The Effect of Religiously Therapy on

Depression and Quality of Life in Indonesian

Elderly: A Quasi Experimental Study

Bayu A. Pramesona
ID 5779191353

Adviser: Prof. Surasak Taneepanichskul, mD.

Introduction
Introduction
Asia-Pacific Region
• Over 52 % the world’s older
population are concentrated
in this region.
• Ranked 3rd amongst 25
Asia-Pacific countries with
almost 22 million of total
elderly population was
counted in 2015
Percentage of elderly age group in Global, Asia,
and Indonesia (1950-2050)
• Total Population in 2010 = 237,641,326 people
• (Population Census Data - Statistics Indonesia)
Life Expectancy at birth in Indonesia, 2015

• Life Expectancy at birth 2015 = 69.1 (both sexes)

• Males = 67.1
• Females = 71.2
Current Situation in Indonesia

In 2015, Indonesia has become the 5th largest elderly population in worldwide
(BPS - Statistics Indonesia, 2010a).
Elderly Population in Indonesia and Yogyakarta Province
Population of Yogyakarta Province was
around 3,457,491 people (BPS, 2010)

Total elderly aged ≥60 years =

448,223 people
Elderly Population in Indonesia and Yogyakarta
Province
Population of Yogyakarta Province is
around 3,457,491 people (BPS, 2010)
Population by age and religion in Indonesia and
Yogyakarta province
 3.5 million people and around 11.81%
were elderly (BPS - Statistics Indonesia,
2010b).
 91.95% of total population were Moslem
(BPS - Statistics Indonesia, 2010c)

87.18% of total population are

moslem, and almost 7% of total
moslem population were aged 60 or
above (BPS - Statistics Indonesia,
2010d)
Depression and Ageing
• Ageing is resulted from the accumulation of the molecular and
cellular damage over time. This gradual damage declines the physical
and psychological ability, increase the risk of getting disease,
eventually death (WHO, 2015).
• Mental health and emotional well-being are considered as crucial things
in older age community. Mental disorder is a problem amongst older adults
aged 60 and above whereas the 15% to over 20% of older adults
suffer from it (WHO, 2016).
• It means approximately 2 billion of the older adults have physical and
mental health problems which need to be solved (WHO, 2016).
Depression and Ageing
• Depression is one of common mental health problems related
ageing process among elderly population (WHO, 2015), depicted by
sadness, loss of interest or pleasure, feelings of guilt or low self-worth,
sleep or appetite disturbance, feelings of tiredness, and lack of
concentration (WHO, 2016c).
• Depression also considered as a feeling of suffering and depth of sadness
which impacts on sleep, appetite, quality of life, self-esteem, and attitude
pertaining own atmosphere (Carp, 2001).
• Depression is a kind of mental disturbance due to imbalance in emotional
aspect and effects on quality of life decrease which can influence the work
and interpersonal relations in different times (Beck, 1970)
• Healthcare providers and older adults rarely recognize toward
the mental health illness, and it impacts to the unwilling to seek the
treatment (WHO, 2016).
Prevalence of depressive elderly
• Prevalence of depression among elderly are various in worldwide, the rates
varied from different settings of study site such as in the community-
dwelling or clinical settings. Studies revealed that around 16% aged 65 and older
with clinically significant depressive symptoms in America, in Myanmar was
22%, Japan was ranged of 17.8%-53.8%, in Iran 23.5%, in Malaysia ranged from
14-30.1%, in Taiwan was 21.3%, in South Korea was varied from 15.2%-63%, in
Pakistan was 19.8%, in Thailand 6%, in India was 31.7%-72.4%, in Saudi Arabia
was 63.7%, in Egypt was 72%, and in Nepal was 57.1%.
• Major depression was rated as 8%-16% in community-dwelling older adults,
5%-10% in outpatients in primary care setting, and 10%-12% in hospitalized
(Blazer, 2009).

• The prevalence of major depression also varied from 0.9% to 9.4% in private
households, 14% to 67% in nursing homes, 1% to 16% among elderly living
in private households or in institutions (Djernes JK, 2006; M Al Jawad, AK Rashid, & KA Narayan,
2007).
Depression and Ageing
• Depression is not a normal part of aging process. Depression can be handled
through appropriate treatment with fast responses. If it is untreated well, the
remain effects can be occurred such as physical, cognitive, functional and social
impairment. Another following impacts for instance decreasing of quality
of life, prolonging patient’s health recovery, increasing the
healthcare utilization, and even suicide (Greenberg S. A, 2012).
• Although the treatment of depressive symptoms already well-known widely,
however less than 10% of depressive elderly who received the
treatments in many countries. Some barriers to receive the appropriate care
for instance lack of resources, lack of trained health care providers,
and social stigma related to mental health disorders are still existed.
Another barrier to adequate care is inaccurate assessment. It impacts on
misdiagnosing and antidepressant prescribing (WHO, 2016b).
Depression elderly in nursing homes
• The depression prevalence in the nursing home was higher three to four times compared
to the prevalence of depression in the community-dwelling elderly (K. Jongenelisa et al., 2004).

• Approximately 54% elderly people suffer from depression especially those who live in a nursing
home (Arifianto, 2006; Borza, et.al., 2015; Lampert & Rosso, 2015), because living in a nursing home
substantiates the feeling of being neglected by the family (Natan, 2008).

• It can decrease their health status, daily living ability,quality of life , and lead to a reduction
in cognitive abilities and an increase in mortality (Mansbach, Mace & Clark, 2015; Meeks, Van Haitsma,
Schoenbachler & Looney, 2015).
• Research findings describe that the risk
factors for depression in nursing home
residents are older age, poor physical health, cognitive impairment,
lower income, lack of care from the nursing home staff, lack of social
support and loneliness (Barca, Engedal, Laks & Selbaek, 2010; Jongenelis et al., 2004).
• Depression in the nursing home is often under diagnosed and undertreated (Mansbach et al.,
2015). The symptoms that are usually observed are sleeping and eating disturbances, less or too much
talking, difficulties in concentrating and decision-making (Lampert & Rosso, 2015; Niu & Arean, 2015).
 Introduction (cont..)
• In order to elevate the physical, psychosocial and well-being of elderly
nursing home residents, it is crucial to apply some beneficial
activities. Numerous studies have examined depression in the
general community. However, studies of depression in the elderly who
live in Indonesian nursing homes have generally been small and limited.
• Yogyakarta is a province with around 11.81% of 3.5 million people
were elderly (BPS - Statistics Indonesia, 2010b) and places Yogyakarta as a province
with the highest of life expectancy rate & elderly
population in Indonesia (BPS - Statistics Indonesia, 2010a, 2010b). In term of
the population distribution by religion, 91.95% of total population
were Moslem (BPS - Statistics Indonesia, 2010c). However, a religiously approach
in order to reduce the depression and to increase the quality of life
amongst elderly is still limited.
RESEARCH GAP
1.Lack of knowledge pertaining the prevalence of depressive
elderly nursing home residents in Indonesia.
2.Lack of information regarding the quality of life amongst
depressive elderly nursing home residents in Indonesia.
3.Lack of studies regarding the alternative therapies to reducing
the depression level and to improving quality of live through
religiously approach amongst depressive elderly nursing home
residents in Indonesia.

•
Research Objectives
General Objective
This study aims to assess the effect of religiously therapy on depression and quality
of life amongst depressive elderly nursing homes residents in Indonesia.

Specific Objective
1. To describe demographics, incidence of depression, and quality of life amongst
elderly nursing home residents in Indonesia
2. To investigate whether the religiously therapy can reduce the depression level
and finally increase the quality of life amongst elderly nursing home residents in
Indonesia.
Research Questions
1. Is there any difference on depression level amongst elderly nursing home
residents between the intervention and control group?
2. Is there any difference on quality of life amongst elderly nursing home residents
between intervention and control group?
Research Hypothesis
• The religiously therapy effect on depression and the QoL amongst
Indonesian elderly
Statistical hypothesis
• H0: There is no difference on depression level amongst elderly
nursing home residents between the intervention and control group.
• H1: There is difference on depression level amongst elderly nursing
home residents between the intervention and control group.

• H0: There is no difference on quality of life amongst elderly nursing

home residents between intervention and control group.
• H1: There is difference on quality of life amongst elderly nursing
home residents between intervention and control group.
Conceptual Framework

Independent Variables Intervention Group Dependent Variables

Religiously Therapy
(by hearing Primary Outcome
Gender
Age qur’anic Recital + Depression
Marital status religious leader’s Level
Education Level lectures)
Family support
Secondary Outcome
Financial support Control Group
Physical illness • Quality of
Length of stay Life
Usual Care
Reason for living in NH
Perceived of care
 TERM OPERATIONAL DEFINITION

Religiously A combination of the qur’anic recital and Moslem religious leader’s (imam) lectures in order to decrease the GDS score or
therapy depression level and to increase the quality of life amongst elderly nursing home residents
Depression A serious mental disorder with the sign and symptoms such as lack of interest and pleasure in daily activities, significant weight
loss or gain, insomnia or excessive sleeping, lack of energy, inability to concentrate, feelings of worthlessness or excessive guilt
and recurrent thoughts of death or suicide (American Psychological Association (APA), 2016).
Depression The level of depression amongst elderly nursing home residents which derived from Geriatric Depression Scale 15-item (GDS)
level score; scores of 0-4 are considered normal; scores of 5-8 indicate mild depression; scores of 9-11 indicate moderate depression;
and scores of 12-15 indicate severe depression (Sheikh JI & Yesavage JA, 1986).
Elderly Older adults those aged 60 or above based on identification card, medical record or self-reported (Badan Pengawasan Keuangan dan
Pembangunan (BPKP), 1998; World Health Organization (WHO), 2016a)

Nursing home A place of elderly residents who require continual nursing care and have significant difficulty coping with the required activities of
daily living.
Quality of life An individual’s 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’ (World Health Organization (WHO), 1996).
Quality of life The level of quality of life amongst elderly nursing home residents which are derived from the WHOQOL-BREF Bahasa Indonesia
level version measurement and classified as good, fair, and poor level.
 Methodology
• Study Design : A Quasi Experimental
• Study Area
2 govern’ nursing homes (NH) in
Yogyakarta Province, Indonesia
Intervention : Abiyoso Nursing Home
(Sleman District)
Control : Budi Luhur Nursing Home
(Bantul District)
Study Period

Study Population
The elderly residents in two government nursing homes which are
located in Sleman and Bantul district of Yogyakarta Indonesia will be
recruited in this study. Total population of elderly nursing home residents
in this study is 180 respondents.
Sample Size
Effect size =0.53
α err = 0.01
1-β err = 0.80 (Kai-Jo Chiang et al., 2015)

Sample size estimated number is 30 respondents in each

group and will be added 10% for anticipating the drop-out
rate. Finally, 33 respondents in each group will be
recruited as sample and the number of total sample will
be 66 respondents.

Sampling Technique
Purposive sampling will be used to allocate the Budi Luhur nursing
home as the intervention group and Abiyoso nursing home as a control
group with 33 respondents in each group will be determined.
Inclusion and Exclusion Criteria
Inclusion
1) Moslem as religion
2) Elderly who had to be 60 years
old or older
3) Elderly are living in the nursing
home for at least one month
4) Have a healthy physical condition
5) Have a Geriatric Depression Scale
score in range of 5-11
6) Willing to participate and being
followed-up until the end of
study
Exclusion
1) Have severe hearing or speech
impairment that might interfere
in the data collection process
2) Have severe cognitive
impairment or dementia
3) Experiencing psychotic disorders
4) Experiencing of alcohol/drug
misuse
5) Under antidepressants
medication treatment
Recruitment and Data Collection Procedures
Enrollment
Eligible (n = 2 nursing homes,
2 districts, 180 respondents)
1 province)
Purposively (n = 2 nursing homes, 2
districts, 66 respondents)
Excluded
 Have severe hearing or speech
impairment that might interfere in the
data collection process
 Have severe cognitive impairment or
dementia
 Experiencing psychotic disorders
 Experiencing alcohol/drug misuse
 Under antidepressants treatment

Allocation and
Baseline Data
Allocated to intervention (n = 33 respondents) Collection Allocated to control (n = 33 respondents)
within 1st week of December 2016 within 1st week of December 2016
 GDS score/ depression level  GDS score/ depression level
 Quality of Life  Quality of Life

Follow-up and Analysis

Intervention Group (n = 33 respondents) Control Group (n = 33 respondents)
between 2nd week of December 2016 – between 2nd week of December 2016 –
1st week of March 2017 1st week of March 2017
 GDS score/ depression level  GDS score/ Depression level
 Quality of Life  Quality of Life
 Religiously therapy implemented  Usual care implemented

Flow chart of recruitment studies setting and participant

 Data Collection Process
• Data collection process in this study will be carried out within 12 weeks, during
1st week of December 2016 –1st week of March 2017:
• 1) Preparation and Database collection ; Asking the permission, GDS score
or depression level and quality of life level measurement will be noted as
baseline data. Information from medical record also will be collected to
accomplish the baseline data.
• 2) Implementation
• The intervention group ; Religiously therapy which is consisted of hearing
the Qur’anic recital in 36 sessions and combined with once a month lecture from
religious moslem leader which commonly called imam. Both intervention will be
performed within 12 weeks. The qur’anic recital will be performed in 30 minutes
per session and the lecture related depression in Islamic perspective from imam
will be performed in 20-30 minutes in each session. A surah Al-Fatihah, An-Naas,
Al-Falaq, and Al-Ikhlas will be delivered as the qur’anic recital intervention (Djalal
A, 2000).
Content of Imam’s lectures in each session
Session Theme Activities Intervention goals Duration
1 Depression in Islamic - The lecture will be delivered by an imam in Building a better understanding 20-30 minutes
perspective; the causes, front of the all respondents in a meeting of depression concept according
sign and symptoms, and room to Islamic perspective
prevention. - The open discussion will be performed

2 How to reduce a - The lecture will be delivered by an imam in Self-understanding on how to 20-30 minutes
depression amongst front of the all respondents in a meeting reduce the depression based on
elderly according to room Islamic perspective
Islamic perspective - The open discussion will be performed.

3 How to increase the - The lecture will be delivered by an imam in - Self-understanding on how 20-30 minutes
quality of life amongst front of the all respondents in a meeting to increase the quality of life
elderly according to room based on Islamic
Islamic perspective - The open discussion will be performed perspective
- The conclusion will be delivered in the of - Self-evaluation
meeting
- Self-evaluation will be performed by
measuring the GDS score/depression level
and quality of life level amongst respondents
Control Group
• The 33 allocated respondents in Abiyoso nursing home in Sleman
district will be a control group in this study. Participants in the control
group engaged in daily regular activities for instance praying,
watching television, counselling, playing music for 50-60 minutes.
These kind of regular and ongoing activities in nursing homes;
participant will not receive any therapeutic interventions during study
period.
 3) Evaluation of religiously therapy on
depression level and its impact on quality of life
amongst elderly
• The evaluation of this study will be derived from the GDS score or
depression level amongst elderly as the primary outcome. The GDS
score or depression level amongst elderly will be evaluated in 4th, 8th
and 12nd week as the primary outcome after the intervention
performed.
• The secondary outcome will be evaluated from the level of quality of
life amongst elderly after 12 weeks intervention.
 Research Instrument
Part 1: Socio-demographics of respondents such as gender, age, marital status, education level,
family support, financial support, physical illness, length of stay in NH, reason for living in NH,
and perceived of care
Part 2: Depression level measurement will use a short form Geriatric Depression Scale (GDS)
which is consisted of 15 questions and has been tested and extensively used in community,
acute and long-term care settings with the older population (Sheikh JI & Yesavage JA, 1986).
The 15-item questionnaire in which participants are asked to respond by answering yes or no in
reference to how they felt over the past week. Of the 15 items, 10 indicated the presence of
depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13)
indicated depression when answered negatively. Scores of 0-4 are considered normal; 5-8
indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe
depression. The Short Form is more easily used by physically ill and mildly to moderately
demented patients who have short attention spans and/or feel easily fatigued. It takes about 5
to 7 minutes to complete.
Research Instrument (cont)
• Part 3: Quality of life measurement will use Bahasa Indonesia version of The World
Health Organization Quality of Life (WHOQOL)-BREF. The WHOQOL-BREF instrument
consisted of 26 items, which measure the four domains such as physical health,
psychological health, social relationships, and environment factors (WHO, 1996).
• The four domain scores denote an individual’s perception of quality of life in each
particular domain. Domain scores are scaled in a positive direction (i.e. higher scores
denote higher quality of life). The mean score of items within each domain is used to
calculate the domain score. Mean scores are then multiplied by 4. Where more than 20%
of data is missing from an assessment, the assessment should be discarded.
• The raw score was converted to transform the scores, and the range of transformed
scores was from 0 to 100 (WHO, 1996). Scores were then categorized into three levels (Issa
BA & Baiyewu O, 2006);
- Good: > mean + SD,
- Fair: mean–SD to mean+SD, and
- Poor: < mean–SD levels
Validity and Reliability
1. The Geriatric Depression Scale questionnaire
In a validation study comparing the Long and Short Forms of the GDS for self-rating
of symptoms of depression, both were successful in differentiating depressed from non-
depressed adults with a high correlation (r = .84, p < .001) (Sheikh JI & Yesavage JA, 1986).
The GDS questionnaire in English version will be translated into Bahasa
Indonesia. Forward-translations and expert panel back-translation will be conducted
as the content validity consideration for this used questionnaire, pre-testing to ensure the
GDS questionnaire in Bahasa Indonesia version will be done as well before disseminating
the final version within data collection period.
2. The WHOQOL-BREF questionnaire (Bahasa Indonesia version)
The WHOQOL-BREF Bahasa Indonesia version has revealed that the Cronbach’s α
value for each domain ranged from 0.41 to 0.77, with the pearson correlation coefficient
between each domain ranged from 0.5 to 0.7 (Salim O C, Sudharma N. I, & Hidayat A, 2007).
Analyses of internal consistency, item–total correlations, discriminant validity and construct
validity through confirmatory factor analysis, indicate that the WHOQOL-BREF has good to
excellent psychometric properties of reliability and performs well in preliminary tests of
validity (S.M. Skevington, M. Lotfy, & K.A. O’Connell, 2004).
Data Analysis
SPSS 16.0 Version will be used
Descriptive statistic
Variables Measurement scales Statistical analysis

Socio-demographics: Descriptive statistics

1) Gender, marital status, Nominal and ordinal Frequency and percentage
education level, physical
illness, and reason for living
in NH, perceived of care
2) Age, monthly income, length Interval and ratio Frequency, mean, SD, minimum
of stay in NH. and maximum, percentage
Depression Interval Descriptive statistics
Frequency, mean, SD, minimum
and maximum, percentage
Quality of life Interval Descriptive statistics
Frequency, mean, SD, minimum
and maximum, percentage
Inferential statistics (cont..)
Variables Measurement Scale Statistical analysis Result

1) Gender, marital status, Nominal and ordinal Chi-square test To test homogeneity between two groups
education level, physical
illness, and reason for
living in NH, perceived
of care
2) Age, monthly income, Ratio Independent t-test To test the difference between two
length of stay in NH groups

Independent t-test To test mean difference before and after

implementation between two groups
- Depression level Interval
- Quality of life Dependent t-test To test mean difference before and after
implementation within group

Depression score in baseline, Interval Repeated measurement To test mean difference of depression
4th, 8th, and 12nd week ANOVA score/level overtime between
intervention and control
Ethical Consideration
The ethical approval will be derived from the Ethical Committee of
Research in the Medical Health Faculty of Medicine, Gadjah Mada
University, Indonesia. The purpose, benefits, data collection process,
and ethical issues in this study will be confidentially informed to the
ethical committee. The permission will be proposed to the local
governments and the nursing homes authority. Finally, the meeting
with the director of nursing homes and local staffs will be carried out in
briefly explanation pertaining this study purposes.
Timeline of Study
Estimation of budget expenses
•Terima kasih
•Khop Khun Ma Krub..