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.

A Web Application About Herd Immunity Using Personalized Avatars: Development Study.

BACKGROUND: Herd immunity or community immunity refers to the reduced risk of infection among susceptible individuals in a population through the presence and proximity of immune individuals. Recent studies suggest that improving the understanding of community immunity may increase intentions to get vaccinated. OBJECTIVE: This study aims to design a web application about community immunity and optimize it based on users' cognitive and emotional responses. METHODS: Our multidisciplinary team developed a web application about community immunity to communicate epidemiological evidence in a personalized way. In our application, people build their own community by creating an avatar representing themselves and 8 other avatars representing people around them, for example, their family or coworkers. The application integrates these avatars in a 2-min visualization showing how different parameters (eg, vaccine coverage, and contact within communities) influence community immunity. We predefined communication goals, created prototype visualizations, and tested four iterative versions of our visualization in a university-based human-computer interaction laboratory and community-based settings (a cafeteria, two shopping malls, and a public library). Data included psychophysiological measures (eye tracking, galvanic skin response, facial emotion recognition, and electroencephalogram) to assess participants' cognitive and affective responses to the visualization and verbal feedback to assess their interpretations of the visualization's content and messaging. RESULTS: Among 110 participants across all four cycles, 68 (61.8%) were women and 38 (34.5%) were men (4/110, 3.6%; not reported), with a mean age of 38 (SD 17) years. More than half (65/110, 59.0%) of participants reported having a university-level education. Iterative changes across the cycles included adding the ability for users to create their own avatars, specific signals about who was represented by the different avatars, using color and movement to indicate protection or lack of protection from infectious disease, and changes to terminology to ensure clarity for people with varying educational backgrounds. Overall, we observed 3 generalizable findings. First, visualization does indeed appear to be a promising medium for conveying what community immunity is and how it works. Second, by involving multiple users in an iterative design process, it is possible to create a short and simple visualization that clearly conveys a complex topic. Finally, evaluating users' emotional responses during the design process, in addition to their cognitive responses, offers insights that help inform the final design of an intervention. CONCLUSIONS: Visualization with personalized avatars may help people understand their individual roles in population health. Our app showed promise as a method of communicating the relationship between individual behavior and community health. The next steps will include assessing the effects of the application on risk perception, knowledge, and vaccination intentions in a randomized controlled trial. This study offers a potential road map for designing health communication materials for complex topics such as community immunity.

Prévention des troubles musculo-squelettiques chez les infirmiers d'un hôpital de province au Vietnam.

OBJECTIVE: To study the situation of MSDs among nursing staff and the barriers to implementing an MSD preventive intervention in Vietnamese hospitals. METHODS: A mixed design has been devised. The quantitative component aimed to study the prevalence of MSDs, the associations between MSDs and potential risk factors and consequences of MSDs; the qualitative component focused on the study of facilitators/barriers to the implementation of a MSDs prevention program in Vietnamese hospitals. RESULTS: The prevalence of lower back, neck and shoulders MSDs, over the past 12 months, was the highest in the neck (59%) and then in lower back (49%), shoulders (40%). Factors associated with these disorders are mainly the presence of stress, being a woman and work intensity. MSD-related pain has an impact on the ability to work and the quality of life. The lack of knowledge on MSDs by health care administrators inside and outside the hospitals and the lack of human resources with expertise in MSD management are important barriers to the implementation of an MSD prevention program in Vietnamese hospitals. CONCLUSIONS: MSDs represent a serious occupational health problem in hospitals. Reducing the prevalence of MSDs requires not only an increased awareness about this serious problem among administrators, but also the development of expertise in MSD management.

Seroprotection at Different Levels of the Healthcare System After Routine Vaccination With Diphtheria-Tetanus-Pertussis whole cell-Hepatitis B-Haemophilus influenzae Type B in Lao People's Democratic Republic.

BACKGROUND: The Lao People's Democratic Republic continues to sustain a considerable burden of vaccine-preventable diseases because of incomplete vaccine coverage and weak vaccine responses. We have assessed seroconversion after routine vaccination with the pentavalent vaccine to capture weaknesses of vaccine management at the different levels of the healthcare system. METHODS: A total of 1151 children (aged 8-28 months) with 3 documented doses of the pentavalent vaccine delivered at central hospitals in Vientiane and the provincial hospital, 3 district hospitals, and 10 health centers in Bolikhamxay province were enrolled. Sociodemographic information was collected with a standardized questionnaire. Serum samples were analyzed for antibodies against vaccine components, and bivariate and multivariable analyses were performed to identify risk factors for low vaccine responses. RESULTS: Seroprotection rates at the provincial, district, and health center level were as high as in central hospitals, but seroprotection rates in areas covered by remote health centers were significantly lower. Protective levels also rapidly decreased with age at sampling. Seroprotection rates in Bolikhamxay against the different components reached 70%-77% and were up to 20% higher than in previous studies in the same region; 18.8% more children received the hepatitis B vaccine birth dose and the hepatitis B virus infection rate was 4 times lower. CONCLUSIONS: Vaccine immunogenicity has dramatically improved in a central province, likely due to training and investment in the cold chain. Nevertheless, there remains a need to focus on the "last mile" in remote areas were most children are vaccinated through outreach activities.

[Prevention of musculoskeletal disorders among nurses of a provincial hospital in Vietnam: Issue and health policy context]. / Prévention des troubles musculo-squelettiques chez les infirmiers d'un hôpital de province au Vietnam.

OBJECTIVE: To study the situation of MSDs among nursing staff and the barriers to implementing an MSD preventive intervention in Vietnamese hospitals. METHODS: A mixed design has been devised. The quantitative component aimed to study the prevalence of MSDs, the associations between MSDs and potential risk factors and consequences of MSDs; the qualitative component focused on the study of facilitators/barriers to the implementation of a MSDs prevention program in Vietnamese hospitals. RESULTS: The prevalence of lower back, neck and shoulders MSDs, over the past 12 months, was the highest in the neck (59%) and then in lower back (49%), shoulders (40%). Factors associated with these disorders are mainly the presence of stress, being a woman and work intensity. MSD-related pain has an impact on the ability to work and the quality of life. The lack of knowledge on MSDs by health care administrators inside and outside the hospitals and the lack of human resources with expertise in MSD management are important barriers to the implementation of an MSD prevention program in Vietnamese hospitals. CONCLUSIONS: MSDs represent a serious occupational health problem in hospitals. Reducing the prevalence of MSDs requires not only an increased awareness about this serious problem among administrators, but also the development of expertise in MSD management.

Cell-Free DNA-Based Non-invasive Prenatal Screening for Common Aneuploidies in a Canadian Province: A Cost-Effectiveness Analysis.

OBJECTIVE: Yearly, 450 000 pregnant Canadians are eligible for voluntary prenatal screening for trisomy 21. Different screening strategies select approximately 4% of women for invasive fetal chromosome testing. Non-invasive prenatal testing (NIPT) using maternal blood cell-free DNA could reduce those invasive procedures but is expensive. This study evaluated the cost-effectiveness of NIPT strategies compared with conventional strategies. METHODS: This study used a decision analytic model to estimate the cost-effectiveness of 13 prenatal screening strategies for fetal aneuploidies: six frequently used strategies, universal NIPT, and six strategies incorporating NIPT as a second-tier test. The study considered a virtual cohort of pregnant women of similar size and age as women in Quebec. Model data were obtained from published sources and government databases. The study predicted the number of chromosomal anomalies detected (trisomies 21, 13, and 18), invasive procedures and euploid fetal losses, direct costs, and incremental cost-effectiveness ratios. RESULTS: Of the 13 strategies compared, eight identified fewer cases at a higher cost than at least one of the remaining five strategies. Integrated serum screening with conditional NIPT had the lowest cost, and the cost per case detected was $63 139, with a 90% reduction of invasive procedures. The number of cases identified was improved with four other screening strategies, but with increasing of incremental costs per case (from $61 623 to $1 553 615). Results remained robust, except when NIPT costs and risk cut-offs varied. CONCLUSION: NIPT as a second-tier test for high-risk women is likely to be cost-effective as compared with screening algorithms not involving NIPT.

Predictors of Acquisition of Competitive Employment for People Enrolled in Supported Employment Programs.

This study aims at assessing the relative contribution of employment specialist competencies working in supported employment (SE) programs and client variables in determining the likelihood of obtaining competitive employment. A total of 489 persons with a severe mental illness and 97 employment specialists working in 24 SE programs across three Canadian provinces were included in the study. Overall, 43% of the sample obtained competitive work. Both client variables and employment specialist competencies, while controlling for the quality of SE programs implementation, predicted job acquisition. Multilevel analyses further indicated that younger client age, shorter duration of unemployment, and client use of job search strategies, as well as the working alliance perceived by the employment specialist, were the strongest predictors of competitive employment for people with severe mental illness, with 51% of variance explained. For people with severe mental illness seeking employment, active job search behaviors, relational abilities, and employment specialist competencies are central contributors to acquisition of competitive employment.

The economic evaluation of human papillomavirus vaccination strategies against cervical cancer in women in Lao PDR: a mathematical modelling approach.

BACKGROUND: Cervical cancer, a preventable disease, is the third leading cause of cancer morbidity and mortality in the Lao People's Democratic Republic (Lao PDR). Since many cervical cancers are linked to human papilloma virus (HPV) infection, vaccination against this virus may lead to a reduction in these types of cancer. The study described here is the first to compare the cost-effectiveness of different HPV vaccination options in Lao PDR. METHODS: A dynamic compartment model was created. The model included routine screening activities already in place, as well as theoretical interventions that included a 10-year old girl-only vaccination programme combined with/without a 10-year old boy vaccination programme and/or a catch-up component. The simulation was run over 100 years. In base case analyses, we assumed 70 % vaccination coverage with lifelong protection and 100 % efficacy against HPV types 16/18. The outcomes of interest were the incremental cost per Disability-Adjusted Life Year (DALY) averted. RESULTS: In base case analyses, according to the WHO definition of cost-effectiveness thresholds, vaccinating 10-year-old girls was very cost-effective. Adding a catch-up vaccination element for females aged 11-25 years was also very cost-effective, costing 1559 international dollars (I$) per DALY averted. Increasing the age limit of the catch-up vaccination component to 75 years old showed that this remained a cost-effective option (I$ 5840 per DALY averted). Adding a vaccination programme for 10-year-old boys was not found to be cost-effective unless a short time simulation (30 years or less) was considered, along with a catch-up vaccination component for both males and females. CONCLUSIONS: Adding a catch-up female vaccination component is more attractive than adding a 10-year-old boy vaccination component.

Perceived stigma by children on antiretroviral treatment in Cambodia.

BACKGROUND: HIV-related stigma diminishes the quality of life of affected patients. Little is known about perceived and enacted stigma of HIV-infected children in resources-limited settings. We documented the prevalence of perceived stigma and associated factors associated among children on antiretroviral therapy (ART) at a referral hospital in Cambodia. METHODS: After informed consent, a standardized pre-tested 47-item questionnaire was confidentially administered to consecutive children (7 to 15 years) or their guardians if the child was 18 months to 6 years, during their routine ART visits. The questionnaire explored the sociodemographics of the child and the parents, HIV history, adherence to ART, tolerance of ART and perceived stigma. Associations between perceived stigma and the children's characteristics were measured by bivariate and multivariate analyses. RESULTS: Of 183 children, 101 (55.2%) had lost at least one and 45 (24.6%) both parents; 166 (90.7%) went to school. Of 183 children (female: 84, 45.9%, median age 7.0 years, interquartile range: 2.0-9.6), 79 (43.2%) experienced perceived stigma, including rejection by others (26.8%), no invitations to social activities (18.6%) and exclusion from games (14.2%). A total of 43 (23.5%) children were fearful of their disease and 61 (53.9%) of 113 older than 6 years reported knowledge of their HIV status. Of 136 children over five years and eligible for education, 7 (3.8%) could not go to school due to perceived stigma. Incomplete adherence to ART was reported for 17 (9.2%) children. In multivariate analysis, school attendance (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 2.0-7.9) and income of less than one dollar per person per day (OR: 2.2, 95% CI: 1.1-4.5) were associated with perceived stigma. Conversely, receipt of social support (OR: 0.4, 95% CI 0.2-0.9) was associated with lower risk of perceived stigma. CONCLUSION: Perceived stigma in pediatric ART patients remains a significant issue in Cambodia. Psychological support and interventions should be developed in hospitals, schools, and underprivileged communities to prevent HIV-related stigma for affected children.

Decentralization and immunization program in a single-party state: the case of the Lao People's Democratic Republic.

BACKGROUND: The Lao People's Democratic Republic (Lao PDR), a lower-middle-income country, lags behind other Southeast Asian countries in immunization coverage for children under two years of age. The organization of health services is a key determinant of the functionality of immunization programs. However, this aspect, and in particular its decentralization component of the healthcare system, has never been studied. METHODS: A case study in the Lao National Immunization Program was performed using a neo-institutional theory-based conceptual framework, highlighting the structure (rules, laws, resources, etc.) and interpretative schemes (dominant beliefs and ideas) that underlie the state of decentralization of the healthcare system that support the conduct of the immunization program. Twenty-two semi-structured interviews were conducted with representative actors from various government levels, external donors, and civil society, in four provinces. Data were complemented with information retrieved from relevant documents. RESULTS: The Lao healthcare system has a deconcentrated form of decentralization. It has a largely centralized structure, albeit with certain measures promoting the decentralization of its immunization programs. The structure underlying the state of centralization of immunization services provided is coherent with a shared dominant interpretive scheme. However, the rapid economic, technical, and educational changes affecting the country suggest that the coherence between structure and interpretative schemes is bound to change. CONCLUSION: Unprecedented opportunities to access quality higher education and the use of social networks are factors in Lao PDR that could affect the distribution of responsibilities of the different levels of government for public health programs such as the National Immunization Program.

Economic Rationality in Decision-Making Regarding Newborn Screening: A Case Study in Quebec.

Health systems in high-resource countries recognize the importance of making decisions about the services offered to the population based on scientific evidence. Producing this evidence is especially challenging in areas such as newborn care where the frequency of conditions is rare. However, methodological advances in the field of economic evaluation could change how this evidence is used in decision-making. This study aimed to investigate how decision-makers in the Canadian province of Quebec perceive the value of recent advances in economic evaluations for perinatal studies and how these advances might affect the offer of neonatal interventions in the public health care system. A qualitative study was conducted. A total of 10 policymakers were interviewed. A neo-institutional conceptual framework highlighting three dimensions, structure, power, and interpretive schemes, was used for data collection and analyses. Structural factors, interpretative schemes, and power management between the groups concerned concur to ensure that providing services to newborns is not hindered by the difficulty of producing evidence. They also ensure that the decisions regarding which disease to screen for take into consideration the specificity of neonatology, in particular, the social value given to children not captured by available evidence.

An Online Application to Explain Community Immunity with Personalized Avatars: A Randomized Controlled Trial.

Background: To evaluate the effects of a web-based, personalized avatar intervention conveying the concept of community immunity (herd immunity) on risk perception (perceptions of the risk of infection spreading (to self, family, community, and vulnerable individuals)) and other cognitive and emotional responses across 4 vaccine-preventable disease contexts: measles, pertussis, influenza, and an unnamed "vaccine-preventable disease." Methods: Through a robust user-centered design process, we developed a web application, " herdimm ," showing how community immunity works. In our application, people personalize a virtual community by creating avatars (themselves, 2 vulnerable people in their community, and 6 other people around them; e.g., family members or co-workers.) Herdimm integrates these avatars in a 2-minute narrated animation showing visually how infections spread with and without the protection of community immunity. The present study was a 2×4 factorial randomized controlled trial to assess herdimm 's effects. We recruited 3883 adults via Qualtrics living in Canada who could complete an online study in English or French. We pre-registered our study, including depositing our questionnaire and pre-scripted statistical code on Open Science Framework ( https://osf.io/hkysb/ ). The trial ran from March 1 to July 1, 2021. We compared the web application to no intervention (i.e. control) on primary outcome risk perception, divided into objective risk perception (accuracy of risk perception) and subjective risk perception (subjective sense of risk), and on secondary outcomes-emotions (worry, anticipated guilt), knowledge, and vaccination intentions-using analysis of variance for continuous outcomes and logistic regression for dichotomous outcomes. We conducted planned moderation analyses using participants' scores on a validated scale of individualism and collectivism as moderators. Results: Overall, herdimm had desirable effects on all outcomes. People randomized to herdimm were more likely to score high on objective risk perception (58.0%, 95% confidence interval 56.0%-59.9%) compared to those assigned to the control condition (38.2%, 95% confidence interval 35.5%-40.9%). Herdimm increased subjective risk perception from a mean of 5.30 on a scale from 1 to 7 among those assigned to the control to 5.54 among those assigned to herdimm . The application also increased emotions (worry, anticipated guilt) (F(1,3875)=13.13, p<0.001), knowledge (F(1,3875)=36.37, p<0.001) and vaccination intentions (Chi-squared(1)=9.4136, p=0.002). While objective risk perception did not differ by disease (Chi-squared(3)=6.94, p=0.074), other outcomes did (subjective risk perception F(3,3875) = 5.6430, p<0.001; emotions F(3,3875)=78.54, p<0.001; knowledge (F(3,3875)=5.20, p=0.001); vaccination intentions Chi-squared (3)=15.02, p=0.002). Moderation models showed that many findings were moderated by participants' individualism and collectivism scores. Overall, whereas outcomes tended not to vary by individualism and collectivism among participants in the control condition, the positive effects of herdimm were larger among participants with more collectivist orientations and effects were sometimes negative among participants with more individualist orientations. Conclusions: Conveying the concept of community immunity through a web application using personalized avatars increases objective and subjective risk perception and positively influences intentions to receive vaccines, particularly among people who have more collectivist worldviews. Including prosocial messages about the collective benefits of vaccination in public health campaigns may increase positive effects among people who are more collectivist while possibly backfiring among those who are more individualistic.

Dabigatran versus warfarin under standard or pharmacogenetic-guided management for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation: a cost/utility analysis using an analytic decision model.

BACKGROUND: Atrial fibrillation (AF) is the most common form of heart arrhythmia and a leading cause of stroke and systemic embolism. Chronic anticoagulation is recommended for preventing those complications. Our study aimed to compare the cost/utility (CU) of three main anticoagulation options: 1) standard warfarin dosing (SD-W) 2) warfarin dosage under the guidance of CYP2C9 and VKORC1 genotyping (GT-W) and 3) dabigatran 150 mg twice a day. METHODS: A Markov state transition model was built to simulate the expected C/U of dabigatran, SD-W and GT-W anticoagulation therapy for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation over a period of 5 years under the perspective of the public health care system. Model inputs were derived from extensive literature search and government's data bases. Outcomes considered were the number of total major events (thromboembolic and hemorrhagic events), total costs in Canadian dollars (1CAD$ = 1$US), total quality-adjusted life years (QALYs), costs/QALYs and incremental costs/QALYs gained (ICUR). RESULTS: Raw base case results show that SD-W has the lowest C/U ratio. However, the dabigatran option might be considered as an alternative, as its cost per additional QALY gained compared to SD-W is CAD $ 4 765, i.e. less than 50 000, the ICUR threshold generally accepted to adopt an intervention. At the same threshold, GT-W doesn't appear to be an alternative to SD-W. Our results were robust to one-way and multi-way sensitivity analyses. CONCLUSION: SD-W has the lowest C/U ratio among the 3 options. However, dabigatran might be considered as an alternative. GT-W is not C/U and should not currently be recommended for the routine anticoagulotherapy management of AF patients.

Cost-effectiveness of the management of rh-negative pregnant women.

OBJECTIVE: The purpose of this study was to determine the most cost-effective option to prevent alloimmunization against the Rh factor. METHODS: A virtual population of Rh-negative pregnant women in Quebec was built to simulate the cost-effectiveness of preventing alloimmunization. The model considered four options: (1) systematic use of anti-D immunoglobulin; (2) fetal Rh(D) genotyping; (3) immunological determination of the father's Rh type; (4) mixed screening: immunological determination of the father's Rh type, followed if positive by fetal Rh(D) genotyping. Two outcomes were considered, in addition to the estimated costs: (1) the number of babies without hemolytic disease, and (2) the number of surviving infants. RESULTS: In a first pregnancy, two options emerged as the most cost-effective options: systematic prophylaxis and immunological Rh typing of the father, with overlapping confidence intervals between them. In a second pregnancy, the results were similar. In all cases (first or second pregnancy or a combination of the two) fetal genotyping was not found to be a cost-effective option. CONCLUSION: Routine prophylaxis and immunological Rh typing of the father are the most cost-effective options for the prevention of Rh alloimmunization. Considering that immunological typing of the father would probably not be carried out by the majority of clinicians, routine prophylaxis remains the preferred option. However, this could change if the cost of Rh(D) fetal genotyping fell below $140 per sample.

Objectif : Cette étude avait pour objectif d'identifier l'option la plus rentable pour la prévention de l'allo-immunisation contre le facteur Rh. Méthodes : Une population virtuelle québécoise de femmes enceintes séronégatives pour le facteur Rh a été créée pour simuler la rentabilité de la prévention de l'allo-immunisation. Ce modèle a pris en considération quatre options : (1) l'utilisation systématique d'immunoglobuline anti-D; (2) le génotypage Rh(D) fœtal; (3) la détermination immunologique du type Rh du père; (4) le dépistage mixte : détermination immunologique du type Rh du père, suivie (en présence de résultats positifs) du génotypage Rh(D) fœtal. Deux critères d'évaluation ont été pris en considération, en plus des coûts estimés : (1) le nombre d'enfants nés sans maladie hémolytique et (2) le nombre de nouveau-nés survivants. Résultats : Dans le cas d'une première grossesse, deux options se sont avérées les plus rentables : la prophylaxie systématique et la détermination immunologique du type Rh du père; leurs intervalles de confiance se chevauchaient. Dans le cas d'une deuxième grossesse, les résultats ont été semblables. Dans tous les cas (première ou deuxième grossesse, ou une combinaison des deux), nous avons constaté que le génotypage fœtal ne constituait pas une option rentable. Conclusion : La mise en œuvre systématique d'une prophylaxie et la détermination immunologique du type Rh du père constituent les options les plus rentables pour la prévention de l'allo-immunisation contre le facteur Rh. Puisqu'il est peu probable que la détermination immunologique du type Rh du père soit mise en œuvre par la majorité des cliniciens, la prophylaxie systématique demeure l'option à privilégier. Cependant, cela pourrait changer si le coût du génotypage Rh(D) fœtal chutait en deçà de 140 $ par prélèvement.

Validation of the Karasek-Job Content Questionnaire to measure job strain in Vietnam.

The objective of this study was to validate the Karasek-Job Content Questionnaire in Vietnamese. A translation/back-translation of the questionnaire was performed prior to its administration to 344 health personnel in Vietnam. Several psychometric properties of the Vietnamese version of the Karasek-Job Content Questionnaire were assessed. A valid Vietnamese version of the Karasek-Job Content Questionnaire was produced, composed of five subscales based on the original theoretical model: Psychological demands, Social support at work, Decision latitude-Autonomy, Decision latitude-Authority, and Skill discretion. Internal consistency and reliability coefficients for each subscale of the questionnaire were satisfactory. The correlations with depression and work absence indicators were weak but statistically significant, as expected. The Vietnamese version of the Karasek-Job Content Questionnaire will help Vietnamese researchers and clinicians appropriately evaluate and document the job strain of workers in Vietnamese workplaces.

The Concepts of Women's Empowerment in Child Malnutrition Programs in Luangprabang Province, Lao People's Democratic Republic.

In several developing countries, such as Lao People's Democratic Republic (Lao PDR), the fight against malnutrition is carried out through programs that involve collaboration between internal (national) and external (international) actors. These actors may have different perceptions on what is one of the pillars of these programs: the empowerment of women, especially mothers of young children. Little is known about these differences and the impact of these differences on the empowerment component of collaborative projects and the perception of its impact on the reduction in malnutrition in the country. A multiple case study was performed. Data collection was carried out in Vientiane Capital and Luangprabang province. The data were obtained from (1) documents, (2) semi-structured interviews with representatives of internal and external organizations, and (3) focus group discussions and individual interviews with mothers of children under five years old. Analysis consisted of characterizing the empowerment component of nutrition programs of internal and external organizations, as well as mothers, based on an OXFAM's adapted conceptual framework on women's economic empowerment. The study revealed a common understanding among government and external organizations regarding the significance of promoting women's empowerment for reducing child malnutrition in Lao PDR. However, variations were observed in the interpretation of specific determinants of women's empowerment, specifically in relation to women's autonomy and the role of social capital. The perspective of internal actors includes the political ideology and traditions that make Lao PDR a distinct country. This perspective dominates the nutrition programs conducted under the collaboration of internal and external actors. In Lao PDR, the concept of women's empowerment in nutrition programs conducted through collaboration between internal and external actors and targeting young Lao mothers gives prominence to political and socio-cultural factors.

Emergence of National Nutrition Policy in the Lao People's Democratic Republic: an analysis of collaborations between governmental and external actors.

BACKGROUND: In most developing countries, addressing malnutrition involves a coalition of stakeholders that includes the government and international development partners. This study explores the evolution of the malnutrition actor coalition landscape before and after the emergence of the National Nutrition Policy in the Lao People's Democratic Republic (Lao PDR) in 2008. METHODS: A qualitative study was conducted based on the theory of coalition structuring. Twenty semi-structured interviews were performed with representatives of national and international organisations involved in addressing malnutrition in Lao PDR. The information obtained from the interviews was complemented by an analysis of relevant documents dating back to 1990. Interviews were recorded and transcribed verbatim. A thematic analysis was performed using NVivo 11 software and the diagrams of collaboration drawn by the participants were turned into a visual collaboration map using SocNetV software. We relied on various types of triangulation to increase the analysis's credibility, reliability, and confirmability. RESULTS: The results showed that before the emergence of the National Nutrition Policy, three coalitions representing the health, agriculture, and education sectors coexisted. These colalitions worked largely in silos, although with some interactions when deemed necessary mainly by United Nations agencies. The emergence of the National Nutrition Policy provided the government with an effective political tool for coalescing the three coalitions into a unique coalition involving all major stakeholders in the nutrition field. All three forces that incite actors to collaborate inside a coalition according to the theory of coalition structuring (transactions, control, intangible factors) were mobilised in the creation of the single coalition. CONCLUSIONS: Combating malnutrition is a government priority in the Lao PDR. The current study showed that the National Nutrition Policy in Lao PDR has led to a significant evolution in the malnutrition coalition landscape, resulting in improved collaboration among stakeholders. This finding highlights the effectiveness of public policies in facilitating intersectoral activities to tackle complex problems, such as malnutrition.

Pregnant women's and policymakers' preferences for the expansion of noninvasive prenatal screening: A discrete choice experiment approach study.

Background and Aims: Quantitative approaches for eliciting preferences for new interventions are mostly conducted by patients and rarely by policymakers. This study aimed to quantify the preferences of pregnant women and policymakers regarding the addition of a new test to prenatal screening programs for detecting chromosomal abnormalities. Methods: A discrete choice experiment was conducted to measure the respondents' preferences for a new prenatal test. A seven-attribute instrument was built based on interviews with pregnant women and policymakers. The data were analyzed using robust conditional logistic regression and nested logit models. Results: In total, 272 pregnant women and 24 policymakers completed the questionnaire (response rates of 48% and 55%, respectively). Overall, all attributes were statistically significant in the pregnant women group, whereas only three attributes (test performance, degree of test result certainty, and cost) were statistically significant in the policymakers group. Statistically significant differences in test performance and information were observed between the two groups. Conclusion: Policymakers differed from pregnant women in their appraisal of attributes related to their preference for a new prenatal screening intervention. The low response rates observed in both groups suggest that further investigation of the relevance of this approach must be conducted.

Development of a discrete choice experiment questionnaire to elicit preferences by pregnant women and policymakers for the expansion of non-invasive prenatal screening.

OBJECTIVE: An instrument for measuring intervention preferences applicable to both patients and policymakers would make it possible to better confront the needs of the supply and demand sides of the health care system. This study aimed to develop a discrete choice experiments (DCE) questionnaire to elicit the preferences of patients and policymakers. The instrument was specifically developed to estimate preferences for new conditions to be added to a screening program for fetal chromosomal anomalies. METHODS: A DCE development study was conducted. The methods employed included a literature review, a qualitative study (based on individual semi-structured interviews, consultations, and a focus group discussion) with pregnant women and policymakers, and a pilot project with 33 pregnant women to validate the first version of the instrument and test the feasibility of its administration. RESULTS: An initial list of 10 attributes was built based on a literature review and the qualitative research components of the study. Five attributes were built based on the responses provided by the participants from both groups. Eight attributes were consensually retained. A pilot project performed on 33 pregnant women led to a final instrument containing seven attributes: 'conditions to be screened', 'test performance', 'moment at gestational age to obtain the test result', 'degree of test result certainty to the severity of the disability', 'test sufficiency', 'information provided from test result', and 'cost related to the test'. CONCLUSION: It is possible to reach a consensus on the construction of a DCE instrument intended to be administered to pregnant women and policymakers. However, complete validation of the consensual instrument is limited because there are too few voting members of health technology assessment agencies committees to statistically ascertain the relevance of the attributes and their levels.

Expansion of non-invasive prenatal screening to the screening of 10 types of chromosomal anomalies: a cost-effectiveness analysis.

OBJECTIVES: To determine the cost-effectiveness of the addition of chromosomal anomalies detectable by non-invasive prenatal screening (NIPS), in a prenatal screening programme targeting common aneuploidies. DESIGN, SETTING AND PARTICIPANTS: A simulation study was conducted to study the addition of chromosomal anomalies detectable by NIPS (sex chromosome aneuploidies, 22q11.2 deletion syndrome, large deletion/duplication >7 Mb and rare autosomal trisomies) to five basic strategies currently aiming the common trisomies: three strategies currently offered by the public healthcare systems in Canada, whose first-tier test is performed with biochemical markers, and two programmes whose first-tier test consists of NIPS-based methods. OUTCOME MEASURES: The total number of cases of chromosomal anomalies detected and the costs related to the consumption of medical services. RESULTS: The most effective and the most cost-effective option in almost all prenatal screening strategies is the option that includes all targeted additional conditions. In the strategies where NIPS is used as first-tier testing, the cost per additional case detected by adding all possible additional anomalies to a programme that currently targets only common trisomies is $C25 710 (95% CI $C25 489 to $C25 934) for massively parallel shotgun sequencing and $C57 711 (95% CI $C57 141 to $C58 292) for targeted massively parallel sequencing, respectively. The acceptability curves show that at a willingness-to-pay of $C50 000 per one additional case detected, the expansion of NIPS-based methods for the detection of all possible additional conditions has a 90% probability of being cost-effective. CONCLUSION: From an economic perspective, in strategies that use NIPS as a first-tier screening test, expanding the programmes to detect any considered chromosomal anomalies other than the three common trisomies would be cost-effective. However, the potential expansion of prenatal screening programmes also requires consideration of societal issues, including ethical ones.