Instruments used to assess quality of life of older adults in African countries: a scoping review

Evidence suggests that over 60% of the population in sub-Saharan Africa lives in informal settlements (slums) with little or no resources [1‐5]. While formal settlements are usually equipped with good houses, sanitation and services such as hospitals, market places and schools, slums lack these amenities. Slum dwellers have to deal with poor quality of housing (such as wooden or metal structures or containers), lack of sanitation, overcrowding, extreme environmental hazards such as choked gutters, burning and improper disposal of waste. Also, educational facilities or health care services are absent in slums [6, 7]. This causes a significant threat to both health status and life expectancy of slum dwellers [2, 8, 9]. Also, research showed that older adults living in slums are dealing with anxiety about poor prospects of their children, aggression and disrespect from younger generations [4]. These factors, coupled with high illiteracy rate, poor socioeconomic status and high level of spirituality among the African population, can make older adults more religious as they cling on to faith to survive [53]. It is common in Ghana, to seek spiritual assistance from pastors, imams, traditionalists for most health problems rather than patronizing the hospital.

The population aged 60 years and above in Africa is projected to be 10% of the total population by 2050 [10] and also slums are becoming more populated with older adults. It is likely that the deplorable circumstances slum dwellers have to deal with are especially rough for them as they often deal with physical decline and a need for health and social care. To effectively develop interventions that focus on the needs of older adults, it is imperative to understand their quality of life (QoL).

The WHO defines Quality of Life (QoL) as ‘individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ [11]. This wide concept encompasses one’s physical health, psychological health, level of independence, social/family relationships, the quality of the living environment and personal beliefs [11].

To gain more insight into the QoL of older people living in slums, validated instruments with good psychometric properties which are culturally appropriate are needed. However, there is little to no research in the area of QoL of the ageing population in Africa, and in slums in particular [12]. Available instruments for assessing QoL are generally developed and validated in high-income countries, which have different socio-cultural, environmental and economic characteristics and different life standards compared to African countries. Additionally, the majority of older adults living in slums are illiterate, making it difficult to use QoL instruments where users have to read or write. Therefore, this study aims to identify instruments which are used in African countries to assess the QoL of older adults, especially those dwelling in slums.

Figure 1 shows a summary of the screening and inclusion process. Databases and hand searches revealed an initial 704 records. After duplicate records (n = 22) were removed, 682 records remained. Screening of titles and abstracts of these records resulted in the exclusion of 561 records that did not meet the inclusion criteria. In total, 121 articles were retrieved for full-text assessment. After screening these full-text articles, 103 articles were excluded, as they did not meet all inclusion criteria. All reasons for exclusion can be found in Fig. 1. The final number of articles included in this review was 18. In total, these studies assessed QoL using seven unique instruments. The main characteristics of the 18 studies included are shown in Table 1.

In this review, 7 different instruments in 18 studies were found to measure QoL among older adults in African countries: the EUROHIS-QOL-8 (n = 7), the SWLS (n = 3), the WHOQOL-OLD (n = 2), the WHOQOL-BREF (n = 2), the SF-36 (n = 2), the SF-12 (n = 1) and the RAND-36 (n = 1). After careful reflection on their respective psychometric properties, it appeared that the SLWS had good internal validity. The other instruments, had little or no information was available about the psychometric properties of the instruments when using them in their specific countries or populations. As not all aspects of life are equally important for all age groups, cultures and settings, it cannot be automatically assumed that all instruments are applicable for its intended purpose [31]. All studies using the EUROHIS-QOL-8 to assess QoL used data from the WHO Study on Global AGEing and Adult Health (SAGE study) refer to Kowal et al. [32] and Schmidt et al. [33] for information on the psychometric properties. Although the conclusion of Schmidt et al. is that the EUROHIS-QOL-8 showed good cross-cultural field study performance and a satisfactory convergent and discriminant validity, this was only assessed in European countries [33]. Furthermore, despite the fact that the EUROHIS-8 instrument is a derivate of the cross-culture validated WHOQOL-BREF, it is unknown if this instrument also shows good psychometric properties when using it in developing countries and more specifically in slum settings. Lastly, the seven studies using the EUROHIS-QOL-8 only reported on outcome and not on process-related measures such as experiences during data collection or feasibility of using the scale in the specific (slum) setting.

As a large proportion of older adults in African countries live in slums and are illiterate, this study also reviewed if the instruments were suitable to use among an illiterate population. Even though there is little information available on time investment when administering the instruments, the number of items per instrument range from 5 to 36, which seems like a relatively permissible time investment. When looking at mode of administration, one study did not describe how the instrument was administered [22] but all other studies described the possibility of interviewer-administration. However, there appeared to be no instrument which made use of VAS scales or pictorial scales, which could have made application in an illiterate population easier. Something else that would make the use of instruments more feasible is the possibility of amendment of questions (to make it understandable to the illiterate population) in the instruments to improve suitability of the instrument towards the population or setting (e.g. climbing stairs in a slum setting is not common or performing heavy exercise is less common among an older population). However, doing this will have consequences for performance characteristics of the instrument and should therefore be performed with caution. The original meaning should not change so as to measure the intended items in the domains.

When looking at the domains included in the different QoL instruments found in our review, the physical, psychological and social domain appeared to be (indirectly) included in almost all instruments. The environmental domain, however, was only included in the EUROHIS-QOL-8 and the WHOQOL-BREF. However, the environmental domain is likely to be of importance in African countries and more specifically in slum settings due to factors mentioned in the introduction paragraph of this article, such as poor housing, lack of sanitation and environmental hazards such as improper disposal of waste. A study performed among adolescents in Bangladesh also showed worse scores on physical environment and QoL among slum dwellers compared to non-slum dwellers [34]. Also, a study by Nilsson et al. [35], a literature search was performed to identify appropriate instruments to assess health related quality of life (HRQoL) among older people in rural Bangladesh. In addition, in-depth interviews with these older adults were performed to retrieve information on QoL domains deemed important by the older adult population. This study concluded that the instruments which were found to assess HRQoL mainly looked at physical, psychological and social domains, while older adults stated that spiritual, economic and environmental domains are equally important but not present in these instruments [50]. Also, some studies argue that in low- and middle-income countries, quality of life is more described in family and group terms, including values such as interdependence and role fulfilment instead of e.g. autonomy. These concepts might currently be underrepresented in QoL instruments [36].

From these findings, it can be concluded that the majority of the instruments found to assess QoL in African countries can be interviewer administered and are relatively short, providing a good starting point for use in an illiterate population. However, the instruments lack basic information on reliability and/or validity and more information is needed to know if the domains used in the different instruments actually reflect quality of life of older adults living in African slums.

The aim of this scoping review was to synthesize the current body of knowledge on the instruments used to assess quality of life of older adults in African countries. The following instruments were found: the EUROHIS-QOL-8, the SLWS, the WHOQOL-OLD, the WHOQOL-BREF, the SF-36 and the SF-12. It appeared that little information is available on both psychometric properties and feasibility of using these instruments among older adults in African countries. Also, it is unknown if the domains used in the instruments actually reflect quality of life in this specific population. This highlights the need for further research on adjustment and validation of currently existing instruments and/or for the development and validation of a new instrument, which can be used in illiterate, older populations living in African slums.