Profiling of Aged Care Facilities and the Quality of Life of elderly residents in KualaLumpur and Selangor

This study aims to profile the aged care facilities and the quality of life of elderly residents in Kuala Lumpur and Selangor. It is a cross-sectional survey conducted on 14 aged-care facilities in the two states. The study explores the status and profile of these facilities and the quality of life of their elderly residents.

Profiling of Aged Care Facilities and the Quality of Life of elderly residents in Kuala-
Lumpur and Selangor
Dr. MarwaAmerAnis Hasson Abbas
000025253
Master of Science in Public Health (MPH)
INTERNATIONAL MEDICAL UNIVERSITY
BUKIT JALIL, KUALA LUMPUR
MALAYSIA
2019

Dedication
This thesis is dedicated to my loving supporting parents, Captain AmerAnis and Dr. Dikra M.
Abdullah for their belief in me, my siblings for their continuous encouragement, my colleagues
and friends for their assistance and efforts.

Abstract
Introduction: with Malaysia projected to be one of the elderly nations within the next decade
(2030), there is a high demand for aged-care facilities that could support and promote a better
quality of life for the senior population. although the Malaysian government passed a new
“Private Aged Healthcare Facilities and Services Act 2017”, its regulation are yet to be
developed, and a current profile of the aged -care facilities present currently and working is not
yet available. This study is attempting to explore the status and profile of these aged -care
facilities and the quality of life of their elderly residents.
Objective: To profile the aged care facilities, personnel characteristics, and the quality of life of
the elderly residents in these facilities in Kuala-Lumpur and Selangor.
Methodology: This was a cross-sectional in-facility based survey that was conducted on 14
aged-care facilities in two states of Kuala Lumpur and Selangor. Stratified random sampling was
used to choose the facilities between private (for profit) and pubic (not for profit)and a universal
sample of the facilities staff and elderly residents (meeting the study’s inclusion criteria) was
obtained. Consenting staff and residents were interviewed using the study instruments adapted

from the Institute of Gerontology, University Putra Malaysia, and the World Health
Organization’sQOL-BREF.
Results:
Conclusion:
Key words:Aged care facilities, elderly, Personnel, Quality-of-life, Malaysia.

Acknowledgement
I would humbly like to thank my research supervisor, Associate Professor To’
PuanDrSafurahJa'afar, for her relentless encouragement, assistance, patience, and guidance
throughout all the stages of this study. I would also like to thank my co-supervisors Associate
Professor Dr. HallySreerama Reddy ChandrashekarThummala andFaculty of Human Ecology,
University Putra Malaysia’s Assc. Prof. Dr. RahimahBinti Ibrahim for their continuous support
and enrichment to this study.
I would like to thank the community medicine department and all its staff headed by Dr. John for
their guidance.
I would also like to give my gratitude and thanks to my colleagues in International Medical
University’s MPH-218, and my friends for their extensive assistance during the data collection
phase and the following phases of this study.
Furthermore, I would like to thank Dr. Kingsley Ugwu and Mr Chai Seng Thye for their kind
support throughout this study.
Last but not least, I would like to thank the Aged care facilities along with their staff and
residents who showed wonderful cooperation and assistance during the commencement of the
field data collection.

Approval Sheet No. 1
I, the main supervisor toDr.Marwa Abbas,hereby certify that the dissertation revisions have
been made based on the recommendations by the Dissertation Examination Committee on date
of viva.
Main Supervisor: DrSafurahJa'afar
Designation: Associate Professor
Name of faculty/ institute: Department of Community Medicine, International Medical
University, Kuala Lumpur, Malaysia

Approval Sheet No. 2
I certify that an Examination Committee has conducted the final examination of Dr. Marwa
Abbas onMaster of Science in Public Health dissertation entitled "Profiling of Aged Care
Facilities and the Quality of Life of elderly residents in Kuala-Lumpur and Selangor". The
Committee recommended that the candidate be awarded the degree of MSc. in Public Health.
_______________________________
Dean of Postgraduate Studies and Research
International Medical University

Approval Sheet No. 3
This Dissertation was submitted to the Senate of the International Medical University and was
accepted by the Senate as having fulfilled the requirements for the degree of. MSc. in Public
Health.
_______________________________
Dean of Postgraduate Studies and Research
International Medical University
Date:

DECLARATION
I hereby declare that the dissertation is based on my original work except for quotations and
citations which have been duly acknowledged. I also declare that it has not been previously or
concurrently submitted for any other degree at the International Medical University or any other
institution.
Dr.Marwa Abbas

TABLE OF CONTENTS
Profiling of Aged Care Facilities and the Quality of Life of elderly residents in
Kuala-Lumpur and Selangor……………………………………………………….1
Dedication……………………………………………………………………………………………………….…………...…..…………….2
Abstract………………………………………………………………………………………………………………………………..…………3
acknowledgment…………………………………………………………………………………………………..…………..…………..4
approval sheet No. 1……………………………………………………………………………………………………………………..5
Approval Sheet No. 2……………………………………………………………………..……………………………………………..6
Approval Sheet No. 3………………………………………………………………….………….………………………………………7
Declaration form…………………………………………………………………………………………...……………………………..8
Chapter 1 : Introduction……………………………………………………………………………………….…………………13
1.1Research justification………………………………………………………………………………………………..14
1.2Literature review……………………………………………………………….14
1.2.1An overview of the Global Population Ageing………………………………12
1.2.2The Ageing Population across Asia…………………………………………16

1.2.3The Ageing Population in Asia………………………………….………….17
1.2.4Impact of Population Ageing in Malaysia…………………………………..18
1.2.5The Elderly care trends in the world………………………………………...20
1.2.6The Elderly Care Trends in Asia including Malaysia……………………….21
1.2.7Services for the Elderly in Asia including Malaysia…………………………22
1.2.7 a.Financial Aid………………………………………………………22
1.2.7 b.Activity Centres……………………………………………………22
1.2.7 c.Home aid services………………………………………………….23
1.2.7. d.Housing Facilities for the Elderly…………………………………23
1.2.8Depression among the Elderly in Malaysia…………………………………..25
1.2.9The personnel or staff characteristics of the healthcare taskforce in world….25
1.2.10The personnel or staff characteristics of the healthcare taskforce in Asia….26
1.2.11 The global accreditation standards in OECD countries……………………27
1.2.12 The Malaysian Private Aged Healthcare Facilities Services act 2017…….28

1.2.13 An overview of the Quality of Life concepts…………………………………..…29
1.2.14The Elderly’s Quality of Life..................................................................................29
1.2.15 Quality of Life major correlates.............................................................................30
1.2.16 The Relationship between Depression, Social support, and QOL..........................31
1.3 Research objectives:…………………………………………………...…………………..…31
1.3.1 General objective……………………………………………….………..………………...31
1.3.2 specific objectives…………………………………………………………...………..……32
Chapter 2: Research materials and methodology ………………………………………...….32
2.1 study background and setting…………………………………………………………….32
2.2 Study design and target population…………………………………...………………….33
2.3 Sampling frame…………………………………………………………………………..33
2.4 Study
duration………………………………………………………………………………………33
2.4 Sampling and selection criteria………………………………..…………………………34
2.5 Data
collection…………………………………………………………………………………….35
2.6 Operational definitions………………………………………………………………….36

2.7 Research instruments…………………………………………………………………….36
2.8 Research ethics……………………………………………………..……………………38
2.9 Data analysis…………………………………………………….……………………….38
References…………………………………………………………………………………..39

List Abbreviations
Abbreviation Meaning
QOL Quality of Life
NGO Non-governmental Organization
UNDESA United Nations Department of Economic and
Social Affairs
DSW Doctor of Social Work Degree
OECD Organisation for Economic Co-operation and
Development
WHOQOL BREFF World Health Organization Quality of Life
Instrument Questionnaire
UPM Unversiti Putra Malaysia
ADL Activities of Daily Living
RM Malaysian Ringgit
CI Confidence Interval

Chapter One
Introduction
Background of study
With medical advances and health awareness increases, life expectancy is improving with
concomitant change in demographical proportions with an increase in the older population.The
definition used in Malaysia for older population is 60 years old and above. The numbers have
increased exponentially by 1.8 million over 40 years from the 1970sto2010s. In 2018 the older
population represents 8% of the Malaysian population and this is expected to incresase to and
estimation of 1 in every 10 Malaysian will be an elderly by the year 2020 (1, 2)
With aging, some relative health complications are expected to develop, such as cognitive,
functional, social, and physical decline. Most noticeably is postural control and preforming daily
living activities that are needed to live independently(3-6).
The major concern is not the growing size of the aging population per se, but meeting their
health needs, providing suitable care, and proper living arrangements for this growing society (3,
4). In most communities, especially Asian ones, aging in place or at home used to be the method
chosen by the elderly, where their primary care givers are family and relatives (7, 8), but now,
with modernization, this approach might opt to change (9).
Increased options of residential elderly care includes adult day care, nursing homes, and assisted
care living. The clients can choose between a variety of living arrangements to meet their
requirements (4, 8).The expectation from these aged care facilities are to provide optimal living

arrangements such asactivity daily living, nutrition, and medical care for their elderly residents
(6, 8-10). Fulfilling these requirementsthrough supervised and interventional care programs and
with the presence of a multidisciplinary teams have shown to improve the quality of life of
residents (10-22)
There are however, empirical evidences that nursing homes residents have often been associated
with poor physical health, cognitive difficulties and vulnerable to psychological and social
pressures. Hence it is imperative that the objective of long term care of residents should continue
to assess their quality of life with regards to physical health, family and social connectedness,
cognitive health and overall well-being and their rights to reasonable care be addressed (25).
Quality of Life, as defined by the World Health Organization is “individuals’ perception of their
position in life in the context of the culture and value systems in which they live and in relation
to their goals, expectations, standards and concerns” (23, 24). The measurement tools have also
been developed in an attempt to measure the “well-being” and “humanistic elements into
healthcare” beyond the disease and disability.

Literature Review
1.2.1. Ageing population trends of worldwide
The physiological processes of ageing encompasses an array of physical, mental, cognitive and
functional changes in an individual, from the moment an individual is born. In addition, ageing
also exhibits significantly challenging consequences on the cultural, social and economic
platforms in a respective population, in both developing as well as developing countries. At
present, the global population is experiencing rapidly emerging trends of ageing, and it is
implicated that by the year 2050, a significant 16% of the population worldwide will reach the
age of 65 years and beyond (26). In accordance to the ‘World Population Ageing 2017’ report
presented by the United Nations, individuals aged 65 years or beyond, comprised of over 962
million of the global population worldwide, and the amount is estimated to double by the year
2050. Such rapid trend of global ageing is a resultant factor of an interplay of factors such as
enhancement of quality of life and life expectancy rates and reductions in the rates of fertility.
Hence, considering such rapid increments in the rates of ageing, every society will be compelled
to address the complex needs of elderly individuals. Hence, it is an urgent call for governments
to consider the implementation of key policies and programs to address such needs such as
healthcare, housing, employment and social support (27).

1990 2015 2050 2100
0.5
0.9
2.1
3.2
Ageing population projections
Projected year
Population in billions
Figure 1: The figure showing the projections of the world’s ageing population (28)
1.2.2. Ageing population trends across Asia
As stated by the report presented by the United Nations Economic and Social Commission for
Asia and the Pacific, the continent of Asia is undergoing an extremely rapid rate of ageing of the
population, with the estimate that out of four individuals, one will be of the age of 60 or beyond,
by the year 2050. The expansion of the population from 535 million in the year 2015 to an
estimated 1.3 billion by the year 2050, further presents a host of challenges for the governments
of the respective countries in the Asia Pacific region, as well as for the Economic and Social
Commission for Asia and the Pacific, to undertake key policy implementation, for the purpose of
fulfilling the unique needs of elderly individuals (28).
Such alarming increments in the rates of ageing of the Asia Pacific regions are due to two major
causative factors. The first causative factor is the significant reduction in the rates of fertility,
with an estimated decline by almost 50% in the regions of South-East Asia, South and South-

West Asia, within a span of 4 decades. The second factor advancements in science and
technology, the accessibility to quality nutrition and healthcare services have resulted in the
enhancement of the rates of life expectancy in the global population, hence, resulting in
alarmingly high rates of ageing in the continent of Asia Pacific (29).
Table 1: Population of the elderly (60+) in different regions in Asia from 2012-2050
Sub-Region/ Population of the Elderly Proportion of the Elderly (%)
Region 2012 2015 2012 2050
Eastern-Asia 237* 521* 15 35
South-Central Asia 138* 473* 8 9
South-East Asia 53* 183* 9 24
West-Asia 17* 73* 7 19
Asia 446* 1,252** 11 24
* In millions
** In billions
Source: UNDESA 2014 (75)
1.2.3. Ageing in Malaysia
In Malaysia, the Department of Statistics estimated that approximately 9.1% of the population to
be comprising of individuals in the age group of 60 years and older, in the year 2015. Further,
this percentage of elderly individuals were estimated to be more than the population of children

under the age of 5 years, by 0.6 % - a value that has contributed the alarming rate, within a
span of 30 years. In addition, as estimated by the National Population and Family Development
Board of Malaysia, the country is estimated to gain the status of an ‘ageing population’ with over
15 % of the population comprising of elderly individuals, in the year 2035 (30).
Additional statistics presented by the Malaysia Population and Housing Census in year 2010,
estimated that a majority of the aged population of Malaysia comprised of females, with the
states of Perak and Perlis exhibiting some of the highest rates of ageing in the nation. Among the
diverse ethnic groups residing in the nation, the highest trends of ageing were noted in the
culturally diverse groups of Indians and the Chinese (31).
A population which is undergoing rapid ageing presents considerable economic and clinical
challenges to a nation, necessitating the governmental allocation of a significant proportion of
funds and policies in order to ensure healthy ageing. Hence, for this reason, the rapid rates of
ageing in country, attracts considerable attention from the governments, who further aim to
execute amendments for the purpose of successful, healthy and dignified ageing among the
elderly, considering the various physiological, psychological and economical challenges which
this significant stage of life is subjected to (32).
Table 2: Some statistics of Malaysia
Malaysia 2013
Landmass (Square kilometer) 329, 847
Total population 29, 628,392
Population <15 years (%) 7,741,432 (26%)

Population 15-64 years (%) 20,352,721(68.5%)
Population 65 years and above (%) 1,602,634 (5.5%)
Total Birth rate (per 1,000 persons ) 17.2
Total death rate per (1,000 persons) 4.7
Total fertility rate (Children per woman) 2.1
Life expectancy at birth (Years) 74.9
Men 72.6
Women 77.2
Source: Department of Statistics Malaysia (74)
Table 2: Shows some vital statistics of Malaysia. These factors contribute to the growing
population of the elderly in Malaysia.
1.2.4. Impact of ageing in Malaysia
The phenomenon of population ageing presents a host of wide range of challenges to a nation’s
economic and social development. One of the primary effect of ageing on a population is the
increased demands on housing. The aged population presents a multitude of complexities and
challenges in the performance of daily life activities, which have impacted the types of housing
and residential demands. This is further poorly resolved due to lack of capacity and knowledge
among engineers and designers in modelling and developing the appropriate residential care
facilities with specialised living standards and arrangements for the elderly (33).

The ageing population also leads to significant impacts on the healthcare and clinical services
for the elderly. Despite the recorded advances in medical science, the increased rates of life
expectancy and the associated ageing processes also increases an individual’s susceptibility to
infectious diseases as well as various complications of co-morbidity. An increasing ageing
population hence places considerable demands in existing healthcare services necessitating the
availability of healthcare policies and programs formulated in accordance to the unique needs of
the elderly, resulting in significant financial impacts due to the government (34).
Another related key challenges of the nation is the management of the social needs of the elderly
individuals. The various detrimental cognitive and functional deficits present in the elderly, often
require the availability of adequate social networks and social interactions. Hence, considering
the significant social impacts exhibited by the aged population, the government of Malaysia will
be required to undertake key policy undertakings and programs which will aim to enhance the
availability of various social activities for the elderly individuals to engage in, in order to ensure
their mental and cognitive well-being and reduce the detrimental impacts associated with ageing
(35).
Another concern that needs mentioning is the changes associated with the dynamic alterations in
the social structure, as evident in the gradual diminishing of the nation’s traditional cultural
system of family support. The high outflow of youth out of their homes to look for jobs has led
to the gradual break-up of the family network and structure. Hence, the need of the hour is for
the Malaysian government to adopt strategies aimed at enhancing public literacy levels and
awareness concerning the implications and needs of ageing, followed by improvements in
infrastructure and research, which will result in key legislative changes aimed at obtaining

positive health outcomes and healthy ageing, not just among the existing elderly population but
also among the future populations of Malaysia (36).
1.2.5. Aged-care Worldwide
As reviewed in the previous paragraphs, with the onset of advancements associated with
treatments and healthcare, there has been rapid improvements in the quality of life of individuals,
leading to increments in the rates of life expectancy. However, the high rates of longevity are
associated negatively with a greater susceptibility to acquiring life-threatening diseases hence
resulting in high co-morbidities or a condition of multi-morbidity (15).
The ageing landscape has seen significant expansions in the market share by institutions and
organizations aimed at providing geriatric care. Such trends have also witness the growth of
private consolidation of aged care residential services as well as health centres, as observed in
the United Kingdom, which witness the growth of over 63% in the field of aged care service
centres which have been own privately (37).
Caring for the elderly population also necessitates incorporation of the presence of loved ones
and the comfort of home with elderly individuals opting for home-based treatment utilising a
patient centred or family centred approach to treatment. Often this is the better option
considering the high susceptibility of infections associated with hospital stays. Preference of
home based treatment with their near and dear ones, usually secures greater dignity, higher levels
of safety and increased possibilities of receiving personalised treatments (38).
In addition to the administration of quality healthcare treatments and clinical surroundings,
family support and parent-child relationships continue to be the key determinants associated with
the present day trends of aged care (39).

An additional key trend in the provision of aged care services worldwide is the greater
inclination towards preventive approach rather than direct disease treatment, later associated with
higher financial implications due to their diverse and complex physiological and psychological
needs and demands of the elderly. Such approach as been well adopted by countries across the
continents of Europe, America as well as Asia, placing greater emphasis on the execution of
health promotional activities which includes imparting information to the public on the
characteristic changes associated with ageing and the required preventive measures (40).
1.2.7. Aged-care services in Malaysia
In Malaysia, the provision of healthcare services is managed by the Ministry of Health of the
Malaysian Government. The Ministry of Health is the key authoritative body ensuring the
adequate functioning of public and private clinics as well as governmental hospitals aimed at
providing services for the elderly. The sector of aged care services in Malaysia comprised of
retirement homes, aged care resorts and acute care centres aimed at providing institutionalized
and intensive aged care services. The Ministry of Health also undertakes training and education
of medical personnel and sets the eligibility criteria for workforce aiming to engage themselves
in the care of elderly individuals. Nurses or any associated healthcare staff are eligible for
employment in elderly services if they possess undergraduate and post graduate degrees nursing
with specialisation in palliative care, family medicine as well as oncology (41).
The high importance that are given to societal importance to family support system, has
propelled the presence of home care and home aid services which are are rapidly gaining
momentum in the provision of aged care services in Malaysia. Traditionally in Malaysia, aged

elders prefer to receive care from their children and family members. However, with the rising
rates of employment coupled with financial constraints and lack of available medical facilities at
home, adults are finding it increasingly difficult to maintain balance between their professional
and personal lives including the caring of their parents. These home care services is an inevitable
option aimed to reduce the familial difficulties in aged care, through the provision of in-house
nurses who will be employed to perform personalised care for the elderly Malaysians in the
comfort of their homes and in the vicinity of their near and dear ones (42).
1.2.8. Elderly’s arrangement of sources of income and its consequent well being
The upcoming silver population have different financial arrangements or sources in which they
rely on, but through the literature, it has been noted that in general, the main sources of income
that were focused on were welfare or government assistance, family or most precisely, children,
and savings or independent sources such as pensions (43-48). With various sources of financial
reliance, the quality of life of the elderly is consequently affected whether in a negative or a
positive direction. With government involvement and attention to this particular population,
welfare programs and assistance is of a positive influence of the quality of life of the elderly
giving a sense of importance and a secure feeling of being cared for and protected (49, 50) while
in countries where there is a lack of government social or financial assistance programs, a
difficult situation is bestowed upon the elderly in various aspects including healthcare (51). Also
worth mentioning is that other self-preserved terms of financial investments such as pension
schemes do have a positive influence on the lives of the senior population (44, 49), and as other
forms of future financial investment, parents will invest in their children as a source of later
support when time of need arrives (47) this arrangement between children and parents showed
positive influence in the lives of older adults especially in psychological terms (47) on the other

hand, with the increase trend of families having less number of children and increased migration
aspirations of adult children, a threat to elderly’s well-being is ensued in the future (43).
1.2.9. Private (for profit) and public (not for profit) aged care facilities
As the senior global population is increasing in number, the demand on providing care is
projected to double within the next 40 years ()and with that a great number of aged care facilities
are being privatized (52). Countries such as United States, United Kingdom, and Canada already
possess private aged care facilities twice as much compared to public owned ones (53).
It is often assumed that the quality of care in the not-for-profit aged care facilities is much lower
than the for-profit counterparts believed to be due to the lower competition and ineffective
consumer choices, where not-for-profit nursing homes provide lower quality of care in many
important areas of process and outcome (21). On the other hand, some studies have shown that
the available evidence does not permit strong conclusions about the association between nursing
homes characteristics and residents’ QOL (54). Furthermore, when comparing privatized aged
care facilities with public ones, it was observed that while public aged care facilities do have
better staffing which has been identified as a key indicator in quality of care and personal-
individualized accommodation options for their elderly residents, the quality of care in public
aged care facilities perform better in review of medications and screening for health-hazardous
predispositions such as screening for falls, malnutrition, and a decrease in mortality(57). Studies
also suggest that private owned facilities tend to have fewer nurses and fewer time for care per
resident (58).

Table 3: Elderly Homes in Malaysia in 2007
Type of Home No. of Capacity No. of Status in year
Homes Residents 2003
Government 80 1,788 823 Annual Grant-
Homes RM 1.8 million
NGO Homes 12 - 751 Annual Grant-
Receiving grant RM 976,041
From SWD
Private Homes 45 - - Registered under
Under Care Act 1993
NGO Homes 20 - - Registered under
not receiving grant Under Act 1993
Source: Malaysia’s Social Welfare Policies [74]
Table 3: shows the number of registered homes in Malaysia in 2007. About 12 NGO homes
collaborated with the DSW, and there were about 45 Private Homes, 80 Residential care
homes for the elderly and 20 Non-profit NGO homes.

1.2.10. Aged-care services : workforce characteristics and challenges
Elderly healthcare services from across the world, are highly dependent on the nursing workforce
specializing in palliative and home care nursing. The role of the registered nurse as well as the
advanced practising nurse play key roles in the provision of nursing services worldwide. In the
United States for example, nursing personnel recruited for aged care services includes a total of
60 % of registered nurses, licensed practical nurses, licensed vocational nurses and assistants in
nursing. Further, the Institute of Medicine’s establishment of the existence of positive
relationship between provision of quality aged care and availability of nursing workforce, has
further necessitated the need for aged care institutions worldwide to recruit licensed and
advanced practicing nurses who are registered (58).
Having adequate number of nurses is paramount to ensure quality of care. A cross sectional
study conducted in an elderly care nursing home facility in Korea proven there was positive
associations between increased number of registered nurses in aged care and quality of care
provided activities such as tube feeding, prevention of falls and enhancement of mobility (59).
Another study showed that extended care hours provided by the staff produce positive
associations between extended staffing care hours and deliverance of quality care among the

aged residents, hence necessitating the usage of effecting workforce retention strategies by age
care organizations worldwide, during the provision of elderly care services (60).
Whilst nurses are critical for the provision of care for the elderly the industry is challenged with
high rates of turnover among nursing staff recruited for the deliverance of aged care. Amongst
the changeable factors associated with high rates of turnover among aged care nursing staff were
shared by a study published in the International Journal of Nursing Studies. They include:
demanding occupational situations leading to reduced performance of coping strategies and lack
of support from co-workers and supervisors along with physically and psychologically
demanding job situations (61).
A study conducted in Adelaide, Australia (62) found that the provision of a specialist care would
offer better outcomes in addressing the various complex needs of the elderly individuals. The
interdisciplinary or multidisciplinary approach was adopted using the case conference
intervention comprising of a team of various multidisciplinary health professionals; residential
staff, pharmacist, general practitioner and geriatricians, has been proven to be effective. This
study was done in a cluster randomized control trial, performed in to evaluate the impact and
effectiveness of multidisciplinary care conference on the adequacy of administration of
medications and behaviours of patients in 10 high quality, aged residential care settings. The
study lead to positive outcomes medication appropriateness among patients and nursing practice
as measured through the aid of tools such as the Medication Appropriateness Index and the
Nursing Home Behaviour Problem Scale.

Another important component of the workforce that should not be dismissed are the care-givers.
They in fact form the majority of providers. They however are not without challenges. Many of
them do suffer depression. A cross sectional study in Taiwan found the underlying causative
factors of depression among family caregivers in an aged care residential facility were those with
risk factors namely: being lack of experience, young age, low educational levels,self-perceived
health status and assuming the huge responsibilities as the major care giver of an elderly patient
in the centre (63).
1.2.11. OECD Countries: Global Accreditation Standards
The global concern towards aged-care has rippled quality initiatives towards creating a global
accreditation standards for aged healthcare care services across several OECD countries nations.
The five key initiatives encompassed: formulation of increased acceptability and understanding
of the instruments of healthcare used by international organizations, enhancing the
implementation of such internally recognized healthcare instruments across countries, ensuring
the engagement of stakeholders across nations, development of a culture of increased evaluation
of healthcare resources and instruments and increasing the availability of opportunities
associated with collaborations between healthcare organizations across various nations (64).
1.2.12. International Society for Quality in Health Care
Another quality effort was initiated in October 2015 by International Society for Quality in
Health Care (ISQ) in Doha, Qatar. Participated by many countries the conference concluded the
need for development of aged care policies and practices, which will involve collective

participation and funding from across the world, for successful implementation of aged care
treatment frameworks (65).
1.2.13. The Malaysian Private Aged Care Facilities Services Act 2017
The quality of care in aged care homes in Malaysia have been in much debate in the mass media,
although not many hard evidences have been shared on the magnitude of services being
provided. Driven by the need to ensure appropriate standards be observed by the private aged-
care facilities, the Malaysian Private Aged Care Facilities Services Act was executed in the year
2017 by the Ministry of Health in Malaysia. The main objective is to regulate the function of
aged care facilities for the provision of quality care and services for the elderly population. In
accordance to the Act, the aged care facilities concerned with deliverance of healthcare services
for the elderly must ensure the availability of staff well trained and competent in basic life
support care along with the provision of mechanism of grievance for any elderly patient or
associated family member during the filing of any complaints. The bill further enhanced
governmental regulation over healthcare centres through mandatory inspection by officers of the
director-general for the purpose of assessing the quality of life of elderly patients residing in the
same, along with granting governmental power to close the centre in case of non-compliance to
certified quality standards in aged care (66).

1.2.14. Quality of Life
The World Health Organization defines “Quality of Life” as the perception of an individual
concerning their life position in accordance to their unique values and cultural standards as well
as personal characteristics in terms of goals, expectations, standards and concerns. Likewise, the
quality of life of an individual is determined by key factors such as emotional wellbeing, social
functioning and the overall health of the individual, mentally and physically (67).
1.2.15. Quality of Life across the elderly population
For the formulation of treatment procedures of the elderly, Quality of Life (QOL) serves to be as
a key determinant. The consideration of QOL is essential for the formulation of healthcare
procedures for elderly individuals engaged in residential and assisted living services.
Additionally, QOL serves as a key determinant of the psychological and physiological needs of
the elderly patients who are suffering from severely debilitating disease conditions. Further, the
QOL for elderly patients receiving institutionalized care has been documented to be lower as
compared to those receiving community oriented healthcare services (68).
1.2.16. Determinants of Quality of Life
Four key determinants affecting the quality of life are addressed here. Firstly , individual’s
health, since poor health status is associated with greater prevalence of detrimental disease
conditions which grossly affect the progress of a society (69).

Secondly, presence of adequate education is also a key determining factor of the quality of life of
an individual since low educational status reduces an individual’s chances of employment along
with the associated difficulties in achieving prosperity and adequate financial status (70).
Thirdly the presence of adequate social networks are key determinants of an individual’s quality
of life since adequate interactions with the community enhances one’s social wellbeing while
social isolation and loneliness hinder the same (71).
Finally, the characteristics of the facility in which elderly patients are residing is a major
determinant of the quality of life of the elderly. Residential care facilities and aged care centres
which provide elders with greater autonomy and freedom to participate in social activities and
decision-making process in their treatments, result in healthy social wellbeing and an improved
quality of life (72).
1.2.17. Quality of Life in the elderly
Some general characteristics of the elderly in relation to QOL. Studies conducted by Takemasa
et al. (73) in 2011 in Turkey. showed that elderly with a higher age above 80 years have a poor
QOL compared to the younger elderly below 70 years. Elderly men are more likely to have a
better QOL than the women according to the Its also considered that the single seniors are more
prone to having a poorer quality of life compared to those who are married.
Studies in Malaysia showed there were ethnics predominance, with Chinese and Indian
ethnicities are more vulnerable to having a poor Quality of life than those who are of Malay
ethnicities. Furthermore, seniors with religious beliefs have a better quality of life compared to
those without religious backgrounds. And the elderly with a higher educational level are more

likely to have a better quality of life than those who don’t. Those elderly persons diagnosed with
stroke, hypertension and heart diseases, visual and renal impairment, are likely to have a poor
quality of life that those elderly without these conditions since such impairment require more
attention and supervision (74).
As for depression amongst elderly, those with a higher level of social support are more resistant
to depression and therefore have a better quality of life than those without concrete social
support (75).

2…. Problem Statement
A minority of the ageing population are getting services from aged care facilities in Malaysia.
However, the number is showing an increasing trend for both the facilities and the number of
residents. The profiles of the staff and services offered by these facilities and the overall quality
of life of the residents utilising these facilities have not been published this far, and it’s the aim
of this study to contribute to this body of knowledge (76).
2…..Research Questions
What is the general current profile of the aged care facilities?
What are the current profiles of private and public facilities in terms of the personnel
characteristics , facility characteristics, and the quality of the elderly life of the elderly residents
in the states of Kuala Lumpur and Selangor?
 What are the types of services and are there differences between the public and private
age care facilities?
 What are the types of personnel providing care and are there differences between the
public and private age care facilities?
 What is the ‘Quality of Life’ of the residents in these aged care facilities and their
differences between the public and private age care facilities?
1.3 Research objectives:
1.3.1 General objective:

To profile the aged care facilities, personnel characteristics and the quality of life of the elderly
residents in these facilities in KualaLumpur and Selangor.
1.3.2 Specific objectives:
1. To determine the types of services currently available provided by the aged care facilities in
public and private aged care facilities
2. To assess the types of personnel providing care in these aged care facilities in public and
private aged care facilities
3. To identify the quality of life among elderly residents in aged care facilities in public and
private aged care facilities
2.2 Hypothesis
First Hypothesis
Ho: there is no association between Quality Of Life of the elderly resident and ownership of the
aged care facility.
HA: there is an association between Quality Of Life of the elderly resident and ownership of the
aged care facility.
Second Hypothesis
Ho: there is no association between perception of health of the elderly resident and ownership of
the aged care facility.
HA: there is an association between perception of health of the elderly resident and ownership
of the aged care facility.
Third Hypothesis

Ho: there is no association between source of income of the elderly resident and their decision to
enter an aged care facility.
HA: there is an association between source of income of the elderly resident and their decision to
enter an aged care facility.
1.1 Research justification:
Following several OECD countries that have established accreditation standards for their aged
care residential homes such as Sweden, Netherlands, Australia, Japan and Germany (25), the
Malaysian Government has also just passed the new “Private Aged Healthcare Facilities and
Services Act 2017” (26). The regulations however are still being developed. The standards,
processes and procedures that will be instituted are expected to regulate the more than 1000 aged
care facilities that are yet registered but providing care (27). The status of these facilities, their
background and types of services are not within the inventory of the government. The types of
residents that patronizes these services are also short of being adequate to know what are their
essential needs, their health and well-being and how much of their Quality of Life have been
addressed. It is hence imperative that the profile of these facilities are examined so that it
provides the characteristics of these facilities and residents. It is hoped that the findings can
contribute to the stakeholders in their strategizing the implementation of the new regulations,
whichhas the bigger agenda to serve the elderly Malaysians in a proper, fulfilling manner.
1. Chapter Three –Methodology
a. Study design
b. Study samples
c. Ethical issues

d. Selection of subjects
e. Sample size
f. Sample and data collection
g. Statistical analysis
Chapter Three
Methodology
2.2 Study design and target population:
This was a cross-sectional in-facility based study of the aged care facilities in the states of Kuala
Lumpur and Selangor.
2.9 Ethical considerations:
Before starting this research, full approval from the IMU (International Medical University)
research and ethics committee was obtained. This also include approval from Institute of
Gerontology, University Putra Malaysia, for using their validated questionnaire as study
instruments, and the acceptance of the co-supervisor from the same institution. On the day of the
facility visit, an introduction and a brief explanation of the data collection procedure were
explained to the facilities staff and residents. It was also elaborated that at any time or point
during the data collection, questions risen either from staff or residents will be answered by the
lead researcher or enumerators.
Contact details (ex, phone numbers, emails.) were exchanged between researcher and the facility
managers, staff, and residents for future reference.
2.3 Study samples

Sampling frame and sampling size:
The Malaysian social welfare department portal, “portal rasmijabatankebajikanmasyarakat”, is
the official list of aged care facilities in the country and it served as a sampling frame for the
study. The names and contact details of all aged care facilities are listed.
2.5 Sampling and selection criteria:
In this study, all facilities that were listed within the Malaysian social welfare department portal
were candidates for inclusion in this study. There were 113 facilities out of total for the country
….. listedfor the two states of KL and Selangor. There were 20 facilities in KL and 93 facilities
in Selangor. As the study data collection period allowable by the IMU is only 14 days,
permission to collect only 14 facilities were approved by the JC (to check full name).
The 14 facilities were chosen using stratified simple random sampling. To sample the facilities
between KL and Selangor, they were proportionately allocated using 20:93 giving a 3:11
proportion accordingly to make up the 14 in numbers. See the formula below:
Using this formula: (sample size/population size) x stratum size:
Number of Facilities = 14
from Kuala-lumpur ( )× 20 = 2.47 = 3 facilities
113
Number of Facilities = 14
From Selangor ( )× 93 = 11.15 = 11 facilities
113
From the 20 and 93 facilities lists above the public and private facilities were not further
stratified by states, but subject to the random sampling with replacement.. Simple random

sampling was then employed using Microsoft excel. After the 14 facilities have been chosen,
some gave initial consent to participate in the study to decline on a later notice and other gave
dates for a visit and cancelled upon the arrival of the researcher, therefore a delay in the data
collection time frame was incurred.
The facilities that refused participation were replaced by the same method of simple random
sampling by Microsoft Excel.
For the residents and staff of each facility selected, all idividuals were to participate in the study
given their consent for participation and their fulfilment of the inclusion criteria.
Inclusion and exclusion criteria
With the 14aged care facilitiesselected,universal sample of the facilities, staff and elderly
residents were included using the following criteria:
Inclusion criteria:
 Elderly residents 60 years old or above.
 Elderly residents residing or living in the aged care facility.
 Elderly residents who can communicate in English or Bahasa Malaysian language.
 Elderly residents that give consent or accept being part of the study.
Exclusion Criteria:
 Elderly residents with mental capabilities.
 Facilities resident aged below 60 years old.
 Elderly residents not residing or living in the aged care facility.
 Elderly residents that refuse or are incapable of giving consent of the study.
 Elderly residents that can’t communicate in English or Bahasa Malaysian.
2.4 Study duration:
This study commenced on the 1st of September 2018 to December 18th 2018. There were delays
in the completion of data collection due to few cancellations, replacement and rescheduling that
needed to complete the 14 facilities.

2.6 Sample and data collection:
After acquiring the listed aged care facilities throughout the Malaysian social welfare portal, and
preforming stratified simple random sampling, the 14 chosen facilities contact number were
obtained from the mentioned internet portal and contacted via phone call to obtain permission
and consent to be a part of the study, furthermore, to explain about the purpose and details of the
research. Those facilities that accepted were included in the study and those who refused to
participate were removed from the sample list and the next facility will be contacted.
During the calls that were made to the selected facilities, the number of staff and residents were
obtained in order to prepare for the field visit.
Before commencement of the research or survey visits, a small team of enumerators consisting
of four individuals were briefed on the objectives of the study, how the interview should be
carried out, and other details pertaining the research. Prior to starting the in-facility survey, an
introduction was made to the staff as well as residents of the facility elaborating the time it
would take and the purpose of the interview questionnaire. Individuals, especially residents, who
refused to participate or were unable to, were not included. And the rest of the staff and residents
will be interviewed. Using three different questionnaires adapted to acquire information about
the facility, its staff, and its elderly residents.
2.7 Operational definitions:
 Elderly residents:
Aged care facilities residents, of 60 years of age or above.(5)
 QOL:

individuals perception of position in life in the context of the culture and value systems in
which they live and in relation to their goals, expectations, standards and concerns.(6-9)
2.8 Research instruments:
The study instruments used in this study were an adapted version of 3 questionnaires from the
Institute of Gerontology, University Putra Malaysia, in which they were used in previous studies
of the institute, and the WHOQOL BREFF questionnaire.
I. Questionnaires from the Institute of Gerontology, University Putra Malaysia:
In a study conducted in 2013 under the name (Issues and Challenges of Residential Aged Care
Institutions in Selangor and Kuala Lumpur), The Institute of Gerontology, University Putra
Malaysia utilised 3 questionnaires to conduct the study. Set A questionnaire, was aimed at the
residents of the facilities, Set B, aimed at the staff of the facility, and Set C, aimed to gather
facilities information. These questionnaires were modified and adapted from the NSRCF 2010
(National Survey of Residential Care Facilities) that was used in the U.S. residential care
providers, their staffs and services, and their residents. in which, a pilot study was done in 2008
to pre-test the surveys methods, protocols, and questionnaires. As a result, data was collected on
2,302 facilities, and 8,094 residents in the U.S.(10).
II. WHOQOL BREFF questionnaire:
The WHOQOL-BREFF, which is a shorter version of the WHOQOL-100, was developed with
the help of 15 collaborating centres around the world as a tool for measuring quality of life. It

has been adapted to more than 20 languages, including Bahasa Malaysian, to be utilised in
different countries and cultural settings. It has been shown to display good discriminant validity,
content validity and test-retest reliability over the years and it includes four main domains,
psychological, social, environmental, and physical, each question is measured by a likert scale
with answers ranging from 1, lowest score, and 5, highest score..(6-9)
Using modified Questionnaire of I and II.
For this study, due the huge volume of the UPM Questionnaires they were furthermodified with
few questions dropped. Several discussions were held to check there are no major structural
changes to the questionnaire context being used. The final versionswere pre-tested on 10 persons
to look at the sequence and their understanding of the “cropped” questionnaire”.
The Bahasa Malaysian version of WHOQOL BREFF was also pre-tested and validated by a
study conducted by UniversitiSains Malaysia, Medical Sciences Department and have been
shown to offer a valid and reliable assessment of quality of life, demonstrating good discriminant
and construct validity, internal consistency, and test-retest reliability.(11)
2.10 Data analysis:
The data obtained from this research was analysed using IBM SPSS (Statistical Package for
Social Sciences) version 21. The variables were expressed in terms of Means, proportions, and
standard deviations.

Chapter Four
Results
The study location
KualaLumpur, and Selangor were the two states selected as they together have the highest
number of age facilities listed in the list. Kuala Lumpur is the capital of Malaysia and is
considered the largest city in it(1). It encompasses the states of Kuala Lumpur and Putrajaya,
covering an area of 243 km2 (94 sq mi), and a total population of 1.79 million(2). It is also
considered as the cultural, financial and economic focal point within Malaysia. Selangor, which
is also known as Selangor Darul Ehsan(3), covers an area of 7,931 and holds a total population
of 6.38 million(4). Both these two states together have areas that are very urban and some parts
are rural.
The study setting took place in 14 aged care facilities within these two states areas and
comprised of two types of facilities namely private that is for profit and public and NGO grouped
as non-profit facilities. Their residents are from various races, but their registration criteria may
vary with the following practice: race base, gender base, mobility status, and financial status.
The facilities that were chosen are as listed in the table below:
Aged care facilities and number of residents included in this study
Facility name Total
number
of
residents
Residents
accepting/
are eligible
to
State Public /
Private

participate
1 RumahWargaEmasBerniece 16 14 KL
2 Attia global aged care centre 17 15 KL
3 Selangor king v silver 25 12 KL
4 Pusatjagaanebenzer home 25 11 Selangor
5 Jaspers lodge 50 10 Selangor
6 Pusatjagaanpersatuankebajikanrumah
grace
25 13 Selangor
7 My aged care 7 6 Selangor
8 PJ wargaemaspenyayang 22 15 Selangor
9 Pertubuhankebajikanchester
Selangor
42 23 Selangor
10 Rumah orang tuaampang 50 13 Selangor
11 Calvary sunshine 8 4 Selangor
12 Belinda aged care home 6 3 Selangor
13 RumahsejahteraseriKembangan 15 7 Selangor
14 Noble care aged care home 21 5 Selangor
Total 329 151
3.1 Residents profile

3.1.1 Basic and sociodemographic characteristics
The sociodemographic pattern of the residents was analysed and the Chinese race 86%
represents the highest with using the aged care facilities with the lowest amongst the Indians.
48% of the residents aged 70 and above. Majority of the residents were Buddhists followed by
Christians.(Table 3.1).
Table 3.1 Residents basic and sociodemographic characteristics.
Demographic Profile of the Residents Frequency (N = 151) Percentage (%)
Ethnicity
Malay 4 3%
Chinese 130 86%
Indian 16 11%
Other 1 1%
Age
59 and under 1 9%
60-69 39 25%
70-79 65 43%
90-99 8 5%
Resident Religion
Islam 3 2%

Buddhism 94 62%
Christianity 39 26%
Hinduism 9 6%
Other 6 4%
(Frequency Analysis)
The percentage of respondents that are still married and using this services is only 8% with the
rest 92% either never married, divorced separated or widowed. More than 40% have less than 2
siblings alive and more than 45% of the residents have no children (Table 3.2).
The children and the welfare department are the main financial supporter of the residents. This
coincides with the children also making decision on the placement of the elderly in this facilities.
Whilst more 72% said the decision was decided by others, 60% of respondent definitely said that
decision was not theirs (Table 3.2).
It was heartening to note that the majority of the respondents (75%) have said that they never
find it difficult to communicate with fellow staffs due to language. 66% of them dependent on
the staffsadministers medicine (Table 3.2).

Table 3.2 Residents basic and sociodemographic characteristics and source of income
Resident Marriage Status
never married 59 39%
now married 12 8%
divorced / separated 18 12%
Widowed 62 41%
Siblings alive
Less than 2 88 58%
2 or more 63 41.7%
Children alive
None 68 45.0%
1 to 3 69 45.7%
More than 3 14 9.3%
Sources of income
other 1 1%
business 1 1%
rent 1 1%
children 58 38%
grandchildren 1 1%

relatives 7 5%
welfare assistance 71 47%
pension 11 7%
Was it resident decision to enter
yes 61 40%
no 90 60%
Did resident choose facility or chosen by family
self 42 28%
spouse 2 1%
children 63 42%
grandchildren 1 1%
relatives 16 11%
friends 14 9%
others 13 9%
Difficulty communicating with staff due to language
Always 8 5%
Sometimes 31 21%
Never 112 74%
Who administer medicine to resident

myself (resident) 48 32%
Family 1 1%
Staff 99 66%
Others 3 2%
(Frequency Analysis)
3.1.2 Inferential Statistics for residents Quality of Life
The association between quality of life and gender of the residents were tested using independent
sample t-test. It was found that there is significant difference between the physical domain of
QOL and gender of the residents, t(149) = -2.129, sig= 0.035. The mean physical domain of
females (12.29 ±2.86) was found to be higher than the mean physical domain of males (11.26 ±
2.73).There were no statistically significant differences in psychological, social and
environmental domain between gender, p-value > 0.05. (Table 3.3)
Table 3.3 - Inferential statistics for Quality of Life domains
Quality of life
domains
Gender Frequency Mean (SD) t df Sig.
Physical
domain
Male 53 11.26 (2.73) -2.129 149 0.035
Female 98 12.29 (2.86
Psychological Male 53 12.17 (2.61) -0.657 149 0.512

domain Female 98 12.48 (2.84)
Social domain Male 53 10.26 (4.05) -0.294 149 0.769
Female 98 10.46 (3.8)
Environmental
domain
Male 53 11.36 (2.57) -1.490 149 0.138
Female 98 11.97 (2.31)
(t-test)
While the association between Quality of life and gender of residents was statistically significant,
the association between Quality of Life and Ethnicity of the residents shows that there is no
statistical difference between the four QOL and Ethnicity, sig > 0.05. (Table 3.3)
Table 3.4- Quality of Life and Ethnicity of residents.
Ethnicity
Malay Chinese Indian other F Sig
Physical Domain 11.3 (2.9) 11.8 (2.9) 12.8 (2.9) 13 (.)
0.68
4
0.563
psychological domain 11.5 (3.7) 12.4 (2.8) 12.3 (2.4) 15 (.)
0.43
3
0.729
social domain 6.8 (2.1) 10.4 (3.9) 11.6 (3.2) 7 (.) 2.01 0.115

2
environmental domain 11.8 (2.2) 11.7 (2.5) 12.6 (2) 10 (.) 0.8 0.482
(ANOVA)
3.1.3 association between source of resident’s income and their decision to enter aged care
facilities.
The study found that the association between a resident’s decision to enter a facility and their
source of income is statistically significant. 32% of residents who stated that it wasn’t their
decision to enter an aged care facility had their children as their main source of income, while
29% of residents who stated that it was their decision to enter an aged care facility depended on
welfare assistance.
Table 3.5 - Residents decision to enter a facility and their source of income
Was it the resident’s decision to enter facility
Yes No Total
Chi-
square
test
df Sig.
Source of income
34.934 7 0.000Business 1 (1%) 0 (0%) 1 (1%)
Rent 0 (0%) 1 (1%) 1 (1%)
Children 9 (6%) 49 (32%) 58 (38%)

Grandchildren 1 (1%) 0 (0%) 1 (1%)
Relatives 2 (1%) 5 (3%) 7 (5%)
Welfare assistance 44 (29%) 27 (18%) 71 (47%)
Pension 3 (2%) 8 (5%) 11 (7%)
Other 1 (1%) 0 (0%) 1 (1%)
(chi-sq test)
3.1.4 association between the residents decision to enter a facility and their QOL.
Was it the resident’s decision to enter facility
Yes No Total
Chi-
square
test
df Sig.
QOL
27.4744 0.000Poor 9 (14.8%) 50
(55.6%)
59
(39.1%)
Good 36 (59%) 23
(25.5%)
59(39.1%)
Neither 16 17 33

(26.2%) (18.9%) (21.9%)
(chi-sq test)
3.2 Staff’s profile
3.2.1 Basic and sociodemographic characteristics
The staff that were interviewed comprised of both the management and care-givers. It was noted
that due to the small size of staff in most facilities, the management and clinical and care-givers
multitask in providing care.
From the 55 staff members that accepted to participate in the study, majority 75% staff members
were female. 31% were Chinese descendants and about 18% are internationals from Philippines,
Sri-Lanka, India, Indonesia, and Myanmar.40% of staff members were Muslim and they were
practiced by the Malay ethnic and some of the internationals. 49% or majority of staff working in
these facilities reported they have never married.
Table 3.6- Sociodemographic profile of facility’s staff members.
Demographic profile of the staff Frequency Percentage
Sex of the Staff Members
Male 14 25%
Female 41 75%
Ethnicity of Staff members
Malay 14 25%

Chinese 17 31%
Indian 14 25%
Other 10 18%
Religion of the Staff Members
Islam 22 40%
Buddhism 6 11%
Christianity 16 29%
Hinduism 6 11%
Other 5 9%
Marital Status of the Staff Members
never married 27 49%
now married 23 42%
divorced / separated 2 4%
Widowed 3 5%
(Frequency Distribution)

The spectrum of staff education is almost evenly spread out from no education as many as 13%
to tertiary education at 33%. However only 18% have received relevant training, but a bigger
percentage of 50.9% did receive training within the facility.
The majority of the aged care facility staff had a full-time employment (90.9%), with 58.2 %
employed in the recent two years. Only 7% earns more than RM3000.00, with a maximum of
RM 6000.00 per month. The average income is RM 1757.00 and the minimum paid received is
RM 400.00 per month.
The staff working here view they pay received comes to perception of income adequacy with
49.1% stated that it was adequate for basic needs, Only 10% says that it was not adequate at all.
Table 3.7- Sociodemographic profile of facility’s staff members and work status.
level of Education of the Staff Members
no formal education 7 13%
primary education 10 18%
secondary education 13 24%
tertiary education 18 33%
Other 7 13%
Staff Completed relevant training
No 37 67%
Yes 18 33%

Work status
Full time 50 90.9%
Part time 5 9.1%
Trained in facility
No 27 49.1%
Yes 28 50.9%
Work status
Full time employment 50 90.9
Part time employment 5 9.1%
Started working in the facility
1988 – 1999 2 3.6%
2000 – 2010 8 14.5%
2010 – 2016 13 23.6%
2016 – 2018 32 58.2%
Monthly income
Less than 1000rm 11 20%
1000-3000rm 40 72.7%
3000rm or more 4 7.3%

Perception of adequacy of monthly income
Not adequate 10 18.2%
Adequate for basic needs 27 49.1%
Adequate for most things but not all 3 5.5%
Adequate for all things needed 7 12.7%
Adequate for all things needed and enough to save 8 14.5%
(Frequency Distribution)
1.2.2 Zarit burden test
The caregivers of residents completed the Zarit Burden Interview Questionnaire. Univariate
Analysis of the Zarit burden was conducted. The analysis showed that the males were less likely
to have a low Zarit burden compared to females. However, this difference is not statistically
significant. P value= 0.899. Furthermore, study also found that there was no association between
ethnicity and marital status of the staff members and Zarit burden χ2(1) = 7.676, p-value =
0.053(Table 3.7).
Chinese (12%) were less likely to have Low Zarit Burden as compared to Malays (7.0%).
However, this difference was not statistically significant (OR=0.000, 95%CI=0.000 -, P=0.999).

Indian (17%) were less likely to have Low Zarit Burden as compared to Malays (7.0%).
However, this difference was not statistically significant (OR=0.000, 95%CI=0.000 -, P=0.999).
Others (0%) were less likely to have Low Zarit Burden as compared to Malays (7.0%). However,
this difference was not statistically significant (OR=0.000, 95%CI=0.000 -, P=0.999).
Budhists (5%) were more likely to have Lower Zarit Burden as compared to Islam (7.0%). This
difference was statistically significant (OR=25.33, 95%CI=2.065 - 310.757, P=0.012).
Christians (7%) were more likely to have Lower Zarit Burden as compared to Islam (7.0%). This
difference was statistically not significant (OR=8.00, 95%CI=0.500 - 127.900, P=0.141).
Hindus (7%) were more likely to have Lower Zarit Burden as compared to Islam (7.0%). This
difference was statistically significant (OR=17.33, 95%CI=1.387 - 216.602, P=0.027).
Others (10%) were more likely to have Lower Zarit Burden as compared to Islam (7.0%). This
difference was statistically not significant (OR=4.00, 95%CI=0.265 - 60.325, P=0.317).
Similarly, Now married (17%) were more likely to have Lower Zarit Burden as compared to
Never married (15.0%). This difference was statistically not significant (OR=1.75, 95%CI=0.134
- 22.778, P=0.669).
Divorced or Separated (2%) were more likely to have Lower Zarit Burden as compared to Never
married (15.0%). This difference was statistically not significant (OR=1.14, 95%CI=0.088 -
14.776, P=0.919).
Widowed (2%) were less likely to have Lower Zarit Burden as compared to Never married
(15.0%). This difference was statistically not significant (OR=0.5, 95%CI=0.013 - 19.562,
P=0.711).

Moreover, primary education(12%) were more likely to have Lower Zarit Burden as compared to
no formal education (2.0%). This difference was statistically not significant (OR=2.40,
95%CI=0.165 - 34.928, P=0.522).
Secondary education(10%) were less likely to have Lower Zarit Burden as compared to no
formal education (2.0%). This difference was statistically not significant (OR=0.40,
95%CI=0.051 - 3.125, P=0.382).
Tertiary education (7%) were less likely to have Lower Zarit Burden as compared to no formal
education (2.0%). This difference was statistically not significant (OR=0.90, 95%CI=0.12 -
6.777, P=0.919).
Other education (5%) were more likely to have Lower Zarit Burden as compared to no formal
education (2.0%). This difference was statistically not significant (OR=2.00, 95%CI=0.256 -
15.623, P=0.509).
Table 3.6 - Univariate analysis of Zarit burden test
Correlates Zarit burden Total
survey
OR
95% CI /
df
p-
valueLow High
Gender
Male
4
(29%)
10
(71%)
14 (25%)
0.976
0.668 -
1.427
0.899
Female
11
(27%)
30
(73%)
41 (75%)
Ethnicity of Staff Members

Malay 3 (7%)
11
(27%)
14 (25%) 1 0.449
Chinese
5
(12%)
12
(29%)
17 (31%) 0.000 0.000 - 0.999
Indian
7
(17%)
7
(17%)
14 (25%)
0.000
0.000 -
0.999
Other 0 (0%)
10
(24%)
10 (18%)
0.000
0.000 -
0.999
Religion of Staff Members
Islam 3 (7%)
19
(46%)
22 (40%) 1 0.074
Buddhism 2 (5%)
4
(10%)
6 (11%) 25.33
2.065 –
310.757
0.012
Christianity 3 (7%)
13
(32%)
16 (29%) 8.00
0.500 –
127.900
0.141
Hinduism 3 (7%) 3 (7%) 6 (11%) 17.33
1.387 –
216.602
0.027
Other
4
(10%)
1 (2%) 5 (9%) 4.00
0.265 –
60.325
0.317
Marital Status of Staff Members

never married
6
(15%)
21
(51%)
27 (49%) 1 0.803
now married
7
(17%)
16
(39%)
23 (42%) 1.75
0.134 –
22.778
0.669
divorced /
separated
1 (2%) 1 (2%) 2 (4%) 1.14
0.088 –
14.776
0.919
Widowed 1 (2%) 2 (5%) 3 (5%) 0.50
0.013 –
19.562
0.711
Level of Education of Staff Members
no formal
education
1 (2%)
6
(15%)
7 (13%) 1 0.408
primary
education
5
(12%)
5
(12%)
10 (18%) 2.40
0.165 –
34.928
0.522
secondary
education
4
(10%)
9
(22%)
13 (24%) 0.40
0.051 –
3.125
0.382
tertiary
education
3 (7%)
15
(37%)
18 (33%) 0.90
0.12 –
6.777
0.919
Other 2 (2%)
5
(12%)
7 (13%) 2.00
0.256 –
15.623
0.509
Completed Relevant training of Staff Members
No 11 26 37 (67%) 0.903 0.654- 0.557

(27%) (63%)
1.249
Yes
4
(10%)
14
(34%)
18 (33%)
(Binary Logistics, taking covariate as Categorical variable)
There is significant association between staffs monthly income and completing any aged care
relevant training, apparently, having no relevant training is associated with increase in monthly
income as 23 out of 55 residents had a monthly income between 100 – 3000 rm, and all the staff
who were paid 3000rm or above monthly did not get any relevant aged care training either,
χ^2(7) = 34.934, sig = 0.000.
Table 3.8
Association between staff training and monthly income
Completed any relevant aged care
training Total
No Yes
Monthly income
Less than 1000rm 10 1 11
1000-3000 rm 23 17 40
3000rm or more 4 0 4
Total 37 18 55

(Frequency Distribution)
Chi-Square Tests
Value Df Asymp. Sig. (2-sided)
Pearson Chi-Square 6.472a 2 .039
Likelihood Ratio 8.295 2 .016
N of Valid Cases 55
(Chi-sq test)
1.3 Aged care facilities profile
14 aged care facilities were randomly selected through stratified sampling.It was found that 57%
are exclusively for older people. While 43% also serve other people such as post-surgical rehab
patients or homeless young individuals. Moreover, 86% of the facilities it is found serve older
people with physical disabilities. Only 12% (or 2 of the 14 facilities) surveyed do not serve
people with physical disabilities.
71% of the facilities provide ADL facilities directly. So it is seen that most of the facilities
surveyed provide ADL directly to the people. Only 29% of the facilities do not at all provide
ADL facilities. The investigation into the Aged care homes show that 57% of the facilities both

medical services and wound care services. while only 29% of the facilities are able to provide
feeding tube services.
14% of facilities provide physiotherapy services. Thus, most of the facilities (86%) do not
provide physiotherapy services. exercise wise, it is found that 93% of the aged care homes have
exercise scheduled. It was found that only 1 of the 14 surveyed did not include exercise in their
residents schedule.
Singing as a recreational activity was offered only in 36% of the facilities. Moreover, Crafts for
older people was available at only 7% of the institutions. In addition, only 14% of the places had
offered for religious lectures. Thus the analysis shows that in most of the facilities physiotherapy,
singing, crafts and religious lecture activities are not available.
Table 3.8 - Basic characteristics of aged care facilities
Basic Correlates of Facilities Frequency (N = 14) Percentage (%)
Ownership of the Institution
Private 7 50%
Public 7 50%
Serves exclusively Older People

Yes 8 57%
No 6 43%
Facility serve older persons with physical disabilities?
Yes 12 86%
No 2 14%
Provide Help with ADL
Directly 10 71%
Not at all 4 29%
Facility provide help with medical / healthcare Services
Yes 8 57%
No 6 43%
Provides wound care Services
Yes 8 57%
No 6 43%
Provides feeding tube services
Yes 4 29%
No 10 71%
Provides Catheter Services
Yes 6 43%

No 8 57%
Provides Physiotherapy Services
Yes 2 14%
No 12 86%
Facility Includes Exercise
Yes 13 93%
No 1 7%
Facility Includes Singing
Yes 5 36%
No 9 64%
Facility Includes Crafts
Yes 1 7%
No 13 93%
Facility Includes Religious Lectures
Yes 2 14%
No 12 86%
(Frequency Distribution)

All aged care facilities are provided with management staff (manager, supervisor, director), and
caregivers. The facility’s analysis showed that 64% of the facilities do not have doctors /
physicians. However, the questionnaire did not specify if it was visiting or resident
doctors/physician. The also showed 57% of the facilities do not have nurses, a bigger number of
71% of the facilities do not have physiotherapists. None of them has a counselor astheoir staff.
Table 3.8 - Aged care facility’s employees
Socio Demographic Correlates of
Facilities
Frequenc
y
Percentage
Facility has manager, supervisor or director
Yes 14 100%
Facility has Caregivers
Yes 14 100%
Facility has Doctor, Physician
Yes 5 36%
No 9 64%
Facility has Nurses
Yes 6 43%
No 8 57%
Facility has Physiotherapist
Yes 4 29%

No 10 71%
Facility has counsellor
No 14 100%
(Frequency Distribution)
The in facility services were for recreational activities for the residents. The study showed that
79% of the facilities had a Garden within the facility.All facilities had no place of worship nor a
swimming pool however all pare provided with a multipurpose hall.
Table 3.9 -In-facility services
Facility has Garden
Frequency Percentage
Yes 11 79%
No 3 21%
Facility has Rehabilitation Centre
Yes 1 7%
No 13 93%
Facility has place of Worship

No 14 100%
Facility has place of Multi-purpose Hall
Yes 14 100%
Facility has place of Swimming Pool
No 14 100%
(Frequency Distribution)
Residents are provided with private rooms or open ward living quarters. Majority (71%) are of
residents are provided with open ward living quarters.
Table 4.0 - Facility’s living quarters
Facility’s Living Quarters Frequency Percentage
Facility has one person living quarter
Yes 3 21%
No 11 79%
Facility has three person living quarter
Yes 3 21%
No 11 79%
Facility has four person living quarter

Yes 1 7%
No 13 93%
Facility has open ward living quarter
Directly 10 71%
Not at all 4 29%
(Frequency Distribution)
private and public aged care facilities.
From the 14 aged facilities sampled, 7 were private and 7 public aged care facilities. Analysis
were made to look for any significant differences between the type of services, personneland
quality of life of the residents between these two types of facilities.
The analysis showed that there were significant differences for all the services provided in the
private facilities as listed in Table 5, except for feeding tube services.
Table 5 - Characteristics of private and public aged care facilities.
Aged Care Facilities Private aged care
facilities
N= 7
Public aged care
facilities
N= 7
P-value
Types of Services provided by aged care facilities
ADL help 100 % 42% 0.007

Staff-administrating medicine 94.8% 5.2% 0.000
Medical/ healthcare services 85.7% 28.6% 0.025
Medical / healthcare services
directly through staff
85.7% 28.6% 0.025
Wound care services 85.0% 28.6% 0.025
Catheter services 57.1% 28.6% 0.276
Self-administrating medicine
(resident)
50.5% 49.5% 0.000
Feeding tube services 28.6% 28.6% 1.000
Physiotherapy 28.6% 0% 0.078
Medical / healthcare services
through volunteers
14.3% 71.0% 0.025
(t-test)
Similar findings were shown with 100% of private aged care facilities providing recreational
services and 85.7% of public aged care facilities do. While private aged care facilities depend on
their staff to provide these services (100%), only 14.3% of public aged care facilities depend on
their staff in providing these services and depend more on volunteers (85.7%) to deliver them.

Table 6 - Private and public aged care facilities providing recreational services.
Recreational services Private aged care
facilities
Public aged care
facilities
P-value
Provide recreational activities 100% 85.7% 0.226
Recreational activities delivered
by staff
100% 14.3% 0.000
Recreational activities delivered
by volunteers
0% 85.7% 0.000
(t-test)
71.4% of private aged care facilities offer a 2-person and an open ward living arrangements,
42.9% offer a one- person living arrangement, 28.6% offer a 3-person living arrangement, and
14.3% offer a 4-person living arrangement.
While 71.4% of public aged care facilities offer an open ward living arrangement, only 28.6%
offer a 2-person living arrangement, 0% offer a one-person living arrangement, 14.3% offer a 3-
person living arrangement, and a 0% 4-person living arrangement.
In regards to customized meal plans, 42.9% of private aged care facilities offer them while
14.3% of public aged care facilities do.

Table 7 -Private and public aged care facilities living quarters.
Living quarters Private aged care
facilities
Public aged care
facilities
P-value
one-person living arrangement 42.9% 0% 0.026
2-perosns living arrangement 71.4% 28.6% 0.060
3-persons living arrangements 28.6% 14.3% 0.512
4-persons living arrangements 14.3% 0% 0.226
Open-ward living arrangements 71.4% 71.4% 1.000
Customized meal plans 42.9% 14.3% 0.229
(t-test)
Table 8 - Private and public aged care facilities living arrangements (in-facility services)
Living arrangements
(in-facility services)
Private aged care
facilities
Public aged care
facilities
P-value
Common dining area 100% 100% -
Multipurpose hall 100% 100% -
Have gardens 71.4% 85.7% 0.512

Rehabilitation center 14.3% 0% 0.226
Hospital or a medical center 14.3% 0% 0.226
Mortuary house 0% 0% -
Gym 0% 0% -
Swimming pools 0% 0% -
Place of worship 0% 0% -
(t-test)
While all private and public aged care facilities have a common dining area and a multipurpose
hall, 71.4% of private aged care facilities and 85.7% of public aged care facilities have a garden.
14.3% of private aged care facilities have a rehabilitation center and a hospital/ medical center
and none of public aged care facilities do. Both private and public aged care facilities don’t have
a mortuary house, gym, swimming pool, nor a place of worship.
Table 9
Private and public aged care facilities types of staff.
Staff Private aged
care facilities
Public aged care
facilities
P-value
Caregivers 100% 100% -
Nurses 71.4% 14.3% 0.025

Doctors 71.4% 0% 0.002
Physiotherapists 57.1% 0% 0.007
Clerical workers 57.1% 85.7% 0.229
Assistant nurses or paramedics 28.6% 0% 0.078
Counselors 0% 0% -
(t-test)
While both private and public aged care facilities have caregivers within their staff, 71.4% of
private aged care facilities have doctors and nurses, 57.1% have physiotherapists and clerical
workers, and 28.6% have assistant nurse or paramedics within their staff.
While Public aged care facilities have clerical staff within their team (85.7%)and nurses (14.3%),
none of them have doctors, physiotherapists, assistant nurse or paramedics within their staff.
Neither private nor public aged care facilities have councillors within their team.
Table 10
Private and public aged care facilities education and training.
Staff education Private aged care
facilities
Public aged care
facilities
P-value

Tertiary education 54.5% 0% 0.000
Secondary education 18.2% 31.8% 0.000
Primary education 3.0% 40.9% 0.000
No formal education 9.1% 18.2%% 0.000
Other 15.2% 9.1 % 0.000
Staff training
Had relevant aged care training. 48.5% 9.1% 0.001
In-facility training 57.6% 40.9% 0.225
(t-test)
54.5% of private aged care facility staff acquired tertiary education, 18.2% acquired secondary
education, 3% acquired primary education, 15.2 % acquired other types of education such as
religious schools, and 9.1% had no formal education.

While none of the public aged care facilities acquired tertiary education, 31.8% acquired
secondary education, 40.9% acquired primary education, 9.1% acquired other types f education
such as religious schools, and 18.2% have no formal education.
In regards to staff training, 48.5% of private aged care facilities staff had relevant aged care
training and 9.1% of public aged care facilities staff did. 57.6% of private aged care facilities
staff had in-facility training and 40.9% of public aged care facility staff did.
Table 11
Private and public aged care facilities residents Quality Of Life.
Resident QOL Private aged
care facilities
Public aged care
facilities
P-value
Poor QOL 53.54% 30.1% 0.012
Good QOL 31% 44.1% 0.012
Neither good or poor QOL 15.5% 25.8% 0.012
(t-test)
As seen in table 11, 53.54% of private aged care facilities stated they have a poor quality of life
while 30.1% of public aged care facilities residents do.
31% of private aged care facility residents stated they have a good quality of life while 44.1% of
public aged care facilities residents do.

Multivariate Analysis for QOL between Facilities
Variable Groups B S.E Wald df OR 95% CI p-value
Facility Private
Public
-17.160 4167.81
7
0.000 1 0.997
1
0.000 0.000
all QOL values below 44 is classified as poor
(Binary Logistics, taking covariate as Categorical variable)
Table 12
Private and public aged care facilities resident’s perception of health
Perception of health Private aged
care facilities
Public aged care
facilities
P-value
Dissatisfied 56.8% 32.2% 0.009
Satisfied 22.4% 42% 0.009
Neither satisfied or dissatisfied 20.7% 25.8% 0.009
(t-test)
56.8% of private aged care facilities residents stated they are dissatisfied with their health and
32.2% of public aged care facilities residents are. And 22.4% of private aged care facility
residents are satisfied with their health and 42% of public aged care residents are.

20.7% and 25.8% of residents stated neither satisfied or dissatisfied with their health in private
and public aged care facilities respectively. the association is statistically significant.

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