caregiving, work, and health: longitudinal findings from the thai … · 2019-02-25 · caregiving,...

Caregiving, work, and health: longitudinal

findings from the Thai Cohort Study

Dr Vasoontara Yiengprugsawan

Centre of Research on Ageing, Health, and Wellbeing

Research School of Population Health

The Australian National University

Number of people aged 60 years and over is expected to increase steadily over the next 15 years

and double by 2050.

Older people will soon represent close to one third of the population in many high-income

countries and in some low- and middle-income countries in the Asia-Pacific region.

2Source: World report on ageing and health. WHO 2015.

World population ageing

3

Population ageing

Lower and middle income countries are

undergoing both demographic and

epidemiological transitions.

The proportion of Thais aged over 60 years

will exceed 25% by 2050, only a little less

than the projected proportion for Australia.

↑ ↑ ↑ demand for informal caregiver

(economic impact including opportunity cost

such as foregone wage)

UN Population Division. 2015. World Population Prospects: The 2015 Revision. United Nations, New York.

• Physical demand in providing care (eg lifting, long hours) can result

in adverse health among caregivers.

• Emotional burden from caregiving can induce health-risk behaviours

such as alcohol abuse.

• Some caregivers report benefits in providing care eg perceived

social honour and improved family ties.

• Caregivers require social support and respite to sustain their caring

responsibilities and maintain quality of care.

4

Literature: health impacts of caregiving

OECD. Help wanted? Providing and paying for long-term care. Ch 3. The impact of caring on family carers. 2011.

Mehta, K. A critical review of Singapore’s policies aimed at supporting families caring for older members. Journal of

Aging and Social Policy. 2006;18(3-4): 43-57.

.

• Unpaid caring lowers workforce participation and this could adversely impact

on household finance; caregivers are more likely to work fewer hours than

non-caregivers and full-time caregivers are significantly more at risk of

withdrawing from the labour market.

• Factors impacting work-care relationship and

intentions to remain in formal employment are

socioeconomic status, household composition,

gender, nature of job (flexibility, security).

Diagram adapted from Berecki-Gisolf J, Lucke J, Hockey R, Dobson A. Transitions into informal caregiving and out of paid employment

of women in their 50s. Social Science & Medicine. 2008; 67(1):122-7.

Farfan-Portet MI, Popham F, Mitchell R, Swine C, Lorant V. Caring, employment and health among adults of working age: evidence from

Britain and Belgium. Eur J Public Health. 2010;20(1):52-7.

Schneider U, Trukeschitz B, Muhlmann R, Ponocny I. "Do I stay or do I go?"--job change and labor market exit intentions of employees

providing informal care to older adults. Health Economics. 2013;22(10):1230-49.5

Literature: economic impact of informal care

Poor Health

Limited

Labour Force

Participation

Caring for a Frail,

ill or Disabled

Person

Low

Socioeconomic

Status

Poor Health

Limited

Labour Force

Participation

Caring for a Frail,

ill or Disabled

Person

Low

Socioeconomic

Status

Caregiver:

Physical health

Psychological and spiritual health

Family and social impact

Time impact

Financial impact

Workforce participation impact

Care recipient:

Classification of illness, frailty or disabilityFunctional impact including: help shopping, preparing food, bathing, getting dressed, mobility, emotional support

Caregiver-Care Recipient:

Covariates such as age, sex, and socioeconomic status of caregiver and

care recipient

Relationship of caregiver and care recipient and other members in the

households

Nature and intensity of caring (duration of caring, hours per week)

Social characteristics of caregiver (formal, informal support)

6

Conceptual framework

• Thailand has a strong Buddhist culture affecting norms and values in

caring for family members and would be expected to make unpaid

caregiving quite common.

• According to the Thai National Statistical Office’s Survey of Thai Elderly,

among Thai elderly requiring care (40% received care from daughters,

28% from spouses and 12% from sons).

• When asked ‘what type of welfare government should provide’ over 95%

of elderly Thais preferred combined daycare centres and home care for

elderly with chronic illnesses rather than formal institutional care.

7

Cultural context

• To investigate prevalence of informal caregivers who also engaged in

paid employment and their mental health.

• To assess the subjective health status of caregivers in particular

overall self-rated health, low back pain.

• To interpret quantitative measures of caregivers psychological

distress (Kessler 6) and mental health domains (state, quality,

capacity, and support).

8

Research objectives

9

Thai Health-Risk Transition

Health-risk transition: combined approach to study

both health outcomes and drivers to investigate changing

disease burdens in middle-income countries such as Thailand.

Omran A. 1971. The epidemiologic transition: A theory of the epidemiology of population change. The Milbank Memorial Fund Quarterly. 49(4) Pt1: 509-38.

Thompson, W. 1929. Population. American Journal of Sociology; 34(6):959-75,

Popkin BM. 1993. Nutritional patterns and transitions. Population and Development Review.19(1): 138-157.

Demographic transition in ThailandCarmichael GA. 2011. Asia Pacific Viewpoint. 53 (1): 85-105.

Sleigh AC et al. 2008. Intl J Epidemiology 37:266-72.

Demographic transition: transition from high to low birth

and death rates (Thomson 1929).

Epidemiological transition: ↓fertility rates ↑ life expectancy;

infection → chronic diseases (Omran 1971).

Nutrition transition: shift from traditional diets (high in fiber)

to more ‘Western’ patterns (high in sugar, fat) (Popkin 1993)

contributing to rise of obesity and related disorders.

10

Thai Health-Risk Transition: A National Cohort Study

Funded by Wellcome Trust (UK) and the National Health and Medical Research Council

(Australia) 2004-present.

International partnership based on a longitudinal cohort of Thai adults enrolled in Open

University and residing nationwide; boost regional public health research capacity (8

Masters, 10 PhDs – topics completed include equity assessment of the Thai universal health

coverage, food system, sexual health, smoking, heat stress, hypertension – current PhD

research: diabetes, nutrition labelling).

Collaboration: The Australian National University (led by Prof Adrian Sleigh); Sukhothai Thammathirat

Open University (led by A/Prof Sam-ang Seubsman); University of Queensland’s School of Population

Health; Monash Injury Research Institute; Thai Ministry of Public Health; National Economic and Social

Development Board; Chulalongkorn University; Chiang Mai University.

11

Thai Cohort Study (Phase I & II)

2005 (n=87151): baseline recruitment from adult Open University students completed 20-

page mail-out questionnaire (eg socio-geo-demographic characteristics, occupation and work hours, health

service use, doctor diagnosed disease, transport and non-transport injury, self-reported health, social and

psychological factors, local environment, diet patterns, physical activity, tobacco and alcohol consumption).

2009 (n=60569): 4-year follow-up 10-page questionnaire (repeated measures and additional

questions introduced such as caregiving status, lower back pain, heat stress).

2013 (n=42785): 8-year follow-up 10-page questionnaire (repeated measures and additional

questions introduced such as nutritional labelling, body image, impact of 2011 flood).

2005-present: mortality records linkage to the Thai Ministry of Interior (using 13-digit citizen ID) and

verified causes of death (International Classification of Diseases, ICD-10) from the Ministry of

Public Health (~1200deaths between 2005 and 2014).

12

Thai Cohort Study characteristics

Sleigh AC et al. 2008. Int J Epidemiol. 37:266-72.

Cohort characteristics vs Thai population

Demo-sociographic attributes

Female (54.8%)

Age groups:

<40 years (51.3%)

40-49 years (33.2%)

50+ years (15.5%)

Marital status:

Married (62.5%)

Divorced, widowed, separated (8.3%)

Never married (29.2%)

Household size:

1-2 (20.2%)

3-4 (47.1%)

5+ (32.6%)

Residence:

Rural (55.3%)

Personal monthly income

<10000 Baht (22.2%)

10001-30000 Baht (37.4%)

20001-30000 Baht (21.8%)

>30000 Baht (18.5%)

Occupation

Professionals/managers (40.3%)

Office assistants (30.5%)

Skilled/manual workers (18.7%)

Others (10.4%)

At the 4-year and 8-year follow up (2009 and 2013), participants were asked:

“do you care for a sick or disabled family member?”

In 2013, participants were asked additional questions:

• “How many hours per week do you provide care?”

• “How many years have you cared for that person?”

• “What types of care do you provide?”

Responses include help with: mobility (moving the person); cognitive care; bath

and/or get dressed; prepare or eat food; attend religious activities; emotional

support; shopping; or financial support.

13

Caregivers (2009-2013 caregiver status)

Hours of care per week %

<10 4.6

10-19 3.8

20-34 3.5

35+ 5.0

Years spent caring

0-5 years 5.4

5-10 years 5.5

10+ years 2.3

Caregiving activities

Help with mobility 3.9

Help with cognitive care 5.1

Help bathing and dressing 3.7

Help preparing or eating food 6.5

Help with religious activities 7.0

Emotional support 8.7

Help shopping 14.1

Financial support 12.5

14

Caregiving activities reported in 2013

In the past 4 weeks, how often did you feel: 1) so sad nothing could cheer

you up, 2) nervous, 3) restless or fidgety, 4) hopeless, 5) everything was an

effort, 6) worthless?”

Responses were scored from 0 ‘none of the time’, 1 ‘a little of the time’, 2

‘some of the time’, 3 ‘most of the time’, 4 ‘all the time’.

Scores for the 6 questions were then combined; those with a total score ≥ 13 (out of the possible 24) were classified as having ‘psychological

distress’.

Kessler RC, Barker PR, Colpe LJ, et al: Screening for serious mental illness in the general population. Arch Gen Psychiatry

2003, 60(2):184–189.

15

Psychological distress (Kessler 6)

16

2009 caregiver status and psychological distress

Yiengprugsawan V, Seubsman S, Sleigh AC. Psychological distress and mental health of Thai caregivers. Psychology of Well-Being. doi:10.1186/2211-1522-2-4

v

17

Table 1 Yiengprugsawan V, Leach L, Berecki-Gisolf, Kendig H, et al. Caregiving and mental health among workers: Longitudinal evidence from a large cohort

of adults in Thailand. Social Science and Medicine – Population Health. 2(2016)149-154

2009-2013 caregivers characteristics

18

2009-2013 caregivers and Kessler 6 (outcome)

Table 1 Yiengprugsawan V, Leach L, Berecki-Gisolf, Kendig H, et al. Caregiving and mental health among workers: Longitudinal evidence from a large cohort

of adults in Thailand. Social Science and Medicine – Population Health. 2(2016)149-154

19Adjusted for demography (age, sex, marital status, household size, personal monthly income, urban-rural residence); work

(occupation groups, weekly paid work hours, job security, and social support)

2009-2013 caregivers and Kessler 6 (outcome)

• To investigate prevalence of informal caregivers who are engaged in

paid employment including their mental health.




distress (Kessler 6) and mental health domains (state, quality,

capacity, and support).

20

Research objectives

Subjective physical health outcomes

Self-assessed health was the first question of the Medical Outcomes Short Form

(SF8) which asked “Overall, how would rate your health during the past 4 weeks?”

• Answers were ‘excellent’, ‘very good’, ‘good’, ‘fair’, ‘poor’, and ‘very poor’.

• Combining the ‘poor’ and ‘very poor’ groups as having ‘poor self-rated health’.

Ware Jr, Kkosinski M, Dewey J, Gandek B. How to score and interpret single-item health status measures: a manual for users of the

SF-8TM health survey. Lincoln RI and Boston MA: QualityMetric Inc and Health Assessment Lab; 2001.

Lower back pain was assessed using two ‘yes-no’ questions: “In the past 4 weeks,

have you had pain in your lower back?” “If yes, was this pain bad enough to limit

your usual activities or change your daily routine for more than one day”? • For our analysis, those who answered ‘yes’ to both questions as having ‘lower back pain’.

Dionne CE, Dunn KM, Croft PR, et al: A consensus approach toward the standardization of back pain definitions for use in prevalence

studies. Spine (Phila Pa 1976) 2008, 33(1):95–103.

21

22

Multivariate adjusted odds ratios

Adjusted for social-demography (age, sex, marital status, household monthly income, work status, geographical residence); health

covariates include: body mass index and health behaviours (smoking and drinking)

• To investigate prevalence of informal caregivers who are also engaged

in paid employment including their mental health.




distress (Kessler 6) and Thai Mental Health Indicators (15 items

across 4 domains including state, quality, capacity, and support).

23

Research objectives

24

Mongkol, A., Tangseree, T., Udomratn, P., Huttapanom, W., & Chuta, W. The development of Thai Mental Health Indicator (TMHI): from past to

present. The 3rd International Conference on Gross National Happiness Towards Global Transformation. Thailand: Ministry of Public Health. 2007.

Songprakun, W., & McCann, T. V. (2012). Evaluation of a cognitive behavioural self-help manual for reducing depression: a randomized controlled

trial. J Psychiatr Ment Health Nurs. doi:10.1111/j.1365-2850.2011.01861.x. 2012.

Yiengprugsawan V, Somboonsook S, Seubsman S, Sleigh AC. Happiness, mental health, and sociodemographic associations among a national

cohort of Thai adults. 13(6): 1019-1029.

http://www.dmh.go.th/test/thaihapnew/thi15/thi15.asp

http://www.dmh.go.th/test/thaihapnew/thi15/thi15.asp

25

2009 caregiver status and Kessler 9

c

Table 2 Yiengprugsawan V, Seubsman S, Sleigh AC. Psychological distress and mental health of Thai caregivers. Psychology of Well-Being. doi:10.1186/2211-1522-2-4

26

2009 caregiver status and Thai Mental Health Indicator (1)


27

2009 caregiver status and Thai Mental Health Indicator (2)

28


Strengths and limitations

Strengths:

+ Prospective longitudinal study.

+ Large sample, a wide range of health and social variables.

Limitations:

- Loss to follow-up and cohort attrition.

- Cohort members have completed at least high school.

- Limited information on nature of caregiving (eg other help in the

household, caregiver-care recipients relationship).

29

• Our findings highlight the physical and mental health impact and

frequently transitional nature of caregiving of Thai workers.

• Balancing work and care could be vital for many to remain in the

workforce -- important for financial and social reasons.

• Protecting caregivers’ mental health could benefit both caregivers and

care recipients (quality of care); potentially minimizing the effects of

caregivers needing care!

• Perceived job security, support at work, and leisure time warrants policy

responses to facilitate workplace flexibility and backup with respite care

and carer leave.

30

Summary

How do these findings add to the literature?

• Large quantitative study investigating various aspects of caregiving (eg non-

specific conditions, social-economic-health impacts).

• The findings highlight the magnitude and importance of informal care.

Relevance to other middle-income Asian countries

• With changes in demographic composition; reliance on family care may not be

sustainable in the future. Important for social welfare services planning.

Suggested additional research

• Impacts of specific health conditions, demands on caregivers, and increasing

interaction with health services (eg chronic diseases).

• Emerging discussion on community care in Thailand.

31

Discussion

Part II Job characteristics and health

32

Collaboration with UCL Professor Andrew Steptoe and Dr Antonio Lazzarino

(now at LSHTM)

Research objective: to investigate psychosocial job characteristics on mental

health among workers (35-45 years) in the England and Thailand, in particular

the role of security-demands-autonomy-support.

Laszlo KD, Pikhart H, Kopp MS, et al. Job insecurity and health: a study of 16 European countries. Soc Sci Med. 2010;70:8678-74.

]Ferrie JE, Shipley MJ, Stansfeld SA, Marmot MG. Effects of chronic job insecurity and change in job security on self reported health,

minor psychiatric morbidity, physiological measures, and health related behaviours in British civil servants: the Whitehall II study. J

Epidemiol Community Health. 2002;56:450-54.

Cheng Y, Chen CW, Chen CJ, Chiang TL. Job insecurity and its association with health among employees in the Taiwanese general

population. Soc Sci Med. 2005;61:41-52.

Inoue A, Kawakami N, Tsuno K, et al. Job demands, job resources, and work engagement of Japanese employees: a prospective

cohort study. Int Arch Occup Environ Health. 2013;86:441–9.

Data harmonisation (age)

The Health Survey for England (HSE) is a nationally representative survey conducted

periodically since 1991. It covers individuals aged 16 years and over in private households

across England using stratified random sampling.

• Restriction of age and paid work distribution: respondents aged between 35 and

45 years had the highest (and most similar) proportion of paid workers.

33

Key variables Health Survey for England (n = 14112) Thai Cohort Study (n = 87134)

Age groups Age distributiona In paid work Age distribution In paid work

<20 43.2 (6093) 3.1 (122) 2.9 (2502) 1.6 (1151)

20-34 11.6 (1642) 25.5 (1014) 68.7 (59894) 68.4 (48690)

35-45 11.5 (1618) 28.5 (1132)b 22.8 (19843) 24.5 (17459)

46-65 20.1 (2837) 40.4 (1606) 5.5 (4792) 5.4 (3820)

65+ 13.6 (1922) 2.5 (98) 0.1 (103) 0.04 (31)

Table1 Yiengprugsawan V, Lazzarino A, Steptoe A, et al. Psychosocial job characteristics, wealth, and culture: differential effects on mental health in the UK and Thailand.

Globalization and Health 2015. 11:31. doI: 10.1186/s12992-015-0116-x

Data harmonisation (outcome)

Psychological distress: In the HSE, psychological distress was assessed using the 12-

item General Health Questionnaire as opposed to the Kessler-6 in the Thai study.

Dichotomised variables were created in both datasets.

34

UK Health Survey for England Thai Cohort Study (TCS)

Original format Original format

Psychological

distress

General Health Questionnaire (GHQ 12)

- able to concentrate;

- lost much sleep over worry;

- felt playing useful part in things;

- felt capable of making decisions;

- felt constantly under strain;

- felt could not overcome difficulties;

- able to enjoy normal day-to-day

activities;

- been able to face problems;

- been feeling unhappy and depressed;

- been losing confidence in self;

- been thinking of self as worthless;

- been feeling reasonably happy

Final binary outcome:

High distress score 4+:

11.7% (132)

Kessler (three anxiety

related questions)

In the past 4 weeks, about

how often… 1) did you feel

nervous? 2) did you feel

restless and fidgety? 3) did

you feel that everything was

an effort?

Responses on a five-point

scale: ‘all of the time’, ‘most

of the time’, ‘some of the

time’, ‘little of the time’,

‘none of the time’.

‘All’ or ‘most’ of the time

coded as having high

distress.

Final binary outcome:

High distress (all/most of

the time) 12.3% (3,857)

Table 3 Yiengprugsawan V, Lazzarino A, Steptoe A, et al. Psychosocial job characteristics, wealth, and culture: differential effects on mental health in the UK and Thailand.


35

Health Survey for England Thai Cohort Study (TCS)UK-TCS harmonised Original format TCS-UK harmonised

Job security

How likely is it that you will lose your

job and become unemployed within

the next twelve months? Please

estimate the probability of such a

chance on a scale from 0 to 100. (0

means that such a change will

definitely not take place. 100 means

that such a change definitely will

take place.)

Collapsed response categories:

0 (28.0%)

10-30 (40.6%)

40-60 (19.5%)

>60 (11.9%)

How secure do you

feel about your job or

career future on your

current occupation?

Extremely secure (18.5%)

Secure (50.1%)

Moderately secure (21.5%)

Not at all secure (10.0%)

Decision at workDo you have a choice deciding how

you go about your work?

All/most of the time (48.5%)

Much/some of the time (35.3%)

Occasionally (11.9%)

Never (4.2%)

I have a good deal of

say in decisions about

work

Often (55.1%)

Sometimes (33.4%)

Rarely (9.1%)

Never (2.5%)

Coping with

demands

How much do you agree or disagree

with the statement that ‘I feel able to

cope with the demands of my job’?

Often (strongly agree) (38.9%)

Sometime (agree) (49.1%)

Rarely/never (12.0%)

Your work situation… I

have enough time to

do everything

Often (48.2%)

Sometime (40.5%)

Rarely/never (11.3%)

Support from

employers

Do you get help and support from

your line manager?

Often (39.9%)

Sometimes (34.6%)

Seldom/never (12.5%)

Does not apply (12.9%)

How would you rate

the support you are

getting from

employer/boss?

Often (58.4%)

Sometimes (23.8%)

Seldom (8.7%)

Not apply (9.1%)



Data harmonisation (job factors)

• Restriction of age and paid work distribution: 35 and 45 years.

• Psychological distress: In the HSE, the 12-item General Health Questionnaire

and Kessler measures in the Thai study.

• Covariates: occupational status and part- or full-time paid work.

36

Occupation status

UK Health Survey for England Thai Cohort Study (TCS)

- Managerial and professional High (53.1%) Professionals/managers High (25.3%)

- Intermediate Medium (18.8%) Office assistants Medium (44.3%)

- Routine and manual Low 28.2% (317) Skilled and manual workers Low (30.4%)



• Job factors: four psychosocial job characteristics include: security, autonomy

(decision at work), ability to cope with demands, and support by employer.

37Table 2 Yiengprugsawan V, Lazzarino A, Steptoe A, et al. Psychosocial job characteristics, wealth, and culture: differential effects on mental health in the UK and Thailand.


cc

c

Key results

• Difference between the UK and Thailand was the effect of low job

autonomy. Job autonomy or control is thought to be a particularly

important aspect of a healthy work environment in Western cultures.

Strengths and limitations of this study

• Data harmonisation was possible producing similar categories for job

conditions, psychological distress, and other covariates.

• We also performed sensitivity analyses excluding UK participants who

had not completed high school but the results were similar.

38

Discussion (1)

Implications of the study and future research

• Empirical evidence on East-West comparisons is very limited; our

results highlight the similar psychosocial job-health effects in

particular job security, coping with demands, and employer support.

• This is an observational study and we are not able to single out the

wealth and cultural influences in these findings.

• For middle-income countries such as Thailand, understanding the

determinants of work and health could be helpful in explaining other

issues such as balancing work and care.

39

Discussion (2)

Contact: [email protected]; [email protected]

40

Feedback and comments

mailto:[email protected]

mailto:[email protected]

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