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Community engagement and local governance are important components of health interventions aiming to empower local populations. Yet, there is limited evidence on how to effectively engage with communities and codevelop interventions, especially in Southeast Asian contexts. Despite rapid progress, the Lao People's Democratic Republic (Lao PDR) still has high maternal and child mortality, with essential service coverage showing significant disparities across socioeconomic strata. Long-standing challenges in community health were exacerbated by the COVID-19 pandemic and reinforced by poor trust between users and health providers. However, the pandemic also provided an opportunity to develop approaches for enhanced community engagement and local governance capacity to tackle health inequities. The Community Network Engagement for Essential Healthcare and COVID-19 Responses through Trust (CONNECT) Initiative, developed by the Lao PDR government, WHO and partners, has resulted in initial positive outcomes in community health such as increased vaccination uptake, facility births and trust in health providers. This case study describes the iterative, adaptive process by which the CONNECT Initiative was developed, and how the core components, key stakeholders, theory of change and evaluation framework evolved from grounded observations and hypotheses. Lessons learnt include (1) awareness of entry points and existing structures to strengthen local governance for health through mutually beneficial intersectoral collaboration; (2) building relationships and trust with an adaptive, grounds-up approach for sustainability and scalability. As a model which can be adapted to other settings, this case study provides evidence on how to engage with communities, strengthen local governance and codevelop interventions towards greater health equity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The global COVID-19 vaccine rollout has been impacted by socioeconomic disparities and vaccine hesitancy, but few studies examine reasons for changed attitudes. In Lao People's Democratic Republic (Lao PDR), a nationwide government-led initiative was developed in response to COVID-19, focused on community health ownership and trust in primary healthcare. The intervention team including health and governance sectors conducted capacity-building workshops with local staff and community representatives and visited villages for vaccination outreach. This study investigates the impact of this intervention on COVID-19 vaccine acceptance in rural communities., Methods: Conducted in Xiengkhuang province, Lao PDR, from December 2022 to February 2023, the study employed a sequential mixed-methods research design. Data on vaccinated individuals from 25 villages were collected from 11 primary healthcare units; pre-post analysis was applied. Qualitative data, gathered through interviews and focus group discussions with villagers, village authorities, health staff and local government (n=102) in six villages, underwent inductive thematic analysis., Results: First-dose vaccine uptake after the intervention increased significantly (6.9 times). Qualitative analysis identified key reasons for vaccination hesitancy: (1) mistrust due to rumours and past experiences; (2) poor communication and inconsistent messaging and (3) challenges in access for priority groups. Influencing factors during the intervention included (1) effective local-context communication; (2) leveraging existing community structures and influential individuals in a multisectoral approach and (3) increased community motivation through improved satisfaction, ownership and relationships., Conclusion: This study highlights the impact and methods of building trust with unreached populations in health interventions, emphasising locally led solutions. Successful reversal of vaccine hesitancy was achieved by addressing root causes and fostering ownership at community and local government levels through a 'positive approach'. This diverges from conventional supplemental immunisation activities and holds potential for systematically building trust between unreached populations and health systems. Further research could explore the impacts of routine vaccination for sustained improvements in health equity., Competing Interests: Competing interests: None declared., (© World Health Organization 2024. Licensee BMJ.)

Lao People's Democratic Republic (Lao PDR) with a population of 6.8 million is a low middle-income country in Southeast Asia. Despite economic development, Lao PDR is still characterized by a weak health system. The Ministry of Health has launched health reforms to provide better health services and University of Health Sciences (UHS) plays an essential role in Human Resources for Health (HRH) reform. Especially, the importance of its role in training health professionals from entry-level to continuing education has been increased. In 2016, the UHS embedded an Interprofessional Education (IPE) concept into a pre-qualifying course, in collaboration with the World Health Organization and the Gunma University Centre for Research and Training on IPE. As a pilot study, some students from faculties of Medicine, Pharmacy, Dentistry, Nursing, and Medical Technology participated in a community-based IPE program. Results suggested that students participating in the IPE program showed more positive attitudes toward collaborative practice than students who did not participate in the IPE program. Based on the results, the UHS is planning to develop an IPE program for health workers. In this article, we describe the strategic international collaboration and discuss the keys to successful IPE planning and implementation in line with HRH reform.

Background: Malaria is a major health problem in Lao People's Democratic Republic (Lao PDR) with high transmission in remote and forest areas, particularly in the South. The military is at risk of malaria infection especially those deployed in forest areas. This study determined the prevalence of malaria infection and assessed knowledge, perception, and preventive and treatment behavior regarding malaria among military personnel in two southern provinces in Lao PDR., Methods: Quantitative and qualitative approaches were undertaken in Champasak and Attapeu provinces in 2017. From 313 military personnel, quantitative data were collected through questionnaire-based interviews and blood samples used for parasite detection by polymerase chain reaction (PCR). Qualitative data were collected through 7 focus group discussions and 17 in-depth interviews among 49 military personnel. Fisher's exact test and Mann-Whitney U test were used to assess the association between malaria infection and participant characteristics. Content analysis for qualitative data was performed to explore perception and treatment behaviors regarding malaria., Results: The prevalence of malaria infection was 11.2% ( Plasmodium falciparum : 1.3%, Plasmodium vivax : 9.3% and mixed infections: 0.6%). Many participants understood that malaria is transmitted through mosquito bites, although they did not necessarily know the name of vector mosquitoes ( Anopheles ). Surprisingly, more than a half also believed that malaria is transmitted through drinking stream water. One-third of the participants used long-lasting insecticidal nets. Due to limited supply, participants were often unable to use mosquito repellent and coils when necessary. Because participants were unable to receive timely diagnosis and appropriate treatment for malaria in their camps, they commonly practiced self-treatment using antibiotics, painkillers, and/or traditional medicines. They only go to a healthcare facility through their supervisor if their conditions worsen., Conclusions: The prevalence of symptomatic and asymptomatic malaria was conspicuous among military in forest areas. Many participants believed that malaria is transmitted not only by mosquito bites but also from drinking stream water. Preventive equipment was often insufficient. Self-treatment was practiced before referring to healthcare facility. To further prevent military from contracting malaria, the National Malaria Control Program and military body should provide adequate and suitable health education, protective equipment, and on-site malaria case management., Competing Interests: Ethical clearance was obtained from the National Ethics Committee for Health Research, Lao PDR (No. 073/NECHR), and from the Ethics Review Committee for Epidemiology Study, University of the Ryukyus (No. 1172). The permission to conduct the study was given by the General Logistic Department, the Ministry of Defense (No. 358), Lao PDR, and also from the camp leaders. The interviewers and moderator explained the purpose of the study and procedures in Laotian. The participants were also informed that their participation was voluntary, and that the results of the blood analyses and interviews would be treated in confidence. Moreover, they were informed that they can withdraw from the interview and discussion anytime without consequences.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Snakebite is a neglected condition and a common public health problem in Lao People's Democratic Republic (Lao PDR), with a high incidence of up to 1,105 cases per 100,000 persons per year. Snakebite patients with systemic envenoming do not receive effective treatment at local health facilities. Healthcare providers have only limited knowledge in assessing and providing the correct treatment for venomous snakebites. A cross-sectional study was conducted among 119 healthcare providers in Savannakhet Province, Lao PDR, with respect to their socio-demographic characteristics, knowledge of snake identification, and management of snakebite. Data was analyzed using SPSS. Logistic regression was performed to estimate the odds ratios (OR) and 95% confidence intervals (CI) of adequate knowledge for treating snakebites among the healthcare providers. Among 119 participants, 27.7% and 45.4% had an adequate knowledge of snake identification and management of snakebites, respectively. Approximately 59% could correctly identify symptoms of envenomation, and 19.3% expressed confidence in treating snakebites. Study participants who had received training achieved significantly better snake identification results compared to those without training, with an OR of 2.54 (95% CI: 1.02-6.28). In particular, physicians achieved significantly better results compared to nurses in knowing how to manage snakebites, with an OR of 2.31 (95% CI: 1.04-5.12). Given the level of inadequate knowledge of snakebite management among healthcare providers in the province, more training in snakebite management is needed. University and Health Science Colleges should include snakebite management into the curriculum, to ensure that medical graduates have the appropriate knowledge and skills to treat snakebites.

Background: Female sex workers (FSWs) are a high-risk population for HIV. Correct and consistent use of condoms is the most effective measure for reducing transmission of HIV. Lao PDR is a low HIV-prevalence country, but FSWs have a relatively high HIV prevalence. To be able to make recommendations for condom promotion interventions in Lao PDR it is important to know more about the context specific situation. This study looked at reasons for and associated factors of consistent condom use among FSWs., Methods: A cross-sectional survey among 258 FSWs in Kaysone Phomvihan district in Savannakhet province was performed., Results: Almost all FSWs had enough condoms (94%), condoms always available (100%) and could always afford condoms (92%). Consistent condom use was 97% with non-regular partners and 60% with regular partners. Almost all respondents (95%) had received information about condoms from the drop-in centre. Stated reasons for consistent condom use were prevention of HIV (94%), STIs (88%) and pregnancy (87%). Most reasons for inconsistent condom use were related to partners not wanting to use condoms because of reduced sexual pleasure. Some FSWs reported that they were physically abused and forced not to use condoms. Shorter time in sex work, higher education and FSW not having regular partners were significantly associated with consistent condom use., Conclusions: Consistent condom use was very high with non-regular partners, but less frequent with regular partners. The main reason for inconsistent condom use was that the partner did not want to use a condom. Associated factors for consistent condom use were not having regular partners, higher education and shorter time in sex work. Condom promotion programs should include both FSWs and their partners and female condoms should be included in condom intervention efforts. Future studies should investigate the validity of self-reported sexual practices, partners' reasons for inconsistent condom use, risk of violence in sex work and why shorter time in sex work is associated with consistent condom use.

Objective: Female sex workers (FSWs) are at risk of unintended pregnancies and induced abortions (IAs). This study aimed to describe attitudes towards and experiences of IA among FSWs in Laos., Methods: 258 FSWs were interviewed in Kaysone Phomvihan, Laos. Descriptive statistics and logistic regression were used to analyse the data., Results: Overall, 24% of the respondents reported experience of IA. Fifteen percent reported experience of unintended pregnancy after entering sex work, whereof all had ended in IA. Thirty-six percent had self-induced the last IA and 64% were carried out in private clinics. The main reasons for having IAs were paternity denial and lack of financial and social support. A majority agreed or strongly agreed that IA should not be legal in Laos and that women who undergo IA are immoral, but also that IA is the only option a FSW has when experiencing an unintended pregnancy. A positive attitude towards IA was associated with longer duration of sex work and being unmarried., Conclusion: IAs were common. Respondents' attitudes and practices reflected limited options when experiencing an unintended pregnancy, and were influenced by negative social perceptions. Interventions targeting FSWs should raise awareness of IA and post-abortion care, and promote dual contraceptive use with highly effective contraceptives., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Female sex workers (FSWs) are vulnerable to sexually transmitted infections (STIs) and other types of health problems and they also encounter socio-economic difficulties. Efforts to develop effective health intervention programs for FSWs have been hampered by a lack of information on why FSWs do not seek or delay seeking treatment for STIs. To further understand their reasons, our study applied a qualitative approach to explore perceptions of health and ill-health among FSWs in Savannakhet province in Laos., Methods: Fifteen in-depth interviews were conducted with FSWs in Savannakhet province. Latent content analysis was used for analysis., Results: Sex workers' definitions of health and wealth are intertwined. Thus, good health was described as strongly related to wealth, and wealth was needed in order to be healthy. This is explained in two sub-themes: health is necessary for work and income and ill-health creates social and economic vulnerability., Conclusions: Female sex workers' beliefs and perceptions about health and ill-health were dominated by their economic need, which in turn was influenced by expectations and demands from their families.

Background: Female sex workers (FSWs) are vulnerable to sexually transmitted infections (STIs) and encounter socio-economic and health problems, including STIs/HIV, unintended pregnancy and complications from unsafe abortion, stigma, violence, and drug addiction. Reducing risks associated with sex work requires an understanding of the social and cultural context in which sex workers live and work. This study aimed to explore the working environment and perceived risks among FSWs in Savannakhet province in Laos., Methods: Five focus group discussions (FGDs) and seven interviews were conducted with FSWs in Kaysone Phomvihan district in Laos. Latent content analysis was used to analyze the transcribed text., Results: The results revealed that the FSWs were aware of risks but they also talked about benefits related to their work. The risks were grouped into six categories: STIs/HIV, unintended pregnancy, stigma, violence, being cheated, and social and economic insecurity. The reported benefits were financial security, fulfilling social obligations, and sexual pleasure. The FSWs reported using a number of strategies to reduce risks and increase benefits., Conclusions: The desire to be self-sufficient and earn as much money as possible put the FSWs in disadvantaged and vulnerable situations. Fear of financial insecurity, obligations to support one's family and the need to secure the future influenced FSWs' decisions to have safe or unsafe sex. The FSWs were, however, not only victims. They also had some control over their lives and working environment, with most viewing their work as an easy and good way of earning money.

This study aimed to assess the knowledge and attitudes among health care providers (HCPs) providing sexually transmitted infection (STI) service to female sex workers (FSWs). A cross-sectional survey was performed in 6 districts along Road 9, traversing Savannakhet province from Thailand to Vietnam. In total, 244 HCPs providing STI services were interviewed. In all, 54% of respondents had no STI training despite providing STI treatment. Misperceptions of STI causes, transmission routes, and symptoms were common among respondents. Attitudes differed neither between male and female respondents nor between those who had or had not received STI training. A higher proportion of pharmacists/drug sellers (68%) had negative attitudes followed by medical doctors (59%) and nurse/midwives (55%). The proportion of herbalists with negative attitudes (53%) was less in comparison with the other professionals. To improve the quality of STI services and to enhance FSWs' access to health care services, educational improvements of HCPs' knowledge about STIs and their attitudes are needed.

Background: Prompt, correct diagnosis and treatment with health information are essential components of reproductive tract infection (RTI) and sexually transmitted infection (STI) services. This study aims to describe care seeking behaviour and barriers to accessing RTI/STI services among female sex workers (FSWs) in Laos., Methods: A cross-sectional survey using closed and open-ended questions was performed in six districts along Road 9, traversing Savannakhet province from Thailand to Vietnam. In total, 407 FSWs were interviewed. The data were analyzed and presented descriptively. Multiple logistic regression analysis was applied to assess associations between respondents' background characteristics and care seeking behaviour., Results: About half of the respondents (49%) were less than or equal to 19 years of age, and 50% had started or completed secondary school. Fifty-eight percent had been engaged in sex work for less than 1 year. Eighty-six percent of the respondents reported RTI/STI signs or symptoms currently or in the last 3 months but only two-thirds of those with symptoms sought treatment. Source of treatment for the last RTI/STI episode was the drop-in centre (53%) followed by a public hospital (23%), private clinic (12%), private pharmacy (9%), and herbalist (2%). The main barriers to service use were long waiting time, inconvenient location of the clinic, not knowing where to get the services needed, and negative attitudes among healthcare providers. Care seeking behaviour was associated with longer duration of sex work (OR = 2.6, 95%CI 1.52-5.36). Forty-four percent received health information from peer educators, 34% from fellow friends, 26% from a pimp, and 26% had received information from a healthcare provider during the visit., Conclusion: There were several barriers to accessing RTI/STI services and they were related to both structural and individual factors. Innovative STI service strategies to inform FSWs about the importance of early diagnosis and treatment should be established. Continuous training for STI service providers focusing on counseling skills and awareness of the sexual health care needs for FSWs is recommended in order to minimize the barriers experienced by FSWs in this particular setting.