The impact of a PARO intervention on depression and well-being in older adults in long-term care in Taiwan

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Moyle, Wendy

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Jones, Cindy J

Wang, Jing-Jy

Petsky, Helen

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Background: Depression is a common mental health condition that can have significant impacts on the physical and psychological well-being among older adults. The prevalence of depression increases substantially in older adults living in long-term care (LTC) facilities and may diminish their ability to pursue and experience pleasure. Pharmacotherapy for depression has adverse side effects and does not always benefit older people. Therefore, psychosocial interventions for older adults with depression are needed to improve mental well-being. A social robot called PARO, developed to engender a beneficial psychological effect or enrichment, is a potential psychosocial intervention for improving mental well-being in older adults with dementia. However, very little is currently known about PARO as an intervention for older adults with depression. Therefore, this study could fill current knowledge gaps and help with our understanding of the effect of using PARO with older people with depression. Objectives: There were two phases in this PhD study. Phase one was an online survey and phase two was a mixed methods experimental study. The aims of the online survey study were to: (1) modify, translate and validate the Chinese version of Attitudes Towards the Use of Social Robot (ATTUSR-C) questionnaire for use with Taiwanese health personnel; and (2) investigate the attitudes of Taiwanese health personnel working in LTC facilities towards the use of social robots for older adults. The aims of the mixed methods experimental study were to explore: (1) the effect of an eight-week 24-hour PARO intervention on depression and well-being in older adults in LTC facilities in Taiwan; and (2) participants’ experiences and perceptions following participation in the intervention. Methods: Phase one involved a cross-sectional design. Settings were LTC facilities across Taiwan. Purposive sampling was used and health personnel working in LTC facilities provided information for the cross-sectional survey. Content validity, internal consistency reliability, and factor analysis of the ATTUSR-C questionnaire were evaluated. All recruited participants received an email containing study information and a URL link to the survey. Data collection took place from November 2017 to May 2018. Phase two involved a mixed methods experimental design with a quasi-experimental approach. Embedded qualitative interviews were used to gain insights into statistical associations and individual perspectives in this present study. Settings were four nursing homes in southern Taiwan and the sample was 20 older adults with depression living in LTC facilities. Phase two consisted of two stages. Stage 1 was an eight-week observation stage in LTC facilities where the purpose was to observe usual mood, behaviour and activities of older adults with depression. Stage 2 was an eight-week 24-hour PARO intervention during which a PARO was introduced to participants and subsequently left with them. The Chinese version of the Geriatric Depression Scale – Short Form, the Chinese version of UCLA Loneliness Scale Version 3, and the Chinese version of the World Health Organization Quality of Life Questionnaire for older adults were administered at four time points: a week before the start of the eight-week observation, immediately after the eight-week observation, mid-point of the PARO intervention, and straight after the eight-week PARO intervention. A semi-structured interview was conducted with the older adults following the completion of their participation in the intervention. Results: Content validity of the modified Chinese version of the ATTSUR questionnaire was first assessed by a panel of five academic nursing professors (I-CVI = 0.83 / S-CVI/Ave = 0.93) followed by face validity examination by 10 clinical instructors (Fleiss’s kappa = 0.82). Finally, psychometric testing (i.e. exploratory factor analysis and internal consistency a = 0.84) was conducted using a convenient sample of 95 nurses. The final modified Chinese version of the ATTSUR questionnaire is a one-factor model consisting of 15 items with good validity and reliability. A total of 416 health professionals responded to the online survey. The mean age of respondents was 39.16 years (SD = 11.37). Of these, the mean length of work experience was 6.12 years (SD = 5.74). About 85.8 % of the respondents were female, and 14.2% were male. The majority of respondents (75.9 %) had obtained college or above education. Registered nurses (43.5%) and nursing aides (31.7%) were the majority of respondents. Over half of the respondents (56.5%) were working in nursing homes, and 25.7% were working in residential aged care. A point-biserial correlation was conducted to explore the relationship between attitudes and awareness of using social robots. Attitudes of respondents towards the use of social robots for older adults in LTC were found to be positively and significantly correlated with their awareness of the use of social robots in nursing homes (rpb = .18, p < .000). Most health personnel had positive attitudes towards the use of social robots in LTC facilities, as they considered social robots to be beneficial and practical in psychosocial care for older adults. The ATTUSR-C questionnaire had good validity and reliability. Twenty participants completed phase two. Scores on depression, loneliness, and quality of life demonstrated significant positive changes over time (p < .000). The qualitative findings showed that participants expressed positive experiences and perceptions about the PARO intervention, such as improved mood, alleviated loneliness, and increased interpersonal interactions with other people. Three themes emerged from the interviews: humanising PARO by relating it to personal experiences and engagement, increased social interaction with other people through participants' use of PARO and companionship, which all resulted in improved mental well-being. The outcomes demonstrate that a 24-hour PARO intervention has the potential to improve mental well-being among older adults with depression who live in LTC facilities. Conclusion: The ATTUSR-C questionnaire is a reliable and valid instrument for assessing the acceptability of social robots for health professionals working in LTC facilities. Positive attitudes towards the use of social robots can increase the acceptance and utilisation of social robots. Health personnel and nursing researchers can use the findings of this study to encourage and inspire further interventions that use robots to improve the quality of life in care settings. The findings of this mixed methods experimental study indicated that PARO has the potential to alleviate depression and loneliness and improve the quality of life for older adults living in LTC facilities. Using PARO for companionship can be a key factor in decreasing depression and loneliness, as it provided comfort and calming effects for older adults with depression. This study was the first study known to undertake a 24-hour PARO intervention in older adults with depression and confirmed the feasibility of the implementation of PARO in aged-care settings. As a consequence, the research findings provided theoretical foundations for further studies about the use of PARO in older adults with depression. The study filled gaps in knowledge and identified the need for further development in the area of PARO interventions with older people with depression.

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Thesis (PhD Doctorate)

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Doctor of Philosophy (PhD)


School of Nursing & Midwifery

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mental health

physical well-being

psychological well-being


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