Background
Research has demonstrated that exposure to life stressors does not only directly influence health [
1], but can also influence health through three main pathways [
2]. First, exposure to life stressors is linked to illness by changes in physiology, including the immune and cardiovascular systems, and endocrine reactivity, which causes illness [
3]. Second, people who experience life stressors are more likely to adopt an unhealthy lifestyle [
4‐
6], such as poor diet [
7], smoking [
4,
7], excess alcohol drinking [
4,
5,
8], physical inactivity [
4,
7], sleep disturbance [
9,
10], and excess BMI [
11], and these lifestyles are associated with decreased health [
12‐
20]. Third, exposure to life stressors is linked with depression [
21], and is associated with illness [
22,
23]. However, the patterns by which life stressors influence health have been investigated in limited contexts. The majority of studies on life stressors and health have been done in Western cultures. Knowledge about life stressors and health in Asian cultures is limited.
Research has shown that compared to men, women usually have greater exposure to life stressors [
24]. Also, even though exposed to the same life stressor, women also appear to be more vulnerable to the negative impacts of stress than men [
5]. These experiences are particularly true for the women who are widowed, members of minority ethnic groups, or poorly educated [
25]. Moreover, the number of people aged 60 and over has been increasing all over the world and is projected to comprise approximately 20% of the global population by 2050 [
26]. Also, despite the innovations in health, aging is still linked to decreased health [
27]. Among older populations, women comprise a higher proportion [
26], and more frequently report lower levels of health than men [
28‐
30]. Yet, only a small number of studies about life stressors and health have been conducted from gender or aging perspectives. Therefore, more research about life stressors and health among older women, especially these who experience disadvantage, is needed.
Currently, there are approximately five million older women in Vietnam [
31]. Vietnamese older women have lived through wars and life after wars with limited resources [
32]. Due to traditional gender beliefs, Vietnamese older women were generally less likely to receive education than men, and so had less chance for well-paid employment [
33]. After marriage, the majority of Vietnamese older women have lived with their husbands’ families, where they are the main caretakers for the housework and the extended family members [
34]. Recently, along with dramatic socio-economic changes, domestic violence has increased in Vietnam [
35], with 58% of women in Vietnam suffering at least one kind of domestic violence in their lifetime [
36,
37]. These factors suggest that Vietnamese older women may have experienced various life stressors, and their experience of life stressors may have influenced their health. Yet, to date, knowledge about life stressors and their impact on health among Vietnamese older women is largely unknown.
Furthermore, the majority of previous studies have used binary analysis, simple regression analysis or multiple regression analysis for data analysis. These data analysis approaches have limited investigation to direct influences among variables, and missed the opportunity to explore the indirect impact of stressors. A combination of the influences among variables found in different studies or data analysis in a comprehensive model might increase statistical errors. While structural equation modelling can increase statistical robustness in modelling a comprehensive model of both direct and indirect influences among variables, few studies have used this statistical approach for their data analysis. Therefore, the use of structural equation modelling to comprehensively model the impact of life stressors on modifiable lifestyle factors, depressive symptoms, physical and mental health among Vietnamese older women is needed.
This study aimed to describe the life stressors of Vietnamese older women, and use structural equation modelling to examine the influences of life stressors on modifiable lifestyle factors, depressive symptoms, and health among Vietnamese older women. As almost all of Vietnamese women abstain from smoking [
38] and alcohol [
39], the modifiable lifestyle factors in this study included vegetable and fruit consumption, physical activity levels, sleeping, and BMI. It is hoped that knowledge gained from this study will be useful for proposing interventions to promote health among Vietnamese older women in the future.
Discussion
This study explored life stressors, and examined the influences of life stressors on modifiable lifestyle factors, depressive symptoms, and physical and mental health among Vietnamese older women. In regard to life stressors, the study found that many Vietnamese older women experienced caring for those with serious health problems and violence, and domestic violence. Vietnamese girls did not receive equivalent education to boys and so frequently had fewer opportunities for paid employment [
33]. Growing up, they mainly took care of housework, and sick family members [
34]. Many Vietnamese older women had been taught to “obey their father when they are young, obey their husbands when they get married and obey their children when their husbands passed away”. Consequently, they might have believed that their husbands had the right to order them what to do, and husbands could have employed punishment on their wives. The fact is that many Vietnamese women reported domestic violence [
36,
37]. Yet, the social norms that existed in Vietnam have inhibited women from marital changes [
37]. This may have increased the risks of suffering from domestic violence.
The study also found that a number of Vietnamese older women experienced family members or themselves in jail, losing a baby/child, and serious physical or mental illness or money problems. There are several possible explanations for this finding. Vietnamese older women have lived through wars against the French, Japanese, Americans, the Pol Pot government, and China. During the wars, people were more likely to experience being in jail or having family member(s) in jail. Until the 1990s, many Vietnamese people still lived with very limited social, economic, and medical resources [
32]. Consequently, the abortion rate in Vietnam rose rapidly between 1976 and 1987, from 70,281 cases to 811,176 cases [
50]. Many children died because of accidents [
51,
52]. Two thirds of children aged six and less in low income families did not receive treatment or they treated themselves when they were sick [
52]. These factors may account for women experiencing health or financial problems and the loss of a baby/child. However, about two thirds of the data were collected from Dong Thap province, where the majority of residents lived on agriculture. In 1978, this area experienced a serious flood, and as a result, many people living in this area experienced famine and poverty. In this context, the prevalence of experience of disaster and serious money problems could be over-reported and so interpretation of these data for the general Vietnamese older women’s population should be undertaken with caution.
Concerning the influences of life stressors on modifiable lifestyle factors, depressive symptoms, and health among Vietnamese older women, the study’s findings are consistent with contemporary literature and support the prevailing theory to a certain extent. More specifically, the study indicated that life stressors directly impacted on mental health [
53,
54]. In addition, the study also indicated that life stressors were linked with depression [
5,
22,
55], which can in turn contribute to decreasing both mental and physical health [
23]. Previous studies also indicated that after adjusting for marital status, education, income, employment status, pregnancy status, or being abused as a child, those who experienced abuse in their adult intimate relationships would be more likely to experience depression than others [
56] and, in turn, depression significantly contributed to decreasing health [
55]. Taking both the direct and indirect impacts of life stressors on health together, the study’s findings suggest that life stressors had moderate impacts on depressive symptoms, and physical, and mental health among Vietnamese older women.
However, two findings from this study are not congruent with the theory and findings from other populations [
57]. One of the differences is the associations between exposure to life stressors and diet, sleep, problems and BMI. Previous studies suggested that exposure to life stressors was linked with an unhealthy diet [
7], sleep disturbance [
9,
10], and excess BMI [
11]. Then, these lifestyles are associated with decreased health [
12‐
20]. These associations were not found among Vietnamese older women. A possible explanation is that Vietnamese older women may have experienced the listed life stressors a long time ago, and the impact of this experience may have decreased over time and may no longer have an influence on their current diet, sleep and BMI. Another difference is in the associations between exposure to life stressors and physical activity, and health. Schwarzer & Schulz [
58] posited that those exposed to stressors would be more likely to have a sedentary lifestyle [
59], and as the result, people would experience decreased physical and mental health [
60]. Among Vietnamese older women, those who reported more life stressors also reported more overall physical activity and these increased physical activity levels then increased their physical health. There are a number of possible explanations for this difference. One possible explanation is that older women in Vietnam may believe that the most common source of their life stressors comes from their low socio-economic status. They may have tried to work harder rather than being sedentary to overcome this situation. Another possible explanation is that Vietnamese older women may have used avoiding stress coping strategies to deal with their stressors. They may have increased physical activity to avoid thinking too much about their life stressors. However, as these possible explanations have not been studied in previous studies, an in-depth interview to further investigate how Vietnamese older women appraise their life stressors and their common coping strategies would be useful to provide better explanations for these interesting findings among Vietnamese older women.
Strengths and limitations
This study has several strengths. First, the study was conducted in a previously unstudied population and provided knowledge of life stressors and their sequelae among Vietnamese older women for the first time. Secondly, as the participants were recruited through the Older People’s Unions in the communities, the study captured a significant proportion of older women in the research areas. Thirdly, the data for this study were collected through Vietnamese versions of validated instruments, which achieved good translation equivalence and internal consistency. As such, the instruments improved the reliability of the study’s findings and provide a basis for further data collection. Fourthly, as the study used SEM for data analysis, both direct and indirect influences of life stressors on modifiable lifestyle factors, depressive symptoms, physical health, and mental health among older women were explored.
However, the study also had a number of limitations. First, this study used face-to-face interviews to collect data which might have introduced social bias, and reporting bias. To minimise this, interviews were conducted in a private location to limit the participants from over or under reporting. Second, as the study asked participants about their life time stressors, recall bias may have occurred. Third, the participants experienced wars, but the LSC-R which was used to measure life stressors does not account for wars. Fourth, since this is a cross-sectional study, findings about relationships among study variables could not be concluded as causal. Fifth, while research suggested that more recent exposure to stressors could have a stronger impact on lifestyle and health, this study did not compare the impact of life stressors by their exposure time. Sixth, perceived stress, rather than the stressor itself, can have a stronger influence on health [
61], and the study did not include perceived stress in the model. Finally, while exposure to stressors has been linked to illness by changing physiology [
3,
62,
63], this study did not include immune, cardiovascular, and endocrine parameters due to limited time and facilities.
Conclusions
This study found that Vietnamese older women experienced various life stressors and exposure to life stressors influenced modifiable lifestyle factors, depressive symptoms, and that health among Vietnamese older women differently. Similar to other cultures, exposure to more life stressors increased depressive symptoms, and decreased physical and mental health among older women in Vietnam. However, among older women in Vietnam, exposure to more life stressors was not linked to diet, sleep problems, and BMI. In fact, it increased their physical health by increasing physical activity levels.
At the moment, the health care system in Vietnam mostly focuses on physical diseases, and available resources and facilities for mental health care in this context are still limited. Findings from this study suggest that further service provisions to promote mental health are required for Vietnamese older women. A development of primary mental healthcare services and psychological counselling services for stress and depressive symptom management might be a helpful approach to promote health for Vietnamese older women in the future.