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Thin Nyein Nyein Aung,1,2 Ei Thinzar Khin,3 Saiyud Moolphate,4 Chaisiri Angkurawaranon,1,2 Motoyuki Yuasa,5,6 Myo Nyein Aung5– 7 1Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand; 2Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, 50200, Thailand; 3Graduate School of Medicine, Juntendo University, Tokyo, 113-8421, Japan; 4Department of Public Health, Faculty of Science and Technology, Chiang Mai Rajabhat University, Chiang Mai, 50300, Thailand; 5Department of Global Health Research, Graduate School of Medicine, Juntendo University, Tokyo, 113-8421, Japan; 6Faculty of International Liberal Arts, Juntendo University, Tokyo, 113-8421, Japan; 7Advanced Research Institute for Health Sciences, Juntendo University, Tokyo, 113-8421, JapanCorrespondence: Myo Nyein Aung, Email myo@juntendo.ac.jpBackground: Non-communicable diseases, including type 2 diabetes (T2DM), are the number one cause of death in Thailand. With its well-known social networking and strong kinship, evidence of social support may be a potential of low-cost approach for T2DM self- management. Social support is quite important for T2DM prevention and control but such evidence in Thai setting is still limited. Therefore, we aimed to study social support and associated determinants for T2DM patients compared to non-diabetes people.Methods: An observational study with a case–control study design was conducted in Chiang Mai, Thailand, in 2019– 2020. Using inclusion and exclusion criteria, a total of 300 participants: 150 cases, 150 controls were recruited. Participants were selected based on outcome status of having “T2DM”. Cases were defined as newly diagnosed (diagnosis of T2DM within 6 months) adult Thai residents and community controls were non-diabetes participants from the same residential area of cases. Data were analyzed by STATA 17. Descriptive analysis compared the characteristics between case and control group. The relation between social support and T2DM was investigated using multivariable Robust regression analysis.Results: About 96.7% of T2DM patients had good social support. T2DM had a significant association with social support in all models defined by potential confounders. Social support was significantly positively associated with having family mealtimes in model 2 and model 3 and increasing age in model 2. BMI and T2DM family history had significant negative association in model 2 and model 3.Conclusion: Social support of Thai T2DM patients is higher than control group. It can either be originated from a newly acquired peer groups network or from the positive social support by family. Future research should focus on behavioral intervention including family and peers to help them understand their role in life-style modification and management of such a prevalent chronic disease.Keywords: diabetes, family, global health, NCDs, social support, Thailand

Makhbuba Kalandarova,1 Ishtiaq Ahmad,1 Thin Nyein Nyein Aung,2 Saiyud Moolphate,3 Yoshihisa Shirayama,1,4 Miyoko Okamoto,1 Myo Nyein Aung,1,4,5 Motoyuki Yuasa1,4 1Department of Global Health Research, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; 2Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand; 3Department of Public Health, Faculty of Science and Technology, Chiang Mai Rajabhat University, Chiang Mai, 50300, Thailand; 4Faculty of International Liberal Arts, Juntendo University, Tokyo, 113-8421, Japan; 5Juntendo Advanced Research Institute for Health Sciences, Juntendo University, Tokyo, 113-8421, JapanCorrespondence: Ishtiaq Ahmad; Myo Nyein Aung, Department of Global Health Research, Juntendo University Graduate School of Medicine, Bunkyo City, Hongo, 2 Chome-1-1, Tokyo, 113-8421, Japan, Email ahmad@juntendo.ac.jp; myo@juntendo.ac.jpBackground: The prevalence of T2DM is escalating in Thailand affecting over 10% of adults aged 20– 79 years old. It is imperative to identify modifiable risk factors that can potentially help mitigate the risk of developing diabetes.Objective: This study aimed to investigate the relationship between dietary habits and type 2 diabetes in Chiang Mai, Thailand.Methods: This case-control study involved 300 individuals aged 25– 74 years residing in Chiang Mai, Thailand including 150 newly diagnosed T2DM patients (cases) and 150 community residents without diabetes (controls). Dietary habits were assessed based on Food Frequency Questionnaire (FFQ). Socio-demographic characteristics and anthropometric information of the participants were collected. Data analysis was performed using the STATA-17.Results: The case group participants were older and had a higher proportion of males compared to the control group. The case group exhibited a significantly higher consumption of meat, beans, nuts, soft drinks, and topping seasonings (p< 0.001), conversely, a lower intake of vegetables (p< 0.001), fruits (p=0.006), fish, rice (p< 0.001), eggs (p=0.032), milk products, coffee, and tea (p< 0.001) compared to the control group. Furthermore, the case group demonstrated a higher level of certain dietary practices such as a greater frequency of having meals with family, not removing visible fat from food (p< 0.001), and eating snacks between meals compared to controls. Multiple logistic regression analysis showed that after adjusting for potential confounding factors not removing visible fat from food (aOR 5.61, 95% CI: 2.29– 13.7, p< 0.001) and using topping seasonings (aOR 3.52 95% CI: 1.69– 7.32 p=0.001) were significantly associated with the risk of T2DM, whereas daily vegetable intake (aOR 0.32 95% CI: 0.15– 0.68 p=0.003) was inversely associated with T2DM.Conclusion: The study findings caution against the consumption of food rich in fat and using salty seasonings, while advocating for an increased intake of vegetables to prevent the prevalence of T2DM.Keywords: Thailand, T2DM, dietary habits, food frequency questionnaire, diabetes prevention, global health

Makiko Komasawa,1,2 Myo Nyein Aung,2 Christopher Nsereko,3 Robert Ssekitoleko,4 Mitsuo Isono,5 Kiyoko Saito,1 Jesca Nantume,4 Yoshihisa Shirayama,2 Shrestha Chandani,1 Motoyuki Yuasa2 1Ogata Sadako Research Institute for Peace and Development, Japan International Cooperation Agency, Tokyo, Japan; 2Department of Global Health Research, Graduate School of Medicine, Juntendo University, Tokyo, Japan; 3Department of Internal Medicine, Entebbe Regional Referral Hospital, Entebbe, Uganda; 4College of Health Sciences, Makerere University, Kampala, Uganda; 5Department of Human Development, Japan International Cooperation Agency, Tokyo, JapanCorrespondence: Makiko Komasawa, Ogata Sadako Research Institute for Peace and Development, Japan International Cooperation Agency, 10-5, Ichigaya Honmura-cho, Shinjuku-ku, Tokyo, 162-8433, Japan, Tel +81-3-3269-2911, Fax +81-3-3269-2054, Email mkomasa@juntendo.ac.jpBackground: The COVID-19 pandemic and its measures have had a profound impact on universal access to health services. We investigated the impact of the closure of the Entebbe Regional Referral Hospital (ERRH) for two years on the accessibility to necessary healthcare among non-COVID-19 patients.Methods: This mixed-methods study focused on ERRH patients with tuberculosis (TB), human immunodeficiency virus (HIV), diabetes/hypertension, and mental illness. A quantitative study used a structured-questionnaire with a primary outcome measure to assess the discontinuation of healthcare accessibility. A qualitative study with a focus group discussion (FGD) was conducted on eight patients.Results: Of the 202 quantitative survey participants, 17.8% discontinued necessary healthcare due to the ERRH closure, and the discontinuation rates differed by disease: 48.1% of TB patients, 16.0% of HIV patients, 7.8% of diabetes/hypertension patients, and 4.0% of mental health patients (P < 0.001). Almost 90% of the patients reported a worsened health condition, regardless of the disease. Multivariable logistic regression analysis showed that patients with diabetes/hypertension (adjusted odds ratio [AOR], 12.69; 95% confidence interval [CI], 2.57– 62.52) and HIV (AOR, 7.52; 95% CI, 1.37– 41.27) were more likely to discontinue healthcare than those with mental illness. The factors associated with discontinued healthcare included age ≥ 50 years vs ≤ 30 years (AOR, 4.88; 95% CI, 1.07– 22.34), and high transportation cost vs low cost (AOR, 3.15; 95% CI, 1.13– 8.75). The FGD also identified difficulties in obtaining medication, especially for TB, even though ERRH provided the outreach services.Conclusion: Our study revealed that the ERRH closure and lockdowns had an overall profound negative impact on access to healthcare and health conditions. Younger patients and those with TB were the most affected patients. This study provides practical suggestions from the field for policy makers to strengthen universal health access during health crises in Uganda and other sub-Saharan countries.Plain Language Summary: This study investigated the impact of service disruption in a tertiary hospital (ERRH) that was converted to a COVID-19-dedicated hospital for two years in Uganda. This mixed-methods study focused on the ERRH patients with tuberculosis (TB), human immunodeficiency virus (HIV), diabetes, hypertension, and mental illness. A quantitative study used a structured questionnaire with the primary outcome measure being the discontinuation of healthcare provision. A qualitative study with a focus group discussion (FGD) was conducted on eight patients. Of the 202 quantitative survey participants, 17.8% discontinued necessary healthcare due to ERRH closure, and the discontinuation rates differed by disease: 48.1% of tuberculosis patients, 16.0% of HIV patients, 7.8% of diabetes/hypertension patients, and 4.0% of mental health patients (P < 0.001). Almost 90% of the patients reported worsening health conditions. The factors associated with discontinued healthcare included age ≥ 50 years vs ≤ 30 years (AOR, 4.88; 95% CI, 1.07-22.34), and high transportation costs vs low cost (AOR, 3.15; 95% CI, 1.13-8.75). The FGD also identified difficulties in obtaining medication, especially for TB, even though the ERRH provided outreach services. Our study revealed that ERRH closures and lockdowns had profound negative impacts on access to health care and health conditions. Younger patients and those with TB were the most affected patients. This study provides suggestions from the field for policy makers to strengthen universal health access during health crises in Uganda and other sub-Saharan countries.Keywords: lockdown, public health and social measures, health service disruption, tuberculosis, HIV, mental illness

Miho Sodeno,1,2 Myo Nyein Aung,3– 5 Motoyuki Yuasa,1,3 Saiyud Moolphate,6 Virat Klinbuayaem,7 Aranya Srikhamsao,8 Thin Nyein Nyein Aung,9 Setsuko Sato,1 Takeshi Tanigawa1 1Department of Public Health, Juntendo University Graduate School of Medicine, Tokyo, Japan; 2National Center for Global Health and Medicine, Tokyo, Japan; 3Department of Global Health Research, Graduate School of Medicine Juntendo University, Tokyo, Japan; 4Advanced Research Institute for Health Sciences, Juntendo University, Tokyo, Japan; 5Faculty of International Liberal Arts, Juntendo University, Tokyo, 113-8421, Japan; 6Department of Public Health, Faculty of Science and Technology, Chiang Mai Rajabhat University, Chiangmai, Thailand; 7Sanpatong Hospital, Chiang Mai, Thailand; 8Ban Hua Rin Subdistrict Health Promotion Hospital, Chiang Mai, 50120, Thailand; 9Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, ThailandCorrespondence: Myo Nyein Aung; Miho Sodeno, Juntendo University, Hongo 2-1-1, Bunkyo Ku, Tokyo, 113-8421, Japan, Email myo@juntendo.ac.jp; msodeno@it.ncgm.go.jpBackground: Health education and promotion is active in Thailand where diabetes is prevalent at 11.6% of the general adult population in 2021.Purpose: This study aimed to describe and compare the levels of physical activity between patients with newly diagnosed diabetes and non-diabetic controls in northern Thailand.Methods: This observational case–control study included participants aged between 25 and 74 years in Chiang Mai. We recruited 150 patients with type 2 diabetes mellitus (T2DM) at Sanpatong District Hospital and 150 control participants (non-T2DM) in the community. Interviews were conducted using the International Physical Activity Questionnaires–Short Form. Anthropometric measurements and social demographic information were collected from both patients and controls in 2019.Results: The mean age of the participants was 58.8 ± 8.4 years in the T2DM group and 56.5 ± 9.9 years in the non-T2DM group. Compared to controls, patients with T2DM had received significantly more physical activity education (P < 0.001, Fisher’s test). Most cases (93.3%) had received such education at a hospital or health center. The median total metabolic equivalents (METs) minutes per week (min/week) for participants in the T2DM group were higher than those in the non-T2DM group (2726 vs 1140 METs min/week) (P < 0.001, Mann–Whitney test). Comparing the case and control groups in the category of PA level, we found that the case group had a higher proportion of high-level physical activity (P < 0.001, chi-square test).Conclusion: Diabetes patients attending a community hospital exhibited high levels of physical activity. The majority of them received education related physical activity from a primary health care service.Keywords: diabetes mellitus, DM, health education, physical activity, international physical activity questionnaires, IPAQ, Thailand

Thin Nyein Nyein Aung,1,2 Saiyud Moolphate,3 Yuka Koyanagi,4 Chaisiri Angkurawaranon,1,2 Siripen Supakankunti,5 Motoyuki Yuasa,6,7 Myo Nyein Aung6– 8 1Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand; 2Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, 50200, Thailand; 3Department of Public Health, Faculty of Science and Technology, Chiang Mai Rajabhat University, Chiangmai, 50300, Thailand; 4Department of Medical and Health Science, Tokyo Ariake University, Tokyo, 135-0063, Japan; 5Centre of Excellence for Health Economics, Faculty of Economics, Chulalongkorn University, Bangkok, 10330, Thailand; 6Department of Global Health Research, Graduate School of Medicine, Juntendo University, Tokyo 113-8421, Japan, and; 7Faculty of International Liberal Arts, Juntendo University, Tokyo, 113-8421, Japan; 8Advanced Research Institute for Health Sciences, Juntendo University, Tokyo, 113-8421, JapanCorrespondence: Myo Nyein Aung, Department of Global Health Research, Graduate School of Medicine, Juntendo University, Tokyo, 113-8421, Japan, Email myo@juntendo.ac.jpBackground: Population aging has been growing worldwide and Thailand has become an aged society with 20% of its population aged 60 and over. Age-related decline in physical and mental health impacts the health-related quality of life (HRQOL) of older adults.Purpose: We aimed to describe the HRQOL of Thai older adults, residing in the community.Methods: This cross-sectional survey was part of a Community-Integrated Intermediary Care project (CIIC), TCTR20190412004. A total of 1509 participants from an intervention arm of a cluster randomized controlled trial were included. A Thai version of the Euro-Qol questionnaire (EQ-5D-5L) was used to determine the HRQOL and associated sociodemographic background, health behaviors and underlying diseases of a representative sample from Maehia, Chiang Mai, Thailand. SPSS version 24 was used to analyze data via descriptive analysis and binary logistic regression.Results: The mean age of the participants was 69.31± 7.10 years, and nearly a quarter (23.8%) was older than 75 years. The mean EQ index score was 0.81± 0.23 and older age, lower educational attainment, unemployment, lack of exercise habits, current smokers, having history of a fall in the last 6 months, diabetes, hyperlipidemia, dependency assessed using Barthel’s Activity of Daily Living (ADL) Index, and depression using the Geriatric Depression Scale (GDS) were more likely to represent HRQOL-related problems.Conclusion: Our findings have highlighted the factors affecting the HRQOL of community-dwelling older adults which could be of importance in preparing for active and healthy aging communities. The routine dependency assessment using the ADL index will be useful in estimating the HRQOL of the aging population. Fall prevention programs are also recommended to reduce dependency. Moreover, the association of having diabetes and hyperlipidemia with problems in HRQOL dimensions highlight the need for public health intervention not only to prevent the increasing burden of non-communicable diseases but also to improve the HRQOL of older adults.Keywords: aging, Community-Integrated Intermediary Care, CIIC, health-related quality of life, HRQOL, Thailand

Ishtiaq Ahmad,1 Myo Nyein Aung,2 Satomi Ueno,1 Ei Thinzar Khin,1 Tint Swe Latt,3 Saiyud Moolphate,4 Motoyuki Yuasa1,5 1Department of Public Health, Graduate School of Medicine, Juntendo University, Tokyo, Japan; 2Advanced Research Institute for Health Sciences and Faculty of International Liberal Arts, Juntendo University, Tokyo, Japan; 3Myanmar Diabetes Association (MMDA), Yangon, Myanmar; 4Department of Public Health, Chiang Mai Rajabhat University, Chiang Mai, Thailand; 5Faculty of International Liberal Arts, Juntendo University, Tokyo, JapanCorrespondence: Myo Nyein AungAdvanced Research Institute for Health Sciences and Faculty of International Liberal Arts, Juntendo University, Bunkyo City, Hongo, 2 Chome-1-1, Tokyo, 〒113-8421, JapanTel +813-3813-3111Email myo@juntendo.ac.jpBackground: Despite the evidence that physical activity (PA) can prevent type 2 diabetes mellitus (T2DM), limited research investigated the level of PA among diabetes and non-diabetes in Myanmar, where there is the escalating prevalence of diabetes recently. We investigated PA as modified the risk of diabetes, in a case-control study.Methods: We conducted a case-control study which included 150 cases and 150 controls age 25– 74 years (Mean age 43.3± 14.7 years) among the cases and (55.1± 10.9 years) among the controls, both sex and residence in Yangon. Cases were newly diagnosed with T2DM within six months before data collection, with laboratory-confirmed fasting blood glucose level ≥ 126mg/dl. Controls were community residents, without diabetes, confirmed with a laboratory test. The IPAQ-S was used to assess the PA level. Multiple logistic regression analysis was applied in STATA 15, using the interaction terms for age and PA, adjusting age, sex and BMI.Results: In comparison to controls, cases were older and having less PA knowledge. The levels of vigorous PA were mean 254.9±standard deviations (SD) 845.6 METsmin.wk− 1 among controls, 73.06± 392.1 cases, moderate PA 631.5± 1240.8 METsmin.wk− 1 among controls and 1050.9± 1601.6 cases and walking PA 569.8± 1060 METsmin.wk− 1 among controls and 777.4± 1249 cases, respectively. The multiple logistic regression analysis showed adjusted odds ratios (aOR) 3.84, 95% confidence interval (CI) 1.18– 12.42 (P< 0.05) for those aged 40 and older, with moderate PA and aOR 18.01, Cl 6.45– 50.26 (P< 0.001) for those aged 40 and older, with low PA. Comparing the strength of association, the risk of T2DM among people aged 40 and older with moderate PA is lower than age over 40 with low PA.Conclusion: PA lessened the risk of T2DM, posted by increasing age. The findings highlighted the importance of promoting PA to reduce the T2DM prevalence in the context of Yangon, Myanmar, a low- and middle-income Asian country.Keywords: METs, effect modification, non-communicable disease; risk of diabetes, global health, public health

Thin Nyein Nyein Aung,1 Yoshihisa Shirayama,2 Saiyud Moolphate,3 Myo Nyein Aung,4 Thaworn Lorga,5 Motoyuki Yuasa21Department of Public Health, Graduate School of Medicine, Juntendo University, Tokyo, Japan; 2Faculty of International Liberal Arts, Juntendo University, Tokyo, Japan; 3Department of Public Health, Faculty of Science and Technology, Chiang Mai Rajabhat University, Chiangmai, Thailand; 4Advanced Research Institute for Health Science, and Faculty of International Liberal Arts, Juntendo University, Tokyo, Japan; 5Department of Research and Community Engagement, Research Coordinating Unit, Boromrajonani College of Nursing, Nakhon Lampang, ThailandBackground and purpose: When migrants go to a new country to work, they experience transition of epidemiological risk factors, a new system of access to healthcare and changing life styles. Their comprehension of health risk factors will depend on acculturation pattern. Moreover, musculoskeletal disorders (MSDs) are significantly prevalent in such a population due to the manual work in their jobs. Myanmar immigrant’s acculturation level has not yet been studied in relation to prevalent diseases. This study aimed to investigate health risk behaviors, the prevalence of musculoskeletal disorders, and associated factors.Methods: A cross-sectional study surveyed 414 Myanmar migrant workers in Chiangmai, Thailand. Face-to-face interviews administered structured questionnaires which comprised the transculturally validated East Asian Acculturation Measure scale, Standardized Nordic musculoskeletal questionnaires, Patient Health Questionnaires 2 and 9 for depression and questionnaires to screen health behaviors and jobs. Data analysis applied binary logistic regression.Results: About 26.3% were current smokers and 40.8% current drinkers. Of the 75.8% of participants did not exercise, 40.1% were overweight and obese, 44.7% had prehypertension, 27.1% hypertension, and 13% had depression. The prevalence of MSDs at any site over the previous 12 months was 53.4% and it was significantly associated (P-value≤0.05) with female (adjusted odd ratio (aOR)=1.75; 95% confidence interval (CI)=1.04–2.94), depression (aOR=2.19;CI=1.10–4.39), marginalization pattern of acculturation (aOR=1.87;CI=1.09–3.21) and MSDs at any site last week (aOR=8.41;CI=4.09–17.30).Conclusion: Health behaviors in this young, working migrant population are risky, and MSDs are common problems for migrant workers in northern Thailand. Findings of the current study highlighted health behaviors and cultural adaption as attributes to chronic, disabling, and common health problems of migrant workers. Public health interventions and recommendations considering this evidence may improve migrants’ health status, leading to better quality-of-life and productivity.Keywords: acculturation, depression, health risk behaviors, musculoskeletal disorders, Myanmar migrant workers, Thailand

Tint-Swe Latt,1,2 Ko-Ko Zaw,3 Ko Ko,4 Moh-Moh Hlaing,3 Mya Ohnmar,3 Ei-Sandar Oo,5 Kyaw-Myint-Myat Thein,6 Motoyuki Yuasa2 1Myanmar Diabetes Association, Yangon, Myanmar; 2Department of Public Health, Juntendo University, Graduate School of Medicine, Tokyo, Japan; 3Department of Medical Research, Ministry of Health and Sports, Naypyidaw, Myanmar; 4University of Medicine 2, Yangon, Myanmar; 5University of Public Health, Yangon, Myanmar; 6Diabetes Project, Department of Health, Ministry of Health and Sports, Naypyidaw, Myanmar Background: Myanmar, a low-income Southeast Asia country with an estimated population of 53.9 million, is currently facing an increasing burden of noncommunicable diseases. Research that systematically measures and reports the national prevalence of diabetes and prediabetes within Myanmar represents a gap in the literature. This study, a national survey, was conducted with the objectives of 1) measuring diabetic population, 2) measuring the prediabetic population, and 3) finding out the risk factors leading to diabetes and prediabetes in Myanmar. Method: Multistage sampling was applied in proportional cluster approach to recruit a nationally representative sample of 8,575 participants from 52 townships selected to represent 332 townships across the country. The Ethical Committee of the Department of Medical Research (Lower Myanmar) approved the current study. Fasting plasma glucose and the level of glucose 2 hours after 75 g glucose load were applied, to screen for diabetes and prediabetes. Interviewer-administered questionnaires were carried out to investigate demographic and lifestyle behaviors. Stadiometer, weighing scale, measuring tape, and Omron blood pressure monitor measuring devices were used for the anthropometric measurements. Survey data analysis used STATA version 13 and application of descriptive statistics with multinomial logistic regression. Result: Prevalence of diabetes in Myanmar was 10.8%: 11.5% in males and 9.2% in females. Overall prevalence of prediabetes was 19.7%: 16.5% in males and 23% in females. Increasing age, urban residence, big waist circumference, and high triglyceride level were significant factors associated with diabetes and prediabetes. Many people with diabetes were found to lack knowledge and awareness of diabetes. Conclusion: Diabetes prevalence in Myanmar is high, and relatively higher than that reported in many Association of Southeast Asian Nations countries. The study findings call for urgent nationwide public health action in Myanmar such as screening people at risk of diabetes and prevention of the disease. The findings can also assist the health authority in Myanmar with the preparation and allocation of resources for diabetes prevention. Keywords: Yangon, waist circumference, prediabetes, diabetes, triglyceride

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