Several studies revealed the importance of older persons’ contribution to society. The enhancement of their potential to engage in civic activities should be encouraged. The purpose of this paper is to investigate factors associated with their civic engagement potential.
Data are from Thailand’s National Survey of Older Persons conducted by the National Statistical Office in 2011. A sample of 24,433 persons aged 60 years or older was analyzed to assess their engagement in four community activities. The data were subjected to logistic regression analysis.
This study found that the readiness and willingness to engage in socially productive activities of Thai older persons ranged from 7 to 23 percent depending on type of activities. The factors of ageing health, confidence in their family’s ability to assist them, and satisfaction with government services were significantly associated with their readiness and willingness to engage in socially productive activities. Inadequacy of income was not found to be an obstructing factor toward their readiness and willingness to engage in civic life in general, it inhibited only the sharing of knowledge and skills with others.
The findings reflect the impact of internal constraining factors and external enhancing factors on engagement of Thai older persons in civic activities. Policy implications on the role of the government to promote active ageing are discussed.
Tangchonlatip, K., Chamratrithirong, A. and Lucktong, A. (2019), "The potential for civic engagement of older persons in the ageing society of Thailand", Journal of Health Research, Vol. 33 No. 5, pp. 386-397. https://doi.org/10.1108/JHR-08-2018-0083
Emerald Publishing Limited
Copyright © 2019, Kanchana Tangchonlatip, Aphichat Chamratrithirong and Aksarapak Lucktong
Published in Journal of Health Research. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode
An ageing society is generally viewed negatively in terms of contributing to an increase in the dependency ratio or the number of younger and older age groups as a proportion of the working-age population. Thailand is becoming an ageing society by virtue of changes in the structure of the population. The proportion of the population aged 60 years or older increased from 7.2 percent in 1993 to 11.4 percent in 2010. This percentage will increase at a faster pace, 19.8 percent of the total by 2021, reaching 26.6 percent in 2030 and 32.1 percent in 2040. The National Economic and Social Development Plan (NESDP) reflects the importance of these challenges and has given priority to policy and programs to address the needs of Thai older people in the 12th Five-year NESDP (2017–2021).
Clearly, not all older people are a burden to society all the time. As a matter of fact, many senior citizens are still performing a valuable role in many services to the community and country. An Australian study found that older people provide social capital through the transmission of positive values to family, neighbors and community. They also perform valuable voluntary roles to maintain community activities and mutual friendship, a contribution that deserves recognition[3, 4].
Studies related to the contribution of older people to the community mostly focus on voluntary work, including those activities which pay a small stipend[5, 6]. The voluntary work of older people can be a more resource-intensive form of participation such as political or civic engagement, or a less demanding form of involvement such as social engagement in groups or collective action. Another form of productive activity for older persons is as a volunteer substitute worker. Other studies have found a correlation between community promotion work of older persons and good mental health[9–12] and an increased sense of capability among older people themselves.
Many factors related to human capital are involved in the decision of older persons to become involved in socially constructive activities[4, 7, 13–15]. Due to ageing, participation outside the home tends to decrease over time[16, 17] and older persons tend to be more rigid about their working hours. Factors constraining elderly participation in socially beneficial activities include frailty, reduced quality of life, and more dissatisfaction with one’s status in life. On the other hand, social capital factors which promote social participation of older people include the enabling environment, social integration with the local community and social support. Citizen attitudes toward government responsibility, democratic institutions and welfare state services are also important determinants of civic engagement among the elderly[24, 25].
The quality of life of older persons cannot be measured solely in terms of what they receive but should include their contribution and outlook as well as the mutual benefit of their active engagement in society. Older persons are the source of knowledge, ideas, advice, counsel and wisdom based on generations of experience and can share their surplus with those in need.
It is therefore important that research uncovers older persons’ potential and/or ability to contribute to society, and investigate factors which would improve their capacity as a community resource and a model of Thai traditional values. There are an increasing number of studies on these issues among older persons in Thailand and other countries. However, most Thai studies are confined to limited geographic areas or are in the form of community case studies in different regions of the country[27–31]. These studies document the range of potential of older persons to contribute to society, their various skill levels and opportunity for capacity-building. However, due to the limited sample size and scope of these studies, it is not possible to generalize the findings to the regional or national level.
Volunteerism is a multidimensional phenomenon and it is the objective of this study to investigate factors affecting the potential for voluntary civic engagement among older persons in Thailand. We propose a conceptual framework in which the civic engagement of older persons is determined by two competing elements: internal constraining and the external enthusing forces. This study, especially with regard to the latter element, is guided by social exchange theory and the social capital framework that contends that civic engagement of older persons is not purely determined by altruism but is related to the reciprocal relationship between them and others, including family and government. As discussed above, factors of interest in this study consist of both individual characteristics, including income and health which are considered to be related to internal constraining factors, as well as family support and government assistance, which are meant to reflect the external enthusing or motivating factors. Civic engagement in this study takes into account the voluntary features of community activities. The results should shed light on the feasibility of enhancing the capacity and value of older persons in the ageing Thai society and elsewhere.
This study analyzed secondary data from the 2011 National Survey of Older Persons, a nationally representative sample survey conducted by the Thai National Statistical Office (NSO). The survey used a stratified two-stage sampling design. The first stratum was the 76 provinces in Thailand, divided into two sub-stratum of urban areas (municipal enumeration areas-EAs) and rural areas (villages). These included 5,796 EAs/villages. For the second stage, 79,560 households having persons aged 50 years or over were selected from these EAs/villages. The survey was conducted during May–July, 2011. The questions related to household information and older persons’ demographics, socio-economic characteristics, health status, satisfaction with family and government assistance and their social engagement. The summary report of the survey can be accessed via the website of the NSO.
We focused only on the population aged 60 years or older who responded to the questions on social engagement by themselves. In the sample of 79,560 households, there were 34,173 persons aged 60 or over. Of these, 24,433 persons answered the engagement questions by themselves and were selected for our sample population. The profile of those who were included and excluded was investigated and found nearly similar. For example, the average age of our target (M=69.52, SD=7.397) was slightly younger than of those who were excluded (M=71.02, SD=9.149). The percentage of the sample who did not enroll in school was also smaller (11.3 percent for included and 13.5 percent for excluded).
Engagement in constructive community activities was classified into readiness and willingness. Four probes for readiness and willingness to engage included the following: assisting with general improvements in the community and society; sharing knowledge and skills; volunteering for community functions; and caring for other older people, both inside and outside the family. The response options to these four items included ready and willing, ready but not willing, willing but not ready and not ready and not willing.
Logistic regression analysis was used to explore statistical associations among the variables to identify determinants of readiness and willingness to contribute to the social good. Since data from the cross-sectional study were recorded at a single point of time, it would be hard to assume that the independent variables were antecedents directly affecting the dependent variable as in a causal relationship. Unlike the nature of a longitudinal design, a cross-sectional study would consider only the statistical association between them. As for the dependent variables, “ready and willing” was coded as 1, while “willing but not ready,” “ready but not willing” and “not willing and not ready” were all coded as 0. We emphasized “readiness and willingness” because we wanted to expose the potential for civic engagement among this sample of older persons.
The following coding schemes were used for the independent variables. Capacity variables included subjective measures of the sufficiency of income of older persons. “More than enough,” “enough” and “periodically enough” were considered as measures for the sufficiency of income, and coded as 1. “Not enough” was considered as insufficient income and coded as 0. Being physically healthy in the current week (based on self-perception of one’s own health status) ranged from “very good,” “good” to “moderately good health,” and were coded as 1. “Poor” or “very poor health” were coded as 0. We chose to use this dichotomous variable rather than use the information of all four categories of rating because the measurement scale is a subjective one and may not be able to reflect the absolute concrete differences. Sense of well-being was measured by a happiness scale from 0 (lowest) to 10 (highest). Confidence in receiving assistance from family members when ill was coded as 1 when responses were “very confident,” “confident” or “somewhat confident,” and 0 if they were “not confident at all.” Satisfaction with government services and/or assistance was coded as 1, while dissatisfaction was coded as 0.
In addition, this analysis included socio-economic and demographic control variables, namely, age group, sex (male=1 and female=0), marital status consisting of three dummy variables: single (1, 0), married spouse present (1, 0) and married spouse not present or divorced, separated or widowed (1, 0), rural/urban residence (urban=1 and rural=0), educational attainment consisting of four dummy variables: no education (1, 0), primary education or lower (1, 0), secondary education (1, 0) and higher than secondary education (1, 0), and work status (currently working during the past week was coded as 1, and not working as 0).
These dependent and independent variables were first examined by bivariate analysis. Then multivariate analysis was applied, using logistic regression on the readiness and willingness of older persons to engage in the four dimensions of community activities.
Ethical approval was obtained from the Institute for Population and Social Research Institutional Review Board, Mahidol University with COE No. 2018/09-260.
The participation of the older persons in constructive community activities, including assisting in community and social projects, sharing knowledge and skills, volunteering in the community and caring for other older people both inside and outside the family are primarily presented. Table I shows that older persons have limited readiness and willingness to engage in community activities, which varies by type of activity. Only one-fourth (23.2 percent) of the sample said they were both ready and willing to be actively engaged in constructive activities for the local community and society, and only 14.9 percent of older persons were prepared to share their traditional knowledge and skills. Fewer still expressed a willingness to volunteer for community causes (10.4 percent), and care for other older people (7. 3 percent). However, when we look at readiness and willingness separately, the potential of engagement is at a higher level. For example, those who were “ready” to engage in constructive activities for the local community and society (regardless of whether they were willing or not) constitute up to 29.6 percent (23.2 and 6.4) and those who were “willing” to do so represent as high as 39.0 percent (23.2 and 15.8). The proportion drops when both readiness and willingness were required. This pattern is consistent across all four activities, and it should be noted that willingness is uniformly higher than readiness.
The reason that the level of engagement of older persons in Thailand is considered to be somewhat low, especially in the case of volunteering (with no payment) and care for other older people, may be because of the level of poverty. Many older persons still have to support themselves and may need some supplemental income to make ends meet. Their willingness and desire to engage may be higher than this but in practice, they may not be ready or able to do so due to financial constraints.
The demographic, socio-economic, subjective health status and other characteristics of the sample under study are presented in Table II. The analysis shows that persons aged 60–64 years form the largest age group, account for about one-third of all older persons in the sample. Female older persons are, unsurprisingly, predominant (about 60 percent of the sample are female). Most elderly persons are married and live with their spouse (almost 60 percent). The majority (two-thirds) of older persons reside in rural areas. Education of older persons is relatively low; the majority completed only primary education. In total, 38 percent of the sample was still currently working. In terms of financial security, 84 percent reported having sufficient income. Regarding self-assessed health status, 85 percent feel they are in good health, overall. For family security, 93 percent are confident or very confident of receiving family support in case they become ill. Also, 87 percent are satisfied with government services. At last, concerning the level of happiness on a scale from 0 to 10, older persons have a relatively high average score of 7.4.
The bivariate analysis of the potential for civic engagement in the four dimensions of activities is also presented in Table II. Readiness and willingness to contribute to the social good was more prevalent among younger, male, married, urban residents, the higher-educated and currently working older persons. Those who had sufficient income and those who could rely on family members to help them when ill expressed a higher level of readiness and willingness to assist with community and social projects. Satisfaction with government services and perception of good health were more likely to motivate older persons to potentially participate in community activities consistently across all four dimensions of community engagement. These associations are statistically significant at a high level (p<0.001 to p<0.05).
Table III presents the results of the logistic regression analysis. The analysis looked at the effects of perception of sufficient income, family and government support, self-perceived health status and level of happiness on “readiness and willingness” to engage in the four dimensions of community activities while controlling for the socio-economic and demographic characteristics of respondents.
The results show that age, sex, education and current work status are significantly related to civic engagement in all four dimensions under study. Involvement in community activities declines with age and increases with educational attainment and current work status. Males engage more than females. Marital status is also significantly related to engagement in selected community activities. Older persons who were divorced, separated or widowed, as well as single persons, were more likely to participate in selected community activities than persons who lived with their spouse. At last, rural residents tended to engage more than their urban counterparts in selected activities.
Table III presents the results of the independent variables of specific interest in this study, namely, physical and mental health status, income sufficiency, and the perception of family and government support. This study found that “readiness and willingness” to engage in community activities across each and all four dimensions of civic engagement is consistently and significantly related to older people’s expectation of family support if they become ill (OR=1.381, 1.318, 1.233 and 1.328 for assisting the community, sharing knowledge and skills, volunteering and caring for others, respectively), satisfaction with government services and assistance (OR=1.322, 1.229, 1.320 and 1.204 for assisting the community, sharing knowledge and skills, volunteering and caring for others, respectively), subjective physical health (with the exception of caring for other older people) (OR=1.482, 1.231 and 1.376 for assisting the community, sharing knowledge and skills and volunteering, respectively) and their perceived level of happiness (sense of well-being) (OR=1.204, 1.221, 1.186 and 1.137 for assisting the community, sharing knowledge and skills, volunteering and caring for others, respectively). These associations are statistically significant at a high level (p<0.001 to p<0.05). As for the perception of sufficient income, its effect on the community is significant only when it comes to sharing knowledge and skill (OR=1.165), but not for the other three community activities.
The findings reflect the importance of both competing elements of active ageing, i.e., the internal constraining factors and the external enthusing elements. First, the internal constraining component was found to be a significant determinant in this study and includes health-related factors (both physical health status and psychological well-being). Confidence in receiving support from family members if facing a health problem is also important. These findings are consistent with many studies investigating the influence of perceived health on helping behaviors and volunteer work[4, 10, 35]. Poor health is more likely to be a barrier to volunteering, and depressive symptoms also decrease voluntary engagement. Good physical and psychological health could encourage older persons to participate in community service. Perceived availability of family support in case of illness could help older persons feel confident to engage in civic activity, as a form of “paying it forward.” Additionally, a previous study on Korean older people found that both giving and receiving family support could contribute to an increase in the older person’s sense of well-being.
Another constraining factor is financial status. In our study, perception of the sufficiency of one’s income had no significant relationship with the interaction of “readiness and willingness” to participate in constructive community works – with the exception of sharing knowledge and skills, which depended significantly on a sense of adequate income (p<0.05). This result partially supports but, to some extent, contradicts previous studies which found that higher income was positively associated with volunteerism[10, 32]. The nature of the volunteer work, therefore, needs to be differentiated. To share one’s knowledge and skills (which was found to be significantly related to income in this study) is a task which not everyone can volunteer to do; only those persons with a secure income would likely have knowledge and materials to share.
As mentioned earlier, our study appears to verify that volunteerism among older persons, similar to other volunteers, is determined by two competing forces: internal constraining factors and external enthusing elements. If older persons are not constrained by health or income, they will respond to motivating factors which could be in-kind rather than financial. These motivating factors (or the external enthusing elements) are reflected in the perspectives under the social capital framework and the social exchange theory. Satisfaction with government assistance, for example, can contribute to a positive outlook on life and volunteerism. Thus, this variable is one more piece of evidence supporting the social exchange theory where reciprocity is uncovered. Older persons in this study definitely responded positively to government inputs implying that the government can stimulate social engagement of older persons. The support to older people, such as health services and other assistance, will generate a positive response from older persons in terms of their engagement in civic life. The desire for social rewards, including Maslow’s needs of belonging, esteem, and self-actualization can be induced by the government through assistance and confidence in older persons. This study confirms that programs to enhance “active ageing” as proposed by the World Health Organization need to further understand the psychological aspects and strategies as well.
As stated above, older Thais who are satisfied with government services (e.g. the social pension from the government’s Old Age Allowance) are more likely to engage in civic life or at least share their willingness, including assisting with community and social projects, sharing knowledge and skills, volunteering in the community and even caring for other older persons. This study has important policy implications on the role of the government in elderly enhancement. The recent report on the situation of Thailand’s older population shows that the well-being of older persons has been improved by significant progress in developing policies and a legal framework. Our study confirms the proposition that, if older persons in society are well taken care of, have supportive families and, especially, have access to responsive public services, they will return this beneficence by being significantly more ready and especially willing to engage with the community in positive and constructive ways. On the part of the government, the exploitation of the potential of the elderly to continue to contribute to an ageing society can be a direct, democratic and responsive welfare policy for older people in itself. The experience of the Chinese Government shows that supporting programs for the elderly increases civic engagement. In any country, instead of focusing on the burden of societal ageing, governments should recognize the productive potential of older people rather than the economic cost. Society should also promote the potential of older persons as a social value and encourage the older population to participate in civic voluntary works. Public expenditure in that area would promote civic engagement of older people and continue to generate significant contributions to the national society and economy. Furthermore, reciprocal assistance among older people and their family is also an enthusing factor which encourages older persons to engage in social activities. Our study suggests that the active participation of older people in the family will be valued and supported.
This study is crucial since the Thai Government is regularly seeking the input of resource persons and related agencies. The Ministry of Social Development and Human Security (MSDHS) is collaborating with the Ministry of Interior and the Thai Elderly Association to design a model of a “Quality of Life (QOL) Development Center with Occupational Development for Older Persons.” The aim of this Center is to build the capacity of older people to help them share their traditional wisdom and to participate in socially constructive activities. Community engagement improves health, future outlook, and sense of well-being among all groups of the population. The MSDHS is implementing a project entitled “Traditional Wisdom Sharing through Volunteerism for Social Development”. That project applies the older person’s traditional wisdom to community needs, especially in the area of ethics and prevention of social problems, through exploiting the potential of local resources. The findings from our study support a strategy where social capital structure and social exchange schema are strategically emphasized.
The potential of older persons to contribute to the Thai ageing society is undeniable. Evidence shows that the intention to participate in social and community activities among Thai older persons is robust. However, achieving an optimal level of “readiness and willingness” still needs attention. The question of how to promote an enabling environment for expanded civic engagement of older persons is a challenge for policymakers. When controlling for demographic and socio-economic variables, this study found that self-perception of good physical and psychological health, as well as confidence in family support in case of illness, was significantly associated with civic engagement across the four types of community activities. However, income inadequacy was shown to inhibit civic engagement in terms of sharing knowledge and skills where the qualifications of the volunteer are more important. In addition, older persons who were satisfied with government services were consistently more likely to engage in all four of those civic activities. This finding supports social exchange theory which premises that state welfare services have a direct and strong relationship with civic engagement among older persons.
Although this study reveals the important findings mentioned above, it has limitations because of the cross-sectional nature of the data set. Unlike the results from a longitudinal-design survey, the causal relationships found in this study need to be interpreted with caution. With that limitation in mind, this study suggests that government policy on active and productive ageing should focus on the demonstration of genuine support to older persons in the areas of health services or other assistance since, due to reciprocity, that is likely to generate a positive response from older persons in terms of their civic engagement.
Propensity to participate in community activities of older persons in Thailand, 2011
|Propensity for community participation||n||Percent|
|Assisting with the community and social projects|
|Ready and willing||5,664||23.2|
|Ready but not willing||1,569||6.4|
|Willing but not ready||3,854||15.8|
|Not ready and not willing||13,346||54.6|
|Sharing knowledge and skills|
|Ready and willing||3,636||14.9|
|Ready but not willing||1,985||8.1|
|Willing but not ready||3,393||13.9|
|Not ready and not willing||15,419||63.1|
|Volunteering in the community|
|Ready and willing||2,531||10.4|
|Ready but not willing||2,054||8.4|
|Willing but not ready||3,584||14.7|
|Not ready and not willing||16,264||66.6|
|Caring for other older people|
|Ready and willing||1,781||7.3|
|Ready but not willing||1,951||8.0|
|Willing but not ready||3,180||13.0|
|Not ready and not willing||17,521||71.7|
Percentage (and χ2 test) of Thai older people being ready and willing to participate in four types of community activities classified by demographic and socio-economic characteristics, health and sense of well-being of the respondents
|Demographic, socio-economic characteristics, health and well-being||n (%)||Assisting with community and social projects||Sharing knowledge and skills||Volunteering in the community||Caring for other older people|
|All old people 60+ years old||24,433 (100.0)||23.2||14.9||10.4||7.3|
|80 or older||2,737 (8.3)||11.3||8.6||4.4||3.7|
|Married, living with spouse||13,415 (57.5)||26.1||16.7||11.6||8.0|
|Married but living separately, divorced, separated or widowed||9,928 (39.0)||19.4||12.4||8.6||6.1|
|Area of residence|
|No education||2,755 (11.5)||15.8||8.3||5.2||3.8|
|Primary level or lower||18,549 (78.2)||22.4||13.7||9.4||6.8|
|Secondary level||1,781 (5.9)||29.7||22.1||16.6||10.6|
|Higher than secondary level||1,308 (4.4)||41.4||36.0||26.8||18.0|
|Still working in the last 7 days||9,052 (38.4)||28.9||18.1||13.2||9.2|
|Not work||15,381 (61.6)||19.8||13.0||8.7||6.2|
|Perception of the sufficiency of income|
|Not sufficient||3,401 (15.7)||19.4||10.4||7.5||5.2|
|Level of happiness|
|Confidence in family assistance if ill|
|Not at all||186 (1.0)||12.4||5.9||5.4||2.2|
|Very confident||8,269 (38.8)||28.2||18.2||12.3||8.8|
|Satisfaction with government services and assistance to older people|
|Not satisfied||2,837 (13.4)||19.2||13.0||8.8||6.5|
Notes: *p<0.05; **p<0.01; ***p<0.001
Results of the logistic regression analysis of the readiness and willingness of older people to participate in four types of community activities
|Assisting with community and social projects||Sharing knowledge and skills||Volunteering in the community||Caring for other older people|
|Odds ratio||95% CI||Odds ratio||95% CI||Odds ratio||95% CI||Odds ratio||95% CI|
|Age group: 60–64 (reference)|
|65–69||0.973||0.893, 1.060||0.983||0.888, 1.089||0.928||0.827, 1.041||1.009||0.882, 1.154|
|70–74||0.770***||0.699, 0.849||0.831**||0.740, 0.933||0.695***||0.606, 0.797||0.753**||0.642, 0.885|
|75–79||0.634***||0.563, 0.713||0.776***||0.675, 0.892||0.594***||0.501, 0.706||0.706**||0.580, 0.859|
|80 or older||0.409***||0.353, 0.475||0.576***||0.485, 0.684||0.390***||0.311, 0.489||0.498***||0.387, 0.641|
|Male||1.297***||1.206, 1.396||1.501***||1.377, 1.637||1.420***||1.284, 1.572||1.235***||1.098, 1.390|
|Marital status: married spouse in house (reference)|
|Single||1.004||0.848, 1.188||1.152||0.947, 1.401||1.247*||1.002, 1.553||1.285*||1.002, 1.648|
|Married but living separately, divorced, separated or widowed||1.011||0.936, 1.092||1.099*||1.003, 1.205||1.166**||1.047, 1.298||1.108||0.978, 1.256|
|Urban residence||0.793***||0.740, 0.850||0.901*||0.829, 0.980||0.970||0.879, 1.071||1.001||0.893, 1.123|
|Education: no education (reference)|
|Primary level or lower||1.261***||1.115, 1.427||1.446***||1.232, 1.697||1.582***||1.291, 1.938||1.522***||1.207, 1.918|
|Secondary level||1.592***||1.346, 1.884||2.141***||1.748, 2.624||2.592***||2.027, 3.313||2.219***||1.670, 2.948|
|Higher than secondary level||2.599***||2.175, 3.105||4.414***||3.587, 5.431||4.812***||3.752, 6.171||3.907***||2.938, 5.196|
|Working||1.252***||1.163, 1.348||1.253***||1.147, 1.368||1.341***||1.211, 1.485||1.353***||1.202, 1.524|
|Perception of sufficiency of income||0.980||0.882, 1.090||1.165*||1.019, 1.331||1.047||0.897, 1.223||1.130||0.940, 1.357|
|Healthy||1.482***||1.322, 1.661||1.231**||1.075, 1.409||1.376***||1.163, 1.629||1.266||1.047, 1.531|
|Happiness level||1.204***||1.172, 1.237||1.221***||1.182, 1.261||1.186***||1.142, 1.232||1.137***||1.089, 1.188|
|Confidence in family assistance if ill||1.381***||1.163, 1.348||1.318***||1.216, 1.430||1.233***||1.121, 1.355||1.328***||1.190, 1.483|
|Satisfaction with government services and assistance to older people||1.322***||1.182, 1.478||1.229**||1.077, 1.402||1.320**||1.127, 1.545||1.204*||1.006, 1.441|
|−2 log likelihood||21,143.735||16,278.249||12,746.764||10,177.294|
|Cox & Snell R2||0.060||0.048||0.041||0.022|
Notes: n=24,433. *p<0.05; **p<0.01; ***p<0.001
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No potential conflict of interest was reported by the authors.