Maternal Risk Factors Associated with Preterm Birth: A Case Control Study.

BACKGROUND: Preterm birth is the child birth before 37 completed weeks .Prematurity is one of the leading causes of neonatal morbidity and mortality due to the complications associated with it. The objective of the study was to determine the maternal risk factors associated with all preterm birth in singleton pregnancy at National hospital. METHODS: Hospital based unmatched case control study was conducted between March 2021 to December 2021 at National hospital, Thimphu, Bhutan. Case to control ratio was 1:2.Data were collected using interviewer -administered structured questionnaires. The collected data were entered into Epi-data and exported into SPSS for analysis. Independent variables with p-valves<0.05 in the univariate analysis were entered to multi variable logistic model to estimate the strength of association .P-valve <0.05 was considered significant. RESULTS: Total of 107 cases and 201 controls participated with a response rate of 95.95%.Multiple logistic regression showed that mothers with ANC follow ≤ four[aOR 9.58(7.36-28.86) ], previous history of preterm delivery [aOR 2.99(1.5-15.77) ], previous caesarean section [aOR 5.72(2.19-14.92)], prelabour rupture of membrane [aOR 8.67(3.78-19.73)], fetal growth restriction [aOR 7.28(2.11-25.11)] , and pre-eclampsia [aOR 10.99(6.75-85.29) were the risk factors positively associated with preterm birth . CONCLUSIONS: This study highlights that preeclampsia, number of antenatal care visits ≤ four, prelabour rupture of membrane, fetal growth restriction, previous caesarean section and previous preterm delivery were the risk factors for preterm birth. This show the need of early screening and prevention of preeclampsia, strengthening of antenatal care follow-up, and treatment of infection to prevent prelabour rupture of membrane, reducing primary caesarean section and more attention and care with previous preterm birth .

Determinants of Neonatal Mortality in Bhutan: A Case-Control Study.

More than half of Bhutan's under-five mortality is attributed to neonatal deaths. Despite this, there is a lack of local evidence on determinants of neonatal mortality. It is critical to generate new evidence to accelerate interventions to achieve sufficient reduction of neonatal mortality rate in line to sustainable development goal target 3.2. Thus, this study was aimed at exploring determinants of neonatal mortality in Bhutan. A case-control study was performed with reported neonatal deaths from hospitals and primary health centers between 2018 and 2019. A total of 181 neonatal deaths were included as cases along with three corresponding controls. Epidata and STATA were used for data management and analysis, respectively. A multivariable model was fitted to identify determinants of neonatal mortality. History of obstetric complications (odds ratio [OR] = 3.53; 95% confidence interval [CI] = 1.48-8.42), intrapartum complications (OR = 3.86; 95% CI = 1.71-8.74) gestational age (OR = 8.07; 95% CI = 2.89-22.52), and Apgar 1 minute (OR = 4.40; 95% CI =1.83-10.59) were associated with neonatal death. Therefore, quality of care during pregnancy and childbirth besides promoting supportive family environment is essential to reduce neonatal mortality.

Challenges in epilepsy diagnosis and management in a low-resource setting: An experience from Bhutan.

Epilepsy is an important cause of morbidity and mortality especially in low- and middle-income countries. People with epilepsy (PWE) face difficulties in access to healthcare, appropriate diagnostic tests and anti-seizure medications (ASM). Bhutan is one such country in the Himalayas that has reported doubling of the prevalence of epilepsy from 155.7 per 100,000 population in 2017 to 312.4 in 2021. The country has one centre for electroencephalography and magnetic resonance imaging for a population of 0.7 million and does not have any neurologists as of 2023. There are 16 ASMs registered in the country but only selected medications are available at the primary level hospitals (phenobarbital, phenytoin and diazepam). There are challenges in the availability of these medicines all time round the year in all levels of hospitals. Neurosurgical treatment options are limited by the lack of adequate pre-surgical evaluation facilities and lack of trained human resources. The majority of PWE have reported facing societal stigma with significant impact on the overall quality of life. It is important to screen for psychiatric comorbidities and provide psychological support wherever possible. There is a need for a comprehensive national guideline that will cater to the needs of PWE and their caregivers within the resources available in the country. A special focus on the institutional and human resource capacity development for the study and care of epilepsy is recommended.

Special Sensory Function Deficit among Patients with Post-COVID-19 Visiting a Tertiary Care Centre.

Introduction: Several patients who recover from COVID-19 infection continue to have persistent symptoms even after recovery from the disease. The special sensory functions such as taste, smell and hearing are affected by COVID-19 infection even after recovery from the illness. The aim of the study was to find out the prevalence of special sensory deficits among patients with post-COVID-19 visiting a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among adult patients who recovered from COVID-19 visiting a tertiary care centre from 1 January 2022 to 31 December 2022. After obtaining ethical approval from the Research Ethics Board of Health, data on patients who were diagnosed with COVID-19 one year ago was obtained from the surveillance register from the Ministry of Health. They were contacted by phone call and invited to the centre to participate in the study. Appropriate clinical examination and tests were carried out to assess the special sensory deficits. A convenience sampling technique was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 271 patients, the prevalence of sensory function deficit was 39 (14.39%) (10.21-18.57, 95% Confidence Interval). Conclusions: The prevalence of special sensory deficits after recovery from COVID-19 infections was found to be similar to the findings of other studies. Keywords: anosmia; COVID-19; hearing loss.

Prevalence, Pattern, and Factors Associated With Self-reported Disability Among the Bhutanese Population: A Secondary Data Analysis of Population and Housing Census.

We analyzed the Population and Health Census of Bhutan (PHCB) 2017 to assess the prevalence and pattern of self-reported disability among people aged ≥15 years and the associated factors. The PHCB 2017 used the Washington Group Short Set on Functioning questionnaire to assess the disability ("lot of difficulty" or "cannot do at all") in seeing, hearing, mobility, cognition, self-care, and communication. Of the 536 443 persons included in the analysis, 384 101(71.6%) were aged <45 years, 283 453(52.8%) were men, and 206 103(38.4%) were from the rural area. The prevalence of any self-reported disability was 2.8%, among whom 34.2% reported multiple disabilities. The disability prevalence (any) was significantly higher among people aged ≥65 years, illiterate, economically inactive, permanent residents, residing in a rural area, and from central and eastern regions of the country compared with their respective counterparts. Further research on access to rehabilitation and linking with social protection schemes for the disabled is required in this country.

Postgraduate Surgical Education in Bhutan.

Postgraduate medical education in Bhutan began in 2014 which marked a new era in the medical education in the country. From a mere handful of surgeons in 2003 to the numbers today, general surgical services have come a long way in Bhutan. Medical education has progressed tremendously to adoption of modern medical educational methods promoting objectivity in all aspects. This article dwells with the historical perspective as well as the state of the general surgical education and the services in Bhutan. It is the first of its kind of article to be written.

Dietary behavior of school-going adolescents in Bhutan: Findings from the global school-based student health survey in 2016.

OBJECTIVES: Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan. METHODS: The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated. RESULTS: Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior. CONCLUSION: Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases.

Knowledge, attitude and practice towards health research and its utilization among health professionals in Bhutan: Results of a nationwide cross-sectional survey in 2019.

OBJECTIVES: Research is an important tool for sustainable development and the advancement of health. In Bhutan, the need for strengthening the national health research effort has been recognized only in recent years. As a part of research capacity building, this study was conducted to assess the knowledge, attitude and practices of the country's health care professionals towards research. METHODS: This was a nationwide cross-sectional study. Simple random sampling was used to obtain a proportionate composition of health professionals. A self-administered questionnaire was developed to assess knowledge through 10 multiple-choice questions, attitude through rating statements, and practices through assessing experiences with research. Knowledge was scored out of 10. Besides analysing proportions, correlation and simple linear regression coefficients were calculated to assess the association of knowledge score with age, work experience, qualification, and the number of research projects undertaken. RESULTS: A total of 420 valid questionnaires were collected (response rate = 95.2%). The mean knowledge score was 6.2 (±2.0) out of 10. There was a negative correlation between the knowledge score and the participant's age (r = -0.15, p = 0.002) and work experience (r = -0.17, p < 0.001). Participants' knowledge score increased by 0.58 (95% CI: 0.50-0.65, p < 0.001) for each unit increase in qualification level and by 0.75 (95%CI: 0.64-0.87, p < 0.001) for every research project conducted. The majority believed that local research would contribute to better clinical decision making (92.8%) by building local evidence (90.3%). Four out of five participants expressed interest in conducting research. However, only 27.4% had ever conducted research, 6.0% had published in journals and 4.3% had presented in scientific conferences. Less than half of the respondents had read (35.2%) or participated in discussions (42.1%) of research articles in their workplace. The major challenges were lack of knowledge (61.2%), time (49.9%) and resources to undertake literature searches (42.6%). CONCLUSIONS: Self-reported knowledge about health research was fair, and the conduct of research and utilization of research articles were poor. However, the majority hold positive attitudes and there is a need for supporting professional development in this area.

Epidemiology of Influenza among patients with influenza-like illness and severe acute respiratory illness in Pakistan: A 10-year surveillance study 2008-17.

In Pakistan, the burden of influenza was largely unknown, as no formal surveillance system was in place. In 2008, an influenza surveillance system was set up in eight sentinel sites. This study describes the epidemiology of influenza virus using a 10-year surveillance data from 2008 to 2017. Nasopharyngeal/throat swabs were collected from patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI) along with relevant epidemiological information. The samples were tested using real-time reverse transcriptase-polymerase chain reaction for the detection and characterization of influenza viruses. A total of 17 209 samples were tested for influenza, out of which 3552 (20.6%) were positive; 2151/11 239 (19.1%) were patients with ILI, whereas 1401/5970 (23.5%) were patients with SARI. Influenza A/H1N1pdm09 was the predominant strain with 40.6% (n = 1442) followed by influenza B (936, 26.4%). Influenza A/H1N1pdm09 was predominant among the children (5-14 years) and adults (15-64 years). Influenza B strain was predominantly found in the elderly age group (≥ 65 years) accounting for 48% of cases followed by children (2-4 years) accounting for 37% of cases. This 10-year surveillance data provides evidence of influenza activity in the country throughout the year with seasonal winter peaks. The results could be used to strengthen the epidemic preparedness and response plan.

Suicidal ideation and attempt among school going adolescents in Bhutan - a secondary analysis of a global school-based student health survey in Bhutan 2016.

BACKGROUND: Suicide is one of the leading causes of death and Disability Adjusted Life Years (DALYs) worldwide. The economic, emotional and human cost of suicidal behaviour to individuals, families, communities and society makes it a serious public health issue. We aim to determine the prevalence and factors associated with self-reported suicidal behaviour (suicidal ideation and attempt) among school going adolescents (13-17 years). METHODS: This is a secondary analysis of a nationally representative data for Bhutan namely Global School Based Student Health Survey in 2016 which reports on various dimensions of adolescent health including suicidal behaviour. The survey employed a multistage sampling method to recruit participants aged 13-17 years (n = 5809) from 50 schools (25 each in rural and urban area). The survey used an anonymous self-administered pre-tested 84-item questionnaire. Weighted analysis was done. Adjusted prevalence ratios (aPRs) and adjusted Odds Ratios (aORs) have been presented with 95% confidence intervals (95% CI). RESULTS: A total of 667 (11.6%) adolescents reported considering a suicide attempt whereas 656 (11.3%) reported attempting suicide in the past 12 months. Among those reporting suicidal ideation, 388 (58.6%) reported attempting a suicide and 274 (41.4%) had ideation alone, whereas, 247 (38.9%) reported attempting a suicide without previous ideation. Female sex, food insecurity, physical attack, sexual violence, bullying, feeling of loneliness, low parental engagement, reported worry about lack of sleep, urge to use drugs/alcohol, smokeless tobacco use, drug abuse and parental smoking were the factors associated with suicidal attempt. All these factors except smokeless tobacco use and parental smoking were associated with suicidal ideation. Having helpful/close friends was found to be protective against suicide ideation. CONCLUSION: Suicidal behaviour among school going adolescents in Bhutan is high and alarming, especially among girls. Bullying, sexual violence, feeling of loneliness and drug abuse were some of the key risk factors identified. It is important to identify these risk factors early and effectively tackle them in order to prevent suicides. It requires a multi-faceted intervention with the support of the children, community, teachers and parents.

Impact of faculty development programme on self-efficacy, competency and attitude towards medical education in Bhutan: a mixed-methods study.

BACKGROUND: Soon after Bhutan's first medical university was established in 2012, Faculty Development Programmes (FDPs) were adopted for efficient delivery of postgraduate medical curriculum. Medical education was an additional responsibility for the clinicians who already had multi-dimensional roles in the healthcare system where there is acute shortage of healthcare professionals. We studied the impact of FDPs on postgraduate medical education in Bhutan. METHODS: This was a mixed-methods study with a quantitative (cohort study - quasi-experimental with 18 participants) and concurrent explanatory qualitative component (focused group discussion (FGD) with 11 teaching faculty members). The 18 participants were given a structured FDP designed by the University. The FGD assessed teacher self-efficacy and competency using standard tools before and after the FDP. Thematic analysis of the FGD explored the impact of FDPs in the delivery of postgraduate residency programmes. RESULTS: There were significant increase in the teacher self-efficacy (31 vs 34, p = 0.009) and competency scores (56 vs 64, p = 0.011). There were significant improvements in self-efficacy in the domain of the teaching relevant subject contents and developing creative ways to cope with system constraints. In teaching-learning assessments, there was a significant appreciation of the effectiveness of lectures and tutorials and the use of essay questions. The FGD demonstrated the acceptance of FDPs and its importance in quality improvement of postgraduate medical education, professional development of teachers and improvement of their communication skills. The teachers have now migrated from the conventional methods of teaching to workplace-based teaching and assessment. The FDPs also resulted in review and revision of postgraduate medical curriculum soon after the first batch graduated in 2018. Lack of adequate support from relevant stakeholders and lack of a medical education centre in the University were seen as major challenges. CONCLUSIONS: The FDPs have brought tangible professionalization of postgraduate medical education at an early stage of the medical university. There is a need for continued efforts to strengthen, sustain and consolidate the gains made thus far.

"If we miss this chance, it's futile later on" - late antenatal booking and its determinants in Bhutan: a mixed-methods study.

BACKGROUND: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. METHODS: This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. RESULTS: Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. CONCLUSION: Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.

Internet Addiction among Secondary School Adolescents: A Mixed Methods Study.

INTRODUCTION: Excessive use of internet can lead to "Internet Addiction". A sharp rise in the number of internet users among adolescents in Bhutan have been observed lately which could have potential side-effects on their health. The aim of this study was to find the prevalence of internet addiction and psychological co-morbidities among the secondary school-going adolescents. METHODS: This is a descriptive cross-sectional quan-qual sequential mixed method design with a quantitative component and qualitative component. The study was conducted between 1st May and 30st November 2017 conducted in twelve schools across Bhutan after taking ethical clearance was from Research Ethics Board of Health of Bhutan. Data were doubleentered in EpiData Entry, validated and imported into STATA version 12.0 for analysis. Point estimate at 95% CI was calculated along with frequency and proportion for binary data. RESULTS: Among 721 adolescents from twelve selected schools, prevalence of internet addiction was 248 (34.440%) at , 95% Confidence Interval (31-38%). Out of A total of 586 (81%) preferred smartphone for internet use with 388 (54%) actually using it. Depression and anxietywere the associated psychological co-morbidities seen along with internet addiction. Internet addiction was high among those using internet at home, using smartphone for internet access, social networking and night time internet use were associated with internet addiction. Boredom, stress/anxiety and peer pressure were triggers of internet use. Internet addiction also affected academic performance, social interactions and sleep. CONCLUSIONS: Prevalence of internet addiction among adolescents in Bhutan is high comparing to previous standard data which requires immediate attention.

Prevalence of Internet Addiction and Associated Psychological Co-morbidities among College Students in Bhutan.

INTRODUCTION: Globally 3.5 billion people have access to internet and most of them are young adults and adolescents. In South Asia, Bhutan has the highest proportion of population with internet access at 37% in 2016. Many studies in Asia have reported significantly high level of internet addiction among college going students. In this light, this study was designed to estimate the prevalence of internet addiction and other co-morbidities. METHODS: This cross sectional study included 823 first year and final year students aged 18-24 from six colleges in Bhutan. A self-administered questionnaire consisting of three parts was utilized for data collection. The data was entered and validated in Epidata and analyzed using STATA/IC 14. RESULTS: The prevalence of moderate and severe internet addiction was 282 (34.3%) and 10 (1%) respectively. Positive correlations between internet addiction and psychological well-being (r= 0.331 95% CI: 0.269, 0.390), between Internet Addiction score and years of internet usage (r=0.104 95% CI: 0.036, 0.171), age and years of using internet (r= 0.8 95% CI: 0.012, 0.148) were observed. The commonest mode of internet use was martphone 714 (86.8%). The use of computer laboratory (aPR 0.80, 95%CI: 0.66, 0.96) and internet use for news and educational purposes (aPR 0.76, 95%CI: 0.64, 0.9) showed protective effects. CONCLUSIONS: The prevalence of internet addiction is high among the college going students in Bhutan. This warrants timely interventions to address the problems of internet addiction.

Epidemiology of Helicobacter pylori infection in asymptomatic schoolchildren in Bhutan.

AIM: Bhutan is a small mountainous country between Tibet and India with relatively homogenous population. According to the World Health Organization, gastric cancer is the most frequent cause of cancer death in Bhutan. This study examined the prevalence of Helicobacter pylori among children in Bhutan with emphasis on water source and living conditions. METHODS: A cross-sectional sero-epidemiologic study was conducted among schoolchildren who attended public schools in Thimphu, Bhutan. Between 2015 and 2016, blood samples from schoolchildren were collected after obtaining an informed consent from the school management and the children's parents. Demographic information, parents' education, family size living in the same household, and aspects of household environment including type of latrines, boiling drinking water were collected. All serum samples were tested for H. pylori immunoglobulin G (IgG) by commercial ELISA kits. RESULTS: There were 327 children between 4 and 19 years of age participated, 44% boys, mean age = 13.6 ± 3 years. The overall prevalence of H. pylori was 66% with no difference between boys and girls (66 vs 64%, respectively), P = .42. H. pylori prevalence was 75% among both 4-7 and 15-19 years and not statically different from that of the 8-10 or 11-14 age groups (59% and 63%, respectively), P = .1. H. pylori prevalence was inversely correlated with the level of mother's education (70% vs 55%) for those without and with a college education, respectively (OR = 2.3; 95%CI = 0.9-1.7), P = .08. The total number of people living in the same household did not correlate with H. pylori sero-prevalence, but households had less than 3 children had lower prevalence than those with 3 or more children (62% vs 71%, respectively OR = 1.7, 95% CI = [1.0-2.6], P = .05). CONCLUSIONS: H. pylori infection is prevalent among all age group children in Bhutan. The results suggest that transmission of H. pylori is related to personal care practices that directly correlate with the mothers' education and crowded living condition with children. Our results are important to developing prevention strategies for gastric cancer in Bhutan.