Disease Control Journal

The investigation of road traffic mass injuries; an 18-wheel trailer collided with a private van on national highway road 4110 Thung Song – Thung Yai, Nakhon Si Thammarat Province, April 2-3, 2023

Sat, 29 Jun 2024 00:00:00 +0700

Road traffic accidents cause a significant loss of life and property. On April 2–3, 2023, the Joint Investigation Team (JIT) from the Office of Disease Prevention and Control Region 11 Nakhon Si Thammarat and the Multidisciplinary Team investigated road traffic mass injuries. The purposes of this investigation were to describe the event, study the characteristics of injuries and deaths, identify factors associated with the accident, and suggest measures for accident preventions in the future. Information was gathered by reviewing medical records, interviewing the people involved in the event, and risk factors by period of the event were analyzed using the Haddon’ s Matrix method. The results showed that the event occurred on April 1, 2023, at about 05.53 a.m. on national highway road 4110 Thung Song – Thung Yai, Nakhon Si Thammarat. An 18-wheel trailer that was traveling in the right lane veered into the left lane and collided with a private van that was travelling. A total of 11 victims were injured. The median age was 35 years (range: 2 - 61). Of all the injured, there were six fatal cases (4 cases died on the spot), 4 cases of serious injuries and 1 case of minor injury. The cause of six deaths was attributed to severe chest injury. Factors that caused the accident include the driver of an 18-wheel trailer being physically tired and a lack of driving ability. Factors that caused severe injury and death were a strong collision causing the front cabin of the van to collapse. The driver and passengers were crammed into the car, four of them were not wearing seat belts and 3 cases were thrown out of the van, and their heads hit the pavement. It is recommended that (1) transportation business operators provide necessary trainings to their drivers to develop safe driving skills and strictly check the physical fitness of the drivers before traveling and (2) responsible agencies strictly enforce the laws requiring all passengers to wear seat belts.

Outbreak investigation of vitamin B1 deficiency in Si Sa Ket Provincial Prison, July 2023

Sat, 29 Jun 2024 00:00:00 +0700

The objective of this descriptive epidemiological study was to verify the diagnosis, identify the causes and risk factors, and determine measures to treat and prevent vitamin B1 deficiency among 1,718 inmates in Si Sa Ket Provincial Prison during July 21-25, 2023. Data were collected from patients’ medical records, environmental observations, dietary behavior surveys, interviews using a form to investigate limb weakness developed specifically for Si Sa Ket Provincial Prison, laboratory tests, electrodiagnostic study, environments and consumption behaviors. Descriptive data analysis was conducted, which includes number, percentage, mean, standard deviation, minimum, and maximum. There were 84 male prisoners experiencing symptoms consistent with the case definition of vitamin B1 deficiency, representing the morbidity rate of 4.89% (84/1,718). Only 4 of the patients who met the case definition were confirmed cases and the rest were suspected cases. Signs and symptoms observed included muscle weakness (92.86%; 78/84), numbness (89.29%; 75/84), and myalgia (82.14%; 69/84). Abnormal examination results included gloss sensation (36.73%; 18/49), pinprick sensation (36.00%; 18/50), polyneuropathy (100%; 5/5), thiamine pyrophosphate below standard value (44.44%; 4/9), and thyroid function disorder (12.50%; 1/8). The risk behaviors that potentially caused vitamin B1 deficiency was that some inmates ate additional foods including instant noodles, fermented foods, processed foods, fish sauce, fermented fish, and canned foods. This outbreak was the first outbreak of dry beriberi in Si Sa Ket province with common sources. The main cause was unbalanced diet or lack of nutrition, together with Influenza B outbreak that was found only one week prior to the outbreak of vitamin B1 deficiency. For disease control measures: treat patients according to WHO treatment guidelines and administration of prophylactic vitamin B 1-6-12 for all prisoners, adjusting the nutrition intake by replacing the white rice with brown rice, consuming an appropriate amount of vitamin B1 by increasing protein from both meats and vegetables, and discontinuation of consumption of food that contains substances which destroy or inhibit the absorption of vitamin B1.

Thailand’s Influenza burden before and during COVID-19 pandemic and factors associated with 30-day mortality among influenza patients between 2016 and 2020

Sat, 29 Jun 2024 00:00:00 +0700

Various studies have reported that the COVID-19 pandemic affected influenza infection trends and severity. This study aimed to analyze influenza infection patterns, severity, and factors associated with 30-day mortality among influenza patients before (2016-2019) and during the COVID-19 pandemic (2020). Using National Health Security Office data, we included weekly influenza admissions. We estimated morbidity and mortality per 100,000 persons and performed descriptive study in sex, age, geographic, influenza vaccination, underlying diseases, length of stay, and adjusted related weight (adjusted RW). Multiple logistic regression was used in inferential study. Our analysis, based on 219,365 inpatients, revealed 2 peaks in influenza admissions during rainy and winter seasons. The highest morbidity rate was found in 2019 then suddenly decreased in February 2020. Most cases were found in young children (0-4 years) in the northern and northeastern regions. The mortality rate increased from 0.38 to 0.74 per 100,000 persons during the COVID-19 period. Factors significantly correlated with mortality were described as being aged 50 years and over at pre-COVID-19 period, being aged 65 years and over during COVID-19 period, adjusted related weight, and comorbidities. Moreover, vaccination was less associated with death during pre-COVID-19 period. We suggest targeted risk awareness campaigns by public health agencies, especially for vulnerable groups, to prevent influenza-related deaths, notably among the elderly and those with multiple comorbidities. Despite reduced influenza morbidity during the COVID-19 pandemic, the mortality rates surged. Further studies should explore the quality of care for influenza patients during COVID-19 period and evaluated non-pharmaceutical interventions in preventing COVID-19, which likely played a role in reducing influenza.

Factors related to ICU transfer among patients with COVID-19 infections hospitalized in intermediate ICU: the study of phase 3 pandemic

Varanporn Panasittivana, Chalida Keadphirom, Wasana Lavin (Author) — Sat, 29 Jun 2024 00:00:00 +0700

In the situation of the COVID-19 outbreak, there are many factors that related with patients need to be transferred to the intensive care unit (ICU). This study was conducted among 439 COVID-19 infected patients who had been admitted to an intermediate care unit in Ramathibodi Chakri Naruebodindra Hospital during the phase 3 pandemic. The inclusion criteria were inpatients who were diagnosed with COVID-19 infection. Fifteen patients were excluded from the study as they died while being hospitalized in the intermediate ICU. There were totally 424 patients. The study was conducted between May 1 and September 30, 2021. Data was analyzed using descriptive statistics, which includes frequency, percentage, and standard deviation. The factors associated with transfer to ICU were assessed using the multiple logistic regression and an adjusted OR (aOR) at a 95% confidence interval. The results indicated that the study population consists of 207 male patients (48.8%), with a mean age of 59.8 ±16.0 years (SD=16.05). Seventy-five patients (17.7%) were transferred to ICU, while 349 patients (82.3%) were not transferred to ICU. The factors associated with transfer to ICU were awake prone position (aOR, 1.88; 95% CI; 1.01-3.51) and used the fraction of inspired oxygen (FiO2) above 0.6 (aOR, 8.32; 95% CI; 4.36-15.86). Findings from this study could be used as supporting information to determine ways to reduce the rate of unplanned ICU admissions and for the purposes of monitoring in high-risk patients to ensure more effective and high quality patient care.

The strategy for management and control of COVID-19 with the cooperation of all sectors, Yala Province

Rusila Tokilay (Author) — Sat, 29 Jun 2024 00:00:00 +0700

Since the outbreak of the Coronavirus Disease 2019 (COVID -19) occurred globally, Yala province has proactively implemented comprehensive management strategies and leveraged collaboration across sectors to curb the impact of the Coronavirus outbreak. The initial outbreak in Yala was reported in March 2020, stemming from religious activities, prompted the declaration of a public health emergency by the Ministry of Public Health. Subsequently, on January 23^rd, 2020, Yala Province established an emergency response center, chaired by the governor of Yala Province and Yala Provincial Chief Medical Officer served as a secretary. The objective of this study is to analyze the strategies and measures for preventing and controlling COVID-19 in Yala province during the years 2020-2023. The study was conducted by document analysis and content analysis. Results revealed that the successful integration of operational strategies across administrative and public health departments was presented through the incident command center. Yala Province's incident command center led by the Provincial Communicable Disease Committee had executed 6 proactive operational strategies. People cooperate in disease control and prevention. Particularly the strategy to increase the coverage of administering the first dose of the COVID-19 vaccine in Yala province and to reach 66.69%, which was a higher rate than those of Pattani and Narathiwat provinces. Recommendations for further improvement in management strategies are proposed, Emphasis is placed on developing business continuity plan (BCP) in every sector to ensure effective preparedness and communication with people in the community which will lead to resilient and sustainable response to future challenges.

Knowledge, perceived benefits, and perceived susceptibility regarding COVID-19 vaccines among health science students at a college in Ubon Ratchathani Province

Naruemol Kingkaew (Author) — Sat, 29 Jun 2024 00:00:00 +0700

This cross-sectional study aimed to investigate the knowledge, perceived benefits and perceived susceptibility regarding COVID-19 vaccines among Health Science students at a college in Ubon Ratchathani Province. The study was conducted from February to March 2022. The population was Health Science students in both regular and weekend undergraduate degree programs at a college in Ubon Ratchathani Province. A total of 145 samples was randomly selected by simple random sampling (SRS). Data was collected using structured questionnaires. Statistical analysis was conducted including number, percentages, means and standard deviations with a significant level of p<0.05. The study resulted that 89.0% of the samples were female. The samples had overall knowledge of the COVID-19 vaccines at a high level (95%CI: 8.04, 8.46), overall perceived benefits of the COVID-19 vaccines at a high level (95%CI: 16.18, 16.90), and overall perceived susceptibility regarding COVID-19 vaccines at a high level (95%CI: 27.34, 28.54). Although overall knowledge about COVID-19 vaccines is at a high level, specific knowledge, such as the types of vaccines and vaccination in breastfeeding women, remains at a low level. Therefore, there should be efforts to improve knowledge in these areas among undergraduate students.

The effect of program of applying social support theory for caregivers with health protective behavior of hand foot mouth disease among the children in child preschool development center, pangkoo sub-district administrative organization, Prakhonchai District, Buriram Province

Suthisa Prom-or, Sarodh Pechmanee, Thanakorn Panyasaisophon (Author) — Sat, 29 Jun 2024 00:00:00 +0700

This experimental study aimed to determine the effects of program of applying social support theory for caregivers on their health behavior to prevent hand, foot, and mouth disease among children in Child Preschool Development Center,Pangkoo Sub-district Administrative Organization, Prakhonchai District, Buriram Province. The samples were divided into 2 groups: the experimental group consisted of 35 caregivers who received program of applying social support theory and the control group consisted of 35 caregivers who received regular health promotion programs by simple random sampling. The instruments were the questionnaire, skills assessment and Illness rate record form. Percentage, mean, standard deviation, paired t-test and independent t-test were applied for data analysis. The results of this study were as follows: 1) after receiving the program, the caregivers had significantly greater mean knowledge regarding the disease, prevention behaviors, and hand washing skills at a significance level of 0.05, compared with those before receiving the program and the control group; and 2) after receiving the program, the incidents of hand foot, and mouth disease were not found among preschool children. This program should be introduced to the caregivers in the kindergarten schools or preschool centers. Additionally, digital media should be developed to provide knowledge, disease prevention behavior and hand washing skills to prevent the spread of hand, foot, and mouth disease.

Center Development for New Management of Chronic Non- Communicable Diseases by District Health Network's Participatory

Sat, 29 Jun 2024 00:00:00 +0700

This action research aimed to develop the center for district health network's participatory in chronic disease management and to study the results of a new chronic disease management center developing. The research was conducted February - August 2022 and divided into 3 phases: Phase I, the study of self-care methods of individual patients in the community, phase 2, the development process, and phase 3, the study of development outcomes. Data were collected by using questionnaires, interview forms, quantitative data analysis using descriptive statistics to describe the personal characteristics of the samples, health awareness and health behaviors. The qualitative data consists of service system, perspective customer view and budget perspective use content analysis together with quantitative data analysis. The results found that the outcome of the development consisted of 1) views on the service system, customer, and the budget perspective, were found that there was 1 non-communicable disease new management center. The overall quality of life of patients with chronic non-communicable diseases was at a good level by 87.50% and was able to reduce the cost of medical care for the patients. And 2) 96 patients (46.15%) who participated in activities and practices did not develop stroke and no complications. There were patients able to stop taking drugs to control blood sugar levels, 38 patients (18.27%) reduced the diabetes and hypertension medications using. There were 8 patients (8.33) who participated in the activities and practice, the doctor decided to stop using the medicine. Therefore, the new participatory non communicable disease management model is considered an effective method and should be further applied.

Development of community health network to prevent cerebrovascular disease in the high-risk group, Pak Thong Chai District, Nakhon Ratchasima Province

Sat, 29 Jun 2024 00:00:00 +0700

The prevention of cerebrovascular disease in a high-risk group in Pak Thong Chai District, Nakhon Ratchasima Province had been operated without cooperation of health network. Consequently, we addressed the weakness through a “participatory action research.” The samples consisted of 20 individuals from the community health network known as “Pak Thong Chai Model” and 257 high-risk subjects (i.e. patients diagnosed with diabetes, hypertension, and hyperlipidemia, and were receiving treatment at Pak Thong Chai Hospital). The study implementation was divided into three phases: preliminary data study, development process, and the outcomes from health network collaboration. The data were collected using questionnaires and recording forms. Data analysis was performed using descriptive statistics (frequency, percentage, mean, and standard deviation), analytical statistics (paired t-test), and content analysis. The results showed: 1) The health network including doctors, nurses, public health officers, village health volunteers (VHVs), and academicians were responsible for 1.1) Organizing health care activities based on the principle of “Eight Healthy Habits”, 1.2) Evaluating results, 1.3) Implementing lessons learned, and 1.4) Adjusting drug use; 2) the program implementation outcomes included: 2.1) Capacity building program for health network, 2.2) Working systems and mechanisms for the health network, 2.3) Guidelines for rational drug use, and 2.4) Increased scores for knowledge and skills of the health network after the program development and implementation (p<0.05); 3) The outcomes from health network collaboration indicated that the high-risk group exhibited a higher behavioral level than before the program development and implementation (p<0.05). Moreover, patients with prolonged illness lasting three to over 10 years were successful in controlling the diseases. There were 60.14%, 64.14%, and 98.11% of the subjects who were able to reduce or stop using medications for the treatment of diabetes, hypertension, and hyperlipidemia, respectively. More importantly, new findings and outcomes were discovered: 1) Patients were the first doctor to care for themselves, 2) There was a novel health station that has made the local communities more self-reliant when it comes to health care, 3) Criteria for dose reduction and permanent discontinuation of medications which includes: 3.1) Unusual symptoms occurring after regular administration of medication, low blood sugar or blood pressure or lipid profile, 3.2) Weekly measurement and recording of blood sugar level and/or blood pressure, and 3.3) The risk group had to regularly practice the Eight Healthy Habits. Suggestion: For those at risk, incorporating lifestyle changes alongside adjusting or discontinuing medication, according to guidelines, is key to preventing cerebrovascular disease.

Factors associated with awareness of teachers on the problem of electronic cigarette use among youth in Nakhon Ratchasima Province

Jaruwan Tritipsombut (Author) — Sat, 29 Jun 2024 00:00:00 +0700

The study aims to assess factors associated with awareness of teachers on the problem of electronic cigarette (e-cigarette) use among youth in Nakhon Ratchasima Province. A total of 344 teachers were selected by sampling without replacement from a list of teachers who met the inclusion criteria. Data were collected between January and March 2023 using a self-reported questionnaire. Results revealed that 71.22% were female with an average age of 39.79 years (SD=9.86), 31.56% were professional teachers. Average income was 34,480.10 Baht (SD=16,297.12), and a median of their working life was 10 years. Of those participants, 47.8% noticed e-cigarette sales online and 77.03% received risk information associated with e-cigarette. Analysis by using multiple logistic regression showed that teachers who were interested in receiving information on internet sale of e-cigarette have a good awareness level of e-cigarette problem among youth at 4.35 times higher than those who had no interest in receiving information on internet sale of e-cigarette (AOR=4.35, 95% CI 1.79 to 11.11). Teachers with bad attitude towards e-cigarettes have a good awareness level of e-cigarette problem among youth at 3.45 times of those with fair to good levels of attitude (AOR=3.45, 95% CI 1.59 to 7.69). Teachers with incomes of 35,001 baht or higher have a good awareness level of e-cigarette problem among youth at 2.83 times higher than those with incomes between 10,000 and 35,000 baht (AOR=2.83, 95% CI 1.53 to 5.23). Teachers with low level of e-cigarette knowledge have a good awareness level of e-cigarette problem among youth at 2.06 times higher than those with moderate to high levels of knowledge (AOR=2.06, 95% CI 1.12 to 3.78). Therefore, a good level of teachers' awareness on e-cigarette problem among youth should be considered regarding the above factors.

Health risk assessment of indoor nitrogen dioxide (NO2) exposure at border checkpoint: case study of the 4th Thai-Lao Friendship Bridge (Chiang Khong-Huay Xai), Chiang Rai Province

Sat, 29 Jun 2024 00:00:00 +0700

This research aims to monitor indoor NO₂ concentrations at the 4^th Thai-Laos Friendship Bridge (Chiang Khong-Huay Xai) border checkpoint in Chiang Rai Province during high season and conduct health risk assessments. The study design is survey research. Indoor NO₂ samples were collected by the passive sampling method using a diffusion tube sampler. The area and sampling sites consist of the International Health and Quarantine Office (BC1), Immigration and Customs Checkpoint Arrival (BC2), Immigration Office Arrival (BC3), Immigration Office Departure (BC4), and Immigration and Customs Checkpoint Departure (BC5). The samplings were done from January to April 2023, after 1 week exposure. The mean and median indoor NO₂ concentrations at the border checkpoint ranged from 15.1 (SD 2.3) to 88.3 (SD 30.6) µg/m³ and 15.3 to 93.6 µg/m³, respectively. Indoor NO₂ concentrations at all sampling sites were significantly different, and the immigration and customs checkpoint arrival site (BC2) had the highest values measured. Additionally, a moderate correlation was found between the indoor NO₂ levels and the number of trucks. Non-carcinogenic risk assessments of indoor NO₂ exposure were calculated by hazard quotient (HQ). The results showed that the average HQ values of children were higher than those of male and female adults, exceeding 1.0, indicating potential health risks

Effects of participatory activities and safety perception on work safety behaviors: case study among employees of an ink product manufacturing plant, Samut Sakhon Province

Sat, 29 Jun 2024 00:00:00 +0700

This research was a quasi-experimental study, one group pertest-posttest design, aimed at comparing the level of safety perception and work safety behaviors before and after participation in the activities. The participatory activities included planning, setting goals, making decisions, providing information, determining work procedures, and evaluation. Data were collected from 25 employees of a printing ink factory located in Samut Sakhon province using questionnaire and behavior observation form. Data were analyzed using the Wilcoxon signed-rank test. Results found that the sample group has planned and selected their target behavior which had the potential to cause an accident or near miss. There were three risky behaviors that all of participants had in common. These included the behavior of not clamping the ground wire on the tank to prevent the generation of static electricity, not wearing safety shoes, and not wearing chemical protection masks. The results of the comparison between safety perception and work safety behavior before and after the experiment were found to have a statistically significant difference at p <0.05. Therefore, the employer should take safety promotion seriously so as to encourage the employees to have the correct safety awareness and continually develop work safety behaviors using the participatory approach. These will lead to the development of sustainable organizational safety culture.

Effectiveness of wearing a back support belt while working among medical personnel in a hospital, Chonburi Province

Eakkarin Lukkanalikitkul (Author) — Sat, 29 Jun 2024 00:00:00 +0700

The objective of this research was to study the effectiveness of wearing back support belt while working among medical personnel in the laundry, warehouse, hospital porter, and building management department in a hospital in Chonburi province. This research was experimental design (randomized controlled trial: RCT) with stratified randomization, categorized by department, age, gender and comparing neck, back, and hip pain, use of pain relief drugs, sick leave and disability factors from back pain by Roland-Morris Disability Questionnaire between groups that used and did not use back support belt, 26 people per group, both groups received ergonomics training. Data were collected every week for 1 month. The results of the study revealed that the experimental group had a statistically significant different in the median for neck, upper back, lower back, and hip pain compared with the pain before using the back support belt. The lower back was the only area where pain was different between the experimental and control groups after the study. Wearing a back support belt significantly reduces sick leave from muscle pain, but no difference was found in the use of pain relief drugs and disability factors for back pain. Most medical personnel were very satisfied after using the back support belt, but some had the wrong attitude, such as thinking that the back support belt was a personal protective equipment (76.9 percent), they can lift heavy objects without paying attention to the correct lifting posture (26.9 percent), and they could lift heavier objects safely (76.9 percent). Therefore, there should be support for the use of quality back support belts that are registered as medical devices and the advice on the proper use of back support belts. Ergonomic principles when lifting and moving materials should be noticed for safety.

The effect of participatory ergonomics program to improve working condition for reducing musculoskeletal risks among concrete workers in a factory, Chonburi Province

Eakkarin Lukkanalikitkul (Author) — Sat, 29 Jun 2024 00:00:00 +0700

The objective was to study the effects of a participatory ergonomics program designed to reduce musculoskeletal risks among workers of a concrete factory, in Chonburi Province. The study was a quasi-experimental study, involving 97 workers. The program period was 90 days. Ergonomic risks, muscle pain, use of pain relievers, and sick leave, were compared using paired sample t-test statistics, before and after the intervention (workplace arrangement with ergonomic support, work protocol arrangement and personal behavioral change). The results showed that workers in every department had a statistically significant decrease in ergonomic risk after the study, workers in the mold cleaning department revealed the greatest decrease of risk (95% CI 4.09-6.17). The decrease in muscle pain intensity at neck, shoulders, back and hips were reported, with the greatest decrease at lower back (95% CI 1.60-2.04). Knowledge and attitudes towards ergonomics had improved (95% CI 5.56-7.30 and 1.23-1.50 respectively). The use of pain relievers, and sick leave from muscle pain had decreased (95% CI 0.41-1.64 and 0.22-0.78 respectively). The key to success is the supports from executives and all workers in the organization; committee appointment to operate the activities, resource allocation, providing knowledge by experts, and participatory decision-making among all employees. Further studied on factors affecting the success of participatory ergonomics program should be identified intensively, so that the guidelines to solve the ergonomics problem among workers should be produced to promote good quality of life and work safely among workers.

Evaluation of the Surveillance and Rapid Respond Team (SRRT) district to disease prevention and control at Thailand’s border with Myanmar, Laos PDR, and Cambodia

Sat, 29 Jun 2024 00:00:00 +0700

The trend of cross-border infectious diseases is continuously increasing despite having robust international disease prevention and control systems in place. The Surveillance and Rapid Response Team (SRRT) is a crucial surveillance, investigation, and disease control tool. This study aimed to investigate and evaluate the outcomes of the SRRT's measures for cross-border rapid response regarding processes, outputs, and outcomes. It also seeks to identify operational challenges from implementing these measures along the border between Thailand and the neighbouring countries of Myanmar, Laos, and Cambodia. This study conducts a summative evaluation after project ending. Data were collected through questionnaires, interviews, in-depth interviews, and focus group discussions. The performance evaluation was focused on 2 Key Results Areas (KRA) and 6 Key Performance Indicators (KPI). The study was conducted at 3 border areas: 1) Thailand - Myanmar border in Muang District, Ranong Province, and Mae Sot District, Tak Province. 2) Thailand - Laos border in Sirindhorn District, Ubon Ratchathani Province, and Muang District, Nong Khai Province. 3) Thailand - Cambodia border in Khlong Yai District, Trat Province, and Aranyaprathet District, Sa Kaeo Province. Quantitative data analysis was conducted using descriptive statistics, and qualitative data analysis was performed using typological analysis, categorizing data into types (typologies). Analytic induction is then applied to analyze the data in a deductive manner. The study found that the overall evaluation of the SRRT measures is equivalent to the target goal, with a score of 2.22 out of a maximum score of 3.0. This indicates that the SRRT measures have the potential for surveillance, prevention, and control of diseases at border areas. The province that has achieved performance higher than the target was Tak province, scoring 2.61. The challenges are identified and categorized as follows: 1) frequent personnel turnover, 2) insufficient budget, 3) inadequate supplies and equipment, 4) coordination with other agencies, 5) inconsistencies between the Ministry of Public Health policies and local government organizations, 6) development of capabilities not covering all diseases, 7) incomplete reporting of disease investigations due to the heavy workload of the SRRT, and 8) language limitations. Recommendations suggest that, due to the complexity of border areas, there should be the establishment of a diverse and comprehensive network, including enhancing the capabilities of public health officials to align with the issues at border areas to ensure that health problems in border regions are appropriately and sustainably addressed.