Early diagnosis of kala-azar in Bangladesh: Findings from a population based mixed methods research informing the post-elimination era.

BACKGROUND: Global annual reports of visceral leishmaniasis or kala-azar ("black fever") reduced from 200,000 cases in 2012 to 23,804 in 2015. India, Bangladesh and Nepal reported 80% of the global cases in 2012, but 39% in 2015. We sought to identify major amenable barriers to early diagnosis of kala-azar in peripheral areas of Mymensingh district, an area of Bangladesh that was highly endemic for kala-azar. METHODS: We conducted sequential exploratory mixed methods research. Qualitative data were first derived from in-depth interviews and focus group discussions among 29 patients diagnosed with kala-azar, their families, and neighbours. Preliminary results from qualitative analysis were used to design a structured questionnaire, which was administered to collect data on the processes leading to the diagnosis of kala-azar from 102 patients. Qualitative and quantitative data were integrated consistent with the chronology for kala-azar patients seeking care. The study was conducted from September 2011 to May 2012 in Fulbaria and Gaffargaon sub-districts of Mymensingh. RESULTS: The median delay from fever onset to confirmatory diagnosis of kala-azar was 60 days, with 38% of the cases diagnosed within 30 days. Public health facilities and Gaffargaon sub-district achieved high proportions of early diagnosis. Individual barriers to early diagnosis were low awareness of symptoms and treatment facilities, poverty, and traditional beliefs. Other factors were the remoteness of health care centres, wet season transport difficulty, mis-diagnosis as typhoid, limited availability of rK-39 testing at the community level, and the inclusion of splenomegaly in the case definition. CONCLUSIONS: Targeted community awareness campaigns appropriate for underprivileged communities will increase care seeking and consequently diagnosis. Improved diagnostic guidelines and a strong referral chain for kala-azar will accelerate diagnosis. These steps will contribute significantly to the National Kala-azar Elimination Program of Bangladesh, especially during the post-elimination era.

Dietary patterns associated with hypertension risk among adults in Thailand: 8-year findings from the Thai Cohort Study.

OBJECTIVE: Dietary intake is a leading risk factor for hypertension. We aimed to assess longitudinal associations between overall dietary patterns and incident hypertension among adults in Thailand. DESIGN: Prospective large Thai Cohort Study (TCS) conducted nationwide from 2005 to 2013. Dietary patterns were identified using factor analysis based on usual intake of fourteen food groups. Multivariable logistic regression assessed associations between dietary patterns and hypertension prevalence and incidence. SETTING: Emerging hypertension and changing diets in Thailand. SUBJECTS: TCS participants who were normotensive at baseline in 2005. RESULTS: Among 36293 participants without hypertension at baseline, 1831 reported incident hypertension (5·1 % incidence) at follow-up. Two dietary patterns were identified: 'Modern' and 'Prudent'. The Modern dietary pattern (high intakes of roasted/smoked foods, instant foods, canned foods, fermented fruits/vegetables, fermented foods, soft drinks, deep-fried foods) was associated with increased incident hypertension (comparing extreme quartiles, OR for incident hypertension=1·51; 95 % CI 1·31, 1·75 in 2013). The Prudent dietary pattern (high intakes of soyabean products, milk, fruits, vegetables) was not associated with incident hypertension in a fully adjusted model. The association between the Modern dietary pattern and hypertension was attenuated by BMI. CONCLUSIONS: Modern dietary pattern was positively associated with hypertension among Thai adults. BMI had a great impact on the relationship between the Modern dietary pattern and incidence of hypertension. Reduction of Modern diets would be expected to prevent and control hypertension. Such a strategy would be worth testing.

Relationship between 8-year weight change, body size, and health in a large cohort of adults in Thailand.

BACKGROUND: Overweight and obesity have been shown to be risk factors for a range of non-communicable diseases, especially cardio-metabolic conditions, worldwide. But less is known about the effects of weight change on adults' overall health and wellbeing, particularly in transitional low- and middle-income countries. This study aimed to assess the relationship between 8-year weight change and measures of self-assessed health among Thai adults. METHODS: Data were collected from Thai adults aged 25-40 years (n = 27,003) enrolled in the Thai cohort Study and surveyed in 2005, 2009, and 2013. We used self-reported weight and height measurements at baseline and 2013, as well as three standard health questions regarding overall health, energy, and emotion asked at the two time points, to investigate the effects of weight change on health. RESULTS: Between 2005 and 2013, 6.0% of participants lost more than 5% of their baseline weight; 38.5% were stable (<5% loss to 5% gain); 23.0% slightly gained weight (>5%-10%); 22.8% gained moderate weight (>10%-20%); and 9.4% had heavy weight gain (>20%). Moderate (>10%-20%) and heavy weight gain (>20%) were both associated with an increased risk of reporting 'poor or very poor' overall health in 2013 among participants who had a normal body mass index (BMI) (adjusted odds ratio [AOR] 1.39; 95% confidence interval [CI], 1.13-1.71 and AOR 1.44; 95% CI, 1.09-1.90, respectively), were overweight (AOR 1.53; 955 CI, 1.01-2.29 and AOR 1.82; 95% CI, 1.04-3.19, respectively) or had obesity (AOR 2.47; 95% CI, 1.74-3.51 and AOR 3.20; 95% CI, 2.00-5.16, respectively) in 2005. Weight gain of over 20% also had a negative impact on energy level among cohort members with a normal BMI in 2005 (AOR 1.36; 95% CI, 1.11-1.65) and among participants with obesity in 2005 (AOR 1.93; 95% CI, 1.38-2.71). For those who were underweight, had a normal BMI, or had obesity at baseline, weight loss of more than 5% was associated with reporting emotional problems. Excessive weight gain adversely impacted participants who were underweight or had obesity at baseline. CONCLUSION: Our study found that weight change, in particular weight gain, was associated with negative health outcomes, and this effect appeared to increase at higher levels of body size. The present findings may be useful to promote weight maintenance and healthy lifestyles.

Low back pain and limitations of daily living in Asia: longitudinal findings in the Thai cohort study.

BACKGROUND: Low back pain (LBP) is a major cause of disability throughout the world. However, longitudinal evidence to relate low back pain and functional limitations is mostly confined to Western countries. In this study, we investigate the associations between low back pain and functional limitations in a prospective cohort of Thai adults. METHODS: We analysed information from the Thai Cohort Study of adult Open University adults which included 42,785 participants in both 2009 and 2013, with the majority aged 30 to 65 years and residing nationwide. We used multivariate logistic regression to explore the longitudinal associations between LBP in 2009 and 2013 ('never': no LBP in 2009 or 2013; 'reverting': LBP in 2009 but not in 2013; 'incident': no LBP in 2009 but LBP in 2013; and 'chronic': reporting LBP at both time points) and the outcome of functional limitations relating to Activities of Daily Living (ADL) in 2013. RESULTS: Low back pain was common with 30% of cohort members reporting low back pain in both 2009 and 2013 ('chronic LBP'). The 'chronic LBP' group was more likely than the 'never' back pain group to report functional limitations in 2013: adjusted odds ratios 1.60 [95% Confidence Interval: 1.38-1.85] for difficulties getting dressed; 1.98 [1.71-2.30] for walking; 2.02 [1.71-2.39] for climbing stairs; and 3.80 [3.38-4.27] for bending/kneeling. Those with 'incident LBP' or 'reverting LBP' both had increased odds of functional limitations in 2013 but the odds were not generally as high. CONCLUSIONS: Our nationwide data from Thailand suggests that LBP is a frequent public health problem among economically productive age groups with adverse effects on the activities of daily living. This study adds to the limited longitudinal evidence on the substantial impact of low back pain in Southeast Asia.

Caregiving and mental health among workers: Longitudinal evidence from a large cohort of adults in Thailand.

BACKGROUND: As people in middle and lower income countries live longer, more people become sick, disabled, and frail and the demand for family caregiving grows. Thailand faces such challenges. This study investigates the relationship between caregiving and mental health among workers drawn from a large longitudinal cohort of Thai adults. METHODS: Participants were drawn from the Thai Health-Risk Transition Study, a cohort study since 2005 of distance-learning adult Open University students residing nationwide. Caregiving status and binary psychological distress outcome (score 19-30 on Kessler 6) were recorded in 2009 and 2013 among cohort members who were paid workers at both years (n=33,972). Multivariate logistic regression was used to estimate the relationship between four-year longitudinal caregiving status and psychological distress in 2013, adjusting for potential covariates. RESULTS: Longitudinal analyses revealed the transitional nature of care with 25% exiting and 10% entering the caring role during the four-year follow-up. Based on multivariate logistic regression, 2009-2013 caregiving status was significantly associated with psychological distress. Cohort members transitioning into caregiving and those who were caregivers in both 2009 and 2013 had a higher risk for psychological distress than non-caregivers (Adjusted Odds Ratios 1.40 [1.02-1.96] and 1.64 [1.16-2.33], respectively). CONCLUSION: Our findings provide evidence on caregiving and associated risk for psychological distress among working Thais. This adds to the limited existing literature in middle-income countries and highlights the potential pressure among caregivers in balancing work and care while preserving their own mental health.

Psychosocial job characteristics, wealth, and culture: differential effects on mental health in the UK and Thailand.

BACKGROUND: Most research on the influence of psychosocial job characteristics on health status has been conducted within affluent Western economies. This research addresses the same topic in a middle-income Southeast Asian country, enabling comparison with a Western benchmark. METHODS: We analysed and compared the Health Survey for England conducted in 2010 and the Thai Cohort Study data at 2005 baseline for workers aged 35-45 years. Multivariate logistic regression was used to assess relationships between psychosocial job characteristics and health, measured as Adjusted Odd Ratios (AOR), controlling for potential covariates in final analyses. RESULTS: In both UK and Thai working adults, psychological distress was associated with job insecurity (AOR 2.58 and 2.32, respectively), inadequate coping with job demands (AOR 2.57 and 2.42), and low support by employers (AOR 1.93 and 1.84). Job autonomy was associated with psychological distress in the UK samples (AOR 2.61) but no relationship was found among Thais after adjusting for covariates (AOR 0.99). Low job security, inability to cope with job demands, and low employer support were associated with psychological distress both among Thai and UK workers. CONCLUSIONS: Job autonomy was an important part of a healthy work environment in Western cultures, but not in Thailand. This finding could reflect cultural differences with Thais less troubled by individualistic expression at work. Our study also highlights the implications for relevant workplace laws and regulations to minimise the adverse job effects. These public health strategies would promote mental health and wellbeing in the population.

Health, happiness and eating together: what can a large Thai cohort study tell us?

Our research investigates the significance of frequent solo consumption of main meals and the association with a holistic wellbeing measure of happiness using data from 39820 Thai Cohort Study members who completed 8-year follow-up in 2013. This nationwide cohort has been under study since 2005 to analyse the dynamics and determinants of the health-risk transition from infectious to chronic diseases. Here we analyse data from the 2009 and 2013 follow-ups. Approximately 11% reported eating more than half of the main meals per week alone. Sociodemographic attributes associated with eating alone were being male, older age, unmarried, smaller household, lower income, and urban residence. Dissatisfaction with amount of spare time (ie 'busyness') was also linked to eating alone. In the multivariate cross-sectional model, reporting being unhappy was associated with frequent solo eating (Adjusted Odds Ratio - AOR 1.54, 95% Confidence Intervals 1.30-1.83). Stratified by age and sex groups, the effects were strongest among females (AOR 1.90 1.52-2.38).  A monotonic relationship linked frequent eating alone and 4-year longitudinal unhappiness. The larger the dose of unhappiness the greater the odds of eating alone - AOR 1.29, 1.31, 1.72 after controlling for potential covariates. Having a meal is not only important for nutritional and health outcomes; it is also a vital part of daily social interaction. Our study provided empirical evidence from a non-Western setting that sharing meals could contribute to increasing happiness.

Performance of kala-azar surveillance in Gaffargaon subdistrict of Mymensingh, Bangladesh.

INTRODUCTION: Elimination of kala-azar is planned for South Asia requiring good surveillance along with other strategies. We assessed surveillance in Gaffargaon upazila (a subdistrict of 13 unions) of Mymensingh district, Bangladesh highly endemic for kala-azar. METHODS: In 4703 randomly sampled households, within nine randomly sampled villages, drawn from three randomly sampled unions, we actively searched for kala-azar cases that had occurred between January 2010 and December 2011. We then searched for medical records of these cases in the patient registers of Gaffargaon upazila health complex (UHC). We investigated factors associated with the medical recording by interviewing the cases and their families. We also did a general observation of UHC recording systems and interviewed health staff responsible for the monthly reports of kala-azar cases. RESULTS: Our active case finding detected 58 cases, but 29 were not recorded in the Gaffargaon UHC. Thus, only 50% (95% CI: 37%-63%) of kala-azar cases were reported via the government passive surveillance system. Interviews with health staff based in the study UHC revealed the heavy reporting burden for multiple diseases, variation in staff experience, high demands on the staff time and considerable complexity in the recording system. After adjusting for kala-azar treatment drug, recording was found more likely for those aged 18 years or more, males, receiving supply and administration of drug at the UHC, and more recent treatment. DISCUSSION: Fifty percent of kala-azar cases occurring in one highly endemic area of Bangladesh were recorded in registers that were the source for monthly reports to the national surveillance system. Recording was influenced by patient, treatment, staff and system factors. Our findings have policy implications for the national surveillance system. Future studies involving larger samples and including interviews with health authorities at more central level and surveillance experts at the national level will generate more precise and representative evidence on the performance of kala-azar surveillance in Bangladesh.

Physically and psychologically hazardous jobs and mental health in Thailand.

This paper investigates associations between hazardous jobs, mental health and wellbeing among Thai adults. In 2005, 87 134 distance-learning students from Sukhothai Thammathirat Open University completed a self-administered questionnaire; at the 2009 follow-up 60 569 again participated. Job characteristics were reported in 2005, psychological distress and life satisfaction were reported in both 2005 and 2009. We derived two composite variables grading psychologically and physically hazardous jobs and reported adjusted odds ratios (AOR) from multivariate logistic regressions. Analyses focused on cohort members in paid work: the total was 62 332 at 2005 baseline and 41 671 at 2009 follow-up. Cross-sectional AORs linking psychologically hazardous jobs to psychological distress ranged from 1.52 (one hazard) to 4.48 (four hazards) for males and a corresponding 1.34-3.76 for females. Similarly AORs for physically hazardous jobs were 1.75 (one hazard) to 2.76 (four or more hazards) for males and 1.70-3.19 for females. A similar magnitude of associations was found between psychologically adverse jobs and low life satisfaction (AORs of 1.34-4.34 among males and 1.18-3.63 among females). Longitudinal analyses confirm these cross-sectional relationships. Thus, significant dose-response associations were found linking hazardous job exposures in 2005 to mental health and wellbeing in 2009. The health impacts of psychologically and physically hazardous jobs in developed, Western countries are equally evident in transitioning Southeast Asian countries such as Thailand. Regulation and monitoring of work conditions will become increasingly important to the health and wellbeing of the Thai workforce.

Association between vision impairment and health among a national cohort of 87,134 Thai adults.

To date, more than 300 million people worldwide live with low vision and blindness, imposing social and economic burdens on individuals and families. This study analyzes a cohort of 87 134 Thai adults, reporting odds ratios (ORs) and calculating population attributable fractions (PAFs). PAF estimates the proportion of the disease or condition that would not occur if no one in the population had the risk factor. Approximately 28% and 8% reported having refractive errors and vision impairment not correctable by visual aids. Both types of vision impairment were positively associated with poor self-assessed health (adjusted ORs = 1.23 to 2.03) and poor psychological health (adjusted ORs = 1.13 to 1.63). PAFs show that refractive errors explain 6.1% of poor self-assessed health, 3.5% of poor psychological health, and 2.2% of falls in the last year. PAFs for vision impairment not correctable by visual aids explain 7.5%, 4.7%, and 3.1%, respectively. Incorporating early detection and prevention of vision impairment at the primary health care level will contribute to promoting the health of Thais.

Relationship between body mass index reference and all-cause mortality: evidence from a large cohort of Thai adults.

We investigate variation in body mass index (BMI) reference and 5-year all-cause mortality using data from 87151 adult Open University students nationwide. Analyses focused on BMI reference bands: "normal" (≥18.5 to <23), "lower normal" (≥18.5 to <20.75), "upper normal" (≥20.75 to <23), and "narrow Western normal" (≥23 to <25). We report hazard ratios (HR) and 95% Confidence Intervals adjusting for covariates. Compared to lower normal, adults aged 35-65 years who were obese (BMI ≥ 30) were twice as likely to die during the follow-up (HR 2.37; 1.01-5.70). For the same group, when using narrow Western normal as the reference, the results were similar (HR 3.02; 1.26-7.22). However, different combinations of BMI exposure and reference band produce quite different results. Older age persons belonging to Asian overweight BMI category (≥23 to <25) were relatively protected from mortality (HR 0.57; 0.34-0.96 and HR 0.49; 0.28-0.84) when assessed using normal (≥18.5 to <23) and upper normal (≥20.75 to <23) as reference bands. Use of different "normal" reference produced varying mortality relationships in a large cohort of Thai adults. Caution is needed when interpreting BMI-mortality data.

Unhappiness and mortality: evidence from a middle-income Southeast Asian setting.

BACKGROUND: A relationship between happiness and mortality might seem obvious, but outside of affluent settings in developed countries there is almost no actual evidence that this is so. FINDINGS: We report our findings on happiness and mortality in Buddhist Southeast Asia. Our data are derived from a prospective nationwide cohort study of 60,569 Thai adults reporting in 2009 and followed up for all-cause mortality over the next four years (296 deaths). We also gathered data on a wide array of covariates and included these in the final model of the unhappiness-mortality effect. All final effect estimates were mutually adjusted odds ratios (AOR) and cohort members who reported being happy 'little' or 'none of the time' in 2009 were more likely to die (AOR 2.60, 95% Confidence Interval 1.17-5.80). Other significant covariates include being female (<40 years AOR 0.66, ≥40 years AOR 0.57), unmarried (AOR 1.64) and current smokers (AOR 2.45). CONCLUSION: Our study provides empirical evidence that the epidemiological effect of happiness is not confined to affluent Western countries, but it also increases the probability of staying alive in a middle-income Asian country.

Predictors of injury mortality: findings from a large national cohort in Thailand.

OBJECTIVE: To present predictors of injury mortality by types of injury and by pre-existing attributes or other individual exposures identified at baseline. DESIGN: 5-year prospective longitudinal study. SETTING: Contemporary Thailand (2005-2010), a country undergoing epidemiological transition. PARTICIPANTS: Data derived from a research cohort of 87 037 distance-learning students enrolled at Sukhothai Thammathirat Open University residing nationwide. MEASURES: Cohort members completed a comprehensive baseline mail-out questionnaire in 2005 reporting geodemographic, behavioural, health and injury data. These responses were matched with national death records using the Thai Citizen ID number. Age-sex adjusted multinomial logistic regression was used to calculate ORs linking exposure variables collected at baseline to injury deaths over the next 5 years. RESULTS: Statistically significant predictors of injury mortality were being male (adjustedOR 3.87, 95% CI 2.39 to 6.26), residing in the southern areas (AOR 1.71, 95% CI 1.05 to 2.79), being a current smoker (1.56, 95% CI 1.03 to 2.37), history of drunk driving (AOR 1.49, 95% CI 1.01 to 2.20) and ever having been diagnosed for depression (AOR 1.91, 95% CI 1.00 to 3.69). Other covariates such as being young, having low social support and reporting road injury in the past year at baseline had moderately predictive AORs ranging from 1.4 to 1.6 but were not statistically significant. CONCLUSIONS: We complemented national death registration with longitudinal data on individual, social and health attributes. This information is invaluable in yielding insight into certain risk traits such as being a young male, history of drunk driving and history of depression. Such information could be used to inform injury prevention policies and strategies.

The associations between unhealthy behaviours, mental stress, and low socio-economic status in an international comparison of representative samples from Thailand and England.

BACKGROUND: Socioeconomic status is a recognised determinant of health status, and the association may be mediated by unhealthy behaviours and psychosocial adversities, which, in developed countries, both aggregate in low socioeconomic sectors of the population. We explored the hypothesis that unhealthy behavioural choices and psychological distress do not both aggregate in low socioeconomic status groups in developing countries. METHODS: Our study is based on a cross-sectional comparison between national population samples of adults in England and Thailand. Psychological distress was assessed using the General Health Questionnaire (GHQ-12) or three anxiety-oriented items from the Kessler scale (K6). Socioeconomic status was assessed on the basis of occupational status. We computed a health-behaviour score using information about smoking, alcohol consumption, fruit and vegetable consumption, and physical activity. RESULTS: The final sample comprised 40,679 participants. In both countries and in both genders separately, there was a positive association between poor health-behaviour and high psychological distress, and between high psychological distress and low socioeconomic status. In contrast, the association between low socioeconomic status and poor health-behaviour was positive in both English men and women, flat in Thai men, and was negative in Thai women (likelihood ratio test P <0.001). CONCLUSION: The associations between socioeconomic status, behavioural choices, and psychological distress are different at the international level. Psychological distress may be consistently associated with low socioeconomic status, whereas poor health-behaviour is not. Future analyses will test whether psychological distress is a more consistent determinant of socioeconomic differences in health across countries.

The effect of injuries on health measured by short form 8 among a large cohort of Thai adults.

INTRODUCTION: We investigate the links between health and injury in Thailand. This is important because of the high burden of injury in transitional countries and limited information for public health. METHODS: We analyse 2005 baseline and 2009, 4-year follow-up data from distance learning students of Sukhothai Thammathirat Open University residing nationwide (n = 60569). Injury was reported for the past year in both periods. Medical Outcome Study Short-Form (SF-8™) health status was reported and Physical and Mental Component Summary Scores (PCS and MCS) were calculated. Analyses used covariate-adjusted multivariate linear regression. RESULTS: In 2009, increasing numbers of traffic injuries (0, 1, 2, 3, 4+) associated with declining PCS scores (49.8, 48.4, 46.9, 46.2, 44.0), along with a similar monotonic decline for MCS scores (47.6, 46.0, 44.2, 42.7, 40.6). A similar (but smaller) dose-response gradient was found between non-traffic injuries and SF-8 scores. Longitudinal analyses showed those with incident injury (no injury 2005, injury 2009) had lower PCS and MCS scores compared to those with no injury in both periods. Individuals with reverting injury status (injury 2005, no injury 2009) reported improvement in PCS and MCS scores over the four-year period. CONCLUSION: We found significant and epidemiologically important associations between increasing injury frequency and worse health in the past year, especially traffic injuries. Longitudinal 2005-2009 results were supportive and revealed statistically significant adverse 4-year effects of incident injury on health. If injury reverted over four years, low initial scores improved greatly. Findings highlight the importance of injury prevention as a public health priority.

Inequalities in Risks and Outcomes in a Health Transitioning Country: A Review of a Large National Cohort of Thai Adults.

This article reviews inequalities in health risks and outcomes based on a large longitudinal cohort study of distance-learning adult students enrolled at Sukhothai Thammathirat Open University (n = 87,134). The study began in 2005 and the first follow-up was completed in 2009. Risks analyzed for health inequalities were divided into demographic, socioeconomic, geographical, behavioral, and environmental groups. Unequal risks and outcomes identified that would be amenable to policy interventions in transitional Thailand include the following: heat stress-contributing to many adverse outcomes, including occupational injury, psychological distress, and kidney disease; urbanization-unhealthy eating, sedentary lifestyles, low social capital, and poor mental health; obesity-increasingly common especially with rising income and age among men; and injury-big problem for young males and associated with excessive alcohol and dangerous transport. These substantial inequalities require attention from multisectoral policy makers to reduce the gaps and improve health of the Thai population.

Longitudinal associations between oral health impacts and quality of life among a national cohort of Thai adults.

BACKGROUND: There is limited evidence on the association between oral health and general health in middle-income countries. This study analysed data from 60,569 adult students enrolled at Sukhothai Thammathirat Open University and residing throughout Thailand who reported oral health impacts at the 2005 baseline and 2009 health status based on Short Form (SF-8) survey. FINDINGS: In 2005, 16.4% had difficulty chewing and/or swallowing, 13.4% reported difficulty speaking and/or discomfort with social interaction, and 10.8% of the cohort reported having pain associated with teeth or dentures. Cohort members reporting one or more oral health impacts in 2005 had lower SF-8 mean scores in 2009. In particular, monotonic dose-response gradients in 2005-2009 associations based on multivariate linear regression were found between an increase in number of oral impacts (0, 1, 2, 3) and a decline in SF-8 Physical Component Summary scores (adjusted means of 50.5, 49.2, 48.6, 47.9) as well as SF-8 Mental Component Summary scores (adjusted means of 43.2, 40.9, 40.3, 38.6) in younger cohort members. Similar dose response gradients were found in older cohort members. CONCLUSIONS: We found strong association between oral health impacts and adverse health and quality of life among Thai adults. This finding confirms that oral health is one of the key determinants of population health.