ObjectivesAssociation of Southeast Asian Nations (ASEAN) is among the hardest hit low-income and middle-income countries by diabetes. Innovative Care for Chronic Conditions (ICCC) framework has been ...adopted by the WHO for health system transformation towards better care for chronic conditions including diabetes. We conducted an umbrella review of systematic reviews on diabetes care components effectively implemented in the ASEAN health systems and map those effective care components into the ICCC framework.DesignAn umbrella review of systematic reviews and/or meta-analyses following JBI (Joanna Briggs Institute) guidelines.Data sourcesHealth System Evidence, Health Evidence, PubMed and Ovid MEDLINE.Eligibility criteriaWe included systematic reviews and/or meta-analyses which focused on management of type 2 diabetes, reported improvements in measured outcomes and had at least one ASEAN member state in the study setting.Data extraction and synthesisTwo reviewers independently extracted the data and mapped the included studies into the ICCC framework. A narrative synthesis method was used to summarise the findings. The included studies were assessed for methodological quality based on the JBI critical appraisal checklist for systematic reviews and research syntheses.Results479 records were found of which 36 studies were included for the analysis. A multidisciplinary healthcare team including pharmacists and nurses has been reported to effectively support patients in self-management of their conditions. This can be supported by effective use of digital health interventions. Community health workers either peers or lay people with necessary software (knowledge and skills) and hardware (medical equipment and supplies) can provide complementary care to that of the healthcare staff.ConclusionTo meet challenges of the increased burden of chronic conditions including diabetes, health policy-makers in the ASEAN member states can consider a paradigm shift in human resources for health towards the multidisciplinary, inclusive, collaborative and complementary team.
The Association of Southeast Asian Nations (ASEAN) Economic Community (AEC) was inaugurated in December 2015 with the primary aim of achieving a strong and prosperous community through accelerating ...economic integration. The notion of a single market, underpinned by the free flow of trade in services and skilled labour, is integral to the spirit of the AEC. To facilitate the intra-regional mobility of health professionals, Mutual Recognition Arrangements (MRAs) were signed, for nursing in 2006 and for medicine and dentistry in 2009, and now sit within the AEC objectives. This study examines the observed and potential impact of the health-related MRAs on health worker mobility within the region, particularly with regard to qualified doctors and nurses. To explore the available evidence, the authors undertook a narrative literature and document review, consistent with the RAMESES guidelines for qualitative research in international development and policy making in the area of health. Peerreviewed articles and the grey literature from the period beginning in 2005 were reviewed. We find that the implementation of health-related MRAs has been slow and complex due to a number of barriers and challenges, such as resistance to the inflow of health professionals by the local workforce, shortcomings in the implementing mechanisms and an individual preference among health professionals for seeking better opportunities outside the region. Despite increasing worker mobility generally within ASEAN through formal and informal mechanisms, the MRAs themselves do not appear yet to have facilitated the freer movement of health workers. To strengthen health worker mobility, the full implementation of the health-related MRAs is essential, requiring support from broader trade and immigration policies and a stronger political commitment. Policy makers in ASEAN Member States will need to manage competing national interests in order to harness support for effective implementation.
La Communauté économique de l’Association des nations de l’Asie du Sud-est (ANASE) a été inaugurée en décembre 2015 dans le but premier de créer une communauté forte et prospère en accélérant l’intégration économique. La notion de marché unique, qui repose sur la libre circulation des services et de la main-d’œuvre qualifiée, fait partie intégrante de l’esprit de cette Communauté économique. Pour faciliter la mobilité intra-régionale des professionnels de la santé, des accords de reconnaissance mutuelle (ARM) ont été signés, pour les soins infirmiers en 2006; pour les soins médicaux et dentaires en 2009, et font maintenant partie des objectifs de la Communauté économique (CEA). La présente étude examine l’impact observé et potentiel des ARM liés à la santé sur la mobilité des agents de santé dans la région, en particulier en ce qui concerne les médecins et les infirmiers qualifiés. Afin d’explorer les données probantes disponibles, les auteurs ont entrepris une analyse documentaire et narrative, conformément aux lignes directrices du RAMESESES pour la recherche qualitative en développement international et l’élaboration de politiques dans le domaine de la santé. Les articles évalués par des pairs et la littérature grise de la période commençant en 2005 ont été examinés. Nous constatons que la mise en œuvre des ARM liés à la santé a été lente et complexe en raison d’un certain nombre d’obstacles et de défis, à l’instar de la résistance de la main-d’œuvre locale à l’afflux des professionnels de la santé, les lacunes des mécanismes de mise en œuvre et une préférence personnelle des professionnels de la santé en quête de meilleures opportunités hors de la région. Bien que la mobilité des agents de santé augmente généralement au sein de l’ANASE grâce à des mécanismes formels et informels, les ARM eux-mêmes ne semblent pas encore en mesure d’améliorer la libre circulation des agents de santé. Pour renforcer la mobilité des agents de santé, il est essentiel de mettre pleinement en œuvre les accords de reconnaissance mutuelle dans le domaine de la santé, ce qui nécessite l’appui de politiques commerciales et d’immigration plus globales ainsi qu’un engagement politique plus ferme. Les décideurs politiques des États membres de l’ANASE devront gérer les intérêts nationaux concurrents afin de mobiliser le soutien nécessaire à une mise en œuvre efficace.
La Comunidad Económica de la Asociación de Naciones del Sureste Asiático (CEA) (ANSEA) fue inaugurada en diciembre de 2015 con el objetivo primario de lograr una comunidad fuerte y próspera a través de la aceleración de la integración económica. La noción de un mercado común, basado en la libre circulación de intercambio de servicios y mano de obra cualificada, es integral al espíritu de la CEA. Para facilitar la movilidad intra-regional de los profesionales de la salud, Acuerdos de Reconocimiento Mutuo (ARMs) fueron firmados, para la enfermería en 2006 y para la medicina y dentistería en 2009, y ahora están dentro de los objetivos de la CEA. Este estudio examina el impacto observado y potencial de los ARMs relacionados con la salud sobre la movilidad de los trabajadores de salud en la región, particularmente en doctores y enfermero/as. Para explorar la evidencia existente, los autores llevaron a cabo un resumen narrativo de la literatura y documentos, consistentes con las pautas de RAMESES para la investigación cualitativa en el desarrollo internacional y las políticas relacionadas con salud. Se analizaron los artículos revisados por pares y la literatura gris desde el periodo que comienza en 2005. Encontramos que la implementación de los ARMs relacionados con la salud ha sido lenta y compleja debido a un numero de barreras y desafíos, como la resistencia por parte de la mano de obra local a la entrada al mercado de los profesionales de la salud, deficiencias en los mecanismos de implementación y una preferencia individual entre los profesionales de salud de buscar mejores oportunidades por fuera de la región. A pesar de la creciente movilidad general de los trabajadores dentro de ANSEA a través de mecanismos formales e informales, los ARMs en sí no parecen hasta ahora haber facilitado la libre circulación de trabajadores de salud. Para fortalecer la movilidad de los trabajadores de salud, la implementación total de los ARMs relacionados con la salud es esencial, y requiere apoyo de políticas más amplias de comercio e inmigración y un compromiso político más fuerte. Los formuladores de políticas de los estados miembros de ANSEA deben manejar los intereses nacionales rivales para crear apoyo para la implementación efectiva.
东南亚国家联盟（ASEAN）经济共同体（AEC）于2015年12 月成立, 主要目的是通过加速经济一体化实现强有力的繁荣共 同体。服务贸易和技术人员自由流动支撑的单一市场是AEC 精神中不可或缺的部分。为了促进医疗人员在区域内流动, 2006年签订了护理人员互相认可协定（MRAs）, 2009年签订 了内科和口腔科MRAs, 并且是AEC目前的目的之一。本研究 分析卫生相关MRAs对卫生工作者区域内流动性的观察影响 和可能影响, 尤其是对取得资格认证的医生和护士的影响。为 探索现有证据, 作者进行了叙述性文献和文件综述, 遵循卫生 领域国际发展和政策制定定性研究的RAMESES指南。回顾了 2005年起发表的同行评审文章和灰色文献。我们发现, 卫生相 关MRAs的实施缓慢且复杂, 其原因是存在一系列阻碍因素和 挑战, 如本地人员对医疗人员流入的抵制, 实施机制缺陷, 以 及医疗人员个人偏好向东盟之外机会更好的地区流动。尽管 通过正式和非正式机制提高了东盟内劳动力的整体流动性, MRAs本身似乎并不促进卫生工作者的自由流动。为增强卫 生人员流动性, 全面实施卫生相关MRAs是关键, 为此需要更 广泛的贸易和移民政策, 以及更强有力的政治支持。东盟成员 国的政策制定者需要平衡国家利益, 以便有效实施卫生人员区 域内流动。
While university students are potential human resources, this population group is particularly involved in health risk behaviours. Preventing risky sexual behaviours among them would contribute to ...prevention of HIV, sexually transmitted infections (STIs), and unwanted pregnancies, which have posed a great burden on population health. This study was therefore conducted to identify social and behavioural factors associated with risky sexual behaviours among university students in nine ASEAN countries. A multi-country, cross-sectional study was conducted in 2015 among university students by a network of researchers in the selected countries. A convenient sampling method and stratified random sampling procedures were employed to select universities and students, respectively. A structured questionnaire was translated into national languages of the participating countries and used to collect data from the selected students in the classrooms. Using STATA, Chi-square test was used to test differences in proportions, and multinomial logistic regression analyses were performed to obtain relative risk ratios and 95% confidence intervals. Multivariate logistic regression analysis was performed with to identify independent social and behavioural factors associated with non-condom use at last sexual intercourse. In total, 8,836 students with a mean age of 20.6 (SD = 2.0) participated in the study. Most of them (98.5%) were unmarried. In all countries, male students were significantly more likely to have two or more sexual partners in the past 12 months compared to female students (4.8% vs. 1.1%, p < 0.001). Female students were significantly more likely to report unprotected sex compared to male students (50.5% vs. 58.8%, p = 0.01). Results of multivariable logistic regression analyses showed that students who reported having two or more partners in the past 12 months were significantly more likely to be male, be aged between 20-30, be current tobacco smokers, be binge drinkers, have severe depressive symptoms, and have been in a physical fight in the past 12 months, compared to students who reported having less than two sexual partners in the past 12 months. Health intervention programmes to prevent and control STIs, especially HIV infection, should focus on university students having the social and behavioural characteristics that are associated with risky sexual behaviours.
Background
Cardiovascular diseases (CVDs) were accountable for 24% of the total deaths in Cambodia, one of the low- and middle-income countries, where primary health care (PHC) settings generally do ...not perform well in the early detection, diagnosis, and monitoring of leading risk factors for CVDs, that is, type 2 diabetes (T2D) and hypertension (HT). Integrated care for T2D and HT in the Cambodian PHC system remains limited, with more than two-thirds of the population never having had their blood glucose measured and more than half of the population with T2D having not received treatment, with only few of them achieving recommended treatment targets. With regard to care for T2D and HT in the public health care system, 3 care models are being scaled up, including (1) a hospital-based model, (2) a health center–based model, and (3) a community-based model. These 3 care models are implemented in isolation with relatively little interaction between each other. The question arises as to what extent the 3 care models have performed in providing care to patients with T2D or HT or both in Cambodia.
Objective
This protocol aims to show how to use primary data from a population-based survey to generate data for the cascades of care to assess the continuum of care for T2D and HT across different care models.
Methods
We adapt the HIV test-treat-retain cascade of care to assess the continuum of care for patients living with T2D and HT. The cascade-of-care approach outlines the sequential steps in long-term care: testing, diagnosis, linkage with care, retention in care, adherence to treatment, and reaching treatment targets. Five operational districts (ODs) in different provinces will be purposefully selected out of 103 ODs across the country. The population-based survey will follow a multistage stratified random cluster sampling, with expected recruitment of 5280 eligible individuals aged 40 and over as the total sample size. Data collection process will follow the STEPS (STEPwise approach to NCD risk factor surveillance) survey approach, with modification of the sequence of the steps to adapt the data collection to the study context. Data collection involves 3 main steps: (1) structured interviews with questionnaires, (2) anthropometric measurements, and (3) biochemical measurements.
Results
As of December 2021, the recruitment process was completed, with 5072 eligible individuals participating in the data collection; however, data analysis is pending. Results are expected to be fully available in mid-2022.
Conclusions
The cascade of care will allow us to identify leakages in the system as well as the unmet need for care. Identifying gaps in the health system is vital to improve efficiency and effectiveness of its performance. This study protocol and its expected results will help implementers and policy makers to assess scale-up and adapt strategies for T2D and HT care in Cambodia.
Trial Registration
International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN41932064; https://www.isrctn.com/ISRCTN41932064
International Registered Report Identifier (IRRID)
DERR1-10.2196/36747
From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would ...facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia.
This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility.
Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms.
The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.
Cambodia has seen an increase in the prevalence of type 2 diabetes (T2D) over the last 10 years. Three main care initiatives for T2D are being scaled up in the public health care system across the ...country: hospital-based care, health center-based care, and community-based care. To date, no empirical study has systematically assessed the performance of these care initiatives across the T2D care continuum in Cambodia.
This study aimed to assess the performance of the 3 care initiatives-individually or in coexistence-and determine the factors associated with the failure to diagnose T2D in Cambodia.
We used a cascade-of-care framework to assess the T2D care continuum. The cascades were generated using primary data from a cross-sectional population-based survey conducted in 2020 with 5072 individuals aged ≥40 years. The survey was conducted in 5 operational districts (ODs) selected based on the availability of the care initiatives. Multiple logistic regression analysis was used to identify the factors associated with the failure to diagnose T2D. The significance level of P<.05 was used as a cutoff point.
Of the 5072 individuals, 560 (11.04%) met the definition of a T2D diagnosis (fasting blood glucose level ≥126 mg/dL and glycated hemoglobin level ≥6.5%). Using the 560 individuals as the fixed denominator, the cascade displayed substantial drops at the testing and control stages. Only 63% (353/560) of the participants had ever tested their blood glucose level in the last 3 years, and only 10.7% (60/560) achieved blood glucose level control with the cutoff point of glycated hemoglobin level <8%. The OD hosting the coexistence of care displayed the worst cascade across all bars, whereas the OD with hospital-based care had the best cascade among the 5 ODs. Being aged 40 to 49 years, male, and in the poorest category of the wealth quintile were factors associated with the undiagnosed status.
The unmet needs for T2D care in Cambodia were large, particularly in the testing and control stages, indicating the need to substantially improve early detection and management of T2D in the country. Rapid scale-up of T2D care components at public health facilities to increase the chances of the population with T2D of being tested, diagnosed, retained in care, and treated, as well as of achieving blood glucose level control, is vital in the health system. Specific population groups susceptible to being undiagnosed should be especially targeted for screening through active community outreach activities. Future research should incorporate digital health interventions to evaluate the effectiveness of the T2D care initiatives longitudinally with more diverse population groups from various settings based on routine data vital for integrated care.
International Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN41932064; https://www.isrctn.com/ISRCTN41932064.
RR2-10.2196/36747.
Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based ...Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.
Significant evidence has supported a positive association between consumption of sugar-sweetened beverage and increased risks of the non-communicable diseases of obesity, metabolic disorders, dental ...caries, and dental erosion. Thus, using social marketing concepts to change people's attitude and behaviour towards the consumption is imperative. Social media is considered as a cheap and quick tool to disseminate health messages in health communication. The use of social media has increased significantly but knowledge of its utilization in sugar-sweetened beverage health campaigns is limited. This study was conducted to identify social media health campaigns against the sugar-sweetened beverage consumption, their social media platforms and types of materials distributed, and to identify health messages being highlighted in the campaigns. The authors conducted a systematic search for the campaigns and employed content analysis to identify health messages. As a result, 34 campaigns were identified. Facebook and YouTube were commonly used to disseminate campaign materials-83% of them were videos and text articles. Obesity/overweight, diabetes, and cardiovascular diseases were the most frequently mentioned health messages in the campaigns. The increased use of social media with their low-cost operation and capacity to increase campaign reach makes them potential communication channels for health campaigns against sugar-sweetened beverage consumption.
In 2012, the European Commission funded Go4Health-Goals and Governance for Global Health, a consortium of 13 academic research and human rights institutions from both Global North and South-to track ...the evolution of the Sustainable Development Goals (SDGs), and provide ongoing policy advice. This paper reviews the research outputs published between 2012 and 2016, analyzing the thematic content of the publications, and the influence on global health and development discourse through citation metrics.
Analysis of the 54 published papers showed 6 dominant themes related to the SDGs: the formulation process for the SDG health goal; the right to health; Universal Health Coverage; voices of marginalized peoples; global health governance; and the integration of health across the other SDGs. The papers combined advocacy---particularly for the right to health and its potential embodiment in Universal Health Coverage-with qualitative research and analysis of policy and stakeholders. Go4Health's publications on the right to health, global health governance and the voices of marginalized peoples in relation to the SDGs represented a substantial proportion of papers published for these topics. Go4Health analysis of the right to health clarified its elements and their application to Universal Health Coverage, global health governance, financing the SDGs and access to medicines. Qualitative research identified correspondence between perceptions of marginalized peoples and right to health principles, and reluctance among multilateral organizations to explicitly represent the right to health in the goals, despite their acknowledgement of their importance. Citation metrics analysis confirmed an average of 5.5 citations per paper, with a field-weighted citation impact of 2.24 for the 43 peer reviewed publications. Citations in the academic literature and UN policy documents confirmed the impact of Go4Health on the global discourse around the SDGs, but within the Go4Health consortium there was also evidence of two epistemological frames of analysis-normative legal analysis and empirical research-that created productive synergies in unpacking the health SDG and the right to health.
The analysis offers clear evidence for the contribution of funded programmatic research-such as the Go4Health project-to the global health discourse.
Since the new global health and development goal, Sustainable Development Goal (SDG) 3, and its nine targets and four means of implementation were introduced to the world through a United Nations ...(UN) General Assembly resolution in September 2015, right to health practitioners have queried whether this goal mirrors the content of the human right to health in international law. This study examines the text of the UN SDG resolution, Transforming our world: the 2030 Agenda for Sustainable Development, from a right to health minimalist and right to health maximalist analytic perspective. When reviewing the UN SDG resolution’s text, a right to health minimalist questions whether the content of the right to health is at least implicitly included in this document, specifically focusing on SDG 3 and its metrics framework. A right to health maximalist, on the other hand, queries whether the content of the right to health is explicitly included. This study finds that whether the right to health is contained in the UN SDG resolution, and the SDG metrics therein, ultimately depends on the individual analyst’s subjective persuasion in relation to right to health minimalism or maximalism. We conclude that the UN General Assembly’s lack of cogency on the right to health’s position in the UN SDG resolution will continue to blur if not divest human rights’ (and specifically the right to health’s) integral relationship to high-level development planning, implementation and SDG monitoring and evaluation efforts.
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