Hearing health survey of the population in Bangkok.

In this cross-sectional random survey among Thai adults living in Bangkok, we aimed to identify the prevalence of hearing problems and examine their relationship with individual factors. We administered a self-report questionnaire and performed pure-tone air conduction threshold audiometry. A total of 2463 participants (1728 female individuals) aged 15-96 years were included. The hearing loss prevalence was 53.02% and increased with age. The prevalence of a moderate or greater degree of hearing impairment was 2.8%. Participants aged 65 years and over had 8.56 and 6.79 times greater hearing loss and hearing impairment than younger participants, respectively. Male participants were twice as likely to have hearing loss and hearing impairment as female individuals. Participants with higher education levels showed less likelihood of having hearing loss and hearing impairment than those with no or a primary school education. Participants who ever worked under conditions with loud noise for > 8 h per day had 1.56 times greater hearing loss than those without such exposure. An inconsistent correlation was found between hearing loss, hearing impairment and noncommunicable diseases (diabetes, hypertension, and obesity). Although most participants had mild hearing loss, appropriate care and monitoring are necessary to prevent further loss in such individuals. The questionnaire-based survey found only people with hearing problems that affect daily communication.

Expected Years Of Life Lost Due To Alcohol Consumption In Thai Adults: A 16-Year Follow-Up Cohort Of National Health Examination Survey 2004-2019.

AIMS: Evidence of premature death attributable to alcohol, a modifiable risk factor, is crucial for guiding public health policy for alcohol control. The aim of this study was to estimate alcohol-related mortality and potential years of life lost (PYLL) in Thailand in 2004-2019. METHODS: We analysed data of the third National Health Examination Survey in 2004 linked to National Death Registry data of 2004-2019. Causes of death were based on International Classification of Diseases version 10. PYLL was calculated by cause of death, age group and sex. All analyses were weighted to take into account the probabilities for the multi-stage sampling of the 2004 Thai population aged ≥15 years. RESULTS: There were 10,704 deaths with a follow-up time of 507,771.7 person-years. The crude mortality rate of the initial sample was 868.6 per 100,000 population. The mortality rate attributable to alcohol was 18.6 per 100,000 population (30.7 per 100,000 population in males and 6.8 per 100,000 population in females). The top leading cause of alcohol-attributable deaths was unspecified liver diseases in both males and females (6.1 and 3.1 per 100,000 population, respectively). The total years of life lost (YLL) at baseline were 9.4 million years or 49.5 years per person on average, with significantly more years in males. Mortality rate and expected YLL were highest in ages of 30-44 years, followed by 15-29 years. CONCLUSION: Males were 4-fold more likely to die from all alcohol-attributable causes compared with females. Young adults had a greater loss of life years than older adults.

Validity and reliability of the Thai version of the simple frailty questionnaire (T-FRAIL) with modifications to improve its diagnostic properties in the preoperative setting.

BACKGROUND: Several methods are available for identifying frailty, but limited tools have been validated in Thai context. Our objective was to evaluate the validity and reliability of the Thai version of the Simple Frailty Questionnaire (T- FRAIL) compared to the Thai Frailty Index (TFI) and to explore modifications to improve its diagnostic properties. METHODS: The T-FRAIL was translated with permission using a standardized protocol, that included forward and back-translation. Content validity analysis was performed using input from 5 geriatricians. Test-retest reliability, concurrent validity, diagnostic properties, and options to increase the sensitivity of the questionnaire were explored. A cross-sectional study for evaluation validity and reliability was carried out among 3 hundred patients aged 60 or more undergoing elective surgery at a university hospital. RESULTS: The item content validity index (I-CVI) showed 1.0 for each questionnaire item. Test-retest reliability within a 7-day interval was done in 30 patients with a good intraclass correlation coefficient of 0.880. Compared with the TFI, the T-FRAIL yielded an excellent accuracy (area under the curve = 0.882). The identification of frailty using a score of 2 points or more provided the best Youden's index at 63.1 with a sensitivity of 77.5% (95% CI 69.0-84.6) and a specificity of 85.6% (95% CI 79.6-90.3). A cutoff point of 1 out of 5 items for original T-FRAIL provided a sensitivity of 93.3% and a specificity of 61.1%. The modified T-FRAIL (T-FRAIL_M1), by reducing the "illnesses" criterion to 4 or more diseases, at a cutoff point at 1 had a sensitivity of 94.2% and a specificity of 57.8%. Another modified T-FRAIL (T-FRAIL_M2), by combining three components, at a cutoff point at 1 yielded a sensitivity of 85.8% and a specificity of 80.6%. CONCLUSION: The T-FRAIL and its modification demonstrated satisfactory validity and reliability to identify frailty in elderly patients. The cutoff score of 1 point from 5 items from the original version of T-FRAIL and T-FRAIL_M1 provides a highly sensitive screening tool. T-FRAIL_M1 with a cutoff point of 2 and T-FRAIL_M2 yields reasonable sensitivity and specificity for practical use.

Socio-demographic characteristics associated with the dietary diversity of Thai community-dwelling older people: results from the national health examination survey.

BACKGROUND: Dietary diversity (DD) is an indicator of nutrient intake and is related to health outcomes in older people. Currently, limited research exists regarding factors associated with DD in older people in developing countries, such as Thailand, despite rapid growth in this population. Therefore, this study aims to examine the association between socio-demographic characteristics and DD in Thai older people. METHODS: A cross-sectional study based on the fifth Thai National Health Examination Survey (NHES-V) conducted between 2013 and 2015 was performed. A total of 7,300 nationally representative older participants aged ≥ 60 years were included. The individual-level dietary diversity score (DDS) was assessed as the frequency of consumption of eight food groups using food frequency questionnaires. Each food group was scored from 0 to 4 according to the frequency of consumption. The DDS was calculated as the sum of the scores, ranging from 0 to 32. Socio-demographic characteristics, including age, sex, highest education level, wealth index, living conditions, and residential area, were assessed. Data were analyzed using multiple linear regression and adjusted for complex survey design. RESULTS: The participants had a mean age of 69.7 (SD 7.6) years. The mean DDS of participants was 18.4 (SD 3.9). In the adjusted model, a higher educational level, a higher wealth index, and living in an urban area were positively associated with DDS, with adjusted ß (95% CI) values of 1.37 (1.04, 1.70) for secondary education or higher, 0.81 (0.55, 1.06) for the richest group, and 0.24 (0.10, 0.44) for living in an urban area. Nevertheless, living alone had negative associations with DDS, with a ß (95% CI) of - 0.27 (- 0.53, - 0.00). CONCLUSIONS: This study showed that a higher educational level, a higher wealth index, and living in an urban area had a positive association, whereas living alone had a negative association with DD among Thai older participants. Interventions aiming to improve dietary diversity among older people might benefit from targeting more vulnerable groups, particularly those with less education and wealth, those living alone, or those in rural areas.

Sleep duration and risk of high blood pressure in Thai adolescents: the Thai National Health Examination Survey V, 2014 (NHES-V).

BACKGROUND: Sleep duration has been proposed to be associated with high blood pressure. However, nationwide studies regarding this association in adolescents remain limited. This study aimed to explore the national prevalence of high blood pressure among Thai adolescents and to determine the association between sleep duration and high blood pressure. METHODS: Data from adolescents aged 10-19 years from the Thai National Health and Examination Survey V were included. We collected demographic data (including age and gender), height, weight, waist circumference, blood pressure, fasting blood chemistries and sleep duration data. Sleep durations were categorized as short, normal or long for each age group based on the United States National Sleep Foundation's recommendations. High blood pressure was diagnosed using the 2017 guidelines of the American Academy of Pediatrics. Factors associated with high blood pressure were analyzed using multivariate logistic regression. RESULTS: A total of 3505 adolescents (1785 female) were included. The prevalence of high blood pressure was 9.4% (95% CI 8.5-10.4%). The high blood pressure group had higher BMI z-score, LDL-C, triglyceride and lower HDL-C than the normotensive group. In the multivariate analysis, BMI z-score, LDL-C and HDL-C were independently associated with high blood pressure. However, there was no association between sleep duration and high blood pressure. CONCLUSIONS: High blood pressure risk was increased in adolescents with high BMI z-score. Neither short nor long sleep duration was associated with an increased risk of high blood pressure.

Spectrum of cutaneous adverse reactions to aromatic antiepileptic drugs and human leukocyte antigen genotypes in Thai patients and meta-analysis.

Aromatic antiepileptic drugs (AEDs)-induced cutaneous adverse drug reactions (cADRs) add up to the limited use of the AEDs in the treatment and prevention of seizures. Human leukocyte antigen-B (HLA-B) alleles have been linked to AEDs-induced cADRs. We investigated the association between cADRs (including Stevens-Johnson syndrome; SJS/toxic epidermal necrolysis; TEN, drug reaction with eosinophilia and systemic symptoms; DRESS, and Maculopapular eruption; MPE) caused by AEDs (phenytoin, carbamazepine, lamotrigine, phenobarbital and oxcarbazepine) and HLA-B alleles in Thai population. Through the case-control study, 166 patients with AEDs-induced cADRs, 426 AEDs-tolerant patients (AEDs-tolerant controls), and 470 healthy subjects (Thai population) were collected. The HLA genotypes were detected using the polymerase chain reaction-sequence specific oligonucleotide probe (PCR-SSOP) method. We also performed a meta-analysis with these data and other populations. The carrier rate of HLA-B*15:02 was significantly different between AEDs-induced cADRs group and AEDs-tolerant group (Odds ratio; OR 4.28, 95% Confidence interval; CI 2.64-6.95, p < 0.001), AEDs-induced cADRs group and Thai population (OR 2.15, 95%CI 1.41-3.29, p < 0.001). In meta-analysis showed the strong association HLA-B*15:02 with AEDs-induced cADRs (OR 4.77, 95%CI 1.79-12.73, p < 0.001). Furthermore, HLA-B*15:02 was associated with SJS/TEN induced by AEDs (OR 10.28, 95%CI 6.50-16.28, p < 0.001) Phenytoin (OR 4.12, 95%CI 1.77-9.59, p = 0.001) and carbamazepine (OR 137.69, 95%CI 50.97-371.98, p < 0.001). This study demonstrated that genetic association for AEDs-induced cADRs was phenotype-specific. A strong association between HLA-B*15:02 and AEDs-induced SJS/TEN was demonstrated with an OR of 10.79 (95%CI 5.50-21.16, p < 0.001) when compared with AEDs-tolerant group. On the other hand, the carrier rates of HLA-B*08:01, HLA-B*13:01, and HLA-B*56:02 were significantly higher in the DRESS group compared with the AEDs-tolerant group (p = 0.029, 0.007, and 0.017, respectively). The HLA-B*15:02 allele may represent a risk factor for AEDs-induced cADRs.

Obesity and occupation in Thailand: using a Bayesian hierarchical model to obtain prevalence estimates from the National Health Examination Survey.

BACKGROUND: Like many developing countries, Thailand has experienced a rapid rise in obesity, accompanied by a rapid change in occupational structure. It is plausible that these two trends are related, with movement into sedentary occupations leading to increases in obesity. National health examination survey data contains information on obesity and socioeconomic conditions that can help untangle the relationship, but analysis is challenging because of small sample sizes. METHODS: This paper explores the relationship between occupation and obesity using data on 10,127 respondents aged 20-59 from the 2009 National Health Examination Survey. Obesity is measured using waist circumference. Modelling is carried out using an approach known as Multiple Regression with Post-Stratification (MRP). We use Bayesian hierarchical models to construct prevalence estimates disaggregated by age, sex, education, urban-rural residence, region, and occupation, and use census population weights to aggregate up. The Bayesian hierarchical model is designed to protect against overfitting and false discovery, which is particularly important in an exploratory study such as this one. RESULTS: There is no clear relationship between the overall sedentary nature of occupations and obesity. Instead, obesity appears to vary occupation by occupation. For instance, women in professional occupations, and men who are agricultural or fishery workers, have relatively low rates of obesity. CONCLUSION: Bayesian hierarchical models plus post-stratification offers new possibilities for using surveys to learn about complex health issues.

Metabolic syndrome in Thai adolescents and associated factors: the Thai National Health Examination Survey V (NHES V).

BACKGROUND: Presence of metabolic syndrome (MetS) in early life may influence cardiovascular outcome later in adulthood. There is limited data regarding MetS among Thai adolescents. This study aimed to estimate the prevalence of MetS and related factors in Thai adolescents. METHODS: Data on MetS components of 1934 Thai adolescents aged 10-16 years were obtained from the 5th National Health Examination Survey. Age at first screen time exposure, duration of screen time, frequency of food intake and physical activities were collected from interviews. MetS was defined according to 3 definitions: International Diabetes Federation (IDF), Cook's, and de Ferranti's. RESULTS: The prevalence of MetS was 4.1% by IDF, 8.0% by Cook's, and 16.8% by de Ferranti's definition. The overall prevalence was higher in male (19.0%) than female adolescents (15.3%). The most common MetS components composition among Thai adolescents was high waist circumference with high serum triglyceride and low HDL-cholesterol (40.0% for IDF, 22.6% for Cook's and 43.5% for de Ferranti's definition). Exposure to screen media during the first 2 years of life had a 1.3- fold increased odds of MetS by 1 out of 3 definitions (OR 1.30, 95% CI. 1.01-1.68). Duration of physical activity associated with decreased odds of MetS by Cook's definition (OR 0.96, 95% CI. 0.92-0.99). CONCLUSIONS: The prevalence of MetS among Thai adolescents was higher than previously reported by other studies. Screen media exposure during the first 2 years of life should be discouraged and measures to promote physical activity among children and adolescents should be strengthen.

Assessing a national policy on strengthening chronic care in primary care settings of a middle-income country using patients' perspectives.

BACKGROUND: To improve care for patients with chronic diseases, a recent policy initiative in Thailand focused on strengthening primary care based on the concept of Chronic Care Model (CCM). This study aimed to assess the perception of patients about the health care services after the implementation. METHODS: We conducted a cross-sectional survey of 4071 patients with hypertension and/or diabetes registered with 27 primary care units and 11 hospital non-communicable diseases (NCDs) clinics in 11 provinces. The patients were interviewed using a validated questionnaire of the Patient Assessment of Chronic Illness Care. Upgraded primary care units (PCUs) were ordinary PCUs with the multi-professional team including a physician. Trained upgraded PCUs were upgraded PCUs with the training input. Structural equation modeling was used to create subscale scores for CCM and 5 A model characteristics. Mixed effect logistic models were employed to examine the association of subscales (high vs low score) of patient perception of the care quality with type of PCUs. RESULTS: Compared to hospital NCD clinics, ordinary PCUs were the best in the odds of receiving high score for every CCM subscale (ORs: 1.46-1.85; p < 0.05), whereas the trained upgraded PCUs were better in terms of follow-up (ORs:1.37; p < 0.05), and the upgraded PCU did not differ in all domains. According to the 5 A model subscales, patient assessment also revealed better performance of ordinary PCUs in all domains compared to hospital NCD clinics whereas upgraded PCUs and trained upgraded PCUs did so in some domains. Seeing the same doctor on repeated visits (ORs: 1.82-2.17; p < 0.05) or having phone contacts with the providers (ORs:1.53-1.99; p < 0.05) were found beneficial using CCM subscales and the 5A model subscales. However, patient assessment by both subscales did not demonstrate a statistically significant association across health insurance status. CONCLUSIONS: The policy implementation might not satisfy the patients' perception on quality of chronic care according to the CCM and the 5A model subscale. However, the arrangement of chronic care with patients seeing the same doctors or patients having telephone contact with healthcare providers may satisfy the patients' perceived needs.

Paradox of sustainability in tobacco control in Thailand: A comprehensive assessment of three-decade experiences.

BACKGROUND: Over the past 3 decades of tobacco control, Thailand has gained international recognition as a middle-income country with sustained achievement of declining smoking prevalence. However, the number of key Framework Convention on Tobacco Control measures implementation is still far away from the highest-level implementation. As a result, we aim to explore explanatory factors for the paradoxical phenomenon of sustainability in tobacco control in Thailand, to understand what the paradox means, why it happens, and how to take further steps in minimizing the paradox. METHODS: We used a mixed-method approach comprising qualitative (review of literature and documents plus Program Sustainability Assessment Tool [PSAT] guided key informant interviews) and semi-quantitative methods (PSAT scoring, Theory of Change [TOC], and causal-loop diagram [CLD]) to synthesize all the findings from the qualitative data. RESULTS: Across all eight domains, sustainability scores at the local level are lower than the national level. The highest total score was in three domains: political support, partnership, and organizational capacity. The lowest total score was for the strategic planning domain. We propose a set of key strategic elements and drivers for future strategic planning. DISCUSSION: Using CLD, we capture a high-level view of tobacco control with dynamic interactions between contexts, mechanisms, interventions, and outcomes. We believe the deep understanding of tobacco control and the proposed strategy to counteract transnational tobacco companies in Thailand will guide future sustainable actions to reduce the prevalence of smoking, especially in the strategic planning domain that has the lowest PSAT score.

Socio-economic inequalities in the association between alcohol use disorder and depressive disorder among Thai adults: a population-based study.

BACKGROUND: Previous evidence indicates significant associations between depressive disorders and alcohol use disorder (AUD) and their strong links with social conditions. This study aims to investigate the association between major depressive episode (MDE) and AUD across various socio-economic groups. METHODS: We analysed data from the 2014 Thai National Health Examination Survey containing a random sample of 13,177 adults aged > 20 years from the general population. The Alcohol Use Disorder Identification Test was used to classify respondents into non-problem drinking (score 0-7), hazardous drinking (score 8-15), and harmful-dependent drinking (score 16-40). MDE was identified using questions based on the DSM-IV. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated using multinomial logistic regression to determine the strength of associations between MDE as a predictor and AUD as an outcome variable across different socio-economic levels. RESULTS: The prevalence of MDE, hazardous, and harmful-dependent drinking was 2.5, 10.3, and 1.9%, respectively. The association between MDE and AUD was modified by wealth index, education level and area of residence. AORs for the association between MDE and harmful-dependent drinking were high among those in the highest (AOR = 8.68, 95% CI: 5.34, 14.11) and lowest (AOR = 7.14, 95% CI: 3.71, 13.73) levels of wealth index but not significant among those in the middle level (AOR = 1.78, 95% CI: 0.74, 4.25). Education had the strongest effect on the relationship between MDE and harmful-dependent drinking (AOR = 16.0, 95% CI: 10.30, 24.90 among those completing secondary school or higher and AOR = 1.44, 95% CI: 0.63, 3.33 among those completing primary school only). The association between MDE and harmful-dependent drinking was higher among people who lived in urban areas (AOR = 8.50, 95% CI: 5.50, 13.13) compared to those living in rural areas (AOR = 4.73, 95% CI: 3.31, 6.77). CONCLUSION: Socio-economic factors modify the association between alcohol use disorder and major depressive disorder among Thai people.

Estimation of the adolescent pregnancy rate in Thailand 2008-2013: an application of capture-recapture method.

BACKGROUND: Adolescent pregnancy is an important health and social issue that affects both individual and social well-being. However, deriving a national estimate is challenging in a country with multiple incomplete national databases especially the abortion statistics. The objective of this study was to estimate the adolescent pregnancy rates in Thailand using capture-recapture method. METHODS: An application of capture-recapture method was conducted using two cross-sectional databases (i.e., the national birth registration and the Ministry of Public Health standard health databases) and one hospital-based data source from medical record reviews. A 3-sources capture-recapture with log-linear model was applied to estimate adolescent pregnancy rates. RESULTS: A total number of 741,084, 290,922 and 25,478 records were respectively identified from the birth registrations, standard health databases and hospital-based survey data during 2008 to 2013. The estimated adolescent pregnancy rates /1000 adolescent women (95% confidence intervals (CI)) ranged from 56.3 (49.4, 66.9) to 70.3 (60.3, 76.6). The estimated rates were about 12-31% higher than adolescent birth rates reported by the Thailand Public Health Statistics. CONCLUSIONS: With the capture-recapture method, more accurate adolescent pregnancy rates were estimated. This method should be able to apply to any setting with similar context.

Seroprevalence of anti--Pythium insidiosum antibodies in the Thai population.

Pythiosis is a life-threatening disease of humans and other animals in tropical and subtropical countries. The causative agent is Pythium insidiosum. Diagnosis of pythiosis can be missed due to the lack of awareness in the medical community. Treatment of the disease is difficult and challenging. Most pythiosis patients end up losing an infected organ (i.e., eye or leg), and many die from uncontrolled infection. In 2006, the largest series of human cases of pythiosis (∼100) was reported from Thailand, highlighting the nationwide distribution of this high morbidity and mortality disease. The global distribution of P. insidiosum is demonstrated by its detection in several regions around the world. Epidemiological studies of exposure to the pathogen in the general population are lacking. Here we used a combination of two established diagnostic tools (i.e., ELISA and Western blot) to explore the seroprevalence of anti-P. insidiosum antibodies in 2641 individuals, aged ≥ 15 years, sampled from Thailand. Four individuals were identified with anti-P. insidiosum antibodies in their sera, thus providing a statistically-estimated prevalence of ∼7 in 10000 or ∼32000 in the entire Thai population. The detection of the anti-P. insidiosum antibodies in healthy people with no history of pythiosis suggests that subclinical infections can occur. Taking into account the seroprevalence of anti-P. insidiosum antibodies, the global distribution of the organism, the nationwide distribution of patients, and the high morbidity and mortality of the disease, awareness of pythiosis should be raised as a public health concern in Thailand and other countries.

Evidence on the magnitude of the economic, health and population effects of palm cooking oil consumption: an integrated modelling approach with Thailand as a case study.

BACKGROUND: Palm oil's high yields, consequent low cost and highly versatile properties as a cooking oil and food ingredient have resulted in its thorough infiltration of the food sector in some countries. Longitudinal studies have associated palm oil's high saturated fatty acid content with non-communicable disease, but neither the economic or disease burdens have been assessed previously. METHODS: This novel palm oil-focussed disease burden assessment employs a fully integrated health, macroeconomic and demographic Computable General Equilibrium Model for Thailand with nine regional (urban/rural) households. Nutritional changes from food consumption are endogenously translated into health (myocardial infarction (MI) and stroke) and population outcomes and are fed back into the macroeconomic model as health and caregiver-related productive labour supply effects and healthcare costs to generate holistic 2016-2035 burden estimates. Model scenarios mirror the replacement of palm cooking oil with other dietary oils and are compared with simulated total Thai health and macroeconomic burdens for MI and stroke. RESULTS: Replacing consumption of palm cooking oil with other dietary oils could reduce MI/stroke incident cases by 8280/2639 and cumulative deaths by 4683/894 over 20 years, removing approximately 0.5% of the total Thai burden of MI/stroke. This palm cooking oil replacement would reduce consumption shares of saturated/monounsaturated fatty acids in Thai household consumption by 6.5%/3% and increase polyunsaturated fatty acid consumption shares by 14%, yielding a 1.74% decrease in the population-wide total-to-HDL cholesterol ratio after 20 years. The macroeconomic burden that would be removed is US$308mn, approximately 0.44% of the total burden of MI/stroke on Thailand's economy or 0.003% of cumulative 20-year GDP. Bangkok and Central region households benefit most from removal of disease burdens. CONCLUSIONS: Simulations indicate that consumption of palm cooking oil, rather than other dietary oils, imposes a negative health burden (MI and stroke) and associated economic burden on a high consuming country, such as Thailand. Integrated sectoral model frameworks to assess these burdens are possible, and burden estimates from our simulated direct replacement of palm cooking oil indicate that using these frameworks both for broader analyses of dietary palm oil use and total burden analyses of other diseases may also be beneficial.

Assessing system-based trainings for primary care teams and quality-of-life of patients with multimorbidity in Thailand: patient and provider surveys.

BACKGROUND: Strengthening primary care is considered a global strategy to address non-communicable diseases and their comorbidity. However, empirical evidence of the longer-term benefits of capacity building programmes for primary care teams contextualised for low- and middle-income countries is scanty. In Thailand, a series of system-based capacity building programmes for primary care teams have been implemented for a decade. An analysis of the relationship between these systems-based trainings in diverse settings of primary care and quantified patient outcomes was needed. METHODS: Facility-based and community-based cross-sectional surveys were used to obtain data on exposure of primary care team members to 11 existing training programmes in Thailand, and health profiles and health-related quality of life of their patients measured in EuroQol-5 Dimension (EQ-5D) scale. Using a multilevel modelling, the associations between primary care provider's training and patient's EQ-5D score were estimated by a generalized linear mixed model (GLMM). RESULTS: While exposure to training programmes varied among primary care teams nationwide, District Health Management Learning (DHML) and Contracting Unit of Primary Care (CUP) Leadership Training Programmes, which put more emphasis on bundling of competencies and contextualising of applying such competencies, were positively associated with better health-related quality of life of their multimorbid patients. CONCLUSIONS: Our report provides systematic feedback to a decade-long investment on system-based capacity building for primary care teams in Thailand, and can be considered as new evidence on the value of human resource development in primary care systems in low- and middle-income countries. Building multiple competencies helps members of primary care teams collaboratively manage district health systems and address complex health problems in different local contexts. Coupling contextualised training with ongoing programme implementation could be a key entity to the sustainable development of primary care teams in low and middle income countries which can then be a leverage for improving patients outcomes.

Palm oil and dietary change: Application of an integrated macroeconomic, environmental, demographic, and health modelling framework for Thailand.

Palm oil is a cooking oil and food ingredient in widespread use in the global food system. However, as a highly saturated fat, palm oil consumption has been associated with negative effects on cardiovascular health, while large scale oil palm production has been linked to deforestation. We construct an innovative fully integrated Macroeconomic-Environmental-Demographic-health (MED-health) model to undertake integrated health, environmental, and economic analyses of palm oil consumption and oil palm production in Thailand over the coming 20 years (2016-2035). In order to put a health and fiscal food policy perspective on policy priorities of future palm oil consumption growth, we model the implications of a 54% product-specific sales tax to achieve a halving of future energy intakes from palm cooking oil consumption. Total patient incidence and premature mortality from myocardial infarction and stroke decline by 0.03-0.16% and rural-urban equity in health and welfare improves in most regions. However, contrary to accepted wisdom, reduced oil palm production would not be environmentally beneficial in the Thailand case, since, once established, oil palms have favourable carbon sequestration characteristics compared to alternative uses of Thai cropland. The increased sales tax also provokes mixed economic impacts: While real GDP increases in a second-best Thai tax policy environment, relative consumption-to-investment price changes may reduce household welfare over extended periods unless accompanied by non-distortionary government compensation payments. Overall, our holistic approach demonstrates that product-specific fiscal food policy taxes may involve important trade-offs between nutrition, health, the economy, and the environment.

Assessment of population coverage of hypertension screening in Thailand based on the effective coverage framework.

BACKGROUND: Hypertension (HT) is a major risk factor, and accessible and effective HT screening services are necessary. The effective coverage framework is an assessment tool that can be used to assess health service performance by considering target population who need and receive quality service. The aim of this study is to measure effective coverage of hypertension screening services at the provincial level in Thailand. METHODS: Over 40 million individual health service records in 2013 were acquired. Data on blood pressure measurement, risk assessment, HT diagnosis and follow up were analyzed. The effectiveness of the services was assessed based on a set of quality criteria for pre-HT, suspected HT, and confirmed HT cases. Effective coverage of HT services for all non-HT Thai population aged 15 or over was estimated for each province and for all Thailand. RESULTS: Population coverage of HT screening is 54.6%, varying significantly across provinces. Among those screened, 28.9% were considered pre-HT, and another 6.0% were suspected HT cases. The average provincial effective coverage was at 49.9%. Around four-fifths (82.6%) of the pre-HT group received HT and Cardiovascular diseases (CVD) risk assessment. Among the suspected HT cases, less than half (38.0%) got a follow-up blood pressure measurement within 60 days from the screening date. Around 9.2% of the suspected cases were diagnosed as having HT, and only one-third of them (36.5%) received treatment within 6 months. Within this group, 21.8% obtained CVD risk assessment, and half of them had their blood pressure under control (50.8%) with less than 1 % (0.7%) of them managed to get the CVD risk reduced. CONCLUSIONS: Our findings suggest that hypertension screening coverage, post-screening service quality, and effective coverage of HT screening in Thailand were still low and they vary greatly across provinces. It is imperative that service coverage and its effectiveness are assessed, and both need improvement. Despite some limitations, measurement of effective coverage could be done with existing data, and it can serve as a useful tool for performance measurement of public health services.

Identification of Potential Leverage Points for Self-Management Support Intervention in Thais with Type 2 Diabetes.

Background: Although social-ecological models and multi-level interventions have been recommended for implementing the holistic self-management support for patients with type 2 diabetes, they are complex, costly, and need long-term effort. A more realistic approach would be to identify and implement a single or limited leverage point(s) that is most effective and feasible to create change. Objective: To assess the independent relationships of the social-environmental supports with self-management behaviors in Thai patients with type 2 diabetes. Material and Method: A cross-sectional survey was conducted among 1,000 type 2 diabetic patients from 64 healthcare facilities throughout Bangkok. A set of structured questionnaires were used to collect data related to social-environmental supports, and self-management behaviors. The predictor-outcome relationships were presented by beta (ß) coefficients (95% confidence limits). Results: Personal support was significantly associated with the overall self-management, dietary, physical activity, and medication taking behaviors. Neighborhood support was significantly associated with the overall self-management, physical activity, and medication taking behaviors. Personal support was found to interact negatively with neighborhood support on the overall self-management and medication taking behaviors. Conclusion: Personal and neighborhood supports are two potential leverage points for self-management support interventions for Thai patients with type 2 diabetes. Patients with low and high personal supports may need different strategies for neighborhood support.

Discrepant association of serum C-3 epimer of 25-hydroxyvitamin D versus non-epimeric 25-hydroxyvitamin D with serum lipid levels.

BACKGROUND: Low vitamin D status has been associated with a number of chronic diseases. For dyslipidemia, vitamin D deficiency has been associated with higher low density lipoprotein-cholesterol (LDL-C) in a number of studies, but with inconsistent results in clinical trials. The purpose of the present study is to explore the relative importance of 3-epi-25-hydroxyvitamin D (25(OH)D) as compared with the non-epimeric form in relation to serum lipid. METHOD: This study used data from 1068 randomly selected volunteers in the Thai 4(th) National Health Examination Survey (NHES IV). Serum 25(OH)D2, 25(OH)D3, 3-epi-25(OH)D2 and 3-epi-25(OH)D3 were analyzed by liquid chromatography-tandem mass spectrometry. RESULTS: There was no association between serum total 25(OH)D and serum LDL-C. However, circulating 3-epi-25(OH)D3 was negatively related to serum LDL-C (r = -0.077, P <0.05), while no such association was found for non-epimeric 25(OH)D3 (r =0.030, P = 0.33). On the other hand, both 3-epi-25(OH)D3 (r = 0.175, P <0.001) and non-epimeric 25(OH)D3 (r = 0.142, P <0.001) were positively related to serum triglyceride (TRIG) levels. In multiple linear regression models with age, gender, body mass index , urban residence, education, hypertension and education as covariates, it was found that 3-epi-25(OH)D3 was independently associated with serum LDL-C (beta = -0.12, P <0.01), while non-epimeric 25(OH)D3 was positively related to LDL-C (beta = 0.13, P = 0.002). For TRIG, there were positive association with 3-epi-25(OH)D3 (beta = 0.27, P <0.001) and negative association with non-epimeric 25(OH)D3 (beta = - 0.10, P = 0.011) independent of age, gender, urban resident and education. CONCLUSIONS: There is a discrepant association of 25(OH)D levels with serum lipids according to 25(OH)D epimeric forms.

Validation and comparison study of three urbanicity scales in a Thailand context.

BACKGROUND: Validity and reliability of an urbanicity scale is of utmost importance in developing effective strategies to minimize adverse social and health consequences of increased urbanization. A number of urbanicity scales for the quantitative assessment of the "static" feature of an urban environment has been invented and validated by the original developers. However, their comparability and robustness when utilized in another study context were not verified. This study aimed to examine the comparability, validity, and reliability of three urbanicity scales proposed by Dahly and Adair, Jones-Smith and Popkin, and Novak et al. in a Thailand context. METHODS: Urban characteristics data for 537 communities throughout Thailand were obtained from authoritative sources, and urbinicity scores were calculated according to the original developers' algorithms with some modifications to accommodate local available data. Comparability, dimensionality, internal consistency, and criterion-related and construct validities of the scores were then determined. RESULTS: All three scales were highly correlated, but Dahly and Adair's and Jones-Smith and Popkin's were more comparable. Only Dahly and Adair's scale achieved the unidimensionality assumption. Internal consistency ranged from very poor to high, based on their Chonbach's alpha and the corrected item-scale correlation coefficients. All three scales had good criterion-related validity (when compared against the official urban-rural dichotomy and four-category urbanicity classification) and construct validity (in terms of their relation to the mean per capita monthly income and body mass index). CONCLUSIONS: This study's results ensure the utility of these three urbanicity scales as valid instruments for examining the social and health impacts of urbanicity/urbanization, but caution must be applied with comparisons of urbanicity levels across different studies when different urbanicity scales are applied.