Lessons from the Thai Health Promotion Foundation

The Thai Health Promotion Foundation: Two Decades of Joint Contributions to Addressing Noncommunicable Diseases and Creating Healthy Populations

Globally, the current investment in preventive care is inadequate and ineffective for addressing noncommunicable diseases and their causes. The Thai Health Promotion Foundation, with its sustainable funding from 2% levies on tobacco and alcohol, together with partners, has been used to address noncommunicable diseases effectively.

Awareness of tobacco industry tactics among tobacco control communities in Thailand and its association with attitudes towards tobacco industry and perceptions of e-cigarettes

BACKGROUND

Tobacco industry denormalisation is a key strategy recommended by the WHO Framework Convention on Tobacco Control as it is associated with reducing smoking behaviours and positively influencing public and policymakers' opinion towards tobacco control. However, studies of awareness of tobacco industry tactics among public health players and policymakers in low-income and middle-income countries are limited.

METHODS

We conducted an online survey of individuals who had been involved in tobacco control in Thailand. Multivariate ordinal logistic regression analysis was used to determine the association between awareness of tobacco industry tactics and different attitudes towards tobacco industry and perceptions towards e-cigarettes, controlling for role in tobacco control and demographics among 441 respondents.

RESULTS

Of the respondents, 11.3% had never heard of any tobacco industry tactics, whereas 11.1% had heard of all tactics asked in the survey. Tobacco industry tactics which were less known by participants were intimidation (30.6%) and illicit trade (37.4%). Participants who were more aware of tobacco industry tactics were more likely to have negative attitudes towards the tobacco industry and e-cigarettes. Compared with active experts of the Provincial Tobacco Products Control Committee and provincial public health officials who work in tobacco control programmes, advocates who worked for civil society organisations in tobacco control were more aware of tobacco industry tactics and had less favourable perceptions of e-cigarettes.

CONCLUSION

This study emphasises the importance of educating public health professionals and policymakers about tobacco industry behaviour, especially in the era of e-cigarettes.

Economic costs of alcohol consumption in Thailand, 2021

BACKGROUND

Alcohol is one of the leading risk factors contributing to avoidable economic loss worldwide. Estimates from the economic cost of alcohol consumption studies play an important role in prioritizing healthcare resource use, supporting policy decisions, and justifying budgets for alcohol policy. This study aimed to estimate the economic burden associated with alcohol consumption in Thailand in 2021.

METHODS

Prevalence-based cost of illness methodology was employed. The following costs were included in the analysis: healthcare costs; cost of law enforcement; cost of property damage due to road traffic accidents; cost of premature mortality; and cost of absenteeism from out-patient hospital visits and hospitalization. Human capital approach was adopted. All costs were presented in Thai baht, 2021.

RESULTS

Alcohol consumption incurred a total estimated economic cost of 165,450.5 million baht, equivalent to 1.02% of Gross Domestic Product (GDP) and 2500 baht per capita. Cost of premature mortality was estimated at 157,918.7 million baht and accounted for the largest proportion of the total cost (95.45%). Healthcare cost was found to be the second highest share representing 4370.1 million baht (2.7% of the total cost). The number of premature death attributable to alcohol consumption in 2021 was estimated at 22,804.

CONCLUSIONS

Alcohol continues to impose a substantial economic burden in Thailand. Enforcement of existing well-formulated alcohol control policies is urgently required to mitigate the economic impact of alcohol consumption in the country.

How Could Taxes on Sugary Drinks and Foods Help Reduce the Burden Of Type 2 Diabetes?

PURPOSE OF REVIEW

Taxes on sugary drinks and foods have emerged as a key strategy to counteract the alarming levels of diabetes worldwide. Added sugar consumption from industrialized foods and beverages has been strongly linked to type 2 diabetes. This review provides a synthesis of evidence on how taxes on sugary products can influence the onset of type 2 diabetes, describing the importance of the different mechanisms through which the consumption of these products is reduced, leading to changes in weight and potentially a decrease in the incidence of type 2 diabetes.

RECENT FINDINGS

Observational studies have shown significant reductions in purchases, energy intake, and body weight after the implementation of taxes on sugary drinks or foods. Simulation studies based on the association between energy intake and type 2 diabetes estimated the potential long-term health and economic effects, particularly in low- and middle-income countries, suggesting that the implementation of sugary food and beverage taxes may have a meaningful impact on reducing type 2 diabetes and complications. Public health response to diabetes requires multi-faceted approaches from health and non-health actors to drive healthier societies. Population-wide strategies, such as added sugar taxes, highlight the potential benefits of financial incentives to address behaviors and protective factors to significantly change an individual's health trajectory and reduce the onset of type 2 diabetes worldwide, both in terms of economy and public health.

Characteristics of successful government-led interventions to support healthier populations: a starting portfolio of positive outlier examples

Despite progress on the Millennium and Sustainable Development Goals, significant public health challenges remain to address communicable and non-communicable diseases and health inequities. The Healthier Societies for Healthy Populations initiative convened by WHO's Alliance for Health Policy and Systems Research; the Government of Sweden; and the Wellcome Trust aims to address these complex challenges. One starting point is to build understanding of the characteristics of successful government-led interventions to support healthier populations. To this end, this project explored five purposefully sampled, successful public health initiatives: front-of-package warnings on food labels containing high sugar, sodium or saturated fat (Chile); healthy food initiatives (trans fats, calorie labelling, cap on beverage size; New York); the alcohol sales and transport ban during COVID-19 (South Africa); the Vision Zero road safety initiative (Sweden) and establishment of the Thai Health Promotion Foundation. For each initiative a qualitative, semistructured one-on-one interview with a key leader was conducted, supplemented by a rapid literature scan with input from an information specialist. Thematic analysis of the five interviews and 169 relevant studies across the five examples identified facilitators of success including political leadership, public education, multifaceted approaches, stable funding and planning for opposition. Barriers included industry opposition, the complex nature of public health challenges and poor interagency and multisector co-ordination. Further examples building on this global portfolio will deepen understanding of success factors or failures over time in this critical area.

Effective coverage of diabetes and hypertension: an analysis of Thailand's national insurance database 2016-2019

OBJECTIVES

This study assesses effective coverage of diabetes and hypertension in Thailand during 2016-2019.

DESIGN

Mixed method, analysis of National health insurance database 2016-2019 and in-depth interviews.

SETTING

Beneficiaries of Universal Coverage Scheme residing outside Bangkok.

PARTICIPANTS

Quantitative analysis was performed by acquiring individual patient data of diabetes and hypertension cases in the Universal Coverage Scheme residing outside bangkok in 2016-2019. Qualitative analysis was conducted by in-depth interview of 85 multi-stakeholder key informants to identify challenges.

OUTCOMES

Estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases) were compared. Controlled diabetes was defined as haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mm Hg.

RESULTS

Estimated cases were 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes, all indicators have shown slow improvement between 2016 and 2019 (67.4%, 69.9%, 71.9% and 74.7% for detected need; 38.7%, 43.1%, 45.1% and 49.8% for crude coverage and 8.1%, 10.5%, 11.8% and 11.7% for effective coverage). For hypertension, the performance was poorer for detection (48.9%, 50.3%, 51.8% and 53.3%) and crude coverage (22.3%, 24.7%, 26.5% and 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1% and 15.7%) than diabetes. Results were better for the women and older age groups in both diseases. Complex interplays between supply and demand side were a key challenge. Database challenges also hamper regular assessment of effective coverage. Sensitivity analysis when using at least three annual visits shows slight improvement of effective coverage.

CONCLUSION

Effective coverage was low for both diseases, though improving in 2016-2019, especially among men and ัyounger populations. The increasing rate of effective coverage was significantly smaller than crude coverage. Health information systems limitation is a major barrier to comprehensive measurement. To maximise effective coverage, long-term actions should address primary prevention of non-communicable disease risk factors, while short-term actions focus on improving Chronic Care Model.

Successful health promotion, its challenges and the way forward in Nepal

Health promotion is the most favorable approach and process to achieve a positive health outcome of the population. Several countries across the world are committed to achieving positive health for their people with the best health promotion strategies. Health promotion, in fact, shares a large portion of health care economy and resources in many countries. A low-income country like Nepal, however, lacks the implementation of rigorous health care strategies on a large scale and is deficient in evidence of the potential scope of health promotion. Nepal has adopted the global health promotion declaration on paper; however, health care providers and authorities are still working in a traditional way using existing health policies and strategies. This paper aims to explore some of the global best practices of health promotion, including the challenges and opportunities by adopting such practices in Nepal, and provides some recommendations as a way forward.

Three Growth Spurts in Global Physical Activity Policies between 2000 and 2019: A Policy Document Analysis

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations-women, girls, and adolescents-requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.

Association Between Physical Activity and Type 2 Diabetes Using the International Physical Activity Questionnaires: A Case-Control Study at a Health Promoting Hospital in Chiang Mai, Northern Thailand

BACKGROUND

Health education and promotion is active in Thailand where diabetes is prevalent at 11.6% of the general adult population in 2021.

PURPOSE

This study aimed to describe and compare the levels of physical activity between patients with newly diagnosed diabetes and non-diabetic controls in northern Thailand.

METHODS

This observational case-control study included participants aged between 25 and 74 years in Chiang Mai. We recruited 150 patients with type 2 diabetes mellitus (T2DM) at Sanpatong District Hospital and 150 control participants (non-T2DM) in the community. Interviews were conducted using the International Physical Activity Questionnaires-Short Form. Anthropometric measurements and social demographic information were collected from both patients and controls in 2019.

RESULTS

The mean age of the participants was 58.8 ± 8.4 years in the T2DM group and 56.5 ± 9.9 years in the non-T2DM group. Compared to controls, patients with T2DM had received significantly more physical activity education (P < 0.001, Fisher's test). Most cases (93.3%) had received such education at a hospital or health center. The median total metabolic equivalents (METs) minutes per week (min/week) for participants in the T2DM group were higher than those in the non-T2DM group (2726 vs 1140 METs min/week) (P < 0.001, Mann-Whitney test). Comparing the case and control groups in the category of PA level, we found that the case group had a higher proportion of high-level physical activity (P < 0.001, chi-square test).

CONCLUSION

Diabetes patients attending a community hospital exhibited high levels of physical activity. The majority of them received education related physical activity from a primary health care service.

Successful countering of tobacco industry efforts to overturn Thailand's ENDS ban

BACKGROUND

After Thailand enacted laws to ban the import and sale of all types of electronic nicotine delivery systems (ENDS, including e-cigarettes and heated tobacco products (HTPs)) in 2015, pro-ENDS advocacy groups pressured the government to lift the ban, particularly after Philip Morris International (PMI) started promoting its HTP IQOS in 2017.

METHODS

We reviewed information related to ENDS in Thailand between 2014 and 2019 from Thai newspaper articles, meeting minutes and letters submitted to government agencies, websites and social media platforms of pro-ENDS networks and Thai tobacco control organisations.

RESULTS

The tobacco industry and the pro-ENDS groups used five tactics to try to reverse the Thai ban on ENDS: creating front groups, lobbying decision-makers, running public relations campaigns, seeking to discredit tobacco control advocates and funding pro-tobacco harm reduction research. ENDS Cigarette Smoking Thailand (ECST), a pro-ENDS group in Thailand, worked in parallel to Philip Morris Thailand Limited (PMTL) to oppose the ban. The group connected with international coalitions that promote harm reduction through the PMI-funded Foundation for a Smoke-Free World.

CONCLUSION

Although ECST and PMTL continuously worked to revoke the ban since 2017, the government still kept ENDS illegal as of October 2020. This decision resulted from the strong commitment and collaboration among Thai tobacco control organisations and their shared vision to protect the public's health from harmful tobacco products. The similar strategies used by the pro-ENDS movement in Thailand and the tobacco companies could inform health advocates and policy-makers in other low and middle income countries facing pressure to market ENDS.

Intervening alcohol marketing to reduce harmful alcohol use and lessons learned from the theory of changes: Case studies in Thailand

Objectives

Study design

Methods

Results

Conclusions

•

Theory of change and causal-loop diagram are practical tools for approaching the complex harmful alcohol use reduction.

•

Intervening alcohol marketing needs a systematic approach in shifting the social norms.

•

Community-based actions/campaigns associated with the decline of alcohol-related injuries in Thailand.

Development and Validation of Oral Health Literacy Questionnaire for Thai Adults

AIM

The purpose of the study was to develop a valid and reliable oral health literacy questionnaire for the Thai adults. It measures functional, communicative, and critical competency, covering four competencies according to the context of daily living, namely, oral health service, home and community, marketplace, and community public forums.

MATERIALS AND METHODS

A cross-sectional study was carried out in 420 Thai adults who were the dental clients of an oral health service system. Subjects were recruited into the study by multistage stratified random sampling. Data were collected by interviewing using the newly developed oral health literacy questionnaire. After checking for the completeness and correctness of the data, the validity and reliability of the questionnaire were analyzed by calculation of the sensitivity, specificity, and positive predictive and negative predictive values. Receiving-operating characteristic (ROC) curve was performed and showed the area under ROC that indicates the diagnostic performance of the questionnaire.

RESULTS

High reliability was found as Cronbach's alpha = 0.878 and the validity proved by known-group method, presented as ability to classify subjects as having adequate, or inadequate oral health literacy was also high, given the sensitivity = 0.853, the specificity = 0.848, and the area under ROC curve = 0.858.

CONCLUSION

The newly developed oral health literacy questionnaire for Thai adults was valid and reliable.

South Africa's Health Promotion Levy: Excise tax findings and equity potential

In 2016, the South African government proposed a 20% sugar-sweetened beverage (SSB) tax. Protracted consultations with beverage manufacturers and the sugar industry followed. This resulted in a lower sugar-based beverage tax, the Health Promotion Levy (HPL), of approximately 10% coming into effect in April 2018. We provide a synthesis of findings until April 2021. Studies show that despite the lower rate, purchases of unhealthy SSBs and sugar intake consumption from SSBs fell. There were greater reductions in SSB purchases among both lower socioeconomic groups and in subpopulations with higher SSB consumption. These subpopulations bear larger burdens from obesity and related diseases, suggesting that this policy improves health equity. The current COVID-19 pandemic has impacted food and nutritional security. Increased pandemic mortality among people with obesity, diabetes, and hypertension highlight the importance of intersectoral public health disease-prevention policies like the HPL, which should be strengthened.

The Science for Profit Model-How and why corporations influence science and the use of science in policy and practice

Science has been at the centre of attempts by major industries, including tobacco, chemical, and pharmaceutical, to delay progress in tackling threats to human and planetary health by, inter alia, obscuring industry harms, and opposing regulation. Some aspects of this influence are well documented, others remain poorly understood, and similarities between industries remain underexplored. This study, therefore, aims to synthesise the literature to develop an evidence-based typology and model of corporate influence on science in order to provide an overview of this multi-faceted phenomenon. We obtained literature examining corporate attempts to influence science and the use of science in policy and practice from: database searches, bibliographies, expert recommendations, and web alerts; using a modified scoping review methodology (n = 68). Through interpretive analysis we developed the Science for Profit Typology and Model. We identified eight corporate sectors repeatedly engaging in activities to influence science, including: manipulation of scientific methods; reshaping of criteria for establishing scientific "proof"; threats against scientists; and clandestine promotion of policy reforms that increase reliance on industry evidence. The typology identifies five macro-level strategies used consistently across the eight industries, comprising 19 meso-level strategies. The model shows how these strategies work to maximise the volume, credibility, reach, and use of industry-favourable science, while minimising these same aspects of industry-unfavourable science. This creates doubt about harms of industry products/practices or efficacy of policies affecting industry; promotes industry-favoured policy responses and industry products as solutions; and legitimises industry's role as scientific stakeholder. These efforts ultimately serve to weaken policy, prevent litigation, and maximise use of industry products/practices-maximising corporate profitability. We provide an accessible way to understand how and why corporations influence science, demonstrate the need for collective solutions, and discuss changes needed to ensure science works in the public interest.

Prevalence of sufficient MVPA among Thai adults: pooled panel data analysis from Thailand's surveillance on physical activity 2012-2019

BACKGROUND

The role of data in informing decision makers in formulating policy to improve population health is undeniably important. During the past few years, the Thai government has undertaken continuous health promotion campaigns and programs. Nevertheless, evidence of how physical activity (PA) has improved is lacking. This study aims to present PA prevalence and trends from nationally-representative surveillance data collected during 2012-2019.

METHODS

This study employed 8 rounds of Thailand's Surveillance on Physical Activity (SPA) survey from 2012 to 2019 as a pooled analysis from two-panel data (SPA2012-2016 and SPA2017-2019). Multistage random sampling was applied to select Thai adults aged 18 or over to produce a nationally-representative dataset, by considering the place of residence (urban or rural), gender, and single year of age. Face-to-face interviews using a structured questionnaire were conducted in 5 regions, 13 provinces, and 36 villages to follow up 5648 individuals in Panel 1 (SPA2012-2016) and 6074 persons in Panel 2 (SPA2017-2019).

RESULTS

The prevalence (%) of Thai adults who met WHO recommendations on sufficient PA tended to increase over time, from 66.6 (CI 65-68) in SPA2012 to 70.1 (CI 69-71), 69.5 (CI 68-71), 73.1 (CI 72-74), 70.6 (CI 69-72), 73.0 (CI 72-74), 75.6 (CI 74-77), and 74.3 (73-75) in SPA2013-2019, respectively. Thai females are less physically active than males, and the prevalence of sufficient moderate and vigorous PA (MVPA) was highest among middle-aged adults (35-64 years), and lowest among older adults (65+ years). Work-related PA dominated the cumulative minutes of MVPA per week, followed by recreational PA.

CONCLUSION

The prevalence of sufficient MVPA has fluctuated over time with a tendency to increase in the most recent years. Work-related is the most common modes of PA among Thai adults, implying further improvement in recreational physical activity is required. Workplace intervention should also be the focus in improving PA of Thai adults by encouraging their work force to engage in more occupational PA.

Paradox of sustainability in tobacco control in Thailand: A comprehensive assessment of three-decade experiences

BACKGROUND

Over the past 3 decades of tobacco control, Thailand has gained international recognition as a middle-income country with sustained achievement of declining smoking prevalence. However, the number of key Framework Convention on Tobacco Control measures implementation is still far away from the highest-level implementation. As a result, we aim to explore explanatory factors for the paradoxical phenomenon of sustainability in tobacco control in Thailand, to understand what the paradox means, why it happens, and how to take further steps in minimizing the paradox.

METHODS

We used a mixed-method approach comprising qualitative (review of literature and documents plus Program Sustainability Assessment Tool [PSAT] guided key informant interviews) and semi-quantitative methods (PSAT scoring, Theory of Change [TOC], and causal-loop diagram [CLD]) to synthesize all the findings from the qualitative data.

RESULTS

Across all eight domains, sustainability scores at the local level are lower than the national level. The highest total score was in three domains: political support, partnership, and organizational capacity. The lowest total score was for the strategic planning domain. We propose a set of key strategic elements and drivers for future strategic planning.

DISCUSSION

Using CLD, we capture a high-level view of tobacco control with dynamic interactions between contexts, mechanisms, interventions, and outcomes. We believe the deep understanding of tobacco control and the proposed strategy to counteract transnational tobacco companies in Thailand will guide future sustainable actions to reduce the prevalence of smoking, especially in the strategic planning domain that has the lowest PSAT score.

A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries

There is growing interest in how different forms of knowledge can strengthen policy-making in low- and middle-income country (LMIC) health systems. Additionally, health policy and systems researchers are increasingly aware of the need to design effective institutions for supporting knowledge utilisation in LMICs. To address these interwoven agendas, this scoping review uses the Arskey and O’Malley framework to review the literature on knowledge utilisation in LMIC health systems, using eight public health and social science databases. Articles that described the process for how knowledge was used in policy-making, specified the type of knowledge used, identified actors involved (individual, organisation or professional), and were set in specific LMICs were included. A total of 53 articles, from 1999 to 2016 and representing 56 countries, were identified. The majority of articles in this review presented knowledge utilisation as utilisation of research findings, and to a lesser extent routine health system data, survey data and technical advice. Most of the articles centered on domestic public sector employees and their interactions with civil society representatives, international stakeholders or academics in utilising epistemic knowledge for policy-making in LMICs. Furthermore, nearly all of the articles identified normative dimensions of institutionalisation. While there is some evidence of how different uses and institutionalisation of knowledge can strengthen health systems, the evidence on how these processes can ultimately improve health outcomes remains unclear. Further research on the ways in which knowledge can be effectively utilised and institutionalised is needed to advance the collective understanding of health systems strengthening and enhance evidence-informed policy formulation.