Journal of Preventive Medicine Association of Thailand

เวชศาสตร์วิถีชีวิต (Lifestyle Medicine) กลยุทธ์ไปสู่การแก้ไขปัญหา NCDs ในประเทศไทย

Surachai Chokkhanchidchai — Thu, 02 Jan 2025 00:00:00 +0700

เวชศาสตร์วิถีชีวิต (Lifestyle Medicine) เป็นการแพทย์แนวใหม่ที่นำองค์ความรู้หลากหลายแขนง เช่นแพทย์ศาสตร์ โภชนวิทยา จิตวิทยา พฤติกรรมศาสตร์ วิทยาศาสตร์การกีฬา มาบูรณาการเชื่อมโยงกัน เพื่อช่วยให้บุคคลที่ได้รับคำแนะนำจาก แพทย์ด้านเวชศาสตร์วิถีชีวิต สามารถปรับเปลี่ยนพฤติกรรมที่ส่งผลต่อสุขภาพได้อย่างยั่งยืนโดยให้ความสำคัญกับวิถีชีวิตที่ปรับเปลี่ยนให้เกิดสุขภาพดีทั้งกายและใจ ในเสาหลัก 6 ด้าน

Preventing Cardiovascular Deaths: Challenges in Thailand’s Imminent Aging Society

Prischa Saengow — Thu, 26 Dec 2024 00:00:00 +0700

Cardiovascular disease (CVD) remains a significant public health issue worldwide and in Thailand, with highest mortality rates despite advancements in medical technology. As Thailand transitions into an aging society, with 30% of its population projected to be over 60 years old in the next 20 years, consequently managing cardiovascular disease in the elderly becomes critical. Cardiovascular disease prevention can be categorized into non-modifiable risk factors (age, gender, genetics) and modifiable risk factors (lifestyle behaviors, socioeconomic factors). Especially in postmenopausal women, due to estrogen insufficiency, prevalence of dyslipidemia significantly increases which sharply rises cardiovascular disease mortality rate. Current guidelines emphasize both primary and secondary prevention through lifestyle modifications and pharmacological interventions. Effective cardiovascular disease prevention and control in Thailand's aging society require multi-faceted strategies, including health promotion, healthcare system development, and stakeholder collaboration. A holistic approach addressing lifestyle changes and psychological well-being is essential. Clinical preventive medicine aims to improve quality of life and ensure healthy aging, reinforcing that prevention is preferable to late-stage treatment.

The Impact of Adequate Protein Intake on Reducing Fall Risk in the Elderly

Pattarin Boonnam, Setthawut Intarapradit — Thu, 26 Dec 2024 00:00:00 +0700

Falls are a significant issue impacting the health and quality of life of older adults, particularly those with sarcopenia, a condition characterized by a decline in muscle mass and strength. This review article aims to analyze the role of adequate protein intake in reducing fall risk among older adults, emphasizing the mechanisms by which protein benefits muscle health and providing recommendations for optimal protein quantity and quality to prevent falls. A synthesis of recent research demonstrates that sufficient protein intake, especially when combined with resistance exercise, significantly reduces fall risk and improves overall health in older adults.

The Effectiveness of Knowledge Transfer Program in the Community to Improve the Health Service Accessibility for Acute Stroke

Tharawut Mekthara — Thu, 26 Dec 2024 00:00:00 +0700

Objective: To study the effectiveness of a knowledge transfer program in the community aimed at improving health service accessibility for acute stroke in terms of cognition and confidence among Village Health Volunteers (VHVs) in knowledge transfer to the community, access to emergency medical services, and timely access to health services. Methods: This research utilized a quasi-experimental, one-group pre-test/post-test design in the area of Bangchak Subdistrict, Phra Pradaeng District, Samut Prakan Province, between April 4 and October 10, 2024. The population included 50 VHVs and 100 inhabitants. VHVs received knowledge and then transferred it to the inhabitants. Data were collected via pretests and posttests, with changes in scores analyzed. A paired t-test was used to assess the effectiveness of the knowledge transfer program in the community to improve health service accessibility for acute stroke in terms of cognition and confidence among VHVs in knowledge transfer to the community. Data on patients with acute stroke were collected from electronic medical records, and chi-square test statistics were employed to analyze changes in the proportion of patients who arrived on time and the patients who used emergency medical services before and after the program implementation. Results: According to the study of the program's effectiveness in 50 VHVs and 100 inhabitants, it was found that the mean posttest score regarding stroke and health service accessibility for acute stroke among VHVs increased by 2.22 points (95%CI 1.73-2.71, p<0.001). The mean posttest score regarding stroke and health service accessibility for acute stroke among inhabitants increased by 3.29 points (95%CI 2.96-3.62, p<0.001). The mean posttest score regarding confidence in knowledge transfer and primary assessment of stroke among VHVs increased by 6.32 points (95%CI 5.15-7.49, p<0.001). Regarding patients with acute stroke in the Bangchak Subdistrict area, the proportion of patients treated at Bangchak Hospital within 4.5 hours increased from 0% to 55.6% after the program implementation (p = 0.006). Furthermore, the proportion of patients using emergency health services increased from 10% to 33.3% (p = 0.213). Conclusions: With the use of a knowledge transfer program in the community to improve health service accessibility for acute stroke, knowledge of stroke and health service accessibility for acute stroke among VHVs and inhabitants increased significantly. Additionally, confidence among VHVs in knowledge transfer and primary assessment of stroke also increased significantly. The number of patients with acute stroke receiving timely treatment showed a statistically significant increase, and an increase in patients who used emergency health services was also found.

Work Ability and Related Factors of Employees Inspecting the Quality among Electronics Factory in Phra Nakhon Si Ayutthaya Province

Pitchayaporn Pathaweesrisutha — Thu, 26 Dec 2024 00:00:00 +0700

Objective: This study aimed to identify factors influencing work ability among employees inspecting workpiece quality in an establishment with high turnover rates in Phra Nakhon Si Ayutthaya Province, Thailand. A cross-sectional study was conducted with 100 quality inspection employees aged ≥18 years. Methods: Data were collected using the standardized survey form from the Department of Disease Control, Ministry of Public Health. Work ability scores were categorized as high (good/very good) or low (moderate/low). Chi-square tests and logistic regression were used to analyze associations between potential factors and low work ability scores. Results: The participants, 76% (n=76) demonstrated high work ability scores, while 24% (n=24) showed low scores. Abnormal occupational vision test (Adjusted OR = 4.18, 95% CI: 1.25 - 13.97, p 0.02) and poor mental health, particularly lack of job satisfaction (Adjusted OR = 0.27, 95% CI: 0.09 - 0.8, p<0.019), were significantly associated with low work ability scores. Conclusion: Abnormal occupational vision test and mental health issues, especially reduced job satisfaction, were significantly associated with lower work ability scores. Interventions focusing on improving the working environment, incorporating regular eye rest periods, and implementing workplace well-being initiatives may help reduce employee sick leave and improve work efficiency.

Development of Ergonomics Management System among Cleaning Workers in one Establishment, Ayutthaya Province

Sudarat Kongkerd, Teeraphun Kaewdok — Thu, 26 Dec 2024 00:00:00 +0700

Objectives: The objective of this study was to develop and evaluate an ergonomic operating system for cleaning staff in establishments to reduce the incidence, severity, and risk of work-related musculoskeletal disorders. Methods: The main activities include: 1) Appointment of an ergonomics committee, 2) Communication, 3) Training, 4) Risk assessment, 5) Job safety analysis, 6) Establish of safe operating procedures. and 7) Monitoring and observing work behavior. The tools used in this study include: 1) A questionnaire, 2) risk assessment form 3) job safety analysis form, and 4) work behavior evaluation form. The study was conducted for a period of 4 months. General data were analyzed using descriptive statistics. Comparative data before and after the development of the ergonomics operating system using Chi-Square statistics and Paired t-test statistics. Results: The results of the study found that most cleaning staff (96.3%) were female, with an average age of 51 years. Their work involves tasks at risk for musculoskeletal pain, including: bending, lifting the neck and reaching jobs, 98.1%, 96.2%, and 92.5%, respectively, mostly pain in the shoulder area lower back and lower legs respectively after developing the ergonomics operating system, it was found that the incidence and severity of musculoskeletal disorders were not significantly different average ergonomics knowledge work behavior increased significantly. and the mean risk scores for working decreased significantly. Conclusion: Development ergonomics management system among cleaning workers in establishment can reduce ergonomics risk, increase knowledge and correct work behavior according to ergonomics principles.

Associations Between Sociodemographic Factors and Diabetes Incidence: A Retrospective Nationwide Cohort Study

Wasin Laohavinij, Wichai Aekplakorn, Piya Hanvoravongchai — Thu, 26 Dec 2024 00:00:00 +0700

Objectives: This study is to calculate diabetes incidence in the Thai population and identify associations between sociodemographic factors and diabetes incidence. People aged 20 and over who had not previously received a diabetes diagnosis from Thai National Health Examination Survey V (NHES V) and used public health services registered with the National Health Security Office Database were included in the study. Methods: The Cox proportional hazards model was used for identifying the associations. The study included 10,203 participants, categorized into three groups based on their blood sugar level at the start of the cohort: 1. normal blood sugar level; 2. prediabetes; and 3. suspected diabetes—a total of 7,482, 2,185, and 536 people, respectively. Results: In the 7-year follow-up from 2013 to 2020, there were 769 newly diagnosed diabetes patients, representing an incidence of 10.6 (95% CI 9.8–11.4) per 1,000 population years. Sociodemographic factors associated with diabetes incidence were the southern region (adjusted HR 0.74, p=0.02; Ref: central region) and highest educational attainment (adjusted HR 0.69, p=0.01; 0.74, p=0.01; and 0.70, p=0.04 for lower secondary, higher secondary, and bachelor’s degree and above, respectively; Ref: primary level). Conclusions: This study showed that the population residing in the southern region and those who completed at least secondary education had fewer chances of developing diabetes compared to their counterparts.

Results of Pulmonary Tuberculosis Screening among Inmates in One Closed Prison, Phra Nakhon Si Ayutthaya Province, 2021-2023

Niti Aromchuen — Thu, 26 Dec 2024 00:00:00 +0700

Objectives: This cross-sectional tuberculosis screening study aims to calculate the detection rate and identify risk factors for new tuberculosis cases. In a closed prison in Phra Nakhon Si Ayutthaya Province between 2021 - 2023, there were 1,240, 1,358 and 1,365 people, respectively. Methods: Chest radiographs were used for all prisoners and sputum samples were tested using Xpert MTB/RIF in cases with abnormal chest radiographs were consistent with tuberculosis. General data were analyzed using descriptive statistics. Risk factors associated with tuberculosis were analyzed by logistic regression analysis with Chi square statistics, Odd ratios and estimation of 95% confidence intervals. Results: showed that they were all male 49.8% were in the age group of 20-39 years, 50.8% had a period of imprisonment between 5-10 years, 3.3% had family members who had been sick with tuberculosis, 5.5% had been sick with tuberculosis before, 10.3% had congenital diseases and 51.6% had ever smoked. Annual chest radiograph screening found abnormalities compatible with tuberculosis in 7.0%, 3.5%, and 8.4%, respectively. Screening found 20.7%, 2.1%, and 14.9% of new tuberculosis patients, respectively, and found 923 new tuberculosis cases per 100,000 people. The risk factors are Someone in the family has been sick with tuberculosis. Have a history of smoking, are less than 40 years old, and have been incarcerated for more than 10 years. Therefore, prisoners should be continually screened for tuberculosis, especially those with risk factors.

Accuracy of Neck Circumference in Predicting the Severity of Obstructive Sleep Apnea at Pranangklao Hospital

Phasawee Thangdechahirun — Thu, 26 Dec 2024 00:00:00 +0700

Background: Obesity is associated with the occurrence of obstructive sleep apnea (OSA) and neck fat. The diagnosis of OSA, typically uses the body mass index (BMI), which reflects overall fat distribution but not specifically indicate neck fat. Neck circumference can be inferred as an indicator of fat distribution and body shape within the population. Objective: This study aims to investigate the relationship between neck circumference and the severity of OSA, as well as to determine the appropriate cutoff point for neck circumference in predicting the severity of OSA at Pranangklao Hospital. Methods: This retrospective study included patients diagnosed with OSA between January 2021 and April 2024, totaling 64 cases. Data were collected using created record form. Relationships were analyzed using Chi-square or Fisher's exact test for categorical variables and one-way ANOVA for continuous variables. The appropriate cutoff point for neck circumference was determined using diagnostic tests, displaying sensitivity, specificity and the area under the receiver operating characteristic curve (AUROC). Results: Among the 64 patients diagnosed with OSA between January 2021 and April 2024, there were 13 cases (20.32%) with mild severity, 14 cases (21.87%) with moderate severity, and 37 cases (57.81%) with severe OSA. The analysis using one-way ANOVA revealed that neck circumference was significantly associated with the severity of OSA (p<0.01). For moderate OSA patients, the cutoff point for neck circumference was 37.5 cm, with a sensitivity of 73%, specificity of 85%, and ROC of 79%. For severe OSA patients, the cutoff point was 38.5 cm, with a sensitivity of 73%, specificity of 74%, and ROC of 74%. Conclusion: Neck circumference is associated with the severity of obstructive sleep apnea (OSA). It is necessary to redefine the appropriate neck circumference for predicting OSA severity specifically for the Thai population. Identifying an optimal neck circumference cutoff point for predicting OSA severity in the Thai population is highly beneficial, as an accurate cutoff point can significantly aid in the diagnosis and treatment of OSA. Therefore, analyzing and developing appropriate OSA screening tools for the Thai population is crucial for effective health care and disease prevention in Thailand.

Effects of Health Literacy Promotion Program on the 3O. 2S. Self-Care Behavior and Health Literacy of the Elderly at Risk of Diabetes Disease, Sam Ngam Tha Bot Subdistrict, Hanka District Chainat Province

Sasima Watthana, Naphatsorn Yotthongdi, Yutdhna Nunla-ong, Piyaporn Jaisan — Thu, 26 Dec 2024 00:00:00 +0700

Objectives: To study effects of health literacy and health behavior promotion on the 3O. 2S. Self-care behavior and health literacy of the elderly at risk of diabetes disease Before and after participating in the health literacy program. Methods: This was a quasi-experimental research Nutbeam's framework of health literacy to develop a health promotion program. The researchers used the simple random method. and determine the characteristics of a sample group of 30 people. They will receive care as stated by the 6-weeks health literacy promotion program and assess
self-care behavior according to 3O. 2S. self-care behavior and health knowledge of risk. The groups before and after participating in the program were analyzed with descriptive statistics and an Independent Sample t-test. Results: The sample group had mean score of the 3O. 2S. self-care behavior and health literacy. The intervention group had a significance higher score than those of
the control group (p<.05). Conclusions: Promoting health literacy in response to the causes of health-risk behavior makes people at risk of diabetes more likely to change their behavior for the better. Therefore, the health team could involve a health literacy promotion program from this research to systematize health promotion activities for people at risk of diabetes to have good health.

The Relationship of Obesity Indices with Metabolic Syndrome in Patients with Type 2 Diabetes Mellitus

Anchana Maneengam — Thu, 26 Dec 2024 00:00:00 +0700

Objective: To compare the prevalence and identify the optimal cutoff values of obesity indices related to metabolic syndrome in patients with Type 2 Diabetes Mellitus (T2DM) between males and females. Methods: This cross-sectional analytical research collected data from T2DM patients diagnosed at Sam Phran Hospital. The study examined obesity indices in T2DM patients receiving annual check-ups between December 2023 and March 2024. A sample size of 448 was calculated, consisting of 224 males and 224 females. Data were collected using general questionnaires and laboratory results to determine obesity indices. Data analysis employed descriptive statistics and inferential statistics including independent t-test, Chi-square test or Fisher exact test and optimal cutoff values were determined using diagnostic tests to present sensitivity, specificity and the area under the ROC curve. Results: Among 224 male T2DM patients, 112 (50.00%) had metabolic syndrome (Mets), and among 224 female T2DM patients, 106 (47.32%) had metabolic syndrome (Mets). The obesity indices associated with metabolic syndrome in both genders are Lipid Accumulation Product (LAP): Males: Cut-off value of 38.22, sensitivity of 85%, specificity of 66%, ROC curve of 0.75 Females: Cut-off value of 52.74, sensitivity of 75%, specificity of 75%, ROC curve of 0.75, Triglyceride - Glucose Index (TyG index): Males: Cut-off value of 9.125, sensitivity of 79%, specificity of 84%, ROC curve of 0.81 Females: Cut-off value of 9.155, sensitivity of 81%, specificity of 81%, ROC curve of 0.81, Visceral Adiposity Index (VAI): Males: Cut-off value of 3.82, sensitivity of 83%, specificity of 81%, ROC curve of 0.82 Females: Cut-off value of 5.54, sensitivity of 79%, specificity of 86%, ROC curve of 0.83 Conclusion: The prevalence of metabolic syndrome in male T2DM patients is 50% and 47.32% in female T2DM patients. The obesity indices related to metabolic syndrome include the LAP, TyG index, and VAI.

Effect of Development of Systems and Mechanisms to Solve Problems of Teenage Pregnancy in Samut Sakhon Province

Sukhon Punjapong — Thu, 26 Dec 2024 00:00:00 +0700

Objective: This study aimed to study effect of developing systems and mechanisms for solving teenage pregnancy problems in Samut Sakhon Province. Methods: This research and development study was conducted between February and September 2024. The sample group consisted of 229 networks members and 241 teenagers under 20 years old. The research tools included a knowledge questionnaire, network participation assessment, perception of pregnancy risk, and pregnancy prevention behavior. Data were analyzed using descriptive statistics, Wilcoxon Signed Ranks Test and Paired t-test. Results: The Knowledge and behavior program to prevent teenage pregnancy consisted of the following components 1) knowledge about problems and effects of premature sexual intercourse, 2) knowledge and strengthening of preventive behavior related to teenage pregnancy, life skills and sexual education, 3) knowledge about reproductive health and family planning, 4) knowledge about sexually transmitted diseases (STDs) and HIV/AIDS, and 5) exchange of knowledge and evaluation. The results indicated that after the network development, there was statistically significant increase in overall knowledge scores (p<0.001), and statistically significant increase in overall participation (p=0.004). Adolescents demonstrate a significantly higher mean awareness of pregnancy risks (p<0.001). Access to information and health services overall increased significantly (p<0.001) and overall teenage pregnancy prevention behaviors also showed a significant increase (p<0.001). Conclusion: After organizing activities, knowledge and behavior programs to prevent teenage pregnancy. This causes behavior to prevent of teenage pregnancy to increase.

Online Social Media Usage Behavior and Health Promotion of Teenagers

Junthara Somtua — Thu, 26 Dec 2024 00:00:00 +0700

Objective: To study the behavior of social media usage and health promotion among teenagers and examine the relationship between social media usage, behavior, and health promotion among adolescents. Methods: This research is a cross-sectional analytical study. The sample group consists of teenagers aged 19-24 years who are studying at Rajamangala University of Technology Isan, Khon Kaen Campus, during the academic year 2024. The study period spans from June to September 2024. Results: The majority of participants used social media 10 or more times per day (40.00%). The average duration of social media usage was 1-2 hours per session (95.00%). Most participants accessed social media while at the university (46.75%), with peak usage occurring between 12:01 p.m. and 4:00 p.m. They primarily used mobile phones or smartphones to access social media. Regarding health promotion, the behaviors across all six dimensions of health promotion among adolescents were at a high level (Mean = 2.18, SD = 0.52). Stress management had the highest average (Mean = 2.79, SD = 0.52), followed by exercise (Mean = 2.25, SD = 0.53) and food consumption (Mean = 2.15, SD = 0.52). Health responsibility had the lowest mean (Mean = 1.85, SD = 0.51). The study found a positive relationship between social media usage and health promotion behavior, with a statistical significance of 0.05. Conclusion: Health promotion efforts among teenagers should be tailored to align with their online media usage patterns, including preferred access channels, duration, and formats that engage their interest. This approach will enhance the effectiveness of health promotion in the current era.

Epidemiology and Associated Factors of Lower-Limbs Amputation of Diabetic Foot Ulcer in Banmi Hospital, Lopburi Province

Pattarika Rittirong — Thu, 26 Dec 2024 00:00:00 +0700

Objectives: To evaluate the epidemiology and associated factors of amputation in patients with diabetic foot ulcers at Banmi hospital. Methods: Retrospective descriptive study of 233 patients with diabetic foot ulcers from January 2020 to December 2023. Generalized characteristic, disease related characteristic, laboratory data were collected. The patients were divided into two groups based on their amputation surgery. To explore causes, levels, result, length of stay, direct cost and medical coverage of diabetic-related lower limbs amputations, the data were analyzed by using descriptive statistics and multiple logistic regression with statistic significant level at 0.05. Results: The total number of diabetic foot ulcers during 2020-2023 was 233 patients. Among them, 97 (41.63%) were amputated. The Most patients (38.1%) over than 60 years old. The most common cause was due to ischemic infection foot ulcers (50.5%). Toe amputation (87.6%) was the most common level of amputation. Length of stay was 13 days with direct cost of 17,426.50 THB. Most of them were paid by universal coverage. Factors related to diabetic foot ulcers amputation were history of previous amputation (OR=9.17, 95%CI= 3.755-22.415), leukocytosis (OR=5.21, 95%CI= 2.252-12.053), anemia (OR=8.42, 95%CI= 1.914-37.056), high blood sugar level (OR=5.87, 95%CI= 1.893- 18.170), high HbA1c level (OR=3.05, 95%CI= 1.092-8.530) and osteomyelitis (OR=25.05, 95%CI= 5.925-105.89), significantly. Conclusion: Diabetic foot ulcers are a major public health problem and are the main cause of lower- limbs amputation in diabetes patients. Therefore, establishing guidelines, early detection of diabetic foot ulcer through multidisciplinary care and knowledge of risk factors for amputation can be helpful and decreased rate of lower-limbs amputation.

Factors Influencing the Timeliness of Treatment for Acute Stroke Patients at Banmi Hospital, Lopburi

Nichapat Ampornmunee — Thu, 26 Dec 2024 00:00:00 +0700

Objective: To examine factors influencing the timeliness of treatment for acute stroke patients at Banmi Hospital, Lopburi. Methods: This is a retrospective analytic study aimed at investigating the factors influencing timely treatment of acute stroke patients at Banmi Hospital, Lopburi Province. The research population consisted of patients presenting with acute stroke symptoms who were treated in the emergency department and outpatient clinic, and who were diagnosed with acute stroke between October 1, 2018, and September 30, 2023. The sample comprised 212 patients, divided into a study group of 106 patients and a control group of 106 patients. Results: The multivariate analysis revealed that the factors influencing the prediction of timely treatment within three hours for acute stroke patients included: having a history of stroke (OR_adj = 0.02, 95% CI: 0.00-0.25), having a history of heart disease (OR_adj = 20.18, 95% CI: 2.46-165.61), and having severe symptoms (GCS ≤ 8) (OR_adj = 5.54, 95% CI: 1.17-26.14). Conclusion: Timely treatment of stroke significantly impacts the quality of life for patients. Therefore, raising public awareness to ensure timely access to treatment, as well as educating the community about the symptoms and warning signs of acute stroke, is crucial. This is essential to prevent mortality or disability among the population.

Model Development of Elderly Care by Digital Health for Primary Care System in Urban Area, Ratchaburi Province

Thu, 26 Dec 2024 00:00:00 +0700

Objectives: To study the situation and needs of elderly care using digital health in urban primary care system in Ratchaburi Province, develop and evaluate a care model. Methods: The four phases in this research and development study were analyzing the current situation and needs, developing a care model, evaluating the effectiveness of the model, and optimizing it. The sample included healthcare providers and elderly residing in Na Muang Subdistrict. Research tools consisted of interview guides, care manuals, care model, and questionnaires. Data was analyzed using content analysis, and Paired Samples t test. Results: The elderly individuals desired clear guidance and hands-on support for using digital health, ideally with simulated scenarios or assistance available when issues occurred. They also requested user manual, easily accessible devices in community, and efficient communication channels with healthcare staffs. The elderly care model using digital health consisted of five key components; service user (technology acceptance and competency), service provider (technology, coaching and administrative competencies), service delivery (online, onsite and community health station), technology (LINE Official Account, Hygge, and MorPrompt app.) and devices and supporters (smartphone, internet, care manuals, devices in community health station and health media). The results of this care model implementation indicated that healthcare accessibility among sample population significantly improved (0.51±0.61, 95% CI 0.31-0.70, P<0.001), along with a statistically significant increased in the use of digital health for self-care (1.16±0.95, 95% CI 0.85-1.46, P<0.001). Conclusions: The elderly healthcare model utilizing digital health in the urban primary healthcare system of Ratchaburi Province is practical and enhances access to primary healthcare services. Implementation recommendations emphasize adherence to the five key components; particularly focusing on hands-on elderly training, digital health care manual, administrative leader by physician, digital health coaching by nurse or public health officer and community health station.