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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)
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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.
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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
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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.
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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.
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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).
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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.
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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
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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.
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Psychological distress (Kessler 6)
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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
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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
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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.
• 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).
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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.
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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.
• 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 Thai Mental Health Indicators (15 items
across 4 domains including state, quality, capacity, and support).
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Research objectives
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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
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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
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2009 caregiver status and Thai Mental Health Indicator (1)
Table 3 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
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2009 caregiver status and Thai Mental Health Indicator (2)
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Table 4 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
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).
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• 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.
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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.
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Discussion
Part II Job characteristics and health
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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.
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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.
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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.
Globalization and Health 2015. 11:31. doI: 10.1186/s12992-015-0116-x
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%)
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.
Globalization and Health 2015. 11:31. doI: 10.1186/s12992-015-0116-x
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%)
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.
Globalization and Health 2015. 11:31. doI: 10.1186/s12992-015-0116-x
• 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.
Globalization and Health 2015. 11:31. doI: 10.1186/s12992-015-0116-x
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: vasoontara.yieng@anu.edu.au; v.yiengprugsawan@ucl.ac.uk
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