A Good Life in Old Age: Accommodating Elderly Patients' Values and Motivations in the Thai Healthcare System
A Good Life in Old Age: Accommodating Elderly Patients' Values and Motivations in the Thai Healthcare System
In college, we are often asked, “What do you want to accomplish in ten years?” The answer to this question eludes many of us until we let go of the feelings of not knowing what to do with the rest of our lives and just follow our passions. Thankfully, college grants us this freedom of expression and guides us to become the people we know we are capable of becoming. This task is accomplished in waves, and in my case, began with taking a medical anthropology class, connecting with an incredible professor, Dr. Natalie Porter, and then applying for an International Research Opportunities Program (IROP) grant.
The author in Ayutthaya, the capital city of the ancient Kingdom of Siam.
As a biomedical science major, I have an interest in pursuing a career in healthcare, yet I discovered that medical anthropology seemed imperative to the practice of medicine, as it raises questions about “how health and illness are shaped, experienced, and understood in light of global, historical and political forces” (Stanford University, 2015). As I progressed in a medical field often focused on diagnosing and treating the disease rather than the person as a whole, I realized the advantages of combining healthcare and anthropology, attending to an individual’s culture, thoughts, feelings, and relationships in everyday medical practice. Therfore, when developing my research project, medical anthropology served as its basis, since anthropological methods provide a means for exploring not only what patients’ views are, but also why they hold these views.
This approach is especially relevant for the elderly, considering that people over sixty-five are the fastest growing segment of the population in most developed and developing nations (Luborsky and Kurn 1999). This demographic change is placing strain on the international economy as well as national healthcare systems and social welfare programs, thereby prompting the implementation of new policies regarding elderly care across many countries and cultures. Many long-standing policies, like the U.S. Older Americans Act (OAA) of 1965, promote “aging well,” “helping to maintain the health and well-being of seniors,” and “meeting the needs” of the elderly population, as stated in the OAA Brief released by the U.S. Department of Health. Yet, elderly populations carry a variety of culturally-specific views of “aging well.” As such, standardizing healthcare and health policy for the elderly, both within individual countries as well as on a global scale, poses an important challenge. Addressing cultural difference in gerontology policy and practice therefore requires defining “aging well” or “a good life in old age” in the eyes of the elderly.
Thailand is located in Southeast Asia’s Indochina peninsula. Courtesy of www.freeworldmaps.net
After learning about the problems that surround providing care to the elderly, I was inspired to conduct a research project under the guidance of Dr. Chulanee Thianthai, in which I used Bangkok’s healthcare system as a model to define “a good life in old age” in the eyes of urban Thai elderly. My goal was to understand how healthcare professionals accommodate elderly patients’ views, values, and motivations surrounding a good life in old age, and to do this, I traveled to Chulalongkorn University in the heart of Bangkok, the capital of the Kingdom of Thailand, from June to August 2015.
Aging and Thailand
In comparison to other regions in Southeast Asia, Bangkok’s social services and healthcare institutions are often held up as a model for surrounding countries because of Thailand’s rapid globalization and economic development (Thianthai, 2007). Chulalongkorn University has played a major role in the development of Thailand, as it is not only Thailand’s first institution of higher education but also the country’s most highly ranked university in every field of study. Chulalongkorn University offered my project endless resources, such as living accommodations at the university’s international apartments and access to all university buildings and libraries, as well as connections with alumni and with members of the faculties of dentistry, medicine, public health, and allied health sciences. When identifying myself as a staff member of Chulalongkorn University, I often received warm regards, due to the university’s reputation throughout the country. This welcoming attitude was also due in part to Thailand’s reputation as “The Land of Smiles.” My Thai mentor, Dr. Chulanee Thianthai, was the epitome of this incredibly helping and friendly attitude. From my first day in Bangkok, Dr. Thianthai took me around the city to get toiletries, sheets, and food, and met with me to begin connecting me with friends, students, and colleagues who could help me.
Chulalongkorn University is Thailand’s leading research institution of higher education and the author’s home base for her research.
Dr. Thianthai helped me to set up my first interview while in Thailand in just the first week (which surprised me greatly, since it took me over three months to talk to a medical doctor while in the U.S.). Following my interview, this informant began connecting me with many resources. Not only did she put me in contact with other healthcare professionals, but she also connected me with Chulalongkorn University’s dental school, where I was able to act as a visiting student for over a week, meeting Thai, Japanese, British, and Italian dental students; she even opened her home to me. This incredible doctor also invited me to travel with a dental class to the rural community of Khok Salung in Lopburi Province, in order to evaluate and assist community members in addressing their health concerns. While there, I observed students while they interviewed community members, and found that rural and urban elders shared conceptions of a good life in old age. For the purposes of this article, however, I confined my findings to urban healthcare professionals and elderly residents.
Thailand lent itself well to my research project due to the demographic changes throughout the country. Although 70% of older people in Thailand live with, or next to, one of their children, as Thailand undergoes further socioeconomic development, it is becoming more common to send elderly people outside of the household for care, or for elderly people to live independently, alone or with only a spouse (Knodel and Chayovan 2009). With elderly individuals in the city finding themselves further removed from relatives who traditionally provide support, healthcare providers and doctors are bearing a greater responsibility for elderly care.
With increased dependence on healthcare professionals, adaptations by healthcare providers are needed if the quality of life of the elderly is to continue to improve. These adaptations hinge first on discovering what the elderly population and healthcare professionals believe to be a good life in old age, and second on figuring out what exactly the needs of the elderly are. While exploring definitions of a good life in old age in Bangkok, I was able to identify what social, cultural, and economic factors contribute to these definitions, and I was able to evaluate how healthcare professionals incorporate patients’ views of a good life in old age in the provision of care.
To address the problem of healthy aging among urban residents in Bangkok, I employed anthropological methods to explore commonalities and deviations in local definitions of a good life in old age. First, I carried out semi-structured interviews with six healthcare professionals between the ages of 31 and 54, and with six urban Thai elderly between the ages of 60 and 83. I carried out interviews in offices and restaurants, with informants who spoke English (although a few times my mentor, Dr. Thianthai, served as a translator. Semi-structured interviewing allowed me to conduct directed yet flexible interviews based on a written set of guiding questions, which allowed for reliable, comparable qualitative data to be collected without strict parameters (Bernard, 1994). The semi-structured interviewing method also helped me to make sure that preconceived assumptions about a good life in old age were not brought into my interviews, with the research topics still being covered in an appropriate amount of time.
My second method of research involved participant observation. These observations took place in community centers, libraries, parks, and temples, and focused on how people discuss aging with one another (if in fact they spoke English, as they often did), the activities they engage in to feel healthy, and ideological factors that influence behavior, such as media and religion. Participant observation proved to be very valuable, as it allowed me to observe what the elderly do and say in their everyday routines, which helped me dig deeper into the ways that their social interactions influenced notions of a good life.
This word cloud shows the most common words found when the author coded her interview transcripts and participant observation notes, excluding words such as “like,” “I,” and “it,” and grouping together root words.
Upon collecting all of my data in the form of interview transcripts from recordings and participant observation field notes, I became overwhelmed not only by the amount and variety of data I had accumulated, but also by how much of it I found interesting. In order to deal with the sheer amount of data, I input all of my notes into a document and coded, or searched, it for common words using an online software, wordcounter.com. I then looked at the informants’ statements that used these common words, and was able to make connections and interpret themes based on the content of their statements.
Based on my research findings, I discovered that Bangkok’s elders value happiness as they work to lead a good and healthy life in old age, and further that they pursue happiness by focusing on mai pen rai, “no worries” and “no stress,” and by building social support networks. In order to provide the best care possible, healthcare professionals in Bangkok aim to accommodate these values and motivations.
Mai Pen Rai
The phrase mai pen rai in Thai loosely translates to “no worries,” or “it doesn’t matter.” The notions of happiness and mai pen rai permeated my research from early on. During many interviews, when I asked informants about healthy aging, I received answers like “no worries, no stress, do not focus or obsess on problems; that will give you real happiness in old age,” and “what makes a good life in old age is up to your heart, spirit, and mind.” From conversations such as these, I was able to draw the conclusion that a good life to Bangkok’s elderly is synonymous with happiness, and one way they work to achieve this happiness is by living a life without stress.
Naturally, the question I began to ask my informants was: why do you focus on happiness and no stress? At first I received answers like, it’s “the life of Thai people,” or that it is “part of Buddhism.” But then these answers were followed up by explanations that offered a view onto individuals’ needs and desires as they grow older, and why those needs and desires are so important. One woman explained to me that in old age, it is important to “just let go of whatever. If your heart is not restricted you will be free, even though your physical condition is not so good. But if you feel like you accept it then you will be ok.” So although Bangkok’s elderly initially explained that it was “Buddhism” or “Thai ways” that caused them to value happiness and “no worries” in old age, throughout my interviews with both elderly and healthcare professionals, I found that Buddhism and Thai ways were a means of articulating and also achieving their values of no stress and no worries and therefore, good health is a result of the connection between the mind and body.
Social Support Networks
Food stands outside one of the 40,700 Buddhist temples in Thailand.
As with many cultures of Southeast Asia, Bangkok’s elderly informants stressed the importance of family support and care of the elderly. In every interview I conducted, informants expressed that it is in Thai blood, or Thai ways, to be good to your parents. One elderly respondent explained to me that this idea comes from the belief that, “If you do good, you will get good result. If you do bad, you will get bad result. So one of the really, really good causes is to take care of your parents. So if you do that cause, we will get many, many of the good things to our life.” The elderly also play a major role in the family dynamic. As a healthcare professional noted, the elderly often “take care of their grandchildren because parents have to work. So they play an important role in the social capital for the family.”
Another aspect of this family dynamic is, as one elderly man said to me, that, “In Thai culture it is said that we have to make our parents, make the older happy, be calmness in their life. Why? Because they have looked after us before. And it’s some kind of pay the debt." It became clear that there is a mutually beneficial relationship between younger and elderly family that add to how the elderly achieve happiness and thus have a good life in old age.
As one elderly man explained, “family support makes happiness” because they help you “enjoy your life [so] every day you wake up, you have something to look forward to." One story that truly illustrated this point came from a man who created a non-profit elderly community center in Bangkok. When I asked him why he created the center, he explained that:
One old man came to me after that class and prayed. He cried and I stopped him and said it’s only a class to teach you email, nothing special. But he said, "No, no, it's very special to my life because I took care of my grandson since he was born but next week he’s going to learn in England. He told me he will email me, but I was too afraid to say I don't have any email. I hear that this place teach computer so I came here very early in the morning, so now I can come back with my email address to give to my grandson. Very thank you." If you see his eyes you think only to extend that class. That is why I start this association."
It was after this conversation that I was fully able to understand the valuable role that families and the elderly play in each other’s lives; yet also that support comes in all forms, including family, friends, neighbors, doctors, and communities.
With the growing elderly population placing strains on the healthcare system in Bangkok, along with a change in family structure and support among urban Thai elderly, healthcare professionals must work to understand, and then accommodate, the needs, values, and desires of the elderly population in order to provide the best care possible.
Many urban Thai healthcare professionals emphasized that there needs to be a "balance between autonomy and their needs, [and] a medical or dental professional has to be in the middle." Respecting the elderly patients' personal views while still attending to their healthcare needs creates challenges for Bangkok’s healthcare professionals, but those I interviewed saw this balance as essential when caring for patients.
To achieve this balance, Bangkok’s healthcare professionals stated that they work to help elderly patients achieve a “better quality of life as they age, by doing little things for patients, as long as you don't force them to do it,” and to just "offer the help and be there when they need you." One healthcare professional explained to me, “We think that support is key,” and “We just make them comfortable. Sometimes the disease cannot be cured, but we can make them comfortable. Physical comfort, emotional comfort, social comfort, spiritual comfort to make them happy."
Many healthcare professionals in Bangkok defined their role as providing tools and resources to their patients, by giving them “knowledge that they want to use themselves, and then what we can provide for them to live happily." By providing patients with knowledge about medicine and also other ways to improve their health and wellbeing, like exercise and maintaining a balanced diet, healthcare professionals respect patients’ autonomy, while also providing care as necessary. This allows elderly patients to achieve their own personal values and goals when it comes to a good life in old age. Thus, in a way, healthcare professionals are becoming a new level of support in the lives of Bangkok’s elderly, as family care and support has lessened with demographic changes.
Understanding is the Future of Healthcare
View from the author’s apartment, overlooking central Bangkok with Chulalongkorn University’s main campus at the center.
We are all patients of healthcare with our own views and beliefs that deserve to be heard and, ideally, accommodated. We deserve to receive the best care possible, and, to the furthest extent possible, care that is in accordance with our own desires and beliefs. Yet, these ideals are not always met.
Being in a developed country with technology, complicated healthcare systems, and the overpowering “business” that is medicine nowadays, sometimes I lose sight of the medicine that I love and that I was drawn to: the medicine that focuses on helping people, listening to people, and caring for people—not just treating them. Now, I constantly ask myself, how can I be better? How can I work to truly listen to people in my future as a healthcare professional?
Although Thailand is a developed country and faces similar issues as the United States in terms of healthcare, during my research I was able to actually hear and see healthcare professionals focus on accommodating patients, something that I tend to feel is lost in the shuffle of everyday medical care in the U.S. This research gave me hope that in my future as a healthcare professional, amid the myriad problems facing medicine worldwide, it is possible to listen to patients and work to provide care that suits their needs and views, first and foremost. To do this, it is critical to gain knowledge about peoples’ diverse understandings and experiences, and such knowledge comes only from social experiences and the desire to truly comprehend those around us. In my undergraduate career, the greatest things I’ve accomplished have come from following my passions of trying to more deeply understand people through social and cultural experiences, to work to make myself a better, more culturally aware medical professional.
As one healthcare professional said to me during my time in Thailand, "in order to change people, we must have understanding of the people we are trying to change, and we have to pay a respect truly. Only then can we really help.” In the future, I intend to help in this very way.
There aren’t even enough thank yous to express how incredibly grateful I am to have had such a wonderful experience. To Dr. Georgeann Murphy, Mr. Peter Akerman, and Dr. Paul Tsang of the Hamel Center for Undergraduate Research for their patience, kindness, and endless support as I worked to accomplish this incredible journey. To my donors through the International Research Opportunities Program – Mr. Dana Hamel, Mr. and Mrs. Frank R. Noonan, Dean Ted Kirkpatrick, and Anna Bruning – for making this experience possible, and having such incredible generosity that I will never forget. To my mom for her encouragement throughout my entire experience, even though she was nervous having me independently tackling this journey. And to my mentor, Dr. Natalie Porter, who has been more than just a mentor for my research but a mentor for my entire life. I would have never realized my potential nor seen where my true passions lay if not for her, as her guidance has helped me accomplish more than I ever thought possible. And to my foreign mentor, Dr. Chulanee Thianthai, whose kindness and hospitality helped me feel comfortable in Thailand from the start, which largely contributed to the success of my research. And with this I say thank you to everyone who helped me along my journey, ขอบคุณ ค่ะ (Khop khun Ka).
Bernard, H.R. 1994. Research Methods in Anthropology: Qualitative and Quantitative Approaches. Altamira Press.
Knodel, J. and Chayovan, N. 2009. Intergenerational Relationships and Family Care and Support for Thai Elderly. Springer Science+ Business Media.
Luborsky, M and Kurn, C. 1999. Culture and Aging, In J. Cavanugh and S. Whitebourne (eds), Gerontology: An Interdisciplinary Perspective. NY: Oxford University Press.
"Medical Anthropology, Department of Anthropology." Department of Anthropology, Stanford University, 2015. Web.
"Older Americans Act Brief: Aging Well Since 1965." Acl.org. US Department of Health and Human Services, 16 June 2015. Web.
Thianthai, C. 2007. Senile Body, but Cheerful Soul: Adapting Dharma in the Lives of the Bangkok Elderly. Asia Japan Journal, March, 2:33-50.
Where Is Thailand Located on the World Map. Digital image.FreeWorldMaps.net. Web.
Author and Mentor Bios
Jennie Lynn Marinucci has a palpable passion for the human experience within the healthcarefield. As a biomedical science major, Jennie gained an interest in anthropology after taking amedical anthropology class with her mentor, Dr. Natalie Porter. Medical anthropology seemed tobe what the Norwood, MA native had been searching for, as it merged her passion for healthcareand patient experience into one. The surging desire to explore medical anthropology, along with encouragement from Dr. Porter and Professor Georgeann Murphy, pushed her to apply for an International Research Opportunities Program (IROP) grant. Travelling to Thailand allowed Jennie to explore her interests in a different country and understand how the Thai healthcare system differs from the American system. She states, “my research was defined by the amazing people I met along the way, and their willingness to help me . . . learn, and to ensure I experienced their country to the fullest.” A member of the University Honors Program, Jennie will graduate in May 2016 with a bachelor of science in biomedical science. After graduation, Jennie will attend dental school where she will become a doctor of dental medicine (DMD).
Dr. Natalie Porter is an assistant professor in the Department of Anthropology at the University of Notre Dame. Prior to her current position, Dr. Porter was an assistant professor in the anthropology department at the University of New Hampshire (UNH) for one and a half years. She specializes in medical anthropology, global health, science and technology studies, human-animal relations, and Southeast Asia. After taking Dr. Porter’s upper-level course, Medical Anthropology: Illness and Healing, Jennie approached her to act as a mentor on this project. Dr.Porter is an experienced mentor; she previously worked with an undergraduate researcher and McNair Scholar, and an Undergraduate Research Award recipient. This is her first time working with an Inquiry author. “The experience was wonderful from start to finish,” Dr. Porter stated." Though she has always been hardworking, Jennie surprised me with the efficiency with which she carried out her research, as well as the depth and scope of her findings . . . The biggest lesson I took away from this experience is that given the right tools and support, UNH undergraduates are able to carry out sophisticated, graduate-level research. They can also act as foreign ambassadors for UNH, forging important academic and social ties abroad.”
Jennie’s foreign mentor was Associate Professor Chulanee Thianthai at Chulalongkorn University in Bangkok, Thailand. She specializes in applied anthropology, medical anthropology, and business anthropology. In addition to providing valuable research guidance, Dr. Thianthai sought to “help create an environment where Jennie could gain more knowledge based on her research and learn more about Thai culture.” This was her first experience as a foreign mentor. “I really enjoyed my time spent with Jennie and I learned a lot from her research as well,” said Dr. Thianthai.
Copyright 2016, Jennie Marinucci