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Jo Durham,1 Alongkone Phengsavanh,2 Vanphanom Sychareun,2 Isaac Hose,1 Viengnakhone Vongxay,2 Douangphachanh Xaysomphou,2 Keith Rickart3 1Faculty of Medicine, School of Public Health, University of Queensland, Brisbane, Queensland, Australia; 2Faculty of Post-Graduate Studies, University of Health Sciences, Vientiane, Lao PDR; 3Communicable Diseases Branch, Department of Health, Brisbane, Queensland, Australia Purpose: The purpose of this study was to gather the necessary data to support the design and implementation of a pilot program for women who are unable to deliver in a healthcare facility in the Lao People’s Democratic Republic (PDR), by using community distribution of misoprostol to prevent postpartum hemorrhage (PPH). The study builds on an earlier research that demonstrated both support and need for community-based distribution of misoprostol in Lao PDR.Methods: This qualitative study identified acceptability of misoprostol and healthcare system needs at varying levels to effectively distribute misoprostol to women with limited access to facility-based birthing. Interviews (n=25) were undertaken with stakeholders at the central, provincial, and district levels and with community members in five rural communities in Oudomxay, a province with high rates of maternal mortality. Focus group discussions (n=5) were undertaken in each community.Results: Respondents agreed that PPH was the major cause of preventable maternal mortality with community distribution of misoprostol an acceptable and feasible interim preventative solution. Strong leadership, training, and community mobilization were identified as critical success factors. While several participants preferred midwives to distribute misoprostol, given the limited availability of midwives, there was a general agreement that village health workers or other lower level workers could safely administer misoprostol. Many key stakeholders, including women themselves, considered that these community-level staff may be able to provide misoprostol to women for self-administration, as long as appropriate education on its use was included. The collected data also helped identify appropriate educational messages and key indicators for monitoring and evaluation for a pilot program. Conclusion: The findings strengthen the case for a pilot program of community distribution of misoprostol to prevent PPH in remote communities where women have limited access to a health facility and highlight the key areas of consideration in developing such a program. Keywords: community distribution, misoprostol, postpartum hemorrhage, prevention, Lao PDR

Abstract Background In 2007, a regulation on smoke-free health facilities and institutions was adopted by the Lao government. Little is known about health policymakers’ knowledge and opinions regarding tobacco policy control, including physicians’ behaviour. This paper aims to describe the knowledge of Lao health policymakers and their opinions regarding physicians tobacco use and national smoking policy control. Methods In 2007, we made a qualitative explorative study with data from a purposive sample of 18 key informants through semi-structured, face-to-face interviews. The key informants, who were heads of departments, directors of hospitals and directors of centres, mainly worked at the national level, and some provincial levels. Content analysis was used. Results Policymakers perceived the inadequate implementation of a smoke-free regulation and policy as being a barrier and that the general public may not accept physicians smoking, since they are regarded as role models. Most of the respondents mentioned that regulations or laws related to control of smoking in health institutions are available in Laos, but they lacked detailed knowledge of them probably because regulations as well as the smoke-free policy documents were not widely disseminated. The respondents agreed that anti-smoking education should be integrated in the training curricula, especially in the medical schools, and that the provision of counselling on health consequences from smoking and methods of smoking cessation was important. Conclusion This study contributes to tobacco policy evidence and to knowledge regarding factors related to the uptake of evidence into policymaking. Dissemination and implementation of a tobacco control policy nationally, and integration of tobacco cessation training programs in the curricula were found to be productive approaches for improvement.

Abstract Background Maternal mortality among poor rural women in the Lao People’s Democratic Republic (Lao PDR) is among the highest in Southeast Asia, in part because only 15% give birth at health facilities. This study explored why women and their families prefer home deliveries to deliveries at health facilities. Methods A qualitative study was conducted from December 2008 to February 2009 in two provinces of Lao PDR. Data was collected through eight focus group discussions (FGD) as well as through in-depth interviews with 12 mothers who delivered at home during the last year, eight husbands and eight grandmothers, involving a total of 71 respondents. Content analysis was used to analyze the FGD and interview transcripts. Results Obstacles to giving birth at health facilities included: (1) Distance to the health facilities and difficulties and costs of getting there; (2) Attitudes, quality of care, and care practices at the health facilities, including a horizontal birth position, episiotomies, lack of privacy, and the presence of male staff; (3) The wish to have family members nearby and the need for women to be close to their other children and the housework; and (4) The wish to follow traditional birth practices such as giving birth in a squatting position and lying on a “hot bed” after delivery. The decision about where to give birth was commonly made by the woman’s husband, mother, mother-in-law or other relatives in consultation with the woman herself. Conclusion This study suggests that the preference in rural Laos for giving birth at home is due to convenience, cost, comfort and tradition. In order to assure safer births and reduce rural Lao PDR’s high maternal mortality rate, health centers could consider accommodating the wishes and traditional practices of many rural Laotians: allowing family in the birthing rooms; allowing traditional practices; and improving attitudes among staff. Traditional birth attendants, women, and their families could be taught and encouraged to recognize the signs of at-risk pregnancies so as to be able to reach health facilities on time.

Abstract Background The Ministry of Health (MOH) launched the National Reproductive Health Policy in 2005, which included recommendations regarding the use of emergency contraceptive pills (ECP). However, ECP have not yet been introduced officially in the public sector of the Lao PDR. Thus, their availability is limited. Understanding the knowledge of ECP and attitudes about their provision, barriers to use, and availability among health providers and policy makers is essential to successfully incorporate ECP into reproductive health services. Methods Qualitative research methods using in-depth interviews were employed to collect data from policy makers and health providers (auxiliary medical staff, nurses, and medical doctors). Altogether, 10 policy makers, 22 public providers, and 10 providers at private clinics were interviewed. Content analysis was applied to analyze the transcribed data. Results The majority of policy makers and health care providers had heard about ECP and supported their introduction in the public sector. However, their knowledge was poor, many expressed inconsistent attitudes, and their ability to meet the demand of potential users is limited. Conclusions There is a need to train health providers and policy makers on emergency contraception and improve their knowledge about ECP, especially regarding the correct timing of use and the availability of methods. In addition, the general public must be informed of the attributes, side effects, and availability of ECP, and policy makers must facilitate the approval of ECP by the Lao Food and Drug Administration. These interventions could lead to increased access to and demand for ECP.

Abstract Background This cross-sectional study, the first of its kind, uses baseline data on smoking prevalence among Buddhist monks in Northern and Central provinces of Lao PDR. Findings Between March and September 2006, 390 monks were interviewed, using questionnaires, to assess smoking prevalence including determinants, knowledge and attitudes. Data entry was performed with Epi-Info (version 6.04) and data analysis with SPSS version 11. Descriptive analysis was employed for all independent and dependent variables. Chi-square or Fisher's exact test were used for categorical variables to compare smoking status, knowledge, attitudes and province. Logistic regression was applied to identify determinants of smoking. Daily current smoking was 11.8%. Controlling for confounding variables, age at start of monkhood and the length of religious education were significant determinants of smoking. The majority of the monks 67.9% were in favor of the idea that offerings of cigarettes should be prohibited and that they should refuse the cigarettes offered to them (30.3%) but, in fact, 34.8% of the monks who were current smokers accepted cigarettes from the public. Conclusion Some monks were smokers, whilst they, in fact, should be used as non-smoking role models. There was no anti-smoking policy in temples. This needs to be addressed when setting up smoke-free policies at temples.

Period shaming is defined as any negative and/or disrespectful behavior in relation to the menstrual cycle and menstruating girls. It is suggested that period shaming may limit girls' potential and ability to fully participate in school and community activities. This study aims to examine the prevalence and factors associated with period shaming among male students in Luang Prabang Province, Lao People's Democratic Republic (Lao PDR). This was a cross-sectional study which was conducted during November 19-27, 2020. This study included 1,232 male students from secondary school grade 9 to 12 in Luang Prabang Province, Lao PDR. Informed consent was obtained from the participants, parents/guardians, and teachers prior to data collection. The data was collected by a self-administered questionnaire. Logistic regression was employed to examine factors associated with period shaming behavior among male students. The mean age of the participants was 16.4 years old. Of all the male students, 18.8% admitted that they had shamed girls during their menstruation at least once. Of those who committed period shaming, they shamed girls some of the times (63.2%). Male students who had consumed alcohol during the last month before the data collection day (AOR = 1.83, 95% CI 1.32-2.55, P

Agricultural systems in Southeast Asia are rapidly transitioning from subsistence-oriented to market-oriented agriculture. Driven by the highly complex and variable decision processes of individual farm households, these transitions have produced a diverse landscape mosaic across the region. Elucidation and characterization of underlying decision-making processes, and the factors that influence land use choices, are thus essential for sustainable land use planning. To enable a study that seeks to understand these linkages, data on plot-level 10-year land use history, management and farm performance indicators were collected from 163 households in the Northern Lao uplands and in the Central Highlands of Vietnam, areas chosen to represent two extremes of the transition gradient. The objectives of the study were (i) to describe plot-level sequence patterns of seasonal variation of land use over several years, (ii) to apply a sequence dissimilarity metric, the complexity index (CI), to measure land use transition in an agricultural system, and (iii) to identify the key drivers of land use change and their linkages with farm performance indicators and plot level characteristics through multi-dimensional analysis. CI allowed compressing historical land use data and quantifying land use complexity in a simple and efficient manner. Land use dynamics varied strongly between the two sites, with 66% of the land use types in the Laos site being completely replaced by others during the recall periods, compared to only 15% in the Vietnam site. Associated key drivers of land use change also differed significantly: while end use of agricultural products was the main driver behind land use changes in the Vietnam site, a more complex relationship between topography and management vs. land use change was evident in the Laos site. Likewise, land use complexity does not exhibit the same relationship with farm performance in the two sites: in the Central Highlands, households with higher food availability are half as likely to transition, while in the Lao uplands, land use complexity was significantly correlated with the Progress out of Poverty index. Multidisciplinary studies remain necessary to assess the impact of innovative sustainable intensification options on system performance and environmental sustainability, before policies are enacted to support their dissemination in Southeast Asian smallholder agricultural systems. Context-specific CI thresholds associated with system quality indicators could support this by informing decision-makers on the pace of agricultural transformation and its environmental impacts.

Newborn skin disorders are quite common and happen to occur during the neonatal period. Most of the birthmarks are transient; however, worried parents often seek medical advice from their child’s physician regarding skin lesions. Thus, it is important to differentiate the skin lesions from pathologic ones to avoid unnecessary diagnostic or therapeutic procedures. This is the first published study in Lao neonates that carried out the data from 4 central hospitals in Vientiane Capital, Lao PDR from September 2019 to February 2020. Among 500 neonates, Sebaceous gland hyperplasia (53%), Mongolian patches (46.6%), and Erythema toxicum neonatorum (30%) were the 3 most common cutaneous conditions found in the Lao newborns. From a clinical point of view, these findings are often a source of parental anxiety and medical concern for inexperienced clinicians.

In Lao People's Democratic Republic (Lao PDR), information on school sanitation and menstrual health among secondary school girls is limited. This study aimed to explore knowledge and practices surrounding menstrual health and to identify factors associated with school absence due to menstruation among secondary school girls in Lao PDR. The study involved 1,366 girls from grade 9 to grade 12 in six secondary schools in Luang Prabang Province. Data on socio-demographics and menstrual health of the girls and data on school toilets was collected. Logistic regression analysis was performed to identify the factors associated with school absence due to menstruation. The mean age was 15.8 years old. The average age of menarche was 12.9 years old. Of 1,366 girls, 64.6% were shocked or ashamed when they reached menarche and 31.8% had been absent from school due to menstruation in the six months before this study was conducted. Factors associated with school absence due to menstruation were age ≥ 16 years old (AOR = 1.79, 95% CI 1.37-2.34), higher income (AOR = 2.38, 95% CI 1.16-4.87), menstrual anxiety (AOR = 1.55, 95% CI 1.09-2.20), using painkillers (AOR = 4.79, 95% CI 2.96-7.76) and other methods (AOR = 2.82, 95% CI 1.86-4.28) for dysmenorrhea, and disposing used pads in places other than the school's waste bins (AOR = 1.34, 95% CI 1.03-1.75). Living with relatives (AOR = 0.64, 95% CI 0.43-0.95) and schools outside the city (AOR = 0.59, 95% CI 0.38-0.90) were significantly less associated with school absence. Although the association between school toilets and school absence was not examined, the results of this study suggest that school toilets should be gender-separated and equipped with waste bins in the toilet. Furthermore, menstrual education should start at elementary schools and teacher training on menstrual health should be promoted.

Introduction: In Lao People's Democratic Republic, despite a policy to provide free maternal health services in healthcare facilities, many rural women continue to deliver at home, without a skilled birth attendant. These women are at high risk of postpartum haemorrhage, the leading cause of maternal mortality in the country. While women in remote areas continue to be unable to access facility-based birthing, interventions to reduce postpartum haemorrhage are a priority. This requires an understanding of how women and their families recognise and manage postpartum haemorrhage in home births. The purpose of this study was to understand community perceptions and management of postpartum bleeding during home births in remote Lao communities. Methods: Five focus group discussions with a total of 34 women and their support networks were conducted in five remote communities in Oudomxay, a province with high rates of maternal mortality. Villages were selected with district health officials based on (1) known cases of postpartum haemorrhage, (2) travel time from the provincial capital (2-4 hours), (3) distance to the district health service (>4 km), and (4) population (50-150 people), with the five selected villages being the farthest from the district health service. The focus group discussions were complemented by qualitative, community-based key informant interviews (n=9). All interviews were conducted in Lao, English or the ethnic language most suitable for the sample and simultaneously translated by native speakers. All transcripts were translated into English, back translated and checked against interview recordings. The qualitative data were coded into key themes while moving between the data and the coded extracts. Interpretation of the data themes and coding was an ongoing process with codes and themes checked by the research team. Results: Women described postpartum bleeding as a normal, necessary cleansing process. Some women felt it was critical in order to expel 'bad blood' and restore the mother to good health. Participants were able to describe late symptoms of postpartum haemorrhage but did not describe any methods to accurately estimate the amount of blood loss that required intervention. Traditional remedies were the first courses of action, potentially delaying treatment at a healthcare facility. When asked about the acceptability of taking oral medication immediately following home births to prevent postpartum haemorrhage, most women felt it would be acceptable provided it would not stop normal bleeding, and its usage, benefits and side-effects were clearly explained. Conclusion: While women continue to home birth in remote communities without skilled birth attendants, an informed understanding of traditional management of postpartum haemorrhage can assist in designing culturally responsive interventions. To support a reduction in morbidity and mortality from postpartum haemorrhage, tailored interventions are needed to raise awareness among women and their families to reduce delays in seeking health care. Women felt it would be acceptable to take oral medication to prevent postpartum haemorrhage. As such, community-based distribution of misoprostol that can be administered by lay people would provide an effective and acceptable prevention strategy. Other strategies should include promoting birthing plans, delivery by skilled birth attendants and early initiation of breastfeeding.

Postpartum depression is a worldwide public health concern. The prevalence of postpartum depression is reported to be greater in developing countries than in developed countries. However, to the best of our knowledge, no papers on postpartum depression in the Lao People's Democratic Republic have been published. In order to strengthen maternal and child health, the current situation of postpartum depression should be understood. This study aims to determine the prevalence of postpartum depression and identify factors associated with postpartum depression in Vientiane Capital, Lao People's Democratic Republic. Study participants were 428 women 6-8 weeks postpartum who visited four central hospitals in Vientiane Capital for postnatal care from July to August 2019. Structured questionnaires were used to collect socio-demographic, obstetrical and infant, and psychiatric data about the women and their partners. The Edinburgh Postnatal Depression Scale (EPDS) was used to identify suspected cases of postpartum depression with the cut-off score of 9/10. Multivariable logistic regression was used to examine independent factors that were associated with suspected postpartum depression (EPDS ≥10). The mean age of the 428 women was 28.1 years, and the prevalence of suspected postpartum depression was 31.8%. Multivariable logistic regression using variables that were statistically significant on bivariate analyses indicated that three variables were associated with suspected postpartum depression: unintended pregnancy (AOR = 1.66, 95% CI 1.00-2.73, P = 0.049), low birth satisfaction (AOR = 1.85, 95% CI 1.00-3.43, P = 0.049), and depression during pregnancy (AOR = 3.99, 95% CI 2.35-6.77, P

Background: Pregnancy induced hypertension (PIH) is a global public health concern as a leading cause of maternal mortality. Lao PDR has a high prevalence of PIH, but little is known about its risk factors. This study aimed to identify risk factors of PIH relating to antenatal care (ANC) in Lao PDR. Methods: This hospital-based age-matched case control study was carried out between July and December 2017 in tertiary and secondary hospitals in Lao PDR. A total of 258 pregnant women (86 hypertensive and 172 normotensive pregnant women) were recruited to join the study based specific inclusion criteria. For each case, two consecutive controls were included in the study with matched maternal age. Data was collected using a structured questionnaire interview to identify the risk factors of PIH relating to ANC. The association between the independent variables and PIH was assessed through bivariable and conditional multiple logistic regression analyses. Results: Mothers with PIH had inadequate ANC (defined as 13kg) ( adj. OR=7.35, 95%CI: 3.06 -17.69, p Conclusion: Inadequate ANC and maternal factors were major risk factors of PIH in Lao PR. National PIH guidelines for effective counseling, ANC and treatment should be promptly developed and implemented at all levels in order to improve pregnancy outcomes.