According to the World Health Organization, non-communicable diseases (NCDs) have caused 40.5 million deaths worldwide, accounting for 71% of all death [1]. More than 50% of the population dies from premature death (death among people ages 30 to 69 years), which affects the global labor supply, productivity, and economy [1, 2]. The burden of NCDs-such as cardiovascular disease, stroke, hypertension, chronic renal failure, and cancer has increased in Thailand [3], and these diseases have become the top cause of mortality, accounting for 72% of all deaths in 2016 [3]. The top five NCDs in Thailand in terms of death rates are cancer, stroke, cardiovascular disease, diabetes, and hypertension; these diseases are largely the result of behavioral risk factors and metabolic aspects [1, 4]. Behavioral risk factors include smoking, physical inactivity, improper diet and nutrition, obesity, and alcohol consumption; metabolic risk factors are high blood pressure, high blood sugar, and high blood fats [4, 5]. These two main factors have been implicated in the development of chronic diseases [1, 4]. Previous studies have shown that most of these risks are generated by individuals’ own behaviors related to lifestyle, the aging process, and working conditions [2].

Phayao Province is located in the upper north of Thailand and is administratively divided into nine districts with geographical areas of forests and steep mountains. Pong District is a remote area with diverse ethnic groups, social and cultural backgrounds, and traditions [6]. Many ethnic people live in the mountainous areas, and most of their ancestors migrated from northwestern Yunnan Province, China, to northern Thailand in the past century [7]. There are four main ethnic groups: Hmong, Mien (Yao), Thin, and Lishu [8]. Each of these ethnic groups has its own culture, tradition, language, and way of life. A review of the literature suggests that these minorities have primitive self-care behaviors, especially in terms of daily cooking [7]. Ethnic people use a variety of ingredients in most of the food depending on their socio-economic status [9]. Some tribes use a large amount of lard oil for cooking, while others use large amounts of salt [9]. One similarity among ethnic groups in terms of cultural patterns is drinking during traditional and religious ceremonies [8]. Ethnic minority groups are defined as vulnerable population and have been reported to have many health problems, including NCDs such as hypertension, diabetes, hyperlipidemia, and other diseases [7, 8]. A previous study in Chiang Rai Province in Thailand found that the majority of hill tribe members had poor knowledge and attitude scores regarding disease prevention and control [10]. Several factors, including smoking, excessive alcohol consumption, unhealthy diet, and physical inactivity, are behavioral risk factors that lead to the development of NCDs [11]. Similarly, a previous report outlined that most NCDs share common behavioral and/or biological risk factors [12]. In addition, previous studies have also concluded that risk factors for NCDs vary according to socio-demographic characteristics of a population [13, 14].

Health-promoting behaviors are one of the best ways to maintain and improve health [15]. Health-promoting activities allow people to track their health, which is useful for improving individual and community health [15, 16]. This study applied Pender’s health promotion model (HPM) as a research planning framework [15]. HPM allows people to visualize several predictive factors of health-related behaviors, and it has been successfully used to predict changes in lifestyles among patients [17]. Various studies have emphasized the effectiveness of this model in controlling unhealthy behaviors [18, 19]. Previous studies have revealed that lifestyle modifications for better hypertension control can be achieved if well-planned activities are chosen based on knowledge and experience [20]. To the best of our knowledge, there have been no previous studies examining the relevance of HPM constructs in predicting disease control behaviors and lipid profile risk factors in this rural area. Moreover, there is currently little data on how an abnormal lipid profile can lead to serious health problems. Therefore, this study aimed to assess the associations among self-care behaviors, lipid profiles, and creatinine among an ethnic minority adult population in Thai rural communities.

This is the first study to evaluate the associations association between self-care Behaviors, lipid profiles, and creatinine among an ethnic minority adult living in the highlands of Phayao Province, Thailand. Furthermore, our study, using Pender's framework, describes the effects that occur due to biological, cultural, and societal factors in the subjects' rural highlands. Regarding the health status among ethnic minorities, it was found more than half of the participants had abnormal TC (59.1%, mean = 203.89) and LDL (69.8%, mean = 119.83) levels. Several similar studies have found that serum cholesterol concentrations tend to increase with age [7, 23-25]. A meta-analysis conducted in the Asia-Pacific region showed that 1 mmol/L higher than normal TC was associated with 45% (95%CI: 35–55%) risk of myocardial infarction or coronary death [26]. The prevalence of high creatinine was reported in 4.4% of the participants (mean = 0.79, SD = 0.20), indicating that these people were likely to be at risk of renal disease. In Thailand, the prevalence of the renal disease is 17.5%, while the global reported average is 13.4% [17-29]. A meta-analysis regarding the prevalence of chronic kidney disease indicated that an increase in creatinine level results in a decrease in renal function and that chronic kidney disease is significantly associated with risk factors such as obesity (OR = 1.33), high blood pressure (OR = 2.55), diabetes (OR = 2.25), and hypertriglyceridemia (OR = 1.45) [28].

For the knowledge scores regarding NCDs, more than half of the participants obtained low (55.6%) and moderate (33.7%) scores. This is a factor most of the participants were illiterate and residing in remote areas, which can be barriers preventing them from accessing education. Cognitive processes developed through learning and experience influence a person’s ability to perform self-care management and make healthy behavior decisions [30]. Previous studies have found that more than half of ethnic minority people obtained knowledge scores at low and moderate levels [7, 31, 32]. Some studies have shown that language differences are a major barrier to communication among patients and health personnel [33] and can result in miscommunication and misinformation during a health visit [34, 35].

Regarding self-efficacy, most of the participants obtained moderate (45.6%) and low (40.1%) scores. This was because the participants had low self-expectation outcomes and decision-making power regarding health care practices for preventing and controlling NCDs. This is consistent with Bandura’s finding that self-efficacy determines the manifestation of behaviors and actions aimed at better expectation outcomes [30]. As previous studies have shown, self-efficacy affects an individual’s management of their health behavior in many ways, and low self-efficacy has been shown to lead to inadequate self-care behaviors among diabetes patients [25, 36].

In terms of self-care behaviors, the majority of participants obtained moderate (62.3%) and low (31.0%) scores. Our results show that engaging in risky behaviors, such as eating, smoking, and drinking alcohol, can lead to the development of NCDs. A review of the literature suggests that health care behaviors among ethnic minority groups are similar, especially in using sweet, salty, and oily ingredients (e.g., coconut milk, salt, and lard oil) in daily cooking [7, 9]. Thus, ethnic minority adults’ health care behaviors and practices rely on the beliefs, traditions, cultures, and lifestyles of their ethnic group [33]. Similar to previous research studies people with low and inadequate self-care behaviors (e.g., cigarette smoking, alcohol consumption, physical inactivity, and insufficient consumption of fruits and vegetables) were at risk of developing NCDs [2].

Age, congenital disease, and knowledge were found to be significantly associated with self-efficacy. The Hmong and Mien participants had lower average self-efficacy scores than the Indigenous group. Individual factors such as age, gender, experience, and social environment affect an individual’s learning process, which in turn affects their belief in their own potential to achieve set goals [30]. Some studies have suggested that patients with high self-efficacy tend to have better glycemic control than those with moderate or low self-efficacy [25, 37, 38].

Ethnicity, age, and education were statistically associated with self-care behaviors. The Mien had lower self-care behavior scores compared to the Hmong and Indigenous groups. According to Pender’s theory, individuals’ characteristics and experiences influence their actions and behaviors regarding their health [15]. Previous studies have confirmed that individual factors such as age, ethnicity, and education can be significant predictors of healthcare behaviors [25, 33, 38, 39]. Additionally, people with high self-efficacy have shown statistically significant improvement in self-care behaviors [25, 33]. Previous studies, a multiple linear regression, also showed that high self-efficacy had a significant impact on the improvements of self-care behaviors among diabetic patients [36].

In terms of the studied variables, we found that participants who consumed alcohol were more likely to have a significantly higher BMI when adjusted for gender. The study also found that alcohol consumption was significantly associated with high SBP and DBP. According to Pender’s theory, biological factors, including gender and BMI can, directly and indirectly, influence the commitment to practicing health-promoting behaviors [15, 17]. Similarly, found that alcohol consumption and ethnicity were factors affecting healthcare behavior [2, 40]. Several studies indicate that alcohol consumption had a significant impact on BMI and high blood pressure and that drinking was a risk factor for NCDs [2, 7]. The Hmong ethnic group had significantly higher TC levels compared to the Mien and Indigenous groups. Similar previous studies found that the Hmong ethnic group was statistically more likely to have higher blood lipids than the Akha ethnic group [9, 10].

The present study also found that smoking and drinking alcohol were significantly associated with TC. The participants in the present study were ethnic minority adults living in Phayao Province, and they had different social and cultural backgrounds, resulting in different health behavior practices. Many ethnic minority adults use alcohol in religious ceremonies [8, 33]. After offering the alcohol to a holy spirit, they will drink it. These minorities believe that drinking alcohol after offering it to the holy spirit will help them stay healthy, and they consider drinking alcohol as a symbol of their economic status [33]. Similar findings in West Nepal indicated that some ethnic groups offer alcohol to a holy spirit during religious rituals [2, 41]. Previous studies explained that self-care behaviors toward health among the highland ethnic groups were poor due to a high rate of alcohol consumption and cigarette smoking as well as ignorance of health consequences [8, 33].

In addition, we found that gender, education, smoking, drinking alcohol, and income adequacy were significantly associated with LDL. One possible explanation is that social and individual factors influence one’s beliefs, leading to actions and consequences [30]. However, comparative results on the relationship between smoking habit, blood pressure, and LDL control in patients and found that smoking can be a significant predictor of the development of health complications [27, 42]. Diet and cultural lifestyle factors among these minority groups were inherited from their ancestors who migrated from China [8]. Moreover, smoking and drinking alcohol are also predictive factors for LDL cholesterol levels and are significantly positively associated with HbA1C in myocardial infarction patients [27, 43].

Ethnicity, age, gender, smoking, and self-care behaviors were found to be significantly associated with creatinine levels. The Mien ethnic group had higher creatinine levels than the other two groups. When analyzed using a multivariate regression model, age, female gender, and smoking were significantly positively associated with creatinine levels [29, 44]. A traditional way of life and cultural background influence health behavior practices among ethnic minority adults, which can be seen in their daily cooking, ritual ceremonies, and drinking behaviors [7, 27]. Studies previously reported that the Mien ethnic group uses verdant seasonings, such as salt and fish sauce, to enhance the flavors of their foods; similarly, other ethnic groups use unhealthy food for their cooking, such as large amounts of salt and monosodium glutamate [7, 9].

Limitations of this study. The study was performed with a small sample in a remote rural area in Phayao province Thailand, which is not necessarily representative of the general population. However, as a strength, this study was conducted on ethnic groups and during the area's COVID-19 outbreak. Additionally, information regarding health status obtained from self-reports may have some discrepancies. However, most of the participants were diagnosed at a healthcare facility in the community to prevent discrepancies from happening during the study. In future studies, additional variables may be identified, such as exercise, diet, stress management, and other related factors. Furthermore, additional biomarker types should be studied for comparison, and a follow-up should be conducted. A qualitative study may also be considered to explore cultural perspectives on health care behaviors to gain in-depth insight into the participants’ health problems.

The study found an increase in the prevalence of lipid profiles and creatinine.

Due to the geographical distance, access to health services, educational institutions, and government operations was limited among these ethnic minorities. Knowledge gained from this study can be used as evidence for government agencies, policymakers, and local public health officials to improve the health and well-being of highland ethnic groups. Biological and social factors, especially female gender, should be an area of focus, as they have a higher risk of NCDs. The Mien and Hmong ethnic groups should undergo health screenings for early treatment and proactive health promotion programs. Behavioral modification programs should emphasize increasing NCD-related knowledge, how to make healthy food choices, food labels, and self-efficacy to reduce NCD risk factors and complications.