Già hóa năng động ở việt nam thực trạng, những yếu tố ảnh hưởng, lợi ich tiềm tàng, so sánh quốc tế và khuyến nghị chính sách

國立臺灣大學公共衛生學院健康政策與管理研究所 博士論文 Institute of Health Policy and Management College of Public Health National Taiwan University Doctoral Dissertation 越南活躍老化指標: 現況、因子、效益、跨國比較、與政策建議 Active Aging Index in Vietnam: Current Status, Determinants, Potential Benefits, Cross-country Comparison and Recommendations for Policy Response 范俊于 Pham Tuan Vu 指導教授：陳雅美, PhD Advisor: Ya-Mei Chen, PhD 中華民國 108 年 月 July, 2019 doi:10.6342/NTU201901838 i doi:10.6342/NTU201901838 ACKNOWLEDGEMENT First of all, I would like to express my deepest thanks to my adviser, Associate Professor Ya-Mei Chen, for her continuous support from the beginning till the end of my PhD journey Words cannot express my gratitude for what she has done to me She has been not only guiding me through my long and difficult academic life but also teaching me how to complete myself Thank her so much for her great dedication, encouragement and patience during my tough time I would never have been able to finish my doctoral program without her guidance and care I would like to send my sincere gratitude to my dissertation committee: Professor Hsiu-Hsu Chen, Wei-Chu Chie, Hui-Chuan Hsu, and Tai-Yin Wu, who gave me insightful comments, support and encouragement from my proposal defense to my dissertation defense My special thanks go to other Professors of College of Public Health, including Chang-Chuan Chan, Ming-Chin Yang, KP Michael Chung, Yawen Cheng, Shou-Hsia Cheng, Wei J Chen, Hsien-Ho Lin, Yu-Kang Tu, Kun-Hsien Tsai, Kuo-Liong Chien, YuChi Tung, Chuhsing Kate Hsiao, for their kindness and useful lectures I am proud to be NTU-CPH student and I especially appreciate the school giving a full scholarship to fulfil my academic dream I am grateful to all the university’s and college’s administrative staffs and my classmates who are so nice and supportive to me I take this opportunity to thank the Presidential Board of Thai Nguyen University of Medicine and Pharmacy, Functional Departments, Dean and Vice Deans of Faculty of Nursing, Head of Nursing Administrative Division, Head of Community Health Nursing Division, and other colleagues who have been supporting and encouraging me during my long journey abroad This work is dedicated to my family members, including my beloved grandmother who is not able to witness this moment, my parents whom I owe their love and sacrifices so that I could have a good education, and my siblings who are always on my side Last but not least, I would like to thank myself who haven’t not given up during this long and challenging journey My efforts have paid off ii doi:10.6342/NTU201901838 ABSTRACT Introduction In response to the challenges of population aging, the WHO has developed a policy framework that promotes active aging, with an emphasis on the following three pillars: health, social participation, and security Several advanced countries have conducted studies to measure and monitor active aging level and evaluate the implementation of aging-related policies However, such studies are scarce in Vietnam, one of the world’s fastest aging countries Therefore, this study was conducted to 1) adapt and validate the active aging index (AAI) in Vietnamese language; 2) assess the current status of active aging in Vietnam and compare it with that in China, South Korea, Taiwan, and 28 European Union (EU) countries; 3) identify the determinants of active aging; and 4) explore the potential benefits of active aging, including health outcomes, health utilization, life satisfaction, and quality of life (hereafter referred to as health-related outcomes) Research methods This study was divided into three phases In the first phase, translation and modification were conducted to adapt the AAI to Vietnam culture A series of one expert panel discussion and two focus groups among older adults were conducted to obtain their perspectives on the tool The second phase consisted of a pilot test and a retest on 40 people to assess the different types of validity and reliability of the questionnaire In the third phase, a cross-sectional investigation was conducted on 1105 older adults in three provinces representing three regions of Vietnam: Thai Nguyen (northern), Hue (central), and Ho Chi Minh (southern) A multi-stratified sampling method was applied to draw study participants General linear regression and multiple ordinal regression models were used to identify the determinants and the potential benefits of active aging Results Psychometric properties of the final version of Vietnamese AAI (VAAI) The VAAI had a good test–retest reliability with a minimum ICC of 0.70 for a single question and an acceptable internal consistency for of groups of items ( = 0.70, 0.94, and 0.65) It also showed acceptable construct validity with model fit indices of χ 2/df = 3.8; RMSEA = 0.059; CFI = 0.939; and SRMR = 0.060 The content validity indices rated by Vietnamese experts were 0.95 and 0.98 for relevant and clarity criterion, respectively The VAAI also achieved concurrent validity VAAI in comparison with other countries Using the validated tool, we observed that Vietnam had an overall AAI score of 43.1, which was ranked nd among 32 countries Vietnam was ranked high in terms of overall AAI due to high rankings in domains, i.e., employment (ranked st) and social participation (ranked 5th) In contrast, Vietnam ranked 32nd the lowest in terms of independent/healthy/secure living and 26th in terms of capacity and enabling environment for active aging These two domains had low rankings because iii doi:10.6342/NTU201901838 several component indicators obtained low scores, including lifelong learning (7.0%), lived alone or with spouse (18.9%), use of internet (26.7%), having had a senior high school degree or above (26.7%), share of healthy life years (39.8%), no poverty risk (46.2%), and physical activity (47.1%) The AAI score for older men (44.9) was higher than that for older women (41.6) Determinants of active aging The bivariate analysis showed that people who were younger, male, married, rural residents, northern residents, without limited activity, and without longstanding illness had significantly higher AAI scores than their counterparts (p < 0.05) However, after controlling for important covariates, only age (p = 0.001), region (p = 0.001), and limited activity (p = 0.001) were found to be significant determinants of the variation in AAI Potential benefits of active aging After controlling for potential confounders, we found that people with higher AAI scores were more likely to have good health, better life satisfaction, quality of life than those with lower AAI scores, and they were also less likely to be frail and suffer a fall Discussion In addition to the interpretation of results and comparison with other studies, some useful policies from advanced countries that Vietnam could learn to promote active and healthy aging have been discussed in this study At the end of this section, we discuss the present study’s strengths and limitations as well as the implications for future studies Conclusion Analysis of the psychometric properties of the VAAI showed that this index is reliable and valid, which therefore ensures that the VAAI can be used in a country with a new cultural setting, such as Vietnam Older Vietnamese adults were more active in labor force and social participation; however, they were not as healthy, independent, secure, and capable of being active as their counterparts in other Asian and EU countries These findings indicate that Vietnam must improve low-score indicators, such as voluntary activity, physical activity, independent living, lifelong learning, educational attainment, use of internet, healthy life expectancy, and risk of poverty The findings of this study also reveal that multidimensional active aging is a beneficial predictor of of health-related outcomes However, when one is designing multidimensional active aging programs, more attention must be paid to people who are female, older, and/or with activity limitation, as they obtained lower AAI scores than their counterparts Keywords: Active aging index (AAI), determinants of active aging, potential benefits, perceived health, fall, frailty, loneliness, doctor visit, life satisfaction, quality of life iv doi:10.6342/NTU201901838 DISSEMINATION OF THE STUDY’S FINDINGS Dissemination of the findings has been undertaken throughout the course of my PhD journey and will be continuing in the future One paper has been published in a peerreviewed journal and one conference paper has been presented at National Health Research Institutes Forum, Taipei, Taiwan in 2019 Pham, V T., Chen, Y.-M., Van Duong, T., Nguyen, T P T., & Chie, W.-C (2019) Adaptation and Validation of Active Aging Index Among Older Vietnamese Adults J Aging Health, 0898264319841524 doi:10.1177/0898264319841524 Pham, V T., & Chen, Y.-M (2019) Active Aging Index in Vietnam Paper presented at the National Health Research Institutes Forum - Active Aging Workshop, Taipei v doi:10.6342/NTU201901838 TABLE OF CONTENTS ACKNOWLEDGEMENT ii ABSTRACT iii DISSEMINATION OF THE STUDY’S FINDINGS v TABLE OF CONTENTS vi LIST OF FIGURES ix LIST OF TABLES x ABRREVIATION xi I INTRODUCTION I.1 Background I.2 Research Questions I.3 Study Purposes and Aims I.4 Significance of This Study II LITERATURE REVIEW II.1 What is Active Aging? II.2 Measurements of Active Aging II.3 Applications of the Active Aging Index 10 II.3.1 Using AAI for comparison purposes 10 II.3.2 Using AAI as a tool for policymaking 13 II.4 Determinants of Active Aging 13 II.4.1 Gender 15 II.4.2 Culture 16 II.4.3 Personal determinants 17 II.5 Potential Benefits of Active Aging 17 II.5.1 Health outcomes 18 II.5.2 Healthcare utilization 19 II.5.3 Life satisfaction 19 II.5.4 Quality of life 20 II.6 Impact of Determinants of Active Aging on Health-related Outcomes 22 II.7 Policies Promoting Active Aging Worldwide 23 II.8 Aging-related Policies in Vietnam 24 II.9 Summary 25 II.10 Conceptual Framework 27 vi doi:10.6342/NTU201901838 III METHODS 28 III.1 Phase 1–Translation and Adaptation of The Questionnaire 28 III.1.1 Translation of the questionnaire 28 III.1.2 Modifying the questionnaire 30 III.1.3 Focus groups 32 III.1.4 Data synthesis 32 III.2 Phase 2–Pilot Study 33 III.2.1 Study Setting 33 III.2.2 Inclusion and exclusion criteria 34 III.2.3 Sample size 34 III.2.4 Sampling 35 III.2.5 Data collection procedure 35 III.2.6 Concluding Meeting 35 III.2.7 Data analysis 36 III.3 Phase 3–Field Study 39 III.3.1 Research design 39 III.3.2 Setting of the field study 39 III.3.3 Study subjects 41 III.3.4 Research Instruments 42 III.3.5 Data collection procedure 53 III.3.6 Ethical consideration 54 III.3.7 Data analysis 55 IV RESULTS 57 IV.1 The Process of Adapting and Validating the Vietnam Active Aging Index 57 IV.1.1 Content Validity 57 IV.1.2 Test-retest Reliability 58 IV.1.3 Internal Consistency 59 IV.1.4 Construct Validity 61 IV.1.5 Concurrent Validity 66 IV.2 Current Status of Vietnam AAI in comparison with other 31 countries 67 IV.2.1 Current status of Vietnam AAI 67 IV.2.2 Vietnam AAI in Comparison with other 31 Countries 70 IV.3 Determinants of Active Aging 73 vii doi:10.6342/NTU201901838 IV.4 Potential Benefits of Active Aging 75 V DISCUSSION 79 V.1 Adaptation and Validation of Vietnam Active Aging Index 79 V.1.1 Indicator Modified 79 V.1.2 Indicators or Questions Added 80 V.1.3 Questions Removed 80 V.1.4 Similarities and Differences from the EUAAI 81 V.2 Vietnam AAI in Comparison with China, Korea, Taiwan and 28 EU Countries 82 V.2.1 Overall VAAI 82 V.2.2 Domain 1: Employment 83 V.2.3 Domain 2: Social Participation 84 V.2.4 Domain 3: Independent, Healthy and Secure Living 88 V.2.5 Domain 4: Capacity and Enabling Environment for Active Aging 91 V.2.6 Gender Inequality in Active Aging Index 92 V.3 Determinants of Active Aging 94 V.4 Potential Benefits of Active Aging 97 V.5 Strengths of This Study 100 V.6 Study’s Limitations and Implications for Future Research 101 VI CONCLUSION 103 REFERENCES 106 APPENDICES 114 Table 15 Definitions of selected indicators for the EU-AAI (the differences with VAAI version are in italic) 115 Table 16 Definitions of selected indicators for Vietnam AAI (the differences with EU version are in italic) 116 Table 17 Test-retest reliability coefficients for VAAI_V2 questions (n = 40, duration = weeks) 117 Table 18 Overall and domain-specific AAI and ranking among 32 countries (region) 119 The Vietnamese Questionnaire for This Study 120 Clinical Frailty Scale 129 Experts’ Profile (TUMP: Thai Nguyen University of Medicine and Pharmacy) 130 List of Translators 130 Approval Decisions for Research Ethics in Taiwan and Vietnam 131 Published paper on Journal of Aging and Health 134 viii doi:10.6342/NTU201901838 LIST OF FIGURES Figure Determinants of active aging – page 19, Active Aging: A policy framework (WHO, 2002a) 15 Figure conceptual framework of this study 27 Figure Translation process 29 Figure The process of adaptation and validation of the VAAI 33 Figure Thai Nguyen position on Vietnam's map (Source: Thainguyen.gov.vn) 34 Figure Study locations 40 Figure Sampling procedure for the field study 43 Figure Active Aging Index developed by Active Aging Index project (2012) 44 Figure Original four-factor model (n = 804) 64 Figure 10 Five-factor model guided by rotated EFA (n= 804) 65 Figure 11 Five-factor model with at least three indicators per latent variable (n = 804) 66 Figure 12 Domain-specific contributions to AAI in Vietnam compared with China, South Korea, Taiwan, and the average of 28 EU countries 70 Figure 13 Overall AAI scores for males, females, and both among 32 countries 71 Figure 14 Scores for Employment; Social participation; Independent, healthy and secure living; and capacity and enabling environment for active aging among 32 countries 72 Figure 15 predetermined sampling for each province 114 ix doi:10.6342/NTU201901838 141 doi:10.6342/NTU201901838 142 doi:10.6342/NTU201901838 143 doi:10.6342/NTU201901838 144 doi:10.6342/NTU201901838 145 doi:10.6342/NTU201901838 146 doi:10.6342/NTU201901838 147 doi:10.6342/NTU201901838 148 doi:10.6342/NTU201901838 149 doi:10.6342/NTU201901838 150 doi:10.6342/NTU201901838 151 doi:10.6342/NTU201901838 152 doi:10.6342/NTU201901838 153 doi:10.6342/NTU201901838 154 doi:10.6342/NTU201901838 155 doi:10.6342/NTU201901838