The concept of continuum of care has gained attention as measures to improve maternal, newborn, and child health. However, little is known about the factors associated with the coverage level of ...continuum of care in Lao PDR. Therefore, this study was conducted 1) to investigate the coverage level of continuum of care and 2) to identify barriers and promoting factors that are associated with mothers' continuation in receiving services in rural Lao PDR.
A community-based, cross sectional study was conducted in a rural district in Khammouane Province, Lao PDR, using a structured questionnaire. The outcome to the express continuum of care was assessed by the modified composite coverage index (CCI) that reflects ten maternal and child health services.
In total, 263 mothers were included in the final analyses. Only 6.8% of mothers continued to receive all MNCH services. Five factors were shown to have statistically significant associations with modified CCI score: higher educational attainment (B = 0.070, p<0.001), being a farmer (B = -0.078, p = 0.003), receiving the first antenatal care within the first trimester (B = 0.109, p<0.001), longer distance from district hospital (B = -0.012, p<0.001), and discussion with husband or family members (B = 0.057, p = 0.022).
In this study, we introduced the modified CCI to better explain the utilization of preventive maternal and child health services along with the continuum of care. By utilizing the modified CCI, we identified five factors as determinants of continuum of care. Furthermore, new and modifiable promoting factors were identified for continuum of care: receiving the first antenatal care within the first trimester and family and male involvement. Such demand side actions should be encouraged to improve the continuity of MNCH service use.
Height is a key component of nutrition assessments in children from limited-resource settings. This study aimed to assess whether handheld digital ultrasound devices for measuring children's height ...provide comparable accuracy to traditional measurement boards, which are bulky and difficult to transport. We trained 12 health workers to measure the standing height of 222 children aged 2-5 years in rural Lao People's Democratic Republic using both the ultrasound device and measurement board. The Bland-Altman method was used to depict limits of agreement and potential bias. We reported the technical error of measurement (TEM) for precision and accuracy, then assessed these results against the Standardized Monitoring and Assessment for Relief and Transition (SMART) Manual 2.0 and the WHO Multicentre Growth Reference Study (MGRS). The average difference between the ultrasound and board measurements was 0.096 cm (95% limits-of-agreement: 0.041cm, 0.61cm) with a systematic bias of 0.1cm (95% confidence interval: 0.067cm, 0.134cm), suggesting the ultrasound measurements were slightly higher than those from the board. The ultrasound and board TEMs for precision were 0.157cm and 0.091cm respectively. The accuracy TEM was 0.205cm. All TEMs were within SMART and WHO MGRS limits. The ultrasound device is comparable to the measurement board among standing Lao children aged 2-5 years for precision and accuracy TEMs but showed a bias of 0.1cm. Further studies are required to assess whether calibration can minimise this bias and determine the ultrasound's accuracy on recumbent length for infants and younger children.
Community-based health programmes have been a cornerstone of primary care in Laos for decades. The study presented here aimed to document prospects for the development of current programmes, ...considering perceptions about health and health care priorities in the communities, implementation challenges, the policy landscape and opportunities associated with the availability of new technologies.
The research design primarily involved qualitative in-depth interviews with stakeholders (n = 35) responsible for the planning, management, or implementation of community-based care in Laos at different levels of the health system. These included health managers at central departments or institutes of the Ministry of Health, provincial health departments, district health offices, heads of health centres, village health volunteers, community representatives, and international stakeholders.
There was consensus that service delivery is still a challenge in many areas, due to geographic inaccessibility of health facilities, communication barriers, health-seeking behaviour, trust, and gender discrimination, particularly among ethnic minorities. In these settings, community health workers have the potential to extend the reach of the formal health system, acting as cultural brokers across sectors of society, ethnicities, and worldviews. To maximise impact, planners need to carefully consider the implementation model, financing arrangements, health system integration, and changing health priorities in the communities.
This study examined challenges to, and opportunities for, the expansion and health system integration of community-based care in Laos. Further development and horizontal integration of community-based care remains a complex financing and governance challenge, although the renewed emphasis on primary care and the ongoing process of decentralisation provide a favourable policy environment in the country to sustain and potentially expand existing programmes.
In the Lao People's Democratic Republic (Lao PDR), village health volunteers play an important role in providing health services including those to reduce the burden of malaria. Over the last two ...decades, the volunteer network has expanded to bring malaria services closer to communities and contributed to the reduction of malaria cases. However, as malaria test positivity rates decreased, many volunteers have lost motivation to continue providing routine malaria services, and other services they provide may not reflect growing healthcare demands for common diseases in the community. This study explored the perspectives, knowledge and inputs of key health stakeholders and community members in southern Lao PDR on community-delivered models in order to refine the volunteer model in the context of Lao PDR's primary health care sector and malaria elimination goals. Semi-structured interviews with multi-level health stakeholders, participatory workshops with community leaders, and focus group discussions with community members and current village health volunteers were conducted. Deductive followed by inductive thematic analysis was used to explore and categorise stakeholders' perspectives on community-delivered models for malaria elimination. Both stakeholders and community members agreed that village health volunteers are essential providers of malaria services in rural communities. Apart from malaria, community members identified dengue, diarrhoea, influenza, skin infections and tuberculosis as priorities (in descending order of importance) and requested community-based primary health care for these diseases. Stakeholders and community members suggested integrating prevention, diagnosis, and treatment services for the five priority diseases into the current malaria volunteer model. A divergence was identified between community members' expectations of health services and the services currently provided by village health volunteers. Stakeholders proposed an integrated model of healthcare to meet the needs of the community and help to maintain volunteers' motivation and the long-term sustainability of the role. An evidence-based, integrated community-delivered model of healthcare should be developed to balance the needs of both community members and stakeholders, with consideration of available resources and current health policies in Lao PDR.
Albendazole and mebendazole are increasingly deployed for preventive chemotherapy targeting soil-transmitted helminth (STH) infections. We assessed the efficacy of single oral doses of albendazole ...(400 mg) and mebendazole (500 mg) for the treatment of hookworm infection in school-aged children in Lao PDR. Since Opisthorchis viverrini is co-endemic in our study setting, the effect of the two drugs could also be determined against this liver fluke.
We conducted a randomized, open-label, two-arm trial. In total, 200 children infected with hookworm (determined by quadruplicate Kato-Katz thick smears derived from two stool samples) were randomly assigned to albendazole (n=100) and mebendazole (n=100). Cure rate (CR; percentage of children who became egg-negative after treatment), and egg reduction rate (ERR; reduction in the geometric mean fecal egg count at treatment follow-up compared to baseline) at 21-23 days posttreatment were used as primary outcome measures. Adverse events were monitored 3 hours post treatment.
Single-dose albendazole and mebendazole resulted in CRs of 36.0% and 17.6% (odds ratio: 0.4; 95% confidence interval: 0.2-0.8; P=0.01), and ERRs of 86.7% and 76.3%, respectively. In children co-infected with O. viverrini, albendazole and mebendazole showed low CRs (33.3% and 24.2%, respectively) and moderate ERRs (82.1% and 78.2%, respectively).
Both albendazole and mebendazole showed disappointing CRs against hookworm, but albendazole cured infection and reduced intensity of infection with a higher efficacy than mebendazole. Single-dose administrations showed an effect against O. viverrini, and hence it will be interesting to monitor potential ancillary benefits of a preventive chemotherapy strategy that targets STHs in areas where opisthorchiasis is co-endemic.
Current Controlled Trials ISRCTN29126001.
BACKGROUND: Helminthiasis is a public health concern in Lao People’s Democratic Republic (Lao PDR, Laos). This study aimed to understand helminth infection and associated risk factors in relation to ...existing local knowledge, attitudes and practices regarding worm infections in endemic communities. METHODS: A cross-sectional survey was conducted in 10 randomly selected villages in Saravane district, Southern Laos. Two stool samples obtained from 574 members (aged ≥2 years) of selected households were examined using the Kato Katz method. Household heads (n = 130) were interviewed. Eight focus group discussions (FGDs) and direct observations were performed. Uni- and multivariate logistic regression analyses were conducted to predict infection. Content analysis was conducted for qualitative data. RESULTS: The prevalence of Opisthorchis viverrini, hookworm, Trichuris trichiura, Ascaris lumbricoides and Taenia sp. was 88.7%, 86.6%, 32.9%, 9.8% and 11.5%, respectively. Most individuals were co-infected with O. viverrini and hookworm. More men had multiple helminth infections than did women. Only one-third of household heads had heard about liver fluke before, of which 59.2% associated it with eating raw fish dish. Among the soil-transmitted helminths, roundworm was the most well known (70.8%) but was attributed to raw food consumption (91.3%). Eating raw fish was a common practice (75.4%); few households possessed a latrine (16.1%); less than half of the study participants mentioned health benefits from latrine use and personal hygiene. Focus group discussion participants had a low level of awareness of worm infections; more men liked eating raw fish than did women; some disliked using latrines because they were not used to it and because of their bad smell. Poor personal and village hygiene practices were observed. CONCLUSIONS: This study highlights a high helminth infection rate and poor community awareness of worm infections and associated risk factors. Only a sound awareness of worm infection and the underlying risk factors may prevent infection and re-infection after treatment.
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.
This study aimed to provide a comprehensive exploration of factors that influence SRH knowledge, attitudes, and practices of adolescents in Bokeo Province, Lao PDR.
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.
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.
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.
Opisthorchiasis is a major public health problem in Southeast Asia. Affected individuals often have mixed infections with the liver fluke Opisthorchis viverrini and minute intestinal flukes such as ...Haplorchis taichui. The usual methods of diagnosing these infections involve the demonstration of fluke eggs in stool samples under light microscopy, but sensitivity and specificity are low. We developed two PCR tests that detect and discriminate between O. viverrini and H. taichui infections. PCR tests were validated by stool samples from purged individuals. We then applied the PCR tests to estimate the prevalence of O. viverrini and H. taichui infections from a random sample of individuals selected from a community in an area of endemicity in Khong District, Laos. PCR results were compared with those from the Kato-Katz (KK) method and the formalin-ether concentration technique (FECT). When validated with purge results, PCR tests of O. viverrini and H. taichui had sensitivities of 93.7% (95% confidence interval CI, 85.8 to 97.9%) and 73.3% (95% CI, 60.3 to 83.9%) and could detect as little as 0.75 pg DNA and 1.32 ng DNA, respectively. The PCR-determined community prevalences of O. viverrini and H. taichui infections were 63.9% (95% CI, 54.1 to 72.9%) and 30.6% (95% CI, 22.1 to 40.2%), respectively. Using PCR as the gold standard to detect O. viverrini, three KK thick smears performed comparably well, whereas one KK smear and FECT were poorer (sensitivities of 91.4% 95% CI, 81.0 to 97.1%,, 62.3% 95% CI, 49.8 to 73.7%, and 49.3% 95% CI, 37.0 to 61.6%, respectively). PCR may be a valuable and sensitive diagnostic tool, particularly for low-intensity O. viverrini and H. taichui infections.
Facility-based delivery has been promoted to improve maternal and child health care in Lao PDR and a free delivery policy was introduced at designated health care facilities (HCF) in 2013. However, ...according to birth records of HCFs in the impoverished and remote district, only a few women utilized the HCFs despite good physical accessibility. The aim of this study was to analyze the factors influencing the choice of facility-based delivery in the impoverished and remote district after a free delivery policy was introduced.
Qualitative case study was employed. Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted from August to October 2015. Five hamlets (or small village) located along the main road where only a few women delivered at HCFs were selected for the study based on birth records. The participants of the FGDs and IDIs were the village heads, village health volunteers, women who delivered at home or at a health facility within the past 2 years, their husbands, and mothers or mothers-in-law. Thematic analysis was used to analyze the data.
A total of 12 FGDs and 27 IDIs were conducted, and the number of participants was 105. The factors influencing the choice of facility-based delivery were classified into nine categories and 19 subcategories. The categories were labeled, "perception of childbirth," "traditional health concept:
(a condition of health, ease, and comfort)," "perception of health care facilities and staff," "previous pregnancy and childbirth experience," "mode of available transportation," "financial burden of childbirth at health care facility," "family and community context," "institutional context," and "government policy on delivery."
Our study demonstrated that five major factors negatively influenced the choice of facility-based delivery: (1) perception of childbirth, (2) preference for
, (3) financial burden, (4) family decision-making, and (5) institutional context. To promote facility-based delivery in the impoverished and remote district, three strategies are recommended: (1) promoting community-based health education involving women and strengthening community-based mutual support, (2) clarifying items essential for delivery at HCFs, and (3) making HCFs more comfortable in terms of "
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Abstract
Background
Maternal mortalities remain high in the Lao
People
’
s Democratic Republic (Lao PDR)
. Since 2012, to improve access to maternal health services for all women, the country ...implemented several policies and strategies including user fee removal interventions for childbirth-related care. However, it remains unclear whether inequalities in access to services have reduced in the post-2012 period compared to pre-2012. Our study compared the change in sociodemographic and economic inequalities in access to maternal health services between 2006 to 2011–12 and 2011–12 to 2017.
Methods
We used the three most recent Lao Social Indicator Survey datasets conducted in 2006, 2011–12, and 2017 for this analysis. We assessed wealth, area of residence, ethnicity, educational attainment, and women’s age-related inequalities in the use of at least one antenatal care (ANC) visit with skilled personnel, institutional delivery, and at least one facility-based postnatal care (PNC) visit by mothers. The magnitude of inequalities was measured using concentration curves, concentration indices (CIX), and equiplots.
Results
The coverage of at least one ANC with skilled personnel increased the most between 2012 and 2017, by 37.1% in Hmong minority ethnic group women, 36.1% in women living in rural areas, 31.1%, and 28.4 in the poorest and poor, respectively. In the same period, institutional deliveries increased the most among women in the middle quintiles by 32.8%, the poor by 29.3%, and Hmong women by 30.2%. The most significant reduction in inequalities was related to area of residence between 2006 and 2012 while it was based on wealth quintiles in the period 2011–12 to 2017. Finally, in 2017, wealth-related inequalities in institutional delivery remained high, with a CIX of 0.193 which was the highest of all CIX values.
Conclusion
There was a significant decline in inequalities based on the area of residence in the use of maternal health services between 2006 and 2011–12 while between 2011–12 and 2017, the largest decrease was based on wealth quintiles. Policies and strategies implemented since 2011–12 might have been successful in improving access to maternal health services in Lao PDR. Meanwhile, more attention should be given to improving the uptake of facility-based PNC visits.
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