Journal of Preventive Medicine and Public Health

Systematic Review

Adjusting for Confounders in Outcome Studies Using the Korea National Health Insurance Claim Database: A Review of Methods and Applications: Seung Jin Han, Kyoung-Hoon Kim; Received June 1, 2023 Accepted October 30, 2023 Published online November 16, 2023; DOI: https://doi.org/10.3961/jpmph.23.250 [Accepted]

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Abstract PDF: Objectives
Adjusting for potential confounders is crucial for producing valuable evidence in outcome studies. Although numerous studies have been published using the Korea National Health Insurance Claim Database, no study has critically reviewed the methods used to adjust for confounders. This study aimed to review these studies and suggest methods and applications to adjust for confounders.
Methods
We conducted a literature search of electronic databases, including PubMed and Embase, from January 1, 2021 to December 31, 2022. In total, 278 studies were retrieved. Eligibility criteria were published in English and outcome studies. A literature search and article screening were independently performed by 2 authors and finally, 173 of 278 studies were included.
Results
Thirty-nine studies used matching at the study design stage, and 171 adjusted for confounders using regression analysis or propensity scores at the analysis stage. Of these, 125 conducted regression analyses based on the study questions. Propensity score matching was the most common method involving propensity scores. A total of 171 studies included age and/or sex as confounders. Comorbidities and healthcare utilization, including medications and procedures, were used as confounders in 146 and 82 studies, respectively.
Conclusions
This is the first review to address the methods and applications used to adjust for confounders in recently published studies. Our results indicate that all studies adjusted for confounders with appropriate study designs and statistical methodologies; however, a thorough understanding and careful application of confounding variables are required to avoid erroneous results.; Summary

Original Articles

Impact of Physical Activity on the Association Between Unhealthy Adolescent Behaviors and Anxiety Among Korean Adolescents: A Cross-sectional Study: Hyo-jung Lee, Jeong-Pil Choi, Kunhee Oh, Jin-Young Min, Kyoung-Bok Min; Received July 9, 2023 Accepted October 26, 2023 Published online November 15, 2023; DOI: https://doi.org/10.3961/jpmph.23.313 [Accepted]

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Abstract PDF: Objectives
Adolescents who engage in unhealthy behaviors are particularly vulnerable to anxiety. We hypothesized that participation in physical activity could influence the relationship between anxiety and unhealthy behaviors in adolescents. These behaviors include smoking, alcohol consumption, and unsafe sexual activity.
Methods
This study included 50,301 students from the first year of middle school to the third year of high school, all from Korea. The unhealthy adolescent behaviors examined included current alcohol consumption, current smoking, and unsafe sexual behavior. Anxiety levels were assessed using the Generalized Anxiety Disorder-7 questionnaire (GAD-7).
Results
The participants had a mean age of 15.19 years and an average GAD-7 score of 4.23. No significant differences were observed in GAD-7 score among exercising participants when categorized by smoking status (p=0.8352) or unsafe sexual behavior (p=0.4895). In contrast, participants in the non-exercise group who engaged in these behaviors demonstrated significantly higher GAD-7 scores (p<0.0001 and p=0.0162, respectively). The only significant interaction was found between unsafe sexual behavior and exercise (p=0.0086). Based on logistic regression analysis, within the non-exercise group, significant positive associations were observed between current smoking and anxiety (OR, 1.36; 95% CI, 1.18-1.57), as well as between unsafe sexual behavior and anxiety (OR, 1.33; 95% CI, 1.02-1.73). However, within the exercise group, no significant association was found between anxiety and either smoking or unsafe sexual behavior. Furthermore, no significant interaction was observed between unhealthy behaviors and exercise.
Conclusions
These findings are insufficient to conclude that physical activity influences the relationship between unhealthy behaviors and anxiety.; Summary

Teachers\' Negative Attitudes and Limited Health Literacy Levels as Risks for Low Awareness of Epilepsy: Gulay Yilmazel; Received July 20, 2023 Accepted November 6, 2023 Published online November 13, 2023; DOI: https://doi.org/10.3961/jpmph.23.330 [Accepted]

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Abstract PDF: Objectives
For students with epilepsy, schools are a critical environment for managing the disease properly. This study examined awareness of epilepsy, attitudes toward epilepsy, and health literacy among school teachers in Turkey.
Methods
This study was conducted in a city in Turkey with 1408 public school teachers from June 2021 to September 2021.
Results
The median scores of the scales were 5, 29, and 32 for epilepsy awareness, epilepsy attitudes, and health literacy, respectively. Epilepsy awareness was higher in women, and epilepsy attitudes were more positive in women than men (p<0.05). While epilepsy awareness was higher in primary school teachers, epilepsy attitudes were more positive in secondary school teachers (p<0.05). Epilepsy awareness was lower in secondary school teachers (odds ratio [OR], 1.27), those who did not have an individual with epilepsy in their family/social environment (OR, 1.57), those who did not have a student with epilepsy in their class (OR, 1.45), and in those who had not witnessed an epilepsy seizure (OR, 1.19) (p<0.001, <0.05). Compared to those with positive attitudes regarding epilepsy, epilepsy awareness was 1.36 times lower in those with negative attitudes. Epilepsy awareness was 1.92 times lower in those with limited health literacy than those with adequate health literacy (p<0.001).
Conclusions
In this study, low epilepsy awareness, negative epilepsy attitudes, and limited health literacy were common among teachers. The findings from this study suggest that panels, workshops, and health training on epilepsy should be organized for school teachers and included at regular intervals in certified first-aid practices.; Summary

Changes in Adolescent Health Behavior and the Exacerbation of Economic Hardship During the COVID-19 Pandemic: A Cross-sectional Study from the Korea Youth Risk Behavior Survey: Chaeeun Kim, Haeun Lee, Kyung-Hee Jung-Choi, Hyesook Park; Received July 6, 2023 Accepted October 26, 2023 Published online November 11, 2023; DOI: https://doi.org/10.3961/jpmph.23.306 [Accepted]

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Abstract PDF: Objectives
This study investigated the association between exacerbated economic hardship during the coronavirus disease 2019 (COVID-19) pandemic and changes in the health behaviors of Korean adolescents.
Methods
We analyzed data from the 2021 Korea Youth Risk Behavior Survey and included 44,908 students (22,823 boys and 22,085 girls) as study subjects. The dependent variables included changes in health behaviors (breakfast habits, physical activity, and alcohol use) that occurred during the COVID-19 pandemic. The aggravation of economic hardship by COVID-19 and the subjective economic status of the family were used as exposure variables. Multiple logistic regression analysis was utilized to calculate the prevalence odds ratios (PORs).
Results
Severe exacerbation of a family’s economic hardship due to COVID-19 was negatively associated with the health behaviors of adolescents, including increased breakfast skipping (POR=1.85; 95% CI, 1.55-2.21 for boys and POR=1.56; 95% CI, 1.27-1.92 for girls) and decreased physical activity (POR=1.37; 95% CI, 1.19-1.57 for boys and POR=1.38; 95% CI, 1.19-1.60 for girls). These negative changes in health behaviors were further amplified when combined with a low subjective family economic status.
Conclusions
The experience of worsening household hardship can lead to negative changes in health behavior among adolescents. It is crucial to implement measures that address the economic challenges that arise from stressful events such as COVID-19 and to strive to improve the lifestyles of adolescents under such circumstances.; Summary

Risks for Readmission Among Older Patients With Chronic Obstructive Pulmonary Disease: An Analysis Using Korean National Health Insurance Service – Senior Cohort Data: Yu Seong Hwang, Heui Sug Jo; Received August 2, 2023 Accepted October 30, 2023 Published online November 10, 2023; DOI: https://doi.org/10.3961/jpmph.23.346 [Accepted]

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Abstract PDF: Objectives
The high readmission rate of patients with chronic obstructive pulmonary disease (COPD) has led to the worldwide establishment of proactive measures for identifying and mitigating readmissions. This study aimed to identify factors associated with readmission, as well as groups particularly vulnerable to readmission that require transitional care services.
Methods
To apply transitional care services that are compatible with Korea’s circumstances, targeted groups that are particularly vulnerable to readmission should be identified. Therefore, using the National Health Insurance Service’s Senior Cohort database, we analyzed data from 4874 patients who were first hospitalized with COPD from 2009 to 2019 to define and analyze readmissions within 30 days after discharge. Logistic regression analysis was performed to determine factors correlated with readmission within 30 days.
Results
The likelihood of readmission was associated with older age (for individuals in their 80s vs. those in their 50s: odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19 to 2.12), medical insurance type (for workplace subscribers vs. local subscribers: OR, 0.84; 95% CI, 0.72 to 0.99), type of hospital (those with 300 beds or more vs. fewer beds: OR, 0.77; 95% CI, 0.66 to 0.90), and healthcare organization location (provincial areas vs. the capital area: OR, 1.66; 95% CI, 1.14 to 2.41).
Conclusions
Older patients, patients holding a local subscriber insurance qualification, individuals admitted to hospitals with fewer than 300 beds, and those admitted to provincial hospitals are suggested to be higher-priority for transitional care services.; Summary

Comorbid Conditions in Persons Exposed to Ionizing Radiation and Veterans of the Soviet–Afghan War: A Cohort Study in Kazakhstan: Saule Sarkulova, Roza Tatayeva, Dinara Urazalina, Ekaterina Ossadchaya, Venera Rakhmetova; Received July 24, 2023 Accepted October 6, 2023 Published online November 1, 2023; DOI: https://doi.org/10.3961/jpmph.23.333 [Accepted]

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Abstract PDF: Objectives
This study investigated the prevalence and characteristics of comorbid conditions in patients exposed to ionizing radiation and those who were involved in the Soviet–Afghan war.
Methods
This study analyzed the frequency and spectrum of morbidity and comorbidity in patients over a long-term period (30-35 years) following exposure to ionizing radiation at the Semipalatinsk nuclear test site or the Chornobyl nuclear power plant, and among participants of the Soviet–Afghan war. A cohort study, both prospective and retrospective, was conducted on 675 patients who underwent comprehensive examinations.
Results
Numerical data were analyzed using the STATISTICA 6 program. The results are presented as the mean ± standard deviation, median, and interquartile range (25th–75th percentiles). The statistical significance of between-group differences was assessed using the Student t-test and Pearson chi-square test. A p-value of less than 0.05 was considered statistically significant. We found a high prevalence of cardiovascular diseases, including hypertension (55%) and cardiac ischemia (32.9%); these rates exceeded the average for this age group in the general population.
Conclusions
The cumulative impact of causal occupational, environmental, and ultra-high stress factors in the combat zone in participants of the Soviet–Afghan war, along with common conventional factors, contributed to the formation of a specific comorbidity structure. This necessitates a rational approach to identifying early predictors of cardiovascular events and central nervous system disorders, as well as pathognomonic clinical symptoms in this patient cohort. It also underscores the importance of selecting suitable methods and strategies for implementing treatment and prevention measures.; Summary

An Important Strategy to Improve Adolescent Health Literacy: COVID-19 Modules in High School in a Developing Country: Nurina Hasanatuludhhiyah, Visuddho Visuddho, Abdul Khairul Rizki Purba, Annette d' Arqom, Ancah Caesarina Novi Marchianti; Received March 1, 2023 Accepted October 6, 2023 Published online November 1, 2023; DOI: https://doi.org/10.3961/jpmph.23.113 [Accepted]

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Abstract PDF: Objectives
During the second coronavirus disease 2019 (COVID-19) surge, cases increased sharply due to low awareness and compliance with measures to limit disease spread. Health literacy (HL) is an important component of public health initiatives, and schools are potential sources of health education to increase HL via the presentation of COVID-19 educational modules.
Methods
This cross-sectional study involved an online questionnaire administered to students from 5 high schools in Surabaya and Sidoarjo, Indonesia, 6–7 weeks after the start of government-issued directives restricting public gatherings. We collected data on each respondent’s age, gender, parental education, and socio-economic variables. HL was determined by the Health Literacy Measure for Adolescents (HELMA). We additionally measured their attitudes and behaviors related to preventing the spread of COVID-19. The students were asked if they watched the COVID-19 module at school, their feelings about vaccination, and preferred online sources of COVID-19-related information.
Results
Most of the 432 respondents had viewed COVID-19 modules at school. Module exposure was associated with significantly higher total and domain-specific HL and more positive attitudes toward government-issued COVID-19 restrictions on travel and public gatherings (p<0.05). However, behaviors to prevent COVID-19 spread and vaccine acceptance were not associated with module exposure. Most students chose social media as their source of COVID-19-related information.
Conclusions
Schools can provide information to increase adolescents’ HL and the public’s support for health initiatives to prevent or limit the spread of COVID-19.; Summary

Vaccination Status and In-Hospital Mortality among Adults with COVID-19 in Jakarta, Indonesia: A Retrospective Hospital-based Cohort Study: Hotma Martogi Lorensi Hutapea, Pandji Wibawa Dhewantara, Anton Suryatma, Raras Anasi, Harimat Hendarwan, Mondastri Korib Sudaryo, Dwi Gayatri; Received August 16, 2023 Accepted October 20, 2023 Published online October 30, 2023; DOI: https://doi.org/10.3961/jpmph.23.360 [Accepted]

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Abstract: Objective
Prospective studies on vaccination status and mortality related to coronavirus disease 2019 (COVID-19) in low-resource settings are still limited. We assessed the association between vaccination status (full, partial, or none) and in-hospital mortality among COVID-19 patients at most hospitals in Jakarta, Indonesia during the Delta predomination wave.
Methods
We conducted a retrospective cohort study among hospitalized COVID-19 patients who met the study criteria (>18 years old and admitted for inpatient treatment because of laboratory-confirmed SARS-CoV-2 infection). We linked individual-level data in the hospital admission database with vaccination records. Several sociodemographic and clinical characteristics were also analyzed. A Cox proportional hazards regression model was used to explore the association between vaccination status and in-hospital mortality in this patient group.
Results
In total, 40,827 patients were included in this study. Of these, 70% were unvaccinated (n=28,543) and 19.3% (n=7,882) died during hospitalization. The mean age of the patients was 49 years (range, 35-59 years), 53.2% were female, 22.0% had hypertension, and 14.2% were treated in the intensive care unit, and the median hospital length of stay across the group was 9 days. Our study showed that the risk of in-hospital mortality among fully and partially vaccinated patients was lower than among unvaccinated adults (adjusted hazard ratio [aHR]=0.43; 95% confidence interval [CI], 0.40-0.47 and aHR=0.70; 95% CI, 0.64-0.77, respectively).
Conclusions
Vaccinated patients had fewer severe outcomes among hospitalized adults during the Delta wave in Jakarta. These features should be carefully considered by healthcare professionals in treating adults within this patient group.; Summary

Association between Parental BMI and Offspring’s Blood pressure by Mediation analysis, From Korean National Health and Nutrition Examination Survey (KNHANES): Hyowon Choi, Hunju Lee, Yeon-Soon Ahn; Received June 21, 2023 Accepted October 16, 2023 Published online October 30, 2023; DOI: https://doi.org/10.3961/jpmph.23.289 [Accepted]

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Abstract PDF: This study analyzed the relationship between parental BMI (BMI_p) and hypertension in their adolescent offspring (HTN_a), focusing on the mediating effect of adolescents’ BMI(BMI_a). The study utilized data from the Korea National Health and Nutrition Examination Survey, including 5,755 participants aged 12-18, and conducted mediation analysis while controlling for confounding factors such as age, gender, physical activity, dietary habits, household income quartile, and parents' alcohol and smoking habits. The study included a total of 5,755 participants, with 3,401 and 5,485 participants having data on fathers' and mothers' BMI, respectively. For child systolic blood pressure (SBP_a), the father's BMI (BMI_f) had a significant total effect (ß=0.21, 95% CI 0.11-0.31) and average controlled mediated effect (ACME) (ß=0.27, 95% CI 0.24-0.21), but the average direct effect (ADE) was not significant. The mother's BMI (BMI_m) had a significant total effect (ß=0.18, 95% CI 0.10-0.26), ACME (ß=0.26, 95% CI 0.23-0.29) and ADE (ß=-0.08, 95% CI -0.16-0.00). For child diastolic blood pressure (DBP_a), both BMI_f and BMI_m had significant ACME (ß=0.10, 95% CI 0.07-0.13), (ß=0.10, 95% CI 0.08-0.12), but insignificant ADE and total effects. The study found that parents' BMI has a significant effect on the SBP_a when mediated through their BMI. Therefore, high BMI of parents is a significant risk factor for systolic hypertension in children and adolescents, which requires appropriate management.; Summary

Healthcare Systems and COVID-19 Mortality in Selected OECD Countries: A Panel Quantile Regression Analysis: Jalil Safaei, Andisheh Saliminezhad; Received April 4, 2023 Accepted September 26, 2023 Published online October 15, 2023; DOI: https://doi.org/10.3961/jpmph.23.162 [Accepted]

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Abstract PDF: Objectives
The pandemic caused by coronavirus disease 2019 (COVID-19) has exerted an unprecedented impact on the health of populations worldwide. However, the adverse health consequences of the pandemic in terms of infection and mortality rates have varied across countries. In this study, we investigate whether COVID-19 mortality rates across a group of developed nations are associated with characteristics of their healthcare systems, beyond the differential policy responses in those countries.
Methods
To achieve the study objective, we distinguished healthcare systems based on the extent of healthcare decommodification. Using available daily data from 2020, 2021 and 2022, we applied quantile regression with nonadditive fixed effects to estimate mortality rates across quantiles. Our analysis began prior to vaccine development (in 2020) and continued after the vaccines were introduced (throughout 2021 and part of 2022).
Results
The findings indicate that higher testing rates, coupled with more stringent containment and public health measures, had a significant negative impact on the death rate in both pre-vaccination and post-vaccination models. The data from the post-vaccination model demonstrate that higher vaccination rates were associated with significant decreases in fatalities. Additionally, our research indicates that countries with healthcare systems characterized by high and medium levels of decommodification experienced lower mortality rates than those with healthcare systems involving low decommodification.
Conclusions
The results of this study indicate that stronger public health infrastructure and more inclusive social protections have mitigated the severity of the pandemic; Summary

The trajectory of depressive symptoms across years of community care utilization among older adults: a 14-year follow-up study using the ‘Korean Welfare Panel Survey’: Il-Ho Kim, Cheong-Seok Kim, Min-Hyeok Jeong; Received January 12, 2023 Accepted September 12, 2023 Published online October 6, 2023; DOI: https://doi.org/10.3961/jpmph.23.022 [Accepted]

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Abstract PDF: Objectives
While older adults using community care services are known to be vulnerable for depression, community care utilization may help to improve the mental health of these elderly. To date, however, it is much less clear how community care utilization affects depressive symptoms in the elderly population. This study focuses on the trajectory of depressive symptoms across years of community care utilization among older adults in South Korea.
Methods
Using the 2006-2019 Korean Welfare Panel Survey, this study is focused on elderly born in 1940 or earlier and selected 3,281 persons for baseline interviews in 2006. This consisted of 35,800 person-year observations during a period of 14 years. Panel data analysis were employed to construct years of community care utilization.
Results
After controlling for covariates, linear term of years using community care was negatively associated with depressive symptoms, but a quadratic term was positively significant. The trajectory of depressive symptoms across the years of community care utilization follows a U-shaped curve. Older adults in the first year of using community care reported the highest level of depressive symptoms. However, a significant and steady decrease in depressive symptoms was observed during the following 9 years of community care utilization, which then gradually increased. The level of depressive symptoms at the 14th year of using community care remains significantly lower than the level at the outset of its utilization.
Conclusions
This finding implies that community care utilization could be beneficial for improving mental health among older adults.; Summary

Multilevel Analysis of the Relationship Between Prescribing Institutions and Medication Adherence: Haryeom Ghang, Juhyang Lee; Received June 1, 2023 Accepted September 19, 2023 Published online October 5, 2023; DOI: https://doi.org/10.3961/jpmph.23.252 [Accepted]

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Abstract PDF: Objectives
This study investigated the relationship between prescribing institutions and medication adherence among patients newly diagnosed with hypertension and diabetes.
Methods
This study investigated patients with new prescriptions for hypertension and diabetes in Korea in 2019 with using data collected from general health screenings. A multilevel logistic regression model was applied to explore the relationship between patients’ first prescribing institution and their medication adherence, defined as a medication possession ratio (MPR) over 80%.
Results
The overall adherence rates were 53.7% and 56.0% among patients with hypertension and diabetes, respectively. The intraclass correlation coefficients were 13.2% for hypertension and 13.8% for diabetes (p<0.001), implying that the first prescribing institution had a significant role in medication adherence. With clinics as the reference group, all other types of hospitals showed an odds ratio (OR) less than 1, with the lowest for tertiary hospitals (OR=0.30 for hypertension, OR=0.45 for diabetes), and the next lowest in health screening specialized clinics (OR=0.51 for hypertension, OR=0.46 for diabetes). Among individual-level variables, female sex, older age, higher insurance premium level, and residing in cities were positively associated with adherence in both the hypertension and diabetes samples.
Conclusions
This study showed that the prescribing institution had a significant relationship with medication adherence. When the first prescribing institution was a clinic, newly diagnosed patients were more likely to adhere to their medication. These results highlight the important role played by primary care institutions in managing mild chronic diseases.; Summary

Correspondence

Letter to the Editor: Tobacco Use: Strategies for Prevention in Low and Middle-income Countries: Israel Oluwasegun Ayenigbara; J Prev Med Public Health. 2023;56(5):485-486. Published online September 26, 2023; DOI: https://doi.org/10.3961/jpmph.23.351

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PDF: Summary

Original Articles

Sleep Duration, Comorbidities, and Mortality in Korean Health Examinees: A Prospective Cohort Study: Sukhong Min, Woo-Kyoung Shin, Katherine De la Torre, Dan Huang, Hyung-Suk Yoon, Aesun Shin, Ji-Yeob Choi, Daehee Kang; J Prev Med Public Health. 2023;56(5):458-466. Published online September 26, 2023; DOI: https://doi.org/10.3961/jpmph.23.311

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Abstract Summary PDF Supplementary Material: Objectives
The association between long sleep duration and mortality is frequently attributed to the confounding influence of comorbidities. Nevertheless, past efforts to account for comorbidities have yielded inconsistent outcomes. The objective of this study was to evaluate this relationship using a large prospective cohort in Korea.
Methods
The study included 114 205 participants from the Health Examinees Study, who were followed for a median of 9.1 years. A composite comorbidity score was developed to summarize the effects of 21 diseases. Using Cox proportional hazards regression, hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause, cancer, and cardiovascular mortality associated with sleep duration were estimated. These estimates were adjusted for socio-demographic factors, lifestyle factors, body mass index, and comorbidity score. Additionally, a stratified analysis by subgroups with and without comorbidities was conducted.
Results
Throughout the follow-up period, 2675 deaths were recorded. After all adjustments, an association was observed between a sleep duration of 8 hours or more and all-cause mortality (HR, 1.10; 95% CI, 1.01 to 1.20). However, no such association was detected in the stratified analysis for the subgroups based on comorbidity status.
Conclusions
Long sleep duration was found to be associated with all-cause mortality among Koreans, even after adjusting for comorbidities. Additional studies are required to explore the mechanism underlying the association between sleep duration and major causes of mortality.; Summary

Korean summary
- 한국의 대규모 코호트 자료를 이용, 긴 수면 시간과 사망률 간의 연관성이 동반 상병으로 인한 교란 효과로 인한 것인지를 검토하였다. - 수면 시간과 총 사망률, 암 사망률, 심혈관질환 사망률 간의 연관성을 확인하였고, 이 중 총 사망률과 긴 수면 시간이 동반 상병 지수로 보정 한 뒤에도 유의한 연관성을 보였다.

Key Message
Using a large prospective cohort in Korea, the association between long sleep duration and mortality was evaluated, after adjusting for the confounding influence of comorbidities. When 114,205 participants from the Health Examinees Study were followed for a median of 9.1 years, sleep duration of 8 hours or more were found to be associated with all-cause mortality (HR, 1.10; 95% CI, 1.01 to 1.20). Additional studies are required to explore the mechanism underlying the association between sleep duration and major causes of mortality.

The Association Between PM_2.5 Exposure and Diabetes Mellitus Among Thai Army Personnel: Apisorn Laorattapong, Sarun Poobunjirdkul, Thanapoom Thanapoom, Wiroj Jiamjarasrangsi; J Prev Med Public Health. 2023;56(5):449-457. Published online September 26, 2023; DOI: https://doi.org/10.3961/jpmph.23.292

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Abstract Summary PDF Supplementary Material: Objectives
This study investigated the association between baseline exposures to particulate matter with a diameter < 2.5 microns (PM_2.5) and subsequent temporal changes in PM_2.5 exposure with the incidence of type 2 diabetes among Royal Thai Army personnel.
Methods
A retrospective cohort study was conducted using nationwide health check-up data from 21 325 Thai Army personnel between 2018 and 2021. Multilevel mixed-effects parametric survival statistics were utilized to analyze the relationship between baseline (i.e., PM_2.5-baseline) and subsequent changes (i.e., PM_2.5-change) in PM_2.5 exposure and the occurrence of type 2 diabetes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were employed to assess this association while considering covariates.
Results
There was a significant association between both PM_2.5 baseline and PM_2.5-change and the incidence of type 2 diabetes in a dose-response manner. Compared to quartile 1, the HRs for quartiles 2 to 4 of PM_2.5-baseline were 1.11 (95% CI, 0.74 to 1.65), 1.51 (95% CI, 1.00 to 2.28), and 1.77 (95% CI, 1.07 to 2.93), respectively. Similarly, the HRs for quartiles 2 to 4 of PM_2.5-change were 1.41 (95% CI, 1.14 to 1.75), 1.43 (95% CI, 1.13 to 1.81) and 2.40 (95% CI, 1.84 to 3.14), respectively.
Conclusions
Our findings contribute to existing evidence regarding the association between short-term and long-term exposure to PM_2.5 and the incidence of diabetes among personnel in the Royal Thai Army.; Summary

Key Message
We simultaneously investigated the impact of the baseline and temporal variations in the exposure to particulate matter (PM) with a diameter <2.5 microns (PM2.5) on type 2 diabetes risk among the Royal Thai Army personnel. We found stronger evidence on the impact of the temporal variation in PM2.5 exposure on the disease risk than that of the baseline variation. This finding may reflect the shorter time frame between the increased PM2.5 exposure and changes in fasting plasma glucose level.

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