Prevalence and Risk Factors of Healthcare-Associated Infections among Hospitalized Pediatric Patients: Point Prevalence Survey in Thailand 2021.

BACKGROUND: Healthcare-associated infections (HAIs) pose a grave threat to patient safety, morbidity, and mortality, contributing to antimicrobial resistance. Thus, we estimated the point prevalence, risk factors, types, and pathogens of HAIs in hospitalized pediatric patients. METHODS: A point prevalence survey (PPS) of HAIs in hospitalized pediatric patients < 18 years old was conducted from March to May 2021. Outcomes, risk factors, and types of HAIs associated with HAIs in 41 hospitals across Thailand were collected. RESULTS: The prevalence of HAIs was 3.9% (95% CI 2.9-5.0%) (56/1443). By ages < 1 month, 1 month-2 years, 2-12 years, and 12-18 years, the prevalence of HAIs was 4.2%, 3.3%, 4.1%, and 3.0%, respectively (p = 0.80). Significant independent risk factors were extended hospital length of stay (LOS) and central venous catheter (CVC) use. Compared to an LOS of <4 days, LOSs of 4-7 days, 8-14 days, and >14 days had adjusted odds ratios (aORs) of 2.65 (95% CI 1.05, 6.68), 5.19 (95% CI 2.00, 13.4), and 9.03 (95% CI 3.97, 20.5), respectively. The use of a CVC had an aOR of 2.45 (95% CI 1.06-5.66). Lower respiratory tract infection (LRTI) was the most common HAI type (46.4%: 26/56). The highest prevalence of HAIs was predominantly observed in LRTI diagnoses, with the highest among these in the <1 month age category at 2.3% (17/738). CONCLUSION: The prevalence of HAIs in hospitalized pediatric patients was 3.9%. Extended LOS and use of CVC were HAI risk factors. A strategy for reducing LOS and reviewing insertion indications or the early planned removal of a CVC was implemented. The surveillance of HAIs stands as a cornerstone and fundamental component of IPC, offering invaluable insights that enhance hospital IPC interventions aimed at preventing HAIs.

Patterns and correlates of physical activity and sedentary behavior among Bangkok residents: A cross-sectional study.

BACKGROUND: Physical inactivity and sedentary behavior are significant risk factors for various non-communicable diseases. Bangkok, Thailand's capital, is one of the fastest-growing metropolitans in Southeast Asia. Few studies have investigated the epidemiology of physical activity and sedentary behavior among Bangkok residents. This study aims to investigate the prevalence of combined physical activity and sedentary behavior patterns among Bangkok residents and examine relationships between participants' characteristics and the combined movement patterns. METHODS: We analyzed data from the nationally representative 2021 Health Behavior Survey conducted by the Thailand National Statistical Office. The Global Physical Activity Questionnaire was used to assess physical activity and sedentary behavior. 'Sufficiently active' was defined as meeting the World Health Organization's guidelines for aerobic physical activity (≥150 minutes of moderate-to-vigorous physical activity per week). 'Low sedentary time' was defined as sitting for ≤7 hours per day. Participants were categorized into one of four movement patterns: highly active/low sedentary, highly active/highly sedentary, low active/low sedentary, and low active/highly sedentary. Multinomial logistic regression was used to identify the factors associated with each group of four movement patterns. RESULTS: Among the 3,137 individuals included in the study, the majority were categorized as highly active/highly sedentary (64.8%), followed by highly active/low sedentary (17.9%) and low active/highly sedentary (14.3%). Only a few (3.0%) of participants were categorized as being low active/low sedentary. Compared to males, female participants had a significantly higher likelihood of belonging to the highly active/low sedentary (AOR = 1.69, 95%CI: 1.25, 2.28) or highly active/highly sedentary (AOR = 1.51, 95%CI: 1.19, 1.93) group, rather than the low active/high sedentary group. Compared to unemployed/retired participants, those in labor-intensive occupations had a significantly higher likelihood of being in the highly active/low sedentary group (AOR = 1.89, 95%CI: 1.22, 2.94). Compared to participants with no chronic physical conditions, participants who reported multimorbidity had a significantly lower likelihood of being in the highly active/low sedentary group (AOR = 0.60, 95%CI: 0.37, 0.98). CONCLUSION: This study provides valuable insights into the patterns of physical activity and sedentary behavior among residents of Bangkok using up-to-date data. The majority belonged to the highly active/highly sedentary group, followed by the highly active/low sedentary group. Correlates such as sex, occupation, and chronic conditions were associated with these patterns. Targeted interventions in recreational activities, workplaces, and urban areas, including screen time control measures, movement breaks and improved built environments, are crucial in reducing sedentary behavior and promoting physical activity.

Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review.

Background: Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. Methods: A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. Results: In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Conclusion: Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.

Point prevalence survey of antibiotic use among hospitalized patients across 41 hospitals in Thailand.

Objectives: To describe the antibiotic use among hospitalized patients in Thailand. Methods: A standardized cross-sectional point prevalence survey (PPS) modified from the WHO PPS protocol was conducted in 41 selected hospitals in Thailand. All inpatients who received an antibiotic at 9 a.m. on the survey date were enrolled. The total number of inpatients on that day was the denominator. Results: Between March and May 2021, a total of 8958 inpatients were enumerated; 4745 inpatients received antibiotics on the day of the survey and there were 6619 prescriptions of antibiotics. The prevalence of antibiotic use was 53.0% (95% CI 51.1%-54.0%), ranging from 14.3% to 73.4%. The antibiotic use was highest among adults aged >65 years (57.1%; 95% CI 55.3%-58.9%). From 6619 antibiotics prescribed, 68.6% were used to treat infection, 26.7% for prophylaxis and 4.7% for other or unknown indications. Overall, the top three commonly used antibiotics were third-generation cephalosporins (1993; 30.1%), followed by first-generation cephalosporins (737; 11.1%) and carbapenems (703; 10.6%). The most frequently used antibiotics for community-acquired infections were third-generation cephalosporins (36.8%), followed by ß-lactam/ß-lactamase inhibitors (11.8%) and carbapenems (11.3%) whereas for the patients with hospital-acquired infections, the most common antibiotics used were carbapenems (32.7%), followed by ß-lactam/ß-lactamase inhibitors (15.7%), third-generation cephalosporins (11.7%) and colistin (11.7%). The first-generation cephalosporins were the most commonly used antibiotics (37.7%) for surgical prophylaxis. Seventy percent of the patients received surgical prophylaxis for more than 1 day post surgery. Conclusions: The prevalence of antibiotic use among hospitalized patients in Thailand is high and one-quarter of these antibiotics were used for prophylaxis. The majority of surgical prophylaxis was inappropriately used for a long duration post operation. Therefore, it is recommended that local guidelines should be developed and implemented.

Paths towards Universal Health Coverage: beyond political commitments.

The rapid economic growth in low and middle-income countries provides the opportunity of translating political commitment into action for achieving Universal Health Coverage. However, this is not straightforward. High donor dependence in low income countries; the lack of fiscal space; the inadequacy of attention to primary health care and under-developed pre-payment systems all pose challenges. Windows of political opportunity open up and ensuring that Universal Health Coverage makes it into the agenda of parties and subsequent holding them accountable by citizens can address political inertia. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing and addressing the main drivers of inefficiency. Moving Universal Health Coverage from political aspiration to reality requires approaching it as a citizen's rights and entitlement to health, through full subsidies for the poor and vulnerable.

Self-assessment of attitudes towards conditions to provide safe abortion among new medical graduates in Thailand, 2018: an application of cross-sectional survey with factor analysis.

BACKGROUND: Unsafe abortion is one of the major public health problems in Thailand. Although the penal code of Thailand and the Thai Medical Council permit doctors to perform safe abortion in certain conditions, little is known about the attitudes that new medical doctors have towards abortion. The objectives of this article are to explore the attitudes towards abortion in certain conditions among new medical graduates and to identify factors related to those attitudes. METHODS: A cross-sectional survey was conducted in 2018 among 2017 medical graduates who attended the annual workplace selection forum. The participants came from the two main tracks of admission to Thai medical schools: normal track and special track physicians, namely, the Collaborative Project to Increase Production of Rural Doctors (CPIRD). Of these 2017 graduates, 926 returned the questionnaire with complete information. Descriptive analysis, factor analysis, and multi-variable regression analysis were performed. RESULTS: We found that most physicians agreed to perform abortions in the context of life-threatening conditions for mothers and children, but not under conditions directly related to physical health (such as pregnancy with socioeconomic problems or pregnancy in adolescents). CPIRD doctors were less amenable than normal track doctors in providing abortions if the reason for the termination of pregnancy was related to socioeconomic problems. CONCLUSION: The study suggests that a proactive campaign for new medical graduates to raise awareness and mutual understanding of abortion services should be exercised. The CPIRD curricula relating to safe abortion should enhance the capacity of medical graduates to deal with pregnant women who face not only a physical health-related problem, but also socioeconomic difficulties and well-being as a whole.

Legislating for public accountability in universal health coverage, Thailand.

Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand's universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand's position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens' rights and government accountability has been implemented. Thailand's constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens' voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens' ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens' trust.

Maintenir la couverture sanitaire universelle exige une forte participation publique à l'élaboration des politiques et à la gouvernance. En Thaïlande, le régime de couverture universelle a été mis en œuvre dans tout le pays en 2002, permettant de couvrir l'ensemble de la population grâce à trois régimes publics d'assurance maladie et d'améliorer les résultats de santé. Bien que la position de la Thaïlande concernant les Indicateurs de gouvernance mondiaux de la Banque mondiale se soit détériorée depuis 1996, des dispositions en matière d'expression et de reddition de comptes ont été intégrées à la législation et à la structure du régime de couverture universelle. Nous discutons ici de la mise en œuvre de la législation relative aux droits des citoyens et à la reddition de comptes du gouvernement. En vertu de la constitution de la Thaïlande, les citoyens ont pu soumettre un projet de loi dont les dispositions en matière d'expression et de reddition de comptes ont été intégrées aux textes législatifs et transposées dans la loi. La législation rend obligatoire l'enregistrement des bénéficiaires, une assistance téléphonique 24h/24 et 7 j/7, des auditions publiques annuelles et une aide financière systématique pour les patients qui ont été victimes d'événements indésirables. Pour garantir le droit à des services de santé, permettre aux citoyens de faire entendre leur voix et s'assurer que des mesures soient prises, les institutions doivent être en mesure d'appliquer la législation. Par exemple, la Thaïlande devait pouvoir enregistrer 47 millions de personnes et les rattacher au réseau de prestataires de soins du district où elles vivaient, et réenregistrer les personnes qui changeaient de district. Les auditions publiques annuelles doivent faire participer les citoyens, les prestataires de soins, les organisations de la société civile et les parties prenantes telles que les collectivités locales et les groupes de patients. Les réponses qui en découlent au point de vue des politiques et de la gestion sont importantes pour instaurer la confiance dans le processus et permettre aux citoyens de se l'approprier. Les rapports annuels publics sur les résultats du régime de couverture permettent d'accroître la transparence et de renforcer la confiance des citoyens.

Para mantener la cobertura sanitaria universal se requiere una sólida participación activa del público en la formulación de políticas y la gobernanza. El plan de cobertura universal de Tailandia se implementó en todo el país en 2002, lo que permitió a Tailandia lograr una cobertura completa de la población a través de tres planes de seguro médico público y demostrar mejores resultados en materia de salud. Aunque la posición de Tailandia respecto de los Indicadores mundiales de gobernanza del Banco Mundial ha disminuido desde 1996, las disposiciones relativas a la voz y la rendición de cuentas estaban incorporadas en la legislación y en el diseño del plan de cobertura universal. Se discute cómo se ha implementado la legislación relacionada con los derechos de los ciudadanos y la rendición de cuentas del gobierno. La Constitución de Tailandia permitía a los ciudadanos presentar un proyecto de ley en el que las disposiciones sobre la voz y la rendición de cuentas se incorporaban con éxito en los textos legislativos y se aprobaban como ley. La legislación exige el registro de los beneficiarios, una línea telefónica de ayuda 24 horas al día los 7 días de la semana, audiencias públicas anuales y asistencia financiera gratuita para los pacientes que han sufrido eventos adversos. Para garantizar el derecho a los servicios de salud y que se escuche la voz de los ciudadanos y se adopten medidas, es necesario contar con la capacidad institucional para aplicar la legislación. Por ejemplo, Tailandia necesitaba la capacidad de inscribir a 47 millones de personas y ponerlas en contacto con la red de proveedores de servicios de salud del distrito en el que viven, y de volver a inscribir a los miembros que se trasladan fuera de sus distritos. Las audiencias públicas anuales deben incluir a los ciudadanos, los proveedores de servicios de salud, las organizaciones de la sociedad civil y las partes interesadas, como los gobiernos locales y los grupos de pacientes. Las respuestas políticas y de gestión subsiguientes son importantes para generar confianza en el proceso y en la apropiación del plan por parte de los ciudadanos. El informe público anual sobre los resultados y el rendimiento del plan fomenta la transparencia y aumenta la confianza de los ciudadanos.

Political economy of Thailand's tax-financed universal coverage scheme.

PROBLEM: The challenge of implementing contributory health insurance among populations in the informal sector was a barrier to achieving universal health coverage (UHC) in Thailand. APPROACH: UHC was a political manifesto of the 2001 election campaign. A contributory system was not a feasible option to honour the political commitment. Given Thailand's fiscal capacity and the moderate amount of additional resources required, the government legislated to use general taxation as the sole source of financing for the universal coverage scheme. LOCAL SETTING: Before 2001, four public health insurance schemes covered only 70% (44.5 million) of the 63.5 million population. The health ministry received the budget and provided medical welfare services for low-income households and publicly subsidized voluntary insurance for the informal sector. The budgets for supply-side financing of these schemes were based on historical figures which were inadequate to respond to health needs. The finance ministry used its discretionary power in budget allocation decisions. RELEVANT CHANGES: Tax became the sole source of financing the universal coverage scheme. Transparency, multistakeholder engagement and use of evidence informed budgetary negotiations. Adequate funding for UHC was achieved, providing access to services and financial protection for vulnerable populations. Out-of-pocket expenditure, medical impoverishment and catastrophic health spending among households decreased between 2000 and 2015. LESSONS LEARNT: Domestic government health expenditure, strong political commitment and historical precedence of the tax-financed medical welfare scheme were key to achieving UHC in Thailand. Using evidence secures adequate resources, promotes transparency and limits discretionary decision-making in budget allocation.

Surveys of knowledge and awareness of antibiotic use and antimicrobial resistance in general population: A systematic review.

BACKGROUND: Currently, various tools exist to evaluate knowledge and awareness of antibiotic use and antimicrobial resistance (AMR) and are applied by various organizations. Previous systematic reviews have focused mainly on study findings such as levels of knowledge and AMR awareness. However, the survey procedures and data instruments used ought to be scrutinized as well, since they are important contributors to credible results. This review aims to assess the study methods and procedures of existing population-based surveys and explore key components which determine the general population's levels of knowledge and awareness of antibiotic use and AMR. METHODS: We searched existing literature for population -based surveys which sought knowledge and awareness of antibiotic use or AMR in the general population. Databases searched included Ovid, MEDLINE and EMBASE, PsycINFO and Scopus, domestic journals and gray literature sources. Population-based cross-sectional studies published in English or Thai from January 2000 to December 2018 were included in the review. Quality assessment was conducted using the 'Appraisal Tool for Cross-Sectional Studies' (AXIS). RESULTS: All 22 studies included in the analysis had clear objectives focusing on assessing people's levels of knowledge, awareness, attitudes and behavior relating to antibiotic use and awareness of AMR. These studies had employed appropriate methodologies for population-based cross-sectional surveys relative to research questions. More than half of studies (14 out of 22) had scientifically soundly designed methodologies which captured the representativeness of the population; whereas the remaining studies had unclear sample size estimations, inappropriate sample frames and selection biases. Half of the studies had tested the validity and reliability of the questionnaire. The common questions used by these surveys were categorized into four themes: behavior related to antibiotic use, knowledge and awareness of antibiotic use, knowledge and awareness of AMR and others such as receiving information about antibiotic use and AMR or cross-cutting issues like self-medication. CONCLUSION: This review identified four key features of good practices in antibiotic use and awareness surveys: a) clear survey objective; b) scientifically sound sampling techniques ensuring representativeness; c) strategies for recruitment of samples and survey administration methods; and d) credible measurement to prevent non-sampling biases. During questionnaire design, the health systems context in terms of access to health services and antibiotics should be taken into account. In conclusion, to maximize the use of surveys, the application of findings in surveys and associated factors related to antibiotic use and AMR should primarily generate public health interventions and target specific groups to make progress in solving AMR problems.

The Political Economy of UHC Reform in Thailand: Lessons for Low- and Middle-Income Countries.

Thailand achieved full population coverage of financial protection for health care in 2002 with successful implementation of the Universal Coverage Scheme (UCS). The three public health insurance schemes covered 98.5% of the population by 2015. Current evidence shows a high level of service coverage and financial risk protection and low level of unmet healthcare need, but the path toward UHC was not straightforward. Applying the Political Economy of UHC Reform Framework and the concept of path dependency, this study reviews how these factors influenced the evolution of the UHC reform in Thailand. We highlight how path dependency both set the groundwork for future insurance expansion and contributed to the persistence of a fragmented insurance pool even as the reform team was able to overcome certain path inefficient institutions and adopt more evidence-based payment schemes in the UCS. We then highlight two critical political economy challenges that can hamper reform, if not managed well, regarding the budgeting processes, which minimized the discretionary power previously exerted by Bureau of Budget, and the purchaser-provider split that created long-term tensions between the Ministry of Public Health and the National Health Security Office. Though resisted, these two changes were key to generating adequate resources to, and good governance of, the UCS. We conclude that although path dependence played a significant role in exerting pressure to resist change, the reform team's capacity to generate and effectively utilize evidence to guide policy decision-making process enabled the reform to be placed on a "good path" that overcame opposition.

Achieving the targets for universal health coverage: how is Thailand monitoring progress?

Universal health coverage (UHC) is one of the targets within the Sustainable Development Goals that the Member States of the United Nations have pledged to achieve by 2030. Target 3.8 has two monitoring indicators: 3.8.1 for coverage of essential health services, for which a compound index from 16 tracer indicators has recently been developed; and 3.8.2 for catastrophic expenditure on health. The global baseline monitoring of these two indicators in 2017 shows that the progress in many low- and middle-income countries is unlikely to be on track and achieved by 2030. The monitoring and evaluation mechanism for UHC progress is a crucial function to hold governments accountable and guide countries along their paths towards UHC. This paper outlines key monitoring and evaluation tools that Thailand uses to track UHC progress; compares the strengths and limitations of each tool; and discusses monitoring gaps and enabling factors related to development of the tools. Thailand uses several data sources to monitor three UHC dimensions: population coverage; service coverage; and financial risk protection. The four key sources are: (i) national surveys; (ii) health facility and administrative data; (iii) specific disease registries; and (iv) research. Each source provides different advantages and is used concurrently to complement the others. Despite initially being developed to track progress for national health priorities, these tools are able to monitor most of the global UHC indicators. Key enabling factors of Thai monitoring systems are a supportive infrastructure and information system; a policy requirement for routine patient data records; ownership and commitment of the key responsible organizations; multisectoral collaboration; and sustainable in-country capacities. The areas for improvement are monitoring in the non-Thai population; tracking access to essential medicines; and maximizing the use of collected data. Lessons learnt from the Thai experience could be useful for other low- and middle-income countries in developing their UHC monitoring platforms.

Ultrasound surveillance for cholangiocarcinoma in an endemic area: A prove of survival benefits.

BACKGROUND AND AIM: Cholangiocarcinoma (CCA) is an aggressive malignancy with rapid progression and poor prognosis. Abdominal ultrasound surveillance may detect early-stage malignancy and improve surgical outcome. However, little data exist on the benefits of abdominal ultrasound surveillance in populations at high risk for CCA development in an endemic area. This study compared survival outcomes of CCA patients recruited through abdominal ultrasound surveillance program and those presented to the hospital independent of surveillance. METHODS: The surveillance population-based cohort was 4225 villagers in Northern Thailand, aged 30-60 years, who consented to a 5-year abdominal ultrasound surveillance program, which included interval ultrasound examinations every 6 months. The non-surveillance cohort was hospital-based CCA patients diagnosed during April 2007 to November 2015. Numbers of operable tumors, percentages of R0 resection, and survival analyses were compared between the two cohorts. RESULTS: There were 48 and 192 CCA patients in the surveillance and the non-surveillance cohorts, respectively. Of these, 37/48 (77.1%) and 22/192 (11.5%) were in an operable stage and R0 resections performed in 36/48 (97.3%) and 14/192 (63.6%), respectively. The median survival in each group was 31.8 and 6.7 months, respectively (with correction of lead time bias) (P < 0.0001). By multivariate analysis, abdominal ultrasound surveillance (hazard ratio [HR] = 0.41; P = 0.012), operable stage (HR = 0.11; P < 0.001), and serum albumin ≥ 3.5 g/dL (HR = 0.42; P < 0.001) were significantly associated with decreased mortality, whereas size of CCA (HR = 1.11; P < 0.001), serum alanine aminotransferase > 40 IU/L (HR = 1.71; P = 0.017), and tumor recurrence (HR = 4.86; P = 0.017) were associated with increased mortality. CONCLUSION: Abdominal ultrasound surveillance provided survival benefits and should be considered in areas highly endemic for CCA to reduce mortality.