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Item Abuse against women in pregnancy: a population-based study from Eastern India.(WHO Regional Office for South-East Asia, 2012-04) Babu, Bontha V; Kar, Shantanu KBackground: Violence against women is widely recognized as an important public health problem. However, the magnitude of the problem among pregnant women is not well known in several parts of India. Hence, the prevalence and characteristics associated with various forms of domestic violence against women in pregnancy were studied in Eastern India. Methods: A population-based cross-sectional sample survey covering married women with a history of at least one full-term pregnancy (n 1525) was carried out in the Orissa, West Bengal and Jharkhand states of India. Interviews were conducted using a pre-piloted structured questionnaire to inquire about physical, psychological and sexual domestic violence. Data on socioeconomic characteristics and behaviours were also collected. The association of independent variables with domestic violence were examined by using logistic regression models. Results: The prevalence of physical, psychological and sexual domestic violence during a recent pregnancy was found to be 7.1%, 30.6% and 10.4% respectively, and the lifetime prevalence during all pregnancies was 8.3%, 33.4% and 12.6% respectively. Urban living, higher maternal age and husbands’ alcoholism were the factors associated with domestic violence in pregnancy. Women belonging to lower social groups were less likely to have physical domestic violence. Factors such as higher prevalence of undesirable behaviours like denying adequate rest and diet, demand for more sex, not providing antenatal care and pressure for male child were also associated with domestic violence in pregnancy. Conclusions: Considerable proportions of women experience some type of domestic violence during pregnancy. Health-care providers should be able to recognize and respond to pregnant women’s victimization and refer them for appropriate support and care.Item Access to and utilization of voucher scheme for referral transport: a qualitative study in a district of West Bengal, India.(WHO Regional Office for South-East Asia, 2014-07) Mukhopadhyay, Dipta K; Mukhopadhyay, Sujishnu; Das, Dilip K; Sinhababu, Apurba; Mitra, Kaninika; Biswas, Akhil BBackground: Lack of motorized transport in remote areas and cash in resourceconstrained settings are major obstacles to women accessing skilled care when giving birth. To address these issues, a cashless voucher transport scheme to enable women to give birth in a health-care institution, covering poor and marginalized women, was initiated by the National Rural Health Mission in selected districts of India in 2009. Methods: The access to and utilization of the voucher scheme were assessed between December 2010 and February 2011 through a qualitative study in the district of Purulia, West Bengal, India. Data were collected from in-depth interviews and focus group discussions with women, front-line health-care workers, programme managers and service providers. Results: The main factors influencing coverage and utilization of the scheme were: reliance on ill-prepared gram panchayats (village councils) for identification of eligible women; poor birth preparedness initiatives by health-care workers; overreliance on telephone communication; restricted availability of vehicles, especially at night and in remote areas; no routine monitoring; drivers’ demand for extra money in certain situations; and low reimbursement for drivers for long-distance travel. Conclusion: Departure from guidelines, ritualistic implementation and little stress on preparedness of both the community and the health system were major obstacles. Increased enthusiasm among stakeholders and involvement of the community would provide opportunities for strengthening the scheme.Item Access to free health-care services for the poor in tertiary hospitals of western Nepal: a descriptive study.(WHO Regional Office for South-East Asia, 2015-07) Mahato, Preeti K; Paudel, Giridhari SharmaBackground: 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.Item Annual risk of tuberculosis infection in Sri Lanka: a low prevalent country with a high BCG vaccination coverage in the South-East Asia Region.(2013-01) Wijesinghe, Pushpa Ranjan; Palihawadana, Paba; Alwis, Sunil De; Samaraweera, SudathIntroduction: Despite its simplicity, efficiency and reliability, Sri Lanka has not used the Annual Risk of Tuberculosis Infection (ARTI) to assess the prevalence and efficiency of tuberculosis (TB) control. Hence, a national tuberculin survey was conducted to estimate the ARTI. Materials and Methods: A school-based, cross-sectional tuberculin survey of 4352 children aged 10 years irrespective of their BCG vaccination or scar status was conducted. The sample was selected from urban, rural and estate strata using two-stage cluster sampling technique. In the first stage, sectors representing three strata were selected and, in the second stage, participants were selected from 120 clusters. Using the mode of the tuberculin reaction sizes (15 mm) and the mirror-image technique, the prevalence and the ARTI were estimated. Results: The prevalence of TB estimated for urban, rural and estate sectors were 13.9%, 2.2% and 2.3%, respectively. The national estimate of the prevalence of TB was 4.2% (95% CI = 1.7-7.2%). ARTI for the urban, rural and estate sectors were 1.4%, 0.2% and 0.2%, respectively, and the national estimate was 0.4% (95% CI = 0.2-0.7%). The estimated annual burden of newly infected or re-infected TB cases with the potential of developing into the active disease (400/100 000 population) was nearly 10-fold higher than the national new case detection rate (48/100 000 population). Conclusion: The national estimate of ARTI was lower than the estimates for many developing countries. The high-estimated risk for the urban sector reflected the need for intensified, sector-specific focus on TB control activities. This underscores the need to strengthen case detection. Repeat surveys are essential to determine the annual decline rate of infection.Item Antibiogram of S. enterica serovar Typhi and S. enterica serovar Paratyphi A: a multi-centre study from India.(WHO Regional Office for South-East Asia, 2012-04) Indian Network for Surveillance of Antimicrobial Resistance GroupBackground: Enteric fever continues to be a public health problem in many countries including India. Emergence of the multidrug resistant strains of S. enterica serovar Typhi may render treatment with antibiotics ineffective. A multi-centre surveillance study was, therefore, conducted in India to monitor the time trends in antibiotic susceptibility patterns of S. enterica serovar Typhi and S. enterica serovar Paratyphi A in India. Methods: All S. enterica serovar Typhi and S. enterica serovar Paratyphi A strains isolated from January 2008 to December 2010 in the 15 participating centres were included in the study. Each centre compiled their data in a predefined template which included data of the antimicrobial susceptibility pattern, location of the patient and specimen type. The data in the submitted templates was collated and analysed using a common protocol. Results: A total of 3275 isolates of Salmonellae causing enteric fever were included in the study. There were 2511 S. enterica serovar Typhi and 764 S. enterica serovar Paratyphi A strains during the three-year study period. Resistance to nalidixic acid was seen in 83% of the S. enterica serovar Typhi and 93% of S. enterica serovar Paratyphi A strains. Majority of the strains were susceptible to third generation cephalosporins. Conclusions: Enteric fever in India is caused by S. enterica serovar Typhi and S. enterica serovar Paratyphi A. Nalidixic acid resistance is high among both S. enterica serovar Typhi and S. enterica serovar Paratyphi A. Susceptibility to ampicillin, chloramphenicol and cotrimoxazole is high. Third generation cephalosporins continue to remain susceptible.Item The application of social impact bonds to universal health-care initiatives in South-East Asia.(WHO Regional Office for South-East Asia, 2014-07) Belinsky, Michael; Eddy, Michael; Lohmann, Johannes; George, MichaelSocial impact bonds (SIBs) have the potential to improve the efficiency of government health-care spending in South-East Asia. In a SIB, governments sign a pay-for-performance contract with one or several providers of health-care services, and the providers borrow up-front capital from investors. Governments outside South-East Asia have started to experiment with SIBs in criminal justice, homelessness and health care. Governments of South-East Asia can advance the goal of universal health care by using SIBs to improve the efficiency of healthcare service providers and by motivating providers to expand coverage. This paper describes SIBs and their potential application to health-care initiatives in the Region.Item An approach to diabetes prevention and management: the Bhutan experience.(WHO Regional Office for South-East Asia, 2016-04) Dorji, Tandin; Yangchen, Pemba; Dorji, Chencho; Nidup, Tshering; Zam, KinleyBhutan has been witnessing a trend of increasing diabetes in recent years. The increase is attributed to a rise in risk factors such as overweight, high blood pressure, unhealthy diet and sedentary lifestyle among the population. To address the rising burden, the health-services response has been to establish diabetes clinics in all hospitals and grade one basic health units. People visiting the health centres who have high risk factors and symptoms for diabetes are screened using the World Health Organization cut-off level for blood glucose. They are then classified into prediabetes and diabetes. Accordingly, diet, medicine and physical activity are recommended as per their body mass index. To improve prevention and control of noncommunicable diseases, which include diabetes, the country piloted the WHO Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings in 2009, to promote early screening, treatment and follow-up, and adopted it in 2013. The WHO PEN has now been successfully integrated into the primary health-care system nationwide. It is planned that diabetes clinics will be upgraded to NCD clinics.Item Appropriate anthropometric indices to identify cardiometabolic risk in South Asians.(WHO Regional Office for South-East Asia, 2013-07) Prasad, D S; Kabir, Zubair; Suganthy, J P; Dash, A K; Das, B CBackground: South Asians show an elevated cardiometabolic risk compared to Caucasians. They are clinically metabolically obese but are considered normal weight based on current international cut-off levels of several anthropometric indices. This study has two main objectives: (i) to predict the most sensitive anthropometric measures for commonly studied cardiometabolic risk factors, and (ii) to determine optimal cut-off levels of each of the anthropometric indices in relation to these cardiometabolic risk factors in South Asians. Methods: The study was conducted on a random sample of 1178 adults of 20–80 years of age from an urban population of eastern India. Obesity, as evaluated by standard anthropometric indices of BMI (body mass index), WC (waist circumference), WHpR (waist-to-hip ratio) and WHtR (waist-to-height ratio), was individually correlated with cardiometabolic risk factors. Receiver operating characteristic (ROC) curve analyses were performed which includes: (i) the area under the receiver operating characteristic curve (AUROC) analysis to assess the predictive validity of each cardiometabolic risk factor; and (ii) Youden index to determine optimal cut-off levels of each of the anthropometric indices. Results: Overall, AUROC values for WHtR were the highest, but showed variations within the sexes for each of the cardiometabolic risk factors studied. Further, WHpR cut-offs were higher for men (0.93–0.95) than women (0.85–0.88). WC cut-offs were 84.5–89.5 cm in men and 77.5–82.0 cm in women. For both sexes the optimal WHtR cut-off value was 0.51–0.55. The optimal BMI cut-offs were 23.4–24.2 kg/m2 in men and 23.6–25.3 kg/m2 in women. Conclusion: WHtR may be a better anthropometric marker of cardiometabolic risks in South Asian adults than BMI, WC or WHpR.Item Assessing compliance to smoke-free legislation: results of a sub-national survey in Himachal Pradesh, India.(2013-01) Kumar, Ravinder; Chauhan, Gopal; Satyanarayana, Srinath; Lal, Pranay; Singh, Rana J; Wilson, Nevin CIntroduction: Exposure to second-hand smoke (SHS) is a serious public health concern. The Indian smoke-free legislation 'Prohibition of Smoking in Public Places Rules, 2008' prohibits smoking in public places, including workplaces. Objective: To measure the status of compliance to legal provisions that protects the public against harms of SHS exposure, identifies the potential areas of violations and informs policy makers for strengthening enforcement measures. Design: A cross-sectional survey in 1401 public places across 11 district headquarters in Himachal Pradesh, India, using a compliance guide developed by partners of the Bloomberg initiatives to reduce tobacco use. Results: In 1401 public places across 11 district headquarters, 42.8% public places had signage; in 84.2% public places, no smoking was observed and in 83.7%, there was absence of smoking accessories such as ashtray, matchbox and lighter . Tobacco litter like cigarette butts was absent in 64.7% of the public places. Overall, at the state level, there was more than 80% compliance on at least three of the five indicators. Among all categories of public places, educational institutions and offices demonstrated highest compliance, whereas most frequently visited public places, eateries and accommodation facilities had least compliance. Conclusions: The compliance to 'Prohibition of Smoking in Public Places Rules, 2008' was variable in various district headquarters of Himachal Pradesh. This study identified the potential areas of violations that need attention from enforcement agencies and policymakers.Item Assessment of cold-chain maintenance in vaccine carriers during Pulse Polio National Immunization Day in a rural block of India.(WHO Regional Office for South-East Asia, 2014-04) Pakhare, Abhijit P; Bali, Surya; Pawar, Radhakishan B; Lokhande, Ganesh SIndia was certified polio free on 27 March 2014. Supplementary immunization activities, in the form of national immunization days, is one of the core strategies for eradication, where oral polio vaccine is administered to children aged under 5 years throughout the country. Oral polio vaccine is heat sensitive and requires maintenance of a stringent cold chain. Therefore, vaccine carriers with ice packs are used in the Pulse Polio Immunization (PPI) programme. This study assessed whether the cold chain is maintained during National Immunization Day in Beed district. A cross-sectional study was conducted at six randomly selected booths, one each from six primary health centres in Georai block of Beed district in Maharashtra. Electronic data loggers, configured to measure half-hourly temperatures, were kept in vaccine carriers throughout the day of PPI. The vaccine carrier temperature was below 8 °C at all six booths; minimum temperature recorded was –9.5 °C, while the maximum was 4.5 °C. The vaccine vial monitor did not reach discard point in any booth. A vaccine carrier with four ice packs very effectively maintains the cold chain required for oral polio vaccine.Item Assessment of risk of type 2 diabetes using the Indian Diabetes Risk Score in an urban slum of Pune, Maharashtra, India: a cross-sectional study.(WHO Regional Office for South-East Asia, 2016-04) Patil, Reshma S; Gothankar, Jayashree SBackground: The urban poor is a group that is known to be vulnerable to adoption of a more urbanized lifestyle that places them at a higher risk for diabetes. Individuals who are unaware of their disease status are more prone to micro- and macrovascular complications. Hence, it is necessary to detect this large pool of undiagnosed participants with diabetes and offer them early therapy. The aim of this study was to use the Indian Diabetes Risk Score, developed by the Madras Diabetes Research Foundation (MDRF-IDRS), to assess the prevalence of people at high risk for developing diabetes, and the correlation with known risk factors. Methods: A cross-sectional study was conducted in the field practice area of the urban health training centre of a private medical college in Pune, Maharashtra. A total of 425 participants aged 20 years and above were screened for risk factors, including age, waist circumference, family history of diabetes and physical activity. Random testing of the blood glucose level of participants with a high risk score was carried out using a glucometer. Statistical analysis of the data was performed by using the chi-squared test and logistic regression analysis. Results: The prevalence of people at high risk of diabetes was 36.55%. Among high-risk participants on univariate analysis, primary education (P = 0.004), lower socioeconomic class (P = 0.002), less physical activity (P < 0.001) and high waist circumference (P < 0.001) were major contributing factors, while in the moderate-risk group, lower socioeconomic class and high waist circumference were the prominent risk factors for diabetes. Multivariate analysis showed that higher education, moderate to vigorous activity and high waist circumference were significantly associated with risk status. Out of 140 high-risk participants, 68 (49%) had a random capillary blood glucose level of 110 mg/dL or above. Conclusion: As the prevalence of people at high risk for diabetes was high, lifestyle changes and awareness regarding risk factors is needed to take control of the diabetes in the study population.Item Association between household air pollution and neonatal mortality: an analysis of Annual Health Survey results, India.(WHO Regional Office for South-East Asia, 2015-01) Neogi, Sutapa Bandyopadhyay; Pandey, Shivam; Sharma, Jyoti; Chokshi, Maulik; Chauhan, Monika; Zodpey, Sanjay; Paul, Vinod KBackground: In India, household air pollution (HAP) is one of the leading risk factors contributing to the national burden of disease. Estimates indicate that 7.6% of all deaths in children aged under 5 years in the country can be attributed to HAP. This analysis attempts to establish the association between HAP and neonatal mortality rate (NMR). Methods: Secondary data from the Annual Health Survey, conducted in 284 districts of nine large states covering 1 404 337 live births, were analysed. The survey was carried out from July 2010 to March 2011 (reference period: January 2007 to December 2009). The primary outcome was NMR. The key exposure was the use of firewood/crop residues/cow dung as fuel. The covariates were: sociodemographic factors (place of residence, literacy status of mothers, proportion of women aged less than 18 years who were married, wealth index); health-system factors (three or more antenatal care visits made during pregnancy; institutional deliveries; proportion of neonates with a stay in the institution for less than 24 h; percentage of neonates who received a check-up within 24 h of birth); and behavioural factors (initiation of breast feeding within 1 h). Descriptive analysis, with district as the unit of analysis, was performed for rural and urban areas. Bivariate and multivariable linear regression analysis was carried out to investigate the association between HAP and NMR. Results: The mean rural NMR was 42.4/1000 live births (standard deviation [SD] = 11.4/1000) and urban NMR was 33.1/1000 live births (SD=12.6/1000). The proportion of households with HAP was 92.2% in rural areas, compared to 40.8% in urban areas, and the difference was statistically significant (P < 0.001). HAP was found to be strongly associated with NMR after adjustment (β = 0.22; 95% confidence interval [CI] = 0.09 to 0.35) for urban and rural areas combined. For rural areas separately, the association was significant (β = 0.30; 95% CI = 0.13 to 0.45) after adjustment. In univariable analysis, the analysis showed a significant association in urban areas (β = 0.23; 95% CI = 0.12 to 2.34) but failed to demonstrate an association in multivariable analysis (β = 0.001; 95% CI = –0.15 to 0.15). Conclusion: Secondary data from district level indicate that HAP is associated with NMR in rural areas, but not in urban areas in India.Item Atypical presentation of visceral leishmaniasis (kala-azar) from non-endemic area.(WHO Regional Office for South-East Asia, 2014-01) Singh, Yatendra; Singh, Paramjeet; Joshi, Subhash Chandra; Khalil, MohammadLeishmaniasis is a major public health problem in various part of world; it has also emerged in new geographic areas and host populations. Visceral infection can remain subclinical or become symptomatic, with an acute, subacute or chronic course. Kala-azar, or visceral leishmaniasis (VL), presents as fever, pancytopenia and hypergammaglobulinaemia. The presence of splenomegaly is characteristic of VL. It may be absent in immunocompromised patients, who may present atypically. Absence of splenomegaly is rare in immunocompetent patients, though it may occur in the early stages. Atypical presentations can be challenging to the clinician. This paper presents an atypical presentation of kala-azar, with multiorgan failure in the absence of splenomegaly or fever.Item Barriers and facilitators to development of standard treatment guidelines in India.(WHO Regional Office for South-East Asia, 2015-01) Sharma, Sangeeta; Sethi, Gulshan R; Gupta, Usha; Choudhury, Ranjit RoyThis paper describes 15 years’ experience of the development process of the first set of comprehensive standard treatment guidelines (STGs) for India and their adoption or adaptation by various state governments. The aim is to shorten the learning curve for those embarking on a similar exercise, given the key role of high-quality STGs that are accepted by the clinical community in furthering universal health coverage. The main overall obstacles to STG development are: (i) weak understanding of the concept; (ii) lack of time, enthusiasm and availability of local expertise; and (iii) managing consensus between specialists and generalists. Major concerns to prescribers are: encroachment on professional autonomy, loss of treating the patient as an individual and applying the same standards at all levels of health care. Processes to address these challenges are described. At the policy level, major threats to successful completion and focused implementation are: frequent changes in governance, shifts in priorities and discontinuity. In the authors’ experience, compared with each state developing their own STGs afresh, adaptation of pre-existing valid guidelines after an active adaptation process involving local clinical leaders is not only simpler and quicker but also establishes local ownership and facilitates acceptance of a quality document. Executive orders and in-service sensitization programmes to introduce STGs further enhance their adoption in clinical practice.Item Barriers to malaria control in rural south-west Timor-Leste: a qualitative analysis.(WHO Regional Office for South-East Asia, 2014-01) Neave, Penny E; Soares, Maria LBackground: Malaria is an important health problem in Timor-Leste. Although funding has been provided to reduce the burden of this disease, few studies have investigated whether this has improved malaria-related knowledge, management of symptoms, and treatment in rural communities. The aim of this study was to explore the perceptions and practices undertaken in relation to all aspects of malaria control by members of two rural communities in Timor-Leste. Methods: A qualitative study was undertaken in two rural hamlets in Timor-Leste. Research methods included transect walks, focus groups and semi-structured interviews. Content analysis was used to identify themes. Results: The location of the hamlets near rice fields, leaking taps, inadequate water supplies and dumping of waste from the local hospital provided opportunities for mosquitoes to breed. Most participants were aware of the link between mosquitoes and malaria, but a lack of control over their environment was a major barrier to preventing malaria. The distribution of bed nets had occurred once, and was the only intervention undertaken by the National Malaria Control Programme. However, limiting the distribution of bed nets to pregnant women and children aged under 5 years had resulted in some focus group respondents believing that only those in these groups could be affected by malaria. Self-diagnosis and home treatment were common. Treatment for unresolved infections depended on access to transport funds, and belief in the power of traditional healers. Conclusion: Improvements in infrastructure, empowerment of rural communities, and better access to treatment are recommended if the incidence of malaria is to be reduced throughout the country.Item Behavioural risk factors of men associated with transmission of sexually transmitted infections (STIs) in Sri Lanka(WHO Regional Office for South-East Asia, 2012-02) Jayawardena, Kuruppu AS; Silva, Kalinga T; Jayawardena, Chantha K; Samarakoon, SujathaBackground: Unprotected sex is a major risk factor for transmission of sexually transmitted infections (STIs). We explored the behavioural risk factors for STIs among men who presented with STI-related symptoms. Methods: A systematic sample of 112 males presenting with STI symptoms at district sexually transmitted disease (STD) clinic located in Kandy, Sri Lanka were enrolled during 2009. They were interviewed using a semi-structured questionnaire. Selected sexual behaviours were discussed with them in greater detail. The chi-square and difference-in-two-proportion tests were used for testing the statistical significance for quantitative data, and qualitative methods were used for the analysis of responses to open-ended questions and in-depth discussion. Results: The median age of the respondents was 28 years. The majority of them (56%) had never been married. The median age at the first sexual intercourse was 22 years. The majority(87%) of respondents had their first intercourse before marriage; mostly with older females. Most (103, 92%) men reported having sexual intercourse during the past six months; of them, 40.8% had sex with multiple partners. Only 18.5% used condoms at the first premarital intercourse. The consistent use of condoms with non-marital partners during the past six months was only 13.7%. Common reasons for non-use of condoms were: belief that partner was faithful; poor knowledge about risk of unprotected sex; view that condoms reduce pleasure and negatively affect intimacy; and inhibition in accessing condoms in public. Conclusions: Sexual behaviours were found to be risky among men attending STD clinics in Sri Lanka. Strategies of sexual health promotion among vulnarable groups should be evaluated for planning proper interventions.Item Benefits and costs of alternative healthcare waste management: an example of the largest hospital of Nepal.(WHO Regional Office for South-East Asia, 2014-04) Adhikari, Shiva R; Supakankunit, SiripenBackground: Management of health-care waste is an essential task, which has important consequences for public health and the well-being of society. Economic evaluation is important for strategic planning and investment programming for health-care waste management (HWM). A cost–benefit analysis of an alternative method of HWM in Bir hospital, Nepal was carried out using data recently collected from primary sources. Methods: Data were collected using mixed quantitative and qualitative methods. Costs and benefits were measured in Nepalese rupees. The values of all inputs were costs associated with the alternative HWM. Benefits were defined as the reduction in cost of transportation; money obtained from selling of recycled waste; and risk reduction, among others. Break-even analysis and calculations of benefit– cost ratio were used to assess the alternative HWM. Results: The alternative HWM reduces the cost of waste disposal by almost 33% per month, owing to reduction in the amount of waste for disposal. The hospital earns 3 Nepalese rupees per bed per day. The results suggest that a break-even point for costs and benefits occurs when 40% of the total beds of the hospital are covered by the alternative HWM, if the bed occupancy rate is at least 68%. If the alternative HWM is introduced in the hospital system, hospitals can reach the break-even point at 40 to 152 beds, depending on their performance in HWM. Conclusions: The results show the economic feasibility and financial sustainability of the alternative HWM. This alternative method of HWM is a successful candidate for replication in all public and private hospitals in Nepal.Item Betel quid chewing and its risk factors in Bangladeshi adults.(WHO Regional Office for South-East Asia, 2012-04) Flora, Meerjady S; Mascie-Taylor, Christopher GN; Rahman, MahmudurBackground: Despite its ill effects, betel quid chewing is a common practice in the South-East Asia Region. However, so far no large-scale study had been conducted, hence, this study was aimed at estimating the extent of betel quid chewing and its association with socio-demographic factors in Bangladeshi adults. Methods: The data of a cross-sectional sample survey, involving 15 155 and 15 719 adults from rural and urban areas of Bangladesh respectively, were analyzed. Data were collected on betel quid chewing and socio-demographic characteristics by interview method using a pre-tested structured questionnaire. Anthropometric measurements were done following standard protocols. Results: Overall 31% of the study samples chewed betel quid regularly. Prevalence was two times higher in rural (43.2%) compared to the urban areas (19.1%). Betel quid use was more common among Hindus (41.4%), farmers (55.3%), and people in the 40-year or more (63.9%) age group; and the habit was less common in unmarried (1.6%) and educated persons (19.6%). Ex-smokers (73.8%) and current smokers (37.3%) were more likely to use betel quid than never smokers (25.6%). The frequency of betel quid chewing was 5.15 times a day which varied significantly with age, locality, religion and occupation. Three-fourths of the betel quid users chewed tobacco with it which was not influenced by socio-economic variables. On average, 2.29 Takas (USD 0.03) was spent a day on betel quid chewing. Conclusions: Betel quid chewing was found to be a common habit in Bangladesh. Mature adults (40+years) of low socio-economic status, i.e., rural residents, farmers and the illiterate are more likely to chew betel quid.Item Birth defects in South-East Asia: a public health challenge: Situation analysis.(World Health Organization, Regional Office for South-East Asia. New Delhi, 2013-01) World Health Organization, Regional Office for South-East AsiaItem Capacity-building of the allied health workforce to prevent and control diabetes: lessons learnt from the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project.(WHO Regional Office for South-East Asia, 2016-04) Wijeyaratne, Chandrika; Arambepola, Carukshi; Karunapema, Palitha; Periyasamy, Kayathri; Hemachandra, Nilmini; Ponnamperuma, Gominda; Beneragama, Hemantha; Alwis, Sunil deIn 2008, to tackle the exponential rise in the clinical burden of diabetes that was challenging the health systems in Sri Lanka, a shift in focus towards patientcentred care linked with community health promotion was initiated by the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project of the Sri Lanka Medical Association. Specific training of “diabetes educator nursing officers” (DENOs), field staff in maternal and child health, footwear technicians, and health promoters from the community, was instituted to improve knowledge, skills and attitudes in the area of control and prevention of diabetes. This article highlights some of the activities carried out to date with the allied health workforce and volunteer community. Specifically, it describes experiences with the DENO programme: the educational and administrative processes adopted, challenges faced and lessons learnt. It also highlights an approach to prevention and management of complications of chronic diabetic foot through training a cohort of prosthetics and orthotics technicians, in the absence of podiatrists, and an initiative to provide low-cost protective footwear. Harnessing the enthusiasm of volunteers – adults and schoolchildren – to address behavioural risk factors in a culturally appropriate fashion has also been a key part of the NIROGI Lanka strategy.