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Hedayati M, Sum S, Pourhadi S, Hosseini S R, Faramarzi M. Effect of Group Physical Games on Life Quality of Older Adults at Adult Daycare Centers. Elderly Health Journal 2022; 8 (1) :6-13
URL: http://ehj.ssu.ac.ir/article-1-232-en.html
Effect of Group Physical Games on Life Quality of Older Adults at Adult Daycare Centers
Maryam Hedayati , Shima Sum , Samaneh Pourhadi * , Seyed Reza Hosseini , Mahbobeh Faramarzi
Social Determinants of Health Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Mazandaran, Iran , Samaneh.pourhadi@gmail.com
Keywords: Aged, Quality of Life, Physical Activity, Game, Adult Day Care Center
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Effect of Group Physical Games on Life Quality of Older Adults at Adult Daycare Centers

Maryam Hedayati 1, Shima Sum 2, Samaneh Pourhadi *2 , Seyed Reza Hosseini 2, Mahbobeh Faramarzi 2
  1. Student Research Committee, Babol University of Medical Sciences, Babol, Mazandaran, Iran
  2. Social Determinants of Health Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Mazandaran, Iran

Article history
Received 16 Jun 2021
Accepted 21 May 2022

A B S T R A C T
 
Introduction: Physical activity is a predictor of the health outcomes of the older adults, and many approaches have been introduced for its implementation. The present study aimed to investigate the effect of group physical games on life quality (QOL) of older adults at an adult day care center.

Methods: This quasi-experimental study was conducted using pre-test and post-test. Using convenience sampling, a total of 50 senior citizens above 60 years of age from two adult daycare centers of Babol and Amol in 2017 was placed in an intervention (25) and a control (25) group, respectively. The intervention group received physical games program twice a week for 6 weeks. The SF12 questionnaire was used to assess the QOL. The statistical analysis of the variables was carried out using t-tests, Wilcoxon, and Mann-Whitney tests at a significant level (P < 0.05) with SPSS software.

Results: The QOL scores of the participants in the intervention group, compared to the control group have significantly improved (p < 0.001). The calculated difference for the quality of life of the intervention group was (d = 4.40±  2.36) being (d = 1.68±  1.74) and (d = 2.72±  1.51) in the physical and mental aspects, respectively.

Conclusion: Physical exercise program (especially stationary physical game) can improve the quality of life of the older adults both physically and mentally. Therefore, such activities can be used to improve the quality of life of the older adults.

Keywords: Aged, Quality of Life, Physical Activity, Game, Adult Day Care Center

Copyright © 2022 Elderly Health Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cite.
 
Introduction
    Considering the increase in the longevity and life expectancy indices today, a more important subject comes up, namely how to spend life or in other words, the quality of life (QOL). It has been confirmed as a fact that the multitude of physiological problems occurring in old age contribute to the decrease in the QOL during this period. Therefore, considering the certain needs in advanced years, it is of crucial importance to attend to behaviors that improve health and QOL in old age, a fact that is often neglected )1(.
    QOL as a multifaceted concept, and assess subjective. It is the individuals themselves who judge their QOL, and aspects such as physical health, mental health, economic conditions, personal beliefs, and interactions with the environment influence this judgment (1). Health is the most important deciding factor in QOL, declining as age advances (2). Lacking health deprives the senior citizen of independence by limiting their activities. Some studies showed that senior citizens who are independent in their daily activities will have a better QOL (3, 4). Also, a study demonstrated that caregiving and remedial procedures for the older adults will be truly effective only when they improve their QOL (5). Thus, health improving behaviors which retain the performance and revive the independence of the individuals are among the major criteria of health and improvement in QOL. In this regard, physical movements and exercise play an important role. The aim of physical activity for the older adults is to improve mental health and combat weakness, vulnerability due to lack of exercise, biological changes arising from advanced age, chronic illnesses, and disability due to acute or chronic illnesses (6). In a study, Lee et al. observed a considerable increase in the QOL of the older adults who exercised (7). Furthermore, studies on the effect of regular and group physical activities on the older adults showed an increase in QOL and the feeling of wellbeing among the individuals who followed these activities (6, 8). Despite the mental and physical benefits of exercise and body movements, motion deficiency is very common among the older adults (9, 10). Studies conducted in Iran show that a very low percentage of the Iranian older adults take part in physical activities (11), and about 68% of the individuals above 60 years take part in no physical activities during the week (12). There are personal and social problems that hinder their motivation and participation in exercise and physical movements, and that a boost is required in motivating factors such as joy, pleasure, stronger social interactions, and health improvement to inspire the older adults to engage in such activities and follow them on a regular basis (13).
    Since QOL can easily be threatened in old age, it is crucial to take their physical activities into consideration. Therefore, considering the increase in the population of the Iranian older adults, the motion deficiency among them, the existence of a relationship between physical activity and health aspects and the QOL, and considering the fact that we couldn't found any research that has been undertaken in the area of physical games, the present study conducted with the aim to examine the effect of such games in improving the QOL of the older adults.

Methods
Study design
    The present study was a quasi-experimental design, in which the QOL variables in physical and mental aspects were evaluated on 50 senior citizens in the control and intervention groups using pre-test and post-test in 2018.
Setting and participants
    Based on convenience sampling, 25 senior citizens from each of the two adult daycare centers in the cities of Amol and Babol in the province of Mazandaran, Iran, were selected as study samples. The Babol daycare center was chosen for the execution of the intervention program as the center had agreed with the implementation of the study design in its yard. Therefore, the intervention group from the Babol adult daycare center and the control group from the Amol adult daycare center participated in this program. The participants were independent seniors with activity of daily living (ADL) scores > 10 and Abbreviated Mental Test Scores (AMTS) > 5 aged between 60 and 85 years. Individuals who had comorbidities with medical prohibitions or intense sight and hearing impairments, and those who were not willing to participate or were absent from the study for more than two sessions, were excluded from the study. (Figure 1)
Data collection
    The interventions in this study were designed and executed according to the Hayat Pouya (Playground) program (14). In this program which has been implemented in some Iranian schools since school year 2013 by the Ministry of Education, simple and feasible methods such as drawing shapes and tables and installing safe and lightweight equipment in the minimum possible space are used (as far as the existing conditions and facilities allow) to make the yard space and surroundings more fun and appealing, so that it will accommodate mental and physical activities during free time. Following the guidance of an advisory team and a sports physiology expert, the yard of the daycare center in Babol was adjusted based on the above-mentioned plan in such a way that it was suitable for the older adults. Some patterns were drawn on the walls and others on the ground, and they were then painted using warm and cheerful colors. Foam, balls, and walnuts were among the tools used in the intervention, with hula hoops used as moving targets. The selected executive games were implemented at their own allocated stations. To further adjust to the conditions, the performance of 50% of the older adults on each exercise was chosen as the criterion for successful play. Two pilot sessions were held in which the game stations were selected based on the capabilities of the senior participants and the execution methods of some of these stations were adjusted accordingly. The objectives expected of these games included boosting focus, memory, balance, interaction, and joy. The games protocol were executed in the forms of skill board games, ball throws and walnut throws for scores, and playing memorable old games. The introductory stage was held in one session at the adult daycare center, during which the participants were taught how to play the games and perform the exercises. Following that, these games and workouts were performed twice a week under the supervision of the program coach and the researcher. Eight stations had been designed and adjusted for the implementation of the intervention. At the first station namely the workout ring, the older adults, based on which zone on the ring they were standing in, would perform the workout assigned to that zone so that the rest would follow suit.
    The second station was the skills board, where the participants were given scores based on which of the three areas their thrown ball hit. At the third station, scores were given for throwing the ball through the rolling hula hoops. The fourth station was called the motion activity station, at which the older adults would either zigzag or walk straight along the designed path based on the prompt card they had picked and the training they had received. The fifth and sixth stations reminded the older adults of their own childhood and teenage years’ plays, and the seniors showed a great deal of enthusiasm about these. At the fifth station, the participants would throw walnut, aiming to make the 10-cm-diameter holes provisioned in the ground. At the sixth station, they would navigate through a diagram drawn on the ground. The move was originally done by hopping along, but owing to the older adults’ physical considerations, walking was specified as the means of navigation. The seventh station was for tic-tac-toe, which was played in a group. Hitting the target areas on the wall by throwing balls was the game for the last station.
    This protocol was executed in 12 sessions of 75–90 minutes each, for the participants in the intervention group. Each session consisted of three parts. First, the participants were instructed to warm up for 10–15 minutes. Then, they would execute the relevant physical moves at the stations for 45 to 60 minutes. Finally, they would stretch for 10 minutes to cool down. After the completion of the physical activities, the QOL status of the older adults' subjects was gauged again based on the introduced tools. No intervention was carried out in the control group (15).
    The data were recorded in two stages for both the exercise and control groups. That is, first at the beginning of the study prior to the intervention, and then immediately after the end of the intervention, the 12-Item Short Form Survey (SF-12) were filled out for the participants.
    For the purposes of data collection, the demographic information questionnaire (created by the researcher including gender, marital status, age group, education, life arrangement, and income), the ADL questionnaire, and the AMTS were filled out only in the pre-test stage and as the criterion for inclusion in the study. The ADL questionnaire is used to determine the daily physical activity status, with a validity of 0.82, a reliability of 0.76, and Cronbach’s alpha above 0.75 (16). The AMTS questionnaire was used to screen the older adults in terms of cognition; Questionnaire standardization was conducted by Foroughan et al. In 2017 in Iran showed that it was reliable (α=0.90.5) and the suitable cut-off point was determined 6 using ROC curve. The sensitivity of this test at this cut-off point is 99% and its specificity is 85%, and it has the advantage of being less dependent on the participants’ educational level (17).
    To determine the older adults' QOL status, Short Form Survey 12-item (SF12) (18, 19) - which is the shortened version of SF36- was used pre - and post-intervention. The psychometric properties of the questionnaire had been examined by Montazeri et al. and the Cronbach's alpha has been %85 (20). The SF12 questionnaire includes 12 questions about eight aspects, grouped in two subscales namely physical and mental:
    The physical subscale includes physical performance (2 questions), perception of general health (2 questions), and physical pain (2 questions).
    The mental subscale includes questions about role limitation due to mental problems, energy and liveliness, mental status, and physical performance (1 question). Based on the questionnaire, the minimum and maximum scores for each QOL dimension and the total QOL are 12 and 56, respectively, where 56 is the best and 12 is the worst QOL score. In this questionnaire, questions 1, 8, 10 and 11 are scored in reverse order.
Statistical analysis
    The distribution status of the data from the study was determined based on the Kolmogorov–Smirnov test. Accordingly, the independent t-test and the paired t-test were used for the variables with a normal distribution. The Mann-Whitney and Wilcoxon tests were used for nonparametric variables of the independent and dependent groups, respectively. The results were considered statistically significant below the threshold of 0.05. Accordingly, the QOL had non-normal distribution, and nonparametric tests were used. The analyses were performed using SPSS software.    
Ethical consideration
    This study was conducted in accordance with the Declaration of Helsinki. The study was carried out following approval from the Ethics Committee of the Babol University of Medical Sciences and obtaining written permission from the university (MUBABOL.HRI.REC.1396.24). The program has been registered at the Iranian Registry of Clinical Trials (IRCT) with the ID 26706. To observe the study ethics, in addition to obtaining the written informed consent of all participants, it was made clear to the individuals at the beginning of the program that the study results are solely for scientific research purposes and will be published in collective form and without mentioning the names of individuals. They were also told that participation in the study was entirely optional. To show appreciation to the participants in the control group, educational pamphlets on spiritual health were distributed among them and they were given two sessions of self-care training.
Statistical analysis
    The distribution status of the data from the study was determined based on the Kolmogorov–Smirnov test. Accordingly, the independent t-test and the paired t-test were used for the variables with a normal distribution. The Mann-Whitney and Wilcoxon tests were used for nonparametric variables of the independent and dependent groups, respectively. The results were considered statistically significant below the threshold of 0.05. Accordingly, the QOL had non-normal distribution, and nonparametric tests were used. The analyses were performed using SPSS software.


 
Results
    The mean age of the participants was 70.6 ± 7 years, with the youngest participant being 61 and the oldest 83 years old. Most of the older adults were either illiterate (26%) or had received primary education (44%). (Table 1)
The two groups of control and intervention were similar in demographic variables (P < 0.05).
In the investigation on the impact of games on QOL, based on the SF12 questionnaire, the findings showed that executing the intervention caused significant changes in the QOL scores in physical and mental dimensions.
    Table 2 shows that after the execution of the program, the changes in the intervention group were significant and positive (P < 0.001), while no significant change was seen in the control group (P = 0.84).
    Table 3 shows the changes in mental health in the intervention and the control groups before and after the intervention. The changes in the intervention group were significant and positive (P < 0.001), while in the control group, the observed changes were negatively significant (P = 0.045). The physical changes in the intervention group were significant and positive (P < 0.001), while in the control group, the observed changes were not significant (P = 0.84).

Discussion
    According to the results of the present study, the hypothesis of the effect of group physical games on the QOL of the older adults has been confirmed. The mean score of QOL of the older adults in the intervention group immediately after the intervention showed an increase in mental, physical, and general dimensions, and the differences were statistically significant. Considering the fact that there had been no significant difference between the intervention and control groups before the study, the growth trend observed in the intervention group can be attributed to the effect of playing games. To elucidate the results from the findings, it can be said that these games boost human connections and interactions particularly among peers, and even playful mocking and teasing during the games further elevate such relations, contributing to a sense of competition and excitement, which in turn encourages motor activities. This is further corroborated as the seniors spoke of the stations as reminiscent of childhood games, so much so that even the older adults excluded from the intervention group for not meeting the inclusion criteria, were willing to perform the station games and used to show up at the game location to cheer their fellow seniors on. The older adults feel depressed and anxious due to a variety of reasons including feeling of loneliness, feeling of uselessness, and experience of loss, financial problems, and the inability to fill their free time. This feeling of anxiety and depression is connected with emotional and QOL elements (21). It seems that playing games and reminiscing the good old days bring the older adults out of the feeling of loneliness and allow them to enjoy the moment by filling their free time and enabling them to connect. In other words, such games can improve the QOL of the older adults by encouraging social interactions, and enhancing their self-confidence, cognitive performance, and independence. This suggests that designing and executing such programs for the older adults will be accompanied by their feeling of satisfaction and a positive outlook towards their life (21). The findings from the study by Mouton et al. in 2017 that had used the strategy of game play for the older adults is consistent with these results (21). Like in our study, women comprised the majority in both the intervention and control groups in Mouton’s study (21). Despite the fact that Mouton’s study was different from the present study in the sense that it conducted the intervention at a 24/7 care center where the older adults apparently have less abilities than those in the present study, and that the mean age of its statistical society was higher than that of this study (a 12-year difference), it still confirmed in a one-month intervention the effect of combined games on increasing movements and QOL.
 

Table 1. The demographic characteristics in the control and intervention subject groups
Variables     Intervention group Control group P*
N (%) N (%)
Gender Male
Female		 3(12)
22(88)		 1 (4)
24 (96)		 0.297
Marital status Married
Single
Widow		 15 (60)
3 (12)
7 (28)		 9 (36)
1 (4)
15 (60)		 0.067
Age group
 60 < Age ≤ 65
65 < Age ≤ 75
75 < Age ≤ 85		 6 (24)
15 (60)
4(16)		 8(32)
7 (28)
10 (40)		 0.056
Education Illiterate
Elementary
High school and higher		 4 (16)
10 (40)
11 (44)		 9 (36)
12 (48)
4 (16)		 0.068
Life arrangement Living alone
Live with husband/wife or children		 5 (20)
20 (80)		 11 (44)
14 (56)		 0.069
Income Poor
Medium
Great		 7 (28)
12 (48)
6 (24)		 10 (40)
13 (52)
2 (8)		 0.277




















*Pearson Chi-Square

Table 2.Comparison of the levels of quality of life before and after the physical games in the groups (intervention and control) 
Quality of life Physical dimension Mental dimension
Intervention group Pre intervention 38.56 ± 6.53 17.68 ± 2.56 20.88 ± 4.58
Post intervention 42.96 ± 6.05 19.36± 2.36 23.60 ± 4.21
p-value < 0.001 < 0.001 < 0.001
Diff 4.40 ± 2.36 1.68± 1.74 2.72 ± 1.51
Control group Pre test 34.00 ± 6.02 15.76 ± 3.64 18.24 ± 2.80
Post test 33.48 ± 6.52 15.80± 3.88 17.68 ± 3.06
p-value 0.127 0.84 0.045
Diff -0.52 ± 1/55 0.40± 0.97 -0.56 ± 1.32
Note: Data presented as mean ± standard deviation

Table 3. Comparison of levels of changes of quality of life, physical dimension, and mental dimension between the intervention and the control group
Quality of life Physical dimension Mental dimension
Intervention group Diff 4.40 ± 2.36 1.68±  1.74 2.72 ± 1.51
Control group Diff -0.52 ± 1.55 0.40±  0.97 -0.56 ± 1.32
p-value 0.001 < 0.001 < 0.001
   
    QOL is a subjective and multifaceted concept, and embodies a variety of aspects such as physical health, mental health, economic conditions, personal beliefs, and interactions with the environment (1). Among these aspects, mental and physical health is considered the most crucial in improving QOL, and an active lifestyle can play an effective role in this regard. To that end, a considerable number of studies assessed the effect of physical activity on the QOL of the older adults, the results of each of which confirmed such an effect in one way or another. Results from a study by Afshar-kohan et al. in 2015 showed that improvement in the QOL of the older adults is dependent on improvement in health, and self-care and exercise make it attainable by reviving personal independence (1). A study by Thiamwong et al. in 2013 suggested physical and mental activities as crucial components in the realization of a model for a healthy old age (22). Results from the studies by Shah et al. (23), Matlabi et al. (24), Asztalos et al. (25), and Martinsen et al. (26) confirm the findings from the present study, and relate improvement in the older adults’ QOL to the effects of exercise and activities on different aspects of mental health such as a reduction in anxiety and depression. Asztalos also showed that improvement in mental health following physical activity with different intensities is observed in both sexes, and the sex variable is not an influential factor in this regard (25). Nazakatolhosaini et al. (27), Geda et al. (28), and Brach et al. (29) confirm the effect of physical activity on QOL by saying that physical activity of medium intensity increases the independence of the older adults and enhances their QOL and wellbeing by decreasing physical limitations and boosting the adoption of an active role. This is while Shamsipour et al. (30) deem only very low- and very high-intensity physical activities as ineffective, and agree with the results from the present study and the ones mentioned above that physical activities in the range from low-, medium-, and high-intensity are effective. Arriving at results agreeing with those of the present study, Tetlie et al. (31), mentioned physical training as an effective agent contributing to physical and mental health, accompanied by a feeling of wellbeing and security. Studies have shown that interventions that aim at improving QOL, generally affect both the physical and the mental aspects of QOL (32-34).
    It has been observed that designing group physical games could help inspire the older adults to engage in physical activities and consequently achieve the beneficial effects of such activities since games were played in the open air of the yard at the adult daycare center, eliminating obstacles such as costs, traffic, and transport requirements. Also, easy access, pleasure of engaging in game activities, having the benefit of light and fresh air, and group interactions were helpful factors. In their study, Nadri et al. have also mentioned similar factors contributing to inspiring the older adults to become active (13). 

Conclusions
    Findings from this study show that the QOL of the older adults in the intervention group improved by executing physical games. Thus, performing physical activity which are targeted and based on science are feasible even with very little facilities, and is advised as a proper means of improving the health of the older adults and a fulfilling old age.

Study limitations
    Inadequate number of intervention studies that focus on physical games, and the small number of the participants particularly male seniors are among the limitations in the present study, and the data obtained from this study can be used in future studies in the same field but with a larger scale. Cognitive health and the independence of the participants in this study were among the limitations which were curbed proactively by the researcher via assessment using questionnaires. So, it is advisable to make adjustments and study the effectiveness of such an intervention on the QOL of the older adults with cognitive and motor problems. Also, extending the intervention period and following up the effectiveness at longer intervals can contribute to optimal planning for achieving positive results with physical activities among the older adults. Among other limitations that need to be taken into account are the influence of the better engagement on the part of the older adults from the intervention group in filling out the post-test questionnaires due to the feeling of satisfaction from participating in the games, and the accidental deaths of two seniors from the control group daycare center.

Conflict of interest
    The authors declare that there is no conflict of interest.

Acknowledgment
    This study is the result of the research program from the Master’s thesis approved by the Babol University of Medical Sciences. The authors would like to thank the officials of the Babol university, the daily care center of Hamrah Salamat in Babol and Javidan in Amol, and all dear older adults at these two facilities.

Authors' participation
    S.P. and M.H. and Sh.S. conceived of the presented idea.
    All authors contribute in research methods.
    M.H. had done the intervention, with supervision of S.P and Sh.S and M.F.
    S.P. and SR.H. had done data analysis.
    M.H wrote the manuscript with support from S.P. and SR. H.
    All authors read the manuscript and verified it.

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  33. Panahi R, Osmani F, Sahraei M, Ebrahimi S, Shamsinejad Gashti M, Javanmardi E. Relationship of health literacy and quality of life in adults residing in Karaj, Iran. Journal of Education and Community Health. 2018; 4(4): 9-13. [Persian]
  34. Habibi A, Nikpour S, Seiedoshohadaei M,  Haghani H. Quality of life and status of physical functioning among elderly people in west region of Tehran: a cross-sectional survey. Iran Journal of Nursing. 2008; 21(53):29-39.

 
Type of Study: Research | Subject: Special
Received: 2021/06/14 | Accepted: 2022/05/21 | Published: 2022/06/29
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