A Predictive Model for Thiamine Responsive Disorders Among Infants and Young Children: Results from a Prospective Cohort Study in Lao People's Democratic Republic.

OBJECTIVE: To develop a predictive model for thiamine responsive disorders (TRDs) among infants and young children hospitalized with signs or symptoms suggestive of thiamine deficiency disorders (TDDs) based on response to therapeutic thiamine in a high-risk setting. STUDY DESIGN: Children aged 21 days to <18 months hospitalized with signs or symptoms suggestive of TDD in northern Lao People's Democratic Republic were treated with parenteral thiamine (100 mg daily) for ≥3 days in addition to routine care. Physical examinations and recovery assessments were conducted frequently for 72 hours after thiamine was initiated. Individual case reports were independently reviewed by three pediatricians who assigned a TRD status (TRD or non-TRD), which served as the dependent variable in logistic regression models to identify predictors of TRD. Model performance was quantified by empirical area under the receiver operating characteristic curve. RESULTS: A total of 449 children (median [Q1, Q3] 2.9 [1.7, 5.7] months old; 70.3% exclusively/predominantly breastfed) were enrolled; 60.8% had a TRD. Among 52 candidate variables, those most predictive of TRD were exclusive/predominant breastfeeding, hoarse voice/loss of voice, cyanosis, no eye contact, and no diarrhea in the previous 2 weeks. The area under the receiver operating characteristic curve (95% CI) was 0.82 (0.78, 0.86). CONCLUSIONS: In this study, the majority of children with signs or symptoms of TDD responded favorably to thiamine. While five specific features were predictive of TRD, the high prevalence of TRD suggests that thiamine should be administered to all infants and children presenting with any signs or symptoms consistent with TDD in similar high-risk settings. The usefulness of the predictive model in other contexts warrants further exploration and refinement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03626337.

Health system inequities in Lao People's Democratic Republic: Evidence from a nationally representative phone survey.

BACKGROUND: Despite substantial economic growth in Lao People's Democratic Republic (PDR) over the past 20 years, high levels of income inequality and poverty persist and have likely been exacerbated by the COVID-19 pandemic. In this article, we use novel survey data to assess the extent to which socioeconomic status is associated with access to quality care in Lao PDR. METHODS: We utilised data from the Lao People's Voice Survey (PVS), which was designed to measure health system performance from the perspective of the population. The survey was conducted between May and August 2022. Primary outcomes of interest were having a usual source of healthcare, using a government health centre (rather than a hospital or private clinic) as the usual source for care, receiving preventive health services, experiencing unmet healthcare needs, the quality of recent healthcare visit, and confidence in accessing and affording healthcare when needed. Poverty was measured using household asset ownership. We used logit models to assess the associations between poverty and health system performance measures, and additionally assessed differences between these associations in urban vs. rural areas by interacting urban residence with poverty. RESULTS: Poverty was negatively associated with having a regular provider for care (adjusted odds ratio (aOR) 0.45, 95% CI 0.26-0.78), receiving preventive health services (aOR 0.54, 95% CI 0.37-0.80), and confidence in the ability to receive care (aOR 0.50, 95% CI 0.34-0.72) and afford care (aOR 0.50, 95% CI 0.34-0.73) when needed. Poverty was positively associated with using government managed health centres as a usual source or for care (aOR 2.16, 95% CI 1.35-3.48). Poverty was not significantly associated with user experience or perceived quality of care in the last visit to the health facility. No differences in the associations between poverty and access to quality care were found between rural and urban settings. CONCLUSIONS: The results presented in this article suggest socioeconomic disparities in health care access in Lao PDR despite major national efforts to provide universal access to care. Universal health care policies may not be reaching the poor and additional targeted efforts may be needed to meet their healthcare needs.

Transition to a market economy and chronic psychosocial stress in northern Laos: An exploratory study of urinary free cortisol in rural residents.

OBJECTIVES: The indigenous population in northern Laos has experienced a transition from self-sufficiency to a market-oriented economy, which may have brought about unprecedented chronic psychosocial stress. This study examined the association between the transition to a market economy and urinary free cortisol (UFC) concentration as a stress biomarker among rural residents of three villages with different degrees of integration into the market economy. METHODS: An interview survey and urine sample collection were conducted in August 2018 and March 2019. We measured the UFC concentration in spot urine samples collected in the morning from participants aged 20-60 years (n = 168) using an enzyme-linked immunosorbent assay. Multiple linear regression analysis was performed to examine differences in UFC concentrations among villages by sex, with time of arrival for the survey, age, and body mass index included as covariates. RESULTS: The UFC concentration was higher in men living in the village with the highest degree of integration into the market economy than in those in the two villages with a lower dependence on cash, possibly linking increased stress levels with a change in employment type. This trend was not observed in women. CONCLUSION: Socioeconomic changes incidental to a transition to a market economy may increase the stress levels of men in northern Laos.

Health system utilization and perceived quality among adults in Lao PDR: evidence from a nationally representative phone survey.

BACKGROUND: The World Health Organization (WHO) defines quality health services as being effective, safe, people-centered, timely, equitable, integrated and efficient. It is critical to understand people's perspectives and care experiences to measure progress against these goals. However, many low- and middle-income governments do not routinely collect such information. In this study, we aim to measure health systems performance from the perspective of the adult population of users and non-users in Lao PDR. METHODS: Using the People's Voice Survey (PVS), a novel phone-based survey designed to integrate people's voices into primary care performance measurement, we conducted a cross-sectional survey of the general adult (18+) population in Lao PDR in 2022. We analyzed health care utilization patterns, user-reported quality of care, and coverage of key preventive health services. Data from the most recent MICS survey was used to create sampling weights generating nationally representative estimates. RESULTS: A total of 2007 adults completed interviews in approximately 3.5 months. About two thirds (65%) of respondents reported visiting a health facility in the past year and, of these, the majority (61%) visited a hospital as opposed to a health center or clinic. Among those that recently visited health facilities, 28% rated their experience as "poor" or "fair". 16% had unmet need for care and 12% reported discrimination during treatment in the past year. 12% of women over 50 years old reported receiving a mammogram and 59% of adults reported receiving blood pressure screening in the previous year. CONCLUSIONS: The study presents data from the first nationally representative survey in Lao PDR to measure health system performance. The results indicate that, despite progress towards universal coverage of health insurance in Lao PDR, significant gaps remain, particularly with respect to bypassing of primary care facilities, significant unmet need for care, experiences of discrimination, and overall low perceptions of quality of care.

The state of decentralization of the healthcare system and nutrition programs in the Lao People's Democratic Republic: an organizational study.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle income country, has a higher malnutrition rate than other Southeast Asian countries. The decentralization of healthcare is a determinant of the effectiveness of programs to reduce malnutrition, but no study has focused on this factor in this country. This organizational study explores the state of decentralization of the healthcare system in Lao PDR that underlies the nutrition programs in the country. METHODS: A qualitative study, which is based on a neo-institutional theory conceptual framework, explored factors related to dominant structure (laws, regulations, resources) and interpretative schemes (dominant ideas and beliefs) that characterize the nutrition services provided in the Lao healthcare system. Twenty-four semistructured interviews were performed with representatives of healthcare institutions involved in nutrition programs at different government levels, external donors and civil society organizations. The interviews were completed with relevant documents. The analysis focused on the convergence of interpretative schemes of the organizations concerned and the coherence between the structure underpinning the nutrition programs and the interpretative schemes. RESULTS: Services deployed to reduce malnutrition in the Lao PDR remain largely centralized, despite factors specific to the country that led it to promote decentralization of its services. The convergence of interpretive schemes and the coherence between the observed structure and the interpretative schemes of actors at all governance levels ensure the stability of this state of decentralization, which has persisted for almost 50 years. CONCLUSION: Nutrition programs in the Laos PDR are largely under the responsibility of the central government. The transformations in the healthcare system, notably with the use of new information technologies and the fact that the provinces are populated by a growing number of professionals trained in nutrition in addition to factors that push the system to be decentralized, such as ethnic diversity, the increasing availability of human resources in provinces, and the use of communication technologies, are not strong enough to change the balance of power between governance levels. The deconcentration that characterizes decentralization is therefore likely to continue for the foreseeable future.

Prospects for the development of community-based care in remote rural areas: a stakeholder analysis in Laos.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Risk factors for anaemia among women and their young children hospitalised with suspected thiamine deficiency in northern Lao PDR.

Anaemia among women and young children remains a major public health concern. This secondary study describes the anaemia prevalence among young hospitalised children and their mothers in northern Lao People's Democratic Republic and explores possible nutritional causes and risk factors for anaemia. Hospitalised children (ages 21 days to <18 months) with clinical symptoms suggestive of thiamine deficiency disorders were eligible along with their mothers. Venous blood was collected for determination of haemoglobin, ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), erythrocyte glutathione reductase activation coefficient (EGRac), thiamine diphosphate (ThDP) and acute phase proteins. Risk factors for anaemia were modelled using minimally adjusted logistic regression controlling for age. Haemoglobin results were available for 436 women (mean ± SD age 24.7 ± 6.4 years; 1.6% pregnant) and 427 children (4.3 ± 3.5 months; 60.3% male). Anaemia prevalence (Hb < 120 g/L for nonpregnant women and <110 g/L for pregnant women and children) was 30.7% among women and 55.2% among children. In bivariate analyses, biomarkers significantly associated with anaemia in women were ferritin, sTfR, RBP, EGRac and ThDP. Other risk factors for women were lower BMI, mid-upper arm circumference < 23.5 cm, lower education, lower socioeconomic index, food insecurity, Hmong ethnicity, not/rarely having attended antenatal care, not having taken antenatal iron-containing supplements and not meeting minimum dietary diversity. Risk factors for anaemia among children were older age, male sex, stunting, sTfR, ThDP and alpha-1-acid-glycoprotein. Anaemia was common among women and their hospitalised children and was associated with micronutrient deficiencies and socioeconomic, dietary and health care-seeking risk factors, suggesting that multiple strategies are required to prevent anaemia among women and children.

Financial burden and health-seeking behaviors related to chronic diseases under the National Health Insurance Scheme in Bolikhamxay Province, Lao PDR: a cross-sectional study.

BACKGROUND: Chronic diseases pose a serious threat to health and longevity worldwide. As chronic diseases require long periods of treatment and may become serious conditions, the ensuing financial burden is often worse than that for non-chronic diseases. In 2016, the Lao PDR implemented the National Health Insurance (NHI) system, which covers select provinces. However, data on health service accessibility and the financial burden on households, especially those with chronically ill members covered by the NHI, are scarce. METHODS: This study used a cross-sectional design. Data collection was conducted in Bolikhamxay province (population = 273,691), from January 15 to February 13, 2019. In total, 487 households, selected through stratified random sampling, were surveyed via questionnaire-based interviews. Healthcare service usage and financial burden were examined. RESULTS: A total of 370 households had at least one member with self-reported health issues within the last 3 months prior to the interview, while 170 had at least one member with a chronic condition. More than 75% of the households accessed a health facility when a member experienced health problems. The majority of households (43.2%) spent the maximum value covered by the NHI, but households in the second largest group (21.4%) spent 10 times the maximum value covered by the NHI. The prevalence of catastrophic health expenditure (i.e., health-related expenditure equivalent to > 20% of total income) was 25.9% (20% threshold) and 16.2% (40% threshold). Through logistic regression, we found that the major factors determining financial catastrophes owing to health problems were household members with chronic illness, hospitalization, household poverty status, household size (for both the 20 and 40% thresholds), visiting a private facility (20% threshold), and distance from the province to the referral hospital (40% threshold). CONCLUSIONS: The NHI system has had a positive effect on households' access to health facilities. However, catastrophic health expenditure remains high, especially among chronically ill patients. Facilities under the NHI system should be improved to provide more services, including care for chronic conditions.

Daily supplementation of a multiple micronutrient powder improves folate but not thiamine, riboflavin, or vitamin B12 status among young Laotian children: a randomized controlled trial.

PURPOSE: To assess the effects of intervention with a daily multiple micronutrient powder (MNP) on thiamine, riboflavin, folate, and B12 status among young Laotian children. METHODS: Children (n = 1704) aged 6-23 mo, participating in a double-blind placebo-controlled randomized trial were individually randomized to receive daily either MNP (containing 0.5 mg of thiamine, 0.5 mg riboflavin, 150 µg folic acid, and 0.9 µg vitamin B12 along with 11 other micronutrients) or placebo and followed for ~ 36 weeks. In a randomly selected sub-sample of 260 children, erythrocyte thiamine diphosphate (eThDP), plasma folate and B12 concentrations, and erythrocyte glutathione reductase activation coefficient (EGRac; riboflavin biomarker) were assessed at baseline and endline. RESULTS: There was no treatment effect on endline eThDP concentrations (110.6 ± 8.9 nmol/L in MNP vs. 109.4 ± 8.9 nmol/L in placebo group; p = 0.924), EGRac (1.46 ± 0.3 vs. 1.49 ± 0.3; p = 0.184) and B12 concentrations (523.3 ± 24.6 pmol/L vs. 515.9 ± 24.8 pmol/L; p = 0.678). Likewise, the prevalence of thiamine, riboflavin, and B12 deficiencies did not differ significantly between the two groups. However, endline folate concentration was significantly higher in the MNP compared to the placebo group (28.2 ± 0.8 nmol/L vs 19.9 ± 0.8 nmol/L, respectively; p < 0.001), and correspondingly, the prevalence of folate deficiency was significantly lower in the MNP group (1.6% vs 17.4%; p = 0.015). CONCLUSIONS: Compared to a placebo, daily MNP for 9 months increased only folate but not thiamine, riboflavin, or B12 status in young Laotian children. TRIAL REGISTRATION: The trial was registered at www. CLINICALTRIALS: gov (NCT02428647) on April 29 2015.

Antibiotic knowledge, attitudes and reported practice during pregnancy and six months after birth: a follow- up study in Lao PDR.

BACKGROUND: Antibiotics are important medicines to prevent maternal and child morbidity and mortality. Women's knowledge and attitudes towards antibiotic use influence their practice. When they become mothers, this may be mirrored in the use of antibiotics for their newborn children. The current study aimed to assess knowledge, attitudes, and reported practice of pregnant women regarding antibiotic use and antibiotic resistance as well as their approach towards antibiotic use for their newborn babies. METHODS: This was a follow-up study with data collected via structured interviews between September 2019 and August 2020 in Feuang (rural) and Vangvieng (urban) districts in Vientiane province, Lao PDR. We identified and invited all women attending antenatal care in their third trimester of pregnancy in the selected areas. Using a structured questionnaire at third trimester of pregnancy we captured data on knowledge regarding antibiotic use and resistance. We collected information on attitudes and reported practice at two time points: (i) at third trimester of pregnancy and (ii) 6 months after birth. Univariate analysis and frequency distributions were used to study pattern of responses. Chi-square and Mann-Whitney tests were used to compare categorical and continuous variables respectively. P value < 0.05 was considered statistically significant. RESULTS: We surveyed 539 women with a mean age of 25 years. Two oral antibiotics, i) ampicillin and ii) amoxicillin were correctly identified by 68 and 47% of participants respectively. Only 24% of women (19% in Feuang and 29% in Vangvieng) answered correctly that antibiotics are effective against bacterial infections. The most prevalent response was "I don't know" suggesting the questions were challenging. Significantly less women would use antibiotics from a previous illness for their child than for themselves (16% vs 29%), however they would be more willing to use antibiotics for their baby even in case of mild symptoms (29% vs 17% while pregnant). The majority of antibiotics were prescribed by healthcare providers and 46% of children with the common cold received antibiotics. CONCLUSIONS: Women's knowledge was sub-optimal, still, they manifested appropriate attitudes towards antibiotic use during pregnancy and for their child. Nearly half of children received antibiotics for the common cold. There is a need for context adapted programs aiming at improving women's knowledge, as well as healthcare providers, emphasising rational antibiotic prescribing during pregnancy and for children.

Perceptions and reported practices of pregnant women and mothers of children under two years of age regarding antibiotic use and resistance in Vientiane province, Lao PDR: a qualitative study.

BACKGROUND: Understanding pregnant women and mothers' perceptions towards antibiotic use and resistance is essential for appropriate antibiotic use and limiting antibiotic resistance. This study aimed to explore perceptions and reported practices of pregnant women and mothers with children under two years of age regarding correct antibiotic use and antibiotic resistance in Vientiane Province, Lao PDR. METHODS: The study employed an exploratory qualitative research design using focus groups discussions (FGDs). Participants were purposively selected based on: being pregnant at third trimester and attending antenatal care and mothers with children under two years of age, attending the health facility for postpartum visit /vaccinations. Six focus group discussions were conducted in September 2019 with a total of 55 women. The FGDs were transcribed verbatim, data were analyzed first by coding then categorizing the data as we looked for patterns and themes by using the qualitative content analysis. RESULTS: Most participants had some understanding of antibiotics but wrongly believed antibiotics can be used to treat viral disease. Over half of the participants had heard the term "antibiotic resistance", but often believed it was their bodies, not the bacteria that developed antibiotic resistance. During pregnancy and for their infants, women preferred to use antibiotics only when prescribed by a doctor. Outside of pregnancy however, consuming antibiotics without a prescription was commonly reported. Participants wanted more information about the indications for antibiotic use and antibiotic resistance. CONCLUSIONS: More effort is required to increase the level of understanding, and practice of mothers to promote optimal antibiotic use. Mothers' desire to learn more, and their fundamental concern for their children, can be used to promote appropriate antibiotic use. Awareness raising should be complemented by efforts to address other determinants of inappropriate antibiotic use, including educating healthcare workers, and pharmacists and addressing health service determinants that contribute to inappropriate antibiotic use.

Impact of modernization on urinary concentrations of arsenic, cadmium, lead, and selenium in rural residents of Northern Laos.

OBJECTIVES: The impacts of modernization on toxic heavy metal exposure and essential trace element intake in indigenous populations of subsistence societies are unknown. We assessed urinary trace element concentrations in rural residents of Northern Laos and examined associations with levels of modernization. METHODS: A cross-sectional study was conducted comprising 380 residents of three villages in Northern Laos with different levels of modernization. We surveyed general characteristics and measured the weight and height of 341 participants. Arsenic, cadmium, lead, and selenium concentrations were measured in spot urine samples by inductively coupled plasma mass spectrometry. We examined associations between urinary trace element concentrations and variables related to modernization (village, roofing material, possessions index [total number of possessions], and body mass index [BMI]) using multilevel analyses with household as a random effect, after adjusting for sex, age, and smoking status. RESULTS: Urinary concentrations of arsenic and cadmium were high, while those of lead and selenium were low in comparison to previous reports of populations in non-contaminated regions or without excess/deficiency. We observed associations between urinary trace element concentrations and village-level modernization: lead and selenium concentrations were higher in more modernized villages and cadmium concentration was highest in the least modernized village. Urinary arsenic concentration was not predicted by the modernization level of a village, although we observed significant differences among villages. In addition, urinary selenium concentration was higher in participants inhabiting more modernized houses. CONCLUSION: Modernization of villages may impact toxic heavy metal exposure and selenium intake in rural residents of Northern Laos.

How do the determinants of exclusive breast-feeding change over time? A multi-survey quasi-longitudinal study in Lao People's Democratic Republic.

OBJECTIVE: The current study aimed to assess trends, associated factors and the changes in these factors for exclusive breast-feeding (EBF) over the past two decades in Lao People's Democratic Republic (Lao PDR). DESIGN: The current study used a quasi-longitudinal design. Descriptive analyses were done with correction for complex survey design. Inferential analyses were done for survey years separately using multiple logistic regression. Finally, pooled logistic regression analysis was done using interaction terms to quantify the difference in association per year. SETTING: The current study used data from all provinces of Lao PDR collected in the years 2000, 2006, 2011/2012 and 2017. PARTICIPANTS: Children aged six months or younger from Lao PDR. RESULTS: EBF practice was estimated at 19·03 %, 26·87 %, 40·67 % and 44·89 % in the four survey years, respectively. Factors significantly associated with EBF included: region of residence, ethnicity, wealth index and age of child. Region and ethnicity saw significant changes in association, and the South developing positively over time as well as in the Lao-Thai ethnic group. Having had any antenatal visits was not associated with EBF practice, nor did this change over time. CONCLUSIONS: Our study shows how EBF trends, and factors associated with EBF, changed over time. We applied an easily replicable methodology to assess similar public health phenomena. We argue that such analysis is particularly relevant for transitioning countries. In such rapidly evolving settings, it is crucial to take into account changing underlying factors when assessing and developing public health policy.

Assessment of cognitive function among adults aged ≥ 60 years using the Revised Hasegawa Dementia Scale: cross-sectional study, Lao People's Democratic Republic.

BACKGROUND: Rapid population ageing remains an important concern for health, social and economics systems; thus, a broader assessment of cognitive decline among adults aged ≥ 60 years is essential. It is important to regularly collect reliable data through validated and affordable methods from people living in different areas and in different circumstances to better understand the significance of this health problem. This study aimed to identify the prevalence of cognitive impairment and the related risk factors by reassessing the scoring of the Revised Hasegawa Dementia Scale among older adults in the Lao People's Democratic Republic. METHODS: A community-based cross-sectional investigation was conducted in rural and urban settings in six districts of three provinces in the country from January to July 2020. In total, 2206 individuals aged 60-98 years (1110 men and 1096 women) were interviewed in person using a pretested Lao version of the Revised Hasegawa Dementia Scale and the WHO STEPwise approach to noncommunicable disease (NCD) risk factor surveillance (the STEPS survey tool). The adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were estimated using a logistic model. RESULTS: The study found that 49.3% (1088/2206) of respondents (39.7% [441/1110] of men and 59.0% [647/1096] of women) had scores associated with some level of cognitive impairment. In addition to age, the following factors were significantly associated with cognitive impairment: having no formal education (AOR = 9.5; 95% CI: 5.4 to 16.8, relative to those with a university education), living in the northern region of the country (AOR = 1.4; 95% CI: 1.1 to 1.9, relative to living in the central region), living in a rural area (AOR = 1.5; 95% CI: 1.2 to 1.8), needing assistance with self-care (AOR = 1.8; 95% CI: 1.2 to 2.7) and being underweight (AOR = 1.5; 95% CI: 1.1 to 2.2). Factors associated with no cognitive impairment among older adults include engaging in moderate-intensity physical activity lasting for 10 minutes and up to 1 hour (AOR = 0.6; 95% CI: 0.5 to 0.8) and for > 1 hour (AOR = 0.6; 95% CI: 0.4 to 0.8). CONCLUSIONS: Using the Lao version of the Revised Hasegawa Dementia Scale, this study found that more than half of adults aged ≥ 60 years had cognitive impairment, and this impairment was associated with several risk factors. The limitations of this study may include possible overdetection due to the cutoff point for the assessment of cognitive decline used in the Revised Hasegawa Dementia Scale, given that the participants were not familiar with the instrument. However, the study results can be used to help inform health policy in the Lao People's Democratic Republic regarding the urgent need for a routine data collection system and for providing an environment that addresses and reduces the identified risk factors for cognitive decline to mitigate their impact.

Traditional prenatal and postpartum food restrictions among women in northern Lao PDR.

Culturally determined food restrictions are common among pregnant and postpartum women in Asia. This study aimed to describe perinatal dietary restrictions, factors associated with food avoidances and attainment of minimum dietary diversity (MDD-W) among women in Lao PDR. Mother-child (aged 21 days to <18 months) dyads (n = 682) were enrolled into a cohort study in northern Lao PDR and interviewed at one time point postpartum. During pregnancy and postpartum, 1.6% and 97% of women reported following dietary restrictions, respectively. Cluster analysis identified four distinct postpartum dietary patterns: most restrictive (throughout first 2 months postpartum); least restrictive; 2 weeks highly restrictive and 1 month highly restrictive, followed by 19%, 15%, 5% and 62% of women, respectively. Greater maternal age, gravidity and higher household socioeconomic status were associated with allowing more diverse foods, while women from food insecure households followed more restrictive diets for longer. Women belonging to the Hmong ethnic group followed a highly restrictive diet of white rice and chicken for the first month postpartum. MDD-W was achieved by 10% of women restricting their diet at the time of the interview compared with 17% of women who were consuming their normal diet (p = 0.04). Postpartum dietary restrictions are widespread among women in northern Lao PDR. These highly restrictive diets, low dietary diversity and food insecurity likely contribute to micronutrient deficiencies in women that may have important consequences for their breastfed infants through reduced breastmilk micronutrient content, which requires further exploration. Culturally appropriate strategies to increase micronutrient intakes among women should be considered.

Hepatitis B virus in Lao dentists: A cross-sectional serological study.

INTRODUCTION AND OBJECTIVES: Hepatitis B virus (HBV) is endemic in Lao PDR, with up to 10% chronic infections in adults. Dentists have high risk of exposure and transmission to their patients. The aim was to investigate the serological profiles of vaccination, exposure and susceptibility to HBV. In addition, we determined the knowledge, attitude and practice (KAP) of Lao dentists toward HBV. MATERIALS AND METHODS: Dentists and dental assistants were recruited from 186 private dental clinics in Vientiane Capital. They completed a KAP questionnaire and serum was tested by ELISA for HBV markers (anti-HB surface antigen, anti-core antigen, HBV surface antigen). RESULTS: 206 dentists and 111 dental workers aged between 18-63 years were included. Serology data showed that 37.8% had previous exposure (49.0% of males and 32.4% of females) and 5.0% were chronically infected (7.7% of males and 3.8% of females). Less than 15% had serological evidence of vaccination and 66.8% were unprotected against infection. Knowledge of HBV was mostly low, for example 61.8% were aware of the childhood HBV vaccine. Just over half said that they should give dental care to HBV carriers. About one quarter reported accidental blood exposure during the last 6 months but knowledge about procedures after exposure was low. CONCLUSIONS: Lao dentists are at high risk of occupational exposure to HBV but have low awareness and serological protection. There is a need to introduce mandatory vaccination, to strengthen occupational health in health care providers and to further develop the academic curricula of dental students.

Daily Preventive Zinc Supplementation Decreases Lymphocyte and Eosinophil Concentrations in Rural Laotian Children from Communities with a High Prevalence of Zinc Deficiency: Results of a Randomized Controlled Trial.

BACKGROUND: Zinc deficiency impairs immune function and is common among children in South-East Asia. OBJECTIVES: The effect of zinc supplementation on immune function in young Laotian children was investigated. METHODS: Children (n = 512) aged 6-23 mo received daily preventive zinc tablets (PZ; 7 mg Zn/d), daily multiple micronutrient powder (MNP; 10 mg Zn/d, 6 mg Fe/d, plus 13 other micronutrients), therapeutic dispersible zinc tablets only in association with diarrhea episodes (TZ; 20 mg Zn/d for 10 d after an episode), or daily placebo powder (control). These interventions continued for 9 mo. Cytokine production from whole blood cultures, the concentrations of T-cell populations, and a complete blood count with differential leukocyte count were measured at baseline and endline. Endline means were compared via ANCOVA, controlling for the baseline value of the outcome, child age and sex, district, month of enrollment, and baseline zinc status (below, or above or equal to, the median plasma zinc concentration). RESULTS: T-cell cytokines (IL-2, IFN-γ, IL-13, IL-17), LPS-stimulated cytokines (IL-1ß, IL-6, TNF-α, and IL-10), and T-cell concentrations at endline did not differ between intervention groups, nor was there an interaction with baseline zinc status. However, mean ± SE endline lymphocyte concentrations were significantly lower in the PZ than in the control group (5018 ± 158 compared with 5640 ± 160 cells/µL, P = 0.032). Interactions with baseline zinc status were seen for eosinophils (Pixn = 0.0036), basophils (Pixn = 0.023), and monocytes (P = 0.086) but a significant subgroup difference was seen only for eosinophils, where concentrations were significantly lower in the PZ than in the control group among children with baseline plasma zinc concentrations below the overall median (524 ± 44 compared with 600 ± 41 cells/µL, P = 0.012). CONCLUSIONS: Zinc supplementation of rural Laotian children had no effect on cytokines or T-cell concentrations, although zinc supplementation affected lymphocyte and eosinophil concentrations. These cell subsets may be useful as indicators of response to zinc supplementation.This trial was registered at clinicaltrials.gov as NCT02428647.

Are dietary intake and nutritional status influenced by gender? The pattern of dietary intake in Lao PDR: a developing country.

BACKGROUND: Recognition of discrepancies between men and women in nutritional intake is important to tackle food and nutrition insecurity and the often-double burden of malnutrition. The purpose of this study was to assess nutritional status and dietary intake of the Lao population, with a focus on possible influences of gender. METHODS: Dietary intake was assessed in a national cross-sectional study of 1771 randomized participants aged from 1.01 to 89 years, using 24-h dietary recall. Dietary reference intakes were used to assess nutrient insufficiency. Chi-square test was used to evaluate gender differences and multiple univariate logistic regression to examine associations between gender, nutritional status, demographics and nutrient insufficiency. RESULTS: Nutrient insufficiencies were higher among pregnant and lactating women than other adult men and women, especially for protein and micronutrients such as vitamin B3, B1, C and other vitamins. Dietary intake and BMI were similar between men and women; all had insufficient intake of all types of nutrients, except sodium. However, women had lower intake than men for almost all nutrients and age groups. The prevalence of overnutrition was higher among those aged 18 years and over for both sexes. Among adult women (15-49.9 years old) and older adult women (50 years old or above), the proportions were: underweight 8.6% (both groups), overweight 18.4 and 20.5%, and obese 34.2 and 39.1%, respectively. Among pregnant and lactating women, the rates of underweight were 7.5 and 1.4%, of overweight were 17.8 and 27.1%, and obese, 21.9 and 40.0%. Among adult and older men, 3.2 and 8.3% were underweight; 21.0 and 18.6% were overweight and 28.2 and 27.6% were obese. Multiple univariate logistic regressions revealed that the factors rural area, dry season and Northern-Lowland region were associated with inadequate micronutrient intake among children, adolescents and adults of both genders. CONCLUSIONS: Dietary intakes were alarmingly micronutrient-insufficient. Macronutrient imbalance and double burden of malnutrition were confirmed in both sexes. Gender differences were limited; men and women had similarly insufficient intakes, but pregnant and lactating women were disproportionately affected. Nutritional interventions should also take men and older people into account to solve nutrition problems.

The prevalence of underweight and overweight/obesity and its correlates among adults in Laos: a cross-sectional national population-based survey, 2013.

PURPOSE: The study aimed to assess the prevalence of underweight and overweight or obesity and their sociodemographic, lifestyle, and health factors in a national adult population in Lao People's Democratic Republic (PDR) (Laos). METHODS: A national cross-sectional study based on a stratified cluster random sampling was conducted in 2013. The total sample included 2531 individuals 18-64 years, (females = 59.3%; mean age 38.7 years, SD = 12.8) from Laos. Questionnaire interview, blood pressure and anthropometric measurements, and biochemistry tests were conducted. Multinomial logistic regression was utilized to determine the association between sociodemographic, lifestyle and health status factors, and underweight and overweight or obesity relative to normal weight. RESULTS: Using Asian criteria for body mass index (BMI) classification, 9.7% of the population was underweight (BMI < 18.5, kg/m2), 47.5% had normal weight (BMI 18.5-22.9 kg/m2), 17.5% overweight (23.0-24.9 kg/m2), 19.6% class I obesity (BMI 25.0-29.9 kg/m2), and 5.6% class II obesity (BMI ≥ 30.0 kg/m2) (or 42.8% overweight, class I or class II obesity). In adjusted multinomial logistic regression, female sex (adjusted relative risk ratio-ARRR 0.67, confidence interval-CI 0.45, 0.99), current tobacco use (ARRR 1.57, CI 1.02, 2.41), and having no hypertension (ARRR 0.50, CI 0.26, 0.97) were associated with underweight, and middle and older age (ARRR 1.79, CI 1.41, 2.25), being Lao-Tai (ARRR 1.37, CI 1.06, 1.76), urban residence (ARRR 1.62, CI 1.20, 2.17), having meals outside home (ARRR 1.36, CI 1.04, 1.77), no current tobacco use (ARRR 0.57, CI 0.34, 0.59), low physical activity (ARRR 1.39, CI 1.01, 1.92), having hypertension (ARRR 2.52, CI 1.94, 3.26), and dyslipidaemia (ARRR 1.56, CI 1.21, 2.00) were associated with overweight or obesity. CONCLUSION: A dual burden of both adult underweight and overweight or obesity was found in Laos. Sociodemographic, lifestyle, and health status risk factors were identified for underweight and overweight or obesity, which can help in guiding public health programmes to address both these conditions. LEVEL OF EVIDENCE: Level V, descriptive cross-sectional survey.

Effects of Daily Zinc, Daily Multiple Micronutrient Powder, or Therapeutic Zinc Supplementation for Diarrhea Prevention on Physical Growth, Anemia, and Micronutrient Status in Rural Laotian Children: A Randomized Controlled Trial.

OBJECTIVES: To evaluate the optimal zinc supplementation strategy for improving growth and hematologic and micronutrient status in young Laotian children. STUDY DESIGN: In total, 3407 children aged 6-23 months were randomized to receive either daily preventive zinc tablets (7 mg/d), high-zinc, low-iron micronutrient powder (10 mg/d zinc, 6 mg/d iron, and 13 other micronutrients), therapeutic zinc supplementation for diarrhea (20 mg/d for 10 days per episode), or daily placebo powder; all were followed for ~9 months. Anthropometry, hemoglobin, zinc, and iron status were assessed at baseline and endline. Analyses were by intention-to-treat, using linear and modified Poisson regression. RESULTS: At baseline, mean (±SD) age was 14.2 ± 5.1 months and stunting and anemia prevalence were 37.9% and 55.6%, respectively. At endline, zinc deficiency in the preventive zinc (50.7%) and micronutrient powder (59.1%) groups were significantly lower than in the therapeutic zinc (79.2%) and control groups (78.6%; P < .001), with no impact on stunting (37.1%-41.3% across the groups, P = .37). The micronutrient powder reduced iron deficiency by 44%-55% compared with other groups (P < .001), with no overall impact on anemia (P = .14). Micronutrient powder tended to reduce anemia by 11%-16% among children who were anemic at baseline (P = .06). CONCLUSIONS: Despite improving zinc status, preventive zinc and micronutrient powder had no impact on growth. The micronutrient powder improved iron status and tended to reduce anemia among the subset of previously anemic children. TRIAL REGISTRATION: ClinicalTrials.govNCT02428647.