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Evaluation of the Flanagan Quality of Life Scale for older adults

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International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

Evaluation of the Flanagan Quality of Life Scale for older adults

Luciana Bronzi de Souza (1)
José Eduardo Corrente (2)
(1) PhD Student at Public Health Department, Botucatu Medicine School, UNESP, Botucatu, São Paulo, Brazil.
Email: luciana.bronzi@gmail.com
(2) Associate Professor, Biostatistics Department, Bioscience Institute, UNESP, Botucatu, São Paulo. Brazil.
Email: jecorren@Ibb.unesp.br
Corresponding author
José Eduardo Corrente

Biostatistics Department - IB - UNESP

Distrito de Rubião Jr, s/n
CEP: 18618-700
Botucatu - São Paulo - Brazil

Abstract:
Purpose: to evaluate the Flanagan Quality of Life Scale applied in a representative sample of urban older
people population of Botucatu city, São Paulo, Brazil. Methods: a cross-sectional study was carried out with a
representative sample of 365 older people obtained considering a prevalence of 50% of satisfaction with the
quality of life, 95% of reliability and an 5% error margin. Descriptive analyzes were initially made for
sociodemographic data and associations with quality of life. To obtain the domains of the Flanagan Quality of
Life Scale, a factor analysis was running extracting the principal components using the varimax rotation.
Results: 361 older people were included and the average age participants was 72.10 (SD= 7.35) years. The
majority were female, married with low education level. The income varied from none to 8.253,50 U.S. dollars,
approximately. The mean score of the questions of the Flanagan Quality of Life Score was 84.76, indicating a
good quality of life. The reliability coefficient Cronbach's α was 0.81, demonstrating the efficiency of the
instrument. After a factorial analysis, the domains considered by the older adults as the most important to their
quality of life agree with those proposed by Flanagan. Conclusion: The Flanagan Quality of Life Scale as
described initially proved to be an efficient and reliable tool to assess the quality of life of older adults.

INTRODUCTION
Population aging is a global phenomenon especially nowadays. The WHO (World Health Organization)
predicts that in 2025 there will be 1.2 billion people over 60 years [1]. In Brazil, there was an increase of older
adults from 8.8% to 11.1% between the years 1998 and 2008. Currently, is estimated that in the country there
are 21 million people aged 60 years and older [2].
Due to the general increase of the population survival, it highlights the importance of ensuring the older
people not only longevity but also happiness, quality of life and personal satisfaction [3].

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International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

Quality of life (QOL) is a multidimensional and subjective construct [4] and is conceptually defined as
the individual's perception of their position in life in the socio-cultural context that considers their goals,
expectations, standards and concerns [5]. It is related to personal well-being and covers aspects such as health,
leisure, personal satisfaction, and lifestyle habits [6]. Currently, there are several instruments to assess quality of
life of the individuals in a population, including the Flanagan Quality of Life Scale (FQOLS), which takes these
aspects into account.
The FQOLS [7] was developed in the United States during the 1970's to measure the quality of life
across a random sampling of 3000 American adults using an interview technique. In a second step, the
instrument was used to survey a total of 3000 people, ages 30, 50, and 70. The results of this national survey
revealed that most people of both genders and all three ages felt that the items were important to them. The
original FQOLS contained 15 items representing 5 conceptual domains of quality of life: physical and material
well being, relationships with other people, social and civic activities, personal development, and recreation [8].

The original FQOLS was translated into more than 16 languages, including Portuguese. In Brazil, the
responsible authors for translation [9] did not made any reference to the reliability of the Portuguese version. In
that, all items were answered using a Liker scale of 7 points (1 = very dissatisfied to 7 = very satisfied). As in
the original scale, the total score ranges from 15 to 105 points, as in the Portuguese version.
Regarding the evaluation of the quality of life of the older adults, it should be noted the complexity of the task
and reinforce the importance of using hybrids criteria evaluation, as presented in FQOLS that would clarify
inter-subjective aspects that have more chance to occur in older than young adults, such as diseases, loss of
occupational roles and emotional losses. [10]
In this context, the objective of this study was to evaluate the Flanagan Quality of Life Scale, applying it
in a representative sample of urban older adults of Botucatu city, São Paulo, Brazil.

METODOLOGY
According to the Census, 2010 [11], Botucatu is a city with 127,370 inhabitants, 17,832 of these seniors,
representing approximately 14% of the older adults in the city.
In order to evaluate the FQOLS, a cross-sectional study was carried out with a sample of 365 older
adults, considering a prevalence of 50% of satisfaction with the quality of life, a confidence level of 95% and an
error margin of 5%. The sample was obtained from a database set up for this purpose.

From 365 older adults, four did not complete the protocol and 361 were interviewed at home, applying
an instrument to obtain demographic data and the FQOLS. Data were collected from August 2009 to January
2011.
Descriptive analyzes were initially made for sociodemographic data, calculating frequencies and
percentages for qualitative variables and mean and standard deviation for quantitative ones. Associations
between quality of life and sociodemographic data were obtained using chi-square test. The domains of the
FQOLS were obtained running a factor analysis and extracting the principal components using varimax
rotation. All analyzes were performed using SAS for Windows, v.9.2.
All procedures were approved by the Research Ethics Committee of the Faculty of Medicine of
Botucatu, following the requirements of Resolution 196/96 of the National Health Council, under protocol
number 3111/2009.

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International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

RESULTS

From the 361 participants, the mean age was 72.10 ± 7.35 years (72,54  7.40 and 71.38  7,22 for women and
men, respectively (p=0,14)). The sociodemographic characteristics are showed in Table 1.
Table 1. Distribution of sociodemographic characteristics of older adults in the city of Botucatu, São Paulo,
Brazil. 2011.

Characteristics N %
Gender
Female 226 62.60
Male 135 37.40
Marital status
Married 210 58.17
Widow 104 28.81
Single 31 8.59
Divorced 16 4.43
Retired
Yes 314 86.98
No 47 13.02
Still working
Yes 39 10.80
No 322 89.20
Level of scholarity
Illiterate 55 15.23
Elementary School 222 61.50
Secondary School 39 10.80
University 45 12.47
Income
No income 43 11.91
1 minimum wage or less 89 27.99
1 to 2 minimum wages 92 28.93
2 to 3 minimum wages 48 15.09
More than 3 minimum wages 89 27.99
People living in the house
1 person 56 15.60
2 people 142 39.55
3 people 81 22.56
4 or more people 82 22.29
According to Table 1, 62.6% of them were female, which is a slightly higher proportion of older females in
Botucatu (57.3% according to the 2010 Census). It can be also observed that the majority were married. The
most of them was retired and some still play remunerated activities.
Most of the older people attended elementary school, followed by illiterates, that represents 15.23% of
the sample, which is to be expected, since, in Brazil, at a time when they should go to school, there was not
much incentive for such facilities. Moreover, the majority gets to a minimum wage, a result of retirement.
Among then, 11.91% (n = 43) would not disclose their monthly income. The mean income was 2.92 ± 3.46
minimum wages, varying from none to 29.13.

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 International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

The number of people living in the house shows that the minority lives alone and the majority lives with
another person, revealing the fact that most are married and possibly live with a spouse.
The sociodemographic questionnaire also contained some questions about morbidity. The results are presented
in table 2.
Table 2. Distribution of the referred morbidities by the older adults from Botucatu city, São Paulo, Brazil. 2011.

Referred morbidities N %
Hypertension 201 55,68
Diabetes 104 28,81
hypercholesterolemia 56 15,51
Osteoporosis 31 8,59
Heart desease 28 7,76
Tireoide disturbances 26 7,20
Depression 8 2,22

They were also asked about their oral health: 94.74% (n = 342) had one or more missing teeth and
78.67% (n = 284) using dentures. Regarding the chewing and swallowing, 83.1% reported that they never/rarely
had to eat less or change food because of teeth, 69.53% never/rarely had difficulty chewing hard foods like meat
and apple, 90.86 % always/often can swallow well, 78.67% never/rarely have trouble eating things that they
wanted to have a problem with your teeth or dentures and 85.05% never/rarely had pain in the teeth because of
cold foods, hot or sweet.
In the sequence, we present the obtained results with the application of the FQOLS, covering the
following categories:

1. physical and material well-being;

2. relationships with others;
3. social activities, community and civic;
4. personal development and achievement;
5. recreation.
As the FQOLS has 15 items grouped into five categories listed above and the answers follow a Likert
scale with seven points, it was used a visual scale to the respondents for fast and to avoid possible
misunderstanding, as shown in Figure 1.

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International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

Figure1. Motivation scale used to obtain answers of the FQOLS (from "very dissatisfied" to "very
satisfied").
The mean of the obtained responses was 5.65 ± 0.34 (a maximum possible value of 7). This result was
slightly higher than found in the original study [7], which the average for items was 5.2 and by other authors
who evaluated the quality of life through adapted scale [12].
The mean score of the questions was 84.76, indicating a good quality of life, as in this case, the scores
varied from 44 to 105 points. The reliability coefficient Cronbach's α was 0.81, demonstrating the efficiency of
the instrument applied to the sample.
Dichotomizing the final score using the median as cutoff (the obtained value was 86.0), 77.33% were
satisfied with the quality of life. Associating this result with social demographic and morbidities variables using
chi-square test, the results are showing in Table 3.
Table 3. Demonstrative of factor analysis and identification of the components that influence the level of
quality of life in the older people sample. Botucatu, São Paulo, Brazil. 2011.

Fatorial
Statements Scale Flanagan
loadings
Factor 1. Physical and material well-being (variance = 28,27%;
eigenvalue=4,28)
Item 10. Understanding yourself - knowing your assets and limitations 0,6278
Item 11. Work: job or in home 0,5807
Item 14. Reading, listening to music or observing entertainment 0,5713
Item 1. Material comfort home, food, conveniences, financial security 0,5456
Item 2. Health - being physically fit and vigorous 0,5232

Factor 2. Relationships with others (variance = 11,45%;

eigenvalue=1,72)
Item 4. Having and rearing children 0,7444
Item 3. Relationships with parents, siblings and other relatives 0,5914
Item 5. Close relationships with spouse or significant other 0,5275

Factor 3. Social activities, community and civic (variance = 9,1%;

eigenvalue=1,36)
Item 12. Expressing yourself creatively 0,7652
Item 13. Socializing - meeting other people, doing things, parties, etc 0,6555
Item 7. Helping and encouraging others, volunteering, giving advice 0,5842

Item 7. Helping and encouraging others, volunteering, giving advice 0,5842

Factor 4. Personal development and achievement (variance =7,25%;

eigenvalue =1,09)
Item 9. Learning - attending school, improving understanding, getting 0,7494
additional knowledge
Item 8. Participating in organizations and public affairs 0,7289

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 International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

Factor 5. Recreation (variance = 5,92%; eigenvalue=0,89)

Item 15. Participating in active recreation 0,5834
Item 6. Close friends 0,5692

Next, we performed a factor analysis with varimax rotation in order to obtain the factors described in
FQOLS. No items of the scale had factor loadings less than 0.5, the standard adopted for this study, thus, no
item was deleted. This was possibly due to the good quality of life of the older people in the sample. The results
of the factorial analysis are shown in Table 4.
Table 4. Comparison of the dimensions of FQOLS and those identified in the sample of older people. Botucatu,
São Paulo, Brazil. 2011.

Domains of the FQOLS Domains identified in the sample

1. Physical and material well-being 1. Physical and material well-being
2. Relationships with others 2. Relationships with others
3. Social activities, community and 3. Social activities, community and
civic civic
4. Personal development and 4. Personal development and
achievement achievement
5. Recreation 5. Recreation
Comparing the obtained results with those suggested for the FQOLS, it is noted that the sequence dimensions
are the same as can be seen in Table 5.
Table 5. Comparison of the mean and standard deviation from the original version, three validated version and
this study.
This
Item English Swedish Norwegian Hebrew Study
N=584 N=100 N=282 N=100 N=361
1. Material and physical well-being 5,6 (1,0) 5,7(1,4) 5,5(1,3) 4,3(1,8) 5,9(1,1)
2. Health 3,9(1,4) 3,9(1,6) 4,4(1,5) 2,3(1,5) 5,4(1,4)
3. Relationships with parents, siblings and
other relatives 5,3(1,1) 6,0(1,0) 5,5(1,5) 5,9(1,2) 6,0(1,0)
4. Having and raising children 5,6(1,2) 5,6(1,6) 5,7(1,2) 5,9(1,2) 5,9(1,2)
5. Relationship with spouse or significant
other 5,5(1,4) 5,6(1,6) 5,5(1,6) 5,8(1,2) 5,3(1,7)
6. Relationships with friends 5,4(1,1) 6,2(0,9) 5,9(1,1) 5,4(1,6) 5,7(1,2)
7. Helping and encouraging others 5,4(0,9) 5,3(1,2) 5,2(1,2) 3,0(2,0) 5,5(1,3)
8. Participating in organizations and public
affairs 4,6(1,2) 4,9(1,6) 4,3(1,6) 2,3(1,9) 5,1(1,3)
9. Intellectual development 4,7(1,2) 5,2(1,4) 4,6(1,5) 2,1(1,6) 5,0(1,5)
10. Understanding of self 5,1(1,1) 5,5(1,2) 5,3(1,1) 3,0(1,8) 5,8(1,2)
11. Occupational role 4,1(1,4) 5,0(1,5) 5,3(1,4) 3,2(1,8) 5,8(1,4)
12. Creativity/personal expression 4,8(1,2) 5,0(1,4) 4,7(1,6) 2,5(1,7) 5,8(1,2)
13. Socializing 4,7(1,2) 5,3(1,3) 5,1(1,4) 3,6(1,9) 5,5(1,5)
14. Passive and observational recreation 5,5(0,9) 6,0(1,0) 5,7(1,1) 3,6(2,0) 6,1(1,3)
15. Active and participatory recreation 4,0(1,5) 4,0(1,7) 4,5(1,6) 2,2(1,5) 5,9(1,4)

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International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

DISCUSSION
Most of the older adults found in our results are female. This finding has been described in other studies
with similar percentages and also showing greater longevity of women [7, 11, 12, 15, and 16]. Yet, according to
the Census of 2000 [13] and the predictions made, the number of older women is always higher than the men. It
is estimated that women live approximately seven years longer than men [14, 17]. In our study, no significant
difference of ages was found.
Although we found high percentage of widows, most were married, retired, less educated, received from
one to two minimum wages and live with other people. This somehow supplement the income of the household
for not missing the minimum necessary for the their survival. Nevertheless, other studies should be made, since
the issue of income is a complicating factor analysis and, in this study, cannot be considered conclusive.
More than half of them reported having hypertension, percentage close to that described in a study
conducted in Uberaba, Minas Gerais, Brazil [12]. This was the second most prevalent disease of the older
people themselves, followed by diabetes, and hypercholesterolemia.

Concerning the oral health, although a high percentage of them has one or more missing teeth, many
uses dental prostheses, which seems to supply the missing teeth since mostly reported no problems of dentition
or swallowing.
Regarding quality of life, most of the older adults referred living with quality, as well as in other studies
[7, 15, and 16].
The mean score of the questions was 84.76, higher than that described in other studies. An average
quality of life of 80.45 was obtained between 59 nurses who work in general hospitals [17]. Among 75 older
adult’s participants of an open university for third age, the average level was 82.65 [18]. Average slightly lower
(74.32) was obtained in the northeastern of Brazil [9], showing that the quality of life of older people varies
from low to regular differently than described in this work. This is possibly due to the social inequality and lack
of access to a standard of living that provides more comfort [19].
It was noted that the aging group, marital status, have heart disease and depression are the ones with that
significantly influence in quality of life (table 3). According to the results, increasing age is inversely related to
satisfaction with quality of life. This is possibly due to the onset of limitations or comorbidities that can occur in
the aging process. Yet, those who are married have a higher quality of life. The non-reference of loneliness was
also associated with life satisfaction [7]. It can also be noted the life satisfaction was related to positive
description of marriage, good social and family life, which should influence the quality of life [20]. Also, heart
disease and depression caused great impact on quality of life for. A study conducted in Ireland showed that
depression was associated with low quality of life [22], similar to ours.
It can be noted that the percentage of older adults with quality of life increases when increases the
income, although no significant difference was found. This fact follows the dimensions proposed by Flanagan
that the physical well-being and material is the most important domain for the quality of life. Economic
situation offers material support for the individual welfare, influencing the way of one deal with the degrees of
quality housing, independence and financial stability. [23]
Our findings revealed that the domains considered by the older adults as the most important to their
quality of life agree with those proposed by Flanagan. In fact, for them, quality of life is related to: first, aspects
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International journal of Science Commerce and Humanities Volume No 1 No 4 June 2013

of health and well-being and physical material; secondly, the relationship with other people; social activities
with third; fourth place, personal development and, in fifth, recreation. This result was not observed in a survey
carried on in sample of 365 older people in Avaré city, São Paulo Brazil [16], and in a sample of 128 older
people in João Pessoa, Paraíba, Brazil [9], showing some particularities related to quality of life in different
populations.

These facts suggest that the FQOLS could change depending on the characteristics of the study
population. It reflects the priority aspects that provide quality of life for the older adults.
As for the mean score of the items (Table 5), we can see that in most of them in our study was higher
than in others. However, these studies evaluated only patients affected by morbidities such as,
Arthritis, fibromyalgia, lupus erythematosus, that can justify the low scores reported in item relating to health.
Most of the research on quality of life was conducted in North America (42%), Europe (21%) and Asia
(18%) [24], which highlights the importance of conducting this type of research in Brazil, enabling greater
insight of the condition and quality of life, supporting actions aimed at groups that need more attention and
allowing people to achieve successful aging. In this context, the FQOLS has revealed an excellent generic
instrument.

CONCLUSION
The FQOLS as described initially revealed to be an efficient tool to assess the quality of life of older
adults. Moreover, FQOLS represented reliably the most relevant factors related to the quality of life of this
group of people.

ACKNOWLEDGMENTS
The authors would like to thank to São Paulo Research Foundation (FAPESP) for the financial support
(Process number 2008/10261-8) for this research.

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