SMJ

E-ISSN 2228-8082

Volume 76, Number 5, May 2024

Siriraj Medical Journal

The world-leading biomedical science of Thailand

MONTHLY ORIGINAL ARTICLE REVIEW ARTICLE

Indexed by

THAILAND SECTION 1954

https://he02.tci-thaijo.org/index.php/sirirajmedj/index

E-mail: sijournal92@gmail.com

By Pa-thai Yenchitsomanus

‌ORIGINAL ARTICLE‌

244 Factors Predicting Psychological Well-being among Survivors of Breast Cancer in A Tertiary

Care Hospital, Thailand

Nuntana Singtaweesuk, Wareerat Thanoi, Nopporn Vongsirimas, Sirada Kesornsri, Piyanee Klainin-Yobas

SMJ

Siriraj Medical Journal

The world-leading biomedical science of Thailand

Volume 76 Number 5

May 2024

255 Survey-based Study to Assess the Self-perceived Competency in and Knowledge about Reconstructive Microsurgery among

Young Plastic Surgeons

Nutthawut Akaranuchat, Min Yongsuvimol, Natthapong Kongkunnavat

262 Validity and Reliability of the Thai version of the International Consultation on Incontinence Questionnaire – Female Lower Urinary Tract Symptoms Long Form (ICIQ-FLUTS LF) and

Its Correlation with the IPSS

Parm Tohroonglert, Valeerat Swatesutipun

272 Emotion Regulation Mediates Functional Impairment in Thai Children with Attention-deficit/ hyperactivity Disorder: A Cross-Sectional Study

Tikumporn Hosiri, Manapawn Chukiatiwongul, Thanayot Sumalrot, Natchaphon Auampradit, Sirinadda Punyapas, Sucheera Phattharayuttawat

282 Role of Resilience in the Relationship between Adverse Childhood Experiences and Behavior Problems among Thai Adolescents in a Province of Southern Thailand: A School-Based

Cross-Sectional Study

Tikumporn Hosiri, Anawin Jongjaroen, Soisuda Imaroonrak, Thanayot Sumalrot, Sucheera Phattharayuttawat

293 Factors Affecting the Mental Health of Thai Medical Staff during the Second and Third Waves of the COVID-19 Pandemic: An Online Cross-sectional Survey

Rungarun Anupansupsai, Nattha Saisavoey, Suroj Supavekin, Woraphat Ratta-apha, Juthawadee Lortrakul, Somboon Hataiyusuk

304 The Association between Visceral Adipose Tissue and Coronary Atherosclerosis in Thai Postmortem Cases

Wanpreedee Prompetch, Peerayuht Phuangphung

REVIEW ARTICLE

313 Cancer Immunotherapy: Challenges and Advancements in CAR T Cell Technology

Pa-thai Yenchitsomanus

325 Lung and Airway Disease Caused by E-Cigarette (Vape): A Systematic Review

Arya Marganda Simanjuntak, Mokhammad Raihan Eka Putra, Nindy Putri Amalia, Anastasya Hutapea, Suyanto Suyanto,

Indi Esha Siregar

SMJ

‌SIRIRAJ MEDICAL JOURNAL

https://he02.tci-thaijo.org/index.php/sirirajmedj/index

Executive Editor: Apichat Asavamongkolkul Editorial Director: Aasis Unnanuntana

Editor-in-Chief: Thawatchai Akaraviputh, Mahidol University, Thailand

Associate Editors

Adisorn Ratanayotha, Mahidol University, Thailand Chenchit Chayachinda, Mahidol University, Thailand Pornprom Muangman, Mahidol University, Thailand Phunchai Charatcharoenwitthaya, Mahidol University, Thailand

Varut Lohsiriwat, Mahidol University, Thailand

Andrew S.C. Rice, Imperial College London, UK

International Editorial Board

Morris Solomon Odell, Monash University, Australia

Anusak Yiengpruksawan, The Valley Robotic Institute, USA Barbara Knowles, The Jackson Laboratory, USA Christopher Khor, Singapore General Hospital, Singapore Ciro Isidoro, University of Novara, Italy

David S. Sheps, University of Florida, USA

David Wayne Ussery, University of Arkansas for Medical Sciences, USA Davor Solter, The Jackson Laboratory, USA

Dennis J. Janisse, Medical College of Wisconsin, USA

Dong-Wan Seo, University of Ulsan College of Medicine, Republic of Korea Folker Meyer, Argonne National Laboratory, USA

Frans Laurens Moll, University Medical Center Ultrecht, Netherlands

G. Allen Finley, Delhousie University, Canada

George S. Baillie, University of Glasgow, United Kingdom

Gregory Bancroft, London School of Hygiene of Tropical Medicine, United Kingdom Gustavo Saposnik, St. Michael’s Hospital, Canada

Harland Winter, Harvard Medical School, USA

Hidemi Goto, Nagoya University Graduate School of Medicine, Japan Ichizo Nishino, National Institute of Neuroscience NCNP, Japan Intawat Nookaew, University of Arkansas for Medical Sciences, USA James P. Doland, Oregon Health & Science University, USA

John Damian Smith, Texas A&M University-San Antonio, USA John Hunter, Oregon Health & Science University, USA

Juri Gelovani, Wayne State University, USA

Karl Thomas Moritz, Swedish University of Agricultural Sciences, Sweden Kazuo Hara, Aichi Cancer Center Hospital, Japan

Keiichi Akita, Tokyo Medical and Dental University Hospital, Japan Kym Francis Faull, David Geffen School of Medicine, USA

Kyoichi Takaori, Kyoto University Hospital, Japan Marcela Hermoso Ramello, University of Chile, Chile Marianne Hokland, University of Aarhus, Denmark

Matthew S. Dunne, Institute of Food, Nutrition, and Health, Switzerland Mitsuhiro Kida, Kitasato University & Hospital, Japan

Moses Rodriguez, Mayo Clinic, USA

Nam H. CHO, Ajou University School of Medicine and Hospital, Republic of Korea Nima Rezaei, Tehran University of Medical Sciences, Iran

Noritaka Isogai, Kinki University, Japan

Paul James Brindley, George Washington University, USA

Pauline Mary Rudd, National Institute for Bioprocessing Research and Training Fosters Avenue Mount Merrion Blackrock Co., Dublin, Ireland

Peter Hokland, Aarhus University Hospital, Denmark

Philip A. Brunell, State University of New York At Buffalo, USA Philip Board, Australian National University, Australia

Richard J. Deckelbaum, Columbia University, USA Richard W. Titball, University of Exeter, USA Robert W. Mann, University of Hawaii, USA

Robin CN Williamson, Royal Postgraduate Medical School, United Kingdom Sara Schwanke Khilji, Oregon Health & Science University, USA

Seigo Kitano, Oita University, Japan

Shomei Ryozawa, Saitama Medical University, Japan Shuji Shimizu, Kyushu University Hospital, Japan

Stanlay James Rogers, University of California, San Francisco, USA Stephen Dalton, University of Georgia, USA

Sue Fletcher, Murdoch University, Australia

Tai-Soon Yong, Yonsei University, Republic of Korea Tomohisa Uchida, Oita University, Japan

Victor Manuel Charoenrook de la Fuente, Centro de Oftalmologia Barraquer, Spain Vincent W.S. Chan, University of Toronto, Canada

Wen-Shiang Chen, National Taiwan University College of Medicine, Taiwan Wikrom Karnsakul, Johns Hopkins Children’s Center, USA

Yasushi Sano, Director of Gastrointestinal Center, Japan Yik Ying Teo, National University of Singapore, Singapore Yoshiki Hirooka, Nagoya University Hospital, Japan

Yozo Miyake, Aichi Medical University, Japan Yuji Murata, Aizenbashi Hospital, Japan

Ampaiwan Chuansumrit, Mahidol University, Thailand Anuwat Pongkunakorn, Lampang Hospital, Thailand Jarupim Soongswang, Mahidol University, Thailand Nopphol Pausawasdi, Mahidol University, Thailand Nopporn Sittisombut, Chiang Mai University, Thailand Pa-thai Yenchitsomanus, Mahidol University, Thailand Pornchai O-Charoenrat, Mahidol University, Thailand Prapon Wilairat, Mahidol University, Thailand Puttinun Patpituck, Mahidol University, Thailand Rungroj Krittayaphong, Mahidol University, Thailand Saranatra Waikakul, Mahidol University, Thailand

Editorial Board

Sayomporn Sirinavin, Mahidol University, Thailand Suneerat Kongsayreepong, Mahidol University, Thailand Supakorn Rojananin, Mahidol University, Thailand Surapol Issaragrisil, Mahidol University, Thailand

Suttipong Wacharasindhu, Chulalongkorn University, Thailand Vasant Sumethkul, Mahidol University, Thailand

Vitoon Chinswangwatanakul, Mahidol University, Thailand Watchara Kasinrerk, Chiang Mai University, Thailand Wiroon Laupattrakasem, Khon Kaen University, Thailand Yuen Tanniradorn, Chulalongkorn University, Thailand

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Proofreaders: Noochpraweeporn Saleeon, Mahidol University, Thailand, Amornrat Sangkaew, Mahidol University, Thailand

‌Factors Predicting Psychological Well-being among Survivors of Breast Cancer in A Tertiary Care Hospital, Thailand

Nuntana Singtaweesuk, R.N. M.N.S.1,2, Wareerat Thanoi, R.N., Ph.D.2, Nopporn Vongsirimas, R.N., Ph.D.2, Sirada Kesornsri, R.N., Ph.D.2, Piyanee Klainin-Yobas, R.N., Ph.D.3

1Master of Nursing Science Program in Psychiatric and Mental Health Nursing, Faculty of Nursing, Mahidol University, Bangkok 10700, Thailand,

2Department of Mental Health and Psychiatric Nursing, Faculty of Nursing, Mahidol University, Nakhon Pathom 73170, Thailand, 3Alice Lee Centre for Nursing Studies, Yoo Loo Lin School of Medicine, 2 National University of Singapore Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597, Singapore.

INTRODUCTION

Breast cancer is one of the most common diseases among women.1 According to a report by the World Health Organization (WHO) in 2022, new cases of breast cancer and the mortality rate were 2.26 and 0.68 million per year, respectively.2 In Thailand, breast cancer is the most common cancer occurring among women, accounting for 22,158 new cases and 8,266 deaths annually.3

Moreover, new breast cancer cases have increasingly been diagnosed and reported globally, revealing breast cancer as a significant public health issue for Asian women worldwide. Even though cancer deaths are prevalent, early diagnosis through detecting cancer by screening provides asymptomatic patients a greater chance of recovery.3-4

Corresponding author: Wareerat Thanoi E-mail: wareerat.tha@mahidol.edu

Received 3 February 2024 Revised 12 March 2024 Accepted 17 March 2024 ORCID ID:http://orcid.org/0000-0003-3739-0041 https://doi.org/10.33192/smj.v76i5.267634

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

A cancer survivor is a term that refers to a patient diagnosed with cancer from their first diagnosis and subsequently lives life as a cancer patient. Most survivors face a variety of cancer-related effects, including physical, mental, and social consequences. After receiving treatments, patients experience physical symptoms such as chronic pain,4 dizziness, fatigue, insomnia, forgetfulness,5 and discomfort.6 Mental symptoms encompass stress, anxiety, and depression.7 Stress may contribute to anxiety and depression, leading to an increased risk of suicide. Social impacts entail discomfort with other family, friends, and colleagues, an inability to maintain family and social roles, and the risk of work problems due to frequent sick leave and compromised work performance.8 However, some of them have reported good psychological well- being without mental health problems, felt happy, had life satisfaction, and handled both disease conditions and lifestyle changes.

Psychological well-being (PWB) is a condition lacking any mental health problems and a vital indicator of personal mental health, mental strength, optimism, and the ability to live everyday life.9 The six dimensions of PWB consist of living with autonomy, purpose in life, self-acceptance, personal growth, positive relations with others, and environmental mastery.9-11 Various studies have examined the factors influencing breast cancer survivors’ PWB, including stress,12,13 self-efficacy,14,15 social support,16,17 and resilience.14,18

Stress is a personal perception reacting to stimuli, which causes physical changes and physiological imbalances between biology and biochemistry in response to those stimuli.19-23 Breast cancer is considered a life-threatening condition that leads to stress, which causes patients to evaluate their illness as a threat, affecting their perceptions and raising stress levels and psychological disruptions.24 Social support is a key factor related to PWB,18 perceived interactions, support,25 and illness management for breast cancer survivors. Social support helps promote appropriate adaptation, leading to beneficial mental health conditions. Optimal social support facilitates self-adaptation and promotes self-acceptance of the

illness condition.26,27

Self-efficacy refers to a personal belief in the capability to do something that supports how one lives. Self-efficacy includes personal feelings, thoughts, motivations, and behaviors.28 Studies have demonstrated that self-efficacy is an essential characteristic of successful self-management for the effects of cancer and its treatments. On the contrary, cancer patients with low self-efficacy tend to be more likely to experience depression.29 Generally, cancer patients aim to be successful in their self-management, which is one of the components of mental health.

Resilience is likewise associated with PWB, perceived growth, and quality of life among breast cancer survivors.30 It is a personality trait that individuals employ to protect themselves from undesirable events and to overcome negative experiences happening in their lives,31 such as being diagnosed with cancer.32

Although the above-mentioned factors were examined among patients with cancer and other chronic diseases in once a factor, limited research simultaneously tested all factors in the same study. Thus, it is inclusive of the magnitude of the effect for each factor. Moreover, most studies focused on promoting a patient’s quality of life rather than PWB. It is unclear which factors predict PWB among breast cancer survivors.16,33,34

Accordingly, this study aimed to examine the factors that predict PWB in breast cancer survivors in Thailand. It is hypothesized that stress, perceived social support, mindfulness, self-efficacy, and resilience would significantly predict PWB among breast cancer survivors in Thailand. The findings from this study would increase awareness among healthcare providers concerning PWB and should result in self-acceptance as well as the ability to live happily as a cancer survivor, maintaining good PWB.

Theoretical framework

This research was guided by Kumpfer’s resilience framework,35 comprising six core concepts including stressors and challenges, external environmental context, person-environment transactional processes, internal resilience factors, resilience processes, and positive outcomes. Considering Kumpfer’s framework and the factors relating to PWB, one recognizes that breast cancer survivors need surveillance for a recurrence, requiring continuous monitoring of treatment results. Cancer- related stress may lead to poor mental health. However, environmental contexts (such as social support from family, friends, and significant people) can minimize the effects of stress. The internal resilience factor and resilience process can lead to good adaptation. Self-efficacy and well-resilience grounds the ability to deal with stress and threats as well as reduce the chances of problems in adapting to the stress of being a breast cancer survivor. These enabling factors result in a positive outcome of effective adaptation to mental health problems and facilitate PWB.

Breast cancer survivors are a group with life goals. They have self-acceptance and good relationships with others, can adapt to threats, have the potential for self- improvement, and can make choices themselves. Besides, they have purposeful lives, take good care of their health, work to reduce relapses, and achieve long-term survivorship.

This determination to survive is consistent with the Ryff and Keyes9 concept of PWB, which recognizes PWB as a personal commitment to a positive lifestyle. Its six dimensions consist of autonomy, self-acceptance, positive relationships with others, purpose in life, environmental mastery, and personal growth, as shown in Fig 1.

MATERIALS AND METHODS

Research design and participants

A predictive descriptive research design and convenience sampling were utilized. The target population included post-treatment breast cancer survivors from a breast surgery clinic at a large tertiary hospital in Bangkok, Thailand. In conclusion, female adults must meet the following incision criteria: (1) aged 18 years and older diagnosed with breast cancer stage 1-3 by attending doctors, (2) completed treatments, including surgery, radiation, chemotherapy, hormone therapy, or combined therapy for at least six months, and (3) were clinically stable as indicated by attending physicians. This study excluded people with a diagnosis of cancer recurrence, metastasis to various organs, and a history of mental disorders.

The sample size was determined by power analysis calculated with the G*Power version 3.1.9.4 program. A study examined the effect of resilience on PWB among breast cancer survivors36 and generated a small effect size (r = .30, Cohen’s = .10). With this effect size, a significance level (α) of .05, power = 80%, four predicting variables, and at least 123 participants were required for this study.

Variables and measurements

There were two groups: tools for screening and data collection.

Screening tool

The Thai Mental State Examination (TMSE)37 was developed by 14 international institutions of brain rehabilitation groups. Patients with total scores less than

or equal to 23 points would be a cut-off for cognitive impairment and excluded from this study.38

Tools for data collection

PWB was evaluated by using the 18-item Thai- version psychological well-being scale (PWES),9 which was translated from the original PWES39 and consisted of six components including autonomy, environmental mastery, purpose in life, personal growth, positive relations with others, and self-acceptance. The assessment form uses a six-point Likert scale. Scores for each item range from 1 to 6, with 1 (strongly disagree), 2 (very disagree),

3 (disagree sometimes), 4 (agree sometimes), 5 (very agree), and 6 (strongly agree), while summed scores range from 18 to 108 points, and high scores indicated a high degree of psychological wellbeing. Cronbach’s alpha for the total scale was .80, and predictive validity was .75.39

Stress was evaluated with the Thai version of the 10-item Perceived Scale (PSS).40 The Thai version of the PSS was translated from the original PSS.41 It is a text style that measures perceived stress situations. It is a question about feelings and thoughts in the past month. The assessment form uses a five-point Likert scale. Scores for each item range from 0 (not at all), 1 (almost none), 2 (sometimes), 3 (quite often) to 4 (very often), while summed scores range from 0-40 points, and high scores indicate a high degree of perceived stress. Cronbach’s alpha for the total scale was .85, and predictive validity was .80.41

Social support was evaluated with the Thai version of the 12-item Multidimensional scale of perceived social support (MSPSS).42 The Thai version of the MSPSS was translated from the original MSPSS.43 It is a text style that measures perceived social support. The assessment form uses a seven-point Likert scale. Each item scored on a 7-point ordinal scale, ranging from 1 to 7 (1 =very strongly disagree, 2= strongly disagree, 3= mildly disagree, 4= neutral, 5= mildly agree, 6= strongly agree, and 7=

Fig 1. Psychological well-being factors of breast cancer survivors according to the conceptual framework of Kumpfer’s resilience

very strongly agree). Summed scores ranged from 12- 84 points, with a high score indicating a high degree of perceived social support. Cronbach’s alpha for the total scale was .89, and predictive validity was .92.43

Self-efficacy was evaluated with the Thai version of the 10-item General self-efficacy scale (GSES).44 The Thai version of the GSES was translated from the original GSES.45 It is a text style that measures self-efficacy. The assessment form uses a four-point Likert scale. Scores for each item range from 1 (not at all true), 2 (barely true), 3 (moderately true) to 4 (exactly true), while summed scores ranged between 10-40 points, and high scores indicated a high degree of self-efficacy. Cronbach’s alpha for the total scale was .84, and predictive validity was

.88.45

Resilience was evaluated with the Thai version of the 10-item Connor-Davidson resilience scale (CD-RISC).46 The Thai version of the CD-RISC was translated from the original CD-RISC.47 It is a text style that measures resilience. The assessment form uses a five-point Likert scale. Scores for each item range from 0 (not at all true), 1 (rarely true), 2 (sometimes true), 3 (often true) to 4 (true nearly always). Summed scores would range from 0-40 points, so high scores indicated a high degree of resilience. Cronbach’s alpha for the total scale was .86, and predictive validity was .89.47

The collection of personal information consisted of age, marital status, education, occupation, religion, income, and perceived income sufficiency. Clinical data encompassed the right to medical treatment, body mass index (BMI), congenital or co-morbid diseases, history of drug allergy and food allergy, past illness history, and duration of illness.

Ethical considerations

Ethical approval was granted by the Institutional Review Board of the Faculty of Nursing for the study of universities (IRB-NS 2020/52.0212) and the study of hospitals (IRB No.072/2564). Participants completed informed consent forms, and all procedures complied with ethical guidelines and regulations. The study was conducted from November 2020 through July 2022, and participant recruitment took place from August 2021 to October 2021. The participants completed the questionnaires, comprising 73 items, which took approximately 30 to 45 min for each participant to complete.

Data collection procedure

After receiving ethical approval, the researchers required permission from the hospital Directors of Study and breast surgery clinic to commence data collection. After that, the

researchers met the director of the breast surgery clinic to clarify the objectives, methods of data collection, and research benefits. Afterward, the researchers coordinated with nurses working at the breast surgery clinic to identify and screen for eligible participants. Subsequently, the researchers approached eligible participants, explained the details concerning the research project, and invited them to participate in the study. Before completing the self-administered questionnaire, each participant received a participant information sheet and signed a consent form. Each completed questionnaire was checked to ensure that there were no missing data. For those who could not read the questionnaire clearly, the researchers assisted by reading for them and recording the data based on their responses. During the process, if participants experienced certain symptoms (such as headache), the researchers would allow them to discontinue answering the questionnaire and provide necessary care immediately. In addition, given that data collection took place during the COVID-19 outbreak, the researcher and participants complied strictly with measures for preventing the spread of infection, including screening for symptoms, checking body temperature, wearing masks, and maintaining social distances of at least two meters.

Data analysis

All data were analyzed by the Statistical Package for Social Science (SPSS). as follows:

1. Personal information (such as age, marital status, and education) and clinical data (such as medical treatments, and congenital or co-morbid disease) were analyzed by univariate statistics such as frequency, percentage, mean and standard deviation.

2. Study variables (stress, social support, self-efficacy, resilience, and PWB) were analyzed by descriptive statistics.

3. The factors predicting PWB among breast cancer survivors were stress, social support, self-efficacy, resilience, and PWB, which were analyzed by running Pearson’s correlation coefficient and multiple regression using the enter method, with a statistical significance level of .05.

RESULTS

Demographics and clinical information ofthe participants In total, the study comprised 123 breast cancer survivors with a mean age of 55.06 (SD =10.67), and most of them were in the age range of 50-59 (37.40%) (Table 1). The majority were married (52.80%; n=65) and Buddhist (94.30%; n=116), had graduated with a bachelor’s degree or vocational certificate (52.00%; n=66), and qualified under the Civil Servant Medical Benefit Scheme (44.70%; n=55). Generally, they were

TABLE 1. Demographics and clinical information of the participants.

Demographics and clinical

information

N

%

Demographics and clinical

information

N

%

Age (years)

30-39 6 4.90

40-49 30 24.40

50-59 46 37.40

> 60 41 33.30

Marital Status Single Married Divorced

Other

34

65

12

12

27.60

52.80

9.80

9.80

(χ =55.06, S.D.=10.67, Max=85, Min=30)

Religion

Buddhism 116 94.30

Islam 4 3.30

Income (monthly)

< 10,000

10,000-29,999

30,000-49,999

> 50,000

32

30

25

36

26.00

24.40

20.30

29.30

(χ =23,361.14, S.D.=28,001.99, Max=150,000, Min=0)

Christianity 3 2.40

Education

Undergraduate 42 34.10

Graduated in bachelor's 64 52.00

degree or vocational certificate

Master's degree 16 13.00

Occupation

Unemployed Government officer

2

35

1.60

28.50

Doctor's degree 1 0.80

Medical Insurance plans

Occupation

Employee 15 12.20

Self-Employed 33 30.90

Adequacy of income

Enough Not enough

106

17

86.20

13.80

Other 38 26.80

Congenital or co-morbid disease

History of drug allergies, food allergies

Yes 20

No 103

16.30

83.70

History of illness

Body mass index (BMI: kg/m2)

<18.5

18.5-22.9

23-24.9

25-29.9

≥30

5 4.10

34 27.60

28 22.80

40 32.50

16 13.00

(χ =25.16, S.D.=4.37, Max=42.24, Min=16.41)

Average duration of illness (monthly)

< 12 71 57.70

12-24 24 19.50

25-36 14 11.40

>37 14 11.40

(χ =21.31, S.D.=24.15, Max=132, Min=2)

housewives, hired workers, or others (30.90%), with 50,000 baht or more being the average monthly income (29.30%). Participants had an average BMI of 25.16 (SD=4.37).

Psychological well-being, stress, social support, self- efficacy, and resilience

The results for psychological well-being, stress, social support, self-efficacy, and resilience are presented in Table 2. PWB (χ=83.19, SD=8.85), stress (χ=13.28,

S.D.=6.16) social support (χ=70.33, S.D.=11.03), self- efficacy (χ=31.90, S.D.=4.61) and resilience (χ=31.39,

S.D.=5.35).

Correlations between psychological well-being, stress, social support, self-efficacy, and resilience

According to the rule of Thumb for interpreting the size of a correlation coefficient, the correlation coefficient in the range of .90 to 1.00 (-.90 to 1.00), .70 to .90 (-.70 to

-.90), .50 to .70 (-.50 to -.70), .30 to .50 (-.30 to -.50), .00

to .30 (.00 to -.30) are assigned to the positive (negative) correlation in the level of very high, high, moderate, low and negligible, respectively.55 The correlations between psychological well-being, stress, social support, self- efficacy, and resilience are presented in Table 3. It is revealed that PWB was positively correlated with resilience (r=.55, p<.01), social support (r=.44, p<.01), and self- efficacy (r=.34, p<.01). On the other hand, stress showed

a negative correlation with psychological well-being (r= -.49, p< .01)

Predictors of mental health among participants

The model summary by an enter model of multiple linear regressions showed that stress, social support, self-efficacy, and resilience could explain the variance of PWB by 44% (adj R2=.43, F(4,118) =23.58, p< .01) are

presented in Table 4. Resilience had the strongest and

significant effect on PWB (β=.33, p< .01), followed by stress (β=-.27, p< .01) and social support (β=.26, p< .01). However, self-efficacy (β=.05, p> .01) did not affect PWB.

DISCUSSION

This study aimed to examine the factors that predicted PWB among breast cancer survivors in Thailand. The findings indicated that stress, social support, and resilience were significant predictors of PWB, except for self-efficacy. All variables explained 44% of the variance on PWB.

Breast cancer survivors with higher levels of stress were more likely to report lower PWB. Therefore, there is a need to help them manage stress, thus enhancing their mental health and PWB.24,48 The findings from the study indicate a significant negative relationship between stress and PWB in breast cancer survivors (r= -.49, p< .01). Moreover, stress emerged as a significant predictor of PWB at a confidence level of .01 (β=-.27,

TABLE 2. Descriptive statistics for the outcome measures (n=123).

TABLE 3. The correlation coefficient between study variables (n=123).

*Correlation is significant at the 0.05 level (two-tailed).

**Correlation is significant at the 0.01 level (two-tailed)

TABLE 4. Predictors of mental health among participants (n=123).

ß=standardized regression coefficient

p< .01). These results are consistent with prior research, which similarly found a negative correlation between stress and PWB in breast cancer survivors (r = -.44, p < .00), with stress being a significant predictor of PWB (β = -.59, p < .00).24,46 A possible explanation for this relationship is that breast cancer survivors who experience stress may be better equipped to handle daily challenges, perceiving stress as a challenge and strengthening their ability to cope with stress effectively. Based on Kumpfer’s resilience framework,35 it has been suggested that stress can function as a personal characteristic that facilitates positive adaptation by encouraging individuals to perceive stressors as challenges. Breast cancer survivors are individuals who have undergone comprehensive treatment and are now in a monitoring phase where continuous follow-ups of treatment outcomes is necessary in case of recurrence. This ongoing process can significantly impact their lifestyle, potentially leading to heightened stress levels compared to their pre-diagnosis state. When individuals experience elevated stress levels and struggle to effectively manage it, they become increasingly aware of stress as a looming threat, difficult to handle. This can result in

mental health issues and hinder their ability to adapt to both their medical condition and its treatment, ultimately contributing to poor mental well-being. It is a process of stressors and challenges within the individual regarding the first component of Kumpfer’s resilience framework. Therefore, it can be concluded that appropriate stress- coping strategies may support patients by helping them achieve good mental health and high levels of PWB.

The results of this study indicated a significant positive correlation between social support and psychological well-being (PWB) (r=.44, p<.01). These findings suggest that individuals with greater social support tend to report higher PWB levels. Additionally, social support emerged as a significant predictor of PWB at a confidence level of .01 (β=.26, p<.01). These results align with earlier research16, which similarly found a positive correlation between family support and improved mental health (r = .42, p < .01) in older cancer patients undergoing chemotherapy. Meanwhile, decreasing social support predicted stress and negatively affected PWB among breast cancer survivors.50 In addition, this group of patients had to have prolonged follow-ups continuously,

allowing patients to meet with fellow patients who went for breast cancer treatment simultaneously. They also acted as consultants or shared their experiences with other patients and interacted about their illnesses and goals for treatment. In addition, this group of patients had to be followed regularly every three months in the first three years post-treatment.54 The follow-ups could enable patients to meet fellow patients undergoing breast cancer treatment. Some served as consultants and interacted by sharing experiences about their illnesses and goals for treatment. In other words, social support is necessary for ill patients to balance their PWB and cope with stress appropriately. Afterward, it brings the individual’s transition process within the inner resilience element.51,52 In line with Kumpfer’s resilience framework,35 social support is an external environmental cortex that balances and interacts with internal/external protective factors and environmental factors. Patients perceiving beneficial social support (especially from family members, friends, or intimate partners) would be able to balance their perceptions towards stress, thus contributing to better mental health and PWB. Additionally, people with high levels of PWB could build good relationships with others, value empathy in relationships, and establish mutual trust.49

The findings of this study revealed a significant positive correlation between resilience and psychological PWB among breast cancer survivors (r=.55, p<.01). This suggests that those with higher levels of resilience are more inclined to report better PWB. Resilience emerged as a significant predictor of PWB with a confidence level of .01 (β=.33, p<.01). Moreover, a prior investigation similarly highlighted the association between resilience and PWB in breast cancer patients (r = .80, p = .00), with resilience significantly predicting PWB (β =.58, p < .00).18 Furthermore, resilience was correlated with growth perception (r=.61, p<.00), and it could predict growth perception (β= .61, p < .00).30 A possible explanation is that breast cancer survivors with resilience could manage every obstacle in daily life. They perceived stress as a challenge, thus strengthening their ability to cope with stress effectively. Based on Kumpfer’s resilience framework,35 resilience is a personal characteristic that helps individuals perceive stress as a challenge and promotes positive adaptation. It is a process of change within the individual regarding flexibility, the fourth component of Kumpfer’s resilience framework.

The results of this study imply that while self-efficacy demonstrates a significant correlation with PWB (r=.34, p<.01), it does not emerge as a significant predictor of PWB. Conversely, a prior study suggested that self-

efficacy correlated to quality of life via personal mental well-being (r=.75, p<.00). Patients with high self-efficacy tend to exhibit good PWB and considered as component of quality of life.53 According to the present findings, self-efficacy could not be a significant predictor for PWB because it has a low correlation. It is implied that some other variables are incorporated into self-efficacy through the resilience process, as shown in Fig 1.

Limitations

The strength of this study was its utilization of acceptable and reliable validated instruments within the Thai population. Subjective data were collected via a questionnaire, allowing participants to express their feelings or needs. The study employed convenience sampling, a method known for its comprehensiveness and accuracy in selecting small sample groups. Furthermore, a cross-sectional design, enabling the simultaneous examination of multiple variables, was employed in this work. However, the findings could involve limitations because data were collected only at one hospital. Thus, the results herein should not be appropriately generalized to diagnose breast cancer patients and survivors of breast cancer in other hospitals at a similar level, primary and secondary hospitals.

CONCLUSION

The present research examined factors related to psychological well-being in survivors of breast cancer. Our results highlighted resilience, stress, and social support factors that could predict psychological well-being. These results would be beneficial for future research and programs of development or innovation to effectively promote PWB among breast cancer survivors, especially among the Thai population.

Recommendations Nursing Practice

Nurses should provide psychological care, particularly for resilience factors, such as delivering a program for breast cancer survivors’ participation by organizing activities that develop resilience in life.56,57 Because it would help them adapt to illness and have good mental health. Also, social support should be advocated, such as Experience Sharing Groups among breast cancer survivors.58,59 Additionally, nurses should assess stress regularly, offer stress management programs support stress relief clinics to alleviate stress in the group of patients, and provide comprehensive and appropriate nursing care, which would lead to better mental health promotion for patients.

Education

The results of this study indicate that the factors that could predict mental health among survivors of breast cancer included stress, social support, and resilience. Therefore, it is necessary to provide nurses with training courses or knowledge about assessing stress levels, promoting social support, and increasing resilience in the care of breast cancer survivors.60-61

Future research

Further research should explore unpredictable factors like self-efficacy in the PWB of breast cancer survivors, potentially increasing sample size and development programs to enhance PWB among survivors warrant investigation.62 Future studies should extend beyond public hospitals to include private and community hospitals, diverse age groups, and other chronic diseases for comprehensive mental health promotion. Longitudinal designs and follow-up studies are essential to uncover the trajectory of Kumpfer’s conceptual theory and understand precise changes in breast cancer survivors’ well-being.

ACKNOWLEDGMENTS

The authors gratefully acknowledge all respondents who participated in this study. The authors are also thankful to the staff nurse of the Breast Surgery Clinic of the study hospital for their willing cooperation in the data collection processes.

Conflicts of interest

The authors declare no conflict of interest.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Authors’ contributions

NS: general research process, framework of the study, data collection procedure, data analysis, writing-original draft preparation; WT: framework of the study, validation, resources, writing -review and editing, visualization, supervision, project administration; NV: framework of the study, methodology, validation, formal analysis, writing – review, and editing; SK framework of the study, methodology, validation, formal analysis, writing–review, and editing; PKY: writing – review, and editing. All authors read and approved the final manuscript.

Data availability statement

Data is unavailable due to privacy and ethical

restrictions from the Institutional Review Board (IRB) of Mahidol University, Thailand.

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‌Survey-based Study to Assess the Self-perceived Competency in and Knowledge about Reconstructive Microsurgery among Young Plastic Surgeons

Nutthawut Akaranuchat, M.D., Min Yongsuvimol, M.D., Natthapong Kongkunnavat, M.D.

Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

ABSTRACT

Objective: Microvascular free tissue transfer has become a preferred reconstructive technique for managing complex wounds and defects. The aim of this questionnaire-based study was to assess self-perceived competency in and knowledge about reconstructive microsurgery among plastic surgeons who graduated from the Faculty of Medicine Siriraj Hospital, Mahidol University during 2015-2019.

Materials and Methods: Questionnaire was sent by email elicited information about the amount of microsurgery performed in practice, types of microsurgeries performed, reconstructive methods, types of flaps used, and respondent’s opinion about the microsurgery course attended during residency/fellowship training.

Results: The total response rate was 87.5%. Almost all respondents work in a government hospital (90.4%), and responses came from all regions of Thailand. Thirty-eight percent of respondents reported no microsurgery cases, and the majority of those who did perform microsurgery did so less than 20 times/year. Hand reconstruction was the most common type of microsurgical procedure. The factors that negatively influence microsurgery in clinical practice include insufficiency of resources and personnel (29.1%), excessive workload (27.3%), and long operative time (23.6%). Suggestions for improvement of the microsurgical training course include having a good objective method for assessing microsurgical practices (27.7%), increasing the volume of practice on animal model (25.5%), and an appropriate number of microsurgery cases to gain necessary experience (25.5%).

Conclusion: Reconstructive microsurgery was found to be a challenging procedure for many junior-level plastic surgeons. A low volume of cases limits a surgeon’s ability to develop needed skills. Important improvements in the microsurgery training course were also recommended.

Keywords: Microsurgery; surgical education; free flap; plastic surgery training; plastic surgeon (Siriraj Med J 2024; 76: 255-261)

INTRODUCTION

Microvascular free tissue transfer has become a preferred reconstructive technique for managing complex wounds and defects, such as limb salvage surgery, breast reconstruction, head and neck reconstruction, and lower extremity reconstruction. The development of meticulous microsurgical skills requires good foundational training, clinical experience, and continuous learning. In order

for plastic surgery residents and fellows to be able to competently and confidently perform microsurgical procedures in routine clinical practice after graduation, they must receive sufficient training and have had adequate hands-on experience in the operating room under the guidance of an experienced instructor.1-5

At our center, microsurgical skill is an important area of competency that is assessed among our trainees, and

Corresponding author: Nutthawut Akaranuchat E-mail: nutthawut.aka@mahidol.ac.th

Received 8 November 2023 Revised 14 February 2024 Accepted 27 February 2024 ORCID ID:http://orcid.org/0000-0003-1798-8484 https://doi.org/10.33192/smj.v76i5.266240

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

more than 100 cases of microsurgery are performed in our division annually.6-9 Our trainees receive reconstructive microsurgery training and experience by both practicing in the microsurgery lab, and by operating on real-life patients in the operating theater for conditions that include replantation, auto-transplantation, revascularization in order to resolve defects arising from tumor ablation, traumatic injuries, and congenital abnormalities.10-13 However, we have never assessed the views about, attitudes towards, reflections of, and experience in reconstructive microsurgery among our plastic surgery trainees after graduation. Accordingly, the aim of this questionnaire- based study was to assess the self-perceived competency in and knowledge about reconstructive microsurgery among plastic surgeons who graduated from the Faculty of Medicine Siriraj Hospital, Mahidol University during 2015-2019.

MATERIALS AND METHODS

Sample selection

All plastic surgeons who graduated from the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during 2015 to 2019 were eligible for study enrollment, and all 24 of those surgeons were sent study questionnaires via email. The surgeons that responded where included in the study and the final analysis. The protocol for this study was approved by the Siriraj Institutional Review Board (SIRB) (COA no. 616/2563), and all included subjects provided written informed consent to participate.

Study design and administration

The survey comprised 44 questions that cover various aspects of microsurgery, including the amount of microsurgery performed per year, the types of microsurgeries performed, the specialists responsible for performing microsurgery, the reconstructive methods used, the types of flaps used, and their opinions about the microsurgery course that they took during their residency/fellowship training. There was no imputation for missing data, such as specific questions for which an answer wasn’t given. Data management was performed using Microsoft Excel spreadsheet program (Microsoft Corporation, Redmond, WA, USA).

RESULTS

Twenty-one of 24 (87.5%) junior plastic surgeons returned a questionnaire, and 47.6% (10 of 21 respondents) answered all of the 44 questions. Almost all respondents (90.4%) work in a government academic or non-academic hospital. The remaining 9.6% work in the private sector. Questionnaires were received from all geographical regions of Thailand. Most doctors work in the Central region (11 of 21 (52.4%), followed by the Southern region (19.0%) and the Eastern region (9.5%) (Table 1).

Annual volume of microsurgery cases

The volume of microsurgery cases per year was 0 cases in 38.1% (8 of 21) of respondents, 1 to 3 cases in

23.8% (5 of 21), and 11 to 20 cases in 14.3% (3 of 21). For the overall number of microsurgery cases, 95.2% of

TABLE 1. Employment and location data of young plastic surgeon respondents.

respondents performed microsurgical reconstruction less than 20 cases annually (Fig 1).

Regarding the percentage of microsurgery performed at each region of the body, hand reconstruction was the most frequently performed procedure (61.9%, 13 of 21), followed by breast reconstruction in 42.9% (9 of 21) and head and neck reconstruction in 42.9% (9 of 21). Trunk reconstruction was performed least often (14.3%, 3 of 21) (Fig 2).

Responsible surgeons for reconstructive microsurgery at each region of the body

For the head and neck region, plastic surgeons performed reconstruction in 88.2%, and otolaryngologists performed reconstruction in 11.8%. Breast reconstruction was performed by plastic surgeons in 62.5%, and by general surgeons in 37.5%. Hand reconstruction was performed by plastic surgeons in 78.9%, and by orthopedists in 21.1%. Hand replantation was performed by orthopedists in 55.6%, and by plastic surgeons in 44.4%. Lower extremity reconstruction and trunk reconstruction was performed by plastic surgeons in 95% and 88.2% of cases, respectively. Perineum reconstruction was performed by plastic surgeons in 83.3%, and the remaining cases were performed by urologists, gynecologists, or general surgeons (Fig 3).

Preferred choices of reconstruction for each region of the body

Head and neck reconstruction (no cases in 23.8% of respondents)

The loco-regional flap was reported to be the preferred

method for managing head and neck defects (66.7%), with the most commonly used flaps being nasolabial flap (40.0%), paramedian forehead flap (30.0%), and pectoralis major myo-cutaneous flap (25.0%). Free flaps were performed in 27.8% of cases, with the anterolateral thigh free flap, fibular free flap, and radial forearm free flap used in 45.5%, 31.8%, and 22.7% of cases, respectively (Supplementary Fig 1).

Breast reconstruction (no cases in 38.1% of respondents) Pedicle transverse rectus abdominis myo-cutaneous (TRAM) flap was the most commonly used flap for coverage of a breast defect (performed by 25.0% of respondents), following by pedicled latissimus dorsi (LD) myo-cutaneous flap with silicone implant (13.6%). Free tissue transfer was seldomly performed, but when it was, free TRAM flap and free deep inferior epigastric perforator (DIEP) flap were the reconstructive flaps of choice (4.5% and 2.3%, respectively). Regarding the timing of reconstruction, nearly one-third of respondents preferred delayed breast reconstruction (28.6%). Other reported types of breast reconstruction that were encountered included implant- based reconstruction (22.7%), mastopexy (18.2%), and

lipofilling (13.6%) (Supplementary Fig 2).

Hand reconstruction (no cases in 38.1% of respondents) The most frequently used flaps for soft tissue reconstruction were loco-regional flap (43%) (such as reverse radial forearm free flap, and posterior interosseous artery flap), followed by tissue substitute with skin graft (24%), and distant flap (14%). For replantation, single

Fig 1. Volume of microsurgery cases per year among our respondent cohort.

Fig 2. The percentage of respondents who performed microsurgical procedures compared among different regions of reconstruction.

Fig 3. Surgeon responsible for performing microsurgical reconstruction between plastic surgeons and other specialties compared among different regions of reconstruction

axial K-wire was the most commonly used method for bony fixation (78.9%). During the postoperative period, most respondents (89.5%) reported the use of nail plate removal and stab incision at the nail bed if blood-letting was required (Supplementary Fig 3).

Lower extremity reconstruction (no cases in 4.8% of respondents)

For the repair of lower limb defects, the reported methods of choice were loco-regional flap (40%) and skin graft (35%). Free flap surgery was performed in only 10% of cases, and the ALT free flap was used in 53.3%. Perforator/propeller flap was used in 15% of lower extremity cases (Supplementary Fig 4).

Trunk reconstruction (no cases in 42.9% of respondents) Loco-regional flaps, such as the rectus abdominis myo-cutaneous flap, the omental flap, and the internal oblique muscle flap, were reported to be preferred

reconstruction techniques (46.7%), followed by skin grafting (33.3%). Free flap (flap of choice was the ALT free flap) and keystone/propeller flap were both used in 6.7% of cases. About 6.7% of respondents performed laparoscopy-assisted component separation (LACS) for abdominal wall reconstruction (Supplementary Fig 5).

Perineum reconstruction (no cases in 42.9% of respondents)

Most cases were performed by plastic surgeons

(83.3%), and loco-regional flap was the reconstructive method of choice (64.3%), followed by skin grafting (35.7%) (Supplementary Fig 6).

Lymphatic reconstruction (no cases in 66.7% of respondents)

The number of lymphatic reconstruction cases per year among our respondents was 0 cases in 66.7%, 1 to 3 cases in 14.3%, and 7 to 10 cases in 14.3%. The majority of cases (66.7%) were performed using non- microsurgical techniques, such as Charles procedure or liposuction. The methods most commonly used for investigation and diagnosis of lymphedema were of circumferential measurement of the affected limb (44.8%), lymphoscintigraphy (27.6%), and indocyanine green (ICG) lymphography with infrared camera (17.2%) (Supplementary Fig 7).

Microsurgical learning experience during the residency/ fellowship training program

During their 3 years learning in our division, about half of trainees participated in more than 30 microsurgical reconstruction cases (31 to 50 cases [28.6%], and more than 50 cases in 23.8%). Regarding the replantation procedure, most trainees had experience with more than 5 cases [6 to 10 cases (38.1%), 11 to 15 cases (19%),

and 16 to 20 cases (19%), respectively] (Supplementary

Fig 8).

Most respondents reported that the microsurgical reconstruction training and experience that they received at our center positively influenced their real-life practices

and surgical outcomes (moderate positive influence in 57.1%, and marked positive influence in 33.3%). In contrast, the factors that were reported to negatively influence having to perform microsurgery in routine clinical practice included insufficiency of resources and personnel (29.1%), excessive workload (27.3%), and long operative time (23.6%) (Fig 4).

In the final part of the survey, our respondents were given an opportunity to suggest ways that the microsurgical learning experience can be improved in terms of take-aways that can be used improve skills for real-life clinical practice after graduation. Those suggestions included having a good objective method for assessing microsurgical practices (27.7%), increasing the volume of practice on animal model (25.5%), and an appropriate number of microsurgery cases to gain necessary experience (25.5%) (Fig 5).

DISCUSSION

Thailand has approximately ten medical schools that train and graduate about 25 plastic surgeons each year. Our center is Thailand’s largest medical school, and we normally graduate 5 plastic surgeons each year or about one-quarter of all plastic surgeons that graduate each year in Thailand. Data from our questionnaire revealed that more than ninety percent of our graduates that completed their plastic surgery training during the study period work in academic or non-academic government hospitals. The questionnaire response rate in this study was a high 87.5%, and nearly half of those (47.6%) answered all of the questions. So, the outcomes of this study might

Fig 4. Factors that negatively influence having to perform microsurgery in routine clinical practice

Fig 5. Suggested ways to improve the microsurgical learning experience during the plastic surgery training program

be thought to reflect the current situation relative to reconstructive surgery and reconstructive microsurgery among junior plastic surgeons in Thailand.

Our results showed that approximately 82.7% of all kinds of surgical reconstructions were performed by plastic surgeons, and that the 3 most frequent regions requiring reconstruction were lower extremity region (95.0%), head and neck region (88.2%), and trunk region (88.2%) (Fig 3). This data might guide us in how we can improve training so that our graduates will be better prepared for the real-life requirements that Thai plastic surgeons most often need after graduation from training. The questionnaire data also revealed insufficient resources and personnel (29.1%), excessive workload (27.3%), and long operative time (23.6%) as the factors that most negatively influence having to perform microsurgical reconstruction. Moreover, 38% of our respondents reported having no microsurgery cases, and 95.2% of those who did perform microsurgery did so less than 20 times per year. The finding of our respondents having to perform no or minimal microsurgical procedures adversely influences the development of experience that is needed to obtain a high level of competence in

microsurgical reconstruction.

About 90% of respondents reported that the experience gained in reconstructive microsurgery during residency/ fellowship training had a substantial positive impact on their real-life practices and surgical outcomes. Our respondents also suggested the following ways that we might improve the microsurgery training: having a good objective method for assessing microsurgical practices (27.7%), increasing the volume of practice on animal model

(25.5%), and participating in an appropriate number of microsurgery cases to gain necessary experience (25.5%). Even though our survey may have some limitations, such as recall bias and the generalizability of the data, we believe this data provides a foundation from which we can begin a process of improvement in microsurgical reconstruction training for plastic surgery residents and fellows at our center. Moreover, knowing the regions of the body most operated upon may guide us in providing more specific training for high prevalence procedures. Importantly, these data also provide some insights into other types of challenges that plastic surgeons face after they enter clinical practice in the Thai public healthcare system. Lastly, in addition to this data benefiting the Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, this data may also be of some benefit to the Society of Plastic and Reconstructive Surgery of Thailand and the Thailand Ministry of Public Health relative to the challenges that junior plastic surgeons encounter during the early period of their career path.

CONCLUSION

Reconstructive microsurgery was found to be a challenging procedure for many junior-level plastic surgeons that graduated from our center. No microsurgery cases or a low volume of cases limits a surgeon’s ability to develop needed skills. Important improvements in the microsurgery training course were also recommended. Enhancements in the microsurgery training course taken by residents and fellows may improve surgeon confidence, skill, and experience for performing microsurgical reconstruction.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the physician respondents that participated in this study.

Conflict of interest declaration

The authors declare no personal or professional conflicts of interest relating to any aspect of this study.

Funding disclosure

This was an unfunded study.

REFERENCES

1. Avraham T, Clavin N, Mehrara BJ. Microsurgical breast reconstruction. Cancer J. 2008;14(4):241-7.

2. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg. 2001;108(4):1029-41.

3. Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck. 2010;32(9):1236-45.

4. Moon SJ, Hong JP, Kang SR, Suh HS. Survey of reconstructive microsurgery training in Korea. J Reconstr Microsurg. 2015; 31(1):54-8.

5. Akaranuchat N. Lower Extremity Reconstruction with Vascularized Free-Tissue Transfer: 20 Years of Experience in the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Siriraj Med J. 2021;73(7):462-70.

6. Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PE. Training in microsurgical skills: Does course-based learning deliver? Microsurgery. 2005;25(6):481-5.

7. Brosious JP, Tsuda ST, Menezes JM, Baynosa RC, Stephenson LL, Mohsin AG, et al. Objective evaluation of skill acquisition in novice microsurgeons. J Reconstr Microsurg. 2012;28(8): 539-42.

8. Gould SH. The role of the microsurgical laboratory in orthopedic training programs. Orthopedics. 1986;9(6):881-2.

9. Nugent E, Joyce C, Perez-Abadia G, Frank J, Sauerbier M, Neary P, et al. Factors influencing microsurgical skill acquisition during a dedicated training course. Microsurgery. 2012;32(8): 649-56.

10. Akaranuchat N. Factors Associated with Improved Microsurgical Learning in a Plastic Surgery Training Program. J Med Assoc Thai. 2020;103:51-4.

11. Pomahac B, Bueno EM, Sisk GC, Pribaz JJ. Current principles of facial allotransplantation: the Brigham and Women’s Hospital Experience. Plast Reconstr Surg. 2013;131(5):1069-76.

12. Pratt GF, Rozen WM, Chubb D, Whitaker IS, Grinsell D, Ashton MW, et al. Modern adjuncts and technologies in microsurgery: an historical and evidence-based review. Microsurgery. 2010; 30(8):657-66.

13. Wang WZ. Investigation of reperfusion injury and ischemic preconditioning in microsurgery. Microsurgery. 2009;29(1): 72-9.

‌Validity and Reliability of the Thai version of the International Consultation on Incontinence Questionnaire – Female Lower Urinary Tract Symptoms Long Form (ICIQ-FLUTS LF) and Its Correlation with the IPSS

Parm Tohroonglert, M.D.1, Valeerat Swatesutipun, M.D.2

1Division of Urology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand, 2Division of Urology, Thammasat University Hospital, Thammasat University, Pathumthani, Thailand.

ABSTRACT

Objective: Incontinence Modular Questionnaire on Female Lower Urinary Tract Symptoms Long form (ICIQ-FLUTS LF) is a robust psychometric tool to assess the severity of lower urinary tract symptoms (LUTS) in women. A Thai language version of the ICIQ-FLUTS LF is available, but it had not been validated yet. This study aimed to validate the ICIQ-FLUTS LF questionnaire in Thai and to identify the correlation between the ICIQ-FLUTS LF and the IPSS. Materials and Methods: We recruited 130 females, 50 with LUTS were recruited from patients visiting the Urology Clinic to assess the test with known group validity. They completed the ICIQ-FLUTS LF twice, two weeks apart, and the IPSS once. Meanwhile, 80 without LUTS (control group) were recruited from relatives of the patients to increase the consistency of the statistical analysis, completed the ICIQ-FLUTS LF. Then validity and reliability were determined using statistical analysis.

Results: Convergent validity showed a moderate correlation between ICIQ-FLUTS LF and IPSS for both storage and voiding symptoms, with Pearson’s correlation coefficient 0.49, 0.66; P<0.001, respectively. Construct validity, using the Wilcoxon signed-rank test, demonstrated statistically significant difference between the target group and the control group (P<0.001). The Thai version of the ICIQ-FLUTS LF showed good internal consistency, with Cronbach’s alpha coefficients 0.76-0.79 and Test–retest reliability strong, with weighted kappa values 0.63 to 0.90. Conclusion: The Thai version of the ICIQ-FLUTS LF shows good validity and reliable measures of females with LUTS, and it is simple to use. This questionnaire in the Thai version can be used in clinical practice and academic research.

Keywords: Lower urinary tract symptoms; Female LUTS; ICIQ-FLUTS LF; validate questionnaire (Siriraj Med J 2024; 76: 262-271)

INTRODUCTION

The International Continence Society (ICS) defined lower urinary tract symptoms (LUTS) as symptoms related to the lower urinary tract. The symptoms may originate from the bladder, urethra, prostate (men) and/

or adjacent pelvic floor or pelvic organs, or from similarly innervated anatomy, e.g., lower ureter.1 LUTS commonly occur in patients who have pathological lower urinary tract organs, which include storage symptoms, voiding symptoms and post-micturition symptoms. LUTS are

Corresponding author: Valeerat Swatesutipun E-mail: valeerat@gmail.com

Received 8 February 2024 Revised 18 March 2024 Accepted 21 March 2024 ORCID ID:http://orcid.org/0000-0002-6394-520X https://doi.org/10.33192/smj.v76i5.267706

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

not life-threatening but can negatively affect quality of life, leading patients to seek treatment. Sometimes, if found together with red flag signs such as hematuria, LUTS can be symptoms of dangerous diseases like bladder cancer.2 Physicians should investigate the causes of the symptoms because various pathologies, for example, overactive bladder or vesical stone, can cause LUTS in women. Many tools have been developed to help physicians diagnose the disease, assess LUTS severity, and guide appropriate treatment, but they have some limitations for use in daily clinical practice and research. The International Prostate Symptoms Score (IPSS) is one of those tools. It is a questionnaire which is widely used to assess the severity of LUTS in both males and females. However, the IPSS was originally developed to assess LUTS in men with benign prostatic hyperplasia and does not have a module about incontinence which is an important and the most bothersome symptom.2 Moreover, some important questions for evaluating female LUTS are not included in the IPSS. Therefore, in the past, urologists lacked of good questionnaire to assess all varieties of aspects of LUTS in females.

The International Consultation on Incontinence (ICI), which is sponsored by the WHO, developed a fully validated international standard questionnaire for lower urinary tract dysfunction. It includes modules to assess pelvic problems, is applicable to clinical practice and to research, and allows cross-comparisons.3 Furthermore, the questionnaires for assessing LUTS have been designed with consideration for gender differentiation.

The International Consultation on Incontinence Modular Questionnaire on Female Lower Urinary Tract Symptoms long form (ICIQ-FLUTS LF) is a high-quality robust questionnaire of the ICIQ series. It was created to evaluate the severity of LUTS in women, and it can be used throughout the world for both clinical practice and research. The questions are simple, easy to understand, and can be self-completed by the patient. ICIQ-FLUTS LF has been translated and validated in various languages, for example, Tamil and Sinhala. In Thailand, sixty-six million people use Thai for daily life and as the official language.4 Recently, patients with LUTS in Thailand either receive an overestimated or underestimated evaluation of severity due to lacking of a standardized tool to help guide the clinical practitioner in accurate diagnosis and such a tool has not been realized yet. Moreover, Thai urologists lack of well-validated questionnaires in Thai for evaluating LUTS specifically tailored for females. Leading to inadequate assessment of the severity, causes, and efficacy of the treatment of LUTS in Thai women. To date, the ICIQ-FLUTS LF is available in Thai but it

has not been validated yet. This study aimed to validate the ICIQ-FLUTS LF questionnaire in the Thai language and to identify the correlation between ICIQ-FLUTS LF and IPSS. We have chosen the IPSS as the comparative questionnaire due to its widely and long-standing usage, simplicity, and has been validated in Thai (21). Moreover, IPSS consists of questions concerning storage, voiding, and postmicturition symptoms, which are somewhat similar to those in the ICIQ-FLUTS LF, albeit with less detail compared to the latter.

MATERIALS AND METHODS

This is a prospective study to evaluate the validity and reliability of the ICIQ-FLUTS long form questionnaire. Permission was granted from the ICIQ Development Group, Bristol Urological Institute to translate into Thai and adapt the questionnaire. The Research Ethics Committee of the Faculty of Medicine, Thammasat University approved the experiment. All participants provided signed informed consent.

Participants

The participants were divided into two groups, the target group and the control group. For questionnaire validation, the optimal number of participants in the target group was 50. During January to December 2023, we recruited 130 female participants, 50 with LUTS for the target group and 80 without relevant symptoms for the control group. Having 80 participants in the control group increased the consistency of the statistical analysis.5 To assess the test in a population with known group validity, we recruited females with LUTS from patients visiting the Urology Clinic of Thammasat University Hospital, Pathum Thani, Thailand. The inclusion criteria were (a) age 18 years or older, (b) chief complaint of lower urinary tract symptoms, and (c) ability to read and understand Thai language. The exclusion criteria were (a) unable to answer the questionnaire twice with an interval of two weeks and (b) diagnosed with urinary tract calculi, urinary tract infection or urinary tract cancer.

For the control group, we recruited participants from relatives of the patients at the urology clinic. The inclusion criteria were (a) age 18 years or older, (b) no history of lower urinary tract symptoms, (c) no history of lower urinary tract disease, and (d) ability to read and understand Thai language.

We took note of the potential of bias in recruiting the population. In control group, the participants were recruited from the relative of the visiting patients in outpatient department. Usually, the caretaker or relative

accompanying patients were younger of age than patients themselves. But overall the method of recruiting still be able to achieve randomization to eliminate the potential occurrence of bias.

Instrument

ICIQ-FLUTS LF is an instrument to evaluate in females the severity of symptoms and the quality of life associated with LUTS. The questionnaire has 18 items with two questions in each item. The first question asks about the severity of LUTS using a Likert scale (with 0 being the least and 4 the most severe). The other questions allow participants to rate their quality of life between 0-10, where 0 means “not bothersome at all” and 10 means “very bothersome.”

This study also uses the International Prostate Symptom Score (IPSS) for comparison to determine the validity of the ICIQ-FLUTS LF. The IPSS consists of 7 questions related to lower urinary tract symptoms. The IPSS is a validated, reproducible scoring system which has long been used worldwide to assess disease severity. Both questionnaires are self-completed by subjects.

Procedure

All participants completed their questionnaires at Thammasat University Hospital and provided their ages as demographic data. Participants in the target group completed both the ICIQ-FLUTS LF and the IPSS questionnaires. Participants in the control group

completed only the ICIQ-FLUTS LF. For test-retest reliability, all participants in the target group completed the questionnaires again after two weeks (Fig 1).

Statistical analysis

The convergent validity (how closely a test is related to other tests that measure the same or similar constructs) was determined by comparing the ICIQ-FLUTS LF scores of the target group with a known validated questionnaire. In this study we used the International Prostate Symptom Score (IPSS) as the comparison test. The comparisons were performed using Pearson’s correlation.

The construct validity (a parameter that defines how well a test measures what it is intended to measure) was determined by comparing the ICIQ-FLUTS LF scores of the target group with the ICIQ-FLUTS LF scores of the control group. In order to easily compare between the target group and the control group, we organized the questions in the questionnaire into six subscales which were storage, voiding, incontinence, bladder pain, post micturition, and ability to stop voiding. The comparisons were performed using the Wilcoxon signed-rank test.

The internal consistency (a parameter that verifies correlations between items within a subscale or domain) was assessed by using Cronbach’s alpha coefficients. The assessment was done in each domain of the instrument. If Cronbach’s alpha coefficients were between 0.7 and 0.95, the instrument was considered to have good internal consistency.

Fig 1. Flow of participants through the study

The test–retest reliability (a property of producing repeated measurements that are consistent) was verified by having the participants of the target group answer the questionnaire twice with an interval of 2 weeks between the evaluations. We calculated test-retest reliability by using weighted kappa (κ).

STATA statistical Software Version 15 (StataCorp, College Station, Texas) was used for data analysis, with P-value of 0.05 considered statistically significant.

RESULTS

Demographic data

The mean age was 54.9 years in the LUTS group and 40.4 years in the control group. The difference was statistically significant, as shown in Table 1.

For the three most common diagnosis in the LUTS group, overactive bladder was the highest at 30 (60%), followed by nocturnal polyuria at 7 (14%), and pelvic organ prolapse at 5 (10%).

Construct validity

The differences between the median ICIQ-FLUTS LF scores of the LUTS group and those of the control group were statistically significant (p<0.001) for all six subscales, as shown in Table 1.

Convergent validity

Convergent validity between ICIQ-FLUTS LF and IPSS was evaluated with voiding symptoms and with storage symptoms. The Pearson’s correlation coefficient

for voiding symptoms was 0.66 (P<0.001) (moderate correlation) (Fig 2), and for storage symptoms it was 0.49(P<0.001) (moderate correlation) (Fig 3).

Reliability

Internal consistency

Internal consistency was assessed using Cronbach’s coefficient alpha score, which ranged from 0.76 to 0.79 for the 18 questions (Table 2).

Test–retest reliability

Test–retest reliability was assessed by using weighted kappa, which ranged from 0.63 to 0.90 for the 18 questions (Table 2).

Correlation between each of questions in each module (storage, voiding, and incontinence)

For the correlation between each of questions about storage symptoms, each of questions in this module showed weak to moderate correlation. Nocturia has a moderate correlation with urgency (r= 0.44) but weak correlation with the frequency (0.24) as shown in Table 3. For voiding symptoms, hesitancy demonstrated moderate correlation with straining to void (r=0.53) but weak correlation with others. Also, intermittency showed moderate correlation with dysuria (r=0.58) whereas showed weak correlation with others (Table 4). For incontinence symptoms, most of the questions in this group demonstrated moderate to good correlation between each other (r=0.41-0.63) as shown in Table 5.

TABLE 1. Construct validity between females with LUTS and the control group.

Abbreviation: N, number; SD, standard deviation; IQR, interquartile range

Fig 2. Convergent validity demonstrated in the Pearson’s correlation coefficient between ICIQ- FLUTS LF and IPSS in voiding symptoms score.

Fig 3. Convergent validity demonstrated in the Pearson’s correlation coefficient between ICIQ-FLUTS LF and IPSS in storage symptoms score.

DISCUSSION

Symptoms caused by urinary tract diseases are common in females of all ages. The EPIC study demonstrated a high prevalence of LUTS in women; 59.2% of women had storage symptoms, 19.5% had voiding symptoms, and 14.2% had post-micturition symptoms. The prevalence of symptoms increased with age.6 Specific co-morbidities such as history of vaginal delivery or hysterectomy, post-menopausal status, high BMI, arthritis, depression, hypertension, and neurological conditions are also associated with female LUTS.8 Women experience lower urinary tract pain more than men. Many patients seek treatment for LUTS, but current management cannot improve the symptoms.7 The most reported risk factor for LUTS in both males and females is increasing age, which this study demonstrated as well. Most previous

studies examining prevalence, risk factors, and comorbid conditions associated with LUTS used the Bristol Female LUTS (BFLUTS) questionnaire for women. A more expansive view, including a broader collection of symptoms would improve clinical recognition and management of LUTS.9 Female LUTS have been significantly associated with reduced work productivity (OR 1.11), presenteeism (OR 1.10), and activity impairment (OR 1.11).10

Although several questionnaires have been developed to measure varying aspects of LUTS, no symptom index has been generally accepted, and no single tool can evaluate all aspects of LUTS in women. An ideal questionnaire should determine the cause of the problem, the frequency and extent of symptoms, and the impact on patient’s activities and well- being. It should be inexpensive. It should not require invasive studies. It should track treatment

The question in an original version

(English)

The question in Thai version

Cronbach’s Weighted coefficient kappa (κ)

alpha scores (N=50)

(N=50)

TABLE 2. Internal consistency (demonstrated in Cronbach’s coefficient alpha score) and Test-retest reliability (demonstrated in weighted kappa value) in females with LUTS.

TABLE 3. The correlation matrix demonstrated in the Pearson’s correlation coefficient values between each of questions about the storage symptoms.

TABLE 4. The correlation matrix demonstrated in the Pearson’s correlation coefficient values between each of questions about the voiding symptoms.

TABLE 5. The correlation matrix demonstrated in the Pearson’s correlation coefficient values between each of questions about the incontinence symptoms.

outcome. It should be easy for the general population to use. And it should be relevant to clinical practice. Paul Abrams stated four characteristics of good symptom questionnaires “ (1) The questionnaire should be facile;

(2) Each item of the questionnaire should have a known causal relationship to the condition being measured; (3) The score should help determine appropriate therapeutic options; (4) Use of the questionnaire should directly improve patient management, and this effect should be demonstrable”.11

The International Prostate Symptom Score (IPSS) is a screening tool commonly used by urologists to evaluate and monitor LUTS in both males and females; however, it was originally developed and validated to assess treatment efficacy in men with benign prostatic hyperplasia. Lower urinary tract pathology differs between males and females, particularly incontinence and urgency. The IPSS excludes urinary incontinence from the questionnaire. Advantages of IPSS are that it is simple to use, is short, and has severity cut-off levels. However, some important questions for evaluating female LUTS are not included in the IPSS, so supplementary questionnaires such as LUTS tool, BFLUTS, etc. were created to better assess female LUTS.12

A population study used the ICIQ-FLUTS (short form) to investigate the prevalence of LUTS in nulligravid women. This helped researchers understand how women not seeking care for LUTS respond to the questions. Good tools are necessary for high quality research regarding epidemiology, diagnosis and management of LUTS.13 In comparison to recent validation of the study of ICIQ- FLUTS short form (22), this questionnaire has 12 items instead of 18 items from ICIQ-FLUTS long form. One of its strength is the ability to be completed within a short period of time, making it less burden to complete compared to the long form. Though the study itself mentioned that its lack of the ability to detect changes of clinical status is the one such limitation that the study has.

The ICIQ-FLUTS LF consists of the 18 items that evaluate frequency, nocturia, nocturnal enuresis, urgency, urge urinary incontinence, frequency of urinary incontinence, stress incontinence, unexplained urinary incontinence, amount of urinary leakage, hesitancy, straining to start urination, intermittency, nocturnal enuresis, strength of stream, urinary retention, dysuria, incomplete emptying, ability to stop urine flow, and bladder pain. All of these topics are relevant to lower urinary tract symptoms and causes of LUTS in women.3

This is the first study to assess the validity and reliability of ICIQ-FLUTS long form in the Thai language.

We demonstrated a moderate correlation between ICIQ- FLUTS LF and IPSS. Both questionnaires evaluate lower urinary tract symptoms, but they have different subdomains, especially in the domains of urinary incontinence and bladder pain. Therefore, their results should correlate to some degree, i.e., they should share the same general concept but not be identical. For reliability, we found good internal consistency for the ICIQ-FLUTS LF; Cronbach alpha ranged 0.76-0.79, which was similar to previous studies. For test-retest reliability, kappa values for individual items ranged from 0.63 to 0.90, indicating adequate reliability, which was also similar to previous studies.14-20 The Cronbach alpha and kappa values in our study were lower than in some previous studies. This might be because some previous studies collected data in specific populations; for example, the Tamil version collected data in pelvic organ prolapse and incontinence patients. LUTS in these groups would differ more from their control groups than in our study, which tested general female LUTS patients.

The clinical significance of the observed correlations and reliability measures in this study may be exemplified by the specific characteristics of the target group participants experiencing LUTS. Among them, 30 were diagnosed with overactive bladder, 7 exhibited nocturnal polyuria, and 5 presented with pelvic organ prolapse.

A limitation of our study was lack of other demographic data such as parity, menopausal status, pelvic organ prolapses, underlying diseases, education status, etc., which would yield more clarity and information regarding both groups. Further studies should include this demographic data and a wide range of ages and education levels of participants to provide more accurate information.

Another limitation was this study recruited the participants from women experiencing LUTS who visited the Urology clinic to conduct a known group validity test and recruited the relative of patients as the control group. This haphazard sampling might cause some selection bias and may affect the study’s finding. For example, the majority of participants in the control group were younger compared to those in the target group, resulting in a lower score of LUTS than observed in the target group.

The correlation coefficients observed between each question in this study demonstrated a range from weak to moderate correlation. It could be because the questions in the ICIQ-FLUTS LF covering all aspects of the female LUTS. Meanwhile, this study recruited participants who present with LUTS from various diagnosis, such as overactive bladder and stress incontinence. Consequently, this broader spectrum of conditions might lead to lower

correlation values between questions compared to studies focusing on specific patient groups. Therefore, future research aimed at further validating these questionnaires should consider recruiting larger participant cohorts and focusing on specific groups of Lower Urinary Tract Symptoms, such as overactive bladder or stress urinary incontinence. This targeted approach will enhance the applicability and effectiveness of these instruments.

CONCLUSION

Assessing Lower Urinary Tract Symptoms can be challenging, but specialized tools can facilitate in accurate diagnosis and guide appropriate treatment decisions. This is particularly crucial in the context of the Thai population, where access to foreign language versions may be limited. The findings of this study affirm that the ICIQ-FLUTS LF in Thai can be aid in diagnosis and treatment LUTS for Thai women. The Thai version of the ICIQ-LUTS LF is a valid and reliable measure of female LUTS, and it is simple to use. The Thai version of this questionnaire can be used in clinical practice and academic research. Using this questionnaire as a standard tool for initial assessment in outpatient department enables patients to easily self-complete it, facilitating clinical practitioners in selecting personalized and optimal treatment approaches for each individual.

ACKNOWLEDGEMENT

We would like to thank Dr. Teerayut Tangpaitoon for his assistance in statistical analysis.

Author contribution

Both authors are involved in the idea of the study, conceptualization of hypothesis, research operation, research design, data collection, data analysis, statistical analysis, data interpretation, discussion of the results, writing the article, critical revision of the article, contribution in manuscript preparation and editing, final approval of the article.

Ethics

All volunteers signed the consent form. The research was approved by the Human Research Ethics Committee of Thammasat University (Medicine): 067/2566. The protocol number MTU-EC-SU-0-002/66.

Conflict of interest

Both authors have no conflict of interest.

Funding

No funding.

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R. Validation of the Thai version of the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS). Int Urogynecol J. 2020;31(12): 2603-10.

‌Emotion Regulation Mediates Functional Impairment in Thai Children with Attention-deficit/ hyperactivity Disorder: A Cross-Sectional Study

Tikumporn Hosiri, M.D., Manapawn Chukiatiwongul, M.Sc., Thanayot Sumalrot, Ph.D., Natchaphon Auampradit, Ph.D., Sirinadda Punyapas, M.D., Sucheera Phattharayuttawat, Ph.D.

Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: The study investigated the potential mediating effects of emotion regulation and emotion lability/ negativity in the relationship between attention-deficit/hyperactivity disorder (ADHD) symptoms and functional impairment while also examining the associations between ADHD symptoms, emotion regulation, and impaired functioning in different life domains among children with ADHD.

Materials and Methods: The clinical sample comprised 118 children diagnosed with ADHD aged 6–12 years. Primary caregivers completed parent reports on symptom severity using the Thai ADHD Screening Scale–Parent Version, assessed emotion regulation and lability/negativity via the Emotion Regulation Checklist, and evaluated functional impairment using the Weiss Functional Impairment Rating Scale–Parent Version.

Results: ADHD symptoms correlated negatively with overall emotion regulation (r = −0.515, p < 0.01) and positively with lability/negativity (r = 0.583, p < 0.01). Functional impairment exhibited a negative correlation with emotion regulation (r = −0.649, p < 0.01) and a positive correlation with lability/negativity (r = 0.701, p < 0.01). Elevated ADHD symptoms were linked with increased functional impairment (r = 0.639, p < 0.01). The parallel mediational model showed that emotion lability/negativity partially mediated the association between ADHD symptoms and functional impairment (β = 0.282, p < 0.001), suggesting that ADHD symptoms and emotion lability/negativity indirectly accentuate functional impairment. Thus, heightened ADHD symptoms may exacerbate emotion lability/ negativity, contributing to increased functional impairments.

Conclusion: Emotion regulation difficulties, particularly emotion lability/negativity, may serve as significant risk factors. Regular monitoring and targeting these challenges hold promise in alleviating adverse functional outcomes co-occurring with elevated ADHD symptoms.

Keywords: Attention-deficit/hyperactivity disorder; emotion regulation; emotion lability; functional impairments; children (Siriraj Med J 2024; 76: 272-281)

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder emerging in childhood, with an estimated worldwide prevalence of 5-7% among school-aged children.1 Its primary features

include a persistent pattern of inattention and hyperactivity/ impulsivity that frequently disrupt academic, occupational, and social settings. While symptoms may change with age, approximately 60-85% of individuals continue to experience some residual symptoms in adolescence and

Corresponding author: Manapawn Chukiatiwongul E-mail: bochukia@gmail.com

Received 18 December 2023 Revised 29 February 2024 Accepted 5 March 2024 ORCID ID:http://orcid.org/0009-0009-4675-8283 https://doi.org/10.33192/smj.v76i5.266803

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

adulthood.2,3 Etiologically, emerging research underscores neuropsychological theories, emphasizing impairments in executive functioning processes and inhibitory control involving emotion self-regulation. This highlights emotion dysregulation as an additional core feature of ADHD that significantly contributes to impaired daily functioning and psychosocial maladjustment.4 Emotion regulation deficits have been proposed as potential mediating mechanisms through which ADHD symptoms contribute to various functional issues, ranging from interpersonal relationship problems to an increased risk of developing psychiatric comorbidities if not properly treated.5,6

Difficulties in regulating emotions arise when individuals struggle to control emotional experiences and expressions to optimize functioning effectively, adapt to daily environments, and foster behaviors conducive to achieving their goals.7 The literature on ADHD greatly supports the theoretical model linking emotion regulation challenges to deficits in executive inhibitory control and dysregulated attention extending to emotions.8 Therefore, children with ADHD experience greater difficulty controlling shifts in emotion (lability), regulating negative emotional responses, recognizing and allocating attention to emotional stimuli, which are often linked with behavioral problems such as frustration, temper outbursts, or reactive aggression.9 Additionally, those struggling with emotional regulation often exhibited fewer prosocial behaviors, encountered higher rates of peer rejection, and had an increased the risk of developing negative self-concept, low self-esteem, and self-destructive behaviors.10 Recognizing transdiagnostic nature of emotion regulation deficits may play a crucial role in understanding the functional consequences suffered by children with ADHD, extending beyond traditional symptoms.8

Given the limited research on the underlying mechanistic relationship between ADHD symptoms and functional impairment, exploring these pathways may shed light on emotion regulation processes that could interfere with developing adaptive regulatory strategies for a healthy emotional adjustment, impacting symptom remission and functional improvement throughout treatment interventions. Therefore, in an effort to identify transdiagnostic targets for treatment and facilitate interventions, our primary objectives were to investigate the associations between ADHD symptoms, emotion regulation, and functional impairment in ADHD children. We also aimed to explore how the specific dimension of emotion regulation may mediate the relationship, using a parallel mediational design to simultaneously examine the indirect effects of emotion regulation and emotion lability/negativity.

MATERIALS AND METHODS

Study design and sample

A sample of 121 participants consisted of children aged 6-12 years diagnosed with ADHD. The clinical diagnosis of each participant was assessed by child and adolescent psychiatrists using the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).1 The exclusion criteria included children with severe medical conditions, individuals with caregivers not serving as the primary caregivers for more than 6 months and those unable to complete the questionnaires. The initial assessment included data from 121 participants; however, reported descriptive information and statistical models refer to the 118 participants remaining after the identification and removal of outliers.

Procedures

This cross-sectional study was conducted at the Child and Adolescent Psychiatry outpatient clinic, Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, between June and July 2023. Participants and primary caregivers were recruited during a regular follow-up visit. All caregivers provided written informed consent and assent to participate was obtained from the children. All questionnaires were completed by caregivers. Medical records were reviewed for patient clinical characteristics. The study protocol was approved by the Siriraj Institutional Review Board (COA no. Si 328/2023).

Measures

Demographic questionnaire

Demographic information including gender, age, and highest education level was collected for the participants. Primary caregivers’ demographic data included age, gender, highest education level, monthly household income and marital status.

ADHD symptoms

ADHD symptoms were assessed using the Thai ADHD Screening Scale–Parent Version (THASS) for children aged 6–12, comprising 30 items. The symptoms are encompassed in two primary subsets: hyperactivity/ impulsivity (e.g., difficulty controlling behaviors and persistent overactivity, 15 items) and inattentiveness (e.g., difficulty paying attention and sustaining focus, 15 items). Symptom frequency was reported using a 5-point scale, ranging from 0 (never) to 4 (very often). Interpretation was performed using the T-scores with designated thresholds for varying levels of severity. The

questionnaire has good psychometric qualities, including a robust internal consistency (α = 0.96), content validity index ≥0.80, and good test-retest reliability (r = 0.80–0.9).11 Internal consistency for total symptom severity (α = 0.91), hyperactivity/impulsivity (α = 0.89), and inattentive subscales (α = 0.90) ranged from good to excellent for the current sample.

Emotion regulation

Parents completed the Emotion Regulation Checklist (ERC)12, a 24-item instrument that evaluates processes integral to adaptive regulation in children aged between 6–12 by capturing two dimensions of emotion regulation:

(1) Emotion regulation subscale (ERC-ER, 8 items), which refers to socially appropriate affective displays, emotional self-awareness, empathy, and (2) Emotion lability/negativity subscale (ERC-LN, 15 items), which refers to emotional inflexibility and reactivity, dysregulated negative affect, and mood lability. Items assessing the frequency of developmentally appropriate behaviors in individuals are measured on a Likert scale ranging from 1 (never) to 4 (almost always). Higher composite scores indicate superior overall emotion regulation, with higher scores in the ER subscale reflecting greater congruence in affective displays and optimal regulation of emotion arousal within the environments. Higher scores on the LN subscale indicate more significant emotion dysregulation and socially incongruent affective displays. The ERC (Thai version) demonstrated adequate internal consistency for both the ER subscale (α = 0.73) and the LN subscale (α = 0.82) in a study involving a Thai clinical sample.13 The internal consistency for the ERC composite (α = 0.79), ER subscale (α =0.67), and LN subscale (α = 0.78) ranged from acceptable to good for the current sample.

Functional impairment

The Weiss Functional Impairment Rating Scale– Parent Report (WFIRS–P) is a 50-item parent-rated scale that assesses functional impairment in various domains, including family, academic, life skills, self-concept, social, and risky activities.14 Each item is measured using a 4-point scale, ranging from 0 (never or not at all) to 4 (very often or very much). Higher total scores equate to greater overall functional impairment, ranging from mild to extreme impaired levels. The psychometric properties of the WFIRS–P (Thai version) have been translated and cross-culturally validated, with excellent internal consistency (α = 0.98) and good test-retest reliability (r = 0.88) for total and domain scores.15 The internal consistency was strong in the current sample (α = 0.90).

Data analyses

Descriptive statistics, including Pearson’s correlation coefficients, were used to describe clinical characteristics and explore relationships among study variables. Partial correlation analyses were additionally performed to examine these relationships while controlling for the potential confounding factors associated with caregivers’ characteristics, including age, gender, and highest education. Prior to conducting the mediation analysis, the assumption of independent values was validated with a Durbin–Watson value of 1.85, below the threshold of 2.5. Multicollinearity was assessed using variance inflation factors (VIF) ≤10 and tolerance values ≥0.10, and through ensuring that all correlations remained below 0.8. The current study revealed no evidence of multicollinearity, as indicated by diagnostic measures: VIF ranging from 1.13 to 1.68 and tolerance ranging from 0.59 to 0.88.

A parallel mediation analysis was examined, utilizing scores from the emotion regulation subscale and the emotion lability/negativity subscale as mediators and total functional impairment as the independent variable. Additionally, a bootstrapping method of 5,000 bootstrapped resamples was constructed empirically to determine the statistical significance of the total and specific indirect effects (calculated as the product of the regression coefficients for a₁b₁ and a₂b₂; Table 4). These mediating indirect effects are considered statistically significant if the upper and lower bounds of the 95% confidence intervals (BootCIs) are entirely above zero.16

RESULTS

Sample characteristics

The average age of the children was 9.49 years (standard deviation [SD] ± 1.782). Male participants comprised a larger proportion (81.4%) than female participants (18.6%), with most falling into the elementary year category (90.7%). A high percentage of the participants had psychiatric comorbidities (51.7%). All participants received pharmacological treatment for ADHD, with the majority (76.8%) using a single medication (methylphenidate) and a subset using additional medications, including alpha-2 agonists, second-generation antipsychotics, and selective serotonin reuptake inhibitors (Table 1).

Descriptive statistics

Tables 2 & 3 show the descriptive statistics and correlations for all study variables. On average, the sample had a total ADHD symptom score of 59.4 (SD

= 7.73), indicating mild symptoms according to age and

TABLE 1. Demographic and clinical characteristics of participants and demographic of primary caregivers.

Diagnosis

Pure ADHD 57 (48.3%)

ADHD + comorbidity 61 (51.7%)

Abbreviation: ADHD = attention-deficit/hyperactivity disorder, +1 US dollar = 35.67 Baht

TABLE 2. Descriptive results of ADHD symptoms, emotion regulation, and functional impairment.

TABLE 3. Mean, standard deviations, observed range, and correlations among study variables (n = 118).

*Statistically significant at p-value<.05, **p-value<.01.

TABLE 4. The mediating effects of the parallel mediation model illustrated in Fig 1.

(a1 b1 + a2 b2)

Abbreviations: b = understandardized coefficient; β=standardized coefficient; SE = standard error; LL = lower limit, UL = upper limit, R²

= coefficient of determination, X = independent variable; Y = dependent variable; M = mediating variable; ADHD = attention-deficit/ hyperactivity disorder, FI = functional impairment, ER = emotion regulation subscale, LN = lability/negativity subscale.

gender norms. The mean score on the emotion regulation composite score was 64.6 (SD = 7.06), suggesting that the sample had good emotion regulation, on average. Furthermore, the emotion regulation subscale showed a mean score of 24.03 (SD = 3.04), and the lability/negativity subscale showed a mean score of 34.43 (SD = 5.42). Overall, the sample had a total functional impairment score of

36.53 (SD = 15.29), indicating moderate impairment in functioning.

Correlations

Pearson’s correlations indicated that ADHD symptoms were negatively associated with overall emotion regulation (ERC composite; r = −0.515, p < 0.01). Specifically, lability/negativity subscale correlated positively with ADHD symptoms (r = 0.583, p < 0.01), while the emotion regulation subscale correlated negatively only with hyperactive/impulsive symptoms (r = −0.201, p < 0.05). Functional impairment showed a negative correlation with overall emotion regulation (r = −0.649, p < 0.01), and the emotion regulation subscale (r = −.285, p < 0.1), and a positive correlation with lability/negativity (r =

0.701, p < 0.01). Increased ADHD symptoms correlated positively with more significant functional impairment across most domains (r = 0.639, p < 0.01), with life skills demonstrating the strongest association with functional impairment, followed by academic and family domains. After adjusting for caregivers’ age, the partial correlation indicated that ADHD symptoms correlated with the lability/negativity (r = .591, p < 0.01) and functional impairment (r = .642, p < 0.01), while the correlation with the emotion regulation subscale remained insignificant (r = -.167, p > 0.05), aligning with observed relationships under caregivers’ age. Further investigation showed a negative correlation between emotion regulation subscale and functional impairment (r = -.260, p < 0.01), and a positive correlation between lability/negativity and functional impairment (r = .702, p < 0.01). Controlling for caregivers’ gender, significant correlations persisted between ADHD symptoms and lability/negativity (r =

.590, p < 0.01) and functional impairment (r = .640, p < 0.01), with the emotion regulation subscale correlation remaining insignificant (r = -.157, p > 0.05), consistent with observed relationships under caregivers’ gender.

The emotion regulation subscale negatively correlated with functional impairment (r = -.258, p < 0.01), while the lability/negativity subscale had a positive correlation with functional impairment (r = .703, p < 0.01). Similarly, after considering caregivers’ highest education, significant correlations were found between ADHD symptoms and the lability/negativity subscale (r = .582, p < 0.01) and functional impairment (r = .643, p < 0.01). The emotion regulation subscale correlation remained insignificant (r = -.162, p > 0.05), in line with observed relationships under caregivers’ highest education. The ER subscale negatively correlated with functional impairment (r = -.286, p < 0.01), while the lability/negativity subscale had a positive correlation with functional impairment (r = .705, p < 0.01). An inspection of zero-order correlations suggested that controlling for caregivers’ characteristics, such as age, gender, and education, minimally impacted the relationship strength between these study variables.

Parallel mediation analysis

To identify whether a specific dimension of emotion regulation most accurately explained the relationship between ADHD symptoms and functional impairment, parallel mediational analyses were performed. Initially, we assessed the significance of the indirect effect of ADHD symptoms through emotion regulation and emotion lability/negativity in functional impairment (path a₁b₁ and a₂b₂) (Fig 1). As Table 4 and Fig 1 show, elevated symptoms of ADHD significantly predicted more significant difficulties regulating negative emotions and controlling emotion lability, which, in turn, predicted higher functional impairment. The indirect effects (path a₂b₂, β = 0.282, Boot 95%CI 0.177, 0.389) from ADHD symptoms to functional impairment through

the mediating effect of the lability/negativity subscale were statistically significant, given that the 95%CIs were entirely above zero. Further, the direct impact of ADHD symptoms on functional impairment (path c’, β = 0.3512, p < 0.01) was significant, suggesting that ADHD children experiencing greater emotional lability and dysregulated negative affects partially mediated the relationship between ADHD symptoms and functional impairment. The direct path had a substantial effect size (R² = 0.4083), with ADHD symptoms being able to predict 40.83% of the variances in functional impairment. The indirect effect (R² = 0.5734, p < 0.001) accounted for 57.34% of the variance in both predictors, ADHD symptoms and functional impairment, when mediated by both mediators. However, the relationship between ADHD symptoms and functional impairment was not significantly mediated by the emotion regulation subscale, as specific indirect effects were not statistically significant (path a₁b₁, β = 0.006; Boot 95%CI −0.021, 0.041).

DISCUSSION

The purpose of this study was to examine the relationships between ADHD symptoms, emotion regulation processes (ERC composite), and functional impairment in children with ADHD. As predicted, higher levels of ADHD symptoms were significantly and positively correlated with more impairments in functioning. Specifically, the symptoms of ADHD had a strong positive relationship with impairments in life skills, academic performance, and family functioning. These findings align with existing research showing that a higher proportion of children with ADHD reported impaired functioning compared with typically developing children. These impairments can be attributed to symptoms related to executive dysfunction,

Fig 1. A statistical diagram of ADHD symptoms predicting functional impairment with emotion regulation (ERC-ER subscale) and lability/ negativity (ERC-LN subscale) as mediators. **p < 0.01. Coefficients are standardized estimates.

such as deficits in working memory, self-motivation, organization, planning, and time management, and contribute to challenges in acquiring necessary life skills and achieving optimal academic potential, as both areas depend highly on executive functioning.17,18

In our sample, we found a negative correlation between ADHD symptoms and emotion regulation processes (ERC composite). At the same time, lability/ negativity displayed a positive association with ADHD symptoms, indicating that heightened ADHD symptoms are linked to greater disinhibition of emotional reactivity and intense shifts in emotional states. These findings might suggest a reciprocal relationship between the tendency to exhibit more ADHD symptoms and challenges in regulating negative emotions or controlling emotional reactivity, which confers a risk of a detrimental impact on functional outcomes. Importantly, even after controlling for potential confounding factors, those correlations remained relatively stable, accentuating the direct impact of ADHD symptoms-particularly those linked with emotion lability/negativity-on functional outcomes in Thai children diagnosed with ADHD.

Notably, parallel mediation analyses examined the causal mechanisms of the emotion regulation and lability/ negativity dimensions. They showed that the only significant mediator was the indirect effect of ADHD symptoms on functional impairment through lability/negativity. Thus, children with higher levels of ADHD symptoms may manifest more dysregulated negative, socially incongruent emotions, which, in turn, leads to increased functional deficits. Increased lability/negativity often hinders the inability to sustain a consistent emotional state over time, as this could then be further exacerbated by increasing sensitivity to emotional stimuli. The reduced ability to return to a normal emotional state within a reasonable timeframe can lead to more severe consequences.19 Based on earlier longitudinal studies, children who are better at managing negative emotions and exhibiting appropriate affective behaviors demonstrate more social competence in peer interactions and prosocial behaviors, ultimately resulting in reduced internalizing symptomatology over time.20,21 This perspective underscores the risk associated with difficulties in modulating responses to negative affect, variability of mood lability, and emotional inflexibility, which pose high risks for other problems, including strained parent-child relationships, negative social experiences, and childhood depression.20,22,23

However, contrary to the literature, the indicators of the emotion regulation subscale did not significantly mediate the pathway in our study, which could be partly explained by measurement differences. Our analysis

focused only on appropriate positive emotion expressions, socially congruent behaviors, and empathy toward others as indicators of adaptive emotion regulation. Future research could incorporate more multifaceted aspects of emotion regulation (e.g., emotion recognition and awareness), using diverse instruments and observational measures to better understand a child’s emotion regulation processes as manifested in various patterns of difficulty. The present findings underscore the importance of interventions targeting the improvement of emotion regulation deficits in alleviating functional impairment in ADHD children. Evidence-based cognitive behavioral interventions and parent management training have been shown to enhance emotional competence and adaptability in children. These multimodal approaches incorporate emotion-focused coping skills, promoting awareness, understanding, and managing of emotional responses through mindful parenting styles, maternal guidance, modeling positive expressiveness, and cognitive reframing of emotions.24,25 Emotion regulation interventions, such as the “Checking the Facts” or “Opposite Action” from Dialectical Behavior Therapy (DBT) skill training26, may specifically target emotion lability and negativity by intentionally identifying emotions that may or may not align with the facts, counteracting action urges with more productive learned options and rehearsing alternative solutions. Acquiring and practicing these set of specific skills can ameliorate a child’s emotional dysregulation in response to emotionally triggered situations while also facilitating adaptive, goal-directed behaviors.27

Limitations

A primary limitation of the current study is that the data was derived from a single center and may not fully represent larger patient populations, thus limiting the generalizability of the findings. Future research should incorporate data from multiple centers to ensure a more diverse and representative sample. Second, our study focused on the ongoing effects of difficulties in emotion regulation and functional outcomes among participants who received various pharmacological treatments and interventions and did not capture the initial baseline conditions reflecting the acute effects before treatment. Thirdly, given that all assessments were parental reports and potentially subjected to the possibility of (positive) attributional bias, future research should ensure that correlation analyses between study variables are adjusted, accounting for parental characteristics. Therefore, a multi- informant perspective would be critical for capturing symptoms and conditions in different settings.

CONCLUSION

Understanding the underlying mechanisms linking ADHD symptoms and functional impairment may play a critical role in developing interventions that can effectively target functional challenges in children with ADHD. Our findings suggest that emotion lability/ negativity partially mediated the link between ADHD symptoms and functional impairment (β = 0.282, p < 0.001), with ADHD symptoms and lability/ negativity indirectly accentuating functional impairment. These findings are consistent with previous research that demonstrated that managing core ADHD symptoms and reducing emotion lability/negativity can play protective roles in reducing the adverse effects of impaired functioning. Therefore, regular monitoring and targeted therapeutic interventions for emotion lability/negativity may be significant priorities in the ongoing effort to improve functional outcomes among Thai children with elevated ADHD symptoms in this age group.

ACKNOWLEDGMENTS

This study received funding from the Siriraj Graduate Scholarship (Type I), Faculty of Medicine Siriraj Hospital, Mahidol University. The authors acknowledge with gratitude the participants and caregivers who participated in the study.

Conflicts of interest

All authors declare no potential conflicts of interest.

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‌Role of Resilience in the Relationship between Adverse Childhood Experiences and Behavior Problems among Thai Adolescents in a Province of Southern Thailand: A School-Based Cross-Sectional Study

Tikumporn Hosiri, M.D., Anawin Jongjaroen, M.Sc., Soisuda Imaroonrak, Ph.D., Thanayot Sumalrot, Ph.D., Sucheera Phattharayuttawat, Ph.D.

Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT

Objective: This study aimed to investigate the relationship between adverse childhood experiences (ACEs), behavior problems, and resilience among adolescents in Southern Thailand, with a particular focus on the role of resilience in mediating the relationship between ACEs and behavior problems.

Materials and Methods: A paper-and-pencil questionnaire, covering participants’ general information, Thai Version of the Adverse Childhood Experiences Questionnaire (ACEs questionnaire), Adolescent Risk Behavior Inventory-12 Items, and Thai Version of the Connor–Davidson Resilience Scale (25-Item CD-RISC), was distributed to 383 senior high school students in a province in Southern Thailand. The data was analyzed using descriptive statistics, correlation analysis, and path analysis.

Results: Out of the 383 students the questionnaire was distributed to, 374 completed the questionnaire, resulting in a response rate of 97.65%. Alarmingly, 59.36% of the respondents reported experiencing at least one type of ACE. Correlation analysis revealed a significant positive association between ACEs and behavior problems (r = 0.17, p < 0.01) and a negative correlation with resilience (r = -0.19, p < 0.01). Path analysis demonstrated that ACEs directly influenced behavior problems (β = 0.23, p < 0.01) and resilience (β = -0.24, p < 0.01). However, the analysis did not support the hypothesis that resilience mediates the relationship between ACEs and behavior problems.

Conclusion: The findings indicate a troubling prevalence of ACEs among senior high school students in Thailand, likely contributing to current adolescent behavior problems. Although the study’s path analysis did not align with prior research, it emphasizes the critical role of resilience in mitigating the adverse effects of ACEs. Therefore, resilience remains a necessary skill in helping adolescents cope with the consequences of ACEs.

Keywords: Adolescent; adverse childhood experiences; behavior problems; resilience (Siriraj Med J 2024; 76: 282-292)

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) in the United States (US) defines adverse childhood experiences (ACEs) as traumatic events or circumstances that can cause lasting emotional harm to children. These events typically occur between birth and age 171 and

are categorized into 10 types: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, household physical violence, household substance abuse, household mental illness, parental separation/divorce, and an incarcerated household member.2 Studies have shown that individuals who have experienced ACEs are

Corresponding author: Anawin Jongjaroen E-mail: new.anawin@gmail.com

Received 9 January 2024 Revised 29 February 2024 Accepted 9 March 2024 ORCID ID:http://orcid.org/0009-0004-5136-5461 https://doi.org/10.33192/smj.v76i5.267232

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

at an increased risk of substance abuse, mental health issues, and even physical illnesses, including heart disease and cancer.3

Research conducted in the US from 2011 to 2014 effectively underscores the extensive nature of this issue, revealing that a substantial 61.55% of individuals aged 18 years old and older in the US had encountered at least one ACE.4 Furthermore, scholarly inquiries in East Asian nations, including in locations such as Singapore,5 China,6 and Thailand,7,8 have consistently revealed congruent patterns. These findings provide compelling evidence that the prevalence of ACEs shows a remarkable degree of uniformity across a diverse array of cultural contexts. In addition to the ACEs that exhibit associations with physical and mental health concerns, these experiences often demonstrate a pronounced link to behavior problems in adolescents, notably within the subset of children subjected to violent or abusive parental environments.9 Substantiating this connection, empirical research has highlighted that individuals who have endured ACEs are predisposed to a heightened likelihood of involvement in delinquent activities.10 An international study, encompassing data from teenagers aged 18 to 20 years old across a diverse array of countries, including Thailand, further underscored the nuanced impact of certain forms of household dysfunction in precipitating the emergence of behavior problems among adolescents. It is noteworthy also that the extent of this influence is contingent upon various factors, including gender and the level of social

well-being.11

Adolescent delinquency presents a pressing concern in the Thai context, demanding both careful attention and the formulation of pragmatic, evidence-based solutions. This issue is notably exacerbated by the participation of a significant proportion of adolescents in various criminal activities.12 Empirical investigations conducted with adolescents in Bangkok have brought to light a discernible correlation between behavior problems, with a particular emphasis on drug use, and the occurrence of ACEs. Furthermore, these studies have revealed that over half of the participating adolescents had encountered ACEs, thus underscoring the pervasive nature of this problem among the youth in Thailand.7,8 These documented findings align coherently with analogous research conducted across different countries, emphasizing the global dimension of the challenges presented by ACEs and their associated ramifications.

Nonetheless, it is essential to acknowledge that not all children exposed to ACEs necessarily will manifest behavior problems. Some children demonstrate a capacity for effective adjustment and possess elevated psychological

resilience, which enables them to develop successful coping strategies. In this context, resilience represents a psychological attribute indicative of one’s ability to adeptly navigate adverse circumstances. This multifaceted concept encompasses the adept adaptation to challenging situations, the shaping of one’s worldview, the acquisition of adequate social support, and the implementation of more suitable problem-solving strategies.13

Supporting this perspective, prior research has emphasized that resilience is a skill that can be cultivated and enhanced.14 Additionally, resilience plays a pivotal role as a psychological attribute that can serve as a protective factor against the adverse consequences of ACEs, particularly concerning emotional and behavioral issues. For example, a study involving high school students aged 14 to 19 in Turkey revealed that resilience and self- esteem can collectively act as mediators in the relationship between exposure to child abuse and the development of emotional and behavioral challenges.15

Adolescence is a crucial period characterized by the emergence of behavior problems as individuals transition from childhood to adulthood. This developmental stage encompasses significant changes across physical, cognitive, emotional, and social dimensions. Notably, the age range of 15 to 18 years old is particularly noteworthy for the increased occurrence of behavior problems and delinquent behaviors.16

Furthermore, it’s important to acknowledge the gap in scholarly research concerning the role of resilience amidst ACEs and their link to behavior problems, especially within Thailand’s distinct context. Recognizing this gap, our study focuses specifically on investigating how resilience acts as a mediator between ACEs and behavior problems among adolescents in the southern region of Thailand. The research objectives aim to comprehensively explore the impact of ACEs on adolescent behavior. Firstly, the study delves into understanding how resilience mediates the connection between ACEs and behavior problems in adolescents. Secondly, it seeks to clarify the direct relationship between ACEs and adolescent behavior problems, shedding light on its nature and scope. Lastly, the study aims to assess the prevalence rates of ACEs, behavior problems, and resilience among adolescents, providing valuable insights into their co-occurrence. Through these objectives, the research endeavors to deepen our understanding of how ACEs, resilience, and behavioral outcomes interact among adolescents.

The collection of empirical data from this specific demographic holds the promise to provide valuable insights that can deepen our understanding and contribute to the prevention and mitigation of the behavioral challenges faced

by young individuals in Southern Thailand. Additionally, the foundations established by this study may serve as a fundamental knowledge base, with potential applications in guiding future research endeavors across diverse geographical areas within the nation.

MATERIALS AND METHODS

Participants

Twenty-two high schools located within a specific province in Southern Thailand were categorized into three groups: small, medium, and large to extra-large schools, according to the criteria set by the Office of the Basic Education Commission. Three high schools were randomly selected from each group. The population consisted of 8,909 students. The sample size, totaling 383 participants, was determined using Taro Yamane’s formula. The participants in this study were senior high school students currently enrolled in these selected high schools. In order to be eligible for participation, individuals had to meet the following inclusion criteria: they had to be between 15 and 18 years old, be proficient in the Thai language, not have a history of psychiatric or developmental disorders, and must obtain parental permission and provide informed consent to partake in the research. Students who did not complete the questionnaires or who responded randomly were excluded from the final dataset.

Questionnaire

A paper–pencil-based questionnaire was used in this study and consisted of 4 parts:

1. General Information Questionnaire, which included questions on the participant’s gender, age, grade level, co-resident parents, parent’s occupation, parent’s income, marital status of parents, and medical condition.

2. Thai Versionofthe Adverse Childhood Experiences Questionnaire (ACEs questionnaire)17, consisting of 28 items covering 10 different types of ACEs. Participants were requested to complete the questionnaire, and their scores were computed and categorized for each type of ACE. The scale of answers and scoring criteria varied based on the type of ACEs, and the total score ranged from 0–10, representing the number of different types of ACEs encountered. The questionnaire demonstrated good content validity and empirical validity. Internal consistency reliability was 0.79 for the child abuse question,

   0.82 for the neglect question, and 0.66 for the household dysfunction question.18

3. Adolescent Risk Behavior Inventory-12 Items

   consisting of 12 items covering question about risk of

   engaging in violent behaviors, such as “Carrying weapons or objects with the intent to harm others,” “Assembling your own weapons,” “Providing illegal drugs to others,” and “Sexually harassing.” Responses measured on a 5-point rating scale from 0 (Never) to 4 (Very often), with the total score ranging from 0–48. Higher scores are indicative of a greater number of behavior problems. The participants were asked to complete the questionnaire by themselves. The overall internal consistency was 0.928.19

4. Thai Version of the Connor–Davidson Resilience Scale (25-Item CD-RISC), as translated by Nauwarat Imlimtharn and approved by Dr. Jonathan Davidson, one of the scale developers, consisting of 25 items. Responses were measured on a 5-point rating scale from 0 (Not true at all) to 4 (True nearly all the time). Self-reporting was required. The total score ranged from 0–100. Higher scores are indicative of a higher level of resilience. The overall internal consistency was 0.89.20

Data collection

The study received approval from the Human Research Protection Unit at the Faculty of Medicine Siriraj Hospital, Mahidol University, under the COA number Si 069/2023. Data collection occurred during the months of June through August in 2023. Participants who met the inclusion criteria were invited to participate through a face-to-face invitation. These participants were provided with detailed information regarding the research’s objectives, data-collection procedures, the expected duration of participation, the potential benefits and risks, data confidentiality, contact information for addressing any procedural concerns, and their right to withdraw from the research at any point. Interested participants received an informational document and a consent form for their parents. Those with parental consent were required to sign their own consent form before starting the questionnaire. After completing the questionnaires, a group relaxation workshop was conducted to mitigate any stress or potential effects that may have arisen during the questionnaire completion process.

Statistical analysis

The collected data were statistically analyzed using SPSS. The analysis was structured into three distinct segments. First, descriptive analysis was performed to present the frequencies and percentages of the main variable scores along with the demographic data, encompassing the respondents’ gender, age, grade level, the co-residency of parents, parental occupation, parental income, marital status of parents, and any existing medical conditions. Second, correlation analysis was performed utilizing

the Spearman correlation coefficient (rs) to assess the relationships between adverse childhood experiences (ACEs), behavior problems, and resilience, encompassing the analysis of the continuous variables. In cases where the relationships involved nominal dichotomous variables and continuous variables, Point Biserial Correlation analysis (rpb) was applied. Additionally, Phi correlation analysis (rØ) was employed to evaluate the relationships between two nominal dichotomous variables. Any unspecified data was considered as missing values. Last, path analysis was conducted, utilizing the mediation model (model 4) from the PROCESS Macro program. This path analysis aimed to investigate the role of resilience as a mediator in the relationship between ACEs and adolescent behavior problems.

RESULTS

Demographic data of the participants

Out of the total 383 participants, 374 completed the questionnaire adequately, for a response rate of 97.65%, resulting in a final sample size of 374 (n=374). The majority of participants were female, accounting for 61.2% of the sample. Additionally, a substantial portion of the participants were enrolled in Grade 10 (40.1%). The average age of the participants was 16 years old, with a small standard deviation of 1.02, indicating a relatively homogeneous age distribution. Regarding the participants’ living arrangements, more than two-thirds resided with both their father and mother (66.6%), while 25.9% lived with either one parent, and 5.1% lived with their grandparents. In terms of parental occupation, the most common category was Agriculturist (32.4%), followed by Self-employed (24.3%), and Government officer/ State enterprise (21.9%). The average monthly income among the parents was 26,684.13 baht, with a relatively high standard deviation of 35,087.41 baht, suggesting large income variability within the sample. However, over half of the parents fell within the income range of 0 to 20,000 baht monthly. A significant majority of the participants reported that their parents were married (73.5%). Notably, the majority of participants (90.1%) did not report any medical conditions, as detailed in Table 1.

Descriptive analysis

The research encompassed three key variables: ACEs, behavior problems, and resilience. Descriptive statistical analysis of these variables revealed specific characteristics. The mean number of ACEs was 1.36 with a standard deviation of 1.66, ranging from 0–8. Behavior problems had a mean score of 1.68 with a

standard deviation of 2.39 and ranged from 0–17. These scores indicate a group not at risk of engaging in violent behaviors. Resilience exhibited an average score of 68.52, with a standard deviation of 15.23, ranging from 19–100.

The data analysis provided insights into the prevalence of ACEs among the participants. Specifically, 40.64% of all participants reported no ACEs, indicating a considerable proportion of participants did not encounter these adverse events during their childhood. In contrast, 59.36% reported experiencing at least one type of ACE, underscoring the prevalence of these experiences within the sample. Among this latter group, 12.03% reported enduring the challenges of four or more ACEs, signifying a significant level of exposure to multiple ACEs.

An examination of the specific types of ACEs reported by the participants revealed that parental separation or divorce was the most commonly reported experience, acknowledged by 31% of the participants. Additionally, emotional neglect was reported by 20.6% of participants, followed by physical neglect (18.7%) and physical abuse (12.8%). These proportions are visually presented in Table 2, offering a comprehensive illustration of the various ACEs prevalent among the study participants.

Relationship between ACEs, behavior problems, resilience, and demographic data

ACEs displayed a low positive correlation with behavior problems (rs = 0.17, p < 0.01) and a low negative correlation with resilience (rs = -0.19, p < 0.01). Notably, resilience did not exhibit a significant relationship with behavior problems. Moreover, a significant, albeit low, negative relationship was observed between gender and behavior problems (rs = 0.12, p < 0.05), indicating that males were more likely to experience behavior problems than females. Additionally, the marital status of parents showed noteworthy associations. Specifically, living with divorced parents was linked to a significantly low positive correlation with ACEs (rpb = 0.44, p < 0.01) and behavior problems (rpb = 0.11, p < 0.05), suggesting that children in such family structures had a higher likelihood of both experiencing ACEs and exhibiting elevated behavior problems. Further details are available in Table 3. Moreover, the correlation analysis between the types of ACEs and behavior problems showed low positive associations with SA (rpb = 0.23, p < 0.05), HS (rpb = 0.23, p < 0.05), EA (rpb = 0.17, p < 0.05), IH (rpb = 0.17, p < 0.05), and PD (rpb = 0.11, p < 0.05).

Relationship between the number of ACEs, behavior problems, resilience, and medical conditions

Having no ACEs was found to be negatively associated

TABLE 1. Demographic data of the participants (n = 374)

TABLE 2. Number and type of ACEs (n = 374).

Note. A participant can have more than one type of ACE.

TABLE 3. Correlation coefficients of the studied variables.

Note. The numbers in brackets refer to Cronbach's coefficient alpha.

*p < 0.05; **p < 0.01.

with medical conditions (rØ = -0.13, p < 0.05) and behavior problems (rpb = -0.14, p < 0.01). In contrast, it displayed a positive association with resilience (rpb = 0.15, p < 0.01). This suggests that individuals who reported having no ACEs were more likely to be free from medical conditions, exhibit no behavior problems, and possess higher levels of resilience compared to those who had experienced ACEs. Conversely, having four or more ACEs was positively

associated with behavior problems (rpb = 0.15, p < 0.01) and negatively associated with resilience (rpb = -0.18, p < 0.01). The specifics of these associations are presented in Table 4, providing a comprehensive overview of the relationships between the number of ACEs and the variables of medical conditions, behavior problems, and resilience.

TABLE 4. Correlation coefficients between the number of ACEs and other variables.

* p < 0.05; ** p < 0.01.

Mediating effect of resilience on ACEs and behavior problems

ACEs were found to have a significant negative effect on resilience (β = -0.24, SE = 0.47, t = -4.84, p < 0.01, 95%CI [-3.20, -1.35], R2 = 0.059). However, resilience did not significantly impact behavior problems (β = 0.09, SE = 0.008, t = 1.70, p = 0.09, 95%CI [-0.002, 0.03]).

Additionally, a direct and significant effect of ACEs on behavior problems was observed (β = 0.23, SE = 0.08, t = 4.39, p < 0.01, 95%CI [0.18, 0.48]). Furthermore,

the results of the Bootstrap Confidence Intervals (CIs) indicated that there was no indirect effect of ACEs on behavior problems that was mediated by resilience (β =

-0.02, SE = 0.02, 95% CI [-0.08, 0.009]). These findings

are presented comprehensively in Table 5 and Fig 1.

DISCUSSION

The study involved a cohort of 374 participants, of whom 40.64% reported having no ACEs, while 59.36% reported the presence of at least one ACE in their lives. A subset of participants, specifically 12.03%, disclosed the challenging experience of enduring four or more ACEs. These findings align with prior studies conducted both on an international scale and within Thailand itself.3-8 The persistence of a significant prevalence of ACEs over more than two decades of research underscores a concerning trend. This trend may be better understood when viewed through the lens of intergenerational transmission.

A meta-analysis, which primarily focused on studies published between 1975 and 2017 in Western countries, delved into the concept of intergenerational transmission,

TABLE 5. Mediation analysis of resilience on the relationship between ACEs and behavior problems.

Note. SE = standard error; LLCI = lower level of the 95% confidence intervals; ULCI = upper level of the 95% confidence intervals; Boot = Bootstrap result.

Fig 1. Mediating effect of resilience on ACEs and behavior problems.

revealing that parents who had themselves suffered childhood abuse were at a heightened risk of perpetuating abusive behavior toward their own children. However, it is crucial to emphasize that this transmission of child abuse is not a universal phenomenon; rather, it varies due to multiple contributing factors. These influencing factors encompass the characteristics of families marked by insecure attachment styles, experiences of social isolation among parents, early parenthood, elevated stress levels, economic hardship, parental psychopathology, maternal substance use, and ongoing exposure to parental violence. The meta-analysis ultimately concluded that parents who had endured childhood abuse often carry an ardent desire to shield their own children from similar suffering. Paradoxically, they often lack access to positive parenting role models and have been raised in environments characterized by insecure relationships. Consequently, they face a formidable challenge in cultivating a safe and secure parent–child relationship, inadvertently perpetuating the cycle of child abuse across generations.21 This enduring cycle consequently contributes to the continued exposure of a substantial number of children to ACEs. This aligns with research findings where participants reported experiencing family issues, particularly parental divorce, and household violence, indicating an upbringing in an insecure environment. Without adequate psychological support, there’s a risk of passing on these emotional or mental challenges to the next generation.

Our findings show that the risk of engaging in violent behaviors is associated with experiences of abuse, household substance abuse, having an incarcerated household member, and parental divorce. These findings, consistent with a prior study, highlight a noteworthy connection between ACEs and behavior problems that emerge during adolescence.9,11 This observation corresponds to the foundational tenets of Bandura’s social learning theory, which posits that behavior is significantly influenced by observational learning processes. To provide a theoretical

underpinning to this relationship, one can invoke Bandura’s classic experiment, which involved exposing children to aggressive models interacting with a Bobo doll. The results of that experiment demonstrated that children who witnessed aggressive behavior directed at the Bobo doll were more inclined to exhibit similar aggressive behaviors when given the opportunity.22 This supports the idea that behavior is shaped through observation and imitation, thereby reinforcing the relevance of social learning theory. As a result, when children find themselves in environments characterized by abuse, insecurity in attachment, violence, substance abuse, or involvement in illegal activities, they are exposed to ample opportunities for observational learning. Consequently, they may imitate behaviors they have witnessed, with the potential culmination being the manifestation of future behavior problems during their adolescent years.

ACEs were found to have a negative association with resilience, suggesting that individuals who have experienced a higher number of ACEs tend to exhibit lower levels of resilience compared to those with fewer such adverse experiences. This finding aligns with prior research studies23,24 that have explored the relationship between ACEs and resilience. However, an intriguing perspective has emerged from an in-depth interview study involving individuals aged 50 to 77 years old. The results of that study indicate that individuals with a history of ACEs tended to develop higher levels of resilience. This counterintuitive outcome can be explained by the notion that challenging childhood experiences can, in fact, facilitate learning, self-development, and improved problem-solving abilities, ultimately contributing to greater resilience25 It is essential to note that the existing body of research on the relationship between ACEs and resilience is limited, and previous findings have been inconclusive. This ambiguity arises from the understanding that resilience is not a fixed personality trait but rather a dynamic quality that can either increase or decrease over time.26,27 Furthermore, most research studies define

resilience as a mediating or protective factor against the adverse impact of ACEs,28,29 adding complexity to the overall picture of this relationship.

The path analysis conducted in this study revealed that resilience did not function as a mediating variable in the relationship between ACEs and adolescent behavior problems. Moreover, it did not exhibit a direct impact on behavior problems. Interestingly, this result contradicts the findings of a previous study,15 which demonstrated that resilience, along with self-esteem, played a mediating or protective role in mitigating the influence of childhood abuse on emotional and behavioral problems. This discrepancy implies the existence of additional variables, apart from resilience, that mediate the relationship between ACEs and behavior problems. For instance, these variables might encompass self-esteem15 and impulsivity,30 both of which have been implicated as contributing factors in prior research.

While this study did not find resilience to be a mediating or protective factor in the relationship between ACEs and behavior problems, it is essential to acknowledge that resilience can play such a role in various other contexts. For instance, research conducted among undergraduate students showed that resilience acted as a protective factor in the relationship between ACEs and depressive symptoms31 Additionally, a study involving homeless individuals demonstrated that resilience served as a protective factor against mental health problems influenced by ACEs.32 These findings underscore the multifaceted nature of resilience and its varying impact in different scenarios. Previous research has demonstrated that resilience can be enhanced.14 Therefore, it is crucial to prioritize resilience development for children and adolescents through interventions such as mindfulness- based approaches.33

Limitations of the present study and recommendations for future research

This research’s exclusivity to school system participants potentially narrowed the diversity of the dataset, particularly in terms of the behavior problem scores; whereby the behavior problem scores in this dataset exhibited limited variability, with a majority of participants scoring low, and a significant 40.4% reporting no behavioral problems. Consequently, this dataset deviated from a normal distribution, thereby affecting the accuracy of the statistical analysis. Additionally, this study asked participants to self-assess their behavioral problems. Therefore, it may underestimate one’s own problems. Different information may be obtained if parents or teachers are the respondents. In future research

endeavors, it is advisable to include behavior problem assessment data from parents or teachers, such as Strengths and Difficulties Questionnaire (SDQ), in the analysis to improve the accuracy of the information gathered. Moreover, future research should expand the scope by incorporating a broader range of population groups. This expansion could include vocational education students, children outside the conventional school system, and even those involved in criminal activities (known groups). The inclusion of such diverse groups could provide a richer spectrum of information and facilitate a deeper understanding of any variations between these groups, effectively overcoming the limitations associated with studying a single homogeneous population.

The generalizability of the research findings is inherently restricted by the study’s narrow scope. Data collection was confined to students within a single province in the southern region of Thailand, primarily due to time and staffing constraints. It is imperative to recognize that social and cultural differences exist across various regions, potentially influencing research outcomes. For future research endeavors, extending the study’s geographical coverage is advisable. This could involve conducting studies at the regional or even national level, allowing researchers to obtain more comprehensive and representative insights, ultimately enhancing the applicability and generalizability of their findings.

Furthermore, this research exclusively focused on the impact of ACEs on behavior problems, but previous studies have demonstrated that ACEs can have a wide range of effects that extend beyond just behavioral issues. It is therefore imperative that future investigations explore additional variables influenced by ACEs, including emotional problems and mental health concerns.

In addition to considering resilience, it is equally important to investigate other variables that may serve as protective factors against the impact of ACEs. These factors may include aspects such as self-esteem and emotional regulation skills. By examining a more comprehensive set of variables, we can gain a better understanding of the multifaceted effects of ACEs and identify potential avenues for intervention to reduce their impact.

In this research, the Intelligence Quotient (IQ) of participants emerges as a confounding factor that can significantly influence their adaptability and, consequently, their resilience levels. Additionally, psychiatric disorders can affect the severity of behavioral issues such as Conduct Disorder and Oppositional Defiant Disorder, as well as attention and concentration levels, and the ability to cope with adverse situations, such as Attention Deficit Hyperactivity Disorder (ADHD), Depression, and Post-

traumatic Stress Disorder (PTSD). However, the inclusion criteria for this study did not encompass individuals with psychiatric or developmental disorders. This criterion was solely based on self-evaluation by the participants. Therefore, for future research, it is essential to employ screening tests for both IQ and psychiatric disorders to control confounding factors. This may involve selecting groups with similar IQ or excluding those with psychiatric disorders from the study. Alternatively, considering IQ as a variable of interest in our research framework could provide an additional avenue for nuanced exploration.

CONCLUSION

The results of this study shed light on the prevalence of ACEs among senior high school students in Southern Thailand, with a notable presence revealed among those whose parents are divorced. This observation highlights a broader child welfare concern in Thailand, even though the data were specifically collected from students within the school system. This situation raises alarms regarding the potential adverse consequences, particularly behavioral and mental problems, that these children might face in the future. While it is true that resilience was not found to serve as a mediating factor between ACEs and behavior problems in this context, it is important to recognize that resilience is a vital skill that can help mitigate the mental and emotional impacts of stress and life difficulties. As such, there is a compelling need to prioritize the development of resilience in children to equip them for future challenges and reduce the risk of them developing emotional or mental health issues.

ACKNOWLEDGEMENTS

The research received funding through the Siriraj Graduate Scholarship under the Faculty of Medicine Siriraj Hospital, Mahidol University. We extend our sincere appreciation to the school guidance teachers and all the research participants for their invaluable cooperation and contributions to this study. Additionally, we express our gratitude to Miss Nerisa Thornsri for her assistance with the statistical aspects of the research.

Conflict of interest

The authors have no conflicts of interest to declare.

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‌Factors Affecting the Mental Health of Thai Medical Staff during the Second and Third Waves of the COVID-19 Pandemic: An Online Cross-sectional Survey

Rungarun Anupansupsai, M.D.1, Nattha Saisavoey, M.D.1, Suroj Supavekin, M.D.2, Woraphat Ratta-apha, M.D.1, Juthawadee Lortrakul, M.D.1, Somboon Hataiyusuk, M.D.1

1Department of Psychiatry, 2Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

INTRODUCTION

Healthcare professionals are an essential group of people who care for COVID-19 patients. Previous studies have found that frontline healthcare staff are at risk of experiencing depression, anxiety, and insomnia, and can face more desperation than non-frontline staff.1

However, a previous study showed no difference in scores on anxiety and depression between frontline workers and non-frontline workers.2 Furthermore, non-frontline staff experienced more vicarious traumatization than frontline staff.3 As a result, it is critical to consider the mental health of all personnel.

Corresponding author: Nattha Saisavoey E-mail: nattha.sai@mahidol.edu

Received 15 January 2024 Revised 11 February 2024 Accepted 27 February 2024 ORCID ID:http://orcid.org/0000-0001-6278-3440 https://doi.org/10.33192/smj.v76i5.267324

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

Siriraj Hospital, part of Mahidol University’s Faculty of Medicine, is a tertiary-level medical service institution in Thailand. With the potential to treat patients infected with the novel coronavirus 2019, many people are expected to visit for disease examination and treatment. During the first wave, the Human Resources Department of the Faculty of Medicine Siriraj Hospital surveyed stress, mental health status, and the basic needs of hospital staff. According to the survey, more than 31% of staff were found to have high levels of stress, 43% to have high levels of anxiety, and 46% to have high levels of depression on the Depression, Anxiety, and Stress Scales (DASS-21).

Each wave of the pandemic has a different level of stress exposure. Following a previous study in China, the second wave of the outbreak’s fear levels was lower than those for the first. Yet compared to the first wave, depression scores in the second wave were significantly greater.4 According to reports from England, anxiety levels in the second wave were much lower than in the first wave. Although there was no significant difference in depression in this study, there was a considerably higher rate of suicide ideation.5 Nevertheless, the prior study was conducted among the general population. Studies on the mental health of medical staff in the subsequent wave are still scarce.

Thailand managed the COVID-19 crisis so efficiently during the early phases of the outbreak that it was ranked first in the global COVID-19 Index (GCI).6 However, the second wave of the outbreak, which started in January 2021, was primarily from a group of migrant workers in the wet market in Samut Sakhon Province, which led to a new wave of panic among the population. Furthermore, during the third wave of the outbreak in May, a cluster of COVID-19 cases was linked to entertainment venues such as pubs, bars, and nightclubs. This wave of the outbreak was caused by the British strain, which was considered more dangerous due to its ability to spread rapidly. As a result of the increased burden on hospitals to treat COVID-19 patients, understanding the mental health status of hospital staff in the second and third waves is critical.

Furthermore, understanding the factors influencing staff mental health status will allow for more effective targeting assistance. A previous study in China indicated that being a nurse, female, a frontline worker, and working in Wuhan were associated with mental heal symptoms.1 Additionally, compliance with and perceived effectiveness of social distancing measures were also associated with lower levels of stress, anxiety, and depressive symptoms, as evidenced in a study in Hong kong.7 Upon closer

examination at university hospital in southern Thailand, being female, having a physical illness, and perceiving exposure to COVID-19 were identified as risk factors for severe mental health outcomes among university staff.8 Therefore, this study focuses on demographic information, staff characteristics, health behavior, and readiness to handle the COVID-19 situation.

The objectives of this comparative study of the second and third waves of the COVID-19 pandemic were to:

1) examine the mental health of the medical staff working in the Faculty of Medicine Siriraj Hospital, Mahidol University; 2) describe the relationships between various factors and the staff’s mental health; and 3) investigate the effects of the COVID-19 situation on staff.

MATERIALS AND METHODS

Study design and participants

The participants were the staff of the Faculty of Medicine Siriraj Hospital who voluntarily agreed to complete the online survey. The survey link was promoted on a local social media platform, Siriraj staff group. The data of the second wave were collected between January and February 2021, and data of the third wave collected between May and June of the same year. This study was approved by the Institutional Review Board (IRB), Faculty of Medicine Siriraj Hospital, Mahidol University (COA no. Si 081/2021). Participants were informed about the study’s objectives and the use of their responses for research. The participants acknowledged consent by completing the survey.

Measurement

A questionnaire on factors affecting the mental health during COVID-19; regarding demographic information, staff characteristics, health behavior, and readiness to handle the COVID-19 situation. Respondents were asked to choose only one option that applied to them in each item.

Questions about the impact of the COVID-19 pandemic; included lists of factors affecting stress and lists of impacts on daily living. Respondents were asked to choose the factors that had an impact on their lives and were allowed to choose more than one factor.

The Thai version of the Depression Anxiety Stress Scales–21 (DASS-21)9 was used to assess the mental health status, which had three subscales (Anxiety, Depression, and Stress). Each subscale consisted of seven items with a 4-point Likert scale ranging from “applied to me very much” to “did not apply at all.” Cronbach’s alpha coefficient cutoffs for Anxiety, Depression, and Stress were .82, .78, and .69, respectively.

Statistical analysis

All statistical analyses were conducted using SPSS

24. The frequency and percentages were used to calculate descriptive data. As distributions of DASS-21 scores were highly right-skewed, the comparisons of scores on DASS-21 with categorical variables were conducted using the Mann-Whitney U and the Kruskal-Wallis tests. Finally, generalized linear models were used for multivariate analysis, including all significant variables from the univariate analysis. P values <.05 were considered statistically significant in this study.

RESULTS

The mental health status of the Siriraj Hospital staff during the second and the third waves.

The number of participants in the second and the third waves was 3,096 and 1,192. In the second and the third waves, the participants’ median scores and Q1-Q3 intervals on the DASS-21 were 10 (3-20) and 8 (2-17), respectively. It was found that the scores on depression, anxiety, and stress in the third wave were significantly higher than those in the second wave (Table 1).

Factors affecting the mental health status of Siriraj Hospital staff in the second and the third waves.

Table 2 showed significant factors in the univariate analysis. After performing a multivariate analysis (Table 3), younger age, longer work hours, a history of external infection exposure, and awareness of social distancing were associated with higher depression, anxiety, and stress scores, only in the second wave. Additionally, readiness to work from home were correlated with higher anxiety and stress, demonstrating significant associations only in the second wave.

Factors significantly associated with all emotional scores in both waves included underlying diseases, sleep issues, alcohol use during stress, lack of exercise, residence

in high-surveillance zones, and social distancing difficulties. Office work was correlated with higher anxiety and stress in both waves, with depression showing association only in the third wave. The lack of potential for self-quarantine at home was associated with higher depression and stress in both waves.

Directly caring for COVID-19 patients was significantly associated with higher depression and anxiety only in the third wave. Less exercise than usual was associated with higher anxiety and stress, with these correlations being significant only in the third wave.

Impact (of COVID-19 pandemic) on Siriraj Hospital staff in the second and the third waves

Table 4 indicated that in the second wave, the top three factors affecting stress were living expenses (57.9%), changes in daily living patterns (53.7%), and the cost of protective equipment (45.6%) (7th in the third wave). In the third wave, the first two factors remained consistant (61.3% and 58.6%, respectively), with news and information about pandemics ranking third (51.1%) (7th in the second wave).

Regarding daily life impacts, the top three in the second wave were income (54.3%), transportation (53.1%), and protective equipment for COVID-19 prevention (33.7%) (4th in the third wave). In the third wave, the first two impacts remained the same (59.5% and 52.0%, respectively), with food ranking third (48.2%) (4th in the second wave).

DISCUSSION

This study aimed to investigate the mental health status of hospital staff, the factors affecting the staff’s mental health status, and the impact of the COVID-19 pandemic on the staff of Siriraj Hospital in comparison between the second and the third waves of the pandemic.

TABLE 1. The difference between depression, anxiety, and stress of the second and third waves.

TABLE 2. Factors that affect the depression, anxiety and stress of the second and third waves.

TABLE 2. Factors that affect the depression, anxiety and stress of the second and third waves. (Continue)

TABLE 3. General Linear Regression for Wave 2 and Wave 3.

TABLE 3. General Linear Regression for Wave 2 and Wave 3. (Continue)