p r i m a r y c a r e d i a b e t e s 5 ( 2 0 1 1 ) 109–115

Contents lists available at ScienceDirect

Primary Care Diabetes

journal homepage: http://www.elsevier.com/locate/pcd

Original research

Cost of informal care for diabetic patients in Thailand

Susmita Chatterjee a , Arthorn Riewpaiboon a,∗ , Piyanuch Piyauthakit b ,

Wachara Riewpaiboon c
a Division of Social and Administrative Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447, Sri Ayutthaya
Road, Bangkok 10400, Thailand
b Waritchaphum Hospital, 83 Moo 13 Waritchaphum sub-district, Waritchaphum District, Sakhon Nakhon 47150, Thailand
c Health promotion program for people with disability, Health System Research Institute, Ministry of Public Health, Tivanond Road,

Nonthaburi 11000, Thailand

a r t i c l e i n f o a b s t r a c t

Article history: Aims: The study estimated the cost of informal care for 475 randomly selected diabetic
Received 3 August 2010 patients as identified by International Classification of Diseases, tenth revision (ICD-10
Received in revised form codes = E10–E14) and who received treatment at Waritchaphum hospital in Sakhon Nakhon
11 November 2010 province of Thailand during the financial year 2008.
Accepted 22 January 2011 Methods: Informal care was valued by using revealed preference method. Information of
Available online 18 February 2011 informal caregiving was collected through direct personal interview method either from
the patients or from the caregivers. The data on time spent for informal care were collected
Keywords: by using recall method.
Cost Results: The study covered a total of 190 informal caregivers. Average time spent on informal
Informal care care was 112.38 h per month. The estimated cost of informal care was USD 110,713.08 using
Diabetes opportunity cost approach and USD 93,896.52 using proxy good method in 2008 (1 USD = 32
Revealed preference method Thai Baht).
Caregivers Conclusions: The study concluded that the hidden cost associated with informal caregiving is
Thailand a burden for the Thai society. Hence, the economic cost associated with informal caregiving
should be considered for future analyses of both the public health consequences of diabetes
and interventions aimed at decreasing diabetic complications.
© 2011 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

lence of diabetic complications. The chronic nature of the

1. Introduction
Diabetes is a common chronic disease with increasing bur-
dens in Thailand [1]. The national prevalence of diabetes
in Thai adults aged ≥35 years was estimated 9.6% in 2000
and 6.7% among people aged ≥15 years in 2004 [2,3]. The
high prevalence of diabetes leads to an increase in preva-
disease and its devastating complications make it a very
costly disease. In Thailand there exist some studies which
tried to estimate the cost of diabetes, however, these studies
focused either on provider or patient perspective, hence, one
cost component namely the cost of informal care had never
been evaluated [4–6]. Even in other countries, where societal
perspective was used to estimate cost of diabetes, this cost

∗
Corresponding author. Tel.: +66 2644 8678 91x5745; fax: +66 2644 8694.
E-mail addresses: s chatterjee 123@yahoo.com (S. Chatterjee), pyarp@mahidol.ac.th (A. Riewpaiboon), pinuch46@yahoo.com
(P. Piyauthakit), wachara16@gmail.com (W. Riewpaiboon).
1751-9918/$ – see front matter © 2011 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.pcd.2011.01.004
110 p r i m a r y c a r e d i a b e t e s 5 ( 2 0 1 1 ) 109–115
component was ignored [7,8]. The only study that evaluated
cost of informal care for elderly individuals with diabetes in
the US found that the cost was between USD 3 and 6 bil-
lion per year, similar to the estimates of the annual paid long
term care cost attributable to diabetes [9]. This emphasized
the importance of valuing the hidden cost related to informal
care in cost of illness analysis following societal perspec-
tive. Cost calculations and economic evaluations excluding
informal care might suggest interventions to be cost sav-
ing or cost effective, but this result might be simply because
of the exclusion of cost of informal care from the analysis
[10,11].
‘Informal care’ is the name given to the care provided
by people from a care recipient’s social network: family,
friends, acquaintances or neighbors [12]. Schulz and Beach
reported that providing informal care can be stressful and
may increase informal caregivers’ morbidity and mortality
risks [13]. Hence, in economic terms, the evidence for informal
caregivers’ increased morbidity and mortality risks due to
providing informal care implies that informal care is not free
when viewed over the medium and long term. Even in the
short term, the provision of informal care is not free, at the
very least it entails opportunity cost in terms of foregone paid
work, unpaid work and leisure [14–18]. Hence, determining
the cost of informal care is important in formulating health
policy, because it reveals society’s opportunity costs of caring
for people with various diseases and what could be saved by
eradicating them [19].
Though relatively little research had focused specifically on
informal caregiving for diabetes [9,20], a significant literature
exist regarding the economic effects of informal caregiving for
dementia and stroke [21–26]. Most studies had found that the
cost associated with unpaid informal caregiver time account
for a majority of the total cost of the disease. Given this back-
drop, the objective of the present study was to estimate the
cost of informal care for the diabetic patients at a public dis-
trict hospital in Thailand.
2. Methods
2.1. Study site and study population
The study was conducted at Waritchaphum hospital, a public
district hospital in Waritchaphum district of Sakhon Nakhon
province in Thailand. As the present study was the first study
which estimated cost of informal care for diabetic patients in
Thailand, hence, there was no sufficient background informa-
tion to calculate a formal sample size for this study. Based on
available resources [27] and sample size used in one informal
care study in Thailand [26], for this study the sample size was
fixed at 475. A total of 1415 diabetic patients (inpatients and
outpatients taken together) received treatment from the study
hospital in 2008. Assuming non-availability and refusal rate of
15%, 546 patients were randomly selected from the electronic
diabetic patient database of the study hospital and were tar-
geted to be sequentially contacted for this study. The study
team stopped contacting patients as soon as complete data
were available from 475 diabetic patients (the pre-determined
sample size for this study). When contacted for interview,
five patients were not available and three refused to be inter-
viewed.
Information of informal caregiving was collected through
direct personal interview method either from the patients or
from the caregivers. The caregivers were approached when the
patients were not sure about the activities of their informal
caregivers. A structured pre-tested questionnaire was admin-
istered to obtain those information. The data collection was
done by a team of trained health centre and hospital staff of
Waritchaphum district during January and March 2009. The
study got ethical clearance from the Institutional Review Board
of Mahidol University, Bangkok, Thailand. Written informed
consent was obtained from all respondents who participated
in this study.
2.2. Conceptual framework of informal care
There are several methods for measurement of time of
informal care. The most important methods are the diary,
considered the gold standard, and the recall method [11].
In diary method, respondents are asked to write down all
their activities during a specific period of time. This method
has an important disadvantage as it requires a lot of time
and effort from the respondents and is also very costly for
the researchers. Therefore this method cannot be used in
all situations. A less demanding method like recall method
is then preferred, even though a major concern with this
retrospective way of questioning is its reliability because of
recall bias [11]. Given this disadvantage, for convenience, in
this study the data on time spent for informal care were
collected by using recall method. The recall period was 1
month prior from the date of interview. In this study, it was
hypothesized that the informal care was needed for activi-
ties of daily living (ADL), household activities of daily living
(HDL) and instrumental activities of daily living (IADL). These
concepts were followed from Van den Berg et al. [28]. For
treating diabetes and its complications, a number of medi-
cations are required. Further, as the disease becomes severe,
the medical regimen becomes complex. Hence, the diabetic
patients need help for managing medications, glucose moni-
toring, foot care, etc. To capture these, an additional activity
namely health care activities (HCA) was added. Informal care-
givers were asked how many minutes per day they spent
on all the activities taken together mentioned under HCA.
The ADL include personal care, moving around in the house,
going to the toilet, bathing, dressing, eating and drinking,
etc. Here also they were asked how many minutes they
spent per day on all the activities taken together men-
tioned under ADL. The HDL includes preparation of food
and drinks, cleaning the house, dishes, washing, ironing,
sewing, etc. For the activities under HDL, informal care-
givers were asked how many hours per day they spent
on all these activities taken together. IADL include making
trips and visiting family or friends, health care contacts,
going to the bank, etc. The time spent on all the activi-
ties taken together under IADL was measured in hours per
month. While asking these questions, it was made clear
that only the additional part of housework due to the dis-
ease of the care recipient should be counted as informal
care.
 p r i m a r y c a r e d i a b e t e s 5 ( 2 0 1 1 ) 109–115
Informal Caregiver (Yes)
One Caregiver (n=104)
Number of caregivers 104x1=104
Total Number of Caregivers = 190
Fig. 1 – Distribution of informal caregivers (N = 190).
2.3. Valuation methods for informal care
The major problem in valuing informal care is that by def-
inition no market prices exist [10]. It is often argued that
informal care should be valued with the opportunity cost
method [18,29,30]. The opportunity costs of informal care are
the informal caregivers’ benefits foregone due to spending
time on providing informal care. In opportunity cost approach,
time can be valued in two ways viz. productivity cost approach
and time cost approach. The productivity cost approach covers
time of caregivers who still work while time cost approach cov-
ers the time spent by all caregivers. An alternative, proxy good
method, is also proposed [30]. This method values time spent
on informal care at the labour market price of a close mar-
ket substitute. The opportunity cost method and proxy good
method are termed as revealed preference method. Informal
care can be valued by stated preference method as well like
contingent valuation method and conjoint valuation method
[31,32]. However, opportunity costs and proxy good methods
are most advocated and most often used. One important rea-
son for recommendations to use either one of these methods
may be their relatively straightforward application [28].
Hence, in this study, informal care was valued by using
revealed preference method. While valuing informal care by
opportunity cost approach, time-cost approach was followed
and minimum official wage rate of Sakhon Nakhon province,
USD 4.63 per day (1 USD = 32 Thai Baht) was used as the base
case [33]. As majority of the informal caregivers were either
agriculturists or labourers, they did not have regular income.
Further, some of them might had earned more than the min-
imum official wage while some others earned less than that,
hence, in order to average out the differences in earning power
of the informal caregivers, minimum wage rate was used.
For valuing informal care using proxy good method, earn-
ings (defined as wage plus other monetary and non-monetary
benefits such as bonus, overtime, meal, etc.) from household
work and from health and social work in 2003 were used. Nom-
inal wages for 2008 (the study year) were calculated using 2003
wages and the consumer price index. According to the Labour
Protection Act B.E. 2541, working time per week cannot exceed
48 h. Based on this, a total working time per month of 192 h was
used to calculate the hourly wage rate. Earnings from health
and social work USD 3.03 per day for Sakhon Nakhon were
used for both HCA and ADL while earning from household
111
Total respondent
N=475
Informal Caregiver (No)
n=142 n=333
Two Caregivers (n=28) Three Caregivers (n=10)
Number of caregivers 28x2=56 Number of caregivers 10x3=30
work USD 4.47 per day for Sakhon Nakhon was used for both
HDL and IADL [34].
A sensitivity analysis examines the effect on the study
results of systematic changes in key assumptions or param-
eters. In order to capture how the assumption of use of
minimum wage rate of Sakhon Nakhon province affected the
cost of informal care in opportunity cost method, sensitivity
analysis was conducted by using minimum wage rate for the
country as a whole. In proxy good method, one-way sensitivity
analysis was performed by using the earnings for the country
as a whole from the respective work, i.e. USD 4.78 per day for
household work and USD 5.16 per day for health and social
work.
3. Results
3.1. Characteristics of the informal caregivers and the
care recipients
Among 475 study participants, 142 (29.9%) reported that they
had informal caregivers. One hundred and four (21.89%) study
participants had one informal caregiver, 28 (5.89%) had two
informal caregivers and 10 (2.10%) participants had three care-
givers. Thus the present study covered a total of 190 informal
caregivers. The distribution is presented in Fig. 1.
The mean ± standard deviation (SD) age of the informal
caregivers was 45.28 (±16.65) years with maximum and mini-
mum age 79 years and 9 years, respectively (Table 1). Females
were relatively more engaged in informal caregiving as com-
pared to their male counterparts (52.6% vs. 47.4%), although
differences were small. Most of the informal caregivers had
primary education (65.3%) and were engaged in farming
(52.6%). Sons/daughters of the patients commonly served as
informal caregiver (40.5%), however, spouses were also sig-
nificantly engaged in informal caregiving (35.3%). Most of the
informal caregivers were married (76.3%) and shared the same
houses with the care recipients (87.4%).
While looking at the characteristics of the care recipients,
it was found that they had higher mean age as compared to
those who did not need informal caregivers (p = 0.001) (Table 2).
Group comparisons were done by unpaired t test and statisti-
cal significance was declared when p value was less than 0.05.
The presence of complications and disability (as measured by
112 p r i m a r y c a r e d i a b e t e s 5 ( 2 0 1 1 ) 109–115

3.2. Time foregone and monetary value of informal

Table 1 – Characteristics of informal caregivers (N = 190).
care
Characteristics Number Percentage
Age The informal caregivers spent maximum time in perform-
Less than 25 years 22 11.58 ing HDL (Table 3). Their mean (±SD) time spent on HDL
25–34 years 30 15.79
was 42.21 (±39.94) hours per month, followed by IADL
35–44 years 41 21.58
(mean ± SD = 9.28 ± 25.90), ADL (mean ± SD = 6.79 ± 15.45) and
45–54 years 32 16.84
55–64 years 41 21.58 HCA (mean ± SD = 5.80 ± 10.13). As regards mean monetary
65 years and above 24 12.63 value of informal caregiving, as per opportunity cost approach
Gender the same was USD 37.17 per month while as per proxy good
Male 90 47.40 method it was USD 33.54 per month. To analyze robustness of
Female 100 52.60 results, sensitivity analysis was conducted. In case of opportu-
Marital status
nity cost approach, country minimum wage rate was used for
Single 34 17.90
sensitivity analysis and for proxy good method country aver-
Married 145 76.30
Divorced/widow 11 5.80 age earnings from household work and from health and social
Education work were considered. The recalculation results showed that
Primary education 124 65.30 for opportunity cost approach, the mean cost increased by 7%
Secondary education 49 25.80 while for proxy good method, the same increased by 16%.
Diploma 2 1.10
Bachelor degree 15 7.90
Occupation 4. Discussion
Housewife 8 4.20
Agriculturist 100 52.60
The demographic characteristics of the study sample were
Labour 38 20.00
Student 13 6.80 similar to those of all diabetic patients received treatment
Govt. officials 13 6.80 from the study hospital during the study period. For exam-
Retired person 14 7.40 ple, mean age and percentage of female patients in all diabetic
Others 4 2.10 patients at the study hospital were 59.77 years and 73% respec-
Relation with the patient tively while the same for the study sample was 59.34 years
Parents 4 2.10
and 74.5%, respectively. As regards disease characteristics of
Spouse 67 35.30
Children 77 40.50
the study participants, the mean duration of the disease was
In-laws 16 8.40 7.20 years, most of the patients had type 2 diabetes (99%)
Brother/sister 7 3.70 and the mean fasting blood sugar level was 156.06 mg/dl. All
Grand children 15 7.90 these results are also comparable with other diabetic studies
Others 4 2.10 in Thailand. For example, Nitiyanant et al., Riewpaiboon et al.
Living arrangements
and Chaikledkaew et al. found 94.7%, 94%, 96% and 99% type
Same house with the patient 166 87.40
2 diabetic patients respectively in their studies in Thailand
Others 24 12.60
Transport for those staying outside [1,6,36,37]. Nitiyanant et al. noted average disease duration 6.2
Walk 12 50.00 and 8.7 years respectively and fasting blood sugar level 167.27
Motorcycle 8 33.33 and 150.91 mg/dl respectively among the diabetic patients in
Others 4 16.67 Thailand [1,36].
The characteristics of the informal caregivers in the present
study were quite similar to those found in a recent study on
informal care of disabled stroke survivors in Thailand [26]. The
using Barthel index score) was significantly higher among the mean age of the informal caregivers in the present study was
care recipients as compared to their counterparts [35]. Fur- 45 years while the same for the other study was 46 years. Both
ther, the care recipients had higher hospitalization rate and studies found that the females were relatively more engaged
they visited more frequently to the provincial hospital. in informal caregiving. This was probably because of typical

Table 2 – Characteristics of the care recipients.

Characteristics Caregiver P value

Yes No
Duration of the disease (mean ± SD) 8.28 ± 6.34 6.74 ± 6.38 0.160
Age (mean ± SD) 62.22 ± 12.31 58.13 ± 10.78 0.001
Fasting blood sugar level (mean ± SD) 158.32 ± 42.21 155.13 ± 35.31 0.435
Presence of co-morbidity (%) 68.31 63.36 0.296
Presence of complications (%) 47.89 24.02 0.000
Presence of disability (%) 29.58 6.61 0.000
Rate of hospitalization (%) 24.65 6.91 0.000
Visit to provincial hospital (%) 14.08 6.01 0.013
 p r i m a r y c a r e d i a b e t e s 5 ( 2 0 1 1 ) 109–115
Table 3 – Time foregone and monetary value of informal care (N = 190).
Time spent on (hours per month)
HCA
ADL
HDL
IADL
Cost per month (USD)
Opportunity cost method
Proxy good method
Sensitivity – opportunity cost method
Sensitivity – proxy good method
HCA = health care activities, e.g. taking medicines; ADL = activities of daily living, e.g. eating and dressing; HDL = household activities of daily
living, e.g. shopping and preparing food; IADL = instrumental activities of daily living, e.g. visit to the clinic and relatives.
Thai family culture where females are primarily responsible
for household tasks, including providing care to all family
members including sick or disabled persons. However, sev-
eral other studies conducted in different parts of the world
also noticed that the females actually provided more informal
care than males. Further, sons/daughters of the patients com-
monly served as informal caregivers followed by the spouses.
This finding was also similar with the study in Thailand as
well as studies in other countries [15,21,26,38]. As diabetes is
a chronic illness and generally has an onset in mid life and
reveal complications and consequently disability in the late
life, sons/daughters or spouses were found mostly serving as
informal caregivers instead of parents who usually serve as
informal caregivers in case of life-long disability.
While looking at the informal caregivers’ time spent on
different activities, it was found that maximum time was
spent for HDL. This finding was consistent with Van den
Berg et al. where time spent by the informal caregivers was
calculated for stroke and rheumatoid arthritis patients in
The Netherlands but contradicted the finding of a recent
stroke study in Thailand where it was found that most care-
givers performed ADL tasks followed by HDL tasks [28,39].
Even though diabetes, stroke and rheumatoid arthritis all
are chronic illnesses but stroke is an acute condition with
immediate acute mobility disability while both diabetes and
rheumatoid arthritis are slowly progressive chronic disease
with slow progression of disability. Because of the progres-
sive onset of disability among the diabetic patients, probably
they mostly needed help for HDL tasks followed by IADL. As
per the Thai culture, the sick or elderly persons are generally
taken care of by their family members and there are several
cases where the patients cannot access the rehabilitation ser-
vices for improving their functional capacity to perform even
the ADL. This is probably another reason for the caregivers per-
formed more ADL tasks in case of disabled stroke survivors in
Thailand. Another possible reason of longer time spent on HDL
activities by the informal caregivers of diabetic patients could
be that “normal” HDL tasks were not fully separated from addi-
tional HDL task. This reason was mentioned by Van den Berg
et al. as well [28]. There exist some studies which incorporated
HDL tasks mentioned in this study under IADL [40,41]. If these
two types are clubbed in the present study, the informal care-
givers were found to spend on average 51.5 h per month on
the new broad IADL category.
113
Mean SD Median
5.80 10.13 0.00
6.79 15.45 0.00
42.21 39.94 30.00
9.28 25.90 2.00
Mean Median Inter-quartile range
37.17 26.77 9.28–52.20
33.54 22.63 6.53–50.29
39.80 28.67 9.94–55.90
38.89 28.15 10.24–53.78
The cost of informal care was calculated by using both
opportunity cost and proxy good method. Several studies
had shown that the opportunity cost method yielded lower
results than the proxy good method [21,25]. However, con-
trary to those studies, in the present study the cost of informal
care was lower in case of proxy good method (USD 6372 per
month) as compared to opportunity cost method (USD 7062
per month). This was because those studies calculated only
the cost of informal caregivers’ leisure time foregone and
therefore, opportunity cost was valued at one-third of the aver-
age wage or minimum wage rate. However, in the present
study, no differentiation was made between foregone paid,
unpaid and leisure work, hence, all these foregone activities
were valued equally by using official average minimum wage
of Sakhon Nakhon province. Further, the earnings from health
and social work (USD 3.03 per day) and from household work
(USD 4.47 per day) which were used to calculate cost as per
proxy good method were lower than the minimum average
wage used to calculate cost as per opportunity cost method
(USD 4.63 per day). Hence, the cost obtained using proxy good
method was lower than the same obtained from opportunity
cost approach.
Apart from the economic burden, there is growing evidence
that informal care has adverse effects on informal caregivers
in terms of quality of life [13]. Further, providing informal
care affects labour market participation [14]. In the present
study, most of the caregivers (about 54%) were in the most pro-
ductive age group of 25–54 years. The average time spent on
informal care was 112.38 h per month. This might have some
impact on labour market participation in the Thai society. On
the other hand, increased labour market participation would
reduce the supply of informal care, which in turn, would force
some care recipients to accept institutionalized care instead
of being cared for at home which would be more costly from a
health care budget perspective. Another point to note here is
that among 142 study participants who reported to have infor-
mal caregivers, 35 (about 25%) were hospitalized during the
study period. The average cost of informal care (using opportu-
nity cost approach) for the hospitalized patients was USD 79.87
as compared to USD 60.10 (p = 0.17) for the non-hospitalized
patients. Hence, while allocating funds for health care, the
policy makers should use the information on cost of infor-
mal care as well as other factors related to informal care. An
increased attention for informal care is also important as the
114 p r i m a r y c a r e d i a b e t e s 5 ( 2 0 1 1 ) 109–115
demand for informal care is likely to increase in future due to
the aging of the Thai population.
The following potential limitations of the present study
merit comment. First, the time spent for informal care was
recorded by using recall method while the diary method is
considered as gold standard. However, given the disadvan-
tages attached with diary method such as it requires a lot of
time and effort from the respondents and the cost involves in
applying this method, a less demanding method, i.e. the recall
method is preferred. Second, it was found that the informal
caregivers spent maximum time on HDL and that time was
significantly higher than times spent for all other activities.
One possible reason of such finding could be that “normal”
HDL tasks were not fully separated from additional HDL task.
However, in this study no attempts were made to compare HDL
performed by general population and the study caregivers.
Even though during the survey it was mentioned repeatedly
that only the additional part of housework due to the disease
of the care recipient should be counted as informal care, but
still it may be difficult for respondents, especially in cases
where informal care has been provided many years already, to
distinguish between normal tasks and informal care. Hence,
the estimates presented in this study particularly related to
HDL might be a bit overestimated. Third, due to lack of neces-
sary data, this study was unable to assess whether informal
care was associated with significant negative health effects
among caregivers. Future research should focus on whether
such negative health effects occur and if so, whether these are
unique aspects of diabetes caregiving. Such research would
help guide potential caregiver interventions aimed at reducing
the negative health outcomes of the caregivers.
The present study concluded that the hidden cost associ-
ated with informal caregiving is a burden for the Thai society.
A recent study estimated cost of diabetes from societal per-
spective in Thailand and found that the cost of informal care
was the highest individual cost component in total cost of
illness of diabetes (about 28%) and for that the contribution
of direct non-medical cost was the highest in total cost of
diabetes (about 40%) while the contributions of direct med-
ical cost and indirect cost were 23% and 37%, respectively
[42]. Hence, the policy makers should consider the economic
cost associated with informal caregiving for future analyses of
both the public health consequences of diabetes and interven-
tions aimed at decreasing diabetic complications. However,
to strengthen this argument a large-scale study to estimate
cost of informal care among the diabetic patients in Thailand
should be conducted as the present study reported the esti-
mates for 475 diabetic patients in a public district hospital in
Thailand.
Conflict of interest statement
No conflicts of interest have been declared.
Acknowledgements
The present study was a part of the research project under the
fellowship program “Asia Fellows Awards 2008–09 (Cohort 10)”
of the first author. The fellowship program was administered
by the Asian Scholarship Foundation, Bangkok, Thailand and
funded by the Ford Foundation. We express our gratitude to the
Asian Scholarship Foundation, Bangkok, Thailand for provid-
ing the opportunity of conducting the research. We are grateful
to the National Research Council of Thailand for giving per-
mission of conducting the present study in Thailand. We
thank Faculty of Pharmacy, Mahidol University, Bangkok, for
being the host institute of the research project. Special thanks
go to the professors and students of Division of Social and
Administrative Pharmacy, Department of Pharmacy, Mahidol
University for their help and support at various stages of this
research. Finally, we are indebted to all staff of Waritchaphum
hospital and health centres for their support and co-operation
during data collection.
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