Introduction

The ageing process presents a challenge to both society and health systems, but the impact of this process can differ by country. For example, Japan has had many decades to adapt to the increasing rates of older adults, while others less developed countries like Brazil have been undergoing an ageing process for fewer years.¹ In Mexico, the population aged 60 years and older currently represents 10.4% of the total population,^2,3 but by 2050, an estimated one fourth of all Mexicans will be in this age group.⁴ The Mexican health system needs to be prepared for the more than doubling increase of the elderly population in the next 30 years.

In Mexico, population aging also has an impact on healthcare expenditures. Mexican families with at least one older adult have healthcare expenditures that are 50.7% higher than those of families without an elderly member.⁵ However, new notions about healthy ageing indicate that old age does not necessarily have a negative impact on health systems.^6,7 

Health promotion in the primary healthcare setting is a key strategy to improve the health status and quality of life of older adults, which may help address certain challenges of population aging worldwide.⁸Studies have suggested that health care needs of the elderly can be better addressed if health care, health promotion and welfare services are integrated.^9,10,11 However, older adults, and the general population, tend to seek healthcare services to treat diseases, instead of looking for health promotion or preventive care services.¹²

In Mexico, health sector offers health care services as well as preventive health services (PHS) to its insured population, through institutions like the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social, IMSS), at its sports facilities and clinical settings.¹³ Since 2014, Mexican health sector has implemented initiatives to encourage health promotion practices through availability and utilization of PHS, such as immunizations and health education sessions, including oral health, and activities to increase physical activity (PA) and promote a balanced diet to improve the well-being of population.^14,15 However, little has been reported, within the context of IMSS in Mexico, about the impact of this type of approach, which includes health promotion programs and activities, to improve life quality and well-being of elderly population.

Previous studies that assessed the relationship between health promotion practices, PA and the perceived HRQoL of older adults have evaluated both strategies separately. For example, one study that focused on health promotion practices found that a health education intervention specifically tailored for older adults was associated with positive changes in the HRQoL of the participants.¹⁶Other studies have shown that PA is associated with quality of life and is essential for successful ageing. A few studies have examined the impact of health promotion practices jointly,¹⁷ and some of them have found that disease prevention reduces functional dependence and preserves individual autonomy the elderly.^18,19 Nevertheless, based on our review of literature, there is scarce information regarding how health promotion practices can contribute to the HRQoL of older adults.²⁰ The purpose of this study was to evaluate the combined use of IMSS preventive health services (PHS) and physical activity (PA) in order to determine their association with the perceived HRQoL of older adults. Our hypothesis was that older adults who engage in both health promotion practices would perceive their HRQoL as better, compared to those who do not.

Materials and methods

Results

Table I reports the sociodemographic characteristics and health status of the study population. A total of 65 subjects with incomplete information were eliminated, and 1 085 elderly adults with complete data were included as participants in this study. A total of 397 participants reported that they used PHS, and 253 indicated that they engaged in PA. The mean age of the participants was 71.5 years (ranging from 60 to 98 years). Most of the study population had little or no formal education (20% had no schooling), and nearly 30% of the participants were widowed. Over 60% of study subjects indicated that they did not have health issues during the month prior to the interview.

More than 35% of the study participants reported that they used preventive health services at IMSS PHCUs over the last 12 months. Use of PHS was slightly higher among females (38%) than among males (35%), while males were more likely to engage in PA (25%) than females (22%). Use of PHS and PA practice declined with age, but both were found to increase with number of years of schooling. Widowed respondents were more likely to use PHS than those who were married or single, while married respondents were more likely to engage in PA than single or widowed respondents. Participants who reported having health issues were less likely to use PHS (42%), and less than a fourth of them practiced physical activity (Table I).

Table II presents the sociodemographic and health status results by each of the eight HRQoL scales. Female participants reported higher physical functioning (PF), social functioning (SF), mental health (MH) and vitality (VT) scores than males, but had lower scores for physical role (RP), emotional problems (RE), bodily pain (BP) and their general health perception (GH). The largest gaps between males and females were observed in emotional problems (RE) and general health perception (GH), with a difference of 22 and 20 points, respectively. However, when the independent variables PA practice and PHS utilization were included, the HRQoL results shifted across all dimensions according to sex, with male participants obtaining the highest scores (data not shown). Scores for all eight scales were found to decrease with increasing age, and the highest scores were reported by respondents who were more educated, married, and did not have health issues.

We also examined the eight HRQoL scales in relation to PA and PHS. The results shown on table III indicate that elderly adults who practiced PA scored higher across all HRQoL scales than those who did not (p<0.001). Mean differences -of 29 and 28 points-were greatest for the RP and RE dimensions, respectively, between those who engage in PA and those who do not. For MH the difference was only of 9 points, but it was still statistically significant (p<0.001). Similar results were observed when we compared elderly adults who use PHS to those who do not. Significant differences were found in all dimensions except for MH, and the greatest differences were observed in the RP and RE dimensions (14 and 18 points, respectively).

Table IV presents our analysis of the combined effect of using PHS and engaging in PA on HRQoL. Those who practice PA and use PHS (group 4) scored higher across all eight HRQoL scales than those who do not practice PA or use PHS (group 1) and those who practice only one preventive behavior (groups 2 and 3). Significant differences were found between group 1 and group 2 (those who use PHS but do not engage in PA) in the PF, MH and VT dimensions. Significant differences in the PF, RP, RE and GH dimensions were observed between group 1 and group 3 (those who engage in PA but do not use PHS). The differences in HRQoL that were reported between group 1 and group 4 were substantially greater than those reported by participants in groups 2 and 3, and they were all statistically significant at the p<0.001 level.

The results of adjusted regression analyses that examined the association between PA practice and use of PHS on HRQoL are reported in table V. Regression analyses indicate that elderly adults who practice PA and use PHS (group 4) have higher scores across all the HRQoL dimensions than group 2 (those who do not engage in PA, but use PHS) and group 3 (those who engage in PA, but do not use PHS). After adjusting for sex, age, education, marital status, health problems in the last month, and use of alcohol and/or tobacco, we observed β coefficients ranging from 0.09 for mental health to 0.15 for vitality and general health (p<0.001).

Discussion

Our results suggest that perceived HRQoL among older adults who engage in both PA practice and use PHS is better than when each preventive approach is used on its own. This is a particularly relevant finding, especially since older adults are more likely to seek treatment for existing health problems rather than preventing them in the first place.²⁶ The results of our study provide evidence to support the development and implementation of preventive behavior approaches that promote PA and the use of PHS in order to improve perceived HRQoL among the elderly population.

The association between PA and HRQoL is supported by numerous studies with older adults and has been examined across different types of study designs, populations, and PA measurement methods.^27,28,29Anokye et al. used both direct (accelerometer) and indirect (questionnaire) PA measurements to document correlation between PA and HRQoL in a sample of 5537 adults (40-60 years) from a representative national survey in England. Their results revealed that higher levels of PA are associated with better HRQoL.³⁰

Although previous studies have examined the relationship between use of health care services such as monthly medical and hospitalization visits, and perceived HRQoL,^31,32 to the best of our knowledge, no studies have examined the association between use of certain PHS and PA practice on the perceived HRQoL of older adults in Mexico.⁸ Exposing the elderly to preventive health information when they seek treatment services could help increase the use of PHS among this population, which could lead to improvements in their life quality. These services should inform older adults about the importance of integrating a positive self-care attitude, promoting healthy behaviors and preventive medical strategies.

Other types of preventive approaches, such as household visits, have also been shown to have a positive impact on the functional status of the elderly, as well as reducing hospital and institutional admissions, improving nursing home stays, and even mortality.^32,33 The evidence obtained from these studies supports the importance of measuring the impact of preventive practices on the perceived HRQoL of older adults.

Our results indicate that there is a positive association between the combination of PA and use of PHS, and an improved perception of various HRQoL aspects. The benefits of using PHS have been documented by Kim and colleagues,³⁴ who found that older adults who use senior center services have a better HRQoL perception than non-users. However, this evidence was obtained from cross-sectional studies. Longitudinal studies are required to explore if the services provided at senior centers, such as language and computer classes, exercise sessions, entertainment, well-being programs, human development groups, and rehabilitation activities are having an effect on perceived HRQoL.

As a large medical institution, IMSS is equipped with the necessary human resources and facilities that could be used to implement prevention and health promotion programs, including educational activities geared toward promoting well-being and healthy lifestyles among older adults. The results of this study indicate that the use of these types of preventive services at IMSS is associated with a better perceived HRQoL among older adults in Mexico. These findings support the recommendation to develop strategies to enhance these types of services, with the added benefit of optimizing institutional resources.

According to the Centers for Disease Control and Prevention (CDC) and the Guidelines from The American College of Sports Medicine,³⁵ it is essential that older adults engage in at least 30 minutes of moderate-to- vigorous exercise on a daily basis. This is particularly relevant if we consider that compliance with international PA recommendations is very low among Mexican adults who are 55 years and older: an estimated 60% of males and 70% of females are physically inactive.³⁶In our study, only 23% of the participants achieved the international PA recommendations. While our aim was not to describe the rates of PA or use of preventive services in our study population, this finding is relevant because our sample is representative of IMSS affiliates, since the participants who engaged in PA or used PHS had the same likelihood of being selected as those who did not. This was possible due to the sampling method we used, which involved the random selection of participants from a list of older adults affiliated with IMSS. We can assume that our results are at least representative of the population from which the participants were selected. Moreover, since IMSS provides services to 40% of the elderly population in Mexico,¹⁵ the positive association observed between PA and use of PHS on perceived HRQOL is relevant to a large number of individuals.

Physical inactivity is the 4^th preventable cause of non-communicable diseases (NCDs) that kill 40 million people each year, equivalent to 70% of all deaths globally.^37,38,39Therefore, health delivery organizations such as IMSS need to develop effective strategies to confront the growing burden of NCDs by promoting preventive services. Furthermore, our findings indicate that efforts to increase PA among older adults, especially in conjunction with the use of PHS, could help to improve the perceived HRQoL and general well-being of this population.

Since PHS are used less frequently than treatment services,^26,39 our study measured the use of PHS as occurring at least once during the previous twelve months. Consequently, a better HRQoL perception among respondents may have been attributable to a better health status (even after adjusting for this variable) rather than to the use of PHS. Additionally, the types of PHS assessed in this study represent an institutional approach toward health promotion and prevention that is specific to IMSS and is not necessarily representative of the PHSs that are available in other institutions and countries.

Our study has a number of limitations, which include applying a cross-sectional design to assess the relationship of persistent behaviors with a multidimensional construct like HRQoL. The cross-sectional nature of the study did not allow us to assess trends in the use of PHS, which ideally would have been measured over several years, since the beneficial effects of using PHS on HRQoL may take longer to become evident. Information on use of PHS and PA levels was measured through self-report and assessed for a period of 12 months prior to the interviews, which might result in the possibility of recall bias, especially in the case of older adults. Additionally, the classification of PA levels relied on the self-report of respondents, who may have overestimated their PA level based on existing guidelines and recommendations.⁴⁰

As for the PA measurements, it is understandable that PA should be lower among older adults due to the physical limitations and health issues inherent in this age group. However, our results regarding the association with HRQoL did not change after adjusting by level of PA. Additionally, we only assessed those health issues that were experienced in the previous month. Also, a number of older adults may have suffered from chronic illnesses that were not measured by our study questionnaire. This could result in reverse causality bias, if subjects who were in better health, and therefore were able to fulfill the aforementioned PA recommendations or engage in sufficient PA to obtain substantial health benefits, reported a better HRQoL. Longitudinal studies are needed to confirm these associations.

Despite these limitations, we were able to detect a strong and significant association between the combination of PA and use of PHS, and a better perceived HRQoL, which supports the findings of other studies that were also based on direct measurements.^30,41To the best of our knowledge, this is the first study to examine the combined benefit of practicing PA and using PHS on the perceived HRQoL of non-institutionalized older adults in Mexico.

In conclusion, our results indicate that PA and use of PHS are associated with a better perception of HRQoL among older adults in Mexico. This study provides additional evidence that supports extending and strengthening existing programs aimed at older adults within or beyond the framework of a health institution such as IMSS. These results could be useful for policy and decision makers in middle income countries such as Mexico, who are trying to meet the challenges of the aging population by finding ways to improve the HRQoL of the elderly.