Factors associated with quality of life among elderly in urban Vietnam

Quality of life (QoL) among the elderly is a big problem in Vietnam due to a growing proportion of the elderly in Vietnam while many conditions, including policies, social facilities, culture and other factors are not ready to support for QoL among elderly.

FACTORS ASSOCIATED WITH QUALITY OF LIFE

AMONG ELDERLY IN URBAN VIETNAM

Dao Thi Minh An¹, Vu Toan Thinh¹, Dunne P Michael²

¹Institute for Preventive Medicine and Public Health, Hanoi Medical University

²School of Public Health, Queensland University of Technology, Australia Quality of life (QoL) among the elderly is a big problem in Vietnam due to a growing proportion of the elderly in Vietnam while many conditions, including policies, social facilities, culture and other fac-tors are not ready to support for QoL among elderly This cross-sectional study was conducted to explore QoL and factors associated with QoL among the elderly in Trung Tu ward, Ha Noi, Viet Nam The findings showed that the four domains of QoL the among elderly fluctuated around 50 Mean scores of social and psychological QoL were higher than those in the physical and environmental domains A statistically significant difference in mean scores of QoL by socio-demographics was re-corded (age profile, educational attainment, and occupation) All four domains of QoL were positively correlated with each other Furthermore, age, psychological, social and environmental domains col-lectively contributed to 47.59% of the physical domain; while the physical, social, and environmental domains accounted for 56.13% of the psychological domain We also found that occupation (work-er), as well as physical, psychological, and environmental metrics, accounted for 34.19% of the so-cial domain Moreover, physical, psychological, soso-cial domains and occupation (home-wife) collec-tively accounted for 45.92% of the transformation of environmental domain Our study suggests that

it is essential to evaluate overall QoL to have a comprehensive view of its effects in the long run.

Keywords: Quality of Life, Elderly, Hanoi, WHO QoL-Bref

I INTRODUCTION

Vietnam’s population structure is in a

pe-riod of dramatic change, presenting a

num-ber of public health benefits as well as

chal-lenges Today, one of the most prominent

issues is how to address a rapidly growing

elderly population Statistics from the Living Standard Survey of Households in Vietnam showed that the number of elderly people (defined as men and women aged 60 years plus) grew from 3.71 million people in 1979 (6.9% of the total population) to 7.72 million

in 2009 (9% of the total population) At this rate, by 2020, it is estimated Vietnam’s el-derly population will be greater than 12 mil-lion [1]

With this in mind, quality of life (QoL) among the elderly is the most pressing

is-Corresponding author: Vu Toan Thinh, Institute for

Preventive Medicine and Public Health, Hanoi Medical

University

Email: vutoanthinhdhy@gmail.com

Received: 05 June 2017

Accepted: 16 November 2017

sue QoL is a multi-dimensional, highly

subjective concept and, as recommended

by the World Health Organization (WHO),

is measured using four major domains,

in-cluding physical, psychological, social, and

environmental [2] Within these categories,

QoL has its own characteristics according to

different economic and socio-cultural levels,

producing trend where an overall negatively

asociates with age QoL [3]

Within Vietnam’s cultural context of

multiple generations living together in the

same household, as well as the impact of

urbanization on a rapidly aging population,

QoL and mental disorders among the

el-derly need to be paid more attention A

re-cent study conducted in 8 provinces on the

health status of Vietnam’s elderly population

showed that about 95% of the participants

were infected with at least one disease On

average an elderly person suffers from 2.6

diseases With this in mind, about 23% of

the elderly people have difficulties in their

daily life, of which more than 90% need

sup-ports from other people [4] According to the

statistic of the National Institute of

Geron-tology, 9.2% of the Vietnamese population

suffer from depression, one third of which

were elderly and largely retired populations

in major cities [5; 6]

This is an important point to understand

in an age of rapid urbanization The

propor-tion of elderly in urban areas is quickly rising

and becoming a far more difficult problem

to properly address Compared to the

elder-ly living in rural areas, the elderelder-ly in urban

zones have distinct lifestyles such as

exten-sive free time, more available information

relating to health problems, but most of all, less integrated neighborhood relationships compared to those in rural areas Further, after retirement, may confront psychological loneliness, emptiness, and even abandon-ment by their children and neighbors, this would put the elderly in isolated situations Hanoi is the capital of Viet Nam where there is a rapidly developing economy and growing population in which many Vietnam-ese households have 2 to 3 generations live together [7] QoL of the elderly in Hanoi af-ter retirement is often influenced by many factors such as home economics, relation-ship with their spouse and children, social issue, physical and mental health, and the medical system [8 - 10] However, few stud-ies have specifically analyzed the extent that these factors impact QoL among the elderly, especially among those living in ur-ban wards in Hanoi In Vietnam, there were some studies conducted on QoL among the elderly [11]; however, none focused on the population living in major cities

Therefore, this study aims to analyze the quality of life based on the four main do-mains among the elderly population living in Hanoi’s Trung Tu ward

II SUBJECTS AND METHODS

1 Subjects

Target population is the elderly living in urban areas in Hanoi city Particularly, the study population is defined as the elderly living in Trung Tu ward, Hanoi Participants who were recruited into this study if they met the following criteria 1) People who living in Trung Tu ward, Hanoi for at least 1 year; 2)

Aged ≥ 60 years old (according to the

or-dinance of the elderly, issued by the

Presi-dent of the National Assembly on 28th April

2000, the elderly are defined as citizens of

the Socialist Republic of Vietnam from 60

years old or more [12]); and 3) Willing to

participate in this study after giving informed

consent Individuals were excluded if they

were living in Hanoi temporarily, refused to

participate, or had difficulties in

understand-ing or completunderstand-ing the questionnaire

2 Methods

Research site

This cross-sectional study was

conduct-ed in Trung Tu ward, Hanoi, which is

locat-ed in Northern Viet Nam This ward has one

of the densest populations in Hanoi and is

mainly comprised of government officers

that live in 62 dormitories and 2 residential

districts with convenient transportation and

close proximity to entertainment venues,

national hospitals, and schools Until 2012,

there were 1,593 elderly people in Trung Tu,

accounting for 11.78% of the total

popula-tion of the ward

Sample size and data collection

This is a pilot study, so we decided on

a convenience sample of 2% (or 299) of

Trung Tu ward’s total elderly population,

who volunteered for the study The first step

of recruiting participants was effectively

announcing the study Ten health

collabo-rators of Trung Tu’s health center wrote an

introduction about the study and announced

the recruitment on the boards at dwelling

areas that they are in charge of The

an-nouncement ordered those who wanted to

voluntarily participate in the study to call a

toll-free number for registration After being contacted by potential subjects, the sec-ond step was to screen them for eligibility using a questionnaire that assessed each participant’s recruiting criteria They were then recruited into the study based on these criteria until the target sample size of 299 elderly people was met In the last step of sampling, collaborators contacted regis-tered participants at home and provided them with consent forms After reading the consent form, if the elderly agree to partici-pate in the study, they would then receive a self-administered questionnaire from collab-orators They then allowed at least 2 weeks for participants to complete their question-naires and return them to health collabora-tors in Trung Tu ward, either by themselves

or their relatives If their relatives delivered the questionnaire, it would be sealed in

an envelope to ensure confidentiality The self-administered questionnaires were im-mediately screened to check for missing information to ensure participants could cir-cle responses they missed If their relatives delivered their questionnaires, we used the telephone number which was recorded on that questionnaire to call the elderly After that, the participants' phone number was deleted to secure their personal informa-tion If the elderly refused to answer, that questionnaire was considered as ineligible

Measures

Demographics: Includes 7 questions about participants’ age, marital status (mar-ried vs unmar(mar-ried), education level, living arrangements, and occupation before re-tirement

Quality of Life: WHO QoL-Bref

ques-tionnaire is self-assessment that antains

24 items, each presenting one facet of QoL

and two “benchmark” items in an

individ-ual’s overall QoL and general health The

facets are defined as those aspects of life

that are considered to contribute to a

per-son’s QoL QoL comprises of four main

do-mains – physical health (7 items relating to

pain and discomfort, dependence on

medi-cal treatment, energy and fatigue, mobility,

sleep and rest, activities of daily living, and

working capacity), psychological health (6

items relating to positive feelings,

spiritual-ity, religion and personal beliefs, thinking,

learning, memory and concentration, body

image, self-esteem, negative feelings),

so-cial relationship (3 items relating to personal

relations, sex life, practical social support),

and environment (8 items relating to

phys-ical safety and security, physphys-ical

environ-ment, financial resources, information and

skills, recreation and leisure, home

environ-ment, access to health and social care, and

transportation) These facets were scored

on a Likert scale from 1 to 5 with 1 = Very

poor, 2 = Poor, 3 = Neither poor or good, 4 =

Good, and 5 = Very good; 1 = Very satisfied,

2 = Dissatisfied, 3 = Neither dissatisfied or

satisfied, 4 = Satisfied, and 5 = Very

satis-fied; 1 = Not at all, 2 = A little, 3 = A

mod-erate amount, 4 = Very much, and 5 =

Ex-tremely; or 1 = Never, 2 = Seldom, 3 = Quite

often, 4 = Very often, and 5 = Always The

raw score from each domain of QoL include

varying scales; for instance, the physical

domain ranges from 7 to 35 points;

psycho-logical domain ranges from 6 to 30 points;

social domain scores ranges from 3 to 15

points; and environmental domain are from

8 to 40 points The raw scores of each do-main were then converted to a scale of 0 to

100 to compare with other populations, with lower scores indicating poor QoL A domain was treated as missing when over 20% of its items were missing With regard to QoL scores, they are on a positive scale

(high-er scores represent bett(high-er QoL) and th(high-ere

is no cut-off point to determine a specific score by which the QoL could be assessed

as “good” or “bad” [13]

Data analysis

Data had been cleaned by checking missing data before it was entered into the database Data was entered and cleaned for outlier and illogical data using Epidata software, then converted into file.data to be analyzed in Stata version 10

The results were initially analyzed using means, standard deviations, and frequen-cies Mean and standard deviation were used to assess normal distribution Subse-quently, Man-Whitney tests were employed

to compare means between the four do-mains of QoL by socio-demographics The relationships between each domain

of QoL were identified by conducting Spear-man tests, since domains of QoL were not normally distributed To analyze the influ-ence of independent variables of each do-main of QoL, bivariate and multiple linear regression analysis were used, in which dependent variables were transformed into ranks because of the absence of normal distribution (physical and social variable was squared to meet this condition) Some socio-demographic factors (age, marital status, gender, occupation, education

lev-els, and living arrangement) and

signifi-cant factors in bivariate linear regression or

in literature documents were then put into

multiple linear regression for the full model

The final model was selected by performing

stepwise linear regression The significance

level adopted for statistical test was 5%

Co-efficient, constant, p value, confidence

interval and R-square for each model were

calculated and presented

The final model was tested for its fitness

by 1) checking its linear predicted value

(_hat) and linear predicted value squared

(_hatsq); 2) check goodness of fit ("predict

resid, r"; 3), by checking for

multi-collinear-ity

3 Ethics

The risk of discomfort to participants and

risk of confidentiality loss were marginal

There were some questions about

individ-ual feelings among the elderly about their

happiness with their life, family members,

sex life, and surrounding physical

environ-ment, as well as their social connectedness

To reduce these risks, in the consent form,

participants were advised that they can

with-draw at any time and that they can refuse

to answer any question which made them

uncomfortable They were also advised that

all their refusal or withdrawal will not have

any effect on them in any way Moreover,

an anonymous self-administered

question-naire was developed and used, in which

can complete by participants without the

survey privately Additionally, participants

were asked to return their completed

ques-tionnaire by themselves to the field workers,

who are outside the participants’ wards The

consent form with participants’ agreement

to participate in the study and their admin-istration group numbers was detached from the main body of the questionnaire and sent

to the principle investigator (PI) to be se-curely stored Therefore, all individual infor-mation will be separate throughout the data collection procedure Our approach was to ensure that participants feel that they have control over the proceedings of the survey They were clearly advised that all informa-tion is anonymous and will only be analyzed

at the group level In the consent form, the PI’s contact number was printed and par-ticipants were instructed to if they have any questions If participants do become dis-tressed during or after filling out the ques-tionnaire, they could also contact the PI for further counseling

All survey questionnaires were anon-ymous (no name and individual address identified) and securely stored This study was submitted and approved by the Ethical Committee of the School of Public Health and accepted in May, 2012

III RESULTS

Among the 299 participants, the propor-tion of males to females was balanced at 48.8% and 51.2%, respectively The mean age of study participants was 70.6 years, while the mean age of males was higher than females (p < 0.05) The proportion of the elderly in the group under 70 years was 45.5% compared to these age 70 years and older 54.5% The majority of participants (40.6%) were post-graduation, working

as government officers (80.3%), married (84.6%) and living primarily with their

hus-band or wife and children (47.8%)

Table 1 Mean scores of four domains of quality of life by socio-demographics

Socio - demographic

characteristics

Mean of scores (Mean ± SD) a

Physical Psychological relationship Environment Social Mean ± SD 53.4 ± 12.1 57.4 ± 11.3 60.4 ± 14.1 54.3 ± 11.3

Gender

Age group

Marital status

Occupation

Education

Living arrangement

aScore in range from 0 - 100;

*Man-Whit-ney test

The mean scores of four domains of QoL

fluctuated around 50 (table 1) Meanwhile,

the social domain had the highest score

(60.4), followed by the psychological,

phys-ical, and environmental domain (57.4; 53.4;

and 54.3, respectively) We found that

par-ticipants under 70 years had higher QoL in

physical, psychological and social domains

than those aged at or over 70 years of age

(56.7 vs 50.6; 59.4 vs 55.7; and 62.7 vs

58.5 with p < 0.01, respectively) However,

this trend was not observed in the

environ-mental domain Additionally, statistically

significant differences were found in the

psychological and environmental domains

among the elderly who worked as

govern-ment officers and others (57.9 vs 54.9; and 55.1 vs 50.8 with p < 0.05, respectively) These differences were not seen in the physical and social domains The more highly educated participants were, the bet-ter their QoL in psychological, social and environmental domains (55.7 vs 59.9; 58.6

vs 63.2; 52.5 vs 56.9 with p < 0.05, respec-tively), however this was not the case in the physical domain We did not find

statistical-ly significant differences in mean scores on all four domains based on gender, marital status and living arrangement (whom living with) (p > 0.05)

Interestingly, all domains of QoL were correlated positively with each other (p < 0.001) (Figure1) Specifically, high correla-tions were identified between the physical (0.6), environmental (0.5), social (0.5), and psychological domains

Table 2 Factors associated with physical domain

Model summary Number of obs 299

Prob > F 0.0000

R-squared 0.4759 Physical_QoL Coef P > t [95% Conf Interval]

For the physical domain (table 2), R-square equal 0.4759 (p < 0.001), meaning that age, psychological, social, and environmental domains contribute 47.59% to this facet of partici-pants’ QoL All determinants were positively correlated except for age, which was inversely correlated For every one unit increase in psychological, environmental and social domains,

we would expect a 48.80; 16.64; and a 9.44 unit increase in the physical domain, respectively The coefficient for age was 29.04, meaning that for a one unit increases with age; a 29.04 unit

decreases in physical domain.

Table 3 Factors associated with psychological domain

Model summary

Number of obs 299

Prob > F 0.0000

R-squared 0.5613

Psychological_QoL Coef P > t [95% Conf Interval]

For psychological domain (Table 3), we found that physical, social, and environmental domains were positively correlated with psychological domain, which collectively accounted for 56.13% (p < 0.001) The domain that contributed the most to psychological domain were physical and environmental (whose coefficient was 0.36, meaning that the psychological do-main increases 0.36 ranked units, p < 0.001), followed by social (whose coefficient was 0.14, meaning that the psychological domain increases 0.14 ranked units, p < 0.001)

Table 4 Factors associated with social domain

Model summary

Number of obs 299 Prob > F 0.0000

R-squared 0.3419

Social_QoL Coef P > t [95% Conf Interval]

For the social domain (Table 4), occupation (worker), physical, psychological, and environ-mental domains were positively correlated and together accounted for 34.19% (p < 0.001) The coefficient for occupation was 539.23, meaning that the elderly individulas who worked

as workers have a score of 539.23 ranked units greater than those who were government offi-cers; the coefficient for physical, psychological and environmental domain was, in turn, 19.81; 41.30 and 30.91, meaning that a one unit increases in physical, psychological or environmen-tal domain produces a 19.81; 41.30 and 30.91unit increase in the social domain, respectively

Table 5 Factors associated with environmental domain

Model summary

Number of obs 299

Prob > F 0.0000

R-squared 0.4592

Environmental_QoL Coef P > t [95% Conf Interval]

Data from Table 5 shows factors

associ-ated with the environmental domain

Physi-cal, psychologiPhysi-cal, social, and occupational

(home-wife) determinants together

account-ed for 45.92% The physical, psychological,

and social domains were positively

correlat-ed with the environmental domain and the

correlation coefficient of these domains

were 0.14, 0.44, and 0.14,

respective-ly, meaning that for a one unit increase in

physical, or psychological, or social domain,

we would expect that a 0.14, 0.44, and 0.14

unit increase in the environmental domain

Working as a homemaker was inversely

re-lated and its coefficient was 10.22, meaning

that elderly with working as homemakers

have a score of 10.22 ranked units lower

than those with government officers

IV DISCUSSION

We found that QoL scores of the

elder-ly living in Trung Tu ward fluctuated around

50 and compared to the maximum score in the 0-100 scale, they presented a moderate QoL level for the four domains of WHO QoL-Bref (table 1) These results are very similar

to other studies on QoL among the elderly

in Brazil [13] and two studies conducted in Can Tho and Ho Chi Minh city, Viet Nam, which indicated that the QoL of people aged

at 18 and over stayed at moderate level [14] These similarities in QoL between these lo-cations can be explained by rapid economic development and urbanization However, the average scores of all four domains of QoL in this study were lower than findings detected in other developing countries,

such as among the elderly living in South

Jakarta (Indonesia), in Taiwan (2010), and

in adults with sickle cell disease in Jamaica

, as well as in France among people age 80

and patients after intensive care unit [15]

In this study, the mean scores of physical

and environmental domain were lower

com-pared to the psychological and social

do-main (Table 1) These findings were similar

to the results of other studies and indicated

that social domain had the highest mean

score when compared to other domains [8;

16] In a study conducted on 240

partici-pants, Sanghee Chun et al also indicated

that environmental and psychological

do-mains had higher mean scores compared

to physical and social domains (78.9; 74.2

vs 73.4; 65.6, respectively) [17] Likewise,

a Vietnamese study performed by Phung

Duc Nhat et al also showed this trend [14]

We suggest that the elderly in Trung Tu

ward have a lower perception of their QoL

in the physical domain This was indicated

by their self-reported pain and discomfort,

medicine dependence, energy and fatigue,

issues related to mobility capability, as well

as sleeping and rest, activities of

day-to-day life, and working abilities This was also

the case of it environmental QoL, which

in-cludes a diversity of physical security;

sup-ports for finance; information sources and

skills; entertainment; housing environment;

accessibility to health services and social

care; and transportation as well This

high-lights the importance of improving elderly’s

physical and environmental QoL via urging

them to participate in clubs and recreational

activities while accessing to health services

Several studies showed the effect of age

on QoL of the elderly [18; 19] The higher age was, the lower QoL on physical, psy-chological and social domains (Table 1) These results are similar to the findings by Barua et al in 2007, Abhay Mudey et al in

2011 [2], Abdul Rashid in 2013 [20], Phung Duc Nhat et al in 2011 [14] As seen in García et al., old age was associated with the worst levels of health-related to QoL Likewise, Laxmikant Lokare’s study in 2011 indicated that the mean score in the age group of under 70 years old and above 70 years old were significantly differences in the psychological domain (p < 0.05) [21]

We found that those with higher educa-tion level attained better QoL This finding supports a study conducted in Can Tho city, Vietnam, which indicated that people aged 18 years or over with the highest

lev-el of education had better QoL on all four domains compared to the lower educated participants [14] In a study by Ping Xia et al., participants who had a degree, voca-tional training or above had mean scores in all domains higher than those without (p < 0.001) [16] A study conducted on 205 el-derly in Malaysia indicated that the elel-derly who had secondary school level education had higher QoL as compared to those with primary level or no education (26.7% vs 21.5% and 2.2%, with p < 0.01, respec-tively) Likewise, the elderly who worked as government officers had better QoL than other participants This result supports pre-vious studies indicating that the elderly who were employed had 22.6% of higher level of QoL when comparing to those who were not (13.4%) [22] Additionally, a study

conduct-ed in Nonthaburi, Thailand revealconduct-ed that the