WHO South-East Asia Journal of Public Health

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The WHO South-East Asia Journal of Public Health (WHO-SEAJPH) is a peer-reviewed, indexed, open access quarterly publication of the World Health Organization, Regional Office for South-East Asia.

The Journal provides an avenue to scientists for publication of original research work so as to facilitate use of research for public health action.

Guidelines for Contributors:
Manuscript should be original which has not been published or is not under consideration for publication in any substantial form in any other publication.

Contact: who-seajph@searo.who.int

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Opportunities in oral health policy for Timor-Leste.
(WHO Regional Office for South-East Asia, 2016-09) Soares, Lucio F Babo; Bettiol, Silvana S; Dalla-Fontana, Isaac J; Allen, Penny; Crocombe, Leonard A
Timor-Leste faces an urgent set of challenges in oral health. The impact of oral diseases in terms of reduced quality of life and cost of treatment is considerable. This paper reviews progress on policy recommendations since the National Oral Health Survey in 2002, the first such national survey. Few proposals have been implemented to date, owing to (i) lack of local support for the recommendations, particularly on promotion of oral health; (ii) lack of financial and budgetary provisions for oral health; (iii) lack of focus on services, human resources and dental personnel; (iv) poor focus, design and implementation of policy and planning in oral health; and (v) lack of transport to facilitate health-care workers’ access to remote areas. Based on this assessment, the present paper presents a reconfigured set of policies and recommendations for oral health that take into consideration the reasons for low uptake of previous guidance. Key priorities are promotion of oral health, legislative interventions, education of the oralhealth workforce, dental outreach programmes, targeted dental treatment, dental infrastructure programmes, and research and evaluation. Interventions include promotion of oral health for schoolchildren, salt fluoridation, fluoride toothpaste and banning sweet stalls and use of tobacco and betel nut in, or near, schools. Timor-Leste should strengthen the availability and quality of outreach programmes for oral health. Dental therapists and dental nurses who can supply preventive and atraumatic restorative dental care should continue to be trained, and the planned dentistry school should be established. Ongoing research and evaluation is needed to ensure that the approach being used in Timor-Leste is leading to improved outcomes in oral health.
Policy opportunities and limitations of evidence-based planning for immunization: lessons learnt from a field trial in Bangladesh.
(WHO Regional Office for South-East Asia, 2016-09) Grundy, John; Rakhimdjanov, Shukhrat; Adhikari, Merina
Despite success in scaling up immunization, the national immunization programme in Bangladesh remains challenged by persisting inequities in health access related to geographic location and social factors, including income and education status. In order to tackle these inequities in access, the national immunization programme has conducted a field trial of the evidence-based planning model in Bangladesh between 2011 and 2013, in 11 low-performing districts and 3 city corporations. The main elements of this intervention included bottleneck analysis in local areas, action planning and budgeting to correct the bottlenecks, and establishment of a monitoring system to track progress. Coverage improved in 8 out of 14 districts post intervention. The main success factors associated with the intervention included more analytic approaches to situation assessment and taking action on health inequities at the local level, as well as more considered use of local data to track immunization drop-outs. The main factors associated with coverage declines in trial areas (6 districts) included poor financial resourcing and supervisory support, and gaps and turnover in human resources. In order to sustain and improve coverage, it will be necessary in future to link pro-equity approaches to subdistrict planning to higher-level health-system-strengthening strategy and planning systems. This will ensure that local area planners have the required resources, comprehensive operational plans and political support to sustain implementation of corrective actions to address identified system bottlenecks and inequities in health access at the local level.
Costing of immunization service provision in Kalutara district, Sri Lanka: a crosssectional study.
(WHO Regional Office for South-East Asia, 2016-09) Jayasekara, Hemali; Silva, Amala De; Amarasinghe, Ananda
Background: Immunization is regarded as the single most cost-effective way to prevent vaccine-preventable diseases. With the rising cost of the National Immunization Programme (NIP) in Sri Lanka, immunization costing studies could help programme managers to ensure sustainable immunization financing in the country. Methods: Four medical officer of health (MOH) divisions in Kalutara district were included, to estimate the cost incurred for the NIP programme. Fifteen immunization clinics from urban and rural settings were selected from the selected MOH divisions, by a simple random sampling method. Data were collected for a period of 3 months, using pretested check-lists. In addition, related data at national and district levels were also collected. Cost estimates were made for direct capital and recurrent costs. Results: The cost of vaccines under the national immunization schedule for infants was 1361.84 SL Rs (US$ 10.32). For children under 5 years of age, it was 1535.64 SL Rs (US$ 11.63). The majority of these costs were direct recurrent costs (93.4%). Vaccines (84.3%) and staff salaries (6.4%) were the main components of direct recurrent costs, while cold-chain equipment (5.3%) was the main contributor to direct capital cost. Conclusion: The cost of vaccine is the highest proportion among all other cost components in the NIP in Sri Lanka, and this is largely attributable to new costly vaccines. Staff payments are not significant, as they are a shared cost of public health service providers. Studies exploring the costing of the NIP in the country would be beneficial, to ensure sustainable immunization financing.
Factors enabling women with pelvic organ prolapse to seek surgery at mobile surgical camps in two remote districts in Nepal: a qualitative study.
(WHO Regional Office for South-East Asia, 2016-09) Chalise, Mala; Steenkamp, Malinda; Chalise, Binaya
Background: Pelvic organ prolapse (POP) is a major reproductive health problem in Nepal, though many women delay seeking treatment. To address this, the Nepalese government has been providing free vaginal hysterectomies with pelvic floor repair to women in mobile surgical camps. Studies exploring factors that enable women to attend these camp settings are limited. This study aimed to identify factors that affected women seeking surgical treatment for POP at mobile surgical camps. Methods: The study used a qualitative approach. Twenty-one women with POP were recruited in two week-long mobile surgical camps held in two remote districts in Nepal during April and May 2013. Data were collected from individual face-toface interviews and were analysed thematically. Results: Three themes and six subthemes emerged from the analysis. The first theme, “health-system factors”, suggests that accessibility and affordability of the treatment, and the supportive role of female community health volunteers facilitate women to seek treatment in the camp. The second theme, “factors related to sociocultural norms”, reveals that reaching the end of reproductive years and approval by relevant influential family members empowers women to take up surgical treatment in the mobile surgical camp. Similarly, the third theme, “individual-level factors”, includes women’s experience of POP, such as worsening symptoms and fear of development of cancer, as factors enabling women to seek treatment. Conclusion: Enablers to seeking treatment at mobile surgical camps for women are related to the Nepalese health system, sociocultural norms and individual experiences of women. Each of these factors should be considered when conducting mobile surgical camps, if women’s uptake of treatment is to be enhanced.
Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey.
(WHO Regional Office for South-East Asia, 2016-09) Rao, Krishna D; Shahrawat, Renu; Bhatnagar, Aarushi
Background: The availability of reliable and comprehensive information on the health workforce is crucial for workforce planning. In India, routine information sources on the health workforce are incomplete and unreliable. This paper addresses this issue and provides a comprehensive picture of India’s health workforce. Methods: Data from the 68th round (July 2011 to June 2012) of the National Sample Survey on the Employment and unemployment situation in India were analysed to produce estimates of the health workforce in India. The estimates were based on self-reported occupations, categorized using a combination of both National Classification of Occupations (2004) and National Industrial Classification (2008) codes. Results: Findings suggest that in 2011–2012, there were 2.5 million health workers (density of 20.9 workers per 10 000 population) in India. However, 56.4% of all health workers were unqualified, including 42.3% of allopathic doctors, 27.5% of dentists, 56.1% of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners, 58.4% of nurses and midwives and 69.2% of health associates. By cadre, there were 3.3 qualified allopathic doctors and 3.1 nurses and midwives per 10 000 population; this is around one quarter of the World Health Organization benchmark of 22.8 doctors, nurses and midwives per 10 000 population. Out of all qualified workers, 77.4% were located in urban areas, even though the urban population is only 31% of the total population of the country. This urban–rural difference was higher for allopathic doctors (density 11.4 times higher in urban areas) compared to nurses and midwives (5.5 times higher in urban areas). Conclusion: The study highlights several areas of concern: overall low numbers of qualified health workers; a large presence of unqualified health workers, particularly in rural areas; and large urban–rural differences in the distribution of qualified health workers.
Social impacts on adult use of tobacco: findings from the International Tobacco Control Project India, Wave 1 Survey.
(WHO Regional Office for South-East Asia, 2016-09) Ray, Cecily S; Pednekar, M S; Gupta, P C; Bansal-Travers, M; Quah, ACK; Fong, GT
Background: Social impacts on tobacco use have been reported but not well quantified. This study investigated how strongly the use of smoked and smokeless tobacco may be influenced by other users who are close to the respondents. Methods: The International Tobacco Control Project (TCP), India, used stratified multistage cluster sampling to survey individuals aged ≥15 years in four areas of India about their tobacco use and that of their close associates. The present study used logistic regression to calculate odds ratios (ORs) for tobacco use for each type of close associate. Results: Among the 9780 respondents, tobacco use was significantly associated with their close associates’ (father’s, mother’s, friends’, spouse’s) tobacco use in the same form. After adjusting for confounding variables, women smokers were nine times more likely to have a mother who ever smoked (OR: 9.0; 95% confidence interval [CI]: 3.3–24.7) and men smokers five times more likely (OR: 5.4; 95% CI: 2.1–14.1) than non-smokers. Men smokers were seven times more likely to have close friends who smoked (OR: 7.2; 95% CI: 5.6–9.3). Users of smokeless tobacco (SLT) were five times more likely to have friends who used SLT (OR: 5.3; 95% CI: 4.4–6.3 [men]; OR: 5.0; 95% CI: 4.3–5.9 [women]) and four times more likely to have a spouse who used SLT (OR: 4.1; 95% CI: 3.0–5.8 [men]; OR: 4.3; 95% CI: 3.6–5.3 [women]), than non-users. The ORs for the association of the individuals’ tobacco use, whether smoked or smokeless, increased with the number of close friends using it in the same form. Conclusion: The influence of family members and friends on tobacco use needs to be appropriately addressed in tobacco-control interventions.
Scrub typhus in Bhutan: a synthesis of data from 2009 to 2014.
(WHO Regional Office for South-East Asia, 2016-09) Tshokey, Tshokey; Choden, Tashi; Sharma, Ragunath
Scrub typhus is an acute, febrile illness, caused by the bacterium Orientia tsutsugamushi, that affects millions annually in the endemic Asia-Pacific region. In untreated cases, the case-fatality rates range from 6% to 35%. In Bhutan, there was a probable outbreak in Gedu in 2009, which resulted in heightened awareness of the disease. Nevertheless, information on scrub typhus in Bhutan is limited and scattered and the epidemiology has yet to be established. To report the current picture of scrub typhus in Bhutan, this review gathered data from scholarly databases, surveillance reports, the Annual health bulletin, research publications and laboratory test reports from hospitals. The weight of evidence indicates an increasing burden of scrub typhus since the Gedu incident, coupled with increased awareness and testing. Another outbreak in a rural primary school in 2014 resulted in two deaths. More hospitals now have testing facilities and laboratory-confirmed cases have been increasing since 2009, with seasonal trends. This review highlights the need for in-depth surveillance and reporting, increased awareness among health-care workers, and initiation of prevention and control programmes in the country.
Sri Lanka takes action towards a target of zero rabies death by 2020.
(WHO Regional Office for South-East Asia, 2016-09) Harischandra, PA Lionel; Gunesekera, Amila; Janakan, Navaratnasingam; Gongal, Gyanendra; Abela-Ridder, Bernadette
Rabies is a 100% vaccine-preventable and 100% fatal zoonotic, viral disease. It is usually spread to humans by saliva, through bites or scratches. Dogs are the source of the vast majority of human deaths from rabies. Political will and leadership have been the main drivers for success of the Sri Lankan effort to reduce the burden of disease attributable to rabies. Post-exposure prophylaxis, which is available in government health facilities, at no cost, to all bite patients, has been a main axis of the rabies-elimination strategy. To attain the last mile in rabies elimination in Sri Lanka by 2020, more will need to be done to scale up dog vaccination, enforce responsible dog ownership, strengthen surveillance for animals and humans and conduct mass awareness programmes. Sri Lanka is the first country in the World Health Organization South-East Asia Region to develop a national strategy for elimination of dog-mediated rabies and is a key country in sharing knowledge, expertise and capacity-building in the region, towards a global target of zero rabies deaths by 2030.
Sustainable dengue prevention and control through a comprehensive integrated approach: the Sri Lankan perspective.
(WHO Regional Office for South-East Asia, 2016-09) Tissera, Hasitha; Pannila-Hetti, Nimalka; Samaraweera, Preshila; Weeraman, Jayantha; Palihawadana, Paba; Amarasinghe, Ananda
Dengue is a leading public health problem in Sri Lanka. All 26 districts and all age groups are affected, with high disease transmission; the estimated average annual incidence is 175/100 000 population. Harnessing the World Health Organization Global strategy for dengue prevention and control, 2012–2020, Sri Lanka has pledged in its National Strategic Framework to achieve a mortality from dengue below 0.1% and to reduce morbidity by 50% (from the average of the last 5 years) by 2020. Turning points in the country’s dengue-control programme have been the restructuring and restrategizing of the core functions; this has involved establishment of a separate dengue-control unit to coordinate integrated vector management, and creation of a presidential task force. There has been great progress in disease surveillance, clinical management and vector control. Enhanced real-time surveillance for early warning allows ample preparedness for an outbreak. National guidelines with enhanced diagnostics have significantly improved clinical management of dengue, reducing the case-fatality rate to 0.2%. Proactive integrated vector management, with multisector partnership, has created a positive vector-control environment; however, sustaining this momentum is a challenge. Robust surveillance, evidence-based clinical management, sustainable vector control and effective communication are key strategies that will be implemented to achieve set targets. Improved early detection and a standardized treatment protocol with enhanced diagnostics at all medical care institutions will lead to further reduction in mortality. Making the maximum effort to minimize outbreaks through sustainable vector control in the three dimensions of risk mapping, innovation and risk modification will enable a reduction in morbidity.
Sri Lanka’s national assessment on innovation and intellectual property for access to medical products.
(WHO Regional Office for South-East Asia, 2016-09) Beneragama, Hemantha; Shridhar, Manisha; Ranasinghe, Thushara; Dissanayake, Vajira HW
In 2008, the Global strategy and plan of action on public health, innovation and intellectual property (GSPA-PHI) was launched by the World Health Organization, to stimulate fresh thinking on innovation in, and access to, medicines and to build sustainable research on diseases disproportionately affecting low- and middleincome countries. As part of the activities of the GSPA-PHI, Sri Lanka has been the first country to date to assess the national environment for medical technology and innovation. This year-long, multistakeholder, participative analysis facilitated identification of clear and implementable policy recommendations, for the government to increase its effectiveness in promoting innovation in health products through institutional development, investment and coordination among all areas relevant to public health. The assessment also highlighted areas for priority action, including closing the technology gap in development of health products, facilitating technology transfer, and building the health-research and allied workforces. The Sri Lankan experience will inform the ongoing independent external evaluation of the GSPA-PHI worldwide. The assessment process coincided with the passing of the National Medicines Regulatory Authority Act in 2015. In addition, there is growing recognition that regional cooperation will be critical to improving access to medical products in the future. Sri Lanka is therefore actively promoting cooperation to establish a regional regulatory affairs network. Lessons learnt from the Sri Lankan assessment may also benefit other countries embarking on a national GSPA-PHI assessment.
Meeting the current and future health-care needs of Sri Lanka’s ageing population.
(WHO Regional Office for South-East Asia, 2016-09) Samaraweera, Dilhar; Maduwage, Shiromi
Sri Lanka is one of the fastest-ageing countries in the world. This rapid demographic transition is expected to result in one quarter of the population being elderly by the year 2041. Profound challenges face the country as a result, especially with respect to planning adequate elderly-oriented services in the social-care and health-care sectors. In response to this need, many initiatives have been put in place to promote and protect the welfare of older people, and these rights have been inscribed in law. Within the health sector, despite the wealth of policies and initiatives in recent years, it is clear that the existing health infrastructure and systems still require strengthening, reorientation and coordination, to meet the needs of the growing population of elderly individuals. Lessons learnt from the successes in reducing the maternal mortality ratio can be applied to strengthening preventive services at the community level, to ensure active healthy ageing in Sri Lanka. Engagement of specialist medical officers of health and general practitioners to provide preventive and curative primary-care services would reduce current pressures on higher-level services. Expansion of dedicated elderlycare wards and units at the tertiary level would restructure care towards changing patient demographics. The key to success in these strategies will be increasing the proportions of the medical, nursing and allied professional cadres who have been trained in geriatric medicine. Such capacity-building in the care of the elderly will allow a move towards provision of multidisciplinary teams that can manage the complex physical, social and psychological needs of the older patient.
Healthy Lifestyle Centres: a service for screening noncommunicable diseases through primary health-care institutions in Sri Lanka.
(WHO Regional Office for South-East Asia, 2016-09) Mallaawarachchi, DS Virginie; Wickremasinghe, Shiranee C; Somatunga, Lakshmi C; Siriwardena, Vithanage TSK; Gunawardena, Nalika S
The Ministry of Health in Sri Lanka initiated the Healthy Lifestyle Centres (HLCs) in 2011, to address the lack of a structured noncommunicable disease (NCD) screening service through the lowest level of primary health-care institutions. The main service objective of the HLCs is to reduce the risk of NCDs of 40–65 year olds by detecting risk factors early and improving access to specialized care for those with a higher risk of cardiovascular disease (CVD). The screened clients are managed at HLCs, based on the total-risk approach to assess their 10-year CVD risk, using the World Health Organization/International Society of Hypertension risk-prediction chart. Those with a 10-year CVD risk of more than 30% are referred to the specialized medical clinics, while others are managed with lifestyle modification and are requested to visit the HLC for rescreening, based on the levels of CVD risk and intermediate risk factors. Identified challenges to date include: underutilization of services, especially by men; weak staff adherence to protocols; lack of integration into pre-existing NCD-screening services; non-inclusion of screening for all the major NCDs; and human resources. The government plans to address these challenges as a priority, within the context of the National multisectoral action plan for the prevention and control of NCDs in Sri Lanka 2016–2020. Key interventions include: extended opening hours for HLCs, outreach activities in workplaces, and integration with “well woman clinics”. Costs related to actions have been realistically estimated. Some actions have already been initiated, while others are being designed with identified funds.
Universal health coverage and the health Sustainable Development Goal: achievements and challenges for Sri Lanka.
(WHO Regional Office for South-East Asia, 2016-09) Silva, Amala de; Ranasinghe, Thushara; Abeykoon, Palitha
With state-funded health care that is free at the point of delivery, a sound primary health-care policy and widespread health-care services, Sri Lanka seems a good example of universal health coverage. Yet, health transition and disparities in provision and financing threaten this situation. Sri Lanka did well on the Millennium Development Goal health indicators, but the Sustainable Development Goal (SDG) for health has a wider purview, which is to “ensure healthy lives and promote wellbeing for all at all ages”. The gender gap in life expectancy and the gap between life expectancy and healthy life expectancy make achievement of the health SDG more challenging. Although women and children do well overall, the comparative health disadvantage for men in Sri Lanka is a cause for concern. From a financing perspective, high out-of-pocket expenditure and high utilization of the private sector, even by those in the lowest income quintile, are concerns, as is the emerging “third tier”, where some individuals accessing state health care that is free at the point of delivery actually bear some of the costs of drugs, investigations and surgery. This cost sharing is resulting in catastrophic health expenditure for individuals, and delays in and non-compliance with treatment. These concerns about provision and financing must be addressed, as health transition will intensify the morbidity burden and loss of well-being, and could derail plans to achieve the health SDG.
Maintaining momentum in Sri Lanka to ensure that malaria is gone – but not forgotten.
(WHO Regional Office for South-East Asia, 2016-09) Dissanayake, Chathuri
Reorienting the focus towards the Sustainable Development Goals: challenges and opportunities for Sri Lanka.
(WHO Regional Office for South-East Asia, 2016-09) Mahipala, Palitha
Foreword.
(WHO Regional Office for South-East Asia, 2016-09) Singh, Poonam Khetrapal
Prevalence of hypercholesterolaemia among adults aged over 30 years in a rural area of north Kerala, India: a cross-sectional study.
(WHO Regional Office for South-East Asia, 2016-04) Aslesh, Ottapura Prabhakaran; Jayasree, Anandabhavan Kumaran; Karunakaran, Usha; Venugopalan, Anidil Kizhakinakath; Divakaran, Binoo; Mayamol, Thekkel Raghavannair; Sunil, Charappilli Bhaskaran; Minimol, Kizhakkedathu Joseph; Shalini, Kannankai; Mallar, Ganesh Bhagyanath; Sani, Thazhathe Peedika Mubarack
to reduce the burden of the disease, it is important to know the level of modifiable risk factors in the population. The aim of this study was to estimate the prevalence of hypercholesterolaemia and associated factors among the population aged over 30 years in a rural area in north Kerala, India. Methods: A cross-sectional study was carried out to find the prevalence of hypercholesterolaemia among 533 residents of Kulappuram village. The fasting blood glucose level, total serum cholesterol level, blood pressure and body mass index of the residents were also assessed. The significance of association of hypercholesterolaemia with age, sex, body mass index and blood pressure was tested using the chi-squared test. Logistic regression was carried out to estimate the adjusted odds ratios (OR). Results: The prevalence of hypercholesterolaemia was 63.8%. It was more prevalent in women (adjusted OR: 1.56; 95% confidence interval [CI]: 1.07–2.27), in those with body mass index in the range 23.0–24.9 kg/m2 (adjusted OR: 1.78; 95% CI: 1.04–3.02) and in those with blood pressure ≥140/90 mmHg (adjusted OR: 1.62; 95% CI: 1.1–2.38). Conclusion: The prevalence of hypercholesterolaemia is high in the study population.
Metabolic syndrome among elderly care-home residents in southern India: a cross-sectional study.
(WHO Regional Office for South-East Asia, 2016-04) Sinha, Nirmalya; Bhattacharya, Ananta; Deshmukh, Pradeep Ranjan; Panja, Tanmay Kanti; Yasmin, Shamima; Arlappa, Nimmathota
Background: The health of the elderly population and the emergence of noncommunicable diseases have become major public health issues in recent years. Metabolic syndrome is thought to be the main driving force for the global epidemic of cardiovascular diseases, as well as for type 2 diabetes. This cross-sectional study aimed to determine the prevalence of metabolic syndrome and its correlates among the residents of care homes for the elderly in Hyderabad city, India. Methods: A total 114 elderly persons (aged ≥60 years) were evaluated in a cross-sectional study. Metabolic syndrome was defined by the 2005 criteria of the International Diabetes Federation. Data were collected on selected sociodemographic, behavioural and nutritional variables and cardiometabolic risk factors. Blood pressure and anthropometric measurements were also recorded. Fasting blood samples were collected for measurement of blood glucose and serum lipid levels. Univariable logistic regression was applied to investigate the associations between metabolic syndrome and known risk factors; adjusted analysis was then done by multivariable logistic regression for significant variables. Results: The overall prevalence of metabolic syndrome was 42.1% (48/114) among the study population. A higher prevalence (50.9%; 27/53) was found among women. High blood pressure or taking antihypertensive medication was found to be the most common (95.8%; 46/48) cardiometabolic component. The risk of metabolic syndrome did not differ significantly by age group, sex, caste, religion, type of diet (vegetarian or non-vegetarian), educational status, behavioural factors such as tobacco use and alcohol intake, physical activity (assessed by modified Eastern Cooperative Oncology Group [ECOG] scale), or physical exercise. However, a body mass index ≥23 kg/m2 was associated with metabolic syndrome (unadjusted odds ratio [OR]: 8.97; 95% confidence interval [CI]: 3.78–21.28); adjusted OR: 9.31; 95% CI: 4.12–22.14) Conclusion: The overall prevalence of metabolic syndrome in this study population of elderly care-home residents in India was more than 40%. Further research on the burden of metabolic syndrome in the elderly population is warranted.
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 S
Background: 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.
Gaps and challenges to integrating diabetes care in Myanmar.
(WHO Regional Office for South-East Asia, 2016-04) Latt, Tint Swe; Aye, Than Than; Ko, Ko; Zaw, Ko Ko
In common with other low-income countries, diabetes is a growing challenge for Myanmar. Gaps and challenges exist in political commitment, policy development, the health system, treatment-seeking behaviour and the role of traditional medicine. National policies aimed at prevention – such as to promote healthy food, create a healthy environment conducive to increased physical activity, restrict marketing of unhealthy food, and initiate mass awareness-raising programmes – need to be strengthened. Moreover, existing initiatives for prevention of noncommunicabledisease (NCD) are channelled vertically rather than being horizontally integrated. Primary health care is traditionally orientated more towards prevention of infectious diseases and staff often lack training in prevention and control of NCDs. Capacitybuilding activities have been modest to date, and retaining trained health workers in diabetes-oriented activities is a challenge. The World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings has been piloted in Yangon Region and countrywide expansion awaits ministerial approval. Recently, the Myanmar Diabetes Care Model was proposed by the Myanmar Diabetes Association, with the aims of both bridging the gap in diabetes care between rural and urban areas and strengthening care at the secondary and tertiary levels. However, implementation will require policy development for essential drugs and equipment, capacity-strengthening of health-care workers, and an appropriate referral and health-information system.

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