STUDY OF FACTORS INFLUENCING THE THAI
ELDERLY ON HERBAL MEDICINE CONSUMPTION
CHOMMANARD SUMNGERN
Tese de Doutoramento em Ciências de Enfermagem
STUDY OF FACTORS INFLUENCING THE THAI ELDERLY ON
HERBAL MEDICINE CONSUMPTION
Tese de Candidatura ao grau de Doutor em
Ciências de Enfermagem submetida ao
Instituto de Ciências Biomédicas Abel Salazar
da Universidade do Porto.
Major advisor/Orientador
Doutora Zaida de Aguiar Sá Azeredo, MD.
Ph.D
Professora Auxiliar
Instituto
de
Ciências
Biomédicas
Abel
Salazar, Universidade do Porto, Portugal
Co-advisor/Co-orientadores
Doutor Anake Kijjoa, Ph.D
Professor Catedrático
Instituto
de
Ciências
Biomédicas
Abel
Salazar, Universidade do Porto, Portugal
Doutora Rarcharneeporn Subgranon, Ph.D
Assistant Professor
Faculty of Nursing, Burapha University,
Thailand
ACKNOWLEDGEMENTS
I would like to express my gratitude to all those who have given me the
possibility to complete this thesis. First and foremost I am heartily thankful
to my supervisor, Professor Dr. Zaida de Aguiar Sá Azeredo, whose help,
stimulating suggestions, encouragement, guidance and support from the
beginning to the end level enabled me to develop an understanding of the
study. I am indebted to my co-adviser, Professor Dr. Anake Kijjoa, for his
valuable hints and encouragement. His collaboration between Burapha
University and University of Porto has provided me an opportunity to study
in the doctoral program. I also wish to thank his wife, Professor Dr.
Madalena Pinto, for her kindness. My sincere appreciation goes to
Assistant Professor Dr. Rarcharneeporn Subgranon, Dean of the Faculty of
Nursing, Burapha University, for her valuable advice and support including
the opportunity for me to study at the University of Porto, as well as her
supervision during the data collection processes in Thailand.
I am grateful to Professor Dr. Antonio Sousa Pereira, Director of the
Institute of Biomedical Science of Abel Salazar (ICBAS) for endorsing the
MOU and for providing logistical support during my study at ICBAS.
It is honour for me to thank Professor Dr. Pichan Sawangwong, Vice
President of International Affairs of Burapha University, Thailand, for his
support and encouragement have helped me to study at the University of
Porto.
I am also deeply grateful to Professor Dr. Corália Vicente, the Director of
the Ph.D Nursing Science Program, Institute of Biomedical Science of Abel
Salazar (ICBAS), University of Porto for her unconditional support. Her help
and encouragement have made me feel like I have home away from home
during my study in Porto.
I also wish to thank and appreciate the kindly support to Professor Dr.
Guilherme Gonçalves for his support at the Community Health
Department, Institute of Biomedical Science of Abel Salazar (ICBAS),
University of Porto. I have furthermore to thank Dr. Eduarda Matos for her
statistical suggestion, her company and support. As well, I appreciate the
friendship and support from Dr. Madalena Tamames and Professor Dr.
João Amado.
My special thanks and appreciation go to Assistant Professor Narirat
Sungvorawongphana, Instructor of the Gerontological Nursing Department,
Burapha University for her constant friendship, valuable advice, and
encouragement. I also wish to thank Assistant Professor Dr. Pornchai
Jullamate for his valuable support giving me an opportunity to study at
ICBAS.
I would like to acknowledge the scholarship from Faculty of Nursing and
the Office of International Relations of Burapha University. I also wish to
acknowledge Department of Mental Health, Ministry of Public Health of
Thailand for giving me permission to use the THI-15 and SPST-20 research
instruments in this study.
I wish to thank Professor Dr. John Bulger for his valuable support in
revising the English language of all my work.
I am also indebted to many of my colleagues in the Faculty of Nursing,
Burapha University who have taken on my responsibility during my
absence. As well, I greatly appreciate my friends in Thailand and Porto for
their friendship and encouragement.
I would like to thank municipality authorities of the districts of Chonburi
Province for their support and the elderly participants for their kindness
and collaboration.
I would like to thank my parents and my family for their love, support and
encouragement for me to pursue this degree. I am indebted to my
husband and his family, for his time caring for the family which gave me
the opportunity to finish my Ph.D.
Lastly, I offer my regards and blessings to all of those who supported me
in any way during my study at ICBAS.
Abstract
Herbal medicines can be important items to promote the health of
the Thai elderly because those people have grown up using them. Most
herbs are safe, but some can cause adverse effects. Based on
h
as a practical research model, as well other health
promoting concepts, we have tried to encourage the self empowerment
and better life styles of the Thai elderly. The cross sectional study was
done in Chonburi Province the communities, Eastern Thailand. The
objectives were: (1) to explore the reasons why the Thai elderly consumed
herbal medicines, (2) to study the conditions contributing to or limiting the
happiness or well being in the Thai elderly in different regions, (3) to
determine the significant predictors of knowledge of herbal medicine
consumption, (4) to elaborate the enhancing knowledge model from
predictors of knowledge of herbal medicine consumption, and (5) to prove
if the enhancing knowledge model fits well with data of this study (the
Goodness of fit). To support the objectives, mixed methods research
design was used including qualitative and quantitative studies. In the first
period, the quantitative design was used to determine factors contributing
the happiness among the 306 elderly in community. As well, the
qualitative study was performed by using interviews, 70 cases during
February and March 2007 to gain primary data and to develop a framework
for the second study. In the second period, the quantitative research
design was performed among the 419 Thai elderly; data collection was
done during July and August 2008.
A structural equation model was tested, and the results confirmed
that the diagram of pathways of factors influencing knowledge of herbal
medicine consumption among the Thai elderly fitted well with the data set
of the study. According to direct paths, (i) social support, and mass-media
(especially outdoor poster/billboard advertisements) significantly predicted
practice, and practice significantly predicted knowledge, (ii) perceived
constraints of herbal medicine consumption and mass-media (especially
outdoor poster/billboard advertisements) predicted knowledge, and (iii)
social support predicted practice. Considering indirect paths, social
support
and
mass-media
(especially
outdoor
posters/billboard
advertisements) predicted knowledge.
Model enhancing knowledge of herbal medicine consumption and
the pathways of influencing factors to promote knowledge may serve as
initial information to create the interventions and strategies of promoting
healthy lifestyle behaviours among the elderly and their families which are
appropriate for their cultures and individual characteristics.
Most of the elderly believe in the benefits of herbal medicines and
they use them not only as traditional medicines but also as nutritional
supplements and food flavorings. In spite of their potential side effects,
healthcare professionals must update their own knowledge of the
combined effects of herbal medicines and conventional medicines on the
elderly. It is important that healthcare professionals question the elderly
and their families on how they use the herbal medicines and what benefits
they believe they get.
The education intervention for both healthcare providers and the
elderly are recommended to promote the best benefits of herbal medicine
consumption among the elderly and also decrease the gap between
acceptance and knowledge of herbal medicine among healthcare
professionals.
Resumo
O uso de ervas medicinais é muito frequente na Tailândia devendo, por isso, utilizar-se este facto para promoção da saúde. Esta dissertação teve como objectivos: conhecer o uso de ervas medicinais pelos Tailandeses bem como estudar os conhecimentos que possuem acerca delas; estudar factores que afectem o bem-estar e a felicidade dos mesmos; a elaboração de um modelo que promova o conhecimento do uso de ervas medicinais
Para o efeito foram elaborados 3 estudos em dois tempos. Num primeiro tempo foram efectuados dois estudos (um qualitativo e outro quantitativo), que foram aplicados respectivamente em 70 e 306 idosos de ambos os sexos na província de Chonburi (Tailândia).) Num segundo tempo realizou-se um estudo quantitativo em 419 idosos, residentes na mesma província, De acordo com os resultados o suporte social bem como os mass-media estavam associados a uma boa prática. O conhecimento sobre as ervas medicinais bem como sobre os seus efeitos secundários também estava associado a uma boa prática.
Baseado nos resultados foi criado um modelo de promoção da saúde em que conhecimento, comportamentos, estilos de vida e características individuais bem como a cultura, são factores importantes na implementação de estratégias de educação para a saúde.
Assim recomenda-se uma intervenção educativa quer nos profissionais da saúde quer nos idosos e suas famílias afim de serem promovidos os benefícios do consumo de ervas medicinais entre os idosos e de haver um melhor conhecimento, uma maior compreensão e aceitação por parte dos profissionais.
RESULTS FROM THIS THESIS HAVE BEEN PUBLISHED AND PRESENTED AS
COMMUNICATIONS IN THE FOLLOWING JOURNALS AND CONFERENCES
Published articles
Sumngern, C., Azeredo, Z., Subgranon, R., Sungvorawongphana, N., & Matos, E. (2010). Happiness among the elderly in communities: A study in senior clubs of Chonburi Province, Thailand. Japan Journal of Nursing Science, 7, 47-54. Sumngern, C., Azeredo, Z., Subgranon, R., Matos, E., & Kijjoa, A. (2011). The
perception of the benefits of herbal medicine consumption among the Thai elderly. The Journal of Nutrition, Health & Aging, 15(1), 59-63.
Oral communication
Sumngern, C., Azeredo, Z., Kijjoa, A., Subgranon, N.,Sungvorawongphana, N., Matos, E. Herbal medicine consumption in Thailand. The First European -28 September, 2008. Porto, Portugal.
Poster communication
Lila, C., Azeredo, Z., Kijjoa, A., Subgranon, R., & Sungvorawongphana, N. Why do the Thai elderly consume herbal medicines?. The VI European Congress of Gerontology. 5-8 July, 2007. St. Petersburg, Russia.
Sumngern, C., Azeredo, Z., Subgranon, R., Sungvorawongphana, N., & Matos, E. Happiness among the elderly in communities: Thai Happiness Indicators; THI-15. The European General Practice Research Network (EGPRN). 7-10 May, 2009. Bertinoro, Italy.
Sumngern, C., Azeredo, Z., Kijjoa, A., Subgranon, R., & Sungvorawongphana, N. The elderly perspective about constraints on using herbal medicine. The III FORUM NACIONAL: envelhecimento, Familia, Longevidade e Qualidade de Vida na Terceira Idade. 30 June, 2009. Porto, Portugal.
Sumngern, C., Azeredo, Z., Kijjoa, A., Subgranon, R., & Sungvorwongphana. Herbal medicines following the elderly perspective: food, nourishment and medicine. The 19th IAGG World Congress of Gerontology and Geriatrics. 5-9
July, 2009. Paris, France.
Sumngern, C., Azeredo, Z., Subgranon, R., Sungvorawongphana, N., & Matos, E. Contenment among the elderly in communities: the happiness; THI-15. The 19th
IAGG World Congress of Gerontology and Geriatrics. 5-9 July, 2009. Paris, France.
Sumngern, C. Azeredo, Z., Subgranon, R., Matos, E., & Sungvorawongphana. The elderly: Their self-efficacy and happiness. The IV Jornadas Nortenhas de Psicologia: em torno da Escola, Familia, Justiça, Saúde e Stress. 7 October, 2009. Porto, Portugal.
Sumngern, C., Azeredo, Z., Matos, E. Stress e estratégias de coping em idosos tailandeses. The VI Jornadas Nortenha de Psicologia: Em torno da escola, família, saúde e stress. 28 February, 2011. Porto, Portugal.
SIGNS AND ABBREVIATIONS
AAMA - American Alternative Medicine Association
AAT - Animal-assisted therapy
AHG - American Herbalists Guild
B.E - Buddhist Era
e - Latent variable(s) which were fixed the variance in path
coefficients leading to knowledge of herbal medicine consumption
EVT - Expectancy-value theory
Min - Minimum value
Max - Maximum value
HPM - Health Promotion Model (revised) of Pender J Nola (1996)
MoPH - Ministry of Public Health, Thailand
N, n - Sample size
NGOs - Non-governmental organization
NIC - Newly Industrialized Country
p - Item difficulty value
p-value - Probability of obtaining a test statistic at the significant level 0.05, 0.01, and 0.001
QOL - Quality of Life
Q-Q Plot - An inspection of the probability plots
r - Discrimination value
r - Cronbach´s alpha value, Pearson product-moment
correlation coefficient
R2 - Squared multiple correlation
SD - Standard deviation
SE - Standard error
SWB - Subjective well-being
TGRI - The Foundation of Thai Gerontology Research and
Development Institute
TTM - Thai Traditional Medicine
WHO - World health Organization
CONTENTS
Page
ACKNOWLEDGEMENTS III
ABSTRACTS V
SIGNS AND ABBREVIATIONS X
INTRODUCTION 1
PART I LITERATURE REVIEW 4
1. The elderly definition, ageing theories, and the elderly population 5
1.1 The Elderly definition and ageing theories 5
1.2 The elderly population 11
2. Health promotion in the elderly 13
2.1 Health: definition and determinants of health 13
2.2 The elderly and health 16
2.3 The Thai elderly and their health 17
2.4 Health promotion 19
2.4.1 The concepts of health promotion 20
2.4.2 Health promotion in Thailand and health promotion in the Thai elderly
28 2.4.3 Influencing factors of health promotion in the Thai
elderly
33
3. Culture and health 34
3.1 Characteristics of culture 34
3.2 Thai cultures related to health 35
3.2.1 Religion and the elderly health 36
3.2.2 Traditions and beliefs related to health 37
3.2.3 Thai food and health 38
3.2.4 Thai Traditional Medicines (TTM) 39
3.2.5 The Thai elderly and the use herbal medicines 45
PART II RESEARCH
Tittle: Study of factors influencing the Thai elderly on herbal medicine
consumption
47
1. Research questions 48
2. Objectives 49
CONTENTS (Cont.)
Page
4. Research hypotheses 49
5. research setting and information of study areas 50
6. Ethical approval 55
7. Limitations of the study 55
8. Study flows of research project 56
STUDY PERIOD I
WHY THE THAI ELDERLY CONSUME HERBAL MEDICINE AND WHAT THE INFLUENCING FACTORS OF WELL-BEING AMONG THE THAI ELDERLY ARE
58
STUDY I WHY THE THAI ELDERLY CONSUME HERBAL MEDICINES 59
Objective 59
Hypothetical framework of the Study I 59
Operational definitions 60 Methodology 62 Research instruments 63 Data collection 64 Data analysis 64 Results 64
1) General characteristics of the participants 65
2)The definitions of herbal medicines according to the elderly perception
67
3) How the elderly knew and learnt to use herbal medicines 70
4) The effects of herbal medicines according to the elderly perception
72 5) Herbal medicine preparation according to the elderly
experiences
76
6) Herbal medicine prices and their accessibility 78
7)The medicinal herbalist characteristics according to the elderly perception
80
Discussion 83
CONTENTS (Cont.)
Page STUDY II WHAT THE INFLUENCING FACTORS OF WELL-BEING
AMONG THE THAI ELDERLY ARE
87 Objective 88 Methodology 88 Research instrument 89 Data collection 90 Data analysis 90 Results 90 Discussion 95 Conclusions 99 STUDY PERIOD II
THE PREDICTIVE FACTORS OF KNOWLEDGE OF HERBAL MEDICINE CONSUMPTION AMONG THE THAI ELDERLY
101
STUDY III THE PREDICTIVE FACTORS OF KNOWLEDGE OF HERBAL
MEDICINE CONSUMPTION AMONG THE THAI ELDERLY
102
Objectives 102
Hypothetical framework of the Study III 102
Operational definitions 104 Methodology 107 Research instruments 109 Data collection 123 Data analysis 124 Results 125
1) The reliabilities of the scale instruments 125
2) General characteristics of the participants 126
3) Body Mass Index (BMI) among the elderly 128
4) Functional abilities of the elderly 131
5)The affective function among the elderly 136
6) Self-efficacy and self-regulation among the Thai elderly 144
7) Health status and how they took care and treated
themselves
CONTENTS (Cont.)
Page
8) The perception of the benefits and constraints of herbal
medicine consumption
156
9) Social support of the elderly 164
10) Knowledge and practice of herbal medicine consumption
among the elderly
167
Discussion 174
PART III PREDICTIVE MODELS AND PATHWAYS OF INFLUENCING FACTORS OF KNOWLEDGE ON HERBAL MEDICINE CONSUMPTION AMONG THE THAI ELDERLY
191
1. Predictive models of knowledge of herbal medicine consumption among the Thai elderly
192
1.1 Assumptions of Multiple regression analysis 194
1.2 The correlation between knowledge of herbal medicine consumption and independent variables
203 1.3 The predictors of knowledge of herbal medicine
consumption
206 1.3.1 The first step analysis using multiple regression to
determine the significant variables
206 1.3.2 The second step analysis using multiple regression to
determine significant variables when biological, social-cultural and health status were controlled variables
213
2. Elaborated path diagram of factors influencing Thai elderly on herbal medicine consumption
215
3. Test of Goodness of fit of the model 221
Discussion 222
Conclusions 224
CONCLUSIONS AND RECOMMENDATIONS 225
Conclusions 226
Recommendations 227
CONTENTS (Cont.)
Page
APPENDIX 248
APPENDIX I Reprint of the publication in the Japan Journal of Nursing Science
249 APPENDIX II Reprint of the publication in the Journal of Nutrition,
Health & Aging
258
APPENDIX III Poster presentation 264
APPENDIX IV Oral presentation 271
APPENDIX V Permission grant for Review of Human Subjects Research
278 APPENDIX VI The permission grant and related documents to use
the standard assessment tools
279 - The permission grant to use the Thai Happiness Indicators
(THI-15) and the Saunprung Stress Test-20 (SPST-20)
279
- Source of information of General Self-efficacy scale 281
- Source of information of self-regulation scale 282
APPENDIX VII Research informed consent form 283
APPENDIX VIII Research instruments 284
Study I Research instrument 284
Study II Research instrument 290
Study III Research instruments 294
INDEX OF TABLES
Table Page
PART I LITERATURE REVIEW
1 Summary of biological theories of ageing 6
2 Retardants of the ageing process following the biological theories of aging
8
3 Sociological theories of ageing 8
4 Psychological theories of ageing 9
5 Distribution of life expectancy (years) at birth of the population of the World, South-eastern Asia and Thailand
13
6 The population dependency of Thailand 18
7 Percentages of older persons who access health welfare
classified according to age groups and types of health welfare
19
8 Summary of theories: focus of health promotion 20
9 The distribution of the Thai population by religion from National Statistical Office, Thailand: The 2008 Survey on Conditions of Society, Culture and Mental Health
36
PARTII RESEARCH
10 The population break down of Chonburi Province in the year
2004 by gender
52
11 The population proportion by gender of Chonburi Province
in the year 2005 by gender
52 12 The population information of districts of Chonburi Province
in the year 2002
53 13 Community characteristic of study areas: rural, suburban,
and rural
54
PART II STUDY I
14 Characteristic of Participants- Thai Community Elderly 65
15 Health perception and their health management 66
16 Types of medicine consumption that they preferred when
they got sick by areas of living
67
17 The reasons why the elderly preferred to consume herbal
medicines
INDEX OF TABLES (Cont.)
Table Page
19 The cautions of herbal medicine consumption 75
20 Herbal medicine preparations for consuming as traditional
medicines
77
21 Sample of fresh herbs that were named from the participants 77
22 The frequency of herbalist characteristics following the elderly perception (multiple responses, N = 70)
81 PART II STUDY II
23 Distribution of demographic data
(N = 306)
9124 Distribution of people by happiness levels and regions 92
25 Distribution of population by happiness and educational
levels
92
26 Distribution of population by happiness level and occupation 93
27 Distribution of frequencies of the important things making the happiness in the elderly
94 PART II STUDY III
28 The interpretation of the reliability considering the Cron
111 29 Item difficulty and item discrimination of knowledge of
herbal medicine consumption test
121
30 The if Item Deleted of herbal medicine
consumption test
122
30a Distribution of the participants by regions 124
31 Reliability of the scale research instruments after data collection (N = 419)
125
32 Characteristics of Participants- Thai Community Elderly 126
33 The prevalence of body mass index (BIM) among the elderly 128
34 Body mass index by the elderly characteristics (n = 398) 129
35 The scores of body mass index among groups: gender, age,
and areas of living
131 36 The prevalence of Barthel Index of Activities of Daily Living
(ADLs) and Instrument Activity Daily Living (IADL) scores among the elderly
INDEX OF TABLES (Cont.)
Table Page
37 Number and percentage of the elderly by functional abilities considering by instrumental activities of daily living (IADL)
133
38 Number and percentage of participants by each item of
Barthel Index of Activities of Daily Living (ADLs)
134
39 The prevalence of the happiness levels among the elderly 138
40 The Distribution of people by happiness levels and regions (N = 416)
138
41 The scores of happiness among groups: gender; education
levels; marital status; health status; income perception; working status; and areas of living
139
42 The prevalence of the stress total scores among the elderly
(n = 419)
141 43 The prevalence of the stress total scores considering Mean
and SD
142
44 Stress levels of the participants by area of living 142
45 The scores of stress among groups: education levels,
number of mass media, income perception, working status, and areas of living
143
46 The prevalence of the self-efficacy total scores considering the median
144 47 The scores of self-efficacy among groups: age, marital
status, education levels, number of mass media, income perception, working status, living arrangements, and health status
145
48 The prevalence of the self-regulation total scores considering Median
147
49 The scores of self-regulation among groups: age, education
levels, working status, income perception, amount of mass media, health status, and stress levels
148
50 Distributions of participants by their characteristics and gender
150
INDEX OF TABLES (Cont.)
Table Page
52 The odds ratios for logistic regression analysis of
characteristics the older people having fair to poor health perception (N = 419)
153
53 Prevalence of types of medicine consumption by health
status perception (N = 419)
155
54 The frequency of types of herbal preparations (N = 419) 155
55 The prevalence of the perception of the benefits of herbal medicine consumption based on the median
157 56 The frequency of sources of information regarding herbal
medicine use
157
57 Distribution of percentage regarding agreement levels on
benefits of herbal medicine consumption (N = 419)
158 58 Distribution of older people by strong agreement levels
(level of agreement = 4) on the perception of benefits of herbal medicine consumption based on health status (N = 419)
159
59 The scores of perception of benefits of herbal medicine consumption among groups: education levels; income perception; verbal discussion; happiness levels; and stress levels
160
60 The prevalence of the perception of the constraints of herbal medicine consumption total scores considering the median
162 61 Distribution of percentage in agreement levels of constraints
of herbal medicine consumption (N = 413)
162 62 The scores of perception of the constraints of herbal
medicine consumption among groups: health status, areas of living, and mass-medium (television) of herbal medicine information
163
63 The prevalence of the social support scores among the
elderly
165
64 The scores of social support among groups: age, education
levels, working status, income perception, number of mass media, health status
INDEX OF TABLES (Cont.)
Table Page
65 The prevalence of the practice total scores of herbal medicine consumption considering the median
168
66 The scores of practice of herbal medicine consumption
among groups: age, education levels, living arrangements, health status, and types and numbers of mass-media of herbal medicine information
168
67 The prevalence of the knowledge total scores of herbal medicine consumption considering Median
171
68 The scores of knowledge of herbal medicine consumption
among groups: education levels, living arrangements, and mass media of herbal medicine consumption
172
PART III PREDICTIVE MODELS AND PATHWAYS OF INFLUENCING FACTORS OF KNOWLEDGE ON HERBAL MEDICINE CONSUMPTION AMONG THE THAI ELDERLY
69 The values of Mean and 5 % Trimmed Mean of the scale
variables
195 70
Correlation between knowledge of herbal medicine
consumption and the influencing variables
204
71 Model summary of influencing factors of knowledge of
herbal medicine consumption (p < 0.05)
208
72 Model summary of influencing factors of knowledge of
herbal medicine consumption when biological factors (age, BMI, ADL, IADL), socio-cultural factors (education, marital status, income perception), and health status were
controlled
214
73
Standardized regression weights among group of
variables of Just Identified Model
217
74
Squared multiple correlations of Just Identified Model
217 75Standardized direct effects (beta), standardized indirect
effects, and standardized total effects of Just Identified
Model
INDEX OF TABLES (Cont.)
Table Page
76
Standardized regression weights among group of
variables of Over Identified Model
220
77
Squared multiple correlations of Over Identified Model
220 78Standardized direct effects (beta), standardized indirect
effects, and standardized total effects of Over Identified
Model
INDEX OF FIGURES
Figure
Page
PART I LITERATURE REVIEW
1 Percentages of older ages (60 year or older): World, South-eastern Asia, Thailand, 1950 2050.
12 2 Actual age profiles of the population of Thailand in 1960,
1980 and 2000, and projected profile in 2020.
12
3 Health determinants (WHO, 2011) 15
4 A conceptual framework for health determinants of
Australia in 2006
15
5 Health determinants of Canadian Elderly in 1993 16
6 Conceptual Model of social cognitive theory 21
7 Health Promotion Model (revised) of Pender J Nola (1996) 23
8 Timeline of activities regarding aging population in Thailand
30 9
the Ministry of Public Health, Thailand in 2002
32
10 The conceptions of causes of illness among Thai people 41
11 Influencing factors of cause of illness related to Thai Traditional Medicine
42 PART II RESEARCH
12 Map, flag and emblem of Thailand 50
13 Maps of the Eastern Thailand and Chonburi Province 51
14 Map of the districts of Chonburi Province 51
15 The categorized districts in Chonburi Province by areas 55
16 The processes of the study of the research project 57
PART II STUDY I
17 Hypothetical framework of the study I 60
18 Multi-stage sampling in research design to choose the
participants in Study I
63 PART II STUDY II
19 Multi-stage sampling of research design to choose the
participants in study II
INDEX OF FIGURES (Cont.)
Figure
Page
PART II STUDY III
20 Hypothetical framework of Study II 103
21 Multi-stage sampling in research design to choose the
participants
109
22 The correlation between the Suanprung Stress Test-20:
SPST-20 and Screening Stress Test
118
23 Frequency distribution of Body Mass Index scores 128
24 Frequency distribution of Activities of Daily Living scores (ADLs) and ADL levels (n = 416)
132 25 Frequency distribution of Instrument Activity Daily Living
(IADL) (n = 417)
132
26 Frequency distribution of happiness total scores 137
27 Frequency distribution of stress total scores and stress levels (n = 413)
141
28 Frequency distribution of self-efficacy total scores 144
29 Frequency distribution of self-regulation total scores 147
30 Frequency distribution of total scores of perception of the benefits of herbal medicine consumption
156 31 Frequency distribution of perception of the constraints
total scores of herbal medicine consumption
161 32 Frequency distribution of social support total scores and
social levels
164 33 Frequency distribution of total scores of practice of
herbal medicine consumption
167
34 Frequency distribution of knowledge total scores of
herbal medicine consumption
170 PART III PREDICTIVE MODELS AND PATHWAYS OF
INFLUENCING FACTORS OF KNOWLEDGE ON HERBAL MEDICINE CONSUMPTION AMONG THE THAI ELDERLY 35 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of knowledge of herbal medicine consumption scores
INDEX OF FIGURES (Cont.)
Figure
Page
36 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and Boxplot of Activity Daily Living (ADL) scores
196 37 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of Instrument Activity Daily Living (IADLs) scores
197 38 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of self-regulation scores
198 39 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of self-efficacy scores
198 40 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of happiness scores
199 41 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of stress scores
200 42 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of perceived benefits of herbal medicine consumption scores
200
43 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and Boxplot of perceived constraints of herbal medicine consumption scores
201
44 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and Boxplot of social support scores
202 45 Normal Q-Q Plot, Detrended Normal Q-Q Plot, and
Boxplot of practice of herbal medicine consumption scores
202
46 The levels of correlation between knowledge of herbal
medicine consumption (HCM) and its influencing factors
205 47 Model 1 209 48 Model 2 209 49 Model 3 210 50 Model 4 211 51 Model 5 212
INDEX OF FIGURES (Cont.)
Figure
Page
53 Final model when Biological factors (age, BMI, ADL, IADL), socio-cultural factors (education, marital status, income perception), and health status were controlled
215
54 Model 1- Input diagram of Just Identified Model of influencing factors of Thai elderly on herbal medicine consumption
216
55 Model 1- The output diagram of Just Identified Model of
influencing factors of knowledge of herbal medicine consumption (Standardized estimates)
218
56 Model 1- The output diagram of Just Identified Model of
influencing factors of knowledge of herbal medicine consumption (Unstandardized estimates)
218
57 Model 2- Input diagram of Over Identified Model of
influencing factors of Thai elderly on herbal medicine consumption
219
58 Model 2- The output diagram of Over Identified Model of
influencing factors of knowledge of herbal medicine consumption (Standardized estimates)
220
59 Model 2- The output diagram of Over Identified Model of
influencing factors of Thai elderly on herbal medicine consumption (Unstandardized estimates)
INTRODUCTION
Ageing societies seem to be developing all over the world. By 2020, more than one billion people worldwide will be age 60 years or over (DerMarderderosian & Briggs, 2006). At the present Thailand is experiencing a ser
developing world. In South-East Asia, Thailand ranked as the second most aged country next to Singapore (United Nations Population Fund, 2006). The proportion of the elderly population is expected to increase from 8.7% in 2000 to 10.8% in 2010, 15.2% in 2020 and 29.6% in 2050 respectively (WHO, 2003). This means that Thailand will become an ageing society within the next decade and there is little time to cope with this significant situation and to properly design strategies for the consequences.
Thai policies regarding aging follow the guidelines of the World Health Organization (WHO) to promote its own policy framework of active ageing (WHO,
health promotion strategy
governmental health budget, which will be a result of the ageing tendency in Thai population. One part of these policies is to support the Thai Traditional Herbal Medicine Therapy as it seems to be a cheap and effective way to maintain good health and to decrease health problems. Herbal medicines have been popular among the elderly and their families as typical traditional household treatments from ancient t
care system had become more self-reliant and cost-effective by looking back at Thai wisdom regarding health care and acknowledged the role of TTM such as herbal medicines.
WHO (2002) defined complementary and alternative medicine (CAM) (also called non-conventional medicine)
Also, WHO defined the t
health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination, to treat, diagnose and prevent illnesses or maintain
well-are worldwide used. Weiss (2001)defined herbal medicines or phytotherapy as a science of using herbal remedies to treat the sick.
Herbal Medicine was defined as plant-derived materials or products with therapeutic or other human health benefits containing either raw or processed ingredients from one or more plants (WHO, 1998). It seems that the herbal consumption is increasing in several countries. Johnson et al. (2008) reported that more than 70 % of Canadian have used natural products. In the United States, the increased use of alternative or unconventional therapies including herbal medicine has been reported: Eisenberg et al (1998) referred to that increase from 33.8% in 1990 to 42.1% in 1997. In 1993, Eisenberg et al., in their study, indicated that one in three respondents (34%) reported using at least one unconventional therapy in the past year. In 2004, Mikhail, Wali, & Ziment, said that 63% of respondents were using or have used one or more types of alternative medicines, herbs being the most commonly reported. Whereby, the herbal market in the United States has been increased rapidly (DerMarderosian & Briggs, 2006). As Eisenberg et al (2001) cited by DerMarderosian and Briggs (2006) mentioned that, in USA, sales have increased nearly 20% annually in recent years.
In Thailand, the popularity of herbal utilization has increased very much during the past decade (Riewpaiboon, 2006), not only for its health and economic values but also because they are promotedand advertised. Thai herbal medicines have been officially and commercially encouraged to promote health and prevent illness in primary health care systems. Some herbal products are already incorporated into the National Essential Drug List (Riewpaiboon, 2006; WHO, 2005).
Thailand which has ancient records of its long tradition of collection and preparation of herbs in food and medicines continuing to pass on this culture by oral communication and books to the younger generation from the elderly, herbalists, monks, and other professional knowledgeable individuals (doctors, pharmacists, nurses, etc.). These preparations can also be found in herbal medicine shops where we can find specific prepared potions. Most popular herbs used among Thai population are Adaptogens. These natural substances are believed to help the body to adapt to stress, support and/or restore normal metabolic functions and balance (Winston & Maimes, 2007).
The Thai elderly populations also consume other herbs for many reasons. The consumers are very satisfied with the benefits they get out from using them, but often they are less concerned about the possible toxicity that can show up taking this herbs, especially as a consequence of the quite wide spread attitude, that increasing the dose would intensify the positive effects. As it could have
been shown already in some studies, Hepatotoxicity may be one of the most frequent and most dangerous adverse reactions which can even lead to liver cirrhosis or hepatic failure.Moreover, it seems that Western countries start to be more and more popular among Westerners. These countries have already established strict laws in handling these kinds of medicines: the manufacturing, the purification of the ingredients, the distribution, the prescription and observation by a doctor are regulated by juridical conventions; on that way, the abuse and the negative side-effects could be effectively reduced.
The understanding of how the elderly perceive, define, prepare herbal medicines will not only provide the appropriate manner to care for the elderly, themselves and/or caregivers to use the herbal medicines in proper ways for better health, but also encourage health care professionals who can inform and encourage the elderly to use the most beneficial herbal medicines.
The purposes of this research were to examine the nature of the Thai elderly about their herbal medicine consumption, the value of the elderly experiences, and through knowledge, to develop a better understanding of the factors of herbal medicine consumption including studying what the influenced factors contributing well-being among Thai elderly in communities. The conceptual framework will be developed for health promoting model. Finally, the model will be proved if it fits well with data of this study.
The thesis is divided into three parts. The first part (literature review) including concepts about the elderly and ageing, health, health promotion, and culture related to health (religion, beliefs, food and traditional medicine). In the second and the third parts (empirical part) presented the mixed method study (qualitative and quantitative studies) which the last part presented the models and pathways to enhance knowledge of herbal medicine consumption among the Thai elderly. Finally, the conclusions and suggestion for the future are showed at the end.
PART I
LITERATURE REVIEW
This part includes the literature reviews as follows:
1. The elderly definition, ageing theories and the elderly population 1.1 The elderly definition and ageing theories
elderly old age older people ageing;
aging erontologists in many studies both with scientific and
humanistic perspectives.
elderly
as the ones who have the chronological age of 65 years or over while this definition often has been associated with the age at which one can start to receive the pension benefits: at this moment, there is no standard numerical criterion, but the United Nations agreed the cutoff could be 60 years or over to referring to the older population (WHO, 2011). In Thailand, especially following the Elderly Act, 2003 and commonly used cutoff age by the Thai government in official documents and in research, the definition of the elderly refers to those who are 60 years and older and holds Thai nationality (Fujioka & Thangphet, 2009; Jitapulkul & Wivatvanit, 2009; Knodel & Chayovan, 2011).
From Miller (2004), ageing was defined objectively, subjectively and functionally. Objectively, ageing is the length of time that has passed since one´s birth. Subjectively, people define ageing in terms of personal meaning and experiences while functional age is related to individual factors that can contribute to society and benefit others and themselves. The concept of functional age has been used worldwide but its meaning varies in different cultures. In addition, the trend to divide older people into chronological subcategories is being used more often such as young-old, middle-old and old-old subgroups which is associated with the benefits from the government that should support the elderly as to their needs in their subcategory. The old-old age may need complicated or more expensive medical treatments to maintain or improve their health status. In any case, the concept of a functional definition has been considered and used by gerontologists considering the important indicators of physiological health, psychological well-being, socioeconomic factors and ability to go on functioning and socializing.
Ageing can be viewed as incorporating aspects of biological, social, psychological, functional and spiritual domains. There are many theories to explain how ageing occurs, and the related changes in ageing. Lueckenotte (1996) summarized the definition of ageing related to the ageing theories as the boxes below.
Source: Modified from Lueckenotte, A.G. (1996). Gerontologic Nursing. MO; U.S.: Mosby-Year Book, Inc.
Lueckenotte (1996) categorized ageing theories into biological, social and psychological theories which were recommended to apply to gerontological nursing. These theories were summarized in the table 1 to table 4.
Table 1 Summary of biological theories of ageing
Theory Dynamics
Molecular theories
Error theory Faulty synthesis of DNA and/or RNA.
Somatic theory Alteration in RNA/DNA; protein or enzyme
synthesis causes defective structure or function.
Transcription Theory Failure of transcription or translation between
cells; malfunctions of RNA or related enzymes. Programmed Theory Biological clock triggers specific cell behavior at
specific time.
the changes in body structure and functions over the life span.
Biological ageing
the individual capabilities to fuction in society comparing with the
orthers in the same age. Functional ageing
the changes of behaviors and self perception that relate to the biological changes.
Psychological ageing
Refers to the individual roles and social habits in the society.
Sociological ageing
Refers to changes of self
perceptions and of relationships to others, of the self´s world view. Spiritual ageing
Table 1 (cont.)
Theory Dynamics
Run-out-of program Theory Organisms´ capability of specific number of cell divisions and specific life span.
System level theories
Immunological/autoimmune Theory
Alteration of B- and T- cells lead to loss of capacity for self-regulation; normal or age-altered cells recognized as foreign matter; system reacts by forming antibodies to destroy these cells.
Cellular theories
Free radical Theory Oxidation of fats, proteins, carbohydrates, and
elements creates free electrons, which attach to other molecules, altering cellular structure.
Cross-link theory Lipids, proteins, carbohydrates, and nucleic acid
react with chemicals or radiation to form bonds that cause an increase in cell rigidity and instability
Clinker Theory Mix of somatic, cross-link, and free radical
theories.
Wear-and-tear Theory Repeated injury or overuse of cells, tissues,
organs, or systems.
Source: Modified from Ebersole P., Hess P.As cited in Lueckenotte, A.G. (1996). Gerontologic Nursing. MO; U.S.: Mosby-Year Book, Inc.
Table 2 Retardants of the ageing process following the biological theories of
ageing
Theory Retardants
Molecular theories Hypothermia and diet can delay cell division but not
the number of divisions
System level theories Immunoengineering, selective alteration, and
replacement or rejuvenation of the immune system.
Cellular theories Improve environmental monitoring; decrease intake
of free radical-stimulating foods; increase vitamin A and C intake (mercaptans); increase vitamin E intake; use of Coenyzme Q10. Caloric restrictions, lathyrogen-anti link agents.
Source: Modified from Ebersole P., Hess P.As cited in Lueckenotte, A.G. (1996). Gerontologic Nursing. MO; U.S.: Mosby-Year Book, Inc.
Table 3 Sociological theories of ageing
Theory
Activity theory The more active older adults are, the greater the life
satisfaction. Self-concept is related to roles, and previous roles must be replaced with new ones to remain active
Disengagement theory Society withdraws from the ageing person to the same extent that the person withdraws from society. Mutual withdrawal
Continuity theory In the process of becoming an adult, the individual
develops habits, commitments, preferences, and a host of other dispositions that become part of his or her personality. As the person ages, these are
Table 3 (cont.)
Theory
maintained. In the life cycle, these predispositions constantly evolve from interactions among personal preferences and experiences and biological and psychological capacities
Age stratification theory Society consists of groups of cohorts that age collectively. The people and roles in these cohorts change and influence each other, as does society at large. A high degree of interdependence therefore exists between the older adult and society
Person-environment fit theory
Personal competencies mold and shape all people with, in turn, assistance for them in dealing with environments. Change occurs in competencies with age, thus affecting the older person´s ability to interrelate with the environment
Source: Lueckenotte, A.G. (1996). Gerontologic Nursing. p.32. U.S.A.: Mosby-Year Book, Inc.
Table 4 Psychological theories of ageing
Theory
Jung´s theory of individualism
Theory was proposed by Carl Jung in 1960. An individual´s personality is composed of the ego, the personal unconscious, and the collective unconscious A person´s personality is visualized to be either oriented toward the external world or toward subjective, inner experiences. A balance between these two forces, which are present in every individual, is essential for mental health.
Table 4 (cont.)
Theory Course of human life Theory
Charlotte Buhler proposed the theory in 1968. The theory focuses on identifying and attaining personal life goals throughout five phases of development. Self-fulfillment was the key to healthy development and that unhappy or maladjusted people are unfulfilled is some way.
Maslow´s Hierarchy of Human Needs theory
Each individual has an innate internal hierarchy of needs that motivates all human behaviors (Maslow, 1954). These human needs have different orders of priorities. The human needs are depicted as a triangle with the most elemental needs at the base.
Developmental task theory
Havighurst proposed the theory in 1972. Each individual must learn specific developmental tasks at various stages of life; the successful achievement of these tasks contributes to the individual´s happiness and feeling of success. Specific developmental tasks arise from several sources: (1) physical
Self-actualization
Self-esteem
Belonging
Safty and security
Table 4 (cont.)
Theory
maturation, (2) cultural expectations of society, and (3) the individual´s personal values and aspirations.
In the elderly, the developmental tasks include: adjusting to the decrease in physical strength and health, adjusting to retirement and reduced income, and adjusting to the death of spouse or a significant other, establishing an explicit association with one´s age group, adopting and adapting social roles in a flexible way, and establishing satisfactory physical living arrangements
Source: Lueckenotte, A.G. (1996). Gerontologic Nursing. MO; U.S.: Mosby-Year Book, Inc.
1.2 The elderly population
Ageing has become a global phenomenon receiving recognition by a government like Thailand which it has enacted in the development policies to improve the quality of life of the elderly. Ageing societies seem to be developing all over the world. By 2020, more than one billion people worldwide will be age 60 years or over (DerMarderderosian and Briggs, 2006). United Nation (2002) reported the proportion of the older persons of the world was 8 % in 1950 and 10 % in 2000, and it was projected to reach 21 % in 2050 (Figure 1). As well, there are an increase of the percentage of the elderly who are 80 years old and older from 10 % in 2000 to 23.6 % in 2050; clearly the increase of this old-old group associate to the state of dependency resulting from functional disability and chronic illness (Kespichayawattana and Jitapunkul, 2009).
Figure 1 Percentages of older ages (60 year or older): World,
South-eastern Asia, Thailand, 1950 - 2050
Source: Modified from United Nation. (2002). World Population Ageing: 1950 2050. Retrieved August 18, 2007, from http://www.un.org/esa/population/publications/ worldageing19502050/regions.htm.
Thailand is experiencing a serious increase in the older population, which is growing much faster than in many other developing countries (Jittapulkul, Chayovan, & Kespichayawattana, 2002). As a result of declining mortality rate, life expectancy at birth of the Thai population has been increasing (United Nation, 2002) (Table 5) and Jitapunkul and Bunnag (1998) depicted the changes in population structure from a pyramid in 1960 towards a bell shape in the twenty first century (Figure 2).
Figure 2 Actual age profiles of the population of Thailand in 1960, 1980
and 2000, and projected profile in 2020.
Source: Jitapulkul, S., & Bunnag, S. (1998). Ageing in Thailand 1997. Bangkok, Thailand: Thai society of Gerontology and Geriatric Medicine publication.
World South-eastern Asia Thailand
1950 8.2 6 5 1975 8.6 5.7 5 2000 10 7.1 8.1 2025 15 12.7 17.1 2050 21.1 22 27.1 8.2 6 5 8.6 5.7 5 10 15 7.112.7 8.1 17.1 21.1 22 27.1 1950 1975 2000 2025 2050
Table 5 Distribution of life expectancy (years) at birth of the population of the
World, South-eastern Asia and Thailand
1950-1955 1970-1980 2000-2005 2025-2030 2045-2050 World Total 46.5 59.8 66.0 72.4 76.0 Male 45.2 58.0 63.9 70.1 73.7 Female 47.9 61.5 68.1 74.7 78.5 South-eastern Asia Total 41.0 54.6 67.0 74.0 77.3 Male 39.9 52.9 64.8 71.6 74.8 Female 42.1 56.5 69.2 76.4 79.8 Thailand Total 52.0 61.4 70.8 76.8 79.1 Male 49.8 58.0 67.9 74.2 76.5 Female 54.3 65.1 73.8 79.4 81.7
Source: United Nation (2002). World Population Ageing: 1950 2050. Retrieved August 18, 2007, from http://www.un.org/esa/population/publications/ worldageing19502050/regions.htm.
2. Health promotion in the elderly
2.1 Health and health determinants Definition and determinants of health
sound and whole of body (Pender et al., 2002). In 1948, the World Health Organization (WHO) defined health as a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity (WHO, 1998).
Related to definition from WHO, Pender, Murdaugh, & Parsons (2002) pointed it out that there were five distinct dimensions as a minimum standard for a comprehensive health determination including physical health (functional and structural integrity), mental health and intellectual functioning), social functioning, role functioning, and general perceptions of well-being.
There are many factors related to the health of individuals and communities such as age, genetics, gender, income and social status, environment, behavior etc. The influencing factors of health are multiple and interactive. WHO (2011), in the project of the Health Impact Assessment (HIA), divided health determinants into three categories: the social and economic environment, the physical environment, and the person´s individual characteristics and behaviors (Figure 3).
In Australia (2006) the government published a framework of health determinants that individual and population health are involved by interplay of general background environmental factors, socioeconomic characteristics and knowledge and attitudes, health behaviors, psychological effects, safety factors, biomedical factors, and these factors interplay with individual makeup (physical and psychological (Australian Institute of Health and Welfare, 2006) (Figure 4). In addition, the elderly health is determined and measured from many factors varying in different cultures. The Canadian government published the health determinants of their older population in 1993 which included six main health determinants: age, socio-economic factors, gender, ethnicity, marital status, and geographic location (Political and Social Affairs Division, Government of Canada, 1993)(Figure 5).
In Thailand, Inmuong et al. (2009) studied on the community perceptions of health determinants and the results were classified into three categories: environmental determinants (related to biophysical, social, and economic environments), individual and family related determinants (such as age, gender, education, occupation, eating behaviour, risk acceptance, risk behaviour, family structure), and institutional determinants (such as local regulation, sub-district health centre services, health volunteer services, sub-district administrative organization).
Figure 3 Health determinants (WHO, 2011)
Source: Modified from World Health Organization (WHO). (2011). Health Impact Assessment (HIA). Retrieved April 28, 2011, from http://www.who.int/hia/evidence/doh/en/#.
Figure 4 A conceptual framework for health determinants of Australia in 2006
Source: Australian Institute of Health and Welfare (AIHW), Australian Government (2006). Australia´s health 2006. Retrieved March 16, 2010, from http://www.aihw. gov.au/publication-detail/?id=6442467855.
HEALTH
Physical environment Person´s individual characteristics and behaviors Social and economic environment General background factors: Culture Resources Systems Policies Wealth Social cohesion Media Other Environmental Factors: Landscape Climate Chemical Human-made Socioeconomic characteristics: Education Employment Income Family, neighbourhood Access to services Other Knowledge and attitudes Health behaviours: Dietary behaviour Physical activity Tobacco use Alcohol consumption Use of illicit drugs Vaccination Sexual practices Other Psychological Effects Safety factors Biomedical factors: Body weight Blood pressure Blood cholesterol Immune status Other Individual and population healthIndividual makeup: physical and psychological (genetics, intergenerational,
Figure 5 Health determinants of Canadian Elderly in 1993
Source: Modified from Political and Social Affairs Division, Government of Canada. (1993). The Health of The Canadian Elderly (BP-351E, November 1993). Retrieved March 16, 2010, from http://dsp-psd.pwgsc.gc.ca/Collection-R/LoPBdP/BP/bp351-e.htm.
2.2 The elderly and health
In view of the fact that, people at an advanced age are more sensitive to the multiple losses related to ageing, thus making them more frail. The elderly may be more physically frail as a result of diminished physical functions, susceptibility to injuries and acute illnesses, chronic illnesses and cognitive impairment. Psychological, social, and financial components are also important aspects of frailty (Lueckenotte, 1996).
Clearly, the results from studies in several countries pointed out that older people have higher percentages of chronic conditions and impaired functions in daily life, which require more care, and higher budgets (Miller, 2004). Lueckenotte (1996) referred to the statistics from US Bureau of the Census in 1993 reporting in the study in 1990 that more than 80 % of the people over 65 years of age were estimated to have one or more chronic conditions for non-institutionalized elderly such as arthritis, hypertension, hearing impairments, heart disease, orthopedic impairments, cataracts and sinusitis, diabetes and tinnitus. As well, Lueckenotte (1996) also referred to the report of American Association of Retired Persons (AARP) in 1992 that the leading causes of death of the elderly in 1990 were heart conditions, malignant neoplasms and cerebrovascular disease. Also, the mortality caused by coronary heart attack,
Health Age Gender Marital status Geographic location Ethnicity Socio-Economic Factors
stroke, malignant neoplasms, accident and trauma, septicemia, and diabetes mellitus are frequent in older Thai people (Jitapulkul & Bunnag, 1998; Sahyoun, Lentzner, Hoyert, & Robinson). The use of conventional medicine also is higher among the older people. Many of the drugs are relatively recent on the market late in the twenty century and at the beginning of the twenty-first. Chronic disease and disability can impair physical and emotional health, decrease ability to care for oneself and so independence.
The elderly and their functional status is one of the important concerns among the gerontologists associated with the gerontology assessment to determine the effect of chronic illness and/or normal ageing. The degree of functional ability is classified by activities of daily living (ADLs) including feeding, grooming, transferring, toileting, mobility, dressing, negotiating staring, bathing, bowels, and bladder activities (Collin, Wade, Davies, & Horne, 1988; Mahoney & Bathel, 1965;) and instrumental activities of daily living (IADLs) including walking outdoors, cooking and doing heavy house work, using public transport, and using money (Jitapunkul, Kamolratanakul, & Ebrahim, 1994). National Institutes of Health, USA., pointed out that improving health and functional status of the elderly and preventing complications of chronic diseases and disability may help to delay the conditions of physical frailty and cognitive impairment which these conditions are the associated with institutionalization of the elderly (as cited in Lueckenotte, 1996).
order to remember that even an older person with disease and/or disability can be healthy and well to some degree. In particular, the elderly prefer to present a positive vision of personal health. By the way, the elderly perception of determinants of health helping the government to design the appropriated activities to keep the senior citizens healthy and also create health promoting programs.
2.3 The Thai elderly and their health
The Thai government specifies health care systems following the right of citizen which states that Thai people have the right of equal access to standard public health care services and receive free medical treatment from public health
the Thai government must be complimented their efforts to fulfill their mandate. In Thailand, health care system is performed in both the public and the private systems. The public health care service is divided into primary, secondary care and tertiary health care. In general, all public health care hospitals or centers are filled with patients, especially tertiary level hospitals. Health care providers in Thailand have an excellent reputation for effective retreating in tertiary hospital care. In 1998, Jitapulkul and Bunnag presented the expected statistics that a dramatic increase in the dependency ratio in which the elderly dependency will become higher than dependency of the young (Table 6). In 2007, the Foundation of Thai Gerontology Research and Development Institute (TGRI)published in their annual report that the Thai elderly could have health security provided by the public or private sector (Table 7). In addition, the statistics also showed the self-assessment of the elderly health which 43 % of them perceived themselves as healthy, and 21.5 % as unhealthy. This report also showed the percentages of the elderly who perceived their own health as very healthy (3.8 %) and very unhealthy (2.8 %). Chronic illness was still being the top high percentage of the physical health problems among Thai elderly. Chamroonsawasdi, Phoolpholang, Nanthamongkolchai, & Munsawaengsub (2010) stated in their publication that three-fourths of the Thai elderly had chronic problems such as high blood pressure, digestion and stomach problems and diabetes mellitus while the top five health problems were muscular pain, joint pain, restlessness, headache and visual problems.
Table 6 The population dependency of Thailand
Dependency ratio Year 1950 1975 2000 2025 2050
Total 83.1 84.4 46.8 44.8 61.9
Youth 77.1 78.6 39.1 28.4 27.7
Old Age 5.9 5.8 7.7 16.4 34.1
Source: Jitapulkul, S., & Bunnag, S. (1998). Ageing in Thailand 1997. Bangkok, Thailand: Thai society of Gerontology and Geriatric Medicine publication.
Table 7 Percentages of older persons who access health welfare classified
according to age groups and types of health welfare Age
groups
total Types of Health Welfare (years)
Health Security Cards Social Security /Compe nsation Fund Civil Servants´ Medical Benefit Security Health Insurance made with insurance companies Welfare provided by Employers Others 60 69 97.5 78.4 1.5 16.9 0.4 Na 0.3 70 79 97.7 74.7 0.2 22.0 0.2 Na 0.6 80 and more 97.6 75.7 Na 21.1 Na Na 0.8
Remark: Na = less than 0.1
Source: The Foundation of Thai Gerontology Research and Development Institute (TGRI), (2007). Situation of the Thai Elderly 2007. Bangkok, Thailand: Foundation of Thai Gerontology Research and Development Institute (TGRI) publication ISBN 978-611-90122-02. TQP Ltd.
2.4 Health promotion
Health promotion is particularly concerned with the outcome of action of improving healthy habits of behavior which may need to modify the determinants of health.
From the first international conference on health promotion in 1986 in Geneva, WHO, Ottawa Charter for Health Promotion defined health promotion as the process of enabling people to increase control over the determinants of health and thereby improve their health (WHO, 1998). In addition, Pender et al. (2002) defined health promotion as a behavior motivated by the desire to increase well-being and actualize human health potential which is different from health protection or disease prevention. Health protection is behavior motivated by desire to actively avoid disease, detect it early, or maintain functioning within the constraints of illness.
