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
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