Abstract
This mixed- methods study with a convergent parallel design examined the
primary healthcare service system for bedridden and dependent older adults after
transferring sub-district health-promoting hospitals (HPHs) to Provincial Administrative
Organizations ( PAOs) . A mixed- method approach was deployed in parallel with
quantitative and qualitative methods running from March to December 2024 to collect
data. Data were collected quantitatively through field surveys and qualitatively through
in-depth interviews and focus group discussions. The data were collected across nine
provinces in Health Regions 2, 3, 4, 5, 6, and 12.
The quantitative sample included bedridden and dependent older adults based
on the Activities of Daily Living (ADL) score of ≤11 and their family caregivers. A total of
576 participants were included in the sample. Using quota sampling, 125 policy-level
administrators and care managers were recruited from the 153 who were expected to
participate, and after the removal of those with incomplete data (5.2% attrition), they
were eligible.
We used the following study instruments: 1) A questionnaire to evaluate views
and standards of the older adults care system from administrators and health care staff,
with a content validity index of 5 experts and a level of reliability Cronbach's alpha
coefficient was 0.95. 2) It is a satisfaction survey of bedridden and dependent older adults
and their caregivers, validated by experts with a reliability coefficient of 0.95. 3) WHOQOLBREF: a quality-of-life assessment tool for older adult individuals (Thai version).
To collect qualitative data, 4 focus group discussions with healthcare personnel
and caregivers from 12 HPHs (transferred and non-transferred) with 12 participants (total
n=124) were initiated. Bed-ridden and dependent older adult persons (n=72) and family
caregivers (n=72) in 36 sub-districts (2 participants per sub-district) were recruited for indepth interviews. Descriptive statistics, paired t-tests, and comparative satisfaction and
quality-of-life outcomes analyses were performed for transferred and non-transferred
HPHs. The qualitative data were analyzed thematically to extract key findings.
Results: The Older adults Care System was rated as good by the administrator
and health personnel in groups with different sequences of HPH transfer (averaged 3.90,4.15, and 4.10; SD = 0.67, 0.66, 0.56, respectively). The final area rated the highest was
leadership and governance (mean scores of 4.20, 4.40, and 4.39; SD = 0.64, 0.50, 0.43,
respectively) in terms of its value (mean scores of 4.41, 4.59, and 4.60; SD = 0.73, 0.70,
0.53, respectively) per perceptions in older adults care work. Financial (mean = 1.00, SD
= 0.00) and resource-sharing (mean = 3.21, SD = 0.95) systems were rated the lowest,
with moderate levels reported in the 100% transfer group. Most notably, health
information and financial/resource-sharing systems < 50 transfer scored higher than the
100% transfer group (p < 0.05).
Older adults satisfaction was high for both transferred and non-transferred HPHs
(mean = 4.19, SD = 0.86; mean = 4.20, SD = 0.89). No other significant differences
between the groups. Quality-of-life scores were overall medium, with transferred HPHs
slightly high for daily healthcare needs and focus during activities (p < 0.05). In contrast,
supportive tactics from friends also scored lower in transferred HPHs (p = 0.02).
Qualitative Findings: Thematic analysis identified seven critical areas impacting
the older adults care system:
1) Health Workforce: Standing roles concerning personnel remained constant but
led to gaps in resource allocation and workload imbalance.
2) Health Information Systems: The absence of consolidated databases made it
difficult to coordinate services.
3) Access to Medicines and Technology — Resources and coverage Inaccessibility
necessitated allocation decisions.
4) Financial Systems: The mechanisms for sharing resources were limited by
administrative regulations.
5) Leadership and Governance Efforts toward morale-building and maintaining
cooperative relationships.
6) Community Health Systems: Current community resources facilitate continuity
of care for older adults.
7) Service Delivery: Barriers included a lack of care managers, delay in long-term
care (LTC) registration, and mismatched caregiver-to-patient ratios.
