Conceptions of Healthy Aging Held by Relatives of Older Persons in Isan-Thai Culture: A Phenomenographic Study

In Thailand, family nurses are expected to provide support for older persons and their family members to promote healthy aging. Family bonds are strong, and relatives are expected to take care of their older family members. However, there is limited research on how older persons' family members perceive healthy aging. This study aimed to describe the conceptions of healthy aging held by the children and grandchildren of older persons in northeast Thailand. In a phenomenographic study, 14 interviews were performed to qualitatively analyze different conceptions of healthy aging. Four descriptive categories emerged: being independent, not being afflicted by diseases or illnesses, being a giver and a receiver, and being wise. The conceptions of healthy aging entail both autonomy and interdependence. The relative's perspective needs to be considered when policies relating to healthy aging are implemented in the community and when family nurses provide support to families to promote healthy aging.


Introduction
ailand's healthcare system emphasizes the importance of family participation in care for older persons [1]. A family nurse is the key person who works with older clients and their family members to provide care and support those people's health. In ailand, a family nurse is de ned as a person who takes responsibility for public health, holistic healthcare, and enhancing the quality of life among the population [2]. e roles of a family nurse include not only identifying health problems and managing chronic and acute medical conditions but also collaborating with families and providing health services [2]. ese tasks encompass preventing diseases and promoting health for families [2]. Family nurses have traditionally been expected to provide support for older persons and their family members. Family members play a key role as the primary caregivers of older persons in ai society, especially in the northeastern region of ailand, also known as Isan. us, family nurses should value the role of family when engaging older persons in their care. With a growing aging population, the ai government has developed health policies to maintain the older population's health and improve their quality of life [3]. e promotion of healthy aging is one of the key strategies adopted in the national agenda for meeting the challenges of caring for the older population [4]. e concept of healthy aging is adopted and studied throughout the world [5,6]. In ailand, studies of healthy aging have focused on older persons' perspectives [7][8][9]. e literature indicates that healthy aging is facilitated not only by older persons themselves but also by their families and culture [6,10]. To promote healthy aging and encourage family members to work together with healthcare providers, family nurses must consider the relatives' perspective, as relatives contribute to the improvement of health among older persons. Understanding what healthy aging means to family members of older persons may be helpful when collaborating with them and their families in the promotion of health among people in the northeast of ailand.

Healthy Aging: Positive Outcomes of Old Age and Policies for Responding to the Aging Situation in ailand.
ere are many terms that can be used to explain the maintenance of well-being in older persons [6], such as successful aging [11], active aging [12], and healthy aging [6]. Healthy aging is a concept that covers the multidimensional aspects of older persons' lives and may help incorporate the overlapping concepts of active aging and successful aging [6]. Moreover, healthy aging is viewed as a complex concept that involves multiple dimensions and relates to physical, mental, and social well-being [8]. Previous studies have shown that healthy aging entails achieving positive health outcomes, maintaining well-being throughout one's life, and preventing long-term health conditions [6,10].
Healthy aging has become a major consideration for global policy-makers aiming to preserve the health and improve the quality of life of the older population [13]. As in many countries worldwide, ailand is currently facing the problem of an aging population [14]. Older persons, their families, and the government need to be aware of the increased risks of chronic diseases and disabilities associated with old age [15]. e ai government is concerned about the aging of the ai population. erefore, healthy aging is one of the goals of the national plan for older persons, which aims to provide support for older individuals to enable them to maintain a healthy lifestyle and to reduce long-term care costs [3]. Implementation of this plan challenges family nurses to achieve the goal of promoting healthy aging.

Family: e Unit Responsible for the Informal Care of Older Persons in Northeast ailand.
Family is viewed as a unit of care [16] and represents the context for individual development, according to one dimension of family nurses [17]. e family has the primary responsibility for advocating the development of family members. e family serves as the context for a client's health, which means that the focus is on the client, and the family is viewed in the background of the client [17]. e individual's health in uences the family, and the capability of the family has an impact on the health of individual members [17]. When caring for older persons and promoting their health, the family nurse should be concerned with both the older person and the family members.
In ai society, family is highly valued [2]. e northeast of ailand, also referred to as Isan, has a large population of older persons [18] and is a icted by poverty, especially among the older population [19]. e children of the current generation of older persons remain an important support group in the northeast of ailand [20,21]. is importance may stem from the Isan culture's long tradition of paying respect to older persons and the cultural belief in the concept of repaying one's parents [20]. According to Isan cultural values, children are obliged to care for their parents based on Buddhist customs [20][21][22][23]. Children and other family members serve as informal caregivers who play an important role in supporting their parents both socially and nancially [21]. Older persons still receive support from their family members (e.g., daughters, sons, and grandchildren) to ful ll their needs [21]. However, societal changes in Isan are a ecting families and older persons' lives. In Isan, similar to other regions in ailand, the family structure has shifted from the extended family to the nuclear family. Older persons and young persons have become separated. Young adults tend to move to larger cities featuring centers of commerce to seek economic opportunities [24,25]. Some adults in Isan leave their own children with their parents and emigrate to the capital city or to other countries to work [21]. A previous study [26] showed that, compared with earlier generations, the current younger generation in the Isan region has fewer opportunities to stay with their older relatives. Sudnongbua et al. [26] reported that older persons in the Isan region felt abandoned because their children had migrated to other areas to work. e consequence of social change is a challenge for family nurses and provides an opportunity for family nurses to improve health among older persons and support their families who live in the northeast of ailand.

Family Members of Older Persons and Healthy Aging in
Northeast ailand. A previous study of healthy aging in the Isan region showed that older persons' perspectives on healthy aging are related to the support that they receive from family members [7]. However, no studies focusing on the conceptions of healthy aging held by the relatives of older persons in the Isan region have been conducted. e understanding of healthy aging that is held by the relatives of older persons in Isan-ai culture needs to be expanded. Such studies may enable family nurses to broaden their views regarding the meaning of healthy aging and provide a foundation for developing care practices consistent with healthcare policies. erefore, the aim of this study was to describe the conceptions of healthy aging held by children and grandchildren caring for older persons in northeast ailand.

Study Design.
is study has a descriptive and phenomenographic design with an epistemological basis in lifeworld theory, as suggested by Ashworth and Lucas [27,28].
is methodology was used because phenomenography and lifeworld theory aim to explain how human beings derive meaning from their connections with the world around them [29,30]. One's lifeworld is the everyday life that he or she experiences [29,31], and each individual experiences things in his or her lifeworld as di erent phenomena [29]. Phenomenography uncovers di erent qualitative conceptions of speci c phenomena [30,32]. e phenomenon of interest in this study was the notion of healthy aging.

Study Setting and Participants.
is study was set in Udon ani Province, which is located in northeast ailand and features a growing population of people aged 60 years or older. We selected this province as the setting because it exhibits both rural and urban characteristics and is an example of an area undergoing modernization and growth [33]. A purposive sampling technique was used to select the participants from a list of family members caring for 17 older persons from 17 families who participated in a previous study on healthy aging in the northeast region of ailand [7].
Various background characteristics, such as age, sex, marital status, and educational level, were used as inclusion criteria. To ensure that the conceptions of healthy aging were not drawn from older persons, this study included older persons' children and grandchildren aged < 60 years. ree family members were excluded because they were the spouses of the participants in a previous study on healthy aging who were aged > 60 years.
Twelve children and two grandchildren of older persons (11 women and three men) participated in this study, and the age range varied from 16 to 56 years. Five participants had an elementary school education, six had a high school education, one had a bachelor's degree, and two had a master's degree. Eight participants were married, and six participants were single. All participants were Buddhists. e participants' characteristics are described in Table 1.

Data Collection.
e rst author collected all data from September to October 2013 using semistructured, in-depth interviews and recorded the interviews to produce verbatim transcripts of each conversation. All the participants agreed to have their conversations recorded. e interviews were initiated using open-ended questions, such as "What is meant by healthy aging, in your opinion?," "Could you tell me about healthy aging?," and "What makes older persons healthy?" en, the rst author asked speci c follow-up questions to prompt the participants to re ect on the meaning of the phrase "healthy aging" and on their own thoughts, such as "What do you mean when you say ...?" or "Please give me an example of ...." e lengths of the interviews varied, depending on the participants' responses, between 45 and 90 minutes. Each interview was transcribed verbatim, and each transcript was then translated from ai to English by a professional ai-English translator to ensure that the translations were accurate [34].

Data Analysis.
e authors analyzed the transcribed interviews according to the steps suggested by Dahlgren and Fallsberg [35]. First, in the familiarization step, the rst author read the transcriptions several times in both ai and English to gain an overview of the relatives' conceptions of healthy aging. is step was necessary to verify the accuracy of the transcriptions in ai and English. e rst author con rmed that the transcriptions completely retained the meaning of the responses. e English transcripts were then used throughout the analysis process. e other authors read the English transcripts several times to familiarize themselves with the content. In the second step, the meaning units associated with healthy aging were condensed into short statements. In the third step, called the comparison step, similarities and di erences in the dialogue excerpts were identi ed.
en, similar statements were grouped into descriptive categories in the fourth step. In the fth step, or the articulating step, embedded conceptions in each group of meaning units were identi ed. e sixth step was the labeling step, in which the authors named the various categories. e nal step was the contrasting step, in which the di erences and similarities between categories were considered.

Ethical Approval.
We followed the guidelines of the principles outlined in the Declaration of Helsinki [36], which emphasize showing respect for all participants and protecting their rights. e rst author orally informed the participants about the study and then provided them with written information detailing the purpose of the study and its possible bene ts. e participants could choose the time and place of the interview and were allowed to withdraw from the study at any time. e participants were also ensured that their information would remain con dential. Permission to conduct this study was granted by the Udon ani Provincial Public Health O ce Committee Board in ailand and the Ethical Review Board of Research Involving Humans.
is study was registered with the Research Ethical Review Board of Uppsala, Sweden (Dnr 2013/019).

Results
e participants' conceptions of healthy aging consisted of four qualitatively di erent descriptive categories: being independent, not being a icted by diseases or illnesses, being a giver and a receiver, and being wise. Each descriptive category is presented and described in detail below.
3.1. Being Independent. Healthy aging means having a desire to do everything by oneself and to avoid relinquishing control or seeking assistance from family members. is category comprised the following two subcategories: "performing activities without the assistance of others" and "not being a burden to others."

Performing Activities without the Assistance of
Others. Healthy aging means being able to care for oneself, to be free, and to participate in activities considered appropriate for one's age without needing assistance from relatives. Healthy aging also means having the ability to work after retirement to earn an adequate income as a means of supporting oneself nancially. One participant described healthy aging as follows: My mother is expected to do things by herself. Older persons should work and earn their own income. ey can choose what they want to do. Some choose to eat vegetables or sh. Some like chili paste. You just live on your own. (6) Healthy aging means having the ability to adjust to di erent circumstances and having autonomy, which fosters a sense of freedom that prevents individuals from being forced to perform unwanted activities.

Not Being a Burden to Others.
According to the participants, healthy aging means not being dependent on family members. Speci cally, healthy aging means that one's needs are su ciently met such that he or she demands nothing. us, one who ages healthily lives a su cient life and does not strive for unnecessary things, o end anyone, or interfere in others' business. One participant described this idea as follows: She does what she can and doesn't impose a burden on her children and grandchildren. Someone always expresses concern that our family spoils her. But my mother isn't like that. We don't have to worry about her. (2) is statement indicates that healthy aging means not being a burden to others and that one should not impose oneself on one's children or grandchildren.

Not Being A icted by Diseases or
Illnesses. Healthy aging was described as a lack of degeneration of the body and mind. is concept means that one does not su er or worry about living with chronic diseases or illnesses. In this state, one has the ability to maintain the functions of his or her body and mind. Healthy aging means having a considerably strong, age-appropriate body and mind, the strength of which is visually apparent to oneself and to others. is category encompassed the subcategories "living with diseases or illnesses" and "exhibiting physical and mental strength."

Living with Diseases or Illnesses.
Healthy aging means having the ability to live with serious diseases or illnesses and to continue performing daily life activities. One relative noted the following: My mother is free from illness. Older persons can have some diseases, but not many. Although they have diseases, they e ectively live with them. As long as they can simply live according to their routine, they are ne. (12) e participants stated that even individuals who have some chronic diseases can exhibit healthy aging, although these individuals must nd a way to live with their health conditions and thus live an ordinary life.

Exhibiting Physical and Mental Strength.
Healthy aging means being in good physical and mental conditions and free of diseases or illnesses that can limit one's ability to perform daily life activities. Healthy aging also means having a good memory, which is particularly desirable among older persons. Such individuals are able to manage their emotions and are as strong as others of the same age. ey must be healthy, both physically and mentally, and free of diseases or illnesses. If you have a strong body, you also have a good mind. If you are well on the inside, your physical body is also well. If you are healthy physically, everything is healthy. When you have a positive state of psychological health, everything is ne. If you are calm people around you feel cool. (9) Healthy aging means being strong and being a psychologically healthy person. Healthy individuals' bodily functions are clearly connected to their mental functions, linking their inner and outer states.

Being a Giver and a Receiver.
e participants conceived of healthy aging as giving and receiving help from others and stated that happiness and satisfaction derive from these exchanges. Furthermore, healthy aging means being generous and performing good deeds in accordance with Buddhist beliefs, resulting in satisfaction, and delight from Buddhist practices. is category comprised the following two subcategories: "giving assistance and receiving support" and "devoting oneself to and being delighted by Buddhist practices."

Giving Assistance and Receiving Support.
Healthy aging means having family members available to provide help, as well as helping children and others by acting as a giver. In this context, healthy individuals are good parents who have raised and provided for their family members but who also receive help from their children and grandchildren.
She makes bamboo sticks for grilled sticky rice for her son. He sells grilled sticky rice in town, and she helps him. She is happy to do it. I help take care of her bed and her mosquito net. My aunt sells grilled eggs in town. She always buys delicious food for my grandmother when she visits. (4) In this context, healthy aging means providing cooking materials for family members and receiving support from family members. It means asking for help, for example, to meet one's daily needs. Healthy aging also means helping family members in their work to support them.

Devoting Oneself to and Being Delighted by Buddhist
Practices. Healthy aging means devoting oneself to the beliefs of Buddhism and attaining peace as a result of Buddhist practices. Healthy individuals live virtuous and positive lives, and perform noble deeds. In return, these individuals experience happy lives and good health. Dedicating oneself to Buddhism involves making merit and practicing the Buddhist doctrine.

She likes to go to temple. e temple is her society. Sometimes, she cuts the grass for the abbot and the monks.
e monks support her, and my mother supports them. She o ers to make merit in religious ceremonies. My mother lives in the community and adheres to Dharmic principles. Making merit is a sign that one's mind is peaceful and that one's health is also good. (9) Healthy aging means that one is dedicated to the act of making merit in accordance with Buddhist teachings. Making merit entails not only doing something good for others but also receiving merit in return, such as happiness, positive energy, peace, and enjoyment.

Being Wise.
Healthy aging means being wise, which entails understanding one's own life and life situations that occur. In particular, being wise means having the inner strength to address life's challenges and the knowledge to prevent diseases and take care of oneself.
is category consisted of the following two subcategories: "experiencing life as a journey" and "preparing for old age."

Experiencing Life as a Journey.
Healthy aging means having su cient knowledge-although not necessarily educational knowledge or an educational degree-to address problems in life. In the context of healthy aging, this subcategory refers to life experiences, which are derived from one's lifestyle. Healthy individuals regularly engage in positive practices in their everyday life to gain experiences that can help them make necessary decisions. (12) e participants stated that healthy aging means having the ability to learn through life experiences and to experience life as a journey.

Preparing for Aging.
Healthy aging means preparing oneself for growing old, which includes being satis ed with one's present life and focusing on the moment. Preparing for aging involves practicing what is bene cial for one's health to continue feeling young.
People should prepare for what they have to confront when they get old. ey have prepared themselves since they were young, that is, our age. My mother has been doing this. She does aerobic dance and jumps rope, for example. (10) Healthy aging is conceived of as preparing oneself to face the process of growing old. Preparing for aging includes preventing a decline in functions, for instance, by exercising and maintaining proper nutrition and hygiene.

Discussion
is study is the rst to examine how the children and grandchildren of older persons in northeast ailand conceive of healthy aging. e participants determined the meaning of healthy aging based on their lived experience of connecting to older persons they lived with and took care of in everyday life. e meaning of healthy aging consists of four descriptive categories: "being independent," "not being a icted by diseases or illnesses," "being a giver and a receiver," and "being wise." e ndings of this study reveal existential aspects of healthy aging. Additionally, the current study elucidates di erent conceptions of healthy aging that family nurses should consider when working together with the family members of older persons. e family is viewed as the context, according to the focus of the family nursing perspective [17], which means that the older person is in the foreground and the family is in the background. Although the older person is the main focus of the promotion of healthy aging, family nurses should also consider the perspectives of older persons' family members. e family is an important unit since the family supports and provides for the older family member. Family nurses therefore need to integrate the conceptions of healthy aging held by the family members of older persons in their care.
is does not mean changing their way of thinking but involves being aware that there is not only one conception of healthy aging when participating with the family members of older persons. To work with the family members of older persons, family nurses should respect and try to understand their conceptions of healthy aging. e challenge for family Journal of Aging Research nurses and policy-makers is to nd strategies to handle the di erent ways in which the relatives experience healthy aging. It is obvious that the family members of older persons conceive of healthy aging di erently. As the results show, family nurses should equally emphasize the importance of being autonomous and depending on others. Moreover, healthy aging is related to disease and illness but is also focused on wisdom in old age. erefore, family nurses should apply these perceptions when promoting healthy aging. Another challenge is to integrate the di erences between the perspectives of older persons and family members when working with these groups of people. is practice may be useful for supporting good relationships among older persons, family members, and healthcare providers when implementing a plan to promote healthy aging.
A comparison of healthy aging from the perspectives of the children and grandchildren of older persons reveals similarities between healthy aging, successful aging, and active aging.
ese similarities demonstrate that the meaning of healthy aging relates to the ability to remain active and to maintain the overall functioning.
is is in line with the de nition of successful aging, which emphasizes healthy cognitive function and focuses on the state of functioning that makes an active life possible [11,37]. When comparing the ndings of this study with the concept of active aging, we found that both healthy aging and active aging refer to the ability to maintain autonomy as well as the importance of independence for the older person [12]. ere is little difference between the concepts of healthy aging found in this study and a previous study [38].
at previous study on healthy aging also showed that healthy aging was de ned as freedom from chronic illness and impairment [38]. However, in the present study, healthy aging is de ned not only as the absence of disease or illness but also the importance of the ability to live with disease or illness.
Our results indicate the diversity of meanings of healthy aging, which is consistent with the characteristics of the ontological health concept [39], which is perceived as a movement toward wholeness and holiness [40]. e four descriptive categories are consistent with the three health levels in the ontological health concept: health as behavior, health as being, and health as becoming [39]. Herberts and Eriksson [39] described the rst dimension of health as having health, which is a way of achieving health through certain behaviors that are considered healthy by the individual or society. e conceptions of healthy aging as being independent and not being a icted by diseases or illnesses are related to the rst dimension of health, that is, having health. Healthy aging also entails being independent, having the ability to care for oneself, being free from diseases or illnesses, and maintaining strong bodily and cognitive functions. Healthy aging is consistent with the idea of evaluating health using external objective criteria and focusing on illness-related problems [39].
A comparison of the meaning of healthy aging found in this study and that reported in other studies reveals explicit di erences and similarities. Regarding the description of the nature of each category, the conceptions of healthy aging as being independent and not a icted by diseases or illnesses are consistent with the ideas expressed by healthcare professionals in earlier studies of healthy aging in Western countries [5,6]. We observed that being independent was a criterion for healthy aging, which may indicate that ai cultural values have been in uenced by Western traditions, in which individualism plays a prominent role [24,41]. us, modern society may have an impact on people's beliefs and normative contexts. A previous study showed that, according to the perspective of older persons in the Isan region, healthy aging still depends on one's relatives [7]. Furthermore, older persons are dependent on caregivers [21,42], whereas their younger relatives may value independence. While older persons still need assistance [21] because of changes in their bodily functions [43], the children and grandchildren of older persons conceptualize healthy aging with respect to the functional capacity of older persons and not being a burden on relatives.
ese conceptions may be partly related to ageism, the belief that older persons are inferior to younger people because of their age [44]. Children and grandchildren view older persons as being di erent from themselves, which may result in negative attitudes toward older persons. is study indicates that family nurses should be aware of these conceptions when collaborating with the children and grandchildren of older persons to promote healthy aging. Considering these aspects, policies should be developed according to the conception of healthy aging with respect to the burden of older persons on family members and the roles of older persons in society. Another suggestion is to support older persons when they lack the capacity to increase the value of their lives. Policy-makers and family nurses should emphasize the value of older persons to younger people.
Healthy aging is also de ned as "being a giver and a receiver." is category is related to the second dimension of the ontological health concept, in which health is viewed as "being health" [39]. Health is characterized as the achievement of balance and harmony, whether between the body and soul; between physiological, psychological, and social factors; or between internal and external elements [39,45]. When comparing that conception of healthy aging to the meaning found in this study, there are di erences between the categories "being independent" and "being a giver and a receiver." Surprisingly, "being independent" and "being a giver and a receiver" seem to be contradictory. e meaning of healthy aging that focuses on healthy aging as a state characterized by independence may re ect the in uence of the Western perspective [5]. In contrast, "being a giver and a receiver" stresses the importance of the relationships between older persons and their family members as an in uential factor in healthy aging, which may be due to the values of Isan culture. Being a giver and a receiver is related to the dynamics of the relationships between children and grandchildren and older persons in Isan culture. is relationship re ects the idea that children are indebted to their parents because their parents raised them from birth [22,42].
us, these relationships may be related to the concept of intersubjectivity, which is de ned in phenomenological theory [29,46,47] as the idea that everyone relies on and exists in relation to others [48]. e children and grandchildren of older persons interact with older persons 6 Journal of Aging Research throughout their lives and use their own bodies to understand how the concept of healthy aging relates to the older persons with whom they live. Parents provide for their children, love them, and take care of them from early childhood, and children are taught that they should live with and repay their parents until the parents die [22]. is connection may be described as an obligation and a social norm in Isan-ai culture, which is based on Buddhism. Although the Isan lifestyle has been changed by modernization [24], people in this region continue to have a strong belief in Buddhism [49]. Isan customs and Buddhist beliefs are passed down from generation to generation [50], and the cultural values tied to these customs and beliefs determine the individual person's thoughts and ideas [51]. Isan people cling to their culture through local customs [49]. Buddhists believe in the concept of karma [22,52], which means that one receives what he or she gives to others; this means that whatever one does to others may also be done to him/herself in the future.
is belief is illustrated by the practice of making merit, which, according to Buddha's teachings, brings happiness and peace [9]. Isan values are rooted in the interactions between an individual and others. us, this category is related to the interdependence [8,53] that characterizes Isan society. is nding indicates that family nurses should endeavor to enhance the relationships between older people and their children and grandchildren to promote healthy aging.
In the nal category, healthy aging is conceived of as "being wise." Comparisons between our results and those of previous studies regarding healthy aging [5,6] indicate that the domains of one's experience, adaptation, and preparation are related to wisdom. Being wise is related to the last dimension of health, in which health is perceived as "becoming" [39], meaning that human beings are becoming something greater than themselves and/or becoming whole at a deeper level [39]. In this context, wholeness refers to physical, mental, and spiritual wholeness [39]. Furthermore, Eriksson [54] noted that health as becoming means that "the person strives to reconcile himself with the circumstances of life and to become whole in a deeper dimension of integration" (p. 76). Our ndings indicate that being wise is linked to self-adjustment and to one's ability to face his or her problems and the changes associated with the aging process. People in society believe that older persons have gained important life experiences that enable them to face life's problems and thus consider these life experiences as valuable sources of wisdom [55]. Wisdom is believed to bene t older persons in facing life situations and is correlated with older age [56,57]. Wisdom also underlies the respect shown to older persons by children and other relatives who greatly admire them [58]. Another explanation for this behavior is consistent with the idea of ego integrity [59,60]. is category may be associated with the ability to integrate one's life experiences. is nding suggests that the life experiences and wisdom of older persons should be revealed in order to promote positive attitudes toward older persons. We observed that participants also de ned healthy aging as preparation for aging. e ndings of this study represent a starting point for family nurses and/or policy-makers when considering the perspectives of young adults regarding healthy aging. For the future challenges of supporting healthy aging, we suggest that family nurses plan for the promotion of healthy aging with adults in parallel with the current older population, according to the ndings of this study. For example, family nurses should serve the workforce and programs for preparing healthy aging in middle adulthood. ese programs should be related to the prevention of health problems. Moreover, the promotion of healthy aging should be relevant to the di erent conceptions of healthy aging. e family members of older persons should be encouraged to brainstorm a list of the key determinant factors in supporting their health and advance care planning to promote healthy aging.

Methodological Considerations.
Rigor in phenomenographic research is based on the study's validity and reliability [61]. e participants of this study were carefully selected using a strategy intended to obtain a varied and broad picture regarding the focus of the study-the conceptions of healthy aging held by the relatives of older persons. e number of participants recruited for this study was considered reasonable, but the participants included more women than men. us, the conceptions of healthy aging held by the men who participated in this study may not be fully representative. In-depth interviews exploring the conceptions of healthy aging were conducted by one person (the rst author), which allowed probing for deeper elaboration and ensuring that all information was considered. Speci c quotations were used to clarify the meaning of healthy aging. e rigorous approach used in this study also yielded ndings that are transferable [62]. is study focused on the conceptions of healthy aging held only by the children and grandchildren of older persons who live in the Isan region of ailand. is restriction may have in uenced our ndings, as cultural backgrounds may impact people's beliefs. However, the ndings of this study may be used to transfer to the relatives of older persons with similar backgrounds, such as the children and grandchildren of older persons who live in the northeast of ailand. Although the results of the present study can be related to the Western perspective on the meaning of healthy aging, data were drawn from the relatives of older persons in only one region of ailand. e information about the meaning of healthy aging gathered from this group of family members of older persons cannot be applied to the entire world. e purposive sampling method may also limit the generalizability of our results. Moreover, all the participants were Buddhists. Although Buddhism is a main religion in ailand, the conceptions of healthy aging held by Buddhists may di er from those held by members of other religions.

Conclusions
e key ndings of this study are the conceptions of healthy aging represented as a set of categories: "being independent," "not being a icted by diseases or illnesses," "being a giver and a receiver," and "being wise." Furthermore, the meaning of healthy aging is linked to older persons, their relatives, Journal of Aging Research and the Buddhist religion, which emphasizes the importance of a holistic view of healthy aging. Although some relatives' conceptions of healthy aging were consistent with Western perspectives, traditional Isan-ai cultural values still inuence the meaning of healthy aging. is study highlights the need to be aware of the unique conceptions held by the children and grandchildren of older persons in the Isan region when promoting healthy aging.

Conflicts of Interest
e authors declare that they have no con icts of interest with respect to this study or the authorship and/or publication of this article.