Journal of Health Science of Thailand

Basic Concepts of Health Literacy for Equitable Thai Health Systems

Saichon Kloyiam — 2024-10-31

Health literacy refers to individual knowledge and competencies needed to access, understand,
appraise, and apply health information for making health related decisions in order to maintain and
improve health for oneself and others. It accumulates throughout the life course through daily activities
and social interactions. Health literacy is influenced not only by individual factors, but also organizational
structures and availability of resources. Therefore, health systems have direct effects on health literacy
among people. With a health literacy friendly health system, people will improve their health literacy and
be able to utilize available health related resources. In contrast, there might be an increasing proportion
of the population with limited health literacy left behind. The rate of utilization of basic preventive and
promotive health services will drop while that of curative services will rise and the health systems cannot
handle the situation. This special article presents the basic concepts of health literacy and enabling factors
for improving Thai health systems to become health literate and promote health equity. The content
covers health literacy as the national agenda, organizational health literacy, health literacy as a modifiable
determinant of health, and health literacy as an empowering factor. Furthermore, enabling factors for
health literacy friendly health systems are elaborated such as health literacy workforce, health literate
organization, health literacy data management, shared decision making in health services, partnerships,
technology and innovation for health literacy, financial support and investment, and health literacy
leadership. These basic concepts have been drawn from theories and practices from various countries.
They will help policy makers, healthcare professionals, and technical health workers to develop equitable
health systems to achieve the goal of the national strategic plan.

Health and Social Factors Related to Tobacco Cultivation: a Literature Review

Chakkraphan Phetphum — 2024-10-31

The World Health Organization Framework Convention on Tobacco Control or WHO FCTC, is a
framework of an agreement aimed at protecting the population from the harmful effects of tobacco consumption
and secondhand smoke exposure. Thailand as one of the countries that participated in ratifying
this framework and need to respond by achieving the specified goals. In the past, it has been found that
Thailand still has limited empirical evidence related to Article 18 on environmental protection and the
health of individuals related to tobacco cultivation and production. This article aimed to review original
research articles on the impact of tobacco cultivation both internationally and domestically, and identify
research gaps in Thailand by collecting data from research articles related to the WHO FCTC Article 18
published in electronic databases generated 559 articles. There were 37 articles met the criteria for inclusion
in the final analysis. The study concluded that all original research articles focus on four main areas
which include physical health impacts, mental health impacts, quality of life impacts, and environmental
impacts. In Thailand, there was a lack of research on the mental health impacts of tobacco farmers and
environmental impacts. These research gaps may lead to a lack of comprehensive empirical evidence that
is a concrete result of tobacco cultivation and production in Thailand. Therefore, the Tobacco Control
Research and Knowledge Management Center should prioritize research topics that are still missing to
address these research gaps in the future.

Factors Associated with Tuberculosis Stigma among School Adolescents in Bangkok, Thailand

Sarut Moonsarn — 2024-10-31

A descriptive study design was employed to explore factors associated with tuberculosis stigma
among school adolescents in Bangkok, Thailand. The participants were school adolescents aged 15-19
years old, who were studying in grades 10-12 in Bangkok-based schools under the Office of Basic
Education Commission (OBEC). Data were collected by questionnaires consisting of the following four
parts: (1) factors related to demographic characteristics, (2) knowledge about pulmonary tuberculosis
(TB), (3) attitudes toward pulmonary tuberculosis, and (4) TB stigma. The data were analyzed using
descriptive statistics, whereas Chi-square test and Fisher’s exact test were used to compare proportions
and associations between variables. The result showed that factors related to demographic characteristics
significantly associated with TB stigma were sex, age, classes, and type of accommodation (p<0.05).
Similarly, attitudes toward pulmonary TB were significantly associated with TB stigma (p<0.05), while
knowledge about pulmonary TB was not. The study suggested that the results should be utilyzed to assist
the development of TB interventions for enhancing TB knowledge, fostering a positive attitude toward
pulmonary TB as well as to advocate social mobilization both directly and indirectly in educational institutions
such as public or private schools, vocational schools, and universities in order to reduce TB stigma
and discrimination against TB patients.

Incidence and High-Risk Factors for Developmental Delay and Cerebral Palsy in Children Aged 0-6 Years at Child Development Clinic, Buddhachinaraj Hospital, Phitsanulok

Mattana Bhumipraphat — 2024-10-31

A retrospective five-year study was aimed to determine the incidence and biological risk-factors
for developmental delay and cerebral palsy (CP) in 905 children aged 0-6 years who received the
first-visit treatments at the Child Development Clinic, Buddhachinaraj Hospital, Phitsanulok in the fiscal
year: 2014-2018. Medical records were examined. Maternal and infant characteristics and incidence
data were analyzed using descriptive statistics. Biological risk-factors associated with developmental
delay and CP were analyzed using the Chi-Square test, Fisher’s Exact test and Crude Odds Ratio at 95%
confidence interval. Of 905 first-visit cases aged 0-6 years, the incidence of developmental delay was
19.78%, equivalent to 14.13 cases per 1,000 live-births of infants born at Buddhachinaraj Hospital. The
incidence of CP was 11.27%, calculated as 8.05 cases per 1,000 live-births. Biological risk factors that
sigmificantly affected developmental delays (p<0.01) in prenatal period were genetic diseases and preeclampsia.
In perinatal period, two important biological factors were (1) premature births (32-37 weeks
GA) with low birth weight, and (2) full-term births with critical complications. In postnatal period, the
risk-factors included but not limited to bronchopulmonary dysplasia, respiratory distress syndrome, and
patent ductus arteriosus. For cerebral palsy, biological risk-factors included meningitis, brain ischemia,
seizure and birth asphyxia. Most children with CP were diagnosed with bilateral spastic CP. In accordance
with the mission of the Child Development Clinic, Buddhachinaraj Hospital, Phitsanulok emphasizes
importance on early intervention, care, and treatment, and following up on treatment outcomes to help
children develop appropriately or to effectively reduce the risks of delayed development and disabilities.

Factors Associated with Wasting among Preschool Children in Child Development Center, Tamot District, Phatthalung Province

Amonrat Yusoh — 2024-10-31

This cross-sectional research aimed to explore factors related to the wasting among preschool
children in child development centers. The sample was 155 pairs of preschool children and caregivers in
child development centers under the responsibility of Tamot hospital, Phatthalung province. The samples
were recruited by simple random sampling. Interview forms were used for data collection; and the data
were analyzed using descriptive statistics and multiple logistic regression. The results of the study revealed
that the factors statistically significantly associated with wasting among preschoolers were child’s age,
nap duration, sleeping with a bottle in the mouth, watching television, eating a high-fat diet, household
income, and caregivers’ marital status (p<0.05). The factors mentioned above contribute to the probability
of children of this age group being vulnerable to wasting. Consequently, it is crucial to observe these
factors in the programs to monitor and promote nutrition in pre-school-aged children.

Relationship between Health Literacy and Covid-19 and Emerging Infectious Diseases Preventive Behaviors among Older Adults in Pa-Sao Sub-district, Mueang District, Uttaradit Province

Pongsak Onmoy — 2024-10-31

This cross-sectional descriptive study aimed to assess the level of health literacy, and preventive
behaviors on COVID-19 and emerging infectious diseases, and study the relationship between the health
literacy and preventive behaviors among older adults in Pa-Sao Sub-district, Mueang District, Uttaradit
Province. The samples were older adults aged between 60-69, totaling 300 people from 10 villages.
They were systematically randomized based on the proportion of elderly individuals in each village. Data
were collected by questionnaires; and were analyzed by using descriptive statistics; percentage, mean,
standard deviation and Pearson product-moment correlation coefficient. The results showed that the older
adults had overall health literacy about coronavirus 2019 and emerging infectious diseases at a fair level
(mean=118.09, SD=34.22); and the preventive behaviors were at a fair level (48.37, SD=13.83).
The overall health literacy had a statistically significant positive correlation to the preventive behaviors
against coronavirus 2019 and emerging infectious diseases, although at a moderate level (r=0.63). There
was a statistically significant positive correlation between each dimension of health literacy and behaviors
to prevent coronavirus 2019 and emerging infectious diseases at a relatively high level. Thus, this study
recommended that responsible governmental sector should applied these results as baseline information
for designing activities to develop health literacy programs to promote preventive behaviors against coronavirus
2019 and emerging infectious diseases for older adults.

Predicting Concentration of Air Pollution Using AERMOD Model and Estimating Its Health Impact on the Population Near Biomass Power Plants in Khon-Buri District, Nakhon Ratchasima Province

Samakarn Tongkliang — 2024-10-31

Although biomass power plants play a role in enabling Thailand to produce electricity in response to
economic development, the potential issue of air pollution should not be overlooked. This study aimed
to predict the air pollution concentration from biomass power plants using the AERMOD air quality
modeling and assess its health impacts on the population residing within a 10-kilometer radius of the
plant in the Khon-Buri District of Nakhon Ratchasima Province. During the period from October 2019
to September 2020, air samples from four potentially affected communities within the radius were
analyzed. These communities were Subkanlueng Subdistrict health promoting hospital, Chorakhehin
Subdistrict health promoting hospital, Khon-Buri Tai Subdistrict municipality, and Ban-Clongyang
(Moonbon Ubpatum) School. The analysis results showed that the concentration of total suspended
particles (TSP), nitrogen dioxide (NO2), and sulfur dioxide (SO2) was lower than the national
ambient air pollution standard in all four locations. In terms of health impacts, the most prevalent symptoms
observed was fatigue (13.5%), followed by blurred vision (12.6%). The analysis of the relationship
between the pollutants and particulate matter with a diameter less than 2.5 micrometers (PM2.5) and
health symptoms using binary logistic regression revealed that only PM2.5 exposure was significantly
associated with multiple symptoms including nasal congestion, runny nose, burning nose, sore throat, dry
cough, cough with mucus, trouble breathing, headache, fatigue, burning and itchy eyes. For instance, an
increase of 1 microgram per cubic meter of PM2.5 was associated with a 1.01 times higher likelihood
of experiencing nasal congestion. In light of these results, the researchers recommend (1) the establishment
of an air pollution health risk assessment center that utilizes AERMOD model to monitor and
alert the public to the impact of air pollution, and (2) the development of database system linking health
and environmental factors for the use in proactive monitoring and warning of health disaster caused by
environmental pollution.

Development of a Model for Health Promotion, Prevention and Control of Chronic Non-Communicable Diseases with the Principles of Buddhism Discussion by Applying the Tools of 3Sor, 3Or and 1Nor Integrating Buddhist Principles

Sudafa Wongharimat — 2024-10-31

This study aimed to develop and analyze a model for health promotion, prevention and control of
chronic non-communicable diseases with the principles of Buddhism discussion by applying the tools of
3Sor (pray, meditation, Buddhism discussion - Dhamma way), 3Or (food, exercise, emotion - Dhamma
way) and 1Nor (biological clock) integrating Buddhist principles. It was conducted with multi-phase
design. Samples were 402 individuals from the North, the Central, the South and the Northeast regions.
The tools were questionnaire and measurement questionnaire developed from the principles of 3Sor, 3Or,
and 1Nor with the principles of Buddhism discussion. Data were analyzed by exploratory factor analysis
(EFA) by principle component analysis. Results of studies revealed changes in health conditions after
participating in the Buddhism discussion for 3 months compared to those before the participation. It was
found that the blood pressure level of most samples (60%) decreased by an average of 7.5 mm Hg. The
waist circumference of 60% of samples decreased by an average of 2.50 inches. The weight of 70%
of samples decreased by an average of 3.20 kg. The blood sugar level of 70% of patients in the patient
group decreased on average by 2 mg/dl. In addition, the body mass index of 50% of samples decreased
by an average of 1.5 kg/m2 (p<0.05). Thus, applying the principles of Buddhism discussion using the
tools of 3Sor, 3Or, and 1Nor integrating Buddhist principles could promote health resulting in the prevention
of chronic non-communicable diseases. This model should be expanded to other groups and areas
with similar contexts.

A Study of Appropriate Caring the Elderly: a Case Study of the Elderly Population in Rim Klong Lat Phrao Community, Chandrakasem Subdistrict, Chatuchak District, Bangkok

Teerasak Koployklang — 2024-10-31

The purposes of this research were to study the suitable patterns of public health care for elderly and
to develop the suitable patterns for elderly public health care. The samples were 30 elderly in Lim Klong
Lad Proa community, Bangkok, selected by purposive sampling, and 15 public health care volunteers.
The instruments used in this research were questionnaires and interviewing. The statistics used to analyze
the data were frequency, percentage, mean, standard deviation and t-test: paired two samples for means.
The result showed that (1) there were 4 patterns of public health care for elderly (elderly taking care
of themselves, elderly taking care by their family, elderly taking care by agency or organization, and
elderly taking care by community); and (2) there were 4 steps that important and suitable for elderly in
developing suitable patterns in public health care for elderly in this area as follows: (1) studying the
context of community and elderly situation, determining the roles and responsibilities of partners, and
initiating a plan of taking care of elderly and improve quality of a life of elderly in community involved
by the community partners with the technique of A-I-C (planning), (2) organizing activities according
to a plan to take care of elderly and improve quality of a life of elderly in community involved by the
community partners (action), (3) assing the elderly quality of life in community (observation), and (4)
synthesizing for the lessons learned (reflection).

Media and Communication Platform Development for Supporting the Intermediate Care Services System in M1 Network Hospital

Siwaporn Sukittanon — 2024-10-31

The research had three primary objectives: firstly, to investigate the context and needs associated
with intermediate care and rehabilitation; secondly, to develop a media and platform for facilitating
the communication of essential information among patients and caregivers; and finally, to assess user
satisfaction. The research and development study consisted of three distinct phases. The first phase
comprised a situational analysis, drawing insights from a focus group report involving 100 individuals
engaged with the intermediate care system. Key insights indicate a lack of understanding among hospital
staff about the intermediate care system. Caregivers and patients also struggle with role comprehension
and express distrust in Village Health Volunteers (VHVs). Insufficient knowledge hampers caregivers
and patients in providing adequate care. In the second phase, media and platform production occurred
through a qualitative approach, employing participatory observation tools. The researchers utilized the
insights obtained from phase 1 to design content, presentation, media, and platform. This effort
resulted in the creation of 12 videos and 15 infographics, distributed through a Facebook page and
a YouTube channel. In the evaluation phase, a mixed-methods approach was employed. Qualitative
findings from focus groups revealed a preference for educational entertainment videos among patients and
caregivers. Viewership could be enhanced by addressing their specific concerns. Recommendations include
producing 3-5 minute videos, generating more content, aligning media use with the interprofessional
team’s advice, and incorporating Line as an additional distribution channel. After 10 months of public
access, quantitative findings from the Facebook page revealed that women from Chiangmai were the main
users. Videos correcting attitudes outperformed knowledge-based ones in terms of reaches, views, shares,
and comments. Infographics reached a smaller audience but had a higher share rate.

Comparison of Cold Copolymer Gel Pack before Botulinum Toxin Injection Versus Standard Cold Pack in Subjects with Crow’s Feet: Non-Inferiority Trial

Sirintip Thongkaow — 2024-10-31

At present, cold compresses are quite expensive. Developing using cold copolymer gel pack can be
useful to reduce skin sensation. This was a split-face non-inferiority double-blind randomized controlled
trial, to compare the effectiveness of cold copolymer gel pack before botulinum toxin injection versus
standard cold pack in subjects with crow’s feet. Twenty-one patients given bilateral periocular injections
for wrinkle reduction were randomized into experimental side (cold copolymer gel pack) and control side
(standard cold pack) using block randomization. Relative pain scores were recorded to assess the effects
of treatment. Non-inferiority hypothesis was evaluated at -1.20 (non-inferiority margin). It was found
that the experimental side and the control side had the pain score 4.52±2.36 and 4.14±2.83 which was
no statistical differences (p>0.05) (absolute difference of 0.38, 95%CI=-0.97 - 1.73). The 95%
confidence interval was on the right side of non-inferiority margin, Thus, cold copolymer gel pack was
not inferior to standard cold pack. The authors recommended that cold copolymer gel pack could be an
effective and acceptable substitution of the standard cold pack.

Clinical Outcomes of the Use of an Innovative Sharp-Tipped Hemostatic Device

Phatchaleepore Pongwasin — 2024-10-31

Most surgeries require the use of an electrical cautery device to stop the bleeding and cut tissue.
Electric cautery head sold in hospitals has a large flat tip unsuitable for surgery and stopping bleeding in
small or narrow areas, resulting in injury to nearby organs. This research is a quasi-experimental research.
The objective was to compare the injury to nearby tissues and organs between a pointed-tip electrocautery
and a normal electrocautery. The sample group consisted of patients who received services at the operating
room of the Otolaryngology Department, Amnat Charoen Hospital from 1 October 2021 to 30 September
2022, totaling 140 people, who were selected by simple random sampling, divided into an experimental
group of 70 people and a control group of 70 people by means of individual matching. The tools used
included a form to record injuries to nearby tissues and organs and the use of an electric cautery during
surgery. The validity and reliability were checked by 3 experts and the content validity index was 0.89
and 0.85, respectively. Data on injury to nearby tissues and organs were analyzed by comparing the
pointed end electric cautery head and the normal electric cautery head. Data were analyzed by using paired
t-test to compare the means of the 2 groups. The results of the study revealed that the use of a pointed
electric cauterizer caused less injury to nearby tissues and organs during surgery than when using a normal
cauterizer (p<0.05). It is an innovation created from observing problems that occur with patients during
surgery; and the innovation can prevent problems from damaging nearby tissues and organs and improve
the efficiency of nursing practice. It is beneficial and convenient to use and it can also reduce hospital
costs.

Lessons learned of Andrographis paniculata Usage in Popular Sector during the COVID-19 Situation in the Years 2020-2021

Yongsak Tantipidoke — 2024-10-31

This qualitative research aimed to extract lessons from the use of Andrographis paniculata (Burm.f.)
Wall. ex Nees or “Fah Talai Jone” herb in population sector during the COVID-19 pandemic, from the
beginning of the outbreak until 31 December 2021. Five case studies were purposively selected including
one family, one community, two volunteer groups and one non-profit organization that involved in assisting
patients during the pandemic. Focus group discussion and in-depth interview were used to collect
data. Case studies and content analysis were performed to answer research questions. The study found
that self-care using the Fah Talai Jone herb by the general public occurred in three patterns: self-care
within families, self-care within communities, and care provided by volunteer groups, with advocacy
and support from non-profit organizations. This led to a more widespread use of herbal remedies and
expanded assistance to other communities. Data regarding the use of herbal medicine in patients were
recorded, monitored, and evaluated in various manner. However, the study concluded several key lessons
that should be reviewed and utilized to promote the more effective use of herbal remedies, including
prioritizing the fastest possible access to medicine for patients, using other types of herbal remedies and
treatment methods to alleviate symptoms for faster recovery, and reducing potential side effects resulting
from excessive use of any particular type of herbal medicine. Furthermore, the study emphasized the use
of herbal remedies in high-risk groups, ensuring that they were able to avoid contracting COVID-19.
Recommendations for the development of herbal medicine use for the self-reliance of general public in
emergency situations were finally formulated.

Exploring the Effects of Establishing a Psychiatric Ward in Hatyai Regional Hospital

Chaiyasit Thepchatri — 2024-10-31

Mental health disorders and substance abuse in Thailand heavily strain healthcare resources. Psychiatric wards in general hospitals improve access to comprehensive care, but their effect on patient outcomes and healthcare system efficiency in Thailand remains underexplored. This study aimed to compare patient
demographics, clinical characteristics, and referral rates before and after establishing a psychiatric ward, and to evaluate the impact of ward on patient’s care outcomes. This quasi-experimental pre-post study analyzed data from patients treated at a tertiary care hospital between 2019 and 2024. Demographic and clinical
characteristics, including psychiatric and physical conditions, referral rates, and outcomes, were compared before and after the psychiatric ward’s establishment in October 2022. Interrupted time series analysis assessed referral trends, and descriptive statistics compared patient characteristics and treatment outcomes. From this study, a total of 783 patients were recruited, with 497 treated before and 286 after the ward’s establishment. The primary diagnoses shifted from substance use disorders (78.7% to 34.9%) to schizophrenia (6.4% to 33.2%), while mood disorders increased from 14.9% to 24.1%. Many patients presented with coexisting physical conditions requiring care. The median length of stay increased from 2 days (IQR: 1-4) to 13 days (IQR: 7-23, p<0.001), while readmission rates remained stable (1.6% vs. 2.8%, p=0.258). Clinical
outcomes improved, with reductions in psychiatric symptoms and SAVE scores at discharge. Referral rates trended downward with a non-significantly immediate reduction (change=-8.64, 95% CI: -234 to 307,p=0.848) and no significant change in trend after the ward’s establishment (slope change=-1.16, 95% CI:-6.33 to 4.01, p=0.656). The establishment of psychiatric wards in regional and general hospitals has
significantly improved patient care outcomes, allowing for comprehensive treatment addressing both physical
and mental health needs through multidisciplinary teams. Patient care outcomes have also markedly improved,
while referral rates to specialized facilities have trended to decline. Expanding psychiatric units and resources
in regional and general hospitals has improved patient access and care continuity. This integrated model
enhances treatment efficacy and reduces mental health stigma by incorporating psychiatric care into general
healthcare settings.

Development Palliative Pharmaceutical Care in Maharaj Nakhonsrithammarat Hospital, Thailand

Supenporn Aksornwong — 2024-10-31

This study aimed to develop a palliative care system at Maharaj Nakhon Si Thammarat Hospital,
enabling patients to access high-quality opioids analgesics while meeting the health service system criteria
(Service Plan) in the field of palliative care which was set at no less than 40 percent, It also aimed to
explore knowledge and understanding of drug use issues, patient behaviors, with a focus on addressing
protection of unwanted side effects of medication. The study was conducted as a action research
involving problem analysis in collaboration with the patient care team, tool development for system
improvement, and following the laid-out system. The study was divided into two periods. The first period, from
October 2018 to September 2020, focused on the system for delivering injectable opioids to
patients for home use. The results showed that patients access to opioid drugs increased from 5.84% to
20.25%, and 42.60% from the year 2018 to 2020, respectively. All patients could choose to return
to pass away at home as per their wishes by receiving injectable opioids pain relief drugs. The second
period, from January to September 2020, concentrated on pharmaceutical care by pharmacists at palliative
outpatient clinics. Data were collected from March to August 2020, involved 85 patients with 40 males
(47.06%), and 45 females (52.94%). The study involved a review of drug use history and medication
recommendations of 345 follow-up visits. The most common issue identified was adverse drug reactions,
accounting for 45.41% of all medication-related problems out of a total of 262 occurrences, with
constipation being the most prevalent (89.07%). The most common reason for non-compliance with
medication was the concern about side effects when patients learned that the medication contained opioids
(29.41%); and the most common problem regarding medication use was the irregular administering of
pain relief drugs (around the clock), with a rate of 27.9%. A system for tracking medication returns was
created, with a total value of 62,747.70 baht.

A Preliminary Study on Computer Vision Syndrome Symptoms among Hospital Staff in Trang Hospital

Watcharin Tayati — 2024-10-31

Currently, the era of digital technology is rapidly advancing in the fields of medicine and public health.
Technology is being leveraged to develop systems and manage healthcare, including the use of digital
platforms for data organization, disease diagnosis, and the development of medical devices to enhance
patient treatment. However, prolonged use of digital devices such as smartphones and computers may
result in computer vision syndrome (CVS), characterized by symptoms like headaches, blurred
vision, dry eyes, and visual instability. This study aimed to investigate and compare CVS symptoms
between medical professionals and support staff at Trang Hospital, Thailand. The investigation involved a
questionnaire on CVS symptoms and utilizes descriptive statistics, Mann-Whitney U test for group
differences, and Chi-square test for population proportions. A total of 139 participants were categorized
into medical professionals (n=85) and support staff (n=54). The basic demographic data showed no
significant differences between the 2 groups, except for the proportion of hours spent using computers,
which was higher in the support staff group. Statistical analysis revealed that support staff, who use
computers regularly, reported higher levels of CVS symptoms compared to medical professionals. The
most reported symptoms were eye pain, eye irritation, and headaches. The study suggests a correlation
between CVS symptoms in hospital staff and the number of hours spent using computers. These
findings offer valuable insights for policy development and preventive measures. Additionally, the study
encourages the exploration of physical therapy interventions to alleviate CVS symptoms in hospital staff
in the future.

Pulmonary Embolism in Reoperation of Alveolar Ridge Cancer: a Case Study

Thitinat Anukoolprasert — 2024-10-31

Complications after alveolar ridge cancer surgery such as a dehiscenced wound or infected wound
because this is rich of saliva organ requiring reoperation to correct these complications. In addition, deep
vein thrombosis and pulmonary embolism are major postoperative complications which life threatening
conditions, particularly in patients with many risk factors such as old age (>70 years old), active
cancer, immobilization for more than 3 days, and infected postoperative wound. In this case report we
found thrombosis in the right internal jugular vein and a massive pulmonary embolism during surgery
making the patient to have unstable vital signs. It was difficult condition to decide because we could not
perform definite treatment for pulmonary embolism between surgery. The use of anticoagulant might
increase blood loss in the surgical field and our institute was unable to perform thrombectomy. This case
study shares an experience when encounters difficult hematological condition during surgical operation.

Challenges of the Public Health Policies for the Year 2025