Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 Asia Journal of Public Health Journal homepage:http://www.ASIAPH.org Original Articles Quality of Life of the Elderly People in Einme Township Irrawaddy Division, Myanmar Myo Myint Naing* Sutham Nanthamongkolchai** Chokchai Munsawaengsub** *Medical officer, Medicines Sans Frontieres-Holland ,Myanmar **Department of Family Health, Faculty of Public Health, Mahidol University, Bangkok,Thailand 4 ARTICLE INFO Article history : Received July 2010 Received in revised form September 2010 Accepted October 2010 Available online January 2011 Keywords: Quality of life Elderly people Self-esteem Family relationship Corresponding Author: Nanthamongkolchai S, Department of Family Health, Faculty of Public Health, Mahidol University, Bangkok 10400,Thailand. Email : phsnt@mahidol.ac.th Asia J Public Health 2010; 1(2):4-10 ABSTRACT Objective: To study the quality of life of the elderly people in Einme Township, Irrawaddy Division, Myanmar, and factors related. Materials and Methods: A cross-sectional survey was conducted among 209 elderly aged 60 and over, who lived in Einme Township, Irrawaddy Division, Myanmar. Data were collected by using structured interview questionnaire from February 1 to 21, 2010. Statistics used for data analysis were frequency, percentage, mean, standard deviation, Pearson product moment correlation coefficient, and Multiple regression analysis. Results: The majority of the elderly people (80.9%) had a moderate level of quality of life, followed by high level(17.2%) and low level(1.9%). The factors that were statistically significantly related to the quality of life of elderly were education level, current illness, self- esteem, family income, family relationship and social support. In addition, self-esteem and family relationship could significantly predict the quality of life of elderly by 53.3%. Self-esteem had the highest predictive power of quality of life. Conclusion: The factors related to quality of life of elderly people were self-esteem and family relationship. To promote quality of life of the elderly, responsible organizations should establish activities that enhance elderly self-esteem and promote good family relationship. INTRODUCTION Quality of life is essential. Improving the quality of life is now a common aim of international development. However, enjoyment in life and a sense of purpose and happiness can still elude elderly people, making these important problems that need to be solved, especially in one’s advanced years 1 . It is not easy growing old and most times, depression attacks elderly people, and especially they tend to feel helpless and inactive after retirement, with their role as primary provider having finished. So, they are more negative and sensitive and rely on others, so they should be cared for to achieve a good quality of life. The quality of life of elderly people has become relevant with the demographic shift towards an aging society. There are indications that concepts and concerns related to quality of life in elderly people are different from the general population. The majority of the elderly people evaluate their quality of life positively on the basis of social contacts, dependency, health, material circumstances and social comparisons. Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 5 Adaptation and resilience might play a part in maintaining a good quality of life. With all other influences controlled, ageing does not influence quality of life negatively, and a long period of good quality of life is possible 2 . Therefore, the maintenance and improvement of the quality of life become important issues. The proportion of elderly people (aged 60 or over) in the world population 3 has increased, and also, in Asia 4 , the size and proportion of the elderly population was 281 million and 8.2% respectively. This means that 52% of the world’s elderly populations are living in Asian countries. In developing countries, including Asia, the elderly populations are increasing rapidly. These demographic changes are a direct result of the success of socio- economic development that has led to a decline in mortality rates at all ages and a reduction in fertility. However, an aged population might be expected to suffer with the problems of dependency and disability leading to an increased burden of disease. Myanmar 5 has also emerged as a nation with an ageing population, and the proportion of elderly people over 60 has gradually increased from 6.4% in 1980-81 to 8.3% in 2005-06. Einme is a sub-urban area in the Myaungmya District, Irrawaddy division. The district is a deltaic tract, bordering south on the sea and traversed by many tidal creeks. The occupations of rice cultivation and fishing engage practically all the inhabitants of the district. According to a report from Help Age International 6 , 2008, dependency ratio of the total older people in delta region, was 51.8% with the highest dependency ratio found in the poorest, female, old-old group. Also, 6.8% of the elderly live alone. The highest percentage of loneliness was found in the poorest male, old-old group. 59.8% of the elderly have no means of earning a living and 82% do not own property. 63.2% of the elderly are classified as the poorest of the poor. 29.2% are considered poor and only 7.7% are moderately self-sustainable. The highest percentage of the poorest was found in the oldest female group. Moreover, the study of the health status and quality of life of Thai elderly by Assantachai P and Maranetra N 7 show that 61.4 % had a good quality of life and 38.6% had a low quality of life. The factors associated with a low quality of life were not living with the spouse, poor financial status, no regular exercise, sleeping or hearing difficulty, suffering from joint pain or diabetes mellitus, and history of a fall within the last 6 months. It is obvious that the elderly have faced both physical and mental problems and resulting bad health that led to negative mind and lower quality of life. Thus, it is no longer possible to ignore the commencing ageing phenomenon in Myanmar and therefore, it is vital to anticipate the requirements of the old age group in Myanmar in order to plan appropriate policies to address their growing needs and to support their quality of life. In Myanmar, there is no specific policy for elderly people such as compulsory welfare services for the elderly or health insurance coverage, and there is still low awareness of the special needs for elderly people and staff working in the homes for the aged who have yet to understand the basics of care for the elderly (daily physical activity, minor illnesses and social support). Cooperation between health staff and social welfare staff is still weak regarding services at the homes for the aged 5 . So, the researcher was interested in studying quality of life of the elderly people in Einme Township, as well as factors affecting the quality of life of elderly people in Einme Township. The researcher also believes that the results derived from the study will be beneficial to public health sectors and other related organizations for conducting an effective plan and aid management to help and take care of elderly people in future. MATERIALS AND METHODS The research was a cross-sectional survey on quality of life of the elderly people with a sample group of 209 elderly people both male and female, aged 60 years and over. Data were collected from February 1 to 21, 2010 by the researchers and village health volunteers. The sample groups were selected by simple random sampling from 6 villages of Einme Township, and were made up of those who had been living in the selected village at least 1 year. The research instrument was an interview questionnaire, developed by the researcher and consisted of 6 parts. Part 1 employed general characteristics of elderly people such as age, sex, education level, marital status, family type, occupation of the old aged, family income and any chronic diseases that they had and included 9 questions. Part 2 was to determine the instrumental activities of daily living by using Barthel ADL index, 8 which was used for measuring the functional status and included 10 questions. Part 3 evaluated family relationships and examined feeling and opinion of elderly people towards family relations such as, love and care, interaction among family members, respect among family members, unity among family members, and relaxation among family members. The family relationships included 10 questions and were developed by the researchers by reviewing the family relationships in later life by Smith S 9 . Part 4 determined the social support by reviewing the work of Cobb S 10 . The set of questionnaires included 10 items relating to social Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 6 support from family and relatives or friends. Part 5 assessed self-esteem by using quick self-esteem assessment and included 11 questions. Part 6 evaluated the quality of life by using WHOQOL- BREF 11 assessment form to provide a quality of life assessment that looks at domain level profiles. It had a total of 26 questions. This structured questionnaire was assessed for content validity by three experts. Also, the tested interview questionnaire was then tested for reliability by doing a pretest in the pilot study among 30 elderly people with similar characteristics to those of the study population. The results were analyzed by calculating the Cronbach’s Alpha Coefficient of each set. The reliability results were as follows: questionnaire for family relationship was 0.88, social support was 0.78, self-esteem was 0.88, and quality of life was 0.97. The data were analyzed by descriptive statistics in terms of frequency, percentage, mean, standard deviation and applied to show the general characteristics of elderly people. Chi-square test and Pearson product moment correlation coefficient were used to determine the factors that were related to the quality of life of elderly people and stepwise multiple regressions were also applied to predict the factors that influence the quality of life of elderly people. A p-value of less than 0.05 was set to consider as statistically significant. Ethical Approval The research proposal was approved by the Research Ethics Committee, Faculty of Public Health, Mahidol University, Bangkok Thailand: Ref. No MUPH2010-027. RESULTS The total sample of 209 elderly people showed that males made up 48.8% of the group and females 51.2%. The age was between 60 and 96 years with the median age of 69 years (SD = .8.2 years). More than half of them (51.2%) were between 60 and 69 years, followed by 35.4% who were between 70 and 79 years and 13.4% who were more than 80 years. The majority (70.3%) had a primary school education and 22.5%,and 7.2% had no education, and secondary school respectively. More than half, 55%, were married, 27.8% were single and 14.8% were divorced. Among them, 52.6% of the respondents lived with nuclear family members and 47.4% lived with their extended family. About half (55.5%) had no occupation in contrast with 44.5% who had an occupation. There were many farmers, 40.3% of respondents (Table 1) . Table1. Number and percentage of elderly people classified by general characteristics (n=209) Personal characteristics No. % Gender Male 102 48.8 Female 107 51.2 age (Years) 60 - 69 107 51.2 70 - 79 74 35.4 80 and above 28 13.4 Median = 69, Minimum = 60, Maximum = 96, Mean = 69.4, S.D.=8.2 Education level Primary school 147 70.3 None at all 47 22.5 Secondary school 15 7.2 Marital status: Married 115 55.0 Single 58 27.8 Widowed 31 14.8 Divorced 3 1.4 Separated 2 1.0 Family type Nuclear 110 52.6 Extended 99 47.4 Occupation of elderly people: No occupation 116 55.5 Occupation present 93 44.5 Farmer 84 40.2 Shop 5 2.4 Carpenter 1 0.5 Merchant 1 0.5 Bus driver 1 0.5 Vender 1 0.5 Current illness With current illness 120 57.4 Without current illness 89 42.6 Chronic diseases Without chronic disease 158 75.6 With chronic disease 51 24.4 Heart disease and Hypertension 38 18.2 Diabetes 9 4.3 Cancer 1 0.5 Others 3 1.4 Health condition (Activities of Daily Living) Just need some help 204 97.6 Need help at moderate level 2 1.0 Need help from other 2 1.0 Totally need help from other 1 0.5 Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 7 Table1. Number and percentage of elderly people classified by general characteristics (n=209) (cont.) Personal characteristics No. % Family income: (in Kyats) <10,000 117 56.0 10,000 – 30,000 53 25.4 > 30,000 39 18.7 Median = 10000, Minimum = 1000, Maximum = 300000, Mean = 21665.07, S.D. = 28951.1 Self-esteem Low level (11-19) 5 2.4 Moderate level (20-26) 143 68.4 High level (27-33) 61 29.2 Family relationship Low level (10-17) 26 12.4 Moderate level (18-23) 113 54.1 High level (24-30) 70 33.5 Social support Low level (10-17) 22 10.5 Moderate level (18-23) 143 68.4 High level (24-30) 44 21.1 Almost half of the respondents (42.6%) were healthy now and 57.4% had some current illness. 75.6% of the elderly people were free of chronic diseases and 24.4% had chronic diseases, with the common diseases of hypertension and heart disease afflicting 18.2% of the respondents. Regarding the health condition (activities of daily living) of the 209 elderly people, the majority of the respondents, 97.6%, could perform tasks themselves and just needed some help (Table 1). Most of the respondents (68.4%) had a moderate level of self-esteem, 29.2% had a high level and only 2.4% had a low level. The results showed that more than half of the elderly people had an income of less than 10000 Myanmar Kyats per month, and 25.4% earned between 10000 and 30000 Kyats monthly. The rest (18.7%) had an income of more than 30000 Kyats per month. The median income per month was 10000 Kyats (SD.28951.1), with the lowest being 1000 Kyats and highest 300000 Kyats (Table 1). Among the 209 elderly people, 54.1% had a moderate level of family relationship, 33.5% had a high level and 12.4% a low level of family relationship. As for the level of social support in the group, 68.4% had a moderate level of social support, followed by 21.1% and 10.5% with high level and low level of social support respectively (Table 1). Quality of life of the elderly people This study indicated that the majority of the elderly people, that is 80.9% had a moderate level of quality of life. 17.2% had a high level of quality of life and only 1.9% showed a low level of quality of life (Table 2). Table 2. Number and Percentage of the quality of life of elderly people (n = 209) Quality of life No. % Low level (26-60) 4 1.9 Moderate level (61-95) 169 80.9 High level (96-130) 36 17.2 Correlation between personal factors, family factors and social factors, and quality of life of the elderly people In testing the relationship between the factors and quality of life of the elderly people by using Chi-square and Pearson’s Correlation Coefficient, the results revealed that education level, current illness, self-esteem, family income, family relationship and social support were significantly correlated with the quality of life of the elderly people in the study at a statistically significant level (p-value) of <0.05. However, sex, marital status, and occupation of elderly people, family type, age and health condition (activities of daily living) were not associated with the quality of life of elderly people (p-value >0.05) (Table 3,4). Factors influencing the quality of life of elderly people Using stepwise multiple regression analysis, self-esteem and family relationship were found to be the factors that had power to predict the quality of life of elderly people in the study. These two factors could predict 53.3% of the quality of life of the subjects. The factor that best predicted the quality of life of the elderly people was self- esteem (Beta = 0.574), followed by family relationship (Beta = 0.226). Therefore, quality of life of elderly people = 16.180 + 0.574 self- esteem + 0.226 family relationship (Table 5). DISCUSSION In this study, it was found that a majority (80.9%) of the elderly had a moderate level of quality of life, followed by 17.2% having a high level. Most of the elderly had a moderate level of quality of life because Myanmar is a developing country and the majority of people live in rural areas, and the socioeconomic status was not very high. In the study, even though most of the elderly Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 8 Table 3 Factors associated with quality of life of elderly people (n=205) General characteristics Total respondents Level of quality of life Moderate High p-value* No. % No. % Gender 0.117 Male 101 79 78.2 22 21.8 Female 104 90 86.5 14 13.5 Education level 0.007 No education 46 45 97.8 1 2.2 Primary level 144 113 78.5 31 21.5 Secondary level 15 11 73.3 4 26.7 Marital status 0.076 Single 90 79 87.8 11 12.2 Married 115 90 78.3 25 21.7 Occupation of elderly people 0.085 No occupation 112 97 86.6 15 13.4 With occupation 93 72 77.4 21 22.6 Family type 0.068 Nuclear 108 94 87.0 14 13.0 Extended 97 75 77.3 22 22.7 current illness <0.001 No illness 85 59 69.4 26 30.6 With illness 120 110 91.7 10 8.3 chronic diseases 0.051 No disease 157 134 85.4 23 14.6 With disease 48 35 72.9 13 27.1 *Tested by Chi-square Table 4 Correlation coefficient between personal factors, family factors and social factors, and quality of life of elderly people (n=209) Variables Quality of life of elderly people Correlation coefficient (r) p-value Age -0.070 0.313 Health condition (Activities of Daily Living) 0.089 0.202 Self-esteem 0.711 <0.001 Family income 0.201 0.004 Family relationship 0.574 <0.001 Social support 0.524 <0.001 Table 5 Stepwise Multiple Regression Analysis between predictors and quality of life of elderly people (n=209) Variables B Beta t p-value Self-esteem 2.120 0.574 9.632 <0.001 Family relationship 0.687 0.226 3.789 <0.001 B 0 = 16.180, R = 0.733, R 2 = 0.533, Sig F = <0.001 Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 9 had a health condition (activity of daily living) of just need some help, they carried out daily activities by themselves and only one fourth had chronic diseases, and more than half (57%) suffered acute current illness. This can affect self- reliance and cause negative mind and also affect the quality of life. But, due to the support from family and friends and neighbors, they were not lonely and had good self-esteem and can confront their problems. For that reason, most of the elderly had a moderate level quality of life and some had a high level. This result was consistent with that of Sirivanarungsan P et al 12 who found that most Thai elderly people had a moderate level of quality of life. However, this was different from what was discovered in a study of early retired government officers in Nonthaburi Province,Thailand 13 , which stated that mostly, 70% of these elderly people had a high level quality of life. Also, a difference was found in the study of Assantachai P and Maranetra N 7 , in a nationwide survey of the health status and quality of life of elderly Thais attending clubs for the elderly from 66 provinces, which showed that 61.4 % had a good quality of life. These studies investigated the quality of life among elderly populations residing in Thailand. In the present study, the majority of elderly people had a moderate level of quality of life. This could be explained by the fact that the study took place in a different country, in Myanmar. The education level was also different, most of the elderly (70.3%) in this study were primary school level as compared with the early retired government officer’s study, in which most of the elderly had a bachelor’s degree (65.5%). When tested with the Stepwise Multiple Regression Analysis, by controlling the other variables, self-esteem, and family relationship are only two variables that can predict the quality of life of the elderly. These two factors predicted the quality of life of elderly in Einme Township at 53.3%. The strongest factor that influenced the quality of life was self-esteem. This is because most of the elderly in this township had at least a moderate level of self-esteem even though they were poor. They had an informal social network, that is a culture and religion in Myanmar and those elements could have affected the self- esteem. These facts could increase life satisfaction and increase the quality of life also. This corresponds with the study of early retired government officers in Nonthaburi Province 13 , which found that factors influencing the quality of life of early retirement elderly people were self- esteem, social participation, and social support. Self-esteem is the attitude, perception and belief of elderly people towards themselves that they are capable and important including their virtue and power to achieve their objectives and success. In this study, most of the elderly live in rural areas and can find satisfaction in life and have good environmental conditions in which to live. Moreover, they have good social support and family relationships which is the culture of the rural area in Myanmar. In the study by Qunnapiruk L et al 14 , it was found that self-esteem had an influence on quality of life in the elderly. In addition, Jo KH. and Lee HJ, 15 who studied the factors related to life satisfaction in elderly women, found that self-esteem was the only predictor in explaining the level of life satisfaction among old women, regardless age . Family relationships were another important factor that could predict the quality of life of elderly people because elderly people feel lonely when they retire from work and lose their role in the community due to the effects of aging such as physical, psychological and social changes. They need good family relationships such as care and warmth from their spouses and family members. This could lead to closeness, sense of security and perceived love and then to happiness in life and a good quality of life. If there was no family relation to other family members, they felt lonely and depressed and that reduced the quality of life. This result was the same as Netuveli G et al 16 who studied the quality of life at older ages, and found that the quality of life was improved by having trusting relationships with family and friends, frequent contacts with friends, living in good neighborhoods, and having two cars. In addition, Nanthamongkolchai S et al 17 found that family relationships had an influence on life happiness among elderly females in Rayong province, which is congruent with the present study. The results of this research suggest that self- esteem and family relationships were the only two factors predicting the quality of life of elderly. So, to promote a good quality of life of elderly people, we should promote their self-esteem by establishing formal as well as informal social networks like elderly clubs and religious activities. 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J Med Assoc Thai 2009; 92: s8-12. . factors, and quality of life of the elderly people In testing the relationship between the factors and quality of life of the elderly people by using Chi-square. can predict the quality of life of the elderly. These two factors predicted the quality of life of elderly in Einme Township at 53.3%. The strongest