The aim of this study was to examine whether objective/subjective ES is associated with happiness in older adults in Myanmar.
Study design and participants
This was a baseline survey of the 2018 longitudinal study “Healthy and Active Aging in Myanmar,” which examined the predictors of physical and psychological health in community-dwelling Myanmar adults aged ≥60 years.
The field sites were the Yangon region and the Bago region, which is located 91 kilometers north-east of Yangon. Multistage random sampling was conducted in the two regions. There are 45 townships in the Yangon region and 28 in the Bago region. First, six townships were randomly selected from each region via population proportional sampling based on the population of each township. Next, in Yangon, 10 wards were further randomly selected from each township, while in Bago, 10 village tracts were selected from each township again based on the population of each township/village tract. Finally, 10 people were randomly selected from each extracted ward/village tract using the ledger lists of residents aged 60 years or more. In rural areas, there are multiple villages within a single village tract. In such cases, one of the villages was randomly selected from the village tract.
The differences between wards and village tracts involve the degree of urbanization. Urban areas are defined as wards, and rural areas are defined as village tracts or villages. Wards and village tracts sometimes co-exist within a township. In the survey, we selected only wards from townships in the Yangon region and only village tracts from among those in the Bago region, as we considered the Yangon region representative of urban areas and the Bago region as representative of rural areas.
Trained surveyors visited homes with public health nurses from each community to conduct face-to-face interviews with the study participants. In Yangon, the surveyors visited 1,083 older adults; 610 were at home. Ten were excluded due to refusing the survey (n = 6) or to severe dementia or being bedridden (n = 4); the response rate was 98.4% in Yangon. In Bago, surveyors visited 1044 older adults; 694 were at home. Ninety-four were excluded due to severe dementia or being bedridden, thus the response rate was 86.5% in Bago. In total, six hundred people each from the Yangon (222 men and 378 women) and Bago regions (261 men and 339 women) were surveyed.
A structured questionnaire for the face-to-face interviews was developed for this study (Additional file), following the Japan Gerontological Evaluation Study (JAGES), which is a nationwide, population-based, prospective cohort study for older community-dwelling Japanese adults . The linguistic translation and validation process followed the “Linguistic Validation Manual for Health Outcome Assessments. It was first translated into English. Thereafter, it was translated into the local language and back translated into English to ensure clarity and consistency.
We hired research staff from the Myanmar Perfect Research Company, a group that conducts epidemiological surveys in Myanmar. The interviewers were recruited from the company. Before the commencement of the actual survey, a two-day training course on the research protocol, administration of the questionnaire, and ethical concerns was conducted for the interviewers.
A small pilot study was carried out before the actual survey for face validity in Urban Health Center, Dagon township, Yangon. Participants were the older adults, age of above 60 came to the out-patient clinic in the center. We recruited the 25 respondents who were gave consent to participate in the pilot study. During the pilot study, the interviewers ensured sequence, flow, and clarity of the study. After the feedback from the interviewers, the questionnaire was revised accordingly.
The inclusion criteria were an age of ≥60 years and residence in a selected ward or village tract. The exclusion criteria were being bed-ridden or having severe dementia. Severe dementia was defined as an Abbreviated Mental Test score of ≤6[37, 38].
We assessed happiness through the following question: “How do you rate your overall happiness level on a score of 0 for very unhappy to a score of 10 for very happy?” This question was previously validated[16, 39].
The wealth index, used as an objective economic indicator, was calculated from household asset items (radio, washing machine, TV, electric rice cooker, video/DVD player, air conditioner, electric fan, bicycle, refrigerator, motorcycle, computer, car/truck, store-bought furniture, microwave oven, personal music player, mobile phone, and internet) using a method described in a previous report . Subjective economic status was assessed by asking the following question: “Which of the following best describes your current financial situation in light of general economic conditions?” The possible responses were (1) very difficult, (2) difficult, (3) average, (4) comfortable, and (5) very comfortable. Based on the responses, participants were categorized as “difficult or very difficult” (answering 1 or 2) or “average or higher” (answering 3 to 5).
The socio-demographic characteristics of the study participants included information regarding age, sex, subjective health status (excellent/good or fair/poor), illness during the preceding year, depressive symptoms (geriatric depression scale [GDS] =>5 or <5), educational level (no school, monastic, some/all primary school, middle/high school or higher), residential area (the Yangon or Bago regions), marital status (married or widow/divorced/never married), living status (alone or not), social supports (giving and receiving emotional & instrumental help), religion (Buddhism or other), and frequency of visits to religious facilities (less than once per week or once per week or more).
The mean happiness scores of the socio-demographic variables that were categorized as above were compared using a one-way analysis of variance test. A linear regression analysis was performed to identify the factors associated with being happy. The multivariate adjusted results were expressed as non-standardized coefficients (B) with 95% confidence interval (CI). We used STATA 14 (StataCorp, College Station, TX, USA) to perform all statistical analyses, and the statistical significance level was set at p < .05.