This study was quasi-experimental research using the intervention and the control groups. Participants were elderly aged 60 years or older living in Phayao province. They were screened using a self-assessment stress test applied from Suanprung Hospital’s instrument (SPST-20) [21, 22] from the Ministry of Public Health, Thailand. It is suitable in the context of elderly people living in the community [21, 22]. The inclusion criteria were: participants who received stress scores at a minimum from moderate level (scores of 25-42) [21, 22] aged between 60-75, both male and female; never been treated by any drugs or alternative medicine within 1-month of recruitment; no hearing, speaking or sighting problems; living in the area of study; willing to participate throughout the program.

The sample size was calculated using the effect size from the mean scores of two groups based on the previous research [23]. The calculation retrieved from the formula [24], the interpretation delta (d) estimates the magnitude influence from the mean score retrieved calculated [25] with the Alpha = 0.05, Power = 0.80, d = 0.5. According to the calculation and the additional 10% of dropout rate, the total number of sample size was 144 elderly, 72 participants for each group. The duration of the study started from October 2017 to March 2018 in the rural area of Muang District of Phayao province, Thailand.

Multi-stage random sampling was employed to select the study area with the homogenous characteristics using the drawing technique. Two sub-districts were randomly selected. Ban Tum sub-district was selected for the intervention group, and Ban Tom sub-district was selected for the control group. One village within one sub-district was selected using a random sampling technique. These two villages were approximately 40 kilometers distant from each other. With the distance, there could be prevention of the contamination of information between two groups. Participants were selected using simple random sampling without replacement, as seen in Fig. (1).

Fig. (1). Participant flow chart.

The questionnaires created by the researcher were used to collect quantitative data. They were divided into four parts: Part 1.) General demographic information questionnaire which included age, gender, education, income, employment, and health conditions. Part 2.) The knowledge questionnaire which consisted of 10 items [22]. There were two choices for participants to select: a correct answer is equal to 1 point, and a wrong answer is equal to 0 points. Part 3.) Stress management [22] questionnaire which consisted of 10 items. The researcher applied the questionnaire based on Pender’s theory and created it to be suitable in the context of elderly living in the rural community [20, 22]. Rating score was used for this questionnaire which included 4 choices: 1 = Never, 2 = Rarely, 3 = Sometimes, and 4 = Regularly. Part 4.) The stress screening test was applied from Suanprung Stress Test-20 (SPST-20) [13, 21, 22] which consisted of 20 items. The test asked about the events that happened within the last 3 months. Participants were asked about the events occurred, how they felt, and how they responded to the events. The level of measurement was an interval scale, and the scoring was a rating scale. There were four choices including Never = 1, Sometimes = 2, Often = 3, and Regularly = 4. The questionnaires were examined for content validity by 2 mental health professionals. The questionnaires were re-checked and improved before being used in a pilot study among 30 participants living in San Pa Muang district. The Cronbach’s Alpha coefficient of the questionnaires of parts 2, 3, and 4 were 0.79, 0.80, and 0.82, respectively.

The stress management training intervention for the elderly was applied from the theory of self-care behavior [20]. The preparation process included the recruitment of research assistants from the field of Applied Thai Traditional Medicine. A total of 10 research assistants, currently studying in the third year of university, were recruited. They passed pre-clinic level from the Educational Institution of Applied Thai Traditional Medicine Council before participating in the study. Two professional health personnel, including a massage with a license to practice Thai traditional medicine from the Ministry of Public Health and a lecturer in the field of Applied Thai traditional medicine, were recruited for lecturing and assisting research program for a day, with the participation duration of 6 hours. Participants could use it for self-practice when stressed and record their performance at least 1-2 times a day (morning and evening sessions). The duration ran for 12 weeks, performed once a week.

Week 1: The stress management training program consisted of 2 parts: The first part of the stress training program focused on warm-up by relationships and providing knowledge [20, 26]. The activities included watching a video regarding stress conditions, health effects of stress, causes and symptoms of stress, stress level, and stress management provided by the researching team.

Week 2-8: The second part of the stress management training program consisted of 2 main activities. (a) Meditation activity integrated with the concept of alternative medicine, which connects mind and body applied from science-based theory [19]. This type of activity helps to relax the body and mind. It stimulates the increase of melatonin, which is an antioxidant chemical that helps to balance the immune system. (b). Stress-management using self-practice massage training was applied from Thai traditional massage [26, 27].

Moreover, the researcher provided additional knowledge regarding Thai traditional medicine. Information was provided as follows: 1). Heat compressing using Thai herbal compress ball (250 g.) which consisted of Thai herbs including turmeric, cane, curcumin, lemongrass, vine, bergamot skin, tamarind leaves, sompoi leaves, camphor, and borneo camphor [27, 28]. Participants should use heat compressing Thai herbal compress ball after practicing self-massage for 10 to 15 minutes. 2). Participants should not eat certain food such as sticky rice, bamboo shoot, and meat. They should not drink alcohol or take a pain reliever before doing self-practice massage. This was to prevent stomachache while having a massage [27-31]. Participants had to record every activity in the notebook every day. In case the participants forgot to record it, a village health volunteer would visit home and remind them to perform the activity every day until the end of the intervention program. The stress management training program is summarized in Table 1.

Week 9-12: The follow-up program consisted of visiting the elder’s house (twice a week, 60 minutes each time) and making one phone call per week for a check-up. The research team encouraged the elderly to perform self-stress management regularly; this helped to reduce their cost of health service and time. For the control group, elderly participants received a massage handbook provided by the local health center. The total program ran for 12 weeks, and the follow-up was done after 3 months of training in order to observe the changes in elders’ behaviors. Both groups used the same assessment test questionnaires provided by the researcher.

Data were analyzed by SPSS Version 20, licensed from the University of Phayao (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to analyze general information. Independent t-test and Chi-square test were used to identify differences in the characteristics of the elderly at baseline of the intervention and the control groups. A repeated measure ANOVA was used to test the effects before and after the program. All analyses used a 95% CI, and the level of significance for all the statistical tests was set at p-value <0.05.

In this study, a total of 142 elderly participants (72 in the intervention group and 70 in the control group) were similar. The findings showed that the mean age of the elderly participants was 68.39 years in the intervention group and 67.33 years in the control group. A total of 66.7% of participants were female in the intervention group compared to 57.1% in the control group. In the intervention group, 30.6% obtained education at the elementary school level compared to 21.4% in the control group. A total of 56.9% of participants were employed in the intervention group compared to 65.7% in the control group. In the intervention group, 45.8% received adequate income compared to 38.6% in the control group. More than half of elderly participants had chronic health conditions including hypertension, diabetes, coronary artery disease, and gout; 58.3% in the intervention group and 55.7% in the control group. There were no significant differences in the age (p=0.373), gender (p=0.300), education (p=0.254), income (p=0.401), employment (p=0.306), and health conditions (p=0.865). It could be that both groups had similar characteristics at baseline.

Regarding stress knowledge before the program, both groups had knowledge levels at low, fair, and high (the intervention group 59.7%, 32.0%, 8.3%, and the control group 58.6%, 25.7%, and 15.7%) respectively, as shown in Table 2. After the program and follow-up (3 months), it showed stress knowledge of the intervention group was higher than the control group. When the mean scores between the post-intervention and follow-up were compared, the mean knowledge scores of the intervention group were higher than the control group with the significance (p<0.05) as shown in Table 3.

Table 2 illustrates the changes of variables between the intervention and the control groups. The findings of the intervention group showed that before the program, the majority of stress levels were at fair, low, and high (47.2%, 41.7%, 11.1%, respectively). The control group showed stress levels at fair, low, and high (51.4%, 35.7%, 12.9%, respectively). In terms of post-intervention and follow-up, the stress levels of the intervention group had reduced to low and fair levels compared to the control group. When the mean scores between the post-intervention and follow-up were compared, the mean stress level scores of the intervention group had statistically significantly decreased (p<0.05), as shown in Table 3.

Regarding stress management before the program, both groups had stress management levels at low, fair, and high (the intervention group 48.6%, 40.3%, 11.1%, and the control group 54.3%, 24.3%, and 21.4%), respectively as shown in Table 2. In terms of post-intervention and follow-up, it was found that stress management in the intervention group had improved better than in the control group. When the mean scores between the post-intervention and follow-up were compared, the mean stress management scores of the intervention group were higher than the control group with the significance (p<0.05) as shown in Table 3.

The analysis of repeated measure ANOVA showed a statistically significant difference in the effects of stress management training program on changes in mean scores of stress knowledge, stress level, and stress management among elderly people between the intervention and control groups at baseline, post-intervention, and 3-month follow-up (p<0.05) as shown in Table 4. For within-subject testing, the Greenhouse-Geisser correction was used due to violation of sphericity. The results gave the overall significant effect of stress management training program on changes in mean scores of stress knowledge and stress management over three-time points (p<0.001), whereas the marginally significant effect on changes in stress mean score was found (p=0.078).

First, the elderly may forget to record their daily routine; therefore, research staff had to visit their homes regularly to make sure they could perform self-management and record their performance routinely and effectively. Second, some participants have chronic conditions such as diabetes and hypertension; therefore, they have to be careful about health complications toward practicing a massage. Third, practice medication and breathing exercises were demonstrated by a person; therefore, there should be a video demonstration for the elderly to use for practicing by themselves. Forth, this study was unable to avoid the Hawthorne effect. Finally, this study was conducted in a rural area within the two-sub district from one province located in the northern part of Thailand; therefore, the results may not be generalizable to other areas of study. In terms of recommendation, this study did not involve family members or elderly caretakers. There should be increased support within family members or the community for the elderly to perform self-stress management. Moreover, long-term studies to see changes in self-management and reduction of health complications should be encouraged. Future research should involve qualitative study in order to gain a better understanding of elders’ self-management behaviors altogether with the integration of Thai traditional medicine among elderly with chronic health conditions.