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The pursuit of good health is fundamental to both personal well-being and social progress. The perception of health has advanced to include not only physical well-being but also mental and social dimensions, aligning with the WHO’s definition of health. Similarly, the importance of population health in fostering national development cannot be overstated. The Health in All Polices (HiAP) framework, endorsed by the WHO, emphasizes the interconnectedness of health with various policy domains. This approach advocates for integrating health considerations into all sectors of governance, including transportation, education and economic planning. By encouraging dialogue and collaboration among diverse sectors, HiAP aims to create healthier environments and generate co-benefits that enhances overall societal well-being. In the Bhutanese context where the national health policy emphasizes on holistic well-being, implementing HiAP represents a significant positive development. By prioritizing health across various policy domains, Bhutan can further enhance its national philosophy of gross national happiness and well-being. This review aims to explain the critical apparatuses for successful implementation of HiAP in Bhutan, highlighting the pivotal roles of effective leadership, intersectoral collaboration and policy coherence in promoting happiness, health equity and fostering a healthy society.

Understanding how past disturbances have influenced the development of forests is critical for deciphering their current structure and composition and forecasting future changes. In this study, dendrochronological methods were applied to uncover the disturbance history of old-growth hemlock-dominated forests in central Bhutan. Analysis of tree-ring samples from two old-growth hemlock stands, located in two different topographic settings, identified the importance of gap-phase dynamics in facilitating recruitment and growth releases and producing complex, multi-aged structures over time. One site showed evidence of a near stand-replacing disturbance in the late 1700s, while the other showed no evidence of high-severity disturbance at any time over the last 400 years. At both sites low-to medium-severity disturbances, some of which appear to be associated with cyclones originating in the Bay of Bengal, dominated the disturbance regime. The hemlock stands exhibited a significant positive association between cyclone occurrence and growth release events and between recruitment pulses and growth release events. From 1800 to 1970 there was an increase in recruitment of angiosperm tree species at most sites and a corresponding decline in conifer recruitment. Over the past 50 years there has been little new recruitment; this may be due to light limitation in the understory from shade-tolerant angiosperms and bamboo in the lower strata of these stands. Significant variations in disturbance dynamics and recruitment were observed across the study sites, suggesting that other factors, such as topography and climate, may be influencing long-term stand development patterns. This study highlights the complex interplay between historical disturbance regimes and tree recruitment in shaping the age and size structures of old-growth hemlock forests in central Bhutan. It also provides new insights into the dynamics of these forests that can be used to support effective forest conservation and management in the future.

Introduction: The global population is undergoing a significant demographic shift, with a rapidly increasing number of elderly population. As people age, their health and quality of life become increasingly important considerations. The elderly population has unique health needs that must be addressed to ensure their well-being and maximize their quality of life. In Bhutan, elderly health needs are lacking despite information on health policy and planning. This study was proposed to assess quality of life and health needs among elderly aged between 60 – 79 years old under Naja, Dogar, Shaba, and Lyungni gewogs (blocks) under Paro district, Bhutan. Methods: An explanatory sequential mixed method design with a quantitative and descriptive qualitative was conducted in the four blocks. For quantitative component, a survey was conducted and for qualitative, focus group discussion was used. This study was carried out in four selected rural areas known as gewogs (blocks) in local language under Paro district. A representative sample of 403 respondents was selected by simple random sampling in quantitative work and 12 elderly people in focus group discussion. The demographic data were analyzed by ANOVA and data from focus group discussion were done in content analysis. Results: The quantitative data for the overall QoL score among elderly showed a mean score of 39.01, which was considered a low level of QoL. Among the eight components of QoL, role of pain and general health showed same result level as the overall QoL. While others (physical function, body pain, vitality, social function, role of emotion, and mental health) were at average level (score 46.19-58.68). Conclusions: Overall QoL of elderly people in Paro district is lower than the average at 47.84 (CI 45.87 – 49.81). Mental health was in average level compared to physical health, which is at a lower level.

Introduction: Several patients who recover from COVID-19 infection continue to have persistent symptoms even after recovery from the disease. The special sensory functions such as taste, smell and hearing are affected by COVID-19 infection even after recovery from the illness. The aim of the study was to find out the prevalence of special sensory deficits among patients with post-COVID-19 visiting a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among adult patients who recovered from COVID-19 visiting a tertiary care centre from 1 January 2022 to 31 December 2022. After obtaining ethical approval from the Research Ethics Board of Health, data on patients who were diagnosed with COVID-19 one year ago was obtained from the surveillance register from the Ministry of Health. They were contacted by phone call and invited to the centre to participate in the study. Appropriate clinical examination and tests were carried out to assess the special sensory deficits. A convenience sampling technique was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 271 patients, the prevalence of sensory function deficit was 39 (14.39%) (10.21-18.57, 95% Confidence Interval). Conclusions: The prevalence of special sensory deficits after recovery from COVID-19 infections was found to be similar to the findings of other studies.

Abstract Chiral materials, similarly to human hands, have distinguishable right-handed and left-handed enantiomers which may behave differently in response to external stimuli. Here, we use for the first time an approach based on the density functional theory (DFT)+PAOFLOW calculations to quantitatively estimate the so-called collinear Rashba–Edelstein effect (REE) that generates spin accumulation parallel to charge current and can manifest as chirality-dependent charge-to-spin conversion in chiral crystals. Importantly, we reveal that the spin accumulation induced in the bulk by an electric current is intrinsically protected by the quasi-persistent spin helix arising from the crystal symmetries present in chiral systems with the Weyl spin–orbit coupling. In contrast to conventional REE, spin transport can be preserved over large distances, in agreement with the recent observations for some chiral materials. This allows, for example, the generation of spin currents from spin accumulation, opening novel routes for the design of solid-state spintronics devices.

Abstract To better understand fire regimes and their relation to climate in the seasonal tropical forests of continental Southeast Asia, we developed the first multi‐century tree‐ring based fire history chronology for the region. The chronology included 776 fire scars collected at Bidoup NuiBa National Park (BNNP) in the Central Highlands of Vietnam and spans the period 1636–2020. Fires were recorded in 116 years, representing 47% of the years covered by the 249‐year period between the first fire scar (1772) and the last (2020). While only 9% of years within the sampled BNNP forests experienced fires before 1905, 70% recorded fires between 1906 and 1963 and 90% showed evidence of fire after 1963. Fire occurrence was highly correlated with climate indices (wet season Nino 3.4 and dry season regional Palmer Drought Severity Index) during the period 1906–1963, but showed no significant correlation after 1963. Our fire reconstruction from BNNP suggests that the fire regime has shifted from one driven primarily by climate to one in which human activities dominate the occurrence of fire within these seasonal tropical landscapes.

Introduction: Preconception care provided before conception or between subsequent pregnancies aims to identify and modify risks to women`s health or pregnancy through prevention and management. For successful implementation and uptake of preconception care services, adequate level of knowledge and positive attitude of women is important. Therefore this study was undertaken to assess the knowledge, attitude and level of practice of preconception care by our women. Methods: This was a hospital based cross sectional study done from July 2021 to December 2021. All pregnant women visiting the Mother and Child Hospital for booking visit were considered for the study. Stringent inclusion and exclusion criteria were utilized during recruitment. Data was collected using an interviewer administered questionnaire. Results: A total of 340 pregnant women consented for the study. The mean age of the participants was 28.3 (SD±4.5) years, 57.6% of the pregnant women had higher education and 54.4% were employed. The overall mean knowledge score on assessment of preconception care was 6.96±2.4 and 217(63.8%) had good knowledge. Of the 340 women, 98.2% had positive attitude towards the preconception care with a median score of 27 (Min-Max: 10-30) but 78.2% had poor practice. A significant association was found between good practice of preconception care with their knowledge level (p=0.012) but not with positive attitude (p=0.346). Conclusions: The study found that despite having good knowledge with positive attitude, the practice of preconception care among the study participants was poor. Therefore, we recommend further detailed study on factors associated with poor practice of preconception care among pregnant women.

Abstract Bhutan has a free healthcare system that covers almost 90% of the population within 2 h of travel distance. The country has achieved remarkable success in many public health indicators despite the chronic shortage of financial resources and trained manpower. However, there are many aspects of health inequities in the government's health policies, programmes and health services. The Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu in 2020 hosted a policy dialogue on health equity in the context of the Bhutanese health system. With changing demographics and socioeconomic conditions, some of the factors that earlier determined an equitable distribution of services and resources are no longer relevant now. The referral system is easily bypassed not only because the patients have easy access to transportation to tertiary hospitals, but because of frequent interruptions in the service and the non‐availability of doctors in the district and general hospitals. The role of the private sector is restricted to a few diagnostic services while there is an apparent adequate spending capacity of consumers. There is an important component of out‐of‐pocket expenditure and catastrophic health expenditure in patients seeking treatments outside the country. The current health policies and strategic plans for the future lack a measure of health equity. We recommend conscientious assessment of health inequities in the current system and introducing policies and programmes to prevent the worsening of such inequities.

In March 2020, the country saw its first case when a foreign tourist tested positive for COVID-19 at Thimphu. There was immediate activation of national preparedness and response plan including the requirements for surge in human resource capacity to handle the novel infection. One key emphasis of the national response was to support the existing 3500 health care workforce by partnering with community in sharing pandemic-related activities. One such initiative was training a pool of people to shoulder basic responsibilities at quarantine and non-hospital isolation facilities. Therefore, Khesar Gyalpo University of medical Sciences of Bhutan was tasked to develop a training program and thus the De-suup plus program was designed with focus on people from non-medical background. This article attempts to describe the development and implementation of the training. The training constituted basic nursing competencies, personal protective equipment and essential public health preventive measures with the purpose of serving at quarantine and non-hospital isolation facilities in the Country.

Introduction: The current choice of anesthesia for the cesarean section is spinal anesthesia. However, hypotension is the major complication. If promptly not recognized and treated, it increases the morbidity and mortality of the mother and fetus. This study was conducted to evaluate the rate of pre-delivery hypotension and risk factors following spinal anesthesia for cesarean section at the National Referral Hospital in Bhutan. Methods: A cohort study was conducted from 1st October 2018 to 30th June 2019 on 350 women undergoing cesarean section under spinal anesthesia. Pre-delivery hypotension was defined as systolic blood pressure < 100 mm Hg. The association of factors for hypotension was tested using multivariable binary logistic regression using a forward stepwise model. A p-value < 0.05 was considered significant. Results: The rate of pre-delivery hypotension was 74.6 % (n=261). History of hypertension during pregnancy (Adjusted OR 0.25, [0.11-0.60], p=0.013), prophylaxis use of ephedrine (Adjusted OR 0.45, [0.22-0.92], p= 0.024) and ondansetron (Adjusted OR 0.43, [0.22-0.82], p= 0.010),longer preoperative fasting duration (Adjusted OR 1.12, [1.01-1.21], p=0.024,), sensory block level

Introduction: Bhutan’s healthcare approach in achieving the sustainable development goal 3 (SDG 3) has been largely through primary healthcare as enshrined in the universal health coverage (UHC). Bhutan has forged a unique primary healthcare model in which oral health is integrated in its primary care initiatives. The Oral Health program under the Department of public health was established in 1999 with clear line objectives. The program has achieved commendable successes over the years. However, with changing needs, enhancing and mainstreaming of oral health and dentistry in the country must be accorded a top priority. This is particularly important as the Oral Health Policy and service standards were drafted fourteen years ago in 2007. The 2021 World Health Orgnization (WHO) agreement “to provide basic oral health services to all”, to which Bhutan is signatory, needs to be strictly implemented. Therefore, oral health dialogue was conducted to deliberate on the oral health systems in the country with experts from the field who were from within and outside Bhutan. This oral health policy dialogue generated important themes such as strategic and competent workforce, capacity development, need to transform oral health services in more people centric ways and mainstreaming oral health in other health policies.

Introduction: The Postgraduate Medical Education has witnessed transition from traditional cognitive based to more competency-based learning globally. Khesar Gyalpo University of Medical sciences of Bhutan introduced Competency Based Medical Education (CBME) through implementation of work place-based assessment (WPBA) in June 2018. The primary objective of this initiative was to produce specialist of highest quality and cultivate competency and outcome based, yet learner centered curricula. Methods: The evaluation was conducted in June, 2019. The mixed methods of data collection techniques were utilized such as survey, interview, and review of the documents and focus group discussion. It was to provide understanding of local challenges and needs in implementation of WPBA. Results: A total of 90% of the faculty members and 40% of administrators evaluated were aware of the implementation of WPBA. Majority of the faculty felt that WPBA is beneficial to both faculty and the residents and all residents felt that it’s beneficial in terms of learning. OBGYN residents have been exposed to maximum numbers of WPBA at 20. The maximum numbers of WPBA activities were performed by residents of general practice department which stood at 56. Lack of time as hindrance of practice of WPBA was implicated by 28% of the faculty and 61% residents. Conclusions: Despite WPBA being implemented for a short duration there is a high level of awareness and acceptability among both the residents and faculties as an effective teaching and learning tool.

Introduction: Ectopic pregnancy is an emergency and a life-threatening condition which is an important cause of major maternal morbidity and mortality. This study was designed to determine incidence, common identified risk factors, clinical presentations, management, morbidity and mortality due to ectopic pregnancy at the national referral hospital in Thimphu, Bhutan. Methods: This was a retrospective study of all cases of ectopic pregnancies for a period of two years from 1st January 2018 to 31st December 2019. Socio-demographic characteristics, risk factors, clinical presentations, investigations and mode of treatments were extracted. Simple descriptive statistics such as frequencies, percentages, mean and range were utilised. Results: There were 9603 pregnant women admitted for delivery, out of which 122 were ectopic pregnancies. The incidence of ectopic pregnancy was 12.7/1000 pregnancies. Majority of them were in the age group of 21-30 years and 32.69% of the affected were nulliparous. While Pelvic inflammatory disease was seen in 41.35%, 20.19% were unmarried. Abdominal pain, amenorrhea, and vaginal bleeding were the most common symptoms. Among the ectopic pregnancies, 99.5% were diagnosed with ultrasound. A total of 94.23% had undergone surgical intervention, of which only 1% had laparoscopic surgery. No maternal mortality had occurred. Conclusions: Women with past history of pelvic inflammatory disease, previous miscarriage, unmarried, and nulliparous presenting with history of amenorrhea, abdominal pain, vaginal bleeding should be a high index of suspicion for ectopic pregnancy. Timely diagnosis and intervention in the form of surgical or medical management will reduced the morbidity and mortality due to ectopic pregnancy.

Healthcare around the world is facing a series of challenges. Though there is publicity given to the technical dimensions, there is an urgent need to make healthcare more humane. This has become more essential given the volumes of information available in current context. The available information has resulted in patient knowing more than the health professionals about their own health needs. The concept of medical humanities is new and gaining awareness. This could be solution to ailing medical practices not just in Bhutan but also globally. This is reflected in many of the policies where medical humanities is gaining attention.

Introduction: Bad-mKhris-mGo-Nad is a type of headache caused by imbalance of bile and phlegm humor. In gSo-ba-Rig-pa, headache is categorized in two categories such as primary headaches and secondary headaches. In total there are 14 types of headaches and Bad-mKhris-mGoNad is one among the principal headaches. The gSo-ba-Rig-pa based bloodletting therapy for Bad-mKhris-mGo-Nad has been practiced by the traditional medicine practitioners since the inception of gSo-ba-Rig-pa more than 2500 years ago. Bloodletting is also believed to be one of the most important and effective therapy in the treatment regime of gSo-ba-Rig-pa. The Subsequent Tantra (last tantra) states that the bloodletting is the best remedy for all types of bile and blood-related disorders. This study was conducted to observe the effectiveness of bloodletting procedure among diagnosed cases of Bad-mKhris-mGo-Nad. Methods: It was an observational prospective study conducted at the National Traditional Medicine Hospital, Kawangjansa, Thimphu. The three main parameters measured were frequency, duration, and severity of the headaches. The samples consisted of 31 patients with 23 females and 8 males. Data collection was carried out over the span of seven months (June - December, 2018) Results: The association test between before and after 10 days, before and after 30 days of bloodletting was conducted on 30 patients by using Mid-Point test in Open Epi and the result was observed to be statistically significant at p< 0.05. Conclusion: This study shows that the bloodletting therapy on Tshoksang reduces the pain duration and frequencies of headaches. Moreover, it was also established to be effective in reducing the severity of the headache caused by Bad-mKhrismGo-Nad.

Background: Accurate blood pressure measurement is vital before any inferences are made on the reading. Since device error is one of the potential causes of inaccurate results, blood pressure measuring (BPM) devices should be periodically assessed for its accuracy. This paper describes the types of BPM devices used in health facilities of Bhutan and the results of their performance verifications. Method: This study assessed the pressure accuracy and leak rates of BPM devices in use at two regional referral hospitals, district hospitals and BHU I using calibrated Vital Signs Simulator (ProSimTM 8) from Fluke Biomedical as reference device. For pressure accuracy assessment, static pressures were simulated against which simultaneous readings of each of the devices were recorded (n=3). For the leak rate assessment, the simulator was set to a target pressure and leak rate (n=3) were recorded over 1 minute. Result: A total of 395 devices of three types, viz., 135 aneroid, 125 electronic and 135 mercury were assessed. Deviations in readings of 64.72% of devices were found to be within acceptable range of ± 3 mmHg. The device-type specific pass percentages for pressure accuracy were 6.40 % for electronic, 88.81 % for aneroid and 94.81 % for mercury. A total of 71.85% of devices (aneroid and mercury) had acceptable leak rates of 15 mmHg per minute. Conclusion: The study shows that not all the blood pressure measuring devices currently being used in the health facilities of Bhutan are accurate. Besides ensuring that only validated BPM devices enter the country, these devices should be verified for its performance periodically once they are in use.

Introduction: Adhering to the astrological recommendations on timing of invasive therapies are a standard practice in gSo-wa Rig-pa based Bhutanese Traditional Medicine. The day (for La-dza, Sog-dza and Shey-dza), lunar date (for La-ney) and time within the day of surgery (for La-ney), along with Wang-thang (field of power) and Lung-ta (Horse of fortune) are important astrological recommendations. However, there are no information about the patients’ knowledge, attitude and practice on astrological recommendations for timing of surgery in an allopathic setting in Bhutan. The study was conducted to assess the knowledge, attitude and practice of considering Buddhist astrological recommendations among patients undergoing elective surgeries. Methods: A cross-sectional study with convenient sampling was conducted at the National Referral Hospital, Thimphu from April to May 2018. Data were collected using a pretested interviewer-administered questionnaire. Ethical clearance was obtained from the Research Ethics Board of Health, Bhutan. Results: From 420 participants (response rate 99.5%), 188 (44.8%) were aware that there are astrologically determined good timings to undergo elective surgeries. Only four persons (1.0%) were aware about La-ney. Among those who believed in such astrological recommendations, the attitude were more favourable towards the areas in which they had higher knowledge. Conclusion: The patients had very poor knowledge about the astrological recommendations to choose the timing for surgery. A well designed study on the effect of astrological recommendations on the surgical outcomes is recommended for generating evidence for further action.

Introduction: Non-communicable diseases (NCDs) pose significant public health challenges in Bhutan. In 2019, Bhutan's Ministry of Health introduced a set of interventions associated with the World Health Organization's Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Income Settings called PEN HEARTS. This initiative encompassed six components: healthy lifestyle intervention, evidence-based protocols, access to medicines and technology, risk-based management, team-based care, and systems monitoring. Evaluations of PEN interventions in other countries documented barriers to implementation. The present report provides the result of a 2019-2020 evaluation assessing implementation of PEN HEARTS in Bhutan and initial impacts on provision of care for NCDs and patient outcomes. Methods: A cross-sectional, mixed-methods evaluation was conducted in six districts, two where the interventions were first initiated, two where they were implemented subsequently, and two where no implementation had begun. In each district, data were collected at the district hospital and three basic health units. Quantitative data collection encompassed facility checklists, health worker surveys, and patient record abstraction. For the survey, health workers were selected using random or convenience sampling depending on facility size. For patient record abstraction, enumerators created a sampling frame at each facility to include eligible patients who were then selected randomly for record review. Qualitative data collection included in-depth interviews (IDIs) with health workers, and IDIs with NCD patients. A convenience sample of health worker IDI participants was selected randomly at hospitals; all health workers at BHUs were invited to participate. A convenience sample of NCD patients was recruited from facility waiting rooms on the day(s) of data collection. Lastly, a convenience sample of homebound patients was recruited to participate in IDIs. Quantitative analysis methods included bivariate analysis of categorical and continuous variables, and pairwise comparisons among groups. Qualitative data were analyzed using thematic content analysis with inductive coding. Results: A total of 153 health workers participated in the knowledge survey and 121 patient records were reviewed. IDIs were conducted with 13 health workers, 18 hospital or BHU patients, and four homebound patients. Most elements of the PEN HEARTS program were implemented as planned, including monitoring and supervision. PEN HEARTS had a positive impact on disease control: group A districts had a significantly lower proportion of patients with a treatment gap (p

Abstract Background Suicide is one of the leading causes of death and Disability Adjusted Life Years (DALYs) worldwide. The economic, emotional and human cost of suicidal behaviour to individuals, families, communities and society makes it a serious public health issue. We aim to determine the prevalence and factors associated with self-reported suicidal behaviour (suicidal ideation and attempt) among school going adolescents (13–17 years). Methods This is a secondary analysis of a nationally representative data for Bhutan namely Global School Based Student Health Survey in 2016 which reports on various dimensions of adolescent health including suicidal behaviour. The survey employed a multistage sampling method to recruit participants aged 13–17 years (n = 5809) from 50 schools (25 each in rural and urban area). The survey used an anonymous self-administered pre-tested 84-item questionnaire. Weighted analysis was done. Adjusted prevalence ratios (aPRs) and adjusted Odds Ratios (aORs) have been presented with 95% confidence intervals (95% CI). Results A total of 667 (11.6%) adolescents reported considering a suicide attempt whereas 656 (11.3%) reported attempting suicide in the past 12 months. Among those reporting suicidal ideation, 388 (58.6%) reported attempting a suicide and 274 (41.4%) had ideation alone, whereas, 247 (38.9%) reported attempting a suicide without previous ideation. Female sex, food insecurity, physical attack, sexual violence, bullying, feeling of loneliness, low parental engagement, reported worry about lack of sleep, urge to use drugs/alcohol, smokeless tobacco use, drug abuse and parental smoking were the factors associated with suicidal attempt. All these factors except smokeless tobacco use and parental smoking were associated with suicidal ideation. Having helpful/close friends was found to be protective against suicide ideation. Conclusion Suicidal behaviour among school going adolescents in Bhutan is high and alarming, especially among girls. Bullying, sexual violence, feeling of loneliness and drug abuse were some of the key risk factors identified. It is important to identify these risk factors early and effectively tackle them in order to prevent suicides. It requires a multi-faceted intervention with the support of the children, community, teachers and parents.

Abstract Background Soon after Bhutan’s first medical university was established in 2012, Faculty Development Programmes (FDPs) were adopted for efficient delivery of postgraduate medical curriculum. Medical education was an additional responsibility for the clinicians who already had multi-dimensional roles in the healthcare system where there is acute shortage of healthcare professionals. We studied the impact of FDPs on postgraduate medical education in Bhutan. Methods This was a mixed-methods study with a quantitative (cohort study – quasi-experimental with 18 participants) and concurrent explanatory qualitative component (focused group discussion (FGD) with 11 teaching faculty members). The 18 participants were given a structured FDP designed by the University. The FGD assessed teacher self-efficacy and competency using standard tools before and after the FDP. Thematic analysis of the FGD explored the impact of FDPs in the delivery of postgraduate residency programmes. Results There were significant increase in the teacher self-efficacy (31 vs 34, p = 0.009) and competency scores (56 vs 64, p = 0.011). There were significant improvements in self-efficacy in the domain of the teaching relevant subject contents and developing creative ways to cope with system constraints. In teaching-learning assessments, there was a significant appreciation of the effectiveness of lectures and tutorials and the use of essay questions. The FGD demonstrated the acceptance of FDPs and its importance in quality improvement of postgraduate medical education, professional development of teachers and improvement of their communication skills. The teachers have now migrated from the conventional methods of teaching to workplace-based teaching and assessment. The FDPs also resulted in review and revision of postgraduate medical curriculum soon after the first batch graduated in 2018. Lack of adequate support from relevant stakeholders and lack of a medical education centre in the University were seen as major challenges. Conclusions The FDPs have brought tangible professionalization of postgraduate medical education at an early stage of the medical university. There is a need for continued efforts to strengthen, sustain and consolidate the gains made thus far.

The Emory-Tibet Science Initiative (ETSI) has embarked on a historic endeavor of introducing a systematic and sustainable science education program within the traditional Tibetan monastic institutions. His Holiness the Dalai Lama, who conceived and supports this initiative, calls it a hundred-year project. From the very beginning, translation from English to Tibetan has been an integral part of this project because of the need to prepare course materials as well as to facilitate on-site classes and lab activities in the Tibetan language. Our translation process involves not just conveying novel and foreign concepts across cultures but doing so with a scientific language peppered with technical terms that are not readily representable in the target language. In addition to the linguistic barriers, cultural and technical ones further complicate the process of communication. A case in point is the concept of life, or correlation versus causation, or the view that consciousness is an emergent property of the brain, where each construct has its corresponding but differing concept in Tibetan Buddhism. When engaging with such existing parallel yet divergent terms or concepts, the translators must strike a delicate balance and avoid forsaking the distinctive characteristics and connotations involved. In this article, the ETSI translation team shares its journey—highlighting the needs felt, challenges faced, and solutions sought. We discuss the translation principles guiding our work and the handling of such scientific features as graphs, acronyms, units, chemical names, and formulas. We hope our work will inspire other similar projects around the globe and encourage them to continue bridging barriers to cross-cultural dialogues, promoting cross-fertilization of knowledge for human flourishing.

Introduction: Direct Observation of Procedural Skills (DOPS) is a valuable method to evaluate procedural skills. The aim of this study was to explore the effect of DOPS as an assessment method and its effect on their learning in Obstetrics and Gynecology Postgraduate students. Methods: Five residents and four faculty members from the department of Obstetrics and Gynecology, Khesar Gyalpo University of Medical Sciences of Bhutan participated in this study. A validated checklist was adopted, from which five core areas of DOPS were utilized for this study. The two skills selected for this study were Pap smear and Intra Uterine Contraceptive Device (IUCD) insertion. The acquired data were analyzed by descriptive statistics (frequency, percent and mean). Results: The results showed that student’s initial mean score was 4/9, which increased to nearly 8/9 in third attempt. Practically, all faculty members and students believed that DOPS was effective in facilitating students’ learning. Some of the students thought that repeated exposure to DOPS reduced their level of stress. Conclusions: It may be stated that DOPS is effective in facilitating students’ learning and clinical skills. Keywords: Assessment; DOPS; learning; Obstetrics and Gynecology; WPBA.

Abstract Background To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. Methods This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May–August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. Results Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. Conclusion Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.

Introduction: Recently, there have been numerous innovations in the field of medical education. Teaching methodology is one of the areas that have received the most attention. The aim of this study was to assess the students’ perceptions of the effectiveness of different teaching methods, teaching aids and forms of evaluation at two faculties under Khesar Gyalpo University of Medical Sciences of Bhutan. Methods: This analytical cross-sectional study was conducted between 1st June and 31st July 2015 using a self-administered questionnaire in 150 first year and 148 final year students from the Faculty of Nursing and Public Health and Faculty of Traditional Medicine. Each participant completed a questionnaire containing items soliciting their opinions on teaching methods, teaching tools, and assessment methods. Results: Modern teaching methods are being practiced at the two faculties studied under KGUMSB. PowerPoint presentation and overhead projector were most preferred by both the groups. Also there was lack of exposure to computer-assisted learning in both the groups. Conclusions: We conclude that the teaching methodologies at KGUMSB are in line with current trends. However, this study also reveals that there is a need to institute robust strategies to encourage more computer-assisted learning.

Development of an inclusive scientific community necessitates doing more than simply bringing science to diverse groups of people. Ideally, the sciences evolve through incorporation of diverse backgrounds, experiences, and worldviews. Efforts to promote inclusion of historically underrepresented racial, ethnic, cultural, religious, gender, and socioeconomic groups among science scholars are currently underway. Examination of these efforts yields valuable lessons to inform next steps in engaging diverse audiences with science. The Emory-Tibet Science Initiative may serve as one example of such efforts. The Dalai Lama invited Emory University to develop and teach a curriculum in Western science to Tibetan Buddhist monks and nuns. As the science curriculum has been taught and refined over the past decade, monastic scholars increasingly have taken ownership of the material. As Western scientific ideas and practices take hold in this setting, the experiences of monks and nuns offer unique insights into the process of translation, modes of communication, and long-term impacts of integrating diverse systems of knowledge. Given that the dominant language of science is English, Tibetan interpreters have been essential throughout the implementation of this project. Through the process of translating scientific terms, interpreters have considered differences in how words categorize, and therefore how people conceptualize, the world. Through comprehensive, culturally-responsive communication, scientific language is used as a tool to build and strengthen connections between monastics and their local and global communities. The intertwining of these complementary systems of knowledge iteratively informs translation, modes of communication, and broader impacts in the community.

Introduction: Excessive use of internet can lead to "Internet Addiction". A sharp rise in the number of internet users among adolescents in Bhutan have been observed lately which could have potential side-effects on their health. The aim of this study was to find the prevalence of internet addiction and psychological co-morbidities among the secondary school-going adolescents. Methods: This is a descriptive cross-sectional quan-qual sequential mixed method design with a quantitative component and qualitative component. The study was conducted between 1st May and 30st November 2017 conducted in twelve schools across Bhutan after taking ethical clearance was from Research Ethics Board of Health of Bhutan. Data were doubleentered in EpiData Entry, validated and imported into STATA version 12.0 for analysis. Point estimate at 95% CI was calculated along with frequency and proportion for binary data. Results: Among 721 adolescents from twelve selected schools, prevalence of internet addiction was 248 (34.440%) at , 95% Confidence Interval (31-38%). Out of A total of 586 (81%) preferred smartphone for internet use with 388 (54%) actually using it. Depression and anxietywere the associated psychological co-morbidities seen along with internet addiction. Internet addiction was high among those using internet at home, using smartphone for internet access, social networking and night time internet use were associated with internet addiction. Boredom, stress/anxiety and peer pressure were triggers of internet use. Internet addiction also affected academic performance, social interactions and sleep. Conclusions: Prevalence of internet addiction among adolescents in Bhutan is high comparing to previous standard data which requires immediate attention.

Bhutan strongly adheres to a policy of ‘High-Value, Low-Impact tourism’ guided by the doctrine of Gross National Happiness (GNH) to make Bhutan a high-end tourist destination. In Bhutan, the tourism industry contributed about US$ 79.87 million in 2017 making it one of the most important economic contributors. However, rural communities are not equally benefitting from tourism activities due to less tourism development. The main objective of this article was to evaluate the opinion of the community towards the opportunities of the village homestay programme. The study was conducted within a small nomadic community in Soe which is located in the North-West of Bhutan. This paper was a qualitative study based on in-depth semi-structured interviews which were limited to twenty key informants due to the small size of the community. Data were analysed with a content analysis approach. The study found that there was some mixed opinion towards the concept of the village homestay programme in the community. The majority of the key informants, particularly the males, expressed quite a strong support for the concept of the village homestay programme. The findings revealed that the male key informants consider that the development could generate additional revenue, enhance health and sanitation and requires less investment for the development. On the other hand, the female key informants expressed some what negative opinions towards the concept of the village homestay programme. The key reasons include lack of experiences in tourism, workloads and the general safety of the women. In spite of varied opinion towards the concept, it was found that the majority of the key informants were very supportive of the development of the village homestay programme and were thus able to see the positive benefits and a good future for the village homestay programme in Soe community.

Introduction: The Widal test is widely used in hospitals in Bhutan for diagnosis of typhoid fever. The right test with high sensitivity and specificity supplements clinical judgement and contributes to correct diagnosis of disease. This study focuses on the contribution of the Widal test in the diagnosis of typhoid fever. Methods: Data was collected from records of patients who presented to Damphu hospital from March 2011 to June 2012 with clinical suspicion of typhoid fever. Blood samples were collected from patients and tested at Damphu Hospital, Tsirang and the Royal Centre for Disease Control, Thimphu. Seventy records were used for the study. Results: There was no growth of Salmonella typhi on blood cultures from patients who had tested positive in the Widal test. There were 20 (28.57%) samples which tested positive for scrub typhus; among these Widal test was positive in 10 (50%) samples. Thirty four out of 36 (94.44%) patients had duration of illness less than seven days and among them 26 (74.47%) had positive Widal test results. Conclusion: None of the samples that tested positive by Widal test gave a definite diagnosis of typhoid fever with blood culture. Clinical judgement may be more challenging because patients with other febrile illnesses like Scrub typhus also have positive Widal test result. We conclude that it is best not to rely on the Widal test alone for the diagnosis of typhoid fever and this test should be replaced by more accurate ones.

Introduction: Globally 3.5 billion people have access to internet and most of them are young adults and adolescents. In South Asia, Bhutan has the highest proportion of population with internet access at 37% in 2016. Many studies in Asia have reported significantly high level of internet addiction among college going students. In this light, this study was designed to estimate the prevalence of internet addiction and other co-morbidities. Methods: This cross sectional study included 823 first year and final year students aged 18-24 from six colleges in Bhutan. A self-administered questionnaire consisting of three parts was utilized for data collection. The data was entered and validated in Epidata and analyzed using STATA/IC 14. Results: The prevalence of moderate and severe internet addiction was 282 (34.3%) and 10 (1%) respectively. Positive correlations between internet addiction and psychological well-being (r= 0.331 95% CI: 0.269, 0.390), between Internet Addiction score and years of internet usage (r=0.104 95% CI: 0.036, 0.171), age and years of using internet (r= 0.8 95% CI: 0.012, 0.148) were observed. The commonest mode of internet use was martphone 714 (86.8%). The use of computer laboratory (aPR 0.80, 95%CI: 0.66, 0.96) and internet use for news and educational purposes (aPR 0.76, 95%CI: 0.64, 0.9) showed protective effects. Conclusions: The prevalence of internet addiction is high among the college going students in Bhutan. This warrants timely interventions to address the problems of internet addiction.

Advanced cardiac life support (ACLS) is one of the important lifesaving procedures administered by emergency medical professionals. International guidelines and literature recommends periodic training of health personnel on ACLS. In Bhutan, the General Duty Medical Officers (GDMO) is often the first line doctors to attend to the critically sick including cardiac arrest patients.

Background: Altered autonomic balance has been noted in Irritable bowel syndrome Regular physical exercise may cause restoration of autonomic balance in health and disease. Objective: To assess the effect of brisk walking on the autonomic balance by analysis of heart rate variability in patients with Irritable bowel syndrome (IBS). Methods: This prospective study was conducted in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University (BSMMU) in 2013.Seventy seven male IBS patients aged 20-50 years, were enrolled from Gastroenterology OPD, BSMMU, Dhaka. Twenty eight healthy sedentary male with similar age were control. HRV measures were recorded once prior to exercise and then after 3 months of brisk walking. For assessing autonomic balance, LF/HF ratio and Max/Min RR was evaluated by Polyrite D machine and software. ANOVA, Independent sample t-test and paired t-test were used for statistical analysis. Results: The pre-exercise mean values of LF/HF ratio were significantly higher (p

Background: Altered autonomic nerve function has been reported by various investigators in IBS and moderate to vigor­ous physical exercise causes autonomic nerve function improvement both in healthy and various clinical conditions. Objective: To observe the effect of brisk walking on the autonomic nerve function by analysis of heart rate in patients with Irritable bowel syndrome. Methods: This prospective interventional study was conducted in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University (BSMMU) between January to December 2013. For this purpose 77 male patients aged 20-50 years with IBS were included in this study, they were enrolled from OPD, Gastroen­terology, BSMMU, Dhaka. For comparison, 28 apparently healthy male were also included as control. HRV measures were recorded once before exercise and also after 3 months of brisk walking. For assessing HRV, frequency domain measures such as total power, LF power, HF power, LF norm and HF norm were recorded by Polyrite D machine. ANOVA, Independent sample t-test and paired t-tests were performed for statistical analysis. Results: The pre-exercise values of HF power, HF norm and total power were significantly lower (p