WHO South-East Asia Journal of Public Health
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   2015| July-December  | Volume 4 | Issue 2  
    Online since May 22, 2017

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Opportunities and obstacles in child and adolescent mental health services in low- and middle-income countries: a review of the literature
Dutsadee Juengsiragulwit
July-December 2015, 4(2):110-122
DOI:10.4103/2224-3151.206680  PMID:28607309
Lower-income, less developed countries have few child and adolescent mental health professionals and a low availability of paediatric community mental health care. Child mental health professionals in low- and middle-income countries (LMICs) must therefore balance comprehensive tertiary care for the minority and provision of child and adolescent mental health services (CAMHS) within primary health care to serve the majority. This review aimed to identify the obstacles to, and opportunities for, providing CAMHS in LMICs. Articles from PsychInfo and PubMed, published up to November 2011, were retrieved using the search terms “child and adolescent”, “mental health services”, “child psychiatry”, “low- and middle-income countries”, “low-income countries” and “developing countries”. Articles were then retrieved from PubMed alone, using these search terms plus the individual country names of 154 LMICs. Fifty-four articles were retrieved from PsychInfo and 632 from PubMed. Searching PubMed with 154 LMIC names retrieved seven related articles. Inclusion criteria were (i) articles relating to CAMHS or child psychiatric services; (ii) subjects included in the articles were inhabitants of LMICs or developing countries; (iii) articles reported in English. After removal of duplicates, 22 articles remained. The contents of these articles were categorized and analysed by use of the six domains of the World Health Organization assessment instrument for mental health systems (WHO-AIMS), a tool developed to collect information on available resources within mental health systems. The provision of CAMHS in LMICs clearly needs a specific strategy to maximize the potential of limited resources. Mental health-policy and awareness campaigns are powerful measures to drive CAMHS. Training in CAMH for primary health-care professionals, and integration of CAMHS into existing primary health-care services, is essential in resource-constrained settings. A wide gap in research into CAMHS still needs to be filled. To overcome these challenges, the child mental health professional’s role in LMICs must encompass both clinical and public-health-related activities.
  12 2,076 258
Regional variation in maternal and childhood undernutrition in Bangladesh: evidence from demographic and health surveys
Masuda Mohsena, Rie Goto, CG Nicholas Mascie-Taylor
July-December 2015, 4(2):139-149
DOI:10.4103/2224-3151.206683  PMID:28607312
Background: Undernutrition among mothers and children is currently a major public health and development concern in Bangladesh. In literature relating to nutritional determinants, of particular interest is the geography, as regions with poor nutrition tend to pull down the overall nutritional status of the country. As such, reducing the regional gap can alone reduce overall undernutrition significantly, especially when regional gaps are high. The aim of this study is, therefore, to assess the magnitude of inequalities in undernutrition in children aged under 5 years in Bangladesh and their mothers, and relate this to the administrative divisions of the country. Methods: The Bangladesh Demographic and Health Surveys (1996–1997, 1999–2000, 2004 and 2007) were the sources of data, and a total of 16 278 mother–child pairs whose records were complete for the required individual and household-level variables were included in the analysis. Maternal nutritional status was measured by the body mass index (BMI). Weight-for-age, height-for-age and weight-for-height z-scores were calculated by use of the World Health Organization (WHO) Child Growth Standards to assess the nutritional status of children aged under 5 years. General linear model, sequential linear and multinomial logistic regression analyses were done to assess the inequalities in maternal and child nutritional status among the six administrative divisions of Bangladesh. Socioeconomic variables that were controlled for were residency, education and occupation of the mothers and their husbands, house type and possession score in the household. Results: Maternal BMI and prevalence of underweight, stunting and wasting in children aged under 5 years were found to vary significantly according to administrative division. Of the six divisions, Sylhet was found to have highest prevalence of undernourished mothers and children. The trends from 1996 to 2007 also established Sylhet as the poorest-performing region overall. Conclusion: The Sylhet administrative division needs specially focused attention from policy-makers if the overall performance of the health, nutrition and population sector is to reach the targets set by the country.
  9 1,978 210
Lessons for addressing noncommunicable diseases within a primary health-care system from the Ballabgarh project, India
Ritvik Amarchand, Anand Krishnan, Deepika Singh Saraf, Prashant Mathur, Deepak K Shukla, Lalit M Nath
July-December 2015, 4(2):130-138
DOI:10.4103/2224-3151.206682  PMID:28607311
Background: Most patients with noncommunicable diseases (NCDs) can be managed appropriately at the primary care level, using a simplified standard protocol supported by low-cost drugs. The primary care response to common NCDs is often unstructured and inadequate in low- and middle-income countries. This study assessed the feasibility of integration of NCD prevention and control within the primary health-care system of India. Methods: This study was done among 12 subcentres, 2 primary health centres (PHCs) and one subdistrict hospital in a block in north India. All 28 multipurpose health workers of these subcentres underwent 3-day training for delivering the package of NCD interventions as a part of their routine functioning. A time–motion study was conducted before and after this, to assess the workload on a sample of the workers with and without the NCD work. Screening for risk assessment was done at domiciliary level as well as at health-facility level (opportunistic screening), and the cost was estimated based on standard costing procedures. Individuals who screened positive were investigated with electrocardiography and fasting blood sugar. PHCs were strengthened with provision of essential medicines and technologies. Results: After training, 6% of the time of workers (n = 7) was spent in the NCD-related activities, and introduction of NCD activities did not impact the coverage of other major national health programmes. Loss during referral of “at-risk” subjects (37.5% from home to subcentre and 33% from subcentre to PHC) resulted in screening efficiency being lowest at domiciliary level (1.3 cases of NCDs identified per 1000 screened). In comparison to domiciliary screening (₹21 830.6; US$ 363.8 per case identified), opportunistic screening at subdistrict level (₹794.6; US$ 13.2) was 27.5 times and opportunistic screening at PHC (₹1457.5; US$ 24.3) was 15.0 times lower. There was significant utilization of NCD services provided at PHCs, including counselling. Conclusion: Opportunistic screening appears to be feasible and a cost-effective strategy for risk screening. It is possible to integrate NCD prevention and control into primary health care in India.
  4 2,074 269
Innovative use of social media platform WhatsApp during influenza outbreak in Gujarat, India
Bhagyesh Shah, Shuchi Kaushik
July-December 2015, 4(2):213-214
DOI:10.4103/2224-3151.206692  PMID:28607321
  3 1,635 151
HIV prevalence in blood donors and recipients in Pakistan: a meta-analysis and analysis of blood-bank data
Bushra Moiz, Barkat Ali, Muhammad Hasnain Chatha, Ahmed Raheem, Hasan Abbas Zaheer
July-December 2015, 4(2):176-183
DOI:10.4103/2224-3151.206687  PMID:28607316
Background: The first instances of HIV-antibody detection in donated blood in Pakistan were reported in 1988. Since then, documentation of HIV in blood donors and of rates of transmission via transfusion has been limited. Previously assumed to have a low prevalence, HIV is an increasing health concern in Pakistan. Since there is no national, centralized blood-banking system, there are no reliable data on which to base estimated risks of transfusion-associated HIV infection. This study was therefore conducted to estimate the prevalence of HIV in blood donors and recipients in Pakistan between 1988 and 2012. Methods: Meta-analyses were undertaken of reported prevalences of HIV in blood donors and recipients published during 1988–2012. Papers were identified by searching PubMed, Google, CINAHL and PakMediNet and the websites of the World Health Organization, the national HIV/AIDS Surveillance Project and the National AIDS Control Programme of Pakistan. In addition, the 1998–2012 records of the Aga Khan University blood bank were analysed. Results: The 254 abstracts identified at the preliminary search were reviewed and, after removal of duplications, case-reports, editorials and reviews, 32 papers were selected that met the inclusion criteria. All studies that reported on HIV antibodies in blood donors/recipients were included, irrespective of the methodology used. Since seroconversion had only been confirmed through supplemental testing in a few papers, the results were analysed separately for reports based on screening only and confirmed cases. A total of 142 of 2 023 379 blood donors and 4 of 3632 blood recipients were HIV positive, giving an overall pooled seroprevalence of 0.00111% in blood donors and 0.00325% in blood recipients. The annual prevalences of HIV in donors at the Aga Khan University blood banks were similar, ranging from 0.013% to 0.116%. Conclusion: Very few reports on HIV in blood donors in Pakistan could be retrieved, and the overall pooled prevalence is low. However, the limited data and confounding factors mean that that these results may significantly underestimate the true situation. It is recommended that a complete survey of blood banks should be conducted throughout the country, in order to provide a more reliable estimate of the risk of transfusion-associated HIV infection in Pakistan.
  3 2,059 209
Access to free health-care services for the poor in tertiary hospitals of western Nepal: a descriptive study
Preeti K Mahato, Giridhari Sharma Paudel
July-December 2015, 4(2):167-175
DOI:10.4103/2224-3151.206686  PMID:28607315
Background: Nepal is an underdeveloped country in which half of the total health expenditure is from out-of-pocket payments. Thus, the Government of Nepal introduced universal free health-care services up to the level of district hospitals, and targeted these services to poor and marginalized people in regional and subregional hospitals. The aim of this descriptive study was to explore the implementation and utilization of free health-care services by the target population (poor and marginalized people) in two tertiary-care hospitals in western Nepal, one with a social care unit (Western Regional Hospital) and one without a social care unit (Lumbini Zonal Hospital). Methods: Medical records maintained by the two hospitals for one Nepali calendar year were collected and analysed, along with information from key informant interviews with staff from each hospital and patient exit interviews. Results: Utilization of free health-care services by poor and marginalized people in the two tertiary-care hospitals was suboptimal: only 8.4% of patients using services were exempted from payment in Western Regional Hospital, whereas it was even fewer, at 2.7%, in Lumbini Zonal Hospital. There was also unintended use of services by nontarget people. Qualitative analysis indicated a lack of awareness of free health-care services among clients, and lack of awareness regarding target groups among staff at the hospitals. Importantly, many services were utilized by people from rural areas adjoining the district in which the hospital was situated. Conclusion: Utilization of free health-care services by the target population in the two tertiary-care hospitals was very low. This was the result of poor dissemination of information about the free health-care programme by the hospitals to the target population, and also a lack of knowledge regarding free services and target groups among staff working in these hospitals. Thus, it is imperative to implement educational programmes for hospital staff and for poor and marginalized people. Unintended use of free services was also seen by nontarget groups; this suggests that there should further simplification of the process to identify target groups.
  2 1,867 149
Exploring the factors that influence the perceptions of disability: a qualitative study of mothers of children with disabilities at a community-based rehabilitation centre in Sri Lanka
Michel D Landry, Sudha R Raman, Elise Harris, Layla Madison, Meera Parekh, Cecile Banks, Huda Bhatti, Champa Wijesinghe
July-December 2015, 4(2):150-158
DOI:10.4103/2224-3151.206684  PMID:28607313
Background: The prevalence of disability is growing worldwide; however, perceptions regarding disability are not well understood. The aim of this study was to explore factors that influence the perception of disability among mothers of children with disabilities who were attending a community-based rehabilitation facility in Sri Lanka. Methods: A descriptive qualitative research design was employed. Thirteen semi-structured interviews were conducted with participants receiving rehabilitation services at a community-based facility. Interviews were recorded, transcribed and coded using software for qualitative data. Results: Three major themes emerged from the analysis: (i) level of family and community support; (ii) spiritual and cultural interpretations of disability; and (iii) outcomes of rehabilitation services. Perceptions of disability appeared to be strongly influenced by the social, community and spiritual/cultural support structure in which the mothers lived. In particular, the support from the participant’s spouse emerged as a primary factor exerting strong influence on perception, and future outlook, among the participants. Engagement in community-based rehabilitation programming also reinforced positive perceptions, created a sense of hope among participants regarding their child’s future, and established aspirations for future education and employment opportunities alongside social integration. Conclusion: Knowledge of factors that influence the perception of disability can inform future implementation of public-health and community-based initiatives, and may improve social integration of children with disabilities in lower-resource settings.
  1 1,915 148
HIV drug-resistance early-warning indicators and quality care in India: preliminary findings from a pilot study in Pune city
Manisha Ghate, Dileep Kadam, Nitin Gaikwad, Subramanian Shankar, Shraddha Gurav, Girish Rahane, Sukarma Tanwar, Bharat Rewari, Raman Gangakhedkar
July-December 2015, 4(2):123-129
DOI:10.4103/2224-3151.206681  PMID:28607310
Background: India has rapidly scaled up its programme for antiretroviral therapy (ART). There is high potential for the emergence of HIV drug resistance (HIVDR), with an increasing number of patients on ART. It is not feasible to perform testing for HIVDR using laboratory genotyping, owing to economic constraints. This study piloted World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR, and quality-of-care indicators (QCIs), in four ART clinics in Pune city. Methods: A retrospective study was conducted in 2015, among four ART clinics in Pune city, India. The data on four standardized EWIs (EWI 1: On-time pill pick-up, EWI 2: Retention of patients in ART care at 12 months after initiation, EWI 3: Pharmacy stock-out, EWI 4: Pharmacy dispensing practices) and three QCIs (QCI 1: Regularity in CD4 testing in patients taking ART, QCI 2: Percentage of patients initiating ART within 30 days of medical eligibility, QCI 3: Percentage of patients initiating ART within 30 days of initiation of anti-tuberculosis therapy) were abstracted into WHO Excel HIV data abstractor tools, from the patient records from April 2013 to March 2014. Results: All four ART clinics met the EWI 4 target (100%) for ART dispensing practices. The target for EWIs on-time pill-pick (EWI 1 >90%) and pharmacy stock-outs (EWI 3: no stock-outs, 100%) were achieved in one clinic. None of the clinics met the EWI 2 target for retention in care at 12 months (>90%) and the overall retention was 76% (95% confidence interval: 73% to 79%). The targets for QCI 1 and QCI 2 (>90% each) were achieved in one and two clinics respectively. None of the clinics achieved the target for QCI 3 (>90%). Conclusion: ART dispensing practices (EWI 4) were excellent in all clinics. Efforts are required to strengthen retention in care and timely pill pick-up and ensure continuity of clinic-level drug supply among the programme clinics in Pune city. The clinics should focus on regularity in testing CD4 count and timely initiation of ART.
  1 1,634 157
Impact of rubella vaccination on elimination of congenital rubella syndrome in Sri Lanka: progress and challenges
Deepa Gamage, Geethani Galagoda, Paba Palihawadana
July-December 2015, 4(2):189-196
DOI:10.4103/2224-3151.206689  PMID:28607318
Rubella infection in pregnancy can lead to pathologies, including miscarriage, stillbirth and congenital rubella syndrome (CRS) in the neonate. Rubella vaccination can prevent all occurrences of CRS. In Sri Lanka, significant outbreaks of CRS occurred in 1994 and 1995, with 275 and 212 reported cases. In 1996, Sri Lanka introduced rubella vaccination for women aged 16–44 years, to stop CRS. Measles–rubella vaccine was introduced into the routine immunization schedule in 2001 and additional campaigns were carried out in 2003 (all 11–15 year olds) and 2004 (all 16–20 year olds). Reported immunization coverage with a single dose of a rubella-containing vaccine has been more than 95% since 2000. Laboratory-supported surveillance for rubella and CRS was started in 1992. Reported rubella cases fell from 364 (incidence 19/million population) in 1999 to 96 cases (incidence 5/million population) in 2002 and further to 12 cases (incidence 0.6/ million population) in 2014. Laboratory-supported CRS surveillance was started in 1990 and the highest number of CRS cases, 275 (incidence 77/100 000 live births), was diagnosed in 1994. Reported CRS cases fell from 22 cases (incidence 7/100 000 live births) in 2002 to 3 cases (incidence <1/100 000 live births) in 2014. Almost 20 years of routine rubella vaccination has resulted in >96% reduction in reported rubella cases and a corresponding >98% reduction in CRS cases. Despite this great achievement, work remains to eliminate rubella and CRS from Sri Lanka.
  1 1,817 145
Towards elimination of parent-to-child transmission of syphilis in India: a rapid situation review to inform national strategy
Vani Srinivas, Prasad LN Turlapati, Anil K Bhola, Aman K Singh, Shobini Rajan, Radha S Gupta, Sunil D Khaparde
July-December 2015, 4(2):197-203
DOI:10.4103/2224-3151.206690  PMID:28607319
In February 2015, India’s National AIDS Control Organisation, Ministry of Health and Family Welfare, launched a national strategy towards elimination of parent-to-child transmission (E-PTCT) of syphilis, with a goal to reduce the incidence of congenital syphilis to 0.3 cases per 1000 live births by 2017. As part of the development of the national strategy, a rapid situation analysis was undertaken to ascertain the current practices, challenges and barriers for E-PTCT of syphilis in India. The analysis was conducted during February and March 2014 in five states selected from five different regions of India. Key informant interviews were conducted with key stakeholders at facility, state and district level. Content analysis was used to identify the themes. Key barriers identified for E-PTCT of syphilis were: low priority for antenatal syphilis testing among providers, limited access to testing, untrained human resources, shortage of test kits and benzathine penicillin, nonadherence to the national protocol for syphilis testing, and poor recording and reporting of antenatal syphilis data. The analysis also identified opportunities for functional integration of E-PTCT within existing maternal and child health programmes. Health-care providers and programme managers expressed a need for training in the programme for E-PTCT of syphilis. The situation analysis identified that, for successful implementation of E-PTCT of syphilis, it is essential that state and district programme managers adopt this initiative; coordinate the programme; plan for an adequate budget in their programme implementation plan; ensure an uninterrupted supply of standardized diagnostics kits and drugs at all levels of health care; and adhere to E-PTCT guidelines when implementing the programme.
  1 1,858 134
Landscaping capacity-building initiatives in epidemiology in India: bridging the demand–supply gap
Sanjay Zodpey, Anuja Pandey, Manoj Murhekar, Anjali Sharma
July-December 2015, 4(2):204-212
DOI:10.4103/2224-3151.206691  PMID:28607320
India, the second most populous country in the world, has 17% of the world’s population but its total share of global disease burden is 21%. With epidemiological transition, the challenge of the public health system is to deal with a high burden of noncommunicable diseases, while still continuing the battle against communicable diseases. To combat this progression, public health capacity-building initiatives for the health workforce are necessary to develop essential skills in epidemiology and competencies in other related fields of public health. This study is an effort to systematically explore the training programmes in epidemiology in India and to understand the demand–supply dynamics of epidemiologists in the country. A systematic, predefined approach, with three parallel strategies, was used to collect and assemble the data regarding epidemiology training in India and assess the demand–supply of epidemiologists in the country. The programmes offering training in epidemiology included degree and diploma courses offered by departments of preventive and social medicine/community medicine in medical colleges and 19 long-term academic programmes in epidemiology, with an estimated annual output of 1172 per year. The demand analysis for epidemiologists estimated that there is need for at least 3289 epidemiologists to cater for the demand of various institutions in the country. There is a wide gap in demand–supply of epidemiologists in the country and an urgent need for further strengthening of epidemiology training in India. More capacity-building and training initiatives in epidemiology are therefore urgently required to promote research and address the public health challenges confronting the country.
  1 1,605 123
Making “prevention and preparedness” a recovery priority: lessons from the response to the 2015 Nepal earthquake
Roderico H Ofrin, Michel D Landry
July-December 2015, 4(2):107-109
DOI:10.4103/2224-3151.206679  PMID:28607308
  - 1,320 103
Tobacco-promotional activities in rural Sri Lanka: a cross-sectional study of knowledge, exposure and responses among adolescent schoolchildren
E Madhurangi Perera, Nalika s Gunawardena
July-December 2015, 4(2):159-166
DOI:10.4103/2224-3151.206685  PMID:28607314
Background: Tobacco promotions are linked to tobacco consumption in adolescents. The aim of this study was to determine knowledge of and exposure and responses to tobacco-promotional activities and factors associated with knowledge among adolescents in a rural setting in Sri Lanka. Methods: Seven schools in Polonnaruwa district were randomly selected for this cross-sectional study. Adolescents (n = 500) aged 14–15 years in grade 10 were selected using convenience sampling and studied by using a self-administered questionnaire during June–October 2014. The questions on exposure to tobacco-promotional activities were based on the validated questionnaire of the Global Youth Tobacco Survey. Adolescents were categorized into two levels of knowledge, exposure and responses to tobacco promotions, based on the scores obtained. Selected factors associated with knowledge of tobacco promotions were assessed using univarate and multivariate analyses. Results: The response rate was 99.6% (498/500). The mean age of the adolescents was 14.9 years (standard deviation ±0.37) and the proportion of females was slightly higher (n = 280, 56.2%) than for males. The prevalence of current smoking was 3.2% (n = 16). Half (48.6%, n = 242) of the adolescents had a good level of knowledge of tobacco-promotional activities. Most (64.9%, n = 323) had experienced a low level of exposure to tobacco-promotional activities, while 85.7% (n = 427) indicated that they had responded/would respond assertively to exposure to tobacco promotion. In the univariate analysis, having a mother with a high level of education (odds ratio [OR] 1.742), having a father with a high level of education (OR 1.997) and the student attending a type 1AB school (OR 1.310) were significant factors associated with a good level of knowledge of tobacco-promotional activities. A father with a high level of education (adjusted OR 1.772) and the student attending a type 1AB school (adjusted OR 1.455) were the factors associated with a good level of knowledge for tobacco-promotional activities, when confounding effects of the variables were taken into consideration. Conclusion: Knowledge of tobacco-promotional activities was poor among the adolescents in the rural setting in Sri Lanka. Nevertheless, most of the adolescents in the study population indicated that their responses to such exposures were/ would be assertive.
  - 1,574 123
Feasibility of implementing an integrated tool for improvement of treatment quality and early-warning indicators for HIV drug resistance: a pilot study of centres in India
Bharat B Rewari, Nicole S Seguy, Sukarma SS Tanwar, Po-Lin Chan, Vimlesh Purohit, Pauline Harvey, Dongbao Yu, AS Rathore
July-December 2015, 4(2):184-188
DOI:10.4103/2224-3151.206688  PMID:28607317
With the rapid scale-up in use of antiretroviral therapy (ART), monitoring the quality of care and factors that may lead to emergence of HIV drug resistance (HIVDR) is an important focus point for programme managers. The National AIDS Control Organisation of India embarked on strengthening the ART programme for continuous quality improvement (CQI), using defined quality-of-care indicators (QCIs), including World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR. In this feasibility study, done during July 2014, an integrated QCI and EWI tool developed by WHO India was pilot tested across 18 purposively selected ART centres. At seven ART centres, the EWI 1 target of >90% on-time pill pick-up was achieved for adult patients, while among the paediatric age group (<15 years old) it was not achieved by any centre. EWI 2 (retention of patients in ART care at 12 months after initiation) showed that two centres had retention of both adult and paediatric patients of >85% at 12 months of ART, while 11 centres had retention between 75% and 85%. EWI 3 (pharmacy stock-out) for adult and paediatric patients showed that 11 ART centres reported a minimum of one stock-out for the first-line ART drugs in the reporting period, while EWI 4 targets (pharmacy dispensing practices) were achieved by all the centres, for both adults and children. Average retention in care at 6, 12 and 24 months after ART initiation was 82%, 77% and 71%, respectively. This feasibility study showed that EWI analyses were much simpler to conduct if information was sought only for patients receiving ART, for whom the quality of record-keeping is better and more consistent. The activity has highlighted the need for improved quality of record-keeping at the facilities and implementation of specific interventions to ensure better patient follow-up. After modifications, use of the tool will be phased in across all the ART centres in India.
  - 1,474 122