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Roles of mutual help of local community networks in community health activities: Improvement for the quality of life of older people in Thailand

Objectives This study aimed to describe work and activities of community networks focusing on the improvement of the quality of life (QOL) of older people in Thailand. The understanding of the work can help enhancing the community development and strengthening of local communities and their networks. Methods Qualitative methods including in-depth interview, observation, and focus group discussion were employed to the study. 64 participants participated to the study and were recruited from 4 key actors within the community. Content analysis was used to analyze the obtained data. This study was conducted in 6 local administrative organizations (LAOs) which selected from the outstanding areas of the project. Each LAO represents one sub-district of the regions of Thailand namely; (1) the upper north, (2) the lower north, (3)the upper eastern, (4) the lower eastern, (5) the central and (6) the south. Results The findings of this study were categorized into three main themes: (1) Social capital including people in the community, social groups, and organizations, (2) Mutual help/collaboration activities composed of six sets of activities related to social capitals working on the improvement of QOL of older people, and (3) Impacts of the mutual help/collaboration activities on older people and local communities who help to improve of QOL of older people. Conclusion The findings are important features for the community development. These themes should be recommended for community nurses, health related groups and organizations for the improvement of QOL of older people in the community.

There are many social capitals working on caring older people in community; but they work on their own mandate. There were few forums for sharing information of problems and needs of older people as well as for learning about activities of social capitals in community. There were few local community networks which linked four key actors in community to work on the improvement for the quality of life (QOL) of older people.

What is new?
Local Administration Organization (LAO) links the other three key actors in community including civil groups, community leaders and public sector officers to work together in order to solve problems and respond to the needs of older people in the community regarding society, economy, environment, health, and policy. Caring activities of social capitals for older people were analyzed; problems and needs of older people and gaps of caring were found. LAO and the other three key actors fulfilled these gaps. This helps to create opportunities for social capitals to improve their capacity by adding new activities and work collaboratively. The local community networks enhance social capitals to share information and learn experiences of working on issues related to older people. There are six sets of activities working on the

Introduction
The percentage of older people in Thailand has increased rapidly. There are approximately 11 million older people aged 60 years and above accounting for (16.5%) of the total population in Thailand. The country will inevitably face the challenges presented by an aging society; and the percentage is growing continuously. It is expected that Thailand will enter a critical period of an aged society by 2024e2025 [1].
According to the data gathered by Thailand Community Network Appraisal Program (TCNAP) [2], there are total number of 2,816 local administrative organizations (LAOs) out of 7,000 LAOs which approximately (35.9%) of LAOs in Thailand. These LAOs are currently working within community networks. The data showed that the percentage of older people living within the networks was 18.9% [3], which is higher than the overall percentage of aging population in Thailand [4].
An increasing in proportion of older people in Thailand results in changes to the social context and culture of the community health care system. The main target groups of care are not only mothers and children, or working age people, but also rising in numbers of "older people", who require more specific and continual care.
Health service alone cannot meet the needs and rights of older people to live happily with dignity. For example, social welfare for the older people is increasingly important, especially it empowers families and older people to take care of themselves. Improving the capacity of the local community to better manage older people health determinants is one of the conditions to strengthen local communities.
Care and support for aged people requires collaboration of community organizations, social groups, and the agencies in the community; however, needs and solutions are different. They can be complemented if appropriate development is made as follows: (1) The health service unit in each area is a health service provider, catering to all the various groups of people, as well as the problem of an aging population, utilizing understanding of science, health care, and social culture. Health services are designed to respond to the problems of each person; (2) Health care and support for older people in the community is health care provided by the people in the community. This requires people in the community who volunteer and are willing to help each other; and (3) The activities for supporting older people are organized by civil groups, LAO, village headmen, community committees, and government agencies, both within and outside the community. This is a mutual help network in communities, implementing activities of health services and community-based care for its population [5].
The total of 134 out of 2,816 LAOs which are the member of local community networks, were appointed to be a center for different purposes such as the networking management center, coordination center and learning center in order to strengthen the operation of members. These 134 LAOs have been employed sets of work and activities of health promoting for various age groups of people, operating within its community. Therefore, the main research project (ref: 61-00-001) aims to study development and strengthening of the local communities in the local community network of Thailand; this research is a part of a larger project. However, it is necessary to study the operation of the LAOs and local community networks that provide impetus for work and activities that can improve the quality of life (QOL) for older people. These findings will lead to an evidence for designing and developing strategies consistent with the needs of the LAOs and local community networks covering all dimensions of QOL for the older people.

Study design
This study was a qualitative descriptive research. The methods including in-depth interviews, observations, and focus group discussions were used to collect data with the aim to describe work and activities of community networks focusing on the improvement of the QOL of older people in Thailand in order to explore for better understanding of the past operations related to culture, knowledge, and action based on the socio-cultural context of communities in Thailand [6,7].

Setting
The study was conducted at the local administrative organizations (LAOs) and the local community networks operating the work and activities for the improvement of QOL for older people. These included six outstanding practice areas, which were selected from LAOs that passed the Local Performance Assessment, assessed by authority of Ministry of Interior team, with scores of over 80%. Each LAO represents, one sub-district of the regions of Thailand namely (1) the upper north, (2) the lower north, (3)the upper eastern, (4) the lower eastern, (5) the central and (6) the south.

Research instruments and reliability verification
Workshops and trainings for researchers have been organized before starting the project. Methodology, tools to collect data, consent forms and related issues were discussed. Three major methods were used to collect data including observations, in-depth interviews, and group discussions using relevance tools. Manual and guidelines for interviews, observations and focus group discussions were provided to researchers.
The main open-ended questions directed at key informants activities concerning issues related to the older people in community were: (1) What is the situation of older people's living conditions in your community? (2) What kind of work or activities were you involved in, toward improving the QOL of the older people? (3) What were the results of what you have done, in general? (4) Who were the beneficiaries of your work? (5) What are your opinions about the work or activities that you were involved in, and the community response toward the improvement of the QOL of the older people? (6) What were conditions that influenced results of the work or activities in a positive way? Later, more questions were added in order to gain insights into data consistent with the objectives of the study. Multiple researchers, methods and data triangulation were used. During the process of data collection, meetings among researchers have been organized for triangulation. The data was rechecked with the original informants in order to validate the quality of data. Confirmation of the results was done by reviewing from the experts who worked on improving the QOL of older people.

Participants
The researchers collected data from 6 study areas specializing in the development of the QOL for older people in all parts of Thailand. A variety of informants from 4 key actors in community were selected according to operations related to older people including civil group leaders, community leaders, public sector officers, and staff members of the LAOs. There were 64 key informants participated in the study, detailed breakdown of the informants appears as (1) Leaders of older people clubs, 4 persons, (2) Leaders of civil groups, 8 persons (3) Village health volunteers and care givers, 7 persons (4) Other volunteers, 6 persons (5) Religious leaders, 3 persons (6) Village headmen, 5 persons (7) Sub-district development committee members, 5 persons (8) Chief Executives and vicechiefs of the LAO, 4 persons (9) Chief Administrators of the LAO, 4 persons (10) LAO officers responsible for social welfare and health division, 10 persons and (11) Health sector officers, 6 persons. The 12 out of 64 informants were leaders of older people clubs and civil groups, who are aged above 60 years old. Therefore, they were also selected to be the representatives of older people whom benefited from work and activities of local community networks to improve the QOL of older people in community.

Ethical considerations
This study was approved by the Khon Kaen University Ethics Committee for Human Research, Thailand. The approval number was HE 612094 on May 24, 2018. Researchers asked for the permission from the mayor of each LAO. Researchers informed key informants regarding to the objective and detailed information before performing the study. Key informants were asked to sign a consent form. Researchers concerned about their privacy and respected about their decision. The rights of the informants were protected. Results of this study and the moral principles were also considered as follows: (1) Respect for persons, (2) Beneficence or non-maleficence, and (3) Justice.

Data collection and data analysis
The study was conducted in 6 study areas from June to August 2018. The researchers collected data by using individual in-depth interviews. The duration of the interview ran for 45e60 min for each related key informant. Observation data was collected by observing the work and activities of those giving care for older people by visiting them at their homes, learning centers, villages, and offices. For the focus group discussions, there were 7e8 key informants participated in the discussion, and the session ran for 2 h. Field notes and an audio tape-recording were required for each interview and discussion. Text data was analyzed by field note analysis and content analysis. Similarities and differences of data from various sources were analyzed. Both typological matrix table analysis and thematic analysis were used to identify key points, to reflect operations and activities, processes, procedures, people or social groups, community organizations, and related organizations. Researchers conducted the analysis along with data collection, and reviewed the material with each informant afterward [8,9].

Results
The findings of this study were categorized into three main themes: (1) Social capital including people in the community, social groups, and organizations, (2) Mutual help/collaboration activities composed of six sets of activities related to social capitals working on the improvement of QOL of older people including potential development; development of an environment conducive to older people; improvement of the service system; establishment of funds and welfare; development and implementation of information systems; and setting up rules and regulations for care of the aged people in community, and (3) Impacts of the mutual help/collaboration activities on older people and local communities who help to improve of QOL of older people. The detailed information is as follows.

Social capital
Social capitals can be categorized as (1) individual level: leaders or community leaders, village headmen, local scholars, and Subdistrict Development Committees; (2) social groups and community organizations level: health volunteer groups, care givers, care managers, social development and human security volunteers, older people clubs, schools for the older people, children's and youth groups, volunteer groups, civil protection volunteers, Funeral Assistance Associations, career groups, community welfare funds, career development funds, Family Development Centers, and the Older people QOL Development and Career Promotion Center (3) relevant organization level: Sub-district Health Promoting Hospitals, LAO, and operational resources such as village pavilions, community activity areas, parks, religious places, markets, etc., and finally, (4) network level: the older people club network, the health volunteer network, and the rescue team network. These social capitals work together and share experiences, skills, information, tools, materials, and budget. Capacity buildings of these social capitals were provided such as trainings, sites seeing within and outside community, leaning and sharing experiences among LAOs under the responsible of learning centers. Regional and National levels forums were organized for sharing experiences and best practices aims to drawing attention on issues related to older people in communities. A declaration of intention to promote QOL of older people in communities was announced as a mandate to focus on. This set of work and activities included (1) training older people for developing potential to prepare for entering old age, or training the older persons and family members in knowledge and skills about self-care, according to each one's relative health status; (2) increasing the number of caregivers, both volunteers and professionals, to provide care for the older people in different ways, covering all problems and needs and all health conditions; (3) preparing courses and instruction manuals for the older people and for caregivers, such as self-care courses and guidelines, and courses and care handbooks for older people with disabilities, and a care manual for home-bound and bed-bound patients; (4) supporting establishment of schools and classes for the older people, and providing instructional programs covering physical health, mental health, occupations, and other learning such as computer use, communication using technology such as 'Line' and Facebook, practicing English skills, and knowledge of their rights; and (5) supporting establishment of clubs for the older people which provide assistance and which supports activities for the older people in all areas, including society, economy, environment, and health "In our area, there is promotion of health of the older people through exercise in the community, in schools for the older people, and vocational training for the older people and the disabled, in order to allow them to take care of their health in the community, such as Thai massage and using herbal medicine for health care." (Registered nurse, Sub-district health promoting hospital, LAO 6)

Development of an environment conducive to older people
This set of work and activities included (1) encouraging the older people to reduce their household expenditure, such as planting vegetables, practicing animal husbandry such as raising chickens, ducks, or fish, for home consumption. Also encouraging the older people to use public places for planting vegetables and for raising animals; (2) adjusting the home and the environment in the home to support the older people, such as adding sturdy stair rails, rails in the bathroom, and brighter lighting, as well as adapting the house and the environment to match problems and needs suited to older people individuals' health status. The staff and community volunteers should get together to help in creating a budget and procuring materials for home adjustment for the poorest older people; (3) providing spaces or community activity areas for group activities, promoting regular exercise for the older people, improving all health conditions in the community, and also providing a clean environment in ways such as waste management, or reduction of chemical use in the community; and (4) adjusting public service areas of local government organizations or public spaces in the community to facilitate the older people by such means as the expressways, elevated toilet seats, lowering the angle of slopes, and adding handrails to all walkways, stairs, or ramps. In addition, wheelchair ramps should be added in place of steps for older people or those of any age who cannot walk.
"The physical environments of five mosques in our sub-district have been adjusted, such as toilets, slopes, and handrails for facilitating Muslims coming to the mosques." (The chief administrator, LAO 1)

Improvement of the service system
This set of work and activities included (1) providing care for the older people at home, as needed, such as health care, and providing care at home for those having special problems and needs, such as those with chronic problems, people with multiple disabilities, bed-bound patients, the homeless, or those experiencing severe violence in the home; (2) day care services in the community to provide care for the older people, such as general health care and physical rehabilitation, e.g., training for walking, sitting, mind training, creating art, and massaging; (3) providing a service center or a coordinating center for borrowing necessary equipment to help the older people, such as air beds, wheelchairs, or oxygen tanks. Also establishing Community Rehabilitation Centers with staff and volunteers providing care, such as muscle exercises, physical therapy, emergency care, and assisting with regular but sometimes difficult needs such as meeting the doctor according to appointment times and contacting government organizations; and (4) supporting the Older People Quality of Life Development and Career Promotion Center as a friendly service center for the older people.
"In our area, there is a system of home visits to provide long-term care for the home-bound and bed-bound older people. Emergency and refer services are also provided. There are services for patients with chronic diseases to prevent complications with feet, kidneys, and osteoarthritis, in chronic disease clinics." (Registered nurse, Public Health Division, LAO 2)

Establishment of funds and welfare
This set of work and activities included (1) support for welfare funds, such as funds to help when people get sick or die, and a 'friends help friends' fund; (2) encouraging the older people to become members of at least one welfare fund organized by the community, and to save money; and (3) encouraging older people and their caregivers to earn extra income through vocational training. There is capital support for occupational training and coordination with markets both in and outside the community, for selling products.
"At our sub-district, we have set up a fundraising agreement among beneficiary groups, civil groups which earn money, and an Islamic committee based on Islamic religion which is called the "Zakat Fund". It is a fund to help solve problems and improve life in Muslim society for those who need help, such as the poor older people, disabled people, those who are in debt, and widows." (Imam, Islamic religion leader, LAO 1)

The development of information systems and implementation
This set of work and activities included (1) having the database system for using in support of care for the older people, such as basic information, health status information, the registration of the home-bound and bed-bound older people as well as the older people with disabilities in the long-term care system, the information of social capital and community potential to provide assistance and using the information of the older people to help with care planning; and (2) supporting the posting of signs in front of the older people's homes and prioritizing the assistance according to urgency.
"At our sub-district, we have collected data on people with problems and needs for long-term care, such as bed-bound patients, people with disabilities, and health status of the older people and risk groups. This information is used for planning to design care and assistance." (Registered nurse, Public Health Division, LAO 2) 3.2.6. Setting up of rules and regulations for the care of older people in the community Rules and regulations have been agreed upon, concerning various issues among civil groups, volunteers, leaders, and LAO, in order to manage the needs and problems of older people. However, some rules and regulations might be updated or improved, and other rules added, to better suit the actual needs of the older people in modern society. Some rules and regulations have already been written into law, such as (1) support for the older people to participate in sharing ideas at community meetings on issues of older people such as being on the board of the older people welfare fund and groups helping older people with disabilities; (2) encouraging community organizations to set rules that favor the older people in terms of social, economic, environmental, and health aspects; and (3) making legislation/ordinances that are consistent with the problems and needs of the older people. These are good rules. However, there should be ongoing study to propose further regulations to be made as time passes and we learn more about the evolving needs of the older people in this changing world.
"There are rules and regulations agreed among LAO, community members and its people to provide care for people who are in difficult conditions, such as assistance with free transportation to get health services continuously. We put in our fiscal plan according to ordinance in order to release the budget." (The chief exclusive, LAO 2)

Impacts on older people
Impacts on older people in the community can be presented as follows.
(1) Older people can now travel and join activities of the older people clubs and schools. (2) bed-bound and home-bound older people were assisted in adjusting their home environment.
(3) Families of older persons were provided with appropriate help. (4) Older persons who were sick and needed help to increase their income and reduce their expenses were economically and socially helped through use of social capital to reduce the burden of caregivers in the household. (5) There are now a variety of volunteer groups to assist with such needs, such as health volunteers, volunteers caring for the older people at home, civil protection volunteers, and rescue volunteers.

Discussion
According to the study on the improvement of the QOL of older people, we found 6 different sets of the development activities on social capital including: (1) potential development, (2) development of an environment conducive to older people, (3) improvement of the service system, (4) establishment of funds and welfare support, (5) development of information systems and implementation; and (6) creation of rules and regulations for the proper care of older people in the community. These projects and activities are carried out by people at many different levels, such as community leaders, volunteers, civil groups, older people clubs and schools, community welfare funds, LAO, and others from the government sector that can be used to solve problems and respond to the needs of older people in the community in terms of society, economy, environment, health, and politics. It can also affect household members, caregivers, volunteers, or staff and personnel of organizations involved in older people care.
This study showed that: (1) the new concept of "social capital" has been introduced. Not just only social capitals at individual level gained more trust and relationship working on improvement of the QOL of older people but also at group and network levels. The mutual efforts, working together in community activities, result in improved the QOL for the older people; (2) 6 different sets of work and activities to improve the QOL of older people are concepts occurred from the analysis of work and activities of related social capitals working on improvement of the QOL of older people. Therefore, social capital refers to the human capacity for improving productivity and effectiveness. This is accomplished by applying the same principles and methods of development in health care to all those involved, utilizing group integration and networking nationwide [10]; and (3) Mutual help of local community networks can mobilize LAOs in Thailand to pay attention and work on improve the QOL of older people in community. These activities not only promote the health and wellbeing of older people in the community [11] but can also lead to improvement in QOL for those who live and interact with the older people in the community. This is social and spiritual fulfillment, which responds to complete wellbeing [12].
These findings can be used as an evidence for the recommendation approach for local community networks to learn from and to apply toward designing further projects and activities; which all aim at ensuring for those older people who need help and support can have a better QOL. This is a community self-management system to move societies towards universal health coverage [13].

Limitations of the study
This study was conducted in selected areas; therefore, the projects and activities aimed at the development of the QOL for older people were slightly different according to the region, social and environmental contexts. Therefore, the context of the area must be taken into account when implementing the program based on the results of this study.

Conclusion and implications for health personnel practice
Community nurses and health team staff are involved in caring for various groups of older people in the community such as the home-bound or bed-bound older people, those with chronic disease or disabilities, the homeless and poor, and older people who live alone or live with their partners [5].To contribute to the development of mutual help and full community social capital participation in improving the QOL for older people, the recommendations are as follows:

Nursing practice
Community nurses should: (1) find social capital and collaborate with community to implement activities for the older people in community, (2) encourage 4 key actors to apply 6 sets of activities to improve QOL of the older people, (3) provide information related to health of older people in the community in order to develop a monitoring and evaluation plan of social capital activities.

Education
Educational institutions should design a short course training focusing on social capital assessment in order to strengthen the community participation as well as mutual help of local community networks in community health activities.

Research
Nursing institutes should develop research projects together with the various areas for capacity building of social capital to improve the QOL of older people in the community.

Policies
Thailand Nursing and Midwifery Council should (1) develop a guideline for community nurses to work with social capital and local community networks, (2) provide a support for knowledge management on mutual help activities between nurses and social capital in order to improve QOL of older people in the community, and (3) encourage the success cases of mutual help activities that helps developing a training centers or learning resources for nurses and people who are interested about this matter.

Conflicts of interest
The authors declare no conflicts of interests.

Funding
The Center of Research and Development in Community Health System, Faculty of Nursing, at Khon Kaen University, Thailand provided supporting for the research grant (Ref:61-00-001).