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While directly observed treatment (DOT) has been recommended as the standard approach to tuberculosis control, empirical data on its feasibility and efficiency are still scarce. We conducted a controlled trial of DOT at 15 health care facilities at various levels of the government health care system in Thailand. A total of 836 patients diagnosed between August 1996 and October 1997 were randomly assigned to be treated either under DOT or self-supervised using monthly drug supplies (SS). Options for treatment supervisors were health staff, community members or members of the patients' families. Treatment outcomes were compared on the basis of cure, treatment-completion, default and death rates. In both study arms, treatment outcomes were improved compared to pre-study conditions. Cure and treatment-completion rates were significantly higher in the DOT cohort (76% and 84%) than in the SS group (67% and 76%). The benefits of DOT were more pronounced at district and provincial hospitals (DOT cure rate 81% vs. 69% in the SS group), while differences for patients treated at referral centres were non-significant (DOT cure rate 72% vs. 66% in the SS group). No significant differences in outcomes could be observed between patient groups receiving DOT under the various options for treatment supervisors. DOT appears especially suited for treatment at decentralized facilities. While a general focus on programme performance can improve outcomes, DOT provides significant additional benefits. If basic conditions are met, a DOT strategy can be tailored to country-specific conditions by exploring multiple observation options, without decreasing its effectiveness.

It is important to calculate the age-adjusted prevalence of osteopenia and osteoporosis to address the overall magnitude of the problem in Thai women. This will allow us to predict the socioeconomic impact of preventable chronic conditions such as osteoporosis. The results obtained from this study are important data for public health policy: maximizing bone mass throughout life as well as detection of important risk factors is essential.

Activities of daily living (ADL) of 703 Thai elderly people (aged 60+ years) living in a Bangkok slum community were studied with the aims of describing the prevalence of disability, considering the appropriateness of Western ADL scales and developing a new ADL index for Asian populations. The levels of disability found were higher than in industrial populations and the important areas of disability were in instrumental ADLs. The mean (SD) Barthel ADL Index (BAI) for the group was 19.5 (1.2) with a range of 10-20. The mean (SD) Office of Populations Censuses and Surveys (OPCS) disability score was 4.8 (1.9) with a range of 0-10 but was unsuitable for use in Thailand because of misinterpretation of behavioural and intellectual disability leading to 99% of subjects being scored as disabled. An analysis of the underlying dimensions making up ADL was conducted using factor analysis. Four dimensions of ADL were found: basic self-care ADLs, extended ADLs, mobility ADLs and continence. An extended ADL index suitable for use in developing countries was developed (the Chula ADL Index) which had strong hierarchical properties and high correlations with both the OPCS disability score and the Barthel ADL Index. Analysis of data derived from ADL instruments should consider each ADL dimension separately. The BAI is useful as an index of self-care ADL but the behaviour and intellectual disability sub-scales of the OPCS scale require further development for cross-cultural applications.

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