation is defined as “chunks o f culturally and personally meaningful activity in which humans engage that R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 11 can be named in the lexicon o f the culture” (Clark et al., 1991, p.301). “Occupation” does not mean a job (although a job can be an occupation), nor does it only include productive activities. Activities such as running, cooking, attending a party, and seeing a movie are all occupations. It includes leisure activities as well as broader categories o f activity such as resting, caring, or playing (Clark etal., 1991). The study o f occupation can involve focusing on the person as the author o f his or her daily life, which includes work, rest, play, leisure and self-maintenance. It also entails an understanding of individuals in interaction with their environments, and the individual’s experience o f engagement in occupation (Yerxa et al., 1989). The definition of occupational science is “the study of the human as an occupational being including the need for and capacity to engage in and orchestrate daily occupations in the environment over the life-span” (Yerxa et al., 1989, p. 6). Knowing more about how humans develop into occupational beings could help occupational therapists to create the just right challenge from the environment. This challenge could elicit the drive for competence and result in greater satisfaction in daily living for everyone including those who are considered disabled (Yerxa et al., 1989). Occupation. Health, and Quality of Life Poor health can limit occupation. Problematic health is the primary reason elderly people cease participation in leisure activities (McGuire, Dottavio, & Leary, 1986). Keith (1980) noted that not all life changes triggered people’s withdrawal from leisure activities. However, change in health affected activities more than R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 12 changes in marital status or income. Health changes tended to decrease participation most in activities that seemed to promote well being. Occupation may contribute to coping with the transitions o f later life, such as physical disabilities. For this study, occupational science provides an appropriate platform from which to view the importance of the study o f occupation in the lives o f the physically disabled elderly. Research conducted by occupational scientists at the University of Southern California found that an occupational therapy (OT) program for the elderly that was based on occupational science concepts was effective for maintaining or improving the subjects’ life quality. Using randomized, controlled, clinical trial research Clark et al. (1997) evaluated the effectiveness of preventive occupational therapy services for elderly people who lived independently. Three hundred and sixty one people, 60 years and over, from diverse cultural backgrounds participated in this study. The subjects were randomly divided into three groups: an OT group, a social activity group and a non-treatment control group. The period of treatment was 9 months. The hypothesis in this study was that an occupation centered, occupational therapy program would have a positive effect on the physical health, daily functioning and psychosocial health of elderly people, and that involvement in a social activity program alone would not have those effects. The OT program was based on the concept in occupational science that health is affected by engaging in occupation. Occupational science’s main focus is the study o f the human as an occupational being and how human occupational beings realize their sense of life’s meaning through R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 13 purposeful activities (Yerxa et al., 1989). This program taught elderly people to understand the importance of meaningful occupation in their daily living and to, further teach them how to select and engage in occupation to have a healthy and satisfying lifestyle (Clark et al., 1997). Five questionnaires, the Functional Status Questionnaire to assess functional disabilities o f daily activities in physical and social domains, the Life Satisfaction Index-Z to measure life satisfaction in the elderly, the Center for Epidemiologic Studies depression scale to determine the frequency o f experiencing depressive symptoms, the Medical Outcomes Study (MOS) Health Perception Survey to assess subject’s perceptions o f their own general health and the Rand 36 item Health Status Survey to assess health related quality o f life, were used as outcome measures. The OT treatment group demonstrated a significant improvement on the Functional Status Questionnaire: quality o f interaction (p = 03), the Life Satisfaction Index-Z (p =. 03), and the MOS Health Perception Survey (p =. 05), and on almost all o f the eight domains on the RAND SF-36. General health was marginally significant (p - 06). These results showed that engaging in social activities and simply keeping busy and filling time were not as effective in creating better health status as participating in an occupational therapy program based on occupational science principles (Clark et al., 1997). Those with the poorest health status showed the most positive responses to the occupational therapy program. This outcome is important because it demonstrated that the elderly who need the most help, those with poor health, are able to benefit R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 14 significantly more from the treatment than those who were healthier (Carlson, Clark, & Young, 1998, Clark et al., 1997). A follow-up post intervention study demonstrated that the gains attributed to the occupational therapy program were sustained over 6 months without further intervention. All participants were reevaluated using the same battery of instruments. Those who had been recipients of the OT treatment were found to show long-term benefit for the quality of interaction scale o f the Functional Status Questionnaire and for six of the eight scales on the RAND SF-36: physical functioning, role functioning, vitality, social functioning, role emotional, and general mental health (p <. 05) (Clark et al., 2001). This study provides strong evidence that occupational therapy that is designed based on the occupational science perspective can improve people’s health, daily function and psychosocial well being. It appears that the elderly can achieve better health and a more satisfying lifestyle through being taught how to select, perform and blend activities (Clark et al., 1997). In order to tailor a lifestyle intervention (similar to that used in the well-elderly study) for the needs o f elders with amputation in Taiwan, a first step is to conduct basic research on the impact amputation has on their quality o f life. The Amputee in the Social World Occupational science is concerned not only with the individual but also with the environment, especially the family and social context, where the individual lives. Most people with amputations agree that they have far more difficulties coping with people than with things (Friedmann, 1978). French (1994) stated, “amputation alters R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 15 the integrity of the body in a particular way that affects not only the amputees themselves but also, in a different way, anyone who comes into contact with them” (p. 71). He proposed that the relations between power and domination in which the body is involved, shape the subjective and personal experience of one’s own body in important ways. According to French (1994), in Cambodia, as in many cultures, men were expected to feed, support and protect their families. However, when soldiers in Cambodia lost their limbs, they were no longer considered a productive part of the society. Men with amputations could not hold any position o f responsibility in the society because others did not respect them. Wives of men with amputations abandoned them. Therefore, in this kind o f society, people with amputation seem to feel ashamed, angry, and worthless. They lose courage, self esteem, and even try to avoid social interaction. While French (1994) found this to be true about amputees in the Thai-Cambodian society, the amputee’s experience may be different in other societies and with different age groups. The study reported in this paper focuses on elderly amputees in Taiwanese society and will explore their occupations and quality of life including their physical, psychological, social relationship and environment. Elderly People in Taiwan’s Society In Taiwanese society, respect for the elderly is seen as a virtue. The definition of respect includes being polite, asking elders for advice, and younger people informing elders of their decisions (Ingersoll & Saengtienchai, 1999). The social status of older adults within the family related to family decision making is dependent on a variety of factors, for example 1) the extent to which older adults have control over the economic R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 16 resources, and 2) the extent of social change in the geographic area o f residence (Williams, Metha, & Lin, 1999). Many elderly Taiwanese still play important roles in the family; in fact, they may be the main decision-makers in the family. Traditionally the family has provided care for the elderly in Taiwan. (Asis, Domingo, Knodel, & Metha, 1995; Li, 1994). Currently, 88.4% o f Taiwanese elderly people live with their family and relatives (National Statistics, 2002). “Raising children prevents getting older” is a common proverb in Taiwan. This is based on the belief that children should be caregivers for their elderly parents, because it is a moral obligation (Asis, Domingo, Knodel, & Metha, 1995). The first son and his wife have special responsibility to take care o f his elderly parents. Getting support from their children is important to the elders. In Taiwan, the elderly’s major source o f income is from children (61%), followed by salaries (12%), pensions (11%), spouses (5%), savings or interest income (4%), and charities (3%) (Li, 1994). On the other hand, many elderly people in Taiwan tend to give their savings to their children when they move into older age or have diseases. Co-residence o f elderly parents and adult children appears to be the most commonly preferred living arrangement in Asian countries (Asis, Domingo, Knodel, & Metha, 1995). With fewer children, larger movements of children to industrial and professional jobs, and changing attitudes toward privacy and self-sufficiency, living arrangements of the elderly are subject to change. Amidst this, however, institutional care is usually considered to be a final option (Li, 1994). Family members tend to care for elderly people with disabilities rather than consider institutionalization. Such R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 17 an approach to caring for the elderly may influence the elder’s willingness to use a prosthesis—an elderly person with an amputation may think that, since dependence on family members is a natural part o f the aging process, she/he need not be independent through use of a prosthesis. With the nuclear family and double salary (husband and wife employed) family style increasing, some people hire foreign laborers to care for the disabled elderly. Very often the laborer will live with a family and his or her job is to care for the elderly person. Sometimes the family’s or caregiver’s views may influence the elderly person’s willingness to use his or her prosthesis or may reduce the older person’s opportunity to use the prosthesis. Chaos and Continuity The experience o f having an amputation is not like having a stroke or traumatic brain injury, both of which occur suddenly. Rather, an amputation due to diabetes or peripheral vascular disease is usually preceded by a period o f decision making and contemplation with regard to the impending surgery. Often before the amputation, the physician and the client have made efforts to keep the extremity, either through medication or through vascular reconstruction surgery. In the case o f problems with the leg, amputation is often the best means through which to maintain the healthier part o f a leg and at the same time, help end foot pain. Despite the fact that having an amputation may be a logical decision, the elder may nevertheless experience psychological disruption. Surgical amputation in Taiwan requires lengthy hospital stays, presenting a possible replacement o f normal routine with seeming chaos in a new biomedical environment. After the amputation, this R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 18 sense of chaos may be intensified as attempts are made to negotiate interactions with surroundings in the absence of a limb. Becker (1997) stated that people whose health is suddenly disrupted, are thrust into chaos. The onset of a chronic health condition disorders a person’s knowledge and experience o f the body, therefore disrupting not only a sense o f the integrity of the body but also understanding of specific body parts and systems. Suffering arises not only from the experience of bodily disruption but also from the difficulty of articulating that disruption. There is a temporal dimension to illness that affects people’s responses to their bodily changes. Both past experience and expectations for the future inform current experiences o f health and illness. People experience illness and impairment from a perspective determined by their historically situated and contextually informed bodies (pp. 38- 39). I agree with Becker’s idea that an illness or disease is a major disruption to one’s life. When the body is affected by a serious illness, one’s sense o f wholeness, on which a sense of order has been disintegrated. One must reconstitute that sense of wholeness in order to regain a sense o f continuity (Becker, 1997). How does the elder with amputations reconstruct wholeness in order to regain a sense o f continuity? Some people use metaphors and some people use narratives to help them deal with their sense of disorder. Others may need the physical sense of wholeness provided by a prosthesis. Wearing the prostheses and engaging in occupation may assist them in constructing their concept o f “wholeness” in both the physical and psychological dimensions. Occupation can be a means for people to recompose their lives after the interruption of a life-changing event such as the onset of physical disabilities. Literature from occupational science suggests that occupation can help individuals R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 19 deal with a sense o f disorder and rebuild a sense of wholeness. By using adaptive strategies to select and organize occupation, people with disabilities seem to be able to engage in a variety of occupations that give happiness and meaning, improve life opportunities and enhance quality of life (Frank, 1996). Therefore, occupational therapists may be able to help and assist elders with amputation to develop adaptive strategies to engage in meaningful occupations. Constructing Self-Concept and Self-Identity Through Occupation Both self-concept and self-identity influence a human being engaging in occupation and influence his or her quality o f life. Behavior is mediated by the sense of self-concept and self-identity (Holland, Skinner, Lachicotte, and Cain, 1998). When elderly people have an amputation it may influence their participation in some meaningful occupations and also may influence their self-concept and self-identity. Self-Concept. Self-concept refers to the understanding that we have about ourselves and includes our understanding o f personality traits and characteristics, our social roles and our relationships (Christiansen, 1999). The self-concept is the personal locus of societal or socio-structural influence. It reveals and integrates what others think o f us, how the we are treated, who are our relevant others and what we make of this (Herzog & Markus, 1999). Herzog and Markus (1999) stated that there is a cultural difference between Japanese and Americans’ self-concept. Japanese are more likely to describe the self in terms o f habitual, everyday actions and also incorporate other persons into their own self-descriptions than are Americans. Similarly, most Taiwanese tend to think that self is not only the single individual but is R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 0 also related to other people. Moreover, one’s self-concept often includes other people’s view o f how he or she should behave in the family and society. Cultural differences in the content of selves requires us to consider the broader cultural contexts within which people live and to define the relations between the cultural criteria for selfhood and well being. It is this author’s belief that personal relationships with others, especially with family members and caregivers, constitute an important part o f Taiwanese elderly people’s self-concept. Self-Identity. Personal identity can be viewed as self-identity and as including self-esteem and self-concept (Christiansen, 1999). From the perspective of occupational science, people, through engagement in occupation, construct and reconstruct their self-identity and create new ways of being. Daily occupations allow us to experience and realize our own identities. When people construct their identities through occupations, they provide themselves with the contexts essential for creating meaningful lives. Life meaning assists them to be well (Christiansen, 1999). Subsequent to the onset o f a disability, an individual enters a completely new world, experiencing fundamental psychological, as well as physical, challenges. The body becomes something unfamiliar and disconnected from the previous self (Ellis- Hill, Payne, & Ward, 2000). When people experience loss and change, the continuity of their lives is disrupted. In facing this discontinuity, each person tries to find and build relations between the old self and the life ahead of him or her and reconstruct the continuity of self. Occupations are opportunities to express the self and to create an identity (Christiansen, 1999). When an elderly person has an amputation, his or her R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 1 self-identity and self-concept changes. The daily occupations during which prostheses may be used include cultural and personal purposes, which are parts of self-identity and which may reflect the aforementioned changes. Prosthesis as a Symbol of Hope for an Able-Bodv or Total Body Borell, Lilja, Sviden, and Sadlo (2001) investigated the experience, values, and meaning of engaging in daily occupations for older adults with functional impairments. They found that some continued their occupations although they had physical disability. These people maintained a positive sense o f drive and hope as they continued doing the occupations they liked and wanted to do. However, others seemed to draw back from their occupations. These people suffered negative experiences of their impaired body and had to give up enjoyable occupations. The loss of both physical ability and occupation seemed to contribute to the experience of reduced hope. Those who had drawn back from their occupations lived with reduced hope, an absence o f intentions and a loss of the will for occupation (Borell, Lilja, Sviden, & Sadlo, 2001). In late life, the loss of interest in occupation may be a sign o f reduced hope. Hope can be seen as an expression of will and optimism. Lack o f hope may express itself as a lack o f intention and will for occupation. “Occupations serve as a unique personal construct for the meaning of the physical limitation or for the enhanced ability experienced by [elderly people with physical limitations] in recovery” (Borell et al., 2001, p. 314). It is important to learn more about how older adults with R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 2 decreased functional abilities experience and express the loss o f hope in occupation (Borell et al., 2001). For elderly people with amputations, a prosthesis may become a symbol of hope for having an able body instead of disability. “Hope is essential to efforts to create continuity: without hope there is no future” (Becker, 1997, p. 177). McWhinnie, Gordon, Collin, Gray and Morrison (1994) discussed the effect o f hope on reaching a purposeful goal. They stated, for example, that even when walking distance is restricted, patients might be able to walk a greater distance unassisted to reach the elevator. Although many patients in declining health may achieve walking ability for only a few months, it may be less demoralizing to regain limited walking ability for a short period than to not walk at all. A prosthesis may also be a symbol for not having an incomplete body and a hope for being able to do things. Artifact. Self and Occupation Artifacts are tools that people use to affect themselves and others’ thinking, feeling and behavior (Vogasky, cited in Holland et al., 1998). A prosthesis is an artifact that relates the person with amputation and other people. A prosthesis can be seen as an artifact whose general function is substitution for a missing limb. It is provided to people with amputations to assist them in acquiring compensatory functions and adaptive living skills. However, a prosthesis should not be seen only as a tool but also as strongly related to the person who uses it. Each prosthesis can be seen, and each has the same purpose (function) but the design, appearance and how people perform with it are individualized. The manufacture of a prosthesis is based on R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 3 the individual human body. The shape, color and function are designed to correspond to the body of each individual. A prosthesis can help people with amputations achieve adaptive functions for some occupations and help construct a complete body image. Artifacts also affect the user and others’ thinking, feeling and behavior (Vogasky, cited in Holland et al., 1998). A prosthesis can affect the amputees and also affect other people’s thoughts and feeling about them. There are psychological, as well as functional, reasons for amputees to use their prostheses. Some amputees wear their prostheses because, with the prosthesis, they feel normal instead o f handicapped. Perhaps, when engaged in some social or formal activities, they feel that they need to wear prostheses to show their respect, similar to people dressing up to attend formal ceremonies. Some people with amputations are not able to tolerate or ignore other people’s normal curious gaze at their stump (Chang, 1993). Hocking (2000) stated that identity could be shaped through the objects that people acquire, make and use in their day-to-day occupation. Therefore, the meaning of a prosthesis use may not just be for walking. Here, the prosthesis can be seen as an artifact or object that people use to create self and identity or to influence others. Quality o f Life The Definition of Quality of Life The definition o f quality o f life varies in different disciplines, cultures, and traditions. In my study, quality o f life is defined as “individuals’ perceptions o f their position in life in the context o f the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (WHOQOL Group, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 4 1998, p. 551). This is a broad ranging concept, incorporating in a complex manner the person’s physical health, psychological state, level of independence, social relations, personal beliefs and relationship to salient features of the environment. This definition focuses on a person’s subjective evaluation of health that also fits certain key concepts associated with the concept o f occupational science. Occupational scientists agree that humans should be viewed as authors o f their lives and should consider the subjective experience o f engagement in occupation and interaction with their environment to be an important component (Yerxa et al., 1989). Health-Related Quality o f Life Health-related quality o f life is an individual’s satisfaction or happiness with domains o f life insofar as they affect or are affected by health. There are two basic types of health-related quality o f life measures: generic and disease-specific (Feinglass, Morasch, McCarthy, 2000). A generic measure is designed to measure all aspects of health and its related quality o f life. Generic measures include domains that are broadly applicable to various diseases and populations and allow the comparisons to be made across many patient populations. In contrast, disease-specific questionnaires include issues o f generic relevance and questions specific to the patient's particular disease. By including disease-specific questions, these questionnaires are more sensitive to disease-related changes in a patient's health status (Feinglass, Morasch, McCarthy, 2000). When measurements of health related quality of life using disease-specific instruments and generic instruments in studies o f people with diabetes are compared, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 5 researchers have found that the generic measurements can provide more information on this population (Jacobson, de Groot, & Samson, 1994; Parkerson et al., 1993). Legro et al. (1998) designed a prosthesis evaluation questionnaire intended for persons with lower limb amputation who use a prosthesis. There are 10 scales in this questionnaire with most of the questions focusing on prosthesis function. The questionnaire is not applicable to people with bilateral amputation or people who do not use their prosthesis as part of their daily routine. In contrast to this limited, disease specific focus, quality o f life is a multidimensional concept, which relates to many domains including physical health, social functioning, emotional well being and general health perceptions (Ory and Cox, 1994). Although many research articles mention the rehabilitation, outcome or prosthesis use of elderly amputees, there is currently no research showing that a relationship exists between quality of life and prosthesis use in occupation in elderly amputees. There is no quality of life measure specific to people with amputation. Different Views o f Quality of Life Starr, Peariman, & Uhlmann (1986) studied the assessments o f 65 elderly inpatients and their physicians concerning patient quality o f life and resuscitation decisions for the patients' current health situations and for two hypothetical situations. The objective o f their study was to determine how well physicians’ view o f their elderly inpatients’ quality of life matched that o f the patients themselves, which is a crucial issue in medical resuscitation decisions. All participants completed a questionnaire containing three sections that included rating the patient’s health and R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 6 quality of life, describing what can improve or decrease quality of life, and questions relating to decisions about the desirability of patient resuscitation in three different situations: 1) the patient’s actual health, with a hypothetical permanent respiratory difficulty with dyspnea on effort, 2) with a hypothetical stroke including immobility, dysarthria and inability to care for self. The results showed that physicians rated current patient quality o f life more negatively than did the patients. From the physicians’ point of view, medically related factors are important variables in determining quality o f life, and medical and surgical care are important factors to improve their quality of life. While patients cited recreation, work, self-esteem, and friends, in addition to medical care, as factors improving their quality o f life. Physicians were also less likely to support resuscitation in the two hypothetical situations. This finding supports the idea that engagement in occupation (work and recreation for example) is related to quality of life. This study also supports the idea that it is important to explore the individual’s quality of life using the patient’s self reported health status, and to avoid judgement based solely on medical conditions. The Measurement o f Quality o f Life There is a widespread interest in the use of generic health related quality o f life measurement. As a result, many measures have been developed with the majority of quality o f life measurements being developed and used in the United States. Fox-Rushby and Parker (1995) compared nine generic measurements o f health related quality of life which included the Sickness Impact Profile (SIP), Quality of R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 7 Well Being Index (QWB), Nottingham Health Profile (NHP), Macmaster Health Index Questionnaire (WHIQ), Dartmouth AOOP charts (COOP), EuroQol, Medical Outcomes Study Short Form 36 (MOS SF-36), Index o f Health Related Quality of Life (IHQL), and the World Health Organization Quality o f Life Assessment (WHOQQL-lOO). Fox-Rushby and Parker (1995) argued that the generic health related quality of life measures are not “culture free” (can be translated from one language to another and can also can be used in a variety o f settings), but, rather, “ culture full,” reflecting the researcher’s values and viewpoint embedded in the measures. The researcher’s own values and viewpoint will influence the design of the measures both in the definition and also the assumptions o f what underlies health-related quality of life. Because no instrument uses the same definition and no instrument contains exactly the same domains, the underlying structure of these instruments’ assumptions of health related quality o f life is different. The structure o f these instruments is highly dependent on the researchers’ background and belief regarding what areas should be included in the measurement o f quality of life. It seems that because each instrument is developed for a different purpose or goal, they vary widely in their construction and with the results they yield. The QWB, COOP, MHIQ, MOS SF-36, and EuroQol did not include fieldwork in development, which means that the researchers defined the domains o f the measures. SIP, NHP, IHQP and WHOQOL were developed, in part, from results o f fieldwork in which the links between development of the health, illness and quality o f life among the selected R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 8 populations were analyzed. The development o f SIP included self-completed questionnaires; the development of NHP and IHQL relied on interviews and the development ofWHOQOL utilized focus group discussion (Fox-Rushby and Parker, 1995). The majority o f these measurements were originally used in the United States. EuroQol and WHOQOL were designed explicitly for cross-country comparisons, and QWB, SIP, COOP, MOS SF-36, MHIQ, NHP and ffltQOL were originally designed for use in one country (the first four in the United States, the following two in United Kingdom and the last one in Canada) (Fox-Rushby and Parker, 1995). Cross-Cultural Quality o f Life Instruments Cross-cultural quality o f life assessment would make it possible to carry out quality of life research in different cultural settings such as the United States and Taiwan. One approach to cross-cultural assessment is through translation o f the original assessment. To date, two quality of life assessments have been translated into a Taiwanese version: the SF-36 Health Survey and the World Health Organization Quality of Life assessment (WHOQOL-100). SF-36 Health Survey. The SF-36 is a standardized, multidimensional health status questionnaire, the most widely used generic questionnaire of quality o f life (Feinglass, Morasch, McCarthy, 2000). Since 1992 more than 2000 articles, from several fields o f research, citing this measurement have been written. Because it is not a disease-specific questionnaire, scores on it can be compared across groups, either in R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2 9 the same disability categories, or among patients with different diagnoses from one study to another. The SF-36 is a self reported measurement o f health-related quality of life from the patient’s viewpoint. The questionnaire evaluates well being and functional status by asking the patient to self rate 36 items. The SF-36 measures 8 health domains: 1) general health perception; 2) general mental health (psychological distress and well being); 3) physical functioning (limitations in physical activities because of health problem); 4) social functioning (limitations in social activity because of physical health problem); 5) role limitation attributable to physical health problems; 6) role limitations attributable to emotional problems; 7) bodily pain; and 8)vitality (energy and fatigue). These eight domains were hypothesized as grounded in two health dimensions: the physical and mental domains (Ware and Sherboiume, 1992). SF-36 Taiwan Version. The translation o f the Taiwanese version of the SF-36 was developed using a standard methodology, following the protocol of the International Quality of Life Assessment (IQOLA) Project in 1996. The protocol included forward and backward translation, focus group discussion, pilot testing, and extensive psychometric analysis of the translation. More than sixty applications for permission to use SF-36 Taiwan version in research have been granted since 1996 (Lu, 2001). To date, there are no normative data on the Taiwan population which can be compared the findings o f my study in Taiwan. A related study using this SF-36 Taiwan version in the Veterans General Hospital in Taiwan had been reported. It was used to assess the quality o f life among headache R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 3 0 diagnoses in 901 patients in Taiwan (Wang, Fuh, Lu, & Juang, 2001). An interesting cultural issue regarding SF-36 Taiwan standard version was discussed in this article. The authors found that Chinese people have lower general health scores than those reported in other cultures because many Chinese people are unwilling to say that their heath is excellent even when it is. This relates back to a Chinese religious belief that God may become jealous and punish them for boasting about their good health. Both differences in cultural beliefs as well as language translation must be taken into account when using an instrument for a cultural group for which it was not originally designed. A field SF-36 Taiwan standard version survey among 1439 Taiwanese women in Kinmen, Taiwan (1999) was used in this study as comparative normative data but the standardized data have not been published (Wang, Fuh, Lu, & Juang, 2001). World Health Organization Quality of Life Assessment (WHOQOL-1001. The World Health Organization (WHO) initiated a cross-cultural project on the development of a quality of life questionnaire in 1991 and finished it in 1995. The World Health Organization Quality o f Life assessment (WHOQOL-100) was developed cross culturally, and concurrently across 15 international field centers. It is a generic quality of life measure designed for use with a wide range o f psychological and physical disorders. This measurement includes 100 items reflecting 24 facets relating to quality of life; the facets are grouped into 4 larger domains: physical, psychological, social relationships and environment. The WHOQOL-100 also includes one facet examining overall quality of life and general health perceptions. It R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 31 is a multidimensional, multi-lingual profile for subjective assessment (WHOQOL Group, 1995). The WHOQOL assesses the individuals’ view of their life in the context of their culture and value systems. WHOQOL is a generic, not disease-specific, measure, assessing health status and quality of life. Pibemik-Okanovic (2001) analyzed properties of the WHOQOL-100 such as its reliability, validity in discriminating patients with different disease characteristics, and responsiveness to change. For example, research showed that the WHOQOL-100 can be considered both a reliable and a valid instrument for quality of life assessment in diabetic patients (Pibemik-Okanovic, 2001). No research has been reported in which this questionnaire was used to measure quality o f life in people with amputations. WHOOOL-BREF Quality of Life Assessment. While the WHOQOL-100 allows a detailed assessment o f individual facets relating to quality of life the WHOQOL Group noted that it might be too lengthy for some uses. Besides, it has been demonstrated that the response rates are higher when short quality o f life measures are employed. One item from each o f 24 facets was chosen plus the 2 items from the overall QOL and general health facet for a brief version, the WHOQOL-BREF. Domain scores produced by the WHOQOL-BREF correlated highly (0.89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL- BREF domain scores demonstrated good discriminate validity, content validity, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 3 2 internal consistency and test-retest reliability. It is a good substitute short instrument for measurement of quality of life (WHOQOL Group, 1998). WHOQOL-100 Taiwan Version. WHOQOL-100 was developed cross- culturally and it allows each nation to add culture-specific questions. The WHOQOL- Taiwan Group started to develop the Taiwan version o f the questionnaire in 1997. The procedures for translating the questionnaire, selecting the appropriate scale descriptors, and proposing suitable culture-specific items were designed according to the standard rules established made by WHOQOL. The internal consistency and the test-retest reliability coefficients of the questionnaire were 0.97 and 0.86 respectively. Further, this version was considered comparable to these from other countries for global study (The WHOQOL-Taiwan Group, 1999). In order to develop the culture-specific items for the Taiwan version o f the WHOQOL, the WHOQOL-T ai wan group had many focus groups, in which they interviewed and held discussions with the participants, including clients with different diagnoses, inpatient and outpatient clients, clients’ family and professionals to explore cultural specific health related quality o f life facets and to determine if some crucial factor may not have been included on the original assessment. In accord with focus group results, 20 cultural specific questions were added as well as two facets: respect/acceptance (face and relationship) and diet, which contain 6 and 5 new questions respectively. Nine other questions were added to other facets. In total, 20 new questions were screened by a trial test and analysis (including cluster analysis, multidimensional scaling, multiple regression, the relationship among each questions R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. and each facet, the relations between the question and the facet, item difficulty, and internal consistency) to choose the most culturally specific questions. At the conclusion o f these processes, 12 questions were added to the original facets, and 8 more questions were added to form the two new facets. Table 1 shows the 12 cultural specific questions related to their facets and also the difference in cultural specific questions among three Chinese versions of the WHOQOL (The WHOQOL-T ai wan Group, 1999). The non - Taiwan versions are not my current focus but as an aside there are commonalities that exist across these three cultures and in the questionnaire: personal relationships, spiritual beliefs, social respect and acceptance and food (diet). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 3 4 Table 1 Cultural Questions Added to WHOQOL-100 Facets Taiwan (12 questions) Hong Kong (12 questions) China (2 questions) F3. Sleep and rest Do you have difficulty sleeping? F.13 Personal relationship Do you feel happy with your relationship with your relatives? Do you feel happy with your relative’s relationship? Are there any family conflicts that affect your life? F.14 Actual social support Can you obtain support from your partner? F.24 Spiritual ritual and personal belief Are you satisfied with your destiny? Are you satisfied with your destiny? Do you feel you have a good destiny and are lucky? Do you feel that you are lucky? F.25 Be respected and accepted (face and relationship) Do you feel respected by others? (*) Do you feel that it is easy to make friends? Do you feel others often respect you or give you face? Do you feel other people respect you? Do you feel that people like you? Do you feel that people like you? Do you feel people accept you? Do you feel people accept you? F.26 Diet Can you eat what you want to eat? (*) Can you eat what you want to eat? Do you enjoy the food you eat? Do you enjoy the food you eat? Are you usually able to obtain food you like to eat? Do you have a good appetite? How is your appetite? Are you able to eat any kinds o f food? Are you able to eat any kinds of food? Note. (*) items chosen for the WHOOOL-BR]E F Taiwan. The 12 culturally specific questions contain 4 questions in the diet facets in the Taiwanese version because food is especially important to Taiwanese. When Taiwanese meet each other, sometimes people will ask “Are you full?” and the meaning is the same as “How are you?” and “How are you doing?” in the United R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 3 5 States. Eating is an important occupation in Taiwanese culture. There is an old Chinese proverb, “Food is God for people.” This proverb demonstrates that common people respect food as they respect God. The Chinese culture influences Taiwanese daily lives and dining habits. There are different foods requested for each festival and occasion in the Chinese culture. For example: sweet dumplings for the 15th night in the first month o f the lunar calendar; moon cakes for the Moon Festival; a pyramid-shaped dumpling made of glutinous rice and ham wrapped in bamboo leaves for the Dragon Boat Festival, and leaf mustard, turnip, and a whole fish for Chinese New Year’s Eve, etc. These festivals and foods link people together through their shared understandings of cultural conventions. Furthermore, food itself may be traditionally attributed with symbolic meanings such as wealth, longevity, joy, or good health. These symbolic meanings directly transfer to the person who eats the food. Food can also used to prevent and treat illness with traditional Chinese medicine. Therefore, it is important for people in Taiwan to get what they want to eat not only for their physical desire but also for the cultural meaning attached for the food. WHOQOL-BREF Taiwan Version. WHOQOL-BREF Taiwan was developed from the generic WHOQOL-BREF. Originally, the WHOQOL was designed using 11,275 subjects from 18 nations and 20 research centers for cross cultural validity. The WHOQOL Group ruled that all 26 o f the questions in the WHOQOL-BREF should be included in each nation’s version but unique national items could be added R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 36 at the end to prevent a testing order effect. In the WHOQOL-100-T ai wan version there are two new facets, respect /acceptance (face and relationship) and diet (food). Thus, with the 26 required questions representing each facet, plus two new questions for the Taiwanese cultural facet, the WHOQOL-BREF Taiwan Assessment has a total o f 28 questions. The two Taiwanese questions are: 1) Do you feel respected by others? 2) Are you usually able to obtain food you like to eat? The internal consistency of this questionnaire was found to be 0.91 and the test-retest reliability coefficients of the four domains were all higher than 0.75 (The WHOQOL-Taiwan Group, 1999). The WHOQOL was designed for international use not only through translation, but also by nations working together to develop the original items for the measure, as well as by allowing for each nation or cultural group to add specific questions. It asked each nation to develop its own response scale descriptors (5 different scale descriptors as options in each question) when they developed their nation’s assessment. Finally, it focused on the respondent’s perspective about his or her own quality of life. Thus WHOQOL-BREF Taiwan is a suitable instrument for this study to assess quality of life for this population. WHOQOL-BREF Taiwan has three parts. The first part consists o f the 28 questions described above. The second part and the third part were developed by the WHOQOL Taiwan group. The second part includes two questions which ask participants to rate the satisfaction o f health related quality o f life before disease and now. The third part contains questions related to demographics. To make this R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 37 instrument more specific for my study, I added 9 questions related to amputation, prosthesis use and social support (Appendix A and B). The Difference Between the SF-36 Taiwan and the WHOOOL-BREF Taiwan Version. The SF-36 Taiwan version was directly or literally translated into the Mandarin language and does not specifically take into account cultural differences. In contrast, WHOQOL-BREF Taiwan version was designed for international use not only through translation, but also by nations working together to develop the original items for the measure, as well as by providing each nation or cultural group the opportunity to add specific items. In the SF-36 Taiwan version, many questions focus on the degree o f health problems limiting the person. For example: How much bodily pain have you had during the past 4 weeks (no?)? In the WHOQOL, questions focus more on how a person feels about a given situation. For example: To what extent do you feel that your pain hinders you in doing what you need to do (no.3). These two quality o f life measures can be viewed as occupational-related quality of life measures that contain concepts related to the form, function and meaning o f occupation. Tables 2 and 3 show the items in each measure related to occupation. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 38 Table 2 related to occupation I I I . llfl M H » I...... ..................................................................... Items Questions No. 3: Does your health now limit you in a Vigorous activities such as running, lifting heavy objects, participating strenuous sports b Moderate activities such as moving a table, pushing a vacuum cleaner, bowling or playing goal c Lifting or carry groceries d Climbing several flights o f stairs e Bending, kneeling or stooping f Walking more than one mile g Walking several blocks h Walking one block i Bathing or dressing No. 4: During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your Physical Health? a Cut down the amount o f time you spent on work or other activities b Accomplished less than you would like c Were limited in the kind of work or other activities d Had difficulty performing the work or other activities (for example, it took extra effort) No. 5: During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your any Emotional Problems (such as feeling depressed or anxious)? a Cut down the amount of time you spent on work or other activities b Accomplished less than you would like c Didn’t do work or other activities as carefully as usual No. 6: During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or group? No. 8 : During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? No. 10: How much of the time has your physical or emotional health interfered with you social activities (like visiting with friends, relatives, etc)? R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 3 Items Questions 39 No. 3: To what extent do you feel that your pain hinders you in doing what you _______ need to do?_____________________________________________________ No. 4: Do you need medical treatment to cope with your daily life? No. 13: Is it convenient for you to get the daily information you need? No. 14: Do you have the opportunity to take leisure time? No. 15: How is your ability to get around? No. 16: How satisfied are you with the sleep you get? No. 17: Are you satisfied with your ability to perform routine daily activities? No. 18: Are you satisfied with your working ability? No. 20: Are you satisfied with your personal relationship? No. 21: Are you satisfied with your sexual life? No. 22: Are you satisfied with the support you get from your friend? No. 24: Are you satisfied with how convenient it is for you to get medical services? No. 25: Are you satisfied with the transportation you use? No. 28: Are you usually able to get the things you like to eat? Quality o f Life and Occupations in People with Amputation This section will begin with a review of studies of elderly people with amputations. These studies provide direction for consideration o f the variables important in the study o f occupation and quality o f life for this population. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 4 0 Few reports have been published about persons with amputations related to their health related quality of life in comparison with other populations. One health related quality of life instrument, SF-36 has been used with people with traumatic lower limb amputation. Smith et al. (1995) compared SF-36 scores o f 20 adults with amputation to published normal age-matched scores in the United States. They reported that those with amputation have significantly lower scores in three o f the four categories of physical health on the SF-36 than age-matched people without amputation. Significant differences were not found in the domains o f general mental health, role limitation due to emotional problems, social activities, energy/fatigue, and general health perception. Miller (2001) compared SF-36 scores between elderly subjects with lower limb amputation and a sample of the general population o f the United States. The results demonstrated that older adults with lower limb amputation reported their quality of life much lower than age comparable healthy people in all eight subscales of the SF-36. These findings showed the impact o f disease and disability in quality of life for people with amputation. Miller (2001) also studied the relationship between body image, self esteem, level o f depression, life satisfaction, and quality of life in older adults following lower limb amputation. Questionnaires including the Amputee Body Image Scale, Rosenberg’s Self Esteem Scale, the Geriatric Depression Scale-Short Form, the Satisfaction with Life Scale, Medical Outcomes Survey (MOS) SF-36, a demographic survey, and three open-ended questions, relating to strategies used for coping with amputation were mailed to the 51 participants in this study. Participant inclusion R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 4 1 criteria included (1) age 50 or older and (2) having owned a prosthesis for more than 3 months. This study found that for more than 53% of the participants5 support of family/friends and various healthcare clinicians contributed positively to their adjustment to their amputations. People who reported a higher quality of life commented more frequently and more positively about support of family/friends and medical persons. The results showed that quality o f life associated with social support. In addition, he suggested that face-to-face interviews combined with questionnaires would have increased the power o f data interpretations and allowed for more comprehensive triangulation o f data. Weiss, Gorton, Read, and Neal (1990) studied a group o f 97 veterans with lower extremity amputations who had a median age o f 64 in 1984 and who were followed for 15 months to identify the factors predicting outcomes for amputations. The research methods included medical record review, telephone interview, and subjective and objective measures. First, the subjects’ medical records, including their medical history, surgical history, and postoperative complications, were reviewed. A follow- up telephone interview was performed to assess their quality of life at 15 months after surgery. Subjective measurement, including a question asking the patient to rate his or her health as excellent, good, fair or poor, and the Affect Balance scale, as well as objective measurements including ambulation or wheelchair mobility for at least 20 feet and the Katz Activity of Living scale, were used in this study. The results showed that, before 1984 (the year o f the study), 30% of the subjects had undergone some type o f vascular surgery and 39% had already had a lower extremity amputation. Only 36 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 4 2 % o f this sample could walk a year after surgery. However, medical review revealed that only 61% were walking before they had surgery (Weiss et al., 1990). The mortality rate was 35% during a 15-month follow-up by Weiss et al. (1990). High co morbidity, high amputation level, and frequent postoperative complications are associated with mortality. Within one year, 21 % of their subjects had contralateral amputations (Weiss et al., 1990). In Weiss et al.’s (1990) research, performing activities o f daily living (eating, dressing, bathing, transferring, and toileting) played an important role in how the patient viewed his or her well being after amputation. More than half of this group of 97 veteran amputees had difficulty performing activities of daily living and 45 % needed help with dressing. Through multiple regression analysis, the ability to perform activities o f daily living was found to be the most important predictor o f quality of life, self-perceived health, and well being. This result strongly showed that engaging in everyday occupation is very important to maintaining health and quality o f life. This implies that it is crucial for occupational therapists to assist people with amputations in performance o f routine daily occupations or in adapting their environment to maximize their possibilities o f performing occupations. This research result also supports occupational science’s perspective that participating in occupations influences health (Reilly, 1962; Yerxa et a l, 1989). A limitation in this study is related to the subjects studied. If only 61% o f the subjects were walking before they had surgery, their physical function was very poor R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 4 3 before the surgery. Around 40% o f the subjects had bilateral amputation when they were recruited in Weiss et al.’s research and physical functioning in this group of elderly veterans was also very poor. Thus, the sample that has lower physical functioning does not seem likely to represent the population adequately. A variety of variables have been shown to influence the frequency with which amputees used their prostheses. Bilodeau, Herbert, and Derosiers (2000) studied factors such as physical and mental health, rehabilitation, physical independence and satisfaction with the prosthesis to understand why older American amputees use or do not use their prostheses. There were 65 unilateral lower vascular amputees in this study who were over 60 years o f age. People who had had bilateral amputations, cognitive impairment, or people who did not have a prosthesis were excluded. This study incorporated a review o f medical records, telephone interviews, and a mailed questionnaire. Through medical reviews, information related to age, gender, level and date of amputation, numbers o f physical and occupational therapy sessions, prescription of a wheelchair and associated medical conditions were reviewed. Through telephone interviews, information about amputees’ activities with their prosthesis, physical independence, cognitive status, and physical health was obtained. Two measurements were mailed to the sample; the SATPRO questionnaire was used to measure amputee’s satisfaction with their prosthesis and the Geriatric Depression Scale was chosen to measure depression (Bilodeau et al., 2000). There were 52 men and 13 women with a mean age of 72 years in this study. The questionnaire on prosthesis use documenting the activity of respondents showed that R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 44 17% were inactive, 62% had restricted activity, and only 21% engaged in a moderate level of activity. Nobody showed a higher level of prosthesis use activity (Bilodeau et al., 2000). The relatively high rate o f prosthesis use may have been because of a selection bias associated with the exclusion o f bilateral amputees and the high mortality rate of this population. There were only 5 subjects who did not use their prosthesis and this finding was associated with declining health. There were 82% who wore their prosthesis daily and 89% wore it for 6 or more hours per day. Those who had had bilateral amputations were already excluded in this study. However, it may be that research participants use their prosthesis more often. The results o f the amputees’ satisfaction questionnaire showed that 83% of the amputees tended to be satisfied with their prosthesis. The frequency of use of the prosthesis decreased with age, and those who had a wheelchair use their prosthesis less. It was found that women used the prosthesis less than men. Altogether, the results indicated that older age, female gender, possession o f a wheelchair, more severe level of physical disability, cognitive impairment, poorer self-perceived health, and the amputees’ dissatisfaction with their prosthesis were related to the diminished use o f the prosthesis. The length o f time between the amputation and the data collection had no statistically significant relationship to the prosthesis use. Chang (1993) studied 31 adults (ages 23-60) with either lower or upper extremity amputation in Taiwan and found several factors influenced their decision o f prosthesis use by using interview method. He found that high level of amputation influenced the R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 45 decision about prosthesis use for people with amputation. In addition, for some people age was also a factor that influenced decisions regarding prosthesis use. This is illustrated by the fact that, some people stated that they were so old they were not concerned about their appearance. Family members’ support and suggestions also influenced prosthesis use and decision making for people with amputations in Taiwan. To a limited extent, studies of health related quality o f life in elders with chronic diseases who have not had amputations, should bring to light variables of potential concern in the present study. For example, a study on elders with end-stage renal disease showed that socioeconomic status was related to quality of life. This study examined the quality o f life by using SF-36 in 180 patients with renal disease. Those who have lower socioeconomic status had greater reduced quality o f life noted during the follow up after 7 month (Sesso, Rodrigues-Neto, and Ferraz, 2003). The other study on elders with arthritis revealed that socioeconomic status and severity of disease were related to quality o f life (Zimmer, Hickey, & Earle, 1995). This study examined the relationship between activity participation and well being among 166 older people with arthritis through the use of structured interviews. The results showed that the severity of arthritis was related to a decrease in physical activities and well-being. Higher education and income were associated with a high sense o f well being. Demographic characteristics, social support, socioeconomic status and the severity of disease were cited as factors that influence well being and engagement in occupation (Zimmer, Hickey, & Searle, 1995). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 46 Variables Included in this Study The literature reviewed suggests that for older people with amputations, age, gender, and level o f amputation (below-knee versus above-knee) (Bilodeau et al., 2000; Chang 1993; Custon & Bongiomi, 1996; Fletcher et al., 2001) strongly influence prosthetic use and functional capacity, especially for walking. In a more general sense, education, income, health status, and social support have all been associated with quality o f life and participation in different occupations (George, Okun, & Landerman, 1985; Miller, 2001; Zimmer et al., 1995). Therefore, age, gender, level o f amputation, socioeconomic status and social support will be included in this study of quality o f life and occupational patterns as related to prosthesis use. Conclusion In sum, the literature on occupation and quality o f life provides a foundation supporting this study. Research has shown that participation in occupation is a consequential determinant o f quality of life. It is also important to research quality of life from the individual’s point o f view within his or her own personal socio-cultural context. Amputation surgery may influence elderly people’s engagement in occupation and prevent them from participating fully in the culture and society. How elderly people with amputation can engage in satisfied and balanced occupations and maintain good life quality is an important question. Only when we more fully understand the impact amputations have on the elderly can the goal o f increasing their quality o f life through engaging in occupation be attained. This study will look at quality o f life and R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 47 daily occupations along with their prosthesis use in the lives o f Taiwanese elderly people with lower extremity amputation, a population that has not yet been studied sufficiently in occupational science and occupational therapy. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 48 Chapter 3 - Methodology First the research design, using both quantitative and semi-structured interview methods, is discussed in this chapter. Next the participants (elderly people with amputations living in Taiwan) are described, as is their recruitment for the data collection. The instruments that were used in this study are then described. Finally, the procedures for data collection and data analysis (quantitative and interview) are presented. Research Design The research was descriptive and correlational using both quantitative and interview data. Quantitative data were collected using two health related quality of life instruments (WHOQOL-BREF Taiwan version and SF-36 Taiwan version) and a demographic data questionnaire. Some of the elderly people who completed the two instruments were also interviewed about their quality o f life, how amputation changed their occupations and quality o f life and how their prosthesis use related to their engagement in occupations. Figure 1 in Chapter 1 describes the design of the study. Integrating quantitative and interview research data offered some advantages, because the two approaches have complementary strengths and offset each other’s limitations (Carlson and Clark, 1991). By integrating two research data collection methods, one can have a multidimensional authenticity, therefore strengthening the validity o f the findings (Polit & Hungler, 1999). Qualitative materials were used to probe more deeply for an understanding of the quantitative results and to offer a more comprehensive and dynamic understanding o f the phenomena under study (Polite & R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 49 Hunger, 1999). Using different data-collection techniques to check the findings generated by the different data collection methods and testing the quality of information gained is a triangulation process designed to maximize the validity and credibility o f the research (Bailey, 1991). By using both quantitative and interview research methods, I obtained a fuller picture o f the quality of life and occupational patterns o f this particular group. Quantitative Approach Participants The participants in the quantitative portion o f this study were 90 elderly people with non-traumatic amputation. Participants included people referred by Taiwanese prosthesis companies or residents o f Veterans’ Homes who were over the age of 55 and (1) had had amputation surgery performed as a consequence o f peripheral vascular disease, diabetic foot infection, or other non-traumatic reasons and (2) had had at least one prosthesis and had owned their prosthesis for at least one month or had completed prosthesis training. Exclusion was proposed if the amputation was performed during childhood or early adulthood or if the amputation was performed less than 3 months prior to potential recruitment. The first criterion was proposed because people who have had amputations during childhood or early adulthood usually have higher adaptability to mobility and daily occupation than elderly people who had their amputation surgically in their late life and their results may therefore not be comparable. Also, if the amputation had been performed within 3 months those elderly people with lower R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 50 extremity amputation may have not completed the whole prosthesis training yet and it may influence their occupational choice. However, no potential subjects were excluded for these reasons. All participants had sufficient cognitive and hearing ability to respond to the two quality o f life measures either in writing or by responding orally after having the items read to them. Subjects were obtained from two prosthesis companies, one located in the north and one in the south of Taiwan (in Taipei and Kaohsiung, respectively), and 14 Veterans’ Homes located throughout Taiwan. The numbers of elderly veterans (all males) with amputation who lived in Veterans’ Homes were listed in a Document o f Participation Agreement from the Veterans Affairs Commission of the Executive Yuan o f the Republic of China, divided into three groups according to their cause o f amputation (diabetes, peripheral vascular disease, and other). There were 43 potential participants from Veterans’ Homes who met inclusion criteria. Of these, six were not available during the time of study due to visits to their family or hospitalization. The nursing staff of the veterans’ homes also excluded three potential participants due to cognitive limitations and two due to inability to read and inability to hear. One participant refused to finish the study. Thus, a total o f 31 (male) veterans participated in this study. The two prosthesis companies were unable to provide lists of their entire population of customers for this study. However, current customers having recently completed training through the prosthetic companies were referred and provided about half o f the nonveteran participants. The other half of the prosthetic company R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 51 participants were referred to the researcher when they come in to the company for a check-up, adjustment or repair of prosthesis or when a company worker went to their home for a check-up. Of 61 eligible potential participants referred, one man refused to participate and one woman refused to complete the study. Thus, 59 participants were from the prostheses company contacts (42 males and 17 females). As mentioned above, one potential participant refused to participate in this study. After receiving an explanation of the study and IRB form, he told me that he did not have time and also he wanted to keep much o f his life private. However, we had a good conversation about his work, but not about amputation related topics. He had a PhD from the US and had been a professor in several universities in Taiwan. His high social status maybe related to his decision not to participate in this study. There were two participants (one veteran and one female nonveteran) who refused to finish the study. The veteran did not want to talk about his amputation and one female said that her son would not be happy about her talking about the family’s private affairs. Determining the sample size for the quantitative data analysis was based on the use of a two-tailed test with 80% power desired for a higher-order correlational test and further assuming .30 as a meaningful degree o f correlation in the population. With the above criteria, 85 subjects would have been a sufficient sample (a = .05, one-tailed test) (Kraemer & Thiemann, 1987). Demographic Description of the Sample Ninety people with single or bilateral lower extremity amputation, 73 men and 17 women, participated in this study. Of the participants, 31 were veterans (34%). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 52 Demographic data, including marital status, level of education, and employment status of participants, are summarized in Table 4. A typical participant was a 71 year old non-veteran single man with elementary school education who was no longer employed. Table 4 Demographic Characteristics of the Participants Variables Frequency Percent Marital Status Not married/not living together 48 53.3 Married/living together 42 46.7 Level of Education Illiterate 22 24.4 Elementary School 45 50.0 Junior High School 8 8.9 Senior High School 8 8.9 College 7 7.8 Employment Status Not employed 84 93.3 Employed 4 4.4 Housewife 2 2.2 The age o f the participants ranged from 55 to 98 years with a mean age of 71.28 years (males 72.19 and females 67.35 years). The veterans were older than non veteran males and females (M = 78.19 years, 67.76, and 67.35 years respectively, p < .01). There was no significant difference (p > .05) between the mean age of the entire group of males and the females. The mean number of years since amputation was 4.14 ( + 7.37). A t-test found a significant difference between the mean years since amputation of the males (4.81years ± 8.02) and females (1.28 + 1.45) (p < .05). The mean age and number of years since amputation o f the participants are shown in Table 5. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 53 Table 5 The mean age and number o f years since amputation of the participants Age Years post amputation All subjects (N = 90) 71.28 + 9.44 (55-98) 4.14+ 7.37 (.25-48) Gender Male (N = 73) 72.19 ±9.35 (55-98) 4.81 ± 8.02 (.25-48) Female (N = 17) 67.35 + 9.01 (55-85) 1.28+ 1.45 (.25-6) Veterans status Veterans (Male)(N = 31) 78.19 + 7.94(62-98) 5.80 ± 10.59 (.25-48) Non-Veterans Male (N = 42) 67.76 ± 7.74 (55-79) 4.07 ±5.45 (.25-25) Non-Veterans Female (N = 17) 67.35 + 9.01 (55-85) 1.28 ±1.45 (.25-6) Other subject characteristics related specifically to lower extremity amputation such as reason for amputation, unilateral or bilateral amputation, level o f amputation and number of hours o f prosthesis use are shown in Table 6. Over 75 % o f the sample reported diabetes as the reason for amputation. Hours o f wearing prostheses each day were more evenly distributed, although over 75 % of the sample reported wearing it daily. The most common pattern was a unilateral below knee amputation due to diabetes with the participant wearing his prostheses over 8 hours per day. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 54 Table 6 Participants’ Characteristics Related to Lower Extremity Amputation Variables Frequency Percent Reason for Amputation Diabetes 68 75.6 Vascular disease 18 20.0 Infection 2 2.2 Malignant tumor 1 1.1 Osteomyelitis 1 1.1 Number o f Amputations Unilateral 71 78.9 Bilateral 19 21.1 Level of Amputation Unilateral Below Knee 56 62.2 Unilateral Above Knee 15 16.7 Bilateral Below Knee 16 17.8 Bilateral Below Knee& Above Knee 2 2.2 Bilateral Above Knee 1 1.1 Average Time wearing Prosthesis per day None 17 18.9 Up to 5 hours 26 28.9 5-8 hours 15 16.7 Over 8 hours 32 35.5 Instruments Two generic measures, The World Health Organization Quality o f Life Assessment -Taiwan short version (WHOQOL-BREF Taiwan)(WHOQOL Taiwanese Group, 2001) and the SF-36 Taiwan version (Lu, 2001) (Appendix B) were used to quantitatively evaluate the elderly amputees’ quality o f life. The demographic data form contained 22 questions, including questions from the demographic questionnaire used in the standardization o f the WHOQOL-BREF Taiwan version and questions related to amputation and prosthesis designed by this researcher. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 55 Fuller information on the background and outcome measures can be seen in Table 7 and Table 8, forming the beginning structure of the quantitative data analysis. Tables 7 and 8 indicate how each variable was measured, the measurement scale range, and the way the variable was used in the data analysis. Table 7 describes the independent variables and Table 8 the dependent variables. The variable o f socio-economic status was calculated by performing a median split on the reported family income. Because 93 percent of the participants were not employed, income was the only factor indicating socio-economic status. Because most o f the participants who lived at home did not have regular income, total family income including both annual income from the participant and live-in family members were used as the socioeconomic status variable. Hours per day wearing the prosthesis was also defined as a dichotomous variable. The questionnaire asked not only the number of hours using a prosthesis, but also included an item between none and less than an hour called “seldom, only wear it for special occasion.” There were two participants who checked this item and they reported that the occasions they used their prosthesis were getting into and out o f car for support and going to the park to exercise. The responses to the question were unable to be viewed as equidistant, therefore, for the variable o f less or more prosthesis wearing, a median split approach was applied. Using a frequency distribution, use o f the prosthesis each day was divided as using prosthesis more than 5 hours per day or less than 5 hours per day. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 7 Overview of Independent Variables in Quantitative Data. Variable Method of measurement Scale range Use of variable Level of Ampu Demographic data form 1 = unilateral BK; 2 = other Theoretical Predictor of HRQOL and Prosthesis Use tation Social Support Demographic data form 1 = not at all; 2 = slight; 3 = moderate; 4 = great; 5 = full Theoretical Predictor of HRQOL and Candidate Predictor Variable for Prosthesis Use Socio- Econo mic Status Demographic data form Median split o f reported monthly family income 0= < 20,000 [< $571]; 1= >20,000 [> $571] Theoretical Predictor of HRQOL and Candidate Predictor Variable for Prosthesis Use Age Demographic data form Number o f years Theoretical Predictor of Prosthesis Use and Candidate Predictor Variable for HRQOL Gender Demographic data form 1 = male; 2 = female Theoretical Predictor of Prosthesis Use and Candidate Predictor Variable for HRQOL R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 57 Table 7 continued. Variable Method of measurement Scale range Use o f variable Veterans Demographic 0 = non veterans; Candidate Predictor Status data form 1 = veterans Variable for HRQOL and Prosthesis Use Education Demographic data form 0 (no schooling) to 5 (college) Candidate Predictor Variable for HRQOL and Prosthesis Use Marital Demographic 1 = not married/not Candidate Predictor Status data form living together; 2 = married/living together Variable for HRQOL and Prosthesis Use Reason for Amputation Demographic data form 1 = diabetes 2 = other Candidate Predictor Variable for HRQOL and Prosthesis Use Hours per Day Wearing Prosthesis Demographic data form Based on median split o f reported hours per day; 1 = <5 hours 2 = >5 hours Candidate Predictor Variable for HRQOL Years since Amputation Demographic data form Number of years Candidate Predictor Variable for HRQOL and Prosthesis Use Unilateral Demographic 1 = unilateral Candidate Predictor vs. Bilateral Amputation data form 2 = bilateral amputation Variable for HRQOL and Prosthesis Use Living Status Demographic data form 0 = alone; 1 = living with others Candidate Predictor Variable for HRQOL and Prosthesis Use Living with Family Demographic data form 1 = living with family; 2 - not living with family Candidate Predictor Variable for HRQOL and Prosthesis Use Helper Demographic data form 1 = none; 2 = yes Candidate Predictor Variable for HRQOL and Prosthesis Use Residence Demographic data form 1 = home; 2 = institution Candidate Predictor Variable for HRQOL and Prosthesis Use Presence of Disease Demographic data form 1 = none; 2 = at least one disease Candidate Predictor Variable for HRQOL and Prosthesis Use R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 58 Table 8 Overview of Dependent Variables in Quantitative Data. Variable Method of Measurement Scale range Type of Variable Health-related SF-36 Taiwan version (physical 0-100 Criterion Quality of Life (physical) functioning, role-physical & bodily pain scales)(vitality, general health and social functioning scales are partially correlated) variable Health-related SF-36 Taiwan version (mental 0-100 Criterion Quality of Life (mental) health, role-emotional & social functioning scales) (vitality, general health and social functioning scales are partially correlated) variable Health-related WHOQOL-BREF Taiwan version Raw domain Criterion Quality of Life (physical health) (pain, energy, sleep, mobility, activity, medication dependence & work facets) scores: 4-20 Transformed domain scores: 0-100 variable Health-related Quality of Life (psycho logical) WHOQOL-BREF Taiwan version (positive and negative feeling, thinking, self esteem, body image & spirituality facets) Raw domain scores: 4-20 Transformed domain scores: 0-100 Criterion variable Health-related WHOQOL-BREF Taiwan version Raw domain Criterion Quality of Life (social relationships) (personal relationships, social support, sexual activity, face & relationship facets) scores: 4-20 Transformed domain scores: 0-100 variable Health-related Quality of Life (environment) WHOQOL-BREF Taiwan version (physical safety, home and physical environment, finance, health and social care availability, opportunities for acquiring information, leisure, transportation & diet facets) Raw domain scores: 4-20 Transformed domain scores: 0-100 Criterion variable R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 59 Procedures The participants from the two prosthesis companies were recruited during their visits to the prosthesis company. When the company representatives visited their home I joined them. I visited a prosthesis company to identify potential subjects for this study about 4 days a week during the subject recruitment phase of the project, which lasted three months. During this same three months, I also visited the Veterans’ Homes to invite elderly veterans with amputation to participate in this study. The timing of my visit depended upon the number o f potential participants at each Veteran’s Home. All participants were given a detailed explanation of the study and provided informed consent. Their informed consent was documented by an IRB form reviewed and approved both by the IRB at University o f Southern California and Chun Shan Medical University in Taiwan (Appendix C and D). If participants agreed, they signed the informed consent and filled out the two quality of life measures and one demographic data form. The amount of time that subjects used to complete the two measures and demographic data form ranged from 25 to 60 minutes. The SF-36 Taiwan version was first administered, followed by the WHOQOL-BREF Taiwan version and then the demographic data form. I read the questions and answers for 48 subjects who had difficulty reading the instruments and then recorded their answers. I read the Mandarin versions in the Taiwanese dialect for some of the participants who could not read the characters and spoke only the Taiwanese dialect. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 6 0 Data Analysis When participants finished the measures, I checked all the items. If there were some items they failed to complete, to avoid missing data I encouraged them to finish those questions. The SF-36 Taiwan version was scored according to the SF-36 health survey manual and interpretation guides (Ware, Kosinski, and Gandek, 1993, 2000) and the SF-36 physical and mental health summary scales (Ware and Kosinski, 2001). The WHOQOL-BREF Taiwan version was scored according to the development and user manual of the WHOQOL-BREF Taiwan version (WHOQOL-Taiwan Group, 1999). When the measures were collected, the data were coded and entered into the computer for data analysis using the SPSS 11.0 program. Descriptive statistics, including minimum scores, maximum scores, means, and standard deviations, were determined on all continuous variables. Distributions were normalized as necessary to make them better fit statistical assumptions (e.g., log transformation if there was positive skew) prior to all hypothesis tests. Hypothesis 1 : Low social support, high level o f amputation, and low socioeconomic status predict reduced health-related quality o f life (as measured bv WHOQOL-BREF Taiwan version: physical, psychological, social relationship, and environmental domains, and SF-36 Taiwan version: physical and mental domains) among elderly Taiwanese people with amputation. To promote a parsimonious test of Hypothesis 1, backward stepwise multiple regression with a given HRQOL scale as the criterion variable (dependent variable) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 6 1 was first used to select the set of candidate control variables. Using a two-tailed test with alpha = .01, candidate variables that significantly predicted HRQOL were retained. Then, simultaneous multiple regression was performed including all significant candidate predictor variables and all theoretical variables. Each theoretical variable was tested using alpha = .05 and a one-sided test, and predictor variables at alpha = .05 using a non directional two sided test. Hypothesis 2: Older age, female gender, and high level of amputation predicts reduced prosthesis use among elderly Taiwanese people with amputation. Based on the median split o f reported number o f hours per day wearing the prosthesis, prosthesis use was converted to a dichotomous dependent variable and logistic regression analysis was used to test this hypothesis. The process was the same as used in testing hypothesis 1. Hypothesis 3: Quality of life fas measured bv WHOQOL-BREF Taiwan version) for elderly Taiwanese people with amputations is significantly lower than that of adults’ with diabetes without amputation and Taiwanese adults’ normative data. Independent t-tests for unequal variances were used to test for differences in quality of life between this study’s elderly sample with amputation and (1) healthy people, and (2) people with diabetes without amputation. Separately for each o f the 4 domains (physical, mental, social interaction, and environment), means o f the WHOQOL-BREF Taiwan were compared among these three groups using alpha = .05, with a one-sided test reflecting the expectation o f lower HRQOL mean for the amputation group. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 62 Comparison Data from WHOOOL-BREF Taiwan. The WHOQOL-BREF Taiwan research group provided unpublished data for comparison in this study. The researchers currently working on development of this Taiwanese version were not able to provide full demographic information about the data that they have gathered at this time, but were willing to share what was currently available with me. Their data analysis was still in process and was not ready to publish yet. They expect that detailed demographic data may be reported in late 2003. They were able to provide limited information: the mean and SD of each WHOQOL-BREF Taiwan domain for two relevant age groups (50-59; 60-69) by gender. Their sample o f respondents to whom the WHOQOL-BREF Taiwan was administered consisted of adults over 20 years old and below 80 years old. They were randomly selected from the Taiwanese population, including people with disease or disability. This group o f people included 673 males and 584 females aged 50-59 years; 191 males and 127 females aged 60-69 years and 10 males and 1 female between 70- 79 years. Because the 70-79 years group had too few persons, these data was not used for a comparison although that age group was the largest in my sample. The WHOQOL-BREF data from this dissertation study was compared with existing data from a group of people with diabetes who had not experienced amputation who were part o f the WHOQOL-BREF Taiwan data (1999). There were scores from 356 of their sample identified as having diabetes, however, the research group was not able to give me their age and gender (The WHOQOL-Taiwan Group, 2003). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 63 Hypothesis 4: There is a positive correlation between scores of quality of life on the SF-36 Taiwan version and the WHOQOL-BREF Taiwan version. Scores from domains of the two quality of life instruments were correlated to determine the similarity between the two measurements within the study sample by using Pearson Correlation coefficients. A correlation matrix was created to illustrate the relationships. Using alpha = .05, with one-sided tests, relationships were tested for significance. Hypothesis 5: Both the SF-36 Taiwan version and the WHOQOL-BREF Taiwan version have acceptable internal consistency, as well as items that correlated properly with scale/domain totals, when used to assess elderly people with amputation. Two techniques were used to assess the psychometric properties of the two main measures—item scale correlations and Cronbach’s Alpha. Item scale correlations that evaluate the extent to which the item is related to the rest o f the items in a scale can uncover which items do not validly contribute to a measurement construct in the subject population. Cronbach’s alpha measures the overall correlation between items within a scale. Reliability is considered acceptable for group comparisons when alpha is 0.7 or above (Polit and Hungler, 1993). Interview Approach Participants Convenient sampling was used in the qualitative segment of this study to select participants. Study participants who had completed the questionnaires, who were willing to be interviewed and also appeared interested in spending their time talking to R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 64 me were my selected interview participants. Thirty people with amputation, 25 males (10 from Veteran’s Homes) and 5 females, were interviewed. Location and Time The location o f the interviews was in the prosthesis company, in participants’ own homes or in participants’ Veterans’ Homes. When the interview location was at a participant’s house, the interview time was determined by the interviewer, a worker at the prosthesis company, and the participant through telephone arrangement. A worker who knew the participants well introduced me to the participants. When the interview was at a prosthesis company, a quiet comer was selected as an interview place and the time depended on the given participant’s visit time to the prosthesis company. When the interview was at a Veterans’ Home, the administrator o f the home assigned a person, usually a nursing staff member who knew the individual with amputation well, to take me to find the veteran. I usually made an appointment with the administrator one week before and knew how many people in the Veterans Home were potential participants so that I could plan for the interviews. The interviews were usually carried out beside the veteran’s bed, in a garden, or in a hallway, depending on the veteran’s preference. Data Collection Individual and semi-structured interviews were used during the data collection. The interview conversations began to flow after they finished the two measures. All interviews were audiotaped. The interviews ranged approximately from 10 minutes to 75 minutes per person. The time depended on the flow o f the conversation in that R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 6 5 particular interview. The total time for the interviews was 18 hours, producing 284 double-spaced pages of transcription in Mandarin. Transcription The transcribers for the interviews were four hired transcribing typists and myself. I personally transcribed approximately 4 hours o f taped interviews and each hourly interview required around 5-8 hours o f transcription time at the early stage o f data collection. The typists were divided into two groups- two could speak both Taiwanese and Mandarin and two could speak Mandarin only. The typists who could speak Mandarin only transcribed those sessions in which Mandarin only was spoken and most of those participants were veterans. All the Taiwanese dialogues were typed in Mandarin Chinese. There are some Taiwanese words/terms for which there are not exact words (literal translations) in Mandarin. Those were recorded with the most similar meaning in Mandarin even if some wording was changed, in order to express the meaning as much as possible (cultural translation). Those words and terms were discussed and agreed to by the typists and me. Transcription o f the Taiwanese interviews took longer than the Mandarin ones because they were not just word for word transcription. After the typists transcribed the interviews, I checked the transcripts against audiotapes to correct any words or meanings. It also allowed me to be personally on the scene again and have more understanding o f the interview content. All tapes were transcribed verbatim in an attempt to retain pauses, laughter, or other nonverbal language. The specific name and places were changed to promote confidentiality. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 66 Data Analysis and Coding The data analysis began with coding the transcripts. Coding is a process of identifying categories (Dey, 1993). I read and reread the text to have a general concept and overall picture of the interview text. I used a highlighter to highlight the sentences that I thought were most meaningful and codes were written at the side of highlighted transcript sentences. I searched among participants for similar or different concepts. The codes for similar concepts were put together as subcategories. Then I went back to all the transcripts and pulled out interview content for examples under each subcategory. Finally, themes related to my research questions and also some important new concepts that arose from the interview texts were identified. As I wrote the analysis, the relationships between some categories were interwoven and sometimes I went back to earlier coding stages to reorganize ideas to make them more coherent. Translation Part o f transcripts and codes were translated into English to be reviewed by the dissertation chair. I translated the data into English by myself and some sentences that I felt were difficult to translate I discussed with a translator who has a master’s degree in translation. Results of the quantitative analysis are presented in Chapter 4 and discussed in Chapter 5. Interview results are presented in Chapter 6. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 67 Chapter 4 - Quantitative Results This chapter presents descriptive summary statistics of the two measures in this study, comparisons of results by gender and veteran status, and statistical tests o f the study hypotheses. Descriptive Data The means and SD for the WHOQOL-BREF Taiwan version domains, and the SF-36 physical and mental component summaries (PCS & MCS) of the participants and subgroups o f participants in this study o f elderly Taiwanese people with amputation are presented in the Appendix E. Before the testing the hypotheses, the results were divided by gender and veterans status in order to see if there were any differences between groups. Table 9 presents the results o f independent t- test comparisons between genders and the male participants’ veterans’ status. There were no significant differences between non veteran males and veterans in WHOQOL domains: physical, social relationship- Taiwan, environment, and environment-Taiwan. Significant differences were found in that the veterans group had lower means in WHOQOL psychological and social relationship domains than the non-veteran male group. There were no significant differences between non-veteran males and veterans in seven domains of the SF- 36 and the SF-36 mental component summary (MCS). The data show that the means of the SF 36-physical function domain and SF-36 physical component summary (PCS) are statistically significantly higher in non-veteran males than veterans (p < .05). The SF-36 physical function domain is part o f the SF-36 physical component summary R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 68 (PCS). Four out o f 16 tests found significant differences. Because of these findings of some differences due to veteran status, this variable was used as a predictor variable for health related quality of life and prosthesis use. Table 9 Independent t - test for comparing groups bv veteran status and gender. Male Groups Gender Groups Non- Veterans Males Females Veteran (N=31) Male (N=42) Total (N-17) (N-73) WHOOOL Mean (SD) p Mean (SD) p W1-Physical 12.94(2.17) 12.28(2.97) .274 12.66(2.54) 12.44(3.35) .763 W2-Psychological 13.27(2.36) 11.70(3.27) .020* 12.60(2.88) 12.12(2.88) .533 W3-Social relationship 13.05(2.66) 11.35(2.71) .009* 12.33(2.79) 12.78(2.83) .547 W3T-Social relationship+ Taiwan 13.12(2.48) 12.00(2.92) .082 12.64(2.72) 13.47(2.79) .264 W4-Environment 13.37(2.25) 13.37(1.70) .997 13.37(2.02) 13.56(1.63) .721 W4T- Environment + 13.53(2.20) 13.62(1.75) .859 13.57(2.01) 13.91(1.55) .518 Taiwan SF-36 PCS (Physical Component Summary) 32.25(7.27) 27.08(7.06) .003* 30.05(7.58) 29.20(9.33) .689 MCS (Mental Component Summary) 48.74(8.24) 49.96(14.28) .646 49.26(11.14) 49.25(11.57) .999 Physical- Function 16.14(5.00) 13.61(4.73) .019* 15.07(5.01) 15.12(4.51) .920 Role-Physical 4.26(0.80) 4.10(0.40) .346 4.19(0.66) 4.18(0.73) .789 Bodily Pain 9.14(2.57) 8.45(3.15) .465 8.85(2.83) 8.56(3.36) .908 General-Health 15.97(3.81) 13.98(5.26) .065 15.12(4.56) 14.12(5.59) .435 Vitality 15.74(4.10) 15.19(5.79) .639 15.50(4.86) 14.82(4.59) .599 Social-Function 6.29(1.58) 5.77(2.31) .265 6.07(1.92) 6.53(1.97) .378 Role-Emotion 4.62(1.17) 4.87(1.34) .394 4.73(1.24) 4.88(1.27) .642 Mental Health 21.64(3.78) 21.10(4.82) .589 21.41(4.23) 20.35(5.62) .387 * p < 05 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 69 Hypothesis 1: Low social support, high level of amputation, and low socioeconomic status predict reduced health-related quality o f life among elderly Taiwanese people with amputation. Multiple regression analyses using each health related quality o f life scale (SF- 36 Taiwan version; WHOQOL-BREF Taiwan version) as a criterion variable were used to test the set o f candidate predictor variables and the theoretical variables. The summary of final regression models for the predictors of WHOQOL-BREF Taiwan Domains and SF-36 Physical and Mental Component Scales are shown in Table 10. The details o f the statistical test o f each domain and scale o f the two measures are shown in the Appendix F. In nearly all (7 o f 8) of the regression analyses, social support was positively correlated with quality o f life, supporting the hypothesis. In contrast, the SF-36 Physical Component Scale (PCS) was the only quality of life measure found to be significantly correlated with level o f amputation (p = .004). Income was not correlated with any domain or scales of the quality of life measures (p > .05). In addition to the results in the set o f predictors, wearing a prosthesis and having a helper (or not) were shown as significantly correlated with the physical domain o f quality o f life (p = .021 and .011 respectively) and having disease or not was significantly correlated with the WHOQOL-BREF Taiwan psychosocial domain (p = .003). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 70 Table 10 Summary of Standardized Beta Values and Significant Test Results o f Predictors of WHOQOL Domains and SF-36 Physical and Mental Component Seales o f Hypothesis 1 WHOQOL __________ SF-36 Wl: Physical W2: W3: Psycho Social -logical Relation -ships W3T: Social Relation -ships+ Taiwan W4: W4T: PCS Environ Environ Physical -ment -ment+ Taiwan MCS Mental Theoretical Variables8 Social Support .077 .388** .325** .345** .299* .291* .100* .078* Level of Amputation -.018 .073 -.047 -.066 -.103 -127 -.290** .269 Income -.147 -.076 .159 .175 -.274 -.303 -.085 -.034 Control Variables1 3 Wearing Prosthesis .272* .............. — — .177 .187 .................. Disease —- .329** —........................... - ............................. Residence —- —- -.046 .034 —- —- ................. Helpers - .......................... — —.................. .282* Note. — the variable was not included in the multiple regression analyses. a one-tailed test.b two-tailed test. * g_< .05. ** g < .005. Through multiple regressions, neither gender nor veteran status was shown to predict quality of life. This finding supported the decision that this study’s group participants could be treated as one sample group in further statistical analysis. Hypothesis 2: Older age, female gender, and high level o f amputation predicts reduced prosthesis use among elderly Taiwanese people with amputation. Logistic regressions with prosthesis use (less or more than 5 hours per day) as a criterion variable (dependent variable) were used to test the set o f candidate predictor variables. The results are shown in Table 11. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 71 In general, the hypothesized relationships were not observed. Female gender was positively correlated with more prosthesis use, opposite to what was expected. The hypothesized relationships between age and prosthesis use and also between level of amputation and prosthesis use were not supported by the data. However, among the predictors, type o f residence (home vs. institution) and years since amputation were significantly correlated with using the prosthesis in daily life. People in institutions used their prosthesis less often and also those with fewer years since their amputation were less likely use their prosthesis. Table 1 1 Variable B S.E. df ........P ........ Theoretical Variables’ 1 Age -0.003 .033 1 .465 Female Gender 1.920 .786 1 .008 Level of Amputation (Low vs. High/Bilateral) 0.235 .563 1 .338 Control Variables'3 Residence (Home vs. Institution) -2.183 .734 1 .003 Years since Amputation a _ a . . . * , -i. 0.966 .272 1 .000 Hypothesis 3: Quality o f life (as measured by WHOQOL-BREF Taiwan version) for elderly Taiwanese people with amputations is significantly lower than that of adults’ with diabetes without amputation and Taiwanese adults’ normative data. To enable comparisons to the data from the WHOQOL-BREF Taiwan normative sample, which was reported by gender and decade of life, I divided my study participants into three groups (Group 1 : < 59 years old, Group 2: 60 - 69 years, and Group 3: > 69 years). There were only 11 people over 70 years old in the WHOQOL- R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 72 BREF Taiwan normative data, so this age group was not compared. The mean scores o f Groups 1 and 2 (participants younger than 70) were compared with available data for the general Taiwanese population under 70 years o f age, comparing the age group to gender norms for that decade. The males in my Groups 1 & 2 had 9 and 16 participants respectively and the female Group 1 & 2 participants were 3 and 8 respectively. Because the number o f my female participants in Group 1 (< 60 years old group) was only three, this group was not used for comparison. Independent t-tests were performed to assess differences for each o f the six domains in the WHOQOL between the each o f the three remaining group samples and available comparable age group norms. The results showed that there were only a few significant differences. Male amputee groups have significantly lower scores in the physical domain (both male groups, 60 years old and 60-69 years) and the social relationship domain (males 60-69 years). The comparison results for each age and gender group are shown in Tables 12-14, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 73 Table 12 Norm Data (N = 673) Amputee Data ( N - 9) WHOQOL Domains Mean SD Mean SD T D f Domain 1 (Physical) 14.60 2.24 13.33 1.92 -1.97 * 8.29 Domain 2 (Psychological) 13.44 2.41 13.48 2.49 0.05 8.20 Domain 3 (Social-Relationship) 13.97 2.28 13.78 1.49 -0.38 8.51 Domain 3T(Social-Relationship + Taiwan specific question) 13.76 2.22 13.89 1.27 0.30 8.67 Domain 4 (Environment) 12.79 2.16 13.00 2.28 0.27 8.19 Domain 4T (Environment +Taiwan specific question) 12.98 2.13 13.09 2.29 0.14 8.19 *2 < .05, one-tailed. * * 2 < 025, one-tailed. Table 13 Norm Data (N = 191) Amputee Data (N = 16) WHOQOL Domains Mean SD Mean SD t df Domain 1 (Physical) 14.30 2.42 12.82 2.88 -2.00* 16.82 Domain 2 (Psychological) 13.45 2.13 13.46 2.51 0.02 16.86 Domain 3 (Social Relationship) 13.93 2.31 12.33 2.78 -2.24 ** 16.79 Domain 3T(Social Relationship + Taiwan specific question) 13.76 2.22 12.63 2.45 -1.79* 17.14 Domain 4 (Environment) 12.81 2.11 13.41 2.15 1.08 17.52 Domain 4T (Environment +Taiwan specific question) 13.04 2.07 13.56 2.03 0.98 17.71 * 2 c .05, one-tailed. **g< .025, one-tailed. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 7 4 Table 14 Comparison of Female Group 2 data (60-69 vrs) in WHOQOL-BREF Taiwan Domains Norm Data (N = 127) Amputee Data (N = 8 ) WHOQOL Domains Mean SD Mean SD T df Domain 1 (Physical) 13.59 2.54 12.29 3.51 -1.03 7.47 Domain 2 (Psychological) 12.98 2.47 12.00 3.60 -0.76 7.42 Domain 3 (Social-Relationship) 13.76 2.44 13.17 3.22 -0.51 7.51 Domain 3T(Social-Relationship + Taiwan specific question) 13.75 2.21 13.63 3.46 -0 .1 0 7.36 Domain 4 (Environment) 13.03 2.32 13.13 1.89 0.14 8.40 Domain 4T (Environment ^Taiwan specific question) 13.21 2.25 13.44 1.77 0.35 8.49 In summary, when comparing the quality o f life means o f the normative data and the sample of elders with amputation, when there is a significant difference, the means tend to be lower in this sample of elders with amputation, although in most cases the difference is not statistically significant. The WHOQOL scores o f this group of elders with amputation were also compared to WHOQOL data for people with diabetes (The WHOQOL Taiwan Group, 2003). The results are shown in Table 15. The elderly participants with amputations in this study scored significantly lower in domains 1 (Physical), 3 (Social), and 3T(Social-Taiwan) than did the sample of people with diabetes. In contrast, their Domain 4 and 4T(environment) means were significantly higher than those of the non-amputee diabetic group. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 7 5 Table 15 Amputation in WHOOOL-BREF Taiwan Domains Diabetics (N = 365) Elderly Amputees (M = 90) WHOQOL Domains Mean SD Mean SD t df W1 Physical 13.68 2 .6 8 12.62 2.70 -3.34 * 136 W2 Psychological 1 2.86 2.57 12.51 2.87 -1.06 126 W3 Social relationship 13.72 2.37 12.41 2.79 -4.10 123 W3T Social relationship (+ Taiwan specific question) 13.56 2.24 12.80 2.73 -2.45 120 W4 Environment 12.53 2.26 13.41 1.95 3.71 154 W4T Environment (+ Taiwan specific question) 12.73 2.23 13.63 1.93 3.84 ** 153 *p < 01, one-tailed. **p < .0005, one-tailed. Because differences were found between subgroups (veterans, non veterans) in some domains (WHOQOL domain 2 and 3), the subgroups were compared individually to the diabetic group data (Table 16-18). Significant differences were found between the elderly veteran amputee group and the diabetic group in all WHOQOL domains with the means of the veteran amputee group lower except for 4 and 4T, the environmental domains. Findings were similar except for lack of significant differences in domains 2 and 3T between the non veteran male amputee group and the diabetic group and also between the elderly female amputee group and the diabetic group. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 76 Table 16 Veterans with Amputations in WHOOOL-BREF Taiwan Domains Diabetics Elderly Veteran (N =365) Amputees (N = 31) WHOQOL Domains Mean SD Mean SD t df W1 Physical 13.68 2 .6 8 12.28 2.97 -2.54 ** 34.28 W2 Psychological 1 2 .8 6 2.57 11.70 3.27 -1.93 * 33.22 W3 Social relationship 13.72 2.37 11.35 2.71 -4.72 *** 34.01 W3T Social relationship (+ Taiwan specific question) 13.56 2.24 1 2 .0 0 2.92 -2.90 ** 33.07 W4 Environment 12.53 2.26 13.37 1.70 2.57 ** 39.61 W4T Environment (+ Taiwan specific question) 12.73 2.23 13.62 1.75 2.65 ** 38.78 *g < .0025, one-tailed. **p < .005, one-tailed. * * * 2 < .0005, one-tailed. Table 17 Comparison o f Means of Taiwanese Adults with Diabetes and Taiwanese NonL- Veteran Male Elders with Amputation in WHOOOL-BREF Taiwan Domains Diabetes (N = 365) Elderly Amputees (N = 42) WHOQOL Domains Mean SD Mean SD t D f W1 Physical 13.68 2 .6 8 12.94 2.17 -2.04 ** 56.46 W2 Psychological 12 .8 6 2.57 13.27 2.36 1.06 52.84 W3 Social relationship 13.72 2.37 13.05 2.66 -1.56* 48.79 W3T Social relationship (+ Taiwan specific question) 13.56 2.24 13.12 2.48 -1.10 49.01 W4 Environment 12.53 2.26 13.37 2.25 2.29 ** 50.99 W4T Environment (+ Taiwan specific question) 12.73 2.23 13.53 2.20 2.23 ** 51.19 * 2 < 05, one-tailed. **g <. 01, one-tailed. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 77 Table 18 Females with Amputations in WHOOOL-BREF Taiwan Domains Diabetics (N - 365) Elderly Amputees (N = 17) WHOQOL Domains Mean SD Mean SD t df W1 Physical 13.68 2 .6 8 12.44 3.35 -1.50* 16.97 W2 Psychological 12 .8 6 2.57 12.12 2.88 -1.04 17.21 W3 Social relationship 13.72 2.37 12.78 2.83 -1.35 * 17.06 W3T Social relationship (+ Taiwan specific question) 13.56 2.24 13.74 2.79 0.26 16.97 W4 Environment 12.53 2.26 13.56 1.63 2.50 ** 18.99 W4T Environment (+ Taiwan specific question) 12.73 2.23 13.91 1.55 3.00 *** 19.23 * 2 < .005, one-tailed. **g < .001, one-tailed. ***p < .0005, one-tailed. Hypothesis 4: There is a positive correlation between scores o f quality of life on the SF-36 Taiwan and the WHOOOL-BREF Taiwan. Scores from domains of the two quality of life instruments were compared to determine the correlation between the two measurements with this sample o f elderly people with amputation by using Person correlation coefficients. A correlation matrix was created to examine the relationships. Table 19 shows the correlation coefficients between the two quality of life instruments. Appendix G shows the details of correlation coefficients within the domains o f the WHOQOL-BREF Taiwan and the SF-36 Taiwan. Out of 60 correlations, 48 were statistically significant (p < .05). WHOQOL Domain 2-Psychological was highly related to the SF-36 Mental Health Scale (.70). The other significant correlations revealed low to moderate relationships, ranging from .21 (low) to ,61(moderate). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 7 8 The SF 36 Role-Physical domain was not significantly related to any Domains of the WHOQOL. Neither WHOQOL Domains 3 (Social Relationships) nor 3T (Social Relationships + Taiwan) were significantly related to Vitality and Role-Emotional domains of the SF-36 and also neither of these WHOQOL domains significantly related to one other of SF-36 scales (mental component scale and bodily pain, respectively). Table 19 Correlations between domains o f the WHOOOL-BREF Taiwan and the SF-36 Taiwan version WHOQOL Wl: Physical W2: W3: Psycho- Social logical Relation - ships W 3T: Social Relation - ships+ Taiwan W4; W 4T: Environ- Environ ment memt + Taiwan SF-36 Physical Component Summary (PCS) 4 9 ** .37** .34** .31** .31** .31** Mental Component Summary (MCS) .55** .61** .20 .24* .30** .33** Physical Function .42** .32** .23* .24* .28** .31** Role-physical .15 .10 .12 .07 .11 .12 Bodily Pain .57** .38** .2 1 * .2 0 .35** .35** General Health .52** .56** .39** .41** .25* .25* Vitality .57** .60** .17 .21 .27* .26* Social Function .58** .50** .35** .31** .33** .37** Role-Emotional .39** .34** .03 .09 .2 2 * .25* Mental Health .54** 70* * .35** .37** .37** .39** * 2 <.05, one-tailed. * * g < .0 1 , one-tailed. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 79 Hypothesis 5: Both the SF-36 Taiwan and the WHOOOL-BREF Taiwan have acceptable internal consistency, as well as items that correlate acceptably with scale/domain totals, when used to assess elderly people with amputation. The reliability o f the SF-36 Taiwan version and WHOQOL-BREF Taiwan in relation to their internal consistency and item analysis are presented in Table 20 and 21 respectively. Cronbach's alpha coefficients ranged from 0.52 (social function) to .90 (bodily pain). Seven o f the eight scales had acceptable alpha coefficients greater than 0.70, with only the two item social function scale lower than that level. The mean o f the alpha coefficients of the eight scales is .77. The item-total correlations of each item were good, >.35, except for the two items in the social function scale (r = .35) and one item (9B - Have you been a very nervous person?) in the Mental Health scale that correlated only marginally (r = = .21) with other items in the same scale. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 80 Table 20 Item Analysis and Internal Consistency for the SF-36 Taiwan Scales Number of Items Corrected Item-Total Internal Consistency Items Correlation (Cronbach’s alpha) Physical- 10 3A .37 .89 Functioning 3B .51 3C .51 3D .75 3E .75 3F .60 3G .79 3H .80 31 .75 3J .41 Role- 4 4A .46 .72 Physical 4B .59 4C .63 4D .45 Bodily Pain 2 7 .82 .90 8 .82 General 5 1 .49 .74 Health 11A .49 11B .58 11C .36 11D .63 Vitality 4 9A .69 .85 9E .69 9G .73 91 .68 Social 2 6 .35 .52 Functioning 10 .35 Role- 3 5A .86 .85 Emotional 5B .8 6 5C .48 Mental 5 9B .21 .71 Health 9C .50 9D .48 9F .63 9H .61 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 81 Table 21 shows the Cronbach’s alpha for each domain o f WHOQOL-BREF Taiwan. Alpha coefficients ranged from 0.63 (Environment) to .81 (Physical). The mean of the Alpha coefficients o f the 6 scales is .71. When adding culturally specific questions to Domains 3 (Social Relationships and 4 (Environment) to form Domains 3T and 4T, the internal consistency of each domain is higher. Table 21 shows that Social Relationship improves from .63 (Domain 3) to .71 (Domain 3T) and the Environment improves from .65 (Domain 4) to .67 (Domain 4T) after adding cultural specific questions. It shows that the culturally specific items fit the domains well and add to the internal consistency o f each domain. Most item-total correlations of each scale are acceptable (>.35), except Social Relationship and Social Relationship- Taiwan Domains 3 & 3-T item 21 (Are you satisfied with your sexual life?) (r = .18, .17 respectively) and the Environment Domain items 13, 14 & 23. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 21 Item Analysis and Internal Consistency for the WHOQOL-BREF Taiwan 82 Scales Number of Items Corrected Item-Total Internal Consistency Items Correlation (Cronbach’s alpha) Physical 7 3 .53 .81 4 .41 10 .51 15 .53 16 .51 17 .72 18 .67 Mental 6 5 .60 .80 6 .60 7 .52 11 .54 19 .63 26 .49 Social 3 2 0 .56 .63 relationship 21 .18 2 2 .65 Social 4 2 0 .65 .71 relationship 21 .17 -Taiwan 22 .68 27 .51 Environment 8 8 .40 .65 9 .43 12 .40 13 .21 14 .27 23 .31 24 .36 25 .44 Environment 9 8 .46 .67 -Taiwan 9 .43 12 .40 13 .24 14 .28 23 .26 24 .36 25 .40 28 .32 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 83 Summary The results showed that lower social support was correlated with reduced health related quality of life. Level o f amputation correlated significantly with the physical component scales of SF-36 measures with higher level o f amputation associated with reduced physical quality o f life. Presence of disease correlated significantly with the psychological domain of WHOQOL-BREF Taiwan. Amount of prosthesis use and presence of a helper each correlated significantly with one o f the two quality o f life measures’ physical domain or scale. For prosthesis use, non-hypothesized but significant relationships emerged demonstrating that people who lived at home were wearing their prostheses significantly more than people who lived in an institution, and that people who have had more years since amputation wore their prostheses significantly more. This study shows little significant difference between its sample of elders with amputations and other older Taiwanese. More significant differences were found that this sample o f elders with amputations had lower means in most o f the WHOQO domains than other adult Taiwanese with diabetes. The two health related quality o f life measures (SF- 36 Taiwan Version and WHOQOL-BREF Taiwan Version) tend to correlate moderately and positively as expected. Both the SF-36 Taiwan version and the WHOQOL-BREF Taiwan version demonstrated acceptable internal consistency with this sample of elderly people with amputation. The interpretation of results for each hypothesis tested will be presented in Chapter 5. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 8 4 Chapter 5 - Discussion o f Quantitative Results This chapter presents my interpretations of the quantitative results for each hypothesis. Within this chapter, these findings are also linked to previous research and limitations are presented. Hypothesis 1 : Low social support, high level o f amputation, and low socioeconomic status predict reduced health-related quality o f life among elderly Taiwanese people with amputation. In general, the theoretically predicted relationships (based on previous research results) were partially observed. Lower social support was found to be related to lower health related quality of life as expected. Higher level o f amputation correlated significantly with the reduced physical domain of quality o f life of SF 36. However, the theoretically anticipated relationship between income and quality of life was not observed. In addition to the results for the set o f theoretical predictors, which supported previous research results, more time spent wearing the prosthesis and having a helper were found to be significantly correlated with the higher physical domain o f quality of life, and having disease was significantly correlated with the lower psychosocial domain o f quality o f life. The finding for the importance of social support in the quality of life is consistent with the results o f previous research by Miller (2001). O f fifty-one American elder participants (34 males and 17 females) with single lower extremity amputation and a mean age o f 6 6 .1 years, those with higher quality of life scores (as measured by SF-36) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 85 reported (when answering open-ended questions) having more social support from people (family, friends and medical professionals). The statistical result of this hypothesis test found seven out o f eight multiple regression models showed higher social support statistically related to the higher quality of life as measured by different scales/domains including physical, mental, social and environment. These findings also show that social support is not only related to social well-being, but also correlated to the physical and psychological well being of the participants. Level of amputation correlated significantly with the physical component scales of SF 36 Taiwan version although this finding was not supported by previous research. For example, Miller (2001) excluded people who had bilateral lower extremity amputation and only compared unilateral below knee and above knee amputations as a dichotomous variable; not finding a relationship between SF-36 health-related quality of life scores and level of amputation. However, it is likely that his exclusion limited the range o f the effect of amputation on people’s occupational performance, removing those bilateral amputees that this studies’ data included. The definition of level o f amputation differs from one study to another. Most studies (e.g., Bilodeau et al., 2000; Miller, 2001) collected data only from people with unilateral amputations. I decided to score level o f amputation as a dichotomous variable because level of amputation involved ordinal categories. While 62 % o f the participants had unilateral below knee amputation, only 17 % had unilateral amputation above the knee and 21 % had bilateral amputation. The subgroups of only R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 86 21 % and 17 % were clearly too small for analysis. With my dichotomous grouping, those who had unilateral below knee amputation were in one group (62%) and those who had unilateral above knee and bilateral amputation were in the other group (38%). This grouping allowed the more severe amputations to be judged and the effect of their inclusion was demonstrated by this study’s finding of lower scores in the physical domain o f quality of life. However, more subtle effects on other aspects of quality o f life were not statistically significant. Even with the combined subgroups, the small sample size on one side of the dichotomous variable (37.8%) may have hindered the ability to demonstrate the hypothesized effects on other domains o f quality o f life. Socioeconomic status had no statistically significant relationship with health related quality o f life in this study. A study reporting the relationship between socioeconomic status and quality o f life such as that by Zimmer et al. (1995) used structured interviews to explore quality of life factors for 166 older people with arthritis in the United States. The different research methods and different disease group in this study might have affected the different findings. Also, measurement of socioeconomic status o f elderly Taiwanese is not a clear cut thing. It is difficult to identify elderly Taiwanese people's socioeconomic status by reported income. Many of them might have lots of savings or properties, yet do not report any monthly or annual income in a demographic data form. Those people who live with their family might have given their money to their children. Those veterans who live at Veterans’ Homes have regular income, most receiving $380 US a month, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 8 7 affecting the sample distribution o f income. It is probable that income really is not irrelevant to quality of life for this population. Those who have higher income may have higher expectation o f life and more disappointment due to the limitations o f their amputation. Because this variable is hard to define in a meaningful way, it might be better to use a more qualitative, in depth exploration in future research involving elderly populations in Taiwan. In additional to the results in the set o f theoretical predictors, wearing their prosthesis and presence o f a helper were shown to significantly correlate with the physical domain of quality of life (p = .0 2 1 and .011 respectively) and presence of disease was significantly correlated with the WHOQOL-BREF Taiwan psychosocial domain (p = .003). These three variables, wearing prosthesis, presence of a helper and presence o f disease would be interesting to explore for future research related to quality of life. Future research should include a quantitative study using these three factors as predictors o f elderly amputee’s quality o f life to learn more about the relationship between them and quality of life. Hypothesis 2: Older age, female gender, and high level o f amputation predicts reduced prosthesis use among elderly Taiwanese people with amputation. In contrast to the hypothesis, age was not significantly related to prosthesis use. Gender and level o f amputation had no statistical relationship with prosthesis use in this study as well. Positive but non-hypothesized relationships found that people who lived at home were wearing their prostheses significantly more than people who lived R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 88 in an institution and people who have had more years since amputation wore their prostheses significantly more. Those findings are only partially consistent with previous studies. While Bilodeau et al. (2002) had found that older age related to diminished use o f prostheses, Chan and Tan (1990) reported that age is not a factor that influences prosthesis use, as did the findings in this study. In this study, females did not have reduced prosthesis use, however, this was in contrast to results of studies reporting that females exhibited diminished use o f their prosthesis (Bilodeau et al., 2002; Chan and Tan, 1990). There was no observed relationship between the level o f amputation and prosthesis use in this study and in the study by Bilodeau et al. (2002) in spite o f the two studies’ different measures of level, as noted previously. On the other hand, Chang (1993) found that level of amputation did influence amputee’s decision o f prosthesis use. Culture may influence whether elderly people really need to use their prosthesis or not. Many Taiwanese elders who have had an amputation do not need nor wish to be independent, if other people take good care of them. Therefore, there was reduced prosthesis use observed in this study. Depending on others when people are old and have disabilities is typical in Taiwanese society. It may influence their motivation and need to wear the prosthesis. Increasing age, with its frequent accompaniment o f physical limitations would not necessarily increase or decrease prosthesis use in Taiwanese elders who had already accepted helpers at the beginning of their “old age”. Females, who in Western society may feel it is more socially appropriate to be R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 8 9 dependent, would not necessarily be any more willing to accept dependency in Taiwan than would older males, because of the different cultural tradition. From a set o f candidate variables, residence (home or institution) and years since amputation significantly predicted prosthesis use. People who live in an institution, such as a Veteran’s Home, may be less self conscious of their missing limb without a prosthesis in an institution and feel comfortable to use a wheelchair instead with many peers who also have disabilities and sit on the wheelchair. They may be less embarrassment about amputation in institutional setting. They may be less likely to use their prosthesis because most of the institutions are disability free environments, and they can simply and easily use a wheelchair or electric power wheelchair to get around instead o f using prosthesis. The home environment is usually more difficult to make accessible for a wheelchair because many people in Taiwan live in an apartment, and thus prosthesis use is a more effective adaptation, costing less and requiring less impact on others. It often requires a period o f time to learn and develop adaptive skills after disability. People who have had an amputation generally need time to adjust to the prosthesis. Their body will be changed, affecting their balance and movement patterns. Their stump will become smaller through increased prosthesis wearing. They will need to adjust to the change o f their stumps by changing the number o f socks or changing to a new socket. Therefore, people who have more years since amputation probably increase prosthesis use because o f more adaptive skills they have over time. They may also become more comfortable and proficient with its use. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 0 Hypothesis 3: Quality of life (as measured by WHOOOL-BREF Taiwan version) for elderly Taiwanese people with amputations is significantly lower than that of adults’ with diabetes without amputation and Taiwanese adults’ normative data. When this study sample was compared with the above control groups, the pattern was that when there was a significant difference, the means were lower in the current sample, indicating a lower quality o f life. Significant differences were found between normative data from 673 Taiwanese males 50-59 year old and 9 similarly aged males with amputation from this study’s sample in the physical domain and between normative data from 191 60-69 year old males and 16 males with amputations from this study in both the physical and social relationship domains o f the WHOQOL BREF Taiwan version. No differences were found for 8 females with amputations who were 60-69 years when compared to 127 females o f the same age and no tests were made for the 3 females who were 50-59 years old. However, because my sample size of these relatively younger persons (50-69 years) was small, and because there was no comparison data yet available for the largest portion of my sample, (age 70 +), there was reduced power in testing differences. At the same time, the means are close for both groups. Therefore, it was surprising to find even those differences noted above and perhaps it will take a larger sample to see further differences that may exist. An alternative view to explanations about why few differences were found is that people with disability do not automatically experience a lower quality of life. An assumption that their quality o f life is lower may very well be unfounded. Having R eproduced with perm ission o f the copyright owner. Further reproduction prohibited without perm ission. 91 disease does not always mean that people must have a low quality o f life. Even for a healthy young adult, quality of life is not always high. An optimistic person may still have high self scored health-related quality o f life after amputation. Another possibility is that people may have different scale anchor interpretation. When this sample o f adults with amputation was compared to a sample of adults with diabetes, a more powerful test resulted and significant differences were found in Domain 2 (physical) and Domains 3 and 3T (Social Relationship). In general, the mean scores o f this sample were lower than those o f the people with diabetes without amputation, suggesting greater impact o f amputation on people’s quality of life. However, a somewhat surprising result, the finding that the Domain 4 and 4T (Environment) scores o f this sample o f elderly people with amputation are significantly higher than the diabetes group, suggests the older persons in my sample are more satisfied their familiar home or institutional environments and perhaps they also accept or treasure what they have after losses from amputation or through the aging process. Since age cannot be changed, people may use this domain to improve their quality o f life by engaging in occupation. To an increased extent for older adults with amputation, the environment may facilitate the opportunity for people to engage in leisure activities, obtain information and food, and in general feel satisfied with their home condition and the available transportation services. The group of adults with diabetes were compared without knowing their age and gender. I will assume that those people with diabetes were younger than my group since they were a part o f the overall Taiwanese sample that was younger; however, to R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 2 be experiencing diabetes they may have been at least middle age, or possibly with a mean around 50 years. Age and gender were not found to be significant predictors of quality of life in this study, so perhaps the effect of not having this data for the diabetic group is not great, but it cannot be determined. Hypothesis 4: There is a positive correlation between scores of quality o f life on the SF-36 Taiwan and the WHQQOL-BREF Taiwan. The two health-related quality o f life measures tended to correlate positively and moderately as expected between most scales and domains (47 of 60 comparisons). The SF-36 Physical Component Scale was more strongly related to the WHOQOL Physical Domain than to the other WHOQOL domains and the SF-36 Mental Component Scale was more strongly related to the WHOQOL Mental Domain than to the other WHOQOL domains (r = .49 and .61, p < .01, respectively). This pattern could be expected, demonstrating the relationship of the content of the specific domains o f the WHOQOL and the components of the SF-36. However, at the same time, the correlations are only moderate, demonstrating that each measure contains some unique content. The convergent validity o f the two measures is satisfactory, while each has its strengths. Based on this study, both of these quality of life measures are valid for use with elderly people with amputation. Quality o f life can be measured in many different ways. Each domain or subscale is trying to capture slight differences within a measure, although they are also somewhat correlated to the other domains or components o f the measure. Because they do capture some meaningful differences within each single R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 3 measure, they correlate positively with similar domains or scales in other quality of life measures, while retaining uniqueness. Thus both measures should be acceptable in clinical and community settings for researchers and professionals interested in the quality of life of older adults with amputation Taiwan. Hypothesis 5: Both the SF-36 Taiwan and the WHOOOL-BREF Taiwan have acceptable internal consistency, as well as items that correlated acceptably with scale/domain totals, when used to assess elderly people with amputation. The internal consistency o f the two measures in general was found to be satisfactory. Both measures are thus found acceptable for use in clinical and community setting for this population of elders with amputation. The Cronbach's alpha values for seven of the eight subscales o f the SF-36 Taiwan version were acceptable at > 70 alpha, although alpha was low for social functioning in the SF-36 (0.52). A lower value in this domain was found by a previous study (Jenkinson, Coulter & Wright, 1993), in which high alphas were found for all scales except the social functioning scale. This finding could be because there are only two items in the social functioning scale, which represents a broad idea that may not be able be to measured in such a few items. The small number of items makes this equivocal for statistical purposes. However, because of the small number o f items in this domain, this level o f correlation was also considered acceptable. Additionally, for the SF-36, the item-total correlations o f each scale were good, except in the Mental Health scale there was one item 9B (Have you been a very nervous person?) that correlated only slightly with other items in the same scale. Most R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 4 elderly people with amputation in this study might sometimes feel nervous, but they seldom were “very” nervous. Sixty percent of the participants rated that they had been very nervous a little bit or none o f the time. Hence, researchers should be wary about including this times in future research with amputees. The internal consistency of the WHOQOL-BREF Taiwan is adequate for all domains. Although the alpha value for the W4 - Environment Domain is slightly low (.65), it can be considered an acceptably borderline score. Further, after adding the culture specific questions to Domains 3 and 4, the internal consistency is higher for each domain (3T & 4T), which indicates that the culturally specific questions are coherent and appropriate for the domain. This demonstrates that the addition of culturally specific questions in new local versions o f the WHOQOL makes the measure more adequate for measuring the social and environment domains in those specific populations. The item-total correlations of each domain o f the WHOQOL-BREF Taiwan are acceptable, except in the Environment-Taiwan domain, where the item-total correlation of each item is weak. There are different facets in the environment domain including safety, home, finance, services, information, leisure, environment, transportation and eating. A possible explanation is that items included in this domain represent separate facets that only weakly compose a single domain. In addition, in the correlation of the Social Relationship-T ai wan domain item 21 (Are you satisfied with your sexual life?) to the domain total is low. Since the item-total correlation is low, when using and interpreting this measure, researchers will need to be careful R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. interpreting this item. In chapter 7, the interview findings will provide more interpretation of this item including how elders with amputation felt about this question. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 6 Chapter 6 - Interview findings Interview Analysis and Interpretation Procedure In my original research proposal, I had planned to use the quantitative results to select interviewees who ranged variously from low to high quality o f life. However, it was convenient for the participants and me to meet at the same time to do the two quality o f life measures and conduct the interviews. Therefore I did not use the quality o f life score as criterion for selecting my participants. I interviewed 30 participants who ranged variously from low to high quality o f life scores, level of amputation, years since amputation and hour wearing prosthesis (Appendix H). My capability to personally meet with the participants when they filled in the measures, instead o f using a mailed questionnaire or using other researchers to contact the participants, was especially advantageous. I began my observation when I met the participants and personally observed their environments. When I asked about their demographic data information, the interview dialogue began. When I had further questions based on their answers to the measures, I would ask the participants for clarification. The interview therefore further illustrated the quantitative data. I analyze my data coding and develop themes from the interview data. Those themes were independently analyzed without interference from the quantitative results. During the interview data analysis procedure, my focus was not set on whether the data could be interpreted or connected with the quantitative data. The interview data R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 97 therefore not only facilitated the interpretation o f the quantitative data, but also produced unique results o f its own, presented in this chapter. All the names o f the following interview dialogues have been changed to maintain confidentiality. It is common in Taiwan for people to call elder by their last names instead of their first names. Therefore, I chose each participant’s last name for the following interview findings. Factors Influencing Quality o f Life This section presents the ways in which elderly people with amputation responded in interviews about their basic concepts of quality of life. It is important to know which factors relate to their quality of life before talking about how amputation changed their quality of life and daily occupation. Several themes reflecting the basic factors that influenced quality of life emerged from the interviews, including life attitude and previous life experience, relationships with other people, material life, and the aging process. Life Attitude and Previous Life Experience Life attitude and previous life experience had an influence on the participants’ current view of their quality o f life. Attitude toward life influences the way people view their own world. Everyone has his/her own life attitude, which may result in each viewing his/her quality o f life differently and also orchestrating daily occupations differently. Previous life experience also influenced the way the elderly people with amputations who participated in the interviews handled and viewed experiences. Each elderly person shared his/her own past life stories and experiences. For example, Mr. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 9 8 Ke was a hooligan for the underworld. He thought he was a brave person and he viewed things positively because of his past life experience. The following interview segment illustrates this life attitude. Y: Did you have a stroke before? K : Yes, I have had three strokes. Y: I can’t tell. K : I can still ride motorcycles. I rode motorcycles after being out of the hospital for only 3 days. Y: Didn’t it influence you at all? K : I went to rehabilitation then. He [therapist] taught me how to rehabilitate myself. Y: You have learned it. K: Anyway, people have to be brave. ... We human beings have to be tough, right? Be tough! You can’t always think “Oh, I can’t I can’t.” If you do think that, you really can’t move (A19; Ke p. 416, lines 265-283). Mr. Ke’s philosophical belief that humans should be brave and tough influenced the way he faced his life changes. He had a positive attitude toward life and this life attitude influenced how he views his own current quality o f life. Not everyone holds the same positive attitude as Mr. Ke. Other people have another kind of life attitude- accept life as it is. For example, Mr. Su mentioned, “ lama happy person because I am not forced to do anything. There is nothing in my mind. If I can live one day, that’s my day” (A 14 Veteran; Su p. 3, lines 45-46). Mrs. Li also stated, “I think if I can lead a long life, I can be very satisfied. I won’t think something else” (Type 2 A4 Female; Li p. 3 lines 65-71). These examples show a life attitude that accepts whatever happens as natural and takes life as it is. Their life attitude and life experiences are different from Mr. Ke’s. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 99 In this study many elderly people with amputation mentioned that they believed their life was determined by fate. They apply this life attitude to face their life or to adjust to life changes. One man described it in the following way, Y: Do you think your life is meaningful? M: God already planned how many years we are going to live for us. There is nothing like you want to live until you are 100 years old and God will permit you to do so. We should be more open-minded. I dare not to say that I want to eat till 100 years old and then the god will let me live until 100 years old, right? I cannot say that. When the day is coming, you leave. It is like the military service. When the day comes, you go to serve the army obediently. After two years, you come back, right? If the day has not come yet, he will not let you serve in the armed forces, right? It is fate. Human beings live a certain number o f years and then go back. This is all set; one day less is not allowed. You are not allowed to live one more day (Type2 A2; Map. 1, lin es2-12). In Taiwan, men are required to serve in the military for two years after they finish their education. Here, it is used as an example to show that life is not controlled by human beings but only by fate. Mr. Lu, a veteran, mentioned this in a similar way. Y: How is your health? L: My health condition is pretty good. The king o f hell has not called my name yet. I will go when he calls my name. People who live here are all waiting for the king o f hell to call their names. ... If the king of hell calls my name, I will prepare to leave. Ha! Ha! You are not the king of the hell, right? When the king of the hell calls someone’s name, he will leave. However, human beings are all the same. We will die. You did not see it. People die a few days after they go to the Veterans General Hospital. ... They die a few days after (Tape 1 A Veterans; Lu pp. 6-8, lines 126-161). In the Veterans’ Homes, the veterans’ average age is over 70. Mr. Lu saw his peers go to the hospital and pass away. The life processes of aging, illness and death are all around those elderly people. Some people understand and accept life processes R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 0 0 and changes by using this life attitude—accepting their fate. They do not believe that they have much control over their lives. For elderly people with amputation who were interviewed, life attitudes have been influenced by previous life experiences. Mr. Chen is a veteran who has never been married, just like most of the veterans in the Veterans’ Home. He came to Taiwan with the Mainland Chinese Nationalist (Kuomintang) troops when he was 20. The troops retreated to Taiwan from China in 1948. At that time, he did not know that he would stay in Taiwan for the rest o f his life. After 50 years, his life experience has taught him how to view things. He stated his life attitude: C: At that time we planned to counterattack Mainland China. Who knows it already took over 50 years? We had a slogan at that time. “The first year preparation, the second year anti-Communist, the third year destruction, and the fourth year success, a complete success.” Who knew it would take over 50 years, through all my life. Therefore, everything should be seen from an open-minded attitude. Y: Open-minded? Can you explain more? C : An individual...the average age among the Chinese people... Male is around 73 or 74 and female is around 76. ... Living in this world for several years. People spent all their life striving for fame and wealth and mentally fight with each other. What’s the purpose? In the future, when they die, eyes closed and extremities stretched, it is over. No matter how high level your position is and how much money you own, you cannot bring them to your coffin. This thing should be seen and thought through. No matter how high level your position is and how much money you own, you cannot bring them with you after you die (B O O 19 Veterans; Chen pp. 1-2, lines 18-28). According to his life experiences, life is short and unpredictable. Everything should be seen from an open-minded attitude. Elderly individuals have accumulated many unique life experiences that influence their decision-making regarding their occupations and how they are going to be engaged. Those who are tough often try to R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 101 change their environment and other aspects of their lives. Those who do not mind most of the things that happened or who believe everything is controlled by fate try to accept their lots. These are just examples o f the many varied life attitudes, which have been developed by the people interviewed for this study. Each person develops a unique perspective on life and it affects their view of their quality o f life. In summary, life attitudes influence how people view their quality o f life. Elderly people with amputations shared their own life attitudes, which had been influenced by their own past life experience. From this finding, we see that participants had different life attitudes. The researcher could not identify a typical life attitude for this group o f people. Relationship with Family Relationship with family members is a powerful factor that can influence one’s everyday life. Family relationships can influence one’s feeling or emotion about one’s well-being and quality o f life. In the traditional society o f Taiwan, it is commonly held that the oldest son and his wife are the ones who have the most responsibility to take care o f the son’s parents. Some participants in this study felt that the relationship with their son was an important factor by which they judged their quality of life When I interviewed Mr. Ke about why he thinks he has a good quality of life and by which criteria he judged it, he stated, “ It means my eldest son is very filial. He gives me money all the time” (A19; Ke p. 11, lines 176-177). Mr. Ke is a man who lives with his oldest son, of whom he is really proud. Mr. Ke’s social life consists o f R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 0 2 going to the park and chatting with his friends. I asked him what topics he usually discussed with his friends. He stated, K: For example, there is an election now, so we would talk about politics. Sometimes we argued a lot because we didn’t reach an agreement. (laugh) ...If there were no election, we bosom friends would compare our sons. Whose son is better; whose is worse (A19; Ke p. 7, lines 105-111)? He told me that people think he leads the best life and had the best fate because his son is the best among peers. When I asked one elderly woman with an amputation what she thinks about her quality of life, Mrs. Tsai said, T: It is really bad. Each of my sons lives separately, and they do not live nearby. ...I live with my granddaughter. She has had no mother since she was young. I raised her. She is married and she did not want me to leave and live with my son. I still live with her now. My granddaughter is filial. Her husband also shows his filial obedience for me. If something happens to me, they drive me to the hospital. Y: Do you feel satisfied about yourself? T: How to say that? How can I be satisfied? If my sons come (I say it for us to laugh), they take care o f me like taking care o f a chicken. Fortunately, my granddaughter is really filial (B003 Female; Tsai pp. 3-4, lines 42-47, 54-56). Mrs. Tsai description o f her sons taking care of her like she is a chicken suggests that they are infrequent and careless in their ministrations to her. Although she stated that her granddaughter is really filial and takes good care o f her, the relationship between her and her sons and the degree her sons care about her still is the most important factor in her perception of her quality o f life. One veteran who has his own family and does not live in the Veterans’ Home thinks that his wife is more important than his children. He explained the importance of the family relationship and gave an example of how a family relationship is better R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 103 than medicine for curing. I asked him his own view of the veterans who have families and those who do not get married. He stated, C: Old veterans are lonely when they are at this age. No matter where he lives, in the veteran’s home or somewhere else, there is no partner accompanying him. We say that “A young couple becomes good companions in old age.” ... No matter how good the welfare from the government is, they do not have their partners. Therefore they might have some sad feelings. Sad that how their time has passed and everything cannot be changed. Like this, we are telling the truth, the elderly people...you think that the older veterans are there being quiet, there are some negative effects. We [married people], at least, no matter what happens, even if your partner thinks you are unhappy; she will take care of you. You want to eat something, and she will cook for you. In the Veteran’s Home, it is a group life, right? When we [people with family] go to sleep and we fall asleep, our children will not dare to make noise. But in the veterans’ home, it is different. This one sleeps, but that one snores. They have their own sad side. [It is] not one hundred percent like this in the veterans’ home, but generally speaking, it is like this. Therefore, I live simply. I am very satisfied. My children are filial, and my partner is taking good care of me (Type 2 A-3 Veterans not living in veterans’ home; Chang pp. 10-12, lines 202-246). Then he described the importance of family relationships, Y: So you feel that family is important to elderly people? C: It is extremely important. The family affection inside is better than any medicine. Y: Taking medicine? C : Taking medicine. It is better than taking medicine. When you feel bad, you said taking some medicine. You see your children and feel happy, and then you recover pretty soon. Really. The natural affection for one’ s family is priceless. You cannot use money for comparison. [If] I spent $100 and ask you to show your filial obedience a little bit for me; do you want to do it? Y: The feeling is different. C: Yes. The family affection is priceless. It cannot be bought by spending money. When you are my age, you will feel that it is really important. Young couples have fights and quarrels with each other. They have a quarrel at the head of bed and then make up at the end of bed. When I get older, I am not willing to talk loudly. I am afraid that she [my wife] feels bad and complains that I talk too loud. I consider her situation. She also thinks about me like if I did not have good appetite tonight when I ate dinner and so on. A young couple will become good companions in old age. This should be R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 0 4 highly treasured. Right now in the industrial society, your children leave home early and go back late. Who takes care of you? This is reality. I have four children. I do not see them. What could I do? They need to make money. Y: They have their own lives C: Yes. They cannot say that they need to depend on me. If they depend on me they have nothing to eat. Therefore, regarding family affection, people getting older really need a companion (Type 2 A-3 Veterans not living in veterans’ home; Chang pp. 10-12, lines 202-246). First, he mentioned that veterans are lonely because most of them do not have partners. Second, he mentioned that family affection is priceless and is more effective than taking medicine to improve psychological well-being. Next, he mentioned that through the development of our industrial society, the family structure changed from the extended family to the core (small) family. Hence, his partner is his good companion in old age. In the Taiwanese industrial society, married children do not always live with their parents. Many young couples choose to live by themselves. The changes in society also change elders’ ways of viewing family relationships and their life quality. Because of this societal change, in the future, elderly people in Taiwan may feel that partners and friends are more important than their relationship with their children. However, in this sample, most of the veterans had not married and thus may have had a different view o f family relationships and quality o f life. Introduction of veterans in Taiwan. In order to provide more understanding o f the interview findings and veterans’ quality of life, this section presents an introduction about the veterans in Taiwan. Veterans are groups o f people who have their own special political, social, and cultural background. The Veterans’ Homes are R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 105 specific long-term care facilities supported by the government. The Taiwanese government has built 14 Veterans’ Homes located in different areas to take care of aged, disabled and pensioned veterans, most of whom in this age group were members of the Nationalist army o f China who came to Taiwan after their loss of control of the mainland. Many veterans who live in the Veterans’ Homes have never been married. As to the veteran participants in this study, some o f them may still have family in Mainland China, where they sometimes visit. A few got married and have family members outside of the Veterans’ Homes in Taiwan. They moved to the Veterans’ Home after their amputation surgery when they needed care. People who live in the Veterans’ Homes are free to go where they please, as long as they tell the staff where they are going and if they will be absent for a long period of time. Each veteran under Veterans’ Home care is given NT $13,100 (US $385) per month. Those who have higher officer levels receive more income from the government. As an outsider who has never been part o f the military service, I was surprised by some aspects of their military culture, especially their dining culture, when I first went to one of Veterans’ Homes. In the Veterans’ Home, they have their own daily routine and the schedule of mealtime is quite different from people who do not live in Veterans’ homes. They have their breakfast at around 4:00 a.m., lunch at 11:00a.m., and dinner at 4 p.m. When mealtime is coming, people prepare their own eating utilities (chopstick and bowl) and go to the big dining room. The nursing aides send meals to those people who cannot walk to the dining room. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 106 Veterans were grouped into different buildings and floors. They have special appellations for the grouping, as in the military. Those who have had amputations are usually those who need more care. Nursing stuff and aides are usually with this group. The ratio of nursing aides and veterans is 1:8. Veterans with amputation usually stay in a big room located on the first level of the building and usually two to six people sleep in the same area, separated by short partitions. Each veteran has his own single bed with one small cabinet. There were only two veterans of the participants in my study who lived in single bedrooms by themselves, and they had higher military ranks. The restrooms are down the hall and the shower is a partly open area without a door. One nurse explained that the facility had been evaluated by a long term care organization, which is required by the government. Occupational therapist evaluators suggested they adapt their environment to make a disability free environment and also provide more personal privacy among the residents. Therefore, they added curtains between beds in order to keep more privacy. But many veterans complained they did not like it, so they moved all the curtains out. In Taiwanese society, many non-veteran elders live with their family, especially when they have a disability and need people to take care o f them. Few people choose to live at an institution. I interviewed one nonveteran participant who lives in a nursing home because he thought a nursing home could take good care o f him and he had no family to take care o f him. One o f his relatives also lived in the same nursing home. He stated, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 0 7 W : I lived by myself. There is no one... no one. ..So I live in the nursing home. Since I left the hospital, I have already lived in the nursing home for several months. ... The ladies in the nursing home take care of me. I spend my money and they can earn the money. One month is NT $22,000 [US $647], Y: Who pays the $22,000? W: I pay it. I need to find a way to pay it... I got worker insurance retirement fees around $5,000,000 [US $ 147,000] in 1999. I also saved money for my grandchildren. Each o f them got 5,000,000. ...I left around 3,000,000 [US $ 88,235] for myself. Now [that I have had an amputation], I already spent much money, I need to save my pocket. I do not earn any money now. I am not able to make money. There is only $3,000 [US $88] per month from the government for the elders. There is a lady from Mainland China who asked me to marry her. She said that she will ran a beef noodle soup restaurant and she asked me to rent a house and take care o f some things. She would like to accompany me all my life, until old, until forever. She has three sons and now she is 54 years old. Her sister married my friend who is a veteran and she always told me that her sister is good and asked me to go to Mainland China to marry her and bring her to Taiwan (A 20; Wang pp. 2-3, lines 18-48). Non-veteran elderly citizens receive only US $88 per month from the government, compared to the US $385 that the veterans receive. He would not be able to pay the monthly nursing home fee using only the money from the government. He couldn’ t afford it if he didn’t have lots of savings. He was considering getting married so that the woman can take care of him. It is common that the elderly, especially old veterans marry ladies from Mainland China so that they have someone for company and with whom they can build a family relationship. To an elderly person who has had an amputation, it seems that although people in the nursing home take good care for him, the desire for family affection or to have a companion is still important. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 0 8 In addition to family members, veterans in this study spoke about feeling close to other veterans who live together. One veteran described how relationships with other veterans were important for his quality o f life. Y: How do you feel about your quality o f life? S: My life is OK. Everyone has the same life here. Here, everyone is pretty good. It is enough. I am happy. Y: Can you explain more? What kind o f things you do make you happy? S: Everyone is all together. When I turn around, we can see each other. Time goes by (A 14 Veteran; Su p. 5, lines 86-91). When he said that everyone has the same life, he pointed out the nature o f that group life in the Veterans’ Home. However, with that group life, he saw other veterans living in the Veterans’ Homes as his buddies and almost his family. In summary, participants in this study have strong thoughts about their relationships with other people such as family or peers. Their relationships with family play an important role in their view o f their quality o f life. They gave many examples to describe what these social relationships mean to them and how the relationship might influence their well-being. Material Life Material objects such as money and food are also related to the amputee’s quality of life. Money can limit or expand one’s occupational choices. Mr. Sun pointed out that money is related to his life satisfaction. I need to have money in order to buy things, go to see a doctor or do something else. If I do not have money, I cannot do anything. How can I be satisfied (CD A17; Sun p. 1, lines 2-6)? R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 0 9 As he mentioned, life satisfaction is related to money because having money allows him to engage in certain occupations. Money is related to obtaining and enjoying the basic survival elements such as food and medical care. It is also related to the freedom to be able to participate in activities and not worry about being unable to do activities because o f lack o f funds. Food/ Eating is often mentioned by some people as related to money and related to their quality of life. When I asked how Mr. Lai felt about his quality o f life, he stated, L : My quality o f life is good. Each of my children has families. Now I depend on them. I have food to eat... I have money to spend and I spend the money (Last one 002; Lai, p. 9 lines 193-197). Y: How would you rate your past life before amputation? Better than right now or worse? L : Past is better, when I ate by myself it was good... Right now is a little bit worse. Now my son takes care of me. I eat less. Mm... I ate by my self before. It is ok. It is about the same Y: Does your life have any difference after surgery? L: No. no. ... Both are good. My children already make money. I am pretty good, too. I have never lacked money (Last one 002; Lai pp. 14-15, lines 305-318). At first, when he tried to compare his quality o f life before and after amputation, he used meals as a criterion to judge his life quality. Having had more freedom to be able to choose what he wanted to eat was the very first thing that came to mind when he rated his quality of life, although he later mentioned that money is related to his quality of life. Money is related to food and is a very basic way for people to describe their life, especially when they do not have much money with which to live. Being R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 1 0 able to eat full and well is a basic component for them to view their life quality. An elderly woman talked about money relating to her quality of life. Y: Do you feel that the quality o f life is better when you have money and without money, quality of life is worse? L: Of course, it is worse when I have no money. If I have money I can go to play everywhere. My children make money. They come back and give it to me. If they do not make money, how can they be able to give it to me? Then we should save money and eat economically. We can eat full eveiy meal, have fruits to eat, have dishes and have money to buy food. Right now, they do not have anything to do and do not have jobs. We use money economically. ... Life is hard to explain. They do not have a regular salary. If you have regular income, it is fine. Sometimes, they make more money and sometimes they make less money. You cannot ask too much and ask how much money they need to give to me every month. ... Human beings should take the world as it is and if we can get along, it is fine. My children make money and life can kind o f get along is fine (Type 2 A4 Female; Li p. 10, lines 202-216). Money is not only related to some basic survival components; material objects can further relate to life satisfaction and security for some people. She described the unstable economic status, which limited occupation (play) and resulted in a low quality of life. However, she is presently content with her life. It is enough if her family can eat full and her children can make enough for the family to live. Her statements in describing quality of life thus combine life attitudes, relationships with family, and relationships with material objects. The Aging Process. Not only Amputation. Influences Quality o f Life Some participants also mentioned that the aging process, not only amputation, influences their life quality. The overall aging degeneration also limited the way they can engage in occupations. For example, Mr. Jing, who rated his health related quality R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. I ll of life score as 70 after Ms amputation and before amputation as 90, explained why his quality of life decreased as he aged: J : I cannot walk. ...I am getting older. I am 80 years old. I am getting older. It is inconvenient, so I am not satisfied. My eyes cannot see very clear. Inside the house is ok, but when I go outside, I cannot see it clear under the sunshine (B0003 Veteran; Jing p. 3, lines 44-54). Another veteran described these feelings in a similar way. He had an amputation 20 years ago and he is able to wear a prosthesis and take care of himself. When I interviewed him about the quality o f life scores he reported a score o f 100 before the amputation and 85 after. He stated: “At tMs moment I am old. I am old and my body has declined. I am not as strong as before” (A14 Veteran; Su p. 11, line 184). It is probable that people who already have had an amputation for so many years, do not view their amputation as the most important part o f loss. It is not only amputation surgery that results in their rating o f their quality of life being lower after the amputation. For those people who have amputations, there are still many other aging processes which deteriorate their bodies and wMch influence their quality o f life. How Amputation Changes Quality of Life and Occupation When I asked people how amputation changed their quality o f life, they often use occupational engagement as an example to show how their quality of life has changed. I am not able to find a line to distinguish between how amputation changed quality of life and how amputation changed occupation. Their statements provide many examples that enforce that occupation is related to their quality o f life. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 112 Mobility is a Basic Component for Occupation For many elderly people with amputations, mobility is more or less limited. Many people stated that, after their amputation, they could not go to places they once enjoyed. They could not attend the leisure activities they engaged in before. For example one veteran, Mr. Yao Yao: The difference in my life between before amputation and after amputation is that I had two legs to move and walk. I could talk a walk in the morning. I could go to the park or somewhere. Now I need to push the wheelchair. I cannot go too far. Mobility is related to engagement in occupation. For some people, outdoor occupations are limited. There is less freedom for them to go out and engage in occupation. The scope of occupation is limited. This veteran further described, If I go to the yard, I will not be able to come back with my wheelchair because there is one step there. I am sad.... In the veterans’ home everyone is all the same. No one cares about you. If I want to drink some water, I need to say some nice words. ... Although it is such a small thing, it requires strenuous efforts. ...It is not easy. If it were easy, it would not bother me. I have no legs and it bothers me. Even though I have a prosthesis, can I walk? It is not easy. If I go out, I will not be able to come back. I have a wheelchair, but it cannot turn around. I am getting old. I do not have enough strength to push my wheelchair (Tapel A2 Veteran; Yao pp. 4-5, lines 74-94). Mobility is related to basic activities o f daily life. When he needs help for his basic activities o f daily living, his dignity and emotional well-being are influenced. Because o f mobility’s strong influence on occupational engagement, the limited occupation impacts life satisfaction. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 1 3 Leisure and Social Activities After an amputation, not only are the mobility and functional statuses limited but also many other leisure activities as well. Many people reported that they do not perform any meaningful activities in their daily life except watching TV, chatting with friends, and dining. Some people said that before their amputation, they went fishing, went to temples, or went traveling, but after their amputation, the outdoor leisure activities were limited. When I asked one veteran why he thinks that before amputation, his quality o f life was better than right now, he stated, C : Because I was able to do activities. I was able to do everything. Now I do not have the strengths to do activities. In the past, I took a walk or went mountain climbing every morning when I woke up. My life was cheerful. After amputation I do not do it anymore. Y: What are other differences between before and after amputation? C : I think it is related to many different aspects. I isolate m yself because I can't make it. Sometimes I couldn't join my friends’ parties, or sometimes my friends invited me to join them, I still couldn't make it. It made a huge difference (Type 2 A-3 Veteran not living in veterans’ home; Chang pp. 5-6, lines 107-131). He said that the amputation has influenced him in many different aspects, not only in functional mobility, but also in preventing him from attending social events. Engaging in occupations, especially leisure and social activities can influence one’s mental well-being. Mr. Ke also mentioned that, Y: Does the surgery influence you to attend some social activities? K : Yes, it does. Y: To what extent? K: Because if now some people get married or die... I don’t attend any weddings or funeral gatherings now. Y: Why not? K: I have the sense o f inferiority (A19; Ke p. 10, lines 162-170). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 114 I asked how he rated his quality of life score both o f the life before amputation and at present. He stated, K: 105, more than 100. Y: You were very satisfied with the life at that time. K: Yes, I was. Y: Why it is 90 now but 100 before? K: My leg was cut so I have sense o f inferiority. Y: What do you mean by sense of inferiority? K; There’s an air garden and a leisure center on the third floor in my buildings. But I am embarrassed to go down there. Y: You mean you feel embarrassed with the interaction between you and your neighbors? K: lam afraid that people will laugh at my son that his father has only one leg left (A19; Ke p. 21, lines 344-352). He used limited engagement in social and leisure activities as examples to illustrate his sense o f inferiority. He considered his son’s social life and does not want his son to lose face in public because of his father’s disability. He gave more examples, K: Now my son doesn’t allow me to ride motorcycles. He said wherever I want to go, I can take a taxi. He will pay for the fare. ...He said if there’s anything happen to me. He will feel shameful... [He started to cry], Y: Why is it? K: He thinks that he takes care of the elders, and the care is so miserable. [Stop crying], I have a best friend. I went to see him. He was a farmer. He had some insecticides. He hired an aide and he asked the aide to push [his wheelchair] him to the farm. He considered committing suicide by drinking the insecticides. Later on, he considered it and said: Then people in the village will say that his son is not filial, so that his father committed suicide. Otherwise, right now, he cannot walk and he cannot move his arm (A19; Ke pp. 15-16, lines 252-262). His examples show that father-son relationships are influenced by the social expectations of Taiwanese culture. Because family relationship is important to many elderly people, they are not only concerned about themselves, but also are concerned R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 1 5 about their families. The sense of self is related to considerations o f other and personal occupational engagements. Relationships with Others Many people mentioned relationships with others as an important way in which they view their quality o f life. After an amputation, interaction and relationships with others might change. It is difficult for them to keep relationships with other people because of limited occupational engagement. Some people do not want people aware that they had amputation surgery. For example, Mrs. Pu stated, “ If they know, they will buy stuff to see me. I do not want that” (CD A18 Female; Pu p. 2, lines 30-33). She did not want to owe for other’s gifts and care. However, a few elderly participants reported that after amputation surgery they feel that family and friend treated them better than before. The following interview7 as an example o f how one’s relationship with others changed. Y: Do you feel that there are some obstructions with the interaction with your family or friends? L: No, no interference, even better... While I pass by either friends I know or I do to know, they all treat me pretty good. [My family] even shows more filial obedience for me. Y: Do you have many friends in your hometown? L: Yes. I will say it for us to laugh. Many friends and much dried milk. ... Many people return my money back. They borrowed money from me. Now I come back from the hospital. For those who did not return my money back in the past, they returned my money in a hurry (Last one 002; Lai pp. 5-6 lines 94-106). He lived by himself before he had his amputation. He mentioned that many friends returned his money fast, probably because his friends thought he would not live much longer. Now he lives with his family instead o f living alone in a small town. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 1 6 Because o f his amputation surgery, he has more opportunities to meet his friends and family. His family and friends show more o f their care for him after amputation. The amputation surgery has provided the opportunity for him to interact with other people and also for his family to show their filial piety. Even if elderly people with amputations do not use their prosthesis, they may still have a good quality o f life. From an occupational science perspective, people can adapt their life and make it meaningful through engaging in occupations (Frank, 1996; Wilcock, 1998). Having a good quality o f life does not depend only on prosthesis use, which enables function, but also on engagement in satisfying occupations. Thus, it seems occupational therapists should not only encourage the use of prosthesis, but also encourage engagement in occupations that are consistent with the elders’ position in the family and society. In summary, amputation changes one’s occupation and quality o f life in many different ways, including mobility, leisure/social activities and relationships with other people. When people said amputation has changed their occupation, they often mentioned their selfhood was related to social and cultural expectation. Elderly people with amputations present quality o f life is not always lower than before amputation; a few participants reported that they have the same quality o f life or even higher quality of life because o f more social support. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 1 7 How Prosthesis Usage Relates to Occupation Activities of Daily Living Prosthesis has been reported to be related to activities o f daily living including mobility: walking, standing, transferring, and weight bearing that are important in occupational engagement. Some people that use their prosthesis to aid in walking believe it is a part o f their body. Except for showering and sleeping, they wear it all day. For example, one veteran, Mr. Hu, said: “My prosthesis is so important to me. Without it, I cannot walk, I cannot go anywhere and I cannot do anything. Everyone is busy for work and no one helps me” (Type 1 A1 Veteran; Hu p. 3, lines 41-42). Because of the limited human resources in the veterans home, many veterans told me that they do all the self care activities by themselves such as taking on and off clothes, taking a shower, and washing clothes because there is no one to take care o f them. For some people who cannot use a prosthesis to walk, they still wear their prosthesis all day long in order to go to the toilet for weight bearing. Mr. Wang wears his prosthesis all the time until he goes to bed. When I asked him what kind o f things he thinks that prosthesis could help, he stated, Y: I wear prosthesis to go to the toilet. I am able to stand up when I wear the prosthesis with one hand support... [I need to use prosthesis] only when I go to the toilet. I do not use it for the others. Because it cannot walk, it is not useful (Tapel A2 Veteran; Yao pp. 10-11, lines 209-221). He goes to the toilet several times per day, so that he wears his prosthesis all the time for his convenience. His prosthesis provides mobility: standing, transfer and weight bearing which assist in daily living activities. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 118 Psychological Meaning Security. In additional to ADL, some people reported wearing a prosthesis for security. For example, Mr. Chang mentioned that he still could do things without the prosthesis at home, like taking a shower and moving around at home. However, his prosthesis provides him a great deal o f security when he walks. He is afraid of falling down when not using a prosthesis. He said that “ I always fear falling, when I walk without a prosthesis, I cannot one hundred percent trust m yself’ (Type 2 A-3 Veteran not living in veterans’ home; Chang p. 7, lines 147-148). In his mind, the meaning o f his prosthesis use is for security/safety. Self-esteem. A prosthesis is not only used for function, but also can be used for improving one’s self-esteem. Mr. Ke does not use the prosthesis at home because he has a disability-friendly environment at home. He thinks his prosthesis is too troublesome for him to wear because he needs to wear 8 socks for fitting with his prosthesis. He usually goes to the park to chat with his friends as his leisure and social activities. He pointed out that when he goes to the park he needs to use his prosthesis and walks well. K : I cannot lose face when I go to the park. ... There are many ladies on the street who always stand there; do you know what I mean? ... In the past I was part o f the underworld.... If I went there and made a fool of myself, people will laugh at me and say lama lame (T004005; Ke pp. 4-5, lines 74- 92). He is proud o f himself for being able to walk again after amputation surgery. His prosthesis provides him with a way to show other people that he is a tough man who has not been beaten by surgery. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 119 In Chapter 24iterature review, French (1994) stated that other people in the Cambodian society did not respect men with amputation. Friedman (1978) also wrote that people with amputation feel it is hard to deal with people. Mr. Ke reported that a taxi did not want to give him a ride when he was in his wheelchair. K: when I was in my wheelchair, some tax drivers who do not know me said that they do not want to drive for those people who sit in the wheelchair. They said that it is troublesome for them. They need to put the wheelchair in the back trunk. Sometimes they have something inside and do not have enough space for the wheelchair. I do not believe that they would not drive me. If he said NT $100 (US$ 3), I would give him NT $100 more. I gave double price. Many taxi drivers were all eager to drive me. I wear my prosthesis now.... They cannot tell. ... They are all very polite. ... Now the taxi drivers are all eager to drive me. Nobody refuses it. Some drivers refused to drive me when I was in my wheelchair in the beginning (TO O 40O 5; Ke pp.7-8, lines 138-166). There is no tip culture in Taiwan. When he was in the wheelchair, he pays double in order to attract taxi drivers and build positive relationship with them. By using prosthesis, his amputation became “invisible”. Prosthesis has therefore been seen as an artifact, which influences both the amputees life and others thoughts about disability. Prosthesis use has provided self-confidence and also self-esteem for him. Although many elderly people reported that prosthesis use has helped them to do many daily activities, there are many participants who do not use their prosthesis all the time in their daily life. They complained that their prosthesis is too heavy, inflexible, a poor fit, or just not the same as their real leg. They used other adaptive devices such as wheelchairs for mobility. In summary, the elderly people with amputations who participated in this study offer much information about their view o f their quality o f life and daily occupations. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 120 This chapter presented the interview findings that show various participants’ points o f view relating to generic (not amputee related) quality of life factors. The chapter also shows how amputation changed their occupation and quality o f life and shows how prosthesis use relates to occupation and the meaning of prosthesis use. Prosthesis use can help people with amputation to engage in daily activities. For some people it also provides security and builds self-confidence. The following chapter will present the interview findings related to the quantitative findings. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 121 Chapter 7 - Interview Findings Related to Quantitative Findings The interview themes of factors influencing quality of life are similar to the culturally specific questions added to the WHOQOL-10O Taiwan version. The 12 cultural specific questions were listed in Table 1 and had five themes: (1) personal relationship, (2) actual social support, (3) spiritual ritual and person’s beliefs, (4) respect and acceptance, and (5) diet. From the interview findings in this study, the life attitude theme is related to the spiritual ritual and person’s beliefs in the WHOQOL- 100 Taiwan questions; The relationship with family is related to the personal relationship/social support and respect and acceptance; The material life, which included food, is related to the diet. Those connections validate the interview findings in this study for the generic quality of life factors for this population. According to interview data reported previously in Chapter 6, many elders who have had amputations believe the relationship with their family (son, wife) or peers is the basis of their quality of life. This qualitative finding supports the quantitative finding that higher social support is significantly related to having a higher quality of life. It further demonstrates how important the relationship with family/other people is for this group o f people. Jackson (1996) stated that older people used adaptive strategies to continue, through their life changes, different themes such as family bonds and social greetings to reconstitute their life after disability. How to maintain continuity in elders’ life was not something that I asked about specifically, but the clear themes o f family relationship/social connection in my data reflect the importance for the elders in R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 2 2 different culture. However, Taiwanese culture has much more emphasis on family relationships than most Caucasian cultures. The family relationship and social connect were strongly thought by elderly amputees to be directly related to their happiness, self-identity, and quality o f life. In the quantitative study, there was no statistical relationship found between family income and quality of life; however, many interviewees stressed that money is important to their quality o f life. It is possible to infer that family income (the quantitative measure used) does not represent the money those people have available. It is also possible that even though they said that money could influence quality o f life, they might be satisfied with what they have right now. Possible, the amount of money available needs merely to be sufficient for a basic economic security. It might also be that even those who are poor do not necessarily perceive that they have a lower quality of life relative to their expectations. Although the level o f amputation was not found to be statistically related to time spent wearing the prosthesis and only showed statistical significance for the physical domain of both the quality o f life measures, many participants mentioned that the level of amputation could make a difference in their wearing prosthesis and engaging in occupation. One veteran who first had a below knee amputation and then, later had an above knee amputation said, “I was able to walk when I had only below the knee amputation. I could ride motorcycles and I could ride bicycles. Everything was ok. I had no problems going on the streets. However, with the above knee amputation, it is impossible to do it” (Tapel A2 Veteran; Yao pp. 15-16, lines 320-322). The active R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 123 control of the natural knee joint is important to enable him to perform activities. Without the knee joint, it takes much more of an effort to do things. With the above knee amputation, he needs to leam to control the artificial knee joint It is more difficult for people who have above knee amputation than people who have below knee amputation to wear their prostheses and use it for many daily occupations. Perhaps, because the small number of people with above knee amputations was not sufficient for statistical testing alone, the quantitative results did not reflect the extent o f the difference reflected by the interview data in effect of level o f amputation. It make sense that when less of the lower extremity that has been amputated, it is easier to use and wear a prosthesis more hours each day for engaging in occupation. However, one veteran mentioned that because he had bilateral amputation, he needs to wear his prostheses everyday, otherwise he cannot move at all. Therefore, prosthesis use might be related not only to ease of use, but also to other factors in addition to level o f amputation. Prosthesis use might be related to their physical condition/strength, caregiver’s assistance and the environment, any o f which might provide alternatives to its use, or the lack of which might require the use of a prosthesis for even basic movement activities. Prosthesis use and perceived quality of life may also be related to the quality o f the prosthesis or the fitting o f their stump with their socket o f the prosthesis, where discomfort and pain affects a reduction in both. Some Taiwanese elders with amputation did not score a level o f satisfaction that seemed to directly correlate with their comments. This may be related to scoring bias, R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 124 either positive (everything is as good as can be expected [and not much can be expected]) or negative (nothing can be that good). For example, a few people did not score as if they were very satisfied with their life even though in the interview they explained why they thought they had good lives. When I asked people to rate their level of satisfaction, one participant told me that it was impossible for a that human being to be one-hundred percent satisfied with everything. So he thinks that even though he has a very good life quality, instead o f rating a 100 score, he told me he would only rate it an 80 scores. For this reason, both quantitative measures, for group comparisons, and qualitative interviews for individual meaning may be useful to the researcher’s understanding. As mentioned in Chapter 2, Wang et al. (2001) used the SF-36 to evaluate quality o f life differences among Taiwanese headache study participants. He pointed out that many Chinese people would not rate their health as excellent even when it is because they are afraid god will punish them for boasting about their good health. However, I asked a participant why he filled out “very satisfied” instead of “extremely satisfied” on every item in the instruments, he stated, G : The best ...I think it is impossible to be the best. If it is already the best, there is no room to improve. Maybe I can be better. ... To be able to be satisfied is the most important thing. Actually it means to be content with what I already have. Although it may not be good from the point o f view of others, at least I know how to be content with myself. The extreme satisfaction already reaches the maximum. My emotion cannot always keep the same. Sometimes something may happen to me. My first feeling is why it happens to me. Then my emotion and thought change after. So I would not say that I am extremely satisfied with everything (Type 2; Gi pp. 8-10, lines 135-160). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 125 Different from Wang et al. (2O01)’s finding that participant’s were wary in rating to avoid punishment from god, this participant mentioned that he should be content with what he has. Because his emotion may fluctuate through time, in order to express the actual feeing that he had in a big picture, he rated a lower level of “very satisfied” instead o f rating the “extremely satisfied”. Not every participant is like him, not rating the “extremely” level, but his statements showed his perspective about why he choose not to use that level. An interesting quantitative finding was that one item was only marginally correlated with other items in the same scale. The interviews show that this item includes occupations in which they do not engage often. The question: “Are you satisfied with your sexual life?” is one of the questions in the social relationship domain in the WHOQOL-BREF Taiwan. More than half o f participants rated the middle level-“moderately satisfied”. Some interviewees told me that they have not had a sexual life for many years or their partner died a long time ago and they do not know how to rate the level of satisfaction. I often needed to ask further before they would share their feelings about it. The following interview shows the dialogue between one participant and me. C : I do not have any sexual life now'. I have not had a sexual life for many years already. Y: Were you satisfied with it? C: Yes. I was very satisfied. I am still satisfied now. Y: How do you feel about it right now? For example, right now you do not have it, how do you feel? C: I don’t mind. We are a couple, one sleeps here and the other sleeps there. We have already separated from each other [in bed] for a long time (Type 2 A-3 Veteran not living in veterans’ home; Chang p. 4, lines 79-88). R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 126 Many elderly stated that they do not have sexual lives anymore. They seem to mean that their sexual life does not include intercourse. Even though they do not have it, some o f them still feel satisfied. However, some people would rate being less satisfied because they are sexually inactive. There are some occupations, for example, sex, work, and running, that elderly people are generally less engaged in their daily lives than younger adults might be, but those occupations are used as part of the questions for generic quality o f life instruments. Elders might just choose the middle level, which does not necessarily reflect their actual engagement in or desire for engagement in these occupations. When researchers interpret the quantitative results, they should not only read the summary or domain scores, but also they should consider each item in order to understand more comprehensively o f the participants. In summaiy, through interviews, the participants in this study offered their experiences to better illustrate the quantitative results. The interview findings provide more ways to interpret the results o f the generic quality of life measures based on individual’s point o f view. Using both methods of research has provided a better understanding of this group of elderly Taiwanese people with amputations. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 2 7 Chapter 8 ■ Implications, Recommendations and Conclusion Implications Elders with Amputation in Taiwan Two research methods were used in this dissertation with a group of elderly individuals with amputation in order to understand their quality o f life and prosthesis use as occupational beings. Both the quantitative results and interview findings demonstrate that more social support is related to higher quality o f life. Wilcock (1998) suggests social well-being can be described as satisfying interpersonal relationships by interacting happily and effectively with other people. This study found that social well-being for Taiwanese elders with amputation was not only related to relationships with other people (especially sons, wives or friends), but also to respect from others, and to the quality of support and care received from other family members or society in general. Many participants mentioned that their mobility has been limited due to the loss o f a limb(s). Their occupational choices were limited because o f the mobility that is a basic component o f much occupational engagement. In addition, some people may suffer from a loss of self-esteem as a result of amputation and try to avoid social occupations. To engage in an occupation, the use of a prosthesis is important for some amputees because it not only serves to restore function, but also provides psychological meaning: feeling able-bodied instead o f disabled, or secure and in control, instead o f fearful of falling. Their prosthesis can be an artifact to support self identity and influence social interaction. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 128 In Taiwan, there are only a few big hospitals have departments for constructing prostheses. In the past, people went to such big hospitals for the amputation where health care personnel (OT, PT, Nurse, Physician) were available for the pre-prosthesis and post-prosthesis consultation and rehabilitation. During the current study, because there were many prosthesis companies competing outside o f the hospital, they provided their own prosthetists and had sales personnel to persuade clients to visit the prosthesis company after an amputation. Most of the prosthesis companies provided clients with free accommodations or free transportation to those clients who live at home while being fitted for their prosthesis and undergoing rehabilitation. There are only a few people who went to the big hospital to have their prosthesis measured, made, fit and trained. The exceptions are amputees who are veterans who went to the Veterans’ General Hospital, where they receive free health care and accommodations from the medical team. The employees o f prosthesis companies who provide prosthesis training are not trained in OT or PT. Because o f further cost concerns, people with amputation receive only short-term prosthesis training from the prosthesis company. Once they finish their training in basic prosthesis use, such as putting on the prosthesis and initial walking, the service that the prosthesis company provides to the clients is completed. The occupational practices, such as walking while carrying things or for engaging in occupation that would be provided by occupational therapy are not standard training when provided by prosthesis companies. Consequently, elderly people with amputation often need to develop adaptive strategies on their own, to fit their lives and R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 129 environment. Furthermore, the current amputee treatment system in Taiwan does not focus on the family support/social support that was found to be the predictor of quality o f life for amputees. These elders with amputation should not only have prosthesis making or basic prosthesis training, but also have the rehabilitation training provided by OT in order to have a completed training. Since occupational therapy provides a more comprehensive view of prosthesis use in daily occupations, training by OT would assure elderly amputees receive comprehensive training. In addition, occupational therapists are able to provide services to increase social well-being, which was found to be associated with quality of life for elders with amputation, an area which has not received much attention in the past. If occupational therapists could be involved more with this part, at which we used to focus slightly, we might do a better job than any other medical personnel and will be most beneficial for those participants. In summary I make the following points: First, OT should more involved in working with this group of people. Prosthesis companies should collaborate with their services with the OT Departments in hospitals or hire individual occupational therapists in order to provide a good health care. A referral system among the health care personnel (Physician, therapist and prosthetist) and occupational therapy post amputation follow up evaluation and treatment should also be established for this population. In addition, occupational therapists and other health care personnel should also leam more about this population in order to provide good health care. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 130 Secondly, OT should look at the social support more. Traditionally, health care personnel who work with people with amputation tend to view the level o f amputation and the functional skills of the individual as the most important factors for their quality of life. Occupational therapists traditionally teach people with amputation to use their prosthesis and/or adapt their environment to achieve their physical independence. However, the findings from this study suggest the need to give greater consideration to social support. Aspects o f life such as availability and quality of social connections, interactions and the care and support by others have been shown to have more relationship to quality o f life than level of amputation. It is also important that occupational therapists view elders with amputation as occupational beings who may be able to improve well-being by practicing a range of socially valued occupations and to by increasing their awareness o f the relationship of social activities and health (Wilcock, 1998). The Veterans Homes in Taiwan would be great places for occupational therapists to start lifestyle redesign programs. Some veterans participating in this study do not have many activities to engage in and do not know how to manage their daily routines. Some elderly veterans with amputation feel depressed about their disability. Instead of leaving them alone to do as little as they want to do, occupational therapy can assist them in designing meaningful occupations in which to engage and enjoy to increase their quality of life. Many veterans with amputation in this study felt that no one cares for them. Therefore, it seems the quality of quantity o f care in the veterans’ homes could be R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 131 improved. Quality of care includes the attitude toward the veterans and how holistic the view of multiple of aspects of care of the caregiver. Some veterans live in the Veterans Homes without family affection support. The attitude of caring from the caregiver is therefore important. People who take care of these elderly veterans should demonstrate more care and concern for all the well-being, physical, psychological, and social, of the veterans. Quantity of care includes the numbers of the nursing aides and other health care personnel and how much time they spent on each individual. The number of staff and the amount of time per amputee should also be increased in order to provide a better health care. Furthermore, Veterans’ Home can also create a better “home” environment for those elderly veterans by adding furniture and using interior design to create the feeling of a home environment. Engaging in activities together can be instrumental in fostering affection among veterans and creating a feeling of family and belonging. In the near future, it may not be possible for all children to care for parents. In this case, the community and government might need to take more responsibility in caring for elders, especially when they have disability and are unable to take care for themselves. Due to the influence of traditional Chinese culture, many elders may still hope to live with their children, as had been the expectation in the past. An elderly day care health care facility, where elders are cared for during the day, would be a good compromise way for the family to be able to meet parental obligations in spite of two jobs. Many other different levels of facilities such as senior apartments, assisted R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 3 2 living sites or nursing homes should also well-established to meet different people’s needs given the rapid changes o f Taiwanese society. Because of the advanced age of many of its current residents, the number of veterans living in Veterans’ Home would have decreased significantly twenty years in the future. Veterans Homes would need to consider to change their goals, perhaps as government means to serve non-veterans population of Taiwan. The fourteen Veterans’ Homes located around Taiwan were already equipped with many of the requirements, such as space and human resources, to become major long term care facilities for Taiwanese elders with or without disability. These efforts will require government regulation and collaboration with health insurance in order to provide an entire long term care system for elders with disability. Quality of Life Measures I used two different instruments to measure health related quality of life, the SF- 36 Taiwan and WHOQOL-BREF Taiwan, for two reasons. The first was to show that the findings are consistent across the two scales and are not artifacts of one particular scale. The other purpose was to validate the use o f the scales among this population. The results showed that these two measures capture different areas but also were significantly and positively correlated with each other. Both measures also had acceptable internal consistency and item total correlations with this sample of elderly people with amputation. The two generic life quality measures demonstrate qualities of validity and reliability for their use in this group of Taiwanese. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 3 3 Since researchers in every field can use life quality instruments, how should occupational science researchers and occupational therapists view them differently from others? To occupational scientists and therapists, the two quality of life measures include numerous items related to occupation. They inherently explore what the form, function and meaning of occupations means to the respondent. These two quality of life measures include whether respondents can engage in some occupations and their satisfaction with their performance o f those occupations. By adding our occupational focus when we look at such a standard measure, better understanding of the interaction between the occupation and life quality is reached. For occupational science researchers and occupational therapists, interviews should also be added to the quality o f life measures. Interviews support the idea that it is important to explore the individual’s quality of life using the client’s self reported health status, and to avoid judgment based solely on standard quantitative quality o f life measures. Interviews provide a more comprehensive method to know a person. Furthermore, individual interviews are closely aligned with the main values of occupational science and therapy: the importance o f individual differences and the view o f humans as occupational beings. By using both the quantitative and interview measures, occupational therapy is able to learn more about the life quality of clients by using an occupational point o f view. Limitations The limitations of the quantitative study findings include the lack of completed normative data that could be compared with this study’s data. There is a lack of R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 134 normative data for people above age 70 in the WHOQOL norm data. The WHOQOL- Taiwan group was unable to provide detailed demographic information about the available normative and the diabetic samples. In addition, there is no Taiwanese normative data for the SF 36 that this study could use for comparison. Therefore, it was not possible to make all the quantitative comparisons that would have been desired. The generalization o f the findings is also limited at this time due to these omissions. The limited number of sessions and length of time o f the interviews could be considered as another limitation o f this study. For a more comprehensive understanding o f the exact and in depth meaning o f what the interviewees thought and said, spending more interview time might have helped. Directions for Future Research The mean age of the participants in this study was over 70 years old; however, there was no normative data for the WHOQOL-BREF Taiwan for people in that age group and none for the SF-36. Future research should add to the amount o f Taiwanese normative data among older age by using these two quality of life measures. This data would assist in a better understanding o f the quality o f life in old age and how aging influences life quality. Future studies conducted about the quality of life with elderly Taiwanese suffering from different diseases would provide information that will provide medical and health care providers with a greater understanding of how other diseases influence quality of life differently for this age group. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 135 While conducting this study, I found that some elderly people needed to respond to oral versions of quality of life measures. Future studies may develop a standardized structure interview format of quality o f life measures both in Taiwanese and Mandarin to accommodate people who cannot read. Perhaps a standardized structured interview format (almost like a verbal questionnaire, where language is more simple and casual) might be considered. The SF-36 health survey manual and interpretation guide (2002) indicates that the SF-36 can be administered in many other forms including telephone interview, mail questionnaires and face-to-face interviews. The SF-36 can also be included as one part of a longer interview, questionnaire or other data collection effort. There is a standard interview script for the telephone and face-to-face interview administration of the SF-36 in the English version but not in Mandarin at this point. The WHOQOL Taiwan group indicated in the user manual of the WHOQOL-BREF Taiwan that they are going to develop a Taiwanese version o f WHOQOL version (WHOQOL-Taiwan Group, 1999). However, further information about this was not available yet. Another suggestion is that occupational scientists involved in future studies allow more interview sessions and longer time periods for the purpose o f knowing more about the meaning o f occupation and quality of life. Meaning is often complex and is combined with many other phenomena. Other kinds o f qualitative methods such as focus groups, narrative research, occupational storytelling and story making may be used to explore different research questions and provide in depth understanding o f the R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 136 meaning and quality of life and prosthesis use for occupation by elders with amputation. This finding has illuminated the need for further research on how social well being is related to occupation in the field o f occupational science. Future studies can focus on social support in order to have a deeper understanding o f how occupational engagement influences social well-being and how it differs in diverse cultural backgrounds. Conclusion The findings in this study suggest that it is not only important that elders with amputation use their prosthesis to maintain their functional mobility, but also engage in occupations which maintain/increase social relationships in the family and the society. Occupational therapists can assist elderly people with amputation to experience a better quality o f life by increasing their opportunities to choose to perform desired occupations and to engage in satisfying and meaningful occupations. 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(1993) Short Form 36 (SF 36) Health Survey Questionnaire: Normative Data for Adults of Working Age. British Medical Journal. 306 (6890), 1437-1440. Keith, P.M. (1980). Life changes, leisure activities, and well-being among very old men and women. Activities. Adaptation & Aging. 1 (1), 67-75. Kraemer, H.C., & Thiemann, S. (1987). How many subjects? Statistical power analysis in research. Newbury Park, CA: Sage. Legro, M. W., Reiber, G. D., Smith, D. G., del Aguila, M., Larsen, J., & Boone, D. (1998). Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality o f life. Archives o f Physical Medicine & Rehabilitation. 79(8). 931-938. Li, R.M. (1994). Aging treads-Tai wan. Journal of cross cultural Gerontology. 9 (4), 389-402. Lu, J. (2001). SF-36 Taiwan Version. Retrieved August 27,2002, from http:// http://www.sQ6.cgu.edu.tw/english/main.htm. McGuire, F. A., Dottavio, D., & Leary, J. T. O. (1986). Constraint to participation in outdoor recreation across the life span: a nationwide study o f limitors and prohibitors. The Gerontological Society of America. 26(51 538-544. McWhinme, D. L., Gordon, A.C., Collin, J., Gray, D. W. R., S c Morrison, J. D. (1994). Rehabilitation outcome 5 years after 100 lower-limb amputations. British Journal o f Surgery. 8 1 .1596-1599. Miller, C. (2001). The relationship between body-image, self-esteem, level of depression, and quality of life in elderly persons following lower limb amputation. Dissertation Abstracts International. 62(05). 2290B. (UMI No. 3015998) National statistic (2002). The general situation of index o f livelihood of national causes o f death in Taiwanese people in 2000. Retrieved May 2,2002, from fa ttp .V /www.dgbasev. gov.tw/dgbas03/bs3/analvse/new91031 .htro. Nielsen, C (2000). Etiology o f amputation. In M. Lausardi & C. Nielsen (Eds.), Orthotics and Prosthetics in Rehabilitation (pp. 327-336). Boston: Butterworth- Heinemaim. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 141 Ory M.G., & Cox D.M. (1994). Forging Ahead: Linking Health and Behavior to Improving Quality of Life in Older People. Social Indicators Research. 3 3 .89- 120. Parkerson, G. R., Jr., Connis, R. T., Broadhead, W. E., Patrick, D. L., Taylor, T. R., & Tse, C. K. (1993). Disease-specific versus generic measurement of health- related quality of life in insulin-dependent diabetic patients. Medical Care. 31(7), 629-639. Pibemik-Okanovic, M. (2001). Psychometric properties o f the World Health Organisation quality o f life questionnaire (WHOQOL-lOO) in diabetic patients in Croatia. Diabetes Research & Clinical Practice - Supplement 51(2), 133- 143. Polit, D.F., & Hungler, B. P (1999). Nursing research: principles and methods (6 th ed.). New York: Lippincott. Reilly, M. (1962). Occupational therapy can be one of the great ideas of 20th century medicine. American Journal of Occupational Therapy. 16 (1), 1-9. Smith, D. G , Horn, P., Malchow, D., Boone, D. A., Reiber, G. E., & Hansen, S. T., Jr. (1995). Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. Journal o f Trauma-Iniurv Infection & Critical Care. 38ffl. 44-47. Starr, T., Peariman, R., S c Uhlmann, R. (1986). Quality o f life and resuscitation decisions in elderly patients. Journal o f General Internal Medicine. 1 .373-379. Ware, J.E., Jr. & Kosinski M. (2001) SP-36 Physical &Mental Health Summary Scales: A Manual For Users of Version 1 (2nd ed.). Lincoln, RI: QualityMetric Incorporated. Ware, J.E., Jr., Kosinski M., & Gandek, B. (1993,2000) SF-36 Health Survey: Manual & Interpretation Guide. Lincoln, RI: QualityMetric Incorporated. Ware, J.E and Sherboiume, C.D. (1992). The MOS 36-item Short-Form Health Survey (SF36):I. Conceptual framework and item selection. Medical Care. 30, 473-483. Wang, S. -J., Fuh, J. -L., Lu, S. -R., & Juang, K.D, (2001). Quality o f life differs among headache diagnoses: analysis o f SF-36 survey in 901 headache patients. Pain. 8 9 .285-292. R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 4 2 Weiss, G.N., Gorton, T.A., Read, R.C., & Neal, L.A. (1990), Outcomes of lower extremity amputations. Journal of American Geriatrics Society. 38. (8). 877- 883. WHOQOL Group (1995). The World Health Organization Quality o f Life assessment (WHOQOL): Position paper from the World Health Organization. Social Science Medicine: 4100). 1403-9. WHOQOL Group (1998). Development of the world organization WHOQOL-BREF quality o f life assessment. Psychological Medicine. 28(3), 551-558. WHOQOL-Taiwan Group (1999). • development and user manual ofWHOQOL-lOO-Taiwan versionJ.-pEMt: 0 Taipei: Taiwan. Wilcock, A. (1998). An occupational perspective on health. Thorofare, NJ: Slack, Inc. Williams, L., Metha, K., & Lin, H.S. (1999). Intergenerational influence in Singapore and Taiwan: the role of the elderly in family decisions. Journal of Cross Cultural Gerontology. 14 (4), 291-322. Yerxa, E. J., Clark, F., Frank, G., Jackson, X, Parham, D., Stein, C., & Zemke, R. (1989). An introduction to occupational science: A foundation for occupational therapy in the 21st century. Occupational Therapy in Health Care. 6 . 1-8. Yerxa, E. J. (1993). Occupational science: a new source o f power for participants in occupational therapy. Journal o f occupational science: Australia. L 3-10. Zimmer, Z., Hickey, T., & Searle, M. S. (1995). Activity participation and well-being among older people with arthritis. Gerontologist. 35(4). 463-471 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 143 Appendix A : SF-36, WHOQOL-BREF, and Demographic Data Form - English Version R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. SF-36 This survey asks for your views about your health. Answer every question by marking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can. 144 1 . In general, would you say your health is: Excellent.......................................................................................................................... ! □ Very good.......................................................................................................................20 Good..........................................................................................................3Q Fair................................................................................................................4D Poor........................................................................ 5Q 2. Compared to one year ago, how would you rate your heath in general? much better now than 1 year ago................................................................................. ! □ somewhat better bow than 1 year ago............................................................... 2 0 about die sane as I year ago.............. 3 D somewhat worse than 1 year ago............................................................ CU Much worse than 1 year ago.................................. 5Q R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 145 3. The following items are about activities you night do during a typical day. Does your health limit you in these activities? If so, how much? Activities Yes, Limited A Lot Yes, Limited A Little No, Not limited at all a. Vigorous activities such as running, lifting heavy objects, participating in strenuous sports IQ 2D 3D b. Moderate activities * such as moving a table, pushing a vacuum cleaner, bowling, or playing golf ! □ 2D 3D c. Lifting or carrying groceries ID 2D 3D d. Climbing several flights o f stairs ID 2D 3D e. Climbing one flight o f stairs ID 2D 3D f. Baiding, kneeling or stooping ID 2D 3D g. Walking for more than one mile ID 2D 3D h. Walking several blocks ID 2D 3D i. Walking one Hock ID 2D 3D j. Bathing or dressing ID 2D 3D 4.During the past 4 weeks, have you had any o f the following problems with your work or other regular daily activities^jxgiilM yQ ig.E H I£I.C .M JiE M JH ? Yes No a. Cut down the amount o f time you spent on work or other activities ID 2D b . Accomplished less than you would like ID 2D c. Were limited in the kind o f work or other activities ID 2D d . Had difficulty performing the work or other activities (for example, it took extra effort). ID 2D R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 4 6 5. During the oast 4 weeks, have you had any o f the following problems with your work or other regular daily activities as a result o f vour any Emotional Problems (such as feeling depressed or anxious)? Yes No a. Cut down the amount o f time you spent on work or other activities ID 2D b. Accomplished less than you would like ID 2D c. Didn’t do work or other activities as carefully as usual ID 2D 6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with fism ily, friends, neighbors, or group? Not at all....................................................................................................................! □ Slightly........................................................................................................................ 2 D Moderately....................................... 3 D Quite a bit.................................................................................................................. 4 Q Extremity.....................................................................................................................SO 7. How much bodily pain have you had during the past 4 weeks? N one.............................................................................................................................I D Very mild................................................................................................................... 2 D M ild............................................................................................................................. 3 Q Moderate............................................... 4 0 Severe.......................................................................................................................... 5Q Very Severe............................................................................................................... 6 0 work outside the home and housework)? Not at all ................................................................................................... ! □ Slightly..................................................... 2 D Moderately...................................................................................................................3 D Quite a bit........................................................................................... 4 D Extremely............................................................................. 5 D R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 4 7 9. These questions are about how you feel and how thing have been w ith you during the past 4 / w eek s. For each question, please give the one answer that com es closest to the w ay your have been feeling. AD of the Time Most of the Time A good Bit of the Time Some of the Time A Little of the Time None of the Time a Did you feel M l o f pep? ID 2D 3D 4D 5D 6 0 b. Have you been a very nervous person? ID 2D 3D 4D 50 6 0 c. Have you felt so sown in the dumps that nothing could cheer you up? ID 2D 3D 4 0 50 6 0 d. Have you felt calm and peaceful? ID 2D 3D 40 50 60 e. D id you have a lot o f energy? ID 2D 3D 4 0 5D 60 f. Have you fdt downhearted and blue ID 2D 3D 4 0 50 6 0 g. Did you feel worn out? ID 2D 3D 4 0 50 60 h. Have you been a happy person? ID 2D 3D 4 0 50 6 0 i. Did you feel tired? ID 2D 3D 4D 5D 6 0 1 0 . D uring the past 4 w eeks, how m uch of die time has your physical health or motional problem s interfered with your social activities (like visiting with friends, relatives, etc.)? All o f the time.........................................................................................................! □ Most o f the time...................................................... 2D Some o f the time..................................................................................................... 3Q A little o f the time. .....................................................................................4 0 None o f the time.................................. 5D II.How TRUE or FALSE is each o f the following statements for you? Definitely true Mostly true Don’t know Mostly false Definitely false a. I seems to get sick a little easier than other people ID 20 30 40 50 b. 1 am as healthy as anybody I know 10 20 3D 40 50 c. I expect my health to get worse ID 20 30 40 5 0 d. My health is excellent 10 20 30 40 50 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 148 WHOQOL-BREF Taiwan Version Questionnaire Instructions: This questionnaire asks you about your quality of life, health, and feeling in your life. Please answ er all the questions. If your are unsure about the answer to any particular question please pick the most suitable one for you form the five answers given. Often the answer is the one you think of first. Our questions are have to do w ith your living situation during these past 2 weeks. U se your personal standard, hopes, happiness, and concerns to answer the questions. Use die follo w in g question for referen ce: ________________________________ E xam ple 1 : In general, are you satisfied with your health? □not satisfied at all □somewhat satisfied □moderately satisfied □ very satisfied □extremely satisfied Please choose the most suitable answer to describe how worried you have been during these past weeks, If you have been very worried about your heath then r very worried j make a mark in that square. Please read carefully every question and evaluate your feeling, then according to the question choose the most suitable answer for you. Thank you for your cooperation! 1. In general, how would you evaluate your quality of life? □not satisfactory at all □somewhat satisfactory □moderately satisfactory □very satisfactory □extremely satisfactory 2. In general, are you satisfied with your heath? □ not satisfied at all □somewhat satisfied □moderately satisfied □very satisfied □extremely satisfied 3. To what extent do you feel that your pain hinders you in doing what you need to do? □never hinders □slight hindrance □moderate hindrance □great hindrance □total hindrance 4 . Do you need medical treatment to copy with your daily life? □no need at all □slight need Qnoderate need Qgreat need □extreme need 5. Do you enjoy life? □ do not enjoy at all □enjoy a little Cjenjoy moderately Oenjoy greatly □totally enjoy 6. Do you feel your life has meaning? □none at all Dslight Qnoderate iHgreat O ctal R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 4 9 7. H ow good is your ability to concentrate? □not good at all Dpoor □moderately good Dreary good nextremely good 8. How safe do you feel in your daily life? □not safe at all D little safe □moderately safe Qvery safe Dxtrem ely safe 9. Do you live in a healthy environment (for example: pollution, climate, noise, transportation)? □not healthy at all □slightly healthy □moderately healthy D e r y healthy nextremely healthy 10. Do you have enough energy for your daily life? □ no energy at all Qa little energy □moderate energy □great energy □ foil of energy 11. Can you accept your appearance? □ no acceptance Q a little acceptance □moderate acceptance □great acceptance D otal acceptance 1 2 . Do you have enough money for whatever you need? □not enough at all □almost enough Qjust enough □quite enough □more than enough 1 3 . Is it convenient for you to get the daily information you need? □not convenient at all D lightly convenient □moderately convenient D e r y convenient □extremely convenient 14. Do you have the opportunity to take leisure time? □no opportunity at all D om e opportunity □moderately amount of opportunity □many opportunities Qevery opportunity 15. How is your ability to get around? □not good at all Qpoor □moderately good D e r y good Dxcellent 16. How satisfied are you with the sleep you get? D o t satisfied at all Domewhat satisfied □moderately satisfied D o ry satisfied Dxtrem ely satisfied R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 150 17. Are you satisfied with your ability to perform routine daily activities? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied □very satisfied □extremely satisfied 18. Are you satisfied with your working ability? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied □very satisfied Qextremely satisfied 19. Are you satisfied with yourself? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied Qvery satisfied Qextremely satisfied 20. Are you satisfied with your personal relationships? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied □very satisfied Qextremely satisfied 21. Are you satisfied with your sexual life? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied Qvery satisfied Qextremely satisfied 22. Are you satisfied with the support you get form your friends? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied Qvery satisfied Qextremely satisfied 23. Are you satisfied with your living conditions? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied Qvery satisfied Qextremely satisfied 24. Are you satisfied with how convenience it is for you to get medical services? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied Qvery satisfied Qextremely satisfied 25. Are you satisfied with the transportation you use? Qnot satisfied at all Qsomewhat satisfied Qmoderately satisfied Qvery satisfied Qextremely satisfied R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 151 26. Do you often have negative feelings (for example: depression, despondency, anxiety, anguish)? □never □som etim es □rather frequently Overy frequently Qalways 27. Do you feel respected by others? □ none at all □ sligh t □moderate flgreat Dicta! 28. Are you usually able to get the things you like to eat? □ never □som etim es □rather frequently □very frequently Dalways The second part Integrated self-gygliiatloa Please according your situation in the last two weete. and answer the following questions. r 0 j point means the worst situation o f quality o f life and r 100 j point means the best situation o f quality o f life, please based on this point o f view, point out your situation by an arrowhead and a number at the bar chart as listed below. Thank you. For example: Overall, I rate my satisfaction level of health related quality o f life. 65 ^ , The worst The best 1 I L _ i I 1 ..........1 ..▼ 1 _____ L ____ 1 _____ ! 0 1 0 20 30 40 50 60 70 80 90 100 1. Overall, I rate my satisfaction level o f health related quality o f life. The worst The best ! L _ _ J L I J _ J ! 0 10 20 30 40 50 60 70 80 90 100 2. Overall, before amputation, I rate my satisfaction level o f health related quality o f life. The worst The best I 1 J J I L 1 L I _ J J 0 10 20 30 40 50 60 70 80 90 100 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 152 Demographic Data Form I 1 3 Name : Telephone: Address: [ 2 3 Gender - lO M a ie 2D F em ale t 3 3 Date o f Birth • _year. month. .day ( 4 3 Education level : 1 □illiteracy 2Q E lem entary school 3QJunior high school 4DSenior High school S O C olIege/ university 6D G raduate school and higher 7[Ilothers_________ C 5 3 What kind o f job you are doing? 1 □Agriculture, Forestry, Fishing and Animal Husbandry 2D M im ng and Quarrying snManufacturing 40Electricitys Gas and Water SdC onstruction 6Q T rade 7D A ccom m odation and Eating-Drinking places 8nTransportatioit, Storage and Comm unication SOFinanee and Insurance lOQReal Estate and Rental and Leasing llOProfessional, Scientific and Technical Services 120E du cation al Services ISQHealth Care and Social Welfare Services 14nC ultural, Sporting and Recreational Services lSQ O th er Services l&DPublic Administration 17Q H ousew ife ISQNojob 1 p o t h e r s _________ ___ R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 153 C 6 ) what is your occupation ? I □Veterans 2Q L egislators, Government Administrators, Business Executives and M anners 3DProfesstona!s 4C]Technicians M id Associate Professionals SQClerks fOservice Workers and Shop and Market Sales Workers ^□A gricultural, Animal Husbandry, Forestry and Fishing Workers SQCraft and Related Trades Workers 9Q P lant and Machine Operators and Assemblers lODElemeotary Occupations II □ H ou sew ife H O N ojob 1SQQttiers_________ [ 7 ; Religious b e lie f: iQ n o n e 2QBuddMsm 3 □Taoism 4Q C hristianity 5dJC aA olicism 6jZ3atheism T Q lslam 8[D believe god but do not have a specific religious 9Ql-Kuan Tao ICOothers ____ t 8 3 Marital status : 1 O single/unm arried 2Q m am ed/ companionate marriage sn d iv o r c e / live separately 4Dbereft spouse SDothers [ 9 3 Which m edical diseases you have? IQ n o n e 2 Q f you have > Please make a list:__________ / / '__________ ( please list the first three types from the most serious, second serious and third serious) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 154 (101 Self rated personal health status • 1 Qvery poor 2 Qpoor 3 Qmoderately good 4Qgood SQvery good ( 1 1 } In general ’ Do you feel that your life is happy ? I Qvery unhappy 2Qunhappy 3 Qmoderately happy 4Qhappy 5Qvery happy f 12 j How much personal average income you had per month you in the past year ? I fln o income 2t~lunder 10,000 dollar 3 f~l10.000-20.000 dollar 4020.000-30,000 dollar 5O 30,000-40,000 dollar 6040,000-50,000 dollar 7130.000-60,000 dollar 8060,000-70,000 dollar 9O 70.000-80,000 dollar 10080.000 -90,000 dollar 11090,000-100,000 dollar 120100.000-110,000 dollar 130110,000 -120,000 dollar 140120.000-130,000 dollar 150130,000 -140,000 dollar 160140.000-150,000 dollar 170150,000 -160,000 dollar 18 0 1 6 0 .0 0 0 -1 7 0 ,0 0 0 dollar 190170,000 -180,000 dollar 2 0 0 1 8 0 .0 0 0 -190,000 dollar 2 1 0 1 9 0 ,0 0 0 -200,000dollar 2 2 0 o v er 200, 000 dollar ( 13 ] How much is your monthly average income in your family in the past year ? 10 n o income 20under 10,000 dollar 3 1 il0.000-20.000 dollar 4020.000-30,000 dollar 5030,000-40,000 dollar 6Q 40,000-50,000 dollar 7050.000-60,000 dollar 8060,000-70,000 dollar 9070,000-80,000 dollar 10Q 80,000 -90,000 dollar 11090,000-100,000 dollar 120100.000-110,000 dollar 130110,000 -120,000 dollar 140120.000-130,000 dollar 150130,000 -140,000 dollar 16Q 140,000-150,000 dollar 170150,000 -160,000 dollar 180160.000 -170,000 dollar 190170,000 -180,000 dollar 200180.000 -190,000 dollar 210190,000 -200,000do!lar 220over 200, 000 dollar ( 14 ) Level of amputation at present iQbelow knee(Left) 2Qabove knee(Left) SQbelow knee(Rigfat) 4Qabove knee (Right) SQothers R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 155 (15 3 How long has it been since the amputation surgery of the present amputated limb? 1 n tleftl_______year_____ month 2Q(rigiit)______ year______month 30others ( please describe____________ ) year_____ month (16 3 Cause of amputation! multiple choice if it all apply) lQDiabetes 20Peripheral vascular disease SQHeart disease 4Qlnfection SQOther______ (17 3 The average number of hours each day wearing prosthesis 1 Drone 2 Qseldom, only wear it for special occasion, please describe occasion 3D ess than an hours 4 0on e to two hours • 50tw o to three hours 6Qthree to four hours 70four to five hours 8 0 five to six hours 9C]six to seven hours KOseven to eight hours 1 iQ over eight hours 1 2 0 others, please describe (18 3 What kind of assistive device you use inside the house? (Multiple choice if all apply) iQwheelchair 2 0 w a !k @ r 30cratches 40cane 50none bQothers, please describe_____________ R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 156 C 19 3 What kind o f assistive device you use outside the house? (Multiple choice if all apply) 1 □wheelchair 20waHker 30crutches 40ca«e SQnone 60others, please describe______________ ( 20 3 What’s your living status? (How many people live in the house totally?) l j~l alone 2 0 living with children or spouse (Nuclear family), ( _______ people) 3 0 living with one married children’s family (Steen family), ( people) 4 0 living with two or more then two married children’s £amily(Joint-stem family), ( _______ people) 5 0 living with two or more then two married children’s family and relatives (extended family), ( _______ people) 6 0 living with relatives or friends, ( _______ people) 7 0 living with grandchildren, ( _______people) 8 0 living with hired laborer, ( _people) 9 0 living in sanatorium, nursing home, care center, veterans hospital, veterans home lO0others, please describe_______________________ [ 21 j Who help you with the daily lives(multiple choice if all apply) 10N one 20Children/ grandchildren 30R elatives/ Friends 40Spouse SQNeighbors 60H ired labor none 70others_______ t 22 3 How much social support (family or friends’ support) do you feel in your daily life? 10N oneata!l 20S ligh t 30M oderate 40G reat 50F ull R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 157 Appendix B: SF-36 Taiwan Version, WHOQOL-BREF Taiwan Version, and Demographic Data Form - Chinese Version R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 5 8 SF-36 mmi mmmmmmmBmmm , m m m a m m m j ) , , m m m i . -mm - « ? J tU Wj ( S f f l « ~ « l g ) l l f f i .............................................................................................ID S 0 ................................................................................................2D 0 .............................. 3D n m ....................................................................................................................................................4 D m j ................................................................................................ sd 2. - Mmmmmmmmmum ? \ t - m w m ....................................................................id .......................................................................................... 2D n - r n i W f ^ ................................................................................3D ......... 4D fc t - m m . m ............................................................ s o Copyright c 1995 H ealth A ssessm ent Lab. All rights reserved. (IQ G L A SF-36 Taiwan Standard Version 1.0) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 5 9 3 . 0 m m u m m m m > ansa e mm ? mm# * m m m m & p ? & _______ it & « * » » ’m m m p •m m m * # i « i i !□ 2D 3D m m ' #«•&**' H'fiici® !□ 2D 3D c.asffi^Rwta«i* ID 2D 3D ID 2D 3D e.m -m m m ID 2D 3D m m * KTsarF ID 2D 3D i ID 2D 3D ID 2D 3D i - M m - m m a ID 2D 3D j.@3 f f i M 3 c ! 0 r & ID 2D 3D (m tjm m m -m nM ) & ID 2D ID 2D ID 2D mmmnwmnmmm m m > iD 2D C opyright c 1995 Health Assessment lab . Ali rig h ts reserved. {JQ O L A S F -3 6 T a iw a n Standard Version 1.0) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 160 • m&xft x m m & 0 ______________ ( m m i m m ....m % ) m § ID 2D ID 2D ID 2D 1 6 . S B S zdS flA - m m m m m m m > m im m xm m x * m m * m m m m m m m m m n ? .................................................................................................i o % -m m ........................................ 2D # ® 1 ........................................................................................... 3D mmm............................................... « I W K ........................................... 5D 7 . ' i t m m u m m m ? m m m - m m ) ................................................................... ...in ................................................. 2 D m m m ..................................................................... 3 D .................................................................. 4 D M M ............................................ 5Q m m m ..............................................« □ Copyright c 1995 H ealth Assessment Lab. Ail rights reserved. (1Q G LA S F -36 Taiwan Standard Version 1.0) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 161 m m zsm -m nm ................................................................................................i n m-mmm........................................ 2 0 .......................................................................................................3 0 m w m m .......................................................................................« wmmmm.......................................................................................s o 9. T v r n m r m , - i s a s i ® § i -mmm A m m n m n WBf m a ? IQ 2 D 3 Q 4 D 5D <D ID 2D 3D 4D 5D 6D c. i m m m m m > n m m m m m m fm m m m ? ID 2D 3D 4 D 5 0 C 3 ID 2D 3D 4 D 5 Q 6D e j m x i s w ? ID 2D 3 D 4 D 5D 6D ID 2D 3 D 4 D 5 D < 0 ID 2D 3 D 4 D 5 D 6D b M m -m & .m m A '? ID 2D 3D 4 0 5D 6 0 i.mmm? ID 2D 3D 4D 5D 6D Copyright c 1995 H ealth A ssessm ent Lab. Ali rights reserved. (IQOLA SF-36 Taiwan Standard Version 1.0} R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 162 io. mnmm. m ) ? mm^m- -mmm - m m ............................................................................ o ^ S M i t .................................. 2D ............................................................................ s o 'm m ................................................................................................ 4D m m ................................................................................................ s o 1 i.T ?ijSSE SS4/S^EW #Z E ? ID 2D 3D 1 ' 4 0 5 0 ID 2D 3D 4D 5 0 ID 2D 3D 4D 5D ID 2D 3 0 4D 5D C opyright c 1995 Health Assessment Lab. All rights reserved. (IQ O L A S F -3 6 Taiwan Standard Version 1.0) R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 163 W&B M ' • (£ W H S 9!JK) ?mmm ■ am±mshM * mm * jmnmMmmmmm • > mmmmm W i l l ! ° • mMmmswm ■ ' » r * i ^ » £ « t i m r * • immrmmmm ■ mm- : g « t g ■ sararaeftfMPW? □ s ^ g n^mm n^m w rnm □ * « a m m mmmmm^^mm ms.mm^m mmmmm m * ^ s s a s s s a f c r t t * * at S rM t j WflO*tfT rVj»fS «8M S * B • 3£fFfliJ&g3W«« * »BSffl*a£*j««ss • mmmmmm! R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 1 6 4 1 . m m m • ? o i T O upf& 0 0 nm& 2. i i s - g i t a e « » i ? a m x m m n*mn m # ss# i a m m □ « « 3 . a f » i t ® i » i w $ i i ? [ K t M W a m ~ m m □ « § ! □ * « BISKS* 4. ? cm -m m m n m m m u m m w 5. a ® m % um& □ w -ssw m i i s i □ « cm □ # - « # n w d s k ? umt± nm& 9. M I M t t i ? tfD^Sfe > Sfe# ' ' * « ) D frH K ft* D ^ f l M * D M S ? □ ! ! « 10. ? n%±^m am&m amm u%^m n . g M B M I ? □4» # e a t g ^ j amm n% -m m 12. m & m & m m m m m ? am&m m m m m & m nmsm a^&m 1 3 . itm m m m m a ± m m m m m m m ? C 3 ^ :£ f« Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 6 5 i4. im m 'm w m m m m ? □ ^ w i t # U 'm m 15 jm m n m m m M m ? r a w * ? a m -m t- m m m m ff 1 6. tasss s ? □ W H S O T M D ^ H g l i S 17. ? □ w n crass mwmmmm is. ? □arass eras □ a r a s s a rm m 20. ? am ^m m o ^m m □ W H S c r a S S 22. i i i k » m » i ? □ W H S O T H S 23. M I S B f t M W ? □ W H S O T H S 24. ? □ s r a s s o t h s 25. ? □w*s crass n tf iiii 2 6 . m m nm & jm ^m ? ( tm m * m m *£&* ) □t&fe&W O TSW □ M I S S I S □ 4 > l§ M i§ S m m m m m □ ta w s # n % ± m m am i- am&- o s s d w amm amm □ms amm r a s s O S S am m amm amm amm ammm C M S ammm □ s m s ammm ummm ammm ammm □ sm s □ —iti&w Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 166 27. ? n w — 28. ? □ « & w o t s w OSW D®^ amm n -u m a a f f i f t . J i l « ’ S ^ T ^ M S : rQj ’ rioo. , ja w M r e a r a a m m ® im * mm • m m ■ M s i i f o w - aif s B eefflfiteE iflfitoE S E ® * 65 i mm 0 10 20 30 40 50 60 70 80 90 100 i . ■ mm 10 20 30 40 50 60 70 80 90 100 2 . m-smw ’ « r£ # j ’ m m sm mm 0 10 20 30 40 50 60 70 80 90 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 167 L 1 3 C 2 3 i 3 3 C 4 3 (5 3 j m ____________ m t- ttM : lOJS 2Q fc j a : in x m ^ l o m ^ m m m w m * c m / j ^ w 5 Q * * /* * 6{3ffi'i%m&M± to m m________ mnimm'ismimnm? 4nAWMMM inamRmmM ioO T»£X iB Jtil % 2 mmR±^mm 30m m snmmw 6 nmtRmmn sum® * ^rm m m 9 0^mR^mm uom m ' m m xm zm m nnm m m m u n sa t • mmR^wmmm \sunmmm lon&m&m itnmmxm lo & r fl? L 6 3 in m m A lOBMAM sO W X fF A J t ?QH 'tt'lk' ttX ftA J i v a im m m ttx m & n : nommxm n o m m _ 2n s B f ^ ' nrnxm ' ±m±WRmmA 4cmsARsmmmAm eom m xftAM Rm sk som m xR ^m x^A R io om m x:Rm .Ax nnm xw [73 (83 C93 m m m = m m an mm sc o m 4 ommm sn x x m < a m m 7o®m c i - j t a i i < o m _ u § « K 2 H : 1 o m i w - B lO E m m m s o w m ifr m 4 0 m m s a n m ____ 1 om lumm ’ § » m _ Reproduced with permission of the copyright owner. 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Further reproduction prohibited without permission. 169 1 17) ? a n c_______ $m) 4D 5D ngjH /M it 6Q H im 4 m 7 0 W M fisim s o n m ^ m 9 0 Am-b'hm lOOtHJ ; \ ' i m n u m m A m m n o n m m m m _______________________ cis) ? in m m 4 m ____yy 20 &bfT&________« _____ft 3 0 5 * T « i i m _____m _____yy 40^-fet_____ /JnB#____ f t sO M T O ffill 6o m f » j f m . _ __________________ [ 19 ] ? in m m 4 m ____ft 2 o m n m _« ft 3 D ] g * T W M t 4 m _____ft c m & _____ 4 m ___ ft 5 D M W I d m i u s a i _______________________ Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 7 0 c 20 3 ? o m m 2D - c ____________a > an * c __________ a ) 4Q - ( ______________ s o f D W i l ^ i i « - A M « « “ f i ( A ^ f i ) ’ { ____________ A ) o m m m & m r - m > ( A) td m w f'tQ m .-m > ( _________ a> »□ M A M 5 ( _________ A) 9D lO D m fS fS M ______________________ (2i 3 m m m b ? i o m x 2 3QMmmm-iz o a « s n ^ g innm m m m _________________ 1 2 2 3 ? iD fc ^ m m m - m s m w m m 4 n m s n m A) 6CWA Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 171 Appendix C: Informed Consent Form - English Version Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 7 2 INFORMED CONSENT FORM TITLE OF PROJECT: Health-related quality of life, occupation and prosthesis use in elderly people with lower extremity amputation in Taiwan PRINCIPAL INVESTIGATOR: Yan-hua Huang, Ph.D. Candidate, OTR TELEPHONE NUMBER: 886-916-518-626 CO-PRINCIPAL INVESTIGATOR: Ruth Zemke, Ph.D., OTR, FAOTA TELEPHONE NUMBER: (323) 442-2880 DEPARTMENT: Occupational Science and Occupational Therapy SCHOOL: University of Southern California 24-HOUR TELEPHONE NUMBER: 886-916-518-626 PU J j PpSEOF m E.STUPY: You are invited to participate in a research study of health related quality of life, occupation/activity, and the meaning of prosthesis in elderly people with amputation in Taiwan. The following information is provided in order to help you make an informed decision whether or not to participate. We hope to leant about the quality of life in elderly people in Taiwan who have had an amputation and their use of their prostheses in relation to their daily activities. You are invited as a possible participant in this study because you had a non-traumatic amputation and you are over 55 years old. About 70 elderly people will take part in the first part of this study and about 6 of these people will take part in the second part of the study. If you decide to participate, we will need you to sign this informed consent. There are two parts to this study: 1 . Questionnaires: you will fill out two questionnaires and one demographic data form. The two questionnaires are (a) the SP-36 Taiwanese version that asks 36 questions and (b) the WBOQOL-BREF Taiwanese version that asks 28 questions about your sense of health and well-being during the fast 4 weeks. For each question, you will choice the most suitable answer for you. The demographic data form asks 22 questions about you and information related to your amputation and prosthesis. A total of about 25-60 minutes is expected for completing the questionnaires and demographic data form. When you complete the questionnaires you will provide us information about your well being, and we will then be able to better understand the quality of life in elderly people with amputations in Taiwan. This is the first part of this study. 2. Interview: When you return the questionnaires, you are also agreeing to participate in the second part of the study. A range of high and low scores of two measures will be used to choose 6 participants to interview. The researcher will call and make m appointment with those of you who are selected and you can pick up the interview time and location. For this second part of the research, the interview will be around an hour. The interview questions will be related to your feelings about your life, your daily activities and your prosthesis use. In this way, this research study will be able to understand more about how the quality of life is related to prosthesis use and daily occupation. 10/18/2002 Page 1 of3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 173 RISKS; There are no known risks other than the inconvenience of spending the time to fill out the questionnaires and interview. If some of these questions make you feel uncomfortable, you can stop filling in the questionnaires and interview at any time. BEN EfM Si Except for the potential of gaining more insight about yourself by filling out the questionnaires and through interview, you may receive no direct benefit from your participation in this study. However, your participation in this study may eventually help us gain knowledge about the quality of life in elderly people with am putations. It may help us to understand meaning of prosthesis, occupation, and quality of life in elderly people with amputation in Taiwan Knowing more about the relationship among occupation, quality of life and the meaning of prosthesis in elderly people with amputations will be contributed to the development of occupational science and assist occupational therapists in their work with these people. 4MiiS.4JiyS§.TO PARpCIFAflON: You m ay choose not to complete the two questionnaires and not participate the interview. You will not be involved in the study. CONFIPIOTTALrr Y S T A T E M E N T ; Every effort will be made by the principal investigator to keep information that is obtained from this study confidential to the extent provided by law. The information from this study m ay be published in scientific journals or presented at scientific meetings but your identity will be kept strictly confidential. OFFER TO A M S W E R QUESTIONS; Y our participation will be supervised by Yan-hua Huang (886-916-518-626) or Ruth Zemke (323- 442-2880). You may contact us with any questions or concerns regarding your participation. If you feel you have been injured as a result of your participation, you may contact the Principal Investigator, Yan-hua Huang at 886-916-518-626. If you have any questions regarding your rights as a study subject, you may contact the Institutional Review Board Office at 886-4-24739595 You will be given a copy of this form to keep. m B g M Y M RTICirATIOH AND W IT H D R A W A L STATEMENT; Your participation in this research study is voluntary. Y our decision whether or not to participate will not interfere with your right to health care or other services to which you are otherwise entitled. You are not waiving any legal claims or rights because of your participation in this study. If you do decide to participate, you are free to withdraw your consent and discontinue your participate at any time. 10/18/2002 Page 2 of 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 7 4 IM fflR Y S lA S iiE g l- In the unlikely event that you should suffer an injury as a direct consequence of the research procedures described above, emergency medical care required to treat the injury will be provided. However the financial responsibility for such care will be yours. m m m m j I have read (or someone has read to me) the information provided above. I have been given the opportunity to ask questions and all o f my questions have been answered to my satisfaction. My signature below indicates that I have decided to participate having read the information provided above. Name of Subject Signature Date Signed Name of Witness Signature Date Signed I have personally explained the research to the subject or the subjects legally authorized representative and answered any questions they posed. I believe that he/she understands the information described in this informed consent and freely consents to participate. Name of Investigator/Person Signature Date Signed Obtaining Informed Consent F o r m Valid F o r E n r o llm e n t F ro m O C T 2 7 2 0 0 2 T n O C T 1 0 2 0 0 3 Institutional Review Board 10/18/2002 Page 3 of 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 7 5 Appendix D: Informed Consent Form - Chinese Version Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 176 mum ■ * m m m m * & m m m ■ m m * m m n m i± m m m m m m - m ± ^ A mmmm tm w • 2 4 /J « M S IS : 0916518626 mm - ' m m m > s n » m m • - m t ; « * a titW 9 a ffe • A « f f 8 M f i ! 70 T K # K ^ A W P I # * T O * 6 f t « 5 t t s a • f i f t & » l l * : m jE m m m m m m m m % • & * « » & £ * & & » « :ci)sf-36-^»k m - m - m A m n • * sf-36 & m * ’ fe^-7 ii m m ’ * 3 6 f a a n ; m m m & m & m m m & m m m m • m o& T so m m m m m m m m m •lEfgAfim* ■ w 2 2 « » i » « mmmm. • snras • m m m m - • mmmmmit 25-60 ^ a e g s t • m ' ■ mmm > f t > mmmmm• 1 f@*Bf• > a m m m m• a »7#7fc“ S 8 t F ^ « P 3 S T O g i S P a ^ * *«TO H U & ££M B £ M i t »&»T 10/18/02 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 7 7 m * ± m . m * m m m m m . m m m m m > M m m i m m > i * i ' « t g - sra* S iQ ljS B fiffi . B*m$m*JMtEmmfflMmm> mm * wm±m m ’ m m m frM tM M M M m • m cmmm) m m m m ftA * § a » w ffiM fn s • -.09i65i8626 . a I ^ J t # : 04-24739595 » - H H M l i f t i w i r a f j • • « m i t » ’ ^ § § r « . m n m m & f e m & m w m m • ( D * i f P # t t : mm 7 0 & T K * ^ A # « { I 5 2 5 - 6 0 £ # > : < 2)85^ 9 : j f tftg j? 6 f t # • W ^ # W » W * « A M • Mffi mmmmmmm» 1 0 /1 8 /0 2 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 7 8 MS mmmm mmAmmm) pxmm • mmmmmmm • m m m m m m m m • ° m m % bm___________________ m x m __________________________ b m ___________ • t i i f M ® • m m m m M m m m m m m m m m - t i i i i g i w t w t e • mmm x m % ________________ b m ________ O C T 2 1 a g i i m 10 m Institutional Mm Board 10/18/02 H H ft’&HM Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 179 Appendix E: Raw Score Means ± SD for WHOQOL-BREF and SF-36 Domains Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 180 Table El Raw score mean ± SD for WHOOOL domains in the study WHOQOL Wl: W2: W3: W3T: W4: W4T: Physical Psycho- Social Social Environ Environ logical Relation Relation - -ment -ment + -ships ship+ Taiwan Taiwan All subjects (N=90) 12.62 +2.70 12.51 +2.87 12.41 +2.79 12.80 +2.73 13.41 +1.95 13.63 +1.93 Gender Males (N-73) 1 2 .6 6 ±2.54 12.60 ±2 .8 8 12.33 ±2.79 12.64 ±2.72 13.37 ±2 .0 2 13.57 ±2.01 Non-Veterans Males (N=42) 12.94 +2.17 13.27 ±2.36 13.05 ±2 .6 6 13.12 ±2.48 13.37 ±2.25 13.53 ±2 .2 0 Veterans (N=31) 12.28 ±2.97 11.70 ±3.27 11.35 ±2.71 1 2 .0 0 ±2.92 13.37 ±1.70 13.62 ±1.75 Females (N=17) 12.44 ±3.35 12 .1 2 ±2 .8 8 12.78 ±2.83 13.47 ±2.79 13.56 ±1.63 13.91 ±1.55 Table E2 Raw score mean ± SD for SF-36 Scales in the study Physical Component Mental Component Summary (PCS)_______ Summary (MCS) All subjects (N=90) 29.89 +7.89 49.26 +11.15 Gender 30.05 49.26 Males (N=73) ±7.58 ±11.14 32 25 48 74 Non-Veterans Males (N=42) ±7.27 ±8.24 Veterans (N=31) 27.08 49.96 ±7.06 ±14.28 Females (N=17) 29.20 49.25 +9.33 +11.57 1 .... Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 181 Table E3 Raw score mean + SD for SF-36 eight scales in the study PF RE BP GH V SF RE MH Physical Role- Bodily General Vital Social Role- Mental Function Physical Pain Health ity Function Emotion Health ing ing al All subjects 15.08 4.19 8.73 14.93 15.38 6.16 4.76 2 1 .2 1 (N=90) +4.90 +0.67 +2.92 +4.75 +4.79 +1.93 ±1.24 ±4.51 Gender Male (N=73) 15.07 4.19 8.85 15.12 15.50 6.07 4.73 21.41 +5.01 +0 .6 6 +2.83 +4.56 +4.86 ±1.92 ±1.24 ±4.23 Male 16.14 4.26 9.14 15.97 15.74 6.29 4.62 21.64 Non-Veteran (N=42) +5.0 +.80 +2.57 +3.81 +4.10 +1.58 ±1.17 ±3.78 Veterans (N=31) 13.61 4.10 8.45 13.98 15.19 5.77 4.87 2 1 .1 0 +4.73 +.40 +3.15 +5.26 ±5.79 ±2.31 ±1.34 ±4.82 Female 01=171 15.12 4.18 8.56 14.12 14.82 6.53 4.88 20.35 +4.51 +.73 +3.36 +5.59 +4.59 +1.97 +1.27 +5.62 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix F: Final Regression Model for Predictors of WHOQOL-BREF Domains in Test of Hypothesis 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 8 3 Table FI Final regression model for predictors ofWHOOOL domain 1 in test of Hypothesis 1 Model Standardized Beta t Sig. (Constant) 8.673 .0 0 0 Theoretical Variables Social support .077 .636 .264 Level of amputation -.018 -.161 .436 Income -.147 -1.212 NS Control Variable Wearing prosthesis .272 2.364 .021 Dependent Variable: WHOQOL Domain 1 Table F2 Final regression model for predictors of WHQOOL domain 2 in test of Hypothesis 1 Model Standardized Beta t Sig. (Constant) 7.506 .0 0 0 Theoretical Variables Social support .388 3.340 .0005 Level of amputation .073 .689 NS Income -.076 -.658 NS Control Variable Disease -.329 -3.022 .003 Dependent Variable: WHOQOL Domain 2 Table F3 Model Standardized Beta t Sig. (Constant) 5.634 .0 0 0 Theoretical Variables Social support .325 2.799 .003 Level of amputation -.047 -.448 .328 Income .159 1.207 .116 Control Variable Living place (Home -.046 -.336 .738 vs. Institution) Dependent Variable: WHOQOL Domain 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 184 Table F4 Model Standardized Beta t Sig. (Constant) 5.640 .0 0 0 Theoretical Variables Social support .345 2.948 .0 0 2 Level of amputation -.066 -.626 .267 Income .175 1.314 .097 Control Variable Living place (Home vs. Institution) .034 .245 .807 Dependent Variable: WHOQOL Domain 3T Table F5 Final regression model for predictors of WHOQOL domain 4 in test of Hypothesis 1 Model Standardized Beta t Sig. (Constant) 13.557 .0 0 0 Theoretical Variables Social support .299 2.573 .0 1 2 Level of amputation -.103 -.956 .342 Income -.274 -2.347 .989 Control Variable Wearing prosthesis .177 1.604 .113 Dependent Variable: WHOQOL Domain 4 Table F6 Model Standardized Beta t Sig. (Constant) 14.364 .0 0 0 Theoretical Variables Social support .291 2.534 .007 Level of amputation -.127 -1.198 .118 Income -.303 -2.626 .995 Control Variable Wearing prosthesis .187 1.712 .091 Dependent Variable: WHOQOL Domain 4T Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 185 Table F7 (PCS) in test ofHvoothesis 1 Model Standardized Beta t Sig. (Constant) 10.195 .0 0 0 Theoretical Variables Social support .1 0 0 .895 .019 Level of amputation -.290 -2.768 .004 Income -.085 -.746 NS Control Variable People’s help -.282 -2.597 .011 Dependent Variable: SF-36 Physical Component Scale (PCS) Table F8 Final regression model for predictors of SF -36 domain Mental Component Scale Model Standardized Beta t Sig. (Constant) 6.959 .0 0 0 Theoretical Variables Social support .078 .645 .026 Level of amputation .269 2.433 NS Income -.034 -.289 NS Dependent Variable: SF-36 Mental Component Scale (MCS) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 186 Appendix G: Correlations Between Domains of the WHOQOL-BREF Taiwan and the SF-36 Taiwan Version Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Appendix G. Correlations between domains of the WHQQOL-BREF Taiwan and the SF-36 Taiwan version. W1 W2 W3 W3T W4 W4T PCS MCS PF RF BP GH V SF RE MH W1 1 W2 .58** 1 W3 .36** .51** 1 W3T 37** .53** .95** 1 W4 4 4 « .50** .37** .38** 1 W4T .45** .46** .36** .41** .97** 1 PCS 49** .37** .34** .31** .31** .31** 1 MCS .55** .61** .2 0 .24* .30** .33** -.64 1 PF 42** .23* .24* .28** .31** .07 1 RP .15 .10 .12 .07 .11 .12 .46** .05 .25* 1 BP .57** .38** .2 1 * .20 .35** .35** 4 9 ** .33** .03 .15 1 GH .52** .56** .39** .41** .25* .25* .53** .4 7 ** .32** .07 .33** 1 V .57** .60** .17 .21 .27* .26* .32** 70** .2 2 * .19 .41** .50** 1 SF .58** .50** .35** .31** .33** .37** .39** .56** .48** .26** .24* .38** .41** 1 RE .39** .34** .03 .09 .2 2 * .25* -.1 0 7 9 ** .07 .10 29** 27** .40** .28** 1 MH .54** .70** .35** .37** 3 7 ** 3 9 ** .15 .83** .23* .05 .34** .56** .61** .50** .45** 1 Note. W1 - WHOQOL Physical Domain; W2 - WHOQOL Psychological; W3 = WHOQOL Social Relationship; W3T = WHOQOL Social Relationship Domain Plus Taiwan Specific Questions; W4 - WHOQOL Environment; W4T = WHOQOL Environment Domain Plus Taiwan Specific Questions; PCS - SF-36 Physical Component Summary; MCS = SF-36 Mental Component Summary; PF = Physical Functioning; RP = Role-Physical; BP = Bodily Pain; GH = General Health; V = Vitality; SF = Social Functioning; RE = Role-Emotional; MH = Mental Health * g < .05. **g < .01. 0 0 188 Appendix H: Demographic Descriptions of Interview Participants Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Appendix H. Demographic Descriptions of Interview Participants Last name Gender (veterans) Age Education Satisfaction Satisfaction Level of Level of Quality o f Quality of Life Score Life Score (0-100) Before Amputation (0-100) Level of Amputa tion* BK= Below Knee; AK= Above Knee Years Hours Since Wearing Ampu Prosthe- tation sis Indoor Dvice Outdoor Device People Who Help with Daily Living Chao Male 73 College 70 90 LBK .58 3 walker walker Children Wu Male 60 Elementary 80 90 RBK .58 >8 none Cane Children Lang Male 68 Elementary 40 100 RBK 1.00 3 wheelchair wheelchair None Ke Male 65 Elementary 90 100 EBK .50 3 wheelchair walker Spouse Jan Male 61 Elementary 65 100 BilBK .50 seldom wheelchair wheelchair Hired labor Gi Male 56 Junior High 80 80 LBK .50 4 crutches cruthes Spouse Huang Male 55 Elementary 45 65 RBK .67 6 walker walker Children Ma Male 70 Elementary 50 65 LBK 1.00 >8 Cane Cane Spouse Sun Male 74 Illiteracy 70 80 LBK 3.00 >8 Cane Cane Children Bia Male 57 College 68 90 Bil BK 2.00 >8 none Cane None Wang Male 68 Elementary 55 65 BilBK .25 5 wheelchair Electric wheelchair Nursing aid Tang Male 76 Junior High 50 90 RAK 5.00 >8 walker Electric wheelchair Spouse Lai Male 76 Elementary 80 80 LAK .83 5 wheelchair wheelchair Children Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Chang Male(V) 79 Junior High 70 90 RBK 7.00 >8 Cane walker Spouse/ Children Hu Male(V) 86 Illiteracy 70 95 RBK 1.58 5 Cane Cane None Yao Male(V) 78 Illiteracy 0 0 RAK 2.00 >8 wheelchair wheelchair None Lu Male(V) 88 Elementary 60 80 RBK 3.00 >8 wheelchair wheelchair None Ban MalefV) 74 Illiteracy 35 100 LBK 1.17 none wheelchair wheelchair Nursing aid Tu Male(V) 73 Illiteracy 80 90 BilBK 1.58 >8 wheelchair wheelchair Nursing aid Su Male(V) 8 1 Elementary 85 100 RBK 28.00 >8 Cane Cane/bicycle None Kuo Male(V) 72 College 100 100 BilBK 1.50 3 wheelchair Electric wheelchair Nursing aid ling Male(V) 77 Elementary 60 75 RBK 4.00 none wheelchair wheelchair Nursing aid Yang Male(V) 76 Elementary 60 80 BilBK 1.25 none wheelchair wheelchair Nursing aid Chen MalefV) 78 College 70 100 BilBK/AK 2.50 seldom wheelchair wheelchair Nursing aid Fu Male(V) 79 Elementary 75 85 LBK 7.17 >8 none Electric wheelchair Nursing aid Yin Female 60 Senior High 60 100 LBK .50 5 crutches walker Hired labor Pu Female 81 Illiteracy 85 100 LBK .50 >8 none walker Grandchildren Li Female 65 Illiteracy 70 100 LBK 2.00 6 none cane Children Lmg..... Female 60 Elementary 50 50 Bil BK .50 8 none/climb wheelchair Children Tsai Female 67 Illiteracy 50 100 Bil BK .50 2 walker wheelchair Children

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Asset Metadata

Creator Huang, Yan-Hua (author)

Core Title Health-related quality of life, occupation and prosthesis use in elderly people with lower extremity amputation in Taiwan

School Graduate School

Degree Doctor of Philosophy

Degree Program Occupational Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,health sciences, rehabilitation and therapy,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Zemke, Ruth (committee chair), Carlson, Michael (committee member), Clark, Florence (committee member), Jackson, Jeanne (committee member), Ying, Shao-Yao (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-484294

Unique identifier UC11340039

Identifier 3133282.pdf (filename),usctheses-c16-484294 (legacy record id)

Legacy Identifier 3133282.pdf

Dmrecord 484294

Document Type Dissertation

Rights Huang, Yan-Hua

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA