Development of a knowledge broker group to support evidence-informed policy: lessons learned from Myanmar.

BACKGROUND: Globally, policy-makers face challenges to using evidence in health decision-making, particularly lack of interaction between research and policy. Knowledge-brokering mechanisms can fill research-policy gaps and facilitate evidence-informed policy-making. In Myanmar, the need to promote evidence-informed policy is significant, and thus a mechanism was set up for this purpose. This paper discusses lessons learned from the development of the Knowledge Broker Group-Myanmar (KBG-M), supported by the Johns Hopkins Bloomberg School of Public Health's Applied Mental Health Research Group (JHU) and Community Partners International (CPI). METHODS: Sixteen stakeholders were interviewed to explore challenges in formulating evidence-informed policy. Two workshops were held: the first to further understand the needs of policy-makers and discuss knowledge-brokering approaches, and the second to co-create the KBG-M structure and process. The KBG-M was then envisioned as an independent body, with former officials of the Ministry of Health and Sports (MoHS) and representatives from the nongovernmental sector actively engaging in the health sector, with an official collaboration with the MoHS. RESULTS: A development task force that served as an advisory committee was established. Then, steps were taken to establish the KBG-M and obtain official recognition from the MoHS. Finally, when the technical agreement with the MoHS was nearly complete, the process stopped because of the military coup on 1 February 2021, and is now on hold indefinitely. CONCLUSIONS: Learning from this process may be helpful for future or current knowledge-brokering efforts, particularly in fragile, conflict-affected settings. Experienced and committed advisory committee members enhanced stakeholder relationships. Responsive coordination mechanisms allowed for adjustments to a changing bureaucratic landscape. Coordination with similar initiatives avoided overlap and identified areas needing technical support. Recommendations to continue the work of the KBG-M itself or similar platforms include the following: increase resilience to contextual changes by ensuring diverse partnerships, maintain advisory committee members experienced and influential in the policy-making process, ensure strong organizational and funding support for effective functioning and sustainability, have budget and timeline flexibility to allow sufficient time and resources for establishment, organize ongoing needs assessments to identify areas needing technical support and to develop responsive corrective approaches, and conduct information sharing and collaboration between stakeholders to ensure alignment.

Promoting community malaria control in rural Myanmar through an active community participation program using the participatory learning approach.

INTRODUCTION: Malaria is prevalent in more than 80% of townships in Myanmar. The National Malaria Control Programme (NMCP) has been implementing community-based malaria control programs nationwide. However, these programs are mostly developed and directed by health authorities, while communities are passively involved. This study aimed to increase community participation in malaria control and promote community malaria control knowledge and practice in rural Myanmar. METHODS: A community-based study, which employed a mixed method approach, collecting data quantitatively and qualitatively, was conducted in two rural villages. The study implemented an active community participation program (ACPP) using the participatory learning approach in a village (ACPP village) but only routine malaria control was given in another village (non-ACPP village). All households with 142 and 96 household representatives from ACPP and non-ACPP villages participated in baseline and endline surveys. The ACPP was evaluated by process and outcome indicators. A spider gram analysis using five process indicators was applied to evaluate the process of the ACPP. Community participation status in malaria control activities and level of community malaria knowledge and practice were determined as outcomes of the ACPP. RESULTS: The spider gram analysis showed that three indicators (needs assessment and planning, leadership and resource mobilization) gained a score of 4, the organization indicator a score of 5 and the management and evaluation indicator a score of 3. The outcome indicators of the program at 6 months showed that the community participation in malaria control activities in the ACPP village had significantly increased (6.9% to 49.3%) (p<0.001). The program promoted community malaria control knowledge and practice in the ACPP village. The mean scores of knowledge, perception, preventive behavior and treatment-seeking behavior were increased significantly, from 3.0 to 5.9 (p<0.001), 20.1 to 21.0 (p<0.001), 3.4 to 4.2 (p<0.001) and 3.1 to 5.6 (p<0.001), respectively. However, no significant change of outcome indicators was found in the non-ACPP village. CONCLUSIONS: The ACPP implemented by community volunteers using the participatory learning approach was feasible in community-based malaria control. This study suggests several features in the ACPP model that may be useful strategies for the implementation of the current NMCP programs in similar rural settings; however, the effect of the ACPP over a longer period to ascertain the impact of such community participation has yet to be further studied.

Policy space and pro-health equity national policymaking: a case study of Myanmar during political transition (2006-16).

Health equity is central to achieving sustainable development goals and COVID-19 has emphasized its importance. Ensuring health equity is prominent in policy discussions and decision-making is a critical challenge in all countries. Understanding the policy space for actors to promote health equity in the policy process may help to strengthen prioritization of equity in policy and programme discussions and decisions. Authors developed a conceptual framework for policy space based on a narrative literature review. This comprised five key elements and their associated factors, i.e. context, policy circumstances, policy characteristics, actor engagement and policy spaces. Authors then applied it in Myanmar during a period of political transition, using a qualitative case study design. Findings showed that political transition provided an important 'policy window' to develop more equitable health policy in Myanmar. Changing policy circumstances offered opportunities for advancing pro-equity policy. However, lack of visibility of health equity and long-standing inequalities were important challenges to policy space. Within a changing context, actors at individual and organizational levels used a range of policy spaces to advance pro-equity health policy. Learning from using the framework in Myanmar was incorporated into a revised framework. Application of this revised framework could provide valuable insights into the opportunities to promote a pro-health equity approach across policy and programme discussions and decision-making for actors trying to promote equity in other transition and non-transition contexts.

Involvement of high school teachers in Health Promoting School program in selected township, Yangon Region, Myanmar: A cross-sectional mixed methods study.

BACKGROUND: Schools provide a big opportunity for promoting the student's health, life skill, and behavior. Teachers play a fundamental role in the promotion and successful implementation of school health services. This study aimed to assess the level of involvement in the Health Promoting School program and its associated factors and to explore the benefits and barriers to involvement among high school teachers in Myanmar. METHODS: A mixed methods explanatory sequential study was conducted among 194 high school teachers in Thanlyin Township, Yangon Region, Myanmar, from June to August 2020. Quantitative data were collected with the pretested structural questionnaire and analyzed by Chi-square tests and Fisher's exact tests. A qualitative strand was added by conducting in-depth interviews (n = 15, five teachers from each level of involvement: poor, medium, and good), analyzed by thematic content analysis. RESULTS: Of the 194 teachers, 23.7% had a good level of involvement in the Health Promoting School program. The factor associated with involvement in Health Promoting School program were age (p value < 0.001), duration of services (p value = 0.001), and a number of accomplished training-related school health (p value = 0.008). Qualitative data revealed that improvement of the health knowledge and awareness on health problems, the progress of healthy behaviors, development of physical and mental health, prevention of the disease spread, achievement of healthy and productive learning environment, and development of academic achievement were major benefits of teachers' involvement. Moreover, the main barriers to involvement were insufficient materials and human resources, time constraints, incompetence of the teachers, poor cooperation of school health partnerships, and insufficient awareness of parents. CONCLUSIONS: The proportion of good involvement in the Health Promoting School program among high school teachers was low in this study area. Providing sufficient human resources and material, conducting the on-the-job and refresher training, enhancing parent-teacher cooperation, and strengthening the community partnerships were crucial to improve the level of involvement and reduced the barriers for the achievement of the Health Promoting School program.

Dissemination of reproductive health knowledge by questions and answers through telephone hotline: a feasibility study in Myanmar.

This study was conducted to determine the feasibility of disseminating reproductive health (RH) information to the general public of Myanmar in a confidential, anonymous and interactive way through a telephone hotline. We carried out a cross-sectional study using a short questionnaire interview with the RH hotline callers and analyzing sample audio recordings of conversations. The hotline was advertised in print media. It was answered by trained hotline responders (medical doctors) of Department of Madical Research (Lower Myanmar) (DMR-LM). There were 743 calls during six months, from all 14 States and Divisions. Most of the calls were from Yangon, Mandalay and Bago Division. Both male (48%) and female (52%) callers used the hotline. The majority of callers (74%) were between 25 and 45 years old; 21% were young people (15-25 years old). Married people (81%) used the hotline more than singles (19%). Most of the callers (91%) had a high school to graduate education level. The most frequently asked topics were infertility (23%), birth spacing (22%), sexual problems (13%) and adolescent health, including reproductive function (12%). The anonymity of the callers, the non-judgmental attitudes of the responders and the use of media for publicity appeared to facilitate the use of the hotline by the public. More linkages with service entry points, enhancement of communication skills, sexual counselling training and use of media can improve topic coverage and utilization of the reproductive health hotline.

A cost comparison of an enhanced primary care diabetes service and standard care.

BACKGROUND: Type 2 diabetes, which contributes 90% of all cases of diabetes mellitus is now mostly managed in the primary care settings in the UK and other advanced health care systems. The UK National Health Service as a whole could potentially benefit if more patients were managed in primary care settings since primary care-based care is likely to be more cost-effective. We initially compared eight larger general practices (Enhanced practices) in Leicester, UK with neighbouring smaller practices (Core practices) matched for comparable demographic characteristics. Even though this initial study did not find any statistically significant differences in terms of clinical outcomes there was trend in favour of the enhanced practices. In this current study, we conducted a cost comparison of enhanced practice model of diabetes care, to standard care delivered in the core practices. METHODS: Data and information were combined from a number of sources and a cost comparison evaluation was carried out in WinBUGs. A probabilistic approach was taken, to allow uncertainty to be included around analysis parameters where appropriate. The analysis evaluated a straight-forward cost comparison of enhanced versus standard care. RESULTS: The cost per person with diabetes per year was £255 (95% CrI 175, 380) in the core practices and £173 (95% CrI 96, 291) in the enhanced practices, resulting in an annual cost saving of -£83 (95% CrI -148, -28) per patient. If the enhanced model of diabetes care were delivered across all the practices in the UK, the cost would be £575,100,000 (95% CrI 320,700,000, 970,700,000), resulting in an annual cost saving of -276,200,000 (95% CrI -495,400,000, -94,480,000). CONCLUSION: A cost comparison analysis of our larger enhanced primary care based diabetes service confirms significant cost saving, probably driven by economies of scale. These benefits could be multiplied manifold if the service was implemented nationally.

Public and/or private health care: tuberculosis patients' perspectives in Myanmar.

BACKGROUND: Tuberculosis is a major public health problem in Myanmar as in other developing countries. About 73% of TB patients seek care at private general practitioners' clinics before presenting to the public TB centre, raising questions about how best to prevent transmission and maintain treatment regimens. METHOD: The study was conducted in two townships in Yangon Division in Myanmar in 2004, and examined treatment seeking behaviour of TB patients and their views towards public and private health care services. This was an exploratory descriptive study. Both quantitative and qualitative research methods were employed in data collection from TB patients, health care professionals, and members of various agencies involved in TB Control Programme. RESULTS: A considerable delay was found between the onset of symptoms of TB and seeking treatment (five days - two months). General practitioners were the first point of contact in all cases. Old TB patients influenced the treatment seeking behaviour and choice of treatment clinics of new TB patients. Most patients viewed the public health sector as a place to obtain free treatment and the private sector as a fee-paying, convenient and better place to seek treatment. CONCLUSION: The involvement of private general practitioners is crucial for effective TB control in Myanmar. The selection of GPs for partnership with the public sector is vital to the success of public-private partnership in controlling TB.

Sexual and reproductive health needs of vulnerable youth in Myanmar.

A cross-sectional survey of 56 youth, using participatory research methods, was conducted with the objective to identify the sexual and reproductive health needs among vulnerable youth in Pyin Oo Lwin town in terms of their livelihoods, perceptions about health and health risks, sex practices, perceived health information needs and preferred channels for health information, and visions for their future generation. The results indicated that a majority of young people of both sexes were deficient in knowledge of the locations and functions of reproductive organs. The majority of respondents of both sexes said that their main health concern was AIDS. Pre-marital sex among youth, 16-20 years of age, was identified in our study. Malaria and AIDS were mentioned as information needed by young people. TV and magazines/journals were prioritized as preferred channels of disseminating health messages. Almost all reported that education was the one thing that they wanted for their own children.

Therapeutic inertia amongst general practitioners with interest in diabetes.

INTRODUCTION: As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. METHODS: In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. RESULTS: Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. CONCLUSION: Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.

Effectiveness of an Integrated Community- and Clinic-Based Intervention on HIV Testing, HIV Knowledge, and Sexual Risk Behavior of Young Men Who Have Sex With Men in Myanmar.

PURPOSE: Young men who have sex with men (YMSM) in Myanmar are disproportionately affected by HIV, with prevalence five times that of the general population. The Link Up project implemented an intervention using peer education and outreach providing education and counseling on health seeking around sexually transmitted infections and reproductive health, combined with focused clinic capacity building to improve the sexual and reproductive health of YMSM. This study aimed to evaluate the effectiveness and acceptability of the intervention. METHODS: Using a mixed-methods approach, and employing a quasi-experimental design, we conducted two quantitative repeat cross-sectional surveys in purposively selected control (no intervention) and intervention townships, before and after implementation of the Link Up intervention. Respondent-driven sampling was used to recruit YMSM aged 15-24 years, and study participants were administered a structured questionnaire assessing intervention exposure, health service access, knowledge of HIV, and sexual risk behavior. Focus group discussions were held to elicit perspectives on the use and acceptability of the health services and peer outreach. RESULTS: At baseline, 314 YMSM were recruited in the intervention townships and 309 YMSM in the control townships. At end line, 267 (intervention) and 318 (control) YMSM were recruited. Coverage of the program was relatively low, with one-third of participants in the intervention townships having heard of the Link Up program by the end line. Comparing changes between baseline and end line, a greater proportion of HIV-negative or unknown status YMSM accessed HIV testing in the past 3 months in intervention townships (from 45.0% to 57.1%) compared with those in control townships (remained at 29.0%); however, this difference in the effect over time was not statistically significant in multivariate modeling (adjusted odds ratio: 1.45; 95% confidence interval: .66-3.17). Qualitative findings showed that the intervention was acceptable to YMSM. CONCLUSIONS: Overall, the intervention was perceived as acceptable. Although not statistically significant, results showed some trends toward improvements among YMSM in accessing HIV testing services and HIV-related knowledge. The modest coverage and short time frame of the evaluation likely limits the ability for any significant behavioral improvements.

Is There a Need for Viral Load Testing to Assess Treatment Failure in HIV-Infected Patients Who Are about to Change to Tenofovir-Based First-Line Antiretroviral Therapy? Programmatic Findings from Myanmar.

BACKGROUND: WHO recommends that stavudine is phased out of antiretroviral therapy (ART) programmes and replaced with tenofovir (TDF) for first-line treatment. In this context, the Integrated HIV Care Program, Myanmar, evaluated patients for ART failure using HIV RNA viral load (VL) before making the change. We aimed to determine prevalence and determinants of ART failure in those on first-line treatment. METHODS: Patients retained on stavudine-based or zidovudine-based ART for >12 months with no clinical/immunological evidence of failure were offered VL testing from August 2012. Plasma samples were tested using real time PCR. Those with detectable VL>250 copies/ml on the first test were provided with adherence counseling and three months later a second test was performed with >1000 copies/ml indicating ART failure. We calculated the prevalence of ART failure and adjusted relative risks (aRR) to identify associated factors using log binomial regression. RESULTS: Of 4934 patients tested, 4324 (87%) had an undetectable VL at the first test while 610 patients had a VL>250 copies/ml. Of these, 502 had a second VL test, of whom 321 had undetectable VL and 181 had >1000 copies/ml signifying ART failure. There were 108 who failed to have the second test. Altogether, there were 94% with an undetectable VL, 4% with ART failure and 2% who did not follow the VL testing algorithm. Risk factors for ART failure were age 15-24 years (aRR 2.4, 95% CI: 1.5-3.8) compared to 25-44 years and previous ART in the private sector (aRR 1.6, 95% CI: 1.2-2.2) compared to the public sector. CONCLUSIONS: This strategy of evaluating patients on first-line ART before changing to TDF was feasible and identified a small proportion with ART failure, and could be considered by HIV/AIDS programs in Myanmar and other countries.

Household income, health and education in a rural area of Myanmar.

This study was to determine the relationship between a commonly used social stratification indicator, net equivalent income, and self-rated health, long-term disability, visual acuity status, death rate, birth rate, unsafe delivery and school enrollment in a rural area of Myanmar. Data were collected from 3,558 respondents in 805 households of all ages. Data analysis for various items was based on different age groups. The results from two income groups (highest and lowest) are as follows: the percent of those who self-rated their health as very good were 17.8% and 10.4% in the highest and lowest income groups, respectively (adjusted coefficient = 0.30, 95% Cl 0.11-0.50); those with an acute medical condition were found in 16.3% and 20.8% in the highest and lowest income groups, respectively (adjusted OR = 1.35, 95% Cl 1.08-1.68); those with long-term disability were found in 15.3% and 21.2% in the highest and lowest income groups, respectively (adjusted OR = 1.39, 95% Cl 1.05-1.84); and those with poor visual acuity at a distance of 13 feet were found in 8.1% and 13.5% in the highest and lowest income groups, respectively (adjusted OR = 1.64, 95% Cl 1.18-2.30). The birth rate ratio was 1.3, the death rate ratio was 1.2, and school enrollment was found in 92.8% and 83.2% in the highest and lowest income groups, respectively (adjusted OR = 0.34, 95% Cl 0.1-0.8). These results indicate that there is an urgent need to strengthen the health care infrastructure and educational system, targeting the poor in rural areas.

The level of knowledge, attitude and practice in relation to malaria in Oo-do village, Myanmar.

A knowledge, attitude and practice (KAP) study concerning the nature and prevention of malaria was carried out in a rural area of Myanmar. According to the findings, many (over 40%) people do not have a clear cut knowledge on the transmission of malaria. Only one fourth of them had chemoprophylaxis before going to the forest, but they do not have the proper knowledge of the chemoprophylaxis regarding the type and dosage. Although there is acceptable knowledge (about 80% of the subject knew that mosquito bite causes malaria) and positive attitude towards malaria (100% of respondents agreed that malaria was a serious health problem in this area and 97% of respondents agreed that they would like to participate in malaria control activities), it is necessary to increase the community awareness of the transmission of the disease, its consequences and ways and means to control the disease to a minimum, especially in endemic areas.