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Background: The Lao People's Democratic Republic (Lao PDR), a lower-middle-income country, lags behind other Southeast Asian countries in immunization coverage for children under two years of age. The organization of health services is a key determinant of the functionality of immunization programs. However, this aspect, and in particular its decentralization component of the healthcare system, has never been studied. Methods: A case study in the Lao National Immunization Program was performed using a neo-institutional theory-based conceptual framework, highlighting the structure (rules, laws, resources, etc.) and interpretative schemes (dominant beliefs and ideas) that underlie the state of decentralization of the healthcare system that support the conduct of the immunization program. Twenty-two semi-structured interviews were conducted with representative actors from various government levels, external donors, and civil society, in four provinces. Data were complemented with information retrieved from relevant documents. Results: The Lao healthcare system has a deconcentrated form of decentralization. It has a largely centralized structure, albeit with certain measures promoting the decentralization of its immunization programs. The structure underlying the state of centralization of immunization services provided is coherent with a shared dominant interpretive scheme. However, the rapid economic, technical, and educational changes affecting the country suggest that the coherence between structure and interpretative schemes is bound to change. Conclusion: Unprecedented opportunities to access quality higher education and the use of social networks are factors in Lao PDR that could affect the distribution of responsibilities of the different levels of government for public health programs such as the National Immunization Program. [ABSTRACT FROM AUTHOR]

Background: In most developing countries, addressing malnutrition involves a coalition of stakeholders that includes the government and international development partners. This study explores the evolution of the malnutrition actor coalition landscape before and after the emergence of the National Nutrition Policy in the Lao People's Democratic Republic (Lao PDR) in 2008. Methods: A qualitative study was conducted based on the theory of coalition structuring. Twenty semi-structured interviews were performed with representatives of national and international organisations involved in addressing malnutrition in Lao PDR. The information obtained from the interviews was complemented by an analysis of relevant documents dating back to 1990. Interviews were recorded and transcribed verbatim. A thematic analysis was performed using NVivo 11 software and the diagrams of collaboration drawn by the participants were turned into a visual collaboration map using SocNetV software. We relied on various types of triangulation to increase the analysis's credibility, reliability, and confirmability. Results: The results showed that before the emergence of the National Nutrition Policy, three coalitions representing the health, agriculture, and education sectors coexisted. These colalitions worked largely in silos, although with some interactions when deemed necessary mainly by United Nations agencies. The emergence of the National Nutrition Policy provided the government with an effective political tool for coalescing the three coalitions into a unique coalition involving all major stakeholders in the nutrition field. All three forces that incite actors to collaborate inside a coalition according to the theory of coalition structuring (transactions, control, intangible factors) were mobilised in the creation of the single coalition. Conclusions: Combating malnutrition is a government priority in the Lao PDR. The current study showed that the National Nutrition Policy in Lao PDR has led to a significant evolution in the malnutrition coalition landscape, resulting in improved collaboration among stakeholders. This finding highlights the effectiveness of public policies in facilitating intersectoral activities to tackle complex problems, such as malnutrition. [ABSTRACT FROM AUTHOR]

Anemia is a severe public health problem in the Lao People's Democratic Republic (PDR). Consequently, a new control strategy to reduce the burden of anemia has been introduced for preschool children (aged 6-52 months). The objective of this study was to assess the current prevalence of anemia and related factors in preschool children in southern rural Lao PDR. A population-based cross-sectional study was carried out in six communities in Songkhone district, Savannakheth province, in February 2009. As a result, the prevalence of anemia was found to be 48.9% (95% confidence interval (CI), 43.5-54.3), although most cases were mild. A multiple logistic regression analysis indicated that there was no protective effect of breastfeeding against anemia. The anemia prevalence was higher in 1) children aged 6-23 months (Odds Ratio (OR) = 1.73, 95% CI, 1.02-2.90) than in older children, 2) children in large families (6 or more members) (OR = 1.96, 95% CI, 1.17-3.29), and 3) children in three remote villages with relatively difficult access to markets (OR = 3.01, 95% CI, 1.25-7.47). In Lao PDR, improvement of food practices and home-fortified food supplementation interventions are essential. High-risk groups should be targeted and a long-term health education program that aims to modify food habits implemented. Furthermore, in settings where iron deficiency is not the only cause of anemia, combining an iron supplement with other measures is necessary. [ABSTRACT FROM AUTHOR]

Background: Maternal mortalities remain high in the Lao People's Democratic Republic (Lao PDR). Since 2012, to improve access to maternal health services for all women, the country implemented several policies and strategies including user fee removal interventions for childbirth-related care. However, it remains unclear whether inequalities in access to services have reduced in the post-2012 period compared to pre-2012. Our study compared the change in sociodemographic and economic inequalities in access to maternal health services between 2006 to 2011–12 and 2011–12 to 2017. Methods: We used the three most recent Lao Social Indicator Survey datasets conducted in 2006, 2011–12, and 2017 for this analysis. We assessed wealth, area of residence, ethnicity, educational attainment, and women's age-related inequalities in the use of at least one antenatal care (ANC) visit with skilled personnel, institutional delivery, and at least one facility-based postnatal care (PNC) visit by mothers. The magnitude of inequalities was measured using concentration curves, concentration indices (CIX), and equiplots. Results: The coverage of at least one ANC with skilled personnel increased the most between 2012 and 2017, by 37.1% in Hmong minority ethnic group women, 36.1% in women living in rural areas, 31.1%, and 28.4 in the poorest and poor, respectively. In the same period, institutional deliveries increased the most among women in the middle quintiles by 32.8%, the poor by 29.3%, and Hmong women by 30.2%. The most significant reduction in inequalities was related to area of residence between 2006 and 2012 while it was based on wealth quintiles in the period 2011–12 to 2017. Finally, in 2017, wealth-related inequalities in institutional delivery remained high, with a CIX of 0.193 which was the highest of all CIX values. Conclusion: There was a significant decline in inequalities based on the area of residence in the use of maternal health services between 2006 and 2011–12 while between 2011–12 and 2017, the largest decrease was based on wealth quintiles. Policies and strategies implemented since 2011–12 might have been successful in improving access to maternal health services in Lao PDR. Meanwhile, more attention should be given to improving the uptake of facility-based PNC visits. [ABSTRACT FROM AUTHOR]

Background: To improve the health of the rural population in the Lao People's Democratic Republic (Lao PDR), the government has emphasized a primary health care approach in the Health Sector Reform Strategy by 2025. The objective of the present study was to describe the health-related situations of remote rural villages of the Lao PDR to inform strategies for promoting primary health care in such villages. Methods: Ten remote rural villages were purposively selected from the catchment areas of two health centers in the Xepon district, Savannakhet province. The surveyors collected data by conducting a questionnaire-based interview with village health volunteers and by observing the village environment in 2018. The survey focused on village situations on the eight elements of primary health care (health education; food supply and nutrition; safe water and basic sanitation; maternal and child health care; immunization; prevention and control of locally endemic diseases; treatment of common diseases and injuries; and provision of essential drug). Results: The common health problems were diarrhea, followed by malaria, and cough. The identified possible risk factors for the health problems were not washing hands with soap, open defecation, not boiling drinking water, not exclusively breastfeeding, presence of animal feces on the village ground, absence of garbage management system, not using a bed net when sleeping in the forest, and exposure to indoor cooking and tobacco smoke. In many villages, villagers were not able to eat enough food and did not eat protein-rich food and vegetables daily. Conclusions: Potential risk factors for the reported common health problems were often prevalent in the study villages. Villagers can address most of these risk factors, as interventions to address such risk factors do not require a large financial input. There is a need for intersectoral actions between the health and other sectors to address food shortages and indoor air pollution due to indoor cooking using biomass fuel. [ABSTRACT FROM AUTHOR]

Background: Although hypertension is becoming more prevalent among the adult population of the Lao People's Democratic Republic (PDR), with a prevalence of approximately 20% in 2013, treatment adherence of patients with hypertension, especially those in rural areas, remains poorly understood. The objective of the present study was to examine the rate of medication adherence to antihypertensive medicines among outpatients with hypertension in rural districts of the Savannakhet. Methods: A prospective observational study was conducted in Xepon, Phin, and Nong districts. The study population was outpatients aged 18 years or older who were prescribed antihypertensive medicines at three district hospitals between February and August 2017. Data were collected on the first day of treatment (day 0) and the day of follow-up (around day 7) through interviews with the patients and outpatient registration books. The medication adherence rate was determined using the four-item Morisky Medication Adherence Scale. The level of adherence was evaluated by the sum of the scale, with scores ranging from 0 to 4 points. The adherent group, namely those with a score of 0, and the non-adherent group, namely those with scores of 1 to 4 points, were compared. Fisher's exact test was used to identify factors associated with medication adherence. Results: Of the 68 patients examined, 38.2% newly began treatment. Half of the patients (n = 34, 50.0%, 95% CI 0.38 to 0.62) adhered to medication instructions. The adherent group was more likely to have received written instructions when prescribed medication, compared to the non-adherent group (79.4% vs 55.9%, p = 0.068). Those who perceived that hypertension needs lifelong treatment were significantly more likely to adhere to the medication regimen (p = 0.028). Conclusions: Medication adherence was present among 50% of outpatients with hypertension who visited a district hospital. Therefore, providing written instructions to patients would be effective for improving medication adherence. [ABSTRACT FROM AUTHOR]

Background: Southeast Asia is experiencing a health transition, where non-communicable diseases (NCD) are exceeding communicable diseases. Despite NCDs accounting for roughly 60–85% of deaths in the region, many developing Southeast Asian countries are beginning to address the impacts of a physically inactive lifestyle for the first time. Our study aims to bridge this gap by objectively measuring physical activity in rural Lao PDR to reveal the association among physical activity, activity space, and seasonal variation. Methods: Multiple waves of survey data were collected in Songkhon District, Lao PDR between March 2010 and March 2011. Adults aged between 18 and 65 were recruited (n = 48). A portable GPS recorded participants' activity and farmland locations and an accelerometer recorded participants' physical activity level and daily steps for seven consecutive days. Using a directional distribution tool in ArcGIS 10.5, the activity space area of each participant in each wave was calculated. Concurrently, participants recorded time spent on each daytime activity. Linear mixed models with the fixed effects as the observations from different waves and the random effects as individual participants were developed to identify factors associated with areas of activity space and counts of daily steps, respectively. Results: A total of 48 respondents aged between 19 and 57 took part in the study. Half of the participants were females. Walking was found to be the most frequent travel mode. Females were physically less active, with a smaller activity space, and were more overweight than the males in the study. Participants were physically less active during the off-farming seasons. Conclusions: Findings contribute to the surveillance of risk factors needed to create healthy living environments. Our research is also one of the first to use empirical evidence demonstrating seasonal variations of rural residents' activities in mainland Southeast Asia. [ABSTRACT FROM AUTHOR]

Background: Village health volunteers (VHVs) are responsible for providing primary care in the communities of Laos. Unlike other districts, in Xepon more than 90% of VHVs are male and therefore experience difficulties interacting with pregnant women. To improve outreach to pregnant women, especially among ethnic minorities, a new project was implemented by local municipalities in 2017: newly selected female VHVs were paired to work with existing male VHVs. The objective of this study was to compare the postnatal depressive symptoms of ethnic minority mothers supported by pair-VHVs and single-VHVs in remote rural areas of Lao People's Democratic Republic (PDR). Methods: A cross-sectional study was conducted in March 2019. Mothers who had delivered a baby within 1 year preceding the study were recruited from 36 villages. Of the 305 mothers, 227 responded. The questionnaires included (1) demographic characteristics such as age, economic status, and birth experience; (2) self-decision to go to a health center/hospital to receive antenatal care; (3) type of VHVs (pair or single), support, and information from VHVs during pregnancy, support from husband and relationship with husband; (4) the Edinburgh Postnatal Depression Scale (EPDS). A Mann-Whitney U test, chi-square test, and multiple linear regression analysis were performed. Ethical approval was obtained from the University of the Ryukyus and National Ethics Committee for Health Research of Lao PDR. Results: The average total EPDS score was 5.5 among mothers supported by pair-VHV and 7.0 among mothers supported by single-VHV. Results of the multiple linear regression analysis showed that the EPDS score was significantly lower among mothers supported by pair-VHV (β=−1.18, p <0.05) even after adjusting for economic and biological factors. Conclusions: Mothers supported by pair-VHV had a significantly lower EPDS score than those supported by single-VHVs in this study area, suggesting that the support of male and female VHV pairs contributed to improving mental health status among ethnic minority mothers in remote rural areas of Lao PDR. Expanding the program to train female VHVs working with male VHVs is necessary for improving maternal and child health in a rural district of Lao PDR. [ABSTRACT FROM AUTHOR]

Background: Facility-based delivery has been promoted to improve maternal and child health care in Lao PDR and a free delivery policy was introduced at designated health care facilities (HCF) in 2013. However, according to birth records of HCFs in the impoverished and remote district, only a few women utilized the HCFs despite good physical accessibility. The aim of this study was to analyze the factors influencing the choice of facility-based delivery in the impoverished and remote district after a free delivery policy was introduced. Methods: Qualitative case study was employed. Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted from August to October 2015. Five hamlets (or small village) located along the main road where only a few women delivered at HCFs were selected for the study based on birth records. The participants of the FGDs and IDIs were the village heads, village health volunteers, women who delivered at home or at a health facility within the past 2 years, their husbands, and mothers or mothers-in-law. Thematic analysis was used to analyze the data. Results: A total of 12 FGDs and 27 IDIs were conducted, and the number of participants was 105. The factors influencing the choice of facility-based delivery were classified into nine categories and 19 subcategories. The categories were labeled, "perception of childbirth," "traditional health concept: sabaai (a condition of health, ease, and comfort)," "perception of health care facilities and staff," "previous pregnancy and childbirth experience," "mode of available transportation," "financial burden of childbirth at health care facility," "family and community context," "institutional context," and "government policy on delivery." Conclusion: Our study demonstrated that five major factors negatively influenced the choice of facility-based delivery: (1) perception of childbirth, (2) preference for sabaai, (3) financial burden, (4) family decision-making, and (5) institutional context. To promote facility-based delivery in the impoverished and remote district, three strategies are recommended: (1) promoting community-based health education involving women and strengthening community-based mutual support, (2) clarifying items essential for delivery at HCFs, and (3) making HCFs more comfortable in terms of "sabaai." [ABSTRACT FROM AUTHOR]

Background: In Lao People's Democratic Republic (PDR), which borders China, Vietnam, Cambodia, Thailand, and Myanmar, the number of HIV-infected patients has increased in recent years. HIV-infected patients diagnosed in Lao PDR are enrolled in a registration network and receive antiretroviral therapy (ART) covered by governmental financial support. Based on the registration network, we investigated intestinal helminth infections and coinfection with HTLV-1 in HIV-infected patients treated with an early intervention using ART in Lao PDR. Methods: This cross-sectional study of all 252 HIV-infected patients at Savannakhet Provincial Hospital, located in the southern part of Lao PDR, was conducted between February and March 2018. Socioepidemiological information and clinical information were collected from a registration network database and by questionnaire administered to participants. Microscopic examination of intestinal helminth infections in stool samples and particle agglutination for anti-HTLV-1 antibody in plasma were performed. Results: The median age of all 252 participants was 39 years old (range, 18–59). Based on the registration network database, there were 156 (61.9%) HIV-infected patients with a CD4-positive cell count ≥ 200 cells/μL and 146 (57.9%) with an HIV viral load < 250 copies/mL. Among 212 stool samples, 75 (35.4%) were found to contain one or more intestinal helminth species, including Opisthorchis viverrini (16.5%), Strongyloides stercoralis (10.8%), hookworm (10.4%), and Taenia saginata (3.3%). This rate of intestinal helminth infections was lower than that of a previous report conducted before the establishment of the registration network for HIV-infected patients in Lao PDR. There was no significant association between intestinal helminth infections and a lower CD4-positive T cell count or higher HIV viral load. HIV-infected patients with anti-HTLV-1 antibody positivity were not found in this cohort. Conclusion: The registration network and an early intervention using ART may provide good medical care and improve the clinical course of HIV-infected patients in Lao PDR. However, the incidence of intestinal helminth infections remains high at 35.4%. The development of a specific medical care system for helminth infection for HIV-infected patients is necessary. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Artemisinin resistance in Plasmodium falciparum has been spreading across Southeast Asia. Patients' adherence to artemisinin-based combination therapy (ACT) is critical to avoid expanding this resistance. The objectives of this research were to examine patients' adherence to ACT for the treatment of uncomplicated malaria and to examine the healthcare workers' perception of medication adherence and their dispensing practices for malaria patients in Savannakhet province, Lao PDR. Methods: A prospective observational study of patients and a descriptive study of healthcare workers were conducted in Xepon, Phin, and Nong districts. In the patient study, patients aged 18 years old or older who were prescribed artemether-lumefantrine (AL) at six healthcare facilities between October 2016 and August 2017 were examined. Patient interviews and tablet counts were conducted on the first day of treatment (day 0) and the follow-up day (around day 3). In the healthcare workers study, a self-administered questionnaire survey was conducted. Results: Of the 54 patients examined, 51 (94.4%) were adherent to the AL regimen. The other three patients stopped medication because they felt better, even though the importance of completing the regimen was explained to all patients when it was prescribed. Among 152 healthcare workers who had ever instructed a malaria patient, 74.3% reported that they occasionally saw a malaria patient who adhered poorly to medication instructions. The healthcare workers perceived the major reasons for poor adherence to be illiteracy and poor understanding of medication instructions by patients. In practice, 27.6% of the healthcare workers did not regularly explain the importance of completing the regimen to patients, and 32.2% did not often or always confirm the patients' understanding of medication instructions. Conclusions: Patient adherence to AL was high. The healthcare workers perceived that poor adherence was attributable to the patients, i.e., their poor understanding and illiteracy, which appeared to be related to linguistic differences. However, poor adherence also appeared to be attributable to the healthcare workers, who should tell patients of the importance of completing the AL regimen regardless of their improvement in physical condition and also confirm the patients' understanding of the instructions. [ABSTRACT FROM AUTHOR]

Background: Lao People's Democratic Republic (Lao PDR) formulated the National Strategic Plan for Disaster Risk Management to reduce risks to the communities. This plan was eventually integrated into the school curriculum, but its implementation has never been evaluated. This study aimed to clarify the present situation to inform better implementation strategies on disaster risk reduction and management in a school setting focused on fire disasters in Lao PDR. Methods: A case study was conducted in Vientiane and five provinces in 2017. Key informant interviews were conducted among 52 policy implementers from the Disaster Management Committee (DMC), the education, and fire service sectors at national, provincial, district and school levels. Observations were done among eight secondary schools, and questionnaires were answered by 869 grade 7 students. Interview transcripts underwent content analysis using the 12 influential components of successful policy implementation and the 3 pillars of comprehensive school safety framework. The level of student knowledge on fire prevention and response was examined. Results: Three themes emerged: policy content and dissemination, factors which affect policy implementation, and impacts of policy implementation facilitating factors include effective coordination and ownership among the national DMC members for scaling up disaster risk reduction (DRR) activities, and strong support from the central government. Barriers include unclear provisions in the national legislation, unclear mandates especially on leading the program, poor monitoring system, insufficient human resources, and lack of public-private partnerships. All the study schools conducted DRR classes and designated a disaster assembly point. More than 80% of the students correctly answered items on fire response. Conclusion: The policy was widely disseminated and implemented in all levels across sectors among the study sites except for some rural areas. Although there is a lack of national legislation and clear mandates, strong leadership, and ownership of the implementers facilitated policy implementation. All the study schools conducted fire prevention activities. Most students knew how to appropriately respond to fire. A comprehensive school-based DRR program would be beneficial in improving student knowledge and practices on DRR. [ABSTRACT FROM AUTHOR]