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2.  Data verification at health centers and district health offices in Xiengkhouang and Houaphanh Provinces, Lao PDR 
Routine health information is an essential health system building block. In low and low-middle income countries however, concerns about the quality of routine administrative data have often undermined their use. The purpose of the present study was to verify the data availability, and consistency of six key maternal and child health indicators (first antenatal care, fourth antenatal care, skilled birth attendants, postnatal care, ‘Bacillus Calmette Guerin and diphtheria-pertussis-tetanus third dose).
The study collected data for the identified indicators in 2011 from Xiengkhouang and Houaphanh provinces in the Lao People’s Democratic Republic (PDR). The data came from health centres (N = 109), sub-districts (N = 26) and district health offices (N = 16). Core indicators were calculated using numerators and denominators from the different data sources at the district and health centre level and standardized statistical tests performed.
The study revealed that data for the six indicators were either not available or not complete in the service logbooks or registers in most of the health centres. Furthermore, few health centres kept the data for up to five years, often destroying it once the report had been sent to the district health office. In addition, there was limited numerator consistency between the different data sources.
Data on the six indicators collected and reported in the public health system across the two provinces lacked completeness, accuracy and consistency. To improve the quality of data, there is a need to train health centre staff in data collection and recording as well as ensuring there is adequate monitoring and supervision. A uniform national standardized form is also necessary with findings shared with district health offices and centres. Additionally, staff should be encouraged to own and value local data.
PMCID: PMC4118319  PMID: 24929940
Data verification; Indicators; Health information system; Lao PDR
3.  Cross-sectional survey: smoking among medical, pharmacy, dental and nursing students, University of Health Sciences, Lao PDR 
BMJ Open  2013;3(8):e003042.
To investigate the prevalence of and attitudes to smoking among third year medical, pharmacy, dentistry and nursing students in Lao People’s Democratic Republic (PDR).
A cross-sectional survey conducted among third year university level, health professional students. The survey used a self-administered questionnaire which was originally developed by WHO, and modified to suit the setting.
The setting was the University of Health Sciences in Vientiane, the capital of Lao PDR. Participants were recruited from the Faculties of Medicine, Pharmacy, Dentistry and Nursing. At the time of the survey, 521 third year students were enrolled.
Primary and secondary outcome measures
The primary outcome measure was prevalence of current cigarette smoking and other tobacco use. Smoking status was categorised as: current smoker, ex-smoker and non-smoker with current smokers defined as those who had smoked cigarettes or used other tobacco on one or more days during the previous 30 days.
In total, 506 respondents completed the questionnaire, giving a response rate of 97.1% to 98.5% across the different faculties. Overall smoking prevalence was 5.07% (95% CI 3.2% to 7.1%), which is lower than previously reported national prevalence rates. Women reported smoking less than men did (OR=0.56, 95% CI=0.013 to 0.242; p=0.003). The majority of students supported tobacco control measures. The number of people who reported receiving formal training in tobacco cessation counselling ranged from 10.9% (95% CI 5.3% to 19.1%) among nursing students to 51.1% (95% CI 40.4% to 61.7%) among medical students.
Smoking prevalence among this cohort was relatively low. Students were supportive of tobacco control policies. Further research is needed to understand what is working in this context, in order to apply lessons learnt in similar settings. In the meantime, health professional students should be provided health education to discourage tobacco use. Information on tobacco control policies needs to be more widely disseminated.
PMCID: PMC3758981  PMID: 23996817
4.  Adherence to Antiretroviral Therapy (ART) among People Living With HIV (PLHIV): a cross-sectional survey to measure in Lao PDR 
BMC Public Health  2013;13:617.
Since 2001, antiretroviral therapy (ART) for people living with HIV (PLHIV) has been available in the Lao People’s Democratic Republic (PDR). A key factor in the effectiveness of ART is good adherence to the prescribed regimen for both individual well-being and public health. Poor adherence can contribute to the emergence of drug resistant strains of the virus and transmission during risky behaviors. Increased access to ART in low-income country settings has contributed to an interest in treatment adherence in resource–poor contexts. This study aims to investigate the proportion of adherence to ART and identify possible factors related to non-adherence to ART among people living with HIV (PLHIV) in Lao PDR.
A cross-sectional study was conducted with adults living with HIV receiving free ART at Setthathirath hospital in the capital Vientiane and Savannakhet provincial hospitals from June to November 2011. Three hundred and forty six PLHIV were interviewed using an anonymous questionnaire. The estimation of the adherence rate was based on the information provided by the PLHIV about the intake of medicine during the previous three days. The statistical software Epidata 3.1 and Stata 10.1 were used for data analysis. Frequencies and distribution of each variable were calculated by conventional statistical methods. The chi square test, Mann–Whitney test and logistic regression were used for bivariate analyses. Multiple logistic regression analysis was conducted to determine the predictors of non-adherence to ART. A p-value < 0.05 was considered to indicate statistical significance.
Of a total of 346 patients, 60% reported more than 95% adherence to ART. Reasons for not taking medicine as required were being busy (97.0%), and being forgetful (62.2%). In the multivariate analysis, educational level at secondary school (OR=3.7, 95% CI:1.3-10.1, p=0.012); illicit drug use (OR=16.1, 95% CI:1.9-128.3, p=0.011); dislike exercise (OR=0.6, 95% CI:0.4-0.9, p=0.028), and forgetting to take ARV medicine during the last month (OR=2.3, 95% CI:1.4-3.7, p=0.001) were independently associated with non-adherence.
Non-adherence to ART was associated with individual factors and exposure to ART. Priority measures to increase adherence to ART should aim to intensify counseling and comprehensive interventions, such as guidance for PLHIV on medication self-management skills, tailoring the regimen to the PLHIV life style, and improving adherence monitoring and health care services.
PMCID: PMC3707741  PMID: 23809431
Antiretroviral therapy; Adherence; PLWHIV; Self-report; Lao PDR
5.  Respiratory illness healthcare-seeking behavior assessment in the Lao People’s Democratic Republic (Laos) 
BMC Public Health  2013;13:444.
Respiratory illness (RI) remains a public health problem in Laos, but little is known about the overall burden and people’s healthcare-seeking behavior for RI. Understanding the burden of RI and community patterns of healthcare-seeking behavior would provide better guidance for Lao public health program and policy planners to improve RI public health practice, surveillance systems, and prevention strategies.
A quantitative and qualitative survey was conducted in 14 randomly selected villages of two purposively selected peri-urban and two rural provinces in Laos. A pre-designed and pre-tested questionnaire was used to collect information on RI in household members (defined as new fever with cough and/or sore-throat in the absence of other diagnoses during the preceding 30 days) from all heads of household in each village. Sixteen focus group discussions were conducted to obtain more information to support the quantitative survey.
Among 1,751 households (9,114 people) studied, 3.5% (317/9,114) had experienced RI (fever, cough, and/or sore-throat) in the 30 days before the survey [6.2% in rural and 2.4% in peri-urban areas (p<0.001)]. The percentage of RI among persons aged ≥15 years was 2.7%, 3.7% for those aged 5 – 14 years, and 8.2% for children < 5 years (p<0.001). Of all sick persons, 71% sought treatment [94% in peri-urban and 48% in rural areas (p<0.001)] and 31.5% of them self-medicated [55.5% in peri-urban and 29% in rural areas (p<0.001)]. Sick people in peri-urban areas preferred to chose private clinics and pharmacies as their first treatment option while in rural areas they frequently consulted with village health volunteers and visited health centres as their first choice. The qualitative study suggests that distance, costs of care, and service availability are the most important determinants of seeking healthcare.
The RI burden and healthcare-seeking behavior are different between rural and peri-urban areas of Laos and this is probably due to the differences in environmental and hygienic conditions, health service availability and socio-economic status between the two areas. Therefore strategies for healthcare service improvement may also need to differ between the two areas.
PMCID: PMC3689642  PMID: 23642240
Respiratory illness; Healthcare-seeking behaviour; Laos
6.  Awareness and attitudes towards emergency contraceptive pills among young people in the entertainment places, Vientiane City, Lao PDR 
BMC Women's Health  2013;13:14.
Emergency Contraception is not officially available to the public sector in Laos. The potential of emergency contraception to prevent unwanted pregnancies is well documented in developed countries, but in Laos no studies of ECPs exist. This study aimed to assess knowledge of and attitudes towards emergency contraceptive pills (ECPs) in Vientiane, the capital city of the Lao PDR.
A cross-sectional survey was conducted among 500 young adults in entertainment venues by using the convenience sampling between May to July, 2007. Data were obtained through face-to-face interview. Participants were asked about socio- demographic characteristics, knowledge, attitudes related to ECPs, and source of information about ECPs. Data analysis was performed with chi-square test and logistic regression (p < .05).
Only 22.4 percent of respondents had heard of ECPs and of these only 17.9 percent knew the correct time-frame for effective use. Most of the respondents (85%) agreed on the need for ECPs to be available in Laos and 66.8 percent stated that they would use them should the need arise, if they were available. Among those who said they would not use ECPs, 63.8 percent were concerned about possible health effects, or other side effects. Awareness of ECPs was associated with increasing age (OR = 2.78, p = .025) and male sex (OR = 2.91, p = .010).
There is needed to provide effective health education about the method, timing of use, and how to obtain ECPs through both informal, peer channels, and also through formal channels such as health care providers.
PMCID: PMC3606843  PMID: 23514104
7.  Health policymakers’ knowledge and opinions of physicians smoking and tobacco policy control in Lao PDR 
BMC Public Health  2012;12:816.
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.
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.
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.
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.
PMCID: PMC3503788  PMID: 22998748
Health policymaker; Opinion; Smoking; Medical doctor; Low-income country
8.  Reasons rural Laotians choose home deliveries over delivery at health facilities: a qualitative study 
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.
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.
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.
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.
PMCID: PMC3449206  PMID: 22925107
9.  Defining and redefining harm reduction in the Lao context 
The response to drug use in Laos has focused on reducing opium supply (supply reduction) and rates of drug use (demand reduction). However, recently there is increased interest among government counterparts to discuss and develop broader responses to injecting drug use (IDU) including the introduction of harm reduction programs. The concept of harm reduction has just been introduced to Lao PDR and as yet there is no agreement on a definition of the concept. We highlight here a range of issues that remain controversial in Lao PDR in the HIV, drug use and harm reduction discourse, the definition of 'harm reduction' and related terms; and the scope of harm reduction.
This was a qualitative study, consisting of in-depth interviews with 27 law enforcement and 8 health officers who work in the fields of HIV and/or drug control about their understanding of HIV related to drug use, and concepts of harm reduction. Content analysis was performed to identify the coding, categories and themes.
We found that law enforcement officers in particular had limited understanding about harm reduction and the feasibility and appropriateness of harm reduction services in the Lao context.
Harm reduction should be a core element of a public health response to HIV where drug use and IDU exists. Recommendations include the necessity of increasing the awareness of harm reduction among law enforcement officers and providing appropriate evidence to support the needs of harm reduction policy and programs. HIV prevention and treatment strategies should be integrated within existing social and cultural frameworks, working with the task force for HIV/IDU and other government counterparts.
PMCID: PMC3404925  PMID: 22769736
10.  Smoking among Lao medical doctors: challenges and opportunities for tobacco control 
Tobacco Control  2010;20(2):144-150.
Smoking is an increasing threat to health in low-income and middle-income countries and doctors are recognised as important role models in anti-smoking campaigns.
The study aimed to identify the smoking prevalence of medical doctors in Laos, their tobacco-related knowledge and attitudes, and their involvement in and capacity for tobacco prevention and control efforts.
This was a cross-sectional national survey by a researcher-administered, face-to-face questionnaire implemented at provincial health facilities throughout the central (including national capital), northern and southern regions of Laos in 2007. Both descriptive and inferential statistics were used.
Of the 855 participants surveyed, 9.2% were current smokers and 18.4% were ex-smokers; smoking was least common in the central region (p<0.05) and far more prevalent in males (17.3% vs 0.4%; p<0.001). Smoking was concentrated among older doctors (p <0.001). Over 84% of current smokers wanted to quit, and 74.7% had made a recent serious attempt to do so. Doctors had excellent knowledge and positive attitudes to tobacco control, although smokers were relatively less knowledgeable and positive on some items. While 78% of doctors were engaged in cessation support, just 24% had been trained to do so, and a mere 8.8% considered themselves ‘well prepared’.
The willingness of doctors to take up their tobacco control role and the lower smoking rates among younger respondents offers an important window of opportunity to consolidate their knowledge, attitudes, skills and enthusiasm as cessation advocates and supports.
PMCID: PMC3045523  PMID: 21106548
Medical doctors; smoking; Lao PDR; tobacco control; prevalence; knowledge; determinants; advocacy; cessation; prevalence
11.  Policy maker and provider knowledge and attitudes regarding the provision of emergency contraceptive pills within Lao PDR 
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.
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.
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.
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.
PMCID: PMC2914037  PMID: 20642863
12.  Smoking prevalence, determinants, knowledge, attitudes and habits among Buddhist monks in Lao PDR 
BMC Research Notes  2009;2:100.
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.
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.
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.
PMCID: PMC2704224  PMID: 19505329

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