KKU MPH Research Papers 2017

Table of content
Page
Message from Dean a
Message from Chairperson of the Organizing Committee b
Schedule of conference c
List of present d
Peer Reviewers h
Manuscript 1-443
Message from
Dean of the Faculty of Public Health, Khon Kaen University
Assist. Prof. Dr. Somsak Pitaksanurat
Khon Kaen University has been classified as one of the research university in
Thailand since 2010. The university has set clear direction for research development
in various fields including public health. The Faculty of Public Health, Khon Kaen
University have continuously develop capacities of staff and students both academic
and research.
The Faculty of Public Health, Khon Kaen University, Thailand has initiated to host
the International Conference on ‘Health Challenges in Sustainable Development
Goals (SDGs): Where and how we have started? between September 25th -26th, 2017
which the aims to create a platform for academics, researchers, students and public
health personnel to share and discuss on their experiences and research findings in
public health situations, challenges, lesson learnt and appropriate measures in
response to SDGs among ASEAN. We have had great supports from both domestics
and international institutions in 6 countries being cohost of this international
conference.
I would like to express my appreciations for their support and cooperation. I do hope
that the participants will gain and exchange knowledge and expertise from special
talks, panel, workshop and poster and oral presentations of public health research
organized in this conference. I wish for the success of this International Conference
on ‘Health Challenges in Sustainable Development Goals (SDGs): Where and how
we have started?
Assist. Prof. Dr. Somsak Pitaksanurat
Dean of the Faculty of Public Health,
Khon Kaen University, Thailand
a
Message from
Chairperson of the Organizing Committee
Assoc. Prof. Dr. Wongsa Laohasiriwong
The Faculty of Public Health, Khon Kaen University, Thailand with the support from
allies institutions will host an International Conference on ‘Health Challenges in
Sustainable Development Goals (SDGs): Where and how we have started? between
September 25th -26th, 2017. The conference is the initiation which the aims to be a
platform for academics, researchers, students and public health personnel in sharing
their experiences and research in public health situations, challenges, lesson learnt
and appropriate measures in response to public health in SDGs era of the ASEAN.
There will be more than 200 participants from six countries joining this international
conference and more than half are international participants.
We have had great supports from both domestics and international institutions being
cohost of this international conference. These institutions are the Graduate School,
the University of Health Sciences, Lao P.D.R.; Faculty of Public Health, Hue
University of Medicine and Pharmacy, Vietnam; Department of Community Health,
Faculty of Medicine, Chiang Mai University, Thailand; Bachelor of Public Health
Program, Faculty of Public Health, Mahasarakham University, Thailand, The
International Rescue Committee (IRC); the Research and Training Center for
Enhancing Quality of Life of Working - Age People, Khon Kaen University; and
academic support from scholars from Faculty of Public Health, University of Public
Health, Myanmar and the Faculty of Public Health, Naresuan University, Thailand.
The research presented in this conference have been assessed and approved by the
researcher organization and by our academic committee
I would like to express my appreciations for their support and cooperation.
Chairperson of the Organizing Committee
b
Schedule of conference
September 25th,, 2017 : Work Shop on “Applying Spatial Analysis in Public Health”
8.00 – 9.00 Registration at Takasila Comference Room.
9.00 – 10.30 Work Shop on “Applying Spatial Analysis in Public Health”
: Assoc. Prof. Dr. Wongsa Laohasiriwong and team
10.30 – 10.45 Coffee Break
12.00 – 13.00 Lunch
14.30 -14.45 Coffee Break
16.30 – 17.00 Summarize of Work Shop: Assoc. Prof. Dr. Wongsa Laohasiriwong
September 26th, 2017
8.00 – 8.45 Registration at Takasila Comference Room.
8.45 – 9.15 Opening Ceremonies
- Cultural Performance from Thailand, Myanmar and Indonesia
- Welcome Remark: Asst. Prof. Dr. Somsak Pitaksanurak, Dean, Faculty of
Public Health
9.15 – 9.45 Opening Remark: Mr. Suraporn Petch-Vra, Committee of University Council
9.45 – 10.30 Keynote Speaker on “Health Challenges and Answer: Thailand Experiences” :
Dr.Supamit Chunsuttiwat, Expert, Department of Disease Control, Ministry
of Public Health
10.30 – 10.45 Coffee Break
10.45 – 12.00 Panel Discussion on “Health Challenges in SDGs: the International
experiences of where and how we have started?”
Moderator: Dr.Nonglak Pagaiya
Spaeker: Prof.Dr.San San Myint Aung, Dr.Vanphanom Sycharean,
Dr.Bigwanto Mouhamad, Dr.Daon Voung Diem Kham
Dr. Sajja Tatinupanwong,
12.00 -13.00 Lunch
12.20 – 13.00 Poster Presentation
13.00 – 17.00 Theme I : NCDs & Health Problems
Theme II : Health Promotion
Theme III : Environmental Health and Nutrition
Theme IV: Health Service System
17.00 – 17.30 Outstanding Oral and Poster Presentation Awarding and
Closing Remark
c
List of Oral Presentation
Room 1307 , 3rd Floors of the Arun Chirawantanakun building, Faculty of Public Health
Chairman : Dr.Vanphanom Sychareun
Dean, Graduate School, University of Health Sciences, Lao PDR

Co-Chairman: Assoc. Prof. Dr.Chanaphol Sriruecha
Faculty of Public Health, Khon KaenUniversity, Thailand.
Asst. Prof. Dr.Pattara Sanchaisuriya
Faculty of Public Health, Khon KaenUniversity, Thailand.
Code Authors Title Page
Environment Sai Saung Kham Socioeconomic disparities and safe drinking water 1
Health and treatment practices in rural areas of Southern Shan state,
Nutrition 01 Myanmar.
Environment Naw Hnin Ei Malnutrition and its associated factors among elderly in 14
Health and Kyaing rural area of Kayin state, Myanmar.
Nutrition 02
Environment Sun Thit Wai Socio-economic disparity and exclusive breastfeeding 27

Health and practices in rural Kayin State, Myanmar.
Nutrition 03
Environment Aye Khin Overweight and obesity and its associated factors among 44
Health and Myanmar personnel in nonprofit health organizations in
Nutrition 04 Tak province, Thailand.
Environment SakesunThongtip Factors related to air quality perception instone mortar 56

Health and workers among Ban Sang sub district in Phayao, Thailand.
Nutrition 05
Environment Min Thura Aung Pesticide literacy, pesticide exposure prevention practices 66
Health and and its associated factors among farm workers in Bago
Nutrition 06 region, Myanmar: Cross sectional analytical study.
Environment Aung Win Min Solid waste management practices and their association 76
Health and factors among urban households in Mon state, Myanmar.
Nutrition 07
Environment Thazin Htwe Infection and malnutrition among pre-school children (3- 87
Health and 5years) in rural area of Mon State, Myanmar: A cross
Nutrition 08 sectional analytical study.
Environment Saw Than Lwin Stunting and wasting among 0-5 year-old Myanmar 97
Health and migrant children and the associated factors in Tak
Nutrition 09 province, Thailand.
d
Chairman : Dr.San San Myin Aung
Technical Advisor IRC, Myanmar.
Co-Chairman: Dr. Wilaiphorn Thinkhamrop
Faculty of Public Health, Khon Kean University, Thailand.
Dr.Bigwanto Mouhamad
University of Muhammadiyah Prof.Dr.Hamka, Jakarta, Indonesia.
Health Nway Nway Oo Socioeconomic disparity and quality of married life 113
Promotion 01 of Myanmar migrant women in Thai-Myanmar
border, Tak province, Thailand.
Health Hkawn Mai Socioeconomic disparity and abortion among migrant 129
Promotion in Thailand-Myanmar border area.
02
Health Payom Thinuan Physical health as a predictor of pre-frail community- 142

Promotion dwelling older persons in Lampang province,
03 Thailand.
Health Bo Bo Lwin Perceived social norms towards sexual health and 150
Promotion associated factors among Myanmar migrant
04 adolescents, in Tak Province, Thailand: A cross
section analytical study.
Health Thin Thin Soe Socio economic disparity and contraceptive practice 172
Promotion among reproductive age women in Kayin state,
05 Myanmar.
Health Pue Pue Mhot Depression and its associated factors among working 190
Promotion aged group in Kayin state, Myanmar.
06
e
Taksila Room , Faculty of Public Health
Chairman : Assoc. Prof. Dr.Wongsa Laohasiriwong
Vice Dean,Faculty of Public Health, Khan Kaen University, Thailand
Co-Chairman: Dr.Terdsak Promarak
Faculty of Public Health , Mahasarakham University, Thailand.
Health Songkramchai Competencies of public health professionals 206

Service Leethongdee framework in Thailand.
System 01
Health Saw Nay Htoo Underutilization of antennal care services and its 215
Service associated factors in conflict-affected areas of Karen
System 02 state, Myanmar.
Health Aung Zaw Htike Child immunization and its associated factors among 229
Service 0-2 years old children living in Mon state, Myanmar.
System 03
Health Min Zayar Linn Socio economic disparities and incompleted child 243
Service immunization in Kayin State, Myanmar.
System 04
Health Thazin Hlaing Socioeconomic disparity and incomplete antenatal 254

Service care practices in Kayah state, Myanmar.
System 05
Health Napatsaporn The quality improvement of clinical risk management 265

Service Choensa-ard system for nursing care standard in the In-Patient
System 06 Department in Atsamat Hospital, Roi-Et Provice,
Thailand.
Health Htay Min Oo Intention to continue working after the project end 276
Service and its associated factors of voluntary health worker
System 07 of the National Malaria Control Program, Kayin
State, Myanmar.
f
Chairman : Professor Frank Peter Schelp
Faculty of Public Health, Khon Kaen University, Thailand.
Co-Chairman: Assoc. Prof.Dr. Songkramchai Leethongdee
Faculty of Public Health, Mahasarakham University, Thailand.
NCDs and Kyaw Thu Win Diabetes mellitus literacy and self-care practices of type 2 291
Health diabetes mellitus patients in Mon State, Myanmar: A cross
Problems 01
sectional analytical study.
NCDs and Saw Aung Tin Hypertension and its associated factors among Myanmar 303
Health Myint personnel in non-profit health organizations in Tak
Problems 02 province, Thailand.
NCDs and Thu Yein Win Psychosocial determinants and smoking behaviors among 319
Health working aged males in Bago Region, Myanmar.
Problems 03
NCDs and Wanna Factors of Mobile Phone use related to quality of sleep 335
Health Chongchitpaisan among high school students in Chiang Mai, Thailand.
Problems 04
NCDs and Saw Myat Lin Betel quid chewing situation and its associated factors 352
Health Kywe among working aged males in Kayin State, Myanmar.
Problems 05
NCDs and Nan Lin Kham Alcohol use disorders among working age males in the 368
Health Southern Shan State, Myanmar.
Problems 06
NCDs and Than Kyaw Soe Health literacy, social determinants and overweight and 385
Health obesity among middle aged women in Myanmar: A cross
Problems 07 sectional analytical study.
NCDs and Chuthamat The influences of alcohol marketing on alcohol 398

Health Choidamrongkun consumption of working aged males in Khon
Problems 08 Kaen province, Thailand.
NCDs and Kong Malika Sociocultural determinants and alcohol use disorder among 411
Health working population in Cambodia.
Problems 09
NCDs and Suwatcharanee Effects of strong program for protection the new smokers 428
Health Sunopuk among secondary school in Roi-Et municipality, Roi-Et
Problems 10 Province, Thailand.
g
Peer Reviewers
University of Health Sciences, Ministry of Health,Vientiane, Lao PDR.
Dr. Vanphanom Sychareun
Dr. Visanou Hansana
Faculty of Public Health, Hue University of Medicine and Pharmacy, Vietnam
Prof. Dr. Vo Van Thang
University of Muhammadiyah, Jakarta, Indonesia
Dr. Bigwanto Mouhamad
University of Public Health, Yagon, Myanmar
Assoc. Prof. Dr. Mya Thandar
International Rescue Committee, Myanmar
Prof. Dr. San San Myint Aung
Dr. Aung Kay Tu
Faculty of Medicine Chiang Mai Unviersity, Thailand
Assoc. Prof. Dr. Penprapa Siviroj
h
Faculty of Public Health, Mahasarakham University, Thailand
Assoc. Prof. Dr. Songkramchai Leethongdee
Dr. Terdsak Promaruk
Faculty of Public Health, Naresuan University,Thailand
Asst. Prof. Dr. Nithra Kitreerawutiwong
Faculty of Medicine, Khon Kaen University, Thailand
Asst.Prof. Dr. Thitima Nutrawong
Faculty of Nursing, Khon Kaen University, Thailand
Prof. Dr. Kessarawan Nilvarangkul
Faculty of Public Health, Khon Kaen University, Thailand
Prof. Dr. Frank Peter Schelp
Assoc. Prof. Dr. Chanaphol Sriruecha
Asst. Prof. Dr. Pattara Sanchaisuriya
Assoc. Prof. Dr. Pongdech Sarakarn
Assoc.Prof. Paricha Nippanon
Dr. Wilaiphorn Thinkhamrop
Sirindhorn College of Public Health Khon Kaen, Thailand
Dr. Teerasak Phajan
i
Environmental Health and Nutrition 01
Socioeconomic disparities and safe drinking water treatment practices in

rural areas of Southern Shan State, Myanmar.
Sai Saung Kham 1, Peuk Tantrirantna 2
1
M.P.H Candidate, International Health, Faculty of Public Health, Khon Kaen University
2
บทคัดย่ อ
การปฏิบตั ิในการปรับปรุ งคุณภาพน้ าดื่มให้ปลอดภัยอย่างเหมาะสม เป็ นความท้าทายที่สาคัญในประเทศกาลังพัฒนา

ประเทศพม่ามี ความเหลื่ อมล้ าที่ โดดเด่ นระหว่างพื้นที่ ในเขตเมื องและเขตชนบท แม้ว่าในปี 2015 ประมาณ 82.3% ของ
ประชากรจะใช้แหล่งน้ าที่ปรับปรุ งให้ดีข้ ึนแล้ว การศึกษานี้เป็ นแบบภาคตัดขวางการมีวตั ถุประสงค์เพื่อประเมินแนวทางปฏิบตั ิ
ในการปรั บปรุ งคุ ณภาพน้ าดื่ มที่ ปลอดภัยและปั จจัยที่ เกี่ ยวข้องในพื้นที่ ชนบทของรั ฐฉานทางใต้ กลุ่มตัวอย่างคื อ หัวหน้า
ครัวเรื อนทั้งหมด 340 รายถูกคัดเลือกโดยใช้แบบสุ่ มตัวอย่างหลายขั้นตอนตามสัดส่ วนของประชากรในรัฐฉานทางใต้ เก็บ
รวบรวมข้อมูลโดยใช้แบบสอบถามที่มีโครงสร้างและวิเคราะห์ดว้ ยสมการถดถอยลอจิสติกแบบพหุ
ผลการศึกษา: เกือบครึ่ งหนึ่งของกลุ่มตัวอย่างไม่รู้หนังสื อ ส่ วนใหญ่เป็ นเพศหญิง (59%( สองในสามเป็ นกลุ่มผูใ้ หญ่ ปฏิบตั ิใน
การปรั บปรุ งคุ ณภาพน้ าดื่ มให้ปลอดภัยคื อ 84.7% (95% CI = 77.96-86.16( ปั จจัยที่ เกี่ ยวข้องกับการปฏิ บัติในการปรับปรุ ง
คุณภาพน้ าดื่มให้ปลอดภัยคือกลุ่มที่แต่งงาน (adj. OR = 3.49, 95% CI: 1.754-6.953, p-value <0.001( การมีรายได้ระดับสูง (adj.
OR = 1.83, 95% CI : 1.175-2.855, p-value = 0.008( ใช้น้ าจากภาชนะที่มีฝาปิ ด( adj. OR = 3.8, 95% CI: 1.731-8.524, p-value =
0.001( และใช้น้ าจากเครื่ องจ่ายน้ า( adj. OR = 2.4, 95% CI: 1.577-3.606, p-value <0.001(
สรุ ป: มีความสัมพันธ์ระหว่างปั จจัยทางสังคมและเศรษฐกิจกับการปฏิบตั ิในการปรับปรุ งคุณภาพน้ าดื่มให้ปลอดภัย ทั้งนี้ ควร

สนับสนุนให้กบั เศรษฐกิจและสังคมที่เปราะบาง
1
Abstract
Background: Secures appropriate safe drinking water treatment practices is a major challenge in
developing country. In Myanmar, there are notable disparities between urban and rural areas even
overall 82.3% of the population were using an improved source of drinking water in 2015.
Objectives: This community-based cross-sectional study aimed to assess the safe drinking water
treatment practices and its associated factors in rural areas of Southern Shan State.
Method: A total of 340 heads of household were selected by using multistage random sampling
with proportional to size of the population in Southern Shan State. Data was collected by using
structured questionnaires, and analyzed with multiple logistic regressions.
Results: Nearly half of those people were illiterate. Participants were male and female with 41%
and 59% respectively. Two-third of them were young adult and middle adulthood. The prevalence
of safe drinking water treatment practices was 84.7% (CI:77.96-86.16(. Factors associated with safe
drinking water treatment practices were participants who were married (adj. OR=3.49, 95%CI: 1.754-
6.953, p-value <0.001(, high income (adj. OR=1.83, 95%CI: 1.175-2.855, p-value=0.008(, fetching
water with covered (adj. OR=3.8, 95%CI: 1.731-8.524, p-value=0.001(, and fetching water with
vehicle (adj. OR=2.4, 95%CI: 1.577-3.606, p-value<0.001(.
Conclusion: There were association between safe drinking water treatment practices and
socioeconomic factors. A further study is also recommended for more understanding about favors
and barriers to complete safe drinking water treatment practices.
Introduction
Nowadays, we are on the way to achieve SDGs, and clean water is also one of the
achievements. In 2015, 6.6 billion people (over 90% of the world’s population( used improved
drinking water sources. Effective water management relies on the participation of a range of
stakeholders, including local communities. A 2016-2017 survey found that over 80% of 74
responding countries had clearly defined procedures for engaging service users/communities in
water management. We need to have a better water treatment practices or system in order to
promote health in the rural community. [1]
2
Consuming unsafe water and unsafe drinking water practices will lead to infections that
include illness or death from water borne diseases such as diarrheal diseases. Currently, there are
many households or villagers still with limited access to and practice with safe drinking water
practices. Some villagers or households depend on the rain, well, and spring water source for their
use. [2] One study indicated that the household location, size, number of children in the family, age
and education of the mother, household head’s employment, drinking water resources are
important correlates of drinking water practices and diarrhea in children. [3] 29% of persons in the
high-income drank bottled water when we compared to those who had low income. How they
fetched the water was also important. [4]
In one study, it reflected that the improper placement of pipe line water distribution system,
lack of sanitary seals and lack of knowledge of the significance of contaminated water were all
found to be the factors that contributing to the poor quality water supply in this area. [5]
Objective
To describe the safe drinking water treatment practices & to determine the association
between the socioeconomic factors and safe drinking water treatment practices in rural areas of
Southern Shan state, Myanmar
Methodology
Study Design
This community-based cross-sectional study was conducted with structured interview
questionnaire to identify the safe drinking water treatment practices in the rural areas of Southern
Shan State, Myanmar. The study conducted in five townships of the Southern Shan State, Myanmar
and a total of 340 of participants.
Sampling Method
All participants were selected by multistage random sampling.
3
Figure 1. Multistage simple random sampling of the participants
Table 1. The sampling procedure flow chart
Township Population Percent of Number of Number of Proportion

No
Name (township) population household population Of sample
1 Lai-Kha 49,616 15.62 114 531 53
2 Loi-Lem 125,777 39.58 230 978 135
3 Ke-Se 71,337 22.45 106 511 76
4 Mawk-Mai 32,393 10.20 114 541 35
5 Lang-Khur 38,609 12.15 187 933 41
Total 5 317,732 100 751 3495 340

Statistical Analysis
Demographic characteristics of the participants were described using frequency and

percentage for categorical data, mean and SD for continuous data. To investigate the factors that
associated with safe drinking water treatment practices, odds ratios (OR) and their 95%CI were
estimated using multiple logistic regression. All analyses were performed by using STATA
software, and all test statistics were two-sided and a p-value of less than 0.05 was considered
statistically significant
4
Demographic Characteristics
Table 2. Baseline demo-socioeconomic characteristics of the participants (n=340(
Characteristics Number Percent (%)

Age (years)
<30 90 26.5
30-39 84 24.7
40-49 63 18.5
50-59 70 20.6
≥60 33 9.7
Mean (±SD( 39.0 (±12.6(
Median (Min:Max( 37.5 (20:70(
Gender
Female 201 59.0
Male 139 41.0
Educational Attainment
Illiterate 104 30.6
Primary school or equivalence 55 16.2
Secondary school or equivalence 64 18.8
High school or equivalence 46 13.5
Others (Summer School – 10.3%, no grade-10.6%( 71 20.9
Marital Status
Married 258 75.9
Single 66 19.4
Widow/Separated/Divorced 16 4.7
Ethnicity
Shan/Tai 296 87.1
Pa-O 26 7.7
Others 18 5.2
Occupation
Own business 229 67.4
Manual labor 44 12.9
Government staff 37 10.9
Dependent 30 8.8
5
Characteristics Number Percent (%(
Household number
<2 number 15 4.4
2 – 4 number 140 41.2
5 and above 185 54.4
Mean (±SD( 4.7 (±1.41(
Median (Min:Max( 5 (2:8(
Children number
<1 number 81 23.8
1 – 3 number 218 64.1
>3 41 12.1
Mean (±SD( 1.84 (±1.41(
Median (Min:Max( 2 (0:5(
Residence area
Rural 338 99.4
Urban 2 0.6
Monthly income (MMK)
<100000 11 3.3
100000-199999 113 33.2
200000-299999 121 35.6
≥300000 95 27.9
Mean (±SD( 220353 (±93306(
Median (Min:Max( 200000 (50000:500000(
Financial Situation
Not Enough 133 39.1
Not enough with debt 12 3.5
Enough with no saving 160 47.1
Enough with saving 35 10.3
Financial support
No 271 79.7
Yes 69 20.3
Government 32 9.4
Community 30 8.8
NGO 4 1.2
Others 3 0.9
6
Financial problems to construct the storage
No 196 57.6
Yes 144 42.4
Table 3. Baseline Characteristics on environmental, knowledge, attitude, and practices

Fetching from the water source
With covered 211 62.1
Without covered 129 37.9
Carrying with vehicle
With bikes 182 53.5
Walking 151 44.4
With cars 7 2.1
Time lasting to fetch the water (minutes)
≥60 337 99.1
>60 3 0.9

How often they fetched the water (times per week)
≥10 302 88.8
>10 38 11.2
Consumption of water (Liters per day)
≥10 222 65.3
11 to 20 113 33.2
>20 5 1.5
Water collector
Household (You( 213 62.7
Family member/s 127 37.3
Son 72 21.3
Daughter 31 9.0
Others 24 7.0
7
Family member got Diarrheal disease during past year
No 212 62.4
Yes 128 37.6
Family member got bladder stone
No 267 78.5
Yes 73 21.5
Knowledge Level of the participants
Low level 172 50.6
Moderate level 114 33.5
High level 54 15.9
Mean +S.D. 8.21 ±1.68
Median (Min:Max( 9 2:11
Attitude Level of the participants
High attitude 102 30.0
Moderate attitude 167 49.2
Low attitude 71 20.8
Mean +S.D. 18.14 ±2.12
Safe drinking water practices
No 52 15.3
Yes 288 84.7

Level of practicing
Low level 52 15.3
High level 28 8.2
Mean +S.D. 38.2 ±4.58
8
Table 4. Crude Odd ratios for each category of factors
% of Crude p-
Characteristics number 95%CI
practices OR. value
Age in years 0.019
<40 183 77.6 1
≥40 157 87.4 1.9 1.103-3.546
Gender 0.788
Female 201 81.59 1
Male 139 82.73 1.1 0.614-1.905
Educational Level 0.461
Illiterate 175 80.6 1
Literate 165 83.6 1.232 0.706-2.151
Marital status <0.001
Single 82 59.8 1
Married 258 89.2 4.0 3.065-9.983
Ethnicity 0.099
Non-Shan/Tai Ethnic 44 54.6 1
Shan /Tai Ethnic 296 58.9 1.9 0.910-3.926
Occupation 0.007
Non-employee 259 85.3 1
Employee 81 71.6 1.232 1.063-1.429
Household number 0.009
<5 members 155 76.1 1
≥5 members 185 87.0 2.1 1.194-3.704
Children number 0.006
≥2 224 78.1 1
>2 116 89.6 2.4 1.234-4.772
Monthly income (MMK) 0.002
<200000 119 35 1
≥200000 221 65 4.3 2.004-9.559
Financial Situation 0.248
Not enough 145 84.8 1
Enough 195 80.0 1.4 0.788-2.480
Financial problem to 0.092
construct the storage
No 196 79.1 1
Yes 144 86.1 1.6 0.914-2.920
9
% of Crude p-
Characteristics number 95%CI
practices OR. value
Without covered 129 76.0 1
With covered 211 85.8 1.91 1.091-3.338
Fetching water 0.0001
Walking 151 72.89 1
With bikes, car 189 89.4 1.7 1.329-2.379
How often they fetched the 0.172
water per week (times/week)
>10 38 73.7 1
≥10 302 83.1 1.76 0.804-3.843
Amount of water they drank 0.118
(Liters per day)
≥10 222 79.7 1
>10 118 86.4 1.62 0.872-3.014
Water collector 0.95
Family members 127 81.9 1
Head of household 213 82.2 1.0 0.575-1.804
Knowledge level 0.107
Low level 54 74.1 1
Moderate level 114 79.8 1.1 0.647-2.965
High level 172 86.1 1.0 1.024-4.551
Attitude level 0.140
Moderate 167 29.2 1
High 102 60.0 1.4 0.726-2.601
Low 71 62.0 2.2 0.950-4.928
10
Figure 2. Adjusted Odd Ratios for each category of factors on safe drinking water treatment
practices based on multiple logistic regression.
Discussion
Out of our participants, the larger households (5 people or more( had more chance to
practice safe drinking water even they had more financial problem to construct the water storage
tanks. But, they didn’t mention about the water shortage for drinking per day. 2013, in Nunavut
households with larger family members showed that they had water shortage. In this study, they
also mentioned about the financial for water storage tanks. [6]
Even the participants who had higher knowledge that towards to safe drinking water
treatment was 86%, it appeared that some ancient knowledge was an independent validation of the
scientific concept. [7] The awareness to practice safe drinking water treatment was also mentioned
in one study in Shenzhen. The students who had more awareness related to their higher knowledge
were had more chance to practice the safe drinking water treatment. [8] Unawareness rate of safe
drinking water treatment practices was also mentioned in the study in four cities of China. [9]
The participants who were using public standpipe, protected dug well, and rainwater
collection, with safe practices occupied 84.7% among 340 of the total with 95% CI=77.96-86.16. One
study from western country showed that pollution of surface water bodies had serious impact on
water resources availability and biodiversity, while weather changes encouraged the health risks
of water insecurity. [10] Between one-third and one-half of rual respondents in Belarus, Moldova
got their water from wells and similar sources. [11]
11
Lao PDR has achieved the safe water and sanitation with 76 percent of the population were
estimated to have access to improved sources of drinking water. 79 percent of households without
water on the premises, females collected the water. This trend is more pronounced among poor
rural families, families whose heads had little or no education and ethnic groups living in remote
mountainous areas.
Conclusion
The prevalence of safe drinking water treatment practices in rural areas of Southern Shan
State, Myanmar was 84.7% with 95%CI=77.96-86.16. The factors significantly associated with safe
drinking water treatment practices were marital status, income, and the ways they fetched water.
Recommendations
A further study was recommended for more understanding about favors and barriers to
complete safe drinking water treatment practices in Southern Shan State. Despite the limitation,
this finding will be applied for public health policy makers as a base-line to develop appropriate
strategies to address the issue on safe drinking water treatment practices. The policy makers should
emphasize and strengthen the policies on live skills developments, and emphasize on the quality
of drinking water. As we are on the way to SDGs and we are also need to improve the safe drinking
water practices.
Acknowledgements
I would like to express my sincere thanks to Ethical Committee of Khon Kaen Univeristy,
DAMASAC team, and faculty of public health, Khon Kaen University for their guidance and wise
opinion towards my study. I would like to thank all the respondents from 5 townships of Southern
Shan State, Myanmar for their active participation.
12
Limitation of the study
This study was totally dependent on the participant’s answer on our structured
questionnaires. Memory recalls and interviewer relationship bias while assessing on determinants
factors, therefore bias could not be excluded.
References:
1. Peterson, H. and M. Torchia, Safe drinking water for rural Canadians. CMAJ, 2008.
179(1(: p. 55.
2. Belay, H., Z. Dagnew, and N. Abebe, Small scale water treatment practice and associated
factors at Burie Zuria Woreda Rural Households, Northwest Ethiopia, 2015: cross
sectional study. BMC Public Health, 2016. 16: p. 887.
3. Murtaza, F., Socio-Environmental Determinants of exposure to water and sanitation
related hazards in Pakistan. 2015.
4. Kenneth P Cantor, Socioeconomic status and exposure to disinfection by-products in
drinking water in Spain. 2011.
5. Zaw, D.A.M., Bacteriological assessment of HH drinking water quality in ward no.1,
yangon. 2015.
6. Daley, K., Municipal water quantities and health in Nunavut households. 2014.
7. HT, M., Metallic iron for safe drinking water provision: considering a lost knowledge.
2017.
8. J, L., Knowledge, attitude and practice on drinking water of primary and secondary
students in Shenzhen. 2014.
9. JL, Z., Knowledge on drinking water of adults in four cities of China. 2011.
10. Hutton, G., The knowledge base for achieving the SDG targets on water supply. 2016.
11. McKee, M., Access to water in the countries of the former Soviet Union. 2006.
13
Malnutrition and its associated factors among elderly in rural area of

Kayin State
Naw Hnin Ei Kyaing1, Paricha Nippanon2
1
MPH Program Student, Faculty Of Public Health, Khon Kaen University, Thailand
2
Faculty Of Public Health, Khon Kaen University Thailand
สถานะทางโภชนาการของผูส้ ูงอายุเป็ นประเด็นที่สาคัญยิง่ ทางด้านสาธารณสุข นอกจากนี้ผลกระทบที่สมั พันธ์กนั

ของปัจจัยที่มีผลต่อสถานะทางโภชนาการอาจแตกต่างกันไปตามลักษณะของประชากรบนพื้นฐานของความแตกต่าง
ทางด้านวัฒนธรรม ทั้งนี้ภาวะทางโภชนาการของคนพม่าก็ยงั คงมีการศึกษาในจานวนน้อยอยู่ การศึกษาครั้งนี้มีจุดมุง่ หมาย
เพื่ออธิบายภาวะขาดสารอาหารและเพื่อหาปัจจัยที่สมั พันธ์กบั ภาวะทุพโภชนาการของผูส้ ูงอายุในชนบทของรัฐคะยิน
ประเทศพม่า
การศึกษาภาคตัดขวางในครั้งนี้ ทาการศึกษาในกลุ่มผูส้ ูง 387 คนที่มีอายุ 60 ปี หรื อมากว่าที่อาศัยอยูใ่ นพื้นที่ชนบท
ของรัฐคะยิน ทาการเก็บรวบรวมข้อมูลโดยใช้วธิ ีการสุ่มกลุ่มตัวอย่างแบบหลายขั้นตอนและทาการเปรี ยบเทียบสัดส่วนของ
กลุ่มประชากรใน 3 อาเภอของรัฐคะยิน ผูว้ จิ ยั จะมีการเก็บข้อมูลน้ าหนักและส่วนสูงร่ วมด้วย หลังจากการเก็บข้อมูลจาก
แบบสอบถามเสร็จสิ้น การวิเคราะห์การถดถอยโลจิสติคพหุกลุ่มจะนามาใช้ในการวิเคราะห์เพื่อระบุความสัมพันธ์ดงั กล่าว
กลุ่มตัวอย่างส่วนใหญ่เป็ นเพศหญิง (65.37%) และไม่มีงานทา (57.88%) ความชุกของภาวะทุพโภชนาการใน
ผูส้ ูงอายุเท่ากับ 28.2% (95% CI= 23.66 ถึง 32.66) ปั จจัยที่มีความสัมพันธ์กบั ภาวะทุพโภชนาการของผูส้ ูงอายุ ประกอบด้วย
เพศหญิง (AOR = 2.92,95% CI= 1.69 – 5.03, p-value: <0.01), รายได้ต่า (AOR = 2.07,95% CI= 1.29 ถึง 3.31, p-value =
0.002) จานวนสมาชิกในครอบครัวมากกว่า 55 คน (AOR =2.03, 95% CI= 1.20-3.42, p-value= 0.01)
เพศและภาวะเศรษฐกิจสังคมมีอิทธิพลต่อผูส้ ูงอายุที่อยูใ่ นภาวะโภชนาการ ผูส้ ูงอายุที่อาศัยอยูก่ บั ครอบครัวที่มี
สมาชิกจานวนหลายคน มีแนวโน้มที่จะแบ่งปั นทรัพยากรอาหารกับสมาชิกในครอบครัวของพวกเขาร่ วมด้วย และควรมีการ
ส่งเสริ มหรื อสนับสนุนกลวิธีเกี่ยวกับโภชนาการแก่ผสู ้ ูงอายุโดยเฉพาะผูท้ ี่อยูใ่ นสถานะทางเศรษฐกิจและสังคมในระดับต่า
14
ABSTRACT
Background: As being growth of elderly, nutrition status in elderly is important in public

health concern. In addition, the relative impact of the factors contributing to nutritional status
may be different from one population to another depending on the cultural background.
Nutrition in elderly Burmese population remains unexplored.
Objective: This study aims to describe the malnutrition situations and to determine the factors
associated with malnutrition among elderly in rural areas of Kayin state, Myanmar.
Methods: A cross-sectional survey was conducted among 387 elderly aged 60 and over, who
lived in rural area of Kayin State. Data was collected by using multistage random sampling
with proportionate to population method at 13 villages under 3 Districts in Kayin State. The
researcher measured the weight and height of the participants, after structured questionnaire
was completed. Multiple logistic regression was used to identify the association.
Results: Most of the samples were females (65.37%), and half of the respondents were
unemployment (57.88%).The mean age of the population was 69.1(±6.84) years. The
prevalence of malnutrition in elderly was 28.2% (95% CI: 23.66-32.66). Factors associated
with malnutrition in elderly were female gender (adj OR=2.92,95% CI:1.69-5.03,p-value:<
0.01),income (adj OR=2.07,95%CI:1.29-3.31, p-value:0.002), elderly who live with more
than five family members (adj OR=2.03, 95%CI: 1.20-3.42, p-value :0.01).
Conclusions The result of this study shows that malnutrition is associated with gender,
income and family member. Elderly who live with more family members were more likely to
share food resources with their family members. Nutrition program should be encouraged for
the elderly. There would be required to find out the ways how to care for the elderly in terms
of the traditional family, norms and values.
Key words: Malnutrition, Elderly, BMI, Oral health status, Rural, Kayin, Myanmar
15
Introduction
According to WHO report, malnutrition occurs one third of the total population in low-
income countries but the figures differ from different age group. In Taiwan, the prevalence of
malnutrition among elderly person aged between 60-80 years is 2% and 5%. Moreover, 38%
of rural elderly people suffer from malnutrition.Tamanna Ferdous1, ˚ ke Wahlin3 et al.
(2009). Data for nutritional status among elderly in low- income counties is inadequate
because of logistic difficulties and not proper instruments for data collection. Moreover, the
important assessment like food-intake to know the interaction between dietary intake and
disease causation are very few among elderly in low-income countries. Nutritional problems
have been an additional impediments to achieve health goal and other sector progress.(WHO
2002).
This study is aim to conduct in Kayin State, South East of Myanmar. As a result of long
history of conflict, poverty and underdevelopment, health situation in SE region is left behind
especially in the area of health system and access to health services. This is because lack of
proper transportation, weak in knowledge, insufficient well-trained staff, poor infrastructure
and equipment, language barrier and local culture and norms. Moreover, majority of migrant
young people in Thailand or Malaysia came from South East region of country. So, SE region
are ongoing process to reform health system especially primary health care and elderly has
been a neglected group when compare to maternal and children. (Aye Aug 2013) In
contrast, nutrition in elderly Burmese population remains unexplored. As being growth of
elderly, nutrition status in elderly is important in public health concern.. In addition, the
relative impact of the factors contributing to nutritional status may be different from one
population to another depending on the cultural background.
Objective
The aim of the study is the association between demographic, socioeconomic,

physical, knowledge, food consumption and practices and malnutrition among elderly in rural
areas of Karen state, Myanmar
Materials and Methods
Study design
16
This study is an analytical cross-sectional study. Structured questionnaire interview
was conducted to describe; the demographic and socioeconomic information including sex,
age, marital status, income, education, occupation, family member, height, weight, oral health
condition and nutritional status. The sampling method was simple random sampling with
probability proportional to size of elderly in each village .Under the 4 district of Kayin State,
two districts were selected randomly and total of 387 respondents who aged 60 and over were
interviewed from 13 villages.
Study outcome
The outcome of the study was undernutrition status in elderly and it was defined by
BMI.BMI is defined as weight in kilograms divided by height in meters squared. A BMI less
than 18.5kg/m2 is widely accepted as underweight. The researcher measured the weight
and height of the participants, after structured questionnaire was completed. Weight and
height of Participants was measured as the participants are in the position of the participants
was straight with their knees; head was horizontal and their arms were in a straight line with
not wearing shoes and light clothes. Body height in centimeters (cm) was measured to the
nearest 0.1 cm by tape. Body weight in kilograms (kg) was measured to the nearest 0.1 kg by
automatic scale. These height and weight variables were converted into body mass index.
Body mass index was used as indicator of underweight (BMI <18.5 kg/m2), Normal (BMI
18.5 to 22.9 kg/m2), Overweight (BMI 23.0 to 24.9kg/m2) and Obesity (BMI >25 kg/m2) by
Asian Standard.
Statistical analysis
The raw data of 387 respondents was recorded into the MS Excel for database
management. The statistical consideration for data analysis of this research was used Stata
10.0 software to study and analyze. Demographic information and physical information was
presented as number and percent for categorical data and for another continuous data was
described with mean and it standard deviation, median and its range (minimum: maximum).
Bivariate and multivariable analyses was performed with the reason of the dependent variable
nutritional status was dichotomized in malnourished and healthy nutrition which is
dichotomous variable. Crude odds ratio (OR) and 95% confidence interval (CI) for each
variable was obtained from simple logistic regression (bivariate analysis) to evaluate the
independence of the observed associations, the variables with a value p< 0.25 were
simultaneously entered in a multiple logistic regression analysis. The backward elimination
solution was selected to consider fitting model. The p-value of p <0.05 was considered to
indicate statistical significance.
17
Result
Multi-stage sampling was used to select the samples in this study. 13 villages under
the Hpaan ,Hlaingbwe, Kawkareik was randomly selected. The totals of 387 samples was
randomly selected proportional to size of the population in each community.
Kayin State
4 Districts
Simple Random sampling

Simple Random sampling (Lottery)
2 Districts
Simple Random Sampling
3 Townships
13 Villages
Elderly (387)
Fig. 1. Multi-stage sampling process of community survey
Results
The socio-demographic characteristic of the respondents were shown in Table (1).
Among the 387 respondents, over half of the respondents were female 253 (62.27%) and male
was 134 (34.63%). The age of the elderly was at the mean of 69.1 with the standard deviation
of 6.84. All of the respondents were Karen ethnic except one respondent of Burma. Related
with marital status, single was at least group 16 (4.13 %) and the percentage of married and
divorced group was not much different respectively 53.49% and 42.38%. In education
attainment, 61.50% of respondents were no formal education and higher education level was
only 258%. Related with religion, majority of the respondents were Buddhist with the
number of 378 (97.67 %). Most elderly were unemployed, 224 (57.88%) and the rest elderly
were farmers and other works. Related with the income of respondent, monthly per capital
income ranged form no income zero Kyat to 300000 Myanmar Kyat with the median income
18
of 10000 Kyat. However, the median of family income was 100000 Kyat within the range of
0 to 500000. Most respondents financial situation was enough with no saving was (61.76%).
Elderly who live with family more than 5 members and less than 5 members were nearly the
same with the percentage of 54.52% and 45.48%. Moreover, elderly were used to live their
children with the percentage of 73.64%.
Table 1. Baseline characteristics presented as percentage unless specified otherwise among

elderly in rural areas of Karen State, Myanmar. (n= 387.)

1. Gender
Male 134 34.63
Female 253 65.27
2. Age of elderly (years)
60-69 232 59.95
≥70 155 40.05
Mean (±SD) 69.1(±6.84)
Median (min : max) 68(60:94)
3. Ethnic
Burma 1 0.26
Karen 386 99.74
4.. Marital Status
Single 16 4.13
Married 207 53.49
Divorced/Widowed/Separated 164 42.38
5. Educational attainment
No formal education 238 61.50
Primary school 119 29.46
Middle school 25 6.46
High school or equivalent 10 2.58
6. Religion
Buddhist 378 97.67
Christian 9 2.33
7. Occupation
None 224 57.88
Farmer, fisherman, 135 34.88
Unskilled worker 19 4.91
Employee 3 0.78
8. Income (Month)
≥10000 197 50.90
<10000 190 49.10
Mean (±SD) 31010(±52390)
Median (min : max) 10000(0-300000)
9. Family’s income (Month)

≥50000 214 55.30
<50000 173 44.70
Mean (±SD) 96609(±96243)
Median (min : max) 100000 (0-500000)
19
10. Financial situation
Not Enough 56 14.47
Not Enough with debt 69 17.83
11. Living status
Alone 38 9.82
Spouse 62 16.02
Children/Relatives 285 73.64
Other 2 0.52
12. Family members living
<5 211 54.52
≥5 176 45.48
Mean (±SD) 4(±2.23)
Median (min : max) 4(0-12)
Prevalence of malnutrition among elderly in rural areas of Karen State, Myanmar.
Nutritional Status Number Percent (%) 95% confidence interval
No malnutrition (BMI ≥ 18.5) 278 71.83 1

Malnutrition (BMI < 18.5) 109 28.17 23.66-32.66
The result shows that 28.17% of elderly population was undernourished. The rest 71.83 %
was normal and over nutrition status.
Factors associated with Malnutrition
Logistic regression was performed to identify the factors associated malnutrition in

elderly. Significant factors in a bivariate analysis with p< 0.25 were included in a multiple
logistic regression analysis. Table 14 presented about the factors associated with malnutrition.
Under the socio demographic, female group were more prone to have malnutrition 2.7 times
than male elderly(OR=2.7,95%CI=1.58-4.51). Related with age group, more than 60 years
age group were likely to have malnutrition than those who less than 60 years age
(OR=1.6,95%CI=1.04-2.56).In Marital status, Unmarried /separate elderly were 1.89 times
than the married group to have malnutrition (OR=1.89, 95%CI=1.20-2.95).Related with per
capital income, elderly who have income less than 10000 Kyat were more likely to have
malnutrition than people who have income more 10000 Kyat (OR=2.12,95%CI=1.34-3.34).
Family income who got less than 50000 Kyat were more likely to have malnutrition than the
family who got more than 50000 Kyat (OR=1.61, 95% CI=1.03-2.51).Finally , malnutrition
happened in the group of elderly who live with family member less than 5 was 1.99 times
more than those who lived more than 5 family members (OR=1.99,95%CI=1.27-3.13).
20
Table 2. Odds ratios for each category of factors on malnutrition based on simple logistic
regression.
Crude
Factors. number % Malnutrition 95%CI p-value
OR.
Characteristic demographic factors.

1. Gender <0.001
Male 134 16.42 1
Female 253 34.39 2.7 (1.58 – 4.51)
2. Age of elderly (years) 0.032
60-69 232 24.14 1
≥70 155 34.19 1.6 (1.04 – 2.56)
3. Marital Status 0.005
Married 207 22.22 1
Unmarried /Separate 180 35.00 1.89 (1.20-2.95)
4. Educational attainment 0.246
Formal education (Primary +
Secondary) 149 24.83 1
No formal education 238 30.25 1.31 0.82-2.09
5. Religion 0.681
Christian 9 22.22 1
Buddhist 378 28.31 1.38 0.28-6.75
6. Occupation 0.98
None 224 28.1 1
Farmer, fisherman, Unskilled
worker 163 28.2 1.0 0.64-1.57
7. Income (Month) 0.001
≥10000 197 20.8 1
< 10000 190 35.8 2.12 1.34-3.34
8. Family’s income (Month) 0.035
≥50000 214 23.83 1
<50000 173 33.53 1.61 1.03-2.51
9. Financial situation 0.24
Enough 262 26.3 1
Not Enough 125 32.0 1.31 0.82-2.09
10. Living status 0.744
Children/Relatives 287 28.92 1
Spouse 62 24.19 0.78 0.41-1.47
Alone 38 28.96 1.001 0.47-2.11
11. Family members living 0.002
<5 211 21.8 1
≥5 176 35.8 1.99 1.27-3.13
0.691
12. Level of situation’s during the past 3
months
Unsatisfactory Oral Health 279 27.60 1
Satisfactory Oral Health 108 29.63 1.05 0.67-1.80
13. Level of Health Status 0.456
Good Health Status 348 27.59 1
Poor Health Status 39 33.33 1.31 0.64-2.65
0.487
21
Crude
Factors. number % Malnutrition 95%CI p-value
OR.
17. Level of Knowledge food

High (9-10) 75 22.7 1
Moderate (7-8) 251 29.5 1.42 0.78-2.61
Low (0-6) 61 29.5 1.42 0.67-3.08
Adjusted Odds ratios for each category of factors on malnutrition based on

multiple logistic regression.
After controlling cofounding factors, female elderly were more likely to have
malnutrition 2.7 times than those of male (Adj OR=2.7,95% CI :1.69-5.03).It was significant
at P-value <0.01. Elderly who live with more than five family members were 2.12 times than
elderly who live less than five family members(Adj OR=2.03, 95%CI: 1.20-3.42)(P value -
0.001). Moreover, monthly per capital income was strongly associated with malnutrition at
the P-value of 0.002 (Adj OR=2.03, 95%CI: 1.20-3.42).
Overall ,the prevalence of malnutrition was 28.2% (95% CI:23.66-32.66). The result
of this study shows that malnutrition is associated with gender, family member and
monthly per capital income. Elderly who live with more family members were more likely to
share food resources with their family members. Therefore, those three factors were strong
associated factors of malnutrition in elderly.
Table 3. Adjusted Odds ratios for each category of factors on malnutrition based on multiple
logistic regression
%
Crude Adj
Factors. number Malnut 95%CI p-value
OR. OR
rition
Characteristic demographic
factors.
1. Gender <0.01
Male 134 16.42 1 1
Female 253 34.39 2.7 1.92 1.69-5.03
2. Family members living 0.001
<5 211 21.8 1 1
>5 176 35.8 1.99 2.03 1.20-3.42
3. Income (Month) 0.002
≥10000 197 20.8 1 1
< 10000 190 35.8 2.12 2.07 1.29-3.31
22
Factors Adj 95%CI p-value

OR
Characteristic demographic factors.

1. Gender
Female 1.92 1.69-5.03 <0.01
2. Family members living
>5 2.03 1.20-3.42 0.001
3. Income (Month)MMK
< 10000 2.07 1.29-3.31 0.002
0 .50 1 2 3
Discussion
The prevalence of malnutrition in elderly was 28.2% (95% CI= 23.66-32.66).The
factor associated with malnutrition in bivariate analysis were gender, age , marital status,
education, financial situation, family members. In this study, the cut point of malnutrition was
less than 18.5 kg/m2, one of the study on elderly aged 60 and over shown that malnourished
in men (7.1%) and women (7.5%) in urban area whereas (17.7%) in men and (20.0%) in
women in rural area. (Luxi Ji a 2012)So Malnutrition was more higher in rural than urban
area. In Taiwan, the prevalence of malnutrition among elderly persons aged 60 to 80 years is
reported to be between 2% and 5%(4). In Malaysia, 38% of rural elderly people are found to
be malnourished according to BMI, using a cut-off of ,18.5Kg/m2.
After controlling the confounding factors, female were more likely to have
malnutrition 2.7 times (95%CI=1.58-4.51) than male and elderly who lived alone was more
chance to have malnutrition. This result was similar with the other result that older female
was found to be associated with risk of malnutrition than older man and live alone were risk
factors for malnutrition. (Söderhamn et al, 2012b). Unmarried and separate elderly were more
likely to have malnutrition than married person with the Odd Ratio 1.89 (P value- 0.005). In
case control study comparing health and nutritional values between widowed and married
participants reported lack of appetite as an important parameter associated with depression
and weight loss in widowed elderly people. Elderly who live with less than five family
members were less likely to have malnutrition than those who live with more family
members. However, nowadays is the urbanization, family members are not given the time to
their family and another reason is migration to another place for their livelihood. The other
study found out that cultural and socioeconomic factors in non-western countries influences
23
on nutritional status in elderly. There was a close relationship between family support and risk
of malnutrition.((al 2012))
The result of the present study focus on elderly who live in rural area because people
who live in rural area are left behind from any facilities compared to urban areas. Children
and elder person are vulnerable person due to the impact of under access to health services.
Most elderly in this study do not have formal education and no income. They have to depend
on their family members.
Overall, the result of this study shows that malnutrition is associated with gender,
family member and monthly per capital income. Female are more vulnerable to be
malnutrition. Then, elderly who live with more family members were more likely to share
food resources with their family members. So, Nutrition program should be encourage for the
elderly. There would be required to find out the ways how to care for the elderly in terms of
the traditional family, norms and values. To support more research, both qualitative and
quantitative, should be done to explore the other underlying problem among elderly group.
Strength of the study
This study was the very first study exploring the malnutrition status among elderly.
This baseline data can contribute to nationwide elderly health care program.
This study is cross-sectional study and it cannot explore the cause and effect related
with malnutrition .As the study conducted in rural area ,this study could not represent the
elderly in urban. This study could not get the information from the elderly who were ill and
hospitalized .
Conclusions
This cross-sectional analytical study was conducted at rural area of Kayin State to
describe the malnutrition situation among the elderly and its associated factors. A total of 387
elderly participated in this study. They were interviewed by structured questionnaire and
measured by anthropometric measurement. Being of female, elderly who live with more
family members and per capital income were associated with malnutrition. Invest nutrition
program , effective family care to elderly and promote the nutrition knowledge to elderly
should be done to prevent the malnutrition in elderly. There is a need to incorporate nutrition
assessment in routine practice and special attention should be given to their nutrition needs
24
Recommendations
The following recommendations were suggested for preventing the malnutrition in
elderly. The strategy may be differ from one community to other. There may be required a
tailored plan based on different culture and socioeconomic status.
Encourage nutrition program among the elderly
Counseling to elderly and their family members
Vitamin and mineral support to elderly.
Since the current study used only BMI to measure the nutritional status, further study
should be done using with another standard tool.
Further study should be done to know the malnutrition in elderly and its related diseases.
Acknowledgements:
I would like to express my most sincere gratitude to Associate Professor Dr.Wongsa

Laohasiriwong for her guidance and support throughout the study period. I also would like to
thank you all the members of Kayin Towship State Health Department and health staffs who
supports data collection .All contents of this material, including opinions, findings, discussion
and conclusions or recommendations, are those of the author and do not reflect any organization .
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8. cross-sectional, multi-centre study." Clinical Nutrition 469–476(29).
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among the oldest-oldq." Clinical Nutrition 31 922-926.
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25
12. Naing, M. M. (2010). "Quality of Life of the Elderly People in Einme Township
13. Irrawaddy Division, Myanmar." Asia J Public Health 2010; Asia J Public Health.
14. Rosy Mitri, C. Boulos1 and a. S. M. Adib2 (2016). "Determinants of the nutritional status of
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26
Socio-economic disparity and exclusive breastfeeding practices in Rural Kayin State,

Myanmar.
Sun Thit Wai 1 , Assoc.Prof. Benja Muktabhant 2
1
MPH Program Student, Faculty of Public Health, Khon Kaen University, Thailand.
2
การให้นมบุตรมีความสาคัญต่อการเจริ ญเติบโตและภูมิคุม้ กันของเด็ก อย่างไรก็ตามการเลี้ยงลูกด้วยนมแม่เพียง
อย่างเดี ยวสาหรับทารกในช่วง 6 เดื อนแรกของพม่ายังคงอยู่ในระดับต่ ามาก การทาความเข้าใจสถานการณ์ และปั จจัยที่
เกี่ยวข้องจะช่วยในการพัฒนามาตรการที่เหมาะสมเพื่อปรับปรุ งหนทางดังกล่าว โดยมีวตั ถุประสงค์เพื่ออธิ บายถึงวิธีปฏิบตั ิ
ในการเลี้ยงลูกด้วยนม ความชุกของการให้นมบุตรเพียงอย่างเดียวและความสัมพันธ์ระหว่างความแตกต่างทางเศรษฐกิจและ
สังคมกับดารเลี้ยงลูกด้วยนมแม่เพียงอย่างเดียวโดยมีการควบคุมตัวแปรแทรกซ้อนร่ วมด้วยในชนบทของรัฐคะยิน ประเทศ
พม่า. การศึกษาชุมชนแบบภาคตัดขวาง ได้ดาเนิ นการเก็บข้อมูลในรัฐคะยินจากผูด้ ูแลทารกจานวน 325 คน ที่ทาการดูแล
ทารกมีอายุอยูร่ ะหว่าง 6-24 เดือนโดยทาการสุ่ มแบบอาศัยความน่าจะเป็ น โดยวิธีการสุ่ มอย่างง่าย มาจานวน 2 อาเภอจาก
ทั้ง หมด 3 อ าเภอของรั ฐ ดังกล่ าว ท าการเก็ บข้อมู ลโดยแบบสัมภาษณ์ แบบมี โครงสร้ า ง โดยใช้ส ถิ ติก ารวิเคราะห์ การ
ถดถอยโลจิสติคอย่างง่ายและการวิเคราะห์การถดถอยโลจิสติคพหุกลุ่ม
ผลการศึ กษา พบว่า ความชุ กของการไม่เลี้ ยงลูกด้วยนมแม่อย่างเดี ยวคื อ 81.85% (95% CI= 77.63 ถึ ง 86.06)
หลังจากการควบคุมปั จจัยแทรกซ้อนด้วยวิธีการวิเคราะห์ตวั แปรหลายตัวแปรด้วยวิธีการขจัดออกคราวละตัวแปร ทั้งนี้
การศึกษาครั้งนี้ มี 3 ตัวแปรที่มีความสัมพันธ์กบั การไม่เลี้ยงลูกด้วยนมแม่เพียงอย่างเดียว ประกอบด้วยการเป็ นเจ้าของบ้าน
ของมารดา (AOR=3.12, 95%CI=1.53-6.35, p-value =0.02)สถานที่จดั ส่ ง (AOR=2.11, 95%CI=1.1 – 4.08, p-value =0.26)
และคุณประโยชน์ของนมปรุ งแต่ง(AOR=1.23, 95%CI=0.02 – 1.47, p-value =0.26) ไม่มีผลต่อการให้นมแม่เพียงอย่างเดียว
การให้นมลูกโดยนมแม่เพียงอย่างเดียวยังคงมีความครอบคุลมอยูใ่ นระดับต่ามาก โดยเฉพาะทั้งด้านเศรษฐกิจและสังคมและ
การรับรู ้ถึงประโยชน์ในการให้นมบุตรมีผลต่อการให้นมลูกเพียงอย่างเดียวอย่างแท้จริ ง
27
Abstract
Breast feeding is essential for child growth and immune. However, exclusive breast
feeding (EBF) for infant within the first six months in Myanmar is still very low. Knowing the
situation and associated factors should help for develop appropriate measures to improve this
practices. This study aims to describe the breastfeeding practices, the prevalence of EBF and
the association between socioeconomic disparity and EBF when control other covariates in
rural Kayin State, Myanmar.
Methodology: A community-based cross-sectional study was conducted in Kayin state. The
total of 325 cares givers of the 6-24 month-old children were selected from 2 out of three
districts of the state to join the study by using sample random sampling techniques. Structured
questionnaire interview was used for data collection. Simple and multiple logistic regressions
were used to identify the association.
Result: In this study, the prevalence of not exclusive breastfeeding 81.85 % (95% CI: 77.63 -
86.06). After controlling the confounding factors with backward elimination multivariate
analysis, three variables were significantly associated with not exclusive breastfeeding were
house ownership of mothers (adj. OR=3.12, 95% CI=1.53-6.35, p-value=0.02), place of delivery
(adj. OR=2.11, 95% CI 1.1 - 4.08, p-value= 0.26) and reason of formula milk (adj. OR=1.23, 95% CI
0.02 - 1.47, p-value=0.26) had not exclusive breastfeeding.
Conclusion: There was very low coverage of exclusive breast feeding, both socioeconomic and
perception of breast feeding benefit had influences on exclusive breast feeding practices.
Key words: exclusive breastfeeding, caregivers
28
Introduction
The United Nations Children's Emergency Fund (UNICEF) recognized breastfeeding
is nature’s way of nurturing the child, creating a strong bond between the mother and the child
by developing baby’s trust and sense of security. It gives all the energy and nutrients that the
infant needs for the first months of life. Children usually get diarrhea and pneumonia because
of inadequate breastfeeding. In developing countries, exclusive breastfeeding reduce less than
5 years old children mortality rate by 13%.
Globally, prevalence of EBF of infants was 30% . An estimated of exclusive
breastfeeding of infants are 49% in Southeast Asia, the highest was in Cambodia (85%) and
whereas the lowest is 15% (WHO, 2017). The situation in Myanmar is lower than other countries
and the proportion of EBF in Rural area was about 23.6 % (UNICEF, 2011).
Exclusive breastfeeding can be reduced the child mortality rate because it protects the
child from suffering malnutrition and communicable diseases also. According to statistics of
Kayin State in 2010, only 9.4% of infant get exclusively breastfeeding which is relatively low
when compared with the national situation. Socio- economic factors including mother age,
mother education, mother occupation, family income, marital status and others factors were
described as influencing factors of EBF practice.
Objective
To describe the breastfeeding practices, the prevalence of EBF and the association
between socioeconomic disparity and EBF when control other covariates in rural Kayin State,
Myanmar.
Methodology
Study design
The community based cross-sectional study was conducted in Kayin State from July to
August, 2017. The study involved 325 mothers or caregivers pairs children identify the
magnitude of prevalence of EBF in Kayin State mother and to find out the association between
socio-economic disparity and EBF. Inclusion criteria included s’ mother, who had lived in the
study site at least 1 consecutive years and who were willing to participate. The exclusion criteria
29
included those were admission hospital of child illness and orphans. Socio-economic factors,
delivery and child health, breastfeeding practices, environmental influences and knowledge &
attitude of mothers or caregivers were collected face to face interview with mothers or
caregivers by using semi-structured pre-tested questionnaire after receiving informed consent.
The semi-structured questionnaires were pretested with 30 infant mothers in Mawlamyine.
Operational and term definitions

Exclusive breastfeeding (EBF)
Exclusive breastfeeding is that the mothers give her infants only breast milk from
birth to reach six months, and also avoid others food such as water, juice, honey, animal milk,
rice, bread, fruit etc. But minerals, vitamin and medicine (ORS) can be given.
Partial feeding
Infants who were fed breast milk only without additional foods or drinks except
water were considered to be exclusively breastfed, while those who were fed formula only
without additional foods or drinks except water were defined as formula fed
Complementary feeding
It is defined as the process starting when breast milk alone is no longer sufficient
to meet the nutritional requirements of infants, and therefore other foods and liquids are needed,
along with breast milk.
Sampling Method
All wards and RHCs were listed as sampling frame. Simple random sampling
using lottery method.
30
Kayin State (4 Districts & 7 Townships)

Simple random sampling
3 Townships
10RHC (20 villages)

Systematic random sampling
325 children with mother or caregiver

If some household has
caregiver pair infant more
than one, use random sampling
325 sample caregiver or
mothers pairs infant
Figure 1 The sampling procedure flow chart
Socio-economic factors
This analysis was adjusted for baseline variables and showing a bivariate relationship
with exclusive breastfeeding such as mothers ages, mothers house ownership, fathers
education, fathers occupation, child sex, place of delivery, give the reason of formula milk and
decision making on EBF for the children, All analyses were performed using Stata version 10.0
all test statistics were two-sided and a p-value of less than 0.05 was considered statistically
significant.
31
Result
Table 1a. Baseline socio-economic characteristics of children with mothers pairs (n=325)
Characteristics Number Percentage (%)
Mother age (years)
<19yrs 8 2.46
20 – 24 yrs 62 19.08
25 – 29 yrs 106 32.62
30-40 yrs 122 37.54
≥ 40 yrs 27 8.31
Mean (±SD) 29.92 (±6.624)
Median (min : max) 29 (18:46)
Education level (mother)

Primary level 170 52.31
Secondary level 121 37.23

High school & above 16 4.92
Graduate 1 0.31
Occupation (mother)
Housewife 235 72.31
Other (work in Bangkok) 57 17.54

Farmer, fisherman 7 2.15
Business 4 1.23
Types of caregiver
Mother 261 80.31
Grandmother 54 16.62
Relative 10 3.08
32
Education level of caregiver

Primary level 210 64.62
Secondary level 71 21.85

Bachelor or equivalence 5 1.54
Higher than bachelor degree 1 0.31
Occupation of caregiver /father
None 17 5.23
Student 2 0.62

Employee 9 2.77
Business 7 2.15
Other (work in Bangkok) 83 25.54
Family income
< 150,000 MMK 133 40.92
150,000-350,000 MMK 176 54.15
> 350000 MMK 16 4.92
Mean (±SD) 177876.9 (±123211.1)
Median (min : max) 150000 (50000:1500000)
House ownship
Owner 200 61.54
Stay with other 125 38.46
33
Table 1b. Baseline characteristics of delivery & child health status and environmental
influences with mothers pairs children (n=325)
The sex of child

Male 160 49.23
Female 165 50.77

Health facility 66 20.31
Home 259 79.69
Types of delivery
Vaginal delivery 309 95.08
Caesarean section 13 4.00
Forceps/ vacuum 3 0.92
Influences in decision marker

Elderly female in family 103 31.69
Husband 149 45.85

Peer person 36 11.08
Health person 33 10.15
Community 4 1.23
Table 2. Odd ratio for each category of factors on EBF of children based on sample logistic
regression
Characteristics Number %notEBF Crude 95% CI P-value

OR
Socio-economic factors
Mother age (years) 0.095
< 24 70 90.00 2.46 1.03-5.9
25-29 106 81.13 1.18 0.63-2.2
30 or more 149 78.52 1 1
34
OR
Education level (mother) 0.235
No formal education:& primary 187 79.68 1 1
Secondary level & above 138 84.78 1.42 0.79 to 2.55
Unskilled workers & daily 33 87.88 1.81 0.61 to 5.41

workers
Education level of caregiver 0.036
No formal & primary 229 79.04 1 1
Secondary level & above 96 88.54 2.05 1.01 - 4.14
Occupation of caregiver /father 0.202
None & Student 19 73.68 1 1
Unskill workers& Employee 128 77.34 1.22 0.41 - 3.67
Farmer, fisherman 82 82.93 1.73 0.54 - 5.60
Others (work in Bangkok) 83 87.95 2.61 0.77 - 8.79
Business & Government staff 13 92.31 4.29 0.44 - 41.95
Family income 0.262
< 150,000 MMK 133 78.95 1 1
≥ 150000 MMK 192 83.85 1.38 0.79to 2.44
House ownership 0.008
Owner 200 77.50 1 1
Stay with other 125 88.80 2.30 1.2 to 4.39
The sex of child 0.086
Male 160 78.13 1 1
Female 165 85.45 1.65 0.93 to 2.92
Place of delivery 0.038
Health facility 66 72.73 1 1
Home 259 84.17 1.99 1.06 to 3.77
35
OR
The reason of formula milk 0.207
Could not live with child 68 76.47 1 1

& healthy & convenience
Others (couldn’t afford) 257 83.27 1.12 0.95 to 1.30
Give the reason of other food within 6 0.504

months
Common practice & Others 147 80.27 1 1
(mother could not live with child)
Healthy & inadequate breast milk 178 83.15 1.21 0.69 to 2.13
of mother & Advise by
family members
After adjusting mothers ages, mothers educations, fathers education, fathers

occupations, house ownership, child sex, place of delivery, give the reason of formula milk are
strong predators for exclusive breastfeeding.
Table 3.Odd ratio for each categorical factors on exclusive breastfeeding on multiple logistic
regression
Factors Odd ratios 95%CI P value
Knowledge of danger 12 5.6-26.6 <0.001

signs
Education of 5 1.8-13.4 <0.001

respondents
Education of 5 1.6-15.6 <0.001
husbands
0 1 5 10 15 20 25
36
Discussion
In this study, we found the prevalence of exclusive breastfeeding under six months age
was 18.15% and the prevalence of partial feeding was 81.85% and mothers feed colostrum to
their children and most of the mother initiated breastfeeding within one hour of after birth. Not
exclusive breastfeeding rate was low in this study because of socio-economic disparity.
This study, I found that the prevalence of not exclusive breastfeeding under six months
age was 81.85% and mothers feed colostrum to their children and most of the mother initiated
breastfeeding within one hour of after birth. EBF practice was significantly associated with
house ownership and it show that mothers with stay other family members such as parents,
relatives that had not exclusive breastfeeding 3.1 2times (95%CI=1.53 to 6.35, p-value=0.02) than
house ownership of mothers. This finding is that mothers are suffering influences of family
members were less likely to feed exclusive breastfeeding within 6 months. Another study, one
of the primary barriers to exclusive breastfeeding were that husbands, and grandmothers
believed that exclusive breastfeeding was not sufficient for babies and solid foods and water
were necessary.
In this study, mothers who delivery at home had not exclusive breastfeeding 2.11 times
(95%CI=1.1 to 4.08, p-value= 0.026) than health facility delivery. Another study mothers who
delivered in home had not EBF than health facility of delivery mothers. Mothers with
Institutional delivery were more likely to give exclusive breast feeding to their children than
mothers who delivered at home.
The good approach could be used to improve exclusive breastfeeding’s knowledge,
attitude, practice in Rural Kayin State and also addressing cultural and elderly and husband’
influences. The health supporter must be explain the mothers and family members such as
mother, grandmother, mother-in-law, husband and peer person to information about how the
important of exclusive breastfeeding and advantage of breast milk.

Because of cross-sectional analytical nature of this study, it was not allowed the cause
and effect relationships between various factors and breastfeeding status. This study was
37
conducted among caregivers who having 6-24 months of children living in rural area of Kayin
state and it could not generalize the migrant mothers. This study was totally dependent on the
participants’ answer of structured questionnaires. Memory recalls and interviewer relationship
bias while assessing on determinants factors; therefore bias could not be excluded.
Conclusion
This cross-sectional analytical study was conducted at 20 villages in 10 Rural Health
Centers of 3 townships from Kayin State, Myanmar. The study objects are to describe the
prevalence of exclusive breastfeeding and to identify association between socio-economic
disparity and exclusive breastfeeding practice. A total of 325 mothers or caregivers were face
to face interviewed with pretest structured questionnaires. The study result described that
81.85% of children had not exclusive breastfeeding.
In this study, < 24 years of mothers were more likely not EBF than elderly mothers for
2.46 times and high school & above mothers were not exclusive breastfeeding 1.15 times than
lower educational mothers. Daily workers & unskilled workers had not exclusive breastfeeding
1.76 times than housewives mothers. Higher family income of children had not exclusive
breastfeeding 1.44 times than lower family income. Stay with other family members had not
exclusive breastfeeding 3.1 2 times (95%CI=1.53 to 6.35, p-value=0.02) than ownership mothers.
Female children had not exclusive breastfeeding 1.6 times than male and Child age and birth
order were association with not found. Mothers who gave birth in home delivery were 2.11
times (95%CI=1.1 to 4.08, p-value= 0.026) more likely to have not exclusive breastfeeding than
those who gave birth at health facility. Common perception in community infant formula was
feed within 6 months in problem & good & others not EBF 1.25 times than not good perception
of mothers.
The study comprised of 325 mothers or caregivers who had a child within 6-24 months
of age. In this study, house ownership, place of delivery and give the reason of formula milk
were associated with the prevalence of exclusive breastfeeding. A highly significant association
38
of house ownership was found that mothers stay with others family members had not EBF of 3
times (95% CI 1.53 to 6.35, p<0.02) than ownership mothers
Recommendation
The following recommendations were suggested for improving exclusive
breastfeeding practice for the children. Improving the family members’ knowledge, information
access, breastfeeding’s advantage, place of delivery, knowledge of feeding practice are very
important to increase exclusive breast feeding rate to the future. Actually this factors made the
children to increase the prevalence of exclusive breastfeeding rate. Therefore we suggested the
health supporter who should be given the advantage of breastfeeding and disadvantage of
formula milk to the pregnant mothers and about safe delivery during the antenatal care sessions.
Family members, peer person and community all of them should be participated to access
exclusive breastfeeding within a supported environment where their knowledge and attitude,
their concerns and cultural are represented. The interaction would empower them to make
changes in their feeding practice and behaviors also. A further study should be conducted to
describe the exclusive breastfeeding status and predict factors of migrant children a qualitative
study was also recommended for more understanding about favors and barriers to complete
exclusive breastfeeding in this area.
Acknowledgement
We would like to acknowledge Khon Kaen University institute of public health for
funding this research. I would like to express my gratitude to KKU for giving ethical clearance.
And I would like to express our ministry of health and support of Kayin State and representative
villagers. We would like to express our thanks to the mothers or caregivers who participate in
this study living Rural Kayin State, in Myanmar.
39
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43
Overweight and obesity and its associated factors among Myanmar

personnel in nonprofit health organizations in Tak province,
Thailand
Aye Khin1, Paricha Nippanon2, Wongsa Laohasiriwong2
1
M.P.H. Student, Faculty of Public Health, KhonKaen University, Thailand
2
Faculty of Public Health, Research and Training Center for Enhancing Quality of Life of Working
Age People KhonKaen University, Thailand
การศึกษาครั้งนี้ มีวตั ถุ ประสงค์เพื่อศึกษาความชุ กและปั จจัยที่มีความสัมพันธ์กบั ภาวะน้ าหนักเกินและ

ความอ้วนของบุคลากรพม่าในจังหวัดตากประเทศไทย ภาวะน้ าหนักเกิ นและโรคอ้วนเป็ นเรื่ องน่ าตกใจเพราะ
ความท้าทายด้านสาธารณสุ ข เป็ นประจาทุกปี มีผเู ้ สี ยชีวติ อย่างน้อย 2.8 ล้านคนที่มีภาวะอ้วนและโรคอ้วนทัว่ โลก
มีการศึกษาจานวนจากัด เพื่อหาปั จจัยที่เกี่ยวข้องกับการมีน้ าหนักเกินและโรคอ้วนในกลุ่มพม่าจานวนทั้งสิ้ น 312
คนได้รับการคัดเลือกโดยใช้แบบสุ่ มตัวอย่างแบบหลายขั้นตอนและมีสัดส่ วนกับขนาดของบุคลากรสาธารณสุ ข
ในจังหวัดตาก เก็บรวบรวมข้อมูลโดยใช้แบบสอบถามที่มีโครงสร้างและวิเคราะห์โดยการวิเคราะห์ถดถอยลอจิ
สติกแบบง่ายและแบบหลายขั้นตอน
ผลการศึกษา พบว่า มีจานวนทั้งสิ้ น 312 คน เป็ นหญิง (58.33%) อายุเฉลี่ย 30.11 ±7.75 ปี ความชุกของโรคอ้วนและ
น้ าหนักเกิน (BMI ≥ 23 กก. / ตร.ม. ) 47.12% ของพม่าโดย 95% CI = 41.54 - 52.68 หลังจากควบคุมปั จจัยอื่น ๆ พบว่าประชากร
ที่อาศัยอยูใ่ นเมืองมีความสัมพันธ์กบั ภาวะน้ าหนักเกินและโรคอ้วนสูงกว่าอยูใ่ นชนบท (Adj. OR = 4.05, 95% CI = 2.43 ถึง 6.75,
p-value = <0.001) แต่งงาน / ม่าย / แยก มีอตั ราการมีน้ าหนักเกินและโรคอ้วนสู งกว่า 3.19 เท่า (Adj. OR = 3.19, 95% CI = 1.92
ถึง 5.31, p-value = <0.001)
โดยสรุ ป เกือบครึ่ งหนึ่งของพม่ามีน้ าหนักเกินและเป็ นโรคอ้วนประชากรที่อาศัยอยูใ่ นเมืองและ

สถานภาพสมรสมีความสัมพันธ์อย่างมากกับโรคอ้วนและโรคอ้วน สิ่ งแวดล้อมและการแทรกแซงที่สนับสนุน
รู ปแบบชีวิตที่มีสุขภาพดีอยูใ่ นความต้องการ
44
Environmental Health Nutrition 04
Abstract
Introduction: Overweight and obesity was alarming as a public health challenges. Annually,
at least 2.8 million adults die relating with overweight and obesity e worldwide. A limited
number of studieswere done to determine overweight and obesity associated factors among
Myanmar personnel.
Objective: This study aimed to describe the prevalence and factors associated with overweight
and obesity among Myanmar personnel in Tak province, Thailand.
Methodology: A total of 312 Myanmar personnel were selected by using multistage random
sampling with proportional to size of the health personnel in nonprofit organization population
in Tak Province, Thailand. Data was collected by using structured questionnaires and analyzed
by simple and multiple logistic regressions.
Result: The majority of 312 Myanmar personnel were women (58.33%) with the average age of
30.11 ± 7.75 years old. The prevalence of overweight and obesity (BMI ≥ 23 kg/m2)was
observed in 47.12% of Myanmar personnel with 95% CI =41.54 - 52.68. After controlling the
other factors, urban residence were found strongly associated with overweight and obesity than
lived in rural areas ( Adj. OR= 4. 05, 95% CI= 2. 43 to 6. 75, p- value = <0. 001) , married/
widow/separated people had 3.19 times higher odds of overweight and obesity than the single
(Adj. OR= 3.19, 95%CI= 1.92 to 5.31, p-value = <0.001).
Conclusion: Almost half of Myanmar personnel were overweight and obesity. Urban resident
and marital status were strongly associated with overweight and obesity. Environment and
interventions that advocate healthy life style are in need.

INTRODUCTION
Overweight and obesity is increasing and alarming as a public health challenges

worldwide. Globally, more than 1.9 billion (39%) persons were overweight and more than 600
million (13%) adults over 18 years old were obese in 2014. Annually, at least 2.8 million people
are dying as a result of overweight and obesity worldwide.[1, 2] The highest prevalence of
overweight and obesity in South East Asia is in Malaysia 14% followed by Thailand 8.8%.
According to a previous studies, when using the Asian BMI cut point of (≥ 23 kg/m2), 35.0% of
men and 44.9% of women are overweight and obese in Thailand [3]
Furthermore, the higher trend of overweight and obesity is also found among 73% of
health care workers in south Africa [4] and 62.2% of Neisseria nurses in Akwa lbom State [5].
According to national STEPS Survey in Myanmar, nearly 22% of the men and 23.07% of the
women are overweight (BMI ≥25 kg/m2) and a little more than 8.4% of women, 4.3% of men of
respondents are obese (BMI ≥30 kg/m2 ). The highest percentage of overweight adults was
seen in the 45-54 age group [6]. One study found a 17.73% overweight and obesity rate in Tha
Song Yang district on Thai Burma border area [7]. But there is no study availiable in myanmar
personnel in Tak province and also in myanmar.
This study aimed to describe the prevalence of overweight and obesity and to
determine factors that affected to overweight and obesity among Myanmar personnel in Tak
province, Thailand
46
MATERIALS AND METHODS
Study design
A community-based cross-sectional study was conducted in Tak province, Thailand. A total
of 312 Myanmar personnel of who working in nonprofit health organizations were selected by
using multistage random sampling with proportional to size of the population in Tak Province,
Thailand. Data was collected after getting signature on the prepared consent forms from all
voluntary participants. Then interview were started with structured questionnaires by face to face
interview and multiple logistic regressions was used for data analysis. It took time around 20- 30
minutes per one interviewee.
Study outcome
The primary research outcome was overweight and obesity (dichotomous outcome) it was
defined base on the Asian BMI cut point in this study. Overweight is a person weighting more than
they should (normal optimal). Overweight is defined as an Asian BMI cut off points of 23.0 to 24.9
kg/m2 and also known as pre-obesity. Obesity mean weight gain much more than overweight and
it can be defined as (BMI ≥ 25 kg/m2) by an Asian populations [8]. This study used weight and height
measurement to calculate the BMI and if BMI ≥ 23 kg/m2 were classified as overweight and
obesity.
Table 1 Proposed classification of weight by BMI in adult Asians

Classification BMI (kg/m2)
Underweight <18.5
Normal 18.5 to 22.9
Overweight 23 to 24.9
Obesity ≥ 25
47
Methods for demographic characteristics of the participants were described using frequency
and percentage for categorical data and mean and standard deviation for continuous data. Methods
for answering the research question(s): The rate was calculated using the number of Myanmar
personnel of who reported overweight and obesity as the numerator and the total number of
Myanmar personnel who responded to the questionnaire as the denominator. The 95% confidence
interval (CI) of the rate was computed based on normal approximation to binomial distribution. To
investigate factors that affect overweight and obesity, odds ratios (ORs) and their 95% confidence
intervals (95%CIs) were estimated using multiple logistic regression for survey sampling.
All analyses were performed using Stata version 13.0 and test statistics were two-sided and
a p-value of less than 0.05 was considered statistically significant. This study was approved by Khon
Kaen University Ethics Committee (KKUEC) for Human Research with the reference number
HE602219.
RESULTS
Among the respondents, percentage of female in the sample slightly exceeded than males
(58.33% vs 41.67%) and the mean age was 30.11 with the standard deviation (SD: ± 7.75)years old. In
marital status, single group 50.96% show slight more than married 45.51% and 3.53% in divorced,
widowed, separate group. Majority, 62.50% of them have family income lower than 10000 THB per
month and only 12.82% have family income more than 15000 THB per month. The others variable
see details in the table.
48
Table 2. Demographic characteristics presented as percentage unless specified otherwise
1. Gender
Female 182 58.33
Male 130 41.67
2. Age (complete years)
< 25 74 23.72
25 to 39 195 62.50
≥ 40 43 13.78
Mean ±SD: 30.11 ± 7.75, Median (min : max): 28 (19 : 58)
3. Marital Status
Single 159 50.96
Married/ 142 45.51
4. Residence
Rural 166 53.21

Urban 146 46.79
5. Occupation
Ordinary staff 233 74.68
Management level staff 57 18.27
Others 22 7.05
6. Average Income (baht/ Month)
< 5000 130 41.67
5000 – 7999 134 42.95
≥ 8000 48 15.38
49
Mean ±SD: 5696.39 ±4381.43, Median (min : max): 5000 (500 : 50000)
7. Family’s income (baht/ Month)
< 10000 195 62.50
10000 – 14999 77 24.68
≥ 15000 40 12.82
Mean ±SD: 9211.37 ±7021.35, Median (min : max): 8000 (2000 : 80000)
8.Level of attitude on nutrition
Poor attitude (< 17 Score) 1 0.32
Indifferent attitude (17 - 23 Score) 125 40.06
Good attitude (24-30 Score) 186 59.62
Mean (±SD) 23.87 (± 2.55), Median (min : max)24 (15 : 28)
9.Level of environment
Low (15 to 25 Score) 129 41.35
Moderate (25 to 34) 143 45.83
High (≥ 35 Score) 40 12.82
Mean (±SD) 26.64 (± 6.87), median (min: max) 26 (15-45)
Prevalence of overweight and obesity among Myanmar personnel (n= 312)
Among the respondents, 50.64% of the Myanmar personnel in normal weight, 18.59% were
overweight and 28.53% with obese. According to this study, prevalence of overweight and obesity
were found out 47.12% of Myanmar personnel in Tak province, Thailand with the 95%CI= 41.54:
52.68.
50
Table 3.Number and percent of nutritional status
Classification BMI (kg/m2) Number Present (%)
Underweight <18.5 7 2.24
Normal weight 18.5 to 22.9 158 50.64
Overweight 23 to 24.9 58 18.59
Obesity ≥ 25 89 28.53
Table 4.Prevalence of overweight and obesity
Percent 95% interval

Overweight and obesity Number
(%) conference
Overweight and obesity 147 47.12 41.54 : 52.68
(BMI ≥ 23kg/m2)
Factors associated with overweight and obesity among Myanmar personnel in Tak province
In simple logistic regression, the respondents, who age between 25 to 39 years aged group
presented an association with 2.92 times more chance of having overweight and obesity (OR=2.92,
95%CI: 1.62 to 5.29) and age 40 years have 6.68 times more chance to get overweight and obesity
than reference group (OR=6.68, 95%CI: 2.90 to 15.38) and p-value= <0.001. Who have family history
have 49% more chance to be overweight and obesity than who have no family history by crude (OR
= 1.49, 95%CI: 0.88 to 2.51) and p-value = 0.133.
Personal behavior factors of respondents were described in Table 5. Cronbach’s alpha
coefficient of behavioral factors = 0.815. Total nutritional behavioral scores range from (0 to 160)
51
scores and used Kiess’s theory for grouping into three group. The nutritional behavior (mean ±SD)
was 41.26 (±12.66).Majority 85.26% of respondents have good level (<53 scores) and (14.74%) of then
in moderate level (≥ 53 to 107 scores) and poor level (scores ranging from 107 to 160) but none of
Myanmar personnel in this level.
After controlling the other factors, there were two factors shown the strongest associated
with overweight and obesity, which included urban resident and married Myanmar health
personnel. In this study, who lived in urban area were 4.05 times higher odds of overweight and
obesity compared to who did not (Adj: OR = 4.05; 95%CI: 2.43 –6.75; p < 0.001) (Table 3). The second
strongest factor was who have been married or currently married have 3.19 times higher odds of
overweight and obesity than single (Adj. OR = 3.19; 95%CI: 1.92 –5.31; p < 0.001). Others factors that
were significant factors, p<0.05, associated with the overweight and obesity included poor eating
habit and who live in poor environment.
Table. 5. Shown the crude and Adjusted Odds ratios for each category of factors on overweight
and obesity based on multiple logistic regression

%
Crude Adj
Factors Number O/w 95%CI P-value
OR OR
Obesity
1.Marital Status <0.001
Single 159 30.82 1 1

Married / Divorced/ 153 64.05 4 3.19 1.92 to 5.31
Widowed/Separated
2.Residence <0.001
Rural 166 29.52 1 1

Urban
146 67.12 4.88 4.05 2.43 to 6.75
52
%
Crude Adj
Factors Number O/w 95%CI P-value
OR OR
Obesity
3.Nutritional behavior 0.026
Good (<53) 266 44.74 1 1

Moderate (≥ 53) 46 60.87 1.92 2.31 1.11 to 4.81
4.Environmental Level 0.045
High 183 42.08 1 1
Low 129 54.26 1.63 1.69 1.01 to 2.82
DISCUSSIONS
Nearly half (47.12%) of Myanmar health personnel were found with overweight and obesity
out of 312 participants, and quite similar with the previous studies among California nurses were
found 48.7% [9]. But high prevalence of overweight and obesity were found in 62.6% among
Neisseria nurses from Akwa lbom State [5] and 75% of health care workers from South Africa were
.[10]
Most of the participant 53.21% from rural area were participate in to this study. In previous
literature also mention of 63. 7% from rural area in south Africa. [ 11] . Nearly one third of the
respondents found eating fatty meat more than 3 days a week. Most of the urban residence, their
eating habit also change and do not have enough time to prepare home food and it lead to increase
of fast food consumption and adoption unhealthy lifestyle and physical activity which was also
mentioned in the previous study. [12]
53
This study is provided great acknowledge to all health personnel from nonprofit health
organizations existing along Thai – Myanmar border. This cross sectional study provide statistical
evidence of an association with overweight and obesity among Myanmar personnel. In addition,
this is the very first research on overweight and obesity among health personnel of Myanmar who
are working at nonprofit organization in Thai – Myanmar border.

This cross sectional study could be defended as the screening of potential risk factors of
overweight and obesity prevalence with the highest statistically significant level. It can be some
information bias distort the findings.
Conclusions
Almost half of Myanmar personnel were overweight and obesity. Urban resident and
married Myanmar personnel were strongly associated with overweight and obesity. Therefore,
environment and intervention that advocate healthy lifestyle are in need.
Recommendations
The recommendation are to improve awareness of eating habit within organizations or
community. Conducting to increase disease prevention and health promotion among health
personnel in border area include, balancing on the daily dietary intake, promoting and create space
to do the physical exercise. Provision of supportive measure for obesity prevention could be helpful
to achieve the reduction of overweight and obesity and lead to decrease non-communicable
diseases. Organizational policy and principle should be set with the consideration on the health
promotion aspect.
54
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Economic Factors in Algerian and Tunisian Adults. 2013.
55
Crystalline silica dust exposure and health impact among stone mortar
workers in Phayao, Thailand.
Sakesun Thongtip1, Penprapa Siviroj2, Anawat Wisetborisut3, Athavudh Deesomchok4,

Tippawan Prapamontol5
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Department of Community Medicine, Faculty of Medicine, Chiang Mai University
3
Department of Family Medicine, Faculty of Medicine, Chiang Mai University
4
Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
5
Research Institute for Health Sciences, Chiang Mai University
การสัมผัสฝุ่ นซิลิกาจากการทางาน ในโรงงานผลิตครกหิ น จะเพิ่มความเสี่ ยงต่อการเกิดโรคระบบทางเดินหายใจ,

โรคซิ ลิโคสิ ส และโรคมะเร็ งปอด เนื่ องจากการสัมผัสฝุ่ นละอองขนาดเล็กและฝุ่ นซิ ลิกาในพื้นที่ ทางานส่ งผลกระทบต่อ
ความเสี่ ยงสุ ขภาพและคุณภาพชีวติ นอกจากนี้ โรคซิ ลิโคสิ สเป็ นโรคที่ไม่สามารถรักษาให้หายขาดได้ แต่การตรวจพบก่อน
จะเกิ ดโรคเป็ นสิ่ งจาเป็ นที่ สามารถช่วยในการวินิจฉัยและทานายโรคได้ ดังนั้น สิ่ งที่ สาคัญคือการศึ กษาการรับรู ้คุณภาพ
อากาศของผูป้ ระกอบอาชีพทาครกหิ น เพื่อสามารถป้ องกันการเกิดโรคและอันตรายต่อชีวิตได้ วัตถุประสงค์ เพื่อประเมิน
การสัมผัสฝุ่ นซิ ลิกาและการรั บรู ้ คุณภาพอากาศในในผูป้ ระกอบอาชี พทาครกหิ น จังหวัดพะเยา วิธีการดาเนิ น การวิจัย
สาหรั บการศึ กษาวิจยั นี้ เป็ นแบบภาคตัดขวาง ซึ่ งศึ กษาในตาบลบ้านสาง ประกอบด้วยโรงงานผลิ ตครกหิ นจานวน 15
โรงงาน ประชากรศึ กษามี จานวนทั้งหมด 57 คน และมี อายุม ากกว่า 18 ปี การสัมภาษณ์ การรั บรู ้ คุณภาพอากาศโดยใช้
แบบสอบถามการรับรู ้คุณภาพอากาศ ผลการวิเคราะห์ขอ้ มูลโดยใช้การอธิบายเชิงพรรณนา
ผลการศึกษาพบว่า ส่ วนใหญ่ของกลุ่มตัวอย่างเป็ นเพศชาย (91.2%) ที่มีอายุเฉลี่ย 47.0 (SD = 13) ปี โรงงานผลิต

ครกหิ นทั้งหมดเป็ นระบบเปิ ดและเป็ นแรงงานนอกระบบ โรงงานส่ วนใหญ่ยงั ไม่มีสวัสดิการให้ผา้ ปิ ดจมูกกับผูป้ ระกอบ
อาชีพทาครกหิ น และมีเพียง 47.4 % ที่ใช้ผา้ ปิ ดจมูกทัว่ ไป และมีเพียง 15.8% ที่ใช้หน้ากาก N95 นอกจากนี้ ยังพบว่ามีเพียง
33.3% ที่มีความตระหนักถึงการสัมผัสฝุ่ นซิ ลิกา พนักงานส่ วนใหญ่ 64.9% มีปัญหาระบบทางเดินหายใจ อาการของระบบ
ทางเดินหายใจที่ พบ คือ ไอ (45.6%), ระคายเคืองตา (40.4%), มีเสมหะ (33.3%) และ ไอและมีเสมหะ (31.6%).ตามลาดับ
สรุ ปผลการศึ กษา ผูป้ ระกอบอาชี พทาครกหิ นยังขาดการรับรู ้คุณภาพอากาศและการป้ องกันตนเองจากโรคระบบทางเดิ น
หายใจ และยังพบปั ญหาของโรคระบบทางเดินหายใจในผูป้ ระกอบอาชีพทาครกหิ น
56
Abstract
Introduction: Occupational exposure to crystalline silica dust in stone mortar factories
increased the risk of respiratory disease, silicosis and lung cancer. Exposure of Particulate
matter and silica dust in workplace effects to health risk and quality of life. Silicosis is disease
that no effective treatment is available but early detection with biomarkers are essential to
detect and can help diagnosis and prognosis of the disease. Therefore, the most importance
thing is the air quality perception of people to self-prevention from disease and injury in life.
Objective: To assess crystalline silica dust exposure and air quality perception on crystalline
silica dust among stone mortar workers in Phayao province.
Methodology: This cross-sectional study was conducted in a Sub district with had fourteen
the stone mortar factories. A total of 57 individuals aged 18 years and over wee recruited to
complete a structured questionnaire interview. Air quality perception was measured using the
air quality perception questionnaire ( AQP) . Descriptive statistics were used to describe the
exposures.
Result: Almost all of the sample were male (91.2%) with the average 47.0 (SD = 13) years. All
of the factories were open system with no occupational system. All of them were informal
worker. The factories had not provided mask of these workers. Only 47.4 % wearing general
mask and 15.8% wearing N95 mask while working all times in the factories. Only 33.3% was
awareness of crystalline silica dust exposure. Almost workers had respiratory tract problems
(64.9% ) during the past one week. The most common symptoms were coughing (45.6% ), eye
irritation (40.4%), phlegm (33.3%) and cough with phlegm (31.6%).
Conclusion: The stone mortar workers had poor perception and practices on respiratory tract
protection. Respiratory tract problems were common among them.
57
Introduction
Occupational exposure to crystalline silica dust in stone mortar industries which risk
to respiratory disease, silicosis and lung cancer. Moreover, Thailand found silicosis patients
total 69 patients in 2015 (1) and the prevalence of radiographic change was 8.9% (68 subjects) in
stone carving workers in 2014. (2) Exposure of Particulate matter and silica dust in workplace
effects to health risk and quality of life. (3) (4) (5) However, silicosis is disease that no effective
treatment is available but early detection with biomarkers are essential to detect and can help
diagnosis and prognosis of the disease. (6) (7)
Air quality perception in developing countries should recognize the health risks of
local context in order to risks to health is the most important things to preventing disease and
injury in life. (6) (7) Due to crystalline silica dust in both working and living environments have
(8) (9)
effect to physical health and mental health of workers and residents. The health risk
perception level in high had associated people affected from particulate matter (PM10), those
susceptible to air pollution effects (respiratory and/or allergic diseases group and depressive
group). (10)
Therefore, Risk factor levels in the population are the first main data input in
estimating potential impact health and behavior changes of mortar stone workers. However,
few studies have evaluated air quality perception among stone mortar workers with silica
content materials such as sandstone. The objective of this paper is to crystalline silica dust
exposure and air quality perception on crystalline silica dust among stone mortar workers in
Phayao province
Objective
This study aimed assess crystalline silica dust exposure and air quality perception on
crystalline silica dust among stone mortar workers in Phayao province.
58
Methodology
This study was a cross-sectional analytical study in two villages that were consist of
fourteen the stone mortar factories among Ban Sang Sub district in Phayao, Thailand. Using a
simple random selection approach for recruitment, a total of 57 individuals over 18 years of
age completed a structured interview. The data collection were conducted through a face-to-
face questionnaire. The study was approved by the Research Ethics Committee of Faculty of
Medicine, Chiang Mai University, Thailand (No. 243/2016). Participants must sign the
informed consent form prior to collecting data. A questionnaire on demographic data (age,
sex, education, marital status and income), medical history (respiratory tract disease), life style
habits (smoking and alcohol use) and a questionnaire was measured by assistant researcher.
Air quality perception was measured using the air quality perception questionnaire
(AQP) in France (11) (10) which translated to Thai language version. Scores of at least 22 in air
quality perception as high level. In contrast with scores of at less than 22 in air quality
perception as low level in that dimension.
The sampling size of the stone mortar workers were selected by random sampling
within fourteen the stone mortar factories of two villages. We need at least 57 participants to
assess air quality perception from crystalline silica dust in stone mortar workers. The SPSS
version 22 software program was used for statistical analyses. Descriptive statistics were used
to describe the exposures.
Result
This study was conducted from January to June 2017 and a total sample of 57 workers
was interviewed. There were fourteen the stone mortar factories in two villages among Ban
Sang Sub district in Phayao, Thailand (Figure 1).
59
Figure 1. Geographical position of stone mortar factories.
= The stone mortar factories
There were 52 (91.2%) of males and 5 (8.8%) of females. Age average of participant was
47.0 (SD = 13) years. The stone mortar workers had aware of health effects of crystalline silica
dust exposure at 33.3% (n=19). Females had air quality perception more 40.0% (n=2) than males
32.7% (n=17). Respiratory tract disease had air quality perception more (n=18, 46.2%) than non-
respiratory tract disorder (n=1, 5.6%). Respiratory tract disease had air quality perception more
(n=3, 27.3%) than non-respiratory tract disorder (n=2, 22.2%). Smoking and respiratory tract
disease were found significantly association with air quality perception in stone mortar
workers (Table 1).
60
Table 1. Characteristics of the study population according to air quality perception.
Characteristic, n (%) Air quality perception p-value

< 22 scores ≥ 22 scores
(n = 38) (n = 19)
Age (years)
< 40 10 (66.7%) 5 (33.3%) 1.000
≥ 40 28 (66.7%) 14 (33.3%)
35 (67.3%) 17 (32.7%) 0.741

Gender 3 (60.0%) 2 (40.0%)
Male
Female
Education
≥ Primary school 23 (67.6%) 11 (32.4%) 0.849
> Primary school 15 (65.2%) 8 (34.8%)
Marital status
Married 32 (65.3%) 17 (34.7%) 0.590
Others 6 (75.0%) 2 (25.0%)
Income per month
< 5,000 Bahts 9 (69.2%) 4 (30.8%) 0.823
≥ 5,000 Bahts 29 (65.9%) 15 (34.1%)
Smoking
No 13 (52.0%) 12 (48.0%) 0.038
Yes 25 (78.1%) 7 (21.9%)
Alcohol use
No 12 (66.7%) 6 (33.3%) 1.000
Yes 26 (66.7%) 13 (33.3%)
Respiratory tract disease
No 17 (94.4%) 1 (5.6%) 0.003
Yes 21 (53.8%) 18 (46.2%)
Only 47.4% wearing general mask while working all times in the factories. The most
general mask wearing were always 47.4% (n=27.0), sometimes 21.1% (n=12), often 19.3% (n=11),
never 10.5% (n=6) and occasionally 1.8% (n=1) respectively (Graph 1).
61
General mask wearing
40.0
35.0
30.0 27.0
Cases
25.0
20.0
15.0 12.0 11.0
10.0 6.0
5.0 1.0
0.0
Never Occasionally Sometimes Often Always
Graph 1. shows general mask wearing in stone mortar worker.
Only 15.8% wearing N95 mask while working all times in the factories. The most N95
mask wearing were never 66.7% (n=38.0), always 15.8% (n=9), sometimes 8.8% (n=5),
occasionally 5.3% (n=3) and often 3.5% (n=2) respectively (Graph 2).
N95 mask wearing

40.0 38.0
35.0
30.0
Cases
25.0
20.0
15.0
9.0
10.0 5.0
5.0 3.0 2.0
0.0
Never Occasionally Sometimes Often Always
Graph 2. shows N95 mask wearing in stone mortar worker.
62
Almost workers had respiratory tract problems (64.9%) during the past one week. The
most common symptoms were coughing (45.6%), eye irritation (40.4%), phlegm (33.3%) and
cough with phlegm (31.6%) (Graph 3).
Respiratory symptoms
30
26
25 23
19 18
20
Cases
15
10
5
0
Cough Eye irritation Phlegm Cough with
phlegm
Graph 3. shows respiratory symptoms in stone mortar worker.
Discussion
5
The results of study found that those stone mortar workers had poor perception and
practices on respiratory tract protection. Respiratory tract problems were common among
them. Air quality perception had low level in smoker and respiratory tract disease. There were
smoking and respiratory tract disease should concern in stone mortar workers, especially, are
known to affect air quality perception. The most importance thing is only 15.8% wearing N95
mask while working all times in the factories due to N95 mask have the potential to prevent
disease
In addition, several previous studies reported demographic factors were associated

(12)
with air quality perception variables. Other contextual and socio-demographic factors that
(13)
have influence in air pollution health risk perception Inhalable particulate matter has
associated with human impacts such as respiratory symptoms and lung function in the work
(14) (15)
place of stone. In Thailand, we found that high-risk communities of environmental
contamination also was significantly related to the degree of risk perception. (16)
63
These findings suggest that the stone mortar workers should increasing knowledge to
self-prevention in crystalline silica dust exposure and hazardous conditions. Smoker and
people with respiratory tract disease should increasing health risk perception. Therefore, these
have the potential to provide education and training for the prevention of occupational lung
disease.
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nearby residents in Abeokuta Ogun State, Nigeria. Ethiopian Journal of Environmental Studies and
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64
15. Isara AR, Adam VY, Aigbokhaode AQ, Alenoghena IO. Respiratory symptoms and
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Risk Management in Contaminated Sites. Int J Environ Res Public Health. 2014;11(6):6291-313.
65
Pesticide Literacy and Pesticide Exposure Prevention Practices

among Farm Workers in Bago Region, Myanmar: Cross Sectional
Analytical Study
Min Thura Aung1, Paricha Nippanon2, Wongsa Lohasiriwong2, Kittipong Sornlorm3
1
M.P.H. Student, Faculty of Public Health, Khon Kaen University, Thailand.
2
Faculty of Public Health, Research and Training Center for Enhancing Quality of Life of
Working Age People Khon Kaen University, Thailand
3
ปั จจุบนั ทัว่ โลกพบการใช้ยากาจัดศัตรู พืชมีจานวนเพิ่มขึ้นอย่างมาก การใช้ยากาจัดศัตรู พืชที่ไม่ถูกต้องจะส่ งผลต่อ

ปั ญหาสุ ขภาพของมนุ ษย์และปั ญหามลภาวะต่อสิ่ งแวดล้อม พฤติกรรมการป้ องกันการสัมผัสยากาจัดศัตรู พืชมีความสาคัญ
และจาเป็ นอย่างยิ่งเพื่อลดปั ญ หาดังกล่าว ซึ่ งการศึ กษาเกี่ ยวกับ พฤติ กรรมการป้ องกันการสัมผัสยากาจัดศัตรู พืชยังคงมี
ข้อจากัดของเกษตรกรในเขตพะโค สาธารณรัฐสหภาพพม่า ซึ่ งการวิจยั แบบภาคตัดขวางครั้งนี้ มีวตั ถุประสงค์เพื่ออธิ บาย
ความรอบรู ้และพฤติกรรมการป้ องกันการสัมผัสยากาจัดศัตรู พืชและปั จจัยที่ เกี่ยวข้องของเกษตรกร เขตพะโค สาธารณรัฐ
สหภาพพม่า ในกลุ่มตัวอย่างจานวน 291 คนซึ่ งได้รับการสุ่ มตัวอย่างโดยการสุ่ มแบบหลายขั้นตอน โดยใช้แบบสัมภาษณ์
ตอบแบบสอบถามแบบมีโครงสร้าง (structured questionnaire interview) วิเคราะห์ความสัมพันธ์โดยสถิติ Multiple logistic
regression
ผลการศึกษา พบว่า ความชุกของพฤติกรรมการป้ องกันการสัมผัสยากาจัดศัตรู พืชที่เหมาะสมคือ 28.18% (95% CI:

0.23-0.33) ปัจจัยที่เกี่ยวข้องกับพฤติกรรมการป้ องกันการสัมผัสยากาจัดศัตรู พืชที่เหมาะสมคือการมีความรอบรู ้ดา้ นการใช้
สารกาจัดศัตรู พืชที่ดี (adj. OR: 2.28; 95%CI: 1.28-4.11; p=0.005) การศึกษาระดับสู(adj. OR: 1.74; 95%CI: 1.01-3.02 p-
0.047) ค่าใช้จ่ายน้อยลงเกี่ยวกับสารกาจัดศัตรู พืช (adj. OR: 1.83; 95%CI: 1.06-3.17; p-0.030).
การศึกษานี้แสดงให้เห็นว่าประมาณสามในสี่ ส่วนของเกษตรกรมีพฤติกรรมการป้ องกันการสัมผัสยากาจัดศัตรู พืช

ไม่เหมาะสม การปรับปรุ งในแง่ของการศึ กษา ความรอบรู ้ดา้ นการใช้สารกาจัดศัตรู พืชและการควบคุมการใช้สารกาจัด
ศัตรู พืชมีความจาเป็ นอย่างยิง่
66
Abstract
Introduction: Pesticide use worldwide has been increasing dramatically. Pesticide misuse
resulted in both human health problems and environmental pollution. Pesticide exposure
preventive practices are essential. There was limited of study concerning Pesticide exposure
preventive practices among farm workers in Myanmar.
Objective: This study aims to describe pesticide literacy and determine its association with
pesticide exposure prevention practices among farm workers in Bago region, Myanmar.
Methodology: This cross-sectional analytical study was conducted among 20-59 years old
farm workers in 3 townships of Bago Region, Myanmar. Total of 291 farmworkers were
randomly selected by using multistage random sampling to response to a structured
questionnaire interview. Multiple logistic regressions were used to identify the associations.
Result: Most of the samples were male (75.52%) with average age of (45.75 ±10.46) years.
The prevalence of appropriate pesticide exposure prevention practice was 28.18% (95% CI:
0.23-0.33). Having good pesticide literacy was associated with appropriate pesticide exposure
prevention practice (AOR: 2.28; 95%CI: 1.28-4.11; p=0.005). Other factors that were
associated with appropriate pesticide exposure prevention practice were had high education
(AOR: 1.74; 95%CI: 1.01-3.02 p-0.047), fewer pesticide expenditure (AOR: 1.83; 95%CI:
1.06-3.17; p-0.030).
Conclusion: This study indicated that about three quarters of the farm workers had
inappropriate pesticide exposure prevention practices. Improvement in term of education,
pesticide literacy and control on pesticide use are in needed.
67
Introduction
Consumption of pesticides worldwide has been increasing dramatically and misuses

resulted in heavy environmental pollution. In developing countries, the poisoning pesticides
are easily available on the markets(1) .30% of the pesticides trading illegally in developing
countries do not meet internationally recognized safety standards(2) and becoming significant
global problem. Myanmar is the second largest country in Southeast Asia. The economy of
Myanmar is mainly based on agriculture. Even though pesticides use in Myanmar is still
relatively low when compared to neighboring countries like Vietnam, Thailand, China and
India(3). Around 60% of the population lives in rural areas sustaining their livelihood directly
or indirectly on agricultural activities. Food security for the people and raw material
production for domestic agro-based industries are heavily dependent on the agricultural
sector(4, 5) The use of pesticides in Myanmar has increased from 2,874 metric tons in 2002-
03 to 11,101 metric tons in 2011-12 (5).
Another concern in Myanmar is poor documentation and regulation of imported
pesticides and the instruction to use is not user-friendly farmers. The improper disposal of
chemicals could cause the environment contamination and ecological disruption over the
times. More effective pesticide regulations and enforcement is needs to reduce the long-term
costs to the sector and health impact of farmers and consumers. In developing countries such
as Myanmar there is often improper management, storage, and disposal to reduce hazards and
risks of pesticides and pesticide handling(6).
Objective
This study aims to describe pesticide literacy and determine its association with
pesticide exposure prevention practices among farm workers in Bago region, Myanmar.
Methodology
Study design
A cross-sectional analytical study was conducted in 3 townships of Bago Region,
Myanmar to identify the magnitude of pesticide literacy, pesticide exposure prevention
practices. The study was 291 farm workers in this area. Inclusion and exclusion criteria were
defined as between 20-59 years old, occupation as farm workers and who were suffering
serious health problems. Find out the association between farm workers and pesticide literacy
levels, pesticide exposure prevention practices.
Study outcome
68
Pesticide exposure prevention practices were defined were prevention measures taken
by individuals having direct contact with pesticide are level (see under table). The farm
workers, 28.18% in this study revealed practicing pesticide exposure prevention. About 36%
of the farm workers pursued recommended preventive measures, reported in a study done in
Thailand(7). Similar result was reported in a study done in Lebanon(8)
Table 1 Baseline characteristics presented as percentage unless specified otherwise among

farm workers, Bago Region, Myanmar. (n=291)

Age
< 35 51 17.52
35 - 49 114 39.18
50 - 59 126 43.30
Mean (±SD) 45.75 (±10.46)
Median (min; max)
47(20; 59)
Gender
Male 220 75.60
Female 71 24.40
Education
Primary school or equivalence 57 19.59
Secondary school or equivalence 119 40.89
Bachelor degree or equivalence 33 11.34
Average family income per month (Kyats)
< 200000 114 39.18
200000 – 300000 134 46.05
>300000 43 14.78
Mean (±SD) 225808(±112552)
Median (min; max)
200000 (100000; 750000)
Table 2. Chemical pesticide exposure prevention practices in farm workers (n=291)
69
Always/
Information Never/ Sometime
usually
seldom n(%) n(%)
n(%)
1. Chemical pesticide based on seller 40(13.75) 152(52.58) 98(33.68)

recommendation
2. Chemical pesticide based on neighbor 49(16.84) 205(70.45) 37(12.71)
recommendation
3. Chemical pesticide based on the authorities 221(75.95) 29(9.97) 41(14.09)
recommendation
4. Check information about the efficacy of pesticides 76 (26.12) 81(27.84) 134(46.05)
before
5. Buy buying
chemical pesticide which labeled properly 138(47.42) 90 (30.93) 63(21.65)
andCheck
6. having
thewarning sign of
information onchemical, manufacturer
adverse impact of 158(54.30) 88(30.24) 45(15.46)
name
7. and
chemical
Read theregistration
pesticide
instructionnumber
before
on using
the label before using 44(15.12) 83(28.52) 164(56.36)
chemical
8. pesticides
Use more than type of pesticide mix together to 51(17.53) 135(46.39) 105(36.08)
increase the effectiveness.
9. Used mouth to blow blocked knapsack nozzles 223(76.63) 68(23.37) 0
10. Used hand (do not wear gloves) to stir or mix 57(19.59) 107(36.77) 127(43.64)
chemical
11. Wear pesticide
mask cover nose and mouth while spraying 200(68.73) 55(18.90) 36(12.37)
chemical
12. Wear pesticide evenshirt
long-sleeved though
and the weather
trousers is hot
when 150(51.55) 75(25.77) 66(22.68)
spraying
13. Wearchemical pesticide.
giggle when spraying chemical pesticide. 253(86.94) 26 (8.93) 12 (4.12)
14. Always check the equipment before spraying 61(20.96) 87(29.90) 143(49.14)
15. Stop spraying chemical pesticide while having 121(41.58) 97(33.33) 73 (25.09)
strong wind
16. Children usually play in the areas which are 236(81.10) 40 (13.75) 15(5.15)
spraying chemical pesticides
17. Separate clothes wearing when spraying 191(65.64) 80 (27.49) 20(6.87)
chemical pesticide, do not washing with other
clothes
18. Eat food or drink water in the chemical pesticide 161(55.33) 111(38.14) 161(55.33)
spraying areas
19. Storage chemical pesticide in separate room, 214(73.54) 29 (9.97) 48(16.49)
does not mixed or contaminate,
20. Reused chemical pesticide containers for water 268(92.10) 16(5.50) 7 (2.41)
or food
70
Table 3. Prevalence of pesticide exposure prevention practice among the farm workers in Bago
Region, Myanmar (n=291)
Pesticide Practice Number Percent 95% interval conference
Inappropriate 209 71.82
Appropriate 82 28.18 0.23-0.33
The data of each research activity once collected was then recorded into MS Excel.
The data was inverted into the Stata program (Stata Corp, College Station, TX). The data
were checked for validation before analysis. The socio-demographic and baseline
characteristics of the participants were described with frequency and percentage for
categorical data and mean and standard deviation for continuous data. The multiple logistic
regressions adjusted OR with 95% of Confident Interval (CI) was used to determine the
association between pesticide exposure prevention practices and pesticide literacy factors by
controlling other related factors.
Result
Study population was farm workers (291) who aged 20 to 59 years old and the period
of at least one year at the time of data collection. The eligible sample was fulfilled with the
following criteria. Their occupation much be farming.
Observing upon the socio-demographic factors associated with pesticide exposure
prevention practices. Among both of two level education group, the first low level education
has 23.86% and higher level education has 34.78 appropriate % which are represents to COR
1.70;95% CI: 1.01-2.85) where p-value is 0.044, are respectively.
Engaged farming years associated with pesticide exposure prevention practices where
p-value is 0.022 where <15 years 38.64% are shown OR=1.94, 95% CI (1.11-3.39) were
strongly associated. Chemical pesticide expensed for paddy (≥100000) kyats that associated
with pesticide exposure prevention practice (OR=1.44; 95%CI: 0.86-2.41). Pesticide
experienced in farming (<10) years that associated with pesticide exposure prevention
practice (OR=1.54; 95%CI: 0.92-2.59) and p-value 0.101 is strongly associated with pesticide
exposure prevention practices. Chemical pesticide expenses in paddy farms have less
significant p-value at 0.159.
71
Pesticide attitude and associated is reveal to high level (OR=1.66; 95%CI: 1.94-2.94;
p-value 0.076). The next pesticide literacy (OR=2.28; 95%CI: 1.30-4.02) were significantly
less likely to pesticide exposure prevention practices. However the respondents who had
pesticide impact experience, pesticide knowledge and pesticide promotion were not associated
with pesticide exposure prevention practices.
Factors. Number % of Crude 95%CI p-value

appropriate OR.
Education 0.044
Low education 176 23.86 1
High education 115 34.78 1.70 (1.01-2.85)
Engaging Farming 0.022
≥15 216 24.54 1
< 15 75 38.64 1.94 (1.11-3.39)
Pesticide Experience 0.101
≥10 178 24.72 1
<10 113 33.63 1.54 (0.92-2.59)
Expense on Chemical pesticide in the
previous season (years)
For Paddy 0.159
≥100000 154 24.68 1
<100000 137 32.12 1.44 (0.92-2.59)
Pesticide Attitude 0.076
Poor 97 21.65 1
Good 194 31.44 1.66 (0.94-2.94)
Pesticide Literacy 0.003
Poor 113 18.58 1
Good 178 34.27 2.28 (1.30-4.02)
72
Multivariate analyses have found that three issues which two are education attainment
level and pesticide literacy and pesticide expenditure on paddy. Such these two criteria are p-
value educational attainment related response is 0.047 accomplished with both low education
and high education in (Crude OR 1.70; AOR= 1.74 and 95% CI: 1.01-3.02) which were
significantly more likely to pesticide exposure prevention practices. Adjusting with literacy
score and associated factor was found to be 2.29 times of poor pesticide literacy that presents
as (AOR=2.29; 95%CI: 1.28-4.11, p- 0.005). Adjusting with pesticide expenditure on paddy
field and associated factors was found 1.83 times of more than 100000 kyats, that presents as
(AOR=1.83; 95%CI: 1.06-3.17, p-0.030).
Table 5. Adjusted Odds Ratios for Each Category of Factors on Pesticide Exposure Practice
on Multiple Logistic Regressions. (n=291)
Factors. No. % of Crude Adj. 95%CI p-value

appropriate OR. OR.
Education 0.047
Low education 176 23.86 1 1
High education 115 34.78 1.70 1.74 (1.01-3.02)
Pesticide Literacy 0.005
Poor 113 18.58 1 1
Good 178 34.27 2.28 2.29 (1.28-4.11)
Pesticide expend (Paddy) 0.030
≥100000 154 24.68 1 1
<100000 137 32.12 1.44 1.83 (1.28-3.17)
Discussion
Explaining the findings

The purpose of this study was aimed to determine the association between pesticides
exposure prevention practices among farm workers of Bago Region in Myanmar. A total
participants of (291) farm workers were participated in this survey conducts. Almost of farm
works were male (75.6%) and female farm workers were only (24.4%) out of total (291)
respondents.
In this section, multivariate analyses have found that three issues which two are
education attainment level and pesticide literacy and pesticide expenditure on paddy. Such
these two criteria are p-value educational attainment related response is 0.047 accomplished
with both low education and high education in (Crude OR 1.70; AOR= 1.74 and 95% CI:
73
1.01-3.02) which were significantly more likely to pesticide exposure prevention practices.
Adjusting with literacy score and associated factor was found to be 2.29 times of poor
pesticide literacy that presents as (AOR=2.29; 95%CI: 1.28-4.11, p- 0.005). Adjusting with
pesticide expenditure on paddy field and associated factors was found 1.83 times of more than
100000 kyats, that presents as (AOR=1.83; 95%CI: 1.06-3.17, p-0.030).
Conclusions
Accordingly, to socioeconomic background data is 4 categories and farming situation
and pesticide using factors has included 7 groups. Other hand of determinants factors of
pesticide related issues, there are principally determine into; firstly structure on health impact
to farmworkers, buying and using behavior, knowledge and altitude, finally inserted to
literacy and promotion.
The proportion pesticide exposure prevention practice in this study was 28.18%. In
this research investigated which factors associated the chemical pesticide prevention
exposure. This study was evident that high education and good literacy were related to
pesticide exposure prevention practice and statistically significant.
Recommendations
Chemical pesticide preventive exposure is closely relying upon the education and
pesticide literacy.
Finally, recommended to encourage on knowledge sharing of pesticide literacy around
the country side of Myanmar because of low education level of farm workers in general.
The main problem about education is accessibility. It is very important to create an
environment that children in the village are enabling to attain the level of education they
wanted to be.
Acknowledgements
I would like to thank Khon Kaen University and Faculty of Public Health, Khon Kaen
University, my advisor Associated Professor Paricha Nippanon, Professor Dr. Wongsa
Laohasiriwosng, IRC (PLE) program and Free Funeral Services Society (Yangon).
74
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International Code of Conduct 2005 [accessed on 14 January 2017]. Available from:
www.fao.org/docrep/008/af340e/af340e05.htm
2. PAN Germany. PAN International List of Highly Hazardous Pesticides. Hamburg:
2011.
3. Myo Myint., editor Proceedings of the Asia Workshop. U FAO Myanmar 2014.
4. Kudo T, Kumagai S, Ishido H. Agriculture Plus Plus: growth strategy for Myanmar
agriculture. Institute of Developing Economies, Japan External Trade Organization (JETRO),
2013.
5. Phu Thit Y. Myanmar to adopt pesticide residue standard in drinking water. The
Myanmar Times. 21012;32(628).
6. Konradsen F, van der Hoek W, Cole DC, Hutchinson G, Daisley H, Singh S, et al.
Reducing acute poisoning in developing countries—options for restricting the availability of
pesticides. Toxicology. 2003;192(2):249-61.
7. Chalermphol J, Shivakoti GP. Pesticide use and prevention practices of tangerine
growers in northern Thailand. Journal of Agricultural Education and Extension.
2009;15(1):21-38.
8. Salameh PR, Baldi I, Brochard P, Saleh BA. Pesticides in Lebanon: a knowledge,
attitude, and practice study. Environmental Research. 2004;94(1):1-6.
75
Solid waste management practices and their association factors among urban
households in Mon State, Myanmar
Aung Win Min1, Somsak Pitaksanurat2, Wongsa Laohasiriwong3, Teerasak Phajan4
1
M.P.H. candidate, Faculty of Public Health, Khon Kaen University, Thailand.
2,3,4
Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
บทคัดย่อ
การจัดการขยะมูลฝอยเป็ นความท้าทายทางด้านสุขาภิบาลสิ่ งแวดล้อมที่สาคัญในประเทศกาลังพัฒนา ทั้งนี้ประเทศ

พม่าก็นบั ว่าเป็ นหนึ่ งประเทศที่ยงั คงเป็ นปั ญหาอยู่ การศึกษาแบบตัดขวางนี้ มีวตั ถุประสงค์เพื่ออธิ บายแนวทางการจัดการ
ขยะมูลฝอยและปั จจัยที่สัมพันธ์กบั ครัวเรื อนแถบชุมชนเมืองในรัฐมอญของประเทศพม่า กลุ่มตัวอย่างที่ใช้ในการศึกษาครั้ง
นี้ มีจานวน 315 ครัวเรื อน โดยมีข้ นั ตอนในการสุ่ มกลุ่มตัวอย่างแบบหลายขั้นตอนตามสัดส่ วนของประชากรในรัฐมอญ ทา
การเก็บข้อมูลจากทุกครัวเรื อนครัวเรื อนละหนึ่งคนโดยใช้แบบสอบถามแบบมีโครงสร้าง สถิติการวิเคราะห์การถดถอยโลจิ
สติคพหุกลุ่ม จะนามาใช้ในการวิเคราะห์เพื่อระบุความสัมพันธ์ระหว่างปั จจัยต่างๆกับการจัดการขยะมูลฝอย
จากกลุ่มตัวอย่างจานวน 315 คน ส่ วนใหญ่เป็ นเพศหญิง จานวน 58.1% มีความชุกของการจัดการขยะมูลฝอยที่
เหมาะสม จานวน 58.7% (95%CI= 2.47 ถึง 2.60) ปั จจัยที่มีความสัมพันธ์กบั การจัดการขยะมูลฝอยที่เหมาะสม ประกอบด้วย
การมีทศั นคติเชิงบวกต่อการกาจัดขยะมูลฝอย (AOR=4.74, 95% CI: 2.49 ถึง 9.03, p-value < 0.001) การความรู ้ความเข้าใจ
เกี่ยวกับการจัดการขยะมูลฝอยในระดับสูง (AOR=2.4, 95%CI= 1.22 ถึง 4.12, p-value = 009) ไปทิ้งขยะที่บริ เวณทางเดินเท้า
(AOR=2.71, 95% CI: 1.23 ถึ ง 5.96,p-value = 0.013) กลุ่ ม ตัว อย่า งประมาณ 40% มี แ นวทางการจัด การขยะมู ล ฝอยที่
เหมาะสม และการจัดการขยะมูลฝอยที่ เหมาะสม มี ความสัมพันธ์กับระดับทัศนคติ เชิ งบวกและความรู ้ ที่ดี รวมทั้งความ
สะดวกร่ วมด้วย การแทรกแซงที่สร้างความเข้มแข็ง ทางด้านความรู ้และและทางด้านทัศนคติและการเข้าถึงพื้นที่ทิ้งขยะง่าย
ขึ้นนับเป็ นสิ่ งสาคัญสู่การยกระดับการจัดการขยะมูลฝอยได้
76
Abstract
Background: Solid waste management is a very important environmental health challenge and
continue to problems for major challenge and also in Southeast Asia’s urban regions. Then
Myanmar also has been facing the challenges.
Objective: The study was a cross-sectional analytic study and aimed to describe Solid Waste
Management practices (SWM) and their association factors among urban households in Mon
state, Myanmar.
Methodology: Samples were randomly selected with proportion to the size of the 315
households involved in this study. Multistage random sampling method was used in the study,
data was collected using structured questionnaire and multiple logistic regression method was
used to identify the association factors.
Results: In this study, female total were 183(58.1%) showed more than male 132(41.9%) out of
315 respondents. The prevalence of appropriate SWM practices high level were 185(58.7%)
respondents with (95% CI 53.26 to 64.19). Level of positive attitude household toward solid waste
disposal were better about 5 times than negative and neutral attitude household toward with
(adj. OR 4.74, 95% CI: 2.49 to 9.03 p-vale=<0.001) and very high statistically significant is in
231(71%) from total participants. Also appropriate SWM practices showed strongly associated
high level on health hazard and safety behavior was nearly 2.5 times better with (adj. OR 2.4,
95% CI 1.22 to 4.12 p-value=0.009) than lower level on knowledge total 215(68.8%) of
respondents. Then going to solid waste service area total 273 (86.6%) respondents who can go
walking was 3 times more better than using motorbike, car and bicycle for appropriate solid
waste management at (adj. OR 2.71 95% CI:1.23 to 5.96 p-vale=0.013) significantly associated.
Conclusion: Appropriate SWM practices were associated with level of positive attitude and
good knowledge factors. Another geographical factors and accessibility to SWM services were
was also associated. Therefore people among urban households in Mon state, with lower level
attitude and poor knowledges are need health and environmental education program about
SWM and have to concern about easy to assess for SWM service.
77
Introduction
The environmental and public health in urban areas solid waste management is becoming a
major problem because urbanization is developing and take places. In the developing countries
face such a problem for solid waste management system, including low collection cover-age
and irregular collection services, crude open dumping and burning without air and water
pollution control. ( 1) Also the municipal solid waste generation rate have greatly faster in
developing countries as increasing population levels, growing economy, rapid urbanization and
community high living standards developed.(2) Industrialization, urbanization, growing income
and consumption levels have brought the challenge of solid waste management in Myanmar.
Then not well management in effect of waste treatment and disposal options, Myanmar has
been facing also the challenges.(3) Management by reducing of solid waste or eliminates adverse
impacts on the environment and human health and supports economic development and better
quality of life.(4)
Methodology
Design of the study: This study was analytical cross-sectional descriptive study. Aim of
this study was proportion of Solid Waste Management practices and their association factors
among urban area in Mon State, Myanmar. Structured questionnaire interview conducted to
describe; the information of demographic and socio-economic, knowledge, attitude and practice
of solid waste management. Mon State is located southern part of Myanmar and include two
districts and ten townships. Total population 2,054,393 and households 422,612 (2014-MPHC).
Inclusion was all households in urban area from selected household included in the study.
Exclusion was not willing to participate in study and all public structures such as training
centers and schools, boarding houses, hospitals, clinic.The sample size was estimated based on
the multiple logistic regressions formula (Hsieh, Bloch, & Larsen, 1998). Multistage sampling
technique used to select 315 study units in this study. There are two districts in Mon state namely
Mawlmyine and Thaton. Among then three townships were randomly selected from
Mawlamyine district and one township from Thaton. Then two quarters were randomly selected
from each township city. Total eight quarters or wards selected and the selected house included
as a sample by using systematic sampling. There were 39 to 40 households from 8 quarters.
78
Research Indicators: Appropriate solid waste management (SWM) practices of factor of each
participants will be measured by demographic and socio-economic factor, geographical factors
and accessibility to the SWM service factor, knowledge on health hazard and safety behavior
related with solid waste disposal and attitude toward solid waste disposal. The appropriate solid
waste management practices was assessed based on cut point of total scores (Kiess’s theory).
Knowledge on health hazard and safety behavior related with solid waste disposal (SWD) were
using score system. Each correct response under health hazard and safety behavior with SWD
attracted one point, whereas wrong any wrong answer attract no mark. Overall, the final
assessment of knowledge of the respondents were labeled to high, medium and low respectively
if more than 80% score, 60% to 80% and less than 60% (Bloom’s theory). Similarly, attitude toward
solid waste disposal of subjects were also assessed based on cut point of total scores (Kiess’s
theory).
Demographic and socio-economic characteristics of participants will be included
age, marital status, education, occupations and family income.
Statistical Analysis: The raw data of 329 respondents were recorded into MS Excel. The data
were inverted into the Stata program version 13. 0. The demographic and socioeconomic
baseline characteristics of the participants were described with frequency and percentage for
categorical data and mean, median, minimum, maximum and standard deviation for continuous
data. The multiple logistic regression, adjusted OR with 95% of Confident Interval were used to
determine the association between appropriate SWM practices by controlling other related
factors. All test statistics were two-sided and a p-value of less than 0.05 was considered as
statistical significant.
Result
Prevalence of appropriate SWM practices: The prevalence of appropriate SWM practice status
among urban household in Mon state. According to the Kiess’s theory, level of appropriate
SWM practices were divided into three groups, low level, medium level and high level. The
interest group is people who entitled in low and medium level and high level group was
identified as reference group. The prevalence of appropriate SWM practices level was 58.7%
(95% CI 53.26 %-64.19%)
79
Prevalence of SWM practices
Table.1: Prevalence of SWM practices

Percentage
Practice Number (%) 95% CI
Inappropriate SWM practices (Medium &
Low level) 130 41.3 -
Appropriate SWM practices(High level) 185 58.7 (53.26-64.19)
Baseline characteristics Demographic and Socio-Economic Factor
The total number of completed survey was 315 respondents participated. This
represented 41.9% of male and 58.1 % female of all total respondents. Age groups are divided
into three groups, which have SD ± 13.9 and minimum 15 ratios to maximum79. Due to the
respondents’ answers, marital Status Percentage of Respondents, most of 66.4% are married
persons. At the following figure compared to the respondents’ ageing, gender and marital status.
At the educational classification were 5 classes, where most of the participants are
attained to primary school level in 40.3% and second most have 31.1% in secondary school level.
Due to the responses the respondent’s occupational level, where the 42.9 % are including to the
unskilled labour group.
According to the religion faithfulness, the 81.6 percent of respondents are Buddhist and
44.8 percent are Burma. In this process, Mon 27%, Karen 14.6% and Bengali 13.6% are
participated.
Family belonging member was classified into 3 groups, where lager family member was
found 7.6 % but family members between 1to 4 was 52.1%. Among the respondents, income level
10000-300000kyat is most participated in this survey that is contributed to 55.5 percent. Average
income per household level mean and SD are 194593.7 (±112126.5), thus medium, minimum
and maximum ratio has represented to 150000(50000:700000).
80
Table.2: Baseline characteristics Demographic and Socio-Economic Factor
% SWM Crude
Characteristics number 95%CI p-value
practices OR
1. Age (years) <0.001
≥40 194 51.5 1 1
<40 121 70.3 2.21 1.37-3.58
2. Gender 0.414
male 132 56.0 1 1
female 183 60.6 1.99 0.76-1.90
3. Marital Status 0.250
Married 209 56.5 1 1

Single, Widow, divorced or
106 63.2 1.32 0.81-2.14
separated
4. Education attainment 0.363
No formal education
Primary school Secondary 244 57.3 1 1
school
High school or equivalence
71 63.3 1.28 0.72-0 .21
Bachelor degree or higher
5. Occupation 0.453
None, Farmer,
fishermanUnskilled 223 57.4 1 1
worker
Employee, Business
92 61.9 1.20 0.73-1.98
Government staff
6. Ethnicity 0.058
Mon Karen Bengali 174 54.0 1 1
Burmese 141 64.5 1.88
81
% SWM Crude
practices OR
7. Religion <0.001
Christian Muslim 58 25.8 1 1
Buddhist 257 66.1 5.60 2.94-10.64
8. Family member 0.398
≥5 151 56.3 1 1
≥4 164 61.0 1.21 0.77-1.90
9. Average household income per

<0.001
month (MMK)
≥100,000 73 41.1 1 1
>100,000 242 64.0 2.55 1.49-4.36
10.Place for household residual

waste discard
Municipal car 40 47.5 1 1 <0.001
Not available 121 49.3 1.07 0.53-2.16
Dump Bin Public garage 154 74.3 3.20 1.52-6.74
11. Distance to throw the residual

0.437
waste
Too far 30 53.3 1 1
Not too far 123 57.7 1.1 0.81-1.60
Near 162 60.4 1.0 0.44-2.40
12. Going to SWM service place 0.001
Motorbike Car Bicycle 42 35.7 1
Walking 273 62.2 2.97 1.50-5.84
82
% SWM Crude
practices OR
13. Convenience to go SWM service
place
No 29 37.9 1 1 0.017
Yes 286 60.8 2.54 1.15-5.58
14. SWM management information

0.053
got from:
Quarter office Neighbour 69 49.2 1 1

Newspaper Journal / Book
66 53.0 1.16 0.59-2.28
Poster / Leaflet
Radio/TV Internet/Mobile 180 64.4 1.86 1.06-3.27
15. Knowledge on hazard and safety <0.001

behaviour (HSB)
Low level
100 37.0 1 1
Medium level
High level 215 68.8 3.76 2.28-6.18
16. Attitude toward solid waste

<0.001
disposal.
Negative Attitude
84 25 1 1
Neutral Attitude
Positive Attitude 231 71 7.34 4.15-2.98
83
Table.3: Adjusted odds ratios (OR) for each category of factors on SWM practices based on
multiple logistic regression
% SWM Crude Adjusted

Practices OR OR
Going to SWM service

place 0.013
Motorbike Car
Bicycle 42 35.7 1 1 1
Walking 273 62.2 2.97 2.71 1.23-5.96
Knowledge on HSB 0.009
Low level
100 37.0 1 1 1
Medium level
High level 215 68.8 3.76 2.24 1.22-4.12
Attitude toward solid
waste disposal. <001
Negative Attitude
84 25 1 1 1
Neutral Attitude
Positive Attitude 231 71 7.34 4.74 2.49-9.03
Discussion: This study described that among urban household (315) responds of appropriate
SWM practices had 58.7%. This study was similar previous study result conducted in good level
of practice was 48.9% found in north Dagon township, Yangon.(5)
After controlling the confounding factors with backward elimination multivariate analysis,
three variables were strongly associated with the geography factors and acessibility to the SWM
services
From the geography factors and acessibility to the SWM services showed place for
household residual waste, going to SWM service place, convience to go SWM service place
and received information source were statistically associated more than ( p- vale 0. 25)
inappropirate solid waste mangement practices. The other knowledge on health hardzard and
84
safety behavior and attitude toward solid waste disposal were correspondingly strongly
associated with appropirate SWM practices (p-vale <0.001).
The respondents having high level of knowledge on health hazard and safety behaviour
were 2.24 time more likely to appropriate solid waste managemnt practice compared with those
havng low and medium level of knowledge (AOR 2.24, 95% CI; 1.22 to 4.12) and it was statically
significant at p-value 0.009. The finding was consistent with the previous ones conducted in
India and Ehiopia(6) (7). If the people have well knowledge related with safety behaviour to
manage solid waste generated by daily activities of them, it can minize the risks to the
environement and human health.(8)
Positive level of attitube toward solid waste disposal for appropriate solid waste
management practice were more than 5 times from the negative and neutral level of attitude by
adjusted OR 4.74, 95% CI; 2.49 to 9.03 strongly siginificant (p value <0.001). In another study,
attitude for SWM practices associated with p value <005 and 95% CI 24.26 to 38.65 that meaned
higher attitude level had positive effect on SWM practice level.(9)
Strength of Study: Despite this study, it is finding the association between appropriate
solid waste management practice among urban houselhod in Mon state of Myanmar. Therefore,
this research study can be a reference for similar studies which will be performed in different
part of Myanmar and other countries.
Recommendation: Solid waste management should further be studied in the perspectives of
cost that people use for solid waste management and its impact on practice, and barriers of
waste management service accessibility.
Acknowledgement: I would like to thank Khon Kaen University and Faculty of Public Health,
Khon Kaen University for giving an opportunity to conduct this study. And I would like to
express my sincere thanks to the administers community leaders of Mon state, Myanmar for
their supports in data collection and information sharing about the sample community. Special
thanks to all the participants, those kindly consented and participated in this study and giving
their information for this study.
85
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86
Infection and malnutrition among pre-school children (3-5years) in rural
area of Mon State, Myanmar: A cross sectional analytical study.
Thaizin Htwe1, Aung Kay Tu 2
1
2
Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
ภาวะทุพโภชนาการในเด็กเป็ นปั ญหาสาธารณสุขที่สาคัญและเป็ นสาเหตุหลักของการตายและการป่ วยของเด็ กใน

ประเทศก าลังพัฒ นา ในประเทศพม่ าเด็ ก อายุต่ ากว่า 5 ปี มี ค วามชุ ก ของน้ าหนัก น้อ ยกว่าเกณฑ์จากรายงานก่ อนหน้านี้
ค่อนข้างมาก การวิจยั ครั้งนี้ มีวตั ถุประสงค์เพื่อระบุความชุกของภาวะทุพโภชนาการและความสัมพันธ์ระหว่างการติดเชื้ อ
และภาวะทุพโภชนาการในเด็กก่อนวัยเรี ยนในพื้นที่ชนบทของรัฐมอญประเทศพม่า การศึกษานี้เป็ นการศึกษาวิเคราะห์แบบ
ภาคตัดขวางดาเนิ นการใน 6 หมู่บ้าน 3 อาเภอในรั ฐมอญประเทศพม่า เก็บข้อมูลผูด้ ู แลเด็กก่ อนเรี ยนอายุระหว่าง 3-5 ปี
จานวน 382 คนได้รับ การคัดเลื อ กโดยการสุ่ ม แบบหลายขั้นตอน มี การชั่งน้ าหนักและวัดความสู งของเด็ก ติ ดตามโดย
แบบสอบถามที่มีรูปแบบของการสัมภาษณ์ น้ าหนักและความสู งจะแปลผลตามเกณฑ์ของน้ าหนักตามเกณฑ์อายุ น้ าหนัก
ตามเกณฑ์ส่วนสู ง และส่ วนสู งตามเกณฑ์อายุ โดยคานวณจากเกณฑ์ของ WHO Anthropometric (V3.2.2) และใช้สถิติการ
วิเคราะห์ การถดถอยพหุ โลจิ สติ กส์ รายงานผลด้วย Adjusted odd ratio ในการหาความสัมพัน ธ์โดยใช้ช่วงความเชื่ อมั่น
95% (CI)
ผลการศึกษาพบว่า ในเด็กก่อนวัยเรี ยน 382 คน พบว่า ร้อยละ 12.3 ในช่วง 1 ปี ที่ผ่านมามีอาการท้องร่ วง ความชุก
ของน้ าหนักน้อยกว่าเกณฑ์ ร้อยละ 22.25 (95% CI = 18-26) ภาวะทุพโภชนาการเฉี ยบพลัน (Wasting ) ร้อยละ 18.59 (95%
CI = 14-22) และแคระแกร็ น ร้อยละ 21.99 (95% CI = 18-26) เด็กที่อายุระหว่าง 48 ถึง 60 เดือนมีโอกาสที่จะมีน้ าหนักน้อย
กว่าเกณฑ์ 1.77 เท่า ( 95% CI = 1.04-3.03, P-value = 035) เด็กที่ได้รับการเลี้ยงดูจากผูด้ ูแลที่มีการศึกษาระดับต่ามีโอกาสที่
จะมีน้ าหนักน้อยกว่าเกณฑ์ 1.71 เท่า (95% CI = 1.00-2.94) เด็กที่มีอาการท้องร่ วงในช่วง 1 ปี ที่ผา่ นมามีโอกาสที่จะมีน้ าหนัก
น้อยกว่าเกณฑ์ 1.81เท่า (95% CI = 1.29-2.54, P-value = 0.001) เด็กที่ป่วยช่วงอายุ 1 ปี มีโอกาสที่จะมีน้ าหนักน้อยกว่าเกณฑ์
2.29 เท่า( 95% CI = 1.21-4.33 , P-value = 0.010) เด็กที่ได้รับการเลี้ยงดูจากผูด้ ูแลที่มีทศั นคติระดับต่ามีโอกาสที่จะมีน้ าหนัก
น้อยกว่าเกณฑ์ 2.47 เท่า (95% CI = 1.33-4.60) เด็กที่ได้รับการเลี้ยงดูจากผูด้ ูแลที่มีการศึกษาระดับต่ามีโอกาสที่จะเกิดภาวะ
ทุพโภชนาการเฉี ยบพลัน (Wasting) 2.16เท่า ( 95% CI = 1.21-3.85, P-value = 0.009) และเด็กที่มีอาการท้องร่ วงในช่วง 1 ปี
ที่ผ่านมามีโอกาสที่จะเกิดภาวะทุพโภชนาการเฉี ยบพลัน (Wasting) 1.80 เท่า (95% CI = 1.28- 2.53, P-value = 0.001) เด็กที่
คลอดช่วงอายุนอ้ ยกว่า 3 ปี มีโอกาสที่จะแคระแกร็ น 2.06 เท่า (95% CI = 0.87-4.83 ค่า P <0.001)
สรุ ป การติดเชื้อมีความสัมพันธ์กบั โภชนาการเด็กทุกรู ปแบบเช่นเดียวกับการศึกษาของผูด้ ูแลเด็ก
87
Abstract
Introduction: Childhood malnutrition was a major public health problem and major causes of
mortality and morbidity in developing countries. In Myanmar, prevalence of underweight in
under-five children was previously reported of rather.
Objective: To identify the prevalence of malnutrition and association between infection and
malnutrition among preschool children in rural areas of Mon state, Myanmar.
Methodology: This cross-sectional analytical study was conducted in 6 village tracts of
3townships in Mon state, Myanmar. A total of caregivers of 382 pre-school children aged 3-5
years old were selected by multistage random sampling. Measuring weight and height of
children were done, followed by structured questionnaire interviewed. Weight and height
were computed for weight-for age, weight for height, height for age by using WHO
Anthropometric calculator ( V3. 2. 2) . The multiple logistic regressions, adjusted odds ratio
(AOR) with 95% confident interval (CI) were used to identify the association.
Result: Among 382 preschool children, 12. 3% had diarrhea during the last one year. The
prevalence of underweight, wasting and stunting were 22. 25% ( 95% CI= 18-26) , 18. 59%
( 95% CI= 14-22) and 21.99% ( 95% CI= 18-26) respectively. Children aged 48to60months ( adj.
OR= 1. 77 ,95% CI= 1. 04-3. 03,P-alue= 035) , low level of education of caregiver ( adj.
OR= 1. 71,95% CI= 1. 00-2. 94) , child who had diarrhea during last one year ( adj.
OR=1.81,95%CI=1.29-2.54, P-value=0.001), child who got illness within one year of aged (adj.
OR= 2. 29, 95% CI= 1. 21-4. 33,P-value= 0. 010) , low level attitude of caregivers ( adj.
OR= 2.47,95% CI= 1.33-4.60) were significantly more likely to be underweight. Low level of
education of caregivers (adj. OR= 2.16, 95% CI= 1.21-3.85, P-value= 0.009), and child who had
diarrhea during last one year (adj. OR=1.80, 95%CI=1.28-2.53, P-value=0.001) were significantly
more likely to get wasting. Less than three years birth interval (adj. OR=2.06, 95%CI=0.87-4.83,
P-value<0.001) were more likely to be stunting.
Conclusion: Infection was associated with all form of child nutrition as well as care giver
education.
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Introduction
Malnutrition is a deviation from normal child’s growth and development (2) Malnutrition is one
of the major public health problem and major causes of mortality and morbidity in developing
countries .Malnutrition not only one of physically and mentally illness in rapidly growing
and developing children but also increasing risk of infectious diseases.(3) Malnutrition under
five year’s children is a state of nutrition where the height for age, weight for age and weight
for height indicates below -2SD.Underweight is chronic and acute malnutrition. It’s included
wasting and stunting (4).Infectious diseases are the main causes of death in under-five children.
Malnutrition and infection are two biggest killers among under-five children. Common causes
of morbidity in under-five children are acute infectious diseases such as diarrhea, ARI, fever,
measles.(5) According to MICS2009-2010, malnutrition (underweight, stunting and wasting) are
28%, 38.6%, 7.7% in Myanmar and 24.1%, 30% and 6% in Mon state. According to annual public
health statistics 2013, percent of under-five diarrhea with severe dehydration is 1.9% and
percent of acute respiratory infection is 15.3% in Mon state. Therefore malnutrition is still
public health problem. The purposes of this study, to find out the prevalence of malnutrition
and association between infection and malnutrition in this study area.(1)
Objective
To identify the prevalence of malnutrition and association between infection and malnutrition
among preschool children in rural areas of Mon state, Myanmar.
Material and methods
Study design: A community based cross sectional study was conducted in rural area of
Mudon, Thanphyuzayat, Bilin Townships, Mon state from August to September, 2017. The
study involved 382 preschool children and their caregivers residing in there. Inclusion criteria
included Preschool children (35years) and their parents. Exclusion criteria study participant
who suffer seriously illness. Infection, socio demographic information, other health care
practice factors, knowledge and attitude were collected face to face interview with caregivers
by using pretest questionnaire after receiving informed consent.
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Operational and tern definitions:
Malnutrition: Malnutrition is any deviation from normal child’s growth and development.
Underweight: weight-for-age Z- score less than -2SD from the median of the reference
population.
Preschool children: Preschool children’s age are defied from 3 years until the age of 4 years 11
months 29 days.
Diarrhea: Diarrhea can be defined as having more than three time loose or watery stool in 24
hours period.
Sampling Method
Mawlamyine Mon State Thaton

District(6) District(4)
township
Mudon Township Thanphyuzayat (33 BilinTownship

village tract) (45) Village Tracts
(35) Village Tracts
(30) Village Tracts
KawtKaPon TaGoneTain Karappi Walkami Shwehlay MuthinVilla

e Village g Village villageTra Village Village ge Tract
Tract Tract ct Tract Tract
(N =853 )
(N =1738) (N =1741)
(N=1787) (N =712) (N =1376)
Sample Sample Sample Sample Sample Sample

(n=77) (n=77) (n=88) (n=35) (n=81) (n=40)
The raw data of 382 participants were recorded into MS Excel. The data were inverted into the
Stata program version 13.0. Weight and height were converted to weight-for age, weight-for-
height, height-for-age using WHO Anthropometric calculator (V3.2.2). The indices were
90
expressed as Z-sore. Children were classified as stunted, wasted and underweight if the
respective Z-score fell below -2SD .The data were checked validation before analysis. The
socio-demographic and baseline characteristics of the participants were described with
frequency and percentage for categorical data and mean (standard deviation), range (minimum;
maximum) for continuous data. The multiple logistic regressions, adjusted odds ratio (OR) with
95% of Confident Interval (CI) were used to determine the association between malnutrition
and infectious diseases among pre-school children.
Results
Table.1 Baseline characteristics caregivers in rural areas of Mon State, Myanmar (n=382)
Education of caregivers
Secondary school 85 22.3

Higher school or equivalence 50 13.1
Age of the child

36-48 months 158 41.36
49-60months 224 58.6
Mean (±SD) : 48.57592 ±6.932615, Median (min : max):48 (36:60)
Diarrhea during last one year

Yes 47 12.30
ARI during last one year

Yes 55 14.40
Child health status at the age of one year

Healthy 324 84.8
Illness 58 15.2
91
Level Knowledge on malnutrition

More than 80 percent ( ≥9.7 & ≥12 Score) 86 22.52
Between 60-80 percent ( ≥7.2 & ≥9.6 Score ) 179 46.86
Less than 60 percent( 0 & <7.2Score) 117 30.63
Mean )±SD:(8.287958 ±1.559262,Median (min : max):8(4:12)
Level of attitude toward malnutrition

High score of attitude ( ≥36 & ≥45Score) 323 84.55
Medium sore of attitude ( ≥26 & ≥35 Score ) 58 15.18
Low score of attitude ( ≥15 & ≥25Score) 1 0.26
Mean )±SD:(38.28796±1.559262,Median (min : max):39(17:43)
Table.2 Nutritional status among pre-school children in rural area of Mon State.(n=382)
Nutritional status Number Percent% 95%CI
Underweight (WAZ<-2SD) 85 22.25 18-26
Stunting (HAZ<-2SD) 84 21.99 17-26
Wasting (WHZ<-2SD) 71 18.59 14.22
Table.3 Adjusted Odd ratios for each category of factors on WAZ (underweight) based on
multiple logistic regressions (382)
% of
Crude Adj.
Factors. number under 95%CI p-value
OR. OR.
weight
Education of caregivers
0.047
High education 156 17.31 1 1 1
low education 226 25.66 1.64 1.71 1.00 to 2.94
Age of the child

0.035
36month to 47 month 158 17.09 1 1 1
48 month to 60 month 224 25.89 1.69 1.77 1.04 to 3.03
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Characteristics Numb Percent Char Numb Percent (%) Charact

er (%) acteri er eristics
stics
Diarrhea during last one
year 0.001
No 335 19.40 1 1 1
Yes 47 42.55 1.71 1.81 1.29 to 2.54
Child health status at the

one year 0.010
Healthy 324 20.06 1 1 1
Illness 58 34.48 2.09 2.29 1.21 to 4.33
Level of attitude
0.004
High 323 19.50 1 1 1
Median & low 59 37.29 2.45 2.47 1.33 to 4.60
Discussion
In my study, mostly of the caregivers 45.3% had primary school and 22.3% secondary
school, 18.6% higher school or equivalence & bachelor or equivalence, 13.9% of caregiver had
no formal education. The previous study, that mostly had primary education, secondary,
tertiary and no-education(3) Similarly studied, most of the mother had primary education(6) In
current study,47 (12.3%) of pre-school children had diarrhea,55 (14.4%) had ARI during last one
year. Similarly previous studies show that, 25.9% had diarrhea and 6.7% had fever.(4) Among
(382) pre-school children (84.8%) were healthy and (15.5%) were illness at the age of one year.
Regarding their knowledge level, found that (22.52%) of caregivers have high, (46.86%) of
caregivers have moderate and (30.63%) have low. Quiet similar previous studies found that,
42%mother have no or poor knowledge on sign and symptoms of under nutrition (7). It was
also quiet similar with previous study described that, 56% of the mothers had moderately
93
adequate knowledge and 22% of mothers had adequate knowledge.(8) But 323 caregiver
(84.55%) have high attitude, 58 (15.18%) have medium attitude and only 1(0.26%) low attitude.
Nutritional status of pre-school children
In this study population, most of the children were normal nutritional status. There
were 77.75% (weight for age), 81.41% (weight for height) and 78.01% (height for age) in normal
nutrition status. Based on the result of the present study, the prevalence of underweight was
85(22.25%), prevalence of wasting was 71(18.59%), and prevalence of stunting was 84 (21.99%).
Underweight shows acute and chronic malnutrition. Wasting shows acute malnutrition.
Stunting shows chronic malnutrition. According to (MICS,2009-10) report, the prevalence of
underweight, wasting and stunting were 24%, 6% and 30% in Mon state.(1) Another previous
study described that 47.6% and 30.9% and 16.7% of children were stunted, underweight and
wasted respectively.(4)
Factors association with underweight (WAZ)
None and primary education of caregiver were more likely to be underweight than
high education of caregiver (adj. OR=1.71, 95%CI=1.00 to 2.94, P-value=0.047). Similar previous
study found that, none and primary education of caregivers were more likely to be
underweight (3). Prevalence of underweight found 48 to 60 months aged of children than 36 to
47 months age of children (adj. OR=1.77,95%CI=1.04 to 3.033, P-value=0.035) .Likewise,
previous studies have found that children in the age group 49-60 month were more
undernourished than other age group. It was agreed that highest prevalence of underweight
found in children aged 48-60 months.(1)

Children who had diarrhea were significantly more likely to get underweight than had
not diarrhea during last one year (adj. OR=1.81, 95%CI=1.29 to 2.54, P-value=0.001). Another
similar previous study also found that diarrhea was positive association with malnutrition (9) So
(5, 10)
malnutrition and infection are two biggest killers among under-five children .Those are
sometimes severe and can lead to death. Children were healthy the age of one year less likely
to be underweight than illness (adj. OR=2.29, 95%CI=1.21 to 4.33, P-value=0.004). High level
attitude of caregiver were less likely to be underweight compared with medium& low level
94
attitude of caregiver (adj. OR=2.47, 95%CI=1.33 to 4.60, P-value=0.004).Mothers' attitude may
be one of the influencing factors for children nutrition.

This study was cross-sectional study and not allowed the causes and effect
relationships between various factor and nutritional status. Research was representing only
pre-school children and their mother in 3 townships in Mon state. Therefore it cannot be
covered the whole population of this region.
Conclusion
In my study, education of caregiver, child age, diarrhea, child health status at the age
of one year, level of attitude were significantly association with underweight. So, low
maternal education was positive correlation between underweight. Education is one of the
most important resources that enable women to provide appropriate care for their children.
Most of the associated factors found were preventable. This is of grave public health problem
as it affects both physical and mental development of the children and thus there is need to
institute simple preventive measure at the community level like health promotion .These
factors were diarrhea during last one year and child health status at the aged of one year.
Recommendation
Nutrition education programs should be provided; using various methods by
mobilizing local level stakeholders, focusing on knowledge, attitude and health education
should be provided causes of diarrhea and personal sanitation. Therefore, should be treat
drinking water which obtained from unprotected source of water by boiling, bleaching and
trained through cloth. Further research is needed to give more clarify information on nutrition
promotion at the national level.
Acknowledgements
First, I would like to express my advisor Dr. Aung Kay Tu (Project for local
empowerment PLE (IRC). I would like to thank Khon Kaen University and Faculty of Public
Health for giving me a KKU scholarship.And I would like to express my warmest and sincere
gratitude to Professor Dr. Wongsa Laohasiriwong. Deep gratitude is also due to Dr. Nyunt
Naing Thein, Chief of Party and IRC (PLE) program.I would like to thank all my sincere Dr
Ph. And then, thanks to Ethical committee of Khon Kaen University, DAMASAC team and
95
faculty of Public Health, Khon Kaen University, Thailand for their valuable guidance and
wise opinion towards my study.
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96
Stunting and wasting among 0-5 year-old Myanmar migrant children and
the associated factors in Tak province, Thailand
Saw Than Lwin1, Thitima Nutrawong2, Wongsa Laohasiriwong3
1
M.P.H. Student, Faculty of Public Health, KhonKaen University, Thailand
2
Faculty of Medicine,KhonKaen University, Thailand.
3
Working Age People KhonKaen University, Thailand
ทัว่ โลก 165 ล้านคน เป็ นเด็กที่อายุต่ากว่า 5 ปี ที่ตอ้ งทนทุกข์ทรมานจากการแคระแกร็ น ; 52 ล้านคนเสี ยชีวติ การ
แคระแกร็ นซึ่ งเป็ นผลมาจากอาการเรื้ อรังที่ อาจนาไปสู่ ผลกระทบทางร่ างกายที่ รุนแรง ตลอดจนความรู ้ความเข้าใจและ
อารมณ์สาหรับเด็ก การศึกษาครั้งนี้ มีวตั ถุประสงค์เพื่อประเมินความชุกของการเกิดแคระแกรนท์และปั จจัยที่เกี่ยวข้องใน
เด็กอายุ 0-5 ปี จากพ่อ แม่ ที่อพยพจากพม่ามาใน 2อาเภอของจังหวัดตาก การศึกษาแบบ cross-sectional กลุ่มตัวอย่างที่ได้รับ
การคัดเลือกจานวน 289 คนที่ได้รับการดูแลเด็กอายุต่ากว่า 5 ปี ได้รับการคัดเลือกโดยใช้แบบสุ่มตัวอย่างหลายขั้นตอนโดยมี
สัดส่ วนของประชากรเด็กต่ ากว่า 5 คน ใน 2 อาเภอของจังหวัดตาก เก็บข้อมูลโดยใช้แบบสอบถามที่มีโครงสร้าง ใช้การ
ถดถอยโลจิสติกแบบง่ายและแบบหลายขั้นตอนเพื่อระบุความสัมพันธ์
ผลการวิจยั พบว่าเด็กจานวน 289 คนเด็กชายอายุ 50.52% มีอายุเฉลี่ย 30.26 ± 6.82 เดือน ผูด้ ูแลส่วนใหญ่ (92.04%)
และ (83.74%) เป็ นแม่ ประมาณครึ่ งหนึ่ งเป็ นแม่บา้ น (50.87%), 53.63% ไม่มีรายได้ ครอบครัวส่ วนใหญ่มีรายได้นอ้ ยกว่า
6000 บาทต่อเดือน (40.48%) ความชุกของการเกิดแคระต่าในเด็กพม่าจานวน 0-5 รายเป็ น 31.14% (95% CI: 25.77 - 36.51)
(AOR = 2.22, 95% CI: 1.15 - 4.26, p-0.017) ใช้หอ้ งน้ าที่ไม่ผา่ นการสุขาภิบาล (AOR = 1.78, 95% CI: 1.05 - 3.00, p-0.031)
ส่วนปั จจัยที่เกี่ยวข้องกับการทาให้แคระแกร็ นไม่คงอยู่
ดังนั้นเกือบหนึ่งในสามของเด็กอายุต่ากว่าห้าขวบมีแคระแกรน ความสนใจของแม่และสุขาภิบาลมีอิทธิพลต่อการ
เจริ ญเติบโตของพวกเขา
97
Abstract
Introduction: Globally, 165 million children under the age of five suffer from stunting; 52
million are wasted. Stunting, resulting from chronic that could lead to serious lifelong physical,
cognitive and emotional consequences for children.
Objective: To assess prevalence of stunting and the associated factors among 0-5 year-old
children from Myanmar migrant parents in two districts of Tak province, Thailand.
Methodology: This community based cross-sectional study was conducted in Tak province,
Thailand. A sample of 289 care givers of children under five were selected by using multistage
random sampling with proportional to size of the under five children population in two districts
of Tak province. Data was collected using structured questionnaire. Simple and Multiple logistic
regressions were used to identify the associations.
Result: Among the total of 289children , 50.52% were boy, the average age was 30.26 ± 6.82
months. Most of care givers were married (92.04%) and (83.74%) were mothers. About half were
housewife (50.87%), 53.63% had no income. The highest proportion of family earned less
than 6000 baht per month (40.48%). The prevalence of stunting among 0-5 Myanmar migrant
children was 31.14% (95%CI: 25.77 – 36.51). The factors associated with stunting were not
retention the immunization card (AOR= 2.22, 95%CI: 1.15 – 4.26, p-0.017), used unsanitary toilet
(AOR= 1.78, 95%CI: 1.05 – 3.00, p-0.031)..
Conclusion: Almost one third of the under five children were stunted. Attention of mother and
sanitation have influence on their growth.
98
Introduction
Stunting is well recognized to be a significant barrier to child survival, learning and

healthy development. (Children, 2016). According to (WHO) child growth standard median, a
height for age scores lower than (-2) standard deviation (SD) is defined as stunting.2.
(Organization, 2012)Although childhood death rates have decreased, 14% of children’s deaths are
related to stunting.
In 2015, 156 million of the world`s children under the age of 5 were stunted. This
represented a rate of 23.2% or one in four children. In Myanmar the rate of stunting declined
from 58.7 % in 1994 to 35.1% in 2010 (U. W. W. B. Group, 2016). Save The Children estimated
that nearly 1.6 million children under 5 years of age, more than one third of Myanmar children,
were stunted using 2014 census information and the Myanmar Multiple Indicator Cluster
Survey (MICS) 2009-2010(Children; Fund, 2011).
Stunting is the result of chronic malnutrition. As well as being irreversible stunting has
lifelong consequences which include increased morbidity and mortality, impaired physical,
neurological and psychological development and a higher risk for metabolic illnesses such as
diabetes, and hypertension. The consequences of this problem could affect a child’s memory
quality, education, future earning and other development in their life. They have a greater
chance to develop chronic disease than non-stunted children when they reach adulthood. The
objective of this study was to determine the prevalence of stunting and the associated factors
in the children of migrant parents in two districts of Tak province, Thailand. Care givers were
tested on their knowledge of child nutrition status using a short questionnaires. Material and
method
Study design
A community based cross-sectional analytical study was conducted in Mae Sot and
Phop Phra, Thailand. The study involved 289 care givers and children under 5 year-old who
resided in these two areas. Inclusion criteria included Myanmar migrant workers who have live
in Thailand at least 3 months. In family with more than one child under five, the only older one
99
was included. Exclusion criteria, any child with any a congenital or acquired deformity that
interfered with the WHO standardized stunting measurement criteria was not included.
Children with thalassemia and other incurable diseases were also not included. In the absence
of the biological mother, children whose information about prenatal and neonatal care was not
available were excluded. Structure interview addressing socio-economic, environmental, health
and care givers level of knowledge were conducted with pretested questionnaires. Height/length
measurement were taken of these child.
Operational definition of term
Breastfeeding is a way of providing nutrition to a child by giving breast milk. This

includes also breast milk fed by other means–bottle, cup, and spoon.
Complementary feeding is a way of providing nutrition to a child by giving solid or

semi-solid foods.
Food/dietary diversity defined as the number of different foods or food groups

consumed over a given reference period (Achenef Motbainor*, 2015).
Food insecurity is a state or a condition in which people experienced limited or

uncertain physical and economic access to safe, sufficient and nutritious food to meet their
dietary needs or food preferences (Achenef Motbainor*, 2015).
Water, Sanitation and Hygiene (WASH) groups together water, sanitation and hygiene.
100
Sampling method
Socio-economic, environmental, health characteristic and care givers level of knowledge

were described using frequency and percentage for categorical data and mean and standard
deviation for continuous data.
To identify the associated factors with stunting, odds ratios (ORs) and their 95%
confidence intervals (95%CIs) were estimated using multiple logistic regressions for cross
sectional study. This analysis was adjusted for baseline variables and showing a bivariate
relationship with stunting. All analyses were performed using Stata version 10.0. All test
statistics were two-sided and a p-value of less than 0.05 was considered statistically significant.
101
Table 1. Caregiver, child and family socioeconomic factors
Socio-economic Number Percent (%)

Care giver
1. Age of care giver
< 20 years 10 3.46
20 - 34 years 159 55.02
35 years and older 120 42.52
Mean (±SD) 33.96 (9.97)
Median (Min : Max) 33(17:69)
2. Gender
Male 14 4.84
Female 275 95.16
3. Type of care giver
Mother 242 83.74
Father 10 3.46
Grand parent 32 11.07
Relative 5 1.73
4. Marital statue
Single 4 1.38
Married 266 92.04
5. Highest education level
Primary 152 52.60
Secondary 71 24.57
6. Occupation
None 11 3.81
Housewife 147 50.87
Farmer 15 5.19
Unskilled labor 53 18.34
Employee 15 5.19
Business 6 2.08
Government officer 1 0.35
Others 41 14.19
7. Monthly household income (in baht)
< 6000 117 40.48
6000 - 8000 102 35.29
> 8000 70 24.22
102

Mean (±SD) 6690.83(±3385.46)
Median (Min : Max) 6000 (0 : 20000)
Not enough 58 20.07
Enough without saving 88 30.45
9. Address in Thailand
Mae Sot 211 73.01
Phop Phra 78 26.99
10. Type of area
Rural 192 66.44
Urban 97 33.56
11. Maternal age at first child birth
< 20 years 71 24.57
20 34 years 210 72.66
35 years and older 8 2.77
Mean (±SD) 22.68 (±4.86)
Median (Min : Max) 22 (14 : 41)
12. Family member
< 4 persons 162 56.06
4 persons and more 127 43.94
Mean (±SD) 4.66 (±1.70)
Median (Min : Max) 4 (2 : 11)
13. Number of ≤ 5 yrs children
1 child 230 79.58

2 children and more 59 20.42
Mean (±SD) 1.22 (±0.45)
Child factors
14. Age of child in month
0 - 11 54 18.69
12 - 23 58 20.07
24 - 35 53 18.34
36 – 47 65 22.49
48 – 60 58 20.42
Mean (±SD) 30.66 (±16.84)
103

15. Sex
Boy 146 50.52
Girl 143 49.48
16. Number of alive child
1 child 117 40.48
2 children and more 172 59.52
Mean (±SD) 2.26 (±1.61)
17. Birth order
1 135 46.71
2 –3 107 37.02
Mean (±SD) 2.15 (±1.59)
18. Type of child
Single 288 99.65
Twin 1 0.35
19. Birth interval
< 18 months 153 52.94
18 months and more 136 47.06
Mean (±SD) 2.74 (±3.26)
20. Country of child was born
Thailand 250 86.51
Myanmar 39 13.49
21. Facility of the child was born
Hospital 96 33.22
Health center 149 51.56
Home 44 15.22
22. Birth certificate
Yes 248 85.81
No 41 14.19
23. Immunization card
Yes 241 83.39
No 48 16.61
24. Child related
Son/Daughter 255 88.24
Nephew/Niece 5 1.73
Other 29 10.03
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Table 2. Health related factors
Health Number Percent (%)

1. Breast feeding (0-1 years)
Yes 264 91.35
No 25 8.65
2. If no breast feeding (n-25)
Milk formula 22 88.00
Pasteurized milk 1 4.00
Others 2 8.00
3. Exclusive breast feeding
Yes 220 76.12
No 69 23.88
4. Duration of exclusive breast feeding
< 6 months 224 77.51
Mean (±SD) 2.9(±2.29)
5. Age of child start getting soft food
< 6 months 158 54.67
Mean (±SD) 4.65 (±2.70)
Median (Min : Max) 5 (0 : 24))
6. Family has enough money for the food of
child
Yes 156 53.98
No 133 46.02
7. Easy to buy nutritious food
Easy 225 77.86
Not very easy 34 11.76
So so 19 6.57
Difficult 11 3.81
8. Boiled water before feed
Never 95 32.87
Seldom 10 3.46
Sometimes 51 17.65
Usually 9 3.11
Always 124 42.91
9. Boiled milk bottle before use
Seldom 3 1.04
Sometimes 5 1.73
Usually 12 4.15
105
Health Number Percent (%)

Always 59 20.42
Not applicable 210 72.66
10. Immunization
Complete 186 64.36
Incomplete 79 27.34
No immunization 24 8.30
Table 3. Infection
Infection Number Percent (%)

1. History of infection
- Yes 97 33.56
- No 191 66.09
5. Loss weight after illness/hospitalization (n=107)
Yes 81 75.70
No 22 20.56
Don’t know 4 3.74
Table 5. Caregiver knowledge level on child nutrition
Level Knowledge on child nutrition Number Percent (%)

Low knowledge (<6 scores) 52 17.99
Medium knowledge (6 - 8 scores) 170 58.82
High knowledge (> 8 scores) 67 23.18
Mean (±SD) 7.10 (±1.60)
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Table 4. Bivariate analysis of socio-economic factors in stunting
Socio-economic Number Percent Crude 95% CI P-value

(%) OR
Care giver
1. Age of care giver 0.331
35 years and older 120 29.17 1
< 35 years 169 32.54 1.17 0.70 – 1.95
2. Gender 0.708
Female 275 30.91 1
Male 14 35.71 1.24 0.40 – 3.82
3. Type of care giver 0.570
Father, Grand parent, 47 27.66 1
Relative
Mother 242 31.82 1.22 0.60 – 2.44
4. Marital status 0.939
Single/ 23 30.43 1
Widow/Separated/
Divorced
Married 266 31.20 1.03 0.41 -2.62
5. Monthly household 0.094
income (in baht)
8,000 and more 70 22.86 1
6,000 – 8,000 102 29.41 1.41 0.70 -2.84
< 6,000 117 37.61 2.03 1.04 – 3.98
6. Address in Thailand 0.182
Mae Sot 211 28.91 1
Phop Phra 78 37.18 1.46 0.84 – 2.51
7. Type of area 0.025
Urban 97 22.68 1
Rural 192 35.42 1.87 1.07 – 3.27
Child factors
8. Age of child in month 0.770
24 – 60 117 30.51 1
0 – 23 112 32.14 1.07 0.65 – 1.80
9. Sex 0.369
Girl 143 28.67 1
Boy 146 33.56 1.26 0.76 – 2.07
10. Birth order 0.207
2 and more 154 27.92 1
one 135 34.81 1.38 0.84 – 2.27
107
Socio-economic Number Percent Crude 95% CI P-value

(%) OR
11. Birth interval (in years) 0.172
< 18 months 136 27.21 1
18 months and more 153 34.64 1.42 0.86 – 2.35
12. Birth certificate 0.131
Yes 248 29.44 1
No 41 41.46 1.70 0.86 – 3.35
13. Immunization card 0.008
Yes 241 27.80 1
No 48 47.92 2.39 1.27 – 4.50
14. Child related 0.144
Nephew/Niece/Relative 34 20.59 1
Son/Daughter 255 32.55 1.86 0.78 – 4.45
Table 5. Bivariate analysis of environmental factor in stunting
Environmental Number Percent (%) Crude 95% CI P-value

OR
1. Type of toilet 0.013
Covered/Uncoveredold in 134 23.88 1
ground
Town pipe/ Closed tank 155 37.42 1.91 1.14 – 3.18
2. Share toilet 0.031
No 113 23.89 1
Yes 176 35.80 1.78 1.04 – 3.02
3. Main source of water 0.006
Pipe water/ Public tap, 183 25.68 1
Bottle water
Protected covered/ 46 30.43 1.26 0.62 – 2.58
Unprotected uncovered dug
well
Surface/Tank water 60 48.33 2.71 1.48 – 4.96
5. Treated drinking water 0.086
Yes 218 28.44 1
No 71 39.44 1.64 0.94 – 2.87
6. Last time management of 0.050
≤3 years stool
Child use/ Put stool into 169 26.63 1
toilet
Put into ditch/garbage/left 120 37.50 1.65 0.99 – 2.73
in open
108
Environmental Number Percent (%) Crude 95% CI P-value

OR
7. Frequencies of washing 0.159
hand before feeding
Always 123 26.83 1
Seldom/ Sometimes/ 145 32.41 1.31 0.77 – 2.22
Usually
Never 21 47.62 2.48 0.96 – 6.38
4.3 Multivariate analysis of factors in stunting
Multivariate analysis after controlling the confounding factors with backward

elimination found that the retention of immunization card and type of toilet were associated
with stunting in children among 0-5 year-old Myanmar migrant children at two districts in Tak
province, Thailand.
Table 5. Adjusted Odds Ratios for each category of factors in stunting based on
multivariate analysis
Statement Number Percent (%) Crude Adj. 95% CI P-value

OR OR
1. Immunization card 0.017
Yes 241 27.80 1 1
No 48 47.92 2.39 2.22 1.15 - 4.26
2. Type of toilet 0.031
Covered/Uncoveredold 134 23.88 1 1
in ground
Town pipe/Closed tank 155 37.42 1.91 1.78 1.05 - 3.00
Strengths and Limitations
The strength of this study was the discovery of the high noncompliance rate, one third, with
the recommended immunization schedules. A second strength is that this study is the first to
determine the prevalence of stunting in this population. No previous academic investigation of
stunting in the Myanmar migrant population had been completed.
109
Limitations of the study relate to its cross sectional design. Populations in the more remote
parts of the study area may not have been captured resulting in a non-representative sample. A
second limitation is that communications with some participants was complicated by more than
one individual speaking for the family resulting in conflicting responses to the questionnaire
leading to a possible recall bias.
Conclusions
In this study the use of closed tank and town piped toilets resulted in an increased
chance of children being stunted. This contradicts many previous studies which stressed that
the use of these types of improved toilet facilities decreased the chance of stunting in children.
The largely marginal housing and sanitation options available to this study’s participants may
account for the different results even when the toilet types could be categorized as improved.
Further investigations of the toilet types used by the participants are necessary to explain this
contradiction.
Caregiver retention of a child’s immunization card was significantly associated with
stunting. This result was reinforced by a comparable risk of stunting determined in the
completeness, incompleteness and no immunization question which showed an almost

identical chance of stunting in children with no immunization history. It is clear that full
participation in immunization programs is invaluable in reducing the risk of stunting. Further
exploration of the barriers to children’s full participation in immunization programs is needed.
Additional factors which were not significantly associated but still were important
included the location of the participants. Children from Phop Phra and rural participants were
more likely to be stunted. These children and families lived in more isolated settings which
increase travel and security complications and can lead to reduced involvement in both
professional and informal health care opportunities – hospitals, clinics, pharmacies, Community
Health Workers and Traditional Birth Attendants outreach and supportive family, volunteers
and neighbours.
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Although most children in this study were breast fed. A number were not and many were not
exclusively breast fed until the WHO recommended 6 months of age. Many mothers need to be
encouraged to follow the WHO breast feeding standards and barriers to mothers not doing so
need to be identified and addressed.
Recommendations
Policies and program planning needs to focus on a number of socioeconomic,

environmental and health related areas.
REFERENCES
1. WASH is now is part of the Sustainable Development Goals and will require countries
to monitor and report on progress in improving WASH services including those in the study
area. Toilet facilities in the study area need to be evaluated.
2. Barriers to children`s full participation in immunization programs need to be identified

and the required support needed to increase participation in immunization programs needs to
be implemented.
3. Support to caregivers can be provided by increasing the number of health outreach
workers, both professional and nonprofessional, to support mothers who may not be accessing
health care and or receiving education on good child care practices.
4. (ASEAN) was established on 8 August 1967. The Member States of the Association are Brunei
Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines,

Singapore, Thailand and Viet Nam. The ASEAN Secretariat is based in Jakarta, Indon
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8.Emre Özaltin, M., Kenneth Hill, PhD, S. V. Subramanian, PhD. (2010). Association ofMaternal
Stature With Offspring Mortality, Underweight, and Stunting in Low- to Middle-Income
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9.Group, U. W. W. B. (2016). LEVELS AND TRENDS IN CHILD MALNUTRITION. Joint
Child Malnutrition Estimates, 8.
10.Group, W. B. (2014). Investing in the Next Generation (pp. 8).
11.Mercedes de Onis, K. G. D., † Elaine Borghi,* AdelheidW. Onyango,* Monika Blössner,*
Bernadette Daelmans,‡ Ellen Piwoz§ and Francesco Branca*. (2013). The World Health
Organization’s global target forreducing childhood stunting by 2025: rationale and
proposed actions. 21.
12.Martorell, R., & Young, M. F. (2012). Patterns of stunting and wasting: potential explanatory
factors. Adv Nutr, 3(2), 227-233. doi: 10.3945/an.111.001107
13.Organization, W. H. (2012). Nutrition Landscape Information System (NLIS) Country Profile
Indicators. 50.
14.Organization, W. H. (2014). WHA Global Nutrition Targets 2025: Stunting Policy Brief (pp.
10).
15.Reynaldo Martorell, a. A. Z. (2012). Intergenerational Influences on Child Growth and
Undernutrition. Paediatric and Perinatal Epidemiology, 13.
16.Richard D. Semba a, Michelle Shardell b, Fayrouz A. Sakr Ashour c, Ruin Moaddel b, Indi
Trehand,e, Kenneth M. Maleta e, M. Isabel Ordiz d, Klaus Kraemer f,g, Mohammed A.
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112
Health Promotion 01
Socioeconomic disparity and quality of married life of Myanmar migrant

women in Thai-Myanmar border, Tak province, Thailand.
Nway Nway Oo1, Wilaiphorn Thinkhamrop2
1
2
เพศภาวะมีอิทธิพลมาตรฐานการดารงชีวติ และต่อคุณภาพชีวติ ชีวติ สมรส โดยอาจส่งผลให้สภาพความเป็ นอยูข่ อง

พวกเขาทั้งดีข้ ึนและแย่ลง คุณภาพชีวติ สมรสของผูอ้ พยพชาวพม่าในประเทศไทยเป็ นเรื่ องที่ยงั ไม่มีการศึกษา การวิจยั ครั้งนี้
มีวตั ถุประสงค์เพื่ออธิ บายถึงสถานการณ์ของคุณภาพชีวิตสมรสและระบุความสัมพันธ์ระหว่างความเลื่อมล้ าทางเศรษฐกิจ
สังคมกับคุณภาพชีวิตสมรสของสตรี อพยพชาวพม่า การศึกษานี้ เป็ นการศึกษาแบบวิเคราะห์ภาคตัดขวาง ทาการศึกษาใน
จังหวัดตากประเทศไทย กลุ่มตัวอย่างทั้งหมดเป็ นสตรี อพยพชาวพม่าที่แต่งงานแล้ว จานวน 332 คน ได้รับการคัดเลือกโดย
การสุ่ มแบบหลายขั้นตอน เก็บรวบรวมข้อมูลโดยใช้แบบสอบถามและวิเคราะห์โดยใช้สถิติการถดถอยโลจิสติกส์แบบง่าย
และการถดถอยพหุโลจิสติกส์
ผลการศึกษาพบว่า กลุ่มตัวอย่างมีอายุเฉลี่ย 34.7 ปี (± 9.59 ปี ) อายุเฉลี่ยเมื่อแต่งงาน 22.09 ปี (± 4.45 ปี ) ความชุก

ของสตรี อพยพชาวพม่าที่มีคุณภาพชีวิตสมรสที่ไม่ดี (poor quality) เท่ากับร้อยละ 65.48 (95% CI = 59% -70%) ปั จจัยทาง
เศรษฐกิ จสังคมที่มีความสัมพันธ์กบั การมีคุณภาพชี วิตสมรสที่ไม่ดี ของ สตรี อพยพชาวพม่าที่แต่งงานแล้วที่ ได้แก่ ผูท้ ี่มี
การศึกษาระดับต่า(adj. OR = 3.16 (95% CI = 1.61-6.19, p-value <0.001) อาศัยอยูใ่ นสภาพแวดล้อมที่ ไม่ดี (adj. OR) =
1.98 (95% CI = 1.05-3.75, p-value = 0.036) ปั จจัยอื่นที่มีความสัมพันธ์กบั การมีคุณภาพชีวิตสมรสที่ไม่ดี ได้แก่ การมีบุตร
มากกว่า 5 คน (adj. OR = 1.89 (95% CI = 1.21-2.97, p-value = 0.005),
สรุ ป ระดับการศึกษา การมีบุตรหลายคน การอาศัยอยูใ่ นสภาพแวดล้อมที่ไม่ดีมีความสัมพันธ์อย่างมากกับคุณภาพ

ชีวิตสมรส การประเมินการศึกษา การวางแผนครอบครัวและการปรับปรุ งสภาพแวดล้อมเป็ นสิ่ งจาเป็ นที่ช่วยปรับปรุ งให้
คุณภาพชีวติ สมรสของพวกเขาดีข้ ึน
113
Health Promotion 01
Abstract
Introduction: Gender issues have influence on living standard and quality of life. Marriage
might result in both improving and deteriorating their wellbeing. Myanmar migrants in
Thailand’s quality of married life are still unknown.
Objective: To describe the quality of married life situation and identify the association between
socioeconomic factors and quality of married life among Myanmar migrant women.
Methodology: This cross sectional analytical study was conducted in Tak Province, Thailand.
The total sample of 332 married Myanmar migrant women were selected by using multistage
sampling method. Data was collected by using structured questionnaire interview and analyzed
by simple and multiple logistic regressions.
Result: The average age of the samples was 34.7 ± 9.59 years old. The average aged at the time
of marriage was 22.09 ± 4.45 years old. The prevalence of poor quality of married life among
Myanmar married migrant women was 65.48% (95% CI = 59%-70%). Having low level educated
(adj.OR= 3.16, 95% CI=1.61-6.19; p-value <0.001) and living in poor environment QMI (adj. OR=
1.98, 95% CI =1.05-3.75; p-value=0.035) were socioeconomic factors that significantly associated
with poor quality of married life of Myanmar migrant women. The other associated factor with
poor quality of married life was had more than five children (adj.OR=1.89, 95%CI=1.21-2.97; p-
value=0.005).
Conclusion: More than half of the women were encounter poor quality of married life.
Education level, poor living environment and having many children were found strongly
associated with quality of married life. Access to education, family planning and improvement
of environment is in need to help improving their QMI.
114
Health Promotion 01
Introduction
The proportions of migrant women are dramatically increased (Sharma, Saraswati, Das, &
Sarna, 2015). Moreover migrant women are highest risk of arrest and deportation since they
are illegal migrant worker. Gender issues have influence on living standard and quality of life.
(Sijapati, 2015; York, 2016) (Curran et al. 2006). Most studies have found that the economic
imperative is the main factor that drives migration. The main drives factors are usually poverty,
high rates of unemployment, low wages and adverse social and political circumstances (Brian
Opeskin, 2015; Chalermpol Chamchan, 2012) .
Malaysian population generally showed a moderate level of marital satisfaction and quality of
life. Couples who have more children tend to report lower marital satisfaction as compared to
couples who have one or two children (Chee Heng,2012) The consequences of poor relationship
may cause of depression. The marital dissatisfaction predicts increases in depressive symptoms
over time. Other researchers have also highlighted the link between relationship quality and
psychological and physical well-being (Hsin-Chieh Chang1, 2015).
Previous study done in United State found that marital dissolution is significantly association
with poor marital and physical health. The prior findings are women with lowest marital
marriage satisfaction may follow with the divorce (Sbarra, 2015). Gender issues have influence
on living standing and quality of life. Married might result in both improving and deteriorating
their wellbeing. Myanmar migrants in Thailand quality of married life are still unknown. The
aims of this study to describe the quality of married life situation and identify the association
between socioeconomic disparity and quality of married life.
Objective
To describe the quality of married life situation and identify the association between
socioeconomic factors and quality of married life among Myanmar migrant women.
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Material and methods

Study design: A cross sectional survey of 332 participants in Thai-Myanmar border Tak
province Thailand. Data are collected by using structured questionnaire interview Multistage
random sampling method was used in selected samples from 4 districts in Tak, Thailand. The
scale measurement of Quality of Married was evaluated by using the Scale for measurement of
a Quality of married life Index (QMI).
Sampling Methods
Multi-stage sampling was selected the samples in this study. The total of 4 sub- districts was
selected from Tak province. Then a community was randomly selected from each selected
district, the totals of 332 samples were randomly selected probability proportional to size of
the population in each sub-districts.
Demographic and socioeconomic factors were described by percentage and frequency for
categorical data. Mean and standard deviation (SD) and median and range (Minimum: Maximum)
were reported for continuous data.
To investigate factors that factors associated with socioeconomic disparity and quaity of
married life , odds ratios (ORs), and their 95% confidence interval (95%CIs) were estimated using
multiple logistic regression for cross sectional study. This analysis was adjusted for baseline
variables and showing a bivariate relationship with quality of married life such as knowledge
and perception toward quality of married life. All analyses were performed using Stata version
10.0 . All test statistics were two-sided and a p-value of less than 0.05 was considered statistically
significant.
Results
Socioeconomic and demographic characteristics of Myanmar married migrant women

The baseline characteristics of socioeconomic and demographic were shown in table 1. A total
of 332 married migrant women were recruited for this study. Majority of them were in the age
group of (above 35) years the mean age was (34.67) with the standard deviation SD of 9.59. In
term of educational level, the highest proportion of them finished primary level 44.58%.
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Table 1. Summary of Background and general attribute about Myanmar married migrant
women (n=332)
Characteristics Total (n=332)
Number Percent (%)
Age
< 25 years old 50 15.06
25 - 35 years old 128 38.55

> 35 years old 154 46.39
Mean )±SD)7.34 (±9.59,( Median )min :max)37 (16:62(
Ethnicity
Burmese 161 48.59
Karen. 136 40.96

Mon 12 3.61
Kachin 6 1.81
Kareni 3 0.90
Shan 3 0.90
Shan Rakhine 1 0.30

Others 10 3.01
Education Level
Primary 148 44.58
Secondary 65 19.58
Bachelor degree or higher 20 6.02
Marriage Situation
More than half of respondents got married when they were aged between 18-25 years old
(59.64%), when they were less than 18 years old was 12.35%. The youngest age of first marriage
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was 14 years old and the oldest was 37 years old. Reason for marriage, most of them (87.95%)
were in love therefore they got marriage. Myanmar migrant women were mostly from
countryside origins, low educated and early married was a common practice in Burmese
community.
There was 24.40% unemployment. Educated married women positively fall in professional job
19.29%. More than half earn monthly personal income lower than 3000 Baht, account for 56.33%.
Monthly Family income lower than 5000 Baht were 81.02% of financial situation fall into not
enough with debt and just enough were 24.70% ,43.98% with undocumented fall into 44.28%.
Migrant women access to birth control was 70.78%, Majority of them had 1-2 children
Regarding of married status fall into large proportion of 72.95 due to most Myanmar women
are keep monogamy marriage in their married status due to culture and tradition are rigorously
control by society.
Table 2. Summary of Marriage situations of Myanmar married migrant women (n=332)
Total (n=332)
Characteristics
Number Percent (%)
Age at time of marriage

< 18 41 13.35
18-25 198 59.64
≥25 93 28.01
Mean )±SD( 22.09(±4.45), Median )min :max( 22(14:37)
Reason for marriage

love 292 87.5
Parents arrangement 26 7.83
Others 14 4.22
Occupation
No occupation 81 24.40
Housewife 55 16.57
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Total (n=332)
Characteristics
Number Percent (%)
Senior officials and managers 28 8.43
Professionals 64 19.28
Technicians and associate

21 6.33
professionals
Skilled agricultural and fishery
41 12.35
workers
Service and sales workers 11 3.3
Craft and related trades workers 18 5.42
Factory and related operators 10 3.01

Clerks 3 0.90
Mean )±SD)17.8 (±1.26), Median )min :max3)8 ( :12(
Personal income
< 3000 187 56.33
3000-7500 124 37.35

>7500 21 6.33
Mean )±SD)45.3086 (±4015.87), Median )min :max)3000 (0 : 45000(
Family income
< 5000 269 81.02
5000 - 8000 43 12.95

> 8000 20 6.02
Mean )±SD)43.8393 (±5271.27), Median )min :max( 7750(0:50000)
Financial situation
Not enough 39 11.75

Enough 146 43.98
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Total (n=332)
Characteristics
Number Percent (%)
Legal Document
Nothing 147 44.28
Work permit 102 30.72
Passport 24 7.23
Legal document 59 17.77
Birth Control
No used 97 29.22
Used 235 70.78
Number of Children
Non 36 10.84
1 – 2 children 189 56.93
3 – 5 children 92 27.71
> 5 children 15 4.52
Mean )±SD( 2.18(±1.57), Median )min :max( 2(0:9)
Demographic data of spouse

The average age of spouse was mean 36.60 ± 10.24 years old. Majority were Burmese
ethnic (52.41%), followed by Karen (35.54%); 42.47% finished primary school. In term of
occupation, agricultural and fishery was 20.18%, professionals was 21.08%, craft and related
trades workers found only 11.75%. More than half earned monthly personal income lower than
3000 Baht (56.33), 37.35% earn between 3000-7500 Baht. Most of them lived with the husband
most of the time (80.72%).
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Table 2. Demographic data of Spouse characteristic (n=332)
Number Percent (%)
Age
< 25 years old 34 10.24
25 - 35 years old 112 33.73
≥ 35 years old 186 56.02
Mean (±SD) 36.60(±9.45), Median (min : max) 36(18:64)
Ethnicity
Burmese 174 52.41
Karen 118 35.54
Mon 11 3.31
Shan 6 1.81
Kachin 3 0.90
Rakhine 1 0.3
Kareni 4 1.20
Others 15 4.52
Education Level
Primary 141 42.47
Secondary 85 25.60
Age at time of marriage
< 18 13 3.92
18-25 172 52.41
>25 145 43.67
Mean (±SD) 24.61(±5.34), Median (min : max) 24(16:42)
Occupation
Unstable work 28 8.43
Senior officials and managers 21 6.38
Professionals 70 21.08
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Number Percent (%)
Technicians and associate professionals 13 3.92

Skilled agricultural and fishery workers 67 20.18
Service and sales workers 20 6.02
Craft and related trades workers 39 11.75
Factory and related operators 35 10.54
Clerks 9 2.71
Working hour a day
< 8 hours 204 65.59
≥ 8 hours 107 34.41
Mean (±SD) 8.29(±1.07), Median (min : max) 8(2 : 13)
Always living with husband

Live together most of the time 268 80.72
Always traveling 33 9.94
Working abroad 31 9.34
Environmental factors
The environment factors scores were categorized into 5 levels for each indices:
According to Kiess’s Theory, total scores were divided into 3 groups such as score more than
36 points as “ Good” 24-23 points as “Moderate” and 24 -36 as Moderate and less than 23 points
as “ Poor”. The mean score of them was 27.64 with SD 5.83. Most of them (68.07%) lived with
moderate environment condition, followed by good environment condition (23.19%).
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Table 3. Level of Environmental factors among Myanmar married migrant women (n=332)
Number Percent(%)
Level of Environmental factors
Good (> 36 scores) 77 23.19
Moderate (24-36 scores) 226 68.07
Poor (≤ 23 scores) 29 8.73
Mean(+ S.D)27.64(±5.83), Median (Min, Max) 27(14:48)
Psychosocial factors from perceived Stress Scale (n=332)
The total scores were calculated from the sum of 15 questions. The PSS scores have a range of
scores between 0 and 60. Higher score show high level of stress and lower value represent low
level of stress. According to Kiess’s Theory, total scores were divided into 3 groups such as
high level (34-49 scores), moderate level (20-33 scores) and Low level for (6-19 Scores). Among
these participants, more than half of them had moderate level 66.57% respectively.
Table 4. Stress level and quality of married life among Myanmar Migrant women (n-332)
Number Percent (%)

Stress level
Low ( ≤ 19 scores) 29 7.83
Moderate (20 – 33 scores) 221 66.57
High (≥34 scores) 85 25.60
Mean + S.D.29.07(±7.18), Median (Min, Max) 29(6:49),Total 60 scors.
Quality of Married Index (QMI)
The quality of married scores were divided into 3 groups such as Good QMI (≥110 scores),
Moderate (70-110 scores), poor QMI (<70 scores) Among these participants, majority had
Moderate level of QMI which was 64.46% respectively.
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Table 5. Categorization of Quality of Married Index (QMI) (n=332)
Percent 95%
Quality of Married Index (QML) number
(%) CI
Good (≥80%) 116 34.94
Moderate (60-79%) 151 45.48
Poor ( ≤60%) 65 19.58 (59-70%)
Mean (±S.D).93.88(±23.57), Median (Min, Max) 92(30:150)
Factors associated with quality of married life using bivariate analysis

The Analysis between social-demographic data and quality of married life (QMI)
Table 6, showed the detailed of demographic, socioeconomic factors that were associated with
socioeconomic disparity and quality of married life. The factors that had p-value < 0.25 were
preceded to the multivariable analysis. These factors were educational attainment, reason for
marriage, financial situation, legal document of their employment, birth control and number of
children.
Table 6. Odds ratios of factor associated with quality of married life using simple logistic
regression.
% Crude
Factors. number 95%CI p-value
Poor QMI OR.
Education Level <0.001

Higher education 90 46.67 1
Low education 242 71.90 2.92 (1.77- 4.82)
Reason for marriage
love 292 63.70 1 0.150
Parents arrangement 40 75.00 1.71 (0.80-3.64)
Financial situation <0.001
Enough ( with saving) 147 53.74 1
Not enough (with 1.57
185 74.05 (1.24-1.97)
debt)
<0.001
Legal document
legal document 185 59.46 1
Nothing 147 72.11 1.88 (1.41- 2.50)
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% Crude
Poor QMI OR.
Birth Control 0.199

No 97 59.79 1
Yes 235 67.23 1.38 (0.85- 2.25)
Children <0.001
No 41 39.02 1
Yes 291 68.73 3.43 (1.75-62.74)
Number of Children <0.001
< 5 children 147 53.06 1
≥ 5 children 185 74.59 2.59 (1.63-4.13)
Socioeconomic and quality of married life its associated factors Multiple logistic regression
The researcher has applied multiple logistic regressions to test the relationship between 7
variables, including educational level, number of children, environment factors, stress level.
knowledge and perception toward quality of married life among Myanmar married migrant
women. The details of analysis are as follows: The finding revealed that factors associated with
poor QML were had lower (adj. OR= 3.16, 95% CI =1.61-6.19;p-value<0.001), had more than 5
children ( adj. OR=1.89, 95% CI = 1.21-2.97;p-value=0.005 and lining in poor environment (adj. OR
= 1.98, 95% CI =1.05-3.75, -value=0.035.
Table 7. Factors associated with quality of married life using multiple logistic regression.
% Poor Crude Adj.

QMI OR. OR.
Education <0.001
Higher education 90 46.67 1
Low education 242 71.36 2.92 3.16 (1.61-6.19)
Number of children 0.005
< 5 children 147 53.06 1
≥ 5 children 185 74.59 2.59 1.89 (1.21-2.97)
Environment Factors 0.035
Good (> 36 scores) 255 63.92 1
poor (≤36 scores ) 77 68.83 1.09 1.98 (1.05-3.75)
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Discussion and Conclusion
The findings revealed the prevalence of poor quality of married life (QMI) among Myanmar
married migrant women residing in Thai-Myanmar border was as high as 65.48%. The
socioeconomic disparity played and important roles on quality of married life of these migrant
women. Women who had low education and lived in poor environment condition also with
more children had poorer quality of married life when compared those with the better
conditions. The reproductive health knowledge and services are still priority to address for
migrant women such as family planning. Myanmar migrant families lived in the poor condition
similar to other study indicated that mostly one family had at least 4 or 5 member and living in
small room and lack of basic facilities (Ruth Pearson, 2012) (phuripanik, 2003). In this study,
the Myanmar migrant women workers’ living conditions that detrimental to their quality of
married life. Most of them were lived in unhygienic settings which lacked basic amenities, such
as proper toilet and cooking facilities. This finding has also been highlighted by Kessarawan
Niarangkul (2008).
Recommendation
The findings of the study have implications for various stakeholders: the migrant workers,
health personnel, employers, government, non- profit organization, community based
organizations and academics to work together to improve self-reliance through education as
well as their living standard. To make more equitable access to health and welfare services for
the workers’ families. Future research should focus on qualitative study of way of life and
quality of married life of the Myanmar married migrant women to gain more inside and leader
to development research to improve the quality of married life.
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Health Promotion 01
Reference
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Route toward (Il)legality for Indonesian Migrant Workers in Malaysia. Asian and Pacific
Migration Journal,, Vol. 21, No.3, 317-244.
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Perceptions, evaluations, and satisfactions: Russell Sage Foundation.
3. Chalermpol Chamchan, K. A. (2012). A Situation Analysis on Health System Strengthening
for Migrants in Thailand. Institute for Population and Social Research, Mahidol University
;no. 398), 166 pages.
4. Chee Heng Leng and Brenda S.A. Yeoh, R. S. Circuitous Pathways: Marriage as a Route
toward (Il)legality for Indonesian Migrant Workers in Malaysia. Asian and Pacific Migration
Journal,, Vol. 21, No.3, 2012, 317-244.
5. Hatch, L. R., & Bulcroft, K. (2004). Does long-term marriage bring less frequent
disagreements? Five explanatory frameworks. Journal of Family Issues, 25(4), 465-495.
6. Hsin-Chieh Chang1. (2015). Marital Power Dynamics and Well-Being of Marriage Migrants.
Journal of Family Issues © The Author(s)
7. Kessarwan Nilvarangkul (2008).Health-Related Quality of Life of Laotian Migrnt Workers
in thailand. Asian and Pacific Migration Journal, Vol. 17, No. 2, 2008.
8. Lee, H.-K. (2013). Employment and Life Satisfaction among Female Marriage Migrants in
South Korea. Asian and Pacific Migration Journal, Vol. 22, No.2, 199-229.
9. Oh, Y. A. (2014). Life Satisfaction of the Families of Migrants in the Philippines. Asian and
Pacific Migration Journal,,, Vol. 23, No. 3, 249-271.
10. Phyllis Zelkowitz, J. S. L. M. U. (December 2004). Factors Associated with Depression in
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Border: A Mixed Methods Study. 1-337.
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12. Sbarra, K. J. B. a. D. A. (2015). Women in Very Low Quality Marriages Gain Life Satisfaction
Following Divorce. Journal of Family Psychology, Vol. 29, No. 3, , 490–499.
13. Sharma, V., Saraswati, L. R., Das, S., & Sarna, A. (2015). Migration in South Asia: A Review.
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14. Statistics, O. (2017). Official Statistics Registration System. Available from Government
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15. Ruth Pearson, K. K. (2012). Thailand Hidden Workforce "Burmese Migrant women Factory
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Health Promotion 02
Socioeconomic disparity and abortion among migrant

in Thailand-Myanmar border area.
Hkawn Mai 1, Paricha Nippanon2

1
M.P.H. Student, Faculty of Public Health, KhonKaen University, Thailand.
2
Faculty of Public Health, KhonKaen University, Thailand.
การแท้งเป็ นหนึ่งในสาเหตุของการเสี ยชีวิตและการป่ วยของมารดาทัว่ โลก มีการศึกษาเกี่ยวกับการแท้ง

ของหมู่ผอู ้ พยพในประเทศไทย ซึ่งยังมีการศึกษาน้อยอยูแ่ ละพบว่าอัตราการทาแท้งของหญิงอพยพสู งกว่าหญิงไทย 2.4 เท่า
ซึ่ งการวิจยั ครั้งนี้ เป็ นการวิจยั เชิ งวิเคราะห์แบบย้อนหลัง (Case-control analytic study) โดยมีวตั ถุประสงค์เพื่อวิเคราะห์
ความสัมพันธ์ของสถานะทางเศรษฐกิ จและการทาแท้งของผูอ้ พยพชาวพม่าในเขตพื้นที่ ชายแดน ไทย – พม่า ในกลุ่ม
ตัวอย่างหญิงชาวพม่าที่อพยพเข้ามาในประเทศไทย จานวน 202 คน แบ่งเป็ นกลุ่มผูป้ ่ วยและกลุ่มควบคุม กลุ่มละ 101 คน
ตามคุ ณสมบัติของเกณฑ์การคัดเข้า เก็บข้อมูลด้วยการตอบแบบสอบถามอย่างมี โครงสร้ าง วิเคราะห์ ขอ้ มูลโดยสถิ ติ
พรรณนาและสถิติวเิ คราะห์ความสัมพันธ์ดว้ ยการวิเคราะห์ถดถอยพหุลอจิสติก
ผลการศึกษา พบว่า ปั จจัยทางเศรษฐกิจสังคม ได้แก่ ครัวเรื อนที่มีรายได้ต่า (adj. OR=1.57, 95% CI: 0.80-2.98, p-
value: <0.001) และระดับทัศนคติที่ไม่ดีเกี่ยวกับการตั้งครรภ์และการทาแท้ง (adj. OR=1.99, 95% CI: 1.06-3.71, p-value:
0.008)มีความสัมพันธ์กบั การทาแท้งอย่างมีนยั สาคัญทางสถิติ
สรุ ปผลการศึกษา สถานะทางสังคมและเศรษฐกิจต่าและทัศนคติที่ไม่ดีต่อการตั้งครรภ์และการทาแท้งมีอิทธิพลต่อ
การทาแท้งในหมู่ผอู ้ พยพชาวพม่าในประเทศไทย
Health Promotion 02
Abstract
Introduction: Abortion is one of the major causes of maternal mortality and morbidity globally.
There are few studies regarding abortion on migrant in Thailand and it was recorded that
abortion rate among the migrant women was 2. 4 times higher than that of the local Thai
population.
Objective: To determine the association of socioeconomic status and abortion among Myanmar
migrant in Thailand-Myanmar Border area.
Methodology: This case control analytic study was conducted in Mae Tao clinic in Maesot,
Tak province, Thailand. The total of 202 Myanmar migrant women (equal of case and control,
101 persons per group) were recruited according to the inclusion criteria. Both case and control
responded to structured questionnaire in private area to ensure their confidentiality. Simple and
multiple logistic regressions were used to determine the association.
Result: Socioeconomic factors that were associated with abortion were; had low household
income (adj. OR=1.57, 95% CI: 0.80-2.98, p-value: <0.001) and had low attitude on pregnancy and
abortion (adj. OR=1.99, 95% CI: 1.06-3.71, p-value: 0.008).
Conclusion: Low socioeconomic status and poor attitude on pregnancy and abortion had
influence on abortion among Myanmar migrant in Thailand.
INTRODUCTION
Abortion is worldwide problem in the world. There were 56 million abortions
happen worldwide between 2010 and 2014.(1) Almost 7 million women in developing countries
are treated for complications from unsafe abortions each year, and at least 22,000 die from
abortion-related complications yearly. (2)
Impact of abortion, Abortion is one of the major causes of maternal mortality and
morbidity in the world. Women who have economic challenges mostly got unintended
pregnancy and they end up with unsafe abortion. And for the women in the developing
Health Promotion 02
countries, because of the abortion and not treated properly, they suffer from reproductive health
issue. They also have challenges in accessing contraceptive methods, lack of information, not
aware well about abortion and contraceptives methods, fear of side effects, and economic
problems. (3)
Association of Southeast Asian Nations (ASEAN) countries and abortion. In ASEAN
countries included Myanmar, Thailand, Laos, Cambodia, Vietnam, Brunei, The Philippines,
Indonesia, Singapore, and Malaysia, one of the leading causes of maternal deaths is abortion 9%
of all maternal death. In ASEAN countries, the works has not done properly or the awareness
and services are very slow in the process of regarding promoting reproductive health and rights.
There was not a country which implement according as the world standard Reproductive Health
and Reproductive Rights. Also when look at the marginalized people, mostly the women are
poor, little education, live far away from the health service centers, disability, and also have
other challenges to obtain the knowledge and service of reproductive health and rights.(3)

This study was a case control study and conducted in Maetao clinic, Maesot, Tak
province in Thailand-Myanmar Border. Geographically, Mae Sot is a district in western
Thailand that shares a border with Myanmar to the west. Thailand’s Tak province there are
60,520 registered migrant workers and an estimated 150,000 unregistered migrant workers
from Burma.
Study population
The population for the study was female Burmese migrant workers in Tak province,
especially in Maesot district. The study sample was the women who come to Maetao clinic for
reproductive health services age between18-44.The eligible sample was fulfilled with the
following inclusion criteria, the Burmese migrant women age between18-44 from Maesot who
came to access reproductive health care at MTC, and women who gave informed consent to
participate in this study. Exclusion criteria were Burmese migrant women age under 18 and
above 44 from Maesot who came to access reproductive health care at MTC and the individuals
with mental disabilities.
Health Promotion 02
Sample Size
The sample size for this study was 101 Cases and 101 Controls of Burmese migrant
women who came to access Maetao clinic for reproductive health services. The sample size
was estimated based on the formula for a case-control study. (Fleiss, 2003). Statistical
analysis
This study was use to analyzed with multiple logistic regression.
RESULTS
Total of 202 questionnaires was returned with one hundred response rate. Their age
ranged in case and control group from 18 to 29 years with an average group, proportion of case
was slightly lower than control group, 40.59% and 65.35% respectively. From 30 to 44 years with
an average group, proportion of case was slightly higher than control group, 59.41% and 34.65%
respectively. Married status was reported among 89.11% and 99.01% of case and control group
respectively. Age of married status from 19 to 40 years was reported among 56.67% and 57%
respectively. The proportion married status of case was slightly lower than control group,
89.11% and 99.01% respectively. Majority of ethnicity of case group were Burman, Karen and
other (71.29%, 20.79% and 3.96% respectively.), and in control group were Burman, Karen and
other too, (73.27%, 14.85% and 10.89% respectively). Majority of Buddhism religion proportion
of case was slightly lower than control group, 93.07% and 88.12% respectively. However, of case
group was stay in Thailand about 6-30 years (53.47%) and in control group was stay in Thailand
about 0-5 years (59.41%). Majority of education level, proportion of case was slightly higher
than control group, 43.56% and 42.57% respectively. Majority of occupation of case group was
housewife and in control group was factory worker (34.65% and 39.60% respectively).
Health Promotion 02
Table 1 Baseline characteristics of participants Case and Control in number (%)
Age in years Case no. (%) Control no. (%)

18 – 29 years 41(40.59) 66(65.35)
30 - 44 years 60(59.41) 35(34.65)
Period of stay in Thailand
0-5 years 47(46.53) 60(59.41)
6-13 years 54(53.47) 41(40.59)
Occupation
No occupation and Housewife 43(42.57) 58(57.43)
Private Employee & Business & Factory 56(55.45) 45(44.55)
worker (sewing)
Family income
More than 8000 THB 67(66.34) 50(49.50)
Less than equal to 8000 THB 34(33.66) 51(50.50)
Health Status
Good 54(53.47) 84(83.17)
Average & poor 47(46.53) 17(16.83)
Health problem during pregnancy
No problems 44 (43.56) 67(66.34)
Severe nausea and vomiting/Baby activity 57 (56.44) 34(33.66)
declines, water breaks, persistent headache, bleeding
and other
Part B: Spouse factors
Age
17-29 years 23(25.56) 46(46.00)
30-64 years 67(74.44) 54(54.00)
Spouse income
Less than equal to 5000 41(45.56) 59 (59.00)
More than 5000
49(54.44) 41 (41.00)
Do you usually do annual health checkup?
Sometimes and always 50(49.50) 72(71.29)

Never 51(50.50) 29(28.71)
Who did accompany you during the visits at this
Clinic?
Nobody (self) & Spouse 21(20.79) 35 (34.65)
Mother in law& Friends and neighbors& 80(79.21) 66(65.35)
Sibling
Health Promotion 02
During pregnancy do you exercise or work hard?

No 21(20.79) 47(46.53)
Sometime & Often/usually 80(79.21) 54(53.47)
During pregnancy, you take supplementary
vitamin
No and sometimes 49(48.51) 80(79.21)
Always 52(51.49) 21(20.79)
Do you use family planning (contraceptives)?
Yes 63(62.38) 72(71.29)
No 38(37.62) 29(28.71)
Had fever during pregnancy
No 68(76.73) 87(86.14)
Sometimes/usually 33 (32.67) 14 (13.86)
Times of pregnancy you had?
<= 2 times 35(34.65) 64(63.37)
>= 3 times 66(65.35) 37(36.63)
Knowledge level
Low knowledge less than equal to 7.8 scores 47(46.53) 59(58.42)
and Medium knowledge (>7.8 – <=10.4 scores)
High knowledge More than 10.4 54(53.47) 42(41.58)
Attitude level
Low and Medium attitude (=20-29 scores) 28(27.72) 51(50.50)
High attitude More than equal to 30 73(72.28) 50(49.50)
Bivariate logistic regression analysis was performed to select variables into multivariate
logistic model. Any variable whose bivariable test with p-value <.25 was considered as candidate
for the model. The results of bivariate logistic regression model identifying the relationship
between characteristics of participants predisposing enabling and reinforcing factors and current
smoking status were presented in Table 2. Predisposing factors namely; period of stay in Thailand,
Health Status, Spouse income, health checkup, accompany you during the visits, exercise or work
hard during pregnancy, fever during pregnancy and Times of pregnancy were significantly related
to abortion at p-values<0.25. Therefore all factors were considered to be included into the further
multiple analysis since all p-values were less than the set criteria 0.25.
Health Promotion 02
Table 2. Simple logistic regression with factors on abortion number (%), OR, 95%CI, and
p-value.
Characteristics Case Control OR 95%CI P-value
Number (%) Number (%)
Age in years <0.001
18 – 29 years 41(40.59) 66(65.35) 1 1
30 - 44 years 60(59.41) 35(34.65) 2.76 1.55-4.88
Period of stay in Thailand 0.066
0-5 years 47(46.53) 60(59.41) 1 1
6-13 years 54(53.47) 41(40.59) 1.68 0.96-2.93
Occupation 0.066
No occupation and 43(42.57) 58(57.43) 1 1

Housewife
Private Employee & 56(55.45) 45(44.55) 1.68 0.96-2.92
Business & Factory
worker (sewing)
Family income 0.015 0.123
More than 8000 THB 67(66.34) 50(49.50) 1 1
Less than equal to 34(33.66) 51(50.50) 2.01 1.13-3.54

8000THB
Health Status <0.001
Good 54(53.47) 84(83.17) 1 1
Average & poor 47(46.53) 17(16.83) 4.3 2.24- 8.25
Health problem during < 0.001

pregnancy
No problems 44 (43.56) 67(66.34) 1 1
Severe nausea and 57 (56.44) 34(33.66) 2.55 1.44-4.51

vomiting/Baby activity
declines, water breaks,
persistent headache,
bleeding and other
Health Promotion 02
Part B: Spouse factors
Age <0.003
17-29 years 23(25.56) 46(46.00) 1 1
30-64 years 67(74.44) 54(54.00) 2.48 1.34-4.59
Spouse income 0.063
Less than equal to 5000 41(45.56) 59 (59.00) 1 1
More than 5000 49(54.44) 41 (41.00) 1.71 0.96-3.05
Do you usually do annual 0.001

health checkup?
Never 50(49.50) 72(71.29) 1 1
Sometime and Always 51(50.50) 29(28.71) 1.82 1.24-2.67
Who did accompany you 0.027

during the visits at this
Clinic?
Nobody (self) & Spouse 21(20.79) 35 (34.65) 1 1
Mother in law& Friends 80(79.21) 66(65.35) 2.02 1.07-3.79

and neighbors& Sibling
During pregnancy do you <0.001
exercise or work hard?
No 21(20.79) 47(46.53) 1 1
Sometime & 80(79.21) 54(53.47) 3.31 1.78- 6.16

Often/usually
During pregnancy, you take <0.001
supplementary vitamin
No and sometimes 49(48.51) 80(79.21) 1 1
Always 52(51.49) 21(20.79)
Do you use family planning 0.178

(contraceptives)?
Yes 63(62.38) 72(71.29) 1 1
No 38(37.62) 29(28.71) 1.49 0.83 - 2.70

Health Promotion 02
Had fever during pregnancy 0.001
No 68(76.73) 87(86.14) 1 1
Sometimes/usually 33 (32.67) 14 (13.86) 3.01 1.49-6.07
Times of pregnancy you had? <0.001
<= 2 times 35(34.65) 64(63.37) 1 1
>= 3 times 66(65.35) 37(36.63) 3.26 1.83-5.80
Knowledge Level 0.090
Low knowledge less than 47(46.53) 1 1

equal to 7.8 scores and
59(58.42)
Medium knowledge (>7.8
– <=10.4 scores)
High knowledge More 54(53.47) 1.61 0.92-2.81
42(41.58)
than 10.4
Attitude level <0.001
Low and Medium 28(27.72) 1 1

51(50.50)
attitude (=20-29 scores)
High attitude More than 2.65 1.48-4.77
73(72.28) 50(49.50)
equal to 30
After entering to the model then participant’s factor having the p-value more than .05 will
be excluded from the model. Then another factors is added and evaluated together with previously
accepted predictor, odds ratio for each of the participant factors along with its corresponding 95%
confidence intervals were presented in Table 3. It showed that participant characteristics had more
effect on current abortion, in this study show that time of pregnancy in three-time pregnancy was
the more the risk of current abortion as compare to those at a lower three time pregnancy (adj.OR
3.82 with 95% CI: 1.80-8.12).Health statusduring pregnancy in moderate and poor status was the
more the risk of current abortion as compare to those at a good health status (adj.OR2.97 with
95% CI: 1.33-6.61). Considering the one did accompany you during the visit at the clinic, mother
in law or friend and neighbors and sibling 3.16 times more than nobody and spouse (95%CI: 1.38-
7.24). Time of exercise or work hard in sometime or/and usually pregnancy was the more the risk
of current abortion as compare to those at a no exercise pregnancy (adj.OR2.86 with 95% CI: 1.29-
Health Promotion 02
6.33).Fever during Pregnancy, in sometime or/and usually got fever during pregnancy was the
more the risk of current abortion as compare to those at a no fever during pregnancy (adj.OR 3.14
with 95% CI: 1.24-7.94).About health check-up during Pregnancy, in never health check-up during
pregnancy was the more the risk of current abortion as compare to those at a sometime or/and
always health check-up during pregnancy (adj.OR 1.73 with 95% CI: 1.07-2.80).About period of
stay in Thailand, 6 years and more was the more the risk of current abortion as compare to those
at less than 5 years (adj.OR 2.31 with 95% CI: 1.09-4.89) were shown in Table 3.
Table 3. Multivariate logistic regression with factors on abortion number (%), OR,
95%CI, and p value.
Characteristics Case Control OR AdjOR 95%CI P-value
Number (%) Number (%)
Period of stay in 0.029

Thailand
0-5 years 47(46.53) 60(59.41) 1 1
6-13 years 54(53.47) 41(40.59) 1.68 2.31 1.09-4.89
Health Status <0.001
Average & poor 54(53.47) 84(83.17) 1 1
Good 47(46.53) 17(16.83) 4.3 2.97 1.33-6.61
Spouse income 0.167
Less than equal to 41(45.56) 59 (59.00) 1 1

5000
More than 5000 49(54.44) 41 (41.00) 1.71 1.66 0.80-3.44
Do you usually do 0.024

annual health checkup?
Never 50(49.50) 72(71.29) 1 1
Sometime and 51(50.50) 29(28.71) 1.82 1.73 1.07-2.80

Always
Who did accompany 0.006
you during the visits at
this Clinic?
Health Promotion 02
Nobody (self) & 21(20.79) 35 (34.65) 1 1

Spouse
Mother in law& 80(79.21) 66(65.35) 2.02 3.16 1.38-7.24

Friends and
neighbors& Sibling
During pregnancy do 0.009
you exercise or work
hard?
No 21(20.79) 47(46.53) 1 1
Sometime & 80(79.21) 54(53.47) 3.31 2.86 1.29-6.33

/usually
Had fever during 0.015
pregnancy
No 68(76.73) 87(86.14) 1 1
Sometimes/usually 33 (32.67) 14 (13.86) 3.01 3.14 1.24-7.94
Times of pregnancy you <0.001

had?
<= 2 times 35(34.65) 64(63.37) 1 1
>= 3 times 66(65.35) 37(36.63) 1.17 3.82 1.80-8.12
DISCUSSIONS
This study investigated whether the socioeconomic disparity factors between abortion
case group and control group have associations.In demographic factors, the woman (30-44) age
group have 3.12 times more risk to abortion compared with (18-29) age group and significantly
association. The period of stay in Thailand 0-5 years group have 1.68 times more chance to
abortion than >5years stayed. (4)
Abortion was significantly associated among different occupation those housewife 4.45
times, unskilled worker 2.16 times, farmer, fisherman 1.34 times more risk to abortion
compared with Private Employee & Business & Factory worker (sewing).The women who
stayed in Maesot have 1.27 times more risks to abortion than who stayed in PhobPhra& Mae
Ra Mat. (4)
Health Promotion 02
Moreover, urban women were 2.79 times more likely to risk abortion than rural women.
The women who average & poor health status were significantly 4.3 times more likely to
chance abortion than good health status. Health problems during pregnancy were strongly
associated with abortion.(3)
With about spouse, abortion was significantly among different spouse age group, those
40-64 years, 26-44 yearswere more likely risk abortion to their wife than 17-29 years. Beside,
spouse education level High school or equivalence & Bachelor and upper, Primary school &
Secondary school more risk abortion to their wife compared with no formal education.(5)
Health behavior factors, the women who have always annual health checkup who have
sometime more get to abortion compared with who never check and significantly association
P=0.005. During pregnancy, who no exercise were 3.31 times more see to abortion than
sometime & often/usually. During pregnancy, who not took supplementary vitamin, who
sometime took were more likely chance to abortion than who took often and these were
significantly association. During pregnancy, Who had sometime& often/usually fever have 3.01
times more risk to abortion than who had no fever (OR=3.01,95%CI=1.49-6.07,P=0.001).The

numbers of times to delivered was slightly associated with abortion, those the women who had
0-4 times delivered were 2.58 times experienced to abortion compared who had delivered 4-8
times.
Concerning about knowledge level, abortion was slightly associated with different
knowledge level. The women who have low and medium knowledge level were 1.61 times more
chanced to abortion compared with high knowledge level. Attitude level was significantly with
abortion case. The women who have low and medium attitude were 2.14 times more likely to
be seen than high attitude level.
This study provided a great acknowledge on abortion to the migrant women along
Thailand-Myanmar border areas. First research on abortion with a case control study among the
Myanmar migrant women who came to access MaeTao clinic in Maesot.

Health Promotion 02
This study could be defended as the findings of potential risk factors of socioeconomic
disparity related to abortion. However it would be more accurate to identify abortion both
miscarriage and induced, and to take longer period of study time, and as well as to do the
research in both quantitative and qualitative.
Conclusions
Health status of the women, annual health checkup practice, spouse income, period of
stay in Thailand, who accompanied the women to the health center, working hard during
pregnancy, had fever during pregnancy, and times of getting pregnant were related with the
abortion.
Recommendations
By looking at this study, the recommendations are,
- To help improve health status of women

- To help improve their income by promoting spouses incomes
- To help increase health awareness to husbands in order to take care of their wives
- To give the awareness to the women not to work too hard during pregnancy
Acknowledgements:
I would like to express my deep thank you to International Rescues Committee Project
for Local Empowerment (IRC-PLE), USAID, the International Public Health Department at
KhonKaen University Thailand, and to all my professors, advisor, and seniors from school.
And also thank you very much to Maetao clinic for allowing me to be done my study there and
for provided me other needed helps. Also thank you very much to all the study participants and
my friends who helped me a lot during data collection.
REFERENCES
1. institute WaG. INDUCED ABORTION WORLDWIDE FACTS.
2. Institute G. Facts on Abortion in Asia. 2015.
3. Neema Mamboleo M. UNWANTED PREGNANCY AND INDUCED ABORTION
AMONGFEMALE YOUTHS: A CASE STUDY OF TEMEKE DISTRICT. 2012.
4. Perez G, Ruiz-Munoz D, Gotsens M, Cases MC, Rodriguez-Sanz M. Social and

economic inequalities in induced abortion in Spain as a function of individual and contextual
factors. European journal of public health. 2014;24(1):162-9.
5. Maung bSBaC. Fertility and abortion: Burmese women’s health on the Thai-Burma
border.
3. Ando & Programme Manager, 2014

Health Promotion 03
Physical Health, Socio-Demographic and Pre-Frailty

Among Community-Dwelling Older Persons
in Lampang Province
Authors: Payom Thinuan1, Penprapa Siviroj2, Peerasak Lerttrakarnnon3, Tawon Lorga4
1 Ph.D. (candidate) in Community Medicine, Department of Community Medicine, Faculty of Medicine, Chiang
Mai University, Chiang Mai, THAILAND
2 Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai,
THAILAND
3 Department of Family Faculty of Medicine, Chiang Mai University, Chiang Mai, THAILAND
4 Boromrajonani College of Nursing Nakhon Lampang, Lampang
Corresponding author’s email: [email protected]
ภาวะเปราะบางเป็ นกลุ่มอาการสู งอายุที่แสดงออกมาให้เห็น และส่ งผลต่อผลลัพธ์ทางสุ ขภาพที่แย่ลง และเกิดภาวะทุพลภาพในผูส้ ูงอายุ
ภาวะก่อนภาวะเปราะบางเป็ นอาการแรกที่จะพัฒนาสู่ภาวะเปราะบางในผูส้ ูงอายุ และมีปัจจัยที่เกี่ยวข้องกับภาวะเปราะบางหลายประการ การวิจยั นี้
เป็ นแบบภาคตัดขวาง ทาการศึกษาในกลุ่มผูส้ ู งอายุ จานวน 1,554 คน ที่อาศัยอยูใ่ นชุมชนจังหวัดลาปาง ทาการสุ่ มตัวอย่างแบบสุ่ มหลายขั้นตอน
เก็บข้อมูลด้วยแบบสัมภาษณ์และตรวจร่ างกายกลุ่มตัวอย่าง โดยใช้เครื่ องมือประเมินของ The Fried Frailty Phenotype เพื่อคัดกรองผูส้ ู งอายุที่มี
ภาวะก่อนเปราะบาง เกณฑ์ประเมินภาวะเปราะบาง ได้แก่ อ่อนเพลีย, น้ าหนักลด, เคลื่อนไหวช้า, ความแข็งแรงกล้ามเนื้อลดลง และการเคลื่อนไหว
ออกแรงช้า ผูส้ ู งอายุที่มีภาวะเปราะบางมี 3 กลุ่มคือ กลุ่มปกติ (0 คะแนน) กลุ่มก่อนภาวะเปราะบาง (1-2 คะแนน) และกลุ่มภาวะเปราะบาง (3-5
คะแนน) วิเคราะห์ปัจจัยที่มีความสัมพันธ์ต่อภาวะก่อนเปราะบางโดยใชสถิติ binary logistic regressions
จากการศึกษาพบว่ากลุ่มตัวอย่างส่ วนใหญ่เป็ นเพศหญิง (70.50%) มีอายุเฉลี่ย 70.74 ±7.46 ปี มีความชุกของภาวะก่อนเปราะบาง 50.2%
(95% CI: 56.8-61.6) และมีภาวะปกติ 40.80% (95% CI: 38.4-43.2) เป็ นเพศหญิง 58.7% และเพศชาย 60.3%. ปั จจัยที่มีความสัมพันธ์กบั ภาวะก่อน
เปราะบางในผูส้ ูงอายุ ได้แก่ การรับรู ้ภาวะสุขภาพที่ดีของตนเอง (OR=0.54; 95% CI: 0.345-0.858) การมีโรคร่ วม (OR=1.25; 95% CI: 1.110-1.399)
น้ าหนักตัว (OR= 0.97; 95%CI: 0.949-0.981) ความสู ง (OR=0.98, 95% CI: 0.966-0.992) และเส้นวัดรอบแขน (OR=0.94; 95% CI: 0.904-0.979)
นอกจากนี้ พบอายุ (OR=1.88; 95% CI: 1.098 -1.139) และระดับการศึ กษาที่ สูงกว่ามัธยมศึ กษามีความสัมพันธ์กับภาวะก่ อนเปราะบางอย่างมี
นัยสาคัญทางสถิติ (OR=1.88; 95% CI: 1.196-2.976)
โดยพบว่าสุขภาพทางกาย และปั จจัยประชากรและและสังคมมีความผลต่อการเกิดภาวะก่นเปราะบางในผูส้ ูงอายุที่อาศัยอยูใ่ นชุมชน
จังหวัดลาปาง
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Health Promotion 03
Abstract
Introduction: Frailty is an emerging geriatric syndrome leading to adverse health outcomes and disability in
older persons. Pre- frailty is the first symptom that will be progressed to frailty. There are multiple factors
associated with frailty.
Objective: To determine association of physical health and socio-demographic with pre-frail among older persons
in Lampang province.
Methodology: This cross-sectional study was conducted among 1,554 community-dwelling older persons in
Lampang province who were multi-stage random sampling to response to structured questionnaire interview and
physical examination. The Fried Frailty Phenotype Assessment was used to identify the pre-frailty. The Fried
frailty phenotype criteria are exhaustion, unintended body weight loss, low gait speed, low grip strength, and low
physical activity. Frailty are divided into 3 stages: non-frail (zero score), pre-frailty (scores 1-2) and frail (score 3-
5). The associated factors on pre-frailty were determined using binary logistic regressions.
Result: Most of the participants were females (70.50%) with the average age of 70.74 ±7.46 years. The prevalence
of pre-frailty was 50.20% (95% CI: 56.8-61.6) and non-frailty was 40.80% (95% CI: 38.4-43.2), 58.7% and 60.3% among
females and males respectively. The factors associated with pre-frailty among older persons were perceived good
health (OR=0.54; 95% CI: 0.345-0.858), having co-morbid (OR=1.25; 95% CI: 1.110-1.399), body weight (OR= 0.97;
95%CI: 0.949-0.981), height (OR=0.98, 95% CI: 0.966-0.992), and arm circumference (OR=0.94; 95% CI: 0.904-0.979).
In addition aged (OR=1.88; 95% CI: 1.098 -1.139) and high level of education (OR=1.88; 95% CI:1.196-2.976) also
significantly associated with pre-frailty.
Conclusion: Both physical health and socio-demographic had influence on pre-frailty among older persons in
Lumpang
Key words: Older person, Pre-frailty, Association
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Health Promotion 03
Introduction
Increasing of older person is similar the entire world. The older population in Thailand is rapidly
increasing. Thai support ratio is rising dramatically. Frailty is considered highly prevalent in older people. Frailty
is an emerging geriatric syndrome leading to adverse health outcome( 1) , disability, falls, long- term care,
dependence and death ( 1- 3) in older persons. Pre-frailty is the first symptom that will be progressed to frailty. Pre-
frailty was indicated as a condition that results of signs and symptoms that high susceptibility to impending
decline in physical function(4). The prevalence of pre-frailty by gait speed was 27.3%(5). Although there were many
study in worldwide but each country difference in genetic, physical, life style and culture so we thought the
associated factors of pre-frailty be difference in each country. Pre-frailty factor already known on this topic. We
don’t know the pre-frailty risk factor in Thai older persons. There are multiple factors associated with per-frailty(2,
4, 6)
such as socio-demographic, and health factors( 1, 4, 6) , which raising questions about how pre-frailty develops,
how we might prevent it, and how we can be detected risk factors. Health care providers should be known about
the risk factors that can reduce pre-frail in older persons such as creating the intervention for stabilizing the pre-
frailty(5).
Methods
A cross-sectional study be designed to identify pre-frailty and non-frailty older person, with five Fried’s
frailty phenotype criteria that be screened for pre-frailty, comprised self-reported, exhaustion, unintended body
weight loss, slow walking speed, grip strength, and a low physical activity, pre-frailty as 1-2 score and non-frailty
as non (zero score) (3,7). We excluded frail older persons from this study. The factors associated of pre-frailty were
collected by questionnaire and physical examination. These Physical factors was predicted for pre-frailty included
socio-demographic e.g. sex, age, education, and income; and physical health e.g. co-morbid, self-health rating,
using of medical pill, body weight (kg.), height (cm.), arm circumference (cm.), calf circumference (cm.) and waist
circumference (cm.).
The number of participants was 1,554. Multi-stage random sampling was used to recruit participants from
3 districts of Lampang province. This study was be done between July 2015 to December 2015. They assessed
with the recruit criteria (aged 60 years up, can communicate and understand in Thai, no impair mobility, no bed
144
Health Promotion 03
bounden, no impair both hands, no crisis signs and symptom such as chest pain, arthritis, dyspnea, severe
headache and cognitive impair).The participants mean age was 70.47 years and 70.50 percentages were female.
The ethical was approved by the Research Ethics Committee of Faculty of Medicine, Thailand (No.3036/2015)
Chiang Mai University. Written informed consents were obtained from all of participants. We determined
association of physical health and socio-demographic with pre-frail among older persons in Lampang province
that predicted by binary logistic regression test with significance determined to be at the p<.05 level and 95% CI.
Characteristic factors of pre-frailty and non-frailty was described by descriptive statistic, mean, standard deviation
and percentage.
Results
50.20% of the participant was pre-frailty and 40.80% non-frailty. The characteristic of pre-frail older by
physical health and socio-demographic shown in table 1-2. Socio-demographic variables of pre-frailty older person
were man more than woman (58.70% in woman, 60.30% in man), no education was the highest (79.70%), and all of
them had income less than 1,000 baths. Physical health of pre-frail older person was 69.60% poor heath (by self-
health rate) and 62.20% moderate health, more than two (68.90%) had co-morbid and using of medical pill more
( 61. 30% ) . Mean score of body weight was 52. 05 kg. , 151. 41 cm. mean of height, 26. 05 cm mean of arm
circumference, 32.34 cm. mean of calf circumference and 82.63 cm. mean of waist circumference. (Table 1, 2)
Table 1: Characteristics of pre-frail and non-frail older person
Characteristics Pre-frailty (n, %) Non-frailty (n, %)

Women 640(58.70) 450(41.30)
Men 280(60.30) 184(39.7)
No education 98(79.70) 25(20.30)
Primary level 700(60.90) 449(39.10)
>high school 122(43.26) 160 (56.74)

Incomes <1,000 (Bath) 384(66.70) 192(33.30)
1,000-4,999(Bath) 355(57.00) 268(43.00)
5,000-9,999(Bath) 106(57.00) 79(43.00)
> 10,000(Bath) 75(44.10) 95(55.90)
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Characteristics Pre-frailty (n, %) Non-frailty (n, %)

Poor health rating 78(69.60) 34 (30.40)
Moderate health rating 500(62.20) 304(37.80)
Good health rating 342(53.60) 296(46.40)
No of Co-morbid 265 (55.90) 209 (44.10)
1-2 482 (58.10) 347 (41.90)
More than 2 173 (68.90) 78 (31.10)
No (no using of medical pill) 321(55.60) 256(44.40)
Yes (used more than 1) 599(61.30) 378(38.70)
Table 2: Physical health of pre-frail and non frail older person
Physical health Pre-frailty, x̄ (Sd.) Non frailty, x̄ (Sd.)

Age (years) 77.88 (7.25) 66.93 (5.53)
Body weight (kg.) 52.05 (10.41) 56.79 (9.68)
Height (cm.) 151.41 (9.37) 154.45 (9.39)
Arm circumference (cm.) 26.05 (3.49) 27.70 (5.27)
Calf circumference (cm.) 32.34 (10.30) 33.47 (4.55)
Waist circumference (cm.) 82.63 (11.74) 84.82 (10.80)
Table 3: Associated variables of pre-frailty after adjustments of physical health
Associated variables OR (95% CI) p-Value

Physical health factors (a)
Co-morbid* 1.246 (1.11-1.39) .00
Mid upper arm circumference* 0.941 (0.90-0.97) .00
Height* 0.979 (0.96-0.99) .00
Poor health status ref ref
Good health status * 0.544 (0.34-0.85) .00
Body weight* 0.965 (0.94-0.98 ) .00
Waist Circumference 1.011 (0.99-1.02) .08
Calf circumference 0.990 (0.96-1.01) .39
Using medicine 0.937 (0.71- 1.23) .64
Socio-demographics (b)
Age* 1.118 (1.09-1.13) .00
No education ref ref
Primary school level * (1) 0.548 (0.34 -0.88) .01
High school up* (2) 0.294 (0.17-0.50) .00
Income 1.000 (1.00-1.00) .35
Sex 0.960 (0.75-1.22) .74
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Reference were poor health, no using medicine, no education and woman

*p<0.01
a. Model adjusted for age, sex, education and incomes
b. Model adjusted for co-morbid, mid upper arm circumference, height, self-health rate,
body weight, waist Circumference, calf circumference and using of medical pill
The associated variables for pre- frailty when adjusted models indicated that physical factors had
significantly oods of developing pre-frailty with non-frailty group were co-morbid (OR=1.25; 95% CI: 1.110-1.399);
arm circumference (OR=0.94; 95% CI: 0.904-0.979); height (OR=0.98, 95% CI: 0.966-0.992); self-health rate, good
health with poor health (OR=0.54; 95% CI: 0.345-0.858); body weight (OR= 0.97; 95% CI: 0.949-0.981), the factors
not significant (P>0.05) were waist Circumference health (OR=1.011 ; 95% CI: 0.99-1.02 ), Calf circumference
health (OR=0.99; 95% CI: 0.96-1.01 ) and Using of medical pill (OR= 0.937 ; 95% CI: 0.71- 1.23). Nevertheless socio-
demographic factors predicted pre-frailty were aged (OR=1.88; 95% CI: 1.098 -1.139) and education (OR=1.88; 95%
CI: 1.196-2.976) that shown in table 3.
Discussion
We have shown that the prevalence of pre-frailty, as defined by Fried, among community-dwelling
older persons were 50.20% and 40.80% non-frailty that associated with result of the study at Rio de Janeiro, Brazil
found pre-frailty was 47.3% (95% CI 43.8-50.8) (4, 8) . There were statistical significances in age, number of chronic
disease, depressive mood, MMSE, falls, hospitalization, IADL disability contributing to frailty (P < 0.05) ( 4, 10) ,
but were study in senior welfare centers located in Seoul, Korea found 27% of pre-frail by the SOF index(7). Clear
highly of older person who lived in Lampang province that aged over 60 years and for women were 58.7% and
60.3% in men. Among per-frailty was significant associated with co-morbid, arm circumference, height, self-health
rate, body weight, aged( 4) . However, waist Circumference, calf circumference, using of medical pill, after
adjustment were not significant association (P>0.05). These finding were the first identified or screening with
Fried’s frailty phenotype of older persons in Lampang, which are important implications.
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The pre-frailty is not uncommon in men and women who live in community-dwelling, there have physical
health problems in pre-frailty which appear to be largely co-morbidities by the variety of chronic diseases and
shown with self- health rate, size of body ( height, and body weight) , muscle strengths ( mid upper arm
circumference, waist Circumference, and calf circumference) that occur among socially disadvantaged
individuals. The size of body, arm circumference represented signs of malnutrition (value 22.5cm. sensitivity of
67.7%, specificity of 94.5%) (11), which indicated when we follow up the older person who had chronic disease. We
should concern about co-morbid, arm-circumference, self-health rate and suggest them to monitor body weight
because the nutritional status have relation with ability and energy intake in older( 12) . If pre- frailty had
malnutrition, they may progress early to frailty. These associations can be the predictors of pre-frailty among
community-dwelling older persons that we should take an interest because it was the basic data that we can focus
easily on them.
Conclusions
Physical health and socio-demographic had influence on pre-frailty among older persons in Lumpang.
Older persons should follow up physical change to delay frailty. Associated factors were protective pre-frailty
seen between health status, body weight, and height and arm circumference. The cross-sectional suggested
physical factors are associated with delaying the onset and progression of pre-frailty.
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sectional study. Aging Clin Exp Res. 2010;22(1):54-62.
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6. Ng TP, Feng L, Nyunt MS, Larbi A, Yap KB. Frailty in older persons: multisystem risk factors and the
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Korean J Fam Med. 2011;32(4):249-56.
8. Linda P. Fried, Catherine M. Tangen, Jeremy Walston, Anne B. Newman, Calvin Hirsch, John
Gottdiener, et al. Frailty in Older Adults Evidence for a Phenotype.pdf.
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10. Moreira VG, Lourenco RA. Prevalence and factors associated with frailty in an older population from
the city of Rio de Janeiro, Brazil: the FIBRA-RJ Study. Clinics. 2013;68(7):979-85.
11. Benitez Brito N, Suarez Llanos JP, Fuentes Ferrer M, Oliva Garcia JG, Delgado Brito I, Pereyra-Garcia
Castro F, et al. Relationship between Mid-Upper Arm Circumference and Body Mass Index in
Inpatients. PLoS One. 2016;11(8):e0160480.
12. Odlund Olin A, Koochek A, Ljungqvist O, Cederholm T. Nutritional status, well-being and functional
ability in frail elderly service flat residents. Eur J Clin Nutr. 2005;59(2):263-70.
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Perceived Social Norms towards Premarital Sexual Practices and Associated

Factors among Myanmar Migrant Adolescents in Tak Province, Thailand
Bo Bo Lwin1, Assoc. Prof. Dr. Wongsa Lohasiriwong2
1
MPH student, Faculty of Public Health, Khon Kaen University, Thailand,
2
Working Age People, Khon Kaen University, Thailand
บทนํา: สถานะสุ ขภาพทางเพศของวัยผูใ้ หญ่มีความสัมพันธ์อย่างใกล้ชิดกับประสบการณ์ในช่วงวัยรุ่ น
เมือเริ มมีการพัฒนาการทางเพศ ความเข้าใจการรับรู ้บรรทัดฐานทางสังคมต่อการปฏิ บตั ิทางเพศและปั จจัยที
เกียวข้องของวัยรุ่ นเป็ นสิ งสําคัญทีนําสามารถมาใช้ในการพัฒนาหามาตรการทีเหมาะสมเพือลดความเปราะบาง
ของแรงงานย้ายถินชาวพม่า
วัตถุประสงค์ : เพือระบุการรับรู ้บรรทัดฐานทางสังคมทีมีต่อการปฏิบตั ิทางเพศสัมพันธ์ก่อนการแต่งงาน
และปั จจัยทีเกียวข้องในหมู่วยั รุ่ นแรงงานย้ายถินชาวพม่าในประเทศไทย
ระเบียบวิธีวจิ ัย: การศึกษาเชิงวิเคราะห์แบบภาคตัดขวางได้ดาํ เนินการใน 4 อําเภอของจังหวัดตาก ศึกษา
ในแรงงานวัยรุ่ นย้ายถินชาวพม่าอายุ 15-19 ปี จํานวน 403 คน ทีถูกคัดเลือกโดยการสุ่ มแบบเป็ นระบบ หลังจากที
ได้รับความยินยอมเป็ นลายลักษณ์อกั ษร กลุ่มตัวอย่างตอบแบบสอบถามแบบมีโครงสร้างด้วยตนเอง วิเคราะห์
ความสัมพันธ์ดว้ ยสถิติ การวิเคราะห์ถดถอยโลจิสติกแบบพหุ
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ผลการศึกษาพบว่ า: กลุ่มตัวอย่างวัยรุ่ นแรงงานย้ายถินชาวพม่าในประเทศไทย ส่ วนใหญ่เป็ นเพศหญิง
(61.54%) เกื อบครึ งหนึ งอยู่ในภาคแรงงาน (42.35%) ความชุ ก ของการรับ รู ้ บ รรทัดฐานของการปฏิ บ ตั ิ ท าง
เพศสัมพันธ์ก่อนการแต่งงานในระดับตํา เท่ากับ 43.18% (95% CI = 38.32% -48.03%) ปั จจัยทีมีความสัมพันธ์
กับการรับรู ้บรรทัดฐานของการปฏิบตั ิทางเพศสัมพันธ์ก่อนการแต่งงานในระดับตํา ได้แก่เป็ น เพศชาย (adj OR
= 2.54, 95% 8;CI:. 1.58-4.08, p-value <0.001) มีระดับการศึกษาตํา (adj OR = 3.66, 95% CI: 1.66-5.38, p-
value <0.001) ไม่ได้อาศัยอยูก่ บั พ่อแม่ (adj OR = 1.91, 95% CI:. 1.20-3.04.13, p-value = 0.006) พ่อแม่แยกทาง
กัน (adj . OR = 1.61, 95% CI: 1.20-3.69, p-value = 0.009) มีทศั นคติทีไม่เหมาะสมในการปฏิบตั ิทางเพศadj OR
= 5.88, 95% CI:. 2.89-11.96, p-value <0.001) และมีอิทธิ พลจากสภาพแวดล้อมเช่นเพือนในระดับสู ง (adj OR =
2.52, 95% CI :. 1.12-5.72 ค่า p- = 0.001)
สรุ ปผล: ผลการศึกษาระบุวา่ วัยรุ่ นแรงงานข้ามชาติส่วนมากมีบรรทัดฐานทางสังคมต่อการปฏิบตั ิทาง

เพศสัมพันธ์ในระดับตําของและได้รับอิทธิ พลอย่างมากเพศภาวะ การศึกษา สภาพครอบครัว และทังสิ งแวดล้อม
ภายในได้แก่ทศั นคติ และปั จจัยทางสิ งแวดล้อม ได้แก่อิทธิพลของเพือนและ สิ งเร้าทางเพศ
คําสํ าคัญ การรับรู ้บรรทัดฐานทางสังคม เพศสัมพันธ์ก่อนแต่งงาน แรงงานย้ายถินชนชาติพม่า
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Abstract
Introduction: Adult sexual health status is closely related to experiences
during adolescence when sexual development is commenced. Understanding their
perceived sexual norms and its associated factors is crucial in developing
appropriate measures to reduce their vulnerabilities.
Objective: To determine perceived social norms towards premarital sexual
relationships and associated factors among Myanmar migrant adolescents in
Thailand.
Method: This cross sectional analytic study was conducted in 4 districts of
Tak province. Total of 403 Myanmar migrant adolescents aged 15 to 19 years were
recruited by using systemic random sampling. After given written consent, the
samples responded to a self-administered structured questionnaire to ensure their
confidentiality. Simple and multiple logistic regressions were used to determine the
association
Results: Most of the samples were females (61.54%), almost half were in
workforce sector (42.35%). The prevalence of poor perceived social norm on
premarital sexual relationship was 43.18% (95% CI = 38.32%-48.03%). Factors
associated with poor perceived social norms towards premarital sexual relationship
were male gender (adj. OR = 2.54, 95%CI: 1.58-4.08, p-value: <0.001), had low
level of education (adj. OR= 3.66, 95%CI: 1.66-5.38, p-value: <0.001), did not
stay with biological parents (adj. OR= 1.91, 95%CI: 1.20-3.04.13, p-value: 0.006),
parents did not lived together (adj. OR= 1.61, 95%CI: 1.20-3.69, p-value: 0.009),
had inappropriate attitude on sexual practices (adj. OR= 5.88, 95%CI: 2.89-11.96,
p-value: <0.001), and had average to high level of influence from environment
such as peer (adj. OR= 2.52, CI: 1.12-5.72, p=0.001).
Conclusion:The study demonstrated poor perceived sexual norms among
adolescents were common and were strongly influenced by sexual orientation,
education, family condition, and both internal (attitude) and environmental (peer,
sexual stimuli) factors.
Key words: Perceived social norms, premarital sex, adolescent,

Myanmar migrant
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Introduction
In 2016 there were 1.2 billion of adolescents making up of 16 percent of
global population, and a quarter of world’s population when they are combined
with ages up to 24 years as youths, they now are the world’s biggest cohort
throughout the history of world. It is obvious that they are holding a massive
potential of changing the world in aspects of economy, politics, social including

health. (WHO, 16th World Health Assembly) (UNICEF). Contrarily, Adolescents are
weak and vulnerable in every perspective and by every received environment and
contextual influence such as socio-economic, cultural circumstances. HIV/AIDS,
unintended pregnancy and teenage mother, education failure, legal touble, etc. have
been series of consequences for adolescents after their risk taking or reduction
behaviors perceived by learning from environment, culture, peers, role models,
families, schools. (SmitaPamar) (Blum, 2005; WHO, 2006) In 2015, 1.8 million
adolescents were living with HIV worldwide (UNAIDS, 2016). Unintended
pregnancies give rise to negative effects at large on adolescents, their children and
society. (Kirby, 2011) Every day, 39,000 girls become child brides or about 140
million in a decade. (Every Women, 2015) (Monica Das Gupta, 2014)
Migration has been a protracted issue among Myanmar and Thailand.
HIV/AIDS prevalence among migrants in Thailand are higher. Migration itself does
not make migrants at high risk, however is presumed to be highly vulnerable to
HIV due to various socioeconomic factors (Press, 2011). For instance, there are
barriers for accessing health care from Migrant Health Insurance Scheme (Baker,
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2011) especially among adolescents possibly because of long working hours,
intimidation by adult employers, poor experience in addressing health issues and

self-care. Therefore they become more vulnerable due to migration. (Thailand, 2014)
Belief of what most other people naturally do or agree with is known as
perceived social norm. What perceived social norms influenced on one’s practices is
demonstrated as in another ways where things surrounding the individual shape his/
her practice. (Goldstein, 2003) Studies revealed that adolescents were prone to
engage in risk practices when they wrongly perceived that these practices were
common among their peers. (Perkins & Craig, 1999; Perkins & Wechsler, 1996).
Then, misperceptions lead to behavioral forming whether risk taking or risk
protection since that time may then lead to life time behaviors. (WHO 2017).
Studies relating perceived social norms towards premarital sexual

practice among Myanmar adolescents was rare and so were the studies among
migrants. If we learn well about their perceived social norms towards premarital
sexual practice, it would benefit to take opportunity of protecting adolescents and

reversing their vulnerabilities (WHO, 2006)
Research Design
This was a cross-sectional analytical study which was conducted among 403
Myanmar migrant adolescents staying in three randomly selected districts of Tak

Province, in Thailand. Inclusion criteria were Myanmar adolescents staying in
Thailand, had ages between 15 and 19 years, were able to read and write Myanmar
language and were willing to participate in the study. Self-administered structured
questionnaire was used to ensure their confidentiality.
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Operational Definitions
Perceived social norm is belief of what most other people naturally do or

agree (Goldstein, 2003). Outcome was poor perceived social norm towards
premarital sexual practice. To assess, adolescents were asked three questions
regarding premarital sexual relationship to respond whether they “disagree”,
“indifferent” or “agree”. Responses and total score were categorized into three;
inappropriate, indifferent and appropriate. (Harold O, Kiess) inappropriate and
indifferent score groups were combined and regarded as “Poor perceived social
norms towards premarital sexual practice and appropriate group was regarded as
“Good perceived social norms”.
Sampling Method
Three districts in Tak Province were randomly selected and out of nine districts,
total study population of 403 was selected.
Sampling Frame
Tak Province, Thailand

Total 9 Districts
Randomly Selected
Mae Sot Mae Ramat PhopPhra

District District District
3 Districts in Tak Province, Thailand

Total sample size is 403
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Reliability and Validity
Pretest of the questionnaire among 30 adolescents aged 15 to 19 years, in

Mae Sot district, who shared similar characteristics with the study subjects, was
conducted to find out the problems concerning the structure, component, wordings
used to be clearly understood by the interviewers and respondents. Cronbach’s
alpha coefficients for attitudes of adolescents was >0.7129. The questionnaire was
consulted with three technical experts to assure validity.
Statistical data analysis was done by STATA software version 10.0.
Frequency distribution and percentage were used for descriptive analysis. Simple
and multiple logistic regressions were used to establish association between
outcome and independent variables.
Results
Total studied samples was 403 and highest proportion of them (48.14%) were
from Mae Sot district, more than half (61.54%) were female. Most of them finished
middle and high school education. Almost half (42.68%) were from workforce
sectors.
Table 1: Socio-demographic characteristics of Myanmar migrant adolescents who
are ages from 15 to 19 years old. (n=403)
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Gender
Male 155 38.46
Female 248 61.54
Age (in full years)
Age group
Age group (15 - 17 years old) 225 55.83
Age group (18 - 19 years old) 178 44.17
Mean (SD): 17.01 (±1.40), Median (Min : Max) 17 (15 : 19)
Married/ not married
Single 372 92.31
Married 30 7.44
Divorced 1 0.25
Educational attainment
High school or higher 188 46.65
Primary 71 17.62
No formal 8 1.99
Occupation
Student 210 52.11
Worker 121 30.02
Farmer/ fisherman/ plantation worker 8 1.99
Staff / employee 6 1.49
No Job 18 4.47
Housewife 3 0.74
Others 37 9.18
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Religion
Buddhism 320 79.40
Christian 79 19.60
Hinduism 3 0.74
Islam 1 0.25
Home language
Bamar 251 62.28
Kayin 129 32.01
Mon 14 3.47
Rakhine 2 0.50
Kayah 2 0.25
Kachin 1 0.99
Type of previous stay in native
Rural 319 79.16
Urban 84 20.84
Address in Thailand
Mae Sot 194 48.14
Mae Ra Mat 129 32.01
Phop Phra 80 19.85
Type of current stay Thailand
Rural 259 64.27
Urban 144 35.73
Financial situation
Not enough 131 32.51
Not enough with debts 66 16.38
Enough but not saved 158 39.21
Enough & saved 48 11.91
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Family background condition and relationship status

Almost half of the participants (44.42%) were staying together with both
parents. Most of the adolescents were having good relationship with their parents or
guardians (74.44%). Good relationship with parents that they were married and lived
together was reported most by 77.67% adolescents. However, 76.18% responded that
they never discussed about sex with their family.
Table 2: Family condition of adolescents and relationship status among their family
and any discussion of sexuality issues among them
Family Characteristics Number Percentage

(%)
Staying with
Alone 19 4.71
Both parents 179 44.42
Single parents 31 7.69
Relatives 88 21.84
Friends 29 7.20
Colleagues 14 3.47
Others 43 10.67
Relationship with parent/ guardian
Poor 9 2.23
Fair 94 23.33
Good 300 74.44
Relationship of your parents
Married & live together 313 77.67
Divorced or separated 40 9.93
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Family Characteristics Number Percentage

(%)
Widower or widow 50 12.41
Discuss about sexuality with family
Never/ seldom 307 76.18
Sometimes 81 20.10
Often/ usually 15 3.72
More than half of the participants (56.58%) were having high level of
knowledge concerning sexual practices. Most of the adolescents had indifferent
attitude related to sexual practices, but 15.68% of these adolescent had poor
attitude.
Table 3: Total knowledge and attitude score on sexual practices
Total knowledge and attitude scores Number Percentage %

Level of knowledge
High knowledge (80%–100%) 228 56.58
Average knowledge (60%–79%) 175 43.42
Poor knowledge (<60%) 0 0.00
Mean (SD): 26.81 (±2.13), Median (Min : Max): 27 (12 : 32)
Level of attitude
Appropriate (25 -33) 62 15.38
Indifferent (17 - 25) 278 68.98
In appropriate (11 - 17) 63 15.63
The most adolescents fall into “low risk” group that is under low level of
environmental influence about 87.81% of them.
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Table 4: Total risks score and grouping of risk for peer, sexual and non-sexual risk
behaviors
Risk group for peer pressure, sexual and Number Percentage

non-sexual risk behaviors
Low risk (Score 12-19) 353 87.81
Moderate risk (Score 20-27) 45 11.19
High risk (Score 28 -36) 4 1.00
Among 403 total adolescents, were found that 68 (16.87%) ever had sexual
intercourse and there were 50 (12.41%) that were sexually active.
Table 5: Sexual experiences of adolescents (n=403)
Past Sexual Behaviors Number Percentage (%)

Ever had sex
No 335 83.13
Yes 68 16.87
Had sex during last 3 months (sexually active no/yes)
No 353 87.59
Yes 50 12.41
Outcome variable (Perceived social norm towards premarital sexual practice)
The prevalence of poor perceived social norm towards premarital sexual

practice was 43.18% (95% CI =38% to 48%).
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Table 6: Outcome variable (perceived social norm towards premarital sexual
practice)
Outcome variable “perceived norm” Number Percentage 95% CI

(%)
Good perceived social norm 229 56.82
(Appropriate norm)
Poor perceived social norm 174 43.18 38.32-48.03
(Inappropriate & indifferent norm)
Associated factors with perceived poor social norms resulted by simple logistic
regression
Each Independent variable was tested for its association with poor perceived
social norms by using simple logistic regression. Variables which had results of p-
value less than 0.25 were preceded to the multiple variables analysis (Table 7).
Table 7: Associated variables for perceived poor social norms toward premarital
sexuality demonstrated by crude odd ratio (OR), based on simple logistic regression
(n=403)
% Poor Crude p-
Characteristics n 95%CI
Perceived OR value
Gender <0.001
Female 248 33.06 1 1
Male 155 59.35 2.96 1.95-4.48
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% Poor Crude p-
Perceived OR value
Age group 0.004
Age (15 - 17 years) 225 36.89 1 1
Age (18 - 19 years) 178 51.12 1.79 1.20-2.67
Educational attainment <0.001

High (middle school & 324 38.58 1 1
higher)
Low (primary & below) 79 62.03 2.60 1.57-4.31
Occupation 0.017
No Job 231 38.10 1 1
Have a job 172 50.00 1.63 1.09-2.42
Student/ Non-student 0.081
Student 210 39.05 1 1
Non -Student 193 47.67 1.42 0.96-2.11
Religion 0.090
Christian & Others 83 34.94 1 1
Buddhism 320 45.31 1.54 0.93-2.55
Home language 0.484
Bamar 251 41.83 1 1
Kayin & Others 152 45.39 1.16 0.77-1.73
Type of previous stay in native 0.947
Urban 84 42.86 1 1
Rural 319 43.26 1.02 0.63-1.65
Address in Thailand 0.141
Mae Sot 194 38.14 1 1
Mae Ra Mat 129 47.29 1.45 0.93-2.28
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% Poor Crude p-
Perceived OR value
Phop Phra 80 48.75 1.54 0.91-2.61
Type of current stay in Thailand 0.381
Urban 144 40.28 1 1
Rural 259 44.79 1.20 0.80-1.82
Financial situation 0.309
Not enough 197 40.61 1 1
Enough 206 45.63 1.23 0.83-1.82
Stay together with
Parents 210 34.29 1 1 <0.001
Relatives & non-relatives 193 52.85 2.15 1.44-3.21
Relationship with parent/ guardian 0.083
Good 300 40.67 1 1
Fair or poor 103 50.49 1.49 0.95-2.33
Relationship status of parent 0.007
Live together 313 39.62 1 1
Not living together/ 90 55.56 1.91 1.19-3.06
divorced/ widower/ widow
Discuss about sex with 0.123
family
Never/ seldom discuss 307 41.04 1 1
Discuss sometimes/ often 96 50.00 1.44 0.91-2.28
Knowledge level
Low & average 175 40.57 1 1
knowledge
High knowledge 228 45.18 1.20 0.81-1.80
Attitude level <0.001
High & average score 341 36.66 1 1
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% Poor Crude p-
Perceived OR value
Low attitude score 62 79.03 6.51 3.40-12.48
Risks of peers, sexual and non-sexual risk behaviors <0.001
Low risk 335 38.24 1 1
Median risk & High risk 49 79.59 6.30 3.04-13.03
Ever had sex (Adolescent sex) <0.001

No 335 38.81 1 1
Yes 68 64.71 2.90 1.68-4.98
Ever had sex in last 3 months (Sexually active or not) 0.002
No 353 40.23 1 1
Yes 50 64.00 2.64 1.43-4.89
Associated factors with perceived poor social norms resulted by multiple

logistic regression
In multiple logistic regression, factors that had association with poor

perceived social norms towards premarital sexual relationship were male gender
(adj. OR = 2.54, 95%CI: 1.58-4.08, p-value: <0.001), had low level of education (adj.
OR= 3.66, 95%CI: 1.66-5.38, p-value: <0.001), did not stay with biological parents
(adj. OR= 1.91, 95%CI: 1.20-3.04, p-value: 0.006), parents did not lived together (adj.
OR= 1.61, 95%CI: 1.20-3.69, p-value: 0.009), had inappropriate attitude on sexual
practices (adj. OR= 5.88, 95%CI: 2.89-11.96, p-value: <0.001), and had average to
high level of influence from environment such as peer (adj. OR= 2.52, CI: 1.12-5.72,
p=0.001) as shown in table 8.
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Table 8: Association of perceived norms about premarital sexual practice and its
determinants after adjusting covariates using multiple logistic regression (n=403)
%Poor Cru
adj. p-
Characteristics n Perceive de 95%CI
OR value
d OR
Gender <0.00
1
Female 248 33.06 1 1 1
Male 155 59.35 2.96 2.54 1.58-4.08
Education <0.00
1
Middle & higher 324 38.58 1 1 1
Low (primary & lower) 79 62.03 1.60 3.66 1.66-5.38
Stay together with 0.006
Parents 210 34.29 1 1 1
Relatives & non- 193 52.85 2.14 1.91 1.20-3.04
relatives
Relationship of parents 0.009
Live together 313 39.62 1 1 1
Not living together/ 90 55.56 1.91 1.61 1.20-3.69
divorced/ widower/
widow
Attitude towards reproductive health and STDs including HIV <0.00
1
High & average score 341 36.66 1 1 1
Low score 62 79.03 6.51 5.88 2.89-11.96
Environmental, peers, sexual related and non-sexual risk 0.010
Low risk 353 38.24 1 1 1
Median risk & High risk 49 79.59 6.29 2.52 1.12-5.72
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Discussion
This study revealed that about 43.18% of adolescents had poor perceived
norms towards premarital sex. Gender, male, had low level of education, did not
stayed with parents, parents did not live together and had high influence from
friends were found associated with these adolescent poor perceived norms towards
premarital sex. Previous study in Sri Lanka showed that 72% adolescents had
acceptable opinion towards sexual relationship of any kind including premarital sex
(Rajapaksa-Hewageegana, 2014). It might be that our study participants had higher
educational attainment. Education was found to be strongly associated with
perceived social norms about premarital sex. The study evidenced the fact that
education was a protective factor against poor perceived norms regarding
premarital sex and risk behaviors. It was studied that the likelihood decreases by 15
percent among those with college education. (Laguna, 2002) According to result,
low education was strongly associated with poor perceived social norms where
odds was 3-4 times greater than middle and higher education. One study in
Myanmar reported that one third of medical students and one fifth of community
youths approved to have premarital sex (San San Htay, 2010). That result was lower
than this study. It might be not only educational attainment but also gender. Male
gender was strongly associated with poor perceived social norms regarding
premarital sex, our study also founded that boys had higher odds of having poor
perceived social norms regarding premarital status than girls. . In Ethiopia among
university students showed that 64.4% had poor perceived norms towards premarital
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sex (Zemenu Mengistie, 2015). Boys were at least 2.5 times more likely to have
poor perceived social norms towards premarital sex than girls since it was similar
with those reported in a number of articles. This was higher than that of Malaysian
study where male were nearly 2 times more likely to have permissive sexual
attitudes than females. (Rahman et al., 2015)
It was obviously revealed in this study that family factor played an important
role in association with perceived social norms towards premarital sexual practice.
Adolescents who did not stay together with biological parents were about 2 times
more likely to have poor perceived social norms than those who stayed together
with parents. In addition, adolescents whose parents do not live together were
about 2 times of having poor perceived social norms than those whose parents lived
together. Adolescents with inappropriate attitude level were about 6 times
higher at chance of developing poor perceived social norms towards premarital
sexual practice than those with average and high level of appropriate attitude. May
be if the family has not educated them or being their good role model, they may
learn from other such as peers and other environemtns. This study showed that
odds of having poor perceived social norms among adolescents at average and high
level environmental influence such as peers, sexual or non-sexual risk behaviors,
were more than 2.5 times greater than those with low level. Previous study
also indicated that peer pressure was greatly influencial on adolescents (Podhisita,
2007). The higher the exposure to environmental, sexual and non-sexual risk, the
poorer perceived social norm towards premarital sex.
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Limitation of the Study
It was a cross-sectional study and it failed to affirm the predictors of
perceived social norms towards premarital sexual practice. Being predisposed by
socio-cultural norms towards sensitive sexuality issues, too much engagement and
time consuming counseling were conducted to get full participation and disclosure
of information from adolescents.
Conclusion and recommendation
In conclusion, the study demonstrated poor perceived sexual norms among

adolescents were reported by almost half of adolescents and this had been strongly
associated with sexual orientation, education, family condition, internal (attitude)
factor and environmental (peer, sexual stimuli) factor and non-sexual risk behaviors.
Sexual reproductive health agenda should be highlighted in school health

implementation, and parent-teacher association activities to disclose sexual health
issues for delaying adolescents’ first sexual initiation and other risks.
It was recommended for further studies that social norms related to other
sexual risks should be studied in future. In addition similar research should be
conducted widespread inside Myanmar since they are dynamic group.
Acknowledgement
I would like to acknowledge with gratitude, the academic support, the

valuable guidance and help this study accomplished to the Faculty of Public Health,
Khon Kaen University lecturers, staff and doctoral students; the Research and
Training Center for Enhancing Quality of Life of Working Age People, Khon Kaen
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University, Thailand for financial support. I would like also express my
gratefulness to all respondents and those who help in the data collection for their
willingly and voluntarily participated in the study.
Reference
1. Blum, R. W. Risk and Protective Factors Affecting Adolescent
Reproductive Health in Developing Countries2000 ; (pp. 207).
2. Chai Podhisita, P. X., and Anchalee Varangrat. The risk of
premarital sex among Thai youth: individual and family influences. 2001; East-
West Center Working Papers, 29.
3. Every Women, E. C. (2015). Saving Lives Protecting Futures (pp. 112).
Kirby, D. Reducing Adolescent Sexual Risk: 2011; A Theoretical Guide for
Developing and Adapting Curriculum-Based Programs.
4. Goldstein, R. B. C. a. N. J. SOCIAL INFLUENCE: 2003;Compliance and
Conformity.
5. Laguna, E. P. 2002; Knowledge of HIV/AIDS and Unsafe Sex Practices
Among Filipino Youth.
6. Monica Das Gupta, R. E., Jessica Levy, Gretchen Luchsinger, Tom
Merrick, James E. Rosen. The Power of 1.8 Billion: Adolescents, 2014; Youths
and the Transformation of the Future (pp. 136).
7. Podhisita, C. (2007) ; Parenting Process And Peer Influence In The
Context Of Sexual Risk Behavior Among Young Adults.
8. Rajapaksa-Hewageegana, N. Sexual and reproductive knowledge,
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attitudes and behaviours in a school going population of Sri Lankan adolescents.
2014; doi: 1877-5756
9. Rahman, A. A., Rahman, R. A., Ismail, S. B., Ibrahim, M. I., Ali, S. H.,
Salleh, H., & Muda, W. A. M. W. Factors Associated With Attitude
Toward Premarital Sexual Activities Among School-Going Adolescents in
Kelantan, Malaysia. Asia Pacific Journal of Public Health, 27(2), NP1549-NP1556.
2015; doi: 10.1177/1010539512449856
10. San San Htay, M. O., Yoshitoku Yoshida and Junichi Sakamoto1.
2010; Risk Behaviours And Associated Factors Among Medical Students And
Community Youths In Myanmar. 12.
11. Thailand, U. N. T. W. G. o. M. i. (2014). Thailand Migration Report
2014; (pp. 228).
12. UNAIDS. (2016). Global Aids Update.
United Nations Children’s Fund, J. U. N. P. o. H. A. a. W. H. O. 2002; Young
People And Hiv/Aids: Opportunity In Crisis. 28.
13. WHO 2006; Defining sexual health: Report of a technical consultation

on sexual health
14. W.H.O. Sixteenth World Health Assembly. A64_R28, W. H. O. (2011).
Zemenu Mengistie, E. W., Enawgaw Abawa, Endris Ebre, Addis Adera.
Knowledge Attitude and Practice Towards Premarital Sex and HIV/AIDS among
Mizan-Tepi University Students, South West Ethiopia. Science Journal of Public
Health. 2015; doi: 10.11648/j.sjph.20150304.30
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Socio Economic disparity and contraceptive practice among reproductive age

woman in Kayin State, Myanmar
Thin Thin Soe 1, Prof Dr San San Myint Aung 2
1
2
การวางแผนครอบครัวโดยสมัครใจได้รับการส่ งเสริ มอย่างแพร่ หลายทัว่ โลก ปั จจุบนั คู่สมรสทั้งหมดในประเทศกาลัง
พัฒนามีมากกว่าครึ่ งหนึ่งยอมรับวิธีการคุมกาเนิดสมัยใหม่สาหรับระยะเวลาที่เหมาะสมในการตั้งครรภ์ การเว้นระยะห่ างและการ
จากัดจานวนบุตรเพื่อให้ได้ขนาดครอบครั วที่ตอ้ งการ การวิจยั ครั้ งนี้ มีวตั ถุประสงค์เพื่อกาหนดรู ปแบบการคุมกาเนิ ดและความ
เกี่ยวข้องกับปั จจัยทางเศรษฐกิจและสังคมในสตรี วยั เจริ ญพันธุ์ในรั ฐกะยิงหรื อรั ฐกะเหรี่ ยง ประเทศพม่า การศึกษานี้ เป็ นแบบ
ภาคตัดขวางดาเนินการในรัฐกะยิงหรื อรัฐกะเหรี่ ยง กลุ่มตัวอย่างทั้งหมด 395 คนได้รับการคัดเลือกโดยใช้วิธีการสุ่ มอย่างง่ายและ
คานวณตามสัดส่ วนของประชากรเพื่อการตอบคาถามโดยใช้แบบสอบถามแบบมีโครงสร้าง ใช้การวิเคราะห์ถดถอยโลจิสติกแบบ
พหุเพือ่ กาหนดความสัมพันธ์ระหว่างปั จจัยทางเศรษฐกิจและสังคมกับการคุมกาเนิดโดยมีการควบคุมตัวแปรร่ วมอื่น ๆโมเดลสุ ดท้าย
จะพิจารณาระดับนัยสาคัญที่ค่า p <0.05
ผลการศึกษา พบว่า กลุ่มอายุ 30 ปี ขึ้นไป 61.77% มีอายุเฉลี่ย 33 ±7.87 ปี เกือบครึ่ งหนึ่งจบการศึกษาระดับประถมศึกษา
(49.62%) ความชุกของการคุมกาเนิดคือ 61.27% (95% CI: 56.44 - 66.09) การฉี ดยาเป็ นวิธีที่ใช้มากที่สุด (34.58%) รองลงมาคือยา
เม็ดคุมกาเนิด (29.58%) การทาหมันหญิง (10.74%) การใช้ห่วงอนามัย (IUD ) 8.75%, ยาฝังคุมกาเนิด9.50% และวิธีอื่น ๆ 6.62%
ปั จจัยทางเศรษฐกิจและสังคมที่มีความสัมพันธ์กบั การคุมกาเนิ ดอย่างมีนัยสาคัญคือการคุมกาเนิ ดที่มีค่าใช้จ่ายต่ า (<1500MMK)
(AOR = 1.87, 95% CI: (1.09-3.21) ค่า p –value 0.023) (AOR = 3.12, 95% CI: 1.81-5.38, p-value <0.001) ปั จจัยที่มีความสัมพันธ์
กับ การคุ ม ก าเนิ ด อย่ า งมี นั ย ส าคัญ คื อ เวลาส่ ว นมากของการอยู่ ด ้ว ยกัน ของสามี ภ รรยา(AOR=3.12; 95% CI: 1.81-5.38; p-
value<0.001), การรั บรู ้ อุปสรรคในการคุมกาเนิ ด อยู่ระดับต่ า (AOR = 2.69; 95% CI: 1.06-6.87; p- value = 0.038) และการรั บ รู ้
ความสามารถของตนเองในการคุมกาเนิด อยูร่ ะดับสู ง (AOR = 3.60; 95% CI: 1.90-6.81 ค่า p <0.001)
สรุ ป การคุมกาเนิดยังคงครอบคลุมอยูใ่ นระดับต่า ผลกระทบเชิงลบของการคุมกาเนิดพบว่าเป็ นอุปสรรคในการคุมกาเนิด
และความมัน่ ใจของคุมกาเนิ ดเพิ่มขึ้น ดังนั้นเพื่อที่จะเพิ่มบริ การวางแผนครอบครั วควรใช้การเสริ มสร้ างขีดความสามารถของผู ้
ให้บริ การในการให้คาปรึ กษา การแบ่งปั นข้อมูลเกี่ยวกับการคุมกาเนิดซึ่งบริ การฟรี เป็ นสิ่ งสาคัญ

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Abstract
Voluntary family planning has been widely promoted around the world. More than
half of all couples in the developing world now accept modern contraceptive methods for
healthy timing, spacing, and limiting of births to achieve their desired family size.This
study aimed to determine the contraceptive use pattern and its association with socio
economic factors among reproductive age women in Kayin State, Myanmar.
Methodology: A community based cross sectional study was conducted in Kayin State, A
total sample of 395 were selected by using simple random sampling and probability
proportional to size to response to a structured questionnaire interview. The Multiple
logistic regression was used to determine the association between the socio economic factor
and the contraceptive use when control other covariates. At the final model, the level of
significance will be considered at p value < 0.05.
Result: The study showed that 61.77% of the respondents was in the older than 30 years
age group, with the mean age of 33 ±7.87 years. Almost half of them finished primary
education level (49.62%). The prevalence of contraceptive use was 61.27% (95%CI: 56.44
to 66.09), injection was the most commonly method used (34.58%) followed by oral pill
(29.58%), female sterilization (10.74%), intrauterine contraceptive device (IUD) 8.75%,
Implant 9.50% and other 6.62%. The socio economic factor that were significantly
associated with contraceptive use was low expense of contraceptive (<1500MMK)
(AOR=1.87; 95%CI: (1.09- 3.21); p value=0.023). Factors significantly associated with
contraceptive use were live together with husband/partner most of the time (AOR=3.12;
95%CI: 1.81-5.38; p value<0.001), had low perceived barriers for using contraception
(AOR=2.69; 95%CI: 1.06-6.87; p value=0.038) and had high self-efficiency to use
contraception (AOR=3.60; 95%CI: 1.90-6.81; p value< 0.001).
Conclusion: The contraceptive coverage was still low. Negative consequence of the
contraceptive use was found to be barriers in taking contraception and confidence of using
contraceptive methods increase contraceptive used. Thus, in order to increase family
planning service use the capacity building of service providers on counseling should be
promoted. Information sharing about contraceptive, free services are priorities.
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Introduction
Family planning is acknowledged for the welfare of human being and it was
launched at the International Conference on Population and Development in 1994.
Voluntary family planning has been widely promoted all around the world. More than half
of all couples in the developing world now accept modern contraceptive methods for
(1)
healthy timing, spacing, and limiting of births to achieve their desired family size .
Myanmar is a traditional country with strong cultural norms regarding sexual behavior.
Social and cultural values contribute as barriers in accessing and providing reproductive
health services including birth spacing (2).
Family planning has saved the lives of millions of women, girls and children and
has improved the well-being of families and communities as well (1). Moreover, access to
contraception is also critical for girls and women to fully enjoy their lives especially rights
to education, employment and political participation (3).
Therefore, the study aims to identify socio economic and demographic
determinants and individual perception using Health Belief Models on the contraceptive
practices among reproductive aged women. This study will provide the stakeholders of the
family planning services how successful family planning programs are and what areas of
opportunity still remain to increase contraceptive use and reduce the unmet need.
Objective
To determine the contraceptive use pattern and its association with socio economic
factors among reproductive age women in Kayin State, Myanmar.
Methodology
Study design
This study was a community based cross sectional study using structured questions
to investigate the contraceptive use pattern among the reproductive aged women and its
associated factors. The sampling method was multistage sampling proportional to size of
population. 395 of reproductive age women were interviewed in this study by using
structured questions. The eligible sample was fulfilled with the inclusion criteria and
exclusion criteria. The inclusion criteria for the eligible was Reproductive age women who
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Health Promotion 05
are healthy physically and mentally and willing to participate. Women who was pregnant
at the time of interview, those with hysterectomy and menopause at the time of interview
and the reproductive age women who were not able to participate were excluded in this
study. Therefore, the sample size was calculated based on multiple logistic regression
formula (4).
Study outcome
The study outcome was contraceptive use which refers within last six months or at
the time of interview and use at least one methods, traditional or modern methods by the
women or her husband/partner. Socio economic factor was primary factor of interest.
Contraceptive services, knowledge on contraception, attitude on contraception and health
belief model perception were included in this study. Three level scoring was used to
conduct the questions related with attitude and perception. The scoring system was
3=Agree, 2= indifferent and 1= disagree for positive statement and it was reverse for
negative statement.
Data analysis was done by Stata version 10. As descriptive statistics number and
percent was shown for categorical data, and mean (standard deviation), median with its
range for continuous data. Simple logistic regression was applied to identify the association
between dependent variable and each of independent variables with crude odd ratio (OR),
95% confidence interval (CI), p-value. The variables with p value less than 0.25 was taken
into the initial model. In multiple logistic regression, adjusted OR, 95%CI and p-value was
computed. At the final model, the level of significance will be considered at p value < 0.05.
Result
Prevalence of contraceptive use
Among the respondents, 242 out of total respondents accepted the contraceptive
methods. 25.06% of the respondents had ever used of contraception. 13.67% of the
respondents had never used of contraception. Thus, the prevalence of contraceptive
practice in this study was 61.27% and 95% CI was within 56.44 to 66.09. Among the
contraceptive users in this study, Injection (35.12%) is the most commonly used
contraception among the respondents. OC pill (29.34%) is the second methods of choice
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followed by female sterilization (10.74%), implant (9.50%), IUD (8.68%), condom

(2.48%) and withdrawal (3.31%) and fertility awareness methods (0.83%). The percentage
of modern contraceptive methods use was 58.73% and the other methods was 2.5%. The
most common reasons for using contraception was 45.46% for birth spacing and 37.19%
for having no more child. The reason like husband away and want more children were
found as reasons for not using contraception among 32.68% and 30.07% respectively.
More than half of the respondents (66.33%) were found among ≥30 years of age
group with mean age of 33 years (SD 7.87). 49.62% of the respondents got primary
education level. The majority of the respondents were Buddhism. 77.21% of the
respondents who their monthly family income were ≥ 100,000 MMK. 34.68% of the
respondents had at least two living children at the time interview. In term of abortion
experience, 76.96% of the respondents never experienced to abortion in their lives.
Table 1. Socio-economic and demographic characteristics of the respondents

Age
≤19 18 4.56
20-29 115 29.11
≥30 244 66.33
Mean (±SD) 33 (±7.87), Median (min : max): 33 (15,49)
Education
Residence
Rural 338 85.57
Urban 57 14.43
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Religion
Buddhist 364 92.15
Christian 16 4.05
Muslim 15 3.80
Marital Status
Married 369 93.42
Single 19 4.81
Divorce 7 1.77
Ethnic
Karen 285 75.15
Pa Oh 62 15.70
Burma 42 10.63
Mon 4 1.01
Shan 2 0.51
Occupation
Housewife 169 42.78
Farmer 94 23.80
Business 61 15.44
Private Employee 11 2.78
None 11 2.78
Monthly Family’s income (MMK)
<50000 32 8.10
≥50000 & < 100000 58 14.68
≥100000 & < 250000 206 52.15
≥250000 99 25.06
Mean (±SD) 186379.7(151201.8),
Median (min : max): 150000(10000-1000000)
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Financial situation
Not Enough 19 4.81
Number of Living children
0 37 9.37
1 109 27.59
2 112 28.35
>2 137 34.68
Mean (±SD) 2.24 ±1.62, Median (min : max): 2 (0-9)
Number of abortion
None 304 76.96
1 67 16.96
>1 24 6.08
Mean (±SD) 0.29 ± 0.58, Median (min : max): 0(0-3)
Cost for contraceptive use (per time) MMK (n=337)

None 94 27.89
< 1500 124 36.80
≥1500 & <5000 82 24.33
≥ 5000 37 10.98
Mean (±SD) 11438.8 ±52356.33, Median (min : max): 800(0-500000)
Affordability to contraceptive cost (n=337)
No expense 95 28.19
Cheap 97 28.78
Normal 119 35.31
Expensive 26 7.72
Living status with husband (n=369)
Live together most of the time 260 70.46
Working abroad 92 24.93
Always traveling 17 4.61
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Level of Environmental factor support on
contraceptive use
Poor support 3 0.76
Fair support 63 15.95
Good support 329 83.29
Mean (±S.D)15.06 +1.99, Median (Min, Max): 15(8-18)
Level of Knowledge on contraception
Low level 131 13.42
Medium level 211 53.42
High level 131 33.16
Mean (±S.D)7.49 + 1.85, Median (Min, Max):8(1-10)
Level of Attitude on Contraception
Negative attitude 4 1.01
Neutral attitude 113 33.67
Positive attitude 258 65.32
Mean (±S.D) 31.76 ±3.71, Median (Min, Max):32(17-39)
Perceived susceptibility of pregnancy
Low Level 7 1.77
Medium Level 57 14.43
High Level 331 83.80
Mean (±S.D)7.57 (±1.43), Median (Min, Max):7 (3-9)
Perceived severity of pregnancy
Low Level 19 4.81
High Level 237 60
Mean (±S.D) 12.47±2.53, Median (Min, Max):13 (5,15)
Perceived benefits for using contraception
Low Level 0 0
Mean (±S.D) 8.29 +1, Median (Min, Max): 9 (5-9)
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Perceived barriers for using contraception

Low Level 348 88.10
High Level 4 1.01
Mean (±S.D) 16.30 ±2.29, Median (Min, Max):18 (8-18)
Cues to using contraception
Low Level 24 6.08
Mean(±S.D) 12.67(+2.38), Median (Min, Max):13(5,15)
Self-efficiency to use contraception
Low Level 39 9.87
Mean (±S.D) 10.41+1.99,Median (Min, Max):11(4,12)
Table2. Prevalence of contraceptive practices
Contraceptive practice Number Percentage (%) 95% CI
Contraceptive use 242 61.27 56.44 to 66.09
Contraceptive not use 153 38.73 33.90 to 43.56
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Table3.Factor associated with contraceptive practice (Bivariate analysis)
%
Crude
Factors number Contraceptiv 95%CI p-value
OR.
e practice
Educational attainment 0.143
No formal education &
243 58.44 1 1
Primary school
Secondary school, High
school & Bachelor 152 65.79 1.37 0.90-2.08
degree or higher
Residence 0.069
Rural 338 59.47 1 1
Urban 57 71.93 1.75 0.94-3.24
Occupation 0.022
None, Housewife, Farmer
310 58.39 1 1
& Unskilled worker
Private Employee,
Business & 85 71.76 1.81 1.07-3.06
Government officer
Monthly Family income (MMK) 0.599
<100000 90 58.89 1 1
≥100000 305 61.97 1.14 0.70- 1.84
Number of living children <0.001
<2 146 47.26 1 1
≥2 249 69.48 2.54 1.67-3.87
0.072
Number of abortion
None 304 58.88 1 1
≥1 91 69.23 1.57 0.95-2.59
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%
Crude
OR.
e practice
Cost for contraceptive use
0.170
(per time) MMK (n=337)
≥ 1500 119 67.23 1
< 1500 218 74.31 1.41 0.87- 2.30
Living status with husband <0.001
Always traveling &
109 48.62 1 1
Working abroad
Live together most of the
260 72.69 2.81 1.77-4.47
time
Source of contraceptive services 0.212
Drug store & Private
clinic, NGO & 107 67.29 1 1
Other
Community Health
Volunteer &
230 73.91 1.38 0.84-2.27
Government Health
Facility
Transportation to contraceptive source 0.049
Walking 128 65.63 1 1
Public vehicle & Private
209 75.60 1.62 1.00-2.63
vehicle
Environmental support on contraceptive use 0.136
Fair support & Poor
66 53.03 1 1
support
Good support 329 62.92 1.50 0.88-2.56
Knowledge on contraception 0.017
Low level & Medium
264 57.20 1 1
level
High level 131 69.47 1.70 1.09-2.66
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%
Crude
OR.
e practice
Attitude on contraception 0.003
Poor Attitude & Neutral
137 51.09 1 1
attitude
Positive attitude 258 66.67 1.91 1.25-2.92
0.046
Perceived susceptibility to pregnancy
Low level & Medium 1
level 64 50 1
High level 331 63.44 1.74 1.01-2.97
Perceived severity of pregnancy 0.064
level 158 55.70 1
High level 237 64.98 1.48 0.98-2.23
Perceived barriers for using contraception <0.001
High level & Medium 1
level 47 25.53 1
Low level 348 66.09 5.69 2.85-11.36
Cues to using contraception <0.001
Low level & Medium
level 121 47.93 1
High level 274 67.15 2.22 1.43-3.44
Self-efficiency to use contraception <0.001
level 91 32.97 1
High level 304 69.74 4.69 2.84-7.73
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Table 4. Contraceptive practice and its associated factors (Multivariate analysis)
%
Contra Crude Adj.
ceptive OR. OR.
use
Cost for contraceptive use
0.023
(per time) MMK
≥ 1500 119 67.23 1 1
< 1500 218 74.31 1.41 1.87 1.09-3.21
Living status with husband <0.001
Always traveling &
109 48.62 1 1
Working abroad
Live together most of
260 72.69 2.81 3.12 1.81-5.38
the time
Perceived barriers for
0.038
using contraception
High level & Medium
47 25.53 1 1 1
level
Low level 348 66.09 5.68 2.69 1.06-6.87
Self-efficiency <0.001
Low level & Medium
91 32.97 1 1 1
level
High level 304 69.74 4.69 3.60 1.90-6.81
After the process of analyzing by using multiple logistic regression, The

respondents having lesser cost for contraception was having 1.87 times odds more
compared with those having lesser cost (<1500 MMK) at (AOR=1.87; 95%CI: 1.09-3.21;
p value= 0.023). The respondents who live together with husband in most of the time were
3.12 time more likely to use contraception than those with husband/partner who always
traveling and working aboard (AOR= 3.12; 95%CI: 1.81-5.38) and it was significant at p
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value <0.001. In 2 out of 6 construct of health belief Model, the respondents with low
level of perceived barriers for using contraception were 2.69 times more likely to use
contraception compared with those with high level and low level of perceived barriers or
using contraception (AOR=2.69; 95%CI: 1.06-6.87; p value=0.038). Finally, the
respondents with high level of self-efficiency was associated with contraceptive use 3.60
times more than those with low level and moderate level self-efficiency (AOR= 3.60;
95%CI: 1.90-6.81) and it was statistically significant at p value <0.001. At the final model,
the level of significance was considered at p value < 0.05.
Discussion
There were the prevalence of contraceptive use (61.27%) found in this study with
(95%CI: 56.44 to 66.09), injection (35.12%) being commonly used methods among the
respondents followed by OC pill (29.3%), female sterilization (10.74%), implant (9.50%),
IUD (8.68%) and the remaining percentage were for condom, withdrawal and fertility
awareness methods. This contraceptive prevalence in current study was a little higher than
national figure 52% but the methods mix was very similar with the study done in
demographic health survey done in Myanmar; injection (27.6%), OC pill (13.8%), female
sterilization (4.8%), IUD (2.8%), Condom (1%), Implant (0.9%) and traditional method
(1%) (5). Currently in most of the township of Kayin State, International organization such
as IRC and MSI are implementing family planning projects especially for long term family
planning methods (IUD & implant). IRC have been implementing for capacity building of
service providers from MOHS for long term FP methods together with MOHS supervisor
by providing continuous commodities supplies to health facilities. After State level implant
training (2016) provided by MOHS and continuous commodity supply for implant from
MOHS and UNFPA after training in Kayin State, the number of contraceptive user for
implant was sharply increased. That is why the rate of long term contraceptive methods
(IUD & implant) are higher than national figure and other studies. Other studies done in
Myanmar showed that the contraceptive prevalence was 74.7% with being injection mostly
used methods 71.1% and oral contraceptive pill 58.7% in the study done in Yangon among
(6)
married reproductive age women and another study done in Thai-Myanmar border
(7)
among migrant reproductive age women of Myanmar showed that the prevalence of
contraceptive use was 73.3%. The finding showed in Ethiopia study was also consistent
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with currently study (8). According to the policy, Male sterilization is only allowed when
the wife is not suitable for operation due to the medical problem (2).
After adjusting socio economic factors and other covariates which was significant
by bivariate analysis with contraceptive use, socioeconomic factor like cost for
contraception, living status with husband/partner, perceived barriers to using contraception
and self-efficiency to use contraception were statically significant in final model. The
reproductive age women who had cost (<1500 MMK) for contraception were 1.87 times
more likely to practice contraception than those having expense for contraceptive cost
(AOR=1.87; 95%CI= 1.09-3.21; p value=0.023). The finding was similar with previous
ones (7, 9). According to living status with husband due to working nature, the reproductive
age women who living together with husband were associated with contraceptive use 3.12
times more than the women whose husband are always traveling or working aboard
(AOR=3.12; 95%CI= 1.81-5.38) and it was statically significant at p value <0.001. This
(10)
finding was consistent with previous one . Thus, the study revealed that women
contraceptive use was very much depending on their husband. Thus women should aware
about the action of contraceptive methods and fertility period and otherwise, unexpected
pregnancies will be appeared. Moreover, the current study pointed out that perceived
barriers such as negative consequence of using contraception and self-efficiency (women
perception on the confidence of using contraceptive methods) were strong predictors on
contraceptive practice (AOR=2.69; 95%CI= 1.06-6.87) and (AOR=3.60; 95%CI= 1.90-
6.81). They were statically significant at p value 0.038 and p value <0.001. Similar finding
(11-13)
was found in the previous ones . Thus, the study pointed out that the women
understanding about side effect and benefits of the contraceptive methods they practice was
essential to reduce the discontinuation of contraception.

The study will provide baseline information about contraceptive practices among
reproductive aged women to health authorities and managers of family planning programs
implementing in Kayin State. By highlighting the factors influencing the contraceptive use,
the study will support as a tool to the program decision makers to set up intervention.
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Due to different authorities in different regions of Kayin State, only reproductive

age women residing in stable areas of Kayin State was included in current study. Thus, the
study could not identify the contraceptive practices of the reproductive age women in
unstable areas. According to Myanmar cultural norms, the single reproductive age women
had less participation in the study.
Conclusions
The negative consequence of the contraceptive use was found as barriers in taking
contraception and self-efficiency for using contraception was also found as important
predictor in this study. Thus, to get the quality family planning services with informed
choice, the capacity building of service providers in family planning counseling should be
promoted in all aspect. Accessibility to contraceptive services among the community
should be promoted. Despite of 33.16% of the respondents having high level of knowledge
about contraceptive methods, they had less awareness about emergency contraceptive pill
and condom. Thus, although there are a few percentage for this two contraceptive methods
users, we should add the pros and cons of EC pill and condom in family planning awareness
session. Although factors like age, residence, education, number of living children, and
number of abortion, knowledge and attitude on contraception and source of contraception
were not found as significant factors in this study, their roles in promoting family planning
should be crucial.
Recommendations
While the respondents were asked about the reason for not using contraception,
more than 35% of the respondents were due to economic condition, health reason, fear side
effects, divorce, single, lack of menstruation and ideas about being not easily get pregnancy
due to elderly although they are not menopause. Some of the above reasons can lead to
unwanted pregnancy and unsafe abortion. Thus, further implementing activities of family
planning program should consider to address to reduce the unmet need.
34.04% of respondents was found that their age of first marriage (started living
with husband) were ≤ 19 years of age. Thus, family planning program should extend
adolescent reproductive health. It is suggested that further study should be considered about
adolescent reproductive health knowledge.
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Acknowledgements:
I deeply acknowledge my gratitude and appreciation to Khon Kaen University, IRC

PLE program, my arjans and my supervisors. I would like to express my sincere thanks to
the participants who gave consent and took part in this study. My special thanks to my data
collection team for their kindly support to fulfil my study.
Reference
1. USAID. Facts for Family Planning. 2012.
2. WHO. Myanmar and Birth Spacing: An overview, 2015. from

http://wwwsearowhoint/entity/maternal_reproductive_health/documents/mmr-
fppdf?ua=1
3. UNFPA.Choices not Chance_UNFPA Family Planning Strategy 2012-2020. 2013.
4. Hsieh, YF BA. & Larsen DM. A Simple Method of Sample Size Calculation for Liner
and Logistic Regression. Statistic in Medicine. 1998.
5. MOHS. Demographic and Health Survey 2015-16, Myanmar. 2016.
6. Myo Min Lwin CM,& Nanthamongkokchai S. Factors Influencing Family Planning

Practice among Reproductive Age Married Women in Hlaing
Township,Myanmar. J Med Assoc Thai, 96:98-106. 2013. from
http://wwwjmatonlinecom.
7. Soe HHK. Contraceptive usage among Myanmar migrant women of reproductive

age in Phang Nga Province, Thailand. 2007.
8. Musa A. , Weldegebreal F., Mitiku H. & Teklemariam Z . Factor associated with

experience of modern contraceptive use before pregnancy among women who
gave birth in Kersa HDSS, Ethiopia. BioMed Central. 2016.
9. Osmani JAR K.A. , Osmani A. R. & Hamajima N. Factors influencing contraceptive
use among women in Afghanistan. In: Department of Healthcare Administration
NUGSoM, editor. 2015. p. 551 ~ 61.
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10. Aung KS. Birth spacing practice among rural women of Hmawbi Township
within one year postpartum. Master Of Public Health University Of Public Health
Yangon. 2011.
11. Liabsuetrakul M-M-MaT. Factors influencing married youths’ decisions on
contraceptive use in a rural area of Myanmar. Southeast Asian J Trop Med
Public Health. 2009;40.
12. AO W.B.& Nguyen S. Breaking the barrier: the Health Belief Model and
patient perceptions regarding contraception. 2010.
13. Rourke T. Association between socio-demographic factors and knowledge of
contraceptive methods with contraceptive use among women of reproductive
age, Liberia. Department of Women’s and Children’s Health Uppsala University.
2013.
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Depression and its associated risk factors among working aged group
in Karen state, Myanmar.
PuePue Mhote1, Dr. Wilaiphorn Thinkhamrop2
1
MPH candidate, Faculty of Public Health, KhonKaen University, Thailand.
2
Data Management and Statistical Analysis Center (DAMASAC), Faculty of Public Health,
KhonKaen University, Thailand.
องค์การอนามัยโลกได้ระบุว่า ระบบบริ การสุ ขภาพตอบสนองต่อความผิดปกติดา้ นจิ ตเวชยังไม่เหมาะสม การ

ตรวจหาภาวะซื มเศร้าเป็ นการดาเนินงานที่ใช้งบประมาณน้อยแต่สามารถใช้ประเมินถึงการบริ การพื้นฐานด้านสุขภาพ เพื่อ
นาไปสู่ กระบวนการควบคุมภาวะซึ มเศร้าต่อไป การวิจยั นี้ เป็ นการวิจยั แบบภาคตัดขวาง มีวตั ถุประสงค์เพื่อศึ กษาภาวะ
ซึมเศร้าในกลุ่มวัยแรงงานในพื้นที่มีความขัดแย้งของรัฐกะเหรี่ ยง สาธารณรัฐแห่งสหภาพพม่า ในกลุ่มตัวอย่าง 420 คน ด้วย
การสุ่ มตัวอย่างแบบหลายขั้นตอนอย่างง่าย เก็บข้อมูลด้วยแบบสอบถามแบบมีโครงสร้าง โดยวิเคราะห์ขอ้ มูลด้วยสถิติ
ถดถอยพหุลอจิสติก
ผลการศึ กษา พบว่า ปั จจัยที่เกี่ ยวข้องกับภาวะซึ มเศร้าระดับน้อยและระดับปานกลางมีความสัมพันธ์ในกลุ่มวัย

แรงงาน เพศชายความเสี่ ยงของภาวะซึ มเศร้าสู งกว่าเพศหญิง (Adj.OR=1.72, 95 % CI: 1.02 – 2.91) กลุ่มที่มีอายุมากกว่า
40 ปี มีความเสี่ ยงมากกว่ากลุ่มที่อายุนอ้ ยกว่า 40 ปี (Adj.OR=1.60 ,95 % CI 1.05 – 2.45 and P value 0.025) ชุมชนที่ไม่ได้
ทางานในเขตพื้นที่มีความขัดแย้งมีภาวะซึ มเศร้าในระดับต่าและระดับปานกลางสูงกว่าชุมชนที่ทางานได้ (Adj.OR:1.34, 95
% CI: 1.05 – 2.65, P-value 0.023) และรายได้ของครัวเรื อนที่นอ้ ยกว่า 20,000 จ๊าด พบความเสี่ ยงสูงมากกว่ารายได้ครัวเรื อน
มากกว่า 100,000 จ๊าด (Adj.OR:1.94, 95 % CI: 1.13 – 3.33) และ รายได้ของครัวเรื อนที่ระหว่าง 20,000 – 100,000 จ๊าด พบ
ความเสี่ ยงสูงมากกว่ารายได้ครัวเรื อนมากกว่า 100,000 จ๊าด (Adj OR 1.99, 95 % CI: 1.17 – 3.30) นอกนากนี้ ปั จจัยอื่นๆที่มี
ความสัมพันธ์กบั ภาวะซึ มเศร้า คือ ผูป้ ่ วยโรคเรื้ อรังมีความเสี่ ยงกว่าผูท้ ี่ไม่ได้ป่วย (Adj.OR: 1.77, 95 % CI: 1.14 – 2.77, P-
value 0.001) และปั จจัยที่มีความสัมพันธ์มากที่สุดกับภาวะซึมเศร้าคือ พฤติกรรมการดื่มสุรา (Adj. OR 2.26, 95 % CI 1.37 –
3.37, P value < 0.001)
สรุ ปผลการศึกษา กลุ่มวัยแรงงานในพื้นที่มีความขัดแย้งของรัฐกะเหรี่ ยง มีความชุกของภาวะซึ มเศร้าสู ง เนื่ อง

ด้วยความลาบากทางเศรษฐกิ จและสังคม, ปั ญหาด้านสุ ขภาพ และปั ญหาความไม่มนั่ คงของพื้นที่ ส่งผลต่อระดับความ
ซึ มเศร้า ดังนั้นแล้ว จาเป็ นต้องศึกษาถึงรายละเอียดที่จาเป็ นเพิ่มเติมเพื่อให้ได้ขอ้ มูลที่เหมาะสมสาหรับในการดาเนิ นงาน
ด้านจิตเวชในพื้นที่ต่อไป
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Health Promotion 06
Abstract
Introduction: “Health systems have not yet adequately responded to the burden of mental disorders”
WHO stated (WHO, April 2016). Detecting of depression in low resource settings is crucial to assure
that advances in availability of evidence-based care translate into delivery care. Depression approaches
is essential for depression control.
Objective: To describe the potential depression status among working aged group in conflict affected
Karen State.
Methodology: This cross-sectional study was conducted among 420 participants in 39 villages of 3
Townships in Karen State by using multistage simple random sampling. Data was collected by using
structured questionnaire interview. The questionnaire covers the demographic and socioeconomic
status, stress presented in last two weeks, workplace environmental situation, and alcohol consumption.
Multiple logistic regressions were used to determine the association.
Result: Present study revealed the first strongest associated factors to mild and moderate level
depression among working aged group is Male are more in higher risk 1.72 times than women (Adj. OR
1.72, 95 % CI: 1.02 – 2.91). Who are older than 40 years old are in higher risk 1.60 times compared to
younger participants ( Adj .OR 1.60, 95 % CI 1.05 – 2.45 and P value 0.025). Non employed community
from rural conflict affected Karen state are more likely in higher risk mild and moderate level of
depression compared with those who were employed (adj.OR:1.34, 95 % CI: 1.05 – 2.65, P-value 0.023),
and Family income less than 20000 MMK are more in higher in risk than who earned more than 100000
MMK (Adj.OR:1.94, 95 % CI: 1.13 – 3.33) and whose family earn between 20000 and less than 100000
were also in higher risk 1.99 times than compared group those who earn more than 100000 MMK
respectively. (Adj OR 1.99, 95 % CI: 1.17 – 3.30). Another factor was those who were suffered from
chronic disease were 1.77 times in higher risk when compared with who do not suffered from chronic
disease (adj.OR: 1.77, 95 % CI: 1.14 – 2.77, P-value 0.001). The last strongest factors that significantly
associated with mild and moderate level of depression was Alcohol consumption factors. The study
shown that Hazardous drinker, Harmful Drinker and Alcohol dependent drinker are in highr risk 2.26
times (Adj, OR 2.26, 95 % CI 1.37 – 3.37, P value < 0.001).
Conclusions: There was high slightly prevalence of participant with depression among
working aged group. Socioeconomic hardship health problems and insecurity had strong influence on
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depression scores. Further more detail investigations is necessary to be conducted for the purpose of
obtaining the precise reflected information rather than making a generalized assumption on
depression status of those community in such conflict affected low resource setting.
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Introduction
Burma (Myanmar) is composed of with many diverse ethnics and culture. It share the border
with Thailand, Cambodia, china, Bangladesh and Lao and include as one of the South -East Asian
countries. The country has been rule by military regime over six decades with loads armed conflict
occurrence in ethnic minority areas. (Burma Link, 2015).The Karen state locate in eastern area of
Myanmar and has experienced almost seven decades of intense armed conflicted between the Karen
ethnic national KNU and Burmese government military that had severe impacts on the minority Karen
civilian population (Lim et al. Conflict and Health 2013). The forced displacement, pillaged food stores,
injury from violence and forced labor, while indirect effected of the war include poor transportation
infrastructure, poor supply chains for clinics, and increased risk for healthcare providers are direct
effects on the population (PMC, 2015, August 26).
Mental Health System in Myanmar is not yet standardized or improved comparing to other
ASEAN countries according to 2007 WHO report. In the report, it mentioned that Myanmar had 84
practicing psychiatrists and only for practicingpsychologists. Experts have suggested that if the mental
health sector of Myanmar is to catch up with an apparent increase in mental health problems, more
human and financial resources are required to fill up. Besides, experts further stressed that there is no
reliable data and the prevalence of mental health problems, particularly depression, is increasing in
Myanmar due to changing lifestyles (Moe Thet War, Nov 14, 2016).
Research Methodology
Study design
A cross sectional survey of 420 participants conducted in conflict affected area of Kayin State,
Myanmar. Data are collected by using structured interview questionnaire.. Multistage random sampling
method was used in selected sample in this study. The scale measurement of level of depression was
evaluated by using the Scale measurement depression level.
Sampling Methods
Multi-stage sampling was selected the samples in this study. Three townships of Kayin State
were randomly selected and then a community was randomly selected from each selected township,
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the totals of 420 samples were randomly selected probability proportional to size of the population in
each townships.
Demographic and socioeconomic factors were described by percentage and frequency for
categorical data. Mean and standard deviation (SD) and median and range (Minimum: Maximum) were
reported for continuous data. To investigate factors that associated with general depression level of
community, odds ratios (ORs), and their 95% confidence interval (95%CIs) were estimated using multiple
logistic regression for cross sectional study. This analysis was adjusted for baseline variables and
showing a bivariate relationship with mild, moderate and severedepression levelsuch as stress, alcohol
consumption and sociodemographic factors. All analyses were performed using Stata version 10.0. All
test statistics were two-sided and a p-value of less than 0.05 was considered statistically significant.
Results
1. Demographic and Social Determinant
The social determinant characteristics of the respondents arepresented in table ( 1). Female
305 ( 72. 62 %) and elder young aged group in the age between 40 and 59 years old 154(36.67%) were
more participated in this study. The unexpected outcome could be seen as 200 (47.62%) of participants
have no income since most of the larged scale contributed particiants state their occoupation as normal
housewife. Family income expressed the finicial situation of people who living in those areas since the
whole monthy income less than 20000 MMK contributed 35.95 % in this study. Detailed information
regarding about the demosocio determinants were shown in table 1.
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Table1. Demographic and Socio- Economiccharacteristics of working aged group in Karen State,
Myanmar.
Characteristics Total (2 = 420)
Number Percent (%)
1. Gender
Male 115 27.38
Female 305 72.62
2. Age (complete years)
18 -24 70 18.57
25 -39 142 33.81
40 -59 154 36.67
≥ 60 46 10.95
Mean (±SD): 39.31 (± 13.91), Median (min : max): 39 (18 : 65)
3. Marital Status
Married 329 78.33
Single 41 9.76
Widowed 41 9.76
Divorced/Separated 9 2.14
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Characteristics Total (2 = 420)
Number Percent (%)
5. Personal income Status
No Income 200 47.62
Income 220 52.38
Mean (±SD): 39935.24 (±80636.58), Median (min : max): 5500 (0 : 1000000)
6. Family’s income (MMK/ Month)
≥ 20000 151 35.95
>20000 – ≥100000 157 37.38
>100000 112 26.67
Mean (±SD) :95843.57 ±149491.4, Median (min : max) :50000 (0 :1500000)
7. Suffered from Chronic

Disease
No 268 63.81
Yes 152 36.19
8Chronic Disease Type ( n= 152)
Unknown 24 15.79
Diabetes 6 3.95
Hypertension 89 58.55
Other 33 21.71
2. Screening of Stress Level among working aged group in conflict affected area of
Karen State.
Generally, most of these working aged group scored in low level of stress 349 (83.10 %)
while asking about their emotion and worry about things during past two weeks prior to data
collection. Detailed information was provided in table 2.
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Table2. Level of Stress of working aged group community in conflict affected area of
Karen State, Myanmar
Level of Stress Total (n = 420)
Number Percent (%)
Low (Score ≤ 20) 349 83.10
Median (Score ≥40 - ≤ 21) 71 16.90
High (Score ≥ 41 - ≥ 60) 0 0.00
Mean (+ S.D) 10.8(+ 5.57), Median (Min, Max) 10(2 - 32)
3. Assessment of Severity of Depression among working aged community in conflict
affected areas of Karen State, Myanmar (Outcome Variable)
Depressive severity was measured by using PHQ-9 tool, which has sensitivity and
specificity of around 88%. PHQ-9 has both reliability and validity in testing severity of
depression based on criteria and used in clinical and research setting. (Kurt Kroenke, 2001) It is
also found able tool in primary care setting. Outcome variable was depression within mild,
moderate and severe levels, resulting in the prevalence of 50% with 95%CI 45.20 -54.80.
Table 3. Depression severity of working aged group in Karen State, Myanmar
Depression Prevalence Total (n = 420)
Number Percent (%) 95% CI
Minimum 210 50.00 -
Mild, Moderate and Severe 210 50.00 45.20 -54.80

depression
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Health Promotion 06
Table 4. Each category of Social – demographic factors influencing depression based on
simple logistic regression: Bivariate analysis
Crude
Characteristic demographic factors number % 95%CI p-value
OR
Gender 0.100
Female 305 47.54 1
Male 115 56.52 1.43 0.93 - 2.20
Age (complete year) <0.001
< 40 220 42.73 1
200 58.00 1.85 1.25 - 2.72

≥ 40
0.246
Ethnic
Burma, Mon and Other 73 43.84 1
347 51.30 1.35 0.81 - 2.24

Karen
0.075
Marital Status
Married 329 47.72 1
Single/Widowed/ Divorce 91 58.24 1.52 0.95 - 2.44
0.068
Education Status
Formal Education 266 46.62 1
154 55.84 1.45 0.97 – 2.16

No formal Education
0.138
Occupation
Employed 241 46.89 1
Not Employed
179 54.19 1.34 0.91 – 1.97
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Health Promotion 06
Crude
OR
Personal Monthly Income 0.078
Have Income 220 45.91 1
200 54.50 1.41 0.96 - 2.07

No Income
0.008
Family Monthly Income
>100000 112 38.39 1
>20000 – ≤ 100000 157 50.96 1.67 1.01 – 2.73
≤20000 151 57.62 2.18 1.32 –3.59
<0.000
Suffering from Chronic Disease
268 43.28 1
No
Yes 152 61.84 2.12 1.41 – 3.19
Table 5. Alcohol consumption factors influencing depression based on simple logistic
regression: Bivariate analysis
Crude
OR
Alcohol Consumption 0.004
Low Risk Drinking (≤ 7) 319 75.95 1

Hazardous and Harmful drinker 101 24.05 1.36 1.23 – 3.07
and Alcohol Dependent (>7 - 19)
Have Safety Problem at Work 0.000
No 279 47.73 1
Yes 122 62.41 2.14 1.41- 3.23
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Health Promotion 06
2. Relationship between influencing factors and depression based on multiple logistic
regression analysis: multivariate analysis.
Present study revealed the first strongest associated factors to mild and
moderate level depression among working aged group is Male are more in higher risk 1.72
times than women (Adj. OR 1.72, 95 % CI: 1.02 – 2.91).
Table 6. Adjusted Odds ratios for each category of factors depression based on multiple
logistic regression.
%
numbe Crude Adj. p-
Factors. Depressio 95%CI
r OR. OR. value
n
1. Gender 0.049
Male 305 47.54 1 1
Female 115 56.52 1.43 1.72 1.02- 2.91
2.Age Group 0.025
<40 220 42.73 1 1
≥ 40 200 58.00 1.85 1.60 1.05- 2.45
3.Marital Status 0.030
Married 329 47.72 1 1
Unmarried 91 58.24 1.52 1.72 1.03- 2.87
4.Occupation Status 0.023
Employed 241 46.89 1 1
Unemployed 179 54.19 1.34 1.67 1.05 - 2.65
5.Family income 0.021
>100000 112 38.39 1 1
>20000 – ≤ 100000
157 50.96 1.67 1.99 1.17 - 3.39
≤ 20000 151 57.62 2.18 1.94 1.13 – 3.33
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Health Promotion 06
%
Crude Adj. p-
numbe
Factors. Depressio 95%CI
r OR. OR. value
n
6.Suffering From 0.001
Chronic Disease
No 268 43.28 1 1
Year 152 61.84 2.12 2.11 1.34- 3.31
7.Work Safty 0.011

Problem
No 279 47.73 1 1
Year 122 62.41 2.14 1.77 1.14- 2.77
8. Alcohol 0.001
Consumption
Low risk or 319 75.95 1 1
abstain from
drinking alcohol
Hazardous 101 24.05 1.36 2.26 1.37 -3.73
drinker ,
Harmful Drinker
, and
Alcohol
dependent
1. Discussion
The present study revealed that Female participants were more represented here
as most of household lead family stay at home at day time were women. Over half of them
stated their job as non-stable and unemployed which might weight on the depression prevalence
at some point. After the data analysis, the result found out that occupation status also highlight
the prevalence of depression as non-employed or unstable job conditioned participants were

more likely to be depressed rather than who have their own jobs or employed people as they
could have more worried for their daily basic surviving.
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Health Promotion 06
In terms of the health status, the study found out that non communicable and chronic
disease like hypertension, diabetes, and other disease like heart attack, asthma, and anemia
affected over 30 % of the participant. Among those who suffered from chronic disease, 10 % of
them were being suffered almost for their whole life while the average suffering period is 7
years and this disease suffering group shown strong association with depression prevalence
based on statistical significant level. Among Psychosocial factors, the study strongly shown
that participants who have problems in mental concentration, task complexity and work rhythm
are almost 3 times in risk of depression when compared with those who have fatigue problems.
2. Limitation of the study

The truth prevalence of this particular population would be difficult to ascertain, as in
any conflict or post conflict situation. It is critical to reiterate that whatever screening threshold
is used for this population, the true population prevalence must be known in order to make
conclusions on prevalence of depression.
3. Recommendations
The studied outcome group with depression severity starting from mild level should be
followed up their conditions and functionality for decision making needed clinical or
psychological intervention.
Detecting of depression in low resource settings is crucial to assure that advances in

availability of evidence-based care translate into delivery care. Depression screening
approaches from high-income countries using self-report questionnaires have limited
application for populations with low literacy and lack of familiarity with completing such
forms. Research shown that primary care workers can add this challenged by employing a
stepped screening process with local idioms of distress followed by applying transculturally
translated and clinically validated self-report questionnaires. Future research is needed to assess
the implementation of similar algorithms in routine primary care in other cross-cultural low-
resource settings.
Based on the study result, the mental health program should be considered in any
health plan since the positive impact of political situation likely less happen and locally
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Health Promotion 06
appropriate rate of income rely on proper job opportunities and stable political situation. Beside
then, the surviving from chronic non communicable diseases put many weight on depression
prevalence in post conflict affect and low resource setting area.
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Health Service System 01
Competencies of Public Health Professionals Qualifications

Framework in Thailand
Wilawun Chada1, Songkramchai Leethongdee2, Supa Pengpid3 and Sa-Ngud Chualinfa4
1
Doctor of Public Health student, Faculty of Public Health, Mahasarakham University
2
Faculty of Public Health, Mahasarakham University
3
ASEAN institute, Mahidol University
4
Mahasarakham Public Health Center
บุคลากรทางสาธารณสุ ขเป็ นองค์ประกอบที่สาคัญในการขับเคลื่อนระบบสุ ขภาพเพราะว่าบุคลากรสาธารณสุขเป็ นคน

บริ หารจัดการทรัพยากรและเป็ นปั จจัยที่สนับสนุนหรื อขัดขวางการพัฒนาระบบสุ ขภาพ การศึกษานี้ เป็ นการประเมินสมรรถนะ
ของกรอบคุณวุฒิวิชาชีพสาธารณสุ ขในประเทศไทย การวิจยั แบบผสมผสานที่ใช้เทคนิคการวิจยั เอกสารและวิธีการที่เป็ นระบบ
จาก 6 แหล่งคือ 1) สมาคมโรงเรี ยนสาธารณสุ ขในยุโรป: ASPHER 2) สภาความสัมพันธ์ระหว่างสถาบันการศึ กษาและการ
สาธารณสุข 3) องค์การอนามัยโลก: WHO 4) ศูนย์ควบคุมและป้ องกันโรค: CDC 5) สภาสถาบันสาธารณสุขศาสตร์ แห่งประเทศ
ไทยและ 6) พระราชบัญญัติวชิ าชีพสาธารณสุขแห่งประเทศไทย
ผลการศึกษาพบว่า สมรรถนะหลัก 7 สมรรถนะคือ 1) ระบาดวิทยาและการเฝ้าระวัง 2) การส่งเสริ มสุขภาพการป้ องกัน

และควบคุม 3) การบริ หารสาธารณสุ ขและระบบสุ ขภาพ 4) ชี วสถิติและวิธีการวิจยั 5) สุ ขภาพสิ่ งแวดล้อมและอาชี วอนามัย
6) การคัดกรองสุขภาพและการรักษาขั้นพื้นฐานและ 7) ปั จจัยทานายสุขภาพและประชากร
สรุ ป สมรรถนะด้านวิชาชีพสาธารณสุ ขมีความหลากหลายและซับซ้อนในเรื่ องกรอบความสามารถตามกรอบคุณวุฒิ

ของประเทศไทยจาเป็ นต้องมีหลักฐานเพิ่มเติมในการกาหนดมาตรฐานแห่ งชาติ มีความจาเป็ นที่จะต้องศึกษาและค้นคว้าเพื่อ
พัฒนาความสามารถของผูเ้ ชี่ยวชาญด้านสาธารณสุข
206
Abstract
Introduction: The health workforce is an important element for a drive of the health system,
because of a health workforce is a manager of resources and whose is an important factor to support
or obstruct to the development of health system.(1)
Objective: The research aimed to examine competencies of public health professional
qualifications framework in Thailand.
Methodology: It was mixed method research which applied a documentary research technique and
systematic approach from 6 sources: 1) Association of Schools of Public Health in the European
Region: ASPHER 2) The Council on Linkages Between Academia and Public Health Practice 3)
World Health Organization: WHO 4) Centers for Disease Control and Prevention: CDC 5) The
Council of Public Health Education Institute of Thailand and 6) The Professional Act of Public
Health in Thailand.
Results: The results reveal the core competency have 7 core competencies : 1) Epidemiology and
surveillance 2) Health promotion, prevention and control 3) Public health administration and health
system 4) Biostatistics and research methods 5) Environmental health and occupational health 6)
Health screening and basic therapy and 7) Determinant of health and population.
Conclusion: In conclusion, the competencies of public health professional qualification are various
and complexity with regards to competency framework for Thailand qualification framework need
more evidences to formulation the National standard. It is necessary to find out and study to
develop competency of public health professional.
207
Introduction
The health workforce is an important element for a drive of the health system, because of a
health workforce is a manager of resources and whose is an important factor to support or obstruct
to the development of health system( 1) .The situation of the health workforce in Thailand in 2015
collected by Office of the Permanent Secretary, Ministry of Public Health Thailand found that the
health workforce in Thailand have total 205,136 people. Classification by work position that the
highest position is a nurse, public health scholar, medicine and public health practice, respectively.
Especially in public health area nationwide have total 44,053 people(2) .

In Thailand was the evolution to produce and develop in public health workforce,
continuously. In concurrent in transitional of social emphasis of expertise and professional
especially in the health workforce. A cause of try to development in public health area to public
health professional. Eventually, announce the Professional Act of Public Health in Thailand in
2013( 3) .However, standardization in competencies of work position by Office of the Civil Service
Commission, Thailand is determined by the role as the set and formulate by the wide specification
qualification(4).
Objective
The research aimed to examine competencies of public health professional qualifications
framework in Thailand.
Methodology
It was mixed method research which applied a documentary research technique and
systematic approach from 6 sources :
1) Association of Schools of Public Health in the European Region: ASPHER
2) The Council on Linkages Between Academia and Public Health Practice
3) World Health Organization: WHO
4) Centers for Disease Control and Prevention: CDC
208
5) The Council of Dean of Public Health Education Institute of Thailand and
6) The Professional Act of Public Health in Thailand.

Additionally, it was approached content analysis to formulate alternatively suggestion to
the competency of public health professional framework.
Result
Association of Schools of Public Health in the European Region: ASPHER (5)
ASPHER defined the competency of public health professional divided into two categories
including intellectual competences and practical competences. The core competencies consist of 6
competencies including
1) Methods in Public Health
2) Population Health and its Social and Economic Determinants
3) Population Health and Determinants
4) Health Policy, Economics and Management
5) Health Promotion and
6) Ethics
The Council on Linkages between Academia and Public Health Practice (6)
The Council on Linkages between Academia and Public Health Practice ( Council on
Linkages) is a collaborative of 20 national organizations that aims to improve public health
education and training, practice, and research. The Core Competencies for Public Health
Professionals (Core Competencies) are a consensus set of skills for the broad practice of public
health, as defined by the 10 Essential Public Health Services. In this paper sets on the 8 core
competencies including
1) Analytical/Assessment Skills
2) Policy Development/Program Planning Skills
3) Communication Skills
4) Cultural Competency Skills
209
5) Community Dimensions of Practice Skills
6) Public Health Sciences Skills
7) Financial Planning and Management Skills
8) Leadership and Systems Thinking Skills
World Health Organization: WHO European Region (7)
This tool is designed to guide a broad self-assessment of all public health operations
within Member States in the WHO European Region. The EPHOs are separated into 10 broad
categories including
1) Surveillance of population health and well-being
2) Monitoring and response to health hazards and emergencies
3) Health protection, including environmental, occupational and food safety and others
4) Health promotion, including action to address social determinants and health inequity
5) Disease prevention, including early detection of illness
6) Assuring governance for health
7) Assuring a competent public health workforce
8) Assuring organizational structures and financing
9) Information, communication and social mobilization for health
10) Advancing public health research to inform policy and practice
4.4 The Centers for Disease Control and Prevention: CDC (8)
The Centers for Disease Control and Prevention in United States of America (9) describe the
10 essential public health services and use that as a framework for public health initiatives. Core
Functions of Public Health have 3 core competencies including 1) Assessment 2) Policy
development and 3) Assurance and presented 10 general competencies
1) Monitor health status to identify and solve community health problems
210
2) Diagnose and investigate health problems and health hazards in the community
3) Inform, educate, and empower people about health issues
4) Mobilize community partnerships to identify and solve health problems
5) Develop policies and plans that support individual and community health efforts
6) Enforce laws and regulations that protect health and ensure safety
7) Link people to needed personal health services and assure the provision of health care
8) Assure a competent public and personal healthcare workforce
9) Evaluate effectiveness, accessibility, and quality of personal and population-based

health services
10) Research for new insights and innovative solutions to health problems
The Council of Dean of Public Health Education Institute of Thailand (9)
The draft of Thailand Qualifications Framework of Bachelor of Public Health in

Thailand by The Council of Dean of Public Health Education Institute of Thailand
presented the framework to education for undergraduate degree for 10 subject
groups including
1) Biostatistics
2) Epidemiology
3) Public health administration and health management
4) Environmental health
5) Occupational health and safety
6) Professionalism ethics and laws
7) Health education and behavioral sciences
8) Disease diagnose, health screening, basic treatment, interfaculty patient transfer
and rehabilitation
9) Health prevention and control
10) Field practicum
211
The Professional Act of Public Health in Thailand (10)
The Professional Act of Public Health in Thailand announced in 2013. The law assigned the
role of public health professional in 8 aspects including
1) Health promotion
2) Health prevention
3) Health control
4) Basic treatment
5) Rehabilitation
6) Disease diagnose and health screening
7) Occupational health and safety
8) Environmental health
Synthesis the Competencies of Public Health Professionals Framework

The comparison of competencies of public health professional that demonstrate the
different standpoint in competencies of public health professional. Classification of standpoint into
2 groups
Group 1 Educational institution constitute 1) Association of Schools of Public Health in the
European Region: ASPHER 2) The Council on Linkages Between Academia and Public Health
Practice and 3) The Council of Public Health Education Institute of Thailand
Group 2 Public health organizations constitute World Health Organization: WHO European
Region and Centers for Disease Control and Prevention: CDC

The appropriate competencies of public health professional framework and classification
of competencies have 7 subject groups including
1) Epidemiology and surveillance cover the content about epidemiology, health diagnoses,
health investigation, surveillance, and response to health hazards and emergencies.
2) Health promotion and control cover the content about health promotion, monitoring of
health status, health prevention, health control and Information, communication and social
mobilization
212
3) Public health administration and health system cover the content about public health
administration, health system, policy, plans, financial, health workforce, laws and professional
ethics.
4) Disease diagnoses and basic treatment cover the content about disease diagnoses , basic
treatment, community skill and mobilize community partnerships.
5) Biostatistics and public health research cover the content about biostatistics, public health
research, development innovation and health risk assessment.
6) Environmental health and occupational health and safety
7) Social determinant of health and population cover the content about social determinant
of health, culture, economics and factors effect to health population reveal in figure 1.
Figure 1 Public Health Professionals Framework
Discussion
It is necessary to find out and study to develop competency of public health professional .
The process of policy option for producing and development
213
Conclusion
In conclusion, competencies of public health professional are various and complexity with
regards to competency framework for Thailand qualification framework need more evidences to
formulation the National standard.
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214
Underutilization of antennal care services and its associated

factorsin conflict-affected areas of Karen state, Myanmar
Saw Nay Htoo1, Wilaiphorn Thinkhamrop2
1
2
การใช้ บริการฝากครรภ์ ตา่ และปัจจัยทีม่ คี วามสัมพันธุ์ในพืน้ ทีร่ ัฐกระเหรี่ยง ประเทศพม่ า

ในประเทศพม่า อัตราการฝากครรภ์ของหญิงตั้งครรภ์มี 4 ครั้ง (ANC) หรื อมีอตั ราการฝากครรภ์มากขึ้นร้อยละ 66.9
และหญิงตั้งครรภ์มีการลงทะเบี ยนก่อน 12 สัปดาห์ ของการตั้งครรภ์ซ่ ึ งถือว่ามีน้อยมาก การรับรู ้ปัจจัยที่มีอธิ พลช่วยปรับปรุ ง
ANC ให้ครอบคลุมยิ่งขึ้น วัตถุประสงค์ เพื่อศึ กษาปั จจัยที่ มีความสัมพันธ์กับการใช้บริ การการฝากครรภ์ต่ า การศึ กษา cross
sectional study โดยกลุ่มตัวอย่างจานวน 346 คน ที่ ได้รับการคัดเลือกแบบสุ่ มตามสัดส่ วนของขนาดประชากรโดยวิธีการสุ่ ม
แบบหลายขั้นตอน การศึกษาครั้งนี้ ใช้แบบสอบถาม การเข้าถึงสถานการณ์การใช้บริ การฝากครรภ์และปั จจัยที่มีความสัมพันธ์
ชนเผ่ากระเหรี่ ยง ประเทศพม่า
ผลการศึกษา: ศึกษาในกลุ่มหญิงตั้งครรภ์ 346 คน มีการศึกษาระดับประถมศึกษาร้อยละ 36.71 และไม่ได้รับการศึกษาร้อยละ
26.01 ผูห้ ญิ งส่ วนใหญ่ร้อยละ 62.14% ไม่มีรายได้ ความชุกของการใช้ ANC เป็ น 60.98% (95% CI = 34% -44%) ปั จจัยที่ มี
ความสัมพัธ์กบั การใช้บริ การฝากครรภ์ ANC ต่า พบว่า ANC เข้ารับการตรวจก่อนตั้งครรภ์ 12 สัปดาห์ (adj. OR = 4, 95% CI =
2.38-6.7, p-value <0.001) การฝากครรภ์ ANC พร้อมคู่สมรส (adj.OR = 2.38, 95% CI = 0.98-5.79) และการฝากครรภ์ ANC คน
เดี่ยว (adj.OR=3.24, 95%CI=1.59-8.19) (p.value=0.034), ความตระหนักในความรุ นแรงของปั ญหา (adj.OR = 2.94, 95% CI =
1.59-5.42, p-value <0.001),การรั บ รู ้ ต่ อ อุ ป สรรคระดับ ปานกลาง (adj.OR = 2.15, 95% IC = 0.98 - 5.79) และการรั บ รู ้ ต่ อ
อุปสรรคระดับสูง (adj.OR = 5.33, 95% CI = 1.95-14.53, p <0.001)
สรุป: ความพร้อมของผูใ้ ห้บริ การ ANC และผูใ้ ห้บริ การมีไม่เพียงพอ ดังนั้นหน่วยงานสาธารณสุขควรพิจารณา: การส่งเสริ ม
สุขภาพในการให้บริ การฝากครรภ์, และความพร้อมของบริ การ ANC ด้าน บุคลากร ยาและเวชภัณฑ์ ควรมีการศึกษาเพิ่มเติมเพื่อ
ทาความเข้าใจเกี่ยวกับความรู ้ ทัศนคติและการปฏิบตั ิเกี่ยวกับบริ การฝากครรภ์ในชุมชน
215
Abstract
Background: In Myanmar, the percentage of pregnant women with ANC 4 times or more in any
period of gestation for a union was 66.9% and pregnant women with early registration around 12
weeks of gestation were 16.7 % . The antenatal care visits among women in the conflict-affected
areas of Karen State, Myanmar is relatively low if compared to the country as a whole. The
reasons for such low utilization lack of understanding.
Objective: The aims of this study are to examine what potential factors are associated with
underutilization of antenatal care services.
Methods: A community-based cross-sectional analytical study was conducted in three townships,

conflict-affected areas of Karen State, Myanmar in 2017. 346 samples were randomly selected
proportional to the size of the population by multi-stage sampling method. The structured
questionnaires were used to access the situation of antenatal care in Karen State, Myanmar.
Descriptive statistics and multivariable logistic regression were performed by using Stata version
13.0.
Results: The prevalence of ANC underutilization was 60.98% with (95% CI= 56-66). Of the 346
mothers, 36.71% had primary education and 26.01% had no formal education. Most of the women
( 62. 14% ) responded that they have no income. From this research, it revealed that factors
associated with underutilization of ANC were women who did not seek ANC during last/current
pregnancy (Adj OR= 8.38, 95% CI=2.19-32.06, p-value=0.002), women who first visited ANC after
12 weeks of pregnancy were 3.76 times ( Adj OR= 3.76, 95% CI= 2.26-6.25, p.value<0.001) , and
women who visited ANC accompanied by spouse (Adj OR=2.38, 95%CI=0.98 – 5.79) and nobody
was 3.24 times (Adj OR=3.24, 95%CI=1.59-8.19, P-value: =0.034). Regarding perception women on
ANC services, low and moderate perception on the severity of the problems associated with
pregnancy ( Adj OR= 2. 93, 95% CI= 1. 59-5. 40, p-value <0. 001) and women who had moderate
perception on barriers ( health care workers attitude, distance to the clinic, long waiting time,
opening time, affordability of the services, cultural factors) (Adj OR=2.15, 95% IC=0.98-5.79) and
those who high perception was (Adj OR=5.33, 95%CI=1.95- 14.53, p-value <0.001).
Conclusions: There was strong association found between underutilization of ANC and
Last/present pregnancy status and perception of ANC utilization. The availability of ANC service
and care providers are inadequate. Therefore, the concerned health authorities should consider on:
health promotion on antenatal care services, and the availability of ANC services, care providers,
216
and medicine and supplies. A further study should be conducted to know more about knowledge,
attitude, and practice of the antenatal care services in the community.
Key words: conflict-affected areas, underutilization, and ANC.

Introduction
In Myanmar, according to the data of public health statistical report in 2012, the
percentage of pregnant women with ANC 4 times or more in any period of gestation for a union
was 66.9% and pregnant women with early registration around 12 weeks of gestation were 16.7 %.
Myanmar has been adopted the WHO antenatal care model as a standard model for utilization of
antenatal care; therefore, quality utilization of antenatal care regarded as early registration before
12 weeks of pregnancy together with 4 or more regular ANC visits. Although attendance in ANC
is encouraging, most women seek ANC less than 4 times or they sought late initiation of ANC
(Wai Mon Soe, 2015). During 2015-16 Myanmar Demographic and Health Survey (MDHS)
showed 81% of women who gave birth in the five years preceding the survey received antenatal
care from a skilled provider at least once for their last birth. Fifty-nine percent of women had four
or more ANC visits (Ministry of Health and Sports, 2016). A Report by the Health Information
System Working Group (HISWG, 2015) stated that over half of women whose last pregnancy
was within the past two years received at least one antenatal care visit in Eastern Myanmar
conflicted areas. However, only 16.4% of women had four or more antenatal care visits, meeting
the World Health Organization recommended standard (HISWG, 2015). The antenatal care visits
among women in the conflict-affected areas of Karen State, Myanmar is relatively low if
compared to the country as a whole. The reasons for such low utilization lack of understanding.
The aims of this study are to examine what potential factors are associated with underutilization
of antenatal care services.
Objective
The aims of this study are to examine what potential factors are associated with
underutilization of antenatal care services.
217
Methodology
Study design
This cross-sectional study was designed to describe the situation of antenatal care services
and determine the association between risk factors and utilization of antenatal care services when
controlled other covariates including socioeconomic factors. Underutilization of ANC was
diagnosed using cup point of ANC <4 times and the first visit is later than 12 weeks of
pregnancy. The study was conducted in June-August, 2017.
Study Population
The study population comprised women in the reproductive age group (15-49 years old)
residing in rural areas of three townships in conflict-affected areas of Karen State, Myanmar who
had delivered a live baby in preceding 6 months. The study was conducted in three townships of
conflict-affected areas of Karen State, Myanmar, and 346 women aged range from 15 to 49 years
old participated in this study.
Data Collection
This study used the structured questionnaires to access the situation of antenatal care in
Karen State, Myanmar. After the research proposal and tools have been approved by the ethical
committee, the researcher started conducting the community-based study of the utilization of
antenatal care. Prior to data collection, women were informed of the aim of the study and assured
that their identity and the information they provided would be treated as confidential and they
would remain anonymous. Primary data was collected to assess the demographic and socio-
economic characteristics of the samples. Information of 346 singleton live-born infants of the
mothers’ most recent birth within six months preceding survey was examined.
Collected data were entered into excel and transferred to STATA ( Version 13, Stata
Corporation, College Station TX) for analysis. The categorical data was reported as number and
218
percentages and mean, standard deviation, median and range (minimum: maximum) to describe
the continuous variables. Odds ratio (OR) and their 95% confident intervals (CI) was estimated
using unconditional logistic regression with underutilization of antenatal care as an outcome. The
bivariate analysis was performed by simple logistic regression to measure the effect of each
variable of interest. Multivariate analysis was performed by multiple logistic regression including
variables that showed a potentially significant statistical effect in the prediction in
underutilization of antenatal care in bivariate analysis. Variables associated with underutilization
of antenatal care from the bivariate analysis with p-value ≤ 0. 25) were included in the
multivariate analysis model. The magnitude of the association between contributing factors and
underutilization of antenatal care when controlled other covariates were determined using odd
ratio (OR), the adjusted odd ratio (Adj OR) and 95% confident interval (CI). Statistical significance
was taken as (p-value <0.05).
Result
A total of (346) respondents participated in this study and table below describe their
characteristic of socio-demographics.
Table 1. Baseline socio-demographic characteristic (n=346)

1. Age (in year)
≤19 37 10.69
20 - 29 187 54.05
30 - 39 106 30.64
≥40 16 4.62
Mean (SD) 27.46 (±6.47)
Median (Min : Max) 26 (17: 48)
2. Education status
Primary 127 36.71
Secondary 87 25.14
3. Marital status
Married 339 97.98
Widow/ Separated/ Divorced 7 2.02
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4. Religion
Buddhist 297 85.84
Christian 49 14.16
5. Ethnicity
Burman 36 10.40
Mon 10 2.89
Karen 297 85.84
Karenni 1 0.29
Others 2 0.58
6. Residence
Urban 2 0.58
Rural 344 99.42
7. Occupation
None 1 0.29
Housewife 261 75.43
Employee 4 1.16
Business 15 4.34
Others 10 2.89
8. Monthly income
No income 215 62.14
≥1 - <50000 84 24.28
≥50000 47 13.58
Median (Min : Max) 0 (0: 500000)
9. Family monthly income
No income 65 18.79
≥1 - <100000 178 51.45
≥100000 103 29.77
Median (Min : Max) 33500 (0:2000000)
Not Enough 111 32.08
characteristic of pregnancy history.
220
Table 2. Baseline pregnancy history characteristic (n=346)

1. Frequency of pregnancies
1 105 30.35
2-3 137 39.60
4-6 82 23.70
>6 22 6.36
2. Age of the first pregnancy
<18 65 18.79
18-20 148 42.77
21-25 96 27.75
>25 37 10.69
Mean (SD) 20.43 (±3.65)
3. Number of children
<1 5 1.45
1-2 203 58.67
>2 138 39.88
Mean (SD) 2.38 (±0.52)
4. Frequency of Abortion
<1 259 74.86
1-2 79 22.83
>2 8 2.31
Mean (SD) 0.35 (± .74)
Median (Min : Max) 0 (0:5)
5. Seeking ANC (previous pregnancy)
Never 19 5.49
Sometimes 109 31.50
Always 218 63.01
6. Availability of health workers
Never 4 1.16
Sometimes 74 21.97
Always 266 76.88
7. Availability of medicines and supplies
Never 4 1.16
Sometimes 98 28.32
Always 244 70.52
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characteristic of ANC utilization during last/current pregnancy.
Table 3. Baseline characteristics of ANC utilization during last/current pregnancy

1. Seeking ANC during last/current pregnancy
No 23 6.65
Yes 323 93.35
2. Week of pregnancy when first seek ANC
<12 weeks 140 40.46
12-28 weeks 195 56.36
>28 weeks 11 3.18
3. ANC services providers:
(Doctor/Nurse) 73 21.10
(HA/ MW/ AMW) 170 49.13
Ethnic health worker/ medic) 123 35.55
Traditional Birth Attendant 91 26.30
4. Iron supplementary pills
<120 176 50.87
>=120 170 49.13
5. Services received during ANC:
Physical checkup 328 94.80
Abdominal checkup 331 95.66
Urine test 284 82.08
Blood test 270 78.03
Vaccine 253 73.12
Iron supplement 328 94.80
De-worming 136 39.31
health education 316 91.33
6. Frequency of receiving deworming
<1 217 62.72
>=1 129 37.58
7. Any health problem
No 272 78.61
Yes 64 18.50
Don’t know 10 2.89
8. Decision making to make ANC visit
Yourself 261 75.43
Spouse 50 14.45
Others 35 10.12
222

9. Accompany during the visits
Nobody 111 32.08
Spouse 195 56.36
Mother in law 9 2.60
Sibling 22 6.36
Other 9 2.60
10. Personal reason not to use ANC
No 324 93.64
Yes 21 6.07
Other 1 0.29
11. Family reason not to use ANC
No 333 96.24
Yes 9 2.60
Other 4 1.16
12. Social/cultural reason not to use ANC
No 339 97.98
Yes 7 2.02
Other
13. Religious reason not to use ANC
No 343 99.13
Yes 2 0.58
Other 1 0.29
14. The most significant reasons to seek ANC
14.1 Health of yourself
No 76 21.97
Yes 270 78.03
14.2 Health of the child
No 56 16.18
Yes 290 83.82
15. The most significant reasons to stop
None 55 15.90
getting ANCHealth Service 9 2.60
Family 1 0.29
Culture 90 26.01
Financial 36 10.40
Others 155 44.80
The prevalence of underutilization of antenatal care was shown in table 4. Among 346
respondents, 211 (60.98%) underutilizes antenatal care with 95% CI (0.34 – 0.4).
223
Table 4. Prevalence of underutilization of Antennal Care (n=346)

Frequency of ANC visits Number Percentage (%) [95% CI]
<4 visits and first ANC visit 211 60.98 56 - 66

≥12 week of pregnancy
>4 and more visits 135 39.02
Table 5. Factors associated with underutilization of ANC: Multivariate analysis

% Crude Adjusted p-
Characteristics Number underutilization 95% CI
OR OR value
of ANC
1. Seeking ANC 0.002
during
last/current
pregnancy
Yes 323 40.87 1
No 23 13.04 4.61 8.38 2.19-32.06
2. Week of <0.001
pregnancy when
first seek ANC
<12 140 53.57 1
weeks
≥12 206 29.13 2.81 3.76 2.26-6.25
weeks
3. Accompany 0.034
during the visits
Mother 40 80.00 1
in law, Sibling,
and
Others
224
% Crude Adjusted p-
Characteristics Number underutilization 95% CI
OR OR value
of ANC
Spouse 195 60.51 2.6 2.38 0.98-5.79
Nobody 111 54.95 3.28 3.24 1.59-8.19
4. Perceived 0.001
severity of the
problems
associated with
pregnancy
High 263 42.59 1
Low and 83 27.71 1.9 2.93 1.59-5.40

moderate
5. Perceived <0.001
barriers
Low 35 80.00 1
Moderate 213 66.20 2.04 2.15 0.98-5.79
High 98 42.86 5.3 5.33 1.95-14.53
The above table 5. Showed the contributing factors which were associated with the
underutilization of antenatal care. Women who did not seek ANC during last/current pregnancy
were 8.38 times (95% CI=2.19-32.06), p-value=0.002 more likely to underutilize antenatal care
services than those who seek ANC. Women who first visited ANC after 12 weeks of pregnancy
were 3.76 times (95%CI=2.26-6.25) more likely to underutilize ANC than women who first visited
ANC before 12 weeks of pregnancy (p.value<0.001). Women who visited ANC accompanied by
spouse were 2.38 times (95%CI=0.98 – 5.79) and nobody was 3.24 times (95%CI=1.59-8.19, P-value:
=0.034) more likely to underutilize ANC services than those accompanied by the mother in law,
sibling, and others. Low and moderate perception on the severity of the problems associated with
pregnancy was 2.93 times (95% CI=1.59-5.40) more likely to underutilize ANC service than those
225
who had a high perception of the severity of the problems associated with pregnancy (p-value
<0.001). Women who had moderate perception on barriers (health care workers attitude, distance
to the clinic, long waiting time, opening time, affordability of the services, cultural factors) were
2.15 times (95% IC=0.98- 5.79) and those who high perception was 5.33 (95%CI=1.95- 14.53) more
likely to underutilize ANC service than those who had low perception on barriers(p-value <0.001)
Discussion
ANC service utilization is determined by several factors including socio-demographic
characteristics, pregnancy history of the mother, knowledge, and attitude, quality of ANC and so
on. From this study, it is found that women who did not seek ANC during last/current pregnancy,
who first visited ANC later than 12 weeks of pregnancy, who visited ANC accompanied by
spouse and nobody, who had low and moderate perception on the severity of the problems
associated with pregnancy, who had moderate perception on barriers (health care workers
attitude, distance to the clinic, long waiting time, opening time, affordability of the services,
cultural factors) were associated with underutilization of ANC. It is confirmed with the study
conducted in Ethiop that mothers who considered pregnancy as a risky event were more likely to
seek ANC than those considering it risk-free (OR=12.9; 95% CI 7.6, 21.9)(Zeine Abosse, 2010). The
finding is consistent with the finding from (Leah, 2013) that when perceived barriers outweigh
perceived benefits, the result of women engaging in the antenatal care compliance with
recommended health seeking behavior is decreasing. Furthermore, inconveniences such as the
long waiting time at antenatal facilities, distance to the health facility would act as barriers to
utilization of ANC. A pregnant woman would opt not to go to the health facilities if she sees no
benefit in doing so. Moreover, inadequate resources both material and human, inadequate
equipment, and supplies, would also impede utilization of ANC (LEAH, 2013).
The information used was subjected to recall bias, as information collected relied on the
women’s ability to remember about her pregnancy. The potential of recall bias will be minimized
226
by restricting the sample only to mothers’ most recent delivery within the last six months of data
collection period.
Conclusion
This study revealed that ANC service utilization rate in the conflict-affected area of Karen
State, Myanmar is similar to the national and state level figure available to date. However, it is
worth noting that a large number of mothers who attended ANC did not receive enough of visits
(60.98%) and initiate the visit later for full ANC service utilization as recommended by WHO.
Furthermore, level of knowledge of mother on ANC service and its benefits, cost of
transportation and the distance of service centers from the residence were major contributing
factors for ANC services use. The socio-economic status of the study population is really poor.
Hence the effort to bring about to a significant change in those major contributing factors at
individual and community level by public awareness and behavioral change communication will
be needed.
Recommendations
Policy makers and health professionals are recommended to enhance the utilization of
quality Antenatal Care in the community-based health facilities. A further study of knowledge,
attitude, and practices on ANC is encouraged to better understand the utilization pattern of
antenatal care in the community. A quality antenatal care should be emphasized in the future
maternal and child health program. The government, communities and other development
partners should increase health infrastructure so that distance to the health facility can be
reduced. Communities should be assisted to come up with strategies which will promote
utilization of ANC services. There should be a multi-sectoral approach to the promotion of
maternal and child health.
227
Reference
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Organizations Leading the Way to Better Health in Eastern Burma".
3. Idemudia, A. F. F. a. E. S. (2015). "Assessment of quality of antenatal care services in Nigeria:
evidence from a population-based survey." Fagbamigbe and Idemudia Reproductive Health.
4. Latt, N. N. (2016). "Healthcare in Myanmar." Nagoya J. Med. Sci.
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Maryland, USA (September 2016). "Myanmar Demographic and Health Survey 2015-16: Key
Indicators Report."
6. Wai Mon Soe, J. C., and Aroonsri Mongkolchati (October 2015). "Predictors of quality utilization
of antenatal care services in Naypyidaw, Myanmar." Journal of Public Health and Development
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8. Zeine Abosse, B., MP1, Mirkuzie Woldie, MD, MPH2*, Shimeles Ololo, BSc, MPH2 (July 2010).
"Factors influencing antenatal care services in Hadia Zone." Ethiop J Health Sci. Vol.20.
228
Child immunization and its associated factors among 0-2 years old
children living in Mon State, Myanmar
Aung Zaw Htike1, San San Myint Aung2
1
MPH Program student, Faculty of Public Health, Khon Kaen University
2
Rector (Retired), University of Community Health,Magway,Myanmar
ในสาธารณรัฐแห่ งสหภาพพม่า ความครอบคลุมของการได้รับวัคซี นยังคงอยูใ่ นระดับที่ ไม่น่าพอใจ ประเทศจึง

จาเป็ นต้องระบุปัจจัยที่มีอิทธิ พลต่อการได้รับวัคซี นในระดับต่า เพื่อการปรับปรุ งในอนาคต การศึกษาครั้งนี้เป็ นการศึกษา
เชิ งวิเคราะห์ แบบภาคตัดขวาง โดยมี วตั ถุประสงค์เพื่ อ อธิ บายความครอบคลุมการได้รับวัคซี น และเพื่อหาปั จจัยที่ มี
ความสัมพันธ์ในการได้รับวัคซี นในเด็กแรกเกิด ถึง 2ปี ที่อาศัยอยูใ่ นรัฐมอญ สาธารณรัฐแห่ งสหภาพพม่า กลุ่มตัวอย่าง
คือ ผูด้ ูแลเด็ก จานวน 353 คนโดยมีการสุ่มตัวอย่างแบบหลายขั้นตอน ตามสัดส่วนของขนาดประชากร รวบรวมข้อมูลจาก
การใช้แบบสอบถามแบบมีโครงสร้าง และวิเคราะห์ขอ้ มูลด้วยสถิติ ใช้การวิเคราะห์ถดถอยโลจิสติกพหุ เพื่อระบุปัจจัยที่มี
ความสัมพันธ์กบั การได้รับวัคซีนในเด็กแรกเกิด ถึง 2 ปี
ผลการศึกษา ผูด้ ูแลเด็กส่ วนใหญ่ คือ มารดา (86.12%) ประมาณครึ่ งหนึ่ งเป็ นกลุ่มชาติพนั ธุ์มอญ (50.42%). ใน
เด็ก 353 คนได้รับวัคซี นครบตามเกณฑ์ 83% (95% CI: 79.06 - 86.94) ปั จจัยที่มีความสัมพันธ์กบั ความครอบคลุมในการ
ได้รับวัคซีน ระหว่างชาติพนั ธุ์พม่าและชาติพนั ธุ์กระเหรี่ ยงเมื่อเทียบกับชาติพนั ธุ์มอญพบว่าการที่เด็กมีความครอบคลุมการ
ได้รับวัคซี น (adj.OR =2.91, 95%CI = 1.40- 6.05, P- value =0.004) กลุ่มที่ มีรายได้ต่อเดื อนในครอบครัวระดับปานกลาง
และระดับสู ง (adj.OR=2.42,95%CI=1.10-5.32 & adj.OR =4.25, 95%CI=1.22 - 14.75, P-value = 0.031), บัตรการได้รับ
วัค ซี น (adj.OR =3.32, 95% CI=1.28-8.66, P-value=0.021), มี ค วามรู ้ ใ นระดับ สู ง (adj.OR=2.98, 95%CI=1.42-6.27,P-
value=0.004) และมีทศั นคติในระดับสู ง (adj.OR=4.37,95%CI=2.129.01,P- value<0.001) ผูด้ ูแลเด็กที่ไม่ได้ทางานในด้าน
การได้รับวัคซี นในเด็ก (adj.OR =3.16, 95%CI=1.658.56, P-value=0.002) ครอบครัวไม่เคยมีภาวะแทรกซ้อนจากการฉี ด
วัคซีน (adj.OR = 6.09, 95%CI= 2.95-12.60, P-value<0.001) ทาให้การได้รับวัคซีนในเด็กมีโอกาสน้อยลงด้วย
สรุ ป : ปั จจัยทางเศรษฐกิ จและสังคม ความรู ้ ทัศนคติ และประสบการณ์ ของผูด้ ู แลเด็ก ในการได้รับวัคซี น มี

อิทธิพลต่อ ความครอบคลุมการได้รับวัคซีนในเด็กแรกเกิด ถึง 2 ปี
229
Abstract
Introduction: In Myanmar, child immunization coverage was still at unsatisfactory level. The
country need to identify the factors influencing low immunization coverage for future
improvement.
Objective: This cross-sectional analytical study aimed to describe the immunization coverage
and to determine its associated factors among 0-2yearsold children living in Mon State,
Myanmar.
Methodology: A total of 353 caregivers were selected by multistage random sampling
proportional to size. Data was collected by using structured questionnaire. Multiple logistic
regression analysis was used to identify associated factors of child immunization.
Result: Most of caregivers were mothers (86.12%), about half were Mon ethnic group
(50.42%).Among 353 children, 83% (95% CI: 79.06 to 86.94) had completely. The factors
associated with complete child immunization were Bamar and Kayin ethic groupswhen
compared with Mon ethic group (adj.OR =2.91, 95%CI = 1.40- 6.05, P- value =0.004), had
medium and high monthly family income (adj.OR=2.42,95%CI=1.10-5.32 &adj.OR =4.25,
95%CI=1.22 - 14.75, P-value = 0.031), retention of immunization card (adj.OR =3.32, 95%
CI=1.28-8.66, P-value=0.021), had high level of knowledge (adj.OR=2.98, 95%CI=1.42-6.27,P-
value=0.004) and high attitude level (adj.OR=4.37,95%CI=2.129.01,P- value<0.001). The
caregivers who had to absent from works for child immunization (adj.OR =3.16,
95%CI=1.658.56, P-value=0.002), had experienced in complications of immunization in family
(adj.OR =6.09, 95%CI= 2.95-12.60, P-value<0.001), were less likely completely immunized to
their children.
Conclusion: Socioeconomic, knowledge, attitude and experience of the caregivers on
immunization had influences on child immunization coverage.
230
Introduction
Immunization was an essential form of primary prevention which protected both the
individual and the wider population by means of impending the spread of infectious disease(1).
Incomplete immunization can lead to greater risk for children acquiring disease and it can
also affect the image of public health status of the country(2). Based on a review article of
immunization coverage in WHO regions, 21.8 million infants worldwide were not reached
with routine immunization services in 2013(3).
In Myanmar, based on EPI fact sheet 2016 by WHO, immunization coverage in 1980-
2015, achievements were stilling with unsatisfactory level by nationwide. The reported cases
of vaccine preventable disease in 2011-2015, the diphtheria cases were 7 in 2011, 19 in 2012,
38 in 2013, 29 in 2014 and 87 in 2015 that was increased by yearly and this might be the
consequences of DPT3 vaccine coverage(4).It seem that the country may be need to find out
the reasons of low immunization coverage in where with low coverage by mean of
conducting surveys and researches. This cross-sectional analytical study aimed to describe the
immunization coverage and to determine its associated factors among 0-2 years old children
living in Mon State, Myanmar.
Objective
1. To describe the magnitude of immunization coverage among the children aged 0-
2 year in Mon state, Myanmar

2. To identify factors associated complete immunization among children 0-2 years
aged children in Mon state, Myanmar
Methodology
Study design
A community-based cross-sectional study was conducted in Mon State, Myanmar. The
study involved 353 mothers/care givers who had 18-24 months old children residing in there.
231
The children who had contraindications at the time of immunized, missed opportunities for
immunization and who were living in crash program area were excluded in this study. Data
collection was done by face to face interviewed using structured questionnaire after doing the
pretest and getting the informed consent. Cronbach’s alpha coefficients of knowledge and
attitude questionnaires were 0.77 and 0.88 respectively. Child immunization status was firstly
accessed from immunization card, in case the card not access, reviewed from immunization
register which kept on Health Center. Multistage random sampling method was used in
selected sample in this study.
Mawlamyine Mon State Thaton

District District
Tsp Tsp Tsp Tsp Tsp Tsp Tsp Tsp Tsp Tsp
1 2 3 4 5 6 1 2 3 4
Mudon Township Ye Township Paung Township
(35) Village Tracts (30) Village Tracts (49) Village Tracts
KawtKaPone TaGoneTaing ZeePhyuTaung HanGan AhHlat KawtKaYin

Village Tract Village Tract Village Tract Village Tract Village Tract Village Tract
(N =502) (N =503) (N =561) (N =403) (N =288) (N =257)
Sample Sample Sample Sample Sample Sample

(n=50) (n=50) (n=78) (n=60) (n=61) (n=54)
Figure 1.Sampling frame and techniques
232
Study outcome
Complete immunization Refers to the extent to which the required vaccines had
been received, as at the time of the interview. The children who had completed all doses of
vaccines these are (BCG, (DTP-HepB-Hib) 3 doses, OPV 3 doses, PCV 3 doses, Measles-
Rubella, Measles) as scheduled in Expended Programme on Immunization, Myanmar.
Incomplete immunization Refers to the extent to which the required vaccines had been
received, as at the time of the interview. The children who had missed any dose of vaccines
these are (BCG, (DTP-HepB-Hib) 3 doses, OPV 3 doses, PCV 3 doses, Measles-Rubella,
Measles) as scheduled in Expended Programme on Immunization, Myanmar.
Statistical analysis was done by using Stata version 13.0. The data were checked for
validation before analysis. The categorical data were described as frequency, percentage and
mean, range (minimum: maximum) standard deviation for continuous data. Bivariate analysis
was used by using of simple logistic regression to estimate the effect of variables. Variables
associated with children immunization status from such analysis with p-value ≤ 0.25 were
included in the multivariate model. The association between child immunization status and
each factor were presented as adjusted odds ratio (AOR) and their 95% confidence interval
(CI), with the level of statistical significance was assigned as 0.05.
Result
The majority of caregivers were mothers 86.12%.(25-40) years age group was represented as
the most 65.16% among caregivers and nearly all 93.48% of them have married.83% of children
completely immunized to all vaccines according to schedule of Myanmar immunization
programme and 17% dropout rate in BCG-Measle-2 vaccines.
233
Table 1. Baseline characteristics presented as percentage unless specified otherwise
among caregivers, child’s father, child and family in Mon State, Myanmar (n=353)
Care giver
Type of care giver
- Mother 304 86.12
- Grand Parent 32 9.07

- Relative 17 4.82
Age (year)
- <25 41 11.61
- 25 – 39 230 65.16
- 40 – 59 72 20.40
- ≤60 10 2.83
Mean (±SD): 34.52±9.239, Median (min : max): 33(18: 63)
Marital Status
- Married 330 93.48
- Window/Separated/Divorced 16 4.53
- Single 7 1.98
Ethnic group
- Mon 178 50.42
- Bamar 160 45.33
- Kayin 15 4.25
Family
Monthly family income(Myanmar kyat)
- < 200000 80 22.66
- 200000 – 349999 222 62.89
- ≤350000 51 14.45
Mean (±SD): 263399.4±146986, Median (min : max): 200000(40000: 1000000)
234
Family members
- (1-3 ) 116 32.86
- (4-6 ) 200 56.66
- ( ≤7 ) 37 10.48
Mean (±SD): 4.482±1.599, Median (min : max): 42:10
Child
Sex
- Girl 181 51.27
- Boy 172 48.73

Birth order
- 1 148 41.93
- 2 99 28.05
- >2 106 30.03
Mean (±SD): 2.12±1.35, Median (min : max): 2(1:8)

Sex
- Girl 181 51.27
- Boy 172 48.73
Birth order
- 1 148 41.93
- 2 99 28.05
- >2 106 30.03
Mean (±SD): 2.12±1.35, Median (min : max): 2(1:8)
Immunization card
- Yes 320 90.65
- No 33 9.35
Place of child delivered

- Health facility 218 61.76
- Home 135 38.24
235
Table 2. Prevalence of immunization status among 0-2 years old children living in Mon
State
Immunization Status Number Percent (%) 95% interval conference
Incomplete 60 17.00 -
immunization
Complete immunization 293 83.00 79.06 to 86.94
Table3. Associated of factors with complete child immunization (simple logistic
regression)
% Complete Crude
Factors number 95%CI p-value
Immunization OR
Ethnic group <0.001
- Mon 178 76.40 1 1
- Bamar & Kayin 175 89.71 2.69 1.48 to 4.89
Highest education level(Child 0.034
father)
- Illiterate & Read and 192 79.17 1 1
write/Monastery &
Primary school
- Secondary school & 161 87.58 2.05 0.88 to 4.74
Higher school &
University/graduate
236
% Complete Crude
Immunization OR
Monthly family income 0.100
(Myanmar kyat)
- < 200000 80 76.25 1 1
- 200000 – 349999 222 83.78 1.61 0.86 to 3.01
- ≤ 350000 51 90.20 2.87 1.03 to 8.25
Family members 0.037
- ( 4-6 ) & (≤7 ) 237 80.17 1 1
- ( 1-3 ) 116 88.79 1.96 1.01 to3.79
Birth order 0.037
- >2 106 75.47 1 1
- 2 99 83.84 1.69 0.84 to 3.38
- 1 148 87.84 2.35 1.21 to 4.55

Immunization card 0.001
- No 33 60.61 1 1
- Yes 320 85.31 3.78 1.76 to 8.1

Travel costs 0.055
- Cost 43 72.09 1 1
- No cost 310 84.52 2.11 1.01 to 4.40

Absent work <0.001
- Absent 46 56.52 1 1
- No absent 307 86.97 5.13 2.62 to10.04
whom usually consults to take 0.037

treatment
- Others 65 73.85 1 1
- Government health staff 288 85.07 2.02 1.06 to 3.83
237
% Complete Crude
Immunization OR
Experience on complications of <0.001
immunization
- Experienced 62 56.45 1 1
- No experienced 291 88.66 6.03 3.25 to11.20

Level of Knowledge <0.001
- Medium )60-80%& ( Low 81 17.75 1 1
level )<60%
- High level )>80%( 272 82.85 4.34 2.41 to7.81
Level of attitude 0.001
- Medium )34– 54 Score& ( 101 24.91 1 1
Low level )15– 33Score(
- High level )55 -75 Score( 252 75.09 2.64 1.49 to4.67
Figure2. Forest plot diagram for factors associated with complete child immunization
(Multiple logistic regressions)
238
Discussion
Among (353) children with their age (18-24) month, 83% have completely immunized to
all vaccines according to schedule of Myanmar immunization programme. This was similar
with previous study result conducted in Eastern, India( 5) . There have 17% dropout rate in BCG-
Measle-2 vaccines and 83% of children were immunized to Measle -2 vaccine. These results
were less than dropout rate 19% and more than fully vaccinated 77% of previous study results
that conducted in Kiandutu Slums, Thika District, Kenya among 12-23 months aged children
( 6)
. After controlling the confounding factors with backward elimination multivariate analysis,
seven variables were significantly associated complete child immunization. Burma and Kayin
ethnic children have (2.91) times more complete immunization status than Mon ethnic children.
Complete child immunization was associated with ethic differences, it accepted to another
( 7)
study result . The caregivers who have high monthly family income and medium monthly
family income, they completely immunized to their children more 4.25 times and 2.42 times
than the caregivers who have low monthly family income. Some studies identified that children
complete immunization status were more likely in high family income than compared with low
family income, and these were significantly association (8) (9) (10).
The children with immunization card have 3. 32 times more likely complete
immunization status than compared with the children who have not immunization card.
Previous study conducted in rural communities of Bida Emirate area,Niger State,Nigeria

identified that complete child immunization was 2.82 times more in the children who have
immunization cards than who have not cards, it similar to this study result ( 11) . In addition, this
study also found that a caregiver absent from work for immunization was barrier to complete
child immunization, those the caregivers who absent from work for immunization ,they have
3.16 times less likely immunized to their children than the caregivers who have not absent from
work for immunization. Previous study described that caregivers busied in other works was
9.5% among the reasons why they have incomplete immunized to their children, and another
study conducted in rural Uganda identified that mother lack of time or being too busy was 15%
among the reasons why they have incomplete immunized to their children, it was revealed with
239
this study result( 12) & ( 13) . In family, experience to any complications of child immunization,
which might to be less likely complete immunized to their children by caregivers. This agreed
with previous study result that conducted in rural communities of Bida Emirate area,Niger
State,Nigeria (11).
The caregivers with high knowledge level, they immunized their children more 2.98
times completely than the caregivers with medium and low knowledge level. Moreover, a
caregiver’ s attitude level towards child immunization was also statically associated with
complete child immunization. This was similar with previous studies results conducted in
Eastern, India and in Damietta Governorate, Egypt (5) (14) . The caregivers who have high attitude
level towards child immunization, they immunized their children completely more 4.37 times,
those comparatively with the caregivers who have medium and low attitude level towards child
immunization (15) (16).
Strength of study
This study was the first study on child immunization in Mon State in Myanmar.
Study participants also obtained better knowledge on immunization.
Limitation of study
Because of cross-sectional analytical nature of this study, it was not allowed the cause
and effect relationships. This study could not generalize the migrant mothers. A further study
should be conducted among migrant children and a qualitative study was also recommended
for better understanding about child immunization in this area.
Conclusion
In this study, 83 % of children had completely immunized to all vaccines. Experiences

any complications regarding child immunization in family was the most obviously barrier to
the children have to be have complete immunization. And also, complete immunization was
baulked that why caregivers absent their work for immunization. Complete immunization was
more likely in Bamar and Kayin ethnic groups than Mon ethnic .High monthly family income,
240
retention of immunization card, high knowledge and attitude level were significantly more
likely to favor the children have complete immunized.
Recommendations
Strengthening immunization education to improve knowledge and attitude of the

caregivers, immunization information should be disseminated emphasize on Mon ethnic group,
give service convenience to the caregivers free times for who busied with their work and focus
on retention of immunization card, these could be encouraged to more relative frequency of
complete child immunization and to less the defaulter children those able to wipe-out vaccine
preventable disease outbreak.
Acknowledgements
My profound appreciation and special thanks to all the participants and all public health staff
from study area for kindly consented and gave their valuable information for my study.
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Socio economics disparities and incompleted child immunization in Kayin

State, Myanmar
Min Zayar Linn1, Aung Kay Tu2
1
2
การสร้ างเสริ ม ภูมิ คุม้ กัน เป็ นวิธี การที่ มีต ้น ทุ น ประสิ ท ธิ ผ ลในด้านสาธารณสุ ขที่ ส าคัญ ต่อ การดู แลสุ ขภาพของ
ประชาชนนับล้านชีวติ จากผลการสารวจสุขภาพประชากรของประเทศพม่า ในปี พ.ศ. 2558-2559 พบว่ากลุ่มเด็กอายุ 12-23
เดือน เข้ารับบริ การวัคซีนเพียง 55% เท่านั้น วัตถุประสงค์ในการศึกษาครั้งนี้มีวตั ถุประสงค์เพื่อศึกษาความสัมพันธ์ระหว่าง
ปั จจัยทางเศรษฐกิ จและสังคมกับความไม่สมบูรณ์ ของการรับบริ การวัคซี นในกลุ่มเด็กอายุต่ ากว่า 24 เดื อน ในรัฐกะยีน
ประเทศพม่า การศึกษาครั้งนี้ เป็ นการศึ กษาแบบภาคตัดขวาง ดาเนิ นการในพื้นที่ 20 หมู่บา้ นของรัฐกะยีน มีผเู ้ ข้าร่ วมวิจยั
ทั้งสิ้ นจานวน 342 คน ซึ่ งเป็ นผูด้ ูแลของเด็กอายุ 24-36 เดือน โดยทาการสุ่ มตัวอย่างแบบหลายขั้นตอน ข้อมูลประวัติการ
ได้รับวัคซี นของเด็กถูกเก็บรวบรวมจากบัตรการได้รับวัคซี นหรื อสัมภาษณ์จากผูป้ กครองโดยใช้แบบสอบถาม การศึกษา
ครั้งนี้ ใช้การถดถอยลอจิสติคอย่างง่ายและพหุ คูณ เพื่อทานายปั จจัยตัวแปรต้นที่ มีผลกับการรับบริ การวัคซี นที่ ไม่สมบูรณ์
จากการศึกษาครั้งนี้พบว่า 54% ของผูด้ ูแลทั้งหมด มีอายุระหว่าง 25-40 ปี
ผลการศึกษาจะเห็นได้วา่ ความชุกของความไม่สมบูรณ์ของการรับบริ การวัคซี นของเด็กอายุระหว่าง 24-36 เดือน

คิดเป็ น 44.44% (95% CI = 39.15 - 49.73) ผลการวิเคราะห์ ด้วยการถดถอยลอจิ สติ คพหุ คูณพบว่า การมี ความรู ้ต่ า (p =
<0.001) ทัศนคติที่ไม่ดี (p = <0.001) ความสะดวกในการเดินทางมารับบริ การฉี ดวัคซีน (p = <0.001, adj. OR = 10.88) และ
การเข้าถึงข้อมูลข่าวสารของวัคซีน (adj.OR = 8.36, 95% CI = 3.93 - 17.89, p value = <0.001) มีผลต่อความไม่สมบูรณ์ของ
การได้รับวัคซี นอย่างมีนัยสาคัญทางสถิ ติ ในประชากรกลุ่มที่ ทาการศึ กษา สรุ ปผลการศึ กษา การรับบริ การวัคซี นที่ ไม่
สมบูรณ์ในเด็กอายุ 2-3 ปี ยังคงมีระดับสู ง บัตรการเข้ารับบริ การฉี ดวัคซี น (adj. OR = 6.94) ความรู ้และทัศนคติของผูด้ ูแล
เป็ นปั จจัยสาคัญที่เกี่ยวข้องกับการได้รับวัคซีนที่ไม่สมบูรณ์ ดังนั้นจึงเป็ นสิ่ งจาเป็ นสาหรับหน่วยงานที่เกี่ยวข้องทุกภาคส่วน
ในการเสริ มสร้างความตระหนักให้แก่ประชาชนเห็นความสาคัญของการสร้างเสริ มภูมิคุม้ กัน
243
Abstract
Introduction: Immunization is one of the most cost-effective public health interference to
save millions of lives. Myanmar Demographic and Health Survey (MDHS) 2015-2016 showed
that complete immunization coverage among children age 12-23 months was only 55% in
Myanmar.
Objective: This study aimed to determine association between socioeconomic factors and
incomplete immunization among under 24 months' old children in Kayin state, Myanmar.
Methodology: This cross-sectional study was conducted in 20 villages in Kayin State. There
were 342 care givers who have a child age 24-36 months' old were multi stage random
sampling. The child's immunization status data was collected based on immunization cards or
caregivers' verbal reports using structured questionnaires interview. Simple and multiple
logistic regressions were used to assess factors associated with incomplete immunization
coverage.
Result: In this study, 54% of care givers were aged between 25 – 40 years. The result indicated
that the prevalence of incomplete children aged between 24-36 months old was 44. 44%
( 95% CI= 39. 15 – 49.73) . In the multivariate logistic regression models, factors significantly
associated with incomplete immunization were low level knowledge (p=<0.001), poor attitude
(p= <0.001) , convenience for travelling to get immunization ( p= <0.001, adj. OR= 10.88) and
accessibly of immunization information (adj. OR = 8.36, 95%CI = 3.93 – 17.89, p value= <0.001).
Conclusion: Incomplete immunization among children 2-3-year olds remains high. Retention
immunization cards [adj. OR=6.94], caregivers' knowledge and caregivers' attitude are the vital
factors that associated with incomplete immunization. It is essential for relevant sectors to
strengthened the awareness of the public on the importance of immunization.
Keywords: incomplete immunization, socioeconomic disparities, child.
244
Introduction
Immunization is one of the most cost-effective public health interference to save
millions of lives and protect countless children from illness and disability. Vaccination is keys
to achieving the Sustainable Development Goals (SDGs), especially the goal to lessen decease
among children under five years old (SDGs_3.2) (11). Myanmar Demographic and Health
Survey (MDHS) 2015-2016 showed that incomplete immunization coverage among children
age 12-23 months was 45% in Myanmar.
Objective
This study aimed to determine association between socioeconomic factors and

incomplete immunization among under 24 months' old children in Kayin state, Myanmar.
Methodology
Study design
A community based cross-sectional analytical study was conducted in Kayin state,
Myanmar. In this study, 342 care givers who have child aged 2- 3 years old involved. The
exclusion criteria included households without children aged 2-3 years not included. Socio
economics factors, child factors, knowledge, attitude were collected via face to face
interviewed with care givers by using structured questionnaires.
Completed immunization – children are thought as completely immunized when they
have received a vaccination against Tuberculosis (BCG), three doses each of the DPT-Hib-
Hep.B, oral Polio Vaccine and Pneumococcal vaccine, and measles rubella vaccination by the
age of 24 months.
Incompleted immunization – children are thought as incompletely immunized when they
miss at least one doses of the above mentioned vaccines on completely vaccinated definition.
Unimmunized – children are considered as unimmunized when they did not receive any
dose of the above mentioned vaccine on vaccinated definition.
245
Immunized – children are considered as immunized when they who took at least one
dose of the above mentioned vaccines on vaccinated definition.
Sampling Method
Kayin State
4 Districts & 7 Townships
2 Districts
5 Townships
3 Townships
RHCs
342 parents or care takers If some household has

care taker pair infant more
than one, use random sampling
Figure 1. The sampling procedure flow chart

percentage for categorical data and mean and standard deviation for continuous data.
To investigate factors that associated incomplete immunization, odd ratios (ORs), and
their 95% confidence intervals (95% CI) were estimated using multiple logistic regression for
cross sectional study. This analysis was adjusted for baseline variables and showing a
bivariate relationship with incomplete immunization such as age of care givers, retention of
immunization cards, children's physical health status, level of care givers' knowledge, level of
246
care givers' attitude. All analyses were performed using STATA version 10.0. All test statistics
were two-sided and a p-value of less than 0.05 was considered statistically significant.
Result
Table 1. Baseline characteristics of Demographic and socio economics of Parents or care
givers in Kayin State, Myanmar (n=342)

Caregivers
1. Age of caregivers
<25 years 45 13.16
25 - < 40 years 198 50.02
40 - < 60 years 82 23.98
 60 years 20 5.85
Mean (±SD) 36.79 ± 11.76
Median (min : max) 34 19:76
2. Care Givers' gender
Male 15 4.39
Female 327 95.61
3. Type of caregivers
Mother 265 77.49
Father 3 0.88
Grandparent 67 19.59
Relative 7 2.05
4. Education Level of Caregivers
Primary 125 36.55
Secondary 102 29.82
5. Occupation of Caregivers
None 29 8.48
Housewife 121 35.38
Farmer, Fisherman 49 14.33
Employee 4 1.17
Business 22 6.43
Others (Orchard) 68 19.88
6. Monthly family income of
20000caregivers
- <100000 Kyats 132 38.60
100000 - <30000 Kyats 169 49.42
247

 300000 Kyats 41 11.99
Mean (±SD) 133695.9 ± 116339.7
Median (min : max) 100000 20000:700000
8. Number of children alive
1 - <2 193 56.43
2 149 43.47
Mean (±SD) 1.65 0.92
Median (min : max) 1 1:5
9. The primary care givers
Mother 266 77.78
Father 4 1.17
Grandparent 62 18.13
Relative 10 2.92
Table 2. Crude OR for each category of factors on incompleted immunization based on
simple logistic regression
% of
Num Crude
Characteristics incomplete 95%CI p-value
ber OR
immunization
1. Age of Care Giver 0.178
<25 + 25 - < 40 years 240 42.08 1 1
40 - < 60 years +  60 years 102 50.00 1.38 0.86 to 2.19
2. Type of Care Givers 0.178
Mother & Father (Parent) 268 42.54 1 1
Grandparent & Native 74 51.35 1.43 0.85 to 2.39
3. Education Level of Care Givers 0.191
No formal education + Primary +Secondary 293 43.00 1 1
High school or equivalence + Bachelor or 49 53.06 1.49 0.81 to 2.75
Not enough + Not enough with debt
equivalence 154 40.26 1 1
Enough with no saving + enough & save 188 47.87 1.36 0.89 to 2.09
5. Number of child alive 0.204
1 - <2 193 41.45 1 1
2 149 48.32 1.32 0.56 to 2.03
6. Relationship with the caregivers 0.183
Son/ daughter 270 42.59 1 1
Grandson/granddaughter + others 72 51.39 1.42 0.85 o 2.39
others 248
% of
Num Crude
Characteristics incomplete 95%CI p-value
ber OR
immunization
7. Immunization card <0.001
Yes 172 29.07 1 1
No 170 60.00 3.66 2.33 o 5.74
8. Children's physical health status 0.012
5 scores 55 60.00 2.12 1.18 to 3.81
 6 scores 287 41.46 1 1
9. Level of caregivers' knowledge <0.001
Low Level (0 – 5 score) 150 30.00 1 1
Medium Level(6–10 score) 143 50.35 2.37 1.47 to 3.82
High Level (11–15 scores) 49 71.43 5.83 2.86 to 11.88
10. Level of caregivers' attitude <0.001
Low Level (13 – 30 scores) 216 57.41 4.72 2.86 to 7.78
High Level 126 22.22 1 1
+ Medium Level cost to get immunization
11. Travel 0.202
(49 – 65 scores)
 0 - < 500 Kyats 261 42.53 1 1
(31–48 scores)
 500 Kyats 81 50.62 1.39 0.84 to 2.28
12. Convenience for travelling <0.001
No + Indifferent 115 82.61 14.17 8.03 - 24.99
Yes 227 25.11 1 1
13. Convenience for immunization schedule 0.001
No + Indifferent 45 68.89 3.22 1.64 - 6.31
Yes 297 40.74 1 1
14. Quality of health care services <0.001
Need to improvement + average 70 78.57 6.62 3.55 - 12.33
Good 272 35.66 1 1
15. Information about immunization <0.001
Never/Seldom + Sometimes 236 53.81 3.78 2.25 – 6.33
Usually, always 106 23.58 1 1
16. Facilitation of Village Health Volunteers <0.061
Never/Seldom + Sometimes 181 49.17 1.50 0.98 – 2.31
Usually/always 161 39.13 1 1
17. Getting support from other families 0.128
Never/Seldom 200 41.00 1 1
Sometimes + Usually/always 142 49.30 1.39 0.91 – 2.16
After adjusting the care givers age, retention of immunization cards, children's
physical health status, level of knowledge concerning immunization, level of care givers'
attitude, convenience for travelling, facilitation of village health volunteers, and information
about immunization are strongly associate with incomplete immunization.
249
Factors associated with incomplete immunization
Figure 2. Forest plot diagram
Discussion
5
In this study, older age of care givers was related with incomplete immunization
status. But, the study conducted in Dschang, West Region, Cameroon shown that the young
age parents’ was related with incomplete immunization situation( 7) . Children of mothers older
than 30 years of age were 2. 20 times more likely to be correctly vaccinated than were
children of mothers younger than 30 years of age.

The previous study that conducted in Mumbai, Maharashtra, India revealed that the
care givers who no retention of immunization cards was (19% ) among the reasons why they
( 9)
have incomplete immunized to their children . In my study, care givers who have no
retention of immunization cards was 6. 94 times to incomplete immunization than who
retention immunization cards.

The research conducted in Nigeria, child illness at the time of immunization is
associated with incomplete immunization (adj. OR=1.74, 95% CI =0.68 – 0.83, p=0.002). In this
study also found that the child illness is also associated with incomplete immunization (adj.
OR=5.81, 95%CI=1.94 – 17.43, p=0.002).
250
In this study found that high level of knowledge concerning immunization was 11.15
times to incomplete their children than those of low attitude. But the previous research
conducted in Lay Armachiho District, North Gondar Zone, Northwest Ethiopia revealed
children born from mothers who were able to know the age when a child will be fully
immunized were three times more fully immunize than those who were not able to know
(AOR = 2.9 (95% CI = 2.02, 4.26). From the research conducted by Kiptoo, 2015 shown that a
child born from a mother who lacks knowledge on immunization schedule was 9 times more
likely not to receive full immunization than mother with knowledge on immunization
schedule.
The research from Cameroon found that, factors significantly associated with
incomplete immunization status were parents’ attitude towards immunization. Parents with
low attitude towards immunization were 20.2 times to incomplete their children than those of
( 7)
high attitude . In this study found that the low attitude and medium attitude towards
immunization were 7.45 times to incomplete their child.
Conclusion
This cross-sectional study was conducted at 20 villages of 3 townships, Kayin State,
Myanmar. The aims of this study were to describe the immunization situations among 0-2
year’ s old children in Kayin state, Myanmar and to determine association between
socioeconomic factors and incomplete immunization among 0-2 year old children in Kayin
state, Myanmar when control other covariates. The study showed factors that are significantly
associated with immunization incompletion among children age 24-36 months were
knowledge about benefit of vaccinating child and age to complete immunization. Factors
associated with incomplete immunization such as caregivers' age, immunization cards, child's
physical health status, level of Knowledge and attitude, convenience for travelling,
facilitation of volunteer's health workers and information about immunization.
It was concluded that there is strong association between knowledge of infants’
mother regarding the danger signs of obstetric complication during pregnancy, delivery, post-
natal periods and home delivery. Home delivery was very high compared to hospital delivery.
251
A significant proportion of infants’ mother in Gwa township were not knowledgeable of
obstetric danger signs.
Recommendations
From this study, it was clear that a lot still needs to be done to increase the
immunization coverage in Kayin State to the recommended WHO standard. Civic education
specifically targeting care givers aged 40 years and above should be implemented in the rural
areas, to increase immunization coverage among their children. The responsible persons and
health personals should be strengthen on health education about the benefit of immunization
and persuade to change negative attitude to positive attitude on immunization.
Acknowledgements
Firstly, I would to express sincere appreciation to Khon Kean University,
USAID_PLE to give me a chance to study MPH. Secondly, I want to thank to our Union
minister and also thank State Public Director. I want to express sincere appreciation to my
teachers and Ethnical committee. Finally, I want to thanks the caregivers who participated in
my study.
Reference
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missed opportunities among rural Nigerian children. Journal of Public Health and Epidemiology. 2011; 10.
2. Basic Health Staff Guidelines for SNID and NID. 2015; 40.
3. Melkamu Beyene Kassahun, G. A. B., Alemayehu Shimeka Teferra. Level of immunization coverage and
associated factors among children aged 12–23 months in Lay Armachiho District, North Gondar Zone,
Northwest Ethiopia: a community based cross sectional study. BMC Research Notes. 2015; 10.
4. R., A. I. S. O. A. T. J. A. A. G. O. A. Reasons for incomplete vaccination and factors for missed opportunities
among rural Nigerian children. Journal of Public Health and Epidemiology.2011; 3(4).
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months in Dschang, West Region, Cameroon: a cross-sectional survey during a polio outbreak. BMC Public
Health. 2015; 11.
6. Shantanu Sharma1, C. K., Nandini Sharma, and Devika Mehra. Incomplete Immunization Coverage in Delhi:
Reasons and Solutions. Primary Health Care: Open Access. 2016; 3.
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7. Gill, N., RavikantMondal, AniketJadhav, Balaram. Immunization coverage and its associated factors among
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Maharashtra, India. International Journal of Community Medicine and Public Health. 2016; 1783-1787.
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9. WHO, U. Myanmar: WHO and UNICEF estimates of immunization coverage. 2015; 23.
253
Socioeconomic Disparity and Incomplete Antenatal Care Practices in

Kayah State, Myanmar
Thazin Hlaing1, Pricha Nippanon2, Wongsa Lohasiriwong2

1
2
สิ่ งสำคัญในกำรลดอัตรำตำยของมำรดำทัว่ โลกจำก 216 ต่อกำรเกิดมีชีพแสนคนในปี พ.ศ. 2558 ให้เหลือน้อยกว่ำ

อัตรำ 70 ต่อกำรเกิ ดมี ชีพแสนคนในปี พ. ศ. 2573 (เป้ ำหมำย SDG อัตรำ 3.1) คื อกำรเข้ำถึ งกำรบริ กำรกำรฝำกครรภ์ที่มี
ประสิ ทธิ ภำพ ซึ่ งกำรระบุปัญหำให้ชดั เจนและแก้ไขปั ญหำที่เป็ นอุปสรรคและข้อจำกัดในกำรเข้ำถึงบริ กำรฝำกครรภ์ที่มี
คุณภำพมีควำมสำคัญต่อกำรพัฒนำสุขภำพมำรดำและเด็กเป็ นอย่ำงมำก กำรวิจยั ครั้งนี้มีวตั ถุประสงค์เพื่อศึกษำอิทธิพลของ
ปั จจัยทำงเศรษฐกิจและสังคมที่มีผลต่อกำรดูแลหญิงตั้งครรภ์ในรัฐกะยำ รู ปแบบกำรศึกษำเป็ นกำรศึกษำแบบภำคตัดขวำง
ดำเนินกำรศึกษำในพื้นที่รัฐกะยำ โดยใช้วธิ ีสุ่มตัวอย่ำงแบบหลำยขั้นตอน กลุ่มตัวอย่ำงที่ถูกคัดเลือกเข้ำมำในกำรศึกษำครั้งนี้
คือ มำรดำที่ มีบุตรอำยุต่ ำกว่ำหนึ่ งปี จำนวน 318 รำย เก็บข้อมูลโดยใช้แบบสอบถำมที่ มีองค์ประกอบเกี่ ยวกับข้อมูลทำง
เศรษฐกิ จและสังคม ประวัติกำรตั้งครรภ์ กำรบริ กำรสำธำรณสุ ข ปั จจัยทำงวัฒนธรรมและปั จจัยทำงสังคม และวิเครำะห์
ควำมสัมพันธ์โดยใช้สถิติกำรถดถอยลอจิสติกเชิงพหุ (Multiple logistic regressions)
ผลกำรศึกษำ พบว่ำ กลุ่มตัวอย่ำงจำนวน 318 คน เป็ นมำรดำของเด็กคิดเป็ นร้อยละ 51.89 ส่ วนใหญ่มีอำยุนอ้ ยกว่ำ
30 ปี และได้รับกำรศึกษำระดับประถมศึกษำ ส่ วนมำกมีอำชีพทำนำ อัตรำกำรฝำกครรภ์ที่ไม่ครบเกณฑ์คุณภำพ คิดเป็ นร้อย
ละ 44.65 (95% CI = 39-50) กลุ่มมำรดำที่มีรำยได้ต่อเดือนน้อยกว่ำ 100000 MMK มีจำนวนมำกที่สุด คิดเป็ นร้อยละ 72.33
กลุ่มตัวอย่ำงส่ วนใหญ่ฝำกครรภ์ไม่ครบตำมเกณฑ์คุณภำพ คิดเป็ นร้อยละ 62.61 จำกกำรวิเครำะห์ควำมสัมพันธ์แบบหลำย
ตัวแปร พบว่ำ ปั จจัยที่มีควำมสัมพันธ์กบั ฝำกครรภ์ไม่ครบตำมเกณฑ์คุณภำพ ได้แก่ รำยได้นอ้ ย (Adjusted OR: 3.51, 95% =
CI: 2.02-6.11, P-value <0.001) กำรคมนำคมที่ไม่สะดวก (Adjusted OR: 1.92, 95% CI = 1.18-3.13, P-value = 0.008) ควำมรู ้
เกี่ ยวกับเกี่ ยวกับกำรดูแลกำรตั้งครรภ์และภำวะแทรกซ้อนอยู่ในระดับต่ ำ (Adjusted OR: 3.00, 95% CI = 1.38-6.54, P -
value = 0.006) และปั จจัยทำงสังคม (Adjusted OR: 2.64, 95% CI = 1.31-5.32, p- value = 0.07)
สรุ ปผลกำรศึกษำในครั้งนี้ มำรดำเหล่ำนี้ส่วนใหญ่ฝำกครรภ์ไม่ครบเกณฑ์คุณภำพ โดยปั จจัยทำงเศรษฐกิจและ
สังคมมีอิทธิพลต่อกำรฝำกครรภ์ที่ไม่ครบเกณฑ์คุณภำพ
คำสำคัญ: กำรฝำกครรภ์ที่ไม่ครบเกณฑ์คุณภำพ, ควำมเหลื่อมล้ ำทำงเศรษฐกิจและสังคม

254
Abstract
Introduction: For reducing the global maternal mortality ratio (MMR) from 216 per 100 000
live births in 2015 to less than 70 per 100 000 live births by 2030 (SDG Target 3.1), it is
important to access to effective antenatal care. Identifying and addressing the barriers that limit
the access to quality antenatal care services are important for improving maternal and child
health.
Objective: To determine the influence of socioeconomic factors on antenatal care practices in
Kayah State.
Methodology: The cross sectional study was conducted in Kayah State. By using multistage
random sampling method, total of 318 mothers who have less than one year old child were
selected to join the study. Data on socioeconomic information, pregnancy history, health
services, cultural factors and social factors were collected by using structured questionnaire.
Multiple logistic regressions were used to identify the association.
Result: Among 318 samples, 51.89% were the child’s mothers, mostly younger than 30 years
and had primary education. Occupation of majority of the mothers and fathers were farmers. The
prevalence of incomplete antenatal care was 55.35% (95% CI=39 – 50). Most of the mothers had
monthly income less than 80000 MMK (50.94%). Most of them had incomplete antenatal care
practices (72.07%). Multivariable analysis indicated factor associated with incomplete ANC
were; that low family income (Adjusted OR:5.25, 95%=CI: 3.15-8.74, P-value<0.001), low
education level ( Adjusted OR:3.30, 95%=CI: 1.92-5.67,P-value<0.001) and social factors
(Adjusted OR:2.31, 95%CI= 1.13-4.70, p-value=0.007).
Conclusion: Most of these mothers had incomplete ANC. Socioeconomic had influence on
incomplete antenatal care practices
255
Keywords: Incomplete Antenatal Care, Socioeconomic, Disparity
INTRODUCTION
WHO indicated that maternal death in Southeast Asia region is still higher than
other regions such as North Africa, Caucasus, Central Asia and Eastern Asia(Nation, 2016).
WHO reported that about 287,000 women of reproductive age die each year from complications
arising from pregnancy and childbirth and almost 99 percent of these deaths occur in developing
countries including Myanmar. For achieving Sustainable Development Goals number 3.1 of
reducing maternal mortality ratio to less than 70 per 100000 live births by 2030, it is important
to provide the appropriate antenatal care. In Myanmar, every year, 1300 of maternal death is
found among the average 1-1.2 million deliveries (DOH 2010). Pregnancy remains a major
health risk for women in several developing countries as well as Myanmar. Pregnancy and its
related complication are the major causes of maternal morbidity and mortality in Myanmar. In
developing countries, every pregnant women are not receiving recommended minimum of four
antenatal visits and only one half of pregnant women receive the four visit of antenatal
care.(Nation, 2016) Inadequate or inappropriate care during pregnancy, delivery and post-natal
period can lead to uterine prolapse, pelvic inflammatory disease, fistula, incontinence, infertility
and pain during sexual intercourse and other serious reproductive tract diseases and disabilities
in developing countries (Teklemariam Gultie*, 2016).
NFOG stated the antenatal care as “Antenatal care is the routine health control of
presumed healthy pregnant women without symptoms (screening), in order to diagnose diseases
or complicating obstetric conditions without symptoms, and to provide information about
lifestyle, pregnancy and delivery”(Backe, Pay, Klovning, & Sand). WHO stated the benefit of
ANC “identification and management of obstetric complications such as preeclampsia, tetanus
toxoid immunization, intermittent preventive treatment for malaria during pregnancy (IPTp),
and identification and management of infections including HIV, syphilis and other sexually
transmitted infections (STIs).
According to the information from WHO 2012, antenatal care coverage in
Myanmar were 80% while other countries such as Vietnam were 96%. When comparing with the
antenatal care visit for at least one time, Myanmar achieved over 70% of ANC coverage at least
one time while other regional countries such as Sri Lanka reached 99%, Thailand 98% and
Indonesia 99%. For using antenatal care, there are many socioeconomic and cultural barriers. To
identify and address the barriers that limit the access to quality maternal health services are
important for improving maternal health(Antenatal care; Pregnancy; Motherhood Needs
Assessment; Ekiti, 2014)In Myanmar, only few study was conducted about the antenatal care
practices and no study was conducted in Kayah State. This study was aimed to identify the
socioeconomic disparity and incomplete antenatal care practices in Kayah State, Myanmar.
256
Objective: To determine the influence of socioeconomic factors on antenatal care practices in

Kayah State.
Materials and Method

Study Design
This is a community based cross-sectional study conducted in Kayah State,
Myanmar from August and September 2017. Total of 318 mothers who gave birth within one
year of data collection were selected by using simple random sampling method and interviewed
by using structured interview questionnaire to identify the demographic and socioeconomic
information including sex, age, income, education, occupation, accessibility to health facility,
knowledge about danger signs during pregnancy and benefit of seeking AN care, practicing AN
care like family support for seeking AN care, frequency of AN practice. Mothers who is
mentally instable were excluded in the study.
Study Outcome
Incomplete Antenatal Care: “Women who could not show AN record. Although
AN record could be shown, ANC was not consulted according to WHO four visit ANC model
and not complete four times. Although the timing of antenatal care is over 4 times, the mother
who didn’t consult the first visit ANC within 12 weeks of gestation, these mother will be
counted as incomplete antenatal care practices.”
percentage for categorical data and mean and standard deviation for continuous data. To
investigate the factors associated with incomplete antenatal care practices, odds ratios (ORs)
and their 95% confidence intervals (95%Cis) were calculated by using multiple logistic regression
for survey sampling. All analysis were performed by using Stata Version and statistics value of
two-sided and p-value of less than 0.05 was considered statistical significant. The study was
approved by Human Research and Ethics Committees of the Ministry of Public Health of
Thailand Ethical Review Committee, Department of Medical Research, Ministry of Health and
Sport, Myanmar.
Result
Half of mothers were age under 30 years of age and the average age was 30 years.
Regarding education level, over half of mothers (54%) completed primary and informal
education, whereas 39.31% completed secondary education. Majority of them were found of
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Christian with 80.19%. Among them, 67.61% worked as farmer and another 16.04% worked as
unskilled labor. It was seen 86.48% of them were Kayen ethnic origin. The husbands of high
school completed and secondary school completed were 40% and 30% respectively. Alike
mothers’ occupation, the majority of nearly 80% worked as farmers too. The average family
income was 101588 kyats; minimally 20,000 kyats and maximally 600,000 kyats were found.
Among the respondents, 88% had their maternal record of seeking AN care. Only 61.29%
received AN care for more than 4 times. Out of 279 mothers, 57.35% of them took AN care
before 12th week of pregnancy. As a result, it was found that the prevalence of incomplete
antenatal care practices are 55.35%.
Table 1. Baseline demographic characteristics of mothers who has under one year old
children (n=318)

Age in years
≤ 30 years 174 54.72
> 30 years 144 45.29
Mean ±SD30±7.02 min-max19- 45
Educational Level
High school and above 71 22.33
Secondary education 125 39.31
Primary Education 72 22.64
Religion
Christian 255 80.19
Buddhism 63 19.81
Occupation
Farmer 215 67.61
Housewife 24 7.55
Bussiness and Employee 28 8.80
Ethnicity
Kayen 275 86.48
Others 43 13.52
Educational Level of Husband
Bachelor and upper 26 8.17
Secondary 94 29.56
Primary and no formal education 72 22.64
Occupation of Husband
Farmer 251 78.93
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Labour 46 14.47
Government staff and other 21 6.61
Monthly family income (Kyats)
≤80000 162 50.94
>80000 156 49.06
Medium:80000 Min – Max:20000-
600000
(The daily wages in Myanmar is 3600 Myanmar Kyats per day)
This study result revealed that 85.85% of mothers was found in good knowledge level and 70%
of mothers were found as high attitude level on receiving AN care services. The majority 82.7%
had good social environment was found in their pregnancy period.
Table 2. Knowledge, Attitude and Social Factors on Pregnancy, care and complication
Knowledge of mothers on pregnancy, care and complication (n=318)
Level of Knowledge on pregnancy, care and Number Percent (%)

complication
High Score ( >80% ) 273 85.85
Medium Score and low score (≤80%) 45 14.15
Mean + S.D 14.14 + 2.05 Min- Max 4-16
Attitude of mothers on pregnancy, care and complication
Level of Attitude on Pregnancy, Care and Number Percent (%)

Complication
High Level (≤76% Score) 225 70.75
Medium level (75%-56% Score) 93 29.25
Mean + S.D 23.56 + 1.86 Min-Max 19-30
Social factors of mothers on pregnancy, care and complication ( n=318)
Condition of social environment Number Percent (%)

Positive (≤77%) 263 82.7
Neutral (76% - 54%) 55 17.3
259
Logistics regression resulted that education level, family income and knowledge level
on AN care had association with incomplete AN care receiving practices at p<0.001. Those who
had no formal education and primary education resulted 3.17 times higher than those who had
secondary and higher edcuation level in incomplete receiving of AN care. As majority of the
occupation in Kayah state is farmer, they are more likely to be incomplete antenatal care
practices then non farmer respondents. When seeing the religion, respondent mothers whose
religion is Christian are 2.39 times higher in incomplete antenatal care practices than mothers
who religion is Buddism. Mothers who is lower family income are 5 times higher on incomplete
antenatal care practices than mothers who
Table 3. Crude odd ratios for the factors on incomplete antenatal care based on simple
logistic regression (n=318)
Incomplete Crude
Factors. number ANC 95%CI p-value
OR.
practices
Age (n=318)
≤30 174 54.02
>30 144 56.94 1.12 0.72-1.75
Educational level <0.001
Higher than secondary school 196 44.90
Lower than primary school 122 72.13 3.17 1.95-5.16
Occupation 0.628
Non-farmer 103 53.4
Farmer 215 56.28 1.12 0.70-1.80
Religion 0.002
Buddhism 63 38.10
Christian 255 59.61 2.39 1.36-4.22
Monthly Family income
<0.001
(Myanmar Kyats)
>80000 MMK 156 35.90
≤80000 MMK 162 72.07 5.10 3.15-8.24
After adjusting the confounding variables, there were 3 variables included in the model
to explain the association with incomplete AN care receiving practices; the variables were
family income, education of mothers and social environment condition. Family income variable
will be the strongest among variables with Adj OR=5.25 to explain association at p<0.001. The
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low income had 5.25 times higher than high income to receive health services incompletely.
The education level of mothers had also significant associated with incomplete antenatal care
practices. Mothers who has no formal education and completed just primary school level were
3.17 times higher in incomplete antenatal care practices than mothers who are secondary school
education and above. Social environment condition had association with incomplete AN care
receiving practices with Adj OR of 2.31 at p<0.05.
Table 4. Adjusted odd ratios for the factors on incomplete antenatal care based on
multiple logistic regression (n=318)
%
Unadj. Adj. p-
Factors. Freq Incomplete OR 95%CI
ANC OR. value
Practices
Family income (Monthly) <0.001
>80000 MMK 156 35.90
≤80000 MMK 162 72.07 2.93 5.25 3.15-8.74
%
Unadj. Adj. p-
Factors. Freq Incomplete OR 95%CI
ANC OR. value
Practices
Educational level <0.001
Higher than
196 44.90
secondary school
Lower than primary
122 72.13 3.17 3.30 1.92-5.67
school
Level of social factors on pregnancy, care and complication 0.007
Good level 263 51.71
Middle and Bad 55 72.73 2.49 2.31 1.13-4.70
Discussion
It has been found that the prevalence of incomplete antenatal care practices in Kayah
State are 55% which was higher than the national figure of 41% which was resulted from
Myanmar Demographic Health Survey 2016. This study has indicated that lower education level
is significantly with incomplete antenatal care. The study result showed that mothers who
education level is primary school and lower are 3.3 times higher incomplete antenatal care
practices than mother whose education level is higher than secondary
level.(AOR:3.30,95%CI:1.92-5.67,P-value <001) The study in South East Nigeria indicated that
261
higher education of mothers are more utilization on antenatal care services and lower education
mothers are less utilization on antenatal care services. The result finding is similar to the other
studies which was conducted in Nigeria in 2012, Vietnam and Southern Benin, which resulted
that lower education level of mother had practiced more incomplete antenatal care than higher
education level of mother. (Bbaale Edward,2011)( Onasoga,2012)( Bui TT Ha,2015)( Ouendo
Edgard-Marius,2015) )( Srijana Pandey,2014) (Emelumadu OF,2017)
In this study, family income is one of the significant factors on association with
incomplete antenatal care practices. Mothers who is from lower family income ( ≤80000MMK)
per month were significantly associated with incomplete antenatal care practices. The study
result showed that mother whose family income is lower than 80000 MMK were 5.25 times
higher in incomplete antenatal care practices than mother who is from higher family income of
more than 80000 MMK.(AOR:5.25, 95%CI:3.15-8.74,P-value:<001) Similar to other studies,
mothers who is from less income family had practiced incomplete antenatal care in their
pregnancy.The study in central Nepal showed that education level of mother are significantly
associated with antenatal care practices. (Ana María Osorio,2014)( Srijana Pandey,2014)( Ha
BTT,2015)( YANG YE,2010)
This study result indicated that mother whose knowledge score is lower than medium
had 3.27 times higher than mother whose knowledge level is higher score on incomplete
antenatal care. Social factors on pregnancy, care and complication, the result finding indicated
that middle and lower band of mothers had practiced incomplete antenatal care 2.49 times
higher than mothers who band is high in social factor.(AOR:2.49, 95%CI: 1.13-4.70,P-
value=0.007) Most of the study showed that knowledge, attitude and social factors were
influence on the behavior of mothers on antenatal care practices. The study in Southern Benin
also indicate that knowledge level of the mothers are associated with the seeking antenatal care
practices.The study in Lao demonstrated that good knowledge and attitude of mothers are
effected on their antenatal care practices. The study in Nigeria also revealed that there is
significant association between knowledge of mother on antenatal care and their behavior on
antenatal care practices. ( Ha BTT,2015)( Ouendo Edgard-Marius,2015) (Onasoga,2012)( YANG
YE,2010)
Conclusion
The objective of this study is to find out the association between socioeconomic
disparity and incomplete antenatal care practices. The result finding indicated that family
income, education of mothers and social factors of mothers are strongly associated with the
incomplete antenatal care practices. Furthermore, transportation cost, distance to health facility,
and relationship with health staffs are also influence on mother’s antenatal care practices. This
study demonstrated that knowledge, attidue and mothers are influencing factors on mother’s
behavior for seeking antenatal care at health facility.
In order to achieve the sustainable development goals, it is important to make
investment on improving the knowledge on effective antenatal care and why it is important to
support pregnant women for seeking antenatal care at health facility.
262
Recommendation
Based on the finding from the study, the following recommendation were
given:
1.Government should support on implementing income generation activity for
women which could give a helping hand for increasing family income and also a kind of
support for women empowerment
2.Policy maker should consider for implementing the nonformal education for
women at village level for improving the education status of women
3.Government policy should help to increase media penetration amongst the masses
and sensitize mothers and family on the importance of effective antenatal care at health
facility and how great important of family support to pregnant women.
4.By conducting the outreach antenatal care services, location disparities should be
eliminated and which can give a lot of support on requirements of a successful antenatal care.
Suggestion for further research

The researcher would like to suggest further studies on socioeconomic determinants of
utilization of antenatal care services in Kayah state and other areas in the country which have
low uptake of antenatal care services. The utilization of antenatal care services and the
relationship between husband involvement and influence in antenatal care services were
suggested to be investigated. Furthermore, the influences of family gate holders and relationship
with antenatal care practices are also needed to be investigated.
References
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The Quality Improvement of Clinical Risk Management System for Nursing

Care Standard in The In-Patient Department in Atsamat Hospital,
Roi-Et Province
Napatsaporn Choengsa-ard1, Terdsak Promarak2, Wachara Eamratsameekool3
1
M.P.H. student, Faculty of Public Health, Mahasarakham University, Thailand. 2Ph.D.,Faculty of
Public Health, Mahasarakham University, Thailand.
3
Director of PhanomPhrai Hospital and Deputy
มิติที่สองของการดูแลสุขภาพผูป้ ่ วยปอดอุดกั้นเรื้ อรังไม่เป็ นตามเกณฑ์มาตรฐาน พบความเสี่ ยงรุ นแรงทางคลินิกระดับ

1 จากการวิเคราะห์สาเหตุของปั ญหา พบว่า เกิดจากระบบของการดูแลผูป้ ่ วยไม่ครอบคลุมถึงความเสี่ ยงทางคลินิก ซึ่ งการวิจยั
ครั้งนี้ เป็ นวิจยั เชิงปฏิบตั ิการ มีวตั ถุประสงค์เพื่อ ศึกษาการปรับปรุ งคุณภาพระบบบริ หารความเสี่ ยงทางคลินิกของมาตรฐานการ
พยาบาลผูป้ ่ วยปอดอุดกั้นเรื้ อรัง ของตึกผูป้ ่ วยใน โรงพยาบาลอาจสามทารถ จังหวัดน้อยเอ็ด ทั้งนี้ เพื่อศึ กษา บริ บทของการ
ปรับปรุ งระบบบริ หารความเสี่ ยง, การปรับปรุ งคุณภาพระบบริ หารความเสี่ ยง, ผลของการปรับปรุ งคุณภาพระบบบริ หารความ
เสี่ ยง และปั จจัยความสาเร็ จของการดาเนินงาน กลุ่มตัวอย่าง จานวน 40 คน คือ กลุ่มที่มีส่วนได้ส่วนเสี ย และมีส่วนร่ วมในการ
ดูแลผูป้ ่ วยตึกผูป้ ่ วยใน โดยรวบรวมข้อมูลในเชิงปริ มาณและเชิงคุณภาพ ระหว่างเดือนมกราคม – พฤษภาคม 2560 การวิเคราะห์
ข้อมูลเชิงปริ มาณด้วยสถิติร้อยละ, ค่าเฉลี่ย, ค่าเบี่ยงเบนมาตรฐาน และวิเคราะห์สถิติอนุมานเพื่อเปรี ยบเทียบค่าเฉลี่ยระหว่างกลุ่ม
ตัวอย่างที่ไม่เป็ นอิสระจากกัน (Paired t-test) ในส่วนของข้อมูลเชิงคุณภาพด้วยการวิเคราะห์เชิงเนื้อหา
ผลการศึกษา พบว่า กระบวนการมีส่วนร่ วมในการปรับปรุ งคุณภาพ ประกอบด้วย 7 ขั้นตอน คือ 1) การรวบรวมข้อมูล
2) การอบรม 3) การวางแผน 4) การดาเนินงาน 5) การติดตามประเมินผล 6) การอภิปรายกลุ่มและกระบวนการเรี ยนรู ้ และ 7) การ
ปรับปรุ งระบบ ซึ่ งหลังจากการดาเนิ นงาน พบว่า ระดับของความรู ้, การปฏิ บตั ิ, การมีส่วนร่ วม, และความพึงพอใจ ของกลุ่ม
ตัวอย่างเพิ่มขึ้นอย่างมีนยั สาคัญทางสถิติ (p-value<0.05) การปฏิบตั ิต่อการประเมินองค์กรด้านความปลอดภัยในการดูแลผูป้ ่ วย
ร้อยละ 65 เกณฑ์มาตรฐานของตึกผูป้ ่ วยในต่อมิติที่สองของการพยาบาล ผ่านเกณฑ์ ร้อยละ 81.25 และผลการดาเนิ นงานด้วย
รู ปแบบ SMILE ประกอบด้วย S-Sensive (ความอ่อนไหว), M-Management (การจัดการ) I-Implement (การดาเนิ นการ), L-
Learning (การเรี ยนรู ้) และ E-Error (ความผิดพลาด)
ปั จ จัย ความสาเร็ จ ของการพัฒ นาคุ ณภาพของการบริ ห ารความเสี่ ย งทางคลิ นิ ก คื อ T-I-P ดัง นี้ ขั้น ตอนที่ ที่ 1 T-
Teamwork คือทีมในการดูแลผูป้ ่ วยด้วยความปลอดภัย ขั้นตอนที่ 2 I-Implement คือ การดาเนิ นงานในการกาหนดมาตรฐานใน
งานประจา และขั้นตอนสุ ดท้าย P-Policy คื อ ความปลอดภัยของผูป้ ่ วยต้องถื อเป็ นนโยบายสาคัญของผูป้ ฏิ บัติง าน เพื่อให้
สอดคล้องกับโรงพยาบาลชั้นนาที่มีคุณภาพและมาตรฐาน
265
Abstract
Introduction: The second dimension of nursing care in IPD not met the criteria. There had severe
clinical risk in class I. From root cause analysis found that the incident was due to patient care
system did not cover any potential clinical risk.
Objectives:
General objective: To study the quality improvement of clinical risk management system
for nursing care standard in IPD in Atsamat hospital, Roi-Et province.
Specific objectives: To study 1.Context of Improving. 2.Improvement the quality.3. Result
of quality improvement. 4. Keys success factors.
Methodology: This action research aimed to study the quality improvement of a clinical risk
management system for nursing care standard in IPD in Atsamat Hospital, Roi-Et Province. The
target group were stake-holders, which were selected 40 personal to participate in the patient care
process in the IPD. Both quantitative and qualitative data were collected during January to May,
2017. The quantitative data analysis applied the descriptive statistics such as percentage, mean,
standard deviation and the inferential statistics as paired samples t-test. The qualitative data was
analysed by content analysis.
Result: The results showed that the participation process of quality Improvement were composed
of 7 processes 1) Data Collecting 2) Cultivation 3) Planning 4) Implementation 5) Monitoring 6)
Group discussion and lesson learned and 7) Improvements. This process effected to the level of
knowledge, practice, participation and satisfaction of participants were increased from the
beginning with the statistical significant (p-value<0.05). That’s a good practice of safety culture
evaluation in patient care of 65 %. According to standard criteria of IPD in the second dimension
passed with a criteria of 81.25 %. It can be found a model called SMILE model which comprised as
S-Sensitive, M–Management, I–Implementation, L-Learning and E-Error.Key success factors in
development quality clinical risk management system is
T-I-P.Firstly, T-Teamwork caring for patients to be safe, secondly I-Implementation to formulate
standards into the routine practice and finally, P-Policy is patient safety as a policy goal with the
manner of the hospital leader with quality concern and value.
Conclusion: Context of developing quality in IPD was found that after the development used risk
report in daily report, due to communicate to all personnel aware of risks involved. Head can
manage the risk quickly. Improving the quality according to the PDCA process, changes and
improvements system are reflected inthe cooperation. Result of quality improvement set patient
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safety Goals for 5 issues and risk management system development SMILE model. Keys success
factors of developing quality is TIP.
BACKGROUND
Trends in development of public health services make hospital improve service quality.
Nursing is one of primary health services. It’s necessary to standard treatment. Upgrade quality to
nursing care goals (Department of nursing, 2008). Nursing management quality of care and safety
for users.Risk management system needed to prevent problems and control the loss of services to
both providers and users(Institute for hospital quality assurance and development,2003). As well as
the high expectations of service providers, daily services face the risk of error. From study reports
found many adverse events can be prevented. The cause of unwanted incident is over 80 % by
human error. Therefore, the development of risk management system is important factor of
quality(Supachutikul A., 2001). The job in hospital every step must analyze the risks to develop
good management system(Thai Damrong P.and other, 2013). Atsamat hospital is a community
hospital service primary and secondary covers the prevention, treatment and rehabilitation to
general public in area. They had developed with guidelines of hospital quality development and
certification. Based on the results for 2016, the second dimension of nursing care in IPD not met
the criteria was 56.25 %. There were 92 clinical risk reports and have severe clinical risk in class
I(Risk management team of Atsamat hospital, 2016). From root cause analysis found that the
incident was due to patient care system did not cover any potential clinical risk.

This study was action research aimed to study the quality improvement of a clinical risk
management system for nursing care standard in IPD in Atsamat Hospital, Roi- Et Province.
Applying the concept of quality development in the organization of Deming cycle from PDCA
(Deming W. Edwards, 1986).Include 4 steps 1) Plan 2) Do 3) Check and 4) Act. The data were
collected during January to May, 2017. Total 5 months. The population is personnel who work in
Atsamat hospital and participate in patient care 88 people.Sample selection from inclusion criteria
consists of 1) Risk Management Team (RMT) 2) Clinical Care Team (PCT) 3) Nursing Service
Committee (NSC) 4) Personnel involved in nursing care standard of IPD 5) Personnel is a level
management and practice 6) Consent to participate in this research by ethical rights.Ethical approval
was made by Mahasarakham University Ethics Committee in Human Research (No.040/2017) and
Roi- Et Provincial Health OfficeEthics Committee in Human Research ( No. 4/ 2017) . Exclusion
criteria is not a qualified person in nursing care standard in IPD. Selected 40 personal, which were
267
to participate in the patient care process in IPD of 14 people.And personnel involved in the nursing
care standard of 26 people. Classification as 6 doctors, 1 dentist, 5 pharmacists, 15 professional
nurses, 4 medical technicians, 1 medical radiologist, 1 medical radiation officer, 2 physical
therapists, 1 nutrition and 4 nurse aids.
Study Tools:
The quantitative tool was a questionnaire, quality inspection of tool in content validity
create a questionnaire then audit by advisor and expert, find Index of Item-Objective Congruence
(IOC) = 0.96. Try out of questionnaire in personnel in PhanomPhrai hospital was conducted 30
participants. Calculated for reliability of the study using Conbach’s Alpha coefficient > 0.70.Finding
in knowledge =0.72, practice = 0.97, participation = 0.96 and satisfaction = 0.98. The qualitative tool
include; 1) Workshop project 2) The quality improvement in nursing care standard in IPD 3) Risk
reporting program and 4)Group discussion and Lesson learn.
Research Technique:
This research improved the quality of clinical risk management system for nursing
carestandards of IPD, used Deming cycle with PDCA process. There were 4 steps as step 1: Plan
have 3 activities 1) Data collecting 2) Cultivation and 3) Planning, step 2: Do have 1 activities 4)
Implementation, step 3: Check have 2 activities 5) Monitoring and 6) Group discussion and lesson
learned, step 4: Act have 1 activities 7) Improvements.
Statistical Analysis:
The data has been validated bring down the code and process statistical data. Using a
computer program to analyzed the questionnaire. The quantitative data analysis applied the
descriptive statistics such as percentage, mean, standard deviation, maximum, minimum and the
inferential statistics as paired samples t-test. The qualitative data was analyzed by content analysis.
RESULTS
1.Context of Improving.
The target group were stake-holders, which were selected 40 personal to participate in the
patient care process in the IPD. 72.5% were female and 27.5% were male. The majority are 40 years
old and up 37.5 %, under the age of 22 years old up to 54 years old. Most of them had a bachelor
degree 72.5%. They were professional nurses 37.5%. Experienced in hospital operations may be 1-5
years 42.5 %. Trained in hospital risk management at 82.5 %. And 80% acknowledge hospital risk
management policy. In the part of work, 95% had a direct interaction or direct contact with the
patient. The study indicated that after improving the quality of clinical risk management, there is a
growing of risk reports compared to before operation.Because personnel aware of the clinical risks
involved.At the time of the operation, there was no serious risk of Grade I. The safety culture in the
268
care of patients found that the quality improvement level was very good before were 55%, after
were 65%. Criteria for nursing services standard in second dimension was 81.25%.
2. Improvement the quality.
There were evaluated in characteristics 4 Steps in knowledge, practice, participation,
satisfaction. It was found that after quality improvement effected to the level of them increased
from the beginning with the statistical significant (p-value<0.05) as follows from table 1-5.
Table 1: Number and percentage of personnel involved in nursing care standards in IPD classified
by Characteristics.(n = 40)

Sex
Male 11 27.5
Female 29 72.5
Age (years)
20-24 4 10.0
25-29 11 27.5
30-34 5 12.5
35-39 5 12.5
Mean=35.75, S.D.=9.66, Min=21, Max=54
Education
Lower degree 5 12.5
Bachelor 29 72.5
Higher degree 6 15.0
Experience (years)
1-5 17 42.5
6-10 10 25.0
More than 10 13 32.5
Mean=9.78, S.D.=9.37, Min=1, Max=32
Position
Doctors 6 15.0
Dentist 1 2.5
Pharmacists 5 12.5
Professional nurses 15 37.5
Medical technicians 4 10.0
Medical radiologist 1 2.5
Medical radiation officer 1 2.5
269
Physical therapists 2 5.0

Nutrition 1 2.5
Nurse aids 4 10.0
Acknowledge the policy
Know 32 80.0
Not know 8 20.0
Table 2: Percentage of knowledge score based on clinical risk management process of sample
before and after quality improvement (n = 40)
Knowledge based on clinical risk Before After
management processes. Score percent level Score percent level
Search for risk. 183 76.25 moderate 233 97.08 high
Risk assessment. 152 63.33 moderate 194 80.83 high
Risk management. 121 75.63 moderate 148 92.50 high
Risk Evaluation. 126 78.75 moderate 148 92.50 high
Total 582 72.75 moderate 723 90.38 high
Table 3: Mean and standard deviation of practice of clinical risk management process of sample
Practice of clinical risk Before After

management process. mean S.D. level mean S.D. level t p-value
Search for risk. 3.08 0.43 moderate 3.92 0.44 high 11.44* <0.001
Risk assessment. 3.14 0.55 moderate 3.85 0.58 high 10.10* <0.001
Risk management. 3.43 0.37 moderate 4.25 0.45 high 13.76* <0.001
Risk Evaluation. 3.05 0.57 moderate 3.80 0.53 high 10.73* <0.001
Total 3.19 0.34 moderate 3.97 0.44 high 17.67* <0.001
Significance p-value <0.05.
Table 4: Mean and standard deviation of participation of clinical risk management process of
sample before and after quality improvement (n = 40)
Participation of clinical risk Before After

Search for risk. 3.15 0.71 moderate 3.75 0.57 high 8.60* <0.001
Risk assessment. 2.95 0.59 moderate 3.55 0.61 moderate 6.88* <0.001
Risk management. 3.02 0.80 moderate 3.75 0.56 high 7.05* <0.001
270
Risk Evaluation. 3.20 0.81 moderate 3.65 0.72 moderate 7.52* <0.001
Total 3.09 0.58 moderate 3.67 0.55 moderate 14.67* <0.001
Table 5: Mean and standard deviation of satisfaction of clinical risk management process of sample
Satisfaction of clinical risk Before After

Process. 3.23 0.09 moderate 4.08 0.07 high 9.11* <0.001
Facility/Support 3.04 0.48 moderate 3.97 0.56 high 10.28* <0.001
Performance 3.31 0.55 moderate 3.92 0.47 high 7.20* <0.001
Related Personnel 3.35 0.69 moderate 4.10 0.61 high 7.46* <0.001
Total 3.23 0.43 moderate 4.02 0.45 high 11.62* <0.001
3. Result of quality improvement.
The study using Deming quality development approach with the PDCA, the result showed
that the participation process of quality Improvement were composed of 7 processes 1) Data
Collecting 2) Cultivation 3) Planning 4) Implementation 5) Monitoring 6) Group discussion and
lesson learned and 7) Improvements. This process effected to the level of knowledge, practice,
participation and satisfaction of participants were increased from the beginning with the statistical
significant ( p- value<0. 05) . From nursing care standard in IPD in the second dimension the
researcher has jointly improved a system of services related to clinical risk management, set patient
safety goals for 5 issues include 1) Patient Identification 2) Patient Fall 3) High Alert Drugs ; HADs
4) Emergency Response and 5) Hand Hygiene. From group discussion and lessons learn of
improvement in the researcher.
Achieving the pattern of quality improvement of clinical risk management systems is

SMILE model which comprised as S: Sensitive; is sensitive to response incident or risk
management. M: Management; is a good management system and good protection. I:
Implementation; is to bring standards into practice by all personnel. L: Learning; is to learn about
the risks and prevent risk repeated. E: Error; is looking at human error. Do not blame the person.
4. Keys success factors.
From this study, found that factors contributing to success of improving quality clinical risk
management systems for nursing care standards in IPD is TIP; T: Teamwork caring for patients to
be safe.I: Implementation to formulate standards into the routine practice. P: Policy is patient safety
as a policy goal with the manner of the hospital leader with quality concern and value
271
Keys success factors for quality improvement in clinical risk management systems
1. Leader concern and value

2. Leader reassure
3. Safety organization
Policy 1. Head Co-practice
2. Practice with standards
3. Update system
1. Patient safety goals
2. Patient focus
Clinical Risk
Management
Teamwork Implement
DISCUSSION
The quality improvement of clinical risk management system for nursing care standard in
IPD in Atsamat hospital, Roi- Et province. This research utilizes the conceptual framework for
Deming’ s quality development approach in the PDCA. Improving quality clinical risk
management.Starting from the personnel involved in nursing care standard of IPD. In terms of
knowledge, practice, participation and satisfaction in 4steps risk management process
(Chantanasombut P. and other, 2012)1) Search for risk 2) Risk assessment 3) Risk management and
4) Risk Evaluation. The research process isanalysis context of clinical risk managementand quality
criteria for nursing care standard of IPD. Consists ofPlan,Do, Check and Act by group discussion
and lesson learn.
From study in context of improving found that the most commonly used incident report
was daily report. Due to communicate to all personnel aware of risks involved and head manager
the risk quickly. In the related agencies report in risk program.Review the risks occurto prevent
repeated risks.To raise awareness of patient safety as safety culture in patient care.Also it was
similar to result study participatory risk management model in public hospitals (Siyawan W., 2002)
by interview, group discussion and model creation risk management. After implementation, it was
found that the risk management model passed the criterion 80%. Improving the quality found that
272
change and improvement of the system was a reflection of cooperation in IPD standard. The results
showed that the participation process of quality Improvement were composed of 7 processes 1)
Data Collecting 2) Cultivation 3) Planning 4) Implementation 5) Monitoring 6) Group discussion and
lesson learned and 7) Improvements. This process effected to the level of knowledge, practice,
participation and satisfaction of participants were increased from the beginning with the statistical
significant (p-value<0.05).That’s a good practice of safety culture evaluation in patient care of 65 %.
According to standard criteria of IPD in the second dimension passed with a criteria of 81.25 %.
Also it was similar to result improving quality of clinical risk management in IPD (Phokapun P.
and other, 2012) . The study indicated that After the development of clinical risk management
quality in IPD standards. Found that the mean of knowledge, practice, participatoryand satisfaction
with the clinical risk management process increased more than before the development. Result of
quality improvement researchers have improved related services. They set patient safety goals 5
issue and found a model called SMILE model. In conclusion, key success factors in development
quality clinical risk management system is T-I-P. Consists of T: Teamwork were patient safety goals
and patient focus. I: Implementation was head co-practice, personnel practice with standard and
update system. P: Policy was leader concern and value, leader reassure and safety organization.
LIMITATION
Knowledge of clinical risk management in risk assessment.They did not understand that the
role of personnel in the unit must be jointly prepared. Practice of clinical risk management found
that search for risk from clinical risk management was moderately performed.Participation in risk
management process was moderate,because personnel understand that risk management is directly
role of the head, lack of risk assessment.
CONCLUSION
1. Context of developing quality in IPD was found that after the development used risk
report in daily report, due to communicate to all personnel aware of risks involved. Head can
manage the risk quickly.
2. Improving the quality according to the PDCA process, changes and improvements system
are reflected in the cooperation.
3. Result of quality improvement set patient safety Goals for 5 issues and risk management
system development SMILE model.
4. Keys success factors of developing quality is TIP.
ACKNOWLEDGEMENTS
273
I am thankful to the study participants and organization for their kind support and
cooperated. I am also thankful to my advisor for away support and advice for achieving this
research.
274
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Nurses.Journal of Nursing Science & Health 2012; 35 (3): 118-124.
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3. Department of Nursing, Department of Medical Services, Ministry of Public Health. Nursing
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Affairs Organization; 2008.
4.Institute for Hospital Quality Assurance and Development.Patient Safety :Concept and Practice.
Bangkok: Dee Co., Ltd; 2003.
5.Institute of Hospital Quality Certification (Public Organization).SPA & Self Enquiry part I A
Guide to Implementing Standards for Hospital and Health Services Standards The 60th
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Management System for Nursing Care Standard in the In-Patient Department of Nurses in
Fort Sunpasitthiprasong Hospital UbonRatchathani Province.Journal of The Royal Thai
Army Nurses 2012; 13 (2): 38-48.
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275
Intention to Continue Working after the Project End and its

Associated Factors of Voluntary Health Worker of the National
Malaria Control Program, Kayin State
Htay Min Oo1, ThitimaNutrawong 2, Wongsa Lohasiriwong3,
1
2
Faculty of Medicine, Khon Kaen University, Thailand.
3
อาสาสมัครสาธารณสุ ข มีความจาเป็ นอย่างยิ่งในการดาเนิ นงานด้านสาธารณสุ ขสาหรับประเทศที่มีรายได้นอ้ ย แต่การ

ลาออกจากโครงการในระยะเริ่ ม แรกจะเป็ นการทาลายวัตถุ ประสงค์ของการดาเนิ น งานการดู แ ลสุ ขภาพถ้วนหน้า (UCH)
สาธารณรัฐสหภาพพม่ายังไม่ได้มีการศึกษาเกี่ยวกับปั จจัยที่มีอิทธิพลต่อการคงอยูห่ รื อการตั้งใจทางานต่อไปในฐานะอาสาสมัคร
สาธารณสุ ข การวิจยั ครั้งนี้เป็ นการวิจยั แบบภาคตัดขวาง มีวตั ถุประสงค์เพื่อระบุสัดส่ วนของอาสาสมัครสาธารณสุ ขในการตั้งใจ
ทางานต่อไปหลังจากสิ้นสุดโครงการใช้ยาอาร์เทมิซินิน(Artemisinin) ในภูมิภาคและปั จจัยที่เกี่ยวข้องของอาสาสมัครสาธารณสุ ข
รั ฐ กระเหรี่ ยง สาธารณรั ฐ สหภาพพม่า ในกลุ่ ม ตัว อย่า ง 340 คน ได้รั บ การคัดเลื อ กโดยการเลื อกใช้ก ารสุ่ ม อย่างเป็ นระบบ
(Systematic random sampling) ด้วยใช้แบบสอบถามที่ให้กลุ่มตัวอย่างกรอกข้อมูลด้วยตนเอง (self -administered questionnaires)
วิเคราะห์ความสัมพันธ์ดว้ ยสถิติ Multiple logistic regression
ผลการศึกษา พบว่า กลุ่ ม ตัว อย่า งส่ ว นใหญ่เ ป็ นเพศหญิ ง ร้ อ ยละ 81.18 มี อ ายุเ ฉลี่ ย 30.51± 9.65 ปี ส่ ว นใหญ่ มี อายุ
ระหว่า ง 25 – 40 ปี ร้ อ ยละ 45.00 พบความชุ ก ของความตั้ง ใจที่ จ ะท างานต่อ คื อ 82.94% (95% CI: 78.92-86.96) ปั จ จัย ที่ มี
ความสัมพันธ์กบั การตั้งใจในการทางานต่อของอาสาสมัครสาธารณสุ ข คือ อายุของอาสามสมัครสาธารณสุ ข (adj. OR=2.18,
95% CI: 1.16-4.09; p-value=0.016), สถานการณ์ทางการเงิน(adj. OR=1.97, 95% CI: 1.04-3.72; p-value=0.037),การรับรู ้เกี่ยวกับ
การเป็ นอาสาสมัครสาธารณสุ ข(adj. OR =4.21, 95% CI: 2.16-8.20; p-value=<0.001)การสนับสนุ นจากชุมชน(adj. OR=2.06,
95% CI: 1.03-4.13; p-value=0.041)และการกากับดูแล(adj. OR=2.95, 95% CI: 1.49-5.83; p-value=0.002)
ลักษณะทางประชากรและสังคม, ชุมชนและโครงการเป็ นปั จจัยที่เกี่ยวข้องที่มีอิทธิ พลต่อทางานต่อไปของอาสาสมัคร
สาธารณสุข ซึ่งปั จจัยเหล่านี้เป็ นสิ่ งสาคัญในการวางแผนและดาเนินงานสาหรับโปรแกรมการดูแลสุขภาพตามชุมชนในอนาคต.
276
Abstract
Introduction: Voluntary Health Workers particularly in low-income countries are essential to
improve healthcare coverage but leaving the program in an early stage undermines the purpose of
achieving universal health coverage (UCH). There have not any studies done in Myanmar to
investigate influential factors on retention or intention to continue working as VHW for longer.
Objective: This study aimed to identify proportion of intention to continue working as VHW after
the end of Regional Artemisinin Initiative Project or for longer and its associated factors.
Methodology: A cross-sectional study was done in six Townships of Kayain State, Myanmar.
Probability Proportionate to Size and Systematic Random Sampling was applied and a total of 340
VHW were interviewed using self -administered questionnaires. Logistic regression analysis was
done to quantify the association between outcome and predictor variables.
Result: Majority of the respondents were female, 81.18%. Average age of the participants was
30.51± 9.65, ranged (16: 61) and 45.00% were between 25 to 40 years old. The prevalence of intention
to continue working was 82.94% (95% CI: 78.92-86.96). It was observed that age (adj. OR=2.18, 95%
CI: 1.16-4.09; p-value=0.016), financial situation (adj. OR=1.97, 95% CI: 1.04-3.72; p-value=0.037),
perception on being a VHW (adj. OR =4.21, 95% CI: 2.16-8.20; p-value=<0.001), community support
(adj. OR=2.06, 95% CI: 1.03-4.13; p-value=0.041) and supervision (adj. OR=2.95, 95% CI: 1.49-5.83; p-
value=0.002) had statistically significant relationship with intention to continue working as VHW.
Conclusion: Socio-demographic characteristics, community and project related factors influenced
on continue to work as VHW. It is very important to control these factors in designing and
implementation of community based healthcare programs in the future.
277
Introduction
Task shifting is commonly applied by many countries around the world to improve health
coverage by shifting some tasks of formal or professional health workers to VHW (1). Voluntary
Health Workers (VHW) has been used to address the shortage of health workers, particularly in
low-income countries (2). In the studies done among VHW in Africa and Bangladesh shown that
proportion of VHW who have worked continuously till the end of the project or for a certain period
of time is not at a satisfactory level to achieve the aim of the programs (3) (4) (5).
In relation to SDGs it is suggested that 44.5 skilled health professionals per 10,000
population is necessary (6). According to World Health Statistics 2016, the figure of Myanmar is
16.2 skilled health professionals per 10,000 population and which is far behind the global
benchmark (6). The role of voluntary health worker is essential in Myanmar to fill the gap of
shortage in health care workforce.
Knowing of factors influencing on continue working help the program managers and
implementers to construct an effective strategy to ensure effective and sustainable VHW programs
in the future. The aim of the study was to investigate the proportion of VHW of NMCP who has
intention to continue working after the end of RAI project and its associated factors.
Objective
This study aimed to identify proportion of intention to continue working as VHW after the
end of Regional Artemisinin Initiative Project or for longer and its associated factors.
Methodology
Study design
A cross-sectional study was conducted among 340 VHW in six Townships of Kayin State,
Myanmar and data were collected by using self-administered structured questionnaire. The study
population included all 377 VHW trained in RAI project of NMCP in Kayin State. To estimate the
required sample size, multiple logistic regressions formula (Hsieh, Bloch, & Larsen, 1998) was
278
used. Two sampling methods were applied, probability proportional to size (PPS) and systematic
random sampling to get the required sample. Although appointments were made for interviews, any
VHW who were absent at the time of data collection for any reasons were mopped up within a
week of initial attempt. Those who were not being able to interview in the follow up visit were
excluded.
Study outcome
The outcome of the study was intention to continue working after the end of RAI project or
longer. It was categorical and dichotomous outcome, Yes=1 and No=0. And the study also
investigated the factors associated with intention to continue working for longer.
The proportion of the outcome was calculated and presented as percentage. In the
descriptive part of the thesis, majority of the variables were presented as categorical. Contiguous
variables such as age and income were described in mean and median (min, max). Logistic
regression analysis was used to quantify association between factors and intention to continue
working, as determined by adjusted Odds ratio and their 95% CIs. Factors resulted from multiple
logistic regression analysis of p-value less than 0.05 were regarded as statistically significant.
Result
Proportion of intention to continue working
82.94% of the respondents with 95% CI of 0.79-0.87 explored that they would like to continue
working for longer or after the end of the RAI project.
279
Socio-demographic characteristics
Majority of the VHW were female, 81.18%, Kayin ethnic origin (80.29%), Buddhist (80.59%)
and resided in village they were posted (80.59%). Mean age of the respondents was 30.51 (±9.65)
years and the highest percentage was observed in age between 20 and 30 years (46.18%). Regarding
the marital status, about half of the respondents were married (53.53%). Concerning the education
level, about half of the respondents attained High School or equivalent (47.94%). It is worthy to note
that 57.94% of the respondents had enough income to fulfill basic family needs.
Table 1: Socio-demographic characteristics of respondents

Total Number
Characteristics
Number Percent (%)
Age (years)
< 20 20 5.88
20-30 157 46.18
30-40 103 30.29
≥ 40 60 17.65
Mean (±SD) 30.51 (±9.65)
Median (min, max) 28 (16, 61)
Gender
Male 64 18.82
Female 276 81.18
Ethnicity
Myanmar 32 9.41
Karen 273 80.29
Mon 14 4.12
Shan 9 2.65
Others 12 3.53
280
Total Number
Characteristics
Number Percent (%)
Marital Status
Unmarried 149 43.82
Married 182 53.53
Widow, divorced or separated 9 2.65
Education Level
Religion
Buddhist 274 80.59
Christian 61 17.94
Muslim 5 1.47
Occupation
None 145 42.65
Employee 3 0.88
Business 50 14.71
Others 37 10.88
Average income per month (MMK)
No income at all 144 42.35
< 20.000 27 7.94
20,000-50,000 60 17.65
50,000-100,000 64 18.82
> 100,000 45 13.24
281
Total Number
Characteristics
Number Percent (%)
Mean (±SD) 33850 (±48626.18)
Median (min, max) 150000 (0, 300000)
Average household income per month (MMK)
< 30,000 20 5.88
30,000-60,000 144 42.35
60,000-100,000 27 7.94
100,000-150,000 76 22.35
< 150,000 73 21.47
Mean (±SD) 92988.24 (±73008.71)
Median (min, max) 60000 (10000, 500000)
Household financial situation

11.Residence of posted village
Yes 274 80.59
No 66 19.41
Community and social factors

Most of the respondents (85.00%) mentioned help to improve the community as the most
important reason in decision making to become a VHW. Regarding VHW job, most of the
respondents (73.53%) answered to be able to diagnose and treat malaria patient as most enjoyable
thing in working as VHW. It is worth to note that (81.18%) of VHW are selected by the involvement
of Community. Average years of experience as VHW were 6.43, SD (±6.08) with minimum
experience 1 year and maximum was 34 years. About half of the respondents had less than 5 years
of VHW experience
282
Table 2: Community and social factors

Total Number
Characteristics
Number Percent (%)
Most important reason to become a VHW

Help to improve the health of the community 289 85.00
Gain medical knowledge and skill 18 5.29
Having been entrusted by the Community 2 0.59
Gain skills that would enable me to work as

6 1.76
health practitioner
Working as a VHW is respectable, honorable job 25 7.35
Most enjoyable thing of working as a VHW

Be able to diagnose and treat malaria patient 250 73.53
The training and medical knowledge obtained 71 20.88
The appreciation and respect from the community 14 4.12
The opportunities from the role give in terms of

2 0.59
Social interaction
Receiving allowance and drug supply 3 0.88
Community involvement in the selection of VHW

Yes 276 81.18
No 64 18.82
Valuing by the community

Yes 340 100.00
No 0 0.00
Community view of VHW services

Needed 334 98.24
Not needed 6 1.76
Community support in terms of cash, food & clothes

Receive 27 7.94
Not receive 313 92.06
283
Total Number
Characteristics
Number Percent (%)
Support of family members

Yes 333 97.94
No 7 2.06
Years of experience as VHW

<3 91 26.76
3-5 91 26.76
5-10 82 24.12
≥ 10 76 22.35
Mean (±SD) 6.94 (±6.79)
Median (min, max) 4 (1, 34)
Project related factors

All the participants disclosed that RAI project conducted regular refresher training and
quarterly coordination meeting. 70.88% and 78.24% of the respondents attended refresher training
and quarterly coordination meeting regularly. The most reasons behind not attended regularly were
ill health, child birth and travel to somewhere at the time of the activity. Around two-third of the
interviewees, 64.23% was visited by BHS and Township malaria focal person for supportive
supervision. Monthly report had sent to health center by all the participants and among them almost
all 98.24% reported in sending on a regular basic like monthly or quarterly or 6 monthly. Concerning
malaria diagnosis and treatment, around half of the respondents, 56.47% mentioned that they have
tested and treated 5 to 10 malaria patients per month.
284
Table 3: Project related factors

Total Number
Characteristics
Number Percent (%)
Years form receiving initial training of malaria prevention

and control
<2 87 25.59
2-4 56 16.47
4-6 136 40.00
>6 61 17.94
Mean (±SD) 3.45(±1.97)
Median (min:max) 4(1, 10)
Provision of refresher training by project

Yes 340 100.00
No 0 0.00
Regular participation in refresher training

Yes 254 74.71
No 86 25.29
Conducting quarterly coordination meeting by project

Yes 340 100.00
No 0 0.00
Regular participation in quarterly coordination meeting

Yes 266 78.24
No 74 21.76
Receiving supportive supervision

Yes 260 76.47
No 80 23.53
Receiving monthly stipend/salary form the project
Yes 0 0.00
No 340 100.00
285
Total Number
Characteristics
Number Percent (%)
Receiving in kind incentives from the project

Yes 335 98.53
No 5 1.47
Monthly report to health center

Yes 340 100.00
No 0 0.00
Frequency of reporting to health center

Monthlh 229 67.35
Quarterly 93 27.35
6 monthly 12 3.53
Ad-hoc 6 1.76
Receiving allowance for travelling to health center for

reporting
Yes 336 98.82
No 4 1.18
No of patients consult for per month

<5 118 34.71
5 -10 192 56.47
11 -15 27 7.94
≥ 15 3 0.88
Average time spending per day for VHW work (in hours)
<2 17 5.00
2-5 19 5.59
6-8 14 4.12
Only when the patient comes 290 85.29
286
Health system factors

BHS were involved somehow in selection of almost all of VHW, 99.71% and 97.35% were
recognized by BHS as a VHW. 95.59% of VHW responded that BHS alone could not able to cover
all of the villages in their catchment area for malaria control the whole year round.
Table 4: Health system factors

Total Number
Characteristics
Number Percent (%)
BHS support in selection of VHW

Yes 339 99.71
No 1 0.29
Recognition by BHS
Yes 331 97.35
No 9 2.65
Capacity and feasibility of the BHS to cover all villages for

malaria diagnosis and treatment
Yes 15 4.41
No 325 95.59
Malaria situation factors

Almost all the respondents, 98.24% mentioned decreasing malaria trend in the area but it is
noted that 97.35% agreed to assign one volunteer per village for malaria control activities.
Table 5: Malaria situation factors

Total Number
Characteristics
Number Percent (%)
Current Malaria trend in the area

Increasing 2 0.59
Decreasing 334 98.24
Not much changes in the past few years 4 1.18
287
Total Number
Characteristics
Number Percent (%)
Assigning one VHW/village for Malaria Control activities
Yes 331 97.35
No 9 2.65
Discussion
82.94% of the participants responded intention to continue working after end of RAI project.
81.56% of VHW who intended to continue working were female and 53.19% were age at the age of 30
and above. In a study done in Ghana mention attrition rate was 21.2% and which means that 78.8% of
VHW remained in the program at the time of the study (Abbeya, 2014). Similar findings were reported
in two studies done in Bangladesh in 2012 and 2014 (K Alam, 2012) (Alam, 2014 ). Majority of the
VHW mentioned to help the community in improving their health status, interested in provision of
healthcare services and to gain more and more medical knowledge were the main reasons for
continuing as VHW for longer.
Majority of VHW in this study were female, 81.18% and male and female ratio was 1:4.3. This
finding was very close to gender distribution of the two studies where 73.8 % (Kambarami, 2016) and
72% (Bagonza, 2014)of the respondents were female. 47.94% of VHW in this study were more than 30
years of age. This study indicated that age was related to intention to continue working and older
VHW who were 30 years and above are more likely to stay in program compare to younger ones.
A study done in Ghana described that older VHWs are less likely to be lost to attrition and stay in
the program for longer compared to younger ones (Abbeya, 2014). VHW with ages 40–49 were
more confident in delivery of healthcare services and higher tendency of continue working for
longer.
Family financial situation was significantly associated with intention to continue working for
longer. 56% of the VHW who intended to continue had enough family income. This finding was
supported by (Sanou, 2016) that most of the VHW were prepared to leave due to financial reasons or
288
less income. Economic hardship influences in decision making to become a VHW (Kok, 2015). VHW
programs are based on the concept of voluntarism and normally the project doesn’t provide any salary
or stipend. So, VHW who don’t have enough household income could not work for long because they
have more important priorities for the survival.
Perception on being a VHW was significant relationship with retention and the desire to
help their own community motivates them to stay in the program for longer (Marincowitz, 2014).
This study indicated that VHW who wanted to help improve health status of the community and
reduce malaria burden in the village by doing timely and effective malaria diagnose and treatment
had higher odds of intention to continue working for longer. About being a VHW, 88.80% of
respondents mentioned diagnosing and treating malaria patient as the most enjoyable thing of
working as a VHW. VHW in the study of (7),(8) were motivated by altruism, desire to improve
community health and feeling needing by community.
Some respondents reported supervision as motivator but some did not and supervision was
not always mentioned as a motivator(9). It depends on individual perception and this study found
out that supportive supervision had effect on intention to continue working and 76.47% of the
participants were visited by their supervisors. Number of supervision received was significantly
associated with VHW performance. Volunteers who were visited regularly by supervisors had
higher probability of retention than those who were visited on ad-hoc basic(10).
Conclusion
A cross-sectional analytical study was done in six Townships of Kayain State, Myanmar.
Probability Proportionate to Size and Systematic Random Sampling was applied and a total of 340
VHW were interviewed using self -administered structured questionnaires. Multiple logistic
regression analysis was done to quantify the association between the outcome and independent
variables after controlling the confounding factors. 82.94% responded to continue working after the
end of RAI project. Socio-demographic characteristics, community and project related factors
influenced on continue to work as VHW for longer. It was observed that age, household financial
289
situation, perception on being a VHW and supportive supervision had relationship with intention
to continue working as VHW for longer and the association was statistically significant.
The study to investigate the factors related to dropout of VHW is suggest to be done in the future.
References
1. Sommanustweechai A. Community health worker in hard-to-reach rural areas of Myanmar:
filling primary health care service gaps. Human Resource for Health. 2016.
2. Lehmann U. The state of the evidence on programmes, activities, costs and impact on
health outcomes of using community health workers. 2007.
3. Abbeya M. Factors related to retention of community health workers in a trial on
community-based management of fever in children under 5 years in the Dangme West District of
Ghana. International Health. 2014;6.
4. Alam K. Impact of dropout of female volunteer community health workers: An exploration
in Dhaka urban slums. Health Services Research 2012;12.
5. Alam K. Reservation wage of female volunteer community health workers in Dhaka urban
slums: a bidding game approach. Health economics review. 2014.
6. WHO. World Health Statistics. 2016.
7. Rahman SM, Ali NA, Jennings L, Seraji MHR, Mannan I, Shah R, et al. Factors affecting
recruitment and retention of community health workers in a newborn care intervention in
Bangladesh. Human resources for health. 2010;8(1):12.
8. Mpembeni RN, Bhatnagar A, LeFevre A, Chitama D, Urassa DP, Kilewo C, et al.
Motivation and satisfaction among community health workers in Morogoro Region, Tanzania:
nuanced needs and varied ambitions. Human resources for health. 2015;13(1):44.
9. Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of
community health worker motivation: a qualitative study in Morogoro Region, Tanzania. Human
resources for health. 2013;11(1):52.
10. Kuule Y, Dobson AE, Woldeyohannes D, Zolfo M, Najjemba R, Edwin BMR, et al.
Community Health Volunteers in Primary Healthcare in Rural Uganda: Factors Influencing
Performance. Frontiers in public health. 2017;5.
290
NCDs and Health Problem 01
Diabetes Mellitus literacy and self-care practices of type 2 Diabetes Mellitus
patients in Mon State, Myanmar: A cross sectional analytical study
Kyaw Thu Win1, Assoc.Prof. Benja Muktabhant 2
1
2
โรคเบาหวาน (DM) เป็ นโรคเรื้ อรังตลอดชีวติ ที่ตอ้ งการการดูแลตนเอง ความฉลาดทางสุขภาพคือความ
เชื่ อ ที่ เป็ นปั จจัยที่ มี อิท ธิ พ ลต่ อพฤติ กรรมการดู แลตนเองของผูป้ ่ วยเบาหวานชนิ ด ที่ 2 อย่างไรก็ ตามยังไม่ มี
การศึกษาก่อนหน้านี้ ในรัฐมอญประเทศพม่าการวิจยั ครั้งนี้ มีวตั ถุประสงค์เพื่อศึกษาความสัมพันธ์ระหว่างความรู ้
ความเข้าใจเกี่ ยวกับ โรคเบาหวานและการดู แ ลตนเองของผูป้ ่ วยเบาหวานชนิ ด ที่ 2 ในรั ฐ มอญประเทศพม่ า
การศึกษาวิเคราะห์แบบภาคตัดขวาง ดาเนิ นการในผูป้ ่ วยเบาหวานชนิ ดที่ 2 กลุ่มตัวอย่างผูป้ ่ วยโรคเบาหวานชนิ ด
ที่ 2 จานวน 329 คนอายุ 18 ปี จาก 4 เมืองในรัฐมอญ ประเทศพม่า ถูกคัดเลือกโดยใช้วิธีแบบสุ่ มหลายขั้นตอน
เก็บรวบรวมข้อมูลด้วยแบบสอบถามมีโครงสร้าง ใช้การวิเคราะห์สมการถดถอยลอจิสติกแบบง่ายและแบบพหุ
เพื่อหาความสัมพันธ์ระหว่างความรับรู ้ความเข้าใจเกี่ยวกับโรคเบาหวานกับการปฏิบตั ิดูแลตนเอง
ผลการศึ ก ษา พบว่า ผูป้ ่ วยเบาหวานชนิ ดที่ 2 จานวน 329 คนส่ วนใหญ่ เป็ นเพศหญิ ง) 82.7%), อายุ
มากกว่า 60.33 ปี ) 36.36%) ความชุกของการดูแลตนเองที่ไม่พึงประสงค์คือ 43.47% (95% CI 38.08-48.84) ปั จจัย
ที่มีความสัมพันธ์กบั การปฏิบตั ิดูแลตนเองที่ไม่พึงประสงค์ ได้แก่ เกษตรกรชาวสวนชาวประมงและแรงงานที่ขาด
ทักษะและกลุ่มไม่ทางาน) adj.OR = 1.48, 95% CI = 0.84-2.62, p-value = 0.003), กลุ่มคนว่างงาน) adj.OR=2.74,
95% CI=1.38-5.43 p-value= 0.003) กลุ่มผูป้ ่ วยเบาหวานชนิ ดที่ 2มีความรู ้เกี่ยวกับเบาหวานอยูร่ ะดับสู ง (adj.OR
= 2.01, 95% CI = 1.05-3.84, p-value = 0.035)
สรุ ป กลุ่ ม ตัว อย่ า งผู ้ป่ วยเบาหวานชนิ ด ที่ 2เกื อ บครึ่ งหนึ่ งมี ก ารปฏิ บั ติ ที่ ไ ม่ พ่ ึ งประสงค์ ผู ้ป่ วย
โรคเบาหวานชนิดที่ 2 เหล่านี้ยงั คงต้องปรับปรุ งความรู ้เข้าใจหรื อความฉลาดทางสุขภาพในเรื่ องโรคเบาหวาน
291
Abstract
Diabetes mellitus ( DM) is a lifelong chronic disease that needs self-care.
Health literacy is belief as factors influencing self-care behaviors of type 2 DM
patients. However, there is no previous study in Mon State, Myanmar.This study aims
to determine the association between diabetes mellitus literacy and self-care practices
of type 2 diabetic patients in Mon State, Myanmar.
Methodology: This hospital based cross-sectional analytical study was conducted
among type 2 DM patients. A total sample 329 type 2 DM patients who were 18 years
old from 4 townships in Mon state, Myanmar were selected by using multistage
random sampling. The data was collected by structured questionnaire interviewed.
Simple and multiple logistic regressions were conducted to determine the relationship
between diabetes-related literacy and self-care practices.
Result: Among 329 type 2 DM patients, most of them were female (82.7% ), 36.36 %
were older than 60 years old. The prevalence of unsatisfactory self-care practices was
43.47% ( 95% CI 38.08 to 48.84). The factors associated with unsatisfactory self-care
practices were those who were farmer, gardener, fisherman and unskilled worker and
no job group (adj.OR=1.48, 95%CI=0.84-2.62, p-value=0.003), unemployed (adj.OR=2.74,
95% CI=1.38-5.43 p-value= 0.003), had high level of knowledge on DM (adj.OR=2.01,
95%CI=1.05-3.84, p-value=0.035).
Conclusion: Almost half has unsatisfactory self are practices. These type 2 DM
patients still needimprovement in health literacy on diabetes
292
Introduction
Diabetes is a chronic disease due to the result when the pancreas cannot
secrete enough insulin or when the body is not able to efficiently utilize insulin,
hormone which controls blood sugar, produced by the pancreas. Diabetes mellitus can
be categorized into type 1, type 2 and gestational diabetes. Type 2 diabetes, which is
also known as non-insulin dependent or adult-onset, is due to ineffective insulin use by
the body. It is very common in general population worldwide. In 2012, mortality of 1.5
million was directly related to diabetes and almost half among all deaths were
associated with high level of blood sugar before they arrived at the age of 70 years (1).
Worldwide around 8.5% of adults aged 18 year and over had high blood sugar in 2014.
The prevalence rates of raised fasting blood glucose were lowest in high-income
countries and highest in upper-middle-income countries (1).

Myanmar is one of the countries from the Western Pacific region out of six
IDF regions. IDF estimated that 2013 national diabetes prevalence was 5.7% and total
population with diabetes was 1,988,850 in Myanmar. Number of people with diabetes
in town and village area was estimated at 1,110,380 and 888,460 respectively. They
are probably getting steroid induced diabetes mellitus, or disturbance of diabetes

mellitus control, rendering adverse consequences of diabetes (2).
Some studies on the relationship between literacy and health outcomes

concluded that limited literacy is linked to several adverse health-related variables,
including knowledge about health and health care, hospitalization, global measures of
health, and some chronic diseases. But other studies were done to identify the
association between diabetes mellitus literacy level and diabetes status of the people.
Moreover, association between diabetes mellitus literacy and self-care behaviors of

type 2 DM patients is still unclear and there is no previous study in Mon State up to
now. The objective of this study are To describe the self-care practices of Type 2
diabetes mellitus patients, association between diabetes mellitus literacy and self-care
practices of Type 2 diabetes mellitus patients in Mon State, Myanmar.
293
Objective
To determine the association between diabetes mellitus literacy and self-care
practices of type 2 diabetic patients in Mon State, Myanmar
Methodology
Study design
This study is a facility-base cross-sectional analytical study was conducted to
identify the magnitude of self-care practices of Diabetes Mellitus types 2 patients and
to find out the association between diabetes mellitus literacy levels, self-care practices
of that Diabetes Mellitus types 2 patients. The eligible sample was fulfilled with the
inclusion and exclusion criteria. Inclusion participants were who gave informed
consent to participate in this study and who lives in the areas during the data
collection period.
Exclusion participants were who were suffering serious health problems (lying
on the bed), who suffered who are individuals with mental disabilities at the time of
data collection, who are not communicate.The sample size was estimated based on the
multiple logistic regressions formula (Hsieh, Bloch, & Larsen, 1998).
Multistage random sampling was used to select samples in this study. Firstly 4
townships were selected by simple random sampling from overall 10 townships of
Mon State. And then, 2 village tracts were selected from these townships by using
simple random sampling also. After that, patients were selected proportional to size of
above 18 years old patients from each village tract by using simple random sampling
procedure.
Research Indicators
Self-Care practices of factors of each participant will be measured by
Medication, Diet pattern, Foot care, Blood glucose testing and Exercise. And then self-
care practices of the subject was also assessed based on cut point of total scores
(Bloom’s theory). The subjects’ diabetes mellitus knowledge and self-care practices
294
regarding diabetes were scored using an arbitrary scoring system. Each correct
response under diabetes mellitus knowledge attracted one point, where as any wrong
or don’t know answer attracted no
mark. Overall, the final assessment of knowledge of the respondents were labeled to
have good relationship if scored greater than 80% of the questions related to patient
professional relationship, moderate if 60-80% and poor if less than 60% were scored
(Bloom’s theory). Similarly, attitude, self-efficacy and health literacy of the subjects
were also assessed based on cut point of total scores (Kiess’s theory).
Socio-demographic characteristics of participants will be included age, marital
status, education, occupations, place of residence, income of family, individual

income, home ownership, and family history of obesity.
The raw data of 329 respondents were recorded into MS Excel. The data were
inverted into the Stata program version 13. 0. The socio-demographic and baseline
characteristics of the participants were described with frequency and percentage for
categorical data and mean, median, minimum, maximum and standard deviation for
continuous data. The multiple logistic regression, adjusted OR with 95% of Confident
Interval were used to determine the association between type 2 diabetes mellitus of
self-care practices and diabetes literacy factors by controlling other related factors. All
test statistics were two-sided and a p-value of less than 0.05 was considered as statistical
significant.
Result
Prevalence of self-care practices among type 2 diabetes patients
The prevalence of self-care practice status among the Type (2) diabetes
patients. According to the Bloom theory, level of self-practice were divided into three
groups, low level(<60%), medium level (60%-80%) and high level (>80%).The interest
group is people who entitled in low and medium level and high level group was
295
identified as reference group. The prevalence of unsatisfactory level was 43.47% (95%
CI-38.08% to 48%).
Table 1 Self-care practices among type 2 Diabetes Mellitus patients above 18 years
Self-care practices status Number Percent (%) 95% conference interval
Satisfactory level 186 56.5
Unsatisfactory level 143 43.47 0.38-0.48
Baseline characteristics presented as percentage unless specified otherwise

among type 2 Diabetes Mellitus patients in Mon State, Myanmar (n=329)
In this study, 82.67% , was female, while those of male 17.33% . The age group
of over 50 years was the higher percentage of 73.46% while the counterparts who are
below 50 years had the lower. % . In terms of marital status of the participants, those
who are married had the higher percentage of 75.68% while the counterparts who are
single and had the lower of 4.56% and who was divorced/widowed or separated were
about 19.76% . About 60.18% of the respondents had primary education level, about
20. 06% had no formal education and about 13. 37% had middle school. The lowest
proportion was belonged to those with high education and bachelor degree or higher.
Table 2 Social determinants characteristics of the respondents
Characteristics Number Percent(%)
Gender
Male 57 17.33
Female 272 82.67
Age of Diabetes Mellitus patients (years)
>= 18 to < =39 23 7.10
>=40 to <=49 63 19.44
≥50 to < 59 121 37.35
296
≥60 117 36.11
Mean ±SD 55.30 (±10.49)
Median (min: max) 55(26.0:91.0)
BMI (kg/m2)
Less than 18.5 (Underweight) 14

4.26
18.5-22.9 (Normal) 120 36.47
23.0-24.9 (Overweight) 63 19.15

132
25.0 and above (Obesity) 40.12
Mean ±SD 24.31 (±4.04)
Median (min:max) 23.74 (14.3-37.1)
Waist Circumference (cm)
Male
< 90 (normal) 247 75.08
≥ 90 (unnormal) 82. 24.92
Female
< 80 (normal) 138 41.95
≥80 (un normal) 191 58.05
Ethnic group
Burma 116 35.26
Mon 125 38.00
Kayin 17 5.17
Paoh 18 5.47
Bangali 53 16.11
Marital Status
Single 15 4.56
Married 249 75.68
297
High school 12 3.65
Religion
Buddhism 279 84.80
Muslin 44 13.37
Christian 3 0.91
Hinduism 3 0.91
Occupation
None 71 21.58
Farmer/Gardner/Fisherman 78 23.71
Employee 40 12.16
Business 26 7.90
Government office 4 1.22
Monthly family income (Myanmar Kyats)
Lower than 100000 27 8.21
100000-300000 190 57.75
300000 or more 112 34.04
Mean ±SD 233829.8(±97147.96)
Median (min :max) 200000(100000:500000)
Financial situation
Not enough 89 27.05
298
Family history of Diabetes Mellitus

None 212 64.44
Mother 26 7.90
Father 9 2.74
Grand parents 3 0.91
Siblings 79 24.01
Table 3. Factors associated with self-care practices among type 2 Diabetes Mellitus
patients (Multivariate analysis):
Crude Adj.
Factors. number % 95%CI p-value
OR. OR.
Occupation 0.022
Employee, Government 70 35.71 1 1 1

office / Business
Farmer/Gardner/Fisher 188 40.43 1.01 1.21 0.68-2.15

man Unstill worker
None 71 59.15 2.60 2.61 1.32-5.18
Level of Health Literacy 0.048

factors on type 2 DM patients
of Self-care practices
High level 77 33.77 1 1 1
Low and medium level 252 46.43 1.67 1.71 0.99-2.93
299
After controlling confounding factors, occupation and Level of Health

Literacy factors on type 2 DM patients of Self-care practices were strongly associated
with unsatisfactory type 2 diabetes mellitus patients. Unskilled workers 1.17 times
(95%CI-0.66-2.08, p-value=0.022) and jobless were 2.74 times (95%CI=1.38-5.43, p-
value=0.022) to have unsatisfactory practice in type2 diabetes mellitus patients.
Regarded with type2 diabetes mellitus health literacy, people who got low and
medium level were 2.52 times to have unsatisfactory practice than those who got high
level group (95% CI-0.99 to 2.93,p-value=0.048).
Overall ,the prevalence of unsatisfactory practice in type2 diabetes mellitus

patients was 43. 47% ( 95% CI-38. 08% - 48% ) . The result of this study shows that
unsatisfactory practice in type2 diabetes mellitus patients was strongly associated with
occupation and level of diabetes literacy.
Discussion
This study described that, among 329 patients with their age above 18 years
old, 43.47%have unsatisfactory self-care practices. This was similar with previous
study result conducted India and west Ethiopia (3, 4)
After controlling the confounding factors with backward elimination

multivariate analysis, two variables were strongly associated with self-care practices
of type 2 DM patients. They were occupation and health literacy. Occupation was
associated with self-care practices. In this study, occupation was also associated of sel-
care, farmer, gardener, fisherman and unskilled worker and no job group statistically
significant predictors of self-care practices. Farmer, gardener, fisherman and unstill
worker and no job group were over 2 times more likely to perform self-care than
employee, government office, business. This study was similar with study done in (5).
Type 2 DM patients need to have low levels of health literacy of diabetes
associated unsatisfactory self-care. low level of diabetes health literacy has a statically
significant among high level on unsatisfactory self-care practices. This similar with
( 5) ( 6)
study done in west Ethiopia and India . As such, these findings inform of the
300
necessity to have consistent diabetic education to address issues related to self-care
practices. In term of health literacy, the respondents with higher health literacy were
more likely to practice DM self-care practice than those with lower health literacy. ( 7)
Netherlands.
Strength of Study
Despite this study, it is the first report on finding the association between
diabetes literacy and type 2 DM among self-care practices in Mon state of Myanmar.
Therefore, this research study can be a reference for similar studies which will be
performed in different part of Myanmar and other countries.
Limitation of Study
Subsequently, the study was a cross-sectional analytical study, being facility
based patients were contacted through, registration status and feasible contacts. And
those who had close contact with clinic are assumed to be good health care practice
than those who no records. The study could miss those kinds of patients.
Conclusions
The self-care practice of diabetes mellitus in Myanmar people is still poor.
Increasing in diabetes mellitus health literacy level and occupational health

intervention could be helpful to raise the satisfactory self-care practices of diabetes
patients. Therefore, health education and motivation program in the community should
be implemented to be positive changes in diabetes-control-related self-care practices. In

occupational health intervention, diabetes mellitus health education should be
emphasized as a priority. Effectiveness of applying IEC materials in diabetes mellitus
need to be revised to be easily understand by the grass root community.
Recommendations
This study encourages to the health policy makers to do the effective decision
on reduction of diabetes mellitus by promoting of diabetes health literacy and
occupational health of the people.
301
Acknowledgement
I would like to thank Khon Kaen University and Faculty of Public Health,
Khon Kaen University for granting me a KKU scholarship that giving an opportunity
to conduct this study. And I would like to express my sincere thanks to the village
administers community leaders and health staffs of Mon state, Myanmar for their
supports in data collection and information sharing about the sample community.
Special thanks to all the participants, those kindly consented and participated in this
study and giving their information for this study.
References:
1. WHO. 2016.
2. Latt TS, Aye TT, Ko K, Myint Y, Thant MM, Myint KNS, et al. Myanmar Diabetes Care
Model: Bridging the Gap Between Urban and Rural Healthcare Delivery. Journal of
the ASEAN Federation of Endocrine Societies. 2015;30(2):105-17.
3. Amente T. Self care practice and its predictions among adults with Diabetes Meliitus
on follow up at Nekemte Hospital Diabetes Clinic,West Ethiopia. World Journal of
Medicine and Medical Science. 2014.
4. Suguna A. Evaluation of self-care practices among diabetic patients in a rural area
Bangalore district, India. International journal of current research andacademic review.
2015.
5. Amente T. Self care practice and its predictions among adults with Diabetes Meliitus
on follow up at Nekemte Hospital Diabetes Clinic,West Ethiopia . World Journal of
Medicine and Medical Science. 2014;2.
6. Shrivastava PS. An Epidemiological Study to Assess the Knowledge and Self Care
Practices among Type 2 Diabetes Mellitus Patients Residing in Rural Areas of Tamil
Nadu. Biol Med. 2015:4.
7. HEIDE IVD. Associations Among Health Literacy, Diabetes Knowledge, and Self-
Management Behavior in Adults with Diabetes: Results of a Dutch Cross- Sectional
Study.. Journal of health communication. 2014.
302
Hypertension and its associated factors among Myanmar personnel in non-
profit health organizations in Tak province, Thailand
Saw Aung Tin Myint1, ThitimaNutrawong2, WongsaLohasiriwong3
1
2,3
โรคไม่ติดต่อเป็ นปั ญหาที่สาคัญของโลก เป็ นสาเหตุสาคัญนาไปสู่โรคเรื้ อรังและภาวะแทรกซ้อนที่รุนแรง โรค
ความดันโลหิ ตสู งเป็ นกลุ่มโรคเรื้ อรังที่มีจานวนผูป้ ่ วยเพิ่มสู งขึ้นอย่างต่อเนื่ อง ซึ่ งแต่ละปี มีผเู ้ สี ยชีวิตด้วยภาวะแทรกซ้อน
ของโรคความดันโลหิ ตสูง จานวน 9.4 ล้านคน การศึกษาครั้งนี้ เป็ นการวิจยั แบบภาคตัดขวาง มีวตั ถุประสงค์เพื่อศึกษาความ
ชุกและปั จจัยที่มีความสัมพันธ์ของโรคความดันโลหิ ตสูงในบุคคลากรชาวพม่าในองค์กรไม่แสวงกาไรด้านสุขภาพ ในพื้นที่
จังหวัด ตาก ตัว อย่างบุ ค ลากรชาวพม่ า จ านวน 324 คน ที่ ไ ด้รั บ การคัด เลื อ กด้วยการเลื อ กใช้ก ารสุ่ ม อย่างเป็ นระบบ
(Systematic random sampling) ซึ่ งเก็บข้อมูลโดยใช้แบบสอบถาม และการประเมินน้ าหนัก, ส่วนสูง และความดันโลหิ ตสู ง
วิเคราะห์ความสัมพันธ์ดว้ ยสถิติ Multiple logistic regression
ผลการศึ กษา พบว่า กลุ่มตัวอย่างส่ วนใหญ่เป็ นเพศหญิ ง ร้อยละ 54.32, เชื้ อชาติกระเหรี่ ยง ร้อยละ 83.33 พบ
ความชุกของการเกิดโรคความดันโลหิ ตสู งร้อยละ 22.22 (95%CI=17.81 – 27.14) ปั จจัยที่มีความสัมพันธ์กบั โรคความดัน
โลหิ ตสูง ได้แก่ น้ าหนักตัวที่เพิ่มขึ้น (adj.OR=2.40, 95%CI=1.08 – 5.36; p-value = 0.032), ความอ้วน (adj.OR=3.70, 95%
CI= 1.11 – 12.26; p-value = 0.032) ครอบครัวมีประวัติการเจ็บป่ วยด้วยโรคเรื้ อรัง (adj.OR=7.52, 95% CI= 3.62 – 15.62; p-
value<0.001) และการสูบบุหรี่ (adj.OR=4.08, 95% CI: 1.81 – 9.14;p-value = 0.001)
บุ คลากรชาวพม่าในองค์กรไม่แสวงกาไรด้านสุ ขภาพ พบความชุ กของการเกิ ดโรคความดัน โลหิ ตสู ง ซึ่ งมี
ความสัมพันธ์กบั น้ าหนักตัวที่เพิ่มขึ้น และโรคอ้วน นอกจากนี้ ยงั มีความสัมพันธ์ทางพันธุกรรมและพฤติกรรมการสูบบุหรี่
ของบุคลากรชาวพม่าในองค์กรไม่แสวงกาไรด้านสุขภาพ
303
Abstract
Introduction: Non-communicable diseases are becoming global burden of diseases and many
complicated with social problems. Every year around the world 9.4 million peoples are died
due to complication of hypertension and, adult with hypertension will reach 60%, among the
total population of 1.56 billion in 2025 was estimated by experts.
Objective: The study objective is to determine the prevalence and patterns of hypertension
among in Myanmar personnel in non-profit health organizations in Tak province, Thailand.
Methodology: Community based and cross-sectional analytical study was conducted in Tak
province, Thailand. Among total population 3576 were selected by systematic randomly from
each 4 districts and 324 participants included in the study. The materials which were blood
pressure cuff, weighting scale, tapes for measuring height were used in the study. The
participants answered the semi-structured questionnaire and face to face interview after taking
inform consent. And then, the participants were measured for their blood pressure, body
weight and height by the researcher. Bivariate and multivariable analyses were used to
identify what factors were strongly associated with hypertension.
Result: (54.32%) of participants were female and (83.33%) of participants were Karen ethnicity.
Prevalence of hypertension was 22.22% (95% CI=17.81–27.14), among the 324 participants. In
this study hypertension and age was associated (adj.OR=24.18, 95% CI= 9.13-64.08, p<0.001).
Regarding of this study, the participants who had overweight associated with hypertension
(adj.OR= 2.40, 95% CI= 1.08-5.36 p<0.022), and the participants who were obesity associated
with hypertension (adj.OR=3.70, 95% CI=1.11− 12.26 p<0.022) respectively. Additionally, the
participants who had family history of chronic diseases associated with hypertension
(adj.OR=7.52, 95% CI=3.62−15.62, p<0.001), and it is significantly. Also, the participants who
smoking associated with hypertension and it was significantly ( adj. OR= 4. 08, 95%
CI=1.81−9.14, p<0.001).
304
Conclusion: the conclusion of this finding, hypertension which non-communicable disease
having association with human behaviors. Therefore, further study also recommend to
continuous find out about what factors strongly will associate with hypertension for Myanmar
personnel in Tak province, Thailand.
Key words: cross sectional study, hypertension, Myanmar personnel
Introduction
Non-communicable diseases (NCDs) are becoming global burden of disease and
problem. There are four main types of non-communicable diseases which can be classified as
cardiovascular disease, cancer, diabetes and chronic respiratory diseases. Among these,
hypertension is one of the cardiovascular diseases and also known as ‘silent killer’ or
‘invisible killer’. Hypertension is a medical term meaning a systolic blood pressure equal to or
above 140 mmHg and/or a diastolic blood pressure equal to or above 90 mmHg in adult aged
18 years old or above (WHO, 2013). Globally, 40% (1 billion) of adults aged 25 and above has
hypertension and the highest prevalence was found in African Region. (WHO 2013). (1)
According to lancet 2005, the topic was global burden of hypertension, globally,
estimated prevalence of hypertension in adult peoples were 972 million (333 million was
from high income with economic developed countries and 639 million was from low and
middle income countries or economic developing countries). In addition, it is estimated and
predicated, in globally, adult peoples with hypertension will reach 60%, among the total
population of 1.56 billion in 2025. There is an imperative trouble with burden for each
country and that study also indicated that it is necessary for early cases detection, prevention
or good control of hypertension otherwise will be losing individual and government budgets
(2 )
.
Regarding the mortality rates of hypertension, in 2011, there were about 17 million
deaths due to cardiovascular diseases and nearly one third of total death globally, of which
9.4 million died due to the complications of hypertension. The symptoms of hypertension are
rarely shown in the early state; therefore they are mostly undiagnosed leading to serious
complications. Peoples who were diagnosed with hypertension by a medical professional
305
should have access to prolong and continuous medical treatment along with healthy life style
and otherwise it can lead to undesirable and serious complications with uncontrollable blood
pressure. Therefore, controlled hypertension which the last measurement of blood pressure,
has systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg (WHO
2013).(1)
According regional health forum 2013, in Southeast Asia, prevalence rate of hypertension
was approximately 35% in adult populations. Moreover, yearly, mortality rate of hypertension
in each countries were nearly 1.5 million due to complications of hypertension (3).
WHO reported the prevalence rate of hypertension in Myanmar was increasing, (18%-
31%) in males and (16%-29%) in females during 2004 to 2009. IN 2014, prevalence rate of
hypertension in Myanmar was the highest in Southeast Asia, 44.3% in males and 39.8% in
females (WHO).(4) Latter, according one of the study in specific age groups, the prevalence
rates of hypertension in Myanmar was 22%, in 2014.(5)
Many professional studies indicated risks factors of hypertension as old age, gender,
body mass index, alcohol consumption, cigarette smoking, high salt intake, low education
and health literacy, coffee drinking, stress, sedentary life style and many other risk
factors.(6)According to border based non-profit health organizations data and statistics, NCDs
are also increasing among peoples who are living in temporary shelters, over past decades,
especially hypertension is more common than others NCDs and also being a top 10
morbidity (MTC’s annual report 2014).
There was no study or research regarding hypertension among Myanmar personnel

who are working in non-profit health organizations in Tak province, Thailand. This survey
will focus Myanmar personnel who are working along border area of Thailand and Myanmar.
They have home country cultural belief and practices although they live in Thailand context.
How this effect their live and hypertension situations. Will be known what factors have
stronger influences on hypertension among this group by conducting this study and it is
beneficial for the strategies which to control and prevent hypertension.
306
Objective
The study objective is to determine the prevalence and patterns of hypertension
among in Myanmar personnel in non-profit health organizations in Tak province, Thailand.
Methodology
Study design
A community-based cross-sectional study was conducted in Tak province, Thailand,
2017. The study involved 324 participants who were working at non-profit health
organizations in Tak province. Inclusion criteria were all Myanmar national or one ethnic
come from Myanmar who were working in non-profit health organizations and the
respondents who would like to participate in the study. The exclusion criteria were foreigner
from foreign country and local citizens were excluded. The respondents who refused to
participate, and who had severe conditions. Socio-demographic information, knowledge,
attitudes and behaviors were asked with face to face interview. And then, the respondents
were measured blood pressure, weight and height by researcher.
Hypertension was defined as systolic blood pressure (BP) ≥ 140mmHg and/or
diastolic ≥ 90mmHg (WHO), and being on regular anti-hypertensive therapy.
Myanmar health personnel are the people who come from Myanmar, living
and working in local and international non-profit health organizations for migrant populations
in Tak province, Thailand. They might be Burma, Karen, Kachin, Kayah or other ethnicities
of Myanmar.
307
Sampling Method
Total Myanmar personnel Total sample

number of each district/ total (persons) Percentage x
Districts Myanmar Myanmar personnel x total sample size
personnel 100% estimation/ 100%
Mae Sot district
MTC 527 14.7% 48
SMRU (Mae Sot Based) 434 12.1% 39
BMA 86 2.4% 8
IRC 73 2% 7
KDHW 245 6.9% 22
BPHWT 157 4.4% 14
Mae Ramat district

SMRU 485 13.6% 44
Tha Sung Yan district

ARC 685 19.2% 62
Phop Phra district

SMRU 884 24.7% 80
Total 3,576 100% 324
Figure 1. the sampling procedure flow chart
308

percentage for categorical data and mean and standard deviation for continuous data. To
investigate factors associated with hypertension, odds ratios (ORs) and their 95% confidence
intervals (95%CIs) were estimated using multiple logistic regressions for cross sectional study.
This analysis was adjusted for baseline variables and showing a bivariate relationship with
hypertension was following in table (2).
All analyses were performed using Stata version 13.1. In simple logistic regressions p-
value < 0.05 were continued to multivariable analysis to find out what factors strongly
associated with hypertension.
Result
Table 1. Baseline demographic characteristics of the respondents (n=324)
Characteristics Number (324) Percentage (%)
1.Gender
Male 148 45.68
Female 176 54.32
2.Age (years old)
< 30 years 170 52.47
≥ 30-40 years 91 28.09
≥ 40 years 63 19.44
Mean (±SD) 31.49(±9.012)
3.BMI (kg/m2)
Underweight 22 6.79
Normal 231 71.30
Overweight 48 14.81
Obesity 23 7.10
Mean (±SD) 23.25(±3.88)
Median (Min : Max) 22.31(16.41:37.38)
309
4. Ethnicity
Karen 270 83.33
Mon 2 0.62
Burmese 36 11.11
Kareni 4 1.23
Shan 4 1.23
Others (Arakan/ Pa-Oh/Muslim) 8 2.47
5. Marital status
Single 158 48.77
Married 157 48.46
7. Position in ward/Occupation
Director 2 0.62
Manager 15 4.63
Supervisor 14 4.32
In charge 22 6.79
Coordinator 13 4.01
Ordinary staff 246 75.93
Others( trainer/intern/volunteers) 12 3.70
8. Individuals income THB
< 5000 THB 182 56.17
≥5000 THB 142 43.83
Mean (±SD) 5252.60(±6287.65)
Median (Min : Max) 4500(500:80000)
9. Family income THB
< 5000 139 42.90
≥5000 – 10000 107 33.02
≥10000 78 24.07
Mean (±SD) 7896.35(±9884.46)
Median (Min : Max) 5000(1000:100000)
310
10. Financial situations

Not Enough 73 22.53
Not Enough with dept. 60 18.52
11. Staying in Thailand
Mae Sot 138 42.59
Tha Sung Yang 62 19.14
Mae Ramat 44 13.58
Phop Phra 80 24.69
12. Area that Staying
Rural 186 57.41
Urban 138 42.59
13. FH of chronic diseases
No 182 56.17
Yes 142 43.83
Hypertension 124 38.27
Diabetes 27 8.33
Hyperlipidemia 7 2.16
Renal impairment 3 0.93
Others(heart disease,chronic asthma,SLE ) 16 4.94
14. Family history of chronic diseases
Mother 103 31.79
Father 53 16.36
Grandparents 23 7.10
Siblings 13 4.01
Table 2. Baseline characteristics behaviors factors of the respondents (n=324)
Factors Number (324) Percentage (%)
1.Smoking
No-Never smoking 259 79.94
Smoking 65 20.06
2. Duration of smoking ( years)
No-Never smoking 259 79.94
Yes 65 20.06
311
1-5 years 25 7.72

6 -10 years 11 3.40
> 10 years 29 8.95
Mean (±SD) 9.31(±8.55)
3. Amount of cigarette smoking/days
1-5 rolls 47 14.51
6-10 rolls 9 2.78
>10 rolls 9 2.78
Mean (±SD) 5(±6.70)
4. Alcohol drinking
No-Never drinking 222 68.52
Drinking 102 31.48
5. Duration of drinking ( years )
No-Never drinking 222 68.52
1-5 years 39 12.04
6-10 years 28 8.64
>10 years 35 10.80
Mean (±SD) 7.27 (±5.68)
6. Frequency of drinking
Daily 13 4.01
1-2 times/week 29 8.95
1-2 times/month 39 12.04
7. Most common types of drinking
Rice whiskey 38 11.73
Whiskey 10 3.73
Beer 46 14.20
Wine 8 2.47
312
8. Annual health check up

Never, seldom 149 45.99
Sometimes 140 43.21
Always 35 10.80
Table 3. Odd rations for each category of factors on hypertension based on simple logistic
regression
% Crude
Factors Number 95%CI p-value
HTN OR.
1.Gender 0.145
Female 176 17.05 1
Male 148 28.38 2 1.13-3.28
2.Age (years old) <0.001
< 30 years 170 3.53 1
≥ 30 years 154 42.86 20.5 8.54-49.17
3.BMI (kg/m2) <0.001
Normal 253 15.02 1
Overweight 48 47.92 5.21 2.68-10.10
Obesity 23 47.83 5.19 2.13-12.60
4. Ethnicity <0.001
Karen 270 17.04 1
Others (Burmese, Kachin, Pa-Oh etc.) 54 48.15 4.52 2.43-8.41
5. Marital status <0.001
Single 158 6.96 1
Married 157 35.67 7.41 3.70-14.84
Divorced/Widowed/Separated 9 55.56 16.70 3.91-71.25
6. Educational attainment 0.162
High school & lower education 274 20.00 1
Bachelor degree or higher 50 30.00 2 0.83-3.20
7. Position in ward/Occupation 0.001
Ordinary staff 246 17.48 1
Others (Manager/Supervisor etc.) 78 37.18 2.80 1.58-4.92
8. Individuals income THB 0.023
< 5000 THB 182 17.58 1
≥5000 THB 142
28.17 1.84 1.08-3.12
313
% Crude
HTN OR.
9. Family income THB 0.001
< 5000 139 12.23 1
≥5000 & <10000 107 24.30 2.30 1.18-4.52
≥10000 78 37.18 4.25 2.14-8.42
10. Financial situations 0.017
Not Enough 73 10.6 1
Not Enough with dept. 60 18.33 1.82 0.68-4.88
Enough with no saving 162 27.16 3.03 1.35-6.82
Enough with saving 29 31.03 3.66 1.25-10.72
11. Staying in Thailand 0.001
Phop Phra 80 11.25 1
Mae Ramat 44 13.64 1.25 0.41-3.76
Tha Sung Yang 62 17.74 1.70 0.65-4.41
Phra Mae Sot 138 33.33 3.94 1.82-8.60
12. Area that Staying <0.001
Rural 186 13.98 1
Urban 138 33.33 3.1 1.78-5.31
13. FH of chronic diseases <0.001
No 182 10.44 1
Yes 142 37.32 5.11 2.84-9.15
14. Smoking 0.001
No-Never smoking 259 18.15 1
Smoking 65 38.46 2.82 1.56-5.10
15. Duration of smoking ( years) <0.001
1-5 years 25 16.00 1
6-10 years 11 27.27 1.70 0.43-6.62
>10 years 29 62.07 7.38 3.27-16.65
16. Amount of cigarette smoking/days 0.009
1-5 rolls 47 36.17 1
6-10 rolls 9 44.44 3.61 0.93-13.95
>10 rolls 9 44.44 3.61 0.93-13.95
17. Alcohol drinking 0.019
No-Never drinking 222 18.47 1
Drinking 102 30.39 1.93 1.12-3.31
18. Duration of drinking ( years ) <0.001
1-5 years 39 7.69 1
6-10 years 28 28.57 4.80 1.14-20.15
>10 years 35
57.14 15.9 4.12-62.01
314
% Crude
HTN OR.
19. Frequency of drinking 0.004
Non-Daily 89 26.97 1
Daily 13 53.85 2 1.24-2.98
20. Most common types of drinking 0.001
(Whiskey/Beer/Wine) 64 20.31 1
Rice whiskey 38 47.37 2 1.28-2.58
21. Annual health check up
Sometimes 289 21.11 1 0.181
Always 35 31.43 2 0.79-3.5
Multivariable analysis was conducted after controlling all the confounding factors
with backward elimination, and then final results of the study were come out factors
Table 4. Multivariable analysis
Factors % Crude Adjusted p-value

Number 95% CI
HTN OR OR
1. Age years old <0.001
< 30 years 170 3.53 1 1
≥ 30 years 154 42.86 20.5 24.18 9.13-64.08
3.BMI (kg/m2) 0.022
Normal 253 15.02 1 1
Overweight 48 47.92 5.21 2.40 1.08-5.36
Obesity 23 47.83 5.19 3.70 1.11-12.26
3. Family history of chronic diseases
No 182 10.44 1 1 <0.001
Yes 142 37.32 5.11 7.52 3.62-15.63
4. Smoking
Never smoking 259 18.15 1 1 0.001
Smoking 65 38.46 2.82 4.08 1.81-9.14
Discussion
5
In this study hypertension was significantly associated with age, that result was
similar; study result was done by Kassawmar Angaw in Ethiopia, 2015. Additionally, also
similar study which was done by Madhur Verma in India, 2015 that study showed
hypertension was significantly associated with age. In this study the participants who had
315
overweight and obesity significantly associated with hypertension, according this study result
was similar with was done by K W Loh in Malaysia, 2013.
In present study the participants who had family history of chronic diseases nearly
half of no family history of chronic diseases, especially family history of hypertension was
(38.27%) when compared with others types of chronic diseases such as diabetes, heart disease
and chronic respiratory diseases, hypertension was almost. And then, in multivariable analysis
hypertension and family history of chronic diseases significantly associated (adj.OR=7.52, 95%
CI=3.62-15.63 p<0.001). Moreover, that were similarity result from Kenya was done by
BRENDA JHUTHI, 2015. In that study family history of hypertension was strongly
associated with hypertension. Additionally, a similarity result from Sri Lankan was done by
Priyanga Ranasinghe, 2015 in that study family history of hypertension was significantly
In this study of multivariable analysis level, the participant who smoking associated
with hypertension (adj.OR=4.08, 95% CI =1.81-9.14, p<0.001). When compared other study
which was done by BRENDA JHUTHI, 2015 in that study smoking status with hypertension
was significantly associated, therefore, there were similar result with present study regarding
of smoking. Additionally, also one of the studies was similar about smoking factor done by
Kassawmar Angaw, Ethiopia in 2015. In bivariate analyses in this study the participants who
drinking alcohol associated with hypertension. If, when compared with some study alcohol
status were almost similar results and one study which done by Saliu Abdulsalam, in Nigeria,
2014 study result of alcohol were similar.

This study conducted by cross-sectional study design and randomly selected point a
time to the Myanmar personnel who were working in non-profit health organizations.
Although, there were no more detail and specific than other study design, if and when the
study design which was more specific will be more effectiveness and best. Also, in term of
health professional and who interest to find out others association factors with hypertension
suggested by present researcher, to carry on further study to be more perfectly and
completely.
316
Conclusion
In this study, the factors which were associated with hypertension were age, family
history of chronic diseases, BMI and the participants who were smoking respectively.
Recommendation
According final result of this study, hypertension was associated with smoking
behaviors. Moreover, (57.10%) of participants were from poor environmental factors
conditions. Therefore, would like suggest to all non-profit organizational authorities and
member not only provide social and health services to community also necessary to
organized and review health policies about hypertension for their personnel.
Acknowledgements
I would like to express my sincere thanks to Ethical committee of Khon Kaen
University, all Dr. Ph students and faculty of Public Health, Khon Kaen University, Thailand
for their valuable guidance and supervision towards my study. I would like to thank all the
respondents from non-profit health organizations with their participations.
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Psychosocial determinants and smoking behaviors among working aged

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Thu Yein Win 1, Channaphol Srirueecha2
1
2
พม่าเป็ นหนึ่ งในประเทศในกลุ่มอาเซี ยน ที่ มีพฤติ กรรมการสู บบุหรี่ และได้รับการยอมรับอย่างกว้างขวางและ

นับว่าเป็ นบรรทัดฐานทางสังคมอย่างหนึ่ งมาตั้งแต่สมัยโบราณ การวิจยั ครั้งนี้ มีวตั ถุประสงค์เพื่อศึกษาความชุกของการสู บ
บุหรี่ และเพื่อหาความสัมพันธ์ระหว่างปั จจัยทางจิตสังคมกับการสู บบุหรี่ ของชายวัยแรงงานในจังหวัดปาโก ประเทศพม่า
การศึ กษาเชิ งวิเคราะห์แบบภาคตัดขวางครั้งนี้ ดาเนิ นการเก็บข้อมูลจาก 4 ตาบลในเขตพื้นที่ 2 อาเภอ ของจังหวัดปาโก
ประเทศพม่า โดยทาการใช้สุ่มตัวอย่างแบบหลายขั้นตอน เพื่อเลือกกลุ่มตัวอย่างที่มีอายุระหว่าง 18 ถึง 59 ปี จานวน 343
คน กลุ่มตัวอย่างจานวนทั้งหมด 343 ได้เป็ นกลุ่มตัวอย่างอย่างครบถ้วนสาหรับการศึกษาครั้งนี้ มีเก็บรวบรวมข้อมูลโดยใช้
แบบสอบถามด้วยตนเอง สถิติที่ใช้ในการวิเคราะห์ความสัมพันธ์ในครั้งนี้ คือการวิเคราะห์การถดถอยโลจิสติคอย่างง่ายและ
การวิเคราะห์การถดถอยโลจิสติคพหุกลุ่ม
กลุ่มตัวอย่างส่วนใหญ่อยูใ่ นกลุ่มอายุ 40 ปี ขึ้นไป (43.73%) มีอายุเฉลี่ย 37.61 ± 11.64 ปี ความชุกของการสูบบุหรี่
ในกลุ่มชายวัยแรงงานเท่ากับ 49.85% (95% CI = 45.0% - 55.0%) ปั จจัยที่ มีความสัมพันธ์กบั การสู บบุหรี่ ในกลุ่มชายวัย
แรงงาน ประกอบด้วย การมีความรู ้ต่าอยูใ่ นระดับและปานกลาง(AOR= 3.42 ,95% CI=2.17 – 5.43, p-value = <0.001) การ
มีอาชีพที่ดี (AOR = 1.73, 95% CI = 1.09- 2.76 ,
p = 0.019) และการมีสมาชิกในครอบครัวสูบบุหรี่ (AOR = 1.99, 95% CI = 1.26- 3.15, p-valve = 0.003)
ทั้งนี้ ครึ่ งหนึ่ งของชายวัยแรงงานมี พ ฤติ กรรมการสู บ บุ ห รี่ สภาวะทางเศรษฐกิ จและสัง คมก็ นับ ว่า
ครอบครัวมีอิทธิพลต่อพฤติกรรมการสูบบุหรี่ ร่วมด้วย
319
Abstract
Introduction: Myanmar is one of the ASEAN countries where smoking has been socially and
widely accepted as a social norm since ancient times.
Objective: The purpose of this study was to determine the prevalence of smoking and
identify the association between psychosocial determinants and smoking among working
aged men in Bago Region, Myanmar.
Methodology: This cross-sectional analytical study was conducted in 4 townships under 2
districts of Bago Region, Myanmar. Multistage random sampling method was used to select
343 samples aged between 18 to 59 years old working men. A total of 343 respondents
participated in this study. Data collection was done by using self-administered questionnaire.
Simple and multiple logistic regressions were used to determine the association.
Result: The highest proportion of the respondents was in the over 40 years old age group
(43.73%) with the mean age of 37.61 ±11.64 years. The prevalence of smoking among working
aged men was 49.85% ( 95% CI = 45.0% – 55.0% ) . Factors associated with smoking among
working aged men were had low and moderate levels of knowledge (adj. OR= 3.42, 95% CI
=2.17–5.43, p-value = <0.001), had well established occupation (adj. OR=1.73, 95% CI =1.09– 276,
p-value = 0.019) and had family members smoking (adj. OR =1.99, 95% CI =1.26– 3.15, p-valve =
0.003).
Conclusion: About half of the working age males smoke. Socioeconomics and family had
influence on their smoking practices.
Keywords: Smoking, Psychosocial factors, working aged, Bago Region
320
Introduction
Smoking is the greatest preventable public health problem in developed

countries, and smoking among working people is one the main concerns for public healthcare
systems. Tobacco is the only legal drug and that kills and harms many of its users and
estimated that about six million people will be die across the world each year by using
tobacco (smoke and smokeless) and among those of deaths occurring prematurely (1). Almost
10% of these deaths were among the ASEAN region, losing one person for every five lives
claimed by tobacco (2). More than 2500 youth and young adults who are occasional smokers
will become regular smokers and third of these replacement smokers will die early from
smoking (3). Myanmar is one of the ASEAN countries where smoking has been socially and
widely accepted as a social norm since ancient times. It is being widely used in socio-cultural
as well as religious ceremonies with betel, tobacco and tea leaf. In Myanmar, cheroots are the
most common type of tobacco products. To make cheroots, there have step by step and most
(4 )
of them are hand-rolled . In addition, there were about 39% of people is exposing to
environmental tobacco smoke in work places (5).
The Myanmar survery in 2010 reported that prevalence of smoking among

men was about 38% and about 8% was women. The highest rate of smoking among men was
seen in the age-group 55-69, and among women in the age-group 70+ (1). The previous study
from Vietnam showed that demographic and socio-economic factors like as education,
(6 )
emplyoment and income were associated with the decision on smoking . In addition, the
study from Pakistan found out the association between smoking behaviors and knowledge,
(7 )
attitude among medical students . This study will contribute to information about the
knowledge influences, especially family and school. This study aimed to describe the
prevalence of smoking among working aged men and identify the association between
smoking and associated factors such as knowledge level of side effect of tobacco used,
occupational group and family members smoking.
There have no significant reduction were found among both boys and girls in
2011 and seconhand smoke at home and in public places did not change and stayed
321
significantly high. Also there have no significant change were also fond in accessibility of
tobacco product. (8).
Rationale : Myanmar is one of the ASEAN countries where smoking has been
socially and widely accepted as a social norm since ancient times.
Objective
The purpose of this study was to determine the prevalence of smoking and identify the
association between factors of psychosocial determinants and the smoking among working
aged men in Bago Region, Myanmar.
Methodology
Study design
This study was the community based cross sectional study and study area was Bago
region, Myanmar. All the participants were 343 people using calculated by Hesieh, Bloch &
Larseen formula (13). A pre-tested, semi-structured and self- administered questionnaire were used as
data collection tool. The questions included single as well as multiple responses. The structured
questionnaire would be consisted of four parts. Part 1 was consisted of demographic and socio-
economic data , situations and characteristics of smoking, psychosocial factors as stress, knowledge
and attitude questionnaire would be in part 2, social and environmental factors included peer
pressure, family influence and community in part 3 and related with marketing strategy
questionnaire asked in part 4.
Study outcome
The prevalence of smoking among working aged men was 49.85% (95% CI = 45.0% –
55.0%). Factors associated with smoking among working aged men were the low and moderate
levels of knowledge group (adj. OR=3.42, 95% CI =2.17–5.43, p-value = <0.001), stable
occupation group (adj. OR=1.73, 95% CI =1.09– 276, p-value = 0.019) and family members
smoking (adj. OR =1.99, 95% CI =1.26– 3.15, p-valve = 0.003).
322

percentage for categorical data and mean, median and standard deviation for continuous data.
After collecting data, editing and cleaning the data collected from respondents, the collected data
was entered into computer by using STATA software 13.0 version and processed and analyzed it.
All analyses were performed using Stata version 13.0. All test statistics were two-sided and a
p-value of less than 0.05 was considered statistical significant. All the questionnaires in this
study had been approved by Khon Kaen University Ethical Committee for human research.
SAMPLING METHOD
The respondents who are being currently working in this study area were the
population of this study. Two districts from this region were randomly selected from study
area and then four townships were randomly selected from those selected two district. Total
343 participants were selected from eight villages which are randomly selected from those
selected four townships. (Fig.1)
Bago Region (4 districts)
) Sampling by lottery
2 districts (16 Townships)
Sampling by lottery
Township (4 Townships)
Sampling by lottery
Villages (8 Villages)
Table of number
Working age male Sampling
(343 workers)
Fig. 1. The inclusion flow chart
323
Result
According to the table, it can be observed that the highest percentage of the
respondents, by 43.73%, was at the age group of 40 and 59 while those at the ages of 30 to 39
had the lowest by 27.70%. The mean age of the respondents was 37.61 (SD=11.64) with the
minimum age of 18 and maximum of 59. Occupational status, the highest percentage was
found at unskilled worker, the second highest at business and the third highest at farmer and
fishermen. Majority of the respondents were Buddhist. About 59.77% of the respondents were
living with 4 and less family members whereas 40.23% with 4 and more family members. The
number of family members, on average, was about 4. Almost all of the respondents, by
61.22%, stayed in rural area.

1. Age (Years)
< 29 98 28.57
30 – 39 95 27.70
> 40 150 43.73
Mean )±SD( 37.61 )±11.64(
Median )min : max( 38 )18 ; 59(
2. BMI )Kg/cm2(
> 18.5 56 16.33
18.5 – 22.9 188 54.81
23.0 – 24.9 46 13.41
> 25 53 15.45
Mean )±SD( 21.674 )±3.738(
Median )min : max( 21.255 )4.841 ; 36.758(
324

3. Ethnic
Burma 338 98.54
Kayin 3 0.87
Rakhine 1 0.29
Shan 1 0.29
4. Marital Status
Married 255 74.34
Single 88 25.66
6. Occupation
Business 77 22.45
Others 30 8.75
Employee 21 6.12
Housewife 4 1.17
Student 3 0.87
7. Religion
Buddhist 340 99.13
Christian 2 0.58
Muslim 1 0.29
8. Family size )Persons(
<3 22 6.42
3 –4 183 53.35
325

>4 138 40.23
Mean )±SD( 4.481 )± 1.518(
Median )min : max( 4 )2 ; 9(
9. Living with
Family 161 46.94
Wife 132 38.48
Friends and Relatives 50 14.58
10. Type of Residence
Rural 210 61.22
Urban 133 38.78
10. Monthly Income )MMK(
≤ 100,000 75 21.87
100,000 – 200,000 196 57.14
≥ 200,000 72 20.99
Mean )±SD( 178,979 )±10,2947.7(
Median )min : max( 150,000 )50,000 ; 1,000,000(
13. Family’s Monthly income )MMK(
≤ 200,000 127 37.03
200,000 – 350,000 111 32.36
≥ 350,000 105 30.61
Mean )±SD( 308,906.7 )± 182,525.5(
Median )min : max( 300,000 )60,000 ; 1,500,000(
Not enough 45 13.12
326
Psychosocial, Environmental factors and smoking behavior
According to the table 2, the participants who reported that their family members have
never used tobacco belonged to the highest proportion by 47.23%, followed by those with
father who has used tobacco by 31.49%, those with brother and sister who have ever used by
11.08% and those with mother by 7% . It is revealed that other families of the respondents have
also used tobacco.
Further, nearly half of the respondents, 49.85%, reported that they, themselves, have
used tobacco. The respondents who smoke last one month has about 44.3% and 55.7%
respondents are not smoking in last one month.
Table 2. Percentage distribution of environmental factors and smoking behaviors. (n=343)

1. Family member use tobacco
Nobody 162 47.23
Father 108 31.49
Sibling 38 11.08
Mother 24 7.00
Others 11 3.21
2. Smoking
Yes 171 49.85
No 172 50.15
3. Last one month smoke
Yes 152 44.3%
No 191 55.7%
Factors associated with smoking
Findings provide the evidence that the high school and higher education level was more
likely to smoke 1.34 times than secondary and below )p=0.197<0.25(. The result shown
occupation can interpret smoking behavior in the government staff, employee, business
327
owners and others were more likely to smoke 1.61 times than students, fishermen and
unskilled workers )p=0.031<0.25(.The respondents who stay with wife and family were more
smoke than who stay with relative and friends )p=0.237<0.25(. The table shown that less
income group also more likely to smoke 1.43 times than more income group )p=0.175<0.25(.
Family member smoking has correlation with smoking behavior. The livelihood of smoking
of the working aged men with family member who has smoke was 1.74 times more than those
without family member who has not )p=0.011<0.25(. It was found statistical significant
correlation knowledge of tobacco between smoking behavior and knowledge of tobacco use.
Those with low and medium level of knowledge had higher probability of smoking than those
with high level by 3.17 times )p=0.001<0.25(. Promotion of the high perception of marketing
factors were more likely to smoke 1.6 times than low and moderate marketing level
)p=0.043<0.25(.
Table. 3. Odds ratios (ORs) each category of factors on smoking based on simple logistic
regression. (n=343)
% Crude
95%CI p-value
Factors number
smoking OR.
1. Age in years 0.483
18 -39 193 48.19 1
40 -59 150 52.00 1.16 )0.76 – 1.78(
2. BMI)kg/m^2( 0.747
Overweight and Obese 99 48.48 1
Under weight and 244 50.41 1.08 )0.68- 1.68(
Normal
2. Marital status 0.599
Married 255 49.02 1 )0.70 – 1.85(
Single 88 52.27 1.39
3. Educational Level 0.197
No formal, primary and 224 47.32 1
secondary
High and bachelor 119 54.6 1.34 )0.85-2.09(
328
4. Occupation 0.031
Household, student, 210 45.24 1
fishermen
Employee,and unskilled
Government 133 57.14 1.61 )1.04 – 2.50(
workers
staff
5. Family ,Own business and
member 0.964
others
Less than 4 persons 205 49.76 1
More than 4 persons 138 50.00 1.00 )0.65-1.55(

6. Living with
Friends and relative 50 44.00 1 0.237
wife 132 46.21 1.79 )0.57 – 2.10(
Family 161 54.66 1.19 )0.81-2.91(
7. Type of residence
Rural 210 48.10 1 0.412
Urban 133 52.63 1.20 )0.78 – 1.85(
8. Income per month )MMK( 0.175
≤ 200,000 271 47.97 1
> 200,000 72 56.94 1.43 )0.85-2.42(
9. Family’s income )MMK( 0.548
≤ 200,000 127 51.97 1
> 200,000 216 53.15 1.14 )0.74-1.77(
Not enough and not 81 49.38 1
enough
Enough with debt
but no saving 262 50.00 1.03 )0.62-1.69(
and Enough
11. Family memberwith saving
smoking 0.011
No body 162 42.59 1
Family 181 56.35 1.74 )1.13-2.67(
12. Knowledge <0.001
High 192 37.50 1
Low and medium 151 65.56 3.17 )2.03– 4.95(
13. Attitude 0.889
Low and medium 45 48.89 1
329
High 298 50.00 1.04 )0.56– 1.95(

14. Marketing )Product( 0.746
Low
perception 99 48.48 1
Moderate and High 244 50.41 1.08 )0.68-1.720(
16. Marketing )Price( 0.708
High
Low and moderate 135 51.11 1.08 )0.70-1.68(
17. Marketing )Place( 0.637
High
Low and moderate 53 52.83 1.15 )0.64-2.07(
18. Marketing )Promotion( 0.043
Low and moderate
High 236 46.19 1.60 )1.01-2.54(
According to the findings, knowledge level of tobacco use was a statistically significant
predictor of smoking behavior. Those with low and medium knowledge level are more likely
to smoke 3.42 times than those with high level )p=0.001<0.05(. Occupation group including
employee, government staff, own business and skill labors was statistically associated with
smoking behavior. The respondents group who have stable job to smoke 1.61 times than
unstable job group )p=0.019<0.05(. It is worthy noted that family member smoking could
explain smoking of the working aged males. Those with family members who were smoking
had a higher chance to smoke than those without family members who were smoking by 1.74
times )p=0.013<0.05(.
Factors. % Crude Adj.

95%CI p-value
number
smoking
OR. OR.
1. Knowledge < 0.001
High 192 37.50 1
Low and medium 151 65.56 3.17 3.42 )2.17- 5.43(
330
Factors. % Crude Adj.

95%CI p-value
number
smoking
OR. OR.
3. Occupation 0.019
Household, student, 210 45.24 1
fishermen
Employee,and 133 57.14 1.61 1.73 )1.09- 2.76(
unskilled
Government
3. Family memberworkers
staff
smoking 0.003
,Own
None business, skill 162 42.59 1
labors
Family 181 56.35 1.74 1.99 )1.26- 3.15(
Fig. 2. Forest plot diagram for factors affecting smoking with family member smoking,
occupation group and low and moderate knowledge level.
DISCUSSIONS
The working aged men at the ages of 40 and below are about 56.27% and higher than
those at fewer than 40 years over with similar finding were found in Natalie Slopenn (9). Most
of the respondents were living in rural area about 61.22% than those of urban area were
38.78%. The average monthly income was 178,979 Kyats and 57.14% of the respondents were
between 100,000 and 200,000 kyats, pointing out that the respondents were not low income
earners. The similar finding was found in the study done in (10).
More than half of the respondents (56.35%) have family members who have ever used
tobacco. Nearly half of the respondents have used tobacco with the most significant reasons
331
of being stylist, curious and their friend’s influence. Further, almost two-third of the smoking
respondents said that they smoke because of their close friends. The previous research shown
that about 80% of the respondents were solid influence of smoking on the non-smoking
members of a family, if a family member smokes in the family. The respondents who
participated in anti-smoke campaign activities were very less percentages 5.23% that is not
much different from other study of 11% participation from Pakistan (7) . Occupation was strong
social factor which can explain smoking behavior, the similar paper from Vietnam shown that
factors associated with the decision on smoking were education, employment and income.
(cuong, 2012). The respondents with family member who are smoking were more likely to
smoke than those without family member smoker. These results confirmed previous studies
found that family member influence with smoking (11). The last strong factor which play very
significant role for smoking behavior was perception of the tobacco knowledge level. Those
with lower and moderate perception knowledge level had higher probability of smoking than
those with those with the higher perception. The previous similar paper showed that there had
significant relationship between the knowledge levels and respondents (p valve <0.033) (12).
This study are using quantitative data which was analyzed using statistic methods. So
findings could be generalized if selection process was well-designed and sample was
representative of study population. Data can be very consistent, precise and reliable and easy
to analyses.
This study was cross sectional study and not allowed the cause and effect relation
between various factors and smoking. Research was represented only working aged men in
four townships in Bago Region, therefore it cannot be covered the whole population of this
region.
332
Conclusions
This study investigated whether knowledge of tobacco use, occupational status and
family members smoking have impact and influencing smoking behavior among the working
aged men. Most of the reasons why the respondents started to smoke were curiosity, stylist
and peer influence and they started to smoke at the young age. More than half of the
respondents did not provided correct answer for the knowledge item: Myanmar does not have
policy to reduce/stop smoking; smoking policy should be shared to the community via the
media.
Recommendations
It is recommended that public health education campaign related to reduction in

smoking should be more intervened in the public as well as private high schools in rural and
urban areas than before in effective ways because if high schools are main centers to share
information about adverse effect of smoking to the teenagers who will enter the youth age.
The law require for prohibited of the smoke free places and tobacco advertising, promotion
and sponsorship. The authorities have plan for roadmap to tobacco control legislation
Acknowledgements
I would like to express my heartfelt thanks to the University of Public Health, Khon
Kaen University giving an opportunity to study in the Master of Public Health program and
undertake the thesis and my special thanks to (IRC PLE Program) who was fully support
though the whole study period. I also wish to express my thanks to all those respondents in
Bago Region who enthusiastically and kindly participated in this study.
Funds
This work was financially supported by IRC (PLE Program).
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333
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5. GYTS (2011), Global Youth Tobacco Survery (GYTS) Fact sheet.
6. Nguyen Viet Cuong)2012(, Smoking behavior in Vietnam: demographic and
socioeconomic determinants.
7. Barkat Ali Babar (2016), Knowledge, attitude and practice regarding smoking among
medical students in Pakistan.
8. GYTS (2011), Myanmar 2011 country report global youth tobacco survery (GYTS).
9. Natalie Slopen (2013), Psychosocial stress and cigarette smoking persistence,
cessation, and relapse over 9–10 years: a prospective study of middle-aged adults in
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11. Shadid HM and Hossain SZ )2013( Understanding Smoking behavior among
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334
Factor of Mobile Phone use related to Quality of Sleep among High School
Students in Chiang Mai, Thailand
Chogchitpaisan W1, Wiwatanadate P1, Tanprawate S2, Narkpongphun A3, Siripon N4
1
Department of Community Medicine, Faculty of Medicine, Chiang Mai University
2
Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
3
Department of Psychiatry, Faculty of Medicine, Chiang Mai University
4
Department of Electrical Engineering, Faculty of Engineering, Chiang Mai University
ปั ญหาการนอนหลับในวัยรุ่ นส่ งผลกระทบต่อสุ ขภาพและการเรี ยนรู ้โดยเฉพาะกลุ่มวัยรุ่ นที่เจริ ญเติบโต

ในยุค โทรศัพ ท์เ คลื่ อ นที่ ส มัย ใหม่ ซึ่ ง มี ก ารครอบครองและใช้ม ากเป็ นอัน ดับ ต้นๆ การศึ ก ษาที่ ผ่า นมาพบ
ความสัมพันธ์ผลกระทบสุ ขภาพและโทรศัพท์เคลื่ อนที่โดยเฉพาะระบบประสาท อย่างไรก็ตามยังขาดข้อมูลที่
ชัดเจนเกี่ยวกับปั จจัยการใช้โทรศัพท์เคลื่อนที่ที่เกี่ยวข้องกับคุณภาพการนอนหลับ การวิจยั ครั้งนี้ มีวตั ถุประสงค์
เพื่อศึกษาความชุ กของปั ญหาการนอนหลับและปั จจัยที่ เ กี่ ยวข้องกับ คุ ณภาพการนอนหลับของเด็กนัก เรี ย น
มัธยมศึกษาตอนปลาย ในจังหวัดเชียงใหม่
ผลการศึกษา พบความชุกปั ญหาการนอนหลับและการนอนหลับจากการใช้โทรศัพท์เคลื่อนที่ ร้อยละ
50.5 และ 55.1, ตามลาดับ คะแนนคุณภาพการนอนหลับเฉลี่ย (Pittsburg Sleep Question Index: PSQI) 4.8±2.9
พบความชุกการเป็ นเจ้าของโทรศัพท์เคลื่อนที่ ร้อยละ 99.8 โดยพบปั จจัยที่มีผลต่อปั ญหาคุณภาพการนอน เป็ น
การสนทนาทางโทรศัพ ท์เคลื่ อนที่ ระยะเวลานาน การดื่ มเครื่ องดื่ มชาและกาแฟและการใช้ย าเมื่ อเจ็บป่ วย
ORadj1.60: 95%CI; 1.09-2.34, ORadj2.95: 95%CI 1.71-5.09 และ ORadj1.54: 95%CI 1.06-2.25 ตามลาดับ
สรุ ป พบวัยรุ่ นส่ วนใหญ่มีปัญหาการนอนหลับ สอดคล้องกับการเพิม่ ขึ้นของการใช้โทรศัพท์เคลื่ อนที่ที่
ทันสมัย โดยพบปั จจัยการใช้โทรศัพท์ก่อนนอนในระยะเวลานาน การดื่มเครื่ องดื่มชาและกาแฟและการใช้ยา มี
ผลกระทบต่อปั ญหาการนอน ซึ่ งควรจากัดเวลาการใช้โทรศัพท์เคลื่อนที่ก่อนนอนเพื่อเกิดคุณภาพการนอนและ
คุณภาพชีวติ ที่ดี
335
Abstract
Sleep problems in adolescents have impacts on health and learning, especially among
adolescents who grew up in a modern age of mobile phone (MP) era. Previous studies identified
relationships between health impacts and mobile phones, especially impacts on nervous systems.
However, there is still insufficient evidence on the influences of MP use on quality of sleep.
This study aimed to determine the prevalence of sleeping problems and the association between
MP use and quality of sleep among high school students in Chiang Mai.
Methodology: This cross-sectional study was conducted among high school students in Chiang
Mai province . The samples were selected to response to a self- administered structured
questionnaire by using stratified randomly sampling based on grades and genders. The response
rate was 94.1%. Sleep quality was assessed by the Pittsburg Sleep Quality Index (PSQI). Sleeping
hygiene, daytime drowsiness, mobile phone use characteristics, headaches, anxiety and depression
were also assessed.
Result: The prevalence of sleep problems and sleep problems from mobile phones use were 50.5
and 55.1 percent, respectively. The Pittsburg Sleep Quality Index (PSQI) mean scores was 4.8 + 2.9.
Mobile phone ownership prevalence was 99.8 percent. The factors influencing poor sleep quality
were long mobile phone conversations (ORadj1.60: 95%CI; 1.09-2.34), stimulating beverage and
medicine use (ORadj2.95: 95%CI 1.71-5.09 and ORadj1.54: 95%CI 1.06-2.25).
Conclusion: Majority of the adolescents had sleep problems both using and non -use of MP. MP
use behaviors and stimulant use had influence on their sleep quality.
336
Introduction
Good sleep is similar to food, drinking water and air, all of which are essential for physical
growth in addition to behavioral, emotional and learning development in adolescents. 1- 4 Sleep
problems among adolescents are encountered in every country worldwide. According to a study
conducted in many countries by Mindell JD (2008), sleep problem prevalence was encountered at
25–40 percent5. Countries around the world are faced with sleep problems (16.9–54.21%) in 2000–
5- 8
2013. 2, Sleep problems increased to 58. 7– 66 percent in 2013– 2016. 4, 9
Adolescents’ sleep
problems are dependent on biological changes, physical, psychological, emotional and behavioral
changes, from growth into adulthood, cultural, social, familial, school and environmental factors.2-
4, 6, 10, 11
Today adolescents are growing up in an age of modern technology12. Electrical devices
and electronic media are found in adolescents’ bedrooms (75%),13 while the use of electronic media
and mobile phone conversations before sleeping has been found to be related to sleep problems
( 77% ) . 13- 21 Therefore, the use of the aforementioned technologies is an environmental factor
influencing sleep. Data which revealed increases in sleepiness during daytime and higher tea or
coffee consumption indicated deficiency sleep among adolescents.14, 15, 22

Mobile phones are samples of modern technology capable of meeting various needs of
adolescents. 23 As a result, adolescents have high rates of mobile phone possession and use. 24
Mobile phones are a source of electromagnetic radiation used closest to the head25, 26 causing
disruptions to brain waves and nerves system controlling sleep balance mechanisms and wake-
sleep cycles with effects on the secretion of neurotransmitters related to sleep and abnormalities
in biological sleep.27
However, the use of mobile phones in relation to sleep quality was inconclusive. In addition
to effects on perception and learning ability leading to low academic performance14, 28, 29, sleep
problems also cause chronic diseases14, 30- 32 and risk of death (RR: 1.12; 95 % CI 1.06 to 1 .18 ). 33
Therefore, studies of mobile phone use with effects on sleep problems will provide data for
recommending safe mobile phone use with provide data for appropriate care and prevention for
adolescents with sleep problems. Moreover, the data from this study can be used to study
337
correlation between electromagnetic radiation from mobile phones and sleep problems in the
future.
Objective
To determine the prevalence of sleeping problems and the association between MP use and
quality of sleep among high school students in Chiang Mai.
Methodology
Study design
This study was based on a cross- sectional design conducted among 1, 422 high school
students in Chiang Mai province who had the same characteristics as high school students
nationwide. This study was conducted in October-December 2015 and certified by the Institutional
Review Board of the Research Ethics Committee, Faculty of Medicine, Chiang Mai University on
21 September. This project was a part of effect of MP use on headache and sleep quality and the
sample size was calculated based on the 10 percent prevalence of headaches caused by mobile
phone use. 34 A total of 1,058 subjects were obtained. The subjects were selected by stratified
randomly sampling based on grades and genders, response rate at 94.13 % (9 9 6 students). Sleep
quality was assessed by using the Pittsburg Sleep Quality Index (PSQI) to assess perception of
sleep sufficiency and satisfaction. Sleep quality consisted of qualitative and quantitative sleep.35-37
Scores were calculated to divide groups. The subjects with good sleep quality had scores of < 5
points while the subjects with scores at >5 points had sleep problems and were assessed for
sleeping habits37. Daytime drowsiness was assessed by using the Epworth Sleepiness Scale (ESS)
Thai Version. 38 Sleep problem prevalence was calculated from students who calculated sleep
quality scores at >5 divided by the total number of students who completed questionnaires. Mobile
phone use characteristics were assessed by using questionnaires modified from the study
conducted by Chu et al. (2011).34 Headaches were assessed by questionnaires. Finally, anxiety and
depression were assessed by the Hospital Anxiety and Depression questionnaire ( HAD, Thai
Version).39 High scores meant high anxiety or depression.
338
The researcher collected data, designated codes and conducted analysis using the SPSS
program (v.20). Category demographics data from the samples were calculated for frequency, and
percentage, while mean and standard deviation were used for continuous data. Prevalence was
shown in percentage with 95 percent of confidence interval (CI). The relationships of factors related
to headaches were analyzed by using binary logistic regression presented as Odd Ratio (OR) and
95% Confidence Intervals ( CIs) with P- value to consider statistically significant differences.
Multiple logistic regression was used to control other variables being considered to be related to
the outcome such as gender, age, diseases, medication adherence, psychological trauma, phobias,
risk behaviors, anxiety, stress and headaches, etc. The variables were selected by the Forward LR
method (Log-likelihood Ratio).
Result
A total of 996 students were randomly sampled and returned completed questionnaires
(94.1%). Most of the subjects were females (74.7%) (Table 1) with a mean age of 17.63 + 1.01 years
(Age Range: 16 – 20 years). The subjects had body mass index with excessive weight (85th percentile
BMI; Female = 26.5 – 31.5, Male = 27–30.5) and obesity 10.1% (95th percentile BMI. Female > 31.55,
Male => 30.5).35 The subjects had chronic diseases and used medications regularly 22.2% and 31.0%,
respectively.
The PSQI was at the normal mean scores of 4.8 ± 2.9. The prevalence of sleep problems
and nighttime MP use were correlated with sleep problems encountered at 50.5 percent and 55.1
percent.
Nearly all of the students were found to be mobile phone owners (99.8%) and smartphone
mobile phone owners (99.9%) (Table 3) who used the iPhones brand at approximately 30.7%. The
researcher found mobile phones to be used in three areas, namely, for conversations, social media
(Facebook, Line, Skype) and entertainment. Frequency of use was assessed as follows: 1) usage of
339
< 50 percent was considered low use, usage of 50 percent was considered occasional and usage of
more than 50 percent was considered regular use. The students were found to have most frequently
used mobile phones for online social communications (80.6%). Hand- free and speaker phone uses
were assessed by using the same levels as mobile phone use with levels consisting of no use, little
use and regular use. Most of the students were found to have low hand-free and speaker phone use
with low mobile phone conversation time and frequency. Students who felt burning sensation at
the ears while holding a telephone conversation were encountered at a rate of 37.7 percent.
Table 1 Demographic data of participants presented as number percentage and mean unless
specified otherwise
Demographic data N Grade 10 Grade 11 Grade 12 Total % (95%CI)
Gender
Male 252 76(23.0) 69(21.6) 107(30.9) 25.30 (22.62-28.12)
Female 744 254(77.0) 251(78.4) 239(69.1) 74.69 (71.88-77.37)
Age 996 16.60±0.60 17.66±0.64 18.58±0.55 17.62±1.01

Overweightand obesity 987 38 (11.7) 32 (11.0) 30 (8.7) 10.13(8.32-12.19)
Medicine use 996 94(28.5) 120(37.5) 95(27.5) 31.02 (28.16-34.00)

Underlying disease 994 69 (20.9) 75 (23.4) 75 (21.7) 22.03 (19.49-24.74)
Vision problem 996 67(20.3) 57(17.8) 97(28.0) 22.18 (19.64-24.90)
Potentially Traumatic 996 10(3.0) 8(2.5) 11(3.2) 2.91 (1.96-4.15)

Interpersonal Events
(PTIEs)
Phobia 996 21(6.4) 14(4.4) 14(4.4) 4.91 (3.66-6.45)
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Table 2 Sleep characteristics of participants compared by grade level presented as number

percentage and mean unless specified otherwise
Sleep characteristics Total (N) n(%) and mean (95%CI)
MP use @ night 804 535(66.54) (63.16 - 69.80)
Poor Sleep 983 496 (50.45) (47.28 - 53.63)

Poor Sleep with MP use@ night 535 295 (55.14) (50.81 - 59.41)
Doze 857 41(4.78) (3.45 - 6.43)
PSQI scores (mean: SD) 983 4.82±2.87
Table 3 Characteristic of MP use compared by grade level presented as number

percentage and mean unless specified otherwise
Characteristic of MP use N (%) Characteristic of MP use N (%)
MP owner 994(99.8) Smartphone 993(99.9)
MP system MP use at night

Apple 281(30.7) No 269(33.5)
Other 634(69.3) Yes 535(66.5)
Mode of MP used ≥50% MP holding
conversation 492(49.5) Close to ear 631(63.5)
Social media (line/facebook) 801(80.6) Transpose holding 171(17.2)

Entertain 788(79.3) Far from ear 191(19.2)
Hand free using On Speaker phone

≥ 50 % (usually) 251 (25.3) ≥ 50 % (usually) 184(18.5)
< 50% (seldom) 448 (45.1) < 50% (seldom) 459(46.2)

No used 294 (29.6) No used 350(35.2)
341
Duration time used (min/time) Frequency used (times/day)
<10 min 707(71.1) <5 809(81.4)
≥10 min 287(28.9) ≥5 185(18.6)
To control the interaction effects, we conducted a statistical test to evaluate the relationship
between various factors and found there existed no interaction effect among them. Multiple logistic
regression analysis was carried out by controlling demographic data, risk behaviors, headache,
anxiety and depression in the sample group. Effect of long duration of MP conversations at >10
and on non-iPhone devices were found to have risk for poor sleep quality (ORadj1.60: 95% CI; 1.09-
2.34 and ORadj1.57: 95% CI; 1.08-2.27, respectively). Doze was a main impact from sleep quality
problems. Poor sleep quality was found to be the strongest effect on daytime dozing (ORadj9.03: :
95% CI; 2.73-29.94) (Table 4).
Table 4 Odds ratios (ORs) of Poor sleep quality and their 95% confidence intervals for
each factor adjusted for all other factors using logistic regression
Factor of MP use Total PSOI Crude Adjust 95%CI p-value

N % OR OR lower upper
Poor sleep quality
Device brand: APPLE 280 41.8% 1
Device brand: other 634 56.0% 1.77 1.57 1.08 2.27 0.02
Duration of MP talking <10 min. 695 45.6% 1
Duration of MP talking >10 min. 286 62.2% 1.965 1.60 1.09 2.34 0.02
Adjusted for age gender BMI underlying disease medicine use vision problem PTIEs MP
at night mode of MP use MP holding Hand-free use speakerphone use duration and frequency of
MP talking device system anxiety depression type of headache sleep hygiene risk behavior
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Figure 1 Factors contributing to sleep quality as odds ratio adjusted for age gender BMI
underlying disease medicine use vision problem PTIEs MP at night mode of MP use MP holding
Hand-free use speakerphone use duration and frequency of MP talking device system anxiety
depression type of headache sleep hygiene risk behavior
Discussion
In the present study, PSQI was found to have a mean of 4.8±2.9. Sleep problem prevalence
(PSQI> 5) was found at 50.5 percent. In this study, prevalence was found to be higher than studies
conducted before 2008. According to the literature review, prevalence was found to be 25 – 40
percent5, 39.61 percent in China in 20142 and 66.10 percent in Australia in 2013. 9 However, the
findings concurred with a study conducted in Brazil in 2010 and in Lebanon in 2016 which
assessed PSQI like presence study and found prevalence at 54.7 and 58.7 percent, respectively.4 In
this study, adolescents were found to have dozed during the day (4.8%), which was lower than the
study in the United States where was found at 22 percent16 or 70 percent in Greece5, and 90.4
percent in China. 2 Lower dozing problems in this study might have been caused by the fact that
adolescents had highly consumption of tea and coffee (68.1%). Furthermore, sleeping time was also
343
dependent on different cultural and environmental factors in each country40. However, sleep
problems have shown rapidly increasing trends due to technological advances, particularly for
mobile phones which have spread quickly14. Many previous studies have found electronic media
use among adolescents to have reduced sleep quality13- 15, 17- 19

while mobile phone use in
adolescents increased rapidly from 2000. In Singapore, mobile phone use was found to be 44.8
percent in 200641, 64 percent in the United States in 201114, 78–84 percent in Malaysia in 201442,
89.34 percent in Rayong Province, Thailand43 and 99.8 percent in the present study in 2015.
This study was found effects of conversations using MP for periods of more than ten
minutes and non-Apple brands of MP have been found to pose a risk for poor sleep quality
(ORadj1.601:95% CI, 1.10-2.34 and ORadj1.57:95% CI, 1.08-2.271, respectively). Extended MP

conversations with exposure to electromagnetic radiation from MP was a risk for poor sleep
quality. This finding concurs with a study conducted by Gogineni S (2010) who found the talking
mode to have higher output power (200mW) than standby mode (20Mw).44 Data from an experiment
conducted by R. Huber et al. (2002) found exposure to electromagnetic radio frequency from MP
for 30 minutes to have increased blood circulation at the dorsolateral prefrontal cortex, enhanced
sleep EEG power in the alpha range before sleeping and increasing spindle brainwave frequency
in Stage 2 of sleep. 45- 47 Sleep latency was prolonged with increasing electromagnetic intensity,
indicating a relationship of dose-response. 47 Furthermore, Burch JB et al., Wood AW. Et al. and
Jarupat S et al. found that MP using for >25 minutes/day to have lower 6-hydroxymelatonin sulfate
(6-OHMS), a melatonin metabolism and excrete in urine and saliva, 48 -50 with decreasing in groups
with high MP use.48 A recent review article supported the fact that MP use before sleeping changes
in melatonin and cortisol secretions, which are hormones in the waking-sleeping cycle51, 52 that
altered the nervous system in the parts related to sleep.51 A study conducted by G. Alexandru et al.
found extended TV viewing and game-playing among students to be related to difficulty sleeping14,
18, 53
; it can also predict shorter sleeping times54. Lights from mobile phones, televisions and gaming
consoles have been found to suppress melatonin secretion and disturb the waking-sleeping cycle,
causing longer time to begin sleeping.14 This is a risk factor for Delayed Sleep Phase Syndrome.53
344
Furthermore, the non-Apple brands of MP device have been found to pose a risk for poor
sleep quality. Each MP device brand has difference of antenna, causing Specific Absorption Rates
to be different. 44, 55 On the contrary, SAR in Apple devices was found to be higher than other
brands. Furthermore, environmental factors involved in the use of MP such as urban areas with
strong signals, density of base stations and service networks might influence lower MP output
power. 55- 58 The effects of APPLE brand devices in rural areas on poor sleep was manifested by
ORadj2.79:95% CI, 1.27-6.41; p<0.05) compared to urban areas. Therefore, mobile phone factors did
not influence sleep quality

The present study had limitations because the study is a report and questionnaires were
completed personally. The data obtained may have caused insufficient or excessive assessment
from recall bias. Moreover, this study is a cross-sectional study. Thus, the study was unable to
determine the temporal relationships accurately and was unable to see accurate relationships.
Finally, the study did not classify the networks or frequency of waves used, which were factors
related to mobile phone output. This study was found to have an advantage due to its high number
of participants, enabling factors to be considered according to sleep quality components.
Conclusions
Poor sleep quality has been found to be more likely in with higher modernity and MP use.
Non-conversational telephone use at night and long conversations, stimulating beverage and use
of medications were found associated with poor sleep quality. The findings recommended
limitations to MP use at night to reduce contact with electromagnetic radiation, lights from devices
and increase sleeping time in order to create good sleep quality and good quality of life.
345
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351
Betel quid chewing situation and its associated factors among working aged
males in Kayin State, Myanmar.
Saw Myat Lin Kywe 1, Paricha Nippanon2, Wongsa Lohasiriwong 2
1
2
Faculty of Public Health, Research and Training Center for Enhancing Quality
of Life of Working Age People Khon Kaen University, Thailand
การกินหมากเป็ นหนึ่งในสาเหตุสาคัญของการเกิดโรคมะเร็ งช่องปาก ประมาณ 600 ล้านคนทัว่ โลกมีการกินหมาก

และประมาณร้ อยละ 30 มี การใช้ยาสู บ ในประเทศพม่า จานวนของผูบ้ ริ โภคและการขายหมากในร้ านค้าขนาดเล็กใน
ประเทศพม่ามีเพิ่มขึ้นทุกปี และถือว่าเป็ นเรื่ องปกติโดยเฉพาะอย่างยิ่งในกลุ่มชายวัยแรงงาน การศึกษาครั้งนี้มีวตั ถุประสงค์
เพื่ อ อธิ บ ายถึ งรู ป แบบการกิ น หมากและปั จจัยที่ มีผ ลต่ อ การกิ น หมากในกลุ่ม ชายวัยแรงงานในรั ฐคายิน ประเทศพม่ า
การศึกษาเชิงวิเคราะห์แบบภาคตัดขวางครั้งนี้ ทาการศึกษาในรัฐคายิน ประเทศพม่า กลุ่มตัวอย่างที่ใช้ในการศึกษาจานวน
350 คน โดยใช้วิธีการสุ่ มตัวอย่างแบบมีข้ นั ตอน และใช้แบบสอบถามในการเก็บข้อมูล สถิติที่ใช้ในการศึกษาได้แก่ สถิต
อย่างง่าย และใช้สถิติ multiple logistics regression ในการหาความสัมพันธ์
จากการศึ ก ษาพบว่า กลุ่มตัวอย่างมี เชื้ อ ชาติ ค ายิน ร้อ ยละ 59.1 ความชุ กของการกิ นหมากคิ ด เป็ นร้ อยละ 66.6
(95%CI;61.60 - 71.53) กลุ่มตัวอย่างมีการกินหมากมากกว่า 5 ครั้งต่อวันคิดเป็ นร้อยละ 42.5 กลุ่มตัวอย่างกินหมากทุกวันคิด
เป็ นร้อยละ 72.94 กลุ่มตัวอย่างมีปัญหาทางด้านเศรษฐกิจจากค่าใช้จ่ายในการกินหมากร้อยละ 30 นอกจากนี้ ยงั พบว่า กลุ่ม
ตัวอย่างร้อยละ 87.5 มีการใส่ ใบยาสู บในหมาก และร้อยละ 42.5 มีการกินหมากหลังจากรับประทานอาหาร หลังจากที่ได้
ควบคุมปั จจัยก่อกวนโดยวิธีการ backward elimination multivariate analysis กลุ่มตัวอย่างที่มีทศั นคติอยูใ่ นระดับไม่ดีและ
ปานกลาง (adj. OR=1.90, 95%CI=1.20-3.01; p-value= 0.006), ดื่ ม แอลกอฮอล์ (adj.OR=1.81, 95%CI=1.12-2.91; p-
value=0.014) และไม่ออกกาลังกาย (adj.OR=1.94, 95%CI=1.21-3.09; p-value=0.005) มีความสัมพันธ์กบั พฤติกรรมการกิน
หมากอย่างมีระดับนัยสาคัญทางสถิติ
ทัศนคติในการกินหมาก การดื่มแอลกอฮอล์ และการออกกาลังกาย มีความสัมพันธ์กบั พฤติกรรมการกินหมากใน
กลุ่มชายวัยแรงงานรัฐคายิน ประเทศพม่า การให้ความรู ้ในเรื่ องของอันตรายที่ เกิ ดจากการกินหมาก การส่ งเสริ มการออก
กาลังกาย และการมีกฎหมายควบคุมการสู บบุหรี่ และการใช้ใบยาสูบ จะเป็ นการช่วยลดพฤติกรรมการกินหมากในกลุ่มชาย
วัยแรงงานเพศชายรัฐคายิน ประเทศพม่า
352
Abstract
Introduction: Betel quid is one of the leading causes of oral cancer. About 600 million people
around the world used betel nut and about 30% used smokeless tobacco in Myanmar. A
number of consumers and betel quid in small shops increased year by year and considered as
common especially among male.
Objective: This study aimed to describe the betel quid chewing patterns and its influencing
factors among working aged males in Kayin State, Myanmar.
Methodology: A cross-sectional analytical study was conducted in Kayin State. Total of 350
respondents were participated in this study.by using multistage random sampling. A structured
questionnaire interviewed was used for data collection. Simple and multiple logistics
regression was used to determine the association.
Result: Over half of the respondents were Kayin ethnic (59.1%). The prevalence of betel quid
chewing in this study was 66.6% (95%CI;61.60 to 71.53). 42.5% chewed betel quid more than 5
quid per day, 72.94% chewed every day and 30% of the respondents have economic burden
from betel quid chewing. Moreover, 87.5% of chewers added tobacco in their betel quid and
42. 5% chewed it after meals. After controlling the confounding factors with backward
elimination multivariate analysis, respondents who had poor and moderate levels of attitude
(adj. OR=1.90, 95% CI= 1.20-3.01; p-value= 0.006), drinkers (adj.OR=1.81, 95% CI=1.12-2.91; p-
value=0.014) and who did not do any exercise (adj.OR=1.94, 95% CI=1.21-3.09; p-value=0.005)
were significantly associated with betel quid chewing.
Conclusion: As attitude toward betel quid chewing, drinking and exercise were associated
with betel quid chewing , health education about the dangers of betel quid chewing,
promoting exercise and reinforcing the control of smoking and consumption of tobacco
product law is helpful to achieve the reduction of betel quid chewing.
Key words: betel quid, working aged males, Kayin state.
353
Introduction
Betel quid chewing is one of the leading causes of oral cancer. Worldwide, it is about
( 2)
600 million people used betel nut . WHO reported that 90% of global smokeless tobacco
(SLT) consumers are from the South-East Asia Region (4) . There are many countries has been
reported for betel quid chewing habit, which are Sri Lanka, Pakistan, Bangladesh, Cambodia,
Thailand, Indonesia, Malaysia, China, Taiwan, Papua New Guinea, Several Pacific Islands
and migrant populations in South Africa, Eastern Africa, North America, UK and Australia (2).
In Myanmar, according to Myanmar GYTS 2011, 7. 5% of students age 13-15 used
betel quid. Another study at Nay Pyi Taw in 2011 reported that 5. 2% of 5th to 7th grade
students use SLT mainly in the form of betel quid. In 2009, WHO reported that 51.4% of male
( 7)
age between 15-64 years use SLT . In 2015, a study in Than-Daung town ( Kayin State)
( 4)
reported that the prevalence of betel quid chewing is 71% among 18-65 years . A study
conducted in Dagon (east) township reported that the prevalence of betel quid chewing is 52%
( 9)
and another study conducted in Insein township shown that the prevalence of betel quid
( 6)
chewing is 55.2% . In 2009, a study in Yangon reported that the prevalence of betel quid
( 8)
chewing is 56.7% .The practice is deep rooted in Burmese traditional culture; one of the
example is that betel quid take the important part of hospitality if offering guest ( 5) . Most of
people in Myanmar belief that chewing betel quid is not as risky as smoking. It is a big
challenge for tobacco control measure (7).
Health education and awareness raising activities are implemented by National

Tobacco Control Program in the year 2000 in Myanmar. As a result of anti-smoking
initiatives in the country, the prevalence of smoking getting down ( 22% in 2009) but the
prevalence of smokeless tobacco still high (30%). Most of smokeless tobacco used in the form
of betel quid in Myanmar ( 9). a number of betel quid small shops and a number of consumers
increasing year by year in Kayin state. And also, the habit is more common in male. In
addition, there are very few study of betel quid chewing in Kayin state. The objectives of this
study are to describe the betel quid chewing patterns and to identified influencing factors
among working aged male in Kayin State, Myanmar.
354
Objective
This study aimed to describe the betel quid chewing patterns and its influencing
factors among working aged males in Kayin State, Myanmar.
Methodology
Study design and participants: This cross-sectional analytical study was conducted
in 3 townships of Kayin state, Myanmar. Study population was the working aged males who
aged 18 to 59 years old at the time of data collection. The eligible sample was fulfilled with
the inclusion and exclusion criteria. Inclusion participants were who live in the study area and
who gave informed consent to participate in this study. Exclusion participants were who were
unable to verbally communicate with the interviewers. The sample size was estimated based
on the multiple logistic regressions formula.
Multistage random sampling was used to select samples in this study. Firstly, 2 districts were
selected by simple random sampling from overall 4 districts of Kayin state. And then, 3 townships
were selected from these 2 districts by using simple random sampling also. And then, 9 wards or
villages were selected from these 3 townships by using simple random sampling. After that, sample
households were selected by using systematic random sampling precedure.
Statistical Analysis: The raw data of 350respondents were recorded into MS Excel. The data were
inverted into the Stata program version 13.0. The baseline characteristics of the participants were
described with frequency and percentage for categorical data and mean, median, minimum, maximum
and standard deviation for continuous data. The multiple logistic regression, adjusted OR with 95% of
Confident Interval were used to determine the association between betel quid chewing situation of
working aged males and influencing factors by controlling other related factors. All test statistics were
two-sided and a p-value of less than 0.05 was considered as statistical significant.
Study design
A community-based cross-sectional study was conducted in Mon State, Myanmar. The
study involved 353 mothers/care givers who had 18-24 months old children residing in there.
The children who had contraindications at the time of immunized, missed opportunities for
355
immunization and who were living in crash program area were excluded in this study. Data
collection was done by face to face interviewed using structured questionnaire after doing the
pretest and getting the informed consent. Cronbach’s alpha coefficients of knowledge and
attitude questionnaires were 0.77 and 0.88 respectively. Child immunization status was firstly
accessed from immunization card, in case the card not access, reviewed from immunization
register which kept on Health Center. Multistage random sampling method was used in
selected sample in this study.
Result
Prevalence of betel quid chewing among working aged males: In total 350 participants,
233 (66.6%, 95%CI: 61.60 to 71.53) chewed betel quid and 117 (33.4%, 95%CI: 28.46 to 38.39) were not
chewed betel quid. Over half of working aged males who lived in Kayin state, Myanmar chewed betel
quid in this study.
Table 1 Betel quid chewing situation among working aged males
Betel quid chewing Number Percent 95%CI
Non-chewer 117 33.4 (28.46 to 38.39)
Chewer 233 66.6 (61.60 to 71.53)
Baseline characteristics of betel quid chewing among working aged males:
Table 2 Demographic and socio-economic of the respondents
Majority of them were married 72.6% , the mean age was 37.7 years. 23.2% of total
respondents had not attained formal education system, 39.7% were unskilled worker and 59.1%
were Kayin ethnic.
356
Characteristics Number Percentage

Age in years
18 - 24 years 53 15.1
25 - 39 years 141 40.3
40 - 59 years 156 45.6
Mean (±SD) 37.7 (±11.71)
Median (min : max) 37.5 (18:59)
Marital status
Single 91 26.0
Married 254 72.6
Educational Level
Primary 89 25.4
Secondary 90 25.7
Occupation
Student 5 1.4
Employee 13 3.7
Farmer, Fisherman 95 27.1
Ethnicity
Kayin 207 59.1
Burmese 112 32.0
Mon 9 2.6
India 1 0.3
Pa-Oh 10 2.9
Muslin 11 3.1
Monthly income (MMK)
Less than 100000 151 43.1
100000 – <300000 164 46.9
300000 and more 35 10.0
Mean (±SD) 117740 (±104388.6)
Median (min : max) 100000 (0: 700000)
357

Financial situation
Not enough 97 27.7
Enough but no saving 153 43.7
BMI(kg/m^2)
Less than 18.5 (Under weight) 27 7.7
18.5- 22.9 (Normal) 186 53.1
23.0- 24.9 (Overweight) 66 18.9
25 and above (Obese) 71 20.3
Mean (±SD) 22.5 (±3.12)
Median (min : max) 22.1 (14.8:35.4)
Smoking
No 201 57.4
Yes 149 42.6
Drinking (in 350ml/glass)
No 207 59.1
Yes 143 40.9
Exercise
No 158 45.1
Yes 192 54.9
Recreation
No 52 14.9
Yes 298 85.1
Age of start chewing (years)

10-20 135 58.0
21- 30 56 24.0
31 and more 42 18.0
Mean (±SD) 23.7 (±9.08)
Duration of betel quid chewing (years)
Less than 5 56 24.0
5-15 84 36.5
16 and more 93 39.5
Mean (±SD) 14.1 (±10.76)
Median (min : max) 12 (0.1:39)
358

Who influence for starting betel quid
Family member 14 6.0
Peer 33 14.2
Person in community 4 1.7
Self-initiate 182 78.1
Number of quid chewing per day (quid)
1-5 134 57.5
6-9 33 14.2
10 and more 66 28.3
Mean (±SD) 6.8 (±5.74)
Number of days chewing per week
1-2 days (Seldom) 6 2.7
3-4 days (Sometimes) 35 16.1
5-6 days (Often) 18 8.3
7 days (Usually) 159 72.9
Mean (±SD) 5.8 (±1.89)
Adding tobacco when chewing betel quid
No 29 12.5
Yes 204 87.5
Liquid of betel quid
Swallow 15 6.4
Spit out 218 93.6
Keep in mouth for a long time
No 185 79.4
Yes 48 20.6
Using spittoon/plastic bag
No 167 71.7
Yes 66 28.3
Health education program
No 95 27.1
Yes 255 72.9
Waning and punishment (school, hospital and health
center)
No 74 21.1
Yes 276 78.9
359

Law concerning tobacco products in Myanmar
No 200 57.1
Yes 150 42.9
Easy to access
No 46 13.1
Yes 304 86.9
Place of access betel quid
Home 85 36.5
Betel quid small shop 148 63.5
Distance to access betel quid
0 mile (at home) 85 36.5
Within one 0.13 miles 108 46.3
0.14 miles and above 40 17.2
Mean (±SD) 0.2 (±0.34)
Median (min : max) 0.13 (0:2)
Money using for betel quid per day (kyats)
100 kyats 45 19.3
200-300kyats 98 42.1
More than 300 90 38.6
Mean (±SD) 377.2
(±362.37)
Median (min : max) 300
(100:3000)
Average expense per day
500-2000 kyats 104 44.6
2001-5000 kyats 109 46.8
More than 5000 kyats 20 8.6
Mean (±SD) 3053.6
(±1800.5)
Median (min : max) 3000
(500:10000)
Economic burden on betel chewing
No 163 70.0
Yes 70 30.0
Try to quit chewing
No 128 54.9
Yes 105 45.1
360

Knowledge Level
High knowledge (7.3-9 scores) 115 32.9
Moderate knowledge (5.4-7.2 scores) 148 42.3
Low knowledge (less than 5.4 scores) 87 24.8
Attitude level
Good attitude (51.5-70 scores) 163 46.6
Moderate attitude (32.8- 51.4scores) 185 52.9
Poor attitude (14-32.7 scores) 2 0.5
Environmental factors level
Good (25.7 - 35 Score) 242 69.1
Moderate (16.4 - 25.6 Score) 104 29.7
Poor (7 - 16.3 Score) 4 1.2
Table 3. Factors associated with betel quid chewing (Multivariate analysis)
% betel
Crude Adj.
Factors. number quid 95%CI p-value
OR. OR.
chewing
Attitude 0.006
Good 163 59.51 1

Poor and moderate 187 72.73 1.81 1.90 (1.20- 3.01)
Drinking 0.014
Non-drinker 207 61.35 1

Drinker 143 74.13 1.80 1.81 (1.12- 2.91)
Exercise 0.005
Do exercise 192 60.42 1

Not do exercise 158 74.05 1.86 1.94 (1.21- 3.09)
361
Factors associated with betel quid chewing

Factors Odd 95%CI P
ratios value
Poor and moderate 1.90 1.20-3.01 0.006
attitude
Drinkers 1.81 1.12-2.91 0.014
Did not do exercise 1.94 1.21-3.09 0.005
1 2 3 4 5
Figure 1. Forest plot diagram
there was significant association between attitude levels and betel quid chewing.
Respondents with poor and moderate levels of attitude were 1.90 times have a chance to chew
betel quid than good level of attitude (AOR=1.90, 95%CI=1.20- 3.01; p-value=0.006). And also,
there was significant association between drinking and betel quid chewing. Drinkers were
1.81 times have a chance to chew betel quid than non-drinkers (AOR=1.81, 95%CI=1.12-2.91;p -
value= 0.014). In addition, there was significant association between betel quid and exercise.
Working aged males who did not do any exercise were 1.94 times have a chance to chew
betel quid than working aged males who did exercises (AOR=1.94, 95%CI=1.21-3.09; p-value=
0.005).
Discussion
66.6% of working aged males in Kayin State chewed betel quid. It was lower than the
previous study from Than-Daung town, Kayin State which was found to be 71%(4) and
another study from Solomon Island 76.8%. 42.5% of chewers chewed betel quid more than 5
quid per day and 68.2% chewed it 7 day per week. A study from Solomon Island reported that
362
chewed higher amount of betel quid per day >5 was significantly higher chance to get
pharyngeal and oral cancer compared with <5 quid (2). And also who chewed betel quid >5
quid per day were less likely to quit betel quid(Ghani, 2011). Very high percentage 87.5% of
chewers adding tobacco in their betel quid which was higher than the report of betel quid
chewing practice in adult population living in a periurban area of Yangon Region 85% and the
report of Dhaka, Bangladesh by Rahman et al, which was 85.2%(9). Moreover, it was higher
than the report three quarters of chewers added tobacco in their betel quid and slightly higher
than the report 85.2% by Rahman et al (2). Very high percent of adding tobacco in the betel
quid was very danger to have non-communicable diseases such as oral cancer and any others
cancer because every tobacco were unsafe for people health. The most common used of
tobacco in Kayin State was Say-mell (Burma Say) 76.5% and followed by parachet (Hnat-Say)
13.7%. It was found that signal, 92,100 and others tobacco were not common used in Kayin
State. 93.6% of chewers spit out the liquid of betel quid, 79% did not keep betel quid in the
mouth for a long time. 71.7% of chewers did not use spittoon/plastic bag when they spitted out
the betel quid liquid. In 2011, government prohibited not to spit out SLT liquid in public area,
however, most of chewers spitted out betel liquid at anywhere they got at this time(7). It
pointed out the still need of reinforcing the existing law and people should be responsible for
their action on spitting betel liquid in public places.42.5% of the respondent chewed betel quid
after meals regularly because they felt that they need something to else in their mouth.
Conducting of awareness raising program such as substitution by snack or chewing gun after
meals could be effective for betel quid chewing after meals regularly.45.1% chewers ever tried
to quit betel quid, however ever failed and still chewing it. 65.7% felt nothing on quitting betel
quid, 11.4% felt mood swings and 12.4% felt others such as sour sensation in the mouth. One of
the study also reported that the sour taste in the mouth was the main reason of re-using and
33.6% of those people replied about it(4). It pointed out the quitting betel quid and feeling were
related in some of the people. The feeling of mood swings and sour sensation were appeared
in people with every day used it for a long time. It might be those people were harder to quit
betel quid than the people who felt nothing on quitting.
363
5.2 Factors associated with betel quid chewing
Poor and moderate levels of attitude were more likely to chew betel quid than high
level of attitude (p-value=0.006). It was nearly the same with the study of betel nut chewing
among adults in west Insein township, Yangon. It reported that betel quid chewing was
significantly associated with having a low score regarding their attitude about the health
effects of betel nut(6). 53.43% of the respondents had low and moderate levels of attitude and
72.73% among those people chewed betel quid. The poorer the attitude, the more likely to
chew betel quid. In this study, most of the respondents agreed that stain from betel quid
chewing could make the teeth look bad. Although the respondents looked to have knowledge
about betel quid chewing, over half 53.43% of the respondents had low and moderate levels of
attitude toward betel quid chewing. Moreover, many of the respondents accepted that betel
quid chewing had addictive effect for them. It pointed the need of health education program
because less health knowledge leading to cause poor attitude and poor attitude leading more
chance to chew betel quid as well.
Drinkers were more likely to chew betel quid than non-drinkers (p-value=0.014).
Similarly, a study at Yangon reported that current alcohol consumer were significantly
associated with betel quid chewing(6). And also, one of the cross-sectional study reported that
who had drinking habit were 2.41 times more likely to chew betel quid than who did not have
drinking habit(1). In current study, 40.9% of the respondents had the habit of drinking alcohol
and 74.13% among those people chewed betel quid. It might be due to the problem of foul
smell. They did not want to know their drinking because alcohol was not socially acceptable
comparing with betel quid in Kayin State. At the same time, most of people in Kayin State
believed that betel quid can cover the bad smell. So that, most of drinkers had one of the habit
was they chewed betel quid after they drunk because they want to cover the smell of alcohol
and they did not want to know their family about their drunk.
Who did not do exercise were more likely to chew betel quid than who did exercise
(p-value=0.005). A study from Taiwan also reported that who did not exercise regularly were
more likely to chew betel quid(3). It might be they did not have much free time to do exercise
364
because they had to struggle for family in their daily life. At the same time, betel quid was
one of the most cheaper, socially accepted in the field of their struggling. So that, they had
more chance to be contacted with betel quid in their daily life. Therefore, who did not do
exercise were more likely to chew betel quid than who did exercise among working aged
males in Kayin State.
Since it was the cross sectional analytical study, it was not allowed the cause and
effect relationships between various factors and betel quid chewing. This study was
conducted among working aged males, therefore it could not covered the whole population in
Kayin State. This study was totally depend on the participant's answer to the structured
questionnaires. Memory recalling and interviewer relationship bias could not be excluded.
Conclusion
Betel quid chewing was associated with poor and moderate attitude, drinkers and who
did not do exercise. Control of smoking and consumption of tobacco product law is already
adopted in 2006(3). As the habit is rooted in the tradition and culture, reinforcing the existing
law, conducting awareness raising program, health education about the danger of betel quid
chewing and promoting to do exercise for older people could be helpful to achieve the
reduction of betel quid chewing and then that lead to decrease non-communicable diseases
that causes by betel quid chewing.
Recommendation
1. As the result showed that knowledge was not association with betel quid chewing in this
study, the better way of awareness raising program which is effective than the existing
program in order to change the betel quid chewing habits should be considered.
2. Reinforcing the control of smoking and consumption of tobacco product law could be
decreased the prevalence of betel quid chewing. For example, taxation on betel quid and its
ingredients could be effective because betel quid is cheaper than smoking and drinking and it
is very easy for people to associate betel quid.
3. Further study covering the whole population in Kayin State should be carried out.
365
Acknowledgements
I would like to express my sincere thanks to Ethical committee of Khon Kaen
University, DAMASAC team and faculty of Public Health, Khon Kaen University, Thailand
for their valuable guidance and wise opinion towards my study. I would like to thank all the
respondents from Kayin state for their active participation.
References
1. CS, L. (2006). Factors associated with quitting areca (betel) quid chewing. doi:
10.1111/j.1600-0528.2006.00305.x
2. Flora, M. S. (2012). Betel quid chewing and its risk factors in Bangladeshi adults. WHO
South-East Asia Journal of Public Health 2012;1(2):169-181, 1-13.
3. Guo, S.-E. (2013). Alcohol, betel-nut and cigarette consumption are negatively
associated with health promoting behaviors in Taiwan: A cross-sectional study. Guo et al.
BMC Public Health 2013, 1-8.
4. Kar, A. ( 2015). Knowledge and practice of betel quid chewing in urban area of Than-
Daung Town, Kayin State. Myanmar Medical Journal,, Vol: 57, No.4, 1-7.
5. Moe. (2016). Yauk gyar mann yin (Be a man!): masculinity and betel quid chewing
among men in Mandalay, Myanmar. Cult Health Sex, 18(2), 129-143. doi:
10.1080/13691058.2015.1055305
6. Myint, S. K. (2016). Prevalence and factors influencing betel nut chewing among adults
in west Insein township, Yangon, Myanmar. Vol 47 No. 5 September 2016, 1-1.
7. NN, K. (2012). Smokeless tobacco use in Myanmar. Indian Journal of Cancer |
October-December 2012 |, Volume 49 | Issue 4.
8. WIN, A. A. (2009). Knowledge, attitude and practices ot tobacco consumption among
shipyard workers, Yangon in 2009.
366
9. Zaw, K. K., Ohnmar, M., Hlaing, M. M., Oo, Y. T., Win, S. S., Htike, M. M., . . . Thein, Z.
M. (2016). Betel Quid and Oral Potentially Malignant Disorders in a Periurban Township in
Myanmar. PLoS One, 11(9), e0162081. doi: 10.1371/journal.pone.0162081
367
Alcohol use disorders and associated factors among working age males
in Southern Shan State, Myanmar.
Nan Lin Kham1, Assoc. Prof. Dr. Chanaphol Sriruecha2
1
M.P.H. candidate, Faculty of Public Health, Khon Kaen University, Thailand.
2
Faculty of Public Health, khon Kaen university, Khon Kaen Thailand.
พฤติ กรรมการดื่ มเครื่ องดื่ มที่ มีแอลกอฮอล์เป็ นปั จจัยเสี่ ยงอันดับสามในการเสี ยชี วิตก่อนวัยอันควร และการ
สู ญเสี ยสมรรถภาพ ประมาณ 76.3ล้านคนทัว่ โลกได้รับการวินิจฉัยว่าเป็ นผูท้ ี่การดื่มเครื่ องดื่มแอลกอฮอล์อย่างผิดปกติ
การศึกษาครั้งนี้ มีวตั ถุประสงค์เพื่ออธิ บายถึงความชุ กและรู ปแบบการดื่ มเครื่ องดื่ มที่ มีแอลกอฮอล์ และศึกษาปั จจัยที่ มี
ความสัมพันธ์กบั การดื่มเครื่ องดื่มที่มีแอลกอฮอล์ในกลุ่มชายวัยแรงงานในรัฐฉานตอนใต้ ประเทศพม่า กลุ่มตัวอย่างที่ใช้
ในการศึกษาได้แก่ชายวัยแรงงานที่มีอายุระหว่าง 18 -59 ปี จานวน 464 คน โดยใช้วิธีการสุ่ มตัวอย่างแบบมีข้ นั ตอน และ
ค านวณค่ า สัด ส่ วนของประชากรในรั ฐ ฉานตอนใต้ ประเทศพม่ า ใช้แ บบสอบถามในการเก็บข้อมู ล สถิ ติ ที่ ใช้ใน
การศึกษาได้แก่ สถิตอย่างง่าย และใช้สถิติ multiple logistics regression ในการหาความสัมพันธ์
จากการศึกษาพบว่า กลุ่มตัวอย่างมีการดื่มเครื่ องดื่มที่มีแอลกอฮอล์ร้อยละ 84.58 ความชุกของพฤติกรรมการดื่ม

เครื่ องดื่ มที่ มีแอลกอฮอล์แบบผิ ด ปกติ คิ ด เป็ นร้ อยละ 40.09 (95% CI = 35.61 to 44.56). ปั จจัย ที่ มีค วามสัมพันธ์ กับ
พฤติกรรมการดื่มเครื่ องดื่มที่มีแอลกอฮอล์แบบผิดปกติในกลุ่มชายวัยแรงงานได้แก่อาชีพ (กรรมกร, ชาวนา, ชาวประมง
, คนขับรถรับจ้าง, ไม่ได้ทางาน, นักเรี ยน และอื่นๆ) (adj. OR = 2.09, 95%CI: 1.28-3.43, p-value:0.003) การมีรายได้ที่
สู ง (adj. OR= 1.82, 95%CI: 1.09 – 3.03, p-value 0.021) และมีคนในครอบครัวที่ดื่มเครื่ องดื่มที่มีแอลกอฮอล์ (adj. OR =
2.49, 95%CI: 1.48 - 4.19, p-value < 0.001). การศึกษานี้แสดงให้เห็นว่าการมีพฤติกรรมการดื่มเครื่ องดื่มที่มีแอลกอฮอล์
แบบผิ ด ปกติ มีค วามสัมพันธ์ กับอาชี พ ที่ ใช้แ รงงาน การมี ร ายได้ที่ สู ง และการมี ค นในครอบครั วที่ ดื่ มเครื่ องดื่ มที่ มี
แอลกอฮอล์
368
Abstract
Introduction: Globally, Alcohol use disorders are the third leading risk factor for premature deaths,
disabilities. Approximately 76.3 million people have a diagnosable alcohol use disorder worldwide
(1 )
Objectives: The purpose of this study was to describe the prevalence and pattern of alcohol use
disorders and to determine the associated factors of alcohol use disorders among working age males
in the Southern Shan State, Myanmar.
Methodology: A total of 464 working age males aged between 18 to 59 years old were selected by
using multistage random sampling with proportional to size of the population in Southern Shan
State. Data was collected using structured questionnaire interviewed. Simple and multiple logistic
regressions were used to determine the association.
Results: Among 464 total participants (84.58%) used to drink alcohol in their life time. The
prevalence of alcohol use disorder was 40.09% (95% CI = 35.61 to 44.56). Factors associated with
alcohol use disorder among working age males were those in the occupation group of (unskilled
worker, farmer, fisherman, driver, none, student, other) (adj. OR = 2.09, 95%CI: 1.28-3.43, p-
value:0.003), had high family income (adj. OR= 1.82, 95%CI: 1.09 – 3.03, p-value 0.021) and had family
members drinking alcohol (adj. OR = 2.49, 95%CI: 1.48 - 4.19, p-value < 0.001).
Conclusion: The finding was showed that Alcohol use disorder was strongly associated with labor
intensive jobs, had income to afford the alcohol and influence from family.
369
INTRODUCTION
In a public health threat, developing by the alcohol use and also including third leading risk
factors of the global disability adjusted life-years (DALYs) in the result of Global Burden of Disease
Study 2010.2 Presently, global status report one of the main concern on alcohol because The World
Health Organization (WHO) described the “reduction of the social and health burden due to harmful
alcohol use”. In2010,4.9 million deaths and5.5% of the global DALYs had put in by use of alcohol 3.
Chronic and acute harm caused as a primary cause in most of countries by too much alcohol
drinking effect. 4.0% of disability cases are related for regulated life years. Then alcohol causes
associated to over 60 types of injury and chronic disease, 3.2% of deaths in the world. Between aged
15-29 years, young people 320,000 die, from alcohol-related cause in the world yearly and included
9% of all deaths in that age group4 .
Alcohol use is related with many socioeconomic, environmental, psychological factors that
act influence anyone to use alcohol. Among the factors associated with AUDs, being male, single,
young are more likely to development of AUDs.5

Alcohol abuse in older adults have been identified and showed there are association factor
with, higher or lower education and income; better health status; male sex; younger age;
smoking; being white; being divorced, isolated, or single; self-reported depressive symptoms;
psychological distress; race and ethnicity; and religious involvement.2

Although there is a substantial progress of research in delineating factors underlying
alcohol and tobacco co-morbidity, several research gaps remain. Investigators and clinicians still
need to fully elucidate and consider the roles of various genetic, neurobiological, conditioning, and
psychosocial factors in developing a more thorough understanding of this dual addiction. There is
no study about data on alcohol use prevalence, no study on associated factors related to alcohol use
disorder in Southern Shan State. Therefore, the purpose of this study was to describe the prevalence
and pattern of alcohol use disorders and to determine the associated factors of alcohol use disorders
among working age males in the Southern Shan State, Myanmar.
370
Study design
A cross-sectional analytical study was conducted to describe the prevalence and
pattern of alcohol use disorders among working age males in the Southern Shan State, Myanmar.
The study involved 464 working aged males between 18 to 59 years old. Inclusion criteria included
who give informed consent to participate in this study, people who live in this area since at least
last one year ago and aged between 18-59 years’ old. The exclusion criteria include those people
who are suffering serious health problems (lying on the bed), people who are in, individuals with
mental disabilities and people who are not communicate. Socio-demographic information, AUDIT,
physical and psychosocial factors, Social and environmental factor, Alcohol marketing.

Alcohol: Beverages that have a substantial amount of ethanol and can drink.
Smoking: Smoking is the breathing of the smoke of burning tobacco encased in cigarettes,
pipes, and cigars. Casual smoking is the act of smoking in sometimes, usually in a social situation or
to relieve stress.
Working-aged men: The populations in men have aged ranges 18 -59 years old.
Southern Shan State: It located in the eastern part of Myanmar, southern Shan State is one
of the best places to visit and relax in summer. In colonial period, senior government offcials head
to in Kalaw or Taunggyi to spend their summer. Shan state is also very diverse and colorful region
since it is home to many national races including Shan, Palaungs, Danu, Lahus, Inthas, Taungyoe,
etc. Almost all ethnic groups have their own traditions and cultures. Then, the places in Southern
Shan state especially Kalaw, Pindaya, Inle Lake, Kakku, Taunggyi, Htam Sam Cave are defnitely
worthy a visit. You can easily get there and also do not need to worry for accommodation. In almost
every region of Southern Shan State, there is a five-day market, where you can buy various fresh
and cheap products from local inhabitants’ own farms.
371
AUDIT: According to WHO, the test for Alcohol Use Disorders Identification (AUDIT) is
a 10-item screening tool. This assess alcohol consumption, drinking behaviors, and alcohol-related
problems.
Hazardous drinking: is a pattern of alcohol consumption that increases the risk of harmful
consequences for the user or others.
Alcohol dependence: is the cluster of behaviors, notices, and physiological incidents that
develop alcohol use regularly.
Alcohol use disorder: is a chronic relapsing brain disease characterized by compulsive
alcohol use, loss of control over alcohol intake, and a negative emotional state not using.
Standard drink: Volume of One standard drinking equal to 10 grams of pure alcohol.
372
Sampling Method
Southern Shan State (3 District)
2 Districts

3 Townships
Table of random numbers
30 villages (1*10 = 30)
(464) sample all working aged Male
Figure 1 The sampling procedure flow chart
Demographic characteristics of the participants were described using frequency

and percentage for categorical data and mean and standard deviation for continuous data.
To investigate factors that affect the home delivery, odds ratios (ORs) and their 95% confidence
intervals (95%CIs) were estimated using multiple logistic regression for cross sectional study.
373
All analyses were performed using Stata version 14.0 All test statistics were two-sided and a p-
value of less than 0.05 was considered statistically significant.
Table 1. Baseline demographic characteristics of working age males (n=464)
Age years
18 - 25 years 88 18.97
25 - 39 years 311 67.03
40 - 59 years 65 14.01
Mean (±SD) 35.96 (±10.97)
Median (min: max) 36 (18:58)
Ethnic
Shan 273 58.84
Burma 93 20.04
Other (Pa-O, Karen, Mon) 98 21.12
Marital Status
Single 146 31.47
Married 68.53
318
374
125 26.94
No formal education
102 21.98
Primary school
89 19.18
Secondary school
82 17.67
High school or equivalence
66 14.22
Bachelor degree or higher
Occupation
107 23.06
Unskilled worker
86 18.53
Farmer, fisherman
79 17.03
Driver
52 11.21
Business
40 8.62
Employee
38 8.19
None
37 7.97
Other
13 2.80
Government officer
Student
12 2.59
375
Monthly Family’s income kyat
89 19.18
< 150000
108 23.28
150000 to 300000
267 57.54
>300000
Mean (±SD) 305086.2 (±153496.3)
300000
Median (min: max) (50000:1000000)
Financial situation
108 23.28
Not Enough
27 5.82
Not Enough with debt
306 65.95
Enough with no saving
23 4.96
Enough with saving
Living status
248 53.45
Wife
93 20.04
Relatives
48 10.34
Alone
Partners 25 5.39
376
18 3.88
Friends
32 6.90
Other
Smoking
125 26.94
Never smoking
206 44.40
Former smoking
133 28.66
Current smoking
Table 2. Prevalence of alcohol use disorders(AUD) among working age males (n=464)
Level of AUD situation’s in last one year Number Percent (%)
Low risk or abstain from drinking alcohol (<7 Scores) 278 59.91
Hazardous drinker (8–15 Scores) 136 29.31
Harmful drinker (16 – 19 Scores) 25 5.39
Alcohol dependence (20 - 40 Scores) 25 5.39
Mean (±SD) 7.51(±6.43)
377
Table 3. Crude odd ratios for the factors on demographic characteristics with alcohol use
disorder on simple logistic regression (n=464)
Characteristics Number Percent Crude OR. 95%CI p-value

(%)
Age years <0.001
18 - 25 years 88 14.77 1
25 - 59 years 376 46.01 4.92 2.64 -
9.17
Ethnic 0.064
Other (Burma, 191 35.08 1
Pa-O, Karen, Mon)
Shan 273 43.59 1.43 0.98 -
2.09
Marital Status 0.606
Single 146 38.36 1
Married 318 40.88 1.11 0.74 -
1.66
Educational <0.001
attainment
High school / 339 35.10 1
equivalence &
Bachelor degree or
higher, primary
school & secondary
school
378

(%)
No formal 125 53.60 2.14 1.41 -

education 3.24
Occupation 0.005
Business, 105 28.57 1

Employee,
Government officer
Unskilled 359 43.45 1.92 1.20 -
worker, Farmer, 3.08
fisherman, Driver,
None, student,
Other
Monthly Family’s 0.105
income kyat
≤ 150000 89 32.58 1
>150000 375 41.87 1.49 0.91 -
2.43
Financial situation 0.101

Enough with 329 37.69 1
no saving &
Enough with saving
Not Enough 135 45.93 1.40 0.92 -
& Not enough with 2.11
debt
379

(%)
Smoking <0.001
Never 125 8.00 1
smoking
Former 206 54.37 13.70 6.79 -
smoking 27.65
Current 133 48.12 10.67 5.14 -
smoking 22.14
Median (min: max) 6(0:31)
Table 4. Crude odd ratios for the factors on Marketing factor with alcohol use disorder on
simple logistic regression (n=464)
Factors. Number Percent Crude 95%CI p-value

(%) OR.
Marketing factor(product) <0.001
Medium & High 411 36.25 1
Low 53 69.81 4.07 2.19 -7.56
Marketing factor (price) 0.678
Low 205 39.02 1
Medium & High 259 40.93 1.08 0.74 -1.57
Marketing factor (place) 0.28
Low 176 36.93 1
Medium & High 288 42.01 1.24 0.84 -1.82
380
Factors. Number Percent Crude 95%CI p-value

(%) OR.
Marketing factor (promotion) 0.075
Low 233 36.05 1
Medium & High 231 44.16 1.40 0.97 -2.04
Table 5. Adjusted odds rations for each category factors on alcohol use disorder among
working age males (n=464)
Factors. number % AUD Crude Adj.OR. 95%CI p-value
OR.
Occupation 0.003
Business, Employee, 105 28.57 1

Government officer
Unskilled worker, Farmer, 359 43.45 1.92 2.09 1.28 - 3.43

fisherman, Driver, None,
student, Other
Monthly Family’s income 0.021
≤ 150000 89 32.58 1
≤150000 375 41.87 1.49 1.82 1.09-3.03
381
Factors. number % AUD Crude Adj.OR. 95%CI p-value
OR.
Immediate Family member <0.001

drinking
No 392 36.48 1
Yes 72 59.72 2.58 2.49 1.48 - 4.19
Discussion
5
Alcohol is the most commonly abused drug largely because it is sold legally and has
attained commodity status. The study was found that overall prevalence of AUDs (40.09%), defined
by an AUDIT score ≤ 8. However, the prevalence of AUDs found in this study was almost similar
to the study conducted in an associated factor among psychiatric out patients in Jimma University
Specialized Hospital, Southwest Ethiopia, using AUDIT score cut off of 8, showed that the
frequency of alcohol use disorder was 38.9% (Y, 2015) and across sectional study done on alcohol
use disorders and associated factors among people living with HIV Southwest Ethiopia the
prevalence of alcohol use disorders was 32.6%. {1}
The prevalence of alcohol abuse ( harmful alcohol use) was found in 5. 39% of the total
participants, which is similar to study done in Jimma University Specialized Hospital, Southwest
Ethiopia. (Y, 2015)
This study was found that the middle age of the respondents was associated with alcohol
use disorder (p=<0.001). Seeing the overall age of the respondents, middle age is high consumed
alcohol than adult ages. Compared to study was done in 2015, on alcohol consumption among adult
males in urban area of Thanlyin Township, Yangon Region, Myanmar, it was found that the older
the age of the male, the lesser of alcohol consumption (p=0.019.6
382
In this study, most of participants were Shan and the rest were Burma, Karen, Mon, Pa-O.
The result was showed that there are no significant association between alcohol use disorder and
ethnic race. This study finding was similar with study done on Determinants and consequences of
alcohol consumption among male adult Myanmar migrant workers in Ratchaburi Province, (p-
value- 0.2).7
The current study shows that, there are association with low educational status, alcohol use
disorder was found in high family income, unemployment and immediate family drinker. The
findings are in line with those studies conducted in prevalence and correlates of alcohol use among
Nigerian Semirural Community Dwellers in Nigeria.8

Research was represented only in three townships in Southern Shan State, Myanmar. The
study could not represent the whole characteristic of drinking behavior in Southern Shan
State, Myanmar.
This research could not possible to determine for alcohol drinking pattern.
The data collection was structure interviewer questioners type and there is no validation to
get their volume of alcohol consumption.
Conclusion
It was concluded that there is strong association between alcohol use disorder was
significantly associated with occupation group (unskilled worker, farmer, fisherman, driver),
monthly family income and immediate family regular alcohol drinking.
Recommendation
There is a need increased awareness on the adverse effects of alcohol at the individual,
community and public. Enhanced interventions program the students who are at risk of developing
alcohol abuse or dependence. On a societal level the price for alcoholic beverages should be
383
increased, moral barriers of drinking alcohol should be reinforced through religious education and
the policy on limiting alcohol accessibility and alcohol purchasing should be enforced. There
should be emphasizing on the liquor selling shops, the official governments should make a careful
supervision on not to sell under age.
Acknowledgements
I would like to express my sincere thanks to my advisor Assoc.Prof. Dr. Chanaphol
Sriruecha, Assoc.Prof. Dr. Wongsa Laohasiriwong and Ethical committee of Khon Kaen University,
DAMASAC team and faculty of Public Health, Khon Kaen University, Thailand for their valuable
guidance and wise opinion towards my study. I would like to thank all the respondents for their
active participation.
REFERENCES
1. K peltzer1, a. N. P.-m., 3. (2013). Problem drinking and associated factors in older adults in South
Africa.pdf.
2. Y, z. (2015). Alcohol use disorders and its associated factors among psychiatric outpatients in
jimma university specialized hospital, Southwest Ethiopia.
3. Who. (2014b). Global status report 2014.pdf.
4. Who. (2014c). Global status report on alcohol and health.
5. Boing, a. F. (2012). Prevalence and associated factors with alcohol use disorders among adults: a
population-based study in Southern Brazil.
6. Win Myint Oo,2015, alcohol consumption among adult males in urban area of Thanlyin
Township, Yangon Region, Myanmar
7. Tay zar soe, 2017, determinants and consequences of alcohol consumption among male adult
Myanmar Migrant workers in Ratchaburi Province, Thailand
8. Victor Olufolahan lasebikan, 2016, prevalence and correlates of alcohol use among a sample of
Nigerian semirural community Dwellers in Nigeria
384
Health literacy, social determinants and overweight and obesity among

Middle aged women in Myanmar: A cross sectional analytical study
Than Kyaw Soe1, Wongsa Laohasiriwong2, Somsak Pitaksanurut3, Teerasak Phajan4
1
M.P.H candidate, Faculty of Public Health, KhonKaen University, Thailand.
2
Working Age People, KhonKaen University, Thailand.
3
Faculty of Public Health, KhonKaen University, Thailand.
4
Sirindhorn College of Public Health, KhonKaen, Thailand.
โรคอ้วนนับว่าเป็ นปั ญหาที่ทา้ ทายด้านสาธารณสุ ขที่ สาคัญของโลกโดยเฉพาะหญิงวัยกลางคน ความรอบรู ้ดา้ น
สุขภาพได้รับการระบุเพื่อเป็ นเครื่ องมือในการประเมินการควบคุมน้ าหนักเกินและโรคอ้วน การวิจยั ครั้งนี้เป็ นการวิจยั แบบ
ภาคตัดขวาง ซึ่ งมีวตั ถุประสงค์เพื่อศึกษาความชุกของภาวะน้ าหนักเกินและโรคอ้วน และระบุความสัมพันธ์ระหว่างความ
รอบรู ้ดา้ นสุ ขภาพ ปั จจัยทางสังคม และภาวะน้ าหนักเกินและโรคอ้วนในกลุ่มหญิงวัยกลางคน ในเขตมาเกว สาธารณรัฐ
แห่ งสหภาพพม่า ในกลุ่มตัวอย่างหญิงวัยกลางคน จานวน 402 คน ซึ่ งคัดเลือกกลุ่มตัวอย่างด้วยการสุ่ มแบบหลายขั้นตอน
เก็บข้อมูลด้วยแบบสอบถามแบบมีโครงสร้าง และการวัดน้ าหนักในกลุ่มตัวอย่าง โดยวิเคราะห์ขอ้ มูลด้วยการวิเคราะห์
ถดถอยพหุลอจิสติก
ผลการศึกษา พบว่า สตรี วยั กลางคนส่ วนใหญ่ มีสถานภาพสมรส ร้อยละ 65.42 มีอายุเฉลี่ย 52.91 + 54.13 ปี พบ
ความชุกของโรคอ้วน ร้อยละ 37.81 (95% CI: 33.18%-42.68%) และ ภาวะน้ าหนักเกิ น ร้อยละ 17.16 (95%CI: 13.77% -
21.19%) ปั จจัยที่มีความสัมพันธ์กบั ภาวะน้ าหนักเกินและโรคอ้วน ด้านความรอบรู ้ในการป้ องกันโรคที่เป็ นปั ญหา (AOR=
4.23, 95%CI:2.06-8.67; p-value<0.001), ความรอบรู ้ดา้ นสุขภาพในการป้ องกันโรคไม่เหมาะสม (AOR=6.97, 95%CI:3.12-
15.56; p-value<0.001), ความรอบรู ้การส่งเสริ มสุขภาพในโรคที่เป็ นปั ญหา (AOR=2.22, 95%CI:1.14-4.35; p-value=0.019)
และ ความรอบรู ้ในการส่ งเสริ มสุ ขภาพที่ ไม่เหมาะสม (AOR=4.48, 95%CI:2.08-9.66; p-value<0.001) นอกจากนี้ ปั จจัย
ด้านอื่นๆที่มีความสัมพันธ์กบั ภาวะน้ าหนักเกินและโรคอ้วน คือ การอาศัยในเขตเมือง (AOR=3.31, 95% CI:1.92 to 5.70; p-
value<0.001), ประวัติ บุ ค คลในครอบครั ว ที่ มี ภ าวะน้ า หนัก เกิ น และโรคอ้ว น (AOR=2.29, 95% CI:1.29 to 4.45; p-
value=0.004), การบริ โภคข้าวมากกว่า 8 ทัพพีต่อวัน (AOR=2.03, 95% CI:1.14 - 3.60; p-value=0.016) และระดับของการ
ออกกาลังกาย (AOR=4.63, 95%CI:1.37 to 15.65; p-value=0.014) โดยสรุ ป ความชุกของภาวะน้ าหนักเกิ นและโรคอ้วน
สะท้อนให้เห็นถึง การรอบรู ้ดา้ นสุขภาพในระดับต่า ประวัติทางพันธุกรรม และพฤติกรรทางสุขภาพ ซึ่งปั จจัยเหล่านี้ ลว้ น
มีอิทธิพลต่อปั ญหาทางโภชนาการในหญิงวัยกลางคนในเขตมาเกว สาธารณรัฐแห่งสหภาพพม่า
385
Abstract
Introduction: Obesity is major public health challenge worldwide especially among middle
aged women. Health literacy have been identified as one of a measured for overweight and
obesity control.
Objective: To determine the prevalence of overweight and obesity and to identify the
association between health literacy, social determinants and overweight and obesity among
middle aged women in Magway Region, Myanmar.
Methodology: This cross-sectional analytical study was conducted in 4 townships of Magway
region, Myanmar. Total of 402 female aged 45-65 years old were selected by using multistage
random sampling. After getting the consent from participants, the weighting and measuring were
done first and the data was collected with the structured questionnaire. The multiple logistic
regressions were used to determine the association presenting adjusted odd ratio with 95%
confident interval.
Result: The results indicated that majority of middle aged women were married (65.42%)c, their
average age was 52.91 + 54.13 years. As high as 37.81% were obesity (95% CI: 33.18%-42.68%) and
17.16% (95%CI: 13.77% - 21.19%) were overweight. Most of them had low level of health literacy
(73.13%). Factors associated with overweight and obesity were having problematic disease
prevention health literacy (AOR=4.23, 95%CI:2.06-8.67; p-value<0.001), inadequate disease
prevention health literacy (AOR=6.97, 95%CI:3.12-15.56; p-value<0.001), problematic health
promotion health literacy (AOR=2.22, 95%CI:1.14-4.35; p-value=0.019) and inadequate health
promotion health literacy (AOR=4.48, 95%CI:2.08-9.66; p-value<0.001). Furthermore, urban
residents (AOR=3.31, 95% CI:1.92 to 5.70; p-value<0.001), had family history of overweight and
obesity (AOR=2.29, 95% CI:1.29 to 4.45; p-value=0.004), consumed rice more than 8 serving
spoons per day (AOR=2.03, 95% CI:1.14 - 3.60; p-value=0.016) and having vigorous activities
(AOR=4.63, 95%CI:1.37 to 15.65; p-value=0.014) also associated with overweight and obesity
among middle aged women.
Conclusions: There were high prevalence of overweight and obesity. Poor health literacy,
heredity and behaviors had influence on these nutritional problems.
386
INTRODUCTION:
Obesity is major public health challenge worldwide especially among middle aged
women. Deaths caused by overweight and obesity in world’s population is more than
underweight deaths.(1)Nearly two-third of diabetes, about one-fourth of ischemic heart diseases
and most of the cancer are relating with overweight and obesity.(2)Obesity is defined as the
accumulation of fat in the body excessively and that situation lead to affect to the health.
In Myanmar, according to the WHO’s NCD surveillance Yangon in 2003-2004,
overweight prevalence in male was 20.6% and female was 29.96%.(3)And according to 2009 non-
communicable disease survey, the overall prevalence of overweight and obesity of Myanmar
population was 25.38% and 6.8%.That survey results identified that 8% and 22% of female
respondents were obese and overweight respectively. Among the middle aged groups of
women, only less than 50% had normal body weight.(3)
Health literacy have been identified as one of a measured for overweight and obesity
control.(4)But a limited number of studies were done to find out the association between health
literacy level and obesity status of the people. Moreover, there is no strong and clear evidence
about the relation between health literacy level and getting weight status among risky
middleaged women. The objective of this study are to determine the prevalence of overweight
and obesity and to identify the association between health literacy, social determinants and
overweight and obesity among middleaged women in Magway Region, Myanmar.
METHODOLOGY:
Study design and participants: This cross-sectional analytical study was conducted in 4
townships of Magway region, Myanmar. Study population was the women who aged 45 to 65
years old at the time of data collection. The eligible sample was fulfilled with the inclusion and
exclusion criteria. Inclusion participants were who gave informed consent to participate in this
study and who live in this area since at least last one year ago. Exclusion participants were who
were suffering serious health problems (lying on the bed), who suffered who are in diarrhea at
the time of data collection (defecating more than 3 times), who were in pregnancy, individuals
387
with mental disabilities, congenital bone deformities. The sample size was estimated based on
the multiple logistic regressions formula (Hsieh, Bloch, & Larsen, 1998).
Multistage random sampling was used to select samples in this study. Firstly 4
townships were selected by simple random sampling from overall 25 townships of Magway
region. And then 2 wards and 3 villages were selected from these townships by using simple
random sampling also. After that, sample households were selected using systematic random
sampling procedure.
Research Indicators: Body height in centimeters (cm) and weight in kilograms (kg) were
measured to the nearest 0.1 cm and o.1 kg by using metering object and digital weighing
instrument these were recognized and used in health department. Body mass index was used
and defined values as underweight and normal for lower than 23 kg/cm2, overweight for over
and equal 23.0 kg/cm2 to under 25.0 kg/cm2 and obesity for over and equal 25.0 kg/cm2.
This Asia health literacy questionnaire tool for obesity was used to measure health
literacy level of individuals. The health literacy score intervals were categorized into 4 levels
for each indices: 0 to 25 points as ‘inadequate’, more than 25 to 33 points as “problematic’,
more than 33 to 42 points as ‘sufficient’ and more than 42 to 50 points as ‘excellent’(5).
Socio-demographic characteristics were included age, marital status, education,

occupation, place of resident, income of family, individual income, reproductive health status
and family history of obesity. Personal behavior of each participants were measured by TV and
internet watching hours, physical activities, current or former smoker, passive smoker, ever
used contraceptives and food intake variables.
Depression factor was measured by Center of Epidemiological Studies Depression
Scale CESD and stress condition of individuals were measured by Perceived Stress Scale
(PSS).Each participants were categorized into 2 states who was living on above the mean score
of depression and stress level or not based on the CESD and PSSalgorithm logic.
Statistical Analysis: The raw data of 402 respondents were recorded into MS Excel. The
data were inverted into the Stata program version 13.0. The socio-demographic and baseline
characteristics of the participants were described with frequency and percentage for categorical
data and mean, median, minimum, maximum and standard deviation for continuous data. The
388
multiple logistic regression, adjusted OR with 95% of Confident Interval were used to determine
the association between overweight and obesity status of middle and old aged women and
health literacy factors by controlling other related factors.All test statistics were two-sided and
a p-value of less than 0.05 was considered as statistical significant.
RESULTS:
Prevalence of overweight and obesity among middleaged women: In 402 total participants,
181 (45.02%, 95%CI: 40.2%-49.9%).) were underweight and normal healthy range of body
weight69 (17.16%, 95%CI: 13.77% - 21.19%)) were overweight and 152 (37.81%, 95% CI: 33.18%-
42.68%) were obesity. Lowest body mass index was 12.73 kg/cm2 and highest index was 44.47
kg/cm2. Mean body mass index of middleaged women was 23.85 kg/cm2. Over half of
middleaged women who lived in Magway region Myanmar were in overweight and obesity.
Table 1. Overweight and obesity among middle and old aged women

Number Percentage 95%CI
Overweight and obesity
status
Underweight and healthy 40.20-49.90
range 181 45.02
Overweight 130 32.34 13.77 - 21.19
Obesity 91 22.64 33.18-42.68
Mean (S.D.) 23.85 (+ 4.72)
Median (Min: Max) 23.44 (12.73:44.47)
95% CI (23.38 24.31)
Baseline characteristics of overweight and obesity among middleaged women: Majority of
them were married (65.42%) and the mean age was 53.52 years. 41.34% of total respondents had
not attained normal education system and over half of them (60.95%) were farmers. In personal
behavior, 11.19% of respondent women used internet over 15 minutes per day and 38.81% of
respondent used contraceptive pill or injection in the past.
Table 2. Social determinants characteristics of the respondents
389

Number Percentage
Age (years)
45-49 130 32.34
50-54 91 22.64
55-59 87 21.64
60-65 94 23.38
Mean (SD) 53.52 (+ 6.26)
Median (Min: Max) 53 (45:65)
Marital status
Single 57 14.18
Married 263 65.42
Separate/Divorce/Widow 82 20.40
University Graduate 51 12.69
High school 27 6.72
Can read and write 103 35.62
Illiterate 23 5.72
Occupation
Private employee 12 2.99
Farmer 245 60.95
Manual labor 31 7.71
Place of resident
Urban 203 50.50
Rural 199 49.50
Average family income per month (USD)
150 169 42.04
150 – 300 166 41.29
300 – 600 52 12.94
> 600 15 3.73
Mean (S.D.) 191.00 (+ 163.98)
Median (Min: Max) 150 (15:1260)
Average personal income per month (USD)
Have personal income 241 59.95
Don’t have personal income 161 40.05
Mean (S.D.) 41.06 (+ 71.48)
Median (Min: Max) 0 (0:518.52)
390

Number Percentage
Reproductive health status
Not in menopause period 89 22.14
In menopause period 313 77.86
Family history of overweight/obesity
Yes 118 29.35
No 284 70.65
TV watching hours per day
< 15 minutes 105 26.12
15 – 90 minutes 153 38.06
> 90 minutes 144 35.82
Mean (S.D.) 76.33 (+ 85.70)
Internet watching hours per day
< 15 minutes 357 88.81
> 15 minutes 45 11.19
Mean (S.D.) 8.28 (+32.53)
Current or former smoking
No 351 87.31
Yes 51 12.69
Secondary smoker
No 245 60.95
Yes 157 39.05
Contraceptive pill or injection using
history
Yes 156 38.81
No 246 61.19
Vegetable eating amount per day
< 4 rice serving spoons 80 19.90
4 – 7 rice serving spoons 310 77.11
> 7 rice serving spoons 12 2.99
Mean (S.D.) 4.69 (+ 1.84)
Median (Min: Max) 6 (0;8)
Meat eating amount per day
Mean (S.D.) 3.80 (+ 2.08)
391

Number Percentage
Rice eating amount per day
Mean (S.D.) 8.28 (+ 1.43)
Having vigorous activities per week
No 377 93.78
Yes 25 6.22
MET score for walking activities per week
<1 239 59.45
1 – 1000 130 32.34
> 1000 33 8.21
Mean (S.D.) 338.60 (+ 616.17)
Depression score (CESD scale)
< 13 188 46.77
> 13 214 53.23
Mean (S.D.) 13.69 (+ 8.52)
Stress score
< 18 194 48.26
> 18 208 51.74
Mean (S.D.) 17.05 (+ 5.07)
Health care health care index
Inadequate health literacy 135 33.58
Problematic health literacy 136 33.83
Sufficient health literacy 105 26.12
Excellent health literacy 26 6.47
Mean (S.D.) 28.97 (+ 7.54)
Median (Min: Max) 28.5 (12:50)
Disease prevention health literacy index
Mean (S.D.) 27.40 (+ 8.42)
392

Number Percentage
Health promotion health literacy index
Mean (S.D.) 27.95 (+ 7.66)
General health literacy index
Mean (S.D.) 28.11 (+ 6.97)
Table 3. Factors associated with overweight and obesity (Multivariate analysis)
Variable Total Overweight Crude Adjuste 95% CI P-value

(No.) and Obesity OR d
(%) OR
Place of resident <0.00
1
Rural 199 40.70 1 1
Urban 203 68.97 3.24 3.31 1.92 - 5.70
Family history of overweight/obesity <0.00
1
No 284 48.24 1 1
Yes 118 71.19 2.65 2.29 1.29 - 4.45
Rice eating amount per day 0.016
< 8 rice serving spoons 111 41.44 1 1
> 8 rice serving spoons 291 60.14 2.13 2.03 1.14 - 3.60
MET score for vigorous activities per week 0.014
>1 25 57.56 1 1
<1 377 16.00 7.21 4.63 1.37 - 15.65
Disease prevention health literacy index <0.00
1
Sufficient & excellent health 108 22.22 1 1
literacy
Problematic health literacy 134 58.21 4.88 4.23 2.06 - 8.67
Inadequate health literacy 160 74.38 10.16 6.97 3.12 - 15.56
<0.00
393
Health promotion health literacy index 1

Sufficient &excellent health 115 21.74 1 1
literacy
Problematic health literacy 149 57.05 4.78 2.22 1.14 - 4.35
Inadequate health literacy 138 80.43 14.8 4.48 2.08 to
9.66
Factors AOR 95%CI P-value

4.48 2.08 to 9.66 <0.001
Problematic health promotion health literacy
Inadequate health promotion health literacy 2.22 1.14 to 4.35 <0.001
Inadequate disease prevention health literacy 6.97 3.12 to 15.56 <0.001
Problematic disease prevention health literacy

4.23 2.06 to 8.67 <0.001
MET score for vigorous activities per week 4.63 1.37 to 15.65 <0.014
Rice eating amount per day 2.03 1.14 to 3.60 <0.016

Family history of overweight and obesity
2.29 1.29 to 4.45 <0.001
Place of residents 3.31 1.92 to 5.70 <0.001
1
10 5 15 20
Figure 1 Forest plot diagram for factors associated with overweight and obesity multivariate
analysis
The respondents who live in urban areas were more likely to have overweight and
obesity compared with women who settled in rural areas about 3 times (AOR=3.31, 95% CI: 1.92
to 5. 70; p- value<0. 001) . Those women who had family history of overweight and obesity
(AOR=2.29, 95% CI: 1.29 to 4.45; p-value=0.004) were also significantly more likely to suffer
overweight and obesity. And over 8 serving spoons rice eating amount per day (AOR=2.03, 95%
CI: 1.14 - 3.60; p-value=0.016) was significantly more likely to get overweight and obesity. Those
women who doesn’t have vigorous activities per week were more likely about over 4 times to
have overweight and obesity than women with weekly basis vigorous activities (AOR=4.63,
95%CI:1.37 to 15.65; p-value=0.014).
The respondents with problematic prevention health literacy level (AOR=4.23, 95%CI:
2.06-8.67; p-value<0.001) and inadequate prevention health literacy (AOR=6.97, 95%CI: 3.12-
15. 56; p- value<0. 001) were more likely to be overweight and obesity than sufficient and
394
excellent health literacy level respondents. Concerning with health promotion health literacy,
middle and old aged women with problematic health literacy (AOR=2.22, 95%CI: 1.14-4.35; p-
value= 0. 019) and inadequate health literacy respondents ( AOR= 4. 48, 95% CI: 2. 08- 9. 66; p-
value<0.001) were more likely to get overweight and obesity than compared group.
DISCUSSION: More than half of the middleaged women respondents were in overweight and
obesity. According to ASEAN standard measurement, this study found that 32.34% of them
were in overweight and 22. 64% were obesity in general population. So, the overweight
percentage of current study was increased than the overweight prevalence of general adult
population of ASEAN Countries.(6)
After controlling the confounding factors with backward elimination multivariate

analysis, six variables were strongly associated with overweight and obesity among
middleaged women. They were place of resident, family history, having vigorous activities per
week, disease prevention health literacy index and health promotion health literacy index.
Urban middle aged women were more likely to be overweight and obesity about 3 times than
rural dwellers. Overweight and obesity was associated with residing place differences in this
study which is similar to the study conducted in Eastern Uganda (Barbara Eva Kirunda et al
2015)(7) and Panama (AnselmoMc Donald et al 2015)(8).

Women with family history for overweight and obesity were also 2 times more chance
to get overweight and obesity than the women with not a family history. Some studies identified
that people with family history of overweight and obesity had 2.7 times more likely to get
overweight and obesity (AnselmoMc Donald et al 2015)(8).

Over rice eating than 8 rice serving spoons had 2 times to get weight than under 8
spoons eating women. Previous study (Simin Liu et al 2003) ( 9) also found that increased intake
of whole or refined grains products consuming over time was positively associated with
overweight and obesity status of middle aged women. This study found that vigorous physical
activities can reduce the risk of overweight and obesity about 7 times among middleaged
women. Some studies identified that there were associations between physical activities and
weight gaining with specifying on other aged groups such as school children and adults aged
group (Shu Fang Shih et al 2016, Marie Claire Chamieh et al 2015, AnselmoMc Donald et al
395
2015)(4, 8, 10). Moreover, Dixie L et al 2004 examined that the relationship between accumulated
walking and body composition of middle aged women.

One Taiwan population based survey study demonstrated strong link between health
literacy and obesity among sixth grade school children( 4) . This study also found that the higher
score in disease prevention and health promotion health literacy index, the less to get
overweight and obesity among middleaged women. And another China study illustrated that
adolescent students with aged 12-16 years old with low health literacy level had 2 times more
likely to be overweight and obesity than the students with high health literacy level. ( 11) This
finding fulfilled and supported previous literature of showing the association between health
literacy level and obesity status.
Strength of Study: Despite this study, it is the first report on finding the association between
health literacy index and overweight and obesity among middleaged women in the Magway
region of Myanmar. Therefore, this research study can be a reference for similar studies which
will be performed in different part of Myanmar and other countries.
Limitation of Study: Since the current study was a cross-sectional analytical study, further
study with operational research or longitudinal cohort study design was recommended to
provide the better understanding of the relationship between health literacy index and
overweight and obesity among middleaged women.
CONCLUSION: There were high prevalence of overweight and obesity. Poor health literacy,
heredity and behaviors had influence on these nutritional problems. Conducting to increase
disease prevention and health promotion health literacy level of middle and old aged women,
balancing on the daily diet intake, promoting to do the strenuous physical exercise, provision
of supportive measure for obesity prevention could be helpful to achieve the reduction of
overweight and obesity and then that lead to decrease non-communicable diseases that caused
by obesity.
RECOMMENDATION: This study encourages the government departments and related
organizations to conduct for the improvement of obesity health literacy among middle and old
aged women in Myanmar. It is also important to promote healthy lifestyle and eating pattern.
396
Acknowledgement: I would like to express my sincere thanks to village and ward administers,
community leaders and health staffs of Magway region, Myanmar to allow me data collection
and for their valuable information, supports and participation in this study. My profound
appreciation and special thanks to all the participants who kindly consented and gave their
valuable information for this study.
Funds: This work is financially supported by Faculty of Public Health, Research and Training
Center for Enhancing Quality of Life of Working Age People, KhonKaen University, Thailand.
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397
The influences of alcohol marketing on alcohol consumption of working

aged males in Khon Kaen province, Thailand.
Chuthamat Choidamrongkun1, Asst.Prof.Dr. Somsak Pitaksanurat2,
Assoc. Prof. Dr.Wongsa Laohasiriwong3, Teerasak Phajan4
1
M.P.H. candidate, Faculty of Public Health, KhonKaen University, Thailand. 2,3Faculty of Public
Health, Khon Kaen University, 3Research and Training Center for Enhancing Quality of Life for
Working Age People, Khon Kaen University, Khon Kaen, Thailand. 4Sirindhorn College of Public
Health, KhonKaen, Thailand.
ในกลุ่มประเทศอาเซี ยน ประเทศไทยถูกจัดเป็ นอันดับแรกในการดื่มแอลกอฮอล์ ในการดื่มแอลกอฮอล์ ซึ่ งมีการ
แข่งขันสูงในตลาดการขายเครื่ องดื่มแอลกอฮอล์ ผูผ้ ลิตใช้กลยุทธ์ทางการตลาดมากมายเพื่อกระตุน้ การขายในกลุ่มเป้ าหมาย
วัตถุประสงค์ เพื่ออธิ บายรู ปแบบการบริ โภคเครื่ องดื่มแอลกอฮอล์ และความสัมพันธ์ระหว่างปั จจัยการตลาดของเครื่ องดื่ม
แอลกอฮอล์ และการบริ โภคแอลกอฮอล์ในกลุ่มชายวัยทางานในจังหวัดขอนแก่ นระเบี ยบวิธีวิจัย เป็ นการศึ กษาแบบ
ภาคตัดขวาง ในจังหวัดขอนแก่น ประเทศไทย กลุ่มตัวอย่าง คัดเลือกกลุ่มตัวอย่างเป็ นชายวัยทางาน 394 ราย คัดเลือกโดย
การสุ่มแบบหลายขั้นตอนตามสัดส่วนประชากรในจังหวัดขอนแก่น เก็บข้อมูลโดยใช้แบบสอบถาม และใช้สมการวิเคราะห์
ถดถอยแบบพหุ อธิบายความสัมพันธ์
ผลการศึกษา ชายวัยทางาน 394 ราย มีอายุเฉลี่ย ปี ส่วนใหญ่แต่งงาน 66.24% และ 46.45% เป็ นคนทางาน ส่วน
ใหญ่ชายวัยทางานจะบริ โภคเครื่ องดื่มแอลกอฮอล์ มากกว่าครึ่ ง ดื่มเบียร์ ค่ามัธยฐานของบริ มาณการดื่มในแต่ละครั้ง
คือ 2,250 มล.ปั จจัยทางการตลาดสัมพันธ์กบั การบริ โภคเครื่ องดื่ มแอลกอฮอล์ คือ สิ นค้ามีคุณภาพดี ราคาเหมาะสมกับ
ปริ มาณและคุณภาพ นอกจากนั้นปั จจัยอื่นๆ ที่มีความสัมพันธ์กบั การบริ โภคเครื่ องดื่มแอลกอฮอล์ คือ การดื่มในกลุ่มเพื่อน
การมีโรคประจาตัว และการสูบบุหรี่
สรุ ป กลยุท ธ์ ก ารตลาดของเครื่ อ งดื่ ม แอลกอฮอล์ใ นตัวผลิ ต ภัณฑ์แ ละราคา รวมถึ ง ปั จ จัย ด้านสุ ข ภาพอื่ น ๆ
พฤติกรรมและสิ่ งแวดล้อมมีความสัมพันธ์กบั การบริ โภคเครื่ องดื่ มมแอลกอฮอล์ ดังนั้นจึงจาเป็ นต้องใช้มาตรการต่อต้าน
การบริ โภคเครื่ องดื่มแอลกอฮอล์โดยเฉพาะในชายวัยทางาน
398
Abstract
Thailand was ranked first for alcohol consumption among ASEAN countries. There
have been high competitions in alcohol market. The manufactures have used various marketing
strategies for different target groups to stimulate alcohol sales. This study aimed to describe
alcohol consumption patterns and determines the association between alcohol marketing
factors and alcohol consumption among working aged males in Khon Kaen province.
Methodology: This cross-sectional study was conducted in Khon Kaen province, Thailand. A
sample of 394 working aged male samples was selected by using multistage random sampling
with proportional to size of the population in Khon Kaen province. Data was collected using
structured questionnaire. Multiple logistic regressions were used to identify the associations.
Result: The majority of 394 working aged were males with the average age of 38.70 ± 10.76
years. Most of them were married (66.24%) and 46.45% were workers. Most of these working
aged males reported consuming alcohol (85.79%; 95%CI: 82.32% - 89.25%). More than half drank
beer (52.07%). The median amount of alcohol consumption each time was 2,250 (750 – 4,500
ml. ) . The marketing factor associated with alcohol consumption were; good product
(adj.OR=3.23, 95% CI: 1.51-6.89; p-value=0.001), appropriate of price with quantity and quality
( adj. OR= 2. 66, 95% CI: 1. 29- 5. 49; p- value= 0. 004) . Moreover, other factors that were also
associated with alcohol consumption were: have friends consume alcohol (adj.OR=5.69, 95% CI:
2.83 – 11.45; p-value<0.001), having underlying disease (adj.OR=3.90, 95% CI: 1.32 – 11.53; p-
value=0.007) and smoking (adj.OR=3.70, 95% CI: 1.86 – 7.34; p-value<0.001).
Conclusion:The alcohol marketing strategies on product and price together with other health,
behavioral and environmental factors were associated with alcohol consumption. Therefore
alcohol marketing counteract measures are in needed especially for the working age males.
399
Introduction
Alcohol is a psychoactive substance that could causes disease, social and economic
burdens (1). Alcohol consumption also causes social impact of the crime on offenses against life
and body such as killings, rape, assault, burglary, robbery and drug trafficking( 2) . Alcohol
consumption kills 3.3 million people every year or 5.9 % of all global deaths (1). In Thailand, was
ranked 1st for alcohol consumption among ASEAN countries. It found that 8.6% of all deaths
( 3)
in males are result of alcohol consumption . The results of the alcohol consumption survey
during the past 3 years indicated that the population that consumed alcohol increased about
7million with the steadily increasing trend (4).
Several researches have been conducted and identified the alcoholic beverage
( 5)
manufacturers in Thailand used the marketing tools to attract the interest of targets group .
The alcohol marketing is the high competitions since the manufactures want to stimulate sales
of alcohol.
Therefore, identifying alcohol consumption pattern, identifying alcohol marketing

strategies used to promote alcohol and influences of alcohol marketing on alcohol consumption
of working age males in Khon Kaen province, Thailand. The evidences from this study will be
used to develop policy recommendations for various levels from individuals, family,
community and national levels to improve systematically control alcohol consumption among
the working males population.
Objective
To describe alcohol consumption patterns and determines the association between
alcohol marketing factors and alcohol consumption among working aged males in Khon Kaen
province.
400
Methodology
Ethical consideration
The ethical consideration for the present study was approved by The Office of the Khon
Kaen University Ethics Committee in Human Research ( Reference No. HE 603014) . The
informed consent was acquired from each study subject to protect their autonomy.
Study design
This cross sectional study was conducted by administering structured questionnaire
interview among working aged males group( age 18 – 59 years) in Khon Kaen province,
Thailand. The study was conducted between June to July 2017. Multistage sampling technique
was used to select the samples. Firstly, 3 districts were randomly selected from the total of 26
districts of Khon Kaen province. Then a sub-district was randomly selected from each selected
district. Then, the total of 6 sub-districts was selected. Finally, the total of 394 samples were
randomly selected proportional to size of the population in each sub district and the respondents
were selected by using simple random sampling technique from the selected sub-districts.
The sample size was estimated based on the multivariate regression analysis suggested
by Hsieh’s formula (Hsieh, 1998). The sample size of 394 was considering possible absolute
precision and feasibility of the study. Such sample size could estimate the proportion of alcohol
consumption in working aged men of the target population at the significant level of 95%. The
questionnaire included all kinds of questions relating to socio- demographics, alcohol
consumption, perception on alcohol marketing, the social context, the basic knowledge on
alcohol and attitude on alcohol. The questionnaire was developed for content validity by 3
experts and the pretest of the questionnaires were conducted to the 20 families in other
commune and was calculated for reliability of this study by using Cronbah alpha coefficient.
Data analysis was done by using the STATA program version 13.0 (STATA Corp,
College Station, TX). The data was checked the validation before analysis. The demographic
and baseline characteristics of the participants and alcohol consumption pattern were described
using frequency and percentage for categorical data and mean and standard deviation for
401
continuous data. To determine the association between alcohol marketing factor and alcohol
consumption, odds ratios ( ORs) and their 95% CI was estimated using multiple logistic
regression from those variables showing the bivariate relationship with the outcome variable
(p<0.25). All test statistics were two-sided and a p-value of less than 0.05 was considered as
statistical significant.
Result
A total of 394 respondents were randomly enrolled from 6 sub-districts of Khon Kaen
provinces. The following [Table/Fig-1] described that majority of participants were in age equal
or more than 35 years old with the mean age was 38.70 ± 10.76 SD years with a median age of
38 years, minimum 18 and maximum of 59 years. Nearly two third of the respondents were
married (66.24%), 34.77% finished Primary education and 46.45% were in worker sectors. In
addition, the median monthly income was 15,000 (5000:150,000 baht). Mostly participants were
none underlying disease 81.98% and most of participants were never take medicine 75.38%.
About smoking, the most of participants were former smoking ( 36. 29% ) . About alcohol
consumption, the participants had family members consumed alcohol 55.33% and had a friend
consumed alcohol 74.87%.
Table 1. Socio-economic and demographic characteristics
Characteristics Number (%)
Age (years)
Less than 35 156(39.59)
More than 35 238(60.41)
Mean (SD) 38.70 (10.76)
Median(Min:Max) 38 (18 : 59)
Marital status
Married 261 (66.24)
Single 109 (27.66)
Widowed/divorced/separate 24 (6.09)
402
Characteristics Number (%)
Education attainment
Primary education 137(34.77)
Secondary education 113(28.68)
High school/Vocational certificate 87(22.08)
Bachelor degree or higher 52(13.20)

Uneducated 5(1.27)
Occupational
Worker 183(46.45)
Agriculture 97(24.62)
Vendor 48(12.18)
Government officer/State enterprise employees 45(11.42)
Others 21(5.33)
Income (per month in Baht)
< 10,000 105(26.65)
10,000 - 20,000 171(43.40)

> 20,001 118(29.95)
Mean (SD) 18,255.46(14,244.12)
Median (Min : Max) 15,000 (5,000:150,000)
Underlying Disease
None 323 (81.98)
Have 71 (18.02)
Smoking
Former smoking 143 (36.29)
Current smoking 129 (32.74)
Never 122 (30.96)
403
Family members consumed alcohol

Yes 218 (55.33)
No 176 (44.67)
Have a friend consumed alcohol

Yes 295 (74.87)
No 99 (25.13)
Alcohol consumption pattern
This study found that most of participant reported consuming alcohol (85.79%; 95%CI:
82.32% - 89.25%). More than half drank beer (52.07%)[Table/Fig-2]. The median amount of alcohol
consumption each time was 2,250 (750 – 4,500 ml.). The most of participants consumed alcohol
with friends 64.26%. The majority main reason to consumed alcohol was socializing with friends
50.89%.
60.00%
50.00%
Percentage
40.00%
30.00%
20.00%
10.00%
0.00%
Figure 1 Type of alcohol consumption
404
Alcohol marketing
Most of the participants responded to agree in information’s of marketing strategy such
as (78.17%) thought that “Buy products from packaged quantities”, (79.19%) “Buy products from
quantity degree of alcohol”, (73.86%) “They liked in taste”, (72.84%) “They liked in smell”, (73.35%)
“They liked in local product”, (71.06%) “They look at the price that is important”, (78.93%) “The
price of the products is appropriate for the quality”, (62.94%) “They choose alcohol beverage at
low prices”, (77.41%) “They never been rejected by a sales person”, (75.89%) “The products that
can be purchased easily”, (68.53%) “They don’t worries about going to alcohol stores”, (75.12%)
“They liked in activities promotions such as buy 1 get 1 free” and (61.67%) thought “They liked
in activities promotions such as free gift”.
Factor influencing alcohol consumption between each category of factors

The final model after adjusting for covariates in multiple logistic regressions indicated
that the alcohol marketing factors were; product factor and price factor strongly increasing the
alcohol consumption then that of the low to moderate level of marketing factor. Moreover, we
found that the people had underlying Disease, former/ current smoking and Have a friend
consumed alcohol was strongly associated with the alcohol consumption.
Table 2 Factor associated with alcohol consumption (Multivariate analysis)
Factors N Crude Adj.OR 95%CI p-value

(%consumer) OR
marketing factor 0.001

Product
Low to Moderate 199(78.39) 1 1
High 195(93.33) 3.86 3.23 1.51-6.89
Price 0.004
Low to Moderate 159(74.21) 1 1
High 235(93.62) 5.10 2.66 1.29-5.49
405
Factors N Crude OR Adj.OR 95%CI p-value

(%consumer)
Underlying Disease 0.007
None 323(84.21) 1 1
Have 71(92.96) 2.48 3.90 1.32-11.53
Smoking <0.001
Never 122(68.85) 1 1
Former/Current 272(93.38) 6.38 3.70 1.86-7.34
Have a friend <0.001

consumed alcohol
No 99(68.69) 1 1
Yes 295(91.53) 4.92 5.69 2.83-11.45
[Table/fig-3]: Factor influencing alcohol consumption between each category of factors
Discussion
The study aimed to described alcohol consumption pattern and determine the
association between alcohol marketing factors. This study was conducted in 6 districts of that
region. We found that the mean age was 38.70 years. Most, 60.41% of the respondents were in
age more than 35 years old. This is quite similar with the study in Situation of alcohol
( 6)
consumption in Northeast 2015 . Majority of respondents were married or ever married
72.34%. This result is also similar with the study of the Prevalence and Associated Factors of
Alcohol Consumption: A Cross-Sectional Study in Khon Kaen, Thailand (7). About occupation,
most of respondents were Agriculture, Worker and Vendor 83.25%. This result is also similar
with the study of alcohol consumption behavior of Thai in urban area (8). Regarding the level of
education, the highest proportion was 64. 72% finished secondary education or lower and
uneducated. The Center for Alcohol Studies Reported that the highest of education that
consumed alcohol were primary education or lower ( 6) . Regarding the median monthly income
was 15,000 Baht, lowest income was 5000 Baht and the highest could earned up to 150,000
406
Baht were significantly associated and observed to increase the alcohol consumption. This
result was similar with study in Bangkok(9). Which supported that when the people had income
per month upper that makes increased to consume alcohol. In addition, found that only one
fourth of participants had underlying disease associated with alcohol consumption. This is quite
similar with previous study Chonburi province (10) which the study supported about the alcohol
consumption has negative effects to health, that the disease resulting from alcohol consumption.
Furthermore, former smoking and current smoking associate with alcohol consumption. This is
similar with recent findings reported in Nakhon Rachasima province(11) with regards to smoking
were significantly associate with alcohol consumed. Including, the participants have a friend
consumed alcohol that associate with alcohol consumption. This result was similar with study
in Banbu community, Bangkok ( 8) which supported that the significant factor effecting first
consumed alcohol was friends.
As per this study, Found that the patterns of alcohol consumption behaviors had the
highest proportion consumed alcohol at the first time 85.79%. Their mean age of first time to
consume was 17.83 ± 4.40 SD years with a median age of 17 years, minimum 12 and maximum
of 38 years. The findings are similar with the previous studies that were conducted in Bangkok
( 9)
The main contributors to this intake were beer (52.07%). This is similar with recent findings
reported in Thailand ( 12) in this study reported the most popular type of alcohol was beer.
According to studies in Nong Phai Sub-District, Udon Thani province (13). Moreover, the result
reported more than sixty percent consumed alcohol with friends and wanted to make a
socializing with friends 50. 89% , this is similar with recent findings reported in Chonburi
( 10)
province . However, this reason leads to alcohol consumption in the future because of the
workers believed that alcohol consumption make socializing with friends.
Furthermore, found the alcohol marketing factor such as the good product, appropriate
price strongly increasing the alcohol consumption. Because of the participants believed in
marketing strategy. Have many studies suggested that alcohol marketing was significantly
associated with alcohol consumption (9,14,15,16,17)
407
Conclusion
The alcohol marketing strategies on product price together with other health, behavioral
and environmental factors were associated with alcohol consumption. Therefore alcohol
marketing counteract measures are in needed especially for the working age males.
Acknowledgement
The authors are grateful to all of the contributors to this research, especially the National
Statistical Office for the data and the Research and Training Center for Enhancing Quality of
Life for Working Age People and the Faculty of Public Health, Khon Kaen University for the
financial and technical support.
Declaration of conflicting interests

Declared none
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410
Sociocultural Determinants and Alcohol Use Disorder

among Working Population in Cambodia.
Kong Malika1, Wongsa Laohasiriwong2, Paricah Nippanon3, Teerasak Phajan4
1
M.P.H.student, Faculty of Public Health, Khon Kaen University, Thailand.
2
Faculty of Public Health, Research and Training Center for Enhancing Quality of Life of Working Age
People. Khon Kaen University, Thailand.
3
4
Sirindhorn College of Public Health, Khon Kaen University, Thailand
บทนำ: การบริ โภคเครื่ องดื่ มแอลกอฮอล์ในประเทศกัมพูชามี แนวโน้มเพิ่มมากขึ้น อย่างไรก็ตาม มีการศึ กษาและมี ก าร

รายงานถึงผลกระทบต่อผูบ้ ริ โภค
วัตถุประสงค์ : เพื่อศึ กษาความสัมพันธ์ระหว่างสังคมวัฒนธรรมและความผิดปกติของการใช้เครื่ องดื่ มแอลกอฮอล์ในหมู่
ประชากรวัยทางานในกรุ งพนมเปญ ประเทศกัมพูชา มีผเู ้ ข้าร่ วม 323 คน ในปี 2017
ระเบียบวิธีวิจัย: การศึกษาแบบภาคตัดขวางได้ดาเนิ นการแล้วในเมืองพนมเปญ ประเทศกัมพูชา ในปี 2017 มีการสุ่ มแบบ
หลายขั้น ตอน ในการเลื อ กตัว อย่า ง 323 คนในวัย ทางานที่ จะตอบแบบสอบถาม โดยความผิ ด ปกติ ของผูใ้ ช้เครื่ องดื่ ม
แอลกอฮอล์มีการระบุการทดสอบ (ตรวจสอบ) ขององค์การอนามัยโลก ถูกนามาใช้เพื่อคัดแยกผูด้ ื่มเครื่ องดื่มแอลกอฮอล์
ของกลุ่มตัวอย่าง สถิติที่ใช้ได้แก่ Multiple logistic regression
ผลกำรศึกษำพบว่ ำ: ส่ วนใหญ่ของผูเ้ ข้าร่ วมเป็ นเพศชาย 75.85% อายุเฉลี่ย 31.8 ปี (SD ± 10.2) ความชุกของความผิดปกติ
ของการใช้เครื่ องดื่มแอลกอฮอล์เป็ น 53.56% ซึ่งรวมถึงการดื่มแบบก่อให้เกิดอันตราย (8-15 คะแนน) 34.67% มีอนั ตรายจาก
การดื่ม (16-19scores) 11.76% และปั ญหาการติดแอลกอฮอล์ (+ 20scores) 7.12% ปั จจัยที่เกี่ยวข้องกับความผิดปกติของการ
ใช้เครื่ องดื่มแอลกอฮอล์เป็ นเพศชาย (adjusted OR: 5.46, 95% CI: 2.7-11.03) น้ าหนักเกิน (adjusted OR: 1.7, 95% CI: 1.04-
3.05) ลูกจ้าง (adjusted OR: 2.83, 95% CI : 1.42-5.65) สูบบุหรี่ ร่วม (adjusted OR: 4.5, 95% CI: 1.88-10.76) ผูท้ ี่มีครอบครัว
ดื่มเครื่ องดื่มแอลกอฮอล์ (adjusted OR: 4.28, 95% CI: 2.24-8.16) ผูท้ ี่มีเพื่อนสนิทที่ดื่มเครื่ องดื่มแอลกอฮอล์ ( adjusted OR:
4.43, 95% CI: 1.22-16.13) มีการใช้ยาร่ วม (adjusted OR: 3.56, 95% CI: 1.28-9.93) และผูท้ ี่มีปัญหาสุ ขภาพเรื้ อรัง (adjusted
OR: CI 2.57, 95%: 1.21 -5.44)
สรุ ป : ความชุกของความผิดปกติจากการดื่มสุ ราอยูใ่ นระดับสู ง;เพศชาย, น้ าหนักเกิน, การจ้างงาน, การสู บบุหรี่ ในปั จจุบนั ,
การดื่มเครื่ องดื่มแอลกอฮอล์ในครอบครัว, เพื่อนดื่มเครื่ องดื่มแอลกอฮอล์, ใช้ยาร่ วม ,และกิดปั ญหาสุขภาพเรื้ อรังที่เกี่ยวข้อง
กับความผิดปกติของการใช้เครื่ องดื่มแอลกอฮอล์ในประเทศกัมพูชา
คำสำคัญ: กำรดื่มเครื่ องดื่มแอลกอฮอล์ ทผี่ ดิ ปกติ, กำรดื่มแบบอันตรำย, ประชำกรวัยทำงำน, สังคมและวัฒนธรรม
411
Abstract
Introduction: There have been increasing trends of alcohol consumption in Cambodia.
However, it effect on consumers seldom been studied and reported.
Objective: To determine association between sociocultural and alcohol use disorder among
working age population in Phnom Penh city, Cambodia. 323 participants in 2017
Methodology: This cross sectional study was conducted in Phnom Penh municipal city,
Cambodia in 2017. Multi stage random sampling was used to select 323 working age people to
response to structured questionnaire. The Alcohol Use Disorders Identification Test (AUDIT) of
the World Health Organization was used to identify the alcohol use disorder status of the
sample. Multiple logistic regression was used to determine the association.
Result: Most of the participants were male 75.85% with the average age was 31.8 years old (SD
± 10.2). The prevalence of alcohol use disorder was 53.56% which was included hazardous
drinking (8-15 scores) 34.67%, harmful drinking (16-19scores) 11.76%, and problem alcohol
dependence (+20scores) 7.12%. The factors associated to alcohol use disorder were male
(Adjusted OR: 5.46, 95%CI: 2.7-11.03), overweight (Adjusted OR: 1.7, 95%CI: 1.04-3.05),
employed (Adjusted OR: 2.83, 95%CI: 1.42-5.65), current smoker (Adjusted OR: 4.5, 95%CI: 1.88-
10.76), those had family drink alcohol (Adjusted OR: 4.28, 95%CI: 2.24-8.16), those had close
friend drink alcohol (Adjusted OR: 4.43, 95%CI: 1.22-16.13), those currently take medicine
(Adjusted OR: 3.56, 95%CI: 1.28-9.93), and those had chronic health problem (Adjusted OR: 2.57,
95%CI: 1.21-5.44), which statistic were significantly p value <0.05.
Conclusion: The prevalence of alcohol use disorder was high; also, male, overweight,
employed, current smoking, family drink alcohol, friend drink alcohol, currently take medicine,
and chronic health problem were associated with alcohol use disorder in Cambodia.
412
Introduction
Alcohol is the third risk factor for many death and disability worldwide (WHO, 2009). A
study in 2010 indicated that 2.5 million people globally in 2004 died by the alcohol consumption
which is included 32 000 people between of 15 to 29 years old. In 2004 worldwide, 3.8% of death
and 45% of disability are caused by alcohol use. (Alwan, 2010). There are more than 200 diseases
and injury conditions which is caused by alcohol consumption (WHO, 2014). However, alcohol
stay connected to people’s living since long time ago and provide people of relax feeling and
more good communication in the social. People consume more alcohol, it will be alcohol
poisoning and lead to abuse. Then that person will become an alcoholic person. Therefore, the
global information system on alcohol and health plays as important role to assess and control
the situation of alcohol consumption, harmful of alcohol consumption, and policies in alcohol
use for many countries. As the actual information has been showed that 3.3 million of people
die every year by drinking alcohol, and 60 vary of diseases are caused by alcohol consumption.
Also, it causes many health problems for people who consume alcohol. 6.2liters of pure alcohol
was consumed by the people aged more than 15 years old, as the report of worldwide about
total alcohol consumption with 25% of total consumption is without any record. (WHO, 2017).
The more people drink alcohol , the more challenge of public health as a result of much increase
of prevalence of disease in region of Asia-Pacific.(Jim E. Banta, 2013) Cambodia is a low income
country in Southeast Asia, with a population of 15,957,223(Factbook, 2017). The number of
alcohol drink in Cambodia increased from 4.6(lite in pure alcohol) in 2003–2005 to 5.5(lite in
pure alcohol) in 2008–2010 in the general population. Also, the pure alcohol consumption per
capita among drinker in Cambodia was 14.2 lite; on the other hand, alcohol use disorders and
alcohol dependence in Cambodia were 4.4% and 2.7%, respectively, in 2010 that was higher than
the Western Pacific region average.(Peltzer, Pengpid, & Tepirou, 2016). The prevalence of
alcohol use disorder in Cambodia was high. (MaleWesley Yeung, 2015). In Cambodia, there is
no law to control related to alcohol use and buy; also, no regulation about industry and local
market. However, Cambodia Ministry of Health has draft the first law related to minimum the
age of alcohol drinking. “The law will limit people who are under 21 years of age from buying
413
alcohol or going to drink alcohol in bars” (Henderson, 2015). A research in 2015 reported about
the prevalence of alcohol use disorder and episodic drinking in rural communities in Cambodia
was high. Male , younger age, and increasing income were significant risk factors.(Wesley
Yeung, 2015)
Materials and Methods
An observational study with cross-sectional design was conducted in August 2017 by
interview after taking informed consent. Ethical approval was made by Khon Kaen University
Ethics Committee in Human Research (No.HE602181). Section Multi-stage sampling was used
to select the samples in this study. Phnom Penh municipality was selected and 5 districts were
randomly selected from the total of 12 districts of Phnom Penh municipality. Then 2 communes
were randomly selected from each selected district, so the total of 10 communes were selected.
Also, the ten communes such as Beorng Salang,Psardepo1,Toul Svay PreyII, Bengkengkong1,
Wat Phnom, Chaktomuk, Phnom Penh Tmey, Tektla, Prek Eng and Prekpra was selected from
district of Khan Toul Kork, Khan Chamcarmon, Khan Doun Penh, Sen Sok, and Khan
Chbarampov. Then a systematic random sampling method was applied to choose 323
households from total 125,527 households. The totals of 323 samples were randomly selected
from each household if there were more than one member of included criteria in each household.
The study population included the working age population (age from 18 to 59 years old) in
Phnom Penh city of Cambodia, who are willing to participate in the study and have no
difficulties to understand the questionnaire and express their ideas.
Study tool
The pre-testing of the questionnaire was conducted 30 participants in any communes and
calculated for reliability of the study using Cronbach alpha coefficient >= 0.70 and Kuder–
Richardson Formula 20 (KR-20)>=0.50 that was considered appropriately. The questionnaire was
adjusted and corrected accordingly to ensure the validity and reliability of the tool. Finally, the
questionnaires were adjusted and corrected accordingly, which were ensured the validity and
reliability of the tool. During data collection real time, researcher served as mentor or supervisor
for data management to review all the forms 323 of participant for completed each day, the
414
check for the completion and other errors. BMI was measured by weight and height; also,
hazardous drinking of alcohol use disorder was measured by AUDIT score ≥8 from WHO.
Then knowledge, marketing, and attitude were measured by rating the scale and classified to
criteria based on Bloom’s cut off point (60%-80%).
Statistical Analysis Plan
The raw data of 323 responded participants had been recorded into MS Excel for database
management before an in-depth analysis. After that the statistical consideration for data analysis
was used by STATA (13.0) software to study and analyze the relationship between dependent
variable and independent variables for this research, as well as descriptive statistic by describing
the frequency and percentage as baseline of characteristic. Then the simple logistic regression
was used for analyze the association between each independent variable and outcome. Finally,
the multiple logistic regressions adjusted OR, 95% of Confident Interval (95%CI) with P value <
0.05 was used to determine the factor associations between sociocultural determinants with
alcohol consumption disorder. Cronbrach Alpha coefficient >=0.7 and Kuder–Richardson
Formula 20 (KR-20)>=0.50 were used to test reliability.
Results
The participants of this study was male 75.85%, and the average age was 31.82 ± 10.26 SD
years old. The subject who were underweight was 11% and normal weight was 41% while those
who were overweight and obesity are nearly 50%. However, those were single was comparable
with married and divorced within average income was 392 USD± 410USD per month, and
monthly expenditure was 286USD±282USD, and 19% was unemployed and being student
without working. The subjects in this study, were bachelor or higher degree, were 28%; also,
most of them were vendor and staff in private company and more than 50% of them had more
than 4 family members. In addition, those who lived with husband/wife and relative was 36%and
37%, respectively. The result of this study also indicated that more than 50% of working age
Cambodian people had physical activities once or less per week. Moreover, the subject who had
never smoke, former smoke, and current smoke was 69%, 13% and 16%, respectively. Among
415
323 respondent, 74.3% of them had family who were the person drink alcohol, and over 90% of
close friends who drink alcohol. However, this result showed that around 80% of subjects never
toke medicine regularly and only 19.81 % who were chronic health problem (Table1). Using the
standard criteria of <60% = low, 60-79% = moderate and ≥80% = high level of marketing. This study
was found that 18.27% of respondents were in the low level and nearly 9% were high level, while
more than 70% were in moderate level of marketing. Using the standard criteria of <60%=
negative attitude, 60-79% = neutral attitude and ≥80% = positive attitude. This study was found
that 15.48% of respondents were in the negative attitude and nearly 10% positive attitude, while
more than 70% were neutral attitude. Using the standard criteria of <60% = poor knowledge, 60-
79% = fair knowledge and ≥80% = high knowledge. This study was found that 5.57% of
respondents were in the poor knowledge and around 60% were fair knowledge, and 32.5% were
high knowledge (Table2). Our present study, the prevalence of hazardous drinking that was
defined by AUDIT score ≥ 8 was 53.56%. The result indicated that male had more chance 5.46
times than female to get HD (Adjusted OR: 5.46, 95%CI: 2.7-11.03) which statistically was
significant p value< 0.001. For people who were overweight had chance 78% more than those
who were normal and underweight to get HD (Adjusted OR: 1.78, 95%CI: 1.04-3.05) and it was
significantly p value: 0.03. Subjects who were employed had more chance 2.83 times to get HD
compared with those who were unemployed (Adjusted OR: 2.83, 95%CI: 1.42-5.65) with p value:
0.003. Those who were current smoker had more chance 4.5times to get HD compared with
never/former smoker (Adjusted OR: 4.5, 95%CI: 1.88-10.76) which statistical was significant p
value: 0.001. People who had family drinking alcohol were more likely to get HD 4.28 times
compared to those did not have family drink alcohol (Adjusted OR: 4.28, 95%CI: 2.24-8.16) p
value< 0.001 was significantly. Subjects who had close friend drinking alcohol were more likely
to get HD 4.43 times compared to those did not have family drink alcohol (Adjusted OR: 4.43,
95%CI: 1.22-16.13) p value: 0.02 was significantly. People who were currently take medicine had
more chance to get HD 3.56 times compared with those who never and former take medicine
regularly (Adjusted OR: 3.56, 95%CI: 1.28-9.93) with statically was significant p value: 0.01. The
416
subjects who had chronic health problem had more chance to get HD 2.57 times compared with
those who were not( Adjusted OR: 2.57, 95%CI: 1.21-5.44) ; p value: 0.01 was significantly.(
Table 5)
Table 1: Baseline characteristics of respondents

Overall 323
Sex
Male 245 75.85
Female 78 24.15
Age (years)
18-20 31 9.60
21-30 130 40.25
31-40 106 32.82
41-50 31 9.60
>50 25 7.74
Mean (SD) 31.8 ± 10.2
Median (Min: Max) 30 (18 – 59)
BMI ( Kg/m2)
Underweight ( <18.5) 37 11.46
Normal (18.5-22.99) 134 41.49
Overweight (23-24.99) 65 20.12
Obesity (>=25) 87 26.93
Marital status
Single 167 51.70
Married 142 43.96
Divorced/widowed/separated 14 4.33
Income (USD/Month)
<200 84 26.01
200-300 126 39.01
>300 113 34.98
Mean (SD) 392 (± 410)
Median (Min: Max) 250 (0-4,500)
Expenditure (USD/Month)
<200 144 44.58
200-300 95 29.41
>300 84 26.01
Mean (SD) 286 (± 282)
Median (Min: Max) 200 (5-2,000)
417

Uneducated 11 3.41
High school 115 35.60
Occupation
Private company officer 87 26.93
Vendor 84 26.01
Student 57 17.65
Worker 19 5.88
Unemployed 5 1.55
Other 46 14.24
Family member
<5 133 41.18
>=5 190 58.82
People live with
Relatives/ family 122 37.77
Husband/wife 118 36.53
Alone 39 12.07
Friends 28 8.67
Partner 8 2.48
Other 8 2.48
Religion
Buddhist 315 97.52
Christian 5 1.55
Muslim 3 0.93
Physical activities
=<1/week 192 59.44
>1/week 131 40.56
Smoking
Never Smoking 226 69.97
Former Smoking 45 13.93
Current smoking 52 16.10
Family drink alcohol
No 83 25.70
Yes 240 74.30
Close friend drink alcohol
No 26 8.05
Yes 297 91.95
418

Take medicine regularly
Never 261 80.80
Former Take 26 8.05
Current take 36 11.15
Chronic health problem
No 259 80.19
Yes 64 19.81
Table 2: Level of Marketing, Attitude, and Knowledge on Alcohol

Marketing on Alcohol
Low level 59 18.27
High level 29 8.98
Attitude
Negative Attitude 50 15.48
Neutral Attitude 241 74.61
Positive Attitude 32 9.91
Knowledge
Poor 18 5.57
Fair 200 61.92
High 105 32.51
Table 3: Alcohol Use Disorder Identification Test

AUDIT (1 year)
Low risk drinking ( 0-7) 150 46.44
Hazardous drinking (8-15) 112 34.67
Harmful drinking (16-19) 38 11.76
Problem Alcohol dependence (20+) 23 7.12
Mean (SD) 9.19 (6.71)
Median (Min: Max) 8 (0 : 30)
419
Table 4. Odds ratios for sociocultural determinants factors on alcohol use disorder
(Hazardous drinking) based on simple logistic regression.
Characteristics Number %HD OR 95%CI p-value

Overall 323 53.56
Sex <0.001
Female 78 28.21 1
Male 245 61.63 4.08 2.34 - 7.13
Age (years) 0.02
18-30 161 45.96 1
31-50 137 61.31 1.86 1.17-2.96
>50 25 60.00 1.76 0.74-4.15
BMI(Kg/m2) <0.001
Underweight and normal ( <23) 171 44.44 1
Overweight (>=23) 152 63.82 2.20 1.40-3.44
Marital status
Single 167 52.10 1 0.36
Married 142 53.52 1.05 0.67-1.65
Divorced/widowed/separated 14 71.43 2.29 0.69-7.62
Income (USD/Month) 0.38
<200 84 48.81 1
200-300 126 52.38 1.15 0.66 - 2
>300 113 58.41 1.47 0.83 - 2.59
Expenditure (USD/Month) 0.10
<200 144 47.22 1
200-300 95 56.84 1.47 0.87 - 2.47
>300 84 60.71 1.72 0.99 - 2.98
Educational attainment 0.87
Under high school 117 52.99 1
Upper high school 206 53.88 1.03 0.65-1.63
Occupation (KHR Thousand/Month) <0.001
Unemployed 62 33.87 1
Employed 261 58.24 2.72 1.52 - 4.86
Family member 0.77
<5 133 52.63 1
>=5 190 54.21 1.06 0.68 - 1.66
People live with 0.81
Alone 39 53.85
Husband/wife 118 54.24 1.01 0.49-2.1
Partner 8 75.00 2.57 0.46-14.35
Friends 28 53.57 0.98 0.37-2.61
420
Characteristics Number %HD OR 95%CI p-value

Relatives 122 50.82 0.88 0.42-1.82
Other 8 62.50 1.42 0.29-6.82
Physical activities 0.02
=<1/week 192 48.44 1
>1/week 131 61.07 1.66 1.06-2.62
Smoking <0.001
Never/former Smoking 271 47.60 1
Current smoking 52 84.62 6.05 2.74 - 13.34
Family drink alcohol <0.001
No 83 36.14 1
Yes 240 59.58 2.60 1.55-4.36
Close friend drink alcohol <0.001
No 26 19.23 1
Yes 297 56.57 5.46 2-14.89
Take medicine regularly 0.001
Never/Former Take 287 50.52 1
Current take 36 77.78 3.42 1.51-7.77
Chronic health problem <0.001
No 259 47.10 1
Yes 64 79.69 4.40 2.28-8.48
Marketing on Alcohol 0.04
Low level 59 38.98 1
Moderate level 235 56.60 2.04 1.13-3.65
High level 29 58.62 2.21 0.89-5.48
Attitude 0.7
Neutral and Positive 273 53.11 1
Negative 50 56 1.12 0.61-2.06
Knowledge 0.24
Fair/High 305 52.79 1
Poor 18 66.67 1.78 0.65-4.88
Significant p value <0.25
421
Table 5. Odds ratios for sociocultural determinants factors on alcohol use disorder
(Hazardous drinking) based on multiple logistic regression
Characteristics Number %HD Crude Adjusted 95%CI p-value

OR OR
Overall 323 53.56
Sex <0.001
Female 78 28.21 1 1
Male 245 61.63 4.08 5.46 2.7-11.03
BMI(Kg/m2) 0.035
Under/ normal weight ( <23) 171 44.44 1 1
Overweight (>=23) 152 63.82 2.20 1.78 1.04-3.05
Occupation 0.003
Unemployed 62 33.87 1 1
Employed 261 58.24 2.72 2.83 1.42-5.65
Smoking 0.001
Never/former Smoking 271 47.60 1 1
Current smoking 52 84.62 6.05 4.50 1.88-
10.76
Family drink alcohol <0.001
No 83 36.14 1 1
Yes 240 59.58 2.60 4.28 2.24-8.16
Close friend drink alcohol 0.024
No 26 19.23 1 1
Yes 297 56.57 5.46 4.43 1.22-
16.13
Take medicine regularly 0.015
Never/Former Take 287 50.52 1 1
Current take 36 77.78 3.42 3.56 1.28-9.93
Chronic health problem 0.014
No 259 47.10 1 1
Yes 64 79.69 4.40 2.57 1.21-5.44
Significant p value <0.05
Discussion
In the study indicated that sex was associated with AUD that define by AUDIT score ≥ 8
that that male had more chance 5.46 times than female to get hazardous drinking (Adjusted OR:
422
5.46, 95%CI: 2.7-11.03) which statistically was significant p value< 0.001. It was comparable to
the study in Korea that women had a lower risk of high risk alcohol drinking (OR: 0.14, 95% CI:
0.13–0.16, P<0.001) than men (Hong et al., 2017). Also, it was similar to the result male versus
female (45.7% versus 17.0%; OR=0.23, p<0.001) (Tynan et al., 2017) and another reported of
female had chance 70% less than male to get hazardous drinking (Adjusted OR: 0.3, 95%CI: 0.17-
0.58) ; p value <0.001.(Jenkins et al., 2015). All in all, this recent result which showed male had
more chance to get hazardous drinking compared to female, it could be the reason that in
Cambodia female was less socialization compared to male, and Cambodia’s culture, female
with alcohol drinking was not appropriate while male with alcohol is just the common thing.
Regarding to occupation, this study showed that subject who were employed had more chance
2.83 times to get hazardous drinking compared with those who were unemployed (Adjusted OR:
2.83, 95%CI: 1.42-5.65) with p value : 0.003. By the same token, the study in Kenya 2015, also,
showed that employed people had more chance to get hazardous drinking nearly 2 times
compared to those were not employed (adjusted OR: 1.8, 95%CI: 1.04 - 2.99, p
value : 0.036)(Jenkins et al., 2015). As a result, this study indicated that employed people had
more chance to get hazardous drinking compared to unemployed people, it could be the result
that those who were working was more socialization and they could afford more than
unemployed people. Also, this study was reported that current smoking was 16% and never and
former smoking was over 80%; likewise, the previous study was 13% and never and former
smoking was more than 80% (Symon, Rankin, Butcher, Smith, & Cochrane, 2017). In our study
indicated those who were current smoker had more chance 4.5times to get HD compared with
never and former smoker (Adjusted OR: 4.5, 95%CI: 1.88-10.76) which statistical was significant
p value: 0.001. This agreed with the result of review in Slovenia was smoker had more chance
nearly 2 times compared to those not smoke to get risky of drinking( adjusted OR: 1.952, 95%CI:
1.615–2.360) with p value < 0.001 significantly (Kolsek & Klemenc Ketis, 2015). The study in
China was reported that the current smoker had change to get HD 3.3 times more than
never/former smoker (adjusted OR: 3.3, 95% CI: 2.68–4.07); p value<0.05 was significant (Gao,
Weaver, Fua, & Pan, 2014). Likewise, the previous study also indicated that smoking was
423
associated with AUD (adjusted OR: 6, 95%CI: 3.12-11.54) with p value: 0.001 (Zenebe Y*, 2015).
In conclusion, current smoker had more chance to get HD. Also, in Cambodia’s society, it could
be the reason that the group of people who smoke, most of them already had experience of
excessive or higher drinking alcohol. In term of family drink alcohol, our analyze showed that
people who had family drinking alcohol were more likely to get hazardous drinking 4.28 times
compared to those did not have family drink alcohol (Adjusted OR: 4.28, 95%CI: 2.24-8.16) p
value< 0.001 was significantly. It was similar to the study in Southern Ireland that had been
reported that parents who were hazardous drinking associated to the adolescent to get HD by
the subjects who had father HD were more likely to get HD almost 3 times compared to those
not (adjusted O.R = 2.90, 95 % CI: 1.32–6.35) with p value <0.05 (Murphy, O'Sullivan, O'Donovan,
Hope, & Davoren, 2016). It could be the reason that family was the role model to their children,
and some time their children are the people who consume the alcohol for their parents. Then it
provided much alcohol drinking in their living style. Regarding to close friend drink alcohol, in
the present study, the result showed that close friend drink alcohol was associated with HD. Our
analyze showed that the subject who had close friend drinking alcohol were more likely to get
hazardous drinking 4.43 times compared to those did not have family drink alcohol (Adjusted
OR: 4.43, 95%CI: 1.22-16.13) ;p value: 0.02 was significantly. It was similar to the other previous
study in Thailand that men who had peer alcohol drinking occasion were more likely to get HD
5 times compared to the men had peer never drink (adjusted OR: 5.57, 95%CI: 2.02-15.31) and the
men who had peer drink usual were more likely to get HD 23 times compared to those not
(adjusted OR: 23.46, 95%CI: 7.29-75.43), which statistically was significant <0.01. Also in the
same study that showed women who had peer drink occasion were more likely to get HD nearly
8 times compared to women who had peer never drink (adjusted OR: 7.94, 95%CI: 1.89-33.43)
and those women who had peer drink usual were more likely to get HD 63 times compared with
women who had peer never drink (adjusted OR: 9.24-435.31), which p value<0.01 (Zenebe
Y*, 2015). It might be the reason that those who had alcohol drinking peer group, more or less
they must be influent by many meeting gatherings.
424
Limitation
Since our study was mentioned on working age population and the location was Phnom Penh
City, the most busy municipality city in Cambodia. Hence, the participants who were in this age
were so busy in their work, most of them go to work outside their house during working hours
in the week day; also, some of them were doing business at their home while we were asking
them to join in this study. However, during working on this study, we were trying to do in
weekend and the time that they are free from their work in order to minimize the selection bias
as much as possible. Moreover, for the people who were doing their own business at their home,
we were trying to convince them to join in this study until they were willing to participate. All
the respondents were selected by systematic random sampling method in order to make the
result more accurate. Moreover, during our study was raining season, so we were not able to
interview more participants for the each raining day; however, we are make sure that our report
was the accurate in this study.
Conclusion
Our present study, the prevalence of hazardous drinking that was defined by AUDIT score
≥ 8 was over 50% and there are 8 factors that associated with hazardous drinking of AUD
included sex, BMI, occupation, smoking, family drink alcohol, close friend, take medicine
regularly, and chronic health problem, which the statistically was significant p value<0.05.
Acknowledgments
I am thankful to the study participants and local administration for their kind and support.
I am also thankful to my professor for always support and advice for achieving this research.
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Effects of Strong Program for protection the new smokers among secondary
school students in Roi-Et municipal. Roi-Et Province
Mrs.Suwatcharanee Sunopuk¹, Terdsak Promarak, Ph.D.²,
Asst. Prof. Phayom Sookaneknun, Ph.D.³
¹Master Degree of Public Health Faculty of Public Health Mahasarakham University

²Faculty of Public Health, Mahasarakham University
³Faculty of Pharmacy, Mahasarakham University
จากสถานการณ์การสู บบุหรี่ ในประเทศไทย รายงานการสารวจเชิงสถิติของรัฐในปี พ.ศ. 2557 จากจานวนประชากร

จานวน 54.8 ล้านคนที่อายุต้ งั แต่กว่า 15 ปี ขึ้นไป พบว่ามีผสู ้ ู บบุหรี่ สูบบุหรี่ 11.4 ล้านคนหรื อ ร้อยละ 20.7 10 ล้านคนเป็ นผูส้ ูบ
บุหรี่ เป็ นประจา เพิ่มขึ้นจาก ปี 2013 อายุเฉลี่ยของผูส้ ู บบุหรี่ ที่เริ่ มสู บบุหรี่ ครั้งแรก 17.8 ปี พบเด็กอายุ 15-24 ปี เริ่ มสู บบุหรี่ เมื่อ
อายุ 15.6 ปี ต่ากว่าปี 2550 ที่เริ่ มสู บบุหรี่ เมื่ออายุ 16.8 ปี ชี้ให้เห็นว่าผูส้ ู บบุหรี่ รายใหม่อายุนอ้ ยลง ดังนั้นจานวนวัยรุ่ นที่สูบบุหรี่
โดยเฉพาะอย่างยิ่งในชั้นมัธยมศึกษามีแนวโน้มที่จะเพิ่มขึ้นควรมีวิธีการป้ องกันปั ญหานี้ การศึกษานี้ ศึกษาผลของโปรแกรมที่
เน้นการป้ องกันผูส้ ูบบุหรี่ รายใหม่ในนักเรี ยนระดับมัธยมศึกษา เปรี ยบเทียบความแตกต่างของค่าเฉลี่ย ความรู ้ทกั ษะชีวติ 6 ด้าน
ได้แก่ ความคิ ดสร้ างสรรค์และการคิ ดเชิ ง วิพ ากษ์ การสื่ อสารที่ มีประสิ ทธิ ภาพและการสร้ างความสัม พันธ์ กับผูอ้ ื่ น ความ
ตระหนักรู ้ในตนเองและเห็นใจคนอื่น การจัดการอารมณ์และความเครี ยด ความนับถือตนเองและความรับผิดชอบต่อสังคม การ
แก้ปัญหาและการตัดสิ นใจและพฤติกรรมในการตัดสิ นใจที่จะหลีกเลี่ยงการสู บบุหรี่ ในกลุ่มทดลองและกลุ่มเปรี ยบเทียบ เป็ น
การวิจยั กึ่ งทดลองในโรงเรี ยนมัธยมศึ กษาเขตเทศบาลเมื องร้ อยเอ็ด จังหวัดร้อยเอ็ด กลุ่มทดลองมีนักเรี ยน 40 คนและกลุ่ม
เปรี ยบเที ยบ 40 คนเก็บรวบรวมข้อมูลจากแบบสอบถามที่ ได้จากการวิเคราะห์ขอ้ มูลโดยใช้สถิติเชิ งพรรณนา ค่าเฉลี่ย ส่ วน
เบี่ยงเบนมาตรฐาน การเปรี ยบเทียบคะแนนเฉลี่ย ผลการทดสอบ t-test และ t-test แบบอิสระอย่างมีนยั สาคัญทางสถิติที่ระดับ
0.05
ผลการศึ กษาพบว่า กลุ่มทดลองส่ วนใหญ่เป็ นเพศชายร้อยละ 72.5 และร้อยละ 92.5 มีอายุ 14 ปี ปั จจุบนั อาศัยอยูก่ บั
ครอบครัว ร้อยละ 97.5 ความสัมพันธ์ในครอบครัว ร้อยละ 82.5 มีผสู ้ ูบบุหรี่ ร้อยละ 52.5 ส่วนใหญ่ไม่เคยสูบบุหรี่ ร้อยละ 42.5 ผู ้
สู บบุหรี่ เลิกสู บบุหรี่ มานานกว่า 6 เดือน ร้อยละ 22.5 และกลุ่มที่ยงั สู บบุหรี่ อยู่ ร้อยละ 20 กลุ่มเปรี ยบเทียบ ร้อยละ 65 เป็ นเพศ
ชาย ร้ อ ยละ 85 เป็ นเด็ ก ที่ อ ายุต่ า กว่า 14 ปี อาศัย อยู่กับ ครอบครั ว ร้ อ ยละ 65 พ่อ แม่ อ ยู่ด้ว ยกัน ร้ อ ยละ 65 ร้ อ ยละ 82.5 มี
ความสัมพันธ์ในครอบครัวที่ดี ร้อยละ 52.5 ปรึ กษาปั ญหากับพ่อแม่ ร้อยละ 52.5 นาเงินมาเรี ยน 31-60 บาท ร้อยละ 57.5 นาเงิน
มาโรงเรี ยน 71.5 บาทต่อวัน ร้อยละ 52.5 ไม่มีคนสูบบุหรี่ ในครอบครัว ร้อยละ 42.5 ไม่เคยสูบบุหรี่ มาก่อน ร้อยละ 22.5 เคยสูบ
แต่เลิกสู บบุหรี่ มานานกว่า 6 เดือน ร้อยละ 17.5 ยังคงสู บบุหรี่ ร้อยละ 42.9 ต้องการหยุดสู บบุหรี่ ผลการทดลองในกลุ่มทดลอง
สู งกว่าก่อนการทดลองและสู งกว่านักเรี ยนในกลุ่มเปรี ยบเที ยบอย่างมีนัยสาคัญทางสถิ ติ p < 0.001 นักเรี ยนในกลุ่มทดลอง
สามารถทาทักษะชีวติ ได้ 6 ด้าน ความคิดสร้างสรรค์และความคิดเชิงวิพากษ์ การสื่ อสารที่มีประสิ ทธิภาพและการสร้าง
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ความสัมพันธ์กบั ผูอ้ ื่น การรับรู ้ดว้ ยตนเองและเห็ นใจคนอื่นการจัดการอารมณ์และความเครี ยดความนับถือตนเองและความ

รับผิดชอบต่อสังคมการแก้ปัญหาและการตัดสิ นใจที่จะไม่สูบบุหรี่ และมีพฤติกรรมที่ดีเพื่อหลีกเลี่ยงการสูบบุหรี่
สรุ ป โครงการนี้ STONG คือ S: การตระหนักรู ้ตนเอง, T: การคิดเชิงวิพากษ์, R: ปฏิเสธ, O: การแสดงออก, N: แค่พดู
ไม่และ G: การมีสุขภาพดี . ปั จจัยเหล่านี้ ช่วยสนับสนุ นนักเรี ยนในการเปลี่ยนพฤติกรรมการสู บบุหรี่ เป็ นเทคนิ คที่ เหมาะสม
ทักษะชีวติ 6 ด้านนี้นกั เรี ยนสามารถนามาประยุกต์ใช้กบั ชีวติ ประจาวัน นักเรี ยนสามารถเรี ยนรู ้วิธีการป้ องกันตนเองจากการสู บ
บุหรี่ ผา่ นบทเรี ยนในแต่ละกิจกรรมดังนั้นโปรแกรมสาหรับการป้ องกันการสูบบุหรี่ จึงสามารถเปลี่ยนพฤติกรรมของนักเรี ยนได้
อย่างดียงิ่ ขึ้น นอกจากนั้นจะช่วยให้ไม่มีผสู ้ ูบบุหรี่ รายใหม่ ๆ
ABSTRACT
Introduction: From the situation of smoking in Thailand.National Statistical Office surveied report
in 2014¹ meet people over 15 years old.There were 54.8 million people have smoked
11.4 million smokers, or 20.7 %, of whom 10 million were regular smokers. This is an increase
from 19.9 % in 2013.The average age of smokers who first started smoking was 17.8 years. It was
found that 15-24 year-olds started smoking at the age of 15.6 years, lower than those in 2007 when
they started smoking at the age of 16. 8 years. Points out that, new smokers are younger. So
effective, the number of teenagers who smoke, especially students in secondary school tends to
increase. Therefore, there should be a way to protect this problem.
Objectives: Study the effects of Strong Program for protecting new smokers among secondary
school students. Compare the mean difference : knowledge, six pairs of life skillswhich are
creativity and critical thinking, effective communication and building relationship with people,
self-awareness and sympathy for others, emotional and stress management, self-esteem and social
responsibility, problem-solving and making decisionand behaviors to avoid smokingin the
experimental group and the comparison group.
Methodology: This Quasi-experimental research was offered to the secondary school in Roi-Et
municipality of Roi-Et province. There were 40 students in experimental group and 40 students in
comparison group.The data was collected from a questionnaire which is analyzed by descriptive
statistics; mean, percentage, standard deviation (S.D), comparison of average scores, Paired t-test,
Independent Sample t-test at a statistically significant level 0.05
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Result: Most of the experimental groups were male 72.5%,92.5% were 14 years old.Currently living
with family is 97. 5% . Relative family relationship 82. 5% . There were 52. 5% smokers in the
family.Most of the experimental group had never smoked 42.5%.Cigarette smokers have quit for
more than 6 months, 22.5%.There are still 20%.The comparison groupthat 65% of students are males.
85% are 14 years old, 92.5% stay with their family, 65% parents stay together, 82.5% have a very
good family relationship, 52.5% consult problems with parents, 52.5% bring money to school 31-60
Baht/day approximately, 57.5% bring money to school 71.5 Baht/day, 52.5% there is no one in the
family smoke cigarette, 42.5% of experimental group never smoke cigarette before, 22.5% used to
smoke but has stopped for more than 6 months, 17.5% still smoke cigarette, 42.9% need to stop
smoking.The result after the experiment was higher than before the experiment and higher than
students in the comparison group at statistically significant p<0.001.Students in the experimental
group could do well in six pairs of life skills which are creativity and critical thinking, effective
communication and building relationship with people, self-awareness and sympathy for others,
emotional and stress management, self-esteem and social responsibility, problem-solving and
making decision to not smoke and having good behaviors to avoid smoking.
Conclusions: STRONG Program is S : Self Awareness, T : Critical Thinking , R : Refuse, O :
Output, N : Just Say No and G : Good Health .The factors that help support students to change
smoking behaviors is the appropriate techniques which are the six pairs of life skills that students
can apply to daily life and be stronger in their hearts. Students can learn how to protect themselves
from smoking through the lessons in each activity.Therefore, the program for smoking protection
can change students’ behaviors in a very better way. Moreover, there will be no more new smokers
when providing this program.
Key words: protection of the new smokers, students in secondary school
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Introduction
According to the situation about smoking in Thailand, the National Statistics Office
reported that in 2014,( 1) among 54.8 million people whose age were 15 years old or older, there
were 11.4 million people or 20.7 percent were smokers. There were 10 million people who smoked
regularly while 1. 4 million people sometimes smoked. The mentioned amount of smokers
increased from 2013 about 19. 9 percent. The average age of new smokers showed a serious
situation that the age of new smokers was getting younger than some years before. The causes that
arouse teenagers to smoke are from environment, friends, and teenage characteristics like excited
to try new experiences. Another factors are lacking of refusing or the way they show outstanding
sexual characteristics.
According to the survey in 2015,( 2) there were 10.9 million people or 19.9 percent of 15-
year-old people started smoking. The number of people who were 19-24 years old and 41-59 years
old did not decrease while the number of other age groups gradually decreased. Cigarettes causes
social problems especially healthy problems, for example; emphysema, vascular and heart disease,
cancers. Moreover, the smoke from cigarette damages the health of smokers and people around.
The factors that leads teenagers to involve with smoking are 1. ) Cigarettes cost 2. )
Teenagers’ characteristics 3. ) Advertisements 4. ) Cigarette sellers 5. ) Cigarette shop 6. ) Law
verification of smokers 7.) Customs and participation of community (3)
According to the study of new smokers students in Secondary Schools of Roi-Et Municipal,
there are 1,231 students in 4 schools. There are 1,099 students who don’t smoke while 132 students
do which is about 10.77 percent of all students. Therefore, the ideas to develop life skills for those
teenage smokers are included in this study as it is known that teenage is the turning point of
behavioral changing which is related to healthy problems.(4)
This study included that ideas that could encourage a person to adapt themselves to
confront unexpected situations in daily life effectively. From the mentioned problems, the
researcher tend to apply the ideas of life skills to protect students in Secondary Schools of Roi-Et
Municipality from smoking.
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Objectives
To compare the differences of average scores of knowledge in six pairs of life-skills which
are 1.) Creativity and critical thinking, 2.)Effective communication and building relationship with
people, 3.)Self-awareness and sympathy for others, 4.) Emotional and stress management, 5.) Self-
esteem and social responsibility, 6.) Problem-solving and making decision to not smoke and having
good behaviors to avoid smoking.
To compare the satisfaction of students in Secondary Schools of Roi-Et Municipality between
experimental group and control group before and after the experiment.
Methodology
Hypothesis
1. After the experiment, the average scores of knowledge and the levels of satisfaction of
the experimental group who uses the program to protect students not to be a new smoker among
secondary schools are higher than before the experiment.
2. After the experiment, the average scores of knowledge and the levels of satisfaction of the
experimental group who uses the program to protect students not to be a new smoker among
secondary schools are higher than the control group.
Method
This is the Quasi-experimental Research which divided students into 2 groups;
experimental group and control group. Both groups have to do pretest and posttest as shown below
Experimental group O1 ---------x--------O2
Control group O3-------- -x--------O4
8 weeks
O1 and O3 means to collect the data from both experimental group and controlgroup
before the experiment
O2 and O4 means to collect the data from both experimental group and controlgroup after
the experiment
X meansto the program to protect students not to be a new smoker among secondary
schools. in Roi-Et municipality, Roi-Et province
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Intervention
Week 1
1. Group activities “Greet friends”
2. Knowledge about cigarettes
Week 2 Creativity and critical thinking

1. Matchmaking activities
2. My Future
Week 3Effective communication and building relationship with people

1. Greet new friends
2. Refusal to invite friends
Week 4Self-awareness and sympathy for others
1. Case study “Dang made mistakes”
Week 5Emotional and stress management

1. Stress management
Week 6Self-esteem and social responsibility
1. Self-esteem
2. Case study “Think before doing”
Week 7Problem-solving and making decision
1. Case study “Deja decided to do”
Week 8
1. Promise not to interfere with cigarettes
Population and Samples

The population that attends this study is eighty M. 2 students from two Secondary Schools
in Roi-Et municipality, Roi-Et province which are school A and school B.
The qualities of the selected schools are schools must have M. 2 students, the schools must
be a co educational school, the schools cooperate with the researcher. Samples for this study are
divided into two groups which are experimental group and control group. School A is the
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experimental group because the school is located in big community. The researcher simply
randoms 40 students of school A to be in the experimental group. On the other hand, The researcher
simply randoms 40 students of school B to be in the control group.
Criteria for attending: 13-14 year-old students who can read and write well, who are
healthy and ready to do the activity, and who can attend for the whole course.
Criteria for cancelling: students who cannot attend the course regularly, who cancel to
attend, or students who move to another place during the study time
Study tool
The pre-testing of the questionnaire was conducted 30 participants in any communes and
calculated for reliability of the study using Cronbach alpha coefficient >= 0.75 and Kuder–
Richardson Formula 20 (KR-20)>=0.50 that was considered appropriately.
Statistical Analysis Plan

The researcher uses descriptive statistic which are frequency value, Average percentage,
standard deviation and inferential statistics to analyze the data. Moreover, the researcher compares
the average scores about knowing of cigarettes and the protection of smoking, compares life-skills
that help protect themselves from smoking, as well as compares smoking behaviors and
satisfaction of students who attends the course between experimental group and control group.
Results
Population characteristics
The results showed the experimental group that 72.5% of students males. 85% are 14 years
old, 97.5% stay with their family, 72.5% parents stay together, 82.5% have a very good family
relationship, 57.5% consult problems with parents, 52.5% bring money to school 31-60 Baht/day
approximately, 70% bring money to school 71.5 Baht/day, 52.5% there is no one in the family smoke
cigarette, 42.5% of experimental group never smoke cigarette before, 22.5% used to smoke but has
stopped for more than 6 months, 20% still smoke cigarette, 37.5% need to stop smoking.
The control group that 65% of students are males. 85% are 14 years old, 92.5% stay with
their family, 65% parents stay together, 82.5% have a very good family relationship, 52.5% consult
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problems with parents, 52.5% bring money to school 31-60 Baht/day approximately, 57.5% bring
money to school 71.5 Baht/day, 52.5% there is no one in the family smoke cigarette, 42.5% of
experimental group never smoke cigarette before, 22.5% used to smoke but has stopped for more
than 6 months, 17.5% still smoke cigarette, 42.9% need to stop smoking.
The Experimental group and the comparison group changed upon receiving the
program.
The average scores of knowing about cigarette, the protection of smoking, and
satisfaction of attending the course after the experiment
Knowledge
Comparison of mean scores on knowledge of cigarettes.After the experiment, the
experimental group scored higher than the control group. 2.35 points (95%CI = 1.81 to 2.89, p-value
< 0.001)
Knowledge ,Comparison of mean scores on knowledge of cigarettes :The Experimental
group and the comparison group were different. The mean score of the experimental group was
higher than that of the control group were significant (p <0.001),As Table 1.
The protection of smoking

Comparison of mean scores on the protection of smoking. After the experiment, the
experimental group scored higher than the control group. 5.47 points (95%CI = 3.60 to 7.35, p-value
< 0.001), As Table 1.
The protection of smoking ,Comparison of mean scores on the protection of smoking. The
Experimental group and the comparison group were different. The mean score of the experimental
group was higher than that of the control group were significant (p <0.001),As Table 1.
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The satisfaction of attending

Comparison of mean scores on The satisfaction of attending the course after the
experiment . After the experiment, the experimental group scored higher than the control group.
2.30 points (95%CI = 1.46 to 3.14, p-value < 0.001), As Table 1.

The satisfaction of attending ,Comparison of mean scores on The satisfaction of attending
the course after the experiment. The Experimental group and the comparison group were different.
The mean score of the experimental group was higher than that of the control group were
significant (p <0.001),As Table 1.
The six pairs of life-skills
Creativity and critical thinking

Comparison of mean scores, After the experiment, the experimental group scored higher
than the control group.4.60 points (95%CI= 3.24 to 5.96, p-value < 0.001), As Table 2.
Creativity and critical thinking: Comparison of mean scores The Experimental
higher than that of the control group were significant (p <0.001), As Table 2.
Effective communication and building relationship with people

Comparison of mean scores, after the experiment, the experimental group scored higher
Effective communication and building relationship with people:Comparison of mean
scores The Experimental group and the comparison groups were different. The mean score of the
experimental group was higher than that of the control group were significant (p <0.001),As Table2
Self-awareness and sympathy for others
Comparison of mean scores, After the experiment, the experimental group scored higher
Self-awareness and sympathy for others : Comparison of mean scoresThe Experimental
higher than that of the control group were significant (p <0.001),As Table 2.
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Emotional and stress management

than the control group.4.40 points (95%CI = 2.60 to 6.20, p-value < 0.001), As Table 2.
Emotional and stress management: Comparison of mean scores The Experimental group
and the comparison groups were different. The mean score of the experimental group was higher
than that of the control group were significant (p <0.001), As Table 2.
Self-esteem and social responsibility
Self-esteem and social responsibility: Comparison of mean scores The Experimental
group and the comparison groups were different. The mean score of the experimental group was
Problem-solving and making decision
Problem-solving and making decision: Comparison of mean scores The Experimental
group and the comparison groups were different. The mean score of the experimental group was
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Table 1 The Experimental group and the control group between average scores of knowing about
cigarette, the protection of smoking, and satisfaction of attending the course after the experiment
(n = 40)
Variable Mean of The Mean of the Mean 95%CI p-value

Experimental control group. Difference
group. (sd.) (sd.)
Knowledge of Cigarettes.
Pre-trial 1.22 1.24 -0.02 -0.57 to 0.52 0.928
Post- trial 8.20 5.58 2.35 1.81 to 2.89 <0.001
The protection of smoking.
Pre-trial 5.75 5.75 0.10 -2.46to 2.66 0.938
Post- trial 1.34 5.74 5.47 3.60 to 7.35 <0.001
The Satisfaction of Attending

Pre-trial 2.77 2.77 0.00 -1.23 to 1.23 1.000
Post- trial 0.53 2.60 2.30 1.46to 3.14 <0.001
Table2 The Experimental group and the comparison group between average scores of the six pairs
of life-skills (n=40)

Experimental comparison Difference
group. (sd.) group. (sd.)
Creativity and critical thinking

Pre-trial 4.34 0.70 0.70 -1.22 to 2.62 0.471
Post- trial 1.01 4.16 4.60 3.24 to 5.96 <0.001
Effective communication and building relationship with people

Pre-trial 3.76 3.89 0.60 -1.10 to 2.30 0.485
Post- trial 1.51 3.74 2.93 1.65 to 4.21 <0.001
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Experimental comparison Difference
group. (sd.) group. (sd.)
Self-awareness and sympathy for others
Pre-trial 5.12 5.15 0.45 -1.84 to 2.74 0.966
Post- trial 2.11 5.10 4.88 3.13 to 6.63 <0.001
Emotional and stress management

Pre-trial 5.00 4.81 0.05 -2.13 to 2.23 0.964
Post- trial 3.39 4.61 4.40 2.60 to 6.20 <0.001
Self-esteem and social responsibility
Pre-trial 4.02 4.05 0.25 -1.55 to 2.05 0.782
Post- trial 1.21 4.00 2.68 1.35 to 4.00 <0.001
Problem-solving and making decision
Pre-trial 3.60 3.59 0.05 -1.55 to 1.65 0.951
Post- trial 1.08 3.62 3.50 2.304 to.70 <0.001
The results of qualitative information

The activities in the 8- week course are group work for worksheet assignment,
brainstorming, and role play which these activities bring the ideas of the program to protect
students not to be a new smoker among secondary schools. The mentioned program entitled “Strong
Program”
Table 3 “Strong Program”
Strong Program Definition Activity
S : Self Awareness To aware of one’s self -Show your own value to others
-show your strong attitude that smoking is

not acceptable
-smoking affects smokers and surrounded

people
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Strong Program Definition Activity
T : Critical Thinking To criticize and to analyze -cigarettes and disadvantage of smoking
R : Refuse To make decision for the -Apply life-skills to daily life

right thing
- Creativity and critical thinking
- Effective communication and building

relationship with people
- Self-awareness and sympathy for others
- Emotional and stress management
- Self-esteem and social responsibility
- Problem-solving and making decision to

not smoke and having good behaviors to
avoid smoking
O : Output Output from appropriate -to protect students notto be a new smoker
characteristics
-to not smoke or to protect one’s self from
smoking
-to do exercise
-to do hobbies
N : Just Say No To refuse smoking -to refuse or not follow what be told from
any friend who smokes
G : Good Health To have a good health if do -to join a campaign “No Smoking”
not smoke
-to convince friends not to smoke
-to take care of the health
-to suggest or help those who want to stop

smoking
440
Discussion
From the study of storng program to protect students not to be a new smoker among
secondary schools in Roi-Et municipality, Roi-Et province. The researcher can explain the result
as follows;
After the experiment, students in experimental group who attended the program to protect
students not to be a new smoker among secondary schools in Roi-Et municipality gained more
knowledge about cigarettes than the control group with a statistical significance (p<0.001)which
related to the study of Manit Kaewmanee. (5)

After the experiment ,the skills of students in experiment groups after attended the program
of the six pairs of life skills; creativity and critical thinking, effective communication and building
relationship with people, self- awareness and sympathy for others, emotional and stress
management, self-esteem and social responsibility, problem-solving and making decision to not
smoke and having good behaviorsto avoid smoking are also higher than the control group with a
statistical significance (p<0.001) which related to the study of Phipadatpole Pinidee( 6) , Chayanisa
Pinata(7), Tidarat Poltem (8).

After the experiment, the behaviors to protect themselves from smoking among students
in experiment groupsare better thanthe control group with a statistical significance (p<0.001) which
related to the study of Benjawan Kitkuandee (9), Supparat Imwattanakul.(10)

After the experiment, the satisfaction result of students in experimental group is higher
than the control group with a statistical significance (p<0.001).
It is obvious that the program to protect students not to be a new smoker among secondary
schools has an effective change among students in experimental group before attending the
program and the overall results are higher than the control group with a statistical significance
(p<0.001).
Conclusion
According to the process of “Strong Program” which inspired by the lessons in each activity,
students in secondary schools gain more skills to protect themselves from smoking which are the
six pairs of life skills; 1.)Creativity and critical thinking, 2.)Effective communication and building
relationship with people, 3. ) Self- awareness and sympathy for others, 4. ) Emotional and stress
management, 5.) Self-esteem and social responsibility, 6.)Problem-solving and making decision to
441
not smoke and having good behaviors to avoid smoking. All these skills help change the behaviors
in a better way and help stop the number of new smokers.
Suggestions
1. This study should be applied to other groups of people such as youth, teenagers, and
university students
2. The eight-week research can provide only the primary results, therefore; there should
be a follow-up research in order to evaluate the continuity of behaviors
3. Another organizations or surrounded community should be a part of the study such as
parents, teachers, administrators, etc. to discuss about the problem and find the appropriate
solutions.
4. This researcher should not only study about using cigarettes among people, but should
also follow up about the disease caused by smoking. The program should be developed
to help more about smoking behaviors among students in secondary schools or teenagers who are
in a risky situation. Besides, this program can be applied to people who want to stop smoking.
Acknowledgments
The researcher would like to pass the gratitude to Dr. Wattanapong ChitsongsawatDeputy
Mayor of Roi- Et Municipality, Mr. Chatchai Nuanpen, Director of Health and
EnvironmentDivision of Roi- Et Municipal and all officers from Health Center 1 of Roi- Et
Municipal who have supported and cooperated from the start of the study until this research is
complete and successful.
Reference
1. National Statistical Office.Survey of smoking and drinking behavior of the population 2014.
Bangkok:Tex& JournalPublication limited;2015.
442
2. Tobacco Control Research and Knowledge Management Center (TRC)Mahidol
University.Situation of Tobacco Controlconsumption in Thailand 2016. Bangkok:Jareandee
Munkong ;2016.
3. Roi Et Municipality Health Service Center.2016.Smoking screening in students.As
ofSeptember 30, 2016.
4. Chakphan Phetchphum and Piyarat Nipitakpong.Literary review of tobacco control
measuresOf the youth.Journal of Public Health.2015;45(3):310-323.
5. Manit Kiewmanee.The application program to prevent smoking by using the individualmodel

of smoking behavior among secondaryschool students in Nom subdistrict,Atsamatdistrict
Roi-Et Province.Master of Public Health Master Thesis, Mahasarakham University;2014.
6. Phipadatpole Pinidee. The application life skills and The Policy Advocacy to Smoking
7. Prevention in Junior secondary school student,Srithat District,Udonthani Province. Master of
Public Health Master Thesis,Khon kean University;2014.
8. Chayanisa pinata.Affect of Health Education Program by Applying of Life Skills
andParticipatory Learning Process for Promoting Smoking Behavior Prevention among

Students in a Secondary School.Journal of Public Health, Khon kean University.2013;6(1):29-
36.
9. Tidarat Poltem.The Effectiveness of Health Education Program by Applying of Life Skills
Education and Social Support for Smoking Prevention Among Grade 6 Students inExtended
Opportunitieseducation School,MuangDistrict, Khon kean Province. Masterof Public Health
Master Thesis,Khon kean University;2010.
10. Benjawan Kitkhuandee.The Effectiveness ofapplication by life skill Enchancement and Social
Support Smoking PreventionJunior High School Students in OneHigh School Udonthani
Province. Masterof Public Health Master Thesis,Khon kean University;2012.
443

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Table of content

Dean of the Faculty of Public Health, Khon Kaen University

Assist. Prof. Dr. Somsak Pitaksanurat

Assist. Prof. Dr. Somsak Pitaksanurat

Dean of the Faculty of Public Health,

Khon Kaen University, Thailand

Chairperson of the Organizing Committee

Assoc. Prof. Dr. Wongsa Laohasiriwong

I would like to express my appreciations for their support and cooperation.

Assoc. Prof. Dr. Wongsa Laohasiriwong

Chairperson of the Organizing Committee

Chairman : Dr.Vanphanom Sychareun

Dean, Graduate School, University of Health Sciences, Lao PDR

Faculty of Public Health, Khon KaenUniversity, Thailand.

Asst. Prof. Dr.Pattara Sanchaisuriya

Faculty of Public Health, Khon KaenUniversity, Thailand.

Code Authors Title Page

Environment Sun Thit Wai Socio-economic disparity and exclusive breastfeeding 27

Environment SakesunThongtip Factors related to air quality perception instone mortar 56

Chairman : Dr.San San Myin Aung

Technical Advisor IRC, Myanmar.

Co-Chairman: Dr. Wilaiphorn Thinkhamrop

Faculty of Public Health, Khon Kean University, Thailand.

University of Muhammadiyah Prof.Dr.Hamka, Jakarta, Indonesia.

Code Authors Title Page

Health Payom Thinuan Physical health as a predictor of pre-frail community- 142

Chairman : Assoc. Prof. Dr.Wongsa Laohasiriwong

Vice Dean,Faculty of Public Health, Khan Kaen University, Thailand

Co-Chairman: Dr.Terdsak Promarak

Faculty of Public Health , Mahasarakham University, Thailand.

Code Authors Title Page

Health Songkramchai Competencies of public health professionals 206

Health Thazin Hlaing Socioeconomic disparity and incomplete antenatal 254

Health Napatsaporn The quality improvement of clinical risk management 265

Chairman : Professor Frank Peter Schelp

Faculty of Public Health, Khon Kaen University, Thailand.

Co-Chairman: Assoc. Prof.Dr. Songkramchai Leethongdee

Faculty of Public Health, Mahasarakham University, Thailand.

Code Authors Title Page

NCDs and Chuthamat The influences of alcohol marketing on alcohol 398

Dr. Vanphanom Sychareun

Dr. Visanou Hansana

Faculty of Public Health, Hue University of Medicine and Pharmacy, Vietnam

Prof. Dr. Vo Van Thang

University of Muhammadiyah, Jakarta, Indonesia

Dr. Bigwanto Mouhamad

University of Public Health, Yagon, Myanmar

Assoc. Prof. Dr. Mya Thandar

International Rescue Committee, Myanmar

Prof. Dr. San San Myint Aung

Dr. Aung Kay Tu

Faculty of Medicine Chiang Mai Unviersity, Thailand

Assoc. Prof. Dr. Penprapa Siviroj

Assoc. Prof. Dr. Songkramchai Leethongdee

Dr. Terdsak Promaruk

Faculty of Public Health, Naresuan University,Thailand

Asst. Prof. Dr. Nithra Kitreerawutiwong

Faculty of Medicine, Khon Kaen University, Thailand

Asst.Prof. Dr. Thitima Nutrawong

Faculty of Nursing, Khon Kaen University, Thailand