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The Effect of Community Risk Perception onType-2 Diabetes Mellitus Screening Patterns of

Adults in Ban Nonsang Moo 10, a Rural Village inNortheast Thailand

Aaron Hedquist1, Rosa Keller2, Josh Kumin3, Carly Freeman4, and Sydney Silver5

Abstract—The purpose of this investigation was to examinethe effect of risk perception on screening participation for Type-2Diabetes Mellitus (T2DM) among adults in Ban Nonsang Moo 10,a rural village in northeast Thailand. Methods and observationswere broken into three phases. The first phase was an initial com-munity needs assessment. The second phase was a concentratedstudy on nutrition knowledge and T2DM. Phase three narrowedthe focus on T2DM screening and risk perception of developingthe disease. Records from the Health Promoting Hospital (HPH)were obtained to calculate prevalence and screening patterns ofthe community. Interviews, participant observation, and surveyswere used to identify risk perceptions and knowledge of nutrition.It was calculated that the prevalence of T2DM in adults overage 45 was 12.8% compared to the population under age 45which was only 0.7%. Screening percentages followed a similarpattern with 22.2% of adults over age 45 screened comparedto the population under age 45 with only 6.3% being screened.Less than half of the population had awareness of the Ministryof Public Health daily dietary recommendations. It was alsonoted that biological determinants of developing T2DM wereemphasized over behavioral determinants. It was concluded thatthere potentially exists an undiagnosed population of T2DMpatients in Ban Nonsang Moo 10 because of a misguided riskperception caused by lack of nutritional knowledge.

I. INTRODUCTION

TYpe-2 Diabetes Mellitus (T2DM) is one of the mostprevalent chronic diseases in Thai society with an es-

timated prevalence of 6.9% in individuals 15 years of age andolder as of 2009 (Deerochanawong 2013). Specifically, thenortheast region of the country is disproportionately affectedby the disease. According to the Ministry of Public Health(MoPH), this region faces the highest mortality rate of diabetesin Thailand with 19.2 per 100,000 individuals (MOPH, 2009)coupled with the lowest rates of awareness in the country(Aekplakorn 2007).

Risk perception is defined as the general risk assessmentfor developing T2DM. Perception of risk varies among in-dividuals, but this assessment will focus on the balance ofassessing biological and behavioral determinants of T2DM.Both behavior and genetic factors lead to the development ofT2DM. However, lifestyle choices, namely dietary practices,dictate the prevention and management of the disease.

This investigation exclusively focuses on family history and

Affiliations: 1The George Washington University,2Oregon State University,3Villanova University, 4Tulane University, and 5Occidental College.

age as biological determinants. Diabetic patients in a ruralvillage in northeast Thailand expressed the belief that geneticscaused their ailment. When one family member was diagnosedwith T2DM, other family members believed their likelihoodof developing the disease increased regardless of lifestylechoices (Nakagasien et al., 2008). In accordance with Buddhistprinciples, many Thais understand the greater likelihood ofdeveloping diabetes with age. Buddhist beliefs accept illnessas an inevitable element of the natural birth-and-death cycle(Sowattanangoon et al., 2009).

This report focuses on the behavioral determinants ofT2DM, namely the consumption of nutritious foods and ap-propriate portion sizes as defined by the MoPH. The ministryrecommends a balanced consumption of food groups to ensureadequate intake of essential nutrients to sustain good healthand prevent non-communicable disease.

Correlated to changes in lifestyle, T2DM is developing inyounger age groups (UCSF, 2007). T2DM screening strategiesshould be revised to compensate for these changes in the at-risk population. This investigation will examine the effect ofrisk perception on the participatory rate of varying age groupsin voluntary screening sessions for T2DM in Ban NonsangMoo 10, a small village in northeast Thailand.

This study hypothesizes that lack of knowledge of recom-mended portion sizes leads community members to overem-phasize the biological determinants for developing T2DM.Consequently, less than 10% of adults under the age of 45participate in screening sessions, therefore, no one under theage of 45 is being diagnosed for T2DM in Ban Nonsang Moo10.

II. METHODS

The study took place in Ban Nonsang Moo 10 in NampongDistrict, Khon Kaen Province, Thailand. The village consistsof 513 people and is located in the northeast region of thecountry.

Statistical Methods Phase OneThe study was conducted in three phases. This report is

composed of results gathered during phase two and phasethree. The data collected in phase one guided the focusof this investigation. In phase one, an initial communityneeds assessment was conducted to identify demographic

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Fig. 1. Conceptual Framework for Research

and health information in order to determine potential healthconcerns. Since this was the first time our organization hadvisited the community, this phase was also used to establishrapport. From this assessment, it was noted that the majorityof the community practices Buddhism. The primary sourceof income in the community is agriculture, with 76.6% ofthe population working in the industry. The most prominentlevel of education is Prathom 4-6, encompassing childrenages 9-11. Informal observations displayed a disproportionateconsumption of rice-starchy foods over other core foodgroups such as fruits and vegetables. Based on this, the focusof research for phase two was concentrated on nutritionalknowledge.

Phase TwoPhase two was an in-depth analysis of the community0s

knowledge of portion sizes relative to the recommendeddietary guidelines set forth by the MoPH. In addition, foodsources were identified and eating practices were observed.

Quantitative and qualitative tools were used for datacollection. The quantitative data was collected throughsurveys distributed to adults ages 15 and older. 60 surveyswere distributed throughout the day, both in the communityand surrounding rice fields. Community volunteers and onetranslator assisted in distributing the survey. The surveyconsisted of 28 questions which focused on three topics:demographics, food frequency, and knowledge of healthynutrition practices. General demographic information entailedage, gender, occupation, and education level. Food frequencyquestions asked for a 24 hour recall of food consumptionand were divided into the core food groups identified by theMoPH nutrition flag (see appendix) with an added section forsnacks and sugary drinks. Portion sizes were estimated usinga standard hand guide (see appendix). This tool was chosenbecause it was easy to visualize and requires no additionalmeasuring tools. These results were interpreted into standardserving sizes. For the food group rice-starchy foods, servingsize was represented by number of plates of rice consumed perday where one plate was equivalent to three serving spoons.

The 1,600 calorie daily dietary intake recommendation wasused for comparison because it was the appropriate diet forworking women and men aged 25-60 as determined by theMoPH. The third topic focused on knowledge of healthynutrition practices assessed by awareness of the nutrition flagand knowledge of a healthy daily dietary intake. Data wasanalyzed using standard descriptive statistical methods, whichwill be discussed further in the Statistical Methods section.

Participant ObservationDuring phase two, participant observation was recorded

of two voluntary host families. Compensation was providedto cover all accommodations and meal costs. Participantobservations followed the entire food preparation andconsumption process. First, participants accompanied hostfamilies to observe what food was being purchased andwhere. The food preparation process was observed in orderto investigate supplementary ingredients such as sugar, oil,salt, and MSG. Once food was prepared and ready forconsumption, participants shared a meal with host families;eating behaviors and portion sizes were noted. General foodconsumption throughout the day was observed and recorded.Observations were compared to the recommended portionsprovided by the MoPH.

InterviewsFour interviews were conducted to determine cultural

factors of nutrition, knowledge of nutrition, food sourcesand access, and T2DM. Key informants for the topicswere selected as interview participants: the head VillageHealth Volunteer (VHV), the headman, a rice farmer, anda vegetable farmer. A translator was present during allinterviews to clarify responses from participants and ensurethe investigation remained culturally appropriate.

Head Village Health VolunteerWithin this community the head VHV is responsible for

the coordination of the VHV network. A VHV oversees theprimary care of 10 households on average. Primary careencompasses maternal and child health, vaccinations, andinitial screening surveys. The head VHV in Ban Nonsang Moo10 has strong knowledge of community nutrition practices,health problems, and perceptions of disease related to poornutrition. Interview questions focused on gaining furtherinsight on overall community understanding of nutrition andrelated disease. Through the interview, the head VHV sharedinsight on the availability of current screening and diabetesannual records, which will be discussed in the StatisticalMethods section.

HeadmanThe headman is an elected official who is responsible for

the civil society institutions of the community. The headmancoordinates various governing bodies of the community,such as the community board, and manages the demographicrecords of the village. Interview questions focused onchanging demographic information, noticeable disease-relatedtrends in the community, and community perception of T2DM

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causes.

FarmersFarmers have a significant presence in Ban Nonsang

Moo 10. Both rice and vegetable farmers were selectedbecause initial survey results indicated that a large portionof community members bought or grew their own foodlocally. The interviews focused on food access, food sources,and the farmers0 perceptions of personal nutrition practices.Questions were designed to understand farming practices,their knowledge of nutrition, and the role their product playsin the community.

Information gathered from phase two interviews werecompiled into a single mind map. A mind map (see appendix)is an organizational tool used to draw connections andunderstand overarching themes. The mind map was dividedinto four components: cultural factors, knowledge of nutrition,food sources and access, and T2DM.

Phase ThreeThe observation and data collected in phase two narrowed

the focus of research to T2DM screening and risk perceptionof developing the disease. The first survey did not includescreening information for the community, therefore a fourquestion survey was developed. This survey was designed togather information on age, gender, screening participation, andtheir perceived primary reason for T2DM screening. Duringmidday, 100 surveys were distributed with the assistancefrom community volunteers and one translator. This data wasanalyzed using standard descriptive statistical methods.

Nampong District Hospital Diabetes ClinicTwo interviews took place at the diabetes clinic at Nampong

District hospital. The majority of diabetes patients from BanNonsang Moo 10 are treated at this facility, therefore, it playsan important role in the health outcomes of the community.In order to understand the screening process, a clinician andmedical practitioner were interviewed. Interview questionsfocused on the screening process, diagnosis, and treatmentto understand the risk perception of developing diabetes anddiscrepancies in screening rates.

Takraserm Health Promoting Hospital (HPH)The HPH plays an important role in screening and is the

base of the VHV network of Ban Nonsang Moo 10. Oneinterview was conducted with the station nurse at the HPH togain insight on the logistical aspect of T2DM screening andto further understand discrepancies highlighted by the districthospital.

Annual records were obtained from the HPH with consentfrom the head VHV and staff. Only case numbers wererecorded, and all records were kept anonymous. During phasetwo, the HPH provided the 2014 Annual Record of all T2DMpatients in Ban Nonsang Moo 10. The records includedgender, age, household number, and the World HealthOrganization International Classification of Disease (ICD)with complications. During phase three, the HPH provided

the screening records of hypertension and diabetes from2013-2014. These records included gender, age, householdnumber, as well as potential risk of developing the diseases.The 2014 population information, provided by the HPH, wasalso intended for use in prevalence calculations.

Surveys and records obtained from the HPH were analyzedusing descriptive statistical methods. These calculationsincluded prevalence, frequency, and percentage of population.Microsoft Excel and SPSS Statistics software were used fordata analysis.

III. RESULTS

This study used both quantitative and qualitative researchmethods to collect and analyze data.

Quantitative ResultsHPH Records

The calculations found in figure one were obtained fromthe most updated diagnostic and population records fromthe HPH using Excel and SPSS Statistics. The prevalencepercentage was calculated for the population of each agegroup in the community. The prevalence percentage of adults35-44 was 3.5% and prevalence percentage of adults ages35 and older was 11%. T2DM affected the 70-74 populationrange the most, with 35.7% of that age group being diagnosedwith the disease. It was concluded that the prevalence ofT2DM in Ban Nonsang Moo 10 was 6.4%, with double theamount of cases in women than men. When broken downby population it was found that no one under age 40 wasdiagnosed with T2DM. Therefore, the prevalence of diabetesin the total population under age 45 was 0.7% compared to12.8% in the population over age 45.

The calculations found in figure two were obtained from the2013-14 diagnostic records and the most updated populationrecords from the HPH, which were calculated using Exceland SPSS Statistics. The screening percentage was calculatedfor the population of each age group in the community.34.9% of the adult population aged 45-49 were screened forT2DM, making them the most screened age group. It wasconcluded that the percentage of screening for T2DM in BanNonsang Moo 10 was 13.8% in the last two years. It wasfound that 6.3% of the population under age 45 had beenscreened compared to 22.2% of the population over age 45being screened for T2DM in the last two years.

Nutrition SurveyDuring phase two, 58 nutrition surveys were administered.

When compared to HPH records for gender and age, thedata followed similar distributions. This suggests that thisdata was an accurate representation for the demographics ofBan Nonsang Moo 10. With a population size of 413 aged15 and older, the error for the survey results was calculatedto be 12%. For the food group rice-starchy foods, averageconsumed (2.60 plates), average recommended (2.60 plates),and MoPH recommended servings (2.66 plates) were aboutthe same. The consumption of fruits and vegetables was low,and the consumption of meat and dairy was higher than

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Fig. 2. Number of T2DM Patients with Prevalence by Age Group and Genderin Ban Nonsang Moo 10

recommended by MoPH. Only 49% of individuals surveyedwere aware of the MoPH nutrition flag.

Screening SurveyDuring phase three, 100 four-question surveys were

distributed to gather information on screening habits inBan Nonsang Moo 10. However, since the survey wasadministered during midday, the population that was availablewas primarily older and did not accurately represent the totalpopulation. As well, community volunteers who assisted inthe administration of the survey misinterpreted the questionregarding the main reason to be screened for T2DM. Due tothese reasons the survey results were not relevant to the studyand were excluded from analysis.

Qualitative ResultsParticipant Observations

Results from both participant observations were closelyrelated, therefore reported as a single narrative. In bothhouseholds the mother was responsible for all mealpreparations. There were three stages of observation:shopping at the local market, food preparation, and eating atthe home. While at the local market, locally grown vegetables,tofu, and meat were purchased. During food preparation,the households cooked a variety of dishes which includedingredients such as tofu, bean sprouts, papaya, chillies, greencurry, leafy greens, chicken, fish sauce, MSG, sugar, soysauce, and oyster sauce. In household one, it was commonto add sugar to main dishes. Both white rice and glutinousrice were provided at every meal. Once prepared, food was

Fig. 3. Number of Screened Individuals with Percentage by Age Group andGender in Ban Nonsang Moo 10

placed on a floor mat and eaten family-style in the home. Inhousehold two, family members felt uncomfortable eating theprepared meal with participants, therefore, observations offood consumption and portions were consistently documentedthroughout phase two.

It was observed that host family members did not useplates. Households used large handfuls of glutinous rice asutensils for grabbing food directly from the serving dishes.As a result, there was a greater consumption of glutinous riceover white rice. Glutinous rice was present in all communalsettings, leading to casual consumption throughout the day.For example, at night villagers roasted glutinous rice, batteredin egg and fish sauce, over a fire and eaten communally.

Head Village Health VolunteerThe head VHV stated that nutrition education in Ban

Nonsang Moo 10 is derived from basic nutrition knowledgeacquired during early school years. While she had heard ofthe nutrition flag, the VHV network had never utilized itas a tool during nutrition education. She proposed that dietchanges, namely an increase in sugar intake over the last 20years, can be linked to the increased prevalence of T2DM.The increase of T2DM was tied to both diet and genetics,according to the head VHV. She went on to state that diabetesis largely related to diet more than genetics because a largernumber of individuals diagnosed with T2DM do not have afamily history of the disease.

HeadmanThe headman reported population statistics of Ban Nonsang

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Fig. 4. Comparison of Average Consumed and Persumed Healthy Servingswith MoPH Recommendations of Adults Aged 15 and older in Ban NonsangMoo 10

Moo 10 over the last three years. He noted that the populationremained consistent from 2012-2014. The main cause ofdeath during these years were diabetes complications (kidneyfailure), cancer, liver failure, and old age. The headmanperceived the community0s nutrition status to be adequate andattributed this to the locally grown and accessible vegetablesand animal protein. When asked about nutrition issues relatedto the high incidence of T2DM in the community, theheadman stated that the consumption of glutinous rice andsugary foods contributed to these high numbers.

Vegetable farmerThe interviewed vegetable farmer primarily grew cucumbers

for the past six years. He believed many community membersover consume rice because it is the staple of Thai eating. Thevegetable farmer proposed that the consumption of stickyrice and sugar led to diabetes. He shared the community0scommonly held perception that socioeconomic status plays arole in access, and consequently consumption, of nutritiousfoods.

Rice farmerThe rice farmer was interviewed in the rice field since winter

rice harvest season was ongoing. She shared that consumingrice led to positive health but could lead to complications ifeaten in excess. When asked about the causes of T2DM, shenoted that genetics played the prominent role; she believedshe may develop health problems in the future because peoplein her family had T2DM. She disclosed little understandingof nutrition and also expressed that the community had basicknowledge of nutrition. Despite this basic understanding,

community members still ate foods that attributed topoor health. In addition, she believed that the community didnot eat healthy portion sizes, instead, eating until they felt full.

Clinician at Nampong District HospitalAt the Nampong District hospital, patients were offered

soy milk and rice porridge upon arrival. While waiting, aclinician educated patients about portions and amounts ofingredients in food. In addition to the biomedical servicesprovided to T2DM patients, traditional practices were offeredfor complications. These services included: traditional footmassage and foot soak in a mangosteen water bath. Meditationpractices were also promoted by clinicians as a means tocope with the disease.

During the interview the clinician acknowledged behavioralfactors for developing T2DM, she believed that geneticfactors were the cause for the recent increase in prevalence.She observed that T2DM patients attribute their diagnosiswith primarily with family history and old age. She expressedgaps in the screening process and misrepresented diagnosticrates for the under 45 population. She believed that 10-20%of the Thai population goes undiagnosed.

Endocrinologist at Nampong District HospitalThe endocrinologist at Nampong District Hospital stated

that in Thailand, the lay people believe the main cause ofT2DM is related to genetics. The doctor expressed difficultyin changing perceptions of genetics as the primary cause ofT2DM because this philosophy has been passed down fromgeneration to generation. This belief is still popular, regardlessof the fact that the most recent diabetes research by theMoPH found lifestyle to be the greatest determinant of diseasedevelopment. The doctor stated the most referenced researchon T2DM is collected outside of Thailand, and about 95% ofresearch is done by the American Diabetes Association. Dueto limited resources, no doctors were present at the clinic0smobile T2DM screening processes, so the procedure wascarried out solely by VHVs and nurses. When questioned onthe low participation rate of community members under theage of 45 in screenings, the doctor attributed it to those underage 45 underestimating their risk of developing T2DM andthe emigration of younger generation to larger cities lookingfor work.

Health Promoting Hospital NurseThe nurse expressed that a large number of people under 40

years old are undiagnosed. She attributed this to perceptionsof equating young age to good health and men, in particular,not wanting to be confronted with the reality of havingT2DM. While there is a focus on the genetic determinants ofT2DM, the number of people in the community with geneticpredispositions is very small, and the majority of peoplebeing diagnosed with T2DM are the first in their family.

IV. DISCUSSION

The initial hypothesis was that no one under the age of 45had been diagnosed with T2DM. The HPH records disproved

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this hypothesis, however, only two cases (0.7%) of T2DMwere diagnosed under the age of 45. As well, no one under theage of 40 was diagnosed. This low percentage of prevalence issurprising when compared to external literature. A study doneon the prevalence and management of diabetes in Thai adultsshows that 8.4% of the rural population had been diagnosedwith T2DM (Aekplakorn, et al. 2003). In Ban Nonsang Moo10, 11% had been diagnosed. This suggests that the diabetesrates in the community are significantly higher than its ruralcounterparts. However, diagnostic percentages of adults 35-44 was 4.9% in the InterASIA study, compared to 3.5% inBan Nonsang Moo 10. This indicates a possibility that thereare more diabetic patients under the age 45 than recorded.The hypothesis that less than 10% of adults under age 45not being screened was supported by the HPH records. Theinvestigation determined 6.3% of the population under 45 hadbeen screened. This small percentage of the under 45 adultpopulation being screened coupled with the low diagnosticpercentage, relative to the InterASIA study, suggests a possibleundiagnosed population.

The last hypothesis was that lack of knowledge of recom-mended portion sizes leads community members to overem-phasize the biological determinant for developing T2DM.With less than half of the surveyed population aware ofthe MoPH nutrition flag, this suggests community membersare not educated about recommended portion sizes. Thisis highlighted by figure three, participant observations, andinterviews. Figure three illustrates the discrepancies in thecommunity0s understanding of healthy portion sizes withMoPH recommendations. There was an overemphasis on theimportance of meat and a lack of importance of fruits andvegetables in a healthy diet. The lack of nutritional knowledgeis further evident in participant observations. Householdsconsumed glutinous rice consistently throughout the day andwere unaware of the amount consumed. Interviews highlightedthe significance of these observations on risk perception ofdeveloping T2DM. Interviews with both farmers, the headman,and the VHV indicated a knowledge that overconsumptionof glutinous rice is a behavioral determinant of developingT2DM. However, some interviewees still expressed geneticsand old age to be more important risk factors in developingthe disease. Interviews suggest this emphasis exists becauseof a lack of understanding of the severe role their diet playsin developing T2DM. A previous study, in a rural villagein northeast Thailand, researched T2DM patient0s perceptionof disease development. It was concluded that patients wereaware of diet factors but overemphasized biological concerns(Nakagasien et al., 2008).

The interviews with the clinician, endocrinologist, and HPHnurse indicated that the overemphasis on biological determi-nants led to younger populations choosing not to screen forT2DM. The HPH nurse expressed that younger populations,specifically under 40, are going undiagnosed because theyassociate old age with illness, failing to comprehend theimpact of diet on developing T2DM. The endocrinologistsupported this observation. The perception of the importancethat genetics and age has in disease development derives fromfamily beliefs. These beliefs cause a decreased risk perception

among younger populations, consequently, discouraging themfrom participating in screening sessions for T2DM. Therefore,there potentially exists an undiagnosed population of T2DMpatients in Ban Nongsan Moo 10 because of a misguided riskperception with an underemphasis on behavioral determinantscaused by a lack of nutritional knowledge.

V. LIMITATIONS AND FURTHER RESEARCH

This investigation encountered social desirability biasthrough participant observations, communication with villagevolunteers, and survey responses. First, both host families andvillage volunteers were aware of the objectives of the research.In an eagerness to satisfy these objectives, households madean effort to eat healthier and were weary about eating duringmeal times. This was alleviated by reframing the observationperiod to the entire research phase. Village volunteers werealso eager to satisfy research objectives. While assisting insurveying, volunteers pushed for more desirable answers.In order to remain accountable, the investigation withdrewanalysis of the screening survey and decided to focus moreon other observations. Finally, survey respondents introducedsocial desirability bias through self reporting of their dietaryhabits. This potentially caused a similarity between consumedservings and presumed healthy servings. This was mitigatedby comparing the presumed healthy servings with the MoPHrecommendations instead of comparing consumed servingswith the recommendations.

The results were influenced by recall bias when participantsof the nutrition survey were asked to recall all food consumedin the last 24 hours. There was a discrepancy because Thaistyle eating makes it difficult to record serving size. Thislimitation was reduced by using the hand guide to portionsizes because it gave a visual representation of dietary intakewhich made it easier to recall consumption.

The language barrier during interviews was mitigatedthrough the use of a translator. However, participant observa-tions were extended through the entirety of the research pro-cess, therefore, one translator was not sufficient to understanddietary habits fully. Also, through the process of translation,information was lost because many of the observations weremeant to understand cultural habits and therefore did not havean exact translation. This limitation was alleviated by com-bining qualitative and quantitative results to fully comprehendrisk perceptions and dietary habits.

Further research for this topic should focus on measuringthe blood glucose levels of adults under the age of 45 to provethat there is an undiagnosed population. As well, researchshould be conducted on ways to change the emphasis ongenetic factors towards a more balanced risk perception.

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VI. APPENDIX

Fig. 5. Nutrition Flag published by the Thai Ministry of Public Health

Fig. 6. Visual Representation of Serving Sizes

Fig. 7. Mind Map for Phase Two Interviews

REFERENCES

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[2] Aekplakorn, W., Stolk, R., Neal, B., Suriyawongpaisal, P., Chongsuvivat-wong, V., Cheepudomwit, S., Woodward, M. (2003) The Prevalence andManagement of Diabetes in Thai Adults. The International CollaborativeStudy of Cardiovascular Disease in Asia. Diabetes care, 26(10).

[3] Aekplakorn, W., Bunnag, P., Woodward, M., Sritara, P., Cheepudomwit,S., Yamwong, S., and Rajatanavin, R. (2006). A risk score for predictingincident diabetes in the Thai population. Diabetes care, 29(8), 1872-1877.

[4] C. Deerochanawon, et al. (2013, March 14). Diabetes managementin Thailand: A literature review of the burden, costs, and out-comes. Globalization and Health. Retrieved November 26, 2014, fromhttp://www.globalizationandhealth.com/content/9/1/11

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[7] Pongmesa, T., Li, S. C., and Wee, H. L. (2009). A survey of knowledgeon diabetes in the central region of Thailand. Value in Health, 12(s3),S110-S113.

[8] Sowattanangoon, N., Kotchabhakdi, N., and Petrie, K. J. (2009). Theinfluence of Thai culture on diabetes perceptions and management.diabetes research and clinical practice, 84(3), 245-251.

[9] UCSF. (2007). What is Type 2 Diabetes? Diabetes Teaching Center atthe University of California, San Fransisco. http://dtc.ucsf.edu/types-of-diabetes/type2/understanding-type-2-diabetes/what-is-type-2-diabetes/

VII. ACKNOWLEDGEMENTS

Thank you to the Takraserm Health Promotion Hospitalfor allowing access to the records necessary for prevalenceand screening calculations. And thank you to SiriwatchayaNaowong for her wonderful translation service and dedicationto our research.