Impact of Supportive Resources on Middle-Aged Women's Self-Care Activities: A Study in The Vietnamese Context

Addressing the fact that studies on self-care of Vietnamese middle-aged women remain scarse, our presenting study aims to investigate the relationship between supportive resources utilized by Vietnamese middle-aged women and their types of self-care. Data were collected from survey interview with 512 middle-aged women (aged from 40 to 60 years old) in Hanoi city and Quang Ninh province. A series of linear regression was performed on the six types of self-care, including: physical care, supportive relationships, mindful awareness, self-compassion & purpose, mindful relaxation, and supportive structure. Three types of supportive resources and other covariates (age, education, and residence area) were entered into these models as key predictors. The study results show that the use of different level of resources was associated with different types of self-care practice. The use of micro-resource system significantly predicted all six types of self-care among Vietnamese middle-aged women. The mesenchymal and peripheral resource systems significantly predicted physical care only among Vietnamese middled-age women. The macro resource system was significantly associated with the practice of mind-relaxing and supportive structure. In addition, people who were older, had better education and lived in urban areas tended to participate more in physical care. Women with a higher education level and living in urban areas were predicted to utilize more supportive relationships and mindful relaxation. Women living in urban areas, having a higher level of education practiced mindful relaxation significantly more than their counterparts. Using more supportive structure was significantly more among women living in urban areas, in older age groups and having higher education levels. The key findings suggest the promotion of active support from the micro-level system, as well as advocate for social policy development to help less privileged groups of women access and use mezzo and macro resources more effectively.


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In addition to finance, welfare, and carers (Nelson et al., 2019;Fivecoat et al., 2018), social support in general, and supportive resources in particular play important role in one's self-care decision. Social support has both direct and indirect effects on health care measures (Bloom, 1990, citing Ahmadi, 2016, disease risk reduction, disease resistance, and recovery from illness. Social relationships generate health-affecting behaviors such as diet, work habits, smoking, alcohol consumption, sleep, and adherence to medical regimens (Cohen et al., (2000) citing Ahmadi, 2016). Family support was positively associated with self-esteem and self-care behavior among patients with chronic obstructive pulmonary disease (Kara & Alberto, 2007;Xiaolian el al., 2002). A study with a group of patients with heart failure also showed similar results about the influence of family support on individual self-care behaviors (Shahriari el al., 2013). For the group of older people who were sick, their family members, particularly their spouses were the closest and most influential people in their self-care activities (Saidi & Sanisah, 2015).
Self-care is a priority for middle-aged women, as they tend to confront many health problems and high risk of chronic non-communicable diseases, such as osteoporosis, cancer, and others, especially after the age of 50 (Arpanantikul, 2004;Truong, 2013). Priotizing self-care helps middle-aged women participate in better prevention, early detection, treatment and recovery if they have a disease. As a result, active self-care is associated with improvements in their physical, psychological, and social well-being.
Among middle-aged women, informal social support from relatives, friends and colleagues plays an important role in reducing the risk of disease, fighting and recovering from disease (Ahmadi, 2016). According to Arpanantikul (2006), social support also reduces isolation and stress for middle-aged women, and provides crisis prevention and interventions that can help them avoid possible negative effects of the change. Mutual support helps women cope with some issues, such as menopause, caring for an aging parent, or financial concerns.
In addition to informal support, the health care system, i.e., health specialists, is also an important source of support. According to Arpanantikul (2004), specific guidelines on care and encouragement of health workers are of great significance for women to perform self-care activities more effectively. They can be a resource as well as a motivator for self-care for women. Encouraging women to take an interest in health literacy and self-care is essential as this enables women to improve their health status both physically and mentally, and let women take control of self-care. This can lead to positive long-term outcomes as women continually take care of themselves in their daily lives.

Bronfenbrener's approach to ecological system theory in understanding supportive resources
Bronfenbrener's approach to ecological system theory has been used in investigating supportive resources across different population groups. In this approach, supportive resources consist of three levels of systems from micro, medium, to macro, and each level of resources has its own impact on people's behaviors and health outcomes. Pilgrim & Blum (2012) argue that in the microsystem, family factors have an important influence on children's health. Strong interpersonal relationship within the family helps reduce stress and trauma in children and adolescents (UNICEF, 2015). For children with intellectual disabilities, family factors, such as relationships between siblings and friends, etc. have a direct influence on the child's life (Vu, 2020). For immigrant women, microsystem factors affecting their health include family, friends, immigrant communities, ethnic and religious communities (Yukashko & Chronister, 2005). Other studies have also shown that regular and direct emotional support from the microsystem has a positive effect on an individual's physical health and longevity (Orth-Gomér, 2009;Thoits, 2011). At the mesosystem and exosystem level, previous studies have identified different resources related to different population groups. For example, resources at this level for immigrant women refer to the availability of legal, financial and social services (Yukashko & Chronister, 2005). Youth groups and their parents could seek help from organizations such as schools, churches, youth centers, health care providers, child protection policies, and social services (Mutumba & Harper, 2015). At the macrosystem www.msocialwork.com level, existing studies have focused on factors such as ideology, cultural values, religious values and beliefs, and political and economic values (Yakushko and Chronister, 2005;McLaren & Hawe, 2005;Vu, 2020). For instance, government policies contribute to create a favorable environment for the education of children with mental retardation (Vu, 2020).

Knowledge gaps and research aims
In Vietnam, there have been a few studies on the role of supportive resources for some specific groups. For example, a study on cancer patients reports that the routine care of the family and regular information update of the medical staff both played an important role in palliative care for them (Tran et al., 2019). Some other studies argue that family and other support helped reduce psychological disturbances in postpartum women (Tran, Bui & Ngo, 2016), resources from family and social organizations contributed to improve and enhance the mental health self-care of older people (Hoang, Trinh, 2019). In short, these studies have shown that the microsystem was found to have the most influence on an individual's self-care and health outcome. However, very little is known about self-care practice of Vietnamese middle-aged women, as well as the relationship between their utilized supportive resources and their types of self-care. Addressing these knowledge gaps, this study aims to investigate the relationship between supportive resources utilized by Vietnamese middle-aged women and their types of self-care. In this study, the ecological system theory, with three levels of systems, including micro, meso-exo, and macro-systems, were used to assess resources to support middle-aged women in self-care.

Ethical consideration and procedure
This study was approved by the university where the principal investigator was affiliated with. In this survey study, a questionnaire was developed based on selected standardized scales. These standardized scales were translated from English to Vietnamese by the core research team. Then, an independent consultant conducted a back translation from Vietnamese to English to validate the translation.
The study was conducted in the two sites, including Hanoi city and Quang Ninh province. The research team collaborated with the Women's Unions at the precinct or commune level in the two sites to invite middle-aged women (aged from 40 to 60 years old) to participate in the study. In our flyers, we introduced our study aims, procedures, and potential benefits and risks of prospective participants when participating in the study. We also declared clearly that participants were welcome to participate voluntarily, and they could withdraw from the study at any time as they wished. Their information would be used for the study purpose only, and their confidentiality was protected.
In total, 512 women agreed to participate in the study and completed the survey. Trained interviewers conducted interviews using the validatedly translated questionnaire with participants at a community center. Each interview lasted from 30 to 35 minutes and each participant received a small incentive after completing the interview.

Self-Care
The Mindful Self-Care Scale Short (MSCS) was used to measures self-care of participants (Cook-Cottone and Guyker, 2018). This scale was intended to help individuals identify areas of strength and weakness in mindful self-care behavior, as well as assess interventions that serve to improve self-care. This scale includes 33 items with six subscales, namely: (i) Physical care (e.g., I exercised at least 30 to 60 minutes); (ii) Supportive relationships (e.g., I scheduled/planned time to be with people who are special to me); (iii) Mindful awareness (e.g., I had a calm awareness of my thoughts); (iv) Selfwww.msocialwork.com compassion and purpose (e.g., I reminded myself that failure and challenge are part of the human experience); (v) Mindful relaxation (e.g., I did something interpersonal to relax); (vi) Supportive structure (e.g., I maintained a manageable schedule). For each item, participants chose one response out of five choices (1 = Never; 2 = Rarely; 3 = Sometimes; 4 = Often; 5 = Regularly). Global self-care was computed by summarizing the scores of all 33 items. Cronbach's alpha coefficients of six subscales were 0.78, 0.81, 0.85, 0.83, 0.79 and 0.81 respectively, and of the global self-care was 0.92.

Supportive resources
The research team developed a supportive resource scale to assess key supportive resources for middleaged women. This scale includes 15 items with three subscales, namely: (i) Microsystem resources (7 items) referring to support from relatives, friends, and colleagues for activities, such as encouragement, help with housework, financial support, health care, information support, and service access (e.g., My relatives encourage me to participate in health care activities); (ii) Meso-Exosystem resources, also known as mesenchymal and peripheral resources (4 items) referring to health information dissemination and healthcare services from local clinics in the community (e.g., Medical health care services in my locality are adequate and of good quality); (iii) Macro-Chronosystem resources (4 items) referring to current health policies of community healthcare services for women's health care, encouragement from religious facilities, the convenience of the technology access (e.g., Current health policies are favorable for people, The age of technology makes it easier for me to access information and knowledge about health care). Participants chose one response ranging from 1 to 5 for each item (1 = strongly disagree; 2 = slightly disagree; 3 = slightly agree; 4 = moderately agree; 5 = strongly agree). The reliability of this scale was good (α = 0.89). The score of each sub-scale was the summation of its items' scores. Cronbach's alpha coefficients of the three subscales were 0.89, 0.82, and 0.65 respectively. Factor analysis resulted in the KMO index of 0.871, Bartlett's test p-value < 0.001 and three factors with eigenvalue greater than 1 that could explain 62.88% of variance of supportive resources.

Data analysis
Survey data were analyzed using SPSS software version 22.0. In addition to descriptive analysis, a series of linear regression was performed on the six types of self-care, including: physical care, supportive relationships, mindful awareness, self-compassion & purpose, mindful relaxation, and supportive structure. Three types of supportive resources and other covariates (age, education, and residence area) were entered into these models as key predictors. Table 1 summarizes the key characteristics of participants and other studied variables. Among 512 middle-aged women participated in the study, the majority of them were in the age group of 40-49 years (64.5%), living in the urban areas (54.9%), having intermediate or lower educational degree (60.0%). Their occupational areas varied from civil service, business and service, industry, farming and fishing, to seasonal work, housework, and retired.

Descriptive characteristics of key studied variables
Supportive resources for and self-care of middle-aged women were also reported in Table 1. Resources belonging to the micro-system showed the highest score (M = 3.59; SD = 0.70), followed by the group of resources belonging to the meso-and exo system (M = 3.19; SD = 0.83), and the group of resources belonging to the macro system (M = 2.95; SD = 0.69). Participants reported self-care at a moderate level www.msocialwork.com (M = 3.31; SD = 0.54). Under self-care, the most reportedly utilized forms were mindful awareness (M = 3.64; SD = 0.69) and self-compassion and purpose (M = 3.61; SD = 0.66), followed by supportive relationships (M = 3.56; SD = 0.67) and supportive structure (M = 3.27; SD = 0.86). Physical care (M = 2.87; SD = 0.63) and mindful relaxation (M = 2.91; SD = 0.72) were least utilized compared to the rest.  Table 2 shows the results of linear regression of the same set of predictors on six different types of selfcare. Among these six models, the predictor set explained 37.8% of the variance of mindful relaxation utilization, 33.3% of the variance of the use of supportive structure, and 31.2% of the variance of supportive relationship use. Approximately 23.4%, 20.7%, and 18.5% of the variance of the use of selfcompassion and purpose, physical care, and mindful awareness respectively was explained by the same set of predictors.

Multivariate models of self-care
In each model, the use of specific resource types could predict women's self-care behaviors. In model 1, micro and mesenchymal resources significantly predicted physical care activity (p < 0.05). In addition, people who were older, had better education and lived in urban areas tended to participate more in physical care. In models 2, 3, and 4, only micro-resources significantly predicted the use of support relationship (β = 0.359), mind awareness (β = 0.297), and self-compassion (β = 0.265), noted that the statistical significance level was identified at 0.001. In addition, women with a higher education level and living in urban areas were predicted to utilize more supportive relationships and mindful relaxation. In models 5 and 6, the use of micro and macro resources significantly predicted the practice of mindful relaxation and supportive structure. Women living in urban areas, having a higher level of education practiced mindful relaxation significantly more than their counterparts. Using more supportive structure was significantly more among women living in urban areas, in older age groups and having higher education levels. www.msocialwork.com

Discussion and Conclusion
Addressing the fact that studies on self-care of Vietnamese middle-aged women remain scarse, our presenting study aims to investigate the relationship between supportive resources utilized by Vietnamese middle-aged women and their types of self-care. Despite its own limitations, such as limited sample size in Northern Vietnam and the lack of economic status as a covariate in investigating the relationship between supportive resources and self-care practice, the study results contribute to the literature on this understudied group.
The study results show that the use of different level of resources was associated with different types of self-care practice. The use of micro-resource system significantly predicted all six types of self-care among Vietnamese middle-aged women. This could be explained by the fact that in order to practice self-care activities, women need time and someone to help with housework as well as some financial support. Help from relatives living with them will help women have more time to take care of themselves. The family model in Vietnam where parents live with their children or in close proximity is quite common. Most of the subjects in this study lived with family members (99%). In Vietnamese culture, it is the responsibility of children to take care of their parents, especially when their parents are old. Living together is also a favorable condition for older adults to receive both material and spiritual help from their children and grandchildren (Le, 2006). Many middle-aged women in rural areas have limited access to information, and their children are the main facilitators in accessing information and health services. Besides family, friends are an indispensable relationship for women entering middle age (Truong, 2013). Friends and colleagues can also accompany women in self-care practices (e.g., dance groups, yoga, etc.) or share health care information.
Studies with similar participants in other contexts also share consistent results. In Thailand specifically, social support from family, friends and colleagues play an important role in middle-aged women's selfcare (Arpanantikul, 2006). In Malaysia, family and close people are always an effective support force for self-care activities of the members living with them, in which the spouse is the closest and most influential people to the older people who are ill (Saidi, 2015).
The findings of the present study show that the mesenchymal and peripheral resource systems significantly predicted physical care only among Vietnamese middled-age women. This level of resources includes health care policy for employees, local health care services, and health care www.msocialwork.com information dissemination to the public. In Vietnam, these services mainly focus on the aspect of physical care. The periodical health check-up at the workplace only includes general physical health examination, while they do not provide mental health examination (Ministry of Health, 2013). Local wellness services also focus more on the physical aspect. In addition, psychological counseling services are severely lacking in rural areas. The macro resource system was significantly associated with the practice of mind-relaxing and supportive structure. Currently, technology makes it easier for each individual to access information and use services. Middle-aged women can relax by reading news, listening to music, watching movies, participating in social networks, chatting online with friends, buying and selling through the internet connection on phones and computers. That helps them relax at any time of the day. Modern technology provides useful tools that make it easier for women to arrange work, plan and execute conveniently without spending much time on travel, especially in the context of social distancing because of the COVID-19 epidemic.
In summary, research results show the relationship between the three levels of resource systems and self-care activities of Vietnamese middle-aged women. The key findings suggest the promotion of active support from the micro-level system, as well as advocate for social policy development to help less privileged groups of women access and use mezzo and macro resources more effectively. In order to improve self-care among rural women, the government should develop support programs aiming at enhancing their socio-economic status, thereby increasing the opportunities and access to resources for self-care of this group.