Urbanization and non-communicable disease in Southeast Asia: a review of current evidence.

OBJECTIVE: Non-communicable diseases (NCDs) have been highlighted as a major public health issue in the Southeast (SE) Asian region. One of the major socio-environmental factors that are considered to be associated with such a rise in NCDs is urbanization. Urbanization is associated with behavioural changes such as eating an unhealthy diet, and a decrease in physical activities, which may result in associated obesity. The SE Asian region also has a substantive burden of infectious disease such as HIV and malaria, which may modify associations between urbanization and development of NCDs. STUDY DESIGN: A systematic review was conducted until April 2013. METHODS: Using four databases: EMBASE, PubMed, GlobalHealth and DigitalJournal, the systematic review pools existing evidence on urban-rural gradients in NCD prevalence/incidence. RESULTS: The study found that in SE Asia, urban exposure was positively associated with coronary heart disease, diabetes and respiratory diseases in children. Urban exposure was negatively associated with rheumatic heart diseases. The stages of economic development may also modify the association between urbanization and NCDs such as diabetes. CONCLUSION: There was pronounced heterogeneity between associations. It is recommended that future studies examine the major constituents of NCDs separately and also focus on the interplay between lifestyle and infectious risk factors for NCDs. Prospective studies are needed to understand the diverse causal pathways between urbanization and NCDs in SE Asia

Active commuting and cardiovascular risk among health care workers.

Background Although the benefit of physical activity on cardiovascular health has been well demonstrated, being physically active can be difficult for healthcare workers. Active commuting such as walking or cycling may be a good way to promote physical activity. Aims To investigate the relationship between active commuting and cardiovascular disease (CVD) risk factors in healthcare workers. Methods A cross-sectional study of healthcare workers conducted in Chiang Mai University Hospital, Thailand. Information on demographics and lifestyle, including active commuting, was obtained from questionnaires. Results were analysed with multiple logistic regression, adjusting for other physical activity and possible confounders. Results Among 3204 participants fewer than half engaged in active commuting. After adjustment for possible confounders, low active commuting was associated with increased risk of hypertension (adjusted OR (aOR) 1.3, 95% CI: 1.1-1.7). High active commuting was associated with central obesity (aOR 1.4, 95% CI: 1.0-1.8). Compared to non-active commuters, younger active commuters (aged under 40) had reduced prevalence of hypertension (aOR 0.4, 95% CI: 0.2-1.0), while older active commuters (aged 40 or over) demonstrated increased hypertension (aOR 1.6, 95% CI: 1.1-2.3) and central obesity (aOR 1.5, 95% CI: 1.1-2.1). Conclusions We found conflicting evidence on the relationship between active commuting and cardiovascular risk factors. Reverse causation may explain the association between active commuting and hypertension and central obesity and should be investigated further. </p

Active commuting and cardiovascular risk among health care workers.

Background Although the benefit of physical activity on cardiovascular health has been well demonstrated, being physically active can be difficult for healthcare workers. Active commuting such as walking or cycling may be a good way to promote physical activity. Aims To investigate the relationship between active commuting and cardiovascular disease (CVD) risk factors in healthcare workers. Methods A cross-sectional study of healthcare workers conducted in Chiang Mai University Hospital, Thailand. Information on demographics and lifestyle, including active commuting, was obtained from questionnaires. Results were analysed with multiple logistic regression, adjusting for other physical activity and possible confounders. Results Among 3204 participants fewer than half engaged in active commuting. After adjustment for possible confounders, low active commuting was associated with increased risk of hypertension (adjusted OR (aOR) 1.3, 95% CI: 1.1-1.7). High active commuting was associated with central obesity (aOR 1.4, 95% CI: 1.0-1.8). Compared to non-active commuters, younger active commuters (aged under 40) had reduced prevalence of hypertension (aOR 0.4, 95% CI: 0.2-1.0), while older active commuters (aged 40 or over) demonstrated increased hypertension (aOR 1.6, 95% CI: 1.1-2.3) and central obesity (aOR 1.5, 95% CI: 1.1-2.1). Conclusions We found conflicting evidence on the relationship between active commuting and cardiovascular risk factors. Reverse causation may explain the association between active commuting and hypertension and central obesity and should be investigated further. </p

Choosing where to give birth: Factors influencing migrant women’s decision making in two regions of Thailand

Background: Choosing where to give birth can be a matter of life and death for both mother and child. Migrants, registered or unregistered, may face different choices and challenges than non-migrants. Despite this, previous research on the factors migrant women consider when deciding where to give birth is very limited. This paper addresses this gap by examining women’s decision making in a respective border and urban locale in Thailand. Methods: We held focus group discussions [13] with 72 non-Thai pregnant migrant women at non-government clinics in a rural border area and at two hospitals in Chiang Mai, a large city in Northern Thailand in 2018. We asked women where they will go to give birth and to explain the factors that influenced their decision. Results: Women identified getting the relevant documentation necessary to register their child’s birth, safe birth and medical advice/quality care, as the top three factors that influenced their care seeking decision making. Language of service, free or low cost care, language of services, proximity to home, and limited alternate options for care were also identified as important considerations. Conclusion: Understanding factors that migrant women value when choosing where to deliver can help health care providers to create services that are responsive to migrants’ preferences and encourage provision of relevant information which may influence patient decision making. The desire to obtain birth documentation for their child appears to be important for migrants who understand the importance of personal documentation for the lives of their children. Healthcare institutions may wish to introduce processes to facilitate obtaining documentation for pregnant migrant women and their newborns.</p

A mixed-methods evaluation of hepatitis B knowledge, attitudes, and practices among migrant women in Thailand

Background Globally 90 % of transmission of Hepatitis B virus (HBV) is from mother-to child and occurs predominantly in resource limited countries where the prevalence of HBV is high. Transmission could be interrupted by timely vaccinations but coverage remains problematic in these areas. Low knowledge or awareness of HBV may play a part in low vaccination coverage. This study examines the provision of antenatal care counselling with a focus on HBV in two different regions of northern Thailand, Sarapee Hospital (SH), Chiang Mai, and Shoklo Malaria Research Unit (SMRU), Tak Province. Methods A mixed-methods sequential explanatory study design was used to evaluate antenatal services for migrants. Cross-sectional knowledge, attitude and practice (KAP) surveys were conducted immediately after counselling at first ANC contact, at 3–6 months after first ANC contact and at delivery. Surveys provided quantitative data, and qualitative methods included observations, focus group discussions (FGD) and in-depth interviews (IDI); analysed thematically to explore concepts of knowledge and understanding, attitude and practice of pregnant women and providers. Results Between September-2019 and May-2020, 757 women participated to KAP surveys, and 31 observations of counselling, 16 FGD and 9 IDI were conducted. KAP surveys showed in spite of low knowledge about HBV transmission, infection, or vaccination (correct response: SH 5.7 %, 9/157; SMRU 34.0 %, 204/600), most women (≥ 93 %, either site) understood they were screened for HBV and were willing to vaccinate infants for HBV. In explaining KAP survey results, qualitative analysis suggests counselling should: use the appropriate language; be tailored to the local health literacy level, provide only pertinent information, be repeated over the antenatal period; and attempt to ensure patient privacy (where possible). Programme effectiveness benefits from positive attitudes to screening and vaccinations and a high level of trust in the providers nevertheless participants provided good suggestions for improvements of the service. Conclusions Limited knowledge of HBV among migrant women can be improved by counselling that emphasizes actionable knowledge such as vaccination schedule. Key improvements to the counselling process include training counsellors to conduct interactive counselling sessions in the woman’s language, using appropriate visual aids and timely repetition over the course of the antenatal period

“I can’t read and don’t understand”: Health literacy and health messaging about folic acid for neural tube defect prevention in a migrant population on the Myanmar-Thailand border

Health literacy is increasingly recognized as an important determinant of health outcomes, but definition, measurement tools, and interventions are lacking. Conceptual frameworks must include both individual and health-systems domains which, in combination, determine an individual’s health literacy. Validated tools lack applicability in marginalized populations with very low educational levels, such as migrant worker communities on the Myanmar-Thailand border. We undertake a comprehensive health literacy assessment following a case study of a recent public health campaign promoting preconceptual folic acid uptake in this community. A mixed-methods design utilized quantitative analysis of the prevalence and predictors of low Health literacy, and focus group discussions to gather qualitative data from women about proposed and actual posters used in the campaign. Health literacy was measured with a locally developed tool that has been used in surveys of the population since 1995. Health literacy was low, with 194/525 (37.0%) of tested women demonstrating adequate health literacy, despite 63.1% (331/525) self-reporting being literate. Only one third of women had completed 4th grade or above and reported grade level attained in school was more predictive of health literacy than self-reported literacy. Focus group discussions revealed that low literacy, preconceived associations, and traditional health beliefs (individual domain) interacted with complex images, subtle concepts, and taboo images on posters (health-systems domain) to cause widespread misunderstandings of the visuals used in the campaign. The final poster still required explanation for clarity. Low health literacy is prevalent among pregnant women from this migrant community and barriers to communication are significant and complex. Public health posters need piloting prior to implementation as unanticipated misperceptions are common and difficult to overcome. Verbal communication remains a key method of messaging with individuals of low health literacy and educational system strengthening and audiovisual messaging are critical for improvement of health outcomes

“I can’t read and don’t understand”: Health literacy and health messaging about folic acid for neural tube defect prevention in a migrant population on the Myanmar-Thailand border

Health literacy is increasingly recognized as an important determinant of health outcomes, but definition, measurement tools, and interventions are lacking. Conceptual frameworks must include both individual and health-systems domains which, in combination, determine an individual’s health literacy. Validated tools lack applicability in marginalized populations with very low educational levels, such as migrant worker communities on the Myanmar-Thailand border. We undertake a comprehensive health literacy assessment following a case study of a recent public health campaign promoting preconceptual folic acid uptake in this community. A mixed-methods design utilized quantitative analysis of the prevalence and predictors of low Health literacy, and focus group discussions to gather qualitative data from women about proposed and actual posters used in the campaign. Health literacy was measured with a locally developed tool that has been used in surveys of the population since 1995. Health literacy was low, with 194/525 (37.0%) of tested women demonstrating adequate health literacy, despite 63.1% (331/525) self-reporting being literate. Only one third of women had completed 4th grade or above and reported grade level attained in school was more predictive of health literacy than self-reported literacy. Focus group discussions revealed that low literacy, preconceived associations, and traditional health beliefs (individual domain) interacted with complex images, subtle concepts, and taboo images on posters (health-systems domain) to cause widespread misunderstandings of the visuals used in the campaign. The final poster still required explanation for clarity. Low health literacy is prevalent among pregnant women from this migrant community and barriers to communication are significant and complex. Public health posters need piloting prior to implementation as unanticipated misperceptions are common and difficult to overcome. Verbal communication remains a key method of messaging with individuals of low health literacy and educational system strengthening and audiovisual messaging are critical for improvement of health outcomes

A mixed-methods evaluation of hepatitis B knowledge, attitudes, and practices among migrant women in Thailand

Background: Globally 90 % of transmission of Hepatitis B virus (HBV) is from mother-to child and occurs predominantly in resource limited countries where the prevalence of HBV is high. Transmission could be interrupted by timely vaccinations but coverage remains problematic in these areas. Low knowledge or awareness of HBV may play a part in low vaccination coverage. This study examines the provision of antenatal care counselling with a focus on HBV in two different regions of northern Thailand, Sarapee Hospital (SH), Chiang Mai, and Shoklo Malaria Research Unit (SMRU), Tak Province. Methods: A mixed-methods sequential explanatory study design was used to evaluate antenatal services for migrants. Cross-sectional knowledge, attitude and practice (KAP) surveys were conducted immediately after counselling at first ANC contact, at 3–6 months after first ANC contact and at delivery. Surveys provided quantitative data, and qualitative methods included observations, focus group discussions (FGD) and in-depth interviews (IDI); analysed thematically to explore concepts of knowledge and understanding, attitude and practice of pregnant women and providers. Results: Between September-2019 and May-2020, 757 women participated to KAP surveys, and 31 observations of counselling, 16 FGD and 9 IDI were conducted. KAP surveys showed in spite of low knowledge about HBV transmission, infection, or vaccination (correct response: SH 5.7 %, 9/157; SMRU 34.0 %, 204/600), most women (≥ 93 %, either site) understood they were screened for HBV and were willing to vaccinate infants for HBV. In explaining KAP survey results, qualitative analysis suggests counselling should: use the appropriate language; be tailored to the local health literacy level, provide only pertinent information, be repeated over the antenatal period; and attempt to ensure patient privacy (where possible). Programme effectiveness benefits from positive attitudes to screening and vaccinations and a high level of trust in the providers nevertheless participants provided good suggestions for improvements of the service. Conclusions: Limited knowledge of HBV among migrant women can be improved by counselling that emphasizes actionable knowledge such as vaccination schedule. Key improvements to the counselling process include training counsellors to conduct interactive counselling sessions in the woman’s language, using appropriate visual aids and timely repetition over the course of the antenatal period

Chiang Mai University Health Worker Study aiming toward a better understanding of noncommunicable disease development in Thailand: methods and description of study population

Chaisiri Angkurawaranon,1,2&nbsp;Anawat Wisetborisut,2&nbsp;Wichuda Jiraporncharoen,2&nbsp;Surinporn Likhitsathian,3&nbsp;Ronnaphob Uaphanthasath,2&nbsp;Patama Gomutbutra,2&nbsp;Surin Jiraniramai,2&nbsp;Chawin Lerssrimonkol,2 Apinun Aramrattanna,2 Pat Doyle,1&nbsp;Dorothea Nitsch1 1Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; 2Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Background: Urbanization is considered to be one of the key drivers of noncommunicable diseases (NCDs) in Thailand and other developing countries. These influences, in turn, may affect an individual&#39;s behavior and risk of developing NCDs. The Chiang Mai University (CMU) Health Worker Study aims to provide evidence for a better understanding of the development of NCDs and ultimately to apply the evidence toward better prevention, risk modification, and improvement of clinical care for patients with NCDs and NCD-related conditions. Methods: A cross-sectional survey of health care workers from CMU Hospital was conducted between January 2013 and June 2013. Questionnaires, interviews, and physical and laboratory examinations were used to assess urban exposure, occupational shift work, risk factors for NCDs, self-reported NCDs, and other NCD-related health conditions. Results: From 5,364 eligible workers, 3,204 participated (59.7%). About 11.1% of the participants had high blood pressure (systolic blood pressure &ge;140 mmHg or diastolic blood pressure &ge;90 mmHg) and almost 30% were considered to be obese (body mass index &ge;25 kg/m2). A total of 2.3% had a high fasting blood glucose level (&ge;126 mg/dL), and the most common abnormal lipid profile was high low-density lipoprotein (&ge;160 mg/dL), which was found in 19.2% of participants. Discussion: The study of health workers offers three potential advantages. The first is that the study of migrants was possible. Socioenvironmental influence on NCD risk factors can be explored, as changes in environmental exposures can be documented. Second, it allows the investigators to control for access to care. Access to care is potentially a key confounder toward understanding the development of NCDs. Lastly, a study of health personnel allows easy access to laboratory investigations and potential for long-term follow-up. This enables ascertainment of a number of clinical outcomes and provides potential for future studies focusing on therapeutic and prognostic issues related to NCDs. Keywords: urbanization, noncommunicable disease, risk factors, Thailan