Myo Nyein Aung

Assessing awareness and knowledge of hypertension in an at-risk population in the Karen ethnic rural community, Thasongyang, Thailand.

Background Hypertension is currently a global health concern. Rural and minority populations are increasingly exposed to risk factors as a result of urbanization, leading to hypertension and cardiovascular disease. We conducted a survey in the rural Karen community in Thasongyang District, Tak Province, Thailand, with the aims of determining: the distribution of blood pressure across different age groups; the prevalence of hypertension and other risk factors for cardiovascular diseases (CVDs), including diabetes, smoking, sedentary lifestyle, and excess alcohol use; knowledge and awareness of hypertension as a disease; and knowledge and awareness of risk factors for hypertension among the population at risk. Methods This was a community-based, cross-sectional survey of 298 rural Karen residents. A set of questionnaires assessing lifestyle-related health risk behaviors and awareness and knowledge of hypertension were used. Blood pressure, fasting plasma glucose, weight, height, and waist circumference were measured. Results Median systolic and diastolic blood pressures were 110 (range 100–120) mmHg and 70 (range 60–80) mmHg, respectively. High blood pressure was observed in more than 27% of the population, with 15% being hypertensive and 12% being prehypertensive. Multinomial logistic regression analysis showed that people in the Karen community who were aware of hypertension were less likely to be current smokers (odds ratio [OR] 0.53, confidence interval [CI] 0.29–0.97) and those with primary school education were more likely to be aware of hypertension than those who did not have a primary school education (OR 6.5, CI 1.9–22.24). Overall, our survey showed that less than half of the Karen community had such knowledge and awareness. Conclusion It is urgently necessary to promote knowledge, awareness, and health literacy among the ethnic Karen tribes to prevent hypertension and associated CVDs.

Time of highest tuberculosis death risk and associated factors: an observation of 12 years in Northern Thailand

Purpose: Northern Thailand is a tuberculosis (TB) endemic area with a high TB death rate. We aimed to establish the time of highest death risk during TB treatment, and to identify the risk factors taking place during that period of high risk. Patients and methods: We explored the TB surveillance data of the Chiang Rai province, Northern Thailand, retrospectively for 12 years. A total of 19,174 TB patients (including 5,009 deaths) were investigated from 1997 to 2008, and the proportion of deaths in each month of TB treatment was compared. Furthermore, multiple logistic regression analysis was performed to identify the characteristics of patients who died in the first month of TB treatment. A total of 5,626 TB patients from 2005 to 2008 were included in this regression analysis. Result: The numbers of deaths in the first month of TB treatment were 38%, 39%, and 46% in the years 1997–2000, 2001–2004, and 2005–2008, respectively. The first month of TB treatment is the time of the maximum number of deaths. Moreover, advancing age, HIV infection, and being a Thai citizen were significant factors contributing to these earlier deaths in the course of TB treatment. Conclusion: Our findings have pointed to the specific time period and patients at higher risk for TB death. These findings would be useful for prioritizing interventions in order to diminish TB-related deaths globally. Studies based on these findings are necessary for the introduction of newer intervention strategies.

Prospective evaluation of simply modified MODS assay: an effective tool for TB diagnosis and detection of MDR-TB

Background and setting Thailand is one of the highest tuberculosis (TB)-burdened countries. Chiang Rai, the northernmost province of Thailand has high tuberculosis and human immunodeficiency virus (HIV) prevalence and the laboratory workload for TB culture and drug susceptibility testing is increasing. Objectives To evaluate the simply modified microscopic-observation drug-susceptibility assay (MODS) in the setting of a developing country. Methods In this cross-sectional diagnostic study, a total of 202 sputum samples of clinically diagnosed TB patients were used to test the performance of MODS assay in reference to gold standard BACTEC™ MGIT™ 960 liquid culture system and Ogawa solid culture. Sputum samples were collected from clinically diagnosed TB patients. Culture growth rate and time to culture positivity were compared among three methods. Performance of modified MODS assay was evaluated for detection of mycobacterium drug resistance in reference to MGIT antimicrobial susceptibility test (AST). Result Median time to culture positivity by MODS, solid, and liquid culture were 12, 30, and 6 days respectively. Compared to the drug susceptibility test (DST) result of reference liquid culture, the sensitivity and specificity of MODS for detection of multidrug-resistant tuberculosis (MDR-TB) was 85.7% and 97.5% respectively. MODS assay has a positive predicative value of 80% and negative predictive value of 96.5% for isoniazid resistance, 70% and 100% for rifampicin resistance, and 66.7% and 99.1% for MDR-TB. Conclusion MODS is a highly effective screening test for detection of MDR-TB.

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai, Northern Thailand

Background The case fatality rate in patients with tuberculosis (TB) associated with human immunodeficiency virus (HIV) has been particularly high in Chiang Rai, Northern Thailand. It was almost 50% before the introduction of antiretroviral therapy in the last decade, and was still at 28% in 2008, despite expanding access to antiretroviral therapy. Reviewing the causes of death may lead to further understanding of the timeline and natural history of TB-HIV coinfection, and in so doing help to devise an effective prevention strategy in Chiang Rai. In this study, we aimed to investigate the distribution of confirmed causes of death in patients coinfected with TB and HIV in Chiang Rai, describe the causes of such deaths along the timeline of TB treatment, and identify predictors of each cause of death. Methods In this retrospective study, we reviewed the causes of death for 331 patients who died of TB-HIV coinfection at Chiang Rai Prachanukroh Hospital from 2005 to 2008. Causes of death were confirmed by reviewing medical records, vital registration, and the TB register in the province, as well as obtaining reconfirmation by two experienced HIV physicians. Results The confirmed causes of death were TB (39%), acquired immune deficiency syndrome (AIDS)-related opportunistic infections other than TB (AOI) (29%), and other systemic diseases which were neither TB nor AIDS-related opportunistic infections (nonTB-nonAOI) (16%). The definitive cause could not be confirmed in the remaining 16% of deaths. After starting the TB treatment, deaths caused by TB occurred earlier compared with deaths caused by AOI, which occurred steadily throughout the course of TB treatment, whilst deaths caused by non-TB-nonAOI increased gradually in later months. Further analysis by multivariate multinomial regression analysis showed that deaths in the first month (adjusted odds ratio [aOR] 4.64, 95% confidence interval [CI] 2.49–8.63), CD4 count ≥ 200 cells/mm3 (aOR 5.33, CI 1.05–26.10), non-category 1 TB treatment regimens (aOR 5.23, CI 1.04–9.77), and TB meningitis (aOR 3.27, CI 1.37–7.82) were significant predictors of confirmed TB deaths. Moreover, age over 45 years (aOR 3, CI 1.32–6.84) and admission as an inpatient were predictors of death caused by neither TB nor AIDS-related opportunistic infections (aOR 3.08, CI 1.39–6.80). Additional analysis showed that non-Thai patients (aOR 0.35, CI 0.12–0.99), those with an unknown CD4 count at TB diagnosis (aOR 0.16, CI 0.08–0.33), and those without an HIV diagnosis before TB treatment (aOR 0.32, CI 0.18–0.59) were less able to access antiretroviral therapy. Conclusion The timeline and predictors of causes of death may assist in devising an intervention strategy for further reduction of the TB-HIV case fatality rate.

Global evidence directing regional preventive strategies in Southeast Asia for fighting TB/HIV.

Tuberculosis (TB) and human immunodeficiency virus (HIV) co-epidemics form a huge burden of disease in the Southeast Asia region. Five out of eleven nations in this region are high TB/HIV burden countries: Myanmar, Thailand, India, Indonesia and Nepal. The trends of TB incidence in these countries have been rising in recent years, in contrast to a falling global trend. Experts in the field of TB control and health service providers have been perplexed by the association of TB and HIV infections which causes a mosaic clinical presentation, a unique course with poor treatment outcomes including death. We conducted a review of contemporary evidence relating to TB/HIV control with the aims of assisting integrated health system responses in Southeast Asia and demystifying current evidence to facilitate translating it into practice.

Evidence-based new service package vs. routine service package for smoking cessation to prevent high risk patients from cardiovascular diseases (CVD): study protocol for randomized controlled trial

BackgroundSmoking cessation is a high-priority intervention to prevent CVD events and deaths in developing countries. While several interventions to stop smoking have been proved successful, the question of how to increase their effectiveness and practicality in developing countries remains. In this study, a newly devised evidence-based smoking cessation service package will be compared with the existing service in a randomized controlled trial within the community setting of Thailand.Method/DesignThis randomized control trial will recruit 440 current smokers at CVD risk because of being diabetic and/or hypertensive. Informed, consented participants will be randomly allocated into the new service-package arm and the routine service arm. The study will take place in the non-communicable disease clinics of the Maetha District Hospital, Lampang, northern Thailand. The new smoking-cessation service-package comprises (1) regular patient motivation and coaching from the same primary care nurse over a 3-month period; (2) monthly application of piCO + smokerlyzer to sustain motivation of smoker’s quitting attempt and provide positive feedback over a 3-month period; (3) assistance by an assigned family member; (4) nicotine replacement chewing gum to relieve withdrawal symptoms. This new service will be compared with the traditional routine service comprising the 5A approach in a 1-year follow-up. Participants who consent to participate in the study but refuse to attempt quitting smoking will be allocated to the non-randomized arm, where they will be just followed up and monitored. Primary outcome of the study is smoking cessation rate at 1-year follow-up proven by breath analysis measuring carbomonoxide in parts per million in expired air. Secondary outcomes are smoking cessation rate at the 6-month follow-up, blood pressure and heart rate, CVD risk according to the Framingham general cardiovascular risk score, CVD events and deaths at the 12-month follow-up, and the cost-effectiveness of the health service packages. Intention-to-treat analysis will be followed. Factors influencing smoking cessation will be analyzed by the structure equation model.DiscussionThis multicomponent intervention, accessible at primary healthcare clinics, and focusing on the individual as well as the family and social environment, is unique and expected to work effectively.Trial registrationCurrent Controlled Trials ISRCTN89315117

Knowledge of communicable and noncommunicable diseases among Karen ethnic high school students in rural Thasongyang, the far northwest of Thailand

Background The double burden of communicable and noncommunicable diseases (NCD) is an increasing trend in low- and-middle income developing countries. Rural and minority populations are underserved and likely to be affected severely by these burdens. Knowledge among young people could provide immunity to such diseases within a community in the long term. In this study we aimed to assess the knowledge of several highly prevalent NCDs (diabetes, hypertension, and chronic obstructive pulmonary disease [COPD]) and several highly incident communicable diseases (malaria and diarrheal diseases) among Karen high school students in a rural district in far northwest of Thailand. The aim of the study is to explore information for devising life-course health education that will be strategically based in schools. Method A cross-sectional survey approved by the ethics committee of Boromarajonani College of Nursing Nakhon Lampang (BCNLP), Lampang, Thailand was conducted in Thasongyang, Tak province, from September 2011 to January 2012. Questionnaires for assessing knowledge regarding diabetes, hypertension, COPD, malaria, and diarrheal diseases were delivered to all 457 Karen high school students attending Thasongyang high school. A total of 371 students returned the questionnaires. Experts’ validation and split-half reliability assessment was applied to the instrument. Results Students’ main sources of health information were their teachers (62%), health care workers (60%), television (59%), and parents (54%). Familial risk factors of diabetes and hypertension were not known to more than two thirds of the students. Except obesity and physical inactivity, lifestyle-related risk factors were also not known to the students. Though living in a malaria-endemic area, many of the Karen students had poor knowledge about preventive behaviors. Half of the students could not give a correct answer about the malaria and hygienic practice, which might normally be traditionally relayed messages. Conclusion Health education and knowledge about common NCD and communicable diseases are yet to be prompted among the Karen students. A broader and more comprehensive school-based health education strategy for prevention of double burden diseases would benefit the rural minority population at the Thai-Myanmar border.

Public knowledge of diabetes in Karen Ethnic rural residents: a community-based questionnaires study in the far north-west of Thailand.

Background and purpose The public knowledge of diabetes is important for prevention of disease. This study aimed to evaluate knowledge of diabetes, risk factors, and the common warning signs of diabetes and complications among community participants in a rural Karen ethnic community. Methods Participants were asked to answer a questionnaire regarding their knowledge of diabetes. Fasting blood glucose testing, blood pressure measurement, and body mass index (BMI) assessment were provided to the participants. The study was conducted at Thasongyang district, Tak province, Thailand. Results A total of 299 Karen rural residents were included in the study. The median age was 45 years and median fasting blood glucose was 88 mg/dL. The response rate to the questionnaires was 91.97%. Half of the participants knew diabetes is a noncommunicable disease needing lifelong treatment. Overall, one-third of the community participants could correctly answer the knowledge assessment questions regarding risk factors and common features of diabetes. whereas the other two-thirds either gave a wrong answer or were “not sure”. Female participants had poorer diabetes knowledge than the males. Conclusion The public knowledge of diabetes, as represented by this sample of the Karen ethic community, is alarmingly low. There is significant gender difference in knowledge level. Culturally tailored and gender-sensitive diabetes health education interventions are urgently needed in this minority ethnic community.

Reducing salt intake for prevention of cardiovascular diseases in high-risk patients by advanced health education intervention (RESIP-CVD study), Northern Thailand: study protocol for a cluster randomized trial

BackgroundDecreasing salt consumption can prevent cardiovascular diseases (CVD). Practically, it is difficult to promote people’s awareness of daily salt intake and to change their eating habits in terms of reducing salt intake for better cardiovascular health. Health education programs visualizing daily dietary salt content and intake may promote lifestyle changes in patients at high risk of cardiovascular diseases.Methods/DesignThis is a cluster randomized trial. A total of 800 high-CVD-risk patients attending diabetes and hypertension clinics at health centers in Muang District, Chiang Rai province, Thailand, will be studied with informed consent. A health center recruiting 100 participants is a cluster, the unit of randomization. Eight clusters will be randomized into intervention and control arms and followed up for 1 year. Within the intervention clusters the following will be undertaken: (1) salt content in the daily diet will be measured and shown to study participants; (2) 24-hour salt intake will be estimated in overnight-collected urine and the results shown to the participants; (3) a dietician will assist small group health education classes in cooking meals with less salt. The primary outcome is blood pressure change at the 1-year follow-up. Secondary outcomes at the 1-year follow-up are estimated 24-hoursalt intake, incidence of CVD events and CVD death. The intention-to-treat analysis will be followed.Blood pressure and estimated 24-hour salt intake will be compared between intervention and control groups at the cluster and individual level at the 1-year follow-up. Clinical CVD events and deaths will be analyzed by time-event analysis. Retinal blood vessel calibers of CVD-risk patients will be assessed cross-sectionally. Behavioral change to reduce salt intake and the influencing factors will be determined by structured equation model (SEM). Multilevel regression analyses will be applied. Finally, the cost effectiveness of the intervention will be analyzed.DiscussionThis study is unique as it will recruit the individuals most vulnerable to CVD morbidity and mortality by applying the general Framingham CVD risk scoring system. Dietary salt reduction will be applied as a prioritized, community level intervention for the prevention of CVD in a developing country.Trial registrationISRCTN39416277

Predicting prediabetes in a rural community: a survey among the Karen ethnic community, Thasongyang, Thailand

Background Diabetes is a growing epidemic in both urban and rural communities worldwide. Aim We aimed to survey fasting plasma glucose (FPG) status and awareness of diabetes in the rural Karen ethnic community. We investigated the predictors of impaired fasting plasma glucose (IFG) status, which would be easily applicable for prevention of diabetes in a rural community. Materials and methods This was a community-based cross-sectional study conducted at Thasongyang, the most north-western district in Thailand. A total of 299 Karen ethnic rural residents were included in the study. FPG, body mass index, and waist circumference were prospectively measured. We assessed the awareness of diabetes and lifestyle-related health behavior with closed questionnaires in a rural community setting. Results On screening for FPG, 16.72% of the Karen ethnic residents had hyperglycemia: 3.68% in the diabetic range and 13.04% in the prediabetic range respectively. After adjustment for age, sex, and BMI, waist circumference (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.29–9.57), and having a diabetic blood relative (aOR 4.6, CI 1.81–11.71) are significant predictors of IFG status. Conclusion It is necessary to promote awareness of diabetes among the Karen ethnic community. Application of simple evidence-based predictors of the prediabetic state may lead to timely and effective prevention of diabetes in rural settings.