J Rehabil Health Sci 2018; 15: 1-7© 2018 Osaka Prefecture University

Journal of Rehabilitation and Health Sciences
Online ISSN 2185-8004

Original Article

Perceptions of Elderly Japanese on the Effect of In-Home Health Care Serviceson their Quality of Life
Miyuki IMANISHI † 1, Hisao TOMOHISA2, Kazuo HIGAKI3
1

Research Institute of Rehabilitation Science, Osaka Prefecture University, Habikino3-7-3, Habikino, Osaka, 583-8555, Japan2

Department of Psychiatry, Kyoto University Hospital, Shogoin-Kawaracho 54, Sakyo-ku, Kyoto, 606-8507, Japan3

Department of Community Health, Osaka Prefecture University, Habikino3-7-3, Habikino, Osaka, 583-8555, Japan

Received 24 April 2017; accepted 20 January 2018
Abstract: In Japan, a growing percentage of elderly individuals are being transitioned from hospital-based tocommunity-based or in-home care. In this study we identified factors affecting the quality of life of elderly people
receiving two types of in-home care. Fourteen subjects (age, 78.1±5.0 years) received narrative approach-based,
occupational therapy, and 15 subjects (age, 78.7±5.4 years) received non-narrative, non-occupational therapy for 1 year.
Subject perceptions on their therapy were evaluated by the content analysis of unstructured and narrative interviews.
Main differences in subject narratives were observed for treatment experience, but not for disease or injury experience.
In particular, we found that the relationship with the therapist, resumption of activities, communication improvements,
acceptance of life events, mental stability and positive outlook are important determinants of quality of life. In conclusion,
the quality of life of elderly receiving in-home care can be improved through personal growth and beneficial relationships
with supporters.
Key words: Functionally impaired elderly, In-home care, Occupational therapy, Narration, Psychosocial rehabilitation, Quality of life

INTRODUCTIONa holistic treatment approach, should be included into guidelines

In Japan, government policy is shifting health care forto broaden the range of evidence in EBM.5,6

the growing percentage of elderly individuals from hospital-

In line with this development, we have been researchingbased to community-based or in-home care. The provision of

the relationship between the use of narrative-based in-home careadequate health care and individualized support for the elderly

services and the QoL of elderly individuals using quantitative

is a prerequisite in the management of a greying society, as isand qualitative methodologies. We have shown that while

striving to maintain happiness in old age. In the face of a “super-

individuals with high and rising QoL scores were predominantly

aging” society1 and given that quality of life (QoL) is largely

users of narrative-based occupational therapy care services,

subjective and therefore difficult to measure via objective

the use of non-narrative, non-occupational health care services

testing, the quality of in-home health care requires critical

was related to low rising and declining QoL scores, suggestingevaluation and effective improvement strategies.

the importance of narrative-based occupational therapy in theConventional treatment guidelines based on evidencebased medicine (EBM) have been demonstrated to be effective.2

improvement of overall QoL.7 Factors affecting QoL in elderly
home care users remain relatively unexplored.

However, EBM has also become the subject of controversy,3 asHere, to reveal factors affecting QoL, in-depth interviews

it is not applicable to all patients or diseases. One example is thewere conducted to survey the perspectives of elderly subjects

physical and mental ailments of elderly individuals at the end ofreceiving either narrative-based occupational therapy or

4life. Recently, it has been argued that narrative-based medicine,

non-narrative, non-occupational in-home care. The results

in which patients provide detailed narratives to enable physicians

complement previous findings and have implications for future

to better understand patients’ circumstances in order to formulate

health care policies for the elderly.

†

Corresponding author, E-mail: miyuki726@kcn.jp

2

METHODSon the treatment goals based on a “collaborative therapeutic

Study Design

relationship” between the client and therapist. Subjects in the

A qualitative content analysis study was conducted to

non-narrative, non-occupational therapy group had received 1 to

explore elderly individuals’ perspectives on their in-home care.

5 weekly visits of 60 to 90 min in length by two or three nurses

The study is a follow-up to 2 quantitative studies investigatingor care workers. Neither a physical nor a narrative program was

the QoL of elderly people who were about to receive or had

provided; instead, services included cleaning, laundry, shopping,received two types of in-home care. In the first study, the QoL

cooking, management of oral administration, and assistance forof 200 elderly individuals was investigated before the start ofdressing, grooming, toileting or meals.

8

their in-home care services. The second study investigated the
QoL of 136 subjects from the same subject pool who received

Data Collection Period and Method

either narrative-based occupational therapy or non-narrative,

Data were collected between May and October 2014 within

non-occupational in-home care. In that study, the Philadelphia

6 months of completion of the 1 year of in-home care. Subjects

Geriatric Center Morale Scale (PGC-MS) was used to measure

were interviewed for 60 min at their homes. First, subjects were

QoL and showed that the QoL scores of the participants changed

asked how in-home health care services had affected their life7

in five different patterns (or QoL categories) over one year.

throughout the past year. Following this question, subjects were

The present study was based on subject data from these

permitted to talk freely (unstructured interview). The interviewer

five QoL categories: 1) high score (PGC-MS score consistently

then asked questions that focused on the context of their speechhigh); 2) low score (PGC-MS score consistently low); 3) rising(narrative interviews). The interviews were audio recorded andscore (PGC-MS score rose steadily); 4) declining score (PGC-MS

transcribed into their written records.

score declined steadily); and 5) low rising score (PGC-MS score
initially low, but increased gradually). Subjects were selected

Data Coding

and interviewed from each of these QoL categories to provide

Coding and categorization were performed using three

individual in-depth perceptions on their in-home health care, andprocesses: 1. Open coding: tentative codes were assigned to

explored the factors affecting their QoL.

themes obtained from collected data. 2. Search for categories(themes): themes obtained from open coding were categorized,

Subject Selection

and tentative codes were modified and converted to coordinate

For the first study, 200 subjects were selected from 12

and unified codes. 3. Focal coding: data were reviewed inhome health care centers in the Kansai region of Japan. Subjects

consideration of obtained themes, and codes were assigned.

whose Mini Mental State Examination9 scores were less thanFinally, codes with similar characteristics were placed in the

24 points were excluded, and those with no major problems insame category. Coded narrative data extracted from transcripts

physical status, communication abilities or cognitive functionsof the interviews and PGC-MS scores for the one-year period

were selected. After excluding subjects who were hospitalized,

were subject to analysis.

or had relocated or died, 136 subjects were able to partake in thesecond study. For the present investigation, three subjects who

Data Analysis

had received narrative-based occupational therapy and three

Each case was analyzed by conferral among one home-

who had received non-narrative, non-occupational in-home carevisiting physician, one psychiatrist (HT), two occupationalfor 1 year were randomly selected from each of the five QoL

therapists (MI and KH), one clinical psychotherapist, one nurse

categories (two subjects in case of the non- occupational therapy

and two health care workers who jointly conducted the coding

group in the rising QoL score category), generating 10 groups

process in reference to the works of Esterberg and Ezzy.10,11 For

with 29 subjects in total.

data analysis, we referenced the subject and structural methodsof narrative analysis used by Nomura.12 Specifically, through theTreatment Characteristics

processes of “extraction of events in temporal order,” “extraction

Subjects in the narrative-based occupational therapy groupof narratives suggesting causal relationships between events”

had received a weekly visit of 60 min duration by a licensed

and “coding”,13,14 we extracted key themes and categories fromoccupational therapist. The services provided included a

subjects’ narratives, which we then used to analyze how subjects

physical treatment program, such as training in getting out offelt about their health care service. Analyses were performed

bed, moving the extremities or walking with crutches, training

on the basis of two axes: the first axis consisted of the 5 QoL

for bathing, toileting or dressing, as well as cooking, handicraft,categories, and the second axis consisted of the 2 home healthand gardening. They also included a narrative treatment program

care conditions, narrative-based occupational therapy and non-comprising empathic listening, discussion on the treatment

narrative non-occupational therapy.

program based on “client-centered therapy”, and discussion

3

Informed Consent and Ethical Approval

their gratitude towards their occupational therapists, while

Subjects signed an informed consent form before thenon-occupational therapy / high QoL subjects acknowledged

interview was scheduled. The present investigation was approved

acceptance of their situation. Rising QoL subjects positively

by the Ethics Committee of Osaka Prefecture University (2012-

and joyfully talked about their daily lives. Occupational therapy

OT-17).

/ low QoL subjects reported being satisfied with their secure
lives, while non-occupational therapy / low QoL subjects tried

RESULTSto think positively of their situation. Declining QoL subjects

Subject Characteristics

were dissatisfied with their situation and felt lonely. In contrast,

The 29 subjects consisted of 11 males and 18 females witha mean age of 78 years. Additional subject characteristics are

Table 1 Subject characteristics.

listed in Table 1.
Characteristic

Occupational therapy group

Non-occupational therapy
group

Male (N)65disease experience, injury experience and treatment experience

Female (N)810(Table 2). Regarding disease experience, many subjects had

Age (mean, SD)

78.1±5.0

78.7±5.4

experienced stomach cancer, cerebral infarction or other serious

†

1(2)

1(1)

2(5)

2(8)

3(2)

3(3)

4(4)

4(3)

Extraction of Events in Temporal Order
From subjects’ narratives, three key themes emerged:

Care level (frequency)

diseases. Although the subjects suffered different disease profiles,
they reported a similar degree of discomfort and suffering. No
particular differences were found between QoL categories ortreatment groups. Regarding injury experience, the subjects

5(1)

5(0)

care of themselves. However, no particular differences between‡

PGC-MS (mean)

9.00

8.59

QoL categories or treatment groups were found.

MMSE§ (mean)

24.5

24.0

reported discomfort due to their inability to independently take

In contrast, with regard to treatment experience, substantial
found. As Table 2 shows, in the high score category,subjects in the occupational therapy group mainly expressed†

Footnotes: level of care defined as the amount of time per day required for careaccording to Japan’s nursing care insurance law: 1 (30 to 50 minutes), 2 (50 to 70
minutes), 3 (70 to 90 minutes), 4 (90 to 110 minutes), 5 (110 minutes or more),‡
Philadelphia Geriatric Center Moral Scale, §Mini Mental State Examination

Table 2 Subject narratives according to key themes.
Key themes†

QoL category

Treatment group

Disease experience

High score

Occupational
therapy- I was hospitalized many times. Each time I
fell, I suffered a fracture.

- I spend most of my time lying or sitting.

- I can remain mentally sound because thetherapist is very kind.

Non- occupational
therapy- I felt lonely when I underwent stomach
cancer surgery because I was alone.

- I am quick to tire and can no longer drive acar.

- The disease gives me the opportunity toconsider how I can improve my life.

Occupational
therapy- I cannot move my hand due to cerebral
infarction.

- I do not want others to see my illness.

- I could once again begin to enjoy my life
since the therapist began teaching me Braille.
- The therapist made a chair that allows me doembroidery with one hand. Since then, I havebeen feeling good.

- I have Parkinson’s disease. I feel as if I am
turning into a robot.

- I completely rely on the helper.

- I am enjoying my life more than ever before,
and I am looking forward to the rest of my life.

- I have difficulties in moving due torheumatism.

- I spend most time sitting in a wheelchair,
which is very tiring.

- I have developed a more positive attitude
towards life since I started playing folk musicagain.

Non- occupational
therapy- I haven’t urinated since I had my kidneys
removed.

- I consider why I am living when I see elderly
dialysis patients.

- I enjoy sharing time with the helper.

Occupational
therapy- I have been receiving home oxygen therapy
for a year. - I feel sick after dialysis.

- I am always in bed except when doing
rehabilitation with the therapist.

- I feel empty when I exercise alone, and I
must refer to the exercise menu the therapist
prepared for me.

Non- occupational
therapy- I ate melon-bread during educational hospital
admission because I felt frustrated.

- Because I have diabetes, I am always toldthat I should not do this and that.

- I want to live as I please.
- I am not happy to be alive.

Occupational
therapy- I have been confined to bed since I lost
consciousness due to myocardial infarction.

- It is exhausting and depressing to be confined - Even though I am in a difficult situation, I am
to the bed.
able to live thanks to the work of many people.

- The left side of my body is paralyzed.

- I do not think the paralysis on the left side of
my body will ever be cured.

Rising score

Non-occupational
therapyLow rising score

Declining score

Low scoreOccupational
therapyNon- occupational
therapy
Footnotes: † quality of life

Injury experience

Treatment experience- I have stopped thinking about my future since
the onset of this disease.

4

low rising QoL and low QoL subjects were found to be mentally

positively accepted their situation, providing statements such as

stable and to hold positive attitudes about their care.

“Being sick gives me the opportunity to meet new people, thus
making life more enjoyable than I had expected.” Occupational

Extraction of Narratives Suggesting Causal Relationships

therapy / rising QoL subjects began learning Braille as

between Events

recommended by their occupational therapists, or resumed

Narratives suggesting causal relationships between events

embroidery. Non-occupational therapy / rising QoL subjects

differed between QoL categories (Table 3). Occupational therapy

reported that health care workers helped them maintain a/ high QoL subjects were mentally and physically exhausted due

positive attitude and gave them hope for the future. Occupational

to events such as the death of a partner or repeated fractures.

therapy / low rising QoL subjects stated “After using home

However, upon having spent time with their occupational

health care services for one year, I’ve finally become a little

therapists, the subjects gave statements such as “I do not feelaccustomed to this lifestyle”, and non-occupational therapy / low

lonely.” Furthermore, although non-occupational therapy / highrising QoL subjects reported similar statements such as “I have

QoL subjects had also undergone difficult experiences, they

gotten used to home health care services”, suggesting that they

Table 3 Subject narratives suggesting causal relationships between events.
QoL†
category

Treatment group

Narratives

Characteristics

Occupational
therapy- When I sit in front of my Buddhist altar and talk to my deceased husband
about the therapist, I no longer feel lonely.
- The therapist cooked with me after my husband passed away. I can remain
mentally sound because the therapist is very kind.
- I am grateful to the helper for helping me clean my house, wash my clothes,and do the cooking.
- I am grateful to the therapist for helping me have a normal life.

- The occupational therapist helped subjects maintain a positive
attitude.
- Subjects were grateful to the occupational therapist.

- The helper enables me to concentrate on treatment.
- I am grateful to have nursing care insurance.
- The disease gives me the opportunity to meet people and enjoy my life.

- Subjects were grateful to the helper.
- Subjects were satisfied with their current situation.

Occupational
therapy- The occupational therapist helps me stay physically and mentally positive.
- I do not hesitate to go out or meet people any more.
- I am learning Braille from the therapist. This allows me to think I am useful tosomeone and enjoy my life.
- The therapist made a chair that allows me do embroidery with one hand.

- Support and activities from the occupational therapist helped
subjects stay confident.
- Subjects’ vital functions were improved and subjects’ social
participation was encouraged.

Non-occupational
therapy- I completely rely on the helper. This allows me to relax and have a positive
attitude.
- I am glad to have a helper I can rely on.
- I am enjoying my life more than ever and looking forward to the rest of mylife.

- Subjects felt secure when they relied on the helper.
- Subjects experienced hope for the future (positive feeling).

Occupational
therapy- I did not know how home rehabilitation would improve my life.
- I was worried what the helper would do, and what the helper would say about
me to others.
- I have gotten used to home health care services after having them for a year.
- I have developed a more positive attitude towards life since I started playing
folk music again.
- I have gotten used to home health care services and enjoy spending time withthe helper.

-Subjects were anxious about home rehabilitation and having
helpers.
- Subjects needed time to accept home health care services.
- Good relationships with occupational therapists and helpers
were important for improvement in subjects’ QOL.

- At first, I worried whether the helper would really support me.
- The helper always supported me with a smile.
- I have gotten used to health care services.

- Subjects trusted their helpers and were also grateful to them.

Occupational
therapy- I am always in bed except when doing rehabilitation with the therapist.
- The therapist is supportive of me, but my family is not. I have no motivation
to do anything except for rehabilitation.
- I want the therapist to explain to my family that I am not happy to be always
confined to bed.
- I was upset when my son accused me of only pretending to be a good person
when in the company of the therapist.
- My family does not understand how sick I feel after dialysis.

- Subjects were upset to know that their families did notunderstand them.
- Subjects were hesitant to ask occupational therapists to do
things.

Non-occupational
therapy- I feel as if instructions from nurses are orders. My nurse is dominant andalways keeps an eye on me. Also, because my nurse tells everything to myfamily, I do not tell anything to my nurse.
- The nurses treat me in a businesslike manner and are angry with me each timethey come. I am dissatisfied.

- Subjects were dissatisfied with their nurses.

High score

Non- occupational
therapy

Rising score

Low rising score

Non-occupational
therapy

Declining score

Occupational
therapyLow scoreNon-occupational
therapy
Footnotes: †quality of life

- The occupational therapist is kind and always creates such a joyful atmosphere - Subjects were satisfied with occupational therapy.
- Subjects accepted suffering from pain or paralysis.
in which I can forget my pain.
- Subjects were grateful to have security in life.
- I feel content and fulfilled during occupational therapy.
- I enjoy socializing with the occupational therapist and nurse.
- I do not think the paralysis on the left side of my body will ever be cured.
However, I am grateful for those who support me.

- Subjects accepted suffering from pain or paralysis.
- Subjects were grateful to have security in life.

5

required a longer duration to accept changes in life than risingtreatment groups, demonstrating that subjects in both groups

QoL subjects. Occupational therapy / declining QoL subjects

shared similar thoughts.

initially reported statements such as “I feel good when having arehabilitation session with the therapist”, suggesting that these

DISCUSSION

subjects experienced good relationships with their occupational

We explored the perceptions of elderly individuals receiving

therapists. However, towards the end of the study they madein-home health care services and attempted to uncover factors

statements such as “I want my therapist to explain to my family

responsible for changes in or the ongoing stability of their QoL.

that I am not happy to always be confined to bed”, suggesting

As a major result, differences in subjects’ narratives between

dependence and dissatisfaction with their therapists. Non-the QoL categories and treatment groups were only observed

occupational therapy / declining QoL subjects made statements

for treatment experience, suggesting treatment experience has asuch as “I feel as if instructions from nurses are orders.”

larger impact than either disease experience or injury experience.

Occupational therapy / low QoL subjects stated “feeling low”

Subjects in both treatment groups expressed their gratitude to

and “lonely after the occupational therapist leaves,” while non-persons of different occupations and similarly established good

occupational therapy / low QoL subjects expressed statements

relationships with them. Such expression of gratitude went handsuch as “I do not think the paralysis on the left side of my bodyin hand with other positive statements, which suggested thewill ever be cured.” Subjects in both groups said negative things;

subjects experienced mental stability and held a positive outlook.

however, occupational therapy subjects also expressed their

These findings suggest that establishing a good relationship withgratitude stating remarks such as “Even though I am uneducatedthe therapist / health care worker / family may be the key factor

and poor, my therapist treats me with dignity.” Similarly,

to improving QoL. It is notable that although subjects in both thenon-occupational therapy subjects held positive attitudes andoccupational therapy and non-occupational therapy groups of theexpressed their gratitude with statements such as “I am very

low rising QoL category had initially expressed feelings of doubt

grateful to my therapist for supporting me.”and anxiety towards in-home health care services, their QoL
eventually improved. This suggests that in-home care services

Extraction of Categories from Narrative Themes

should be administered on a long-term basis, as some individuals

Categories extracted from subjects’ narratives are presented
in Table 4.

may require a substantial period of time to become accustomed
to the service.

On brief overview it would seem that there would have

Even though motivators differed between the occupational

been substantial differences in the categories between the hightherapy group and non-occupational therapy group, the act of

QoL subjects and low QoL subjects. However, subjects in both

meeting with the care supporter is considered to have helped

QoL categories consistently expressed their gratitude to others.

subjects stay confident and enjoy life. The rising QoL score

Furthermore, there were no substantial differences between theeventually exceeded that of the high QoL score.7 We consider

Table 4 Categorization of subject narratives.
QoL† category

High score

Rising score

Low rising score

Declining score

Low score

Treatment group

Categories

Occupational
therapy“Acceptance of life events” “joyful and positive attitude towards life”

Non-occupational
therapy“Acceptance of life events” “Satisfaction with life”

Occupational
therapy“Regaining of self-esteem” “Regaining of joy of life”“Communications improvement”

Non- occupational
therapy“Hope for the future” “Harmony with others”

Occupational
therapy“Anxieties about unknown environments” “Expression of selfefficacy” “Feeling of security with others”

Non- occupational
therapy“Anxieties about unknown environments” “Positive expectancy
disconfirmation effects‡”

Occupational
therapy“Suffering due to the inability to live independently”

Non- occupational
therapy“Suffering due to the inability to live independently”

Occupational
therapy“Gratefulness to all possible events”

Non- occupational
therapy“Gratefulness to all possible events”

Footnotes: † quality of life, ‡ Subjects felt satisfied (dissatisfied) when health care services were better (worse) than their expectations.

6that this is related to the subjects’ changes in life and theiraccepting difficulties in life enables an acceptance of death andwillingness to accept these changes. Occupational therapy

the living of a joyful life.18,19 Occupational therapists should/ declining QoL subjects and non-occupational therapy /therefore maintain a sense of modesty and establish the good

declining QoL subjects complained about their families andrelationship required to provide individualized treatment on the

caretakers. Such complaints were likely to indirectly reduce theirbasis of sympathy and collaboration. If occupational therapists

willingness to accept changes in life. We observed that although

do not try to understand the thoughts and ideas of their clients, orthe subjects understood that the nurses were working hard, theif they treat them unilaterally and dominantly, the clients might

subjects strongly expressed that they did not feel understood bylose the chance to become independent or to attain mental andtheir nurses. Furthermore, the subjects interpreted the nurses’

physical recovery, or might even fall into depression.
With consideration to the limited scope of this study, theadvice to mean that they were being coldly ordered around.
Subjects of both treatment groups in the low QoL score

factors affecting QoL in elderly individuals receiving in-homecategory provided narratives suggesting “gratitude towards any

health care that emerged here were quality of the relationshippossible event”, accepted their situations and expressed gratitudewith the therapist / health care worker / family, resumption of

towards their supporters. We consider this passively gratefulactivities / hobbies, communication improvement, acceptance of

attitude responsible for the stability observed in their QoL

life events / self, mental stability and positive outlook. Previous

scores. From this perspective, subjects in both treatment groups

studies that investigated the perspectives of older, healthy people

maintained a “stable feeling of self-esteem,” as Rosenberg

living at home on QoL also found that social relationships,

described.15

activities and psychological wellbeing were among the factors

Occupational therapy / rising QoL subjects expressed many

that influenced QoL.20,21 Similarly, Breggin stated that we cannarratives suggesting “regaining self-esteem,” “regaining joy ofachieve relief through a combination of our personal growthlife,” and “communication improvement.” This was considered

and beneficial relationships with others based on “empathic

attributable to learning Braille and embroidery. Resuminglove”.22 In line with this, the present findings suggest that elderly

activities enabled subjects to recognize what they could do to

individuals who receive home health care services can improveregain joy in their lives. “Communication improvement” intheir QoL through a combination of personal growth andrising QoL subjects was also found to be related to resumption

beneficial relationships with their supporters.

of activities. Judging from the subject narratives, if occupational
therapists were to encourage elderly to engage in hobbies or

Acknowledgements
We thank all subjects for their participation. We would also

other joyful activities, the QoL of the elderly would improve.
Non-occupational therapy / rising QoL subjects provided

like to thank Dr. H. Inadomi for his continuous support.

narratives suggesting “hope for the future” and “harmony
with others.” QoL scores in the non-occupational therapy
group improved despite that there was no “resumption of

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