INTRODUCTION

The World Health Organization defines ‘quality of life (QoL) as an individual’s perception of their position in life within the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’¹. QoL may include four different sub-domains, including psychological, physical, social and environmental², and can be used to evaluate the health impacts of diseases¹. Questions on QoL have become a needed component of public health surveillance and are considered as valid indicators of intervention outcomes³. In a systematic review, better or higher QoL has been found to reduce mortality risk⁴. Screening for QoL in general clinical practice, in addition to biological and health behavior measures, QoL measures may be able to predict mortality risk⁴. QoL is often assessed in relation to specific illness conditions, e.g. depressive disorders⁵, chronic obstructive pulmonary disease⁶, or cancer⁷. However, fewer studies on QoL are conducted on the general primary care population, i.e. in a primary care clinic and a monk healer setting⁸. Understanding how sociodemographic and clinical patterns influence QoL is important to public health as it may influence healthy choices that people make or lifestyles. For example, does showing a patient – using a QoL measurement scale – the impact of smoking behaviors on their QoL influence smoking cessation? We have no information on how ‘clinical patterns’ across two service delivery models (primary care and monk healers) might affect QoL, which prompted the study.

Monk healers are traditional health practitioners that are widely distributed across all regions in Thailand⁹ providing various types of treatments, such as Thai traditional medicine and prayers at Buddhist temples^10,11. For example, in a rural Buddhist temple in Thailand, herbal medicines, dietary treatment and meditation are provided for spiritual, mental and physical problems¹¹; with a monk healer in central Thailand, treatments are given for various chronic diseases, such as pain conditions, diabetes, and cancer, and for skin, respiratory and digestive problems¹⁰; and in a Buddhist monastery in central Thailand, treatments are given for substance use disorders using religious, physical and herbal therapy¹².

Several studies, as reviewed in Brazil⁸ and Nigeria¹³ found that social QoL had the largest contribution and environment QoL had the lowest contribution to overall QoL. In a study on QoL among older adults in a community in Brazil, lower QoL scores were identified in the environment and autonomy QoL subdomains¹⁴. In Reference Centers for the Elderly in Brazil, most older adults (63.4%) had a good overall QoL score, while the lowest QoL was found in the environmental QoL subdomain¹⁵. In this case, a Reference Centre is a public facility that provides health promotion, legal and social services to older adults¹⁵.

In primary care patients, factors associated with lower overall QoL include younger age¹⁴, lack of schooling and income, a negative perception of health^8,14, lower socioeconomic status^13,16, lack of family support¹³, chronic conditions (such as diabetes, hypertension, depression, and musculoskeletal diseases)^8,13,15,17, and functional disability¹⁴.

In primary care patients, factors associated with lower psychological QoL include female sex, lower education, lower income, being a smoker, having a chronic disease, and poor self-rated health⁸. In primary care patients, factors associated with lower physical QoL include female sex¹⁸, lower education level, lower income, having no occupation, having a chronic disease, and poor self-rated health⁸.

In primary care patients, factors associated with lower social QoL include older age, not living with a partner, lower income, and being a smoker⁸. Likewise, factors associated with lower environmental QoL include older age, lower education level, and having own income⁸.

The aim of this investigation was to measure QoL and its correlates in users of two different types of health services (public primary care and monk health practitioners) in Thailand. QoL is an important outcome measure in primary care patients¹⁹. Therefore, an understanding of the QoL of attendees of two different health services (monk healers and primary care) in Thailand would be vital in improving primary care. To our knowledge, there is currently no knowledge on QoL among attendees of a monk healer setting. It is hypothesized that primary care attendees have higher QoL than monk healer attendees. This may have health policy implications, such as the existence of social determinants and QoL²⁰, and integrated care interventions for improving patients with low QoL²¹. The aim of this investigation was to assess the levels of QoL and to identify the associated factors in users of two different health services (monk healers and health center) in Thailand.

METHODS

RESULTS

In all, 1251 patients of both treatment settings participated in the study, while the non-response rate was 3%. The average age of participants of primary care attendees was significantly higher than among monk healer attendees (p<0.01), and the educational level (p<0.01) and prevalence of substance use disorders (p<0.01) were significantly higher in monk healer than health center attendees. Further study sample characteristics are shown in Table 1. The overall quality of life had a mean score of 68.9, significantly higher in primary care attenders than in monk healer attenders (mean: 66.6) (p<0.01). Among the four QoL subdomains social had the highest scores, 72.5 and 72.1 in attendees of primary care and monk healers, respectively, followed by physical with 69.6 and 69.4, psychological with 66.1 and 62.9, and environmental with 67.3 and 62.2 (Table 1).

DISCUSSION

The study aimed at investigating QoL and its correlates in users of two different types of health services (public primary care and monk health practitioners) in Thailand. The average age of participants of primary care attendees was significantly higher than among monk healer attendees and the educational level and prevalence of substance use disorders were significantly higher in monk healer than health center attendees. It is possible that similar to the utilization of complementary medicine^26,27, young and middle-aged and educated people in Thailand are more attracted to monk healer than health center care. Moreover, several previous studies^26,28 have also shown that the prevalence of mental, including substance use, problems was higher in a traditional healer or complementary medicine setting compared to a primary health care setting. It is possible that the expected treatment efficacy for mental health and substance use disorder is, in particular for young and middle-aged and educated people in Thailand, lower in the primary care than monk healer setting, which may mean that efforts should be made for integrated management.

This first study in Thailand found that the overall QoL had a mean of 68.9, significantly higher in primary care attenders than in monk healer attenders (mean: 66.6). QoL was probably a little higher in this study than in Reference Centers for the Elderly in Brazil (63.4%)¹⁵. Consistent with previous studies^8,13,15, this study found that social QoL was the highest and environmental QoL was the lowest. It is possible that environmental QoL was low, particularly in the monk healer setting, because the studied communities were located in areas of greater social vulnerability⁸. It may be important to promote investment to improve the living condition of individuals residing in vulnerable areas⁸. The Brazil study in basic health units⁸ was in various aspects similar to our study in the primary care setting, using the same QoL measures, and similar patient profile, e.g. the preponderance of female patients (79.9% vs 72.7% in our study), primary education (64.7% vs 64.6% in our study), and having a chronic disease (64.4% vs 66.5% in our study). The finding that the lowest-rated QoL domain was the environmental domain which calls for attention to the social determinants of health via improved social protection and support, especially among vulnerable populations.

In agreement with previous studies^8,14,15,17, this study found in both monk healer and primary care setting an association between increasing age, higher educational level, and better overall QoL, while having chronic conditions was inversely associated with overall QoL. It is possible that some domains of QoL (psychological, social and environmental) similarly increase with age, as found in the case of life satisfaction²⁹ and subjective well-being³⁰. Having a higher educational level and being employed may be related to greater awareness and practice of health promoting behaviors and prompt healthcare access, which can all lead to improvements in QoL and health³¹. Having chronic conditions is more likely to limit daily functioning and negatively affect physical and psychological QoL^8,32. In the primary care setting, employment was associated with all QoL indicators. Similarly, having an occupation increased the odds for physical QoL among primary care patients in Brazil.⁸ There were no sex differences in subdomain and overall QoL, as previously observed in a study among general practice clinic patients in Nigeria¹³.

Having a smoking disorder in the primary care setting was inversely associated with environmental QoL, while in a previous study being a smoker⁸ was associated with poorer social and psychological QoL. In a previous review, smoking has been found negatively associated with QoL, increasing with the number of cigarettes smoked, while smoking cessation significantly increases QoL³³. Being married or cohabiting was in the monk health setting associated with overall QoL, physical, social, and environmental QoL, while in the study in Brazil not living with a partner was negatively associated with social QoL⁸. Similarly, in a study among older adults in Myanmar, being married was positively associated with QoL; spouses may play a significant role in providing material and psychosocial support to older adults³⁴. Not having a social network seems to affect negatively various domains of QoL, including social QoL. Findings of this study have relevant research and clinical implications for primary care in Thailand, such that they highlight the relevance of interventions to improve QoL in primary care users in a religious and primary care setting⁸. Specifically, it is recommended that QoL issues be integrated into the management in the religious care management, in particular among those with chronic conditions, those who are single, divorced or widowed, who are younger and those with less education. Furthermore, in primary care management QoL issues should be integrated in those who are not employed, have lower education level, and have chronic conditions.

CONCLUSIONS

The study extends previous research on QoL and its subdomains in both monk healer and primary care settings in Thailand. Social QoL had the highest scores, followed by physical, psychological, and environmental QoL. Sociodemographic characteristics such as younger age and lower education level, and clinical factors such as having chronic conditions, were associated with lower QoL in both treatment settings. Actions are indicated to improve QoL in both public primary and monk healer care settings in Thailand by targeting to improve environmental, psychological and physical QoL.