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and stress-related factors (e.g., poverty) and personal resources (e.g., income).10 Improvement of these factors could help alleviate symptoms of psychological distress and ultimately mitigate its adverse effects on functional capability. Although its small sample size and cross-sectional design limit this study, to the knowledge of the authors, it is the first conducted in elderly adults in Sri Lanka on HGS and ADL and their correlates. Given Sri Lanka’s increasing life expectancy, rapidly growing elderly population, and limited resources, there is value in encouraging policy-makers to emphasize maintaining cognitive function and SRH and reducing psychological distress in Sri Lanka’s elderly adults. Ugochi Ukegbu, BA School of Medicine, Duke University, Durham, North Carolina Joanna Maselko, SM, ScD Department of Psychiatry and Behavioral Sciences, Duke Global Health Institute, Duke University, Durham, North Carolina Rahul Malhotra, MD, MPH Program in Health Services and Systems Research, Duke— National University of Singapore Graduate Medical School, Singapore Bilesha Perera, MSc, PhD Department of Community Medicine, University of Ruhuna, Galle, Sri Lanka Truls Østbye, MD, PhD, MPH Program in Health Services and Systems Research, Duke— National University of Singapore Graduate Medical School, Singapore Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina
ACKNOWLEDGMENTS We are thankful to the National Institutes of Health/ Fogarty IC (R21 TW009151) for funding the research upon which this article is based. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: concept and design or analysis and interpretation of data, drafting of the article or revising it critically for important intellectual content, and final approval of the version to be published. Sponsor’s Role: The sponsors had no role in the concept, design, analysis, interpretation of data, or in the drafting, revising, or final approval of the version to be published.
REFERENCES 1. Gunasekera H. Life Tables for Sri Lanka and Districts, 2000–2002. Colombo, Sri Lanka: Department of Census and Statistics, 2008.
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2. Castaneda-Sceppa C, Price L, Noel S et al. Physical function and health status in aging Puerto Rican adults: The Boston Puerto Rican Health Study. J Aging Health 2010;22:653–672. 3. Borchelt M, Steinhagen-Thiessen E. Physical performance and sensory functions as determinants of independence in activities of daily living in the old and the very old. Ann N Y Acad Sci 1992;673:350–361. 4. Moy F, Chang E, Kee K. Predictors of handgrip strength among the free living elderly in rural Pahang, Malaysia. Iran J Public Health 2011;40:44–53. 5. Schnittger R, Walsh C, Casey A et al. Psychological distress as a key component of psychosocial functioning in community-dwelling older people. Aging Ment Health 2012;16:199–207. 6. Hohl U, Grundman M, Salmon D et al. Mini-Mental State Examination and Mattis Dementia Rating Scale performance differs in Hispanic and non-Hispanic Alzheimer’s disease patients. J Int Neuropsychol Soc 1999;5:301–307. 7. Weaver J, Huang M, Albert M et al. Interleukin-6 and risk of cognitive decline: MacArthur Studies of Successful Aging. Neurology 2002;59:371– 378. 8. Barberger-Gateau P, Fabrigoule C, Amieva H et al. The disablement process: A conceptual framework for dementia-associated disability. Dement Geriatr Cogn Disord 2002;13:60–66. 9. Cesari M, Onder G, Zamboni V et al. Physical function and self-rated health status as predictors of mortality: Results from longitudinal analysis in the ilSIRENTE study. BMC Geriatr 2008;8:34. 10. Drapeau A, Marchand A, Beaulieu-Pre´vost D. Epidemiology of psychological distress. In: Labate L, ed. Epidemiology of Psychological Distress, Mental Illnesses—Understanding, Prediction and Control. Rijeka, Croatia: InTech, 2012, pp. 105–134
DETERMINANTS OF USE OF COMMUNITY-BASED LONG-TERM CARE SERVICES To the Editor: Singapore, like many Asian countries, is rapidly aging, and the government is accelerating the development of long-term care (LTC) services. Determinants of health services use offer insights into characteristics of users and ways to assist nonusers.1 Care recipients’ age and disability status2,3 are shown to be important determinants of LTC use. Families are the foundation of LTC. Formal LTC may complement family care or provide respite to family caregivers. Qualitative studies suggest that psychosocial factors,4,5 caregiver needs, and ability to undertake informal care are determinants of formal LTC use.6,7 The importance of these factors needs to be confirmed in quantitative studies. In Singapore, a national agency assesses people and refers them to specific LTC services. The assessment considers the care recipient’s disability and needs and the availability of a family caregiver but not the needs of family caregivers. Nursing homes record high occupancy, but utilization rates by people referred to community-based LTC (CBLTC—day rehabilitation, dementia day care, home medical, home nursing, home therapy) are lower than in the West.5 To understand how formal CBLTC can complement family care, a cross-sectional study of the determinants of CBLTC use was conducted in a population of older people assessed and referred to CBLTC services.
RESEARCH STUDY This study used baseline data from the Singapore Longitutidinal Survey for LTC Use conducted from December 2011 to December 2013. The study population was a representative sample of 4,402 people from the national referral database. The baseline survey comprised 1,416
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respondents (546 care recipients, 870 proxies of care recipients, 1,333 caregivers) who made the decision whether to use the referred CBLTC services between December 2011 and July 2012. Andersen’s Model for LTC Use4 was modified by adding caregiver factors.5,7 The relationship between CBLTC use and care recipient and caregiver predisposing factors, need and enabling factors, and psychosocial factors were examined using logistic regressions. Stratified analyses for use of center-based services (day rehabilitation, dementia day care) and home-based services (home medical, nursing, physical therapy, occupational therapy) were also conducted. The results showed that care recipient age, housing type, education, income, availability of medical savings account, and activities of daily living and caregiver age, sex, living arrangement, social support needed, and working status were significantly associated with the use of CBLTC. These factors also differ across services (Table 1).
CONCLUSIONS The main finding of this study was that enabling and need but not psychosocial factors are significant determinants of CBLTC use in Singapore. The finding also highlights the importance of caregiver-related factors. Enabling factors that influenced CBLTC use were higher care recipient education and household income, higher caregiver socioeconomic status, and care recipient living arrangement (co-residence of caregiver and care recipient; household of three or more other family members). That co-residence of care recipient and caregiver influenced CBLTC use confirms that the services complemented family care.5 Policy to support co-residence of older adults with their children (especially for small families) or senior housing can enhance use of CBLTC. Older people who lived alone were more likely to use center-based LTC (Table 1). It is likely that these people welcomed the opportunity for social interactions at these centers.5 The use of home care services is associated with higher household income, and the use of center-based care is associated with care recipients having personal national medical saving accounts (or Medisave, Table 1). Unlike day care services, home care users could not use these savings to offset service fees. This may explain why the use of home care services is associated with higher household income. There is heavy reliance on informal LTC by mainly female family caregivers in Singapore.8 Care recipients younger than 65 and those with female caregivers were more likely to use center-based LTC. Because of other commitments, younger caregivers experienced more stress.8 The only caregiver need associated with use of centerbased care was their need for social support. This finding suggests the need for formal caregiver support services to moderate the negative effect of caregiving9 and better complement family care. Center-based care can also offer caregiver services such as befriending, support groups, and self-care and management to better support family caregivers. Improvement in LTC financing can also assist payment for CBLTC and support informal caregiving.
SEPTEMBER 2014–VOL. 62, NO. 9
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In 2013, elderly policy offices in Singapore were consolidated from separate government ministries to the health ministry. Agencies that plan and fund services were also integrated.10 This should offer greater opportunities for accessible and innovative services where care recipients and families are perceived as partners in LTC.
Table 1. Odds Ratios for Use of Referred Community Long-Term Care (LTC) Services
Variable
Any Community LTC Services, n = 1,185
Center-Based LTC Services, n = 668
Care recipient characteristics Predisposing Age (reference
SEPTEMBER 2014–VOL. 62, NO. 9
and stress-related factors (e.g., poverty) and personal resources (e.g., income).10 Improvement of these factors could help alleviate symptoms of psychological distress and ultimately mitigate its adverse effects on functional capability. Although its small sample size and cross-sectional design limit this study, to the knowledge of the authors, it is the first conducted in elderly adults in Sri Lanka on HGS and ADL and their correlates. Given Sri Lanka’s increasing life expectancy, rapidly growing elderly population, and limited resources, there is value in encouraging policy-makers to emphasize maintaining cognitive function and SRH and reducing psychological distress in Sri Lanka’s elderly adults. Ugochi Ukegbu, BA School of Medicine, Duke University, Durham, North Carolina Joanna Maselko, SM, ScD Department of Psychiatry and Behavioral Sciences, Duke Global Health Institute, Duke University, Durham, North Carolina Rahul Malhotra, MD, MPH Program in Health Services and Systems Research, Duke— National University of Singapore Graduate Medical School, Singapore Bilesha Perera, MSc, PhD Department of Community Medicine, University of Ruhuna, Galle, Sri Lanka Truls Østbye, MD, PhD, MPH Program in Health Services and Systems Research, Duke— National University of Singapore Graduate Medical School, Singapore Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina
ACKNOWLEDGMENTS We are thankful to the National Institutes of Health/ Fogarty IC (R21 TW009151) for funding the research upon which this article is based. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: concept and design or analysis and interpretation of data, drafting of the article or revising it critically for important intellectual content, and final approval of the version to be published. Sponsor’s Role: The sponsors had no role in the concept, design, analysis, interpretation of data, or in the drafting, revising, or final approval of the version to be published.
REFERENCES 1. Gunasekera H. Life Tables for Sri Lanka and Districts, 2000–2002. Colombo, Sri Lanka: Department of Census and Statistics, 2008.
LETTERS TO THE EDITOR
1801
2. Castaneda-Sceppa C, Price L, Noel S et al. Physical function and health status in aging Puerto Rican adults: The Boston Puerto Rican Health Study. J Aging Health 2010;22:653–672. 3. Borchelt M, Steinhagen-Thiessen E. Physical performance and sensory functions as determinants of independence in activities of daily living in the old and the very old. Ann N Y Acad Sci 1992;673:350–361. 4. Moy F, Chang E, Kee K. Predictors of handgrip strength among the free living elderly in rural Pahang, Malaysia. Iran J Public Health 2011;40:44–53. 5. Schnittger R, Walsh C, Casey A et al. Psychological distress as a key component of psychosocial functioning in community-dwelling older people. Aging Ment Health 2012;16:199–207. 6. Hohl U, Grundman M, Salmon D et al. Mini-Mental State Examination and Mattis Dementia Rating Scale performance differs in Hispanic and non-Hispanic Alzheimer’s disease patients. J Int Neuropsychol Soc 1999;5:301–307. 7. Weaver J, Huang M, Albert M et al. Interleukin-6 and risk of cognitive decline: MacArthur Studies of Successful Aging. Neurology 2002;59:371– 378. 8. Barberger-Gateau P, Fabrigoule C, Amieva H et al. The disablement process: A conceptual framework for dementia-associated disability. Dement Geriatr Cogn Disord 2002;13:60–66. 9. Cesari M, Onder G, Zamboni V et al. Physical function and self-rated health status as predictors of mortality: Results from longitudinal analysis in the ilSIRENTE study. BMC Geriatr 2008;8:34. 10. Drapeau A, Marchand A, Beaulieu-Pre´vost D. Epidemiology of psychological distress. In: Labate L, ed. Epidemiology of Psychological Distress, Mental Illnesses—Understanding, Prediction and Control. Rijeka, Croatia: InTech, 2012, pp. 105–134
DETERMINANTS OF USE OF COMMUNITY-BASED LONG-TERM CARE SERVICES To the Editor: Singapore, like many Asian countries, is rapidly aging, and the government is accelerating the development of long-term care (LTC) services. Determinants of health services use offer insights into characteristics of users and ways to assist nonusers.1 Care recipients’ age and disability status2,3 are shown to be important determinants of LTC use. Families are the foundation of LTC. Formal LTC may complement family care or provide respite to family caregivers. Qualitative studies suggest that psychosocial factors,4,5 caregiver needs, and ability to undertake informal care are determinants of formal LTC use.6,7 The importance of these factors needs to be confirmed in quantitative studies. In Singapore, a national agency assesses people and refers them to specific LTC services. The assessment considers the care recipient’s disability and needs and the availability of a family caregiver but not the needs of family caregivers. Nursing homes record high occupancy, but utilization rates by people referred to community-based LTC (CBLTC—day rehabilitation, dementia day care, home medical, home nursing, home therapy) are lower than in the West.5 To understand how formal CBLTC can complement family care, a cross-sectional study of the determinants of CBLTC use was conducted in a population of older people assessed and referred to CBLTC services.
RESEARCH STUDY This study used baseline data from the Singapore Longitutidinal Survey for LTC Use conducted from December 2011 to December 2013. The study population was a representative sample of 4,402 people from the national referral database. The baseline survey comprised 1,416
1802
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respondents (546 care recipients, 870 proxies of care recipients, 1,333 caregivers) who made the decision whether to use the referred CBLTC services between December 2011 and July 2012. Andersen’s Model for LTC Use4 was modified by adding caregiver factors.5,7 The relationship between CBLTC use and care recipient and caregiver predisposing factors, need and enabling factors, and psychosocial factors were examined using logistic regressions. Stratified analyses for use of center-based services (day rehabilitation, dementia day care) and home-based services (home medical, nursing, physical therapy, occupational therapy) were also conducted. The results showed that care recipient age, housing type, education, income, availability of medical savings account, and activities of daily living and caregiver age, sex, living arrangement, social support needed, and working status were significantly associated with the use of CBLTC. These factors also differ across services (Table 1).
CONCLUSIONS The main finding of this study was that enabling and need but not psychosocial factors are significant determinants of CBLTC use in Singapore. The finding also highlights the importance of caregiver-related factors. Enabling factors that influenced CBLTC use were higher care recipient education and household income, higher caregiver socioeconomic status, and care recipient living arrangement (co-residence of caregiver and care recipient; household of three or more other family members). That co-residence of care recipient and caregiver influenced CBLTC use confirms that the services complemented family care.5 Policy to support co-residence of older adults with their children (especially for small families) or senior housing can enhance use of CBLTC. Older people who lived alone were more likely to use center-based LTC (Table 1). It is likely that these people welcomed the opportunity for social interactions at these centers.5 The use of home care services is associated with higher household income, and the use of center-based care is associated with care recipients having personal national medical saving accounts (or Medisave, Table 1). Unlike day care services, home care users could not use these savings to offset service fees. This may explain why the use of home care services is associated with higher household income. There is heavy reliance on informal LTC by mainly female family caregivers in Singapore.8 Care recipients younger than 65 and those with female caregivers were more likely to use center-based LTC. Because of other commitments, younger caregivers experienced more stress.8 The only caregiver need associated with use of centerbased care was their need for social support. This finding suggests the need for formal caregiver support services to moderate the negative effect of caregiving9 and better complement family care. Center-based care can also offer caregiver services such as befriending, support groups, and self-care and management to better support family caregivers. Improvement in LTC financing can also assist payment for CBLTC and support informal caregiving.
SEPTEMBER 2014–VOL. 62, NO. 9
JAGS
In 2013, elderly policy offices in Singapore were consolidated from separate government ministries to the health ministry. Agencies that plan and fund services were also integrated.10 This should offer greater opportunities for accessible and innovative services where care recipients and families are perceived as partners in LTC.
Table 1. Odds Ratios for Use of Referred Community Long-Term Care (LTC) Services
Variable
Any Community LTC Services, n = 1,185
Center-Based LTC Services, n = 668
Care recipient characteristics Predisposing Age (reference
