A strategic approach to social accountability: Bwalo forums within the reproductive maternal and child health accountability ecosystem in Malawi.

BACKGROUND: The majority of documented social accountability initiatives to date have been 'tactical' in nature, employing single-tool, mostly community-based approaches. This article provides lessons from a 'strategic', multi-tool, multi-level social accountability project: UNICEF's 'Social Accountability for Every Woman Every Child' intervention in Malawi. METHODS: The project targeted the national, district and community levels. Three Civil Society Organisations (CSOs) were engaged to carry out interventions using various tools to generate evidence and political advocacy at one or more levels. This article focuses on one of the social accountability methods - the bwalo forum (a meeting based on a traditional Malawian method of dialogue). A detailed political economy analysis was conducted by one of the co-authors using qualitative methods including interviews and group discussions. The authors conducted in-country consultations and analysed secondary data provided by the CSOs. RESULTS: The political economy analysis highlighted several ways in which CSO partners should modify their work plans to be more compatible with the project context. This included shifting the advocacy and support focus, as well as significantly expanding the bwalo forums. Bwalos were found to be an important platform for allowing citizens to engage with duty bearers at the community and district levels, and enabled a number of reproductive, maternal, newborn, child and adolescent health issues to be resolved at those levels. The project also enabled learning around participant responses as intermediate project outcomes. CONCLUSIONS: The project utilised various tools to gather data, elevate community voices, and facilitate engagement between citizen and state actors at the community, district and national levels. This provided the scaffolding for numerous issues to be resolved at the community or district levels, or referred to the national level. Bwalo forums were found to be highly effective as a space for inter-level engagement between citizens and state; however, as they were not embedded in existing local structures, their potential for sustainability and scalability was tenuous. A key strength of the project was the political economy analysis, which provided direction for partners to shape their interventions according to local and national realities and be sensitive to the barriers and drivers to positive action.

Implementing the WHO integrated tool to assess quality of care for mothers, newborns and children: results and lessons learnt from five districts in Malawi.

BACKGROUND: In 2014 the World Health Organization (WHO) developed a new tool to be used to assess the quality of care for mothers, newborns and children provided at healthcare facility level. This paper reports on the feasibility of using the tool, its limitations and strengths. METHODS: Across 5 districts in Malawi, 35 healthcare facilities were assessed. The WHO tool includes checklists, interviews and observation of case management by which care is assessed against agreed standards using a Likert scale (1 lowest: not meeting standard, 5 highest: compliant with standard). Descriptive statistics were used to provide summary scores for each standard. A 'dashboard' system was developed to display the results. RESULTS: For maternal care three areas met standards; 1) supportive care for admitted patients (71% of healthcare facilities scored 4 or 5); 2) prevention and management of infections during pregnancy (71% scored 4 or 5); and 3) management of unsatisfactory progress of labour (84% scored 4 or 5). Availability of essential equipment and supplies was noted to be a critical barrier to achieving satisfactory standards of paediatric care (mean score; standard deviation: 2.9; SD 0.95) and child care (2.7; SD 1.1). Infection control is inadequate across all districts for maternal, newborn and paediatric care. Quality of care varies across districts with a mean (SD) score for all standards combined of 3 (SD 0.19) for the worst performing district and 4 (SD 0.27) for the best. The best performing district has an average score of 4 (SD 0.27). Hospitals had good scores for overall infrastructure, essential drugs, organisation of care and management of preterm labour. However, health centres were better at case management of HIV/AIDS patients and follow-up of sick children. CONCLUSIONS: There is a need to develop an expanded framework of standards which is inclusive of all areas of care. In addition, it is important to ensure structure, process and outcomes of health care are reflected.

The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach.

Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health--that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematical-modelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011-15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equity-focused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions.

Engaging undergraduate medical and dental students with academic medicine: The Aberdeen INSPIRE summer school.

UK medical and dental school curricula limit opportunities for students to gain experience in research. This parallels a decline in the number of clinical academics. To address this at grass roots level, we organised and arranged a residential summer taster week; INSPIRE (Introducing New Skills to Promote Inspirational Research Experience)-Aberdeen). The purpose was to give first and second year medical and dental students who wished to explore a potential clinical academic career a taste of wet laboratory research and to gain experience in basic research skills. Seventeen students from eight different UK medical and dental schools attended this free residential course and were exposed to various laboratory techniques with clinical translation and application in diagnostic and therapeutic medicine. Students were given access to relevant online learning tools of the techniques being used beforehand and seminar style presentations were used to emphasise their clinical application. Students met daily with clinical academics from different specialities to give them a flavour of potential clinical academic career pathways and options. All students felt that the summer school helped them consider academic medicine as a career thus achieving our aim to inspire clinical academics of the future.

Clinical Profile of COVID-19 Patients Admitted at a Private Hospital During Three Surges in Mandalay, Myanmar.

Introduction During the coronavirus disease 2019 (COVID-19) pandemic, private hospitals in Mandalay started to manage COVID-19 infections according to national treatment guidelines since February 2021. Variations of clinical characteristics and their outcomes in different surges could be evaluated in the private hospital. This study aimed to assess the clinical profile and outcomes of COVID-19 patients admitted at a private hospital during three surges in Mandalay. Methods This study is a retrospective record review of the case series of COVID-19 patients admitted at City Hospital, Mandalay. The study was conducted from January to December 2022. All of the hospital records of COVID-19 patients admitted during the second wave from February 2020 to 26 May 2021, the third wave from 27 May 2021 to 27 January 2022, and the fourth wave from 28 January to April 2022 were included in the study. Results A total of 1606 admitted cases were included in the study. The mean with standard deviation (SD) of age was 55.7±18.5, and males were 778 (48.4%). The mean duration of hospital stay in days was 10.8±5.94, 10.6±6.11, and 7.3±2.88 in second, third, and fourth waves, respectively. The mean duration of hospital stay was shortened in the fourth wave. Comorbid conditions with hypertension and/or diabetes diseases were mostly observed in three waves of COVID-19 infection. Fever was the most presented symptom in three waves. Cough, sore throat, and rhinorrhea were observed more in the fourth wave compared with previous waves. Complication with pneumonia (71.3%), liver dysfunction (21.0%), acute respiratory distress syndrome (10.0%), thrombocytopenia (6.2%), acute kidney injury (5.5%), bleeding (3.9%), and pulmonary embolism (2.9%) were investigated. Antiviral treatment such as remdesivir or molnupiravir was used more in the patients of third and fourth waves than those of the second wave. Oxygen therapy (59.9%), prone position (35.5%), non-invasive ventilation (9.5%), invasive ventilation (0.5%), inotropes (4.6%), and renal replacement therapy (1.1%) were recorded in serious cases. Only 7.9% and 9.4% died in the hospital in second and third waves. No mortality was observed in the fourth wave. Conclusions The study recommended that COVID-19 patients with comorbid conditions of hypertension or diabetes and ages 65 and older should be taken with intensive care support at the hospital. This study also concluded that a private hospital in Mandalay could tackle with COVID-19 severe cases in line with national treatment guidelines since the second wave and could provide better management in the fourth wave. Antiviral treatment should be used in severe COVID-19 cases for further emergency management. In conclusion, private hospital involvement in the COVID-19 pandemic is supportive of the healthcare provision in Myanmar in an emergency situation.

Hkakabo Razi landscape as one of the last exemplar of large contiguous forests.

Deforestation and forest degradation around the world endanger the functioning of ecosystems, climate stability, and conservation of biodiversity. We assessed the spatial and temporal dynamics of forest cover in Myanmar's Hkakabo Razi Landscape (HRL) to determine its integrity based on forest change and fragmentation patterns from 1989 to 2016. Over 80% of the HRL was covered by natural areas, from which forest was the most prevalent (around 60%). Between 1989 and 2016, forest cover declined at an annual rate of 0.225%. Forest degradation occurred mainly around the larger plains of Putao and Naung Mung, areas with relatively high human activity. Although the rate of forest interior loss was approximately 2 to 3 times larger than the rate of total forest loss, forest interior was prevalent with little fragmentation. Physical and environmental variables were the main predictors of either remaining in the current land-cover class or transitioning to another class, although remaining in the current land cover was more likely than land conversion. The forests of the HRL have experienced low human impact and still constitute large tracts of contiguous forest interior. To ensure the protection of these large tracts of forest, sustainable forest policies and management should be implemented.

Risk indicators of dental caries and gingivitis among 10-11-year-old students in Yangon, Myanmar.

OBJECTIVES: To obtain basic data on dental caries and gingival status of students in Myanmar, and to identify related risk indicators, including socioeconomic conditions and oral health behaviours and habits. STUDY DESIGN: This cross-sectional study enrolled 537 fifth-grade students in Myanmar. Oral health behaviours and dietary patterns of students were assessed using questionnaires. Oral examinations were conducted to identify dental caries and gingivitis, and the oral samples were obtained to determine the bacteria levels in dental plaque. RESULTS: The dental caries prevalence was 68.5%, with a mean number of decayed teeth of 2.07 ± 2.15. The prevalence of gingivitis was 98.9%, and the mean number of inflamed gingival areas in the anterior region was 16.2 ± 5.4. No significant differences were found between the sexes in terms of dental caries and gingivitis. Oral hygiene was significantly poorer, and levels of bacteria in dental plaque were significantly higher in boys than in girls. Multiple linear regression tests were used to analyse the association between risk indicators and dental caries and gingivitis. Tooth brushing frequency, a daily habit of mouth rinsing, dental visit experience, consumption of sugary snacks and oral hygiene status were significantly associated with dental caries. Mother's occupation, tooth brushing frequency, consumption of sweet drinks, oral hygiene status and bacterial levels in dental plaque were significant predictors of gingivitis. CONCLUSIONS: Myanmar students had a high prevalence of dental caries and gingivitis. Socioeconomic condition, oral hygiene status and oral health behaviours were all determined to be significant risk indicators.

Measurement of diabetes, prediabetes and their associated risk factors in Myanmar 2014.

BACKGROUND: Myanmar, a low-income Southeast Asia country with an estimated population of 53.9 million, is currently facing an increasing burden of noncommunicable diseases. Research that systematically measures and reports the national prevalence of diabetes and prediabetes within Myanmar represents a gap in the literature. This study, a national survey, was conducted with the objectives of 1) measuring diabetic population, 2) measuring the prediabetic population, and 3) finding out the risk factors leading to diabetes and prediabetes in Myanmar. METHOD: Multistage sampling was applied in proportional cluster approach to recruit a nationally representative sample of 8,575 participants from 52 townships selected to represent 332 townships across the country. The Ethical Committee of the Department of Medical Research (Lower Myanmar) approved the current study. Fasting plasma glucose and the level of glucose 2 hours after 75 g glucose load were applied, to screen for diabetes and prediabetes. Interviewer-administered questionnaires were carried out to investigate demographic and lifestyle behaviors. Stadiometer, weighing scale, measuring tape, and Omron blood pressure monitor measuring devices were used for the anthropometric measurements. Survey data analysis used STATA version 13 and application of descriptive statistics with multinomial logistic regression. RESULT: Prevalence of diabetes in Myanmar was 10.8%: 11.5% in males and 9.2% in females. Overall prevalence of prediabetes was 19.7%: 16.5% in males and 23% in females. Increasing age, urban residence, big waist circumference, and high triglyceride level were significant factors associated with diabetes and prediabetes. Many people with diabetes were found to lack knowledge and awareness of diabetes. CONCLUSION: Diabetes prevalence in Myanmar is high, and relatively higher than that reported in many Association of Southeast Asian Nations countries. The study findings call for urgent nationwide public health action in Myanmar such as screening people at risk of diabetes and prevention of the disease. The findings can also assist the health authority in Myanmar with the preparation and allocation of resources for diabetes prevention.

The prevalence of HIV infection in women attending antenatal clinics in Fiji.

HIV (human immunodeficiency virus) is an increasing concern in the South Pacific. We estimate, based on reported figures, that the prevalence of HIV infection in women attending antenatal clinics in Fiji in 2003 was 0.04%. The number of children born to HIV-positive mothers is small, though perinatal transmission appears to be high. Fiji's preliminary strategies for prevention of perinatal transmission have been significant, but require ongoing support and implementation.

Bird diversity in northern Myanmar and conservation implications.

We conducted four bird biodiversity surveys in the Putao area of northern Myanmar from 2015 to 2017. Combined with anecdotal information collected between 2012 and 2015, we recorded 319 bird species, including two species (Arborophila mandellii and Lanius sphenocercus) previously unrecorded in Myanmar. Bulbuls (Pycnonotidae), babblers (Timaliidae), pigeons and doves (Columbidae), and pheasants and partridges (Phasianidae) were the most abundant groups of birds recorded. Species richness below 1 500 m a. s. l. was higher than species richness at higher elevations. Our results suggest that the current protected areas in this region should be expanded to lower elevations to cover critical conservation gaps.

Work Productivity Loss in Young Workers Is Substantial and Is Associated With Spinal Pain and Mental Ill-health Conditions.

OBJECTIVE: The aim of this study was to estimate the effect of spinal pain and mental ill-health conditions on work productivity in 22-year-old workers. METHODS: A cross-sectional design using data from the Raine Study cohort (n = 867) including self-reported work productivity and self-report of health practitioner diagnosed medical conditions. RESULT: Mean (median, 25th-percentile, 75th-percentile) annualized cost of health-related absenteeism was $AUD1899 ($0, $0, $1738) per worker. Annualized cost of presenteeism was $AUD10,674 ($6573, $4003, $13,087) per worker. Spinal pain and mental ill-health conditions were associated with increased health-related absenteeism, but not presenteeism. CONCLUSION: Work productivity loss in young workers is a substantial problem needing priority attention. Addressing spinal pain and mental ill-health may improve productivity of this important sector of the workforce.

Selliguea kachinensis (Polypodiaceae), a new fern species of uncertain affinity from Northern Myanmar.

We describe Selliguea kachinensis as a new species from Northern Myanmar and discuss its generic placement in either Selliguea or Arthromeris. The conservation status is assessed as Data Deficient. In addition, we make the new combination Selliguea erythrocarpa (Mett. ex Kuhn) Hovenkamp, S. Linds., Fraser-Jenk.

Alpha-1-antitrypsin in duodenal fluid and gallbladder bile.

Using the immunoelectrophoretic method alpha-1-antitrypsin was detected in all but 6 of 26 samples of duodenal fluid obtained from 16 patients with various gastroenterological problems. The concentrations (mg/100 ml) of alpha-1-antitrypsin in duodenal aspirates from children with liver disease (7.32 plus or minus 6.1) were less than those from children with cystic fibrosis, Shwachman Diamond syndrome, or Hirschsprung's disease (16.7 plus or minus 11.9; p smaller than 0.02). Alpha-1-antitrypsin was detected in all but one of 6 samples of gallbladder bile, the exception being that from a patient with extrahepatic biliary atresia. No significant correlation was found between the alpha-1-antitrypsin concentration in the samples studied and the corresponding total antitrypsin activity.

The efficacy of compression immobilization technique in retarding spread of radio-labeled Russell's viper venom in rhesus monkeys and 'mock venom' NaI131 in human volunteers.

The efficacy of the modified compression immobilization technique in retarding spread of radio-labeled Russell's viper venom in 3 rhesus monkeys (Macaca mulata) and "mock venom" NaI131 in 14 human volunteers was studied. 0.1 microgram of Russell's viper venom having 10 microCi radioactivity in 0.2 ml normal saline containing 0.5% bovine serum albumin was injected subcutaneously at the lateral aspect of the right hind limb of a rhesus monkey. A hand-tight bandaging of a rubber pad measuring 55 x 28 x 16 mm over the injection site and splinting effectively retard spread of radio-labeled venom for the entire length of time applied, although complete immobilization was not achieved. In human volunteers, application of a pad measuring 60 x 50 x 17 mm over the subcutaneous injection site of 20 microCi or 12 microCi/0.2 ml NaI131 with a hand-tight bandaging (60 +/- 10 mmHg) and immobilization of limb was found to be effective in retarding the movement of radioactive NaI131. These results suggested that the compression pads tried in this study effectively retard the spread of radio-labeled Russell's viper venom (MW ranging from 20,000-90,000) and radioactive NaI131 (MW 150) from the site of injection. Thus, it is highly likely that the present compression pad will be useful as a first-aid measure in Russell's viper bite victims.

Promoting antenatal care services for early detection of pre-eclampsia

A prospective, quasi-experimental study was carried out in 2009 at urban health centres (UHCs)of five townships of Mandalay, Myanmar, to improve the skill of midwives (MWs) in diagnosis andreferral of pre-eclampsia (PE) from UHC to the Central Women’s Hospital (CWH) and to enhancethe supervision of midwives by lady health visitors (LHVs). The intervention was training on qualityantenatal care focusing on PE using an updated training manual. Altogether, 75 health care providers(MWs & LHVs) participated. In this study, data were extracted from patient registers and monthlyreports of UHCs and CWH. Interviewers were trained regarding the conduct of semi-structuredquestionnaires to elicit knowledge and to use checklists in observation of skills in screening ofPE, measuring blood pressure and urine protein (dipstick test). A guide for LHVs was also usedto obtain data, and data was collected six months prior to and after the intervention. Significantimprovements from baseline to endline survey occurred in the knowledge (p<0.001) and skill levels(p<0.001) including skills for screening, measuring blood pressure and urine protein. At CWH, therewas an increase in referred cases of PE after the intervention, from 1.25% to 2.56% (p<0.001). Inconclusion, this study highlights the early detection of pre-eclampsia by widespread use of qualityantenatal care, education and training of health-care providers to improve their performance andincrease human resources for health care, in order to enable women in our society to have healthypregnancies and healthy babies.

Four highly oxygenated isopimarane-type diterpenes of Orthosiphon stamineus.

Four highly oxygenated isopimarane-type diterpenes, named orthosiphols O, P and Q and nororthosiphonolide A, have been isolated from the aerial parts of Orthosiphon stamineus from Myanmar, together with three known diterpenes, orthosiphols D and E and orthosiphonone A. Their structures were determined on the basis of extensive spectral analysis. All the isolated compounds displayed mild antiproliferative activities against highly liver metastatic colon 26-L5 carcinoma and human HT-1080 fibrosarcoma cell lines.

Nutritional rickets without vitamin D deficiency in Bangladesh.

To understand nutritional rickets in Bangladesh better, 14 rachitic and 13 'unaffected' children were evaluated. Seventy per cent of children with active rickets had no evidence of either vitamin D deficiency or familial rickets. Rickets in Bangladesh is probably related to calcium deficiency. Abnormalities in 'unaffected' children suggest that subclinical calcium insufficiency is common.