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Petchprapai N. Health Status and Health Patterns in Urban-rural Dwelling Elderly in Nakhonratchasima Province, Thailand. Elderly Health Journal. 2019; 5 (2) :108-116
URL: http://ehj.ssu.ac.ir/article-1-150-en.html
Department of Adult and Elderly Nursing, Institute of Nursing, Suranaree University of Technology, Thailand , nutthita2004@hotmail.com
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Health Status and Health Patterns in Urban-rural Dwelling Elderly in Nakhonratchasima Province, Thailand
 
Nutthita Petchprapai *1
 
1. Department of Adult and Elderly Nursing, Institute of Nursing, Suranaree University of Technology, Thailand


Article history
Received 14 Mar 2019
Accepted 14 Sep 2019


A B S T R A C T
Introduction: As rapid urbanizing spreads throughout Thailand, the combination of urban-rural lifestyle has been gradually found. These changes may effect on health pattern of the older adults. This study was aimed to explore the incidence of health problems and life styles of the elderly in urban-rural areas.
 
Methods: A random interview survey with qualitative approach was used. Data were randomly collected from 14 areas in central sub-districts of Nakhonratchasima province, Thailand. Twenty-five older adults in each area were interviewed. The recording forms consisted of demographic data, perceived health status and health problems, medication use, activities of daily living, instrumental activities of daily living, mental health, social and religious activities, and accommodation and environment. Non-invasive physical examinations of the elderly were performed by weighing, measuring height and testing muscle strength with one leg standing.
 
Results: Most of the elderly reported having at least one chronic disease and/or degenerative problems that had impact on their daily lives. Forty percent rated their health status as moderate to poor, 18% encountered falls while 18% were hospitalized in the past six months. Only one-third underwent an annual health checkup while 30% of the female had cancer cervix screening. Most of the elderly could perform daily tasks on their own with assistive instruments and were healthy in mind. However, many of them drank tap water without boiling or filtering.
 
Conclusion: The older adults in the urban-rural areas had access to health care services and had a good health status. However, their health promotion and prevention behaviors are questionable.

Keywords: Elderly; Health Status; Suburban Health; Well-being; Health Patterns

 
Copyright © 2019 Elderly Health Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cite.
 
 
Introduction
 
    Thailand is experiencing global trend of rapid increasing elderly population from 5% in 1950 to more than 10% in 2013 (1), that have made Thailand the top second elderly population country in Southeast Asia (2). The elderly population of Thailand is expected to up to 30% by 2050 that makes Thailand a super-aged society (3). Aging on human is progressing as the interactions of physical, psychological, social, and environmental declines along with chronic illness. Although many elderly people are in good health, biological changes in ageing process still increase the risk of illness and disability (4, 5). They require more health care expenses, rate of dependence and the burdens for the working population and the government expenditures (6).
     Health promotion and disease prevention are important issues to reduce the burden of disease and health care expenses (7, 8). Older people are valuable to their societies in either economic terms or other un-measurable values (9). However, older people may have weak social support networks, lack income, or be subject to discrimination and abuse. Although the United Nation has focused on the rights and well-being of the older adults for more than thirty years, recent researches still reveal many gaps and influential factors related to them. In 2012, Rozanova et al. (10) found that gender, class, age, and health status were significant factors influent social engagement among seniors in rural communities in Canada. Whereas, Monma et al. concluded that mental health was the most important factor of activity limitations in Japanese older adults (11). Furthermore, low back pain regardless of age and sex, other musculoskeletal diseases only for women and cardiovascular diseases mainly for men could also be significant risk factors to activity limitations. Moreover, household income, which may directly reflect accessibility to healthcare and psychosocial stress, was added as an important modifying factor in the health risks attributable to overweight among older Japanese men (12) and a cause of caregiver strain (13). In addition, other factors related to older adults well-being were widely reported globally. Behavioral risk factors such as tobacco use, unhealthy diet, insufficient physical activity and the harmful use of alcohol are known and modifiable contributors to a number of non-communicable diseases and health mediators but are commonly reported among the seniors (14).
Theoretical framework
    Aging is a time when the physical, psychological, social and environmental declines lead to risks and health problems. It is also a time of suffering from chronic or non-communicable diseases with long term consequences. Burdens of long term care arise for many reasons such as from disease itself, from the consequences of the diseases, from deviation of health and from being disabled. Eighty-five percent of diseases found among the elderly were non-communicable or chronic diseases resulting from lifestyle, habits and their environment (7). It was found that 54% of the elderly reported their health as moderate healthy while only 11% reported having poor health. The most common health problems of elderly people were joint pain, insomnia, fainting, dizziness, constipation, hemorrhoids, high blood pressure, heart disease and diabetes (7). The major causes of death among the elderly were coronary heart disease, cancer, diabetes, liver diseases, kidney diseases, strokes, pneumonia and accidents. Health promotion, sickness prevention, treatment of the early stages and rehabilitation in the elderly are important issues to be addressed in order to reduce the burden of disease and health care expenses (8).
    The Office for National Statistics (2004) reported that 2.4 million older adults (39.8%) had sickness or illness in the past month. The incidence of illness reports were higher among female older adults. Most of the older adults reported the frequency if illness or sickness at the average of three times a month. The most frequently reported symptoms were muscular and orthopedic diseases, respiratory diseases and cardiovascular diseases (15). Several health risk behaviors among the seniors were also revealed. One-fourth of the seniors smoke cigarettes. Among those, 43.3% of the male seniors were smoking while 4.6 %of the female seniors did. Twenty-five percent of the seniors occasionally drank alcohol. The proportion was higher among male seniors (41.6: 8.6). More than half (60.6%) of the seniors were drivers or front seat passengers; however, 44.1% of them neglected seatbelt. Only 21.9% of the seniors always used seatbelts. It was interesting that more than half of female seniors refused to use seatbelts whereas only 18.9% always used seatbelts even though seatbelt law was enforced in Thailand since 2001. For male senior's drivers or front seat passengers, 38.7% reported never wear seatbelts while only 25% reported always wore seatbelts. Motorcycles are the most popular vehicles in Thailand and it is also the top cause of death in traffic accidents. Helmets law was enforced in Thailand since 1979. More than half of the seniors who used motorcycles never wore helmet whereas 9.4% always did. For female seniors, 66.9% never used helmets while only 6.2 %used. The incidence was slightly better among male seniors with 12.7% always used helmets and 47.4% never wore (15). For health promotion behaviors, 21.0% reported regularly exercise by daily basis.  The activities that the older adults reported to be difficult to perform were as mobility, self-care both inside and outside the house, illness, emotion, feeling and concentration, memory and social participation (15).
Purpose of the study
    From reviewing of literatures, differences of perceived health status existed between the elderly livings in rural and urban areas were mostly explored. Living environment, life style, and health care accessibility are correlated with urban and rural development that led to the health status distinction among the elderly living in different areas were also studied. The setting of this study, Nakhonratchasima province, is a new trend of big cities in Thailand. As rapid urbanizing spreads throughout the country, the combination of urban-rural lifestyle has been gradually found. Traditional family relations have been changed, sometimes increasing burdens on the traditional family support network. Nakhonratchasima has the largest territory and the second largest population in Thailand located 330 kilometers away from the capital Bangkok. As a province with huge population distributed in vast territory that might be different from urban area. Its health care system is at the top level (tertiary care) and throughout with exceptional quality.
    Research question guiding the study was what was the health status and health perception of the elderly who lived in the municipal areas of central district, Nakhonratchasima province, Thailand.In light of the research objective, this study aimed to 1) explore the incidence of health problems and chronic diseases, 2) define potential health problems, trends, and health behaviors, and 3) explore health patterns and lifestyles of the elderly living in municipal areas.
    The main purpose of this study was to explore the perceived health status of the elderly who lived in the municipal areas of central district, Nakhonratchasima province, Thailand. Therefore, information regarding the accessibility of health services, mental health status, social and family support, and health promotion behaviors are still needed. Findings would provide fundamental information for health and education services promoting quality of life for the elderly and their families.
 
Method
Research design
    A random interview survey with qualitative approach was used.
Subjects selection
    Data were collected with interview survey from 350 elderly that were randomly selected from 14 municipal areas of central district, Nakhonratchasima province, Thailand. In order to alleviate the bias rooted in literacy and visual problems of the elderly, questionnaires were read and written down by the research assistants trained by the principal investigator.
Instruments
    The questionnaire contained 11 items: demographics, perceived health status and problems, medication use, activities of daily living (ADL) (16), ability to use the devices in their daily lives (Instrumental Activities of Daily Living; IADL) (17), mental health (18), social and religious activities, and accommodation and environment. Weight, height, muscle strength with one leg standing were collected as well.
    The Barthel index ADL was used to evaluate physical performances. It contains ten variables that describe ADL and mobility. The possible scores were
 0-100, 0-20 represented unable to perform ADL or being dependent while 100 referred to able to perform ADL without any assistant. The inter-observer reliability of the Barthel index ADL was .714, the intra-observer reliability was .968 (16) and the Cronbachs alpha coefficient was 0.79 (17). The Barthel index ADL had acceptable content validity (Spearmans rho .629, p < .001) when compared to the de Morton Mobility Index (16). The Cronbachs alpha coefficient from this study was .82.
    The IADL was used to assess independent living skills. There are eight domains of function measured with the Lawton IADL scale. Women are scored on all 8 areas of function, for men, the areas of food preparation, housekeeping, laundering may be excluded. Clients are scored according to their highest level of functioning in that category. A summary score ranges from (0 low function, dependent) to (8 high function, independent) for women, and 0 through 5 for men. The Cronbachs alpha coefficient from the prior study was 0.78 (17) while this study yielded at .84.   
    The 20 items in the Center for Epidemiologic Studies Depression Scale (CESD) measure symptoms of depression in nine different groups as defined by the American Psychiatric Association Diagnostic and Statistical Manual, fifth edition. These symptoms are sadness, loss of interest, appetite, sleep, concentration, worthlessness, tired, agitation and suicidal ideation. People who have a total CESD scores less than 16 will be considered as no probable major depressive episode while the scores of 21 or more are at high risk. The Cronbachs alpha coefficient from the prior study was .88 (17) to .92 (18), the sensitivity was 86.67% whereas the specificity was 96.67% (18). The Cronbachs alpha coefficient from this study was .93.
Data analysis
    Data were analyzed with descriptive statistics of means, percentages, and standard deviations. Inferential statistics of Chi-square and independent t-test were used to delineate health patterns among different groups of elderly.   
Ethical consideration
    This study was approved by the Ethical Committee at Suranaree University of Technology. Informed consent was read to all participants before obtaining their permission. Participants were voluntary to participate and could withdraw from the study at any time with no immediate risks involved. Collected data was anonymous and kept confidentially by the researcher for presentation and publication use only.
Results
    Study results are outlined with participant demographics, perceived health status, health patterns, psychosocial activities, and environmental issues.
    The majority of participants were married, elementary school educated female with the average age of 70.86 years who lived in their own homes. One-third of the elderly still had the productivity of earning 3,030 Baht (95 USD) per month (Table 1). There were no statistical differences of average age and weight on gender. However, the proportions of Body Mass Index (BMI) categories were statistically different on gender (Chi-square = 21.0, df = 3, p < 0.001) along with 3/4 of males and half of females have normal BMI (18.5 24). (Table 2).
    Most elderly had at least one chronic illness like hypertension, joint pain and headache were the mostly reported complaint. Forty-six percent of the elderly perceived their health at moderate and/or poor condition while 17.8% had been hospitalized in the past six months (Table 3).
Table 1. Demographic data, activities of daily living (ADL), instrumental activities of daily living (IADL) and depression scores
Variables N (%) Min-max Means SD
Age 60 - 94 70.86 7.57
Income per month (THB)(USD) 0 - 55,730
(0 - 1741.56)
3,030.27
(94.70)
5,496.90
(171.78)
ADL 10 - 30 28.98 3.23
IADL 5 - 18 16.57 2.58
Depression scores 0 - 7 1.25 1.36
Gender
Male
Female
 
118 (37.6)
196 (62.4)
BMI
less than 18.5
18.5-24.9
25.0-29.9
30.0 or more
 
30 (9.6)
198 (63.1)
74 (23.6)
12 (3.8)
Age
60-69
70-79
80 or more
 
57 (45.6)
47 (37.6)
21 (16.8)
 
Table 2. Health patterns among male and female older adults
Variables Male Female Parameters p
Depression scores 1.25 1.24 t = -1.045, df = 227 .297
IADL scores 16.36 16.69 t = 005, df = 313 .996
ADL scores 28.60 29.21 t = -1.633, df = 312 .104
Age 70.67 70.97 t = -345, df = 312 .730
Weight 57.02 55.49 t = 1.285, df = 312 .200
BMI 21.97 23.50 t = -3.478, df = 312 .001
BMI categories
Less than 18.5
18.5-24.9
25.0-29.9
30 or more
 
14
89
14
1
 
16
109
60
11
Chi - square = 21.002,df = 3 .000
 

Table 3. Frequencies and percentages of health perception and health accessibility
Variables Frequencies Percentages
Health Perception
Excellent
Good
Moderate
Poor
 
42
127
104
41
 
13.4
40.4
33.1
13.1
Annual health check-up
High blood pressure
Eye problems    
Oral problems   
Diabetes
112
96
46
12
12
35.67
30.6
14.6
3.8
3.8
Health problems that affect ADL
None
At least one problem
Two problems
Tree problems
Four problems
High blood pressure
Musculoskeletal and joints
Headache
Cardiovascular disease
Diabetes Melitus
 
34
280
143
82
31
125
37
16
12
7
 
10.8
89.17
45.54
26.11
9.87
39.8
11.8
5.1
3.8
2.2
Hospitalization in the past six months    56 17.8
Health services of choice
Medical facilities with physician
Over the counter
Medical facilities without physician
Traditional medicine
 
284
25
4
1
 
90.4
8.0
1.3
0.3
 
Table 4Frequencies and percentages of health problems
Variables Frequencies Percentages
Vision Problems
None
Blurred vision
Combination of eyes problems
Blind         
Double vision   
 
195
92
15
7
5
 
62.1
29.3
4.8
2.2
1.6
Hearing problems    33 10.5
Number of working teeth
< 20
20 or more
 
120
194
 
38.2
61.8
Falls (in the past six month)
Never
Fell, outside the house
Fell, in the bedroom
Fell, in the restroom/bathroom
Fell, in the living room
Fell, in the kitchen
 
257
26
11
10
6
1
 
88.8
8.3
3.5
3.2
1.9
0.3
One leg stand (men at least 20 seconds, female at least 10 seconds)
Able to
Able to but very difficult
Unable to
 
202
79
33
 
64.3
25.2
10.5
Urination problems
None
Urination at night (Nocturia)
Burning     Frequent urination (Polyuria)
Leaking (Incontinence)
(Dysuria)   
 
237
35
19
12
5
 
75.5
11.1
6.1
3.8
1.6
Defecation problems
None
Constipation
Changes of defecation patterns
 
260
48
6
 
82.8
15.3
1.9
 
    Health problems caused by organs degeneration including visual, audial, urinal, and defecation problems (Table 3) and nearly 1/5 of participants had fall experiences in the past 6 months (Table 4). Most participants had access to health facilities with a physician when needed (90.4%), only 35.6% went for annual health check-up and 8% of participants bought over-counter medications. Although breast and cervical cancer are the top two causes of death of Thai women for years, only 30-40% of elderly females received annual cancer screening for both cancers (Table 5).
    Health patterns: Less than 10% of participants consumed tobacco and alcohol. Most participants (83.4%) have routine exercise of walking, running, or other physical activities. Most of them ate two or three meals a day whereas only five of them had only one meal a day (Table 6).
    Psychosocial activities: The elderly perceived their mental health status as good with very low depression and high abilities of performing daily activities. However, 7% of the elderly reported not having caregiver when they got sick. Participants had opportunities to meet with their relatives and almost 1/4 of them did such meeting weekly. Almost half of them were regularly involved in decision making with families. Participants participated in various activities including health promotion, religious, and social service activities that are helpful to their mental health (Table 1).
    Environmental issues: nearly 1/3 of the elderly lived in single-storey houses while 84.4% had their bedrooms at the first floor. However, environmental risks such as the bathroom needs to be modified. As results showed 1/3 of the elderly used squat toilets that might increase risks for dizziness and falls when getting up. Moreover, almost 3/4 of the elderly drank rain water and/or ground water without boiling or filtering (Table 6).
 
Table 5. Frequencies and percentages of health screening among female elderly
Variables Frequencies Percentages
Pap smear examination
Never
Yes
 
 
117
40
 
 
59.69
40.3
Self-breast examination
Never
Yes
 
 
136
60
 
 
69.39
30.61
Clinical breast examination
Never
Yes
 
 
130
66
 
 
66.33
33.67

Table 6. Frequencies and percentages of health promotion behaviors
Variables Frequencies Percentages
Medication usage
Yes
Prescribed
Over the counter
 
133
152
7
 
42.4
48.4
2.2
Smoking
None
Use to but recently stop
Yes   
 
263
23
28
 
83.8
7.3
8.9
Drinking alcohol
None
Use to but recently stop
Yes
 
266
22
26
 
84.7
7.0
8.3
Exercise (thirty minutes a day, three days a week)
None
Walking
Other physical activities
Running 
 
52
140
13
10
 
16.6
44.6
4.1
3.2
Number of Meals per day
1
2
3
 
5
70
239
 
1.6
22.3
76.1
Drinking water
Tap water
Underground water
Rain water
Others (Bottle drinking water)
 
102
6
150
56
 
32.5
1.9
47.8
17.8
 
Discussion
    The contexts of the municipal areas illustrated in this study was a combination of the urban and the rural areas. Findings on most female participants were consistent with another report (15) since female has longer longevity. Living in their own homes is congruent with the context of suburban society in Thailand where people tended to own and live in their own real states rather than renting property. Many elderly still have productivity with low incomes of around 95 USD (3,030 Thai Baht) per month compared to 426 USD/month of the GDP. On top of the social welfare (19 - 31 USD/month) the elderly receive from the government, half of the elderly perceived those incomes was sufficient or satisfied. Part of this might be attributed to the Thai government supports most of their medical expenses (19) as a welfare state benefit that covers medical expenses, room and board for hospitalization, and other costs of necessary medical equipment (20). Furthermore, relatives of the elderly or community volunteers provided transportation to health care facilities without cost (3). For people in the degenerative period of health, above support helps alleviating additional living expense on health.
    All of the elderly had at least one health issue that influenced their lives. Nearly half of participants rated their overall health as moderate to poor status while 17.8% of participants had hospitalization experiences in the past six months. Most of the elderly had access to health facilities when needed but an annual health check-up was low. However, the prevalence of smoking and drinking found in this study was lower than the evidence from a nationwide consensus (8) which was reported at 25%. many elderly (83.4%) regularly exercised compared to 21% in the nationwide consensus. Generally, life in the sub-urban areas is more hostile and competitive; therefore, people may neglect taking care of their health. Moreover, in developed areas, there may be limited places to exercise. The results of health behaviors from this study are better than those reported among other urban areas (21).
    Although breast and cervical cancer are the top causes of death among Thai women (22, 23) cancer screening rate remains relatively low (30 40%) that could be attributed to the traditional Thai culture that Thai women perceived breasts and genital organs as very personal body parts that women of all ages neither disclose their private body parts for cancer screening nor discuss about signs and symptoms.  Health care personals should put cultural issues into the account of innovative screening techniques to avoid exposing the organs and embarrassment are required for launching a campaign that educate the benefits of screening, providing screening services at home, training female providers, and educate self-observation.
    It is believed that municipal communities are indifferent; urban people do not socialize in a big way resulting in possible loneliness for many. However, 70.1% of the elderly in this study were participating in social and other activities to develop their mental health. Rates of participating in such activities were close to reports from the National Bureau of Statistics (8) which reported participation at 64.2%. Rates of social participation were congruent with their high ADL score as reported by Senanarong and colleagues in 2003 (24). However, the findings of the activities scores in this study were different from reports of the National Bureau of Statistics (8) where it was concluded that older adults had difficulties in moving (11.5%) working outside the house or doing chores (10.3%) with major discomforts illnesses (8.1%).
    As a result of living in the sub-urban communities, it was expected that the elderly would have been depressed and had low social interaction. However, The findings of better mental health were controversial compared to other studies who reported more evidence of depression, sadness and anxiety (56%) among the older adults (24, 25), more problems with moods, concentration and memory (26) and low social participation (27). Better mental health; low depression, and high social participation are strongly correlated with high family and social supports (28). As 65% of the elderly had chances to meet relatives and involved with decision making regarding their family affairs, it might be concluded that they were fulfilled their self - esteem and life satisfaction.
    Although only 7% of the elderly reported the lacking of caregivers when they got sick, cooperation between health/trained community volunteers and local authoritys administration offices providing care to those elderly is recommended that can compensate the shortage of caregivers of those elderly in those areas (29).
    Although most of the elderly did not have a history of falls, study results indicated that the bathroom was the most frequent place the fall occurred. This might be related with 33% of them still used squat toilet that could easily cause joint pain, dizziness and accidents. The design of daily living environment should put the reduction of fall risk into consideration that might decrease the risk of fall along with other means for fall prevention.
    Education regarding drinking water safety is strongly needed as most of the elderly drink rain or tap water without boiling or filtering since the quality of drinking water in rural Thailand was poor that often contaminated with Coliform bacteria (30). Issues regarding unsealed storage containers, contaminated handling, sharing drinking cups/glasses that cause bacterial contamination in household drinking water should also be covered (30).
 
Conclusion
    The elderly living in the municipal areas have chronic illness and degenerative problems that have led to their risk of poor health conditions deteriorated by inappropriate health behaviors in the future. Education given to the elderly and their family are essential to enhance their health literacy of health promotion and chronic illness prevention that integrate with the strength of living in the municipal areas including accessibility to health services and strong social support that provides health personnel greater platform developing feasible health care plan and delivering equivalent health services with less disparity rooted in rural area.
 
Study limitations
    Data in this study was collected from 14 urban-rural of one municipal district only. Generalization of the findings may be limited.
 
Conflicts of interest
none
 
Acknowledgements
    The author would like to thank the Suranaree University of Technology, Thailand for providing the fund for this research project.
 
 
Authors' contribution
    The author was responsible for preparing the proposal, applying for funding, submitting for ethic committee approval, collecting data, analyzing data, and writing report and manuscript as a corresponding author.  
 
Type of Study: Research | Subject: General
Received: 2019/03/14 | Accepted: 2019/09/14 | Published: 2019/12/29

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