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.

Lifestyles, sexuality and gender: vulnerability to STIs and unplanned pregnancy among female migrant beer promoters in Lao PDR.

In Southeast Asia, many young rural female migrants supplement their income by working as beer promoters. This study examined how young, female beer promoters working in Vientiane Capital, Lao PDR, navigate intimate relations and sexual encounters and how their experiences create sexual vulnerabilities. A total of 30 female beer promoters aged 18-24 years old were recruited using snowball sampling. Repeated face-to-face in-depth interviews were undertaken and thematic analysis conducted to identify common themes. Most participants had their first coital experience pre-migration but living in the city introduced them to a larger pool of potential partners. Unprotected sexual intercourse was common, with young women usually deferring to their male partners preference for non-condom use. Working as beer promoters, the sexualised environment of the bar room promoted male ideals of femininity and exposed the young women to sexual harassment. While the young women used various strategies to assert their autonomy, and challenge unequal gender norms, the prevailing male hegemony acted to subvert female sexual agency. Leveraging young urban migrants' desire to complete education, live independently and postpone motherhood may provide opportunities to examine and challenge gender norms and harmful practices.

Current Status of Thalassemia in Lao People's Democratic Republic.

Thalassemia is a major public health and economical burden in Lao People's Democratic Republic (Lao PDR). This study is aiming to elaborate the current situation of Thalassemia in Laos. α- and ß-thalassemia (α- and ß-thal) includes the common Hb S (HBB: c.20A>T) and hemoglobins (Hbs) such as Hb Constant Spring (Hb CS or HBA2: c.427T>C) and Hb E (HBB: c.79G>A) that are prevalent in the country. Overall, the prevalence of α-thal in Lao PDR is 26.8%. There was high prevalence of homozygous (12.8%) and heterozygous (39.7%) Hb E among migrant workers from Lao PDR who crossed the border to work in Thailand. Iron chelation, blood transfusion, prenatal screening and diagnosis, comprehensive treatment are still the major problems. Splenectomy is still performed. A national registry has still not been established. This is a national economic burden for the country. Thalassemia prevention and control strategy should be established and advocated by the government in order to reduce morbidity and premature mortality.

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.

Perceptions and management of postpartum haemorrhage among remote communities in Lao PDR.

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

Impact of the change in WHO's severe pneumonia case definition on hospitalized pneumonia epidemiology: case studies from six countries.

OBJECTIVE: To quantify the impact of the change in definition of severe pneumonia on documented pneumonia burden. METHODS: We reviewed existing data acquired during observational hospitalized pneumonia studies, before the introduction of the pneumococcal conjugate vaccine, in infants aged 2-23 months from Fiji, Gambia, Lao People's Democratic Republic, Malawi, Mongolia and Viet Nam. We used clinical data to calculate the percentage of all-cause pneumonia hospitalizations with severe pneumonia, and with primary end-point consolidation, according to both the 2005 or 2013 World Health Organization (WHO) definitions. Where population data were available, we also calculated the incidence of severe pneumonia hospitalizations according to the different definitions. FINDINGS: At six of the seven sites, the percentages of all-cause pneumonia hospitalizations due to severe pneumonia were significantly less (P < 0.001) according to the 2013 WHO definition compared with the 2005 definition. However, the percentage of severe pneumonia hospitalizations, according to the two definitions of severe pneumonia, with primary end-point consolidation varied little within each site. The annual incidences of severe pneumonia hospitalizations per 100 000 infants were significantly less (all P < 0.001) according to the 2013 definition compared with the 2005 definition, ranging from a difference of -301.0 (95% confidence interval, CI: -405.2 to -196.8) in Fiji to -3242.6 (95% CI: -3695.2 to -2789.9) in the Gambia. CONCLUSION: The revision of WHO's definition of severe pneumonia affects pneumonia epidemiology, and hence the interpretation of any pneumonia intervention impact evaluation.

Prevalence and social and health determinants of pre-diabetes and diabetes among adults in Laos: a cross-sectional national population-based survey, 2013.

OBJECTIVE: Diabetes is a major and fast-growing public health problem in Southeast Asia. We determined the prevalence of pre-diabetes and diabetes and assessed the levels of awareness, treatment and control in Lao People's Democratic Republic (PDR). METHODS: A national cross-sectional study based on a stratified cluster random sampling was conducted in 2013. The sample comprised 2492 individuals aged 18-64 years (59.3% females; mean age 38.7 years, SD = 12.8) from Lao PDR. We followed the WHO STEPS method: step 1, questionnaire interview; step 2, anthropometric and Blood Pressure (BP) measurements; and step 3, biochemistry tests. Multinominal logistic regression was used to investigate the determinants of pre-diabetes and diabetes (fasting plasma glucose levels ≥ 7.0 mmol/L; or using insulin or oral hypoglycaemic drugs; or having a history of diagnosis of diabetes). RESULTS: 5.7% of the population had diabetes, 4.7% of men and 6.4% of women, and 2.3% had pre-diabetes, 1.8% of men and 2.6% of women. Only 14.1% of the population sample indicated that they had ever their blood glucose measured by a health-care worker. This was higher in urban (20.9%) than rural (10.9%) dwellers (P < 0.001), and among female (16.6%) than male (10.5%) participants (P < 0.001). Among those with diabetes, 58.1% were aware of their diabetes status, 40.3% were taking treatment and 10.9% had controlled diabetes. The factor independently associated with impaired fasting glycaemia (IFG) or pre-diabetes was central obesity (Adjusted Relative Risk Ratio-ARRR: 3.92, Confidence Interval-CI: 1.89, 8.14) but none of the other health (general body weight, fruit and vegetable consumption, physical activity, substance use, hypertension and cholesterol) and sociodemographic (age, sex, education, employment status, marital status, ethno-linguistic group and residence status) variables. Factors independently associated with diabetes were older age (ARRR: 5.12, CI: 1.55, 10.20), central obesity (ARRR: 2.15, CI: 1.16, 4.00), low or moderate physical activity (ARRR: 0.75, CI: 0.60, 0.93), having hypertension (ARRR: 1.68, CI: 1.01, 2.83), and dyslipidaemia (ARRR: 1.75, CI: 1.08, 2.81). CONCLUSION: A public health response is needed in the form of integrated and comprehensive action targeting major non-communicable diseases in the country.

The determinants of vaccination in a semi-rural area of Vientiane City, Lao People's Democratic Republic: a qualitative study.

BACKGROUND: Immunisation is a cost-effective and highly efficacious public health intervention, saving over 20 million lives in the last two decades due to decreases in childhood bacterial infections. In the Lao People's Democratic Republic, significant gaps in childhood immunisation coverage rates remain, which are a cause for concern and a barrier to the country reaching its Sustainable Development Goal targets for child health. Efforts to increase coverage have had limited success, with widening inequities being observed between urban and remote and rural areas. METHODS: The objectives of this study were two-fold; firstly, to describe the knowledge, attitudes and practices of mothers regarding their children's immunisation status; and, secondly, to identify individual and health system determinants of access to immunisation in five rural villages within a rural district in Lao People's Democratic Republic. This qualitative research used observation and interviews with healthcare workers (n = 10) and mothers (n = 10) with at least one child aged 12-23 months. RESULTS: The study identified several health system barriers that lower community demand for immunisation. These included the use of multiple providers, inconsistent record keeping and an inadequate health information system. At the individual and household level, there was a lack of understanding of the role of immunisation and the role of the different services provided. CONCLUSIONS: The study suggests that increasing immunisation coverage in Lao People's Democratic Republic requires clearer immunisation pathways, an integrated or unified information recording system across the different levels of the health system, and strategies to increase demand, including increasing individual and household understanding of the role of immunisation in child health.

Determinants of adolescent pregnancy and access to reproductive and sexual health services for married and unmarried adolescents in rural Lao PDR: a qualitative study.

BACKGROUND: Early marriage and pregnancy is a risk factor for poor maternal and child health and socio-economic outcomes. Bokeo and Luang Namtha provinces in northern Lao People's Democratic Republic (PDR) has high rates of teenage pregnancy. The purpose of this research was firstly to explore factors contributing to teenage pregnancy in rural Lao. Secondly, to understand the specific challenges adolescent mothers face in accessing maternal health services. METHODS: Qualitative interviews were undertaken with adolescent mothers and unmarried adolescents aged 12 to 19 years, living in rural areas, and from different ethnic groups. In total, we undertook six focus group discussions with adolescents aged 13-19 years, twenty in-depth interviews with unmarried/married adolescents aged 12-19 years. In addition, we interviewed husbands of the adolescent mothers (N = 8) and mothers-in-law of both male and female adolescents (N = 9), community leaders and healthcare providers (health providers N = 17 and community leaders N = 12). Thematic analysis was used to analyze the data, based on a conceptual framework identified at the outset of the study. RESULTS: The findings suggest that pre-marital sex, early marriage and pregnancy are the norm in these settings. Determinants of teenage pregnancy included liberal attitudes to teen pre-marital sexual intercourse, early marriage and pregnancy, incomplete knowledge of sexual and reproductive health and limited access to appropriate services. CONCLUSION: The determinants of teenage pregnancy in this setting are multi-dimensional, and require a range of responses. As some of the determinants are deeply embedded in the system of local values, beliefs and practices, and form part of the logic of what it is to become a healthy woman, these practices are deeply entrenched and may be resistant to new knowledge. The challenge therefore is to find culturally responsive strategies that enable individual and collectively agency.

Methamphetamine-type stimulant use in Lao PDR: qualitative findings from users aged 15-25 years in Vientiane Capital and Vientiane Province.

BACKGROUND: Methamphetamine is one of the most widely used illicit drugs in several Southeast Asian countries, including the Lao People's Democratic Republic (PDR). The purpose of this study was to examine the socio-cultural context of its use in Lao PDR. METHODS: We conducted a cross-sectional qualitative survey among young people, aged 15-24 years, who use methamphetamine (or Yaba as it is commonly known in the region) in Vientiane Capital and Vientiane Province, Lao PDR. In total, we conducted 21 in-depth interviews (6 female, 13 males and 2 transgender) and 8 focus group discussions with 47 participants (10 female, 29 male and 8 transgender). The data analysis drew on the theory and insights of the social theorist Pierre Bourdieu (1990, 1997) to understand the Yaba consumption practices among young Laotians. RESULTS: Yaba consumption among young people in this study was used to enhance both productivity and pleasure. Its pleasure-producing affects were often linked to core Laotian notions of having fun, partying and being together. Its increased productivity effects on the other hand, were used to pursue goals related to self-betterment within an emerging market economy. CONCLUSIONS: This study highlights the complex interaction between agency and identity, structure, context and practices. In terms of public health policy and programme responses, developing proper interventions implies a good understanding of how young people interpret Yaba consumption, its dynamics and the relationships and resources that mediate the behaviours.

Prehypertension and psychosocial risk factors among university students in ASEAN countries.

BACKGROUND: Existing evidence suggests that the cardiovascular morbidities are increasing among pre-hypertensive individuals compared to normal. The aim of this study was to evaluate the prevalence of prehypertension, hypertension and to identify psychosocial risk factors for prehypertension among university students in Association of South East Asian Nation (ASEAN) countries. METHODS: Based on a cross-sectional survey, the total sample included 4649 undergraduate university students (females = 65.3%; mean age 20.5, SD = 2.9, age range of 18-30 years) from 7 ASEAN countries (Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand and Vietnam). Blood pressure, anthropometric, health behaviour and psychosocial variables were measured. RESULTS: Overall, 19.0% of the undergraduate university students across ASEAN countries had prehypertension, 6.7% hypertension and 74.2% were normotensives. There was country variation in prehypertension prevalence, ranging from 11.3% in Indonesia and 11.5% in Malaysia to above 18% in Laos, Myanmar and Thailand. In multivariate analysis, sociodemographic variables (male gender, living in an upper middle income country, and living on campus or off campus on their own), nutrition and weight variables (not being underweight and obese, having once or more times soft drinks in a day and never or rarely having chocolate or candy), heavy drinking and having depressive symptoms were associated with prehypertension. CONCLUSION: The study found a high prevalence of prehypertension in ASEAN university students. Several psychosocial risk factors including male gender, obesity, soft drinks consumption, heavy drinking and depression symptoms have been identified which can help in intervention programmes.

"We Might Get Some Free Beers": Experience and Motivation for Transactional Sex Among Behaviorally Bisexual Men in Vientiane, Laos.

People engaging in transactional sex are considered a key population for HIV prevention. Prior quantitative surveys demonstrated that behaviorally bisexual men in Vientiane, Laos commonly transact sex. In 2013, we conducted a qualitative study to explore behaviorally bisexual men's experience, motivations, and perceptions related to transactional sex in Vientiane. Behaviorally bisexual men were recruited from bars, nightclubs, and dormitories for five focus group discussions (FGDs) and 11 in-depth interviews (n = 31). Additionally, young women were recruited from a university, garment factory, and nightclub for four FGDs (n = 22). Transcripts were translated and thematically coded. Bisexual male participants most commonly described being paid for sex by male-to-female transgender people and buying sex from women. Both male and female participants reported that older, single women pay younger men for sex. Negotiation and direction of sexual transactions are influenced by age, attraction, and wealth. Common motivations for selling sex included the need for money to support family or fund school fees, material gain, or physical pleasure. Transactional sex was often opportunistic. Some behaviorally bisexual men reported selling sex in order to pay another more desirable sex partner or to buy gifts for their regular sex partner. Participants perceived high risk associated with intercourse with female sex workers but not with other transactional sex partners. Health interventions are needed to improve knowledge, risk perception, and health behaviors, but must recognize the diversity of transactional sex in Vientiane. Both physical and virtual settings may be appropriate for reaching behaviorally bisexual men and their partners.

An investigation of stigmatizing attitudes towards people living with HIV/AIDS by doctors and nurses in Vientiane, Lao PDR.

BACKGROUND: Despite global efforts, HIV-related stigma continues to negatively impact the health and well-being of people living with HIV/AIDS. Even in healthcare settings, people with HIV/AIDS experience discrimination. Anecdotal evidence suggests that healthcare professionals in the Lao People's Democratic Republic, a lower-middle income country situated in Southeast Asia, stigmatize HIV/AID patients. The purpose of this study was to assess HIV stigmatizing attitudes within Laotian healthcare service providers and examine some of the factors associated with HIV/AIDS-related stigma among doctors and nurses. METHODS: A structured questionnaire, which included a HIV-related stigma scale consisting of 17 items, was self-completed by 558 healthcare workers from 12 of the 17 hospitals in Vientiane. Five hospitals were excluded because they had less than 10 staff and these staff were not always present. The questionnaire was pre-tested with 40 healthcare workers. Descriptive statistical analysis was performed and comparisons between groups undertaken using chi-square test and t-test. Bivariate and multiple linear regression analyses were carried out to examine the associations between stigmatizing attitudes and independent variables. RESULTS: Out of the 558 participating healthcare workers, 277 (49.7%) were doctors and 281 (50.3%) were nurses. Nearly 50% of doctors and nurses included in the study had high levels of stigmatizing attitudes towards people living with HIV/AIDS. Across the different health professionals included in this study, lower levels of HIV/AIDS knowledge were associated with higher levels of stigmatizing attitudes towards people living with HIV/AIDS. Stigmatizing attitudes, including discrimination at work, fear of AIDS, and prejudice, were lower in healthcare workers with more experience in treating HIV/AIDS patients. CONCLUSIONS: This study is the first to report on HIV/AIDS-related stigmatization among healthcare workers in Lao PDR. Stigmatizing attitudes contribute to missed opportunities for prevention, education and treatment, undermining efforts to manage and prevent HIV. Reversing stigmatizing attitudes and practices requires interventions that address affective, cognitive and behavioral aspects of stigma. Alongside this, health professionals need to be enabled to enact universal precautions and prevent occupational transmission of HIV.

Measuring health literacy in university students in Vientiane, Lao PDR.

Health literacy includes the knowledge, motivation and competence of a person to make judgments and decisions on health information in order to promote and maintain their health in relation to health care, disease prevention and health promotion. The role health literacy plays in determining health outcomes makes it an important focus of public health research. In line with a larger Asia wide initiative (HLS-Asia), this study set out to measure health literacy in the Lao People's Democratic Republic (Lao-PDR). A mixed-methods study design was employed. The HLS-Asia questionnaire was conducted as a self-administered survey with first year students at the National University of Lao PDR in Vientiane. The survey was complimented with in-depth, vignette style interviews. Student's scores on the questionnaire showed problematic health literacy levels, with clear patterns to the type of questions students struggled with. However, responses in the interviews suggested a higher level of health literacy. These findings highlight the importance of health systems and social context in health literacy. The results question the appropriateness of the HLS measurement tool, but more broadly suggest that health literacy may be a concept only comparable between populations when social, economic and health systems are measured concurrently.

Informal workers and access to healthcare: a qualitative study of facilitators and barriers to accessing healthcare for beer promoters in the Lao People's Democratic Republic.

BACKGROUND: Informal workers often face considerable risks and vulnerabilities as a consequence of their work and employment conditions. The purpose of this study was to examine the interplay between the experience of informal work and access to health, using as an example, female beer promoters employed in the informal economy, in the Lao People's Democratic Republic. METHODS: In-depth interviews were undertaken with 24 female beer promoters working in beer shops, restaurants and entertainment venues in Vientiane City. The recruitment strategy of snowball sampling was used. Interviews explored the beer promoter's experience of the organization of work, perceived healthcare needs, access to healthcare and insurance, and health seeking practices. The data was analysed thematically and subsequently using Bourdieu's concepts of habitus, capital and field. RESULTS: Most of the beer promoters included in the study were 18 years of age, single, had worked as beer promoters for more than one year and just over half were working to support their higher education. The beer promoters demonstrated a holistic view of health, also viewing good health as contributing to being beautiful - an important attribute in their work. Many reported that their work conditions, including the noisy environment, exposure to second-hand tobacco smoke, long hours on their feet and sexual harassment negatively affected their physical and mental health. Only four participants had any form of health insurance with access to healthcare constrained by individual characteristics, health system factors and the conditions of their informal employment. CONCLUSIONS: Drawing on the work of Bourdieu, the study shows how both employment and illness are linked to habitus embodied in everyday practices, access to capital and the position the female beer promoters hold in the social hierarchy in the field of employment.

Perceptions and understandings of pregnancy, antenatal care and postpartum care among rural Lao women and their families.

BACKGROUND: Lao People's Democratic Republic (Lao PDR) has the highest maternal mortality rate (MMR) and infant mortality rate (IMR) due to traditional practice and beliefs on pregnancy, delivery and postpartum. The objective of this study was to get a better understanding of cultural beliefs and practices surrounding pregnancy, ANC and postpartum care among rural women in Lao PDR. METHODS: Eight focus group discussions and 52 interviews were carried out with delivered women, husbands, mothers, traditional birth attendants, head villagers, Lao Women's Union members and healthcare workers, in Khammouane and Champasack provinces in Lao PDR. In order to accurately grasp participants' perceptions and understandings, content analysis was used to analyze the transcripts. RESULTS: Most women in the study claimed to have attended ANC, but participants also explained that it was unnecessary to attend ANC and give birth at a clinic if the woman felt healthy. Factors that discouraged ANC attendance and giving birth at clinics included: time and money constraints; the perceived necessity of giving birth on a "hot bed"; the need for "mother-roasting" after giving birth; the belief that preparing for a birth was a bad omen for the birth; the belief that colostrum is unhealthy for the newborn child; and the preference for cutting the umbilical cord with a piece of sharpened bamboo. CONCLUSIONS: Harmful cultural practices such as discarding colostrum should be discouraged; beneficial practices such as family involvement in birthing and keeping a mother warm after birth could be integrated into biomedical practice. Given the prevalence and importance of the cultural understandings we have described in this study, it is clear that proposed changes in cultural practices need to be addressed with sensitivity and that community stakeholders and trusted leaders will need to be involved.

Recovering disrupted social capital: insights from Lao DPR rural villagers' perceptions of local leadership.

BACKGROUND: Social capital is often believed to be one of the key prerequisites for successful implementation of community-based health programs. In less-developed countries, local leaders are positioned as major players in broad community health strategies and interventions, and their capacities and roles are expected to increase in prominence in future community-health-care promotions. In this study, we examined how local leaders' capacities could be related to social capital in rural villages in Lao PDR, and thus to villagers' willingness to participate in community-based health efforts. METHODS: We adopted a qualitative approach, conducting semi-structured interviews for both individuals and focus groups. In 2012, 103 people from six villages in the Khoun and Phoukoud districts participated in the interviews. For the individual interviews, we interviewed 22 mothers who had given birth in the past 5 years. For the focus groups, we interviewed 30 women (six groups), 30 men (six groups), and 21 senior villagers (five groups). RESULTS: First, we noted large variations in the levels of community social capital across villages: four out of six study villages showed a high level of social capital, while two villages suffered greatly from a low level of social capital. In search of the reasons for the disrupted social capital in the latter two villages, interviews revealed that failed leadership, especially in regard to local resource allocations-lack of transparency and corrupt practices-were commonly cited reasons for disrupted social capital. The data also showed that the villagers' mistrust of these failed local leaders critically reduced their willingness to participate in community-based health efforts, and especially in those that involved resource mobilization and risk-sharing for healthcare. Finally, we found that good communication skills and participatory decision-making styles were attributes that rural villagers in Lao PDR expected of their local leaders. CONCLUSION: This study suggests that failed local leadership is detrimental to community participation, resource mobilization, and building communities' social capital. To achieve intended health care goals through community-based interventions, there is a need to first support local leadership at all levels through capacity-building and improved communication within communities.

Health information systems and disability in the Lao PDR: a qualitative study.

The Convention on the Rights of Persons with Disabilities provides an opportunity to strengthen disability-related health information. This study analysed the health information system in Lao PDR and sought evidence of interventions to improve disability-related health information. The study was based on a literature review and key informant interviews (N = 17) informed by the Health Metrics Network's Framework and Standards and the Performance of Routine Information System Management framework. The Lao health information system is in an embryonic stage with health data often incomplete, inaccurate and poorly used. Indicators related to disability or functioning are not included, and capacity to diagnose the health condition of disability is limited. No studies of health information interventions were found. As a State Party to the CRPD, the Lao PDR has a legal obligation to collect health-related information on people with disabilities. Given the nascent stage of development of the health information system in the Lao PDR and diagnostic capacity, indicators related to basic functioning and access to services should be integrated into household level surveys. As the health information system further develops, small, incremental changes in the type of disability information and rehabilitation and the way it is collected can be implemented. Copyright © 2015 John Wiley & Sons, Ltd.

Perceptions and acceptability of pictorial health warning labels vs text only--a cross-sectional study in Lao PDR.

BACKGROUND: In Lao PDR, health warnings were first introduced with printed warning messages on the side of the cigarette package in 1993 and again in 2004. Lao PDR same year ratified the Framework Convention on Tobacco Control (WHO FCTC) but has not yet implemented pictorial health warnings. This paper aims to examine the perception and opinion of policymakers on "text-only" and "pictorial" health warnings and to understand lay people's perceptions on current health warnings and their opinions on the recommended types of health warnings. METHODS: A combination of quantitative and qualitative methods were used in this cross-sectional study conducted in 2008. A purposive sample of 15 policymakers, and a representative sample of 1360 smokers and non-smokers were recruited. A range of different areas were covered including consumer attitudes towards current and proposed cigarette package design, views on health warning messages on the flip/slide and inserts, and views on the relative importance of the size, content and pictures of health warning messages. Descriptive statistics and content analysis were used. RESULTS: Policy makers and survey respondents said that the current health warning messages were inappropriate, ineffective, and too small in size. All respondents perceived pictorial health warnings as a potentially powerful element that could be added to the messages that can communicate quickly, and dramatically. The majority of policymakers and survey respondents strongly supported the implementation of pictorial health warnings. The non-smokers agreed that the graphic pictorial health warnings were generally more likely than written health warnings to stimulate thinking about the health risks of smoking, by conveying potential health effects, increasing and reinforcing awareness of the negative health effect of smoking, aiding memorability of the health effects and arousing fear of smoking among smokers. CONCLUSIONS: The study suggested that current warnings are too small and that content is inadequate and designed to be hidden on the side pack. These findings are in line with FCTC's requirements and provide strong support for introducing pictorial warning labels also in Lao PDR. Furthermore, the awareness of Members of Parliament about tobacco control measures holds promise at the highest political level.