Estimating causes of community death of adults in Myanmar from a nationwide population sample: Application of verbal autopsy.

In Myanmar 84% of deaths occur in the community, of which half are unregistered and none have a reliable cause of death (COD) recorded. Since 2018, Myanmar has introduced improved registration practices and verbal autopsy (VA) to assess whether such methods can produce policy relevant information on community COD. Community health midwives and public health supervisors grade II collected VAs on over 80,000 deaths which occurred between January 2018 and December 2019 in a nationwide sample of 42 townships in Myanmar. Electronic methods were used to collect and consolidate data. The most probable COD was assigned using the SmartVA Analyze 2.0 computer algorithm. Completeness of VA death reporting increased to 71% in 2019. Most adult (12+ years) deaths (82%) were due to non-communicable diseases, primarily stroke, ischemic heart disease and chronic respiratory disease, for both men and women. VA results were consistent with Global Burden of Disease (GBD) Study estimates, except for cirrhosis in men, which was more common, and had a younger age distribution of death than the GBD. Large scale implementation of improved death registration practices and COD diagnosis using VA is feasible and provides plausible, timely, disaggregated and policy relevant information on the leading causes of community death. Addressing the burden of non-communicable diseases, particularly cirrhosis in young men, is an important public health priority in Myanmar. Improving completeness of VA death reporting in poorly performing townships and in neonates, children and women will further improve the policy utility of the VA data.

Developing and validating a questionnaire to assess an individual's perceived risk of four major non-communicable diseases in Myanmar.

Adopting healthy lifestyles is greatly influenced by an individual's perceived risk of developing non-communicable diseases (NCDs). This study aimed to develop and validate a questionnaire that can assess an individual's perceived risk of developing four major NCDs. We used the exploratory sequential mixed methods design. The qualitative part developed a questionnaire by two rounds of Delphi expert panels. The quantitative part validated the questionnaire using both exploratory (EFA) and confirmatory factor analysis (CFA). We used separate samples for EFA (n = 150) and CFA (n = 210). The participants were aged between 25-60 years of both sexes with no known history of NCDs, and face-to-face interviews were conducted. First, we generated an 86-item questionnaire based on the health belief model. Two expert panels ensured the questionnaire's content validity. The experts removed the overlapped items and items that did not represent the specific construct and developed a 51-item questionnaire. Next, we validated the questionnaire. We conducted a parallel analysis to determine the number of factors to be extracted. EFA constituted a five-factor model with 22 high loading items, which extracted 54% of the variance. We run four CFA models (single factor, five-factor, bifactor, and hierarchical) and tested the hypothesized five-factor model. It was found that the 21-item questionnaire (removed one efficacy item due to low loading) was satisfied with good psychometric properties and fitted with observed data in the bifactor model (RMSEA = 0.051, CFI = 0.954, TLI = 0.938, SRMR = 0.054). Hence, an individual's perceived risk of getting NCDs was constituted with a general perceived risk construct and five specific constructs (perceived susceptibility, perceived barrier, perceived benefit, perceived self-efficacy, and perceived behavioral change intention). It can be measured using the developed questionnaire (NCD-PR5-21). Further research is warranted to assess the questionnaire's utility in a mismatch between risk perception and current risk; and individualized counseling for behavioral change communication.

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.

Chronic low grade inflammation measured by dietary inflammatory index and its association with obesity among school teachers in Yangon, Myanmar.

BACKGROUND AND OBJECTIVES: This study was aimed to investigate the association between obesity and chronic low grade inflammation (CLGI) measured by Dietary Inflammatory Index (DII) as a proxy indicator of CLGI among obese and non-obese teachers. METHODS AND STUDY DESIGN: We conducted a cross sectional study among 128 non-obese (BMI <25) and 116 obese (BMI >=25) female teachers aged 25-60 years from six urban schools in Yangon, Myanmar between January and March 2015. Usual dietary intake was collected by 3-day nonconsecutive estimated 24 hour's dietary records and semi-quantitative Food Frequency Questionnaires. Adapted DII was calculated by standardized methods using literature-derived population-based dietary inflammatory weights of 31 food parameters. C-reactive protein (CRP) was analysed by a sandwich Enzyme-Linked Immunosorbent Assay (ELISA) technique. Mean DII between obese and non-obese was compared by independent t test. The association between obesity indices and high DII (DII >=1.1) and high CRP (>3 mg/L) were investigated by logistic regression. RESULTS: Obese teachers had lower intakes of anti-inflammatory nutrients (vitamin B-6, vitamin A and zinc)/food (onion) compared with non-obese teachers (p<0.05) and obesity was significantly associated with CRP (Odd ratio (OR)=5.5, 95% Confidence interval (CI) 1.2-24.1, p=0.02). However, there was no significant association between obesity and DII (OR=1.4, 95% CI -0.8-2.3, p=0.23). CONCLUSIONS: Role of antiinflammatory foods should be promoted for prevention of obesity and related diseases. Further use of DII among Myanmar general population for prevention of obesity and its related diseases should be explored with longitudinal studies.

Lipid profiles and determinants of total cholesterol and hypercholesterolaemia among 25-74 year-old urban and rural citizens of the Yangon Region, Myanmar: a cross-sectional study.

OBJECTIVE: The first is to estimate the prevalence of dyslipidaemia (hypercholesterolaemia, hypertriglyceridaemia, high low-density lipoprotein (LDL) level and low high-density lipoprotein (HDL) level), as well as the mean levels of total cholesterol, triglyceride, LDL and HDL, in the urban and rural Yangon Region, Myanmar. The second is to investigate the association between urban-rural location and total cholesterol. DESIGN: Two cross-sectional studies using the WHO STEPS methodology. SETTING: Both the urban and rural areas of the Yangon Region, Myanmar. PARTICIPANTS: A total of 1370 men and women aged 25-74 years participated based on a multistage cluster sampling. Physically and mentally ill people, monks, nuns, soldiers and institutionalised people were excluded. RESULTS: Compared with rural counterparts, urban dwellers had a significantly higher age-standardised prevalence of hypercholesterolaemia (50.7% vs 41.6%; p=0.042) and a low HDL level (60.6% vs 44.4%; p=0.001). No urban-rural differences were found in the prevalence of hypertriglyceridaemia and high LDL. Men had a higher age-standardised prevalence of hypertriglyceridaemia than women (25.1% vs 14.8%; p<0.001), while the opposite pattern was found in the prevalence of a high LDL (11.3% vs 16.3%; p=0.018) and low HDL level (35.3% vs 70.1%; p<0.001).Compared with rural inhabitants, urban dwellers had higher age-standardised mean levels of total cholesterol (5.31 mmol/L, SE: 0.044 vs 5.05 mmol/L, 0.068; p=0.009), triglyceride (1.65 mmol/L, 0.049 vs 1.38 mmol/L, 0.078; p=0.017), LDL (3.44 mmol/L, 0.019 vs 3.16 mmol/L, 0.058; p=0.001) and lower age-standardised mean levels of HDL (1.11 mmol/L, 0.010 vs 1.25 mmol/L, 0.012; p<0.001). In linear regression, the total cholesterol was significantly associated with an urban location among men, but not among women. CONCLUSION: The mean level of total cholesterol and the prevalence of hypercholesterolaemia were alarmingly high in men and women in both the urban and rural areas of Yangon Region, Myanmar. Preventive measures to reduce cholesterol levels in the population are therefore needed.

Changes in prevalence, awareness, treatment and control of hypertension from 2004 to 2014 among 25-74-year-old citizens in the Yangon Region, Myanmar.

BACKGROUND: Hypertension is the leading risk factor for cardiovascular diseases, and little is known about trends in prevalence, awareness, treatment and the control of hypertension in Myanmar. This study aims at evaluating changes from 2004 to 2014 in the prevalence, awareness, treatment and control of hypertension in the Yangon Region, Myanmar, and to compare associations between hypertension and selected socio-demographic, behavioural- and metabolic risk factors in 2004 and 2014. METHODS: In 2004 and 2014, household-based cross-sectional studies were conducted in urban and rural areas of Yangon Region using the WHO STEPS protocol. Through a multi-stage cluster sampling method, a total of 4448 and 1486 participated in 2004 and 2014, respectively, with the response rates above 89%. RESULTS: From 2004 to 2014, there was a significant increase in the age-standardized prevalence of hypertension from 26.7% (95% CI:24.4-29.1) - 34.6% (32.2-37.1), as well as an awareness from 19.4% (17.2-21.9) to 27.8% (24.9-31.0), while treatment and control rates did not change. The age-standardized mean systolic blood pressure increased from 122.8 (SE) ± 0.82 mmHg in 2004 to 128.1 ± 0.53 mmHg in 2014, whereas diastolic blood pressure increased from 76.2 ± 0.35 mmHg to 80.9 ± 0.53 mmHg. In multivariate analyses, hypertension was significantly associated with age, alcohol consumption, overweight and diabetes in both 2004 and 2014, and additionally associated with low physical activity and hypercholesterolemia in 2004. Combining all data, a significant association between study-year and hypertension persisted in different models with an adjustment for socio-demographic variables and behavioural variables, but not when adjusting for a combination of socio-demographic variables, the metabolic variables, BMI and hypercholesterolemia. CONCLUSION: The prevalence of hypertension has risen from 2004 to 2014 in both urban and rural areas of the Yangon Region, while, the awareness, treatment and control rate of hypertension remains low in urban and rural areas among both males and females. It is likely that changes in the metabolic variables, BMI and hypercholesterolemia have contributed to an increase in the prevalence of hypertension from 2004 to 2014. Factors associated with hypertension in both study years were age, alcohol consumption, overweight and diabetes. A national hypertension control programme should be implemented in order to reduce premature deaths in Myanmar.

Active case-finding for tuberculosis by mobile teams in Myanmar: yield and treatment outcomes.

BACKGROUND: Since 2005, the Myanmar National Tuberculosis Programme (NTP) has been implementing active case finding (ACF) activities involving mobile teams in hard-to-reach areas. This study revealed the contribution of mobile team activities to total tuberculosis (TB) case detection, characteristics of TB patients detected by mobile teams and their treatment outcomes. METHODS: This was a descriptive study using routine programme data between October 2014 and December 2014. Mobile team activities were a one-stop service and included portable digital chest radiography (CXR) and microscopy of two sputum samples. The algorithm of the case detection included screening patients by symptoms, then by CXR followed by sputum microscopy for confirmation. Diagnosed patients were started on treatment and followed until a final outcome was ascertained. RESULTS: A total of 9 349 people with symptoms suggestive of TB were screened by CXR, with an uptake of 96.6%. Of those who were meant to undergo sputum smear microscopy, 51.4% had sputum examinations. Finally, 504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%. Among total cases examined by microscopy, 6.4% were sputum smear positive TB. Treatment success rate was high as 91.8% in study townships compared to national rate 85% (2014 cohort). CONCLUSIONS: This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts, especially when equipped with portable, digital CXR machines that provided immediate results. However, the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis. In order to optimize the ACF through mobile team activity, future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.

The contribution of a non-governmental organisation's Community Based Tuberculosis Care Programme to case finding in Myanmar: trend over time.

BACKGROUND: It is estimated that the standard, passive case finding (PCF) strategy for detecting cases of tuberculosis (TB) in Myanmar has not been successful: 26% of cases are missing. Therefore, alternative strategies, such as active case finding (ACF) by community volunteers, have been initiated since 2011. This study aimed to assess the contribution of a Community Based TB Care Programme (CBTC) by local non-government organizations (NGOs) to TB case finding in Myanmar over 4 years. METHODS: This was a descriptive study using routine, monitoring data. Original data from the NGOs were sent to a central registry within the National TB Programme and data for this study were extracted from that database. Data from all 84 project townships in five regions and three states in Myanmar were used. The project was launched in 2011. RESULTS: Over time, the number of presumptive TB cases that were referred decreased, except in the Yangon Region, although in some areas, the numbers fluctuated. At the same time, there was a trend for the proportion of cases treated, compared to those referred, that decreased over time (P = 0.051). Overall, among 84 townships, the contribution of CBTC to total case detection deceased from 6% to 4% over time (P < 0.001). CONCLUSIONS: Contrary to expectations and evidence from previous studies in other countries, a concerning reduction in TB case finding by local NGO volunteer networks in several areas in Myanmar was recorded over 4 years. This suggests that measures to support the volunteer network and improve its performance are needed. They may include discussion with local NGOs human resources personnel, incentives for the volunteers, closer supervision of volunteers and improved monitoring and evaluation tools.

Different challenges, different approaches and related expenditures of community-based tuberculosis activities by international non-governmental organizations in Myanmar.

BACKGROUND: International non-governmental organizations (INGOs) have been implementing community-based tuberculosis (TB) care (CBTBC) in Myanmar since 2011. Although the National TB Programme (NTP) ultimately plans to take over CBTBC, there have been no evaluations of the models of care or of the costs of providing CBTBC in Myanmar by INGOs. METHODS: This was a descriptive study using routinely-collected programmatic and financial data from four INGOs during 2013 and 2014, adjusted for inflation. Data analysis was performed from the provider perspective. Costs for sputum examination were not included as it was provided free of charge by NTP. We calculated the average cost per year of each programme and cost per patient completing treatment. RESULTS: Four INGOs assisted the NTP by providing CBTBC in areas where access to TB services was challenging. Each INGO faced different issues in their contexts and responded with a diversity of strategies. The total costs ranged from US$ 140 754 to US$ 550 221 during the study period. The cost per patient completing treatment ranged from US$ 215 to US$ 1 076 for new cases and US$ 354 to US$ 1 215 for retreatment cases, depending on the targeted area and the package of services offered. One INGO appeared less costly, more sustainable and patient oriented than others. CONCLUSIONS: This study revealed a wide variety of models of care and associated costs for implementing CBTBC in diverse and challenging populations and contexts in Myanmar. Consequently, we recommend a more comprehensive evaluation, including development of a cost model, to estimate the costs of scaling up CBTBC country-wide, and cost-effectiveness studies, to best inform the NTP as it prepares to takeover CBTBC activities from INGOs. While awaiting evidence from these studies, model of CBTBC that have higher sustainability potential and allocate more resources to patient-centered care should be given priority support.

Prevalence of cardiovascular morbidities in Myanmar.

BACKGROUND: Cardiovascular diseases (CVDs) are now in a rising trend in South East Asia including Myanmar due to increase in major cardiovascular risk factors in both urban and rural areas, such as smoking, obesity and diabetes mellitus. It is necessary to determine CVD morbidities in Myanmar for planning of prevention and control activities for CVDs. The cross-sectional household survey was conducted in 2012 with 600 people aged 40 years and above in four townships (Kyauk-Tan, Mawlamyaing, Pathein and Pyay) and used face-to-face interview with standard questionnaire [Rose Angina Questionnaire and Questionnaire by European Cardiovascular Indicators Surveillance Set (EUROCISS) Research Group] to determine the level of reported CVD morbidities in adult population. RESULTS: Age of the study population ranged from 40 to 99 years with the mean age of 56 years. Seventy-one percent of the study population was women. Nine percent of the study population have suffered from angina according to Rose Angina Questionnaire. Prevalence of possible heart attack, stroke and heart failure was 7.5, 1.5 and 2.8%. Prevalence of hypertension was 51%. CONCLUSION: The CVD morbidities are high. There is a need for strengthening prevention and control activities of CVDs.

Betel Quid and Oral Potentially Malignant Disorders in a Periurban Township in Myanmar.

This study aims to describe betel quid chewing practice and compare oral potentially malignant disorders between chewers and non-chewers of betel quid among residents in Dagon Myothit (East) Township, Myanmar. The study used a cross-sectional design conducted with a representative sample of 542 adults aged 18 years and above in the township. The trained interviewers collected data using a pretested structured questionnaire. On-site oral examination was done for suspected oral lesions. The mean age of the respondents was 45 years and 59% were women. Fifty-two percent of the respondents were currently in the habit of chewing betel quids (72% of men and 39% of women). Among 284 current betel quid chewers, 240 (85%) chewed betel quids together with tobacco. Out of 284 current betel quid chewers, 24 (8.5%) were found to have oral potentially malignant disorders; out of 258 betel quid non-chewers, only 1 (0.4%) was found to have oral potentially malignant disorders. This highlights the growing importance of smokeless tobacco use as public health problem.

Prevalence and determinants of hypertension in Myanmar - a nationwide cross-sectional study.

BACKGROUND: Non-communicable diseases (NCDs), malaria and tuberculosis dominate the disease pattern in Myanmar. Due to urbanization, westernized lifestyle and economic development, it is likely that NCDs such as cerebrovascular disease and ischemic heart disease are on a rise. The leading behavioral- and metabolic NCDs risk factors are tobacco smoke, dietary risks and alcohol use, and high blood pressure and body mass index, respectively. The study aimed at estimating the prevalence and determinants of hypertension, including metabolic-, behavioral- and socio-demographic risk factors. METHODS: A nationwide, cross-sectional study of 7429 citizens of Myanmar aged 15-64 years were examined in 2009, using the WHO STEPS methodology. In separate analyses by gender, odds radios (ORs) and 95 % confidence intervals (CIs) for determinants of hypertension were estimated using logistic regression analyses. Confounders included in analyses were chosen based on Directed acyclic graphs (DAGs). RESULTS: The prevalence of hypertension was 30.1 % (95 % CI: 28.4-31.8) in males and 29.8 % (28.5-31.1) in females. The mean BMI was 21.7 (SD 4.3) kg/m(2) for males and 23.0 (5.1) kg/m(2) for females. In fully adjusted analyses, we found in both genders increased OR for hypertension if the participants had high BMI (males: OR = 2.6; 95 % CI 2.1-3.3, females: OR = 2.3; 2.0-2.7) and high waist circumference (males: OR = 3.4; 1.8-6.8, females: OR = 2.7; 2.2-3.3). In both sexes, associations were also found between hypertension and low physical activity at work, or living in urban areas or the delta region. Being underweight and use of sesame oil in cooking was associated with lower odds for hypertension. CONCLUSIONS: The prevalence of hypertension was high and associated with metabolic-, behavioral- and socio-demographic factors. Due to expected rapid economic growth in Myanmar we recommend similar studies in the future to follow up and describe trends in the risk factors, especially modifiable factors, which will most likely be on rise. Studies on effectiveness on interventions are needed, and policies to reduce the burden of NCD risk factors should be implemented if proven effective in similar settings.

Gaps and challenges to integrating diabetes care in Myanmar.

In common with other low-income countries, diabetes is a growing challenge for Myanmar. Gaps and challenges exist in political commitment, policy development, the health system, treatment-seeking behaviour and the role of traditional medicine. National policies aimed at prevention - such as to promote healthy food, create a healthy environment conducive to increased physical activity, restrict marketing of unhealthy food, and initiate mass awareness-raising programmes - need to be strengthened. Moreover, existing initiatives for prevention of noncommunicable-disease (NCD) are channelled vertically rather than being horizontally integrated. Primary health care is traditionally orientated more towards prevention of infectious diseases and staff often lack training in prevention and control of NCDs. Capacity-building activities have been modest to date, and retaining trained health workers in diabetes-oriented activities is a challenge. The World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings has been piloted in Yangon Region and country-wide expansion awaits ministerial approval. Recently, the Myanmar Diabetes Care Model was proposed by the Myanmar Diabetes Association, with the aims of both bridging the gap in diabetes care between rural and urban areas and strengthening care at the secondary and tertiary levels. However, implementation will require policy development for essential drugs and equipment, capacity-strengthening of health-care workers, and an appropriate referral and health-information system.