Differences in knowledge about epilepsy and antiepileptic drugs among pharmacy-dispensing workers in Cambodia and in Lao PDR.

Epilepsy is the most common neurological disorder encountered in primary care in Southeast Asia. People with epilepsy require long-term therapy management. Nonadherence to antiepileptic drugs (AEDs) has been identified as a major factor in suboptimal control of epilepsy. Pharmacies offer patients a first-line point of contact with the healthcare system. Many pharmacies operate with limited or nonqualified human resources that can lead to insufficient knowledge, inappropriate supply of medicines, and insufficient counseling. OBJECTIVE: The aim of this study was to evaluate the qualification and knowledge concerning epilepsy and AEDs among pharmacy-dispensing workers who sell drugs to people with epilepsy. METHOD: A cross-sectional qualitative study was conducted in public and private pharmacies, in both urban and rural areas of Cambodia and Lao People's Democratic Republic (Lao PDR). The knowledge was collected through a questionnaire. RESULTS: A total of 180 respondents from 123 outlets in the two countries were included in this study. A proportion of 40.8% (31) of respondents in Cambodia and 38.5% (40) in Lao PDR were pharmacists, followed by sellers who did not received any healthcare training with a proportion of 18.4% (14) in Cambodia compared to 20.2% (21) in Lao PDR. Head trauma was cited as the main cause of epilepsy by 72.4% (55) in Cambodia and 27.2% (28) in Lao PDR (p < 0.001). Epilepsy was considered as a contagious disease by 6.6% (5) of respondents in Cambodia compared to 18.4% (19) in Lao PDR (p = 0.03). Eighty-seven percent (66) of respondents in Cambodia knew at least one long-term AED versus 67.3% (70) in Lao PDR (p = 0.003). Phenobarbital was mentioned in more than 90.0% of cases in both countries. In overall, 15.4% (21) thought that if seizures are controlled for some months, people with epilepsy could stop taking their AEDs. Only one respondent from Lao PDR was aware of drug-drug interaction between AEDs and oral contraception. CONCLUSION: An educational intervention should be implemented to improve the knowledge of epilepsy and AEDs for pharmacy-dispensing workers. This could include advice for all pharmacy-dispensing workers in order to improve AED management and follow-up of therapeutic adherence.

Explanatory factors of adherence to community-based management of epilepsy in Lao PDR.

RELEVANCE: A low level of knowledge about epilepsy among health workers, a context of stigmatizing sociocultural beliefs, and a low availability of antiepileptic drugs in Lao People's Democratic Republic (PDR) are major gaps in the medical management of people with epilepsy in this country. OBJECTIVES: The principal objective of the study was to identify the associated factors of adherence to community healthcare structures in Lao PDR. Specific objectives were to evaluate patients' adherence status, practices and knowledge about epilepsy and its care, and factors influencing decision-making on therapeutic interventions. MATERIALS AND METHODS: The study was an observational cross-sectional survey about knowledge, attitudes, and practices, handled from February to May 2016. Eighty-seven people with epilepsy were identified in two areas in the periphery of Vientiane Capital through an active screening in villages and homes. Semidirective questionnaires were conducted to collect quantitative and qualitative data. Quantitative analysis included a comparison of adherent vs. nonadherent people with epilepsy, using Chi-square or Fisher's test. Advanced qualitative lexical analysis was carried out on the open-ended questions. RESULTS: Sixty-two people with epilepsy were included and the adherence rate to community care was 67.7%. The only sociodemographic variable that differed significantly between adherent and nonadherent members was the income level (p = 0.015): the wealthiest class of people with epilepsy did not adhere to community healthcare. Eleven percent of people with epilepsy thought that epilepsy was contagious, 80.6% that medication may reduce epilepsy seizure rates, and 33.9% that it was possible to cure epilepsy permanently. Physicians informed about the disease in 69.0% of adherent people with epilepsy and in 40.0% of nonadherent ones (p = 0.029), whereas villagers were involved in 29.0% and 50.0% of cases, respectively. There was a significant difference between the two groups for the prescribed antiepileptic drugs (p = 0.012): phenobarbital covered 73.8% of adherent people with epilepsy but only 40% of nonadherent ones. Half of nonadherent people with epilepsy went regularly to a central hospital in the Vientiane Capital, 15.0% went to Thailand, and 10.0% practiced self-medication in occasional mobilities. CONCLUSION: A wider range of antiepileptic drugs at a reduced cost and the promotion of adherence to community healthcare would allow a better management of people with epilepsy in Lao PDR.

Is insufficient knowledge of epilepsy the reason for low levels of healthcare in the Lao PDR?

BACKGROUND: The treatment gap for epilepsy is considerable in low and middle-income countries. In the Lao PDR it is estimated at over 90%. Health workers play a significant role in bridging the gap between people with epilepsy (PWE) and access to epilepsy care. In a national survey we assessed: 1) the knowledge and practices of health workers in the Lao PDR towards the disease, and, 2) patient attendance at health facilities. METHODS: We conducted a random three-stage sampling of health workers at the provincial, district and health center levels in 2009. RESULTS: Overall, 284 health workers were enrolled in 50 health facilities of 11 provinces: health centers 24.7%; district hospitals 23.2%; and province hospitals 52.1%. Only a minority of these (2.5%) recalled ever having received training or seeking information on epilepsy. Our survey showed a lack of knowledge in diagnosing and prescribing drugs for epilepsy, including phenobarbital, the first-line of treatment. The majority of respondents (59.9%) was unaware of the availability of antiepileptic drugs in health facilities. Only 10 (20%) health facilities, and no health centres, received people with epilepsy. It was estimated that one PWE per month receives medical attention. Traditional beliefs about PWE were common; such as the idea that epilepsy could be transmitted through saliva (63.2%). A higher attendance of PWE was observed in province hospitals where the knowledge of epilepsy care was higher. Global acceptance of people with epilepsy was low. CONCLUSIONS: The low level of knowledge of epilepsy on the part of health workers may be contributing to the wide treatment gap in the Lao PDR. Improving knowledge of this disease and increasing the availability of antiepileptic drugs will reduce misconceptions about epilepsy, thus encouraging more PWE to seek treatment. Community-based educational programs and extensive advocacy for people with epilepsy only began in 2009.

Management of epilepsy in Laos: Perceptions of healthcare professionals from Vientiane Capital province and traditional healers in Southern Laos.

BACKGROUND AND AIM: Traditional practices are deeply rooted in Lao people's perceptions and beliefs about health and illness.The objective of the study was to understand the perceptions of healthcare professionals and traditional healers regarding the management of epilepsy in Laos, and their reciprocal views. EXPERIMENTAL PROCEDURE: An observational study was carried out in two areas of Laos from February to May 2017. Semi directive questionnaires were used to collect quantitative and qualitative data. Semiotic square was carried out to highlight relationships between attitudes of traditional healers and healthcare professionals. For quantitative approach, the proportions were reported, and the test used was Fisher's test for nominal variables. The mean and standard deviation expressed the continuous variables and the Student's t-test was used. RESULTS AND CONCLUSION: Epilepsy was cited by 90.9% of traditional healers as a convulsive disease with saliva or urine, and herbal medicines were predominantly used (86.4%) to treat it. Few healthcare professionals (26.5%) pointed out that they knew remedies to treat epilepsy other than antiepileptic drugs (AEDs), and 76.5% of healthcare professionals mentioned that epilepsy was a disease which only AEDs could treat. On the other hand, 54.5% of traditional healers confirmed a traditional remedy could cure completely epilepsy through long-term use. Ninety percent of traditional healers said the collaboration with healthcare professionals was a good idea and 44.1% of the healthcare professionals group said was complicated.The combination of these medicines for the management of epilepsy needs to be adapted to Lao's medical context.

Good participatory practice for coronavirus disease 2019 (COVID-19) research: the case of a COVID-19 prevention study.

Background: The COPCOV study (chloroquine/ hydroxychloroquine prevention of coronavirus disease), which started recruitment in April 2020, is a multi-country double-blind, randomised, placebo-controlled trial which is being conducted in healthcare facilities involved in coronavirus disease 2019 (COVID-19) case management. COPCOV aims to recruit healthcare workers and other staff employed in facilities managing people with proven or suspected COVID-19. Methods: We conducted a series of engagement sessions, each involving a short presentation of the study, a section where attendees were asked to express if they would be interested in participating in such a study and which information they would need to change their view and an open Q&A section. Answers were transcribed and coded into themes by two independent investigators. Themes were derived from the data. The aims were to assess the feasibility of the study at the respective sites, to identify context-specific ethical issues, to understand concerns potential participants might have, to fine tune research procedures and to refine COPCOV information materials. They complemented other site-specific engagement, communication and public relation activities such as press releases and websites. Results: From 16 th March 2020 to 20 th January 2021, 12 engagement sessions were conducted in Thailand, Laos, Vietnam, Nepal and the UK involving 213 attendees in total. The sessions were designed to encourage potential participants and research professionals not directly involved in the project to interact with those who planned the study and those conducting it. Many attendees were keen to join the study while others had concerns. Questions raised revolved around the social value and study rationale; safety of trial medications and risk-benefit balance; study design and commitments. Conclusions: These sessions helped us refine information materials, identify misunderstandings about the study as well as complement site feasibility assessments. Our experience strongly supports the use of participatory practices prior to conducting clinical trials.

Availability, affordability, and quality of essential antiepileptic drugs in Lao PDR.

OBJECTIVE: Epilepsy is a chronic condition treatable by cost-effective antiepileptic drugs (AEDs), but limited access to treatment was documented. The availability and affordability of good quality of AEDs play a significant role in access to good health care. This study aimed to assess the availability, affordability, and quality of long-term AEDs in Lao PDR. METHOD: A cross-sectional study was performed in both public and private drug supply chains in urban and rural areas in Lao PDR. Data on AEDs availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest-paid government employee must work to purchase a monthly treatment. Samples of AEDs were collected, and the quality of AEDs was assessed through Medicine Quality Assessment Reporting Guidelines. RESULTS: Out of 237 outlets visited, only 50 outlets (21.1% [95% CI 16.1-26.8]) had at least one AED available. The availability was significantly different between urban (24.9%) and rural areas (10.0%), P = .017. Phenobarbital 100 mg was the most available (14.3%); followed by sodium valproate 200 mg (9.7%), phenytoin 100 mg (9.7%), and carbamazepine 200 mg (8.9%). In provincial/district hospitals and health centers, AEDs were provided free of charge. In other healthcare facilities, phenytoin 100 mg and phenobarbital 100 mg showed the best affordability (1.0 and 1.2 day wages, respectively) compared to carbamazepine 200 mg (2.3 days) and other AEDs. No sample was identified as counterfeit, but 15.0% [95% CI 7.1-26.6] of samples were classified as of poor quality. SIGNIFICANCE: We quantified and qualified the various factors contributing to the high treatment gap in Lao PDR, adding to diagnostic issues (not assessed here). Availability remains very low and phenobarbital which is the most available and affordable AED was the worst in terms of quality. A drug policy addressing epilepsy treatment gap would reduce these barriers.

Community-based management of epilepsy in Southeast Asia: Two intervention strategies in Lao PDR and Cambodia.

BACKGROUND: Epilepsy affects more than 50 million people worldwide, 80% of whom live in low- and middle-income countries (LMICs). In Southeast Asia, the prevalence is moderate (6‰), and the main public health challenge is reducing the treatment gap, which reaches more than 90% in rural areas. METHODS: This 12-month comparative study (intervention vs. control areas) assessed the community effectiveness of two different strategies for the identification and home follow-up of people with epilepsy by Domestic Health Visitors for epilepsy (DHVes). In Lao PDR, DHVes were health center staff covering several villages via monthly visits; in Cambodia, DHVes were health volunteers living in the villages. FINDINGS: At baseline, the treatment gap was >95% in Lao PDR and 100% in Cambodia. After 12 months, the treatment gap in Lao PDR decreased by 5·5% (range: 4·0-12·2) in the intervention area and 0·5% (range: 0·4-0·8) in the control area (p<0·0001). In Cambodia, the treatment gap decreased by 34·9% (range: 29·0-44·1) in the intervention area and 8·1% (range: 6·7-10·2) in the control area (p<0·0001). Among the PWEs followed at home by the DHVes, the proportion adhering to drug treatment was 85·2% in Lao PDR and 78·1% in Cambodia. The cost associated with strategy implemented in Cambodia, compared with the control area, was lower than the cost associated with strategy implemented in Lao PDR." INTERPRETATION: The treatment gap was significantly reduced with both intervention strategies, but the effect was larger in Cambodia. The results of this cost analysis pave the way for scaling-up in rural areas of Lao PDR and Cambodia, and experimental adaptation in other LMICs. FUNDING: The study was funded by the Global Health Department of Sanofi and Grand Challenges Canada (grant number 0325-04).

Vaccination status, knowledge and awareness towards hepatitis B among students of health professions in Vientiane, Lao PDR.

Health care workers (HCW) are a population at high risk of hepatitis B virus (HBV) infection, especially in endemic countries such as Lao PDR. Effective vaccines are available since over 10 years, but many HCWs are not aware of the risk of infection and are still not immunized against hepatitis B. This study aimed to assess immunization coverage against hepatitis B among the students of the University of Health Sciences (UHS) of Lao PDR in 2013 and to look for the causes of non-vaccination. A cross-sectional survey was conducted by self-administered questionnaire on a representative stratified sample of each academic year in each faculty. In total, 961 questionnaires were collected, Basic Sciences: 143, Medicine: 167, Pharmacy: 148, Dentistry: 139, Nursing Sciences: 159, Medical Technology: 99, and Postgraduate Studies: 106. Respondents were predominantly female (59.1%), mean age 25.1±7.0 years, single (76.3%), from the provinces (68.0%), of the Lao Loum ethnic group (84.4%). Among them, 21% were fully vaccinated against hepatitis B and 9.5% partially. Immunization coverage rates were significantly higher among women (p=0.01), students aged over 25 years, married or belonging to the post-graduate faculty (p<0.001). The most common reason (38.6%) given for non-vaccination was not knowing where to get vaccinated. Knowledge about hepatitis B, scored from 0 to 5, was poor (0-1) for 86.5% of the students, but 77.5% were aware of the hepatitis B vaccine. The knowledge scores were significantly higher for students aged over 25 years, married or post-graduated (p<0.001). Vaccination coverage against hepatitis B is dramatically low among students of health professions in Laos, largely because of their lack of knowledge and awareness. Upon admission to the University, all future HCWs should receive information about the occupational risks of blood-borne viruses transmission and be encouraged to get vaccinated against hepatitis B.

2009 A(H1N1) seroconversion rates and risk factors among the general population in Vientiane Capital, Laos.

OBJECTIVE: To assess 2009 A(H1N1) seroconversion rates and their determinants within an unvaccinated population in Vientiane Capital, Laos. METHODS: CoPanFlu Laos, a general population cohort of 807 households and 4,072 participants was established in March 2010. Sociodemographic data, epidemiological data, and capillary blood samples were collected from all the household members in March, and again in October 2010, in order to assess the level of antibodies to 2009 A(H1N1) with the haemagglutination inhibition assay. 2009 A(H1N1) seroconversion was defined as a fourfold or greater increase in titre between inclusion and follow-up. Determinants for pandemic influenza infection were studied using the generalized estimating equations model, taking household clustering into account. RESULTS: Between March and November 2010, 3,524 paired sera were tested. Prior to the pandemic, our cohort was almost completely vaccine-naive for seasonal influenza. The overall seroconversion rate among nonvaccinated individuals (n = 2,810) was 14.3% (95%CI [13.0, 15.6]), with the highest rate for participants under 20 yo (19.8%, 95%CI [17.4, 22.4]) and the lowest rate for participants over 60 yo (6.5%, 95%CI [3.7, 10.4]). Participants with lower baseline titres had significantly higher infection rates, with a dose-effect relationship. Odds ratios (ORs) ranged from 76.5 (95%CI [27.1, 215.8]), for those with a titre at inclusion of 1∶10, to 8.1 (95%CI [3.3, 20.4]), for those with a titre of 1∶40. Having another household member with a titre ≥1∶80 was associated with a higher likelihood of immunity (OR = 3.3, 95%CI [2.8, 3.9]). CONCLUSION: The determinants and age distribution for seroconversion within a vaccine-naive population were similar to those found in developed countries. This pandemic was characterized by strong epidemiological determinants, regardless of geographical zone and level of development. Moreover, we detected pre-existing cross-reacting antibodies in participants over 60 yo, which could not have originated from former multiple vaccination as has been suggested elsewhere.