As populations age in many parts of the world, caregivers are becoming increasingly numerous, yet little attention has been paid to their needs [1]. Informal caregivers contribute to the health system and constitute an important shadow workforce [2]. For example, in the USA, each year, almost a quarter of the population provides unpaid assistance to ill, disabled, or elderly persons [3].

Caregivers have to balance their caring responsibilities with employment and financial security, their own physical and mental health, and overall quality of life [4]. It is vital to understand the emotional stress and psychological health experienced by caregivers [5]. Caregivers who face social and emotional burdens related to caregiving have more health-risk behaviors such as alcohol use [6]. A meta-analysis study on health correlates of caregiving found that predictors of physical health are different from psychological health hence both merit theoretical and empirical attention [7]. Chronic physical conditions among caregivers tend to be worsen over time [8]. One such condition is lower back pain [9, 10].

Information on the prevalence, health and wellbeing of caregivers in middle-income economies is quite limited. Some studies on caregivers have been reported from Asia but most of these have been conducted in more affluent countries. For example, there are reports from Japan on stress and female family caregivers [11–13]. A study in Hong Kong noted adverse physical and psychological health, and poor quality of life among caregivers of the elderly [14]. A report from Korea emphasized the role of the mental and the physical health of caregivers in predicting their overall health, regardless of impairment of the care recipients [15].

There is an urgent need for studies of caregiving in countries with emerging economies. Thailand is such a country and its caregiving needs are substantial. According to the Thai National Statistical Office’s 2007 Disability Survey [16], 1.8 million Thais are disabled and the majority requires caregivers [17]. Thai culture has characteristics that could influence caregiving and its consequences. For example, a strong Buddhist culture affects norms and values in caring for family members and would be expected to make unpaid caregiving quite common.

Thailand is facing one of the world’s most rapid processes of population ageing [18]. In 2000, 17% of Japanese, 16% of British, 13% of Australian, and 6% of Thai people were aged over 65 years. By 2025 these estimates are projected to rise to 30%, 19%, 19% and 13% respectively, with the highest proportionate increase (more than double) being for Thailand [18]. The Thai projection reflects better health care for the elderly and has as a consequence an increase in the need for caregivers [19]. According to the Thai National Statistical Office’s 2007 Survey of Thai Elderly [20], 10% of Thai elderly require caregivers (40% received care from daughters, 28% from spouses and 12% from sons). When asked ‘what type of welfare government should provide’ over 95% of elderly Thais preferred combined daycare centres and home care for elderly with chronic illnesses rather than formal institutional care. As Thais live longer, caregivers will become even more important to healthcare systems.

Our study focuses on family caregivers among adult working Thais residing throughout the country. Our objective is to investigate both physical and mental health among Thai adult caregivers and compare these to non-caregivers. Findings will be useful for health and social service providers and policymakers. Our results will facilitate identification of vulnerable caregivers to provide support and necessary resources.

Younger participants were more likely to report psychological distress than older participants; this was also noted for those who were never married, divorced, separated or widowed compared to married respondents. Currently seeking work, smoking and drinking were also associated with psychological distress. Belonging to the lowest income group, smoking and obesity were all associated with ‘poor or very poor’ self-assessed health and lower back pain. These associations indicate the need to include these covariates in the analyses of caregiver status and health.

We examined the physical and mental health of adult Thai caregivers. Taking into account possible confounders, being a caregiver was associated with lower back pain and psychological distress among males and females and ‘poor or very poor’ self-assessed health only among females. This could partly be explained by gender difference in reporting self-assessed health among middle-aged adults. Previously we found that females were much more likely to perceive and report worse self-assessed health than males [30]. We conducted a telephone follow-up of 120 caregivers and found that one-third has been caring for 1–2 years and two-thirds have been caring for 3–5 years. Over 60% reported cause of caring was illness. Assistance included mobility, provision of food and medication, as well as help with daily care.

Our study supports other reports on caregivers and their health, but unlike most work on this topic, our results derive from a developing economy in Asia. Generally, the effects of caring in Thailand are quite similar to those reported in rich, developed countries. For example, in the USA, higher levels of stressors among caregivers have been associated with poor self-reported health, more negative health behaviors, and greater use of health care services [33]. One study in the UK also found caregiving at home to be associated with morbidity, bodily pain, and obesity [34]. However, one of the main differences in lower income nations was the limited formal social welfare support system for family caregivers. This could further exacerbate the caregiver burden in emerging economies.

Depression experienced by the caregivers may negatively impact the care recipient, which may further limit self-care and functioning abilities, thus necessitating additional assistance [35]. Emphasis should also be placed on interventions during the transition to and adjustment into caring roles [36]. A prospective, British population-based study highlighted that transition into and out of unpaid caregiving is associated with increased risk for onset of or delayed recovery from psychological distress [36]. One report emphasised the importance of effective caregiver support and early health promotion for care recipients, monitoring high risk groups, and timing interventions [37]. Exercise programs for caregivers could also help if focused on preventing back pain by developing endurance strength [38].

There is a need for a coordinated system that makes easier the complex work of family caregivers by providing the training and support needed. In order for caregivers to maintain their wellbeing, various studies highlight the need for information in areas including finance, law, and health [39–41]. A qualitative study of informal caregiving provided to elderly stroke survivors in Thailand highlighted caregiver needs for information, assistance, and support [42]. Relevant Thai studies on family caregivers reported social support to be vitally important for both caregivers and care recipients among impaired Thai older adults [43, 44].

Cultural differences among caregivers should be taken into account. For example, differences were found in level of stress and coping mechanisms among Korean, Korean-American and Caucasian-American caregivers [45]. Caucasians reported affection while Koreans and Korean Americans reported filial obligation as their motivation for caregiving. In addition, Korean caregivers reported higher extended family support than Caucasian caregivers, while Caucasian caregivers reported higher utilisation of formal support than Korean caregivers. In Thailand, Buddhist concepts are viewed by many as part of daily life, for example, the return of good karma by caring for the loved ones in the family. Our earlier study has found Thai adults strongly affirming their belief in karma and the importance of religion to calm one’s mind [46].

As noted in the results of this study, 874 participants did not report their caregiving status and were excluded from analyses. Could this relatively small group bias the results? Setting the values for the 874 non-responding participants according to three scenarios (1. ‘all non-caregivers’; 2. ‘all part-time caregivers’; 3. ‘all full-time caregivers’) enables new estimates on health associations (e.g., lower back pain). These estimates differ little from the tabulated estimates shown in Tables 3 and 4. For example, without the 874 non-responding participants, the back pain estimates for males were AORs 1.36 and 1.67; with the 874 non-responding participants set to ‘all non-caregivers’ AORs became 1.38 and 1.71, set to ‘all part-time caregivers’ AORs became 1.38 and 1.72, set to ‘full-time caregivers’ AORs became 1.39 and 1.66. We conclude that the bias was minimal and did not change the epidemiological results.

The strength of this study is its large national scale with its wide array of socio-demographic, health-risk behaviours and measures of health available. Caution should be applied when interpreting the findings: our study is based on a group of long-distance adult students aspiring to improve their modest socioeconomic circumstances. The causes of adverse physical and mental health in our study may be different than those among caregivers in the general population. Further in-depth study on the nature and type of caregiving among Thai adults will provide insights into the long term social and health outcomes of caregiving and the support they require [12, 47].

Our study found that caregiving among Thai adults was strongly associated with adverse health. Further, these findings were consistent across physical and mental health. Our findings should raise awareness of the unmet needs of caregivers, and the need for support of caregivers in Thailand and other similar middle-income countries.

Thailand: Jaruwan Chokhanapitak, Suttanit Hounthasarn, Suwanee Khamman, Daoruang Pandee, Suttinan Pangsap, Tippawan Prapamontol, Janya Puengson, Sam-ang Seubsman, Boonchai Somboonsook, Nintita Sripaiboonkij, Pathumvadee Somsamai, Duangkae Vilainerun, Wanee Wimonwattanaphan, Cha-aim Pachanee, Wimalin Rimpeekool, Tewarit Somkotra, Arunrat Tangmunkongvorakul, Benjawan Tawatsupa.

Australia: Chris Bain, Emily Banks, Cathy Banwell, Bruce Caldwell, Gordon Carmichael, Tarie Dellora, Jane Dixon, Sharon Friel, David Harley, Matthew Kelly, Tord Kjellstrom, Lynette Lim, Anthony McMichael, Tanya Mark, Adrian Sleigh, Lyndall Strazdins, Susan Jordan, Janneke Berecki-Gisolf, Roderick McClure, Vasoontara Yiengprugsawan.