Factors Influencing Health Promoting Behaviors among the Elderly Under the Universal Coverage Program, Buriram Province, Thailand ppt

AsiaJournalofPublicHealth,JanuaryJune2010 Vol.1No.1 15 FactorsInfluencingHealthPromotingBehaviors amongtheElderly UndertheUniversalCoverageProgram, BuriramProvince,Thailand KanitthaChamroonsawasdi * SukanyaPhoolphoklang ** SuthamNanthamongkolchai * ChokchaiMunsawaengsub * *DepartmentofFamilyHealth,FacultyofPublicHealth,MahidolUniversity,Bangkok,Thailand **DepartmentofCommunity HealthNursing,FacultyofNursing,Thammasart University,Thailand ARTICLEINFO Articlehistory: Received23May 2010 Receivedinrevisedform 25June 2010 Accepted9July 2010 AvailableonlineJuly 2010 Keywords: Elderly HealthPromotingBehaviors UniversalCoverageProgram CorrespondingAuthor: Chamroonsawasdi K, DepartmentofFamilyHealth, FacultyofPublicHealth, MahidolUniversity, Bangkok10400,Thailand. Email: phknt@mahidol.ac.th AsiaJPublicHealth 2010;1(1):1519 INTRODUCTION Concerning unavailability and inaccessibility of healthcare services and limited affordability of poor people, the Thai government launchedtheuniversalcoverageprogramknownas “30 baht scheme” in 1991 1 .  The purpose of this program was to increase equity utilization of healthcare services by providing standard careand reducing medical care costs for Thai people. The principleofthisprogramwasfocusedonpreventive and promotive strategies to promote healthy lifestyleofpeopleratherthancurativestrategies 1 as well as to prevent unnecessary utilization of healthcareservices 12 . Atpresent,thenumber of elderlyhasbeen increasing annually year by year and the exempt frommedicalfeescriterionletstheelderlybecome a major group whoutilize healthcare services. In ABSTRACT Objective:Acrosssectionalsurveyresearchaimedatstudyingfactors influencinghealthpromotingbehaviors(HPB)oftheelderlyunderthe universal coverage program. Materials and methods: The sample group was 341 elderly in Buriram Province.  A multistage sampling techniquewasusedtoselectthesample.Datawerecollectedbyusing interviewquestionnaireduring1731October,2005andwereanalyzed byfrequency,percentage, mean,standarddeviation, Pearson’s Product MomentCorrelationandstepwisemultipleregressionanalysis.Results: Theresultsshowedthat53.7%oftheelderlyhadHPBatmoderatelevel and30.2%hadHPBathighlevel. FactorssignificantlypredictingHPB amongtheelderly werehavingoccupation,knowledgescoreonHPB, havingcurrentillnessforonemonth,experienceobtainingknowledgeor information on HPB from health personnel, and social support from family.ThesefactorswereabletopredictHPBoftheelderlycorrectly 42.1%. Conclusion: From these findings, the authors recommend healthproviderstopromoteelderlyHPBinallcommunitiesbygiving knowledge on HPB through various means, enhancing social support from family and paying attention to unemployed groups to encourage themindailypractice ofHPB. AsiaJournalofPublicHealth Journalhomepage:http://www.ASIAPH.org OriginalArticles AsiaJournalofPublicHealth,JanuaryJune2010 Vol.1No.1 16 2007, the estimated total number of Thai elderly was around7 millionand in the next12 years the number will increase to 11 million or equal to 17 percentofallagegroups 3 .Theelderlyhasbecome amajorgroupofpublichealthconcernbecausethey are living with health deterioration in all aspects, physical,mentalandpsychosocial.Threefourthsof the elderlyhavechronic healthproblems.Thetop five health problems are; muscular pain (75.1%), joint pain (47.5%), restlessness (38.7%), headache (36.8%),andvisualproblems(33.2%).Thechronic diseases found among the elderly are high blood pressure (20%), digestion and stomach problems (11.4%)anddiabetes(8.3%) 4 .Healthproblemsof the elderly result from poor health promoting behaviors 5 whichmayleadtochronicdiseasessuch as cardiovascular disease, hypertensive disorder, diabetes mellitus and mental health problems.   A national survey onhealth promotingbehaviors and lifestyles ofthe elderlyin 2007 foundthat 28% of themhaddailyexercise,13%hadregularsmoking, 3% had daily drinking alcohol, 63% ate fruits and vegetables daily and 74.1% had annual physical check up 6 . The World Health Organization emphasizes health promoting behaviors as a key strategytomaintainhealthstatusoftheelderlyand assist them to survive with a good quality of life without depending on any family members or the society 7 . From previous findings, factors related to healthpromotingbehaviorsoftheelderlywereage, sex, education, economic status, chronic illness, perceived health status, perceived selfefficacy, perceivedbenefitsofpractice,perceivedbarriersto practiceandsocialsupportfromfamily 811 . Buriram province is located in the northeastern part of Thailand where the total number oftheelderlyhas annuallyincreased.The percentage of the elderly in this province has increasedfrom4.2percentsin1980to6.3percents in 1990, 8.9 percents in 2000 and 9.9 percents in 2006 12 .  Around 89.2 percent of them were registered under the universal coverage program. Thetop3problemsthat the majority of them face are respiratory problems, muscular weakness and pain 13 .TohelptheelderlyinBurirumprovinceto maintain good health status under the universal coverage, the health promoting behaviors and its influencing factors based on Pender’s health promoting model 14 and PRECEDEPROCEED framework of Green LW and Kreuter MW 15 are explored.  Fruitful findings would be used as a guideline for planning effective implementing strategiestopromotehealthylifestyleandbehaviors among the elderly under the universal coverage programinthisprovinceinthefuture. MATERIALSANDMETHODS A crosssectional study was conducted to collectdatabyinterviewquestionnaireduring1731 October,2005.Thepopulationwere theelderlywho had their residence in Buriram province. The samples were the elderly who were able to communicate,whoheldahealthgoldcard,whohad noserioushealthproblemsandwhowerewillingto participate in this study by signed consent form. The sample size was calculated. Total sample size was341cases.Themultistagesamplingtechnique was used to select the elderly from each of the target6villagesobtainedfromthe3districtsofthe northern,centralandsouthernpartoftheprovince. The research instrument was an interview questionnaire to examine the predisposing factors composed of demographic characteristics, knowledge on HPB and perception of illness; enabling factors composed of accessibility to healthcare services and reinforcing factors composed of perception on benefits of gold card and social support from family. The questionnaire consisted of 7 parts.  Part 1 was demographic characteristics of the elderly which were sex, age, marital status, education, occupation, income, having chronic and present illness during one month, experience receiving knowledge or information on HPB from health personnel, and people who live with participants.  Part 2 was 25 questions on knowledge on health promoting behaviors based on a concept of Healthpromoting Life Style of Walker SN et al 16 . Part 3 was 5 questions on perception of chronic and current illness. Part 4 was 8 questions regarding accessibility to healthcare services.  Part 5 was 8 questions on perception toward benefits of gold card.  Part 6 was 15 questions on social support fromfamilybasedonconceptsofTardyCH 17 .Part 7 was 25 questions on health promotingbehaviors of the elderly adapted from Health Promoting Lifestyle Profile (HPLP) 16 in 6 domains such as eatingbehavior,exercise,healthresponsibility,self actualization, stress management and interpersonal relationship. Contentvaliditywasexaminedby4experts anda reliability test given to30 elderly who were living in Sao Dieo subdistrict, Buriram province. TheCronbrach’salphacoefficientofeachpartwas as follows: knowledge on health promoting behaviors = 0.80, perception of illness = 0.65, perceptionofbenefitsofgoldcard=0.60andsocial supportfromfamily=0.80. Ethicalapproval Theresearchproposalwasapprovedbythe Committee on Human Rights Related to Human Experimentation, Mahidol University (MU 132/2005). AsiaJournalofPublicHealth,JanuaryJune2010 Vol.1No.1 17 Dataanalysis Frequencies,percentage,meanandstandard deviation were used to describe demographic characteristics, perception of illness and accessibility to healthcare services. Pearson’s productmomentcorrelationcoefficientwasusedto find out factors correlated to the health promoting behaviors of the elderly. In addition, stepwise multiple regression was used to determine the predicting factors of health promoting behaviors. Thelevelofstatisticalsignificancewasatp<0.05. RESULTS Demographiccharacteristics Itwasfoundthat66.4%oftheelderlywere femaleandhalfofthem(50.4%)wereintheage60 69yearsold.Morethanhalf(62.5%)weremarried, 54% lived with their spouse, son and daughter, 83.3% completedprimaryschool level, and62.5% had their own occupation. Twothirds of them (67.7%) had income equal or less than 1,000 baht/month where 74.8% had a source of income from a son or daughter.  Concerning adequacy of income,37% hadenoughbutnotforsaving,while 31.7% had inadequate income and had to borrow from others. Threefourths of them (75.4%) had a high level of knowledge on health promoting behaviors. Nearly half (46%) perceived that they had some chronic illness  of which the highest ranked were hypertension (37.4%) followed by pepticulcer(25.2%)anddiabetesmellitus(19.4%), and68.6%perceivedpresentillnessasmuscularor jointpainandbodypain.Seventypercentofelderly utilizedacommunity hospital most whenthey had becomesickandamongwhich100%usedthegold cardandperceived that it was convenient totravel tohealthfacilitiesbyvehicles.Nearlyhalf(45.8% and45.8%)perceivedthatbenefitsofthegoldcard andsocialsupportwereatalowlevel. Healthpromotingbehaviorsoftheelderlyunder universalcoverage Concerning each domain of the study’s HPB,itwasfoundthatmorethanhalfofthemhada high HPB level on interpersonal relationship (68.8%),followedby eatingbehavior(56.7%),and self actualization (52.9%), while the high HPB scores were found to have been lower among exercise (20.4%), stress management (28.4%) and health responsibility by having an annual physical checkup(39%). Morethanhalfoftheelderly(53.7%)hada total score of health promoting behaviors at moderate level while onethird (30.2%) were at a high level.  Mean scores of health promoting behaviors (HPB) were equal to 50.82+9.03, min max=3168(Table1). Table1 Healthpromotingbehaviorscores Levelofhealthpromoting behaviorscores Number (n=341) Percent Low(040marks) 55 16.1 Moderate(4155marks) 183 53.7 High(5675marks) 103 30.2 Mean+SD=50.82+9.03,Min=31,Max=68 FactorsassociatedwithHPB From Chisquare test of predisposing, enabling and predisposing factors which were significantly associated with HPB were having an occupation, having present illness for one month, andexperienceobtainingknowledgeorinformation onHPBfromhealthpersonnel. From Pearson’s correlation analysis between numeric variables of predisposing, enabling and reinforcing factors and health promoting behaviors of the elderly under the universal coverage, it was found that age, income, knowledge on HPB, perception of illness, perception of benefits of gold card and social supportwerecorrelatedwithHPB(Table2). Table 2 Pearson’s correlation between age, income, knowledge on HPB, perception of illness, perception on benefits of gold card, social support and HPB of theelderly(n=341) Variables Pearson’sCorrelation Coefficient pvalue Age 0.228 <0.001 Income 0.231 <0.001 KnowledgeonHPB 0.208 <0.001 Perceptionofillness 0.309 <0.001 Perceptionon benefitsofgoldcard 0.326 <0.001 Socialsupport 0.403 <0.001 Predicting factors on HPB of the elderly using stepwisemultipleregressionanalysis The significant predicting factors on HPB of the elderly consisted of having an occupation, knowledge on HPB, present illness during one month, experience to obtain knowledge or information from health personnel on HPB and socialsupport.Thismodel wasabletopredictthe HPBamongtheelderlyasbeing42.1%(Table3). Table 3 Predicted factorsofHPB among the elderly bystepwisemultipleregressionanalysis(n=341) StepwisemultipleregressionPredictors B Beta pvalue Havingoccupation 0.324 0.270 <0.001 KnowledgeonHPB 0.142 0.136 <0.001 Presentillnessduringone month 0.351 0.268 <0.001 AsiaJournalofPublicHealth,JanuaryJune2010 Vol.1No.1 18 Table 3 Predicted factorsofHPB among the elderly by stepwise multiple regression analysis (n=341) (cont.) StepwisemultipleregressionPredictors B Beta pvalue Experiencetoobtain knowledgeor informationonHPBfrom healthpersonnel 0.173 0.139 <0.001 Socialsupport 0.264 0.253 <0.001 B 0 =6.64;R 2 =0.482;AdjustedR 2 =0.421 DISCUSSION Healthpromotingbehaviorsoftheelderlyunder theuniversalcoverage Fifty three percent of the respondents had theirHPBatamoderatelevel,while30%wereata highlevel.WhenconsideringeachdomainofHPB, interpersonal relationship, eating behavior and self actualization were found to be most practiced among the elderly, while exercise was found to have been practiced at the lowest.  These findings were similar to the previous studies done by Seo HM and Han YS 18 , Anise Man SW, et al 19 and Kyeong YS, et al 12 .  This may be due to the limitation of their body fitness when getting older becauseexerciseinducedmoreofafeelingofbeing tired than among those who are young. Practicing exercise had the lowest score of all the present study’s HPB domains. Concerning the most practiced HPBs, interpersonal relationship, eating behavior and self actualization were daily life practices.  The elderly need social contact with others because they are human beings. Additionally, they eat vegetables and fruitsto help easyexcretionandreducefatandnegativeeffectsof spice in spicy food and to reduce digestion and absorptionproblem. FactorspredictingHPBoftheelderly From the findings, having an occupation, knowledge onHPB, present illness for one month, experiencetoobtainknowledgeorinformationfrom health personnel on HPB and social support from family were the significant predicting factors of HPB of the elderly under universal coverage. The highest level predicting factor was having present illness for one month. When having a present illness, the elderly need to see the doctor or visit healthfacilities.Theywillreceivepropertreatment as well as receive knowledge or information on HPB from health personnel to motivate them to practice more.Theresult was similar tothestudy ofLeeTWetal 20 ,StollerEPandPollowR 9 . Theelderlywhohavetheirownoccupation willhaveasourceofincometoelevatetheirliving arrangements which increases their perception on selfefficacytolivewithoutpassivelydependingon theirsonsordaughters.Thisfindingwascongruent withthestudydonebyKimHJetal 11 andKyeong YS et al 12 .  Social support from the family was found to be positively correlated with the HPB of theelderly.Itcanbeexplainedthattheelderlyneed to depend on the support from family in terms of financial support, living arrangement, health information as well as psychological support to motivate them to reach their optimum during the last period of life 6 . The elderly who have strong socialsupportfromfamilywillenhancetheirsense of wellbeingthat facilitate moreHPB while those whohaveweaksocialsupportwillfeelalackofself efficacy in the practice of HPB.  This result was similartothestudyofKattikaTandKusolS 21 and Kim HJ et al 10 .  The fourth and fifth predicting factors of HPB in the elderly were experience to obtain knowledge or information on HPB from health personnel and knowledge on HPB.  These can be explained as knowledge and understanding inHPBwhichwillinfluencemotivationsormodify attitudesofpeopletopracticeofhealthpromotion 22 . Thisfinding wassupportedbythestudy ofHuang LHetal 23 andCoulsonIetal 24 .ThemoretheHPB knowledge, the more the frequency of practice on HPB amongtheelderlywasfound. Regarding the results of the study, recommendationsareasfollows: 1. Health promoting behaviors of the elderly were still at the moderate level.   The routine servicesfortheelderlyshouldimprovetheabilityof health personnel to provide knowledge and information on HPB through different channels suchasfacetoface,demonstrations,pamphletsand homevisits,aswellastomotivatethecaregiverto motivate the elderly to engage in daily practice of HPB. 2.Healthcareservicesshouldemphasizegiving information on HPB among the elderly who are unemployed and stay at home for continuous practiceofHPB. 3.  The healthcare services should encourage family members of the elderly to pay attention to HPB of the elderly and to give untiring social support to increase their motivation to practice on HPB. ACKNOWLEDGEMENTS The authors would like to thank all health personnel and the village headman of Buriram provincewhofacilitatedthedatacollectingprocess. Also,wewouldliketo giveaspecialthankstoall elderlywhodevotedtheirtimetoparticipateinthis study.Theauthorswouldfinallyliketogivethanks to Eric Curkendall from the Mahidol University Faculty of Public Health, Office of International Affairsforhisassistanceeditingthismanuscript. AsiaJournalofPublicHealth,JanuaryJune2010 Vol.1No.1 19 REFERENCES 1.TowseA,MillsA,TangcharoensathienV.Learn ing from Thailand’s healthreforms.BMJ2008; 328:1035. 2.BureauofHealthPolicyandPlanOffice,Perma nentSecretaryOffice,MinistryofPublicHealth. A handout on universal health care coverage. NonthaburiProvince: Ministryof PublicHealth, 2001. 3.KanchanajittraC,PodhisitaC,ArchavanitkulK, PattaravanichU, SiriratmongkonK,Seangdung H,etal.Thaihealth2007.InstituteofPopulation andSocialResearch,MahidolUniversity,Nako rnPathom:InstituteofPopulationandSocialRe search,2007. 4.NationalStatisticOffice,MinistryofInformation and Technology.Asurvey report of elderlyin Thailand in 2002,Bangkok : Chan ChomPub, 2003. 5. Palank CL.Determinantsofhealth promotion behavior:Areviewofcurrentresearch.Nursing ClinicsofNorthAmerica1991;26: 81532. 6.BureauofHealthPolicyandStrategies,Ministry ofPublicHealth.Thailandhealthprofile:Report on health situationand healthbehavioralofthe ThaiElderly2009;4: 132. 7.WorldHealthOrganization.Aging and working capacity:ReportofaWHOstudygroup.Geneva: WorldHealthOrganization,1993. 8. StollerEP, PollowR.Factors affecting thefre quencyof health enhancingbehaviorsbytheel derly.JPubHReports1994;109: 37789. 9.NikpourS,SolaAH,SeiedoshohadaeiM,Hagha niH,HadjikazemiE.Healthpromotionbehaviors among elderly in westareaof TehranIran.Mid dleEastJAgeAging2006;3: 106. 10.KimHJ,KimLH,ParkYH.Factorsinfluencing health promotingbehavioroftheelderly.Avai lable at http://www.koreamed.org/SearchBasic. php.AccessedonJune22,2009. 11.KyeongYS,SueS,HyeAY.Healthpromoting behaviors of elderlyKoreanimmigrants in the UnitedStates.JPub HNurs 2002;19: 294300. 12.Statistical Office,Buriram Province,Reportof censuspopulationsurveyin2005.Unpublished, 2006. 13.Buriram Provincial Health Office,Ministry of PublicHealth.Annualreportsontheelderlysitu ationsurvey,2003.Unpublished,2005. 14.PenderNJ.Healthpromotioninnursingpractice, 2 nd edition.Norwalk:Appleton & Lange,1987. 15.GreenLW,KreuterMW.Healthpromotingpla ning:An educational and ecologicalapproach, 3 rd edition.California:MayfieldPubCom,1999. 16.WalkerSN,SechristKR,PenderNJ.Thehealth Promoting lifestyles profile:Development and psychometriccharacteristics.JNurs Resh1987; 36:7681. 17.Tardy CH.Social support measurement.Am J ComPsy1985;13: 187202. 18.SeoHM.andHahYS.AStudyof FactorsInflu encingon Health Promoting Lifestyleintheel derly:ApplicationofPender’sHealthPromotion Model,Availableathttp://www.ncbi.nlm.nih.gov /pubmed/.AccessedonJanuary4,2009. 19.AniseManSW,CatherineST,TimothyChiYK. Physical and psychosocial factors associated withhealth promotingbehaviorsamongelderly withtypesdiabetes.JH Psy2004;9: 73140. 20.Lee TW,KoIS,LeeKJ,Kang KH.Health sta tus,health perceptionand health promotionbe haviorsof low incomecommunitydwellingel derly. Available at http://www.ncbi.nlm.gov/. pubmed.AccessedonJune22,2009. 21.KattikaT,KusolS.Family relationsandhealth promoting behavioramongolderpeopleinNan province.JMedAssocThai2008;91: 11028. 22.KemmJandCloseA,Healthpromotion:Theory andpractice.London:Macmillan,1995. 23.HuangLH,ChenSW,YuYP,ChenPR,LinYC. Theeffectivenessof healthpromotioneducation programs for community elderly. J Nurs Res 2002; 10: 26170. 24.CoulsonI,MarinoR,MinichielloV.Olderpeo ple’sknowledgeandpracticeaboutlifestylebe haviorsthatmaypreventvasculardementia.Ge rontandGeriatJ2001;33:27385. . AsiaJournalofPublic Health, JanuaryJune2010 Vol.1No.1 15 Factors Influencing Health Promoting Behaviors among the Elderly Under the Universal Coverage Program, Buriram Province, Thailand KanitthaChamroonsawasdi * SukanyaPhoolphoklang ** SuthamNanthamongkolchai * ChokchaiMunsawaengsub * *DepartmentofFamily Health, FacultyofPublic Health, MahidolUniversity,Bangkok ,Thailand **DepartmentofCommunity. and pain 13 .Tohelp the elderly inBurirumprovinceto maintain good health status under the universal coverage,  the health promoting behaviors and its influencing