This study applied the research and development model aiming to propose policy recommendations for community health management approaches during the post COVID-19 crisis management for village health volunteers (VHVs) under the New Normal Medical Services policy. Both quantitative and qualitative data were obtained from the sample groups during the post COVID-19 pandemic, which consisted of the VHVs and the groups of stakeholders participating in community health management practices in both health regional zones 5 and 6. Samples were categorized using the Social Ecological Model-based study methodology as a framework. This comprises five levels; 1) Intrapersonal Factors are the collection of elements within the VHVs that influence behavior or performance abilities. These include knowledge, attitude, and skills or KAS of VHVs; 2) Interpersonal Factors or the environment surrounding VHVs that impacts their work performances, such as peer groups, patients and family members of the VHVs, reflecting their satisfaction towards VHVs' work performance with community participation; 3) Community Factors refer to community capitals including social, human, physical, financial, and natural capitals assisting VHVs in carrying out their duties efficiently in collaboration with community stakeholder groups, such as community committees, the District and the Subdistrict Quality of Life Development Committees in each neighborhood; 4) Organizational Factors refers to factors in sectors where the VHVs works or is associated and is related to the command or control lines. These include various key performance indexes (KPIs) with many groups of stakeholders including subdistrict health promoting hospitals, district and provincial health offices, the Provincial Communicable Disease Committees and inspectors of both health regional zones; and 5) Global Crisis and Policy refers to situations at home and abroad that impact other nations throughout the globe, including the public policies declared by governments. Stakeholders are top executives of the Ministry of Public Health from the Department of Health Service Support, the Department of Disease Control, and the Department of Medical Services. Data were collected between July 2021 and February 2022. Intrapersonal and Interpersonal Factors data gathering utilized both quantitative and qualitative data collecting methods. With regards to community, organizations, global crisis conditions and public policy factors, this study used semi-structured interviews to obtain qualitative data. According to the findings, the structure of the VHV prior to the COVID-19 pandemic consisted of the following four categories: 1) project writing and implementation, 2) health promotion and disease prevention, 3) use of health information technology, and 4) community leadership and participation. After designing a model to develop a handbook for VHVs, community health managers in post-crisis management, the responsibility of the VHVs in the fifth component was determined to be crisis management after the COVID-19 pandemic. It will be required for VHVs in the future to be able to deal with the context of future public health issues that are complicated and transnational.


The World Health Organization was announced that a major pandemic a health emergency in April 2020 due to the COVID-19 pandemic. This evidence was impacted many people to stress and anxiety. Self-care is important. For reducing interpersonal interactions, technology is now increasingly active. Objectives: To develop a web application that reduces stress and anxiety resulting from the effects of the COVID-19 pandemic. This web application was designed to (1) Assess satisfaction with the use of the application website. (2) Measure the levels of stress and anxiety, and coping mechanisms. (3) Compare the effects of using a website application with a positive thinking program on reducing anxiety. (4) Synthesizing people's self-help approaches to stress and anxiety from the COVID-19 pandemic. Methodologies: Phase I was a mixed - method research to analyze data from the web application (N = 400) collected in Pathum Thani province. The instruments were the satisfaction survey, GHQ-28 Tool, Anxiety questionnaires, Coping questionnaires, and Positive Thinking Program, with the web application usage. Phase II was a quasi-experimental research method. The sample (N = 80) was randomly selected from Phase I into the experimental group (N = 40) and control group (N = 40). The experimental group completed the 15-Positive Thinking Program exercises within 20 days. Data collection was conducted from February 2022 to April 2022. The data analysis used were descriptive statistics, percentages, frequencies, averages, standard deviations, t-test dependent, and t-test independent. The content analysis used Atlast.ti software to synthesizing people's self-help Results: The sample consisted of individuals of working age, 21-30 years old (23%), 41-50 years old (19%), and 31-40 years old (18.5%). The satisfaction of using the web application was evaluated in three parts, the most satisfaction with the benefits (x ̅ = 4.04, S.D. + 0.83). The satisfaction with design, and performance were x ̅ = 4.00, S.D. + 0.78 and x ̅ = 3.14, S.D. + 1.64 respectively. The stress levels were categorized as normal (86.3 %) and abnormal levels (13.8 %). The anxiety levels were categorized as high (4.5%), moderate (49%), and low (46.5%). The coping methods used by the sampled individuals were distractions (x ̅ = 2.72, S.D. + 0.61) and positive thinking (x ̅ = 2.70, S.D. + 0.61). As a result of using web applications to reduce anxiety, anxiety scores were found within the trial group before and after using web applications with positive thinking training programs. Statistically significant differences at .05 (= 3.47, S.D. + 0.29) and (= 3.18, S.D. + 0.17) respectively, and anxiety scores between the trial group and the control group after using web applications with positive thinking training programs differed statistically significantly at .05 (= 3.18, S.D. + 0.16) and (= 3.48, S.D. + 0.33) respectively. People's self-help approaches to stress and anxiety from the COVID-19 pandemic which can reduce stress and anxiety, including relaxing by watching movies, listening to music. Cooking, planting trees, living with nature, and adjusting ideas in a positive way. Self-defense in the form of prevention of direct infection and indirect were reducing to read news which causing anxiety, choose useful news, get enough rest. exercise, eat healthy foods, and other methods, such as using mindfulness to solve problems. Promoting mental health, acceptance, etc. On the other hand, Self-help practices that have been done but rarely effect to reduce stress and anxiety include not being able to adjust your mindset, trying to forget about stress but not being able to. can't stay focused or calm your mind and can't let go. too much news. not being able to avoid risky places because it is necessary to go to work and go about daily life.


Rationale: Founded in 2009, HSRI’s Drug System Research Program has been operated as research granter and manager. In response to continual changes in Thailand’s drug system and its environment, it is necessary to revise the research direction and also enhance the Program’s management capability. Objectives: 1) to propose research direction and questions those help strengthen the Thai drug system; 2) to conduct a review of HSRI’s Drug System Research Program since its establishment in 2009; and 3) to make recommendations to the HSRI concerning drug system research management over the next five years. Methods: This study was conducted during November 2021 to June 2022. Qualitative approaches, namely document analysis, in-depth interview, and focus group discussion were involved. Results: 1. Research direction for Thailand’s drug system: over the next five years, priority should be given to research in six areas: 1) Governance of the drug system, 2) ‘pharmaceutical management and care’ to catch up the transforming health service delivery, 3) Medication literacy, 4) Roles of civil society in drug policy development and implementation, 5) Drug system and disasters /public health emergency, and 6) Development of drug industry for the country’s self reliance. 2. Review of HSRI’s Drug System Research Program: The Program’s focus was on research management at the program and organization level, without formal mechanism to gather and prioritize research questions from policymakers and stakeholders. A framework for drug system research was set annually, but some elements were left without submission from researchers. Most of the research grants were given to address the issue of rational drug use and antimicrobial resistance. Additionally, different tactics were employed in order to encourage research utilization. 3. Recommendations for drug system research management: over the next five years, HSRI should pay attention to managing drug system research at country level. The following actions should be taken: 1) Enhancing the capability of research managers, 2) Learning from past experiences of HSRI and other organizations, 3) Setting a clear definition and scope of “drug system research”, 4) Analysing the landscape of the country’s drug system research, and 5) Building drug system research capacity. Conclusion: The landscape of drug system research in Thailand is complex, as different groups of actors have a role in evidence generation and utilization. This means that national research strategy and effective governance mechanism are required, in order to pursue not only policy-relevant research with high quality, but also efficient use of resources.


Introduction The Subcommittee for Development of the Benefit Package and Service Delivery (SCBP), which holds decision-making authority for the health benefit package of the Universal Coverage Scheme (UC), requested the Health Intervention and Technology Assessment Program (HITAP) to conduct a health technology assessment of “Endovascular treatment for acute ischemic stroke”. This information will be used by the SCBP to decide whether to include endovascular therapy in the UC benefit package. Objectives This study aims to determine the value for money and the fiscal burden to the Thai government of introducing endovascular treatment for acute ischemic stroke into the UC. We also review the feasibility of providing endovascular treatment in Thailand. Methods Model-based economic evaluations, consisting of a decision tree and a Markov model, were conducted to assess the value for money (societal perspective) and budget impact analysis (provider perspective) of endovascular treatment for acute ischemic stroke, either alone or in combination with intravenous alteplase. The methodology follows the Thai methodological and process guidelines for conducting health technology assessment. Model input parameters were collected locally from retrospective data and from a literature review of both national and international studies. In addition, number of hospitals and number of specialists in radiology/neurology were gathered from the relevant Royal Colleges. Results According to the Thai cost-effectiveness threshold of 160,000 THB per quality-adjusted life-year (QALY) gained, treatment with endovascular treatment as an adjunct therapy to intravenous alteplase for alteplase eligible-patients, and endovascular therapy alone for alteplase ineligible patients is cost-effective in treating patients with acute ischemic stroke. Adding endovascular treatment to intravenous alteplase was associated with an ICER of 147,000 THB per QALY gained compared to intravenous alteplase alone. For patients ineligiblefor intravenous alteplase, the ICER of endovascular treatment alone compared to supportive care was estimated at 114,000 THB per QALY gained. With an assumption that there will be 2,000 new cases per year, an additional budget of 887 million THB over a time horizon of 5 years would be incurred if SCBP decides to adopt endovascular therapy under the Thai health benefits package. Currently, in Thailand, there are 50 specialists in radiology and neurology, located across 52 hospitals with the capacity to provide endovascular treatment for acute ischemic stroke. However, most are located in Bangkok. Conclusions Endovascular treatment for acute ischemic stroke represents good value for money, when provided alone and when delivered with intravenous alteplase. Provision of endovascular treatment in Thailand is likely to be feasible in terms of government budget and provider capacity. Thus, endovascular treatment should be included in the Thai health benefits package, with the thrombectomy device priced between 73,800 and 88,100 THB.


Genomics Thailand Project: Database for Common Single Nucleotide Polymorphisms (SNPs) in Non Communicable Diseases (NCD) is a project to study NCD patients. In the first year, 1,800 samples were received from 4 projects as follows. 1) Genetic Study in patients with high risk for cardiovascular events compared to controls, 849 samples, by Prof.Dr. Rungroj Krittayaphong and researcher team (NCD_01). 2) Association of Type 2 Diabetes Mellitus related SNP genotypes, 640 samples, by Assoc.Prof. Somlak Chuengsamarn and researcher team (NCD_02). 3) Advanced clinical phenotyping and genotyping of Thai patients with familial hypercholesterolemia (FH) for clinical application, 73 samples, by Prof.Dr. Weerapan Khovidhunkit and researcher team (NCD_05). 4) Genetic variation study of obesity in Thai patients: To develop a polygenic risk score for clinical risk assessment and personalized medicinal treatment, 238 samples, by Dr. Chartchai Chaichana (NCD_06). SNP genotyping was performed using a chip-based microarray technique on an East Asian-specific platform known as the Asian Screening Array (ASA). This is based on information in the Asian genetic database, which includes data from ethnic groups in Southeast Asia. Quality control of 659,184 SNP genotypes (SNP QC) by the GenomeStudio Software analysis program found that 1,760 samples had a call rate > 98%, (less than 2% missing data). Another 40 samples had a call rate < 98% (more than 2% missing data) and will not be analyzed further. Hardy Weinberg Equilibrium (HWE) testing of 657,060 SNP genotypes from 4 NCD research projects found that most of them had a P-value of 1, which means there were no differences in the population, and that the population is in equilibrium. This study includes examples of NCDs in the Thai population and allele frequencies of genes associated with each disease. Genes with different reported allele frequencies in hypercholesterolemia include GIPR, FAM60A, CAMK1D, HERC4, RRP12, HLA-DRA, HLA-DRB5, and QPCTL genes (P-value < 5.0E−8). The MOV10, SLC4A7, MECOM, SLC39A8, GUCY1A3 and GUCY1B3 genes are associated with hypertension (P-value < 5.0E−8). These preliminary analyses of each group of NCD patients have provided insights into genetic aspects of the diseases. Genetic factors should be analysed in combination with physiological, environmental, and behavioural characteristics of patients. These data will be analysed separately for each research project. Knowledge gained will facilitate further studies into the effective diagnosis, prevention, control, and treatment of non-communicable diseases in Thailand.


This third year research project has the main objective to compare the outcomes of treatment for at-risk of dyslexia children between the supplementary teaching group and the control group, after two years of small group reinforcement teaching with 42 and 77 high-risk students in the supplementary and control group schools entering the experiment in the second year. Teaching for a total of 24 weeks during the 3rd grade has been adjusted for in accordance with the situation of the COVID-19 epidemic. Unfortunately, the school was closed for onsite teaching in the 4th grade level. However, the students was followed up to test reading ability and to measure learning achievement in reading with the WRAT tool at the fifth grade level, with the children in the supplementary group and the control group of 32 and 58 people, respectively. For students in research projects who are not at risk group, the remaining 621 students were monitored for reading ability of elementary school children from grade 1 to grade 5. Reading abilities of not-at risk of dyslexia pupils develop at a faster rate than those of at risk of dyslexia pupils. The result of the reading test when in the fifth grade showed that the children in the at-risk group who received supplemental teaching had higher scores on reading and basic reading skills in almost all areas than the children in the control group, but not reach statistically significance. Learning achievement in reading from the WRAT test showed that 68% of the children in the supplementary teaching group and 58 percent of the children in the control group had a reading domain not lower than the standard value for more than 2 classes as there was a mild reading problem. However, the results showed that more than 90 percent of children from both groups had an achievement of writing domain less than the standard for more than two classes. In addition, reading test scores were highly correlated with WRAT scores. So, scores from the Reading Test at Grade 2 and 5 can be used to help determine the severity of the reading disability.


Background: Nakhon Phanom Hospital has the main mission of serving patients in Nakhon Phanom Province, neighboring provinces, including tourists traveling across the border from Khammouane Province, Lao PDR, but due to security regulations cause delay, and there's costs more. Objective: 1) To study the problem condition of the cross-border referral system 2) To develop the cross-border referral system Methods: The purposive sampling was used by 31 persons. The instrument was a satisfaction questionnaire with accuracy (IOC) 0.67-1.00, reliability equal 0.91. the data were analyzed using frequency, percentage, mean, standard deviation, and content analysis. The study consisted of 4 steps: 1) to study the problem condition of patient referral operation 2) develop the referral system 3) test the referral system 4) evaluate the referral system. Results: 1) Important issues in the operation of the cross-border referral system were (1) the availability of care personnel during cross-border referrals; (2) the movement of personnel who refer patients across borders; (3) the emergency expressway system during the situation. COVID-19 (4) Limitations of consulting specialists in Thailand (5) Coordination according to regulations International law (6) Information system before referral via khammouane refer (7) Ambulance cannot be delivered through border country (8) Problems with national security and special circumstances (9) the needs of the patient's relatives who must be accompanied to take care of the patient; and (10) Traffic jam from Khammuan Sub-District Hospital to Nakhon Phanom Hospital. 2) The cross-border referral system consists of 3 components: 1) Human resource development by subcomponent (1) the personnel capacity development system in providing care during referral (2) the personnel governance system and transfer equipment 2) the development of the guidelines aspects by subcomponent (1) the guidelines for caring for patients with critical illnesses (2) the emergency expressway system and consulted a specialist 3) the development of information systems by subcomponent (1) the coordination according to the regulation international law (2) the information system before referral via khammouane refer, the level of satisfaction with the referral system across border found that 1) Human resource development at a high level (x ̅ = 4.49, SD. = 0.51) by subcomponent 1.1) Satisfied with the personnel capacity development system in providing care during referral at a high level. (x ̅ = 4.59, SD. = 0.49) 1.2) Satisfied with the personnel governance system and transfer equipment at a high level (x ̅ = 4.39, SD. = 0.52) 2) Satisfied with the development of the guidelines aspects at the highest level (x ̅ = 4.56, SD. = 0.50) by subcomponent 2.1) Satisfied with the guidelines for caring for patients with critical illnesses at the highest level (x ̅ = 4.55, SD. = 0.50) 2.2) Satisfied with the emergency expressway system and consulted a specialist at the highest level (x ̅ = 4.58, SD. = 0.50) 3) Satisfied with the development of information systems at the highest level (x ̅ = 4.63, SD. = 0.48) by subcomponent 3.1) Satisfied with the coordination according to the regulation international law at the highest level (x ̅ = 4.61, SD. = 0.49) 3.2) Satisfied with the patient information system before referral via khammouane refer at the highest level (x ̅ = 4.66, SD. = 0.48) Conclusion: An effective cross-border referral system requires a personnel development plan. Development of guidelines for caring for critically ill patients as well as the development of information systems to provide quality services to patients.


The objective of this study was to develop the benefit package for diagnosis, treatment/rehabilitation, and prevention for MPS patients under universal coverage scheme. According to the medical record review from 7 rare disease centers, in November 2564 there were 81 MPS patients in Thailand (both alive and unsure status). Of these 10 were MPS I, 35 were MPS II, 11 were MPS III, 13 were MPS IV, 10 were MPS VI, and 2 were MPS VII. Proposed benefit package after stakeholder meetings include the followings; 1) Benefits for diagnosis a. Diagnosis with enzyme activity assay and molecular testing b. Carrier-testing for at-risk family members c. Prenatal diagnosis (in case that the couple desire to have another child) The 5-year budget impact for diagnosis with enzyme activity assay was estimated at 85,714 – 214,286 Baht (Average approximately 17, 143 – 42, 857 Bath per year) while those of molecular testing, carrier testing for at-risk family members, and pre-natal diagnosis were 450,000 Baht (average 90,000 baht per year), 300,000 Baht (average 60,000 baht per year), and 75,000 Baht (average 15,000 baht per year), respectively. 2) Benefit for supportive treatment. We proposed continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) for MPS patients who were in medical need. This is based on the evidences that MPS patients are at risk of severe respiratory insufficiency and these patients will get benefit from CPAP and BiPAP. This was also consistent with our interview, which found that MPS patients were in need for CPAP/BiPAP. However, both CPAP/BiPAP are not included in the benefit package. The estimated budget for inclusion of CPAP/BiPAP for MPS patients is approximately 300,000-750,000 Baht for the first year (estimate budget for year 2 onwards is approximately 40,000 to 100,000 Baht annually). 3) Benefit related to treatment system. We proposed that affected patients can receive treatment and monitoring at rare disease centers without the need for referral for every visit. We also proposed for the development of co-ordinate care so that patients could receive routine and continuous care at the local hospitals. This was based on the fact that patients with MPS requires continuous care while the number of geneticists were limited and mostly available at rare disease centers. According to the interviews, patients were facing with difficulty in transporting to get treatment. 4) Benefit related to specific treatment with HSCT: We proposed the development of the payment mechanism that reimbursed for HLA Matching cost before translation. The new payment mechanism is expected to improve patients access to HSCT care. 5) Benefit related to specific treatment with ERT Our rapid review indicated that the efficacy of ERT in terms of mortality reduction, quality of life, and important clinical outcomes were unclear and that most studies were of moderate to low quality due to small sample size. Due to the challenges in conducting studies in very limited number of patients, most studies had no comparison group and emphasized on the change on surrogate outcome after short term use of ERT. While MPS is a rare disease that profoundly affects socio-economic status, and quality of life of patients and family and that ERT is the only specific treatment available (besides HSCT) treatment with ERT is very costly. During the 2nd and 3rd stakeholder meetings, it was suggested to firstly propose ERT for MPS II into the benefit package as ERT for MPS II is currently under consideration of National List of Essential medicine committee and that there is a proposed criteria for starting, stopping, and monitoring ERT treatment for MPS II. On the other hand, ERT for MPS VI and VII are not currently approved in Thailand. Based on the expert opinion, the use of ERT among MPS II can delay disease progression and improve quality of life of the patients. Therefore, ERT for MPS II is proposed to be included in the benefit package. Nevertheless, there should be an expert committee to effectively monitor its use. If government could manage the budget in the future, the stakeholders propose to include ERT for treatment of MPS I, IV, VI, and VII, respectively.


The objective of this study was to develop the benefit package for diagnosis, treatment/rehabilitation, and prevention for pompe patients under universal coverage scheme based on service provision situation of the providers, services utilization by the patients, evidences on effectiveness/safety of Enzyme Replacement Therapy (ERT), clinical practice guideline, benefit package in other countries, and budget impact analysis. This study employed mixed method research design, which included both quantitative approach and qualitative approach, which were rapid review, analysis of secondary database, and medical record review at 7 rare disease centers, budget impact analysis, In- depth interview, and focus group discussion among stakeholders. According to the medical record review from the 7 rare disease centers, at present (year 2564) there are 2 Infantile-onset pompe disease (IOPD) patients and 4 late-onset pompe disease (LOPD) patients in Thailand. Proposed benefit package after stakeholder meetings include the followings; 1) Benefits for diagnosis: The following benefits were proposed: a. Diagnosis with enzyme activity assay and molecular testing b. Carrier-testing for at-risk family members c. Prenatal diagnosis (in case that the couple desire to have another child) The 5-year budget impact for diagnosis with enzyme activity assay was estimated at 153,333 Baht while those of molecular testing, carrier testing for at-risk family members, and pre-natal diagnosis were 105,000 Baht, 70,000 Baht, and 17,500 Baht. At present, enzyme activity assay can be performed at Chulabhorn research institute and Ramathibodi hospital while molecular testing can be performed at Chulabhorn Research Institute and several rare disease centers. 2) Benfit for specific treatment: We proposed ERT treatment with alglucosidase alfa for pompe patients and also propose to have the expert committee to closely monitor the use of ERT by adopting the starting and stopping criteria for ERT treatment as proposed by national expert working group on National List of Essential Medicine for rare disease 2565. This was based on the review of evidences, which found that ERT can dramatically alter natural history of IOPD in that ERT can reduce the risk of mortality by 87% to 99%. For LOPD, evidences also indicated that ERT can significantly reduce the risk of death as well. Based on the systematic review among LOPD patients, ERT can significantly increase 6 minute-walk test (6MWT) and improve/stabilize respiratory function. With respect to safety, ERT is relatively safe. Frequent adverse event was mild to moderate infusion associated reaction which could be prevent or manageable. Treatment with ERT was also recommended in several clinical practice guideline. In addition, treatment with ERT is currently covered by national health insurance program in England, Canada, Australia, Taiwan, and Switzerland. Budget impact if ERT is included in the benefit package for IOPD patients is estimated at 8.3, 1 2 .5, 16.7, 2 0. 9, and 25. 0 million baht for year 1 to 5, respectively. For LOPD, the budget impact for ERT was estimated at 70.1, 70.1, 87.6, 87.6, and 105.2 million baht for year 1 to 5, respectively. 3) Benefit related to treatment system. We proposed that affected patients can receive treatment and monitoring at rare disease centers without the need for referral for every visit. We also proposed for the development of co-ordinate care so that patients can receive routine and continuous care at the local hospitals. The reasons were that patients with Pompe disease require continuous care while the number of geneticists were limited and mostly were available at rare disease centers. According to the interviews, patients were facing with difficulty in transporting to get treatment. This led to the high direct nonmedical cost. 4) Benefit for supportive treatment. We proposed continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) for patients with Pompe who are in medical need. According to the clinical practice guideline, pompe patients are at risk of severe respiratory insufficiency and these patients will get benefit from CPAP and BiPAP. This was also consistent with our interview, which found that patients were in need for CPAP/BiPAP. However, both CPAP/BiPAP are not currently included in the benefit package. The estimated budget for inclusion of CPAP for pompe patients was approximately 200,000 Baht for 5 years (estimate budget for inclusion of BiPAP was around 500,000 Baht for 5 years).


Primary liver cancers, including both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), is an important cause of cancer-related deaths in Thailand and worldwide due to ineffectiveness of current available treatments. The recently developed organoid technology, which allows long-term culture of patient-derived liver cancer cells in 3D while maintaining morphology, expression pattern, and the genetic heterogeneity of the original tumors, has been shown to be powerful research tool for the discovery of biomarkers and therapeutic drugs for various cancers. In this study we successfully established 31 cancer organoids line from Thai patients with CCA and HCC, and characterized in detail these organoids with whole exome sequencing, whole transcriptomics study, single-cell RNA sequencing and pharmacophenotyping with various anticancer drugs. Our data shows patient specific response in CCA organoids and supports the usage of personalized treatment strategy for CCA. Moreover, we identified new potential biomarkers and novel compounds that can be applied to CCA management. One of the candidates for CCA drugs showed promising result in 3/3 PDX models tested. For HCC, although there is high heterogeneity among patients’ sample and limited drug response to standard drugs used in HCC management, we identified new subpopulation of HCC with high stemness, unique immunogenic profiles, and treatment response which may become interesting candidate for developing new treatment option for HCC. Overall, we successfully generate database and important tools for future development of new treatment for Thai patient with liver cancer.


This project developed the database system for health service management and health status of migrant workers in Health region number 6th of Thailand. The database was developed from public health folder of 43 health databases from the Ministry of Public Health's health information system. The result presents the information through a dashboard which can be accessed through a web browser (http://www.r6-health.info). The display consists of 5 main categories; site of health care center, time to access to health care center, demographics of migrant workers, spatial data of disease distribution, and data of COVID-19. Dashboard is friendly to user and easily for understanding. Example, a case study of COVID-19 situation, found that the prevention measures implemented by the Ministry of Public Health were able to control the outbreak of COVID-19 in the first and second wave of outbreaks. In addition, the developed database may use to show the location of medical facilities and distance to hospital which can be used for further planning of health services. There are still problems on data input to the system. Ministry of Public Health should pay attention on data input process to improve the accuracy of the dashboard.


Background: Obstructive sleep apnea (OSA) was the most common sleep-related breathing disorder. The prevalence of OSA was 15.4 in males and 6.3 in females in Thai population. OSA increased risk of car incidence and cardiovascular diseases and reduced quality of life. Level 1 polysomnography (PSG) was a precision method of OSA diagnosis. To grade the severity of sleep apnea, the number of events per hour was reported as the apneahypopnea index (AHI). Continuous positive airway pressure (CPAP) was the most common treatment for obstructive sleep apnea in patients who do not need surgery. In Thailand, PSG and CPAP were expensive and only reimbursed through the Civil Servant Medical Benefit scheme (CSMBS). Objective: To evaluate the cost-utility analysis and budget impact analysis of OSA diagnosis and treatment by PSG and CPAP compared to standard care. Method: Decision tree model and Markov model were used to estimate total costs, life years (LYs) and quality adjusted life years (QALYs) in societal perspective and governmental perspective. Relevant costs were direct medical costs and direct non-medical costs. Health outcomes were LYs gained and QALYs gained. The results were presented the incremental cost effectiveness ratio (ICER) of PSG diagnosis and CPAP treatment compared to standard care. Uncertainty analysis was conducted by one-way sensitivity analysis and probabilistic sensitivity analysis. Results: Full-night PSG and Split night PSA and CPAP treatment were cost-effective in Thai context at 160,000 Baht per QALY compared to standard care. The ICERs of moderate to severe OSA and only severe OSA patients were 86,635 – 90,014 Baht per QALY for Full-night PSG and CPAP treatment and 85,733 - 88,877 for Split-night PSG and CPAP treatment. If the capacity of PSG diagnosis increased 30% per year, the 5 years budget impact of Full-night PSG and Split-night PSG were 2,204 – 3,730 million Baht and 2,084 – 3,631 million Baht respectively.


Cholangiocarcinoma is a major public health in Thailand, especially in the northeastern region. Due to lack of early detection and poorly responsed of chemotherapeutic treatment, thus new biomarkers are urgently needed. MicroRNA/miRNA is an important genetic molecule that may function as either oncogenes or tumor suppressors. The current study aimed to identify the differential miRNA expression among serum of 50 CCA patients and 50 healthy subjects. The miRNA expression was measured by Nanostring technology. Four miRNA were found siginificantly increased expression in CCA patients; miR-320e, miR-223-3p, miR-122-5p and miR-302d-3p. These miRNA might be played a key role in oncogenesis. And three miRNA that decreased expression in CCA patients were miR-451a, miR-16-5p and miR-23a-3p. The role of these 3 miRNA might be involved with suppressed tumor growth. All these candidate miRNA might be further used as diagnosis markers or prognosis markers.


Food industry intentionally takes actions to protect its benefit through direct or indirect industrial interferences with the public policy makers. The interferences mediate via direct contact with relevant government staff. This study aimed to collect lessons learnt from the experiences of industrial interferences with the public policies from government staff, and to develop recommendations for appropriate interactions between government and the industry. This qualitative study applied 3 methods: 1) a review of the literature and related documents, 2) in-depth interviews with key informants, and 3) a Delphi survey. The present study found that Thai and multinational companies in food industry used same interference strategies, such as, written communication, direct contact with administrators and policy makers. However, multinational companies tended to more often refer to international trade regulations and rules as an important strategy that created arguments when the intervened health policy was implemented. Based on the corporate political activity (CPA), the strategies directly applied to government officials include 1) information and messaging, 2) constituency building, and 3) legal strategy. Recommendations from the present study are 1) transparency throughout the process of communication between government and industry, 2) citation of academic evidence, including the rules and regulations related to international trade in communication, 3) a clearly defined process of communication between government and industry.


The aims of this research and development were to 1) develop a model and 2) study the effectiveness of using the healthier choice nutrition symbol in noodle shops, Mueang Lampang district, Lampang province. The research process consisted of 4 steps: 1) analyze, assess needs by in-depth interview with relevant parties (R1). 2) Design and develop of a model by adjusting the noodle soup recipe using low sodium seasonings to replace the original seasonings (D1). 3) The experimental model consisted of guidelines for adjusting soup recipes, how to cook soup, measurement of sodium salt content in the soup, placement of healthier choice nutrition symbol seasonings in the shop (R2), then assessing knowledge, attitudes, and behaviors on healthier choice nutrition symbol and sodium salt content in noodle soup in the experiment group, assessing satisfaction on new noodle soup recipe with 16 purposively selected experiment samples. Data were collected by using a questionnaire and an in-depth interview. 4) The evaluations on knowledge, attitude, behavior, sodium content in soup and post-satisfaction were undertaken to improve the final optimal soup recipe (D2) using content analysis from group discussions. The results found that: step 1, noodle shop owners realized the need to reduce the use of sodium salt in soup. Step 2, developed new soup recipe using soy sauce containing potassium chloride to replace the original sodium salt. Cooking manual was developed as guidelines explaining new recipes, how to cook soup, measuring the amount of sodium salt and placement of extra seasonings in a noodle shop. Step 3, after serving new soup recipe, the noodle shop owners gained better knowledge, attitude and behavior, with reduced sodium consumption. They were satisfied at the highest level. Step 4: The evaluations revealed that the amount of sodium salt use decreased from the daily measurement. However, the present study was just a pilot scale with small sample size. The model should be extended to a larger population for more reliable results.


Increasing physical activity brings various benefits, not only preventing premature mortality and saving health care expenditure from non-communicable diseases, but also strengthening social solidarity, reducing social inequity, and improving quality of life. Environmental and policy-level interventions for physical activity are promising population-level interventions, however, the number of studies on those interventions were limited in the lower- and middle-income countries. Therefore, this study aimed to assess the existing environmental and policy interventions in Thailand for the future direction of the intervention design and development. A systematic scoping review was conducted in the primary databases (PubMed, Scopus, and Web of Science) and domestic secondary databases. To gain more understanding of the local context, 77 provincial administrative organizations’ strategic plans were further retrieved and analyzed by using the critical interpretative synthesis method. From the systematic review, 11 out of 1,681 studies were included. The results found that evidence on the active environment and active policy physical activity interventions in Thailand were limited in number and diversity, and were rather in sports facilities than physical activity. Infrastructures and urban planning for active transport were seen as a significant facilitating element by adults, while recreational amenities were the most essential factor in improving the elderly’s quality of life. At the local level, only nine provinces out of 77 invested in bicycle pathways, and 16 provinces invested in green spaces, while 42 provinces focused on sports facilities. Policy communication and translation at the local level on a comprehensive concept of physical activity, a collaborative platform between the Ministry of Public Health and Ministry of Interior to provide physical activity implementation, public communication, and routine policy evaluation should be prioritized. Further studies on physical activity policy designs for specific age groups of people were recommended.


A retrospective cohort study using real-world data was conducted to analyze the treatment patterns of tyrosine kinase inhibitors in patients with chronic myeloid leukemia (CML), compared with the guideline for regulating drug use of the National List of Essential Medicine (NLEM) category E(2), with the purpose of determining the effectiveness of tyrosine kinase inhibitors in CML patients covered by Thailand’s universal coverage scheme and social security scheme. This study focused on the treatment patterns and effectiveness of imatinib, nilotinib, and dasatinib. Data were obtained from the reimbursement database of the NLEM category E(2) during fiscal year 2012-2018. Patients were followed up until death or the end of fiscal year 2019. Descriptive statistics and non-parametric test using Kaplan-Meier method were performed in the analysis. CML patients were divided into 3 groups based on their medical history until the time of death or last follow-up as follows; 1) patients who received imatinib only (group A), 2) patients who received first-line imatinib and second-line nilotinib (group B), and 3) patients who received first-line imatinib, second-line nilotinib, and third-line dasatinib (group C). Of 574 CML patients, there were 400, 113 and 61 CML patients in groups A, B and C, respectively. The majority of patients in each group were between the ages of 30 and 39 years old (34.2%, 36.3% and 29.5 %, respectively), with a median follow-up of 36.6, 50.7 and 47.6 months. Prior to the last follow-up or drug switching, the average daily dose of imatinib in group A, B and C was 444.3, 474.1 and 474.8 mg, respectively. Real-world effectiveness using survival analysis revealed 2-year survival rates at 84.3% (95%CI: 80.3-87.6%) for group A, 91.0% (95%CI: 83.9-95.1%) for group B and 85.2% (95%CI: 73.4-92.0%) for group C, with 5-year survival rates in each group were 83.2% (95%CI: 78.9-86.7%), 85.7% (95%CI: 76.7-91.4%), and 66.4% (95%CI: 52.3-77.2%), respectively. Average daily dose of imatinib prior to drug switching was not complied with the guideline, which recommended high-dose imatinib (600-800 mg/day). The 2-year survival rates were comparable across groups (log-rank p-value 0.295), while the 5-year survival rates in group A and B were significantly higher than in group C (log-rank p-value: group A vs. C; 0.016, group B vs. C; 0.004). However, the causes of non-adherence to the guideline could not be identified due to the lack of important clinical data including cytogenic/hematologic response, drug resistance, and occurrence of adverse drug events during the treatment of CML.


This study aimed to investigate rehabilitation services framework by the disabled and family for people with intellectual disabilities, autism and learning disabilities, and to study the feasibility of developing other necessary services for policy recommendations. Data were collected using the process of lessons learnt and the focus group discussions with service providers, people with disabilities and their families in 8 disability service centers. Then, analyzing data based on the framework, considering the care process of people with disabilities throughout their lives from birth to death and needs of people with disabilities for each age range. The ultimate outcomes were that people with disabilities could live to their full potential. The results showed that the disability services centers for intellectual disabilities and autism had similar service characteristics including family peer counseling, independent living skills and social skills training, respite care, job skills training and job coach, life stop service and family support. Obviously, there were unclearly services providing in the center of disability services for individuals with learning disability. However, lessons learned from experts, parents of people with learning disabilities and related organizations indicated that emphasis should be placed on learning skills both in school and out of school together with school buddy for teacher and family in order to increase learning skills and potentiality based on individuals’ condition. This services framework would lead to the establishment of standards for service provision in the disability services centers in the future, together with the adjustments in accordance with the guidelines for the development of service systems for the disabled in the disability services centers. It covered the issue of amending the rules and regulations related to the establishment of service centers, setting service standards, service provider development, financial support, and information system.


The coronavirus disease (COVID-19) is a massive pandemic crisis occurring across Thailand and the world. It has entirely affected the health system responsiveness of Thailand. The purpose of this study was to examine the governance mechanism and management processes in response to the first wave of COVID-19 in Thailand in 2020. A retrospective document review was conducted by studying the government’s management during the COVID-19 situation between January and December 2020 via online resources and websites, and summarized our research team’s lessons learnt from direct participation in academic and strategic supports for the Operation Center of the Center for COVID-19 Situation Administration (OC-CCSA) as well as key informant interview in the stakeholders from government, private and civil society sectors. The results revealed that crisis management differed at each step. From the preparatory phase to the full outbreak response phase, the policies and measures were unidirectionally implemented as “one-size-fits-all”. During the continuous phase, regional and provincial decentralization has been used in order to align with local context to balance between health and economic outcomes.


The present qualitative study aimed to explore and understand reasons why insured persons under Social Security Act Article 40 missed paying contribution. Two data collection methods were used. First, telephone interviews, data were collected from nine village labour volunteers and community-based social security network members for Article 40 and one insured person who had experiences with Article 33, 39, and 40. The informants were from Lamphun, Burriram, Khon Kaen, Bangkok, and Phuket. Second, online public comments related to Social Security Act Article 40 published during 2011-2021 were reviewed. The findings showed that reasons the insured persons under Article 40 missed contribution payment included: too complex procedures of benefit claim, less elderly lump sum than expected, unequal benefits compared to other insurance schemes, not knowing the consequences of missed contribution payment, not knowing what and how to do when having missed contribution payments, being unaware of contribution payment deadline, inconvenience with available contribution payment channels, and poverty. These findings suggest eliminating barriers and improving ease of claiming benefits, raising awareness of health risks and consequences of missing contribution payments on benefit claims, and developing out-reach communication for contribution payment alert system, and easy to access contribution payment methods in remote communities.


There are an increasing number of dental specialists in Thailand especially within the Ministry of Public Health (MOPH), but information about their tasks’ characteristics is not well understood. This cross-sectional descriptive study aimed to explore the task proportion of specialists in MOPH’s hospitals and the determinants of their performance in three dimensions; work factors, health facility environment, and administrative environment. The results show that, aside from specialized dental services, 95.5% of dental specialists still provided basic services, and 68.2 % of them had documentary and administrative activities as part of their routine. On average, dental specialists allocated their working time to basic, specialized service, documentary and administrative works at a proportion of 41%, 48% and 11%, respectively. Work factors that might influence the performance of dental specialists were: 65.9% of respondents reported an intra-organizational agreement, 40.9% pinpointed the overwhelming burden of basic treatments over advance procedures. 18.2% reported low number of patients wanting specialized care, and 15.9% reported a shortage of general practitioners compared to work burden. Regarding health facility environments; 4.6% of dental specialists indicated lack of equipment for their advanced skills, while 31.8% mentioned absence of clear guidelines and systems for consultation or referral within a provincial dental service network. Regarding administrative environments; 38.6% and 43.2% of dental specialists pointed to a lack of policy and monitoring systems that support specialized dental services at provincial and regional levels, respectively. In conclusion, dental specialists in MOPH were responsible for basic and specialized services at similarly high proportions (41% vs. 48%), with additional documentary and administrative works. There are still rooms for development in terms of equipment adequacy, consultation and referral guidelines, policy direction and monitoring system.


3-Moh policy launched in 2020 aims that each family has three doctors at the community, health center (or Health Promoting Hospital) and hospitals (a district hospital and a provincial hospital/regional hospital). The three-doctor policy recognize three doctors at three levels. The first doctor or Moh#1 is a village health volunteer who provide health services at community level. The second doctor or Moh#2 is health workers of a health center or a sub-district health promoting hospital providing health services at Tumbon or sub-district level. The third doctor or Moh#3 is a family medicine at district or provincial hospital. working at district level. Furthermore, 3-Moh policy aims to strengthen primary care development in Thailand. This study aims to explore lesson-learned and implementation process of 3-Moh policy in 4 target provinces namely Kamphaeng Phet, Roi Et, Saraburi and Trung. These provinces have had outstanding primary care development and they target a full-area implementation of 3-Moh policy. Mixed method was employed to capture all information. To assess an understanding and satisfaction on this policy, a total of 644 self-administered questionnaires were completed by 597 respondents who are Moh#1 and47 respondents who are Moh#2 & 3. In-depth interview was conducted among 30 administrators at provincial, district and sub-district level, and 24 healthcare providers. The study demonstrated that 3-Moh policy notably fostered an achievement of Primary Care Act B.E. 2562. In term of quantity, these 4 provinces achieve the target on registration of health and care providers to population. However, the implementation of this policy is still far from achieving its goal in term of quality which consist of “recognition, familiarity, accessibility and trustworthy”. There are rooms for improvement to achieve the goals of this policy. Key enabling factors for success are an integration of primary care-related policies among departments at ministerial level, an establishment of primary care division at provincial health office for integrated implementation and systematical monitoring and evaluation and an increase number of family doctors which is considered as a bottleneck of this policy. In addition, key challenge in the future is decentralization of health centers to local governments which is considered to affect a relationship and implementing of this policy


The research objective of project “Policy Recommendation for model development of health services system and appropriated environment for elderly people in Town Municipality” were to 1) develop the health and environmental services for the elderly in Pathum Thani municipality and Khelang Nakhon Municipality, 2 ) evaluation of health and environmental service arrangements for the elderly in Pathum Thani Municipality and Khelang Nakhon Municipality and 3) synthesize policy recommendations on providing appropriate health and environmental services for the elderly in urban communities. Study design was conduct with AIC- Participatory Action Research. Qualitative data was collected from community leaders, health volunteer’s worker and government workers. Quantitative data was collected from 1,399 elderly people from Pathum Thani Municipality and 1,912 in Khelang Nakhon Municipality. The results showed that the development of health services system and appropriated environment for elderly people in Town Municipality are difference between Pathum Thani Municipality and Khelang Nakhon Municipality. The model proposed by Khelang Nakhon Municipality are to proactively organize health services for the elderly, organize recreational activities regularly, educating the elderly, setting up funds for elderly, establishing goodness banks, promoting the careers of the elderly care for the neglected or unsupervised elderly, improve the home environment, reshape and lighting of the house, provide suitable and safe shelters such as railings. While Pathum Thani Municipality proposes a model for patient referral system, EMS emergency operations centers express health volunteers to check in regularly with bedridden patients, creating value for the elderly by exchanging learning activities and earning money, find a model for sale promote the ability of caregivers to be elderly at home, organize communities, provide a conducive environment for learning for the elderly, such as online learning and assessing the environment in the elderly's home to be safe. The result of evaluation of health and environmental service arrangement models for municipal elderly found that blood glucose levels, blood pressure, body weight, body Mass Index in elderly people of Pathum Thani Municipal higher than the municipality of Khelang Nakhon, except muscle mass. Elderly people in Pathum Thani Municipality could normally defecation and urination around 90-94%, while the elderly of Khelang Nakhon Municipality the ability to defecation and urine normally 96-97 % Mental health problems in the elderly of both municipalities showed 56-62% of elderly people had the same mental health as the average, 17-21% better mental health than the average person, 19-21 % lower mental health than the average person. For depression problem in the elderly found 97% of elderly people are satisfied with their lives right now. Around 14-15% of elderly feel empty life, 12-15% feel frequently bored, 14-17% are constantly anxious and unthinkable, 21-23% have anxiety about life ahead, 17-21% is feel not as good memory as others, 7-8% feel discouraged or sad, and 5-6 % feel life is worthless. Quality of life status result found that elderly people are satisfied with their health now to a considerable extent. Around 6 2 - 6 7 % were most satisfied with sleep. 68-72% feel moderated satisfied in life (e.g. happiness, peace, hope). 65-81% feel a very high level of self-satisfaction and 65-68% as well as high satisfaction in other quality of life. Satisfaction on the appropriate health and environmental service model for the elderly of both municipalities is satisfied with the development process of the service model, but the implementation of the service model has not been fully implemented due to the complexity of the operation and requires public participation. This includes integrating work from different sectors, which must be conducted continuously. Religiously relevant activity patterns can incentivize older people to come out and participate. For environmentally safe housing arrangements in Kalen Nakhon Municipality Seven elderly people received municipal funding to repair toilets and stairs. For the municipality, Pathum Thani has not yet undertaken to explore a safe housing environment for the elderly. The Policy recommendations on providing appropriate health and environmental services for the elderly in urban communities including development of local government potential, integration of health information between local governments and health authorities for the development of the elderly services system, specify of qualifications and potential of public health volunteers, promoting supports public participation in elderly people and providing safe housing. Moreover, enhancing the use of health insurance fund budgets at the local level and push the role of educational institutions in creating initiative-taking changes in healthcare provision for local elderly people.


The universal hepatitis B vaccination for Thai newborns was integrated into the EPI in 1992. After that HB vaccine schedule had to be changed for facility to provide the vaccination. In the future, WHO will be not provide a weakened poliovirus given by mouth to infants and changed to be an inactivated poliovirus given by injection as combine vaccine likes pentavalent (wP) or hexavalent (aP) vaccine which result in the infant will be received five doses of HB vaccination in age at birth, 2, 4, 6 and 18 months. Therefore, this study is the long term to determine anti-HBs titers in the new born whom were received combine wP or aP vaccine.This study is determine anti-HBs titer in the new borns in age at birth, 7, 18, 19, 24, 36, 48, 60 and 72 months. And the results show that aP vaccine group had the anti-HBs titer and GMT level higher than wP vaccine group. However, the vaccination in age 18 months (5th dose) was influent to stimulate anti-HBs titers more than 4th dose for the both of combine vaccine. Then the long-term study show that the ant-HBs titer was initiate decreasing at age 2 year old and rapidly dropping at age 3 year old but the GMT level was remain in the same log scale in age between 3 - 6 year old. Children aged 6 year old had the level of anti-HBs (anti-HBs ≥ 10 mIU/ml) 94.2 and 62 of aP and wP vaccine group, respectively. Thus, the 5th dose for the both of combine vaccine was influent to stimulate the long term protective HB infection likes the long term study of the antibodies persistence more than 20 years after infant received monovalenct hepatitis B vaccination. Moreover, the study of antibody response to hepatitis B after immunization with monovalent hepatitis B vaccine at birth, and DTPw-HiB-HB+OPV at 2, 4, 6 months as part of national program immunization was imitating in June, 2019. After 1 and 6 moth of the 4th dose stimulation found that anti-HBs and GMT level was highly increasing levels and similar with the results of aP vaccine group at age 7 and 18 month. Therefore, the combine vaccine in EPI program might be highly effective long term against HBV infection.


The prevalence of thalassemia is found in approximately 1% of the population about 30-40% of carriers of thalassemia, it is possible to estimate that 5,125 new cases of severe thalassemia in every 1 million new born babies in Thailand. The severity of this disease is that the fetus dies while in the womb or dies within hours of birth, or if the fetus does not die, will incur the burden of direct and indirect care costs including delivery. As a result, the quality of life of patients and caregivers decreases. Currently, the National Health Security Office (NHSO) has set the rate of reimbursement for the screening and diagnosis of thalassemia in pregnant women by being included in the health benefit package. However, this compensation rate does not cover all screening costs, including hemoglobin (Hb) typing and deoxyribonucleic acid (DNA) analysis, which are considered sensitive techniques. and high specificity to screening. For this reason, couples are burdened with additional screening costs as well as the waiting time for screening and diagnosis results. Moreover, the frequency of screening follow-up and the ability to access services that are only available in large hospitals. It may be a factor contributing to a decrease in the rate of visits to screening and diagnosis of thalassemia. This study was an economic evaluation by using a cost-benefit analysis through the decision-tree model. The aim of this study was to analyze the costs and benefits of married couples from a social perspective if couples at risk were given genetic testing to diagnose thalassemia. Also, Thailand’s budget impact was determined. From the cost evaluation results, it was found that genetic testing for diagnosing thalassemia in married couples according to the Thai standard guidelines is economically cost-effective. The cost savings was 23,785 THB per prevention of a thalassemia case, and the benefit-to-cost ratio was 5.38 per 1 proportion. However, the disadvantage of Thailand's practice of screening for thalassemia carriers in pregnant women and their spouses is that the process after a pregnant woman is screened by MCV/MCH and DCIP techniques and shows positive results that we have to follow up with the husband at risk to come for an examination If there is a risk, it will continue to be examined with Hb typing technique. In case, reducing the screening process to be able to perform Hb typing immediately if a pregnant woman is at risk without waiting for results from her husband. A cost savings of 6,622 THB for the prevention of a thalassemia case when compared to the standard screening guidelines of Thailand. For the results of the budget impact analysis, it was found that there will be an increase in budget burden equal to 36 million baht per year. Therefore, from the results of the study, there are policy recommendations as follows: 1. The Royal College of Obstetricians and Gynecologists of Thailand should consider revising their screening and diagnostic guidelines, suggesting that after a pregnant woman has tested positive for MCV/MCH and DCIP, Hb typing should be screened immediately without the need to wait results from husband and after Hb typing is positive, she should be suggested to genetic test if it is unable to catch up her husband for reducing waiting time and screening process. Moreover, it would increase response rate whole diagnosis. 2. The National Health Security Office (NHSO) should manage the budget to cover both screening and diagnosis of thalassemia among pregnant women and at-risk spouses. 3. The quality of private laboratory testing by the Department of Medical Sciences should be carried out in order to increase the Hb typing and genetic testing services in order to increase the accessibility of all pregnant women and husbands. 4. There should be a systematic record of the results of screening and diagnosis, such as a health link system to be used as information for pregnant women and their husbands in the event of more than one pregnancy or transfer of medical rights. Subsequently, the screening data is not lost and the cost of screening and re-diagnosis is reduced. 5. Policy and control for new cases of thalassemia should be communicated, especially in couples planning pregnancy and general population.


In Thailand, incidence of chromosomal abnormalities such as Down syndrome is 1:800 - 1:1,000, with the risk increasing with maternal age. However, 75-80 percent of newborns with Down syndrome are found in pregnant women who less than 35 years old. In 2016, the subcommittee on health promotion and disease prevention Under the National Health Security Board (NHSO) approved the screening of Down syndrome in pregnant women as a new benefit for pregnant women aged 35 and over, and the NHSO has had agreed to expand the quadruple test in pregnant women of all age groups (quadruple for all). In 2019, there was A report evaluating the Down Syndrome Prevention and Control Pilot Program in five provinces which found that the acceptance rate for quadruple screening was relatively high, but the results of quadruple screening were false positive around 95 percent. This situation resulted in a larger number of unnecessary amniocentesis which lead to the service system cannot support. Currently, there is a non-invasive prenatal screening test (NIPT), which is a screening test for chromosomal abnormalities of the fetus by examining the genetic material of the fetus in the mother's blood, such as Trisomy 13, Trisomy 18, Trisomy 21. This test is very high sensitivity and specificity. This study used a model decision-tree to analyze the cost and benefit of various prenatal chromosomal abnormalities screenings compared to no screening, and budget impact analysis From the cost-benefit analysis, it was found that, from a government perspective, NIPT was the most cost-effective among the three groups. It was found that pregnant women younger than 35 years had a 2.37:1 cost-benefit ratio. Pregnancy over 35 years, the proportion is 12.41 : 1 and all pregnant women the proportion is 5.44 : 1. Since the cost of NIPT testing is a factor that increases the cost-effectiveness of universal NIPT testing, at the NIPT test price of 1,805 baht (80 percent reduction) found that the increased budget from serum screening at the acceptance rate that varies from 50 to 100 percent is 19-39 million baht. In summary, there are policy recommendations as follows: Governments should introduce NIPT screening policy to screen all pregnant women nationally which may be required to limit the price of NIPT examination by various agencies to be in the range of approximately 1,800 – 2,000 baht.


Objective: The objective of this study was to identify gene or genetic variants that would be responsible cannabis dependence in Thai people. Methods: We studied 144 cannabis dependent Thai people and 20 cannabis non-dependent people using whole exome sequencing and bioinformatic analysis. We used an integrated bioinformatic pipeline that combines two techniques: gene collapsing and disease module detection to identify potential genes involved in cannabis dependence. Results: Disease module detection analysis identified a single module of 53 genes with significantly higher rate of potentially damaging variant careers in cannabis dependent group compared to non-dependent group (Percentile Bootstrap’s p-value = 0.0000337, FDR=0.024). Of this module, we found that MYEF2 (Myelin Expression Factor 2; MIM 619395) was associated with cannabis dependence in our Thai cohort (Fisher’s Exact p-value = 0.0013, Odds ratio = 2.43(1.38-4.23), FDR = 0.04). MYEF2 is a single-stranded DNA-binding protein. Its role is to inhibit transcription of MBP (Myelin Basic Protein; MIM 15940) gene. MBP regulates maintenance of myeline structure. Conclusion: We propose for the first time based on our bioinformatic analyses that MYEF2 was associated with cannabis dependence.


Over the past 5 decades the government initiated compulsory three years rural service and scaled up the production. Although the number of physicians is constantly increasing, there is a lack of policy to control their mobility. The distribution of physicians varies over area and time, increases, or decreases in their number are important issues for the healthcare system. This study aimed to examine associated factors and synthesized policy options to increase the supply of rural physicians. Mixed method descriptive research design was conducted. Data collection process comprised of STEEPV analysis from document review, expertises indepth interview, rural physician stock and flow analysis, survey of factors associated with rural retention among 121 last 5 years graduated physicians, applied DCE method to determine job preference among 400 last year medical students and introduced Modified Delphi method comprising panelist with 32 expertises to develop policy options. Findings showed that 1. ageing society, chronic diseases, urbanization, technology disruption are major driving forces to transform health care system in Thailand. 2. COVID-19 impacts are still to be determined. 3. primary care is a foundation of population health improvement, any where any time service is needed. 4. Tele-health, Digital health and rapid change of advance medical & information technologies can reduce the geographical imbalance in the health workforce and increase health care accessibility. 5. urban facilities, specialist residency training and low intensity of workload are preferable job characteristics among young generation of physicians. 6. rural background physicians retain in rural areas longer than others 7. Ten policy options with high impact to retain rural physician and high possibility to implement include 1) targeted admission 2) promote task shifting & sharing among health professionals with appropriate training and regulation 3) senior/expertise supervision system 4) Telemedicine/Tele-consultation strengthening 5) prosecution support 6) fair performance based payment 7) career advancement 8) good work-life balance and manageable workloads 9) cooperation among all sectors to share resource in local area 10) Decentralized HR management in the regional level to improve performance. This study suggested to improve important interventions of compulsory service, taking multiple factors of rural retention into distribution strategy. Increasing reasonably penalty rate, non-civil servant employment and demand side financing for medical students are policy measures that should be improved based on the evidence from further studies.


When high–price drugs or new drugs with immature information about their efficacy come to market, will cause uncertainty in the health systems, especially for health–service buyers as the payers in the health systems. Managed Entry Agreement (MEA) is the tools for manage uncertainty that are widely used in many countries such as United Kingdom, two third of OECD member countries, European Union countries. MEA can be divided into two types: financial–based agreement and performance–based agreement. The financial–based agreement aims to limit budget impact through controlling drug costs. It is a simple method, effective in reduce drug prices and limit budget impact, but the details contained in the agreement are confidential, resulting in a lack of transparency. It may give some payers the benefit of such details. It can be implemented at 2 levels: population level and patient level. At the population level, consists of MEA in the model of discount / rebate, price–volume agreement, and expenditure cap. At the patient level, consists of MEA in the model of free initiation treatment and utilization cap that provides individual patient coverage. The performance–based agreement is an agreement based on the actual treatment efficacy. Sometimes referred to as health outcome–based agreement. This agreement is divided in two groups. The first group aims to optimize drug use, known as performance linked reimbursement, which consists of MEA in the model of conditional treatment continuation and pay by result. The second group aims to address uncertainty about drug efficacy with more research studies. This model of MEA is known as coverage with evidence development, or CED. It is a good solution to the problems, but it is complicated to operate, and affect stakeholders in the health systems widely, and high cost in operation. However, the decision–makers in the health system should carefully consider in the selection and implementation of MEA, as each model of MEA has different strengths and limitations, for efficient budgeting and equal access to medicines.


The cochlear implant surgery is currently an only option to treat the patients with bilateral severe or profound hearing loss. The cost of cochlear implant surgery in Thailand is around 1 million baht per case and it needs the experience surgeon to perform this operation. The success of the operation depends on many factors such as hearing level before surgery, the cause of hearing loss, duration of hearing loss, experience of using hearing aids, and readiness to rehabilitation. The Royal College of Otolaryngology – Head and Neck Surgery of Thailand had issued the guideline for cochlear implantation and suggested the need of cochlear implants registry to collect the operation results prospectively including hearing and speech levels, costs, and quality of life of the patients after surgery. This report collected the cochlear implantation data from 16 May 2016 to 29 June 2022. 1. The status of Cochlear Implants Registry in Thailand. The phase 1 to phase 3 of this study start from 16 May 2016 to 29 June 2022. There were 580 patients who underwent cochlear implant surgery. There were 289 males (52 percent), 268 females (48 percent), and 23 no gender data (4 percent). The mean age was 27. 43 ± 24. 65 years. Most patients were adults (50 percent). In children, the most common age group was 2-4 years old (15 percent). The most common cause of hearing loss was congenital (45.36 percent) and mostly idiopathic (38 percent). While the most common cause of acquire hearing loss is meningitis (18.56 percent). The mean hearing level before surgery was 95.53 dB (profound hearing loss). The mean CAP score before surgery was 0 (no awareness of environmental sound). 2. The results of cochlear implantation in Thailand After surgery, the mean hearing level at 500-4,000 Hz was significantly improved at first month post operation. The mean pure-tone hearing level was improved from profound to mild hearing loss at third month after surgery (p < 0.001). The speech hearing level was also improved from profound to mild hearing loss at third month after surgery (p < 0. 001). The speech discrimination score was improved to the level that can communicate that sixth month after surgery. The complication after surgery were found in 7.51 percent of patients. The most common events were facial palsy, vertigo, and extrusion of electrode. 3. Pre-authorization System The National Health Security Office of Thailand announced the cochlear implantation benefit for the newborn and young children since 1 January 2021 who had severe to profound hearing loss to improve the speech and language development of this group of patients. Pre-authorization (PA) for cochlear implantation surgery was developed by this project to ensure the benefit of patients including review pre-surgical condition to ensure the fitness to undergo cochlear implant surgery, review that the surgeon is adequately trained and review that the hospital has adequate staffs and instruments for surgery and rehabilitation after the surgery. The National Health Security Office of Thailand agreed to use this project’s preauthorization system as announcement NHSO 2.57/vor.2685 on 3 May 2021 before performing the cochlear implantation under the National Health Security Office of Thailand benefit.


The study of a situation analysis and system development to increase the accessibility of assistive devices with telehealth, Phase 1 was survey research. by surveying the situation of access to assistive devices in the type of wheelchairs in Thailand regarding the supply of wheelchairs, service and access systems, system gaps, obstacles, and development opportunities as well as the possibility of implementing telehealth systems. Then develop a model of a system to increase the accessibility of wheelchairs with telehealth. The study found a wheelchair for Persons with a physical disabilities to be able to be independent living, it needs to be a customizable type of device with the physical condition and lifestyle of each person with disabilities. However, it was found that the wheelchairs that can be disbursed from the three health security funds are non-adjustable metal folding wheelchairs. which is not suitable for people with physical disabilities. At the same time, a customizable wheelchair for people with disabilities can be disbursed from the list of high-value assistive devices from the Sirindhorn National Institute for Medical Rehabilitation only. causing limitations because Persons with disabilities must pick up the equipment at Sirindhorn Institute. Or even there will be a development of hospital networks in 5 provinces to be able to disburse this type of equipment. It still doesn't add much to the device's accessibility. Combined with the disbursement of such wheelchairs, body measurements, angular measurements, adjustments, and trials are required to ensure that people with mobility disabilities get the right equipment for their disability. which requires experience and knowledge of service. Therefore, training courses for providers and intensive consultations between Sirindhorn Institute and the hospitals that provide services by telehealth will help people with mobility disabilities get a truly suitable wheelchair that is for each person with disabilities under the system model which must be further implemented piloted in the second phase study.


Background: There are several recommendations for the role of a physiotherapy program (PTP) in patients with COVID-19. However, the role of PTP in COVID-19 patients with mild to moderate severity during their hospital stay remains limited. In addition, there are lack of studies on the effects of telerehabilitation in COVID-19 after discharge from the hospital. Thus, these are the reason for the current study. Objectives: 1) to determine the feasibility, safety, and effect of PTP programs in acute phase of COVID-19 patients, and 2) to investigate the effect of home-based telerehabilitation (HBT) in COVID-19 patients after discharge from the hospital. Study design: This research was a quasi-experimental study design Methods: This study comprised of two phases. Phase I (In-patient phase): Fifty-two participants were equally assigned into two groups matched on gender and age (1:1 ratio). Most of participants were identified as mild to moderate severity of disease. Experimental Group one (Ex-G1) and Experimental Group two (Ex-G2) received 1-2 times and once a day of PTP, respectively. Outcome measures included the survival and mortality rates, length of hospitalization (LoH), referrals to the intensive care unit (ICU), in-hospital complications, adverse events for patients and the physiotherapists Phase II (Out-patient phase): Participants in the control group (n = 26) were instructed to perform stretching exercises, breathing exercises, and their preferred general exercise program. Participants in experimental group (HBT) (n = 25) received aerobic exercise combined with resisted exercise and breathing exercise for 3 months. Participants in control and experimental group were called by the physiotherapists one time/ month, and one time/ week, respectively for monitoring their exercise program. The outcome measurement comprised of six minutes walk test (6MWT), one minute sit to stand (1MSTS), pulmonary function test (PFT), hand grip dynamometer, body composition, and quality of life (SF-36). Results: Phase I (In-patient phase): The overall survival rate was 98%. There was no difference in LoH between groups. One participant from the Ex-G2 was referred to the ICU. Two and four of the participants had complications in Ex-G1 and Ex-G2, respectively. There were no participants who had serious adverse events during and immediately after PTP. None of the physiotherapists tested positive for COVID-19 after performed bedside PTP. Phase II (Out-patient phase): None of participants of both groups reported of any adverse events during performed their exercise at home. There were no physical fitness components found significant differences between the group. 6MWT, and 1MSTS, were significantly increased compared to the baseline of both groups. Conclusions Phase I: The PTP is safe and feasible for COVID-19 patients in the acute phase, and safe for physiotherapists. A randomized controlled group should be confirmed the beneficial effects in the future. Phase II: The HBT is safe and feasible for patients with mild to moderate severity of COVID- 19. The higher degree of COVID-19 severity might have seen the differences in outcome measurements.


Background and Objectives: Familial hypercholesterolemia (FH) is the most common genetic cause of cardiovascular disease. This study was aimed to examine the Achilles tendon thickness using plain radiograph of lateral heels in FH subjects (diagnosed using the Dutch Lipid Clinic Network [DLCN] score above 3 [possible, probable or definite FH]), non-FH subjects with elevated LDL-cholesterol (LDL-C) >130 mg/dL and subjects with LDL-C below 130 mg/dL. The sensitivity, specificity, and optimal cutoff values with the highest diagnostic accuracy for diagnosis of FH were determined. In addition, the coronary calcium score (CAC) and aortic valve calcium (AoVC) score using computed tomography were also investigated in FH and non-FH subjects. Results: Analysis was performed among 113 FH subjects, 58 non-FH subjects with high LDL-C and 55 subjects with LDL-C <130 mg/dL. The Achilles tendons in FH subjects were significantly thicker than those in the other 2 groups. Men had thicker Achilles tendons than women, but not significantly different. The cutoff thickness values ≥6.875 mm gave the highest diagnostic accuracy of 74% with 70% sensitivity and 78% specificity. For CAC scores among 112 FH subjects and 58 non-FH subjects, the proportion of FH subjects who had CAC >0 AU was not significantly different than that of non-FH subjects but the proportion of FH subjects who had AoVC > 0 AU was significantly higher that that of the non-FH subjects (10.7% vs. 1.7%, P= 0.029). CAC scores were significantly associated with age, LDL-C burden and Thai CV risk score Conclusions: Measurements of Achilles tendon thickness by plain radiographs in 133 FH subjects showed that cutoff values of ≥6.875 mm gave 74% accuracy with 70% sensitivity and 78% specificity. The proportion of FH subjects with CAC >0 was not significantly different than that of non-FH subjects but the proportion of FH subjects who had AoVC > 0 AU was significantly higher that that of the non-FH subjects.


The COVID-19 epidemic situation is affecting the health workforce in the public health is not enough to care for the infected people. This has led to home isolation and volunteer group was formed using a telehealth care model. The objectives of this study were to 1) learned lessons from the telehealth care model of home isolation in terms of health workforce in the public health region 12 2) study the role and operation process of health workforce 3) study the success factors, problems and obstacles in the implementation of the telehealth care model with the home isolation, and 4) to synthesize lessons to form a knowledge in the 12th health zone. Used qualitative research methodology. Data were collected through structured in-depth interviews. And online group discussions with 30 volunteers and 50 patients. Data were analyzed by qualitative content analysis. Data is checked at every step of the analysis. Using a triple check Content Analysis and interpretations creates conclusions. The results of the study revealed that the telehealth care operation model with the home isolation system consists of 1) Building human resources in the form of volunteering to help carry out work in caring for home isolation patients. 2) Understanding common goals by explaining the objectives and goals of work to all volunteers. 3) Organizing training sessions to provide knowledge on various issues related to the care of COVID-19 patients. and 4) Follow up on the activities of volunteers through online meetings. The role and operation process consisted of 3 teams: the central team, the patient follow-up team, the community team, and the corps volunteer team. The key success factors were attitudes, thoughts, beliefs towards volunteer work. Knowledge and process of developing knowledge and competence of the volunteer team the problems and obstacles encountered include accessing the database system. Health workers are not only health officials, but may also come from those who consciously go through the step-by-step construction and development process. Health promotion consultation during the operation of the system.


Currently, there are no epidemiological studies in Thailand on diabetes diagnosed before the age of 30. Long-term studies in Thai children and adolescents have been published periodically less 5 years ago. Recent evidence has shown that the ratio of type 2 diabetes in Thai children has increased as well as type 1 diabetes. The etiology and clinical features of diabetes in children and adolescents have tendency to change according to environmental factors and lifestyles. The study of diabetes diagnosed under 30 years old, The project was to collect baseline patient data for registration of diabetic patients admitted to network hospitals across the country. Basic data from the patients were analyzed. Autoantibodies against three islets antigens, GAD65, IA2 and ZnT8 were measured in the laboratory to determine the incidence of type 1 diabetes. To examine the molecular genetics of diabetic patients diagnosed before the age of 30. This study was conducted in patients who were clinically compatible with NDM and MODY. The subject who had negative autoantibodies will be used to study the variation of diabetic genes by whole exome sequencing. Data on the number of people with diabetes diagnosed before the age of 30 in Thailand were collected from 31 network hospitals nationwide. Sample specimens were obtained from 750 diabetic patients diagnosed before the age of 30 years. 448 cases of type 1 diabetes (59.7%), type 2 diabetes 156 (20.8%), 43 cases of MODY diabetes (5.7%) A study of autoantibodies against three antigens islets GAD65, IA2 and ZnT8 found that patients with type 1 diabetes were positive 61.3 %. Of the 316 patients with type 1 diabetes, GAD antibody positive 52.2%, IA2 antibody positive 34.8%, and ZnT8 antibody positive 28.7%. Fourty-four patients clinically compatible with MODY subtype, in which diabetes is a dominant familial trait and no islets autoantibodies. Based on exome sequencing analysis, gene variations associated with diabetes were reported in 15 cases, while the other 29 patients with MODY had no previously reported pathogenic genes (MODY-X). This study, systematic nationwide, is a preclinical and scientific study that directly contributes to Thailand's cognition related to diagnosed diabetes under 30 years of age in Thailand. It can be used as an empirical reference and may lead to the formulation of appropriate public health policies related to diagnosis. Treatment and prevention of diabetes in young people in Thailand as well.


Background: Hereditary angioedema (HAE) is a rare and life-threatening genetic disease. This disease can lead to recurrent attacks of severe swelling occurring in areas such as the face, gastrointestinal tract, and larynx. These attacks can result in hospitalization or death. Thus, effective medications are necessary for treating the acute attacks. However, Thailand did not specify medication for treatment and prophylaxis. Therefore, effective strategies for universal health coverage for the management of HAE patients remain a challenge in Thailand. This review aims to determine the extent of research in the published literature that examine benefit package and strategies for universal health coverage for the management of HAE patients in Thailand. Method: On 5th January 2022, Embase, Scopus, OpenGrey, PubMed, Science direct, Clinicaltrials.gov, and Cochrane were searched for literature published from inception. Studies evaluating the efficacy and safety of medication for treating acute attacks in HAE patients were included. Additionally, this study performed a survey of data from the drug company, experts in the field, and stakeholders. Our survey asked about the situation, cost, and health service systems for screening, diagnosis, treatment, and referring HAE patients in Thailand. Result: Of 4,834 articles identified, 28 studies were included. Twenty-four studies are original articles, one study was a systematic review and network meta-analysis, and three studies were cost-effectiveness analyses. From current trials, first-line therapy such as Plasma-derived C1 inhibitor, Recombinant C1 inhibitor Conestat alfa, Icatibant, and Ecallantide showed benefits over placebo.However, the study related to the full economic evaluation of first-line therapy in Thailand has not been provided. Conclusion: HAE may affect the budget of Thailand if patients do not receive appropriate treatment. Thus, screening, diagnosis, and effective medication for treating acute attacks are essential measures to decrease the overall HAE-related healthcare cost. However, full economic evaluation studies of first-line therapy in Thailand are needed.


Background: Decentralization plan and Action plan of local government organization (LGO) indicate that the Office of the Permanent Secretary Ministry of Public Health (MoPH) transfers the mission regarding primary care services at Chaloem Phrakiat Health Center (CPHC) and health promotion hospital (HPH), in which the transfer should be transparent in terms of fiscal management, equity, and equality. Objectives: 1) to explore the present situation and pattern of the financial management between CPHC and HPH and public insurances, and possible patterns in the future; 2) to propose practical guidelines concerning the financial management for CPHC and HPH after transferring to the LGO, together with comparing subsequential impacts respecting to different public insurances; and 3) to develop recommendations for public insurances regarding budget allocation to CPHC and HPH after transferring to the LGO. Methods: A qualitative research to explore the pattern of financial management was conducted from the provider and healthcare payer perspectives, including both government subsidy budgets, non-government subsidy budgets, and budgets from other sources. The process consisted of 3 steps: 1) we explored the present situation and pattern of the financial management between CPHC and HPH and public insurances, and possible patterns in the future, by interviewing 48 stakeholders. Content analysis was performed afterward; 2) we proposed practical guidelines concerning the financial management for CPHC and HPH after transferring to the LGO, together with comparing subsequential impacts respecting to different public insurances, by analyzing research documents in respect to concepts and theories relating to budget allocation after decentralization; and 3) we developed recommendations for public insurances regarding budget allocation to CPHC and HPH after transferring to the LGO, using the content analysis technique. Results: 1) Health service provisions of CPHC and HPH were financed by many insurances, with the biggest contribution from the National Health Security office (NHSO). Budgets from each insurance were managed following to the regulation of the respective source. For example, the condition to allow/ not allow to use budgets for the purposes of particular activities, pharmaceuticals/non-pharmaceuticals, employment, and personnel work support in CPHC and HPH. This depends on the financial status of the service providers or contracting hospitals. 2) Suggestions for budget allocation should be divided into 2 phases. For the early phase, CPHC and HPH should deal with the current contracting hospitals to transfer budgets due to the flexibility of management and the economy of scale. Experiences from CPHC and HPH, which were already transferred to LGO several years ago, shows the consistent connection with the previous contracting hospitals; this is to minimize the effect of decentralization action to the patients during the first phase. For the late phase, there should consider finding the contracting providers under LGO to improve management flexibility in the long run. Nonetheless the selection of contracting providers should not affect access to healthcare of the patients in the area. 3) Recommendations for managing per-capita-payment for health services during the transition, MoPH should provide support to the transferring units to LGO pertaining to the regulations of how to use subvention. Supports for pharmaceuticals/non-pharmaceuticals should consider the purpose to provide services to the patients. Regarding the employment, LGO may be considered as the funder role.


Obesity has become one of the world's most serious public health issues. Because the causes of obesity are complex and multifactorial, new eras of research are opening for the effective control of obesity through gene and nutrition intake interactions. Individuals' obesity tendencies are thought to be determined by GWASs (genome-wide association studies), which leads to powerful discoveries relevant to population health. Over 300 Thai obesity participants in the Siriraj Genomic Thailand cohort to conduct a GWAS on obesity-related variables such as BMI, body composition, blood clinical profile, and dietary intake. We examined 446,370 single-nucleotide polymorphisms (SNPs) and obesity trait associations, yielding 50 SNPs with significant obesity-associated traits. We discovered five SNPs (rs114330431, rs4964357, rs12190237, rs140552528, rs12103676, and rs4713103) that were associated with increased weight, BMI, waist circumference, and hip circumference (P 0.05). Seven SNPs have been linked to rising lipid profile levels, including rs4964357, rs12190237, rs117828572, rs142722966, rs9577364, and rs11779272. We discovered the effect of genetic variants on the risk of obesity-related comorbidities, including rs142722966, rs116845541, and rs2059238 have been associated with Diabetes and metabolic syndrome difficulties, while 6 SNPs have been linked to high blood pressure issues (rs79392564, rs12033263, rs79949466, rs77592423, rs6111497, and rs1597468). Linear regression analyses of dietary energy and macronutrient intakes with the SNP. The risk allele at rs4739762 and rs75047180 was associated with increased total fat (per allele effect: 18.06 g/d (95%IC 3.83-32.29, p= 0.013)), animal protein intake (per allele effect: 23.45 g (95%IC 10.69-36.22, p<0.001)), Vitamin A intake (per allele effect: 993.86 RAE (95%IC 454.68-1533.03, p<0.001) and Niacin intake (per allele effect: 5.24 mg (95%IC 1.39-9.09, p=0.008)). In conclusion, the obesity-related genetic loci identified here provide new insights into the genetic underpinnings of adiposity in the Thai population. This study adds to our understanding of the factors that contribute to obesity, which can help influence precision nutrition for obesity prevention and treatment.