Barriers to the Digitization of Health Information: A Qualitative and Quantitative Study in Kenya and Lao PDR Using a Cloud-Based Maternal and Child Registration System.

Digitalization of health information can assist patient information management and improve health services even in low middle-income countries. We have implemented a mother and child health registration system in the study areas of Kenya and Lao PDR to evaluate barriers to digitalization. We conducted in-depth interviews with 20 healthcare workers (HCWs) who used the system and analyzed it qualitatively with thematic framework analysis. Quantitatively, we analyzed the quality of recorded data according to missing information by the logistic regression analysis. The qualitative analysis identified six themes related to digitalization: satisfaction with the system, mothers' resistance, need for training, double work, working environment, and other resources. The quantitative analysis showed that data entry errors improved around 10% to 80% based on odds ratios in subsequent quarters compared to first quarter periods. The number of registration numbers was not significantly related to the data quality, but the motivation, including financial incentives among HCWs, was related to the registration behavior. Considering both analysis results, workload and motivation to maintain high performance were significant obstacles to implementing a digital health system. We recommend enhancing the scope and focus on human needs and satisfaction as a significant factor for digital system durability and sustainability.

Impact of village health volunteer support on postnatal depressive symptoms in the remote rural areas of Lao People's Democratic Republic: a cross-sectional study.

BACKGROUND: Village health volunteers (VHVs) are responsible for providing primary care in the communities of Laos. Unlike other districts, in Xepon more than 90% of VHVs are male and therefore experience difficulties interacting with pregnant women. To improve outreach to pregnant women, especially among ethnic minorities, a new project was implemented by local municipalities in 2017: newly selected female VHVs were paired to work with existing male VHVs. The objective of this study was to compare the postnatal depressive symptoms of ethnic minority mothers supported by pair-VHVs and single-VHVs in remote rural areas of Lao People's Democratic Republic (PDR). METHODS: A cross-sectional study was conducted in March 2019. Mothers who had delivered a baby within 1 year preceding the study were recruited from 36 villages. Of the 305 mothers, 227 responded. The questionnaires included (1) demographic characteristics such as age, economic status, and birth experience; (2) self-decision to go to a health center/hospital to receive antenatal care; (3) type of VHVs (pair or single), support, and information from VHVs during pregnancy, support from husband and relationship with husband; (4) the Edinburgh Postnatal Depression Scale (EPDS). A Mann-Whitney U test, chi-square test, and multiple linear regression analysis were performed. Ethical approval was obtained from the University of the Ryukyus and National Ethics Committee for Health Research of Lao PDR. RESULTS: The average total EPDS score was 5.5 among mothers supported by pair-VHV and 7.0 among mothers supported by single-VHV. Results of the multiple linear regression analysis showed that the EPDS score was significantly lower among mothers supported by pair-VHV (ß=-1.18, p <0.05) even after adjusting for economic and biological factors. CONCLUSIONS: Mothers supported by pair-VHV had a significantly lower EPDS score than those supported by single-VHVs in this study area, suggesting that the support of male and female VHV pairs contributed to improving mental health status among ethnic minority mothers in remote rural areas of Lao PDR. Expanding the program to train female VHVs working with male VHVs is necessary for improving maternal and child health in a rural district of Lao PDR.

Factors influencing the choice of facility-based delivery in the ethnic minority villages of Lao PDR: a qualitative case study.

BACKGROUND: Facility-based delivery has been promoted to improve maternal and child health care in Lao PDR and a free delivery policy was introduced at designated health care facilities (HCF) in 2013. However, according to birth records of HCFs in the impoverished and remote district, only a few women utilized the HCFs despite good physical accessibility. The aim of this study was to analyze the factors influencing the choice of facility-based delivery in the impoverished and remote district after a free delivery policy was introduced. METHODS: Qualitative case study was employed. Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted from August to October 2015. Five hamlets (or small village) located along the main road where only a few women delivered at HCFs were selected for the study based on birth records. The participants of the FGDs and IDIs were the village heads, village health volunteers, women who delivered at home or at a health facility within the past 2 years, their husbands, and mothers or mothers-in-law. Thematic analysis was used to analyze the data. RESULTS: A total of 12 FGDs and 27 IDIs were conducted, and the number of participants was 105. The factors influencing the choice of facility-based delivery were classified into nine categories and 19 subcategories. The categories were labeled, "perception of childbirth," "traditional health concept: sabaai (a condition of health, ease, and comfort)," "perception of health care facilities and staff," "previous pregnancy and childbirth experience," "mode of available transportation," "financial burden of childbirth at health care facility," "family and community context," "institutional context," and "government policy on delivery." CONCLUSION: Our study demonstrated that five major factors negatively influenced the choice of facility-based delivery: (1) perception of childbirth, (2) preference for sabaai, (3) financial burden, (4) family decision-making, and (5) institutional context. To promote facility-based delivery in the impoverished and remote district, three strategies are recommended: (1) promoting community-based health education involving women and strengthening community-based mutual support, (2) clarifying items essential for delivery at HCFs, and (3) making HCFs more comfortable in terms of "sabaai."

Malaria among foreign migrant workers in Savannakhet Province, Lao People's Democratic Republic.

BACKGROUND: Although mobile and migrant populations are considered an important group in malaria elimination settings, there is currently a lack of understanding about foreign migrant workers in the Lao People's Democratic Republic (Lao PDR). The present study aimed to document the migration characteristics, positive rate of malaria infection, and preventive and treatment-seeking behavior for malaria among foreign migrant workers in the malaria-endemic districts of Savannakhet province, Lao PDR. METHODS: A community-based survey was undertaken in four districts of Savannakhet province between February and June, 2015. Questionnaire-based interviews and blood examinations, including rapid diagnostic tests and PCR assays, were conducted with 391 migrant workers who were registered at local police departments. RESULTS: Most of the study participants were men (75.7%) and Vietnamese (92.6%). The median age (interquartile range) was 31 (25 to 41) years old. Most common occupation was factory worker (47.6%), followed by trader/shopkeeper (21.5%) and plantation worker/farmer (16.4%). The median length of stay (interquartile range) in the districts was 405 (183 to 1207) days. The majority of the participants (85.9%) had not worked in a province other than the study province, nor had the majority (92.6%) worked in a foreign country other than the Lao PDR. Although most of the participants (62.7%) reportedly used a bed net daily, these nets were mostly conventional untreated ones. No one tested positive for malaria. However, 10.0% of the participants reported a malaria-like illness episode that had occurred in the Lao PDR. The most common measure taken for the episode was to visit a hospital/health center in the Lao PDR, followed by conducting self-medication alone. Forty-one participants reported an experience of working in the forest while living in the Lao PDR. CONCLUSIONS: Foreign migrant workers who are registered at local police departments are unlikely to play a major role in maintaining local transmissions and spreading drug-resistant malaria in the study province. However, some of them were involved in forest-related activities, suggesting that these workers are potentially at risk of malaria. The Lao National Malaria Control Program should educate foreign migrant workers about the risk of malaria when living in Lao PDR.

Household clustering of asymptomatic malaria infections in Xepon district, Savannakhet province, Lao PDR.

BACKGROUND: In the Lao PDR, malaria morbidity and mortality have remarkably decreased over the past decade. However, asymptomatic infections in rural villages contribute to the on-going local transmission. The primary objective of this study was to explore the characteristics of infections in a malaria-endemic district of the Lao PDR. The specific objectives were to investigate the prevalence and species of malaria parasites using molecular methods and to assess individual and household parasite levels and the characteristics associated with malaria infection. METHODS: The study population included 870 participants from 236 households in 10 villages of the Xepon district. Interviews, blood examinations and body temperature measurements were conducted between August and September 2013. A multilevel logistic regression model, with adjustment for clustering effects, was used to assess the association between predictor variables and an outcome variable (malaria infection status as principally determined by PCR). The predictive factors included individual-level factors (age, gender, past fever episode, and forest activity during night time) and household-level factors (household member size, household bed net usage/density and a household with one other malaria-infected member). RESULTS: Fifty-two participants (including 26 children) tested positive (positive rate: 6.0 %): Plasmodium falciparum mono-infection was the most common infection (n = 41, 78.8 %), followed by P. falciparum and Plasmodium vivax mixed infections (n = 9, 17.3 %). The majority of infected participants (n = 42, 80.8 %) had no fever episodes in the two previous weeks or a measurable fever (>37 °C) at the time of survey. Living in a household with one other malaria-infected member significantly increased the odds of infection (odds ratio 24.33, 95 % confidence interval 10.15-58.32). Among the 40 households that had at least one infected member, nine households were responsible for 40.4 % of the total infections. CONCLUSIONS: Plasmodium vivax was detected more frequently than it was reported from the district hospital. Most infections were asymptomatic and sub-microscopic and were highly clustered within households. To further eliminate malaria in Xepon and other similar settings in the country, the National Malaria Control Programme should consider household-based strategies, including reactive case detection targeting the household members of index cases.

Asymptomatic malaria, growth status, and anaemia among children in Lao People's Democratic Republic: a cross-sectional study.

BACKGROUND: Asymptomatic malaria can be observed in both stable endemic areas and unstable transmission areas. However, although much attention has been given to acute malaria infections, relatively little attention has been paid to asymptomatic malaria. Nonetheless, because the asymptomatic host serves as a reservoir for the malaria parasite, asymptomatic malaria is now recognized as an important obstacle to malaria elimination. Asymptomatic malaria is also associated with anaemia, a global public health problem with serious consequences on human health as well as social and economic development. In Lao People's Democratic Republic (Lao PDR), malaria, anaemia, and malnutrition are serious public health concerns. However, few studies have focused on the relationship between these variables. Therefore, this study investigated the relationship between asymptomatic malaria, growth status, and the prevalence of anaemia among children aged 120 months old or younger in rural villages in Lao PDR. METHODS: In December 2010 and March 2011, data were collected from five villages in Savannakhet province. Anthropometric measurements, blood samples, and malaria rapid diagnostic tests were conducted. The presence of malaria was confirmed with polymerase chain reaction assays for Plasmodium falciparum. Underweight status, stunting, and anaemia were defined according to World Health Organization standards. RESULTS: The mean age of participants (n = 319) was 88.3 months old (Standard Deviation: 20.6, ranged from 30-119 months old), and 20 participants (6.3 %) had an asymptomatic malaria infection, 92 (28.8 %) were anaemic, 123 (38.6 %) were underweight, and 137 (42.9 %) were stunted. Stunted children were more likely to be infected with asymptomatic malaria [odds ratio (OR) 3.34, 95 % confidence interval (CI) 1.25-8.93], and asymptomatic malaria was associated with anaemia [OR 5.17, 95 % CI 1.99-13.43]. CONCLUSIONS: These results suggest a significant association between asymptomatic malaria and anaemia in children. Furthermore, stunted children were more likely to have lower Hb levels and to be infected with asymptomatic malaria than children without stunting. However, further studies examining the impact of asymptomatic malaria infection on children's nutritional and development status are necessary.

Morbidity assessment of Opisthorchis viverrini infection in rural Laos: I. Parasitological, clinical, ultrasonographical and biochemical findings.

BACKGROUND: Infections with the food-borne trematode Opisthorchis viverinni are common in Southeast Asia. In Lao PDR alone, two million people are supposed to be infected. Opisthorchiasis may cause severe liver disease, eventually leading to cholangiocarcinoma. The objective of this study is to assess the eating habits, complaints, symptoms, signs and ultrasonographical findings in three different areas of Savannakhet Province. METHODS: Study participants were recruited in Lahanam village in the flood-prone lowland of, Sonkhone district, Savannakhet Province (group A); in Non Somboon village, a community located on a hilly plateau in the same district (group B); and in staff of Savannakhet Province Hospital, Savannakhet town (group C). Eating habits, complaints and symptoms were recorded by standardized structured questionnaires. Participants were thoroughly examined clinically, and ultrasonography was performed. O. viverrini eggs were looked for in stool and in duodenal fluid. An array of biochemical and haematological parameters potentially related to liver disease was determined. Group A consisted of 45, group B of 31 and group C of 18 individuals. RESULTS: Eating habits were similar in the three groups, except that participants from group C tended to consume less high-risk types of fish dishes and more frequently ate beef and pork. Average intensity of infection (eggs per gram of stool) was low, but significantly higher in group A than in group B and C (p < 0.001). Medical history and complaints were similar in the three groups. Ultrasonography did not reveal any bile duct pathology. The only pathological finding was a slight elevation of ASAT and gamma-GT in a few participants in groups A and B. CONCLUSIONS: The study shows that eating habits favouring the infection with O. viverrini are common in south Laos. Although the average intensity of infection was low, there was a significant difference between the groups, paralleling slightly different eating habits. Clinically, this corresponded to a paucity of liver disease-associated complaints and signs. The low intensity of infection probably explains why no alterations of bile ducts were detectable by ultrasonography.

Households with Insufficient Bednets in a Village with Sufficient Bednets: Evaluation of Household Bednet Coverage Using Bednet Distribution Index in Xepon District, Lao PDR.

In Lao PDR, the National Malaria Control Program (NMCP) evaluates bednet coverage, often at the village level, using a coverage target of one net per 2.5 (or fewer) persons in a given population. However, in villages that meet the target, not all households necessarily meet the target or utilize all available bednets. This study explored households that fell short of the target and household utilization of bednets in villages that met the target of bednet coverage set by the NMCP. The person per net ratio (PPNR), which is defined as the population divided by the number of available bednets in a household/village, was used to determine whether a household/village met the NMCP target. Using a household survey, we collected and analyzed the data of 635 households in 17 villages in Xepon district in 2012. Households that fell short of the target (households with a PPNR of > 2.5 or no bednet) existed in every village. The proportion of these households differed greatly among the villages, ranging from 3.4-50%, with some households falling far short. Of the 635 households, 275 (43.5%) had at least one bednet that was not being used on the night preceding the survey and 131 (20.6%) had at least two. In conclusion, in villages that met the NMCP target, a considerable number of households fell short of the target, and the available bednets were not fully utilized in many of the surveyed households.

Successful mobile phone network-based approach to integration of the health care system in rural Laos: strengthening lay health worker performance.

INTRODUCTION: Little has been reported regarding how the effects of mobile phone-based improvements to healthcare worker communications may improve the activities of lay health workers, who form the crucial bridge between the official healthcare system and rural/remote communities. The objective of this study was to establish and assess the usefulness of a mobile phone-based communication network between village health volunteers (VHVs) and their supervisors in a rural district of Laos. METHODS: This study involved 154 villages out of a total of 158 villages located in Xepone district, Laos. Mobile phones with pre-paid cards were provided to 154 VHVs and 11 VHV supervisors; all were trained in the use of the phones and instructed to use the provided phone ad libitumfor work purposes. The supervisors recorded how or whether VHVs submitted their regular monthly vital event surveillance report and also took note of information pertaining to subject(s) discussed in the phone calls, whenever a call was made to or received from a VHV. RESULTS: In the 6-month period following mobile phone distribution, the group of supervisors received a total of 364 calls from VHVs. The most common purposes for the calls were the delivery of the monthly report; the second-most frequent purpose was the seeking of advice on case management, vitamin A distribution and delivery. The group of supervisors together made a total of 478 calls to VHVs during the 6-month period; the most frequent purpose was to request the monthly report and, second-most frequently, to inform in advance the scheduling of meetings, training, and outreach activities such as immunizations and health check-ups. Compared to the baseline, the number of villages with VHV submissions of monthly vital event surveillance reports significantly increased from 79 (51.3%) to 127 (82.5%) at 6 months after phone distribution. This increase was maintained at the 1-year time point (81.2%). CONCLUSION: The district-wide mobile phone communication network facilitated regular reporting, the seeking of advice, and the delivery of information regarding scheduling of various activities. The improved frequency and quality of communications has strong potential to translate into an improvement in health outcomes of people living in geographically remote and rural communities.