Sound environment of bedrooms in typical long-term care facilities in

China

Mingxuan Xie Kunming University of Science and Technology No. 727, Jingming South Road, Chenggong District, Kunming, Yunnan Province 650500, China Zhixiao Deng 1 Kunming University of Science and Technology No. 727, Jingming South Road, Chenggong District, Kunming, Yunnan Province 650500, China

ABSTRACT Evidence shows that older individuals would be more sensitive to noises, whereas the sound environ- ment of healthcare facilities for seniors is largely ignored in China. In this study, acoustic measure- ments were carried out over 24-hour in eleven bedrooms in five typical long-term care facilities in- cluding two nursing homes and three adult homes in Kunming, China. Sound perception and prefer- ence of older adult and nursing staff were also investigated through questionnaire surveys. The re- sults showed that the noise levels of the measured bedrooms reached 47.4-59.3 dBA during the day- time, and 39.1-49.3 dBA during the nighttime. The nursing homes were measured higher noise levels than the adult homes mainly due to nursing care activities. While a larger gap was found between the roadside bedrooms and non-roadside bedrooms. In terms of subjective evaluation similar re- vealed that ‘traffic noise’ was the most common and unwanted noise source considered by both re- cipients and staff. Residents from nursing homes indicated that noises have more significant impact on their ‘sleep’, ‘health’ and several psychological index, namely ‘relaxation’, ‘anger’ and ‘anxiety’. The indoor soundscape could be improved by introducing some natural sounds such as ‘stream’ and ‘birds’, which were considered as the wanted sounds by most participants.

1. INTRODUCTION

Noise has shown a negative impact on humans with regards to comfort and health, making it a major physical environmental problem. Shreds of evidence have validated that daily exposure to excessive noise can have a significant impact on physical and mental health [1, 2]. Compared with the adult under healthy condition, older individuals are more sensitive to the physical environment, and the noise has negative impacts on their sleep, emotion, and cardiovascular indicators [3]. However, a number of studies have been reported on the sound environment of healthcare facilities for elder person, and the results of average sound levels have largely exceeded the WHO recommendation (30 dBA) by 20-30 dBA [4, 5].

In recent years, China has one of the fastest-growing aging populations in the world, and therefore, a large number of long-term care (LTC) facilities have been built in China where the two main types are nursing homes and adult homes. Here, the nursing homes are places that provide 24-hour special- ist care for older adults having serious illnesses or injurie; adult homes are temporary or permanent accommodation for adults who are unable to live independently, and they are provided with personal 1 dzx@kust.edu.cn

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care, housekeeping, and three meals a day depending on the requirement. In addition, it was found that older adults in LTC facilities spent most of time in their bedrooms [6]. While related studies mainly focused on the nursing homes in China, and found that the noise levels of bedrooms in nursing homes were exceeded the Chinese national standard by 15-25 dBA [7, 8]. However, detailed infor- mation on acoustic conditions, including noise level, spectrum and characteristics of noise sources, and the impact of noise on older adults and nursing staff in different kind of LTC facilities is still lacking.

Therefore, this study aims to reveal the acoustic characteristics of typical bedrooms in nursing homes and adult homes in China, and its impact on older adults and nursing staff through a field acoustic measurement and questionnaire survey.

2. METHODS 2.1. Case study sites Typical adult bedrooms from the facilities provided by five LTC institutions in Kunming city located in southwest of China were chosen as the study sites, where two nursing homes and three adult homes were included as shown in Figure 1. The research was carried out between September 2021 and Jan- uary 2022.

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Figure 1. Site plans and corresponding bedroom interior plans of the case study sites.

Notes: ‘NH’ = ‘Nursing home’, ‘AH’ = ‘Adult home’.

2.2. Measurement procedures Three AWA6228+ sound level meters (Level 1) were utilized to record the 24-h sound pressure level, statistical noise levels L 10 , L 90 , and noise frequency measurements in eleven typical bedrooms from the selected five LTC facilities. To minimize the interference with daily activities, the meters were placed on the bedroom ceiling at a distance of at least 1.2 m from all reflective surfaces.

2.3. Questionnaire survey Two similar questionnaires were designed separately for older adults and nursing staff constituting two parts. The first part was designed for collecting basic information including gender, health status, and bedroom information (roadside or non-roadside, number of beds, for older adults only). The sec- ond part was focused on the following three detailed questions: (1) Satisfaction with the indoor sound environment from the healthcare environment and their own homes, respectively. (2) Impact of noise generated from healthcare environment on their ‘communication’, ‘work’, ‘reading’, ‘relaxation’,

(a) AH2-Wosiwojia JUrban: in

‘anger’, ‘anxiety’, ‘healthy’, ‘sleeping’. (3) Preferences for the sources of sound including ‘talking’, ‘yelling’, ‘footsteps’, ‘nursing activity’, ‘music’, ‘TV’, ‘chessboard’, ‘traffic’, ‘construction’, ‘stream’, ‘wind’, ‘rain’.

A total of 90 valid filled questionnaires were collected, including 55 from older adults and 35 from nursing staff. 3. RESULTS

3.1. Noise levels As shown in Table 1, L eq of all the eleven measured bedrooms exceeded the WHO’s recommended level (30 dBA) with a larger deviation both in daytime and nighttime. Compared with the bedrooms of adult homes, the L eq in the bedrooms of two nursing homes was measured 5-7 dBA higher during the daytime with L eq_day ranged between 53.6-59.3 dBA, and 2-3 dBA higher during the nighttime with L eq_night ranged between 41.3-49.3 dBA. Significant differences in L max (5-15 dBA) can be found between the two types of health facilities i.e., adult homes and nursing homes.

Besides, there was a significant impact of traffic noise on roadside bedrooms in adult homes i.e., L eq was 5-15 dBA higher for roadside bedrooms than non-roadside during the daytime and 10-20 dBA during the nighttime. For the nursing homes, the L eq of the roadside and non-roadside bedrooms doesn’t show a significant difference during the daytime and nighttime. Further, there was a phenom- enon that the L eq of the non-roadside bedrooms was higher than the roadside bedrooms, indicating that noise sources from interior building had a greater impact on the noise levels.

Table 1. L eq , L max , L 10 , L 90 in the measured bedrooms during daytime and nighttime. Notes on ‘Bedroom #’: F=floor, Y/N=roadside/non-roadside, 1/2/3=number of beds. Building

L eq (dBA) L max (dBA) L 10 (dBA) L 90 (dBA) 24 h day night day night day night day night

Bedroom

#

#

2F-Y-2 52.6±6.7 54.3±6.2 41.3±3.5 69.3 47.1 58.1 44.6 42.1 35.6 2F-N-3 52.1±7.9 53.6±5.7 44.8±6.6 65.7 57.8 57.4 48.2 42.2 31.7 2F-N-2 57.6±12.1 59.3±9.6 44.0±5.0 68.7 62.3 63.4 38.0 35.5 29.6

NH1

NH2 2F-Y-2 54.5±10.5 55.8±9.2 49.3±7.7 70.4 68.0 59.1 47.2 35.5 28.1 2F-N-2 54.4±12.0 56.0±7.5 41.7±6.2 65.0 56.7 60.1 35.1 38.9 26.8

2F-Y-2 46.2±3.8 47.4±2.9 41.6±2.4 52.2 47.1 49.8 44.4 42.2 38.7 6F-Y-2 50.0±4.3 51.2±3.9 45.7±3.2 56.8 50.4 54.7 48.3 45.1 40.9 15F-Y-2 49.5±2.5 50.3±1.6 47.5±2.6 59.3 53.1 51.4 50.0 47.9 43.6 AH2 3F-Y-2 50.9±6.9 52.5±5.9 39.1±2.6 65.2 50.1 54.8 39.8 40.2 35.4

AH1

AH3 4F-Y-1 57.4±3.5 58.5±1.9 53.3±3.0 61.5 57.5 59.9 56.2 56.0 48.1 4F-N-1 42.1±2.2 43.7±2.6 33.1±0.5 58.7 39.4 47.7 34.6 32.0 30.1 For the tested bedrooms of nursing homes (see Figure 2a and 2b), the variation of noise levels was closely associated with the daily nursing activities. The noise level was at its peak at 6:00 am with a value of around 65 dBA, followed by a relatively flat trend till the lunch break from 12:00 to 14:00 pm, and decreased at 22:00 as most of the residents went to sleep. However, numbers of high value were generated at night from 22:00 to 6:00, and the primary reasons for the high noise events were due to some yelling in pain by older adults and simultaneous pain management activities during the nighttime.

Owing to the absence of nursing activities, lower noise levels with relatively negligible variations were found in the bedrooms of adult homes (see Figure 2c-2e). However, obvious differences on

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noise levels can also be noticed while comparing roadside and non-roadside bedrooms. In the case of roadside bedrooms, the out-windows environment severely affects the noise level due to the influence of traffic (see Figure 2e) as well as the marketplace located nearby the building (see Figure 2d). Whereas the non-roadside bedrooms were comparatively quiet, the variation in SPL was ascribed to the daily activities of the resident themselves, including communication with visitors, watching TV, cooking, etc. (see Figure 2e).

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2F-Y-2 2F-N-3 2F-N-2

2F-Y-2 2F-N-2

70

70

Leq_5min(dBA)

Leq_5min(dBA)

60

60

50

50

40

40

30

30

20

20

（ a ） （ b ）

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3F-Y-2

2F-Y-2 6F-Y-2 15F-Y-2

70

70

Leq_5min(dBA)

Leq_5min(dBA)

60

60

50

50

40

40

30

30

20

20

（ c ） （ d ）

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4F-Y-1 4F-N-1

70

Leq_5min(dBA)

60

50

40

30

20

（ e ） Figure 2. The noise level variation over 24-h of the eleven measured bedrooms,

(a) NH1, (b) NH2, (c) AH1, (d) AH2, (e) AH3. At the same time, Figure 3 clearly distinguishes the variations between roadside and non-roadside bedrooms. In the roadside bedrooms, predominantly SPL was found at low frequency at around 125 Hz that contributed by traffic noise, and mid frequencies at around 1 kHz that contributed by car horns. In contrast, 500 Hz was more prominent in non-roadside bedrooms during the daytime due to

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the occurrence of frequent talking in their bedroom. At night, the noise sources from the indoors were stopped generating sound, and the impact of traffic noise on the roadside bedrooms was more prom- inent (see Figure 3b).

10 15 20 25 30 35 40 45 50 55 60

10 15 20 25 30 35 40 45 50 55 60

NH1-2F-Y-2 NH1-2F-N-3 NH1-2F-N-2 NH2-2F-Y-2 NH2-2F-N-2 AH1-2F-Y-2 AH1-6F-Y-2 AH1-15F-Y-2 AH2-3F-Y-2 AH3-4F-Y-1 AH3-4F-N-1

Leq (dB)

125 250 500 1K 2K 4K 8K Frequency (Hz)

125 250 500 1K 2K 4K 8K

Frequency (Hz)

(a) (b) Figure 3. The L eq distribution in each frequency band, (a) daytime, (b) nighttime. 3.2. Questionnaire survey As shown in Figure 4a, both older adults and nursing staffs from adult homes and nursing homes were less satisfied with the sound environment in the bedroom than in their own homes ( p <0.01), mainly due to the presence of more unfamiliar noises in the LTC buildings. Moreover, significant differences can be found between nursing homes and their own homes ( p <0.01). The satisfaction of the older adults with the sound environment in nursing homes with higher noise levels was worse than in adult homes ( p <0.01).

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Due to the impact of traffic noise in roadside bedrooms, the older adult group was significantly less satisfied with the sound environment in roadside bedrooms than in non-roadside bedrooms ( p <0.01) (Figure 4b). However, there was no significant difference in nursing group. The main reason is that, compared with the nursing staff, the older adults live in the bedroom for more than 12 h per day including sleep, and this would make the older adults to be more sensitive to traffic noise, espe- cially in the nighttime.

Older adults Nursing staff ** ** **

Older adults Nursing staff **

5

5

Evaluation

4

4

3

3

2

2

1

1

Nursing homes Adult homes Own home

Roadside Non-roadside

*

**

(a) (b) Figure 4. Satisfaction rating of sound environment between (a) nursing homes, adult homes and

own home ， (b) roadside and non-roadside. Notes: ‘*’ means p <0.05, ‘* *’ means p <0.01, ‘1’ = ‘not satisfied’, ‘5’ = ‘extremely satisfied’.

Due to the fact that noisier indoor environment with more noise sources in nursing homes, the impacts of noise on ‘communication’ ( p <0.05), ‘relaxation’ ( p <0.01), ‘anger’ ( p <0.05), ‘anxiety’ ( p <0.01), ‘healthy’ ( p <0.01), and ‘sleeping’ ( p <0.05) of older adults from nursing homes were sig- nificantly higher than those from adult homes, as shown in Figure 5a.

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For the same building (Figure 5b), the older adults residing in roadside bedrooms were influenced by higher noise impacts on their ‘communication’, ‘healthy’, and ‘sleeping’ than the older adults residing in non-roadside bedrooms. In particular, the noise from out-windows had the most significant effect by disturbing the sleep ( p <0.01) of older adults in roadside bedrooms (extremely 4.5±0.5).

Compared with the older adults, the nursing staff perceived greater noise impacts on their psycho- logical index of anger ( p <0.01) and anxiety ( p <0.05). The possible reason is that the noise can en- hance stress-related tension when working, which is consistent with the finding of a similar study [9].

5

Adult homes Nursing homes

Evaluation

4

3

2

1

Communication

Reading Relaxation

Anger

Anxiety

Healthy

Sleeping

*

**

*

**

**

*

(a)

5

Roadside Non-roadside

4

Evaluationn

3

2

1

Communication Reading Relaxation Anger Anxiety Healthy Sleeping

**

(b)

5

Older adults Nursing staff

4

Evaluaton

3

2

1

Communication Reading/Work Relaxation Anger

Anxiety

Healthy Sleeping

**

*

(c) Figure 5. Comparison of noise impacts (‘1’ = ‘not at all’, ‘5’ = ‘extremely’) in various aspects, on

different groups (a) nursing homes and adult homes in older adult group ， (b) roadside and non-

roadside in older adult group ， (c) older adults and nursing staff. The results depicted in Figure 6 show that the sound preference of older adults and nursing staff was similar. Both groups preferred ‘entertainment sounds’, ‘natural sounds’ such as ‘stream’ and

‘birds’, instead of sounds from people such as ‘yelling’ and ‘footstep’, ‘medical devices’, and ‘sounds from outdoor’ such as ‘traffic’ and ‘construction’.

The older adults disliked ‘yelling’ ( p <0.01) and ‘footstep’ ( p <0.01) more than the nursing staff. As per the interview with older adults, the possible reason was that ‘yelling’ and ‘footstep’ in the night significantly influence their sleep quality. Moreover, older adults prefer entertainment sounds of ‘music’ ( p <0.05) and ‘television’ ( p <0.01) and natural sounds of ‘stream’ ( p <0.05) and ‘birds’ ( p <0.01), and the age might be responsible for this behavior. The age of the adult participants was in the range of 55-93 years old with a mean value of 76, whereas the age of nursing staff was in the range of 22-65 years old having a mean value of 40. Spearman's correlation analysis was conducted and revealed that the preference for natural sounds was positively correlated with age of the partici- pants. This result is found similar to that of another study [6].

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Older adults Nursing staff

2

Sound from

Sound from

outdoor

people

1

Evaluation

0

-1

Entertainment

Natural

sound

sound

-2

Talking

activities

Footstep

Radio

Traffic

Nursing

Music

Television

Rain

Stream

Medical

Construction

Birds

Yelling

activity

Leisure

device

** ** * ** * **

Figure 6. Sound preference evaluation (‘-2’ = ‘very annoy’, ‘0’ = ‘neutral’, ‘2’ = ‘very pleasant’). 4. CONCLUSIONS

In terms of field measurements, the noise levels in all the eleven tested bedrooms from five nursing homes and adult homes exceeded the WHO's recommendations by at least 20 dBA during both day- time and nighttime. Nursing homes have higher noise levels with more significant short-term varia- tion in both day and night mainly due to nursing activities and patients’ yelling in pain. Besides, noise levels in the roadside bedrooms were 5-15 dBA higher than those in non-roadside bedrooms, espe- cially at the night.

In terms of subjective evaluation, older adults from nursing homes indicated that noise has a more significant impact on their communication, emotions, sleeping, and healthy, compared with those from adult homes. Traffic noise was a great issue that disturbs the sleep of older adults in roadside bedrooms as expected. Interestingly, the nursing staff group pointed out that noise has more serious impacts on their emotions than the older adult group. To improve the indoor sound environment for the older adults, several natural sounds such as ‘stream’ and ‘birds’ can be introduced in their bed- rooms.

5. ACKNOWLEDGEMENTS

The authors would like to express their gratitude to all the residents and nursing staff in this study. The financial support was given by Natural Science Foundation of Yunnan Province (No. 202201AU070134).

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