Determinants of Happiness among Older Adults in Nigeria: A quantitative study Protocol (Preprint)
Authors: Oyinlola Oluwagbemiga , Adebusoye Lawrence Adekunle , Cadmus Eniola Olubukola , Afolayan Oladipo Kunle 
Published: June 2023

BACKGROUND

Happiness among older adults is subjective well-being, although this is a new research area in Nigeria and Sub-Saharan African countries as a paucity of studies have been conducted that are related to the health and quality of life of older adults in the region. In contrast, several extensive studies have been conducted in developed countries like the UK, the US and other European countries1. The Global Happiness Policy 2021 report indicated that Nigeria is ranked 85 from 156 countries and second in the sub-Saharan African region, while Finland has the happiest country in the World, followed by Denmark, Norway, Iceland, and Netherlands2. Although several factors influence happiness in older adults, some include income level, daily living activities, occupation, education level, level of freedom, religion, culture, and values. However, they have not been explored in any African countries.
However, a review of available literature from the global north includes the cultural perceptive on the concept and relatedness of happiness among older adults in Mexico; the study employed a qualitative study using an exploratory, descriptive design following two successive phases from a sample 76 older adults with the average of 65years3. The study revealed that the cultural perception and concepts of happiness among older adults are related to the level of economic stability and support received from several sources. According to the authors, the cultural meaning of happiness for older women was children and tranquillity. Similarly, 4examined the role of work status on daily activities and its influence on happiness in later life (i.e. working versus not working status) which were based on the time-use and momentary happiness in older adults; this was a longitudinal design collected from a monthly assessment of 579 older adults over a 3year period4. Although, engagement in work as a daily activity mostly coincides with higher momentary happiness in older adults. However, the study revealed that working older adults experience more happiness during relaxing activities and on the weekends.
A community-based study in Thailand indicated the level of happiness perception among older adults in all the regions in Thailand using the Thai Happiness indicators (THI-15) among 306 older adults residing in rural, sub-rural and urban region of Thailand who are members of the Thai Senior Clubs. Using the Thai Happiness Indicators, 49.7% of the elderly perceived their happiness as poor, 37.9% as fair, and 12.4% as good5. The study revealed that formal education, geographic location, and gender positively impact the happiness level among older adults. On the contrary, 6tested the happiness hypothesis among older adults in Uruguay from socioeconomic factors. The study revealed that older adults could report being happy with access to high standard health services, higher income earners and when married. There was a lower happiness level when they were alone and had insufficient nutrition.
The only study emanating from Nigeria was from the World Value Survey of five countries (Nigeria, Ghana, South Africa, Rwanda, and Zimbabwe). 9,869 participants assessing the socioeconomic differences and their correlation with happiness and health7. The study revealed that there was poor self-reported health ranging from approximately 9% in Nigeria to Zimbabwe having 20% while unhappiness was significantly lower in Rwanda with about 9.5% and higher in South Africa at 23.3%. Unhappiness was excessively more among the poorest socioeconomic status in all the countries. However, the magnitude differs by country.
Therefore, this study is considered an essential step towards increasing the knowledge and awareness of the clinical importance of exploring happiness among older adults in the Nigerian Geriatric Center, as there was no previous study on happiness among older Nigerians. Additionally, it will serve as the reference point for policymakers in the health sector to better understand the modifiable factors that need to be addressed appropriately to improve happiness and, subsequently, health among older in Nigerian geriatric centers.

OBJECTIVE

Aim and Research Objectives
The study aims to explore determinants of happiness and health-related factors associated with happiness among ambulatory and non-ambulatory older adults in the Nigerian Geriatric Center.
Specific objectives
1.	To determine the level of happiness among older patients presenting in the Nigerian Geriatric Centre
2.	To describe the clinical factors such as morbidities, disabilities, functionality, and frailty associated with the level of happiness.
3.	To explore the influence of family relationships, quality of life, spirituality, religiosity and beliefs on happiness.
4.	To determine the predictors of happiness among older patients.

METHODS

METHODS
Study design: This will employ a case-control design involving older adults that attends the geriatric center, at (blinded for reviewers) as the case group and non-ambulatory older adults residing in the community will be used as a control group
Study site: This study will be conducted at the (blinded for reviewers),. Ibadan is the capital city of Oyo State in the southwestern area of Nigeria and has a population of 3.6 million inhabitants, while Oyo State has 5.6 million people8. The (blinded for reviewers)is a purpose-built center established on November 17, 2012, to give holistic care to older patients coming to (blinded for reviewers). (blinded for reviewers)is the pioneer geriatric center in Nigeria and renders both in-patient and out-patient services. This will be a pilot center for the study, with anticipation that it will be extended to other geriatric centers in Nigeria.
Study population: Male and female patients aged 60 years and above who presented at the (blinded for reviewers) during the study period and met the inclusion criteria will be recruited.
Inclusion criteria: All newly registered male and female patients aged 60 years and above present at the (blinded for reviewers)Clinic during the study period. The age of the respondents will be determined by asking them, by the use of historical events 9,10 the age at marriage and the age of their first child.
Exclusion criteria: All non-consenting and very ill elderly patients.
Sample size calculation
The sample size will be calculated using the Leslie-Kish formula for a single proportion
N =	Z2 pq
d2
N =	minimum sample size
Z =	1.96 (for 5% level of significance) is the standard normal deviate
P =	the prevalence of value. Since the prevalence of happiness is not known among older patients in Nigeria, the estimated prevalence of 50% will be used.
q=	1- p
d = the absolute precision of the study, which is taken to be 5%
N=	1.962 x 0.50 x 0.50
0.052
N=	0.9604
0.0025
N=	384.16
N ≈	384 The minimum sample size for this study is three hundred and eighty-four respondents.
Sampling procedure: Each month, 230 newly registered older patients are seen at the (blinded for reviewers)clinic. During the three months of the study, 690 (230 x 3) older patients will be expected to present at the (blinded for reviewers), (blinded for reviewers). Since the sample size is 384, the sample interval is 1.8 (690/384) ≈ 2. Thus, one in every two older patients present at the GOP clinic will be recruited.
Sampling technique: This will be by systematic sampling.
Data collection: Instrument
This would be an interviewer-administered semi-structured questionnaire.
Section A: will seek information on the respondents' demographic characteristics such as their age, sex, ethnicity, religion, marital status, and number of children; socioeconomic characteristics like educational level, income, occupation (present and past), living arrangement, lifestyle habits, financial and social support. Information on the previous out-patient visits, hospitalization, healthcare utilization pattern and medication use in the last month will be obtained.
Section B: Validated tools that will be used include the 29-item Oxford Happiness Questionnaire (OHQ) to measure the happiness family relationship index (FRI) to assess family cohesion, expressiveness, and conflict (reversed) subscales. The scale items consist of statements concerning family life, and respondents will be asked to rate how true or false each statement is for their own family. Each subscale has a maximum raw score of 9 and a minimum of 0 using true or false. All the scores will be converted to standard as stated in the scale11
Section C: The International Classification of Primary Care diseases (ICPC), which was developed by World's Organization of Family Doctors (WONCA)12, 13 will be used to seek information on the health problems of the respondents. Anthropometric height and weight measurements will be done using the standard method, and a complete physical examination will be conducted on the respondents to arrive at the diagnoses.
The questionnaire will be administered by the researchers in English language and interpreted into the Yoruba language (the local dialect of most respondents) when necessary. The questionnaire will take about 25 minutes to administer, and measurements will take about 30 minutes.
Blood pressure:
The blood pressure will be measured with an AccosonR mercury sphygmomanometer England, which will be calibrated and validated before use. The patients will sit comfortably with their left arm bared and supported at the level of the heart and their feet on the floor. Patients will be allowed to relax, and measurement will start after 5 minutes of rest. Appropriate cuff sizes will be used for each patient, encircling at least 80% of the arm. Two averages of two readings separated by 2 minutes will be taken as the blood pressure14. The appearance of the first sound (Korotkov 1) will be taken as the systolic blood pressure and the disappearance of the sound (Korotkov 5) as the diastolic blood pressure. The staging of hypertension will be done according to the eighth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension 15.
Instruments for determining the predictors
Oxford Happiness Questionnaire (OHQ)
The level of happiness will be measured using the Oxford Happiness questionnaire, a 29 items tool developed by psychologists Michael Argyle and Peter Hills at Oxford University16. The response format is a 7-point Likert-type scale. A single composite score is computed by averaging the responses to the four items following the reverse coding of the fourth item. Scores range from 1.0 to 7.0, with higher scores reflecting greater happiness17.
The Family Relationship Index
The family dynamics of the respondents will be assessed using the Family Relationship Index (FRI), an extract of the family environment scale (FES). It is a self-report 27--item questionnaire assessing family functioning in three domains of; cohesion, expressiveness, and conflict (reversed) subscales. The scale items consist of statements concerning family life, and respondents will be asked to rate how true or false each statement is for their own family. Each subscale has a maximum raw score of 9 and a minimum of 0 using true or false. All the scores will be converted to standard as stated in the scale11

World Health Organisation Quality of Life Brief Questionnaire (WHOQoL-Bref)
The World Health Organization Quality of Life instrument (WHOQoL- Bref) will be used to measure the quality of life of the subjects. The WHOQOL-Bref is a cross-culturally applicable tool developed by the WHOQOL Group in 1998 for the subjective evaluation of health-related QoL 18s. It validates QoL in the elderly 18;19. The WHOQOL-Bref is designed as a self-rating instrument that can also be interviewer-administered with excellent internal reliability (Cronbach alpha = 0.86) and has four domains: physical, psychological, social, and environmental 18;19.
Barthel's Basic Activities of Daily Living (BADL)
The functionality disability of the respondents will be assessed using Barthel's activities of daily living index. The Barthel Index is a 10-item simple-to-administer tool for assessing self-care and mobility activities of daily living. It is widely used in geriatric assessment settings 20. Reliability, validity and overall utility of the Barthel Index are rated as good to excellent (Mahoney and Barthel, 1965). Information for assessing functional disability among older adults is gained from observation, self-report, or informant report. Total possible scores range from 0 – 20, with lower scores indicating increased functional disability 20;21
Six-item screener
Cognition will be screened with 'the six-item screener' 22. This is a brief and reliable instrument for identifying subjects with cognitive impairment, and its diagnostic properties are comparable to the full MMSE (sensitivity 95.2 and specificity 86.7) 22 . A simple summation of errors easily scores it. The sensitivity and specificity of the six-item screener for a diagnosis of dementia were 88.7 and 88.0, respectively22

Mini-nutritional assessment- short form (MNA-SF)
Mini-nutritional assessment- short form (MNA-SF) used in Nigerian study will screen for malnutrition among the subjects 23;12;24.

Geriatric Depression Scale (GDS)
The Geriatric Depression Scale (GDS) developed by Sheikh and Yesavage will be used to assess depression25. The GDS-short form used in Nigerian studies26;27 and the same scoring system will be used.
Self-reported frailty scale
The self-reported frailty scale will be applied to the respondents or their proxy. It consists of dichotomous questions directly related to each component of the frailty phenotype, which is considered the gold standard model: unintentional weight loss, fatigue, low physical activity, decreased physical strength, and decreased walking speed. The score will be classified as not frail (no component identified), pre-frail (presence of one or two components), and frail (presence of three or more components). The sensitivity and specificity for identifying pre-frail individuals were reported as 89.7% and 24.3%, respectively, while those for identifying frail individuals were 63.2% and 71.6%, respectively 28.
Three-item perception of illness scale
The respondents' self–reported health would be assessed and scored using the 'three-item perception of illness scale.' Each item is graded from 1 to 5 (poor to excellent), which are aggregated into a composite score of perception of health (score = 3 to 15)29. The perception of illness scale has a Cronbach's alpha coefficient of 0.65 30
Consent for the Study: Approval for the study will be obtained from the Director of the (blinded for reviewers), (blinded for reviewers), (blinded for reviewers), and Informed consent from each respondent will be obtained before the examination and administration of the questionnaire.
Data analysis
The administered questionnaires will be sorted out, cross-checked after each interview, and coded serially. Data entering, cleaning and analysis would be done using SSPS (version 21). Descriptive statistics will be used to describe the socio-demographic characteristics of the respondents. Appropriate charts will be used to illustrate categorical variables. Chi-square statistics will be used to assess the association between categorical variables and student t-test to test the association between continuous variables. The values of significance would be set at p < 0.05. Logistic regression will be used to explore the relationship between significant variables and happiness.
Ethical Considerations
Approval for the study was obtained from the University of Ibadan/ University College Hospital Institutional Review Board (UI/EC/19/0603). Each respondent will give informed consent before the administration of the questionnaire. Permission will also be sought from the Director, (blinded for reviewers). Written informed consent will be obtained from each participant prior to data collection. The respondent will either be signed or thumb-printed depending on their literacy level.
Confidentiality of Data: The names of participants will not be on the questionnaire to maintain confidentiality. Only serial numbers allocated to the participants will be written on the questionnaire. The names, hospital numbers and identification codes will be recorded in a separate notebook accessible only to the researcher and the assistant for easy retrieval of results of physical findings and investigations as the respondents may request. They will be assured that their responses will be kept confidential. The questionnaires will be kept safely in a locked cupboard. Data entered on the computer will be pass-worded and accessible only to the researcher, data entry clerk and statistician.
Translation of protocol to the prominent local language for accessible communication: The questionnaire will be translated into Yoruba, the local language, back-translated to English, and field tested to ensure the original meaning was retained.
Beneficence to the participants: All respondents will be managed for their primary complaints. The study's outcome will be helpful in focussed counselling and appropriate intervention for the respondents.
Non-maleficence to the participants: This study will not harm the participant, as confidentiality will be ensured. The consulting rooms set apart for the interview will ensure the privacy of the respondents.
Right to decline/withdraw from the study without loss of benefits (Voluntariness): The participants are free to decide not to participate and could choose to discontinue at any point during the interview process without jeopardizing their opportunity to be treated.

RESULTS

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CONCLUSIONS

Discussion and Implications
While it is acknowledged that diverse factors influence the happiness of older adults in sub-Saharan African regions and countries like Nigeria, the most populous African country, the level of happiness of older adults is rarely studied in clinical settings. Although there are general assumptions that older adults in Nigerian communities are happy, evidence exploring the level of happiness is unknown; thus, this study is considered a critical step toward providing a research landscape for Nigerian geriatric researchers to explore the happiness of older adults visiting geriatric centers. This would ultimately give them a sense of purpose and meaning as older adults31.
Although happiness is an important marker of successful aging in high-income countries, factors associated with lower happiness levels are often found among older adults (Luchesi et al., 2018). This type of study is considered first in many ways, (1) it provides ideas on the level of happiness among older adults attending the pioneer geriatric centre in the West African sub-region, and (2) it provides a new direction for the understanding of different determinants to happiness among older adults attending clinical settings in Nigeria where infrastructural resources are limited and (3) healthy ageing is central to happiness of older adults in Africa, this study provides an opportunity for dialogue with African government toward the actualization of healthy ageing by 2030 ((blinded for reviewers)et al., 2022)(in press).
The increasing life expectancy of older adults in developing countries like Nigeria calls for improved services-structures specifically designed to make older adults happy. The study will utilize the contextually validated Oxford happiness scale to understand older adults' happiness level in the Nigerian Geriatric Center.
Knowledge and Dissemination Strategy
This study on happiness will mobilize knowledge to academic audiences through scholarly publications and conferences. Part of the outcome of this study has been accepted in the Journal for Gerontology ((blinded for reviewers) et al. 2022). For broader coverage, the outcome of this study would project by the websites of the geriatric hospital and assessment scales will be developed for the physician to utilize during clinical assessment. And to enable project outputs to reach community physicians to assess the happiness of older adults in rural communities of Nigeria.

CLINICALTRIAL

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