The increased number of older adults worldwide is causing a change in the structure of the population. In 2020, 13 percent of the world's population was aged over 60 years, with an increase of 3% per year, and the highest rank was in Asia since 2005 (United Nations, 2020). Thailand is among the highest ranks, where the older population accounts for 18 percent of the total population. Among this number, 21 percent are living with dependency conditions. Of these, 15% are homebound older adults (Foundation of Thai Gerontology Research and Development Institute, 2019).
The World Health Organization (WHO) has urged a strategy for healthy aging and defined it as ‘the process of developing and maintaining the functional ability that enables well-being in older age’ (World Health Organization, 2017). This has necessitated the intervention to promote the health of older adults and prevent health problems related to aging, chronic illness, and the inability to perform daily activities. A previous study showed that many older people living at home face some physical health conditions that may deteriorate into bedridden (Husebø & Storm, 2014). In addition, the deterioration of the physical condition and chronic diseases is the leading cause of declining quality of life for older adults, particularly those who are homebound. Therefore, homebound older adults (HOAs) are classified as a significant group regarding the great need for care to slow or prevent the deterioration of their physical condition and who require a particular health service system in accordance with their health needs.
Research suggests that developing an age-friendly environment is also necessary to promote health within and around living areas. Each older person is culturally different in lifestyle, including social structure (Gunawan & Huang, 2022); for example, the living characteristics and social conditions of urban and rural communities differ in terms of housing. The older people in a rural community often live together with their children in a community, helping each other in Thai culture and having traditions and beliefs that have been passed on from ancestors and from generation to generation. The older adults are valuable social capital and affect the minds of their children, and they have their own wisdom, while the urban community has a modular style of living. However, the living conditions may be in different patterns, such as many children leaving home for work outside, leaving the elders alone, or living with their spouse without support. Therefore, it affects the quality of life and mental state of all older adults (Foundation of Thai Gerontology Research and Development Institute, 2021). In addition, Thailand has prepared a 20-year National Strategic Plan (Public Health section), which focuses on people’s life span, from youth up until old age. Its goal is to enable older adults to take care of themselves in 'active and healthy aging' (Ministry of Public Health, 2016). If health or social professionals have a better recognition of older people and their way of life in a community, a more 'health in the older adults targeted approach’ could be applied to address health and social problems and the needs of senior citizens. These working methods should be culturally sensitive and effective (Leininger & McFarland, 2002).
In regards to the Muslim healthcare culture, it is often consistent with religious principles at each stage of life as a way of life, especially in the mental and spiritual aspects of Muslims who have faith in God. Muslims regard the body as a gift from God. Therefore, when an individual is ill, the sickness needs to be healed (Suprayitno & Setiawan, 2021). The recovery from illness will depend on God's schedule because Muslims believe God ordains sickness to test that person’s strength (Mohmula, 2007). In addition, a healthy person must have a good relationship between man and God and between self and environment. Muslims then focus primarily on spiritual well-being, believing it leads to better overall well-being (Dwidiyanti et al., 2021).
Many Thai Muslims believe that spirit is the power of life which acts as a goal in a person's daily life. Spiritual wellness is the power to hold the mind that creates motivation and hope, awareness of one's self-worth and self-confidence, leads to interactions with others and the environment, and brings life satisfaction (Chansangrat et al., 2014). Religious practices are often aligned with Muslim lifestyles to become cultural health care. The belief that actual health starts with a strong and stable spirit can create the power to make decisions for oneself and maintain one’s own independently without falling to emotional desires or material values. To achieve holistic health, the value of life and health must be firmly contained in the soul, not the value seen by others except the value guided by Allah (Iman), followed by the conversion of value into action (Amal), which is the composition of “Ibadah” (Lohwithee, 2020). Thus, the attempt to balance health and life in their cultural practice is essential among Thai Muslims and may increase as they age. In addition, being within their own ways of life and having the ability to perform their daily activities based on their belief and values could promote healthy and active aging of older adults.
Older adults living at home may enjoy life and wish to continue life as long as possible, but there has been limited study on HOAs. A previous study in a southern Thai province showed that the Thai HOAs were able to take care of themselves at home despite some health limitations (Detthippornpong et al., 2022). Some perceived themselves as a healthy group and able to control their illness by performing self-care, sharing a positive view of life with others, and integrating their beliefs in folk with modern medicine to maintain health. Supportive family networks and Thai cultural beliefs on respecting older people in the community and participating in religious activities were identified as facilitating factors. More importantly, HOAs who are virtually isolated and may have limited mobility should be taken into consideration for appropriate strategies in providing services for health promotion. However, the previous study was limited to Thai Buddhists, which suggests a need to explore another ethnic group, such as the older Thai Muslim population. This study then focused on those Muslim homebound older adults living in a different sociocultural context from Thai Buddhists. This study aimed to explore cultural care practices related to the health and well-being of Thai Muslim homebound older adults.
The concept of holistic health nursing (Dossey, 2016) and Leininger’s culture care diversity and universality theory (Leininger & McFarland, 2006) informed this study. According to this theory, the goal of nursing is to offer culturally congruent care for the benefit of people’s health and well-being. Leininger defines culture as a set of beliefs, values, norms, and lifeways shared and learned by a group of people. In her theory, a cultural group shares folk and professional care systems, which can be mediated by nursing care (Leininger & McFarland, 2006). Various cultural and social dimensions were described that can influence health in a cultural group, for example, technological, religious, or economic factors. The meanings of health and those dimensions present differences and similarities between cultures (Leininger & McFarland, 2002). Another concept of Leininger’s theory is caring, which is the essence of nursing. It involves understanding and knowing about people being cared for by helping them improve their human condition and health. Cultural care is usually embedded in the daily life of humans as individuals, family members, and communities. Since this study focuses on cultural care, ethnography is an appropriate approach to gaining cultural data of the participants (Leininger & McFarland, 2002). It allows nurses to take actions to preserve, accommodate, or repattern cultural care to improve their health.
Based on this theory, the health practice among Thai Muslim HOA in Southern Thailand is influenced by cultural dimensions. Therefore, to provide culturally congruent care, nurses need to better understand those health practices, particularly from the views of folk or traditional care systems and the influencing religious beliefs, to better support their holistic health and well-being. This theoretical perspective guided the various methodological aspects of this study, such as sampling, data collection, and analysis.
This ethnographic research was used to explore cultural care among Muslim older adults at home in order to maintain holistic health. The rationale for using ethnography is that its root is in cultural anthropology. It is an approach to studying the culture of the virtual world and is concerned with learning about people by learning from people. The systemic inquiry and interpretivism paradigm allow the researchers to research human experiences and evaluate the purposeful acts of people in various situations to understand behavioral patterns and the meaning of these patterns in certain contexts (Spradley, 1979).
COREQ (COnsolidated criteria for REporting Qualitative research) Checklist (Tong et al., 2007) was used to report the study. The study was conducted in two subdistricts (one in an urban and another from a rural area) in Songkhla province. The areas were selected based on the 2020 annual report of the Songkhla Public Health office, which reported them as having the highest number of Muslim older adults and where the Subdistrict Administrative Organization identified more cases who were partially dependent and were mainly living at home (Regional Medical Science Center 12 Songkhla, 2020).
In this study, homebound older adults were approached as key participants. To ensure that those participants could provide rich information and were willing to participate in this study, we used participant observation by visiting the primary health center in the study site and joining with the community nurses and health volunteers to gain access to information related to the health records of the older population. In addition, purposive and snowball sampling was used to ensure the HOA experiences in health practice. Fifteen key informants who met the selection criteria participated, including 1) a homebound older person, as defined based on the National Health Security Office: NHSO (2016), with a Barthel Index score between 5-11, 2) a Thai Muslim older person (age over 60) who was able to take care or move with ease by his or herself, mainly living at home, 3) being healthy according to their own perception although there was a current underlying chronic disease but no history of complications or hospital admission for at least one year, and 4) able to speak and understand the Thai language or southern Thai dialect. In addition, to obtain in-depth information, the associate informants (family members) who were well recognized or referred by the key informants were approached to explain and clarify the studied phenomenon.
Semi-structured interview guidelines were mainly used to capture in-depth data from key and associate informants. The team developed the interview guideline based on the literature review and Leininger’s transcultural care theory (Leininger & McFarland, 2002). The interview format was based on open-ended questions in the Thai language to encourage extended responses. The general questions about the lives of participants were usually used at the start of each interview, and then the meaning of health and care for themselves in everyday life situations were probed. For example, “What do you think about your health and what do you practice in daily life, and why do you do those activities? How are life and health perceived at your age?”.
The associate participants were asked about the daily life and activities usually performed to support or maintain key informants’ health. Each of the interviews lasted 45-60 minutes. In addition, a group interview with Muslim health professionals took place at the local hospital to gain more knowledge about the health services offered to people at the study site. All instruments were allowed to be used after receiving permission from the authors of a previous study in a Thai Buddhist homebound group (Detthippornpong et al., 2022) and were modified for use among Thai Muslim older adults.
The researchers and research assistants collected data after gaining entry into the community. The researcher contacted and coordinated with the nurses working at the two selected Sub-District Health Promoting Hospitals, which many healthy Thai Muslim HOAs attended, to explain the objective of the research project and the data collection process. The Muslim older adults living at home were listed based on the community database and health report, and then the participants were introduced by community/home health care nurses. Due to the pandemic, local research assistants in each area (healthcare workers with public health backgrounds) were trained in the qualitative approach and interview skills during the community survey. A skill-building workshop on ethnographic research with a pilot study was held at the community hospital, focusing on qualitative techniques such as focus group discussion, semi-structured interviews, participant observation, and content analysis.
The informants were interviewed in their homes at least twice with the help of family members living with them or those referred by participants when some had difficulty explaining. The observation of the informants’ behaviors and activities in their daily lives during the interview was also conducted using diary/record forms. A personal diary, field notes, an audio tape recorder, and a camera were used in the field. The field notes were recorded according to the first author’s reflection during the interviews, including the general context. Data were collected between August 2021 and February 2022 through participant observation and semi-structured interviews until the data were saturated.
In addition, a meeting was organized to present the progress of data collection and analysis with research assistants through the ZOOM (https://zoom.us) system and video conference for researchers to verify that the data were consistent with the research objectives. This enabled the data to be analyzed and issues that needed additional information to be explored. Although there was an outbreak of COVID-19 during the data collection period, each household was aware of and protected the older adults by keeping them at home and avoiding taking them to the doctor. In addition, mask-wearing, hand washing, and keeping their distance were strictly performed by both researchers and associate informants.
Data analysis was performed parallel with data collection in Thai until the data were saturated. Then, thematic analysis was used to identify, analyze, and report patterns of health practices. Four steps in ethno-nursing data analysis were used (Leininger & McFarland, 2006). First, researchers initially transcribed in-depth verbatim interviews. The recorded tape and field notes were repeatedly listened to and read, including the text used several times to understand the context or words that appeared to ensure that all information was covered. Second, descriptors and components were identified, coded, and categorized after becoming familiar with the data set. For example, the daily dietary practice of eating steamed rice, soup, and a lot of fish, avoiding spicy food, and drinking honey with warm water, were grouped into a potential subtheme of eating a soft diet to improve digestive function.
Similarly, other subthemes were searched, such as praying and reading the Qur'an to restore mind, body, and spiritual health. Third, the researchers analyzed patterns and contexts related to the cultural care and health practice of the participants. For example, eating a soft diet to improve digestive function was analyzed among eating patterns for good health, and it was generated to “consuming safe food in the adequate amount.” Lastly, the researcher synthesized the major pattern and summarized the findings. For example, the eating patterns for good health was generated with other related information to understand health practice in their way of life under the theme of “having a simple and comfortable life with support.” All processes in data analysis were prepared in Thai to maintain the context and meaning before being translated into English by the Thai-English translator, who was bilingual and understood both languages. To ensure rigor, the forward and backward translation was performed by the researchers who knew the field of research and acted as co-researchers.
Trustworthiness was provided by prolonged engagement in the field, maintaining field notes and a reflexive journal, peer debriefing, and a form of data triangulation based on Lincoln and Guba (1985). Data were collected through different methods and different groups of participants. The researchers visited HOAs and their families a few times, at least 2 hours each visit, in their natural settings. Rapport and trust with the informants were established before the visits, which were arranged at different times to gain various perspectives for the data. Field notes and a reflexive journal were maintained to describe the research process in detail and the researcher’s role. Each step of the research process was appraised and confirmed by the team to check the accuracy of coding in data analysis and to ensure the consistency of the inferences.
The study was an ethnographic study approved by the Institutional Research Board Committee of the Faculty of Nursing, Prince of Songkla University (PSU IRB code 2021-LL-Nur011). The study objectives, research methods, and potential risks and benefits were described to the informants before the data collection. Permission from the informants for audio recording was obtained, and data were kept confidential on a personal laptop secured by a password. The participants were free and had time to decide whether to participate in the research. Verbal consent was used instead of written form due to vision and handwriting problems. During participation, if the participants wished to leave or withdraw from the research before the end of the action, it could be done without giving any reason. However, no one left the study.
The findings were presented in two parts: 1) characteristics of the participants; 2) cultural care of health practice of Thai Muslim HOAs.
Characteristics of the Participants
The demographic characteristics of the 15 key informants (six males and nine females) are presented in Table 1. Nine older adults in urban areas and 6 six older adults in rural areas participated. Their age was between 60-94 years, and most had activities of daily living (ADL), although some remained working in the rubber plantations. All lived at home with at least one of their family members, and five of them lived with their wives. Most had at least one illness; the most common diseases were hypertension and diabetes. In this study, six daughters (Ma1, Pa2, Ma6, Ma7, MaT2, MaT6) participated in an interview to gain more information.
|ID||Sex||Age||Marital status||Education level||Occupation||Past illness (year)||ADL score||No of child||Caregiver|
|Ma 1||F||94||Widow||Grade 2||Trade market||
|Pa 2||M||84||Married||Grade 4||Rubber cutting/gardening||
|Ma 3||F||86||Widow||Grade 2||Trade market||
|Pa 4||M||73||Married||Grade 4||tailor||
|Ma 5||F||84||Widow||none||selling fish in the market||
|Ma 6||F||89||Widow||Grade 4||Farming/||
|Ma 7||F||93||Widow||none||trade market||
|Ma 8||F||67||Widow||Grade 4||Manager||
|Pa 9||M||76||Married||Grade 4||General contracting, cattle raising||
|Ma-T1||F||68||Married||Grade 4||Rubber farmer||
|Ma-T2||F||82||Widow||Grade 4||Rubber farmer||
|Pa-T3||M||60||Married||Grade 7||Rubber agent||
|Pa-T4||M||67||Married||Grade 4||Rubber farmer||
|Ma-T6||F||85||Widow||Grade 4||Rubber farmer||
Note: DM = Diabetes Mellitus, HT = Hypertension, CKD = Chronic Kidney Disease, BPH = Benign Prostatic Hypertrophy, MI = Myocardial Infarction
Cultural Care of Health Practices among Thai Muslim HOAs
In describing their health, the participants (HOAs) defined health as mostly related to their physical functioning and emotional and spiritual well-being. This definition included how these components affected their daily lives and health. Although physical health and medical issues were part of living, participants holistically viewed their health, more in terms of basic needs, close to nature in a simple and self-sufficient way. “Life and health are designated by Allah for living with nature and comfort at their age” were merged as the overall theme of the health practice experienced by participants, as shown in Figure 1. Their daily health practices consisted of four patterns: 1) maintaining day-to-day functioning to stay independent, 2) having a simple and comfortable life with support, 3) performing religious activities as a priority of life for well-being, and 4) managing symptoms to gain a balance and restore health.
Pattern 1. Maintaining day-to-day functioning to stay independence
In daily life, participants described the importance of maintaining independence, which they considered a primary source of staying strong in health. They valued the ability to support themselves without burdening others. The activity of daily living (ADL), such as eating, bathing, and dressing, were considered the essential individual ability that should be maintained. Some talked about their self-care ability by performing these activities as much as possible in and out of their home. Some participants performed regular exercise for their recovery from illness. Some could go out where they wanted (even with limitations) and enjoy their life when they felt they could do so by themselves. One participant who had just recovered from paralysis reported:
Currently, I have stopped working because I'm old, and my children do not allow me to leave the house since falling last year. Now, I try to help myself as much as I can, picking up things, moving to the bathroom, and taking a shower when staying at home alone because I can't go anywhere. I try not to stand still but try to exercise, move my arms and legs, flicking legs, swinging arms, and kicking my legs daily. I sometimes use massage oil to loosen the stretched muscles. (Ma1)
Another participant also demonstrated her body movement after she stopped working.
I exercise regularly, sit still and kick my legs, turn my arms around, and flick my arms every morning-evening or when I have free time. In the past, I sold fish at the market, working hard, I worked hard every day. After I had diabetes, I stopped selling stuff and stayed home for the past five years. Always exercise to keep my body strong. (Ma5)
In the rural area, some participants enjoyed working at their farm by lifting muscles exercises and taking the cows for a walk in the early morning and evening, as a field note and interview:
I exercise every day after waking up. I do many of the same postures. I can't remember them all. There are body lifts, leg lifts, arms up, or taking the cows for a walk. There are about six positions that the nurse has taught me. Do each position and move 20 times. (PaT3)
Pattern 2. Performing religious activities as a priority of life for the well-being
Participants addressed the importance of religious activities by accepting the laws of God's circumstances and believing their life and health as a destiny originated by God. Natural health care linked to divine blessings was performed daily with some modern medicine as necessary to restore health. All participants accepted their body's limitations and viewed the Muslim spiritual practices as important to life, health and death. The belief is that praying and reciting the Quran enables individuals to balance their mind and body and gain spiritual well-being by achieving inner peace and wisdom and bringing good health.
I pray five times and pray to God for good health. Reading Quran is necessary for all Muslims. I believe in the laws of God that giving birth, being old age, having sickness, and death are normal. I always relax my body, keeping no stress or worry about health problems. Every day I pray, sometimes recite the remembrance of God 1,000 times, and read Yaseen (Chapter one of the Qur'an). Every morning, it helps me remember things to do in a good mood. Many people say that I am a kind person, have never felt angry with anyone, and it helps to sleep better. (Ma1)
During the illness, there is a period of stress, too much thinking, feeling angry, irritability, trouble, and self-inflicted. I have no strength at all after having a stroke. I need a great power from God to walk. Must be a great power, not a little power. Let's look at others to heal. We feel empowered by God. In the past, I couldn't sit and stand or help myself. I can solve it by praying for blessings from God for good health; I pray and Zikr Ullah (Remembrance of God) every morning and evening 300 times. I then feel better; my mood has improved. (Pa4)
In addition, adhering to religious doctrines is the culture where older people are regarded as the most important in later life when compared to other ages. The belief is that practicing religious principles brings merit, and having a happy mind to gain happiness in this world and the next and for a long life. Practicing a good deed and being faithful to religion throughout life is considered essential to enhance the peacefulness of mind and happiness, as some participants reflected:
Allah said that by doing Prue (whatever way), we could combine our minds with Allah. You can lie or sit down, can think about it. You can go in your heart, ask Allah, and you will feel comfortable. To hurt, to be sick, to have a fever, to die is the duty of Allah. Allah is in control of everything; I feel comfortable when thinking like this. Don't be afraid if it's time Allah takes you back. We are not capable of holding on to life. Allah takes everyone back and leaves no one behind. It depends on whether it's slow or fast. (PaT3)
Moreover, the participants were concerned with having good hygiene habits consistent with religious teachings, such as eating quality and wholesome food and cleaning the body and clothes. The participants tended to place personal hygiene as a top priority by believing cleanliness is the most basic form of health, a part of Muslim's obligation and individual responsibility. As some participants described:
After taking a bath and praying five times a day, use clean water to wash hands, mouth, face, nose, arms, head, ears, and legs. I have to keep my body clean even if I can't walk. If it is clean, it will make the body strong. During the nighttime, the child will help me take a bath. Now, I can do it by myself; I feel happy that I can take good self-care. (PaT5)
Pattern 3. Having a simple and comfortable life with the support
In everyday life, participants described their lives as simple and self-sufficient. They focused on consuming safe food in the adequate amount, getting enough sleep and, being careful of falling, keeping the mind relaxed as the following details:
Consuming safe food in the adequate amount
Most Muslim older adults living in their homes focused on eating natural food in moderation, not overeating. They often used a product from the local market and cooked for themselves rather than buying from outside. They focused on eating fresh food, avoiding sweet, oily, salty foods, and focusing more on eating fish and vegetables rather than meat. In addition, non-toxic food was obtained by growing vegetables in the kitchen or on farms themselves. Some used herbs and ate dietary supplements, and focused on drinking enough water.
Food, we must eat things that are grown by ourselves. My favorite food is kaeng som (spicy curry), yellow curry. Sometimes my kids make a curry with their own chickens. After eating, I must eat one banana every time (Ma1)
Food that makes me strong. I like to eat Tom Yum Snapper. My wife makes sea bass tom yum. The fish is a marine fish, not the farmed fish to cook; it must be fresh, 2-3 pieces per plate. Cooking still has some good flavor, do not eat salty, but eat plain flavor following a doctor’s advice. When I woke up and grabbed water, I drank two glasses of water every day because the body is dehydrated during the night, the blood becomes viscous, and it is not good for the brain. Drinking water helps for better blood circulation. This idea came from a conversation with a friend a long time ago, who is a Chinese doctor, who said that we had to drink six glasses of water after waking up, saying that one glass goes to the heart, another glass to the liver and the rest to the body and other organs, so I use it. (Pa4)
In addition, more organic food and vegetables, which they can find around the house and grow for their own farms, were consumed. Some participants avoided eating too much dinner under the belief that it would harm the digestive system as a participant who had gastritis said:
I eat vegetables that I grow myself in the backyard. There are eggplants, long beans, morning glory, Chinese cabbage, and some fruits such as grapefruit and papaya to treat myself; during dinner time try not to eat a lot and avoid excreting heavily. I do not want to call my children to come and help me at night. (Ma1)
Getting enough sleep and be careful of falling
Participants described the important daily life practice as getting enough sleep and being careful of falling when staying home alone. Although the participants had much time to sleep at home, none reported difficulty sleeping. As a participant said, they always find ways to manage and get enough sleep by doing some activities.
I will not sleep too much. If I can't sleep, I will recite a prayer for blessings. (Ma3)
In addition, some participants emphasized carelessness and the need to be careful of falling due to muscle weakness and having enough sleep. A participant who recovered from paralysis reflected that sleeping is essential as being safe when mobilized at home.
When I get better, I can start walking on my own. I do not underestimate my risk wherever I walk, keep in mind, don't forget to walk with assistance or use a four-legged cane, and don't think about walking on your own. I also sleep well and nap in the afternoon because feeling sleepy can increase my risk of falling. I always reminded myself of the risk of falling due to muscle weakness; be careful not to fall again. I used to go to the bathroom, couldn't lift a cane and legs, almost fell down, and couldn't move forward. Since that day, I have been very careful. (Pa4)
Keeping relax the mind with a simple life that does not make a burden to children
Some informants tried to live a simple life so as not to cause trouble for children, especially those whose children have low incomes and must go out to work. They would not be offended, not complain, and stay for the children. One said that living a simple life would not increase the burden on the children.
I tried to live and eat easily. I have breakfast, and my children bought only 10 baht of Khanom Krok (local dessert), and it's okay. One banana is enough to eat, a piece of fruit; I will not think much, never insulted children. I live for the children with love and cherish, and I think of Allah only to relax the mind. (Ma5)
All participants try to find simple stress-relieving activities for themselves in order to find happiness in doing what they enjoy, relieving emotions and stress, such as watching a favorite TV program, talking to their children and neighbors, and making products from crops near the house for sale. A field note from observation also reflected the participant’s daily life.
In the morning, I will take a seat in front of the house. When someone I know walks or rides passes by my house, I greet them. I like talking to other people; it is enough to relieve loneliness. I also like watching the TV; my favorite was the shows, the news, and advertisements for alternative medicines and dietary supplements. It can help relieve boredom; TV could be a friend. (MaT1)
Men would go out and sit in the sun in front of the house every morning. Get around the sun outside, help me Bye Jai (a Thai word that means happy). It is more comfortable in the sun and feels warm rather than cold inside. When sitting in the sun, we would greet neighbors each other. This just makes me feel comfortable. (PaT 3)
When feeling bored or in the evening, I talk to my children and grandchildren; sometimes, I go out to talk with other people, which helps relieve my loneliness. (PaT 5)
Moreover, preparing for their death was also thought of in advance. Some people have planned for their possessions by managing the assets available to their children. They felt no worry because it brings unity among relatives as clear information. Some participants who had a plan for their inheritance felt relaxed as it would not cause a burden to their children in the future. As one participant said:
The properties are divided equally and prepared for each child. That stuff has already been set up. Let's allocate the land to every child, 3-4 rai (acre) each, so that each child won't have a debate; I have no stress, no worries. (MaT2)
Pattern 4. Managing symptoms to gain a balance and restore health
The participants in this study usually enjoyed staying at home. Some who had symptoms related to chronic illness, such as pain in the knee, backache, and numbness from their condition, often used self-management to relieve symptoms with natural methods, and some used alternative healthcare methods, as detailed below.
I usually drink honey every day, about one bottle/month, to help my appetite. By dissolving warm water with two tablespoons of honey, eat before breakfast - evening. And take some pills to reduce wind when having symptoms of nausea, as it helps the circulation of blood and wind; eat real honey obtained from the island. (Ma3)
I sometimes use massage, herbal baths, and holy water to rub the area that is painful or weak. It is also a method that Muslim elders widely use, and it has been recognized that it works well. In the past, my grandmother used to be a masseuse to treat people (this is an additional occupation learned from a great-grandfather). I used it when I had aches and pains and tended to massage by myself by touching, squeezing, and ironing. Massage oil was used when having sprains. (Ma2)
Moreover, most participants could take care of their health when their illness was not severe or could be controlled by using alternative medicine to treat and restore health, such as using herbal medicines, relaxation massage, or seeking a local healer, especially for neuromuscular symptoms. Some participants with limb weakness from ischemic stroke described how chiropractors did their rehabilitation to improve muscle strength. They also shared time and information about the methods to heal and restore the body by folk healers.
I had a stroke and weak limbs. In the past, there was a masseuse in the village who came to give massages with assistance from a daughter. I was then able to eat and go to the bathroom by myself.
Now my daughter is urged to rejuvenate herself every day by squeezing my arms and legs by herself. My legs gained more strength (MaT1)
Some participants reflected the ability to treat their own minor ailments using first aid and herbs found in the community. The herb was often used partly because it is easy-to-get access, as one participant reflected:
We use Plai oil that Yo (Khao) made to treat toothache, gum pain, and swollen gums. When we have pain, we apply it to the gums. It will not be inflamed. Put some oil on hands and rub it inside; it becomes hot, feels numb, and has no sensation. When we have symptoms such as abdominal pain, flatulence, and body aches, we put oil on it, and it will get better soon. (PaT4)
In addition, most participants sought ways to keep the mood clear when staying at home, particularly during the COVID-19 pandemic. The activities such as relaxing the mind by praying, finding a stress-relieving activity, watching a favorite TV program, meeting neighbors on occasion
During this period, you can only watch television to relieve stress. I love to watch boxing shows. In the past, when there was no COVID-19, I went to sit and talk with friends who used to work in Malay and were able to speak multilanguage, both Malay, Chinese, and Thai. It helps to encourage, relax, and reduce boredom. (PaT2)
This year there is an epidemic. I don't go to the doctor. My children said it was difficult to go to the doctor. I have diabetes and heart disease. If I don't take medicine. I cannot walk a lot due to being tired. I must sit and rest. God has given us what we are going to be; we must accept it and pray and pray. God bless you so you can live and help yourself. I pray five times and pray to God for good health. When I still see it, I read the Qur'an and donate some stuff occasionally because we believe giving to others will make merit and create good health for ourselves. (Ma5)
The findings showed that 15 HOAs who participated in this study living in either the urban or rural districts similarly described their health practice based on their cultural beliefs for maintaining holistic health even though they were living in different areas. Religious beliefs related to health are regarded as part of life which guide their health practice. The living conditions, way of life, and culture were integrated according to the traditional and traditional Islamic principles (Lillahkul & Supanakul, 2020). Some participants preferred to treat their ailments using alternative medicine such as massage, using oil to massage the painful area, eating herbs to prevent disease, and selecting dietary supplements under the belief that it helps to improve health more than using modern medicine treatment alone. So, their daily health practices were perceived and experienced as “life and health are designated by Allah for living with nature and comfort at their age,” consisting of four patterns (Figure 1). Their health practices were integrated as a way of life with family, religion, and community support.
In maintaining day-to-day functioning to stay independent, participants in this study spent most of their time at home to take care of their body, mind, and spirit, integrated between Islam, medicine, and public health principles. The participants had a belief and lifestyle that strictly adhered to the religious principles and teachings of the Quran. Holistic health care and health-promoting behaviors of Muslim elders are therefore continually practiced together until they become part of their daily lives. Maintaining day-to-day functioning to stay independent is essential and linked to having a simple and comfortable life with support.
In addition, the participants described personal relationships with friends or neighbors to maintain their social networks as necessary. Although they were at home, the social context and interactions with others influenced their lives positively and were described as essential. It means being able to see and interact with family members and friends daily. Their social context of being central to this view is shared with Garbaccio et al. (2018), who found that active older adults generally enjoy their life of one able to stay in a private home, enjoying relationships with family and friends as part of life. In addition, it was consistent with the previous study on older adults’ perception of health, who defined their health in more psychological and social components (Tkatch et al., 2017).
By having a simple and comfortable life with support, participants took care of their physical, mental, social, and spiritual health together to stay healthy and happy, eating natural food, organic food, or local vegetables available locally and seasonally. Most of them ate freshly cooked food, soft diet, and ate in moderation. They addressed the important issues which could promote health and strength by not overeating, avoiding sugary, oily, and salty foods, and eating foods that were appropriate for the disease or foods grown on their farms. This practice accords with the commandments set forth in the Quran regarding the care of food consumed, such as eating enough food (not too much) to sustain life and strengthen the body and eating nutritious, clean, chemical-free food appropriate for each person's age and condition. The proper foods for older adults should be easily digestible because the stomach, intestines, liver, and kidneys begin to deteriorate, and they should not include very salty foods (Sutheravut & Nima, 2009). In addition, some participants took herbs, honey, and immune-boosting supplements to prevent disease by nourishing health according to beliefs that it helps to maintain physical health. This is consistent with the study by Panyathorn and Thajang (2020), who addressed the attitudes towards products and consumption of dietary supplements among older adults in a rural district that supplements were considered to give strength in life. The Quran also mentions honey as a cure for human ailments because honey contains nectar from all fruits (Lillahkul & Supanakul, 2020).
The findings showed that having a simple and comfortable life was interrelated with performing religious activities as a life priority for well-being and managing symptoms to gain balance and restore health. Most participants who had illnesses often consumed foods, supplements, and alternative medicine to achieve balance and restore health, which was considered essential for healthy older adults. Using herbal massage oil to rub and massage the sprained area alone would help them relax at home. A similar pattern of drinking holy water has also been found in the study of local wisdom on the self-care of Muslims in the southern border provinces. Healing with holy water is a prevalent treatment among the locals, particularly Muslim folk healers. It is also a drug listed in the Quran and Hadith. However, it is a treatment in conjunction with modern medicine (Hemman, 2016). In addition, participants described their exercises for health according to religious principles, such as swinging arms, swinging legs, and walking regularly to help keep the body healthy, which was similar to Lillahkul and Supanakul (2018), who explored its activities among Thai Muslim older adults for health promotion. In our research, HOAs tended to do some exercises with a low intensity that did not focus on strengthening the heart and lungs. This may be partly due to the presence of physical limitations.
As part of religious practice, the HOAs were concerned with good hygiene habits by using clean water to wash their four organs, namely the face, both hands and arms, head and feet, before praying and linked it with the belief that those who are physically unclean would not be able to practice certain religions. Cleanliness is also a part of the faith and is connected with their mental health. They were taught as an inner purification by clinging to one Allah, and having faith would make the soul pure, calm, energetic, and ready to worship God. As a result, those who maintain cleanliness would have good health (Sutheravut & Nima, 2009). In addition, some HOAs drank warm water and enough amount of water to meet their physical needs under the belief that it helped blood circulation and body excretion (AlAbdulwahab et al., 2013).
In mental health care, all HOAs tried to keep their minds refreshed and relaxed by doing stress-relieving activities such as watching television and greeting their children and grandchildren. Meeting the neighbors occasionally would help them enjoy life based on the principle of satisfaction in the present life. The practice of religious doctrine in enhancing mental health and being satisfied with Allah's destiny was critical to good mental health. A person's dissatisfaction with their condition would make them unhappy partly because of unappreciated what Allah said (AlAbdulwahab et al., 2013). In contrast, all participants believed that Allah had given them living in their homes to have good human relations and have smiling faces with their children and neighbors. Therefore, they spent a simple life by not acting as a burden to their children. In addition, they were taught to consider the charity given to others and keep their own mental health care according to religious teachings. So, the participants relied on their religion as a mental relief by praying regularly and reading and listening to the Quran regularly. Prayer was one of the religious practices that helped relax the mind and created peace of mind by purifying the mind without any sin or bad thing. As Allah says, “The reward of performing five prayers and Friday prayers is that Allah will atone (cleanse)”, and “even prayer suppresses badness and evil” (Sutheravut & Nima, 2009).
Greeting their neighbors occasionally and participating in religious activities at the mosque were usually performed in everyday life. Although some HOAs could not walk and suffer from chronic diseases, they would greet their neighbors from a distance. They were accompanied by children to religious activities at the mosque when needed. Most HOAs had families who lived either in their homes or surrounding, which allowed them to have close relationships with family members by meeting neighbors and participating in religious activities. Similar to a study by Roket et al. (2019), who focused on the health behaviors of older Muslim adults in Satun province, they received support and assistance from their family, relatives, and neighbors whenever they needed it.
Spiritual health care was found for all participants who performed strictly religious practices. They had brought the religious doctrines outlined in the Quran as a way of life and took care of their spiritual health for a variety of vitality and spiritual health as peaceful life. They described its importance by praying five times a day, saying Zikrullah (Remembrance of Allah) after the praying, including asking du'a (blessings) to Allah for good health to accept the laws of God's circumstances. Some participants listened to religious teachings from Baba (Tho Chru) on YouTube and donated money for merit-making on some occasions. Faith in Allah is regarded as the heart of being a Muslim (Sutheravut & Nima, 2009). They all believed that following Allah would bring them good health, happiness, and peace of mind. Strong willpower in the face of illness gained a lot of merit in this and the next world, similar to the study by Lillahkul and Supanakul (2020). Some participants had the plan to manage their wealth for their children to relieve anxiety when departing with the allocation of the existing assets to the children. It was a preparation for a peaceful departure according to religious principles in the Quranic text (Mhadman, 2014). Therefore, spiritual health care was often performed at all stages of their life under the faith of religion. This was consistent with the previous analysis of Muslim older adults in Malaysia, highlighting that religiosity and well-being among older adults were interrelated and essential to life (Achour et al., 2019).
Family support also facilitated the health of the HOAs living at home by having children as their primary caregivers. The children rotated to take care of various aspects such as doing daily activities, offering disease-appropriate diet, movement, excretion, and religious and ritual activities at the mosque. Islam has urged all Muslims to do good and show gratitude to their parents as a noble and essential duty. Therefore, it is obligatory (compulsory) for children to care for their parents to the best of their ability (Tohma et al., 2019). It is consistent with a study by Aree (2013), who found that the children of Muslim older in urban communities had religious beliefs regarding living with older adults as a wondrous thing. The longer the older adults lived, the better the family life for children was. The longevity allowed them to do good deeds more than others. In addition, some participants who received regular family care felt worthy and gained the power to continue living. Getting visits and encouragement from neighbors was associated with the health of the Muslim older adults living at home, particularly being visited at home by healthcare workers. This is consistent with previous studies (Detthippornpong et al., 2022; Phithakkumpol, 2004), which found that village health volunteers in the community often acted in the form of kinship and could easily reach the older adults and support the work of nurses following home visits. All participants received a pension from the government; some received a disability allowance, but most received money from their children, who provided for personal expenses. It is consistent with a study by Kuhirunyaratn et al. (2018), who found that family and community members supported the health promotion behaviors of older adults living in suburban communities.
In this study, all participants had God as their spiritual dependency, which was regarded as an essential factor in promoting their good health. They strongly committed to and had faith in God and strictly performed their religious duties. Doing Du`a' (blessings) keeps them healthy always, raising their peace of mind with good emotional control and accepting everything that happens to them as a will of God. This is consistent with the previous study (Thiprat, 2008) that the older adults had a high level of religious beliefs related to health. When stressed or worried about illness, they prayed for help to calm their minds. Therefore, it can be concluded that the Muslim HOAs had faith in Allah and holistically viewed their health as “Life and health are designated by Allah for living with nature and comfort at their age.” Therefore, Allah is always in their heart of health practice.
The overall theme derived from the four patterns suggested that Muslim HOAs in our study addressed health practice to pursue an independent life and maintain their health with the purpose of God and a given tradition and value of relationships and social networks for as long as possible. Although they did realize that life would change, it was thought of as nature and a return to God under the religious concept. The ability to lead a whole and balanced life close to family, friends, nature, and activities were necessary for their feelings of good health and well-being. Therefore, Muslim older adults living at home performed self-care through natural methods, similar to a previous study (Detthippornpong et al., 2022).
Based on Leininger’s theory, health-related religious practice was the main method, and the practice was performed regularly by all HOAs under the belief that religious practice would help them maintain health and happiness (Leininger & R McFarland, 2002). Each participant used religion to lead their practice naturally based on a warm environment and integrated both folk and modern medicine. Various modalities for health care, such as traditional massage, oil massage, and herbal therapy following the Quran teaching, were used. Muslim prayer was believed to improve the physical function of all bodies and personal hygiene. In addition, their health practices were supported and influenced by their family, community health workers, and health volunteers, including their Allah as a spiritual retreat. In addition, the concept of holistic health nursing (Dossey, 2016) also supports the health practice of participants by understanding individual care and respecting and attending to a human being’s spiritual and faith-based needs as an integral part of promoting health and healing.
Some limitations could be 1) the participants were recruited from small areas, which might influence the transferability to apply the findings in other areas, and 2) the COVID-19 pandemic might have influenced the relationship between researchers and the informants and could have influenced their response during data collection.
Implications to Nursing Practice
The four patterns of health practice among HOAs include 1) maintaining day-to-day functioning to stay independent, 2) having a simple and comfortable life with support, 3) performing religious activities as a priority of life for well-being, and 4) managing symptoms to gain a balance and restore health could be included in the education of nurses and primary health care workers to cultivate the cultural awareness and provide better services for older adults at home or in long-term care. In addition, interventions need to consider older people’s cultural sensitivity and family values to strengthen and promote holistic health among Thai Muslim HOAs.
The study provides a holistic picture of traditional health practice in a natural setting in the Thai Muslim community describing the daily health practice of homebound older adults to maintain their health at home. The findings showed that healthy, independent living, meaningful relationships with family, and following God were essential to all participants in maintaining holistic health. The results also suggest that healthcare services for homebound older people should be integrated with religion and the nature of health practice.