Psychosocial Risks and Mental Health of Preschool Care Providers in Kuala Lumpur, Malaysia: A cross-sectional study

Psychosocial Risks and Mental Health of Preschool Care Providers in Kuala Lumpur, Malaysia: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychosocial Risks and Mental Health of Preschool Care Providers in Kuala Lumpur, Malaysia: A cross-sectional study Sin Wan Tham, Min Fui Esther Wong, Maslinor Ismail, Noriklil Bukhary Ismail Bukhary This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4016028/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Child maltreatment in daycare is a public health issue. As childcare is stressful, high care provider negativity independently predicted more internalising behaviour problems, affecting children’s psycho-neurological development. This study aimed to determine psychosocial factors associated with the mental health of preschool care providers in Kuala Lumpur . Methods: A random cluster sampling cross-sectional survey was conducted in 2019. The study involved registered care providers for preschoolers under 4 years old without acute psychiatric illness. Centre for Epidemiologic Studies Depression Scale (Malay-CES-D) and Karasek’s Job-Content-Questionnaires (Malay-JCQ) were used to assess depression symptoms and psychosocial job-related risks. Logistic regression (p < 0.05) guided by Hosmer-Lemeshow strategy was used for analysis, with the final model evaluated for assumptions and goodness-of-fit. Results: A total of 247 providers were recruited from 36 preschools. All respondents were females (mean age of 32.1 years old), Malays (70.4%), married (38.1%), attained secondary school education (51.8%) and had low income (80.2%). The prevalence of depressive symptoms and job strain were 28.7%. Final logistic regression revealed individual factors (married, stressful life events: assault and marital issues), job strain (AOR = 2.32, CI = 1.22, 4.42), and job insecurity (AOR = 1.30, CI = 1.08, 1.57) determine depressive symptoms. Good supervisor support was inversely associated with depression. Conclusion: Job strain and insecurity contribute significantly to depressive symptoms among preschool care providers in Kuala Lumpur. The Social and Welfare Department can promote supportive supervision through skill training for supervisors, fostering a positive mental health environment for improving workers' mental health. Mental health Psychosocial Job strain Preschool care-providers INTRODUCTION Family structures and dynamics have undergone remarkable paradigmatic shifts over the years [ 1 – 3 ]. Throughout the 21st century, a transformation in family structures has been observed, featuring an increase in dual-income households and single-parent families [ 4 – 6 ]. The growing number of working parents led to a significant rise in demand for childcare services. Furthermore, the rising availability of education and employment opportunities is leading to a higher proportion of women joining the workforce [ 7 – 8 ], and this trend increases the demand for childcare centres around the world, including Malaysia [ 9 – 10 ]. In this era, childcare services are an indispensable requirement for families [ 11 – 12 ]. Thus, ensuring the safety and development of children is paramount. However, the alarming number of child daycare maltreatment cases poses a risk, with some incidents resulting in fatal outcomes for the children. There is growing evidence of its occurrence not only on a global scale [ 13 – 15 ] but also in Malaysia [ 12 , 16 ]. In 2022, the Social and Welfare Department reported a rise in child abuse cases, increasing from 3,831 in 2012 to 6,770 [ 17 ]. This issue has been recognised as a major global public health concern [ 18 , 19 ], as it directly impacts the safety of vulnerable children [ 20 – 22 ], hindrances to their psychosocial development, resulting in enduring physical and psychological consequences [ 14 , 23 , 24 ]. Additionally, it gives rise to broader societal and economic implications [ 25 – 27 ]. Indeed, good mental health among childcare providers is vital to ensure good quality care for the children. Hamre and Pianta (2004) revealed that depressed childcare workers exhibit lower sensitivity and increased withdrawal compared to their non-depressed counterparts [ 28 ]. The burden of mental health issues among these caregivers is substantial, ranging from 6–47.5% [ 29 – 30 ]. The role of a childcare provider is challenging, with job strain strongly linked to the development of depression in working adults [ 31 – 34 ]. Traumatic life events and chronic illness are established predictors of mental illness, particularly in the general [ 35 ] and working [ 36 ] population. Other noteworthy risk factors for common mental illness in the workforce include being single or unmarried and having a lower education [ 37 ]. While ample evidence exists on familial caregiver mental health and its impact on child development, there is a notable dearth of studies examining the impact of mental illness and associated risk factors among non-familial childcare caregivers. The caregiver-child interaction and the childcare environment are pivotal in the first three years of a child’s life. This study aims to identify psychosocial factors associated with the mental health of preschool care providers in Kuala Lumpur. METHODS This was a cross-sectional study conducted in Kuala Lumpur, Malaysia from March to July 2019. Kuala Lumpur’s preschool areas were selected as statistics from the Social and Welfare department showed it ranked second highest in child maltreatment cases, with 6.5% involving caregivers to the child [ 17 ]. Utilising Open Epi, the estimated sample size for this study was determined as n = 262, based on effect sizes from similar studies [ 38 – 40 ] (Supplementary Table 1). Thirty-six preschools were randomly selected from a sampling frame provided by the Kuala Lumpur Social and Welfare Department (138 preschools) for the study. All childcare providers aged 18 years and above working in preschools serving children under four were eligible to participate. Participants with acute psychiatric illness were excluded and referred for further assessment at the nearest clinic. Written consent was obtained from each eligible respondent before enrolment. The data collection involved face-to-face interactions with the study subjects, utilising standardised questionnaires covering sociodemographic details, the 5-item Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ-5), the Center for Epidemiological Studies-Depression Scale (CES-D), and the Job Content Questionnaire (JCQ) (Supplementary Questionnaires). The survey took approximately 20 minutes to complete. The sociodemographic questionnaire includes age, gender, ethnicity, marital status, education level, income status, family history of mental illness, chronic illness, and stressful life events. Participants indicate “yes” or “no” to major events causing emotional distress, such as assault, loss of a loved one, childhood abuse, serious marital problems, family problems, and injury or accidents. Participants who answered “yes” to any life events were taken as positive for life events in the binary category [ 41]. For past medical illnesses, participants were asked about the presence of chronic disease for the past year or more. The positive answers were cross-checked with the participant’s home-based treatment card by the participant herself. They were guided by a list of chronic diseases adopted from a study by Kader Moideen et al. [ 42 ]. Participants assess the strength of religiosity using the 4-point Likert scale Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ-5). Each of the five items is scored from 1 to 4 (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree), with analysis based on the sample median cut-off [ 43 ]. The current study yielded a Cronbach’s alpha coefficient of 0.829. The CES-D, comprising 20 items in English and Malay, assessed subjects’ current depressive symptoms based on Radloff’s 1977 publication [ 44 ]. General population-based validation studies revealed a strong Cronbach alpha coefficient ranging from 0.85 to 0.90 [ 44 – 45 ]. Participants reported depression-related symptoms from the past week, with each item scored from 0 to 3 (0 = Rarely or None of the Time, 1 = Some or Little of the Time, 2 = Moderately or Much of the Time, 3 = Most or Almost All the Time). Scores ranged from 0 to 60, and a score of 16 or higher indicated significant clinical depressive symptoms. This study used English and Malay Job Content Questionnaires (JCQ) to measure job strain and psychological exposure. The Malay Version of the tool was validated with Cronbach’s alpha coefficients of 0.75 (decision latitude), 0.50 (job demand) and 0.84 (social support) [ 46 ]. The JCQ assesses psychosocial job domains, including skill discretion, demand, decision-making, supervisor support, co-worker support, and insecurity. Participants rated questions on a 4-point scale (1 = strongly disagree, 4 = strongly agree), and reversed coding was employed for questions on job insecurity. The summation of scoring for each participant was based on the formula (Supplementary Table 2). The level of job strain is interpreted based on the Karasek Job Strain Model (Supplementary Fig. 1). Job demand components measure the psychological stressors concerning fulfilling workload, unexpected tasks, and job-related personal conflicts. Meanwhile, job decision latitude refers to the worker’s potential to control tasks and conduct during the working day [ 47 ]. The scoring disclosure was done privately in a separate room towards the end of the sessions. All the participants with high scores were given a referral letter for further assessment at the nearest government clinics or hospitals. Participants received a confidential envelope with a referral letter, participation certificate, and contact details for additional counselling support through the local Befriender’s platform. Statistical Analysis Statistical analyses were conducted using IBM SPSS Statistics (version 24.0, IBM Corp LP, Armonk, NY, USA). The preliminary data exploration was conducted to identify the centrality, dispersion, normality, and missing data. Variables with < 5% missing data were included. Symptomatic depression was assessed using CES-D (scores ≥ 16 = depressed or < 16 = not depressed). The univariate analysis involved students’ independent sample T-test or Mann-Whitney U-test for continuous variables. Meanwhile, Pearson’s Chi-square or Fisher’s Exact test was used for categorical variables. Multivariable logistic regression was performed with the Hosmer-Lemeshow model development strategy to determine the final model. Effect modification first-order main effects of explanatory variables were checked using the likelihood-ratio test. The final model was assessed for assumption compliance, multicollinearity, and model fitness test. The rule of thumb recommended by Paul et al. (2013) [ 48 ]. was applied to ensure the effectiveness of the Hosmer-Lemeshow test. Model sensitivity was evaluated with the area under the receiving operating characteristics (AUROC) curve. A significance level of P -value < 0.05 was applied. RESULTS A total of 32 preschools have been visited. Two hundred forty-seven preschool care providers (n = 247) were recruited for this study, giving a response rate of 94.3%. Non-respondents were those of Chinese participants who refused to participate. The sociodemographic characteristics of the respondents are illustrated in Table 1 . All the respondents were female, with a mean age of 32.1 years (SD = 12.0). The majority (55.5%) were less than 30, and 9.4% were more than 50. Almost two-thirds of the respondents were from outstations, followed by Selangor (21.9%) and Kuala Lumpur (14.2%). The respondents comprised Malay (70.4%), Chinese (11.3%), Indian (11.7%), and Other (6.5%). The other races were Bumiputra Sabah, Bumiputra Sarawak and a few non-Malaysians with valid legal documents. The majority of the preschool care providers were married (55.1%), followed by single (38.1%), divorcee (5.3%) and widowed (1.6%). Approximately 45.3% of the care providers completed secondary school, while 50.6% possessed a diploma or higher education; a minority had education up to the primary school level. Based on the national socioeconomic classification for household income, most of the respondents (80.3%) have earned below the low-income group (≤ RM 3860). The majority of the participants were Muslims, and a high proportion of them (61.8%) were found to have strong religious strength. Nine respondents (3.7%) reported that their 1st-degree or 2nd-degree family members had neurotic or psychotic-related mental illnesses. Twenty-four (9.8%) respondents reported having chronic illnesses such as hypertension, type 2 diabetes, asthma, and previous cancer history. One-third of the respondents (38.2%) have a history of stressful life events. The most frequently reported stressful life events were the loss of loved ones (24.0%), followed by severe chronic illness, serious family problems and serious financial problems. Table 1 Participants Characteristic (n = 247) Participant’s Characteristic n (%) Age (n = 245) < 30 30–39 40–49 ≥ 50 136 51 35 23 55.5 20.8 14.3 9.4 Ethnicity Malay Chinese Indian Others 174 28 29 16 70.4 11.4 11.7 6.5 Marital Status Single Married Divorce/ Separated Widowed 94 136 13 4 38.1 55.0 5.3 1.6 Religion Muslim Christian Buddhist Hindu others 178 25 16 23 5 72.1 10.1 6.5 9.3 2.0 Religiosity (n = 246) Low (< 17) High (≥ 17) 94 152 38.2 61.8 Education level None Primary Secondary certificate diploma and above 1 6 112 3 125 0.4 2.4 45.3 1.3 50.6 Monthly Income ≤ RM 3860 RM3861-RM 8318 ≥ RM 8319 198 38 11 80.1 15.4 4.5 Family History of mental illness (n = 246) Yes No 9 237 3.7 96.3 Hx Chronic Illness (n = 245) Yes No 24 221 9.8 90.2 Stressful life Event (n = 246) Yes No 94 152 38.2 61.8 Training (n = 244) Yes No 226 18 92.6 7.4 Among the 247 female respondents, 28.7% of them were found to have fulfilled the depressive symptoms criteria rated by the CES-D. Based on the cut-off point (the sample median) for psychosocial job risk assessment, 40.9% have high job insecurity, 46.2% have low co-worker support, and 52.3% have low supervisor support. According to the Karasek’s formula, seventy-one participants (28.7%) perceived high job strain (Table 2 ). Table 2 Psychosocial Job Characteristics Psychosocial Job Characteristic n (%) CESD ≥ 16 71 28.7 1 in 4 < 1 in 4 138 103 57.3 42.7 Job strain High Low 71 176 28.7 71.3 Job Insecurity Low High 146 101 59.1 40.9 Supervisor Support (n = 243) Low High 127 116 52.3 47.7 Co-worker support Low High 114 133 46.2 53.8 Table 3 demonstrates the relationship between sociodemographic and psychosocial job characteristics with depressive symptoms. The sociodemographic characteristics which had a significant relationship with depressive symptoms were marital status (OR = 3.04; 95% CI = 1.60, 5.78), monthly income (OR = 2.31; 95% CI = 1.02, 5.24), and stressful life event (OR = 1.91; 95% CI = 1.09, 3.35). The psychosocial job characteristics associated with depressive symptoms were high job strain (OR = 2.64; 95% CI = 1.47, 4.74), high job insecurity (OR = 3.40, 95% CI = 1.92, 6.04), and low supervisor support (OR = 1.63, 95% CI = 0.93, 2.85). Table 3 Respondents characteristic in relation to depressive symptoms rated by CES-D (n = 247) Participant’s Characteristic Presence of Depression Symptoms CES-D ≥ 16 n(%) Absence of Depression symptoms CES-D < 16 n(%) χ 2 Crude OR 95% CI P -value Age ≥ 30 24(24.2) 75(75.8) Reference < 30 44(32.2) 99(67.8) 1.81 1.48 (0.83, 2.64) 0.178 Ethnicity Non-Malay 16(21.9) 57(78.1) Reference Malay 55(31.6) 119(68.4) 2.36 1.65 (0.87, 3.12) 0.127 Marital Status Married 56(36.6) 97(63.4) Reference Non-Married 15(16.0) 79(84.0) 12.12 3.04 (1.60, 5.78) < 0.001* Religion Muslim 56(31.5) 122(68.5) Reference Non-Muslim 15(21.7) 54(78.3) 2.29 1.652 (0.86, 3.18) 0.132 Religiosity ≥ 17 38 (25.0) 114(75.0) Reference RM3860 8 (16.7) 40 (83.3) Reference ≤ RM 3860 62(31.6) 134(68.4) 4.22 2.31 (1.02, 5.24) 0.044* Family History of mental illness No 67(28.3) 170(71.7) Reference Yes 4(44.4) 5(55.6) 1.11 2.03 (0.53,7.79) 0.293 Hx Chronic Illness No 66(29.9) 155(70.1%) Reference Yes 5 (20.8) 19 (79.2) 0.86 0.62 (0.22, 1.73) 0.358 Stressful life Event No 36(23.7) 116(76.3) Reference Yes 35(37.2) 59(62.8) 5.19 1.91 (1.09, 3.35) 0.023* Training No 5(27.8) 13(72.2) Reference Yes 66(29.2) 160(70.8) 0.02 1.07 (0.37, 3.13) 0.898 Providers to Child Ratio 1 in 5 27(25.2) 80(74.8) 1.14 0.74 (0.42, 1.29) 0.286 Job strain Low 40(22.7) 136(77.3) Reference High 31(43.7) 40(56.3) 10.83 2.64 (1.47, 4.74) 0.001* Job Insecurity: total score 7.0 (2.0) 6.0(2.0) 4343 a 1.37 (1.16, 1.62) 0.001* Job Insecurity: Category Low 27(18.5) 119(81.5) Reference High 44(43.6) 57(56.4) 18.32 3.40 (1.92, 6.04) < 0.001* Supervisor support: Total score 1.0 (3.0) 2.0 (3.0) 5364 a 0.17 (0.06, 0.30) 0.004* Supervisor support - Category High 31(24.4) 96(75.6) Reference Low 40(34.5) 76(65.5) 2.98 1.63 (0.93, 2.85) 0.085 *Significant at P < 0.05, a = Mann Whitney U According to the Hosmer–Lemeshow criteria, 11 variables ( P -value < 0.25) were included in the multivariable logistic regression model analysis. The final model contained five explanatory variables (Table 4 ). Non-married subjects were prone to depressive symptoms. Subjects who have a history of stressful life events, particularly for assault and marital issues, were at a 6-to-9-fold higher risk of getting depressive symptoms than the subjects without a history of stressful life events. Subjects with high job strain had a 2.32 times higher risk of developing depressive symptoms compared to the low job strain. Participants with high job insecurity have higher CES-D scores than those with low job insecurity. In contrast, support from supervisors was a protective factor against depressive symptoms. Table 4 Risk factors of Depressive Symptoms as rated by CES-D (n = 247) Factors B Crude OR (95% CI) P -value B Adjusted OR (95% CI) P- value Job Strain Low High Ref. 0.97 Ref. 2.64(1.47,4.74) 0.001 Ref. 0.84 Ref. 2.32(1.22, 4.42) 0.011* Supervisor Support -0.18 0.84 (0.74,0.94) 0.004 -0.13 0.88(0.77, 0.99) 0.047* Job Insecurity 0.31 1.37 (1.16, 1.62) < 0.001 0.27 1.30(1.08, 1.57) 0.006* Marital Status Married Non-married Ref. 1.11 Ref 3.04(1.60,5.78) < 0.001 Ref 0.79 Ref 2.20(1.10, 4.39) 0.025* SL – Assault No Yes Ref. 1.18 Ref 3.24(0.84,12.43) 0.087 Ref 1.77 Ref 5.89(1.34, 25.77) 0.019* SL- Marital Issues No Yes Ref. 2.25 Ref 9.46(1.92, 46.74) 0.006 Ref 2.15 Ref 8.56(1.56,47.07) 0.014* *Significant at P < 0.05 Model Development: The Hosmer-Lemeshow strategy 4, entry criterion of P -values 0.05 guided by the likelihood-ratio test. All the models were assessed for good model fitting (AUC: 0.770, R²N: 0.2467, VIF < 5 classification table 0.7397), SL – Stressful Life Event, Ref. – Reference. DISCUSSIONS This study provides one of the first studies to explore the prevalence of depressive symptoms among preschool care providers and the associated risk factors in Kuala Lumpur. The current study has revealed a high prevalence of depressive symptoms (28.7%). At the global level, few related studies on depression were conducted in the United States of America targeting female educators from the state-funded early childhood programme [ 38 ]. By adopting a similar self-reported instrument (CES-D), the prevalence rates of clinically significant depressive symptoms reported were estimated as 9.4–24% [ 28 , 38 , 49 ]. The lower prevalence rates found in the current study may be attributed to America’s more structured and well-established education system, whereby the workers may have better resources to handle the children. Besides, the difference may be due to different work cultures in other countries despite using the same instrument as in Malaysia. As conceptualised by Raina et al. for caregiving, the caregivers’ psychological health outcomes were determined by a few factors, which include personal background factors and work-related strain [ 50 ]. Non-married care providers exhibited significantly higher odds of developing depression compared to their married counterparts. Substantial evidence from a systematic review with meta-analysis confirms that widowhood is a predictor for depression [ 51 ]. Wang et al. conducted one study in 2010 on workers; findings indicate that single, divorced and separated have a higher risk of developing depression with an odds ratio of 2.13 to 3.79 [ 39 ]. In another cross-sectional study by local researcher Krishnaswamy et al., which adopted baseline data from 2003–2005, stated that divorce and separation have a predicting role in depression [ 52 ]. During the data collection, it was noted that many care providers were single and staying at the preschool, as they were mostly from other states, and some expressed loneliness. Lack of family and social support is a precursor for poor mental health outcomes [ 53 ]. The childcare centre should explore additional activities to enhance social connectedness among childcare workers, aiming to prevent emotional isolation and mitigate the risk of mental breakdowns. Stressful life events were found to be a risk factor for developing depressive symptoms in this studied population in the final analysis. The most frequent life events found among the care providers were childhood bully or abuse, loss of loved ones, serious family issues and serious financial issues. Out of these events, serious family issues were statistically associated with depression. These findings were consistent with other studies done locally and in Canada [ 42 , 52 , 54 ]. A national survey in Canada found that among the adult working population with a history of adverse life events were 1.9 times (OR = 1.90; 95% CI = 1.51, 2.40) higher risk of developing depression, and this is consistent with the findings in this study [ 54 ]. Another two local cross-sectional studies among the general population have stratified and analysed their results according to individual life events. Among the significant events were serious issues at the workplace, serious issues with friends and neighbourhood, serious marital problems, financial issues, and family issues [ 42 , 52 ]. For the final model of multivariable analyses, job strain was found to be significantly related to depressive symptoms rated by CES-D. Job strain is a well-recognised risk factor for depression and has been proven by substantial cross-sectional studies, longitudinal studies, systematic reviews, and meta-analyses. A large cohort study conducted by Stansfield et al. in 2012 reported that repeated high job strain on few occasions increases the risk of major depression (AOR = 2.19; 95% CI = 1.48, 3.26) [ 55 ]. Job insecurity was associated with depressive symptoms as well. As a result of globalisation, workplace conditions have changed tremendously. These changes lead to more job demand; thus, workers would compete to work harder to keep pace. Consequently, it would increase workplace stress and cause employees to feel insecure about their jobs. Eventually, it will add to the job strain and contribute to the occurrence of mental illness. Therefore, a supportive supervisor is a positive factor that may play a crucial role in reducing the job stress faced by childcare providers. A Canadian community-based study revealed that higher job security and social support give rise to flourishing mental health [ 56 ]. A recent longitudinal study has revealed that high job demand with low social support in the long term increases the risk of depression [ 57 ]. According to the 2012 preschool regulations, each childcare provider must attend and pass the early childcare course. The Social and Welfare Department should consider implementing a managerial skills course for supervisors to enhance communication and better support the needs of childcare workers under their supervision. Expected associations with religiosity, family history, and history of chronic illness were not observed in this study, which is likely attributed to the smaller sample size and relatively high proportion of young workers. This study has constituted fewer positive cases with the respective underlying exposures for inferential analysis. This pioneering study explores the mental health state of Malaysian preschool care providers using a local language-validated tool. It yields insights to inform policy improvements for their working environment. The findings serve as a stepping stone for future large-scale studies to enhance the generalizability and address caregiver mental health issues. This study has several limitations. Its cross-sectional design hinders establishing true causal relationships between outcomes and exposure. Bidirectional relationships among some variables remain uncertain without temporal relationships in a cross-sectional study. Preexisting depression in caregivers may influence perceptions of job strain [ 40 ]. Although the CES-D was a validated tool with good reliability, it could not replace the gold standard tools like the Structured Clinical Interview for DSM-IV (SCID) and confirmation of diagnosis by a clinical physician. However, the cost of diagnostic tools poses a challenge in research in low- and middle-income countries (LMIC). Recall biases may affect responses, particularly for symptoms present over the past two weeks. Efforts were made to mitigate biases through participant briefings. There was a notable refusal rate among Chinese providers, consistent with patterns observed in other studies in the country. Therefore, future research should delve into the reasons behind these refusals. Consequently, caution is advised when interpreting the study’s findings. CONCLUSION High prevalence of depressive symptoms among Kuala Lumpur’s preschool care providers is attributed to job strain and insecurity. To address this, the Social and Welfare Department could advocate for supportive supervision, including skill training for supervisors to create a positive mental health environment. To enhance overall risk assessment, the public health department could integrate mental health screening into preschool inspections, focusing on individual risk factors. Collaborative efforts between Public Health and Social and Welfare Department stakeholders are crucial for identifying gaps and developing strategies to enhance workers’ mental health for children’s safety. Declarations ACKNOWLEDGMENTS The authors would like to thank the Director-General of Health Malaysia for permission to publish this paper. We also gratefully acknowledge Staffs from the Department of Social and Preventive Medicine, Faculty of Medicine, University Malaya, All the Health offices Staffs from Kuala Lumpur dan Putrajaya Health Department and Malaysia Health Systems Research, National Institute of Health Malaysia. Funding: No funds or other support was received for this research and submitted work. There is no conflict of interest. Ethics approval Ethics approval was granted by the University of Malaya Research Ethics Committee (UMREC) (UM.TNC2/UMREC450, 6th March 2019), the Ministry of Health (NMRR-19-28-45740 (KKM/NIHSEC/P19-254) and My Research Social and Welfare Department (18th February 2019). Participants were provided sufficient time to review and comprehend the information sheets. Written consent was obtained from each participant before the study commenced. Author Contributions (Use CRediT taxonomy) Conceptualisation: S.W Tham, M.F Wong, I.M.; Methodology: S.W Tham, M.F Wong, N.B.I; Data curation: S.W Tham, M.F Wong; Formal analysis: S.W Tham, M.F Wong; Investigation: S.W Tham, M.F Wong; Software: S.W Tham, M.F Wong; Validation: S.W Tham, M.F Wong; Visualization: S.W Tham, M.F Wong; Writing - original draft preparation and edit: S.W Tham, M.F Wong; All authors reviewed the manuscript; Funding acquisition: S.W Tham, M.F Wong; Supervision: I.M and N.B.I References Cliquet RL. Major trends affecting families in the new millennium: Western Europe and North Amerika. Citeseer; 2003. De Silva I. Demographic and social trends affecting families in the south and central Asian region. na; 2003. Crissman B, Smith C, Ransley J, Allard T. Women’s Health in Queensland Prisons. Int J Offender Ther Comp Criminol. 2017 Apr 28;61(5):582–603. Meder M, ÇİÇEK Z. Changing Family Structure In Our Day. Sci Educ Begin 21ST CENTURY TURKEY. 2013;148. Rincón GB, Martínez YM. Work/family life by 2040: Between a gig economy and traditional roles. Futures. 2020;119:102544. Sharma R. The family and family structure classification redefined for the current times. J Fam Med Prim Care. 2013;2(4):306. Akbulut R. Sectoral changes and the increase in women’s labor force participation. Macroecon Dyn. 2011;15(2):240–64. Kabeer N. Gender equality, inclusive growth, and labour markets. Women’s Econ Empower Insights from Africa South Asia. 2021;13–48. Omar NA, Abu NK, Sapuan DA, Aziz NA, Nazri MA. Service quality and value affecting parents’ satisfaction and behavioral intentions in a childcare centre using a structural approach. Aust J Basic Appl Sci. 2010;4(9):4440–7. Sulaiman Y, Othman AR, Perumal S. Escalating the employee organisational commitment through employee job satisfaction: A Malaysian childcare centre perspective. 2015; Adamson P. The Child Care Transition: A League Table of Early Childhood Education and Care in Economically Advanced Countries. Innocenti Report Card 8. UNICEF. 2008; Mutalib MA, Saleh NSSN, Masod AM. Quality Enhancement of Child Care Centres In Malaysia: An Analysis on Laws And Regulations. J Educ Soc Sci. 2018;9(1):23–8. Grossman ER, McClendon JE, Gielen AC, McDonald EM, Benjamin‐Neelon SE. A review of state regulations for child care: Preventing, recognizing and reporting child maltreatment. Child Care Health Dev. 2023;49(4):657–68. Talmon A, Ditzer J, Talmon A, Tsur N. Maltreatment in daycare settings: a review of empirical studies in the field. Trauma, Violence, Abus. 2023;15248380231155528. U.S. Department of Health & Human Services, Administration for Children and Families Administration on Children, Youth and Families CB. Child Maltreatment 2021 [Internet]. 2023. Available from: https://www.acf.hhs.gov/cb/data-research/child-maltreatment. Mutalib MA, Saleh NSSN, bin Masut A. Regulating Child Care Centres In Malaysia: Is There A Bright Future? Int J Stud Child Women, Elder Disabl. 2017; Department S and W. Annual Statistic Report of Social Welfare Department [Internet]. 2016. Available from: http://www.jkm.gov.my/ Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of childhood exposure to violence, crime, and abuse: Results from the national survey of children’s exposure to violence. JAMA Pediatr. 2015;169(8):746–54. Merrick MT, Latzman NE. Child Maltreatment: A Public Health Overview and Prevention Considerations. Online J Issues Nurs. 2014;19(1). Font SA, Berger LM. Child maltreatment and children’s developmental trajectories in early to middle childhood. Child Dev. 2015;86(2):536–56. MacKenzie MJ, Kotch JB, Lee L-C, Augsberger A, Hutto N. A cumulative ecological–transactional risk model of child maltreatment and behavioral outcomes: Reconceptualizing early maltreatment report as risk factor. Child Youth Serv Rev. 2011;33(11):2392–8. Sharma S. Behavioural consequences of child abuse. Institutionalised Child Explor Beyond. 2016;3(1):66–76. Toth SL, Cicchetti D. Child maltreatment and its impact on psychosocial child development. Encycl early Child Dev. 2004;1–8. Wurdeman M. Impact of abuse throughout a child’s psychological development. 2015; Berger LM, Waldfogel J. Economic determinants and consequences of child maltreatment. 2011; Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012;36(2):156–65. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373(9657):68–81. Hamre BK, Pianta RC. Self-reported depression in nonfamilial caregivers: prevalence and associations with caregiver behavior in childcare settings. Early Child Res Q 19 297–318. 2004;19:297–318. Chhagan MK, Mellins CA, Kauchali S, Craib MH, Taylor M, Kvalsvig JD, et al. Mental health disorders among caregivers of preschool children in the Asenze study in KwaZulu-Natal, South Africa. Matern Child Heal J [Internet]. 2013/03/08. 2014;18(1):191–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23467845 Santos DN, Almeida-Filho N, Cruz SS, Santos Souza S, Costa Santos E, Barreto ML, et al. Mental disorders prevalence among female caregivers of children in a cohort study in Salvador, Brazil. Rev Bras Psiquiatr. 2005;28(2):111–7. Bonde JP. Psychosocial factors at work and risk of depression: a systematic review of the epidemiological evidence. Occup Env Med. 2008/04/18. 2008;65(7):438–45. Netterstrom B, Conrad N, Bech P, Fink P, Olsen O, Rugulies R, et al. The relation between work-related psychosocial factors and the development of depression. Epidemiol Rev [Internet]. 2008/07/01. 2008;30:118–32. Siegrist J. Chronic psychosocial stress at work and risk of depression: evidence from prospective studies. Eur Arch Psychiatry Clin Neurosci. 2008/12/05. 2008;258 Suppl:115–9. Theorell T, Hammarstrom A, Aronsson G, Traskman Bendz L, Grape T, Hogstedt C, et al. A systematic review including meta-analysis of work environment and depressive symptoms. BMC Public Health. 2015/08/02. 2015;15:738. Maideen KSF, Sherina MS, Rampal L, Firdaus M. Prevalence, associated factors and predictors of anxiety: a community survey in Selangor, Malaysia. BMC Psychiatry [Internet]. 2015;15:262. Wang J. Work stress as a risk factor for major depressive episode(s). Psychol Med. 2005/07/07. 2005;35(6):865–71. Wang JL, Smailes E, Sareen J, Schmitz N, Fick G, Patten S. Three job-related stress models and depression: a population-based study. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2012;47:185–93. Available from: https://link.springer.com/article/10.1007/s00127-011-0340-5 Whitaker RC, Becker BD, Herman AN, Gooze RA. The physical and mental health of Head Start staff: the Pennsylvania Head Start staff wellness survey, 2012. Prev Chronic Dis. 2013/11/02. 2013;10:E181. Wang JL, Smailes E, Sareen J, Fick GH, Schmitz N, Patten SB. The Prevalence of Mental Disorders in the Working Population Over the Period of Global Economic Crisis. Can J Psychiatry [Internet]. 2010;55(9):598–605. Blackmore ER, Stansfeld SA, Weller I, Munce S, Zagorski BM, Stewart DE. Major depressive episodes and work stress: results from a national population survey. Am J Public Heal. 2007/09/29. 2007;97(11):2088–93. Rosmalen JGM, Bos EH, de Jonge P. Validation of the Long-term Difficulties Inventory (LDI) and the List of Threatening Experiences (LTE) as measures of stress in epidemiological population-based cohort studies. Psychol Med [Internet]. 2012 Dec 11;42(12):2599–608. Kader Maideen SF, Sherina MS, Rampal L, Firdaus M. Prevalence, Associated Factors and Predictors of Depression among Adults in the Community of Selangor, Malaysia. PLoS One. 2014;9(4):1–14. Plante TG, Boccaccini MT. The Santa Clara Strength of Religious Faith Questionnaire. Pastoral Psychol [Internet]. 1997 May;45(5):375–87. Available from: http://link.springer.com/10.1007/BF02230993 Radloff LS. The CES-D scale: A self report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401. Cosco TD, Prina M, Stubbs B, Wu Y-T. Reliability and Validity of the Center for Epidemiologic Studies Depression Scale in a Population-Based Cohort of Middle-Aged U.S. Adults. J Nurs Meas [Internet]. 2017 Jan 1;25(3):476–85. Available from: http://connect.springerpub.com/lookup/doi/10.1891/1061-3749.25.3.476 Hadi AA, Naing NN, Daud A, Nordin R. Work Related Depression among Secondary School Teachers in Kota Bharu, Kelantan, Malaysia. Int Med J. 2008;15(2):145–52. Karasek JA. Job Demands, Job Decision Latitude, and Mental Strain: Implications for Job Redesign. Adm Sci Q. 1979;24(2):285–308. Paul P, Pennell ML, Lemeshow S. Standardizing the power of the Hosmer-Lemeshow goodness of fit test in large data sets. Stat Med. 2012/07/27. 2013;32(1):67–80. Whitaker RC, Dearth-Wesleya T, Goozea RA. Workplace stress and the quality of teacher–children relationshipsin Head Start. Early Child Res Q. 2014; Raina P, O’Donnell M, Schwellnus H, Rosenbaum P, King G, Brehaut J, et al. Caregiving process and caregiver burden: Conceptual models to guide research and practice. BMC Pediatr. 2004;4(1):1–13. Köhler CA, Evangelou E, Stubbs B, Solmi M. Mapping Risk Factors for Depression across the Lifespan: An Umbrella Review of Evidence from Meta-Analyses and Mendelian Randomization Studies. J Psychiatr Res. 2018;103:189–207. Krishnaswamy S, Subramaniam K, Jemain AA, Low WY, Ramachandran P, Indran T, et al. Common mental disorders in Malaysia: Malaysian mental health survey, 2003–2005. Asia-Pacific Psychiatry [Internet]. 2012;4(3):201–9. Available from: https://doi.org/10.1111/j.1758-5872.2012.00180.x Wang J, Mann F, Lloyd-Evans B, Ma R, Johnson S. Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry [Internet]. 2018 Dec 29;18(1):156. Available from: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1736-5 Wang J, Schmitz N. Does job strain interact with psychosocial factors outside of the workplace in relation to the risk of major depression? The Canadian National Population Health Survey. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2011 Jul 21;46(7):577–84. Available from: http://link.springer.com/10.1007/s00127-010-0224-0 Stansfeld SA, Shipley MJ, Head J, Fuhrer R. Repeated Job Strain and the Risk of Depression: Longitudinal Analyses From the Whitehall II Study. Am J Public Health [Internet]. 2012 Dec;102(12):2360–6. Available from: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2011.300589 Fan JK, Mustard C, Smith PM. Psychosocial Work Conditions and Mental Health: Examining Differences Across Mental Illness and Well-Being Outcomes. Ann Work Expo Heal [Internet]. 2019 May 21;63(5):546–59. Available from: https://academic.oup.com/annweh/article/63/5/546/5487669 Åhlin JK, Rajaleid K, Jansson-Fröjmark M, Westerlund H, Magnusson Hanson LL. Job demands, control and social support as predictors of trajectories of depressive symptoms. J Affect Disord [Internet]. 2018 Aug;235:535–43. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0165032717322656 Additional Declarations No competing interests reported. Supplementary Files SupplementalmaterialTSW.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4016028","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276725762,"identity":"ee988f2f-8ca7-4c92-ae4a-09419893d2d4","order_by":0,"name":"Sin Wan Tham","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDCCAwxsIIoHzPnAwJBAhBZmhBbGGaRoAQNmHmK08N0+f+zBz5w6GXOJ5GePbXNs8hj4Fx+TYMw5jFOL5LlkdsPebYd5LGekmRvnbksrZpB4libBuA23FoMzzGwSvNsO8BjcTjCTzt12OLFB4oyxASEtkn+31QG1pH+TtiRWizTvNmaglhwzaUaQFv4ewwf4tEieYTaTlgX6xeD+mzLJ3m1piW0SbIkPErel49TCd4bxmeTbbXX2BmeOb5P4uc0msZ//8IEDH7dZ49SCCdgkEkCx00yCFgb+AyCyjhQto2AUjIJRMLwBAGANVPJOFui/AAAAAElFTkSuQmCC","orcid":"","institution":"National Institutes of Health","correspondingAuthor":true,"prefix":"","firstName":"Sin","middleName":"Wan","lastName":"Tham","suffix":""},{"id":276725763,"identity":"596fdfd4-092d-469e-9106-20bf0d26d30a","order_by":1,"name":"Min Fui Esther Wong","email":"","orcid":"","institution":"National Institutes of Health","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"Fui Esther","lastName":"Wong","suffix":""},{"id":276725764,"identity":"8e58e40a-4b13-49df-94ac-95b2ee0f851e","order_by":2,"name":"Maslinor Ismail","email":"","orcid":"","institution":"University Malaya","correspondingAuthor":false,"prefix":"","firstName":"Maslinor","middleName":"","lastName":"Ismail","suffix":""},{"id":276725765,"identity":"9e5c2894-fbb0-4133-b90b-c2ce781dfcc5","order_by":3,"name":"Noriklil Bukhary Ismail Bukhary","email":"","orcid":"","institution":"Health office of Lembah Pantai District, Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Noriklil","middleName":"Bukhary Ismail","lastName":"Bukhary","suffix":""}],"badges":[],"createdAt":"2024-03-05 08:44:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4016028/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4016028/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54655524,"identity":"bf7b14da-8470-4512-9159-4fdb75239627","added_by":"auto","created_at":"2024-04-14 18:37:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":620043,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4016028/v1/1e574b5a-fe24-4571-80a6-0b0430a8f40b.pdf"},{"id":52255919,"identity":"3576ce39-62ec-4579-b979-13d4faa6c0b5","added_by":"auto","created_at":"2024-03-08 10:47:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":3261412,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalmaterialTSW.docx","url":"https://assets-eu.researchsquare.com/files/rs-4016028/v1/4ac2868c62a7ad90777cb620.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychosocial Risks and Mental Health of Preschool Care Providers in Kuala Lumpur, Malaysia: A cross-sectional study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eFamily structures and dynamics have undergone remarkable paradigmatic shifts over the years [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Throughout the 21st century, a transformation in family structures has been observed, featuring an increase in dual-income households and single-parent families [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The growing number of working parents led to a significant rise in demand for childcare services. Furthermore, the rising availability of education and employment opportunities is leading to a higher proportion of women joining the workforce [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and this trend increases the demand for childcare centres around the world, including Malaysia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this era, childcare services are an indispensable requirement for families [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Thus, ensuring the safety and development of children is paramount. However, the alarming number of child daycare maltreatment cases poses a risk, with some incidents resulting in fatal outcomes for the children. There is growing evidence of its occurrence not only on a global scale [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] but also in Malaysia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In 2022, the Social and Welfare Department reported a rise in child abuse cases, increasing from 3,831 in 2012 to 6,770 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This issue has been recognised as a major global public health concern [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], as it directly impacts the safety of vulnerable children [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], hindrances to their psychosocial development, resulting in enduring physical and psychological consequences [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, it gives rise to broader societal and economic implications [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndeed, good mental health among childcare providers is vital to ensure good quality care for the children. Hamre and Pianta (2004) revealed that depressed childcare workers exhibit lower sensitivity and increased withdrawal compared to their non-depressed counterparts [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The burden of mental health issues among these caregivers is substantial, ranging from 6\u0026ndash;47.5% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The role of a childcare provider is challenging, with job strain strongly linked to the development of depression in working adults [\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Traumatic life events and chronic illness are established predictors of mental illness, particularly in the general [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and working [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] population. Other noteworthy risk factors for common mental illness in the workforce include being single or unmarried and having a lower education [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile ample evidence exists on familial caregiver mental health and its impact on child development, there is a notable dearth of studies examining the impact of mental illness and associated risk factors among non-familial childcare caregivers. The caregiver-child interaction and the childcare environment are pivotal in the first three years of a child\u0026rsquo;s life. This study aims to identify psychosocial factors associated with the mental health of preschool care providers in Kuala Lumpur.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was a cross-sectional study conducted in Kuala Lumpur, Malaysia from March to July 2019. Kuala Lumpur\u0026rsquo;s preschool areas were selected as statistics from the Social and Welfare department showed it ranked second highest in child maltreatment cases, with 6.5% involving caregivers to the child [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUtilising Open Epi, the estimated sample size for this study was determined as n\u0026thinsp;=\u0026thinsp;262, based on effect sizes from similar studies [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] (Supplementary Table\u0026nbsp;1). Thirty-six preschools were randomly selected from a sampling frame provided by the Kuala Lumpur Social and Welfare Department (138 preschools) for the study. All childcare providers aged 18 years and above working in preschools serving children under four were eligible to participate. Participants with acute psychiatric illness were excluded and referred for further assessment at the nearest clinic.\u003c/p\u003e \u003cp\u003eWritten consent was obtained from each eligible respondent before enrolment. The data collection involved face-to-face interactions with the study subjects, utilising standardised questionnaires covering sociodemographic details, the 5-item Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ-5), the Center for Epidemiological Studies-Depression Scale (CES-D), and the Job Content Questionnaire (JCQ) (Supplementary Questionnaires). The survey took approximately 20 minutes to complete.\u003c/p\u003e \u003cp\u003eThe sociodemographic questionnaire includes age, gender, ethnicity, marital status, education level, income status, family history of mental illness, chronic illness, and stressful life events. Participants indicate \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; to major events causing emotional distress, such as assault, loss of a loved one, childhood abuse, serious marital problems, family problems, and injury or accidents. Participants who answered \u0026ldquo;yes\u0026rdquo; to any life events were taken as positive for life events in the binary category [ 41]. For past medical illnesses, participants were asked about the presence of chronic disease for the past year or more. The positive answers were cross-checked with the participant\u0026rsquo;s home-based treatment card by the participant herself. They were guided by a list of chronic diseases adopted from a study by Kader Moideen et al. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Participants assess the strength of religiosity using the 4-point Likert scale Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ-5). Each of the five items is scored from 1 to 4 (1\u0026thinsp;=\u0026thinsp;strongly disagree, 2\u0026thinsp;=\u0026thinsp;disagree, 3\u0026thinsp;=\u0026thinsp;agree, 4\u0026thinsp;=\u0026thinsp;strongly agree), with analysis based on the sample median cut-off [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The current study yielded a Cronbach\u0026rsquo;s alpha coefficient of 0.829.\u003c/p\u003e \u003cp\u003eThe CES-D, comprising 20 items in English and Malay, assessed subjects\u0026rsquo; current depressive symptoms based on Radloff\u0026rsquo;s 1977 publication [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. General population-based validation studies revealed a strong Cronbach alpha coefficient ranging from 0.85 to 0.90 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Participants reported depression-related symptoms from the past week, with each item scored from 0 to 3 (0\u0026thinsp;=\u0026thinsp;Rarely or None of the Time, 1\u0026thinsp;=\u0026thinsp;Some or Little of the Time, 2\u0026thinsp;=\u0026thinsp;Moderately or Much of the Time, 3\u0026thinsp;=\u0026thinsp;Most or Almost All the Time). Scores ranged from 0 to 60, and a score of 16 or higher indicated significant clinical depressive symptoms.\u003c/p\u003e \u003cp\u003eThis study used English and Malay Job Content Questionnaires (JCQ) to measure job strain and psychological exposure. The Malay Version of the tool was validated with Cronbach\u0026rsquo;s alpha coefficients of 0.75 (decision latitude), 0.50 (job demand) and 0.84 (social support) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The JCQ assesses psychosocial job domains, including skill discretion, demand, decision-making, supervisor support, co-worker support, and insecurity. Participants rated questions on a 4-point scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 4\u0026thinsp;=\u0026thinsp;strongly agree), and reversed coding was employed for questions on job insecurity. The summation of scoring for each participant was based on the formula (Supplementary Table\u0026nbsp;2). The level of job strain is interpreted based on the Karasek Job Strain Model (Supplementary Fig.\u0026nbsp;1). Job demand components measure the psychological stressors concerning fulfilling workload, unexpected tasks, and job-related personal conflicts. Meanwhile, job decision latitude refers to the worker\u0026rsquo;s potential to control tasks and conduct during the working day [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe scoring disclosure was done privately in a separate room towards the end of the sessions. All the participants with high scores were given a referral letter for further assessment at the nearest government clinics or hospitals. Participants received a confidential envelope with a referral letter, participation certificate, and contact details for additional counselling support through the local Befriender\u0026rsquo;s platform.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted using IBM SPSS Statistics (version 24.0, IBM Corp LP, Armonk, NY, USA). The preliminary data exploration was conducted to identify the centrality, dispersion, normality, and missing data. Variables with \u0026lt;\u0026thinsp;5% missing data were included. Symptomatic depression was assessed using CES-D (scores\u0026thinsp;\u0026ge;\u0026thinsp;16\u0026thinsp;=\u0026thinsp;depressed or \u0026lt;\u0026thinsp;16\u0026thinsp;=\u0026thinsp;not depressed). The univariate analysis involved students\u0026rsquo; independent sample T-test or Mann-Whitney U-test for continuous variables. Meanwhile, Pearson\u0026rsquo;s Chi-square or Fisher\u0026rsquo;s Exact test was used for categorical variables. Multivariable logistic regression was performed with the Hosmer-Lemeshow model development strategy to determine the final model. Effect modification first-order main effects of explanatory variables were checked using the likelihood-ratio test. The final model was assessed for assumption compliance, multicollinearity, and model fitness test. The rule of thumb recommended by Paul et al. (2013) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. was applied to ensure the effectiveness of the Hosmer-Lemeshow test. Model sensitivity was evaluated with the area under the receiving operating characteristics (AUROC) curve. A significance level of \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was applied.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 32 preschools have been visited. Two hundred forty-seven preschool care providers (n\u0026thinsp;=\u0026thinsp;247) were recruited for this study, giving a response rate of 94.3%. Non-respondents were those of Chinese participants who refused to participate. The sociodemographic characteristics of the respondents are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All the respondents were female, with a mean age of 32.1 years (SD\u0026thinsp;=\u0026thinsp;12.0). The majority (55.5%) were less than 30, and 9.4% were more than 50. Almost two-thirds of the respondents were from outstations, followed by Selangor (21.9%) and Kuala Lumpur (14.2%). The respondents comprised Malay (70.4%), Chinese (11.3%), Indian (11.7%), and Other (6.5%). The other races were Bumiputra Sabah, Bumiputra Sarawak and a few non-Malaysians with valid legal documents. The majority of the preschool care providers were married (55.1%), followed by single (38.1%), divorcee (5.3%) and widowed (1.6%).\u003c/p\u003e \u003cp\u003eApproximately 45.3% of the care providers completed secondary school, while 50.6% possessed a diploma or higher education; a minority had education up to the primary school level. Based on the national socioeconomic classification for household income, most of the respondents (80.3%) have earned below the low-income group (\u0026le;\u0026thinsp;RM 3860). The majority of the participants were Muslims, and a high proportion of them (61.8%) were found to have strong religious strength. Nine respondents (3.7%) reported that their 1st-degree or 2nd-degree family members had neurotic or psychotic-related mental illnesses. Twenty-four (9.8%) respondents reported having chronic illnesses such as hypertension, type 2 diabetes, asthma, and previous cancer history. One-third of the respondents (38.2%) have a history of stressful life events. The most frequently reported stressful life events were the loss of loved ones (24.0%), followed by severe chronic illness, serious family problems and serious financial problems.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants Characteristic (n\u0026thinsp;=\u0026thinsp;247)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u0026rsquo;s Characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (n\u0026thinsp;=\u0026thinsp;245)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;30\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e30\u0026ndash;39\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e40\u0026ndash;49\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e136\u003c/p\u003e \u003cp\u003e51\u003c/p\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.5\u003c/p\u003e \u003cp\u003e20.8\u003c/p\u003e \u003cp\u003e14.3\u003c/p\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalay\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eChinese\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eIndian\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOthers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e174\u003c/p\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.4\u003c/p\u003e \u003cp\u003e11.4\u003c/p\u003e \u003cp\u003e11.7\u003c/p\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSingle\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eDivorce/ Separated\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eWidowed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003cp\u003e136\u003c/p\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003cp\u003e55.0\u003c/p\u003e \u003cp\u003e5.3\u003c/p\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMuslim\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eChristian\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eBuddhist\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHindu\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eothers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.1\u003c/p\u003e \u003cp\u003e10.1\u003c/p\u003e \u003cp\u003e6.5\u003c/p\u003e \u003cp\u003e9.3\u003c/p\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligiosity (n\u0026thinsp;=\u0026thinsp;246)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLow (\u0026lt;\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHigh (\u0026ge;\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.2\u003c/p\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNone\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePrimary\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSecondary\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ecertificate\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ediploma and above\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e112\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003cp\u003e2.4\u003c/p\u003e \u003cp\u003e45.3\u003c/p\u003e \u003cp\u003e1.3\u003c/p\u003e \u003cp\u003e50.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026le; RM 3860\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eRM3861-RM 8318\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026ge; RM 8319\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e198\u003c/p\u003e \u003cp\u003e38\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.1\u003c/p\u003e \u003cp\u003e15.4\u003c/p\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily History of mental illness (n\u0026thinsp;=\u0026thinsp;246)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003cp\u003e96.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHx Chronic Illness (n\u0026thinsp;=\u0026thinsp;245)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003cp\u003e90.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStressful life Event (n\u0026thinsp;=\u0026thinsp;246)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.2\u003c/p\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining (n\u0026thinsp;=\u0026thinsp;244)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e226\u003c/p\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.6\u003c/p\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the 247 female respondents, 28.7% of them were found to have fulfilled the depressive symptoms criteria rated by the CES-D. Based on the cut-off point (the sample median) for psychosocial job risk assessment, 40.9% have high job insecurity, 46.2% have low co-worker support, and 52.3% have low supervisor support. According to the Karasek\u0026rsquo;s formula, seventy-one participants (28.7%) perceived high job strain (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePsychosocial Job Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial Job Characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCESD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProviders to Child Ratio (n\u0026thinsp;=\u0026thinsp;241)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;1 in 4\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1 in 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.3\u003c/p\u003e \u003cp\u003e42.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob strain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob Insecurity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.1\u003c/p\u003e \u003cp\u003e40.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupervisor Support (n\u0026thinsp;=\u0026thinsp;243)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003cp\u003e47.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCo-worker support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e demonstrates the relationship between sociodemographic and psychosocial job characteristics with depressive symptoms. The sociodemographic characteristics which had a significant relationship with depressive symptoms were marital status (OR\u0026thinsp;=\u0026thinsp;3.04; 95% CI\u0026thinsp;=\u0026thinsp;1.60, 5.78), monthly income (OR\u0026thinsp;=\u0026thinsp;2.31; 95% CI\u0026thinsp;=\u0026thinsp;1.02, 5.24), and stressful life event (OR\u0026thinsp;=\u0026thinsp;1.91; 95% CI\u0026thinsp;=\u0026thinsp;1.09, 3.35). The psychosocial job characteristics associated with depressive symptoms were high job strain (OR\u0026thinsp;=\u0026thinsp;2.64; 95% CI\u0026thinsp;=\u0026thinsp;1.47, 4.74), high job insecurity (OR\u0026thinsp;=\u0026thinsp;3.40, 95% CI\u0026thinsp;=\u0026thinsp;1.92, 6.04), and low supervisor support (OR\u0026thinsp;=\u0026thinsp;1.63, 95% CI\u0026thinsp;=\u0026thinsp;0.93, 2.85).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondents characteristic in relation to depressive symptoms rated by CES-D (n\u0026thinsp;=\u0026thinsp;247)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u0026rsquo;s Characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresence of Depression Symptoms\u003c/p\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026ge;\u0026thinsp;16\u003c/p\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbsence of Depression symptoms\u003c/p\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026lt;\u0026thinsp;16 n(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eCrude OR\u003c/p\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(75.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99(67.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.48 (0.83, 2.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Malay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57(78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119(68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.65 (0.87, 3.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56(36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97(63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79(84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3.04 (1.60, 5.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56(31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122(68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Muslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54(78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.652 (0.86, 3.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligiosity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114(75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61(63.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.81 (0.98,3.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertificate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39(32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(67.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.46 (0.84, 2.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; RM3860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; RM 3860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134(68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.31 (1.02, 5.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.044*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily History of mental illness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67(28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170(71.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.03 (0.53,7.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHx Chronic Illness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155(70.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.62 (0.22, 1.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.358\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStressful life Event\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116(76.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35(37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59(62.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.91 (1.09, 3.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.023*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160(70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.07 (0.37, 3.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.898\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProviders to Child Ratio\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 1 in 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(68.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 1 in 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27(25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.74 (0.42, 1.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob strain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136(77.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.64 (1.47, 4.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob Insecurity: total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4343\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.37 (1.16, 1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob Insecurity: Category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27(18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119(81.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57(56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3.40 (1.92, 6.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupervisor support: Total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5364\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.17 (0.06, 0.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupervisor support - Category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(75.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76(65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.63 (0.93, 2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e*Significant at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, a\u0026thinsp;=\u0026thinsp;Mann Whitney U\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the Hosmer\u0026ndash;Lemeshow criteria, 11 variables (\u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25) were included in the multivariable logistic regression model analysis. The final model contained five explanatory variables (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Non-married subjects were prone to depressive symptoms. Subjects who have a history of stressful life events, particularly for assault and marital issues, were at a 6-to-9-fold higher risk of getting depressive symptoms than the subjects without a history of stressful life events. Subjects with high job strain had a 2.32 times higher risk of developing depressive symptoms compared to the low job strain. Participants with high job insecurity have higher CES-D scores than those with low job insecurity. In contrast, support from supervisors was a protective factor against depressive symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors of Depressive Symptoms as rated by CES-D (n\u0026thinsp;=\u0026thinsp;247)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude OR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP-\u003c/em\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob Strain\u003c/p\u003e \u003cp\u003eLow\u003c/p\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e2.64(1.47,4.74)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e2.32(1.22, 4.42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.011*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupervisor Support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84 (0.74,0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.88(0.77, 0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.047*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob Insecurity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.37 (1.16, 1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.30(1.08, 1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.006*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eNon-married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e3.04(1.60,5.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e2.20(1.10, 4.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.025*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSL \u0026ndash; Assault\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e3.24(0.84,12.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e5.89(1.34, 25.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.019*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSL- Marital Issues\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e9.46(1.92, 46.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e8.56(1.56,47.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.014*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e*Significant at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003eModel Development: The Hosmer-Lemeshow strategy 4, entry criterion of \u003cem\u003eP\u003c/em\u003e-values\u0026thinsp;\u0026lt;\u0026thinsp;0.25 backwards in purposive variables exclusion with \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05 guided by the likelihood-ratio test. All the models were assessed for good model fitting (AUC: 0.770, R\u0026sup2;N: 0.2467, VIF\u0026thinsp;\u0026lt;\u0026thinsp;5 classification table 0.7397), SL \u0026ndash; Stressful Life Event, Ref. \u0026ndash; Reference.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSIONS","content":"\u003cp\u003eThis study provides one of the first studies to explore the prevalence of depressive symptoms among preschool care providers and the associated risk factors in Kuala Lumpur. The current study has revealed a high prevalence of depressive symptoms (28.7%). At the global level, few related studies on depression were conducted in the United States of America targeting female educators from the state-funded early childhood programme [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. By adopting a similar self-reported instrument (CES-D), the prevalence rates of clinically significant depressive symptoms reported were estimated as 9.4\u0026ndash;24% [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The lower prevalence rates found in the current study may be attributed to America\u0026rsquo;s more structured and well-established education system, whereby the workers may have better resources to handle the children. Besides, the difference may be due to different work cultures in other countries despite using the same instrument as in Malaysia.\u003c/p\u003e \u003cp\u003eAs conceptualised by Raina et al. for caregiving, the caregivers\u0026rsquo; psychological health outcomes were determined by a few factors, which include personal background factors and work-related strain [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Non-married care providers exhibited significantly higher odds of developing depression compared to their married counterparts. Substantial evidence from a systematic review with meta-analysis confirms that widowhood is a predictor for depression [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Wang et al. conducted one study in 2010 on workers; findings indicate that single, divorced and separated have a higher risk of developing depression with an odds ratio of 2.13 to 3.79 [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In another cross-sectional study by local researcher Krishnaswamy et al., which adopted baseline data from 2003\u0026ndash;2005, stated that divorce and separation have a predicting role in depression [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. During the data collection, it was noted that many care providers were single and staying at the preschool, as they were mostly from other states, and some expressed loneliness. Lack of family and social support is a precursor for poor mental health outcomes [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The childcare centre should explore additional activities to enhance social connectedness among childcare workers, aiming to prevent emotional isolation and mitigate the risk of mental breakdowns.\u003c/p\u003e \u003cp\u003eStressful life events were found to be a risk factor for developing depressive symptoms in this studied population in the final analysis. The most frequent life events found among the care providers were childhood bully or abuse, loss of loved ones, serious family issues and serious financial issues. Out of these events, serious family issues were statistically associated with depression. These findings were consistent with other studies done locally and in Canada [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. A national survey in Canada found that among the adult working population with a history of adverse life events were 1.9 times (OR\u0026thinsp;=\u0026thinsp;1.90; 95% CI\u0026thinsp;=\u0026thinsp;1.51, 2.40) higher risk of developing depression, and this is consistent with the findings in this study [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Another two local cross-sectional studies among the general population have stratified and analysed their results according to individual life events. Among the significant events were serious issues at the workplace, serious issues with friends and neighbourhood, serious marital problems, financial issues, and family issues [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the final model of multivariable analyses, job strain was found to be significantly related to depressive symptoms rated by CES-D. Job strain is a well-recognised risk factor for depression and has been proven by substantial cross-sectional studies, longitudinal studies, systematic reviews, and meta-analyses. A large cohort study conducted by Stansfield et al. in 2012 reported that repeated high job strain on few occasions increases the risk of major depression (AOR\u0026thinsp;=\u0026thinsp;2.19; 95% CI\u0026thinsp;=\u0026thinsp;1.48, 3.26) [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eJob insecurity was associated with depressive symptoms as well. As a result of globalisation, workplace conditions have changed tremendously. These changes lead to more job demand; thus, workers would compete to work harder to keep pace. Consequently, it would increase workplace stress and cause employees to feel insecure about their jobs. Eventually, it will add to the job strain and contribute to the occurrence of mental illness. Therefore, a supportive supervisor is a positive factor that may play a crucial role in reducing the job stress faced by childcare providers. A Canadian community-based study revealed that higher job security and social support give rise to flourishing mental health [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. A recent longitudinal study has revealed that high job demand with low social support in the long term increases the risk of depression [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. According to the 2012 preschool regulations, each childcare provider must attend and pass the early childcare course. The Social and Welfare Department should consider implementing a managerial skills course for supervisors to enhance communication and better support the needs of childcare workers under their supervision. Expected associations with religiosity, family history, and history of chronic illness were not observed in this study, which is likely attributed to the smaller sample size and relatively high proportion of young workers. This study has constituted fewer positive cases with the respective underlying exposures for inferential analysis.\u003c/p\u003e \u003cp\u003eThis pioneering study explores the mental health state of Malaysian preschool care providers using a local language-validated tool. It yields insights to inform policy improvements for their working environment. The findings serve as a stepping stone for future large-scale studies to enhance the generalizability and address caregiver mental health issues.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Its cross-sectional design hinders establishing true causal relationships between outcomes and exposure. Bidirectional relationships among some variables remain uncertain without temporal relationships in a cross-sectional study. Preexisting depression in caregivers may influence perceptions of job strain [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Although the CES-D was a validated tool with good reliability, it could not replace the gold standard tools like the Structured Clinical Interview for DSM-IV (SCID) and confirmation of diagnosis by a clinical physician. However, the cost of diagnostic tools poses a challenge in research in low- and middle-income countries (LMIC). Recall biases may affect responses, particularly for symptoms present over the past two weeks. Efforts were made to mitigate biases through participant briefings. There was a notable refusal rate among Chinese providers, consistent with patterns observed in other studies in the country. Therefore, future research should delve into the reasons behind these refusals. Consequently, caution is advised when interpreting the study\u0026rsquo;s findings.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eHigh prevalence of depressive symptoms among Kuala Lumpur\u0026rsquo;s preschool care providers is attributed to job strain and insecurity. To address this, the Social and Welfare Department could advocate for supportive supervision, including skill training for supervisors to create a positive mental health environment. To enhance overall risk assessment, the public health department could integrate mental health screening into preschool inspections, focusing on individual risk factors. Collaborative efforts between Public Health and Social and Welfare Department stakeholders are crucial for identifying gaps and developing strategies to enhance workers\u0026rsquo; mental health for children\u0026rsquo;s safety.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Director-General of Health Malaysia for permission to publish this paper. We also gratefully acknowledge Staffs from the Department of Social and Preventive Medicine, Faculty of Medicine, University Malaya, All the Health offices Staffs from Kuala Lumpur dan Putrajaya Health Department and Malaysia Health Systems Research, National Institute of Health Malaysia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds or other support was received for this research and submitted work. There is no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was granted by the University of Malaya Research Ethics Committee (UMREC) (UM.TNC2/UMREC450, 6th March 2019), the Ministry of Health (NMRR-19-28-45740 (KKM/NIHSEC/P19-254) and My Research Social and Welfare Department (18th February 2019). Participants were provided sufficient time to review and comprehend the information sheets. Written consent was obtained from each participant before the study commenced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions (Use CRediT taxonomy)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualisation: S.W Tham, M.F Wong, I.M.; Methodology: S.W Tham, M.F Wong, N.B.I; Data curation: S.W Tham, M.F Wong; Formal analysis: S.W Tham, M.F Wong; Investigation: S.W Tham, M.F Wong; Software: S.W Tham, M.F Wong; Validation: S.W Tham, M.F Wong; Visualization: S.W Tham, M.F Wong; Writing - original draft preparation and edit: S.W Tham, M.F Wong; All authors reviewed the manuscript; Funding acquisition: S.W Tham, M.F Wong; Supervision: I.M and N.B.I\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCliquet RL. Major trends affecting families in the new millennium: Western Europe and North Amerika. Citeseer; 2003. \u003c/li\u003e\n\u003cli\u003eDe Silva I. Demographic and social trends affecting families in the south and central Asian region. na; 2003. \u003c/li\u003e\n\u003cli\u003eCrissman B, Smith C, Ransley J, Allard T. Women\u0026rsquo;s Health in Queensland Prisons. Int J Offender Ther Comp Criminol. 2017 Apr 28;61(5):582\u0026ndash;603. \u003c/li\u003e\n\u003cli\u003eMeder M, \u0026Ccedil;İ\u0026Ccedil;EK Z. Changing Family Structure In Our Day. Sci Educ Begin 21ST CENTURY TURKEY. 2013;148. \u003c/li\u003e\n\u003cli\u003eRinc\u0026oacute;n GB, Mart\u0026iacute;nez YM. Work/family life by 2040: Between a gig economy and traditional roles. Futures. 2020;119:102544. \u003c/li\u003e\n\u003cli\u003eSharma R. The family and family structure classification redefined for the current times. J Fam Med Prim Care. 2013;2(4):306. \u003c/li\u003e\n\u003cli\u003eAkbulut R. Sectoral changes and the increase in women\u0026rsquo;s labor force participation. Macroecon Dyn. 2011;15(2):240\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eKabeer N. Gender equality, inclusive growth, and labour markets. Women\u0026rsquo;s Econ Empower Insights from Africa South Asia. 2021;13\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eOmar NA, Abu NK, Sapuan DA, Aziz NA, Nazri MA. Service quality and value affecting parents\u0026rsquo; satisfaction and behavioral intentions in a childcare centre using a structural approach. Aust J Basic Appl Sci. 2010;4(9):4440\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eSulaiman Y, Othman AR, Perumal S. Escalating the employee organisational commitment through employee job satisfaction: A Malaysian childcare centre perspective. 2015; \u003c/li\u003e\n\u003cli\u003eAdamson P. The Child Care Transition: A League Table of Early Childhood Education and Care in Economically Advanced Countries. Innocenti Report Card 8. UNICEF. 2008; \u003c/li\u003e\n\u003cli\u003eMutalib MA, Saleh NSSN, Masod AM. Quality Enhancement of Child Care Centres In Malaysia: An Analysis on Laws And Regulations. J Educ Soc Sci. 2018;9(1):23\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eGrossman ER, McClendon JE, Gielen AC, McDonald EM, Benjamin‐Neelon SE. A review of state regulations for child care: Preventing, recognizing and reporting child maltreatment. Child Care Health Dev. 2023;49(4):657\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eTalmon A, Ditzer J, Talmon A, Tsur N. Maltreatment in daycare settings: a review of empirical studies in the field. Trauma, Violence, Abus. 2023;15248380231155528. \u003c/li\u003e\n\u003cli\u003eU.S. Department of Health \u0026amp; Human Services, Administration for Children and Families Administration on Children, Youth and Families CB. Child Maltreatment 2021 [Internet]. 2023. Available from: https://www.acf.hhs.gov/cb/data-research/child-maltreatment.\u003c/li\u003e\n\u003cli\u003eMutalib MA, Saleh NSSN, bin Masut A. Regulating Child Care Centres In Malaysia: Is There A Bright Future? Int J Stud Child Women, Elder Disabl. 2017; \u003c/li\u003e\n\u003cli\u003eDepartment S and W. Annual Statistic Report of Social Welfare Department [Internet]. 2016. Available from: http://www.jkm.gov.my/\u003c/li\u003e\n\u003cli\u003eFinkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of childhood exposure to violence, crime, and abuse: Results from the national survey of children\u0026rsquo;s exposure to violence. JAMA Pediatr. 2015;169(8):746\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eMerrick MT, Latzman NE. Child Maltreatment: A Public Health Overview and Prevention Considerations. Online J Issues Nurs. 2014;19(1). \u003c/li\u003e\n\u003cli\u003eFont SA, Berger LM. Child maltreatment and children\u0026rsquo;s developmental trajectories in early to middle childhood. Child Dev. 2015;86(2):536\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eMacKenzie MJ, Kotch JB, Lee L-C, Augsberger A, Hutto N. A cumulative ecological\u0026ndash;transactional risk model of child maltreatment and behavioral outcomes: Reconceptualizing early maltreatment report as risk factor. Child Youth Serv Rev. 2011;33(11):2392\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eSharma S. Behavioural consequences of child abuse. Institutionalised Child Explor Beyond. 2016;3(1):66\u0026ndash;76. \u003c/li\u003e\n\u003cli\u003eToth SL, Cicchetti D. Child maltreatment and its impact on psychosocial child development. Encycl early Child Dev. 2004;1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eWurdeman M. Impact of abuse throughout a child\u0026rsquo;s psychological development. 2015; \u003c/li\u003e\n\u003cli\u003eBerger LM, Waldfogel J. Economic determinants and consequences of child maltreatment. 2011; \u003c/li\u003e\n\u003cli\u003eFang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012;36(2):156\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eGilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373(9657):68\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eHamre BK, Pianta RC. Self-reported depression in nonfamilial caregivers: prevalence and associations with caregiver behavior in childcare settings. Early Child Res Q 19 297\u0026ndash;318. 2004;19:297\u0026ndash;318. \u003c/li\u003e\n\u003cli\u003eChhagan MK, Mellins CA, Kauchali S, Craib MH, Taylor M, Kvalsvig JD, et al. Mental health disorders among caregivers of preschool children in the Asenze study in KwaZulu-Natal, South Africa. Matern Child Heal J [Internet]. 2013/03/08. 2014;18(1):191\u0026ndash;9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23467845\u003c/li\u003e\n\u003cli\u003eSantos DN, Almeida-Filho N, Cruz SS, Santos Souza S, Costa Santos E, Barreto ML, et al. Mental disorders prevalence among female caregivers of children in a cohort study in Salvador, Brazil. Rev Bras Psiquiatr. 2005;28(2):111\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eBonde JP. Psychosocial factors at work and risk of depression: a systematic review of the epidemiological evidence. Occup Env Med. 2008/04/18. 2008;65(7):438\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eNetterstrom B, Conrad N, Bech P, Fink P, Olsen O, Rugulies R, et al. The relation between work-related psychosocial factors and the development of depression. Epidemiol Rev [Internet]. 2008/07/01. 2008;30:118\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eSiegrist J. Chronic psychosocial stress at work and risk of depression: evidence from prospective studies. Eur Arch Psychiatry Clin Neurosci. 2008/12/05. 2008;258 Suppl:115\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eTheorell T, Hammarstrom A, Aronsson G, Traskman Bendz L, Grape T, Hogstedt C, et al. A systematic review including meta-analysis of work environment and depressive symptoms. BMC Public Health. 2015/08/02. 2015;15:738. \u003c/li\u003e\n\u003cli\u003eMaideen KSF, Sherina MS, Rampal L, Firdaus M. Prevalence, associated factors and predictors of anxiety: a community survey in Selangor, Malaysia. BMC Psychiatry [Internet]. 2015;15:262. \u003c/li\u003e\n\u003cli\u003eWang J. Work stress as a risk factor for major depressive episode(s). Psychol Med. 2005/07/07. 2005;35(6):865\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eWang JL, Smailes E, Sareen J, Schmitz N, Fick G, Patten S. Three job-related stress models and depression: a population-based study. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2012;47:185\u0026ndash;93. Available from: https://link.springer.com/article/10.1007/s00127-011-0340-5\u003c/li\u003e\n\u003cli\u003eWhitaker RC, Becker BD, Herman AN, Gooze RA. The physical and mental health of Head Start staff: the Pennsylvania Head Start staff wellness survey, 2012. Prev Chronic Dis. 2013/11/02. 2013;10:E181. \u003c/li\u003e\n\u003cli\u003eWang JL, Smailes E, Sareen J, Fick GH, Schmitz N, Patten SB. The Prevalence of Mental Disorders in the Working Population Over the Period of Global Economic Crisis. Can J Psychiatry [Internet]. 2010;55(9):598\u0026ndash;605. \u003c/li\u003e\n\u003cli\u003eBlackmore ER, Stansfeld SA, Weller I, Munce S, Zagorski BM, Stewart DE. Major depressive episodes and work stress: results from a national population survey. Am J Public Heal. 2007/09/29. 2007;97(11):2088\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eRosmalen JGM, Bos EH, de Jonge P. Validation of the Long-term Difficulties Inventory (LDI) and the List of Threatening Experiences (LTE) as measures of stress in epidemiological population-based cohort studies. Psychol Med [Internet]. 2012 Dec 11;42(12):2599\u0026ndash;608. \u003c/li\u003e\n\u003cli\u003eKader Maideen SF, Sherina MS, Rampal L, Firdaus M. Prevalence, Associated Factors and Predictors of Depression among Adults in the Community of Selangor, Malaysia. PLoS One. 2014;9(4):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003ePlante TG, Boccaccini MT. The Santa Clara Strength of Religious Faith Questionnaire. Pastoral Psychol [Internet]. 1997 May;45(5):375\u0026ndash;87. Available from: http://link.springer.com/10.1007/BF02230993\u003c/li\u003e\n\u003cli\u003eRadloff LS. The CES-D scale: A self report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385\u0026ndash;401. \u003c/li\u003e\n\u003cli\u003eCosco TD, Prina M, Stubbs B, Wu Y-T. Reliability and Validity of the Center for Epidemiologic Studies Depression Scale in a Population-Based Cohort of Middle-Aged U.S. Adults. J Nurs Meas [Internet]. 2017 Jan 1;25(3):476\u0026ndash;85. Available from: http://connect.springerpub.com/lookup/doi/10.1891/1061-3749.25.3.476\u003c/li\u003e\n\u003cli\u003eHadi AA, Naing NN, Daud A, Nordin R. Work Related Depression among Secondary School Teachers in Kota Bharu, Kelantan, Malaysia. Int Med J. 2008;15(2):145\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eKarasek JA. Job Demands, Job Decision Latitude, and Mental Strain: Implications for Job Redesign. Adm Sci Q. 1979;24(2):285\u0026ndash;308. \u003c/li\u003e\n\u003cli\u003ePaul P, Pennell ML, Lemeshow S. Standardizing the power of the Hosmer-Lemeshow goodness of fit test in large data sets. Stat Med. 2012/07/27. 2013;32(1):67\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eWhitaker RC, Dearth-Wesleya T, Goozea RA. Workplace stress and the quality of teacher\u0026ndash;children relationshipsin Head Start. Early Child Res Q. 2014; \u003c/li\u003e\n\u003cli\u003eRaina P, O\u0026rsquo;Donnell M, Schwellnus H, Rosenbaum P, King G, Brehaut J, et al. Caregiving process and caregiver burden: Conceptual models to guide research and practice. BMC Pediatr. 2004;4(1):1\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eK\u0026ouml;hler CA, Evangelou E, Stubbs B, Solmi M. Mapping Risk Factors for Depression across the Lifespan: An Umbrella Review of Evidence from Meta-Analyses and Mendelian Randomization Studies. J Psychiatr Res. 2018;103:189\u0026ndash;207. \u003c/li\u003e\n\u003cli\u003eKrishnaswamy S, Subramaniam K, Jemain AA, Low WY, Ramachandran P, Indran T, et al. Common mental disorders in Malaysia: Malaysian mental health survey, 2003\u0026ndash;2005. Asia-Pacific Psychiatry [Internet]. 2012;4(3):201\u0026ndash;9. Available from: https://doi.org/10.1111/j.1758-5872.2012.00180.x\u003c/li\u003e\n\u003cli\u003eWang J, Mann F, Lloyd-Evans B, Ma R, Johnson S. Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry [Internet]. 2018 Dec 29;18(1):156. Available from: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1736-5\u003c/li\u003e\n\u003cli\u003eWang J, Schmitz N. Does job strain interact with psychosocial factors outside of the workplace in relation to the risk of major depression? The Canadian National Population Health Survey. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2011 Jul 21;46(7):577\u0026ndash;84. Available from: http://link.springer.com/10.1007/s00127-010-0224-0\u003c/li\u003e\n\u003cli\u003eStansfeld SA, Shipley MJ, Head J, Fuhrer R. Repeated Job Strain and the Risk of Depression: Longitudinal Analyses From the Whitehall II Study. Am J Public Health [Internet]. 2012 Dec;102(12):2360\u0026ndash;6. Available from: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2011.300589\u003c/li\u003e\n\u003cli\u003eFan JK, Mustard C, Smith PM. Psychosocial Work Conditions and Mental Health: Examining Differences Across Mental Illness and Well-Being Outcomes. Ann Work Expo Heal [Internet]. 2019 May 21;63(5):546\u0026ndash;59. Available from: https://academic.oup.com/annweh/article/63/5/546/5487669\u003c/li\u003e\n\u003cli\u003e\u0026Aring;hlin JK, Rajaleid K, Jansson-Fr\u0026ouml;jmark M, Westerlund H, Magnusson Hanson LL. Job demands, control and social support as predictors of trajectories of depressive symptoms. J Affect Disord [Internet]. 2018 Aug;235:535\u0026ndash;43. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0165032717322656\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental health, Psychosocial, Job strain, Preschool care-providers","lastPublishedDoi":"10.21203/rs.3.rs-4016028/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4016028/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eChild maltreatment in daycare is a public health issue. As childcare is stressful, high care provider negativity independently predicted more internalising behaviour problems, affecting children’s psycho-neurological development. This study aimed to determine psychosocial factors associated with the mental health of preschool care providers in Kuala Lumpur\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA random cluster sampling cross-sectional survey was conducted in 2019. The study involved registered care providers for preschoolers under 4 years old without acute psychiatric illness. Centre for Epidemiologic Studies Depression Scale (Malay-CES-D) and Karasek’s Job-Content-Questionnaires (Malay-JCQ) were used to assess depression symptoms and psychosocial job-related risks. Logistic regression (p \u0026lt; 0.05) guided by Hosmer-Lemeshow strategy was used for analysis, with the final model evaluated for assumptions and goodness-of-fit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 247 providers were recruited from 36 preschools. All respondents were females (mean age of 32.1 years old), Malays (70.4%), married (38.1%), attained secondary school education (51.8%) and had low income (80.2%). The prevalence of depressive symptoms and job strain were 28.7%. Final logistic regression revealed individual factors (married, stressful life events: assault and marital issues), job strain (AOR = 2.32, CI = 1.22, 4.42), and job insecurity (AOR = 1.30, CI = 1.08, 1.57) determine depressive symptoms. Good supervisor support was inversely associated with depression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Job strain and insecurity contribute significantly to depressive symptoms among preschool care providers in Kuala Lumpur. The Social and Welfare Department can promote supportive supervision through skill training for supervisors, fostering a positive mental health environment for improving workers' mental health.\u003c/p\u003e","manuscriptTitle":"Psychosocial Risks and Mental Health of Preschool Care Providers in Kuala Lumpur, Malaysia: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-08 10:47:19","doi":"10.21203/rs.3.rs-4016028/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fdef1f66-6f33-4c52-84af-10152d2a8805","owner":[],"postedDate":"March 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-23T05:09:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-08 10:47:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4016028","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4016028","identity":"rs-4016028","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}