Introduction

Noncommunicable Diseases (NCDs) are the number one health problem in the world and in Thailand. In particularly, the main causes of death among Thais are the four main NCDs groups, namely 1) cardiovascular disease and cerebrovascular disease, 2) cancer, 3) chronic obstructive pulmonary disease, and 4) diabetes. Those diseases result from key factors including smoking, drinking alcoholic beverages, consuming sweet, fatty, salty foods, and not having enough physical activities, affecting people’s way of life and cause them to continually suffer from NCDs. The illnesses have impacted on their quality of life, on the economy in terms of increased expenses, and on society in terms of the loss of labor capabilities (Bureau of Noncommunicable Diseases, Department of Disease Control, Ministry of Public Health, 2018).According to the 2019 Thai National Health Examination Survey, it was found that Thailand had approximately 14 million people (25.4 percent) with high blood pressure. This means that 1 in 4 Thais have high blood pressure and almost half (48.8 percent) do not know that they have it. It was also found that there were 5 million people with diabetes (9.5 percent), 1 in 3 people (30.6 percent) did not know that they had diabetes and only 1 in 4 people (26.3 percent) were able to control their disease. Service quality development was another essential role in the care and management of chronic non-communicable diseases so that patients with chronic non-communicable diseases could access important health services to reduce risk factors, reduce diseases, and prevent complications from illnesses to have a better trend (Division of Non-Communicable Diseases, Department of Disease Control, Ministry of Public Health, 2023).The World Health Organization had proposed community-based operations as a key strategy for the prevention and control of non-communicable chronic diseases. Controlling factors and lifestyles that affect health was one of strategies for prevention, treatment and rehabilitation, which must cover all four aspects of health: physical, mental, social and spiritual, or what is called holistic care, using methods that are correct and appropriate for each person's physical condition, such as exercise, nutrition and health-risk behaviors, not smoking and not drinking alcoholic beverages. Health surveillance using health promotion strategies was a social movement process with cooperation from all sectors and community strengths to improve public health, including normal, at-risk, sick and disabled groups, with the aim of developing all aspects of health determinants to support public health development (Bureau of Noncommunicable Diseases, Department of Disease Control, Ministry of Public Health, 2019).

Chachoengsao Province is a province located in the Eastern Economic Corridor (EEC), designated as a green zone to be developed into a livable city. It has the highest rates of NCDs, with the top two being unexplained hypertension (87,239 people) and diabetes (65,730 people).The rate of diabetes in the age group 60 years and over was 24,797 people, accounting for 21.11 percent. The rate of high blood pressure in the age group 60 years and over was 52,241 people, accounting for 46.94 percent (Disease Control Office 6, 2022). Most of the diabetes and hypertension patients in Chachoengsao Province are elderly and are the main cause of death. If these risky behaviors can be reduced or changed, it will reduce the risk of NCDs by 80%, reduce the risk of cancer by 40%, and reduce the risk of stroke and heart disease and type 2 diabetes by 80%. In the past, public health agencies had encouraged people to change their behavior and follow up on treatment to reduce the rate of patients and deaths from NCDs all along, but the target had not been achieved. According to the population registration database as of December 2024, Chachoengsao Province had 20 percent of elderly people, ranked 9th in the country and 3rd in the Eastern region and was a province in the EEC area with the set goal of becoming a livable city. The Office of Social Development and Human Security of Chachoengsao Province (2021) reported a summary of the social problems of the elderly in Chachoengsao in 2021 as follows: “The number of elderly people increasing every year reflects health problems, lack of knowledge in health care, bedridden patients, some groups of elderly people do not receive care, some do not have access to government welfare, and some are elderly people who live alone / or elderly people take care of each other. The government should give importance to the elderly by supporting the elderly in the group that can take care of themselves to participate in physical and mental development.” (Office of Social Development and Human Security of Chachoengsao Province, 2021).

Bang Khla District is a district of Chachoengsao Province. It has a population of 45,313 people, including 14,939 elderly people, accounting for 39% of the total population (Bang Khla District Public Health Office, 2022).It is the district with the highest proportion of elderly people in the province. Almost one-third of the people in the community are elderly, which is a very high number. If there are no effective and adequate measures to support the care of the elderly, it will lead to subsequent problems. Elderly health care must focus on disease control and prevention, especially NCDs or non-communicable chronic diseases that are most found in Bang Khla District, namely high blood pressure and diabetes. This is because these people live in the same community and must rely on each other and take care of each other better than people from other communities. That is, there should be role models to take care of the community's holistic health, help promote and prevent NCDs, focusing on working in collaboration with all sectors in the community, from the elderly, families, community leaders, sub-district health promotion hospitals, local administrative organizations, neighbors, various network clubs, and local universities. Developing a healthcare system for the elderly that considers the needs of service recipients or cares for people holistically means providing care to meet physical, mental, emotional, and spiritual needs within the context of society, the environment, beliefs, and values of each person (Willison, 2006: Olive, 2003: Jasemi, Valizadeh, Zamanzadeh and Keogh, 2017). The research team is the academic faculty of Rajabhat Rajanagarindra University, the only university in the province whose mission is for serving the local area. The researcher realizes the significance of developing the quality of life of the elderly for controlling and preventing NCDs in Bang Khla District because of increased number of NCDs among the elderly. Therefore, we are interested in studying and finding ways to improve the quality of life of the elderly to control and prevent NCDs for sustainable development with community participation in Bang Khla District, Chachoengsao Province. This project will be beneficial to improve the quality of life of the elderly who are normal and those who have NCDs, especially hypertension and diabetes, by participating in promoting the health of the elderly to be able to control blood sugar levels in the case of the elderly with diabetes or to be able to control blood pressure levels in the elderly with hypertension and to allow the elderly who do not have NCDs to be able to prevent themselves from having NCDs.

Research Objectives

1. To improve the health-related quality of life of the elderly in Bang Khla District, Chachoengsao Province by providing holistic healthcare for non-communicable diseases (NCDs) control and prevention.
2. To develop the role-model elderly in holistic healthcare for controlling and preventing NCDs in Bang Khla District communities.
3. To promote physical health of the elderly by providing holistic healthcare in controlling and preventing NCDs.
4. To promote mental, emotional and spiritual health of the elderly based on the holistic healthcare approach.
5. To improve the quality of life in terms of society and environment of the elderly through community participation in holistic healthcare.
6. To establish a sustainable holistic healthcare network for the elderly in Bang Khla District communities.

Research Conceptual Framework

Figure 1: Research Framework

Methodology

The steps of participatory action research (PAR) cover qualitative data and quantitative data collection using the plan-do-check-act (PDCA) process are as follows:

Step 1 Planning: (Plan: P)

Providing community engagement teams: The research team met the District Health Officer and Presidents of Subdistrict Administrative Organizations to consult and find a work team to help drive the operation of improving the quality of life of the elderly for sustainable development with community participation in Samet Tai Subdistrict. The director of Samet Tai Subdistrict Health Promotion Hospital was the chairperson while committee members consisted of community leaders, village health volunteers, local experts, etc., whose duties included supporting and assisting the work of the role-model elderly in holistic care to prevent NCDs in the subdistrict.

Qualitative data collection: The study explored the community context by interviewing people guided by a self-created interview guide about holistic healthcare for the elderly (current situation and problems regarding holistic healthcare for the elderly, general information, age, occupation, blood sugar levels, blood pressure, and weight) .Common healthcare problems in the elderly include inability to control diabetes, blood pressure, being overweight, and taking medications. The guidelines for solving health problems, promoting holistic healthcare, and proving other health information that could have an impact on holistic healthcare and quality of life of the elderly through community participation during the interview.

Key informants included professional nurses responsible for NCDs at Samet Tai Subdistrict Health Promotion Hospital, the elderly together with their family members, monks, local government executives, subdistrict headmen or village headmen, village health volunteers, and health promotion teachers, totaling 20 people.

Qualitative data analysis and design of programs or guidelines for developing prototype elderly people: The researcher analyzed the qualitative data using content analysis principle to analyze the components or guidelines for developing a holistic healthcare program and quality of life for the model elderly. The main points from the qualitative research were summarized as “Programs or guidelines for improving the quality of life of the elderly with the holistic care approach to control and prevent NCDs.” The program must go through a group discussion with nine local experts, including academics, local administrators, directors of health promotion hospitals, nurses who care for the elderly, and village health volunteers.

Step 2: Implementation of the plan: (DO)

It was the implementation of the program or guidelines for raising standards to train the elderly to be a model for holistic healthcare to control and prevent NCDs, including: 1) Physical healthcare workshop activities: Contents were obtained from integrated interviews with the 3E2A (eating good food, good emotion, exercise, abstaining from both tobacco and alcohol consumption) principles to design the curriculum. 2) Training activities for mental, emotional, and spiritual healthcare, 3) Training activities for social and environmental health care, 4) Home visit activities to follow up on the implementation of knowledge, and 5) Activities to establish a network of NCDs prevention centers in Samet Tai Subdistrict. The participants were 60 selected elderly people or their families.

Step 3: Follow up and check :(Check: C)

It was a process of monitoring, controlling, supervising, and inspecting by systematically collecting and analyzing data in operations, giving the role-model elderly time to apply what they had learned to themselves and others, including the general public and the elderly in their own communities. The team of sub-district health promotion hospitals supported and joined the research team to visit and give advice after the training and evaluate the results of the application to the general public or the elderly in the community.

Summarizing and confirming the model: After analyzing quantitative data of the program or guideline trial, it provided an overall picture of the level of factors affecting the health quality of life of the elderly with the holistic healthcare approach to control and prevent NCDs with community participation and identify the factors affecting the health quality of life of the elderly with the holistic healthcare approach to control and prevent NCDs through community participation. The researchers revised the draft guidelines to be consistent with the findings and presented the draft guidelines to nine experts, including academics, community leaders, nurse representatives from sub-district health promotion hospitals, representatives of the elderly club, representatives of village health volunteers, representatives of local administrative organizations, and representatives of monks, in a focus group discussion to consider the format and confirm the appropriate guidelines for use.

Step 4: Operational Improvement/Expansion: (Act: A)

It was a workshop to return the obtained data to the community. In the workshop, researchers presented the program for improving the health quality of life of the elderly through the holistic healthcare approach to control and prevent NCDs in Bang Khla District. The program, the product of participatory research from all sectors in the community, contained guidelines, advantages, disadvantages, and gratitude of those who helped develop the guidelines. It was also an announcement of the collaboration with the Subdistrict Health Promotion Hospital to develop guidelines to improve the health quality of life of the elderly with the holistic healthcare approach to control and prevent NCDs with participation to be of better quality, which would be a good model for other communities to use in the future.

Population and Sample

Population

Population was the group of people involved in holistic healthcare and quality of life of the elderly in the community and the social addicted elderly group in Samet Tai Subdistrict.

Sample: The stratified random sampling method was applied in Bang Khla District, and one sub-district was selected as the sample. Then, people in Samet Tai Sub-district were studied.

The key informants for qualitative approach were those involved in holistic healthcare and quality of life of the elderly in Samet Tai Subdistrict community, Bang Khla District, Chachoengsao Province. There were a professional nurse responsible for NCDs at Samet Tai Subdistrict Health Promotion Hospital, 8 older people together with their families in all 6 villages, one monk (drawn by lot from 1 of 3 temples), a local government organization executive, two subdistrict headmen or village headman (drawn by lot from 2 of 6 villages), and 6 village health volunteers, and one health promotion teacher (drawn by lot from 1 of 4 schools), totaling 20 people. The selection of a sample group was referred to creating grounded theory (Creswell, 2007, 2013 cited in Chamnian Chuangtrakul, 2018); purposive sampling was selected from those who had the characteristics according to the population and ability to communicate and consent to provide information. The sample group for training the elderly as a model for holistic care to control and prevent NCDs included the elderly or their families in Sa Med Tai Subdistrict, Bang Khla District, Chachoengsao Province. By using the population size criteria, the estimation was based on the population, calculated from 15% of the total population of 401 people = 60.15 people. The researcher therefore determined the sample group to be 60 people (Bunchom Srisa-ard, 2002. If the population was in the hundreds, the sample size was 15-30%) and then selected purposive sampling of those who were interested and ready to participate in the activities and had enough time, representing 10 people from each of the 6 villages, for a total of 60 people.

The local experts in the focus group discussion included academics, local administrators, directors of sub-district health promotion hospitals, nurses taking care for the elderly, and village health volunteers. In totaling, nine people were selected using purposive sampling. The sample group for quantitative research included the sample group for training role-model elderly in holistic healthcare for NCDs control and prevention. The variables used in the quantitative research on improving the health quality of life of the elderly with the holistic healthcare approach to control and prevent NCDs in Bang Khla District, Chachoengsao Province, consisted of:

1. The independent variables were the development of the role-model elderly in holistic healthcare to control and prevent NCDs, consisting of:

1.1 Physical dimension

1.2 Mental dimension

1.3 Social dimension

1.4 Spiritual dimension

1.5 Intellectual dimension

2. The dependent variables were the quality of life of the elderly, consisting of:

2.1 Happiness

2.2 Relationships with other people

2.3 Social and community activities

2.4 Personality development

2.5 Recreation

Research Tools

The instruments used for collecting qualitative data were semi-structured interviews and in-depth interviews to obtain guidelines for programs to improve the quality of life of the elderly. It was combined with concepts, principles, documents, and research related to the quality of life of the elderly through the holistic care approach to control and prevent NCDs which would meet the needs of the elderly. The instruments used for collecting quantitative data were questionnaires on improving the quality of life of the elderly through the holistic healthcare approach to control and prevent NCDs in Bang Khla District, Chachoengsao Province. Quality testing of instruments: Quality control of qualitative research instruments in terms of content validity was verified by three experts. The interview guide was tested with three non-sample participants before being revised and used in practice as a guideline for adjusting questions to make them understandable. The quality of the quantitative research instruments was the questionnaire by giving the questionnaire to 5 experts to consider the content validity by finding the Index of Objective Congruence (IOC) between the questions and the definitions and then selecting the questions with an IOC value of 0.5 or higher. The questionnaire was revised and improved as recommended by experts before being tested with a sample group of 30 people in Hua Sai Subdistrict, Chachoengsao Province. The questionnaire was tested for reliability by using the alpha coefficient method according to Cronbach's (1990) method. If the reliability of the entire questionnaire was greater than 0.75, it was considered reliable, and a complete version was made to collect further data.

Data Collection

Qualitative data were collected using in-depth interviews and fieldnotes. The interview data were transcribed verbatim and analyzed according to Strauss & Corbin (1998). Therefore, the researcher had self-prepared before going to the actual field by preparing knowledge of qualitative research methodology by reading documents, textbooks, works, and related research to cover the issues to be interviewed.

The data collection process is as follows:

1. 1. Preparation for preparing an in-depth interview guide: Before proceeding with data collection, the researcher asked for permission from the sample group for the study and explained the research steps and the research duration. All participants signed in the consent form to participate in the research and were informed that they could refuse to participate in the research and withdraw from the research without any negative consequences. In addition, the information obtained from this research would be kept confidential and would not be disclosed to cause damage to the sample group. The researcher would use the research results only for academic purposes.
2. 2. Implementation: The interview would be conducted at a location convenient for the key informants. The researcher asked key informants about what date and time convenient for being interviewed as in Part After the informants trusted and were ready to provide in-depth information, the in-depth interview would begin as in Part 2.During the interview, questions will be adjusted for clarity according to the context and facial expressions and emotions of the informants, using in-depth interview skills, considering the rights and dignity of the informants. There will be a 2-minute break for each question to prevent stress. After the interview is complete, thank you will be expressed.
3. 3. Observation and recording: The researcher used observation of the sample group's behavior in expressing their opinions during the interview. After the observation, the researcher recorded the data.

Quantitative data collection using a researcher-created questionnaires based on the holistic healthcare approach to control and prevent NCDs and the health-related quality of life of the elderly. In total 60 people were divided into 3 parts:

Part 1: General information of the respondents, including information on gender, age, marital status, and chronic diseases.

Part 2: Questionnaires on opinions about holistic healthcare for NCD control and prevention. The questions were standardized and were rated as rating scale by using Likert's method (Likert, 1967), dividing the level of opinions into 5 levels.

Part 3: Questionnaires on opinions about the quality of life of the elderly: It was a standard rating scale questionnaire using Likert's method (Likert, 1967). The level of opinions was divided into 5 levels.

And the form for monitoring and evaluation about application of knowledge gained from the training to the general public and the elderly in the communities of the trainees after 1 month of training had 2 parts: Part 1 was general information, including gender and age; Part 2 was the application of knowledge, including 8 items of open-ended questions.

Before collecting this data in both qualitative and quantitative research, the researcher had the research participants signed the RSU-ERB.005-1 letter of consent before data collection.

Data Analysis

Analysis of Qualitative Data: By coding the data and using the method of interpreting the data, the researcher created concepts by comparing with theories and research works that had already been researched according to the qualitative study guidelines of content analysis. Data analysis consisted of three steps according to the guidelines of Strauss and Corbin (1998) as follows:

1) Open coding was the process of defining codes or creating indexes (Supang Chantawanich, 2016) from data obtained from interviews. The analysis was to find the consistency reflecting the types or groups of data obtained from the interviews. The researcher considered opening the code and reading it line by line. If there was any text indicating holistic healthcare to control and prevent NCDs and the health quality of life of the elderly and according to the research objectives, it would be coded.

2) The axial coding step was the step of defining the code by processing the data types and the properties of the data types together. It was the creation of the relationship between the data of each code in the first step.

3) The coding selection stage was the process of selecting key events leading to the conclusion of the decoding findings from the interview data. It was a process of taking types and relationships or core data to summarize the characteristics of relationships or phenomena found in holistic care to control and prevent NCDs and the health quality of life of the elderly.

Data reliability testing (Rigor criteria) was performed by the researcher using the method of testing the same data from multiple sources (Data Triangulation) such as annual reports, newspapers, analysis of related documents, etc. And there was a reflective note after data collection to record ideas, beliefs based on data and connections found in the data collection to be used in data analysis completely and correctly.

The quantitative data analysis steps were as follows:

The returned questionnaires were given a score (code) for each item and the results were recorded on the computer using a ready-made program.

Statistics used in data analysis

1. Qualitative Research: Content analysis
2. Quantitative Data: include frequency, percentage, average, and standard deviation (S.D.)

Results of the Study

1. Current situation and problems in holistic health care for the elderly: It was found that most elderly people have health problems that were deteriorating, not very strong; they ate food that were not appropriate for their age, lacked exercise, had chronic diseases, and lacked knowledge and understanding in taking care of themselves. They had mental problems including loneliness, boredom, abandonment, and depression, while their social and environmental issues included lack of social interaction, not going out much, negligent by families such as that they were not taken care as much as they should. Their surrounding environment was not conducive to healthy living. Improving the elderly in holistic healthcare to control and prevent NCDs included physical, mental, social, spiritual and intellectual aspects, and good quality of life. The elements that effectively and successfully supported the development of the health-related quality of life of the elderly included happiness, recreation, interpersonal relationships, social and community activities, and personality development. The guideline for improving the quality of life of the elderly through the holistic care approach to control and prevent NCDs was that all parties cooperated and participated in organizing various activities, organizing training to provide knowledge to keep up with the changes in the current era continuously and consistently; there was monitoring and evaluation of the actual situation, leading to improvements and solutions that directly addressed the problems, which would result in a good quality of life.

2. Development of the elderly role models in holistic healthcare to control and prevent NCDs in Bang Khla District community by developing the elderly role models according to the holistic healthcare training program to control and prevent NCDs and survey scores:

From the questionnaire on opinions on holistic care to control and prevent NCDs, the study results found that the overall level of holistic care factors to control and prevent non-communicable diseases (NCDs) was at a high level. The aspect with the highest average value is the intellectual dimension, followed by the mental dimension, the spiritual dimension, and the physical dimension. The aspect with the lowest average value is the social dimension.

When considering each aspect, it was found in the following:

1) In terms of physical dimensions, the overall level is at a high level. The item with the highest average score is that you eat nutritious food appropriate for your age. The second most important factor is that you exercise appropriately for your age. You are physically fit. The last most important factor is that you can move your body flexibly.

2) In terms of mental dimensions, the overall level is at a high level. The items with the highest average scores are: You meditate to calm your mind, and you exercise to release endorphins that relax your mind. The second most common item is that you know how to manage your own stress. The last most common item is that you are a person who does not have any worries.

3) In terms of social dimensions, the overall level is at a high level. The item with the highest average score is that you are compassionate and fair to everyone. The second most common item is that you live happily with your family, that you live with your family with good relationships, and that you go out and spend more time with your friends or family, and that your family can provide care and support to each other.

4) In terms of spiritual dimensions, overall it is at a high level. The item with the highest average score is that you understand the truth of life, understand nature and everything around us. The second most common item is that you are kind, compassionate, and unselfish towards others. You build your family and community with love, warmth, and respect for each other's dignity. The last most common item is that you are selfless and willing to help others.

5) In terms of intellectual dimensions, the overall level is at a high level. The item with the highest average value is that you are engaged in a career and have achieved success in life. The second most common item is that you have the knowledge to adapt to various situations. You can learn new things and add challenges to your life. The last most common item is that you have the knowledge to take good care of your health.

3) Promoting physical health of the elderly through holistic care in controlling and preventing NCDs It was found that most elderly people eat inappropriate foods for their age, lack exercise, and have chronic diseases. They lack knowledge, understanding, and access to health information to take care of themselves, resulting in problems with behaviors in taking care of their health incorrectly. The solution should be to recommend eating healthy food and exercising appropriately for your age, which will help you stay healthy and move your body flexibly according to your age.

4) Promoting mental, emotional and spiritual health of the elderly based on the concept of holistic care: From the interview, it was found that there were mental problems such as being left alone at home, being lonely, bored, and being afraid that children and grandchildren will not take care of them when they get older. Knowing how to manage one's own emotions. The solution should be to meditate to calm the mind and exercise to make the brain release endorphins that make the mind relax. Understand the truth of life, understand nature and everything around us. Build a family and community with love, warmth, respect for each other's dignity and regularly participate in religious activities according to your beliefs.

5) Enhancing the socio-environmental quality of life of the elderly through community participation in holistic healthcare:

From the interview, it was found that residential houses were not suitable for the elderly, and public areas were not specifically suitable for the elderly. Solutions for these issues are suggested that all public utilities should be provided for the elderly to receive equal and fair treatment for everyone, such as appropriate walkways and ramps for the elderly. The elderly should be treated kindly and live happily with your family, with good relationships, and go out to meet and spend more time with friends or family members. They should take care of each other and regularly participate in community social activities.

6. Improving the quality of life of the elderly in Bang Khla District, Chachoengsao Province by providing holistic care to control and prevent non-communicable diseases (NCDs)

Data from the questionnaire on opinions about the quality of life of the elderly before and after training according to the program found that the average quality of life score after training was higher than before training. But overall, it was at a high level. Ranked from highest to lowest average, they were relationships with other people, personality development, happiness, social and community activities, and recreation.

2.1 General information of the respondents: Most of them were female, aged 76 years and over, married, had chronic diseases including diabetes, high blood pressure, and other diseases such as high cholesterol, cancer, and heart disease.

2.2 Data on the quality of life of the elderly by holistic care to control and prevent non-communicable diseases (NCDs) were generally at a high level. The aspect with the highest average value was the aspect of relationships with other people, followed by the personality development and happiness. The aspect with the lowest average value was the social and community activities and recreation.

When considering each aspect, it was showed in the following:

1) In terms of happiness, overall it was at a high level. The item with the highest average value was “You have a permanent and safe place to live.” Secondly, “You can help yourself, such as going out to buy food and other necessities from shops in your village or community,” and “You are free from illness, making you very happy.” The last item with the lowest average score was “Your house has facilities for daily living.”

2) In terms of relationships with other people, overall it was at a high level. The item with the highest average value was “In any house where the elderly person lives alone, the neighbors will take care of them.” The following item was “The elderly person visits and meets with members of the community and helps take care of each other closely.” And “They can live happily with others.” The last item with the highest average score was “You have good relationships with your neighbors in your community.”

3) In terms of social and community activities, the overall level was at a high level. The item with the highest mean score was “You participate in community meetings on issues such as community development guidelines, etc.” Second item was “You have participated in various festivals such as Loi Krathong, Children's Day, and Senior Citizens Day.” and “You have participated in various community activities as the opportunity allows.” The last item with the highest average value was “You are accepted and respected by people in the community” and “You sometimes donate money and things when you have the opportunity.”

4) In terms of personality development, the overall level was at a high level. The item with the highest mean score was “You can use your knowledge to advise others.” The next item was “Your community provides training to improve your quality of life, such as disease control and self-care for good health. You develop yourself for career advancement.” The last item with the highest average score was “You are interested in learning new things by taking part in training.”

5) Recreational aspects were generally at a high level. The item with the highest mean score was “You socialize with friends in activities such as reading, listening to music, watching sports and other forms of entertainment.” The second most common item was “You get enough sleep, you do activities for enjoyment and relaxation, and you reduce stress.” The last most common item was “You use your free time to do physical activities that make you feel good, and “You participate in community recreational activities.”

7. Building a sustainable holistic elderly healthcare network: In Bang Khla District community, it was found that networking by returning the obtained information to the community at the presentation of guidelines for improving the quality of life of the elderly through holistic healthcare approach to control and prevent NCDs to be of better quality. There were brainstorming with participation from all sectors, both government and public sectors, including the Subdistrict Administrative Organization (SAO), professional nurses, community leaders, the elderly, and the public, and announcing cooperation with Samet Tai Subdistrict Health Promotion Hospital. It was agreed to establish an NCDs Prevention Center in Samet Tai Subdistrict, located at the house of the model elderly selected from this project, to be a place to provide basic advice to the elderly who need knowledge and to measure blood pressure or check sugar levels without having to go to the hospital, which would be a good model for other communities to use in the future. This results in people in the community knowing how to manage their own health effectively and being able to have a good quality of life happily.

8. Quality of life in elderly people with NCDs has improved - health status (blood sugar and high blood pressure have decreased or are under control):

The study found that the number of elderly people with diabetes who had better blood sugar control increased by 2 percent from 42 percent in 2023 to 44 percent in 2024, and elderly people with hypertension who had better blood pressure control increased from 81 percent in 2023 to 88 percent in 2024.

Discussions

1. Results of exploring the current situation and problems regarding holistic healthcare for the elderly: It was found that most elderly people had physical health problems, including deteriorated body, loss of strength, eating food inappropriate for their age, lack of exercise, having chronic diseases, and lack of knowledge and understanding in taking care of themselves. They had mental problems, including loneliness, boredom, abandonment, and depression while their social and environmental issues were lack of social contact with others, not going out much, and not being given care by their families as much as they should; their environment was not conducive to healthy living. Developing the elderly in holistic healthcare for controlling and preventing NCDs included physical, mental, social, spiritual and intellectual aspects, and good quality of life. The elements that effectively and successfully supported the improvement of the health-related quality of life of the elderly were happiness, recreation, interpersonal relationships, social and community activities, and personality development. The guidelines for improving the quality of life of the elderly through the holistic healthcare approach for controlling and preventing NCDs were that all parties had cooperated and participated in organizing various activities, organizing training to provide knowledge to keep up with the changes in the current era continuously and consistently, and there were monitoring and evaluation of the actual situation, leading to improvements and solutions that directly addressed the problems, which would result in a good quality of life. It was consistent with Montchai Anowanphan (2021, page 20) who stated that the result of physical deterioration, along with the influence of Thai culture where people were considerate and did not like to ask medical personnel questions, thinking that it was a nuisance, resulting in the elderly to lack a thorough understanding of health information in order to improve their quality of life. It was also consistent with Chatri Matchi and Sivilait Wanaratwichitra (2017, page 96) who stated that the situation of changes in the economy, society and environment made the way of life of Thai people at the individual, family and community levels in the surrounding context full of health risks, causing health problems and a tendency for chronic non-communicable diseases to become more severe, resulting in people having to rely more on the medical service system. Therefore, it was necessary to have some guidelines for promoting and supporting people enable to manage and take care of themselves appropriately, access health information and knowledge from various sources, have an understanding and assess the reliability and appropriateness of various contents so that they could apply knowledge and skills in their lives. They could have the judgment to think logically in giving importance to that information and knowledge, and lead to the decision to try it out and evaluate the results of the experiment until it could be used in daily life. This might be because Thailand has entered a complete aging society. The government is interested in the quality of life of the elderly and is aware of the need to improve their quality of life. Therefore, the government has enacted a policy for driving development of health literacy so that the elderly and the general public can develop health behaviors of the elderly towards good health in terms of physical, emotional, social, intellectual and environmental aspects through participation of all sectors for the goal of good health among Thai people. It was consistent with Siriphan Satsat (2010), stating that the elderly are anxious because some of them have health problems, namely being sick or having at least one chronic disease, which results in the elderly having less ability to help themselves, becoming disabled or handicapped, becoming dependent, leading to the need for long-term care. For the above reasons, it is found that most elderly people have health problems and lack sufficient knowledge to take care of themselves.

2.Results of the study on opinions regarding holistic care for NCDs control and prevention: It was found that the holistic care for control and prevention of non-communicable diseases (NCDs) was at a high level overall. Being ranked from highest to lowest average are showed as follows: relationships with other people, personality development, happiness, social and community activities, and recreation.

When considering each aspect, it was found in the following:

1) In terms of happiness, overall, the level is at a high level. This may be because the elderly have a permanent place to live, are safe, can take care of themselves, such as going out to buy food and supplies from shops in the village or community, and are free from illness, making the elderly very happy. There were facilities for daily use in the house. This is consistent with Jitthiya Sombatbun, Nuchnat Prakas, and Busarin Eiawseeyok (2019, p. 219) who stated that happiness is important for people entering the elderly age group. The elderly tend to lack happiness or have less happiness than other age groups because they must face changes in many aspects of their lives and also have more limitations in their lives than other age groups. Therefore, promoting the happiness of the elderly by organizing health promotion activities covering physical, psychosocial and spiritual aspects would help create positive feelings. These positive feelings would allow the elderly to live happily in their families and society, with dignity and honor as human beings, be able to do good and drive the community as those who have experience amidst social changes in the Thailand 4.0 era sustainably.

2) In terms of relationships with other people, overall, they were at a high level. This might be because in houses where the elderly lived alone; they were dependent on assistance of neighbors who visited them at home, and members of community help take care of each other closely. They could live happily with others and have good relationships with their neighbors in the community. It is consistent with Sheldon Cohen (2004) who studied social relationships and health, found that participation in social activities or various relationships, community integration and identification with one's social role often affect health in the form of mental health, reducing stress, which would have a positive effect on health.

3) In terms of social and community activities, overall, they were at a high level. This might be because the elderly had gathered with their families, neighbors, and people in the community, and had done activities together with their families, neighbors, and people in the community. They had participated in community meetings on various issues, such as community development guidelines, etc. They had participated in various festivals, such as Loi Krathong, Children's Day, and Senior Citizens Day. They had participated in various activities in the community as opportunities allow. They had been accepted and honored by people in the community and had made merit by donating money and items as available occasion. It was consistent with Saranrat Srikham (2023, p. 85) who stated that the more the elderly who raise their grandchildren participate in social activities, the better their quality of life would be. If the elderly who raise their grandchildren participate in social activities, their quality of life would be better. The elderly sample group participated in social activities at a moderate level. Although the elderly sample group had a role in raising their grandchildren, most of them had people to help take care of them. Therefore, the elderly had time to participate in various activities in the community and family, such as meeting neighbors, joining the elderly club, participating in health check-ups, exercising, etc. It was consistent with Pornthip Malatham, Jiraporn Kong-iam, and Prakong Intarasombat (2009, p. 445) who stated that approximately half of the elderly had met and talked with their neighbors every day. They had relied on one another with their neighbors, such as sharing food and supplies, transportation, and exchanging information. As for friends they knew in the past, they might not meet often because they had lived far apart, inconvenient for traveling, or when they beame older, some of them had health problems and their strength decreased, so they could not visit their friends often. In addition, public utilities in rural areas, such as telephones, were not as convenient as in the urban context.

4) In terms of personality development, the overall level was at a high level. This might be because those whose dressing, walking, standing, sitting, and acting are appropriate in time and place have good personality and are accepted by others; they conduct themselves appropriately according to the time and place; they are kind, do things with consideration for others, can use their knowledge to advise others, creating credibility. The program can be organized training to provide knowledge to develop a good quality of life, such as disease control, taking care of oneself to have good health, self-development for career advancement, and being interested in learning new things. It was consistent with Phra Maha Phitsanu Sanyametho, Wirakan Kanokkamales and Wai Chirum (2021, p. 68) who said that personality is a person who keeps his word, has a stable temperament, has reason, behaves appropriately according to time and place, is kind, does things by thinking of others' feelings, etc. If he/she is a boss, he/she would be accepted by his subordinates, be a good friend and create a sense of trust for customers. But if the person is not trustworthy, there are often problems and obstacles in the work. Others may not trust, do not believe, do not accept, do not work with him, which may damage the work.

5) Recreation was at a high level overall. This might be because of meeting friends in various activities such as reading books, listening to music, watching sports and other forms of entertainment, getting enough sleep, doing activities for enjoyment and relaxation, and using free time to benefit from physical activities that brighten the mood, and participating in community recreational activities. It was consistent with the Asian Nursing Home Elderly Care Center (2023) stated that doing activities that are willing to do in free time, having a passion for doing them, not getting bored, or doing them for enjoyment, feeling relaxed both emotionally and mentally, having fun in those activities, such as doing recreational activities on the weekends, whether it is going out, playing music, reading books, watching movies, listening to music, participating in merit-making ceremonies or various traditional ceremonies organized by the community, possibility of joining groups of elderly people who gather to meet and talk to create new relationships and to have new societies that are not monotonous. The Elderly Care Center (2018) stated that activities done during free time to develop the body, mind, emotion, intellect and society help the elderly relax and develop their bodies to be refreshed and to always keep the elderly alert. However, caring for the elderly does not only mean taking care of physical health, but also includes promoting mental and emotional health. Recreational activities are therefore important to help people entering old age feel valuable and create happiness in daily life.

3. Results of a survey on opinions about the quality of life of the elderly who completed training according to the program: It was found that the overall quality of life of the elderly was at a high level. It was consistent with Nitipat Chitanon et al. (2020) who studied the quality of life of the elderly in Samet Subdistrict Municipality, Mueang Chonburi District; it was found that quality of life of the elderly in Samet Subdistrict Municipality, Mueang District, Chonburi Province was overall at a high level. Ranked from highest to lowest average, they were intellectual dimension, mental dimension, spiritual dimension, physical dimension, and social dimension. It was consistent with Chatree Matsi and Sivilait Wanaratwijit (2017, p. 99) who stated that the ability of individuals in terms of knowledge, thinking, and life skills, including seeking various methods to lead themselves to physical, mental, social, and intellectual perfection, having knowledge and awareness of things that would affect health both positively and negatively. These would lead to appropriate behaviors in health care management, both in terms of health promotion, disease prevention and various dangers, as well as access to health services in all aspects, which if people have a deficiency in perceiving and learning information, there would be limitations in perceiving, thinking, and choosing ways to behave appropriately according to the situation in various areas for good health. The findings might be because Thai elderly people have received sufficient knowledge about quality of life in various aspects, and government policies have continuously given importance and provided budget support for the past 10 years. Therefore, the overall quality of life of the elderly is at a high level.

When considering each aspect, it was found in the following.

1) In terms of physical dimensions, the overall level was at a high level. It was consistent with Nitipat Chitanon et al. (2020, p. 73) who studied the quality of life of the elderly in Samet Subdistrict Municipality, Mueang Chonburi District, it was found that the quality of life of the elderly in Samet Subdistrict Municipality, Mueang Chonburi District, Chonburi Province, in terms of physical health, was at a high level. It was consistent with Chanjira Thitipisutthikun (2017) who studied the quality of life of the elderly in Huai Hin Subdistrict Municipality, Nong Hong District, Buriram Province, it was found that the overall physical aspect was at a high level. This may be because they ate nutritious food appropriate for their age, exercised appropriately for their age, had good health, and were able to move their bodies nimbly. It was consistent with Narisa Wongpanarak (2013, p. 163) who said that in terms of physical dimensions, in order for the elderly to be able to maintain their health and be strong at all times, they should eat foods appropriate for their age and exercise appropriately for their physical condition and age regularly, which would help the muscles work, provide relaxation, and also help brain cells work better, and it is recommended that the elderly have health checks at least once a year. This finding might be because the elderly Thais have received sufficient training in physical care, and the eating culture of the elderly Thais still prefers to eat chili paste with vegetables and drink plain water. Therefore, the overall physical dimensions have found to be at a high level.

2) In terms of mental dimensions, the overall level was at a high level. It was consistent with Nitipat Chitanon et al. (2020, p. 74) who studied the quality of life of the elderly in Samet Subdistrict Municipality, Mueang Chonburi District, found that the quality of life of the elderly in Samet Subdistrict Municipality, Mueang District, Chonburi Province, in mental aspect, was at a high level. This might be because they meditate to calm their minds and exercise to make their brains release endorphins that relax their minds, know how to manage their own stress, and are people who have no worries. It was consistent with Narisa Wongpanarak (2013, p. 160) who stated that the promotion of good mental health was very important which would result in complete well-being in all dimensions. Good mental health enables the elderly to accept and manage all-round changes that cause various problems according to their potential in order to become a valuable elderly society, the elderly could take care of themselves, live long and have a good quality of life. The elderly who were not able to adapt and accept change might lack happiness, feel stressed, have conflicts with themselves, their families, children and loved ones. Some might have mental health problems, such as depression, hopelessness, discouragement and ultimately not wanting to continue living. The elderly could take care of their mental health and be able to accept and manage change; the elderly should have activities that promote awareness and awareness of their own emotions and find appropriate ways to cope with problems, resulting in stable emotions and appropriate adjustment mechanisms.

3) In terms of social dimensions, the overall level was at a high level. It was consistent with Nitipat Chitanon et al. (2020, p. 74) who studied the quality of life of the elderly in Samet Subdistrict Municipality, Mueang Chonburi District, it was found that the quality of life of the elderly in Samet Subdistrict Municipality, Mueang Chonburi District, Chonburi Province, in terms of social conditions, was at a high level. It was consistent with Patcharanee Kitchomphu (2014) who studied the quality of life of the elderly in Song Pluea Subdistrict Municipality, Namon District, Kalasin Province, it was found that the elderly had a high level of social quality of life. This may be because they were kind and had equality and fairness with everyone, lived happily with their families, lived with their families with good relationships, went out to meet and spend more time with friends or family members, and the families were able to provide care and assistance to each other. Therefore, it was found that the overall mental dimension was at a high level.

4) In terms of spiritual dimensions, overall it was at a high level. This might be because most Thai elderly people are Buddhists and go to the temple every Buddhist holy day. They understand the truth of life, understand nature and all things around; they are kind, compassionate, and selfless towards others. They build their families and communities with love, warmth, respect for each other's dignity; they are selfless, and willing to help others. It was consistent with Narisa Wongpanarak (2013, p. 163) who stated that spiritual dimension was to enable the elderly to maintain their beliefs, faith, have something to hold on to, have encouragement, have goals in life and have hope. Therefore, the spiritual dimension was at a high level overall.

5) In terms of intellectual dimensions, the overall level was at a high level. This might be because the elderly accept new knowledge and ideas, have knowledge in their careers, and are successful in life. They could adapt to various events, learn new things, add challenges to their lives, and participate in activities that enhance their intelligence, giving them knowledge in taking good care of their health. It was in line with the Life of Wellness Institute (2022), stating that intellectual health involves having an open mind as you continually encounter new ideas and expand your knowledge, fostering active participation in academic, cultural and community activities. It was also in line with Colorado State University PUEBLO (2023) stating that intellectual well-being is one of the eight dimensions that affect overall health and well-being. Intellectual well-being encompasses all aspects of well-being related to brain health and growth through stimulating mental activities, intellectual growth, curiosity about all there is to learn, valuing lifelong learning, and responding positively to intellectual challenges. Enhance your knowledge and skills while discovering your potential to share your gifts with others, thus finding that the overall intellectual dimension is at a high level.

4. Building a sustainable holistic elderly care network in Bang Khla District community: It was found that networking by returning the obtained information to the community and announcing cooperation with Samet Tai Subdistrict Health Promoting Hospital to establish an NCDs prevention center in Samet Tai Subdistrict. It was located at the house of the elderly model selected from this project to be a place to provide basic advice to the elderly who need knowledge and measure blood pressure or check sugar levels without having to go to the hospital, which would be a good model for other communities to use in the future. It was consistent with Thitirat Rasiri and Ajin Songtap (2018, p. 319) who stated that from the health condition of the elderly, it was known that the elderly live longer, are healthy, are not a burden to their children, and can help themselves both socially and economically. In this regard, the government agency, the Ministry of Public Health, plays an important role in promoting and caring for the health of the elderly. For those approaching old age, government agencies should provide opportunities for local sectors, private organizations, community organizations, and the public to become aware of and participate in analyzing problems, jointly implementing, jointly receiving benefits, jointly monitoring, and evaluating projects or related activities. It has created cooperation between organizations as a network, creating a community of people who come together to create, creating a good quality of life, and being beneficial to society without expecting profit. The principle of participation is therefore the heart of development and a strategy for sustainable development. It is due to that a collaboration between the government and the people, and aims to develop the people's ability to have confidence in self-reliance, under the condition of distributing the benefits of development fairly and equally. This is because Thai society has entered the aging society since 2014, which shows the importance of cooperation networks from all sectors in helping each other to prevent NCDs in the elderly. Although it was found that studies have been conducted for a long time, NCDs have not been defeated and there has never been a health office to prevent NCDs at the elderly's homes before. Therefore, creating a network of NCD centers at the elderly's homes is a new strategy that has been devised and is closest to the elderly, which should help increase the prevention of NDCs.

Suggestions

1. Suggestions from the research

1) The results of the study found that the health-related quality of life of the elderly was at a high level, both overall and in each aspect, but the recreational aspect was ranked last. Therefore, it is recommended that the relevant units and sub-district health centers should have guidelines for organizing activities for the elderly to make good use of their free time, activities for extra income, exercise in physical activities that will brighten their mood, and allow the elderly to participate in community recreational activities. There should be invitations and public relations regularly so that the elderly could live happily and appropriately.

2) The study results found that development of elderly role models in holistic health care to control and prevent NCDs in Bang Khla District communities was at a high level, both overall and in each aspect. However, the social dimension had the lowest average ranking. Therefore, the Ministry of Public Health and local administrative organizations should cooperate to accelerate the development of health-related quality of life by organizing activities and providing budgets to support the elderly to go out and meet and spend more time with friends or family, organize some field trips, visit the elderly in the community, and develop models to provide advice to family members to be able to take care of and help the elderly appropriately.

3) Sub-district health promotion hospitals and local administrative organizations should cooperate to monitor and assess the holistic health quality of life of the elderly periodically to compare and identify trends in health behaviors, which would determine more effective strategies.

4) Sub-district health promotion hospitals and local administrative organizations should cooperate in organizing training activities to enhance correct health knowledge and understanding in a variety of appropriate ways, such as lectures, demonstrations, hands-on practice, skills training, study tours, etc., including increasing access to information and health services by promoting and supporting a forum for exchanging knowledge among the elderly and interested groups, building confidence in the application of knowledge until it becomes new knowledge that could be effectively applied in other communities.

5) Subdistrict Health Promotion Hospitals and local administrative organizations should cooperate to support immediate assistance. If a survey finds elderly people with mental health problems, they should give importance and assistance at the beginning by providing them with screening, assistance, treatment, finding the cause, the problem, and finding appropriate solutions to prevent further violence or escalation.

6) Subdistrict health promotion hospitals and local administrative organizations should cooperate emphasizing on social dimensions so that the elderly could maintain their roles, value and relationships in society. They should promote the creation of good relationships within the family to reduce stress and anxiety that might follow and to make them feel like they are family advisors because they are experienced in life. The elderly should do their daily routines consistently in things that they could do themselves in order to maintain feeling proud and self-worthy. Importantly, there should be activities to prepare themselves for entering the old age.

7) Families of the elderly, sub-district health promotion hospitals, and local administrative organizations should cooperate and support the elderly’s religious activities, meditation, recreational activities and hobbies. The activities should be consistent with the beliefs, culture, values and needs that be appropriate for the lifestyle and context of the elderly.

2. Suggestions for further study

1) Quasi-experimental research should be conducted to study the effects of recreational and social programs on the happiness of the elderly.

2) It is recommended to conduct the mixed methods study of the desired models for improving the quality of life of the elderly in urban and rural areas.

3) It should study a concrete approach to promote quality of life to reduce NCDs in the Thai elderly.

Acknowledgement

I would like to thank the Research and Development Institute, Rajabhat Rajanagarindra University, for funding support this research. Special thanks are to the elderly participants and their families, executives of local administrative organizations, directors of sub-district health promotion hospitals and village health volunteers for their cooperation in data collection, including interviews, questionnaires, and focus group discussions with experts.

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