Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 1 | 23 ORIGINAL RESEARCH Health behavior, stress and obesity among working age women in Myanmar Win Mya Mya Htut1, Kittipong Sornlom1, Wongsa Loahasiriwong1 1 Faculty of Public Health, Khon Kaen University, Thailand. Corresponding author: Dr. Kittipong Sornlom; Address: Faculty of Public Health, Khon Kaen University, Thailand; Telephone: +66-0850020225l; Email: kittsorn@kku.ac.th Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 2 | 23 Abstract Aim: This study aimed to determine the prevalence of overweight and obesity and to investigate the association between socioeconomic factors, health behaviors, health literacy, knowledge, attitude, physical and mental health status, and overweight and obesity among working age women in Myanmar . Methods: A cross-sectional study was conducted among 1,094 women aged 18 to 59 years old who were recruited by using multistage random sampling from 12 townships out of 6 districts among three states/regions. A structured questionnaire was developed and applied to assess the prevalence of overweight and obesity. Generalized Linear Mixed Model (GLMM) was performed to determine the association between dependent and independent variables after controlling the effects of covariates presenting adjusted OR and 95% confidence interval. Results: More than half of the respondents were with overweight and obesity (51.28%; 95%CI: 48.31-54.23). The multivariable analysis indicated that factors significantly associated with overweight and obesity included; aged 31-59 years (Adjusted Odds Ratio (AOR) = 1.72, 95%CI:1.22- 2.40), living without family (AOR= 2.07, 95%CI:1.20-3.57), average monthly income ≥200,000MMK (AOR= 1.38, 95%CI:1.05-1.82), parity≥1 (AOR= 1.61, 95%CI: 1.17- 2.23), high fat & protein consumption ≥5-days per week (AOR= 2.90, 95%CI:1.91-4.39), alcohol consumption (AOR= 2.53, 95%CI:1.91-3.36) and moderate-severe stress (AOR= 1.47, 95%CI:1.11-1.94). Conclusion: More than half of working age women were with overweight and obesity. Socioeconomic status, health behavior and stress are the factors behind over nutrition. The findings provide relevant evidence to develop the appropriate policies and public health interventions in order to minimize the burden of overweight and obesity. Likewise, it is anticipated that this outcome would support the prevention of cardiovascular and other chronic diseases. Keywords: alcohol consumption, Generalized Linear Mixed Model, Myanmar, overweight and obesity. Conflicts of interest: None declared. Ethical Consideration: Ethical Consideration was taken from Khon Kaen University Ethics Committee in Human Research (the approval number, HE632117) and Department of Medical Research, Yangon, Myanmar (Approval number Ethics/DMR/2020/109). A coding scheme was used and every document was destroyed on completion of research. Written consent was obtained from all participants prior to participation. Acknowledgement: The authors would like to express our sincere appreciation to all working age women in study areas for the data collection. Special thanks to the Faculty of Public Health, Khon Kaen University, Thailand for the financial and technical support. Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 3 | 23 Introduction Globally, the prevalence of overweight and obesity have risen to nearly threefold since 1975 and as a result, more than 1.9 billion adults were overweight and over 650 million were obese (1). Moreover, in the low-and middle-income countries, over 115 million people are suffering from obesity related problems including non-communicable diseases (NCDs) like coronary heart disease, ischemic stroke, hypertension, diabetes mellitus and certain cancers such as endometrial carcinoma, colon cancer and breast cancer (2,3). Among the various risk factors responsible for the NCDs, obesity has been considered as one of the major risk factors (2,4). Myanmar is among the 23 countries with high burden of NCDs (4). As a result of epidemiological and socioeconomic transition in the last few decades, NCDs have emerged as main public health issues in Myanmar. Therefore, it is now facing double burden of diseases (5,6). Moreover, women are highly affected by overweight and obesity as compared to men (7). Evidence shows that the prevalence of overweight and obesity is in increasing trend in Myanmar, particularly among women. The trend of overweight among women in Myanmar has been raised from 22% to 28.1% and obese women from 8.4% to 13.1% during the period between 2009 and 2015 (6,8). Overweight and obesity have wide-range of genetic, socio-economic and behavioral factors, which consist of those who are women, urban residents, having high income, have low education, consuming high sugar daily, having deep fried foods, snacks, fatty foods, low fruits and vegetable intake, low physical activity, high stress and low health literacy level (8-15). While the general risk factors for overweight and obesity are known, the magnitude and strength of association of the factors and their significance may vary depending on socioeconomic background, ethnic groups and the place where they reside (i.e. townships/states and regions). Hence, this study was conducted to assess the prevalence and the influence of socioeconomic factors, health behaviors, health literacy, knowledge, attitude, physical and mental health status on overweight and obesity among working age women (18-59 years) in Mandalay Region, Shan State and Mon State. Methods Study Population A cross-sectional study was conducted in 2020. The study population was working age women aged 18-59 years old in Mandalay Region, Shan State and Mon State of Myanmar. The sample size was calculated by using the sample size estimation formula for the logistic regression analysis of Hsieh by taking references of previous study done on socio-demographic factors and overweight and obesity in India, which showed 63% proportion of overweight and obesity among those who had family history of NCD with 95% confidence interval and a margin error of 5% (16,17). So, the estimated sample size was 1,094. Firstly, Mandalay Region, Shan State and Mon State were randomly selected from 15 states and regions. After that, two districts of each state/region were randomly selected from 4 states/regions and then two townships were randomly selected from each district. Finally, one community was randomly selected from each township. Then, simple random sampling method was applied to select 1,094 individuals on the basis of proportionate to size of the population (PPS). The inclusion criteria of the respondents were: women living in the study area for at least one year, women of working age (18-59 years) and willing to participate in the study. The exclusion criteria were pregnant women, lactating women, physically and mentally ill women. The participants were requested to answer a structured questionnaire followed by interview and anthropometric measurements by trained interviewers. Data Collection A structured questionnaire was developed based on the research questions and relevant Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 4 | 23 literature. The questionnaire consisted of seven parts: Demographic and Socioeconomic Characteristics; Health Behavior; Health literacy; Knowledge; Attitude; Physical Health Status; and Mental Health Status. The questionnaires had been verified for content validation by 5 experts and revised to improve the validity. Moreover, the questionnaire was tested for reliability by calculating Cronbach’s alpha among 30 participants in another region. The Cronbach’s alpha coefficient was 0.857. Measurement of outcome: Body height in centimeters (cm) and weight in kilograms (kg) were measured by using metering object and digital weighing instruments. Overweight and obesity defined as BMI ≥23 kg/m2 by WHO (18) for Asian cut-off points was the main outcome of the study. The respondents were asked to sign the written consent form if they were willing to participate in the study after obtaining ethical clearance and approval from the office of the Khon Kaen University ethics committee in human research (Reference No. HE632117). All confidentiality of data was fully assured. A structured questionnaire interview was conducted to collect the data from 1,094 respondents by 5 experienced interviewers who were trained and standardized for data collection skills. Statistical Analysis STATA version 14 (College Station, Texas, USA) was used for analysis. The categorical data were presented as frequency and percentage, whereas, the continuous data as mean standard deviation, median and range. GLMM was operated to model the random effects and correlations inside clusters. In the modeling, the residential area/township was set as the random effect. Bivariate analysis was performed to define the association of each independent variable with overweight and obesity. The variables were significant in the bivariate analysis with p-value <0.05 were proceeded for multivariate analysis. Results in the final model defined the magnitude of association with independent variables and overweight and obesity with an AOR and its 95% CI. GLMM was performed to control the clustering effects. Results Among the total of 1,094 respondents, about one third of them were in the age between 18- 29 years and almost all of them were Buddhists (85.19%), most of the respondents were married (59.51%), 35.19% were dependent, and 39.49% had completed high school level education. The median of family size was 4 persons and 55.85% of women lived with a spouse. The median monthly income and expenditure were 150,000MMK and 100,000MMK respectively; however, 47.54% of women had enough saving and nearly half of women (44.15%) had 1-2 parity. The study revealed that 52.92% of participants did not consume fast food. However, women consuming fast food and sugar-sweetened beverage 1-4 days per week were 40.86% and 56.58% respectively. Women who did vigorous-intensity activity during recreation <5 days and ≥5 days per week were53 . 9 3 % and 7.77% respectively. Women who did and moderate-intensity activity during recreation <5 days and ≥ 5 d a y s per week were 53.02% and 14.17% respectively. Only 8.14% were current smoker, 12.98% were current alcohol consumers, and 15.08% were current betel chewers. About one third (33.18%) of participants had sufficient to excellent health literacy however, the respondents with problematic and inadequate health literacy were 18.55% and 48.27% respectively. More than half of them had good general knowledge (64.44%) but only 0.09% had good attitudes. Of the study participants, currently 92.41% of women had good health status, 68.83% did not have family history of overweight and obesity and 27.63% used contraception. More than half (61.33%) of them had moderate stress and 50.82% of women had mild depression (Table 1). As high as 31.63% of the working age women were obese and 19.65 % were overweight. Less than half were normal weight (44.70%) and only 4.02% were underweight (Table 2). Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 5 | 23 Table 1. The Characteristics of respondents Characteristics Frequency (n) Percentage (%) State/Region Mandalay 399 36.47 Shan 330 30.16 Mon 365 33.36 District Ya Mae Thinn 189 17.28 Meiktila 210 19.20 Taunggyi 197 18.01 Loilem 133 12.16 Mawlamyaing 171 15.63 Thaton 194 17.73 Socio-Economic Status Age 18-29 344 31.44 30-30 274 25.05 40-49 257 23.49 50-59 219 20.02 Religion None 24 2.19 Buddhism 932 85.19 Christian 83 7.59 Muslim 20 1. 83 Hinduism 12 1.10 Other 23 2.10 Education Level No Formal Education 28 2.56 Primary School 103 9.41 Secondary School 235 21.48 High School 432 39.49 Bachelor Degree 283 25.87 Higher than Bachelor Degree 13 1.19 Marital status Single 334 30.53 Married 651 59.51 Divorced/Widowed/Separated 109 9.96 Occupation Agriculture and Livestock 33 3.02 Government staff 159 14.53 Own business 157 14.35 Private employee 139 12.71 Manual labor 221 20.20 Dependent 385 35.19 Family members less than and equal to 3 399 36.47 4-5 550 50.27 More than 5 145 13.25 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 6 | 23 Characteristics Frequency (n) Percentage (%) Whom they live with Parents 357 32.63 Spouse 611 55.85 Relatives 50 4.57 Alone 30 2.74 Friend 17 1.55 Others 29 2.65 Monthly income (MMKs) <100,000 373 34.10 100,000-200,000 337 30.80 ≥200,000 384 35.10 Monthly expenditure (MMKs) <100,000 402 36.75 100,000-200,000 431 39.40 ≥200,000 261 23.86 Financial situation Not Enough 165 15.08 Not Enough with debt 174 15.90 Enough with saving 520 47.54 Enough with no saving 235 21.48 Parity 0 395 36.11 1-2 483 44.15 >2 216 19.74 Health Behavior Frequency of fast food consumed per week (days) Nil 579 52.92 1-4 447 40.86 ≥5 68 6.22 Frequency of sugar-sweetened beverage consumed per week (days) Nil 142 12.98 1-4 619 56.58 ≥5 333 30.44 Frequency of high fat protein consumed per week (days) Nil 272 24.86 1-4 671 61.33 ≥5 151 13.80 Frequency of vigorous-intensity activity during recreation per week (days) Nil 419 38.30 <5 590 53.93 ≥5 85 7.77 Frequency of moderate-intensity activity during recreation per week (days) Nil 359 32.82 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 7 | 23 Characteristics Frequency (n) Percentage (%) <5 580 53.02 ≥5 155 14.17 Smoking Never 798 72.94 Former 207 18.92 Current 89 8.14 Alcohol Drinking Never 714 65.27 Former 238 21.76 Current 142 12.98 Betel Chewing Never 801 73.22 Former 128 11.70 Current 165 15.08 Health Literacy of overweight and obesity Inadequate 528 48.27 Problematic 203 18.55 Sufficient 203 18.55 Excellent 160 14.63 Knowledge Level of knowledge on overweight and obesity Poor (0.0-5.9) <60% 156 14.26 Fair (6-7.9) 60-79% 233 21.30 Good (8-10) ≥80% 705 64.44 Attitude Level of attitude on overweight and obesity Poor attitude (10-29) <60% 779 71.21 Moderate attitude (30-39) 60-79% 314 28.70 Good attitude (40-50) ≥80% 1 0.09 Physical health status Health status Healthy 1,011 92.41 Unhealthy 83 7.59 Family history of overweight/obesity Yes 341 31.17 No 753 68.83 Use of contraception Yes 244 27.63 No 639 72.37 Mental Health Status Stress Mild (1-13) 367 33.55 Moderate (14-26) 671 61.33 Severe (27-40) 56 5.12 Depression Mild (0-16) 556 50.82 Moderate (16-23) 316 28.88 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 8 | 23 Characteristics Frequency (n) Percentage (%) Severe (24-60) 222 20.29 Total 1094 100.0 Table 2. Overweight and Obesity of Women Characteristics Number of women (%) 95% CI Underweight (<18.5 kg/m2) 44 (4.02) 3.00-5.36 Normal Weight (18.5-22.99 kg/m2) 489 (44.70) 41.77-47.66 Overweight (23.0-24.99 kg/m2) 215 (19.65) 17.40-22.11 Obesity (≥25 kg/m2) 346 (31.63) 28.93-34.45 Mean ±SD 24.25 ± 4.54 Median (Min: Max) 23.01 (14.81: 45.23) The multivariable analysis for associated factors of overweight and obesity were identified by using the Generalized Linear Mixed Model (GLMM) to control the clustering effect of the sampling selection of the participants. Factors that were significantly associated with overweight and obesity of participants included; age 31-59 years (adj.OR=1.72; 95%CI: 1.22-2.40), living with family (adj.OR= 2.07; 95%CI: 1.20-3.57), average monthly income ≥ 200,000 (adj.OR= 1.38; 95%CI: 1.05-1.82), parity ≥1 (adj.OR= 1.61; 95%CI: 1.17-2.23), high fat protein consumption ≥5 days per week (adj.OR= 2.90; 95%CI: 1.91-4.39), did not drink alcohol (adj.OR= 2.53; 95%CI: 1.91-3.36) and moderate and severe stress (adj.OR= 1.47; 95%CI: 1.11-1.94) (Table 3). Table 3. Multivariable Analysis of Factors Associated with overweight and obesity by using the GLMM Characteristics No %O/B Crude OR Adjusted OR 95%CI p-value Age (years) 0.002 18-30 344 38.95 1 1 31-59 750 56.93 2.07 1.72 1.22-2.40 Whom you live with 0.009 With family 1018 50.00 1 1 Without family 76 68.42 2.17 2.07 1.20-3.57 Average monthly income (MMK) 0.023 <200,000 710 47.46 1 1 ≥ 200,000 384 58.33 1.55 1.38 1.05-1.82 Parity 0.004 0 395 40.51 1 1 ≥1 699 57.37 1.98 1.61 1.17-2.23 High fat protein consumption per week (days) <0.001 <5 943 47.40 1 1 ≥5 151 75.50 3.42 2.90 1.91-4.39 Alcohol Consumption <0.001 Yes 380 36.05 1 1 No 714 59.38 2.59 2.53 1.91-3.36 Stress 0.007 Low 367 41.42 1 1 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 9 | 23 Characteristics No %O/B Crude OR Adjusted OR 95%CI p-value Moderate to severe 727 56.26 1.82 1.47 1.11-1.94 *As the participants were selected from different geographical areas, GLMM was performed to control the clustering effect. Discussion Our study showed that the combined prevalence of overweight and obesity (BMI ≥ 23 kg/m2) among working age women in Myanmar was 51.28 % in which overweight (BMI ≥23.0-24.99 kg/m2) was 19.65% and obesity (BMI≥25 kg/m2) was 31.63% respectively. The prevalence of overweight in this study was lower but obesity was higher as compared to 2015-16 Myanmar Demographic Health Survey (MDHS) and Myanmar national STEP survey of risk factors for NCDs conducted in 2009 (3, 19). The observed difference between this study and others in Myanmar may be due to different cut-off points. In a study conducted in Malaysia by using the same cut off point of BMI ≥25 kg/m2, the prevalence of overweight and obesity in women was similar to the results of the current study (20). However, compared to other studies using the same cut off point (BMI ≥ 23 kg/m2), the combined prevalence of overweight and obesity from the current study was higher than in Bangladesh and India (21,22). This high prevalence of overweight and obesity among working age women in Myanmar bears risks for chronic non- communicable diseases such as ischemic heart diseases, cancer, hypertension, diabetes, stroke and reproductive health diseases (14). Our multivariate analysis revealed that the factors associated with overweight and obesity were significantly associated with overweight and obesity among women aged 31-59-year- old. With the trend of increasing age, people follow sedentary lifestyle, less physical activities, not control over dietary habit and less willingness to reduce body weight regardless of their health status led to gain excessive body weight (14-24). The study demonstrated that participants who lived without family were more likely to be overweight and obese as compared to those living with family. It may be due to the women those living alone consume convenient and unbalanced dietary intake such as fast food and also is related with higher intake of high carbohydrate and fatty foods (25,26). The study revealed that average monthly income was significantly associated with overweight and obesity, as those whose monthly income was (≥ 200,000 MMK) were1.38 times more likely to be overweight and obese than those whose average monthly income was (<200,000 MMK). It can be assumed that females with high income follow sedentary lifestyle and consume more fast foods which can lead to overweight and obesity among them (27). Regarding the parity, women with ≥1 pregnancy were 1.61 times more likely to be overweight and obesity than women with no parity. Most of the women gain weight during and after the pregnancy and reduction in ovulation cycles in multiparous women can stimulate to accumulate more fat among them (28). Moreover, the study revealed that protein with high fat consumption was significantly associated with overweight and obesity where, those who consumed ≥5 days per week were more likely to be overweight and obese as compared to those who consumed < 5 days per week. It might be that high fat foods contain cholesterol, saturated fatty acids and also dietary fat prompts the overconsumption and increase weight through high calories (29). Regarding the alcohol consumption, the women who did not consume the alcohol were more likely to be overweight and obesity than those who consumed alcohol in this study. In comparison with my descriptive study, only 12.98% of women were current drinkers. Light to moderate amount of alcohol consumption was less likely to be associated with overweight and obesity in this study. Also, Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 10 | 23 women drinkers appear to be substitute alcohol for their daily dietary intake without increasing more calories (24). Moreover, moderate and severe stress was significantly associated with overweight and obesity than those who has low stress level, and more likely to be overweight and obesity. A possible explanation for this finding could be physiologic mechanisms might play a role, such as stress-induced cortisol secretion, which increases lipogenesis, so increasing the likelihood of being obese (29). Study limitations This study had some limitations. Firstly, this study was conducted among working age women (18 to 59 years old) living in Mandalay Region, Shan State and Mon State. So, it cannot be generalized to all working age women in Myanmar. Secondly, this study was dependent on the participants’ answers to the structured questionnaires. Therefore, memory recalling and interviewer relationship bias could not be excluded. Finally, as this is cross- sectional study it does not allow establishing the causality of association therefore further longitudinal studies are needed. In addition, COVID-19 related travel restrictions have caused delayed in the data collection period. Conclusion The study found a high prevalence of overweight and obesity and very low levels of good attitudes regarding excess body weight among working-age women in Myanmar. Socioeconomic and behavioral risk factors of overweight and obesity were identified and this finding will be used as evidence to develop the appropriate policies and public health interventions. These will address the problems in reducing overweight and obesity that can further lead to prevent non-communicable diseases. There is also a need for urgent intervention targeted to women with information, education and communication (IEC). References 1. World Health Organization. Obesity and overweight [Internet]. Available from: https://www.who.int/news- room/fact-sheets/detail/obesity-and- overweight (accessed: February 11, 2022). 2. Alwan A, MacLean DR, Riley LM, D’Espaignet ET, Mathers CD, Stevens GA, et al. 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Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 12 | 23 © 2022 Htut et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26. French SA, Wall M, Mitchell NR. Household income differences in food sources and food items purchased. Int J Behav Nutr Phys Act 2010;7:1-8. 27. Gravena AAF, Brischiliari SCR, Lopes TCR, Agnolo CMD, Carvalho MDB, Pelloso SM. Excess weight and abdominal obesity in postmenopausal Brazilian women: A population-based study. BMC Womens Health 2013;13:1-7. 28. Kratz M, Baars T, Guyenet S. The relationship between high-fat dairy consumption and obesity, cardiovascular, and metabolic disease. Eur J Nutr 2013;52:1-24. 29. Lee M-J, Fried SK. The glucocorticoid receptor, not the mineralocorticoid receptor, plays the dominant role in adipogenesis and adipokine production in human adipocytes. Int J Obes 2014;38:1228- 33. ________________________________________________________________________________________________ Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 13 | 23 Annex I - Questionnaires Health literacy and overweight and obesity among working age women in Myanmar: A cross sectional analytical study Please circle the answer or fill in the blanks for explanations the truth. Part 1. Demographic and Socioeconomic Characteristics Information For Researcher 1 How old are you? |__|__| years (completed year) SD1 |__|__| 2 What is your ethnic? ( ) 1. Barma ( ) 2. Mon ( ) 3. Karen ( ) 4. Rakhine ( ) 5. Kachin ( ) 6. Shan ( ) 7. Pa Oh ( ) 8. Other please specify --------------- SD2 |__| 3 What is your religion? ( ) 1. None ( ) 2. Buddhism ( ) 3.Christian ( ) 4. Muslim ( ) 5. Hinduism ( ) 6. Ghost ( ) 7. Others please specify --------------- SD3 |__| 4 What is the highest level of education you completed? ( ) 1. No formal education ( ) 2. Primary ( ) 3. Secondary ( ) 4. High school or equivalence ( ) 5. Bachelor degree or equivalence ( ) 6. Higher than bachelor degree SD4 |__| 5 What is your marital status? ( ) 1. Single ( ) 2. Married ( ) 3. Divorced/Widowed/Separated SD5 |__| 6 What is your major occupation? ( ) 1. Agriculture and Livestock ( ) 2. Government staff ( ) 3. Own business ( ) 4. Private employee ( ) 5. Manual labor ( ) 6. Dependent ( ) 7. Others please specify--------------- SD6 |__| 7 What is your family type? ( )1. Nuclear ( ) 2. Extended F1 |__| Participant ID  Date--------/--------/-- ----- Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 14 | 23 Information For Researcher ( )3. Others please specify --------------- 8 What is your family size (family members)? |__||__| persons F2 |__|__| 9 Do you stay with whom? ( ) 1. Parents ( )2. Spouse ( )3. Relatives ( )4. Alone ( )5. Friend ( )6. Others please specify --------------- F3 |__| 10 What is your average monthly income? ---------------MMK E1 -------- 11 What is your average monthly expense? ----------------MMK E2 -------- 12 What is your average family monthly income? ---------------MMK E3 -------- 13 What is your average family monthly expense? ----------------MMK E4 -------- 14 What is your financial situation? ( ) 1. Not Enough ( ) 2. Not Enough with debt ( ) 3. Enough with no saving ( ) 4. Enough with saving E5 |__| 15 What is your parity? |__||__| (leave 0 if you are single) M1 |__|__| 16 How many children do you have? |__||__| M2 |__|__| Part 2: Health Behaviors No Information No 1-2 days 3-4 days 5-6 days 7 days Code 2.1 Dietary pattern: In 1 week, how often do you 1 Consume fast food such as pizza, Hamburger, Sandwiches, Doughnuts? 1 2 3 4 5 D1|__| 2 Consume sugar-sweetened beverage such as coca cola, Pepsi, coffee with milk, energy drink, and fruit juice? 1 2 3 4 5 D2|__| 3 Eat sweet fruits such as durian, mango, pineapple, grapes, and banana? 1 2 3 4 5 D3|__| 4 Eat fruits that not sweet such as dragon fruit, kiwi, lime, lemon? 1 2 3 4 5 D4|__| 5 Eat vegetables that contain starch such as potatoes, sweet potatoes, taro, corn and pumpkin? 1 2 3 4 5 D5|__| 6 Eat vegetables that not contain starch such as carrot, cabbage, cauliflower, mushrooms? 1 2 3 4 5 D6|__| 7 Eat protein such as lean meat, chicken, eggs, soy products like tofu? 1 2 3 4 5 D7|__| 8 Eat protein with high fat such as cheese, nuts, seeds, streaky pork? 1 2 3 4 5 D8|__| 9 Eat protein from vegetable such as bean, pea, lentils, chickpeas, cauliflower, tofu? 1 2 3 4 5 D9|__| 10 Eat food cooked with animal oil? 1 2 3 4 5 D10|__| 11 Eat food cooked with vegetable oil? 1 2 3 4 5 D11|__| 2.2 Physical activity Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 15 | 23 No Information No 1-2 days 3-4 days 5-6 days 7 days Code Activity at work 12 How often do you do vigorous-intensity activity that causes large increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] for at least 10 minutes continuously at work? 1 2 3 4 5 P1|__| 13 How often do you do moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking [or carrying light loads] for at least 10 minutes continuously at work? 1 2 3 4 5 P2 |__| Travel to and from places 14 How often do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places? 1 2 3 4 5 P3 |__| Recreational activities 15 How often do you do any vigorous- intensity sports, fitness or recreational (leisure) activities that cause large increases in breathing or heart rate like [running or football] for at least 10 minutes continuously? 1 2 3 4 5 P4 |__| 16 How often do you do any moderate- intensity sports, fitness or recreational (leisure) activities that cause a small increase in breathing or heart rate such as brisk walking, [cycling, swimming, and volleyball] for at least 10 minutes continuously? 1 2 3 4 5 P5 |__| 2.3 Leisure time 17 During the leisure time, what do you do? (Remark: More than 1 answer is possible. Please circle all the possible answers.) L1.a Watching Television 1. Yes 2. No L1.b Using internet 1. Yes 2. No L1.c Playing internet games 1. Yes 2. No L1.d Playing guitar 1. Yes 2. No L1.e Listening music 1. Yes 2. No L1.f Sing the songs 1. Yes 2. No L1.g Others(specify) ------------------------- L1a |__| L1b |__| L1c |__| L1d |__| L1e |__| L1f |__| L1g |__| 18 TV watching hours /day (self-estimated) -------------------- hours L2 |__| 19 Internet media watching hours /day (self-estimated) --------------hours L3 |__| 2.4 Sleep pattern 20 In average how many hours per day do you sleep? ---- hours SL1 |__| 21 During sleeping, do you get sound sleep? ------days per week SL2 |__| 2.5 Smoking Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 16 | 23 No Information No 1-2 days 3-4 days 5-6 days 7 days Code 22 Have you ever smoked? [ ]1. Never smoke (Skip to Question 27 ) [ ]2. Former smoking [ ]3. Current smoking S1 |__| 23 What is the most common type of cigarette you use? [ ]1. cigar [ ]2. cheroot [ ]3. cigarette [ ]4. tobacco for betel quit [ ]5. Others(specify)------------- S2 |__| 24 How often do you smoke? -------------days per week S3 |__| 25 How many cigarettes do you smoke per day? -------------pcs S4 |__| 26 How much do you spend for smoking per month? ------------MMK S5 |__| 2.6 Alcohol drinking 27 Have you ever consumed an alcoholic beverage in the past 1month? [ ] 1. Never Drink ( Skip to Question 32 ) [ ] 2. Former Drinker [ ]3. Current Drinker (drinking any alcohol product in past 30 days) A1|__| 28 How often do you drink alcohol? …………. days per week A2 |__| 29 What is the most common type of alcohol you drink? [ ]1. Beer [ ]2.Whiskey [ ]3. Rice alcohol [ ]4.wine [ ]5. Others (specify) ------------------- A3 |__| 30 Drink volume per time (estimated) -----------g 1 standard drink=10 gram of pure alcohol A4 |__| 31 How much do you spend for alcohol drinking per month? ----------------MMK A5 |__| 2.7 Betel chewing 32 Have you ever betel chewing in the past 12 months? [ ]1. Never chew ( Skip to Part 3 ) [ ]2. Former chewer [ ]3. Current chewer B1 |__| 33 Have often do you chewed?...................... days/ week B2 |__| 34 What is the most common type of betel you chew? [ ]1. Signal [ ] 2.92 [ ]3. tobacco leaf [ ]4.100 [ ]5. Others(specify), ------------------- B3 |__| 35 How many chews in a day? ----------chews B4 |__| 36 How much do you spend for betel chewing per month? ----------------MMK B5 |__| Part 3: Health Literacy HC = Health care; DP = Disease Prevention; HP = Health Promotion Please mark √ in ( ) or fill in the blanks for explanation the truth. Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 17 | 23 No. Action Area Domain Very Difficult Fairly Difficult Fairly Easy Very Easy 1 Access to information HC Find information on the causes of overweight and obesity 1 2 3 4 2 Find information about how to eat proper food for not to get overweight and obesity 1 2 3 4 3 Find information on how to reduce your body weight if you are overweight or obesity 1 2 3 4 4 DP Find out information on how to manage stress, depression that could cause overweight and obesity 1 2 3 4 5 Find information about how to manage unhealthy behavior such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 6 HP Find information on how to promote healthy activities such as exercise 1 2 3 4 7 Find out how to practice at home, working place and community to stay fit and healthy 1 2 3 4 8 Understand information HC Understand the information on causes of overweight and obesity 1 2 3 4 9 Understand the information on how to eat proper food for not to get overweight and obesity 1 2 3 4 10 Understand the information on how to reduce your body weight if you are overweight or obesity 1 2 3 4 11 DP Understand the information on how to manage stress, depression that could cause overweight and obesity 1 2 3 4 12 Understand the information on how to manage unhealthy behavior such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 13 HP Understand the information on how to promote healthy activities such as exercise 1 2 3 4 14 Understand the information on how to practice at home, 1 2 3 4 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 18 | 23 No. Action Area Domain Very Difficult Fairly Difficult Fairly Easy Very Easy working place and community to stay fit and healthy 15 Appraise information HC Judge the causes of overweight and obesity 1 2 3 4 16 Judge the correctness of the information how to eat proper food for not to get overweight and obesity 1 2 3 4 17 Judge correctness of the information how to reduce your body weight if you are overweight or obesity 1 2 3 4 18 DP Judge measures to manage stress, depression that could cause overweight and obesity 1 2 3 4 19 Judge the correctness of the information on how to manage unhealthy behavior such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 20 HP Justified information on how to promote healthy activities such as exercise 1 2 3 4 21 Justified appropriate practice to stay fit and healthy at home, working place and community, 1 2 3 4 22 Making Decision HC Decide to prevent overweight and obesity by yourself based on information 1 2 3 4 23 Decide to eat proper food to prevent overweight and obesity 1 2 3 4 24 Decide to take actions to reduce your body weight if you are overweight or obesity 1 2 3 4 25 DP Decide to manage stress, depression that could cause overweight and obesity 1 2 3 4 26 Decide to manage unhealthy behaviors such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 27 HP Decide to do activities such as exercise to promote the health 1 2 3 4 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 19 | 23 No. Action Area Domain Very Difficult Fairly Difficult Fairly Easy Very Easy 28 Decide to practice to stay fit and healthy at home, working place and community. 1 2 3 4 Part 4: Knowledge Please mark √ in ( ) or fill in the blanks for explanation the truth. No Information Answer For researcher Yes No 1 BMI can be used to define overweight and obesity. 1 2 D1 |__| 2 Eating more vegetables could cause overweight and obesity. 1 2 D2 |__| 3 Drinks soda such as Coca Cola, Pepsi and Fanta could help burning fat which is good for those with hyperlipidemia. 1 2 D3 |__| 4 Animal fats are more beneficial than vegetable oil. 1 2 D4 |__| 5 Overweight and obesity can be lowered by medicine only. 1 2 D5 |__| 6 Reading the nutritional labeling before buying foods could help reducing overweight and obesity. 1 2 D6 |__| 7 Breast cancer is related with obesity. 1 2 D7 |__| 8 Overweight and obesity increases the risk of type2 diabetes but not hypertension and heart diseases. 1 2 D8 |__| 9 Obesity is not related with irregular periods and infertile. 1 2 D9 |__| 10 Obesity is not related with bones and joints problems 1 2 D10 |__| Part 5: Attitude Positive items Score Strongly agree 5 Agree 4 Neutral 3 Disagree 2 Strongly disagree 1 Please mark √ in ( ) or fill in the blanks for explanation the truth. No Opinion Answer For researcher Strongly Disagree Disagree Neutral Agree Strongly Agree 1 Overweight and obesity are unhealthy. 1 2 3 4 5 E1 |__| 2 Obesity makes females look ugly. 1 2 3 4 5 E2 |__| 3 Overweight and obesity among male is acceptable. 1 2 3 4 5 E3 |__| 4 Obesity reduces self-esteem and self-confidence. 1 2 3 4 5 E4 |__| 5 It is hard to control weight. 1 2 3 4 5 E5 |__| Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 20 | 23 No Opinion Answer For researcher Strongly Disagree Disagree Neutral Agree Strongly Agree 6 Overweight / obese people are lazy. 1 2 3 4 5 E6 |__| 7 Obesity is my serious problems. 1 2 3 4 5 E7 |__| 8 Overweight and obesity is genetic, therefore we could not prevent it. 1 2 3 4 5 E8 |__| 9 Medicine is the best measure to reduce obesity. 1 2 3 4 5 E9 |__| 10 Behavior modification with long term monitoring is the healthiest measures to prevent and control obesity. 1 2 3 4 5 E10 |__| Part 6: Physical Health status Information For researcher 1 How do you rate your current health status? 1 2 3 4 5 6 7 8 9 10 Very sick Very Healthy PHS1 |__| 2 Do you suffer any acute illness during last 2 weeks? [ ]1. No [ ]2. Yes my problems is ………………….. PHS 2 |__| 3 Do you have any chronic diseases? [ ]1. No (If No, skip to Question7) [ ]2. Yes PHS 3 |__| 4 What chronic diseases are you suffering? PHS4.a.Hypertension ( ) 1.No ( ) 2.Yes PHS4.b.Diabetes Mellitus ( ) 1.No ( ) 2.Yes PHS4.c.Stroke ( ) 1.No ( ) 2.Yes PHS4.d.Muscle pain ( ) 1.No ( ) 2.Yes PHS4.e.Heart disease ( ) 1.No ( ) 2.Yes PHS4.f.Tuberculosis ( ) 1.No ( ) 2.Yes PHS4.g.Malaria ( ) 1.No ( ) 2.Yes PHS4.h.STD ( ) 1.No ( ) 2.Yes PHS4.i.Skin diseases ( ) 1.No ( ) 2.Yes PHS4.j.Others (specify), ------------------- PHS4a|__| PHS4b|__| PHS4c|__| PHS4d|__| PHS4e|__| PHS4f|__| PHS4g|__| PHS4h|__| PHS4i|__| PHS4j |__| 5 Do you take regular treatment for your chronic disease? [ ]1.Yes [ ]2.No [ ]3. Others (specify), ------------------- PHS5 |__| 6 Where do you get treatment for your disease? [ ]1.Drug Store [ ]2.Health personals [ ]3.Private clinic [ ]4.NGOs [ ]5.UHC [ ]6.Public Hospital [ ]7.Others (specify), ------------------- PHS6 |__| 7 Did you have any hospitalization during the past one year? [ ]1. Yes for ------------------- days PHS7 |__| Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 21 | 23 Information For researcher [ ]2. No 8 Did you have any accidents during the past one year? [ ]1. Yes [ ]2. No PHS8 |__| 9 Do your family have history of overweight/obesity? 1.Yes 2.No If “Yes” choose any of follow; (can answer more than one) FH1.a Mother 1. Yes 2. No FH1.b Father 1. Yes 2. No FH1.c Grandparents 1. Yes 2. No FH1.d Siblings 1. Yes 2. No FH1|__| FH1a |__| FH1b |__| FH1c |__| FH1d |__| 10 Do your family have history of hypertension? 1.Yes 2.No If “Yes” choose any of follow; (can answer more than one) FH2.a Mother 1. Yes 2. No FH2.b Father 1. Yes 2. No FH2.c Grandparents 1. Yes 2. No FH2.d Siblings 1. Yes 2. No FH2 |__| FH2a |__| FH2b |__| FH2c |__| FH2d |__| 11 Do your family have history of diabetes mellitus? 1.Yes 2.No If “Yes” choose any of follow; (can answer more than one) FH 3.a Mother 1. Yes 2. No FH 3.b Father 1. Yes 2. No FH 3.c Grandparents 1. Yes 2. No FH 3.d Siblings 1. Yes 2. No FH 3|__| FH3a |__| FH3b |__| FH3c |__| FH3d |__| 12 What is your reproductive health status? 1.Not in menopause period. 2. In menopause period (If menopause, skip to Part 7) RH1 |__| 13 Do you use contraception? 1.Yes 2. No If “Yes” choose any of follow RH2.a Oral contraception 1. Yes 2. No RH2.b Injection 1. Yes 2. No RH2.c Others please specify………….. RH2 |__| RH2a |__| RH2b |__| RH2c |__| Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 22 | 23 Part 7: Mental health status 7.1 Stress Relating Factors by Perceived Stress Scale (PSS) The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate with a check how often you felt or thought a certain way. No Information In the last month, Never Almost never Some- times Fairly often Very often 1 How often have you been upset because of something that happened unexpectedly? 0 1 2 3 4 2 How often have you felt that you were unable to control the important things in your life? 0 1 2 3 4 3 How often have you felt nervous and “stressed”? 0 1 2 3 4 4 How often have you felt confident about your ability to handle your personal problems? 4 3 2 1 0 5 In the last month, how often have you felt that things were going your way? 4 3 2 1 0 6 How often have you found that you could not cope with all the things that you had to do? 0 1 2 3 4 7 How often have you been able to control irritations in your life? 4 3 2 1 0 8 How often have you felt that you were on top of things? 4 3 2 1 0 9 How often have you been angered because of things that were outside of your control? 0 1 2 3 4 10 How often have you felt difficulties were piling up so high that you could not overcome them? 0 1 2 3 4 Total Stress score s1------------------------------ Stress 1. No 2. Yes s2-------------------- 7.2 Depression index Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week. Respond to all items. No Place a check mark (!) in the appropriate column. During the past week. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of time (3-4 days) All of the time (5-7 days) 1 I was bothered by things that usually don’t bother me. 0 1 2 3 2 I did not feel like eating; my appetite was poor. 0 1 2 3 Htut WMM, Sornlom K, Loahasiriwong W. Health behavior, stress and obesity among working age women in Myanmar (Original research). SEEJPH 2022, posted: 27 May 2022. DOI: 10.11576/seejph-5494 P a g e 23 | 23 No Place a check mark (!) in the appropriate column. During the past week. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of time (3-4 days) All of the time (5-7 days) 3 I felt that I could not shake off the blues even with help from my family. 0 1 2 3 4 I felt that I was just as good as other people. 0 1 2 3 5 I had trouble keeping my mind on what I was doing. 0 1 2 3 6 I felt depressed. 0 1 2 3 7 I felt that everything I did was an effort. 0 1 2 3 8 I felt hopeful about the future. 0 1 2 3 9 I thought my life had been a failure. 0 1 2 3 10 I felt fearful. 0 1 2 3 11 My sleep was restless. 0 1 2 3 12 I was happy. 0 1 2 3 13 I talked less than usual. 0 1 2 3 14 I felt lonely. 0 1 2 3 15 People were unfriendly. 0 1 2 3 16 I enjoyed life. 0 1 2 3 17 I had crying spells. 0 1 2 3 18 I felt sad. 0 1 2 3 19 I felt that people disliked me. 0 1 2 3 20 I could not "get going." 0 1 2 3 Total score d1…………………… ………… Depressive symptoms 1.No 2.Yes d2…………………… ………… Part 8: Case record form Anthropometric measurement For researcher 1. Height--------------------------------- centimeters A1----------cm 2. Weight--------------------------------- kilograms A2----------kg 3. Waist circumference------------------- centimeters A3----------cm 4. Hip circumference------------------- centimeters A4----------cm This is the end of the questionnaire, thank you for your participation.