Hong Kong J Psychiatry 2002;12(2):2-7


Relationship Between Perceived Quality of Life, Social Functioning, and Life Skills Performance of Patients with Chronic Psychiatric Conditions in a Long Stay Care Home

KKP Law, SB Yau, DLY Wan, CCH Chan

Mr KKP Law, RSW, Superintendent, New Life Building Long Stay Care Home, New Life Psychiatric Rehabilitation Association, Hong Kong, China
Mr SB Yau, RMN, Assistant Superintendent, New Life Building Long Stay Care Home, New Life Psychiatric Rehabilitation Association, Hong
Kong, China
Ms DLY Wan, Chief Executive Officer, New Life Psychiatric Rehabilita- tion Association, Hong Kong, China
Dr CCH Chan, Associate Professor, Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China

Address for correspondence: Ms Deborah LY Wan, Chief Executive Officer, New Life Psychiatric Rehabilitation Association, 332 Nam Cheong Street, Kowloon, Hong Kong, China
E-mail: ho@nlpra.org.hk

Submitted: 23 May 2001; Accepted: 13 November 2001

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Objective:During the past decade, many patients with chronic psychiatric conditions have transferred to live in long stay care homes in Hong Kong. Few studies on the outcome of these rehabilitation services are available. This study aimed to investigate the relationships between quality of life, social functioning, and life skills performance of patients residing in such rehabilitation facilities.

Methods:179 residents were recruited, and 171 were assessed on 3 occasions during 1 year to examine the relationships between demographic characteristics, quality of life, social functioning level, and life skills performance.

Results:The residents had high perceived quality of life and low level of social disability with a gradual increase in the perceived quality of life and reduction in the level of social disability during the study period. Perceived quality of life was not correlated with level of social functioning. Life skills performance levels were correlated with level of social functioning, but were not correlated with level of perceived quality of life.

Conclusions:The findings suggest that patients with chronic psychiatric conditions can lead a more independent life with high perceived quality in a long stay care home. Further studies are required to evaluate the factors contributing to high perceived quality of life and impact of skills training programmes on social functioning of these patients.

Keywords: hronic, Long stay care home, Quality of life, Social functioning


Since the 1980s, there has been a large-scale planned trans- fer of patients from psychiatric hospitals to community care in Hong Kong. Residential care provisions of various levels of supervision have been developed. One of those residential services is the long stay care home (LSCH), which is specially designed for people with chronic psychiatric illness. The first LSCH was opened in 1989. It has capacity for 200 residents. Two more LSCHs were opened in the mid-1990s, catering for another 370 residents.

Recently, quality of life has become an important outcome measure of community services for patients with chronic psychiatric illness.1,2 Despite its significance, quality of life is still rarely measured in routine clinical practice. Often, symptoms of psychiatric disorder are interpreted as equi- valence to poor quality of life, while psychiatric disorders often result in social deficit that renders patients difficult to assess. Furthermore, the stigmatising effect of psychiatric disorder has detrimental effects on multiple aspects of life for many psychiatric patients.

Since the average life expectancy of the general popula- tion, including patients with psychiatric illness, has increased by 40% due to the improved standard of living, Sartorius argues that the ultimate goal of rehabilitation for patients with a chronic psychiatric illness is improvement in their quality of life.3 Therefore, quality of life should be consider- ed an important indicator of the success of a rehabilitation process.

Social Functioning

Dysfunctional social behaviour has long been recognised as a common feature of chronic psychiatric illness. With recent advances in pharmacological treatment, many patients with a chronic psychiatric illness can live independently in the community. Cohen and Kochanowicz found that social deficit of psychiatric patients often leads to social disintegration and isolation.4 Thus, Bennett suggested that psychiatric rehabilitation of patients with a chronic psychiatric illness should aim to help them optimise their social functioning.5 The same applies to preventing further deterioration.

Literature on the relationship between quality of life and level of social functioning is scarce. Several studies have shown that problems in social functioning may lead to low quality of life for patients with chronic psychiatric illness.6,7 However, Tempier et al reported that patients with chronic psychiatric illness living in the community with support services had no change in their perceived quality of life over a time span of 7 years, although they showed a decrease in functional status.8

Life Skills Training

Life skills training is an integral part in the rehabilitation of patients with chronic psychiatric illness. The training aims to improve their independent living skill abilities and to reduce their handicap. Dickerson et al found that there was significant association between the level of social functioning and independent living skills.9 Arns and Linney also found that the skill level of these patients was positively correlated with the level of residential and vocational independence.10 However, the study showed that skill level was not necessarily related to life satisfaction.

The relationship between quality of life and life skills training may be a complex one. Improvement of life skills may enable patients to lead a more independent life. However, the training process may have mixed effects on the patients. Spector and Takada suggested that patients’ participation in organised activities that encouraged activity and social interaction had a strong positive effect on quality of life.11 On the other hand, Linn et al observed that people in residential care settings with a diagnosis of schizophrenia responded negatively to increased activity and supervision.12

The Setting

The New Life Building Long Stay Care Home (LSCH) is a community-based psychiatric rehabilitative facility. The LSCH serves psychiatric patients who have been discharged from hospital with residential care and rehabilitation. It caters for 200 residents in a 5-storey building with 40 residents of the same sex residing on each floor. A multi-disciplinary team consisting of social workers, nurses, occupational therapists, and direct care staff (welfare workers and personal care workers) provides a 24-hour service for the residents. The training activities in the LSCH focus mainly on domestic, social, self-care, and community living skills.

Rationale for the Study

Despite the increased use of patient satisfaction in different treatment and service provisions, the use of quality of life as a major outcome indicator in the rehabilitation of patients with chronic psychiatric illness is seldom reported. In addition, objective evaluation of the degree of disability of this group of people has not been formally reported before in Hong Kong.

Systematic evaluation of the quality of life and the level of social functioning of this group, and the effect of life skills training on these 2 variables are invaluable to service providers in planning for service delivery. The proposal was discussed in the agency research committee and approval was sought for its implementation.

The study aimed to explore the following:

  • the perceived quality of life of patients with chronic psychiatric illness who reside in an LSCH
  • the level of social disability of people in the LSCH
  • the relationship between their perceived quality of life and level of social disability
  • the relationship between their level of social disability and life skills performance.


Research Design

A longitudinal study design was used to examine the cor- relation between the perceived quality of life and the level of social functioning of the residents. The residents were followed up for 1 year and data collection was carried out at 3 time points (round 1, round 2, and round 3).


The study included residents who had been living in the LSCH for more than 3 months at the time of the first data collection. Residents who had a psychiatric diagnosis of dementia or those who had problems understanding the contents of the questionnaire were excluded. Of the 200 residents of the LSCH, 4 residents were excluded (3 had dementia and 1 could not understand the questionnaire due to the language barrier).

Two social workers explained the study to the residents and informed consents were sought. Data of the residents who did not return their quality of life questionnaires were not used in the analysis.

Data were collected every 6 months from mid-May 1999 and each collection lasted for 2 weeks. For each round of data collection, residents were asked to complete a ques- tionnaire on quality of life. Rating of social functioning was done by social workers. For round 3, assessment of life skills performance was done by social workers, nurses, and occupational therapists.

Demographics and social circumstances of the residents were retrieved from the client database of the LSCH. The psychiatric diagnosis of the residents referred to the diag- nosis made by the referring psychiatrist in the application form for the LSCH.


World Health Organization Psychiatric Disability Assessment Schedule

The World Health Organization Psychiatric Disability Assessment Schedule (WHO/DAS) was used to assess the social functioning of the psychiatric patients. The schedule is available in many languages including Chinese and has been used in studies in a variety of settings in different cultures. The psychometric properties of the scale were found to be satisfactory, including the inter-rater reliability across culture. The Kappa value was found to be 0.60 or higher.13

To ensure the reliable use of the instrument, 2 social workers completed 4 training workshops conducted by the principal research investigator of the HKPU. Using a sample of 40 subjects, a satisfactory inter-rater reliability was achieved (reliability coefficient, 0.94).

World Health Organization Quality of Life Measure

The Hong Kong Chinese Version of the WHO Quality of Life Measure — abbreviated version [WHOQOL- BREF(HK)] was used to measure the perceived quality of life of the residents. This is a self-report questionnaire that consists of 28 questions to evaluate quality of life in 5 areas including physical, psychological, psychological-Hong Kong, social, and environmental domains. The measure was adapted from the WHOQOL and was validated locally. The different domains of the measure had an internal con- sistency ranging from 0.67 to 0.79 and had high construct validity ranging from 0.86 to 0.99.14

Life Skills

The performance of the residents in 4 different life skills areas (self-care, budgeting, work ability, and ability to access the community independently) was assessed. These 4 areas were chosen since 4 respective skills-training programmes had been running for all residents and the achievement of the residents in these structured programmes had been monitored.

The training outcome monitoring measures of each training programme were used to assess the residents life skills performances. These measures were designed at the same time as the programmes were developed by a team of social workers, nurses, and occupational therapists. For budgeting and ability to access the community independently, each point of the scales corresponded to a specific perfor- mance level of the training programmes.

The self-care performance of the residents was rated by the case nurses. This was done on a 5-point 57-item ‘self- care tasks performance rating list’. An adjusted overall score of between 0 and 4 indicated the self-care performance from being totally unable to perform by oneself to being totally independent to perform the task.

The ability of the residents to budget their money was rated on a 5-point scale by the case nurses according to the level of staff supervision the residents needed to use their money properly.

The ability of the residents to go out into the nearby community independently was rated according to how far and how frequently the residents could go out unescorted during the week. This was rated by a panel comprising a social worker, a nurse, and an occupational therapist on a 5-point scale.

The work performance of the residents was rated on a 3-point 7-item scale by an occupational therapist during completion of the individual care plan for all the residents when data collection of round 3 was taking place.

Data analysis

Data gathered in the 3 rounds of data collection were analysed using the computer software package Statistical Package for Social Sciences (SPSS), version 9. The strength and direction of the relationships between variables were assessed using Pearson Product-moment correlation coefficient(r). T-test (t) was used to test the significance of differences between the means of different grouping categories.


Patients Characteristics

At the beginning of the study, 196 residents met the inclusion criteria and 179 agreed to participate in the study, but only 171 completed all 3 rounds of assessment. 110 resi- dents (61.5%) were men and 69 (38.5%) were women. The ages ranged from 26 to 76 years (mean, 50.6 years). More than 80% of the residents were single. The majority of the residents (81%) had a diagnosis of schizophrenia, and more than 10% had dual diagnoses, one of which was mental retardation. All patients were receiving medication. Details of the patients’ characteristics are presented in Table 1. In the second round of data collection, the number of the patients remained unchanged. Two of the residents had died by the time of the third round of data collection, 3 were admitted to hospitals, and 3 did not return their questionnaire.

Quality of Life

The mean scores of WHOQOL in the 3 rounds of data collection are presented in Table 2. Both male and female patients had similar mean scores in all 3 rounds. There was a gradual increase in the mean score of WHOQOL from round 1 to round 3. T-test showed that there were statistically significant changes between successive round scores (see Table 3).

The significant change between round 1 and round 2 scores was due to large sample size, and had limited clinical significance (effect size = 0.05). However, the effect size for round 2 and round 3 indicated a small to modest change in quality of life scores.

Social Functioning

The mean scores of WHO/DAS for the 3 rounds are pre- sented in Table 2. There was a continual decrease in the scores from round 1 to round 3. The change between each round was statistically significant (Table 3). Although the mean scores of WHO/DAS of the 3 rounds were consistently <1, which suggested minimum level of dysfunction, some residents had a score of >2, indicating obvious to serious dysfunction. The mean scores of the male residents (0.88, 0.75, and 0.59) were higher than those of the females (0.50, 0.47, and 0.38) in all 3 rounds, but the differences were not significant (Table 4).

In all 3 rounds of data collection, there was no signifi- cant correlation between the scores of WHO/DAS and WHOQOL. Gender, diagnosis, educational background, and marital status were used to stratify the patients to look for any possible confounders. No significant correlation was found for all these groupings.

Life Skills Performance

Female residents had higher mean scores than males in all 4 life skills studied (Table 5). Females had significantly higher scores in self-care performance (t = 4.07; df = 169; p < 0.05) and work performance (t = 2.43; df = 169; p < 0.05). The 4 life skill scores were all significantly correlated with WHO/ DAS but not with WHOQOL. A similar correlation pattern was found for the male and female groupings except that there was no correlation between WHO/DAS and budgeting of the female residents (Table 6).


Quality Of Life

The results showed that the residents had a high level of perceived quality of life. This suggests that given adequate support and services, the most dependent and chronic psy- chiatric patients can live successfully in a community setting. The results also showed a steady increase in the overall perceived quality of life during a 1-year period of data collection. The reasons behind such improvement were not clear. A possible reason may be the changes in the content and varieties of programmes after the results of the first 2 rounds were made known. Also, changes in some of the environmental conditions such as installation of air- conditioners to all bedrooms may contribute to the change in the residents’ level of satisfaction. On the other hand, the study may have had a positive effect on staff and resulted in more attention being paid to the residents and better quality service provision.

The wide range of the WHOQOL scores in all 3 rounds indicated that there may be a number of residents who were not satisfied with their life in the LSCH. It will be important for service providers to look into the factors contributing to the exceptionally high and low perceived quality of life in the residents. Also, large differences between the scorings of successive rounds were noted for approximately 10% of the residents. This may be due to the sensitivity of the questionnaire. However, detailed investigation into these residents showed that some of them (70 to 80%) had some minor changes in their mental state or had some life events prior to the completion of the questionnaire. For example, a trivial argument between residents was found coincident with a markedly lowered score in the relationships domain of WHOQOL. Thus, the perceived quality of life of the

Social Functioning

The results showed that on average the residents had only minimum dysfunction, although some had obvious or serious dysfunction. This indicated that patients with chronic psychiatric illness could function well in an LSCH. However, it is difficult to determine whether the results can be generalised to other community facilities. Under staff supervision in an LSCH, few residents had scores below 3 on individual items of the schedule. This may explain why these residents seem to have minimum social disability.

Correlation Between Quality of Life and Social Functioning

The lack of correlation between WHOQOL and WHO/DAS showed that some of the residents may perceive themselves to have a satisfactory quality of life despite poor social func- tioning. It also indicated that there were other factors that affected quality of life and were not covered in this study.

Life Skills Performance

The results showed that female residents had better life skills performance than male residents. This was consistent with the pattern of social functioning. The strong correlation between life skills performance and social functioning did not indicate whether poor social functioning was the result of poor life skills performance or vice versa. However, the clinical observation was that most of the residents had made marked improvements in their performance after undergoing structured training programmes. Since there was gradual improvement in the social functioning of the residents, prospective study on the level of social functioning and the outcomes of life skills training programmes could help to clarify their causal relationship.

Implications for Rehabilitation Services

Patients with chronic psychiatric conditions are always thought to be unable to express reliable information about their quality of life. However, this study shows that they are able to reliably articulate their subjective experience. Therefore, rehabilitation services can assess their effective- ness not only by the users’ satisfaction with the service, but also by the subjective overall wellbeing of the service users.

The study shows that with adequate support and services, the most dependent and chronically ill patients can enjoy life and function satisfactorily in an LSCH. Thus, LSCHs may be a satisfactory alternative to admission to hospital.

The strong correlation between social functioning and life skills performance indicates that systematic assessment of the outcomes of this training are essential to service planning. The lack of any significant factors affecting the

perceived quality of life should also prompt the service providers to look for contributing factors.

Limitations of the Study

Since most of the residents in this study had moved into the LSCH more than 3 years prior to the start of the study, their level of social functioning and life skills performance may have reached relatively optimal levels. Characteristic changes in the first few years may have been missed. Clinical observations supported the view that there were marked changes in residents’ level of satisfaction and level of social functioning during that period of time.

The quality of life of the residents was only captured by a self-rating questionnaire. Objective improvement was not included in the study. Although subjective well being is important, some people with chronic mental illness do have expectations that are quite unacceptable by society. It is, again, the issue of whether a person always knows what is best for himself/herself. However, quality of life measurement may be a better indicator in assessing residents’ progress than direct feedback on services.

The performance of the 4 different life skills was not measured using validated tools. The tools used were all designed by staff developing the training programmes with- out proper validation. Also, inter-rater reliability was not established for these measurements. Since the assessment process involved panels of professional staff such as social workers, occupational therapists, and nurses, one can only assume face validity for the tools used.


The results of the 1-year follow-up study show that long stay patients from psychiatric hospitals can live less dependently in an LSCH. Residents reported a stable and relatively high quality of life. The residents’ perceived quality of life was found to be unrelated to demographic factors such as age, chronicity, and diagnosis. Residents’ perceived quality of life also had little correlation with their level of social functioning. However, their life skills performance was strongly associated with their level of social functioning. More in-depth investigation into the factors contributing to high quality of life is needed. Also, there is a need to have a systematic outcomes review of the training programmes and to investigate how these training programmes may contribute to better quality of life and social functioning.


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