WHO South-East Asia Journal of Public Health
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   2017| April  | Volume 6 | Issue 1  
    Online since May 12, 2017

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Suicide and depression in the World Health Organization South-East Asia Region: A systematic review
Helal Uddin Ahmed, Mohammad Didar Hossain, Afzal Aftab, Tanjir Rashid Soron, Mohammad Tariqul Alam, Md Waziul Alam Chowdhury, Aftab Uddin
April 2017, 6(1):60-66
DOI:10.4103/2224-3151.206167  PMID:28597861
Background Depression is the most common comorbid psychiatric disorder in people who die by suicide and 39% of global suicides occur in the World Health Organization (WHO) South-East Asia Region. The aim of this systematic review was to identify, for countries of this region, first the prevalence of depression among people who (i) die by, or (ii) attempt, suicide, and second, the proportion of people with depression who attempt or die by suicide. Methods PubMed, PsycINFO, EMBASE and Google Scholar were searched, together with five available national databases, for quantitative research papers published in English between 1956 and 4 September 2016 from the 11 countries of the WHO South-East Asia Region. Results The 19 articles that met the predefined eligibility criteria were from five countries: Bangladesh (1), India (12), Indonesia (1), Sri Lanka (3) and Thailand (2); no eligible papers from the remaining countries of the region were retrieved. Eight studies, from Bangladesh, India, Indonesia and Sri Lanka, reported the prevalence of depression among people who had died by suicide. The study settings varied, as did the proportion of depression recorded (6.9–51.7%), and the study sample sizes ranged from 27 to 372. Eight studies from India and one from Sri Lanka investigated depression among people who had attempted suicide. Using a range of screening and diagnostic tools, the reported prevalence of depression ranged between 22.0% and 59.7%. The study sample sizes ranged from 56 to 949. Only two articles were found, both from Thailand, that reported on suicide in people with depression. Conclusion Despite the high burden of mortality of suicide in the WHO South-East Asia Region, evidence on the relation between suicide and depression is scarce. There is a need to understand this phenomenon better, in order to inform suicide-prevention strategies in the region.
  9 5,914 973
Post-disaster mental health and psychosocial support: Experience from the 2015 Nepal earthquake
Surendra Sherchan, Reuben Samuel, Kedar Marahatta, Nazneen Anwar, Mark Humphrey Van Ommeren, Roderico Ofrin
April 2017, 6(1):22-29
DOI:10.4103/2224-3151.206160  PMID:28597855
On 25 April 2015, an earthquake of magnitude 7.8 struck Nepal, which, along with the subsequent aftershocks, killed 8897 people, injured 22 303 and left 2.8 million homeless. Previous efforts to provide services for mental health and psychological support (MHPSS) in humanitarian settings in Nepal have been largely considered inadequate and poorly coordinated. Immediately after the earthquake, the Government of Nepal declared a state of emergency and the health sector started to respond. The immediate response to the earthquake was coordinated following the Inter-Agency Standing Committee (IASC) cluster approach. One month after the disaster, integrated MHPSS subclusters were initiated to coordinate the activities of many national and international, governmental and nongovernmental, partners. These activities were largely conducted on an ad-hoc basis, owing to lack of focus on MHPSS in the health sector’s contingency plan for emergencies. The mental health subcluster attempted to implement a mental health response according to World Health Organization and IASC guidelines. The MHPSS response highlighted many strengths and weaknesses of Nepal’s mental health system. This provides an opportunity to “build back better” through reform of mental health services. A strategic response to the lessons of the 2015 earthquake will deliver both improved population mental health and increased preparedness for the future.
  6 2,770 442
Suicide burden and prevention in Nepal: The need for a national strategy
Kedar Marahatta, Reuben Samuel, Pawan Sharma, Lonim Dixit, Bhola Ram Shrestha
April 2017, 6(1):45-49
DOI:10.4103/2224-3151.206164  PMID:28597859
Suicide is a major cause of deaths worldwide and is a key public health concern in Nepal. Although routine national data are not collected in Nepal, the available evidence suggests that suicide rates are relatively high, notably for women. In addition, civil conflict and the 2015 earthquake have had significant contributory effects. A range of factors both facilitate suicide attempts and hinder those affected from seeking help, such as the ready availability of toxic pesticides and the widespread, although erroneous, belief that suicide is illegal. Various interventions have been undertaken at different levels in prevention and rehabilitation but a specific long-term national strategy for suicide prevention is lacking. Hence, to address this significant public health problem, a multisectoral platform of stakeholders needs to be established under government leadership, to design and implement innovative and country-contextualized policies and programmes. A bottom-up approach, with active and participatory community engagement from the start of the policy- and strategy-formulation stage, through to the design and implementation of interventions, could potentially build grass-roots public ownership, reduce stigma and ensure a scaleable and sustainable response.
  4 2,444 214
Motivating and demotivating factors for community health workers: A qualitative study in urban slums of Delhi, India
Mathew Sunil George, Shradha Pant, Niveditha Devasenapathy, Suparna Ghosh-Jerath, Sanjay P Zodpey
April 2017, 6(1):82-89
DOI:10.4103/2224-3151.206170  PMID:28597864
Background Community health workers play an important role in delivering health-care services, especially to underserved populations in low- and middle-income countries. They have been shown to be successful in providing a range of preventive, promotive and curative services. This qualitative study investigated the factors motivating or demotivating community health workers in urban settings in Delhi, India. Methods In this sub-study of the ANCHUL (Ante Natal and Child Healthcare in Urban Slums) implementation research project, four focus-group discussions and nine in-depth interviews were conducted with community health workers and medical officers. Utilizing a reflexive and inductive qualitative methodology, the data set was coded, to allow categories of motivating and demotivating factors to emerge. Results Motivating factors identified were: support from family members for their work, improved self-identity, job satisfaction and a sense of social responsibility, prior experiences of ill health, the opportunity to acquire new skills and knowledge, social recognition and status conferred by the community, and flexible work and timings. Negative experiences in the community and at health centres, constraints in the local health system in response to the demand generated by the community health workers, and poor pay demotivated community health workers in this study, even causing some to quit their jobs. Conclusion Community-health-worker programmes that focus on ensuring the technical capacity of their staff may not give adequate attention to the factors that motivate or discourage these workers. As efforts get under way to ensure universal access to health care, it is important that these issues are recognized and addressed, to ensure that community health worker programmes are effective and sustainable.
  3 1,780 259
Challenges and opportunities in suicide prevention in South-East Asia
Lakshmi Vijayakumar
April 2017, 6(1):30-33
DOI:10.4103/2224-3151.206161  PMID:28597856
Suicide is a global public health problem, with over 800 000 people worldwide dying by suicide in 2012, according to the World Health Organization (WHO). The WHO South-East Asia Region is especially affected, with 39% of global suicides occurring in the 11 countries in this region. Women are a particularly vulnerable population, for a variety of social and cultural reasons. In India specifically, deaths by suicide for women peak in the age range 15–29 years. There is sufficient evidence to show that reduction of easy access to means of suicide is an effective prevention strategy. A common method of suicide in the region is by ingestion of pesticides. Strategies that have targeted limiting access to pesticides as a means of preventing suicide, such as the use of central storage and locked boxes, have shown promising results. Given the limited human and economic resources in these countries, it is essential to involve all stakeholders, including health services, voluntary and community organizations, teachers, social workers, traditional healers and other gatekeepers, in suicide prevention. A multisectoral approach, specifically targeting women and reducing easy access to pesticides, should be the way forward to reducing suicides in this region. In addition, more research is needed, to identify cost-effective and sustainable strategies.
  3 1,885 267
Services for depression and suicide in Thailand
Thoranin Kongsuk, Suttha Supanya, Kedsaraporn Kenbubpha, Supranee Phimtra, Supattra Sukhawaha, Jintana Leejongpermpoon
April 2017, 6(1):34-38
DOI:10.4103/2224-3151.206162  PMID:28597857
Depression, together with suicide is an important contributor to the burden of disease in Thailand. Until recently, depression has been significantly under-recognized in the country. The lack of response to this health challenge has been compounded by a low level of access to standard care, constraints on mental health personnel and inadequate dissemination of knowledge in caring for people with these disorders. In the past decade, significant work has been undertaken to establish a new evidence-based surveillance and care system for depression and suicide in Thailand that operates at all levels of health-care provision nationwide. The main components of the integrated system are: (i) community-level screening for depression in at-risk groups, using a two-question tool; (ii) assessment of the severity of depression using a nine-question scale; (iii) diagnosis and treatment by general practitioners; (iv) psychosocial care provided by psychiatric nurses; (v) continuous care for relapse and suicide prevention; and (vi) promotion of mental well-being and prevention of depression in at-risk populations. Factors such as appropriate financial mechanisms, capacity-building programmes for health-care workers, and robust treatment guidelines have contributed to the success and sustainability of this comprehensive surveillance and care system. By 2016, more than 14 million people at risk had been screened for depression and received mental health education; more than 1.7 million people with depression had received psychosocial interventions; 0.7 million diagnosed patients had received antidepressants; and 0.8 million were being followed up for relapse and suicide prevention. The application of this surveillance and care system has led to an enormous increase in the accessibility of standard care for people with depressive disorders, from 5.1% of those with depressive disorders in 2009 to 48.5% in 2016.
  2 2,702 309
Policy and governance to address depression and suicide in Bhutan: The national suicide-prevention strategy
Gampo Dorji, Sonam Choki, Kinga Jamphel, Yeshi Wangdi, Tandin Chogyel, Chencho Dorji, Damber Kumar Nirola
April 2017, 6(1):39-44
DOI:10.4103/2224-3151.206163  PMID:28597858
Suicide and mental disorders are a growing public health issue in Bhutan, due in part to a rapidly transitioning society. The burden of suicide has been recognized by the Royal Government of Bhutan and, as a result, it introduced the country’s first ever national suicide-prevention plan in 2015. The 3-year action plan takes a holistic approach to making suicide-prevention services a top social priority, through strengthening suicide-prevention policies, promoting socially protective measures, mitigating risk factors and reaching out to individuals who are at risk of suicide or affected by incidents of suicide. This article documents Bhutan’s policy and governance for addressing depression and suicide within the context of its national suicide-prevention strategy, examines progress and highlights lessons for future directions in suicide prevention. Since the endorsement of the 3-year action plan by the prime minister’s cabinet, the implementation of suicide-prevention measures has been accelerated through a high-level national steering committee. Activities include suicide-prevention actions by sectors such as health, education, monastic communities and police; building capacity of gatekeepers; and improving the suicide information system to inform policies and decision-making. Suicide-prevention activities have become the responsibility of local governments, paving the way for suicide prevention as an integral mandate across sectors and at grass-root levels in the Kingdom of Bhutan.
  2 2,487 234
Mental health policies in South-East Asia and the public health role of screening instruments for depression
Pratap Sharan, Rajesh Sagar, Saurabh Kumar
April 2017, 6(1):5-11
DOI:10.4103/2224-3151.206165  PMID:28597852
The World Health Organization (WHO) South-East Asia Region, which contributes one quarter of the world’s population, has a significant burden due to mental illnesses. Mental health has been a low priority in most countries of the region. Although most of these countries have national mental health policies, implementation at ground level remains a huge challenge. Many countries in the region lack mental health legislation that can safeguard the rights of people with mental illnesses, and governments have allocated low budgets for mental health services. It is imperative that concerned authorities work towards scaling up both financial and human resources for effective delivery of mental health services. Policymakers should facilitate training in the field of mental health and aim towards integrating mental health services with primary health care, to reduce the treatment gap. Steps should also be taken to develop a robust mental health information system that can provide baseline information and insight about existing mental health services and help in prioritization of the mental health needs of the individual countries. Although evidence-based management protocols such as the WHO Mental Health Gap Action Programme (mhGAP) guidelines facilitate training and scaling up of care in resource-limited countries, the identification of mental disorders like depression in such settings remains a challenge. Development and validation of brief psychiatric screening instruments should be prioritized to support such models of care. This paper illustrates an approach towards the development of a new culturally adapted instrument to identify depression that has scope for wider use in the WHO South-East Asia Region.
  2 2,608 325
Alcohol consumption among adults in Bangladesh: Results from STEPS 2010
Jessica Yasmine Islam, M Mostafa Zaman, Mahfuz R Bhuiyan, Md Mahtabuddin Hasan, HAM Nazmul Ahsan, Md Mujibur Rahman, Md Ridwanur Rahman, MA Jalil Chowdhury
April 2017, 6(1):67-74
DOI:10.4103/2224-3151.206168  PMID:28597862
Background Alcohol use is a risk factor for the development of noncommunicable diseases. National data are needed to assess the prevalence of alcohol use in the Bangladeshi population. The objective of this study was to describe the prevalence and patterns of alcohol use among men and women of rural and urban areas of Bangladesh. Additionally, predictors of ever alcohol use were also identified. Methods A nationally representative cross-sectional survey (STEPS 2010) was conducted on 9275 adults between November 2009 and April 2010. Participants were selected using multi-stage random cluster sampling. Data on several risk factors for noncommunicable diseases, including alcohol use, were collected by an interviewer-administered questionnaire. Results Among the total population, 5.6% (n = 519) reported to have ever drunk alcohol and 94.4% (8756) were lifetime abstainers; 2.0% (n = 190) of participants reported to have drunk alcohol within the last 12 months. Of these, 94.7% (n = 180) were men. Only 0.9% (n = 87) of the total population had drunk alcohol within the last 30 days and were categorized as current drinkers. Among current drinkers, 77.0% (n = 67) were defined as binge drinkers, having had at least one episode of heavy drinking in this time period; 92.0% (n = 80) were current smokers and 59.8% (n = 52) had either no formal education or less than primary school education. Ever alcohol use was more common among men, those who live in urban areas and smokers. Conclusion Alcohol use is low in Bangladesh; however, those who do use alcohol frequently binge drink, which is a public health concern. Targeted efforts should be made on these specific groups, to control and prevent the continued use of alcohol in Bangladesh.
  1 1,599 148
Decentralizing provision of mental health care in Sri Lanka
Neil Fernando, Thirupathy Suveendran, Chithramalee de Silva
April 2017, 6(1):18-21
DOI:10.4103/2224-3151.206159  PMID:28597854
In the past, mental health services in Sri Lanka were limited to tertiary-care institutions, resulting in a large treatment gap. Starting in 2000, significant efforts have been made to reconfigure service provision and to integrate mental health services with primary health care. This approach was supported by significant political commitment to establishing island-wide decentralized mental health care in the wake of the 2004 tsunami. Various initiatives were consolidated in The mental health policy of Sri Lanka 2005–2015, which called for implementation of a comprehensive community-based, decentralized service structure. The main objectives of the policy were to provide mental health services of good quality at primary, secondary and tertiary levels; to ensure the active involvement of communities, families and service users; to make mental health services culturally appropriate and evidence based; and to protect the human rights and dignity of all people with mental health disorders. Significant improvements have been made and new cadres of mental health workers have been introduced. Trained medical officers (mental health) now provide outpatient care, domiciliary care, mental health promotion in schools, and community mental health education. Community psychiatric nurses have also been trained and deployed to supervise treatment adherence in the home and provide mental health education to patients, their family members and the wider community. A total of 4367 mental health volunteers are supporting care and raising mental health literacy in the community. Despite these important achievements, more improvements are needed to provide more timely intervention, combat myths and stigma, and further decentralize care provision. These, and other challenges, will be targeted in the new mental health policy for 2017–2026.
  1 2,617 254
Adoption of the 2015 World Health Organization guidelines on antiretroviral therapy: Programmatic implications for India
Bharat Bhushan Rewari, Reshu Agarwal, Suresh Shastri, Sharath Burugina Nagaraja, Abhilakh Singh Rathore
April 2017, 6(1):90-93
DOI:10.4103/2224-3151.206171  PMID:28597865
The therapeutic and preventive benefits of early initiation of antiretroviral therapy (ART) for HIV are now well established. Reflecting new research evidence, in 2015 the World Health Organization (WHO) recommended initiation of ART for all people living with HIV (PLHIV), irrespective of their clinical staging and CD4 cell count. The National AIDS Control Programme (NACP) in India is currently following the 2010 WHO ART guidelines for adults and the 2013 guidelines for pregnant women and children. This desk study assessed the number of people living with HIV who will additionally be eligible for ART on adoption of the 2015 WHO recommendations on ART. Data routinely recorded for all PLHIV registered under the NACP up to 31 December 2015 were analysed. Of the 250 865 individuals recorded in pre-ART care, an estimated 135 593 would be eligible under the WHO 2013 guidelines. A further 100 221 would be eligible under the WHO 2015 guidelines. Initiating treatment for all PLHIV in pre-ART care would raise the number on ART from 0.92 million to 1.17 million. In addition, nearly 0.07 million newly registered PLHIV will become eligible every year if the WHO 2015 guidelines are adopted, of which 0.028 million would be attributable to implementation of the WHO 2013 guidelines alone. In addition to drugs, there will be a need for additional CD4 tests and tests of viral load, as the numbers on ART will increase significantly. The outlay should be seen in the context of potential health-care savings due to early initiation of ART, in terms of the effect on disease progression, complications, deaths and new infections. While desirable, adoption of the new guidance will have significant programmatic and resource implications for India. The programme needs to plan and strengthen the service-delivery mechanism, with emphasis on newer and innovative approaches before implementation of these guidelines.
  1 1,694 117
Care for mental disorders and promotion of mental well-being in South-East Asia
Nazneen Anwar, Thaksaphon Thamarangsi
April 2017, 6(1):1-4
DOI:10.4103/2224-3151.206157  PMID:28597851
  - 1,488 140
Poonam Khetrapal Singh
April 2017, 6(1):0-0
  - 1,024 63
Perinatal care practices in home deliveries in rural Bangalore, India: A community-based, cross-sectional survey
N Ramakrishna Reddy, CT Sreeramareddy
April 2017, 6(1):75-81
DOI:10.4103/2224-3151.206169  PMID:28597863
Background A slowing in the decline in neonatal mortality in India has hindered progress made in reducing overall child mortality. The persisting use of unsafe home deliveries and harmful neonatal care practices may contribute to this stagnation in neonatal mortality rates. Methods A community-based cross-sectional study of mothers residing in rural Bangalore, India, who had given birth within 42 days of the day of home visit was done during 2013–2014. Trained health workers interviewed women who delivered at home about perinatal care practices. The questionnaire used was adapted from previous studies assessing perinatal care practices according to World Health Organization guidelines. Descriptive analyses of perinatal practices were reported as frequencies. The association of various factors with the outcomes clean cord care, thermal care and early initiation of breastfeeding were assessed using multivariate logistic regression analyses. Results Of a total of 2230 deliveries, 945 (42.4%) took place in hospitals, while the remainder were at home (57.6%). Among home deliveries, only 30.6% were attended by a skilled worker; a safe-delivery kit was used in 40.6% and 47.1% of attendants had washed their hands before delivery. In most cases (94.6%), the umbilical cord was cut after delivery of the placenta and a non-sterile instrument was used in 26.6% of births. Harmful practices of applications on the cord stump (35.0%), bathing within 6 h (61.6%), pre-lacteal feeding (30.8%) and delayed initiation of breastfeeding (73.3%) were reported. Wrapping was usually delayed, and most (64.7%) neonates were wrapped between 10 min and 60 min after birth. Being Hindu was positively associated with good perinatal care practices, and attending antenatal care at least once was associated with clean cord care and early breastfeeding. Having a trained birth attendant at delivery was associated only with clean cord care. Having a medical doctor/nurse in attendance was associated with only early initiation of breastfeeding. Being a member of a scheduled caste/tribe was positively associated with clean cord care and thermal care. Conclusion Appropriate and culturally acceptable behaviour-change communication strategies are needed to improve delivery and neonatal care practices in Bangalore.
  - 1,514 159
Depression and physical noncommunicable diseases: The need for an integrated approach
Nazneen Anwar, Pooja Patnaik Kuppili, Yatan Pal Singh Balhara
April 2017, 6(1):12-17
DOI:10.4103/2224-3151.206158  PMID:28597853
Depression is globally the third-leading cause of disability in terms of disability-adjusted life-years. Depression in patients with diseases such as cancer, diabetes mellitus, stroke or cardiovascular disease is 2-4-fold more prevalent than in people who do not have physical noncommunicable diseases, and may have a more prolonged course. The significant burden due to depression that is comorbid with chronic physical disease, coupled with limited resources, makes it a major public health challenge for low- and middle-income countries. Given the bidirectional relation between depression and chronic physical disease, the clear way forward in managing this population of patients is via a system in which mental health care is integrated with primary care. Central to this integrated approach is the Collaborative Care Model, adapted to the local sociocultural context. In this model, care is jointly led by the primary care physician, supported by a case manager and a mental health professional. Various successful initiatives in low- and middle-income countries may be used as templates for collaborative care in other low-resource settings. The model involves a range of interwoven components, such as capacity-building, task-sharing, task-shifting, developing good referral and linkage systems, anti-stigma initiatives and lifestyle modifications. Policies based on adoption of this approach would not only directly address depression that is comorbid with physical noncommunicable disease but also facilitate achievement of Sustainable Development Goal 3, to “ensure healthy lives and promote well-being for all at all ages”.
  - 2,114 340
Delivery of antiretroviral treatment services in India: Estimated costs incurred under the National AIDS Control Programme
Reshu Agarwal, Bharat Bhushan Rewari, Suresh Shastri, Sharath Burugina Nagaraja, Abhilakh Singh Rathore
April 2017, 6(1):94-98
DOI:10.4103/2224-3151.206172  PMID:28597866
Competing domestic health priorities and shrinking financial support from external agencies necessitates that India’s National AIDS Control Programme (NACP) brings in cost efficiencies to sustain the programme. In addition, current plans to expand the criteria for eligibility for antiretroviral therapy (ART) in India will have significant financial implications in the near future. ART centres in India provide comprehensive services to people living with HIV (PLHIV): those fulfilling national eligibility criteria and receiving ART and those on pre-ART care, i.e. not on ART. ART centres are financially supported (i) directly by the NACP; and (ii) indirectly by general health systems. This study was conducted to determine (i) the cost incurred per patient per year of pre-ART and ART services at ART centres; and (ii) the proportion of this cost incurred by the NACP and by general health systems. The study used national data from April 2013 to March 2014, on ART costs and non-ART costs (human resources, laboratory tests, training, prophylaxis and management of opportunistic infections, hospitalization, operational, and programme management). Data were extracted from procurement records and reports, statements of expenditure at national and state level, records and reports from ART centres, databases of the National AIDS Control Organisation, and reports on use of antiretroviral drugs. The analysis estimates the cost for ART services as US$ 133.89 (?8032) per patient per year, of which 66% (US$ 88.66, ?5320) is for antiretroviral drugs and 34% (US$ 45.23, ?2712) is for non-ART recurrent expenditure, while the cost for pre-ART care is US$ 33.05 (?1983) per patient per year. The low costs incurred for patients in ART and pre-ART care services can be attributed mainly to the low costs of generic drugs. However, further integration with general health systems may facilitate additional cost saving, such as in human resources.
  - 1,513 117
Co-occurring depression and alcohol-use disorders in South-East Asia: A narrative review
Yatan Pal Singh Balhara, Prashant Gupta, Deeksha Elwadhi
April 2017, 6(1):50-59
DOI:10.4103/2224-3151.206166  PMID:28597860
Depression and alcohol-use disorders frequently co-occur and the presence of one augments the adverse consequences of the other. This article reviews and synthesizes the available literature on depression and alcohol-use disorders from the World Health Organization (WHO) South-East Asia Region, with respect to epidemiology, screening instruments, interventions and services, and policy. In common with other low- and middle-income settings, data from this region on co-occurring depression and alcohol-use disorders are scarce. The wide variations in language and cultural diversity within the countries of this region further make the identification and management of people with co-occurring depression and alcohol-use disorders a major challenge. A range of interventions for individuals with the two disorders have been studied. However, most of this work has been done in high-income countries, highlighting the need to explore the effectiveness and cost effectiveness of various pharmacological and non-pharmacological interventions in the WHO South-East Asia Region. Much of this region comprises low-resource settings, with a dearth of trained personnel and resources. Flexible transdiagnostic approaches, delivered by community health workers and integrated into primary health care may be a pragmatic approach. Such services should form part of strengthened national responses to alcohol-related public health problems across the region.
  - 1,916 219