Perspectives on Health, Participation, and Security Related to Active Aging Among Older Adults in North-eastern Thailand – a qualitative study

doi:10.21203/rs.2.21854/v1

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Perspectives on Health, Participation, and Security Related to Active Aging Among Older Adults in North-eastern Thailand – a qualitative study

https://doi.org/10.21203/rs.2.21854/v1

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Background Health, participation, and security are basic pillars of Active Aging suggested by WHO is used by professionals but need to be explored from the perspectives of older people themselves. This study aims to explore how older adults experience and describe health, participation, and security.

Methods A qualitative research approach based on open-ended interview questions with 20 older Thai adults, aged 60-92 years was used. The interviews were analysed using qualitative content analysis. Findings The results showed perspectives related to experiences of daily life and local culture. Health was described as status of the body in the absence of barriers to a continued daily living, and a peaceful mind with an adaptive mind-set while aging. Participation was described as maintaining social networks and being a formal volunteer emphasizing the making of merits, on meaningful activities and being respected. Security was described as manageable living conditions and managing to finalize life well, balancing dependency and independency in relation to children to sustain the traditional value of gratitude between generations.

Conclusions These understandings benefit the providing of resources and activities related to older adults’ perspectives to enhance their quality of life for both Thai and other cultural contexts.

Health Policy

active aging

health

participation

qualitative

security

Population aging is a phenomenon that occurs in many countries around the world [1]. Thailand has been an Aged society since 2005 and is expected to become a Complete-aged society in 2021 when 20 percent of the population will be 60 years old or above [2]. Taking care of the older population is an important mission of the public health system in order to keep their long life and well-being. A positive experience of a long life must be accompanied by continuing opportunities for quality of life and well-being.

Quality of life, implies a sense of well-being, including aspects of happiness and satisfaction with life [3]. Both quality of life and well-being of older people could also be described as “aging well”. Several conceptions of the terms are related to aging well, such as successful aging [4], healthy aging [5] positive aging, productive aging, [6] and active aging [7]. These concepts are semantically diverse, but the goal for all of them points to the potential of aging [8].

This study was inspired by the concept of active aging to enhance the potentials of aging well. “Active Aging is the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age” [9, p. 12]. It mentions participation in society and providing protection, security and care [10]. Health, Participation, and Security are thus the main basic pillars of active aging. The health pillar is based on the prevention of disease and disabilities, the participation pillar includes work, voluntary activities and learning opportunities according to individual needs, and the security pillar aims to ensure the protection, safety and dignity of older people by addressing their social, financial and physical security [11]. Active aging has been used in global management of aging populations, gerontological research and popular media. It is a central concept globally and has been defined in various ways within the context of unique cultures and values across different countries and organizations. However, although it is considered as a concept that lacks a precise universally agreed upon definition and as being too wide to use appropriately with diverse people, it has been widely used in many countries beyond these past 10 years [8]. The European countries designated the year 2012 as the European Year for Active Aging and Solidarity between Generations, to raise awareness of the position of older people enjoying a better quality of life and still playing an active role in society [12]. The concept of active aging was used as an important policy in Nordic countries. Norway reflected on this concept in at least five Norwegian Policy Papers [13]. Another example is the Maltese government that launched the National Strategic Policy for Active Aging: Malta 2014–2020 [14]. From a governmental perspective, “active aging” establishes new standards for aging well and promotes new types of active aging citizens. It has been used as practice guidelines in settings such as health clubs. The Active Ageing Index (AAI) has been developed to measure the level of active ageing. This instrument is a quantitative index composed of several indicators which can be aggregated into a single overall index [15]. AAI was modified in several countries to use in their own context. It serves as a tool for monitoring overall progress from the population perspective [16]. In Finland, the University of Jyväslyöä has developed an instrument to measure active aging, called University of Jyväskylä Active Aging Scale (UJACAS). The tool consists of seventeen items focusing on activities and the capacity to maintain daily living [17]. In Thailand, a study used items including 17 selected indicators (range 0–1) to measure the active aging level and found that it is not high (average female = 0.64, male = 0.61) [18]. Active aging was used in Thailand for several years. Thailand’s official Elderly report of the year 2017 selected active aging as the special theme of evaluation and reporting [2]

Since older persons show diversity, their own perceptions on aging well and active aging may differ depending on age, gender, ethnicity and socio-cultural contexts. The promotion of active aging should be dynamic, enabling people to create their own forms of activity based on their perceptions, instead of focusing on a limited number of domains which were developed from the perspective of an expert [8]. For example, Jacobsen [13] found that policy papers from Norway demonstrate that active aging is growing in importance, but stressed on productive activities related to working life, voluntary work or sports and physical training while activities that are meaningful for many older people, like joining family events or reading books, were ignored. Instead of using the same instrument for everyone, it is important to understand active aging from the perspective of older adults themselves and particularly important when providing resources relevant to their own ways of aging well. The most common perception of the term was maintaining physical health and functioning, social activities, mental functioning and activity and having a network of social relationships according to Bowling [19] and Stenner et al [20]. Similarly, Marsillas et al. [21] emphasized the importance of the active aging concept in relation to life satisfaction in old age. In Thai studies, older adults identified active aging as the process of being actively engaged in life in the sense that elders made contributions and achieved happiness by doing things beneficial for themselves, family and society [22]. Older adults´ perceptions of active aging ´were related to having economic stability, good health and, having children who were grateful to them [23]. Comparing western and Thai studies, the emphasis on maintaining physical and mental ability to continue daily functioning for life satisfaction are similar. However, Thai studies showed that older adults´ perspectives on active aging seem related to being a valuable person and always connect to one’s family especially to having grateful children. From the perspective of older adults, active aging related to health, participation, and security, is a concept about continuing activities which are positive for them, which may vary in different socio-cultural contexts.

Although the earlier studies seem to illustrate the perspective of active aging related to the three basic pillars, when considering the method these tend to be a problem. When it comes to the meaning of the term “active aging” researchers and older adults may use the same word but with different understandings. A common presumption is that the researcher may understand “active aging” as one word which includes several determinants, while older people perhaps view the two words separately as “active” and “aging” in a literal sense. A study of the subjective aspect of aging actively in England, Stenner et al [20] found that older people in England also were interested in the word “active”, indicated by their describing “active aging” in terms of activity or passivity. Active aging was defined as being alert, being active, or becoming active, which all are opposites of “passive”. For Thai studies, the term “active aging” is very difficult to translate into Thai words in a way that makes sense for people in general. Asking about active aging in a direct way may risk an invalid understanding of active aging between researcher and participants. There was an unclear conception of each basic pillar of the whole concept of active aging as the following example shows. Thanakwang et al. [24] asked for the meaning of active aging followed by questions pointing to the three pillars, for instance “What do you think healthy older persons should achieve?” Although the interview went on to ask about health, participation, and security, the findings illustrated that the participants described the meaning of the whole concept of active aging. Earlier findings are unclear as to whether or not older adults had given their meaning or perspective of active aging. As mentioned in the beginning, aging well is considered as a desired status for older people. Several terms including active aging were used to describe, measure and used as a practical guideline for aging well. Focus on active aging, diverse perspectives with a lack of clarity and coverage makes it difficult to apply in practice when developing activity programmes for older adults. Therefore, there is a need to study active aging based on the perspectives of older adults.

In contrast to the studies mentioned above on the term “active aging” [19, 20, 23, 24], this current study starts with its´ three pillars health, participation, and security. In this study, the perspectives of health, participation, and security are not synonymous with, but still related to active aging. By breaking down “active aging” into its pillars, misunderstandings and confusion of the concept could be eliminated. Further, it could lead to practical outcomes relevant to Thai older adults and be useful in various kinds of activity groups within the realm of public health to combine the perspectives of older people with those of experts.

The aim of this study was to explore how older adults experience and describe health, participation, and security. This research was conducted with a qualitative design and approach which is useful in exploring people´s experiences as the goal is to gain a deeper understanding of the studied phenomenon. Qualitative content analysis was used as the method of analysis which can be applied to a variety of data and to various depths of interpretation [25]

Study context

This study was conducted in the province Nakhon Ratchasima with a population of 2.62 million, which is one of the 20 provinces of the North-eastern region of Thailand. North-eastern Thailand has a high diversity of cultures and the people in the Nakhon Ratchasima province belong to the Isan culture. Although with specific cultures such as regarding language, cuisines, and folk songs, this province is also part of general Isan culture. Korat is the main language spoken together with Isan and Thai. The Nakhon Ratchasima province has both rural and urban areas, but with agriculture as the largest sector of the economy. Isan is also the poorest region of Thailand with one of the fewest physicians per capita and the highest increase of older people [2]. This is the first sub study of a doctoral research project, titled “Lomwong Saangsook” meetings among older adults in North-eastern Thailand. The aim of the meetings is to encourage older people to take care of daily life by themselves. By exploring the perspectives of older adults in Northeastern Thailand regarding health, participation, and security, the results of this study can indicate what kind of guidelines in public health that may be used to promote health and well-being among the older Thai adults.

Participants

The inclusion criteria for the participants were age 60 years or above, both men and women, with various educations and working experiences, no severe illnesses, being able to communicate well and be willing to participate in the study. The participants were chosen based on the inclusion criteria by suggestions from college staff and health volunteers working in three different contexts, such as a senior club organized by the nursing college, an urban and a rural community. The first author contacted the older adults by telephone to ask if they were interested in participating in the study. The presumptive participants received both oral and written information about the study.

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Table 1

Participants classified by residence gender, age, education and occupation
	Area of resident
	Urban	Rural
Gender
Male	3	5
Female	7	5
Age
60–70	4	3
Over 70	6	7
Education
Primary school	6	8
High school	1	1
Bachelor	3	1
Occupation
Former teacher	2	1
Farmer	4	6
Housewife	3	2
Former factory worker	1	1

The participants consist of 8 men and 12 women, aged 60–92, with an average age of 75.05. There were 14 participants educated in primary school and 6 were high school graduates and above. They consist of four retired teachers, eight farmers, four housewives, two retired mechanics, a retired banker, and a retired government employee. All participants were Buddhists.

Data collection

The interview guide consisted of open-ended questions emanating from the three basic pillars, health, participation, and security, which according to WHO [9] constitute important aspects of active aging. Examples of questions asked from each pillar were: How do you think about older persons’ health? How should older persons participate socially, with people, and community? What makes you feel secure in life? The questions were discussed between the authors for validity. A pilot study to test the interview questions was conducted with 5 older persons similar to prospective participants before the actual study started and the interview questions were improved. During interviewing, additional questions were asked to inspire the participants to develop their answers and to gain a deeper understanding between interviewer and participants such as; Can you explain more? or How do you mean? Can you develop it further? Almost all participants were interviewed in their own homes, while three were interviewed at the senior club. The interviews were conducted in Thai by the first author (MW) and were audio-recorded. Some participants were very talkative and could express much although only concentrating on a few of the questions, while other participants needed supportive questions. Each interview took an average of around forty minutes. The recorded interviews were transcribed verbatim by the first author (MW) and half of these were translated into English, considered sufficient to strengthen the analysis since two of the authors were non-Thai speaking.

Data Analysis

The method of the data analysis was qualitative content analysis according to Graneheim and Lundman [25]. The first step included the reading of the interviews several times to obtain a sense of the whole. The second step was re-reading the data to identify meaning units which were related to the aim of the study. A meaning unit is a part of a sentence, or a complete sentence, or several sentences containing aspects related to each other and the aim of the study. The third step was condensing the text, i.e. shortening the text so that the core meaning of the unit remains. In the fourth step meaning units were labelled with codes. A code is a word or phrase that refers to a core meaning unit. In the fifth step the codes that were similar and different from one another were sorted into subcategories. In the sixth step, subcategories with similar content were abstracted into main categories. Finally, the categories were separately checked and revised. The categories were discussed between the authors until agreement was reached about the final main categories and subcategories.

Ethical considerations

The participants received oral and written information about the overall purposes and protocols of the study and the time required for participation. The right to withdraw from the study without negative consequences was guaranteed and the participants were asked to sign a consent form. The names were protected by referring the participants as male/female and age. Confidentiality was maintained in all data collecting and analysis processes by keeping the material in a safe place and protecting against exposure. This study was approved by ethical review boards in Sweden and Thailand.

The findings presented here are based on the pillars Health, Participation, and Security from the perspectives of older adults in North-eastern Thailand. Diversity among older people, such as, local culture and community traditions that influence their living, was assumed in this study.

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Table 2

Categories and subcategories of findings
Basic Pillars	Main Categories	Sub-categories
Health	Status of physical body	Absence of severe illness and physical pain
		Having enough physical capacity to manage daily life.

	Status of mind	Having peace of mind
		Being able to review life

Participation	Maintaining social network	Joining neighbor events and community activities
		Being a formal volunteer

	Supporting spirituality	Joining religious activities
		Doing useful things for others

Security	Living conditions	Social status
		Economic status
		Emotional status

	Managing to finalize life well	Financial preparations
		Thoughts about dying

Health

Health is presented in two main categories. First, status of physical body including two subcategories: absence of severe illness and physical pain, having enough physical capacity to manage daily life. Second, status of mind including two subcategories: having peace of mind and being able to review life. According to the older participants, status of body was related to physical symptoms and functional capacity as well as having a balanced lifestyle. Female participants described ‘health’ as the absence of severe illness, physical pain and being able to manage daily life without physical limitations.

A healthy person is someone who has no illness, no physical pain, have no diabetes, no high blood pressure and no heart disease and should not take medicine. (Female, 66)

A male participant on the other hand described that ‘health’ does not necessarily mean a complete absence of illness. When a condition is controlled by medication and the daily life is not affected by the disease, one might feel healthy.

I think older adults in general has some chronic disease, it is not a problem when it’s controlled by medicine or healthy lifestyle. I take medicine to control my blood pressure and I think I’m healthy. (Male, 67)

Moreover, a healthy life is characterized by balance, regarding physical exercise and intake of food. According to the participants, balance is not doing too much or too little (por dee in Thai) of anything as well as it is an awareness of, but not being too strict with a healthy lifestyle.

Having enough physical capacity to manage daily life was described by most of participants. This means that healthy persons are able to take care of themselves, continue with their daily routines and have the same abilities as when they were younger and thereby not being a burden to their family and society. In addition, gender differences were found, since a female participant thinks of her ability to look after housework and family, while the male participant focuses more on his physical abilities.

As I’m in my seventies, I think I’m a strong person. I can work. I feel pain when the weather is cold. I can do housework and take care of my family, just have a rest when I’m tired. (Female 76)

Health is being able to rely on ourselves, still being able to use our body to do everything, such as drive a car, read a book, go to the toilet or meditate for one hour. Everything is the same as we used to do without relying on the others. (Male, 92)

Further, the participants said that the limitation in mobility is a serious health problem. This results in lower capacity in taking care of oneself, in one’s duties, in participating in social activities and in important personal relationships.

Status of mind was described as being able to relax and control their thinking. From the participants perspective, older persons should be less materialistic and ambitious, which results in happiness and is viewed as a way to good mental health. A peaceful state of mind was expressed as the absence of and choosing not to worry, since this could lead to distress and dissatisfaction. Feelings of both sadness and joy should be expressed, not bottled up.

Whatever makes you happy or joyful you should let it out. You should let off the steam from being unhappy and express happiness in whatever way you can. (Male, 82)

Participants pointed out that expressing happy feelings through action increases the experience of joy. Engaging in activities that makes one happy, such as singing or dancing increases happiness in life. Participants expressed that old age is a time to review life and make changes such as: give up drinking and gambling and do good deeds to earn merit, being helpful and forgiving people.

Bad things that we used to do like gambling or cockfighting for gambling should stop by now. I keep thinking that at this age, I’ve done everything I have wanted to, and it is time to take a break from all this. It is better to use time to go see friends and earn merit for myself. (Male, 82)

Participants said that old age is a time to think about your own morals and consider how to interact with people based on self-understanding and how people understand you. Older adults should not be self-centred and harbouring anger because it causes distress. On the other hand, having an optimistic outlook on life and forgiving people are ways to peace of mind and contentment. In summary, older adults described health as a combined status of body and mind.

Participation

Participation is presented in two main categories. First, maintaining social network including two subcategories: joining neighbour events and community activities, and being a formal volunteer. Second, supporting spirituality including two subcategories: joining religious activities, and doing useful things for others. Maintaining social networks are important forms of participation and a part of their well-being. The participants said that living with each other is crucial. Joining neighbour events and community activities such as weddings, ordinations and new house ceremonies are important. The participants emphasized that joining in others’ events and expecting them to respond in likewise manner, maintains relationships. Joining community activities is an important way to remain a part of society. Being socially involved with friends and society results in life satisfaction and longevity.

When neighbours have weddings or Buddhist ordination ceremonies at their home, I have to join and donate some money. If I don’t join their event, they ignore me when it is my turn (Female, 75).

We’re helping to make a better community. I do everything because people know me. People greet me whenever we meet. It makes me happy. (Male 84)

Taking the role of a volunteer, is an activity that makes older adults feel accepted and respected by members of society. There are many kinds of formal volunteers in this North-eastern Thai society such as the Village Health Volunteer, established by Ministry of Public Health, and other formal groupings established by various government organizations. Being a formal volunteer was associated with being a helpful and amiable person capable of maintaining social networks.

A health provider invited me to be a Village Health Volunteers (VHV). I have been working full-time. It is very important for my life. I feel VERY HAPPY! I would recommend someone else to follow, especially my son. It’s good for me to do this for others. (Female, 67)

Older Thai adults expressed that good participation for them is also related to spirituality. Supporting spirituality was seen as joining religious activities and doing useful things for others.

I go to the temple every day. When I wake up in the morning, I set a pot of rice, do some work then prepare rice and foods for monks at the temple. I usually earn merit by donating money to the temple. (Female, 79)

As Buddhists, participants believed that earning merit benefits current life, after death and the next life. Some of the older adults said that they have less time remaining to accumulate merit before death, so later life is an important time to accelerate merit-making. This involves not only doing rituals but also donations and doing good things for other people. Consequently, being a generous person is a way to support spirituality. Doing useful things for others such as helping people could create the feeling of being a valuable person, bringing happiness and good things to their life.

When we have good health, we can benefit the family and the community and the world. I think, I have done the best of my ability. Doing useful things results in happiness like being in heaven. (Male, 92)

In addition, taking a role in the family, such as housekeeping, cooking and taking care of grandchildren, were suggested by the participants who live with their adult children. This makes them feel valuable instead of burdensome. Positive participation not only benefits one’s social status but also supports spirituality of these Thai participants.

Security

Security was described in two main categories, first, living conditions including three subcategories: social status, economic status, and emotional status. Second, managing to finalize life well, including two subcategories: financial preparations, and thoughts about dying.

Living conditions from the aspect of social “status” was described as having good children who take care of their aging parents; economic status was described as having one’s own money or assets and being supported by the family; and emotional status as self-satisfaction and pride. According to the participants, older people should not live alone without relatives and that the support by adult children is important and was at times accepted when needed.

I think children or grandchildren are needed. We need help when we are old or sick ... I don’t know how to say. I have three adult children; some are living close to me but some far away. Those who live close always take care of me, while the far away ones send me money every month. Now I live with a son without difficulty. I have money and children as caregivers. (Male, 71)

The participants expressed that receiving gratitude from children who take care of them or support their living makes the participants proud and adds to their sense of dignity.

Another living factor was economic status was described in terms of housing, food and money. Housing and food were not difficult for the participants because they had their own houses or lived as extended family with adult children. In addition, older Thai adults have their own small pensions when retired or are senior citizens with allowances from the government.

It is enough, 700 Baht [allowance] is enough for me, I don’t use too much. The money sometimes does not last out if there were too many events to pay in that month. I always donate to earn merit. For neighbour events, I put money in the invitation envelope they gave me, much or less depending on how much money I have. (Female, 79)

However, some of the participants complained that sometimes money do not suffice if there are too many ritual donations and neighbour events, so sometimes they skip a donation.

Emotional status was mentioned in terms of feelings of self-satisfaction and stability of mind.

I feel it is enough for me. I don’t need to chase anything, both good and bad things. I don’t mind praising or reprimanding, but don’t refuse the good things, just not be too concerned about it. It is balance. (Male, 92)

Moreover, being successful in developing a good life in old age for themselves makes the participants proud, as does also the sense of being good parents. The participants voiced that it gives a feeling of emotional security. Older adults described security from the point of view of living conditions as the first main category. In addition, when talking about security of life, many participants spoke of death and the preparations they had made. Managing to finalize life well was mentioned in terms of preparing for their impending death, which was comprised of financial measures and preparing the mind by viewing death as something normal, and not something to be afraid of. Financial preparations were described as securing money for the funeral. The most common way was to be a member of a funeral fund arranged by the community or a government organization. The participants emphasized concern about the funeral as it is the last time of being treated with dignity as a human being.

Nowadays, I am happy, no trouble, no debt. I also have my own funeral fund in my Agriculture Bank Funeral. I live with my children, doing just somethings I prefer. I sometimes make some desserts to sell in flea market. It’s just a hobby (Female, 80)

Transferring inheritance to children was mentioned by several participants. They explained that the transfer of inheritance not only supported the children’s economy but also reduced worry about inheritance disputes between siblings. Thoughts about dying was mentioned by almost all participants. The thought of dying in the future could be accepted since the older participants expressed that they had done many worthwhile things and completed their mission as parents and human beings.

I’m ready for death. I’m not afraid of any things. It isn’t difficult for me to think about death. I have done many worthwhile things in my life. Some younger ones have already gone. I’ve helped my children and grandchildren many times. (Female, 76)

Furthermore, the participants said that dying is something which all must face. Another reason that makes some of the older adults not being afraid of dying is earning merit. That means doing good things so that you don’t have to worry about life after death.

I am what I am. I usually earn merit and I am generally kind. I let my health be as it is. I’m not afraid of death. I’m afraid of being tortured (laugh). I’m not afraid of other things. (Male, 84)

Preparing for death is important for these older people in Thailand who emphasize that appropriate thinking about death reduces worry both in current life and for life after death. The participants described security from the aspects of living status and managing to finalize life well. Although they seem to regard security as good living status, they do not disregard spiritual issues linked to death and dying.

This study shows significantly nuanced perspectives of active aging of older adults.

While earlier studies tend to use the technical term of “active aging” as a governing concept, the current study focuses on its basic pillars. The current result showed that the pillar of health was described as related to status of living, in terms of how Thai older people wish to be, the pillar of participation was described in terms of how and what they wish to do, and the pillar of security revealed what composes secure feelings for them.

The current findings provided new understandings of older adults´ perspectives, that physically healthy persons were not just those with less illness or with capacity to be independent but also referred to those who had less barriers to live well such as physical pain and mobility limits. Another important finding is that capacity to age-relate role adaptation is an indication of mental health. Maintaining participations to keep social networks and fulfil duties of merit-making was very important for older people but sometimes caused economic burdens. The findings also highlighted that older persons needed to join meaningful activities and to be respected. Important aspects of security were balancing between being burdensome parents and maintaining dignity by receiving care from their children. This is according to Liljas el al. [26] which found that older people wish to remain independent, but to stay independent they also need some support from family.

By breaking down the term active aging to its three basic pillars and clarifying subjective perspectives of older adults’ certain misunderstandings regarding the concept of active ageing found in earlier studies have been disentangled. It thereby becomes more useful on practice, policy and research levels, as will be shown in the following. Physical and mental health found in the present study differed from the study by Thanakwang et al. [22], who described physical health as absence of chronic disease. In contrast, the current study showed that chronic disease was accepted when it was kept under control, without pain or being a barrier to well-being. Thus, pain seems to be a kind of indicator of physical ill-health. Moreover, the current study showed that ability to maintain daily function was mentioned by participants which is in line with the study by Ferreira et al. [27] which reported that maintaining functional independence is the first step of active aging and thus improving their quality of life. The important difference in the current study was that Thai older adults emphasized the ability to be physically mobile as an indicator of good health. Moreover, although gender issues were not inquired in the interviews, some gender role differences slightly appeared, women being a bit more concrete about their support and activities for children and community. In addition, the current study pointed to a distinction that mental health was related to improving behaviors and roles when aging according to their culture. Nantsupawat et al. [23] mentioned that healthy older persons were those who changes health behaviour when aged, but did not specify this as related to mental health.

Compared with Stenner et al. [20] who contended that good participation was being involved in leisure and social activities, this study added a description of reasons for participation related to religion and local traditions, and in addition clarified that appropriate participation results in feelings of being part of society, being respected and being regarded as valuable persons. Regarding this issue, it is therefore necessary to provide meaningful activities for older adults. This is in line with what Voraroon et al. [28] found that older persons felt valued if having meaningful duties assigned by the staff when they participated in activities, and were bored, disinterested and frustrated when the activities were meaningless, without duty, and did not match their needs. Good opportunities took into account both external and internal aspects, which are closely interwoven. For example, while the external perspective means joining activities with others, the internal motive could be a personal effort to live well. Spirituality can likewise be seen as doing good for others driven by internal motivations, but it also results in being accepted by other people in the community. That older persons needed appreciation and respect from children, grandchildren, and friends was also found in Manasatchakun [29]. In late life, they mention having less time to accumulate merit that benefits current living and the next life. Nonetheless, joining events and earning merit were important, but since some events cost money it may cause difficulties to older adults with low economic status. The challenge is how to provide opportunities to participate in activities which are not too expensive and still provide a feeling of self-esteem. The current study found a noteworthy contrasting aspect of taking care of older parents in Thailand. Although being taken care of by adult children may result in feelings of being a burden, this on the other hand is a proof of successful parenting, resulting in feelings of pride. When the children are dutiful, the family will be admired and perceived successful in their parenting. Children’s gratitude was also mentioned as one perspective on active aging in an earlier study in Thailand [23]. According to Buddhism, the main way to show respect for parents is to recognize their advice and provide for their needs [30]. Some Thai people in the present study believed that taking care of their parents earns higher merit than performing religious rituals. Yet they were careful in expressing this, perhaps due to ambivalent feelings in times of socio-cultural changes, affecting also the North-eastern way of life?

Regarding security, the findings do not explore only the perspectives on security in social and economic aspects as influenced by others, but also on an emotional level. Self-satisfaction and stability of mind are mentioned. Consistent with Buddhist belief, older people acknowledge and learn to accept that all things are uncertain, so they avoid feeling worried and try to be at peace [31]. The findings of this study showed that important perspectives on security could emanate from these feelings of older adults. Another matter that participants brought up was to prepare for the end of life by way of traditional customs. Managing late life was related to both economic and emotional aspects. Emotional aspects referred to understanding, acceptance and merit accumulation were similar to the findings of Manasatchakun [29] that older people in good health viewed death as a natural occurrence to accept and be at peace with when it comes. The current study further found that they trusted merit-making to be a means to safeguard security after death. The Thai older adults described that dying well and having a good funeral are dignity for them and their family. Thus, preparedness for death is an important topic for older people.

Studying health, participation, and security separately undoubtedly elicited perspectives on aging well. The advantage of using each pillar separately compared with using the whole concept of Active Aging as a single term was that the findings created a more distinctive picture of the concept of Active Aging as such. Although three pillars of active aging – health, participation, and security – were assumed to cover the well-being of older people, the perspective on active aging explored by asking about the whole concept of “active aging” may not ensure the coverage and validity. For example, asking about “health” could collect information related to “health”, where the same meaning is shared by the researcher and the participants. Exploring each pillar separately could yield more detailed and meaningful perspectives than a question/concept that is confusing and difficult to understand. It showed more concretely what benefits on a practical level.

Limitations: Most participants described themselves as healthy and living well. The findings may lack the perspectives of older adults with serious chronic illness, disability and low living status as well as those who are single or have no children. The setting was in a province that may not be representative of others in North-eastern Thailand. Suggestions for further studies could therefore be to include other categories of older adults and other areas of Thailand. A limitation is that gendered aspects were not so prominent in the current study and may have needed more attention with added questions or added analytical tools.

The findings illustrated that there are diverse perspectives on aging well and the goals of older people. The study clarified the character of healthy older adults, the desires of the participants and what they need to feel secure. Their main goals are to maintain capacity to continue daily living without too many barriers, participating in activities that they find meaningful and valuable and having a good life in old age characterized by dignity until the end of life. The knowledge yielded by this study could constitute a practical guideline to develop aging well for older people in North-eastern Thailand. It added more clarity and broader perspectives on aging well than starting with well-known technical terms like active aging, healthy aging, and successful aging. Alternatively, other concepts may not be needed when considering how the participants of this study expressed their desires for a good life and well-being in old age. Living in a globalized world, similarities may be seen in terms of the importance of voicing and shaping own perspectives on aging well, even when using common definitions or “pillars”. Thus, this study can add insights not only for Thai contexts but also for global application in public health.

Implications for practice: This study reveals the importance to involve older adults themselves in programs and activities for them. This may be more or less a challenge depending on different cultures and contexts. While the study took place in North-eastern Thailand as a case in point, the basic idea can be applied generally in programs for older people in public health, nursing care and gerontological social work. It can likewise be useful in policy work, not least locally, when policies are to be implemented, to involve older people as co-actors to enhance their quality of life.

Ethic approval and consent to participate

The ethics committee of the Regionala Etikprövningsnämnden Uppsala, Sweden number 2016/567 (2003:460) and Institutional Review Board Committee of Boromarajonani College of Nursing Nakhonratchasima, Thailand number AF09-10COA No. 001/2560 approved the study. All participants received oral and written information about the overall purposes, protocols, time required for participation, and the right to withdraw from the study. The written consent forms were completed before collecting data start.

Consent for publication

Not applicable.

Availability of data and materials

Data will not be available according to the restrictions of our ethical vettings and as this is an ongoing doctoral research project with unpublished data.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no specific grant funding from public or commercial sectors.

Authors' contributions

MW contributed to the study design, data collection, data analysis, and wrote the manuscript. EMA and SR provided with research supervision, refined the study design, assisted in the interpretation of data, did critical reading of the manuscript and participated partly in writing/ OR and gave suggestions during the writing process.

Acknowledgements

We would like to thank all participants in the interviews and Dr.Vialiaporn Rungkawatt who helped us to get access to the field. Thanks also to Ministry of Public Health in Thailand.

Special thanks to Dr. Dan Rosendahl who checked the language.

AAI

The Active Ageing Index

UJACAS

University of Jyväskylä Active Aging Scale

WHO

World Health Organization

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Perspectives on Health, Participation, and Security Related to Active Aging Among Older Adults in North-eastern Thailand – a qualitative study

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