Pesticides use and health impacts on farmers in Thailand, Vietnam, and Lao PDR: Protocol for a survey of knowledge, behaviours and blood acetyl cholinesterase concentrations.

Pesticides use in Southeast Asia has increased steadily, driven by the growth of large-scale commercial farming, as well as a desire to maximise food production in rural subsistence economies. Given that use of chemical pesticides, such as organophosphates and carbamates, has known potential health impacts, there are concerns about the safety of agricultural workers, and a need for a better evidence base to underpin regulation and worker education. This study, undertaken in 9 districts in Lao PDR, Thailand and Vietnam, will interview agricultural workers to investigate how they use pesticides, their knowledge of risks and self-protective practices, and their self-reported illness symptoms. In each district researchers will recruit and interview 120 participants engaged in vegetable farming, who have recently used pesticides, making a total of 1080 subjects divided equally between the three study countries. Workers' degree of pesticides exposure will be determined from acetyl cholinesterase concentrations in capillary blood samples collected using field test kits, and these data will be analysed together with the interview findings. Country findings will be compared and contrasted, and general patterns noted. Knowledge gained about risky behaviours, self-protective practices and degree of association with serious pesticides exposure will assist policy makers and inform health improvement programmes.

Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR.

BACKGROUND: Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector. OBJECTIVE: The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment. METHODS: Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces. RESULTS: All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8). CONCLUSIONS: A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

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.

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.

Factors Influencing Access to Sexual Health Care Among Behaviorally Bisexual Men in Vientiane, Laos: A Qualitative Exploration.

In Laos, men who have sex with men (MSM) are disproportionately affected by HIV, and bisexual behavior among men is common. We conducted a qualitative study to explore access and influences on sexual health care seeking among bisexual men in Vientiane. In 2013, behaviorally bisexual men were recruited from bars, clubs and dormitories for 5 focus group discussions and 11 in-depth interviews. Participants (aged 18-35 years) commonly reported high-risk sexual behaviors, yet most had never been tested for HIV, and none reported testing for sexually transmitted infections. Common barriers to testing were low perception of risk, expectation of symptoms, fear of HIV, shyness, perceived stigma, confidentiality concerns, and waiting times. Many men were unaware of available services. Most clinics cannot provide comprehensive HIV and sexually transmitted infection services. Strategies are needed to generate demand for testing, improve the capacity of sexual health care providers, and promote available services among behaviorally bisexual men in Vientiane.

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.

Retrospective appraisal of cancer patients from Vientiane Capital City, Lao People's Democratic Republic (PDR), seeking treatment in Thailand.

BACKGROUND: Recent estimates suggest that in the Lao People's Democratic Republic (Lao PDR) the burden of cancer in terms of DALYs lost is amongst the highest in South East Asia. As such, increasingly cancer is becoming an important public health concern in the country. Lao PDR however has no population-based cancer registry and only one hospital-based registry. Cancer treatment within the country is extremely limited. Patients who can, may travel to neighboring countries for treatment, but little information about this is available in the country. The aim of this study was to estimate some of the otherwise largely unknown parameters of the cancer burden in Lao PDR. MATERIALS AND METHODS: This is a retrospective, descriptive study based on the records of 847 Lao cancer cases treated with surgery, radiation and chemotherapy at Srinagarind Hospital, Khon Kaen University, in Thailand between 1988 and 2010. RESULTS: The annual rate of registration of Lao cancer cases fluctuated, but showed an increasing trend. Most cancers were diagnosed by histology (65.2%), and a combination of endoscopy and radiology (15.6%). In most cases (70.2%) the stage of cancer at diagnosis could not be determined. In those whose stage could be identified, 54.0% were at the final stage (Stage IV). Among males, the commonest cancer sites were the liver (16.1%), blood (12.3%) and nasopharynx (10.6%). Those in female patients were the cervix (22.2%), breast (14.6%) and blood (8.1%). CONCLUSIONS: This study indicates that despite some fluctuations, the number of Lao cancer patients presenting at Srinagarind Hospital, Khon Kaen, gradually increased between 1988 and 2010. The unfavorable pattern of late-stage cancer diagnosis among male and female patients suggests a need for cancer control interventions and the establishment of cancer registration and treatment facilities within Lao PDR.

Cross-sectional survey: smoking among medical, pharmacy, dental and nursing students, University of Health Sciences, Lao PDR.

OBJECTIVES: 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). DESIGN: 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. 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. RESULTS: 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. CONCLUSIONS: 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.

Health policymakers' knowledge and opinions of physicians smoking and tobacco policy control in Lao PDR.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Concurrent multiple health risk behaviors among adolescents in Luangnamtha province, Lao PDR.

BACKGROUND: Multiple health risk behaviors (HRBs) among adolescents pose a threat to their health, including HIV/AIDS. Health risk behaviors such as alcohol use, smoking, substance use, and sexual risk behaviors among youth have been shown to co-occur with each others. The objectives of this study was to estimate the prevalence of single and concurrent health risk behaviors and to explore how health risk behavior is associated with socio-demographic factors and peers' behaviors. METHODS: A cross sectional design was used to examine health risk behaviors of adolescents between the age 14 and 19 years living in the Luangnamtha province, Lao PDR. The study was conducted between June and August, 2008. An ordinal logistic regression model that simultaneously explored demographic factors and the influence of the behavior of peers on three categories of multiple HRBs (no risk, one risk, and two or more health risk behaviors) was performed. RESULTS: A total of 1360 respondents, 669 (49.1%) boys with mean age 16.7 ± 1.6 and 699 (50.9%) girls aged 16.1 ± 1.5 were recruited into the study. The majority reported two or fewer risk behaviors. However, multiple risk behaviors increased with age for both sexes. About 46.8% (n = 637) reported no risk, 39.3 percent (n = 535) reported one risk, 8.1 percent (n = 110) reported two risks, and 5.8 percent reported more than two health risk behaviors.The protective factors among boys were school attendance (OR = .53, CI = .33-.86), being Hmong and Yao ethnicity (OR = .48, CI-.26-.90), while being above the age of 15 (OR = 2.20, 95% CI = 1.33-3.60), Akha ethnicity (OR = 2.20, 95% CI = 1.04-4.61), peer's smoking (OR = 3.11, 95% CI = 2.1-4.6), and peer's drinking alcohol (OR = 1.88, 95% CI = 1.1-3.21) were significantly associated with the presence of multiple risk behaviors among boys.Having some education (OR = 0.17, 95% CI = 0.06-0.45), and being of Hmong and Yao ethnicity (OR = 0.38, 95% CI = 0.18-0.80) were factors that protected girls from multiple risk behaviors; while peer's drinking alcohol (OR = 2.55, 95% CI = 1.59-4.09) and peer's being sexually active (OR = 2.82, 95% CI = 1.65-4.8) were significantly associated with the presence of multiple risk behaviors among girls. CONCLUSION: There are sex, age and ethnic differences in the concurrent health risk behaviors. The influencing factors are adolescent's education and peer influence. Interventions should focus to encourage adolescents to complete the compulsory primary education as well as help them to establish friendships and follow peers with good behavior. Risk reduction messages need to take account of diverse multiple HRBs within the specific socio-cultural and gender specific context and target vulnerable adolescents such as ethnic minorities and less educated adolescents.