HKJOT 2010;20(2):7179

ORIGINAL ARTICLE

ELEMENTS OF LIFE SATISFACTION AMONGST ELDERLY PEOPLE LIVING IN INSTITUTIONS IN MALAYSIA: A MIXED METHODOLOGY APPROACH
Akehsan Dahlan, Margaret Nicol and Donald Maciver

Background: Changes in demographic characteristics, social structure and economic status have shifted the direction of care of elderly people in Malaysia. Subsequently, nursing homes and institutions for elderly people becoming a significant care option. The aim of this study is to identify the level of life satisfaction and to examine the elements of life satisfaction amongst the elderly people living in the institutions. Methods: In this mixed methodology, a survey using translated version of Satisfaction with Life Scale (SWLS) was conducted to 82 participants who conformed to the inclusion criteria. Twenty participants who volunteered to discuss about their live experience regarding life satisfaction living in a public elderly institution in Malaysia. The participants were stratified according to age group and gender. Four focus groups were conducted and the Interpretative Phenomenological Analysis were used to identify the key themes emerged from the focus groups. Results: The level of life satisfaction is equivalent to the norms and there is no statistical significant difference between the levels with the demographic variables. Two main themes were developed, contentment and acceptance, reflecting the elements of life satisfaction of the participants in the institution. Conclusion: The findings are inconsistent with previous findings. However, it identified new elements of life satisfaction for elderly people in the institution.

KEY WORDS: Institutionalised elderly people Life satisfaction Mixed methodology Occupational therapy

Introduction
It is anticipated that the elderly people population in Malaysia will increase up to 9.9% by the year 2020 (Pala, 2005), whilst life expectancy has increased from 66.4 to 70.2 years old in males, and from 70.5 to 75.0 in females (Ministry of Health, 2008). These increased changes have implications for health services, as people living longer will require more health care and hospitalisation for chronic illness, functional dependence, mental health, sensory deficiency and cognitive impairment, thus increasing the government expenditure for health services.

(Chen, 1987; Jamaiyah & Hanafiah, 2006; Sherina, Lekhraj, & Mustaqim, 2004; Yeoh, 1980). The Malaysian family has long been regarded as a care institution, which bears the responsibility for looking after the elderly people. This belief derived from the teaching of Islam and Confucians ethics of filial piety that put a strong emphasis on respect for the elderly people. Therefore, elderly people in Malaysia are greatly respected and are usually cared for by their family. In addition, Kim et al. (2005) indicated that 62% of adults surveyed believe that they should support their elderly people parents and they should not send their parents to nursing homes.

Department of Occupational Therapy and Art Therapy, School of Health Sciences, Queen Margaret University, Edinburgh, United Kingdom. Reprint requests and correspondence to: Akehsan Dahlan, Department of Occupational Therapy and Art Therapy, School of Health Sciences, Queen Margaret University, Edinburgh EH21 6UU, United Kingdom. E-mail: adahlan@qmu.ac.uk

Hong Kong Journal of Occupational Therapy 2010 Elsevier. All rights reserved.

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A. Dahlan, et al The social characteristics of people in Malaysia are changing as a result of urbanisation and modernisation of the population, for example, the changing role of women and their participation in the labour force, delay in marriage, smaller family size, migration of the younger generation to urban areas with more jobs and education opportunities (Aminah, 1996; Arpita, 2000; Hew, 2007; Sim, 2002). These changes have social implications for elderly people. The extended family structure is being replaced by a nuclear family structure, consequentially affecting and putting a strain on the family as the role of the care giver for elderly people (Cheng, 2003; Hew, 2007; Martin, 1989; Mubarak, 1997; Ng, Lim, Jin, & Shinfuku, 2005; Selvaratnam & Tin, 2007). For example, the urban population has increased from 33.5% (as a percentage of total populations) in 1970 to 65.1% in 2005, the elderly people who lived in an extended family decreased from 57.8% in 1991 to 43.8% in 2000, whilst the average household size decreased from 5.2 people in 1980 to 4.6 people in 2000 (Department of Statistics Malaysia, 2008). In addition, the fertility rate has continuously declined, for example the fertility for all races is 4.9 children born per women in 1970 to 2.95 in 2009. The birth rate has also continuously declined from 23.7 birth to 22.24 per 1000 populations in 2009. These changes have created a vacuum that has seen the development of many private and public nursing homes and other institutional care facilities which reflect the demand and ability to purchase, and are perceived as a significant care option. For example, the first nursing home was established in 1983, and by the year 2001, there were 50 moderate-sized nursing homes which contained 40 beds, but there are hundreds more smaller homes in operation (fewer than 10 beds) which are located in bungalows and private residences (Sim, 2002). By the year 2007, there were 209 moderate size nursing homes and 7 institutions for elderly people (Social Welfare Department of Malaysia, 2009). As the need and demand increases, placing elderly people in institutions or nursing homes is becoming increasing common practice in spite of the cultural expectation and assumption that placing the elderly people in a nursing home is a violation to tradition and personal beliefs. Elderly people institutions have negative effect on health and well-being as the institutional environment creates feelings of dependency and reinforces a sick role amongst the residents (Dommenwerth & Petersen, 1992). In addition, the institutions and nursing homes are viewed as dumping place where one would idle till death, close to death and possessing an uncontrolled future (Lee, 1997, p. 333). The elderly people also feel dissatisfied with the quality of care, erosion of personal autonomy, loss of meaning and sense of belonging in life as a

HKJOT 2010;20(2) result of institutional policy, stiffness of general routine and the hierarchical structure of the institution (Berglund, 2007; Bowling & Formby, 2002; Brooker, 2008; Brown, 1995; Lee, 1997). As a result, elderly people feel isolated and lonely (Fessman & Lester, 2000; Kim, Jeon, Sok, & Kim, 2006) and depressed (Brooker, 2008; Sabariah & Hanafiah, 2006). A study by Jones, Marcantonio and Rabinowitz (2003) indicated that 20.3% of the elderly people who resided in the nursing home or institutionalised type of care were depressed. Sherina, Rampal, Hanim and Thong (2006) who conducted a study of elderly people in an institution in Kuala Lumpur reported that 54% of the elderly people were depressed. In addition, Oksoo et al. (2009) reported that 66.7% of Korean elderly people and 41.7% of Japanese elderly people who live in nursing homes were depressed. Choi, Ransom, and Wyllie (2008) indicated that depression amongst elderly people in the institutions and nursing homes is due to loss of independence, inability to continue previous occupations, feelings of isolation and loneliness, lack of privacy and meaningful occupations. Depression causes the failure to thrive in the institution (Bergland & Kikrevold, 2006), thus they are likely to comply and participate in the programme, processes and routine occupations run by the institution. As a result, the elderly people have a low level of life satisfaction and quality of life (Hjaltadottir & Gustafsdottie, 2007; Subasi & Hayran, 2005).

Research Aim
The aim of this research is to identify the level of satisfaction with life and to examine the relationship between life satisfaction and the sociodemographic characteristics of the elderly people living in the institution. In addition, the study aims to describe the elements which constitute to the life satisfaction experience living in the institute.

Methodology
Overview of the Design
A mixed method of both quantitative and qualitative designs was chosen to answer the research aims. The method will provide strong inference and complement the strength of each methodology to provide more meaningful in-depth data (Barbour, 1998; Brannen, 2005; Creswell, 2003; Morse, 2005; Shin, 1998; Tashakkori & Teddlie, 1998). The simultaneous strategy models were used to obtain the data, thus the data can be collected and analysed concurrently in a short period of time (Schulenberg, 2007; Tashakkori & Teddlie, 2003). Aligned with this, a cross-sectional survey was conducted to identify the level of life satisfaction followed by focus group interview that aimed to understand the elements of lived satisfaction Hong Kong Journal of Occupational Therapy

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LIFE SATISFACTION IN INSTITUTIONALISED ELDERLY PEOPLE through the life experience of the participants who are living in the institution. groups were stratified through stratified purposeful sampling strategy. The participants were divided based on two age categories (6075 years old and above 76 years old) and gender (male and female group). There were four focus groups in the study and each group consist of 46 elderly people. The focus groups will preserve the life experience of the participants and provide rich data as a result of the opportunity for the participants to reflect, cross-check and clarify their shared experience (Bradbury-Jones, Sambrook, & Irvine, 2009).

Research Setting and Participants

The participants were located at the public funded elderly peoples institution in Malaysia. The institution houses independent elderly people, 60 years old and above. There are seven hostel types of buildings, occupied by 3040 residents per house. The institute could house about 250300 residents at one time and is currently staffed by 64 people. Medical staff consisted of two full time nurses and a physiotherapist. The institution provides free basic amenities to the elderly people such as six meals per day, clothes and items for personal hygiene. There were no structured activity for the elderly people, and they were free to move around the compound of the institution. All of the residents were sampled and 82 participants were found fit into the inclusion criteria which was elderly people aged 60 and above, independent in basic self-care skills, able to understand and or speak fluently in either in Bahasa or English, scores of 22 and above in the Mini Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) and scores below 7 in the Geriatric Depression Scale (GDS; Yesavage et al., 1983).

Data Analysis
The survey was analysed using the PASW v18. Spearmans rho, one-way between groups analysis of variance (ANOVA) with post hoc were conducted to determine whether there are any differences between the life satisfactions with the subgroups within the demographic variables. The critical value for significant were set at p < .05 with 95% confidence interval and Cohens (1988) guideline will be used to determine the strength of the relationship. The interview transcripts was analysed using four stages of Interpretative Phenomenological Analysis (IPA) as outlined by Smith, Flowers, and Larkin (2009). Initially the first transcript from the first group was read over several times and the left margin of the transcripts was used to annotate the key points and provide comment on language, linguistic differences, contradictions and what was considered important from the respondents words, then the key points were compiled into the list. The lists were reviewed and the points that had similar characteristics were clustered together to form subsummations of themes. Further analyses were conducted to ensure all of the important key points were compiled and clustered accordingly. When all key points are included, masters of theme were developed alongside with the participants details and the quotes from the participants. This process was repeated for the remainder of the focus groups transcripts. After each transcript was analysed, a further analysis was conducted to highlight disparities and resemblances within the groups. Constant reflection and re-examination of the themes was conducted throughout the analytical process to ensure that the themes were interconnected. Subsequently, some themes are expended or dropped from the master themes. The quotes and themes developed were translated into English using forward translation (Heij, Hooglander, Kerling, & Velden, 2006; World Health Organisation, 2008). The quotes were used to validate the research findings and to provide clear examples for the research report (Sandelowski 1994). Few measures were taken to ensure trustworthiness of the themes developed as outlined by Curtin and Fossey (2007). Detailed descriptions of the participants backgrounds

Survey and Focus Groups Interview

The survey was conducted through face to face interview using Satisfaction with Life Scale (SWLS) (Diener, Emmonas, Larsen, & Griffin, 1985). The scale was translated into Malay language and the translated version has a good internal consistency of 0.83 across demographic variables (Swami & Chamorro-Premuzic, 2009). The scale consists of five items intended to measure life satisfaction. Participants indicate their agreement or disagreement with the statements on a 7-point Likert type of scale and the scores range from 5 to 35 with higher scores indicating a greater life satisfaction. The psychometric properties were tested in numerous studies (Diener et al., 1985; Hultell & Gustavsson, 2008) and the internal consistency generally exceeds .80. Pavot, Diener, Colvin, and Sandvik (1991) obtained an alpha coefficient of .83 and the results were correlated with other types of life satisfaction measurement such as the Life satisfaction Index-A (p < .01). This measurement is considered suitable for the participants in view of their education level. Assistance was given if the participants needed further clarification about the scale. The focus groups were conducted using semi-structured interview to collect data regarding the life satisfaction experience of the elderly people living in the institute. Semistructured questionnaires were prepared. To ensure representation and homogeneity, 20 participants who volunteered for focus Hong Kong Journal of Occupational Therapy

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A. Dahlan, et al and situation of the phenomena understudy are obtained, so that the meaning and experience of the elderly participants can be fully understood. In addition, the focus groups were facilitated by three different individuals and an external researcher was invited to validate the themes which emerge from the focus groups. The quantitative and qualitative data were integrated into a coherent whole and inference between the data was made aligned with the principles of mixed methods data synthesis (Onwuegbuzie & Teddlie, 2003).

HKJOT 2010;20(2) The relationship between life satisfaction (as measured by SWLS) and the demographic variables indicated that there was a positive correlation between life satisfaction with duration of living in the institute, rho = 0.23, n = 82, p < .05 as shown in Table 1. The assumption for homogeneity using Levines test for homogeneity of variance indicated that the assumption for oneway between groups ANOVA is not violated (p > .05) in all the groups in the socio-demographic variables. A one-way betweengroup ANOVA was conducted to explore the impact of demographic variables such as age group, duration of staying in the institute, number of friends outside the institute, number of family members who keep in touch and reason for admission on life satisfaction, as measured by SWLS. There was no statistical significant differences at the p < .05 level in SWLS scores for the demographic variables. Demographic variables measured did not influence SWLS as shown in Table 2.

Ethical Consideration
The confidentiality and anonymity of the participant information was obtained from the participants and the study was approved by Research Ethic Committee of the Queen Margaret University. In addition, the study was registered and approved by the Ministry of Women, Family and Community Development in Malaysia.

Themes Generated From Focus Groups

Results
Demographic Characteristics
The sample consists of 68.3% male (n = 56), 31.7% female (n = 26) and 68.3% (n = 56) are Malay elderly people. There are 43.3% (n = 36) of the participants who never attended school, the mean age of the participants is 74.1 year old and the duration of living in the institute is 42.2 months. There are 51.2% (n = 42) did not have contact with their family members and 45.1% (n = 37) were referred by family members or friends.

Two key themes emerged from the analysis of the residents experience in relation to their life satisfaction living in the institute: (a) Contentment (Syukoor) (b) Acceptance (Redha). The themes and the subthemes are summarised in Table 3.

Theme 1: Contentment (Syukoor)

Three subthemes from contentment were identified from the analysis, these included contentment to the benefits obtained, hospitality from staff and the institute, and health and contentment with health and safety. These superordinate themes were shared amongst six focus groups. The participants were contented with the benefits. Thus this theme was closely related to the living situations, facilities obtained and benefits gained by the participants living in the institute.

Survey on Satisfaction With Life

The scores indicated that 59% (n = 48) have an average life satisfaction, 30.5% (n = 25) are below average satisfaction with life and 8.5% (n = 7) are dissatisfied with their life. The mean for life satisfaction is 20.2 ( 4.1). In spite of 55% (n = 45) of the elderly people stating that they did not have the opportunity to engage in important occupations in life such as work and leisure, 66% (n = 54) state that their life is in an excellent condition and 63% (n = 52) are satisfied with their life condition.

Subtheme 1: Benefits
This subtheme was shared by many participants. One participant said, I feel happy with my life here, I feel happy to live here [break] syukoor I have what I need, I am contented, I am not worried about work and means to look for

Table 1. Spearmans Rho correlation between Satisfaction with Life Scale (SWLS) with demographic variables
Scale 1. 2. 3. 4. 5. 6. SWLS Age Duration Friend outside the institute In-touch with family member No. of health problems SWLS Age .94 Duration .02* .43 Friend outside .94 .82 .59 In-touch .69 .72 .58 .02* No. of health problems .42 .46 .71 .77 .56

*Correlation is significant at .05 (2-tailed).

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Table 2. Analysis of variance between demographic variables and life satisfaction, as measured by Satisfaction with Life Scale (SWLS)
Variables Age group (yr) 6069 (n = 23) 7079 (n = 29) 80 (n = 30) Duration of stay in the institution (mo) 1260 mo (n = 65) 61120 mo (n = 14) 120180 mo (n = 3) Friends outside the institute None (n = 29) 15 (n = 34) 610 (n = 17) 1134 (n = 2) In-touch with family members None (n = 42) 15 (n = 29) 612 (n = 11) School qualification Never gone to school (n = 36) Up to standard six (612 yr) (n = 37) Lower certificate (1315 yr) (n = 5) Others/certificate (n = 4) Referral agencies Self-referral (n = 14) Referred by others (n = 37) Directly referred by the Department of Social Welfare (n = 29) Referred by the enforcement agency (n = 2) SWLS Mean (SD) F p

Another acclaimed, Nobody ask me to do anything or forced me to do anything (69-year-old male).

Master Themes 2 and 3: Hospitality, Health and Safety

The staff hospitality and feeling safe living in the institute were also indicated as a mean for contentment. One participant described, I feel safe in here, nobody is teasing me because I am old, I feel that I am respected... [The staff] call me Mak Cik (Auntie). They really take care of me, I can go to the clinic if I am not feeling well at anytime and I dont have to worry about my children and my relatives and they dont have to worry about me in here, they can come and visit me anytime (78-year-old female). Another explained that he was contented with the current health status and the benefits of living in the institute and described that, Syukoor, I am still be able to walk although I am very old, I can do my daily activities without any help from other inmates, I can perform daily praying, go the mosque and to the dining halls, not like other people here nobody can force me to do anything (73-year-old female).

20.7 (3.6) 21.7 (4.0) 20.2 (4.6)

4.60

.37

20.4 (4.0) 22.8 (3.5) 21.0 (4.1) 20.8 (4.4) 21.1 (4.3) 19.5 (3.5) 20.9 (4.1) 21.2 (4.0) 20.5 (4.5) 20.5 (3.5) 20.8 (4.4) 21.1 (3.8) 18.6 (5.3) 21.5 (2.9) 20.1 (3.2) 20.1 (3.9) 20.6 (4.7)

1.90

.16

0.15

.93

0.31

.74

0.57

.63

Superordinate Theme 2: Acceptance (Redha)

This superordinate theme coveyed a sense that the participants were accepting of their current life conditions and this sense was shared among almost all of the participants. One participant said that It is ok, Redha with what happen in my life, what was determine in my life, [break] left by my husband for another women. I cant stand staying with my children, they have a small house in the city, I felt that I lived in a prison and I dont have friends there. I redha that I have a place to stay, at least, I am not homeless. Even though the food here sometime is not nice, thats ok [break] , at least I have food to eat (68-year-old female).

0.57

.63

23.5 (0.7)

Table 3. Overview of the themes and subthemes

1. Contentment (Syukoor) Subtheme 1.1: Semua ada (everything available) Subtheme 1.2: Hospitality Subtheme 1.3: Health and safety 2. Acceptance (Redha) Subtheme 2.1: Personal changes Subtheme 2.2: Adjustments and adaptations

Discussion
There is substantial literature indicating the effect of health status, demographic characteristics, social relationships and occupations towards life satisfaction for elderly people in the community (Chou & Chi, 1999; Depaola & Ebersole, 1995; Iwatsubo, Derriennic, Cassou, & Poitrenaud, 1996; Melendez, Tomas, Oliver, & Navarrow, 2009). However, there is a scarcity of recent literature regarding the life satisfaction of elderly people who lived in an institution or a long term type of care, especially in the developed countries. The changes in government policy of elderly peoples care which focus on

money to buy food, everything is prepared, I have six meals a day, and then I relax all day I feel free from the pressure to work, house maintenance and so on I dont even have to clean my plates, I dont have to worry about anything anymore (72-year-old male). Hong Kong Journal of Occupational Therapy

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A. Dahlan, et al community orientation services and smaller size type of care like nursing homes, dominated recent literature. This study attempted to identify the level of satisfaction and the relationship between life satisfaction with sociodemographic characteristics of the elderly people (60 years and above) and the elements that constitute the level of life satisfaction. The statistical analysis shows that the duration living in the institute weakly influences the SWLS scores. However, one way between groups ANOVA indicated that there are no significant differences in the life satisfaction as measured with SWLS with other socio-demographic variables. The SWLS scores indicated that there are no significant differences with the norms of elderly people living in the community (20.2 4.1 and 22.41 7.74 respectively). According to Swami and Chamorro-Premuzic (2009), this value is common amongst elderly people in the developing countries. The majority of the people are satisfied in most areas of their life, but they need to see an improvement in other areas (Diener et al., 1985). Another possible reason for the value could be predicted by looking at the base line demographic characteristic of the participants, for example the reasons for admissions and education level. Many of the participants come from low economic background status, thus the opportunity to live in a modest environment (which is better than previous living environment) could contribute to the current level of life satisfaction. The qualitative findings indicated that they are happy with their life which is free from pressure of life, expectations and obtaining free amenities. Happiness and life satisfaction is a synonymous term and one of the important predictor for life satisfaction for people in Asian countries (Jagodzinski, 2005), thus this provides an important finding. To ensure life satisfaction is achieved for elderly people who lived in the institution, the living environment in the institution should surpass the previous living environment in the terms of the physical infrastructure, hospitality and social connection. Although the participants are disconnected from mainstream society and have limited social connections (as a result of the institutes regulations) as indicated in quantitative findings, they, on average found life to be satisfying. This was hypothesized as an effect of the self adjustment and adaptation, in addition to the level of hospitality and relationship that shows counter dependency or interdependency amongst the residents and the relationship with the staff. For example, the participants volunteered to help the disabled elderly people and the way they are addressed by the staff, which indicates respect and closeness in Asian context. The elderly people in the institute were addressed in personal way such as mother, father, uncle or auntie as indicated in qualitative findings. Previous literature indicated that the need for social gratification,

HKJOT 2010;20(2) intimate relationships which involved mutual disclosure and continues ties with familiar people had a great impact on moral and life satisfaction for individuals who live in the institution (Harel, 1981). The harmonious reciprocal relationship between the residents and the staff facilitate the elderly people to thrive in the institute (Bergland & Kirkevold, 2008; Jacelon, 1995). Furthermore, the institute adopted an open policy, thus there is an encouragement for the public and any organisation to visit the centre, providing social visits or donations especially during the festive seasons. Although the opportunity to socialise with the community outside the institute is limited, it was compensated by the intensity of the relationship among inmates and the staff. Intensity of relationships was determined as one of the variables that improve satisfaction with life for the Chinese elderly people who live in the community (Silverman, Hecht, & McMillan, 2000). Other variables that contribute to the life satisfaction are social supports, active socialisation and engagement in meaningful occupational activities (McGuinn & Mosher-Ashley, 2000; Nimroad, 2007; Parker, 1996; Subasi & Hayran, 2005; Yeung & Fung, 2007). Qualitative findings indicated that there is a lack of opportunity for the residents to engage in meaningful occupational activities due to the lack of resources, the custodial elements and authoritarian type of care that were shown through the rules and regulations imposed on the residents. However, the findings from this study indicated that although they lack occupational opportunity, the participants are satisfied with life. Life satisfaction can be obtained as a result of acceptance and contentment with the unavoidable social and psychological changes and withdrawn from others in the social system (Madigan, Mise, & Maynard, 1999). Contentment is defined as the feeling of happiness and ease with ones life situations which is synonymous with good life (Carson, 1981). A degree of contentment is required to adjust and adapt to a new environment (Clare, Rowlands, Bruce, Surr, & Downs, 2008). The respondents indicated their contentment with the benefits obtained through indigenous words, such as alhamdullilah or syukoor. Both words have a religious connotation. Syukoor is an Arabic word frequently used by Malay Muslims to show gratitude and gratefulness towards God who is providing a fortune, whilst alhamdullilah literally means thank you God or all praise to God and it is similar to the Hebrew word of Halelu Yah. Both words are frequently used by Malay to indicate thankfulness and contentment with what was given regardless of what it was. This indicated that the participants are grateful and contented with the experience of living in the institute which is further exemplified with moderate level of satisfaction as measured by SWLS in spite of the limitations in the institute. Feeling of contentment with life conditions Hong Kong Journal of Occupational Therapy

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LIFE SATISFACTION IN INSTITUTIONALISED ELDERLY PEOPLE

Phenomena & strategies Subtheme 2: Hospitality Subtheme 3: Health & safety Theme 1: CONTENTMENT (Syukoor) LIFE SATISFACTION Theme 2: ACCEPTANCE (Redha) Subtheme 1: Personal changes Subtheme 2: Adjustment & adaptation Subtheme 1: Benefits Consequences

Figure 1. Life satisfaction model for the institutionalised elderly people. was identified as one of the factors to perceived health status amongst elderly people in spite of problem associated with hearing, mobility, sleep and fear of fall (Lindgren, Svardsudd, & Tibblin, 1994). However, being contented is not compatible with having no desire to change or improve the life situations which facilitate the highest level of potentials (Carson). The findings indicated that the participants are contented but describe their expectations to have the opportunity to perform various occupations, exercising autonomy, independence and various physiological expectations thus changing life situations. The findings provide ideographic explanations and patterns amongst the themes, thus a life satisfaction model for institutionalised elderly people was developed as shown in Figure 1. The model shows that connection between contentment with the benefits obtained, feeling of safe and good relationship with the staff. In addition, the life satisfaction was also contributed by acceptance with the changes in life and ability to adjust and adapt with the institutional environment. facilitate life satisfaction through engagement in meaningful activities and traditional occupational therapy techniques such as the Life Review or the reminiscence therapy.

Acknowledgements
This study was not supported by any research grant and is a small part of a PhD thesis entitled The Development and Testing of Lively Later Life Programme (3LP) for institutionalised elderly people.

References
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Conclusion
This study has indicated that the elderly people who lived in the institution could have a satisfaction with life in spite of constrains, occupation and social deprivation and improvised living situations as a result of adjustment, acceptance and contentment with current life. Occupational therapy could facilitate adjustment and integrate or encourage acceptance and contentment to Hong Kong Journal of Occupational Therapy

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A. Dahlan, et al
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