{'fraction_non_alphanumeric': 0.023658536585365854, 'fraction_numerical': 0.00548780487804878, 'mean_word_length': 5.089356435643564, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
How primary care providers promote active aging in community-dwelling older people with mental disorders: A qualitative study

The promotion of active aging in community-dwelling older people with mental disorders is an under-researched area. Primary care providers play an important role in engaging older people with mental health disorders to optimize active aging and increase their quality of life. This study explored how primary care providers apply the concept of active aging in community-dwelling older people with mental disorders and to identify factors that facilitate or hinder such application for promoting active aging in this group. Two focus groups were conducted. Fourteen primary care providers were recruited by purposive sampling from two primary care units located in Ubonratchathani province, the northeast region of Thailand. Content analysis was used to analyse the data. The study found that the majority of primary care providers were unfamiliar with the notion of active aging and that older people with mental disorders were not encouraged to join the health promotion activities organised by the community centre. Thai primary care providers need to be supported with training to enhance skills for promoting active ageing in this group. They also lack resources from the national and local government. The findings of this study were used to help develop a new instrument to measure perspectives of primary care providers in a quantitative study.


INTRODUCTION
In 2002, the Active Aging Framework was established by the World Health Organization (WHO) in order to promote the engagement of older people in activities that focus on improving their health, security, and social participation to optimize the quality of life in older people. [1] Healthy aging, productive aging, aging well, optimal aging, positive aging and successful aging are terms often used interchangeably with active aging. [2] However, the concept of active aging is more comprehensive than the related concepts as it includes aspects of quality of life, a mental and physical health and well-being focus, and independence for people to remain productive as they age. [1] Active aging in community-dwelling older people has become an important area of research because of the need to encourage older people to live in their homes as they age. [3] Many countries have since implemented active aging policies, including Australia, New Zealand (NZ), the United Kingdom (UK), Canada, Sweden, the United States of America (USA), Taiwan, and Thailand. [2,4,5] There are also many studies based on the concept of active aging. [5][6][7][8][9] However, the promotion of active aging amongst older people with mental disorders living in the community is an under-researched area. Of concern is that older people with mental disorders are less likely to age successfully as they need to be supported and encouraged by healthcare professionals. [10][11][12] In developing countries, the majority of older people are living in the community with primary care the main source of health care and support. [13] However, most primary care units are busy centres where primary care providers lack both time and resources to support all the needs of people living in the community. [13,14] In most instances, primary care providers also lack the knowledge and skills to meet the needs of older people living in communities, in particular, those with mental disorders. [15] The aims of the study were to explore how primary care providers apply the concept of active aging in community-dwelling older people with mental disorders in a Thai community and to identify factors that facilitate or hinder such application for promoting active aging in this group.

MATERIAL AND METHODS
This article provides the qualitative phase of an exploratory sequential design mixed methods study. Focus groups (FG) were used to collect data. An interview guide was used to guide the interview. Data were collected from mid-December 2015 to end-January 2016.

Sample and setting
Primary care providers are defined as interdisciplinary healthcare workers, who include: general medical doctors, assistant dentists, assistant pharmacists, registered nurses, assistant nurses, health officers, and primary care workers who work in primary care units or Health Promoting Hospitals in Thailand and are employed under the Ministry of Public Health, the Royal Thai Government.
Two focus groups were conducted with primary care providers who were recruited by purposive sampling from the two primary care units under Ministry of Public Health, located in Detudom District, Ubonratchathani Province, Thailand. Inclusion criteria were the first and the second primary care unit willing to participate in the focus group discussion and who replied to the consent forms. Krueger and Casey [16] recommend between five and eight participants and no more than ten for an effective FG. In this study, there were two FGs with six and eight participants respectively.

Data collection methods
Seventh main questions were used to guide the focus group interview: ( KK, a Thai national with research experience, facilitated both focus groups. The focus groups commenced with introductions from all group members. KK reminded everyone of the purposes of the focus group interview, the need for confidentiality and anonymity within the group, and the discussion requirements. Using a conversational approach to start the focus groups, the researcher then asked the above questions of the group, ensuring that everyone had heard and understood the questions clearly and had an opportunity to respond. The questions progressed from broad topics to the specific, depending on the participants' response. For example, when the researcher asked the primary care providers about their experience in promoting active aging in their communities, the primary care providers said they had a variety of experiences. The researcher prompted elaboration by asking for examples of how they promoted active aging and then, more specifically, by how they focused activities on older people with mental disorders.
Each session was audiotaped on a voice tracer with three mic system of Philips' band by the researcher and later transcribed verbatim by KK. The interview transcripts were reviewed and verified against the audio file as they were completed. In addition, field notes were recorded at the time of each interview. All participants were encouraged to speak freely about their perceptions and experiences. The questions were often repeated gently to ensure understanding and prompts were provided for the participants in order to take the lead and respond. The researcher also welcomed other related topics the participants wished to discuss. Most par-ticipants were able to relate to the questions and to describe their experiences. The focus group meetings ended when participants had nothing more to say. The duration of the focus groups was between one to 1.5 hours.

Data analysis
Directed content analysis as described by Hsieh and Shannon, [17] was used to analyse the data from the FGs. The directed content analysis is used to validate or extend a theoretical framework or theory. [17,18] In this study, the concept of active aging from the WHO model and previous studies relevant to this research were used to guide the exploration and analysis of participants' experiences.

Trustworthiness
The trustworthiness is applied in all processes of this study: data collection, data analysis, and data interpretation as suggested by Lincoln and Guba. [19] Four principles of rigourcredibility, dependability, conformability, and transferability -are considered. [19] 2

.5 Ethical considerations
The Human Research Ethics Committee of the University of Newcastle approved the study. In addition, the Head of all primary care units in Ubonratchathani Province, the Provincial Health Officer, and the Provincial Chief Medical Officer Ubonratchathani approved the study proposal. Participants signed informed consent. During focus groups discussion, participants were given a pseudonym to protect their identity.

Participants' characteristics
Participants were 14 primary care providers, aged 24-52 years. All participants had at least one year experience working in primary care units. They had on average 12 years (SD = 8.91, range 3-30) of working experience. The roles of participants included registered nurses, public health officers, public health administrators, dental assistant, aides, and workers.
Content analysis revealed three major categories, namely, unfamiliarity with the concept of active aging, promotion activities in communities, and factors that influence the promotion of active aging as follows.

Unfamiliarity with the concept of active aging
The majority of participants in this study were unfamiliar with the term "active aging". Being unfamiliar with the concept of active aging meant that health care providers had not ever heard of the concept or the idea, had not heard the term used or they were not sure about how it was defined.
Unfamiliarity also meant that some health care workers simply could not understand the concept even after the terms was described to them as per the WHO pillars. Others suggested that there may be an alternative term used by the Thai language. When asked what they knew some said: "Umm, I have never heard about the concept of active aging." The researcher then explained the meaning of active aging as per the WHO model [1] with reference to the three pillars of the concept; participation, health, and security. Some primary care providers said they did not understand what these terms meant to them or in terms of providing care. There were others, however, who recognised some of the elements of the WHO model in their everyday work as the following exemplars show.

Promotion activities in communities
Despite not being fully aware of the concept "active aging" and the meaning according to the WHO model, the participants described activities that might promote active aging. These related to health promotion, education and training, participation in the community, and personal security.

Health promotion activities
The participants' descriptions of health promotion activities primarily related to health examinations to assess physical health for older people in their communities annually and some activities relating to health promotion. The annualized health examinations were linked to a significant annual cultural event, with older people with mental illnesses screened initially by volunteers from the village.
Participants also described what they do for all older people and the link to Thai cultural events. Older people with men- A participant said that older people living with chronic diseases such as diabetes, heart disease, and chronic renal failure were screened for symptoms of depression.
"Older people who are experiencing chronic disease were being assessed for the risk of depressive disorders with 2questions and 9-questions tools at least once a year." [PCP for 23 years]

Education and training
The primary care providers have educated and trained both older people and caregivers in order to care themselves and their relatives. As two participants said: "We are also trained on how to care for older people who suffer from chronic diseases both older people and caregivers." [PCP for 23 years] "We trained caregivers to clean wound for older people." [PCP for 8 years]

Security
The participants said that older people in their care received an allowance every month from the central government. They also built handrails in the corridors of buildings in the primary care units to prevent falls in older people. Older peo-ple with mental disorders or disability in the community were also supported with equipment, such as walkers and or wheelchairs, to enhance safety in their home. As two participants said: "All older people in our communities receive an allowance every month." [PCP for 23 years] "We are preparing railing along the corridor of the health services unit for older people who are visiting in our primary care. Older people with mental disorders or disability about six persons in our responsibility are protected to be living safety by renting equipment such as wheelchair or walker in living safety from the local government." [PCP for 8 years]

Participation
Older people living in the community organize senior clubs to facilitate their activities associated with the concept of active aging. Activities of the senior clubs are normally linked culturally and spiritually for Buddhists, such as making merit and producing baskets. As participants said: "Some village has managed senior clubs for promoting activities which older people can participate in their group. Older club normally consists of religious activities such as making merit in the temple of the Buddha or in the national day. However, the clubs are not providing all essential activities for older people." [PCP for 23 years] "In some villages, there are activities in order to produce baskets but they are not running the activities all year." [PCP for 23 years]

Factors that influence the promotion of active aging
The findings indicated that there were several factors influencing the promotion of active aging in older people with mental disorders living in communities, namely, facilitators, barriers, resources and support, knowledge, and skills.

Facilitators
Participants said they needed help from the staff of the mental health service to supervise or train them in relation to promoting active aging in older people with mental disorders. As participants said: "Well, for me, mental health service should provide support and supervision. We need the mental health service help us anytime whenever we need urgent support to deal with emergency mental health crisis." [PCP for 20 years] "If Psychiatric Hospital or district hospital supported and trained our health care professionals. We are really happy to promote active aging in all older people in our communities."

[PCP for 23 years]
Cooperation from local government, politicians, teachers, police, and people in communities was also an important facilitator to help primary care workers promote active aging in communities. As a participant said: "People in communities should help us whenever we promote active aging. We also need to cooperate with another organisation such as local government, police, teacher, politics." [PCP for 20 years] In addition, one participant mentioned that the leader of a community was an important person to help promote activities of active aging for older people.
"I think it depends on the strength of communities. I mean that the leader is important key informant to motivate people in villages for promoting every activity." [PCP for 4 years] Furthermore, older people and their family also play a crucial role in promoting active aging. As participants said: "I think everyone in our primary care happy to promote active aging. But, we need cooperation with other organisation such as politics, teacher, police, local government including older people and their family." [PCP for 23 years] "For me, family background is an important factor to work with people in our communities. I mean that some families are willing to participate in any activities, in particular, those families that have education and a retirement person from the government organisation." [PCP for 17 years]

Barriers
There were several barriers identified to promote active aging in older people with mental disorders living in communities, namely, lack of knowledge and skills, heavy workload, lack of budget, and lack of support networks.
Lack of knowledge and skills on how to deal with people who are experiencing mental illnesses is one vital barrier of primary care workers. As a participant said: In addition, one participant mentioned that the funding and health policy from the Thai government was not directed to supporting mental health tasks.
"Well, the budget for supporting mental health tasks is indirect in another part. It is not budget for developing mental health. The government should give more money and pay directly to promote active aging in older people with mental disorders." [PCP for 23 years] They also noted that there was no mental health policy to guide mental health care.
"Department of Mental Health is not a specific policy about mental health task. We have to follow the policy of the central government." [PCP for 20 years] "The policy should scope what we need to do in urgent. Sometimes, we do not know what should be our priority for mental health tasks. Now, physical health is the main priority because the government give the main policy and report key performance indicators, support resources including more money." [PCP for 23 years] The participants also noted that there is a lack of role clarity and support for staff for mental health services in primary care units. As two participants said: "Umm, I also think the role of working is unclear role especially mental health tasks." [PCP for 17 years] "I think health service system in relation to mental health is not supporting our staff in working. It is not clear what we have to do." [PCP for 23 years] Two participants did not know the channels for referring psychiatric patients to the psychiatric hospital.
"Umm, we need to be supported by the Psychiatric Hospital. Now, we do not know the channel to refer psychiatric patients." [PCP for 3 years] "We need to know how to contact or ask for help from the psychiatric hospital. What is the service we have to cooperate? Sometimes, we got problems in our communities such as aggressive behaviours, suicide or homicide. At that time, I need to consult specialist in mental illness for managing the problem in urgent." [PCP for 20 years]

Resources and support
Resources and support were found to be important factors that influenced the promotion of active aging in communities. As two participants said: One participant also complained that the psychiatric hospital should educate them on how to deal with psychotic patients, in particular, on the job training when they visit and follow up the patients in the community.
"For mental health service, the officers followed up and visited psychiatric patients in our communities. I think they should teach us how to manage psychiatric patients as well.
We are working in the communities and then we should know how to deal with these patients and knowledge about active aging." [PCP for 23 years]

DISCUSSION
Primary care providers are recognised as influencing the health of older people living in communities worldwide, especially those who work in the primary care of developing countries. [20] In Thailand, primary care workers play active roles in relation to preventative care and promotion of healthcare for individuals and communities. [21] The findings of this study show that primary care workers were unfamiliar with the notion of active aging despite the fact that some participants have worked in primary care for 30 years. This may be because active aging is defined differently by Thai experts and that it has a different meaning. [22] Overall, The notion of active aging from Thai experts is concerned with physical health, independence, volunteering, participation in social activities, and living safety which based on the concept of active aging from the WHO model. [1] Even after explanation of the definition and determinants of the concept of active aging by WHO, some primary care providers did not understand what this meant. However, they gave examples of health activities relevant to the concept.
The perspectives of primary care staff in this study indicated that promotional activities in rural Thai communities consist of four components, namely, health promotion, education or training, security, and participation. This is quite different from the findings of a previous study and the concept of active aging. [1,5] The concept of active aging can be divided into three pillars, namely, participation, health, and security, as suggested by WHO. [1] The promotion of active aging in Taiwan showed that it was separated into five components, namely, participation, education, health, leisure, and security. [5] Overall, the health promotion activities revealed in the findings of this study were not inclusive of all of the components of the concept by the WHO model. [1] The findings of this study also indicated that there were a variety of facilitators and barriers that impacted upon the promotion of active aging in older people. For instance, the public psychiatric hospital in Ubonratchathani Province should be a facilitator to support primary care providers for promoting active aging in this group. Moreover, funding and direct mental health policies from both national and regional governments are also crucial facilitator factors to promote active aging in this group. A heavy workload in primary care units, lack of knowledge and skills of primary care providers, lack of resources and support from specialists were important barriers of primary care providers to promote active aging in this group. These results may link to WHO-Aims report on the mental health system in Thailand, that primary care providers face challenges in caring older people living in the community because they lack resources and skills regarding mental illnesses. [23] In addition, supervision and training for primary care providers in Thailand are still inadequate with few resources. [24] Furthermore, WHO reported that integration of mental health in primary care needs to overcome several issues and challenges [14] including the need for investment in the training of staff, reduction of heavy workloads, and adequate supervision from specialists' services. WHO recommended all governments should pay attention to key human resource management with adequate payment, resources, and support for dealing with people with mental disorders in primary care. [14] In addition, coordination of a collaborative network between primary care and men-tal health service should be an urgent concern to integrate mental health services into primary care. [14] Strengths and limitations The two focus groups interviews discussed in this article can provide insight and rich information. However, there are limitations. The head of primary care and a primary care worker had to leave the FG about 30 minutes into the discussion and may have been able to provide valuable information relating to her roles. However, other primary care staff remained in the discussion and seemed more relaxed once the head had left. This research did not recruit village health volunteers of the primary care units to the discussion in the FGs. Additionally, the participants are not representative of all public primary care units under the Ministry of Public Health, Thailand.

CONCLUSIONS
Promotional activities in this study were provided for all older people living in the community. Older people with mental disorders were not directly offered or encouraged to join the health promotion activities. Primary care providers lack knowledge and skills including resources to promote active aging amongst older people with mental disorders. Furthermore, they need cooperation in the form of funds and sufficient human resources from local government organisations and the family member of older people for undertaking the activities.
The findings of this study raise the issues that primary care providers are not able to do all the activities regarding caring older people living in the community by themselves and they need community support. Promoting active aging in communities may be established with cooperation from community and partnership networks. Promoting active aging in older people with mental disorders also needs to be supported by mental health services. More importantly, the findings of this study have led to the development of a new instrument; "Promoting Active Ageing in Older People with Mental Disorders Scale" (PAA-MD). The PAA-MD was divided into three main sections based on the results of this study, namely, general information and familiarity with the concept of active aging, promoting active aging in older people with mental disorders living in the community, and factors that influence the promotion of active aging in this group. Further testing of this instrument is needed in order to ensure its completeness and utility in other cultural settings.