Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach

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In 2017, the Ministry of Social Development and Human Security launched the “elderly school” initiative to foster lifelong learning and enhance the QoL among senior citizens. However, comprehensive evaluations of its impact on QoL remain limited. Methods This cross-sectional survey aimed to assess the policy’s effect on QoL in Phetchabun province, Thailand. Using quota and systematic sampling, 1,374 senior citizens aged 60-80 participated. Propensity score matching (PSM) with a 1:1 match was employed to estimate the average treatment effect (ATE) of attending the elderly school on QoL. Additionally, multiple linear regression was analyzed to assess the association between QoL and its associated factors. Results PSM were matched successfully, the standardized difference was less than 10 percent, and the baseline after matching indicated balances with 687 elderly people in each group. The mean QoL score of the non-attending group was 44.40 (SD = 7.11), and that of the attending group was 57.50 (SD = 7.53). The ATE for elderly people attending school was 10.67 scores (95% CI: 9.67 – 11.67 scores) higher than those unattended. Being female, having monthly income higher than 20,000, having employment, having a caregiver, and attendance at elderly school were positively associated with QoL, and the standardized beta coefficients were 0.078, 0.059, 0.094, 0.066, and 0.550, respectively. Additionally, higher education was positively associated with higher QoL. Conclusion The elderly school policy significantly enhanced the QoL of the attending senior citizens. Findings suggest continued collaboration among stakeholders to sustain and optimize this policy for improved seniors’ QoL, which has the potential to utilize lifelong learning to create an inclusive framework for healthy aging among senior citizens. 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F1000Research 2025, 13 :735 ( https://doi.org/10.12688/f1000research.151221.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] Worapath Kratoo https://orcid.org/0009-0007-5899-1221 1 , Nuchanad Hounnaklang https://orcid.org/0000-0003-1129-3219 1 Worapath Kratoo https://orcid.org/0009-0007-5899-1221 1 , Nuchanad Hounnaklang https://orcid.org/0000-0003-1129-3219 1 PUBLISHED 31 Mar 2025 Author details Author details 1 College of Public Health Sciences, Chulalongkorn University, Bangkok, Bangkok, 10330, Thailand Worapath Kratoo Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Nuchanad Hounnaklang Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background As Thailand’s population ages, promoting senior citizens’ quality of life (QoL) is crucial. In 2017, the Ministry of Social Development and Human Security launched the “elderly school” initiative to foster lifelong learning and enhance the QoL among senior citizens. However, comprehensive evaluations of its impact on QoL remain limited. Methods This cross-sectional survey aimed to assess the policy’s effect on QoL in Phetchabun province, Thailand. Using quota and systematic sampling, 1,374 senior citizens aged 60-80 participated. Propensity score matching (PSM) with a 1:1 match was employed to estimate the average treatment effect (ATE) of attending the elderly school on QoL. Additionally, multiple linear regression was analyzed to assess the association between QoL and its associated factors. Results PSM were matched successfully, the standardized difference was less than 10 percent, and the baseline after matching indicated balances with 687 elderly people in each group. The mean QoL score of the non-attending group was 44.40 (SD = 7.11), and that of the attending group was 57.50 (SD = 7.53). The ATE for elderly people attending school was 10.67 scores (95% CI: 9.67 – 11.67 scores) higher than those unattended. Being female, having monthly income higher than 20,000, having employment, having a caregiver, and attendance at elderly school were positively associated with QoL, and the standardized beta coefficients were 0.078, 0.059, 0.094, 0.066, and 0.550, respectively. Additionally, higher education was positively associated with higher QoL. Conclusion The elderly school policy significantly enhanced the QoL of the attending senior citizens. Findings suggest continued collaboration among stakeholders to sustain and optimize this policy for improved seniors’ QoL, which has the potential to utilize lifelong learning to create an inclusive framework for healthy aging among senior citizens. READ ALL READ LESS Keywords Elderly school, Health policy, Quality of life, Propensity score matching Corresponding Author(s) Nuchanad Hounnaklang ( [email protected] ) Close Corresponding author: Nuchanad Hounnaklang Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Kratoo W and Hounnaklang N. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Kratoo W and Hounnaklang N. Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.12688/f1000research.151221.2 ) First published: 03 Jul 2024, 13 :735 ( https://doi.org/10.12688/f1000research.151221.1 ) Latest published: 31 Mar 2025, 13 :735 ( https://doi.org/10.12688/f1000research.151221.2 ) Revised Amendments from Version 1 This version includes additional details on the sampling technique, a participant flow diagram following the CONSORT guidelines, measurement and an expanded discussion on and policy implications and recommendations. Furthermore, the results in Table 4 have been reorganized for clarity. This version includes additional details on the sampling technique, a participant flow diagram following the CONSORT guidelines, measurement and an expanded discussion on and policy implications and recommendations. Furthermore, the results in Table 4 have been reorganized for clarity. See the authors' detailed response to the review by Ueamporn Summart See the authors' detailed response to the review by Andrew Kweku Conduah See the authors' detailed response to the review by Aye Sandar Mon READ REVIEWER RESPONSES Introduction A global surge in the elderly population, defined as those aged 60 and above, presents a major challenge and opportunity for healthcare systems worldwide. From 2015 to 2050, the proportion of elders is projected to nearly double, from 12% to 22% 1 , with 80% residing in middle-income countries. 2 This trend is particularly evident in Thailand, where the elderly population is expected to reach 17 million by 2040, exceeding one-quarter of the national total. 3 , 4 This necessitates immediate attention to preparing and evolving healthcare systems to adequately support the QoL of senior citizens. Thailand, with its rapidly aging population, stands at the forefront of this global challenge. By acknowledging the urgency of the situation and proactively adapting its healthcare systems, Thailand can not only serve as a model for other countries but also ensure the health and QoL of its senior citizens, paving the way for a brighter future for all. 5 , 6 The concept of QoL encompasses an individual’s or population’s overall QoL, integrating both positive and negative experiences over a defined timeframe. 7 The World Health Organization (WHO) defines QoL as an individual’s subjective perception of their life position, influenced by cultural and value systems. 8 , 9 This multidimensional concept, as outlined by the WHO, encompasses four key domains: physical health, mental health, social relationships, and the environment. 10 QoL serves as a crucial indicator for achieving Sustainable Development Goals (SDGs), particularly for the elderly population, with relevance to SDG 3: Good Health and Well-being. 11 Despite achieving a moderate average QoL amongst senior citizens nationwide, Thailand faces disparities in urban-rural QoL, with literature suggesting consistently lower QoL for rural older adults 12 – 14 which is similar to Myanmar, and South India 15 , 16 This presents a significant challenge for Lomkao district, Phetchabun province, a rural area boasting a 24.8% elderly population and exhibiting moderate QoL scores for elder residents. 17 , 18 Research points beyond individual characteristics such as age, income, education, and chronic health conditions as sole determinants of QoL for older adults. Living arrangements and social interactions have also emerged as crucial factors deserving consideration in an effort to enhance elderly QoL. 19 – 21 Therefore, a comprehensive approach addressing both individual and environmental factors is essential to effectively improve QoL for Thailand’s rural elderly population. In response to the crucial role of health promotion interventions in improving and maintaining QoL for older adults, numerous such programs have been implemented globally. 22 – 24 These interventions typically share three core objectives: enhancing functional capacity, promoting self-care behaviours, and preventing or delaying chronic illness onset. 25 Implementation often involves collaboration among social welfare organizations, healthcare professionals, and educational systems. 26 , 27 Thailand exemplifies this trend with the 2017 establishment of the elderly school initiative by the Department of Older Persons, Ministry of Social Development and Human Security. 28 This program, grounded in the concepts of awareness, empowerment, and lifelong learning, aims to equip older adults with the knowledge and skills necessary to achieve optimal QoL. 29 , 30 In 2018, Lomkao district was identified as one of 73 districts in Thailand by the District Health Board for the implementation of specific programs to address the challenges posed by an aging population. Recognizing the district’s demographic shift, the Board selected Lomkao as a priority area due to the prevalence of older adults residing within its boundaries. One of the key initiatives implemented in Lomkao to address this demographic trend is the “Elderly School” program. This program represents a targeted intervention aimed at improving the well-being and QoL for older adults in the district. 31 , 32 As of 2022, Thailand boasts a network of 2,370 elderly schools established through partnerships with local administrative organizations (LAOs), private entities, and community groups. 33 These schools offer a core curriculum encompassing four key modules: health, social, economic, and environmental education, in which the officers invite elderly people in communities to attend through voluntary participation. 28 , 34 , 35 Program adaptations cater to specific regional contexts, aligning with the curriculum framework developed by the Department of Older Persons (DOP), Ministry of Social Development and Human Security. Annual budgetary allocations for elderly school support have ranged from $283,700 to $425,687 USD over the past five years. Notably, the 2021 allocation fell below the minimum due to the COVID-19 pandemic necessitating online instruction in some areas where there is hardly any regular class. 33 , 36 – 39 Recognizing the program’s value, alternative funding avenues through LAOs, the Community Health Security Fund, and the Thai Health Promotion Foundation have been established to bolster implementation initiatives. 40 Beyond budgetary considerations, elderly schools demonstrably contribute to active aging, improved QoL, and ongoing learning among senior citizens. They provide valuable social interaction, alleviating loneliness and fostering a sense of community. Moreover, they empower older adults to productively utilize their free time, contributing to a sense of agency and QoL. 41 , 42 The establishment of the Elderly School initiative in Thailand in 2017 aimed to address the growing needs of the nation’s aging population. However, despite its implementation across various districts, a comprehensive and dedicated assessment of its impact on senior citizens’ QoL remains elusive. This lack of evaluation presents a significant gap in understanding the effectiveness of the program and its potential for improvement. Existing research has primarily focused on the program’s development and limitations of design, which could not control the influence of covariates. This might lead to a selection bias, leaving a critical gap in understanding its effectiveness. 43 – 46 To address this void, the present study employs PSM to evaluate the initiative’s causal effect on QoL within an aging society. Through PSM, we compare the QoL of two groups: senior citizens not attending and attending elderly schools. This approach facilitates the creation of comparable groups in real-world settings, mimicking an experimental study while mitigating selection bias and strengthening the robustness of regression analyses. In addition, investigating the association between various factors and QoL. Our findings aim to contribute to the existing body of literature, providing valuable guidance for the future implementation and refinement of lifelong learning initiatives for senior citizens in Thailand. Methods Research design This cross-sectional study was conducted in Lomkao, Phetchabun province, Thailand between December 2022 to June 2023. Sample size The study population consisted of 11,254 elderly individuals aged 60–80 years in Lomkao district, Phetchabun province, Thailand. 17 The sample size was calculated for the continuous data since this study analyzed multiple linear regression. A pilot test comparing the QoL between elderly individuals who attended and did not attend elderly school indicated a small effect size of 0.02, a power of 0.8, 13 predictors, and a significance level of 0.05. 47 There are 901 elderly people, with a minimum of 451 participants in each group. Inclusion criteria were 1) age between 60 and 80 years 2) residency in Lomkao, Phetchabun province, for at least one year and 3) literacy and proficiency in Thai communication (listening and speaking). The exclusion criteria focused on individuals with mental health illnesses that include anxiety disorders, mood disorders, and physical disabilities that would significantly impede their ability to participate in the study activities. Sampling technique In this study, researchers utilized a combination of quota and systematic sampling techniques. The quota sampling was based on a 1:1 matching model, comparing elderly people who attended an elderly school with those who did not. For systematic sampling, the sampling interval was determined using the formula I = N/n, where “I” represents the sampling interval, “N” is the total population (11,254), and “n” is the sample size (902). This calculation resulted in a sampling interval of approximately 13 (I = 11,254/902 ≈ 12.5 ≅ 13). Therefore, we included every 13th elderly person in the population who met the eligibility criteria. A random starting point between 1 and 13 was selected using a random number generator, and from this random start, every 13th elderly person in the population who met the eligibility criteria was included in the sample. Figure 1. Participant flow diagram (CONSORT). Data collection Data were collected through face-to-face interviews conducted from December 2022 to June 2023. Prior to data collection, the research team, composed of the lead investigator and five experienced healthcare workers in geriatric care, underwent one week comprehensive training. This training covered the study protocol, interview techniques, and participant selection criteria. During data collection, the research team rigorously adhered to inclusion and exclusion criteria for each potential participant. All participants were provided with written informed consent before the interview process began. We thoroughly explained the study’s objectives, methods, potential risks and benefits, and participants’ rights. Each participant received and signed a written consent form, confirming their voluntary participation. Confidentiality was assured, and participants were informed of their right to withdraw from the study at any time without consequences. To ensure data quality, the lead researcher provided ongoing supervision and support to the research assistants throughout the data collection process. Measurement The questionnaires were used for data collection as follows: part 1: Individual characteristics, part 2: the Activities of Daily Living (ADLs), and part 3: the World Health Organization Quality of Life – BREF (WHOQOL-BREF). Part 1 , included 12 questions assessing demographic and socioeconomic factors, including age, gender, educational level, monthly income of the elderly person, employment, number of family members, living arrangement, illnesses, caregiver, and ADLs. Additionally, participation in an elderly school program was recorded. Part 2 , The Barthel Index, an ordinal scale with 10 items, was used to measure ADL performance. Each item, encompassing activities like feeding, toileting, bathing, dressing, and mobility, is scored on a 0-2 scale, reflecting the degree of assistance required. The total score, ranging from 0 to 20, indicates functional capability, with lower scores suggesting greater disability. 48 The Cronbach’s alpha was 0.83. Part 3 , we used WHOQOL-BREF (Thai version), in which there are 26 questions, ranging from 26 to 130. This questionnaire contains four domains (physical health, psychological health, social relationships, and environment). According to a 5-point Likert scale, each of these domains was scored. 49 Following the T-score, raw scores were transformed into a T-score with a range of 20 to 80, with higher scores denoting better QoL in each domain. The WHOQOL-BREF questionnaire showed a Cronbach’s alpha of 0.80. Treatment variable The Elderly School program in Thailand operates on a two-semester basis, with each semester consisting of 50 hours (3 hours per week). This collaborative initiative brings together diverse stakeholders, including the government, Local Administrative Organizations (LAOs), local communities, the private sector, and network partners. Their combined contributions ensure the provision of a wide range of activities and essential facilities for program participants. The core curriculum for this learning process adheres to the established standards set by the Ministry of Social Development and Human Security. Quality control of teachers and curriculum implementation falls under the responsibility of LAOs, ensuring adherence to national guidelines. However, recognizing the importance of contextually relevant learning, the program allows for flexibility. Additional activities can be specifically tailored to cater to the unique needs and interests of each participating community. This customization plays a crucial role in enhancing engagement and ensuring the program addresses the specific challenges and opportunities faced by local senior citizens. 29 In this study, we operationalize the elderly school program as the treatment variable. Individuals who attend more than 80% of classes throughout the program are as “attending elderly school” while those who do not attend classes regularly are “non-attending elderly school”. The elderly school curriculum consists of physical and mental health, social, economic, and environmental domains. The content can be delivered through workshops, seminars and training. LAOs is the main source for providing staff, financial, and material support, as detailed in Table 1 . Table 1. The elderly school curriculum. Subjects Content Physical and mental health Focusing on understanding and coping with the evolving health needs of elderly populations requires a multifaceted approach that addresses various dimensions of QoL. This encompasses physical, oral, and mental health, nutrition, alongside chronic disease management and responsible medication use. Recognizing the potential value of complementary and integrative practices, such as traditional Thai massage and natural therapies, can further enhance the health care provided to older adults. Social This subject tackles the crucial task of adapting social activities to better suit the functional abilities of older adults, covering the topics of laws and benefits, aging and living, knowledge exchange, religious principles, meditation, local wisdom transmission, volunteering, technology, music, singing, rhythm activities, and preserving local traditional cultures. The approach emphasizes tailoring activities to individual needs, considering physical limitations, cognitive abilities, sensory impairments, and social and emotional needs. Economics Empowering older adults with the knowledge and skills necessary to achieve financial security and improve their overall QoL, the subject covers such areas as Household Accounting; Sufficiency Economy; Craft Development and Income Generation; Vocational Reskilling and Upskilling, etc. Environmental This subject delves into the crucial topic of raising awareness and shaping positive attitudes towards the environment among older adults. It focuses specifically on environment development, encompassing the creation and maintenance of environments, housing, and infrastructure that promote and enhance their QoL. By fostering environmental awareness, promoting safe and accessible environments, and collaborating with key stakeholders, the subject empowers older adults to live healthier, more fulfilling lives while contributing to the creation of sustainable communities for all. Covariates This study employed PSM to address potential selection bias. Demographic variables were considered to calculate the predicted probability of covariates (gender, age, educational level, monthly income, employment, number of family members, living arrangement, illnesses, caregiver, and ADLs) for each individual. A balancing score of the propensity score, and distribution of measured baseline covariates between elderly people who attend elderly school and those who do not attend were compared in Table 2 and Figure 2 . Table 2. Demographic characteristics and covariate balancing by standardized difference of non-attending and attending the elderly school. Factor Non-attending elderly school n = 687 Attending elderly school n = 687 Standardized difference N % N % Raw Matched Gender Male 213 31.00 146 21.25 Female 474 69.00 541 78.75 0.22 - 0.02 Age (years) (Mean (SD)) 67.75 (5.16) 68.66 (4.78) 0.18 0.01 Educational level No Education 94 13.68 30 4.37 Primary school 413 60.12 286 41.63 - 0.38 - 0.06 Secondary school 72 10.48 136 19.80 0.26 0.01 Higher than Vocational Certificate 108 15.72 235 34.21 0.44 0.03 Monthly income (Baht) 20,000 or less 539 78.46 464 67.54 Higher than 20,001-30,000 148 21.54 223 32.46 0.25 0.04 Employment Unemployed 174 25.33 113 16.45 Employed 513 74.67 574 83.55 0.22 0.01 Number of family members Mean (SD) 3.69 (1.53) 3.75 (1.38) 0.04 - 0.01 Living arrangement Living alone 30 4.37 40 5.82 With family 465 67.69 450 65.50 - 0.05 - 0.04 With a partner 175 25.47 177 25.76 0.01 0.04 With relatives 15 2.18 12 1.75 - 0.03 - 0.04 With friend 2 0.29 8 1.16 0.10 0.01 Hypertension No 357 51.97 408 59.39 Yes 330 48.03 279 40.61 - 0.15 - 0.02 Diabetes No 516 75.11 575 83.70 Yes 171 24.89 112 16.30 - 0.21 - 0.03 Heart disease No 676 98.40 682 99.27 Yes 11 1.60 5 0.73 - 0.08 0.08 Caregiver No 140 20.38 153 22.27 Yes 547 79.62 534 77.73 - 0.46 - 0.09 The activities of daily living (ADLs) Mean (SD) 18.46 (1.98) 18.90 (1.60) 0.16 - 0.01 Figure 2. Density of propensity scores before and after match between non-attending and attending the elderly school. Statistical analysis Categorical variables were described by frequency and percentage (%). Continuous variables were described by mean and standard deviation (SD). PSM was applied to match between the elderly people who attended the elderly school and those who did not. A regression model based on characteristic variables was used to compute propensity scores for each participant. K-nearest neighbor 1:1 matching model with no replacement and no callipers was employed as the propensity score matching estimator in Python. The standardized difference was used to examine the balance of covariate distribution between groups, which was independent of the unit of measurement. It allows comparison between variables with different units of measurement to calculate the propensity scores with a maximum standardized difference of 10%. Then, the average treatment effects of the population (ATE) were analyzed to investigate the effect size of the elderly schools on QoL, and multiple linear regression was analyzed to investigate the association between elderly school attendance and QoL using Stata 17.0. The level of two-sided statistical significance was set at p < 0.05. Results There were 1,508 participants who completed the interview in this study. Following PSM, the sample size remained at 1,374 individuals, with 687 in each group (elderly school non-attending group and attending group). Comparison of the demographic characteristics of elderly people between non-attending and attending the elderly school There were 687 participants in each group, with 474 (69.00%) elderly women in the non-attending elderly school group and 541 (78.75%) in the attending group. The average age of elderly people in the non-attending group was 67.75 (SD = 5.16) and in the school-attending group was 68.66 (SD = 4.78). Most participants had completed primary school, monthly income of less than 20,000 baht, and were employed in both groups, as over half of the participants lived with their families and had caregivers to take care of them. The results indicate the standardized difference was less than 10% on all covariates, which identified improved balance between the two groups ( Table 2 ). The effect of elderly school on quality of life The average overall QoL of elderly people in the attending elderly school group was 57.50 (SD = 7.53) and that of those in the non-attending elderly school group was 44.40 (SD = 7.11). The ATE of overall QoL was 10.67 (95% CI: 9.67–11.67, p-value <0.001), indicating a positive effect of attending the elderly school on QoL. Additionally, the ATE between the two groups for QoL domains: physical health, psychological, social relationships, and environmental dimensions were 8.89, 8.17, 6.37, and 8.41, respectively. There was a statistically significant difference in each QoL domain between the two groups ( Table 3 ). Table 3. The average treatment effects (ATE) on quality of life after PSM. Outcome Mean (SD) ATE (scores) SE 95% CI of ATE p-value Non-attending elderly school n = 687 Attending elderly school n = 687 Overall QoL 44.40 (7.11) 57.50 (7.53) 10.67 0.51 9.67 – 11.67 <0.001 Physical health 45.40 (8.09) 56.22 (8.51) 8.89 0.60 7.71 – 10.08 <0.001 Psychological 45.61 (8.41) 57.32 (8.57) 8.17 0.56 7.06 – 9.27 <0.001 Social relationships 46.64 (8.80) 54.46 (9.51) 6.37 0.61 5.16 – 7.58 <0.001 The association between elderly school attendance and quality of life A multiple linear regression was conducted to assess the relationship between factors and QoL. As presented in Table 4 , QoL was significantly associated with gender, educational level, monthly income, employment, caregiver, and elderly school attendance (F (8, 1365) = 251.88, p < 0.001 R 2 = 0.5962 and adjusted R 2 = 0.5938). Notably, elderly school attendance showed a strong association with QoL. The unstandardized beta coefficient for elderly school attendance was 10.811. Higher education levels among elderly people were also associated with higher QoL. The unstandardized beta coefficients for primary, secondary, and education higher than vocational certificates are 5.472, 10.090, and 10.157, respectively. This suggests that, for each elderly person with a higher educational level, the QoL score increases by the respective unstandardized beta coefficient ( Table 4 ). Table 4. The association between elderly school attendance and quality of life. Factors (n=1,374) Full model Final model Unstandardized Standardized Unstandardized Standardized B SE of B β B SE of B β Constant 29.918 3.118 Age (years) 0.052 0.034 0.027 Elderly school attendance No Ref. Yes 10.674 0.098 0.544 * 10.811 0.360 0.550 * Gender Male Ref. Female 1.812 0.392 0.081 * 1.754 0.389 0.078 * Educational level No Education Ref. Primary school 5.478 0.644 0.279 * 5.472 0.619 0.279 * Secondary school 9.965 0.822 0.364 * 10.090 0.803 0.368 * Higher than vocational certificate 10.04 0.840 0.443 * 10.157 0.824 0.448 * Monthly income (Baht) 20,000 or less Ref. Higher than 20,001-30,000 1.380 0.580 0.062 ** 1.313 0.576 0.059 * Employment Unemployed Ref. Employed 2.284 0.438 0.095 * 2.270 0.434 0.094 * Number of family members 0.168 0.119 0.025 Living arrangement Living alone Ref. With family - 0.927 0.794 - 0.045 With a partner - 1.582 0.831 - 0.070 With relatives - 0.103 1.427 - 0.001 With friend - 0.928 2.124 - 0.008 Hypertension No Ref. Yes - 0.306 0.365 - 0.015 Diabetes No Ref. Yes - 0.499 0.454 - 0.021 Heart disease No Ref. Yes - 0.629 1.591 - 0.007 Caregiver No Ref. Yes 1.528 0.418 0.064 * 1.574 0.414 0.066 * Elderly school attendance No Ref. Yes 10.674 0.098 0.544 * 10.811 0.360 0.550 * The activities of daily living (ADLs) 0.066 3.118 0.012 * p < 0.001. ** p < 0.005. Discussion This study investigates the effect of elderly school policy on QoL across its four domains: physical health, psychological, social relations, and environment. Furthermore, the associations between the factors and QoL were identified. Notably, in our study, the QoL of elderly people in the attending elderly school group was higher than that of those in the non-attending elderly school group, and the ATE indicated a positive effect of attending the elderly school on QoL. This finding is comparable with previous research on elderly schools in the northern and eastern regions of Thailand, which similarly found higher QoL among attending elderly school groups compared to non-attending elderly school groups. 50 – 52 Physical health was shown to be the highest domain in ATE, followed by the psychological, environmental, and social relationships domains, all of which had similar values except for social relationships. This result reflects the fact that the elderly people emphasized their health deterioration with increasing age and the burden of diseases. 53 , 54 Moreover, our results resonate with broader international research highlighting the positive impact of interventions based on the concept of lifelong learning. Our finding was consistent with a study in Portugal that investigated the effect of participation in community intervention programs and indicated that QoL was better in the physical domain than others. 55 Similarly, a systematic literature review on the effects of later-life formal education on the QoL of elderly people also revealed a positive impact on QoL. 56 Additionally, a study in Canada regarding community-based participation in programs for mental health found a positive impact on psychological well-being, particularly in the context of non-formal lifelong learning 57 and the elderly individuals attending evening schools for lifelong learning in Korea experienced positive well-being impacts, including in the environmental dimension. 58 Our study further strengthens the evidence for a significant positive association between elderly school attendance and QoL after adjusting for other independent variables in a multiple linear regression model. This finding mirrors that of a study in Rayong Province, Thailand, which similarly identified the participation of senior citizens in educational management in elderly schools as a positive predictor of QoL, demonstrating the program’s potential to elevate QoL among attendees. 59 Furthermore, our results confirmed that sociodemographic factors, including gender, educational level, monthly income, and employment, were significant factors in QoL. For instance, this result was consistent with a study conducted in a rural area of the northern and northeast region of Thailand that found sociodemographic factors related to the elderly’QoL. 60 , 61 Additionally, male gender, lack of education, and lower economic status are associated with low QOL of elderly people in rural area, India. 62 In Korea, higher monthly income of elderly people had a positive effect on QoL. 63 Furthermore, the presence of a caregiver was a positively significant factor in the QoL of elderly people. This result was consistent with a study conducted by developing caregivers’ potential to improve the QoL for the elderly in the southern region of Thailand. 64 It is important to note that the specific factors associated with QoL vary across these studies. This variability can be attributed to differences in research methodology. Strengths and limitations This study displays several key strengths that contribute to its significance and pave the way for future research. Firstly, the utilization of PSM and estimation of average treatment effects (ATEs) strengthens the study’s internal validity. By creating a setting that mimics real-world conditions, PSM facilitates a comparison between elderly school attendees and non-attendees, minimizing selection bias. Furthermore, it stands as a pioneering analysis of the elderly school policy’s influence on QoL. This comprehensive approach provides a nuanced understanding of the policy’s multifaceted impact, surpassing previous research that primarily focused on program development. However, this study acknowledges several limitations. Firstly, geographical scope: conducted in a single district, the results may not directly generalize to other populations or cultural contexts. Nevertheless, Lomkao district with its significant elderly population serves as a valuable study, offering important insights applicable to similar demographics. Secondly, cross-sectional design: While providing valuable data on QoL and its association with elderly school attendance, the cross-sectional design restricts the ability to establish causal relationships. Longitudinal studies are needed to definitively examine the impact of the policy over time. Future studies may benefit from incorporating additional assessments and corroborative data sources. Policy implications and recommendations The findings of this study offer profound policy implications and recommendations towards optimizing Thailand’s approach to senior citizens through lifelong learning initiatives like the elderly school program. 1) Integration into broader health promotion strategies: recognizing the significant QoL improvements associated with elderly school attendance underscores the imperative to embed this program within broader health promotion strategies for aging populations. This integration can leverage synergies between lifelong learning and other QoL initiatives. 2) Fostering continuous education policies: our results further advocate for the development of dedicated policies specifically aimed at supporting and promoting continuous education among senior citizens. Such policies could range from targeted funding mechanisms for elderly school expansion to incentivizing the creation of age-friendly learning materials and curricula. 3) Collaborative action for strong support systems: to maximize the impact of elderly schools and similar initiatives, we propose enhanced collaboration and awareness promotion among relevant authorities and stakeholders. This could involve partnerships between government agencies, community organizations, and the private sector to foster robust support systems for aging societies, prioritizing elderly schools, health promotion programs, and QoL initiatives. 4) Rural-specific models for inclusive QoL enhancement: recognizing the unique needs and challenges of rural elderly populations, we strongly recommend the development and promotion of elderly school models specifically tailored for rural communities. These models may require adaptations to curriculum content, delivery methods, and resource allocation to ensure equitable access and maximize QoL improvements for all senior citizens regardless of location. By embracing these policy implications and recommendations, Thailand can leverage the power of lifelong learning to establish a comprehensive and inclusive framework for healthy aging within its growing senior population. More importantly, to broaden the context and enhance the study’s global relevance, it is essential to consider how the findings from Thailand’s elderly school policy could inform similar initiatives in other countries with aging populations. Many middle-income countries facing rapid demographic aging share similar socioeconomic and healthcare challenges, including limited access to educational and social support services for older adults. Developing elderly school models tailored to rural communities, as proposed in this study, could serve as a valuable framework for other nations seeking to improve the quality of life among their senior citizens. For instance, countries in Southeast Asia, Latin America, and Eastern Europe, where rural aging populations are growing, could adopt and adapt Thailand’s approach by modifying curriculum content, delivery methods, and resource allocation to reflect local cultural, economic, and infrastructural conditions. This cross-cultural application would not only promote healthy aging but also foster social inclusion and lifelong learning on a global scale. Conclusion The present study underscores the elderly school policy as a potentially impactful health promotion intervention, offering valuable insights into its effectiveness. Notably, the study reveals significantly higher overall QoL, and improvements across specific domains, among senior citizens attending elderly schools compared to their non-attending counterparts. Additionally, attendance at elderly schools emerges as a significant predictor of QoL, highlighting the program’s direct contribution to QoL. While certain sociodemographic factors also exhibit significant associations with QoL, the study’s findings provide compelling evidence that the lifelong learning policy embodied by elderly schools has demonstrably enhanced the QoL of senior citizens in Thailand. To maximize the program’s potential, policymakers should prioritize robust support efforts across various domains. Crucial areas include adequate human resources, dedicated financial resources, well-equipped facilities, and effective management structures. Furthermore, encouraging collaboration with LAOs, communities, and the private sector can play a vital role in promoting and expanding the implementation of elderly schools. By prioritizing such strategic investments and collaborative efforts, Thailand can leverage the powerful potential of lifelong learning initiatives to significantly improve the QoL of its aging population. Ethical and consent This study received ethical approval from the Institutional Review Board (IRB) of Phetchabun Hospital (approval number IEC-20-2565, date: November 9, 2022). The study adhered to the ethical principles outlined in the Declaration of Helsinki, The Belmont Report, CIOMS Guideline, and International Conference on Harmonization in Good Clinical Practice (ICH-GCP). Written informed consent was obtained from all participants before the interview process began. Participants were informed that they could withdraw from the study at any time without providing a reason. The confidentiality of participant data was ensured throughout the entire study. Data availability Underlying data Figshare: Effect of elderly school policy on quality of life among Thailand’s senior citizens, https://doi.org/10.6084/m9.figshare.25894831.v2 . 65 The project contains the following underlying data: • Data.xlsx • Ethical considerationsap • Participant information sheets and consent forms • Questionnaire Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Extended data Questionnaire, ethical considerations, participant information sheets and consent forms were provided in data availability https://doi.org/10.6084/m9.figshare.25894831.v2 . 65 Acknowledgements We would like to express our genuine appreciation to all participants in the dissertation seminars at the College of Public Health Sciences, the research assistants involved in this research, the Celebration of Chulalongkorn University 100th Anniversary Scholarship and all the participants in this study. We are also immensely grateful to Dr. Suwanchai Hounnaklang for the comments and editing on an English version of the manuscript, despite the fact that any mistakes are our own. References 1. Affairs UND of E and S: World Population Ageing 2019. United Nations; 2020. Publisher Full Text 2. World Health Organization: Ageing and health.Published October 1, 2022. Accessed July 11, 2023. Reference Source 3. 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Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Jul 2024 ADD YOUR COMMENT Comment Author details Author details 1 College of Public Health Sciences, Chulalongkorn University, Bangkok, Bangkok, 10330, Thailand Worapath Kratoo Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Nuchanad Hounnaklang Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 31 Mar 2025, 13:735 https://doi.org/10.12688/f1000research.151221.2 version 1 Published: 03 Jul 2024, 13:735 https://doi.org/10.12688/f1000research.151221.1 Copyright © 2025 Kratoo W and Hounnaklang N. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Kratoo W and Hounnaklang N. Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.12688/f1000research.151221.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 31 Mar 2025 Revised Views 0 Cite How to cite this report: Mon AS. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.179137.r374503 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v2#referee-response-374503 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Apr 2025 Aye Sandar Mon , University of Public Health, Yangon, Myanmar Approved VIEWS 0 https://doi.org/10.5256/f1000research.179137.r374503 No further comments from my side. All my ... Continue reading READ ALL No further comments from my side. All my previous comments have been addressed in the revised version. Competing Interests: No competing interests were disclosed. Reviewer Expertise: My areas of research include maternal health and other public health-related topics, epidemiological studies in communicable and non-communicable diseases, and the application of advanced statistical models in various types of research. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mon AS. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.179137.r374503 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v2#referee-response-374503 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 03 Jul 2024 Views 0 Cite How to cite this report: Summart U. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r310490 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-310490 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 13 Feb 2025 Ueamporn Summart , Faculty of Nursing, Roi Et Rajabhat University, Tha Muang, Thailand Approved VIEWS 0 https://doi.org/10.5256/f1000research.165851.r310490 Title: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach. After conducting a thorough analysis of all your articles, this manuscript seeks to assess the impact of geriatric ... Continue reading READ ALL Title: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach. After conducting a thorough analysis of all your articles, this manuscript seeks to assess the impact of geriatric education on the quality of life of older individuals. The findings of this article are essential for informing government policies aimed at enhancing the quality of life for this specific demographic. The author employs statistical tools to mitigate biases and apply the results to favorable health outcomes. However, there are certain aspects that leaders should comprehend and acknowledge: 1. Calculation of the required sample size: Please provide further elaboration on the concept of "effect size = 0.02," including information on how to compute it and the specific value obtained from the pilot study. 2. Study samples: This study employed quota and systematic simple random sampling techniques, which can be considered a two-step sampling process or referred to as multi-stage random sampling. In this section, I suggest that the author include a CONSORT diagram detailing the process of participant enrollment in the trial, which would enhance the reader's comprehension. 3. Results: This study employed the beta coefficient to represent the extent of the study's influence. Given that this study used multiple linear regression to assess the impact of covariates on quality of life (QOL), it is necessary to report the mean difference. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Nursing and Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Summart U. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r310490 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-310490 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 31 Mar 2025 Worapath Kratoo , College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 31 Mar 2025 Author Response We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation ... Continue reading We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation of the Required Sample Size: Effect Size Response: An effect size of 0.02 in the sample size calculation, derived from a pilot study comparing QoL between the means of the two groups (attending and not attending elderly school) divided by the standard deviation. Comment 2: Study Samples: Sampling Process and CONSORT Diagram Response: We have already added CONSORT diagram Comment 3: Results: Beta Coefficients and Mean Differences Response: In our analysis, we have chosen to present Average Treatment Effects (ATE) as our primary measure of impact, as these values provide a more robust estimate of causal effect by accounting for potential confounding variables. The ATEs reported in our results section represent the estimated average effect of each variable on quality of life after controlling for other covariates in the model. We believe this approach is more appropriate for our study design than unadjusted mean differences because it addresses potential selection bias and confounding factors that could influence the outcomes. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation of the Required Sample Size: Effect Size Response: An effect size of 0.02 in the sample size calculation, derived from a pilot study comparing QoL between the means of the two groups (attending and not attending elderly school) divided by the standard deviation. Comment 2: Study Samples: Sampling Process and CONSORT Diagram Response: We have already added CONSORT diagram Comment 3: Results: Beta Coefficients and Mean Differences Response: In our analysis, we have chosen to present Average Treatment Effects (ATE) as our primary measure of impact, as these values provide a more robust estimate of causal effect by accounting for potential confounding variables. The ATEs reported in our results section represent the estimated average effect of each variable on quality of life after controlling for other covariates in the model. We believe this approach is more appropriate for our study design than unadjusted mean differences because it addresses potential selection bias and confounding factors that could influence the outcomes. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 31 Mar 2025 Worapath Kratoo , College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 31 Mar 2025 Author Response We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation ... Continue reading We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation of the Required Sample Size: Effect Size Response: An effect size of 0.02 in the sample size calculation, derived from a pilot study comparing QoL between the means of the two groups (attending and not attending elderly school) divided by the standard deviation. Comment 2: Study Samples: Sampling Process and CONSORT Diagram Response: We have already added CONSORT diagram Comment 3: Results: Beta Coefficients and Mean Differences Response: In our analysis, we have chosen to present Average Treatment Effects (ATE) as our primary measure of impact, as these values provide a more robust estimate of causal effect by accounting for potential confounding variables. The ATEs reported in our results section represent the estimated average effect of each variable on quality of life after controlling for other covariates in the model. We believe this approach is more appropriate for our study design than unadjusted mean differences because it addresses potential selection bias and confounding factors that could influence the outcomes. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation of the Required Sample Size: Effect Size Response: An effect size of 0.02 in the sample size calculation, derived from a pilot study comparing QoL between the means of the two groups (attending and not attending elderly school) divided by the standard deviation. Comment 2: Study Samples: Sampling Process and CONSORT Diagram Response: We have already added CONSORT diagram Comment 3: Results: Beta Coefficients and Mean Differences Response: In our analysis, we have chosen to present Average Treatment Effects (ATE) as our primary measure of impact, as these values provide a more robust estimate of causal effect by accounting for potential confounding variables. The ATEs reported in our results section represent the estimated average effect of each variable on quality of life after controlling for other covariates in the model. We believe this approach is more appropriate for our study design than unadjusted mean differences because it addresses potential selection bias and confounding factors that could influence the outcomes. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Conduah AK. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r302071 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-302071 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 20 Sep 2024 Andrew Kweku Conduah , University of Professional Studies, Madina, Ghana Approved VIEWS 0 https://doi.org/10.5256/f1000research.165851.r302071 Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach. Summary of the Manuscript: This manuscript evaluates the impact of Thailand’s 'elderly school' initiative on the quality of ... Continue reading READ ALL Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach. Summary of the Manuscript: This manuscript evaluates the impact of Thailand’s 'elderly school' initiative on the quality of life (QoL) among senior citizens using a propensity score matching (PSM) approach. The study, conducted in Phetchabun province, found that attending the elderly school significantly improved QoL compared to non-attendees, offering a beacon of hope for the elderly population. The research also identified several factors positively associated with QoL, including gender, income, employment, caregiving, and education. Evaluation of the Introduction Global Context: The introduction effectively situates the research within the global context by highlighting the significant increase in the elderly population worldwide. It references the international trend of an ageing population, emphasizing the impact on healthcare systems. Statistics about the projected growth of the elderly population from 2015 to 2050 and the concentration in middle-income countries provide a strong foundation for understanding the global scale of the issue. The comparison with other regions, such as South India and Myanmar, also enhances the global perspective. Research Problem Articulation and Justification: The research problem is well-articulated and justified. The introduction clearly identifies the urgent need for effective interventions to improve senior citizens' quality of life (QoL) in the face of the ageing population in Thailand. The discussion on the disparities in QoL between urban and rural areas, as well as the specific context of Lomkao district, further justifies the need for the study. The problem is contextualized by noting the lack of comprehensive evaluations of the elderly school initiative’s impact, which underscores the significance of the research. Objectives: The introduction does not explicitly state the research objectives. While the problem is well-defined and justified, and the gap in the literature is highlighted, the study's specific aims should be more clearly articulated. For instance, the introduction could explicitly state that the study aims to evaluate the causal effect of the elderly school initiative on QoL using propensity score matching (PSM) and to investigate the association between various factors and QoL among senior citizens. Opinion: The introduction provides a robust and comprehensive background for the study. It effectively places the research in a global context, identifies the problem, and justifies the need for the study. However, the specific research objectives should be clearly stated to strengthen the introduction. This will provide readers with a clear understanding of the study’s aims and how it intends to address the identified gap in the literature. Additionally, expanding the discussion on similar interventions in other regions could further enhance the global context and relevance of the research. Overall, the introduction sets a solid foundation for the study but would benefit from a more explicit articulation of the research objectives. Methodology 1. Research Design Cross-Sectional Study: Appropriateness: The cross-sectional design is suitable for simultaneously assessing the prevalence of characteristics or conditions. This study is used to compare the quality of life (QoL) of elderly individuals who attended and did not attend an elderly school. This design effectively examines differences in QoL and determines associations with the elderly school program. 2. Sample Size Sample Size Calculation: Appropriateness: The sample size calculation is based on continuous data and considers effect size, power, predictors, and significance level. The study's sample size of 901 participants is derived from these calculations, ensuring sufficient statistical power for detecting meaningful differences. 3. Sampling Technique Quota and Systematic Sampling: Appropriateness: Combining quota sampling with systematic sampling ensures a representative sample of elderly individuals attending and not attending the elderly school. Quota sampling ensures demographic representation, while systematic sampling introduces randomness into the selection process. 4. Data Collection Face-to-Face Interviews: Appropriateness: Face-to-face interviews effectively collect detailed and accurate data concerning literacy or language barriers. The research team’s training ensures consistency and reliability in data collection. 5. Measurement Instruments Used: Demographic and Socioeconomic Factors: Detailed questionnaires assess various factors relevant to QoL. Activities of Daily Living (ADLs): The Barthel Index is an established tool for measuring ADL performance, suitable for evaluating functional capacity. WHOQOL-BREF: This validated instrument assesses QoL across multiple domains. Using the Thai version ensures cultural and linguistic relevance. 6. Treatment Variable Elderly School Program: Appropriateness: The definition and criteria for attendance in the elderly school program are clear and relevant to the study's objectives. Participants are categorised based on their attendance, which aligns with the study’s aim to evaluate the program’s impact. 7. Covariates and Propensity Score Matching (PSM) PSM for Addressing Selection Bias: Appropriateness: PSM is a robust method for controlling confounding variables and ensuring balanced groups. Demographic and socioeconomic factors are used as covariates, enhancing comparability between attendees and non-attendees of the elderly school. 8. Statistical Analysis Analysis Methods: Appropriateness: The use of PSM, standardised differences, and multiple linear regression is appropriate for analysing the effect of the elderly school program on QoL. These methods effectively control for confounding and assess the treatment's impact. Results Demographic Characteristics of the Participants A total of 1,508 participants completed the interview. After Propensity Score Matching (PSM), 1,374 individuals remained, with 687 participants in the non-attending and attending elderly school groups. In the non-attending group, 474 (69.00%) were women, and 541 (78.75%) were women in the attending group. The average age in the non-attending group was 67.75 years (SD = 5.16), while in the attending group, it was 68.66 years (SD = 4.78). Most participants in both groups had completed primary school, had a monthly income of less than 20,000 baht, and were employed. More than half of the participants lived with their families and had caregivers. The standardised difference was less than 10% for all covariates, indicating improved balance between the two groups (Table 2). Quality of Life Outcomes The average overall Quality of Life (QoL) score was 57.50 (SD = 7.53) in the attending group and 44.40 (SD = 7.11) in the non-attending group. The Average Treatment Effect (ATE) of attending elderly school on overall QoL was 10.67 (95% CI: 9.67–11.67, p < 0.001). The ATEs for QoL domains were as follows: physical health (8.89), psychological (8.17), social relationships (6.37), and environmental (8.41). Each domain showed a statistically significant difference between the two groups (Table 3). Associations Between Elderly School Attendance and QoL Multiple linear regression analysis revealed that QoL was significantly associated with gender, educational level, monthly income, employment, caregiver presence, and elderly school attendance (F (8, 1365) = 251.88, p < 0.001, R² = 0.5962). Elderly school attendance had a strong positive association with QoL, with an unstandardised beta coefficient of 10.811. Higher education levels were also associated with higher QoL scores (Table 4). Discussion This study examined the impact of attending an elderly school on QoL across four domains: physical health, psychological well-being, social relationships, and environment. The findings revealed that elderly school attendance significantly improved QoL compared to non-attendance. The positive effect of elderly school attendance was consistent with previous research in different regions of Thailand, which also found higher QoL among school attendees. The highest impact was observed in the physical health domain, followed by the psychological, environmental, and social relationships domains. The study's results align with international research, highlighting the benefits of lifelong learning for elderly populations. Studies from Portugal, Canada, and Korea have observed similar positive impacts on QoL, underscoring the global relevance of these findings. Strengths and Limitations The study's strengths include using PSM to enhance internal validity and provide a realistic comparison between groups. It is one of the first to analyze the elderly school policy's impact on QoL comprehensively. However, limitations include the study's geographical scope, as it was conducted in a single district, limiting generalizability. The cross-sectional design also restricts the ability to establish causality, and future longitudinal studies are needed to confirm these findings. Policy Implications and Recommendations The findings suggest important policy implications for optimizing Thailand's approach to ageing populations. The study recommends integrating elderly schools into broader health promotion strategies, developing continuous education policies for seniors, fostering stakeholder collaboration, and creating rural-specific models to enhance QoL for elderly populations in similar contexts. The conclusion is well-structured and effectively summarizes the essential findings and implications of the study. Here’s a brief evaluation: Clear Summary of Findings : The conclusion restates the primary outcomes, particularly the positive impact of elderly school attendance on Quality of Life (QoL). It effectively highlights the significance of these schools in enhancing overall QoL among senior citizens in Thailand. Implications for Policy : The discussion on policy implications is well-founded. By recommending robust support across various domains (human resources, finances, facilities, and management), the conclusion addresses practical steps that policymakers can take to enhance the program's effectiveness. Encouragement of Collaboration : A strategic recommendation is to emphasise collaboration with local administrative organisations (LAOs), communities, and the private sector. This suggests a comprehensive approach to expanding the program and ensures the reader understands the context needed for success. Forward-looking Perspective : The conclusion reflects on the current findings and looks ahead, suggesting how Thailand can further leverage these initiatives to improve the QoL of its ageing population. This gives the study a forward-looking angle, which is valuable in research conclusions. Minor Suggestions for Enhancement : Reinforce Study Limitations : Depending on what was discussed earlier in the paper, briefly mentioning any limitations or areas for future research here might be helpful. This adds balance and shows a critical engagement with the study’s scope. Broaden the Context : While the focus on Thailand is appropriate, you could briefly mention how these findings might inform similar initiatives in other countries, especially those with ageing populations, to widen the study's impact. Overall, the conclusion is appropriate, but adding a sentence or two to address limitations or broader implications could make it even stronger. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: § Population Estimates and Projections.§ Population Health and Mortality- Health Emergencies & Preparedness, Ageing & Intergeneration Relations, and Non-Communicable Disease & Health Projection (Physical Activity, Obesity, Tobacco Control, etc.)§ Business Demography§ Business Policy and Strategy§ Business Management§ Public Administration, Entrepreneurial Innovation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Conduah AK. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r302071 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-302071 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 31 Mar 2025 Worapath Kratoo , College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 31 Mar 2025 Author Response We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce ... Continue reading We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce Study Limitations Response: Thank you for your thoughtful suggestion to reinforce the study limitations. We would like to note that the manuscript already includes a detailed discussion of the study limitations in the 'Strengths and limitations' section. Specifically, we have addressed geographical limitations (the single-district scope and generalizability concerns), methodological limitations (cross-sectional design and its constraints on establishing causality), and have suggested directions for future research including longitudinal studies and additional assessment approaches. Suggestion 2: Broaden the Contex t Response: Thank you for your suggestion to broaden the context. We agree this would strengthen the paper's impact. While our policy implications section currently focuses on the Thai context, we will add a paragraph explicitly discussing how our findings could inform similar initiatives in other countries with aging populations. This addition will highlight the potential transferability of our findings regarding elderly education models to various cultural and socioeconomic contexts globally, particularly in other middle-income countries experiencing rapid demographic aging. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce Study Limitations Response: Thank you for your thoughtful suggestion to reinforce the study limitations. We would like to note that the manuscript already includes a detailed discussion of the study limitations in the 'Strengths and limitations' section. Specifically, we have addressed geographical limitations (the single-district scope and generalizability concerns), methodological limitations (cross-sectional design and its constraints on establishing causality), and have suggested directions for future research including longitudinal studies and additional assessment approaches. Suggestion 2: Broaden the Contex t Response: Thank you for your suggestion to broaden the context. We agree this would strengthen the paper's impact. While our policy implications section currently focuses on the Thai context, we will add a paragraph explicitly discussing how our findings could inform similar initiatives in other countries with aging populations. This addition will highlight the potential transferability of our findings regarding elderly education models to various cultural and socioeconomic contexts globally, particularly in other middle-income countries experiencing rapid demographic aging. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 31 Mar 2025 Worapath Kratoo , College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 31 Mar 2025 Author Response We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce ... Continue reading We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce Study Limitations Response: Thank you for your thoughtful suggestion to reinforce the study limitations. We would like to note that the manuscript already includes a detailed discussion of the study limitations in the 'Strengths and limitations' section. Specifically, we have addressed geographical limitations (the single-district scope and generalizability concerns), methodological limitations (cross-sectional design and its constraints on establishing causality), and have suggested directions for future research including longitudinal studies and additional assessment approaches. Suggestion 2: Broaden the Contex t Response: Thank you for your suggestion to broaden the context. We agree this would strengthen the paper's impact. While our policy implications section currently focuses on the Thai context, we will add a paragraph explicitly discussing how our findings could inform similar initiatives in other countries with aging populations. This addition will highlight the potential transferability of our findings regarding elderly education models to various cultural and socioeconomic contexts globally, particularly in other middle-income countries experiencing rapid demographic aging. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce Study Limitations Response: Thank you for your thoughtful suggestion to reinforce the study limitations. We would like to note that the manuscript already includes a detailed discussion of the study limitations in the 'Strengths and limitations' section. Specifically, we have addressed geographical limitations (the single-district scope and generalizability concerns), methodological limitations (cross-sectional design and its constraints on establishing causality), and have suggested directions for future research including longitudinal studies and additional assessment approaches. Suggestion 2: Broaden the Contex t Response: Thank you for your suggestion to broaden the context. We agree this would strengthen the paper's impact. While our policy implications section currently focuses on the Thai context, we will add a paragraph explicitly discussing how our findings could inform similar initiatives in other countries with aging populations. This addition will highlight the potential transferability of our findings regarding elderly education models to various cultural and socioeconomic contexts globally, particularly in other middle-income countries experiencing rapid demographic aging. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Mon AS. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r310486 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-310486 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Aug 2024 Aye Sandar Mon , University of Public Health, Yangon, Myanmar Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.165851.r310486 General comment The manuscript is well written and the study findings could contribute to the substantial policy implication. Specific comments In sampling technique, the researchers applied quota ... Continue reading READ ALL General comment The manuscript is well written and the study findings could contribute to the substantial policy implication. Specific comments In sampling technique, the researchers applied quota and systematic sampling. For systematic sampling, how to calculate the sampling interval was described but I did not find about the random start. Could you please clarify it? In data collection method, was any pre-testing conducted? If so, please mention the procedure and the results including the reliability of the questionnaire and participants’ understanding of the question items. According to previous literature and evidence from international studies, in addition to the factors you considered as covariates in the statistical model, the social support and mental health status such as depression have been recognized as the important predictors for QoL. Although your questionnaire included the items assessing the social support and mental health status (DASS-21), why weren’t these variables considered as covariates in the statistical model? While presenting the results of multiple linear regression in “Table 4”, as the variable “elderly school attendance” is the main factor of interest, this variable should be described first instead of being the second-to-last description. I did not find the statistical procedures for assumption checks for multiple linear regression (regression diagnostics) in the 'Methods' or 'Results' sections. Were these tests performed? If not, please check the necessary assumptions, and if they were, please mention the results in the manuscript. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: My areas of research include maternal health and other public health-related topics, epidemiological studies in communicable and non-communicable diseases, and the application of advanced statistical models in various types of research. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mon AS. Reviewer Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r310486 ) The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-310486 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 31 Mar 2025 Worapath Kratoo , College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 31 Mar 2025 Author Response We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling ... Continue reading We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling Technique (Systematic Sampling - Random Start) Response: Thank you for pointing out the omission regarding the random start in our systematic sampling procedure. To clarify, we have now added this important information to the sampling technique section. Specifically, we used a random number generator to select a starting point between 1 and 13, and from this random start, we then selected every 13th elderly person in the population who met our eligibility criteria. This random start was essential to ensure the systematic sample maintained randomness properties. Comment 2: Data Collection Method (Pre-testing and Reliability) Response: We conducted a pilot study for pre-testing, and the reliability of the questionnaire was evaluated using Cronbach's alpha. All items demonstrated reliability coefficients between 0.80-0.83, indicating good internal consistency. These reliability measures have been incorporated into the methodology section. Comment 3: Covariates (Social Support and Mental Health) Response: The propensity score matching (PSM) analysis, we focused on demographic characteristic variables that enable the matching of similar characteristics, thus maintaining’s model simplicity, focusing on direct effects rather than confounding relationships that could complicate analysis. Comment 4: Presentation of Multiple Linear Regression Results (Elderly School Attendance) Response: We agree that the variable 'elderly school attendance, being the main factor of interest, should be highlighted. In the revised manuscript, we have reordered the results in Table 4. Comment 5: Regression Diagnostics (Assumption Checks) Response: There is no multicollinearity, as indicated by the VIF scores, which are all less than 10 in Table 4. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling Technique (Systematic Sampling - Random Start) Response: Thank you for pointing out the omission regarding the random start in our systematic sampling procedure. To clarify, we have now added this important information to the sampling technique section. Specifically, we used a random number generator to select a starting point between 1 and 13, and from this random start, we then selected every 13th elderly person in the population who met our eligibility criteria. This random start was essential to ensure the systematic sample maintained randomness properties. Comment 2: Data Collection Method (Pre-testing and Reliability) Response: We conducted a pilot study for pre-testing, and the reliability of the questionnaire was evaluated using Cronbach's alpha. All items demonstrated reliability coefficients between 0.80-0.83, indicating good internal consistency. These reliability measures have been incorporated into the methodology section. Comment 3: Covariates (Social Support and Mental Health) Response: The propensity score matching (PSM) analysis, we focused on demographic characteristic variables that enable the matching of similar characteristics, thus maintaining’s model simplicity, focusing on direct effects rather than confounding relationships that could complicate analysis. Comment 4: Presentation of Multiple Linear Regression Results (Elderly School Attendance) Response: We agree that the variable 'elderly school attendance, being the main factor of interest, should be highlighted. In the revised manuscript, we have reordered the results in Table 4. Comment 5: Regression Diagnostics (Assumption Checks) Response: There is no multicollinearity, as indicated by the VIF scores, which are all less than 10 in Table 4. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 31 Mar 2025 Worapath Kratoo , College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 31 Mar 2025 Author Response We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling ... Continue reading We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling Technique (Systematic Sampling - Random Start) Response: Thank you for pointing out the omission regarding the random start in our systematic sampling procedure. To clarify, we have now added this important information to the sampling technique section. Specifically, we used a random number generator to select a starting point between 1 and 13, and from this random start, we then selected every 13th elderly person in the population who met our eligibility criteria. This random start was essential to ensure the systematic sample maintained randomness properties. Comment 2: Data Collection Method (Pre-testing and Reliability) Response: We conducted a pilot study for pre-testing, and the reliability of the questionnaire was evaluated using Cronbach's alpha. All items demonstrated reliability coefficients between 0.80-0.83, indicating good internal consistency. These reliability measures have been incorporated into the methodology section. Comment 3: Covariates (Social Support and Mental Health) Response: The propensity score matching (PSM) analysis, we focused on demographic characteristic variables that enable the matching of similar characteristics, thus maintaining’s model simplicity, focusing on direct effects rather than confounding relationships that could complicate analysis. Comment 4: Presentation of Multiple Linear Regression Results (Elderly School Attendance) Response: We agree that the variable 'elderly school attendance, being the main factor of interest, should be highlighted. In the revised manuscript, we have reordered the results in Table 4. Comment 5: Regression Diagnostics (Assumption Checks) Response: There is no multicollinearity, as indicated by the VIF scores, which are all less than 10 in Table 4. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling Technique (Systematic Sampling - Random Start) Response: Thank you for pointing out the omission regarding the random start in our systematic sampling procedure. To clarify, we have now added this important information to the sampling technique section. Specifically, we used a random number generator to select a starting point between 1 and 13, and from this random start, we then selected every 13th elderly person in the population who met our eligibility criteria. This random start was essential to ensure the systematic sample maintained randomness properties. Comment 2: Data Collection Method (Pre-testing and Reliability) Response: We conducted a pilot study for pre-testing, and the reliability of the questionnaire was evaluated using Cronbach's alpha. All items demonstrated reliability coefficients between 0.80-0.83, indicating good internal consistency. These reliability measures have been incorporated into the methodology section. Comment 3: Covariates (Social Support and Mental Health) Response: The propensity score matching (PSM) analysis, we focused on demographic characteristic variables that enable the matching of similar characteristics, thus maintaining’s model simplicity, focusing on direct effects rather than confounding relationships that could complicate analysis. Comment 4: Presentation of Multiple Linear Regression Results (Elderly School Attendance) Response: We agree that the variable 'elderly school attendance, being the main factor of interest, should be highlighted. In the revised manuscript, we have reordered the results in Table 4. Comment 5: Regression Diagnostics (Assumption Checks) Response: There is no multicollinearity, as indicated by the VIF scores, which are all less than 10 in Table 4. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Jul 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 31 Mar 25 read Version 1 03 Jul 24 read read read Aye Sandar Mon , University of Public Health, Yangon, Myanmar Andrew Kweku Conduah , University of Professional Studies, Madina, Ghana Ueamporn Summart , Roi Et Rajabhat University, Tha Muang, Thailand Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Mon A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Apr 2025 | for Version 2 Aye Sandar Mon , University of Public Health, Yangon, Myanmar 0 Views copyright © 2025 Mon A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions No further comments from my side. All my previous comments have been addressed in the revised version. Competing Interests No competing interests were disclosed. Reviewer Expertise My areas of research include maternal health and other public health-related topics, epidemiological studies in communicable and non-communicable diseases, and the application of advanced statistical models in various types of research. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Mon AS. Peer Review Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.179137.r374503) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-735/v2#referee-response-374503 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Summart U. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13 Feb 2025 | for Version 1 Ueamporn Summart , Faculty of Nursing, Roi Et Rajabhat University, Tha Muang, Thailand 0 Views copyright © 2025 Summart U. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Title: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach. After conducting a thorough analysis of all your articles, this manuscript seeks to assess the impact of geriatric education on the quality of life of older individuals. The findings of this article are essential for informing government policies aimed at enhancing the quality of life for this specific demographic. The author employs statistical tools to mitigate biases and apply the results to favorable health outcomes. However, there are certain aspects that leaders should comprehend and acknowledge: 1. Calculation of the required sample size: Please provide further elaboration on the concept of "effect size = 0.02," including information on how to compute it and the specific value obtained from the pilot study. 2. Study samples: This study employed quota and systematic simple random sampling techniques, which can be considered a two-step sampling process or referred to as multi-stage random sampling. In this section, I suggest that the author include a CONSORT diagram detailing the process of participant enrollment in the trial, which would enhance the reader's comprehension. 3. Results: This study employed the beta coefficient to represent the extent of the study's influence. Given that this study used multiple linear regression to assess the impact of covariates on quality of life (QOL), it is necessary to report the mean difference. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Nursing and Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 31 Mar 2025 Worapath Kratoo, College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Calculation of the Required Sample Size: Effect Size Response: An effect size of 0.02 in the sample size calculation, derived from a pilot study comparing QoL between the means of the two groups (attending and not attending elderly school) divided by the standard deviation. Comment 2: Study Samples: Sampling Process and CONSORT Diagram Response: We have already added CONSORT diagram Comment 3: Results: Beta Coefficients and Mean Differences Response: In our analysis, we have chosen to present Average Treatment Effects (ATE) as our primary measure of impact, as these values provide a more robust estimate of causal effect by accounting for potential confounding variables. The ATEs reported in our results section represent the estimated average effect of each variable on quality of life after controlling for other covariates in the model. We believe this approach is more appropriate for our study design than unadjusted mean differences because it addresses potential selection bias and confounding factors that could influence the outcomes. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Summart U. Peer Review Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r310490) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-310490 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Conduah A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 20 Sep 2024 | for Version 1 Andrew Kweku Conduah , University of Professional Studies, Madina, Ghana 0 Views copyright © 2024 Conduah A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach. Summary of the Manuscript: This manuscript evaluates the impact of Thailand’s 'elderly school' initiative on the quality of life (QoL) among senior citizens using a propensity score matching (PSM) approach. The study, conducted in Phetchabun province, found that attending the elderly school significantly improved QoL compared to non-attendees, offering a beacon of hope for the elderly population. The research also identified several factors positively associated with QoL, including gender, income, employment, caregiving, and education. Evaluation of the Introduction Global Context: The introduction effectively situates the research within the global context by highlighting the significant increase in the elderly population worldwide. It references the international trend of an ageing population, emphasizing the impact on healthcare systems. Statistics about the projected growth of the elderly population from 2015 to 2050 and the concentration in middle-income countries provide a strong foundation for understanding the global scale of the issue. The comparison with other regions, such as South India and Myanmar, also enhances the global perspective. Research Problem Articulation and Justification: The research problem is well-articulated and justified. The introduction clearly identifies the urgent need for effective interventions to improve senior citizens' quality of life (QoL) in the face of the ageing population in Thailand. The discussion on the disparities in QoL between urban and rural areas, as well as the specific context of Lomkao district, further justifies the need for the study. The problem is contextualized by noting the lack of comprehensive evaluations of the elderly school initiative’s impact, which underscores the significance of the research. Objectives: The introduction does not explicitly state the research objectives. While the problem is well-defined and justified, and the gap in the literature is highlighted, the study's specific aims should be more clearly articulated. For instance, the introduction could explicitly state that the study aims to evaluate the causal effect of the elderly school initiative on QoL using propensity score matching (PSM) and to investigate the association between various factors and QoL among senior citizens. Opinion: The introduction provides a robust and comprehensive background for the study. It effectively places the research in a global context, identifies the problem, and justifies the need for the study. However, the specific research objectives should be clearly stated to strengthen the introduction. This will provide readers with a clear understanding of the study’s aims and how it intends to address the identified gap in the literature. Additionally, expanding the discussion on similar interventions in other regions could further enhance the global context and relevance of the research. Overall, the introduction sets a solid foundation for the study but would benefit from a more explicit articulation of the research objectives. Methodology 1. Research Design Cross-Sectional Study: Appropriateness: The cross-sectional design is suitable for simultaneously assessing the prevalence of characteristics or conditions. This study is used to compare the quality of life (QoL) of elderly individuals who attended and did not attend an elderly school. This design effectively examines differences in QoL and determines associations with the elderly school program. 2. Sample Size Sample Size Calculation: Appropriateness: The sample size calculation is based on continuous data and considers effect size, power, predictors, and significance level. The study's sample size of 901 participants is derived from these calculations, ensuring sufficient statistical power for detecting meaningful differences. 3. Sampling Technique Quota and Systematic Sampling: Appropriateness: Combining quota sampling with systematic sampling ensures a representative sample of elderly individuals attending and not attending the elderly school. Quota sampling ensures demographic representation, while systematic sampling introduces randomness into the selection process. 4. Data Collection Face-to-Face Interviews: Appropriateness: Face-to-face interviews effectively collect detailed and accurate data concerning literacy or language barriers. The research team’s training ensures consistency and reliability in data collection. 5. Measurement Instruments Used: Demographic and Socioeconomic Factors: Detailed questionnaires assess various factors relevant to QoL. Activities of Daily Living (ADLs): The Barthel Index is an established tool for measuring ADL performance, suitable for evaluating functional capacity. WHOQOL-BREF: This validated instrument assesses QoL across multiple domains. Using the Thai version ensures cultural and linguistic relevance. 6. Treatment Variable Elderly School Program: Appropriateness: The definition and criteria for attendance in the elderly school program are clear and relevant to the study's objectives. Participants are categorised based on their attendance, which aligns with the study’s aim to evaluate the program’s impact. 7. Covariates and Propensity Score Matching (PSM) PSM for Addressing Selection Bias: Appropriateness: PSM is a robust method for controlling confounding variables and ensuring balanced groups. Demographic and socioeconomic factors are used as covariates, enhancing comparability between attendees and non-attendees of the elderly school. 8. Statistical Analysis Analysis Methods: Appropriateness: The use of PSM, standardised differences, and multiple linear regression is appropriate for analysing the effect of the elderly school program on QoL. These methods effectively control for confounding and assess the treatment's impact. Results Demographic Characteristics of the Participants A total of 1,508 participants completed the interview. After Propensity Score Matching (PSM), 1,374 individuals remained, with 687 participants in the non-attending and attending elderly school groups. In the non-attending group, 474 (69.00%) were women, and 541 (78.75%) were women in the attending group. The average age in the non-attending group was 67.75 years (SD = 5.16), while in the attending group, it was 68.66 years (SD = 4.78). Most participants in both groups had completed primary school, had a monthly income of less than 20,000 baht, and were employed. More than half of the participants lived with their families and had caregivers. The standardised difference was less than 10% for all covariates, indicating improved balance between the two groups (Table 2). Quality of Life Outcomes The average overall Quality of Life (QoL) score was 57.50 (SD = 7.53) in the attending group and 44.40 (SD = 7.11) in the non-attending group. The Average Treatment Effect (ATE) of attending elderly school on overall QoL was 10.67 (95% CI: 9.67–11.67, p < 0.001). The ATEs for QoL domains were as follows: physical health (8.89), psychological (8.17), social relationships (6.37), and environmental (8.41). Each domain showed a statistically significant difference between the two groups (Table 3). Associations Between Elderly School Attendance and QoL Multiple linear regression analysis revealed that QoL was significantly associated with gender, educational level, monthly income, employment, caregiver presence, and elderly school attendance (F (8, 1365) = 251.88, p < 0.001, R² = 0.5962). Elderly school attendance had a strong positive association with QoL, with an unstandardised beta coefficient of 10.811. Higher education levels were also associated with higher QoL scores (Table 4). Discussion This study examined the impact of attending an elderly school on QoL across four domains: physical health, psychological well-being, social relationships, and environment. The findings revealed that elderly school attendance significantly improved QoL compared to non-attendance. The positive effect of elderly school attendance was consistent with previous research in different regions of Thailand, which also found higher QoL among school attendees. The highest impact was observed in the physical health domain, followed by the psychological, environmental, and social relationships domains. The study's results align with international research, highlighting the benefits of lifelong learning for elderly populations. Studies from Portugal, Canada, and Korea have observed similar positive impacts on QoL, underscoring the global relevance of these findings. Strengths and Limitations The study's strengths include using PSM to enhance internal validity and provide a realistic comparison between groups. It is one of the first to analyze the elderly school policy's impact on QoL comprehensively. However, limitations include the study's geographical scope, as it was conducted in a single district, limiting generalizability. The cross-sectional design also restricts the ability to establish causality, and future longitudinal studies are needed to confirm these findings. Policy Implications and Recommendations The findings suggest important policy implications for optimizing Thailand's approach to ageing populations. The study recommends integrating elderly schools into broader health promotion strategies, developing continuous education policies for seniors, fostering stakeholder collaboration, and creating rural-specific models to enhance QoL for elderly populations in similar contexts. The conclusion is well-structured and effectively summarizes the essential findings and implications of the study. Here’s a brief evaluation: Clear Summary of Findings : The conclusion restates the primary outcomes, particularly the positive impact of elderly school attendance on Quality of Life (QoL). It effectively highlights the significance of these schools in enhancing overall QoL among senior citizens in Thailand. Implications for Policy : The discussion on policy implications is well-founded. By recommending robust support across various domains (human resources, finances, facilities, and management), the conclusion addresses practical steps that policymakers can take to enhance the program's effectiveness. Encouragement of Collaboration : A strategic recommendation is to emphasise collaboration with local administrative organisations (LAOs), communities, and the private sector. This suggests a comprehensive approach to expanding the program and ensures the reader understands the context needed for success. Forward-looking Perspective : The conclusion reflects on the current findings and looks ahead, suggesting how Thailand can further leverage these initiatives to improve the QoL of its ageing population. This gives the study a forward-looking angle, which is valuable in research conclusions. Minor Suggestions for Enhancement : Reinforce Study Limitations : Depending on what was discussed earlier in the paper, briefly mentioning any limitations or areas for future research here might be helpful. This adds balance and shows a critical engagement with the study’s scope. Broaden the Context : While the focus on Thailand is appropriate, you could briefly mention how these findings might inform similar initiatives in other countries, especially those with ageing populations, to widen the study's impact. Overall, the conclusion is appropriate, but adding a sentence or two to address limitations or broader implications could make it even stronger. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise § Population Estimates and Projections.§ Population Health and Mortality- Health Emergencies & Preparedness, Ageing & Intergeneration Relations, and Non-Communicable Disease & Health Projection (Physical Activity, Obesity, Tobacco Control, etc.)§ Business Demography§ Business Policy and Strategy§ Business Management§ Public Administration, Entrepreneurial Innovation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 31 Mar 2025 Worapath Kratoo, College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Suggestion 1: Reinforce Study Limitations Response: Thank you for your thoughtful suggestion to reinforce the study limitations. We would like to note that the manuscript already includes a detailed discussion of the study limitations in the 'Strengths and limitations' section. Specifically, we have addressed geographical limitations (the single-district scope and generalizability concerns), methodological limitations (cross-sectional design and its constraints on establishing causality), and have suggested directions for future research including longitudinal studies and additional assessment approaches. Suggestion 2: Broaden the Contex t Response: Thank you for your suggestion to broaden the context. We agree this would strengthen the paper's impact. While our policy implications section currently focuses on the Thai context, we will add a paragraph explicitly discussing how our findings could inform similar initiatives in other countries with aging populations. This addition will highlight the potential transferability of our findings regarding elderly education models to various cultural and socioeconomic contexts globally, particularly in other middle-income countries experiencing rapid demographic aging. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Conduah AK. Peer Review Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r302071) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-735/v1#referee-response-302071 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Mon A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Aug 2024 | for Version 1 Aye Sandar Mon , University of Public Health, Yangon, Myanmar 0 Views copyright © 2024 Mon A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions General comment The manuscript is well written and the study findings could contribute to the substantial policy implication. Specific comments In sampling technique, the researchers applied quota and systematic sampling. For systematic sampling, how to calculate the sampling interval was described but I did not find about the random start. Could you please clarify it? In data collection method, was any pre-testing conducted? If so, please mention the procedure and the results including the reliability of the questionnaire and participants’ understanding of the question items. According to previous literature and evidence from international studies, in addition to the factors you considered as covariates in the statistical model, the social support and mental health status such as depression have been recognized as the important predictors for QoL. Although your questionnaire included the items assessing the social support and mental health status (DASS-21), why weren’t these variables considered as covariates in the statistical model? While presenting the results of multiple linear regression in “Table 4”, as the variable “elderly school attendance” is the main factor of interest, this variable should be described first instead of being the second-to-last description. I did not find the statistical procedures for assumption checks for multiple linear regression (regression diagnostics) in the 'Methods' or 'Results' sections. Were these tests performed? If not, please check the necessary assumptions, and if they were, please mention the results in the manuscript. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise My areas of research include maternal health and other public health-related topics, epidemiological studies in communicable and non-communicable diseases, and the application of advanced statistical models in various types of research. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 31 Mar 2025 Worapath Kratoo, College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand We sincerely appreciate the reviewer's insightful comments, which have significantly helped us to improve the clarity of our manuscript. We have addressed each point as follows: Comment 1: Sampling Technique (Systematic Sampling - Random Start) Response: Thank you for pointing out the omission regarding the random start in our systematic sampling procedure. To clarify, we have now added this important information to the sampling technique section. Specifically, we used a random number generator to select a starting point between 1 and 13, and from this random start, we then selected every 13th elderly person in the population who met our eligibility criteria. This random start was essential to ensure the systematic sample maintained randomness properties. Comment 2: Data Collection Method (Pre-testing and Reliability) Response: We conducted a pilot study for pre-testing, and the reliability of the questionnaire was evaluated using Cronbach's alpha. All items demonstrated reliability coefficients between 0.80-0.83, indicating good internal consistency. These reliability measures have been incorporated into the methodology section. Comment 3: Covariates (Social Support and Mental Health) Response: The propensity score matching (PSM) analysis, we focused on demographic characteristic variables that enable the matching of similar characteristics, thus maintaining’s model simplicity, focusing on direct effects rather than confounding relationships that could complicate analysis. Comment 4: Presentation of Multiple Linear Regression Results (Elderly School Attendance) Response: We agree that the variable 'elderly school attendance, being the main factor of interest, should be highlighted. In the revised manuscript, we have reordered the results in Table 4. Comment 5: Regression Diagnostics (Assumption Checks) Response: There is no multicollinearity, as indicated by the VIF scores, which are all less than 10 in Table 4. We believe that these revisions have addressed the reviewer's concerns and significantly improved the manuscript. We are grateful for the opportunity to enhance the quality of our work. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Mon AS. Peer Review Report For: Effect of Elderly School Policy on Quality of Life among Thailand’s Senior Citizens: A Propensity Score Matching Approach [version 2; peer review: 3 approved] . F1000Research 2025, 13 :735 ( https://doi.org/10.5256/f1000research.165851.r310486) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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