Background

According to the World Health Organization [1], the older people has almost doubled over the past 35 years, from 12 to 22% of the global population, and will account for one-fifth of the global population in the near future. According to the estimation of the National Development Council [2], the older people in Taiwan is increasing each year. In 2019, a survey conducted in Taiwan revealed that 11.2% of people aged above 65 have frailty [3]. In 2022, the older people aged 65 years and above reached 17.5%, and it is estimated that by 2065, the older people will account for 41.2% of the population. Thus, Taiwan faces the problem of rapid ageing.

A report on ageing and health published by the WHO in 2015 noted that the concept of health is no longer the absence of disease, and special attention should be given to the concept of healthy ageing. The WHO healthy ageing model emphasizes the importance of influencing factors, including the social, economic, and built environments. Healthy ageing should include the management of diseases and symptoms, lifelong cognition as well as physical, mental, and social health promotion, and adjustments to social policies and clinical phenomena [4]. The WHO also stated in the Integrated Caring for Older People Guidelines (ICOPE) published in 2017 that older adults care requires health management and advice related to primary prevention and disease management, which can help the older people to improve and maintain their functioning to meet the goals of healthy ageing and independent living [5]. Regarding the impact of demographic attributes and chronic disease on healthy ageing, some studies have found that older adults are associated with decreased perceptions of health, including individuals who are older, female, low-educated, low-income, single, and living alone as well as those with chronic conditions [6,7,8,9]. Warmoth et al. found that people with negative perceptions of ageing were more prone to frailty and that these perceptions could predict frailty problems among older people in 6 years [10].

Some studies indicated that frail older people decreased physical activity levels, which may affect their perspective on healthy ageing [11, 12]. Levy et al. [13] and WHO [14] emphasized the importance of a positive perception of aging and healthy aging for older individuals. Hansen-Kyle [15] and Howse [16] mentioned that the awareness of healthy aging required preventing disability and encouraging older people’s ability to support self-health. Therefore, regular physical activity was essential for enhancing physical functioning, preventing disabilities, and actively participating in life, ultimately reducing mortality risk [14].

Given the problems of ageing and frailty, Taiwan began to promote the Long-Term Care Plan 2.0 in 2017. The scope of care was extended to primary prevention, and frail older people were included as the objects of care while promoting aging in place. The care service model of Community Long-Term Care Stations (CLTC stations) was based on The Program of All-Inclusive Care for the Elderly (PACE) from the United States [17] and Japan’s long-term care insurance system. These stations were established within local communities [18]. The CLTC stations were to provide diversified services such as shared meals or meal delivery, health promotion activities, preventive and delayed disability care services, community care visits or phone greetings, and health counselling and referrals to improve the functions of primary prevention and delay deterioration due to disability among older people in communities [19]. Based on the above, to cope with rapid ageing and the increased need for care among older people with chronic diseases and under the promotion of the Long-Term Care Plan 2.0, strategies related to preventing and delaying of disability for frail older people at CLTC stations have been conducted. However, studies at home and abroad have not explored the influence of physical activities and perspectives on healthy ageing. Therefore, this study aimed to explore the influence of physical activities and ageing perception on the perspectives of healthy ageing for frail older people with chronic diseases to serve as a reference for future policy-making and care.

Methods

Research design

This study involved descriptive cross-sectional research. The research period was from April 2021 to the end of March 2022. The B-APQ-C (Brief Ageing Perceptions Questionnaire Chinese version) [20], HAPQ (Healthy Ageing Perspectives Questionnaire) [21], and PASE-C (Physical Activity Scale for the Elderly Chinese version) [22] were mainly used to probe the physical activity, ageing perceptions, and healthy ageing perspectives among frail older people with chronic diseases. Therefore, this study aimed to explore the association of physical activities and ageing perception on the perspectives of healthy ageing for frail older people with chronic diseases to serve as a reference for future policy-making and care.

Measures

The measurement tools for frail older people with chronic diseases included demographic variables and three survey scales. The demographic variables included age, gender, marital status, level of education, occupation, chronic conditions, household income, height, weight, smoking, drinking, and living patterns. The survey scales included frailty status, the Brief Ageing Perceptions Questionnaire (B-APQ) Chinese version, the Healthy Ageing Perspectives Questionnaire, and the Physical Activity Scale for the Elderly, which are detailed as follows.

  1. 1.

    Frailty status was assessed using the Study of Osteoporotic Fracture (SOF) to evaluate frail older people in CLTC stations [23]. To expedite the identification of frailty patients within the community, the SOF index has become widely utilized among healthcare providers. It was used to predict falls, disability, fractures, and mortality-related comorbidities [24, 25]. The scale assessment items included weight loss, lower extremities, and reduced energy level. If older adults in the community have more than two items, this is designated as “frailty.“ If they have only one item, this is designated as “prefrailty.“ The concurrent validity of the SOF index was established through a moderate to high correlation (Spearman’s rho = 0.51–0.75) with the Fried Frailty Phenotype index [23].

  2. 2.

    The Brief Ageing Perceptions Questionnaire (B-APQ), published by Barker in 2007, measures the two aspects of ageing perception and health-related experience. It includes 32 items and 7 dimensions on a 5-point Likert scale, with 1 indicating strongly disagree and 5 indicating strongly agree. The higher the score, the better the ageing perception [26]. Sexton et al. subsequently revised the scale to a 17-item scale with 5 dimensions, all with good validity and reliability (CFA: chi-square = 1433.54, df (109), p < 0.01, RMSEA = 0.04, CFI = 0.97, TLI = 0.96; Cronbach’s alpha: 0.75 ~ 0.84) [27]. Wang et al. [20] then translated it into the Chinese version in accordance with the process of translation and adaptation of instruments [28]. One localized item was added according to experts’ suggestions to make the 18-item Brief Ageing Perceptions Questionnaire Chinese version and a 23-item Health-Related Experience Questionnaire with CVIs of 0.9-1 and 0.8-1, respectively. After formal administration of the questionnaires, the Cronbach’s α of each dimension was between 0.86 and 0.91, while the overall internal consistency Cronbach’s α was 0.87. After the exploratory factor analysis and confirmatory factor analysis, the original 5 dimensions were adjusted to 4, and the overall reliability and validity of the new model and model fit were good (chi-square: 387.79, GFI: 0.91, RMSEA: 0.07, SRMR: 0.054; AGFI: 0.88) [20]. In this study, the internal consistency of Cronbach’s α was 0.82 for frail older people.

  3. 3.

    The Healthy Ageing Perspectives Questionnaire (HAPQ) was based on the analysis results of 3 focus group discussions and 6 qualitative in-depth interviews [21]. It also referred to a structured questionnaire based on healthy ageing theory proposed by Ryff and Singer [29] and the healthy aging model proposed by the World Health Organization. The scoring of this questionnaire was based on a 5-point Likert scale, with 1 indicating strongly disagree and 5 indicating strongly agree. The higher the score, the better the ageing perspective. The original scale had a total of 21 items, and the content validity index (CVI) was 0.8-1. After exploratory factor analysis, two items with low factor loadings were deleted. The finalized scale had a total of 19 items. The internal consistency of each dimension in the formal testing was between 0.71 and 0.89, while the overall Cronbach’s α internal consistency was 0.80. The overall scale explained 62.71% of the healthy ageing status among older adults with chronic diseases. The questionnaire established criterion validity through a significant correlation (ranging from 0.14 to 0.65) with the World Health Organization Quality of Life scale (WHOQOL) [21]. For our study, the internal consistency of Cronbach’s α was 0.71 for frail older people.

  4. 4.

    The Physical Activity Scale for the Elderly used the Chinese version of the Physical Activity Scale (PASE-C) published by Ku et al. [22]. This is a 12-item scale focusing on the physical activities of older people in their lives, including the overall activity level, leisure, household, and work-related physical activities. The questionnaire was tested for reliability and validity and was simultaneously measured with accelerometer measures (energy expenditure and walking steps), grip strength, and the Geriatric Depression Scale (GDS) for reliability and validity. The intraclass correlation (ICC) of the test-retest was 0.85. In terms of concurrent validity, the total score of the male and female scales showed a significantly positive correlation with grip strength (r = 0.34 for males, r = 0.24 for females) and a significantly negative correlation with the Geriatric Depression Scale (GDS) (r = 0.38 for total score). The reliability and validity test results were supported by evidence. Our study’s criterion validity with the overall physical activity and B-APQ showed a significantly positive correlation (r = 0.39).

Participants

The participation criteria followed the Study of Osteoporotic Fracture (SOF) criteria for the assessment of frailty in older people [30] in the CLTC stations under the Long-Term Care Plan 2.0 of the Ministry of Health and Welfare in Taiwan. The inclusion criteria included (1) the ability to communicate in Mandarin Chinese and Taiwanese; (2) aged 65 years or above; (3) at least one chronic according to the WHO definition [31]; and (4) meeting at least one item of the frailty index in the SOF frailty assessment results. The exclusion criteria were cognitive impairment and inability to communicate verbally. G*power 3.1.9.2 was used to calculate the sample size. The type I error α was set at 0.05, the power at 0.8, and the explanatory power R2 was a medium effect size (0.13). The number of samples required was 260. With the estimated sample attrition rate of 20%, a total of 312 people were needed [32].

Data collection

Before data collection, the researcher first contacted the competent authority of the CLTC stations in the community care centres and entered the care centres to collect data after obtaining consent. The purpose of this study was explained to the older people in the care centres, and those who were not willing to be interviewed were told that their decision would not impact their rights and interests in the care centres. Those who were willing to participate in the study signed consent forms before the 20- to 30-minute face-to-face interviews with the researcher or the research assistant coupled with the questionnaire survey. After collecting the data, the participating elders were given a small gift. Before collecting the questionnaire, the inter-rater reliability (Kappa coefficient) was conducted to examine the consistency between the researcher and the research assistant, the Kappa coefficient was 0.9 in the current study.

Data analysis

The collected data were organized and analysed using SPSS 23.0 for Windows. The demographic variables were analysed by means, standard deviation (SD), and percentages. The association of demographic characteristics, physical activity level, and aging perceptions with healthy ageing perspectives were further analysed by independent t-test, Pearson product-moment correlation, and one-way analysis of variance (ANOVA). Finally, hierarchical regression analysis was used to explore the impact of the significant variables in demographic characteristics, level of physical activity, and ageing perceptions on healthy ageing perspectives among frail older people with chronic diseases.

Results

Demographic characteristics

This study included 312 frail older people with chronic diseases in Taiwan, whose average age was 75.71 years (SD = 7.84), with females accounting for the majority (69.9%). They had at least 2 chronic diseases (SD = 0.69), with hypertension being the most common chronic disease (63.14%), followed by diabetes (17.95%) (Table 1). For the remaining demographic variables, most of the older adults were overweight (59.9%) and in the stage of prefrailty (52.9%), had an education level of junior high school and below (83%), had religious beliefs (95.8%), were not working (76%), were married (54.2%), had a monthly household income of NT$ 20,000 and below (68.3%), were nonsmokers (95.8%), were nondrinkers (98.1%), and lived with their children (55.1%) (Table 1).

Table 1 Demographic characteristics of the participants and associated with the perspectives on healthy aging
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Correlation between B-APQ, PASE-C and perspectives on healthy aging

Among the demographic variables of frail older people with chronic diseases, those with older age (r = -0.24, p < 0.05), with low education level (t = -3.02, p < 0.05), and who were single/widowed/divorced (t = -3.36, p < 0.05) had worse healthy ageing perspectives, while those with better physical activity (r = 0.30, p < 0.05) had better healthy ageing perspectives, showing a significant difference (Table 1). In particular, the frailty index showed that older persons with chronic disease had better prefrailty (mean = 3.22, SD = 0.25) than frailty (mean = 3.08, SD = 0.21) from a healthy ageing perspective (t = 5.35, p < 0.05). In terms of ageing perception, the better the scores in time-line chronic (r = 0.21, p < 0.05), positive control (r = 0.17, p < 0.05), and negative ageing control emotion and consequences (r = 0.26, p < 0.05), the better their healthy ageing perspectives. For health-related changes, the higher the scores in health-related changes (r = -0.32, p < 0.05) and health-related changes due to ageing (r = -0.32, p < 0.05), the worse their healthy ageing perspectives. For the Physical Activity Scale for the Elderly (PASE-C), the higher the scores in overall activity (r = 0.22, p < 0.05), leisure activity (r = 0.11, p < 0.05), household activity (r = 0.21, p < 0.05) and work activity (r = 0.30, p < 0.05), the better their healthy ageing perspectives (Table 2).

Table 2 Correlation between B-APQ, PASE-C and perspectives on healthy aging
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Results of hierarchical regression analysis for healthy aging

In the establishment of the Model 1 regression model of frail older people with chronic diseases, since ADL was highly correlated with frail status (r = 0.70, p < 0.05), the regression model was entered with the frailty condition. Frailty was one significant variable in Mode 1, with R2 = 0.10; after adjustment, R2 = 0.09 and F value = 8.83 (p < 0.05). Step 2 added the ageing perception (B-APQ-C) and health-related changes (HRC) for the establishment of the Mode 2 regression model. Since health-related changes were highly correlated with health-related changes due to ageing (r = 0.99, p < 0.05), health-related changes were selected into the analysis of the regression model. The results showed that the variables with significant influence were time-line chronic, positive control, and health-related changes, with R2 = 0.22; after adjustment, the R2 = 0.19 and the F value = 10.35 (p < 0.05), and the explanatory power increased by 12% compared with Mode 1. Step 3 added the leisure, household, and work activities of the PASE-C for the establishment of the Mode 3 regression model. The results showed that the variables with significant influence were time-line chronic, positive control, health-related changes, and work activities, with R2 = 0.24; after adjustment, R2 = 0.21 and the F value = 8.61 (p < 0.05) (Table 3).

Table 3 Results of hierarchical regression analysis for healthy aging
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Discussion

This study explored associations of ageing perception and physical activities on healthy ageing perspectives among older people with frailty with chronic diseases. The subjects were frail older adults with chronic diseases in the Community long-term care stations established under the Long-Term Care Plan 2.0. The study’s participants were close to the average age of 75 and above and were the subjects of the Long-Term Care Plan 2.0 of the Ministry of Health and Welfare in 2021 [33]. Our study, similar to the Japanese government’s report on an aging society, found that frail older adults over the age of 75 in Japan require nursing care in the community [34]. In terms of health data, lifestyle and other conditions, the BMI results of the participants in this study were different from the average of the results in the 2013–2016 Nutrition and Health Survey in Taiwan (NAHSIT) [35]. The BMI of the participants in the present study showed that most were overweight. The main reason was that the participants in this study were mainly frail older adults with chronic diseases in the community, in contrast to the Nutrition and Health Survey, whose participants were not limited to frail older adults with chronic diseases [35]. The results of our study are consistent with those of a systematic review, which found that obesity is one of the risk factors in frail older people [36]. Furthermore, regarding smoking and drinking behaviours, the results of this study showed that the participants had lower rates of smoking and drinking compared to those found in surveys conducted in China and Japan [37, 38]. The difference could be associated with the higher average age of the participants, which may also lead to a lower rate of poor lifestyle. In addition, in terms of the living patterns among older people, most older people in Taiwan live with their children (55.1%) and most of them are families with three generations living together. This finding is similar to the results of the Report of the Senior Citizen Condition Survey 2017, where 54.3% of the older people surveyed expected to live with their children [39]. Taiwan’s family construct was the majority of three-generation households and different from nuclear families in China [40].

To date, only a few studies have mentioned the factors that affect healthy ageing [41,42,43]. Therefore, we compared studies that recruited the same group as the subjects and had similar concepts, such as self-perceived health status, quality of life (including mental and physical), and well-being. The study found that the older people’s age, the worse their physical activity and the greater their level of frailty, which lowers health ageing perspectives among frail older people with chronic diseases. It has also been suggested in several studies that the older people’s age is, the greater their decline in perceived health status [6, 7, 44]. The level of education also affects heath ageing perspectives. People with a higher level of education had better self-perceived heath, and those whose marital status is single/widowed/divorced had lower scores in healthy ageing than those who were married [6, 7, 43], similar to the findings in this study.

The results of the study showed that ageing perceptions (B-APQ-C) and the results of the subscales of health-related changes were significantly correlated with healthy ageing perspectives. The influence of positive ageing perspectives in older people’s lives improves their well-being [27]. This finding is similar to the results of a related Taiwanese study that showed that the more positive people’s attitude towards ageing was, the better their overall health status was in a self-assessment [45]. A British study also noted that an optimistic ageing attitude was better for self-perceived health status [46], and a study conducted by Levy et al. showed that the more positive older people’s ageing perceptions were, the better their quality of life and well-being [47].

In terms of associations of physical activity on healthy ageing, leisure activity, household activity, and work activity had significantly low correlations with healthy ageing perspectives among frail older people with chronic diseases. Compared with the healthy ageing perspective of older people with chronic diseases [41], this study found that some frail older people with chronic diseases still thought that they were able to work, which had a positive association with their healthy ageing perspectives. The results are also similar to an Australian study on the total scores of the Health Ageing Quiz and the Frequency Activities Index, which showed that higher activity frequency promoted healthy ageing and optimistic attitudes [42].

When predicting the healthy ageing perspectives of frail older people, the demographic variable with the greatest influence was the degree of frailty. After adding the perspectives of ageing perception, the explanatory power gradually increased, confirming that ageing perception had an impact on healthy ageing perspectives among frail older people with chronic diseases. It was proposed in the literature that more positive ageing perceptions improve self-perceived health, well-being and quality of life among older people [27, 48, 49]. The finding that time-line chronic and positive control affect healthy ageing perspectives, similar to the result of the positive impact on the quality of life in the psychological domain [48] and a greater influence on well-being [49, 50], showed that if older people have higher self-control and better management of the ageing process, their healthy ageing perspectives improve. With regard to physiological ageing-related health changes, frail older people with chronic diseases believed that the more health-related changes they experienced, the lower their healthy ageing perspectives were, similar to the results in the studies conducted by Machón and Steptoe [7, 46] showing that the more self-perceived diseases older people had, the worse their self-perceived health was. For physical activity, frail older people with chronic diseases believed that being able to conduct work activities influenced their ageing perspectives. Work activities include work for pay or as a volunteer. This may be due to the long-standing concept of exercising for health and the promotion of policies in Taiwan such as social participation, civic participation, and employment of the Healthy Ageing and Age-Friendly City Policy [51], which also affect healthy ageing perspectives.

Limitation.

The limitations of this study were that the subjects of the study were mainly members of frail groups with better mobility in the CLTC stations in Southern Taiwan, while those with poor mobility were excluded. Regarding data collection, there were fewer male participants and the research period coincided with the epidemic period. There is a possibility that this study may have been impacted by reduced activity, which could be a significant limitation of the research. In addition, a face-to-face interview questionnaire was conducted, and frail older people had to recall their physical activity for the past week with a short period of time. Therefore, there is a possibility of some recall bias, which may also cause underestimation of the activity.

Conclusion

This study found that the time-line chronic and positive control of the ageing perspective (B-APQ-C), health-related changes, and work activity influence healthy ageing perspectives among frail older people with chronic diseases, with 24% of the explanatory power from the model. he explanatory power of ageing perceptions could be increased to 12%, showing that positive control in ageing perceptions and health-related changes had a greater association on healthy ageing.

Implications of the study findings for community care

In the CLTC stations, when the conditions of frail older people with chronic diseases are debilitating, some work activities that they can accomplish independently within the care stations could be combined to enhance positive control, such as the cultivation of senior volunteers to enable them to have a sense of social participation and the opportunity to serve society to improve their healthy ageing perspectives further. Future studies could focus on intervention measures to enhance positive aging perceptions and physical activity among older people. Additionally, conducting long-term follow-ups would allow for observing changes in older adults following such interventions.