Journal of Public Health and Development Vol. 14 No. 1 January-April 2016

GENERAL ARTICLE Health situation of Akha in Province, Tawatchai Apidechkul1, Pilasinee Wongnuch2, Siriyaporn Sittisarn3 and Thapakorn Ruanjai4 1 Dr.P.H.(Epidemiology), School of Health Science, , Thailand, Center of Excellence for the Hill tribe Health Research, Mae Fah Luang University, Thailand 2 M.Sc (Counseling Psychology), School of Health Science, Mae Fah Luang University, Thailand, Center of Excellence for the Hill tribe Health Research, Mae Fah Luang University, Thailand 3 M.Sc (Public Health), School of Health Science, Mae Fah Luang University, Thailand, Center of Excellence for the Hill tribe Health Research, Mae Fah Luang University, Thailand 4 M.Sc.(Public Health), School of Health Science, Mae Fah Laung University, Thailand Corresponding author: Tawatchai Apidechkul Email: [email protected], [email protected] Received: 24 March 2016 Revisde: 21 June 2016 Accepted: 29 June 2016 Available online: June 2016

Abstract Apidechkul T, Wongnuch P, Sittisarn S and Ruanjai T. Health situation of Akha Hill Tribe in , Thailand J Pub Health Dev.2016;14(1):77-97 Akha is one of six main hill tribe groups living in , and approximately 150,000 persons in 2014. This study was to assess the Akha population health status who lived in Chiang Rai province. A cross-sectional study design was applied. Totally, 550 participants were recruited into the study by a cluster sampling from 20 of 243 Akha villages from Chiang Rai Province, Thailand. Participants were grouped into 8 aged clusters; 0-1 year old, 1-5 years old, 6-12 years old, males aged 13-25 years old, females aged 13-44 years old, males aged 26-60 years old, females aged 45-60 years old, and aged ≥ 60 years old. Data were obtained by validated questionnaires which included general information, history of vaccination, child development assessment, child and mother health assessment, and family planning, etc. Results showed among chlidren aged < 1 year old; 30.0% received Measle Mumps, and Rubella (MMR) vaccine, 70.0% received the 3rd dose of Diptheria, Tetanus, and Pertussis/ Polio vaccine (DTP/OPV). Children aged 1-5 years old; 90.0% gave birth at home, 40.0% received the 5th dose of DTP/OPV, and only 4.0% had been assessed health development regarding to the Ministry of Public Health (MOPH) protocol Children aged 6-12 years old; 22.04% had health development assessment, 66.0% had dental carries. Men aged 13-25 years old; 28.0% smoked, 18.0% drank alcohol and 26.0% used marijuana, 64.3% had sexual experience before aged 16 years old. Women aged 13-44 years old; 56.0% were illiterate, 50.0% did not receive antenatal clinic (ANC) during their pregnancies, 64.3% gave birth at home by un-trained midwives, 7.1% received three doses of Tetanus Toxoid (TT) during pregnancy, 12.5% had been screened a PAP smear. Men aged 26-60 years old; 78.0 % were illiterate, 28.0% could not communicate in Thai, 62.0% smoked, 64.0% drank alcohol. Women aged 45-60 years old; 92.0% were illiterate, 92.0% could not communicate in Thai, 84.0% ate raw food. Those aged ≥ 60 years old; 100.0% were illiterate and 74.0% could not communicate in Thai. in Thailand are having many risk behaviors and difficulty accessing health care due to language barrier. There is an urgent need to develop a proper health promotion program to reduce susceptibility to diseases. Keywords: Akha, Hill tribe, Health status, Thailand

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สถานะสุขภาพชาวอาข่า จังหวัดเชียงราย ประเทศไทย ธวัชชัย อภิเดชกุล1 พิลาสินี วงษ์นุช2 ศิริญาพร สิทธิสาร3 และฐาปกรณ์ เรือนใจ4 1 Dr.P.H.(Epidemiology), ส�ำนักวิชาวิทยาศาสตร์สุขภาพ มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย 1 ศูนย์ความเป็นเลิศการวิจัยสุขภาพชาวเขา มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย 2 M.Sc (Counseling Psychology), ส�ำนักวิชาวิทยาศาสตร์สุขภาพ มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย 2 ศูนย์ความเป็นเลิศการวิจัยสุขภาพชาวเขา มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย 3 M.Sc (Public Health), ส�ำนักวิชาวิทยาศาสตร์สุขภาพ มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย 3 ศูนย์ความเป็นเลิศการวิจัยสุขภาพชาวเขา มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย 4 MSc(Public Health), ส�ำนักวิชาวิทยาศาสตร์สุขภาพ มหาวิทยาลัยแม่ฟ้าหลวง ประเทศไทย

บทคัดย่อ ธวัชชัย อภิเดชกุล พิลาสินี วงษ์นุช ศิริญาพร สิทธิสาร และฐาปกรณ์ เรือนใจ สถานะสุขภาพชาวอาข่า จังหวัดเชียงราย ประเทศไทย ว. สาธารณสุขและการพัฒนา. 2559;14(1):77-97

ชาวอาข่าเป็นชาวเขากลุ่มหนึ่งที่อาศัยอยู่ทางภาคเหนือของประเทศไทย ซึ่งมีประมาณ 150,000 คนในปี 2557 โดย ในการศึกษาครั้งนี้มีวัตถุประสงค์เพื่อประเมินภาวะสุขภาพของชาวอาข่าโดยวิธีศึกษาแบบภาคตัดขวาง กลุ่มตัวอย่างทั้งหมด 550 คน สุ่มคัดเลือกจาก 20 หมู่บ้านจากทั้งหมด 243 หมู่บ้านของอาข่าในจังหวัดเชียงราย กลุ่มตัวอย่างแบ่งออกเป็น 8 กลุ่มอายุ กล่าวคือ เด็กอายุ 0-1 ปี เด็กอายุ 1-5 ปี เด็กอายุ 6-12 ปี ผู้ชายอายุ 13-25 ปี ผู้หญิงอายุ 13-44 ปี ผู้ชายอายุ 26-60 ปี ผู้หญิงอายุ 45-60 ปี และกลุ่มอายุ 60 ปีขึ้นไป ข้อมูลเก็บด้วยแบบสอบถามที่ผ่านการทดสอบคุณภาพ ข้อมูลที่ เก็บประกอบด้วย ข้อมูลทั่วไป ประวัติการรับวัคซีน การประเมินพัฒนาการเด็ก การประเมินสุขภาพอนามัยแม่และเด็ก การวางแผนครอบครัวเป็นต้น ผลการวิจัยพบว่า ในกลุ่มเด็กอายุต�่ำกว่า 1 ปี ได้รับวัคซีน MMR ร้อยละ 30.0 และร้อยละ 70.0 ได้ DTP/ OPV 3 ครั้ง กลุ่มเด็ก 1-5 ปี ร้อยละ 90.0 คลอดที่บ้าน ร้อยละ 40.0 ได้รับวัคซีน DTP/OPV เข็มที่ 5 ร้อยละ 4.8 ได้รับการประเมินพัฒนาการตามแบบประเมินกระทรวงสาธารณสุข และร้อยละ 66.0 มีฟันผุ ในกลุ่ม 6-12 ปี ร้อยละ 22.0 ได้รับการประเมินพัฒนาการ และร้อยละ 66.0 มีฝันผุ ในกลุ่มชายอายุ 13-25 ปี ร้อยละ 28.0 สูบบุหรี่ ร้อยละ 18.0 ดื่มสุราและร้อยละ 26.0 เสพกัญชา ร้อยละ 40.0 มีประวัติมีเพศสัมพันธ์ก่อนอายุ 16 ปี ในกลุ่ม หญิงอายุ 13-44 ปี ร้อยละ 56.0 ไม่ได้เรียนหนังสือ ร้อยละ 64.3 ไม่ได้รับการดูแลขณะตั้งครรภ์ ร้อยละ 64.3 คลอดที่ บ้านโดยหมอต�ำแย ร้อยละ 7.1 ได้รับวัคซีน TT ครบ 3 ครั้งช่วงตั้งครรภ์ ร้อยละ 12.5 ได้รับการตรวจคัดกรองมะเร็ง ปากมดลูก ในกลุ่มผู้ชาย 26-60 ปี ร้อยละ 78.0 ไม่ได้เรียนหนังสือ ร้อยละ 28.0 ไม่สามารถสื่อสารภาษาไทยได้ ร้อยละ 62.0 สูบบุหรี่ ร้อยละ 64.0 ดื่มสุรา ในกลุ่มหญิงอายุ 45-60 ปี ร้อยละ 92.0 ไม่ได้เรียนหนังสือ ร้อยละ 92.0 ไม่สามารถ สื่อสารภาษาไทยได้ ร้อยละ 84.0 กินอาหารสุกๆ ดิบๆ ในกลุ่มอายุตั้งแต่ 60 ปีขึ้นไป ร้อยละ 100.0 ไม่ได้เรียนหนังสือ ร้อยละ 94.0 ไม่สามารถสื่อสารภาษาไทยได้ ชาวอาข่าในประเทศไทยมีพฤติกรรมเสี่ยงหลายอย่างและมีความยากล�ำบากในการเข้าถึงสุขภาพเนื่องจากความสามารถ ในการใช้ภาษาไทย เราควรพัฒนาโครงการส่งเสริมสุขภาพในกลุ่มประชากรเหล่านี้ที่เหมาะสมเพื่อให้เกิดสุขภาพดีและ มีความยั่งยืนต่อไป

ค�ำส�ำคัญ: อาข่า ชาวเขา ภาวะสุขภาพ ประเทศไทย

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Introduction system while getting health problems together with Health is a status of complete physical, mental, using their own traditional belief and medical systems. and social well-being and not merely the absence Akha is one of a Lo-Lo group who have original of diease and infirmity1. Thailand has a good health residence in southern China6. is a care system and health care facilities for providing Tibatient-Burman which is in a Burmese-Loloish health care services for its citizens. Generally, health branch6. There is little documentation about the health care system provided in Thailand is for everyone in status of Akha people in Thailand. The objective of the country, however, there is need to evaluate the this study was to investigate the health status by health status of some groups like the hill tribe in pooling the subjects from different age categories order to improve the health care system. Hill tribe to draw a whole picture of the Ahka people health people are non-Thais living in the mountainous areas in Thailand. in 16 provinces in northern Thailand. They have been migrating to and formed settlements along the Thai Methods border areas for many decades2. Their settlements A cross sectional study design aimed to assess are gradually becoming more permanent with later health status of the Akha people who lived in Chiang generations but there is still a tradition of hill tribe Rai Province, Thailand. A validated questionnaire people crisscrossing the border according to their was used for assessing health status in different age economic, cultural or political necessity from time categories. to time. Their villages are often in very remote areas making applying for a house registration or address Study design either difficult or unnecessary. Their status is rather A cross-sectional study design was carried out like one of alien refugees even well into a second to assess the health status of the Akha people from or third generation of immigrants. 20 selected Akha villages in Chiang Rai Province. The hill tribe in Thailand is divided into six main groups: Akha Lahu, Lisu, Kmong, Yao, and Karen. Study sites There are having different cultures, languages, and In 2013, there were 243 Akha villages in Chiang beliefs particularly in health care practices3,4. Akha Rai Province7. The simple random sampling technique tribe is the greatest group of the hill tribe, migrated by computer program was used for selecting 20 of from the South to Thailand since 150 years 243 Akha villages in Chiang Rai Province to be the ago, and living in 5 major provinces in Thailand: study sites, with results as follows: Chiang Rai, , Tak, Phrae, and Lampang a) Six villages from Muang District; Hua Kum provinces. Akha people predominately lives in Chiang Nai (312 males, and 214 females), Ban Ruam Mit Rai Province with totally 243 villages in 2014; 12,564 (225 males, and 290 females), Ban Pa Na Sa Wan households, and 68,897 populations (34,101 males, (296 males, and 335 females), Ban Hua Ma Liam and 34,796 females)5. Akha people use modern health (294 males, and 294 females), Ban Pan Korn (168

79 วารสารสาธารณสุขและการพัฒนา ปีที่ 14 ฉบับที่ 1 มกราคม-เมษายน 2559 males, and 151 females), Ban Mae Sat (180 males, Ban Mae Sa Lab (312 males, and 293 females), and and 169 females); Ban Hua Kra (343 males, and 358 females). b) Three villages from ; Ban Ni Kom (212 males, and 215 females), Ban Pan Pu Study population Loei (176 males, and 191 females), Ban San Ti Suk There were 243 Akha villages in Chiang Rai (335 males, and 351 females), Province with totally 68,897 persons in 20135. Twenty c) One village from ; Ban Dong selected villages with total of 10,598 populations Num Roun (129 males, and 143 females), (5,228 males, and 5,070 females) were the study d) Four villages from ; Ban population. Study population were categorized into Pa Na Sae Ree (610 males, and 637 females), Ban 8 aged clusters7; aged < 1 year old, aged 1-5 years Pong Pa Kaem (226 males, and 217 females), Ban old, aged 6-12 years old, males aged 13-25 years Wa Wee (182 males, and 184 females), Ban Pong old, females aged 13-44 years old, males aged 26-60 Krang Num (209 males, and 225 females), years old, females aged 45-60 years old, and aged > e) One village from ; Ban 60 years old. Lo (180 males, and 176 females), Study sample f) Five villages from Mae Fah Luang District; We selected the study sample by a cluster random Ban Ar Ku Ar Hi (292 males, and 260 females), Ban sampling technique. The respondents were classified Pa Ya Prai Li Tu (298 males, and 302 females), Ban as shown inTable 1. Saen Jai Pat Ta Na (249 males, and 287 females),

Table 1 Study sample and health indicators

Age-group (years) Number Health Indicators < 1 50 Birth weight, Immunization, Health Development Assessment, VDRL of mother 1-5 50 Immunization, Health Development Assessment 6-12 50 Health Development Assessment, Oral Health, 13-25 (men) 50 Health Risk Behaviors, STIs, Receiving Health Information, Ability of communication in Thai 13-44 (women) 100 ANC, Tetanus Toxiod, Postpatum Health Checking, Family Planing, PAP Smear Testing, Receiving Health Information 26-60 (men) 100 Health Risk Behaviors, STIs, Ability of Communication in Thai 45-60 (women) 50 Health Risk Behvaiors, Ability of Communiction in Thai > 60 100 Health Risk Behaviors, Ability of Communication in Thai Total 550

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Inclusion criteria aged 13-25 years old which was consisted of education The inclusion criteria of the study was people level, occupation, sexual behaviors, and other health who were defined as Akha by verbal confirmation, behaviors such as smoking and drinking behaviors, and lived in the study area for at least 3 years before etc.; e) the 5th part of questions was used for getting commencement of the project. information of women aged 13-44 years old group which was consisted of a history of pregnancy care, Exclusion criteria family planning, postpartum care, child feeding Participants who did not clearly identify as mem- behavior, immunization, etc.; f) the 6th part of questions bers of the Ahka tribe, and having a severe stage was used for getting information of men aged 26-60 of physical or mental illness which could have led years old which was consisted of education level, to limitation in providing accurate information were income, occupation, sexual behaviors, smoking and excluded from the study. drinking behaviors, etc.; g) the 7th part of questions was used for getting information of women aged Research instruments 45-60 years old which was consisted of education Questionnaire was developed after the literature level, occupation, and health behaviors; f) the last set review and validation was done by three external of questions was used for getting information of men experts, and piloted in Akha village at Mae Chan and women aged > 60 years old in their education, District. The pilot study was conducted at Ban Jor Pa occupation, health behaviors etc. Ka, Mae Chan District. Questionnaire was separated into 8 parts8 ; a) the 1st part of questions was used Data collection procedures for getting information of participants aged <1 year Two trained interviewers who could speak Akha old group which was consisted of place of getting language helped in collecting information; one male born, birth weight, height, and a history of receiving and one female. Participants were selected by a cluster of immunization; b) the 2nd part of questions was random sampling. All the lists of people living in used for getting information of participants aged 1-5 the 20 selected villages of 243 Akha vaillges were years old group which was consisted of birth weight, obtained from 6 districts of government offices. Lists height, history of receiving of immunization, and of study population were classified into 8 different child health development assessments including oral age-categories. A simple random were conducted for health assessment; c) the 3rd part of questions was getting the participants from each category (cluster). used for getting information of schoolchildren’s health Each village headman had been informed about among the participants’ aged 6-12 years old group the information of collecting data one week ahead. which was consisted of child health development Before asking questions, participants were asked for assessments in different grades in school, oral health obtaining their permission to participate the project assessment, school immunization; d) the 4th part of and signing on the consent form. A face-to-face questions was used for getting information of men interview method was applied for collecting data.

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However, those participants who had aged less than Results 18 years old, all information were inquired from Totally 550 participants from 8 age categories their parents instead. Information of immunization, were recruited into the study from 20 selected Akha receiving antenatal care (ANC), family planning, villages. The following were the specific health and and health development assessments were recorded health behavior characteristics in eight different age from various secondary-sources of information. The categories; process of interview lasted for 30 minutes in each. Children aged < 1 year old group: Fifty A small gift was provided for each individual as a participants of Akha children aged < 1 year old were compensation for his or her participation. recruited into the analysis: 41 participants (82.0%) were born at home by untrained midwives. Twenty Data management and data analysis seven participants (54.0%) were males, only 18.0% Data were double-entered and validated using had a record of birth weigh and height which found Microsoft Excel. Data analyses were performed that one (2.0%) of 9 had ≤ 2,499 grams of birth using SPSS (version 20; 2006 SPSS, Chicago, Illinois), weight, and 6.0% had ≤ 50 cm at birth. Regarding STATA (version 8.2; Stata Corp, College Station, the history of immunization based on the National TX), and Epi-Info (version 6.04d; US Centers for Expanded Immunization Program (EPI): 76.0% had Disease Control and Prevention, Atlanta, GA). All a history of receiving BCG vaccine. Thirty-seven the data were kept secured with a specific password participants (74.0%) received HBV vaccine at least accessible only by the researchers. once, and 70.0% completely received of 3 doses of Descriptive statistics were used for explaining DTP-HB at sub-district health promoting hospital. the charactersitcs of different groups of participants. For the mothers: only 16.0% had been tested for VDRL, HBV, HIV, and thalassemia during pregnancy, Ethical considerations and none of them showed a positive result of the All study forms and procedures were approved tests. by the Committee for the Protection of Human Sub- Regarding history of child development jects of Mae Fah Luang University, Thailand (No. assessments, only 12.0% children had been assessed REH 51002). Consent form was obtained from the for child health development according to the standard participants before asking the questions. For those protocol of the Ministry of Public Health, and one participants who had aged < 18 years old, the consent of them had an abnormal stage. form had been obtained from their parents before investigating information.

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Table 2 Health status of children aged 0-1 year old

Charcateristics n % Total 50 100.0 Sex Male 27 54.00 Female 23 46.00 Place of birth Hospital 9 18.0 Home 41 82.0 Birth weight (gram) ≤ 2,499 1 2.0 ≥ 2,500 8 16.0 No information 41 82.0 Height at birth (cm) ≤ 50 3 6.0 ≥ 51 4 8.0 No information 43 86.0 Vaccination Yes 48 96.0 No 1 2.0 No information 1 2.0 Receiving BCG Yes 38 76.0 No information 12 24.0 Receiving HB Yes 37 74.0 No 13 26.0 Receiving DTP-HB1 Yes 47 94.0 No 1 2.0 Before schedule 2 4.0 Receiving DTP-HB2 Yes 44 88.0 No 4 8.0 Before schedule 2 4.0 Receiving DTP-HB3 Yes 35 70.0 No 8 16.0 Before schedule 7 14.0 Receiving M/MMR Yes 15 30.0 No 26 52.0 Before schedule 9 18.0 Institute of getting vaccination Health promoting hospital 50 100.0 Others 0 0.0

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Children aged 1-5 years old group: Fifty school, 82.0% were secondary school and higher participants were recruited into the study: 48.0% groups, 14.0% could not read and write Thai , and were male, 10.0% were born at a hospital, and only 4.0% could not communicate in Thai. Regarding 10.0% had a record of birth weight and height; 2.0% occupation: 10.0% were unemployed, 36.0% were of them had a birth weight < 2,500 grams, and 4.0% agriculturist, 2.0% was government officer, 34.0% had a height at birth < 50 cm. Only 4.0% had been were students, and 18.0% were temporary employees. assessed for child development program, and none Regarding health behaviors; 28.0% smoked, of them had an abnormal stage. 50.0% ever smoked, 18.0% drank alcohol, 16.0% Regarding the history of immunization based ever used , 20.0% used methamphetamine, on the (EPI): 96.0% had a history of having 86.0% ate raw food on weekly basis. About sexual received at least one vaccine, 96.0% received the 4th behaviors: 40.0% had sexual intercourse experience, dose of DTP/OPV, 92.2% received JE vaccine, and and 90.0% had their first sexual intercourse before 40% received the 5th dose of DTP/OPV. All of the reaching age of 16 years old, 35.0% did not use con- participants received their immunization at a sub- dom during their first sexual intercourse, and 75.0% district health promoting hospital. had known their partners < 2 months before having Children aged 6-12 years old group: Fifty sexual intercourse, 20.0% had ≥ 4 sexual partners, participants were recruited into the study, 60.0% 10.0% reported ever having sex with men, 10.0% were male. Thirty-nine (22.0%) received the health had been diagnosed with STIs. development assessment at the 1st grade school; Among married men aged 13-25 years old; only 66.0% had a dental carries problem, and 75% had 6.5% reported that they had married the women whom brushed their teeth at least once a day. they had their first sexual intercourse with. Finally, Men aged 13-25 years old group: Fifty 76.0% reported receiving health information through participants were recruited into the analysis, and the television programs. 38.0% were married. Regarding educational level: 14.0% were non- educated group, 4.0% were primary

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Table 3 General charcteristics and health behaviors of men aged 13-25 years old

Characteristics n % Total 50 100.0 Age (year) 13-18 13 26.0 19-21 19 38.0 22-25 18 36.0 Min.=13, Max.=25, Mean=20.36, SD=5.25 Marital status Married 19 38.0 Single 31 62.0 Education No education 7 14.0 Primary school 2 4.0 Secondary and high school 16 32.0 Vocational school 20 40.0 University 5 10.0 Ability of reading Thai Yes 43 86.0 No 7 14.0 Ability of writing Thai Yes 43 86.0 No 7 14.0 Ability of communication in Thai Yes 48 96.0 No 2 4.0 Number of family member(person) ≤ 5 22 44.0 ≥ 6 28 56.0 Occupation Unemployed 5 10.0 Students 17 34.0 Government offcier 1 2.0 Agriculturalist 18 36.0 Temporary employee 9 18.0 Income (baht/year) Unknown 22 44.0 ≤ 50,000 15 30.0 ≥ 50,001 13 26.0 Major channel of getting health information Television 38 76.0 Health providers 1 2.0 Health journals 2 4.0 News 7 14.0 Community health volunteers 1 2.0 Other 1 2.0

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Table 3 General charcteristics and health behaviors of men aged 13-25 years old (Conts.)

Characteristics n % Smoking No 11 22.0 Yes 14 28.0 Ever 25 50.0 Alcohol drinking No 27 54.0 Yes 9 18.0 Ever 14 28.0 Marijuana use No 37 74.0 Ever 13 26.0 Opium use No 42 84.0 Ever 8 16.0 Matamphetamine use No 40 80.0 Ever 10 20.0 Eating raw food No 7 14.0 Yes 43 86.0 Sexual experience No 30 60.0 Yes 20 40.0 First sexual experience (years old) ≤ 16 18 90.0 ≥ 17 2 10.0 Used condom in first sexual expereince Yes 13 65.0 No 7 35.0 Number of partners ≤ 3 16 80.0 ≥ 4 4 20.0 Having sex with men Yes 2 10.0 No 18 90.0 Oral sex Yes 7 23.3 No 13 76.7 Anal sex Yes 2 10.0 No 18 90.0 History of STIs Yes 2 10.0 No 18 90.0

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Women aged 13-44 years old group; One the ANC clinic during their recent pregnancy, only hundred participants were recruited into the study: 7.1% completely received 3 doses of (TT), 94.6% 36.0% were 23-31 years old, 32.0% were 13-22 provided breast feeding for their child at least 6 years old, and 32.0% were 32-44 years old. Sixty-two months, 19.2% reported use of local herbs after giving (62.0%) were married, and 42.0% were temporary birth, 11.5% had postpartum health checking twice employees . Regarding education: 56.0% were illiterate, at a sub-district health promoting hospital. Regarding 60.0% could not read and write , and family planning after giving birth in recent pregnancy: 26.0% could not communicate in Thai. Fivety-two 19.2%% used an injecting birth control method, from 62 married women had children: 26.9% had a 7.7% used a pill method, 7.7% were vasectomy, and single child, 61.5% had 2-3 children, and 11.5% had other 65.4% were being free of use of birth control ≥ 5 children. Two participants (3.2%) had pregnancy method. Seven participants (12.5%) had been detected at the date of interview. According to getting care for cervical cancer by PAP (Papanicolao) smear test during pregnancy of 56 women who had a child: at a sub-district health promoting hospital. Fifty-six 35.7% had visited the ANC at least once during partcipants (56.0%) received health information recent pregnancy at a sub-district health promoting through television programs. hospital whereas 50.0% reported not getting care at

Table 4 General characteristics and health behaviors of women aged 13-44 years old

Characteristics n % Total 100 100.0 Age (yesr) 13-22 32 32.0 23-31 36 36.0 32-44 32 32.0 Min.=13, Max.=44, Mean= 27.42, SD=3.20 Marital status Maried 62 62.0 Single 30 30.0 Divorce 8 8.0 Family member (person) ≤ 6 58 58.0 ≥ 7 42 42.0 Occupation Agriculturalist 6 6.0 Students 22 22.0 Temporaly employment 42 42.0 Business 12 12.0 Unemployed 18 18.0

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Table 4 General characteristics and health behaviors of women aged 13-44 years old (Conts.)

Characteristics n % Income (baht/year) ≤ 50,000 28 28.0 ≥ 50,001 42 42.0 Unknown 30 30.0 Channel of geeting health information Television 88 88.0 Health personal 2 2.0 Community health volunteers 4 4.0 Other 6 6.0 Education Illiterate 56 56.0 Primary school 14 14.0 Scondary and high school 26 26.0 Vocational school 4 4.0 Ability in reading Thai Yes 40 40.0 No 60 60.0 Ability in writing Thai Yes 40 40.0 No 60 60.0 Ability in communication Thai Yes 74 74.0 No 26 26.0 Number of child (person) <=3 46 65.7 >=4 10 14.3 No child 14 20.0 ANC Yes 20 35.7 No 36 64.3 Places of receiving ANC District hospital 7 35.0 Health promoting hospital 13 65.0 Place of getting birth Hospital 20 35.7 At home 36 64.3 Birth weight (gram) ≤ 2,000 10 17.9 ≥ 2,001 10 17.9 Unknown 36 64.2 People who processed delivery Health professional 20 35.7 Untranied midwives 36 64.3 Breast feeding Yes 53 94.6 No 2 5.4 Receiving three doses of TT Yes 4 7.1 No 52 92.9 PAP smear test Yes 7 12.5 No 49 87.5

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Men aged 26-60 years old group: One hundred not use Thai. Family income: 38.0% had an income participants were recruited into the study, 22.0% were < 50,000 baht per year, 22.0% had 50,001-100,000 aged 25-32 years old group, 16.0% were aged 33-43 baht per year, 16.0% had >100,001 baht per year. years old, 28.0% were aged 44-50 years old, 34.0% Family member: 22.0% had a family member ≤ 3 were aged 51-60 years old. persons, 32.0% had 4-6 persons of family member, Ninety-two participants (92.0%) were married, 34.0% had 7-9 persons of family member, and 12 6.0% were single, and 2.0% was divorced. Regarding had ≥10 persons of family member. occupation: 60.0% were agriculturalist, 28.0% were Health behaviors: 62.0% smoked, 38.0% quitted employee, and 12.0% were unemployed. Educa- smoking, 64.0% drank alcohol, 4.0% used marijuana, tion: 78.0% were illiterate, 14.0% attended primary 20.0% used opium, 6.0% used methamphetamine, school, 2.0% had university degrees, 72.0% could 86% ate raw foods, 90.0% did not exercise regularly.

Table 5 General characteristics and health behaviors of males aged 26-60 years old

Characteristics n % Total 100 100.0 Age (years old) 25-32 22 22.0 33-43 16 16.0 44-50 28 28.0 51-60 34 34.0 Min.=25, Max.=60, Mean=44.28, SD=4.41 Marital status Married 92 92.0 Single 6 6.0 Divorce 2 2.0 Family member (person) ≤ 3 22 22.0 4-6 32 32.0 7-9 34 34.0 ≥ 10 12 12.0 Occuaption Unemployed 12 12.0 Agriculralist 60 60.0 Employed 28 28.0 Annual income (baht) Unknown 24 24.0 ≤ 50,000 38 38.0 50,001-100,000 22 22.0 ≥ 100,001 16 16.0

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Table 5 General characteristics and health behaviors of males aged 26-60 years old (Conts.)

Characteristics n % Channel of receiving health information Television 74 74.0 Health personnal 16 16.0 Other 10 10.0 Education Illiterate 78 78.0 Primary school 14 14.0 Vocational 6 6.0 University 2 2.0 Ability to read Thai Yes 26 26.0 No 74 74.0 Ability to communicate in Thai Yes 72 72.0 No 28 28.0 Ability to write in Thai Yes 28 28.0 No 72 72.0 Smoking No 38 38.0 Yes 62 62.0 Drinking alcohol No 36 36.0 Yes 64 64.0 Used marijurna No 96 96.0 Yes 4 4.0 Used opium No 80 80.0 Yes 20 20.0 Used mathamphetamine No 94 94.0 Yes 6 6.0 Women aged 45-60 years old: Fifty participants Health behaviors: 10.0% smoked, 4.0% drank were recruited into the analysis; 98.0% were married, alcohol, 84.0% ate raw food. 78.0% were agriculturist. Regarding to education: 92.0% were illiterate, 8.0% graduated primary school, 92.0% could not communicate in Thai.

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Table 6 General characteristics and health behaviors of women aged 45-60 years old

Characteristics n % Total 50 100.0 Age (years old) 45-48 15 30.0 49-52 12 24.0 53-56 12 24.0 57-60 11 22.0 Min.=45, Max.=60, Mean=51.88, SD=5.09 Marital status Married 49 98.0 Divorced 1 2.0 Family member (person) ≤ 3 9 18.0 4-6 15 30.0 7-9 19 38.0 ≥ 10 7 14.0 Occupation Unemployed 7 14.0 Agriculturalist 39 78.0 Employed 4 8.0 Annual income (Baht) Unknown 27 54.0 ≤ 50,000 13 26.0 50,001-100,000 7 14.0 ≥ 100,001 3 6.0 Sources of getting health information Television 37 74.0 Health personnel 10 20.0 Other 3 6.0 Education Illiterate 46 92.0 Primary school 4 8.0 Ability of reading Thai Yes 4 8.0 No 46 92.0 Ability of writing Thai Yes 4 26.0 No 46 74.0 Ability to communicate in Thai Yes 13 8.0 No 37 92.0

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Table 6 General characteristics and health behaviors of women aged 45-60 years old (Conts.) Characteristics n % Smoking No 45 90.0 Yes 5 10.0 Alcohol drinking No 48 96.0 Yes 2 4.0 Marijuana used No 50 100.0 Yes 0 0.0 Opium used No 50 100.0 Yes 0 0.0 Mathamphetamine used No 50 100.0 Yes 0 0.0 Men and women aged > 60 years old: One agriculturist, 100.0% were illiterate, and 98.0% could hundred participants were recruited into the study not communicate in Thai. Health behaviors: 6.0% and 58.0% were males. Occupation and education used opium, 68.0% ate raw foods, and none of them characteristics: 56.0% were unemployed, 38.0% were had a regular exercise.

Table 7 General characteristics of people aged > 60 years old. Characteristics n % Total 100 100.0 Sex Male 58 58.0 Female 42 42.0 Age (years old) 60-64 22 22.0 65-69 24 24.0 70-76 42 42.0 77-86 12 12.0 Min.=60, Max.=86, Mean=69.52, SD=8.04 Marital status Married 94 94.0 Single 4 4.0 Divorced 2 2.0

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Table 7 General characteristics of people aged > 60 years old. (Conts.) Characteristics n % Family member (persons) ≤ 3 8 8.0 4-6 36 36.0 7-9 26 26.0 ≥ 10 30 30.0 Occupation Unemployed 56 56.0 Agriculturalist 38 38.0 Employed 6 6.0 Annual income (baht) ≤ 50,000 26 26.0 50,001-100,000 12 12.0 ≥ 100,001 4 4.0 Unknown 58 58.0 Channel of receiving health information Television 70 70.0 Health personnel 14 14.0 Newspaper 8 8.0 Other 8 8.0 Ability of reading Thai Yes 4 4.0 No 96 96.0 Ability of writing Thai Yes 4 4.0 No 96 96.0 Ability to communicate in Thai Yes 26 26.0 No 74 74.0

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Discussion use of health services for illness resulting in hospitali- Thailand has become an upper-middle income zation were still disproportionately reported between economy since 20119. An economic growth was 0.7% rural and urban residents, even though Thailand had in 2014, and an approximately 7.3 million people in launched a universal health insurance program since Thailand were defined as poor people particularly those 2001. Most urban residents have a better chance to who lived in rural areas in the North and Northeast get a standard care than those who lived in rural such as ethnic groups that lag greatly behind others, areas. The inequalities were found to be associated and the benefits of economic success have not been with older age, low education, and residence in the shared equally. Thailand is also likely to meet most rural north of Thailand13,14. of the Millennium Development Goals (MDGs) on More than half of Akha pregnant wowen did not an aggregate basis; maternal mortality and under-five receive care at the ANC clinic including receiving mortality rates have been greatly reduced and more tetatnus vaccine, postpartum care, and screening for than 97.0% of the population, both in the urban and cervical cancer. This is indicating on accessibility rural areas, now have access to clean water and of health care system and also the level of concern sanitation10. However, in this study it was found for having care during pregnancy among the Akha that a large proportion of Akha people lived in poor people. condition areas and drank untreated water. In this study, it was found that many age cat- Thailand has various levels of health system egories of Akha people had a low level of receiving from the district to the regional level which have immunization particularly young children. In general, different capacities and missions for providing cares. most of Thai population have been exposed in a good However, a sub-district health promoting hospital is schedule of immunization since they were born, it has the most favorite for the people in the remote areas been launched in 197715. The MOPH reported that of Thailand particularly the Akha people. This kind the coverage of BCG was 99.0%, DTP3 was 99.0%, of hospital directly supports the need of the people in OPV3 was 99.0%, MMR was 99.0%15. However, from poor settings. Therefore, it is reasonable to improve the survey, we found that many groups of children the capability of the sub-district health promoting still get low coverag of immunization and health hospital, including manpower and resource allocation, development assessment according to the MOPH with the ultimate benefit being the overall well standard protocol. This reflects an ineffectiveness of being of Thai population. Bouphan et al11 reported health care service of health system in Thailand for that many factors affecting public health professional those specific populations. A low level of immuniza- performances who were working in a sub-district healt tion will increase an opportunity of having disease promoting hospital, and the most problemtic problem outbreak in a specific of preventable diseases. Pham was lacking of suitable health promoting programs. et al16 reported that the episode of having a measles Yiengprugsawan et al12 reported that getting access to epidemic among children is related to low coverage care in use of health services for recent illnesses, and of immunization. Moreover, most Akha people are

94 Journal of Public Health and Development Vol. 14 No. 1 January-April 2016 living in the border areas with neighboring countries investigated more with a proper method for imple- and some of them still are migrating which makes menting health promotion program. them susceptible hosts for many infectious dieseases. The most crucial barrier for access to health care Among Akha adults, it was found having many services and health information of the Akha people risk behaviors such as having experience of early is language. A few proportion of the Akha people age sexual intercourse, unused condom, including who have aged > 45 years old understood Thai. smoking and drinking behaviros. The smoking rate This result agrees with study of Apidechkul et al24 among the Akha young adults (28.0%) had a greater reported that the major problem of access health care rate than Thai young adults (19.9%)17. This reflects service in the hill tribe was language. Most of the the urgent need to reduce the the consequent health young Akha are receiving health information through problems in this population. Erawan18 and Sommart19 the tevevsion programs. It would be a great channel reported that implementing a school health promoting for health personal to choose the effective chanel program was a key factor to improve the schools for transferring health information to this vunerable children health in Thailand particularly in sexual population. behaviors. Ounjit20 reported that it was not an easy Transportation is a factor that influenc the health to get sexual health information among the Thai status of the Akha people in remote areas. Most of adolescent due to the restriction of culture and belief, the Akha villages had been stettled far away from and most of the sexual information were acquired a district hospital24, then, there was low coverage of from their friends. It was also found that most Ahka vaccine implementation in this group of population. young adults do not discuss sexual issues in public Moreover, the study found that the sub-district health areas. Apidechkul21 reported that specific training promoting hospital was the most favorite health program could increase the personal skills for HIV/ setting for the Akha people in Thailand. AIDS prevention among the Akha youths in the community. Apidechkul22 also reported that Akha Conclusion adult was the most vulnerable group for HIV/AIDS In conclusion, Akha people in Thailand are still infection among the hill tribe in Thailand. having different health problems in different age Akha adult population has a problem of language groups. In young children, there are many problems barriers for accessing health system because most of related to health such as low coverage of immuni- them were illiterate. Rittirong et al23 reported that zation and lacking of appropriate health assessment. among the elderly who lived in the rural areas in Among young adult populations, sexual beahviors Thailand needed to be supported in transportation and use of narcotic drugs are the major problems. In for taking them to receive medical care, and also women, assessing level of mother and child health needed financial support. This scenario also found in care including pospatrum care is still low. In adult the Akha elderly population due to living far away population, having a high level of alcohol use, smoking, from a hospital. However, the real context should be and eating raws foods regularly. Most Ahka people

95 วารสารสาธารณสุขและการพัฒนา ปีที่ 14 ฉบับที่ 1 มกราคม-เมษายน 2559 lack access to the educational system leading to their 4. Apidechkul T. The 1st year final report of health inability to use Thai language, which consequently status, the local wisdom, and community - based influences access to health care system. health promotion of Akha in Thailand (Phase-I). Recommendations; to improve Akha people’s Chiang Rai : [S.n]; 2009. (in Thai) health, the Ministry of Public Health should encourage 5. Apidechkul T. The 2nd year final report of health health professionals who are working in the health status, the local wisdom, and community-based setting in the Akha residences, to develop the innova- health promotion of Akha in Thailand (Phase-II). tion and a proper health promotion program which Chiang Rai : [S.n]; 2011. (in Thai) is having a good integration with Akha local culture 6. Joachim S. Ethni groups of 4-profile of and belief. To extend the educational system to the Sino-Tibetan-speaking peoples. 1st ed. Bangkok: Akah remote villages is one crucial point to improve White Lotus Co, Ltd.; 2014. the general Akha health. Finally, starting with various 7. The hill tribe welfare and development center, channels to provide essential health information to Chiang Rai province. Hill tribe population 2013. the Akha population are also very important issue to Chiang Rai: The Hill Tribe Welfare and Develop- improve Akha population health in Thailand. ment Center, Ministry of Interior; 2013. p.14-27 8. Department of Health, Ministry of Public Health. Acknowledgements Strategic plan of helath promotion and prevention The author is grateful to the National Research 2014. Avalaible from http://www.anamai.moph. Council of Thailand for supporting the grant. The go.th/download/download/strategic plan2557.pdf author also would like to thank the participants, [Accessed 2015 September 4]. community leaders, and director of health promoting 9. World Bank. Thailand: Thailand overview. Avail- hospitals for their kind participation. able from: http://www.worldbank.org/en/country/ thailand/overview. [Accessed 2015 September References 21]. 1. World Health Organization (WHO). Definition 10. UNDP Thailand. Human development report: Eight of health. Geneva, Switzerland, 2016. Avaliable goals for 2015.. Available from: http://www.th. from: http://www.who.int/about/definition/en/ undp.org/content/thailand/en/home/mdgoverview. print.html [Accessed 2016 June 1]. html. [Accessed 2015 September 18] 2. Princess Maha Chakri Siridhorn Anthropology 11. Bouphan P, Apipalakul C, Ngang TK Factors Center. Hill tribe. Bangkok, Thailand, 2012. affecting public health performance evaluation of Available from: http://www.sac.or.th/main/index. sub-district health promoting hospital directors. php [Accessed 2015 September 21]. Social and behavioral Sceince. 2015; 185; 128-32. 3. The hill tribe organization in Thailand. Akha tribe 12. Yiengprugsawan V, Carmeichael GA, Lim LY, in Thailand. Available from: http://akha.hilltribe. Seubsman S, Sleigh AC. Has universal health org/thai/ [Accessed 2015 September 2015]. insurance reduced socioeconomic inqualities in

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