Loading...

Human Practices

We ask every team to think deeply and creatively about whether their project is responsible and good for the world. Consider how the world affects your work and how your work affects the world.

Section 1: Thailand-RIS and Integrated Human Practices


    Thailand-RIS' vision for Integrated Human Practices is to showcase the potential of scientific innovation to improve humanity through communication and collaboration.

    Our project focuses on a sustainable and culturally relevant synthetic biology solution for neurodegenerative disease prevention and treatment. Thailand-RIS's Human Practices team connected with our local community through interactive experiences aimed at a range of stakeholders to foster a more profound understanding of the social and practical implications of our project that aims to redesign traditional herbal medicine into a more accessible and cost-effective product.

Section 2: Upper Elementary Curriculum Connections


IHP_grade4workshop1img IHP_grade3synbioactivity2img IHP_grade3synbioactivity3img IHP_grade3synbioactivity4img

4th-grade and 3rd-grade Workshop on the “Symbio Zoo” activity that visualizes allele shuffling and recombination to yield a diverse array of traits, coming together to paste it onto the large poster and recap what they learned today.

Connecting with NGSS Life Science Standards (American-based curriculum)

Ruamrudee International School (RIS) is a Pre-K through Grade 12 international school with the mission of nurturing the intellectual development, compassion, and moral character of tomorrow's leaders. To do so, RIS utilizes the Principles of Phoenix—heads, hands, and heart—that focus on developing open-minded and collaborative critical thinkers who embrace diversity and lead meaningful lives. These learner outcomes motivated our decision to develop the Thailand-RIS 2023 elementary school workshops into a robust upper-elementary curriculum piece that could lay the groundwork for genetic engineering principles for our future global citizens. Through our educational outreach, we hope to spark interest in synthetic biology and eliminate the fear of topics such as GMOs that stem from limited access to balanced conversation and reliable information.

This year, rather than holding a one-time workshop for a single grade level, we created a comprehensive curriculum piece that could have a long-term impact on curriculum design through standards on variation and inheritance.

Our Upper-Elementary School (ES) Curriculum Implementation Program integrates a student-developed synthetic biology discovery program into the upper-elementary science curriculum.

Our approach references the Next Generation Science Standards (NGSS), specifically, 3-LS3 Heredity: Inheritance and Variation of Traits.

These standards focus heavily on how the characteristics of different organisms are inherited from their parents, and how those traits influence the organism’s interaction with the environment. We wanted to deliver those ideas in a way that would allow students to analyze data and make informed decisions when designing a solution to a particular problem. We also allowed students to extend their learning by introducing the possibility of targeted rather than random genetic modification.

The lesson design—iGEM 2024 Upper ES Curriculum Lesson Plan (Thai Version)—allowed students to meet the standard in the following ways:

  • Understandings: Students analyzed and interpreted data by “decoding” which alleles result in beneficial traits based on problems (e.g., poaching, deforestation) that a particular animal faces. Furthermore, we discussed how traits made the animals more or less fit to survive based on the environment they are in; for example, white mice were no longer as fit when the landscape changed to dark-colored volcanic rock.
  • Science and Engineering Practices: The students designed solutions to help animals develop advantageous traits based on real-life scenarios. Students also gained a stronger grasp of concepts as they practiced with a number of different traits and alleles to evaluate the strengths and limitations of their solution.
  • Disciplinary Core Ideas: Students tested their knowledge of inheritance by varying traits passed down from parents to offspring. They expanded their understanding of trait variation by introducing a new environmental factor: human intervention.
  • Crosscutting Concepts: Students examined how environmental change may cause scientists to intervene by discussing cause and effect. They also evaluated how such interventions may pose risks, including ethical ones.

The DNA demonstration and Symbio Zoo activity were inspired by lessons from some of our members’ biology classes. We wanted to apply what we’d learned in class to iGEM and upper ES. In Grade 10 Biology, we completed the University of Utah’s Learn Genetics “Build a Bird: The Pigeon Gene Shuffle” activity that visualizes allele shuffling and recombination to yield a diverse array of traits. This activity was adapted to better suit the younger audience and the synthetic biology concepts explored.

IHP_pigeonshuffleactivity5img

Taken from The University of Utah's build a bird

From this program, third- and fourth-grade students are expected to walk away with knowledge of how synthetically modifying the genes that code for certain traits can influence the survival of the organism. Thailand-RIS teams in the following years can also have the opportunity to extend the program to cover synthetic biology with plants—an area that has gathered significant focus around the globe.

Addressing the IHP Cycle

Key to implementing a feedback cycle were the regular meetings that we set up with our ES advisor, Ms. Mina Park (Grade 3 Teacher and ES Science Head of Department), who had previously worked with the Thailand-RIS 2023 team. She advised us on how to develop a program that fit the learning level and interests of her students and that enhanced rather than simply added on to her units of study. She explained how the students collaborated best with each other—in groups of four—as well as appropriate techniques for breaking down time allocations for each section of the program.

Our program’s first trial was in May 2024 and involved a session with an 18-student fourth-grade class. The second trial was held in September 2024 in three separate sessions with approximately 20 third-graders each.

The Symbio Zoo, our central activity, changed between the two workshops. We refined our program to better suit the levels and interests of grade 3 versus grade 4 students. Initially, the grade 4 students were asked to randomly select and decode animal traits and then discuss how these traits would provide advantages or disadvantages for the animals for certain environmental conditions; however, to better meet the attention span of grade 3 students and direct them to the true nature of synthetic biology, we presented them with scenarios that inspired what changes they should make in their animal’s traits instead—similar to how we used genetic engineering to produce Pueraria more efficiently.

This increased their understanding of how genetic engineering can affect the survival of living organisms rather than simply learning about diversity in traits, and allowed our program to meet with the overarching idea of synthetic biology in a more nuanced manner.

Students were also asked to give their thoughts on the program in an interview that immediately followed the event. Through this feedback, it became more apparent that we were successful in creating a learning environment where students were able to explore and grasp the foundation of synthetic biology from a relatively young age.

Expanding to Thai Curriculum

Our team will be translating our Upper-Elementary School (ES) Curriculum Implementation Program into Thai in order to increase the accessibility of information about synthetic biology and to align with the United Nations Sustainable Development Goal 4: Quality Education.

Example of scenarios that students were given:

Scenario 1: Due to deforestation and climate change, the once-thriving forests of Thailand are being fragmented, and water sources are drying up. As a result, the endangered Thai tigers are losing their natural habitat and struggling to find food and shelter. One tiger, in particular, is forced to leave its shrinking forest home in search of a new territory. It wanders into a savanna-like grassland area, a completely unfamiliar environment where water is scarce, and prey is harder to find. Now, the tiger must adapt to this open, arid landscape and develop new strategies to survive.

Translation: เนื่องจากการตัดไม้ทำลายป่าและการเปลี่ยนแปลงสภาพภูมิอากาศ ป่าไม้ที่เคยเจริญเติบโตในประเทศไทยถูกแยกและแหล่งน้ำกำลังเหือดแห้งไป ส่งผลให้เสือโคร่งไทยที่ใกล้สูญพันธุ์ต้องสูญเสียที่อยู่อาศัยตามธรรมชาติและประสบปัญหาในการหาอาหารและที่พักพิง เสือตัวหนึ่งที่ต้องถูกบังคับให้ออกจากบ้านป่าเล็กที่กำลังหดตัวของมันเพื่อหาแดนใหม่ มันเดินหลงเข้าไปในพื้นที่ทุ่งหญ้าซาวันนาที่เป็นสภาพแวดล้อมที่ไม่คุ้นเคย โดยที่น้ำจำกัดและเหยื่อหายากขึ้น ตอนนี้เสือต้องปรับตัวให้เข้ากับภูมิประเทศที่เปิดโล่งและแห้งแล้ง และพัฒนากลยุทธ์ใหม่เพื่อความอยู่รอด

Scenario 2: A volcano eruption has occurred, covering the surrounding area with lava. After the lava has cooled down, it forms dark-colored rocks that are rough and hard to walk on. Finally, life begins to regrow and repopulate the area, including a species of white mice. However, the mice stand out from the rocks and are straightforward targets for predators.

Translation: เกิดเหตุภูเขาไฟระเบิดปกคลุมพื้นที่โดยรอบด้วยลาวา หลังจากลาวาเย็นลง มันก็เกิดขึ้นเป็นหินสีเข้มที่ขรุขระและยากที่จะเดินผ่านไป ชีวิตก็เริ่มงอกใหม่และอาศัยอยู่ในพื้นที่ รวมถึงสายพันธุ์หนูสีขาวด้วย ซึ่งมีลักษณะโดดเด่น ด้วยสีสันที่จางอยู่ท่ามกลางโขดหิน จึงทำให้หนูสายพันธุ์นี้กลายเป็นเป้าหมายสำหรับสัตว์ผู้ล่า

Our Human Practices team will be consulting with Kru Yui Nichapa Srisuk–an RIS high school teacher who has taught Thai Language & Culture as well as IB Thai Language & Literature for many years–for feedback regarding the translation of the curriculum and outreaching to local schools. An additional goal would be to share this resource/experience with the Thai Ministry of Education and/or International Journal of Science Education and Teaching. We hope to have an update by the end of October!

We have also successfully managed to reach a point in our work where we feel that it is a comprehensive and informative curriculum program that does an excellent job at introducing the foundation principles of synthetic biology in a clear and concise way.

Although our team targeted instruction to align with NGSS standards, we are confident that the program would be highly insightful and informative to any student that engages with it. We feel that this program helps achieve our goal of inspiring an interest in synthetic biology for students who are learning in varied systems and is laying the foundation for a sustainable iGEM program at our school.

Section 3: Developing a Synthetic Biology Community in Thailand


Our team’s most ambitious goal was to grow the Thai Synbio Community in Bangkok by fostering connections among local schools and learning from other iGEM teams. Over the past 4 iGEM cycles (2019, 2022–2024), Thailand-RIS has been one of very few, if not the only high school track team representing Southeast Asia, a geographic area representing almost 700 million people. Although this unique representation has been an honor, the consequent regional isolation has been a notable challenge for securing local and sustainable partnerships and funds. We have, however, initiated steps to create a community that is broader than a select few. Using our growing presence on social media platforms (Instagram & TikTok), Thailand-RIS not only collaborated with other iGEM teams, such as McMaster to create group merchandise and Boston-BOSLab to conduct a mutually beneficial interview, but also used social media to capture the attention of students and advisors from other international schools.

IHP_BOSlabzoom6img

Team Meet Ups:

This year, the Boston-BOSLab iGEM team—a new High School team—reached out to the Thailand-RIS team through social media. They wanted to hear more about our project and our perceptions of using porcine-based heparin, and we wanted to hear more about their successes and challenges integrating Human Practices into their project. Interestingly, we are both manufacturing a medicinal product: puerarin (Thailand-RIS) and heparin (Boston-BOSLab). Thus, we anticipated some overlap in stakeholders, but recognized that the Boston-BOSLab is operating in one of the biotech hubs of the world and might have some unique experiences to share. Similar to us, however, the Boston-BOSLab team shared that they also faced challenges in interviewing patients and had to do so indirectly through advocacy groups, as universally it is not common or ethical practice to have high school students interview patients without a personal connection.

The table below compares and contrasts several aspects of our teams that we learned through the zoom exchange.

  Thailand-RIS Similarities Boston-BOSLab
Team History 4th cycle since 2019   New in 2024
Team Size Between 15-18 members    
Team Format All HS students from the same school Smaller groups for different parts of the project (lab, IHP, etc.) with clear leadership for each part HS students from different schools
Project Focus Puerarin: A plant-based compound as a preventative for neurodegenerative diseases Biomanufacturing Heparin: An animal-based compound synthetically engineered as a blood clot preventative
Type of Knowledge Eastern, traditional medicine from indigenous knowledge   Universal, modern medicine
IHP Ethics addressed in educational outreach and interview practice Challenges of not being able to interview patients due to ethical considerations Bioethics handbook
Team Access to Resources Bangkok: Emerging ecosystem of synthetic biology
No sponsorship this year
  Boston: World-renowned biotech hub
Sponsorship for registration fees

Thailand-RIS team is very fortunate to have been able to secure a lab and have the guidance of advisors at Chulalongkorn University, but this key resource is connection dependent and highlights a significant reason why there may be a low number of iGEM teams in Thailand and South East Asia. Access to lab facilities and the finances to support the material costs is a limiting factor of growing iGEM in the area. The Boston-BOSLab team shared that they too lacked some equipment at their main lab and required assistance from other labs, so there is some universality to the challenges of resourcing a sustainable program. From this, we can see that high school teams in general may find it more difficult to participate in robust projects on an annual basis.

We look forward to connecting with Boston-BOSLab at the Jamboree in October to continue some dialogue with more students and advisors that will support our work in reaching out to other international schools in our area about iGEM and synthetic biology.

International School Outreach:

Our goal is to collaborate with other Bangkok schools to help jumpstart their synthetic biology journey and/or iGEM program.

Bangkok international schools are developing an interest in iGEM. As such, our team set out to host a synthetic biology meet-up event that would consist of an array of like-minded students from multiple high schools. We sent formal email invitations to both advisor and student contacts asking for a show of interest.

IHP_synbiomeetupemail7img

Though our intention for an in-person symposium was reverted to an after-school Zoom call, we solicited interest from three international schools in the metro Bangkok area in which 14 students showed interest.

IHP_internationalschoolzoomcall8img

We began by sharing the history of iGEM at RIS and how we have developed over the years. During the meeting, we provided detailed guidance on how to start a team and the qualifications that iGEM teams will need to meet. Our advisor and team leader shared valuable insights based on their experiences, emphasizing that dedication is a crucial asset for setting up a successful team. We clarified any queries and offered advice on the competitive landscape.

As the meeting concluded, we encouraged each participating school to develop their ideas for potential projects that they could work on in the coming year. Students will follow up with our team for support in this effort, and we hope to foster additional discussions as they navigate the early stages of their iGEM journey. Building this network with other schools to share our experiences may create a foundation for greater access to knowledge and mentorship.

Local Engagement:

The Thailand-RIS team is dedicated to promoting synthetic biology and raising awareness in our local communities. We are excited about the potential impact that synthetic biology can have on our society, especially in the areas of sustainability and public health.

As part of our local outreach efforts, our team participated in the 2023 iGEM Giant Jamboree, which took place in October. At this event, we showcased our work and shared our experiences with attendees, including students, educators, and professionals from the field of synthetic biology.

We also organized a workshop for local high school students, where we introduced them to the basics of synthetic biology and its applications. The workshop included hands-on activities and discussions on current research in the field, allowing students to engage with the subject matter actively. Our goal was to inspire the next generation of scientists and innovators in Thailand.

In summary, our efforts to develop a synthetic biology community in Thailand involved collaborations with other iGEM teams, outreach to international schools, and local engagement initiatives. Through these activities, we aimed to create a supportive network for students interested in synthetic biology and contribute to the growth of this exciting field in our region.

Section 4: Key Stakeholder Perspectives/Interviews


Social media and public surveys:

https://www.instagram.com/tris.igem/

Social media provided us an opportunity to showcase our work to both a local and global audience; whereas our public survey was used to gauge awareness and understanding of our project’s topic as well as perspectives on Thai traditional medicine.

Our 2024 team used Instagram more effectively than any previous Thailand-RIS team to establish a larger online presence: #iGEM, #biology, and #tris. Consistent hashtags and our continued online presence made the tracking of our content easier, showcased our lab and human practices, and optimized the algorithm that boosted our posts to other interested parties and pulled in more viewerships. Additionally, with a change in format from only posting still pictures to posting Instagram reels, we’ve managed to total our viewership to approximately 2,000+ views, which has greatly expanded our audience engagement. This helped us achieve our goal of reaching a wider audience and establishing connections with our community and beyond.

Social media promoted our one fundraiser, which included ticket sales for a popular band, Indigo, which was able to raise a little over 10,000 baht.

By posting a general form link on members’ personal social media we were able to gain more responses on our public survey on synthetic and traditional medicine.

The General Public Survey focused on the current awareness of neurodegenerative diseases in Thailand, and drew attention to the problem we are aiming to solve. It also looked into biases and/or misconceptions that exist with respect to Eastern versus Western medicine.

IHP_qonegenersalsurvey9img
IHP_qtwogenersalsurvey10img

To begin with, we would like to reaffirm the severity of the struggle against neurodegenerative diseases in Thailand, as around 2 to 4% of the population aged 60 and over have been diagnosed with Alzheimer's disease. It may not be immediately apparent from the data above that neurodegenerative diseases are a substantial issue, especially when the percentage of people who have come into contact with neurodegenerative diseases is significantly smaller than that of diabetes; however, it is crucial to consider the age demographic of those taking the survey, especially when comparing the percentage of people with diabetes against that of Alzheimer’s. For instance, the percentage of people in Thailand with diabetes is 9.9% [8] compared to only 3.1% for Alzheimer's disease [2]. Having said that, when taking into account the percentage of the Thai population that is susceptible to Alzheimer’s—people aged 65 and older [7] which only represents 19.5% of the population[3]—it becomes clear that neurodegenerative diseases like Alzheimer’s are far more prevalent than previously perceived.

IHP_qthreegenersalsurvey11img
IHP_qfourgenersalsurvey12img

As observed from the data above, it is clear that there has been a considerable preference towards the usage of modern medical treatment as opposed to traditional herbal medicine in Thailand. Additionally, knowledge of herbal medicine is quite limited even in its native country. Many assert that it holds little value in the future development of medical advancement. This is largely due to the lack of evidence provided through scientific processes; unlike modern medicine, traditional medicine may not have the funding and research necessary to provide sufficient conclusions about its benefits in an evidence-based way. This line of thinking has led to the decline of interest in herbal medicine. Though this is warranted to an extent due to the extensiveness of modern medicine, it would be unwise to completely neglect the use of alternative medicine as this would limit the options for further exploration.

The survey depicts that around 84% of the participants prefer modern medicinal treatments like chemotherapy or radiation treatment over Thai herbal medicine (though admittedly we did not distinguish well between preventative treatment and cure in the formation of our question, leading to potential bias). This highlights the disparity in the trust in herbal medicine against modern medicine. It is clear that within this sample size, which mainly includes those with college-level education, modern medicine is the favored choice. As a whole, Thailand is moving in the direction of completely disregarding these alternative forms of medicine. Consequently, few know of native plants such as Pueraria despite their excellent medicinal properties as a phytoestrogen which provides benefits like those present in soymilk, various fruits, and spinach. This displays one of the key issues within modern Thai society: knowledge that has been cultivated over centuries of experience is being lost. Indigenous knowledge is rapidly losing its place in modern medicine, despite its tried and true benefits being well documented, albeit largely untested through scientific methods.

Out of our 122 respondents, 46 reported having heard of the Pueraria plant before, and considering that a significant portion of those taking the survey have some form of connection to the Thailand-RIS iGEM project, it becomes clear that the limitation in the demographic range of the survey may be skewing the data. Meaning that in reality, the knowledge of such a plant may be even less than how the survey depicted it. It is quite worrisome that even in its native environment, the knowledge of medical plants is extremely limited. This may point to the effects of the stigmatization of herbal medicine, and how at this point the place of traditional medicine in Thai society is diminishing greatly.

Our previous survey questions have demonstrated that in Thai society there is a clear divide between Eastern and Western medicine. We would like to argue that they do not have to be mutually exclusive. There is more to modern medicine than just compounds created in the lab; several medicinal drugs like aspirin, morphine, and chemotherapy are powered by plants [5]. The reason there is this stigmatization around herbal medicine is mainly grounded in the fact that there isn’t as much strong research based around it, and thus not much money going into its research and development. However, despite alternative medicine not having been backed by millions in R&D, its use has been cultivated and selected across thousands of years of history and experience, and its medicinal properties have been proven time and time again. The issue is that the representation of such medicinal plants is limited due to the lack of exposure in this specific field.

As international students, it is with our unique viewpoint that we wish to be able to combine the two; they are not and do not have to be mutually exclusive. We hope to bring out the best of both worlds in the sense that we have a natural compound with phytoestrogenic properties which are massively beneficial and combine that with the innovation and science behind modern medicine, to ultimately create a final product that will provide benefits from both worlds to treat neurodegenerative diseases.

Interviews

We had the opportunity to connect with several professionals in the field, who provided insight into our project and possible areas for collaboration.

Initially, we spoke with Dr. Phongkan, who specializes in traditional medicine in Thailand. He informed us that the usage of traditional medicine has been declining rapidly in the country, especially among younger generations. He asserted that one of the main issues regarding traditional medicine is that there isn’t as much funding available to investigate its medicinal properties, which prevents any solid conclusions from being drawn. However, he mentioned that there is potential for collaboration as he believes that if traditional medicine is able to prove itself through scientific evidence, it may regain its status.

Dr. Phongkan also indicated that a promising avenue of exploration could involve integrating herbal medicine with modern pharmaceutical methods. His belief is that these methods will ultimately validate the medicinal properties of various plants like Pueraria and that further exploration into it could lead to significant advances in treatment.

We also had the opportunity to speak with Professor Chatchai, who specializes in pharmaceutical sciences. His viewpoint echoed those of Dr. Phongkan, particularly with regard to the limited research surrounding traditional medicine. He emphasized the importance of scientific backing in legitimizing traditional medicine and the need for collaboration between the two fields.

Finally, we reached out to a local herbalist named Khun Somchai, who has been practicing for over 30 years. He shared that there is still a strong demand for traditional medicine among certain demographics, particularly the elderly, but he agreed that awareness is dwindling among younger generations. He mentioned that traditional medicine is becoming less popular because people are more inclined to turn to modern medicine as they see its effectiveness.

Through these interviews, it became clear that there is potential for collaboration and growth between traditional medicine and modern pharmaceutical practices. With the right approach and funding, we hope to bridge the gap between these two worlds and enhance the value of both.

Final Thoughts and Reflections


Thailand-RIS's goal with human practice this year was to showcase the positive impact synthetic biology can have on humanity and to build up opportunities for connection and collaboration.

The biggest strengths Human Practices had this year were its educational and community outreach.

Thailand-RIS has always chosen projects that are locally relevant, but for the first time, the project is relevant to everyone, because the issue we are fighting for can directly impact anyone.

When it came to interviewing different stakeholders, there were different pieces of information we wanted to collect. When interviewing family and friends of patients affected by neurodegenerative diseases we were looking for a ‘why’ to our project. This serves as the heart for what our Project is about and why it is so important to address this problem. When talking to Mr. Komson Penpoo, a Thai herbal medicine aficionado, our goal was to attain a different perspective on our chosen plant, as the information readily available in terms of modern research is minor, while in contrast, the traditional medicine sector has significant experience with Puerarin. And when we interviewed the Associate Professor, Dr. Supaart Srikantharamas, we were looking for a ‘how’. How the synthetic biology community in Thailand is currently structured and how future growth will be made by raising awareness of its potential among a new generation of biologists and other interested stakeholders.

Overall, our team took steps in the right direction to achieve our goal. Although the steps may seem a beginning, they are authentic and carry potential for further follow-through with future Thailand-RIS teams. They show our local community the benefits and exciting nature of synthetic biology and, more particular to this year, they lend hope to those directly and indirectly affected by neurodegenerative diseases.

References


1. Donepezil Prices, Coupons, Copay Cards & Patient Assistance. (n.d.). Drugs.com. Retrieved October 1, 2024, from https://www.drugs.com/price-guide/donepezil

2. Karger, S. (2021, April 15). Etiology of Dementia in Thai Patients - PMC. NCBI. Retrieved October 1, 2024, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138237/

3. More than 1/3rd of Thailand's 13.6 million 60-plus population still working. (2024, April 20). Nation Thailand. Retrieved October 1, 2024, from https://www.nationthailand.com/thailand/policies/40037391

4. Nussbaum, R. L., & Ellis, C. E. (2003). Alzheimer's Disease and Parkinson's Disease. New England Journal of Medicine, 348(14). Retrieved October 1, 2024, from https://www.nejm.org/doi/full/10.1056/NEJM2003ra020003

5. Pavid, K. (2021, February 19). Aspirin, morphine and chemotherapy: the essential medicines powered by plants. Natural History Museum. Retrieved October 1, 2024, from https://www.nhm.ac.uk/discover/essential-medicines-powered-by-plants.html

6. Seroquel Prices, Coupons, Copay Cards & Patient Assistance. (n.d.). Drugs.com. Retrieved October 1, 2024, from https://www.drugs.com/price-guide/seroquel

7. National Institute on Aging. (2023, October 25). Thinking About Your Risk for Alzheimer’s Disease? Five Questions To Consider. Retrieved October 1, 2024, from https://www.nia.nih.gov/health/alzheimers-causes-and-risk-factors/thinking-about-your-risk-alzheimers-disease-five

8. Tunsuchart, K. (2020, March 30). Type 2 Diabetes Mellitus Related Distress in Thailand. NCBI. Retrieved October 1, 2024, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177402/