Research ArticleEstimating Long-Term Care Costs among Thai Elderly A PhichitProvince Case Study

Pattaraporn Khongboon 12 and Sathirakorn Pongpanich 1

1College of Public Health Sciences Chulalongkorn University Pathumwan Bangkok 10330 ailand2Prince Mahidol Award Foundation under the Royal Patronage Faculty of Medicine Siriraj Hospital BangkoknoiBangkok 10700 ailand

Correspondence should be addressed to Sathirakorn Pongpanich sathirakornpchulaacth

Received 19 June 2017 Revised 14 September 2017 Accepted 5 November 2017 Published 17 January 2018

Academic Editor Rainer Beurskens

Copyright copy 2018 Pattaraporn Khongboon and Sathirakorn Pongpanich is is an open access article distributed under theCreative CommonsAttribution License which permits unrestricted use distribution and reproduction in anymedium providedthe original work is properly cited

Background Rural-urban inequality in long-term care (LTC) services has been increasing alongside rapid socioeconomic de-velopment is study estimates the average spending on LTC services and identifies the factors that influence the use and cost ofLTC for the elderly living in urban and rural areas of ailandMethods e sample comprised 837 elderly aged 60 years drawnfrom rural and urban areas in Phichit Province Costs were assessed over a 1-month period Direct costs of caregiving and indirectcosts (opportunity cost method) were analyzed Binary logistic regression was performed to determine which factors affected LTCcosts Results e total annual LTC spending for rural and urban residents was on average USD 7285 and USD 72806 re-spectively Formal care and informal care comprise the largest share of paymentsere was a significant association between ruralresidents and costs for informal care daynight care and home renovation Conclusions Even though total LTC expenditures donot seem to vary significantly across rural and urban areas the fundamental differences between areas need to be recognizedReorganizing country delivery systems and finding a balance between formal and informal care are alternative solutions

1 Introduction

Compared to other Asian developing countries ailand isin serious need of long-term care (LTC) due to its rapidaging population [1] Since an average ai survives beyond80 years LTC should be increased to nearly tenfold from2000 to 2050 Unlike earlier cohorts the population ofailand and other developing countries who would reach70ndash80 years in the next few decades are expected to be proneto noncommunicable diseases [2 3] According to theWorldHealth Organization (WHO) LTC includes activities carriedout by formal caretakers such as professionals auxiliarieslike social health or other workers or informal caregiverslike neighbors friends and family [4] LTC policies aredifferent in different nations and are influenced by culturehistory structure and economic performance [5 6]

e government ofailand completely understands thechallenge that LTC poses regarding the declining availabilityof family aid [7 8] In 2011 a new community care policy

was developed as a part of a project in the district of LamSonthi in Lopburi Province [9] Additionally a funding ofUSD 174 million was created by the National Health Se-curity Office (NHSO) for LTC facilities for the elderly [10]In the fiscal year 2016 a trial program announced by thegovernment spread across 1000 subdistricts including100000 severely disabled individuals [11]

Previous studies in ailand show that the averageoperating cost of NGOsrsquo nursing homes in 2007 was USD271 per resident while the average monthly operating costsof government institutions were USD 313ndash361 per residente average monthly expenses were USD 748 per residentwhich were paid by private nursing homes [1] In Bangkokthe averagemonthly expenditure of private institutionsrsquo LTCwas USD 46445 per personndashUSD 406 in the northern areasand USD 638 in the southern areas [12] According toWongsin et al [13] the total cost per day of LTC-dependentelderly citizens in hospitals in 2012 was USD 130624 an-nually and that of formal care assistants was USD 12191

HindawiJournal of Aging ResearchVolume 2018 Article ID 4180565 11 pageshttpsdoiorg10115520184180565

annually e average expenditure of institutional LTC forthe elderly moderate ADL dependence was USD 13ndash1335per person daily

Considering physical and social health rural and urbanresidents receive different access to health care services[14 15] Due to dualistic urban-rural economic structurethere are vast inequalities among both rural and urban areasin spite of the rapid economic growth [16 17] e progressof health care expenditures is of particular concern to a ruralpopulation whose incomes are lower than their urbancounterparts [17 18]

Studies conducted in other countries show that healthcare and LTC costs were related to factors like age gendercomorbidity admission dependence in personal activities ofdaily living (ADL) living arrangement and health statusamong others [19ndash21] To be specific the aforementioneddemographic factors may exert a significant influence on thescope of an individualrsquos access to care exclusively related toresidential care placement For example an individualrsquosincome and health insurance might help them gain easieraccess to health care Similarly there are other sources ofhelp such as social support networks and publicly financedLTC Individuals who do not have the adequate economicbackup or health insurance support can seek help from theaforementioned formal service providers within the healthcare service sector [22]

One can easily decipher that functional impairment isgenerally regarded as the factor behind the failure to in-dulge in ADLs Against this backdrop those who are inneed of health or personal care services confront theproblem of ADL impairment for instance those who dealwith household works tend to depend on the aforemen-tioned services On the other hand one can expect extremeADL impairment and related assistance from formal andinformal bases within the parlance of long-term healthcare [23] Besides senior citizens with ADL impairmentbut living with their relatives are less likely to be placed inany health care facility including nursing homes On theother side loner unmarried senior citizens with ADLimpairment are usually taken care of by their relatives orfriends [24]

Regional differences can be seen in the context ofutilizing health care facilities especially within the supplyof LTC choices like patient care facilities at nursing homes[25] Research works conducted on elderly citizens whotend to live in their own homes prove that men usually seekhelp from informal sources whereas women tend to seekhelp from formal sources [21] Similarly onersquos maritalstatus can determine the range of assistance within ADLimpairment treatment In this scenario research premisedupon community involvement proves that family supportis an essential factor which determines the level of assis-tance sought by married individuals divorcees and wid-owers Besides married individuals tend to seek formalassistance as compared to their unmarried counterparts ingeneral [24]

e policy care for ailand has been formed usinga costing model that takes into account projected expen-diture and actuarial estimates to bring about various LTC

options [13 26] However no research has been undertakenon the difference in LTC expenditures between rural andurban areas In addition when the LTC provisions forailand are planned influencing factors should be un-derstood together with LTC service costs With this in-formation policy-makers can understand the health careneeds of elderly citizens and their families and will be able toestablish an appropriate LTC system

is study is not focused on the LTC policy under theNational Health Security funding Assuming that theelderly are the primary payers and that the rural elderlyhave higher LTC spending than those in urban areas theaverage spending on LTC services is estimated and thefactors influencing the use of LTC in urban and rural areasare extracted

2 Materials and Methods

21 StudyArea A transversal survey was conducted with thehelp of in-person interviews in Phichit Province duringFebruary to June 2016 Phichit is situated in the north ofailand Of its population 211 are aged 60 years andover which is higher than the national average (149)Based on the 2015 National Civil Registration Systems [27]the area in Phichit with the highest percentage of peopleaged 60 and above was Bang Mun Nak subdistrict (1944)followed by Muang subdistrict (1829) So in this studyBangkmulnark subdistrict represents rural areas and Muangsubdistrict represents urban areas

22 e Number of Subjects or Sample Size e sample sizeof the elderly was determined by adopting the Taro Yamaneformula for minimum sample size [28] e minimumsample size was 364 in the rural area and 333 in the urbanarea e nonresponse rate was 20 and thus the samplesize in the rural and urban area increased to 437 and 400people respectively

23 Recruitment of Subjects A simple random samplingwas employed by computerized random selection of theelderly names from the National Civil Registration list esubjects were recruited from the community in subdistrict(Tambon) areas Phichit Province e interviewing teammade contact with the community headman prior to visitingeach selected subject at their home e subjects comprisedelderly people and their main caregivers all of whom werewilling to participate and gave their consent e inclusioncriteria were (1) being 60 years old or above having theability to talk with clarity and being in possession of onersquossenses and (2) living alone or with someone who was as-sumed to be a caregiver and had served in that role for atleast 1 month

24 Survey Tools and Data Collection Suwanrada et al [12]designed the structured interview-administered survey usedin this study e survey which had open-ended as well asclosed-ended queries included queries regarding the

2 Journal of Aging Research

sociodemographic characteristics of elderly people (ageplace of stay education salary gender single or marriedlifestyle and health details) In addition the survey askedwhether elderly respondents had any sort of disability whichit described as problems carrying out any of 10 normal tasks(taking a bath eating food maintaining personal hygienegoing to the toilet climbing stairs getting dressed walking200 meters moving in bed urinary incontinence and fecalincontinence) Moreover the survey inquired about thecaretakersrsquo characteristics (education age salary number ofhours devoted to caregiving and gender)

Furthermore the survey asked subjects for the details ofitems bought in the previous month including the price ofmedical equipment (eg hearing aid glucometer bedpanbubble mattress back brace and bathing chair) the price ofeveryday goods (eg adult diapers) the cost of medicalprocedures (out of pocket) lifestyle travel and homerenovation for elderly during the year

25 Data Quality Skilled research associates conducted thedata collection Data management tasks were carried out tomonitor the quality of the information At the end of everyinterview the examiner checked whether the data collectedwere complete e data were entered twice into SPSS 18data To enhance their quality data-cleaning techniqueswere used Moreover where data were not included SPSS 18displayed the term ldquosystem-missingrdquo

26 Cost Component In this study the cost componentconsisted of both direct and indirect costs

(i) Direct costs are expenses that can be directly tracedto a product e direct costs that the elderly peopleincurred were out-of-pocket medical expenses forthe previous month which covered doctorsrsquo ap-pointments and medications medical devices ev-eryday necessities and proper care

(ii) e indirect costs associated with LTC are mainlyrelated to the loss of human capital of carers eindirect costs of the elderly were translated into theeconomic value of the informal care that relativesprovided even if no money was charged the re-source was not considered free

(iii) Formal care was provided by experts in institutionswhether government-operated or handled by pri-vate organizations e present research regardedformal caregivers as hired caretakers

(iv) Informal care refers to unpaid caregivers providingconstant care and support It includes care providedby family members neighbors and volunteers inthe community e costs of informal care in thisstudy are measured in terms of opportunity costs

27 Cost Calculation e total costs were evaluated bysumming the direct and indirect costs that the caretakerspaid for one month e total cost excludes the elderlyrsquosearning loss due to their inability to work It is assumed that

the earning loss due to age-related bodily changes hasa minimal effect Cost variable descriptions are given inTable 1

e direct costs including out-of-pocket expenses fordaily supplies those paid for hired caretakers and those paidfor daynight care in the last month were transformed intoyearly expenditure through multiplication by 12

Regarding medical devices (eg bathing chairs wheel-chairs and canes) when an elderly person purchased themwe applied a 5-year useful life to the straight-line de-preciation technique to evaluate the annual costs of themedical devices [29 30]

e cost of home renovation for elderly in the previousyear was divided by the number of people living in the hometo calculate each personrsquos expenditure e price of homerenovation for each person was then divided by 20 years ofpractical life [29 30]

With respect to opportunity costs Suwanrada et al [12]calculated the salaries on a weekly basis in an effort todetermine the value of the time of the respondents whowere not working by assigning salaries to them In thisscenario salary differences could have resulted from age-related and educational level-related differentiation in bothgenders consequently both constraints were used aspredictors Furthermore Suwanrada et al [12] consideredthe coefficients of all the constraints Moreover the antilogwas multiplied by 52 to calculate the annual income ofevery subject

e complete relationship between wage age genderand education level is written as follows

Logit(WAGE) β0 + β1 middot (AGE)minus β2 middot AGE21113872 1113873

+ β3 middot (GENDER) + β4 middot (EDULEVEL)

(1)

In addition all estimated costs were further convertedinto 2017 USD using an exchange rate of USD 1THB 3445(the exchange rate as of March 31 2017) [31]

28 StatisticalAnalysis To summarize the features of peoplewho took part in the research descriptive statistics andsample probability weights were applied

e entire direct and indirect costs that the aged indi-vidual relative and caretaker incurred were said to be equalto the price of care of a single individual for 1 monthAccording to the following theoretical viewpoint and generalmethod the LTC expenses of a person were considered toentail operational parameters (eg gender education singleor married lifestyle disabled or not income and anypersistent sickness)

Dependent variables were found to be dichotomous asduring the study the investigators observed a large mass ofzero-costs It presented a skewed distribution skewed to theright by rare but extremely high-cost events In additionapplying linear model can result in biased parametersSubsequently in this study the investigators employeda logistic regression instead of the linear model towards thedetermination of the probability of LTC services [32ndash34]

Journal of Aging Research 3

Correspondingly during the study a binary logisticregression and maximum likelihood function were used forcalculation of the log odds ratio y 0 if no costs were in-curred and y 1 if costs were incurred It was presumed forthe analysis that a parametric binary probability modeldirected the probability of positive expenses Pr (Ygt 0 X)

We selected independent variables potentially associatedwith LTC costs based on literature reviews It was presumedthat the following factors determine a personrsquos probability ofincurring care expenses age gender education living ar-rangement marital status region extent of disability incomeand persistent sickness [21 24 35ndash40] e independentvariables were found to be dichotomous Table 2 displays thevalues and corresponding labels

29 Ethical Considerations is research was approved bythe Ethics Review Committee for Research Involving HumanResearch Subjects Health Sciences Group ChulalongkornUniversity Certificate of Approval number 1702558 eauthors obtained written consent from all participants priorto their involvement in this study

3 Results

31 Sample Characteristics Of the rural participants themean age was 7144 years 476 were aged 60ndash69 years Ofthem 691 were accounted for by women 46 weremarried but without spouses while 178 were living alone

Around 835 alongside half of caregivers had primaryeducation with 673 of them being workless Nearly778 along with 629 of caregivers had an annual incomeof less than USD 4354 whereas 902 used old age al-lowance (OAA) for support 249 suffered from a dis-ability while 815 had a chronic disease About 748 hadcaregivers with the mean age being 5282 years 446 wereaged 41ndash60 years Of the 80 women 245 were un-married 856 lived with recipients and 439 spent 5ndash8hours daily

Of the urban participants the mean age was 6858 years593 were aged 60ndash69 years 655 of them were womenClose to 51weremarried and had spouses while 188 weresingle Also 633 alongside 326 of their caregivers hadprimary education while 623 were workless Meanwhile556 had an annual income of less than USD 4354 while715 depended on OAA 98 had a disability whilst 758had a chronic disease In addition 338 of them hadcaregivers with the mean age of 5250 years 481 were aged41ndash60 years Nearly 652 were women 57 were marriedand had spouses 83 lived with recipients and 422 wereworkless and without income whereas 60 spent 5ndash8 hoursdaily

e elderly in the rural area were more likely to haveprimary education (χ2 4493 plt 0001) and less likely tobe aged 60ndash69 (χ2 5032 plt 0001) ey were more likelyto have an annual income of less than USD 4345 than thoseelderly in urban areas (x2 5284 p lt 0001) Moreoverthe elderly in the rural areas were more likely to have caregivers

Table 1 Description of cost variables

Cost type Cost categories Description

Direct costs

Daily supplies

Costs associated with medication special testingmaterial supplies (feeding tubes nasal oxygen

urinary catheters etc) dressing set bed pads adultdiapers tissue paper care transportation medical

procedure and physical therapy

Daynight care Costs associated with paying for adult day healthdaycare or overnight care

Formal careCosts associated with paying for a licensed practicalnurse a certified nursing assistant trained caregiversuntrained caregivers or any kind of paid providers

Home renovation

Costs associated with various modifications that canmake it easier for aging residents to navigate throughand live in their homes including brighter lightinghandrails stair lifts and accessible workspaces esehomemodifications can range in cost from a few bahtfor a brighter light bulb to thousands of baht for

significant remodeling (stair lifts etc)

Medical devices

Costs associated with back brace bedpan blood sugartesting bubble mattress chair for bathing hearingaid manual home care bed nebulizers overbed tableoxygen saturation monitor oxygen tanks single cane

suction tripod cane walker and wheelchair

Indirect cost Informal care (opportunity cost)

e cost of informal care that family members offeredwithout payment It constituted productivity lossesdue to lost work time and was estimated using thehuman capital approach which measured output

losses in lost earnings

4 Journal of Aging Research

(x2 14250 p lt 0001) had OAA as the source of support (x2

4738 p lt 0001) had some type of disability (x2 3312 p lt0001) and had a chronic disease (x2 407 p 0044) than thoseelderly in urban areas (χ2 4738 plt 0001) they had sometype of disability (χ2 3312 plt 0001) a chronic disease(χ2 407 p 0044) and were more likely to have caregivers(χ214250 plt 0001) Caregivers in the rural area weremore likely to have primary education (χ21403 p 0001)live with the elderly (χ2 10914 plt 0001) be workless(χ21254 plt 0001) and spend more time (13ndash24 hours)daily providing care (χ2 3557 plt 0001) (Tables 3 and 4)

32AnnualCost andUse of Services e annual cost and useof services are shown in Table 5 e total annual LTCspending was USD 7285 for rural residents and USD 72806on average for urban residents

For the rural area the average spending on paid care-givers per year was USD 33091 by men and USD 26125 bywomen these amounts were less than those for urban men(USD 40058) and women (USD 31349)

e informal care cost of rural residents was USD20652year for men and USD 21452year for womensimilarly the informal care cost of urban residents was USD21923year for men and USD 20214year for women ecost of daynight care for rural residents was USD 2717yearfor men and USD 12689year for women

e cost of daily supplies for rural men was USD6812year and for rural women was USD 664year Simi-larly the cost of daily supplies for urban men was USD7247year and for urban women was USD 6633year

e average spending on home renovation for the ruralelderly was USD 427year and that on medical devices forthe rural elderly was USD 243year e average spendingon home renovation for the urban elderly was USD 224yearand that on medical devices was USD 184year

33 Logistic Regression Analysis to Identify Factors at In-fluence LTC Utilization e binary logistic regressionanalysis results are shown in Table 6 Age was positivelyassociated with the cost of daily supplies (OR 104 95 CI101ndash106 p 0010) and that of medical devices (OR 10695 CI 103ndash109 plt 0001) However it was negativelyassociated with the institutional cost (OR 092 95 CI084ndash099 p 0033)

Living in an urban area was negatively associated withthe cost of an institutional stay (OR 009 95 CI 002ndash040 p 0002) the cost of home renovation (OR 06995 CI 049ndash094 p 0020) and the informal care cost(OR 048 95 CI 030ndash077 p 0002)

Being female was negatively associated with the cost offormal care (OR 012 95 CI 002ndash064 p 0013) andthat of home renovation (OR 156 95 CI 108ndash227p 0019) Being single was negatively associated with theopportunity cost (OR 059 95 CI 037ndash094 p 0026)Work was positively associated with the cost of daily supplies(OR 148 95 CI 100ndash218 p 0048) but negativelyassociated with the opportunity cost (OR 052 95 CI032ndash086 p 0010)

An income of more than USD 4354 per year was posi-tively associated with the cost of medical devices (OR 17795 CI 115ndash273 p 0010) and the cost of home reno-vation for elderly (OR 153 95 CI 104ndash226 p 0031)

e presence of at least one of eight chronic diseases waspositively associated with the cost of daily supplies (OR 39895 CI 218ndash726 plt 0001) the cost of medical devices(OR 224 95 CI 133ndash380 p 0003) and the cost ofhome renovation (OR 172 95 CI 113ndash263 p 0012)Some form of disability was positively associated with the costof medical devices (OR 344 95 CI 227ndash522 plt 0001)but not significantly associated with the cost of daily suppliesthe daynight care cost the cost of formal care the cost ofhome renovation for elderly and informal cost

4 Discussion

41 Annual LTC Costs per Person is study focuses on thesignificance of social security and provision of care in costsfor the elderly citizens living in the cities and villages ofailand Furthermore this study seeks to explain some verycritical determinants of care and its costs

Noteworthy is the fact that the contribution of the ruralareas on average yearly to the total amount of money es-timated for this program was USD 7285 A major sharearound USD 28447 was distributed to formal care while

Table 2 Study variables for logistic regression

Value labelDependent variablesDaily supplies 0 did not pay 1 did payDaynight care cost 0 did not pay 1 did payFormal care 0 did not pay 1 did payHome renovation 0 did not pay 1 did payInformal care(opportunity cost) 0 did not pay 1 did pay

Medical devices 0 did not pay 1 did payIndependent variablesAge ContinuousArea 0 rural 1 urbanAnnual incomegeUSD4354 0 no 1 yes

Chronic diseases

0no 1 present at least one of eightchronic diseases (hypertensiondiabetes stroke heart dementia

osteoarthritis paralysis orhypercholesterol)

Disability 0no 1 present at least one of tendisabilities

Education 0 any education 1 no educationGender 0male 1 femaleLiving status 0 living with other 1 living alone

Marital status0married 1 single single includesnever married divorced widowed and

married but separatedWorking status 0 did not work 1work

Journal of Aging Research 5

USD 2114 was allocated to informal care e citiesrsquo LTCtotal yearly cost on average was USD 72806 Additionallythe formal and informal sectorrsquos yearly economic value ofUSD 23803 and USD 2089 respectively accounted for thebigger share of the total expenditure

In this study the hypothesis made is that the total ex-penditures of the rural elderly are higher than the urbanelderly However this research does not completely rejectthe null hypothesis as the total average annual LTC ex-penditures for both rural and urban elderly are equivalentaccording to this research

is study arrives at a different finding than the severalexisting types of research which hypothesized that the

expenditure in urban areas is much higher than that of therural [41 42] is observation can be ascribed to the fact thaturban areas have better health care and medical facilitiescompared to the rural areas [14] In addition those living inurban areas owing to their lifestyles can afford better medicalfacilities and advanced treatments because they are eco-nomically endowed e low-income people living in ruralareas however might not be able to even afford low-costhealth care [16 18]

e 2014 Elderly Population survey evidenced 10 millionelderly citizens in ailand of which 41 were urban res-idents [43] In such a scenario if every citizen were to accessall kinds of care such as the ones included in this study the

Table 3 Characteristics of elderly in study area (N 837)

Care recipients Rural N () Urban N ()N 437 (100) 400 (100)Mean age (SD) 7144plusmn 786 6858plusmn 57160ndash69 208 (476) 114 (593) χ2 5032 plt 000170ndash79 156 (357) 154 (385)ge80 73 (167) 9 (23)

Gender χ2 124 p 0266Female 302 (691) 262 (655)

Marital status χ2 657 p 0037Never married 45 (103) 47 (118)Married living together 191 (437) 204 (510)Married not living togethera 201 (460) 149 (373)

Education level χ2 4493 plt 0001Primary school and lower degree 365 (835) 253 (633)High school 44 (101) 82 (205)Diploma and higher degree 28 (64) 65 (163)

Living arrangement χ2 011 p 0736Not alone 359 (822) 325 (813)

Working status χ2 232 p 0128Did not work 294 (673) 249 (623)

Annual incomeb χ2 5079 plt 0001No income 21 (53) 70 (187)ltUSD 4354 311 (778) 208 (556)geUSD 4354 68 (170) 96 (257)

Source of support (not including work)c

Old age allowance 388 (902) 284 (715) χ2 4738 plt 0001Children 154 (359) 120 (302) χ2 299 p 0084Pensionslump sums 30 (70) 70 (176) χ2 2205 plt 0001Property incomed 32 (74) 28 (71) χ2 005 p 0829Other 24 (56) 19 (48) χ2 027 p 0607

Disability χ2 3312 plt 0001Any disabilities 109 (249) 39 (98)

Chronic diseasese χ2 407 p 0044Any chronic disease 356 (815) 303 (758)

Caregiver χ2 14250 plt 0001Have caregiver 327 (748) 135 (338)

aMarried not living together includes separated widowed and divorced bData were missing for some respondents for the yearly personal income (62) cOneperson may have more than one source of support dProperty income includes rental income equityfixed interest and return from another investmentseChronic diseases include hypertension diabetes stroke heart problems dementia osteoarthritis paralysis and hypercholesterol

6 Journal of Aging Research

total care expenditurersquos approximate value would be aroundUSD 73 billion in average per year for the whole country

e expenditures for both urban and rural contributorsin this study were compared with six different types of LTCcosts e results showed that the expenditures on averageon informal and formal care health care devices and homemakers were lower in urban areas in comparison to ruralareas However the day and night care costs as well as thecosts of regular medical supplies in the cities are higher thanthat of the rural areas is could be largely attributed to thedifferent settings in rural and urban areas [16]

When compared to women the larger part of everycategory of the rural areasrsquo expenditure is associated withmen save for the informal care Whereas in urban areasmen spend higher than women in a day or night care andinformal care [21] Also according to sociology this isattributed to a belief in conventional gender roles whereinevery gender is culturally assigned roles for instancewomen being assigned familiesrsquo caregiver roles [7]

Most senior citizens despite having a choice of estab-lished LTC prefer to remain at home and thus obtainsupport from the formal caregivers or informal programs

Table 4 Characteristics of caregivers (N 462)

Rural N () Urban N ()N 327 (100) 135 (100)Mean age (SD) 5282plusmn 1511 5250plusmn 1454lt40 73 (223) 31 (230) χ2 078 p 067440ndash59 146 (446) 65 (481)ge60 108 (330) 39 (289)

Gender χ2 149 p 0222Female 232 (709) 88 (652)

Marital status χ2 130 p 0523Never married 80 (245) 32 (237)Married living together 198 (242) 77 (570)Married not living togethera 49 (150) 26 (193)

Education level χ2 1403 p 0001Primary school and lower degree 165 (505) 44 (326)High school 79 (242) 37 (274)Diploma and higher degree 83 (254) 54 (400)

Relationship with care recipients χ2 386 p 0276Spouse 133 (407) 57 (422)Sonson-in-law 43 (131) 21 (156)Daughterdaughter-in-law 94 (287) 43 (319)Relatives 57 (174) 14 (104)

Residence status χ2 10914 plt 0001Coresidence with elderly 280 (856) 112 (83)

Working status χ2 1254 plt 0001Did not work 197 (602) 57 (422)

Annual income χ2 7721 plt 0001No income 22 (73) 57 (422)ltUSD 4354 190 (629) 50 (370)geUSD 4354 90 (298) 28 (207)

Reason for leaving a jobb χ2 090 p 0636Care for an elderly 96 (558) 19 (475)Retirement 40 (233) 11 (275)Other 36 (209) 10 (250)

Time spent in informal caregiving (hoursday) χ2 3557 plt 0001Less than 4 35 (115) 27 (208)5ndash8 134 (439) 78 (600)9ndash12 57 (187) 21 (156)13ndash24 79 (259) 4 (31)

aMarried not living together includes widowed and divorced bData were missing for some respondents for the reason for quitting their job (42)

Journal of Aging Research 7

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

sociodemographic characteristics of elderly people (ageplace of stay education salary gender single or marriedlifestyle and health details) In addition the survey askedwhether elderly respondents had any sort of disability whichit described as problems carrying out any of 10 normal tasks(taking a bath eating food maintaining personal hygienegoing to the toilet climbing stairs getting dressed walking200 meters moving in bed urinary incontinence and fecalincontinence) Moreover the survey inquired about thecaretakersrsquo characteristics (education age salary number ofhours devoted to caregiving and gender)

Furthermore the survey asked subjects for the details ofitems bought in the previous month including the price ofmedical equipment (eg hearing aid glucometer bedpanbubble mattress back brace and bathing chair) the price ofeveryday goods (eg adult diapers) the cost of medicalprocedures (out of pocket) lifestyle travel and homerenovation for elderly during the year

25 Data Quality Skilled research associates conducted thedata collection Data management tasks were carried out tomonitor the quality of the information At the end of everyinterview the examiner checked whether the data collectedwere complete e data were entered twice into SPSS 18data To enhance their quality data-cleaning techniqueswere used Moreover where data were not included SPSS 18displayed the term ldquosystem-missingrdquo

26 Cost Component In this study the cost componentconsisted of both direct and indirect costs

(i) Direct costs are expenses that can be directly tracedto a product e direct costs that the elderly peopleincurred were out-of-pocket medical expenses forthe previous month which covered doctorsrsquo ap-pointments and medications medical devices ev-eryday necessities and proper care

(ii) e indirect costs associated with LTC are mainlyrelated to the loss of human capital of carers eindirect costs of the elderly were translated into theeconomic value of the informal care that relativesprovided even if no money was charged the re-source was not considered free

(iii) Formal care was provided by experts in institutionswhether government-operated or handled by pri-vate organizations e present research regardedformal caregivers as hired caretakers

(iv) Informal care refers to unpaid caregivers providingconstant care and support It includes care providedby family members neighbors and volunteers inthe community e costs of informal care in thisstudy are measured in terms of opportunity costs

27 Cost Calculation e total costs were evaluated bysumming the direct and indirect costs that the caretakerspaid for one month e total cost excludes the elderlyrsquosearning loss due to their inability to work It is assumed that

the earning loss due to age-related bodily changes hasa minimal effect Cost variable descriptions are given inTable 1

e direct costs including out-of-pocket expenses fordaily supplies those paid for hired caretakers and those paidfor daynight care in the last month were transformed intoyearly expenditure through multiplication by 12

Regarding medical devices (eg bathing chairs wheel-chairs and canes) when an elderly person purchased themwe applied a 5-year useful life to the straight-line de-preciation technique to evaluate the annual costs of themedical devices [29 30]

e cost of home renovation for elderly in the previousyear was divided by the number of people living in the hometo calculate each personrsquos expenditure e price of homerenovation for each person was then divided by 20 years ofpractical life [29 30]

With respect to opportunity costs Suwanrada et al [12]calculated the salaries on a weekly basis in an effort todetermine the value of the time of the respondents whowere not working by assigning salaries to them In thisscenario salary differences could have resulted from age-related and educational level-related differentiation in bothgenders consequently both constraints were used aspredictors Furthermore Suwanrada et al [12] consideredthe coefficients of all the constraints Moreover the antilogwas multiplied by 52 to calculate the annual income ofevery subject

e complete relationship between wage age genderand education level is written as follows

Logit(WAGE) β0 + β1 middot (AGE)minus β2 middot AGE21113872 1113873

+ β3 middot (GENDER) + β4 middot (EDULEVEL)

(1)

In addition all estimated costs were further convertedinto 2017 USD using an exchange rate of USD 1THB 3445(the exchange rate as of March 31 2017) [31]

28 StatisticalAnalysis To summarize the features of peoplewho took part in the research descriptive statistics andsample probability weights were applied

e entire direct and indirect costs that the aged indi-vidual relative and caretaker incurred were said to be equalto the price of care of a single individual for 1 monthAccording to the following theoretical viewpoint and generalmethod the LTC expenses of a person were considered toentail operational parameters (eg gender education singleor married lifestyle disabled or not income and anypersistent sickness)

Dependent variables were found to be dichotomous asduring the study the investigators observed a large mass ofzero-costs It presented a skewed distribution skewed to theright by rare but extremely high-cost events In additionapplying linear model can result in biased parametersSubsequently in this study the investigators employeda logistic regression instead of the linear model towards thedetermination of the probability of LTC services [32ndash34]

Journal of Aging Research 3

Correspondingly during the study a binary logisticregression and maximum likelihood function were used forcalculation of the log odds ratio y 0 if no costs were in-curred and y 1 if costs were incurred It was presumed forthe analysis that a parametric binary probability modeldirected the probability of positive expenses Pr (Ygt 0 X)

We selected independent variables potentially associatedwith LTC costs based on literature reviews It was presumedthat the following factors determine a personrsquos probability ofincurring care expenses age gender education living ar-rangement marital status region extent of disability incomeand persistent sickness [21 24 35ndash40] e independentvariables were found to be dichotomous Table 2 displays thevalues and corresponding labels

29 Ethical Considerations is research was approved bythe Ethics Review Committee for Research Involving HumanResearch Subjects Health Sciences Group ChulalongkornUniversity Certificate of Approval number 1702558 eauthors obtained written consent from all participants priorto their involvement in this study

3 Results

31 Sample Characteristics Of the rural participants themean age was 7144 years 476 were aged 60ndash69 years Ofthem 691 were accounted for by women 46 weremarried but without spouses while 178 were living alone

Around 835 alongside half of caregivers had primaryeducation with 673 of them being workless Nearly778 along with 629 of caregivers had an annual incomeof less than USD 4354 whereas 902 used old age al-lowance (OAA) for support 249 suffered from a dis-ability while 815 had a chronic disease About 748 hadcaregivers with the mean age being 5282 years 446 wereaged 41ndash60 years Of the 80 women 245 were un-married 856 lived with recipients and 439 spent 5ndash8hours daily

Of the urban participants the mean age was 6858 years593 were aged 60ndash69 years 655 of them were womenClose to 51weremarried and had spouses while 188 weresingle Also 633 alongside 326 of their caregivers hadprimary education while 623 were workless Meanwhile556 had an annual income of less than USD 4354 while715 depended on OAA 98 had a disability whilst 758had a chronic disease In addition 338 of them hadcaregivers with the mean age of 5250 years 481 were aged41ndash60 years Nearly 652 were women 57 were marriedand had spouses 83 lived with recipients and 422 wereworkless and without income whereas 60 spent 5ndash8 hoursdaily

e elderly in the rural area were more likely to haveprimary education (χ2 4493 plt 0001) and less likely tobe aged 60ndash69 (χ2 5032 plt 0001) ey were more likelyto have an annual income of less than USD 4345 than thoseelderly in urban areas (x2 5284 p lt 0001) Moreoverthe elderly in the rural areas were more likely to have caregivers

Table 1 Description of cost variables

Cost type Cost categories Description

Direct costs

Daily supplies

Costs associated with medication special testingmaterial supplies (feeding tubes nasal oxygen

urinary catheters etc) dressing set bed pads adultdiapers tissue paper care transportation medical

procedure and physical therapy

Daynight care Costs associated with paying for adult day healthdaycare or overnight care

Formal careCosts associated with paying for a licensed practicalnurse a certified nursing assistant trained caregiversuntrained caregivers or any kind of paid providers

Home renovation

Costs associated with various modifications that canmake it easier for aging residents to navigate throughand live in their homes including brighter lightinghandrails stair lifts and accessible workspaces esehomemodifications can range in cost from a few bahtfor a brighter light bulb to thousands of baht for

significant remodeling (stair lifts etc)

Medical devices

Costs associated with back brace bedpan blood sugartesting bubble mattress chair for bathing hearingaid manual home care bed nebulizers overbed tableoxygen saturation monitor oxygen tanks single cane

suction tripod cane walker and wheelchair

Indirect cost Informal care (opportunity cost)

e cost of informal care that family members offeredwithout payment It constituted productivity lossesdue to lost work time and was estimated using thehuman capital approach which measured output

losses in lost earnings

4 Journal of Aging Research

(x2 14250 p lt 0001) had OAA as the source of support (x2

4738 p lt 0001) had some type of disability (x2 3312 p lt0001) and had a chronic disease (x2 407 p 0044) than thoseelderly in urban areas (χ2 4738 plt 0001) they had sometype of disability (χ2 3312 plt 0001) a chronic disease(χ2 407 p 0044) and were more likely to have caregivers(χ214250 plt 0001) Caregivers in the rural area weremore likely to have primary education (χ21403 p 0001)live with the elderly (χ2 10914 plt 0001) be workless(χ21254 plt 0001) and spend more time (13ndash24 hours)daily providing care (χ2 3557 plt 0001) (Tables 3 and 4)

32AnnualCost andUse of Services e annual cost and useof services are shown in Table 5 e total annual LTCspending was USD 7285 for rural residents and USD 72806on average for urban residents

For the rural area the average spending on paid care-givers per year was USD 33091 by men and USD 26125 bywomen these amounts were less than those for urban men(USD 40058) and women (USD 31349)

e informal care cost of rural residents was USD20652year for men and USD 21452year for womensimilarly the informal care cost of urban residents was USD21923year for men and USD 20214year for women ecost of daynight care for rural residents was USD 2717yearfor men and USD 12689year for women

e cost of daily supplies for rural men was USD6812year and for rural women was USD 664year Simi-larly the cost of daily supplies for urban men was USD7247year and for urban women was USD 6633year

e average spending on home renovation for the ruralelderly was USD 427year and that on medical devices forthe rural elderly was USD 243year e average spendingon home renovation for the urban elderly was USD 224yearand that on medical devices was USD 184year

33 Logistic Regression Analysis to Identify Factors at In-fluence LTC Utilization e binary logistic regressionanalysis results are shown in Table 6 Age was positivelyassociated with the cost of daily supplies (OR 104 95 CI101ndash106 p 0010) and that of medical devices (OR 10695 CI 103ndash109 plt 0001) However it was negativelyassociated with the institutional cost (OR 092 95 CI084ndash099 p 0033)

Living in an urban area was negatively associated withthe cost of an institutional stay (OR 009 95 CI 002ndash040 p 0002) the cost of home renovation (OR 06995 CI 049ndash094 p 0020) and the informal care cost(OR 048 95 CI 030ndash077 p 0002)

Being female was negatively associated with the cost offormal care (OR 012 95 CI 002ndash064 p 0013) andthat of home renovation (OR 156 95 CI 108ndash227p 0019) Being single was negatively associated with theopportunity cost (OR 059 95 CI 037ndash094 p 0026)Work was positively associated with the cost of daily supplies(OR 148 95 CI 100ndash218 p 0048) but negativelyassociated with the opportunity cost (OR 052 95 CI032ndash086 p 0010)

An income of more than USD 4354 per year was posi-tively associated with the cost of medical devices (OR 17795 CI 115ndash273 p 0010) and the cost of home reno-vation for elderly (OR 153 95 CI 104ndash226 p 0031)

e presence of at least one of eight chronic diseases waspositively associated with the cost of daily supplies (OR 39895 CI 218ndash726 plt 0001) the cost of medical devices(OR 224 95 CI 133ndash380 p 0003) and the cost ofhome renovation (OR 172 95 CI 113ndash263 p 0012)Some form of disability was positively associated with the costof medical devices (OR 344 95 CI 227ndash522 plt 0001)but not significantly associated with the cost of daily suppliesthe daynight care cost the cost of formal care the cost ofhome renovation for elderly and informal cost

4 Discussion

41 Annual LTC Costs per Person is study focuses on thesignificance of social security and provision of care in costsfor the elderly citizens living in the cities and villages ofailand Furthermore this study seeks to explain some verycritical determinants of care and its costs

Noteworthy is the fact that the contribution of the ruralareas on average yearly to the total amount of money es-timated for this program was USD 7285 A major sharearound USD 28447 was distributed to formal care while

Table 2 Study variables for logistic regression

Value labelDependent variablesDaily supplies 0 did not pay 1 did payDaynight care cost 0 did not pay 1 did payFormal care 0 did not pay 1 did payHome renovation 0 did not pay 1 did payInformal care(opportunity cost) 0 did not pay 1 did pay

Medical devices 0 did not pay 1 did payIndependent variablesAge ContinuousArea 0 rural 1 urbanAnnual incomegeUSD4354 0 no 1 yes

Chronic diseases

0no 1 present at least one of eightchronic diseases (hypertensiondiabetes stroke heart dementia

osteoarthritis paralysis orhypercholesterol)

Disability 0no 1 present at least one of tendisabilities

Education 0 any education 1 no educationGender 0male 1 femaleLiving status 0 living with other 1 living alone

Marital status0married 1 single single includesnever married divorced widowed and

married but separatedWorking status 0 did not work 1work

Journal of Aging Research 5

USD 2114 was allocated to informal care e citiesrsquo LTCtotal yearly cost on average was USD 72806 Additionallythe formal and informal sectorrsquos yearly economic value ofUSD 23803 and USD 2089 respectively accounted for thebigger share of the total expenditure

In this study the hypothesis made is that the total ex-penditures of the rural elderly are higher than the urbanelderly However this research does not completely rejectthe null hypothesis as the total average annual LTC ex-penditures for both rural and urban elderly are equivalentaccording to this research

is study arrives at a different finding than the severalexisting types of research which hypothesized that the

expenditure in urban areas is much higher than that of therural [41 42] is observation can be ascribed to the fact thaturban areas have better health care and medical facilitiescompared to the rural areas [14] In addition those living inurban areas owing to their lifestyles can afford better medicalfacilities and advanced treatments because they are eco-nomically endowed e low-income people living in ruralareas however might not be able to even afford low-costhealth care [16 18]

e 2014 Elderly Population survey evidenced 10 millionelderly citizens in ailand of which 41 were urban res-idents [43] In such a scenario if every citizen were to accessall kinds of care such as the ones included in this study the

Table 3 Characteristics of elderly in study area (N 837)

Care recipients Rural N () Urban N ()N 437 (100) 400 (100)Mean age (SD) 7144plusmn 786 6858plusmn 57160ndash69 208 (476) 114 (593) χ2 5032 plt 000170ndash79 156 (357) 154 (385)ge80 73 (167) 9 (23)

Gender χ2 124 p 0266Female 302 (691) 262 (655)

Marital status χ2 657 p 0037Never married 45 (103) 47 (118)Married living together 191 (437) 204 (510)Married not living togethera 201 (460) 149 (373)

Education level χ2 4493 plt 0001Primary school and lower degree 365 (835) 253 (633)High school 44 (101) 82 (205)Diploma and higher degree 28 (64) 65 (163)

Living arrangement χ2 011 p 0736Not alone 359 (822) 325 (813)

Working status χ2 232 p 0128Did not work 294 (673) 249 (623)

Annual incomeb χ2 5079 plt 0001No income 21 (53) 70 (187)ltUSD 4354 311 (778) 208 (556)geUSD 4354 68 (170) 96 (257)

Source of support (not including work)c

Old age allowance 388 (902) 284 (715) χ2 4738 plt 0001Children 154 (359) 120 (302) χ2 299 p 0084Pensionslump sums 30 (70) 70 (176) χ2 2205 plt 0001Property incomed 32 (74) 28 (71) χ2 005 p 0829Other 24 (56) 19 (48) χ2 027 p 0607

Disability χ2 3312 plt 0001Any disabilities 109 (249) 39 (98)

Chronic diseasese χ2 407 p 0044Any chronic disease 356 (815) 303 (758)

Caregiver χ2 14250 plt 0001Have caregiver 327 (748) 135 (338)

aMarried not living together includes separated widowed and divorced bData were missing for some respondents for the yearly personal income (62) cOneperson may have more than one source of support dProperty income includes rental income equityfixed interest and return from another investmentseChronic diseases include hypertension diabetes stroke heart problems dementia osteoarthritis paralysis and hypercholesterol

6 Journal of Aging Research

total care expenditurersquos approximate value would be aroundUSD 73 billion in average per year for the whole country

e expenditures for both urban and rural contributorsin this study were compared with six different types of LTCcosts e results showed that the expenditures on averageon informal and formal care health care devices and homemakers were lower in urban areas in comparison to ruralareas However the day and night care costs as well as thecosts of regular medical supplies in the cities are higher thanthat of the rural areas is could be largely attributed to thedifferent settings in rural and urban areas [16]

When compared to women the larger part of everycategory of the rural areasrsquo expenditure is associated withmen save for the informal care Whereas in urban areasmen spend higher than women in a day or night care andinformal care [21] Also according to sociology this isattributed to a belief in conventional gender roles whereinevery gender is culturally assigned roles for instancewomen being assigned familiesrsquo caregiver roles [7]

Most senior citizens despite having a choice of estab-lished LTC prefer to remain at home and thus obtainsupport from the formal caregivers or informal programs

Table 4 Characteristics of caregivers (N 462)

Rural N () Urban N ()N 327 (100) 135 (100)Mean age (SD) 5282plusmn 1511 5250plusmn 1454lt40 73 (223) 31 (230) χ2 078 p 067440ndash59 146 (446) 65 (481)ge60 108 (330) 39 (289)

Gender χ2 149 p 0222Female 232 (709) 88 (652)

Marital status χ2 130 p 0523Never married 80 (245) 32 (237)Married living together 198 (242) 77 (570)Married not living togethera 49 (150) 26 (193)

Education level χ2 1403 p 0001Primary school and lower degree 165 (505) 44 (326)High school 79 (242) 37 (274)Diploma and higher degree 83 (254) 54 (400)

Relationship with care recipients χ2 386 p 0276Spouse 133 (407) 57 (422)Sonson-in-law 43 (131) 21 (156)Daughterdaughter-in-law 94 (287) 43 (319)Relatives 57 (174) 14 (104)

Residence status χ2 10914 plt 0001Coresidence with elderly 280 (856) 112 (83)

Working status χ2 1254 plt 0001Did not work 197 (602) 57 (422)

Annual income χ2 7721 plt 0001No income 22 (73) 57 (422)ltUSD 4354 190 (629) 50 (370)geUSD 4354 90 (298) 28 (207)

Reason for leaving a jobb χ2 090 p 0636Care for an elderly 96 (558) 19 (475)Retirement 40 (233) 11 (275)Other 36 (209) 10 (250)

Time spent in informal caregiving (hoursday) χ2 3557 plt 0001Less than 4 35 (115) 27 (208)5ndash8 134 (439) 78 (600)9ndash12 57 (187) 21 (156)13ndash24 79 (259) 4 (31)

aMarried not living together includes widowed and divorced bData were missing for some respondents for the reason for quitting their job (42)

Journal of Aging Research 7

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

Correspondingly during the study a binary logisticregression and maximum likelihood function were used forcalculation of the log odds ratio y 0 if no costs were in-curred and y 1 if costs were incurred It was presumed forthe analysis that a parametric binary probability modeldirected the probability of positive expenses Pr (Ygt 0 X)

We selected independent variables potentially associatedwith LTC costs based on literature reviews It was presumedthat the following factors determine a personrsquos probability ofincurring care expenses age gender education living ar-rangement marital status region extent of disability incomeand persistent sickness [21 24 35ndash40] e independentvariables were found to be dichotomous Table 2 displays thevalues and corresponding labels

29 Ethical Considerations is research was approved bythe Ethics Review Committee for Research Involving HumanResearch Subjects Health Sciences Group ChulalongkornUniversity Certificate of Approval number 1702558 eauthors obtained written consent from all participants priorto their involvement in this study

3 Results

31 Sample Characteristics Of the rural participants themean age was 7144 years 476 were aged 60ndash69 years Ofthem 691 were accounted for by women 46 weremarried but without spouses while 178 were living alone

Around 835 alongside half of caregivers had primaryeducation with 673 of them being workless Nearly778 along with 629 of caregivers had an annual incomeof less than USD 4354 whereas 902 used old age al-lowance (OAA) for support 249 suffered from a dis-ability while 815 had a chronic disease About 748 hadcaregivers with the mean age being 5282 years 446 wereaged 41ndash60 years Of the 80 women 245 were un-married 856 lived with recipients and 439 spent 5ndash8hours daily

Of the urban participants the mean age was 6858 years593 were aged 60ndash69 years 655 of them were womenClose to 51weremarried and had spouses while 188 weresingle Also 633 alongside 326 of their caregivers hadprimary education while 623 were workless Meanwhile556 had an annual income of less than USD 4354 while715 depended on OAA 98 had a disability whilst 758had a chronic disease In addition 338 of them hadcaregivers with the mean age of 5250 years 481 were aged41ndash60 years Nearly 652 were women 57 were marriedand had spouses 83 lived with recipients and 422 wereworkless and without income whereas 60 spent 5ndash8 hoursdaily

e elderly in the rural area were more likely to haveprimary education (χ2 4493 plt 0001) and less likely tobe aged 60ndash69 (χ2 5032 plt 0001) ey were more likelyto have an annual income of less than USD 4345 than thoseelderly in urban areas (x2 5284 p lt 0001) Moreoverthe elderly in the rural areas were more likely to have caregivers

Table 1 Description of cost variables

Cost type Cost categories Description

Direct costs

Daily supplies

Costs associated with medication special testingmaterial supplies (feeding tubes nasal oxygen

urinary catheters etc) dressing set bed pads adultdiapers tissue paper care transportation medical

procedure and physical therapy

Daynight care Costs associated with paying for adult day healthdaycare or overnight care

Formal careCosts associated with paying for a licensed practicalnurse a certified nursing assistant trained caregiversuntrained caregivers or any kind of paid providers

Home renovation

Costs associated with various modifications that canmake it easier for aging residents to navigate throughand live in their homes including brighter lightinghandrails stair lifts and accessible workspaces esehomemodifications can range in cost from a few bahtfor a brighter light bulb to thousands of baht for

significant remodeling (stair lifts etc)

Medical devices

Costs associated with back brace bedpan blood sugartesting bubble mattress chair for bathing hearingaid manual home care bed nebulizers overbed tableoxygen saturation monitor oxygen tanks single cane

suction tripod cane walker and wheelchair

Indirect cost Informal care (opportunity cost)

e cost of informal care that family members offeredwithout payment It constituted productivity lossesdue to lost work time and was estimated using thehuman capital approach which measured output

losses in lost earnings

4 Journal of Aging Research

(x2 14250 p lt 0001) had OAA as the source of support (x2

4738 p lt 0001) had some type of disability (x2 3312 p lt0001) and had a chronic disease (x2 407 p 0044) than thoseelderly in urban areas (χ2 4738 plt 0001) they had sometype of disability (χ2 3312 plt 0001) a chronic disease(χ2 407 p 0044) and were more likely to have caregivers(χ214250 plt 0001) Caregivers in the rural area weremore likely to have primary education (χ21403 p 0001)live with the elderly (χ2 10914 plt 0001) be workless(χ21254 plt 0001) and spend more time (13ndash24 hours)daily providing care (χ2 3557 plt 0001) (Tables 3 and 4)

32AnnualCost andUse of Services e annual cost and useof services are shown in Table 5 e total annual LTCspending was USD 7285 for rural residents and USD 72806on average for urban residents

For the rural area the average spending on paid care-givers per year was USD 33091 by men and USD 26125 bywomen these amounts were less than those for urban men(USD 40058) and women (USD 31349)

e informal care cost of rural residents was USD20652year for men and USD 21452year for womensimilarly the informal care cost of urban residents was USD21923year for men and USD 20214year for women ecost of daynight care for rural residents was USD 2717yearfor men and USD 12689year for women

e cost of daily supplies for rural men was USD6812year and for rural women was USD 664year Simi-larly the cost of daily supplies for urban men was USD7247year and for urban women was USD 6633year

e average spending on home renovation for the ruralelderly was USD 427year and that on medical devices forthe rural elderly was USD 243year e average spendingon home renovation for the urban elderly was USD 224yearand that on medical devices was USD 184year

33 Logistic Regression Analysis to Identify Factors at In-fluence LTC Utilization e binary logistic regressionanalysis results are shown in Table 6 Age was positivelyassociated with the cost of daily supplies (OR 104 95 CI101ndash106 p 0010) and that of medical devices (OR 10695 CI 103ndash109 plt 0001) However it was negativelyassociated with the institutional cost (OR 092 95 CI084ndash099 p 0033)

Living in an urban area was negatively associated withthe cost of an institutional stay (OR 009 95 CI 002ndash040 p 0002) the cost of home renovation (OR 06995 CI 049ndash094 p 0020) and the informal care cost(OR 048 95 CI 030ndash077 p 0002)

Being female was negatively associated with the cost offormal care (OR 012 95 CI 002ndash064 p 0013) andthat of home renovation (OR 156 95 CI 108ndash227p 0019) Being single was negatively associated with theopportunity cost (OR 059 95 CI 037ndash094 p 0026)Work was positively associated with the cost of daily supplies(OR 148 95 CI 100ndash218 p 0048) but negativelyassociated with the opportunity cost (OR 052 95 CI032ndash086 p 0010)

An income of more than USD 4354 per year was posi-tively associated with the cost of medical devices (OR 17795 CI 115ndash273 p 0010) and the cost of home reno-vation for elderly (OR 153 95 CI 104ndash226 p 0031)

e presence of at least one of eight chronic diseases waspositively associated with the cost of daily supplies (OR 39895 CI 218ndash726 plt 0001) the cost of medical devices(OR 224 95 CI 133ndash380 p 0003) and the cost ofhome renovation (OR 172 95 CI 113ndash263 p 0012)Some form of disability was positively associated with the costof medical devices (OR 344 95 CI 227ndash522 plt 0001)but not significantly associated with the cost of daily suppliesthe daynight care cost the cost of formal care the cost ofhome renovation for elderly and informal cost

4 Discussion

41 Annual LTC Costs per Person is study focuses on thesignificance of social security and provision of care in costsfor the elderly citizens living in the cities and villages ofailand Furthermore this study seeks to explain some verycritical determinants of care and its costs

Noteworthy is the fact that the contribution of the ruralareas on average yearly to the total amount of money es-timated for this program was USD 7285 A major sharearound USD 28447 was distributed to formal care while

Table 2 Study variables for logistic regression

Value labelDependent variablesDaily supplies 0 did not pay 1 did payDaynight care cost 0 did not pay 1 did payFormal care 0 did not pay 1 did payHome renovation 0 did not pay 1 did payInformal care(opportunity cost) 0 did not pay 1 did pay

Medical devices 0 did not pay 1 did payIndependent variablesAge ContinuousArea 0 rural 1 urbanAnnual incomegeUSD4354 0 no 1 yes

Chronic diseases

0no 1 present at least one of eightchronic diseases (hypertensiondiabetes stroke heart dementia

osteoarthritis paralysis orhypercholesterol)

Disability 0no 1 present at least one of tendisabilities

Education 0 any education 1 no educationGender 0male 1 femaleLiving status 0 living with other 1 living alone

Marital status0married 1 single single includesnever married divorced widowed and

married but separatedWorking status 0 did not work 1work

Journal of Aging Research 5

USD 2114 was allocated to informal care e citiesrsquo LTCtotal yearly cost on average was USD 72806 Additionallythe formal and informal sectorrsquos yearly economic value ofUSD 23803 and USD 2089 respectively accounted for thebigger share of the total expenditure

In this study the hypothesis made is that the total ex-penditures of the rural elderly are higher than the urbanelderly However this research does not completely rejectthe null hypothesis as the total average annual LTC ex-penditures for both rural and urban elderly are equivalentaccording to this research

is study arrives at a different finding than the severalexisting types of research which hypothesized that the

expenditure in urban areas is much higher than that of therural [41 42] is observation can be ascribed to the fact thaturban areas have better health care and medical facilitiescompared to the rural areas [14] In addition those living inurban areas owing to their lifestyles can afford better medicalfacilities and advanced treatments because they are eco-nomically endowed e low-income people living in ruralareas however might not be able to even afford low-costhealth care [16 18]

e 2014 Elderly Population survey evidenced 10 millionelderly citizens in ailand of which 41 were urban res-idents [43] In such a scenario if every citizen were to accessall kinds of care such as the ones included in this study the

Table 3 Characteristics of elderly in study area (N 837)

Care recipients Rural N () Urban N ()N 437 (100) 400 (100)Mean age (SD) 7144plusmn 786 6858plusmn 57160ndash69 208 (476) 114 (593) χ2 5032 plt 000170ndash79 156 (357) 154 (385)ge80 73 (167) 9 (23)

Gender χ2 124 p 0266Female 302 (691) 262 (655)

Marital status χ2 657 p 0037Never married 45 (103) 47 (118)Married living together 191 (437) 204 (510)Married not living togethera 201 (460) 149 (373)

Education level χ2 4493 plt 0001Primary school and lower degree 365 (835) 253 (633)High school 44 (101) 82 (205)Diploma and higher degree 28 (64) 65 (163)

Living arrangement χ2 011 p 0736Not alone 359 (822) 325 (813)

Working status χ2 232 p 0128Did not work 294 (673) 249 (623)

Annual incomeb χ2 5079 plt 0001No income 21 (53) 70 (187)ltUSD 4354 311 (778) 208 (556)geUSD 4354 68 (170) 96 (257)

Source of support (not including work)c

Old age allowance 388 (902) 284 (715) χ2 4738 plt 0001Children 154 (359) 120 (302) χ2 299 p 0084Pensionslump sums 30 (70) 70 (176) χ2 2205 plt 0001Property incomed 32 (74) 28 (71) χ2 005 p 0829Other 24 (56) 19 (48) χ2 027 p 0607

Disability χ2 3312 plt 0001Any disabilities 109 (249) 39 (98)

Chronic diseasese χ2 407 p 0044Any chronic disease 356 (815) 303 (758)

Caregiver χ2 14250 plt 0001Have caregiver 327 (748) 135 (338)

aMarried not living together includes separated widowed and divorced bData were missing for some respondents for the yearly personal income (62) cOneperson may have more than one source of support dProperty income includes rental income equityfixed interest and return from another investmentseChronic diseases include hypertension diabetes stroke heart problems dementia osteoarthritis paralysis and hypercholesterol

6 Journal of Aging Research

total care expenditurersquos approximate value would be aroundUSD 73 billion in average per year for the whole country

e expenditures for both urban and rural contributorsin this study were compared with six different types of LTCcosts e results showed that the expenditures on averageon informal and formal care health care devices and homemakers were lower in urban areas in comparison to ruralareas However the day and night care costs as well as thecosts of regular medical supplies in the cities are higher thanthat of the rural areas is could be largely attributed to thedifferent settings in rural and urban areas [16]

When compared to women the larger part of everycategory of the rural areasrsquo expenditure is associated withmen save for the informal care Whereas in urban areasmen spend higher than women in a day or night care andinformal care [21] Also according to sociology this isattributed to a belief in conventional gender roles whereinevery gender is culturally assigned roles for instancewomen being assigned familiesrsquo caregiver roles [7]

Most senior citizens despite having a choice of estab-lished LTC prefer to remain at home and thus obtainsupport from the formal caregivers or informal programs

Table 4 Characteristics of caregivers (N 462)

Rural N () Urban N ()N 327 (100) 135 (100)Mean age (SD) 5282plusmn 1511 5250plusmn 1454lt40 73 (223) 31 (230) χ2 078 p 067440ndash59 146 (446) 65 (481)ge60 108 (330) 39 (289)

Gender χ2 149 p 0222Female 232 (709) 88 (652)

Marital status χ2 130 p 0523Never married 80 (245) 32 (237)Married living together 198 (242) 77 (570)Married not living togethera 49 (150) 26 (193)

Education level χ2 1403 p 0001Primary school and lower degree 165 (505) 44 (326)High school 79 (242) 37 (274)Diploma and higher degree 83 (254) 54 (400)

Relationship with care recipients χ2 386 p 0276Spouse 133 (407) 57 (422)Sonson-in-law 43 (131) 21 (156)Daughterdaughter-in-law 94 (287) 43 (319)Relatives 57 (174) 14 (104)

Residence status χ2 10914 plt 0001Coresidence with elderly 280 (856) 112 (83)

Working status χ2 1254 plt 0001Did not work 197 (602) 57 (422)

Annual income χ2 7721 plt 0001No income 22 (73) 57 (422)ltUSD 4354 190 (629) 50 (370)geUSD 4354 90 (298) 28 (207)

Reason for leaving a jobb χ2 090 p 0636Care for an elderly 96 (558) 19 (475)Retirement 40 (233) 11 (275)Other 36 (209) 10 (250)

Time spent in informal caregiving (hoursday) χ2 3557 plt 0001Less than 4 35 (115) 27 (208)5ndash8 134 (439) 78 (600)9ndash12 57 (187) 21 (156)13ndash24 79 (259) 4 (31)

aMarried not living together includes widowed and divorced bData were missing for some respondents for the reason for quitting their job (42)

Journal of Aging Research 7

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

(x2 14250 p lt 0001) had OAA as the source of support (x2

4738 p lt 0001) had some type of disability (x2 3312 p lt0001) and had a chronic disease (x2 407 p 0044) than thoseelderly in urban areas (χ2 4738 plt 0001) they had sometype of disability (χ2 3312 plt 0001) a chronic disease(χ2 407 p 0044) and were more likely to have caregivers(χ214250 plt 0001) Caregivers in the rural area weremore likely to have primary education (χ21403 p 0001)live with the elderly (χ2 10914 plt 0001) be workless(χ21254 plt 0001) and spend more time (13ndash24 hours)daily providing care (χ2 3557 plt 0001) (Tables 3 and 4)

32AnnualCost andUse of Services e annual cost and useof services are shown in Table 5 e total annual LTCspending was USD 7285 for rural residents and USD 72806on average for urban residents

For the rural area the average spending on paid care-givers per year was USD 33091 by men and USD 26125 bywomen these amounts were less than those for urban men(USD 40058) and women (USD 31349)

e informal care cost of rural residents was USD20652year for men and USD 21452year for womensimilarly the informal care cost of urban residents was USD21923year for men and USD 20214year for women ecost of daynight care for rural residents was USD 2717yearfor men and USD 12689year for women

e cost of daily supplies for rural men was USD6812year and for rural women was USD 664year Simi-larly the cost of daily supplies for urban men was USD7247year and for urban women was USD 6633year

e average spending on home renovation for the ruralelderly was USD 427year and that on medical devices forthe rural elderly was USD 243year e average spendingon home renovation for the urban elderly was USD 224yearand that on medical devices was USD 184year

33 Logistic Regression Analysis to Identify Factors at In-fluence LTC Utilization e binary logistic regressionanalysis results are shown in Table 6 Age was positivelyassociated with the cost of daily supplies (OR 104 95 CI101ndash106 p 0010) and that of medical devices (OR 10695 CI 103ndash109 plt 0001) However it was negativelyassociated with the institutional cost (OR 092 95 CI084ndash099 p 0033)

Living in an urban area was negatively associated withthe cost of an institutional stay (OR 009 95 CI 002ndash040 p 0002) the cost of home renovation (OR 06995 CI 049ndash094 p 0020) and the informal care cost(OR 048 95 CI 030ndash077 p 0002)

Being female was negatively associated with the cost offormal care (OR 012 95 CI 002ndash064 p 0013) andthat of home renovation (OR 156 95 CI 108ndash227p 0019) Being single was negatively associated with theopportunity cost (OR 059 95 CI 037ndash094 p 0026)Work was positively associated with the cost of daily supplies(OR 148 95 CI 100ndash218 p 0048) but negativelyassociated with the opportunity cost (OR 052 95 CI032ndash086 p 0010)

An income of more than USD 4354 per year was posi-tively associated with the cost of medical devices (OR 17795 CI 115ndash273 p 0010) and the cost of home reno-vation for elderly (OR 153 95 CI 104ndash226 p 0031)

e presence of at least one of eight chronic diseases waspositively associated with the cost of daily supplies (OR 39895 CI 218ndash726 plt 0001) the cost of medical devices(OR 224 95 CI 133ndash380 p 0003) and the cost ofhome renovation (OR 172 95 CI 113ndash263 p 0012)Some form of disability was positively associated with the costof medical devices (OR 344 95 CI 227ndash522 plt 0001)but not significantly associated with the cost of daily suppliesthe daynight care cost the cost of formal care the cost ofhome renovation for elderly and informal cost

4 Discussion

41 Annual LTC Costs per Person is study focuses on thesignificance of social security and provision of care in costsfor the elderly citizens living in the cities and villages ofailand Furthermore this study seeks to explain some verycritical determinants of care and its costs

Noteworthy is the fact that the contribution of the ruralareas on average yearly to the total amount of money es-timated for this program was USD 7285 A major sharearound USD 28447 was distributed to formal care while

Table 2 Study variables for logistic regression

Value labelDependent variablesDaily supplies 0 did not pay 1 did payDaynight care cost 0 did not pay 1 did payFormal care 0 did not pay 1 did payHome renovation 0 did not pay 1 did payInformal care(opportunity cost) 0 did not pay 1 did pay

Medical devices 0 did not pay 1 did payIndependent variablesAge ContinuousArea 0 rural 1 urbanAnnual incomegeUSD4354 0 no 1 yes

Chronic diseases

0no 1 present at least one of eightchronic diseases (hypertensiondiabetes stroke heart dementia

osteoarthritis paralysis orhypercholesterol)

Disability 0no 1 present at least one of tendisabilities

Education 0 any education 1 no educationGender 0male 1 femaleLiving status 0 living with other 1 living alone

Marital status0married 1 single single includesnever married divorced widowed and

married but separatedWorking status 0 did not work 1work

Journal of Aging Research 5

USD 2114 was allocated to informal care e citiesrsquo LTCtotal yearly cost on average was USD 72806 Additionallythe formal and informal sectorrsquos yearly economic value ofUSD 23803 and USD 2089 respectively accounted for thebigger share of the total expenditure

In this study the hypothesis made is that the total ex-penditures of the rural elderly are higher than the urbanelderly However this research does not completely rejectthe null hypothesis as the total average annual LTC ex-penditures for both rural and urban elderly are equivalentaccording to this research

is study arrives at a different finding than the severalexisting types of research which hypothesized that the

expenditure in urban areas is much higher than that of therural [41 42] is observation can be ascribed to the fact thaturban areas have better health care and medical facilitiescompared to the rural areas [14] In addition those living inurban areas owing to their lifestyles can afford better medicalfacilities and advanced treatments because they are eco-nomically endowed e low-income people living in ruralareas however might not be able to even afford low-costhealth care [16 18]

e 2014 Elderly Population survey evidenced 10 millionelderly citizens in ailand of which 41 were urban res-idents [43] In such a scenario if every citizen were to accessall kinds of care such as the ones included in this study the

Table 3 Characteristics of elderly in study area (N 837)

Care recipients Rural N () Urban N ()N 437 (100) 400 (100)Mean age (SD) 7144plusmn 786 6858plusmn 57160ndash69 208 (476) 114 (593) χ2 5032 plt 000170ndash79 156 (357) 154 (385)ge80 73 (167) 9 (23)

Gender χ2 124 p 0266Female 302 (691) 262 (655)

Marital status χ2 657 p 0037Never married 45 (103) 47 (118)Married living together 191 (437) 204 (510)Married not living togethera 201 (460) 149 (373)

Education level χ2 4493 plt 0001Primary school and lower degree 365 (835) 253 (633)High school 44 (101) 82 (205)Diploma and higher degree 28 (64) 65 (163)

Living arrangement χ2 011 p 0736Not alone 359 (822) 325 (813)

Working status χ2 232 p 0128Did not work 294 (673) 249 (623)

Annual incomeb χ2 5079 plt 0001No income 21 (53) 70 (187)ltUSD 4354 311 (778) 208 (556)geUSD 4354 68 (170) 96 (257)

Source of support (not including work)c

Old age allowance 388 (902) 284 (715) χ2 4738 plt 0001Children 154 (359) 120 (302) χ2 299 p 0084Pensionslump sums 30 (70) 70 (176) χ2 2205 plt 0001Property incomed 32 (74) 28 (71) χ2 005 p 0829Other 24 (56) 19 (48) χ2 027 p 0607

Disability χ2 3312 plt 0001Any disabilities 109 (249) 39 (98)

Chronic diseasese χ2 407 p 0044Any chronic disease 356 (815) 303 (758)

Caregiver χ2 14250 plt 0001Have caregiver 327 (748) 135 (338)

aMarried not living together includes separated widowed and divorced bData were missing for some respondents for the yearly personal income (62) cOneperson may have more than one source of support dProperty income includes rental income equityfixed interest and return from another investmentseChronic diseases include hypertension diabetes stroke heart problems dementia osteoarthritis paralysis and hypercholesterol

6 Journal of Aging Research

total care expenditurersquos approximate value would be aroundUSD 73 billion in average per year for the whole country

e expenditures for both urban and rural contributorsin this study were compared with six different types of LTCcosts e results showed that the expenditures on averageon informal and formal care health care devices and homemakers were lower in urban areas in comparison to ruralareas However the day and night care costs as well as thecosts of regular medical supplies in the cities are higher thanthat of the rural areas is could be largely attributed to thedifferent settings in rural and urban areas [16]

When compared to women the larger part of everycategory of the rural areasrsquo expenditure is associated withmen save for the informal care Whereas in urban areasmen spend higher than women in a day or night care andinformal care [21] Also according to sociology this isattributed to a belief in conventional gender roles whereinevery gender is culturally assigned roles for instancewomen being assigned familiesrsquo caregiver roles [7]

Most senior citizens despite having a choice of estab-lished LTC prefer to remain at home and thus obtainsupport from the formal caregivers or informal programs

Table 4 Characteristics of caregivers (N 462)

Rural N () Urban N ()N 327 (100) 135 (100)Mean age (SD) 5282plusmn 1511 5250plusmn 1454lt40 73 (223) 31 (230) χ2 078 p 067440ndash59 146 (446) 65 (481)ge60 108 (330) 39 (289)

Gender χ2 149 p 0222Female 232 (709) 88 (652)

Marital status χ2 130 p 0523Never married 80 (245) 32 (237)Married living together 198 (242) 77 (570)Married not living togethera 49 (150) 26 (193)

Education level χ2 1403 p 0001Primary school and lower degree 165 (505) 44 (326)High school 79 (242) 37 (274)Diploma and higher degree 83 (254) 54 (400)

Relationship with care recipients χ2 386 p 0276Spouse 133 (407) 57 (422)Sonson-in-law 43 (131) 21 (156)Daughterdaughter-in-law 94 (287) 43 (319)Relatives 57 (174) 14 (104)

Residence status χ2 10914 plt 0001Coresidence with elderly 280 (856) 112 (83)

Working status χ2 1254 plt 0001Did not work 197 (602) 57 (422)

Annual income χ2 7721 plt 0001No income 22 (73) 57 (422)ltUSD 4354 190 (629) 50 (370)geUSD 4354 90 (298) 28 (207)

Reason for leaving a jobb χ2 090 p 0636Care for an elderly 96 (558) 19 (475)Retirement 40 (233) 11 (275)Other 36 (209) 10 (250)

Time spent in informal caregiving (hoursday) χ2 3557 plt 0001Less than 4 35 (115) 27 (208)5ndash8 134 (439) 78 (600)9ndash12 57 (187) 21 (156)13ndash24 79 (259) 4 (31)

aMarried not living together includes widowed and divorced bData were missing for some respondents for the reason for quitting their job (42)

Journal of Aging Research 7

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

USD 2114 was allocated to informal care e citiesrsquo LTCtotal yearly cost on average was USD 72806 Additionallythe formal and informal sectorrsquos yearly economic value ofUSD 23803 and USD 2089 respectively accounted for thebigger share of the total expenditure

In this study the hypothesis made is that the total ex-penditures of the rural elderly are higher than the urbanelderly However this research does not completely rejectthe null hypothesis as the total average annual LTC ex-penditures for both rural and urban elderly are equivalentaccording to this research

is study arrives at a different finding than the severalexisting types of research which hypothesized that the

expenditure in urban areas is much higher than that of therural [41 42] is observation can be ascribed to the fact thaturban areas have better health care and medical facilitiescompared to the rural areas [14] In addition those living inurban areas owing to their lifestyles can afford better medicalfacilities and advanced treatments because they are eco-nomically endowed e low-income people living in ruralareas however might not be able to even afford low-costhealth care [16 18]

e 2014 Elderly Population survey evidenced 10 millionelderly citizens in ailand of which 41 were urban res-idents [43] In such a scenario if every citizen were to accessall kinds of care such as the ones included in this study the

Table 3 Characteristics of elderly in study area (N 837)

Care recipients Rural N () Urban N ()N 437 (100) 400 (100)Mean age (SD) 7144plusmn 786 6858plusmn 57160ndash69 208 (476) 114 (593) χ2 5032 plt 000170ndash79 156 (357) 154 (385)ge80 73 (167) 9 (23)

Gender χ2 124 p 0266Female 302 (691) 262 (655)

Marital status χ2 657 p 0037Never married 45 (103) 47 (118)Married living together 191 (437) 204 (510)Married not living togethera 201 (460) 149 (373)

Education level χ2 4493 plt 0001Primary school and lower degree 365 (835) 253 (633)High school 44 (101) 82 (205)Diploma and higher degree 28 (64) 65 (163)

Living arrangement χ2 011 p 0736Not alone 359 (822) 325 (813)

Working status χ2 232 p 0128Did not work 294 (673) 249 (623)

Annual incomeb χ2 5079 plt 0001No income 21 (53) 70 (187)ltUSD 4354 311 (778) 208 (556)geUSD 4354 68 (170) 96 (257)

Source of support (not including work)c

Old age allowance 388 (902) 284 (715) χ2 4738 plt 0001Children 154 (359) 120 (302) χ2 299 p 0084Pensionslump sums 30 (70) 70 (176) χ2 2205 plt 0001Property incomed 32 (74) 28 (71) χ2 005 p 0829Other 24 (56) 19 (48) χ2 027 p 0607

Disability χ2 3312 plt 0001Any disabilities 109 (249) 39 (98)

Chronic diseasese χ2 407 p 0044Any chronic disease 356 (815) 303 (758)

Caregiver χ2 14250 plt 0001Have caregiver 327 (748) 135 (338)

aMarried not living together includes separated widowed and divorced bData were missing for some respondents for the yearly personal income (62) cOneperson may have more than one source of support dProperty income includes rental income equityfixed interest and return from another investmentseChronic diseases include hypertension diabetes stroke heart problems dementia osteoarthritis paralysis and hypercholesterol

6 Journal of Aging Research

total care expenditurersquos approximate value would be aroundUSD 73 billion in average per year for the whole country

e expenditures for both urban and rural contributorsin this study were compared with six different types of LTCcosts e results showed that the expenditures on averageon informal and formal care health care devices and homemakers were lower in urban areas in comparison to ruralareas However the day and night care costs as well as thecosts of regular medical supplies in the cities are higher thanthat of the rural areas is could be largely attributed to thedifferent settings in rural and urban areas [16]

When compared to women the larger part of everycategory of the rural areasrsquo expenditure is associated withmen save for the informal care Whereas in urban areasmen spend higher than women in a day or night care andinformal care [21] Also according to sociology this isattributed to a belief in conventional gender roles whereinevery gender is culturally assigned roles for instancewomen being assigned familiesrsquo caregiver roles [7]

Most senior citizens despite having a choice of estab-lished LTC prefer to remain at home and thus obtainsupport from the formal caregivers or informal programs

Table 4 Characteristics of caregivers (N 462)

Rural N () Urban N ()N 327 (100) 135 (100)Mean age (SD) 5282plusmn 1511 5250plusmn 1454lt40 73 (223) 31 (230) χ2 078 p 067440ndash59 146 (446) 65 (481)ge60 108 (330) 39 (289)

Gender χ2 149 p 0222Female 232 (709) 88 (652)

Marital status χ2 130 p 0523Never married 80 (245) 32 (237)Married living together 198 (242) 77 (570)Married not living togethera 49 (150) 26 (193)

Education level χ2 1403 p 0001Primary school and lower degree 165 (505) 44 (326)High school 79 (242) 37 (274)Diploma and higher degree 83 (254) 54 (400)

Relationship with care recipients χ2 386 p 0276Spouse 133 (407) 57 (422)Sonson-in-law 43 (131) 21 (156)Daughterdaughter-in-law 94 (287) 43 (319)Relatives 57 (174) 14 (104)

Residence status χ2 10914 plt 0001Coresidence with elderly 280 (856) 112 (83)

Working status χ2 1254 plt 0001Did not work 197 (602) 57 (422)

Annual income χ2 7721 plt 0001No income 22 (73) 57 (422)ltUSD 4354 190 (629) 50 (370)geUSD 4354 90 (298) 28 (207)

Reason for leaving a jobb χ2 090 p 0636Care for an elderly 96 (558) 19 (475)Retirement 40 (233) 11 (275)Other 36 (209) 10 (250)

Time spent in informal caregiving (hoursday) χ2 3557 plt 0001Less than 4 35 (115) 27 (208)5ndash8 134 (439) 78 (600)9ndash12 57 (187) 21 (156)13ndash24 79 (259) 4 (31)

aMarried not living together includes widowed and divorced bData were missing for some respondents for the reason for quitting their job (42)

Journal of Aging Research 7

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

total care expenditurersquos approximate value would be aroundUSD 73 billion in average per year for the whole country

e expenditures for both urban and rural contributorsin this study were compared with six different types of LTCcosts e results showed that the expenditures on averageon informal and formal care health care devices and homemakers were lower in urban areas in comparison to ruralareas However the day and night care costs as well as thecosts of regular medical supplies in the cities are higher thanthat of the rural areas is could be largely attributed to thedifferent settings in rural and urban areas [16]

When compared to women the larger part of everycategory of the rural areasrsquo expenditure is associated withmen save for the informal care Whereas in urban areasmen spend higher than women in a day or night care andinformal care [21] Also according to sociology this isattributed to a belief in conventional gender roles whereinevery gender is culturally assigned roles for instancewomen being assigned familiesrsquo caregiver roles [7]

Most senior citizens despite having a choice of estab-lished LTC prefer to remain at home and thus obtainsupport from the formal caregivers or informal programs

Table 4 Characteristics of caregivers (N 462)

Rural N () Urban N ()N 327 (100) 135 (100)Mean age (SD) 5282plusmn 1511 5250plusmn 1454lt40 73 (223) 31 (230) χ2 078 p 067440ndash59 146 (446) 65 (481)ge60 108 (330) 39 (289)

Gender χ2 149 p 0222Female 232 (709) 88 (652)

Marital status χ2 130 p 0523Never married 80 (245) 32 (237)Married living together 198 (242) 77 (570)Married not living togethera 49 (150) 26 (193)

Education level χ2 1403 p 0001Primary school and lower degree 165 (505) 44 (326)High school 79 (242) 37 (274)Diploma and higher degree 83 (254) 54 (400)

Relationship with care recipients χ2 386 p 0276Spouse 133 (407) 57 (422)Sonson-in-law 43 (131) 21 (156)Daughterdaughter-in-law 94 (287) 43 (319)Relatives 57 (174) 14 (104)

Residence status χ2 10914 plt 0001Coresidence with elderly 280 (856) 112 (83)

Working status χ2 1254 plt 0001Did not work 197 (602) 57 (422)

Annual income χ2 7721 plt 0001No income 22 (73) 57 (422)ltUSD 4354 190 (629) 50 (370)geUSD 4354 90 (298) 28 (207)

Reason for leaving a jobb χ2 090 p 0636Care for an elderly 96 (558) 19 (475)Retirement 40 (233) 11 (275)Other 36 (209) 10 (250)

Time spent in informal caregiving (hoursday) χ2 3557 plt 0001Less than 4 35 (115) 27 (208)5ndash8 134 (439) 78 (600)9ndash12 57 (187) 21 (156)13ndash24 79 (259) 4 (31)

aMarried not living together includes widowed and divorced bData were missing for some respondents for the reason for quitting their job (42)

Journal of Aging Research 7

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

[44 45] Noteworthy is the fact that in developed economiesthere are well-sustained formal care expenditures for thesenior citizens to access excellent medical and social servicesConversely the dependent senior citizens of the low- andmiddle-income economies lack formal care assistance orsocial security and thereby are dependent on their families[7 45 46]

Owing to this situation many policy initiatives suggestenhancement of abilities of families to provide health se-curity and care to their elderly members Yet recent studiesfrom low- and middle-income countries indicate that littleattention has been accorded to dependent elderly citizensrsquoinformal caregivers as compared to certain informal care forcertain diseases [47 48]

is study concludes that around 70 of caregivers arefemales which differed with other studies across ailandthat put it at 57ndash81 [49 50] ese results further revealedthat majority of the caregivers fall between the age group of41 and 60 years Of these statistics the majority constitutesspouses accounting for 422 in urban areas and 407 inrural areas In addition daughters constitute 319 in urbanareas and 287 in rural areas

In consideration of sociodemographic variables ma-jority studiesrsquo variations regarding the informal caregiversare indicative of spouses and children to quit their careerstowards taking care of the elderly [44 48]

42 Factors Influencing LTC Utilization e results of thisstudy substantially linked the ages of the people to theirexpenditures on health care devices and regular supplies epolicy-makersrsquo view point suggests that the process of agingcould yield unwanted results like (i) higher consumption ofhealth care (ii) increased dependency and (iii) higher ex-penditures on health care e existing studies indicate thatthemedical services relating to LTC and acute care are costlierfor seniors than it is for the young and the old [35 51]

Also an urban center dweller presented an inverseproportional to the use of informal health care home

renovation expenditures and day and night care is isevidenced by the fact that people from the rural areas usemore of informal care than those from the urban Addi-tionally the findings show that there are more homemodifications in rural areas than there are in the urban areasis scenario could be explained by the existence of higherrates of handicap zones (249) in rural areas than in theurban (98) In the past being married or unmarried wasinversely proportional to the use of informal care which isone factor that affects the financial and mental well-being ofpeople because it impacts on the provision of care andquality of the elderly life [37]

e potential risk of receiving informal care is consid-erably lower for the elderly who have jobs compared withthose who are unemployed is could be attributed to thefact that people facing health issues might have to quit theircareers and need informal care is means the elderly whoare part of the workforce have better health than those whoare not working [38]

On average an elderly person who has an annual incomeexceeding USD 4354 spends more on medical care andhome renovation for elderly because they have an eco-nomical endowment to pay [52] e study found that OAAassistance is a significant source of income for urban andrural elderly offering USD 20ndash30 per month

is study also found that living conditions and edu-cation have minimal effect on the use of health care servicese highly educated are assumed to be more aware of thechronic diseases than the uneducated [20 40] Moreoversome form of disability that some people have affects the useof medical devices For instance the elderly people havinga functional disability often use acute care and formal LTCleading to an increased health care costs [39 53]

43 Strengths andWeaknesses emajor contribution of thisstudy to the current knowledge lies in the provision of uniqueeffects associated with the LTC in cities and villages is studyevaluates the expenditures related to factors which affect the

Table 5 Cost on services for rural and urban residents (personyear)

Rural UrbanMale Female Average Male Female Average

Formal care (USD) 33091 26125 28447 40058 31349 23803Service use () 374 387 391 427 412 327Informal care (USD) 20652 21452 2114 21923 20214 2089Service use () 234 317 290 233 266 287Daynight care (USD) 2717 12689 15907 24383 17416 2090Service use () 307 188 218 260 229 287Daily supplies (USD) 6812 664 6687 7247 6633 6806Service use () 77 98 92 77 87 94Home renovation (USD) 346 423 427 215 226 224Service use () 05 06 06 02 03 03Medical devices (USD) 250 238 243 105 207 184Service use () 03 04 03 01 03 02Total cost (USD) 88412 67566 7285 53874 76047 72806e exchange rate of USD 1THB 3445 (the exchange rate as of March 31 2017)

8 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

prices of every care e most desirable consequences of thisresearch are those connected to social resources optimizationsuch as promoting health care volunteer and measures toensure institutionalization of the older people

ough this study contributes significantly to the currentknowledge in this field it presents certain limitationsFirstly this survey is rather cross-sectional and not longi-tudinal which demands a cautious use of linkages Secondlythis study has self-reported information and thereby issubject to biasirdly some of the important variables were

neither optimally coded nor available For instance the lackof optimal coded levels of diseases and functional statuswhich may affect the perfection and thus the modificationmay be imperfect e regression process lacks consider-ation of the levels of disability Lastly the absence of the dataon health care volunteer services and occupation detailsemployed an average local formal care wage to derive theapproximate value of the informal care is was done asmore than half of the caregivers were female which mightsuggest an overestimation of this informal care expenditure

Table 6 Factors associated with LTC utilization from logistic regression analysis

Independent variableFormal care Informal care

Coefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p valueAge (years) minus001 099 (090ndash109) 0869 003 103 (100ndash106) 0078Urban versus rural minus063 053 (012ndash244) 0416 minus074 048 (030ndash077) 0002Female versus male minus213 012 (002ndash064) 0013 minus017 084 (052ndash136) 0479Singlea versus married living together 137 394 (078ndash1999) 0098 minus053 059 (037ndash094) 0026No education versus any education 129 364 (031ndash4278) 0304 045 157 (067ndash365) 0296Living alone 021 124 (022ndash690) 0809 004 104 (049ndash218) 0923Work versus not work minus141 025 (003ndash214) 0203 minus065 052 (032ndash086) 0010Annual incomegeUSD 4354 099 269 (058ndash1248) 0208 020 122 (070ndash212) 0479Any chronic diseaseb minus072 049 (011ndash214) 0342 minus081 044 (025ndash080) 0007Any disabilityc 057 177 (038ndash838) 0470 004 104 (062ndash174) 0895Constant minus320 004 0375 minus050 061 0663

Independent variable Daynight care Daily suppliesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus009 092 (084ndash099) 0033 004 104 (101ndash106) 0010Urban versus rural minus241 009 (002ndash040) 0002 005 105 (073ndash151) 0787Female versus male 009 109 (035ndash342) 0884 009 109 (073ndash165) 0668Singlea versus married living together 030 135 (047ndash385) 0576 minus001 099 (067ndash147) 0960No education versus any education minus056 057 (007ndash495) 0597 minus015 086 (042ndash176) 0683Living alone minus024 079 (024ndash261) 0698 035 142 (090ndash224) 0130Work versus not work minus096 038 (013ndash115) 0088 039 148 (100ndash218) 0048Annual incomegeUSD 4354 minus076 047 (010ndash215) 0328 030 135 (087ndash209) 0184Any chronic diseaseb 089 242 (052ndash1123) 0258 138 398 (218ndash726) lt0001Any disabilityc minus184 016 (002ndash124) 0080 039 148 (095ndash232) 0086Constant 271 1503 0356 minus540 001 lt0001

Independent variable Home renovation Medical devicesCoefficient Odds ratio (95 CI) p value Coefficient Odds ratio (95 CI) p value

Age (years) minus002 098 (096ndash100) 0078 006 106 (103ndash109) lt0001Urban versus rural minus039 068 (049ndash094) 0020 minus011 090 (062ndash131) 0577Female versus male 045 156 (108ndash227) 0019 minus023 080 (053ndash120) 0282Singlea versus married living together minus003 097 (068ndash137) 0857 minus011 090 (060ndash135) 0612No education versus any education minus072 049 (023ndash104) 0062 009 110 (054ndash221) 0797Living alone minus026 077 (05ndash120) 0245 minus029 075 (044ndash127) 0281Work versus not work 001 101 (071ndash143) 0960 minus037 069 (045ndash105) 0086Annual incomegeUSD 4354 043 153 (104ndash226) 0031 057 177 (115ndash273) 0010Any chronic diseaseb 054 172 (113ndash263) 0012 081 224 (133ndash380) 0003Any disabilityc 009 110 (072ndash168) 0665 124 344 (227ndash522) lt0001Constant minus005 095 0956 minus586 000 lt0001aSingle includes never married divorced widowed and married but not living together bAny chronic disease includes hypertension diabetes stroke heartproblems dementia osteoarthritis paralysis and hypercholesterol cAny disability includes personal hygiene bathing eating toileting upstairs 1-2 stepdressing walking 200 meters moving around the bed urinary incontinence and fecal incontinence

Journal of Aging Research 9

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

Despite these limitations this research will prove im-portant to policy-makers and health workers in their quest tooptimize social resources and determine ways of handlingthis situation and encouraging specific forms of home andcommunity formal care Moreover from the social point ofview further studies on longitudinal approaches gearedtowards assessing the long-term economic effects must beconducted In addition further study of LTC policy underthe National Health Security funding is desirable

5 Conclusion

is study found the total average annual LTC expendituresbetween rural-urban residents to be similar e rapid urbandevelopment in coastal areas drives ailandrsquos economicgrowth but threatens to leave the rural population behind Incontrast rural areas surrounding the city are mainly concernedwith agriculture that generates lower incomes and these pop-ulations are reported to have reduced access to LTC servicese superior ability to pay of urbanites enables them to accessbetter quality health care services whereas even small LTCexpenditures can have a devastating impact on the householdeconomy of rural residents It is important that to reduce healthinequality and to promote greater socioeconomic equalityailandmust invest in health infrastructure in its rural regionsTo meet the needs of increasing populations of disabled elderlypeople and rising expenditures countries must restructure theirdelivery systems and find a balance between the costlier formaland cheaper informal care options

Disclosure

e funding agency had no role in the study design datacollection data analysis manuscript writing or publication

Conflicts of Interest

eauthors declare no potential conflicts of interest with respectto the research authorship andor publication of this article

Acknowledgments

e authors would like to express their sincere thanks toDr Robert S Chapman MD for his suggestions on thestatistical analysis and gratefully acknowledge Dr SuwitWibulpolprasert MD for his helpful advices e authorsalso wish to express their appreciation to the staff in Muangand Bangmulnark subdistricts of Phichit Province for theirassistance in data collection is research has been sup-ported by the National Research University Project Office ofHigher Education Commission (WCU-58-031-AS)

References

[1] S Srithamrongsawat K Bundhamcharoen S Sasat P Odtonand S Ratkjaroenkhajorn Projection of Demand and Ex-penditure for Institutional Long Term Care inailand HealthInsurance System Research Office Bangkok ailand 2009

[2] Y Porapakkham C Rao J Pattaraarchachai et al ldquoEstimatedcauses of death in ailand 2005 implications for healthpolicyrdquo Population Health Metrics vol 8 no 1 p 14 2010

[3] A Dans N Ng C Varghese E S Tai R Firestone and R Bonitaldquoe rise of chronic non-communicable diseases in southeast Asiatime for actionrdquoe Lancet vol 377 no 9766 pp 680ndash689 2011

[4] WHO Study Group Home-Based Long-Term Care Report ofa WHO Study Group World Health Organization GenevaSwitzerland 2000

[5] G Damiani V Farelli A Anselmi et al ldquoPatterns of long termcare in 29 European countries evidence from an exploratorystudyrdquo BMCHealth Services Research vol 11 no 1 p 316 2011

[6] World Bank ldquoLong-term care in aging East Asia and PacificrdquoLive Long and Prosper Aging in East Asia and Pacific WorldBank Washington DC USA 2016

[7] N Wongsawang S Lagampan P Lapvongwattana andB J Bowers ldquoFamily caregiving for dependent older adults inai familiesrdquo Journal of Nursing Scholarship vol 45 no 4pp 336ndash343 2013

[8] J Knodel J Kespichayawattana S Wiwatwanich andC Saengtienchai ldquoe future of family support for ai el-derly views of the populacerdquo Journal of Population and SocialStudies vol 21 no 2 pp 110ndash132 2013

[9] Hfocus ldquoLamsonthi model Family Care Team prototyperdquoFebruary 2017 httpswwwhfocusorgcontent20160412048

[10] Isranew Agency ldquoNHSO set a budget 600 million baht fordependent elderly care for 1000 subdistrictrdquo February 2017httpswwwisranewsorgisranews41355-nsho_41355html

[11] National Health Security Office Financial ManagementFramework for Severe Dependency Elderly Fiscal Year 2016National Health Security Office Nonthaburi ailand 2015

[12] W Suwanrada S Sasat and S Kumruangrit Financing LongTerm Care Services for the Elderly in the Bangkok MetropolitanAdministration Foundation of ai Gerontology Researchand Development Institute (TGRI) and ai Health Pro-motion Foundation Bangkok ailand 2009

[13] U Wongsin T Sakunphanit S Labbenchakul andD Pongpattrachai ldquoEstimate unit cost per day of long termcare for dependent elderlyrdquo Journal of Health Systems Researchvol 8 no 4 2014

[14] M Liu Q ZhangM Lu C S Kwon andH Quan ldquoRural andurban disparity in health services utilization in ChinardquoMedical Care vol 45 no 8 pp 767ndash774 2007

[15] L M Goeres A Gille J P Furuno et al ldquoRural-urban differ-ences in chronic disease and drug utilization in older orego-niansrdquo Journal of Rural Health vol 32 no 3 pp 269ndash279 2016

[16] T Ikai S Yamtree T Takemoto et al ldquoMedical care idealsamong urban and rural residents in ailand a qualitativestudyrdquo International Journal for Equity in Health vol 15 no 1p 2 2016

[17] H Nishiura S Barua S Lawpoolsri et al ldquoHealth inequalitiesinailand geographic distribution of medical supplies in theprovincesrdquo Southeast Asian Journal of Tropical Medicine andPublic Health vol 35 no 3 pp 735ndash740 2004

[18] S Pannarunothai and A Mills ldquoe poor pay more health-related inequality in ailandrdquo Social Science and Medicinevol 44 no 12 pp 1781ndash1790 1997

[19] S Kehusmaa I Autti-Ramo H Helenius K HinkkaM Valasteand P Rissanen ldquoFactors associatedwith the utilization and costsof health and social services in frail elderly patientsrdquo BMCHealthServices Research vol 12 no 1 2012

[20] C Zyaambo S Siziya and K Fylkesnes ldquoHealth status andsocio-economic factors associated with health facility

10 Journal of Aging Research

utilization in rural and urban areas in Zambiardquo BMC HealthServices Research vol 12 no 1 p 389 2012

[21] N Saikia Moradhvaj and J K Bora ldquoGender difference inhealth-care expenditure evidence from India Human De-velopment Surveyrdquo PLoS One vol 11 no 7 Article IDe0158332 2016

[22] K Alam and A Mahal ldquoEconomic impacts of health shocks onhouseholds in low andmiddle income countries a review of theliteraturerdquo Globalization and Health vol 10 no 1 p 21 2014

[23] L J Ku L F Liu andM J Wen ldquoTrends and determinants ofinformal and formal caregiving in the community for disabledelderly people in Taiwanrdquo Archives of Gerontology and Ge-riatrics vol 56 no 2 pp 370ndash376 2013

[24] J Woo S C Ho J Lau and Y K Yuen ldquoAge and maritalstatus are major factors associated with institutionalisation inelderly Hong Kong Chineserdquo Journal of Epidemiology andCommunity Health vol 48 no 3 pp 306ndash309 1994

[25] J A Oladipo ldquoUtilization of health care services in rural andurban areas a determinant factor in planning and managinghealth care delivery systemsrdquo African Health Sciences vol 14no 2 pp 322ndash333 2014

[26] W Suwanrada S Sasat NWitvorapong and S Kumruangritldquoe cost of institutional Long Term Care for Older Personsa case study of ammapakorn Social Welfare DevelopmentCenter for Older Persons Chiang Mai Provincerdquo Journal ofHealth Systems Research vol 10 no 2 2016

[27] National Health Security Office National Civil RegistrationSystem National Health Security Office Nonthaburi ai-land 2015

[28] T Yamane Statistics An Introductory Analysis Harper andRow Publishers New York NY USA 1973

[29] K Tisayaticom W Patcharanarumol and V TangcharoensathienDistrict Hospital Costing Manual (in ai Language) In-ternational Health Policy Planning Bangkok ailand 2001

[30] A L Creese and D Parker Cost Analysis in Primary HealthCare A Training Manual for Programme Managers WorldHealth Organization Geneva Switzerland 1994

[31] Bank of ailand Foreign Exchange Rates Bank of ailandBangkok ailand March 2017 httpswwwbotorthEnglishStatisticsFinancialMarketsExchangeRate_layoutsApplicationExchangeRateExchangeRateaspx

[32] P Diehr D Yanez A Ash M Hornbrook and D LinldquoMethods for analyzing health care utilization and costsrdquoAnnual Review of Public Health vol 20 no1 pp125ndash144 1999

[33] T P Hofer R A Wolfe P J Tedeschi L F McMahon andJ R Griffith ldquoUse of community versus individual socio-economic data in predicting variation in hospital userdquo HealthServices Research vol 33 no 2 pp 243ndash259 1998

[34] D Gregori M Petrinco S Bo A Desideri F Merletti andE Pagano ldquoRegression models for analyzing costs and theirdeterminants in health care an introductory reviewrdquo In-ternational Journal for Quality in Health Care vol 23 no 3pp 331ndash341 2011

[35] J X Nie L Wang C S Tracy R Moineddin andR E Upshur ldquoHealth care service utilization among the el-derly findings from the Study to Understand the ChronicCondition Experience of the Elderly and the Disabled(SUCCEED project)rdquo Journal of Evaluation in ClinicalPractice vol 14 no 6 pp 1044ndash1049 2008

[36] W J Baumol ldquoHealth care education and the cost of diseasea looming crisis for public choicerdquo Public Choice vol 77no 1 pp 17ndash28 1993

[37] K Bolin B Lindgren and P Lundborg ldquoInformal and formalcare among single-living elderly in Europerdquo Health Eco-nomics vol 17 no 3 pp 393ndash409 2007

[38] J Lee andM H Kim ldquoe effect of employment transitions onphysical health among the elderly in South Korea a longitu-dinal analysis of the Korean Retirement and Income StudyrdquoSocial Science and Medicine vol 181 pp 122ndash130 2017

[39] T R Fried E H Bradley C S Williams and M E TinettildquoFunctional disability and health care expenditures for olderpersonsrdquo Archives of Internal Medicine vol 161 no 21pp 2602ndash2607 2001

[40] S MacLeod S Musich S Gulyas et al ldquoe impact of in-adequate health literacy on patient satisfaction healthcareutilization and expenditures among older adultsrdquo GeriatricNursing vol 38 no 4 pp 334ndash341 2017

[41] M Li Y Zhang Z Zhang Y Zhang L Zhou and K ChenldquoRural-urban differences in the long-term care of the disabledelderly in ChinardquoPLoSOne vol 8 no11 Article ID e79955 2013

[42] C E McConnel and M R Zetzman ldquoUrbanrural differencesin health service utilization by elderly persons in the UnitedStatesrdquo Journal of Rural Health vol 9 no 4 pp 270ndash280 1993

[43] National Statistical Office Survey of Elderly in ailand 2014National Statistical Office (NSO) ailand 2014

[44] C Laubunjong N Phlainoi S Graisurapong andW Kongsuriyanavin ldquoe pattern of caregiving to the elderlyby their families in rural communities of Suratthani ProvincerdquoABAC Journal vol 28 no 2 pp 64ndash74 2008

[45] S Srithamrongsawat and K Bundhamcharoen Synthesis oflong-term care system for the elderly in ailand Foundationof ai Gerontology Research and the Development InstituteBangkok ailand 2010

[46] U Schneider B Trukeschitz R Muhlmann and I PonocnyldquoDo I stay or do I gordquondashjob change and labor market exitintentions of employees providing informal care to olderadultsrdquoHealth Economics vol 22 no 10 pp 1230ndash1249 2013

[47] M Zencir N Kuzu N G Beser A Ergin B Catak andT Sahiner ldquoCost of Alzheimerrsquos disease in a developingcountry settingrdquo International Journal of Geriatric Psychiatryvol 20 no 7 pp 616ndash622 2005

[48] A Riewpaiboon W Riewpaiboon K Ponsoongnern andB Van den Berg ldquoEconomic valuation of informal care inAsia a case study of care for disabled stroke survivors inailandrdquo Social Science and Medicine vol 69 no 4pp 648ndash653 2009

[49] N Sharma S Chakrabarti and S Grover ldquoGender differencesin caregiving among family-caregivers of people with mentalillnessesrdquo World Journal of Psychiatry vol 6 no 1 pp 7ndash172016

[50] R del-Pino-Casado A Frias-Osuna P A Palomino-Moraland J Ramon Martinez-Riera ldquoGender differences regardinginformal caregivers of older peoplerdquo Journal of NursingScholarship vol 44 no 4 pp 349ndash357 2012

[51] C de Meijer M Koopmanschap T B drsquo Uva and E vanDoorslaer ldquoDeterminants of long-term care spending agetime to death or disabilityrdquo Journal of Health Economicsvol 30 no 2 pp 425ndash438 2011

[52] S Limwattananon V Tangcharoensathien K TisayaticomT Boonyapaisarncharoen and P Prakongsai ldquoWhy has theUniversal Coverage Scheme in ailand achieved a pro-poorpublic subsidy for health carerdquo BMC Public Health vol 12no 1 p S6 2012

[53] T Lee ldquoe relationship between severity of physical im-pairment and costs of care in an elderly populationrdquo GeriatricNursing vol 21 no 2 pp 102ndash106 2000

Journal of Aging Research 11

Stem Cells International

Hindawiwwwhindawicom Volume 2018

Hindawiwwwhindawicom Volume 2018

MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of

Hindawiwwwhindawicom Volume 2018

Hindawiwwwhindawicom Volume 2018

Disease Markers

Hindawiwwwhindawicom Volume 2018

BioMed Research International

OncologyJournal of

Hindawiwwwhindawicom Volume 2013

Hindawiwwwhindawicom Volume 2018

Oxidative Medicine and Cellular Longevity

Hindawiwwwhindawicom Volume 2018

PPAR Research

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwwwhindawicom Volume 2018

Journal of

ObesityJournal of

Hindawiwwwhindawicom Volume 2018

Hindawiwwwhindawicom Volume 2018

Computational and Mathematical Methods in Medicine

Hindawiwwwhindawicom Volume 2018

Behavioural Neurology

OphthalmologyJournal of

Hindawiwwwhindawicom Volume 2018

Diabetes ResearchJournal of

Hindawiwwwhindawicom Volume 2018

Hindawiwwwhindawicom Volume 2018

Research and TreatmentAIDS

Hindawiwwwhindawicom Volume 2018

Gastroenterology Research and Practice

Hindawiwwwhindawicom Volume 2018

Parkinsonrsquos Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwwwhindawicom

Submit your manuscripts atwwwhindawicom