Siriraj Medical Journal
E-ISSN 2228-8082
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SMJ
Volume 74, Number 3, March 2022
By Robyn G. Langham, et al.
ORIGINAL ARTICLE
REVIEW ARTICLE
MONTHLY
Siriraj Medical Journal
SMJ
Volume 74, Number 3, March 2022
ORIGINAL ARTICLE
142 Factors Influencing the Quality of Life and Nutritional Status of 0-2 Years Old Children
Somsiri Rungamornrat, et al.
152 Increasing Dialysate Flow Rate Over 500 ml/min for Reused High-Flux Dialyzers
do not Increase Delivered Dialysis dose: A Prospective Randomized Cross Over Study
Wiparat Srisuwan, et al.
161 Survival of Non-Small Cell Lung Cancer Patients With Unexpected N2 After Complete
Resection: Should Aggressive Invasive Mediastinal Staging be Encouraged?
Suparauk Geanphun, et al.
169 Incidence and Risk Factors of Neonatal Sepsis in Preterm Premature Rupture of
Membranes Before 34 Weeks of Gestation
Thitiporn Sirivunnabood, et al.
178 Incidence of Adverse Perioperative Airway Complications in Obese Non-Pregnant
and Pregnant Patients Undergoing General Anesthesia
Natwara Asanathong, et al.
185 Burnout among Mental Health Professionals in a Tertiary University Hospital
Nichada Khanngern, et al.
193 Attitudes Toward Long-Acting Injectable Antipsychotics Among Schizophrenia Patients in
Southern Thailand: A Multihospital-Based Cross-Sectional Survey
Jarurin Pitanupong, et al.
REVIEW ARTICLE
202 Kidney Health for All: Bridging the gGap in Kidney Health Education and Literacy
Robyn G. Langham, et al.
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Philip Board (Australian National University, Australia)
Richard J. Deckelbaum (Columbia University, USA)
Yozo Miyake (Aichi Medical University, Japan)
Yik Ying Teo (National University of Singapore, Singapore)
Harland Winter (Massachusetts General Hospital, USA)
Philip A. Brunell (State University of New York At Bualo, USA)
Noritaka Isogai (Kinki University, Japan)
Yuji Murata (Aizenbashi Hospital, Japan)
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David S. Sheps (University of Florida, USA)
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Anusak Yiengpruksawan (e Valley Robotic Institute, USA)
Stanlay James Rogers (University of California, San Francisco, USA)
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Shomei Ryozawa (Saitama Medical University, Japan)
Christopher Khor (Singapore General Hospital, Singapore)
Yasushi Sano (Director of Gastrointestinal Center, Japan)
Mitsuhiro Kida (Kitasato University & Hospital, Japan)
Seigo Kitano (Oita University, Japan)
Ichizo Nishino (National Institute of Neuroscience NCNP, Japan)
Masakazu Yamamoto (Tokyo Women’s Medical University, Japan)
Dong-Wan Seo (University of Ulsan College of Medicine, Korea)
George S. Baillie (University of Glasgow, UK)
G. Allen Finley (Delhousie University, Canada)
Sara Schwanke Khilji (Oregon Health & Science University, USA)
Matthew S. Dunne (Institute of Food, Nutrition, and Health, Switzerland)
Marianne Hokland (University of Aarhus, Denmark)
Marcela Hermoso Ramello (University of Chile, Chile)
Ciro Isidoro (University of Novara, Italy)
Moses Rodriguez (Mayo Clinic, USA)
Robert W. Mann (University of Hawaii, USA)
Wikrom Karnsakul (Johns Hopkins Children’s Center, USA)
Frans Laurens Moll (University Medical Center Ultrecht, Netherlands)
James P. Dolan (Oregon Health & Science University, USA)
John Hunter (Oregon Health & Science University, USA)
Nima Rezaei (Tehran University of Medical Sciences, Iran)
Dennis J. Janisse (Subsidiary of DJO Global, USA)
Folker Meyer (Argonne National Laboratory, USA)
David Wayne Ussery (University of Arkansas for Medical Sciences, USA)
Intawat Nookaew (University of Arkansas for Medical Sciences, USA)
Victor Manuel Charoenrook de la Fuente
(Centro de Oalmologia Barraquer, Spain)
Karl omas Moritz
(Swedish University of Agricultural Sciences, Sweden)
Nam H. CHO (University School of Medicine and Hospital, Korea)
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SMJ
Volume 74, No.3: 2022 Siriraj Medical Journal
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142
Somsiri Rungamornrat, Ph.D.*, Apawan Nookong, Ph.D.*, Yuwadee Pongsaranuntakul, M.A.*, Chonlasin
Srilasak, M.S.**
*Faculty of Nursing, Mahidol University, Bangkok 10700, ailand **Bangsai Hospital, Phra Nakhon Si Ayutthaya 13190, ailand.
Factors Inuencing the Quality of Life and
Nutritional Status of 0-2 Years Old Children
ABSTRACT
Objective: To investigate the eects of children factors, family factors, and access to healthcare services on children’s
quality of life as perceived by caregivers and nutritional status of 0 to 2 years old children.
Materials and Methods: is study employed predictive design. e sample group consisted of 106 caregivers with
children aged 0 to 2 years old from ve subdistricts in one province in Central region in ailand. e research
instruments included the Demographic Data of Parents and Children Questionnaire; the Access to Healthcare
Services Questionnaire; the Child-Rearing Practices Questionnaire; the Quality of Life of 0-2-year-old Children
Questionnaire. e data were analyzed by using the Chi-square, Fisher’s exact test, and multivariate logistic regression.
Results: Logistic regression model accounted for 34 % of variance in children’s quality of life (Nagelkerke R
2
= 0.34)
and 35.3% of variance in their nutritional status (Nagelkerke R
2
=.35). Factors predicting the QoL of children were
the maternal age (OR=4.75; 95%CI = 1.16, 19.45, p < .05), and the child-rearing practices (OR=5.68; 95%CI = 1.97,
16.40, p < .05). Factors predicting nutritional status were maternal age (OR=0.088; 95%CI = 0.01, 0.79; OR=0.225;
95%CI=0.02, 2.34, p < .05), and child-rearing practices (OR=7.84; 95%CI = 1.93, 31.84, p < .05). Finally, access to
healthcare services had a signicant association with QoL of children (χ
2
= 9.632, p < .05).
Conclusion: Healthcare personnel should improve children’s quality of life and nutritional status by organizing
programs to promote child-rearing practices and facilitating parents for accessibility to healthcare services.
Keywords: Children aged 0-2; quality of life; nutritional status; child-rearing practice; access to healthcare (Siriraj
Med J 2022; 74: 142-151)
Corresponding author: Apawan Nookong
E-mail: apawan.noo@mahidol.ac.th
Received 5 May 2021 Revised 14 December 2021 Accepted 12 January 2022
ORCID ID: https://orcid.org/0000-0001-9329-6282
http://dx.doi.org/10.33192/Smj.2022.18
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
Rungamornrat et al.
INTRODUCTION
e rst 0 to 2 years of a child’s life are critical for
future health and development. One of the primary causes
is a rapid change in one’s physical, mental, and emotional
development, which is fundamental for growth and
development. According to a national survey conducted
in 2014, 9.8 percent of ai children aged 1 to 2 years
had severely short stature (height for age < -3 SD.). e
data regarding children in the central region of ailand
demonstrated the highest prevalence of short stature and
obesity (9.2% and 7.3%, respectively).
1
According to a
2019 UNICEF survey, 4.3 percent of ai children under
the age of ve had severely short stature. e highest
prevalence of short stature was found in Bangkok and
Central region (6% and 4.8%, respectively).
2
ese data
demonstrate that ai children in Central region are
malnourished. Malnutrition leads to child morbidity,
which is the underlying cause of about 45 percent of
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143
Original Article
SMJ
child fatalities worldwide.
3
Young children are more
vulnerable to malnutrition because they require more
protein and energy to grow and are more susceptible to
infections than adults.
3-4
Quality of life has become an essential component
of pediatric outcome evaluation. It is a multi-dimensional
concept with physical, psychological, social, and
environmental dimensions.
5
e concerns about the
QoL require capturing children’s subjective sense of
well-being.
6
Additionally, children are a vulnerable
group because they are not empowered, or are unable
to identify and address their own needs. When it comes
to children, QoL involves their health status, capacity to
participate in daily activities such as play, and other kinds
of interactions and being reared in a healthy environment.
7
However, there are a variety of QoL dimensions in
children, such as, physical, emotion, behavior, somatic,
pain, discomfort, and basic needs of infants.
8-9
ose
denitions are inconsistent with the denition by the
WHO. e PedsQL
TM
Infant Scales for 1 to 12 months
old
6
and TAPQOL for infants
10
(0-1-year-old) are two
tools for assessing young children’s QoL (0–1-year-old).
In the meantime, ailand utilizes the WHOQOL-BREF-
THAI
11
scale to assess ai QoL. is tool, on the other
hand, was developed for adults and inappropriately for
children. As a result, the researchers developed a quality-
of-life assessment tool for children aged 0 to 2, based on
the WHO’s conceptual framework. A child’s nutritional
status and QoL are both essential indicators of a child’s
quality. Determining the relationship between individual
variables and health-related factors in the child population
is necessary to identify the priorities of the quality of
children in the central region in ailand. However,
nutritional status refers to the health outcomes derived
by measuring children’s height and weight, whereas
the QoL refers to caregivers’ perceptions of physical,
emotional, psychological, and social dimensions. As a
result, these two aspects represent the quality of children
from two perspectives.
To confirm the relationship of factors related
to nutritional status and QoL in children aged 0 to 2
years in the central region of ailand.e scoping
literature review presented in this article addresses based
on ecological framework which includes ve levels of
individual, interpersonal, organizational, community, and
policy levels. However, three levels were selected based
on the scope of problems. Factors inuencing nutritional
status and children’s QoL were individual, interpersonal,
and organizational levels. e individual level includes
breastfeeding period and severity of illness; interpersonal
level includes maternal age, maternal education and family
income, child-rearing practices, and organizational level
includes access to healthcare services. e rationale for
selecting these factors was as follows 1) the incidence rate
of breastfeeding in ailand is decreasing
2
while breast
milk can promote child’s growth and signicantly lower
odds of wasting.
12,13,14
2) A healthy child can encounter
an illness such as diarrhea, cold, or pneumonia. e
illness may have an impact on children’s nutritional
status or QoL.
12,14
However, the majority of the research
discuss only the relationship between child with chronic
illness and nutritional status or QoL.
15,16
3-4) According
to the 2019 MICS survey
2
, underweight ai children
were detected in mothers aged 35 to 49 years old and
mothers with less than a primary school education. Lower
maternal education was associated with less healthy food
choices, which could be detrimental to child health.
17
5) Low-income families were associated with underweight
children compared to families with adequate income
owing to a lack of money to purchase adequate meals.
18,19
6) Inappropriate child-rearing practices, such as nutritional
support, child development stimulation, and hygiene care,
impacted children’s growth.
14,18,19
7) Healthcare system
in ailand has been transformed since the adoption
of universal healthcare coverage in 2002.
20
Improving
access to healthcare services may have an impact on
children health. However, some child health issues,
such as child development, have persisted, and there
is no literature on the impact of healthcare access on
healthy young children.
e preceding research investigated the relationships
of the studied variables on nutritional status and QoL of
children as perceived by caregivers. However, there were
few literatures that were specic to children aged 0 to 2
years, and even fewer that were investigated in terms of
predictive study. As a result, the aim of this study is to
investigate the eects of children factors (breastfeeding
period and severity of illness), family factors (maternal
age, maternal education, family income, and child-
rearing practices), and access to healthcare services
on children’s quality of life as perceived by caregivers
and nutritional status of children aged 0 to 2 years. e
ndings of this research will provide vital information
to improve childcare practices and the system of care
for children aged 0 to 2 years in ailand.
MATERIALS AND METHODS
Ethical considerations
is research was approved by the Institutional
Review Board, Faculty of Nursing, Mahidol University
(COA No. IRB-NS2017/15-0506). e participants were
informed about the purpose of the study, data collection
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144
strategies, rights of research participants, including the
right to withdraw at any time without repercussions,
anonymity, and condentiality issues. ose who consented
to participate were asked to complete an informed consent
form.
Methodology
is study is predictive design research. e sample
group consisted of caregivers of children aged 0 to 2 years
from ve sub-districts: Ratchakram, Changyai, Potang,
Chaingraknoi, and Bangsai in Bangsai district, Pranakorn
Sri Ayutthaya, who participated in the project entitled
“e academic advocacy for the well-being of children
through community-based programs in the Central
and Western regions.” e inclusion criteria were that
parents or caregivers be close relatives with children, ages
between 18 and 59 years old, be able to communicate
in ai, live in the same house with children, and have
cared for the children for at least three months. e
sample size was calculated using G*Power, with the
eect size computed from the proportion of nutritional
status in low income (p1 = 0.234) and high income (p2
= 0.0322)
15
, .9 power of test, and .05 errors. A total of 98
caregivers was included in the estimated sample group.
For unanticipated missing questionnaires, the number
of participants increased by 20% (118 samples). A total
of 106 questionnaires were completed. e attrition rate
was 10.17%.
Instruments
Data were collected using questionnaires and a
child health handbook. e questionnaires consisted
of ve parts as follows:
1) e Parental Demographic Questionnaire was
composed of seven items: parents’ age, parents’ academic
level, family type, marital status, family income, and
income suciency.
2) The Children’s Demographics and Medical
History Questionnaire was composed of gender, age,
breastfeeding period, number of siblings, and medical
history. e medical-history was classied into two
categories, ranging from (0) no illness or mild symptoms
(1) moderate or severe symptoms. e total possible
score ranged from 0 to 1.
3) e Access to Healthcare Services Questionnaire
was developed from literature review.
21-22
It consisted of 12
questions divided into two parts. ere were six questions
about access to healthcare services, including patients’
waiting time, expenses, convenience, and availability of
care. ere were six questions on receiving healthcare
services, including receiving information, the rights to
inquiries, and parental participation in childcare. e scale
was a three-level rating scale ranging from (1) sometimes
to (3) regularly. e total possible scores ranged from
12 to 36. e scores were cut by comparing the mean
score to the midpoint score. Scores lower than the median
(< 29 scores) indicated less access to healthcare services.
Good access to healthcare service was dened as scores
equal to or higher than the median (≥ 29 scores).
4) The Child-Rearing Practices Questionnaire,
which included 30 items, was developed based on the
child-rearing practice standard
23
and literature review.
24
ere were ve questions on nutritional status, eight
on hygiene and fundamental care, and seventeen on
growth and development. e scale was a four-level
rating scale, ranging from (0) none to (3) regularly. e
possible scores ranged from 0 to 90. e scores were
cut by comparing the mean score to the median (the
midpoint score). e scores less than the median (< 70
scores) denoted poor child-rearing practices, whereas
scores equal to or more than the median (≥ 70 scores)
indicated good child-rearing practices.
5) e Quality of Life of 0-2-Year-Old Children
Questionnaire consisted of 20 items adapted by the
researchers from the World Health Organization’s short-
form quality-of-life questionnaire in the ai version
(WHOQOL-BREF-THAI).
11
ere were 20 questions:
17 positive and three negative related to four dimensions
of health: physical, mental, social, and environmental
dimensions. One item was asked on general quality of
life. e scale was a ve-level rating scale, ranging from
(1) extremely dissatised to (5) extremely satised. e
scores 20-73 indicated a poor quality of life, while the
scores higher than 73 indicated a good quality of life.
6) e Children’s Health Record includes the child’s
gestational age, birth weight, history of illness, and latest
weight and height. Data were collected from child health
handbook. According to the ai standard growth chart
for children 0 to 5 years old, children’s growth was divided
into three categories: (1) normal, which implies having
an average weight and height, (2) overweight and obese,
and (3), thin and relatively thin.
Instrument quality testing
e questionnaires were all developed by the researchers.
ree specialists evaluated the validity. e CVI of the
questionnaires are as follows: CVI = 1 for e Access
to Healthcare Services Questionnaire; CVI = 0.92 for
e Child-Rearing Practices Questionnaire, and CVI
= 1 for e Quality of Life of Children aged 0-2 Years
Old Questionnaire. e questionnaires’ reliability was
evaluated with 30 subjects who were all comparable to the
Rungamornrat et al.
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Original Article
SMJ
research participants. e Cronbach’s alpha coecients of
the instruments were 0.821, 0.90, and 0.760, respectively.
Data collection methods
Data were collected from November 2017 to February
2018. e researchers requested permission to collect
data from the 5 provincial administrators, as well as
cooperation from administrators of the health promotion
hospitals to introduce the projects to the village volunteers
and survey the names of parents and children aged 0 to
2 years old who met inclusion criteria. e researchers
trained data collection strategies to project sta and village
volunteers who served as research assistants. Village
volunteers visited participants’ homes and requested
permission to present the initiative introduce the project.
e research assistants introduced themselves, explained
the research objectives, data collection processes, rights
protection, and requested permission to utilize data from
child health book. e questionnaire could be completed
by the participants individually or through a 30-minute
interview.
Statistical analysis
Data were analyzed using the SPSS version 18.
Statistical signicance was congured at the level of 0.05.
Descriptive statistics were used to examine demographic
data and variables. e Chi-square and Fisher’s Exact tests
were used to analyze the relationships between parents
and children’s factors, child-rearing practices, and access
to healthcare services, as well as their eects on QoL
and nutritional status. e fundamental assumptions
for binary logistic regression were satised. A multiple
logistic regression analysis was performed to examine
the predicting power of maternal age, child-rearing
practices, and access to healthcare services on children’s
nutritional status and overall QoL.
RESULTS
Descriptive statistics
e majority of mothers with children aged 0 to 2
years were between the ages of 26 and 35 years old (48
percent), had completed high school (55.9 percent); had
an extended family (53.8 percent), and were married
(82.7 percent). e majority of caregivers who raised the
children were parents, followed by grandparents (43.4 and
31.3 percent, respectively). ey had a monthly salary of
10,000-30,000 baht (56.6 percent) and adequate income
(74.2 percent). e majority had only one child (87.7
percent), with a breastfeeding period of 3 to 11 months
(53.0 percent). e prevalence of low birth weight and/or
preterm delivery was 11.3 and 15.1, respectively. Severity
of illness, such as fever and diarrhea, from birth to 2
years old, was 19.8 percent, while those with a normal
weight and height was accounted for 77.4 percent; those
with obesity was accounted for 15.1 percent; and those
with thin weight was accounted for 7.5 percent. Access
to HCS, child-rearing practices, and QoL all received
high scores (Table 1).
Correlational analysis
e maternal age, access to HCS, and child-rearing
practices were associated with the children’s quality of
life. (p < 0.05) (Table 2). e maternal age and child-
rearing practices were also related to children’s nutritional
status. (p < 0.05) (Table 3).
Logistic regression analysis
A multivariate logistic regression analysis was
employed to assess the predictive power of variables
on the QoL as perceived by parents and the nutritional
status of their children. According to the ndings, this
model accounts for 34 percent of the variance in these
children’s QoL (Nagelkerke R
2
= .34) and 35.3 percent
of the variance in the nutritional status of their children
(Nagelkerke R
2
= .35). e maternal age could predict
the children’s QoL (OR=4.75; 95%CI = 1.16, 19.45, p <
0.05). Maternal age of more than 36 years old and less
than 25 years old increased the probability of children
having a high QoL by 4.747 times that of a maternal age
of less than 25 years old. Child-rearing practices could
also predict children’s QoL (OR=5.68; 95%CI = 1.97,
16.40, p < 0.05), indicating that each unit increment in
child-rearing practices will increase a child QoL by 5.677
times.
In addition, the maternal age could predict the
children’s nutritional status (OR=0.088; 95%CI = .01,
0.79, p < 0.05). Maternal age of 26-35 years old reduced
the probability of having a healthy nutritional status by
0.088 times that of maternal age of less than 25 years
old. Child-rearing practices could predict the child
nutritional status (OR=7.84; 95%CI = 1.93, 31.84, p <
0.05), indicating that each unit increment in child-rearing
practice increases their nutritional status by 7.84 times.
(Table 4)
DISCUSSION
Regarding nutritional status, 14.7 percent of the
children in this study were obese, which was higher
than the national average (10 percent).
25
is nding,
however, was consistent with a 2016 survey of children’s
nutritional status at a child development center in the
central region, which revealed that 13.9 percent of children
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146
TABLE 1. e range, mean, standard deviation, and interpretation of each studied variables.
Variables N Possible Range Mean (S.D) Median Interpretation
(%) score (IQR) by mean
Accessing and receiving HCS 101 12-36 16-36 28.93 (3.94) 29 (4.0) High
Receiving HCS 6-18 8-18 16.06 (2.32) 17 (3.0)
Accessing HCS 6-18 4-18 13.03 (2.47) 12 (2.0)
Child-rearing practices 106 0-90 15-90 67.04 (15.73) 70.5 (19.0) High
Nutrition, 0-15 0-15 10.38 (3.10) 11 (3.0)
Hygiene and basic care 0-24 9-24 20.55 (3.82) 22 (6.0)
Growth and development 0-51 0-51 37.92 (9.12) 40 (11.0)
Quality of life 106 20-100 31-93 72.51 (9.09) 73 (10.0) High
Physical health 1-25 11-22 19.73 (2.17)
Mental health 1-25 12-25 18.24 (2.48)
Social health 1-25 10-25 18.01 (3.23)
Environmental health 1-25 10-25 19.00 (2.90)
Overall quality of life 1-5 1-5 3.52
Low QoL 54 20-100 31-73 66.04 (7.60) 68 (7.0)
High QoL 52 20-100 74-93 79.23 (4.40) 78 (6.0)
Nutritional status 106
Appropriate 82 (77.4)
Obese/ 16 (15.1)
Thin 8 (7.5)
were obese.
26
Since 2000, the prevalence of overweight
children under the age of ve has grown by approximately
24 percent globally, with the highest incidence in low-
and middle-income countries such as ailand.
27
is
situation may be owing to a more convenient lifestyle and
easy availability of high-energy food. Because the data
gathering locations were suburban, there are numerous
factories and marketplaces where families could get a
variety of meals for their children. In addition, parents
and relatives believed that overweight children were
healthy and that youngsters would lose weight as they
grew older.
26
Maternal age and child-rearing practices were potent
predictors of children’s nutritional status. Mothers under
the age of 25 had more children with an adequate nutritional
status than mothers in other age groups. e majority
of mothers under the age of 25 worked in factories and
had a high school diploma. is group of mothers had
easy Internet access to search for childcare information.
Not surprisingly, according to the ndings of a survey
conducted in ailand, persons aged 19-38 years old
were the most likely to utilize the Internet.
28
Income
suciency was not shown to be associated with children’s
nutritional status. e explanation may be the majority
of the participants in this study were middle-income
individuals who could aord the infant food. is nding
contradicts a childhood obesity study, which reported a
positive association between high socioeconomic status
(SES) of families and 2-19 years old childhood obesity in
developing countries. Since high-SES households have
more access to high-energy meals.
29
At the same time,
a study in China reported that high-SES had a positive
eect on the height of 10-15 years old city youngsters.
Because a high-SES family was associated with higher
education, the family had more knowledge to choose
appropriate meals for their children.
30
e discrepancy
may be because the children in this study were between
the ages of 0 to 2. ey consumed breast milk, milk, and
supplementary diet, and children relied on caregivers
for their meals.
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TABLE 2. Factors associated with quality of life of 0–2-year-old children as perceived by caregivers.
Variables N Quality of life of children
χ
2
Test P Value
(%) High Low
Age of mother
Younger than 25 years 31 (31.0) 15 (48.4) 16 (51.6) 6.740 0.034 *
26-35 years 48 (48.0) 18 (37.5) 30 (62.5)
Older than 36 21 (21.0) 15 (71.4) 6 (28.6)
Education of mothers
Primary school 10 (9.8) 6 (60.0) 4 (40.0) 2.537 0.469
High school 57 (55.9) 29 (50.9) 28 (49.1)
Vocational 12 (11.8) 5 (41.7) 7 (58.3)
Bachelor’s degree 23 (22.5) 8 (34.8) 15 (52.9)
Income sufciency
Sufcient income 61 (62.9) 29 (47.5) 32 (52.5) 0.588 0.745
Sufcient income with saving 11 (11.3) 6 (54.5) 5 (45.5)
Insufcient income 25 (25.8) 14 (56.0) 11 (44.0)
Breastfeeding period
Less than 2 months 29 (34.9) 17 (58.6) 12 (41.4) 1.214 0.545
3-11 months 44 (53.0) 20 (45.5) 24 (54.5)
More than 12 months 10 (12.0) 5 (50.0) 5 (50.0)
Severity of illness
No 85 (80.2) 44 (51.8) 41 (48.2) 1.259 0.262
Yes 21 (19.8) 8 (38.1) 13 (61.9)
Access to HCS
Low 55 (51.9) 19 (34.5) 36 (65.5) 9.632 0.002*
High 51 (48.1) 33 (64.7) 18 (35.3)
Child-rearing practices
Low 51 (48.1) 15 (29.4) 36 (70.6) 15.178 < 0.001*
High 55 (51.9) 37 (67.3) 28 (32.7)
f
Fisher’s Exact Test, * P Value < .05
Child-rearing practices also predicted children’s
nutritional status. e scores on child-rearing practices
were high in all dimensions, including nutrition, hygiene
care, and growth and development. When considering
the item score, the parents provided the proper quantity
of meals for their children had a high item score. On the
other hand, the item score of being a parental role model
for dietary behaviors was medium. ese ndings are
consistent with Australian and New Zealand research
of parental feeding practices at 20 months of age. e
highest score was dietary restriction for health. Limiting
unhealthy food consumption in children up to 20 months
old predicted a lower risk of becoming overweight when
they were ve years old.
31
For the growth and development
dimension of child-rearing practices, parents demonstrated
high scores on providing child play and activities as well
as routinely taking children for health check-ups and
vaccinations. ese practices were considered adequate
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148
TABLE 3. Factors associate with nutritional status of 0–2-year-old children.
N Nutritional status
χ
2
Test P Value
(%) Normal (%) Obese/ thin (%)
Age of mother
Younger than 25 28 (27.5) 27 (96.4) 1 (3.6) 8.798 0.012 *
25-36 52 (51.0) 35 (67.3) 17 (32.7)
Older than 36 22 (21.5) 16 (72.7) 6 (27.3)
Education of mothers
Primary school 9 (8.7) 8 (88.9) 1 (11.1) - 0.781
F
High school 55 (52.9) 43 (78.2) 12 (21.8)
Vocational 15 (14.4) 11 (73.3) 4 (26.7)
Bachelor’s degree 25 (24.0) 18 (72.0) 7 (28.0)
Income sufciency
Sufcient income 59 (61.5) 42 (71.2) 17 (28.8) 4.430 0.109
Sufcient income with saving 10 (10.4) 10 (100.0) 0 (0.0)
Insufcient income 27 (28.1) 22 (81.5) 5 (18.5)
Breastfeeding period
Less than 3 months 31 (35.6) 20 (64.5) 11 (35.5) 4.477 0.107
3-12 months 47 (54.0) 40 (85.1) 7 (14.9)
More than 12 months 9 (10.4) 7 (77.8) 2 (22.2)
Severity of illness
No 85 (80.2) 69 (65.2) 21 (19.8) - 0.777
Yes 21 (19.8) 16 (75.0) 5 (25.0)
Access to HCS
Low 53 (52.0) 40 (78.5) 13 (24.5) 0.571 0.450
High 49 (48.0) 40 (81.6) 9 (18.4)
Child-rearing practices
Low 52 (50.0) 32 (61.5) 20 (38.5) 13.867 < 0.001 *
High 52 (50.0) 48 (92.3) 4 (7.7)
f
Fisher’s Exact Test, * P Value < .05
childcare under the 2003 Act’s minimal requirements for
child-raising. Children’s play and activities will help them
metabolize carbohydrates and energy as well as reduce
fat deposits. Another explanation is that child-rearing
practices are associated with healthcare accessibility.
Caregivers who had a high score for their child-rearing
practices pursued more information about childcare
from healthcare personals, resulting in an appropriate
nutritional status for their children.
e children in this study had a good QoL, with
the highest score for environmental health, followed by
physical health, and the lowest score for social relationships.
is might be because the environmental and physical
health elements included health promotion for children,
such as safety, child health, and developmental care.
Additionally, healthcare personnel encouraged caregivers
to provide health promotion activities upon their visits
to well-baby clinics. ese ndings are consistent with
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TABLE 4. Factors predicting the quality of life and nutritional status of children 0-2 years old.
QOL Nutritional status
OR 95% CI P Value OR 95% CI P Value
Constant 0.205 - 0.004 37.00 - 0.007
Age of mother
Younger than 25 Ref. Ref. - Ref. Ref. -
26-35 0.698 0.24, 2.03 0.509 0.088 0.01, 0.79 0.030 *
Older than 36 4.747 1.16, 19.45 0.030 * 0.225 0.02, 2.43 0.219
Access to HCS
Low Ref. Ref. - - - -
High 2.017 0.74, 5.53 0.172 - - -
Child-rearing practices
Low Ref. Ref. - Ref. Ref. -
High 5.677 1.97, 16.40 0.001 * 7.840 1.93, 31.84 0.004 *
Nagelkerke R
2
0.340 0.353
Hosmer and Lemeshow Test 0.720 0.968
those of the QoL of healthy children aged 0 to 1 year
measured by PedsQL
TM
in the United States6, and the
QoL of healthy children aged 0 to 1 year measured by
TAPQOL in the Netherlands
10
, which caregivers reported
that their children had high scores in both physical and
psychosocial health. Similarly, parents in Europe place a
high value on providing a safe physical environment for
their children.
32
In comparison, parents in the United
States place a high value on social functioning, while
ai parents had a lower score in this dimension. e
discrepancy of QoL domains scores may be attributed
to dierences in caregiving and parenting styles. ai
caregivers become accustomed to responding to children’s
fundamental needs rather than allowing the children to
do it independently. More study is needed to investigate
the factors that dierentiate QoL between Western and
Eastern perceptions.
Maternal age and child-rearing practices were factors
that predicted the QoL of 0–2-year-old children. Maternal
age of more than 36 years old generally resulted in better
parenting since such parents tend to have a higher SES and
can aord better childcare. ese ndings are congruent
with a study on Brazilian parenting practices, which
discovered that mothers with higher education and
economic status organized more activities to promote
their children’s motor development, such as playing,
toy, lap time, and free movement space.
33
Child-rearing practice predicted the QoL of children
aged 0 to 2 years. According to the study, parents over
the age of 36 oered adequate nutrition, hygiene, and
developmental care than younger parents. Parents arranged
play activities, a safe home environment, disease prevention,
health check-ups, and vaccines for their children. ese
health-promoting behaviors can help children avoid
illness and improve their QoL. In Malaysia, parents
from various SES backgrounds provide various types
of child-rearing to stimulate cognition and emotions,
as well as to interact with children, leading to diverse
cognitive and social functioning.
34
Access to healthcare services was associated with
QoL of children, but it did not predict the QoL and
nutritional status in children aged 0 to 2 years. Parents
reported that their children’s access to and receiving
healthcare services was excellent. e explanation might
be universal healthcare coverage for children, under which
children have rights to access care. Moreover, data were
collected in ve sub-districts of a single district. Two
secondary hospitals and one tertiary level hospital are
located near the sub-urban regions. Scores for accessing
healthcare services, such as cost, convenience, time and
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150
availability, were in moderate level. Whereas scores for
receiving healthcare services, such as information on
child growth and development screening, childcare
suggestion, and listening and responding to concerns
were high. e good relationship between caregivers
and healthcare personnel might be attributed to parents’
ability to obtain health services and childcare information,
resulting in improving their child-rearing practices as
well as the children’s QoL. e ndings of this study are
consistent with those of a previous study conducted in the
United States
21
, which discovered that continued access
to essential care was associated with improved health
and QoL scores.
21
Another study in Brazil and Columbia
reported that inequities in access to care between lower
SES and higher SES groups resulting in disparities in
accessing to primary care, outpatient secondary care,
and having health issues in preventable and controlled
diseases, such as caries, and glycemic control.
35
Access to
health services was not associated with nutritional status
of children. It is possible that these children had good
health and development and did not require intensive
healthcare. Similarly in ailand, a study revealed no
statistically signicant relationship between access to
care and nutritional status of preterm migrant children.
As a result of ailand’s low-cost healthcare insurance
for migrant workers and their families to have access to
healthcare services.
13
erefore, no variation in access to
healthcare scores, resulting in non-signicant relationship
between healthcare access and nutritional status.
Regarding children’s factors, breastfeeding period
and severity of illness were not associated with children’s
QoL as perceived by caregivers or nutritional status. ese
children were healthy and their caregivers provided quality
care for them. In contrast, a study in ailand reported
that exclusive breastfeeding from birth to six months of
age, as well as a history of cold in infants predicted growth
in preterm migrant children. e explanation may be
that preterm infants are more susceptible to infections,
resulting in a poorer child growth rate, and unemployed
migrant mothers employed exclusive breastfeeding for
their child.
13
Recommendations and implications
1. Healthcare personnel should assess caregivers’
child-rearing practices, recognize variations in
those practices depending on maternal age, and
design interventions accordingly.
2. e child-rearing practice program should focus
on social functioning activities to help youngsters
develop social skills.
Limitations
e use of the instrument based on WHO denitions
to assess children’s QoL is a strength of this study. e
limitation is that the samples were randomly recruited
from ve suburban sub-districts. e samples might not
be representative of ai children and families. Missing
data from the survey questionnaire were discovered in
both dependent and independent variables.
CONCLUSION
When children are 0 to 2 years old, parental factors
signicantly inuence their nutritional status and quality
of life. Two of these factors are maternal age and child-
rearing practices. Healthcare personnel should encourage
caregivers to use age-appropriate child-rearing practices,
such as using social media with younger parents. Access to
and utilization of healthcare services was solely associated
with children’s quality of life. Caregivers should be assisted
in increasing their access to and receipt of healthcare in
order to improve the quality of life for children aged 0
to two.
ACKNOWLEDGEMENTS
This research was supported from Thai Health
Promotion Foundation.
Conict of interest: ere are no conicts of interest.
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Wiparat Srisuwan, M.N.S.*, Saranya Charoensri, R.N.*, Kanittha Jantarakana, M.Ed.*, awee Chanchairujira,
M.D.**
*Nursing Department, **Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700,
ailand.
Increasing Dialysate Flow Rate over 500 ml/min for
Reused High-Flux Dialyzers do not Increase
Delivered Dialysis Dose: A Prospective Randomized
Cross Over Study
ABSTRACT
Objective: e primary objectives were: 1) to study the impact of Qd (500 vs 800 ml/min) on the delivered dose by
reused dialyzers, and 2) to determine dialysis eciency of a dialyzer reused 15 times.
Materials and Methods: A prospective randomized-controlled crossover study was conducted in 42 thrice-weekly
hemodialysis (HD) patients (630 HD sessions in each Qd). Delivered doses at both Qds were assessed by single-pool
Kt/V (spKt/V), equilibrated Kt/V (eKt/V) and online clearance monitoring Kt/V (Kt/V
OCM
), measured at mid-week
HD session using a new dialyzer and then again at every mid-week HD session.
Results: Although the spKt/V in HD sessions using new dialyzers at Qd of 500 ml/min was slightly lower than
spKt/V at Qd of 800 ml/min (2.19±0.08 vs. 2.34±0.08, respectively, P=0.04), when accounting for urea rebound as
assessed by eKt/V and Kt/V
OCM
, there was no signicant dierence. e average delivered doses in dialyzers reused
15 times, with the mean average of spKt/V, eKt/V and Kt/V
OCM
at Qd 500 ml/min, were not signicantly inferior to
the delivered doses at Qd 800 ml/min. Reusing a dialyzer 15 times did not decrease dialysis eciency and delivered
doses in all HD sessions reached spKt/V >1.4.
Conclusion: Increasing Qd over 500 ml/min for modern dialyzers does not signicantly increase delivered dose of
dialysis. Dialyzer reuse does not aect dialysis eciency and provides adequate dialysis therapy.
Keywords: Dialysate ow rate; hemodialysis adequacy; reused dialyzer; delivered Kt/V; online Kt/V; equilibrated
Kt/V (Siriraj Med J 2022; 74: 152-160)
Corresponding author: awee Chanchairujira
E-mail: thaweechan@hotmail.com
Received 31 September 2021 Revised 7 January 2022 Accepted 8 January 2022
ORCID ID: https://orcid.org/0000-0001-7692-2560
http://dx.doi.org/10.33192/Smj.2022.19
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
INTRODUCTION
An adequate hemodialysis dose delivery is an
important and independent predictor of morbidity
and all-cause mortality in maintenance hemodialysis
(HD) patients.
1
Current clinical practice guidelines for
hemodialysis adequacy recommend a delivered single-
pool Kt/V (spKt/V) of at least 1.2 per HD session (for
3-time-weekly HD patients without signicant residual
renal function), and higher doses of up to 1.4 in females
and patients with high comorbidities.
1,2
e delivered
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SMJ
dose of HD depends on dialyzer mass transfer-area
coecient (KoA), HD treatment time, and operating
parameters, especially blood ow rate (Qb) and dialysate
ow rate (Qd).
3
High-eciency dialysis requires dialyzer
with high KoA, Qb > 300 ml/min and Qd ≥ 500 ml/min.
Increasing Qd from 500 ml/min to 800 ml/min has been
recommended to maximize dialysis eciency in high-
eciency HD. Previous studies
4-6
in early generation
dialyzers showed that increasing Qd from 500 ml/min to
800 ml/min alter the dialyzer KoA and results in a larger
increase in urea clearance than the predicted assuming
a constant KoA, which was explained by a better ow
distribution through the dialysate compartment and
a decrease in dialysate-side boundary layer resistance.
Recent studies
7-10
of newer dialyzers with improved
dialysate ow distribution designs (such as hollow ber
undulations, spacer yarns, and changes in ber packing
density) have been accompanied by an increase in urea
clearance of the dialyzer, and revealed that dialysate
ow rate beyond 500 - 600 ml/min does not signicantly
increase delivered Kt/V. However, these studies were
performed in single-use dialyzers.
In chronic hemodialysis, reuse of dialyzers has
been widely practiced in developing countries, including
ailand. In our hemodialysis unit, patients who were
treated with high-eciency high-ux dialysis usually
increasing Qd to 800 ml/min in order to maximize
the dialysis dose and the dialyzer was reused 15 times.
ere is limited data on the eect of Qd in high-ux
high-eciency dialysis with a reused dialyzer related to
delivered dose and hemodialysis adequacy. Increasing
the dialysate ow rates results in a higher dialysis cost,
require more water treatment, and leads to a higher risk
of exposure to dialysis water impurities. e objectives
of this study were to: 1) evaluate the eect of Qd of 800
ml/min and 500 ml/min on delivered dialysis dose in
high-eciency high-ux dialysis patients who used a
reused dialyzer; 2) to determine dialysis eciency and
HD adequacy of a reused dialyzer.
MATERIALS AND METHODS
Study design
We performed a single-center prospective randomized-
controlled crossover study in maintenance HD patients
conducted at Siriraj Hospital, Mahidol University, ailand
between June 2018 - April 2020. Inclusion criteria for
the study were age above 18, 4-hour three time weekly
high-ux dialysis with a stable spKt/V (±5%) for at least
two months, and the reuse of a dialyzer. e exclusion
criteria were pregnancy, hepatitis B virus infection and
being seropositive for HIV.
Before the intervention in each patient, bolus dose
and maintenance dose of heparin were adjusted according
to activated partial thromboplastin time (aPTT) level
(at baseline, 3, 60, 180 and 240 minutes) to maintain
a ratio of 1.8-2.5 for the duration of HD and at least
1.4 at the end of dialysis to prevent dialyzer clots and
achieve reuse. Automatic dialyzer reprocessing machine
(Meditop KIDNY- KLEEN®) was used to reprocess
dialyzers and disinfected with peracetic acid, and measure
blood compartment volume or total cell volume (TCV)
of reused dialyzers. Percentage of TCV (%TCV) of a
reused dialyzer was dened as the percentage of blood
compartment volume measured by automatic dialyzer
reprocessing machine divided by the priming volume value
of the new dialyzer that provided by the manufacturer
(Supplement Table 1). Reused dialyzers were discarded
if its TCV less than 80% of baseline value or if it failed
a leak test.
Patients were randomly assigned (using online soware
www.randomization.com) to be dialyzed according to an
AB or BA schedule, where A represents 15 consecutive
dialysis treatments with a Qd of 800 ml/min, and B
represents 15 consecutive dialysis treatments with a Qd
of 500 ml/min. e blood ow rate and dialyzer were
kept constant for a given patient. e intervention of A
and B began during a mid-week dialysis session with a
new dialyzer followed by sessions with a reused dialyzer
for a total of 15 times. e delivered dialysis dose was
measured (during both A and B) at mid-week HD sessions
with a new dialyzer and again at every mid-week HD
session corresponding to the reused dialyzer no. 4, 7, 10,
13, and 15 (total of six measurements in each dialyzer).
e delivered doses of dialysis were assessed by spKt/V
(the Daugirdas second generation equation), equilibrated
Kt/V (eKt/V) estimated by the rate equation
11
, and online
clearance monitoring Kt/V (Kt/V
OCM
).
12
Kt/V
OCM
was
calculated by serial measurements of ionic dialysance
of sodium (as a surrogate for eective urea clearance)
made throughout HD treatment by using HD machines
equipped with an online conductivity monitor and soware
dose-calculation tool DCTool (Fresenius Medical Care,
Germany). Volume distribution of urea (V) will be
calculated by the system from the weight, height, age
and sex using the formula developed by Watson.
Data collection
Baseline data included patient’s age, sex, height,
body weight, dialysis vintage, comorbidities, medical
history, vascular access, and HD treatment parameters,
which consist of dialysis dose, Qb, Qd, post-HD body
weight (W), ultraltration (UF), total processed blood
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154
Supplement TABLE 1. Summary of dialyzer specications
#
Hdf 100s Hf 80s EL210HR EL190HR FB190U
Surface area (m
2
) 2.3 1.8 2.1 1.9 1.9
Priming volume (ml) 138 110 130 115 115
Ultraltration coefcient (Kuf) (ml/h/mmHg) 60 55 82 76 37.70
Dialyzer KoA
urea
(ml/min) 1,167 805 1,976 1,171 1,367
Inulin clearance (ml/min)* 145 120 145 132 N/A
Myoglobin clearance (ml/min)* N/A N/A 104 101 47
Membrane component Polysulfone Polysulfone Polynephron Polynephron Cellulose
triacetate
Number of patients n, (%) 15 (35.70%) 3 (7.10%) 22 (52.40%) 1 (2.40%) 1 (2.40%)
* Blood ow rate 300 ml/min, Dialysate ow rate 500 ml/min
# Data from the manufacturer’s dialyzer specication sheets
Calculations
Single-pool delivered Kt/V (spKt/V) was calculated using the Daugirdas second generation equation** as follows: spKt/V = -Ln(R-
0.008×t) + (4-3.5×R) × UF/W, where Ln is the natural logarithm, R is the post-dialysis/pre-dialysis blood urea nitrogen ratio, t is dialysis
time (in hours), UF is ultraltration volume (in liters), and W is the patient’s post-dialysis body weight (Kg).
Equilibrated Kt/V (eKt/V) was calculated by adjusting the spKt/V for postdialysis urea rebound using the rate equation described
by Daugirdas and Schneditz as follows: eKt/V = spKt/V – [0.6 x(spKt/V)/t] + 0.03 (for arteriovenous access) and eKt/V = spKt/V –
[0.47×(spKt/V)/t] + 0.02 (for venous catheters), where t represents the duration of dialysis in hours.
** Daugirda JT. Second generation logarithmic estimates of single-pool variable volume Kt/V: An analysis of error. J Am Soc Nephrol 1993;
4:1205-13.
volume (TBV), eective dialysis time, heparin dosage,
type of dialyzer and number of dialyzer reuse with %TCV.
Patients gave written informed consent to participate in
this study as approved by the Human Research Protection
Unit, Faculty of Medicine Siriraj Hospital, Mahidol
University, ailand.
Exposures and outcomes
The primary outcome was differences between
delivered spKt/V, eKt/V and Kt/V
OCM
at two dierent
dialysate ow rates. Secondary outcomes were dierences
between eKt/V and Kt/V
OCM
, and how the number of
times a dialyzer was related to dialyzer urea clearance
ecacy and HD adequacy. In this study, the hemodialysis
adequacy threshold was set to delivered spKt/V > 1.4,
considering high proportion of comorbidities and females
(43%) in the patient population.
Statistics
e data are reported as mean ± standard deviation
(SD) or median (minimum-maximum), depending on
the distribution analysis. A two-sided p value of <0.05
was considered as signicant. e primary outcome was
non-inferiority of delivered dialysis dose at two Qds in
rst use and reused dialyzer, which were assessed by
ANOVA using NCSS program with signicance, α =
0.05 and non-inferiority margin of spKt/V = 0.25.
RESULTS
Forty-two HD patients were studied and a total of
1,260 HD sessions (630 HD sessions in each Qd) were
performed. e dialyzers used in this study were HdF100s
35.7%, HF80s 7.1%, EL210HR 52.4%, EL190HR 2.4%,
FB210U 2.4% and FB190U 2.4%. e characteristics
of the dialyzers were summarized in the Supplement
Table 1. Eighty-one percent of patients needed heparin
dose adjustments to achieve an appropriate aPTT level
throughout the HD sessions for prevent dialyzer clots
before the intervention. All dialyzers used in this study
were reused 15 times. e average %TCV in reused
dialyzers at both Qds were not signicantly dierent
(Qd 800 ml/min, %TCV 97.80±1.20% vs Qd 500 ml/
min, %TCV, 97.99±0.96%).
Srisuwan et al.
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Baseline patient characteristics
e patient’s baseline characteristics are summarized
in Table 1. e mean age of 42 patients was 66.3±15.3
years (range 29.2 - 84.4 years) and 57.1% were men.
e eect of dialysate ow rate on delivered spKt/V
in reused dialyzers
e mean spKt/V in the HD sessions using new
dialyzers at Qd of 500 ml/min was slightly less than
the mean spKt/V at Qd of 800 ml/min (2.19± 0.08 vs.
2.34± 0.08, respectively, p=0.04) (Table 2). In the HD
sessions of reused dialyzers no. 4, 7, 10 and 13, the mean
spKt/V at Qd 500 ml/min were signicantly inferior to
spKt/V at Qd 800 ml/min, whereas, the mean spKt/V
in reused dialyzers no. 15 at both Qds was not dierent.
However, the magnitude of dierences in spKt/V was
not clinically meaningful. e mean average spKt/V of
dialyzers reused 15 times was calculated from the average
of spKt/V of the new dialyzers and reused dialyzers (total
of six measurements of spKt/V in each dialyzer). e
mean average spKt/V of the reused dialyzers aer 15
times at Qd 500 ml/min was not signicantly inferior
to spKt/V at Qd 800 ml/min (2.21±0.07 vs 2.31±0.07,
respectively, p<0.01). All measurements of the delivered
dose achieved hemodialysis adequacy thresholds of
spKt/V > 1.4 at both dialysate ow rates.
e eect of dialysate ow rate on eKt/V
e mean eKt/V in the HD sessions of new dialyzers,
and reused dialyzers no. 4, 7, and 13 at Qd of 500 ml/min
TABLE 1. Baseline characteristics of study population (n = 42 patients).
Parameters
Age, years 66.3±15.3
Male sex, n (%) 24 (57.10)
Mean post-HD body weight, Kg 58.85±11.82
Comorbid diseases, n (%)
Hypertension 39 (92.9)
Diabetes 16 (38.1)
Atherosclerotic heart disease 16 (38.1)
Polycystic kidney disease 2 (4.8)
Miscellaneous (hyperlipidemia (3)/chronic 7 (16.7)
glomerulonephritis (1)/gout (1) /benign prostate
hypertrophy (1)/ malignancy (1)
Dialysis vintage, months 106.2±68.4
Vascular access, n (%)
Arteriovenous stula 17 (40.48)
Arteriovenous graft 6 (14.29)
Permanent dual lumen catheter 19 (45.23)
Blood ow rate, n (%)
300/350/400 ml/min 1 (2.4) / 11 (26.2) / 30 (71.4)
Heparin dose, units/session
Total 4,431±3,712
Loading dose 1,681±1,761
Maintenance dose 2,750±1,944
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TABLE 2. Mean delivered spKt/V at dialysate ow rate of 800 and 500 ml/min.
Dialyzer Mean spKt/V Mean 95%CI P value
Reuse No. Qd 800 ml/min Qd 500 ml/min difference Lower Upper Non-Inferiority
New 2.34±0.08 2.19±0.08 0.15 -0.07 0.37 0.04
4 2.35±0.07 2.22±0.07 0.13 -0.07 0.33 0.22
7 2.35±0.07 2.21±0.07 0.14 -0.07 0.35 0.29
10 2.30±0.08 2.24±0.08 0.07 -0.17 0.30 0.13
13 2.29±0.07 2.19±0.07 0.10 -0.10 0.30 0.14
15 2.23±0.07 2.23±0.07 0.00 -0.21 0.21 0.02
Average 2.31±0.07 2.21±0.07 0.10 0.05 0.14 <0.01
were not signicantly inferior to the mean eKt/V at Qd of
800 ml/min (Table 3). In reused dialyzers no.10 and 15, the
mean eKt/V at Qd 500 ml/min were signicantly inferior
to eKt/V at Qd 800 ml/min. However, the magnitude
of dierence of eKt/V may not be clinically signicant.
e mean average eKt/V of dialyzers reused 15 times at
Qd 500 ml/min was not signicantly inferior to eKt/V
at Qd 800 ml/min (1.93±0.27 vs 2.03±0.29, respectively,
p<0.01).
e eect of dialysate ow rate on Kt/V
OCM
e mean Kt/V
OCM
at Qd of 500 ml/min in HD
sessions using new dialyzers and reused dialyzers were
not signicantly inferior to Kt/V
OCM
at Qd of 800 ml/min
(Table 4). e mean average Kt/V
OCM
of dialyzers reused
15 times at Qd 500 ml/min was also not signicantly
inferior to Kt/V
OCM
at Qd 800 ml/min (1.85±0.04 vs
1.98±0.05, respectively, p<0.01).
Comparison between eKt/V and Kt/V
OCM
e mean average of Kt/V
OCM
at both Qds were
signicantly lower than the mean average eKt/V (Table
5). However, the magnitude of dierence between Kt/
V
OCM
and eKt/V may not be clinically signicant. e
Kt/V
OCM
was highly correlated with eKt/V at the both
Qds, with r = 0.91 at Qd 800 ml/min (p<0.01), and r =
0.87 at Qd 500 ml/min (p<0.01).
e total processed blood volume and eective time
in HD sessions of new dialyzers and reused dialyzers were
not signicantly dierent (Table 6). e average eective
TABLE 3. Mean eKt/V at dialysate ow rate of 800 and 500 ml/min.
Dialyzer Mean eKt/V Mean of 95%CI P value
reuse No. Qd 800 ml/min Qd 500 ml/min difference Lower Upper Non-Inferiority
New 2.03±0.35 1.92±0.30 0.10 0.04 0.17 <0.01
4 2.04±0.30 1.95±0.29 0.09 0.03 0.16 <0.01
7 2.00±0.34 1.97±0.31 0.03 -0.06 0.11 <0.01
10 2.08±0.54 1.94±0.31 0.14 0.01 0.27 0.11
13 1.98±0.29 1.93±0.30 0.06 -0.01 0.12 <0.01
15 2.04±0.36 1.90±0.43 0.15 0.02 0.26 0.09
Average 2.03±0.29 1.93±0.27 0.10 -0.12 -0.03 <0.01
Srisuwan et al.
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TABLE 4. Online clearance Kt/V at dialysate ow rate of 800 and 500 ml/min.
TABLE 5. Comparison of Kt/V
OCM
and eKt/V at dialysate ow rate of 800 and 500 ml/min.
Dialyzer Mean Kt/V
OCM
Mean of 95%CI P value
Reuse No. Qd 800 ml/min Qd 500 ml/min difference Lower Upper Non-Inferiority
New 1.99±0.32 1.87±0.29 0.11 0.06 0.17 <0.01
4 1.99±0.32 1.85±0.28 0.14 0.08 0.19 <0.01
7 1.99±0.34 1.87±0.29 0.12 0.05 0.18 <0.01
10 1.93±0.34 1.87±0.29 0.06 0.00 0.12 0.05
13 1.96±0.32 1.82±0.30 0.14 0.07 0.20 <0.01
15 2.00±0.40 1.83±0.29 0.17 0.07 0.27 <0.01
Average 1.98±0.05 1.85±0.04 0.13 0.06 0.17 <0.01
Dialyzer Kt/V
OCM
eKt/V Mean 95% CI P value
reuse No. difference Lower Upper Inferiority
Qd 800 ml/min
New 1.99±0.32 2.03±0.35 -0.04 -0.11 0.03 <0.01
4 1.99±0.32 2.04±0.30 -0.05 -0.12 0.03 <0.01
7 1.99±0.34 2.00±0.34 -0.02 -0.08 0.04 0.61
10 1.93±0.34 2.08±0.54 -0.15 -0.28 -0.02 0.03
13 1.96±0.32 1.98±0.29 -0.03 -0.10 0.05 0.48
15 2.00±0.40 2.04±0.36 -0.04 -0.16 0.08 0.49
Average 1.98±0.30 2.03±0.05 -0.05 -0.00 0.11 <0.01
Qd 500 ml/min
New 1.87±0.29 1.92±0.30 -0.05 -0.12 -0.02 <0.01
4 1.85±0.28 1.95±0.29 -0.09 -0.17 -0.02 <0.01
7 1.87±0.29 1.97±0.31 -0.10 -0.18 -0.02 <0.01
10 1.87±0.29 1.94±0.31 -0.07 -0.13 -0.00 0.04
13 1.82±0.30 1.93±0.30 -0.11 -0.19 -0.03 <0.01
15 1.83±0.29 1.90±0.43 -0.07 0.18 0.05 <0.01
Average 1.85±0.30 1.93±0.04 -0.08 0.02 0.14 <0.01
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TABLE 6. Total processed blood volume (TBV), eective dialysis time, % total cell volume (TCV) related to Kt/V
OCM
and eKt/V at Qd 800 and 500 ml/min.
Qd 800 New Reused Dialyzer P value
ml/min Dialyzer no. 4 no. 7 no. 10 no. 13 no. 15
TBV (L) 90.21±6.57 89.95±6.21 89.98±6.91 89.63±6.23 89.53±6.65 89.90±5.96 0.89
Time* 3.52±0.08 3.52±0.03 3.51±0.04 3.53±0.08 3.51±0.03 3.52±0.09 0.76
%TCV 100±0 98.63±2.59 98.46±2.54 97.42±3.61 96.62±4.36 96.49±5.04 0.00
Kt/V
OCM
1.99±0.32 1.99±0.32 1.99±0.34 1.93±0.34 1.96±0.32 2.00±0.40 0.53
eKt/V 2.03±0.35 2.04±0.30 2.00±0.34 2.08±0.54 1.98±0.29 2.04±0.36 0.23
Qd 500 New Reused Dialyzer P value
ml/min Dialyzer no. 4 no. 7 no. 10 no. 13 no. 15
TBV (L) 90.66±6.44 89.67±6.50 89.97±7.24 90.59±6.60 90.08±6.00 89.51±7.12 0.33
Time* 3.54±0.11 3.51±0.05 3.53±0.08 3.51±0.08 3.54±0.11 3.51±0.04 0.07
%TCV 100±0 99.39±1.56 98.29±3.25 98.15±2.87 97.62±4.09 96.42±5.23 0.00
Kt/V
OCM
1.87±0.29 1.85±0.28 1.87±0.29 1.87±0.29 1.82±0.30 1.83±0.29 0.19
eKt/V 1.92±0.30 1.95±0.29 1.98±0.31 1.94±0.31 1.93±0.30 1.90±0.43 0.72
% TCV dened as % of blood compartment volume of a reused dialyzer divided by the priming volume value of new dialyzer provided by
the manufacturer.
*Eective time (hr.min)
Srisuwan et al.
treatment time was 3 hours 52 minutes. e TCV remained
above 80% of the baseline value for dialyzers reused up
to 15 times, and the average decrease in %TCV was only
1.4-3.5%. e reused dialyzers did not alter ecacy of
hemodialysis. e eKt/V and Kt/V
OCM
measured in
HD sessions using new dialyzers and reused dialyzers
were not signicantly dierent at both Qds (Table 6).
DISCUSSION
We found little improvement in delivered dialysis
dose as assessed by spKt/V, eKt/V and Kt/V
OCM
while
increasing Qd from 500 ml/min to 800 ml/min. Although
the mean spKt/V in HD sessions using new dialyzers
at Qd of 500 ml/min was slightly lower than spKt/V at
Qd of 800 ml/min (2.19±0.08 vs. 2.34±0.08, P =0.04),
when accounting for urea rebound by assessing eKt/V
and Kt/V
OCM
, there was no signicant dierence at both
Qds (eKt/V 1.93±0.27 vs. 2.03±0.29; Kt/V
OCM
1.85±0.04
vs.1.98±0.05 at Qd 500 and Qd 800 ml/min, respectively).
When comparing the average delivered dialysis dose of
dialyzers reused 15 times between Qd of 500 ml/min and
800 ml/min, the mean average spKt/V was not signicantly
dierent (2.21±0.07 vs 2.31±0.07), as well as the mean
average eKt/V and Kt/V
OCM
. A study by Bhiman JP,
et al
10
showed that the urea KoA was independent of Qd
in the range 500 ml/min to 800 ml/min for dialyzers with
enhanced dialysate ow distribution features, suggesting
that increasing the dialysate ow rate in this range would
not signicantly increase delivered Kt/V in modern
dialyzers. Consistent with our results, a study by Ward
RA, et al
8
in 42 patients comparing delivered Kt/V at
Qd of 600 and 800 ml/min with a median Qb of 450
ml/min showed that an increase in Qd beyond 600
ml/min for dialyzer with enhanced Qd distribution
does not oer extra benet in delivered spKt/V and Kt/
V
OCM
. A recent randomized crossover study
13
reported
that reducing the Qd from 500 ml/min to 400 ml/min
in small patients (body weight < 65 kg) had no impact
on Kt/V, interdialytic weight gain, blood pressure or
electrolyte disturbance.
The equilibrated Kt/V, which accounts for the
postdialysis urea rebound, can be determined by eKt/V
estimated from rate equation or Kt/V
OCM
by ionic dialysance
method.
14
Although Kt/V
OCM
was slightly lower than
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eKt/V, but the magnitude of dierence did not appear to
be clinically meaningful, and it is highly correlated with
eKt/V. Our results showed that Kt/V
OCM
is a practical
instrument and the easiest method to use to monitor
delivered dialysis doses in each HD treatment, and help
maintain recommended HD adequacy, especially in
patients using reused dialyzers.
We found that reused dialyzers did not alter ecacy
of hemodialysis and the delivered dose in all HD sessions
at both Qds reached the HD adequacy thresholds of
spKt/V > 1.4. Our results are consistent with Cheung
AK’s study
15
which showed that urea clearance decreased
only slightly in reused dialyzers (approximately 1 to
2% per 10 reuses). A study by Ousseph et al
16
showed
that both high-ux cellulosic and high-ux polysulfone
dialyzers maintained their Kt/V at the 12
th
and 15
th
use, respectively, when dialyzers were reprocessed with
Renalin and %TCV above 80% of the original value. In our
study, 81% of patients needed heparin dose adjustment
to achieve adequate aPTT level throughout HD session,
and this resulted in a high residual TCV (mean %TCV
> 96%) in dialyzers reused up to 15 times. e delivered
dialysis doses of dialyzers reused for 15 times were not
signicantly dierent from those of new dialyzers (Table
6). is may result from a high residual TCV as well
as the optimized eective HD time and adequate total
processed blood volume (Table 6).
In our study, 78% of high-eciency high-ux dialysis
patients were prescribed with large dialyzers (dialyzer
KoA > 1,160 ml/min with dialyzer surface area ≥ 2.1
m
2
and Kuf ≥ 60 ml/h/mmHg), which resulted in high
delivered Kt/V in the range of 2, especially in patients
with small body size (mean body weight 58.8 kg). High
Kuf of the dialyzer has the benet of a higher convective
clearance from back ltration, resulting in increased
middle molecule clearance. However, in the subgroup
of small body size patients with this high range of Kt/V,
dialysis prescription (especially Qd and Qb) should
be adjusted to a more appropriate Kt/V range to save
resources and preserve vascular access.
Our ndings have some practical applications. First,
the eect of reducing the Qd from 800 ml/min to 500 ml/
min on delivered dialysis doses of high-eciency dialysis
using modern dialyzers is minimal. e delivered dialysis
dose at Qd of 500 ml/min is preferred and this would result
in dialysate cost savings of around 72 liters per dialysis
session, less raw water consumption, and less the wear
and tear on water treatment systems.
17
Reducing in water
consumption will also decrease waste water production
and electrical consumption, and these have a positive
eect on the environment and carbon emissions, which
has been recently concerned in dialysis practice as green
nephrology and eco-dialysis.
17,18
However, increasing the
Qd beyond 500 ml/min should be considered in selected
patients who have not achieved HD adequacy despite
using an appropriate dialyzer KoA and optimized Qb,
especially in patients with high body weight. Second,
reusing a dialyzer up to 15 times does not aect dialysis
eciency and provides adequate dialysis therapy as long
as adequate anticoagulation throughout HD session
and high residual TCV are maintained. Dialyzer reuse
has some advantages, including less environmental
impact from limiting waste disposal from dialyzers and
packaging, and cost saving favoring in some developing
countries. However, reprocessing of dialyzers requires
additional personnel, disinfectants, room maintenance
for safety and sterilization, and oversight mechanism
of the dialyzer reuse standard. In developed countries,
single-use practice is now preferable to reuse of dialyzers
because the price of a high-ux dialyzer has recently gone
down, and the operational cost of dialyzer reprocessing
is rising, along with safety regulatory burden.
19,20
Our study had some limitations. It was a single-
center study. e Qbs used in this study were Qb of
400 ml/min in 71.4% of patients, and Qb of 350 ml/
min in 26% of patients. erefore, our results cannot be
extrapolated to dierent dialysis treatment conditions
that maximize Qb to >400 -450 ml/min. We did not
evaluate the eect of Qd on other solutes removal such
as protein-bound solutes or middle molecules, and the
eect of reused dialyzer on sieving coecient of middle
molecule. However, increasing Qd in the range from 500
ml/min to 800 ml/min would not have any signicant
eect on clearance of these solutes.
CONCLUSION
Our data suggest that increasing dialysate ow
rate beyond 500 ml/min for modern high-ux dialyzers
does not signicantly increase delivered dialysis dose.
e delivered dose at Qd of 500 ml/min is more cost-
eectiveness. Reuse of a dialyzer up to15 times does not
aect dialysis eciency and provides adequate dialysis
therapy.
ACKNOWLEDGMENTS
e authors give special thanks to Mr Suthipol
Udompunturak, Department of Research Development,
Faculty of Medicine Siriraj Hospital, Mahidol University
for statistical analysis. is study was supported by the
Siriraj Research Development Fund (Managed by Routine
to Research: R2R).
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3. Hootkins R. Lessons in dialysis, dialyzers, and dialysate. Dialysis
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4. Leypoldt JK, Cheung AK, Agodoa LY, Daugirdas JT, Greene
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5. Hauk M, Kuhlmann MK, Riegel W, Köhler H. In vivo eects
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6. Ouseph R, Ward RA. Increasing dialysate ow rate increases
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7. Hirano A, Kida S, Yamanoto K, Sakai K. Experimental evaluation
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8. Ward RA, Idoux JW, Hamdan H, Ouseph R, Depner TA,
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9. Albalate M, Pere-Garcia R, de Sequra P, Corchete E, Alcazar R,
Ortega M, et al. Is it useful to increase dialysate ow rate to
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10. Bhimani JP, Ouseph R, Ward RA. Effect of increasing
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12. Aslam S, Saggi SJ, Salifu M, Kossmann RJ. Online measurement
of hemodialysis adequacy using eective ionic dialysance of
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risks. Hemodialysis Int 2018; 22:425-34.
13. Molano-Trivino A, Meid B, Guzman G, et al. Eect of decreasing
dialysis uid ow rate on dialysis ecacy and interdialytic
weight gain in chronic hemodialysis-FLUGAIN Study. Nephrol
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14. Ahrenholz P, Taborsky P, Bohling M, Rawer P, Ibrahim N,
Gajdos M, et al. Determination of dialysis dose: A clinical
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Srisuwan et al.
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Original Article
SMJ
Suparauk Geanphun, M.D.*, Vilasinee Rerkpichaisuth, M.D.**, Ruchira Ruangchira-urai, M.D.**,
Punnarerk ongcharoen,
M.D.*
*Department of Surgery, **Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Survival of Non-Small Cell Lung Cancer Patients
with Unexpected N2 after Complete Resection: Role
of Aggressive Invasive Mediastinal Staging should
be Considered
ABSTRACT
Objective: Mediastinal lymph node (N2) metastasis is one of the poor prognostic factors in non-small cell lung
cancer patients (NSCLC). However, the accuracy of mediastinal lymph node staging in real practice is uncertain
and inadequate. Consequently, the aim of this study was to determine the survival of NSCLC patients with clinically
non-suspicious mediastinal lymph node metastases who underwent complete resection but were pathologically
conrmed as having N2 metastases (unexpected N2).
Materials and Methods: A retrospective review was performed of all pathology-proven N2 metastases NSCLC
patients who underwent curative surgical resection from January 2007 to December 2016. A total of 158 patients
were initially included in the study. Aer the exclusions (known N2, small cell carcinomas, neuroendocrine tumor),
125 unexpected N2 patients who underwent complete resection were analyzed. Survival analysis was determined
using the Kaplan–Meier method and multivariate analysis was determined using the Cox regression method.
Results: e overall 2-year, 3-year, and 5-year survival rates were 40%, 24%, and 20% respectively. Complete
resection was achieved in all patients. Invasive mediastinal staging (IMS) was performed in 47 patients (37.6%),
by endobronchial ultrasonography (EBUS) in 46 (36.8%) patients (82.6% negative and 17.4% inadequate tissue)
while only 1 patient underwent mediastinoscopy. e factors aecting the survival rate upon comparison were
the histology type (p=0.019), dierentiate characteristics (p=0.004), adjuvant therapy (p=0.011), and presence
of distant metastasis by postoperative re-staging (p=0.003). e independent predictive factors for survival were
chemo-radiation therapy (odds ratio 0.367, 95% condence interval 0.176–0.766) and distant metastasis (odds ratio
2.280, 95% condence interval 1.334–3.897). However, a small size, periphery lesion, T staging, and number of N2
lesions were not signicant factors.
Conclusion: e survival rate of unexpected N2 patients was low despite complete resection being achieved in
these patients. Adjuvant therapy seemed to improve survival for those with unexpected N2 metastasis as it is a
systemic disease. However, not all patients received IMS, which was mostly done by EBUS and which had a high
false negative, leading to underestimating the staging. Other modalities, such as cervical mediastinoscopy, video-
assisted mediastinoscopic lymphadenectomy (VAMLA) or open biopsy should be considered for the adequate e
valuation of N2 metastasis, nonetheless further study is still needed.
Keywords: N2 disease, Unexpected N2, Non-small lung cancer (NSCLC), Invasive mediastinal staging (IMS), Stage
3A NSCLC (Siriraj Med J 2022; 74: 161-168)
Corresponding author: Punnarerk ongcharoen
E-mail: punnarerk.tho@mahidol.ac.th
Received 7 September 2021 Revised 30 November 2021 Accepted 25 December 2021
ORCID ID: https://orcid.org/0000-0002-0420-1462
http://dx.doi.org/10.33192/Smj.2022.20
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
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162
INTRODUCTION
e prognosis of non-small cell lung cancer (NSCLC)
patients with mediastinal lymph node metastases (N2
disease) is usually poor.
1-3
N2 involvement is one of the
important factors that determine the prognosis and
treatment. Because N2 disease seems to indicate systemic
spreading, systemic therapy, such as chemotherapy,
radiation therapy, or combined chemo-radiation therapy,
has better 5-year survival than surgery alone (38% vs
30%).
4
Despite the recommendation for mediastinal lymph
node tissue conrmation when there is a high suspicion
of N2 by imaging, such as enlarged lymph nodes seen
by computed tomography (CT) or an increased uptake
in the mediastinum by positron-emission tomography
(PET)
5
, the accuracy of the clinical staging still has a high
false negative rate ranging from 25% to 40%
6
; therefore,
some patients undergo surgery as the rst course of
treatment. Previous reports showed that unexpected
N2 disease patients had a poor prognosis and a survival
rate ranging from only 10%-35%.
7-10
Consequently, the objective of this study is to determine
survival rate in ai population of the clinical N0 NSCLC
patients who underwent complete pulmonary resection
with systematic mediastinal lymph nodes dissection and
who had unexpected N2 as a nal pathological result.
MATERIALS AND METHODS
Patients and staging
is study is a retrospective review of all the pathology-
proven N2 metastases NSCLC patients included in the
data registry of the Division of Cardio-oracic Surgery
and in reports from the Department of Pathology, Siriraj
Hospital, Bangkok, ailand, between January 2007 and
December 2016. Among all the patients aged 18 years old
and older who received complete pulmonary resection
with systematic mediastinal lymphadenectomy (n = 158),
we excluded patients (n = 33) who had a diagnosis of N2
disease as either highly suspicious (14 patients whose
CT shows enlarged N2 lymph node more than 1 cm in
short axis) or conrmed from preoperative imaging
(2 patients whose N2 uptake in PET-CT), small cell
carcinoma (10 patients), and neuroendocrine tumor (7
patients). Following the exclusions, the remaining patients
(n = 125) were proven to be NSCLC preoperatively or
at the time of surgery, and had been clinically staged
as N0 or N1 from an imaging study (CT or FDG-PET
scan) and from invasive mediastinal staging if done. All
of the included patients had not received neoadjuvant
systemic chemotherapy nor radiation therapy before
surgical resection. e Siriraj Ethic and Clinical Research
Institutional Review Board approved this study as well
as the electronic database used. e need for individual
patient consent was waived due to the nature of the
retrospective study design.
Staging was primarily performed by chest computed
tomography (CT). Only a small number of patients
received positron-emission tomography (PET-CT scan)
due to the cost and availability. Invasive mediastinal
staging, such as endobronchial ultrasound ne needle
aspiration (EUS-FNA) or cervical mediastinoscopy, were
performed in cases with a mediastinal lymph node larger
than 1 cm in short axis as determined by the imaging
and when all the results were negative for N2 disease.
Nevertheless, there is no specic criteria in the institution
for selecting patients to receive particular preoperative
invasive mediastinal staging, the decision depends on
experienced pulmonologists or surgeons.
Surgery was performed by both standard thoracotomy
and video-assisted thoracoscopic surgery (VATS).
Anatomical complete resection (R0 resection) was
achieved by lobectomy, bi-lobectomy, or pneumonectomy.
Systematic lymphadenectomy was performed in all
patients and included lymph node stations 2R, 4R,
7-9
for
the right-sided lesions, and stations
5-9
for the le-sided
lesions. e pathological review was done using the
standard technique for both the primary lung lesions
and mediastinal lymph nodes.
All the patients received routine follow-up examination
in the thoracic out-patient unit and were referred to an
oncologist and radiotherapist for appropriate adjuvant
chemotherapy or radiation therapy.
Statistical analysis
Data analysis was performed using SPSS statistical
soware (SPSS version 25, 2017, IBM Corporation).
Categorial data are presented as the percentage and
continuous variables are expressed as the mean. Continuous
variables between groups were compared using the
t test and discrete variables using Pearson’s chi square
test. Survival rates were calculated using the Kaplan–
Meier method and log-rank test for adjusting for the
dierences between subgroups. Univariate analysis for
the prognostic factors was performed using the log-rank
test and multivariate analysis using multiple logistic
regression analysis method. A p-value of less than 0.05
was dened as statistically signicant.
RESULTS
In total, 125 patients were included in this study.
Complete surgical lung resection and systematic mediastinal
lymphadenectomy were achieved in every patient. As
shown in Table 1, male and female in age group of 60 is
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TABLE 1. Patients’ characteristics (n = 125).
*EBUS endobronchial ultrasonography.
Gender
Male 60 (48%)
Female 65 (52%)
Median age (years, range) 62 (31-82)
Clinical presentation
Abnormal chest radiograph 66 (52.8%)
Chest discomfort 4 (3.2%)
Prolong cough 34 (27.2%)
Hemoptysis 16 (12.8%)
Dyspnea 3 (2.4%)
Weight loss 1 (0.8%)
Pneumonia 1 (0.8%)
Site of primary tumor
Right upper lobe 32 (25.6%)
Right middle lobe 14 (11.2%)
Right lower lobe 30 (24%)
Left upper lobe 33 (26.4%)
Left lower lobe 16 (12.8%)
Invasive mediastinal staging (IMS) 47 (37.6%)
EBUS*(negative result) 38 (30.4%)
EBUS (inadequate tissue) 8 (6.4%)
Mediastinoscopic biopsy 1 (0.8%)
(negative result)
Mean time to surgery (months) 1.29 (±0.875)
Extent of surgery
Segmental resection 2 (1.6%)
Lobectomy 104 (83.2%)
Bilobectomy 11 (8.8%)
Pneumonectomy 8 (6.4%)
Adjuvant therapy 102 (81.6%)
Chemotherapy 45 (36%)
Radiation therapy 4 (3.2%)
Chemo-radiation therapy 53 (42.4%)
Distant metastases (restaging) 71 (56.8%)
not dierent for the lung cancer characteristics. e most
common presentation was an abnormal chest radiography
on annual check-up followings with prolong cough
and hemoptysis. One-third of the patients received an
invasive mediastinal staging procedure by endobronchial
ultrasonography (EBUS), for which the results were all
negative or there was inadequate tissue for evaluation,
and only 1 patient received mediastinoscopy with lymph
node biopsy. e mean time from diagnosis to surgery
was less than 60 days. Lobectomy was performed most
oen, which was equally performed in the right upper lobe,
right lower lobe, and le upper lobe. Among the study,
almost patients received adjuvant therapy, comprising
chemotherapy alone, radiation therapy alone, or combined
chemo-radiation therapy.
For the tumor characteristics (Table 2), the most
common T staging was still early (T2a). Adenocarcinoma
was the predominant histologic subtype along with
moderate dierentiation. ere was a rather high incidence
of visceral pleural invasion and lymphovascular invasion.
e most common site of mediastinal nodal metastasis
for unexpected N2 disease was station 7 followed by
stations 4R and 4L, while three quarters of patients had
multiple N2 station metastases.
e overall 2-year, 3-year, and 5-year Kaplan–Meier
survival rates were 40%, 24%, and 20%, respectively (Fig 1).
For the pathological characteristics, the histologic subtype
and dierentiation had signicant dierences in their
eect on the survival rates (Fig 2). e adenocarcinoma
group had a better 5-year survival rate compared to the
squamous cell carcinoma group (24% vs. 14%, p = 0.019),
whereas good dierentiation had a better 5-year survival
rate than moderate and poor dierentiation (45%, 24%,
and 13%, p = 0.004). ere was no signicant dierence
among the T staging classes (p = 0.282, Fig 2). e presence
of visceral pleural invasion of the tumor had a 5-year
survival rate of 16% compared to the absence group,
but this was not signicantly dierent (p = 0.199, Fig 3).
Lymphovascular invasion also showed no signicant
dierence (p = 0.097, Fig 3), and the 5-year survival rate
was 15% in the presence of lymphovascular invasion.
For unexpected N2 metastasis, the numbers of nodal
stations were analyzed. Fig 4 shows the Kaplan–Meier
5-year survival for 39 patients with single nodal station
metastasis compared to 86 patients with multiple nodal
stations metastases (25% vs. 18% respectively), but the
dierence was not statistically signicant (p = 0.103). In
terms of the patient follow-ups, 23 patients declined the
adjuvant therapy. Here, all the patients with or without
adjuvant therapy were compared, and the best prognosis
was found in the adjuvant chemo-radiation therapy
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TABLE 2. Tumors’ characteristics (n = 125).
For the tumor characteristics (Table 2), the most common T staging
was T2a (55.2%) with the median size of 4.31 cm. Adenocarcinoma
was the predominant histologic subtype (83.2%) along with moderate
dierentiation (67.2%). ere was a rather high incidence of visceral
pleural invasion (69.6%) and lymphovascular invasion (75.2%). e
most common site of mediastinal nodal metastasis for unexpected
N2 disease was station 7 (49.6%) followed by stations 4R and 4L
(44%), while 68.8% of patients had multiple N2 station metastases.
Size of primary tumor (cm) 4.31 ± 1.921
Histology
Adenocarcinoma 104 (83.2%)
Squamous cell carcinoma 16 (12.8%)
Other 5 (4%)
Differentiation
Well 6 (4.8%)
Moderate 84 (67.2%)
Poor 27 (21.6%)
Not evaluated 8 (6.4%)
Visceral pleural invasion 87 (69.6%)
Lymphovascular invasion 94 (75.2%)
Adjacent structure invasion 16 (12.8%)
T staging (from pathology)
T1a 5 (4%)
T1b 10 (8%)
T2a 69 (55.2%)
T2b 20 (16%)
T3 16 (12.8%)
T4 5 (4%)
N1 station involvement
10R, 10L 45 (36%)
11R, 11L 71 (56.8%)
N2 station
3 6 (4.8%)
4R,4L 55 (44%)
5 33 (26.4%)
6 3 (2.4%)
7 62 (49.6%)
8R,8L 2 (1.6%)
9R,9L 10 (8%)
Number of N2
Single 39 (31.2%)
Multiple 86 (68.8%)
Fig 1. Overall 2-, 3-, and 5-year survival rates, which were 40%, 24%,
and 20%, respectively.
group, which had a 5-year survival rate of 30%, while
the 5-year survival rates of the radiation therapy alone
group, chemotherapy alone group, and did not receive
adjuvant therapy group were 25%, 15%, and 10%, and
the dierence was statistically signicant (p = 0.011,
Fig 4).
Post-treatment re-staging data were also collected
and analyzed. The survival graph demonstrated the
5-year survival rate of patients with a presentation of
distant metastasis in any organ was 10%; while for the
group with no distant metastasis, it was 40%, and there
was a highly signicant dierence in statistical terms as
the p-value was 0.003 (Fig 4). e univariate analysis
was insignicant. e multivariate analysis results in
Table 3 depict that the independent predictive factors
for survival were receiving adjuvant chemo-radiation
therapy and a distant metastasis on re-staging.
DISCUSSION
Recently, Krantz and colleagues
11
did a study based
on e Society of oracic Surgeons General oracic
Surgery Database (STS-GTSD) participants in the United
States (US) and reported that 34% of lung cancer patients
staged by computed tomography and positron-emission
tomography and rst treated with anatomical resection
underwent invasive mediastinal staging (IMS). Compatible
with our study, which found that in all 125 “unexpected
N2” disease patients, only 47 patients (37.6%) received
IMS, which included 46 EBUS and only 1 who underwent
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Fig 2. Survival rates according to histologic subtype (le upper)
with signicant dierence between the subgroups (p = 0.019),
where it can be seen the ve-year survival rate in the adenocarcinoma
group was 24% and 14% in the squamous cell carcinoma group.
Right upperpicture shows the survival rates according to cell
dierentiation; where the ve-year survival rates of well, moderate
and poor dierentiation were 45%, 24%, and 13%, respectively.
Dierence between the subgroup was signicant (p = 0.004).
Survival rates according to T-staging of the tumor characteristic
(right lower). ere was no signicant dierence between T1,
T2, T3, and T4 (p = 0.282).
Fig 3. Survival rate according to visceral plural invasion (le) and lymphovascular invasion (right). e 5-year survival rate of patients with
pleural invasion was 16%, while it was 26% in the absence group, with no signicant dierence (p = 0.199). For the lymphovascular invasion,
the presence group had a 5-year survival of 15%, while the absence group it was 38%; however, there was no signicant dierence (p =
0.097).
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Fig 4. Survival rate according to number of N2 station metastasis
(le upper); the 5-year survival rate of single station metastasis was
25% while the multiple station metastasis was 18%. However, there
was no statistically signicant dierence (p = 0.103). Survival rate
according to receiving adjuvant therapy (Right upper); the 5-year
survival rate of patients who had received CMT/RT was 30%, while
for radiation therapy alone, chemotherapy alone or had not received
adjuvant therapy, the rates were 25%, 15%, and 10%, and the dierence
was statistically signicant. e le lower gure showed survival
rate according to post-treatment re-staging; the 5-year survival of
patients with the presentation of distant metastasis in any organ was
10% while the group with no distant metastasis was 40%. e signicant
dierence was high, p = 0.003.
TABLE 3. Multivariate analysis of the risk factors of mortality.
Variables Number of patients Adjusted OR (95%CI) p-value
Adenocarcinoma 103 1.378 (0.655–2.902) 0.398
Poor differentiation 27 2.345 (0.734–7.489) 0.150
Visceral pleural invasion 81 0.838 (0.477–1.474) 0.541
Lymphovascular invasion 88 0.725 (0.421–1.247) 0.245
Multiple N2 82 1.429 (0.819–2.494) 0.209
Adjuvant therapy
52 0.367 (0.176–0.766) 0.008
(CMT/RT)
Distant metastasis 66 2.280 (1.334–3.897) 0.003
Adjusted OR, adjusted odds ratio; CI, condence interval.
Geanphun et al.
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mediastinoscopy; all the invasive study results were
either negative for malignancy or had inadequate tissue
for evaluation. Although our population was based on
a clinical non-N2 group with pathological N2 disease
conrmed by the nal pathological report, the rate of
patients who received IMS was not dierent. Whereas
numerous population-based studies have shown low
rates of lung cancer patients who have underwent IMS,
ranging from 21%-27%,
12-18
our result showed higher
rates of IMS.
e information suggests that preoperative non-
invasive image staging only revealing a low suspicion of
N2 metastasis is not adequate. For patients who had a
preoperative PET/CT done, the information provided was
also inadequate. Further prospective randomized trials
on the role of PET/CT are needed. All the patients who
received IMS staging, such as by EBUS, had many false
negatives, leading to a dispute over inadequate tissue.
is was similar to a previous study by Sawhney,
19
which
showed a very low incidence of unexpected N2 disease
by EBUS (3%) when only a CT scan was performed for
preoperative staging, which, when compared to other
modalities, such as mediastinoscopy, video-assisted
mediastinoscopic lymphadenectomy (VAMLA), or
open biopsy of mediastinal lymph node, might play an
important role in the preoperative staging consensus
with previous studies. Further, Bendzsak et al,
20
showed
85% of patients used IMS, which concorded with the
guidelines,
6,21-23
Call et al,
24
concluded that VAMLA is
a feasible and highly accurate technique, with a rate of
unexpected N2–3 of 18%.
Compared to previous reports
3,4,25
, we considered the
dierent results about which adenocarcinoma cell type
and cell dierentiation were factors impacting the survival
rate in the comparisons; however, not T staging (T2),
visceral pleural invasion, and lymphovascular invasion,
which had insignicant dierences in the survival rates
in comparison, even though we found this coincident
with the N2 metastasis (71.2%, 69.6%, and 75.2%). e
number of N2 stations and associated N1 did not show
a statistical relation with unexpected N2, although the
coincidence of multiple N2 stations was rather high
(68.8%). Mediastinal lymph node station 7 was the most
common position for nding unexpected N2 (49.6%),
which was compatible with Eckardt and colleagues
26
,
who reported subcarinal lymph node metastases were
common in NSCLC regardless of the primary location
and should be considered an IMS modality or routinely
dissected during operation.
e present study reported an overall 5-year survival
of only 20% for patients with unexpected N2 disease
despite complete pulmonary resection and systematic
mediastinal lymphadenectomy being achieved, which
correlated with previous studies that reported 5-year
survival rates varying from 10%–38%.
7-10
Surgery is
benecial in early stage NSCLC
27
but still controversial
in stage IIIA-N2, reecting the general trend away from
surgery.
28,29
Pneumonectomy for lung cancer also results
in poor prognosis and followed by several post operative
complication
30
, since then this operation is less performed.
Comparison of the survival rate showed that in our series,
patients who had received adjuvant chemo-radiation
therapy had a better survival rate than the others (p
= 0.011). Pathological N2 disease indicates a systemic
spreading, and like in a previous study, it was found
that systemic therapy tends to play a more important
role and improve survival more than surgery alone
31-33
,
whereby we found a correlation to distant metastases
in 71 patients (56.8%), with a signicant dierence in
the survival comparison (p = 0.003). e multivariate
analysis results also supported that CMT/RT and distant
metastases are independent factors for survival.
ere are several limitations of this study to note.
First, the study population only involved a single group
of clinical N0/N1 patients with unexpected N2 disease,
and we did not compare the overall survival rates of early
stage (stage I–II) patients. Second, as a result of the limited
population, IMS results showing false negatives were
analyzed with the unexpected N2 base patients, and so
the overall IMS information was inadequate. Other than
that, in general, adjuvant chemotherapy is considered in
all patients with N2 disease, despite complete resection
previously being performed. However, in our study, it
depended on the patient preference. In particular, some
patients who were diagnosed distant metastases aer
complete re-staging declined receiving adjuvant therapy,
which might have resulted in a dierent survival rate.
CONCLUSION
e overall 5-year survival rate of unexpected N2
patients was low despite complete pulmonary resection and
mediastinal lymphadenectomy being achieved. Adjuvant
chemo-radiation therapy seems to improve survival for
those with unexpected N2 metastasis as it is a systemic
disease. However, not all patients received IMS, and those
who did it was mostly by EBUS and which had a high
false negative, leading to underestimating the staging.
Other modalities, such as cervical mediastinoscopy, video-
assisted mediastinoscopic lymphadenectomy (VAMLA)
or open biopsy should be considered for the adequate
evaluation of N2 metastasis, nonetheless further study
is still needed to compare each methods.
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Geanphun et al.
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Original Article
SMJ
itiporn Sirivunnabood, M.D., Prapat Wanitpongpan, M.D., Piengbulan Yapan, M.D.
Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Incidence and Risk Factors of Neonatal Sepsis in
Preterm Premature Rupture of Membranes before
34 Weeks of Gestation
ABSTRACT
Objective: Early-onset neonatal sepsis (EONS) is a leading cause of newborn morbidity and mortality, particularly in
preterm premature rupture of membranes (PPROM) before 34 weeks of gestation, in which expectant management
was performed until reaching 34 weeks of gestation, evidence of maternal chorioamnionitis, or unfavorable fetal
conditions. e interval between membrane rupture and delivery has a positive correlation with neonatal sepsis.
e purpose of this study was to investigate the incidence and risk factors of EONS in PPROM.
Materials and Methods: is was a retrospective cross-sectional study. e medical records of pregnant women
who gave birth between 2005 and 2018 and their newborns were reviewed. e inclusion criterion was singleton
pregnancies complicated by PPROM between 24 and 33
+6
weeks of gestation. Multifetal pregnancies, fetal malformation,
stillbirths, and records with incomplete data were excluded. PPROM was diagnosed by obstetricians while EONS
was diagnosed by neonatologist.
Results: e incidence of EONS in with PPROM was 24%. Risk factors included excessive maternal weight gain
based on IOM (OR = 2.40, 95% CI = 1.16-4.94), extremely preterm at admission (before 28 weeks of gestation)
(OR = 3.38, 95% CI 1.12-10.21) and very low birth weight (≤ 1,500 g) (OR 3.68, 95% CI = 1.86-7.30). Maternal
hematologic laboratory results were not associated with neonatal sepsis.
Conclusion: e incidence of EONS in PPROM was similar to data provided by other studies. Obstetricians and
pediatricians should be cautious about neonatal sepsis, especially in cases of excessive maternal weight gain, extremely
preterm admissions, and very low birth weight.
Keywords: Early-onset neonatal sepsis; incidence; PPROM; risk factors (Siriraj Med J 2022; 74: 169-177)
Corresponding author: Piengbulan Yapan
E-mail: piengbulan.yap@gmail.com
Received 25 October 2021 Revised 15 January 2022 Accepted 21 January 2022
ORCID ID: https://orcid.org/ 0000-0001-7194-4365
http://dx.doi.org/10.33192/Smj.2022.21
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
INTRODUCTION
Preterm birth is dened as babies born prior to
completion of 37 weeks of gestation. At Siriraj Hospital,
the incidence of preterm birth between 28 and 37 weeks
of gestation is 9-13%.
1,2
Due to the immature development
of several organs, these babies tend to have short-term
or long-term morbidities in the respiratory system
(respiratory distress syndrome, bronchopulmonary
dysplasia, apnea of prematurity), gastrointestinal system
(feeding intolerance, necrotizing enterocolitis, growth
failure), immunological system (infection) and central
nervous system (intraventricular hemorrhage, cerebral
palsy, neurodevelopmental delay, hearing loss, retinopathy
of prematurity).
3
One of the causes of preterm birth is preterm premature
rupture of membranes (PPROM) in which the fetal
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170
membranes spontaneously rupture before completion
of 37 weeks of gestation and onset of labor. At Siriraj
Hospital, the incidence of PPROM between 24 and
37 weeks of gestation is 2.93%.
4
Aer the rupture of
fetal membranes, microorganisms from the maternal
lower genital tract ascend the uterine cavity, resulting
in infectious morbidities such as chorioamnionitis, fetal
inammation and neonatal sepsis. Besides PPROM,
risk factors of neonatal sepsis include preterm labor,
low birth weight, maternal colonization of group B
streptococcus, chorioamnionitis and intrapartum infection.
5,6
e interval between the rupture of membranes and
delivery has a positive correlation with neonatal sepsis.
7
Early-onset neonatal sepsis (EONS) is an important
cause of morbidity and mortality of newborns. Short-
term outcomes are hypotension requiring vasopressor
support; respiratory distress or suppression requiring
intubation or noninvasive ventilation; and hyper- and
hypoglycemia, thrombocytopenia, and disseminated
intravascular coagulation (DIC). Long-term outcomes are
bronchopulmonary dysplasia (BPD), brain injury, including
periventricular leukomalacia (PVL), neurodevelopmental
delays, and cerebral palsy.
8
Management of PPROM remains challenging as it
is dicult to balance the risk of terminating a pregnancy
as long as expectant management exists. While expectant
management poses a risk of maternal and fetal infection,
placental abruption, and umbilical cord accidents,
termination of pregnancy, especially at an early gestational
age, presents a danger of prematurity.
9
Over the last few
decades, the decision to terminate a pregnancy with
PPROM complications have been based on evidence of
maternal chorioamnionitis or unfavorable fetal conditions.
Chorioamnionitis is dened by maternal fever and uterine
tenderness, which results in severe infection in newborn
babies. Indications of early stage chorioamnionitis have
been proposed, however, they remain controversial and
unreliable. Our aim was to study the incidence of EONS
and parameters associated with this condition.
MATERIALS AND METHODS
Study design
is was a retrospective cross-sectional study approved
by the institutional ethical committee.
Participants
Based on previous report from Arora and colleagues
10
,
the sample size of 274 samples would yield a power
of 80% and type I error of 5%, 2-sided. e medical
records of pregnant women who gave birth between
2005 and 2018 were reviewed. e inclusion criterion
was singleton pregnancies aected by PPROM between
24 and 33
+6
weeks of gestation. Multifetal pregnancies,
fetal malformation, stillbirths, indicated preterm birth
conditions such as maternal diseases, preeclampsia and
placenta previa, and records with incomplete data were
excluded. Gestational age was dened by menstrual
history or ultrasonography performed before 20 weeks
of gestation.
Outcomes
e clinical parameters included maternal demographic
data, parity, history of previous preterm birth, body mass
index (BMI), weight gain during pregnancy according
to the Institute of Medicine (IOM) pregnant women,
diabetes mellitus status, gestational age at PPROM and
at delivery, interval between rupture of membranes and
delivery, dexamethasone dosage, delivery mode, birth
weight of newborns, APGAR score, diagnosis of EONS,
length of neonatal hospital stay, and neonatal discharge
status. e maternal hematological parameters included
complete blood count (CBC), neutrophils to lymphocytes
(N/L) ratio, and erythrocyte sedimentation rate (ESR).
e IOM recommended that pregnant women should
have a total weight gain of 12.5 to 18 kg, 11.5 to 16 kg, 7
to 11.5 kg, and 5 to 9 kg for those whose pre-pregnancy
BMI were categorized as underweight (<18.5 kg/m
2
),
normal weight (18.5-24.9 kg/m
2
), overweight (25.0-29.9
kg/m
2
), and obesity (≥30 kg/m
2
), respectively.
11,12
All newborns were assessed by neonatologist at Siriraj
Hospital. e EONS was dened by a positive culture of
pathogenic bacteria in the blood or cerebrospinal uid
(CSF) within 72 hours aer birth. Blood culture remains
the diagnostic standard for EONS. CSF culture should
ideally be performed along with blood culture for newborns
who are at the highest risk for EOS. However, lumbar
puncture should not be performed if the newborn’s clinical
condition was compromised, or antibiotic initiation
would be delayed by the procedure.
13
In our institute, all PPROM cases of less than
34 weeks of gestation were managed by a combined
administration of antibiotics (ampicillin/amoxicillin
plus erythromycin)
14
, corticosteroids, and short-term
tocolytics to complete course of corticosteroids. Aer
completing the course of antibiotics and corticosteroids,
expectant management was performed until 34 weeks
of gestation when delivery was induced. Termination
of each pregnancy was individually encouraged before
34 weeks using evidence of maternal chorioamnionitis
or unfavorable fetal conditions. Complete blood count
and ESR were checked every other day from admission
until delivery.
Sirivunnabood et al.
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Statistical analysis
e continuous variables are presented as mean
± SD, median, and range. e categorical variables are
presented as frequencies and percentage. A T-test was
used to compare two groups ofcontinuous datawhich
were normally distributed while the Mann-Whitney
U test was used to compare dierences between two
independent groups when the dependentvariableswere
either ordinal orcontinuous, but not normally distributed.
e Chi-square test was used to compare a group with a
value or to compare two or more groups, always using
categorical data. Risk factors of EONS were shown as an
odds ratio by binary logistic regression analysis. IBM SPSS
Statistics version 21 (Copyright International Business
Machines Corporation and other(s) 1989, 2012) was
used for statistical analysis. A P-value of less than 0.05
was considered statistically signicant.
Fig 1. Flow of PPROM cases in
Siriraj Hospital from 2005 to
2018
Fig 2. Incidence of EONS in
PPROM pregnancies before 34
weeks of gestation at Siriraj
Hospital from 2005 to 2018.
RESULTS
A total number of 407 medical records were initially
included into this study. One hundred and thirty-three
records were excluded. Data from the remaining 274
records were used for further analysis (Fig 1).
e overall incidence of EONS in PPROM before 34
weeks of gestation was 24%. e trend of incidence has
decreased over the past 14 years (Fig 2). e maternal
characteristics and pregnancy outcomes were shown
in Table 1. Maternal age was not signicantly dierent
between those with and without EONS, which was similar
to parity and history of previous preterm birth. e PPROM
interval prior to delivery, clinical chorioamnionitis and
unfavorable fetal conditions did not relate to neonatal
sepsis. Most pregnant women received four doses of
dexamethasone before delivery. ere was only one case
of prolapsed cord among those without EONS. Placental
abruption was not found in both groups.
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172
TABLE 1. Maternal characteristics and pregnancy outcomes of 274 women enrolled in the study in the PPROM
without EONS or PPROM with EONS group.
Variables PPROM without EONS PPROM with EONS P
(n=221) (n=53)
Maternal age (years) 27.9 ± 7.2 28.8 ± 6.5 0.386*
<20 37 (16.7%) 5 (9.4%) 0.381
#
20-34 139 (62.9%) 38 (71.7%)
≥35 45 (20.4%) 10 (18.9%)
Parity
Nulliparous 125 (56.6%) 37 (69.8%) 0.088
#
Multiparous 96 (43.4%) 16 (30.2%)
Previous PTB history 23 (10.4%) 1 (1.9%) 0.056
##
Weight gain (kg) 9.8 ± 4.7 11.7 ± 5.0 0.021*
Non-excessive 161 (81.7%) 28 (65.1%) 0.016
#
Excessive 36 (18.3%) 15 (34.9%)
GA at admission (weeks) 32 (25 - 34) 31 (25 - 34) 0.007
†
24-27
+6
8 (3.6%) 6 (11.3%) 0.027
#
28-31
+6
60 (27.1%) 18 (34.0%)
32-33
+6
153 (69.2%) 29 (54.7%)
GA at delivery (weeks) 33 (25 - 34) 32 (26 - 34) 0.003
†
24-27
+6
8 (3.6%) 6 (11.3%) 0.150
28-31
+6
50 (22.6%) 13 (24.5%)
32-33
+6
163 (73.8%) 34 (64.2%)
PPROM interval prior to delivery (hr) 26 (0 - 523) 25 (0 - 241) 0.279
†
<18 99 (44.8%) 25 (47.2%) 0.353
#
18-48 35 (15.8%) 12 (22.6%)
>48 87 (39.4%) 16 (30.2%)
Dexamethasone (dose)
0 14 (6.3%) 6 (11.3%) 0.164
#
1 80 (36.2%) 15 (28.3%)
2 17 (7.7%) 9 (17.0%)
3 11 (5.0%) 2 (3.8%)
4 99 (44.8%) 21 (39.6%)
Delivery mode
Vaginal delivery 163 (73.8%) 40 (75.5%) 0.863
#
Cesarean section 58 (26.2%) 13 (24.5%)
Clinical chorioamnionitis 8 (3.6%) 2 (3.8%) 1.000
##
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TABLE 1. Maternal characteristics and pregnancy outcomes of 274 women enrolled in the study in the PPROM
without EONS or PPROM with EONS group. (Continue)
Variables PPROM without EONS PPROM with EONS P
(n=221) (n=53)
Unfavorable fetal conditions 16 (7.2%) 6 (11.3%) 0.396
##
Birth weight (g) 1891 ± 389 1626 ± 350 <0.001*
<1,500 29 (13.1%) 19 (35.8%) <0.001
#
1,500-2,499 179 (81.0%) 34 (64.2%)
2,500-3,999 13 (5.9%) 0
APGAR score at 1 min 8 (0 - 10) 8 (1-10) 0.149
†
APGAR score at 5 mins 10 (0 - 10) 9 (5 - 10) 0.016
†
Length of neonatal hospital stay (days) 10 (0 - 158) 30 (2 - 218) <0.001
†
<7 61 (27.6%) 1 (1.9%) <0.001
#
7-30 111 (50.2%) 26 (49.1%)
>30 49 (22.2%) 26 (49.1%)
Neonatal discharge status
Alive 217 (98.2%) 52 (98.1%) 1.000
#
Deceased 4 (1.8%) 1 (1.9%)
Abbreviations: PPROM=preterm premature ruptured of membranes, EONS=Early-onset neonatal sepsis, PTB=preterm birth, GA=
gestational age
* Mean ±SD, p-value (T-test)
#
Count, p-value (Chi-square)
##
Count, p-value (Fisher’s exact test)
†
Median, p-value (Mann-Whitney U test)
e parameters signicantly associated with EONS
included excessive maternal weight gain, gestational
age at admission, gestational age at delivery and birth
weight. An earlier gestational age at admission meant
higher incidence of EONS as well as gestational age
at delivery. Again, a lower birth weight meant higher
chance for neonatal sepsis.
Newborns with EONS stayed in the hospital longer.
e overall mortality rate of newborns from PPROM
mothers is 2%. ere is no statistical dierence in mortality
rate between the two groups.
Laboratory results were obtained from 241 women
and data comparing cases with and without EONS at
admission, before delivery and dierence from admission
to delivery are shown in Table 2. All maternal laboratory
results were similar between the EONS and no EONS
group.
Pregnant women in the EONS group gained more
weight than the other group. According to IOM guidelines
for weight gain during pregnancy, the odds ratio (OR) of
EONS among pregnant women with excessive weight gain
was 2.40 (95% CI 1.16-4.94). Furthermore, risk factors
of EONS at admission before 28 weeks of gestation was
preterm (OR = 3.38, 95%CI 1.12-10.21) and low birth
weight ≤ 1,500g (OR 3.68, 95%CI = 1.86-7.30), as shown
in Table 3.
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TABLE 2. Maternal laboratory results in PPROM without EONS and PPROM with EONS groups
Variables At admission Before delivery Difference from admission
to delivery
No EONS EONS P No EONS EONS P No EONS EONS P
(n=193) (n=48) (n=193) (n=48) (n=92) (n=20)
Hb (g/dl) 11.5 ± 1.3 11.3 ± 1.2 0.21* 11.2 ± 1.5 11.2 ± 1.2 0.89* -0.6 ± 1.2 -0.1 ± 0.9 0.08*
Hct (%) 35.2 ± 3.8 34.2 ± 3.6 0.10* 34.3 ± 4.4 34.1 ± 3.6 0.73* -1.8 ± 3.3 -0.2 ± 2.8 0.06*
WBC 13.5 ± 7.3 13.3 ± 4.2 0.86* 14.5 ± 7.5 15.1 ± 4.6 0.60* 2.1 ± 5.0 4.3 ± 4.2 0.74*
(10
3
cells/ul)
N (%) 78.2 ± 7.3 76.9 ± 8.7 0.32* 80.0 ± 8.2 80.0 ± 8.7 0.99* 3.9 ± 9.8 7.4 ± 11.4 0.16*
L (%) 15.4 ± 6.0 16.3 ± 6.9 0.40* 14.1 ± 6.6 14.0 ± 6.9 0.93* -2.7 ± 7.0 -5.4 ± 8.2 0.14*
N/L ratio
5.2 (1.1
–
27.4) 4.3 (1.7
–
21.5) 0.32
†
5.6 (1.1
–
46.4) 6.4 (1.7
–
36.8) 0.99
†
1.6 (-2.3
–
40.1) 3.0 (-8.1
–
34.2) 0.74
†
Plt 271.4 ± 62.9 272.7 ± 78.7 0.90* 268.7 ± 61.6 269.6 ± 73.3 0.93* -5.6 ± 38.2 -7.4 ± 38.5 0.84*
(10
3
cells/ul)
ESR 64.2 ± 19.5 62.2 ± 18.0 0.56* 64.2 ± 21.2 62.7 ± 18.2 0.69* 0.1 ± 18.8 7.6 ± 14.4 0.15*
(mm/hr)
Abbreviations: Hb = Hemoglobin, Hct = Hematocrit, WBC = White Blood Cells Count, N = Neutrophils, L = Lymphocytes, Plt = Platelets,
ESR = Erythrocyte Sedimentation Rate
* Mean ±SD, p-value (T-test)
†
Median, p-value (Mann-Whitney U test)
TABLE 3. Maternal laboratory results in PPROM without EONS and PPROM with EONS groups
Risk factors OR 95% CI P
Excessive weight gain 2.40 1.16 – 4.94 0.016
BMI at admission 1.04 0.96 – 1.12 0.324
Gestational age at admission
24-27
+6
weeks 3.38 1.12 – 10.21 0.023
28-31
+6
weeks 1.57 0.81 – 3.04 0.177
32-33
+6
weeks 1.00 - -
VLBW (≤ 1,500 g) 3.68 1.86 – 7.30 <0.001
Abbreviations: BMI = body mass index, VLBW = very low birth weight
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DISCUSSION
e overall incidence of EONS in pregnant women
with PPROM before 34 weeks of pregnancy was found to
be 24% in this study. We chose to study gestational age
less than 34 weeks because PPROM that arises beyond
34 weeks of gestation is not treated expectantly, newborn
sepsis is infrequent. Our incidence was in agreement with
certain research
10
but not with others.
15,16
We hypothesize
that the dierence in incidence between hospitals is due
to the varying diagnostic criteria used to identify EONS.
During the 14-year period, the incidence of EONS in
PPROM pregnancies before 34 weeks of gestation seems
to have decreased. is could either be the result of
better guideline management for premature rupture of
membranes
14
or more advanced neonatal management.
However, EONS incidence in preterm was higher than
term deliveries. In Siriraj Hospital, the perinatal mortality
rate has continuously declined and was less than 10%.
e survival rate of premature babies has been increased
due to the improvement of obstetric and newborn care.
e well-trained neonatologists and excellent equipment
result in the best care for newborns.
1
Our study found that a maternal risk factor for
EONS was excessive weight gain during pregnancy,
according to IOM recommendations (OR = 2.40, 95%CI
= 1.16-4.94; p=0.016). According to Stotland NE, et al.,
who conducted a retrospective cohort study in singleton
births, the rate of neonatal infection was higher when
maternal weight gain was above IOM guidelines, when
compared to the appropriate or low weight gain group
(5.86%, 4.44% and 3.38% respectively).
17
It was reported
earlier that the incidence of sepsis among newborns of
obese women was higher than those of normal-weight
women.
18,19
Maternal overweight and obesity increased
the risk of EOS by group B Streptococcus, Staphylococcus
aureus, and Escherichia coli. Half of the association was
mediated through preeclampsia, cesarean section, and
preterm delivery.
19
Furthermore, obesity is a low-grade
inammatory state mediated primarily by leptin
20
, which
is associated with an increase in circulating inammatory
markers that are well characterized in the context of
preeclampsia and maternal intrauterine infections. Since
incremental weight gain has been associated with higher
leptin levels
21
, systemic inammation may play a role in
the higher incidence and trends of neonatal morbidities.
18
Neonatal conditions at birth aect a baby’s life
in many aspects. According to previous studies
22-26
,
unanimous agreement states that gestational age, birth
weight and APGAR scores play a vital role in neonatal
well-being and complications. A study by Belachew A,
et al. found that prematurity increased the risk of neonatal
sepsis 3.36 times compared with term newborns (95%
CI 2.50-4.54), and low birth weight (birth weight <2,500
grams) increased the risk of neonatal sepsis 1.42 times
compared to the normal birth weight group (95% CI
1.07-1.88).
22
Meanwhile, avarajah H, et al. claimed
that there was a statistically signicant dierence in the
incidence of neonatal sepsis among dierent APGAR
groups (low = 0-3, intermediate 4-6, normal = 7 or more).
23
Prematurity impairs adequate tissue oxygenation due to
an immature respiratory function. An underdeveloped
immune system along with hypoxic conditions put these
babies at higher risk of infection. Our study found that
a very low birth weight ≤ 1,500 g was associated with
increased risk of EONS (OR 3.68, 95%CI 1.86-7.30).
Maternal hematological parameters such as white
blood cell count (WBC) and erythrocyte sedimentation rate
(ESR) have been proposed as predictors of chorioamnionitis
and fetal infection but with some degree of controversy.
27-31
Panwar C, et al. mentioned that maternal WBC >12,000/
mm
3
could predict EONS with a sensitivity of 67.2% and
a specicity of 77.5% but without achieving statistical
signicance.
32
However, Mayuka WAB, et al. concluded
that maternal WBC >12,000 /mm
3
was signicantly
associated with neonatal sepsis.
33
Our goal was to nd
parameters associated with EONS, but we did not notice
any signicant relationship between maternal hematological
parameters and EONS. One possible explanation is
that leukocytosis in PPROM mothers was the result of
corticosteroids injections and not infection.
34
Many studies
have advocated the usefulness of an elevated Neutrophils/
Lymphocytes (N/L) ratio to predict adverse outcomes
in PPROM and is associated with chorioamnionitis
and EONS in preterm babies.
30,35,36
Contradicting this
suggestion, the N/L ratio in our study was not signicantly
associated with EONS in PPROM. Future studies that
can control the eect of corticosteroids might show the
true relationship between leukocytosis, chorioamnionitis,
and neonatal sepsis.
e strength of this study was that it found more
information about maternal hematological parameters
and EONS, about which there is relatively little knowledge.
However, it was limited by its retrospective nature, low
power in subgroup analysis and incomplete data of some
parameters. More prospective studies should be carried
out to eliminate these limitations.
CONCLUSION
In conclusion, the incidence of EONS in pregnant
women with PPROM before 34 weeks of gestation was
24%, indicating a decrease over time. Excessive maternal
weight gain, extremely preterm at admission and low birth
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176
weight are associated with increased incidence of EONS,
which aects the well-being of babies born prematurely.
From this study, some maternal hematologic parameters
may not reveal any risk factors of EONS. A regular check
of some parameters to guide the management of PPROM
cases should be considered.
ACKNOWLEDGEMENTS
e authors gratefully acknowledge Dr.Supasaek
Virojanapa and Julaporn Pooliam for assistance with
statistical analysis.
No conict of interest
is study passed the requirements of the ethical
committee at SIRB, COA no. Si 106/2019.
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178
Natwara Asanathong, M.D.*, Natticha Jiamjira-anon, M.D.**, Jatuporn Eiamcharoenwit (onsontia), M.D.
***, Sumon Mantaga, Nsc. ****, Chayanan anakiattiwibun, Msc. *****,
Arunotai Siriussawakul, M.D.*****,
******,
Nonthida Rojanapithayakorn, M.D.******
* Sisaket Hospital, Sisaket, 33000 ailand, ** Sawang Daen Din Crown Prince Hospital, Sakon Nakhon, 47110 ailand, *** Anesthesiology Department,
Prasat Neurological Institute, Bangkok, 10400 ailand, **** Department of Nurse Anesthetists, Ratchaburi Hospital, Ratchaburi, 77000 ailand,
***** Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700 ailand,
****** Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700 ailand.
Incidence of Adverse Perioperative Airway
Complications in Obese Non-Pregnant and Pregnant
Patients Undergoing General Anesthesia
ABSTRACT
Objective: Airway complications in obese patients are a major concern during surgical operation. is study
aimed to determine the incidence of airway- and respiratory-related anesthetic complications for obese (including
maternal) patients undergoing general anesthesia.
Materials and Methods: is multicenter, retrospective, observational study evaluated obese female patients (BMI
≥ 30 kg/m
2
), both non-pregnant and pregnant, undergoing general anesthesia in 5 hospitals across ailand during
May 2013 - August 2016. e primary observation was anesthesia-related airway complications (dicult and failed
intubations, aspiration, desaturation, and airway injuries) detected during anesthesia. An analysis was performed
to compare the incidents of the adverse events and to determine the risk factors for airway-related adverse events
in both groups.
Results: ere were 1,347 obese patients enrolled (777 non-pregnant and 570 pregnant). e overall incidence of
airway and respiratory complications was observed in 129 patients (9.6%), with a higher rate in pregnant patients
(12.5% vs. 7.5%; p<0.05). e most common complications were desaturation (5.6%) followed by airway injuries
(3.6%) and dicult intubation (1.5%). e factors signicantly associated with adverse airway-related events were
obesity class II (OR=1.63 [1.05–2.54]), obesity class III (OR=2.25 [1.19–4.25]), pregnancy (OR=1.73 [1.18–2.54]),
Mallampati classications III–IV (OR=1.69 [1.16–2.48]), and neck circumference <43 cm (OR=3.33 [1.02-10.81]),
p<0.05).
Conclusion: e incidence of the anesthesia-related airway and respiratory complications was 9.6%, with a higher
rate in pregnant patients. e most common adverse airway event was desaturation. However, the frequency of
serious airway events was low.
Keywords: Airway; obesity; perioperative; complication (Siriraj Med J 2022; 74: 178-184)
Corresponding author: Nonthida Rojanapithayakorn
E-mail: nonthida.roj@mahidol.ac.th
Received 19 December 2021 Revised 21 January 2022 Accepted 25 January 2022
ORCID ID: https://orcid.org/0000-0002-0305-0316
http://dx.doi.org/10.33192/Smj.2022.22
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
Rojanapithayakorn et al.
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179
Original Article
SMJ
INTRODUCTION
Obesity is a major risk factor of various diseases
and associated with an increase in all-cause mortality.
1
According to the World Health Organization, obesity
rates have almost tripled worldwide since 1975. In 2016,
39.8% of adults in the USA were overweight,
2
and during
2013-2014, 7.7% of adults in the USA were extremely
obese.
3
Performing general anesthesia in obese patients is
challenging, beginning from induction to immediate
post operation. e airway and respiratory system are
the most common area in which complications occur
in obese patients, accounting for more than 80% of all
events.
4
e incidence of dicult intubation in obesity
varies from 4% to 15%
5
, depending on the population and
the denition of dicult intubation utilized by studies.
e incidence of dicult airway in obese patients was 3
times that of non-obese patients.
6
Moreover, it is a risk
factor for aspiration, which is one of the main causes of
airway-related mortality in anesthesia.
7
Anesthesia is one of the leading cause of maternal
mortality. Of all the causes of maternal complication
from anesthesia, dicult intubation and aspiration is
the second only to high spinal block in frequency.
8
e
pregnancy-related anatomical and physiological changes
heighten the risk of airway and respiratory problems
occurring during general anesthesia. us, it is important
to be aware of the risks of complications associated with
general anesthesia in obese patients. Furthermore, it is
very likely that the risk would be even higher in obese
patients with pregnancy.
e main aims of the present study were to determine
the incidences of airway- and respiratory-related anesthetic
complications in female obese patients, and to ascertain
the resulting airway management outcomes. e secondary
objectives were to compare the airway-complication
incidences between obese non-pregnant patients and
obese pregnant patients, and to assess the characteristics
of the patients in order to identify factors associated with
the occurrence of such complications.
MATERIALS AND METHODS
This retrospective analysis evaluated on obese
non-pregnant and pregnant female patients undergoing
general anesthesia during May 2013 to August 2016
from a university hospital (Siriraj Hospital, Bangkok)
and 4 tertiary hospitals across ailand (Taksin hospital,
Bangkok; Surat ani Hospitals, Surat ani Province;
Phaholpolpayuhasena Hospital, Kanchanaburi Province;
and Maharat Nakhon Ratchasima Hospital, Nakhon
Ratchasima Province).
e inclusion criteria were female patients, aged
≥18 years old, having undergone surgery under general
anesthesia with conventional endotracheal tube intubation,
a BMI of ≥30 kg/m
2
, and gestational age of 34-42 weeks
for obese pregnant patients. Exclusion criteria included
patients who had a signicant orofacial pathology likely to
disturb intubation; having a history of dicult intubation;
having a condition leading to an abnormally increased
BMI (such as a huge intra-abdominal tumor, massive
ascites, or a patient with a full stomach).
Data collected were extracted by an anesthesiologist
from each hospital. e details were compiled on a
standardized data collection form and comprised each
patient’s demographic prole (sex, age, body weight,
and height), ASA physical status, diagnosis, type of
operation, and airway assessment parameters. In this
study, the airway and respiratory adverse events during
anesthesia were (1) dicult intubation, (2) desaturation,
(3) aspiration, (4) failed intubation and (5) airway injury.
Dicult intubation was dened and classied according
to the Intubation Diculty Scale,
9
a score of > 5 indicates
dicult intubation. Desaturation was dened as having at
least one episode of oxygen saturation (SpO
2
) below 90%
for more than 10 seconds intra-operatively.
10
Aspiration
was dened as the entry of liquid or solid material into
the trachea and/or lungs.
11
An airway injury included
various levels of injury, ranging from a sore throat; lip,
gum, or tongue trauma; palate and tonsil abrasion; to
tooth mobility or tooth extraction. e postponement
of the operation; remaining on endotracheal intubation
to the post anesthesia care unit as a result of an airway
or respiratory event; an unplanned, intensive-care-unit
admission; brain damage; and an in-hospital, anesthesia-
related death were also recorded.
Statistical analysis
Using the estimated prevalence of 3% and a 1% error,
a minimum sample size of 1,118 cases was obtained. To
compensate for a 20% dropout for unforeseen reason, the
size was adjusted to 1,342 cases. Demographic variables
were presented as median and interquartile range for
continuous data, and frequency and percentage for
categorical data. Comparison of the categorical data
were performed using Chi-square or Fisher’s exact test.
Comparison of the continuous data were performed using
T-test or Mann-Whitney U test. e characters associated
with the adverse airway events were identied using
logistic regression. Risk factors with a univariable p–value
of < 0.2 were entered into a multiple logistic regression
model. Crude odds ratio (OR) and adjusted odds ratios,
with their respective 95% condence intervals, were
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180
reported. e data were analyzed using SPSS Statistics
for Windows, version 18 (SPSS Inc., Chicago, IL, USA).
RESULTS
e study included a total of 1,347 obese patients
(777 not pregnant, and 570 pregnant) who had undergone
surgery under general anesthesia using conventional
endotracheal intubation. e median age of the patients
was 37 years old. eir average BMI was 33.1 kg/m
2
; the
majority were in obesity class I under World Health
Organization criteria (66.5%), with about 8.3% being
morbidly obese. As to ASA status, 69.0% were class
II due to obesity or pregnancy (Table 1). The most
frequently performed surgical procedure types were
general surgery; gynecological; head, neck, and breast
surgery; and cesarean sections. Mallampati classication
III or IV was recorded in 30.5% of the patients. e
median mentosternal distance and neck circumference
were 16.0 and 37.0 cm, respectively. Almost all patients
were successfully intubated on the rst attempt by the
rst operator, with the initial technique being applied
without the need for a high liing eort or external
laryngeal pressure. Most patients had a laryngoscopic-
view grade of I or II (66.1% and 28.5%, respectively).
e incidence of anesthesia-related airway and
respiratory complications was observed in 129 patients
(9.6%), with a higher incidence occurring among pregnant
than non-pregnant patients (12.5% vs. 7.5%; p=0.002)
(Table 2). Among them, there were over all 147 airway-
related complications. e most common was a briey
sustained, oxygen desaturation below 90% (5.6%), with
a signicantly greater incidence for the pregnancy group
than the non-pregnancy group (11.6% vs. 1.3%; p<0.001).
e second most common event was airway injury (3.6%),
followed by dicult intubation (1.5%). ere was no
patients experiencing aspiration or a failed intubation.
The characteristics of the patients with airway
and respiratory complications are listed in Table 3.
Compared with patients without any complications,
those with complications had a higher frequency of
Mallampati classications III and IV (39.5.% vs. 28.2%).
Patients with obesity class III had a higher incidence of
complications (15.2%) than those with obesity class I
(7.9%), and II (12.1%). In the multivariate analysis, the
independent risk factors for adverse airway-related events
were determined to be obesity class II (OR=1.63 [1.05–
2.54]; p=0.031), obesity class III (OR=2.25 [1.19–4.25];
p=0.012); pregnancy (OR=1.73 [1.18–2.54]; p=0.005); and
Mallampati classications III–IV (OR= 1.69 [1.16–2.48];
p=0.007). Neck circumference > 42 cm had adjusted
odds ratio of 0.30 [0.09–0.98]; p=0.046).
Only 1 patient remained on endotracheal intubation
upon transferred to the post anesthesia care unit. No
operation postponement, unplanned intensive care unit
admission, brain death, or in hospital mortality occurred.
DISCUSSION
Obesity can have a profound impact on anesthesia-
related morbidity and mortality, particularly the airway
and respiratory system. In the current research, the
incidence of airway and respiratory complications was
9.6% (7.5% for the non-pregnancy group, and 12.5% for
the pregnancy group; p=0.002), which was higher than
the overall incidence of airway-related events in the ai
general population previously reported (0.61%).
12
Dicult intubation and airway injuries occur in
the presence of the excess fatty tissue.
13
Physiological
changes that arise during pregnancy can cause dicult
intubation through both capillary engorgement and
enlarged breasts.
14
Additionally, obesity causes reduced
functional residual capacity; atelectasis; greater work of
breathing; and worsened ventilation-perfusion mismatch.
All of these resultant conditions cause rapid desaturation
in obese patients relative to non-obese patients, and they
are aggravated during pregnancy.
15
In the current research, desaturation was found to
be the most common adverse event among obese patients
(5.6%), and its incidence was signicantly higher among
the obese pregnant patients than the non-pregnant
patients (11.6% vs. 1.3%; p<0.001). A total of 66 out of 78
events (84.6%) in the pregnancy group involved oxygen
desaturation. In 2 studies reporting anesthesia-related
events in ailand
16,17
, the most common adverse event
during cesarean delivery was desaturation (13.8%–17.39%
of all adverse events).
More than half of the patients in our study were
easily intubated (60.3%). The incidence of difficult
intubation was 1.5%, which was higher than the gure
of 0.08% reported for general patients by the Perioperative
Anesthetic Adverse Events in ailand Study.
4
A meta-
analysis has found the incidences of dicult intubation
for obese patients to be 4.2%-4.3%.
5
As for the current
research, the low incidence of dicult intubation relative
to other studies could result from 3 factors. Firstly, the
majority of the patients were of class I obesity status
(which carries a lower risk for dicult intubation than
the higher obesity classes). Secondly, the population in
the current study were female patients; fat in females
tends to be localized to the hips and buttocks, where it
has a negligible eect on intubation diculty. irdly, the
present study was undertaken at tertiary hospitals, where
the anesthesiologists are likely to have had considerable
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TABLE 1. Demographic and airway management data.
Total
Obesity Obesity
Characteristic
(n = 1347)
without pregnancy with pregnancy p-value
(n=777) (n=570)
Age (years) 37.0 (29.0, 51.0) 49.0 (38.0, 59.0) 29.0 (25.0, 34.0) <0.001
Body mass index (kg/m
2
) 33.1 (31.2, 36.1) 33.0 (31.2, 36.1) 33.2 (31.2, 36.0) 0.405
Obesity (kg/m
2
) 0.977
Obesity class I (30–34.9) 896 (66.5) 515 (66.3) 381 (66.8)
Obesity class II (35–39.9) 339 (25.2) 197 (25.4) 142 (24.9)
Obesity class III (≥ 40) 112 (8.3) 65 (8.4) 47 (8.2)
ASA classication <0.001
II 929 (69.0) 599 (77.1) 330 (57.9)
III 414 (30.7) 178 (22.9) 236 (41.4)
IV 4 (0.3) 0 4 (0.7)
Operation <0.001
Cesarean section 570 (42.3) 0 570 (100)
General surgery 237 (17.6) 237 (30.5) 0
Gynecology 175 (13) 175 (22.5) 0
Head-neck and breast 131 (9.7) 131 (16.9) 0
Orthopedic 83 (6.2) 83 (10.7 0
Ear, nose, and throat 52 (3.9) 52 (6.7) 0
Other 99 (7.3) 99 (12.7) 0
Mallampati classication <0.001
I 315 (24.3) 250 (32.2) 65 (12.5)
II 585 (45.2) 296 (38.1) 289 (55.8)
III 305 (23.6) 150 (19.3) 155 (29.9)
IV 90 (6.9) 81 (10.4) 9 (1.7)
Sternomental distance (cm) 16 (15.0, 17.2) 16.0 (15.0, 17.5) 16.0 (15.0, 17.0) 0.038
Neck circumference (cm) 37.0 (36.0, 39.0) 37.5 (36.0, 39.5) 37.0 (35.0, 38.0) <0.001
Intubation data
First attempt successful 1325 (98.4) 756 (97.3) 569 (99.8) <0.001
First operator successful 1334 (99.0) 769 (99.0) 565 (99.1) 0.415
First technique successful 1335 (99.1) 772 (99.4) 563 (98.8) 0.099
Lifting force 0.002
Little effort 891 (66.1) 523 (67.3) 368 (64.6)
Increase lift force 384 (28.5) 201 (25.9) 183 (32.1)
Maximal lift force 72 (5.3) 53 (6.8) 19 (3.3)
No external pressure 1171 (86.9) 688 (88.5) 483 (84.7) 0.040
Cord position: Abduction 1164 (86.4) 660 (84.9) 504 (88.4) 0.066
Laryngoscopic view 0.006
I 891 (66.1) 523 (67.3) 368 (64.6)
II 384 (28.5) 201 (25.9) 183 (32.1)
III 67 (5) 49 (6.3) 18 (3.2)
IV 5 (0.4) 4 (0.5) 1 (0.2)
Data presented as n (%) or median (IQR)
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TABLE 2. Airway and respiratory system adverse events.
TABLE 3. Characteristic of patients with airway and respiratory events.
Adverse events
Total without pregnancy with pregnancy
(n = 1,347) (n = 777) (n = 570)
p-value
Patients experiencing ≥1 adverse event 129 (9.6) 58 (7.5) 71 (12.5) 0.002
Overall adverse events (n) 147 (100) 69 (46.9) 78 (53.1) 0.002
Difcult intubation 0.107
Easy (IDS score = 0) 812 (60.3) 478 (61.5) 334 (58.6)
Slight difculty (IDS score = 1-5) 515 (38.2) 291 (37.5) 224 (39.3)
Major difculty (IDS score >5) 20 (1.5) 8 (1.0) 12 (2.1)
Desaturation 76 (5.6) 10 (1.3) 66 (11.6) < 0.001
Airway injury: Patients with injury 48 (3.6) 48 (6.2) 0 < 0.001
Lip, gum, tongue injury 17 (1.2) 17 (2.2) 0
Sore throat 30 (2.2) 30 (3.9) 0
Tooth injury 3 (0.2) 3 (0.4) 0
Soft palate injury 1 (0.1) 1 (0.1) 0
Data presented as n (%), IDS = Intubation Diculty Scale
Without event With event
Crude OR
Adjusted OR
Factor (n = 1,218; (n = 129;
(95% CI)
p-value
(95% CI)
p-value
90.4%) 9.6%)
Age (years) 37 (29, 52) 35 (29, 49) 1.00 (0.98-1.01) 0.423
Obesity (kg/m
2
)
Obesity class I 825 (67.7) 71 (55.0) 1 1
Obesity class II 298 (24.5) 41 (31.8) 1.60 (1.07-2.40) 0.024 1.63 (1.05-2.54) 0.031
Obesity class III 95 (7.8) 17 (13.2) 2.08 (1.18-3.68) 0.012 2.25 (1.19-4.25) 0.012
ASA classication
II 850 (69.8) 79 (61.2) 1
III–IV 368 (30.2) 50 (38.8) 1.46 (1.01-2.13) 0.047 1.04 (0.67-1.63) 0.853
Pregnancy 499 (41.0) 71 (55.0) 1.76 (1.22-2.54) 0.002 1.73 (1.18-2.54) 0.005
Mallampati Classication
I–II 874 (71.8) 78 (60.5) 1 1
III–IV 344 (28.2) 51 (39.5) 1.66 (1.14-2.42) 0.008 1.69 (1.16–2.48) 0.007
SMD < 12 cm 62 (5.1) 6 (4.7) 0.91 (0.39-2.15) 0.829
NC < 43 cm 78 (6.4) 3 (2.3) 2.87 (0.89-9.24) 0.076 3.33 (1.02-10.81) 0.046
Data presented as n (%) or median (IQR), OR: Odds ratio; 95% CI: 95% condence interval, SMD = sternomental distance, NC = Neck
circumference
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experience in the intubation of obese patients. is is
supported by the absence of failed intubations despite
30.5% of the patients having Mallampati classications
III-IV. e neck circumference < 43 cm was a sensitive
predictor for uneventful airway intubation.
18
In contrast,
the current research found neck circumference < 43 cm
to be risk factor for airway complication, which could
be explained by the complication recorded in the study
were not only dicult airway but the most common
adverse event was desaturation.
Airway injuries were recorded in 3.6% of the cases,
and all were in the non-pregnancy group. Of the injuries,
the most common was a sore throat (2.0%). e absence
of airway injuries in the pregnancy group might have
resulted from the use of smaller-sized endotracheal
tubes in the pregnancy group than in the non-pregnancy
group.
e major consequences of events was very low
(0.1%). e endotracheal tube remained intubated in
only 1 patient, who had undergone a tonsillectomy with
a dicult intubation. However, the sample size in this
study does not mirror the population since the incidence
of fatal complications in the general population during
anesthesia is low (0.004%-0.006%).
e risk factors associated with adverse airway-
related events have previously been identied to be
Mallampati classication III or IV, obstructive sleep
apnea syndrome, reduced mobility of the cervical spine,
limited mouth opening, severe hypoxemia (< 80%), and
coma.
19
Some of those factors were observed in the current
research. From the multivariate analysis conducted for
this study, it was found that a higher obesity class and that
Mallampati classications III–IV were associated with
a higher frequency of adverse airway events. Pregnancy
was also determined to be associated with elevated risks
of adverse airway events, compared with that for obesity
without pregnancy.
is research compared obese female patient and
showed that difference pathophysiology associated
with obesity might contribute to difference adverse
events. Pregnant obese patients were more susceptible to
desaturation. erefore, ensuring optimum pre-oxygenation
are crucial. While non pregnant patient associated with
higher incidence of airway injury, appropriate intubation
plans and prophylaxis technique should be considered.
This study had limitation primarily due to its
retrospective design. Another limitation was that no
records of pre-pregnancy weights were available, not
possible to ascertain whether the pregnant patients were
obese before - or only during - their pregnancy. e
durations might have inuenced the pathophysiology and
consequences of the obesity. Because the present study did
not compare obese and non-obese patients, a comparison
of the incidence of adverse events with those might prove
dicult.
12
Dierences in the intubation management of
the pregnancy and non-pregnancy groups might have
provided relatively easier access for the endotracheal
tube in the pregnancy group. As well, the rapid sequence
induction employed for the pregnant patients might have
increased their susceptibility to rapid desaturation. On
the other hand, as the respective anesthesia techniques
used for the non-pregnant and pregnant patients were
standard, the incidence of adverse events would still
reect what is found in normal anesthesiological practice.
It would be benecial if a future study compared obese
non-pregnant patients and obese pregnant patients in
a controlled design. Further study is also recommended
to improve the anesthesiological procedures for patients
with dierent levels of obesity.
CONCLUSION
e incidence of anesthesia-related airway and
respiratory events was 9.6%, with a signicant higher
incidence in the pregnant than the non-pregnant patients.
Based on the ndings, patients with obesity should be closely
monitored during general anesthesia. Anesthesiologists
should be aware on the most common complication
as identied in this study so as to be well prepared to
minimize undesirable outcomes.
ACKNOWLEDGEMENTS
is research project was supported by Faculty of
Medicine Siriraj Hospital, Mahidol University, Grant
Number (IO) R016231036. e funders had no role
in study design, data collection, and analysis, decision
to publish, or preparation of the manuscript. We are
grateful to Assist. Prof. Dr. Chulaluk Komoltri for her
statistical support as well as Miss Tashita Pinsanthia and
Miss Chanita Janonsoong, research assistants, for their
invaluable help with the paperwork.
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Original Article
SMJ
Nichada Khanngern, M.Sc.*, Woraphat Ratta-apha, M.D., Ph.D.**, Kamonporn Wannarit, M.D., M.Sc.**
*Songkhla Rajanagarindra Psychiatric Hospital, Mueang Songkhla, Songkhla 90000, ailand.
**Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Burnout among Mental Health Professionals in
a Tertiary University Hospital
ABSTRACT
Objective: To examine the level of burnout syndrome, and to investigate the relationship between burnout,
personality traits, coping strategies, and other related personal factors among mental health professionals working
in a tertiary hospital.
Materials and Methods: Online questionnaires were sent to 160 mental health professionals at Siriraj Hospital.
e questionnaire comprised questions collecting demographic data, the Copenhagen Burnout Inventory (ai
version), the Big Five Inventory, and the Coping Scale. e data were analyzed through descriptive statistics, analysis
of variance, Pearson correlation, and stepwise multiple regression.
Results: A total of 121 (75.6%) responses were collected. Of the 121 participants, 41.3% reported high total burnout
levels. However, no dierence in total burnout was found between the dierent mental health professions. e
group aged between 20-29 years demonstrated higher burnout than the others. Individuals with bachelor’s and
master’s degrees showed greater burnout than those with lower than undergraduate degrees. Moreover, individuals
who worked for less than ve years had higher burnout than those in other groups. Furthermore, neuroticism and
avoidance signicantly predicted the burnout syndrome.
Conclusion: In contrast to previous studies in ailand, the results highlighted the risk factors for burnout syndrome
in terms of personal, work-related, and client-related burnout. ese results can strengthen awareness surrounding
mental health conditions, for the eective provision of psychoeducation and psychological interventions.
Keywords: Burnout; coping strategies; health care professionals; personality traits (Siriraj Med J 2022; 74: 185-192)
Corresponding author: Kamonporn Wannarit
E-mail: kamonporn.wan@mahidol.edu
Received 18 January 2022 Revised 7 February 2022 Accepted 7 February 2022
ORCID ID: https://orcid.org/0000-0002-5395-7848
http://dx.doi.org/10.33192/Smj.2022.23
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
INTRODUCTION
Burnout syndrome is a mental health condition
commonly found in present-day society among working
populations, with an annually ascending number. Rising
concern about the adverse impacts of burnout syndrome
has led the World Health Organization (WHO) to include
burnout syndrome in ICD-11, which will be in eect 2022
onwards. Burnout is not dened as a medical disorder,
but rather as an abnormality caused by occupational
phenomena, specically in the workplace environment.
1
Burnout syndrome may arise from chronic stress that
aects an individual’s daily functioning, thus contributing
to mental and physical health problems among those who
fail to cope with stress and consequently seek treatment.
Burnout is a state when work-related chronic stress has
not been handled appropriately, thus, causing physical,
emotional, and mental consequences.
2
Physical symptoms
of burnout are fatigue, lethargy, headache, and insomnia
while mental symptoms include apathy, despair, and
frustration. Some consequences of burnout in healthcare
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186
workers included an impaired work ability and high
turnover intention.
3,4
Borritz, Rugulies, Bjorner, Villadsen,
Mikkelsen, and Kristensen described burnout with an
emphasis on exhaustion with both physical and mental
eects, in which burnout consists of three components:
personal, work-related, and client-related burnout.
5
Burnout can occur due to external factors such as
workplace environment, stressful job, high workload,
and jobs related to interpersonal interactions.
6
However,
researchers have noticed that not everyone in the same
workplace environment would experience similar burnout;
thus, there may be personal factors besides job specic
factors that aect how individuals perceive, respond, and
cope with stress. Past research revealed that the number of
patients a physician attends to per day directly contributes
to their burnout.
7
Further, individuals who employ harm
avoidant strategies to cope with stress experience the
most burnout. Moreover, self-control plays an important
role in burnout prevention, where stress, neuroticism,
negative aectivity, and disengagement coping has a
positive relationship with burnout.
8
Furthermore, in
the same study, negative relationships have been found
between burnout and certain personality traits, including
extraversion, agreeableness, conscientiousness, positive
aectivity, and engagement coping. Additionally, young
married females with a bachelor’s degree tend to have
higher stress.
9
Neuroticism is considered a risk factor
that increases stress levels, while extraversion and active
coping styles are the best at stress prevention. Previous
studies in ailand demonstrated many signicant factors
that were associated with burnout such as work hours
per week, perception of sleeping/rest quality, perception
of having stress from work and family relationships.
10
In
addition, the prevalence of burnout syndrome among
residents in medical school training was 95.4%, with the
highest score revealed to be emotional exhaustion.
11
e
associated factors of sleep quality were environmental
problems in the bedroom while being on duty and
emotional exhaustion.
Burnout syndrome can occur to anyone in any
profession, but it is common in the medical eld.
3,4,12
As medical professionals engage with activities related
to safety, specialistic skills must be properly delivered
so that clients recover eectively, particularly in mental
health services. Previous studies on burnout syndrome
showed that 67% (2 out of 3) mental health professionals
experienced burnout as their profession is a health-
related service that entails dealing with clients’ emotional
problems, mood swings, and expectations of illness
improvement.
13
Despite the increasing number of patients
with mental health problems, the number of mental
health professionals is still limited, making them prone
to experience negative emotions, thus causing chronic
work stress and, eventually, burnout. Overall, burnout
syndrome may aect people at all levels, including service
providers, clients, and organizations as a whole.
14
erefore, this study aimed to examine the inuence
of personal factors on burnout syndrome among mental
health professionals in Siriraj Hospital. e ndings may
aid in the assistance and prevention of burnout syndrome
in both, mental health professionals and patients.
MATERIALS AND METHODS
Participants
In June 2020, the online questionnaires were sent to
all 160 mental health professionals who were working
as a multidisciplinary team to deliver integrated care
for patients with mental health problems and were
employed in three departments at that time, including
the Department of Psychiatry, Division of Child and
Adolescent Psychiatry of the Department of Pediatrics,
and Medical Nursing Department, at Siriraj Hospital,
a tertiary referral university hospital in ailand. e
sample included psychiatrists, psychiatric residents,
registered nurses providing psychiatric nursing, practical
nurses providing psychiatric nursing, psychologists,
social workers, occupational therapists, special educators
(evaluate children’s educational needs and make those
specic needs more accessible to each person with learning
disability), and speech therapists (help children who
have diculties in speaking and communication such as
patients with delayed speech development, intellectual
disability and autistic disorder).
e sample size was calculated by using G power
program version 3.1.9.4. e appropriate sample size
for this research was 109; however, the sample size
was increased by 10% to compensate for incomplete
questionnaires and random responses. Hence, the total
sample size was 121.
MATERIALS AND METHODS
e demographic questionnaire contained six
items recording gender, age, education, marital status,
years of work experience, and number of work hours
per week.
e ai version of the Copenhagen Burnout
Inventory (T-CBT) consists of 19 items separated into
three components: personal burnout, work-related burnout,
and client-related burnout. e overall internal coecient
was .96.
15
T-CBT was measured on a 5 point Likert scale
from 1 (Never/Almost Never) to 5 (Always).
The Big Five Inventory (BFI) consists of 12
Khanngern et al.
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items categorized into ve components: neuroticism,
extraversion, openness to experience, agreeableness, and
conscientiousness. e overall internal consistency was
.80 for 60 items.
16-17
e Coping Scale comprises 39 items that measure
coping strategies in three aspects: problem-focused
coping, social support coping, and avoidance coping,
with scores ranging from 1 (not at all) to 5 (always).
18
e
score tabulation is represented by each coping strategy
according to the scale.
Data collection
is study was approved by the Siriraj Institutional
Review Board (SIRB) of the Faculty of Medicine Siriraj
Hospital (Si 433/2020). Participants who matched the
inclusion criteria were invited to participate using an
online survey (Google form) which could be accessed
through an online link or QR code. Participants were
informed via an online platform with a description of the
study and types of questions that they would be asked.
ey were also allowed to withdraw from the study if
they found it distressful. We ensured them that the
questionnaires did not ask about the information that
could identify their identity.
Statistical analysis
Data were analyzed using SPSS version 18. Descriptive
statistics were used to analyze demographic data and
the main variables (frequency, percentage, mean, and
standard deviation). Independent t-tests and analysis
of variance (ANOVA) were conducted to compare the
means between personal characteristics and burnout
syndrome. Pearson’s correlation coecient was used to
determine the relationship between burnout syndrome,
personality traits, and coping strategies. e predictive
value of personality traits and coping strategies regarding
burnout syndrome of mental health professionals in
Siriraj Hospital were examines using stepwise multiple
regression analysis.
RESULTS
Demographic data of participants
ere were totally 160 mental health professionals,
and the response rate was 75.6% (n=121). e most
participants were nurses (54.5%) followed by psychiatrists
(25.6%) and others (29.8%). eir personal characteristics
are summarized in Table 1. e majority of participants
were female (86%) and the mean age was 34.36 ± 10.6.
Working hours per week ranged between 0 and 72 hours,
with an average of 40.2 hours ± 14.1.
TABLE 1. Demographic data of the sample in this study
(n=121).
Demographics N %
Gender Male 17 14
Female 104 86
Age 20 – 29 56 46.3
30 – 39 36 29.7
40 – 49 11 9.1
50 – 59 18 14.9
Mean ± SD 34.36 ± 10.6
Education Undergraduate Degree 25 20.7
Bachelor’s Degree 55 45.5
Master’s Degree 31 25.6
Doctoral Degree 10 8.3
Marital Status Single 86 71.1
Married 32 26.4
Widow/Divorced 3 2.5
Occupational
Psychiatrists Psychiatrist 11 9.1
Psychiatry Resident 20 16.5
Nurses Registered Nurse 39 32.2
Practical Nurse 27 22.3
Demographics n %
Others Psychologist 13 10.7
Social Worker 5 4.1
Occupational Therapist 2 1.7
Special Educator 3 2.5
Speech Therapist 1 0.8
Year in present < 5 years 50 42.1
working 5 – 10 years 28 23.5
11 – 15 years 11 9.2
16 – 20 years 5 4.2
> 20 years 25 21
Mean ± SD 10.34 ± 10.3
Working hours Less than 40 hours 23 20.2
per week 40 – 50 hours 73 64
More than 50 hours 18 15.8
Mean ± SD 40.2 ± 14.1
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Burnout syndrome among mental professionals
e study found that 41.3% of the participants scored
a high level of total burnout; specically, in subscales,
personal burnout was 46.3%, work-related burnout was
43.8%, and client-related burnout was 27.3%. When
considered by occupation, 51.6% of psychiatrists had a
high mean burnout score (Table 2).
Personal characteristics and burnout syndrome
e 20-29 years-old group showed higher average
and work-related burnout scores than the 40-49 years-
old group and 50-59 years-old group. Additionally, the
average personal burnout score was lower in the 40-49
year-old group than in the 20-29 and 30-39 year-old
groups. e average burnout score, personal-related
burnout, and work-related burnout were greater in
participants with master’s and bachelor’s degrees as
opposed to undergraduate degree holders. Moreover,
participants with less than ve years of work experience
had signicantly higher average scores, work-related
burnout, and client-related burnout than those with
5-10 years and more than 20 years of work experience.
However, no signicant dierence was detected between
total burnout and demographic factors, including gender,
marital status, occupation, and weekly work hours.
Relationship between burnout syndrome, personality
traits and coping strategies
A moderate positive correlation between burnout
syndrome, avoidance, and neuroticism was detected,
while low negative correlations were found between
burnout syndrome and conscientiousness, agreeableness,
and extraversion. Additionally, burnout was negatively
correlated with openness and problem-focused coping
at a negligible level (Table 3).
TABLE 2. Burnout syndrome among mental professionals (n=121).
Occupational
Level
M SD
low high
Psychiatrists Total Burnout 15 (48.4%) 16 (51.6%) 2.52 0.63
(n=31) Personal Burnout 15 (48.4%) 16 (51.6%) 2.52 0.55
Work-related Burnout 15 (48.4%) 16 (51.6%) 2.58 0.77
Client-related Burnout 20 (64.5%) 11 (35.5%) 2.46 0.67
Nurses Total Burnout 41 (62.1%) 25 (37.9%) 2.40 0.69
(n=66) Personal Burnout 37 (56.1%) 29 (43.9%) 2.50 0.68
Work-related Burnout 37 (56.1%) 29 (43.9%) 2.49 0.87
Client-related Burnout 49 (74.2%) 17 (25.8%) 2.21 0.70
Others Total Burnout 15 (62.5%) 9 (37.5%) 2.27 0.71
(n=24) Personal Burnout 13 (54.2%) 11 (45.8%) 2.56 0.85
Work-related Burnout 16 (66.7%) 8 (33.3%) 2.26 0.79
Client-related Burnout 19 (79.2%) 5 (20.8%) 2.01 0.68
Total Total Burnout 71 (58.7%) 50 (41.3%) 2.41 0.68
Personal Burnout 65 (53.7%) 56 (46.3%) 2.52 0.68
Work-related Burnout 68 (56.2%) 53 (43.8%) 2.47 0.83
Client-related Burnout 88 (72.7%) 33 (27.3%) 2.24 0.70
Note: Psychiatrists = psychiatrists and psychiatric residents; nurses = registered nurses and practical nurses; Others = psychologists, social
workers, occupational therapists, special educational needs, and speech therapists. e level of burnout syndrome was classied using a
cut-o point equal to 2.5.
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TABLE 3. Pearson’s correlation coecients between burnout syndrome, personality traits, and coping strategies.
TABLE 4. Stepwise multiple regression analysis for the predictive variable of burnout syndrome.
N E O A C PFC SSS AVO
Total Burnout .648** -.422** -.194* -.428** -.451** -.190* .019 .680**
Personal .562** -.331** -.152 -.351** -.357** .143 .053 .640**
Work-related .631** -.417** -.223* -.409** -.455** -.188* -.001 650**
Client-related .573** -.401** -.141 -.408** -.411** -.184* .008 572**
Abbreviations: N = neuroticism, E = extraversion, O = openness to experience, A = agreeableness, and C = conscientiousness. PFC =
problem-focused coping; SSS = Seek social support; AVO = avoidance
*p < .05; **p < .01
The personal burnout subscale was positively
correlated with avoidance and neuroticism at a moderate
level, but negatively associated with conscientiousness,
agreeableness, and extraversion at a low level.
For the work-related burnout subscale, positive
correlations were found for avoidance and neuroticism, while
low negative correlations were detected for conscientiousness,
extraversion, and agreeableness. Moreover, work-related
burnout was negatively correlated with openness and
problem-focused coping at a negligible level.
Client-related burnout was positively correlated
with neuroticism and avoidance at a moderate level, but
negatively correlated with conscientiousness, agreeableness,
and extraversion at a low level. e relationship with
problem-focused coping was correlated at a negligible
level.
e eect of personality traits and coping strategies
on burnout
Multiple regression analysis was conducted using the
stepwise method. Avoidance and neuroticism (predictive
variables) could explain burnout (dependent variable)
at a signicant level (F=63.82, P <.001). Aer adjusting
the value, avoidance and neuroticism could predict
burnout by 51.1% (adjusted R
2
=.511). When considering
multiple regression at a standardized value, the highest
value fell to avoidance (β= .444), followed by neuroticism
(β =.336) (Table 4).
Model Predictors R R
2
R
2
change
Coefcients
t p
b SE β
1 AVO .680 .462 .462 .783 .077 .680 10.113 <0.001
2 AVO .721 .520 .057 .512 .103 .444 4.959 <0.001
N .373 .099 .336 .3756 <0.001
Adjusted R
2
=.511 F = 63.820 P <0.001
Constant = .145 SE = .207
Abbreviations: N = neuroticism, AVO = avoidance
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190
DISCUSSION
is research illustrated that the overall burnout
syndrome among mental health professionals in Siriraj
Hospital was low. However, 41.3% of mental health
professionals in Siriraj Hospital reported having high
burnout, which corresponds with past research.
9,19,20
In
line with Ogresta and Rusac, no signicant associations
between professions in the mental health eld were
detected. Close investigation of a group with a high
burnout rate showed that 51.6% were psychiatrists, 37.9%
were nurses, and 37.5% belonged to other professions.
20
is is consistent with previous research suggesting
that high burnout was detected among psychiatrists in
ailand, with greater emotional exhaustion (49.3%).
21
When examining burnout components, the results
showed that personal burnout was the highest among
mental health professionals in Siriraj Hospital. is is
congruent with a previous study examining burnout
patterns in Australian midwives.
22
However, our results
contradict research on physicians where work-related
burnout (46.7%) was highest, followed by personal burnout
(44.8%) and client-related burnout (35.1%); while all
sub-scale scores indicated high burnout.
23
Consistently,
although no signicant dierence in burnout level was
detected between dierent mental health professions,
psychiatrists still had the highest risk of burnout compared
to other professions.
24,25
One possible explanation is that
psychiatrists are more involved with work associated
with complex emotional problems alongside high patient
expectations; thus, they are more likely to experience
stress, pressure, and burnout.
Consistent with previous studies, our results showed
no signicant dierence between genders and burnout.
7,26,27
is may be due to the low number of male samples
(14%) in this study. Therefore, samples may not be
representative of gender and burnout score dierences
among mental health professionals. Moreover, there is
a very limited number of studies that have examined
gender and burnout among mental health professionals
using the Copenhagen Burnout Inventory (CBI). e
current ndings are supported by Erik Erikson’s theory
on psychosocial development, where the age between 21
and 40 years is a period when individuals hold greater
responsibilities, and thus are more prone to stress and
burnout. Additionally, previous research reported
similar results where older sta had lower scores for
all burnout components than younger stas.
24
Older
ages seemed to signify lower burnout, particularly in
personal and work-related burnout.
23,28
Similarly, younger
age was found to be correlated with high emotional
exhaustion.
19
Moreover, there were dierences in the burnout
average scores and burnout component scores across
dierent education levels. Samples with education of
lower than undergraduate degrees had lower personal
and work-related burnout than those with bachelor’s and
master’s degrees. is is in line with a Taiwanese research
demonstrating that a graduate school group had higher
average burnout than college group.
24
Furthermore,
a research also showed that master’s-level education
corresponded with greater burnout scores.
6
Taking the
above research into consideration, this suggested that
bachelor’s and master’s degrees require a more specied
level of training, expertise, and work experiences in mental
health services, and thus, are more prone to experiencing
burnout. Strikingly, the dierences in burnout scores
were not signicant in those with a doctorate level of
education. is may be due to the collected experiences
related to work that had already been adjusted and
managed.
Concerning marital status, no signicant dierence
between being single, married, or divorced and experiencing
burnout was detected, which is consistent with other
studies.
7,28
e uneven number of single samples (71.1%)
and married samples (26.4%) might explain the above
nding. erefore, future research conducted with mental
health professionals should further investigate whether
there are dierences in burnout scores based on marital
status.
Moreover, our study showed that individuals who
had worked for less than ve years had signicantly
higher average scores. Although research on years of
employment using CBI is very limited, one study found
an association between longer working hours and lower
personal and work-related burnout.
23
Furthermore, a study
revealed that greater emotional exhaustion correlated
with fewer years of work experience among mental
health providers.
29
Furthermore, we found that only neuroticism and
avoidance could predict higher burnout, similar to past
research showing that neuroticism was a risk factor for
workplace stress.
9
Similarly, openness, extraversion,
agreeableness, conscientiousness, and active coping styles
could be protective factors against stress.
9
Correspondingly,
neuroticism was one of the main factors that could
predict burnout, whereas social support and self-blame
aected personal and work-related burnout.
30
Additionally,
behavioral disengagement inuenced work-related and
client-related burnout.
30
Furthermore, factors such as
gender, job stress, weekly work hours, positive aectivity,
negative aectivity, extraversion, conscientiousness, and
problem-focused disengagement could predict burnout.
8
Khanngern et al.
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Study limitations and suggestions for future research
is research was a cross-sectional design which
explained factors related to work exhaustion in mental
health professionals in a certain period. erefore, future
research may include a continual burnout monitoring and
evaluating with interventions such as a group therapy,
workplace health promotion programs or stress management
training to assess whether there are changes in burnout
scores aer participating in the interventions or not.
Moreover, our research employed a self-report in the
data collection method, a sort of an online questionnaire,
in which straightforward responses from participants
might not be provided, and the evaluation was merely
based on their point of views; subsequently, the result
accuracy was diverse. In addition, e online survey may
not be able to reach participants who do not use the social
network platforms or those who nd this type of survey
bothersome. ere might also be a potential confounding
factor like the COVID-19 pandemic situation which
could have emotional impacts on health care workers;
however, this issue was not included in our questionnaires
since we would like to investigate participants’ overall
perceptions on themselves, work and clients in the rst
place so further studies to explore the COVID-19-related
burnout should be done. Furthermore, for the reason
that burnout is merely a syndrome without specic
diagnosis criteria while an assessment tool is simply a
questionnaire, further research may include responses
from participant’s associate people, for example, superiors,
colleagues and intimate friends or, on the contrary,
an additional interview with the participant. Lastly, it
is feasible to establish more precise diagnosis criteria
for burnout as the syndrome threatens mental health
of working age people. Another limitation is that our
samples only comprised mental health professionals,
and thus the ndings cannot be generalized to other
populations. erefore, it might be useful for future
studies to examine the eect of other positive factors
and dierent workplace settings (such as general and
psychiatric hospitals) on burnout among mental health
professionals. In addition, future studies should examine
other positive factors (such as sleep factors, exercise,
and job description) that may be useful in preventing or
reducing work-related exhaustion among mental health
professionals.
CONCLUSION
e present research is one of the rst studies in
ailand that examined factors related to burnout in
mental health professionals. Our results highlighted
personal, work-related and client-related factors that
could predict a high level of burnout. ese results could
be used to inform future research and aid prevention
schemes for more specic work-related exhaustion among
the ai population.
ACKNOWLEDGMENTS
is research was funded by the Siriraj Graduate
Scholarship under the Faculty of Medicine Siriraj Hospital,
Mahidol University. e authors would like to express
their gratitude to the participants from the Department
of Psychiatry, the Department of Pediatrics (Division
of Child and Adolescent Psychiatry), and medical and
psychiatric nursing.
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Jarurin Pitanupong, M.D.*, Apinan Karakate, M.D.*, Laddaporn Tepsuan, M.D.**, Grittin Sritrangnant, M.D.***
*Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, ailand, **Songkhla Hospital, Mueang
Songkhla District, Songkhla, 90110, ailand, ***Songkhla Rajanagarindra Psychiatric Hospital, Mueang Songkhla District, Songkhla, 90110, ailand.
Attitudes Toward Long-Acting Injectable
Antipsychotics among Schizophrenia Patients in
Southern Thailand: A Multihospital-Based Cross-
Sectional Survey
ABSTRACT
Objective: To identify the attitudes toward long-acting injectable antipsychotics (LAIs) among schizophrenia at
three psychiatric outpatient clinics in Southern ailand from February to April 2021.
Materials and Methods: A study was conducted at three psychiatric outpatient clinics. All patients, who met the
criteria of having schizophrenia based on ICD-10 criteria, aged 20-60 years were included. e questionnaires
utilized were:1) Demographic information, 2) Prole of schizophrenia disorder, and 3) Attitude, knowledge, and
satisfaction towards LAIs. All data were analyzed using descriptive statistics.
Results: ere were 259 participants who completed the questionnaires. From the participants, 39% had a history
of being treated with LAIs. A quarter of them felt LAIs made them feel stigmatized (26.3%), that they lost autonomy
(24.7%), and embarrassed (16.6%). e reasons for refusing to receive LAIs were not fear of needles or pain at the
injection site (49%), but rather that LAIs had more adverse eects than oral medications (47.9%). Half of them
(51.8%) knew that they must continue to use LAIs, even though their symptoms had improved as LAIs played an
important role by improving their symptoms (68.8%), and preventing relapse (51.8%). ey were satised about
having been involved in the decision making of using LAIs for their treatment (63.6%), having information on the
risk-benets from LAIs provided to them (72.3%), and the cost of LAIs (75.2%).
Conclusion: Before deciding to prescribe LAIs, we should ensure that all patients receive information about the risks,
and benets of LAIs, boosting acceptance for this formulation and mitigating concerns about patient autonomy
reduction and stigmatization.
Keywords: Antipsychotics; attitude; knowledge; long-acting injectable; schizophrenia (Siriraj Med J 2022; 74: 193-201)
Corresponding author: Jarurin Pitanupong
E-mail: pjarurin@medicine.psu.ac.th
Received 2 October 2021 Revised 24 October 2021 Accepted 9 February 2022
ORCID: https://orcid.org/0000-0001-9312-9775
http://dx.doi.org/10.33192/Smj.2022.24
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
INTRODUCTION
Schizophrenia is a mental illness aecting about
0.7% of adults globally.
1
It is a long-term chronic disease,
has residual symptoms and functional impairment.
erefore, using integrated treatment strategies; in terms
of medication, psychosocial interventions,
2
including
psychiatric rehabilitation, and decreasing stigmatization
for schizophrenia are essential to both lessen the burden
for family members and improve patients’ quality of life.
3-5
In the past, the core concept of schizophrenia
management was a combination of ensuring patients
gain insight, medical treatment, and the teaching of
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essential community-living skills, so as to integrate
patients back into society.
6
Moreover, occupations and
employment can reduce stigma and promote quality of
life.
4-6
Although, some schizophrenia patients gain insight
well, the truth of this illness makes them suer from
stigmatization. Because of this, patients usually deny or
refuse medication, which in turn makes them relapse.
4
In addition, the relapse rate aer the rst episode of
schizophrenia (FES) is high, oen due to non-adherence
with medication.
7
Presently, antipsychotic medications play an eective
role in schizophrenia symptom control and relapse
prevention;
1,7
however, non-adherence to medication is still
a major problem in the treatment of schizophrenia,
8
and
is one of the most important predictors for relapse rates
of more than 80% within 5 years.
9
Although, treatment
response is better in FES than in multi-episode patients,
10
and within one-year response rates of about 87%, relapse
rates are still high;
9
therefore, long-acting injectable
antipsychotics (LAIs) have a role for promoting adherence
to medication
1,7
in schizophrenia patients who having
poor drug compliance.
11,12
However, in many countries,
fewer than 20% of schizophrenia patients receive LAIs.
The rate of LAIs usage among schizophrenia at the
psychiatry department of the Faculty of Medicine, Prince
of Songkla University, in 2018, was 12.7%.
13
e reason
for this low prescribing rate of LAIs may be the patient
attitudes and reluctance to accept depot treatment.
10
Despite good clinical evidence, depot treatment rates
are still low across countries,
7
and depot antipsychotics
are only seldom prescribed for patients with FES.
12
Currently, some systematic review studies have reported
that patients have generally positive attitudes toward LAIs
compared with oral medication.
14-17
Additionally, it is
generally considered that providing adequate information
to patients and having a therapeutic relationship with the
psychiatrist, which includes a shared decision-making
processes, can promote a positive image to depot injections.
7
Although, some previously reviewed literature found that
LAIs are associated with a better outcome, as a reduction
of re-hospitalization and better adherence, schizophrenia
patients are particularly fearful of being stripped of their
autonomy when treated with LAIs, and that the injections
may be painful. Moreover, the lack of adequate information
given to patients may be a reection of their negative
attitudes towards LAIs. Providing adequate information
on LAIs can help promote positive attitudes, especially
as LAIs don’t particularly increase the risk of side-eects
such movement disorder.
11
erefore, to enhance the use
of LAIs, psychiatrists could improve their practice, by
providing patients with more information regarding the
dierent forms of available treatment during the early
stages of this illness.
12
In addition, the availability of the
deltoid route of administration would oer increased
choices in LAIs administration, and may be perceived
as more respectful and less socially embarrassing.
16
e
aim of this study was to identify the prevalence of LAIs
usage, attitudes, and satisfaction toward LAIs among
schizophrenia outpatients, as this may provide useful,
basic knowledge for enhancing the use of LAIs.
MATERIALS AND METHODS
Aer being approved by the Ethics Committee of the
Faculty of Medicine, Prince of Songkla University (REC:
63-521-3-4) and Rajanagarindra Psychiatric Hospital
(SKPH.IRB.COA 1/2021), this cross-sectional study
was conducted at the three listed psychiatric outpatient
clinics: Songklanagarind Hospital, which is an 800-bed
university hospital serving as a tertiary referral center in
Southern ailand, Songkla Hospital, which is a 508-bed
provincial hospital, and Songkhla Rajanagarindra Psychiatric
Hospital, which is a 200-bed psychiatric hospital serving as
a referral center in Southern ailand. All schizophrenia
outpatients, who had an appointment and were followed
up at three psychiatric outpatient clinics; from February
to April 2021, were invited to participate in the study. To
be included, they had to meet the criteria of being adult
schizophrenia outpatients by their psychiatrists and their
case les were selected in the medical register, based on
the following criteria: ICD-10 code F20.0-F20.9, aged
20-60 years, agreeing to participate in the study, able to
understand and use the ai language well and to complete
all of the questionnaires. Patients who had more than
one psychiatric diagnosis or comorbidity, did not wish
to participate or decided to withdraw from the study
and/or lacked mental capacity (judged by an outpatient
psychiatric nurse) to complete all of the questionnaires,
were excluded. We tried to calculate a sample size to
determine the minimum number of subjects to enroll
in our study. Following a literature review we could not
nd any information from studies about the prevalence of
patient attitudes in regards to long-acting antipsychotic
injections, in ailand. erefore, we simply identied
all patients with an appointment and we followed them
up during that period.
Data collection
All of the eligible schizophrenia outpatients were
approached by the research assistant for recruitment,
and were provided with an information sheet; which
delineated the rationale for the study and the allotted time
to complete the survey. All eligible participants had at
Pitanupong et al.
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Original Article
SMJ
least 20-30 minutes to consider whether to participate in
the study or not. Participants willing to collaborate were
invited to a private location to complete the questionnaire,
and were informed that they could stop at any time if
they felt distressed, uneasy or were unwilling to perform
any further. All participants were allowed to nish and
return the questionnaires immediately, or at a later time.
Participants could submit the questionnaires via two
options: by dropping them in a secure box at the front
of the clinic upon leaving, or by returning them later by
placing them in a secure box located at the Psychiatry
Department and/or Unit. erefore, protecting respondent
condentiality.
Instruments
1) Personal and demographic information: inquiries
around areas related to age, gender, marital status, religion,
education, income, occupation, and history of physical
illnesses.
2) Prole of schizophrenia disorder: the number
of hospital admissions, duration of illness, and history
of injection experience.
3) Self-rating questionnaires to evaluate attitude,
knowledge, and satisfaction toward LAIs: 4 tools. e
Drug Attitude Inventory (DAI-30) containing 30 questions
concerning the aspects of the patient’s perceptions
and experiences of treatment.
18
e Satisfaction With
Antipsychotic Medication scale (SWAM scale) containing 33
questions evaluating the patient’s beliefs, patient’s concerns,
and other aspects of treatment; including social support
and information regarding the patients.
19
A questionnaire
from a study in Nigeria;
20
and a questionnaire from a
study in Croatia.
21
Our tool consisted of 15 questions,
in 3 domains: attitude, knowledge, and satisfaction.
e response to each question ranged from disagree;
neutral; agree, and strongly agree. is questionnaire’s
modication and content validity was reviewed by 5
psychiatrists; the content validity (CVI) score was 0.8.
A pilot study was conducted with 20 volunteers; thus,
Cronbach’s alpha was 0.8.
Statistical analysis
Descriptive statistics; such as frequency, percentage,
proportion, mean, and standard deviation (SD) were
calculated. Chi-square tests were used in regards to the
comparison of ‘knowledge’, ‘attitude of schizophrenia
patients who received LAIs’ and ‘no experience of receiving
LAIs’. e analyses were conducted using R version 3.4.1
(R Foundation for Statistical Computing). Statistical
signicance was dened as a p-value of less than 0.05.
RESULTS
Demographic characteristics
From February to April 2021, 262 schizophrenia
patients attended all three Psychiatric Clinics, and 259 of
them agreed to collaborate and complete the questionnaires.
e response rate was 98.9%. e majority of participants
were male (62.5%), Buddhist (74.9%), and unmarried
(82.2%). Overall, their mean age was 41.2 ± 10.9 years,
and their median income (IQR) was 9,000 (4,000-15,000)
baht, per month. Fiy-three participants (20.5%) reported
having history of physical illness (Table 1). e most
common physical illness were diabetes mellitus (32.7%),
hypertension (25%), and dyslipidemia (21.2%). No
statistically signicant dierence in demographic data
was detected between the participants, according to the
three hospitals.
Prole of schizophrenia disorder
For all the participants, their mean (S.D) duration
of illness was 139.8 (104.5) months. e majority of
participants (58.3%) reported having a history of inpatient
admission; with the mean (S.D) number of admissions
at 2.6 (2.4). No statistically signicant dierence in
the prole of schizophrenia was observed between the
participants, according to all three hospitals. 101 (39%)
participants had a history of being treated with LAIs
(Table 2), with the most common LAIs received being
conventional LAIs; there were only 5 (4.9%) participants
who had received novel LAIs.
However, a statistically signicant dierence in the
history of psychiatric inpatient admission was detected
between the participants who had received and those who
had no experience of receiving LAIs. Of all participants
who received LAIs, 75% of them had history of psychiatric
inpatient admission; whereas, 52.6% of participants who
had no experience of receiving LAIs had a history of
psychiatric inpatient admission (Table 3).
Knowledge and attitude toward long-acting injectable
antipsychotics
In regards to knowledge and attitude toward LAIs,
the majority of participants knew that LAIs played an
important role and improved their symptoms (68.8%),
and that they must continue to use LAIs even though
their mental health was improved (51.8%). ey also
knew that LAIs prevented symptom relapse (51.8%).
However, 64 (24.7%) participants felt that LAIs made
them feel a loss of autonomy, and 68 (26.3%) participants
reported feeling stigmatized due to LAIs. Only 98 (37.8%)
participants felt that LAIs were more convenient than oral
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TABLE 1. Demographic characteristics (N = 259).
TABLE 2. Prole of schizophrenia disorder (N = 259).
Demographic characteristics Number (%)
Gender
Male 162 (62.5)
Female 97 (37.5)
Religion
Buddhism 194 (74.9)
Islam/Christianity/Other 62 (23.9)
No answer 3 (1.2)
Marital Status
Single/Divorced 213 (82.2)
Married 39 (15.1)
No answer 7 (2.7)
Education level
Secondary school/below 99 (38.2)
High school/diploma 92 (35.5)
Bachelor’s degree or above 64 (24.7)
No answer 4 (1.5)
Occupation
Employee/Agriculture 68 (26.3)
Government employees ofcer/state Enterprise ofcer/Private company employee 32 (12.4)
Merchant/Personal business 37 (14.3)
Unemployed/Student 118 (45.6)
No answer 4 (1.5)
Having income
No 127 (49.0)
Yes 127 (49.0)
No answer 5 (1.9)
Having physical illness
No 199 (76.8)
Yes 53 (20.5)
No answer 7 (2.7)
Schizophreniaprole Number(%)
Having history of inpatient admission
No 97 (37.5)
Yes 151 (58.3)
Not answer 11 (4.2)
Having history of being treated with injectable antipsychotic agents
No 89 (34.4)
Yes 170 (65.6)
Type of injectable antipsychotic agents
Short-acting injectable antipsychotics 69 (26.6)
Long-acting injectable antipsychotics 53 (20.5)
Both 48 (18.5)
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TABLE 3. e demographic characteristics comparison between a group of being treated with LAIs or not.
History of being treated with LAIs
Chi2
Demographic characteristics Total Yes No
P-value
(n=259) (n=101) (n=158)
Gender 0.054
Male 162 (62.5) 71 (70.3) 91 (57.6)
Female 97 (37.5) 30 (29.7) 67 (42.4)
Education level 0.006
Secondary school/below 99 (38.8) 49 (50.0) 50 (31.8)
High school/diploma 92 (36.1) 33 (33.7) 59 (37.6)
Bachelor’s degree or above 64 (25.1) 16 (16.3) 48 (30.6)
Occupation 0.78
Employee/Agriculture 68 (26.7) 29 (29.6) 39 (24.8)
Government employees ofcer/ 32 (12.5) 12 (12.2) 20 (12.7)
state Enterprise ofcer/
Private company employee
Merchant/Personal business 37 (14.5) 12 (12.2) 25 (15.9)
Unemployed/ Student 118 (46.3) 45 (45.9) 73 (46.5)
Religion 0.024
Buddhism 194 (75.8) 67 (67.7) 127 (80.9)
Islam/Christianity/Other 62 (24.2) 32 (32.3) 30 (19.1)
Marital Status 0.095
Single/ Divorced 213 (84.5) 88 (89.8) 125 (81.2)
Married 39 (15.5) 10 (10.2) 29 (18.8)
Having income 0.302
No 127 (50.0) 53 (54.6) 74 (47.1)
Yes 127 (50.0) 44 (45.4) 83 (52.9)
Having physical illness 0.637
No 199 (79.0) 77 (81.1) 122 (77.7)
Yes 53 (21.0) 18 (18.9) 35 (22.3)
Having history of admission < 0.001
No 97 (39.1) 23 (25.0) 74 (47.4)
Yes 151 (60.9) 69 (75.0) 82 (52.6)
medications. However, more than half of the participants
(61.8%) felt that their families accepted LAIs treatments.
e reasons for refusing to receive LAIs did not appear
to be due to a fear of needles or pain at the injection site
(49%), but due to a belief that LAIs had more adverse
eects than oral medications (47.9%) (Fig 1).
From a comparison between 101 participants who
had experienced receiving LAIs and 158 participants
who had no experience in receiving LAIs, statistically
signicant dierences in knowledge, and attitude were
identied between these two groups. In regards to the
knowledge of LAIs, participants who had experience in
receiving LAIs had higher percentages of knowledge in
connection to LAIs improving their symptoms (79.6%)
and that they must continuously use them even though
their mental health had improved (65.3%) than the
participants who had no experience of receiving LAIs who
had percentages of knowledge at 63.5%, 40.8%, respectively.
Regarding attitude toward LAIs, the participants who
had an experience of receiving LAIs had less percentage
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198
of negative attitude and of feeling embarrassed and
stigmatized than the participants who had no experience
of receiving LAIs. Additionally, they were more likely
to have families accepting LAIs treatment (78.2%) than
the residual group who had no experience of receiving
LAIs (51.3%) (Fig 2).
Satisfaction toward long-acting injectable antipsychotics
Of all 101 schizophrenia patients who had an
experience of receiving LAIs, the majority of them (63.6%)
thought that they were involved in the decision or choice
of LAIs treatments. Despite this, they were satised with
the provided information of the risk-benets from LAIs,
type, and cost of LAIs that they received (72.3%, 64.3%,
and 75.2% respectively). Regarding LAIs causing any
adverse eects, 41 (40.6%) participants agreed that LAIs
caused adverse eect, whereas, 40 (39.6%) participants
disagreed with LAIs causing any adverse eects (Fig 3).
Fig 1. Knowledge and attitudes toward LAIs (N = 259).
Fig 2. Comparison of knowledge, attitude of schizophrenia patients who received LAIs (N=101) or no experience of receiving LAIs (N = 158).
*p-value<0.05, **p-value<0.001
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DISCUSSION
In clinical practice, the advantages and disadvantages
of LAIs are still controversial. A better understanding of
attitudes toward LAIs would likely enhance their acceptance
and use in patients with schizophrenia. e objective of
this study was to evaluate the attitudes of schizophrenia
patients in regards to LAIs. In our study, there were 101
(39%) participants receiving LAIs. Furthermore, patients
who received LAIs had favorable attitudes about LAIs
in regards to: being involved in the decision or choice of
treatment, family acceptance, ecacy, relapse prevention,
type, and cost. However, participants who were receiving
LAIs had a higher frequency of past psychiatric inpatient
admission than the participants who had no experience
of receiving LAIs.
According to the number of patients who received
LAIs, this survey found a higher rate than the study in
Japan
22
that found twenty-nine (18.2%) participants
were on LAIs. However, another study from Australia
showed that more than half of schizophrenia patients were
receiving LAIs prescriptions.
23
e reason for the dierent
rates of LAIs prescription might be the same as shown in
previous studies; that LAIs prescriptions by psychiatrists
and the patients’ preference for LAIs depended on their
preference of antipsychotic treatment in terms of their
attitude and experience with the formulation.
10
Some
psychiatrists frequently assume that patients with a FES
would not recognize depot medication, and that depots
were mostly suitable for chronic patients.
8
However, a
recent study from several European countries found
physicians willing to accept the usage of LAIs, and that
having a positive attitude toward LAIs could inuence
the acceptance and usage of them to treat patients with
schizophrenia.
24
is study found that most patients had favorable
attitudes towards LAIs, in regards to their cost. e
reason might be that most prescriptions of LAIs in this
study were of the conventional type, which incurred less
economic burden to the patient and their family than a
novel type.
Attitudes toward LAIs in this study identified
that, the participants had favorable attitudes toward
LAIs concerning ecacy because LAIs improved their
symptoms (68.8%), and assisted them to prevent relapse
(51.8%). ey did not fear needles, being injected, or
pain (49%). is nding was the same as a prior study
that identied that the expectation of relapse prevention
was signicantly related with patients’ acceptance of
LAIs.
22
Moreover, some studies revealed that patients
receiving LAIs prescribing rated their current medication
useful and helpful, even among patients lacking insight.
23
Choosing the appropriateness of
LAIs treatment, providing
information of risks and benets, and side eects from
LAIs to patients might enhance the recognition and
acceptance of this formulation, among schizophrenia
patients. Besides, the discrepancy between the psychiatrists’
and patients’ opinions regarding the suitability of LAIs
treatment was signicantly associated with symptom
severity, expectations about relapse prevention, beliefs
that LAIs are painful, and LAIs providing a reduced
range of antipsychotic choices.
22
Moreover, mental health professionals are required
to have a range of competencies to assist patients handle
their medication eectively; and when clinicians and
patients make a joint decision then they are both more
likely to adhere to the treatment plan. Good practice in
the administration of LAIs that points on where and when
they should be given and administration techniques is
Fig 3. Satisfaction of schizophrenia patient toward LAIs (N = 101).
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200
therefore very important. Clinician ability for talking
with patients concerning their medication, including the
exchange of data, monitoring the eects of medication,
and planning choices in advance about treatment, in
the event of a crisis should also be scrutinized.
25
is
study revealed that the patients felt LAIs were not more
convenient than oral antipsychotics (42.1%) and also had
more adverse eects than oral antipsychotics (47.9%).
Concerning autonomy and stigmatization, our
results indicated that even though more than half of the
participants (63.6%) were involved in the choice of LAIs
and had family acceptance for LAIs treatment (61.8%);
a quarter of them (24.7%) regarded LAIs treatment as
something that was limiting their autonomy, caused
them to be stigmatized (26.3%), and made them feel
embarrassed when seen by others to be taking LAIs
(16.6%). A previous study showed that patients, more
than psychiatrists, felt that LAIs restricted patient
autonomy.
15
erefore, psychiatrists and the patients’
caretakers should be concerned about these ethical issues;
especially regarding coercion. In addition, minimizing
the patients’ feelings of coercion by providing complete
information to all patients in a therapeutic relationship,
which includes a shared decision-making processes, could
also reduce the negative image, being embarrassed by,
and the stigmatization attached to depots.
8,17
Finally, as the destinations of schizophrenia treatment
are to manage symptoms, prevent relapse, and enhance
both functioning and quality of life, the recommendations
should include: 1) adopting a patient-centered approach;
2) selecting medications based on a balanced risk-benet
assessment, including a point on addressing symptoms
related to the agents; 3) considering LAIs as an alternative
to oral medications, as they offer benefits; such as,
uncovering poor adherence, and reduced relapse risk;
and 4) implementing psychosocial interventions that
have been proven to be eective in enhancing adherence
and overall outcomes.
26
Strengths and limitations
is study had both strengths and limitations worth
mentioning. To our knowledge, this is the only study on
this topic conducted in Southern ailand over the past
decade. However, this study had some limitations as it
was a cross-sectional survey and utilized self-administered
questionnaires; therefore, some misunderstanding
regarding the intended meaning of the questions may
have taken place. Another drawback was that our data
was quantitative, the sample size, and that participants
were only schizophrenia outpatients in lower, Southern
ailand. Hence, its ndings may not fairly represent
the situation of schizophrenia patients throughout the
country. Henceforward, studies are recommended to
enclose a larger number of schizophrenia patients, with
age group and gender dierences from other hospitals
in ailand. erefore, a more comprehensive, multi-
centered research study should be performed. Moreover,
other studies should retain more qualitative or in-depth
methods.
CONCLUSION
Before deciding to prescribe LAIs formulations, the
schizophrenia patient’s attitude, and knowledge needs
to be considered. is is particularly relevant as the
care for schizophrenia is focused on symptom control,
relapse prevention, and optimizing their quality of life.
Clinicians should ensure that patients receive access to
information such as the risks and benets of treatment
with LAIs, helping to improve the acceptance and use
of such formulations and addressing any concerns that
LAIs treatment is limiting their autonomy or causing
stigmatization.
ACKNOWLEDGMENTS
All authors would like to acknowledge the participants
for their willingness to oer information and the nursing
sta of the psychiatric clinic for providing space at the clinic
as well as facilitating a number of operational aspects in
the study. We would like to also acknowledge Associate
Professor Hutcha Sriplung, and the research assistants;
Nisan Werachattawan and Kruewan Jongborwanwiwat, for
their assistance. e English of this article was proofread/
edited by the Oce of International Aairs, Faculty of
Medicine, Prince of Songkla University.
Disclosure statement: e authors declare no conict
of interest.
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Robyn G. Langham, MBBS, Ph.D.*, Kamyar Kalantar-Zadeh, M.D., MPH, Ph.D.**, Ann Bonner, RN, Ph.D.***,
Alessandro Balducci, M.D.****, Li-Li Hsiao, M.D., Ph.D.*****, Latha A. Kumaraswami, BA.******, Paul Lan,
MS.*******,
Vassilios Liakopoulos, M.D., Ph.D.********, Gamal Saadi, M.D.*********, Ekamol Tantisattamo,
M.D., MPH**,
Ifeoma Ulasi, M.D.**********, Siu-Fai Lui, M.D.*********** for the World Kidney Day Joint
Steering Committee************
*St. Vincent’s Hospital, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; **Division of Nephrology, Hypertension
and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA;***School
of Nursing and Midwifery, Grith University, Southport, Queensland, Australia; ****Italian Kidney Foundation, Rome, Italy; *****Brigham
and Women’s Hospital, Renal Division, Department of Medicine, Boston, Massachusetts, USA; ******Tamilnad Kidney Research (TANKER)
Foundation, e International Federation of Kidney Foundations - World Kidney Alliance (IFKF - WKA), Chennai, India; ******International
Society of Nephrology, Brussels, Belgium; ********Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital,
Aristotle University of essaloniki, essaloniki, Greece; *********Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo
University, Giza, Egypt; **********Renal Unit, Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria;
***********International Federation of Kidney Foundations – World Kidney Alliance, e Jockey Club School of Public Health and Primary Care,
e Chinese University of Hong Kong, Hong Kong, China; ************e World Kidney Day Joint Steering Committee is listed in the Appendix.
Kidney Health for all: Bridging the Gap in Kidney
Health Education and Literacy
ABSTRACT
e high burden of kidney disease, global disparities in kidney care, and poor outcomes of kidney failure bring
a concomitant growing burden to persons aected, their families, and carers, and the community at large. Health
literacy is the degree to which persons and organizations have or equitably enable individuals to have the ability
to nd, understand, and use information and services to make informed health-related decisions and actions for
themselves and others. Rather than viewing health literacy as a patient decit, improving health literacy largely
rests with health care providers communicating and educating eectively in codesigned partnership with those
with kidney disease. For kidney policy makers, health literacy provides the imperative to shi organizations to
a culture that places the person at the center of health care. e growing capability of and access to technology
provides new opportunities to enhance education and awareness of kidney disease for all stakeholders. Advances
in telecommunication, including social media platforms, can be leveraged to enhance persons’ and providers’
education; e World Kidney Day declares 2022 as the year of “Kidney Health for All” to promote global teamwork
in advancing strategies in bridging the gap in kidney health education and literacy. Kidney organizations should
work toward shiing the patient-decit health literacy narrative to that of being the responsibility of health care
providers and health policy makers. By engaging in and supporting kidney health–centered policy making, community
health planning, and health literacy approaches for all, the kidney communities strive to prevent kidney diseases
and enable living well with kidney disease.
Keywords: Educational gap; empowerment; health literacy; health policy; information technology; kidney health;
partnership; prevention; social media (Siriraj Med J 2022; 74: 202-210)
Corresponding author: Robyn G. Langham
E-mail: rlangham@unimelb.edu.au
Received 11 February 2022 Revised 11 February 2022 Accepted 14 February 2022
ORCID: https://orcid.org/0000-0002-2735-0161
http://dx.doi.org/10.33192/Smj.2022.25
Reprints: Ekamol Tantisattamo
E-mail: etantisa@hs.uci.edu
ORCID: https://orcid.org/0000-0003-0883-6892
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
Langham et al.
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Review Article
SMJ
Given the high burden of kidney disease and global
disparities related to kidney care, in carrying forward
our mission of advocating Kidney Health for All, the
challenging issue of bridging the well-identied gap in
the global understanding of kidney disease and its health
literacy is the theme for World Kidney Day (WKD) 2022.
Health literacy is dened as the degree to which persons
and organizations have-or equitably enable individuals to
have-the ability to nd, understand, and use information
and services to inform health-related decisions and
actions for themselves and others.
1
Not only is there is
growing recognition of the role that health literacy has
in determining outcomes for persons aected by kidney
disease and the community in general, but there is an
emergent imperative for policy makers worldwide to
be informed and cognizant of opportunities and real
measurable outcomes that can be achieved through
kidney-specic preventative strategies.
e global community of people with kidney disease
Most people are not aware of what kidneys are for
or even where their kidneys are. For those aicted by
disease and the subsequent eects on overall health, an
eective health care provider communication is required
to support individuals to be able to understand what to
do, to make decisions, and to take action. Health literacy
involves more than functional abilities of an individual;
it is also the cognitive and social skills needed to gain
access to, understand, and use information to manage
health condition.
2
It is also contextual
3
in that as health
needs change, so too does the level of understanding
and ability to problem solve alter. Health literacy is,
therefore, an interaction between individuals, health
care providers, and health policy makers.
4
is why the
imperatives around health literacy are now recognized
as indicators for the quality of local and national health
care systems and health care professionals within it.
5
For
Chronic Kidney Disease (CKD), as the disease progresses
alongside other health changes and increasing treatment
complexities, it becomes more dicult for individuals to
manage.
6
Promoted in health policy for around a decade
involving care partnerships between health-centered
policy, community health planning, and health literacy,
7
current approaches need to be shied forward (Table1).
Assessing health literacy necessitates the use of
appropriate multidimensional patient-reported measures,
such as the World Health Organization–recommended
Health Literacy Questionnaire (available in over 30
languages) rather than tools measuring only functional
health literacy (e.g., Rapid Estimate of Adult Literacy in
Medicine or Short Test of Functional Health Literacy
in Adults).
8
It is therefore not surprising that studies
of low health literacy (LHL) abilities in people with
CKD have been demonstrated to be associated with
poor CKD knowledge, self-management behaviors, and
health-related quality of life and in those with greater
comorbidity severity.
7
Unfortunately, most CKD studies
have measured only functional health literacy, so the
evidence that LHL results in poorer outcomes, particularly
that it increases health care utilization and mortality,
9
and reduces access to transplantation,
10
is weak.
Recently, health literacy is now considered to be an
important bridge between lower socioeconomic status
and other social determinants of health.
4
Indeed, this is
not a feature that can be measured by the gross domestic
product of a country, as the eects ofLHL on the extent
of CKD in the community are experienced globally
regardless of country income status. e lack of awareness
of risk factors ofkidney disease, even in those with high
health literacy abilities, is testament to the diculties in
understanding this disease, and why the United States,
for instance, recommends that a universal precautions
approach toward health literacy is undertaken.
11
So, what does the perfect health literacy program
look like for people with CKD? In several high-income
countries, there are national health literacy action plans
with the emphasis shied to policy directives, organizational
culture, and health care providers. In Australia, for instance,
a compulsory health literacy accreditation standard makes
the health care organization responsible for ensuring
providers are cognizant of individual health literacy
abilities.
12
Although many high-income countries, health
care organizations, nongovernmental organizations, and
jurisdictions are providing an array of consumer-facing
web-based programs that provide detailed information and
self-care training opportunities, most are largely designed
for individual/family use that are unlikely to mitigate LHL.
ere is, however, substantial evidence that interventions
improving health care provider communication are more
likely to improve understanding of health problems and
abilities to adhere to complex treatment regimens.
13
Access to information that is authentic and tailored
specically to the needs of the individual and the community
is the aim. e challenge is recognized acutely in more
remote and low- to middle-income countries of the world,
specically the importance of culturally appropriate
knowledge provision. e principals of improving health
literacy are the same, but understanding how to proceed,
and putting consumers in charge, with a codesign approach,
is critical and may result in a dierent outcome in more
remote parts of the world. is principal especially applies
to communities that are smaller, with less access to
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TABLE 1. Summary characteristic of kidney health promotion, involving kidney health–centered policy, community
kidney health planning, and kidney health literacy, and proposed future direction.
Kidneyhealth Denition Stakeholders Currentstatus Limitations/ Suggestedsolutions
promotion challenges /future research
Kidney
health-
centered
policy
Community
kidney health
planning
Kidney
health
literacy
• Incorporate
kidney health
into policy
decision
making
• Prioritize
policies with
primary
prevention for
CKD
• Building up
preventive
strategies to
promote healthy
communities and
primary health
care facilities
• Receive
knowledge,
skills, and
information to
be healthy
• Governance
• Policy makers
• Insurance
agencies
• Community
leadership
• Kidney patient
advocacy
• People with
CKD
• Care partners
• Health care
providers
• Policy
emphasizing
treatment for
CKD and kidney
failure rather
than kidney
health
prevention
• Belief in
community
leaders in LMIC
• Lack of
awareness of
CKD and risk
factors
• Care partner
burden and
burnout
• Inadequate
health care
workers
• High patients-to-
health care
workers ratio,
especially in
rural areas
• Economic-
driven situation
challenging
CKD risk factor
minimization
(e.g., food
policy)
• Education and
understanding
kidney health
promotion of
community
leadership and
people
• Inadequate
policy direction
• Ineffective
health care
providers’
communication
skills
• Promote implementation
of public health program
for primary CKD prevention
• Promote sustainable
treatment for CKD and
dialysis
- Increase kidney
transplant awareness
- Enhance visibility and
encourage brother-sister
nephrology and transplant
program in LMIC
• Support research
funding from government
- Health care cost-
effectiveness for caring
for CKD
- Kidney failure,
including maintenance
dialysis and transplant
- Promote surveillance
programs for kidney
diseases and their
risk factors
• Improve role model of
community
• Enhance kidney support
networks
• Organizational paradigm
shift toward health
literacy
• Improving communication
between health care
providers with patients
and care partners
•
Using teach-back methods
for consumer education
• Adapting technologies for
appropriate health
literacy and sociocultural
environments
• Family engagement in
the patient care
• Incentive for community
health care providers in
rural areas
Abbreviations: CKD = chronic kidney disease; LMIC = low- to middle-income country.
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electronic communication and health care services,
where the level of health literacy is shared across the
community and where what aects the individual also
aects all the community. Decision support systems are
dierent, led by elders, and in turn educational resources
are best aimed at improving knowledge of the whole
community.
A systematic review of the evaluation of interventions
and strategies shows this area of research is still at an
early stage,
14
with no studies unravelling the link between
LHL and poor CKD outcomes. e best evidence is in
supporting targeted programs on improving communication
capabilities of health care professionals as central. One
prime example is Teach-back, a cyclical, simple, low-cost
education intervention, shows promise for improving
communication, knowledge, and self-management in the
CKD populations in low- or high-income countries.
15
Furthermore, the consumer-led voice has articulated
research priorities that align closely with principals
felt to be important to success of education: building
new education resources, devised in partnership with
consumers, and focused on the needs of vulnerable groups.
Indeed, programs that address the lack of culturally safe,
person-centred and holistic care, along with improving
the communication skills of health professionals, are
crucial for those with CKD.
16
e networked community of kidney health care workers
Nonphysician health care workers, including nurses
and advanced practice providers (physician assistants and
nurse practitioners) as well as dietitians, pharmacists, social
workers, technicians, physical therapists, and other allied
health professionals, oen spend more time with persons
with kidney disease, compared with nephrologists and
other physician specialists. In an ambulatory care setting
at an appointment, in the emergency department, or in
the inpatient setting, these health care professionals oen
see and relate to the patient rst, last, and in between,
given that physician encounters are oen short and
focused. Hence, the nonphysician health care workers
have many opportunities to discuss kidney disease-related
topics with the individuals and their care partners and
to empower them.
17,18
For instance, medical assistants
can help identify those with or at risk of developing
CKD and can initiate educating them and their family
members about the role of diet and lifestyle modication
for primary, secondary, and tertiary prevention of CKD
while waiting to see the physician.
19
Some health care
workers provide networking and support for kidney
patient advocacy groups and kidney support networks,
which have been initiated or expanded via social media
platforms (Fig1).
20,21
Studies examining the ecacy of
social media in kidney care and advocacy are on the
way.
22,23
Like physicians, many activities of nonphysician
health care workers have been increasingly aected by
the rise of electronic health recording and growing access
to internet-based resources, including social media, that
oer educational materials related to kidney health,
including kidney-preserving therapies with traditional
and emerging interventions.
24
ese resources can be used
for both self-education and for networking and advocacy
on kidney disease awareness and learning. Increasingly,
more health care professionals are engaged in some types
of social media-based activities, as shown in Table2. At
the time of this writing, the leading social media used
Fig 1. Schematic representation of
consumer and health care professionals’
collaborative advocacy using social
media platforms with the goal of
Kidney Health for All.
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by many-but not all-kidney health care workers include
Facebook, Instagram, Twitter, LinkedIn, and YouTube.
In some regions of the world, certain social media are
more frequently used than others given unique cultural
or access constellations (e.g., WeChat is a platform oen
used by health care workers and patient groups in China).
Some health care professionals, such as managers and
those in leadership and advocacy organization positions,
may choose to embark onsocial media to engage those
with CKD and their care partners or other health care
professionals in alliance building and marketing. To that
end, eective communication strategies and outreach skills
specic to responsible use of social media can provide
clear advantages given that these skills and strategies
are dierent and may need modication in those with
LHL. It is imperative to ensure the needed knowledge
and training for accountable approach to social media is
provided to health care providers, so that these outreach
strategies are utilized with the needed awareness of their
unique strengths and pitfalls, as follows
25
:
(i) Consumers’ and care partners’ condentiality may
not be breached upon posting anything on social
media, including indirect referencing to a specic
individual or a particular description of a condition
unique to a specic person (e.g., upon soliciting
for transplant kidney donors on social media).
26,27
(ii) Condential information about clinics, hospitals,
dialysis centers, or similar health care and advocacy
TABLE 2. Social media that are more frequently used for kidney education and advocacy.
Social media Strength Limitations Additional comments
Facebook
Instagram
Twitter
LinkedIn
YouTube
WeChat
Pinterest
Frequently used social media
platform by many kidney
patients and patient groups
Photo-predominating platform
Often used by physician
specialists and scientists,
including nephrologists
More often used by
professionals, including in
industry
Video-predominating platform
Widely used in mainland China
Picture-based, often used by
dietitians
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
►
Widely used for entertaining
purposes, which can dilute its
professional utility
Not frequently used by health
care professionals
Less frequently used by
patients and care partners
Originally designed for
employment and job-seeking
networking
Less effective with non–
video-based formats
Access is often limited to those
living in China or its diaspora
Currently limited use by some
health care workers
User-friendly platform for
kidney advocacy, enabling
wide ranges of outreach goals
Picture friendly, potentially
effective for illustrative
educational purposes
Increasing popularity among
physician and specialty circles
Mostly effective to reach out
to industry and managerial
professionals
Wide ranges of outreach and
educational targets
Effective platform to reach out
to patients and health care
professionals in China
Useful for dietary and lifestyle
education
Other popular social media at the time of this publication include, but not limited to, Tik Tok, Snapchat, Reddit, Tumblr, Telegram, Quora,
and many others that are currently only occasionally used in kidney advocacy activities. Mobile and social media messaging apps include,
but not limited to, WhatsApp, Zoom, Facebook Messengers, Skype Teams, and Slack.
Note: at platforms that are more oen used as internet-based messaging are not included.
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entities may not be disclosed on social media
without ensuring that the needed processes,
including collecting authorizations to disclose,
are undertaken.
(iii)Health care workers’ job security and careers
should remain protected with thorough review
of the content of the messages and illustrations/
videos before online posting.
(iv) Careless and disrespectful language and emotional
tones are oen counterproductive and may not
be justied under the context of freedom of
speech.
e global kidney community of policy and advocacy
Policy and advocacy are well-recognized tools that, if
properly deployed, can bring about change and paradigm
shi at jurisdictional level. e essence of advocating
for policy change to better address kidney disease is,
in itself, an exercise in improving health literacy of
the policy makers. Policy development, at its core, is a
key stakeholder or stakeholder group (e.g., the kidney
community, who believes that a problem exists that should
be tackled through governmental action). ere is an
increasing recognition of the importance of formulating
succinct, meaningful, and authentic information, akin
to improving health literacy, to present to government
for action.
Robust and ecacious policy is always underpinned
by succinct and applicable information; however, the
development and communication of this message, designed
to bridge the gap in knowledge of relevant jurisdictions,
is only part of the process of policy development. An
awareness of the process is important to clinicians who
are aiming to advocate for eective change in prevention
or improvement of outcomes in the CKD community.
Public policies, the plans for future action accepted
by governments, are articulated through a political process
in response stakeholder observation, usually written as a
directive, law, regulation, procedure, or circular. Policies
are purpose t and targeted to dened goals and specic
societal problems and are usually a chain of actions
eected to solve those societal problems.
28
Policies are an
important output of political systems. Policy development
can be formal, passing through rigorous lengthy processes
before adoption (such as regulations), or it can be less
formal and quickly adopted (such as circulars). As already
mentioned, the governmental action envisaged by the
key stakeholders as solution to a problem is at its core.
e process enables stakeholders to air their views and
bring their concerns to the fore. Authentic information
that is meaningful to the government is critical. e
policy development process can be stratied into 5 stages
(i.e., the policy cycle), as depicted by Anderson (1994)
29
and adapted and modied by other authors
30
(Fig2).
Fig 2. Policy cycle involving 5 stages of policy development.
Abbreviations: CKD=chronic kidney disease; KRT=kidney replacement therapy; LGA=local government area.
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e policy cycle constitutes an expedient framework for
evaluating the key components of the process.
Subsequently, the policy moves on to implementation
phase. This phase may require subsidiary policy
development and adoption of new regulations or budgets
(implementation). Policy evaluation is integral to the
policy processes and applies evaluation principles and
methods to assess the content, implementation, or impact
of a policy. Evaluation facilitates understanding and
appreciation of the worth and merit of a policy as well
as the need for its improvement. More important, of the
5 principles of advocacy that underline policy making,
31
the most important for clinicians engaged in this space is
that of commitment, persistence, and patience. Advocacy
takes time to yield the desired results.
e Advocacy Planning Framework, developed
by Young and Quinn in 2002,
30
consists of overlapping
circles representing 3 sets of concepts (way into the
process, the messenger, and message and activities) that
are key to planning any advocacy campaign:
(i) “Way into the process”: discusses the best
approaches to translate ideas into the target policy
debate and identify the appropriate audience to
target.
(ii) Messenger: talks about the image maker or face
of the campaign and other support paraphernalia
that are needed.
(iii) Message and activities: describe what can be
said to the key target audiences that is engaging
and convincing. And how best it can be
communicated through appropriate communication
tools.
Advocacy is defined as “an effort or campaign
with a structured and sequenced plan of action which
starts, directs, or prevents a specic policy change.”
31
e goal being to inuence decision makers through
communicating directly with them or getting their
commitment through secondary audiences (advisers,
the media, or the public) to the end that the decision
maker understands, is convinced, takes ownership of the
ideas, and nally has the compulsion to act.
31
As with
improving health literacy, it is the communication of
ideas to policy makers for adoption and implementation
as policy that is key. ere is much to be done with
bridging this gap in understanding of the magnitude
of community burden that results from CKD. Without
good communication, many good ideas and solutions
do not reach communities and countries where they are
needed. Again, aligned with the principles of developing
resources for health literacy, the approach also needs to
be nuanced according to the local need, aiming to have
the many good ideas and solutions be communicated
to communities and countries where they are needed.
Advocacy requires galvanizing momentum and
support for the proposed policy or recommendation. e
process is understandably slow as it involves discussions
and negotiations for paradigms, attitudes, and positions to
shi. In contemplating advocacy activities, multiple factors
must be considered, interestingly not too dissimilar to that
of building health literacy resources: What obstructions
are disrupting the policy-making process from making
progress? What resources are available to enable the
process to succeed? Is the policy objective achievable
considering all variables? Is the identied problem already
being considered by the policy makers (government or
multinational organizations)? Any interest or momentum
generated around it? Understandably, if there is some
level of interest and if government already has its spotlight
on the issue, it is likely to succeed.
Approaches to choose from include the following
31,32
:
• Advising (researchers are commissioned to
produce new evidence-based proposals to assist
the organization in decision making).
• Activism: involves petitions, public demonstrations,
posters, iers, and leaet dissemination, oen
used by organizations to promote a certain value
set.
• Media campaign: having public pressure ondecision
makers helps in achieving results.
• Lobbying: entails face-to-face meetings with
decision makers; often used by business organizations
to achieve their purpose.
Here lies the importance of eective and successful
advocacy to stakeholders, including policy makers, health
care professionals, communities, and key change makers
in society. e WKD, since inception, has aimed at playing
this role. WKD has gained people’s trust by delivering
relevant and accurate messaging and supporting leaders
in local engagement, and it is celebrated by kidney care
professionals, celebrities, those with the disease, and their
care givers all over the world. To achieve the goal, an
implementation framework of success in a sustainable way
includes creativity, collaboration, and communication.
e ongoing challenge for the International Society
of Nephrology and International Federation of Kidney
Foundations-World Kidney Alliance, through the Joint
Steering Committee of WKD, is to operationalize how to
collate key insights from research and analysis to eectively
feed the policy-making process at the local, national,
and international levels, to inform or guide decision
making (i.e., increasing engagement of governments
and organizations, like World Health Organization,
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United Nations, and regional organizations, especially in
low-resource settings). ere is a clear need for ongoing
renewal of strategies to increase eorts at closing gap in
kidney health literacy, empowering those aected with
kidney disease and their families, giving them a voice
to be heard, and engaging with the civil society. is
year, the Joint Steering Committee of WKD declares
“Kidney Health for All” as the theme of the 2022 WKD
to emphasize and extend collaborative eorts among
people with kidney disease, their care partners, health
care providers, and all involving stakeholders for elevating
education and awareness on kidney health and saving
lives with this disease.
CONCLUSION
In bridging the gap of knowledge to improve outcomes
for those with kidney disease on a global basis, an in-
depth understanding of the needs of the community is
required. e same can be said for policy development,
understanding the processes in place for engagement of
governments worldwide, all underpinned by the important
principal of codesign of resources and policy that meets
the needs of the community for which it is intended.
For World Kidney Day 2022, kidney organizations,
including the International Society of Nephrology and
International Federation of Kidney Foundations-World
Kidney Alliance, have a responsibility to immediately
work toward shiing the patient-decit health literacy
narrative to that of being the responsibility of clinicians
and health policy makers. LHL occurs in all countries
regardless of income status; hence, simple, low-cost
strategies are likely to be eective. Communication,
universal precautions, and teach back can be implemented
by all members of the kidney health care team. rough
this vision, kidney organizations will lead the shi to
improved patient-centered care, support for care partners,
health outcomes, and the global societal burden of kidney
health care.
Conict of Interest disclosure
KK-Z reports honoraria from Abbott, Abbvie, ACI
Clinical, Akebia, Alexion, Amgen, Ardelyx, AstraZeneca,
Aveo, BBraun, Cara erapeutics, Chugai, Cytokinetics,
Daiichi, DaVita, Fresenius, Genentech, Haymarket Media,
Hospira, Kabi, Keryx, Kissei, Novartis, Pzer, Regulus,
Relypsa, Resverlogix, Dr Schaer, Sandoz, Sano, Shire,
Vifor, UpToDate, and ZS-Pharma.
VL reports nonfinancial support from Genesis
Pharma.
GS reports personal fees from Multicare, Novartis,
Sandoz, and AstraZeneca.
ET reports nonnancial support from Natera.
All the other authors declared no competing interests.
APPENDIX
e World Kidney Day Joint Steering Committee
includes coauthors Robyn G. Langham, Kamyar
Kalantar-Zadeh, Alessandro Balducci, Li-Li Hsiao,
Latha A. Kumaraswami, Paul Lan, Vassilios Li
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