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Objective:The current study aimed to assess trends, associated factors and the changes in these factors for exclusive breast-feeding (EBF) over the past two decades in Lao People’s Democratic Republic (Lao PDR).Design:The current study used a quasi-longitudinal design. Descriptive analyses were done with correction for complex survey design. Inferential analyses were done for survey years separately using multiple logistic regression. Finally, pooled logistic regression analysis was done using interaction terms to quantify the difference in association per year.Setting:The current study used data from all provinces of Lao PDR collected in the years 2000, 2006, 2011/2012 and 2017.Participants:Children aged six months or younger from Lao PDR.Results:EBF practice was estimated at 19·03 %, 26·87 %, 40·67 % and 44·89 % in the four survey years, respectively. Factors significantly associated with EBF included: region of residence, ethnicity, wealth index and age of child. Region and ethnicity saw significant changes in association, and the South developing positively over time as well as in the Lao-Thai ethnic group. Having had any antenatal visits was not associated with EBF practice, nor did this change over time.Conclusions:Our study shows how EBF trends, and factors associated with EBF, changed over time. We applied an easily replicable methodology to assess similar public health phenomena. We argue that such analysis is particularly relevant for transitioning countries. In such rapidly evolving settings, it is crucial to take into account changing underlying factors when assessing and developing public health policy.

The role of agriculture in reducing undernutrition is widely recognized, yet there is also consensus on the need to make the sector nutrition-sensitive. Evidence on the impact pathways from nutrition-sensitive agriculture (NSA) interventions, agricultural interventions with specific nutrition objectives, and actions detailing each temporal stage to reach nutrition outcomes is limited, however. We thus synthesized study results regarding impact of NSA interventions on nutrition outcomes relating to undernutrition, and constructed an impact pathway by mapping the evidence on each temporal stage from interventions to nutrition outcomes. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses to conduct and report our systematic review of studies on NSA interventions implemented in low- and lower-middle-income countries. Forty-three studies that met the inclusion criteria were extracted and synthesized across impact and pathways analyses. We carried out a thematic analysis of the effect of NSA interventions using evidence-based indicators and constructed the pathways by adopting a published framework on agriculture to nutrition pathways. Our findings reveal that NSA interventions can significantly improve dietary practices, and have the potential to enhance care practices and reduce occurrence of diseases, indicating their effectiveness in simultaneously addressing multiple determinants of undernutrition. However, NSA interventions have a lesser impact on nutritional status. NSA interventions lead to nutrition outcomes through 5 key pathways: food production, nutrition-related knowledge, agricultural income, women's empowerment, and strengthening of local institutions. We emphasize the need to carefully design, implement, and evaluate interventions with consideration for factors affecting impact pathways. Future research should focus on the effect of interventions combining multisector components, and pathways through non-food-production-related income, women's empowerment, strengthening of local institutions, food prices at intervention level, and expenditure on health care., This review synthesizes the impact of NSA interventions on nutrition outcomes and constructs pathways by mapping the evidence on each temporal stage, from the interventions to the nutrition outcomes.

In Vietnam, the overall prevalence of hypertension (HTN) was 21%, with lower estimates for the prevalence of HTN awareness and treatment. The health systems, like other low- and middle-income countries, were designed to provide acute care for episodic conditions, rather than a chronic condition where patients need long-term care across time and disciplines. This article describes the delivery and organization of HTN care at primary healthcare (PHC) settings in both urban and rural areas at Hue Province of Central Vietnam in comparison with Thai Nguyen province in Northern Vietnam based on the infrastructure capacity and patients’ and providers’ perspectives and experiences We used mixed-methods design that included in-depth semi-structured interviews with patients and healthcare providers at purposively selected PHC facilities in two districts of each province and a modified version of the service availability and readiness assessment inventory at all PHC facilities. We found that HTN patients in both provinces can access healthcare services to diagnose, treat and control their HTN condition at the PHC level with a focus on district facilities. Health services in Hue have allowed commune health stations (CHSs) to provide routine monitoring and prescription refills for HTN patients while maintaining periodical visits to a higher level of care to monitor the stability of the disease. Such provision of care at CHSs remained restricted in Thai Nguyen. Further improvements are necessary for referral procedures, information system to allow for longitudinal follow-up across levels of care and defining a basic health insurance or benefits package, which meets patients’ preferences with a monthly timespan for prescription refills.

Background: The maternal mortality rate in Lao PDR (Laos) is still the highest in Southeast Asia, at 197 per 100,000 live births. Antenatal care (ANC) could contribute to maternal and child mortality reduction. The quality of ANC service remains inadequate and little information is available on the quality of health education and counseling services of health providers in Laos. This study aims to gain insight into the perceptions of stakeholders on both supply and demand sides of public ANC services in Laos and evidence for recommendations to improve the quality of ANC services. Methods: Semi-structured interviews were conducted with 50 participants from different stakeholder groups; on the demand side, couples with a currently pregnant woman and mothers with children under one year of age and a family member; and on the supply side, health providers, managers, policy makers of the Ministry of Health, and development partners. The interviews were voice recorded and transcribed verbatim for analysis by open and thematic coding, using the MAXQDA software program. Results: All respondents reported that the number of pregnant women who visit ANC services has increased. However, an analysis of the supply side identified issues related to the quality of ANC that need to be improved in the areas of facilities, human resources, privacy and confidentiality, providers’ behavior, attitudes, and ineffective communication skills when it comes to providing health education and counseling to pregnant women and their family members. The analysis of the demand side mainly emphasized the issues of providers’ behavior, attitude, communication and unequal treatment, and the lack of privacy. Both sides also suggested solutions to the problems, such as training, effective materials, rewarding good role models, and building a feedback system. Conclusion: The number of public ANC services has increased, but both supply and demand sides experienced challenges with the quality of ANC. All respondents proposed possible solutions to improve quality of ANC service in public health facilities in Laos.

BackgroundThe transition between hospital and home is a vulnerable period for acutely hospitalized older patients during which they are at increased risk for adverse health outcomes. Yet, studies describing experiences of a geriatric patient population postdischarge from a patient perspective are missing.ObjectiveTo characterize patient experiences with recovering at home after acute hospitalization.Design and MethodsQualitative semi-structured interviews, involving 20 recently discharged patients (age ≥ 70), were conducted. A thematic analysis of the content was performed.ResultsTen categories were identified as recurring topics, which were grouped into 3 major themes. The first theme describes the effect of hospitalization on daily life. Participants described that the problems they encountered were mostly caused by symptoms they experienced since discharge, which were grouped into 2 themes: (a) physical consequences of hospitalization and (b) motivational and psychological problems after hospitalization. Among most frequently presented symptoms were fatigue, apathy, unsteadiness while standing, and fear of falling.ImplicationsImpairment in mobility and instrumental activities of daily living was the dominant experience for interviewed patients. This disability was mainly attributed to four main symptoms: fatigue, apathy, unsteadiness while standing, and fear of falling. We propose a tentative model that summarizes the role of posthospital symptoms in the recovery process and the potential syndromes (frailty, posthospital syndrome, palliative symptoms, and sickness behavior) that could underlie these shared symptoms which may act as a conceptual framework for future research. Our study points at the relevance of symptom experiences in functional recovery postdischarge.

Background Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare. Methods This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group. Results A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires. Conclusion Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient–provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality. Electronic supplementary material The online version of this article (10.1186/s12961-019-0426-1) contains supplementary material, which is available to authorized users.

Introduction: Leprosy is a neglected tropical disease and although a cure is available, each year over 200,000 persons are newly diagnosed with leprosy and many more suffer from long-term complications, such as disabilities. The Leprosy Research Initiative (LRI) provides competitive research funding for research projects related to one of five research priorities. Five years after its launch in 2013 and with new developments in the field, the LRI consulted a wide range of stakeholders to evaluate its research priorities and to contribute to a wider research agenda. Material & Methods: A mixed methods approach was used in which qualitative methods (enquiry panel, focus group discussions (FGD) and key informant interviews) were followed by quantitative methods (e-survey and Delphi process). The Delphi process was the final phase of the study with the aim to reach consensus on the priority ranking of the research topics. Results: In total, 124 people contributed to the study. Stakeholders consulted included leprosy-affected persons, researchers, health professionals and policy makers. 50% of the participants came from Africa, Asia or Latin America (endemic areas). In total, 84 research topics were identified. The Delphi process resulted in three top five lists of research topics in the categories Zero Transmission, Zero Disability and Zero Discrimination. Discussion: In conclusion, 15 research priorities categorised in Zero transmission, Zero disabilities and Zero discrimination were prioritised in this study. A research priority new to LRI was research into the mental health of persons affected by leprosy. These findings are not only relevant for the LRI – but may also contribute to research agenda setting by others, most notably the Global Partnership for Zero Leprosy.

Objectives: Optimal antenatal care (ANC) visits help improve health outcomes and decrease perinatal mortality but they are often not optimal in low and middle-income countries (e.g., few mothers attend the recommended four or more ANC visits). The aim of this study was to identify determinants that influenced mothers who did make sufficient visits for ANC in rural Lao in order to inform the design of more effective interventions to change the behavior of mothers who do not make such visits. Materials and Methods: A qualitative study was conducted using semi-structured interviews with mothers who made four or more ANC visits during their last pregnancy in rural Lao. Manual analysis was used for open and thematic coding of the interview data. Results: All mothers reported taking special care of themselves during pregnancy. They perceived the clear benefits of ANC visits regarding reassuring them of their health and reducing the risk of negative events. Family members, particularly husbands, played a key role in making decisions to seek more ANC when they were aware of its benefits. In addition, friends and neighbors were an important source of information for mothers. The quality of ANC provision and the provision of incentives such as an information booklet, along with soap and mosquito net were directly influencing factors in increasing ANC visits. Conclusions: In general, feeling a need for taking special care during pregnancy was a common factor among pregnant women who did use ANC in rural Laos. Accordingly, improving the quality of ANC and increasing appreciation in communities regarding the need for good ANC are strongly recommended to increase attendance by all mothers.

Background Undernutrition threatens the health and future of preschool children in disadvantaged ethnic minority communities. Home-grown school feeding (HGSF) in nursery schools could have a positive impact on children’s nutrition while creating multiple benefits for the community and local food system. Evidence is lacking on the implementation and sustainability of HGSF as part of multi-sectoral programs in remote areas. This study assessed a HGSF pilot intervention, implemented within a four-year nutrition-sensitive agriculture (NSA) program, in five nursery schools in a mountain ethnic minority community in Vietnam. It aimed to gain insights into the diversity and cost of school meals, food sources, effects on children’s nutritional status and on process aspects related to implementation and sustainability, especially HGSF synergy with other NSA program components. Methods Mixed-methods assessment covered school meal diversity and cost; food sources; anthropometric data; and the process, including changes triggered by HGSF, perceived barriers and facilitators to implementation, and prospects for sustainability. Data came from participants selected by purposive sampling for semi-structured interviews (n = 30) and seven focus group discussions (n = 76), and from field observations and transect walks. Results School meals increased daily dietary diversity; meals cost USD 0.65/child/day. About 44% of the foods used were home-grown. There was an indicative reduction in underweight children, an increase in school attendance, and improvements in food preferences and WASH practices. Parents’ caring and feeding practices improved and their willingness to pay for school meals increased. At community level, local food systems became less cash crop-oriented and more self-reliant in production of nutrient-rich foods, contributing to household food security and income generation. Social capital increased. Positive changes were attributed to HGSF and to synergy among NSA program components. Enhanced confidence and motivation, stimulated by role models and change agents, facilitated the process. Socio-economic conditions of poor households and limited resilience to external shocks were barriers that threatened sustainability. Conclusions This study showed that implementing HGSF in a mountain ethnic minority area with a high prevalence of undernutrition benefitted children and their communities, when integrated in a multi-sectoral program that mobilises all stakeholders and stimulates both supply and demand of nutritious food.

BACKGROUND: In Lao PDR, 15% of the married women want to postpone or prevent having a child, yet most are not using contraceptives to achieve this. Literature shows that usage of contraceptives is strongly dependent on the quality of family planning services. However, little is known about the quality of family planning services in Lao PDR.OBJECTIVE: To assess the quality of family planning services provided in public health facilities in Lao PDR.METHODS: Using a cross-sectional study design, public health facilities in three provinces in Lao PDR were assessed on structure, process and outcome measures of quality. Following the Quick Investigation of Quality approach, client exit interviews (n = 393), structured observations (n = 218) and facility audits (n = 17) were conducted.RESULTS: Facility audits, observations and client exit interviews painted different pictures of the overall quality of family planning services. Taking all together, the quality was rated as moderate to high. Only marginal differences in quality were found between family planning services located in different geographical areas. Notably, only married women with children were using these services. Although contraceptives were provided, little attention was given to the information provided during consultations and to the interpersonal relationship between client and provider.CONCLUSION: The results suggest that although improvements are needed to enhance quality of individual consultations, the greatest gain in reducing unwanted pregnancies would be made by ensuring access for all women of reproductive age.

BACKGROUND: Adolescents are particularly vulnerable to poor sexual and reproductive health outcomes. In addition, Lao PDR has the highest teenage pregnancy rate in southeast Asia and a high maternal mortality ratio.OBJECTIVE: This study aimed to provide a comprehensive exploration of factors that influence SRH knowledge, attitudes, and practices of adolescents in Bokeo Province, Lao PDR.METHOD: Data from the Adolescent Girl Situation Analysis cross-sectional study, collected in 2018 using a mixed-method approach with 837 adolescents aged 10-19, and key informant interviews, were analysed. Regression analyses were used to identify predictors of modern contraception knowledge, autonomy, gender-based violence, sexual activity, and contraception use. This was complemented with qualitative thematic content analysis.RESULTS: Adolescents living in two rural districts had lower sexual and reproductive health knowledge compared to urban district residents. Findings showed misconceptions about the birth control pill, a belief that sex education is important, but that the current teaching quality is problematic. There was a strong positive association between knowledge and autonomy. In the two rural districts, residents were more likely to lack autonomy. Marriage was described as an autonomous decision, yet 40.4% lacked autonomy regarding marriage. Among sexually active adolescents, 35.2% used contraception. Boys and girls were said to be equal, yet education access and gender roles favoured boys. Additionally, violence was more justified by husbands against their wives.CONCLUSION: The study helps to understand the views and perceptions of adolescents and key informants on gender equality and gender-based violence. Three main areas require more effort and greater investment to improve adolescent sexual and reproductive health: knowledge and use of contraceptives, gender inequality, and autonomy. There is poor knowledge of contraceptive methods, indicating a need to further integrate comprehensive sexual education, introduced in primary school, and to increase investment in training and monitoring teachers.

BACKGROUND: Universal health coverage is target 3.8 of the Sustainable Development Goals. In many lower-middle-income countries, however, major coverage gaps exist. Those who do receive services often experience high out-of-pocket expenses. To achieve universal health coverage, Lao PDR, a lower-middle-income country in South-East Asia, is shifting from a fragmented model of health financing to a national health insurance scheme.OBJECTIVE: The objective of this cross-sectional survey was to assess the knowledge of the NHI in Lao PDR among insured in- and out-patients using health services at selected public health facilities at provincial, district and health centre level in six provinces.METHODS: This was a cross-sectional survey. Healthcare facilities were selected based on the rate of use of health services at the health facility and participants selected using systematic random sampling. Exit interviews were conducted with in- and out-patients of each selected health facility, using a pre-tested structured questionnaire. Descriptive statistics were generated including means (median), frequency and percentages. Poisson regression was applied to determine the factors associated with knowledge of the insurance scheme.RESULTS: In total 326 participants were recruited (response rate 93%). Of these, less than two-thirds (62.3%) said they had their eligibility documents with them. Only 23.6% knew the co-payment fee at the health centre level; while 18.1% and 18.7% knew about the co-payment fee at the district and provincial healthcare level, respectively. A key determinant of accessing NHI and health services was knowledge of the scheme and its benefits.CONCLUSION: This study suggests in Lao PDR, awareness about health insurance is low. More innovative demand-side strategies are needed to create awareness and understanding of the NHI and its benefits. Without an understanding of what insurance policies mean, universal health coverage cannot be achieved, even where appropriate and acceptable services are accessible.

BACKGROUND: Although in many low- and middle-income countries undernutrition is steadily decreasing, nutritional challenges persist in remote communities, such as those in mountainous areas of Lao PDR. Isolated, with limited access to food and to health care and other public services, local diets are low in both quantity and diversity. Data needed to guide policy and planning are lacking.OBJECTIVES: The study aimed to identify the extent of malnutrition and associated factors among children aged 12-47 months in remote mountainous communities in Lao PDR.METHODS: A cross-sectional survey was conducted in Nong district, Savannakhet province, covering 173 households, involving heads of households, mothers and their children aged 12-47 months.RESULTS: The prevalence of undernutrition was very high among the 173 children studied: 72.8% were stunted, 50.3% underweight and 10.4% wasted. Key factors showing significant positive associations with nutritional status were assets (mobile phone or electric rice mill), collection of non-timber forest products, and household dietary diversity. Negative associations were found with experience of malaria and consuming high amounts of white roots and tubers. Immediate causes of malnutrition were prevalent; half the children had insufficient consumption of all micro- and macronutrients. Diseases were highly prevalent; 30% had recently experienced fever. The households in these villages were quite homogeneous. All scored high on causes of malnutrition; 90% of households experienced food insecurity, nearly all lived below the poverty line, and almost two-thirds of household heads and nearly all mothers had had no education.CONCLUSION: This study identified multiple factors influencing child malnutrition, including low household food diversity, food insecurity, and poor feeding practices among ethnic minority people living in a difficult environment with limited resources. Child undernutrition in these poor communities is complex. Interventions are needed in different sectors, including agricultural production, knowledge on feeding and health services.

Background Recognition of discrepancies between men and women in nutritional intake is important to tackle food and nutrition insecurity and the often-double burden of malnutrition. The purpose of this study was to assess nutritional status and dietary intake of the Lao population, with a focus on possible influences of gender. Methods Dietary intake was assessed in a national cross-sectional study of 1771 randomized participants aged from 1.01 to 89 years, using 24-h dietary recall. Dietary reference intakes were used to assess nutrient insufficiency. Chi-square test was used to evaluate gender differences and multiple univariate logistic regression to examine associations between gender, nutritional status, demographics and nutrient insufficiency. Results Nutrient insufficiencies were higher among pregnant and lactating women than other adult men and women, especially for protein and micronutrients such as vitamin B3, B1, C and other vitamins. Dietary intake and BMI were similar between men and women; all had insufficient intake of all types of nutrients, except sodium. However, women had lower intake than men for almost all nutrients and age groups. The prevalence of overnutrition was higher among those aged 18 years and over for both sexes. Among adult women (15–49.9 years old) and older adult women (50 years old or above), the proportions were: underweight 8.6% (both groups), overweight 18.4 and 20.5%, and obese 34.2 and 39.1%, respectively. Among pregnant and lactating women, the rates of underweight were 7.5 and 1.4%, of overweight were 17.8 and 27.1%, and obese, 21.9 and 40.0%. Among adult and older men, 3.2 and 8.3% were underweight; 21.0 and 18.6% were overweight and 28.2 and 27.6% were obese. Multiple univariate logistic regressions revealed that the factors rural area, dry season and Northern-Lowland region were associated with inadequate micronutrient intake among children, adolescents and adults of both genders. Conclusions Dietary intakes were alarmingly micronutrient-insufficient. Macronutrient imbalance and double burden of malnutrition were confirmed in both sexes. Gender differences were limited; men and women had similarly insufficient intakes, but pregnant and lactating women were disproportionately affected. Nutritional interventions should also take men and older people into account to solve nutrition problems.

BackgroundSexual activity during youth is common in Lao PDR. However, young people seldom utilize sexual and reproductive health services and subsequently suffer from poor sexual and reproductive health. The aim of this qualitative study was to explore the barriers perceived by youth that prevent their access to sexual and reproductive health services.MethodsTwenty-nine semi-structured interviews were conducted with 22 participants aged 15-25 years, from urban and rural areas. A vignette was used during interviews with those who had no experience with sexual and reproductive health services. Additionally, seven semi-structured interviews were conducted with health providers from youth-friendly health clinics and from public sexual and reproductive health services. Data were analyzed using a thematic approach.ResultsThe main barriers preventing young people from accessing sexual and reproductive health services were related tocognitive accessibilityandpsychosocial accessibility. Thecognitive accessibilitybarriers were a lack of sexual knowledge and a lack of awareness of services. Perceived barriers inpsychosocial accessibilitywere the feelings of shyness and shame caused by negative cultural attitudes to premarital sex, and the fear of parents finding out about visits to public sexual and reproductive health services, due to lack of confidentiality in the services and among health providers. In addition, the barriers ofgeographical accessibility, mainly insufficient availability of youth-friendly health clinics.ConclusionTo improve access to services, a multi-component strategy is needed: promotion of youth-friendly health clinics; sexual education in schools; a formal referral system between schools and youth-friendly health clinics; and community support interventions. Prior to implementation, more research should be done on the applicability of these methods in the Laos context. Future research should try to determine the cost-effectiveness of youth-friendly health clinics integrated in a district hospital and stand-alone clinics, to provide insight into which form should be further developed.

Background: It is increasingly recognized that improving the quality of maternal health care delivery is of utmost importance in many countries. In Laos, the quality of antenatal care (ANC) service remains inadequate, but it has never been assessed thoroughly. This study aims to determine the ANC quality at the urban and rural public health facilities in Laos and provides suggestions to improve health education and counseling in addition to other routine care in public ANC services. Methods: This health-facility based, cross-sectional observation study included both health providers (n = 77) and pregnant women (n = 421) from purposively selected health facilities (n = 16). Information on the mothers’ current pregnancies, previous visits and their last children was collected. The time spent for each ANC session as well as ANC services provided were recorded. Descriptive and inferential statistics were applied to analyze the data. Results: Overall performance of ANC services by health care providers was poor in both urban and rural areas. Insufficient provision of information on danger signs during pregnancy, nutrition, breast feeding and iron supplements was revealed. Generally the communication skills, behavior and attitude of health providers were very poor. Less than a quarter of pregnant women were treated with kindness and respect. Only 4% of the observed ANC session took privacy into consideration. Less than 10% of available information materials were used during each ANC session. None of the health providers in both rural and urban areas performed specific counseling. Overall mean (SD) time-spent for each ANC session was 16.21 (4.28) minutes. A positive correlation was identified between the length of working experience of health providers and their physical performance scores (adjusted R square = 0.017). Conclusions: The overall performance of ANC services by health care providers was inadequate in both urban and rural areas. Insufficient provision of health education and poor communication skills of health care providers were revealed. Existing IEC materials were scarcely used. Taking action to improve the quality of ANC services by training and providing specific guidelines, creating dedicated rooms, and providing sufficient and effective materials for counseling are all greatly needed in public health facilities in Laos.

Background: Health care in Vietnam is challenged by a high burden of hypertension (HTN). Since 2000, several interventions were implemented to manage HTN; it is not clear what is the status of patient access to HTN care. Objective: This article aims to perform a systematic narrative review of the available evidence on access to HTN care and services in primary health-care settings in Vietnam. Methods: Search engines were used to identify relevant records of scientific and grey literature. Data from selected articles were analysed using standardised spreadsheets and MaxQDA and following a framework synthesis methodology. Results: There has been increasing interest in research and policy concerning the burden of HTN in Vietnam, covering many aspects of access to treatment at the primary health-care level. Vietnam’s National HTN Programme is managed as a vertical programme and its services integrated into the network of primary health-care facilities across the public sector in selected provinces. The Programme financed population-wide screening campaigns for the early detection of HTN among people above 40 years of age. There was no information on the acceptability of HTN health services, especially regarding the interaction between patients and health professionals. In general, articles reported good availability of medication, but problems in accessing them included: fragmentation and lack of consistency in prescribing medication between different levels and short timespans for dispensing medication at primary health-care facilities. There was limited information related to the cost and economic impact of HTN treatment. Treatment adherence among hypertensive patients based on four studies did not exceed 70%. Conclusions: Although the Vietnamese health-care system has taken steps to accommodate some of the needs of HTN patients, it is crucial to scale-up interventions that allow for regular, systematic, and integrated care, especially at the lowest levels of care.

Purpose In order to address the complex problems of society, the innovation research process should incorporate technical, social, economic and ethical factors, but also actively involve a diverse group of non-scientific actors. One way to prepare students for this type of research is to create “Citizen Scholars,” students who want to work for the betterment of society. Arvanitakis and Hornsby (2016) argue that we need to change how we teach and train students in specific proficiencies. The purpose of this paper is to assess how the pedagogical approach applied within the program contributes to building the proficiencies and attributes as described by Arvanitakis and Hornsby (2016). Design/methodology/approach The authors conducted a total of 12 interviews with alumni who started their program in 2014, one focus group discussion with lecturers and 132 questionnaires with alumni to discuss to what extend the proficiencies are trained in the program and whether these are used in their current jobs. The authors also included data of an earlier study conducted in 2014. These data contain 26 interviews with students during the first year of the program. These students graduated in 2017 and are thus from the same cohort as the alumni. Findings The results show that the pedagogical approach in the management policy analysis program trains all the attributes. Important elements in the program are: the inquiry-based approach intertwined with community service learning (CSL) throughout the program; gradually increased complexity of the real-world problems addressed; students working in teams; and gradually reducing support of the lecturer. Research limitations/implications The authors conclude that our pedagogical approach applied in the program contributes to learning the proficiencies. The authors argue that for the training of inter- and transdisciplinary, the proficiency knowledge integration should be added. Practical implications The result show that more inquiry-based approaches and CSL programs can stimulate the four clusters of proficiencies, which should hold a central place in universities if we want to create citizen scholars. Social implications With the approach, students contribute to research issues of local communities. Originality/value Despite the increasing interest of higher education to involve civic activities in the curricula, few pedagogical approaches are described. The research shows that theoretical insights in the adaption of a model to realize a citizen scholar.

Studies on the prevalence of hypertension in Vietnam have reported various estimates. There is no up-to-date assessment of the evidence on the magnitude of hypertension in Vietnam. Search engines for scientific and gray literature were used to identify relevant records for eligibility screening and quality assessment. Data from selected articles were extracted using standardized spreadsheets. Statistical analysis included estimating pooled prevalence and odds ratio, heterogeneity evaluation, meta-regression, and subgroup analysis, in addition to sensitivity analysis and publication bias evaluation. The pooled prevalence of measured hypertension in Vietnam was 21.1% (95% confidence interval = 18.5-23.7) based on 10 studies, and 18.4% (95% confidence interval = 15.2-21.8) based on 3 national surveys. Lower pooled prevalence was estimated for hypertension awareness (9.3%) and hypertension treatment (4.7%). The pooled prevalence of measured hypertension is significantly higher among men. The pooled prevalence of measured hypertension and hypertension awareness and treatment were significantly lower in rural settings. There is a need to strengthen efforts for primary and secondary prevention and disease management to reduce morbidity and mortality, especially in rural residence settings.

Background There are an estimated 80,100 female sex workers (FSWs) in Ukraine, of whom 7% are living with HIV. Early HIV diagnosis continues to be a public health priority in Ukraine as only approximately 54% of people living with HIV are diagnosed nationwide. This study aims to analyse the content, context and discourse of HIV testing policies among female sex workers in Ukraine and how these policies are understood and implemented in practice. Methods To analyse past and current national policies, we searched the database of the Ukrainian Parliament and the Ministry of Health for relevant policy documents (e.g. legislation and orders). To analyse the day-to-day practice of those involved in the implementation of these HIV programmes, we conducted face-to-face semi-structured interviews with key stakeholders. All data were coded using deductive thematic analysis initially guided by the Policy Triangle, a framework which addresses policy content, the process of policy-making, the health policy context, actors involved in policy formulation and implementation. Results HIV testing policies are formed and implemented in the post-Soviet context through a vertical system of AIDS clinics, resulting in the separation of key affected populations from the rest of the health system. Successive testing policies have been strongly influenced by international donors and non-governmental organisations. Furthermore, a lack of government funding for HIV prevention created a gap that international donors and local non-governmental organisations covered to ensure the implementation of testing policies. Their role, however, had limited influence on the Ukrainian government to increase funding for prevention, including testing of FSWs. Since the early 1990s, when stigmatising and discriminatory forced/mandatory HIV testing was applied, these approaches were slowly replaced with voluntary testing, self-testing and assisted HIV testing, yet stigma was found to be a barrier among FSWs to access testing. Conclusion Poor governance and the fragmentation of the health system, ongoing health sector reforms, shrinking international funding, and persisting stigma towards people living with HIV and sex workers might impede the continuity and sustainability of HIV testing programmes. Local civil society may now have the opportunity to contribute to the development and further implementation of HIV testing policies in Ukraine. Electronic supplementary material The online version of this article (10.1186/s12961-019-0415-4) contains supplementary material, which is available to authorized users.

Rational Increased maternal health literacy (MHL) has contributed considerably to maternal and child health outcomes in many countries. Malnutrition, and low coverage of child vaccination and breastfeeding are major health concerns in Laos, but there is little insight into mothers’ literacy on these issues. The aim of this study was to identify the level of MHL of Lao mothers and to explore factors influencing it, in order to provide evidence that can inform policies and planning of health services. Methods A cross-sectional survey was conducted using a questionnaire on health literacy (ability to access, understand, appraise and apply health-related information) in relation to care during pregnancy, childbirth, and the postpartum period. We interviewed 384 mothers with children aged under five years; 197 from urban and 187 from rural areas. Descriptive and inferential statistics were applied to analyze the data. Results Overall, MHL of Lao mothers was very low in both urban and rural areas; 80% of mothers had either inadequate or problematic MHL, while only 17.4% had sufficient and 3.5% excellent MHL. The MHL scores were significantly higher in urban than in rural areas. One third of mothers found it very difficult to access, understand, appraise and apply information on mother and child (MCH). Health personnel were the main source of MCH information for the mothers. Years of schooling, own income, health status, and number of ANC visits significantly predicted a higher level of MHL (R square = 0.250; adjusted R square = 0.240, P = Conclusions MHL of Lao mothers was inadequate in both urban and rural areas. Socio-demographics and key practices of the mothers were significantly associated with a better level of MHL. Health education on MHL to mothers in both urban and rural areas needs attention, and could best be done by improving the quality of health providers’ provision of information.

BACKGROUND: Lao PDR has identified the need to target adolescent public health concerns. Adolescents suffering from poor health and nutrition during rapid growth and development may be at risk of anaemia due to high iron requirements and the rapid depletion of body iron stores.OBJECTIVE: This study assessed the prevalence and severity of anaemia among school adolescents in Pholhong district, Vientiane province, Lao PDR.METHODS: A school-based cross-sectional study was conducted among 405 randomly selected school adolescents across 8 high schools in a rural district of Vientiane province. Adolescents aged 10-18, both male and female, were recruited. Haemoglobin concentration from capillary blood was measured. Descriptive statistics were computed for prevalence of anaemia, anthropometric measurements, socio-economic and socio-demographic variables. Multivariate logistic regression analysis was performed to identify determinants of anaemia among subjects. Results were expressed as odds ratios and 95% confidence intervals.RESULTS: The prevalence of anaemia among adolescents in the study area was 19.4%. There was no difference in the prevalence of anaemia between younger and older adolescents, but the prevalence of anaemia was higher in female adolescents than among males (crude OR = 3.91, 95% CI 2.20 to 6.96). On univariate analysis, coming from an ethnic minority household was found to be significantly associated with anaemia among these adolescents (p < 0.05). After adjusting for other variables, only the effect of sex remained significant. Other factors showing no significant association with anaemia included parents' employment status, family size, and living conditions.CONCLUSIONS: The prevalence of anaemia in this population is of public health concern with adolescents of both sexes at risk of developing anaemia. The national nutrition programme to control and manage anaemia by distributing a weekly iron and folate supplement for adolescent girls together with a deworming programme twice per year appears to have partly successful but could be strengthened.

BACKGROUND: Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector.OBJECTIVE: The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment.METHODS: Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces.RESULTS: All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8).CONCLUSIONS: A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

BACKGROUND: Currently the health research system in Lao PDR is fragmented and largely donor led. Capacity among national public health institutes is limited to select priority research questions for funding.OBJECTIVE: The objective of this capacity building and practice-oriented study is to describe the process and outcome of the first National Health Research Agenda for Lao PDR and how the agenda contributes to institutional capacity of the Ministry of Health, in order to contribute to evidence-informed public health policy making.METHOD: This activity used a mixed-methods approach. The overall design is based on principles of the interactive Learning and Action approach and consists out of 6 phases: (1) identification of needs, (2) shared analysis and integration, (3) nation-wide prioritization of research domains, (4) exploring specific research questions, (5) prioritization of research avenues, (6) dialogue and planning for action. The process involved interviews with experts in health policy and research (n = 42), telephone-based survey with district, provincial and national health staff (n = 135), a two-round Delphi consultation with experts in health policy and research (n = 33), and a workshop with policymakers, researchers, international organisations and civil society (n = 45) were held to gather data and conduct shared analysis.RESULTS: 11 research domains were identified and prioritised: Health-seeking behaviour; Health system research; Health service provision; Mother and child health (MCH); Sexual & reproductive health; Health education; Non-communicable diseases (NCDs); Irrational drug use; Communicable diseases (CDs); Road traffic accidents; Mental health. Within these domains over 200 unique research questions were identified.CONCLUSION: Our approach led to a comprehensive, inclusive, public health agenda for Lao PDR to realise better informed health policies. Questions on the agenda are action-oriented, originating in a desire to understand the problem so that immediate improvements can be made. The agenda is used within the MoH as a tool to fund and approve research.

Introduction: This study was aimed at determining factors affecting utilization of public health facilities by pregnant Kenyan women living in Kibera slums, Nairobi since the implementation of the Free Maternal Service (FMS) Program in 2013.Methods: This was a cross-sectional study done on 396 women who delivered between 2014 and 2015. Interview questions addressed socio-demographic characteristics, perception of quality of care in public health facilities, awareness of the FMS Program, antenatal care (ANC) and delivery service utilization.Results: 43.9% delivered in a public health facility, 30.3% in a private non-profit health facility (NGO), 22.7% in a private health facility and 3.0% at home. Of the 97% of the women who delivered in a health facility, only 43.9% delivered in a public health facility despite these facilities having free maternal services. Factors that favoured the Free Maternal Service uptake included a positive perception of the public health facility, living within close proximity, learning about the Program from a support group and a short waiting time before being examined by the doctor. On the other hand, safe delivery, quality of service, accessing a health facility on foot, ANC attendance at a private and a non-profit health facility were associated with low uptake of the free maternal services.Conclusion: The uptake of the Free Maternal Service program can improve if the Kenyan government directs its efforts towards changing women's perception on quality of care in public health facilities and to improve access to health facilities in slum areas of Nairobi.

RationaleAdolescent pregnancy in Lao PDR is the highest in Southeast Asia. It leads to negative health and social consequences in young people. It is anticipated that this problem is partly caused by limited sexual and reproductive health literacy (SRHL), leading to poor sexual and reproductive health (SRH) decisions. Based on the concept of health literacy, SRHL goes beyond knowledge and behavior and is the self-perceived ability of an individual to access the needed information, understand the information, appraise and apply the information into informed decision making for a good way to contribute to sexual and reproductive health. It is not only knowing (knowledge) and doing (behavior), but it is the process of individual's thought on an SRH problem before taking an action. The aim of this study was to measure SRHL among school-going adolescents aged 15-19 and to determine factors associated with SRHL.MethodWe conducted a cross-sectional study in rural and urban areas of Lao PDR in 2017. Respondents completed a self-administered questionnaire with five parts: socio-demographic, personal health, SRH knowledge and behavior, SRHL, and functional literacy. We calculated the SRHL score based on the HL-EU index and used descriptive statistics to determine the score and levels. Then we used bivariate statistics and multiple linear regression to identify factors associated with SRHL in these adolescents.ResultAmong 461 respondents, 65.5% had inadequate SRHL. Scores were positively and significantly associated with several factors, including: school location (β: 3.218; pConclusionBecause most school adolescents had inadequate SRHL, comprehensive sexual education and enabling information as well as service access for adolescents are essential to ensure that adolescents can access, understand, appraise and apply good SRH knowledge in decision-making to benefit their own health.

Even though the flipped classroom is an increasingly popular method in education, a literature search shows a gap in research on this method in higher education. This article describes an experiment with two central questions: (1) How do students and lecturers assess the effectiveness of the FC method? And (2) What are crucial design elements? To be able to answer these questions we designed an experiment within a large-size, interdisciplinary, course. For three years we carefully monitored and evaluated the course. A mixed-method approach was used to collect data. Our findings show a positive contribution of the FC approach to the learning experience of students. We also found that a strong link between theory and practice is essential in the course design; combined with active learning we were able to involve students and stimulate them to reach a deeper level of understanding. Moreover, we believe that the FC approach offers opportunities to have a large interdisciplinary group, with different learning needs, work together on higher attainment levels.

Background Miltefosine (MF) is the only oral drug available for treatment of visceral leishmaniasis (VL) and post-kala-azar dermal leishmaniasis (PKDL). Although the drug is effective and well tolerated in treatment of VL, the efficacy and safety of MF for longer treatment durations (>28 days) in PKDL remains unclear. This study provides an overview of the current knowledge about safety and efficacy of long treatment courses with MF in PKDL, as a strategy in the VL elimination in South Asia. Methodology/Principal findings Literature was searched systematically for articles investigating MF treatment in PKDL. A meta-analysis included eight studies (total 324 PKDL patients) to estimate the efficacy of MF in longer treatment regimens (range 6–16 weeks). We found a per-protocol (PP) initial cure rate of 95.2% (95%CI 89.6–100.8) and a PP definite cure rate of 90% (95%CI 81.6–96.3). Descriptive analysis showed that 20% of patients experienced adverse events, which mostly had an onset in the first week of treatment and were likely to get more severe after four weeks of treatment. Gastrointestinal (GI) side effects such as vomiting, nausea, diarrhoea, and abdominal pain were most common. Conclusions/Significance Longer treatment regimens with MF are effective in PKDL patients in India, however with the caveat that the efficacy has recently been observed to decline. GI side effects are frequent, although mostly mild or moderate. However, on the basis of limited data, we cannot conclude that longer MF treatment regimens are safe. Moreover, VL and PKDL pharmacovigilance studies indicate a risk for serious adverse events, questioning the safety of MF. The provision of safer treatment regimens for PKDL patients are therefore recommended. Until these regimens are identified, it should be considered to halt the use of MF monotherapy for PKDL in order to preserve the drug’s efficacy., Author summary In this study, we reviewed the available literature on the subject of safety and efficacy of the oral drug miltefosine in the treatment of post-kala-azar dermal leishmaniasis (PKDL). Literature was searched systematically in the PubMed database and eight articles, with a total of 324 PKDL patients, were included. A meta-analysis was performed to estimate the percentage of patients cured after longer (>4 weeks) miltefosine treatment. An estimated 90% of patients was found to be cured one year after treatment with miltefosine. In addition, descriptive analysis showed that nearly 20% of the PKDL patients suffered from side-effects. The majority of these side-effects, such as vomiting, nausea, diarrhea and abdominal pain, were mild and related to the gastro-intestinal tract. The findings of this study show that miltefosine is effective, although the efficacy has been observed to decline. The gastro-intestinal side effects were frequent but mostly mild. However, based on the limited data in this study we cannot conclude that longer treatment regimens with miltefosine are safe. In order to preserve the drug’s efficacy, we suggest it may be put under consideration to halt the use of miltefosine monotherapy for PKDL until alternative treatment regiments (e.g. short combination therapies including miltefosine) are identified.