Short-term effects of air pollution and temperature on daily morbidity in Chiang Mai Thailand

Air pollution is associated with mortality and morbidity worldwide. Hot and cold temperature is also related to increased deaths and possibly hospital visits and admissions in many settings. Climate change is anticipated to pose increasing risks of deaths and illnesses associated with air pollution and temperature variations, particularly in developing world. To date, research studies about health effects of air pollution and temperature have been conducted in developed countries with cool climate more than in developing countries with subtropical or tropical climate. Furthermore, studies to identify susceptible populations are still limited. This study aims to investigate heath effects of air pollution and temperature and to identify people who are more susceptible to air pollution and temperature in a developing, tropical country, Thailand. A regression analysis of retrospective time series data was employed to assess the shortterm effects of air pollution and temperature on daily out-patient visits and hospital admissions in Chiang Mai, Thailand, from October 2002 to September 2006. Generalised negative binomial regression was used to model the relationships between the exposure and health outcomes, controlling for seasonal patterns and other possible potential confounders. Lag effects up to 4 days for air pollution, and up to 13 days for temperature were considered. Effect modification by age, sex, occupation, season, and previous out-patient visits before admissions were also examined. There were positive, but not significant, effects of air pollution for some pollutants (particularly for S02), with notably larger effect sizes compared to previous studies in Western countries. There was evidence of hot temperature effects (though wide confidence intervals), with an increase in diabetic visits of 26.3% (95% Cl, 7.1% to 49.0%), and in circulatory visits of 19.2% (95% Cl, 7.0% to 32.8%) for each 1°C increase in temperature above 29°C. There was a rise of both the visits (3.7% increase, 95% Cl, 1.5% to 5.9%) and admissions (5.8% increase, 95% Cl, 2.3% to 9.3%) due to intestinal infectious disease for each 1°C increase across the whole temperature range. Despite no statistically significant differences between subgroups, air pollution effects were stronger in the elderly, females and manual workers, whereas temperature effects were stronger in the elderly, male and unemployed people. This study suggests that while there was little evidence of air pollution effects, there was significant evidence of high temperature effects on daily morbidity in Chiang Mai. The elderly seemed to be more vulnerable to the daily changes of both air pollution and temperature

Factors associated with the choice of public health service among nursing students in Thailand.

BACKGROUND: Despite the fact that public and private nursing schools have contributed significantly to the Thai health system, it is not clear whether and to what extent there was difference in job preferences between types of training institutions. This study aimed to examine attitudes towards rural practice, intention to work in public service after graduation, and factors affecting workplace selection among nursing students in both public and private institutions. METHODS: A descriptive comparative cross-sectional survey was conducted among 3349 students from 36 nursing schools (26 public and 10 private) during February-March 2012, using a questionnaire to assess the association between training institution characteristics and students' attitudes, job choices, and intention to work in the public sector upon graduation. Comparisons between school types were done using ANOVA, and Bonferroni-adjusted multiple comparisons tests. Principal component analysis (PCA) was used to construct a composite rural attitude index (14 questions). Cronbach's alpha was used to examine the internal consistency of the scales, and ANOVA was then used to determine the differences. These relationships were further investigated through multiple regression. RESULTS: A higher proportion of public nursing students (86.4% from the Ministry of Public Health and 74.1% from the Ministry of Education) preferred working in the public sector, compared to 32.4% of students from the private sector (p = <0.001). Rural upbringing and entering a nursing education program by local recruitment were positively associated with rural attitude. Students who were trained in public nursing schools were less motivated by financial incentive regarding workplace choices relative to students trained by private institutions. CONCLUSIONS: To increase nursing workforce in the public sector, the following policy options should be promoted: 1) recruiting more students with a rural upbringing, 2) nurturing good attitudes towards working in rural areas through appropriate training at schools, 3) providing government scholarships for private students in exchange for compulsory work in rural areas, and 4) providing a non-financial incentive package (e.g. increased social benefits) in addition to financial incentives for subsequent years of work

Building the evidence base for stigma and discrimination-reduction programming in Thailand: development of tools to measure healthcare stigma and discrimination

Abstract Background HIV-related stigma and discrimination (S&D) are recognized as key impediments to controlling the HIV epidemic. S&D are particularly detrimental within health care settings because people who are at risk of HIV and people living with HIV (PLHIV) must seek services from health care facilities. Standardized tools and monitoring systems are needed to inform S&D reduction efforts, measure progress, and monitor trends. This article describes the processes followed to adapt and refine a standardized global health facility staff S&D questionnaire for the context of Thailand and develop a similar questionnaire measuring health facility stigma experienced by PLHIV. Both questionnaires are currently being used for the routine monitoring of HIV-related S&D in the Thai healthcare system. Methods The questionnaires were adapted through a series of consultative meetings, pre-testing, and revision. The revised questionnaires then underwent field testing, and the data and field experiences were analyzed. Results Two brief questionnaires were finalized and are now being used by the Department of Disease Control to collect national routine data for monitoring health facility S&D: 1) a health facility staff questionnaire that collects data on key drivers of S&D in health facilities (i.e., fear of HIV infection, attitudes toward PLHIV and key populations, and health facility policy and environment) and observed enacted stigma and 2) a brief PLHIV questionnaire that captures data on experienced discriminatory practices at health care facilities. Conclusions This effort provides an example of how a country can adapt global S&D measurement tools to a local context for use in national routine monitoring. Such data helps to strengthen the national response to HIV through the provision of evidence to shape S&D-reduction programming

The Devil Is in the Detail-Understanding Divergence between Intention and Implementation of Health Policy for Undocumented Migrants in Thailand.

Migrants' access to healthcare has attracted attention from policy makers in Thailand for many years. The most relevant policies have been (i) the Health Insurance Card Scheme (HICS) and (ii) the One Stop Service (OSS) registration measure, targeting undocumented migrants from neighbouring countries. This study sought to examine gaps and dissonance between de jure policy intention and de facto implementation through qualitative methods. In-depth interviews with policy makers and local implementers and document reviews of migrant-related laws and regulations were undertaken. Framework analysis with inductive and deductive coding was undertaken. Ranong province was chosen as the study area as it had the largest proportion of migrants. Though the government required undocumented migrants to buy the insurance card and undertake nationality verification (NV) through the OSS, in reality a large number of migrants were left uninsured and the NV made limited progress. Unclear policy messages, bureaucratic hurdles, and inadequate inter-ministerial coordination were key challenges. Some frontline implementers adapted the policies to cope with their routine problems resulting in divergence from the initial policy objectives. The study highlighted that though Thailand has been recognized for its success in expanding insurance coverage to undocumented migrants, there were still unsolved operational challenges. To tackle these, in the short term the government should resolve policy ambiguities and promote inter-ministerial coordination. In the long-term the government should explore the feasibility of facilitating lawful cross-border travel and streamlining health system functions between Thailand and its neighbours

Managing In- and Out-Migration of Health Workforce in Selected Countries in South East Asia Region

Abstract Background: There is an increasing trend of international migration of health professionals from low- and middleincome countries to high-income countries as well as across middle-income countries. The WHO Global Code of Practice on the International Recruitment of Health Personnel was created to better address health workforce development and the ethical conduct of international recruitment. This study assessed policies and practices in 4 countries in South East Asia on managing the in- and out-migration of doctors and nurses to see whether the management has been in line with the WHO Global Code and has fostered health workforce development in the region; and draws lessons from these countries. Methods: Following the second round of monitoring of the Global Code of Practice, a common protocol was developed for an in-depth analysis of (a) destination country policy instruments to ensure expatriate and local professional quality through licensing and equal practice, (b) source country collaboration to ensure the out-migrating professionals are equally treated by destination country systems. Documents on employment practice for local and expatriate health professionals were also reviewed and synthesized by the country authors, followed by a cross-country thematic analysis. Results: Bhutan and the Maldives have limited local health workforce production capacities, while Indonesia and Thailand have sufficient capacities but are at risk of increased out-migration of nurses. All countries have mandatory licensing for local and foreign trained professionals. Legislation and employment rules and procedures are equally applied to domestic and expatriate professionals in all countries. Some countries apply mandatory renewal of professional licenses for local professionals that require continued professional development. Local language proficiency required by destination countries is the main barrier to foreign professionals gaining a license. The size of outmigration is unknown by these 4 countries, except in Indonesia where some formal agreements exist with other governments or private recruiters for which the size of outflows through these mechanisms can be captured. Conclusion: Mandatory professional licensing, employment regulations and procedures are equally applied to domestic and foreign trained professionals, though local language requirements can be a barrier in gaining license. Source country policy to protect their out-migrating professionals by ensuring equal conditions of practice by destination countries is hampered by the fact that most out-migrating professionals leave voluntarily and are outside government to government agreements. This requires more international solidarity and collaboration between source and destination countries, for which the WHO Global Code is an essential and useful platform

Health insurance for people with citizenship problems in Thailand: a case study of policy implementation.

In 2002, Thailand achieved universal health coverage through the introduction of the Universal Coverage Scheme (UCS). However, people with citizenship problems, so-called 'stateless people', were left uninsured. Consequently, the 'Health Insurance for People with Citizenship Problems' (HIS-PCP) policy was adopted in 2010 with features emulating the UCS. This study sought to examine the operational constraints faced by health providers in implementing the HIS-PCP policy. Qualitative methods were used, and a case study was conducted to explore the implementation of the HIS-PCP in Ranong and Tak provinces. Individual in-depth interviews and group interviews were conducted with a total of 33 key informants. Interview data were analysed by a thematic approach. The study found that the HIS-PCP faced several operational challenges. Inadequate communication and unclear service guidelines contributed to ineffectiveness in budget spend and service provision. Other problems included the legal instruments that permitted stateless people to live only in certain areas, when such people were in fact highly mobile. Some providers adapted their practices to cope with on-the-job difficulties, including establishing a mutual agreement with neighbouring hospitals to allow stateless patients to bypass primary care gatekeepers. The challenges were aggravated by the delays in nationality verification procedures and insufficient collaboration between the Ministry of Public Health (MOPH) and the Ministry of Interior. Policy recommendations are suggested. In the short term, collaboration with relevant authorities both within and outside the MOPH should be improved. Guidelines concerning budgeting and scope of service provision should be fine-tuned. In the long run, the nationality verification process for stateless people should be expedited. The MOPH should develop clear and practical guidelines to assist health personnel to support patients to resolve their citizenship problems

Extreme exploitation in Southeast Asia waters: Challenges in progressing towards universal health coverage for migrant workers.

Rapeepong Suphanchaimat and colleagues present the plight of migrant workers in the fishing industry in Southeast Asia and discuss challenges in providing for their health and safety

High temperature effects on out-patient visits and hospital admissions in Chiang Mai, Thailand.

OBJECTIVES: This study investigated the short-term effects of temperature on out-patient visits and hospital admissions in Chiang Mai, Thailand. While mortality outcomes in the literature have been reported, there is less evidence of morbidity effects with very few studies conducted in developing countries with subtropical or tropical climate. METHODS: Time-series regression analysis was employed using generalized negative binomial regression to model the short-term relationships between temperature and morbidity after controlling for seasonal patterns and other potential confounders. Lag effects up to 13 days and effect modification by age (0-14 years, 15-64 years, ≥65 years) were examined. RESULTS: Temperature effects with wide confidence intervals were found, with an increase in diabetic visits of 26.3% (95% CI: 7.1%-49.0%), and circulatory visits of 19.2% (95% CI: 7.0%-32.8%) per 1 °C increase in temperature above an identified threshold of 29 °C. Additionally, there was a rise of both visits (3.7% increase, 95% CI: 1.5%-5.9%) and admissions (5.8% increase, 95% CI: 2.3%-9.3%) due to intestinal infectious disease in association with each 1 °C increase across the whole temperature range. The effects of temperature were stronger in the elderly though not statistically significant. CONCLUSIONS: Daily morbidity in Chiang Mai was positively associated with temperature with a lag effect of up to 2 weeks, which was longer than lag effects previously reported. Public health preparedness and interventions should be considered to minimise possible increased hospital visits and admissions during hot weather

Asian countries with the highest percentage of people working in extreme exploitation.

<p>Asian countries with the highest percentage of people working in extreme exploitation.</p