Influence of active ageing and health literacy on quality of life among elderly persons in northeast Thailand

Abstract

Objectives:

Ageing populations are a global phenomenon resulting from increasing life expectancy and decreasing fertility rates. Thus, investigation into the factors affecting the quality of life (QOL) of the elderly has become important. This study aimed to assess the association between active ageing and health literacy, and QOL in a sample of elderly people in Northeast Thailand.

Methods:

Cross-sectional data were collected from 1,226 persons aged 60 years and above from Northeast Thailand. A general linear mixed model (GLMM) was used to determine the association between active ageing, health literacy and sociodemographic factors and the outcome variable, good QOL, as determined using the WHOQOL-BREF.

Results:

Overall, 42.09% of participants had a good QOL. After adjusting for the effects of the other covariates, a multivariable analysis indicated that a high level of active ageing (adj. odds ratio [OR] = 4.51; 95% confidence interval [CI]: 3.27–6.23), adequate health literacy (adj. OR = 2.53; 95% CI: 1.79–3.59), age < 70 years (adj. OR = 4.09; 95% CI: 3.03–5.50), having completed secondary school or higher education (adj. OR = 2.43; 95% CI: 1.57–3.76), and having a monthly household income ⩾ 15,000 baht (adj. OR = 3.01; 95% CI: 1.73–5.22) were significantly associated with good QOL in the sample.

Conclusion:

The QOL of the elderly must be prioritised. Active ageing and health literacy should be promoted as part of socioeconomic and health policies. Negative attitudes and ‘ageism’ towards the elderly should be reduced among populations of all ages. Health communication for members of a demographic with limited health literacy should be enhanced, and employment of the elderly encouraged.

Keywords

Active aging elderly health literacy quality of life WHOQOL-BREF

Introduction

People are living longer all over the world and most countries are experiencing growth in both the size of the population and the proportion of older people within it. The share of the population aged 60 and over has been estimated to increase from 1 billion in 2019 to 1.4 billion by 2030. By 2050, two-thirds of the world’s population over the age of 60 will likely live in low- and middle-income countries (World Health Organization (WHO), 2021). Population ageing is fastest in East and Southeast Asia (United Nations Department of Economic and Social Affairs Population Division, 2020). Thailand (17%) is one of three countries within the Association of Southeast Asian Nations (ASEAN) already qualified as having an aged population (defined as having more than 10% of its population aged 60 years or older), alongside Singapore (20%) and Vietnam (11%) (Institute for Population and Social Research et al., 2017).

Quality of life (QOL) is an important consideration among the elderly. The WHO defines QOL as the perception of individuals of their position in life in the context of the culture and value systems in which they live, while considering their goals, expectations, standards, and concerns (World Health Organization Quality of Life assessment (WHOQOL), 1995). QOL links to a broad concept of health that is related to an individual’s physical health, level of independence, social relationships, beliefs, and surrounding environment (WHO, 1998). These factors can be adversely affected with increased age, as numerous underlying physiological changes occur and the risk of chronic disease increases. Major burdens of disability and death among the elderly derive from age-related hearing loss, cataracts, back and neck pain, osteoarthritis and non-communicable disease such as pulmonary disease, cardiovascular disease, cancer, diabetes, depression and dementia. Furthermore, as people age, they are more likely to experience multimorbidity, which affects functionality, QOL and risk of mortality (WHO, 2021). Nonetheless, many older adults maintain a good functional ability and experience high levels of well-being despite the presence of one or more diseases. Understanding the factors influencing QOL in the elderly is important for the development of policies that can foster health, happiness and a better QOL [Hekmatpou et al., 2013; Lowsky et al., 2014).

These facts suggest that one of the most important tasks for older adults is to find ways to improve their QOL. Becoming an ageing society affects the development and growth of a country. In particular, it affects Thailand’s long-term economy and budget, and the overall QOL in Thai society. In response, the Thai government has given importance to preparing the country for this new context. Specifically, a Cabinet resolution of 4 December 2018 announced preparation for an ‘elderly society’ as a national priority and assigned six ministries to jointly drive related work. On 10 August 2020, the Ministry of Development held a meeting to report on progress and future directions in line with the national agenda. Actions are needed to encourage the elderly in Thailand to maintain their status as ‘actively ageing’ in an era of a ‘new normal’ (Department of Older Persons (DOP), 2020a).

By 2022, Thailand will have become a fully fledged ageing society when fully 20% of the total population is aged 60 and over. Regarding the economic dimensions, about 17% of the elderly have a total income (from all sources) of less than 40,000 baht per year and have no savings at all. Regarding health dimensions, 3% are elderly and bed-ridden; regarding environment and housing dimensions, about 5% have experienced falls in the home and around the house; and regarding social dimensions, about 1% are single and live alone. Among elderly people in the future, the average level of education is expected be higher, many of these individuals will be single with no children and there is no formal system of insurance to guarantee old age income. Although the fiscal burden on the government is likely to increase in the future with respect to the care of the elderly due to medical expenses and welfare, at the same time there are ‘opportunities’ for an increasing number of older people. These opportunities have arisen because an ageing population will contribute more human capital to the country as a whole, especially if its members have good financial and health literacy. Importantly, the knowledge, skills and wisdom of the elderly can be utilised for self-development, the development of communities, and to contribute to society (Foundation of Thai Gerontology Research and Development Institute (TGRI), 2022).

WHO defines active ageing as ‘the process of optimising chance for health, participation, and security in order to enhance wellbeing as people age’ (WHO, 2002). The notion of active ageing or ‘compression of morbidity’ aims to improve QOL by delaying the onset of disability (Fries et al., 2011). As opposed to considering the elderly dependent and burdensome, this is a new perspective in which longevity is said to intimately linked to health status. Healthy living among the elderly means that older people can develop and maintain their functional ability. For example, empirical evidence from longitudinal studies conducted between 1984 and 2005 suggests that regular vigorous exercise can delay disability for 14–16 years (Fries, 2012). The concept of active ageing is not new however, but research on active ageing among the elderly in Thailand has only been ongoing since 2006 (Thanakwang and Soonthorndhada, 2006). Research suggests that the majority of elderly Thai people experience moderately active ageing. Participation in society is moderate, mainly due to involvement in group/club activities of the elderly. Security is moderate, mainly due to the adequacy of income and a safe living environment, however Northeast Thailand where this study took place shows the lowest levels of income adequacy (National Statistical Office (NSO), 2017).

Health literacy has become increasingly important in public health research (Berens et al., 2016), and is widely seen as an important factor affecting behavioural and health outcomes (Fernandez et al., 2016). Low health literacy is common among the elderly (Kobayashi et al., 2015). Older adults with lower health literacy have low income and education, rate their health as poor or fair, and have difficulty seeing and hearing. Many of these factors are associated with health disparities (Cutilli et al., 2018). Low health literacy is also associated with health-risk behaviours (Javadzade et al., 2012), poor health outcomes (Mõttus et al., 2014), higher mortality rates (Bostock and Steptoe, 2012), and lower well-being, such as worsening physical and mental health and difficulty in daily life activities (Geboers et al., 2016). Previous studies have shown that overall, elderly people in Thailand have inadequate health literacy (Roma and Kloyiam, 2019). The overall performance of older adults decreases as age increases. As a result, there are decreased opportunities to learn, exchange or receive health information, as well as lower access to social welfare and health services. Health literacy is, therefore, of value to society because it is linked to the health of the elderly, with major implications for the future.

In the light of the above issues, the goals of this study were to identify the effect of active ageing and health literacy on QOL. The results will support measures to challenge discrimination due to age and promote the acceptance of older people as independent citizens. The attitudes of Thai society towards ageing and the elderly need to change from viewing the elderly as only those who receive relief to viewing them as diligent members of the community who can contribute to and help society.

The Northeastern region of Thailand covers 20 provinces and includes one-third of the country’s population and the largest number of the country’s elderly people (DOP, 2020b). Within the region, there has been rapid economic and social development and dramatic demographic change (decreased fertility and increased out-migration), causing the number of elderly people in rural areas in particular to increase. Villagers in these areas are gentle and open to change but are among the poorest people in the country. Most of the population comprises farmers who participate in low value-added gross farming with low profits (Office of the National Economic and Social Development Council, 2020). Therefore, the northeastern region is an appropriate area in which to understand QOL problems and opportunities associated with an ageing population.

Methods

Study design and population

This cross-sectional study was conducted between June and October 2020. Work took place in the Northeastern region, which we divided into four health areas to obtain a sample of the adults aged 60 years and older using a four-stage sampling technique. The first step used simple random sampling (SRS) to identify 4 provinces from 20 provinces which covered 4 different health areas. Second, SRS was used to select 12 districts representative of each province by the number of districts. Third, using SRS we selected 12 sub-districts in each district. Finally, cluster random sampling was used to define a framework for selecting samples in proportion to village size in each sub-district with at least 1,226 adults. All random sampling took place using the lottery method. Participants agreed to participate by signing an informed consent form. Data were collected by means of a questionnaire-based interview, with an average of approximately 45 minutes being devoted to each participant. We trained research assistant teams from 12 subdistricts to collect the field data.

Dependent variables

The outcome variable in this study, QOL, was assessed using the 26-item WHO QOL questionnaire (WHOQOL-BREF), which was originally developed from 100 items and evaluates 4 main dimensions of QOL: physical health and psychological, environmental, and social relationships (WHOQOL, 1998). The Thai version of the WHOQOL-BREF-THAI contains 26 questions, each scored from 1 to 5 on a response ordinal scale, and aims to assess QOL over the previous 2-week period. Internal consistency (Cronbach’s alpha) in this study was 0.84. The QOL score can be categorised into three levels: poor QOL (26–60), normal QOL (61–95), and good QOL (⩾ 96) (Department of Mental Health, 2002). In this study, the WHOQOL-BREF had an internal consistency of 0.96.

Independent variables

Three categories of independent variables were measured in this study: active ageing, health literacy, and relevant sociodemographic factors. Active ageing questionnaires were used to measure active ageing, as defined by WHO. The following three dimensions were assessed: health, social engagement, and social security. Active ageing scores were calculated by combining 3/1health scores + 3/1 participation scores + 3/1 security scores (NSO, 2017; Punyakaew et al., 2019). Active ageing scores ranged from 0 to 1 (⩽0.5 low level, 0.51–0.79 moderate level, and ⩾0.8 high level) (United Nations Development and Programme, 2005).

Health literacy can be assessed by means of a matrix with four dimensions of health literacy (access, understand, appraise and appeal) applied to three health domains (health care, disease prevention, and health promotion) (Sørensen et al., 2012). To measure this, European countries utilise an instrument called the HLS-EU-Q47 (Sørensen et al., 2015). For each item in the HLS-EU-Q47, respondents assess the perceived difficulty of a range of tasks using a four-point Likert-type scale (i.e. very easy, easy, difficult, and very difficult). Six countries in Asia1 have translated the HLS-EU-Q47 into the local language, and the instrument’s validity and reliability have been assessed, suggesting that the HLS-EQ-Q47 can be used in this context (Duong et al., 2017). However, the instrument has not yet been translated into Thai.

This study therefore used the HLS-EU-47 as a framework for the development of a local instrument. Similar to the HLS-EU-Q47, the developed instrument comprised 47 questions, and responses were recorded using a Likert-type scale with four scores (1 = very difficult to 4 = very easy). Possible obtainable overall scores ranged from 47 to 188 points. These scores were then converted to percentages and categorised in the same way as the HLS-EU (⩽50% = inadequate, 51%−66% = problematic, 67%−84% = sufficient, and 85% or more = excellent health literacy).

Demographic factors explored included sex (male or female), age (in years) and marital status. Sociodemographic factors assessed included educational level, occupation, household income (Baht per month, where 1 US$ = 29.9 baht in February 2021), and living circumstances (alone, with family members). Health factors explored included body mass index (BMI), smoking status, alcohol consumption, disability and history of injury or fall in the 6 months prior to the interview date.

Statistical analysis

Descriptive statistics, including frequencies and percentages, were used to describe categorical data, whereas means and standard deviations were used for continuous data. A general linear mixed model (GLMM) was used to identify the association between each independent variable and QOL. Independent factors with a p-value < .25 in a bivariate analysis were entered into a multivariable analysis using the GLMM to identify their association with QOL when controlling for the effect of other covariates. All data were analysed using STATA, version 15.0.

Ethics

The study was approved by the ethics committee of Khon Kaen University (No: HE 632078).

Results

Sample characteristics

A total of 1,226 elderly individuals (aged 60 years or older) participated in this study (Table 1). Participants’ average age was 70.28 ± 7.44 years, with the oldest being 98 years old. Almost two-thirds were female (62.97%). Nearly half (41.60%) had a normal BMI, most (59.54%) were married, and the vast majority had only completed elementary school (81.41%). Most commonly, participants were not employed (40.86%), followed closely by working in agriculture (39.97%) and earning a median income of 6,000 Baht per month (min: 600, max: 125,000). Most (70.55%) lived with at least three family members in their homes. Few reported currently smoking (9.30%), drinking alcohol (12.24%) or having been injured (5.30%) or falling (9.54%) in the 6 months prior to the interview date. Disability was reported by 8.56% of the participants. The most common level of active ageing was moderate (49.27%), with a mean score of 0.69 ± 0.19. In terms of health literacy, approximately half (50.90%) were categorised as having problematic health literacy, with a mean score of 113.85 ± 24.80.

Table 1.

Characteristics of study participants.

Variable	Number (n = 1,226)	Percent
Sex
Male	454	37.03
Female	772	62.97
Age in years
60–69	635	51.79
70–79	421	34.34
80 or more	170	13.87
Mean ± SD = 70.28 ± 7.44; median = 69 Min: 60, Max: 98
Body mass index ([BMI] kg/m2)
Underweight (<18.5)	110	8.97
Normal weight (18.5–22.9)	510	41.60
Overweight (23.0–24.9)	257	20.96
Obese (>25)	349	28.47
Mean ± SD = 23.25 ± 3.73 Min: 13.6, Max: 37.72
Marital status
Single	62	5.06
Married	730	59.54
Widowed	404	32.95
Divorced/separated	30	2.45
Education
Uneducated	41	3.34
Completed elementary school	998	81.41
Completed middle school/associate degree	97	7.91
Completed high school/associate degree	53	4.32
Diploma or undergraduate	18	1.47
Completed bachelor’s degree or higher	19	1.55
Occupation
Does not work	501	40.86
Agriculture	490	39.97
Livestock/fisheries	12	0.98
General hire	78	6.36
Merchant	105	8.56
Government pension/state enterprise	40	3.27
Household income per month
<5,000 Baht	444	36.23
5,000–15,000 Baht	647	52.77
15,001–25,000 Baht	80	6.53
25,001 Baht or more	55	4.49
Mean ± SD = 8,800.90 ± 10,360.49; median = 6,000 Min: 60, Max:125,000
Living circumstance
Alone	63	5.14
With spouse	124	10.11
With family members (2 persons)	174	14.20
With family members (3 or more persons)	865	70.55
Smoking behaviour
Never smoked	952	77.65
Ever smoked	160	13.05
Current smoking	114	9.30
Alcohol drinking
Never drank	888	72.43
Ever drank	188	15.33
Current drinking	150	12.24
Accident (6 months ago)
No	1,161	94.70
Yes	65	5.30
Fall (6 months ago)
No	1,109	90.46
Yes	117	9.54
Disability
No	1,121	91.44
Yes	105	8.56
Health literacy
Inadequate	261	21.29
Problematic	624	50.90
Sufficient	275	22.43
Excellent	66	5.38
Mean ± SD = 113.85 ± 24.80, median = 113 Min, Max (63:188)
Active ageing level
Low	220	17.94
Moderate	604	49.27
High	402	32.79
Mean ± SD = 0.69 ± 0.19 Min, Max (0.07:1)

SD: standard deviation; BMI: body mass index.

One US$ = 29.9 Baht.

Overall, the mean QOL score was 84.4 ± 16.3, with 42.1% of participants considered as having a good QOL (⩾96). Table 2 shows that several factors were identified by the final GLMM as significantly associated with a good QOL when compared to the opposite. After adjusting for other factors, elderly individuals with high active ageing were about four times more likely to have a good QOL as those with low active ageing. Elderly individuals with adequate health literacy were about two times more likely to have a good QOL than those with limited health literacy. Those who were aged less than 70 years were nearly four times more likely to have a good QOL than the older age group. Elderly individuals who completed secondary school or higher were about two times more likely to have a good QOL than those who completed elementary school or lower. Elderly individuals with a monthly household income of ⩾ 15,000 Baht were three times more likely to have a good QOL than those with a lower monthly household income.

Table 2.

Factors associated with good QOL according to the final general linear mixed model.

Variables	Number (n = 1,226)	% Good QOL	Crude OR	Adj. OR	95% CI	p-value
Health literacy						<.001
Limited	885	31.19	1	1	–
Adequate	341	70.38	5.24	2.53	1.79–3.59
Active ageing level						<.001
Low/moderate	824	25.97	1	1	–
High	402	75.12	8.61	4.51	3.27–6.23
Sex						.006
Female	772	38.73	1	1	–
Male	454	47.80	1.45	1.53	1.13–2.06
Age in years						<.001
⩾70	591	22.34	1	1	–
<70	635	60.47	5.32	4.09	3.03–5.50
Education						<.001
Uneducated/completed elementary school	1,039	36.28	1	1	–
Completed secondary school or higher	187	74.33	5.08	2.43	1.57–3.76
Household income per month						<.001
<15,000 Baht	1,091	37.86	1	1	–
⩾15,000 Baht	135	76.30	5.28	3.01	1.73–5.22
Living circumstance						.007
Alone	63	15.87	1	1	–
With family members	1,163	43.51	4.08	3.12	1.36–7.16
Fall (within the last 6 months)						.021
Yes	117	23.08	1	1	–
No	1,109	44.09	2.63	1.90	1.10–3.28

QOL: quality of life; OR: odds ratio; CI: confidence interval.

Discussion

Findings reveal that most of the elderly people surveyed had a moderate QOL (45.5%), which is consistent with previous QOL surveys conducted with similar populations (Hongthong et al., 2015; Tiraphat et al., 2017). Almost two-thirds of participants (65.3%) experienced active ageing at low to moderate levels, which is also consistent with findings in previous studies (Haque, 2016; NSO, 2017; Thanakwang and Soonthorndhada, 2006).

Considering the three pillars of active ageing, the pillars of participation and security are important to address. Factors increasing both sides of the index are joblessness and a stable income. However, in modern-day Thai society, the elderly lack job opportunities, are discriminated against because of their age, are affected by laws that force them into unemployment, have no jobs and have no income. According to the Civil Service Pension Act of 1951, the age of retirement is set at 60 years. Most private companies use a 55-year-old threshold to end employment contracts. Much of society brands the elderly as weak, unhealthy and suffering from mental health issues, and believe they should rest at home. The elderly are thought of as incapable of working other than engaging in a few chores, among others. Given such negative attitudes, discrimination is rampant discouraging older people from becoming part of the country’s working society or the labour force (Aroonjit, 2021). In contrast, and in this study, high active ageing levels were significantly associated with a good QOL among older adults. This finding was similar to those in other countries where active ageing has been shown to positively influence QOL among older adults (Dajak et al., 2016; Eum and Kim, 2021).

Around half of the participants (50.90%) in this study had problematic levels of health literacy. A high proportion of limited health literacy was previously observed in 2019, with inadequate health literacy being most common among the elderly and those who had only completed primary education or lower (Roma and Kloyiam, 2019). Health literacy decreases with age and is associated with a subtle decrease in cognitive decline in older persons (Kobayashi et al., 2015). However, in this study, adequate health literacy was found to be associated with a good QOL, with our findings confirming the results of previous studies (Lee and Oh, 2020; Zheng et al., 2018).

Demographic factors significantly associated with good QOL in this study included age (age < 70 years). Previous research in Thailand has found that being of a younger age is associated with a better QOL (Tiraphat et al., 2017). In this study, being male was also associated with a good QOL, a finding which contradicts those found in previous studies in Thailand (Somrongthong et al., 2017; Tiraphat et al., 2017), but is consistent with research in Vietnam (Van Nguyen et al., 2017). Regarding sociodemographic factors, in this study, more education was also associated with a good QOL, which is also consistent with findings from previous research in Thailand (Tiraphat et al., 2017) and Hong Kong (Zhang et al., 2019). Having a higher income was associated with good QOL, which past studies in Thailand and other parts of the world have also previously shown (Hongthong et al., 2015; Somrongthong et al., 2017; Tiraphat et al., 2017; Zhang et al., 2019). Having a good income is an important asset for older adults, not only in order to pay for other expenses, including holidays, private healthcare and emergency expenses. Elderly people with a low income are more likely to experience high emotional stress and a poor QOL. In Thailand, the level of social security payments varies by age: the monthly stipend available to those 60–69 years old is 600 Baht. In all, 70- to 79-year-olds receive 700 Baht, 80- to 89-year-olds receive 800 baht, while those aged 90 years or over receive 1,000 baht. These amounts are quite insufficient to cover the financial needs of older individuals. Although older adults have free access to standard health services at public hospitals, they still require support from other sources (Rittirong et al., 2014). Being elderly while living with one’s family was found to be associated with a good QOL in one study, which contradicts previous research in Thailand (Tiraphat et al., 2017). Regarding health factors, not having experienced a fall in the past 6 months has been shown to be associated with a good QOL. This finding is consistent with those of many studies from other parts of the world (Thiem et al., 2014).

A high level of active ageing and adequate health literacy has been shown to be associated with a good QOL among elderly individuals living in Northeast Thailand. This underscores the need for a more strategic approach to promoting active ageing and health literacy as part of an overall QOL framework. An ageing society is likely to experience a growth in health problems and chronic diseases. However, most people view dealing with this problem as simply dealing with the health of the elderly rather than an ageing population in society as a whole. Health literacy must be enhanced by managing health communications with a demographic with limited health literacy access. The health information that individuals receive must be clear, specific and practical, and in line with an individual’s needs and social circumstances. The paradigm of social welfare must be changed to keep pace with changes in Thai society and become more cosmopolitan. We must change from an approach based on ‘relief’, towards a concept of social welfare informed by ‘civil rights’ for populations of all ages (TGRI, 2021).

Conclusion

Among elderly persons in this study, a high level of active ageing, adequate health literacy, being less than 70 years of age, having completed secondary school or higher education, and having a monthly household income ⩾ 15,000 Baht were significantly related to a good QOL. In the light of this, active ageing and health literacy should be promoted in socioeconomic and health policies. People in Thailand should be able to expect to live into their 60s and above with good quality of life. In support of such a goal, ageism towards the elderly should be reduced, health literacy should be enhanced and the continued employment of elderly people encouraged.

Footnotes

Acknowledgements

We acknowledge and thank all the participants in this study.

Correction (January 2025):

Article updated online to rectify the affiliation to Petcherut Sirisuwana^a,b

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Petcherut Sirisuwan

Surachai Phimha

Data availability

The data associated with this paper are available from the corresponding author of this paper upon reasonable request.

Notes

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